ArticleLiterature Review

Cognitive-Behavioral Therapy for Adult Anxiety Disorders: A Meta-Analysis of Randomized Placebo-Controlled Trials

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Abstract

Cognitive-behavioral therapy (CBT) is frequently used for various adult anxiety disorders, but there has been no systematic review of the efficacy of CBT in randomized placebo-controlled trials. The present study meta-analytically reviewed the efficacy of CBT versus placebo for adult anxiety disorders. We conducted a computerized search for treatment outcome studies of anxiety disorders from the first available date to March 1, 2007. We searched MEDLINE, PsycINFO, PubMed, Scopus, the Institute of Scientific Information, and Dissertation Abstracts International for the following terms: random*, cognitive behavior*therap*, cognitive therap*, behavior*therap*, GAD, generalized anxiety disorder, OCD, obsessive compulsive disorder, social phobia, social anxiety disorder, specific phobia, simple phobia, PTSD, post-traumatic stress disorder, and acute stress disorder. Furthermore, we examined reference lists from identified articles and asked international experts to identify eligible studies. We included studies that randomly assigned adult patients between ages 18 and 65 years meeting DSM-III-R or DSM-IV criteria for an anxiety disorder to either CBT or placebo. Of 1165 studies that were initially identified, 27 met all inclusion criteria. The 2 authors independently identified the eligible studies and selected for each study the continuous measures of anxiety severity. Dichotomous measures reflecting treatment response and continuous measures of depression severity were also collected. Data were extracted separately for completer (25 studies for continuous measures and 21 studies for response rates) and intent-to-treat (ITT) analyses (6 studies for continuous measures and 8 studies for response rates). There were no significant differences in attrition rates between CBT and placebo. Random-effects models of completer samples yielded a pooled effect size (Hedges' g) of 0.73 (95% CI = 0.88 to 1.65) for continuous anxiety severity measures and 0.45 (95% CI = 0.25 to 0.65) for depressive symptom severity measures. The pooled odds ratio for completer treatment response rates was 4.06 (95% CI = 2.78 to 5.92). The strongest effect sizes were observed in obsessive-compulsive disorder and acute stress disorder, and the weakest effect size was found in panic disorder. The advantage of CBT over placebo did not depend on placebo modality, number of sessions, or study year. Our review of randomized placebo-controlled trials indicates that CBT is efficacious for adult anxiety disorders. There is, however, considerable room for improvement. Also, more studies need to include ITT analyses in the future.

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... 16 Exposure-based interventions have been shown to be effective for a range of anxiety disorders amongst those without autism and/or learning disabilities including specific phobias, obsessive-compulsive disorder, panic disorder, agoraphobia, and post-traumatic stress disorder. 5,105 The exclusion of cognitive strategies, which are delivered using verbal communication within 'talking' therapy, and a reliance upon exposure-based techniques have been shown to be associated with no reduction in therapy effect size. 5,6,8 Considering this, psychological interventions which are not entirely delivered using verbal communication are likely to be advantageous when used with autistic adults with moderate to severe learning disabilities because it is not possible for many individuals to engage effectively within 'talking' psychological therapy due to their difficulties with verbal communication and processing. ...
... 5,105 The exclusion of cognitive strategies, which are delivered using verbal communication within 'talking' therapy, and a reliance upon exposure-based techniques have been shown to be associated with no reduction in therapy effect size. 5,6,8 Considering this, psychological interventions which are not entirely delivered using verbal communication are likely to be advantageous when used with autistic adults with moderate to severe learning disabilities because it is not possible for many individuals to engage effectively within 'talking' psychological therapy due to their difficulties with verbal communication and processing. As a consequence, the delivery of appropriately adapted behavioural interventions for anxiety amongst autistic adults with moderate to severe learning disabilities may be advantageous. ...
... The results indicated that it was feasible to deliver this intervention to autistic participants with moderate to severe learning disabilities with support from carers. Adjustments to the intervention following the completion of this study were recommended which included: (1) reinforcing the importance of consistent carer engagement, understanding, and motivation, (2) further guidance on the timing, frequency and number of intervention sessions, (3) further guidance on the creation of bespoke intervention materials to meet participant need, (4) further guidance about teaching relaxation to people with learning disabilities, noting that it is challenging to teach relaxation to some people with moderate to severe learning disabilities, (5) increased guidance about the nature and degree of intervention adaptation to meet need and (6) formalising arrangements for supervision within the context of a future trial. This would most likely be group-based supervision led by members of the trial team and in addition to local supervision. ...
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Background: Interventions for anxiety need to be adapted to meet the needs of autistic people with moderate to severe learning disabilities and successfully modelled before evidence about efficacy can be generated from clinical trials. Objectives: The objectives were to: (1) adapt a behavioural intervention for anxiety, develop an intervention fidelity checklist and logic model, and appraise candidate outcome measures, together with carers, autistic people, and clinicians, (2) characterise treatment-as-usual, (3) model the adapted intervention to determine the acceptability and feasibility for all stakeholders, judge the appropriateness of outcome measures, examine the feasibility and acceptability of consent and associated processes and (4) describe factors that facilitate or challenge intervention delivery. Design: This study had two phases. Phase 1a: using consensus methods, an intervention adaptation group was formed who met to adapt the intervention, appraise candidate outcome measures, and contribute to the development of the intervention fidelity checklists and logic model. Phase 1b: a national online survey was conducted with professionals to characterise treatment-as-usual. Phase 2: this was a single-group non-randomised feasibility study designed to model the intervention to test intervention feasibility and acceptability, outcome measures, and aspects of the research process. Setting: Participants were recruited from National Health Service community adult learning disabilities teams in England. Participants: Participants aged 16 and over with a diagnosis of autism, moderate to severe learning disabilities, an anxiety disorder, and a carer who was available to take part in the intervention. For those who lacked capacity to make a decision about taking part, a consultee had to provide advice that the participant should be included in the study. Interventions: The intervention comprised 12 sessions alongside treatment-as-usual. Main outcome measures: The feasibility and acceptability of the intervention and research processes, outcome measure completion rates, and intervention adherence. Results: The intervention was successfully adapted and modelled with 28 autistic participants with moderate to severe learning disabilities. The intervention was judged to be feasible and acceptable by autistic adults with learning disabilities, carers, and therapists. Carers and therapists suggested minor intervention revisions. Carers completed 100% of outcome measures and the missing data rate was low; however, they indicated that some of the questions were repetitive and said they had difficulty responding to some items. The use of the Mental Capacity Act, 2005, led to an average 5-week delay to participant enrolment. The accrual rate was affected by the COVID-19 pandemic and improved during the summer and early autumn of 2022. Limitations: Randomisation was not modelled within this feasibility study, although carers and therapists indicated that this would be acceptable. Conclusions: The BEAMS-ID intervention and associated study processes were judged to be feasible and acceptable. The intervention required minor revision. Future work: The BEAMS-ID intervention should be tested further within a trial. Study registration: This study is registered as ISRCTN12637590. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129804) and is published in full in Health Technology Assessment; Vol. 28, No. 72. See the NIHR Funding and Awards website for further award information.
... Pharmacotherapy and cognitive behavioral therapy (CBT), or a combination of these, are frequently used to treat anxiety disorders, although up to one-third of patients may not benefit from these conventional methods, which results in treatment dropout, poor results, and impaired functioning [10,11]. Physical activity (PA)-based therapies symbolize a unique strategy that has shown potential in addressing symptoms of a variety of mental health disorders, from psychosis to dementia [12]. ...
... BAI was able to discriminate homogeneous and heterogeneous anxious diagnostic groups from other psychiatric groups. BAI scores are classified as minimal (0-7), mild (8)(9)(10)(11)(12)(13)(14)(15), moderate (16)(17)(18)(19)(20)(21)(22)(23)(24)(25), and severe (26-63) [23]. ...
