Treatment of generalized anxiety disorder in older adults

Older adults with generalized anxiety disorder (GAD; N = 75; M age = 67.1 years) were randomly assigned to cognitive-behavioral therapy (CBT), a discussion group (DG) organized around worry-provoking topics, or a waiting period. Participants in both active conditions improved relative to the waiting list. Although CBT participants improved on more measures than DG participants, the authors found only I significant difference immediately after treatment and no differences at 6-month follow-up. Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed medium-sized effects Overall, results indicate that brief treatment of late-life GAD is beneficial, but they provide only limited support for the superiority of CBT to a credible comparison intervention.     

Psychosocial treatments for negative symptoms in schizophrenia: Current practices and future directions

Schizophrenia can be a chronic and debilitating psychiatric disorder. Though advancements have been made in the psychosocial treatment of some symptoms of schizophrenia, people with schizophrenia often continue to experience some level of symptoms, particularly negative symptoms, throughout their lives. Because negative symptoms are associated with poor functioning and quality of life, the treatment of negative symptoms is a high priority for intervention development. However, current psychosocial treatments primarily focus on the reduction of positive symptoms with comparatively few studies investigating the efficacy of psychosocial treatments for negative symptoms. In this article, we review and evaluate the existing literature on three categories of psychosocial treatments — cognitive behavioral therapy (CBT), social skills training (SST), and combined treatment interventions — and their impact on the negative symptoms of schizophrenia. Of the interventions reviewed, CBT and SST appear to have the most empirical support, with some evidence suggesting that CBT is associated with maintenance of negative symptom improvement beyond six months after treatment. It remains unclear if a combined treatment approach provides improvements above and beyond those associated with each individual treatment modality. Although psychosocial treatments show promise for the treatment of negative symptoms, there are many unanswered questions about how best to intervene. We conclude with a general discussion of these unanswered questions, future directions and methodological considerations, and suggestions for the further development of negative symptom interventions.     

A comparison of the efficacy and acceptability of group versus individual cognitive behaviour therapy in the treatment of panic disorder and agoraphobia in primary care

Panic disorder and agoraphobia is a prevalent clinical condition which places heavy demands on treatment resources in primary care. The efficient delivery of evidence‐based psychological treatment for this disorder is therefore important. Previous research has investigated both individual and group treatment formats for cognitive behaviour therapy (CBT) for panic disorder and agoraphobia. These two modalities of treatment delivery are, however, rarely compared within the same study format. Also little is known of patients' preferences regarding treatment delivery formats. The present study investigated the relative efficacy of a group treatment CBT and an individual treatment CBT in comparison with a waiting list control group in the treatment of panic disorder with or without agoraphobia in primary care. Ninety‐seven patients suffering from DSM‐IV panic disorder with or without agoraphobia were randomly allocated to receive either group CBT, individual CBT, or waiting list control. All patients were seen by the same therapist and all received an identical treatment manual. Treatment response was measured by blind assessor, therapist and patient‐rated measures of anxiety, depression, and agoraphobic avoidance, and was analysed in terms of both traditional statistical significance and clinical significance of outcome. At treatment end‐point, in terms of traditional statistical significance, both the group and individual CBT were significantly superior to waiting list control but did not differ significantly from each other. When clinical significance of outcome at treatment end‐point was considered, individual CBT showed a significant advantage over both group CBT and waiting list control. At 3‐month follow‐up, however, the individual CBT treatment group showed significant superiority to the group CBT treatment on clinical significance of outcome on one outcome measure only. This was principally due to a reduction in the proportion of patients achieving criteria of clinically significant change in the individual CBT treatment group over the 3‐month follow‐up period. When given a free choice of group or individual CBT at the end of the waiting list period, the overwhelming majority (95%) of the waiting list patients chose individual CBT. The implications of these findings for future research and for wider clinical practice are discussed. Copyright © 2004 John Wiley & Sons, Ltd.     

