Sessions Of Cognitive-behavioral Treatment Research Articles

A Comparison of Interactions Among Children, Parents, and Therapists in Cognitive Behavior Therapy for Anxiety Disorders in Australia and Japan

Despite growing attention to the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at posttreatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.

Randomised controlled trial of integrated cognitive behavioural treatment and motivational enhancement for comorbid social anxiety and alcohol use disorders.

Alcohol use disorder and social anxiety disorder are interconnected disorders that commonly co-occur. We report the first trial to assess whether integrated treatment for social anxiety and alcohol use disorder comorbidity improves outcomes relative to standard alcohol-focussed treatment. Participants were recruited to a randomised controlled trial, and randomly allocated to one of two treatments, Integrated (n = 61) or Control (alcohol-focussed; n = 56). Assessment and treatment session were conducted at two sites in Sydney, Australia. Inclusion criteria were as follows: (1) clinical diagnosis of social anxiety disorder and (2) Diagnosis or sub-clinical symptoms of alcohol use disorder. Diagnoses were determined according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). All participants (n = 117) received 10 sessions of cognitive behavioural treatment and motivational enhancement. The Integrated treatment simultaneously targeted social anxiety disorder, alcohol use disorder and the connections between these disorders. The Control treatment focussed on alcohol use disorder only. Outcomes were assessed at 6-month follow-up, with interim assessments at post-treatment and 3 months. Primary outcomes were social anxiety disorder severity (composite Social Phobia Scale and Social Interaction Anxiety Scale), alcohol use disorder severity (standard drinks per day and Severity of Alcohol Dependence Questionnaire) and quality of life (Short-Form Health survey) was assessed to capture the combined impairment of social anxiety and alcohol use disorder comorbidity. At 6-month follow-up, both conditions showed significant reductions in social anxiety and alcohol use disorder symptoms, and improved quality of life. There was no evidence of between-condition differences for alcohol outcomes, with mean consumption reduced by 5.0 (0.8) and 5.8 (1.0) drinks per day following Alcohol and Integrated treatments, respectively. Integrated treatment achieved greater improvements in social anxiety symptoms (mean difference = -14.9, 95% confidence interval = [-28.1, -1.6], d = 0.60) and quality of life (mean difference = 7.6, 95% confidence interval = [1.2, 14.0], d = 0.80) relative to alcohol-focused treatment. These results suggest that integrated social anxiety and alcohol use disorder treatment enhances quality of life and social anxiety disorder symptom improvement, but not alcohol outcomes, compared to treatment focussed on alcohol use disorder alone.

ENHANCING COGNITIVE-BEHAVIORAL THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER WITH TRANSCRANIC MAGNETIC STIMULATION: A PROOF OF CONCEPT

Cognitive behavioral therapy (CBT) is a well established first line treatment for obsessive compulsive disorder (OCD). It consists of a cognitive and a behavioral treatment (exposure and response prevention therapy (ERP)) [1]. The goal of the cognitive treatment is the cognitive restructuring of meta-cognitions while the goal of exposure therapy is enhancing and facilitating patients’ fear extinction processes in front of the feared object, situation or thought/obsession. Several studies have tried to enhance fear extinction through pharmacological agents with mixed results [2]. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS), through its capacity to induce long-term potentiation, is able to modulate learning processes and hippocampal plasticity [3]. Moreover, several studies showed that HF-rTMS over the dosrsolateral prefrontal cortex (DLPFC) is able to induce better working memory performance after active stimulation [4]. Thus, rTMS could represent a promising tool to enhance cognitive restructuring and fear extinction learning processes during the cognitive-behavioral treatment sessions. Recently, we published a case report of a patient treated with HF-rTMS over the left DLPFC before each ERP session [5]. Here we adopted a new protocol in order to potentiate both the cognitive and the behavioral part of the treatment. The aim of this study was to evaluate the potential CBT enhancing effect of HF-rTMS over the left DLPFC in OCD patients who failed to respond to a previous CBT trial. Each patient underwent a 16 sessions CBT trial (1 session per week, 50/60 minutes per session). The first six sessions were dedicated to establishing an individual hierarchy of obsessions and compulsions and to a cognitive restructuring of meta-cognitions. The following 10 sessions focused on in vivo ERP exercises. For the first six sessions patients underwent a HF-rTMS session over the left DLPFC immediately before the session in order to enhance working memory processes during cognitive restructuring of metacognitions (6 stimulation sessions). Subsequently, each exposure session was immediately followed by an HF-rTMS session over the left DLPFC (10 stimulation sessions). During the treatment, 32 trains of 5 seconds has been applied at 10 Hz and at 110% of the left motor trheshold over the left DLPFC, with a 25 seconds inter-train interval (a total of 1600 stimuli per session). No pharmacological treatment changes were allowed during the CBT trail and patients were stable on their undergoing medications since 4 weeks before starting the CBT sessions. We enrolled two OCD patients (with prominent checking and symmetry/ordering symptoms respectively) who failed a previous CBT trial and showed only slight depressive symptoms. At the end of the 16 CBT sessions patients showed a 35% and 30% symptoms reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) respectively. HF-rTMS was well tolerated. rTMS could represent e tolerable tool in order to enhance the effect of CBT with exposure and response prevention techniques in patients with obsessive-compulsive disorder.

