Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Psychotherapy of depression: current status, future directions

This article reviews recent studies of psychotherapy for treatment of depression. There is evidence that cognitive behavioral and interpersonal therapies are useful treatments for depressed outpatients, roughly comparable to antidepressant pharmacotherapy. Pharmacotherapy and psychotherapy do not, however, necessarily treat the same patients and there is emerging evidence of a neurobiological "boundary" that may delimit therapy response. Psychotherapy plus pharmacotherapy combinations appear particularly useful for outpatients with more severe, recurrent depressions. Depression-focused psychotherapy may also provide an important alternative to an indefinite course of maintenance pharmacotherapy for patients at high risk for recurrence.     

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.     

Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: a clinical case series.

The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.     

Do tricyclic responders have different brain laterality?

A previous study showed that depressed patients who improved with tricyclic antidepressant medication had dichotic complex tones test results suggesting right-hemisphere dysfunction relative to nonresponders and controls (G. E. Bruder et al., 1990). A new sample of 68 depressed patients completed dichotic consonant-vowel (CV) and complex tones (CT) tests and then were treated with imipramine or placebo. A significant Ear x Test x Treatment x Response interaction was accounted for by significantly poorer left-ear accuracy for CVs among imipramine responders compared with nonresponders, placebo responders, and controls. CV left-ear accuracy was also significantly greater among placebo responders than placebo nonresponders and controls. The results only partially replicate the prior study in that evidence of right-hemisphere dysfunction in tricyclic responders was seen for the CV test but not the CT test.     

Social anxiety in body dysmorphic disorder

Although clinical impressions suggest that patients with body dysmorphic disorder (BDD) experience distress in social situations, social anxiety in BDD has received little investigation. This study examined social anxiety in 81 patients with BDD and change in social anxiety with pharmacotherapy. Subjects completed the Social Avoidance and Distress Scale (SADS) and were assessed with measures of BDD symptomatology. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean SADS score was 1.3 SD units higher than nonclinical sample means but consistent with other clinical sample means. Social anxiety was significantly correlated with BDD severity. Greater depressive symptoms as well as comorbid avoidant personality disorder, but not comorbid social phobia, were also associated with higher SADS scores. Social anxiety did not improve more with fluoxetine than placebo, yet it improved significantly more in fluoxetine responders than in nonresponders. Understanding social anxiety in BDD has implications for reducing rates of misdiagnosis and treatment dropout.     

Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients

This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.     

Sociotropy and autonomy: relationship to antidepressant drug treatment response and endogenous-nonendogenous dichotomy.

This study evaluated the relationship of sociotropic and autonomous personality traits with response to pharmacotherapy for 217 depressed outpatients using the Sociotropy-Autonomy Scale. Sociotropy was related to nonendogenous depression, whereas autonomy was related to endogenous depression. Subjects who had high autonomous-low sociotropic traits showed greater response to antidepressants (and greater drug-placebo differences) than those who had high sociotropic-low autonomous traits (who showed no drug-placebo differences). Hierarchical multiple regression analysis showed that the sociotropy-autonomy, but not the endogenous-nonendogenous, distinction was a predictor of drug treatment response. The combination of endogeneity and autonomy predicted response to placebo. If replicated, these findings may enable better matching of patient traits to various treatment modalities for depression.     

Self-esteem in body dysmorphic disorder

Although studies indicate that poor body image is associated with poor self-esteem, few investigations have examined self-esteem in a clinical sample of individuals with body dysmorphic disorder (BDD). The present study examined self-esteem in 93 BDD patients and change in self-esteem with pharmacotherapy. Subjects completed the Rosenberg Self-Esteem Scale (RSES) and were assessed with other measures. Participants in a placebo-controlled fluoxetine trial completed measures at baseline and endpoint. The mean RSES score was approximately 1.5 SD units lower than means reported for nonclinical samples. Although poorer self-esteem was associated with more severe BDD and depression, as well as greater delusionality, the relationship between self-esteem and BDD severity was largely mediated by depressive symptoms. Self-esteem did not improve significantly more with fluoxetine than placebo, although it improved significantly more in fluoxetine responders than in nonresponders. It is unclear whether poor self-esteem predisposes to BDD and/or is a consequence of the disorder.     

