Ulrich Stangier

Cognitive therapy for social phobia: individual versus group treatment

Cognitive-behavioural group treatment is the treatment of choice for social phobia. However, as not all patients benefit, an additional empirically validated psychological treatment would be of value. In addition, few studies have examined whether a group treatment format is more effective than an individual treatment format. A randomized controlled trial addressed these issues by comparing individual cognitive therapy, along the lines advocated by Clark and Wells (Clark, D.M. and Wells, A., 1995. A cognitive model of social phobia. In: R. G. Heimberg, M. Liebowitz, D. Hope and F. Schneier (Eds.), Social Phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York: Guilford.), with a group version of the treatment and a wait-list control condition. 71 patients meeting DSM-IV criteria for social phobia participated in the trial, 65 completed the posttreatment assessment and 59 completed a six-month follow-up. Social phobia measures indicated significant pretreatment to posttreatment improvement in both individual and group cognitive therapy. Individual cognitive therapy was superior to group cognitive therapy on several measures at both posttreatment and follow-up. The effects of treatment on general measures of mood and psychopathology were less substantial than the effects on social phobia. The results suggest that individual cognitive therapy is a specific treatment for social phobia and that its effectiveness may be diminished by delivery in a group format.

Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to relapse prevention

A randomized controlled trial compared the effectiveness of 4 group treatments for atopic dermatitis, a chronic skin disorder characterized by severe itching and eczema: dermatological educational program (DE), autogenic training as a form of relaxation therapy (AT), cognitive-behavioral treatment (BT), and the combined DE and BT treatments (DEBT). BT comprised relaxation, self-control of scratching, and stress management. Group treatments were also compared with standard medical care (SMC). Assessments at 1-year follow-up showed that the psychological treatments (AT, BT, and DEBT) led to significantly larger improvement in skin condition than intensive (DE) or standard (SMC) dermatological treatment, accompanied by significant reductions in topical steroids used. The results corroborate preliminary reports that psychological interventions are useful adjuncts to dermatological treatment in atopic dermatitis.

Die Erfassung sozialer Phobie durch die Social Interaction Anxiety Scale (SIAS) und die Social Phobia Scale (SPS)

Zusammenfassung. Die vorliegende Arbeit berichtet erste Analysen zur Reliabilitat und Validitat sowie klinische cut-off-Werte der deutschen Bearbeitung der Social Interaction Anxiety Scale und der Social Phobia Scale (Mattick & Clarke, 1989). Die Skalen wurden 43 Patienten mit Sozialer Phobie, 69 Patienten mit anderen psychischen Storungen und 24 Kontrollpersonen ohne psychische Storungen vorgelegt. Die ermittelten Werte fur die innere Konsistenz und Test-Retest-Korrelation sprechen fur eine sehr hohe Reliabilitat. Hinweise auf eine konvergente Validitat ergaben sich aus hohen Korrelationen mit konstruktnahen Mesinstrumenten zur Sozialen Phobie, wahrend die Korrelationen zu Depressions- und Angstmasen erwartungsgemas geringer ausfielen. Die beiden Skalen diskriminieren Soziophobiker sehr gut von Personen ohne psychische Storung und Angstpatienten, wahrend die Diskriminationsleistung von depressiven Patienten geringer ausgepragt ist. Die ermittelten cut-off-Werte liegen deutlich unter den amerikanischen We...

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.

Maintenance Cognitive-Behavioral Therapy and Manualized Psychoeducation in the Treatment of Recurrent Depression: A Multicenter Prospective Randomized Controlled Trial

OBJECTIVE This multicenter study compared the relapse and recurrence outcomes of two active treatments, maintenance cognitive-behavioral therapy (CBT) and manualized psychoeducation, both in addition to treatment as usual, in patients in remission from depression. METHOD This was a multicenter prospective randomized observer-blinded study with two parallel groups. The authors assessed 180 patients with three or more previous major depressive episodes who met remission criteria over a 2-month baseline period and who were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation over 8 months and then followed up for 12 months. The main outcome measure was time to first relapse or recurrence of a major depression, based on DSM-IV criteria, as assessed by blinded observers with the Longitudinal Interval Follow-Up Evaluation. RESULTS Cox regression analysis showed that time to relapse or recurrence of major depression did not differ significantly between treatment conditions, but a significant interaction was observed between treatment condition and number of previous episodes (<5 or ≥5). Within the subsample of patients with five or more previous episodes, maintenance CBT was significantly superior to manualized psychoeducation, whereas for patients with fewer than five previous episodes, no significant treatment differences were observed in time to relapse or recurrence. CONCLUSIONS The results indicate that maintenance CBT has significant effects on the prevention of relapse or recurrence only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, nonspecific effects and structured patient education may be equally effective.

Measuring adjustment to chronic skin disorders: validation of a self-report measure.

