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Ample evidence supports the use of Virtual Reality (VR) for anxiety disorders. Nonetheless, currently there is no evidence about moderators or potential negative effects of VR treatment strategies. An Individual Patient Data (IPD) approach was employed with 15 retrieved datasets. The current study sample was composed of 810 patients. Randomized control trials (RCTs) for each primary outcome measure were performed, in addition to moderator analyses of the socio-demographic variables. Deterioration rates were 14 patients (4.0%) in VR, 8 (2.8%) in active control conditions, and 27 (15%) in the WL condition. With regard to receiving treatment, patients in a waiting list control condition had greater odds of deteriorating than in the two active conditions, odds ratios (ORs) 4.87, 95% confidence interval (CI) [0.05, 0.67]. In the case of the socio-demographic variables, none of them were associated with higher or lower odds of deterioration, with the exception of marital status in the WL condition; married people presented a significantly lower probability of deterioration, OR 0.19, 95% CI [0.05, 0.67]. Finally, when comparing pooled effects of VR versus all control conditions, the OR was 0.61 (95% CI 0.31–1.23) in favor of VR, although this result was not statistically significant. This study provides evidence about the deterioration rates of a therapeutic VR approach, showing that the number of deteriorated patients coincides with other therapeutic approaches, and that deterioration is less likely to occur, compared to patients in WL control groups.

This randomized controlled trial investigated the efficacy of a stand-alone virtual reality exposure intervention comprising verbal interaction with virtual humans to target heterogeneous social fears in participants with social anxiety disorder. Sixty participants (Mage = 36.9 years; 63.3% women) diagnosed with social anxiety disorder were randomly assigned to individual virtual reality exposure therapy (VRET), individual in vivo exposure therapy (iVET), or waiting-list. Multilevel regression analyses revealed that both treatment groups improved from pre-to postassessment on social anxiety symptoms, speech duration, perceived stress, and avoidant personality disorder related beliefs when compared to the waiting-list. Participants receiving iVET, but not VRET, improved on fear of negative evaluation, speech performance, general anxiety, depression, and quality of life relative to those on waiting-list. The iVET condition was further superior to the VRET condition regarding decreases in social anxiety symptoms at post- and follow-up assessments, and avoidant personality disorder related beliefs at follow-up. At follow-up, all improvements were significant for iVET. For VRET, only the effect for perceived stress was significant. VRET containing extensive verbal interaction without any cognitive components can effectively reduce complaints of generalized social anxiety disorder. Future technological and psychological improvements of virtual social interactions might further enhance the efficacy of VRET for social anxiety disorder.

Background and objectives Control of obsessive thoughts in Obsessive Compulsive Disorder (OCD) involves both avoidance and removal of undesirable intrusive thoughts. Thought suppression tasks tap both of these processes but experimental results have been inconsistent. Experimental tasks allowing more focused study of the processes involved in controlling intrusive thoughts may be needed. In two experiments, control over neutral, standardized intrusive and personal intrusive thoughts was investigated as participants attempted to replace them with neutral thoughts. Methods Non-selected university students (Experiment 1: N = 61) and university students scoring high and low on self-report measure of OC symptoms (Experiment 2: N = 40) performed a computerized thought replacement task. Results In experiment 1 replacing personal intrusive thoughts took longer than replacing neutral thoughts. Self-reports showed that intrusive thoughts were rated more difficult to replace and were associated with greater thought reoccurrence during replacement, larger emotional reaction and more discomfort. These results were largely replicated in experiment 2. Furthermore, the high OC symptom group experienced greater overall difficulty controlling thoughts on the replacement task, experienced more reoccurrences of personal intrusive thoughts, larger emotional reactions and discomfort associated with them, and felt a greater urge to remove them. Limitations All participants were non-clinical university students, and older adults with OCD should be tested. Conclusions The findings are in line with cognitive behavioural theories of OCD. They support the usefulness of thought replacement as a research paradigm to study thought control in OCD and possibly other psychological conditions characterized by repetitive thoughts.

