To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Cognitive-behavior therapy (CBT) is a well-established first-line intervention for anxiety-related disorders, including specific phobia, social anxiety disorder, panic disorder/agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. Several neural predictors of CBT outcome for anxiety-related disorders have been proposed, but previous results are inconsistent.
We conducted a systematic review and meta-analysis of task-based functional magnetic resonance imaging (fMRI) studies investigating whole-brain predictors of CBT outcome in anxiety-related disorders (17 studies, n = 442).
Across different tasks, we observed that brain response in a network of regions involved in salience and interoception processing, encompassing fronto-insular (the right inferior frontal gyrus-anterior insular cortex) and fronto-limbic (the dorsomedial prefrontal cortex-dorsal anterior cingulate cortex) cortices was strongly associated with a positive CBT outcome.
Our results suggest that there are robust neural predictors of CBT outcome in anxiety-related disorders that may eventually lead (probably in combination with other data) to develop personalized approaches for the treatment of these mental disorders.
Eating disorders (EDs) and posttraumatic stress disorder (PTSD) frequently co-occur and can share a functional relationship. The primary aim of this initial randomized controlled trial was to determine whether integrated cognitive-behavioral therapy (CBT) for co-occurring ED-PTSD was superior to standard CBT for ED in improving PTSD symptoms. Intervention safety and desirability, as well as the relative efficacy of the treatments in improving anxiety, depression, and ED symptomatology, were also examined.
Following a course of intensive ED treatment, individuals with ED-PTSD were recruited to participate and randomized to integrated CBT for ED-PTSD or standard CBT for ED. The sample consisted of 42 individuals with a range of ED diagnoses. Outcomes were assessed at end-of-treatment, 3-, and 6-month follow-up using interview and self-report measures.
Mixed models revealed significant interactions of time and therapy condition on clinician-rated and self-reported PTSD symptom severity favoring Integrated CBT for ED-PTSD. Both treatments were associated with statistically significant improvements in PTSD, anxiety, and depression. Improvements were maintained at 3- and 6-month follow-up. There was good safety with both interventions, and satisfaction with both treatments was high. However, there was a stronger preference for integrated treatment.
Integrating CBTs for PTSD and ED following intensive ED treatment is safe, desirable, and efficacious for improving PTSD symptoms. Future studies with larger sample sizes are needed to determine whether Integrated CBT for ED-PTSD provides benefits over standard CBT for ED with respect to ED outcomes.
Impulsivity may be a process underlying binge-eating disorder (BED) psychopathology and its treatment. This study examined change in impulsivity during cognitive-behavioral therapy (CBT) and/or pharmacological treatment for BED and associations with treatment outcomes.
In total, 108 patients with BED (NFEMALE = 84) in a randomized placebo-controlled clinical trial evaluating the efficacy of CBT and/or fluoxetine were assessed before treatment, monthly throughout treatment, at post-treatment (16 weeks), and at 12-month follow-up after completing treatment. Patients completed established measures of impulsivity, eating-disorder psychopathology, and depression, and were measured for height and weight [to calculate body mass index (BMI)] during repeated assessments by trained/monitored doctoral research-clinicians. Mixed-effects models using all available data examined changes in impulsivity and the association of rapid and overall changes in impulsivity on treatment outcomes. Exploratory analyses examined whether baseline impulsivity predicted/moderated outcomes.
Impulsivity declined significantly throughout treatment and follow-up across treatment groups. Rapid change in impulsivity and overall change in impulsivity during treatment were significantly associated with reductions in eating-disorder psychopathology, depression scores, and BMI during treatment and at post-treatment. Overall change in impulsivity during treatment was associated with subsequent reductions in depression scores at 12-month follow-up. Baseline impulsivity did not moderate/predict eating-disorder outcomes or BMI but did predict change in depression scores.
Rapid and overall reductions in impulsivity during treatment were associated with improvements in specific eating-disorder psychopathology and associated general outcomes. These effects were found for both CBT and pharmacological treatment for BED. Change in impulsivity may be an important process prospectively related to treatment outcome.