P.4.d.004 - Enhancing cognitive-behavioral therapy for obsessive-compulsive disorder with transcranial magnetic stimulation: a proof of concept

Background Cognitive behavioral therapy (CBT) is a well established first line treatment for obsessive compulsive disorder (OCD). It consists of a cognitive and a behavioral treatment (exposure and response prevention therapy (ERP)) [1]. The goal of the cognitive treatment is the cognitive restructuring of meta-cognitions while the goal of exposure therapy is enhancing and facilitating patients’ fear extinction processes in front of the feared object, situation or thought/obsession. Several studies have tried to enhance fear extinction through pharmacological agents with mixed results [2]. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS), through its capacity to induce long-term potentiation, is able to modulate learning processes and hippocampal plasticity [3]. Moreover, several studies showed that HF-rTMS over the dosrsolateral prefrontal cortex (DLPFC) is able to induce better working memory performance after active stimulation [4]. Thus, rTMS could represent a promising tool to enhance cognitive restructuring and fear extinction learning processes during the cognitive-behavioral treatment sessions. Recently, we published a case report of a patient treated with HF-rTMS over the left DLPFC before each ERP session [5]. Here we adopted a new protocol in order to potentiate both the cognitive and the behavioral part of the treatment. Aims The aim of this study was to evaluate the potential CBT enhancing effect of HF-rTMS over the left DLPFC in OCD patients who failed to respond to a previous CBT trial. Methods Each patient underwent a 16 sessions CBT trial (1 session per week, 50/60 minutes per session). The first six sessions were dedicated to establishing an individual hierarchy of obsessions and compulsions and to a cognitive restructuring of meta-cognitions. The following 10 sessions focused on in vivo ERP exercises. For the first six sessions patients underwent a HF-rTMS session over the left DLPFC immediately before the session in order to enhance working memory processes during cognitive restructuring of metacognitions (6 stimulation sessions). Subsequently, each exposure session was immediately followed by an HF-rTMS session over the left DLPFC (10 stimulation sessions). During the treatment, 32 trains of 5 seconds has been applied at 10 Hz and at 110% of the left motor trheshold over the left DLPFC, with a 25 seconds inter-train interval (a total of 1600 stimuli per session). No pharmacological treatment changes were allowed during the CBT trail and patients were stable on their undergoing medications since 4 weeks before starting the CBT sessions. Results We enrolled two OCD patients (with prominent checking and symmetry/ordering symptoms respectively) who failed a previous CBT trial and showed only slight depressive symptoms. At the end of the 16 CBT sessions patients showed a 35% and 30% symptoms reduction on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) respectively. HF-rTMS was well tolerated. Conclusion rTMS could represent e tolerable tool in order to enhance the effect of CBT with exposure and response prevention techniques in patients with obsessive-compulsive disorder.

