Shireen L. Rizvi

Randomized Trial of Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Prevention of Relapse and Recurrence in Major Depression

This study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through 1 year of follow-up compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the 2nd year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to patients withdrawn from medication, although the difference was not significantly different. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full 2-year follow-up, and each therapy was at least as efficacious as the continuation of medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy and that both psychotherapies are less expensive and longer lasting alternatives to medication in the treatment of depression.

Test-retest reliability of the eating disorder examination.

OBJECTIVE The purpose of this investigation was to determine the test-retest reliability of the Eating Disorder Examination (EDE). METHOD This study examined the test-retest and interrater reliability of the EDE in 20 adult women with a range of eating disorder symptoms. Trained assessors administered the EDE to participants on two separate occasions, ranging from 2 to 7 days apart. RESULTS Test-retest correlations were.7 or greater for all subscales and measures of eating disorder behaviors except for subjective bulimic episodes and subjective bulimic days. Interrater reliability was uniformly high with correlations above.9. DISCUSSION Results provide further support for the reliability of the EDE, but suggest that smaller binge episodes may not be reliable indicators of eating pathology.

Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder.

A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.

A Pilot Study of the DBT Coach: An Interactive Mobile Phone Application for Individuals with Borderline Personality Disorder and Substance Use Disorder

Dialectical behavior therapy (DBT) has received strong empirical support and is practiced widely as a treatment for borderline personality disorder (BPD) and BPD with comorbid substance use disorders (BPD-SUD). Therapeutic success in DBT requires that individuals generalize newly acquired skills to their natural environment. However, there have been only a limited number of options available to achieve this end. The primary goal of this research was to develop and test the feasibility of the DBT Coach, a software application for a smartphone, designed specifically to enhance generalization of a specific DBT skill (opposite action) among individuals with BPD-SUD. We conducted a quasiexperimental study in which 22 individuals who were enrolled in DBT treatment programs received a smartphone with the DBT Coach for 10 to 14 days and were instructed to use it as needed. Participants used the DBT Coach an average of nearly 15 times and gave high ratings of helpfulness and usability. Results indicate that both emotion intensity and urges to use substances significantly decreased within each coaching session. Furthermore, over the trial period, participants reported a decrease in depression and general distress. Mobile technology offering in vivo skills coaching may be a useful tool for reducing urges to use substances and engage in other maladaptive behavior by directly teaching and coaching in alternative, adaptive coping behavior.

Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression.

Pharmacotherapy and psychotherapy are generally effective treatments for major depressive disorder (MDD); however, research suggests that patient preferences may influence outcomes. We examined the effects of treatment preference on attrition, therapeutic alliance, and change in depressive severity in a longitudinal randomized clinical trial comparing pharmacotherapy and psychotherapy. Prior to randomization, 106 individuals with MDD reported whether they preferred psychotherapy, antidepressant medication, or had no preference. A mismatch between preferred and actual treatment was associated with greater likelihood of attrition, fewer expected visits attended, and a less positive working alliance at session 2. There was a significant indirect effect of preference match on depression outcomes, primarily via effects of attendance. These findings highlight the importance of addressing patient preferences, particularly in regard to patient engagement, in the treatment of MDD.

Cognitive and Affective Predictors of Treatment Outcome in Cognitive Processing Therapy and Prolonged Exposure for Posttraumatic Stress Disorder

This study examined cognitive and affective predictors of treatment dropout and treatment efficacy in Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) for PTSD. Study participants were women with PTSD from a sexual assault who received at least one session of either treatment (n = 145) as part of a randomized clinical trial. Results revealed that younger age, lower intelligence, and less education were associated with higher treatment dropout, whereas higher depression and guilt at pretreatment were associated with greater improvement in PTSD symptomatology. Results by treatment condition indicated that women with higher anger at pretreatment were more likely to dropout of PE and that older women in PE and younger women in CPT had the best overall outcomes. These findings have implications for efforts to enhance treatment efficacy and retention in CBT treatment protocols.

Borderline Personality Characteristics and Treatment Outcome in Cognitive-Behavioral Treatments for PTSD in Female Rape Victims

Many studies report that comorbid borderline personality pathology is associated with poorer outcomes in the treatment of Axis I disorders. Given the high rates of comorbidity between borderline personality pathology and posttraumatic stress disorder (PTSD), it is essential to determine whether borderline symptomatology affects PTSD treatment outcome. This study examined the effects of borderline personality characteristics (BPC) on 131 female rape victims receiving cognitive-behavioral treatment for PTSD. Higher BPC scores were associated with greater pretreatment PTSD severity; however, individuals with higher levels of BPC were just as likely to complete treatment and also as likely to show significant treatment response on several outcome measures. There were no significant interactions between type of treatment and BPC on the outcome variables. Findings suggest that women with borderline pathology may be able to benefit significantly from cognitive-behavioral treatment for PTSD.

Dialectical behavior therapy for substance abuse: A pilot application to methamphetamine-dependent women with borderline personality disorder

The primary aim of this paper is to describe key modifications made to standard Dialectical Behavior Therapy (DBT) for use with substance-dependent individuals with borderline personality disorder (BPD). Key modifications include application of dialectics to issues surrounding abstinence, a new set of substance abuse behavioral targets, a set of attachment strategies for difficult-to-engage and easily lost clients, and modification of some skills geared for substance abusing clients. Treatment outcome findings from a small 12-month uncontrolled pilot trial of DBT for methamphetamine-dependent women with BPD are presented. Of the 3 participants who commenced treatment, 2 completed treatment and were abstinent from use of all illicit drugs by 6 months; results were maintained for the duration of the assessment period 6 months later. These encouraging results suggest that DBT may hold promise for treating methamphetamine dependence.

Beyond Fear The Role of Peritraumatic Responses in Posttraumatic Stress and Depressive Symptoms Among Female Crime Victims

This study examines peritraumatic (and posttrauma) responses in a sample of female crime victims who had been sexually or physically assaulted within the previous 2 months. Women were interviewed about their emotional and behavioral responses during the trauma and assessed for posttraumatic stress disorder and depression symptomatology. Results indicate that women experience a wide range of behavioral and emotional responses during a traumatic event and that these responses have implications for posttrauma adjustment. Women who experienced behaviors typical of a freeze response are more likely to have a greater degree of symptomatology after the assault. Peritraumatic emotions, other than fear, such as sadness, humiliation, and anger, also appear to be related to posttrauma depression symptoms. These findings highlight the necessity of exploring the full range of possible reactions during a trauma.

Emotional Cascades and Self-Injury: Investigating Instability of Rumination and Negative Emotion

OBJECTIVE Nonsuicidal self-injury (NSSI) is a public health concern and risk factor for suicide. The Emotional Cascade Model (ECM) proposes that NSSI partially functions as a distraction from cascades of negative affect and rumination. The purpose of this study was to examine the roles of trait rumination, and momentary instability of rumination and negative emotion, in NSSI. METHOD Experience sampling methods were used to monitor thoughts, emotions, and behaviors in 47 individuals reporting dysregulated behaviors including NSSI. Instability indices were generated for rumination and negative emotion using the momentary assessments. RESULTS Twenty-five episodes of NSSI were reported during monitoring. Trait rumination prospectively predicted NSSI episodes, and the instability indices interacted to predict NSSI. CONCLUSIONS Consistent with the ECM, the interaction between rumination instability and negative affect instability during monitoring significantly predicted NSSI, with the strongest effects occurring for sadness and rumination about past. These findings may enhance conceptualization and treatment of patients with NSSI.