Florian Weck

Maintenance Cognitive-Behavioral Therapy and Manualized Psychoeducation in the Treatment of Recurrent Depression: A Multicenter Prospective Randomized Controlled Trial

OBJECTIVE This multicenter study compared the relapse and recurrence outcomes of two active treatments, maintenance cognitive-behavioral therapy (CBT) and manualized psychoeducation, both in addition to treatment as usual, in patients in remission from depression. METHOD This was a multicenter prospective randomized observer-blinded study with two parallel groups. The authors assessed 180 patients with three or more previous major depressive episodes who met remission criteria over a 2-month baseline period and who were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation over 8 months and then followed up for 12 months. The main outcome measure was time to first relapse or recurrence of a major depression, based on DSM-IV criteria, as assessed by blinded observers with the Longitudinal Interval Follow-Up Evaluation. RESULTS Cox regression analysis showed that time to relapse or recurrence of major depression did not differ significantly between treatment conditions, but a significant interaction was observed between treatment condition and number of previous episodes (<5 or ≥5). Within the subsample of patients with five or more previous episodes, maintenance CBT was significantly superior to manualized psychoeducation, whereas for patients with fewer than five previous episodes, no significant treatment differences were observed in time to relapse or recurrence. CONCLUSIONS The results indicate that maintenance CBT has significant effects on the prevention of relapse or recurrence only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, nonspecific effects and structured patient education may be equally effective.

Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder.

Several studies have demonstrated a positive relationship between competence and outcome in CBT for depression but studies of CBT for anxiety disorders are lacking. The present study explores the relationship between competence and outcome in cognitive therapy (CT) for social anxiety disorder, using hierarchical linear modeling analyses (HLM). Data were drawn from a multicenter randomized controlled trial. Five trained raters evaluated videotapes of two therapy sessions per patient using the Cognitive Therapy Competence Scale for Social Phobia (CTCS-SP). Overall adherence to the treatment manual and patient difficulty were also assessed. Patient outcome was rated by other assessors using the Clinical Global Impression Improvement Scale (CGI-I) and the Liebowitz Social Anxiety Scale (LSAS). Results indicated that competence significantly predicted patient outcome on the CGI-I (β = .79) and LSAS (β = .59). Patient difficulty and adherence did not further improve prediction. The findings support the view that competence influences outcome and should be a focus of training programs. Further research is needed to compare different ways of assessing competence and to understand the complex relationships between competence and other therapy factors that are likely to influence outcome.

Screening for hypochondriasis with the Illness Attitude Scales.

The Illness Attitude Scales (IAS; Kellner, 1986, 1987) may prove highly useful for the screening of hypochondriasis. We expected the IAS subscales to be equally as effective as the 7-item short version of the Whiteley Index (Whiteley–7; Fink et al., 1999), which has previously been shown to be useful in screening for somatoform disorders. We investigated participants of a German population (n = 1,575) and 61 patients with the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994) diagnosis of hypochondriasis. The Bodily Preoccupations (BP) subscale showed high sensitivity (.92) and specificity (.90) as well as demonstrating convergent and discriminant validity. We found evidence for the superiority of the BP subscale over the Whiteley–7 in the screening of hypochondriasis.

The Factor Structure of the Illness Attitude Scales in A German Population

BackgroundThe illness attitudes scales (IAS) were developed to identify different dimensions of hypochondrical attitudes, fears, beliefs, and abnormal illness behavior (Kellner 1986). Although there are several studies which focus on the scale structure of the IAS, the factor structure has not yet been made quite clear.PurposeTherefore, the aim of this study was to investigate the factor structure of the IAS on a large representative sample.MethodParticipants (N = 1,575) comparable with the general German population regarding sex, age, and education level completed the IAS. For the data analyses, a principal components analyses with subsequent oblique rotations was used.ResultsThe minimum average partial method suggested a three-factor solution. The three factors were named (1) health anxiety, (2) health behavior, and (3) health habits. Internal consistency (Cronbach’s alpha) for the three scales were (1) α = 0.88, (2) α = 0.75, and (3) α = 0.56.ConclusionThe results support previous findings, namely that the IAS factor structure appears to be less complex than originally suggested by the author. For a sample of the general German population, a three-factor solution fit best. Further items should be added to improve the internal consistency, especially for the third scale (health habits).

The restrictive concept of good health in patients with hypochondriasis

The restrictive concept of good health and the misinterpretation of bodily symptoms as a sign of illness are considered in the DSM and in well-established cognitive models as central characteristics of hypochondriasis. However, until now it has not been satisfactorily resolved whether this tendency is unique for hypochondriasis. In the current study a modified card sorting technique was used to investigate the extent to which bodily complaints were seen as compatible with a state of good health. We found that patients with hypochondriasis (n = 45) showed a more restrictive concept of good health than anxiety patients (n = 45) and healthy controls (n = 45). Those differences were only observable when a concrete evaluation of own bodily symptoms was carried out in comparison to a more general evaluation of symptoms. The misinterpretation of bodily symptoms demonstrates to be a highly specific characteristic of hypochondriasis.

Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial.