Cognitive-behavioral therapy for generalized anxiety disorder is associated with attenuation of limbic activation to threat-related facial emotions

BackgroundThe neural processes underlying the benefits of cognitive behavioral treatment (CBT) for generalized anxiety disorder (GAD) are not well understood. MethodsTwenty-one (n=21) adults with a principal diagnosis of GAD and eleven (n=11) non-anxious healthy controls (HC) underwent functional magnetic resonance imaging while completing a facial emotion processing task. Responses to threat-related emotionality (i.e., the contrast of fear and angry vs. happy faces) were assessed at pretreatment and again following 10 sessions of CBT in the GAD group and a comparable waiting period in the HC group. ResultsAt pretreatment, GAD participants displayed blunted responses in the amygdala, insula, and anterior cingulate to the happy face-processing comparison condition, and greater amygdalo–insular connectivity. CBT was associated with attenuated amygdalar and subgenual anterior cingulate activation to fear/angry faces and heightened insular responses to the happy face comparison condition, but had no apparent effects on connectivity. Pre-treatment abnormalities and treatment-related changes were not associated with symptoms of worry. LimitationsThere was no active control condition (e.g., treatment waitlist) for comparison of treatment effects. ConclusionsTaken together, these results provide evidence for a dual-process psychotherapeutic model of neural systems changes in GAD in which cingulo-amygdalar reactivity to threat-cues is attenuated while insular responses to positive facial emotions are potentiated. Future work is needed to determine the clinical implications of these changes and their specificity to CBT.

Changing motives for use: Outcomes from a cognitive-behavioral intervention for marijuana-dependent adults

BackgroundMotives for use have been identified as important predictors of substance use and related problems; however, little is known about how motives for use change following an intervention and how this change may impact future substance use behaviors. The present study sought to describe change in motives following an intervention for marijuana-dependent adults. Furthermore, investigators examined change in motives as a predictor of treatment outcome. MethodThe study randomized 74 adults to one of two conditions: both of which received 9-sessions base treatment of cognitive behavioral therapy and motivational enhancement therapy and had access to additional sessions of cognitive behavioral treatment on an as-needed basis. The experimental condition received two additional “check-ups” during the course of follow-up. ResultsSignificant decreases in reported frequency of motives used were observed following treatment. Changes in Expansion and Coping were associated with differential treatment outcomes. Decreases in Expansion were associated with poorer treatment outcome, while decreases in Coping were associated with better treatment outcome. ConclusionsThe relationship between expansion motives and outcomes was paradoxical. Although there were some inconsistencies in the findings, the results regarding the coping motive were consistent with hypotheses and may have important implications for treatment.

Intensive Cognitive Behavioral Therapy for Anxiety Disorders in School-aged Children with Autism: A Preliminary Comparison with Treatment-as-Usual

Children with autism spectrum disorders (ASDs) frequently present with a comorbid anxiety disorder that can cause significant functional impairment, particularly at school. An intensive modular cognitive behavioral treatment (CBT) program was delivered to address anxiety, self-regulation, and social engagement in school and in the community. A particular emphasis was placed on increasing generalizability of coping skills and positive social behavior by involving school personnel in the treatment process. Children (7–11 years old) were randomly assigned to an immediate treatment condition (IT) that included 32 sessions of CBT (n = 7) or a 16-week treatment-as-usual (TAU) condition (n = 5). The CBT sessions emphasized behavioral experimentation and emotion regulation training as well as social coaching on increasing positive peer interactions. School observations and consultations were included in the treatment model. Independent evaluators blind to treatment condition conducted structured diagnostic interviews at baseline and post-IT/post-TAU. Post-treatment analyses showed that 71.4 % of the IT group had remitted from their primary anxiety disorder diagnosis as compared with none of the TAU group. In addition, an ANCOVA analysis conducted with baseline anxiety scores included as a covariate revealed a statistically significant difference by treatment group in anxiety severity favoring the IT group at post-treatment. The 32-session CBT program is an intensive approach for children with ASD and moderate-to-severe anxiety disorders that appears to yield a clinically significant impact on anxiety symptoms. The generalizability of coping skills may be enhanced by the inclusion of school-based treatment components due to the consistency of supports this permits across the child’s daily settings.

