Efficacy of two brief trauma-focussed writing interventions in comparison to positive experiences writing: A randomized controlled trial.

BACKGROUND: There is emerging literature regarding the efficacy of trauma-focussed writing therapies (TF-WTs) for posttraumatic stress. Such therapies have the potential to reduce posttraumatic stress symptoms (PTSS) in a brief time frame and can be delivered remotely. There remains a need for further research assessing the efficacy of different types of TF-WTs, as well comparing them to alternative control conditions not previously assessed. The present study assessed two TF-WTs that had differing writing instructions in comparison to an intervention that involved writing about positive experiences. METHODS: Adult community participants (n = 83) with subthreshold or clinical PTSD symptoms were randomized to one of three conditions (two of which involved trauma-focussed writing, and the other involved writing about positive experiences). All conditions involved three weekly telehealth-delivered writing appointments. Outcomes were measured using the PTSD Checklist (PCL-5) and the Depression, Anxiety and Stress Scales (DASS-21), and were evaluated at baseline, one-week post-intervention, and five-weeks post-intervention. This trial was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR Protocol 12620001065987). RESULTS: There was no evidence that the two TF-WTs were more efficacious in reducing PTSS or producing clinically meaningful change in comparison to positive experiences writing. Instead, a significant reduction from baseline to follow-up in PTSS, depression, anxiety and stress was observed in all three conditions. LIMITATIONS: The results should be interpreted with consideration of the modest sample size and absence of longer-term follow-up. CONCLUSIONS: Three-session trauma-focussed writing delivered via telehealth may not be superior to writing about positive experiences.

Moderators and predictors of outcomes in telephone delivered compared to face-to-face cognitive behaviour therapy for paediatric obsessive-compulsive disorder: preliminary evidence from a non-inferiority RCT.

This study provides a preliminary exploration of factors which differentially predict treatment response to telephone-delivered cognitive behavioural therapy (TCBT) compared to face-to-face CBT (CBT) in a randomised non-inferiority controlled trial of 72 children (aged 11-18 years) with obsessive-compulsive disorder (OCD). Potential moderator variables, their interaction with treatment group (CBT, TCBT) and baseline levels of OCD severity were entered into separate regression models where the primary outcome measure was the post-intervention Children's Yale-Brown Obsessive-Compulsive Scale total score (CYBOCS). Separate regressions were also used to test associations between predictors and outcome controlling for pretreatment CYBOCS. Only pretreatment level of parent-rated child peer problems moderated the effects of the two interventions on CYBOCS severity at post-treatment. After controlling for baseline CYBOCS, only family accommodation rated by mothers predicted poorer outcomes in both groups. While CBT and TCBT may be equally effective for adolescents with OCD, the current results tentatively suggest that higher baseline level of peer problems strengthened the response to therapy for youth receiving TCBT and the predictor analyses reinforce the importance of directly addressing family accommodation during CBT for paediatric OCD regardless of delivery mode. Limitations of the current findings and directions for future work are discussed.

Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents.

BACKGROUND: While behavioural or cognitive-behavioural therapy (BT/CBT) is recommended as the psychotherapeutic treatment of choice for children and adolescents with obsessive-compulsive disorder (OCD), the application of BT/CBT to paediatric OCD may not be straightforward. OBJECTIVES: This review examines the overall efficacy of BT/CBT for paediatric OCD, its relative efficacy against psychopharmacology and whether there are benefits in using BT/CBT combined with medication. SEARCH STRATEGY: We searched CCDANCTR-Studies and CCDANCTR-References (searched on 5/8/2005), MEDLINE, EMBASE, PsycINFO, the reference lists of all selected studies and handsearched journals specifically related to behavioural treatment of OCD. SELECTION CRITERIA: Included studies were randomised controlled trials or quasi-randomised trials with participants who were 18 years of age or younger and had a diagnosis of OCD, established by clinical assessment or standardised diagnostic interview. Reviewed studies included the standard behavioural or cognitive-behavioural techniques, either alone or in combination, compared with wait-list or pill placebo. DATA COLLECTION AND ANALYSIS: The quality of selected studies was assessed by two independent reviewers. The primary outcomes comprised of endpoint scores on the gold standard clinical outcome measure of OCD symptoms, distress and interference (CY-BOCS) and endpoint OCD status. MAIN RESULTS: Four studies with 222 participants were considered eligible for inclusion and for data extraction. Two studies showed significantly better post-treatment functioning and reduced risk of continuing with OCD at post-treatment for the BT/CBT group compared to placebo or wait-list comparisons. We suggested that the POTS 2004 result, equal to a difference of about eight points on the CY-BOCS, represented the best available estimate for the efficacy of BT/CBT relative to no treatment. (WMD -7.50; 95% CI -11.55, -3.45). Pooled evidence from two trials indicated that the efficacy of BT/CBT and medication did not differ significantly (WMD -3.87; 95% CI -8.15, 0.41). There was evidence of the benefit of combined BT/CBT and medication compared to medication alone (WMD -4.55; 95% CI -7.40, -1.70), but not relative to BT/CBT alone (WMD -2.80; 95% CI -7.55, 1.95). The rates of drop out suggested BT/CBT is an acceptable treatment to child and adolescent patients and their families. AUTHORS' CONCLUSIONS: Although only based on a small number of studies, behavioural or cognitive-behaviour therapy appears to be a promising treatment for OCD in children and adolescents. It can lead to better outcomes when combined with medication compared to medication alone. Additional trials are needed to confirm these findings. In the interim, consideration should be given to the ways in which BT/CBT might be made more widely available as a treatment for OCD in children and adolescents.

