Simone Salzer

Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial

OBJECTIVE Various approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial. METHOD In an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well. RESULTS Remission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were significantly superior to waiting list for both remission and response. CBT was significantly superior to psychodynamic therapy for remission but not for response. Between-group effect sizes for remission and response were small. Secondary outcome measures showed significant differences in favor of CBT for measures of social phobia and interpersonal problems, but not for depression. CONCLUSIONS CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT. For CBT, the response rate was comparable to rates reported in Swedish and German studies in recent years. For psychodynamic therapy, the response rate was comparable to rates reported for pharmacotherapy and cognitive-behavioral group therapy.

Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial

OBJECTIVE While several studies have shown that cognitive-behavioral therapy (CBT) is an efficacious treatment for generalized anxiety disorder, few studies have addressed the outcome of short-term psychodynamic psychotherapy, even though this treatment is widely used. The aim of this study was to compare short-term psychodynamic psychotherapy and CBT with regard to treatment outcome in generalized anxiety disorder. METHOD Patients with generalized anxiety disorder according to DSM-IV were randomly assigned to receive either CBT (N=29) or short-term psychodynamic psychotherapy (N=28). Treatments were carried out according to treatment manuals and included up to 30 weekly sessions. The primary outcome measure was the Hamilton Anxiety Rating Scale, which was applied by trained raters blind to the treatment conditions. Assessments were carried out at the completion of treatment and 6 months afterward. RESULTS Both CBT and short-term psychodynamic psychotherapy yielded significant, large, and stable improvements with regard to symptoms of anxiety and depression. No significant differences in outcome were found between treatments in regard to the primary outcome measure. These results were corroborated by two self-report measures of anxiety. In measures of trait anxiety, worry, and depression, however, CBT was found to be superior. CONCLUSIONS The results suggest that CBT and short-term psychodynamic psychotherapy are beneficial for patients with generalized anxiety disorder. In future research, large-scale multicenter studies should examine more subtle differences between treatments, including differences in the patients who benefit most from each form of therapy.

Interpersonal Subtypes Within Generalized Anxiety Disorder

In this study, we addressed the heterogeneity in interpersonal problems across patients with generalized anxiety disorder (GAD). We assessed interpersonal problems by the Inventory of Interpersonal Problems (IIP–C; Horowitz, Alden, Wiggins, & Pincus, 2000) in a sample of 78 GAD patients. We used IIP–C profiles describing interpersonal characteristics of the total GAD sample as well as clustered GAD interpersonal subtypes. Although the overall sample was located in the friendly submissive quadrant of the circumplex model, this was true only for the Exploitable cluster, which includes more than 50% of the patients. Importantly, clusters of GAD patients with other locations reporting predominantly Cold, Nonassertive, or Intrusive interpersonal problems were also identified. The 4 clusters did not differ in terms of gender, comorbid disorders, or the severity of depression or anxiety. Thus, the assessment of interpersonal problems provides additional diagnostic information covering the heterogeneity of GAD patients. This information could be used for differential indication and individual case formulation in GAD.

A Unified Protocol for the Transdiagnostic Psychodynamic Treatment of Anxiety Disorders: An Evidence-Based Approach

Although there is evidence for the efficacy of psychodynamic therapy (PDT) in anxiety disorders, results are not yet satisfactory, for example, if rates of remission and response are considered. To address this problem, a unified psychodynamic protocol for anxiety disorders (UPP-ANXIETY) is proposed that integrates the treatment principles of those methods of PDT that have proven to be efficacious in anxiety disorders. In addition, this protocol is transdiagnostic, implying that it is applicable to various forms of anxiety disorders and related disorders (generalized anxiety disorder, social phobia, panic disorders, avoidant personality disorder). Based on supportive-expressive therapy, the UPP-ANXIETY represents an integrated form of psychodynamic therapy that allows for a flexible use of empirically supported treatment principles. UPP-ANXIETY encompasses the following 9 treatment principles (modules): (1) socializing the patient for psychotherapy, (2) motivating and setting treatment goals, (3) establishing a secure helping alliance, (4) identifying the core conflict underlying anxiety, (5) focusing on the warded-off wish/affect, (6) modifying underlying internalized object relations, (7) changing underlying defenses and avoidance, (8) modifying underlying response of self, and (9) termination and relapse prevention. Some principles are regarded as core components to be used in every treatment (principles 3-8). A unified protocol for the psychodynamic treatment of anxiety disorders has several advantages, that is (1) integrating the most effective treatment principles of empirically supported psychodynamic treatments for anxiety disorders can be expected to further improve the efficacy of PDT; (2) using a unified protocol in efficacy studies has the potential to enhance the evidence-based status of PDT by aggregating the evidence; (3) a unified protocol will facilitate both training in PDT and transfer of research to clinical practice; and (4) thus, a unified protocol can be expected to have a significant impact on the health care system. We are planning to test the UPP-ANXIETY in a multicenter randomized controlled trial.

