Elizeth Heldt

Cognitive-Behavioral Group Therapy in Obsessive-Compulsive Disorder: A Randomized Clinical Trial

Background: The present study was designed to verify the efficacy of cognitive-behavioral group therapy (CBGT) in reducing obsessive-compulsive symptoms and the intensity of overvalued ideas, as well as in improving the patient’s quality of life. Methods: Forty-seven patients meeting DSM-IV criteria for obsessive-compulsive disorder (OCD) were randomly assigned to either 12 weekly CBGT sessions or a waiting list (control group). Treated patients were followed for three months. Results: There was a significant reduction in the Yale-Brown Obsessive-Compulsive Scale (p < 0.001), in the National Institute of Mental Health Obsessive-Compulsive Scale (p < 0.001), in the Overvalued Ideas Scale (p < 0.001), and a significant improvement in the quality of life in the four domains of the World Health Organization Quality of Life Assessment Scale: physical (p < 0.001), psychological (p < 0.017), social (p < 0.018) and environmental (p < 0.04). No significant reduction was found in the Hamilton Rating Scale for Anxiety (p = 0.111) and the Hamilton Rating Scale for Depression (p = 0.271). The concomitant use of anti-obsessional medications did not influence the results. The rate of improved patients was 69.6% in the treated group and 4.2% in the control group (p < 0.001). The therapeutic gains were maintained and an additional reduction in symptoms was observed during the 3-month follow-up period. Conclusions: The results suggest that CBGT is effective in reducing the intensity of OCD symptoms and of overvalued ideas, and that it improves the OCD patient’s quality of life in a short period of time.

Treating Medication-Resistant Panic Disorder: Predictors and Outcome of Cognitive-Behavior Therapy in a Brazilian Public Hospital

Background: In Brazil, treatment of panic disorder is most frequently initiated with pharmacotherapy, but only half of the patients can be expected to be panic free after medication. Studies have suggested that individual or group cognitive-behavior therapy (CBT) is an effective treatment strategy for panic patients who have failed to respond to pharmacotherapy. Methods: Thirty-two patients diagnosed with panic disorder with agoraphobia having residual symptoms despite being on an adequate dose of medication were treated with 12 weeks of group CBT. The outcome was evaluated for panic frequency and severity, generalized anxiety, and global severity. Comorbid conditions, a childhood history of anxiety, and defense mechanism styles were assessed as potential predictors of treatment response. Results: Twenty-nine patients completed the 12-week protocol. Treatment was associated with significant reductions in symptom severity on all outcome measures (p < 0.001). Patients with depression had a poorer outcome of the treatment (p = 0.01) as did patients using more neurotic (p = 0.002) and immature defenses (p = 0.05). Conclusion: Consistent with previous reports, we found that CBT was effective for our sample of treatment-resistant patients. Among these patients, depression as well as neurotic defense style was associated with a poorer outcome. The use of CBT in Brazil for treatment-resistant and other panic patients is encouraged.

Evaluation of defense mechanisms in adult patients with panic disorder: before and after treatment.

Patients with acute panic disorder (PD) use a more maladaptive pattern of defense mechanisms. This study investigated the use of defense mechanisms by patients with acute symptomatic PD and those in complete remission. Thirty-three patients and 33 controls were evaluated by the Mini International Neuropsychiatric Interview. The defense mechanisms were evaluated by the Defense Style Questionnaire at the beginning of the study and after 16 weeks of sertraline treatment. Panic disordered patients used more neurotic (4.6 vs. 3.6; p = 0.003) and immature (3.6 vs. 3.0; p = 0.024) defenses at baseline. Patients who achieved complete remission (N=25) differed from the control group in the use of neurotic defenses at the baseline (4.4 vs. 3.6; p = 0.033). After treatment, they showed a reduction in the use of neurotic (4.4 vs. 3.7; p=0.014) and immature (3.4 vs. 3.1; p = 0.019) defenses. Defense mechanisms in PD are influenced by the presence of symptoms, severity, and outcome of the disease.

Brazilian patients with panic disorder: the use of defense mechanisms and their association with severity.

