logo

dr-james-hawkins

  • icon-cloud
  • icon-facebook
  • icon-feed
  • icon-feed
  • icon-feed

Recent research: CBT for a variety of conditions – back pain, PTSD, obsessions, bipolar disorder, schemas & social anxiety

Here are six recent papers on CBT treatment for a variety of disorders - for fuller details, abstracts and links, see further down this page.  Lamb et al explored the value of "Group cognitive behavioural treatment for low-back pain in primary care".  That their results were reported in the Lancet, highlights the importance of their findings.  The active treatment group received an additional assessment and then six 1.5 hour group therapy sessions (average group size, eight participants).  Therapy focused on "guided discovery, identifying and countering negative automatic thoughts, pacing, graded activity, relaxation, and other skills."   Outcomes demonstrated that "Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider."

Ehlers et al argue cogently that, in contrast to conclusions reached in a recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746-758), seven other meta-analyses or systematic reviews have "concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied."  They go on to point out reasons that they think explain this discrepancy between the meta-analyses and make suggestions for further research into PTSD.

Whittall & colleagues, in their paper "Treatment of obsessions: A randomized controlled trial", tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions.  "The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT) ... Overall, CBT and SMT showed large and similar reductions in symptoms ... Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period ... The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment."  

Szentagotai & David investigated "The efficacy of cognitive-behavioral therapy in bipolar disorder: a quantitative meta-analysis" in CBT's role as "adjunctive treatment to medication."  They found "a low to medium overall effect size of CBT at posttreatment and follow-up" concluding that "Cognitive-behavioral therapy can be used as an adjunctive treatment to medication for patients with bipolar disorder, but new CBT strategies are needed to increase and enrich the impact of CBT at posttreatment and to maintain its benefits during follow-up."  

Bosmans et al, in their paper  "Attachment and symptoms of psychopathology: early maladaptive schemas as a cognitive link?", investigated whether "early maladaptive schemas can explain the relation between attachment anxiety and avoidance dimensions and symptoms of psychopathology."  They reported that "Results indicate that the association between attachment anxiety and psychopathology is fully mediated by cognitions regarding rejection and disconnection and other-directedness. The association between attachment avoidance and psychopathology is partly mediated by cognitions regarding rejection and disconnection.  Key Practitioner Message:   Our findings suggest that cognitive therapy might be useful in the treatment of attachment-related psychopathology.  Our findings suggest that therapists should be wary for attachment-related relapse.  Especially the cognitive schemas regarding expectations to be rejected or disconnected mediated the association between attachment anxiety and attachment avoidance dimensions and psychopathology."  

In the last of these six papers, Taylor & Alden investigated "Safety behaviors and judgmental biases in social anxiety disorder."  They reported on two experiments exploring this link.  "Safety behaviors were manipulated in the context of a controlled laboratory-based social interaction, and subsequent effects of the manipulation on the social judgments of socially anxious participants ... were examined. ... Results revealed across both studies that participants in the SB + EXP (safety behaviour reduction + exposure) group were less negative and more accurate in judgments of their performance following safety behavior reduction relative to EXP (exposure only) participants. Study 2 also demonstrated that participants in the SB + EXP group displayed lower judgments about the likelihood of negative outcomes in a subsequent social event compared to controls. Moreover, reduction in safety behaviors mediated change in participant self-judgments and future social predictions. The current findings are consistent with cognitive theories of anxiety, and support the causal role of safety behaviors in the persistence of negative social judgments in SAD."

