Changes in quality of life following cognitive-behavioral group therapy for panic disorder.

BACKGROUND: Data about quality of life (QoL) are important to estimate the impact of diseases on functioning and well-being. The present study was designed to assess the association of different aspects of panic disorder (PD) with QoL and to examine the relationship between QoL and symptomatic outcome following brief cognitive-behavioral group therapy (CBGT). METHOD: The sample consisted of 55 consecutively recruited outpatients suffering from PD who underwent CBGT. QoL was assessed by the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at baseline, post-treatment and six months follow-up. SF-36 baseline scores were compared with normative data obtained from a large German population sample. RESULTS: Agoraphobia, disability, and worries about health were significantly associated with decreased QoL, whereas frequency, severity and duration of panic attacks were not. Treatment responders showed significantly better QoL than non-responders. PD symptom reduction following CBGT was associated with considerable improvement in emotional and physical aspects of QoL. However, the vitality subscale of the SF-36 remained largely unchanged over time. CONCLUSIONS: Our results are encouraging for cognitive-behavior therapists who treat patients suffering from PD in groups, since decrease of PD symptoms appears to be associated with considerable improvements in QoL. Nevertheless, additional interventions designed to target specific aspects of QoL, in particular vitality, may be useful to enhance patients' well-being.

Enhanced perceived responsibility decreases metamemory but not memory accuracy in obsessive-compulsive disorder (OCD).

Mixed findings have been obtained in prior research with respect to the presence and severity of memory and metamemory deficits in obsessive-compulsive disorder (OCD). We tested the hypothesis that experimentally induced increments of subjective responsibility would lead to a disproportionately strong decline of memory confidence and enhanced response latencies in OCD while leaving memory accuracy unaffected. Twenty-eight OCD patients and 28 healthy controls were presented a computerized memory test framed with two different scenarios. In the neutral scenario, the participant was requested to imagine purchasing 15 items from a do-it-yourself store. In the recognition phase, the 15 needed items were presented along with 15 distractor items. The participant was asked to decide whether items were on his or her shopping list or not, graded by subjective confidence. In the responsibility scenario, the general experimental setup was analogous except that the participant now had to envision that he or she was a helper in a region recently struck by an earthquake, dispatched to provide 15 urgently needed goods from a nearby town. In line with prior work by our group, samples did not differ in either condition on memory accuracy in a subsequent recognition task. As hypothesized, OCD participants were less certain in their responses for the high responsibility condition than controls. Whereas patients and controls did not differ in their subjective estimates for memorized items, patients expressed stronger doubt that their earthquake mission was successful. The findings indicate that low memory confidence in OCD may only be elicited in situations where perceived responsibility is high and that patients may share higher performance standards ("good is not good enough") than controls when perceived responsibility is inflated.

The cardiothoracic ratio in AGA and SGA very low birth weight newborn infants.

BACKGROUND: Cardiothoracic (CT) ratio is a common measurement used to assess heart size in chest radiographs of pediatric patients, but no recent studies have analyzed the standards for CT ratios in very low birth weight (VLBW) infants. OBJECTIVE: The aim of this study was to provide improved standards for CT ratios measured from chest radiographs of VLBW (<1500 g) infants, and to compare CT ratios between small for gestational age (SGA) and appropriate for gestational age (AGA) infants in this population. DESIGN/METHODS: Among VLBW infants admitted to the Jacobi Medical Center NICU from 2002 to 2004, CT ratios were calculated from anteroposterior supine chest radiographs taken of 54 VLBW infants (18 SGA and 36 AGA group-matched on the basis of birthweight and sex) during the first 24 h of life. RESULTS: There were no significant differences between the two groups with respect to birthweight, sex, 1-min Apgar score, 5-min Apgar score, intubation status and degree of inspiration. Median GA of the SGA infants was significantly greater than the AGA infants (30 and 27 weeks, respectively; P<0.001). CT ratios among SGA infants were significantly larger than those among AGAs. Using the widest internal width of the bony thorax, the mean CT ratio among SGA and AGA infants was 0.523 and 0.479, respectively (P=0.00102). CONCLUSIONS: VLBW SGA infants have larger CT ratios than VLBW AGA infants, suggesting that existing standards for normal CT ratios may be inappropriate for use among SGA infants.

Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome.

