Arnoud Arntz

Mind the gap: Improving the dissemination of CBT.

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout

The present study investigated predictors of treatment outcome and dropout in two samples of PTSD-patients with mixed traumas treated using prolonged imaginal exposure. Possible predictors were analysed in both samples separately, in order to replicate in one sample findings found in the other. The only stable finding across the two groups was that patients who showed more PTSD-symptoms at pre-treatment, showed more PTSD-symptoms at post-treatment and follow-up. Indications were found that benzodiazepine use was related to both treatment outcome and dropout, and alcohol use to dropout. Demographic variables, depression and general anxiety, personality, trauma characteristics, feelings of anger, guilt, and shame and nonspecific variables regarding therapy were not related to either treatment outcome or dropout, disconfirming generally held beliefs about these factors as contra-indications for exposure therapy. It is concluded that it is difficult to use pre-treatment variables as a powerful and reliable tool for predicting treatment outcome or dropout. Clinically seen, it is therefore argued that exclusion of PTSD-patients from prolonged exposure treatment on the basis of pre-treatment characteristics is not justified.

Cognitive therapy for obsessive-compulsive disorder

This paper discusses three cognitive models for the obsessive-compulsive disorder (OCD). Further, a cognitive formulation of OCD which stresses the importance of the perception of danger and responsibility is described. Several specific cognitive interventions, which address the estimation of catastrophes and the perception of personal responsibility, are presented and illustrated with patient material. Furthermore, problems with cognitive therapy with OCD patients are described and some solutions for these pitfalls are discussed. Finally, the findings of controlled studies into cognitive therapy with OCD are given.This paper discusses three cognitive models for the obsessive-compulsive disorder (OCD). Further, a cognitive formulation of OCD while stresses the importance of the perception of danger and responsibility is described. Several specific cognitive interventions, which address the estimation of catastrophes and the perception of personal responsibility, are presented and illustrated with patient material. Furthermore, problems with cognitive therapy with OCD patients are described and some solutions for these pitfalls are discussed. Finally, the findings of controlled studies into cognitive therapy with OCD are given.

Treatment of childhood memories: theory and practice

With the growing interest of cognitive behaviour therapy in early developed psychopathology like personality disorders there is an increased need for therapeutic methods for more directly treating pathogenic schemas. Exploring and reinterpreting memories of early childhood experiences that are assumed to have contributed to the pathogenesis are more and more viewed as a promising way to modify core schemas. Experiential methods seem to be the most effective. This article discusses two main forms of these methods: (i) imagery with rescripting and (ii) role play, both of childhood interactions with key figures. For both, protocols are provided as guidelines for clinicians and to stimulate standardization so that this new field can be opened for experimental research. Theoretical views are discussed as to why these methods might be so effective in treating chronic problems that originated in childhood.

Predictions of dental pain: The fear of any expected evil, is worse than the evil itself ☆

In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.

Attention, not anxiety, influences pain

Four hypotheses about the influences of anxiety and attention on pain impact were tested in a critical experiment: (1) anxiety increases pain; (2) anxiety decreases pain; (3) attention to pain increases pain; (4) only the combination of anxiety and attention to pain increases pain (interaction hypothesis). In a 2 x 2 design, anxiety (low vs high) and attention (attention vs distraction from the pain) were experimentally manipulated. Subjects received 20 electrically produced painful stimuli. Subjective pain experiences, skin conductance responses and heart rate responses gave no support for a pain impact increasing effect of anxiety. The anxiety-attention interaction hypothesis did not receive any support either. There was some support, only from the heart rate responses, that anxiety reduces pain impact. The critical factor appeared to be attention. Attention to the pain stimulus was related to a stronger pain impact (indicated by all measures) and to less subjective habituation, compared to distraction.