Suicide ideation as a predictor of treatment outcomes in cognitive-behavioral therapy for unipolar mood disorders

Background/Objective: Suicide ideation is common in depressed patients. However, no studies to date have examined whether pretreatment suicide ideation is associated with poorer outcomes after cognitive-behavioral therapy for adult depression. Method: 475 depressed outpatients (age: M = 39.9 years, SD = 11.71; 60.2% female) took part in a pre-treatment and a post-treatment assessment. Pre-treatment suicide ideation measured with the BDI suicide item was considered as a predictor of treatment outcomes – controlling for age, gender, number of attended therapy sessions, as well as pre-treatment depression severity. Results: Hierarchical regression revealed that age, gender, number of completed therapy sessions and depression severity at baseline could explain 25% of the variance in post-treatment BDI-scores. Adding suicide ideation significantly improved the amount of variance explained to 27%. Treatment outcomes were worse for patients with more severe depression, suicidal patients, patients receiving more therapy-sessions and older patients. Conclusions: Suicide ideation added only little incremental variance to the prospective prediction of post-treatment depression severity. Depressed patients with suicide ideation can attain almost as good treatment outcomes as patients without suicide ideation, which is a clinically encouraging result.     

Delayed Sleep Timing in Obsessive-Compulsive Disorder Is Associated With Diminished Response to Exposure and Ritual Prevention

Exposure and ritual prevention (ERP) and pharmacotherapy are typically associated with significant symptom reductions for individuals with obsessive-compulsive disorder (OCD). However, many patients are left with residual symptoms and other patients do not respond. There is increasing evidence that delays in sleep timing/circadian rhythms are associated with OCD but the potential effects of delays in sleep timing on ERP warrant attention. This paper presents data from 31 outpatients with OCD who participated in ERP. Results showed that delayed sleep timing was common and that individuals with delayed bedtimes benefited significantly less from treatment and were significantly more likely to be nonresponders compared to individuals with earlier bedtimes. Further, the effects of sleep timing remained statistically significant even after controlling for global sleep quality, negative affect, and several other variables. These findings add to a growing literature suggesting the utility of better understanding the role of disruptions in the timing of sleep in OCD.     

Symptom Severity at Week 4 of Cognitive-Behavior Therapy Predicts Depression Remission

Early response has been shown to predict psychotherapy outcome. We examined the strength of the relationship between early response and remission in 82 patients who received naturalistic cognitive-behavior therapy in a private practice setting, and 158 patients who received protocol cognitive therapy in a research setting. We predicted that the relationship between early response and remission would be substantial enough to guide clinical decision making in both samples, and that a simple model of severity at Week 4 of treatment would predict remission as effectively as a more complex change score. Logistic regressions showed that a simple model based on the Week 4 Beck Depression Inventory (BDI) score was as predictive of remission as more complex models of early change. A receiver operating characteristics analysis showed that BDI score at Week 4 was substantially predictive of remission in both the naturalistic and research protocol samples; the area under the curve was .80 and .84 in the naturalistic and protocol samples, respectively. To guide clinical decision making, we identified threshold scores on the BDI corresponding to various negative predictive values (probability of nonremission when nonremission is predicted). Our results indicate that depressed patients who remain severely depressed at Week 4 of cognitive therapy are unlikely to reach remission at the end of relatively brief (maximum 20 sessions) treatment. We discuss implications of our findings for clinical decision making and treatment development.     

Treating body dysmorphic disorder with medication: evidence, misconceptions, and a suggested approach

Body dysmorphic disorder (BDD) is a relatively common and often disabling disorder with high morbidity and mortality. Both psychotropic medication and cognitive behavioral therapy (CBT) are considered first-line treatments for BDD, and medication treatment is often essential for more severely ill and suicidal patients. In this practical overview of the pharmacotherapy of BDD, we briefly describe BDD's clinical features, associated morbidity, and how to recognize and diagnose BDD. We describe the importance of forming a therapeutic alliance with the patient, the need for psychoeducation, and other essential groundwork for successful treatment of BDD. We review available pharmacotherapy research, with a focus on serotonin-reuptake inhibitors (SSRIs, or SRIs), which are currently considered the medication of choice for BDD. Many patients have substantial improvement in core BDD symptoms, psychosocial functioning, quality of life, suicidality, and other aspects of BDD when treated with appropriate pharmacotherapy that targets BDD symptoms. We also discuss practical issues such as dosing, length of treatment, and potential side effects associated with the use of SRIs. In addition, we discuss pharmacotherapy approaches that can be tried if SRI treatment alone is not adequately helpful. Finally, some misconceptions about pharmacotherapy, gaps in knowledge about BDD's treatment, and the need for additional research are discussed.     