Introduction: This meta-analysis compares effect-sizes of methylphenidate and psychosocial treatments and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviors and academic functioning. Method: Several databases (PubMed, PsycInfo, ISI Web of Science) were searched for articles published between 1985 and September 2006. Inclusion criteria were: a diagnosis of ADHD; age from 6-12 years; a randomized controlled treatment design; efficacy established with parent and teacher rating scales; psychosocial treatments used were described as behavioral or cognitive-behavioral; the methylphenidate treatment was short-acting; and finally, treatment was conducted in a clinical setting. Results: ADHI) outcomes showed large mean weighted effect-sizes for both methylphenidate and combined treatments, psychosocial treatments had a moderate mean weighted effect-size; a similar pattern emerged for oppositional and conducted behavior symptoms. Social behavior outcomes showed comparable moderate mean weighted effect-sizes for all treatments, while on academic functioning, all treatments had low mean weighted effect-sizes. There was no correlation between duration of psychosocial treatment and effect-size. Conclusions: Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions. Psychosocial treatment has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behavior and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective. (C) 2007 Elsevier Ltd. All rights reserved

Narrative reviews conclude that behavioral couples therapy (BCT) produces better outcomes than individual-based treatment for alcoholism and drug abuse problems (e.g., [Epstein, E. E., & McCrady, B. S. (1998). Behavioral couples treatment of alcohol and drug use disorders: Current status and innovations. Clinical Psychology Review, 18(6), 689-711; O'Farrell, T. J., & Fals-Stewart, W. (2003). Alcohol abuse. Journal of Marital and Family Therapy, 29(1), 121-146]). However, the strength and consistency of this effect favoring BCT has not been examined because a meta-analysis of BCT studies has not been reported. This meta-analysis combines multiple well controlled studies to help clarify the overall impact of BCT in the treatment of substance use disorders. A comprehensive literature search produced 12 randomized controlled trials (n=754) that were included in the final analyses. There was a clear overall advantage of including BCT compared to individual-based treatments (Cohen's d=0.54). This was true across outcome domains (frequency of use d=0.36, consequences of use d=0.52, and relationship satisfaction d=0.57). However the pattern of results varied as a function of time. BCT was superior to control conditions only in relationship satisfaction at posttreatment (d=0.64). However, at follow-up BCT was superior on all three outcome domains (frequency of use d=0.45, consequences of use d=0.50, and relationship satisfaction d=0.51). In addition to other control conditions, BCT also outperformed individual cognitive behavioral therapy without couples therapy (d=0.42). Larger sample sizes were associated with higher effect sizes (p=0.02). However, treatment dose and publication year were not related to effect size. Overall, BCT showsbetter outcomes than more typical individual-based treatment for married or cohabiting individuals who seek help for alcohol dependence or drug dependence problems. The benefit for BCT with low severity problem drinkers has received little attention and one study suggests its efficacy may not extend to this subgroup.

The relationship between attachment styles and Cluster B personality disorders were examined among prisoners, forensic inpatients and controls from the general population. Forensic inpatients and prisoners reported significantly less frequently the secure attachment style (Relationship Questionnaire) and significantly more the fearful attachment style compared to the normal controls. Both forensic groups could not be distinguished from each other. Further, prisoners, forensic inpatients and controls could not be differentiated on the basis of the dismissing nor the preoccupied attachment style. With respect to personality pathology, almost all relationships between Cluster C pathology, on the one hand, and attachment styles, on the other, were significant. Cluster A pathology was clearly related to the secure and fearful attachment style. With respect to cluster B pathology, the results were more specific but also less clear. The results were strongly dependent on the way the personality pathology variables were treated, as either categorical or dimensional. None of the cluster B personality pathology variables were associated with the fearful attachment style and histrionic personality pathology was negatively associated with the dismissing attachment style. Antisocial personality features were associated with a dismissing attachment style. Borderline personality pathology, when treated as a categorical variable, was significantly related to the preoccupied attachment style. These results show that (1) cluster A and cluster C pathology are more strongly associated with attachment than cluster B, (2) treating personality data as either dimensional or categorical is of major importance to the conclusions that can be drawn, (3) it is important to control for the influence of co-morbid personality pathology when examining the relationship between (Cluster B) personality pathology and attachment.

