EXPLORING PERSONALITY DIAGNOSIS STABILITY FOLLOWING ACUTE PSYCHOTHERAPY FOR CHRONIC POSTTRAUMATIC STRESS DISORDER.

BACKGROUND: Axis I comorbidity complicates diagnosing axis II personality disorders (PDs). PDs might influence Axis I outcome. No research has examined psychotherapy effects on PDs of treating Axis I comorbidity. Secondary analysis of a randomized controlled trial examined PD diagnostic stability after brief psychotherapy of chronic posttraumatic stress disorder (PTSD). METHODS: Patients with chronic PTSD were randomly assigned to 14 weeks of prolonged exposure, interpersonal psychotherapy, or relaxation therapy. Assessments included the Structured Clinical Interview for DSM-IV, Patient Version (SCID-P) and Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) at baseline, week 14, and for treatment responders (≥30% clinician-administered PTSD scale improvement, defined a priori) at week 26 follow-up. We hypothesized patients whose PTSD improved would retain fewer baseline PD diagnoses posttreatment, particularly with personality traits PTSD mimics, e.g. paranoid and avoidant. RESULTS: Forty-seven (47%) of 99 SCID-II patients evaluated at baseline received a SCID-II diagnosis: paranoid (28%), obsessive-compulsive (27%), and avoidant (23%) PDs were most prevalent. Among 78 patients who repeated SCID-II evaluations posttreatment, 45% (N = 35) had baseline PD diagnoses, of which 43% (N = 15/35) lost at week 14. Three (7%) patients without baseline PDs acquired diagnoses at week 14; 10 others shifted diagnoses. Treatment modality and PTSD response were unrelated to PD improvement. Of treatment responders reevaluated at follow-up (N = 44), 56% with any baseline Axis II diagnosis had none at week 26. CONCLUSION: This first evaluation of Axis I psychotherapy effects on personality disorder stability found that acutely treating a chronic state decreased apparent trait-across most PDs observed. These exploratory findings suggest personality diagnoses may have limited prognostic meaning in treating chronic PTSD.

Is Exposure Necessary? A Randomized Clinical Trial of Interpersonal Psychotherapy for PTSD.

OBJECTIVE: Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). The authors tested interpersonal psychotherapy (IPT), which has demonstrated antidepressant efficacy and shown promise in pilot PTSD research as a non-exposure-based non-cognitive-behavioral PTSD treatment. METHOD: The authors conducted a randomized 14-week trial comparing IPT, prolonged exposure (an exposure-based exemplar), and relaxation therapy (an active control psychotherapy) in 110 unmedicated patients who had chronic PTSD and a score >50 on the Clinician-Administered PTSD Scale (CAPS). Randomization stratified for comorbid major depression. The authors hypothesized that IPT would be no more than minimally inferior (a difference <12.5 points in CAPS score) to prolonged exposure. RESULTS: All therapies had large within-group effect sizes (d values, 1.32-1.88). Rates of response, defined as an improvement of >30% in CAPS score, were 63% for IPT, 47% for prolonged exposure, and 38% for relaxation therapy (not significantly different between groups). CAPS outcomes for IPT and prolonged exposure differed by 5.5 points (not significant), and the null hypothesis of more than minimal IPT inferiority was rejected (p=0.035). Patients with comorbid major depression were nine times more likely than nondepressed patients to drop out of prolonged exposure therapy. IPT and prolonged exposure improved quality of life and social functioning more than relaxation therapy. CONCLUSIONS: This study demonstrated noninferiority of individual IPT for PTSD compared with the gold-standard treatment. IPT had (nonsignificantly) lower attrition and higher response rates than prolonged exposure. Contrary to widespread clinical belief, PTSD treatment may not require cognitive-behavioral exposure to trauma reminders. Moreover, patients with comorbid major depression may fare better with IPT than with prolonged exposure.

Apples don't fall far from the tree: influences on psychotherapists' adoption and sustained use of new therapies.

OBJECTIVE: The purpose of this investigation was to identify influences on the current clinical practices of a broad range of mental health providers as well as influences on their adoption and sustained use of new practices. METHODS: U.S. and Canadian psychotherapists (N=2,607) completed a Web-based survey in which they rated factors that influence their clinical practice, including their adoption and sustained use of new treatments. RESULTS: Empirical evidence had little influence on the practice of mental health providers. Significant mentors, books, training in graduate school, and informal discussions with colleagues were the most highly endorsed influences on current practice. The greatest influences on psychotherapists' willingness to learn a new treatment were its potential for integration with the therapy they were already providing and its endorsement by therapists they respected. Clinicians were more often willing to continue to use a new treatment when they were able to effectively and enjoyably conduct the therapy and when their clients liked the therapy and reported improvement. CONCLUSIONS: Implications for dissemination and sustained use of new psychotherapies by community psychotherapists are discussed. For example, evidence-based treatments may best be promoted through therapy courses and workshops, beginning with graduate studies; to ensure future use of new therapies, developers of training workshops should emphasize ways to integrate their approaches into clinicians' existing practices.

