Fear conditioning and extinction are central in the cognitive behavioral model of obsessive-compulsive disorder (OCD), which underlies exposure-based cognitive behavioral therapy (CBT). Youth with OCD may have impairments in conditioning and extinction that carries treatment implications. The present study examined these processes using a differential conditioning paradigm. Forty-one youth (19 OCD, 22 community controls) and their parents completed a battery of clinical interviews, rating scales, and a differential conditioning task. Skin conductance response (SCR) served as the primary dependent measure across all three phases of the conditioning procedure (habituation, acquisition, and extinction). During habituation, no meaningful differences were observed between groups. During acquisition, differential fear conditioning was identified across groups evidenced by larger SCRs to the CS+ compared to CS-, with no significant group differences. During extinction, a three-way interaction and follow-up tests revealed youth with OCD failed to exhibit differential fear conditioning during early fear extinction; whereas community controls consistently exhibited differential fear conditioning throughout extinction. Across participants, the number and frequency of OCD symptoms was positively associated with fear acquisition and negatively associated with fear extinction to the conditioned stimulus. OCD symptom severity was negatively associated with differential SCR in early extinction. Youth with OCD exhibit a different pattern of fear extinction relative to community controls that may be accounted for by impaired inhibitory learning in early fear extinction. Findings suggest the potential benefit of augmentative retraining interventions prior to CBT. Therapeutic approaches to utilize inhibitory-learning principles and/or engage developmentally appropriate brain regions during exposures may serve to maximize CBT outcomes.

Advances in cancer treatment have led to a significant increase in the number of pediatric oncology survivors. These survivors often have late effects in their cognitive, academic, executive, and psychological functioning subsequent to their chemotherapy and radiation treatment. In particular, executive functioning (EF), which is crucial for cognitive and academic functioning, has been recognized as an area that is impacted by treatment. Several studies have described cognitive remediation programs that seek to improve EF skills in pediatric oncology survivors. Although these programs have led to improvements in EF skills, they are often difficult to replicate due to the extensive time requirement. Many survivors also experience distress and anxiety and would likely benefit from cognitive behavioral therapy, which has been shown to be an effective intervention for children with internalizing disorders. Thus, a brief intervention that combines treatment for executive functioning and psychological distress is warranted. A mixed methods study was conducted to evaluate the impact of a nine-week blended cognitive remediation and cognitive behavior therapy group for pediatric oncology survivors and their parents. Participants were pediatric cancer survivors, age 9-14, and their parents who were referred through a local children's hospital that specialized in oncology treatment. Pre and post measures of EF, psychological functioning, and parental stress were examined. Semi-structured interviews with participants and their parents were completed and analyzed to learn more about the function of short-term group therapy for pediatric oncology survivors. Content analysis of the parent support group sessions was also conducted. Significant changes were found for youth internalizing symptoms, youth adaptive skills, youth executive functioning, and parental stress. There was also a positive correlation between parental stress and parent-rated youth internalizing problems as well as parent-rated youth behavioral symptoms and a negative correlation between parental stress and parent-rated youth adaptive behavior. Qualitative interviews indicated that participants felt that the intervention was helpful. Themes from the parent group included the challenge of managing late effects, balancing multiple roles, and coping with distress. Implications, limitations, and recommendations for further areas of research are presented. / text

