Anxiety Disorders: Foa EB

Foa EB, Cahill SP, Boscarino JA, Hobfoll SE, Lahad M, McNally RJ, Solomon Z. · Department of Psychiatry, University of Pennsylvania, 3535 Market Street 6th Floor, Philadelphia, PA 19104, USA. · Neuropsychopharmacology. · Pubmed #16012536 links to  free full text

Abstract: The terrorist attacks of September 11, 2001, and the constant threat of imminent terrorist activity have brought into the forefront the urgent need to prepare for the consequences of such attacks. Such preparation entails utilization of existing knowledge, identification of crucial gaps in our scientific knowledge, and taking steps to acquire this knowledge. At present, there is little empirical knowledge about interventions following terrorism and absolutely no available empirical knowledge about interventions following bioterrorism. Therefore, this paper reviews knowledge about (1) reactions following the September 11 terrorist attacks in New York City and other places, (2) the practical experiences accumulated in recent years in countries (eg, Israel) that have had to cope with the threat of bioterrorism and the reality of terrorism, and (3) interventions for acute and chronic stress reactions following other types of traumatic events (eg, rape, war, accidents). Our review found several treatments efficacious in treating individuals for acute and chronic post-traumatic stress disorder (PTSD) related to other traumatic events that will likely be efficacious in treating PTSD related to terrorist attacks. However, there were significant gaps in our knowledge about how to prepare populations and individuals for the possibility of a terrorist attack and what interventions to apply in the immediate aftermath of such an attack. Accordingly, we conclude the paper with several questions designed to guide future research.

Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY. · Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston 29425-0742, USA. · J Clin Psychiatry. · Pubmed #10761680 No free full text.

Abstract: OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in posttraumatic stress disorder (PTSD) and guide clinical practice with recommendations on the appropriate management strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Edna B. Foa, Ronald C. Kessler, Alexander C. McFarlane, and Arieh Y. Shalev. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: PTSD is often a chronic and recurring condition associated with an increased risk of developing secondary comorbid disorders, such as depression. Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed.

Friedman MJ, Foa EB, Charney DS. · No affiliation provided · Biol Psychiatry. · Pubmed #12725968 No free full text.

This publication has no abstract.

Foa EB. · Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia 19104, USA. · J Clin Psychiatry. · Pubmed #17092193 No free full text.

Abstract: Controlled clinical trials in social anxiety disorder (SAD) have shown benefit with the use of medication and cognitive-behavioral therapies as well as incorporation of combined therapeutic modalities. This article briefly summarizes the literature on the outcome of group and individual cognitive-behavioral therapy for SAD and concludes that individual therapy is superior to group therapy. Finally, the article discusses comorbidity of depression and SAD and its implications for cognitive-behavioral therapy.

Cahill SP, Foa EB, Hembree EA, Marshall RD, Nacash N. · Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA. · J Trauma Stress. · Pubmed #17075914 No free full text.

Abstract: Since the introduction of posttraumatic stress disorder (PTSD) into the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association, 1980), considerable research has demonstrated the efficacy of several cognitive-behavioral therapy (CBT) programs in the treatment of chronic PTSD. Among these efficacious treatments is exposure therapy. Despite all the evidence for the efficacy of exposure therapy and other CBT programs, few therapists are trained in these treatments and few patients receive them. In this article, the authors review extant evidence on the reasons that therapists do not use these treatments and recent research on the dissemination of efficacious treatments of PTSD.

Foa EB. · Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, PA 19104, USA. · J Clin Psychiatry. · Pubmed #16602814 No free full text.

