Chapter eight - Cognitive Behavioral Treatments for Substance Use Disorders

The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.

Background/Objectives: The treatment of dual disorders (DDs) must be comprehensive and multidisciplinary. Evidence supports the effectiveness of psychotherapy in treating DDs. The second part of this consensus synthesizes the available evidence on psychological treatment for specific DDs. Methods: Two consensus methods were sequentially implemented: the nominal group technique and the Delphi method. Results: This consensus review encompassed a compilation of recommendations for the psychological treatment of neurodevelopmental, anxiety, post-traumatic stress, somatic symptom, eating, and personality disorders. Finally, recommendations for the future research agenda on the psychological treatment of DD were included. Conclusions: (1) Psychological treatment, particularly integrated treatment, is effective. (2) In the case of dual autism, interventions for substance use disorders should be adapted to this population's characteristics. (3) More research is needed on dual social anxiety, panic, generalized anxiety, somatic symptom, and eating disorders, for which Cognitive Behavioral Therapy (CBT) is the most commonly used treatment. (4) For dual attention deficit hyperactivity disorder, multicomponent treatment is recommended (psychoeducation, CBT, and peer or family support). (5) For dual anxiety disorders, CBT is the first-line treatment. (6) For dual post-traumatic stress disorder, CBT (cognitive processing therapy and prolonged exposure therapy), acceptance and commitment therapy, stress inoculation training, and Eye Movement Desensitization and Reprocessing (EMDR) are effective. (7) For dual personality disorders, evidence is scarce. (8) For borderline personality disorder, dialectical behavior therapy, dynamic deconstructive psychotherapy, and dual-focus schema therapy show promise. (9) For antisocial personality disorder, CBT, contingency management, and counseling on impulsive lifestyles may be useful. (10) Much more evidence is needed from studies that overcome the methodological limitations of existing ones.

Cognitive behavioral therapies and multiple sclerosis fatigue: A review of literature

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

Cognitive behavioral therapy (CBT) is one of the main approaches in psychotherapy. It teaches the patient to examine the link between dysfunctional thoughts and maladaptive behaviors and to re- evaluate the cognitive biases involved in the maintenance of symptoms by using strategies such as guided discovery. CBT is constantly evolving in part to improve its' effectiveness and accessibility. Thus in the last decade, increasingly popular approaches based on mindfulness and acceptance have emerged. These therapies do not attempt to modify cognitions even when they are biased and dysfunctional but rather seek a change in the relationship between the individual and the symptoms. This article aims to present the historical context that has allowed the emergence of this trend, the points of convergence and divergence with traditional CBT as well as a brief presentation of the different therapies based on mindfulness meditation and acceptance. Hayes (2004) described three successive waves in behavior therapy, each characterized by "dominant assumptions, methods and goals": traditional behavior therapy, cognitive therapy and therapies based on mindfulness meditation and acceptance. The latter consider that human suffering occurs when the individual lives a restricted life in order avoid pain and immediate discomfort to the detriment of his global wellbeing. These therapies combine mindfulness, experiential, acceptance strategies with traditional behavior principles in order to attain lasting results. There are significant points of convergence between traditional CBT and therapies based on mindfulness meditation and acceptance. They are both empirically validated, based upon a theoretical model postulating that avoidance is key in the maintenance of psychopathology and they recommend an approach strategy in order to overcome the identified problem. They both use behavioral techniques in the context of a collaborative relationship in order to identify precise problems and to achieve specific goals. They focus on the present moment rather than on historical causes. However, they also present significant differences: control vs acceptance of thoughts, focus on cognition vs behavior, focus on the relationship between the individual and his thoughts vs cognitive content, goal of modifying dysfunctional beliefs vs metacognitive processes, use of experiential vs didactic methods, focus on symptoms vs quality of life, strategies used before vs after the unfolding of full emotional response. The main interventions based on mindfulness meditation and acceptance are: Acceptance and Commitment Therapy, Functional Analytic Therapy, the expanded model of Behavioral Activation, Metacognitive Therapy, Mindfulness based Cognitive Therapy, Dialectic Behavior Therapy, Integrative Behavioral Couples Therapy and Compassionate Mind Training. These are described in this article. They offer concepts and techniques which might enhance therapeutic efficacy. They teach a new way to deploy attention and to enter into a relationship with current experience (for example, defusion) in order to diminish cognitive reactivity, a maintenance factor for psychopathology, and to enhance psychological flexibility. The focus on cognitive process, metacognition as well as cognitive content might yield additional benefits in therapy. It is possible to combine traditional CBT with third wave approaches by using psychoeducation and cognitive restructuring in the beginning phases of therapy in order to establish thought bias and to then encourage acceptance of internal experiences as well as exposure to feared stimuli rather than to continue to use cognitive restructuring techniques. Traditional CBT and third wave approaches seem to impact different processes: the former enhance the capacity to observe and describe experiences and the latter diminish experiential avoidance and increase conscious action as well as acceptance. The identification of personal values helps to motivate the individual to undertake actions required in order to enhance quality of life. In the case of chronic illness, it diminishes suffering by increasing acceptance. Although the evidence base supporting the efficacy of third wave approaches is less robust than in the case of traditional cognitive or behavior therapy, therapies based on mindfulness meditation and acceptance are promising interventions that might help to elucidate change process and offer complementary strategies in order to help patients.

