Manual-based Cognitive-behavioral Therapy Research Articles

Group cognitive behavioural therapy (CBT) for university students with attention-deficit/hyperactivity disorder (ADHD): a feasibility study

Coping with academic demands can be challenging for university students with Attention-Deficit/Hyperactivity Disorder (ADHD). Treatment can help them cope and prevent related mental health issues. The present study aimed to investigate the feasibility of a randomized controlled trial for group Cognitive Behavioural Therapy (CBT), including the use of an app for CBT homework assignments, and to explore the effects of CBT for university students with ADHD. University students (n = 36) participated in the first phase of the study, involving the design of an app to present CBT homework assignments, by evaluating prototypes of the app along with the development team. In the second phase, a pre- vs. post-test design was used. Students with ADHD (n = 7) were offered manual-based CBT once a week for 6 weeks using the app or a paper manual to do the homework, as preferred. University students who took part in the development of the app noted that they would rather use the app than a printed manual. On the other hand, participants in the CBT feasibility study preferred doing homework on paper rather than using the developed app. They all found group CBT and the key elements in the CBT manual helpful. The findings suggest that providing group CBT for university students with ADHD through 6 sessions is feasible and assessing its effects in a randomized controlled trial (RCT) is feasible. Such treatment might improve coping with ADHD symptoms and related mental health issues. Further studies on the development of an app supporting CBT are needed.Trial registration Registry name: Cognitive Behavioural Therapy for University Students with Attention-deficit Hyperactivity Disorder (ADHD). URL: https://register.clinicaltrials.gov. Registration number: NCT 04714866.

Online versus in-person delivery of cognitive behaviour therapy for obsessive compulsive disorder: An examination of effectiveness.

Cognitive behavioural therapy (CBT) including exposure and response prevention is the first-line psychological treatment for obsessive compulsive disorder (OCD). Given changes in the clinical landscape, there are increasing efforts to evaluate its effectiveness in online contexts. Mirroring the traditional in-person delivery, few studies have assessed the role of therapist-guided, manual-based CBT for OCD delivered in real-time via videoconferencing methods. The present study sought to fill this gap by comparing in-person and online delivery of group-based CBT for the treatment of OCD. A convenience sample of participants with moderate to severe OCD (n = 144) were recruited from a naturalistic database from two large OCD specialty assessment and treatment centres. Patients received group-based CBT that was provided in-person (pre-COVID-19 pandemic; March 2018 to March 2020) or online via videoconferencing (during the COVID-19 pandemic; March 2020 to April 2021). In both delivery methods, treatment consisted of 2-h weekly sessions led by trained clinicians. Analyses revealed that, regardless of treatment modality, both in-person and online groups demonstrated significant, reliable, and statistically equivalent improvements in OCD symptoms post-treatment. Videoconferenced, clinician-led CBT may be a promising alternative to in-person delivery for those with moderate to severe OCD symptoms.

Psychotherapy readiness domains as predictors of psychotherapy outcome in trauma-affected refugees

IntroductionLittle is known about predictors of psychotherapy outcome in trauma-affected refugees. Knowledge on outcome predictors can help clinicians identify patients prior to treatment who are not likely to benefit from standardized psychotherapy and take additional measures to adjust treatment to the individual patient. Given the dynamic nature of psychotherapy readiness domains, they represent potential targets to be worked with in therapy in order to improve outcomes. MethodsPsychotherapy readiness domains (locus of control, cognitive functioning, motivation for therapy, and personality functioning) were examined as potential predictors of psychotherapy outcome in trauma-affected refugees. Secondary analyses were conducted on data from a pragmatic randomized controlled trial. Study participants (N = 190) were refugees with PTSD who received flexible manual-based Cognitive Behavioral Therapy (CBT) at a psychiatric outpatient clinic in Denmark. Psychotherapy readiness domains were assessed via semi-structured interviews at the beginning of psychotherapy. Outcome variables were pre-post change in PTSD symptomology and global level of functioning. ResultsMultiple regression analyses revealed that higher motivation for psychotherapy predicted improvement in PTSD symptomology and global level of functioning. Moreover, higher cognitive functioning predicted improvement in global level of functioning. LimitationsThe predictor rating scales need further psychometric evaluations in cross-cultural contexts. ConclusionsThese findings highlight the importance of considering motivation in psychotherapy offered to trauma-affected refugees. Further research is needed to identify potential barriers to motivation in this diverse patient population and to determine whether motivational interventions can lead to improved treatment outcomes.