Changes in Beliefs about the Social Competence of Self and Others Following Group Cognitive-Behavioral Treatment

The current study examined changes in social anxiety thoughts and beliefs following cognitive-behavioral treatment (CBT). Participants (N = 77) were adults with a principal diagnosis of SAD who received 12, 2-h sessions of group CBT at a hospital-based outpatient anxiety disorders clinic. There were significant decreases from pretreatment to posttreatment in social anxiety symptoms and in symptoms of depression, nonspecific anxiety and tension, as well as significant improvements in social anxiety beliefs, as assessed via the Social Thoughts and Beliefs Scale (STABS; Turner et al., Psychol Assess 15:384–391, 2003). Change in social anxiety beliefs made a significant contribution to the prediction of social anxiety symptoms at posttreatment over and above pretreatment social anxiety symptoms and changes in depression, nonspecific anxiety and tension. A positive change in the belief that others are more socially-competent emerged as a significant unique predictor of social anxiety symptoms at posttreatment. The findings demonstrate that the STABS is sensitive to cognitive-behavioral treatment. The findings also suggest that social comparison processes in particular are a key aspect of improvement in social anxiety symptoms. This is an important direction for future research.

Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials

Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3months later. Participants who were randomised to receive ABM reported less average (P=0.001) and current pain (P=0.008) and experienced pain for fewer days (P=0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n=22) or placebo (n=12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group-by-time effect for disability. By 6-month follow-up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.

Using Extended Cognitive Behavioral Treatment and Medication to Treat Dependent Smokers

We evaluated smoking-cessation efficacy of an extended course of sustained-release bupropion (bupropion SR) and cognitive-behavioral treatment (CBT). Participants who smoked at least 10 cigarettes per day and who smoked within 30 minutes of arising (n = 406) completed a 12-week smoking-cessation treatment including group counseling, nicotine-replacement therapy, and bupropion SR. Participants were then randomly assigned to 1 of 5 conditions: (1) no further treatment, (2) active bupropion SR for 40 weeks, (3) placebo for 40 weeks, (4) active bupropion SR and 11 sessions of CBT for 40 weeks (A-CBT), or (5) placebo and 11 sessions of CBT for 40 weeks. Participants were assessed at baseline and at weeks 12, 24, 52, 64, and 104. A-CBT was not superior to the other 3 extended treatments. From weeks 12 through 104, all extended treatment conditions were superior to standard treatment. At weeks 64 and 104, the 2 CBT conditions produced significantly higher abstinence rates than did the other 3 conditions. Brief contact with providers can increase abstinence during treatment. CBT may increase long-term abstinence after extended treatment is terminated.

Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder

This study investigated a multicomponent cognitive behavioral treatment (CBT) for hoarding based on a model proposed by Frost and colleagues and manualized in Steketee and Frost (2007). Participants with clinically significant hoarding were recruited from the community and a university-based anxiety clinic. Of the 46 patients randomly assigned to CBT or waitlist (WL), 40 completed the 12-week assessment and 36 completed 26 sessions. Treatment included education and case formulation, motivational interviewing, skills training for organizing and problem solving, direct exposure to nonacquiring and discarding, and cognitive therapy. Measures included the Saving Inventory-Revised (self-report), Hoarding Rating Scale-Interview, and measures of clinical global improvement. Between group repeated measures analyses using general linear modeling examined the effect of CBT versus WL on hoarding symptoms and moodstate after 12 weeks. Within group analyses examined pre-post effects for all CBT participants combined after 26 sessions. After 12 weeks, CBT participants benefited significantly more than WL patients on hoarding severity and mood with moderate effect sizes. After 26 sessions of CBT, participants showed significant reductions in hoarding symptoms with large effect sizes for most measures. At session 26, 71% of patients were considered improved on therapist clinical global improvement ratings and 81% of patients rated themselves improved; 41% of completers were clinically significantly improved. Multicomponent CBT was effective in treating hoarding. However, treatment refusal and compliance remain a concern, and further research with independent assessors is needed to establish treatment benefits and durability of gains.

Community Treatment for Problem Gambling: Sex Differences in Outcome and Process

This study compared sex differences in related treatment outcomes and processes in a community sample of outpatient problem gambling treatment-seekers. Participants attended approximately seven sessions of cognitive-behavioral treatment. Women were more likely to have a history of psychiatric comorbidity, prefer non-strategic/non-skill forms of gambling, and have a more rapid progression towards a gambling problem than did men. At the 6-month post-treatment follow-up, men were found to have improved to a significantly greater degree on measures of gambling severity and rates of abstinence in comparison to women. Moreover, men rated treatment components to be more helpful, whereas women found specific gambling-related treatment interventions (e.g., identification of high-risk situations, gambling beliefs and attitudes) to be less helpful. Implications for identifying treatment needs of women seeking problem gambling treatment are discussed.

