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Recent research: three studies on CBT, one on implementation intentions and two on compassion

Here are details of half a dozen recent research papers - three on CBT, one on implementation intentions (and CBT), and two on compassion.  Fuller details, links and abstracts of all the studies mentioned are given further down this post.  The first, by Gulliksson et al, is "Randomized Controlled Trial of Cognitive Behavioral Therapy vs Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients With Coronary Heart Disease".  This is important stuff - "Results: During a mean 94 months of follow-up, the intervention group had a 41% lower rate of fatal and nonfatal first recurrent CVD events ... 45% fewer recurrent acute myocardial infarctions ... and a nonsignificant 28% lower all-cause mortality ... In the CBT group there was a strong dose-response effect between intervention group attendance and outcome ... Conclusions: A CBT intervention program decreases the risk of recurrent CVD and recurrent acute myocardial infarction."  It reminds me of the startling results reported in the 2009 Orth-Gomer et al paper "Stress reduction prolongs life in women with coronary disease".  The second recent CBT study I want to mention is the big Lancet one "Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial."  This demonstrated that CBT and GET (graded exercise therapy) were more helpful than APT (adaptive pacing therapy) and SMC (specialist medical care) for chronic fatigue ... and that adverse effects of these therapies were not a significant problem.  Although results were statistically very significant, we still desperately need to develop more effective treatments for chronic fatigue. 

The third recent CBT study I'm noting is Sorensen et al's "A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis".  They reported "Patients who received CBT did significantly better on all measures relative to the waiting-list control group, and on a specific measure of health anxiety compared with STPP (short-term psychodynamic psychotherapy). The STPP group did not significantly differ from the waiting-list group on any outcome measures. Similar differences were observed between CBT and STPP during follow-up, although some of the significant differences between groups were lost.  Conclusions: A modified and time-saving CBT programme is effective in the treatment of hypochondriasis ...".  The fourth study I'm mentioning today is also about CBT, but it's about making the therapy more effective by linking it with implementation intentions.  This is such an obvious marriage of methods (CBT & implementation intentions), it's great to see publications of this type emerging.  Varley et al report on "Making self-help more helpful: A randomized controlled trial of the impact of augmenting self-help materials with implementation intentions on promoting the effective self-management of anxiety symptoms."  They concluded "Findings showed a significant reduction in anxiety in the augmented self-help condition (implentation intentions added to CBT) compared with both the standard self-help (just CBT) and no-intervention conditions (caseness rates on the HADS at follow-up were 21%, 49%, and 44%, respectively). Mediation analyses indicated that the benefits of augmented self-help materials were explained by improved detection of anxiety-related triggers and greater experienced benefits of the self-help techniques. Conclusions: These findings suggest that implementation intentions offer a valuable supplement to self-help materials that can enhance their impact on outcomes".  Hurray!  About time!!  So if you're a therapist, learn about implementation intentions.  If you're someone looking to make self-help methods more effective, learn about implementation intentions.  See the blog posts "Implementation intentions & reaching our goals more successfully" and also glance at the sister technique "Mental contrasting: a way to boost our commitment to goals we care about".  

The last two, of the six recent studies I'm mentioning, are both on compassion.  Challengingly (considering the furore around 'mindfulness' in CBT) Van Dam et al report "Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression."  They comment "Despite a common emphasis of mindfulness, at least in name, among MBIs (mindfulness-based interventions), mindfulness proves difficult to assess, warranting consideration of other common components. Self-compassion, an important construct that relates to many of the theoretical and practical components of MBIs, may be an important predictor of psychological health. The present study compared ability of the Self-Compassion Scale (SCS) and the Mindful Attention Awareness Scale (MAAS) to predict anxiety, depression, worry, and quality of life in a large community sample seeking self-help for anxious distress (N = 504). Multivariate and univariate analyses showed that self-compassion is a robust predictor of symptom severity and quality of life, accounting for as much as ten times more unique variance in the dependent variables than mindfulness".  Gosh.  This links well with last year's Spring BABCP Conference report about the important mediation analysis on a major mindfulness-based cognitive therapy intervention - " ... there was evidence suggesting that it was particularly increases in self-compassion that nullified the toxic reactivity-outcome link.  This last point is consistent with emerging evidence that a compassionate stance, when faced with upsetting thoughts and feelings, is particularly adaptive".  Fascinating.  And the sixth paper in this current blog post is also about compassion - "Attachment, self-compassion, empathy, and subjective well-being among college students and community adults."  This free full text article comments "Research on subjective well-being suggests that it is only partly a function of environmental circumstances. There may be a personality characteristic or a resilient disposition toward experiencing high levels of well-being even in unfavorable circumstances. Adult attachment may contribute to this resilient disposition ... findings suggested that self-compassion mediated the association between attachment anxiety and subjective well-being, and emotional empathy toward others mediated the association between attachment avoidance and subjective well-being".  This emphasis on the importance of self-compassion and its links with attachment leads pretty straightforwardly to the series of other blog posts this month on "Boosting self-compassion and self-encouragement by strengthening attachment security - twelve practical suggestions".    

