Long-Term Effectiveness of Cognitive Behavioral Therapy in Routine Outpatient Care: A 5- to 20-Year Follow-Up Study.

OBJECTIVE: Long-term follow-ups several years after receiving cognitive behavioral therapy (CBT) are scarce and most of the existing literature describes follow-up data of randomized-controlled trials. Thus, very little is known about the long-term effects of CBT in routine care. METHODS: We investigated psychological functioning in a sample of 263 former outpatients who had received CBT for a variety of mental disorders such as depression, anxiety-, eating- or somatoform disorders 8.06 (SD 5.08) years after treatment termination. All participants completed a diagnostic interview as well as the Brief-Symptom Inventory (BSI) and the Beck Depression Inventory (BDI). Effect sizes and response rates according to Jacobson and Truax [J Consult Clin Psychol 1991;59:12-9] were calculated from pre- to posttreatment and from pretreatment to follow-up assessment. RESULTS: Pre- to posttreatment effect sizes ranged between 0.75 (BDI) and 0.63 (BSI) and pretreatment to follow-up effect sizes were 0.92 (BDI) and 0.75 (BSI). Of all patients, 29% (BDI) and 17% (BSI) experienced clinically significant change at posttreatment and 42% (BDI) and 24% (BSI) at follow-up. CONCLUSION: The results point to the long-term effectiveness of CBT under routine conditions for a wide array of problems, especially when compared to the long-term effects of medical treatment. It is noteworthy that the results at follow-up were even better than at posttreatment, indicating further improvement. However, about a quarter of the patients did not respond sufficiently to therapy, neither concerning short-term nor long-term effects.

Correction to: Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies.

The original version of this article unfortunately contained a mistake. In Results section, under the heading the "Application", CI difference values were incorrect in one of the sentences. The corrected sentence is given below.

Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies.

This paper aims to provide researchers with practical information on sample sizes for accurate estimations of therapist effects (TEs). The investigations are based on an integrated sample of 48,648 patients treated by 1800 therapists. Multilevel modeling and resampling were used to realize varying sample size conditions to generate empirical estimates of TEs. Sample size tables, including varying sample size conditions, were constructed and study examples given. This study gives an insight into the potential size of the TE and provides researchers with a practical guide to aid the planning of future studies in this field.

Patterns of change in different phases of outpatient psychotherapy: a stage-sequential pattern analysis of change in session reports.

Knowledge about typical change patterns of psychotherapy patients can help to improve treatment guidelines for psychological disorders. Recent studies showed that it is possible to identify several patient subgroups with regard to their early change pattern. However, although focusing on the early phase of treatment, change patterns in later stages have hardly been investigated yet. In this study, Growth Mixture Modelling was used to identify latent change classes in different phases of therapy in a naturalistic sample of 1229 psychotherapy outpatients. Furthermore, this paper inquired into the relation between the change patterns in different phases as well as their predictive power for therapy length and outcome. Results revealed different change patterns for the three investigated phases. While in an early treatment phase, (sessions one-six) five different change patterns could be identified: the number of change classes decreased considerably over time, resulting in three patterns in the second (sessions 7-12) and two in the third phase (sessions 13-18). In each phase, by far, the biggest class showed a pattern of good progress with small/no further improvements. KEY PRACTITIONER MESSAGES: Most change in patients' progress estimates took place in an early phase of the treatment and levelled out on a relatively high level in later phases of the treatment. Substantial improvements were still present in later phases of the treatment but occurred less frequent than in early stages. Continuous outcome monitoring and feedback systems should integrate progress measures to monitor patients progress especially in the early phase of the treatment and feed the so gained information back to therapists.

Internet-based motivation program for women with eating disorders: eating disorder pathology and depressive mood predict dropout.

BACKGROUND: One of the main problems of Internet-delivered interventions for a range of disorders is the high dropout rate, yet little is known about the factors associated with this. We recently developed and tested a Web-based 6-session program to enhance motivation to change for women with anorexia nervosa, bulimia nervosa, or related subthreshold eating pathology. OBJECTIVE: The aim of the present study was to identify predictors of dropout from this Web program. METHODS: A total of 179 women took part in the study. We used survival analyses (Cox regression) to investigate the predictive effect of eating disorder pathology (assessed by the Eating Disorders Examination-Questionnaire; EDE-Q), depressive mood (Hopkins Symptom Checklist), motivation to change (University of Rhode Island Change Assessment Scale; URICA), and participants' age at dropout. To identify predictors, we used the least absolute shrinkage and selection operator (LASSO) method. RESULTS: The dropout rate was 50.8% (91/179) and was equally distributed across the 6 treatment sessions. The LASSO analysis revealed that higher scores on the Shape Concerns subscale of the EDE-Q, a higher frequency of binge eating episodes and vomiting, as well as higher depression scores significantly increased the probability of dropout. However, we did not find any effect of the URICA or age on dropout. CONCLUSIONS: Women with more severe eating disorder pathology and depressive mood had a higher likelihood of dropping out from a Web-based motivational enhancement program. Interventions such as ours need to address the specific needs of women with more severe eating disorder pathology and depressive mood and offer them additional support to prevent them from prematurely discontinuing treatment.