Comparative Case Study of Diffusion of Eye Movement Desensitization and Reprocessing in Two Clinical Settings: Empirically Supported Treatment Status Is Not Enough.

An in-depth comparative case study was conducted of two attempts at diffusion of an empirically supported, but controversial, psychotherapy: eye movement desensitization and reprocessing (EMDR). One Department of Veterans Affairs (VA) treatment setting in which there was substantial uptake was compared with a second VA setting in which it was not adopted. Qualitative interviews were conducted with 10 mental health clinicians at the first site, and 19 at the second. Critical selling points for EMDR were a highly regarded champion, the observability of effects with patients, and personally experiencing its effects during a role training session. Compatibility with existing psychotherapist practices and values further allowed the therapy to become embedded in the organizational culture. At the second site, a sense that EMDR was not theoretically coherent or compelling overwhelmed other considerations, including its empirical status. Comparative studies contrasting settings in which innovative therapies are implemented versus those in which they were rejected may aid in refining theories of and strategies for dissemination.

Influential psychotherapy figures, authors, and books: An Internet survey of over 2,000 psychotherapists.

In a partial replication and extension of a survey conducted 25 years ago (Smith, 1982), over 2,400 North American psychotherapists completed a Web-based survey in which they identified prominent figures in the psychotherapy field who have most influenced their practice and the best psychotherapy books they had read in the past 3 years. There is a continued prominence to leaders of the field from 25 years ago but who are now deceased, notably the top-ranked Carl Rogers. Three books on the top-10 list represent empirically supported therapies (ESTs); two are treatment manuals for an EST, and one is a self-help book derived from an EST that has itself been shown to be efficacious bibliotherapy. Differences between psychologist and nonpsychologist therapists in the choice of influential figures, authors, and books are negligible. Implications are discussed in terms of the contemporary context into which therapeutic innovations are disseminated, as well as the conditions that may be necessary for successful dissemination. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Barriers to adoption of new treatments: an internet study of practicing community psychotherapists.

Over 1,600 North American psychotherapists from a wide range of disciplines and practice settings completed an open-ended question on perceived barriers to adoption of new treatments as part of an internet survey. Content analysis indicated that there were five overall themes: clinician attitudes, client characteristics, contextual or institutional factors, training issues and other. The most frequently endorsed theme revolved around training issues, particularly, insufficient time and cost for training, lack of confidence in mastering the technique, and lack of opportunities for refining skills. Specific ideas for overcoming these barriers are identified.

Older primary care patients' willingness to consider discontinuation of chronic benzodiazepines.

OBJECTIVE: To examine factors related to older primary care patients' willingness to consider tapering/discontinuation of long-term benzodiazepine use. METHOD: Forty-six long-term anxiolytic benzodiazepine users, aged 61-95 years, were assessed over the telephone using a semi-structured qualitative interview and standardized self-report questionnaires for anxiety (Beck Anxiety Inventory), sleep quality (Pittsburgh Sleep Quality Index), depression (Center for Epidemiological Studies Depression Scale), psychological dependence on benzodiazepines (Severity of Dependence Scale), and anxiety sensitivity (Anxiety Sensitivity Index). RESULTS: Frequency of daily benzodiazepine intake and anxiety sensitivity significantly contributed to willingness to attempt taper/discontinuation of benzodiazepines. CONCLUSION: Many older long-term benzodiazepine users and their physicians perceive tapering of use an arduous, low priority, time-intensive task. These findings highlight factors that can help identify a subpopulation of older patients who may be easier to engage in the discontinuation process.

Older patient perspectives on long-term anxiolytic benzodiazepine use and discontinuation: a qualitative study.

OBJECTIVE: The objective of the study is to understand patient factors contributing to the chronicity of benzodiazepine use by older adults as a first step in the development of acceptable intervention strategies for taper/discontinuation or prevention of chronic use. DESIGN: The design of the study consists of qualitative semi-structured patient interviews. SETTING AND PARTICIPANTS: The participants were 50 anxiolytic benzodiazepine users, 61-95 years of age, recruited through referrals from primary care physicians who practiced in the general Philadelphia, Pennsylvania area. RESULTS: Many older chronic users have come to rely and psychologically depend on benzodiazepines for their unique soothing properties, attributing to these medications characteristics that extend beyond an ordinary medication, i.e., affording control over daily stress, bringing tranquility, and even prolonging life. Most of the patients denied or minimized side effects and expressed resistance to taper or discontinuation, ranging from subtle reluctance to outright refusal and fear of being left suffering without these medications. CONCLUSIONS: The reluctance of older chronic benzodiazepine users to taper or discontinue use highlights the importance of prevention and early intervention strategies to avoid the development of chronic use. Suggestions for curbing chronic use are presented.