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CBT for Treatment of Intolerance of Uncertainty

Intolerance of uncertainty usually involves negative emotional, cognitive, and behavioral reactions to uncertain situations, and it has often been associated with generalized anxiety disorder (GAD) and obsessive compulsive disorder (OCD). Studies show that intolerance of uncertainty may be the common feature within these various anxiety disorders.

The current study published in the Journal of Clinical Psychology aims to investigate the relationship between intolerance of uncertainty and emotional disorders such as GAD, OCD, panic disorder, and social phobia, and/or depressive disorders. Thirty-seven participants were randomly assigned to receive eighteen weeks of transdiagnostic cognitive-behavioral therapy intervention (Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders; UP) or were waitlisted for treatment.

Results indicated that intolerance of uncertainty was positively correlated with symptoms of depression and anxiety, and that intolerance of uncertainty decreased during CBT treatment. Additionally, reduced post treatment intolerance of uncertainty was associated with reduced post treatment symptoms of depression and anxiety. These results suggest that transdiagnostic treatment to target intolerance of uncertainty can help improve treatment outcomes across emotional disorders.

Boswell, J. F., Thompson-Hollands, J., Farchione, T. J., & Barlow, D. H. (2013). Intolerance of uncertainty: a common factor in the treatment of emotional disorders. Journal of Clinical Psychology, 69, 6, 630-45.

Psychotherapy as an epigenetic ‘drug’: psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs

Psychotherapy may be just as effective as psychopharmacology in treating psychiatric disorders. Psychotherapy focuses on psychodynamic and psychoanalytic prinicples while psychopharmacology is based on neurobiology. In the past, more emphasis was placed on psychopharmacology to treat psychiatric disorders. This article suggest that a psychotherapy could change the brain chemistry, eliciting the same results as drug therapy. Circuits in the brain are affected by efficiency of information processing. Many different disorders, that have various symptoms, are marked by inefficiency to process information, this could be too high or too low. By stimulating brain activity, symptoms of the disorder should be alleviated.

Psychotherapy can now be defined by its psychodynamic aspects and its capability of inducing epigenetic changes in the brain. The best approach is to combine psychotherapy and drug therapy. A study found that using cognitive behavior therapy and SSRIs to treat SSRI resistant depression was more effective than just medication treatment. This combination of treatments was also found more effective in treating adults with depression. The article states the best therapies to use in this combined approach are cognitive behavior therapy and interpersonal therapy.

Psychotherapy can activate epigenetic changes in the brain, or change brain circuits. This is the effect that psychopathic medications can also elicit. Given the limitations of both psychotherapy and pharmaceuticals, a combination of the two is best for therapies.

Stahl, S.M. (2011). Psychotherapy as an epigenetic ‘drug’: Psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs. Journal of Clinical Pharmacy and Therapeutics. doi:10.1111/j.1365-2710.2011.01301.x

CBT/MET Therapy Helps Improve Symptoms in Comorbid MDD/AUD Adolescents

A recent, two-year acute phase trial published in Addictive Behaviors found both manual-based cognitive behavior therapy (CBT) and motivation enhancement therapy (MET) to be beneficial treatments for adolescents suffering from both major depressive disorder (MDD) and alcohol use disorder (AUD). This was the first controlled study to compare CBT/MET with fluoxetine or placebo versus naturalistic care (control group), among adolescents with comorbid MDD/AUD.

Participants included 50 adolescents (ages 15-20) who met DSM-IV criteria for AUD and MDD. Qualified and trained masters level staff delivered nine sessions of manual-based CBT/MET, coupled with either fluoxetine (SSRI) or a placebo pill, to participants in the experimental condition. The Hamilton Rating Scale for Depression (HAM-D-27) and the Beck Depression Inventory (BDI) were used to assess depressive symptoms. The timeline follow-back method (TLFB), a tool used to measure controlled drinking, assessed drinking behavior.

Participants in the experimental condition who received CBT/MET demonstrated superior outcomes to the control group who did not receive any psychological intervention. Furthermore, no differences were noted between participants who received CBT/MET and fluoxetine versus CBT/MET and a placebo. These findings suggest that CBT/MET may be most efficacious for the treatment of comorbid MDD/AUD.

