G.P.J. Keijsers

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.

Work stress and attentional difficulties: An initial study on burnout and cognitive failures

Professional burnout is a stress-related disorder, having mental exhaustion due to work stress as its most important characteristic. Burned out individuals also often complain about attentional problems. However, it is currently not clear whether such complaints are based on true cognitive deficits or whether they merely reflect the way burned out individuals rate their own cognitive performance. To confirm the cognitive complaints we used a cognitive failure questionnaire (CFQ) to assess the level of self-reported attentional difficulties in daily life. We also measured performance on tasks of sustained attention and response inhibition (the SART and the Bourdon-Wiersma Test). We compared three groups: (1) a group of ‘burned out’ individuals (n=13) who stopped working due to their symptoms and sought professional treatment; (2) teachers at a vocational training institute (n=16) who reported high levels of burnout symptoms but continued to work; and (3) teachers from the same institute (n=14) who reported no burnout symptoms. The level of burnout symptoms was found to be significantly related to the number of cognitive failures in daily life, and to inhibition errors and performance variability in the attentional tasks. To our knowledge, explicit tests of objective cognitive deficits in burned out individuals have not been conducted before. Consequently, this is the first study to indicate that burnout is associated with difficulties in voluntary control over attention and that the level of such difficulties varies with the severity of burnout symptoms.

Exposure with response prevention versus habit reversal in Tourettes’s syndrome: a controlled study

The intentional nature of tics provides the opportunity to apply behavioural interventions aimed at tic reduction through interruption of stimulus-response sequences. The aim of this study has been to evaluate the effect of exposure and response prevention (ER) versus habit reversal (HR) in 43 Tourettes syndrome (TS) patients. The three outcome measures were: the Yale Global Tic Severity Scale (YGTSS), 15-min tic frequency registrations monitored at the institute and 15-min home tic frequency registrations. Both treatment conditions resulted in statistically significant improvements on all outcome measures (p < 0.001). No significant differences were found between the treatment conditions on any of the outcome measures, although there was a tendency in favour of ER on the YGTSS (p = 0.05). These results suggest that, at least in the short term, TS tic symptoms can be treated effectively with both types of treatment.

Behavior therapy versus clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents.

OBJECTIVE To compare, via a pilot study, the effectiveness of behavior therapy and of drug treatment in children and adolescents with obsessive-compulsive disorder. METHOD Twenty-two children aged between 8 and 18 years were randomly assigned to behavior therapy (n = 12) or open clomipramine (n = 10) in a parallel design lasting 12 weeks. Behavior therapy included exposure and response prevention administered in weekly sessions. The mean dosage of clomipramine was 2.5 mg/kg (range = 1.4-3.3 mg/kg). The main outcome variables were the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Leyton Obsessional Inventory-Child Version (LOI-CV). RESULTS Significant improvement was obtained in both treatment conditions. Behavior therapy produced stronger therapeutic changes than clomipramine on the CY-BOCS (p < .05), whereas on the LOI-CV no significant differences between the results of the two treatments were found. Five of the nine initial nonresponders showed significant changes after extension of treatment for another 12 weeks. CONCLUSION Behavior therapy is shown to be a good alternative for drug treatment and deserves further study in larger samples of children with obsessive-compulsive disorder.

The Impact of Interpersonal Patient and Therapist Behavior on Outcome in Cognitive-Behavior Therapy A Review of Empirical Studies

Empirical studies are reviewed, the aim being to investigate characteristics of the therapeutic relationship in cognitive-behavior therapy (CBT) and to identify therapist or patient interpersonal behavior that affects treatment outcome. CBT is characterized by a more active and directive stance on the part of the therapists and higher levels of emotional support than are found in insight-oriented psychotherapies. Therapists express high levels of empathy and unconditional positive regard, similar to those expressed by insight-oriented psychotherapists. Two clusters of interpersonal behavior have been identified that are clearly associated with CBT outcome: (a) the Rogerian therapist variables—empathy, nonpossessive warmth, positive regard, and genuineness; and (b) therapeutic alliance. There is some evidence for the impact on outcome of three additional clusters of patient behavior: (a) the patients’ perception of the therapist as being selfconfident, skillful, and active; (b) the patients’ openness to discuss their problems; and (c) the patients’pretreatment predisposition to change and to accept psychological treatment as a means of achieving this. It is further concluded that relationship factors in general have a consistent but moderate impact on CBT outcome.

