Cognitive therapy versus Rogerian supportive therapy in borderline personality disorder. Two-year follow-up of a controlled pilot study.

BACKGROUND: To date, there have been no studies comparing cognitive therapy (CT) with Rogerian supportive therapy (RST) in borderline personality disorder. METHOD: Sixty-five DSM-IV borderline personality disorder outpatients were recruited at 2 centres: Lyon and Marseille. Thirty-three patients were randomly allocated to CT and 32 to RST. The therapists were the same in both groups. Both treatments shared the same duration (1 year) and amount of therapy. Assessment by independent evaluators utilised the Clinical Global Impression (CGI) Scale, the Hamilton Depression Scale, Beck Depression Inventory, Beck Anxiety Inventory, Hopelessness Scale, Young Schema Questionnaire II, Eysenck Impulsivity Venturesomeness Empathy (IVE) Inventory, a self-harming behaviours checklist and scales measuring quality of life and the therapeutic relationship. The response criterion was a score of 3 or less on the CGI, associated with a Hopelessness Scale score of <8. RESULTS: No patient committed suicide during the trial. Fifty-one patients were evaluated at week 24, 38 at week 52 and 21 at week 104. Cognitive therapy retained the patients in therapy for a longer time. The response criterion found no significant between-group differences at any measurement point in the completers. However, at week 24, CT was better than RST on the Hopelessness Scale, IVE scale and regarding the therapeutic relationship. At week 104, the CGI improvement (patient and evaluator) was significantly better in CT than in RST. High baseline depression and impulsivity predicted dropouts. CONCLUSIONS: CT retained the patients in therapy longer, showed earlier positive effects on hopelessness and impulsivity, and demonstrated better long-term outcomes on global measures of improvement.

[A clinical trap: acute and chronic psychogenic dyspnea]. / Un piège clinique: les dyspnées psychogènes aiguës et chroniques.

Psychogenic dyspnea may be part of two main clinical pictures. The first one is acute with dyspnea in the foreground of a panic disorder with or without agoraphobia. The second one is chronic, dyspnea being a background symptom of a generalized anxiety disorder. The problems related to the diagnosis and the implementation of psychological or pharmacological treatments are reviewed with reference to evidence-based medicine.

Randomized controlled comparison of cognitive behavior therapy with Rogerian supportive therapy in chronic post-traumatic stress disorder: a 2-year follow-up.

BACKGROUND: To date, there have been no studies comparing cognitive behavior therapy (CBT) with Rogerian therapy in post-traumatic stress disorder. METHOD: Sixty outpatients with DSM-IV chronic post-traumatic stress disorder were randomized into two groups for 16 weekly individual sessions of CBT or Rogerian supportive therapy (ST) at two centers. No medication was prescribed. Measures included the Post-Traumatic Stress Disorder Checklist Scale (PCLS), the Hamilton Anxiety Scale, Beck Depression Inventory, and Quality of Life. The general criterion of improvement (GCI) was a score of less than 44 on the PCLS. RESULTS: Forty-two patients were evaluated at post-test, 38 at week 52 and 25 at week 104. At post-test, the rate of patients leaving the trial due to worsening or lack of effectiveness was significantly higher in the ST group (p = 0.004). At this point, no between-group difference was found on the GCI and any of the rating scales. Intent-to-treat analysis found no difference for the GCI, but patients in the CBT group showed greater improvement on the PCLS and Hamilton Anxiety Scale. Naturalistic follow-up showed sustained improvement without between-group differences at weeks 52 and 104. CONCLUSIONS: CBT retained significantly more patients in treatment than ST, but its effects were equivalent to those of ST in the completers. CBT was better in the dimensional intent-to-treat analysis at post-test.

Specificity of belief domains in OCD: validation of the French version of the Obsessive Beliefs Questionnaire and a comparison across samples.

This paper assesses the psychometric properties of the French version of the Obsessive Beliefs Questionnaire (OBQ-44) and investigates whether the questionnaire discriminates between obsessive-compulsive disorder (OCD), anxious control (AC), and non-clinical control (NCC) participants. A confirmatory factor analysis suggested a poor fit of the model. An exploratory factor analysis replicated the original factor structure. The subscales were moderately intercorrelated and highly correlated with the total score. There was partial support for convergent/divergent validity of the OBQ-44. In analyses of variance comparing the three samples, the participants in the OCD sample scored significantly higher than the participants in the AC and NCC samples on all of the OBQ-44 scores. In analyses of covariance comparing the OCD and NCC samples while controlling for general distress and age, the participants with OCD scored significantly higher than the NCC participants on all of the OBQ-44 scores. Implications of the current study are discussed.

Brain serotonin synthesis capacity in obsessive-compulsive disorder: effects of cognitive behavioral therapy and sertraline.

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[11C]methyl-L-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[11C]methyl-L-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

Prevention of implantable defibrillator shocks by cognitive behavioral therapy: a pilot trial.