Attentional bias and spider phobia: Conceptual and clinical issues

Experimental evidence indicates that anxious subjects show an attentional bias for threat-relevant information. Foa and McNally (1986) (Cognitive Therapy and Research, 10, 477-485) and Watts et al. (1986) (British Journal of Psychology, 77, 97-108) reported that behaviour therapy can eliminate this attentional bias. A replication study was carried out in order to increase the evidence for exposure being the crucial component in reducing attentional bias. Moreover, in this study some conceptual and clinical issues are explored. The theoretical and clinical implications of the results are discussed.

Negative beliefs of spider phobics: A psychometric evaluation of the spider phobia beliefs questionnaire

Abstract Beliefs held by spider phobics about a confrontation with a spider are investigated. Study 1 explores the content of thoughts and images which spider phobics ( N = 44) report to have during a confrontation with a spider and investigates the frequency and strength of the subjective belief in the idea. Spider phobics appear to have an abundance of negative, irrational ideas about the spider and about their own reactions during a confrontation with a spider. A one-session therapistassisted exposure therapy strongly attenuates these beliefs. Study 2 investigates the psychometric properties of the Spider Phobia Beliefs Questionnaire (SBQ), which measures the strength of belief of a large number of ideas derived from Study 1, in a second sample of spider phobics ( N = 112). Factor analysis revealed 5 spider-related factors: harm, hunter and prey, unpredictability, territory , and multiplication ; and 4 self-related factors: panic, paralysis, incubation , and unrestrained behavior . These factors have good internal consistency and reasonable test-retest reliability. The SBQ discriminates strongly between spider phobics and normals ( N = 33) and has good concurrent validity as indicated by positive associations with other indices of spider phobia. It appears that spider phobics have a lot of misconceptions about spiders, e.g., that spiders attack them, take revenge, or are incalculable and about their own reactions about a confrontation with a spider, e.g., they expect to have a heart attack, to die of fear, or to exacerbate their fear. Most self-related ideas resemble those held by panic patients. Both spider-related and self-related ideas can be corrected by a one-session treatment.

Posttraumatic stress disorder after pregnancy loss

This prospective longitudinal study investigated the prevalence of posttraumatic stress disorder (PTSD) in response to pregnancy loss. About 1,370 women were recruited in the early stages of pregnancy and 113 of them had a subsequent pregnancy loss. One and four months after pregnancy loss, they were assessed for PTSD with the Posttraumatic Symptom Scale. Depression was also assessed. The majority had an early loss, i.e., within 20 weeks. At one month, the prevalence of PTSD was 25%, and the symptom-severity was similar to other traumatized populations. Women with PTSD had increased risk of depression: 34% of PTSD cases and 5% of non-cases reported depression. At four months, 7% met the criteria for PTSD, of which half were chronic. In contrast, rates for depression had not declined. The results indicate that pregnancy loss is potentially traumatic, putting women at risk of developing PTSD. In most cases, the disorder is immediate and persists for several months.

THE INFLUENCE OF ANXIETY ON PAIN - ATTENTIONAL AND ATTRIBUTIONAL MEDIATORS

&NA; Two psychological processes mediating the influence of anxiety on pain have been proposed: an attributional process in which the pain‐relevance of anxiety is the essential factor, and an attentional process in which the focus of attention is the essential factor. The present study investigated the influences of attentional focus, pain‐irrelevant anxiety and pain‐relevant anxiety in a within‐subject design (n = 40). Subjects received painful electrical stimulation in each of 5 experimental conditions. The results indicate that pain ratings were only influenced by attentional focus and not by anxiety, regardless of whether it was pain‐relevant or pain‐irrelevant. Autonomic responses (skin conductance responses) were, however, only influenced by pain‐relevant anxiety. Thus, it seems that with respect to subjective pain responses the attentional theory on the influence of anxiety on pain can explain the results. The attributional theory seems to hold for autonomic pain responses. However, these responses might as well be considered as fear responses. Whereas there is clear evidence for a role of attentional focus in the influence of anxiety on pain, the role of attributional processes remains to be demonstrated.