Lamb, S. E., Z. Hansen, et al. (2010). "Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis." Lancet.   [PubMed].
BACKGROUND: Low-back pain is a common and costly problem. We estimated the effectiveness of a group cognitive behavioural intervention in addition to best practice advice in people with low-back pain in primary care. METHODS: In this pragmatic, multicentre, randomised controlled trial with parallel cost-effectiveness analysis undertaken in England, 701 adults with troublesome subacute or chronic low-back pain were recruited from 56 general practices and received an active management advisory consultation. Participants were randomly assigned by computer-generated block randomisation to receive an additional assessment and up to six sessions of a group cognitive behavioural intervention (n=468) or no further intervention (control; n=233). Primary outcomes were the change from baseline in Roland Morris disability questionnaire and modified Von Korff scores at 12 months.  (Those randomized to the CBT group attended the BeST program, which consisted of an individual assessment of up to 1.5 hours and 6 sessions of group therapy again lasting 1.5 hours. "Training consisted of guided discovery, identifying and countering negative automatic thoughts, pacing, graded activity, relaxation, and other skills," the study authors explain, "and each group started with a mean of 8 participants.")  Assessment of outcomes was blinded and followed the intention-to-treat principle, including all randomised participants who provided follow-up data. This study is registered, number ISRCTN54717854. FINDINGS: 399 (85%) participants in the cognitive behavioural intervention group and 199 (85%) participants in the control group were included in the primary analysis at 12 months. The most frequent reason for participant withdrawal was unwillingness to complete questionnaires. At 12 months, mean change from baseline in the Roland Morris questionnaire score was 1.1 points (95% CI 0.39-1.72) in the control group and 2.4 points (1.89-2.84) in the cognitive behavioural intervention group (difference between groups 1.3 points, 0.56-2.06; p=0.0008). The modified Von Korff disability score changed by 5.4% (1.99-8.90) and 13.8% (11.39-16.28), respectively (difference between groups 8.4%, 4.47-12.32; p<0.0001). The modified Von Korff pain score changed by 6.4% (3.14-9.66) and 13.4% (10.77-15.96), respectively (difference between groups 7.0%, 3.12-10.81; p<0.0001). The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0.099; the incremental cost per QALY was £1786, and the probability of cost-effectiveness was greater than 90% at a threshold of £3000 per QALY. There were no serious adverse events attributable to either treatment. INTERPRETATION: Over 1 year, the cognitive behavioural intervention had a sustained effect on troublesome subacute and chronic low-back pain at a low cost to the health-care provider.

Ehlers, A., J. Bisson, et al. (2010). "Do all psychological treatments really work the same in posttraumatic stress disorder?" Clin Psychol Rev 30(2): 269-276.  [PubMed]
A recent meta-analysis by Benish, Imel, and Wampold (2008, Clinical Psychology Review, 28, 746-758) concluded that all bona fide treatments are equally effective in posttraumatic stress disorder (PTSD). In contrast, seven other meta-analyses or systematic reviews concluded that there is good evidence that trauma-focused psychological treatments (trauma-focused cognitive behavior therapy and eye movement desensitization and reprocessing) are effective in PTSD; but that treatments that do not focus on the patients' trauma memories or their meanings are either less effective or not yet sufficiently studied. International treatment guidelines therefore recommend trauma-focused psychological treatments as first-line treatments for PTSD. We examine possible reasons for the discrepant conclusions and argue that (1) the selection procedure of the available evidence used in Benish et al.'s (2008) meta-analysis introduces bias, and (2) the analysis and conclusions fail to take into account the need to demonstrate that treatments for PTSD are more effective than natural recovery. Furthermore, significant increases in effect sizes of trauma-focused cognitive behavior therapies over the past two decades contradict the conclusion that content of treatment does not matter. To advance understanding of the optimal treatment for PTSD, we recommend further research into the active mechanisms of therapeutic change, including treatment elements commonly considered to be non-specific. We also recommend transparency in reporting exclusions in meta-analyses and suggest that bona fide treatments should be defined on empirical and theoretical grounds rather than by judgments of the investigators' intent.

Whittal, M. L., S. R. Woody, et al. (2010). "Treatment of obsessions: A randomized controlled trial." Behaviour Research and Therapy 48(4): 295-303. [Abstract/Full Text]
This study tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment.

