[Evaluation of Post-traumatic Stress Disorder: validation of a measure, the PCLS]. / Evaluation des états de stress post-traumatique: validation d'une échelle, la PCLS.

Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder frequently found in psychiatric clinic and in the population of victims of traumatic events. PTSD, characterized by an intense fear, helplessness or horror, resulting from exposure to a traumatic event, is clinically manifested with three main syndromes: reexperiencing, avoidance behavior and numbing of emotion, and physiological hyperarousal. The Post-Traumatic Checklist Scale (PCLS) is a brief and self-report questionnaire for evaluating the severity of three main syndromes of PTSD. The scale can be divided into three sub-scores corresponding to the three main syndromes of the disorder: reexperiencing (items 1-5), avoidance (items 6-12) and hyperarousal (items 13-17). The validation studies in English version (Weathers et al., 1993, Blanchard et al., 1996) and French version (Ventureyra et al., 2001) showed that the PCLS possesses good psychometric properties. But the discriminating validation with another pathological group and the sensitivity of the scale to change of treatment have not yet been studied up to now. The aim of this study is the validation of the French version of the PCLS in Post-Traumatic Stress Disorder (PTSD) subjects compared with subjects suffering from other anxiety disorders and non-clinical subjects. The sensitivity of the PCLS after a cognitive behavioral therapy (CBT) for PTSD was studied for the first time. Fifty-seven outpatients suffering from PTSD according to DSM IV criteria, 23 patients suffering from other anxiety disorders and 28 non-clinical subjects were included in this study. All subjects were assessed with the PCLS. The Beck Depression Inventory--13 items (BDI-13) and the Fear Questionnaire (FQ) were used for the two groups of patients. Fifty-five PTSD patients were administered the PCLS twice over an interval of one to two weeks without any intervention in order to determine the test-retest reliability of the PCLS. And 24 PTSD patients were reassessed with the PCLS after 16 sessions of cognitive behavioral therapy (CBT) in order to study the sensitivity to treatment of the PCLS. The CBT technique for PTSD consisted of relaxation, exposition, recital, cognitive restructuration and stress management. The total score and the subscores on the PCLS were found to be significantly higher in PTSD patients than in two control groups: suffering from other anxiety disorders subjects (61.2/41.4, p<0.0001) and non-clinical subjects (61.2/28.8, p<0.0001). The correlation between the PCLS total score and the others measures showed that the PCLS correlated significantly with the depression measure, the BDI-13 (p<0.001), and the sub-scores of Fear Questionnaire (agoraphobia: p<0.001; anxiety-depression: p<0.001; distress: p<0.001), but not with the social phobia sub-score of the FQ. The PCLS showed a satisfactory test-retest reliability in 55 patients (the total score: r=0.75, p<0.0001; the sub-score of reexperiencing: r=0.844, p<0.0001; the sub-score of avoidance: r=0.702, p<0.0001; the sub-score of hyperarousal: r=0.712, p<0.0001). The t-test showed that the total score of the PCLS was significantly reduced in 24 patients after 16 sessions of CBT (the mean gain=13.1, t=5.63, p<0.0001). The results of our study confirm that the PCLS possesses good empirical and discriminating validity and a good sensitivity. The fact that the PTSD patients reported significantly higher total scores on the PCLS and its three subscores than other anxiety disorder subjects and non-clinical subjects indicates that the PCLS differentiates well the patients presenting PTSD from other anxiety disorder subjects and non-clinical subjects. The PCLS total score also correlates significantly with the other measures of psychopathology used in the study, such as measures of phobia (the Fear Questionnaire agoraphobia subscale), depression (the Beck Depression Inventory -13) and distress (the Fear Questionnaire distress subscale). This may be explained by the fact that some PTSD symptoms overlap with those of depression and of anxiety or phobia. The PCLS showed anxiety or phobia. The PCLS showed a satisfactory test-retest reliability. The PCLS is therefore a valid and effective measurement of PTSD. It may be a useful tool for screening and assessing PTSD in clinical practice and research in psychiatry.

A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder.

BACKGROUND: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. METHODS: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. RESULTS: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. CONCLUSIONS: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.

Visuo-spatial attention processes in panic disorder with agoraphobia: a pilot study using a visual target discrimination task.

