Maladaptive schemas of patients with functional neurological symptom disorder.

BACKGROUND: The psychological underpinnings of functional neurological symptom disorders (FNSD) remain poorly understood. A disintegration of explicit and implicit information processing in patients with FNSD has previously been suggested; however, this suggestion has so far received little empirical support. Trauma and maladaptive schemas probably reinforce disintegration in FNSD. The present study explored the occurrence of maladaptive schemas and investigated the impact of trauma-related maladaptive schemas in patients with FNSD. METHODS: Forty-eight FNSD patients were assessed at the start of treatment using the Young Schema Questionnaire (YSQ-2) to explore maladaptive schemas. The Life Event Checklist (LEC-5) and the PTSD Checklist for DSM-5 (PCL-5) were used to explore trauma states, and the Sickness Impact Profile (SIP-68) was used to measure health dysfunction. RESULTS: The self-sacrifice schema scored within a clinically relevant range where no increased scores were found in other maladaptive schemas. Linear regression models showed a positive association between mistrust/abuse and severity of health dysfunction. DISCUSSION: Results suggest that maladaptive schemas play a modest role in FNSD at the start of treatment. It is suggested to examine the occurrence of maladaptive schemas in FNS-disordered patients with a longitudinal design.

A randomized trial of cognitive-behavioral therapy or selective serotonin reuptake inhibitor or both combined for panic disorder with or without agoraphobia: treatment results through 1-year follow-up.

OBJECTIVE: To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated. METHOD: Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2). RESULTS: In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P < .001), degree of coping (P < .001), and remitter status (P < .001), as well as on the secondary outcome measures of depressive symptomatology (P < .001), and from pretest to posttest 2 for health-related quality of life (P < .001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P < .05) more satisfied than those receiving CBT only. CONCLUSIONS: No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner. TRIAL REGISTRATION: Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.

Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial.

OBJECTIVE: This study, to the authors' knowledge, is the first randomized controlled trial comparing the efficacy of cognitive behavior therapy (CBT), paroxetine, and a placebo (administered in a double blind fashion) in the treatment of hypochondriasis. METHOD: The authors randomly assigned 112 subjects with hypochondriasis according to DSM-IV criteria to 16 weeks of outpatient treatment with CBT, paroxetine, or a placebo. The main outcome measure was the Whiteley Index. The authors made pretest and posttest assessments and analyzed all outcome measures using a General Linear Model 3x2 repeated measures analysis of variance with Helmert contrasts. The authors considered subjects who scored at least one standard deviation below the mean pretest score on the Whiteley Index as responders. All analyses were conducted on intent-to-treat and completer bases. RESULTS: On the Whiteley Index, Helmert contrasts on the intent-to-treat and completer cohorts revealed that pooled CBT and paroxetine were significantly superior to placebo, but did not differ significantly from each other. The responder analysis on the intent-to-treat cohort and completer cohort, respectively, revealed the following percentages of responders per group: CBT group, 45% and 54%; paroxetine group, 30% and 38%; and placebo group, 14% and 12%. In the intent-to-treat analysis, only CBT differed significantly from the placebo. In the completer analysis, both paroxetine and CBT differed significantly from the placebo. CONCLUSIONS: CBT or paroxetine are effective short-term treatment options for subjects with hypochondriasis.

Investigation of the syndrome of apotemnophilia and course of a cognitive-behavioural therapy.

BACKGROUND: The syndrome of apotemnophilia, body integrity or amputee identity disorder, is defined as the desire for amputation of a healthy limb, and may be accompanied by behaviour of pretending to be an amputee and sometimes, but not necessarily, by sexual arousal. SAMPLING AND METHODS: A case history is presented of a 35-year-old man who was referred because of his desire for amputation of his left leg, without sexual connotations. The course of a combined cognitive behavioural psychotherapy with SSRI treatment is described. RESULTS: Symptoms showed considerable similarity with obsessive-compulsive disorder, and some similarity with body dysmorphic disorder according to DSM-IV, but the core symptom seemed to be strongly connected with a sense of identity. Treatment with a selective serotonin re-uptake inhibitor decreased levels of distress only. The effects of cognitive restructuring of the psychotherapy were limited, whereas the behavioural elements substantially reduced the behaviour of pretending to be an amputee. CONCLUSIONS: The rare syndrome of apotemnophilia raises unresolved questions of classification. Psychotic disorders should be ruled out carefully. The model designed in the current cognitive behavioural approach may serve as a starting point for further development of intervention protocols for this rare disorder.

Treatment of anxiety disorders in primary care practice: a randomised controlled trial.

BACKGROUND: Anxiety disorders are prevalent in primary care. Psychological treatment is effective but time-consuming, and there are waiting lists for secondary care. Interest has therefore grown in developing guidelines for treatment that would be feasible in primary care. AIM: To compare the effectiveness and feasibility of guided self-help, the Anxiety Disorder Guidelines of the Netherlands College of General Practitioners and cognitive behavioural therapy (CBT). DESIGN OF STUDY: Randomised controlled study lasting 12 weeks with follow-up at 3 and 9 months for primary care patients with panic disorder and/or generalised anxiety disorder. SETTING: The first two forms of treatment were carried out by 46 GPs who were randomly assigned to one or the other form. CBT was carried out by cognitive behaviour therapists in a psychiatric outpatient clinic. METHOD: Participants (n = 154) were randomly assigned to one of the three forms of treatment. The main outcome measure used was the state subscale of the Spielberger Anxiety Inventory. RESULTS: All three forms of treatment gave significant improvement between pre-test and post-test, and this improvement remained stable between post-test and the follow-ups. The results obtained with the three treatment forms did not differ significantly over time. The feasibility of the Anxiety Disorder Guidelines was low compared with that of guided self-help. CONCLUSION: Our results indicate that primary care patients with prevalent anxiety disorders for whom the GP does not find referral necessary can be adequately treated by the GP. Psychiatric outpatient clinic referral does not give superior results. Guided self-help is easier for the GP to carry out than a less highly-structured treatment like that laid down in the Anxiety Disorder Guidelines.