Eric Leibing

Acupuncture treatment of chronic low-back pain – a randomized, blinded, placebo-controlled trial with 9-month follow-up

&NA; There is some evidence for the efficacy of acupuncture in chronic low‐back pain (LBP), but it remains unclear whether acupuncture is superior to placebo. In a randomized, blinded, placebo‐controlled trial, we evaluated the effect of traditional acupuncture in chronic LBP. A total of 131 consecutive out‐patients of the Department of Orthopaedics, University Goettingen, Germany, (age=48.1 years, 58.5% female, duration of pain: 9.6 years) with non‐radiating LBP for at least 6 months and a normal neurological examination were randomized to one of three groups over 12 weeks. Each group received active physiotherapy over 12 weeks. The control group (n=46) received no further treatment, the acupuncture group (n=40) received 20 sessions of traditional acupuncture and the sham‐acupuncture group (n=45) 20 sessions of minimal acupuncture. Changes from baseline to the end of treatment and to 9‐month follow‐up were assessed in pain intensity and in pain disability, and secondary in psychological distress and in spine flexion, compared by intervention groups. Acupuncture was superior to the control condition (physiotherapy) regarding pain intensity (P=0.000), pain disability (P=0.000), and psychological distress (P=0.020) at the end of treatment. Compared to sham‐acupuncture, acupuncture reduced psychological distress (P=0.040) only. At 9‐month follow‐up, the superiority of acupuncture compared to the control condition became less and acupuncture was not different to sham‐acupuncture. We found a significant improvement by traditional acupuncture in chronic LBP compared to routine care (physiotherapy) but not compared to sham‐acupuncture. The trial demonstrated a placebo effect of traditional acupuncture in chronic LBP.

Validation of the German version of the Fear‐Avoidance Beliefs Questionnaire (FABQ)

Fearful avoidance of physical activities is a major factor in low back pain (LBP) and disability. In 1993 Waddell et al. developed the Fear‐Avoidance Beliefs Questionnaire (FABQ) focusing on patients’ beliefs about how physical activity and work affect LBP. The focus of our study was to analyse and validate the German version of the FABQ. Three‐hundred and two consecutive LBP outpatients participating on a functional restoration programme filled in the FABQ. Factor analysis yielded three factors which accounted for nearly 65% of the total variance of the questionnaire. Whereas the factor ‘physical activity’ (8.9% of the variance) remained the same as in the English version, the second factor of the original version split into two: one related to, ‘work as cause of pain’ (43.4% of the variance) and the other to patients’ assumptions of their probable return to work (11.8% of the variance). Both work‐related subscales showed a good internal consistency (α =0.89, resp. α =0.94), whereas the consistency of the subscale 3 ‘physical activity’ was only modest (α =0.64). Test–re‐test reliability score was fair to good for the whole scale (r =0.87;n =30). Regression analysis demonstrated that fear‐avoidance beliefs account for the highest proportion of variance (35%) regarding disability in activities of daily living and work loss. Patients out of work demonstrated more fear‐avoidance beliefs in comparison to those who were still working. It can be concluded that the German version of the FAQB is a reliable and valid instrument, but it shows a different factor structure from the original English version. The FABQ has been proven to identify patients with maladaptive beliefs which have to be focused on in proper treatment.

Effectiveness of a multimodal treatment program for chronic low-back pain

&NA; In recent years, multidisciplinary pain programs were seen to successfully treat patients by basing treatment on a combination of physical exercise and psychological interventions. However, in spite of their effectiveness, it still remains to be clarified exactly which features of these programs were responsible for patient improvement. Cognitive‐behavioral models posit that improvement is due, in part, to changes in patient coping strategies. Nonetheless, as reflected by the conflicting opinions present in the literature, it is questionable whether a so‐called ‘cognitive shift’ is an accurate indicator for return to work of disabled patients. Ninety patients with chronic low back pain took part in a multidisciplinary treatment program. Therapeutic environment reinforces wellness behavior and enhances the patients’ sense of control over their pain and resulting disability. The main therapeutic target point was to facilitate return to work. Ways of coping were measured by a well studied coping inventory in the German language (FEKB). Factor analysis revealed three factors: ‘catastrophizing’, ‘search for information’ and ‘cognitive control’. In addition, assessment included measurements of pain intensity, depression, disability, flexibility of the lumbar spine, and different performance parameters. All of them were measured prior to and at the end of treatment, and following intervals of 6 and 12 months after discharge from program. Measurements showed significant changes over time, but more importantly, nearly all results were seen to stabilize at the 6‐ and 12‐month evaluation following treatment. The coping strategies demonstrated little or poor change. In addition, coping measures and change in coping behavior showed poor prognostic relevance. But other psycho‐social parameters like self‐evaluation of potential return‐to‐work, application for pension, the length of pre‐absence from work, and a decrease in subjective disability following treatment were effective indicators for ‘back‐to‐work’. Other objective parameters, such as medical history, physical impairment and general physical variables were seen to have little predictive value in determining a return to work. The results suggest that the primary target point for further investigation is the analysis of the patients’ beliefs about their pain. Our results indicate that future research must be attentive to the complex interactions between environmental factors and the coping demands posed by the specific nature of pain problems.

Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial

OBJECTIVE Various approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial. METHOD In an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well. RESULTS Remission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were significantly superior to waiting list for both remission and response. CBT was significantly superior to psychodynamic therapy for remission but not for response. Between-group effect sizes for remission and response were small. Secondary outcome measures showed significant differences in favor of CBT for measures of social phobia and interpersonal problems, but not for depression. CONCLUSIONS CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT. For CBT, the response rate was comparable to rates reported in Swedish and German studies in recent years. For psychodynamic therapy, the response rate was comparable to rates reported for pharmacotherapy and cognitive-behavioral group therapy.