Cornelius, J.R., et al. (2011). Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors, 36(8), 843-848.

CBT for Depression

Dr. Aaron Beck explains the history of biological and psychological research on depression. He also discusses studies that looked at the likelihood of depression in people who experienced trauma during childhood. This video was taken at Beck Institute’s CBT for Children and Adolescents workshop, for more information, or to register for our next workshop visit: www.beckinstitute.org/cbt-workshops/

Evaluation of a DVD-Based Self-Help Program in Highly Socially Anxious Individuals – Pilot Study

A recent study published in Behavior Therapy found a CBT-oriented DVD-based self-help program (SHP), to be a potential treatment option for those with nonclinical degrees of social anxiety. Social anxiety disorder is described as a constant fear of particular social or performance situations coupled with acting in an embarrassing manner in those situations. The current study sought to evaluate the effectiveness of CBT-oriented DVD-based SHP supplemented by therapeutic assistance. The participants in the current study suffered from subthreshold social anxiety, which if not treated could evolve into social anxiety disorder as diagnosed in the DSM-IV. Participants had access to therapists via phone, email, or in-person sessions, in addition to the SHP.

Following several self-report questionnaires and an interview, twenty-four participants were selected to participate in the study. Twelve participants were assigned to the control group and were placed on a wait-list while the remaining twelve were given the SHP. Both groups completed self-report measures before and after the intervention. The experimental group underwent an eight-week trial program during which time they viewed guided lessons and were subsequently given homework assignments (e.g., approaching a stranger and asking for the time.) Participants then emailed their therapist a summary of their homework assignment. This helped researchers ensure that participants were truly completing the program and understanding the material presented to them.

Results demonstrated that participants in the experimental group showed improvement in their scores on the self-report assessments. Out of the twelve participants in the experimental group, only one withdrew during the eight-week session for unknown reasons. This low attrition rate may suggest that the program was well-received. The researchers concluded that CBT-oriented DVD-based SHPs supplemented by therapeutic assistance could benefit those with social anxiety symptoms.

Mall, A.K., et al. (2011). Evaluation of a DVD-based self-help program in highly socially anxious individuals—Pilot study. Behavior Therapy, 42, 439-448.

First Comparative Study of Early and Delayed CBT Interventions for PTSD

A recent and first comparative study of early and delayed cognitive behavior therapy (CBT) interventions for PTSD found that prolonged exposure (PE), cognitive therapy (CT), and delayed PE prevent chronic PTSD in recent survivors. This study published in the Archives of General Psychiatry used equipoise-stratified randomization with trauma survivors who were recruited from Hadassah Hospital in Jerusalem. Adult trauma survivors were initially screened via telephone to ensure that they met DSM-IV criteria for PTSD. Adults (516) who met criteria were randomly assigned to receive treatment in a prolonged exposure (PE) group, a cognitive therapy (CT) group, double blind comparison of treatment with escitalopram (SSRI) or placebo groups, and a control wait-list group. Of the 756 adults who did not meet DSM-IV criteria, 296 of them accepted an invitation to receive clinical assessment.

The participants were evaluated following early interventions at 5 months and assessed again at 9 months. PE and CT treatment sessions were recorded and evaluated by CT experts. The Clinician-Administered PTSD Scale (CAPS) was used to measure the presence of PTSD at 5 and 9 months following treatment. Results showed that PE, CT, and delayed PE treatments were effective in lowering the rates and symptoms of PTSD in participants. Furthermore, there was no significant difference between the presence of PTSD in participants who received PE or CT and delayed PE treatment. This suggests that delaying PTSD interventions may not pose a threat to treatment outcomes. There was also no difference in improvement between the groups who received the SSRI versus placebo pills.

Since this was the first comparative study of early and delayed PTSD interventions, the researchers recommend replication studies to test for reliability. They also propose that future research focus on more simple CBT techniques to determine how those methods play a role in preventing PTSD. Finally, the lack of improvement from pharmacological treatment with escitalopram necessitates further evaluation and replication with larger samples.

Shalev, A.Y., Ankri, Y., Israeli-Shalev, Y., Peleg, T., Adessky, R., & Freedman, S. (2011). Prevention of posttraumatic stress disorder by early treatment. Arch Gen Psychiatry.

