Therapist contribution, client reflective functioning, and alliance rupture-repair: A microprocess case study of psychodynamic therapy for pregnancy after loss.

Meta-analysis has found a significant relation between rupture-repair and client outcome (Eubanks et al., 2018). Rupture-repair processes may be particularly important in psychotherapy for pregnancy loss wherein ruptures related to client feelings of shame and inadequacy, the societal invalidation of perinatal grief, and reenactments in the therapy relationship of early attachment experiences have been theorized to be common and important events (Markin, 2024). Thus, it is important to understand what occurs on a microlevel during the process of therapy to ultimately explain the rupture resolution (RR) and treatment outcome association. In particular, while both the therapist and client are believed to contribute to ruptures and to their repair (Safran & Muran, 2000), little is known about how therapist contributions impact rupture events, rupture resolution, and treatment progress. Further, client reflective functioning (RF) may represent a set of capacities that contribute to and are increased by rupture resolution yet vary depending on the role of the therapist in the rupture. The current investigation examined how observer-rated therapist contribution to ruptures and client RF were related to rupture events, rupture resolution, and client-reported symptom change and session quality over 22 sessions of psychodynamic therapy for pregnancy after loss. Therapist contribution to ruptures predicted rupture significance, high and steady within-session client RF scores, and symptom change. Client RF and rupture resolution predicted symptom change differently, often depending on type of symptom. Importantly, client RF and rupture resolution may predict successful outcomes through ameliorating commonly reported symptoms during pregnancies after loss. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data.

BACKGROUND: Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions. METHODS: PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models. RESULTS: IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations. CONCLUSIONS: These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

How does hostile resistance interfere with the benefits of cognitive-behavioral therapy for panic disorder? The role of therapist adherence and working alliance.

Objective Although clients' hostile behavior directed at therapists (hostile resistance) predicts worse outcomes in cognitive-behavioral therapy (CBT) for panic disorder, the process by which this happens remains unknown. This study examines two putative mechanisms: working alliance and therapist adherence. Method: Seventy-one adults with primary panic disorder received CBT in a larger trial. Hostile resistance and adherence in Sessions 2 and 10 were reliably coded using observer-rated measures; client- and therapist-rated questionnaires assessed working alliance. Outcome measures were attrition and symptomatic improvement, assessed at multiple timepoints with the Panic Disorder Severity Scale. Results: Hostile resistance was significantly related to both preexisting (r = -.36, p = .04) and subsequent declines (r = -.58, p < .0001) in the working alliance. Nevertheless, hierarchical linear modeling revealed that neither a declining alliance nor therapist adherence (whether treated as linear or curvilinear) was independently predictive of symptom change, nor did these factors mediate hostile resistance's association with worse symptomatic improvement. Exploratory logistic regressions similarly indicated that neither adherence nor alliance moderated whether hostilely resistant clients dropped out. Conclusion: This is the first study to establish a bidirectional association between hostile resistance and a declining working alliance. Findings also add to a mixed literature on the adherence-outcome relationship.

The Association Between Political Climate and Trainees' Supervision Experiences and Needs.

This study examined whether political climate influenced trainees' clinical work, supervisory experiences, and supervisory alliance. Data were collected from 366 trainees in a nationwide survey. Most trainees believed the political atmosphere affected clients to some degree. Over half reported political dialogue with supervisors, more often when political affiliation was similar. Supervisory alliances were most positive when trainees were aware of their supervisors' political beliefs, regardless of agreement. Trainees wanted supervisors to provide greater awareness of multicultural issues and political climate in their clinical work. We recommend that supervisors invite trainees to discuss political effects on their clinical work.

Psychometric properties of concussion knowledge and cognitive mediators of reporting measures.