BACKGROUND: Although psychological stress is known to favor ventricular arrhythmic events, there is no evidence that stress management intervention decreases ventricular electrical instability in implantable cardioverter-defibrillator (ICD) patients. The aim of the study was to determine whether cognitive behavioral therapy (CBT) results in a decrease of arrhythmic events requiring ICD intervention through an improvement in sympathovagal balance. METHODS: Of 253 consecutive ICD patients (age 59 +/- 10 years, 64 men), 70 were randomly assigned to CBT (n = 35) or conventional medical care (n = 35). Measures of heart rate variability, psychological well-being, and quality of life were assessed at baseline, 3 months, and 1 year. The primary outcome was appropriate ICD shock. RESULTS: Although, it was not statistically different, the number of patients requiring shocks was less in the CBT group than in the conventional treatment group. At 3 months, among patients without antiarrhythmic drugs, none of the subjects in the CBT group had experienced arrhythmic events requiring ICD intervention, as compared with 4 in the control group (P < .05). At 12 months, there was no difference in the number of arrhythmic events requiring therapy between the CBT group versus the control group. Among heart rate variability indexes, daytime pNN 50 and nocturnal SDNN improved significantly in the CBT group, as compared with the control group. CONCLUSIONS: By decreasing anxiety and possibly improving sympathovagal balance, cognitive behavior therapy may decrease the propensity for ventricular arrhythmias in ICD patients. However, these effects appear to be limited over time.

Recent developments in research and treatment for social phobia (social anxiety disorder).

PURPOSE OF REVIEW: This review covers three themes of research that brought fresh data useful for clinical practice in a handicapping anxiety disorder: social phobia. Recent findings deriving from basic biological research, new forms of psychological therapies, and recent psychopharmacology controlled trials are reviewed. RECENT FINDINGS: The basic neuroimaging research suggests that greater activation of the amygdala to novel versus familiar faces may be an underlying trait marker for social phobia. Social phobia may represent a phenotype that expresses a genetically driven trait of social withdrawal, which may be related to infantile inhibited temperament (Kagan's syndrome). The development of virtual reality therapy as therapeutic tool for social phobia appeared promising in one controlled, but not randomized, study. A controlled study suggests that social phobias in children can be effectively treated with cognitive behavioural therapy. This represents an extension of the work done with adults. Venlafaxine appears an effective short-term treatment for social anxiety disorder in two controlled studies. A new compound, pregabalin, appeared clearly effective in a positive controlled study. This trial marks the advent of a new pharmacological lineage for social phobia. Both venlafaxine and pregabalin, however, have been studied in short-term studies. Longer follow-up and relapse prevention studies are warranted. SUMMARY: Neuroimaging research points to a temperamental basis for social phobia. Virtual reality therapy is an emerging tool to carry out exposure treatment. Group cognitive behavioural therapy can be extended successfully to children. Venlafaxine and pregabalin have a proven short-term effectiveness in social phobia.

Nonpharmacological treatments for anxiety disorders.

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.

Musical obsessions: a comprehensive review of neglected clinical phenomena.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Behavioral versus cognitive treatment of obsessive-compulsive disorder: an examination of outcome and mediators of change.

OBJECTIVE: To examine symptom change over time, the effect of attrition on treatment outcome, and the putative mediators of cognitive therapy (CT) versus behavior therapy (BT) for obsessive-compulsive disorder (OCD) using archival data. METHOD: Sixty-two adults with OCD were randomized to 20 sessions of CT (N = 30) or BT (N = 32) that consisted of 4 weeks of intensive treatment (16 hr total) and 12 weeks of maintenance sessions (4 hr). Independent evaluators assessed OCD severity using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and at Weeks 4, 16 (posttreatment), 26, and 52 (follow-up). Behavioral avoidance, depressive symptoms, and dysfunctional beliefs regarding responsibility were also measured at each assessment. Study hypotheses were tested using multilevel modeling. RESULTS: The slope of change in Y-BOCS scores was significantly greater in BT than in CT (d = 0.69), and those receiving BT had lower Y-BOCS scores at the final assessment than those receiving CT (d = 1.17). The greater slope of change in BT versus CT did not differ for dropouts versus completers. Reduction in depressed mood mediated changes in Y-BOCS across the 2 treatments, but a reduction in sense of responsibility and a decrease in avoidance did not. Instead, Y-BOCS improvements appeared to precede a decrease in avoidance. CONCLUSIONS: BT may have some therapeutic advantage over CT in the treatment of OCD, and this advantage does not appear to be due to a differential pattern of responding for treatment dropouts versus completers. Further, inconsistent with hypotheses, improvements in OCD symptoms were mediated by reductions in depressed mood instead of decreases in avoidance and responsibility. Theoretical, methodological, and clinical implications are discussed.

Combining Pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder.

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.

The validation of the Posttraumatic Stress Disorder Checklist Scale in posttraumatic stress disorder and nonclinical subjects.

BACKGROUND: The Posttraumatic Stress Disorder Checklist Scale (PCLS) is a short self-report inventory for assessing the 3 main syndromes of Posttraumatic Stress Disorder (PTSD). The aim of this study was the validation of the French version of the PCLS in PTSD subjects and nonclinical subjects. METHODS: One-hundred and thirteen outpatients suffering from PTSD according to DSM-IV were administered the PCLS. The patients' scores on the PCLS were then compared to those of 31 nonclinical control subjects. Thirty-five of the patients were administered the PCLS twice over an interval of 1-2 weeks and also completed questionnaires measuring depression, phobia and anxiety. RESULTS: The patients' total score and subscores on the PCLS were found to be significantly higher than those of control subjects. The cutoff score of 44 on the French version PCLS distinguishes well between the PTSD group and control group with a high diagnostic efficacy (0.94). Factor analysis revealed 3 main factors corresponding to the reexperiencing, numbing and hyperarousal syndromes. The PCLS showed satisfactory test-retest reliability and internal consistency. CONCLUSIONS: The PCLS is therefore a valid and effective measurement of PTSD. It may be a useful tool for screening and assessing PTSD in psychiatric as well as in primary-care settings.