Dietmar Schulte

Tailor-made versus standardized therapy of phobic patients

Abstract The Bochum anxiety-therapy study examined the question as to whether adaptation of treatment to an individual case, typical for clinical practice but untypical for research projects, will lead to better treatment outcome. 120 phobic patients were randomly assigned to one of three treatment groups: an experimental group with individual treatment planned by the therapist, a control group with standardized therapy (exposure in vivo ), and a yoked control group. Contrary to expectations, the standardized group proved to be most successful. This holds true for experienced and inexperienced therapists and for patients with different phobias and panic disorders of various severities. The superiority of the standardized group proved to be the result of the method “ exposure in vivo ”. The factor “adaptation” was of no relevance. The results support the assumption that too much flexibility and too much adaptation can be disadvantageous, at least for the treatment of phobic patients.

Embodiment of Sadness and Depression—Gait Patterns Associated With Dysphoric Mood

Objective: To analyze gait patterns associated with sadness and depression. Embodiment theories suggest a reciprocal relationship between bodily expression and the way in which emotions are processed. Methods: In Study 1, the gait patterns of 14 inpatients suffering from major depression were compared with those of matched never-depressed participants. In Study 2, we employed musical mood induction to induce sad and positive mood in a sample of 23 undergraduates. A Fourier-based description of walking data served as the basis for the computation of linear classifiers and for the analysis of gait parameters. Results: Gait patterns associated with sadness and depression are characterized by reduced walking speed, arm swing, and vertical head movements. Moreover, depressed and sad walkers displayed larger lateral swaying movements of the upper body and a more slumped posture. Conclusion: The results of the present study indicate that a specific gait pattern characterizes individuals in dysphoric mood. ANCOVA = analysis of covariance; BDI = Beck Depression Inventory; DSM = Diagnostic and Statistical Manual of Mental Disorders; MANOVA = multivariate analysis of variance; MDD = major depressive disorder; SCID = Structured Clinical Interview for DSM-IV; SNRI = serotonin noradrenalin reuptake inhibitors; SSRI = selective serotonin reuptake inhibitors.

Reduction of gray matter density in the extrastriate body area in women with anorexia nervosa

Body processing has been associated functionally to the so called extrastriate body area (EBA) which is located in the lateral occipital cortex. As body image disturbance is one of the main diagnostic criteria in anorexia nervosa (AN) this study aimed at looking for alterations in gray matter density in women with (AN) especially in the EBA. High resolution T1 images from 15 women with AN and 15 age matched healthy controls women were contrasted using voxel based morphometry (VBM). Additionally functional localizer scans were used to determine functionally the EBA of each participant. In general, total gray matter volumes did differ between groups. VBM results yielded evidence for a reduction of gray matter density in the left EBA. This reduction, which resulted from whole brain analysis, was localised within the activation cluster of the EBA localizer scan. The current results provide for the first time evidence for structural alterations in the EBA in patients with AN which might suggest that body image distortion is related at least in part to structural alteration in the EBA.

Mindfulness predicts relapse/recurrence in major depressive disorder after mindfulness-based cognitive therapy.

Empirical evidence for the effectiveness of mindfulness-based cognitive therapy (MBCT) is encouraging. However, data concerning the role of mindfulness in its relapse preventive effect are lacking. In our study, 25 formerly depressed patients received MBCT. Mindfulness was assessed before and immediately after MBCT using the Mindful Attention and Awareness Scale. Mindfulness significantly increased during MBCT, and posttreatment levels of mindfulness predicted the risk of relapse/recurrence to major depressive disorder in the 12-month follow-up period. Mindfulness predicted the risk of relapse/recurrence after controlling for numbers of previous episodes and residual depressive symptoms. The results provide preliminary evidence for the notion that mindfulness is an important factor in relapse prevention in major depression.

Manualized behavior therapy: Merits and challenges

Treatment manuals have been hailed as an important breakthrough in the development, evaluation, and dissemination of empirically validated therapies. Yet manualized behavior therapy has also been criticized because (a) practice involves the application of validated principles of behavior rather than the application of fixed strategies, and (b) successful behavioral interventions must supposedly be based on an idiographic functional problem analysis and tailored to each individual patient. This article evaluates the relative merits, potential limitations, and misconceptions about the use of manuals. We conclude that individualizing treatment and manual use are not mutually exclusive and propose that manuals be used in a flexible theory-driven fashion guided by empirically tested clinical decision rules.

