Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting.

OBJECTIVES: Exposure and response prevention (ERP) remains the most empirically supported psychological treatment for obsessive compulsive disorder (OCD). Clinical guidelines recommend the addition of cognitive approaches to ERP although the presumed additive benefits have not been directly tested. The aim of this was to compare a treatment that integrated cognitive therapy with ERP (ERP + CT) to traditional, manualized ERP to test the additive benefits. DESIGN: A longitudinal, randomized control trial design was used. METHODS: Participants (N = 127) with OCD were randomly assigned to receive individual outpatient ERP or ERP + CT. Obsessive-compulsive symptom severity measures were completed pre- and post-treatment and at 6-month follow-up. RESULTS: While both conditions led to significant symptom and obsessive belief reduction, ERP + CT led to significantly greater symptom and belief reduction as compared to ERP across all main symptom presentations of OCD. Based on a priori definitions of effectiveness, more patients in ERP + CT compared to the ERP group were also deemed treatment responders. CONCLUSIONS: The results of this study suggest that cognitive therapy can be readily integrated with ERP to improve clinical outcomes beyond ERP alone. PRACTITIONER POINTS: Both ERP and ERP + CT were effective, however a course of ERP + CT was significantly more effective at reducing symptoms of OCD than the ERP treatment condition. Significantly more participants who received ERP + CT experienced clinically significant change in OCD symptoms compared to those who received ERP. OCD symptom dimension did not significantly impact response to either ERP or ERP + CT treatments.

Predictors and moderators of between-therapists and within-therapist differences in depressed outpatients' experiences of the Rogerian conditions.

The extent to which patients experience their therapists as providing empathy, positive regard and genuineness (the Rogerian Conditions) is an important predictor of outcome in the psychotherapy of depression (Zuroff & Blatt, 2006). Using data from 157 depressed outpatients treated by 27 therapists in the cognitive-behavior therapy, interpersonal therapy, or clinical management with placebo conditions of the Treatment of Depression Collaborative Research Program (Elkin et al., 1989), Zuroff, Kelly, Leybman, Blatt, and Wampold (2010) showed that between-therapists and within-therapist differences in Rogerian Conditions at the second treatment session predicted more rapid reductions in overall maladjustment. We conducted novel analyses intended to identify: 1) predictors of between-therapists and within-therapist differences in Rogerian Conditions and 2) moderators of the effects on maladjustment of between-therapists and within-therapist differences in Rogerian Conditions. Patients with lower levels of self-critical perfectionism, higher levels of an adaptive form of dependency or higher expectations of warmth from their therapists experienced higher levels of Rogerian Conditions than their therapist's average patient. High baseline self-critical perfectionism diminished the between-therapists effect of Rogerian Conditions on maladjustment, whereas baseline adaptive dependency enhanced the within-therapist effect of Rogerian Conditions. Results shed additional light on the centrality of patient characteristics, the Rogerian Conditions, and their transactions and interactions on outcome in brief outpatient therapy for depression.

Conceptualizing and Measuring Self-Criticism as Both a Personality Trait and a Personality State.

Blatt's ( 2004 , 2008 ) conceptualization of self-criticism is consistent with a state-trait model that postulates meaningful variation in self-criticism both between persons (traits) and within person (states). We tested the state-trait model in a 7-day diary study with 99 college student participants. Each evening they completed a 6-item measure of self-criticism, as well as measures of perceived social support, positive and negative affect, compassionate and self-image goals during interactions with others, and interpersonal behavior, including overt self-criticism and given social support. As predicted, self-criticism displayed both trait-like variance between persons and daily fluctuations around individuals' mean scores for the week; slightly more than half of the total variance was between persons (ICC = .56). Numerous associations at both the between-persons and within-person levels were found between self-criticism and the other variables, indicating that individuals' mean levels of self-criticism over the week, and level of self-criticism on a given day relative to their personal mean, were related to their cognitions, affect, interpersonal goals, and behavior. The results supported the construct validity of the daily self-criticism measure. Moreover, the findings were consistent with the state-trait model and with Blatt's theoretical analysis of self-critical personality.

Recalled peer relationship experiences and current levels of self-criticism and self-reassurance.

