Mia S. O'Toole

Efficacy of internet-delivered cognitive-behavioral therapy for insomnia – A systematic review and meta-analysis of randomized controlled trials

Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedgess g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.

A systematic review of neuropsychological performance in social anxiety disorder.

Background: Over the past few years, there has been an increasing interest in the neuropsychological performance of patients with anxiety disorders, yet the literature does not provide a systematic review of the results concerning adult patients with social anxiety disorder (SAD). Aims: The primary aim of this paper is to review the literature on neuropsychological performance in adult patients with SAD. Methods: This paper is a systematic review of empirical studies investigating neuropsychological performance as assessed by cognitive tests. Results: 30 papers were located comprising a total number of 698 adult patients with SAD. The review revealed indication for decreased performance regarding visual scanning and visuoconstructional ability as well as some indication for verbal memory difficulties. Conclusion: The impact of possible confounding variables on the neuropsychological performance is discussed. It is suggested that the decreased performance should be attributed to an increased level of situational anxiety, and an engagement in disorder-related, cognitively costly activities rather than trait-like cognitive dysfunctions. Future experimental studies are needed to explore the causal relationship between these constructs. Knowledge from such studies is important in order to improve the understanding of why SAD is such a disabling disorder, both educationally and interpersonally, and could assist in the planning and evaluation of psychotherapeutic treatment.

Mechanisms of change in cognitive behaviour therapy for panic disorder: The role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.

The effect of expressive writing intervention on psychological and physical health outcomes in cancer patients--a systematic review and meta-analysis.

This study aimed to evaluate the effectiveness of expressive writing intervention (EWI) for improving psychological and physical health in cancer patients and survivors.

Cognitive and Emotion Regulation Change Processes in Cognitive Behavioural Therapy for Social Anxiety Disorder

UNLABELLED The objective of the study was to investigate variables, derived from both cognitive and emotion regulation conceptualizations of social anxiety disorder (SAD), as possible change processes in cognitive behaviour therapy (CBT) for SAD. Several proposed change processes were investigated: estimated probability, estimated cost, safety behaviours, acceptance of emotions, cognitive reappraisal and expressive suppression. Participants were 50 patients with SAD, receiving a standard manualized CBT program, conducted in groups or individually. All variables were measured pre-therapy, mid-therapy and post-therapy. Lower level mediation models revealed that while a change in most process measures significantly predicted clinical improvement, only changes in estimated probability and cost and acceptance of emotions showed significant indirect effects of CBT for SAD. The results are in accordance with previous studies supporting the mediating role of changes in cognitive distortions in CBT for SAD. In addition, acceptance of emotions may also be a critical component to clinical improvement in SAD during CBT, although more research is needed on which elements of acceptance are most helpful for individuals with SAD. The studys lack of a control condition limits any conclusion regarding the specificity of the findings to CBT. KEY PRACTITIONER MESSAGE Change in estimated probability and cost, and acceptance of emotions showed an indirect effect of CBT for SAD. Cognitive distortions appear relevant to target with cognitive restructuring techniques. Finding acceptance to have an indirect effect could be interpreted as support for contemporary CBT approaches that include acceptance-based strategies.

The mediational role of panic self-efficacy in cognitive behavioral therapy for panic disorder: a systematic review and meta-analysis.

Cognitive models of panic disorder (PD) with or without agoraphobia have stressed the role of catastrophic beliefs of bodily symptoms as a central mediating variable of the efficacy of cognitive behavioral therapy (CBT). Perceived ability to cope with or control panic attacks, panic self-efficacy, has also been proposed to play a key role in therapeutic change; however, this cognitive factor has received much less attention in research. The aim of the present review is to evaluate panic self-efficacy as a mediator of therapeutic outcome in CBT for PD using descriptive and meta-analytic procedures. We performed systematic literature searches, and included and evaluated 33 studies according to four criteria for establishing mediation. Twenty-eight studies, including nine randomized waitlist-controlled studies, showed strong support for CBT improving panic self-efficacy (criterion 1); ten showed an association between change in panic self-efficacy and change in outcome during therapy (criterion 2); three tested, and one established formal statistical mediation of panic self-efficacy (criterion 3); while four tested and three found change in panic self-efficacy occurring before the reduction of panic severity (criterion 4). Although none of the studies fulfilled all of the four criteria, results provide some support for panic self-efficacy as a mediator of outcome in CBT for PD, generally on par with catastrophic beliefs in the reviewed studies.

Mindfulness-based cognitive therapy in COPD: a cluster randomised controlled trial

A considerable proportion of patients with chronic obstructive pulmonary disease (COPD) entering pulmonary rehabilitation (PR) report psychological distress, which is often accompanied by poor physical health status. Mindfulness-based cognitive therapy (MBCT) has been shown to improve psychological and physical outcomes in other chronic diseases. We therefore evaluated the efficacy of MBCT as an add-on to a standard PR programme in COPD. COPD patients eligible for PR were cluster randomised to receive either an 8-week, group-based MBCT programme as an add-on to an 8-week PR programme (n=39), or PR alone (n=45). The primary outcomes of psychological distress and physical health status impairment were measured with the Hospital Anxiety and Depression Scale (HADS) and the COPD Assessment Test (CAT) before randomisation (T1), mid- (T2) and post-intervention (T3), and at 3 (T4) and 6 (T5) months’ follow-up . A statistically significant time×arm effect was found for the HADS (Cohens d=0.62, 95% CIs (d)=0.18–1.06, p=0.010). The treatment effect on the CAT failed to reach statistical significance (d=0.42, 95% CIs (d)=−0.06–0.90, p=0.061). MBCT showed a statistically significant and durable effect on psychological distress, indicating that MBCT may be an efficacious add-on to standard PR programmes in COPD. Mindfulness-based cognitive therapy: an efficacious add-on to PR programmes to reduce psychological distress in COPD http://ow.ly/9noC30hnlxr

Negative autobiographical memories in social anxiety disorder: A comparison with panic disorder and healthy controls.

