Behavioral disturbances in dementia

Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. A large number of standardized, reliable, and well-validated instruments for assessing the behavioral and psychological symptoms of dementia have been developed in order to evaluate the efficacy of treatment. Neurodegenerative processes in various brain areas, particularly in the frontotemporal cortex and limbic regions, leading to cholinergic, serotonergic, and noradrenergic neurotransmitter dysfunctions constitute the biological matrix of behavioral symptoms, whereas psychological factors and personality traits play a modifying role. A large number of pharmacological, psychoeducational, psychotherapeutic, and social strategies have been developed to improve the quality of life of patients and their caregivers.     

Non-pharmacological and pharmacological treatment of the cognitive and behavioral symptoms of Alzheimer disease

This paper discusses the various pharmacological and behavioral treatments for the cognitive, emotional, and behavioral symptoms of Alzheimer disease (AD). The medications that are currently FDA-approved for the treatment of the cognitive/functional deficits of AD will first be discussed. Next, neuropsychiatric behavioral disturbances, including hallucinations and delusions, agitation and aggression, activity disturbances, depression, and anxiety will be described along with treatment interventions. Sleep disturbance and its treatment in AD and the issue of fitness to drive a motor vehicle are also reviewed. Principles of behavioral management, tips for communication, and recommendations for caregivers are discussed. Lastly, risk and protective factors and their relevance to delaying the expression of dementia are also examined.     

A palmtop computer program for the treatment of generalized anxiety disorder.

This is the first report of a palmtop computer program developed to increase the efficiency and cost-effectiveness of cognitive behavioral therapy for generalized anxiety disorder (GAD). The computer program offers advantages to researchers, therapists, and clients. These advantages include continuous, unobtrusive collection of process data on treatment adherence as well as on the impact of cognitive behavioral therapy techniques in the client's natural setting. In addition, the computer extends treatment beyond the therapy hour and motivates clients to comply with homework assignments by prompting practice of cognitive behavioral strategies. The successful application of the palmtop computer program reported in this integrated series suggests a new line of research directed toward increasing the cost-effectiveness of what is currently the gold-standard treatment for GAD.     

Optimal Treatment of Depression and Anxiety in Parkinson's Disease

Depression and anxiety are highly prevalent and have major adverse effects on function and quality of life in Parkinson's disease (PD). Optimal management requires that motor symptoms and psychiatric symptoms be simultaneously addressed. While there is fairly robust evidence for the treatment of motor symptoms, there are no completed randomized controlled trials to guide pharmacological treatment of anxiety in PD and no nonpharmacologic interventions have proven efficacious. Several high-quality trials for depression in PD suggest a number of antidepressants and cognitive behavioral therapy may help, but there is no data on rates of recurrence, comparative efficacy, or augmentation strategies. In order to address the gaps in knowledge, the authors provide a summary of the current evidence for treating depression and anxiety in PD and offer an algorithm that extends beyond the current literature based on clinical experience working in a multidisciplinary specialty center.     

Predictors of outcome in a cognitive-behavioral group program for children and adolescents with social anxiety disorder

The present study examined predictors of treatment outcome among children and adolescents with social anxiety disorder (SAD). Seventy-five participants (8-13 years) participated in a 12-session cognitive behavioral group treatment (CBT). Potential predictors were the pre-treatment severity of anxious symptoms assessed from both the child's and parent's perspective as well as depressive symptoms (child report only) and general emotional distress in parent (parent self-report). Furthermore, the relationship between treatment outcome and child's self-reported pre-post changes in self-consciousness and maladaptive anxiety regulation was investigated. Pre-treatment level of social anxiety reported by the child was a significant predictor for outcome, i.e. children with higher levels of social anxiety at pretreatment reported a greater reduction in social anxiety at post-treatment. Reduction in self-consciousness and maladaptive anxiety regulation both predicted reduction in social anxiety, although not independently. The results suggest that tailoring intervention to include strategies for emotion regulation of anxiety may improve treatment outcome.     

Differentiating cognitive impairment from symptoms of anxiety in postcoronary artery bypass grafting encephalopathy: a case report

Post-coronary artery bypass grafting encephalopathy (CABGE) is associated with cognitive decline in a significant number of post-cardiac surgery cases. Patients may experience this condition as a result of being maintained on a heart-lung machine, which is referred to as the “pump”. The pump is used to circulate oxygenated blood during heart or valve surgery and may contribute to complication with oxygen flow to the brain. In some cases, the emotional traumatic effects of CABGE may produce symptoms of anxiety that can often mimic the cognitive decline associated with cardiac bypass and use of the pump. When this is the case, cognitive–behavioral assessment may be useful in helping patients to differentiate symptoms generated by anxiety from those produced by the effects of the pump. A discussion section addresses further implications of such overlapping symptoms and therapeutic strategies for treatment and remediation, along with the potential adverse effects that may occur through psychotherapy.     