OBJECTIVE: A significant number of patients with obsessive-compulsive disorder (OCD) fail to benefit sufficiently from treatments. This study aimed to evaluate whether certain OCD symptom dimensions were associated with cognitive-behavioral therapy (CBT) outcome. METHOD: Symptoms of 104 CBT-treated in-patients with OCD were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale symptom checklist. Logistic regression analyses examined outcome predictors. RESULTS: The most frequent OCD symptoms were aggressive and contamination obsessions, and compulsive checking and cleaning. Patients with hoarding symptoms at baseline (n = 19) were significantly less likely to become treatment responders as compared to patients without these symptoms. Patients with sexual and religious obsessions tended to respond less frequently, although this failed to reach statistical significance (P = 0.07). Regression analyses revealed that higher scores on the hoarding dimension were predictive of non-response, even after controlling for possible confounding variables. CONCLUSION: Our results strongly indicate that in-patients with obsessive-compulsive hoarding respond poorly to CBT.

[Specific behaviour therapy day clinic]. / Die spezifische Verhaltenstherapie-Tagesklinik.

Psychiatric day care has a long tradition. However, psychotherapeutic day care institutions specialising in particular disorders or certain therapeutic approaches are still the exception. A day care unit for behaviour therapy was established at the Clinic for Psychiatry and Psychotherapy, University Hospital Hamburg-Eppendorf in 1998 as part of a complex inpatient, day care, and outpatient behaviour therapy unit. The immediate and high acceptance by patients and their doctors indicates a strong need of such a treatment setting. We present how this day care unit works and how it differs from the traditional psychiatric day care.

Impact of comorbid depressive symptoms on neuropsychological performance in obsessive-compulsive disorder.

There is indirect evidence from previous research that several executive disturbances in obsessive-compulsive disorder (OCD) are mediated by comorbid depressive symptoms. For the present study, the authors investigated whether OCD patients with elevated Hamilton Rating Scale for Depression (HRSD) scores would exhibit deficits in tasks sensitive to the medial and dorsolateral frontal cortex as well as other executive tasks. The 36 OCD patients were split along the median according to their HRSD scores and compared with matched control subjects. Patients with high HRSD scores performed significantly worse than control subjects and patients with low HRSD scores on the Wisconsin Card Sorting Test, the Trail-Making Test (TMT, Part B), and the TMT difference score. Moreover, patients with high HRSD scores exhibited deficits on a (creative) verbal fluency task. It is suggested that comorbid depressive symptoms may have artificially inflated some executive deficit scores in previous studies.

The effects of intrauterine cocaine exposure on the respiratory status of the very low birth weight infant.

OBJECTIVES: This study examined the effects of intrauterine cocaine exposure on very low birth weight infants with respect to their surfactant requirement and need for ventilatory support. STUDY DESIGN: A retrospective cohort study was conducted on infants with birth weight between 750 and 1500 g admitted to the neonatal intensive care unit between January 1992 and January 1995. RESULTS: Of the 149 infants studied, 48 infants were exposed only to cocaine and 101 infants had no drug exposure. There were no significant differences between the two groups for gestational age, sex, abruptio placenta, prolonged rupture of membranes, and antenatal steroid usage. The cocaine-exposed group had a significantly greater birth weight (1190 vs. 1109, p<0.02), less prenatal care (48% vs. 14%, p<0.00007), older maternal age (30 vs. 24, p<0.00002), more black race (79% vs. 57%, p<0.01), and more rapid plasma reagin (RPR) positivity (25% vs. 2%, p<0.00006). There were no significant differences in median APGAR scores, or incidence of necrotizing enterocolitis, retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH), and bronchopulmonary dysplasia (BPD) between the two groups. Cocaine-exposed infants received surfactant treatment less often (73% vs. 48%, p<0.0035), received fewer mean doses of surfactant (0.4 vs. 10.0, p<0.0014), and were intubated less frequently (44% vs. 65%, p<0.012). There was no significant difference between groups for intubation at 24 and 48 hours and for the development of bronchopulmonary dysplasia. CONCLUSION: Perinatal cocaine exposure appears to have some significant short-term effects on the need for surfactant replacement therapy and need for initial intubation in respiratory distress syndrome (RDS) but no overall effect on the development of BPD.

Serum cholesterol in patients with obsessive compulsive disorder during treatment with behavior therapy and SSRI or placebo.