Abstract: Immediately after experiencing a traumatic event, many people have symptoms of posttraumatic stress disorder (PTSD). If trauma victims restrict their routine and systematically avoid reminders of the incident, symptoms of PTSD are more likely to become chronic. Several clinical studies have shown that programs of cognitive-behavioral therapy (CBT) can be effective in the management of patients with PTSD. Prolonged exposure (PE) therapy-a specific form of exposure therapy-can provide benefits, as can stress inoculation training (SIT) and cognitive therapy (CT). PE is not enhanced by the addition of SIT or CT. PE therapy is a safe treatment that is accepted by patients, and benefits remain apparent after treatment programs have finished. Nonspecialists can be taught to practice effective CBT. For the treatment of large numbers of patients, or for use in centers where CBT has not been routinely employed previously, appropriate training of mental health professionals should be performed. Methods used for the dissemination of CBT to nonspecialists need to be modified to meet the requirements of countries affected by the Asian tsunami. This will entail the use of culturally sensitive materials and the adaptation of training methods to enable large numbers of mental health professionals to be trained together.

Connor KM, Foa EB, Davidson JR. · Department of Psychiatry and Behavioral Science, Duke University Medical Center, Durham, NC 27710, USA. · J Clin Psychiatry. · Pubmed #16602812 No free full text.

Abstract: Almost all individuals who experience a severe trauma will develop symptoms of posttraumatic stress disorder (PTSD) shortly after the traumatic event. Although the natural history of PTSD varies according to the type of trauma, most people do not develop enduring PTSD, and, in many of those who do, it resolves within 1 year without treatment. To the extent that is possible, maintenance of normal daily activities is believed to help patients cope more successfully in the aftermath of major trauma. In the case of a disaster such as the Asian tsunami, the whole community is involved, and it is impossible to continue with normal daily activities. To improve overall outcome after trauma, it would be optimal to identify individuals at increased risk for developing PTSD. This article describes screening and assessment tools for posttrauma mental health problems, particularly PTSD, and examines in more detail instruments that can be used in rapid field assessment of individuals who may be affected or who have already been identified and require monitoring. Self-rated instruments are most appropriate, but the choice of instrument will depend on the local situation and availability of appropriately validated questionnaires. The article also addresses important aspects of training nonmedical personnel in screening and assessment.

Foa EB, Stein DJ, McFarlane AC. · Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA, and the University of Adelaide, Department of Psychiatry, Queen Elizabeth Hospital, Woodville, Australia. · J Clin Psychiatry. · Pubmed #16602811 No free full text.

Abstract: A variety of reactions are observed after a major trauma. In the majority of cases these resolve without any long-term consequences. In a significant proportion of individuals, however, recovery may be impaired, leading to long-term pathological disturbances. The most common of these is post-traumatic stress disorder (PTSD), which is characterized by symptoms of reexperiencing the trauma, avoidance and numbing, and hyperarousal. A range of other disorders may also be seen after trauma, and there is considerable overlap between PTSD symptoms and several other psychiatric conditions. Risk factors for PTSD include severe exposure to the trauma, female sex, low socioeconomic status, and a history of psychiatric illness. Although PTSD may resolve in the majority of cases, in some cases risk factors outweigh protective factors, and symptoms may persist for many years. PTSD often coexists with other psychiatric disorders, such as depression, anxiety disorders, and substance abuse, and with physical (somatization) symptoms. There is growing evidence that PTSD does not merely represent a normal response to stress, but rather is mediated by specific neurobiological dysfunctions.

Nemeroff CB, Bremner JD, Foa EB, Mayberg HS, North CS, Stein MB. · Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 1639 Pierce Drive, Atlanta, GA 30322-4990, USA. · J Psychiatr Res. · Pubmed #16242154 No free full text.

