Pragmatic psychodynamic psychotherapy for a patient with depression and breast cancer: functional MRI evaluation of treatment effects.

Time-limited psychodynamic psychotherapy is garnering empirical support as an intervention for clinical depression. However, research is needed to examine the efficacy of psychodynamic approaches among patients presenting with diverse psychiatric and medical problems. This case study examined the efficacy of eight sessions of pragmatic psychodynamic psychotherapy (PPP) in treating a woman with major depression and breast cancer. Pre- to posttreatment assessment indicated significant reductions in depression and weekly assessment indicated increased environmental reward was associated with reduced depression. Secondary aims involved piloting a functional magnetic resonance imaging (fMRI) task as a neurobiological indicator of depression attenuation as a function of PPP. This assessment was conducted to explore alternative means of evaluating treatment responsiveness and addressing the problem of arbitrary metrics in measuring change. Clinical and assessment implications are discussed, with a focus on innovative approaches to evaluate treatment outcome and behavioral and neurobiological mechanisms of change associated with PPP.

The impact of decreased environmental reward in predicting depression severity: support for behavioral theories of depression.

Insufficient response-contingent positive reinforcement and decreased environmental reward have been hypothesized to directly contribute to the onset and persistence of depression. The present study examined whether decreased environmental reward was significantly associated with self-reported depression and diagnosed major depression relative to other well-established risk factors that included gender, stressful life events, traumatic life events, childhood maltreatment, and cognitive vulnerability. Based on hierarchical regression analyses, all variables except gender were significantly associated with self-reported depression, and stressful life events, cognitive vulnerability, and decreased environmental reward were associated with diagnosed depression. Of all variables, decreased environmental reward was most strongly related to both self-reported depression and diagnosed clinical depression. The incremental validity of environmental reward in predicting self-reported depression and clinical depression was established, accounting for significant unique variance (12%) in each regression equation. Implications for conceptualizing and treating depression are discussed.

Treatment failure in behavior therapy: focus on behavioral activation for depression.

Behavioral activation (BA) has come to be recognized as an empirically supported treatment for depression. Despite the general success of the approach, many patients experience treatment failure. Based on behavioral models of depression, we present several reasons for treatment failure in BA, including patient inability to understand and adopt the treatment rationale, lack of awareness or ability to articulate and behave according to life values, behavioral noncompliance, and ineffectiveness of contingency management to increase exposure to environmental rewards and reduce contact with both aversive environmental events and reinforcement of depressed behavior. A case study of treatment failure with a depressed breast cancer patient is presented, along with recommendations to reduce failure rates in BA.

Experiential avoidance: a moderator of the relationship between age and emotional expression.

OBJECTIVES: Experiential avoidance (EA) is the unwillingness to remain in contact with particular private experiences, and higher levels of EA are associated with increased psychopathology. This study explored relationships between EA, age, and the use of emotion words in positive and negative autobiographical narratives. METHOD: Participants included younger (n = 60) and older adults (n = 60) who completed a measure of EA and described a positive and negative autobiographical narrative. RESULTS: In the positive autobiographical narrative, there was a significant interaction between age and EA whereby among low EA participants, younger adults used more emotion words than older adults. In the negative autobiographical narrative, there was a main effect of age in which older adults utilized fewer emotional words and a significant interaction whereby among high EA participants, younger adults used more emotion words than older adults. CONCLUSION: Results are explained in the developmental context of Socioemotional Selectivity Theory (Carstensen, 1991), which posits that older adults may be more likely to verbally communicate in a style characterized by emotion regulation. Research and clinical implications are discussed.

Predicting high school truancy among students in the Appalachian south.

Truancy is a considerable problem among adolescents. Considering the historical emphasis on studying truancy in urban regions, a concerted effort is needed to extend this research into rural areas to examine cultural generalizability of findings. The purpose of this study was to assess variables associated with truancy in a rural sample (N = 367) of students attending high school in a southern rural region of the Appalachian Mountains. The primary objective was to assess the relative predictive strength of the following variables: academic performance, religiosity, environmental factors (family structure, parental education, and adolescent perceptions of family functioning), internalizing problems (anxiety, depression, thought problems, attentional problems), externalizing problems (substance use and rule-breaking behaviors), and prosocial overt behaviors (participation in school and leadership activities). Regression analysis indicated that truancy was significantly associated with poor school performance, increased depression, social problems, having a less educated mother, a less structured home environment, higher grade, and decreased participation in school sports. EDITORS' STRATEGIC IMPLICATIONS: These findings are critical for the understanding of truancy in rural areas, and they highlight contextual factors that must be identified and addressed through systematic prevention programs targeting adolescents at risk for truancy.

Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review.

Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.

Cognitive-behavior therapy for depressed cancer patients in a medical care setting.

Major depression is the most common psychiatric disorder among cancer patients and is associated with decreased quality of life, significant deterioration in recreational and physical activities, relationship difficulties, sleep problems, more rapidly progressing cancer symptoms, and more metastasis and pain relative to nondepressed cancer patients. Although some research has explored the utility of psychological interventions with cancer patients, only one study to date has explored the potential benefits of cognitive-behavior therapy among cancer patients with well-diagnosed depression. Addressing this gap in the literature, this study represents an open clinical trial to assess the effectiveness of a brief Cognitive-Behavioral Treatment for Depression (CBTD) among depressed cancer patients in a medical care setting. Results revealed strong treatment integrity, good patient compliance, excellent patient satisfaction with the CBTD protocol, and significant pre-post treatment gains across a breadth of outcome measures assessing depression, anxiety, quality of life, and medical outcomes. These gains also were associated with strong effect sizes and generally maintained at 3-month follow-up. Behavioral activation interventions, especially when paired with cognitive techniques, may represent a practical medical care treatment that may improve psychological outcomes and quality of life among cancer patients. Study limitations and future research directions are discussed.

The Environmental Reward Observation Scale (EROS): development, validity, and reliability.

Researchers acknowledge a strong association between the frequency and duration of environmental reward and affective mood states, particularly in relation to the etiology, assessment, and treatment of depression. Given behavioral theories that outline environmental reward as a strong mediator of affect and the unavailability of an efficient, reliable, and valid self-report measure of environmental reward, we developed the Environmental Reward Observation Scale (EROS) and examined its psychometric properties. In Experiment 1, exploratory factor analysis supported a unidimensional 10-item measure with strong internal consistency and test-retest reliability. When administered to a replication sample, confirmatory factor analysis suggested an excellent fit to the 1-factor model and convergent/discriminant validity data supported the construct validity of the EROS. In Experiment 2, further support for the convergent validity of the EROS was obtained via moderate correlations with the Pleasant Events Schedule (PES; MacPhillamy & Lewinsohn, 1976). In Experiment 3, hierarchical regression supported the ecological validity of the EROS toward predicting daily diary reports of time spent in highly rewarding behaviors and activities. Above and beyond variance accounted for by depressive symptoms (BDI), the EROS was associated with significant incremental variance in accounting for time spent in both low and high reward behaviors. The EROS may represent a brief, reliable and valid measure of environmental reward that may improve the psychological assessment of negative mood states such as clinical depression.

Assessing worry in older and younger adults: Psychometric properties of an abbreviated Penn State Worry Questionnaire (PSWQ-A).

Among older adults, recent work indicated that Penn State Worry Questionnaire (PSWQ) data fit poorly with previously established models, leading to use of model modification procedures to create an abbreviated worry questionnaire (PSWQ-A; Hopko, D. R., Stanley, M. A., Reas, D. L., Wetherell, J. L., Beck, J. G., Novy, D. M., et al. (2003). Assessing worry in older adults: Confirmatory factor analyses of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model. Psychological Assessment, 15, 173-183). Given limitations of this prior study that included the post hoc statistical development of the scale and undefined relevance toward assessing worry in younger cohorts, psychometric properties of the PSWQ-A were explored among independent samples of older (n = 115) and younger adults (n = 183). Exploratory factor analyses supported a unidimensional model (breadth and control of worry) that accounted for substantial variance in older (57%) and younger adult samples (70%) and was associated with high factor loadings (.66-.89). Internal consistency (alpha = .89-.94) and test-retest reliability (r = .87-.95) was strong in both samples. Moderate to strong convergent validity with measures of worry and anxiety was evident (r = .46-.83), as was support for the construct validity of the PSWQ-A via its relation to the PSWQ (r = .65-.83) and similar relations with other anxiety and worry measures. Although further study is required, the PSWQ-A may be a parsimonious method to assess worry in older and younger adults.

Pretreatment depression severity in breast cancer patients and its relation to treatment response to behavior therapy.