Context: Concussion education and prevention programs require reliable and valid instruments to evaluate the theory, mechanisms, and outcome of these interventions Objective: To assess the psychometric properties of measures evaluating concussion education and prevention programsDesign: Descriptive epidemiological Setting: 10 NCAA-member universities Patients or Other Participants: 841 student-athletes in an RCT control group testing an ecological, peer-led concussion education program Main Outcome Measures: Instruments adapted for assessing concussion knowledge and Theory of Planned Behavior/Theory of Reasoned Action (TPB/TRA) cognitive mediators of reporting behavior (attitudes, subjective norms, perceived control, and intentions to report concussion). Participants completed measures at baseline, after one hour, and after one month Results: Internal consistency and test-retest reliability were moderate for both the concussion knowledge and cognitive mediator measures. TPB/TRA was supported subscale intercorrelation and item factor analysis in the cognitive mediator scale. Factor analysis of the concussion knowledge measure revealed subscales for physical/cognitive, psychological/affective, and non-symptoms. The intermediate TPB/TRA mediators of attitudes, norms, and perceived control predicted greater intention-to-report, which predicted increased likelihood of reporting concussion one month later.Conclusions: Measures of concussion knowledge and cognitive mediators of reporting adapted from the literature show adequate psychometric properties and support TPB/TRA application for concussion reporting behaviors.

Randomized Controlled Trial of a Novel Peer Concussion-Education Program for Collegiate Athletes.

CONTEXT: The National Collegiate Athletic Association and US Department of Defense have called for educational programs to change the culture of concussion reporting, increase reporting behavior, and enhance the safety of players and service members. OBJECTIVE: To evaluate the effects of a novel peer concussion-education program (PCEP) in changing knowledge, attitudes, and norms about concussion reporting among collegiate student-athletes and assess program implementation. DESIGN: Randomized controlled trial and qualitative analysis of interviews. SETTING: National Collegiate Athletic Association athletic teams from randomly selected colleges or universities. PATIENTS OR OTHER PARTICIPANTS: A total of 1614 male and female student-athletes from 60 teams at 10 colleges and universities and 8 athletic trainers. INTERVENTION(S): The PCEP intervention trains 2 peer concussion educators to provide 2 education modules to their teammates. Knowledge, attitudes (oneself and teammates), and concussion occurrence or reporting were assessed at baseline, postintervention, and 1 month later. Eight athletic trainers were interviewed about program implementation. RESULTS: Compared with the control group, the intervention group showed greater increases occurred postintervention and at 1 month in concussion knowledge (F1,2648 = 51.3, P < .0001), intention to report (oneself, F2,2633 = 82.3, P < .0001; teammates, F2,2624 = 53.9, P < .0001), return-to-play protocol knowledge, (F2,2632 = 28.4, P < .0001), direct subjective norms (oneself, F2,2625 = 51.7, P < .0001; teammates, F2,2644 = 40.6, P < .0001), direct perceived behavioral control (oneself, F2,2628 = 53.7, P < .0001; teammates, F2,2615 = 68.2, P < .0001), and indirect attitudes (oneself, F2,2626 = 47.1, P < .001; teammates, F2,2623 = 40.9, P < .0001). Peer concussion-education program participants discussed concussion more often with a teammate (F1,1396 = 13.96, P < .0001) or athletic staff (F1,1396 = 6.62, P < .001). Qualitative program analysis revealed both positive aspects of the PCEP and areas for improvement. CONCLUSIONS: The PCEP showed promise in increasing concussion knowledge, intention to report concussion, reporting a teammate's concussion, and facilitating attitudinal changes that support reporting among student-athletes.

Processes of therapeutic change: Results from the Cornell-Penn Study of Psychotherapies for Panic Disorder.

To examine process of changes in two distinct psychotherapies-cognitive-behavioral therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP). Two hypothesized processes of change-misinterpretation of bodily sensations and Panic Specific Reflective Function (PSRF)-were tested in the CBT and PFPP arms of the Cornell-Penn Study of Psychotherapies for Panic Disorder. The Brief Bodily Sensations Interpretation Questionnaire (BBSIQ) measures misinterpretation of bodily sensations-a focus of CBT interventions. PSRF, a target of PFPP, assesses the capacity to reflect on the underlying meaning of panic symptoms. A sample of 138 patients (37.7% men, 72.56% Whites, and 16.7% Latinx) with primary Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) panic disorder were included in the present analyses. Mixed effects models tested the effects of early change in BBSIQ and PSRF (intake through Week 5) on subsequent change in the Panic Disorder Severity Scale (PDSS; Week 5 through termination). Early change on both PSRF and BBSIQ predicted subsequent change in panic severity across the two treatments. As predicted, PSRF changed more in PFPP than in CBT, but, contrary to expectation, BBSIQ showed comparable changes in both groups. Counterintuitively, CBT patients benefited more in terms of panic symptom improvement when their PSRF improved than did PFPP patients. This is the first demonstration of general processes of change (PSRF and BBSIQ) across psychotherapies for panic disorder, suggesting that to the extent patients change their beliefs about the meaning of panic, their panic symptoms improve in time-limited, panic-focused psychotherapies. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Differential effects of alliance and techniques on Panic-Specific Reflective Function and misinterpretation of bodily sensations in two treatments for panic.