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Background Generalized anxiety disorder is one of the most prevalent mental disorders, characterized by excessive anxiety and worry that affect both mental and physical health. These pervasive illnesses have a crippling effect on people's everyday lives, quality of life, and wellness and are also highly linked with cardiovascular risk factors. Physical activity-based therapies have shown promising effects in treating a range of mental disorders, from psychosis to dementia. Out of many conventional therapies, aerobic exercise and plyometrics have been found to be effective in reducing anxiety levels. Aim This study aims to compare the effectiveness of aerobic exercise and plyometrics in reducing anxiety levels in college students with mild generalized anxiety disorder. Materials and methods A total of 96 subjects were selected for the study using a stratified sampling technique; 48 subjects were assigned to the aerobic exercise group (Group A) and 48 to the plyometric group (Group P). Randomization was done using the sealed envelope method. This study includes students aged 18-25 years, both genders, with a body mass index of <30, a Beck Anxiety Inventory (BAI) score of 8-15, and at least six months without practicing any kind of physical activity. The exclusion criteria are subjects with other psychotic disorders, a history of cardiovascular disease, chronic kidney disease, inflammatory disease, malignant conditions, neurological disorders, anemia, with comorbid conditions, who were involved in supportive therapy for anxiety such as cognitive behavioral therapy, use of anxiolytic drugs, females with menstrual disorders, and subjects with recent trauma or injuries (fracture, ligament sprain, or muscle strain). The treatment duration for both groups was three days per week for a total of four weeks. Group A consists of five minutes of warm-up, 30 minutes of walking, and five minutes of cool-down, for a total of 40 minutes. Group P consists of warm-up of five minutes, high knees, single leg hop and jump squats of two sets and 10 repetitions for 30 minutes, and a cool-down of five minutes, for a total of 40 minutes. Conclusion The anxiety levels were analyzed using the BAI, revealing that both groups have shown improvements in Beck anxiety scores; however, Group A has shown a comparatively more significant improvement than Group P.
... These endorsed approaches are all grounded in exposing a person to feared stimuli via a variety of means (e.g., narrative exposure, interoceptive exposure) with the intent to reduce fear-based symptoms of PTSD. Such approved approaches include cognitive behavioral therapy (CBT) and prolonged exposure (PE; Hofmann & Smits, 2008), cognitive processing therapy (CPT; Asmundson et al., 2019), and eye movement desensitization and reprocessing (EMDR; Chen et al., 2014). In recent years, the focus of PTSD intervention has shifted beyond exposure to feared stimuli to targeting how a person understands and attributes meaning to past traumatic experiences. ...
... We restricted our search to meta-analyses and systematic reviews that included studies with active comparison conditions because inactive conditions tend to inflate findings and are therefore not as helpful to verify the relative efficacy of an approach. Our search yielded three robust reviews, one for CBT and PE (Hofmann & Smits, 2008), one for CPT (Asmundson et al., 2019), and one for EMDR (Chen et al., 2014). Table 3 depicts effect sizes for SIPs and conventional nonspiritual PTSD treatments. ...
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In this scoping review, we sought to determine the current quality of the evidence base for spirituality-integrated psychotherapies (SIPs) for posttraumatic stress disorder (PTSD) compared with existing evidence-based practices. Using a rigorous identification, screening, selection, and inclusion method, we extracted data from 33 articles to analyze trends within and across four categories of SIPs between 2002 and 2022 (building spiritual strengths and moral injury, spiritually integrated meditation and mind–body–spirit interventions, Islamic healing practices, other SIPs). Meditation and mind–body–spirit interventions such as transcendental meditation have high-quality randomized controlled trials demonstrating equivalent effect sizes and efficacy to existing evidence-based treatments for PTSD. Transcendental meditation specifically appears to have sufficient empirical support to be considered “evidence based.” Interventions in the other categories currently lack sufficient research support to be designated as such. We contend that more high-quality randomized controlled trial designs with bona fide comparison conditions and between-group comparative baseline symptom evaluation are needed to support the efficacy of these approaches.
... Therefore, phobias need to be addressed through appropriate treatment. Phobias can be eased or even eliminated by various methods, including drug therapy and psychological therapy [23]. One of the effective therapies used to overcome phobias is cognitive behaviour therapy (CBT), which consists of exposure therapy and cognitive restructuring needed for people who have Mansell, CBT is a therapy that shows more effective results for anxiety disorders and phobias [24], [25]. ...
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People with spider phobia experience excessive anxiety reactions when exposed to spiders that will interfere with daily life. Diagnosing and measuring anxiety levels in patients with spider phobia is a complex challenge. Conventional diagnosis requires psychological evaluations and clinical interviews that take time and often result in a high degree of subjectivity. Therefore, there is a need for a more objective and efficient approach to measuring anxiety levels in patients. This study performs anxiety level classification based on electrodermal activity, electrocardiogram (ECG) and respiratory signals using the dataset of Arachnophobia subjects. Each raw data is preprocessed using 24 types of features. Feature performance is processed using the recursive feature elimination method. Data processing was performed in 3 anxiety levels (high, medium, low) and two anxiety levels (high, low) with the support vector machine method and hold-out validation method (7:3). The performance of the model is evaluated by showing the accuracy, precision, recall and F1 score values. The polynomial kernel can perform optimal classification and obtain 100% accuracy in 2 classes and three classes with 100% precision, recall, and F1 score values. This result shows excellent potential in measuring anxiety levels that correlate with mental health issues.
... Exposure therapy is the most effective form of treatment for anxiety, fear, stress-related, and obsessive-compulsive disorders (Choy, Fyer, & Lipsitz, 2007;Ferrando & Selai, 2021;Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010;Wolitzky-Taylor, Horowitz, Powers, & Telch, 2008). However, non-response, premature dropout, and relapse are common, and treatment is costly (Davidson et al., 2004;Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000;Hofmann & Smits, 2008). Thus, there is a need for developing treatment augmentations and alternatives to enhance the efficacy, efficiency, and tolerability of exposure therapy. ...
... Notably, research from a cohort study has demonstrated that anxiety disorders increase mortality risk by 25% [38] and that severe anxiety can lead to suicide [8,10,25]. However, traditional medication approaches have been shown to be ineffective for approximately onethird of individuals with anxiety [12,16], with barriers to accessing healthcare resources and limited income levels posing significant challenges and hindering the widespread adoption of conventional treatment options [13]. Alarmingly, less than half of individuals with anxiety have received formal treatment for their condition [28]. ...
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Background The effectiveness and generalisability of conventional anxiety treatment programmes is low across the population, and it is important to explore the research evidence for preventing and improving anxiety from a physical activity perspective. This study examined sedentary activity’s impact on anxiety, its dose–response relationship, and the interactive effects of 10-min walks and sedentary duration on anxiety. Methods A total of 28,977 individuals were chosen from the Chinese Psychological and Behavioural Study of the Population (PBICR) 2022. Binary logistic regression analyzed the association between sedentary time and anxiety and the interaction effect of daily 10-min walks and sedentary time on anxiety. Restricted cubic spline model explored the dose–response relationship between sedentary time and anxiety risk. Results Participants who were sedentary for > 6 h had a 25.1% increased risk of anxiety (OR = 1.251). Among those sedentary for > 6 h, each additional hour of sedentary time increased the risk of anxiety by 4.3%. However, for participants sedentary for ≤ 6 h, sedentary time did not increase the risk of anxiety. A non-linear J-shaped relationship between sedentary time and the risk of anxiety (non-linear trend p < 0.001). Among individuals who were sedentary for > 6 h, those who walked more than 10 min on ≤ 5 days per week had a 67.1% increased risk of anxiety (OR = 1.671), whereas those who walked more than 10 min on > 5 days per week experienced a 19% decreased risk of anxiety (OR = 0.810). For individuals sedentary for ≤ 6 h, each additional day of walking for > 10 min reduced the risk of anxiety by 9.8%. Among those sedentary for > 6 h, each additional day of walking for > 10 min reduced the risk of anxiety by 10.3%. Conclusions A non-linear J-shaped relationship between sedentary time and anxiety risk. Walking for more than 10 min was associated with fewer negative effects of sedentary activity on anxiety. It is recommended that future empirical studies with a higher level of evidence be conducted to further confirm the effect of 10-min walking days on anxiety risk through empirical studies and to use specialized wearable devices to improve the accuracy of the measurements. By further exploring the effects of sedentary time and 10-min walking days on anxiety risk, the most effective treatment programs based on physical activity interventions can be established to reduce the prevalence of anxiety in the whole population.
... 2. Cognitive Restructuring: It helps individuals recognize and challenge negative or distorted thoughts, replacing them with more adaptive and realistic beliefs (Beck, 2011). 3. Behavior Modification: CBT also emphasizes changing harmful behaviors by encouraging clients to adopt positive activities and coping strategies (Hofmann & Smits, 2008). 4. Skill-Building: It provides clients with practical tools to manage emotions, cope with stress, and improve well-being (Beck, 2011). ...