The effect of an integrated care intervention of multidisciplinary mental health treatment and employment services for trauma-affected refugees: study protocol for a randomised controlled trial

BackgroundThe complexity of past trauma and ongoing post-migration stressors challenges the existing mental health treatment for trauma-affected refugees. Therefore, interventions are needed to accommodate these complex challenges in mental health treatment. This study examines the effect of an add-on integrated care intervention compared to treatment as usual (TAU) for trauma-affected refugees in a randomised controlled trial (RCT).MethodsThe study is carried out at a Danish outpatient clinic and will include 197 treatment-seeking refugees with post-traumatic stress disorder (PTSD) who are unemployed and affiliated with municipal employment services. Mental health TAU comprises 10 sessions with a medical doctor (pharmacological treatment and psychoeducation) and 16–20 sessions with a psychologist (manual-based cognitive behavioural therapy) for a period of 8 to 12 months. The add-on intervention strengthens coordination between mental health treatment and employment interventions with three cross-sectoral collaborative meetings during the mental health treatment. The integrated care intervention draws attention to the bidirectional impact of mental health problems and post-migration stressors and focuses on cross-sectoral shared plans. The primary outcome is functioning, measured by WHODAS 2.0, the interviewer-administered 12-item version, with secondary outcomes measuring quality of life, mental health symptoms, and post-migration stressors.DiscussionThe RCT is novel in intervention design for trauma-affected refugees and will bring forward new perspectives and knowledge of integrated care interventions for trauma-affected refugees. The integrated care intervention is expected to reduce post-migration stressors that negatively affect the treatment of trauma-related mental health problems, thereby improving preconditions for enhanced treatment outcomes. The intervention builds on existing practices in the Danish healthcare and employment sectors, which ensures high scalability and sustainability for future practices.Trial registrationClinicalTrials.gov Identifier: NCT04244864, registered 28 January 2020. Protocol version: 17 September 2022, version 2.

Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy

BackgroundExposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome.MethodIn a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions.ResultsIn a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings.ConclusionsThe results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.

ILC-OPI: impulsive lifestyle counselling versus cognitive behavioral therapy to improve retention of patients with opioid use disorders and externalizing behavior: study protocol for a multicenter, randomized, controlled, superiority trial

BackgroundSubstance use disorders show a high comorbidity with externalizing behavior difficulties, creating treatment challenges, including difficulties with compliance, a high risk of conflict, and a high rate of offending post-treatment. Compared with people with other substance use disorders those with opioid use disorders have the highest risk of criminal activity, but studies on the evidence base for psychosocial treatment in opioid agonist treatment (OAT) are scarce. The Impulsive Lifestyle Counselling (ILC) program may be associated with better retention and outcomes among difficult-to-treat patients with this comorbidity.MethodsThe study is a multicenter, randomized, controlled, superiority clinical trial. Participants will be a total of 137 hard-to-treat individuals enrolled in opioid agonist treatment (OAT). Participants will be randomized to either a standard treatment (14 sessions of individual manual-based cognitive behavioral therapy and motivational interviewing (MOVE-I)) or six sessions of ILC followed by nine sessions of MOVE-I. All participants will receive personalized text reminders prior to each session and vouchers for attendance, as well as medication as needed. The primary outcome is retention in treatment. Secondary measures include severity of drug use and days of criminal offending for profit three and nine months post-randomization. A secondary aim is, through a case-control study, to investigate whether participants in the trial differ from patients receiving treatment as usual in municipalities where ILC and MOVE-I have not been implemented in OAT. This will be done by comparing number of offences leading to conviction 12 months post-randomization recorded in the national criminal justice register and number of emergency room contacts 12 months post-randomization recorded in the national hospital register.DiscussionThis is the first randomized, controlled clinical trial in OAT to test the effectiveness of ILC against a standardized comparison with structural elements to increase the likelihood of exposure to the elements of treatment. Results obtained from this study may have important clinical, social, and economic implications for publicly funded treatment of opioid use disorder.Trial registrationISRCTN, ISRCTN19554367, registered on 04/09/2020.