Szentagotai, A. and D. David (2010). "The efficacy of cognitive-behavioral therapy in bipolar disorder: a quantitative meta-analysis." J Clin Psychiatry 71(1): 66-72.  [PubMed]
OBJECTIVE: The goal of the current study was to conduct a quantitative meta-analysis investigating the role of cognitive-behavioral therapy (CBT) as adjunctive treatment to medication for patients diagnosed with bipolar disorder. DATA SOURCES: Studies included in the sample were identified through a computer search of articles in English in the MEDLINE database from January 1980 to March 2008. Key terms entered were cognitive and bipolar disorder, cognitive therapy and bipolar disorder, cognitive behavioral therapy and bipolar disorder, psychotherapy and bipolar disorder, and psychosocial and bipolar disorder. STUDY SELECTION: Inclusion criteria were (1) randomized clinical trial investigating the role of adjunctive CBT in patients diagnosed with bipolar disorder, (2) clearly defined CBT intervention, (3) the inclusion of a control group, and (4) sufficient data reported to allow calculation of effect sizes. Twelve randomized clinical trials were selected for analysis on the basis of these criteria. DATA EXTRACTION: Effect sizes (Cohen d) were calculated according to published procedures. DATA SYNTHESIS: We found a low to medium overall effect size of CBT at posttreatment (d = -0.42, P < .05) and follow-up (d = -0.27, P < .05), and we found a positive impact of CBT on clinical symptoms (posttreatment d = -0.44, P < .05), cognitive-behavioral etiopathogenetic mechanisms (posttreatment d = -0.49, P < .05), treatment adherence (posttreatment d = -0.53, P < .05), and quality of life (posttreatment d = -0.36, P < .05). The impact was less evident in the case of relapse and/or recurrence (posttreatment d = -0.28). These effects on outcome categories were more evident at posttreatment compared to follow-up. CONCLUSIONS: Cognitive-behavioral therapy can be used as an adjunctive treatment to medication for patients with bipolar disorder, but new CBT strategies are needed to increase and enrich the impact of CBT at posttreatment and to maintain its benefits during follow-up.   

Bosmans, G., C. Braet, et al. (2010). "Attachment and symptoms of psychopathology: early maladaptive schemas as a cognitive link?" Clinical Psychology & Psychotherapy.  [Abstract/Full Text]  
This study investigated whether early maladaptive schemas can explain the relation between attachment anxiety and avoidance dimensions and symptoms of psychopathology. For this purpose, 289 Flemish, Dutch-speaking, late adolescents participated on a questionnaire study. Using a non-parametric re-sampling approach, we investigated whether the association between attachment and psychopathology was mediated by early maladaptive schemas. Results indicate that the association between attachment anxiety and psychopathology is fully mediated by cognitions regarding rejection and disconnection and other-directedness. The association between attachment avoidance and psychopathology is partly mediated by cognitions regarding rejection and disconnection.  Key Practitioner Message:   Our findings suggest that cognitive therapy might be useful in the treatment of attachment-related psychopathology.  Our findings suggest that therapists should be wary for attachment-related relapse.  Especially the cognitive schemas regarding expectations to be rejected or disconnected mediated the association between attachment anxiety and attachment avoidance dimensions and psychopathology.

Taylor, C. T. and L. E. Alden (2010). "Safety behaviors and judgmental biases in social anxiety disorder." Behaviour Research and Therapy 48(3): 226-237.  [Abstract/Full Text]
Two experiments were conducted to examine the link between safety behaviors and social judgments in social anxiety disorder (SAD). Safety behaviors were manipulated in the context of a controlled laboratory-based social interaction, and subsequent effects of the manipulation on the social judgments of socially anxious participants (N = 50, Study 1) and individuals meeting diagnostic criteria for generalized SAD (N = 80, Study 2) were examined. Participants were randomly assigned to either a safety behavior reduction plus exposure condition (SB + EXP) or a graduated exposure (EXP) control condition, and then took part in a conversation with a trained experimental confederate. Results revealed across both studies that participants in the SB + EXP group were less negative and more accurate in judgments of their performance following safety behavior reduction relative to EXP participants. Study 2 also demonstrated that participants in the SB + EXP group displayed lower judgments about the likelihood of negative outcomes in a subsequent social event compared to controls. Moreover, reduction in safety behaviors mediated change in participant self-judgments and future social predictions. The current findings are consistent with cognitive theories of anxiety, and support the causal role of safety behaviors in the persistence of negative social judgments in SAD.

 

Share this

Post new comment

The content of this field is kept private and will not be shown publicly. If you have a Gravatar account associated with the e-mail address you provide, it will be used to display your avatar.