Cognitive Reactivity in Depressed Outpatients: How Different is Severe Depression?

Cognitive behavioral approaches have been able to demonstrate some of the underlying and perpetuating factors of depression such as cognitive reactivity (CR). The association of CR and the severity of depression is yet to be reported. We aimed to compare the CR of a group of outpatients based on their self-reported severity of depression (SRSD), and to identify the role of specific CR vulnerability markers in depression. The study population consisted of 221 outpatients diagnosed with Major Depressive Disorder. We used the Mini International Neuropsychiatric Interview, and completed a demographic and clinical data form. The participants completed the Leiden Index of Depression Sensitivity-Revised (LEIDS-R), and the Hospital Anxiety and Depression Scale. To identify how well CR, as measured by the scores of the LEIDS-R, could discriminate the groups based on the SRSD, one-way analysis of variance was used. To examine the unique associations between the CR and the SRSD, a hierarchical linear regression analysis was performed. To identify group membership to severe depression, the scores of the LEIDS-R were entered in a logistic regression model. Large, and small group differences emerged on the rumination, and control scores, respectively. The other group differences were all in the medium range. The control, risk aversion, and rumination scores were the subscales which explained a significant proportion of the variance in the SRSD. Overall, the logistic regression model classified 93.7 % of the severely depressed patients correctly. These results indicated that rumination, risk aversion, and perfectionism were particularly associated with severe depression.     

Suicidality and its relationship to treatment outcome in depressed adolescents

This study investigates the impact of suicidality on treatment outcome in 107 depressed adolescents who participated in a clinical trial, and received either cognitive-behavioral (CBT), systemic-behavioral-family (SBFT), or non-directive-supportive therapy (NST). Suicidal depressed adolescents had a higher dropout rate and were more likely to be depressed at the end of treatment, in large part due to the particularly poor response of suicidal patients to NST. The relationship between suicidality and treatment response was mediated by severity of depression and hopelessness at intake. Hopelessness should be specifically targeted early in treatment. Suicidal depressed adolescents should not receive NST but a specific treatment like CBT.     

The false consensus bias as applied to psychologically disturbed adolescents

In order to examine whether the false consensus bias applied to psychologically disturbed adolescents, outpatients at a rural mental health center who described themselves as very depressed or suicidal, and nondisturbed teenagers (who had no history of psychological treatment and were not at that time seeking psychological treatment), were asked to read a newspaper article about either a child's suicidal or viral illness death. Both groups of adolescents, like adults in previous research, viewed the suicidal child and the surviving family more negatively than they did the child and survivors of a viral illness death. Further, consistent with the false consensus hypothesis, adolescent clients viewed either child as more psychologically disturbed than did nonclients. Also, clients, as compared to nonclients, viewed both parents as more psychologically disturbed prior to either child's death. Results somewhat support the hypothesis of a false consensus bias which operates for depressed, suicidal adolescents when they view the tragedy of a child's death, but not when they are making recommendations about psychological help for the surviving family. Results are interpreted as suggesting that adolescent outpatients either view therapy as not particularly beneficial or as not particularly appropriate for bereaved individuals.     

Does personality disorder co-morbidity impact treatment outcome for patients with major depression? A multi-level analysis

In literature, there exists disagreement regarding the impact of comorbid personality disorder(s) (PD[s]) on treatment outcome for patients with major depressive disorder (MDD). The aim of this paper was to investigate whether statistical heterogeneity and inter-dependency are potential moderators of the effect of co-morbid PDs on outcome for patients with MDD. Clinician-rated MADRS scores and DSM-IV Axis II personality disorder diagnoses were obtained from 562 outpatients with MDD who received 6 months of combined psycho- and pharmacotherapy. Single-level regression showed significantly worse treatment outcome among patients with co-morbid PD, as compared to patients with no PD. After controlling for statistical heterogeneity and interdependency, treatment outcome was no longer significantly worse for patients with co-morbid PD. In conclusion, heteroscedasticity and inter-dependency should be considered as potentially compelling explanations for inconsistencies in findings on treatment outcome for depressed patients with co-morbid PDs.     

