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 Affects Automatic Threat Processing in Patients with Panic Disorder

According to a recent study published in Biological Psychiatry, cognitive behavior therapy (CBT) impacts automatic threat processing early on in treatment for patients with panic disorder. Research suggests that biased processing of emotional information is an underlying mechanism of affective disorders and influences the effectiveness of interventions used to treat them. For example, when simultaneously shown a face with a negative expression and a face with a neutral expression, patients with anxiety will automatically direct their attention to the face with the negative expression. This is believed to increase the likelihood of anxiety attacks.

Pharmacological treatment methods have been shown to reduce the automatic threat processing bias after an acute, short-term dose, before changes in anxiety and mood become evident. These changes have been shown to be predictive of later changes in therapeutic effects measured 6 weeks later, suggesting that the early changes in automatic biases drive recovery. While CBT has been shown to reduce the automatic threat processing bias as well, it is usually assumed that CBT functions primarily as a top-down treatment approach, primarily targeting more explicit cognitive beliefs and control processes rather than automatic processes. By this view, CBT would only reduce the automatic threat processing bias over time with repeated practice and learning. The current study sought to examine the effects of an acute-dose CBT administration on the automatic threat processing bias.

Participants (n=28) satisfied DSM-IV criteria for panic disorder and were randomly assigned to either the treatment group (n=14), which received a single session of CBT, or the control group (n=14), which received no intervention. Participants completed a faces dot probe task the day after treatment, which measured reaction times to the presentation of negative, neutral, and happy expression faces. Additionally, participants’ general clinical symptoms were measured at baseline, the day after treatment, and at a 4-week follow-up. Participants’ responses to a stress test, which placed them in situations designed to elicit anxious reactions, were also measured at all three test times to provide evidence for the efficacy of the single CBT session.

Results showed that the treatment group showed significantly reduced vigilance for the negative expression faces one day following treatment, while the control group showed no reduction. The two groups did not differ in measures of clinical symptoms at baseline or the day after treatment. However, the treatment group showed significant reductions in fear of physical symptoms and agoraphobia severity at the 4-week follow-up, while the control group showed no changes. In fact, 35.7% of patients in the treatment group fulfilled criteria for agoraphobia recovery at the follow-up, with their scores falling within the range of healthy individuals. The treatment group also reported lower stress in response to the stress tests both the day after treatment and at the 4-week follow-up. The reduction in fear bias was also attributed to 22% of the variance in symptom improvement over time.

These results indicate that a single session of CBT rapidly reduces the automatic threat processing bias, before the more explicit cognitive changes occur. This finding contradicts the generally assumed model of CBT, suggesting that it is more similar to pharmacological models, at least for anxiety and panic disorders, than previously thought. The results also provide evidence for the predictive effects of automatic threat processing bias reduction on overall symptom improvement over time, suggesting that this is a key component to the effective treatment of panic disorders. Additionally, these results imply that a subset of roughly one-third of panic disorder patients may only require a single session of CBT in order to recover from co-morbid agoraphobia.

Reinecke, A., Waldenmaier, L., Cooper, M. J., & Harmer, C. J. (2013). Changes in Automatic Threat Processing Precede and Predict Clinical Changes with Exposure-Based Cognitive-Behavior Therapy for Panic Disorder. Biological Psychiatry.

Long-Term Comparison of Traditional CBT and Acceptance and Commitment Therapy

According to a recent study published in Behavior Therapy, traditional cognitive behavior therapy (CT) may be more effective for treating anxiety and depression in the long-term than Acceptance and Commitment Therapy (ACT). The current study is a follow up comparison of the long-term outcomes of CT and ACT. The original study measured symptoms of students seeking treatment, (n=132) age 18-52 (M=26.7) before and after receiving CT and ACT. At post treatment, both groups improved on measures of depression, anxiety, and general functioning, and the results did not yield a significant difference in effectiveness between the two samples receiving treatment.

This long-term follow up study, conducted 18 months later included a majority (n=91) of the original sample who received either CT (n=45) or ACT (n=46). Although participants in both treatment groups benefitted initially from the different therapies, participants from the CT treatment group gained significant and lasting improvement in their symptoms and functioning:


  • 81.8% of CT patients versus 60.7% of ACT patients remained reliably recovered on measures of depression (Beck Depression Inventory-II);
  • 72.7% of CT patients versus 56.0% ACT patients remained in the recovered range for anxiety (Beck Anxiety Inventory);
  • 46.4% of CT patients versus 22.6% ACT patients maintained improvements in interpersonal and occupational functioning (Outcome Questionnaire); and
  • 37.8% of CT patients versus 22.9% of ACT patients remained in the normative range on measures of quality of life (Quality of Life Inventory).

