Psychological treatment of cardiovascular disease.

Recent clinical research on the psychological treatment of cardiovascular diseases is reviewed in four categories: hypertension, cardiac arrhythmias, coronary artery disease, and peripheral circulatory disease. In the treatment of hypertension biofeedback of blood pressure, electromyography and galvanic skin responses both seem useful, as does systematic relaxation training of either an active or passive-meditative nature. Biofeedback of heart rate has shown some utility in treating premature ventricular contractions and sinus tachycardia. Supportive and educational group therapy for patients recovering from myocardial infarctions has shown some utility. In the treatment of Raynaud's disease, biofeedback of skin temperature is helpful. In no area has a large scale clinical trial been conducted, and only three controlled group outcome studies have been reported (two in hypertension, one in coronary artery disease). Overall, the evidence is impressive enough to warrant more systematic controlled investigation in all four areas.

Gender identity change in transsexuals. Follow-up and replications.

An apparently successful change in gender identity of an adolescent transsexual was reported several years ago. Gender-specific motor behavior, appropriate sex role social behavior, cognitive sexual activity, and finally sexual arousal patterns were defined, measured, and sequentially modified. In this report, a 6 1/2-year follow-up is presented and the application of a similar therapeutic package to two additional cases is described. In the first case, sweeping changes in gender identity, sex-role behavior, and sexual arousal patterns were observed. In the second of these cases, rigid feminine gender was given up, but the patient chose to retain homosexual arousal. Social adaptation was satisfactory. These findings and other recent developments point to the possibility of psychosocial intervention as an alternative to surgery in the treatment of transsexualism.

The components of rapists' sexual arousal.

The erections of rapists and nonrapists were measured during audio descriptions of rape and nonrape sexual scenes. On the basis of their erection measures, rapists were separated from nonrapists in that the former developed erections to rape descriptions while the latter did not. The method also discriminated those rapists with the highest frequency of rape, those who had injured their victim, and those who chose children as victims.

Reliability of DSM-III anxiety disorder categories using a new structured interview.

The reliability of DSM-III anxiety disorder diagnoses was determined using a new structured interview, the Anxiety Disorders Interview Schedule (ADIS). Two interviewers examined 60 consecutive outpatients at an anxiety disorders clinic and assigned primary and secondary diagnoses based on the ADIS. The kappa statistic, calculated on the basis of perfect matches on primary diagnoses, indicated good agreement for anxiety, affective, and adjustment disorders, as well as for the specific anxiety disorder categories of agoraphobia, panic, social phobia, and obsessive-compulsive disorder, but not for generalized anxiety disorder. We evaluated the causes for diagnostic disagreement, particularly in relation to the difficult differentiation between generalized anxiety disorder and other anxiety disorders.

Temperature biofeedback in the treatment of migraine headaches: a controlled evaluation.

After an initial four-week baseline phase, during which daily records of headache frequency and intensity and daily medication records were kept, 30 patients with frequent (at least one per month) migraine headaches were randomly assigned to three conditions: (1) temperature biofeedback, autogenic training, and regular home practice; (2) progressive relaxation with regular home practice; and (3) a waiting-list control condition. Comparisons of headache data from the four weeks of baseline and last two weeks of treatment showed that both the relaxation and biofeedback groups improved significantly on total headache activity, duration of headaches, and peak headache intensity and reduced consumption of analgesic medication, while the waiting list control group did not. All three groups showed significant decreases in headache frequency. Although the relaxation training was more effective than biofeedback training at the last week of treatment, follow-up data at one, two, and three months showed no differences between the two treated groups on any dependent measure.

Generalized anxiety and generalized anxiety disorder: description and reconceptualization.

One hundred eight patients complaining of anxiety were diagnosed using the Anxiety Disorders Interview Schedule and classified into the various anxiety disorder categories as well as major depression. Although patients with a primary diagnosis of generalized anxiety disorder were more chronic than were panic disorder patients, most patients in each category met the DSM-III criteria for generalized anxiety disorder with the exception of simple phobic patients. On the basis of these data, it would seem that generalized anxiety disorder is a residual category within the anxiety disorders, since generalized anxiety disorder symptoms are almost always present. But if one distinguishes anticipatory anxiety, which is often part of panic or phobic disorders, from generalized anxiety, an independent anxiety disorder category emerges. This category is characterized by apprehensive expectation or chronic worry focused on multiple life situations.

Nonpharmacologic treatment of chronic headache: prediction of outcome.

We studied the ability of headache history, a 4-week headache diary, standard psychological tests, and laboratory measures of psychophysiologic responses to stress to predict the outcome of relaxation therapy and biofeedback for three types of chronic headache. Using canonical discriminant function analyses, each potential predictor set was tested separately, and all four were tested together. Information from the headache history alone correctly classified 89 to 95% of patients as improved or unimproved. No other single predictor set was consistently better than headache history. When all four predictor sets were combined, prediction improved; 93 to 100% of patients were correctly classified.