Abstract: This article reviews the state-of-the-art research in posttraumatic stress disorder (PTSD) from several perspectives: (1) Sex differences: PTSD is more frequent among women, who tend to have different types of precipitating traumas and higher rates of comorbid panic disorder and agoraphobia than do men. (2) Risk and resilience: The presence of Group C symptoms after exposure to a disaster or act of terrorism may predict the development of PTSD as well as comorbid diagnoses. (3) Impact of trauma in early life: Persistent increases in CRF concentration are associated with early life trauma and PTSD, and may be reversed with paroxetine treatment. (4) Imaging studies: Intriguing findings in treated and untreated depressed patients may serve as a paradigm of failed brain adaptation to chronic emotional stress and anxiety disorders. (5) Neural circuits and memory: Hippocampal volume appears to be selectively decreased and hippocampal function impaired among PTSD patients. (6) Cognitive behavioral approaches: Prolonged exposure therapy, a readily disseminated treatment modality, is effective in modifying the negative cognitions that are frequent among PTSD patients. In the future, it would be useful to assess the validity of the PTSD construct, elucidate genetic and experiential contributing factors (and their complex interrelationships), clarify the mechanisms of action for different treatments used in PTSD, discover ways to predict which treatments (or treatment combinations) will be successful for a given individual, develop an operational definition of remission in PTSD, and explore ways to disseminate effective evidence-based treatments for this condition.

Huppert JD, Moser JS, Gershuny BS, Riggs DS, Spokas M, Filip J, Hajcak G, Parker HA, Baer L, Foa EB. · Center for the Treatment and Study of Anxiety, University of Pennsylvania, 3535 Market St., Suite 600N, Philadelphia, PA 19104, USA. · J Anxiety Disord. · Pubmed #15488372 No free full text.

Abstract: Although case reports suggest the existence of a unique relationship between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), results from large-scale epidemiological and clinical studies have been more equivocal. Furthermore, symptom overlap may artificially inflate the significance of the relationship between OCD and PTSD. Utilizing the Obsessive-Compulsive Inventory [OCI; Psychol. Assess. 10 (1998) 206] and the Posttraumatic Diagnostic Scale [PDS; Psychol. Assess. 9 (1997) 445], this study examined the relationship between OCD and PTSD symptoms in 128 patients diagnosed with OCD, 109 patients diagnosed with PTSD, 63 patients diagnosed with another anxiety disorder, and 40 college students. Experts in OCD and PTSD independently rated items on the OCI and PDS for the degree of overlap across the disorders. On the basis of these ratings, we created a scale from each measure that included only non-overlapping items. Results revealed that overall symptoms of OCD and PTSD were related in all samples. However, after controlling for depression and overlapping symptoms simultaneously, this relationship was no longer significant in the OCD and PTSD samples, although it remained significant in the anxious and college student comparison groups. These results support the presence of a relationship between symptoms of OCD and PTSD that may be largely accounted for by a combination of symptom overlap and depression.

Hembree EA, Foa EB, Dorfan NM, Street GP, Kowalski J, Tu X. · School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. · J Trauma Stress. · Pubmed #14690352 No free full text.

Abstract: Many studies have demonstrated the efficacy of exposure therapy in the treatment of chronic post-traumatic stress disorder (PTSD). Despite the convincing outcome literature, a concern that this treatment may exacerbate symptoms and lead to premature dropout has been voiced on the basis of a few reports. In this paper, we examined the hypothesis that treatments that include exposure will be associated with a higher dropout rate than treatments that do not include exposure. A literature search identified 25 controlled studies of cognitive-behavioral treatment for PTSD that included data on dropout. The results indicated no difference in dropout rates among exposure therapy, cognitive therapy, stress inoculation training, and EMDR. These findings are consistent with previous research about the tolerability of exposure therapy.

Huppert JD, Roth DA, Foa EB. · Department of Psychiatry, University of Pennsylvania Medical Center, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA. · Curr Psychiatry Rep. · Pubmed #12857532 No free full text.

Abstract: Cognitive-behavioral treatment (CBT) for social phobia is an effective treatment for many patients, but some patients do not benefit from the treatments and many remain symptomatic. Therefore, researchers have been examining techniques that may improve treatment outcome. In this paper, recent psychopathology and treatment outcome research, much of which supports the expectation that a second-generation CBT treatment may further improve outcome, are discussed. Finally, the authors present a number of CBT techniques that are tailored for the individual treatment of patients with social phobia. These methods, based on comprehensive CBT developed by Foa et al. and on cognitive therapy for social phobia developed by Clark et al. include developing an idiographic model for the patient, conducting safety behaviors experiments, providing video feedback after cognitive preparation, developing a hierarchy, conducting in vivo exposures and other behavioral experiments, imaginal exposure, social skills training, assertiveness training, and behavioral activation for depression.

