A randomized controlled trial of guided internet-delivered cognitive behaviour therapy for older adults with generalized anxiety

This study aimed to establish the efficacy of guided Internet-delivered cognitive-behaviour therapy (ICBT) for older adults with generalized anxiety disorder (GAD) or subclinical GAD. Participants were randomized to receive seven modules of ICBT (n = 24) or to a waiting list condition (WLC; n = 22). Faster improvements in symptoms of anxiety and depression were observed for participants in the ICBT condition relative to the WLC, with large between-group effect sizes on the Generalized anxiety disorder-7 (d = .85) and the Patient health questionnaire (d = 1.17) obtained at post-treatment. Further reduction in generalized anxiety symptoms was reported over the one-month follow-up. Treatment effects were replicated when control participants subsequently underwent treatment. Higher ratings of treatment credibility, but not expectancy, prior to ICBT predicted improvements over time. The results support the efficacy of ICBT as treatment for older adults with GAD.     

Worry and rumination enhance a positive emotional contrast based on the framework of the Contrast Avoidance Model

The Contrast Avoidance Model (CAM) suggests that worry increases negative affect and decreases positive affect. CAM also suggests that in response to a positive event, higher worry enhances the probability of experiencing greater decreased negative affect and increased positive affect (positive emotional contrasts; PECs). Consequently, worrying may be reinforced by repeated PECs. However, no study has tested whether rumination enhances PECs. Also, emotional specificity in these processes has not been considered. Therefore, we tested whether both rumination and worry enhanced PECs related to specific emotions. After resting baseline, participants with pure generalized anxiety disorder (GAD group, n = 91), pure depression symptoms (depression group, n = 91), and non-GAD and non-depressed healthy controls (HCs, n = 93) engaged with randomly assigned induction tasks (either worry, rumination, or relaxation), and then watched an amusement video. Regardless of group, both worry and rumination increased sadness and fear and decreased amusement more than relaxation from baseline. However, worry increased fear more than rumination, and rumination increased sadness more than worry. Although all inductions led to PECs during the video, worry enhanced fear PECs more than rumination, and rumination enhanced sadness PECs more than worry. The GAD group who worried experienced the most salient PECs of amusement relative to other groups.     

Long-Term Effects of Cognitive-Behavioral Therapy and Yoga for Worried Older Adults

ObjectivesCognitive-behavioral therapy (CBT) and yoga decrease worry and anxiety. There are no long-term data comparing CBT and yoga for worry, anxiety, and sleep in older adults. The impact of preference and selection on these outcomes is unknown. In this secondary data analysis, we compared long-term effects of CBT by telephone and yoga on worry, anxiety, sleep, depressive symptoms, fatigue, physical function, social participation, and pain; and examined preference and selection effects.DesignIn this randomized preference trial, participants (N = 500) were randomized to a: 1) randomized controlled trial (RCT) of CBT or yoga (n = 250); or 2) preference trial (selected CBT or yoga; n = 250). Outcomes were measured at baseline and Week 37.SettingCommunity.ParticipantsCommunity-dwelling older adults (age 60+ years).InterventionsCBT (by telephone) and yoga (in-person group classes).MeasurementsPenn State Worry Questionnaire - Abbreviated (worry);^1,2 Insomnia Severity Index (sleep);³ PROMIS Anxiety Short Form v1.0 (anxiety);^4,5 Generalized Anxiety Disorder Screener (generalized anxiety);^6,7 and PROMIS-29 (depression, fatigue, physical function, social participation, pain).^8,9ResultsSix months after intervention completion, CBT and yoga RCT participants reported sustained improvements from baseline in worry, anxiety, sleep, depressive symptoms, fatigue, and social participation (no significant between-group differences). Using data combined from the randomized and preference trials, there were no significant preference or selection effects. Long-term intervention effects were observed at clinically meaningful levels for most of the study outcomes.ConclusionsCBT and yoga both demonstrated maintained improvements from baseline on multiple outcomes six months after intervention completion in a large sample of older adults.Trial Registrationwww.clinicaltrials.gov Identifier NCT 02968238.     

Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: A randomized controlled trial with a three-year follow-up

BackgroundInternet-delivered treatment may reduce barriers to care in those unwilling or unable to access traditional forms of treatment.ObjectiveTo assesses the efficacy of web-based therapist-assisted cognitive behavioral treatment (web-CBT) of panic symptoms.DesignA randomized waiting-list controlled trial with an uncontrolled three-year follow-up.ParticipantsA community sample of 58 participants with chronic panic symptoms of varying severity (immediate treatment: n = 27, waiting-list control: n = 31).Outcome measuresThe primary outcome measures were a one-week Panic Diary and the Panic Disorder Severity Scale – Self-Report (PDSS-SR); secondary measures were the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ), the Mobility Inventory – Alone subscale (MI-AAL), and the Depression Anxiety Stress Scales (DASS-42).ResultsIn the RCT, 54 participants (93%) completed posttest measurements. With regard to the primary outcome measures, intention-to-treat ANCOVAs revealed that participants in the treatment condition improved more than the participants in the waiting-list control condition (p < .03), with a pooled between-group effect size of d = .7. After three years (n = 47; 81% study compliance), effects were more pronounced.ConclusionThe results demonstrate the efficacy of therapist-assisted web-CBT in the treatment of panic symptoms.     

Effect of Tai Ji Quan training on self-reported sleep quality in elderly Chinese women with knee osteoarthritis: a randomized controlled trail

ObjectiveThe purpose of this study was to explore the effects of a 24-week Tai Ji Quan training program on sleep quality, quality of life, and physical performance among elderly Chinese women with knee osteoarthritis (OA).MethodsA 24-week randomized, controlled trial of 46 elderly women with knee OA. Participants were randomly assigned to either a Tai Ji Quan group (n = 23) or a control group (n = 23). Participants in the Tai Ji Quan group completed training sessions three times per week, while those in the control group had bi-weekly educational classes. The primary outcome was total score of the Pittsburgh Sleep Quality of Index (PSQI). Secondary outcomes were: seven subscales of the PSQI; sleep latency; total sleep time; sleep efficiency; physical component summary (PCS) and mental component summary (MCS) of the 36-item Short Form Health Survey (SF-36); Berg Balance Scale (BBS); and Timed Up and Go (TUG).ResultsCompared with the control group, participants in the Tai Ji Quan group had significantly improved primary outcome (global PSQI score, p = 0.006) and secondary outcomes, including three PSQI sub-scores (sleep latency, p = 0.031; sleep duration, p = 0.043; daytime dysfunction, p = 0.007), total sleep time (p = 0.033), and SF-36 PCS (p = 0.006). The Tai Ji Quan group also had significant improvements compared with baseline in three PSQI sub-scores (sleep latency, p = 0.031; habitual sleep efficiency, p = 0.049; sleep disturbance, p = 0.016), sleep latency (p = 0.003), BBS (p = 0.001), and TUG (p = 0.006).ConclusionTai Ji Quan training is an effective treatment approach to improve sleep quality and quality of life in elderly Chinese women with knee OA.Trial registration: Chinese Clinical Trial Registry (June 16, 2013): ChiCTR-TRC-13003264.     

Do religious patients need religious psychotherapists? A naturalistic treatment matching study among orthodox Jews

Religion is professed by the majority of the general population, but a minority of mental health practitioners. We evaluated whether religious patients benefited more from treatment with religious psychotherapists in a naturalistic study among adult Orthodox Jewish (n = 117) and control patients (n = 91) receiving psychotherapy from Orthodox Jewish (n = 15) and other (n = 7) psychotherapists at a New York based outpatient clinic. Groups did not differ with respect to diagnoses (χ²(200) = 7.5, p = .76), likelihood of having an Orthodox Jewish therapist (χ²(200) = .06, p = .81), or number of therapy sessions (t(206) = .73, p = .47). Multilevel regression modeling revealed that Orthodox patients reported lower initial anxiety (t(198) = 3.71, p < .001, d = .54) and depression (t(198) = 3.71, p < .001, d = .54, d = .50), but were equivalent to controls at termination (Anxiety t(189) = .36, p = .72; Depression t(182) = 1.00, p = .32). Interactions between patient and therapist religious affiliations were not significant. These results suggest that religious (and non-religious) patients may benefit equally from treatment delivered by religious and non-religious therapists.     