Using CBT to Target Body Image Issues in Female College Smokers

A recent study showed that using CBT techniques to target body image issues among female smokers in smoking cessation intervention programs can help lower their smoking rates. High smoking rates and the health risks associated with smoking are a serious concern. An alarming twenty-two to thirty-four percent of college students smoke cigarettes. Previous research has shown that smoking rates in some female college students are related to their body image beliefs. This research used the cognitive pathway of body image and smoking to explain how females’ schemas of their body image serve as a foundation for smoking. These previous studies suggest that when females ruminate about their weight, they develop a cognitive bias about their body, which leads them to use smoking as a method for weight loss.

In the current study published in Behavior Modification researchers created two intervention programs for female college students to help them decrease the number of cigarettes they smoked. Twenty-four female college students were recruited to participate in an eight-week cognitive behavior smoking cessation program. They were placed into either an internet smoking session and body image group or an internet smoking session and exercise group. Both groups participated in a an hour long smoking cessation workshop which involved cognitive behavior therapy techniques (e.g., goal setting and skill building) followed by either a body image workshop or an exercise class. In addition, an internet site called Blackboard was used for group discussions and to distribute handouts.

Smoking, body image, and weight concerns were assessed using questionnaires following the intervention. Results showed that the smoking cessation rates for those who participated in the internet smoking session and body image group were greater than the rates for those who participated in the internet smoking session and exercise group. This research supports the hypothesis that body image schemas affect smoking habits in female college students.

In terms of limitations, the current study used a small sample size, lacked a control group, and used web-based instead of face-to-face group discussions. All of the participants involved in this research recommended the program to others, and they suggested that future studies incorporate face-to-face programs to make sure that everyone can participate and attend the sessions. The authors recommend replication studies with larger sample sizes in order to obtain more significant findings.

Napolitano, M.A., Llyod-Richardson, E.E., Marcus, B.H. (2011). Targeting body image schema for smoking cessation among college females: Rationale, program description, and pilot study results. Behavior Modification; 35(4): 323-346. PMID: 21502132.

Using Pupil Dilation to Screen Depressed Patients for Remission Likelihood with CBT Treatment

Research indicates that cognitive behavior therapy (CBT) is an effective treatment for up to 60% of patients with Major Depressive Disorder (MDD). However, some patients are more likely to remit than others, depending on the severity of the disorder. It is important and beneficial to patients, clinicians, and third-party payers alike, therefore, that scientists identify those who will most likely benefit from treatment.

One facet of CBT treatment involves interrupting the “downward spiral” of automatic negative thoughts. While neuroimaging has shown that CBT influences this type of brain activity via sustained limbic activity and decreased prefrontal function, functional magnetic resonance imaging (fMRI) can be costly and time-consuming. A recent study by Siegle, et al. published in Biological Psychiatry proposes that pupillary response to negative words may be a cost-effective measure to predict the likelihood of remission for certain depressed patients treated with CBT. Previous research has shown that depressed patients have increased and sustained pupillary response to negative words and that this response reflects cognitive and emotional processes, including prefrontal control.

Patients (n=32) with recurrent MDD were recruited for the current study. Participants completed an emotion-identification task that required they identify certain words as positive, negative, or neutral.  Participants also completed a digit sorting task to assess executive control. Pupillary response was measured during these tests. Participants then received a 16-session CBT intervention. The Beck Depression Inventory (BDI) was used to determine which patients had achieved remission (i.e., a score of less than 10 on the BDI coupled with no diagnosis of MDD). To test whether pupillary response was related to limbic activity, fMRI data was used for the 20 subjects able to complete this part of the experiment.

In the current study, patients who exhibited lower pretreatment depressive severity had better remission rates. These patients also presented with increased and sustained pupillary response. These results suggest that increased pupillary response is related to higher remission rates. That is, patients with a higher level of pupillary response may be more likely to remit with CBT; those with lower scores may be less likely and might choose to pursue other, more intensive treatment options. Increased pupillary response also correlated with increased prefrontal activity, which can be linked to executive control and emotional regulation. Siegel, et al. conclude that measuring pupillary response may be a noninvasive, cost-effective, and quick (requiring less than 10 minutes) tool to help depressed patients and their providers decide on effective treatment.