The ups and downs of psychotherapy: Sudden gains and sudden losses identified with session reports

Abstract Psychotherapy does not always follow a linear path. The present study explores the frequency of sudden gains and losses during the course of outpatient psychotherapy. The sample includes 1500 patients treated at three different outpatient centers. The patients were 57.4% female, and suffered primarily from anxiety and depressive disorders. Progress was measured by session reports. Significant sudden shifts in both directions were prevalent for 28.9% of the patients. Patients with early sudden gains showed the highest effect sizes and patients with sudden losses showed the smallest at the end of treatment. The therapeutic relationship was significantly better after the sudden gain sessions. Results suggest further investigation of the occurrence of sudden gains in relation to early response as well as further exploration of sudden losses during the course of treatment with respect to differential patterns of change and outcome.

Changes in neuronal correlates of body image processing by means of cognitive-behavioural body image therapy for eating disorders: a randomized controlled fMRI study

BACKGROUND Previous neuroimaging studies have demonstrated abnormalities in visual body image processing in anorexia and bulimia nervosa, possibly underlying body image disturbance in these disorders. Although cognitive behavioural interventions have been shown to be successful in improving body image disturbance in eating disorders, no randomized controlled study has yet analysed treatment-induced changes in neuronal correlates of visual body image processing. METHOD Altogether, 32 females with eating disorders were randomly assigned either to a manualized cognitive behavioural body image therapy consisting of 10 group sessions, or to a waiting list control condition. Using functional magnetic resonance imaging, brain responses to viewing photographs of ones own and another females body taken from 16 standardized perspectives while participants were wearing a uniform bikini were acquired before and after the intervention and the waiting time, respectively. RESULTS Data indicate a general blood oxygen level dependent signal enhancement in response to looking at photographs of ones own body from pre- to post-treatment, whereas exclusively in the control group activation decreases from pre- to post-waiting time were observed. Focused activation increases from pre- to post-treatment were found in the left middle temporal gyrus covering the coordinates of the extrastriate body area and in bilateral frontal structures including the middle frontal gyrus. CONCLUSIONS Results point to a more intense neuronal processing of ones own body after the cognitive behavioural body image therapy in cortical regions that are responsible for the visual processing of the human body and for self-awareness.

Reduced connectivity between the left fusiform body area and the extrastriate body area in anorexia nervosa is associated with body image distortion

The aim of the present study was to investigate the network and its effective connectivity subserving body processing in women suffering from anorexia nervosa (AN) and also in healthy controls. Ten women diagnosed with AN and 15 healthy, age matched controls were investigated using fMRI during viewing images of bodies and chairs. Effective connectivity between cortical areas which are involved in human visual body processing was accessed. Effective connectivity analysis yielded evidence for a different network in AN and healthy controls during visual processing of human bodies. Left sided effective connectivity in the occipital cortex of women with AN showed a highly negative correlation with body size misjudgment. Present results yield evidence for altered networks for body processing in women with AN. Results explain body size misjudgment, a key feature in AN, which seems to be based on reduced effective connectivity in the body processing network.

The Impact of Comorbidity of Depression on the Course of Anxiety Treatments

Although anxiety disorder patients often present with comorbid disorders, little is known about differences in the course of the treatment due to comorbidity. The present study investigated whether cooccurring major depression predicts individual differences in the course of cognitive-behavioral treatment for panic disorder or social anxiety disorder in a total of 179 patients. Additionally, changes in depression scores were analyzed using growth-curve models. Overall, the results show comparable improvement for comorbid and noncomorbid patients. However, for patients with panic disorder and comorbid depression, anxiety scores were higher than for patients without comorbid conditions throughout the treatment. The results suggest that comorbid depression does not have a detrimental effect on the course of the anxiety treatment, but that the depression scores remain elevated at posttreatment.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patients response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.