Paula Ventura

A systematic review on the effectiveness of cognitive behavioral therapy for posttraumatic stress disorder

Objective: Cognitive behavioral therapy (CBT) is the most common psychotherapy approach for the treatment of PTSD. Nevertheless, previous reviews on the efficacy of several types of psychotherapy were unable to detect differences between CBT and other psychotherapies. The purpose of this study was to conduct systematic review on the efficacy of CBT in comparison with studies that used other psychotherapy techniques. Method: Databases were searched using the following terms: posttraumatic stress disorder/stress disorder, treatment/psychotherapy/behavior cognitive therapy, randomized trials, and adults. Randomized clinical trials published between 1980 and 2005 and that compared CBT with other treatments for PTSD was included. The main outcomes were remission, clinical improvement, dropout rates and changes in symptoms. Results: The 23 clinical trials included in the review comprised 1,923 patients: 898 in the treatment group and 1,025 in the control group. CBT had better remission rates than EMDR (RR = 0.35; 95%CI: 0.16; 0.79; p = 0.01) or supportive therapies (RR = 0.43; 95%CI: 0.25; 0.74; p = 0.002, completer analysis). CBT was comparable to Exposure Therapy (ET) (RR = 0.90; 95%CI: 0.58; 1.40; p = 0.64), and cognitive therapy (CT) (RR = 1.01; 95%CI: 0.67; 1.51; p = 0.98) in terms of efficacy and compliance. Conclusions: These findings suggest that specific therapies, such as CBT, exposure therapy and cognitive therapy are equally effective, and more effective than supportive techniques in the treatment of PTSD.

Efficacy of Virtual Reality Exposure Therapy in the Treatment of PTSD: A Systematic Review

The use of Information and Communication Technologies, such as virtual reality, has been employed in the treatment of anxiety disorders with the goal of augmenting exposure treatment, which is already considered to be the first-line treatment for Post-traumatic Stress Disorder (PTSD). To evaluate the efficacy of virtual reality exposure therapy (VRET) in the treatment of PTSD, we performed a systematic review of published articles using the following electronic databases: Web of Science, PubMed, PsycINFO, and PILOTS. Eligibility criteria included the use of patients diagnosed with PTSD according to DSM-IV, the use of cognitive behavioral therapy (CBT) and the use of virtual reality for performing exposure. 10 articles were selected, seven of which showed that VRET produced statistically significant results in comparison to the waiting list. However, no difference was found between VRET and exposure treatment. Of these 10, four were randomized, two were controlled but not randomized and four were non-controlled. The majority of the articles used head-mounted display virtual reality (VR) equipment and VR systems specific for the population that was being treated. Dropout rates do not seem to be lower than in traditional exposure treatment. However, there are a few limitations. Because this is a new field of research, there are few studies in the literature. There is also a need to standardize the number of sessions used. The randomized studies were analyzed to assess the quality of the methodology, and important deficiencies were noted, such as the non-use of intent-to- treat-analysis and the absence of description of possible concomitant treatments and comorbidities. Preliminary data suggest that VRET is as efficacious as traditional exposure treatment and can be especially useful in the treatment of patients who are resistant to traditional exposure.

Does D-cycloserine enhance exposure therapy for anxiety disorders in humans? A meta-analysis.

The treatment of anxiety is on the edge of a new era of combinations of pharmacologic and psychosocial interventions. A new wave of translational research has focused on the use of pharmacological agents as psychotherapy adjuvants using neurobiological insights into the mechanism of the action of certain psychological treatments such as exposure therapy. Recently, d-cycloserine (DCS) an antibiotic used to treat tuberculosis has been applied to enhance exposure-based treatment for anxiety and has proved to be a promising, but as yet unproven intervention. The present study aimed to evaluate the efficacy of DCS in the enhancement of exposure therapy in anxiety disorders. A systematic review/meta-analysis was conducted. Electronic searches were conducted in the databases ISI-Web of Science, Pubmed and PsycINFO. We included only randomized, double-blind, placebo-controlled trials with humans, focusing on the role of DCS in enhancing the action of exposure therapy for anxiety disorders. We identified 328 references, 13 studies were included in our final sample: 4 on obsessive-compulsive disorder, 2 on panic disorder, 2 on social anxiety disorder, 2 on posttraumatic stress disorder, one on acrophobia, and 2 on snake phobia. The results of the present meta-analysis show that DCS enhances exposure therapy in the treatment of anxiety disorders (Cohen d =  −0.34; CI: −0.54 to −0.14), facilitating the specific process of extinction of fear. DCS seems to be effective when administered at a time close to the exposure therapy, at low doses and a limited number of times. DCS emerges as a potential new therapeutic approach for patients with refractory anxiety disorders that are unresponsive to the conventional treatments available. When administered correctly, DCS is a promising strategy for augmentation of CBT and could reduce health care costs, drop-out rates and bring faster relief to patients.