Behavioral medicine approaches to somatoform disorders

This article reviews the research evidence for the efficacy of cognitive-behavioral therapy (CBT) for somatoform disorders. Randomized controlled studies support the efficacy of individual CBT for the treatment of hypochondriasis, body dysmorphic disorder (BDD), and undifferentiated somatoform disorders including medically unexplained symptoms, chronic fatigue syndrome, and noncardiac chest pain, and group CBT for the treatment of BDD and somatization disorder. On the basis of this review of the existing research and a theoretical model of the processes involved in somatoform disorders, the authors offer suggestions for future research and effective treatment.     

Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating,Improving, and Transporting What Works

Pediatric obsessive-compulsive disorder is a chronic and impairing condition that often persists into adulthood. This review refreshes the state of support for psychosocial treatments and the predictors or moderators that relate to their efficacy and evaluates how the literature has improved since the last update in 2014. A secondary goal is to propose an additional framework for the categorization of studies based on central research questions rather than treatment format. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the Journal of Clinical Child and Adolescent Psychology evidence-based treatment evaluation criteria. Findings again converge in support of cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with obsessive-compulsive disorder. Family-focused CBT is now well-established. A number of other treatments including CBT+ D-Cycloserine, CBT+ Sertraline, CBT+ positive family interaction therapy, and technology-based CBT are now probably efficacious. Demographic, clinical, and family factors are consistent predictors of CBT outcome with conflicting findings for neurocognitive predictors. The field has advanced significantly since the last review, but there is still room for improvement. Some of the conclusions that can be drawn may be limited by our evaluation criteria. Future directions are proposed to advance treatment outcome research beyond a focus on which treatments work to exploring factors that account for how and why they work.     

Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review

We systematically reviewed empirical studies that investigated the use of cognitive-behavioral therapy (CBT) for premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Our multi-database search identified seven published empirical reports. Three were identified as randomized controlled trials (RCTs). The methods utilized to investigate therapeutic efficacy of CBT in these studies varied widely from case reports to RCTs with pharmacotherapy comparison groups. Initially we provide a brief overview of CBT and justifications for its potential use to treat PMS/PMDD. Next, we provide critical evaluations of the analyses used in each study focusing on the detection of intervention effects assessed by statistically significant time by group interactions. When possible we calculate effect sizes to elucidate the clinical significance of results. Our review revealed a dearth of evidence providing statistically significant CBT intervention effects. Issues such as overall time investment, latency to treatment effects, and complementary and combined therapies are considered. We present a theoretical argument for applying mindfulness- and acceptance-based CBT interventions to PMS/PMDD and suggest future research in this area. In conclusion, to produce the necessary evidence-base support for PMS/PMDD given the limited empirical evidence reported here, researchers are called on to produce methodologically rigorous investigations of psychosocial interventions for PMS/PMDD.     

Well-being therapy of generalized anxiety disorder

BACKGROUND: There is increasing awareness that the goal of treatment in generalized anxiety disorder (GAD) should not simply be a response, but restoration of normal function. The aim of this study was to apply a novel psychotherapeutic approach for increasing the level of remission in GAD. METHODS: Twenty patients with DSM-IV GAD devoid of comorbid conditions were randomly assigned to 8 sessions of cognitive behavioral therapy (CBT) or the sequential administration of 4 sessions of CBT followed by other 4 sessions of well-being therapy (WBT). Assessment methods included the Anxiety and Depression Scales of Paykel's Clinical Interview for Depression, Ryff's Psychological Well-being Scales and Kellner's Symptom Questionnaire. A one-year follow-up was undertaken. RESULTS: Significant advantages of the CBT-WBT sequential combination over CBT only were observed with both observer and self-rated methods after treatment. Such gains were maintained at follow-up. CONCLUSIONS: These preliminary results suggest the feasibility and clinical advantages of adding WBT to the treatment of GAD. They lend support to a sequential use of treatment components for achieving a more sustained recovery.     

