Internet-based CBT helps service members with post-traumatic stress

A recent study in the American Journal of Psychiatry reviews therapist-assisted, Internet-based, self-management cognitive behavior therapy (CBT) for service members with post-traumatic stress disorder (PTSD). This protocol was compared with Internet-based supportive counseling for PTSD. Both groups used websites, homework assignments, and educational information concerning PTSD. The authors found that the CBT protocol led to “sharper declines in daily log-on ratings of PTSD symptoms and global depression” in addition to other symptom reduction; these improvements were also noted at 6 months. The authors state that this protocol “may be a way of delivering effective treatment to large numbers with unmet needs and barriers to care.”

Study authors: B. T. Litz, C. C. Engel, R. A. Bryant, A. Papa  

 

Complicated grief helped by cognitive restructuring and exposure therapy

The death of a loved one can precipitate the devastating clinical condition known as “complicated grief” (CG). In a study reported in Journal of Consulting and Clinical Psychology, maladaptive thinking and behaviors were described as significant contributors to CG. The effectiveness of cognitive-behavioral therapy (CBT) was compared with nonspecific supportive counseling (SC). In this study, CBT methods included cognitive restructuring and exposure.

People suffering with CG often avoid reminders of the loss, which, the authors suggested, “is a key maintaining factor in CG.” Recovery was aided when patients “gradually confront these reminders and elaborate on the implications of the loss.” For example, patients were asked to recount the story of the loss, and therapists identified aspects that were particularly distressing. Homework assignments were aimed at gradually increasing exposure to the reality of the loss.

The study results showed CBT to be more effective than SC and the authors concluded that helping patients to confront and work through the loss is important in treating CG.

Study authors: P. A. Boelen, J. de Keijser, M. A. van den Hout, J. van den Bout 

 

 

 

Refractory angina (chronic chest pain) positively affected by CBT

People with chronic refractory angina are frequently hospitalized with severe chest pain. A recent study in the Journal of Pain and Symptom Management indicates that outpatient cognitive-behavioral therapy improves angina status and quality of life, and reduces hospital admissions. In this study, after patients participated in a brief CBT protocol, admissions for chest pain were reduced from 2.40 per patient per year to 1.78. Only 8 myocardial infarctions (MI) were recorded in the year after in enrollment the program, whereas 32 were recorded in the year prior. Additionally, overall mortality was lower than in comparable groups treated with surgery.

Patients who are incapacitated by angina suffer “intense anxiety and apprehension” as a result of the pain itself, and of their assumptions about what the pain indicates about their underlying heart conditions. Using a 5-item questionnaire, patients’ misconceptions and counter-therapeutic beliefs and behaviors were identified. One typical finding was that angina patients avoid exercise, for example, because of a mistaken belief that it will damage their hearts. This maladaptive behavior, which results from this misconception, actually increases their risk of MI. The authors challenged these beliefs and offered evidence-based, alternative explanations for their symptoms.

The authors indicate that brief outpatient CBT was effectively used to educate patients and demystify angina, which produced “an immediate and sustained reduction in hospital admission.”

Study authors: R. K. G. Moore, D. G. Groves, J. D. Bridson, A. D. Grayson, H. Wong, A. Leach, R. J. P. Lewin, M. R. Chester 

 

CBT reduces fear and restores function for patients after cardiac defibrillator implantation

A recent article in Current Psychiatry reviews the negative effects on quality of life for people who receive an implantable cardioverter defibrillator (ICD) for irregular heart rhythms. These effects are particularly severe after the first experience of a “shock”—or ICD discharge. Though life-saving, these high-energy electrical discharges (shocks) are typically painful, and many patients experience anxiety, anger, and a sense of helplessness.

After a shock, patients instinctively begin to analyze the events or behaviors leading to the shock—which are often routine and not truly associated with the discharge event—so that they can avoid or even eliminate them from their lives. The fear of another shock and the fear of anything that could precipitate one can result in a “fear of fear” cycle. Patients may then start limiting their lifestyles so dramatically that depression ensues.

The authors suggest that this scenario can be avoided by routine cognitive-behavioral assessments during follow-up visits after the ICD implantation. Ideally, treatment consists of a combination of medication, psychotherapy, and support. With CBT, patients are guided to see how their thoughts about the device might be erroneous. Daily logs of ICD-related thoughts and cognitive re-structuring are useful CBT strategies.

In an example referenced in this article, eight sessions of CBT, which included exposure therapy and relaxation training, allowed a patient to resume most of his activities, and had a beneficial effect on his personal relationships and quality of life.