BACKGROUND AND OBJECTIVES Empirical interest in mental imagery in social anxiety disorder (SAD) has grown over the past years but still little is known about the specificity to SAD. The present study therefore examines negative autobiographical memories in participants with social anxiety disorder (SAD), compared to patients with panic disorder (PD), and healthy controls (HCs). METHODS A total of 107 participants retrieved four memories cued by verbal phrases associated with either social anxiety (SA) or panic anxiety (PA), with two memories for each cue category. RESULTS PA-cued memories were experienced with stronger imagery and as more traumatic. They were also rated as more central to identity than SA-cued memories, but not among participants with SAD, who perceived SA-cued memories as equally central to their identity. When between-group effects were detected, participants with anxiety disorders differed from HCs, but not from each other. LIMITATIONS Central limitations include reliance on self-report measures, comorbidity in the anxiety disorder groups, and lack of a neutrally cued memory comparison. CONCLUSIONS The findings align with models of SAD suggesting that past negative social events play a central role in this disorder. Future research is suggested to further explore the function of negative memories, not only in SAD, but also in other anxiety disorders.

A randomized controlled trial of emotion regulation therapy for generalized anxiety disorder with and without co-occurring depression.

Objective: Generalized anxiety disorder (GAD) and major depression (MDD), especially when they co-occur, are associated with suboptimal treatment response. One common feature of these disorders is negative self-referential processing (NSRP; i.e., worry, rumination), which worsens treatment outcome. Emotion Regulation Therapy (ERT) integrates principles from affect science with traditional and contemporary cognitive–behavioral treatments to identify and modify the functional nature of NSRP by targeting motivational and regulatory mechanisms, as well as behavioral consequences. Method: Building on encouraging open trial findings, 53 patients with a primary diagnosis of GAD (43% with comorbid MDD) were randomly assigned to immediate treatment with ERT (n = 28) or a modified attention control condition (MAC, n = 25). Results: ERT patients, as compared with MAC patients, evidenced statistically and clinically meaningful improvement on clinical indicators of GAD and MDD, worry, rumination, comorbid disorder severity, functional impairment, quality of life, as well as hypothesized mechanisms reflecting mindful attentional, metacognitive, and overall emotion regulation, which all demonstrated mediation of primary outcomes. This superiority of ERT exceeded medium effect sizes with most outcomes surpassing conventions for a large effect. Treatment effects were maintained for nine months following the end of acute treatment. Overall, ERT resulted in high rates of high endstate functioning for both GAD and MDD that were maintained into the follow-up period. Conclusions: Findings provide encouraging support for the efficacy and hypothesized mechanisms underlying ERT and point to fruitful directions for improving our understanding and treatment of complex clinical conditions such as GAD with co-occurring MDD.

Mindfulness-based Cognitive Therapy and Persistent Pain in Women Treated for Primary Breast Cancer: Exploring Possible Statistical Mediators: Results From a Randomized Controlled Trial

Objectives: The aim of this study was to investigate possible statistical mediators in a randomized controlled trial of mindfulness-based cognitive therapy (MBCT) on pain intensity in women treated for primary breast cancer. Materials and Methods: The sample consisted of 129 women treated for breast cancer, presenting with persistent pain, who were randomly assigned to MBCT or a wait-list control. We previously reported a statistically significant and robust effect of MBCT on pain intensity (11-point numeric rating scale), which was included as the primary outcome. The proposed mediators were mindfulness (the Five Facet Mindfulness Questionnaire), self-compassion (the Short-Form Self-Compassion Scale), and pain catastrophizing (the Pain Catastrophizing Scale). Measurement points included baseline (T1), postintervention (T2), and 3- (T3) and 6-month (T4) follow-ups. All indirect effects of the mediators were tested in separate Multilevel Models, using the product-of-coefficients approach with bias-corrected confidence intervals (95% BSCI). The statistically significant mediators were then included in a multiple mediator model. Results: Statistically significant indirect effects were found for mindfulness nonreactivity (B=−0.17, BSCI [−0.32 to −0.04]) and pain catastrophizing (B=−0.76, BSCI [−1.25 to −0.47]). No statistically significant indirect effect was found for self-compassion (B=−0.09, BSCI [−0.30 to 0.04]). In a multiple mediator model, including mindfulness nonreactivity and pain catastrophizing, only pain catastrophizing remained statistically significant (B=−0.72, BSCI [−1.19 to −0.33]), explaining 78% of the effect. Discussion: The results of the present study may have clinical implications. An increased focus on the proposed mediators may optimize the clinical use of MBCT for persistent pain in women treated for breast cancer.