Effects of Psychotherapy on Trauma-related Cognitions in Posttraumatic Stress Disorder: A Meta-Analysis

New Study (1)Abstract

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria for posttraumatic stress disorder (PTSD) incorporate trauma-related cognitions. This adaptation of the criteria has consequences for the treatment of PTSD. Until now, comprehensive information about the effect of psychotherapy on trauma-related cognitions has been lacking. Therefore, the goal of our meta-analysis was to determine which psychotherapy most effectively reduces trauma-related cognitions.

Our literature search for randomized controlled trials resulted in 16 studies with data from 994 participants. We found significant effect sizes favoring trauma-focused cognitive-behavioral therapy as compared to nonactive or active nontrauma-focused control conditions of Hedges’ g = 1.21, 95% CI [0.69, 1.72], p < .001 and g = 0.36, 95% CI [0.09, 0.63], p = .009, respectively. Treatment conditions with elements of cognitive restructuring and treatment conditions with elements of exposure, but no cognitive restructuring reduced trauma-related cognitions almost to the same degree. Treatments with cognitive restructuring had small advantages over treatments without cognitive restructuring.

We concluded that trauma-focused cognitive-behavioral therapy effectively reduces trauma-related cognitions. Treatments comprising either combinations of cognitive restructuring and imaginal exposure and in vivo exposure, or imaginal exposure and in vivo exposure alone showed the largest effects.

 

Diehle, J., Schmitt, K., Daams, J.G., Boer, F., & Lindauer, R.J. (2014). Effects of psychotherapy on trauma-related cognitions in posttraumatic stress disorder: a meta-analysis. Journal of  Traumatic Stress, 27(3), 257-264. doi: 10.1002/jts.21924.

Disrupting The Downward Spiral of Chronic Pain and Opioid Addiction With Mindfulness-oriented Recovery Enhancement: A Review of Clinical Outcomes and Neurocognitive Targets

New Study (1)Abstract

Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.

 

Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.

Workshop Participant Spotlight – Dr. Ignacio Etchebarne

Dr. Ignacio Etchebarne

Dr. Etchebarne works as a clinical psychologist treating adults with anxiety and performs psychotherapy research. He is currently developing a research program in Argentina about CBT for Personal Growth. He was so excited to (finally) come to Beck Institute after completing supervision and consultation with multiple Beck Institute staff.

He combined this training, Teaching and Supervising CBT, with his presentation next week at the Society for Psychotherapy Research conference at the University of Pennsylvania, which has a theme of “Psychotherapy: improving adaptation from the inner life to the outer world.” His presentation will focus on psychotherapy for personal growth.

This workshop came at the perfect time for him, because he plans to begin providing supervision to new therapists. “I’m eager to start doing everything I learned” “This workshop is a must if you want to learn how to provide evidence based supervision and teaching in CBT.”

“It’s been so good, I learned so much about teaching in general that took me by surprise. It was shocking in a good sense, I was unconsciously confident.”

Cognitive-Behavior Therapy for Menopausal Symptoms (hot flushes and night sweats): Moderators and Mediators of Treatment Effects

New Study (1)Abstract

OBJECTIVE:

Cognitive-behavior therapy (CBT) has been found in recent randomized controlled trials (MENOS1 and MENOS2) to reduce the impact of hot flushes and night sweats (HFNS). In the MENOS2 trial, group CBT was found to be as effective as self-help CBT in reducing the impact of HFNS. This study investigates for whom and how CBT works for women in the MENOS2 trial.

METHODS:

This study performed a secondary analysis of 140 women with problematic HFNS who were recruited to the MENOS2 trial: 48 were randomly assigned to group CBT, 47 were randomly assigned to self-help CBT, and 45 were randomly assigned to usual care. Self-report questionnaires were completed at baseline, 6 weeks postrandomization, and 26 weeks postrandomization. Potential moderators and mediators of treatment effects on the primary outcome-hot flush problem rating-were examined using linear mixed-effects models and path analysis, respectively.

RESULTS:

CBT was effective at reducing HFNS problem rating regardless of age, body mass index, menopause status, or psychological factors at baseline. Fully reading the manual in the self-help CBT arm and completing most homework assignments in the group CBT arm were related to greater improvement in problem rating at 6 weeks. The effect of CBT on HFNS problem rating was mediated by changes in cognitions (beliefs about coping/control of hot flushes, beliefs about night sweats and sleep) but not by changes in mood.