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Background/Aim: Psychological distress, encompassing conditions like anxiety and depression, significantly affects the well-being of adults globally, particularly in regions such as Khyber Pakhtunkhwa, Pakistan. This study aims to compare the effectiveness of Cognitive Behavioral Therapy (CBT) and pharmacotherapy in alleviating psychological distress among young adults in this area. Methods: A randomized controlled trial was conducted over 120 days with 200 participants aged 18-35 years. Standardized psychological assessments, including the Beck Depression Inventory (BDI) and the Hamilton Anxiety Rating Scale (HAM-A), were used, along with measures of physical activity and sleep quality. Participants were randomly assigned to either CBT or pharmacotherapy. Results: Both CBT and pharmacotherapy significantly reduced depression and anxiety symptoms. However, CBT showed a 37% greater reduction in depression and a 29% greater reduction in anxiety compared to pharmacotherapy. CBT also led to a 22% improvement in physical activity and a 30% enhancement in sleep quality, whereas the pharmacotherapy group showed 16% and 15% improvements, respectively. Dopamine levels increased by 14.37 units in the CBT group versus 10.88 units in the pharmacotherapy group, highlighting a stronger neurobiological effect from CBT. Gender-specific analysis revealed that females experienced a 42% reduction in depression symptoms with CBT, while males showed similar improvements with both treatments. Conclusions: These results emphasize CBT as a more effective, holistic, and sustainable approach to managing psychological distress. The study stresses the importance of personalized, culturally sensitive mental health interventions to address the growing mental health challenges among young adults in Pakistan.
... The comprehensive nature of Ms. R.'s symptoms and their impact on daily functioning underscores the importance of considering both psychological and physiological aspects in assessment and treatment planning. This holistic approach is supported by current neurobiological research (Graeff & Del-Ben, 2008) and contemporary cognitive-behavioral conceptualizations of panic disorder (Hofmann & Smits, 2008). ...
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Abstract: This study explores the potential of Ruqyah, an Islamic spiritual healing practice, as a complementary therapeutic approach for managing panic disorder. The study used an A-B-A’ single case design with one participant (aged 24 years) experiencing test-related fear (test anxiety). Panic and Agoraphobia Scale and Chambless Worry Questionnaire were used to assess before and after the 7-week Ruqyah intervention (5 sessions). The intervention combined Ruqyah recitation with imaginal exposure techniques. Post-intervention results revealed: • Reduction in panic symptoms from 66.66% to 16.66% • Reduction in avoidant behavior from 75% to 37.5% • Improvement in anticipatory anxiety from 62.5% to 12.5% • Work/family related problems reduced from 62.5% to 25% • Health anxiety reduced from 50% to 12.5% • Overall anxious mood reduced from 60% to 24.28% This study provides preliminary evidence on the potential of Ruqyah as a complementary treatment for panic disorder, especially for patients who value spiritual modalities.
... Numerous trials have shown that SAD can be treated effectively with pharmacotherapy and psychotherapy [6]. Among psychological treatments, cognitive-behavioral therapy (CBT) has received consistent research support in meta-analyses [6][7][8][9][10] and is considered one of the firstline treatments [11]. However, despite evidence-based treatments for SAD, many affected people do not seek help. ...
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Introduction: Many studies have demonstrated that social anxiety disorder (SAD) can be effectively treated with psychotherapy, particularly cognitive-behavioral therapy (CBT), including internet-based CBT (ICBT). Despite evidence-based treatments, many individuals do not sufficiently benefit from them. Identifying the active components could help improve the effectiveness of SAD treatment. This study tested the effects of four treatment components (psychoeducation, cognitive restructuring, attention training, and exposure) within ICBT for SAD to investigate its active components. Methods: This randomized full factorial trial consisted of four factors (i.e., treatment components) and 16 conditions. A total of 464 adults with a diagnosed SAD were recruited from the community. The primary outcome was SAD symptoms at 8 weeks (post-assessment). Secondary outcomes included SAD diagnosis, SAD symptoms at follow-up (4 months after post), depression and anxiety symptoms, quality of life, client satisfaction, and adverse effects. Results: Conditions including psychoeducation and exposure were significantly more effective in reducing SAD symptoms at post compared to conditions without these components. Conditions including cognitive restructuring and attention training did not show superiority over conditions without them at post. However, all treatment conditions significantly reduced symptoms compared to the condition without a treatment component. At follow-up, the superiority of psychoeducation and exposure was not significant anymore due to the version without the respective components catching up. Conclusion: The findings suggest that while all treatment components of ICBT for SAD are beneficial compared to no treatment, psychoeducation and exposure include specific active components that significantly improve treatment outcomes more quickly in ICBT for SAD.
... Therefore, considerable effort has been devoted to the development of therapeutic approaches for SAD. Currently, the combination of cognitive behavioral therapy (CBT) and antidepressant medication with carefully planned procedures is considered the gold standard treatment for SAD (3,4). However, with advances in science and technology, virtual reality (VR) has accelerated a paradigm shift in psychiatric treatment (5). ...
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Introduction Machine learning (ML) is an effective tool for predicting mental states and is a key technology in digital psychiatry. This study aimed to develop ML algorithms to predict the upper tertile group of various anxiety symptoms based on multimodal data from virtual reality (VR) therapy sessions for social anxiety disorder (SAD) patients and to evaluate their predictive performance across each data type. Methods This study included 32 SAD-diagnosed individuals, and finalized a dataset of 132 samples from 25 participants. It utilized multimodal (physiological and acoustic) data from VR sessions to simulate social anxiety scenarios. This study employed extended Geneva minimalistic acoustic parameter set for acoustic feature extraction and extracted statistical attributes from time series-based physiological responses. We developed ML models that predict the upper tertile group for various anxiety symptoms in SAD using Random Forest, extreme gradient boosting (XGBoost), light gradient boosting machine (LightGBM), and categorical boosting (CatBoost) models. The best parameters were explored through grid search or random search, and the models were validated using stratified cross-validation and leave-one-out cross-validation. Results The CatBoost, using multimodal features, exhibited high performance, particularly for the Social Phobia Scale with an area under the receiver operating characteristics curve (AUROC) of 0.852. It also showed strong performance in predicting cognitive symptoms, with the highest AUROC of 0.866 for the Post-Event Rumination Scale. For generalized anxiety, the LightGBM’s prediction for the State-Trait Anxiety Inventory-trait led to an AUROC of 0.819. In the same analysis, models using only physiological features had AUROCs of 0.626, 0.744, and 0.671, whereas models using only acoustic features had AUROCs of 0.788, 0.823, and 0.754. Conclusions This study showed that a ML algorithm using integrated multimodal data can predict upper tertile anxiety symptoms in patients with SAD with higher performance than acoustic or physiological data obtained during a VR session. The results of this study can be used as evidence for personalized VR sessions and to demonstrate the strength of the clinical use of multimodal data.
... Despite the promise of DSM-III (APA, 1987) and subsequent editions to promote effective tailored interventions for specific diagnoses, this has not borne out in treatment research, particularly among negative emotional disorders such as anxiety or depressive disorders. Both Norton and Price (2007) and Hofmann and Smits (2008), for example, reported meta-analyses showing few if any differences in outcomes across different anxiety disorder diagnoses when treated using cognitive therapy, behavioural therapy, or CBT. As a result, many independent research teams have developed and empirically evaluated the efficacy, and more recently, real-world effectiveness, of transdiagnostic CBT approaches to the treatment of negative emotional disorders. ...
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Les modèles émergents de psychopathologie commencent à s’écarter des cadres diagnostiques multicatégoriels établis dans le Manuel diagnostique et statistique des troubles mentaux et la CIM. Des approches transdiagnostiques, c’est-à-dire des modèles et des interventions qui ciblent des facteurs et des mécanismes étiologiques communs à plusieurs diagnostics, ont été mises au point et évaluées de manière approfondie. Elles sont très prometteuses pour réduire le fardeau des maladies mentales et en faciliter la diffusion et l’accessibilité. Cet article donne un aperçu des principaux modèles comportementaux cognitifs transdiagnostiques et des interventions pour le traitement des troubles émotionnels négatifs, généralement définis comme des troubles anxieux et dépressifs, en soulignant leurs points communs et leurs différences et en fournissant un résumé complet des bases de données probantes. La thérapie cognitivo-comportementale transdiagnostique pour les troubles émotionnels négatifs a démontré des preuves d’efficacité et d’efficience et des preuves émergentes de rentabilité, bien que des différences entre les protocoles soient apparentes. Des orientations futures pour la recherche et la pratique clinique sont proposées.
... Excessive anxiety can trigger or increase the potential for the emergence of various more complicated health problems, such as the emergence of generalized anxiety disorder (GAD) and post-traumatic stress disorder (PTSD) which can be triggered by changes in connectivity between brain regions that influence stress and anxious behavior [9]. Anxiety disorders are also associated with poor quality of life [10], suicidal ideation [11], and creating a large financial and social burden [12]. Therefore, efforts to find effective treatments for the various harmful effects of anxiety are very important. ...