This study aims to evaluate the defense mechanisms most frequently used by Brazilian patients with panic disorder when compared with a control group. The study also examines the association between severity of disease and comorbidity and the use of specific defense mechanisms. Sixty panic-disordered patients and 31 controls participated in the study. The Mini International Neuropsychiatric Interview was used to confirm the panic disorder diagnosis and to establish the comorbid diagnosis. The Clinical Global Impression (CGI) was used to assess severity and the Defensive Style Questionnaire (DSQ-40) was used to evaluate the defense mechanisms. Panic patients used more neurotic (mean = 4.9 versus 3.6; p < 0.001) and immature (mean = 3.9 versus 2.8; p < 0.001) defenses as compared with controls. Panic patients with severe disease (n = 37; CGI>4) had more depression comorbidity and used more immature defenses than patients with CGI≤4 (n = 23; mean = 4.2 versus 3.5; p < 0.001). It was concluded that the panic severity and depression comorbidity found in Brazilian panic-disordered patients are associated with the use of maladaptive mechanisms, namely immature defenses.

The multidimensional evaluation and treatment of anxiety in children and adolescents: rationale, design, methods and preliminary findings

OBJECTIVE This study aims to describe the design, methods and sample characteristics of the Multidimensional Evaluation and Treatment of Anxiety in Children and Adolescents - the PROTAIA Project. METHOD Students between 10 and 17 years old from all six schools belonging to the catchment area of the Primary Care Unit of Hospital de Clínicas de Porto Alegre were included in the project. It comprises five phases: (1) a community screening phase; (2) a psychiatric diagnostic phase; (3) a multidimensional assessment phase evaluating environmental, neuropsychological, nutritional, and biological factors; (4) a treatment phase, and (5) a translational phase. RESULTS A total of 2,457 subjects from the community were screened for anxiety disorders. From those who attended the diagnostic interview, we identified 138 individuals with at least one anxiety disorder (apart from specific phobia) and 102 individuals without any anxiety disorder. Among the anxiety cases, generalized anxiety disorder (n = 95; 68.8%), social anxiety disorder (n = 57; 41.3%) and separation anxiety disorder (n = 49; 35.5%) were the most frequent disorders. CONCLUSION The PROTAIA Project is a promising research project that can contribute to the knowledge of the relationship between anxiety disorders and anxiety-related phenotypes with several genetic and environmental risk factors.

Do defense mechanisms vary according to the psychiatric disorder

OBJECTIVE The aim of this study was to evaluate the defense mechanisms used by depressive and anxious patients without comorbidities compared to those used by controls and to determine whether these patterns differ between diagnoses. METHOD The sample was composed of 167 psychiatric patients and 36 controls that were evaluated using the Defense Style Questionnaire 40. All subjects were evaluated through a clinical interview, and each evaluation was confirmed through the application of the Mini International Neuropsychiatric Interview, a structured psychiatric interview. We used ANOVA and discriminant analysis to assess differences between groups. RESULTS Neurotic defense mechanisms discriminated controls from all patients except those with social anxiety. Immature defense mechanisms differentiated controls from all patients, as well as distinguished depressive patients from panic disorder and obsessive disorder patients. The discriminant analysis indicated that depressive patients are characterized by projection, panic disorder patients by sublimation and obsessive-compulsive patients by acting out. CONCLUSIONS Depressive and anxious patients differ from other individuals in their use of defense mechanisms, and each diagnosis has a particular pattern. These findings could lead to the development of specific psychotherapeutic interventions.

Quality of Life and Treatment Outcome in Panic Disorder: Cognitive Behavior Group Therapy Effects in Patients Refractory to Medication Treatment

Background: Improvements in quality of life (QoL) as well as symptomatic relief are important outcomes for the treatment of panic disorder (PD). The aim of this study is to assess the impact of brief cognitive behavior group therapy (CBGT) for panic disorder on QoL and to identify the clinical features associated with these changes. Methods: Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT. To evaluate the changes in QoL, the WHOQOL-bref was administered before and after treatment. Results: Thirty-two patients completed the treatment. Significant improvement in all domains of QoL was observed (p< 0.001), which was associated with reductions in general and anticipatory anxiety (p = 0.018) and agoraphobic avoidance (p = 0.046). Consistent with previous findings, associations between QoL and panic-free status did not reach significance in this small study (p = 0.094). Conclusions: CBGT was efficacious in the treatment of PD; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting QoL.

