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Modular CBT for Body Dysmorphic Disorder

A recent pilot study published in Behavior Therapy found that modular Cognitive Behavior Therapy (CBT) may help reduce symptom severity and depression in Body Dysmorphic Disorder (BDD). BDD is characterized by an often-delusional preoccupation with an imagined or slight defect in appearance that causes significant distress and impairment in daily functioning. The current study incorporates a broadly applicable CBT treatment manual with a specific focus on the BDD model and BDD symptoms.

Participants included twelve individuals, male and female, who met DSM-IV-TR criteria for BDD. Participants were randomly assigned to two treatment groups: one which received 18 therapy sessions and one which received 22 therapy sessions. Two licensed psychologists delivered manualized treatment via individual 60-minute sessions twice per week for the first four weeks, and once per week thereafter. CBT methods and techniques included psycho-education, cognitive restructuring, mindfulness/perceptual retraining, relapse prevention, as well as modular interventions tailored to each participant’s individual symptoms. Participants were encouraged to evaluate their negative and maladaptive thoughts and avoidance behaviors, identify adaptive and robust responses, and engage in homework assignments. Before and following treatment, participants were assessed with the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the Clinical Global Impression Scale (CGI), the Brown Assessment of Beliefs Scale (BABS), the Beck Depression Inventory-II (BDI-II), and the Client Satisfaction Inventory (CSI).

Results, which include a decrease in BDD symptom severity and delusionality, improvement in depressive symptoms, and high retention and satisfaction rates, suggest that modular manualized CBT treatment for BDD is a practical, well-received, and effective treatment for this disorder. This modular approach maintains the integrity of the core procedures of manualized treatment while incorporating flexible treatment tailored to meet individual patient’s needs.

Sabine Wilhelm, Ph.D., and Gail Stetekee Ph.D., two of the authors, were nominated for and participated in the Beck Institute Scholar Supervision program.

Fama, J.M., Greenberg, J.L., Phillips, K. A., Steketee, G., Wilhelm, S. (2011). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder. Behavior Therapy, 42(4), 624-633.

Exercise and Depression

Dr. Aaron Beck discusses the effect of exercise on depressed patients. Some contributing factors include the importance of exercise and whether an individual has a genetic predisposition to depression. Dr. Beck encourages therapists to collaboratively work on activity scheduling with individual suffering from depression.

Psychotherapy as an epigenetic ‘drug’: psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs

Psychotherapy may be just as effective as psychopharmacology in treating psychiatric disorders. Psychotherapy focuses on psychodynamic and psychoanalytic prinicples while psychopharmacology is based on neurobiology. In the past, more emphasis was placed on psychopharmacology to treat psychiatric disorders. This article suggest that a psychotherapy could change the brain chemistry, eliciting the same results as drug therapy. Circuits in the brain are affected by efficiency of information processing. Many different disorders, that have various symptoms, are marked by inefficiency to process information, this could be too high or too low. By stimulating brain activity, symptoms of the disorder should be alleviated.

Psychotherapy can now be defined by its psychodynamic aspects and its capability of inducing epigenetic changes in the brain. The best approach is to combine psychotherapy and drug therapy. A study found that using cognitive behavior therapy and SSRIs to treat SSRI resistant depression was more effective than just medication treatment. This combination of treatments was also found more effective in treating adults with depression. The article states the best therapies to use in this combined approach are cognitive behavior therapy and interpersonal therapy.

Psychotherapy can activate epigenetic changes in the brain, or change brain circuits. This is the effect that psychopathic medications can also elicit. Given the limitations of both psychotherapy and pharmaceuticals, a combination of the two is best for therapies.

Stahl, S.M. (2011). Psychotherapy as an epigenetic ‘drug’: Psychiatric therapeutics target symptoms linked to malfunctioning brain circuits with psychotherapy as well as with drugs. Journal of Clinical Pharmacy and Therapeutics. doi:10.1111/j.1365-2710.2011.01301.x

CBT/MET Therapy Helps Improve Symptoms in Comorbid MDD/AUD Adolescents

A recent, two-year acute phase trial published in Addictive Behaviors found both manual-based cognitive behavior therapy (CBT) and motivation enhancement therapy (MET) to be beneficial treatments for adolescents suffering from both major depressive disorder (MDD) and alcohol use disorder (AUD). This was the first controlled study to compare CBT/MET with fluoxetine or placebo versus naturalistic care (control group), among adolescents with comorbid MDD/AUD.