While cognitive therapy (CT) is one of the most well-validated and widely used treatments for patients with Major Depressive Disorder (MDD), many individuals remain symptomatic at the end of treatment or drop out prematurely (Cuijpers, van Straten, Anderson, & van Oppen, 2008; Vittengl, Clark, Dunn, & Jarrett, 2007). Evidence suggests that certain types of therapist relational styles, such as one characterized by empathy and support, are facilitative of better therapeutic outcomes (Keijsers, Schaap, & Hoogduin, 1997) and motivational interviewing (MI; Miller & Rollnick, 2002) is a therapeutic approach which emphasizes this type of relational stance. The present study examined whether cognitive therapists exhibit a relational stance that is emphasized in motivational interviewing and whether this relational stance is associated with greater symptomatic improvement in cognitive therapy for depression. The Motivational Interviewing Treatment Integrity Skills Code (MITI; Moyers, Martin, Manuel, Miller, & Ernst, 2007), an observational coding system originated for assessing fidelity to MI, was used to assess three aspect of MI relational stance (MI Spirit, MI Adherent behaviors, and MI Nonadherent behaviors) among cognitive therapists in a randomized-controlled of CT for individuals with moderate to severe depression. Multilevel modeling was employed to examine the effect of MI relational stance on overall symptom trajectories throughout treatment and subsequent symptom reduction immediately after the use of MI relational stance. In order to rule out early symptom reduction as a potential confound, shared variance between MI relational stance and early symptom reduction was removed. The hypothesis that MI relational stance would be associated with more rapid symptom reduction was confirmed for MI Adherent behaviors but not for MI Spirit or MI Nonadherent behaviors. The prediction that initial depression severity would moderate the effect of MI relational stance on symptomatic improvement was not confirmed; however, a three-way interaction between initial depression severity, MI Adherence, and session number revealed that patients with high initial depression severity did not significantly improve through the course of therapy unless they received high MI Adherence. The hypothesis that MI relational stance in a given session would be associated with a reduction in depressive symptoms in the following sessions across the first four sessions was not confirmed. As predicted, early clinical improvement was not associated with MI relational stance in a later session, suggesting that MI relational stance was not merely an artifact of early clinical improvement. There was no support for the prediction that MI relational stance would be associated with subsequent retention in therapy or the therapeutic alliance. Overall, these findings suggest that a specific type of MI relational stance, MI Adherent behaviors, contribute to more symptomatic improvement. Implications of the role of MI relational stance in cognitive therapy are discussed.

Cognitive-behavioral therapy (CBT) is used to treat children and adolescents with depression. Researchers determined that many individuals undergoing CBT and other therapies experienced sudden gains, meaning that they experienced a rapid and large improvement in their symptoms between sessions. The studies demonstrated that by the end of treatment, individuals who experienced sudden gains were significantly less depressed and had better long-term outcomes than individuals who did not experience sudden gains. Previous studies investigated sudden gains in individual therapy while the present study examined sudden gains in group treatment. In addition to replicating results of previous studies, the present study sought to examine the effect of sudden gains on depressive symptoms, family environment, cognitive triad, and negative life events at pre-treatment and at a one year follow-up using multivariate analysis of variance. Participants included 136 girls, aged 9 to 13, in two treatment conditions (CBT, CBT+ parent training (CBT+PT), and a Minimal Contact Control (MCC)). At pre-treatment, post-treatment, and at a one year follow-up, participants completed self-report measures of the family environment, cognitive triad, and negative life events. They also completed a semi-structured diagnostic interview designed to symptoms of depression. After beginning the study, participants’ depressive symptoms were monitored with a brief symptom interview and/or a self-report measure of depressive symptoms. Findings from the study provided further evidence that sudden gains occur during group CBT, and that the majority of sudden gains occur early in CBT. The number of sudden gains did not vary significantly by treatment condition, and similar to previous research, the presence of a parent intervention component did not appear to significantly change the relation between sudden gains and treatment outcome. One important finding was participants in the Minimal Contact Control group experienced sudden gains despite not being in treatment. Another important finding was that the participants who experienced sudden gains differed significantly from the participants who did not experience sudden gains on pre-treatment measures of family environment and the cognitive triad but no differences were found at post-treatment or at a one year follow-up. Implications of these results, limitations, and recommendations for future research are provided. / text

The purpose of this research study is to explore the role of culture in how Mexican Americans respond to mental health treatment. Cultural background is likely to affect not only the meaning attributed to mental illness, but also help-seeking and responses to treatment. Creating a match between treatment modalities and people's cultural backgrounds requires consideration of a person's cultural context. Cultural characteristics can vary not only across cultural groups, but even within groups can change across time. This study used a quasi-experimental pretest/posttest comparison group design to analyze culturally adapted cognitive behavioral therapy (CACBT) with Mexican Americans diagnosed with depression. A purposive nonprobability sample of 81 adult Mexican Americans diagnosed with depression was recruited from a mental health agency in El Paso, Texas. Forty-eight participants were assigned to a treatment group, which received CACBT, and 33 to a comparison group, which received treatment as usual. Depression was measured using the Patient Health Questionnaire (PHQ-9). Participant acculturation level was measured using the Acculturation Rating Scale for Mexican Americans-II. Independent and paired t tests were used to examine the effectiveness of the culturally adapted intervention. OLS regression analyses examined whether acculturation mediated the relationship between the culturally adapted intervention and depression. No direct effect was found between CACBT and depression relative to treatment as usual. The results showed that CACBT and treatment as usual both decreased depression scores. However, the interaction effect between acculturation and group assignment was significantly related to posttest depression scores. Thus, the effect of CACBT varied according to acculturation level. This study demonstrates the role that acculturation plays in how Mexican Americans respond to mental health treatment. An implication for social work practice is the need to use evidence-based practices that have been tested for their cultural appropriateness with Mexican Americans. / text