A comparison of purging and nonpurging eating-disordered outpatients: mediating effects of weight and general psychopathology.

OBJECTIVES: The present study compared purging and nonpurging eating-disordered outpatients on key behavioral and psychological features of their disorder. It also investigated the possible mediating effects of current level of depression, anxiety or general psychopathology, and current weight on differences between purgers and nonpurgers. METHOD: Seventy-seven patients from an outpatient eating disorder clinic who purged were compared to 48 clinic patients who did not purge on measures of eating behavior disturbances and specific psychopathology while controlling for weight, level of depression, anxiety, and general distress. RESULTS: Purgers reported significantly more eating behavior disturbance and higher scores on measures of specific psychopathology than the nonpurgers. These differences were unrelated to current weight, level of anxiety, or general distress. However, severity of depression did moderate some of the difference between the groups. CONCLUSION: These data provide further support for the proposition that purging is a distinctive clinical marker in all types of eating-disordered patients.

Attachment disruption in anorexia nervosa and bulimia nervosa: a review of theory and empirical research.

OBJECTIVE: To critically review both the theoretical propositions about the connections between attachment disruption and eating disorders and the empirical work directly examining these associations. METHOD: The major theoretical positions advocating an influential role for disruptions in the early development of secure attachments in the development of eating disorders were identified and a comprehensive review of empirical studies derived from these positions undertaken. RESULTS: There is evidence for the presence of attachment disturbances in eating-disordered populations and for an association of these disturbances with key aspects of eating disorder psychopathology. DISCUSSION: Because of the limitation of the single pathway conceptualization adopted by the theoreticians and researchers reviewed, few inferences about the role of attachment processes in the etiology and maintenance of eating disorders can be drawn from the existing literature. The paper argues for the development of multifactorial and process-orientated models of the role of attachment functions in the pathogenesis of eating disorders.

Additional considerations in the cognitive-behavioral treatment of obsessional ruminations--a case study.

The cognitive-behavioral treatment of a 24-year-old woman with moderately severe obsessional ruminations is described. The case demonstrates both the effectiveness and limitations of exposure with response prevention techniques for obsessive-compulsive disorder. The client's response raises questions about the clinical utility of viewing obsessions exclusively as conditioned anxiety stimuli. In addition, the case shows that cognitions related to control rather than appraisals of responsibility were instrumental in initiating neutralising activity. Further modification of the current cognitive-behavioural hypotheses regarding obsessions is recommended.

Changes in hostility during the course of hypomanic illness.

Thirty patients with hypomania (or mania) were studied using the Hostility and Direction of Hostility Questionnaire to establish by testing and retesting the same patients the changes that take place in hostility as a hypomanic illness remits. Highly significant decreases in total hostility, in extrapunitiveness, in criticism of others and in projected hostility were demonstrated. There was some evidence to suggest that acquiescent response set may be characteristic, not of the hypomanic state itself, but of individuals predisposed to develop such an illness. Hostility scores in recovered female hypomanics did not differ from those of control subjects once correction had been made for the effects of age and social class. As an exception to the rule, the case is described of a man with mild mental retardation where testing confirmed clinical and collateral observations of a massive increase in hostility on recovery from a hypomanic illness.

ECT: misconceptions and attitudes.

One hundred and seventy-eight subjects completed a questionnaire regarding ECT. The sample comprised three groups of approximately equal size: a group of patients who had received ECT, a group of visitors to ECT-treated psychiatric patients, and a group of visitors to non-ECT-treated psychiatric patients. Misconceptions about ECT were common throughout, particularly in the young, those giving films and television as a source of information and those visiting patients not receiving ECT. Fewer misconceptions occurred among those who were more highly educated or had experience of ECT either personally or via a visited friend or relative. Less fear of the procedure was expressed by those given the treatment and those who had the treatment explained to them by a doctor. Over half of the patient group denied having had ECT explained to them.