A Prospective,Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild-to-Moderate Traumatic Brain Injury

ObjectivesTranslingual neurostimulation (TLNS) studies indicate improved outcomes in neurodegenerative disease or spinal cord injury patients. This study was designed to assess the safety and efficacy of TLNS plus targeted physical therapy (PT) in people with a chronic balance deficit after mild-to-moderate traumatic brain injury (mmTBI).Materials and MethodsThis international, multicenter, randomized study enrolled 122 participants with a chronic balance deficit who had undergone PT following an mmTBI and had plateaued in recovery. Randomized participants received PT plus either high-frequency pulse (HFP; n = 59) or low-frequency pulse (LFP; n = 63) TLNS. The primary efficacy and safety endpoints were the proportion of sensory organization test (SOT) responders (SOT composite score improvement of ≥15 points) and fall frequency after five weeks of treatment, respectively.ResultsThe proportion of SOT responders was significant in the HFP + PT (71.2%) and LFP + PT (63.5%) groups compared with baseline (p < 0.0005). For the pooled population, the SOT responder rate was 67.2% (p < 0.00005), and there were clinically and statistically significant improvements in SOT composite scores after two and five weeks (p < 0.0005). Both groups had reductions in falls and headache disability index scores. Mean dynamic gait index scores in both groups also significantly increased from baseline at weeks 2 and 5.ConclusionsSignificant improvements in balance and gait, in addition to headaches, sleep quality, and fall frequency, were observed with TLNS plus targeted PT; in participants who had a chronic balance deficit following an mmTBI and had plateaued on prior conventional physiotherapy.     

Lay persons' beliefs and knowledge about Parkinson's disease: Prevalence and socio-demographic correlates

BackgroundAlthough studies have shown that lay persons' beliefs and knowledge about a disease are associated with increased adherence to health behaviors, there is a dearth of knowledge in this area regarding Parkinson's disease (PD).ObjectivesTo assess the prevalence and socio-demographic correlates of lay persons' beliefs and knowledge about PD.MethodsA phone survey was conducted with a representative sample of 632 lay persons (mean age = 45) in Israel. Information regarding participants' perceptions about their susceptibility, worry, fear and knowledge about PD was assessed together with their socio-demographic characteristics.ResultsLay persons perceived their risk to develop PD to be minimal. They also reported low levels of worry, fear and knowledge. Female participants and those with lower education reported higher levels of worry and fear while religious participants reported consistently lower levels of worry, fear and knowledge.ConclusionsThese data suggest the need to expand this line of research and to encourage the development of programs aimed at disseminating knowledge about PD.     

Interprofessional education increases knowledge,promotes team building,and changes practice in the care of Parkinson's disease

ObjectiveExamine outcomes for the National Parkinson Foundation (NPF) Allied Team Training for Parkinson (ATTP), an interprofessional education (IPE) program in Parkinson's disease (PD) and team-based care for medicine, nursing, occupational, physical and music therapies, physician assistant, social work and speech-language pathology disciplines.BackgroundHealthcare professionals need education in evidence-based PD practices and working effectively in teams. Few evidence-based models of IPE in PD exist.MethodsKnowledge about PD, team-based care, the role of other disciplines and attitudes towards healthcare teams were measured before and after a protocol-driven training program. Knowledge, attitudes and practice changes were again measured at 6-month post-training. Trainee results were compared to results of controls.ResultsTwenty-six NPF–ATTP trainings were held across the U.S. (2003–2013). Compared to control participants (n = 100), trainees (n = 1468) showed statistically significant posttest improvement in all major outcomes, including self-perceived (p < 0.001) and objective knowledge (p < 0.001), Understanding Role of Other Disciplines (p < 0.001), Attitudes Toward Health Care Teams Scale (p < 0.001), and the Attitudes Toward Value of Teams (p < 0.001) subscale. Despite some decline, significant improvements were largely sustained at six-month post-training. Qualitative analyses confirmed post-training practice changes.ConclusionsThe NPF–ATTP model IPE program showed sustained positive gains in knowledge of PD, team strategies and role of other disciplines, team attitudes, and important practice improvements. Further research should examine longer-term outcomes, objectively measure practice changes and mediators, and determine impact on patient outcomes.     

Understanding the perception of stakeholders in reducing adolescent-to-parent violence/aggression