A Randomized Clinical Trial to Examine Enhancing Cognitive-Behavioral Group Therapy for Obsessive-Compulsive Disorder with Motivational Interviewing and Thought Mapping

BACKGROUND Obsessive-compulsive disorder (OCD) is characterized by repeated and persistent attempts to control thoughts and actions with rituals. These rituals are used in order to prevent feared or personally distressing outcomes. Cognitive behavioral group therapy (CBGT) has been reported to be effective for treating OCD patients. However, about one-third (30%) of patients do not benefit from CBGT. Some of these patients do not show significant improvement and continue to use rituals following CBGT, partially because they fail to complete the exposure and ritual prevention (ERP) exercises. Consequently, it is important to motivate patients to fully engage in CBGT treatment and complete the ERP exercises. AIMS A randomized behavioral trial examined 12 weeks of manual directed CBGT, with the addition of individual sessions of Motivational Interviewing (MI) and Thought Mapping (TM), and compared treatment outcome to the effectiveness of CBGT group alone. METHOD Subjects were randomized (n=93) into a CBGT group or a CBGT group with MI+TM. RESULTS When the two groups were compared, both groups reduced OCD symptoms. However, symptom reduction and remission were significantly higher in the MI+TM CBGT group. Positive outcomes were also maintained, with additional symptom reduction at the 3-month follow-up for the MI+TM CBGT group. CONCLUSIONS Adding two individual sessions of MI and TM before CBGT successfully reduced OCD symptoms and was more effective than using CBGT group alone.

Brazilian–Portuguese version of defensive style questionnaire-40 for the assessment of defense mechanisms: construct validity study

Abstract The aim of this study is to analyze the reliability and validity of the Brazilian–Portuguese version of the Defensive Style Questionnaire (DSQ). Participants were evaluated by clinical interview and the Mini-International Neuropsychiatric Interview. Reliability was assessed by factor analysis and Cronbachs alpha. The 3-factor models replication was tested using confirmatory factor analysis (CFA). Controls were reevaluated after 4 months to assess test–retest reliability. Subsamples were also evaluated using the Minnesota Multiphasic Personality Inventory and Defensive Functioning Scale (DFS). Factor analysis of the various defense mechanisms produced a distribution of mechanisms among the factors that was largely similar to previous analyses based on the original instrument. The 3-factor model was supported by CFA. The test–retest evaluation showed sufficient intraclass correlation for all factors. Patients used more immature and neurotic defenses than controls. There was a correlation between DFS and immature defenses. Individuals with pathological personality traits scored higher on the immature and neurotic factors than those without. The Brazilian–Portuguese version of the DSQ-40 has psychometric features that allow the use of this instrument in our culture.

Terapia cognitivo-comportamental no transtorno de pânico

OBJECTIVE: Panic disorder is a chronic and recurrent condition that impairs an individuals psychosocial functioning and quality of life. Despite the efficacy of psychopharmacological treatment in reducing panic attacks, many patients fail to respond adequately to these interventions. Cognitive behavioral therapy provides an alternative and efficacious method for treating panic disorder and agoraphobic avoidance. The objective of the study is to describe the use of cognitive behavioral therapy for panic disorder. METHOD: Narrative review of data collected from Medline, SciELO and PsycInfo and specialized textbooks. RESULTS: We describe the cognitive-behavioral model for the treatment of panic disorder, and review both short and long-term efficacy findings. We also discuss the role of combined treatment (cognitive behavioral therapy and psychopharmacology). CONCLUSIONS: Cognitive behavioral therapy, either individual or in group, can be used as first-line therapy for panic disorder. This treatment modality can also be indicated as a next step for patients failing to respond to other treatments.