Gulliksson, M., G. Burell, et al. (2011). "Randomized Controlled Trial of Cognitive Behavioral Therapy vs Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients With Coronary Heart Disease: Secondary Prevention in Uppsala Primary Health Care Project (SUPRIM)." Arch Intern Med 171(2): 134-140.  [Abstract/Full Text]   Background Psychosocial factors are independently associated with increased risk of cardiovascular disease (CVD) morbidity and mortality, but the effects of psychosocial factor intervention on CVD are uncertain. We performed a randomized controlled clinical trial of cognitive behavioral therapy (CBT) to measure its effects on CVD recurrence. Methods The study included 362 women and men 75 years or younger who were discharged from the hospital after a coronary heart disease event within the past 12 months. Patients were randomized to receive traditional care (reference group, 170 patients) or traditional care plus a CBT program (intervention group, 192 patients), focused on stress management, with 20 two-hour sessions during 1 year. Median attendance at each CBT session was 85%. Outcome variables were all-cause mortality, hospital admission for recurrent CVD, and recurrent acute myocardial infarction. Results During a mean 94 months of follow-up, the intervention group had a 41% lower rate of fatal and nonfatal first recurrent CVD events (hazard ratio [95% confidence interval], 0.59 [0.42-0.83]; P = .002), 45% fewer recurrent acute myocardial infarctions (0.55 [0.36-0.85]; P = .007), and a nonsignificant 28% lower all-cause mortality (0.72 [0.40-1.30]; P = .28) than the reference group after adjustment for other outcome-affecting variables. In the CBT group there was a strong dose-response effect between intervention group attendance and outcome. During the first 2 years of follow-up, there were no significant group differences in traditional risk factors. Conclusions A CBT intervention program decreases the risk of recurrent CVD and recurrent acute myocardial infarction. This may have implications for secondary preventive programs in patients with coronary heart disease.

White, P., K. Goldsmith, et al. (2011). "Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial." Lancet[PubMed]    BACKGROUND: Trial findings show cognitive behaviour therapy (CBT) and graded exercise therapy (GET) can be effective treatments for chronic fatigue syndrome, but patients' organisations have reported that these treatments can be harmful and favour pacing and specialist health care. We aimed to assess effectiveness and safety of all four treatments. METHODS: In our parallel-group randomised trial, patients meeting Oxford criteria for chronic fatigue syndrome were recruited from six secondary-care clinics in the UK and randomly allocated by computer-generated sequence to receive specialist medical care (SMC) alone or with adaptive pacing therapy (APT), CBT, or GET. Primary outcomes were fatigue (measured by Chalder fatigue questionnaire score) and physical function (measured by short form-36 subscale score) up to 52 weeks after randomisation, and safety was assessed primarily by recording all serious adverse events, including serious adverse reactions to trial treatments. Primary outcomes were rated by participants, who were necessarily unmasked to treatment assignment; the statistician was masked to treatment assignment for the analysis of primary outcomes. We used longitudinal regression models to compare SMC alone with other treatments, APT with CBT, and APT with GET. The final analysis included all participants for whom we had data for primary outcomes. This trial is registered at http://isrctn.org/, number ISRCTN54285094. FINDINGS: We recruited 641 eligible patients, of whom 160 were assigned to the APT group, 161 to the CBT group, 160 to the GET group, and 160 to the SMC-alone group. Compared with SMC alone, mean fatigue scores at 52 weeks were 3.4 (95% CI 1.8 to 5.0) points lower for CBT (p=0.0001) and 3.2 (1.7 to 4.8) points lower for GET (p=0.0003), but did not differ for APT (0.7 [-0.9 to 2.3] points lower; p=0.38). Compared with SMC alone, mean physical function scores were 7.1 (2.0 to 12.1) points higher for CBT (p=0.0068) and 9.4 (4.4 to 14.4) points higher for GET (p=0.0005), but did not differ for APT (3.4 [-1.6 to 8.4] points lower; p=0.18). Compared with APT, CBT and GET were associated with less fatigue (CBT p=0.0027; GET p=0.0059) and better physical function (CBT p=0.0002; GET p<0.0001). Subgroup analysis of 427 participants meeting international criteria for chronic fatigue syndrome and 329 participants meeting London criteria for myalgic encephalomyelitis yielded equivalent results. Serious adverse reactions were recorded in two (1%) of 159 participants in the APT group, three (2%) of 161 in the CBT group, two (1%) of 160 in the GET group, and two (1%) of 160 in the SMC-alone group. INTERPRETATION: CBT and GET can safely be added to SMC to moderately improve outcomes for chronic fatigue syndrome, but APT is not an effective addition.

