Hannah T. Boettcher

Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: a meta-analysis.

OBJECTIVE Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches. METHOD The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life. RESULTS The pre-post within-group and controlled effect sizes were moderately strong (Hedgess g = 0.54 and Hedgess g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments. CONCLUSION CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life.

D-Cycloserine as an augmentation strategy for cognitive behavioral therapy of anxiety disorders

The goal of this review is to examine the clinical studies on d-cycloserine, a partial glutamatergic N-methyl-D-aspartate agonist, as an augmentation strategy for exposure procedures during cognitive behavioral therapy for anxiety disorders. Although cognitive behavioral therapy and anxiolytic medications are more effective than placebo for treating anxiety disorders, there is still considerable room for further improvement. Traditional combination strategies typically yield disappointing results. However, recent studies based on translational research have shown promise to augment the neural circuitry underlying fear extinction with pharmacological means. We discuss the current state of the literature, including inconsistencies of findings and issues concerning the drug mechanism, dosing, and dose timing. D-cycloserine is a promising combination strategy for cognitive behavioral therapy of anxiety disorders by augmenting extinction learning. However, there is also evidence to suggest that d-cycloserine can facilitate reconsolidation of fear memory when exposure procedures are unsuccessful.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial

Importance Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. Objective To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. Design, Setting, and Participants From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. Interventions The UP or SDPs. Main Outcomes and Measures Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. Results Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, −0.93; 95% CI, −1.29 to −0.57) and SDPs (Cohen d, −1.08; 95% CI, −1.43 to −0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (&bgr;, 0.25; 95% CI, −0.26 to 0.75) and from baseline to the 6-month follow-up (&bgr;, 0.16; 95% CI, −0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. Conclusions and Relevance The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders. Trial Registration clinicaltrials.gov Identifier: NCT01243606

Origins and outlook of interoceptive exposure

BACKGROUND AND OBJECTIVES Interoceptive exposure (IE) is a behavioral intervention that reduces anxiety sensitivity and distress associated with somatic sensations. In this discussion, we describe the history, current applications and additional clinical potential of IE. METHOD We review the origins of IE and its historical application to panic disorder, as well as the accumulating evidence for transdiagnostic application to other disorders including post-traumatic stress disorder, social anxiety disorder, specific phobias and physical disorders. Then, we discuss ways in which IE could contribute to the treatment of additional disorders. RESULTS IE is well-established in the treatment of panic disorder and increasingly used to target anxiety-provoking physical sensations in other disorders. Research and clinical evidence suggests that anxiety sensitivity is present across a range of disorders, and may actually be one variation on a broader phenomenon of interoceptive sensitivity, or anxiety focused on physical sensations that have been conditioned to unpleasant emotional states. Moreover, somatic symptoms are central to the experience of most emotions and may contribute to avoidant coping, a maintenance factor for disorders of emotion. IE has potential as a transdiagnostic intervention targeting interoceptive sensitivity in disorders such as depression and eating disorders. Nevertheless, IE is underutilized by clinicians in practice. Recent research in inhibitory learning and extinction suggests strategies for maximizing the effectiveness of IE. LIMITATIONS This review is not exhaustive in nature, and systematic research on transdiagnostic applications of IE remains scarce. CONCLUSIONS IE is a potentially powerful yet understudied transdiagnostic intervention.

A Transdiagnostic Temperament-Phenotype Profile Approach to Emotional Disorder Classification: An Update

Although the emotional disorders (EDs) have achieved favorable reliability in the Diagnostic and Statistical Manual of Mental Disorders (DSM), accumulating evidence continues to underscore limitations in ED diagnostic validity. In particular, taxometric, comorbidity, and other descriptive psychopathology studies of transdiagnostic phenotypes suggest that the EDs may be best conceptualized as dimensional entities that are more similar than different. Despite optimism that the fifth edition of the DSM (DSM-5) would constitute a meaningful shift toward dimensional ED assessment and diagnosis, most changes contribute little movement in that direction. In the present report, we summarize past and anticipate persisting (i.e., in DSM-5) limitations of a purely categorical approach to ED diagnosis. We then review our alternative dimensional-categorical profile approach to ED assessment and classification, including preliminary evidence in support of its validity and presentation of two ED profile case examples using our newly developed Multidimensional Emotional Disorder Inventory. We end by discussing the transdiagnostic treatment implications of our profile approach to ED classification and directions for future research.

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders:

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

Improvement in quality of life and sexual functioning in a comorbid sample after the unified protocol transdiagnostic group treatment

Patients with multiple mental disorders often experience sexual dysfunction and reduced quality of life. The unified protocol (UP) is a transdiagnostic treatment for emotional disorders that has the potential to improve quality of life and sexual functioning via improved emotion management. The present study evaluates changes in quality of life and sexual functioning in a highly comorbid sample treated with the UP in a group format. Forty-eight patients were randomly assigned to either a UP active-treatment group or a medication-only control group. Treatment was delivered in 14 sessions over the course of 4 months. Symptoms of anxiety and depression were assessed using the Beck Anxiety Inventory and Beck Depression Inventory. Sexual functioning was assessed by the Arizona Sexual Experience Scale (ASEX), and quality of life was assessed by the World Health Organization Quality of Life-BREF scale (WHOQOL-BREF). Quality of life, anxiety and depression all significantly improved among participants treated with the UP. Some improvement in sexual functioning was also noted. The results support the efficacy of the UP in improving quality of life and sexual functioning in comorbid patients.

Transdiagnostic Treatment for Anxiety Disorders

Anxiety disorders are a common class of disorders, and comorbidity among anxiety disorders is frequently observed. Cognitive-behavioral and behavioral psychotherapies for anxiety disorders are effective, though most evidence-based treatment protocols focus on the treatment of one principal anxiety disorder. In the last decade, treatments that aim to treat underlying vulnerabilities shared across anxiety disorders have been developed to more efficiently help patients that present with one or more anxiety and related disorders. We discuss two of these transdiagnostic treatments, the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, developed by David Barlow and colleagues, and Transdiagnostic Group Cognitive-Behavioral Therapy, developed by Peter Norton and colleagues. Background, similarities and differences, as well as evidence for each treatment are discussed. To date, the evidence from initial trials demonstrates efficacy for unified transdiagnostic treatments that is comparable to single-diagnosis protocols, providing promise for reducing therapist burden in acquiring and using evidence-based psychotherapies.

Social Phobia across the Lifespan

Social anxiety disorder is characterized by fear and avoidance of social situations in which one may be evaluated by others. The disorder results from a complex interplay among genetic factors (e.g., family history of the disorder); temperamental factors (e.g., behavioral inhibition and anxiety sensitivity); biological contributors; parenting style and other environmental considerations; and cognitive factors, such as interpretation biases and heightened self-focused attention. In this article, we discuss the contribution of these factors for the etiology and maintenance of the disorder throughout the lifespan.