Hembree EA, Foa EB. · Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. · J Trauma Stress. · Pubmed #12699206 No free full text.

Abstract: This paper provides an overview of several treatment interventions for trauma-related disturbances in adult victims of crime. Following a brief discussion of mental health service utilization among crime victims, we describe interventions for acute and chronic reactions to trauma. We present some controlled studies of psychosocial treatments for posttraumatic stress disorder (PTSD) that have gained empirical support and are recommended as first line interventions by expert consensus (E. B. Foa, J. R. T. Davidson, & A. Francis, 1999) including exposure therapy, cognitive therapy, and stress inoculation training, followed by a brief summary of selected studies examining the efficacy of pharmacological treatment for PTSD. Finally, we discuss multicultural issues, factors associated with treatment outcome, and challenges we have encountered in treating crime victims.

Foa EB, Franklin ME, Moser J. · University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. · Biol Psychiatry. · Pubmed #12437939 No free full text.

Abstract: Cognitive-behavioral therapy (CBT) and pharmacotherapy demonstrate efficacy across the anxiety disorders, but recognition of their limitations has sparked interest in combining modalities to maximize benefit. This article reviews the empirical literature to examine whether combining treatments influences efficacy of either monotherapy. We conducted a comprehensive literature search of published randomized trials that compared combined treatment with pharmacologic or CBT monotherapies. Ten studies that met our inclusion criteria were reviewed in detail, and within-subjects effect sizes were calculated to compare treatment conditions within and across studies. At posttreatment and follow-up, effect size and percentage responder data failed to clearly demonstrate an advantage or disadvantage of combined treatment over CBT alone for obsessive-compulsive disorder, social phobia, and generalized anxiety disorder. Some advantage of combined treatment over pharmacotherapy alone emerged from the few studies that allowed for such a direct comparison. In contrast, combined treatment for panic disorder seems to provide an advantage over CBT alone at posttreatment, but is associated with greater relapse after treatment discontinuation. The advantage of combined treatment may vary across the anxiety disorders. The potential differences in usefulness of combined treatment are discussed, directions for future research are suggested, and implications for clinical practice are considered.

Foa EB, Street GP. · Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia 19104, USA. · J Clin Psychiatry. · Pubmed #11495093 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) gained the status of a psychiatric disorder in 1980, although the syndrome had already been recognized widely for many years. PTSD is distinguished by alternations between reexperiencing of the traumatic event that triggered the PTSD in the first place and avoidance and numbing. Increased arousal (e.g., exaggerated startle reaction) also forms part of the diagnosis. Although the majority of trauma victims recover spontaneously, more than 30% develop persistent PTSD symptoms, with women being twice as likely as men to suffer PTSD. To date, the most studied psychosocial treatments for PTSD are the cognitive-behavioral interventions. Exposure therapy (systematic exposure to the traumatic memory in a safe environment) has been demonstrated to be quite effective with adult women who were sexually or nonsexually assaulted in adulthood as well as with women who were sexually abused in childhood. Supportive counseling does not appear as effective as exposure therapy, but is better than no therapy.

Hembree EA, Foa EB. · Center for the Treatment and Study of Anxiety, University of Pennsylvania, Philadelphia, USA. · J Clin Psychiatry. · Pubmed #10795607 No free full text.

Abstract: In this article, we propose that successful processing of traumatic events involves emotional engagement with the trauma memory, organization of the trauma narrative, and correction of dysfunctional cognitions that often follow trauma. We further propose that the success of psychosocial treatments of posttraumatic stress disorder hinges on the ability of the treatments to address impairments in these processes. We focus our presentation of psychosocial interventions on cognitive-behavioral treatments (CBT), since this approach had gained the most empirical support to date, and describe the results of controlled trials that compare the relative efficacy of several CBT interventions.

