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Maximizing exposure therapy

Michelle Craske & colleagues from the Anxiety Disorders Research Center of UCLA have, for many years, been publishing careful, challenging research on underlying mechanisms & on ways of boosting the effectiveness of exposure therapies for different forms of anxiety.  Craske's list of publications & research presentations runs to 31 pages and begins with a study on musical performance anxiety published in 1984.  As the presentation titles on her list show, for some years the majority of her many lectures at prestigious conferences all over the world have revolved around the theme of how to take evolving scientific findings about fear learning and use them to optimize exposure treatments for anxiety disorders.

Recent research: a mixed bag of six papers on anxiety

Here are half a dozen papers with anxiety relevance.  The first couple are about the interaction between genetic vulnerability (or resilience) and childhood experience.  The Stevens et al paper is an update on the large body of research looking at psychological genetic vulnerability/resilience in macaque monkeys and how this interacts with parenting quality to lead, or not lead, to emotional and neurophysiological disturbances in adulthood.  The Battaglia paper particularises this gene/environment investigation by looking at the connections between early human childhood separation anxiety, loss of a parent, and panic disorder in adulthood.  

Handouts & questionnaires for increasing access to psychological therapies (IAPT) outcomes toolkit, an upgrade

Over nearly 35 years of practice as a doctor and psychotherapist I've assembled a collection of 300 to 400 handouts and questionnaires that I use in my work.  I'm gradually uploading most of these handouts to this website so people can use any that they'd like to.  The collection is searchable in the Good Knowledge section of the site at Handouts, questionnaires and other leaflets.  Of the twenty two subsections on this part of the website, one of the more frequently visited areas is the Increasing access to psychological therapies (IAPT) outcomes toolkit.  This is a pretty full hand of cards for the recommended IAPT assessment measures.  I've recently updated the list of downloadable questionnaires available by including:

Recent research: half a dozen studies on cognitive therapy

Here are half a dozen recent studies involving cognitive therapy (CBT).  The first by Craigie et al explores the use of mindfulness-based cognitive therapy (MBCT) to treat generalized anxiety disorder (GAD).  Although, as one would expect, MBCT helped GAD sufferers, it was noteworthy that results "fall well short of outcomes achieved by past research".  This adds to my concern that mindfulness training may at times be being over-hyped - see a blog I wrote in September for for more on this.  The next study by Cuijpers et al also suggests limitations to the march of CBT with interpersonal psychotherapy looking a somewhat better candidate for prevention of depression onset.  I guess one could argue that CBT can - and probably more often should - include  behavioural interventions to promote improved relationships.  Click here for tools that can help this approach.   The third piece of research by Grey et al is exciting.  It challenges the Alice in Wonderland dodo bird suggestion that "everyone has won, and all must have prizes"

Handouts & questionnaires for “outcomes toolkit” (IAPT)

The "Improving Access to Psychological Therapies" (IAPT) initiative is very ambitious and exciting.  It states its principal aim is to support English Primary Care Trusts in implementing "National Institute for Health and Clinical Excellence" (NICE) guidelines for people suffering from depression and anxiety disorders.  IAPT go on to say that "At present, only a quarter of the 6 million people in the UK with these conditions are in treatment, with debilitating effects on society."

One aspect of this carefully planned initiative is strong encouragement to assess and monitor the progress of those who are getting help.  Visiting the IAPT "Outcomes Toolkit and FAQ" web page provides access to several freely downloadable documents.  The emphasis is on good assessment measures that are free to use.  See below:

IAPT Outcomes Toolkit 2008/9 PDF - this 81 page 1.1Mb Adobe PDF is the September 08 version with amended IAPT Paper Based Data Set Questionnaires.

Specific phobias

“ The most important thing is caring, so do it first, for the caring physician best inspires hope and trust. ” - Sir William Osler

Specific phobias

Agoraphobia

“ Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from, as no disease suffered by a live man can be known, for every living person has his own peculiarities and always has his own peculiar, personal, novel, complicated disease, unknown to medicine. ” - Leo Tolstoy

The US DSM IV diagnostic system describes the "essential features" of agoraphobia in the following way: "There is intense fear of, or discomfort in, settings from which escape is difficult or embarrassing, or in which help (e.g. to alleviate a panic attack) is not available."  It then adds the following three criteria:

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