Panic attacks can be observed in a wide range of situations, but most common are those providing complex and unstructured stimulations, suggesting an impairment in attentional processing of visuo-spatial information. This study evaluated agoraphobics' attentional processing of neutral (i.e., not anxiety-provoking) visuo-spatial stimulation. Twelve patients suffering from panic attacks with agoraphobia were compared with 22 normal controls on a computerized visual target discrimination task specifically designed for this study. Psychometric measures assessed the phobic avoidance, the level of depression and anxiety. The numbers of errors and reaction times were analysed with a three-way ANOVA (Group x target modality x number of stimulations). No between-group significant difference was found for the reaction time performance and the mean number of detection errors. However, an interaction effect was observed for this last variable depending on the target modality: agoraphobic patients made fewer omission errors than control subjects when the target was present among distractors, while they made more commission errors when the target was absent. Outcomes are discussed in terms of attentional hyperactivation related to anxiety and perseverative decision process in agoraphobic patients.

Cognitive behavior therapy versus supportive therapy in social phobia: a randomized controlled trial.

BACKGROUND: The efficacy of cognitive behaviour therapy (CBT) in social phobia has been demonstrated in several controlled trials and meta-analyses, but no comparison of CBT with supportive therapy (ST) can be found in the literature. METHOD: The aim of the trial was to study the effectiveness of CBT versus ST carried out 'as usual'. Sixty-seven DSM-4 social phobic patients (89% generalized subtype, most with avoidant personality) were randomly allocated into two groups. Group 1 (CBT) received 8 1-hour sessions of individual cognitive therapy (CT) for 6 weeks, followed by 6 2-hour sessions of social skills training (SST) in group weekly. Group 2 received ST for 12 weeks (6 half-hour sessions), then the patients were switched to CBT. All patients agreed not to take any medication during the whole trial. In group 1, 29 patients reached week 6, 27 reached week 12, and 24 weeks 36 and 60 (endpoint). In group 2, 29 patients reached week 6, 28 reached weeks 12 and 18, 26 week 24, and 23 reached weeks 48 and 72 (endpoint). RESULTS: At week 6, after CT, group 1 was better than group 2 on the main social phobia measure. At week 12, after SST, group 1 was better than group 2 on most of the measures and demonstrated a significantly higher rate of responders. This finding was replicated after switching group 2 to CBT. Sustained improvement was observed in both groups at follow-up. Compliance with abstinence from medication increased over time. CONCLUSIONS: CBT was more effective than ST and demonstrated long-lasting effects. This may suggest that social phobia management requires more than a simple and inexpensive psychological intervention.

Psychometric appraisal of the Scale for Interpersonal Behavior (SIB) in France.

The present study was carried out in France to evaluate the reliability and validity of the Scale for Interpersonal Behavior (SIB), a multidimensional measure of difficulty and distress in assertiveness that was originally developed in The Netherlands. This appraisal was conducted with a clinical sample (N = 166) and a general population sample (N = 150). The clinical series comprised 115 patients with social phobia and 51 patients with personality disorder, 28 of whom were of the avoidant type. Support was found for internal consistency and test-retest reliability of the French SIB. Compared to controls, both social phobics and patients with an avoidant personality disorder had significantly lower mean scores on all performance scales and significantly higher ones on all distress scales, with the social phobics occupying a position in between. Findings in relation to convergent and divergent validity were quite satisfactory. Sensitivity of the French SIB for detecting change was demonstrated in a subgroup of the clinical Ss who had undergone 15 sessions of cognitive-behavioral group therapy for underassertiveness.

Validation of the French translation of the agoraphobic cognitions questionnaire.

BACKGROUND: The goal of the present study was to validate the French version of the Agoraphobic Cognitions Questionnaire (ACQ). METHODS: Subjects consisted of 115 patients with panic disorder and agoraphobia, 54 obsessive-compulsive patients and 72 normal controls. Patients were referred for outpatient treatment. They filled in the questionnaire before and after entering treatment. The control group consisted of people taken from the general population. It was matched with the clinical groups on age, sex and education. RESULTS: The ACQ appears to have a constant factor structure across US, Dutch and French samples. Results support the validity of the total score of the ACQ. Patients with panic disorder and agoraphobia scored significantly higher than obsessive-compulsive patients and control subjects. On the ACQ physical concerns subscale agoraphobic patients were significantly different from obsessive-compulsive patients and control subjects. On the social/behavioural subscale agoraphobic patients and obsessive-compulsive patients were significantly different from control subjects. The French translation of the ACQ was found to be stable over an interval of 15 days in the control group. The Cronbach coefficients of both subscales were also satisfactory. These results support the stability and the internal consistency of the questionnaire. In addition, the French translation of the ACQ was sensitive to changes with cognitive-behavioural therapy. CONCLUSIONS: These results support the findings of Chambless and Gracely [Cogn Ther Res 1989;13:9-20]. The ACQ physical concerns subscale is a specific feature for the anxiety status experienced by patients with panic disorder and agoraphobia. The ACQ social/behavioural subscale seems to be a more general feature of anxious patients.