Foa EB. · Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia 19104, USA. · J Clin Psychiatry. · Pubmed #10761678 No free full text.

Abstract: This article reviews empirically validated psychosocial treatments for posttraumatic stress disorder (PTSD) and considers factors associated with successful therapy outcome. Most of the treatments whose efficacy was studied empirically fall within the broad category of cognitive-behavioral therapy. These include exposure therapy, anxiety management programs, and cognitive therapy. These therapy modalities have been developed to modify conditioned fear and erroneous cognitions that are thought to underlie PTSD. Exposure therapy has the most empirical support because it was found to be effective across different populations of trauma victims with PTSD. Combinations of therapies have also been used, and the value of these is discussed. In addition, this article presents recent evidence about the efficacy of eye movement and desensitization reprocessing. A growing body of evidence supports the use of psychosocial treatments for PTSD, but not all patients benefit. Future research should develop programs that increase the motivation of patients to take advantage of these efficacious treatments.

Simpson HB, Zuckoff A, Page JR, Franklin ME, Foa EB. · Anxiety Disorders Clinic, New York State Psychiatric Institute, New York, NY, USA. · Cogn Behav Ther. · Pubmed #18365797 No free full text.

Abstract: Exposure and ritual prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD), but high dropout rates and variable treatment adherence limit its effectiveness. Motivational interviewing (MI) has shown promise as an adjunct to symptom-focused treatments for improving treatment adherence and outcomes. The authors developed a manual integrating MI with EX/RP, consisting of three information-gathering/motivational enhancement sessions and 15 EX/RP sessions with an optional MI module to be used as needed. Six patients with moderate to severe OCD symptoms (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score> or =16) underwent treatment. Five showed a decrease in their baseline Y-BOCS scores and an increase in their quality of life, with three achieving an excellent response (i.e. Y-BOCS< or =12 at Session 18). The authors briefly describe the motivational strategies used in the six cases and suggest that integrating MI with standard EX/RP is a promising method to increase and sustain patient engagement with EX/RP. Challenges in combining these treatments and maintaining the integrity of each as well as limitations of the study are discussed.

Simon NM, Connor KM, Lang AJ, Rauch S, Krulewicz S, LeBeau RT, Davidson JR, Stein MB, Otto MW, Foa EB, Pollack MH. · Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston, MA 02114, USA. · J Clin Psychiatry. · Pubmed #18348595 No free full text.

Abstract: OBJECTIVE: Little is known about the efficacy of "next step" strategies for patients with post-traumatic stress disorder (PTSD) who remain symptomatic despite treatment. This study prospectively examines the relative efficacy of augmentation of continued prolonged exposure therapy (PE) with paroxetine CR versus placebo for individuals remaining symptomatic despite a course of PE. METHOD: Adult outpatients meeting DSM-IV criteria for PTSD were recruited from February 2003 to September 2005 at 4 academic centers. Phase I consisted of 8 sessions of individual PE over a 4- to 6-week period. Participants who remained symptomatic, defined as a score of >or= 6 on the Short PTSD Rating Interview (SPRINT) and a Clinical Global Impressions-Severity of Illness scale (CGI-S) score >or= 3, were randomly assigned to the addition of paroxetine CR or matched placebo to an additional 5 sessions of PE (Phase II). RESULTS: Consistent with prior studies, the 44 Phase I completers improved significantly with initial PE (SPRINT: paired t = 7.6, df = 41, p < .0001; CGI-S: paired t = 6.37, df = 41, p < .0001). Counter to our hypothesis, however, we found no additive benefit of augmentation of continued PE with paroxetine CR compared to pill placebo for the 23 randomly assigned patients, with relatively minimal further gains overall in Phase II. CONCLUSION: Although replication with larger samples is needed before definitive conclusions can be drawn, our data do not support the addition of paroxetine CR compared with placebo to continued PE for individuals with PTSD who remain symptomatic after initial PE, suggesting that the development of novel treatment approaches for PTSD refractory to PE is needed. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT00215163.

van Minnen A, Foa EB. · GGZ Nijmegen, Outpatient Clinic of Anxiety Disorders, Nijmegen, The Netherlands. · J Trauma Stress. · Pubmed #16929519 No free full text.