Participants included 50 adolescents (ages 15-20) who met DSM-IV criteria for AUD and MDD. Qualified and trained masters level staff delivered nine sessions of manual-based CBT/MET, coupled with either fluoxetine (SSRI) or a placebo pill, to participants in the experimental condition. The Hamilton Rating Scale for Depression (HAM-D-27) and the Beck Depression Inventory (BDI) were used to assess depressive symptoms. The timeline follow-back method (TLFB), a tool used to measure controlled drinking, assessed drinking behavior.

Participants in the experimental condition who received CBT/MET demonstrated superior outcomes to the control group who did not receive any psychological intervention. Furthermore, no differences were noted between participants who received CBT/MET and fluoxetine versus CBT/MET and a placebo. These findings suggest that CBT/MET may be most efficacious for the treatment of comorbid MDD/AUD.

Cornelius, J.R., et al. (2011). Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors, 36(8), 843-848.

The Biological Aspect of Depression

Dr. Aaron Beck discusses the neurological effects of depression and how Cognitive Behavior Therapy works in treating it. He also describes the biological aspect of the negative bias and how CBT can be used to reverse that bias. This video was taken at Beck Institute’s CBT for Children and Adolescents workshop. For more information, or to register for our next workshop visit: www.beckinstitute.org/cbt-workshops/

CBT for Depression

Dr. Aaron Beck explains the history of biological and psychological research on depression. He also discusses studies that looked at the likelihood of depression in people who experienced trauma during childhood. This video was taken at Beck Institute’s CBT for Children and Adolescents workshop, for more information, or to register for our next workshop visit: www.beckinstitute.org/cbt-workshops/

Using Pupil Dilation to Screen Depressed Patients for Remission Likelihood with CBT Treatment

Research indicates that cognitive behavior therapy (CBT) is an effective treatment for up to 60% of patients with Major Depressive Disorder (MDD). However, some patients are more likely to remit than others, depending on the severity of the disorder. It is important and beneficial to patients, clinicians, and third-party payers alike, therefore, that scientists identify those who will most likely benefit from treatment.

One facet of CBT treatment involves interrupting the “downward spiral” of automatic negative thoughts. While neuroimaging has shown that CBT influences this type of brain activity via sustained limbic activity and decreased prefrontal function, functional magnetic resonance imaging (fMRI) can be costly and time-consuming. A recent study by Siegle, et al. published in Biological Psychiatry proposes that pupillary response to negative words may be a cost-effective measure to predict the likelihood of remission for certain depressed patients treated with CBT. Previous research has shown that depressed patients have increased and sustained pupillary response to negative words and that this response reflects cognitive and emotional processes, including prefrontal control.

Patients (n=32) with recurrent MDD were recruited for the current study. Participants completed an emotion-identification task that required they identify certain words as positive, negative, or neutral.  Participants also completed a digit sorting task to assess executive control. Pupillary response was measured during these tests. Participants then received a 16-session CBT intervention. The Beck Depression Inventory (BDI) was used to determine which patients had achieved remission (i.e., a score of less than 10 on the BDI coupled with no diagnosis of MDD). To test whether pupillary response was related to limbic activity, fMRI data was used for the 20 subjects able to complete this part of the experiment.

In the current study, patients who exhibited lower pretreatment depressive severity had better remission rates. These patients also presented with increased and sustained pupillary response. These results suggest that increased pupillary response is related to higher remission rates. That is, patients with a higher level of pupillary response may be more likely to remit with CBT; those with lower scores may be less likely and might choose to pursue other, more intensive treatment options. Increased pupillary response also correlated with increased prefrontal activity, which can be linked to executive control and emotional regulation. Siegel, et al. conclude that measuring pupillary response may be a noninvasive, cost-effective, and quick (requiring less than 10 minutes) tool to help depressed patients and their providers decide on effective treatment.

Lead author, Greg Siegle, Ph.D., was selected and participated in our Beck Institute Scholars Program in 2007-2008.

Siegle, G.J., Steinhauer, S.R., Friedman, E.S., Thompson, W.S., Thase, M.E. (2011). Remission prognosis for cognitive therapy for recurrent depression using the pupil: Utility and neural correlates. Biological Psychiatry; 69: 726-733. doi:10.1016/j.biopsych.2010.12.041

What research is Dr. Beck presently involved in? (Students Ask Dr. Beck – Part SEVEN)

This is the seventh question from the Q&A portion of Beck Institute’s 3-Day CBT Workshop on Depression and Anxiety for students and post-doctoral fellows, held on August 15 – 17, 2011. In this video Dr. Aaron Beck discusses research he is presently involved in and/or leading at the University of Pennsylvania. Dr. Beck explains the work being done by three different teams within his unit; including clinical trials with suicidal patients, groundbreaking research on CBT treatment for schizophrenia, and a community mental health center project involving dissemination of cognitive behavior therapy.