ABSTRACTObjective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

The process and outcome of psychodynamic psychotherapy for pregnancy after loss: A case study analysis.

This is an evidence-based case study examining the process and outcome of 22 prenatal sessions and 1 postpartum follow-up session of psychodynamic therapy for a woman pregnant after a history of repeated pregnancy losses. Self-report measures of depression, anxiety, pregnancy-specific anxiety, prenatal attachment, trauma, and perinatal grief were completed prior to each session. A session quality item was completed after each session and a therapy outcome measure at termination and follow-up. The therapist and the patient completed an exit interview on the therapy relationship, which focused on moments of tension or misunderstanding, over the course of treatment. All sessions were transcribed and scored by certified raters for reflective functioning. Results suggest that the patient experienced reliable and clinically significant change on all pregnancy-specific measures, with most change happening in the early phase of treatment. However, general symptoms of depression and anxiety were variable and highly volatile over time. Exit interviews suggest that therapist empathy and validation were helpful in promoting change on pregnancy-specific symptoms, whereas problems or ruptures in the alliance may have been associated with a lack of change on general psychiatric symptoms. The patient showed little change on reflective functioning, perhaps contributing to ruptures in psychotherapy and lack of change on general psychiatric symptoms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A meta-analysis of psychodynamic treatments for borderline and cluster C personality disorders.

Personality disorders (PD) carry high psychosocial dysfunction and are associated with treatment resistance in nonspecialized care. Psychodynamic therapies (PDT) are often used to treat PDs, but there has never been a systematic meta-analysis of PDT trials for PD. To evaluate the evidence base for PDTs for PDs across multiple outcome domain, a systematic search for PDT for PD trials was conducted through PubMed and PsycINFO. Sixteen trials were identified, comprising 19 dynamic, 8 active, and 9 control groups predominantly reflecting treatment of borderline and mixed Cluster C PDs, and a random effects meta-analysis was undertaken. PDTs were superior to controls in improving core PD symptoms (g = -0.63; 95% confidence interval [CI; -0.87, -0.41]), suicidality (g = -0.79, p = .02; 95% CI [-1.38, -0.20]), general psychiatric symptoms (g = -0.47; 95% CI [-0.69, -0.25]), and functioning (g = -0.66; 95% CI [-1.01, -0.32]), but not for interpersonal problems due to heterogeneity (g = -1.25; 95% CI [-3.22, 0.71]). Outcomes for PDTs were not different from other active treatments in core PD (g = 0.05; 95% CI [-0.25, 0.35]) or other symptoms. This pattern continued into posttreatment follow-up (average 14 months). Study quality was generally rated as adequate and was unrelated to outcomes. Compared with other treatments, PDTs do not have different acute effects and are superior to controls, although only trials treating BPD employed active controls and non-BPD trials were of lower quality. Underresearched areas include narcissistic PD, specific Cluster C disorders, and personality pathology as a continuous construct. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Postelection stress: Symptoms, relationships, and counseling service utilization in clients before and after the 2016 U.S. national election.