[Cognitive behavior therapy of agoraphobia, retrospective study of 345 cases]. / Thérapie cognitivo-comportementale de l'agoraphobie, étude rétrospective de 345 cas.

Epidemiological data of 533 (42% male) agoraphobic patients referred to an anxiety disorder unit are reported. Comorbidity with mood disorders was high (48%). Therapeutic response was studied in 345 patients who received cognitive-behaviour therapy (CBT): 131 patients dropped out and 214 completed treatment. At post-test 71% of the completers were improved with maintenance of the gains in patients reevaluated at follow-up points ranging from 6 months to 18 years. Medication intake was significantly decreased. Intent to treat analysis of the whole CBT sample showed that 57% of the 345 patients were improved. Drop-outs were predicted by female sex and psychotic personality traits. This suggests that personality assessment should be carried out in agoraphobia and therapeutic interventions on personality considered in patients with disordered personality. The relatively low prevalence of women in the whole sample and their higher prevalence in drop-outs are discussed.

Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone.

BACKGROUND: The change of psychopathological dimensions during treatment of panic disorder is attracting increasing interest. METHODS: A population of subjects experiencing panic disorder with agoraphobia is evaluated with the French version of the factor structure of the Symptom Checklist 90 R (SCL 90 R). Two groups of patients are compared: a group receiving cognitive behaviour therapy (CBT) combined with buspirone and a group receiving cognitive behaviour therapy combined with placebo. RESULTS: Comparative analysis of pre- and post-test changes between both groups completing treatment showed that the combination cognitive behaviour therapy plus buspirone provided better results than those in patients who had received cognitive behaviour therapy plus placebo. This difference between treatments did not persist at the 1-year follow-up, since, while results had been effectively maintained in the CBT plus buspirone group, the CBT plus placebo group continued to improve significantly for the target dimensions of treatment. CONCLUSIONS: Psychopathological dimensions on the SCL 90 R show that combination of buspirone and cognitive behaviour therapy accelerates the behaviour modification process only in the short term.

Exposure therapy, fluvoxamine, or combination treatment in obsessive-compulsive disorder: one-year followup.

Sixty outpatients with obsessive-compulsive disorder (OCD, 22 men, 38 women) were randomized to receive 6 months of antiexposure therapy with fluvoxamine (group F), exposure therapy with fluvoxamine (group Fe), or exposure therapy with placebo (group Pe). Patients in group F did not comply with antiexposure therapy, so it was in fact a neutral condition. Patients began with depressed mood (mean Hamilton depression score = 19). Fifty patients were reevaluated at week 8, 44 at week 24 (posttest), 37 at week 48, and 33 at 18 months, 1 year posttreatment (group F, n = 10; group Fe, n = 12; group Pe, n = 11). The three groups improved on rituals and depression. There was a drug effect on rituals at week 8 and on depression at week 24; both these effects disappeared at week 48. The 33 18-month completers had been comparable at baseline to those not followed up, apart from having more severe behavioral avoidance. At 18-month followup, patients as a whole remained improved with no between-group differences; over 80% of the Fe and Pe patients versus 40% of the F patients were not receiving antidepressant treatment (Fe vs. F: p < 0.04; Pe vs. F: p = 0.053; Fe vs. Pe: NS). In OCD fluvoxamine and exposure therapy were synergistic in the short term, and exposure reduced subsequent need for antidepressants in the followup year after they had been stopped.

A controlled study of fluvoxamine and exposure in obsessive-compulsive disorder.