This is the first known comparison of the long-term efficiency of CT versus ACT. While research and replication studies are necessary, these preliminary findings suggest that traditional CT has long-term advantages over ACT in treating depression and anxiety, and in increasing general functioning and overall quality of life.

Forman, E.M., Shaw, J.A., Goetter E.M., Herbert, J.D., Park, J.A., & Yuen, E.K, (2012). Long-term follow-up of a randomized controlled trial comparing acceptance and commitment therapy and standard cognitive behavior therapy for anxiety and depression. Behavior     Therapy, 43(4) 801-811

Group CBT Helps Women with Low Self-Esteem

A recent study published in Behavioural and Cognitive Psychotherapy indicates that cognitive behavioral therapy (CBT) group intervention may be helpful for women with low self-esteem, and co-morbid depression and anxiety. In the current study, researchers used a set of CBT-based self-help workbooks, Overcoming Low Self-Esteem Self-Help Course (Fennell, 2006), to implement group therapy in a recruited sample of 37 women with low self-esteem (as indicated by the Robson Self Concept Questionnaire (RSCQ)). The group met once per week for two hours, for a total of eight sessions. Final results revealed clinically significant improvements in self-esteem and mood, including decreased depression and anxiety scores at post-intervention. While the mechanism for change is not yet clear, the researchers hypothesize that the group experience, combined with their learning adaptive skills and gaining new perspectives via CBT treatment, enhanced participants’ overall feelings of acceptance and increased confidence, both of which contribute to healthy self-esteem.

Morton, L., Roach, L., Reid, H., & Stewart, S. H. (2012). An evaluation of a CBT group for women with low self-esteem. Behavioural and Cognitive Psychotherapy, 40, 2, 221-5.

CBT Is Effective For Social Anxiety Disorder

According to a recent study published in Behaviour Research and Therapy, modifying maladaptive beliefs via cognitive behavior therapy (CBT) can significantly reduce the severity of Social Anxiety Disorder (SAD) symptoms. In the current study, researchers sought to determine, specifically, whether belief modification via CBT mediates treatment effects for SAD. Participants (47 adults) who met criteria for SAD were randomly assigned to either a CBT treatment condition (16 hour-long, weekly sessions of manualized CBT) or a waitlist control condition. Maladaptive interpersonal beliefs as well as the emotional and behavioral components of social anxiety were measured at baseline and post-treatment. Results showed that maladaptive beliefs were associated with SAD at baseline and post-treatment, that CBT significantly reduce those beliefs, and that reducing maladaptive beliefs accounted for reductions in social anxiety symptoms following CBT treatment.  These findings suggest that belief change is critical to effective CBT treatment for social anxiety disorder.

Boden, M. T., John, O. P., Goldin, P. R., Werner, K., Heimberg, R.G., & Gross, J. J. (2012). The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder. Behaviour Research and Therapy, 50, 287-291.

Beck Institute’s Level I CBT Workshop for Students and Faculty

Click the picture to see all group photos with Dr. Judith Beck

AUGUST 13-15, 2012: 173 post-doctoral fellows, psychiatry residents, other graduate students, and faculty from mental health, medical, and related fields traveled from 27 states and 10 foreign countries, including: Australia, Brazil, Canada, Costa Rica, Dominican Republic, Mexico, Philippines, Slovenia, South Africa and Thailand, to Philadelphia, PA for Beck Institute’s 3rd Annual Cognitive Behavior Therapy Workshop for Graduate Students and Faculty. The diversity of attendees was remarkable. Students and faculty came from all over the world, demonstrating a tremendous commitment to the study and practice of cognitive behavior therapy.

Cognitive Behavior Therapy Training with Dr. Judith BeckOn the first two days of training, Dr. Judith Beck covered the fundamentals of cognitive behavior therapy and CBT for depression. On the third day of training, Dr. Randy Fingerhut , Assistant Professor of Psychology at LaSalle University, covered CBT for anxiety disorders.

In addition to didactic instruction, our attendees participated in case discussions, dyadic role plays, and other experiential exercises to practice newly learned CBT strategies and techniques with their peers and colleagues.

Father of Cognitive TherapyDr. Judith Beck conducted several role plays with workshop participants to demonstrate a variety of CBT techniques for treating depression, and Dr. Aaron Beck participated in a special question and answer and role play session with workshop participants. He answered clinical questions and questions about CBT history, research, and theory, and role played with a workshop participant on how to divert a client’s attention from distress.

Afterward, both Drs. Beck met with the Beck Institute scholarship winners for an intimate discussion about current CBT research.

Cognitive Behavior Therapy Scholarship Winners

Next year’s CBT Workshop for Graduate Students and Faculty will be held on August 12-14, 2013.  Click here for more information.  For more pictures from our Student and Faculty Workshop visit our Facebook page.