A systematic review of the behavioral effects of levetiracetam in adults with epilepsy,cognitive disorders,or an anxiety disorder during clinical trials

This report reviews behavioral adverse events occurring among adults receiving levetiracetam (LEV) or placebo who participated in short-term, placebo-controlled studies in epilepsy (1023), cognitive disorders (719), or anxiety disorders (1510) and epilepsy patients (1393) observed in long-term trials. Behavioral events (affective, psychotic, and suicidal symptoms) were significantly more common among epilepsy patients than cognition or anxiety patients treated with LEV for similar durations (P=0.022). Affective symptoms occurring at 1% or more often in epilepsy placebo-controlled trials included depression (3.8% LEV-2.1% placebo), nervousness (3.8%-1.8%), hostility (2.3%-0.9%), anxiety (1.8%-1.1%), and emotional lability (1.7%-0.2%). Patients with cognitive and anxiety disorders had lower incidences of these symptoms. The incidence of behavioral events in LEV-treated epilepsy patients was lower than rates reported for some other antiepileptic drugs. These data support the hypothesis that some feature related to epilepsy is the cause of many behavioral events rather than the addition of a specific antiepileptic drug.     

Role of Cholinesterase Inhibitors in Managing Behavioral Problems in Alzheimer's Disease

Alzheimer's disease is characterized by progressive cognitive and functional decline and the emergence of behavioral disturbances. Behavioral symptoms, in particular, cause great distress to caregivers, creating an emotional and financial burden that often prompts the caregiver to place the patient in a nursing facility. The clinical deterioration in Alzheimer's disease is, in part, a result of deficits involving several neurochemical pathways. The cholinergic system, which is the most consistently and dramatically affected neurotransmitter system in Alzheimer's disease, has been strongly implicated in the emergence of neuropsychiatric symptoms. This article reviews evidence suggesting that, in addition to effects on cognition and function, the cholinesterase inhibitors benefit the behavioral symptoms of Alzheimer's disease. Pharmacologic and nonpharmacologic treatment strategies for the management of behavioral symptoms are discussed.     

Treatment-resistant anxiety disorders

Several epidemiological studies confirmed that Anxiety Disorders as a group are the most prevalent psychiatric conditions in the United States. The importance of these conditions is underlined by the fact that they cause significant disability, poor quality of life, alcohol and drug abuse. Anxiety disorders are treatable conditions and respond to the front-line interventions such as serotonin reuptake inhibitors and cognitive behavioral therapy. However, only about 60% of patients respond to those treatments to any significant degree. Many still have residual symptoms or stay treatment refractory. The group of anxiety patients that is resistant to the treatment has been shown to have very poor quality of life and have highest rate of suicidal attempts than any other disorders. Many biological, treatment specific and social factors are affecting treatment resistance. In this paper, we are attempting to review reasons for the treatment resistance. In addition, we would like to review current strategies that could be helpful in reducing treatment resistance and aiding people chronically suffering from these severe and disabling conditions.     

Symptomatic and syndromal anxiety and depression.

The diagnosis of anxiety disorders and major depression can be reliably made based on signs and symptoms. However there are significant limitations to the current system of classification including overlapping criteria, high comorbidity, and the issue of subthreshold syndromes. The literature on treatment response documents that selective serotonin reuptake inhibitors are effective in the treatment of the various anxiety disorders, including when comorbid major depression is present. The literature also suggests that tricyclic antidepressant medications have superior benefits over selective serotonin reuptake inhibitors in major depression. Examination of the functional anatomy of the fear and reward systems may shed light on the underlying processes in the anxiety and depressive disorders. Such an approach points out the importance of addressing avoidance behaviors, which may be more responsive to cognitive behavioral treatments than pharmacological agents.     

Treatment Refractory Schizophrenia

Treatment resistance constitutes a significant dilemma in schizophrenia since it affects a substantial number of patients, their families and the health care professionals involved in their care. Nonresponsiveness needs to be approached as a multidimensional syndrome by specifying which symptoms in the spectrum of positive symptoms, negative symptoms, excitement/hostility, cognitive symptoms, and anxiety/depression are failing to respond to treatment. This review presents some of the clinical, demographic and biological correlates of nonresponse, in addition to compliance issues, psychosocial factors or side effects and as-yet-untreated comorbidities as a source for nonresponse. The effects of the atypicals clozapine, olanzapine, risperidone and quetiapine as compared to typicals are reviewed using available double-blind studies in this treatment refractory group of schizophrenia patients. The limited number of reports on the comparison of atypical compounds amongst each other are critically presented. Given that a subset of patients still do not respond to these agents, clinicians are using various augmentation strategies. We review studies with augmentation strategies which remain difficult to interpret given the open label and uncontrolled nature of most of these studies.     