Cognitive-behavioural therapy for late-life anxiety disorders: a systematic review and meta-analysis

Objective:  To examine and estimate the efficacy of cognitive‐behavioural therapy (CBT) for late‐life anxiety disorders.

Prognostic factors in the behavioral treatment of panic disorder with and without agoraphobia

Pretreatment and early treatment variables were evaluated as predictors of outcome for the behavioral treatment of panic disorder (PD) with and without agoraphobia. The following variables were examined: severity of agoraphobic complaints, catastrophic agoraphobic cognitions, level of depression, quality of the therapeutic relationship, motivation for treatment, personality psychopathology, and marital dissatisfaction. Sixty patients, diagnosed with PD, received a standardized exposure-based behavioral treatment program. Severity of agoraphobiccomplaints, level of depression, motivation for treatment, personality psychopathology, and catastrophic agoraphobic cognitions were related to treatment outcome, whereas the quality of the therapeutic relationship and marital dissatisfaction were not. Catastrophic agoraphobic cognitions were the strongest predictor of poorer outcome. Patients frequently distressed by maladaptive cognitions tended to improve less with an exposure-based treatment program. Based on several predictors taken together, 75% to 85% of the patients were correctly classified as treatment failures or treatment successes. A decision model based on multiple prognostic variables may lead to a reliable screening method of PD patients who are unlikely to improve. Treatment programs can then be adapted for these patients.

The emotional Stroop: a comparison of panic disorder patients, obsessive-compulsive patients, and normal controls, in two experiments.

An emotional Stroop task with four word types (panic threat, obsessive-compulsive threat, general threat, and neutral) and two presentation conditions (supraliminal, subliminal) was used in two experiments. The first experiment involved 21 panic disorder (PD) patients and 20 normal controls; the second experiment 20 PD patients and 20 obsessive-compulsive patients. PD patients, obsessive-compulsive patients, and normal controls did not differ in Stroop interferences. In addition, there were no significant correlations between reduction of PD symptoms and differences between pre- and post-treatment Stroop response latencies.

Social anxiety and evaluation of social crowds: Explicit and implicit measures

To investigate whether social anxiety disorder is indeed characterized by a biased negative evaluation of facial expressions, 25 highly socially anxious (SA) participants and 30 non-anxious controls (NACs) were asked to respond to different ratios of neutral-angry or happy-angry face combinations (crowds). In an indirect Approach-Avoidance Task (AAT), participants used a joystick to pull the crowds towards themselves (approach) or push them away (avoidance). SAs showed faster avoidance of neutral-angry crowds when the number of angry faces in the crowd increased. The happy-angry crowds were generally avoided, independent of the ratio of the two emotions. NACs did not show any specific response tendency. When directly rating the friendliness of the crowds, the two groups did not differ.

Habituation of Premonitory Sensations During Exposure and Response Prevention Treatment in Tourette's Syndrome

Exposure to premonitory sensations and response prevention of tics (ER) has been shown to be a promising new treatment for Tourettes syndrome (TS). The present study tested the hypothesis that habituation to unpleasant premonitory sensations associated with the tic is an underlying mechanism of change in ER. Patients rated the severity of sensations and urges at 15-minute intervals during ten 2-hour ER sessions. Multilevel models using multiple time trend analyses showed significant reductions of the sensory severity ratings both within and between sessions. The decrease of these severity ratings was related to the frequency of tics exhibited during sessions, regardless of tic severity at baseline. These results support the hypothesis that habituation may be at least part of the underlying working mechanism of exposure in the treatment of tics in TS and that effective tic suppression during sessions is an important factor in this habituation process.