Online Mindfulness Based Cognitive Therapy Reduces Perceived Stress Levels

Cognitive Behavior Therapy StudyThere is evidence that Mindfulness Based Cognitive Therapy (MBCT) can be an effective intervention for a wide range of chronic health problems.  Previous research suggests that mindfulness practices help alleviate stress. The authors of the current study sought to determine if online MBCT would also help decrease perceived stress levels among a self-referred sample.  Participants (100) took part in a 6-week mindfulness based stress reduction and cognitive therapy intervention program. They completed the Perceived Stress Scale (PSS) before the program, after the program, and at 1-month follow up.  Results showed that online MBCT significantly reduced perceived stress levels; perceived stress levels remained stable at the 1-month follow up; and pre and post effect sizes were equivalent to levels found in other mindfulness and cognitive therapies delivered face-to-face. This study provides preliminary support for online based MBCT.

Krusche A., Cyhlarova E., King S., Williams J.M.G.  Mindfulness online:  A preliminary evaluation of the feasibility of web-based mindfulness courses and the impact on stress.  BMJ Open 2012; 2: e000803 doi: 10.1136/bmjopen-2011-000803

Social Competence Influences CBT Treatment Response in Anxious Youth

According to a recent study published in Child Psychiatry & Human Development, there are significant associations between measures of social functioning and the severity of a child’s principal anxiety disorder. Further, social competence is likely to influence several key elements of cognitive behavior therapy (CBT) and CBT treatment response.

Participants (161, ages 7-14) diagnosed with a principal anxiety disorder participated in a randomized clinical trial. They received either individual CBT treatment, family CBT treatment, or an active comparison treatment (family-based education, support, and attention). According to results, children rated to be more socially competent by their mothers prior to treatment were more likely to respond positively to CBT and were less likely to have their initial anxiety continue to meet diagnostic criteria at a 1-year follow up, than children rated less socially competent. Future research should explore the mechanisms through which social competence may impact treatment response and mediators of the relationship better poor social functioning and anxiety in youth.

Settipani, C. A., Kendall, P.C. (2012). Social functioning in Youth with Anxiety Disorders: Association with Anxiety Severity and Outcomes from Cognitive-Behavioral Therapy. Child Psychiatry & Human Development.

March 12 – 14, 2012, Cognitive Behavior Therapy Workshop

Social workers, psychiatrists, family physicians, nurses, psychologists, graduate students, and other professionals from mental health, medical, and related fields traveled from Australia, Brazil, Canada, Japan, Latvia, United Kingdom, and thirteen U.S. states.

Workshop participants engaged in dyadic roleplay to practice CBT skills.

Workshop participants agreed that the diversity of the classroom enriched the learning experience. Participants received professional training in Cognitive Behavior Therapy from Judith S. Beck, Ph.D., Rosanna Sposato, Psy.D., and other Beck Institute faculty.

Dr. Judith Beck (pictured above) lectured on CBT for depression and instructed participants on how to: establish a strong therapeutic alliance; educate patients about their diagnosis; explain the cognitive model; elicit expectations for treatment; socialize patients to treatment; and, most importantly, instill hope.

Dr. Rosanna Sposato (left) lectured on CBT for Anxiety (including Generalized Anxiety Disorder, Social Anxiety Disorder, and Panic Disorder). Dr. Sposato explained cognitive behavior therapists must focus on the catastrophic thoughts patients have about their symptoms. For example, a patient with panic disorder might believe that the increase in his heart rate and chest pain he is experiencing means he is about to have a heart attack. One of the ways that CBT has been elaborated and expanded upon has been the development of a cognitive formulation for each of the different disorders, as well as the development of specific techniques for each disorder. Cognitive behavior therapists must determine the key cognitions and behaviors of each individual patient and use their conceptualization to plan treatment.

Click here to learn more about CBT workshops at Beck Institute.

CBT is Effective in Primary Health Care

A recent study published in Family Practice reviewed research on the effectiveness of cognitive behavior therapy (CBT) in the treatment of depression and anxiety in primary care clinics. Researchers conducted a literature review of seventeen studies, eight of which evaluated the effectiveness of supported computer-based CBT in primary care. They discovered that CBT in primary care is more effective than generic care and that primary care therapists (e.g., practice nurses, general practitioners, social workers and other therapists without specialized training in delivering structured psychological therapy) provide CBT effectively. This is especially true when CBT incorporates computer-based treatment or internet-based self-help programs, used widely in the UK.

Heifedt, R.S., Strem, C., Koistrup, N., Eisermann, M., Waterlo, K., (2011). Effectiveness of cognitive behavioural therapy in primary health care: a review. Family Practice, 28, 489-504.