The 2016 U.S. national election brought increased anxiety, relationship conflict, and counseling utilization for many Americans, especially among women, millennials, racial and ethnic minority (REM) members, and economically disadvantaged persons. The present study examined psychological symptoms, interpersonal tension, and counseling service requests over 36 months of data (April 2015-March 2018) from 56 clients and 14 therapists engaged in a routine outcomes monitoring project at a training community counseling center. Clients resided in a Democratic-leaning area in a Republican-voting state, and 78% were women, 53% were under 30 years of age, 33% were an REM, and 92% earned below the median state income level. Symptoms did not show an association with the political climate, and interpersonal problems reduced during counseling. Although interpersonal conflict decreased prior to the election, it increased afterward, largely due to problems of dominance and control in relationships. Younger and REM individuals showed larger increases in interpersonal tension after the election than did older and non-REM persons. Alliances decreased over the entire data-collection period. Counseling intakes increased after the election, although potentially due to seasonal patterns. With attention to the effect of political events on individuals, the field of counseling psychology may be able to help clients and the larger society manage difficult interactions around real differences in political opinions and disparities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Client resistance predicts outcomes in cognitive-behavioral therapy for panic disorder.

Objective: Little is known about how therapy processes relate to outcome in cognitive-behavioral therapy (CBT) for panic disorder (PD). This study examined whether client resistance predicts CBT for PD outcomes beyond the effects of established pre-treatment predictors. A secondary aim was to assess the consistency of resistance over treatment. Method: Data were from 71 adults participating in up to 24 biweekly sessions of CBT in a randomized controlled trial. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Trained coders reliably rated resistance in videos of Sessions 2 and 10 using the Client Resistance Code. Results: Resistance was found to be moderately consistent (r = .64). Although overall resistance was unrelated to outcomes, hierarchical linear modeling revealed that openly hostile resistance at Session 10 predicted significantly diminished symptom change (r = .28, CI95% = [.01, .51]), beyond the effects of pretreatment predictors. Hostile resistance at Session 2 predicted attrition (rrb = -.30, p = .001), even after established predictors were controlled. Conclusions: Although some forms of resistance may be benign, openly hostile resistance is an important therapy marker that warrants increased clinical and research attention.

The Multitheoretical List of Therapeutic Interventions - 30 items (MULTI-30).

Objective: To develop a brief version of the Multitheoretical List of Therapeutic Interventions (MULTI-60) in order to decrease completion time burden by approximately half, while maintaining content coverage. Study 1 aimed to select 30 items. Study 2 aimed to examine the reliability and internal consistency of the MULTI-30. Study 3 aimed to validate the MULTI-30 and ensure content coverage. Method: In Study 1, the sample included 186 therapist and 255 patient MULTI ratings, and 164 ratings of sessions coded by trained observers. Internal consistency (Chronbach's alpha and McDonald's omega) was calculated and confirmatory factor analysis was conducted. Psychotherapy experts rated content relevance. Study 2 included a sample of 644 patient and 522 therapist ratings, and 793 codings of psychotherapy sessions. In Study 3, the sample included 33 codings of sessions. A series of regression analyses was conducted to examine replication of previously published findings using the MULTI-30. Results: The MULTI-30 was found valid, reliable, and internally consistent across 2564 ratings examined across the three studies presented. Conclusion: The MULTI-30 a brief and reliable process measure. Future studies are required for further validation. Clinical or methodological significance of this article: The MULTI-30, developed and validated in this study, is a valid, reliable, and cost-effective brief measure which could be used to assess patients, therapists, and observers' perceptions of use of interventions from eight major therapeutic approaches. The MULTI-30 could be used to examine the role of use of specific interventions on process and outcome of different treatment modalities. It could also be used as a clinical tool in teaching, training, and supervision.

Twelve-Month Outcomes Following Successful Panic-Focused Psychodynamic Psychotherapy, Cognitive-Behavioral Therapy, or Applied Relaxation Training for Panic Disorder.