... Over the years, intervention approaches, such as psychotherapy and pharmacotherapy, have been developed for the treatment of anxiety disorders (Bandelow et al., 2017;Hans & Hiller, 2013). Numerous studies have explored the factors contributing to the development of anxiety disorders and demonstrated the efficacy of cognitivebehavioral therapy (CBT) as a viable treatment option (Hofmann et al., 2012;Hofmann and Smits, 2008). The primary objective of CBT is to enhance an individual's functionality by challenging and reducing distorted thoughts. ...
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Anxiety symptoms often relate to perceived negative parenting styles inherited from one's parents, impacting cognitive processes in interpersonal relationships. This study investigates the association between anxiety symptoms, parenting styles, and interpersonal cognitive distortions in individuals with anxiety disorders compared to healthy controls. The study involved 164 adult participants—82 with diagnosed anxiety disorders and 82 without psychiatric diagnoses, comprising 42 (26%) males and 122 (74%) females, aged 18-60 years (mean age = 30.5±8.84). Participants completed a demographic questionnaire, the Young Parenting Inventory, the Interpersonal Cognitive Distortions Scale, and the Beck Anxiety Inventory. The anxiety disorder group exhibited heightened levels of anxiety symptoms, interpersonal cognitive distortions, and specific maternal parenting styles (overprotective/unbounded, conditional/achievement-oriented, and pessimistic/anxious), as well as a paternal resistant/suppressive parenting style, in contrast to the control group. Interpersonal cognitive distortions were identified as mediators in the relationships between overprotective/unbounded maternal parenting and anxiety, as well as closed to change/repressing paternal parenting and anxiety. However, the diagnosis of anxiety disorder did not moderate the relationship between parenting styles and cognitive distortions. These findings emphasize the importance of targeting interpersonal cognition in treating and preventing anxiety disorders, especially in individuals with overprotective/unbounded mothers and resistant/suppressive fathers.
... maintenance of anxiety-and stress-related disorders (Craske et al., 2022;Duits et al., 2015). Exposure-based therapies are an evidence-based and highly effective form of cognitive-behavioral therapy (CBT) for anxiety, post-traumatic stress disorder (PTSD) and OCD, which specifically target the underlying learning processes (Hofmann and Smits, 2008). However, a significant proportion of individuals do not respond to these treatments, and symptom recurrence is a common phenomenon (Craske and Mystkowski, 2006;Pittig et al., 2021aPittig et al., , 2021bSpringer et al., 2018). ...
... Studies using neuroimaging techniques have shown that CBT can lead to structural and functional changes in brain regions implicated in depression and anxiety, such as the amygdala and prefrontal cortex (Goldin et al., 2013;Hölzel et al., 2011). Despite its efficacy, CBT faces challenges such as treatment dropout rates and the need for further dissemination in underserved populations (Hofmann & Smits, 2008). Ongoing research aims to address these issues, refine treatment protocols, and explore the integration of CBT with other therapeutic modalities, such as pharmacotherapy and neuromodulation techniques. ...
Article
The article explored the experiences of psychologists in delivering CognitiveBehavioral Therapy (CBT) for the treatment of depression and anxiety in Jordan. To gain valuable insights into the challenges, strategies, and perspectives of practitioners in the field, the study employs a well-structured questionnaire to provide a comprehensive view of the CBT delivery process. The study involved a purposive sample of 30 licensed psychologists who have been practicing CBT for a minimum of three years and have experience in treating patients with depression and anxiety in Karak, Jordan. With the help of descriptive and inferential statistics, the study intended to contribute to a better understanding of the nuanced interactions between psychologists and patients within the context of depression and anxiety treatment, ultimately informing the improvement of CBT practice and patient outcomes. The study found a statistically significant variation in psychologists' satisfaction with the way CBT for depression and anxiety is delivered, with a number of areas that need to be improved. Self-care practices, supervision, and a supportive professional network play pivotal roles in sustaining psychologists' emotional and mental health, safeguarding against burnout, and promoting a rewarding career in mental health care. يستكشف المقال تجارب علماء النفس في تقديم العلاج السلوكي المعرفي لعلاج الاكتئاب والقلق في الاردن ، من اجل الحصول على رؤى ذات قيمة حول التحديات والاستراتيجيات ووجهات نظر الممارسين في هذ المجال، تستخدم الدراسة مقابلات عميقة لتقديم رؤية شاملة لعملية تقديم العلاج السلوك المعرفي، شملت الدراسة عينة من 30 طبيب نفسي مرخص يمارسون العلاج السلوكي المعرفي لمدة لا تقل عن ثلاث سنوات ولديهم حبرة في علاج المرضى الذين يعانون من الاكتئاب والقلق ، تهدف الدراسة الى المساهمة في فهم افضل التفاعلات الدقيقة بين علماء النفس والمرضى في علاج الاكتئاب والقلق، مما يؤدي في النهاية الى تحسين ممارسة العلاج السلوكي المعرفي ونتائج المرضى.
... While being feasible and ethical, this approach may be an effective supplement to exposure therapy and may assist in the reduction of return of fear. Exposure therapy is widely employed in treating various disorders, such as specific phobias, social anxiety disorder, agoraphobia, posttraumatic stress disorder and obsessive-compulsive disorder (Hofmann and Smits, 2008;Norton and Price, 2007;Mendes et al., 2008;Olatunji et al., 2013). Hence, imaginal ORE holds promise for enhancing treatment response rates across various anxiety and stress-related disorders and it is worth considering testing this approach in the treatment of these disorders in the future. ...
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Although exposure-based therapy is widely recognized as effective for treating various anxiety disorders, a significant proportion of patients fail to benefit or experience a return of fear following successful treatment. One promising strategy involves occasional presentation of fear-evoking stimuli during extinction (occasional reinforced extinction, ORE). This study investigates a novel approach to translate ORE into clinical practice by incorporating occasional vivid imagery of individuals' worst-case fear scenarios during in-vivo exposure. Forty-seven spider-fearful individuals were randomly assigned to receive either a one-session in-vivo standard exposure treatment (Exp-Only) or an one-session in-vivo exposure treatment supplemented with occasional mental imagery of their worst-case spider scenario (Exp+ORE). Fear of spider questionnaires and a generalization behavioral approach test were administered prior to and one week after treatment. Both groups showed improvement from baseline to post-assessment, but the Exp+ORE group demonstrated significantly greater reductions in self-reported fear and avoidance of spiders compared to standard exposure training. During the generalization behavioral approach test, subjective distress and approach behavior toward the spider significantly improved from baseline to post-assessment in all participants, with no discernible group differences. Findings moreover indicate that occasional imagery during exposure lead to greater expectancy violation compared to standard exposure, providing insights into potential underlying mechanisms of the ORE approach. Incorporating mental imagery into the occasional reinforced extinction approach could hold promise for enhancing the efficacy of exposure-based treatments for anxiety disorders in clinical settings.
... Anxiety disorders are amongst the most prevalent mental disorders, leading to both high individual and societal costs [1][2][3]. Exposure therapy, i.e., the therapeutic confrontation with fear eliciting stimuli and situations, is an efficient treatment [4,5]. However, there is still an insufficient understanding of its underlying mechanisms [6]. ...
... CBT encompasses multiple therapeutic components, including cognitive restructuring, exposure therapy, and relaxation techniques. The therapy helps patients identify and challenge maladaptive thought patterns while developing more effective coping strategies [39]. Recent adaptations of CBT, including mindfulness-based cognitive therapy (MBCT), have shown promising results in reducing anxiety symptoms and preventing relapse [40]. ...
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Anxiety disorders represent a significant global mental health challenge, affecting approximately 4% of the world's population with a notably higher prevalence among women. These disorders encompass various conditions, including Generalized Anxiety Disorder (GAD), Social Anxiety Disorder (SAD), Panic Disorder, Specific Phobias, and Post-Traumatic Stress Disorder (PTSD). Each condition presents unique manifestations while sharing common features of excessive fear and worry that significantly impair daily functioning. The pathophysiology involves complex interactions between neurobiological systems, particularly the GABA, serotonin, and norepinephrine pathways, along with structural and functional changes in key brain regions such as the amygdala and prefrontal cortex. Recent advances in understanding genetic and epigenetic factors have revealed the role of genes like SLC6A4 and BDNF in anxiety susceptibility. Current treatment approaches combine psychological interventions, primarily Cognitive Behavioral Therapy (CBT), with pharmacological treatments such as Selective Serotonin Reuptake Inhibitors (SSRIs). Emerging therapeutic options, including ketamine therapy and Transcranial Magnetic Stimulation (TMS), show promise for treatment-resistant cases. Despite available treatments, barriers such as social stigma and limited access to mental health services prevent many individuals from seeking help. The aim of this review is to provide current knowledge about anxiety disorders
... Its efficacy has been supported by extensive research, making it the gold standard treatment for numerous psychological disorders. Importantly, CBT empowers individuals with the skills to manage their symptoms and prevent relapse, focusing on making long-term changes rather than merely providing temporary relief [11]. ...