Cost-of-illness studies and cost-effectiveness analyses in anxiety disorders: A systematic review

AIMS To review cost-of-illness studies (COI) and cost-effectiveness analyses (CEA) conducted for anxiety disorders. METHODS Based on a database search in Pubmed, PsychINFO and NHS EED, studies were classified according to various criteria. Cost data were inflated and converted to 2005 US-

Psychodynamic psychotherapy: A systematic review of techniques, indications and empirical evidence

purchasing power parities (PPP). RESULTS We finally identified 20 COI and 11 CEA of which most concentrated on panic disorder (PD) and generalized anxiety disorder (GAD). Differing inclusion of cost categories limited comparability of COI. PD and GAD tended to show higher direct costs per case, but lower direct cost per inhabitant than social and specific phobias. Different measures of effectiveness severely limited comparability of CEA. Overall CEA analysed 26 therapeutic or interventional strategies mostly compared to standard treatment, 8 of them resulting in lower better effectiveness and costs than the comparator. CONCLUSIONS Anxiety disorders cause considerable costs. More research on phobias, more standardised inclusion of cost categories in COI and a wider use of comparable effectiveness measures (like QALYs) in CEA is needed.

Interpersonal Subtypes Within Generalized Anxiety Disorder

PURPOSE Psychodynamic psychotherapy is one of the most frequently applied methods of psychotherapy in clinical practice. However, it is the subject of controversial discussion, especially with regard to empirical evidence. In this article we aim to give an up-to-date description of the treatment and to review the available empirical evidence. Evidence is reviewed for both efficacy and mechanisms of change of short- and moderate-term psychodynamic psychotherapy. Furthermore, results of effectiveness studies of long-term psychoanalytic therapy are reviewed. METHODS With regard to efficacy, a protocol for a Cochrane review for (short-term) psychodynamic psychotherapy is available specifying inclusion criteria for efficacy studies. RESULTS Twenty-three randomized controlled trials of manual-guided psychodynamic psychotherapy applied in specific psychiatric disorders provided evidence that psychodynamic psychotherapy is superior to control conditions (treatment-as-usual or wait list) and, on the whole, as effective as already established treatments (e.g. cognitive-behavioural therapy) in specific psychiatric disorders. With regard to process research, central assumptions of psychodynamic psychotherapy were confirmed by empirical studies. CONCLUSIONS Further research should include both efficacy studies (on specific forms of psychodynamic psychotherapy in specific mental disorders) and effectiveness studies complementing the results from experimental research settings. Future process research should address the complex interactions among interventions, patients level of functioning, helping alliance and outcome.

The Social Phobia Psychotherapy Research Network : The First Multicenter Randomized Controlled Trial of Psychotherapy for Social Phobia: Rationale, Methods and Patient Characteristics

In this study, we addressed the heterogeneity in interpersonal problems across patients with generalized anxiety disorder (GAD). We assessed interpersonal problems by the Inventory of Interpersonal Problems (IIP–C; Horowitz, Alden, Wiggins, & Pincus, 2000) in a sample of 78 GAD patients. We used IIP–C profiles describing interpersonal characteristics of the total GAD sample as well as clustered GAD interpersonal subtypes. Although the overall sample was located in the friendly submissive quadrant of the circumplex model, this was true only for the Exploitable cluster, which includes more than 50% of the patients. Importantly, clusters of GAD patients with other locations reporting predominantly Cold, Nonassertive, or Intrusive interpersonal problems were also identified. The 4 clusters did not differ in terms of gender, comorbid disorders, or the severity of depression or anxiety. Thus, the assessment of interpersonal problems provides additional diagnostic information covering the heterogeneity of GAD patients. This information could be used for differential indication and individual case formulation in GAD.

Interpersonal subtypes and change of interpersonal problems in the treatment of patients with generalized anxiety disorder: a pilot study.

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Long-Term Effects of Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioural Therapy in Generalized Anxiety Disorder: 12-Month Follow-Up

Interpersonal problems are highly relevant to the treatment of generalized anxiety disorder (GAD) patients. Previous studies using the Inventory of Interpersonal Problems identified several interpersonal subtypes in GAD patients. In this study, we wanted to replicate earlier findings of interpersonal subtypes in GAD. We investigated whether these interpersonal subtypes are characterized by different types of interpersonal problems and different levels of interpersonal distress, and we further examined whether they differed with regard to improvement of interpersonal problems after short-term treatment. This study is based on results from a randomized controlled trial that investigated short-term treatments in GAD outpatients. For secondary analysis, interpersonal subtypes were identified by cluster analysis and Inventory of Interpersonal Problems profiles were calculated for both the total sample (N = 52) and the interpersonal subtypes using the Structural Summary Method for Circumplex Data. This study confirmed previous results demonstrating the existence of interpersonal subtypes in GAD. Four interpersonal subtypes were identified: Overly Nurturant, Intrusive, Socially Avoidant, and Nonassertive. Short-term treatment significantly improved interpersonal problems (d = 0.46) within the total GAD sample. Interestingly, the effect sizes of the four clusters differed considerably (d = 0.19-1.24) and the clusters displayed different changes in the two circumplex axes Dominance and Nurturance. Our study indicates that change of interpersonal problems needs to be specifically analyzed, even within homogenous diagnostic groups.