The ups and downs of psychotherapy: sudden gains and sudden losses identified with session reports.

Psychotherapy does not always follow a linear path. The present study explores the frequency of sudden gains and losses during the course of outpatient psychotherapy. The sample includes 1500 patients treated at three different outpatient centers. The patients were 57.4% female, and suffered primarily from anxiety and depressive disorders. Progress was measured by session reports. Significant sudden shifts in both directions were prevalent for 28.9% of the patients. Patients with early sudden gains showed the highest effect sizes and patients with sudden losses showed the smallest at the end of treatment. The therapeutic relationship was significantly better after the sudden gain sessions. Results suggest further investigation of the occurrence of sudden gains in relation to early response as well as further exploration of sudden losses during the course of treatment with respect to differential patterns of change and outcome.

Psychotherapy for social anxiety disorder: long-term effectiveness of resource-oriented cognitive-behavioral therapy and cognitive therapy in social anxiety disorder.

OBJECTIVE: Resource-oriented cognitive-behavioral therapy (ROCBT) and cognitive therapy (CT) have been shown to be effective treatments for social anxiety disorder. However, so far few studies have examined the long-term effectiveness of these treatments. Thus, there is little information available about the durability of change in treated patients with social anxiety disorder. DESIGN: This study examined the effectiveness of both treatments at 2-year and 10-year follow-up assessments. Patients who received ROCBT or CT were re-contacted after 2 (n = 51), and 10 years (n = 27), respectively, and completed a battery of self-report questionnaires. RESULTS: Treatment gains were maintained over the 2-year follow-up on all measures. Furthermore, there was a significant improvement on 2 social anxiety measures between posttreatment and the 10-year follow-up. ROCBT and CT did not differ in overall effectiveness. CONCLUSION: The results suggest that both treatments are effective and durable approaches in the treatment of social anxiety disorder.

[Resource-focused treatment for unipolar depression: a randomized controlled psychotherapy study]. / Ressourcenorientierte Akutbehandlung unipolarer Depressionen: Eine randomisierte kontrollierte Psychotherapiestudie.

BACKGROUND: Resource activation is considered to be a central mechanism in psychotherapeutic change. However, it is widely unknown whether a special focus on resource activation is associated with higher efficacy in cognitive behavioural therapy. METHOD: 52 patients with unipolar depression took part in a randomized controlled study comparing cognitive behavioural therapy plus resource activation (RFCBT) with cognitive behavioural therapy (CBT) alone. RESULTS: Overall, treatment effects were comparable to published research. In both treatment groups patients equally improved on cognitive, emotional and interpersonal outcome measures. CONCLUSIONS: A combined treatment approach of cognitive behavioural therapy and resource activation was shown to be an effective treatment of unipolar depression. Yet, compared to a standard CBT-treatment an additional focus on resource was not associated with higher efficacy.

Be careful what you strive for: the significance of motive-goal congruence for depressivity.

In a sample of 61 psychotherapy outpatients, the current study investigated the association between progress at motive-congruent personal goals and depressivity. In a correlational design, motives were measured with a Picture Story Exercise. Personal goals and goal progress were assessed using a self-report approach. The Beck Depression Inventory was used to determine patients' levels of depressive symptoms. In accordance with Beck's congruency hypothesis, results showed that only motive-congruent goal progress was related to depressivity. Motive-incongruent progress could not account for interindividual differences in depressive symptoms. Implications of the findings are discussed in terms of the aetiology of depression and the definition of explicit treatment goals.

Differential neuronal responses to the self and others in the extrastriate body area and the fusiform body area.

The extrastriate body area (EBA) and the fusiform body area (FBA) are selectively activated by viewing human bodies. However, the role of these functionally defined brain areas in self-other discrimination is still unresolved. Thirty-one females were presented with 16 pictures of their own body and another body in a bikini and with scrambled images while fMRI was performed. Moreover, standardized stimulus material was used in order to localize the EBA and FBA. Region-of-interest analysis showed an enhanced BOLD response to the self-images relative to the non-self-images in the right EBA and FBA. The right EBA and FBA are activated differently by viewing oneself and others and might thus play a role in visual self-other discrimination.