Building resilience for future adversity: a systematic review of interventions in non-clinical samples of adults

BackgroundPotentially traumatic events happen in people’s lives, leading to the risk of the development of posttraumatic stress disorder, depression and even suicide. Resilience is an individual’s ability to maintain or regain his/her mental health in the face of significant adversity or risk of death. The aim of this study was to conduct a systematic review of studies evaluating the effectiveness of resilience promotion interventions in adults.MethodsElectronic searches were conducted in databases ISI, PsycINFO and PubMed, including every language and every year until January 20, 2013. We selected studies with nonclinical samples of adults that evaluated the effectiveness of the intervention through randomized and non-randomized controlled trials and open-ended studies. We also considered valid constructs directly related to resilience, such as hardiness.ResultsAmong 2.337 studies, 13 were selected for the review, 5 through electronic databases and 8 through search in references or the “times cited list” (list of articles that cited the selected papers). Of these, 7 are randomized controlled trials, 5 non-randomized controlled trials, and one an open-ended trial. Most of the studies included reported some degree of improvement in resilience-like variables among those subjects exposed to resilience-promoting programs. Furthermore, positive findings were more consistent among randomized controlled trials - six out of the seven suggested efficacy.ConclusionThere is evidence pointing towards some degree of effectiveness of resilience promotion programs, despite the poor operationalization of the construct and great heterogeneity in the studies. Indeed, the analysis of the methodological quality of the selected studies was hampered by the poor quality of reporting. There were faults in reporting in most studies on almost all items (random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, description of concurrent treatment and intent-to-treat analysis), except for the item “selective reporting”. Additional efforts should be made to determine the actual effect size of the interventions, since this is crucial for calculating the cost-effectiveness of resilience promotion strategies.

CBT for pharmacotherapy non-remitters--a systematic review of a next-step strategy.

BACKGROUND Non-remission rates to pharmacotherapy for anxiety disorders are related to higher relapse rates, decreased quality of life and greater functional impairment. Here we sought to investigate the efficacy of cognitive-behavior therapy (CBT) as a next-step strategy in the treatment of patients with anxiety disorders who did not remit after a pharmacological intervention. METHOD We carried out a systematic review in the ISI, Pubmed and PsycINFO/PsychLit databases. Studies that did not use CBT and that did not focus on resistance to drug therapy were excluded. We considered resistant patients who failed to respond (did not fully remit) to an adequate trial of pharmacotherapy and still exhibited residual symptoms of anxiety disorder. RESULTS We identified 603 references in our survey, of which 17 were included: eight were on OCD, five on panic disorder, and four on PTSD. No studies were found on social anxiety disorder and generalized anxiety disorder. We observed a lack of standardization of terminology and of definitions of resistance, which makes comparison of results difficult. Finally, all of the identified studies showed benefits from the addition of CBT as a next-step strategy. LIMITATIONS A limited number of randomized controlled studies were found. CONCLUSIONS CBT seems to be a promising next-step strategy for patients with anxiety disorders who did not remit with drug-based therapies. However, further clinical trials with strong methodological designs are needed to definitely establish its efficacy in this population.

Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders

INTRODUCTION The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders. METHODS To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search. RESULTS 474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive-compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education. LIMITATIONS Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria. CONCLUSIONS Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.

Neurobiologia da regulação emocional: implicações para a terapia cognitivo-comportamental

Emotion regulation represents a crucial ability for social interaction, guiding behavior and modulatin g emotional expression. Current essay reviews the available lite rature on emotion regulation, points out the differ ent coping strategies and investigates the underlying neural network. Studies on cognitive reappraisal of emotion have noted a pa ttern of brain response characterized by the activation of the prefrontal c ortex associated with the reduction of amygdala acti vity. A modulatory mechanism between these structures has been suggested. Recent work showed that psychotherapeutic approaches may modify the dysfunctional neural circuitry associated with p sychiatric disorders. Results show that investigating the neurobiology of emotion regulation offers a potential repercussion on the understanding of the basis of psychiatric di sorders, orienting the development of applied studies and improving their clinical relevance.Emotion regulation represents a crucial ability for s cial interaction, guiding behavior and modulatin g emotional expression. Current essay reviews the available lite rature on emotion regulation, points out the differ ent coping strategies and investigates the underlying neural network. Studies on cognitive reappraisal of emotion have noted a pa ttern of brain response characterized by the activation of the prefrontal c ortex associated with the reduction of amygdala acti vity. A modulatory mechanism between these structures has been suggeste d. Rec nt work showed that psychotherapeutic approach es may modify the dysfunctional neural circuitry associated with p sychiatric disorders. Results show that investigating the neurobiology of emotion regulation offers a potential repercussion on the understanding of the basis of psychiatric di sor ers, orienting the development of applied studies and improving their clinical relevance.