The current article represents the further validation of the construct of inferential confusion amongst clinical samples. Inferential confusion is proposed to be a meta-cognitive confusion particularly relevant to obsessive compulsive disorder (OCD) that leads a person to confuse an imagined possibility with an actual probability. As such, it conceptualizes OCD as a form of belief disorder similar to a delusion or overvalued idea that is a product of distorted reasoning processes. In contrast, other cognitive models of OCD emphasize a phobic model of development in OCD, and thus consider the exaggerated interpretation of intrusions as an essential element in OCD. The present study administered a revised version of the Inferential Confusion Questionnaire, and the Obsessive Belief Questionnaire (OBQ), to a total of 183 participants in three clinical groups and a non-clinical control group. Results suggest that OCD, at least in part, follows a non-phobic model of development with inferential confusion significantly related to obsessive-compulsive symptoms independently of cognitive domains as measured by the OBQ, and mood states. Further, scores on inferential confusion were particularly high in those with OCD and delusional disorder as compared to anxious and non-clinical controls.

In this study the effects of virtual reality exposure therapy (VRET) were investigated in patients with acrophobia. Feelings of presence in VRET were systematically varied by using either a head-mounted display (HMD) (low presence) or a computer automatic virtual environment (CAVE) (high presence). VRET in general was found to be more effective than no treatment. No differences were found in effectiveness between VRET using an HMD or CAVE. Results were maintained at 6 months follow-up. Results of VRET were comparable with those of exposure in vivo (Cyberpsychology and Behavior 4 (2001) 335). In treatment completers no relationship was found between presence and anxiety. Early drop-outs experienced less acrophobic complaints and psychopathology in general at pre-test. They also experienced less presence and anxiety in the virtual environment used in session one as compared to patients that completed VRET.

In this study we examine the effects of a stress-management training program on individuals without serious (mental) health complaints but with an increased chance of developing them as a consequence of stress. Potential subjects were randomly selected from the community at large and, then screened for participation in the training program if some of several (mental) health risk factors could be attributed to them: past life-events, neuroticism, inassertiveness, avoidant coping style and lack of social support. The control group, which did not take part in the training program, consisted of individuals with a similar risk profile as those in the training group. The training program consisted of several stress-management techniques: changing unhealthy life-style, relaxation training, problem-solving training and social skills-training. Multivariate analyses of variance showed that the training group, as compared to the control group, reported significantly less distress, less trait anxiety, less daily hassles, more assertiveness and more satisfaction with social support at follow-up. There were, however, no significant changes found in the coping skills of either group.

Parental representations of a Dutch sample of psychiatric patients with diagnoses of dysthymia and unipolar depression were compared with those of a matched sample of non-depressed patients and a matched sample of healthy controls. No differences in recalled parental rearing styles were found between depressives with a diagnosis of dysthymia and those with a diagnosis of unipolar depression. Depressive did not differ from the mixed (but non-depressed) sample of psychiatric patients, whereas both the depressed and the mixed group of patients reported more adverse parenting than the healthy controls. Analysis of repeated measurements of parental representations showed that memories of parental behavior were highly stable across clinically significant changes in depressed mood, so that it seems unlikely that patients' relatively negative recollections of their parents' behavior were due to mood state dependent recall. Results are discussed within the framework of depression theories and with regard to the validity and utility of self-report instruments for parental rearing styles.

Publisher Summary This chapter investigates the cognitive changes in patients with obsessive compulsive rituals treated with exposure in vivo and response prevention. Obsessive compulsive disorder (OCD) is related to perfectionism, but it does seem more likely that perfectionism is a dispositional trait for the development of psycho-pathology in general, rather than for OCD in particular. Further, indecisiveness, magical thinking, aversion to risk-taking, and guilt have also been found to be related to OCD. Although some have proposed that cognitive therapy may be inappropriate for treating obsessive compulsives, because these patients already over-emphasize their thoughts, there is evidence that cognitive therapy may be effective in treating OCD. On the obsessive compulsive targets (Maudsley obsessional compulsive inventory and anxiety/discomfort scale), the results of cognitive therapy were about equally effective as self-controlled exposure in vivo. Both treatments led to a reduction of social anxiety. On depressed mood, cognitive therapy led to significant improvement, whereas self-controlled exposure did not.