Cognitive therapy (CT) and behavior therapy (BT) are both effective for insomnia. In this study we applied Network Intervention Analysis to investigate specific effects of CT and BT on outcomes and process measures. The analysis was based on a randomized controlled trial comparing CT (n = 65), BT (n = 63) and cognitive behavioral therapy for insomnia (n = 60; not included in this study). In the first networks, the separate items of the Insomnia Severity Index and sleep efficiency were included. In the second networks, the pre-specified process measures for BT and CT, sleep efficiency, and the sum-score of the Insomnia Severity Index were included. At the different time points, we found CT-effects on worry, impaired quality of life, dysfunctional beliefs, and monitoring sleep-related threats, and BT-effects on sleep efficiency, difficulty maintaining sleep, early morning awakening, time in bed, sleep incompatible behaviors and bed- and rise time variability. These observed effects of CT and BT were consistent with their respective theoretical underpinnings. This study provided new information on the mechanisms of change in CT and BT. In the future, this may guide us to the most effective treatment modules or even subsets of interventions.

Objective To investigate the regulatory effect of cognitive behavioral therapy (CBT) on the functional connectivity of cognitive control network in untreated obsessive-compulsive disorder (OCD) patients, so as to provide evidence for understanding the neurobiological mechanism of CBT. Methods A total of 45 OCD patients and 45 matched normal controls were recruited at the outpatient clinic in Beijing Anding Hospital. Four therapists provided 14 times of CBT treatment for OCD patients. All subjects underwent clinical symptom assessment and magnetic resonance imaging at baseline and at the end of 12 weeks. The clinical symptoms were assessed by the psychiatrists using Y-BOCS, HAMD17 and HAMA. The clinical symptoms of OCD patients before and after CBT treatment were compared. The GRETNA software package was used to preprocess the resting-state fMRI data. The whole brain function network was constructed with the template of Power 264 functional brain area as the network node. The function connection intensity outside the cognitive control network was calculated, and the function connection of 2 groups of brain networks at two timepoints were compared by repeated measurement of variance analysis. Results A total of 41 patients completed CBT. The scores of obsessive-compulsive symptoms, anxiety symptoms and depressive symptoms decreased at the end of 12th week, of which 32 patients were improved (Y-BOCS reduction ≥35%). Single factor repeated analysis of variance and post hoc tests were performed between patients with improvement and normal controls. At baseline, the functional connection between the cingulo-opercular network and the salience network of OCD patients was lower than that of the normal control (0.172±0.060 vs. 0.215±0.076, t=1.731, P=0.040), it increased after treatment (0.186±0.171 vs. 0.172±0.060, t=2.480, P=0.010). At baseline, the functional connection of cingulo-opercular network and subcortical network in OCD patients was lower than that of normal control (0.119±0.081 vs. 0.129±0.070, t=1.640, P=0.040), and it increased after treatment (0.130±0.161 vs. 0.119±0.081, t=2.421, P=0.020). At baseline, the functional connection between the frontal-parietal network and subcortical network was lower than that of normal controls (-0.004±0.039 vs. 0.021±0.054, t=2.280, P=0.020), and it increased after treatment (0.020±0.042 vs.-0.004±0.039, t=-2.300 P=0.020). Conclusions CBT could effectively improve obsessive-compulsive symptoms accompanying with improvement of the external functional connectivity of cognitive control network in OCD patients. Key words: Obsessive-compulsive disorder; Cognitive therapy; Cognitive control network; Functional connectivity