Decreased defensive reactivity to interoceptive threat after successful exposure-based psychotherapy in patients with panic disorder

Panic disorder (PD) is characterized by a dysfunctional defensive responding to panic-related body symptoms that is assumed to contribute to the persistence of panic symptomatology. The present study aimed at examining whether this dysfunctional defensive reactivity to panic-related body symptoms would no longer be present following successful cognitive behavior therapy (CBT) but would persist when patients show insufficient symptom improvement. Therefore, in the present study, effects of CBT on reported symptoms and defensive response mobilization during interoceptive challenge were investigated using hyperventilation as a respiratory symptom provocation procedure. Changes in defensive mobilization to body symptoms in the course of CBT were investigated in patients with a primary diagnosis of PD with or without agoraphobia by applying a highly standardized hyperventilation task prior to and after a manual-based CBT (n = 38) or a waiting period (wait-list controls: n = 20). Defensive activation was indexed by the potentiation of the amygdala-dependent startle eyeblink response. All patients showed a pronounced defensive response mobilization to body symptoms at baseline. After treatment, no startle reflex potentiation was found in those patients who showed a clinically significant improvement. However, wait-list controls and treatment non-responders continued to show increased defensive responses to actually innocuous body symptoms after the treatment/waiting period. The present results indicate that the elimination of defensive reactivity to actually innocuous body symptoms might be a neurobiological correlate and indicator of successful CBT in patients with PD, which may help to monitor and optimize CBT outcomes.

Beyond 16 Sessions: Extending Manualized Treatment of Anxious Youth.

Cognitive behavioral therapy (CBT) is well established as an efficacious treatment for anxious youth, yet a number of youth remain symptomatic after the 10-16 sessions of treatment stipulated by most CBT treatment manuals. While a significant minority do not respond, no study has examined the frequency and impact of additional therapy sessions. This study examined youth receiving outpatient therapy at an anxiety clinic who were offered the option to continue treatment after completing 16 sessions of manual-based CBT. Fifty-nine percent of participants chose to continue treatment, with an average of approximately 20 total sessions across participants. Therapist ratings demonstrated a significant overall improvement between session 16 and the final session. No pre-treatment measure of symptom severity differed between those who extended treatment and those who ended at session 16. Parent-rated anxiety differed between groups at session 16, as did the length of time between the pre-treatment assessment and week 16 assessments. Findings indicate that extending treatment is not uncommon, is typically limited to several additional sessions, and is associated with an increase in treatment gains. Current results suggest that two factors at session 16, parental perceptions of anxiety and time to complete 16 sessions, are influential and may be central to the decision to continue treatment past this point. Clinical implications and future directions are discussed.

Treatment outcomes of a CBT-based group intervention for adolescents with Internet use disorders.