国内认知行为疗法联合药物治疗广泛性焦虑疗效的元分析

目的:分析认知行为疗法(CBT)联合药物治疗与单纯使用药物治疗对广泛性焦虑干预的疗效。方法:对CBT和药物联合治疗与单纯使用药物治疗广泛性焦虑的对照研究进行回顾研究,使用Revman 5.3进行系统评价。结果:共获得7篇文献符合本文的元分析选择标准,被试人数共435人。7组数据比较了CBT和药物联合治疗与单独使用药物治疗广泛性焦虑的治愈率、显效率和有效率,结果显示,联合治疗组的治愈率(OR=2.69,Z=4.33,P0.05)、显效率(OR=2.07,Z=3.58,P0.05)与有效率(OR=3.11,Z=3.50,P0.05)均优于单纯药物组。结论:在国内治疗广泛性焦虑中,认知行为疗法联合药物治疗8周后比单独使用药物治疗效果更好。     

Cognitive-behavioral therapy for children who have obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a relatively chronic and impairing disorder in children and adolescents. Whereas childhood OCD was largely ignored in the past, major advances in the identification and treatment over the past 20 years have led to a significant upsurge in the prevalence of youngsters seeking treatment for this problem. The present article describes the use of exposure-based cognitive-behavioral therapy (CBT) for the treatment of childhood OCD. Although the phenomenology of OCD is largely consistent across the age span, traditional adult CBT approaches have been modified for use with children and adolescents in order to address those developmental differences that do exist. The case example describes the use of CBT for a child who has OCD and highlights these developmental considerations, including age-appropriate techniques to address family involvement in the disorder and the impact of symptoms on the psychosocial functioning of the patient.     

Psychosocial treatments for adolescent depression

Major Depressive Disorders affect between 2% and 5% of adolescents at any one point in time. Depression in adolescence is associated with serious psychosocial deficits and has negative effects on functioning during young adulthood. Starting with the pioneering work of Lenore Butler and her colleagues, many psychosocial interventions have been developed and studied, with generally positive results. On the basis of a meta-analysis of the existing cognitive-behavioral therapy (CBT) studies we estimate an overall effect size of 1.27 and that 63% of patients show clinically significant improvement at the end of treatment. It seems reasonable to conclude that CBT has been demonstrated to be an effective treatment for depressed adolescents. In this article we describe these interventions, most of which are meant to address the problems shown by depressed adolescents. The purpose of our article is to bring this literature to the attention of clinicians in a manner which quickly and clearly summarizes the key features of the interventions to make it easy for clinicians to take advantage of this wealth of information and to avail themselves of the existing resources. We conclude by suggesting future directions and several additional areas of application for adolescent depression treatments.     

Efficacy of cognitive behaviour therapy in generalized anxiety disorders. Results of a controlled clinical trial (Berlin CBT-GAD Study)

BACKGROUND: Generalized anxiety disorders (GAD) are amongst the most prevalent mental disorders. Recent studies have suggested that cognitive behaviour therapy (CBT) is an effective treatment for GAD. A controlled clinical trial was done to evaluate the efficacy of CBT treatment in outpatients with pure GAD who were treated by a therapist working in routine care. METHODS: Seventy-two outpatients, fulfilling GAD criteria according to DSM-IV, were included in the study. From this group, 36 patients (CBT-A) were randomly assigned to 25 sessions of CBT and the other 36 formed a contact control group (CCG). After the contact control period (CC period), these patients were also treated with CBT (CBT-B), allowing not only a parallel group comparison but also an A-B comparison. Therapists were licensed full-time psychologists who worked routinely in outpatient care and had a professional training in CBT. Treatment was done in accordance with a manual, and treatment conformity was controlled by several methods. RESULTS: The reduction in the score on the Hamilton Anxiety Observer Rating Scale was 6.4% (1.5 points) in the CCG, 35.4% (9.5 points) in the CBT-A and 47.3% (10.3 points) in the CBT-B. In the self-rating Spielberger State-Trait Anxiety Inventory, a reduction of 2.7% was seen in CCG, 14.6% in CBT-A, and 11.6% in CBT-B. According to the Clinical Global Impression Rating, 65.6% of patients were still at least moderately ill at the end of the CC period, while this rate was 33.4% at the end of CBT-A, or 15.7% at the end of CBT-B. All these differences between treatment and control group are statistically highly significant. The clinical improvement remained stable over a follow-up period of 8 months. CONCLUSIONS: CBT is an effective method of treatment for GAD. Differences between control and treatment group are comparable to or larger than those reported in studies on antidepressant drugs.     

