In a study that may significantly advance the understanding of how cognitive-behavioral therapy affects the brain, researchers have shown that significant changes in activity in certain regions of the brain can be produced with as little as four weeks of daily therapy in patients with obsessive-compulsive disorder (OCD). The discovery could have important clinical implications, according to principal investigator Sanjaya Saxena, M.D., Director of the Obsessive-Compulsive Disorders Program at the University of California, San Diego (UCSD) School of Medicine, whose findings are published on line this week in the journal Molecular Psychiatry.

“The study is exciting because it tells us more about how cognitive-behavioral therapy works for OCD and shows that both robust clinical improvements and changes in brain activity occur after only four weeks of intensive treatment," said Saxena.

OCD is an anxiety disorder in which individuals have unreasonable fears or worries that they try to manage through ritualized compulsive behaviors to reduce the anxiety. For example, a patient may experience the urgent need to engage in certain rituals, such as hand washing or repeatedly checking that the oven is off or the front door is locked.

Past studies using functional brain imaging studies of patients with OCD have demonstrated that elevated activity along the frontal-subcortical circuits of the brain decreases in response to treatment with serotonin reuptake inhibitor (SRI) medications or cognitive-behavioral therapy. However, clinical improvement of OCD symptoms was expected to require up to 12 weeks of behavioral therapy or medication treatment, the standard treatments for OCD. Only a handful of studies have looked at how therapy affects brain function, and all previous studies had examined changes over several months of treatment.

Saxena and colleagues at the David Geffen School of Medicine at UCLA made two novel discoveries in their study of 10 OCD patients and 12 control subjects. “First of all, we discovered significant changes in brain activity solely as the result of four weeks of intensive cognitive-behavioral therapy,” said Saxena. “Secondly, these changes were different than those seen in past studies after a standard 12-week therapeutic approach using SRI medications or weekly behavioral therapy.” The researchers obtained positron emission tomography (PET) scans of the ten OCD patients both before and after they received four weeks of a therapy known as “exposure and response prevention,” which gradually desensitizes patients to things that provoke obsessional fears or worries. “This is the primary kind of therapy used for OCD. It teaches patients to pay attention to their internal experiences and tolerate scary thoughts without having to act on them,” said Saxena. “They learn that nothing terrible happens if they refrain from their usual compulsive behaviors.”

The normal control subjects received no treatment and were scanned twice, several weeks apart, and metabolic changes in the brain were compared between the two groups. After four weeks of therapy and without any changes in medication, the OCD patients showed significant improvements in OCD symptoms, depression, anxiety and overall functioning. The PET scans of OCD patients demonstrated significant decreases in glucose metabolism – a measure of brain cell activity – in the right and left thalamus after treatment. These are areas of the brain involved in OCD and where changes have been seen in numerous past studies after longer-term treatment.

However, the PET scans in this study also showed a significant increase in activity in an area of the brain called the right dorsal anterior cingulate cortex, a region involved in reappraisal and suppression of negative emotions. Increasing activity in this region corresponded to the OCD patients’ improvement in clinical symptoms after the four-week course of intensive therapy. Activity in this area had previously been found to increase after cognitive-behavioral therapy for major depression. Therefore, the researchers theorize that response to cognitive-behavioral therapy across a variety of disorders may require activation of the dorsal anterior cingulate cortex, according to Saxena.

An interview with Albert Ellis, developer of Rational Emotive Behavior Therapy (REBT). The groundbreaking treatment rests on the premise that most of our emotional problems are based on irrational beliefs.

A common drug [propranolol] administered in the first hours following trauma to patients deemed to be at risk of developing post-traumatic stress disorder (PTSD) reduced the occurrence of PTSD, according to a study led by researchers at the University of Lille, France [in 2003].

While the study involved a small number of subjects, its results are encouraging, says its senior author, Charles Marmar, MD, associate chief of staff for mental health at the San Francisco VA Medical Center and professor and vice chair of psychiatry at University of California, San Francisco.

"The study is based on the new theory that PTSD is most likely to occur in patients who experience a particularly severe and prolonged response to trauma. If this model proves accurate after five or ten replications of studies like this one, it could have very profound ramifications. From a public health perspective, if you could identify the subgroup of people who are susceptible to PTSD, giving them this course of medication -- which is brief, very well tolerated and inexpensive -- could be very effective prevention [following major trauma] and may have great social relevance." The study appears in the November 1 issue of Biological Psychiatry. [read rest of article]

Also: The Memory Pill (60 Minutes video -- 26 Nov 2006)
Bad Memory? Wipe It Clean With New Pill (16 Jan 2006)

Why Does Cognitive Therapy Work?
By James Krehbiel

Cognitive-Behavioral Therapy for Somatization Disorder [abstract]
A Randomized Controlled Trial

Lesley A. Allen, PhD; Robert L. Woolfolk, PhD; Javier I. Escobar, MD; Michael A. Gara, PhD; Robert M. Hamer, PhD || Arch Intern Med 2006;166:1512-1518.

Background: Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD.

Methods:  Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records.

Results:  Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P<.001). Patients treated with CBT also were significantly more likely to be rated as either very much improved or much improved than patients treated with only augmented standard medical care (40% [n = 17] vs 5% [n = 2]). Cognitive-behavioral therapy was associated with greater improvements in self-reported functioning and somatic symptoms and a greater decrease in health care costs.
Author Affiliations: Department of Psychiatry, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway (Drs Allen, Escobar, and Gara); Department of Psychology, Rutgers University, Piscataway (Dr Woolfolk); Department of Psychology, Princeton University, Princeton, NJ (Dr Woolfolk); and Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill (Dr Hamer).

When Alcoholics Anonymous and other 12-step programs are examined in controlled studies, a new review reports, scientists find no proof that they are superior to any other intervention in reducing alcohol dependence or alcohol-related problems.

The researchers, led by Marica Ferri of the Italian Agency for Public Health in Rome, found little to suggest that 12-step programs reduced the severity of addiction any more than any other intervention. And no data showed that 12-step interventions were any more — or any less — successful in increasing the number of people who stayed in treatment or reducing the number who relapsed after being sober.

Alcoholics Anonymous is a self-help group that offers emotional support for alcohol abstinence and holds that alcoholism is a spiritual and a medical disease. [read more]

New York Times
By Nicholas Bakalarp
Published: July 25, 2006

On his 150th anniversary, Freud's legacy is being dismantled by the ideas of his greatest challenger, Aaron Beck. Cognitive therapy is now the orthodox talking cure in Britain, and the government wants more of it. But with cognitive science comes a new battle for the meaning of the human mind.

After Freud by Alexander Linklater & Robert Harland
Prospect (June 2006)

...but researchers say side effects, interactions largely unknown. Read more about pediatric polypharmacy in this HealthDay News article.

The efficacy of cognitive therapy was evaluated in a University of Pennsylvania study of 120 suicide attempters from an emergency room. Half of the subjects received cognitive therapy and half received standard therapy. Over the course of an 18 month follow-up, 24.1% of those who got cognitive therapy made a second suicide attempt, compared to 41.6% of those who got standard treatment. Subjects who had received cognitive therapy also scored significantly lower on measurements of depression. Read more about the study:

Cognitive Therapy Halves Risk of Second Suicide Attempt
By Ed Edelson
HealthDay Reporter