A history of suicide attempt (SA) is a strong predictor of future suicide re-attempts or suicide. The aim of this systematic review is to evaluate the efficacy of psychotherapeutic interventions specifically designed for the prevention of suicide re-attempts. A systematic search from 1980 to June 2020 was performed via the databases PubMed and Google Scholar. Only randomized controlled trials were included which clearly differentiated suicidal self-harm from non-suicidal self-injury in terms of intent to die. Moreover, psychotherapeutic interventions had to be focused on suicidal behaviour and the numbers of suicide re-attempts had to be used as outcome variables. By this procedure, 18 studies were identified. Statistical comparison of all studies revealed that psychotherapeutic interventions in general were significantly more efficacious than control conditions in reducing the risk of future suicidal behaviour nearly by a third. Separate analyses revealed that cognitive-behavioural therapy as well as two different psychodynamic approaches were significantly more efficacious than control conditions. Dialectical behaviour therapy and elementary problem-solving therapy were not superior to control conditions in reducing the number of SAs. However, methodological reasons may explain to some extent these negative results. Considering the great significance of suicidal behaviour, there is unquestionably an urgent need for further development of psychotherapeutic techniques for the prevention of suicide re-attempts. Based on the encouraging results of this systematic review, it can be assumed that laying the focus on suicidal episodes might be the key intervention for preventing suicide re-attempts and suicides.
Mindfulness-based cognitive therapy (MBCT) is a third wave cognitive-behavioral therapy (CBT) that incorporates meditation exercises in the classical, structured intervention. Mindfulness has been associated with psychological well-being, and certain symptoms that occur in major depressive disorder (MDD), e.g. worries, ruminations, ideas of incapacity or self-devaluation, are considered potential targets for MBCT.
To evaluate the current level of evidence for the MCBT efficacy in MDD.
A literature serach was performed in the main electronic databases, targeting clinical trials that evaluated in a randomized manner the efficacy of MCBT versus active comparators or placebo in patients with MDD.
MBCT was efficient in a 10-week randomized controlled trial (RCT) versus standard treatment, and it decreased ruminations, increased patients quality of life, mindfulness abilities, and self-compassion. In another randomized, 8-week RCT, MBCT prevented relapses in MDD, with similar rates when compared to psychoeducation and standard treatment. A 26-month follow-up study evidenced the persistence of symptoms improvement detected after 12 months of the trial, when compared to active control group and treatment as usual. MCBT was compared to cognitive therapy in a randomized 8-week trial, and both treatments had similar efficacy in MDD relapse prevention.
MCBT may be an useful adjuvant to the current treatment in acute MDD, but it may also decrease the risk of relapse after psychotherapy termination.
Altered fear learning processes could be mechanistically linked to the development and/or maintenance of obsessive-compulsive disorder (OCD). From a clinical perspective, the first-line psychological treatment for OCD is cognitive-behavioral therapy (CBT), which is based on the principles of fear learning. However, no previous functional magnetic resonance imaging (fMRI) studies have evaluated the predictive capacity of regional brain activations during fear learning on CBT response in patients with OCD.
We aimed at exploring whether brain activation during fear learning in patients with OCD are associated with CBT outcome.
We assessed 18 patients with OCD and 18 healthy participants during a 2-day experimental protocol where brain activation and skin conductance responses (SCR) where assessed during fear conditioning, extinction learning, and extinction recall within the fMRI scanner. Following the protocol, patients with OCD received CBT.
We found non-significant between-group differences in SCR during fear learning. Patients with OCD showed significantly diminished activation of the dorsal anterior cingulate cortex and the right insula during fear conditioning. Importantly, our analyses revealed a significant negative association between clinical improvement after CBT and activity at the right insula during fear conditioning (x = 39, y = 12, z = -11; t = 5.64; p<0.001; k = 928). This finding is displayed in Figure 1 below.
Patients with OCD may require less fear-conditioned brain responses to achieve the same level of psychophysiological fear conditioning as healthy participants. Interestingly, insula activations during fear-conditioned responses may represent a potential predictor biomarker of response to CBT for OCD.