Cognitive Behavior Therapies for Psychotic Disorders: Current Empirical Status and Future Directions

Although cognitive behavior therapy (CBT) has strong empirical support for treating a diverse array of psychological conditions, only recently has research begun to examine its efficacy in treating the symptoms associated with schizophrenia and other psychotic disorders. Several randomized controlled trials have been conducted on CBT for psychosis with some positive results, but trials comparing CBT to other nonspecific interventions have yielded less impressive findings. No well-controlled trial to date has attempted to dismantle the components of CBT for psychosis, to compare it to another empirically supported psychosocial intervention for this population, or to identify the specific mechanisms responsible for treatment effectiveness. In this paper, a review of the empirical status of CBT for psychosis is presented. In addition, promising but preliminary new research in this area is reviewed, including prevention and early intervention approaches and acceptance/mindfulness-based strategies. Within this context, limitations in the current literature are reviewed, and recommendations for future research are discussed.     

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind–body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind–body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.     

Group cognitive therapy for chronic pain

Group therapy for chronic pain management, particularly that using cognitive-behavioral treatment (CBT), has become a common treatment format. This article provides a rationale and framework for group CBT, including the research evidence and clinical considerations related to the practitioner and patient. We then present an example of group therapy focusing on the cognitive components of CBT for chronic pain. Examples from group therapy are used in order to illustrate the principles of optimizing the group approach in the context of cognitive therapy.     

Do we need to challenge thoughts in cognitive behavior therapy?

Cognitive behavior therapy (CBT) emphasizes the primacy of cognition in mediating psychological disorder. It aims to alleviate distress by modifying cognitive content and process, realigning thinking with reality. Recently, various authors have questioned the need for CBT therapists to use logico-rational strategies to directly challenge maladaptive thoughts. Hayes [Hayes, S.C. (2004). Acceptance and commitment therapy and the new behavior therapies. In S.C. Hayes, V.M. Follette, & M.M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive behavioral tradition. (pp. 1-29). New York: Guilford] has identified three empirical anomalies in the research literature. Firstly, treatment component analyzes have failed to show that cognitive interventions provide significant added value to the therapy. Secondly, CBT treatments have been associated with a rapid symptomatic improvement prior to the introduction of specific cognitive interventions. Thirdly, there is a paucity of data that changes in cognitive mediators instigate symptomatic change. This paper critically reviews the empirical literature that addresses these significant challenges to CBT. A comprehensive review of component studies finds little evidence that specific cognitive interventions significantly increase the effectiveness of the therapy. Although evidence for the early rapid response phenomenon is lacking, there is little empirical support for the role of cognitive change as causal in the symptomatic improvements achieved in CBT. These findings are discussed with reference to the key question: Do we need to challenge thoughts in CBT?     

Psychotherapy of bipolar disorder: a review

Background: Bipolar disorder is often only partially treated by medication alone, which has led to recent developments in the adjunctive psychological treatment of bipolar disorder. This paper aims to examine the current evidence for effectiveness of psychological interventions for bipolar disorder and to identify issues for future research in this area. Method: A review of outcome studies of psychological interventions reported since 1990, including psychoeducation, cognitive-behavioural, interpersonal and social rhythm and psychoanalytic therapy. Results: The research to date indicates that a range of psychological approaches appear to benefit people with bipolar disorder. The clearest evidence is for individual CBT which impacts on symptoms, social functioning and risk of relapse. Limitations: Many studies lack appropriate control groups and standardised measures of symptoms and diagnosis. Better designed studies would reduce the risk of over-estimates of effect sizes and subsequent failure to replicate. Further developments of psychotherapy need to be based on clear theoretical models of bipolar disorder. Conclusions: Many current studies are uncontrolled and of poor quality leading to a risk of over-estimating effectiveness of some interventions. Suggestions are made for future research including improving quality of studies, basing treatment developments on clear theoretical models and identifying specific treatment components for particular phases of the bipolar illness course.     

