Stepped care cognitive behavioural therapy for children with anxiety disorders: a new treatment approach.

BACKGROUND: The current nonrandomized clinical trial explored changes over time in children with an anxiety disorder during stepped care, manual-based cognitive behaviour therapy (CBT). METHODS: Clinically anxious children (8-12 years, n = 133) and their parents participated in child focused CBT (10 sessions). If assessments indicated additional treatment was necessary, participants could step up to a second and possibly third treatment phase (each 5 sessions) including more parental involvement. RESULTS: After the first treatment phase 45% of the Intention-To-Treat sample was free of any anxiety disorder; after the second and third phase an additional 17% and 11% respectively. In total, 74% of the children no longer met criteria for any anxiety disorder following treatment. Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases, as well as child reported anxiety sensitivity and negative affect. Children participating in more treatment showed significant improvements during additional treatment phases, indicating that late change occurred for the subgroup that had not changed during the first phase. CONCLUSIONS: Stepped care offers a standardized, assessment based, yet tailored treatment approach for children with anxiety disorders. A more intensive treatment is offered when initial CBT is insufficient, providing children additional opportunities to reach the desired outcome.

Prolonged cardiac effects of momentary assessed stressful events and worry episodes.

OBJECTIVES: To test the hypothesize that increased heart rate (HR) and decreased heart rate variability (HRV) are not only due to concurrent stressful events and worries but also to stressors and worries occurring in the preceding hours or stressors anticipated to occur in the next hour. Worry was expected to mediate at least part of the prolonged effects of stressors. METHODS: Ambulatory HR and HRV of 73 teachers were recorded for 4 days, during which the participants reported occurrence and duration of worry episodes and stressful events on an hourly basis, using computerized diaries. Multilevel regression models were used, accounting for effects of several biobehavioral variables. RESULTS: Stressful events were not associated with changes in HR or HRV. However, worry episodes had effects on concurrent HR and HRV (2.55 beats/minute; -5.76 milliseconds) and HR and HRV in the succeeding hour (3.05 beats/minute; -5.80 milliseconds) and 2 hours later (1.52 beats/minute; -3.14 milliseconds). These findings were independent of emotions, physical activity, posture, and other biobehavioral factors. CONCLUSION: Worry has effects on cardiac activity, and these effects were still visible after 2 hours. The latter finding suggests that a considerable part of prolonged activation may be induced by unconscious stress-related cognition.

A priori power analysis in longitudinal three-level multilevel models: an example with therapist effects.

Over the last few years, three-level longitudinal models have become more common in psychotherapy research, particularly in therapist-effect or group-effect studies. Thus far, limited attention has been paid to power analysis in these models. This article demonstrates the effects of intraclass correlation, level of randomization, sample size, covariates and drop-out on power, using data from a routine outcome monitoring study. Results indicate that randomization at the patient level is the most efficient, and that increasing the number of measurements does not increase power much. Adding a covariate or having a 25% drop-out rate had limited effects on study power in our data. In addition, the results demonstrate that sufficient power can be reached with small sample sizes, but that larger sample sizes are needed to prevent estimation bias for the model parameters and standard errors.

Effects of sad mood on autobiographical memory in older adults with and without lifetime depression.

OBJECTIVES: The main objective of this study was to determine whether reduced autobiographical memory specificity is also a marker for depression in older adults. To answer this question two experiments and a prospective longitudinal clinical study were executed with the autobiographical memory task (AMT) as measure for memory specificity. The objective of the 1st experimental study was to assess the influence of a negative mood induction versus the effect of multiple testing in a neutral condition in 58 never depressed (ND) elderly. In the 2nd experimental study a negative mood was induced in 63 participants remitted from depression (RD) compared to 60 matched ND controls. All participants were 55 and older. Lastly, the predictive value of the AMT for the course of depressive symptoms was assessed in the RD individuals over a 14-17 months follow-up (FU) period. RESULTS: Performance did not improve with repeated testing, but a trend was found suggesting fatigue. There was no difference between the RD and ND group on baseline AMT. The mood induction had no effect on the AMT regardless of clinical history. Changes in the level of depressive symptoms at the 14-month FU were predicted by residual symptoms at baseline and the number of previous depressive episode, but not by baseline AMT, changes in AMT or mood after mood induction. CONCLUSION: The results of this study suggest that memory specificity on the AMT may not be a useful marker for vulnerability for clinical depression in older adults.

Daily frustration, cognitive coping and coping efficacy in adolescent headache: a daily diary study.