Neural correlates of viewing photographs of one's own body and another woman's body in anorexia and bulimia nervosa: an fMRI study.

BACKGROUND: In spite of many similarities in the psychopathology of anorexia nervosa (AN) and bulimia nervosa (BN), the 2 groups seem to differ in terms of body image disturbances. Therefore, the aim of the present study was to compare neuronal correlates of viewing photographs of one's own body and another woman's body in patients with these forms of eating disorders as well as controls. METHODS: We performed functional magnetic resonance imaging while women with AN (n = 13), BN (n = 15) and healthy controls (n = 27) viewed 16 standardized pictures of their own body and another woman's body, taken while the participants were wearing a bikini. RESULTS: When viewing their own body, participants with AN and BN showed reduced activity in the inferior parietal lobule compared with healthy women. In response to looking at another woman's body, participants with AN had higher amygdala activity than did those in the BN and control groups. LIMITATIONS: The generalizability of the results is limited by the small sample size. CONCLUSION: Our data suggest decreased attentional processes in AN and BN toward one's own body, possibly reflecting body-related avoidance behaviour. Enhanced limbic activity elicited by looking at another woman's body in participants with AN might be a neural correlate of stronger emotional activation and enhanced vigilance, possibly resulting from social comparison processes. Our study reveals hints about body image-associated alterations in brain activity, which seem to be more pronounced among women with AN than among those with BN.

Effects of body image therapy on the activation of the extrastriate body area in anorexia nervosa: an fMRI study.

To test effects of body image therapy in anorexia nervosa, functional magnetic resonance imaging was used to assess neuronal responses to viewing photographs of one's own body before and after treatment. Activation decreases emerged in a distributed network and increases were observed in the extrastriate body area, possibly reflecting more intense body image processing.

Embodiment of sadness and depression--gait patterns associated with dysphoric mood.

OBJECTIVE: To analyze gait patterns associated with sadness and depression. Embodiment theories suggest a reciprocal relationship between bodily expression and the way in which emotions are processed. METHODS: In Study 1, the gait patterns of 14 inpatients suffering from major depression were compared with those of matched never-depressed participants. In Study 2, we employed musical mood induction to induce sad and positive mood in a sample of 23 undergraduates. A Fourier-based description of walking data served as the basis for the computation of linear classifiers and for the analysis of gait parameters. RESULTS: Gait patterns associated with sadness and depression are characterized by reduced walking speed, arm swing, and vertical head movements. Moreover, depressed and sad walkers displayed larger lateral swaying movements of the upper body and a more slumped posture. CONCLUSION: The results of the present study indicate that a specific gait pattern characterizes individuals in dysphoric mood.

Some like it specific: the difference between treatment goals of anxious and depressed patients.

OBJECTIVES: While clinical diagnoses are the primary criteria for differential indication in psychotherapy, treatment-goal themes may provide additional information on diagnosis-specific and extra-diagnostic aspects of treatment motivation. It is hypothesized that the goals of anxiety patients focus on symptom relief, while the goals of depression patients are thematically more heterogeneous. Additionally, it is hypothesized that patients with various specific anxiety disorders can be differentiated on their treatment-goal themes. DESIGN: To obtain a sufficiently large number of diagnostically non-comorbid patients, a sample of 328 patients with non-comorbid anxiety and depression patients was merged from two subsamples: 255 outpatients from a university-based clinic in Germany and 73 outpatients from a comparable clinic in German-speaking Switzerland. METHODS: The treatment-goal themes of the 328 outpatients were coded using the Bern inventory of treatment goals. RESULTS: Patients with non-comorbid diagnoses of depression or anxiety differed as hypothesized. Anxiety patients' treatment goals predominantly focused on symptom relief, while depression patients' treatment goals were thematically more heterogeneous. In addition, patients with various specific anxiety disorders differed in their treatment-goal themes. CONCLUSIONS: Implications for clinical assessment and treatment planning are discussed.

Catastrophic associations predict level of change in anxiety sensitivity in response to cognitive-behavioural treatment for panic.