Habit reversal versus supportive psychotherapy in Tourette's disorder: a randomized controlled trial and predictors of treatment response

Tourette syndrome (TS) is characterized by chronic motor and vocal tics. Habit reversal therapy (HR) is a behavioral treatment for tics which has received recent empirical support. The present study compared the efficacy of HRT in reducing tics, improving life-satisfaction and psychosocial functioning in comparison with supportive psychotherapy (SP) in outpatients with TS. In addition, we investigated whether impairments in response inhibition in patients with TS predict response to HR treatment which specifically aims to inhibit tics. Thirty adult outpatients with DSM-IV TS were randomized to 14 individual sessions of HR (n = 15); or SP (n = 15). HR but not SP reduced tic severity over the course of the treatment. Both groups improved in life-satisfaction and psychosocial functioning during active treatment. Reductions in tic severity (HR) and improvements in life-satisfaction and psychosocial functioning (HR and SP) remained stable at the 6-month follow-up. The extent of pre-treatment response inhibition impairment in the HR group predicted reductions in tic-severity from pre- to post-treatment. Our results suggest that HR has specific tic-reducing effects although SP is effective in improving life-satisfaction and psychosocial functioning. Assessments of response inhibition may be of value for predicting treatment response to HR.     

Cognitive-behavioral therapy for panic disorder: a review of treatment elements,strategies, and outcomes

This article provides an overview of cognitive-behavioral therapy (CBT) for panic disorder. CBT is currently considered a first-line treatment for panic disorder. It offers benefit after short-term intervention, typically consisting of 12-15 sessions conducted in either an individual or a group format. The treatment focuses on the elimination of the patterns that underlie and perpetuate the disorder. Through CBT, patients learn about the nature of the disorder and acquire a set of strategies that counter the fears of panic attacks themselves, and break the recurring cycle of anticipatory anxiety, panic, and agoraphobic avoidance. The collaborative format of treatment, and a focus on elimination of core fears may be factors in enhancing longer-term outcome. In this article, we review the efficacy of CBT as a first-line treatment, a strategy for medication nonresponders, a replacement strategy for patients who wish to discontinue pharmacotherapy, and a potential preventive strategy for at-risk individuals. We also discuss some of the complex issues involved with combination-treatment strategies.     

Short-Term Psychoanalytic Supportive Psychotherapy for Depressed Patients

Short-Term Psychoanalytic Supportive Psychotherapy (SPSP) is a face-to-face, individual psychotherapy, consisting of sixteen sessions in six months (first eight weekly, then eight fortnightly sessions). It is rooted in psychoanalytic theory. Its primary aim is to cure depression. A secondary goal is to reduce a patient's vulnerability to depression. The emphasis is on supportive techniques that counter regression and foster psychological growth. The putative process consists in experiencing a relational dissonance, i.e., feeling two contradictory relationships in the therapeutic situation simultaneously, one determined by the past, the other by the present. We assume an important curative factor is to experience, mostly unconsciously, an adequate gratification of developmental needs inadequately met in early infancy and, therefore, manifesting themselves in the archaic aspects of the therapeutic relationship. SPSP unfolds as a discourse in which we distinguish nine levels. Each regards a specific subject, which at that level is the focus of the interaction between patient and therapist. The efficacy of SPSP in ambulatory patients presenting a DSM-IV defined, mild to moderate major depressive disorder has been tested in five randomized clinical trials. The results have been aggregated in a mega-analysis. They suggest that, in the treatment of outpatients with mild to moderate major depressive disorder, SPSP and pharmacotherapy are equally efficacious and that the combination of SPSP and pharmacotherapy is more efficacious than pharmacotherapy alone but not than SPSP alone. We, therefore, consider SPSP a valuable extension to the existing options for the treatment of depressed patients.