Treatment of acute posttraumatic stress disorder with brief cognitive behavioral therapy: a randomized controlled trial

OBJECTIVE: The purpose of this study was to evaluate the efficacy of brief cognitive behavioral therapy for patients with acute posttraumatic stress disorder (PTSD) resulting from various types of psychological trauma. METHOD: The authors randomly assigned 143 patients with acute PTSD (irrespective of the time criterion), within 3 months after experiencing a traumatic incident, to either brief cognitive behavioral therapy (N=79) or a waiting list comparison group (N=64). Cognitive behavioral therapy consisted of four weekly sessions containing education, relaxation exercises, imaginal exposure, in vivo exposure, and cognitive restructuring. Main outcome measure was PTSD score measured by structured interview; secondary outcomes were anxiety and depression measured by questionnaire. Assessments took place before the intervention and 1 week and 4 months after the intervention. RESULTS: Symptoms of PTSD, anxiety, and depression decreased in both groups over time. One week after the intervention, the cognitive behavioral therapy group had significantly fewer symptoms of PTSD than the comparison group, but this difference was smaller and no longer significant 4 months after the intervention. Similar results were found for anxiety and depression scores. Subgroup analyses showed that cognitive behavioral therapy led to significantly lower PTSD scores at 4 months in patients with baseline comorbid major depression and in patients who were included within the first month after the traumatic incident both at 1 week and at 4 months. CONCLUSIONS: Brief early cognitive behavioral therapy accelerated recovery from symptoms of acute PTSD but did not influence long-term results. Brief early cognitive behavioral therapy showed enhanced efficacy in patients with baseline comorbid depression and patients who were included within 1 month after their traumatic experience.     

A comparison study of antidepressants and structured intensive group psychotherapy in the treatment of bulimia nervosa

Previous research on the treatment of outpatients with bulimia nervosa has focused on two treatment strategies: (1) drug therapy, primarily using tricyclic antidepressants, and (2) psychotherapy, often employing behavioral and cognitive behavioral techniques. We report here the short-term treatment outcome of a 12-week comparison trial of bulimic outpatients who were randomly assigned to one of four treatment cells: (1) imipramine hydrochloride treatment, (2) placebo treatment, (3) imipramine treatment combined with intensive group psychotherapy, and (4) placebo treatment combined with intensive group psychotherapy. All three active treatment cells resulted in significant reductions in target-eating behaviors and in a significant improvement in mood relative to placebo treatment. However, the results also suggested that the amount of improvement obtained with the intensive group psychotherapy component was superior to that obtained with antidepressant treatment alone. The addition of antidepressant treatment to the intensive group psychotherapy component did not significantly improve outcome over intensive group psychotherapy combined with placebo treatment in terms of eating behavior, but did result in more improvement in the symptoms of depression and anxiety.     

Cognitive-behavioral treatment of persistent functional somatic complaints and pediatric anxiety: an initial controlled trial

Background: Children and adolescents who seek medical treatment for persistent physical distress often suffer from co‐occurring anxiety disorders. Treatment options for this impaired population are limited. This study tests the feasibility and potential efficacy of a cognitive‐behavioral intervention targeting pain and anxiety for youth with impairing functional physical symptoms and anxiety disorders presenting to pediatricians for medical care. Methods: Children and adolescents (aged 8–16) experiencing somatic complaints, without an explanatory medical disorder (i.e., functional), were recruited from primary care and specialty (gastroenterologists and cardiologists) pediatricians. Forty children, primarily with gastrointestinal symptoms, who met criteria for a co‐occurring anxiety disorder, were randomly assigned to a cognitive‐behavioral treatment addressing pain and anxiety, Treatment of Anxiety and Physical Symptoms (TAPS), or to a waiting list control. Results: TAPS was found to be an acceptable treatment for this population and was superior to the waiting list condition. Eighty percent of children in TAPS were rated as treatment responders by independent evaluators compared with none of the controls. Overall, self‐ and parent ratings indicated reductions in children's somatic discomfort and anxiety following intervention. TAPS participants maintained clinical gains 3 months following treatment. Conclusions: The study supports the feasibility and preliminary efficacy of a cognitive‐behavioral intervention targeting co‐occurring physical distress and anxiety in youth presenting for medical treatment. Such an approach has the potential to exert broad impact on children's dysfunction and to minimize exposure to invasive, ineffective, and costly medical procedures and treatments. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Tailoring Cognitive-Behavioral Therapy to Treat Anxiety Comorbid with Advanced Cancer