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Social Anxiety Disorder (SAD) is a common yet underestimated mental health disorder. While non-native English speaker (NNES) students face public speaking, they are more likely to suffer some public speaking anxiety (PSA) due to linguistic and sociocultural differences \cite{cite1}. Virtual Reality (VR) technology has already benefitted social-emotional training. The core objective is to summarise the benefits and limitations of using VR technology to help NNES students practice and improve their public speaking skills. This is not a comprehensive survey of the literature. Instead, the selected papers are intended to reflect the current knowledge across various broad topics. Virtual Reality, Social Anxiety Disorder, Public Speaking Anxiety, English as a Second Language, and Non native English speakers are the keywords used for searching mainly in the Academic Search Complete (ASC) database. Compared with native English speaker (NES) students, NNES students have the potential to achieve better results when using VR technology for PSA social-emotional training.
... Although non-pharmacological approaches, such as Cognitive Behavioral Therapy (CBT), has shown success in treating patients with anxiety disorders [50][51][52][53][54], there remains a significant unmet need for alternative treatment options for those patients experiencing stress/anxiety-related symptoms and issues that do not respond to CBT. Gaining a better understanding of how the brain interacts with external stimuli, such as through VTT, may lead to viable, safe and effective, non-invasive, drug-free treatment options, with limited or no side effects. ...
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Anxiety chronically affects 49.9% of all US adults aged 18-24, 32.3% of all US adults, and an estimated 4% of the global population currently experience an anxiety disorder. Nonpharmacologic, behavioral therapies are useful yet underutilized. Treatment with antidepressants and anxiolytics are the most common pharmacotherapy for anxiety disorders, with variable effectiveness, significant side-effect burden [including being implicated with suicide] and high misuse liability. Identifying alternative treatments, including non-invasive and non-pharmacologic options that are safe, efficacious, and have reduced or limited side effect profiles would be preferred over conventional therapies targeting anxiety-related symptoms. Ongoing research suggests that brain patterns can be altered in response to various haptic stimuli. A novel patch that delivers haptic vibrotactile trigger technology (VTT) was designed and theorized to target various neural pathways to influence brain centers. The technology is over-the-counter, non-invasive, non-pharmacological and applied topically. The purpose of this IRB-approved, blinded, minimal-risk observational study was to evaluate and compare patients’ experiences, perceptions and response for those who received a haptic vibrotactile trigger technology (VTT) embedded stress and anxiety-relieving patch (PEACE Patch with VTT; Super Patch Company, Srysty Holding Co, Toronto, Canada) with those who received a control patch without the embedded technology. Methods: A total of 65 patients (49 females, 16 males) at 3 US investigator sites who presented with stress and/or anxiety- related issues or associated symptoms were enrolled in the treatment (n=65) arm of the study and completed baseline, day 7, and day 14 surveys. Demographic results were similar for gender and age at the baseline survey. The mean age at baseline was 46.8 years. The study evaluated changes in stress and anxiety symptoms, mental health perceptions and other relevant domains via validated stress and anxiety measurement and symptom scales (e.g., The Perceived Stress Scale (PSS) and the Medical Outcomes Study Short Form20 (SF-20)) as well as additional survey questions regarding patient satisfaction, patient quality of life, change in medication usage, change in other treatment modalities attempted, and any side effects reported during the study period. Results: After using the VTT embedded stress and anxiety-relieving patch, results showed statistically significant decreases in stress and anxiety related symptoms, improved mental health scores, and improved perceptions about overall health. At day 14, over 90% of patients in the treatment group indicated that they were satisfied with the patch and approximately 90% of subjects indicated that they would recommend it to others for the treatment of anxiety related symptoms. Conclusions: Study results indicate that this non- harmacologic, non-invasive, haptic vibrotactile trigger technology (VTT) embedded topical patch reduces stress and anxiety levels, improves mental health perceptions, and may encourage initiation and incorporation of exercise and other concomitant behavioral activities. These results suggest that further investigation is warranted, and may support the use of this OTC patch as a first-line, noninvasive and nonpharmacological therapy and also as a component of the multimodal treatment approach to anxiety and related symptoms.
... Thus, transferring negative cognition into positive cognition could help reduce the stress and negative emotions level. Cognitive behavioral therapy could change the negative thoughts that lead to poor mood states and was considered as an important treatment for mental health disorders 34,35 . Therefore, the hospitals need to offer not only physical treatment but also psychological intervention for good psychological state could produce positive effects on patients' quality of life and treatment effect. ...
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Infertility is not a fatal disease but it really produces infertility-related stress and affects individuals’ quality of life to a great extent. This study aims to investigate the relations among infertility-related stress, negative emotions and quality of life in infertile outpatients, and suppose gender difference as well as Dark Triad, which contained three dark personality traits: Machiavellianism, narcissism, and psychopathy, would moderate the relations. 105 infertile outpatients age range 20–49 completed a cross-sectional questionnaire on the Fertility Quality of Life scale, the Fertility Problem Inventory, the Hospital Anxiety and Depression Scale a the Chinese version of Dirty Dozen. Results showed that negative emotions mediated the relations between infertility-related stress and quality of life. Dark Triad could not moderate the relations between infertility-related stress, negative emotions, and quality of life, but gender can moderate the associations between infertility-related stress and negative emotions. Specifically, the association between infertility-related stress and negative emotions was stronger in men than in women. Infertility-related stress has direct and indirect effects on infertile outpatients’ quality of life. It is important to consider the important roles of emotions and gender difference between patients, and delivering targeted intervention programs.
... Most of the antipsychotic medications, while essential for controlling psychotic symptoms, fail to adequately address anxiety. In contrast, selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT) have demonstrated efficacy in treating anxiety within this population (Hofmann, Smits, 2008). ...
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Schizophrenia is a chronic mental disorder characterized by severe cognitive and behavioral impairments. It often coexists with multiple and complex anxiety symptoms that exacerbate the clinical challenges associated with schizophrenia. This case report presents the history of a 32-year-old woman with a final diagnosis of both paranoid schizophrenia and mixed anxiety disorders. The patient presented with persistent auditory pseudohallucinations, severe anxiety together with occasional panic attacks, which were treated with a variety of antipsychotics. Treatment adjustments were necessitated by the emergence of side effects, including neutropenia, motor disturbances and the observation of major anxiety symptoms, including panic disorder. Ultimately, the successful use of quetiapine in monotherapy was achieved. This case study emphasizes the need for comprehensive treatment strategies to address the complex interplay of psychotic and anxiety symptoms. Increased clinical awareness and targeted treatment of comorbid anxiety can significantly improve the quality of life of patients with schizophrenia.
... Alterations in fear and safety learning processes have been identified as crucial in the onset and maintenance of anxiety disorders (Craske et al., 2022;Duits et al., 2015). Exposure-based therapies are an evidence-based and highly effective form of cognitive-behavioral therapy (CBT) 1 for anxiety and obsessive-compulsive disorder (OCD), which specifically target the underlying learning processes (Hofmann & Smits, 2008). However, a significant proportion of individuals do not respond to these treatments, and symptom recurrence is a common phenomenon (Craske & Mystkowski, 2006;Pittig et al., 2021;Springer et al., 2018). ...
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Fear learning processes are believed to play a crucial role in the development and maintenance of anxiety and stress-related disorders. To integrate results across different studies, we conducted a systematic meta-analysis following PRISMA guidelines to examine differences in fear conditioning during fear acquisition, extinction, and extinction recall between individuals with anxiety-related or stress-related disorders and healthy participants. This analysis updates the work of Duits et al. (2015) while also refining distinctions between physiological and behavioral outcomes and examining extinction recall. Our meta-analysis encompasses 77 studies published from 1986 to 2022, involving 2052 patients with anxiety disorders, OCD, or PTSD, and 3258 healthy controls. The results indicate significant differences in fear acquisition, extinction, and recall between the two groups. Specifically, during acquisition patients exhibited heightened physiological and behavioral responses to the CS- and reported increased affect ratings for the CS+. During extinction and extinction recall, patients continue to show heightened threat expectancy and negative affect ratings towards the CS- and increased affect ratings towards the CS+. No differences were found in CS+/CS- differentiation between groups. These findings imply that individuals with anxiety and stress-related disorders may exhibit amplified responses to safety cues and stronger reactions to threat cues during fear conditioning, lasting through extinction and extinction recall. These changes may lead to increased sensitivity in detecting fear and slower extinction process, resulting in more enduring anxiety responses. We discuss these results in the context of existing literature on fear and safety learning and consider potential underlying mechanisms.