OBJECTIVE: Major depressive disorder is prevalent in breast cancer patients. There is a paucity of research on variables associated with depression severity and the link between depression severity and response to psychotherapy. To provide optimal mental health services to breast cancer patients, examining correlates of depression severity and its relation to treatment response is critical. METHOD: In the context of a randomized trial of behavior activation and problem-solving therapy for depressed breast cancer patients, this study evaluated demographic (marital status, age, education), psychosocial (social support, environmental reward, anxiety, number of coexistent anxiety disorders), and cancer-related (bodily pain, length of diagnosis, cancer stage) variables associated with pretreatment depression severity. Second, the relation of pretreatment depression severity with posttreatment and 12-month response and remission was assessed. RESULTS: For pretreatment depression severity, the overall regression model accounted for 40% of the variance, F(5, 74) = 9.87, p < .001. Less environmental reward and greater somatic anxiety were significantly and uniquely associated with depression severity. Depression severity was unrelated to treatment remission but was a significant moderator of treatment response at posttreatment and 12-month follow-up; individuals with higher depression severity were more responsive to therapy. For patients treated with behavior activation, environmental reward significantly mediated the relationship between pre- and posttreatment depression. CONCLUSIONS: Consistent with behavioral models of depression, less environmental reward and greater anxiety might influence depression severity in breast cancer patients. Data support the efficacy of behavior therapy for breast cancer patients, particularly those with more severe depression.

Construct validity of the Balloon Analog Risk Task (BART): associations with psychopathy and impulsivity.

To continue research assessing the validity of the Balloon Analog Risk Task (BART) as a measure of risk taking, the BART was administered to a nonforensic sample of individuals with varying levels of psychopathic characteristics. Construct validity of the BART was evaluated by measuring risk-taking behavior in relation to self-reported psychopathy, anxiety, psychophysiological data, and demographic variables. Supporting the construct validity of the BART, while controlling for variance accounted for by interrelated variables in the context of hierarchical regression analyses, higher self-reported psychopathy was significantly predictive of increased risk taking on the BART. Findings also revealed interesting gender differences in self-reported psychopathy and a trend for men to engage in riskier behavior. Limitations and research directions are presented.

Contemporary behavioral activation treatments for depression: procedures, principles, and progress.

In the past decade, there has been renewed interest in the feasibility and efficacy of purely behavioral treatments for clinical depression. Emphasizing the functional aspects of depressive and nondepressive behavior, these treatments focus on the concept of behavioral activation, which guides implementation of procedures aimed at increasing patient activity and access to reinforcement. Although researchers have provided positive preliminary support for behavioral activation-based interventions, many fundamental issues concerning strategies, principles, and change processes involved in behavioral activation have yet to be addressed. In this paper, we compare and contrast contemporary behavioral activation interventions, explore strategies and process of change issues, clarify the basic behavioral principles underlying activation strategies, and outline questions that need to be addressed to improve outcomes and better understand the potential significance of behavioral activation as it pertains to the future of behavior therapy for depression.

Cognitive-behavioral treatment of late-life generalized anxiety disorder.

This study addressed the efficacy of cognitive-behavioral therapy (CBT), relative to minimal contact control (MCC), in a sample of 85 older adults (age 60 years and over) with generalized anxiety disorder (GAD). All participants completed measures of primary outcome (worry and anxiety), coexistent symptoms (depressive symptoms and specific fears), and quality of life. Results of both completer and intent-to-treat analyses revealed significant improvement in worry, anxiety, depression, and quality of life following CBT relative to MCC. Forty-five percent of patients in CBT were classified as responders, relative to 8% in MCC. Most gains for patients in CBT were maintained or enhanced over 1-year follow-up. However, posttreatment scores for patients in CBT failed to indicate return to normative functioning.

The use of daily diaries to assess the relations among mood state, overt behavior, and reward value of activities.

Recent data has sparked renewed interest in behavioral treatments for depression; however several fundamental questions remain regarding the mechanisms of such approaches. To this end, the current study directly tested the assumption that non-clinical mildly depressed individuals receive less response-contingent positive reinforcement than non-depressed individuals, indicated by less engagement in behaviors perceived as rewarding in terms of both immediate pleasure and potential for these behaviors to result in more distal rewards. The data presented support this assumption and provide support for the role of reinforcement-based strategies such as behavioral activation in the treatment of depression.

'Minor GAD': characteristics of subsyndromal GAD in older adults.

Subsyndromal emotional symptoms are common in older adults and are associated with increased disability, health care utilization, and risk for developing psychiatric disorders. The purpose of this study was to examine subsyndromal generalized anxiety disorder (GAD) in older adults. Participants included 30 older adults with diagnosable GAD, 19 with subsyndromal anxiety symptoms [minor GAD; (MGAD)], and 21 normal control volunteers (NC). Participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV and completed self-report measures of anxiety, worry, depression, and life satisfaction. Excessive worry on more days than not, difficulty controlling worry, and clinically significant distress or impairment were the diagnostic criteria endorsed by MGAD participants least often. Therefore, these criteria may be useful in distinguishing between GAD and subsyndromal GAD. Self-reported anxiety and worry also systematically differed across groups in the expected directions, with a discriminant analysis yielding good classification of the GAD and NC groups based on these measures. Categorization of MGAD participants generally was poor, with most misclassified as GAD patients. Clinical implications of these findings are discussed.

Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder.

Clinical approaches in treating and preventing suicidal behaviors in patients with borderline personality disorder (BPD) have received limited attention. To stimulate further work in this area, we present a behavioral activation treatment for depression (BATD; Lejuez, Hopko, & Hopko, 2002) that has shown promising results in treating clinically depressed patients and a theoretical conceptualization for why BATD may prove particularly useful in reducing the frequency of suicide-related behaviors and other symptoms characteristic of patients with BPD. We also present theoretical consistencies between BATD and the well-established intervention of dialectical behavior therapy (DBT; Linehan, 1993), which may allow for their practical integration, and conclude with a case study that illustrates the assimilation of these strategies in the treatment of a patient with BPD.

The effects of anxious responding on mental arithmetic and lexical decision task performance.

Anxiety-related responding and skill deficits historically are associated with performance-based problems such as mathematics anxiety, yet the relative contribution of these variables to substandard performance remains poorly understood. Utilizing a 7% carbon dioxide (CO2) gas to induce anxiety, the present study examined the impact of anxious responding on two performance tasks, mental arithmetic and lexical decision. Independent variables included math anxiety group, gender, and gas condition. Dependent variables included task performance and physiological and self-report indices of anxiety. A total of 64 university undergraduate students participated. Physiological and verbal-report measures of anxiety supported the utility of 7% carbon dioxide-enriched air as an anxiety-inducing stimulus. Behavioral disruption on performance tasks, however, did not differ as a function of carbon dioxide inhalation. Performance did differ as a function of math anxiety. High math anxious individuals generally exhibited higher error rates on mathematical tasks, particularly on tasks designed to measure advanced math skill and those requiring working memory resources. These findings are discussed with reference to processing efficiency theory, discordance among anxiety response systems, and the intricacies associated with skill measurement.

Assessing worry in older adults: confirmatory factor analysis of the Penn State Worry Questionnaire and psychometric properties of an abbreviated model.

The assessment of worry among older adults typically has involved measures designed with younger cohorts. Because of special concerns in assessing older adults, modifications to existing instruments may be necessary. Addressing equivocal factor analytic data on the Penn State Worry Questionnaire (PSWQ) among younger adults, the authors conducted confirmatory factor analyses to evaluate the generalizability of previous models to older adults with generalized anxiety disorder. Data fit poorly with established single- and two-factor models. The single-factor model was modified, resulting in the elimination of 8 items, strong fit indices, high internal consistency, adequate test-retest reliability, and good convergent and divergent validity. Further psychometric work is required to assess whether the revised model is a more parsimonious method to assess late-life anxiety.

Effects of emotion on pain reports, tolerance and physiology.

The effects of specific emotional states on a laboratory pain task were tested by examining the behavioural, verbal and psychophysiological responses of 80 student volunteers (50% female). Participants were assigned to one of four Velten-style emotion-induction conditions (ie, anxiety, depression, elation or neutral). The sexes of experimenters were counterbalanced. Overt escape behaviour (ie, pain tolerance), pain threshold and severity ratings, verbal reports of emotion and physiological measures (ie, electrocardiogram, corrugator and trapezium electromyogram) were recorded. A pressure pain task was given before and after the emotion induction. As predicted, those who participated in the anxiety or depression condition showed reduced pain tolerance after induction of these negative emotions; pain severity ratings became most pronounced in the depression condition. Emotion induction did not have a discernable effect on pain tolerance or severity ratings in the elation condition. A pattern of participant and experimenter sex effects, as well as trials effects, was seen in the physiological data. The influence of negative affective states (ie, anxiety and depression) on acute pain are discussed along with the unique contributions of behavioural, verbal and physiological response systems in understanding the interactions of pain and emotions.

Cognitive behavioral treatment for older adults with generalized anxiety disorder. A therapist manual for primary care settings.

At least four academic clinical trials have demonstrated the utility of cognitive behavior therapy (CBT) for older adults with generalized anxiety disorder (GAD). These data may not generalize, however, to more heterogeneous and functionally impaired patients and the medical settings in which they typically receive care. A recent pilot project suggested the potential benefits of a new version of CBT for GAD among older patients in primary care. The manual developed and tested in this pilot project is presented here. Treatment components include motivation and education, relaxation skills, cognitive therapy, problem-solving-skills training, exposure exercises, and sleep-management-skills training. Procedures are designed to be administered flexibly to maximize attention to individual patient needs. Examples of session summaries, patient handouts, and homework forms are provided.