CONCLUSIONS:

These findings suggest that CBT is widely applicable for women having problematic HFNS, regardless of sociodemographic or health-related factors, and that CBT works mainly by changing the cognitive appraisal of HFNS.

 

Norton, S., Chilcot, J., & Hunter., M.S. (2014). Cognitive-behavior therapy for menopausal symptoms (hot flushes and night sweats): moderators and mediators of treatment effects. Menopause, 21(6), 574-578. doi: 10.1097/GME.0000000000000095.

Core Beliefs and Assumptions in Posttraumatic Stress Disorder: A Case Example

Norman Web

Norman Cotterell, Ph.D.  Clinical Coordinator, Beck Institute for Cognitive Behavior Therapy

Posttraumatic Stress Disorder (PTSD) refers to a problematic and prolonged response to traumatic events. Ehlers and Clark (2000) note its puzzling nature, identified by both inattention and hyper-arousal, by memories that won’t go away and others that cannot be found, and by both recklessness and an excessive desire for safety. Rothbaum (2006) describes it as a failure of natural recovery.


Mike, a 49 year old production packer, was involved in an accident and suffered 3rd degree burns on the back of his right hand. He is right handed. He remembers watching the machine coming down on his hand. He remembers in vivid detail the smell of burning flesh. 


Mike’s initial response is matter-of-fact. He tells his wife, “Everything is fine.” He makes it through surgeries and skin grafts without much overt difficulty. But he doesn’t own up to any emotional distress. So he misses out on the emotional support that could have helped him process the trauma. Why does he fail to reveal his feelings? One key belief he holds is, “If I reveal any vulnerability, people will lose faith in me and view me as weak.”

Shortly after the medical procedures are finished, Mike experiences cognitive intrusions: flashbacks and nightmares. While these intrusions are distressing, what is more distressing is the special meaning he puts to them. “[They show] I can’t control my own mind.” Dissociative amnesia is further evidence to Mike of his loss of control.

His perceived loss of control leads to Mike’s experiencing intense and distressing negative emotions. He feels highly anxious, sad, and ashamed. “I should be able to cope. I’m weak.” The experience of negative emotion, too, leads Mike to feel out of control. His core beliefs — “I’m out of control. I’m helpless. I’m weak. I can’t function” — become fully activated. He sees himself as being in grave danger, not from an external threat, but from one that he cannot escape. No matter where he goes, his mind goes with him. Mike adopts a battlefield mentality. He is alert, on-guard, aggressive, unable to sleep. Because he views this extreme mentality as unwarranted(“It’s only a burned hand!“) — he takes these symptoms as proof of his weakness.

Mike also engages in extensive behavioral avoidance. He believes he must avoid all that he loves, or risk tainting it with insanity. He also engages in emotional avoidance through the use of alcohol. But avoidance fuels his belief of weakness. He is in a double bind: “If I avoid, I’m in control, I can function. But If I avoid, it means I’m helpless, defective, out of control. But if I don’t avoid, I’m in danger.”

To summarize, when individuals develop PTSD, they put dysfunctional meanings to their symptoms: intrusions, cognitions, emotions, avoidance, and arousal, among others. Their dysfunctional behaviors and the intensity of their emotions are understandable once we grasp the assumptions they are making. Their assumptions make sense once we comprehend the core beliefs that have become activated. The trauma itself doesn’t directly lead to PTSD; rather it is the meanings they attribute to the trauma, to their cognitive, emotional, physiological, and behavioral symptoms, and to their changed circumstances that are more closely tied to the development of the disorder.

 

Learn to treat clients with PTSD in our CBT for PTSD workshop.

 

Readings:

Ehlers, A. & Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder, Behaviour Research and Therapy 38, 319-345.

Foa, E.B., Hembree, E.A., & Rothbaum, B.O. (2007). Prolonged Exposure Therapy for PTSD. Oxford: Oxford University Press.

Morris, D. (2015). The Evil Hours. New York: Houghton Mifflin Harcourt.

Resick, P. A. (2001). Cognitive therapy for posttraumatic stress disorder. Journal of Cognitive Psychotherapy, 15(4), 321 – 329.

Rothbaum, B.O. (2006). Virtual Vietnam: Virtual Reality Exposure Therapy. (2006). In M. Roy (Ed.), Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. Amsterdam: IOS Press.