Publisher Summary This chapter discusses a research which shows that there is no evidence yet that individualized treatment based upon a problem analysis of the individual patient is better than treatment based on standardized treatment manuals. The results of the studies conducted so far demonstrate that the standardized treatment protocols developed over the past few years for obsessive-compulsives, phobics, and depressives have not yet been beaten by an individualized cognitive or behavioral treatment. Thus, although tailoring the treatment to different patient characteristics has some intuitive appeal, results are rather inconclusive with respect to matching of treatment to individual characteristics. The implication for treatment selection is that it can be both economically and therapeutically wise to start with a standardized behavioral program and provide individualized treatment only to those patients who do not improve with standardized treatment. Another potentially fruitful research strategy is to treat patients with a homogeneous disorder with a specific treatment and to treat those patients who have insufficiently improved with an alternative treatment.

The current study presents data on reliability and validity of the Relationship Beliefs Inventory (RBI), a 40-item questionnaire which was designed to assess beliefs people hold about intimate relationships. The RBI was administered to clinical and non-clinical couples along with measures of marital functioning, communication, and irrational beliefs. The RBI-scales are relatively unaffected by social desirability and have adequate internal consistency and test-retest reliability. Evidence was provided for its construct validity, but discriminant validity is poor.

In this investigation of agoraphobic patients, 3 different flooding procedures were compared: (1) prolonged exposure in vivo, (2) flooding in the imagination by a ‘live’ therapist and (3) a combination of flooding in the imagination and flooding in vivo. After an intermediate-test all clients were treated by the self-observation method, with a minimum of therapeutic intervention. Assessments were made at the beginning of treatment, during and at the end of treatment and at the follow-up one month later. Assessments were carried out by the therapist (in vivo measurement; phobic anxiety and avoidance scales; anxious mood and panic), by an independent observer (idem. minus in vivo measurement) and by the client (phobic anxiety and avoidance scales; FSS; social anxiety scale; SDS and I-E scale). Prolonged exposure in vivo plainly proved to be superior to flooding in the imagination. Combined flooding resulted in a greater improvement than flooding in the imagination, though only on the therapist's ratings. Self-observation did not add much to the effect of prolonged exposure in vivo and of flooding combined whereas self-observation, preceded by flooding in the imagination, resulted in a significant improvement on nearly all the variables.

Psychometric evaluation of the 20-item Dutch version of the Maudsley Marital Questionnaire (MMQ) in a non-distressed-couples group (N=64 couples) supported further the reliability, factorial as well as divergent, and convergent construct validity of the Marital, Sexual and General Life Adjustment scales. Correlational analyses revealed both the MMQ items and the scales to be negligibly lowly correlated with Social Desirability. Some important relationships between different aspects of marital communication and marital adjustment were established and briefly discussed.

The present experiment sought to investigate the process of exposure in vivo. Heart rate (HR) and subjective anxiety were monitored during exposure in vivo with acrophobics. To assess the influence of cognitive processes half of the Ss were instructed in adaptive thinking during the exposure in vivo task. Significant differences between conditions were found on cognitive measures only. Both on subjective anxiety and cognitions during the behavioral test, the Cognitive-Exposure condition was found to be superior to the Exposure-alone condition. Changes in subjective anxiety during treatment did not precede changes in HR. Results of this study support the notion that anxiety-reduction through exposure is a passive process leading to synchronous changes in subjective anxiety and psychophysiological arousal.

Thirteen obsessive-compulsive clients were treated with different methods of response prevention. Four experimental conditions were obtained through a 2 × 2 factorial design, in which the two main variables were varied: (1) gradual treatment vs flooding; and (2) modeling vs no-modeling. Clients were treated at their homes, three times weekly. Each session lasted 2 hr. Results at the post-test revealed, that modeling was superior to no-modeling (p

The effects of 5.4 months of inpatient behavioral treatment and of 20 sessions of outpatient behavioral therapy were studied in a quasi-experimental design with 22 inpatient and 43 outpatient obsessive-compulsives. Within each group there was a significant drop in scores on the Maudsley Obsessive-Compulsive Inventory after the therapy. Even after controlling—through covariance analysis—for initial differences between groups, no differences emerged between inpatient and outpatient treatment effects. Considering the clinical and economical relevance of the issue, and acknowledging the quasiexperimental nature of the present study, it is argued that controlled tests are justified.