Abstract: The effects of prolonged imaginal exposure sessions (60 minutes; n=60) were compared with those of shorter exposure sessions (30 minutes, n=32) for patients with chronic posttraumatic stress disorder (PTSD). Consistent with the authors' hypothesis, patients who received 30-minute imaginal exposure sessions showed less within-session habituation than patients who received 60-minute exposure sessions. However, no differences between patients who received 60-minute and 30-minute exposure sessions emerged on improvement in PTSD-symptoms, state anxiety, depression, and end-state functioning, both at posttreatment and at 1-month follow-up. No group differences were found with regard to between-sessions habituation, number of sessions, and dropout rate. Results suggest that 30-minute imaginal exposure sessions are as effective as 60-minute exposure sessions and that within-session habituation may not be a necessary condition for successful treatment of PTSD. Future research is needed to replicate these findings and extend them to other clinical populations.

Simpson HB, Franklin ME, Cheng J, Foa EB, Liebowitz MR. · Anxiety Disorders Clinic, New York State Psychiatric Institute, New York, New York 10032, USA. · Depress Anxiety. · Pubmed #15806597 No free full text.

Abstract: To assess how different criteria for relapse affect inferences about relapse in obsessive-compulsive disorder (OCD), a post hoc analysis of relapse was conducted using data from a multisite randomized controlled trial comparing clomipramine (CMI), exposure and ritual prevention (EX/RP), and its combination (EX/RP+CMI) in adults with OCD. Different relapse definitions were constructed based on criteria used in prior studies. For each definition, the number of relapsers was computed, and the proportion of relapsers and time to relapse were compared. When applied to this data set, relapse criteria used in prior OCD studies yielded different observed relapse rates (range: 27-63% for CMI; 0-50% for EX/RP; and 7-67% for EX/RP+CMI). Most criteria found that EX/RP responders (with or without CMI) had a significantly lower relapse rate and longer time to relapse after treatment discontinuation than did responders to CMI alone. However, some relapse criteria (e.g., those requiring minimal worsening) found no significant treatment differences in relapse rates or time to relapse, and some generated biases against one treatment or another. Most definitions concurred: in adults with primary OCD, EX/RP treatment (with or without CMI) can produce more durable short-term gains after treatment discontinuation than CMI alone. However, different relapse criteria can lead to very different observed relapse rates and even contradictory inferences about relapse. Standard criteria for relapse are needed in OCD to facilitate comparisons between studies (enabling better treatment guidelines) and to advance research on mechanisms of relapse and relapse prevention.

Rauch SA, Foa EB, Furr JM, Filip JC. · Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. · J Trauma Stress. · Pubmed #15730064 No free full text.

Abstract: The present paper examines imagery vividness and anxiety during Prolonged Exposure (PE) for chronic PTSD among 69 female survivors of sexual or nonsexual assault. All participants received between 9 and 12 individual sessions of either PE alone or in combination with cognitive restructuring. As hypothesized, vividness and anxiety ratings from early imaginal exposure sessions were moderately to highly correlated, but these correlations decreased in later sessions. Both subjective distress and vividness decreased significantly with exposure. Greater reductions in subjective distress between the first and last exposure session were related to better outcome. However, contrary to hypothesis, vividness was not related to outcome. Theoretical implications of the results are discussed.