Behavioral and prophylactic pharmacological intervention studies of pediatric migraine: an exploratory meta-analysis.

In this review, the effectiveness of behavioral and pharmacological treatments for pediatric migraine was quantitatively summarized following the meta-analytic approach outlined by Hedges and Olkin (1985). A first meta-analysis based on treatment outcome within treatment conditions revealed that thermal biofeedback and interventions combining biofeedback and progressive muscle relaxation seem to be significantly more efficacious than other behavioral treatment modalities, psychological and drug placebo, and the more commonly used prophylactic drug regimens. Though there is some evidence suggesting good effectiveness of propranolol, the lack of systematic data precludes more definitive conclusions. A second meta-analysis that included only studies providing data on the comparison between control versus active treatment conditions replicated the initial findings only partially. In the light of the relative small number of studies that met basic inclusion requirements, the methodological flaws of many studies, and the under-representation of certain treatment types, conclusions regarding differential effectiveness of the treatment types have to be drawn with caution. Overall, our findings clearly demonstrate the need for direct comparisons between behavioral and pharmacological treatments and the need for more theory-driven research in order to determine the most promising treatment approaches for pediatric migraine.

A multilevel data-analytic approach for evaluation of relationships between daily life stressors and symptomatology: patients with irritable bowel syndrome.

Four statistical strategies were used to evaluate whether occurrence of daily stressors increases lower gastrointestinal (GI) symptoms in irritable bowel syndrome (IBS) patients. Across-subject concurrent correlations between weekly stress and symptoms were positive but casually ambiguous and obscured between- and within-subject and occasion relationships. Multiple regressions assessing (weekly and daily) relations showed that prior symptoms predicted subsequent symptoms but that prior and concurrent daily stress had no consistent effects. Idiographic correlations also showed little evidence for a relationship between stress and symptoms. Daily stress did not appear to increase GI symptoms in IBS patients on a general basis. Daily recording methodology, in conjunction with within-subject analytic strategies, is proposed as an innovative approach to examine relations between stress and physical symptomatology.

Specificity in social support: perceptions of helpful and unhelpful provider behaviors among irritable bowel syndrome, headache, and cancer patients.

Perceived social support was assessed among 53 patients suffering from non-life-threatening chronic illnesses (i.e., irritable bowel syndrome or recurrent headache). Subjects recalled predominantly helpful support interactions and reported the three major types of social support as equally helpful. In addition, irritable bowel syndrome patients, who experience embarrassing physical symptoms, reported fewer instances of tangible assistance than chronic headache patients. Comparisons to cancer patients studied by Dakof and Taylor (1990) revealed differences in perceived social support as a function of diagnosis. These results offer insight into the needs of patients with noncatastrophic illnesses and suggest that the challenges and tasks confronting these individuals are unique from those encountered by patients with catastrophic diseases.

A controlled comparison of thermal biofeedback and relaxation training in the treatment of essential hypertension: II. Effects on cardiovascular reactivity.

In the course of conducting a controlled comparison of progressive muscle relaxation and thermal biofeedback as possible substitutes for second-stage (sympatholytic) antihypertensive medications, we measured reactivity (heart rate, systolic blood pressure, and diastolic blood pressure) to three different stressors (mental arithmetic, cold pressor, and negative mental imagery) before and after treatment and drug withdrawal. Neither treatment was consistently effective in reducing reactivity across a variety of stressors. Relaxation led to more reductions in some aspect of reactivity than did biofeedback. The modest level of reductions in reactivity were seen more for mental arithmetic and systolic blood pressure.

Effects of 24-hour ambulatory blood pressure monitoring on daily activities.

Compared the self-monitored activities, locations, and postural positions of 28 hypertensives while they wore an alarm watch and then while they wore a 24-hr ambulatory blood pressure monitor (ABPM) to see if wearing the ABPM led to alterations in behavior. Within the limitations of the study (no counterbalancing of order and twice as many ABPM measures as watch measures), we found significant differences in frequency of being at home or in miscellaneous settings, in standing and reclining positions, and in mental, physical and miscellaneous activities between the two occasions.

The USA-USSR collaborative cross-cultural comparison of autogenic training and thermal biofeedback in the treatment of mild hypertension.

We have conducted a cross-cultural (USA and USSR) comparison of thermal biofeedback (TBF) and autogenic training (AT) to a self-relaxation control condition in 59 unmedicated males with mild hypertension. Identical assessment and treatment protocols were carried out in both settings (Albany, New York, and Moscow). Treatments were delivered in small groups on an outpatient basis twice per week for 10 weeks. Results showed comparable, significant (p less than .05), short-term decreases (M = 8.5 mm Hg) in diastolic blood pressure (DBP) for both treatments at both sites. However, the Soviet patients, starting with significantly (p less than .01) higher systolic blood pressures (SBPs), showed significant decreases (M = 12.8 mm Hg) in SBP, whereas the American patients did not change appreciably (M = 4.6 mm Hg). During follow-up, the treated Soviet patients showed significantly (p less than .05) better maintenance of treatment effects, from 3 months to 1 year, than did the American patients. At 1 year, 75% of the treated Soviet patients had DBPs less than 90 mm Hg, whereas only 24% of the American patients had comparable DBPs.