OBJECTIVE: Patients with panic disorder are reported to have elevated cholesterol levels. There is also some evidence that cholesterol elevation is not so much a specific condition in panic disorder but is generally associated with anxiety. So far, there is little data on cholesterol levels in patients with obsessive compulsive disorders (OCD) which is also classified as anxiety disorder. METHOD: Thirty-three patients with OCD participated in the study. Serum cholesterol was measured as pretreatment and at the end of a ten-week treatment-period. All patients received behavior therapy and, in a double-blind fashion, fluvoxamine or placebo. Severity of OCD was assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). RESULTS: Pretreatment cholesterol values of OCD patients were compared with cholesterol levels of thirty panic disorder patients and thirty normal controls. OCD patients had elevated cholesterol levels comparable with those of panic disorder patients. Cholesterol levels decreased significantly from pre- to posttreatment. OCD patients with high cholesterol levels (> or = 240 mg/dl, n = 7) could make best use of the treatment whereas patients with desirable cholesterol levels (< 200 mg/dl, n = 11) did not change their cholesterol during treatment. CONCLUSIONS: Our data support the assumption that not only panic disorder but also other anxiety disorders, e.g., obsessive compulsive disorders, may be associated with serum cholesterol elevations. Effective treatment (behavior therapy and/or treatment with a selective serotonin reuptake inhibitor [SSRI]) seems to decrease cholesterol levels, especially in patients with pathological cholesterol elevations.

Clinically relevant cholesterol elevation in anxiety disorders: a comparison with normal controls.

Recently, several studies reported elevated cholesterol levels in panic disorder, agoraphobia, and general anxiety disorder, but the clinical relevance is still unsettled. All studies so far have disregarded the possible influence of dietary and physical exercise factors. In this study, 30 patients with different anxiety disorders and 30 normal controls were compared for total cholesterol, low-density lipoprotein (LDL), and cholesterol high-density lipoprotein (HDL) ratio. Dietary and physical exercise habits were measured by self-rating questionnaires. Patients with anxiety disorders had significantly elevated total cholesterol, LDL, and cholesterol/HDL ratios. Patients showed borderline-high or high cholesterol levels almost 3 times as often as control participants. Anxiety-specific avoidance of physical exercise and special dietary habits of anxiety patients had a significant but minor impact on differences in cholesterol between both groups. Our data support the assumption that serum cholesterol elevations in anxiety disorder patients are within a clinically relevant range.

[Exposing obsessive-compulsive patients: often only 3 simple questions are enough. The family physician as "facilitator of self-disclosure"]. / Zwangspatienten entlarven: Oft genügen drei einfache Fragen. Der Hausarzt als "Geburtshelfer der Offenbarung".

For numerous patients with obsessive-compulsive disorder, the family doctor is the first contact person. Many of these patients have concealed their problem for years. This paper summarizes the forms of the disorder and their indirect manifestations in the doctor's office, discusses the reasons for concealment on the part of the patient and/or his relatives, and describes the family doctor's help in three areas: aiding the "birth of revelation"; initiating pharmacotherapy and supporting behavior therapy-related self-help for patient and relatives; motivating patient and relatives to seek expert psychiatric and psychotherapeutic aid. In the second part of the paper, the family doctor is given model explanations designed as answers to common questions asked by sufferers from obsessive-compulsive disorder.

Out-patient, multi-modal behaviour therapy for obsessive-compulsive disorder.

BACKGROUND: With regard to long-term outcome, behaviour therapy is the first choice treatment for obsessive-compulsive disorder (OCD), with or without concomitant selective serotonin reuptake inhibitor (SSRI) medication. Yet, results from research trials, usually restricted to exposure with response-preventions and other symptom-directed techniques, may not be generalisable to people with OCD in community health care services. METHOD: For more than 20 years we have delivered out-patient behaviour therapy to unselected people with OCD from the community, including those with motivational and compliance problems. Prospective-retrospective follow-ups were carried out from 1-13 years after treatment. RESULTS: This paper describes the applied multi-modal, strategic-systemic behaviour therapy, and our partially new model of OCD. Compliant patients achieved the usual success rate of 65-70%, but this drops to 50% if all patients treated are included in the analysis. CONCLUSIONS: For major subgroups of OCD, behavior therapy is a very effective treatment modality. Exposure is essential, but additional ('causal') interventions are equally important in about half of the patients from unselected samples. Both behaviour therapy and drug-treatments need to be improved and predictive variables for outcome of either of them are urgently needed.

Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo. Results of a multicentre study.

BACKGROUND: We investigated whether the combination of multi-modal behaviour therapy (BT) with fluvoxamine is superior to BT and placebo in the acute treatment of severely ill in-patients with obsessive-compulsive disorder (OCD). METHOD: In a randomised, double-blind design, 30 patients were treated for nine weeks with BT plus placebo and 30 patients with BT plus fluvoxamine (maximum dosage 300 mg, mean dose 288.1 mg). BT included exposure with response prevention, cognitive restructuring and development of alternative behaviours. RESULTS: Both groups showed a highly significant symptom reduction after treatment. There were no significant differences between the groups concerning compulsions. Obsessions were significantly more reduced in the fluvoxamine and BT group than in the placebo and BT group. Furthermore, the group BT plus fluvoxamine showed a significantly higher response rate (87.5 v. 60%) according to a previously defined response criterion. Severely depressed patients with OCD receiving BT plus placebo presented a significantly worse treatment outcome (Y-BOCS scores) than all other groups. CONCLUSIONS: The results suggest that BT should be combined with fluvoxamine when obsessions dominate the clinical picture and when a secondary depression is present.