The aim of the present study was to elucidate one of the factors that might be responsible for the maintenance of panic patients' harmful beliefs about anxiety. Specifically, it was hypothesized that harmful beliefs about anxiety, i.e. anxiety sensitivity, is maintained in panic patients by automatic activation of idiographic catastrophic cognitions. To test this prediction, panic patients participated in a one-session cognitive-behavioural treatment of 4-8h to reduce anxiety sensitivity. The strength of automatic catastrophic cognitions in response to idiographic anxiety symptoms, measured with a modified semantic priming task, as well as the strength of the consciously accessible catastrophic meaning of these symptoms were assessed before treatment. In accordance with the hypothesis, stronger automatic catastrophic cognitions predicted a smaller reduction of anxiety sensitivity independently of the strength of conscious catastrophic cognitions. Moreover, in a first exploration, the strength of catastrophic associations was also shown to have an incremental predictive value for change in anxiety sensitivity beyond that of a number of demographic, clinical, treatment and assessment variables. The theoretical and clinical implications are discussed.

Mindfulness predicts relapse/recurrence in major depressive disorder after mindfulness-based cognitive therapy.

Empirical evidence for the effectiveness of mindfulness-based cognitive therapy (MBCT) is encouraging. However, data concerning the role of mindfulness in its relapse preventive effect are lacking. In our study, 25 formerly depressed patients received MBCT. Mindfulness was assessed before and immediately after MBCT using the Mindful Attention and Awareness Scale. Mindfulness significantly increased during MBCT, and posttreatment levels of mindfulness predicted the risk of relapse/recurrence to major depressive disorder in the 12-month follow-up period. Mindfulness predicted the risk of relapse/recurrence after controlling for numbers of previous episodes and residual depressive symptoms. The results provide preliminary evidence for the notion that mindfulness is an important factor in relapse prevention in major depression.

Patients' outcome expectancies and their impression of suitability as predictors of treatment outcome.

In treatment studies, the correlation of patients' outcome expectancies and their impression of treatment suitability with treatment outcome shows a contradictory pattern. It seems that a significant correlation can be shown only if outcome is measured with posttherapy scores or with retrospective success ratings but not if outcome is operationalized as any form of pre-post change scores. This study with 499 outpatients (222 with anxiety disorders, 63 with affective disorders, 136 with both anxiety and depression, and 78 with other disorders) examines whether this difference in the correlation pattern can be replicated by simultaneously using three kinds of outcome assessment. Three subscales of the Patients' Therapy Expectation and Evaluation questionnaire (Hope of Improvement, Fear of Change, and Suitability) were correlated with the treatment outcome. Results confirm the hypothesized model. Possible explanations of this pattern of results are discussed.

Panic patients reveal idiographic associations between anxiety symptoms and catastrophes in a semantic priming task.

In the present study, a modified semantic priming paradigm was used to test whether panic patients more strongly associate catastrophes with anxiety symptoms than nonclinical subjects. Subjects named catastrophic target words (e.g. infarction) and target words neutral to anxiety themes (e.g. weekend) that followed auditive prime sentences immediately (i.e.0ms) or with a delay (i.e. 1500ms). Prime sentences described the perception of anxiety symptoms (e.g. You feel tense) or sensations neutral to anxiety (You feel relaxed). Consistent with an earlier study [Schniering C.A., & Rapee, R.M. (1997). A test of the cognitive model of panic: Primed lexical decision in panic disorder. Journal of Anxiety Disorders, 11, 557-571] the two groups did not differ if semantic priming effects were calculated in the usual way, i.e. by averaging across identical stimuli for all subjects. As expected, however, panic patients demonstrated stronger semantic priming effects for catastrophes immediately following prime sentences if priming effects were calculated for idiographically selected stimuli. The latter result indicated stronger automatic associations between idiographic anxiety symptoms and catastrophes in panic patients consistent with the cognitive model of panic disorder (Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470). The restriction of stronger associations in panic patients to idiographic stimuli is explained from an evolutionary perspective.

Empirically and clinically useful decision making in psychotherapy: differential predictions with treatment response models.

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Reduced connectivity between the left fusiform body area and the extrastriate body area in anorexia nervosa is associated with body image distortion.

The aim of the present study was to investigate the network and its effective connectivity subserving body processing in women suffering from anorexia nervosa (AN) and also in healthy controls. Ten women diagnosed with AN and 15 healthy, age matched controls were investigated using fMRI during viewing images of bodies and chairs. Effective connectivity between cortical areas which are involved in human visual body processing was accessed. Effective connectivity analysis yielded evidence for a different network in AN and healthy controls during visual processing of human bodies. Left sided effective connectivity in the occipital cortex of women with AN showed a highly negative correlation with body size misjudgment. Present results yield evidence for altered networks for body processing in women with AN. Results explain body size misjudgment, a key feature in AN, which seems to be based on reduced effective connectivity in the body processing network.