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CBT Today: keeping up with the literature (take two)

I have been asked to write a column on "Keeping up with the literature" for CBT Today "the official magazine of the British Association for Behavioural & Cognitive Psychotherapies".  I sent in a first copy a couple of months ago, but unfortunately the editors couldn't get the space to squeeze it in.  Today's post is an extension of that first copy, with several additions to the original publications that were initially recommended.  As before, I thought it might be helpful to put an online version onto this website so that I can include relevant hyperlinks to the various research articles that I mention.

There's a great river of new CBT-relevant research flowing past all the time.  In this quarterly column I comment on four themes that have recently caught my attention.  These involve articles on social anxiety disorder, obsessive compulsive disorder, questionnaire reference values and effects of early life conflict & abuse.

Social anxiety disorder is very much in the news with May's new NICE guideline - "Social anxiety disorder: recognition, assessment and treatment" - and its clear statement that we should "Offer adults with social anxiety disorder individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (based on the Clark and Wells model or the Heimberg model)".  Since then, the large scale (495 patients) American Journal of Psychiatry study - "Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: A multicenter randomized controlled trial" - further underlines the particular value of CBT for this problem.  Somewhat dauntingly, the May guideline underlined that "Psychological interventions should be based on the relevant treatment manual(s), which should guide the structure and duration of the intervention.  Practitioners should ... receive regular, high-quality outcome-informed supervision ... and ... engage in monitoring and evaluation of treatment adherence and practitioner competence."   The guidance comments that 12% of us are likely to suffer from social anxiety disorder at some stage in our lives, and that the disorder is highly persistent.  Maybe the potentially overwhelming demand for trained therapists could partly be eased via internet delivered treatment.  This certainly looks increasingly possible following the pilot study by Richard Stott & colleagues published in Behavioral & Cognitive Psychotherapy - "Internet-delivered cognitive therapy for social anxiety disorder: A development pilot series" (freely available in full text online).  I went to a workshop with David Clark in the summer and there is a pretty full freely downloadable set of the dozen or so questionnaires that he recommended (and a copy of the "Cognitive Therapy Competence Scale for Social Phobia") at "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder".  

Obsessive compulsive disorder is another problem that has recently benefited from the publication of new guidance.  In this case it's an update to the 2007 American Psychiatric Association guideline - see Koran & Simpson's "Guideline watch (March 2013): Practice guideline for the treatment of patients with obsessive-compulsive disorder."  This useful 22 page document is freely available online.  In another paper, "Age of onset in obsessive-compulsive disorder", the authors Anholt et al. suggest that OCD development before age 20 constitutes "early onset" and is associated with a more severe clinical picture.  Meanwhile Olatunji et al. in "Behavioral versus cognitive treatment of obsessive-compulsive disorder: An examination of outcome and mediators of change" highlight the importance of behavioural exposure & response prevention and uncover some surprising mechanism findings.  Finally if like me, you suspect we can all be a bit OCD'ish at times, then you may enjoy the free full text findings of Lindeman et al. in their paper "Atheists become emotionally aroused when daring god to do terrible things."

I am a big fan of Routine Outcome Monitoring (ROM) as a way to track the effectiveness of our treatments and, especially, to pick up non-response as early as possible.  Questionnaire reference values are important here and the Dutch Leiden group have published a whole series of helpful articles on this in the last few years.  There are three papers I have noted this year, all by Schulte-van Maaren et al. - "Reference values for anxiety questionnaires: The Leiden routine outcome monitoring study", "Reference values for major depression questionnaires" (giving cut-off values for the BDI-II of 15 for women and 12 for men), and the background "Reference values for mental health assessment instruments: Objectives and methods of the Leiden routine outcome monitoring study."  If you find it hard to pay for all these papers, there's a free full text overview from the same research team published in last year's BMC Psychiatry that's worth looking at - "Reference values for generic instruments used in routine outcome monitoring: The Leiden routine outcome monitoring study."  Although I would argue that Routine Outcome Monitoring already has the potential to boost our effectiveness as therapists more than most other new initiatives that we could try - see the 48 slide talk "How can we help our clients more effectively?" - there is still a huge amount to learn here, including a better understanding of likely trajectories of improvement, as shown in the recent paper "Nomothetic and idiographic symptom change trajectories in acute-phase cognitive therapy for recurrent depression." 

The last of the four themes I'm mentioning is recently published work on the effects of early life conflict & abuse.  There are a series of articles linking trauma to psychosis and to bipolar disorder - for example Kelleher et al's "Childhood trauma and psychosis in a prospective cohort study: Cause, effect, and directionality" and Larsson et al's "Patterns of childhood adverse events are associated with clinical characteristics of bipolar disorder."  There are also a bunch of studies on forms of bullying - for example Copeland et al's "Adult psychiatric outcomes of bullying and being bullied by peers in childhood and adolescence" and Lang et al's "Influence of problematic child-teacher relationships on future psychiatric disorder: Population survey with 3-year follow-up."  And additionally there's a somewhat shocking paper on the biological effects of trauma by Heim et al. "Decreased cortical representation of genital somatosensory field after childhood sexual abuse" with its conclusion "Neural plasticity during development appears to result in cortical adaptation that may shield a child from the sensory processing of the specific abusive experience by altering cortical representation fields in a regionally highly specific manner. Such plastic reorganization may be protective for the child living under abusive conditions, but it may underlie the development of behavioral problems, such as sexual dysfunction, later in life."  Worrying ... but there's hope too in very recent developments in our understanding of how much experience can effect gene expression positively as well as negatively, sometimes in a matter of minutes.  See, for example, the fascinating interviews reported in "The social life of genes" with comments about the powerful mind-body effects achievable through psychotherapy and Professor Steve Cole of UCLA's admonition that "A cell is a machine for turning experience into biology" and, more challengingly, that "Your experiences today will influence the molecular composition of your body for the next two to three months or, perhaps, for the rest of your life. Plan your day accordingly."

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