Exposure therapy has received a great deal of support as an effective treatment for social anxiety. However, not all those who undergo exposure therapy improve, and some of those who do respond continue to report significant levels of symptoms. A theorized mechanism of change for exposure therapy is extinction learning. Extinction learning is believed to occur across exposure sessions during which new associations are formed and stored in memory. Individuals with social anxiety are prone to engage in post event processing (PEP), or rumination, after social experiences, which may interfere with extinction learning, and thus attenuate response to treatment. The current study examined whether PEP limits treatment response to two different exposure based treatments, a group based cognitive behavioral intervention and an individually based virtual reality exposure therapy among participants (n = 75) diagnosed with social anxiety disorder. The findings suggested that PEP decreased as a result of treatment and that social anxiety symptoms for those with greater amounts of PEP improved at a slower rate of change than those with lower levels of PEP. Implications for the role of PEP on treatment response are discussed.

Depressive and anxiety disorders are the most commonly encountered mental health problems seen in the primary care setting; they represent a serious public health concern, and are inordinately time consuming for the primary care provider. Cognitive behavioral therapy (CBT) is an effective tool for the treatment of both depression and anxiety, and can be delivered in a variety of abbreviated forms appropriate for use in the primary care setting. Despite its apparent benefits, few primary care providers report using CBT in their practices. The purpose of this project was to develop a better understanding of provider knowledge and perceived barriers regarding the use of CBT for the treatment of depression and anxiety in the primary care setting. A better understanding of practitioners' knowledge of CBT and their perceived barriers to its use will establish a baseline for further exploration of the issue, and will help guide the development of strategies to address the gap in practice. A brief questionnaire was provided to a convenience sample of Nurse Practitioners (NP) during a regular meeting of the Southern Arizona Advanced Practice Nurse/Nurse Practitioner Society. The results of the data analysis showed that 90% of the sampled NPs considered themselves to be skilled in detecting depression and anxiety in their patients, and 80% were confident in their abilities to treat patients with these disorders. However, only 30% of sampled NPs currently use CBT in their practices. The sample indicated a broad lack of knowledge related to multiple aspects of CBT including technique, training, implementation, and reimbursement. Education and training were revealed to be the strongest predictors of willingness to use CBT. Only 30% of NPs were introduced to the use of CBT in their NP programs. The results suggest that increased education in the proper technique, process, and billing methods for CBT may contribute to greater utilization by NPs in the primary care setting.

