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Internet-Based Cognitive Behavior Therapy is Effective for Severe Health Anxiety

OBJECTIVE: A sudden gain is defined as a large and stable individual improvement occurring between two consecutive treatment sessions. Sudden gains have been shown to predict better long-term improvement in several treatment studies, including cognitive behavioural therapy for depression and anxiety disorders, but have not been studied in the treatment of health anxiety or any form of internet-based cognitive behavioural therapy. The aim of this study was to investigate the role of sudden gains in internet-based cognitive behavioural therapy for severe health anxiety.

METHOD: We examined the occurrence and significance of sudden gains in measures of health anxiety in 81 participants receiving internet-based cognitive behavioural therapy. We compared patients with sudden gains, patients without sudden gains, and patients with gradual gains.

RESULTS: Thirteen participants (16%) experienced one sudden gain in health anxiety with individual sudden gains distributed across the treatment. As expected, patients with a sudden gain showed larger improvements than patients without a sudden gain at post-treatment (d = 1.04) and at one-year follow-up (d = 0.91) on measures of health anxiety.

CONCLUSIONS: Consistent with previous studies, sudden gains in internet-based cognitive behavioural therapy are associated with significantly larger and stable treatment effects up to one-year follow-up.

Hedman, E., Lekander, M., Ljotsson, B., Lindefors, N., Ru?ck, C., Hofmann, S. G., Andersson, E., … Schulz, S. M. (January 01, 2014). Sudden gains in internet-based cognitive behaviour therapy for severe health anxiety. Behaviour Research and Therapy, 54, 22-9.

Internet-Based CBT is Effective for Panic Disorder

OBJECTIVE: Guided Internet-based cognitive behaviour therapy (ICBT) for panic disorder has been shown to be efficacious in several randomized controlled trials. However, the effectiveness of the treatment when delivered within routine psychiatric care has not been studied. The aim of this study was to investigate the effectiveness of ICBT for panic disorder within the context of routine psychiatric care.

METHOD: We conducted a cohort study investigating all patients (n = 570) who had received guided ICBT for panic disorder between 2007 and 2012 in a routine care setting at an out-patient psychiatric clinic providing Internet-based treatment. The primary outcome measure was the Panic Disorder Severity Scale-Self-report (PDSS-SR).

RESULTS: Participants made large improvements from screening and pretreatment assessments to posttreatment (Cohen’s d range on the PDSS-SR = 1.07-1.55). Improvements were sustained at 6-month follow-up.

CONCLUSIONS: This study suggests that ICBT for panic disorder is as effective when delivered in a routine care context as in the previously published randomized controlled trials.

Hedman, E., Ljo?tsson, B., Ru?ck, C., Bergstro?m, J., Andersson, G., Kaldo, V., Jansson, L., … Lindefors, N. (January 01, 2013). Effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care. Acta Psychiatrica Scandinavica, 128, 6, 457-67.

Group CBT for Social Anxiety Disorder: A Meta-Analysis

OBJECTIVE: A few meta-analyses have examined psychological treatments for a social anxiety disorder (SAD). This is the first meta-analysis that examines the effects of cognitive behavioural group therapies (CBGT) for SAD compared to control on symptoms of anxiety.

METHOD: After a systematic literature search in PubMed, Cochrane, PsychINFO and Embase was conducted; eleven studies were identified that met the inclusion criteria. The studies had to be randomized controlled studies in which individuals with a diagnosed SAD were treated with cognitive-behavioural group therapy (CBGT) and compared with a control group. The overall quality of the studies was moderate.

RESULTS: The pooled effect size indicated that the difference between intervention and control conditions was 0.53 (96% CI: 0.33-0.73), in favour of the intervention. This corresponds to a NNT 3.24. Heterogeneity was low to moderately high in all analyses. There was some indication of publication bias.

CONCLUSIONS: It was found that psychological group-treatments CBGT are more effective than control conditions in patients with SAD. Since heterogeneity between studies was high, more research comparing group psychotherapies for SAD to control is needed.

Wersebe, H., Sijbrandij, M., & Cuijpers, P. (January 01, 2013). Psychological group-treatments of social anxiety disorder: a meta-analysis. Plos One, 8, 11.)

Pilot Study: Web-based CBT Adheres to Professional Practice Standards and Outcomes

Background: The primary objective of this pilot study was to demonstrate reliable adherence to a group cognitive behavioral (CBT) therapy protocol when delivered using on-line video conferencing as compared with face-to-face delivery of group CBT. A secondary aim was to show comparability of changes in subject depression inventory scores between on-line and face-to-face delivery of group CBT.