OBJECTIVE: To investigate both concurrent and prospective relationships between daily frustration, cognitive coping and coping efficacy on the one hand and daily headache occurrence on the other. METHODS: Eighty-nine adolescents aged 13-21 completed an online daily diary for 3 weeks. Data were analyzed using multilevel modeling. RESULTS: Daily frustration of goal pursuits was significantly related to both same day and next day headache occurrence. Coping efficacy beliefs were significantly related to lower next day headache occurrence (no same day relationship was found). None of the cognitive coping strategies used in response to daily frustration were related to headache occurrence on the same or next day. CONCLUSIONS: Daily frustration to goal pursuit is suggested to be an important stressor contributing to concurrent and prospective headache occurrence. Furthermore, the extent to which adolescents believe in their ability to cope also appears to influence experience of subsequent headache. Further prospective studies are necessary to confirm these findings and to further unravel the possibly reciprocal relations between these factors. These findings offer useful insights into the dynamic interplay between daily stressful experiences and headache in youths.

Cognitive behavioral therapy versus paroxetine in the treatment of hypochondriasis: an 18-month naturalistic follow-up.

BACKGROUND: The present maintenance study investigated whether the reduction in hypochondriacal complaints after initial treatment with CBT or paroxetine sustained during a follow-up period and whether psychiatric severity at pretest predicted the course of hypochondriacal symptoms. METHOD: A naturalistic follow-up period of 18 months after a 16-week RCT consisting of 33 patients initially allocated to a CBT condition and 29 patients to a paroxetine condition. The main outcome measure was the Whiteley Index. RESULTS: The initial treatment effect of CBT and paroxetine sustained during the follow-up period. No significant differences between CBT and paroxetine were found. Treatment course could not be predicted by psychiatric comorbidity. CONCLUSION: CBT and paroxetine are both effective treatments for hypochondriasis in the long term.

Cognitive-behavioural intervention for self-harm: randomised controlled trial.

BACKGROUND: Self-harm by young people is occurring with increasing frequency. Conventional in-patient and out-patient treatment has yet to be proved efficacious. AIMS: To investigate the efficacy of a short cognitive-behavioural therapy intervention with 90 adolescents and adults who had recently engaged in self-harm. METHOD: Participants (aged 15-35 years) were randomly assigned to treatment as usual plus the intervention, or treatment as usual only. Assessments were completed at baseline and at 3 months, 6 months and 9 months follow-up. RESULTS: Patients who received cognitive-behavioural therapy in addition to treatment as usual were found to have significantly greater reductions in self-harm, suicidal cognitions and symptoms of depression and anxiety, and significantly greater improvements in self-esteem and problem-solving ability, compared with the control group. CONCLUSIONS: These findings extend the evidence that a time-limited cognitive-behavioural intervention is effective for patients with recurrent and chronic self-harm.

Cardiac effects of momentary assessed worry episodes and stressful events.

OBJECTIVE: To hypothesize that increased heart rate (HR) and decreased heart rate variability (HRV) occurs not only during stressful events but also during episodes in which stress is cognitively represented, but not necessarily present, i.e., during worry. METHODS: Ambulatory HR and HRV of 73 female and male teachers were recorded for 4 days, during which they reported, on an hourly basis using computerized diaries, the number and characteristics of worry episodes and stressful events. Multilevel regression models were used, controlling for biobehavioral variables. RESULTS: Compared with neutral periods, worry episodes and stressful events had independent effects on HR (2.00 beats/min and 2.75 beats/min, respectively) and HRV (-1.07 ms and -1.05, respectively). Neither psychological traits nor biobehavioral variables influenced these results. Effects were most pronounced for work-related worry on HR (9.16 beats/min) and HRV (-1.19 ms), and for worry about anticipated future stress on HR (4.79 beats/min). CONCLUSIONS: Worry in daily life might have substantial cardiac effects in addition to the effects of stressful events, especially in the form of work-related and anticipatory stress, the latter being a type of stress that has been largely neglected in stress research.

From moral theory to penal attitudes and back: a theoretically integrated modeling approach.

From a moral standpoint, we would expect the practice of punishment to reflect a solid and commonly shared legitimizing framework. Several moral legal theories explicitly aim to provide such frameworks. Based on the theories of Retributivism, Utilitarianism, and Restorative Justice, this article first sets out to develop a theoretically integrated model of penal attitudes and then explores the extent to which Dutch judges' attitudes to punishment fit the model. Results indicate that penal attitudes can be measured in a meaningful way that is consistent with an integrated approach to moral theory. The general structure of penal attitudes among Dutch judges suggests a streamlined and pragmatic approach to legal punishment that is identifiably founded on the separate concepts central to moral theories of punishment. While Restorative Justice is frequently presented as an alternative paradigm, results show it to be smoothly incorporated within the streamlined approach.