IntroductionAdolescent-to-parent violence/aggression (APV/A) is an understudied yet increasingly common social problem for adolescents and families, particularly those involved in the juvenile justice system. The current study focused on improving interventions for this population by gathering qualitative data from stakeholders to inform treatment targets.MethodsParticipants (N = 23) comprised of court professionals (n = 7), parents/guardians (n = 9), and their male adolescent children (n = 7) in the United States. Parent and adolescent participants were recruited through monthly court-mandated domestic violence education classes offered by the juvenile court. Parent/guardian participants were between the ages of 38 and 77 and consisted of four males and five females. Adolescents were between the ages of 14 and 17. Court professional participants consisted of judges, probation officers, and court psychologists. Semi-structured interviews were analyzed qualitatively using grounded theory.ResultsResults indicated that, from the perspective of key stakeholders, an effective intervention to reduce APV/A likely involves a two-pronged approach: (1) address specific and theoretically modifiable emotional, behavioral, and psychological factors at the adolescent-level; and (2) induce change in the family system by addressing environmental barriers to seeking treatment and by creating positive family relationships.ConclusionsThe present study aimed to gather the perspectives of court professionals, adolescents, and parents/guardians regarding the development of an effective intervention for APV/A-involved families. This study represents the first step toward the development of a feasible, acceptable, sustainable, and effective intervention for adolescents and their families who are involved in the juvenile justice system due to APV/A.     

Differential responses of positive affect,negative affect,and worry in CBT for generalized anxiety disorder: A person-specific analysis of symptom course during therapy

Introduction: Research indicates that individuals with generalized anxiety disorder (GAD) may experience deficits in positive affect (PA), and tend to dampen or intentionally suppress PA. Despite the presence of PA-related pathology in GAD, little is known about change in PA during GAD treatment. Objective: This study examines changes in PA, negative affect (NA) and worry in seven participants during cognitive behavioral therapy (CBT) for GAD. Method: Intensive repeated measures (i.e., time series) data were subjected to person-specific regression analysis to delineate individual change trajectories. Results: Significant improvement in worry was observed in all but one participant. Fear and irritability - indices of NA - each improved in 5/7 participants while sadness improved in 4/7 participants (worsening in one). Of all symptom domains, PA had the poorest treatment response: PA improved in only 2/7 participants and actually significantly worsened in 5/7 individuals even as NA and worry improved during therapy. Conclusion: These findings indicate that treatment gains from traditional CBT for GAD may not generalize to improvements in PA regulation, or even emotional functioning more broadly. This evidence is a call to increase the focus on PA regulation in treatment for GAD; perhaps PA could be a missing piece in our understanding of ways to bolster GAD treatment outcomes.     

Subsyndromal psychosomatic concepts and personality traits in community adults

ObjectiveTo investigate the prevalence of features of the Diagnostic Criteria for Psychosomatic Research (DCPR) in the Taiwanese community and to explore their relationships with psychological states and personality traits.MethodThe participants were 153 individuals without a DSM-5 psychiatric diagnosis who were grouped according to whether they had a DCPR diagnosis (at least one DCPR diagnosis, DCPR(+): n = 66; no DCPR diagnosis, DCPR(−): n = 87). The groups were compared with respect to psychological states (measured with Patient Health Questionnaire-15 [PHQ-15], Health Anxiety Questionnaire [HAQ], Beck Depression Inventory-II [BDI-II], Beck Anxiety Inventory [BAI)]) and personality (measured with Tridimensional Personality Questionnaire). Multiple logistic and linear regressions were used to examine associations among demographic, personality, DCPR, and psychological states.ResultsThe DCPR(+) group had higher BDI-II, BAI, PHQ-15 and HAQ scores than the DCPR(−) group and also had a higher anticipatory worry. The most common DCPR diagnoses were health anxiety (42.42%) and alexithymia (37.88%). Anticipatory worry was the variable most closely associated with all the DCPR diagnoses. Health anxiety was related to anticipatory worry and age, whereas alexithymia was associated with dependence and fatiguability. PHQ-15, HAQ, and BDI-II scores were related to health anxiety but not alexithymia.ConclusionDCPR has clinical utility in the community samples without DSM-5 diagnoses. DCPR may be a valid mediator between psychological trait and state.     

Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management

ObjectiveThe aim was to assess the efficacy of two brief cognitive–behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes.MethodA 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n= 71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences.ResultsThe seven-session CBT (n= 19), one-session panic management (n= 24) and pharmacotherapy (n= 13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n= 15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED.ConclusionsThese results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP.     