Combination of physiotherapy and cognitive therapy in chronic pain

Through refinements from research and judicious combination with other therapies, behavior therapy has become increasingly relevant in the treatment of psychiatric disorders. After outlining the four models that serve as a framework for behavior therapy (classical conditioning, operant conditioning, social learning theory, and cognitive behavior modification), the authors provide an update for clinicians on developments in the behavioral treatment of anxiety disorders, sexual disorders, depression, and schizophrenia. Most advances have been made in the treatment of anxiety disorders, including definition of variables for successful use of exposure to phobic stimuli in the treatment of phobic disorders and the use of flooding for post-traumatic stress disorder. By becoming better acquainted with cognitive and behavioral therapies, clinicians may be able to offer their patients more effective treatment options.

Being exposed to life-threatening physical traumas, for example, a motor vehicle accident or combatrelated injury, may also contribute to the development of chronic physical pain and PTSD. The use of opiates to treat chronic pain may result in the development of opiate addiction. Therefore, PTSD, pain, and opiate addiction commonly co-occur. The signs and symptoms of these disorders may overlap, which can make it challenging to determine which led to which. For example, the opioid withdrawal syndrome may mimic the hypervigilance and exacerbated startle response in patients with PTSD. A common neurobiological circuit is suggested for the pathophysiologic mechanism of this comorbidity. There is evidence that opioid substitution therapy may improve opioid addiction and chronic pain outcomes in patients with comorbid PTSD, pain, and opioid use disorder. Further, non-pharmacological approaches utilizing cognitive behavioral therapy (CBT) show promise in addressing the treatment needs of those with co-occurring PTSD, pain, and opioid use disorder; however, additional research is needed to validate these results. In this chapter, the prevalence and etiology of these comorbidities will be reviewed. The neurobiological link between PTSD, pain, and opiate addiction will be discussed. The available treatment options for these comorbidities with a focus on illicit opiate use, PTSD, and pain outcome will be elaborated. The reader will be updated about the basic and most recent information available about these comorbidities. Then the gap in the current treatment and the need for future research will be mentioned. List of Abbreviations ACT Acceptance and commitment therapy ACTH Adrenocorticotropic hormone CBT Cognitive behavioral therapy CNCP Chronic non-cancer pain COPE Concurrent Treatment of PTSD and Substance Use Disorders with Prolonged Exposure CPT Cognitive Processing Therapy CRH Corticotropin-releasing hormone DSM-IV Diagnostic Statistical Manual of Mental Disorders – Fourth Edition HPA axis Hypothalamic pituitary adrenal axis ICBT Integrated Cognitive Behavioral Therapy MI Motivational Interviewing mPFC Medial prefrontal cortex OEF/OIF Operation Enduring Freedom/Operation Iraqi Freedom OIH Opioid-induced hyperalgesia PCP Primary care physicians *Email: bethany.ketchen@va.gov Comprehensive Guide to Post-Traumatic Stress Disorder DOI 10.1007/978-3-319-08613-2_28-1 # Springer International Publishing Switzerland (outside the USA) 2015

Background: Tuberculosis not only affects the physical condition of sufferers but also causes psychological problems such as anxiety and depression in tuberculosis patients. These psychological disorders will have an impact on treatment that is still undergoing treatment. The efforts that can be given are non-pharmacological therapy, namely Cognitive Behavioral Therapy (CBT), this therapy is carried out by changing the wrong way of thinking about the disease experienced by the patient. Purpose: To determine the effectiveness of Cognitive Behavioral Therapy (CBT) in reducing psychological stress and increasing medication compliance in pulmonary tuberculosis patients. Method: A systematic review with article selection guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The systematic review process begins with the formulation of clinical questions relevant to the topic. Before this, the authors establish PICOS criteria, which stand for: P (problem, patient, or population), I (intervention, prognostic factor, or exposure), C (comparison or control), O (outcome), and S (study design). For this article, P: Patients diagnosed with pulmonary tuberculosis who experience psychological stress, I: Cognitive Behavioral Therapy (CBT), C: Standard care or conventional treatment without CBT, O: Reduction in psychological stress (levels of stress, anxiety, or depression), S: Randomized Controlled Trials. The article search was conducted systematically using the keywords: "Tuberculosis" AND "Cognitive Behavioral Therapy” AND “Cognitive Therapy” AND “Medication Adherence” AND “Medication Compliance” AND “Psychological“AND “Depression” AND “Anxiety”. Results: This study shows that Cognitive Behavioral Therapy (CBT) is effective in reducing psychological stress and increasing medication compliance in pulmonary tuberculosis patients. Conclusion: CBT is effective in increasing medication adherence in pulmonary tuberculosis patients.