Beck Institute Scholar Meets with Dr. Aaron Beck

Marcus Huibers, Ph.D., a former Beck Institute Scholar, visited us last week. He has conducted important research in the field of Cognitive Therapy and Depression in the Netherlands and followed up his visit with this message:

When I was first invited to become a Beck Institute Scholar in June 2006, I initially thought someone was pulling a prank on me. It was late at night when I received the email from Drs. Aaron T. Beck and Judith Beck, inviting me for the extramural training program in Philadelphia for the upcoming academic year, and it felt like I had just won the lottery. At that time, I was an assistant professor at Maastricht University, fortunate to have been awarded three large research grants in the previous years, but also struggling with the responsibilities that came along with it and the theoretical directions my work was about to take. The year before, I had met Dr. Steven Hollon for what turned out to be the start of a long and fruitful collaboration on depression research in the Netherlands, and he had nominated me for the Scholarship, which in itself was a great honor. The academic year that followed (2006-2007), I visited Philadelphia three times on overseas trips that were a tremendous learning experience, and great fun at the same time. I felt I already was a pretty good cognitive therapist, but coming to Philadelphia made me realize there was so much more I could learn on the art and wonders of state-of-the-art cognitive therapy. Not surprising, of course, since it was the founder of cognitive therapy that stood in front of the classroom to pass on his infinite knowledge.

I learned so much, talking (and even role playing) with Dr. Beck, but also from Judy Beck and Leslie Sokol, my all-time favorite CT supervisor. It also opened up the (international) world of CT research for me, with many new friends and colleagues I made during my many stays in Philly, the undisputed CT capital of the world. Since then, the depression research program we are doing in the Netherlands has expanded, with treatment studies on Internet CT, CT and interpersonal therapy (IPT), CT and behavioral activation, schema-focused therapy for chronic depression, mechanisms of change studies and experimental lab studies on cognitive theory in depression., This month, I am on a ‘mini-sabbatical’ visiting with Dr. Robert DeRubeis at the University of Pennsylvania, another one of my ‘heroes’ in the field of cognitive therapy. It has been so great to interact with Rob, his students and colleagues at the Department of Psychology, and meet Dr. Beck, Judy and many others at the Beck Institute again. Coming back here, I realize what a strong impact the Beck Institute Scholarship has had on my professional career as a researcher and therapist, and I am very grateful for that. My time at the Beck Institute has been most rewarding, and I can recommend the training program to anyone who is interested in CT. Here is where you learn from the best.

Marcus J.H. Huibers, PhD,
Professor of Empirically Directed Psychotherapy
Chair of the Department of Clinical Psychological Science
Maastricht University
The Netherlands

The Use of Mindfulness to Improve Mental Health

A recent article  contains a systematic review of  research on Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT).  Mindfulness is a skill that allows individuals to  have moment to moment, non-judgmental awareness of their emotions, thoughts, and sensations.  MBSR and MBCT are used to promote wellbeing through meditation, body scans, and mindful yoga in combination with whole day retreats, group discussion sessions, and daily homework exercises.

Many studies have been conducted on mindfulness and its effectiveness in reducing depression, stress, and anxiety.  Previous review articles were less systematic and included non-randomized studies and small sample groups.  As such, the conclusions of these reviews were varied and the efficacy of MBSR/MBCT unclear.

In an attempt to clear up this uncertainty, Fjorback et al  performed a systematic review of all articles published on MBSR and MBCT in the last 30 years but examined only randomized trials with control groups and a minimum of 33 participants.  The effects of MBSR and MBCT on stress, anxiety, and depression were investigated.            Results of the review showed that MBSR was beneficial for reducing stress and distress, alleviating depressive symptoms, and improving anxiety in both clinical and non-clinical populations.  MBCT was found to reduce the risk of relapse in depressive patients who had recovered from three or more previous episodes of depression.  The researchers concluded that MBSR is a good complementary method of improving mental health for both clinical and non-clinical populations.

Fjorback, L. O., Arendt, M., Ornbol, E., Fink, P., & Walach, H.  (2011).  Mindfulness-based stress reduction and mindfulness-based cognitive therapy – A systematic review of randomized controlled trials.  ACTA Psychiatrica Scandinavica.