Background and aimsInstances of Internet use disorders (IUD) including Internet gaming disorder (IGD) and non-gaming pathological Internet use (ng-PIU) have the extent that they are now a growing mental health issue. Individuals suffering from IUD show a large range of symptoms, high comorbidities and impairments in different areas of life. To date there is a lack of efficient and evidence-based treatment programs for such adolescents. The present registered single-arm trial (ClinicalTrials.gov: NCT03582839) aimed to investigate the long-term effects of a brief manualized cognitive behavioral therapy (CBT) program for adolescents with IUD.MethodsN = 54 patients (16.7% female), aged 9–19 years (M = 13.48, SD = 1.72) received the CBT group program PROTECT+. IUD symptom severity (primary outcome variable) as well as comorbid symptoms, risk-related variables and potentially protective skills (secondary outcome variables) were assessed at pretest, posttest, as well as 4 and 12 months after admission.ResultsPatients showed a significant reduction in IUD symptom severity at the 12-month follow-up. Effect sizes were medium to large depending on the measure. Beyond the statistical significance, the clinical significance was confirmed using the reliable change index. Secondary outcome variables showed a significant reduction in self-reported depression, social anxiety, performance anxiety and school anxiety as well as in parental-reported general psychopathology.Discussion and conclusionsThe present study shows long-term effects of a manual-based CBT treatment for adolescents suffering from IUD. The results indicate that even a 4-session brief intervention can achieve a medium to large effect over 12 months. Future work is needed to confirm the efficacy within a randomized controlled trial (RCT).

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment.

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41years, SD = 1.56years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

Cognitive behavioral therapy with interoceptive exposure and complementary video materials for irritable bowel syndrome (IBS): protocol for a multicenter randomized controlled trial in Japan

BackgroundThere is growing evidence of the treatment efficacy of cognitive behavioral therapy (CBT) for irritable bowel syndrome (IBS). CBT is recommended by several practice guidelines for patients with IBS if lifestyle advice or pharmacotherapy has been ineffective. Manual-based CBT using interoceptive exposure (IE), which focuses on the anxiety response to abdominal symptoms, has been reported to be more effective than other types of CBT. One flaw of CBT use in general practice is that it is time and effort consuming for therapists. Therefore, we developed a set of complementary video materials that include psycho-education and homework instructions for CBT patients, reducing time spent in face-to-face sessions while maintaining treatment effects. The purpose of this study is to examine the effects of CBT-IE with complementary video materials (CBT-IE-w/vid) in a multicenter randomized controlled trial (RCT).MethodsThis study will be a multicenter, parallel-design RCT. Participants diagnosed with IBS according to the Rome IV diagnostic criteria will be randomized to either the treatment as usual (TAU) group or the CBT-IE-w/vid + TAU group. CBT-IE-w/vid consists of 10 sessions (approximately 30 min face-to-face therapy + viewing a video prior to each session). Patients in the CBT-IE-w/vid group will be instructed to pre- view 3- to 13-min videos at home prior to each face-to-face therapy visit at a hospital. The primary outcome is the severity of IBS symptoms. All participants will be assessed at baseline, mid-treatment, post-treatment, and follow-up (3 months after post assessment). The sample will include 60 participants in each group.DiscussionTo our knowledge, this study will be the first RCT of manual-based CBT for IBS in Japan. By using psycho-educational video materials, the time and cost of therapy will be reduced. Manual based CBTs for IBS have not been widely adopted in Japan to date. If our CBT-IE-w/vid program is confirmed to be more effective than TAU, it will facilitate dissemination of cost-effective manual-based CBT in clinical settings.Trial registrationThe trial was registered to the University Hospital Medical Information Network Clinical Trial Registry: UMIN, No. UMIN000030620 (Date of registration: December 28, 2017).

Treatment Gains Are Sustainable in Pediatric Obsessive-Compulsive Disorder: Three-Year Follow-Up From the NordLOTS