Methods: We screened 31 individuals, 18 of whom met the criteria for a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) diagnosis of mood and/or anxiety disorder. All qualifying participants had the necessary equipment (computer, webcam, Internet) for participation in the study, but could exercise their preference for either the on-line or face-to-face format. Eighteen completed the 13 weekly session intervention program (ten face-to-face; eight video conferencing). We coded adherence to protocol in both intervention formats and generated pre–post changes in scores on the Beck Depression Inventory Second Edition (BDI-II) for each participant.

Results: Application of the CBT protocol coding system showed reliable adherence to the group CBT intervention protocol in both delivery formats. Similarly, qualitative analysis of the themes in group discussion indicated that both groups addressed similar issues. Pre–post intervention scores for the BDI-II were comparable across the two delivery formats, with 60% of participants in each group showing a positive change in BDI-II severity classification (e.g., from moderate to low symptoms).

Conclusion: This pilot study demonstrates that group CBT could be delivered in a technology-supported environment (on-line video conferencing) and can meet the same professional practice standards and outcomes as face-to-face delivery of the intervention program.

Khatri, N., Marziali, E., Tchernikov, I., & Sheppard, N. (May 01, 2014). Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: a pilot study. Clinical Interventions in Aging, 765.

CBT for Health Anxiety: A Meta-Analysis of Treatment Outcome and Moderators

The present investigation employed meta-analysis to examine the efficacy of cognitive-behavioral therapy (CBT) for hypochondriasis/health anxiety as well as potential moderators that may be associated with outcome. A literature search revealed 15 comparisons among 13 randomized-controlled trials (RCTs) with a total sample size of 1081 participants that met inclusion criteria. Results indicated that CBT outperformed control conditions on primary outcome measures at post-treatment (Hedges’s g = 0.95) and at follow-up (Hedges’s g = 0.34). CBT also outperformed control conditions on measures of depression at post-treatment (Hedges’s g = 0.64) and at follow-up (Hedges’s g = 0.35). Moderator analyses revealed that higher pre-treatment severity of hypochondriasis/health anxiety was associated with greater effect sizes at follow-up visits and depression symptom severity was significantly associated with a lower in effect sizes at post-treatment. Although effect size did not vary as a function of blind assessment, smaller effect sizes were observed for CBT vs. treatment as usual control conditions than for CBT vs. waitlist control. A dose response relationship was also observed, such that a greater number of CBT sessions was associated with larger effect sizes at post-treatment. This review indicates that CBT is efficacious in the treatment of hypochondriasis/health anxiety and identifies potential moderators that are associated with outcome. The implications of these findings for further delineating prognostic and prescriptive indicators of CBT for hypochondriasis/health anxiety are discussed.

Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A. J., & Powers, M. B. (July 01, 2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58, 10, 65-74.

Individual Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) Improve Depressive Symptoms in Patients with Diabetes

Depression is a common comorbidity of diabetes, undesirably affecting patients’ physical and mental functioning. Psychological interventions are effective treatments for depression in the general population as well as in patients with a chronic disease. The aim of this study was to assess the efficacy of individual mindfulness-based cognitive therapy (MBCT) and individual cognitive behavior therapy (CBT) in comparison with a waiting-list control condition for treating depressive symptoms in adults with type 1 or type 2 diabetes. In this randomized controlled trial, 94 outpatients with diabetes and comorbid depressive symptoms (i.e., Beck Depression Inventory-II [BDI-II] ?14) were randomized to MBCT (n = 31), CBT (n = 32), or waiting list (n = 31). All participants completed written questionnaires and interviews at pre- and postmeasurement (3 months later). Primary outcome measure was severity of depressive symptoms (BDI-II and Toronto Hamilton Depression Rating Scale). Anxiety (Generalized Anxiety Disorder 7), well-being (Well-Being Index), diabetes-related distress (Problem Areas In Diabetes), and HbA1clevels were assessed as secondary outcomes. Results showed that participants receiving MBCT and CBT reported significantly greater reductions in depressive symptoms compared with patients in the waiting-list control condition (respectively, P = 0.004 and P < 0.001; d = 0.80 and 1.00; clinically relevant improvement 26% and 29% vs. 4%). Both interventions also had significant positive effects on anxiety, well-being, and diabetes-related distress. No significant effect was found on HbA1c values.
CONCLUSIONS: Both individual MBCT and CBT are effective in improving a range of psychological symptoms in individuals with type 1 and type 2 diabetes.