Lead author, Greg Siegle, Ph.D., was selected and participated in our Beck Institute Scholars Program in 2007-2008.

Siegle, G.J., Steinhauer, S.R., Friedman, E.S., Thompson, W.S., Thase, M.E. (2011). Remission prognosis for cognitive therapy for recurrent depression using the pupil: Utility and neural correlates. Biological Psychiatry; 69: 726-733. doi:10.1016/j.biopsych.2010.12.041

Using CBT and Smart Phones for the Self-Management of Chronic Pain

In this age of technology, internet interventions are becoming more common in the practice of Cognitive Behavioral Therapy (CBT).  Chronic Widespread Pain (CWP) causes patients to live in constant pain, as well as fear of that pain, which can lead to avoidant behavior and depression.  Kristjansdottir et al (2011) hope to develop an intervention program that will help patients with CWP to self-manage their pain.  Using CBT with a focus on mindfulness and the acceptance of pain, researchers developed a four week intervention that is administered to the patients via Web-enabled smart phones.  In the present study, the researchers look into the feasibility of the intervention.

Six women with CWP were recruited to participate in the intervention.  Each participant first met one-on-one with a therapist where she was asked about her condition, informed of the intervention, and lent a web-enabled phone.  For the next four weeks, the participants received an SMS text message three times a day (morning, evening, and a random time between 11:30 am and 2 pm) reminding the participants to fill out an online diary.  This diary included a set of questions asking about current thoughts and pain awareness.  Within 90 minutes, each participant received online feedback from a therapist, who was supervised by two other professionals of mindfulness meditation and CBT.

Each online diary included questions regarding the usefulness of the previous diary’s feedback.  The effects of the intervention were quantified by use of the Chronic Pain Acceptance Questionnaire (CPAQ) and the Pain Catastrophizing Scale (PSC), given to participants before and after the intervention.  Half-way through the intervention, and after completion, researchers met with participants to ask them about their experiences and opinions.

Kristjansdottir et al found that the participants were responsive to the intervention and saw it as supportive and useful.  Despite minimal technical difficulties, the program was found to be user-friendly and feasible.  Future randomized studies can adapt the program and explore its effects on CWP.

Kristjansdottir, O. B., Fors, E. A., Eide, E., Finset, A., van Dulmen, S., Wigers, S. H., & Eide, H. (2011).  Written online situational feedback via mobile phone to support self-management of chronic widespread pain: A usability study of web-based intervention.  BMC Musculosketital Disorders, 12(51).

CBT Interventions: The SPIRIT Training Course

Recently, due to important policy changes, there has been a significant increase in the demand for psychologists specializing in CBT in the United Kingdom.   As a result, specialists have been stressing the importance of various teaching approaches in CBT, such as workbooks or courses, to enable more professionals to practice CBT. In a recent study, the Structured Psychosocial InteRventions in Teams (SPIRIT) course, which is a university accredited program consisting of 38.5 hours of workshops and 5 hours of clinical supervision, was utilized to train professionals in CBT.

17 Mental Health Teams, consisting of 267 professionals from mental health fields in Glasgow were recruited to participate in this study.  These clinicians completed the SPIRIT course, in which they learned how to build relationships with their patients and modify the distorted thinking of their patients through various problem solving activities. Participants were given a subjective skill test, subjective knowledge test, and objective skill test three separate times: before the intervention, immediately following the intervention, and 3 months after the intervention.

The results demonstrated that the SPIRIT course was effective in teaching professionals CBT. The baseline scores on the subjective skill test, subjective knowledge test, and objective skill test all significantly increased after the SPIRIT training program.  In addition, the scores on each test after the intervention and the scores on each test 3 months after the intervention remained constant. This implies that the participants were still able to utilize the knowledge they had learned from the intervention 3 months after their training. Future research is still necessary to investigate whether patients are benefiting in therapy sessions from techniques learned in the SPIRIT course.

Williams, C., Martinez, R., Dafters, R., Ronald, L., & Garland, A. (2011). Training the wider workforce in cognitive behavioural self-help: The SPIRIT (structured psychosocial inteRventions in teams) training course. Behavioural and Cognitive Psychotherapy.