Chapter
Oral communication is crucial in the academic journey of health professionals, especially during public academic assessments, and can have a determinant impact on their professional careers. This chapter highlights the growing importance of oral communication skills in higher education, focusing on their critical role in both academic and professional success amid contemporary challenges like the rise of Artificial Intelligence (AI). The widespread anxiety around public speaking, which hinders many students from completing their degrees, emphasizes the need for effective interventions. The chapter presents the PedPac program, an innovative initiative in the healthcare field, aimed at helping students develop oral communication skills, reduce anxiety, and improve performance in public academic evaluations, including dissertation defenses. This work underscores the need for higher education institutions to prioritize oral communication as a vital skill for student well-being as well as their academic and professional success.
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Although research on virtual-reality (VR) exposure therapy (VRET) in anxiety disorders has primarily focused on effectiveness and acceptability, the underlying working mechanisms have received scant attention. To fill this knowledge gap, we discuss potential theoretical underpinnings of VRET based on three dominant theoretical accounts on exposure: inhibitory-learning theory (expectancy violation), emotional-processing theory (habituation), and self-efficacy theory. Whereas theoretically speaking, habituation and self-efficacy seem plausible candidate mechanisms to explain the effects of VRET, the role of expectancy violation is less straightforward. Because of the simulated nature of VR, some feared outcomes cannot occur, and therefore, possibilities to violate expectancies about their occurrence may be compromised. Empirical evidence on the working mechanisms of VRET is scarce and has important limitations. Avenues for future research are provided. Insights into the mechanisms of VRET not only are of theoretical importance but also can provide theory-based directions to optimize the application of VRET.
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Introduction: The issue of mental wellness is a complex phenomenon, and some people are affected by Body Dysmorphic Disorder (BDD). This mental health condition occurs when people are preoccupied with the defects in their physical appearance or spend excessive time moping about the flaws in their physical appearance. It is an invisible mental condition that distorts the quality of life of people, and those whom this phenomenon affects are silently hurting. Studies have concluded that individuals start noticing their appearance at the start of their adolescent years-12 or 13. Monzani and colleagues reinforced that common genetic factors accounted for a 64% covariation between BDD and obsessive-compulsive disorder (OCD). The genetic and neuroscientific paradigms have been a catalyst in helping us to understand the aetiology and environmental predispositions of BDD.
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Mental stress may lead to ovarian dysfunction. Psychological stress disrupts ovarian function, leading to adverse in vitro fertilization outcomes, premature ovarian insufficiency and decreased ovarian reserve. Furthermore, psychological stress caused by decreased ovarian function and infertility can exacerbate the mental burden. In animals, psychological stress leads to ovarian insufficiency, resulting in irregular estrous cycles and decreased ovarian reserve. The present study summarizes effects of psychogenic stress on ovarian function and the underlying mechanisms, highlighting involvement of the hypothalamic-pituitary-adrenal, sympathetic-adrenal-medullary and hypothalamic-pituitary-ovarian axes, as well as the neuroendocrine-metabolic network. Moreover, the present review outlines psychological intervention and metabolic strategies for improving ovarian function, offering potential new approaches for treating ovarian hypofunction. The present study aims to clarify understanding of psychological stress-induced ovarian dysfunction and propose alternative intervention strategies for ovarian dysfunction and infertility.
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Anxiety disorders detrimentally affect individuals’ quality of life, often manifesting in physical symptoms such as palpitations and muscle tension. PMHNPs play a vital role in early detection and culturally sensitive treatment, considering individual variations in symptom presentation. Effective management typically involves a multifaceted approach combining pharmacotherapy, cognitive-behavioral therapy (CBT), and alternative treatments like mindfulness-based therapies. This chapter provides an overview of anxiety disorders, including generalized anxiety disorder, panic disorder, and phobias, as well as OCD, exploring diagnostic criteria, pharmacological interventions, side effects, and therapeutic strategies.
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Aim This study aimed to assess the psychological distress, specifically anxiety and depression, among nurses employed at University Hospital Center of Rabat in Morocco and tested the associations between support in the workplace and nurses’ psychological well-being. Methods A cross-sectional observational study was conducted at University Hospital Center of Rabat in Morocco, based on a prospective data collection employing an ad-hoc self-report questionnaire. 223 nurses were enrolled with a minimum of 1 year of practice in any care unit. Socio-demographic and professional characteristics of each participant were included. A validated tool was utilized to measure the support from superiors and colleagues in the workplace, while the Hospital Anxiety and Depression Scale (HADS) was employed to evaluate anxiety and depression. Univariate and multivariate analyses were conducted to explore the relationships between different independent and dependent variables. Results Significant socio-demographic and professional factors associated with increased anxiety included female gender, age over 41 years old, Baccalaureate level of education, intention to leave the hospital, and less support from superiors. Regarding the levels of depression, the Baccalaureate level of education was significantly associated with higher levels of depressive symptoms (β 2.444; CI [1.203, 3.686]). Conclusions Our findings suggested that ensuring support from superiors was crucial for safeguarding the psychological well-being of nurses. Therefore, hospital managers should prioritize addressing the workplace support for professionals, and the organizational enhancement.
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Introdução: O Transtorno de Ansiedade Generalizada (TAG) é uma condição prevalente e debilitante, caracterizada por preocupação excessiva e impacto significativo na qualidade de vida. A Terapia Cognitivo-Comportamental (TCC) é amplamente reconhecida como uma das abordagens mais eficazes para o tratamento do TAG. Objetivo: Portanto, esta revisão bibliográfica busca analisar as intervenções terapêuticas disponíveis para o TAG, com ênfase nos tratamentos cognitivo-comportamentais. Métodos: Foi realizada uma busca sistemática na literatura científica nas bases de dados PubMed, Scopus e Google Scholar, cobrindo o período de 2009 a 2024. Foram incluídos estudos originais e revisões que focavam nas abordagens terapêuticas e eficácia da TCC para o TAG. Inicialmente, 750 artigos foram identificados, dos quais 32 foram incluídos nesta revisão após uma triagem rigorosa.Resultados e Discussão: A revisão revelou que a TCC é eficaz na redução dos sintomas de TAG e na melhoria da qualidade de vida dos pacientes, especialmente quando combinada com outras terapias, como ACT e mindfulness. Além disso, foi destacada a necessidade de personalização do tratamento e a importância de explorar novas formas de ampliar o acesso à TCC, como as terapias online. A TCC demonstrou ser uma ferramenta crucial para o manejo do TAG, mas desafios permanecem, especialmente no que diz respeito à acessibilidade. Conclusão: A TCC se consolida como uma abordagem de primeira linha para o TAG, mas é necessário continuar a investigação para aprimorar sua aplicação e acessibilidade. Esta revisão fornece uma base sólida para a prática clínica e políticas de saúde mental eficazes.
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Opioid use disorder is associated with an elevated risk of most psychiatric disorders, as well as many health conditions. Among the most common co-occurring conditions are anxiety disorders and chronic pain. As opioids can provide potent relief of both negative affect and pain, the presence of these co-occurring conditions can complicate recovery from opioid use disorder. The objective of this chapter is to provide an overview of the co-occurrence of anxiety and pain among people with opioid use disorder and guidance on the application of cognitive-behavioral strategies for these conditions. Common mechanisms that can be targeted transdiagnostically are highlighted, as are possibilities for navigating potentially discrepant treatment elements (e.g., approach-oriented exposure techniques vs. avoidance-oriented environmental risk modification). Treatment principles are illustrated using with case examples of their application. Importantly, the treatment of this co-occurrence is understudies, and research on optimal treatment approaches for this population is needed.
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Research on unconscious fear responses has recently been translated into experimental paradigms for reducing fear that bypass conscious awareness of the phobic stimulus and thus do not induce distress. These paradigms stand in contrast to exposure therapies for anxiety disorders, which require direct confrontation of feared situations and thus are distressing. We systematically review these unconscious exposure paradigms. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-based search yielded 39 controlled experiments based on 10 paradigms that tested whether exposure without awareness can reduce fear-related responses. In randomized controlled trials of phobic participants, unconscious exposure interventions: (a) reduced behavioral avoidance (weighted mean d = 0.77, N = 469) and self-reported fear (d = 0.78, N = 329) during in vivo exposure to feared situations; (b) reduced neurobiological indicators of fear and enhanced such indicators of fear regulation (d = 0.81, N = 205); (c) had significantly stronger effects on reducing symptomatic behaviors and enhancing neurobiological indicators of fear regulation than did conscious exposure (d = 0.78, N = 342); and (d) produced these effects without inducing subjective fear. In fear-conditioned participants, unconscious exposureinduced extinction learning (d = 0.80, N = 420), even during sleep, and yielded somewhat stronger extinction learning than conscious exposure did (d = 0.44, N = 438). We organize these findings within a neuroscientific framework and evaluate alternative mechanisms for unconscious exposure. The use of incommensurate outcome measures across exposure paradigms and nonreporting of relevant statistics limited meta-analyses. Despite steps taken to address publication bias, 25.6% of included studies came from a single laboratory. We propose potential clinical applications of these findings. Future research should clarify underlying mechanisms, use common outcome measures, and explore effects on other anxiety disorders.