This study evaluated the long-term outcomes of a stepped care treatment for pediatric obsessive-compulsive disorder (OCD) and investigated whether response to first-step cognitive-behavioral therapy (CBT) is an important indicator of 3-year outcomes. This study is a part of the Nordic Long-term OCD Treatment Study (NordLOTS), in which 269 children and adolescents were treated with CBT. Nonresponders to CBT were randomized to extended treatment with continued CBT or pharmacotherapy with sertraline. Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) scores no higher than 15 and no higher than 10 were defined as treatment response and remission, respectively. Participants were assessed 2 and 3 years after first-step CBT. Linear mixed-effects models were used to analyze the outcomes. Intent-to-treat analyses showed a significant decrease in CY-BOCS total score from baseline (24.6) to 3-year follow-up (5.0; p= .001), with a mean decrease of 5.9 from after treatment to 3-year follow-up. Three years after treatment, 90% (n= 242) of participants were rated as responders and 73% were in clinical remission. The duration of treatment did not influence the symptom level at 3-year follow-up (p= .998) and no significant difference was found (p= .169) between the extended treatment conditions. The results suggest that evidence-based treatment for pediatric OCD has long-term positive effects, whether a first step of manual-based CBT or extended treatment with CBT or sertraline. The improvements were maintained, and the symptoms decreased further during follow-up and were, after 3 years, similarly independent of treatment duration and form of extended treatment. Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119.

Cognitive-Behavioral Therapy for Children With Anxiety and Comorbid Attention-Deficit/Hyperactivity Disorder

To determine whether comorbid attention-deficit/hyperactivity disorder (ADHD) diagnosis (including subtype) predicts response to cognitive-behavior therapy (CBT) for anxiety in children and to examine change in ADHD symptoms after treatment of primary anxiety. A sample of 842 children 5 to 18 years of age received CBT for a primary anxiety disorder. A subsample of 94 children met criteria for comorbid mild-to-moderate ADHD, mostly consisting of predominantly inattentive (n= 61) and combined (n= 27) subtypes. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each time point (after treatment and 3- and/or 6-month follow-up) and analyzed using linear and logistic mixed models. Neither ADHD diagnosis nor subtype predicted response or remission rates for children's primary anxiety disorders. Children with ADHD also showed modest yet significant improvements in ADHD symptoms after CBT for anxiety. The present findings support the suitability of manual-based group-based CBT for anxiety treatment in children with nonprimary ADHD. Further research should examine whether the positive outcomes reported can be extended to children with primary or severe ADHD.

Do emotion regulation, attentional control, and attachment style predict response to cognitive behavioral therapy for anxiety disorders? – an investigation in clinical settings

Objective: Approximately, 50% of all individuals with anxiety disorders do not benefit from the “gold standard” treatment, namely cognitive behavioral therapy (CBT). Reliable predictors of treatment effect are lacking. The primary aim of this study was to investigate the predictive value of emotion regulation, attentional control, and attachment style for group-based CBT outcomes in routine clinical settings. Method: A total of 76 patients with anxiety disorders received manual-based group CBT at psychiatric outpatient clinics. Emotion regulation, attachment style, and attentional control were assessed with self-report measures and with an experimental computer-based attentional control task at baseline. The severity of anxiety was assessed at intake, post-treatment, and at a 6-month follow-up. Results: Attentional control, emotion regulation, and attachment avoidance did not predict treatment outcomes. Higher attachment anxiety at baseline was significantly related to poorer outcome. Conclusion: In routine clinical settings, high attachment anxiety may predict poorer outcomes for group-based CBT.

Treatment of sleep disturbances in trauma-affected refugees: Study protocol for a randomised controlled trial