Information processing and PTSD: a review of the empirical literature.

This article reviews a series of studies that have utilized information-processing paradigms with posttraumatic stress disorder (PTSD) populations. The review suggests that pretrauma measures of intelligence (IQ) are predictive of the development of PTSD symptoms following trauma. There is also evidence of impaired performance on standardized tests of memory (independent of IQ) in PTSD populations. PTSD populations are found to exhibit deficits in memory function that may be due to hippocampus damage secondary to excessive neuroendocrine responses to conditioned stimuli. In addition, individuals with PTSD evince an attentional bias towards trauma-related stimuli at postrecognition stages of information processing. The review also includes that there is insufficient evidence to either support, or reject, the theoretical proposition that PTSD patients are sensitive to global valence effects at the earliest stages of information processing relative to traumatized non-PTSD populations. Finally, there is some evidence to suggest that the processes associated with autobiographical memory in PTSD populations are similar to those seen in depression. The implications of these findings for the behavioral and cognitive treatment of PTSD are discussed. Directions for future research with such paradigms are also discussed in light of contemporary information processing theories of PTSD.

Psychological treatment of benign headache disorders.

This article presents a selective summarization and critique of research on the psychological treatment of headache, with the primary focus on research appearing since 1980. Suggestions for future research directions and methodological improvements are included.

Cognitive therapy for irritable bowel syndrome.

Twenty patients with irritable bowel syndrome (IBS) were randomly assigned either to intensive, individualized cognitive therapy (10 sessions over 8 weeks) or to 8 weeks of daily gastrointestinal (GI) symptom monitoring. Pre- to posttreatment evaluations showed significantly (p = .005) greater GI symptom reduction for those receiving cognitive therapy than for those in symptom monitoring. At posttreatment, 80% of the cognitive therapy group showed clinically significant improvement, whereas only 10% of the monitoring group showed this. Results held up well at a 3-month follow-up. Within the cognitive therapy group, GI symptom reductions correlated significantly with increases in positive and reductions in negative automatic thoughts.

A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome.

Thirty-four patients with irritable bowel syndrome were randomly assigned to 1 of 3 treatment conditions: individualized cognitive treatment (CT), self-help support group (SG), or symptom-monitoring waiting-list control (WL). Each of the 3 conditions lasted approximately 8 weeks. Pre- to posttreatment analyses revealed significantly greater reductions in both individual gastrointestinal (GI) symptoms and in a composite index for GI symptom change for the CT condition than for the SG or WL conditions. When compared with the SG and WL conditions, the CT condition also showed significant improvement on psychological measures of depression and anxiety. At 3-month follow-up, the results for the CT condition were maintained and revealed further numerical improvements.

Biofeedback treatment for pediatric migraine: prediction of treatment outcome.

Despite a growing number of studies showing good effectiveness of nonpharmacological treatments such as thermal biofeedback (TBF) for pediatric migraine, little is known about psychosocial variables that might be predictive of treatment outcome. The identification of predictors appears especially important when children are treated in a home-based treatment format that tends to be somewhat less effective than a therapist-administered treatment. A total of 32 children between the ages 8 and 16 years completed a home-based TBF treatment program with treatment outcome being of similar magnitude as previously reported in the literature. Multiple regression analysis revealed externalizing behavior tendencies, initial level of psychosomatic complaints, and the child's age to be highly predictive of outcome, whereas dimensions of family functioning failed to exert a direct influence. The implications of these findings for the development and evaluation of future treatment programs are discussed.

The role of regular home practice in the relaxation treatment of tension headache.

This study evaluated the contribution of regular home practice in the treatment of tension headache (HA) with progressive muscle relaxation (PMR) by giving 14 tension HA sufferers 10 sessions (over 8 weeks) of standard PMR with home practice and application instructions while 13 additional patients received the same PMR training (except for the omission of cue-controlled relaxation) with no home practice or application instruction. A third group of 6 patients merely monitored HA activity. Both treated groups showed significant reduction in HA activity, whereas the symptom monitoring group did not change. The 2 treated groups did not differ. On a measure of clinically significant reduction in HA activity (at least 50% reduction in HA activity), however, the group receiving home practice instruction (50%) showed a trend (p = .056) to improve more than did those receiving PMR without home practice (15%).

The role of home practice in thermal biofeedback.

The role of regular home practice of hand warming was examined in the thermal biofeedback (TBF) treatment of vascular (migraine and mixed migraine and tension) headache (HA) by giving 12 sessions (over 6 weeks) of TBF to two groups of vascular HA patients (n = 23 per group). One group was asked to practice regularly at home with a home trainer between clinic sessions, whereas no mention of practice was made to the other group. A third group merely monitored HAs. Treatment was superior to no treatment. There was no advantage for the group receiving home practice, either in headache reduction or in acquisition of the hand-warming response.