US Dept of Veteran’s Affairs: How common is PTSD? PTSD: National Center for PTSD. (n.d.). Retrieved May 26, 2015, from http://www.ptsd.va.gov/PTSD/public/PTSD-overview/basics/how-common-is-ptsd.asp

Resting-state connectivity predictors of response to psychotherapy in major depressive disorder.

New Study (1)Abstract
Despite the heterogeneous symptom presentation and complex etiology of major depressive disorder (MDD), functional neuroimaging studies have shown with remarkable consistency that dysfunction in mesocorticolimbic brain systems are central to the disorder. Relatively less research has focused on the identification of biological markers of response to antidepressant treatment that would serve to improve the personalized delivery of empirically supported antidepressant interventions. In the present study, we investigated whether resting-state functional brain connectivity (rs-fcMRI) predicted response to Behavioral Activation Treatment for Depression, an empirically validated psychotherapy modality designed to increase engagement with rewarding stimuli and reduce avoidance behaviors. Twenty-three unmedicated outpatients with MDD and 20 matched nondepressed controls completed rs-fcMRI scans after which the MDD group received an average of 12 sessions of psychotherapy. The mean change in Beck Depression Inventory-II scores after psychotherapy was 12.04 points, a clinically meaningful response. Resting-state neuroimaging data were analyzed with a seed-based approach to investigate functional connectivity with four canonical resting-state networks: the default mode network, the dorsal attention network, the executive control network, and the salience network. At baseline, the MDD group was characterized by relative hyperconnectivity of multiple regions with precuneus, anterior insula, dorsal anterior cingulate cortex (dACC), and left dorsolateral prefrontal cortex seeds and by relative hypoconnectivity with intraparietal sulcus, anterior insula, and dACC seeds. Additionally, connectivity of the precuneus with the left middle temporal gyrus and connectivity of the dACC with the parahippocampal gyrus predicted the magnitude of pretreatment MDD symptoms. Hierarchical linear modeling revealed that response to psychotherapy in the MDD group was predicted by pretreatment connectivity of the right insula with the right middle temporal gyrus and the left intraparietal sulcus with the orbital frontal cortex. These results add to the nascent body of literature investigating pretreatment rs-fcMRI predictors of antidepressant treatment response and is the first study to examine rs-fcMRI predictors of response to psychotherapy.

 

Crowther, A., Smoski, M.J., Minkel, J., Moore, T., Gibbs, D., Petty, C., Dichter, G.S. (2015). Resting-state connectivity predictors of response to psychotherapy in major depressive disorder. Neuropsychopharmacology, 40, 1659-1673. doi: 10.038/npp205.12

Workshop Participant Spotlight: Douglas Liano, MD

DSC_0068Douglas is a primary care pediatrician from Rochester, New York who works in the Unity Health Systems Center of Rochester Regional. He attended our CBT for Children and Adolescents (Level 2) workshop this week and is working on a way to personally use CBT with his patients.
He discussed that behavioral health must be incorporated in the current health care reform, and “now is the time” for that change. It is “vital for healthcare to embrace behavioral health, but there are challenges.” Health care providers are unprepared for the mental and physical health issues that are affecting our modern society.

He enjoyed the caliber of attendees at this level 2 training, and “listening to Dr. (Aaron) Beck’s role play was “quite enriching.”

Couple-based CBT for Intimate Partners of Those with OCD

CBT studyBackground and Objectives: This study investigated the effect of a couple-based cognitive behavioral therapy (CBT) for the treatment of obsessive-compulsive disorder (OCD) on the intimate partners of patients. Previous research has shown this intervention to be efficacious in reducing OCD symptoms and comorbidities in patients.

Method: In an open-treatment trial, 16 couples completed the 16-session manualized treatment, and were followed up 6- and 12-months post-treatment.

Results: Multilevel modeling analyses were conducted to examine change over time, and results indicated that relative to baseline, partners showed improvements in relationship functioning, communication, and criticalness in the short-term, and maintained their gains in communication skills over the long-term.

Limitations: The non-controlled design and small sample size limit the certainty of the study’s findings. Conclusions: Overall, this investigation offers preliminary evidence that including intimate partners in couple-based CBT for OCD has no negative effects on partners, and in fact, can provide them with residual positive effects.

Belus, J. M., Baucom, D. H., & Abramowitz, J. S. (2014). The effect of a couple-based treatment for OCD on intimate partners. Journal of Behavior Therapy and Experimental Psychiatry, 45, 4, 484-488.