DSM-3 obsessive-compulsive out-patients were randomly assigned to fluvoxamine with antiexposure (F), fluvoxamine with exposure (Fe), or placebo with exposure (Pe) for 24 weeks. Of 65 patients offered treatment 60 entered the trial, 50 reached week 8, 44 completed treatment to week 24, and 37 reached follow up to week 48. On average the patient had depressed mood (mean Hamilton depression rating scale = 19). Drop-out numbers, clinical status and behavioural measures were comparable across groups. Most F patients did not do antiexposure, but Fe and Pe patients complied in doing exposure. All three groups improved in rituals and depression from week 0 to week 24 and 48, with a slight but non-significant superiority for combined treatment up to week 24. At week 8 there was a drug between-group effect on rituals, but not on depression. At week 24 there was a drug between-group effect on depression, but not on rituals. The drug superiority was short-lived. At week 48 there was no between-group difference in rituals or depression. Depression was related to ritual outcome at week 24 in F, and tended to be so in Fe.

[French version of the Yale-Brown Obsessive Compulsive Scale]. / Version française de l'échelle d'obsession-compulsion de Yale-Brown.

A French translation and adaptation of the Yale-Brown obsessive compulsive scale is presented, with reference to validation studies. This new synthetic and specific measurement tool represents an advance and would deserve a French validation study.

[Preliminary study of a list of obsessional thoughts. Validation and factorial analysis]. / Etude préliminaire d'une liste de pensées obsédantes. Validation et analyse factorielle.

The validation study and factorial analysis of a list of obsessive thoughts is presented. Four groups were compared. They included patients suffering from obsessive compulsive disorders (n = 22), depression (n = 21), phobias (n = 16) and a control group (n = 21). The four groups were comparable as far as age, sex, and educational level were concerned. The list of obsessive thoughts is valid, reliable, and has a good internal consistency. The factorial analysis showed a first factor (accounting for 37.22% of the variance) reflecting perfectionism, and a second factor (accounting for 12.10% of the variance) reflecting a pathological sense of responsibility.

Predictive value of MMPI scales on smoking cessation programs outcomes.

Five hundred and fifty-eight cigarette smokers were randomized in 4 groups: acupuncture, behavior therapy, placebo and waiting list. The MMPI scales showed stability across pretest, posttest and a one-year follow-up. Principal components analysis isolated a "depression-psychasthenia" factor accounting for 61% of the variance. Moreover 43% of the subjects had an abnormal MMPI profile. Segmentation isolated predictive factors: a high number of pathological MMPI scales predicted failures in any kind of treatment. Acupuncture yielded better outcomes when the profiles were normal. Behavior therapy and placebo had better outcomes when the anxiety index was abnormal. The study underscores the role of personality factors in tobacco addiction and their influence on cessation programs outcomes.

[Results obtained in a behaviour therapy consultation. 319 referrals, including 124 fully treated (author's transl)]. / Bilan d'une consultation de thérapie comportementale. 319 malades dont 124 traités complètement.

Out of 319 patients referred to a behaviour therapy consultation in a general hospital, 217 were considered as amenable to this form of treatment which was undertaken in 176 and brought to completion in 124. At the end of treatment 90.5% of the patients fully treated were improved. an actuarial study of the results showed that 66% remained improved after one year.

Behavioral and bodily self concept changes after assertive training. A pilot study.

The study aims at finding correlations between the development of assertiveness through assertive training and the modification of the bodily self concept (or body image). Eleven social phobic patients (6 women, 5 men, mean age 31.5) are treated in two groups and measured by Rathus's assertiveness schedule, and Osgood's semantic differential (key concepts: my self, my body, my voice, my gestures, my look; control concept: a table). At post test and follow-up (between 6 and 9 months), an ANOVA shows a significant positive change in assertiveness (p 0.001), correlated with modifications in bodily self concept. The patients are rating their body and their look as more active and stronger, but the body is perceived as more dangerous (p 0.05). No change appears in the other key concepts and the control concept. The interrelation between behavioral and cognitive changes are discussed.

[Prolonged exposure (flooding) in phobic and obsessive compulsive patients: 21 cases (author's transl)]. / Le traitement comportemental des obsessions et des phobies par "immersion" (flooding). 21 cas.

A first appraisal of 21 patients with phobic (n = 15), obsessive-compulsive (n = 5) and bereavement problems (n = 1) is carried out after a flooding procedure (prolonged exposure). One case is reported in detail. The actuarial rate of improvement amounts to 73% at a follow up between 6 and 9 months. The failures and relapses take place in the first month following the treatment. Two psychotic subjects show a significant improvement. The importance of the patient's expectations and motivation and the interpersonal aspects are underlined.