Patients with advanced cancer often experience debilitating anxiety symptoms that interfere with quality of life and relate to worse medical outcomes. Although cognitive behavioral therapy (CBT) is an empirically-validated, first-line treatment for anxiety disorders, clinical trials of CBT for anxiety typically exclude patients with medical comorbidities in general, and those with terminal illnesses, such as advanced cancer, in particular. Moreover, CBT has generally targeted unrealistic fears and worries in otherwise healthy individuals with clinically significant anxiety symptoms. Consequently, traditional CBT does not sufficiently address the cognitive components of anxiety in patients with cancer, especially negative thought patterns that are rational but nonetheless intrusive and distressing, such as concerns about pain, disability and death, as well as management of multiple stressors, changes in functional status and burdensome medical treatments. In this paper, we describe a treatment approach for tailoring CBT to the needs of this population. Three case examples of patients diagnosed with terminal lung cancer are presented to demonstrate the treatment methods along with outcome measures for anxiety and quality of life.     

Pathways to change in one-session exposure with and without cognitive intervention: an exploratory study in spider phobia

It is well established that exposure therapy is an effective treatment for anxiety disorders. It is less clear, however, which mechanisms are crucial in explaining its success. In previous studies, cognitive change has been identified as a mediating variable. Several theorists have argued that the addition of cognitive interventions will, therefore, result in enhanced treatment effects. We tested this hypothesis by examining cognitive mediation of treatment in a purely behavioral versus a cognitive–behavioral exposure format. Thirty-one spider phobics were randomly assigned to either behavioral exposure or to exposure as a test for maladaptive cognitions (i.e., behavioral experiments). Both treatment formats showed large treatment effects and strong cognitive mediation of these effects. This indicates that, even when cognitions are not explicitly targeted, exposure effects are cognitively mediated. This challenges the idea that cognitions have to be explicitly challenged to elicit cognitive change in exposure treatment.     

A clinical review of cognitive therapy for schizophrenia

Major advances have been made in the cognitive understanding and treatment of the symptoms of schizophrenia, including delusions, hallucinations, and emotional withdrawal. Experimental studies on the psychologic aspects of schizophrenia demonstrate the importance of information processing biases, such as cognitive biases and distortions, that are functionally related to the maintenance of symptoms. Understanding the aspects of schizophrenia in cognitive terms provides a framework for psychotherapeutic intervention with the adaptation of the cognitive strategies proven effective in the treatment of mood and anxiety disorders. The authors of this paper first outline the cognitive conceptualization and strategies employed by cognitive therapists to treat positive and negative symptoms, and conclude with a summary of the empiric status of cognitive therapy for schizophrenia. Cognitive therapy has been shown to be an important adjunct to standard treatments of schizophrenia.     

Sudden gains during cognitive–behavioral group therapy for anxiety disorders

Sudden gains in psychotherapy are characterized by large and relatively stable decreases in psychiatric symptoms and have been associated with cognitive shifts in clients and shown to predict superior treatment outcomes in studies of depression and, to a lesser extent, anxiety disorders. The purpose of this study was to examine prevalence and impact of sudden gains during a transdiagnostic cognitive–behavioral group therapy (CBGT) for anxiety disorders, as well as the temporal relationship between sudden gains and cognitive changes. Data were used from two trials of transdiagnostic CBGT for anxiety disorders (n = 130). Criteria for determining sudden gains in anxiety symptoms were based upon previous research on sudden gains from trials of cognitive–behavioral treatments for major depressive disorder. A total of 17 out of 98 (17.3%) clients experienced at least one sudden gain, with three clients showing two sudden gains during treatment. Three patients showing a sudden gain experienced a reversal of these gains, although one of these three had a subsequent second sudden gain. Clients experiencing sudden gains showed greater overall improvement following treatment than did clients who did not experience a sudden gain, with 65% of the sudden gainers’ overall improvement accounted for by the sudden gain. Greater cognitive change in the pregain sessions was observed for clients with a sudden gain than those not showing a sudden gain. This finding lends support to the theory of cognitive mediation through CBGT in which substantial cognitive changes in pregain sessions lead to greater improvement overall.     

Predictors of Treatment Effectiveness for Youth with ASD and Comorbid Anxiety Disorders: It all Depends on the Family?

The study aimed to explore predictors of treatment effectiveness in a sample of 79 children with ASD who received cognitive behavioral therapy (CBT) for their anxiety disorders. Severity of anxiety disorders and anxiety symptoms were used to measure treatment effectiveness and was assessed pre-treatment, post-treatment, 3 months-, 1 and 2 years after CBT. Child characteristics and maternal anxiety did not predict treatment effect. Children with anxious fathers and children in ‘un-involved’ families had less anxiety symptoms at pre-treatment and displayed a less steep decline. Children from ‘authoritarian’ families showed higher pre-treatment anxiety levels but responded quite well to treatment. Findings stress the importance of parent (father) and family factors in the treatment of anxiety disorders in youth with ASD.