Study authors: D. P. Gibson, K. K. Kuntz  

 

Antidepressants used in combination with CBT reduces risk of teen suicide

The use of the antidepressant fluoxetine (Prozac) alone has been associated with increased suicidality among teens and children, leading to black-box warnings on antidepressants in those populations. This in turn has caused serious concern in parents and has discouraged prescription, according to some researchers. A recent report on this issue focused on combining Cognitive Behavioral Therapy (CBT) with the fluoxetine and found that “adding CBT to medication enhances the safety of medication. Taking benefits and harms into account, combined treatment appears superior to either monotherapy as a treatment for major depression in adolescents.”

In a related report, the researchers added that cognitive behavior therapy “should be made readily available as part of comprehensive treatment for depressed adolescents” and added that such a shift in the current practice would be of “considerable public health relevance.”

Adolescent Depression & Suicide Prevention: National Review of Cognitive Behavioral Therapy

A national review of treatments for depressed adolescents (ages 13-17), with special focus on preventing teen suicide, finds Cognitive Behavioral Therapy (CBT) to be highly effective. Age-appropriate adaptations of CBT yielded these key results: “CBT achieved a higher remission rate among youth (60%) than either systemic behavior family therapy (37.9%) or nondirective support therapy (39.4%).” Additionally, CBT yielded no adverse effects.

(The reporting agency is a program of the US Department of Health and Human Services Substance Abuse & Mental Health Services Administration.)

CBT cutting down on the sweat in patients with hyperhidrosis

Hyperhidrosis, a condition that causes excessive sweating, is brought on by a combination of the body’s temperature regulating system and emotional factors. The way emotional triggers affect this condition had never been studied in depth.

A recent study at the Mayo Clinic in Minnesota showed that Cognitive Behavioral Therapy (CBT) helps not only with the general anxieties that trigger sweating, but also with social anxiety brought on by hyperhidroses itself and therefore can further reduce the unwanted sweating.

Fibromyalgia – real disease getting real benefit from CBT

People with Fibromyalgia suffer on many levels. They live with a chronic and painful, life-altering, multi-system disease that affects about 2% of the general U.S. population. For many years, they also suffered from widespread skepticism and debate about the disease itself. Was it real? Wasn’t it the same as Chronic Fatigue Syndrome, which the media disparagingly called Yuppie Flu?

Thankfully, the uncertainty officially ended in 1990 when the American College of Rheumatology established criteria for its diagnosis. This was a positive step; however, appropriate treatment would remain unclear.

A good deal of research has emerged since then and a recent review of treatment protocols for Fibromyalgia showed that the best outcomes involved pharmacologic therapies in combination with Cognitive Behavioral Therapy (CBT). Exercise and patient education, part and parcel of a CBT approach, were also important.

Cognitive therapy strategies “help patients understand the effect that thoughts, beliefs, and expectations have on their symptoms.” It was also very important to use the strategies to help patients prioritize time to achieve balance in their daily lives.

When patients get angry in session

Judith S. Beck writes in:

Some therapists are quite concerned about their patients becoming angry at them. Yet when therapists respond sensitively, they can help patients learn important lessons.

The first thing I do when a patient becomes angry is to elicit their automatic thoughts and positively reinforce them, in a genuine way. “I’m so glad you told me that.” And I am glad. If there’s a problem, I want to know about it, so I can fix it.

Next, I conceptualize the problem in order to decide what to do. If I think the patient is correct, I’ll apologize – and in so doing, become a good role model. For example, a patient might be annoyed because he felt I was interrupting him too much. If he had that reaction, he’s right. I overestimated his tolerance for interruptions, so I can – again genuinely – say, “You know, I think you’re right. I did interrupt you too much. I’m sorry.”

If I don’t think I made a mistake, I can still genuinely say, “I’m sorry you’re feeling distressed,” because I truly am sorry if something I’ve said or done (or not said or done) made the patient feel worse. Then I try to figure out how to solve the problem, which might involve helping the patient evaluate his negative ideas about me or suggesting we change what we’re doing in the session.

Demonstrating to patients that interpersonal problems can be solved is sometimes one of the greatest benefits of therapy.

There’s nothing either good or bad, but thinking makes it so…

Does Shakespeare’s famous maxim apply to head injury?

According to a new study, the answer is yes.

Researchers recently looked at patients with mild head injuries (90% of head injuries in Western countries are classified as “mild”) to see whether perceptions of illness contributed to the development and severity of post-concusional syndrome (PCS). 73 patients with mild head injuries participated in the study. They were monitored for PCS symptoms, post-traumatic stress symptoms, perceptions of illness, depression and anxiety. Scales were completed at the time of injury, and at 3-month follow-up.

The results: patients who believed their injuries would have a serious effect on their quality of life were at greater risk for post-concusional symptoms.

What are the implications for treatment? As the article states: “Recognition of the maladaptive cognitions that contribute to poor outcome of the sort suggested by this study will be helpful in the development of effective cognitive-behavioral interventions.”