This article describes the development of a questionnaire that assesses problems in adapting to chronic skin disorders, the Adjustment to Chronic Skin Diseases Questionnaire. Patients (N = 442) with different skin disorders completed the original item pool. Principal-components analysis suggested a 6-factor solution that was largely replicated with 2 additional samples of 192 patients with psoriasis or atopic dermatitis and 165 patients with atopic dermatitis. Four of the subscales showed very good internal consistencies, retest reliabilities, and sufficient correlations with expert ratings: Social Anxiety/Avoidance, Itch-Scratch Cycle, Helplessness, and Anxious-Depressive Mood. Two short additional subscales, Impact on Quality of Life and Deficit in Active Coping, showed moderate internal consistencies, but good retest reliabilities. Correlations of the subscales with measures of depression, anxiety, and coping, and meaningful differences between dermatological subgroups support their construct validity. A treatment study showed that changes in some of the subscales correlated with changes in the severity of the skin condition.

Mental imagery vividness as a trait marker across the schizophrenia spectrum

We investigated the vividness of mental imagery and its possible relationship with the predisposition towards hallucinations in 52 schizophrenia (SZ) patients, 44 of their first-degree relatives (R) and two healthy control groups (high-schizotypy [CHS; n=24]; low-schizotypy [CLS; n=24]). We investigated phenomenological and cognitive trait markers of schizophrenia, including cognitive correlates of hallucinations and vividness of mental imagery, and the influence of individual psychopathology. Overall, scores on the mental imagery questionnaire (QMI [Sheehan, P.W., 1967. Reliability of a short test of imagery. Perceptual and Motor Skills 25, 744.]) suggested higher mental imagery vividness in first-degree relatives, high-schizotypy controls and patients, than in low-schizotypy controls. However, vividness of mental imagery was independent of predisposition towards hallucinations and cognitive test performance scores. These results suggest that vividness of mental imagery may be a trait marker across the schizophrenia spectrum. In addition we propose that imagery proneness is relatively independent of the individual psychopathology.

The Social Phobia Psychotherapy Research Network : The First Multicenter Randomized Controlled Trial of Psychotherapy for Social Phobia: Rationale, Methods and Patient Characteristics

This paper presents the Social Phobia Psychotherapy Research Network. The research program encompasses a coordinated group of studies adopting a standard protocol and an agreed-on set of standardized measures for the assessment and treatment of social phobia (SP). In the central project (study A), a multicenter randomized controlled trial, refined models of manualized cognitive-behavioral therapy and manualized short-term psychodynamic psychotherapy are compared in the treatment of SP. A sample of 512 outpatients will be randomized to either cognitive-behavioral therapy, short-term psychodynamic psychotherapy or waiting list. Assessments will be made at baseline, at the end of treatment and 6 and 12 months after the end of treatment. For quality assurance and treatment integrity, a specific project using highly elaborated measures has been established (project Q). Study A is complemented by 4 interrelated add-on projects focusing on attachment style (study B1), on cost-effectiveness (study B2), on variation in the serotonin transporter gene in SP (study C1) and on structural and functional deviations of the hippocampus and amygdala (study C2). Thus, the Social Phobia Psychotherapy Research Network program enables a highly interdisciplinary research into SP. The unique sample size achieved by the multicenter approach allows for studies of subgroups (e.g. comorbid disorders, isolated vs. generalized SP), of responders and nonresponders of each treatment approach, for generalization of results and for a sufficient power to detect differences between treatments. Psychological and biological parameters will be related to treatment outcome, and variables for differential treatment indication will be gained. Thus, the results provided by the network may have an important impact on the treatment of SP and on the development of treatment guidelines for SP.

Implicit self-esteem in recurrently depressed patients.

Negative self-esteem is suggested to play an important role in the recurrence of depressive episodes. This study investigated whether repeated experiences of a negative view of the self within a recurrent course of depression might cause implicit self-esteem to be impaired and negative self-attributes to even be chronically activated beyond remission. We measured implicit self-esteem using an Implicit Association Test. The sample consisted of N = 24 currently depressed patients with first-onset depressive episode, N = 28 currently depressed patients with recurrent depressive episodes, N = 33 currently remitted patients with recurrent depressive episodes, and N = 34 controls with no history of depression. In line with cognitive theories, results revealed significantly lower implicit self-esteem in current depressive patients than in healthy controls but no significant differences in implicit self-esteem between remitted recurrent depressive patients and healthy controls. However, remitted depressive patients with three or more depressive episodes showed a significantly lower implicit self-esteem than those with less than three depressive episodes. The current findings underline the necessity of relapse prevention treatments which not only enhance self-esteem at an explicit but also at an implicit level as well as emphasizing the need for evaluations of treatment efficacy to focus upon both implicit and explicit levels of self-esteem.

Brain activation during anticipatory anxiety in social anxiety disorder

Exaggerated anticipatory anxiety during expectation of performance-related situations is an important feature of the psychopathology of social anxiety disorder (SAD). The neural basis of anticipatory anxiety in SAD has not been investigated in controlled studies. The current study used functional magnetic resonance imaging (fMRI) to investigate the neural correlates during the anticipation of public and evaluated speaking vs a control condition in 17 SAD patients and 17 healthy control subjects. FMRI results show increased activation of the insula and decreased activation of the ventral striatum in SAD patients, compared to control subjects during anticipation of a speech vs the control condition. In addition, an activation of the amygdala in SAD patients during the first half of the anticipation phase in the speech condition was observed. Finally, the amount of anticipatory anxiety of SAD patients was negatively correlated to the activation of the ventral striatum. This suggests an association between incentive function, motivation and anticipatory anxiety when SAD patients expect a performance situation.