Introduction: Blood- and injection phobia is an anxiety disorder with a prevalence of approximately 3-5% in the general population. The etiology is often a combination of genetic factors and a conditioning experience. The symptoms of blood- and injection phobia are dizziness, confusion, nausea, epigastria discomfort, anxiety and sometimes panic attacks when receiving injections, seeing blood or having a blood sample taken. Unique for this specific phobia is the high probability of fainting when the phobic situation is encountered if there is no possibility to escape or to avoid the stimuli. During pregnancy and labor, women with blood- and injection phobia are exposed to most of their fears and they therefore find themselves in anxiety-ridden situations. Stress and anxiety during pregnancy is known to be risk factors for adverse obstetric and neonatal outcomes. Studies have shown an altered hypothalamic-adrenal-pituitary axis in women with stress or/and anxiety during pregnancy and increased cortisol concentrations can imply negative consequences for the unborn child. Cognitive behavioral therapy (CBT) is known to be effective in treating specific phobias such as blood- and injection phobia. Aim: The prevalence, obstetric and neonatal consequences, impact on the hypothalamic adrenal-pituitary axis and treatment aspects of blood- and injection phobia in a pregnant population have not been investigated before. The aims of this thesis were to study each of these phenomena. Material and methods: During 2005 a total of 1606 pregnant women were approached at their first visit in an antenatal care clinic in the southeast region in Sweden. They were asked to complete the “Injection Phobia Scale-Anxiety” questionnaire. All women who scored ≥ 20 on the “Injection Phobia Scale-Anxiety” questionnaire (N=347), were interviewed and either diagnosed for blood- and injection phobia or dismissed. In total, 110 women were diagnosed as having blood- and injection phobia. Among the women who scored <20 on the “Injection Phobia Scale-Anxiety” questionnaire, 220 women were randomly stratified for age and parity as a control group. The women in the study population answered questionnaires in gestational week 25, 36 and postpartum concerning symptoms of blood- and injection phobia, depression and anxiety. Samples of cortisol in the saliva were collected in the morning and evening in gestational week 25 and 36 in both groups of pregnant women. The medical records from the antenatal care visits, the delivery and postpartum check-up was used to collect data of importance. A treatment study was conducted using a two session cognitive behavioral therapy in a group of pregnant woman with blood- and injection phobia. Results: The prevalence of blood- and injection phobia is 7 % in a pregnant population. Pregnant women with blood- and injection phobia stated more often a fear of childbirth (p<0.001) and were more frequently delivered by elective cesarean section (p=0.032). The incidence of having a baby diagnosed with a complication (p=0.001) was also higher among these women. The women with blood- and injection phobia had increased cortisol concentrations in the saliva compared to the healthy controls (p=0.014). A two-session CBT in group for pregnant women with blood- and injection phobia reduced phobic (p<0.001) anxiety (p<0.001) and depressive (p<0.001) symptoms during pregnancy. Conclusions: Blood- and injection phobia during pregnancy is rather common. Pregnant women with blood- and injection phobia are more likely to be delivered by elective cesarean section and having a baby born with a complication compared to women not suffering from this specific phobia. Untreated blood- and injection phobia during pregnancy increases salivary cortisol concentrations indicating an altered hypothalamic-adrenal-pituitary axis during these weeks of pregnancy. To enhance psychological well being in pregnant women with blood- and injection phobia a two-session program providing CBT for groups of pregnant women is valuable and produces stable results for at least 3 months after delivery.

Recorded by Eugene Barsky, Physiotherapy Outreach Librarian, UBC / This is a Systematic Review Presentation titled - "Effectiveness of Combined Vestibular Rehabilitation & Cognitive Behavioral Therapy in the Treatment of Chronic Dizziness", created by Master of Physical Therapy Graduating Students, University of British Columbia - 2006, Presented on September 14-15, 2006 , Vancouver, BC, Canada

Den föreliggande studien syftade till att utvärdera behandlingseffekten av den kognitiva beteendeterapin som bedrivs av terapeutkandidater vid psykoterapimottagningen på Karlstads universitet, med fokus på hälsorelaterad livskvalitet. Dessutom ämnade studien undersöka effekter på optimism och symptombild. Upprepad mätning användes och studien innefattade en behandlingsgrupp (n = 21), som erhöll kognitiv beteendeterapi under i genomsnitt 10,7 sessioner och en kontrollgrupp (n = 14), som stod på väntelista i genomsnitt 8,6 veckor. Resultatet av studien antyder en förbättring hos klienterna i behandlingsgruppen avseende delar av hälsorelaterad livskvalitet och optimism samt en minskning av ångestsymptom. Efter närmare 11 terapisessioner förbättrades klienterna i behandlingsgruppen signifikant avseende allmän hälsa (p = 0,028) och uppvisade en signifikant ökning gällande optimism (p = 0,027). Dessutom förbättrades klienterna beträffande flera områden inom psykisk hälsa samt uppvisade en minskning av ångestsymptom. Samtidigt pekar studien på att en viss förbättring sker även inom kontrollgruppen, vilket kan bero på den initiala terapeutiska kontakten, förväntanseffekt eller spontanremission. Studien indikerar att kognitiv beteendeterapi utförd av terapeutkandidater kan ha en positiv effekt på delar av HRQOL och optimism.