The efficacy of integrated cognitive behavioral therapy (CBT) and acupressure versus CBT for insomnia: a three-arm pilot randomized controlled trial

ObjectivesThis pilot study aimed to examine the efficacy of integrated cognitive behavioral therapy (CBT) and acupressure in treating insomnia and its daytime impairments in a Chinese adult population.Methods40 eligible participants with insomnia were randomly assigned to either the integrated CBT and acupressure (CBTAcup) group (n = 14), the CBT group (n = 13), or the waitlist control (WL) group (n = 13). Participants in the CBTAcup group attended a 2-hour integrated CBT and self-administered acupressure group treatment once per week for six consecutive weeks, while participants in the CBT group attended six weekly 2-hour CBT for insomnia. Sleep, mood, daytime impairments, quality of life, and treatment credibility and adherence were assessed at baseline, immediate post-treatment (Week 7), and 4-week post-treatment (Week 11).ResultsLinear mixed-effects models showed that both the CBTAcup and CBT groups had significantly lower insomnia severity (d = −1.74 and d = −2.61), dysfunctional beliefs related to sleep (d = −2.17 and −2.76), and mental fatigue (d = −1.43 and −1.60) compared with the WL group at Week 7. The CBTAcup group provided additional benefits in reducing total fatigue (d = −1.43) and physical fatigue (d = −1.45). Treatment credibility was found to be improved in the CBTAcup group from baseline to Week 7.ConclusionsIntegrated CBT and acupressure demonstrated comparable efficacy to pure CBT in treating insomnia symptoms, with additional advantages to improve fatigue symptoms and acceptability in the Chinese population. Further methodologically rigorous studies on a larger scale and longer follow-up are warranted to confirm these findings.     

High-frequency repetitive transcranial magnetic stimulation over the primary motor cortex relieves musculoskeletal pain in patients with Parkinson's disease: A randomized controlled trial

BackgroundPain is common in Parkinson's disease, and there is no effective treatment. We conducted a clinical trial to determine whether high-frequency repetitive transcranial magnetic stimulation over the primary motor cortex alleviates musculoskeletal pain in patients with Parkinson's disease.MethodsIn this single-center and double-blind trial, 52 patients with Parkinson's disease and musculoskeletal pain were randomly allocated to 26-member groups receiving 5 sessions of either 20-Hz repetitive transcranial magnetic stimulation or sham stimulation over the primary motor cortex. The participants underwent assessments in the “ON” medication state at baseline, after the fifth session, and at 2- and 4-week follow-up timepoints. The primary outcomes were pain scores on a numeric rating scale. The secondary outcomes were scores on clinical scales assessing motor symptoms, depression, anxiety, autonomic symptoms, sleep quality, and the overall severity of Parkinson's disease.ResultsAnalyses revealed significant group × time interactions for numeric rating scale pain scores (p < 0.001), motor symptom scores (p < 0.001), depression scores (p = 0.009), anxiety scores (p = 0.013), and overall disease severity scores (p < 0.001). Post hoc analyses confirmed that the repetitive transcranial magnetic stimulation group, but not the sham stimulation group, exhibited significant improvements in numeric rating scale pain scores, motor symptom scores, depression scores, anxiety scores, and overall disease severity scores.ConclusionHigh-frequency repetitive transcranial magnetic stimulation over the primary motor cortex may be an effective adjunct therapy for alleviating musculoskeletal pain in patients with Parkinson's disease.     

Impact of a brief behavioral treatment for insomnia (BBTi) on metacognition in older adults

IntroductionBrief (≤4 sessions) behavioral treatment for insomnia (BBTi) improves insomnia symptoms in older adults. Findings for BBTi-related improvements in objective cognition are mixed, with our recent trial reporting no effects. Metacognition (appraisal of one's own performance) has not been examined. This study examined the effects of BBTi on metacognition in older adults with insomnia.MethodsOlder adults with insomnia [N = 62, Mage = 69.45 (SD = 7.71)] were randomized to 4-weeks of BBTi (n = 32; psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, review/maintenance) or self-monitoring control (SMC; n = 30; social conversations). Throughout the study (2 week baseline, 4 week treatment, 2 week post-treament, 2 week 3-month followup), participants completed daily paper/pencil cognitive tasks (measuring verbal memory, attention, processing speed and reasoning) and provided daily metacognition ratings of their performance in four areas: quality, satisfaction, compared to same age peers, compared to own ability. Two-week averages of metacognitive ratings were calculated for baseline, treatment-first half, treatment-second half, post-treatment, and 3-month follow-up. Multilevel Modeling examined treatment effects (BBTi/SMC) over time on metacognition, controlling for age and sex.ResultsA significant group by time interaction (p = 0.05) revealed consistent improvements over time in better metacognitive ratings relative to same age peers for BBTi. Specifically, baseline ratings [mean (M) = 51.21, standard error (SE) = 3.15] improved at first half of treatment (M = 56.65, SE = 3.15, p < 0.001), maintained improvement at second-half of treatment (p = 0.18), showed additional improvement at post-treatment (M = 60.79, SE = 3.15, p = 0.02), and maintained improvement at follow-up (M = 62.30, SE = 3.15; p = 0.02). SMC prompted inconsistent and smaller improvements between baseline (M = 53.24, SE = 3.29) and first-half of treatment (M = 56.62, SE = 3.28; p = 0.004), with additional improvement at second-half of treatment (M = 59.39, SE = 3.28; p = 0.02) that was maintained at post-treatment (p = 0.73) and returned to levels observed at first-half of treatment (M = 57.78, SE = 3.21; p = 0.55). Significant main effects of time (all ps < 0.001) for other metacognition variables (Quality, Satisfaction, Compared to own ability) indicated general improvements over time for both groups.DiscussionMetacognition generally improved over time regardless of treatment. BBTi selectively improved ratings of performance relative to same age peers. Repeated objective testing alone may improve metacognition in older adults with insomnia. Better understanding of metacognition and how to improve it has important implications for older adults as metacognitive complaints have been associated with mild cognitive impairment.     