Foa EB, Liebowitz MR, Kozak MJ, Davies S, Campeas R, Franklin ME, Huppert JD, Kjernisted K, Rowan V, Schmidt AB, Simpson HB, Tu X. · Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, USA. · Am J Psychiatry. · Pubmed #15625214 links to  free full text

Abstract: OBJECTIVE: The purpose of the study was to test the relative and combined efficacy of clomipramine and exposure and ritual prevention in the treatment of obsessive-compulsive disorder (OCD) in adults. Serotonin reuptake inhibitors (SRIs) and cognitive behavior therapy by exposure and ritual prevention are both established treatments for OCD, yet their relative and combined efficacy have not been demonstrated conclusively. METHOD: A double-blind, randomized, placebo-controlled trial comparing exposure and ritual prevention, clomipramine, their combination (exposure and ritual prevention plus clomipramine), and pill placebo was conducted at one center expert in pharmacotherapy, another with expertise in exposure and ritual prevention, and a third with expertise in both modalities. Participants were adult outpatients (N=122 entrants) with OCD. Interventions included intensive exposure and ritual prevention for 4 weeks, followed by eight weekly maintenance sessions, and/or clomipramine administered for 12 weeks, with a maximum dose of 250 mg/day. The main outcome measures were the Yale-Brown Obsessive Compulsive Scale total score and response rates determined by the Clinical Global Impression improvement scale. RESULTS: At week 12, the effects of all active treatments were superior to placebo. The effect of exposure and ritual prevention did not differ from that of exposure and ritual prevention plus clomipramine, and both were superior to clomipramine only. Treated and completer response rates were, respectively, 62% and 86% for exposure and ritual prevention, 42% and 48% for clomipramine, 70% and 79% for exposure and ritual prevention plus clomipramine, and 8% and 10% for placebo. CONCLUSIONS: Clomipramine, exposure and ritual prevention, and their combination are all efficacious treatments for OCD. Intensive exposure and ritual prevention may be superior to clomipramine and, by implication, to monotherapy with the other SRIs.

Davidson JR, Payne VM, Connor KM, Foa EB, Rothbaum BO, Hertzberg MA, Weisler RH. · Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina 27710, USA. · Int Clin Psychopharmacol. · Pubmed #15602116 No free full text.

Abstract: There has been growing interest in the concept of resilience and the question as to whether psychotropic medications or psychosocial treatments might have resilience-enhancing effects. This pilot study investigates resilience in a sample of patients with post-traumatic stress disorder (PTSD) before and after treatment. Effects of treatment with tiagabine, fluoxetine, sertraline alone, and sertraline with cognitive behavioural therapy on resilience were assessed using the Connor-Davidson Resilience Scale (CD-RISC). Changes in resilience after treatment were measured and response to treatment was predicted from demographic, resilience and baseline disability measures. Changes in resilience following treatment were statistically significant. Items that showed the greatest change related to confidence, control, coping, knowing where to turn for help and adaptability. Items showing the least change related to religious and existential aspects of resiliency, effort, acting on a hunch, decision-making and goals. In linear and logistic regression models, gender, baseline CD-RISC score, baseline Sheehan Disability Scale score and an individual item from the CD-RISC scale, 'Sense of Humor', were significant predictors of response to treatment. Treatment of PTSD significantly improved resilience and reduced symptoms in this sample. Further controlled studies are indicated.

Foa EB, Rauch SA. · Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA 19104, USA. · J Consult Clin Psychol. · Pubmed #15482045 No free full text.

Abstract: The authors report on changes in cognitions related to posttraumatic stress disorder (PTSD) among 54 female survivors of sexual and nonsexual assault with chronic PTSD who completed either prolonged exposure alone or in combination with cognitive restructuring. Treatment included 9-12 weekly sessions, and assessment was conducted at pretreatment, posttreatment, and a modal 12-month follow-up. As hypothesized, treatment that included prolonged exposure resulted in clinically significant, reliable, and lasting reductions in negative cognitions about self, world, and self-blame as measured by the Posttraumatic Cognitions Inventory. The hypothesis that the addition of cognitive restructuring would augment cognitive changes was not supported. Reductions in these negative cognitions were significantly related to reductions in PTSD symptoms. The addition of cognitive restructuring did not significantly augment the cognitive changes. Theoretical implications of the results are discussed.