OBJECTIVES: Numerous studies have shown that personality factors may increase or decrease individuals' vulnerability to depression, but little research has examined the role of peer relationships in the development of these factors. Accordingly, this study examined the role of recalled parenting and peer experiences in the development of self-criticism and self-reassurance. It was hypothesized that, controlling for recalled parenting behaviours, specific recalled experiences of peer relationships would be related to current levels of specific forms of self-criticism and self-reassurance. DESIGN: Hypotheses were tested using a retrospective design in which participants were asked to recall experiences of parenting and peer relationships during early adolescence. This age was chosen as early adolescence has been shown to be a critical time for the development of vulnerability to depression. METHODS: A total of 103 female and 97 male young adults completed measures of recalled parenting, overt and relational victimization and prosocial behaviour by peers, and current levels of self-criticism and self-reassurance. RESULTS: Hierarchical regression analyses showed that parents and peers independently contributed to the development of self-criticism and self-reassurance. Specifically, controlling for parental care and control, overt victimization predicted self-hating self-criticism, relational victimization predicted inadequacy self-criticism, and prosocial behaviour predicted self-reassurance. As well, prosocial behaviour buffered the effect of overt victimization on self-reassurance. CONCLUSIONS: Findings highlight the importance of peers in the development of personality risk and resiliency factors for depression, and suggest avenues for interventions to prevent the development of depressive vulnerabilities in youth. PRACTITIONER POINTS: The nature of a patient's personality vulnerability to depression may be better understood through a consideration of the patient's relationships with their peers as well as with parents during adolescence. An understanding of adult patients' past peer relationships may further the therapist's understanding of the client's core schemas and dysfunctional attitudes, as well as potential transference reactions during therapy. Identifying and helping youth to better cope with peer victimization may help prevent the development of a vulnerable personality style in adulthood. Fostering positive peer relationships in adolescence may buffer the effects of other more negative relationships with peers.

Between-therapist and within-therapist differences in the quality of the therapeutic relationship: effects on maladjustment and self-critical perfectionism.

The relationship between therapeutic outcome and a patient-reported measure of the Rogerian conditions of positive regard, empathy, and genuineness was decomposed into between-therapist effects and within-therapist effects using multilevel modeling. Data were available for 157 depressed outpatients treated by 27 therapists in the cognitive-behavioral therapy, interpersonal therapy, or placebo with clinical management conditions of the Treatment of Depression Collaborative Research Program (Elkin, 1994). Consistent with prior findings of significant between-therapist variability in outcome (e.g., Baldwin, Wampold, & Imel, 2007), patients whose therapists provided high average levels of the perceived Rogerian conditions across the patients in their caseloads experienced more rapid reductions in both overall maladjustment and depressive vulnerability (self-critical perfectionism). Within each therapist's caseload, differences between patients in perceived Rogerian conditions had weaker effects. The results underline the importance of differences between therapists as determinants of outcome in the treatment of depression.

Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity.

The tendency to perceive anxious states as aversive and harmful is hypothesized to confer vulnerability to the development of anxiety disorders. The most commonly used measure of anxiety sensitivity, the Anxiety Sensitivity Index [ASI; Reiss, S., Peterson, R.A., Gursky, D.M., & McNally R.J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behavior Research and Therapy, 24, 1-8], is composed of multiple lower-order factors, assessing fear of physical symptoms, fear of publicly observable anxious symptoms, and fear of cognitive dyscontrol. This study examined the convergent validity of the lower-order anxiety sensitivity dimensions in DSM-IV diagnosed anxiety disorders. Participants with primary diagnoses of panic disorder with agoraphobia, social phobia, and generalized anxiety disorder (GAD) completed the ASI and measures of anxiety and depression severity. Support was found for the convergent validity of all ASI dimensions in reference to thematically related anxiety disorders and in the identification of patients presenting with and without secondary major depressive disorder (MDD). The ASI-fear of cognitive dyscontrol dimension displayed strong and nonredundant associations with GAD, dimensional depression scores, and secondary diagnoses of MDD. The conceptual implications of the shared importance of fear of cognitive dyscontrol in GAD and MDD are discussed.