Interpersonal subtypes and change of interpersonal problems in the treatment of patients with generalized anxiety disorder: a pilot study.

Interpersonal problems are highly relevant to the treatment of generalized anxiety disorder (GAD) patients. Previous studies using the Inventory of Interpersonal Problems identified several interpersonal subtypes in GAD patients. In this study, we wanted to replicate earlier findings of interpersonal subtypes in GAD. We investigated whether these interpersonal subtypes are characterized by different types of interpersonal problems and different levels of interpersonal distress, and we further examined whether they differed with regard to improvement of interpersonal problems after short-term treatment. This study is based on results from a randomized controlled trial that investigated short-term treatments in GAD outpatients. For secondary analysis, interpersonal subtypes were identified by cluster analysis and Inventory of Interpersonal Problems profiles were calculated for both the total sample (N = 52) and the interpersonal subtypes using the Structural Summary Method for Circumplex Data. This study confirmed previous results demonstrating the existence of interpersonal subtypes in GAD. Four interpersonal subtypes were identified: Overly Nurturant, Intrusive, Socially Avoidant, and Nonassertive. Short-term treatment significantly improved interpersonal problems (d = 0.46) within the total GAD sample. Interestingly, the effect sizes of the four clusters differed considerably (d = 0.19-1.24) and the clusters displayed different changes in the two circumplex axes Dominance and Nurturance. Our study indicates that change of interpersonal problems needs to be specifically analyzed, even within homogenous diagnostic groups.

Long-Term Effects of Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioural Therapy in Generalized Anxiety Disorder: 12-Month Follow-Up

Objective: In a previous randomized controlled trial (RCT), short-term efficacy of cognitive-behavioural therapy (CBT) and short-term psychodynamic psychotherapy (STPP) in generalized anxiety disorder (GAD) was demonstrated. In this article, long-term stability of these effects will be examined. Effects of CBT and STPP will be compared. Method: In the original RCT, patients with GAD were treated with either CBT (n = 29) or STPP (n = 28). Treatments were carried out according to manuals and included up to 30 sessions. As the primary outcome measure the Hamilton Anxiety Rating Scale was used. In addition to short-term outcome previously reported, treatment effects were assessed 12 months after termination of treatment. Results: Both CBT and STPP yielded large improvements at 12-month follow-up. No significant differences were found between treatments concerning the primary outcome measure. This result was corroborated by 3 self-report measures of anxiety. However, in measures of trait anxiety and worry, CBT was superior. Concerning depression, differences reported at posttreatment were no longer significant at 12-month follow-up. Conclusions: In GAD, both CBT and STPP yield large and stable effects 12 months after treatment. Concerning trait anxiety and worry, CBT seems to be superior. For STPP, further studies should be carried out to confirm the results.

Baseline Patient Characteristics Predicting Outcome and Attrition in Cognitive Therapy for Social Phobia: Results from a Large Multicentre Trial.

UNLABELLED We examined the role of baseline patient characteristics as predictors of outcome (end-state functioning, response and remission) and attrition for cognitive therapy (CT) in social anxiety disorder (SAD). Beyond socio-demographic and clinical variables such as symptom severity and comorbidity status, previously neglected patient characteristics (e.g., personality, self-esteem, shame, interpersonal problems and attachment style) were analysed. METHOD Data came from the CT arm of a multicentre RCT with n = 244 patients having DSM-IV SAD. CT was conducted according to the manual by Clark and Wells. Severity of SAD was assessed at baseline and end of treatment with the Liebowitz Social Anxiety Scale (LSAS). Multiple linear regression analyses and logistic regression analyses were applied. RESULTS Up to 37% of the post-treatment variance (LSAS) could be explained by all pre-treatment variables combined. Symptom severity (baseline LSAS) was consistently negatively associated with end-state functioning and remission, but not with response. Number of comorbid diagnoses was negatively associated with end-state functioning and response, but not with remission. Self-esteem was positively associated with higher end-state functioning and more shame with better response. Attrition could not be significantly predicted. CONCLUSIONS The results indicate that the initial probability for treatment success mainly depends on severity of disorder and comorbid conditions while other psychological variables are of minor importance, at least on a nomothetic level. This stands in contrast with efforts to arrive at an empirical-based foundation for differential indication and argues to search for more potent moderators of therapeutic change rather on the process level. KEY PRACTITIONER MESSAGE Personality, self-esteem, shame, attachment style and interpersonal problems do not or only marginally moderate the effects of interventions in CT of social phobia. Symptom severity and comorbid diagnoses might affect treatment outcome negatively. Beyond these two factors, most patients share a similar likelihood of treatment success when treated according to the manual by Clark and Wells. Copyright