Neuroticism, other personality variables, and serum lipid levels in patients with anxiety disorders and normal controls.

OBJECTIVE: This study evaluates the association between certain personality variables, especially neuroticism, and serum lipid levels in patients suffering from anxiety disorders as opposed to normal control individuals. It addresses the question whether in anxiety disorder patients neuroticism is associated with elevated serum cholesterol and serum LDL cholesterol levels. METHOD: Thirty (15 male, 15 female) patients with anxiety disorders as defined by DSM-IV and thirty normal matched controls were enrolled in this study. The patients were either admitted for inpatient treatment or referred to the behavioral therapy outpatient clinic at the Department of Psychiatry of the University Hospital Eppendorf (Hamburg/Germany). Control individuals were selected on a voluntary basis and recruited from the authors' colleagues and peers. Matching included Body-Mass-Index, age, and gender. RESULTS: This study showed a significant positive association of neuroticism and serum cholesterol (r = .29) and serum LDL cholesterol (r = .35) within the entire cohort of participants. An even higher significant positive relation (r = .43) could be detected between neuroticism and serum LDL cholesterol within the psychiatric patient group. As far as differences of personality variables between patients and normal controls are concerned, patients seemed to be significantly less satisfied with life, more generally inhibited, more irritable, more stressed, and more emotionally labile than controls. Anxiety disorder patients also tended to complain significantly more often about physical problems. CONCLUSIONS: Our data suggest that high scores of neuroticism in anxiety disorders patients may be involved in elevated serum LDL cholesterol levels and, thereby, may lead to an increased risk of coronary heart disease.

[Ambulatory behavior therapy in obsessive-compulsive disorders]. / Ambulante Verhaltenstherapie bei Zwangsstörungen.

The term Obsessive Compulsive Disorder (OCD) is a label for a variety of syndromes with changing symptom configurations and different intraindividual as well as interactional functions. They are among the most difficult to treat psychiatric disorders. Heterogeneous variables affecting personal development in family, school, and peer-group, as well as genetic or brain organic variables contribute to the development of obsessions and compulsions. In more than 50% of patients with OCD we find one or more of the following disturbances before the outbreak of the disorder: low self-esteem; social deficits; increased anxiety level with increased, latent aggressiveness; striving for 100% security. Behaviour therapy today is the "treatment of choice" for OCD--both in respect of direct symptom reduction as well as the treatment of "causes", co-morbidity and risk factors. Additionally to the use of highly standardised "symptom techniques" individualized, multimodal treatment is necessary in the more severely disturbed patients. Long-term follow-up results show 50-80% success--probably depending on variations in the study samples regarding the type of obsessions and compulsions, the degree of developmental deficits before the occurrence of OCD, actual co-morbidity, and professional as well as private life conditions. Whether and to what degree additional psychotropic medication can enhance the efficacy of behaviour therapy, and whether the high relapse rates of 70% after discontinuation of previously successful drug treatment can be reduced by concomitant or subsequent behaviour therapy, cannot be safely concluded from the currently available studies. Are the non-responders in each of these treatments the responders of the non-responders in the alternative treatment mode?

[Behavior therapy and/or drug therapy in depression? Critical remarks on published comparative studies]. / Verhaltenstherapie und/oder Pharmackotherapie bei Depressionen? Kritsche Anmerkungen zu Publizierten Therapievergleichsstudien.

Are published results of comparative treatment-evaluation studies in depression meaningful for everyday practice? The most recent German- and English-language review-articles and large scale comparative studies--with tricyclic antidepressants, cognitive behavior therapy, and interpersonal psychotherapy--are assessed using a specific list of criteria, in order to find an answer to this question. Basic design problems and specific weaknesses in the pharmacological as well as in the non-pharmacological treatments are identified. It turns out, that the published "statistically significant" results of these studies are not clinically convincing, neither for the pharmacological nor for the two nonpharmacological treatments--not even for the emerging superiority of cognitive behavior therapy. A cost-comparison does not reveal a major advantage of pharmacotherapy. Recommendations for future research and psychiatric practice are derived.