Tovote, K. A., Fleer, J., Snippe, E., Peeters, A. C. T. M., Emmelkamp, P. M. G., Sanderman, R., … Schroevers, M. J. (2014). Individual Mindfulness-Based Cognitive Therapy (MBCT) and Cognitive Behavior Therapy (CBT) for Treating Depressive Symptoms in Patients with Diabetes: Results of a Randomized Controlled Trial. Diabetes Care, doi: 10.2337/dc13-2918 1935-5548.

Emotional Management Training CBT in Social Settings May Reduce Children’s Anxiety

A recent study published in the Journal of Research in Childhood Education, investigated the effect of using Cognitive Behavior Therapy (CBT) in a social setting on children’s anxiety levels. Typically, children with anxiety have the most difficulty with evaluating and managing emotions, which may lead to poor peer relationships and maladaptive coping strategies. Because anxiety disorders are the most common mental health conditions in children, research on early intervention is warranted. Emotional Management Training (EMT) is a form of CBT that helps children learn to regulate anxious emotions. Participants in the current study were primarily recruited from a New York City mental health clinic and included 58 children, ages 5-14, diagnosed with anxiety disorders. The program included social and therapeutic group activities, as well as CBT skills to help children manage anxious emotions. Specifically, the EMT CBT intervention consisted of psychoeducation about emotional and physical anxiety symptoms, relaxation and meditation therapy, cognitive restructuring, and exposure activities. Results demonstrated overall improvement in anxiety symptoms measured by the Multidimensional Anxiety Scale for Children, program satisfaction surveys, self-reports, and therapist and parent reports. These findings suggest that EMT may be a helpful alternative for anxious children in social settings.

Kearny, R., Pawlukewicz, J., & Guardino, M. (2014). Children with anxiety disorders: Use of a cognitive behavioral therapy model within a social milieu. Journal of Research in Childhood Education, 28, 59-68. doi: 10.1080/02568543.2013.850130

The Cognitive Model and Case Formulation

In this video from Beck Institute’s 4th Annual Student Workshop, Dr. Aaron Beck discusses how the cognitive model can be applied to various psychiatric disorders and psychological problems. Dr. Beck provides an example of a client with several problems including back pain, panic attacks, generalized anxiety, and depression to illustrate how the cognitive model is used to inform case formulation.

For more information on Beck Institute’s Student Workshop, visit our website.

Child Perfectionism May Impact CBT Anxiety Treatment Outcomes

A recent study published in Behavior Research and Therapy investigated the effect of child perfectionism before treatment on the outcome of cognitive behavior therapy (CBT) for anxiety.  Perfectionism is typically defined as a trait involving personally demanding standards for performance.  Although a link has been found between perfectionism and adult anxiety treatment outcomes, there is a paucity of research on how perfectionism impacts CBT anxiety treatment in children.  Participants included 67 children ages 6-13 who were attending a group-based CBT program for their primary diagnoses of anxiety as part of a larger randomized controlled trial.  While perfectionism reduced following CBT anxiety treatment, higher levels of pre-treatment self-oriented perfectionism predicted higher levels of anxiety symptoms (self-reported) following treatment and at the 6-month follow up. Thus, some features of perfectionism may present as an obstacle for desirable treatment outcomes in children with anxiety.  Research is warranted to further understand the link between perfectionism and anxiety in children and how to enhance the ability to identify children at risk for anxiety and improve CBT interventions for anxious children.

Mitchell, J. H., Newall, C., Broeren, S., & Hudson, J. L. (September 01, 2013). The role of perfectionism in cognitive behaviour therapy outcomes for clinically anxious children. Behaviour Research and Therapy, 51, 9, 547-554.

CBT Reduces Shame in Individuals with Social Anxiety Disorder

According to a recent study published in Plos One, cognitive behavior therapy (CBT) may help reduce experiences of shame (specifically associated with how individuals judge themselves) among patients diagnosed with social anxiety disorder (SAD.) Participants (n= 161) in the current study were initially evaluated for experiences of shame, guilt, depression, and social anxiety. Participants diagnosed with SAD (n=67) were assigned to a CBT treatment condition; the remaining participants (n=94) were assigned to two samples of healthy controls. According to results, shame, social anxiety, and depressive symptoms were each associated in participants with SAD. Further, shame was shown to be elevated among SAD patients compared to the main healthy control. Following treatment, shame significantly reduced among participants with SAD. These findings suggest that shame and social anxiety are associated, that socially anxious patients may be more likely to experience shame than patients without social anxiety, and that CBT treatment can help reduce shame among individuals with SAD.

Hedman, E., Strom, P., Stunkel, A., & Mortberg, E. (April 19, 2013). Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms. Plos One, 8, 4.