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CBT & Quality of Life for Individuals with Anxiety Disorders

CBT studyCorrection Notice: An Erratum for this article was reported in Vol 82(6) of Journal of Consulting and Clinical Psychology (see record rid]2014-49169-001/rid]). In the article, the effect size of the Schnurr et al. (2003) study was incorrectly calculated because the standard error value was used instead of the standard deviation for the effect size formula. In addition, the Schnurr et al. (2007) study was omitted because it was not identified by the electronic search using keywords, but should have been identified by the authors’ manual search. The corrected and added effect sizes changed the results and are included.

Objective: Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches.

Method: The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life.

Results: The pre-post within-group and controlled effect sizes were moderately strong (Hedges’s g = 0.54 and Hedges’s g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments.

Conclusion: CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life.

Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 3, 375-391.

CBT for Panic Disorder with Agoraphobia in Older Adults

CBT studyBackground: Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive?behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults.

Methods: A total of 172 patients with PDA (DSM?IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18–60 years) and older (?60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions.

Results: Attrition rates were 2/31 (6%) for the over?60s and 31/141 (22%) for the under?60s group (?² = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate?to?large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age?related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P?values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (? = ?0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late?onset type and short DOI were linked to superior improvement of agoraphobic avoidance.

Conclusions: CBT appears feasible for 60+ PDA?patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.

Hendriks, G.-J., Kampman, M., Keijsers, G. P. J., Hoogduin, C. A. L., & Voshaar, R. C. O. (2014). Cognitive-behavioral therapy for panic disorder with agoraphobia in older people: A comparison with younger patients. Depression and Anxiety, 31, 8, 669-677.


Cognitive Behavior Therapy for Schizophrenia – Participant Spotlight

Phillip Smith, from Kansas City, MO, works at Truman Medical Center as well as in a private practice. He works as a designated therapist for an ACT team, where he facilitates Cognitive Enhancement Therapy (CET) and is currently working on an expansion grant for the center. He uses CBT by re-conceptualizing the symptoms of his patients. His goal in treatment is “to instill hope in patients who have been beaten down by their disorders”.

He enjoyed how Dr. Aaron Brinen “rolls with it” and was blown away by Dr. Aaron Beck during the question and answer session. He also appreciated learning from his co-worker who accompanied him to the workshop and he loved the opportunity to explore Philadelphia restaurants!

CBT for Chronic Insomnia

CBT studyObjective: To examine the unique contribution of behavior therapy (BT) and cognitive therapy (CT) relative to the full cognitive behavior therapy (CBT) for persistent insomnia.

Method: Participants were 188 adults (117 women; M age = 47.4 years, SD = 12.6) with persistent insomnia (average of 14.5 years duration). They were randomized to 8 weekly, individual sessions consisting of BT (n = 63), CT (n = 65), or CBT (n = 60).

Results: Full CBT was associated with greatest improvements, the improvements associated with BT were faster but not as sustained and the improvements associated with CT were slower and sustained. The proportion of treatment responders was significantly higher in the CBT (67.3%) and BT (67.4%) relative to CT (42.4%) groups at post treatment, while 6 months later CT made significant further gains (62.3%), BT had significant loss (44.4%), and CBT retained its initial response (67.6%). Remission rates followed a similar trajectory, with higher remission rates at post treatment in CBT (57.3%) relative to CT (30.8%), with BT falling in between (39.4%); CT made further gains from post treatment to follow up (30.9% to 51.6%). All 3 therapies produced improvements of daytime functioning at both post treatment and follow up, with few differential changes across groups.

Conclusions: Full CBT is the treatment of choice. Both BT and CT are effective, with a more rapid effect for BT and a delayed action for CT. These different trajectories of changes provide unique insights into the process of behavior change via behavioral versus cognitive routes.

Harvey, A. G., Bélanger, L., Talbot, L., Eidelman, P., Beaulieu-Bonneau, S., Fortier-Brochu, É., . . . Morin, C. M. (2014). Comparative efficacy of behavior therapy, cognitive therapy, and cognitive behavior therapy for chronic insomnia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 82, 4, 670-683. doi:10.1037/a0036606.supp

Impact of CBT on Heart Rate for Individuals with Anxiety Disorders

CBT studyIntroduction: The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders.

Methods: To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search.

Results: 474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive–compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education.

Limitations: Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria. Conclusions: Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.

Gonçalves, R., Rodrigues, H., Novaes, F., Arbol, J., Volchan, E., Coutinho, E. S. F., . . . Ventura, P. (2015). Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders. Journal of Affective Disorders, 172, 231-240.

CBT & Social Anxiety Disorder

CBT studyWe examined whether Cognitive-Behavioral Therapy (CBT) for social anxiety disorder (SAD) would modify self-reported negative emotion and functional magnetic resonance imaging brain responses when reacting to and reappraising social evaluation, and tested whether changes would predict treatment outcome in 59 patients with SAD who completed CBT or waitlist groups. For reactivity, compared to waitlist, CBT resulted in (a) increased brain responses in right superior frontal gyrus (SFG), inferior parietal lobule (IPL), and middle occipital gyrus (MOG) when reacting to social praise, and (b) increases in right SFG and IPL and decreases in left posterior superior temporal gyrus (pSTG) when reacting to social criticism. For reappraisal, compared to waitlist, CBT resulted in greater (c) reductions in self-reported negative emotion, and (d) increases in brain responses in right SFG and MOG, and decreases in left pSTG. A linear regression found that after controlling for CBT-induced changes in reactivity and reappraisal negative emotion ratings and brain changes in reactivity to praise and criticism, reappraisal of criticism brain response changes predicted 24% of the unique variance in CBT-related reductions in social anxiety. Thus, one mechanism underlying CBT for SAD may be changes in reappraisal-related brain responses to social criticism.

Goldin, P. R., Ziv, M., Jazaieri, H., Weeks, J., Heimberg, R. G., & Gross, J. J. (2014). Impact of cognitive-behavioral therapy for social anxiety disorder on the neural bases of emotional reactivity to and regulation of social evaluation. Behaviour Research and Therapy, 62, 97-106.

Workshop Participant Spotlight – Natasha Mullen, LPCMH


Natasha Mullen, LPCMH works in a pilot program by the state of Delaware as a Behavioral Health Consultant. In this position, she provides counseling for middle school students. She also works as a coordinator and intensive outpatient counselor for Delaware guidance services, as a youth group leader, and as an instructor at Wilmington University. She is trained in TF-CBT, but has always wanted to learn the full foundation of CBT – “I learned so much over the last 3 days”. Learning about behavioral interventions was especially helpful and rewarding for her professional life. “CBT aligns with my personal beliefs of treatment and the relationship with clients”. She most enjoyed seeing Dr. Aaron Beck “If I could just be a pinch of him!”


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