Cognition, commitment language, and behavioral change among cocaine-dependent patients.

Patients' cognitive abilities and verbal expressions of commitment to behavioral change predict different aspects of substance abuse treatment outcome, but these 2 traits have never been examined conjointly. The authors therefore investigated patients' cognitive abilities and verbal expressions of commitment to behavioral change as predictors of retention and drug use outcomes in an outpatient cognitive behavioral treatment (CBT) of adult cocaine-dependent patients. A neuropsychological battery was administered at baseline. Two independent raters used recordings of CBT sessions to code commitment language strength across the temporal segments (e.g., beginning, middle, and end) of 1 session per patient. Better cognitive abilities predicted treatment retention (p < .01) but not drug use, whereas mean commitment strength across the session segments predicted reduced drug use (p = .01). Results indicate that although commitment to behavioral changes such as abstinence may occur independently of patients' cognitive abilities, engagement in the behavioral intervention process appears to depend on cognitive abilities. Future clinical studies should further investigate the relations between cognition and commitment to change and their differential contributions to treatment processes and outcome.

An open trial of cognitive-behavioral therapy for compulsive hoarding

The aim of the present study was to provide preliminary data on the efficacy of a new cognitive-behavioral treatment (CBT) for compulsive hoarding. Fourteen adults with compulsive hoarding (10 treatment completers) were seen in two specialty CBT clinics. Participants were included if they met research criteria for compulsive hoarding according to a semistructured interview, were age 18 or above, considered hoarding their main psychiatric problem, and were not receiving mental health treatment. Patients received 26 individual sessions of CBT, including frequent home visits, over a 7–12 month period between December 2003–February 2005. Primary outcome measures were the Saving Inventory-Revised (SI-R), Clutter Image Rating (CIR), and Clinician's Global Impression (CGI). Significant decreases from pre- to post-treatment were noted on the SI-R and CIR, but not the CGI-severity rating. CGI-Improvement ratings indicated that at mid-treatment, 40% ( n=4) of treatment completers were rated “much improved” or “very much improved;” at post-treatment, 50% ( n=5) received this rating. Adherence to homework assignments was strongly related to symptom improvement. CBT with specialized components to address problems with motivation, organizing, acquiring and removing clutter appears to be a promising intervention for compulsive hoarding, a condition traditionally thought to be resistant to treatment.

Feasibility and acceptability of a telephone psychotherapy program for depressed adults treated in primary care

Objective Telephone psychotherapy is an emerging model of care that appears feasible for extending the reach of evidence-based psychotherapy treatment without accruing the full costs of traditional office-based, mental health care. This manuscript describes the development, implementation and acceptance of a 12-month telephone psychotherapy program (TPP) for depressed adults not fully responding to standard antidepressant treatment in primary care. Method The TPP combined a population-based medication monitoring and information system with a structured cognitive-behavioral treatment (CBT) program. The TPP included 8–12 telephone sessions (eight core CBT sessions and three to four clinical booster sessions) delivered by a master-level therapist working in tandem with each patient's primary care physician (PCP). Results The TPP was well accepted (i.e., 80% completed the core program) by a population-based sample of adult primary care patients initiating antidepressant treatment. The mean duration of core telephone psychotherapy sessions was approximately 31 min during acute-phase treatment (0–6 months). Eighty-two percent of TPP patients maintained contact with their therapist during maintenance-phase treatment (6–12 months). Conclusions The practical and efficient nature of this TPP appears to sidestep many of the treatment barriers encountered in traditional office-based care. Implementation of this TPP program in other primary care settings may be valuable for enhancing standard pharmacotherapy treatment of adult depression, especially among populations facing greater barriers of care.