Examining the latent structure of worry and generalized anxiety in a clinical sample

Generalized anxiety disorder (GAD) is characterized by “pathological” worry, suggesting that GAD worriers differ qualitatively from non-GAD worriers. However, results from taxometric studies of worry in undergraduate and community samples have been mixed and to date, no studies have utilized clinical samples. The current study examined the latent structure of worry and GAD symptoms in a diagnostically heterogeneous clinical sample. Indicators were selected from the Penn State Worry Questionnaire-Abbreviated (n = 1175) and the GAD-7 (n = 638) and submitted to three taxometric procedures: MAXCOV, MAMBAC, and L-Mode. Results from all three procedures suggested that both worry and generalized anxiety are best conceptualized as dimensional constructs. Findings also indicated that ongoing conceptualization, assessment, and treatment of worry and GAD may be hampered by the application of a categorical framework.     

The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder

ObjectiveObsessive-compulsive disorder (OCD) is a severe condition with varied symptom presentations. The behavioral treatment with the most empirical support is exposure and ritual prevention (EX/RP). This study examined the impact of symptom dimensions on EX/RP outcomes in OCD patients.MethodThe Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to determine primary symptoms for each participant. An exploratory factor analysis (EFA) of 238 patients identified five dimensions: contamination/cleaning, doubts about harm/checking, hoarding, symmetry/ordering, and unacceptable/taboo thoughts (including religious/moral and somatic obsessions among others). A linear regression was conducted on those who had received EX/RP (n = 87) to examine whether scores on the five symptom dimensions predicted post-treatment Y-BOCS scores, accounting for pre-treatment Y-BOCS scores.ResultsThe average reduction in Y-BOCS score was 43.0%, however the regression indicated that unacceptable/taboo thoughts (β = .27, p = .02) and hoarding dimensions (β = .23, p = .04) were associated with significantly poorer EX/RP treatment outcomes. Specifically, patients endorsing religious/moral obsessions, somatic concerns, and hoarding obsessions showed significantly smaller reductions in Y-BOCS severity scores.ConclusionsEX/RP was effective for all symptom dimensions, however it was less effective for unacceptable/taboo thoughts and hoarding than for other dimensions. Clinical implications and directions for research are discussed.     

Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol

BackgroundFunctional (“psychogenic”) gait and other movement disorders have proven very difficult to treat.ObjectivesDescribe the Mayo Clinic functional movement disorder motor-reprogramming protocol conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and long-term outcomes.DesignHistorical-cohort-study assessing non-randomized PMR intervention.SettingTertiary care center.PatientsInterventional group: 60 consecutive patients with a chronic functional movement disorder that underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sex-matched patients with treatment-as-usual (n = 60).InterventionsAn outpatient, one-week intensive rehabilitation program based on the concept of motor-reprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/psychological assessment.Main outcome measuresImprovement of the movement disorder by the end of the week-long program (patient- and physician-rated), plus the long-term outcome (patient-rated).ResultsPatient demographics: median symptom duration, 17 months (range, 1–276); female predominance (76.7%); mean age 45 years (range, 17–79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months) revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9% of controls (p < 0.001).ConclusionsShort-term and long-term successful outcomes were documented in the treatment of patients with functional movement disorders by a rehabilitative, goal-oriented program with intense physical and occupational therapy. The rapid benefit, which was sustained in most patients, suggests substantial efficacy that should be further assessed in a prospective, controlled, clinical trial.