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This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
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Details the psychometric evaluation of the Quality of Life Inventory (QOLI), a measure of life satisfaction that may complement symptom-oriented measures of psychological functioning in evaluating the outcome of interventions aimed at ameliorating mental disorders, disabling physical illnesses, and community-wide social problems. Test–retest coefficients for the QOLI ranged from .80 to .91, and internal consistency coefficients ranged from .77 to .89 across 3 clinical and 3 nonclinical samples. QOLI item–total correlations were found to be adequate, and the QOLI had significantly positive correlations with 7 related measures of subjective well-being, including a peer rating and clinical interview measure. Significant negative correlations were obtained between the QOLI and measures of general psychopathology and depression. Clinical and nonclinical criterion groups differed significantly in mean QOLI scores. QOLI norms are presented, and the usefulness of the QOLI for assessing treatment outcome and for psychotherapy treatment planning is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The development, reliability, and discriminative ability of a new instrument to assess social phobia are presented. The Social Phobia and Anxiety Inventory (SPAI) is an empirically derived instrument incorporating responses from the cognitive, somatic, and behavioral dimensions of social fear. The SPAI high test–retest reliability and good internal consistency. The instrument appears to be sensitive to the entire continuum of socially anxious concerns and is capable of differentiating social phobics from normal controls as well as from other anxiety patients. The utility of this instrument for improved assessment of social phobia and anxiety and its use as an aid for treatment planning are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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For any given research area, one cannot tell how many studies have been conducted but never reported. The extreme view of the "file drawer problem" is that journals are filled with the 5% of the studies that show Type I errors, while the file drawers are filled with the 95% of the studies that show nonsignificant results. Quantitative procedures for computing the tolerance for filed and future null results are reported and illustrated, and the implications are discussed. (15 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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There are 2 families of statistical procedures in meta-analysis: fixed- and random-effects procedures. They were developed for somewhat different inference goals: making inferences about the effect parameters in the studies that have been observed versus making inferences about the distribution of effect parameters in a population of studies from a random sample of studies. The authors evaluate the performance of confidence intervals and hypothesis tests when each type of statistical procedure is used for each type of inference and confirm that each procedure is best for making the kind of inference for which it was designed. Conditionally random-effects procedures (a hybrid type) are shown to have properties in between those of fixed- and random-effects procedures. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Developed to offer researchers an informative account of which methods are most useful in integrating research findings across studies, this book will enable ...
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In this paper, we examine comparative analysis of rates with a view to each of the usual comparative parameters-rate difference (RD), rate ratio (RR) and odds ratio (OR)-and with particular reference to first principles. For RD and RR we show the prevailing statistical practices to be rather poor. We stress the need for restricted estimation of variance in the chi-square function underlying interval estimation (and also point estimation and hypothesis testing). For RR analysis we propose a chi-square formulation analogous to that for RD and, thus, one which obviates the present practice of log transformation and its associated use of Taylor series approximation of the variance. As for OR analysis, we emphasize that the chi-square function, introduced by Cornfield for unstratified data, and extended by Gart to the case of stratified analysis, is based on the efficient score and thus embodies its optimality properties. We provide simulation results to evince the better performance of the proposed (parameter-constrained) procedures over the traditional ones.
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We conducted a meta-analysis using all available controlled treatment outcome studies of cognitive-behavioral and pharmacological treatments for social phobia (N= 24 studies, N= 1079 subjects). The mean social anxiety effect size for cognitive-behavioral treatments was .74 and for pharmacological treatments was .62. Both were significantly different from zero and the difference between them was not significant. Among cognitive-behavioral treatments, exposure-interventions yielded the largest effect size (ES) whether alone (ES = .89) or combined with cognitive restructuring (ES = .80). Selective serotonin reup-take inhibitors (ES = 1.89) and benzodiazepines (ES = .72) yielded the largest effect sizes for pharmacotherapy. According to cost projections, group cognitive-behavioral treatment offered the most cost-effective intervention.
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The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inner-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
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One hundred and ninety patients meeting DSM-III-R criteria for panic disorder with or without agoraphobia were randomly allocated to (a) Fluvoxamine, (b) placebo, (c) Fluvoxamine + cognitive behaviour therapy, (d) placebo + cognitive behaviour therapy, or (e) cognitive behaviour therapy alone. Patients were treated over 13 weeks and all participated in nine sessions plus follow-up at 6 months. Numbers in each group were as follows—(a) Fluvoxamine: entered n = 36, completed n = 29, attended follow-up n = 23; (b) placebo: entered n = 37, completed n = 28, attended follow-up n = 21; (c) Fluvoxamine + cognitive behaviour therapy: entered n = 38, completed n = 29, attended follow-up n = 24; (d) placebo + cognitive behaviour therapy: entered n = 36, completed n = 33, attended follow-up n = 30; (e) cognitive behaviour therapy: entered n = 43, completed n = 30, attended follow-up n = 28. A balance across treatments for therapist contact was attempted. A fixed-dose medication regimen was used with patients taking 150mg Fluvoxamine per day. A range of process and outcome measures both therapist- and patient-rated was used. Outcome at treatment end point and at 6-month follow-up was assessed in terms of both statistical and clinical significance and revealed that all active treatments showed improvement over time. This improvement was better preserved over follow-up in those groups receiving cognitive behaviour therapy (Groups c, d, and e) with these groups showing larger proportions of patients continuing to achieve predetermined criteria of clinically significant change on the Hamilton Anxiety Scale, Kellner and Sheffield Symptom Rating Test, and the Fear Questionnaire-Agoraphobia Scale at 6-month follow-up than those of the medication-alone groups (Groups a and b). The largest and most consistent treatment gains were evidenced by the cognitive behaviour therapy (Group e) and the Fluvoxamine + cognitive behaviour therapy (Group c) groups, with the latter showing these gains 2 weeks earlier in treatment, at Day 28 rather than Day 42.
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The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
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Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.
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In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.
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There are 2 families of statistical procedures in meta-analysis: fixed- and random-effects procedures. They were developed for somewhat different inference goals: making inferences about the effect parameters in the studies that have been observed versus making inferences about the distribution of effect parameters in a population of studies from a random sample of studies. The authors evaluate the performance of confidence intervals and hypothesis tests when each type of statistical procedure is used for each type of inference and confirm that each procedure is best for making the kind of inference for which it was designed. Conditionally random-effects procedures (a hybrid type) are shown to have properties in between those of fixed- and random-effects procedures.
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Over 150 meta-analyses of randomized control trials have so far been published in the English language, and new ones are appearing at a rate of over fifteen per year. This explosion of a relatively new method of evaluating clinical medicine presents a number of challenges to statisticians and those responsible for health care policy. The pitfalls of retrospective research must be avoided, and the quality of the original trials should be evaluated. Heterogeneity of the control event rates and the treatment differences need to be dealt with statistically. Most important are the problems raised by the need to update meta-analyses as new trials are published.
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Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.
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This study examines the psychometric properties of two versions of the PTSD Sympton Scale (PSS). The scale contains 17 items that diagnose PTSD according to DSM-III-R criteria and assess the severity of PTSD symptoms. An interview and self-report version of the PSS were administered to a sample of 118 recent rape and non-sexual assault victims. The results indicate that both versions of the PSS have satisfactory internal consistency, high test-retest reliability, and good concurrent validity. The interview version yielded high interrater agreement when administred separately by two interviewers and excellent convergent validity with the SCID. When used to diagnose PTSD, the self-report version of the PSS was somewhat more conservative than the interview version.
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The recent emphasis on cognitive factors in the treatment of emotional problems has stimulated the development of cognitive assessment techniques. This paper presents the development and initial validation of an instrument to assess self-statements about social interactions. The 30-item questionnaire contains 15 positive (facilitative) and 15 negative (inhibitory) self-statements that were derived from subjects who listed thoughts while imagining difficult social situations. Item selection was accomplished by using judges' ratings of those thoughts. Validity studies with two samples compared scores on the self-statement measure with self-report, judges' and confederates' ratings of skill and anxiety following taped role-play and face-to-face interactions, and with questionnaire measures of social anxiety and skill. The measure appears to be a reliable, valid measure of cognitions associated with social anxiety. Research directions in cognitive assessment are suggested.