OBJECTIVE: Given the chronic, episodic nature of panic disorder, it is important to examine long-term outcomes of patients who respond well to various psychotherapies. METHOD: Out of 116 patients with DSM-IV panic disorder who evidenced a ≥ 40% reduction in panic and avoidance symptoms on the Panic Disorder Severity Scale (PDSS) after 12-14 weeks of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation training as part of a 2-site randomized controlled trial conducted between January 2007 and July 2012, 91 patients provided at least 1 PDSS datapoint during follow-up. Patients were assessed at each of the 12 following months using the PDSS, the Sheehan Disability Scale (SDS), and the Hamilton Depression Rating Scale (HDRS) and twice during the follow-up period with the Anxiety Disorders Interview Schedule. RESULTS: Patients with panic disorder who responded to 1 of 3 treatments maintained their gains on the PDSS, SDS, and HDRS with no differences by condition in rates of change over the follow-up period (all P values ≥ .20). Similarly, 57% of improved patients did not have a panic disorder diagnosis by the end of 1 year, regardless of the treatment received. No differences in rates of panic disorder diagnosis were found across treatment conditions at either 6 months or 12 months (all P values ≥ .78). Results should be interpreted in light of the fact that patients giving data at follow-up experienced lower symptom levels at treatment termination than those not providing data. CONCLUSIONS: Improvement in any of the 3 treatments examined in this trial was largely maintained for a year following the end of therapy. Future treatment development could focus on factors to increase the level of response in the active phase of therapy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00353470.

Fluctuations in alliance and use of techniques over time: A bidirectional relation between use of "common factors" techniques and the development of the working alliance.

OBJECTIVE: The aim of this study was twofold: (a) Investigate whether therapists are consistent in their use of therapeutic techniques throughout supportive-expressive therapy (SET) and (b) Examine the bi-directional relation between therapists' use of therapeutic techniques and the working alliance over the course of SET. METHOD: Thirty-seven depressed patients were assigned to 16 weeks of SET as part of a larger randomized clinical trial (Barber, Barrett, Gallop, Rynn, & Rickels, ). Working Alliance Inventory-Short Form (WAI-SF) was collected at Weeks 2, 4, and 8. Use of therapeutic interventions was rated by independent observers using the Multitheoretical List of Therapeutic Interventions (MULTI). Intraclass correlation coefficients assessed therapists' consistency in use of techniques. A cross-lagged path analysis estimated the working alliance inventory- Multitheoretical List of Therapeutic Interventions bidirectional relation across time. RESULTS: Therapists were moderately consistent in their use of prescribed techniques (psychodynamic, process-experiential, and person-centred). However, they were inconsistent, or more flexible, in their use of "common factors" techniques (e.g., empathy, active listening, hope, and encouragements). A positive bidirectional relation was found between use of common factors techniques and the working alliance, such that initial high levels of common factors (but not prescribed) techniques predicted higher alliance later on and vice versa. CONCLUSION: Therapists tend to modulate their use of common factors techniques across treatment. Additionally, when a strong working alliance is developed early in treatment, therapists tend to use more common factors later on. Moreover, high use of common factors techniques is predictive of later improvement in the alliance.

The Process of Change in Ethnic Minority Males Undergoing Psychodynamic Psychotherapy: A detailed comparison of two cases.

OBJECTIVE: Better understanding of the connection between therapeutic processes and outcomes in minority groups can help design and use culturally-adapted treatments. METHOD: To explore the active ingredient in the therapeutic process, the present case study compared two ethnic minority male clients, recruited as part of a randomized controlled trial (RCT), one with a good outcome, the other with a poor one. The 12-item Working Alliance Inventory-Observer (S-WAI-O) coding system was used to capture the process of change, alongside a qualitative analysis of content. The cases were identified based on their change in pre- to post-treatment scores on the Beck Depression Inventory (BDI) and the Hamilton Rating Scale for Depression (HRSD). RESULTS: The findings suggest a rupture-resolution process in the good outcome case, including a process of negotiation of the alliance and work on issues of trust. In contrast, the poor outcome case showed strong and steady alliance, but context analysis pointed to withdrawal ruptures. CONCLUSIONS: Although it is difficult to generalize from a two-case study analysis, the present work suggests that building and negotiating alliance with minority clients has a potential for treatment success.

Prediction and moderation of improvement in cognitive-behavioral and psychodynamic psychotherapy for panic disorder.

OBJECTIVE: To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients. METHOD: Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS). RESULTS: Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment. CONCLUSIONS: Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

Psychometric Properties of the Reconstructed Hamilton Depression and Anxiety Scales.