Systematic Review of the Efficacy of Cognitive-Behavior Therapy Related Treatments for Victims of Natural Disasters: A Worldwide Problem

Natural disasters can have devastating consequences. Each year, about 225 million people are victims of natural disasters worldwide, and up to 13,5 million of these people can develop post-traumatic stress disorder (PTSD) in the first or second year following the disaster. Cognitive-behavior therapy (CBT) is the first-choice treatment for this disorder. In order to evaluate the efficacy of psychotherapeutic treatment based on cognitive-behavior therapy for people who developed post traumatic stress disorder after natural disasters we conducted a systematic search of published studies. We used the terms reported below in the electronic databases ISI Web of Science, PsycINFO, PubMed, PILOTS and Scopus with no restrictions of language or publication date. Articles that described randomized controlled, non-randomized controlled and non controlled studies on the efficacy of cognitive-behavior therapy for individuals diagnosed with post-traumatic stress disorder after exposure to a natural disaster were eligible for inclusion. The studies were required to use a standardized measure of effectiveness before and after the intervention and have a group of patients who had used cognitive-behavior therapy as the only intervention. Our search identified 820 studies, and 11 were selected for this review. These 11 studies involved 742 subjects, 10 related to earthquakes and 1 to a hurricane. The cognitive-behavior therapy techniques used were various: 7 studies used exposure therapy, 2 studies used problem solving, and the only 2 studies with adolescents used techniques including reconstructions and reprocessing of the traumatic experience. As limitations, the search involved only five electronic databases, no experts in the field were consulted, and the heterogeneity of the findings made it impossible to perform a meta-analysis. The results suggest the efficacy of cognitive-behavior therapy, particularly exposure techniques, for the treatment of post-traumatic stress disorder after earthquakes. However, further studies with stronger methodologies, i.e. randomized-control trials and non-randomized controlled trials, are needed.

Marcadores neurobiológicos e psicométricos da eficácia da terapia cognitivo-comportamental no transtorno de estresse pós-traumático associado a sintomas dissociativos: relato de caso

INTRODUCAO: O transtorno de estresse pos-traumatico (TEPT) tem sido associado a desregulacao de diversos parâmetros psicofisiologicos e pode apresentar comorbidade com diversas psicopatologias, inclusive a dissociacao, podendo dificultar o tratamento. O objetivo do presente trabalho foi investigar os efeitos da terapia cognitivo-comportamental em um paciente com TEPT e sintomas dissociativos com base em medidas psicofisiologicas e psicometricas em diferentes momentos do tratamento. DESCRICAO DO CASO: O paciente e um homem de 38 anos, com diagnosticos de TEPT e transtorno depressivo maior recorrente com sintomas dissociativos e resistencia ao tratamento farmacologico. O tratamento psicoterapico teve duracao de 4 meses, sendo composto por uma sessao semanal de terapia e tres sessoes semanais de coterapia. Os parâmetros fisiologicos (frequencia cardiaca, tonus vagal, balanco simpatico e cortisol) e psicometricos (afeto negativo e positivo, resiliencia e sintomas de estresse pos-traumatico, depressao, ansiedade e dissociacao) foram medidos antes, durante (uma vez ao mes) e apos o tratamento. COMENTARIOS: Os resultados mostraram diminuicao do balanco simpatico e aumento do tonus vagal, da frequencia cardiaca e dos niveis de cortisol ao longo do tratamento. O tratamento tambem promoveu reducao no afeto negativo e nos sintomas de estresse pos-traumatico, depressao, ansiedade e dissociacao, alem de um aumento nos escores de resiliencia, apoio social e afeto positivo. Esses resultados sugerem que a terapia cognitivo-comportamental e um tratamento eficaz para o TEPT com sintomas dissociativos. Alem disso, parece promover a normalizacao das alteracoes fisiologicas do sistema nervoso autonomo e neuroendocrino relacionadas ao TEPT.

Evidências científicas das neurociências para a terapia cognitivo-comportamental

Os transtornos de ansiedade estao envolvidos com a incapacidade de controlar o medo e a dificuldade em regular emocoes negativas. A terapia cognitivo-comportamental (TCC) abrange tecnicas que permitem tanto a extincao do medo condicionado quanto a regulacao cognitiva de emocoes. Este artigo tem como objetivo apresentar resultados de estudos de regulacao da emocao que podem ilustrar a associacao e colaboracao entre a TCC e as neurociencias. Amparado nas pesquisas de regulacao da emocao, este estudo corrobora os resultados dos ensaios clinicos com TCC revelando que as intervencoes de distracao, reestruturacao cognitiva e exposicao sao eficazes para a regulacao emocional.Os transtornos de ansiedade estao envolvidos com a incapacidade de controlar o medo e a dificuldade em regular emocoes negativas. A terapia cognitivo-comportamental (TCC) abrange tecnicas que permitem tanto a extincao do medo condicionado quanto a regulacao cognitiva de emocoes. Este artigo tem como objetivo apresentar resultados de estudos de regulacao da emocao que podem ilustrar a associacao e colaboracao entre a TCC e as neurociencias. Amparado nas pesquisas de regulacao da emocao, este estudo corrobora os resultados dos ensaios clinicos com TCC revelando que as intervencoes de distracao, reestruturacao cognitiva e exposicao sao eficazes para a regulacao emocional.