Treatment Integrity: An Unresolved Issue in Psychotherapy Research

Background: Treatment integrity is defined as the extent to which a treatment is carried out as intended. It includes several interrelated components (e.g. therapy adherence, therapist competence and therapy differentiation). Treatment integrity is regarded to play an essential role in psychotherapy outcome research. Objective: This article discusses (1) conceptual aspects, (2) empirical results and (3) methodological problems of research on treatment integrity. Results: (1) Therapy integrity refers to different aspects of experimental validity. It is usually discussed with regard to internal validity. Maybe even more important, however, treatment integrity also refers to construct validity. Treatment integrity is also related to external validity and validity of statistical conclusions. (2) Results for the relationship between treatment integrity (adherence to a treatment model and competent delivery of techniques) and outcome are heterogeneous and suggest that the relationship between outcome and treatment integrity is not yet clear. Even in studies which found a relationship between treatment integrity and outcome, the proportion of variance explained by intended techniques was between 10% and 30%. Thus, the majority of variance was not explained by intended techniques. (3) Methodological problems may contribute to the lack of consistent results. As most results come from randomized controlled efficacy studies, the ranges of data for both outcome and adherence/competence may be restricted by the selection of patients and therapists, as well as by training of therapists, manualization and monitoring of treatment. These factors attenuate the association between treatment integrity and outcome. Other factors that may contribute to the inconsistent results are unreliability of measures, instability of adherence and competence during the process of psychotherapy or nonlinear relationships between treatment integrity and outcome. Conclusions: Further studies are required that address the relationship between adherence, competence and outcome, especially for those methods of psychotherapy that were shown to be effective in a particular disorder. Factors that moderate or mediate the relationship between outcome and therapy integrity should be included. Due to their high level of standardization, randomized controlled efficacy studies seem to be only of limited use to study the relationship between treatment integrity and outcome. The recent shift from a single-disorder focus of the traditional manualized interventions to transdiagnostic, modular and component-based interventions may lead to a change in the conceptualization of treatment integrity. It allows for a more flexible use of interventions while maintaining treatment integrity. This shift may both enhance the external validity of studies using manualized treatments and lead to more consistent results regarding the relationship between treatment integrity and outcome.

Short-term cost-effectiveness of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: Results from the SOPHO-NET trial.

BACKGROUND To investigate the short-term cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL). METHODS The analysis was conducted alongside the SOPHO-NET multi-center efficacy trial. Patients were randomly assigned to CBT (n=209), PDT (n=207), or WL (n=79). Resource use was assessed prior and during treatment to determine direct and absenteeism costs. Unadjusted incremental cost-effectiveness ratios (ICERs) were calculated based on remission and response rates. To visualize statistical uncertainty, cost-effectiveness acceptability curves (CEACs) were constructed based on adjusted net-benefit regression. Different values for the society׳s willingness to pay (WTP) were assumed. RESULTS Both interventions were more efficacious than WL but were associated with increased direct costs besides intervention costs. Unadjusted ICERs per responder were €3615 for CBT and €4958 for PDT. Unadjusted ICERs per remitted patient were €5788 and €10,733. CEACs revealed a high degree of uncertainty: applying the 97.5% probability threshold, CBT proved cost-effective at a WTP ≥€16,100 per responder and ≥€26,605 per remitted patient. Regarding PDT cost-effectiveness only was certain for response at a WTP ≥€27,290. LIMITATIONS The WL condition is assumed to represent untreated patients, although the expectation to start treatment in the near future probably affects symptom severity and health care utilization. CONCLUSIONS At the end of treatment cost-effectiveness of CBT and PDT compared to WL is uncertain and depends on the societal WTP. The interventions may induce a more adequate utilization of other health care services - involving increased costs. Development of costs and effects in the long-run should be considered.

The costs of social anxiety disorder: The role of symptom severity and comorbidities

BACKGROUND Social anxiety disorder (SAD) is associated with low direct costs compared to other anxiety disorders while indirect costs tend to be high. Mental comorbidities have been identified to increase costs, but the role of symptom severity is still vague. The objective of this study was to determine the costs of SAD, and to explore the impact of symptoms and comorbidities on direct and indirect costs. METHODS Baseline data, collected within the SOPHO-NET multi-centre treatment study (N=495), were used. Costs were calculated based on health care utilization and lost productivity. Symptom severity was measured with the Liebowitz-Social-Anxiety-Scale; comorbidities were included as covariates. RESULTS Total 6-month costs were accrued to €4802; 23% being direct costs. While there was no significant association with SAD symptom severity for direct costs, costs of absenteeism increased with symptom severity in those with costs >0; comorbid affective disorders and eating disorders had an additional effect. Self-rated productivity was lower with more pronounced symptoms even after controlling for comorbidities. LIMITATIONS As the study was based on a clinical sample total costs were considered, rather than net costs of SAD and no population costs could be calculated. DISCUSSION The burden associated with lost productivity was considerable while costs of healthcare utilization were rather low as most patients had not sought for treatment before. Efforts to identify patients with SAD earlier and to provide adequate treatment should be further increased. Mental comorbidities should be addressed as well, since they account for a large part of indirect costs associated with SAD.