Cognitive behavioral therapies (CBT) represent a heterogeneous group of psychotherapies in continuous development that share a directive, structured, collaborative approach. Due to a high degree of treatment-resistant cases of major depressive disorder (MDD), new augmentation therapies are urgently needed, in order to increase the chance of recovery in these patients.
To analyze data that may support the indication of third wave CBT in patients with MDD.
A literature search was performed in the main electronic databases, and papers published between January 2000 and August 2020 were included.
Acceptance and commitment therapy has been associated with positive results, but data are derived from low quality trials (n=2). Dialectical-behavioral therapy (DBT)-based skill group have been also associated with favorable outcome, in MDD patients (n=2). Mindfulness-based cognitive therapy (MBCT) was also proven effective in the treatment in MDD (n=4), treatment-resistant MDD included, but the difference between MBCT and active comparators was not always significant. Metacognitive therapy (MCT) has been evaluated in good quality clinical trials (n=4), and its efficacy was confirmed. Mild and moderate MDD patients may benefit from compassion-focused therapy (CFT) (n=1). Behavioral activation (BA) is dedicated to MDD patients and according to a meta-analysis (n=26 randomized controlled trials) BA is superior to other active comparators, although the quality of clinical trials was modest.
Third generation CBT could be useful in MDD patients as augmentative strategy, but more good-quality data are necessary before recommending them in an evidence-based treatment guideline as a distinctive intervention from classical CBT.
This chapter provides a basic introduction to the relationship between thoughts, feelings, and behaviors, and introduces our cognitive-behavioral model of ARFID. We return to the case examples from Chapter 1 to illustrate a cognitive-behavioral understanding of sensory sensitivity, fear of aversive consequences, and lack of interest in eating or food.
This chapter explains what avoidant/restrictive food intake disorder (ARFID) is and provides diverse and relatable case examples of each of the three prototypical ARFID presentations, including sensory sensitivity, fear of aversive consequences, and lack of interest in eating or food.
Are you a picky eater? Do you worry that food will make you vomit or choke? Do you find eating to be a chore? If yes, this book is for you! Your struggles could be caused by Avoidant Restrictive Food Intake Disorder (ARFID); a disorder characterized by eating a limited variety or volume of food. You may have been told that you eat like a child, but ARFID affects people right across the lifespan, and this book is the first specifically written to support adults. Join Drs. Jennifer Thomas, Kendra Becker, and Kamryn Eddy - three ARFID experts at Harvard Medical School - to learn how to beat your ARFID at home and unlock a healthier relationship with food. Real-life examples show that you are not alone, while practical tips, quizzes, worksheets, and structured activities, take you step-by-step through the latest evidence-based treatment techniques to support your recovery.
Psychiatric comorbidity is common in binge-eating disorder (BED) but effects on treatment outcomes are unknown. The current study aimed to determine whether psychiatric comorbidity predicted or moderated BED treatment outcomes.
In total, 636 adults with BED in randomized-controlled trials (RCTs) were assessed prior, throughout, and posttreatment by doctoral research-clinicians using reliably-administered semi-structured interviews, self-report measures, and measured weight. Data were aggregated from RCTs testing cognitive-behavioral therapy, behavioral weight loss, multi-modal (combined pharmacological plus cognitive-behavioral/behavioral), and/or control conditions. Intent-to-treat analyses (all available data) tested comorbidity (mood, anxiety, ‘any disorder’ separately) as predictors and moderators of outcomes. Mixed-effects models tested comorbidity effects on binge-eating frequency, global eating-disorder psychopathology, and weight. Generalized estimating equation models tested binge-eating remission (zero binge-eating episodes during the past month; missing data imputed as failure).
Overall, 41% of patients had current psychiatric comorbidity; 22% had mood and 23% had anxiety disorders. Psychiatric comorbidity did not significantly moderate the outcomes of specific treatments. Psychiatric comorbidity predicted worse eating-disorder psychopathology and higher binge-eating frequency across all treatments and timepoints. Patients with mood comorbidity were significantly less likely to remit than those without mood disorders (30% v. 41%). Psychiatric comorbidity neither predicted nor moderated weight loss.