Removing the stigma of medication for opioid use disorder

Body Dysmorphic Disorder (BDD) is a debilitating psychiatric condition characterized by obsessive concern over perceived physical flaws, which significantly impair daily functioning. While cognitive behavioral therapy (CBT) is considered the standard treatment, the comparative effectiveness of various psychotherapeutic interventions for BDD remains unclear. This study aims to systematically review and perform a network meta-analysis (NMA) of different psychotherapies for treating BDD, evaluating their relative efficacy. A systematic search was conducted across PubMed, EMBASE, Cochrane Library, and Web of Science to identify randomized controlled trials (RCTs) assessing psychotherapeutic interventions for BDD. The search was updated to October 2024. The main interventions evaluated were CBT, Digital Cognitive Behavioral Therapy (Digital CBT), Cognitive Therapy (CT), Supportive Psychotherapy (SPT), Anxiety Management (AM), Interpretation Bias Modification (IBM), and Progressive Muscle Relaxation (PMR). Waiting List Control (WLC) groups were used as comparators. The primary outcome was the reduction in BDD symptom severity, assessed using the Yale-Brown Obsessive-Compulsive Scale modified for BDD and the Brown Assessment of Beliefs Scale. Two independent reviewers screened studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias tool. A Bayesian NMA was used to compare the interventions, considering both direct and indirect evidence. Mean differences with 95% credible intervals (CrI) were reported, and Surface Under the Cumulative Ranking (SUCRA) probabilities were used to rank treatment effectiveness. Forest and funnel plots were generated to visualize results and assess publication bias. The NMA included 16 RCTs with a total of 914 participants, comparing the efficacy of several psychotherapeutic interventions for BDD. Among these, traditional CBT was the most effective, significantly reducing BDD-YBOCS scores by a mean difference of -9.24 (95% CI: -18.07 to -0.40) compared to WLC. Digital CBT also demonstrated notable efficacy, with a mean difference of -5.89 (95% CI: -20.38 to 8.60) compared to WLC, making it a promising alternative, though slightly less potent than traditional CBT. AM ranked second overall, with a mean difference of -6.52 (95% CI: -27.02 to 13.98) compared to WLC. CT provided moderate benefits, showing a mean difference of -2.29 (95% CI: -15.38 to 10.81) compared to WLC. IBM and PMR showed limited effectiveness, with mean differences of -1.17 (95% CI: -19.66 to 17.32) and -1.00 (95% CI: -27.14 to 25.15) compared to WLC, respectively. SPT led to a moderate reduction in symptoms, with a mean difference of -3.41 (95% CI: -15.86 to 9.05), though it was less effective than CBT-based therapies. SUCRA rankings placed traditional CBT as the most effective treatment (77.9%), followed by AM (59.4%) and Digital CBT (60.2%). Forest plots confirmed CBT's superior efficacy, while funnel plots suggested no publication bias, although some concerns about detection bias and reporting bias were noted in a few studies. This NMA confirms that traditional CBT is the most effective treatment for reducing symptoms of BDD. Digital CBT and AM offer moderate efficacy and are viable alternatives. CT and SPT show some effectiveness, but to a lesser degree. Future research should focus on optimizing digital therapies and evaluating long-term outcomes.

Substance use disorders appeared earlier in the history of human development with the discovery of alcohol and drugs. As society develops, more and more people exhibit substance abuse and substance addiction. Therefore, substance use disorders are gradually appearing in the limelight. This review begins with an analysis of the pathology and prevalence of substance use disorders, dividing those psychological factors that can lead to substance use disorders into internalizing and social factors. Five specific therapies, including cognitive behavioral therapy, mindfulness-based cognitive therapy, prize-based contingency management approach, cue-exposure therapy, and acceptance and commitment therapy, are analyzed and discussed, also categorized as internal promotion and external influence, based on how these therapies affect clients. Finally, for future research and treatment of substance use disorders, this review combines the previous literature and suggests ways to combine two or more therapies in order to achieve the best treatment results.

Posttraumatic Stress Disorder Among Military Returnees From Afghanistan and Iraq