Anxiety-based cognitive-behavioral therapy for paranoid beliefs

Seven patients with chronic paranoid schizophrenia or schizoaffective disorder, in remission from substance dependence, received 8 sessions of cognitive-behavioral treatment (CBT) aimed at reducing their conviction in paranoid beliefs and associated anxiety (both measured on a 0% to 100% scale). Treatment was modeled on established CBT treatments for anxiety and included psychoeducation, relaxation training, and cognitive restructuring. Starting with neutral situations and gradually addressing paranoid situations, participants were taught to generate and evaluate alternative explanations for events. Participants were assigned diagnoses using the SCID-IV. They were assessed at baseline, posttreatment, and 1-month follow-up using interview, self-report, and cognitive measures. A multiple-baseline-across-subjects design was used. Results indicated clinically significant improvement by 3, mixed results for 1, and no change for 3.

Cognitive-behavioral treatment of tortured asylum seekers: a case study

The present study examined results of cognitive-behavioral treatment (CBT) in a 22-year-old, male, tortured asylum-seeker living in Sweden. The patient received 16 sessions of CBT involving mainly self-exposure to trauma-related cues. Clinical measures (assessor- and self-rated) were completed at pre-treatment, weeks 6, 8, 12, and 16, post-treatment and at follow-up (1-, 3-, and 6-month). Treatment led to significant improvement across all measures of post-traumatic stress disorder, anxiety, and depression. The improvement was maintained at 6-month follow-up. The results suggest that CBT could be useful in treating tortured asylum-seekers and refugees despite the additional stressors experienced by asylum-seekers and refugees.

Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes

Complex regional pain syndromes (CRPS; type 1, reflex sympathetic dystrophy, and type 2, causalgia) involve persistent pain, allodynia, and vasomotor signs. We conducted a prospective, randomized, single-blind trial of physical therapy (PT) and cognitive-behavioral treatment for children and adolescents with CRPS. Children 8 to 17 years of age (n = 28) were randomly assigned to either group A (PT once per week for 6 weeks) or group B (PT 3 times per week for 6 weeks). Both groups received 6 sessions of cognitive-behavioral treatment. Assessments of pain and function were repeated at two follow-up time periods. Outcomes were compared at the three time points through the use of parametric or nonparametric analysis of variance and post hoc tests. All five measures of pain and function improved significantly in both groups after treatment, with sustained benefit evident in the majority of patients at long-term follow-up. Recurrent episodes were reported in 50% of patients, and 10 patients eventually received sympathetic blockade. Most children with CRPS showed reduced pain and improved function with a noninvasive rehabilitative treatment approach. Long-term functional outcomes were also very good. (J Pediatr 2002;141:135-40)

Comorbid panic disorder and major depression: implications for cognitive-behavioral therapy.

Panic disorder and major depression frequently coexist, yet the implications of comorbidity for psychological treatments have rarely been studied. The objective of this study was to evaluate whether pretreatment comorbidity of major depression affects the outcome of cognitive-behavioral treatment (CBT) of panic disorder. Thirty-seven clients who met diagnostic criteria for both panic and major depression participated in 10 sessions of individual CBT for panic. Treatment outcome was contrasted with the outcome of 53 clients having only panic disorder who received the same treatment. The co-occurrence of depression did not adversely affect CBT for panic. These results have implications for clinical practice and theoretical implications for the nature of the relationship between panic and depression.

Nonpsychiatric medical comorbidity, health perceptions, and treatment outcome in patients with panic disorder.

Panic disorder is frequently complicated by high rates of co-occurring nonpsychiatric medical conditions. The present study examined the relationship between medical morbidity, perceived physical health, and treatment outcome in panic disorder. Patients meeting the American Psychiatric Association's Diagnostic and Statistical Manual of mental disorders (1994) criteria for panic disorder (N = 71) completed 12 sessions of cognitive-behavioral treatment and were assessed at posttreatment and 6-month follow-up. Medical comorbidity and perceived health were both found to be related to end-state functioning. Medical comorbidity did not uniquely predict outcome beyond its shared variance with perceived health. At posttreatment, 71% of patients who perceived their physical health as good met recovery criteria compared with only 35% of those who perceived their health as poor. At follow-up, 67% of those who perceived their physical health as good met composite recovery criteria compared with only 33% of those with perceived poor health. These findings offer preliminary support for the impact of physical health, both actual and perceived, on treatment outcome of patients with panic disorder.