OBJECTIVE Cognitive-behavioral therapy has proven to be highly effective in the treatment of hypochondriasis and health anxiety. However, little is known about which therapeutic interventions are most promising. The aim of the present study was to compare the efficacy of cognitive therapy (CT) with exposure therapy (ET). METHOD Eighty-four patients with a diagnosis of hypochondriasis were randomly allocated to CT, ET, or a waiting list (WL) control group. The primary outcome measure was a standardized interview that evaluated hypochondriacal cognitions as well as behaviors conducted by independent diagnosticians. Several self-report questionnaires were evaluated as secondary outcome measures. Treatment success was evaluated at posttreatment and at 1-year follow-up. RESULTS Both CT (Hedgess g = 1.01-1.11) and ET (Hedgess g = 1.21-1.24) demonstrated their efficacy in comparison with the WL in the primary outcome measure. Moreover, a significant reduction in depressive symptoms and bodily complaints was found in the secondary outcome measures for both treatments in comparison with the WL, but anxiety symptoms were only significantly reduced by ET. In a direct comparison, no significant differences were found between CT and ET in the primary or the secondary outcome measures. Regarding safety behaviors, we found a significantly larger improvement with ET than with CT in the completer analyses. CONCLUSIONS The results suggest high efficacy of CT as well as ET in the treatment of hypochondriasis. Cognitive interventions were not a necessary condition for the change of dysfunctional cognitions. These findings are relevant to the conceptualization and psychotherapeutic treatment of hypochondriasis and health anxiety.

Attribution of Somatic Symptoms in Hypochondriasis

The misinterpretation of bodily symptoms as an indicator of a serious illness is a key feature of the criteria and the cognitive-behavioural models of hypochondriasis. Previous research suggests that individuals suffering from health anxiety endorse attributions of physical disease, whereas persons with elevated general anxiety have the tendency to attribute psychological causes to their symptoms. However, whether a somatic attribution style is specific to patients with hypochondriasis, as opposed to those with anxiety disorders, has not yet been investigated and is therefore part of the present study. Fifty patients with hypochondriasis, 50 patients with a primary anxiety disorder and 50 healthy participants were presented with nine common bodily sensations and had to spontaneously attribute possible causes to the symptoms. Patients with hypochondriasis differed from patients with anxiety disorders and healthy controls in giving significantly fewer normalizing explanations, but attributing more often in terms of moderate or serious diseases. Patients with anxiety disorders also made significantly fewer normalizing attributions and more somatic attributions to a severe illness than healthy controls. There were no differences between the groups in the frequency of psychological attributions and somatic attributions concerning mild diseases. The present study demonstrates that hypochondriasis is associated with a disorder-specific attribution style connecting somatic symptoms primarily with moderate and serious diseases. By contrast, normalizing attributions are largely omitted from consideration by patients with hypochondriasis. The findings conform with the cognitive conception of hypochondriasis and support the strategy of modifying symptom attributions, as practiced in cognitive-behavioural therapy.

The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: secondary analysis of a randomized trial.

Meta-analyses reveal that homework compliance is associated with a better treatment outcome. However, little is known about the processes that could be responsible for patient compliance with homework. It has been proposed that therapist competence, in particular with respect to reviewing homework, is highly relevant for homework compliance. The present study is a secondary analysis of a randomized controlled trial. Altogether, 54 patients with recurrent depressive disorder (currently in remission) who were treated with maintenance cognitive therapy (MCT), were considered. One videotaped treatment session of each patient was randomly selected and therapist competence (general competence and specific competence in setting and reviewing homework) was assessed by 2 independent raters. Furthermore, both patient and therapist views of the therapeutic alliance were evaluated by questionnaire in this therapy session. Homework compliance (considering quantitative as well as qualitative aspects) in the following session was evaluated by 2 additional raters. These 2 raters were blinded regarding the ratings of the therapeutic competence. In a multilevel path analysis model, a significant association between the therapeutic competence in reviewing homework and homework compliance was detected, while the therapeutic alliance and several patient characteristics were not associated with homework compliance. We found no relationship between homework compliance and treatment outcome. Our results demonstrate that a specific therapeutic competence (i.e., competence in reviewing homework) is associated with patient compliance with homework, and therefore, provides further empirical evidence of the importance of therapist competence in the psychotherapeutic process.

Behandlungsintegrität: Implementierung, Messung, Evaluation und Zusammenhänge zum Therapieerfolg

Die Sicherung und Überprüfung der Behandlungsintegrität stellt eine essenzielle Voraussetzung für Wirksamkeitsanalysen in der Psychotherapieforschung dar. Die Behandlungsintegrität liefert wichtige Hinweise darüber, ob eine Behandlung so durchgeführt wurde, wie es intendiert war. Es lassen sich 3 unterschiedliche Aspekte der Behandlungsintegrität unterscheiden. Diese sind Adhärenz, Differenzierbarkeit und Kompetenz. Die vorliegende Arbeit gibt Empfehlungen zur Implementierung, Messung und Evaluation der Behandlungsintegrität. Zudem wird eine Übersicht über empirische Befunde gegeben, die einen Bezug zwischen Behandlungsintegrität und Behandlungserfolg herstellen. Es wird deutlich, dass das methodische Vorgehen, insbesondere bei Messung und Evaluation, heterogen und somit die Vergleichbarkeit der Ergebnisse erschwert ist. Dennoch findet sich für viele Studien ein direkter oder indirekter Zusammenhang zwischen Behandlungsintegrität und Behandlungserfolg. Bei nachfolgenden Studien sollten die vorliegenden Empfehlungen zur Implementierung, Messung und Evaluation der Behandlungsintegrität stärker berücksichtigt werden, um eine bessere Vergleichbarkeit der Studien zu ermöglichen.

Assessment of adherence and competence in cognitive therapy: Comparing session segments with entire sessions

Abstract The aim of the study was to compare the reliability and validity of adherence and competence judgments of four raters, based on session segments on the one hand and on entire sessions on the other. The global adherence/competence judgments based on the middle section of 34 therapy sessions demonstrated satisfactory interrater reliability (ICC=.81/.71) and the highest correlations with therapy outcome (r=.55/.45). These results were comparable with judgments based on entire therapy sessions. However, the reliability of specific aspects of adherence and competence was higher when judgments were based on the entire session. The implications of these results are important in terms of reducing time and costs associated with the judgment process.