BackgroundSleep disturbances are often referred to as a hallmark and as core symptoms of post-traumatic stress disorder (PTSD). Untreated sleep disturbances can contribute to the maintenance and exacerbation of PTSD symptoms, which may diminish treatment response and constitute a risk factor for poor treatment outcome. Controlled trials on treatment of sleep disturbances in refugees suffering from PTSD are scarce. The present study aims to examine sleep-enhancing treatment in refugees with PTSD. We aim to assess if add-on treatment with mianserin and/or Imagery Rehearsal Therapy (IRT) to treatment as usual (TAU) for PTSD improves sleep disturbances. We will study the relation between sleep disturbances, PTSD symptoms, psychosocial functioning and quality of life.MethodsThe study is a randomised controlled superiority trial with a 2 × 2 factorial design. The study will include 230 trauma-affected refugees.The patients are randomised into four groups. All four groups receive TAU – an interdisciplinary treatment approach covering a period of 6–8 months with pharmacological treatment, physiotherapy, psychoeducation and manual-based cognitive behavioural therapy within a framework of weekly sessions with a physician, physiotherapist or psychologist. One group receives solely TAU, serving as a control group, while the three remaining groups are active-treatment groups receiving add-on treatment with either mianserin, IRT or a combination of both.Treatment outcome is evaluated using self-administered rating scales, observer ratings and actigraph measurements at baseline, during treatment and post treatment. The primary outcome is subjective sleep quality using the Pittsburgh Sleep Quality Index. Secondary outcome measures are objective sleep length, nightmares, PTSD severity, symptoms of depression and anxiety, pain, quality of life and psychosocial functioning.DiscussionThis trial will be the first randomised controlled trial to examine sleep-enhancing treatment in trauma-affected refugees, as well as the first trial to investigate the effect of IRT and mianserin in this population. Therefore, this trial may optimise treatment recommendations for sleep disturbances in trauma-affected refugees. Based on our findings, we expect to discuss the effect of treatment, focussing on sleep disturbances. Furthermore, the results will provide new information regarding the association between sleep disturbances, PTSD symptoms, psychosocial functioning and quality of life in trauma-affected refugees.Trial registrationEudraCT registration under the name ‘Treatment of sleep disturbances in trauma-affected refugees – a randomised controlled trial’, registration number: 2015-004153-40, registered on 13 November 2015.ClinicalTrials.gov, ID: NCT02761161. Registered on 27 April 2016.

Validity and utility of the DSM-5 severity specifier for binge-eating disorder.

To test both the concurrent and predictive significance of the new DSM-5 severity specifier for binge-eating disorder (BED) in adult outpatients. Existing data from 195 adults with DSM-5 BED who received evidence-based treatment (manual-based cognitive-behavioral therapy) in an outpatient setting were re-analysed to examine whether these patients sub-grouped according to the DSM-5 severity levels, defined by the frequency of binge-eating (BE) episodes, would show meaningful differences in a range of variables of clinical interest assessed at pre-treatment and end-of treatment abstinence from BE. Participants categorized with mild (33.3% of the sample), moderate (35.4%), severe (15.9%), and extreme (15.4%) severity of BED, based on their pre-treatment clinician-rated frequency of BE episodes, differed significantly from each other in physical characteristics (body mass index) and another sixteen variables of clinical interest assessed at pre-treatment regarding eating disorder psychopathology and putative maintenance factors, lifetime and current psychiatric disorder comorbidity, general psychiatric distress, and psychosocial impairment. The four DSM-5 severity groups were statistically indistinguishable in demographics or age-of-BED onset. However, significant between-group differences were observed in the treatment outcome, i.e., abstinence from BE, achieved by 98.5%, 66.7%, 38.7% and 6.7% of participants categorized with mild, moderate, severe, and extreme severity respectively. The outcome analyses repeated in the completer sample (n = 187) yielded the same pattern of the aforementioned intent-to-treat (N = 195) results. The findings provide support for the severity specifier for BED introduced in the DSM-5 as a means of addressing within-group variability in severity.

Validity and clinical utility of the DSM-5 severity specifier for bulimia nervosa: results from a multisite sample of patients who received evidence-based treatment.