Although widely used, the Hamilton Rating Scale for Depression (HRSD) and Hamilton Anxiety Rating Scale (HARS) discriminate poorly between depression and anxiety. To address this problem, Riskind, Beck, Brown, and Steer (J Nerv Ment Dis. 175:474-479, 1987) created the Reconstructed Hamilton Scales by reconfiguring HRSD and HARS items into modified scales. To further analyze the reconstructed scales, we examined their factor structure and criterion-related validity in a sample of patients with major depressive disorder and no comorbid anxiety disorders (n = 215) or with panic disorder and no comorbid mood disorders (n = 149). Factor analysis results were largely consistent with those of Riskind et al. The correlation between the new reconstructed scales was small. Compared with the original scales, the new reconstructed scales correlated more strongly with diagnosis in the expected direction. The findings recommend the use of the reconstructed HRSD over the original HRSD but highlight problems with the criterion-related validity of the original and reconstructed HARS.

Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension.

OBJECTIVE: We tested the relation of perceived criticism (PC) from a parent or spouse/romantic partner to outcome of psychotherapy for panic disorder (PD). METHOD: Participants were 130 patients with PD (79% with agoraphobia) who received 24 twice-weekly sessions of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation therapy. Patients were predominantly White (75%), female (64%), and non-Hispanic (85%). At baseline, Week 5 of treatment, termination, and at 6- and 12-month follow-up, patients rated PC from the relative with whom they lived. Independent evaluators assessed the severity of PD at baseline, Weeks 1, 5, and 9 of treatment, termination, and the 2 follow-up points. Data were analyzed with piecewise (treatment phase, follow-up phase) latent growth curve modeling. RESULTS: The latent intercept for PC at baseline predicted the latent slope for panic severity in the follow-up (p = .04) but not the active treatment phase (p = .50). In contrast, the latent intercept for PD severity at baseline did not predict the latent slope on PC in either phase (ps ≥ .29). Nor did the slopes of PC and PD severity covary across treatment (p = .31) or follow-up (p = .13). Indeed, PC did not change significantly across treatment (p = .45), showing the stability of this perception regardless of significant change in severity of patients' PD (p < .001). CONCLUSIONS: Because PC predicts worse long-term treatment outcome for PD, study findings argue for interventions to address perceived criticism in treatment. (PsycINFO Database Record

Psychotherapies for Panic Disorder: A Tale of Two Sites.

OBJECTIVE: To compare cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), and applied relaxation training (ART) for primary DSM-IV panic disorder with and without agoraphobia in a 2-site randomized controlled trial. METHOD: 201 patients were stratified for site and DSM-IV agoraphobia and depression and were randomized to CBT, PFPP, or ART (19-24 sessions) over 12 weeks in a 2:2:1 ratio at Weill Cornell Medical College (New York, New York) and University of Pennsylvania ("Penn"; Philadelphia, Pennsylvania). Any medication was held constant. RESULTS: Attrition rates were ART, 41%; CBT, 25%; and PFPP, 22%. The most symptomatic patients were more likely to drop out of ART than CBT or PFPP (P = .013). Outcome analyses revealed site-by-treatment interactions in speed of Panic Disorder Severity Scale (PDSS) change over time (P = .013). At Cornell, no differences emerged on improvement on the primary outcome, estimated speed of change over time on the PDSS; at Penn, ART (P = .025) and CBT (P = .009) showed greater improvement at treatment termination than PFPP. A site-by-treatment interaction (P = .016) for a priori-defined response (40% PDSS reduction) showed significant differences at Cornell: ART 30%, CBT 65%, PFPP 71% (P = .007), but not at Penn: ART 63%, CBT 60%, PFPP 48% (P = .37). Penn patients were more symptomatic, differed demographically from Cornell patients, had a 7.2-fold greater likelihood of taking medication, and had a 28-fold greater likelihood of taking benzodiazepines. However, these differences did not explain site-by-treatment interactions. CONCLUSIONS: All treatments substantially improved panic disorder with or without agoraphobia, but patients, particularly the most severely ill, found ART less acceptable. CBT showed the most consistent performance across sites; however, the results for PFPP showed the promise of psychodynamic psychotherapy for this disorder. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00353470.