Article
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample. Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change. The inter-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.
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This paper describes the development of a new self-report anxiety scale. The multidimensional conception of anxiety was used to create a comprehensive self-rated instrument. The study included 694 subjects from three populations: anxiety patients, medical patients, and university employees (controls). Strict selection of criteria was used, including content analysis, factor analysis, and a recently developed multitrait analysis to choose items for the scale from an item pool constructed from most of the known anxiety inventories. The 40-item scale consisted of four major dimensions and nine subscales. The total scale had internal consistency of 0.93 and close to 0.8 for separate dimensions. The scale correlated, as hypothesized, with several validating instruments (Zung Anxiety Scale and others). The analysis revealed the multidimensional and multifactorial structure of self reports of anxiety. More research is needed to further explore the validity and the usefulness of the new scale in biological and social experiments.
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Catastrophic cognitions are theorized to be an important construct for the development and maintenance of panic disorder with or without agoraphobia. However, there is a lack of reliable and valid self-report instruments for measuring catastrophic cognitions. This study presents the development and validation of the Catastrophic Cognition Questionnaire (CCQ) using 507 students from introductory psychology classes. Factor Analysis yielded a five-factor solution, which accounted for 54% of the total variance. The five are the Emotional, Physical, Mental, Social, and Bodily Catastrophes factors. The CCQ shows good reliability with Cronbach's Alpha for individual scales ranging from .86 to .94. The CCQ has good discriminant validity and correlates moderately with other self-report questionnaires that measure anxiety and cognitions associated with anxiety problems.
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Unanswered questions from controlled studies of posttraumatic stress disorder concern the value of cognitive restructuring alone without prolonged exposure therapy and whether its combination with prolonged exposure is enhancing. In a controlled study, 87 patients with posttraumatic stress disorder of at least 6 months' duration were randomly assigned to have 10 sessions of 1 of 4 treatments: prolonged exposure (imaginal and live) alone; cognitive restructuring alone; combined prolonged exposure and cognitive restructuring; or relaxation without prolonged exposure or cognitive restructuring. Integrity of audiotaped treatment sessions was satisfactory when rated by an assessor unaware of the treatment assignment. Seventy-seven patients completed treatment. The pattern of results was similar regardless of rater, statistical method, measure, occasion, and therapist. Exposure and cognitive restructuring, singly or combined, improved posttraumatic stress disorder markedly on a broad front. Gains continued to 6-month follow-up and were significantly greater than the moderate improvement from relaxation. Both prolonged exposure and cognitive restructuring were each therapeutic on their own, were not mutually enhancing when combined, and were each superior to relaxation.
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Incl. app., glossary, index
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Thesis (Ph. D.)--University of Texas at Austin, 1993. Vita. Includes bibliographical references (leaves 222-234).
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Synopsis Fifty-seven chronic agoraphobic outpatients were treated by 12 hours of exposure in vivo on four days over two weeks to check the effects of oral diazepam versus placebo during group exposure, group versus individual exposure, and high versus medium anxiety arousal during individual exposure. The controlled parallel design allowed comparative evaluation of each treatment condition to six months follow-up. Assessment was blind with respect to drug and psychological treatment. Patients in all treatment conditions improved significantly in phobias and in related life areas. Outcome to group exposure on phobias and other measures was similar in all three drug conditions (placebo, waning diazepam, peak diazepam) with no significant differences between them. Diazepam patients had significantly less discomfort than placebo patients during group exposure treatment. Group exposure patients improved slightly but significantly more than individual exposure patients on non-phobic measures, though group exposure was accompanied by more panics during treatment yet was easier to run by the therapist. Individual exposure under high anxiety arousal was no more therapeutic than with lower anxiety. Diazepam is a mild palliative during group exposure but does not facilitate outcome to treatment. Group exposure in vivo is mildly facilitatory for outcome compared with individual exposure. Anxiety evocation during treatment was not therapeutically helpful.
Article
Clinical, field, and experimental studies of response to potentially stressful life events give concordant findings: there is a general human tendency to undergo episodes of intrusive thinking and periods of avoidance. A scale of current subjective distress, related to a specific event, was based on a list of items composed of commonly reported experiences of intrusion and avoidance. Responses of 66 persons admitted to an outpatient clinic for the treatment of stress response syndromes indicated that the scale had a useful degree of significance and homogeneity. Empirical clusters supported the concept of subscores for intrusions and avoidance responses.
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A one-page self-rating form is described to monitor change in phobic patients. It is derived from earlier versions used in 1000 phobic club members and 300 phobic patients. The form yields four scores: main phobia, global phobia, total phobia and anxiety-depression. The total phobia score is composed of agoraphobia, social and blood-injury subgroups. The form is short, reliable and valid. Adoption of this standard form for research in clinical populations would facilitate comparison of results across centres and studies.
Article
A simple questionnaire was developed as an instrument for assessing the existence and extent of different obsessional-compulsive complaints. Two major types of complaint, checking and washing compulsions, and two minor types, slowness and doubting, were established. The final form of the questionnaire, and major properties, are presented.
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Seventy-four patients who met DSM-III criteria for social phobia completed 8 weeks of double-blind, randomly assigned treatment with the monoamine oxidase inhibitor phenelzine sulfate, the cardioselective beta-adrenergic blocker atenolol, or placebo. The overall response rates were 64% for phenelzine, 30% for atenolol, and 23% for placebo. Phenelzine was widely superior to both atenolol and placebo on independent rater analyses and, to a lesser extent, on self-report, with no significant differences between atenolol and placebo. At the end of 16 weeks, phenelzine was still significantly superior to placebo, while atenolol showed an intermediate response that did not differ significantly from either of the other treatments. Patients with generalized social phobia constituted 76% of the sample, and they were preferentially responsive to phenelzine. The small size of the discrete social phobic sample precluded separate outcome analyses for this subtype. Overall, the findings support the responsivity of social phobia to monoamine oxidase inhibitors.
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The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.
Article
Seventy-four patients meeting DSM-III criteria for social phobia completed 4 or more weeks of double-blind, randomized treatment with the monoamine oxidase inhibitor phenelzine, the cardioselective beta-adrenergic blocker atenolol, or placebo. Sixty-four percent of the patients on phenelzine demonstrated moderate or marked improvement, compared to 30 percent on atenolol and 23 percent on placebo. Phenelzine was significantly more effective than atenolol or placebo, whereas the efficacy of atenolol and placebo did not differ significantly. Patients were also prospectively divided into generalized and discrete subtypes of social phobia. Phenelzine appeared to be a particularly effective treatment for the generalized form of social phobia. Atenolol may be useful for discrete forms of social phobia such as performance anxiety.
Article
The Yale-Brown Obsessive Compulsive Scale was designed to remedy the problems of existing rating scales by providing a specific measure of the severity of symptoms of obsessive-compulsive disorder that is not influenced by the type of obsessions or compulsions present. The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4 (extreme symptoms) (total range, 0 to 40), with separate subtotals for severity of obsessions and compulsions. In a study involving four raters and 40 patients with obsessive-compulsive disorder at various stages of treatment, interrater reliability for the total Yale-Brown Scale score and each of the 10 individual items was excellent, with a high degree of internal consistency among all item scores demonstrated with Cronbach's alpha coefficient. Based on pretreatment assessment of 42 patients with obsessive-compulsive disorder, each item was frequently endorsed and measured across a range of severity. These findings suggest that the Yale-Brown Scale is a reliable instrument for measuring the severity of illness in patients with obsessive-compulsive disorder with a range of severity and types of obsessive-compulsive symptoms.
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Article
The Padua Inventory (PI) consists of 60 items describing common obsessional and compulsive behavior and allows investigation of the topography of such problems in normal and clinical Ss. It was administered to 967 normal Italian Ss, ranging in age from 16 to 70 yr. Inventory consistency and 1-month reliability were satisfactory. Females reported more complaints, more intensely than males. Ss aged from 16 to 20 yr and Ss aged from 46 to 70 complain of more obsessions and compulsions than Ss of intermediate ages. Four factors were identified: impaired control of mental activities, becoming contaminated, checking behaviors, urges and worries of losing control over motor behaviors. The PI correlates with the Maudsley Obsessional-Compulsive Questionnaire (0.70), Leyton Obsessional-Compulsive Inventory (0.71 with Symptom and 0.66 with Trait scales) and Self-rating Obsessional Scale (0.61). Furthermore, it allows discrimination between a group of 75 outpatients with obsessive-compulsive disorders and a similar group of outpatients with other neurotic disorders. Relationships with fears and neuroticism traits were also found, reflected in moderately high correlations with the Fear Survey Schedule and the Neuroticism scale of the Eysenck Personality Questionnaire.