A new "severity specifier" for bulimia nervosa (BN), based on the frequency of inappropriate weight compensatory behaviours (IWCBs), was added to the DSM-5 as a means of documenting heterogeneity and variability in the severity of the disorder. Yet, evidence for its validity in clinical populations, including prognostic significance for treatment outcome, is currently lacking. Existing data from 281 treatment-seeking patients with DSM-5 BN, who received the best available treatment for their disorder (manual-based cognitive behavioural therapy; CBT) in an outpatient setting, were re-analysed to examine whether these patients subgrouped based on the DSM-5 severity levels would show meaningful and consistent differences on (a) a range of clinical variables assessed at pre-treatment and (b) post-treatment abstinence from IWCBs. Results highlight that the mild, moderate, severe, and extreme severity groups were statistically distinguishable on 22 variables assessed at pre-treatment regarding eating disorder pathological features, maintenance factors of BN, associated (current) and lifetime psychopathology, social maladjustment and illness-specific functional impairment, and abstinence outcome. Mood intolerance, a maintenance factor of BN but external to eating disorder pathological features (typically addressed within CBT), emerged as the primary clinical variable distinguishing the severity groups showing a differential treatment response. Overall, the findings speak to the concurrent and predictive validity of the new DSM-5 severity criterion for BN and are important because a common benchmark informing patients, clinicians, and researchers about severity of the disorder and allowing severity fluctuation and patient's progress to be tracked does not exist so far. Implications for future research are outlined.

Examining the dynamic relationships between exposure tasks and cognitive restructuring in CBT for SAD: Outcomes and moderating influences

Meta-analyses indicate that cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) leads to substantial symptom alleviation. Although there is an emphasis on engaging in exposure and cognitive restructuring during treatment, the longitudinal relationship between skill use and symptom alleviation is not well understood. Furthermore, treatment response may be attenuated by pre-existing patient vulnerabilities. This study examined the longitudinal association of skill use (i.e. exposure (EX), thought record use (TR)), symptom reduction and the potential moderating influence of perfectionism during a 12-session, manual-based CBT for SAD intervention for 100 patients (51% female) meeting DSM-IV criteria for SAD. Results obtained from Latent Difference Score (LDS) models indicated that the frequency of both EX and TR skill use led to subsequent symptom alleviation; however, this varied based on the type of skill used. Further, although both EX and TR interventions were associated with subsequent symptom reduction, the association of EX and subsequent symptom alleviation was greater than the association of TR and subsequent symptom alleviation. Finally, higher pre-treatment perfectionism was associated with greater initial skill use, followed by significantly reduced skill use in later sessions. These preliminary results suggest that perfectionistic individuals demonstrate differential engagement in EX and TR interventions during treatment.

A Case Series of Individual Six-Week Cognitive Behavioral Therapy With Individually Tailored Manual-Based Treatment Delivery for Depressed College Students With or Without Suicidal Ideation

Despite their prevalence, depression and suicidal ideation (SI) are relatively unaddressed problems in the college student population. There are limited individual treatment studies targeting this population. Nine students (M = 19.33 years of age; SD ± .87) with depressive symptoms and/or SI were enrolled in 6-weeks of individual cognitive behavioral therapy (CBT) with a individually tailored manual-based treatment delivery. Measures were given before and after treatment. Primary results, presented as a case series, suggested decreases in depression across students and an overall downward trend in SI. As a secondary analysis, paired samples t tests showed significant decreases in both depression and SI. In summary, short-term, individually tailored manual-based CBT may be beneficial for reducing depressive symptoms and SI among college students. More research is needed to determine the best clinical interventions and targeted treatments for this vulnerable population.

Encoding risk: Probation work and sex offenders’ narrative identities

Legislation governing the management of released sex offenders in England and Wales has frequently focused on the monitoring of behaviour and the structuring of external controls. Such policies would appear to limit concern for the subject’s internal world to manual-based cognitive behavioural therapy courses. Interviews conducted in England both with paroled individuals convicted for sexual offences and their supervising (probation) officers, however, reveal the various ways in which officers attempt to direct the narrative identities of their parolees – shaping their subjectivities. Drawing upon Foucauldian descriptions of confession as a ‘technology of the self’, it is possible to see how probation officers sought to transform their clients’ self-conceptualisations. This analysis highlights the internal nature of supervisory work, offering insights into the reasons why sex offenders may engage with or resist their community management. Furthermore, the potential impact of the narratives encouraged must be considered; while explanatory discourses of public protection and risk management prevailed, there are good reasons to suggest that the work conducted may have hindered the pursuit of these aims.