Sørensen, P., M. Birket-Smith, et al. (2011). "A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis." Psychological Medicine 41(02): 431-441.  [Abstract/Full Text]   Background: Hypochondriasis is common in the clinic and in the community. Cognitive behavioural therapy (CBT) has been found to be effective in previous trials. Psychodynamic psychotherapy is a treatment routinely offered to patients with hypochondriasis in many countries, including Denmark. The aim of this study was to test CBT for hypochondriasis in a centre that was not involved in its development and compare both CBT and short-term psychodynamic psychotherapy (STPP) to a waiting-list control and to each other. CBT was modified by including mindfulness and group therapy sessions, reducing the therapist time required. STPP consisted of individual sessions.  Method: Eighty patients randomized to CBT, STPP and the waiting list were assessed on measures of health anxiety and general psychopathology before and after a 6-month treatment period. Waiting-list patients were subsequently offered one of the two active treatments on the basis of re-randomization, and assessed on the same measures post-treatment. Patients were again assessed at 6- and 12-month follow-up points.  Results: Patients who received CBT did significantly better on all measures relative to the waiting-list control group, and on a specific measure of health anxiety compared with STPP. The STPP group did not significantly differ from the waiting-list group on any outcome measures. Similar differences were observed between CBT and STPP during follow-up, although some of the significant differences between groups were lost.  Conclusions: A modified and time-saving CBT programme is effective in the treatment of hypochondriasis, although the two psychotherapeutic interventions differed in structure.

Varley, R., T. L. Webb, et al. (2011). "Making self-help more helpful: A randomized controlled trial of the impact of augmenting self-help materials with implementation intentions on promoting the effective self-management of anxiety symptoms." Journal of consulting and clinical psychology 79(1): 123-128.  [PubMed]   Objective: The effectiveness of self-help materials may be constrained by failures to undertake recommended exercises or to deploy the techniques that one has learned at the critical moment. The present randomized controlled trial investigated whether augmenting self-help materials with if-then plans (or implementation intentions) could overcome these problems and enhance the self-management of anxiety symptoms. Method: At baseline, participants who reported anxiety symptoms completed the Hospital Anxiety and Depression Scale (HADS) and the state version of the State-Trait Anxiety Inventory (STAI). Participants were then randomized via a computer program to standard self-help (n = 86), augmented self-help (n = 90), or no-intervention (n = 86) conditions. Eight weeks later, 95% (n = 249) of the participants completed the HADS and STAI again. Results: Findings showed a significant reduction in anxiety in the augmented self-help condition compared with both the standard self-help and no-intervention conditions (caseness rates on the HADS at follow-up were 21%, 49%, and 44%, respectively). Mediation analyses indicated that the benefits of augmented self-help materials were explained by improved detection of anxiety-related triggers and greater experienced benefits of the self-help techniques. Conclusions: These findings suggest that implementation intentions offer a valuable supplement to self-help materials that can enhance their impact on outcomes.

Van Dam, N. T., S. C. Sheppard, et al. (2011). "Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression." Journal of Anxiety Disorders 25(1): 123-130.  [Abstract/Full Text]   Mindfulness has received considerable attention as a correlate of psychological well-being and potential mechanism for the success of mindfulness-based interventions (MBIs). Despite a common emphasis of mindfulness, at least in name, among MBIs, mindfulness proves difficult to assess, warranting consideration of other common components. Self-compassion, an important construct that relates to many of the theoretical and practical components of MBIs, may be an important predictor of psychological health. The present study compared ability of the Self-Compassion Scale (SCS) and the Mindful Attention Awareness Scale (MAAS) to predict anxiety, depression, worry, and quality of life in a large community sample seeking self-help for anxious distress (N = 504). Multivariate and univariate analyses showed that self-compassion is a robust predictor of symptom severity and quality of life, accounting for as much as ten times more unique variance in the dependent variables than mindfulness. Of particular predictive utility are the self-judgment and isolation subscales of the SCS. These findings suggest that self-compassion is a robust and important predictor of psychological health that may be an important component of MBIs for anxiety and depression.

Wei, M., K. Y.-H. Liao, et al. (2011). "Attachment, self-compassion, empathy, and subjective well-being among college students and community adults." Journal of Personality 79(1): 191-221.   [Free Full Text]  Research on subjective well-being suggests that it is only partly a function of environmental circumstances. There may be a personality characteristic or a resilient disposition toward experiencing high levels of well-being even in unfavorable circumstances. Adult attachment may contribute to this resilient disposition. This study examined whether the association between attachment anxiety and subjective well-being was mediated by Neff's (2003a, 2003b) concept of self-compassion. It also examined empathy toward others as a mediator in the association between attachment avoidance and subjective well-being. In Study 1, 195 college students completed self-report surveys. In Study 2, 136 community adults provided a cross-validation of the results. As expected, across these 2 samples, findings suggested that self-compassion mediated the association between attachment anxiety and subjective well-being, and emotional empathy toward others mediated the association between attachment avoidance and subjective well-being.

 

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