Psychiatric comorbidity was associated with more severe BED psychopathology throughout treatment but did not moderate outcomes. Findings highlight the need to improve treatments for BED with psychiatric comorbidities but challenge perspectives that combining existing psychological and pharmacological interventions is warranted. Treatment research must identify more effective interventions for BED overall and for patients with comorbidities.
Anxiety is common in older adults with cancer (OACs) and their caregivers and is associated with poor outcomes including worse physical symptoms, poor treatment adherence and response, and longer hospitalizations. This study examined the feasibility, acceptability, adherence, and preliminary efficacy of a cognitive-behavioral therapy (CBT) intervention for OACs and their caregivers.
Patients with active cancer age 65 years and older and their caregivers were randomized to Managing Anxiety from Cancer (MAC), a seven-session CBT-based psychotherapy intervention delivered over the telephone or usual care. Patients and caregivers completed the intervention separately with licensed social workers. Self-report measures of anxiety, depression, and quality of life were administered after randomization and following intervention completion. Analyses were conducted separately for patients and caregivers and at the dyad level. Hierarchical Linear Modeling accounted for the within-dyad intraclass correlation coefficients (ICCs) by random intercepts associated with the dyads.
Twenty-nine dyads were randomized; 28 (96.6%) patients and 26 (89.7%) caregivers completed all study procedures. Of dyads randomized to MAC, 85.7% (n = 12) of patients and caregivers completed all seven sessions. Most patients (≥50%) and over 80% of caregivers rated the overall intervention and intervention components as “moderately” to “very” helpful. MAC was associated with a greater reduction in anxiety among dyads than usual care, the effect of MAC was greater in caregivers than in patients, and improvement in patient anxiety was associated with the reduction in caregiver anxiety. However, these results did not reach statistical significance.
Significance of results
This pilot study demonstrates the feasibility of MAC and suggests strategies for improving acceptability, with a focus on adherence. Furthermore, these results indicate that MAC is promising for the reduction of anxiety in OAC–caregiver dyads and may be particularly beneficial for OAC caregivers. Larger randomized controlled trials are needed to evaluate the efficacy of MAC.
Drawing upon the GKC framework, this chapter presents an ethnographic study of Woebot – a therapy chatbot designed to administer a form of cognitive behavioral therapy (“CBT”). Section 3.1 explains the methodology of this case study. Section 3.2 describes the background contexts that relate to anxiety as a public health problem. These include the nature of anxiety and historical approaches to diagnosing and treating it, the ascendency of e-Mental Health therapy provided through apps, and relevant laws and regulations. Section 3.3 describes how Woebot was developed and what goals its designers pursued. Section 3.4 describes the kinds of information that users share with Woebot. Section 3.5 describes how the designers of the system seek to manage this information in a way that benefits users without disrupting their privacy.
Several pathways can lead out of destructive drug use, including natural recovery with no treatment. Mental-health professionals in treatment programs or working independently offer treatment, and Alcoholics Anonymous (AA) and secular groups enable mutual support for recovery from SUD. The Minnesota Model, based on the principles of AA, heavily influences many treatment programs. Counseling and psychotherapy are primary treatments for SUD, often conducted in groups. Sharing of common SUD experiences relieves shame and isolation that impede recovery. Office-based treatment may provide individual psychotherapy. Therapists and counselors try to establish an alliance with clients to promote intrinsic motivation for secure abstinence. Therapies include cognitive-behavioral, 12-step facilitation, mindfulness, dialectical behavior change, and couples or family therapy. Brief Interventions are short counseling sessions most appropriate for early-stage substance abuse. Alcohol or other drug use often recurs after treatment, and prevention of relapse is a primary goal of SUD treatment. Participation in mutual assistance groups is associated with lower rates of relapse.
Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition.
Patients with principal anxiety disorders (N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms.
At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT (t(218) = −2.17, p = 0.03, d = −0.32) and WL conditions(t(207) = −2.33, p = 0.02, d = −0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms.
Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.
This guidance paper from the European Psychiatric Association (EPA) aims to provide evidence-based recommendations on early intervention in clinical high risk (CHR) states of psychosis, assessed according to the EPA guidance on early detection. The recommendations were derived from a meta-analysis of current empirical evidence on the efficacy of psychological and pharmacological interventions in CHR samples. Eligible studies had to investigate conversion rate and/or functioning as a treatment outcome in CHR patients defined by the ultra-high risk and/or basic symptom criteria. Besides analyses on treatment effects on conversion rate and functional outcome, age and type of intervention were examined as potential moderators. Based on data from 15 studies (n = 1394), early intervention generally produced significantly reduced conversion rates at 6- to 48-month follow-up compared to control conditions. However, early intervention failed to achieve significantly greater functional improvements because both early intervention and control conditions produced similar positive effects. With regard to the type of intervention, both psychological and pharmacological interventions produced significant effects on conversion rates, but not on functional outcome relative to the control conditions. Early intervention in youth samples was generally less effective than in predominantly adult samples. Seven evidence-based recommendations for early intervention in CHR samples could have been formulated, although more studies are needed to investigate the specificity of treatment effects and potential age effects in order to tailor interventions to the individual treatment needs and risk status.
To identify the presence of factors associated with treatment outcome in patients under group cognitive-behavioral therapy (GCBT) for obsessive-compulsive disorder (OCD).
Subjects and methods
This study evaluated 181 patients with OCD that attended a 12-session weekly GCBT program. Response criteria were: ≥35% reduction in Y-BOCS scores and global improvement score of the Clinical Global Impression (CGI) ≤ 2 at post-treatment evaluation. Sociodemographic data, OCD characteristics, and treatment data were studied.
In the bivariate analysis, the following variables showed statistical significance (p < 0.20) to enter the regression model: being woman (p = 0.074), greater insight (p = 0.017) and better quality of life (QOL) in all domains before treatment (p = 0.053), overall severity of disease according to the CGI (p = 0.007), number of associated comorbidities (p = 0.063), social phobia (p = 0.044), and dysthymia (p = 0.072). In the final regression model, these variables were associated with response to GCBT: female gender (p = 0.021); WHOQOL-BREF psychological domain (p = 0.011); insight (p = 0.042); and global improvement score of the CGI severity-scale before therapy (p = 0.045).
Special attention should be paid to patients with poor insight, increasing the cognitive aspects of the therapy in an attempt to modify the rigidity and fixity of their beliefs. In addition, male patients should be more observed, since they showed lower chance of response to GCBT when compared to women. Patients with more severe global symptoms (CGI) are poorer responders to GCBT, which indicates that not only obsessive-compulsive symptoms (OCS) should be evaluated, since other symptoms, such as depression and anxiety, may affect the treatment; therefore, an attempt to reduce these symptoms, prior to the treatment of OCD, should be considered as an option in some cases.
DSM-5 proposed a new operational system by using the number of fulfilled criteria as an indicator of gambling disorder severity. This method has proven to be controversial among researchers and clinicians alike, due to the lack of studies indicating whether severity, as measured by these criteria, is clinically relevant in terms of treatment outcome. Additionally, numerous studies have highlighted the associations between gambling disorder and impulsivity, though few have examined the impact of impulsivity on long-term treatment outcomes.
In this study, we aimed to assess the predictive value of DSM-5 severity levels on response to cognitive-behavioral therapy (CBT) in a sample of male adults seeking treatment for gambling disorder (n = 398). Furthermore, we explored longitudinal predictors of CBT treatment response at a follow-up, considering UPPS-P impulsivity traits.
Our study failed to identify differences in treatment outcomes between patients categorized by DSM-5 severity levels. Higher baseline scores in negative urgency predicted relapse during CBT treatment, and higher levels of sensation seeking were predictive of drop-out from short-term treatment, as well as of drop-out at 24-months.
These noteworthy findings raise questions regarding the clinical utility of DSM-5 severity categories and lend support to the implementation of dimensional approaches for gambling disorder.