Ulrike Willutzki

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.

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.

Working with patients’ strengths: A microprocess approach

Abstract Previous research has supported the immediate activation of patients’ strengths (resource activation) as an important change mechanism in psychotherapy. Two different studies of integrative cognitive–behavioral therapy (CBT) treatments demonstrated that fostered strengths-oriented CBT treatments were more effective than the control conditions. Within these two studies, the authors tested the effect of specific resource-activating strategies at the beginning of therapy (Sessions 2, 5, and 8) using a pairwise matched control group design. The in-session processes were measured by video observer ratings (N=96 sessions). Results indicate that in the strengths-fostering treatments therapists and patients focus more strongly on patient competencies and personal goals in comparison to the control groups. These in-session processes have a direct impact on session outcome (particularly self-esteem, mastery, and clarification experiences). Results are discussed in regard to actively implementing resource-activating behavior as superordinate principles of change and their relevance for therapy outcome.

Psychotherapy for Social Anxiety Disorder: Long-Term Effectiveness of Resource-Oriented Cognitive-Behavioral Therapy and Cognitive Therapy in Social Anxiety Disorder

OBJECTIVE Resource-oriented cognitive-behavioral therapy (ROCBT) and cognitive therapy (CT) have been shown to be effective treatments for social anxiety disorder. However, so far few studies have examined the long-term effectiveness of these treatments. Thus, there is little information available about the durability of change in treated patients with social anxiety disorder. DESIGN This study examined the effectiveness of both treatments at 2-year and 10-year follow-up assessments. Patients who received ROCBT or CT were re-contacted after 2 (n = 51), and 10 years (n = 27), respectively, and completed a battery of self-report questionnaires. RESULTS Treatment gains were maintained over the 2-year follow-up on all measures. Furthermore, there was a significant improvement on 2 social anxiety measures between posttreatment and the 10-year follow-up. ROCBT and CT did not differ in overall effectiveness. CONCLUSION The results suggest that both treatments are effective and durable approaches in the treatment of social anxiety disorder.

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

Zur Psychotherapie sozialer ?ngste: Kognitive Verhaltenstherapie im Vergleich zu einem kombiniert ressourcenorientierten Vorgehen

Zusammenfassung. Theoretischer Hintergrund: Im Rahmen einer Interpretation sozialer Angste als Handlungsregulationsproblem wird die Relevanz von Ressourcen in der Psychotherapie herausgearbeitet. Fragestellung: Kann das Therapieangebot fur Patienten mit sozialen Angsten durch Fokussierung der Ressourcen der Person verbessert werden? Methode: In einer randomisierten kontrollierten Interventionsstudie fur 83 Patienten mit sozialen Angsten wird ein kombiniert kognitiv-verhaltenstherapeutisch/ressourcen-orientiertes Vorgehen (KROT) mit einem fokal kognitiv-verhaltenstherapeutischen Angebot (KVT) verglichen. Ergebnisse: Bei insgesamt im Vergleich zu anderen Therapiestudien befriedigenden Ergebnissen profitiert die KROT-Gruppe sowohl auf der Ebene der sozialphobischen Symptomatik wie auch der psychischen Belastung starker. Dies schlagt sich in hoheren Effektstarken nieder (fur die sozialphobische Symptomatik: KVT = .86, KROT = 1.39; psychische Belastung insgesamt: KVT = .84, KROT = 1.18). Schlussfolgerungen: De...

A randomized controlled trial on the effectiveness of a rumination-focused group treatment for residual depression

Abstract The maintenance of residual symptoms following acute treatment is common and is associated with poor long-term prognosis. This study investigates whether a cognitive-behavioral group treatment is effective in reducing residual depression by targeting depressive rumination. Participants (N=60) were randomly assigned to either the group treatment or a wait-list control condition. Treatment significantly improved depressed mood, rumination, perceived control over rumination and dysfunctional metacognitive beliefs compared with the wait condition. Treatment gains were maintained over the follow-up period of 1 year. Attrition was low and treatment satisfaction was high. Eight individuals suffered from a depressive relapse/recurrence in the year following treatment. The results indicate that cognitive-behavioral group therapy for depressive rumination is effective and well accepted by patients suffering from residual depression.

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.

Zur aktuellen Stimmung von Patienten: Wie relevant ist sie im Therapiegeschehen?

Zusammenfassung. Theoretischer Hintergrund: Das Stimmungsmediationsmodell von Robinson schreibt der aktuellen Stimmung von Personen sowohl eine retrospektive als auch eine prospektive Funktion bei der Verarbeitung aktueller Lebensereignisse zu. Die Implikationen des Modells fur die Psychotherapie werden untersucht. Fragestellung: Inwieweit kommt der aktuellen Stimmung von Patienten eine Mediatorfunktion im Therapiegeschehen zu? Methode: Im Rahmen einer randomisierten kontrollierten Studie zur Psychotherapie sozialer Phobie (N = 74 Patienten) wurde die zum Ende jeder Therapiesitzung erhobene Stimmung in Beziehung zu Therapieprozess und Sitzungsergebnis gesetzt. Die Zusammenhange zur Eingangssymptomatik wurden analysiert. Ergebnisse: Es ergeben sich fur fast alle Therapiephasen positive Zusammenhange zwischen Stimmung und Therapieprozess sowie Sitzungsergebnis. Je hoher die Symptombelastung vor Therapiebeginn, desto negativer ist die aktuelle Stimmung in der ersten Therapiephase. Schlussfolgerungen: Die Erg...

Social anxiety as a potential mediator of the association between attachment and depression

OBJECTIVE The study represents a conceptual replication of the study by Eng et al. (2001) in a sample of adult patients diagnosed with social anxiety disorder as primary diagnosis. METHODS Two different attachment questionnaires (Bielefeld Questionnaire of Client Expectations (BQCE) and Experiences in Close Relationships (ECR-RD)) were applied to examine whether the effect of attachment on depression (measured by the BDI) is mediated by social anxiety (measured by the LSAS) in a cross-sectional study. RESULTS The data confirms such a mediation. The effect of attachment measured with the BQCE on depression was completely mediated, whereas the effect of both scales of the ECR-RD (attachment related avoidance and anxiety) on depression was only partially mediated by social anxiety disorder. CONCLUSION The study supports the association of attachment, social anxiety, and depressive symptoms and the need to consider different perspectives on attachment.