Group cognitive-behavioral therapy for generalized anxiety disorder: treatment outcome and long-term follow-up

A recently developed cognitive-behavioral treatment for generalized anxiety disorder (GAD) targets intolerance of uncertainty by the reevaluation of positive beliefs about worry, problem-solving training, and cognitive exposure. As previous studies have established the treatment's efficacy when delivered individually, the present study tests the treatment in a group format as a way to enhance its cost-benefit ratio. A total of 52 GAD patients received 14 sessions of cognitive-behavioral therapy in small groups of 4 to 6 participants. A wait-list control design was used, and standardized clinician ratings and self-report questionnaires assessed GAD symptoms, intolerance of uncertainty, anxiety, depression, and social adjustment. Results show that the treatment group, relative to the wait-list group, had greater posttest improvement on all dependent variables and that treated participants made further gains over the 2-year follow-up phase of the study.     

Internet-Based Psychodynamic versus Cognitive Behavioral Guided Self-Help for Generalized Anxiety Disorder: A Randomized Controlled Trial

Background: Guided Internet-based cognitive behavior therapy (ICBT) has been tested in many trials and found to be effective in the treatment of anxiety and mood disorders. Generalized anxiety disorder (GAD) has also been treated with ICBT, but there are no controlled trials on guided Internet-based psychodynamic treatment (IPDT). Since there is preliminary support for psychodynamic treatment for GAD, we decided to test if a psychodynamically informed self-help treatment could be delivered via the Internet. The aim of the study was to investigate the efficacy of IPDT for GAD and to compare against ICBT and a waiting list control group. Method: A randomized controlled superiority trial with individuals diagnosed with GAD comparing guided ICBT (n = 27) and IPDT (n = 27) against a no treatment waiting list control group (n = 27). The primary outcome measure was the Penn State Worry Questionnaire. Results: While there were no significant between-group differences immediately after treatment on the main outcome measure, both IPDT and ICBT resulted in improvements with moderate to large within-group effect sizes at 3 and 18 months follow-up on the primary measure in the completer analyses. The differences against the control group, although smaller, were still significant for both PDT and CBT when conforming to the criteria of clinically significant improvement. The active treatments did not differ significantly. There was a significant group by time interaction regarding GAD symptoms, but not immediately after treatment. Conclusions: IPDT and ICBT both led to modest symptom reduction in GAD, and more research is needed.     

Benzodiazepine discontinuation among adults with GAD: A randomized trial of cognitive-behavioral therapy

This study evaluated the specific effectiveness of cognitive-behavior therapy (CBT) combined with medication tapering for benzodiazepine discontinuation among generalized anxiety disorder (GAD) patients by using a nonspecific therapy control group. Sixty-one patients who had used benzodiazepines for more than 12 months were randomly assigned to the experimental conditions. Nearly 75% of patients in the CBT condition completely ceased benzodiazepine intake, as compared with 37% in the control condition. Results of the 3-, 6-, and 12-month follow-ups confirmed the maintenance of complete cessation. Discontinuation rates remained twice as high in the CBT condition. The number of patients who no longer met GAD criteria was also greater in the CBT condition. The addition of specific CBT components thus seemed to facilitate benzodiazepine tapering among patients with GAD.     

A randomized trial of a group based cognitive behavior therapy program for older adults with epilepsy: the impact on seizure frequency,depression and psychosocial well-being

Few studies have examined the effectiveness of cognitive behavior therapy to manage seizures and improve psychosocial functioning in older adults with epilepsy. This study evaluated the efficacy of a 6 week group CBT program in community dwelling adults with epilepsy who were aged over 60 years. A total of 37 participants were randomly assigned to either a CBT group or a control group. Measures of depression, dysthymia, psychosocial functioning and seizure frequency were completed at pre and post intervention. Seizure frequency was significantly reduced in the CBT group compared to the control group (Cohen’s d 0.63). The results suggest that the relationship between seizure frequency and psychological and psychosocial well being in older adults requires further investigation. Although there were no significant between group differences on measures of depression and psychosocial functioning, both the CBT and control groups improved significantly from baseline.