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Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[11C]methyl-l-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[11C]methyl-l-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

Objective: To examine symptom change over time, the effect of attrition on treatment outcome, and the putative mediators of cognitive therapy (CT) versus behavior therapy (BT) for obsessive-compulsive disorder (OCD) using archival data. Method: Sixty-two adults with OCD were randomized to 20 sessions of CT (N = 30) or BT (N = 32) that consisted of 4 weeks of intensive treatment (16 hr total) and 12 weeks of maintenance sessions (4 hr). Independent evaluators assessed OCD severity using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at baseline and at Weeks 4, 16 (posttreatment), 26, and 52 (follow-up). Behavioral avoidance, depressive symptoms, and dysfunctional beliefs regarding responsibility were also measured at each assessment. Study hypotheses were tested using multilevel modeling. Results: The slope of change in Y-BOCS scores was significantly greater in BT than in CT (d = 0.69), and those receiving BT had lower Y-BOCS scores at the final assessment than those receiving CT (d = 1.17). The greater slope of change in BT versus CT did not differ for dropouts versus completers. Reduction in depressed mood mediated changes in Y-BOCS across the 2 treatments, but a reduction in sense of responsibility and a decrease in avoidance did not. Instead, Y-BOCS improvements appeared to precede a decrease in avoidance. Conclusions: BT may have some therapeutic advantage over CT in the treatment of OCD, and this advantage does not appear to be due to a differential pattern of responding for treatment dropouts versus completers. Further, inconsistent with hypotheses, improvements in OCD symptoms were mediated by reductions in depressed mood instead of decreases in avoidance and responsibility. Theoretical, methodological, and clinical implications are discussed.

Accessible online at: www.karger.com/pps ‘Case management’ is a section which addresses biopsychosocial management of cases in clinical medicine. It integrates research evidence with clinical experience. Full disclosure of conflict of interest is required. However, clinicians with substantial conflicts of interest (owing a patent, being a stockholder or executive or serving in the board of directors or being a regular consultant in a company with commercial interests tied to the research discussed) cannot contribute. The patient is a 35-year-old married woman with an obsessive compulsive disorder. She had a 21-year history of obsessive thoughts and ritualistic behaviors including compulsive checking which had become persistent since the birth of her first child. There is no evidence of comorbidity, except for a mild generalized anxiety disorder. She wants to know which treatment is right for her at this point.

This article reports on the validation of the Obsessive Beliefs Questionnaire (OBQ) and Interpretations of Intrusions Inventory (III) developed by the Obsessive Compulsive Cognitions Working Group (OCCWG) to assess the primary beliefs and appraisals considered critical to the pathogenesis of obsessions. A battery of questionnaires that assessed symptoms of anxiety, depression, obsessive-compulsive symptoms and worry was administered to 248 outpatients with a DSM-IV diagnosis of Obsessive-Compulsive Disorder (OCD), 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Tests of internal consistency and test-retest reliability indicated that the OBQ and III assessed stable aspects of OC-related thinking. Between-group differences and correlations with existing measures of OC symptoms indicated that the OBQ and III assess core cognitive features of obsessionality. However, the various subscales of the OBQ and III are highly correlated, and both measures evidenced low discriminant validity. The findings are discussed in terms of the relevance and specificity of cognitive constructs like responsibility, control and importance of thoughts, overestimated threat, tolerance of uncertainty and perfectionism for OCD.

Background: The Posttraumatic Stress Disorder Checklist Scale (PCLS) is a short self-report inventory for assessing the 3 main syndromes of Posttraumatic Stress Disorder (PTSD). The aim of this study was the validation of the French version of the PCLS in PTSD subjects and nonclinical subjects. Methods: One-hundred and thirteen outpatients suffering from PTSD according to DSM-IV were administered the PCLS. The patients’ scores on the PCLS were then compared to those of 31 nonclinical control subjects. Thirty-five of the patients were administered the PCLS twice over an interval of 1–2 weeks and also completed questionnaires measuring depression, phobia and anxiety. Results: The patients’ total score and subscores on the PCLS were found to be significantly higher than those of control subjects. The cutoff score of 44 on the French version PCLS distinguishes well between the PTSD group and control group with a high diagnostic efficacy (0.94). Factor analysis revealed 3 main factors corresponding to the reexperiencing, numbing and hyperarousal syndromes. The PCLS showed satisfactory test-retest reliability and internal consistency. Conclusions: The PCLS is therefore a valid and effective measurement of PTSD. It may be a useful tool for screening and assessing PTSD in psychiatric as well as in primary-care settings.

The present study was carried out in France to evaluate the reliability and validity of the Scale for Interpersonal Behavior (SIB), a multidimensional measure of difficulty and distress in assertiveness that was originally developed in The Netherlands. This appraisal was conducted with a clinical-sample (N = 166) and a general population sample (N = 150). The clinical series comprised 115 patients with social phobia and 51 patients with personality disorder, 28 of whom were of the avoidant type. Support was found for internal consistency and test-retest reliability of the French SIB.;Compared to:controls, both social phobics and patients with an avoidant personality disorder had significantly lower mean scores on all performance scales and significantly higher ones on:all distress scales, with the social phobics occupying a position in between. Findings in relation to convergent and divergent validity were quite satisfactory. Sensitivity of the French SIE for detecting change was demonstrated in a subgroup of the clinical Ss who had undergone 15 sessions of cognitive;behavioral group therapy for underassertiveness. (C) 1999 Elsevier Science Ltd. All rights reserved.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Behavioral psychotherapy may promote physical health and treat some behavior-linked medical conditions. Prevention of risk factors, and relapse through self-management, the development of a healthy life-style and the possibility to use its technology in the community at a relatively low cost are emphasized. Controlled studies suggest its effectiveness in cardiovascular diseases, headaches, stuttering, alcoholism, pain and bulimia nervosa. Cancer, psychoneuroimmunology and AIDS are under investigation. Psychogeriatrics in an emerging field. More basic research is needed to establish firmly the theoretical underpinnings of behavioral medicine including a cognitive component and to extend its practice to medical staff.

Psychogenic dyspnea may be part of two main clinical pictures. The first one is acute with dyspnea in the foreground of a panic disorder with or without agoraphobia. The second one is chronic, dyspnea being a background symptom of a generalized anxiety disorder. The problems related to the diagnosis and the implementation of psychological or pharmacological treatments are reviewed with reference to evidence-based medicine.

To date, there have been no studies comparing cognitive therapy (CT) with Rogerian supportive therapy (RST) in borderline personality disorder.Sixty-five DSM-IV borderline personality disorder outpatients were recruited at 2 centres: Lyon and Marseille. Thirty-three patients were randomly allocated to CT and 32 to RST. The therapists were the same in both groups. Both treatments shared the same duration (1 year) and amount of therapy. Assessment by independent evaluators utilised the Clinical Global Impression (CGI) Scale, the Hamilton Depression Scale, Beck Depression Inventory, Beck Anxiety Inventory, Hopelessness Scale, Young Schema Questionnaire II, Eysenck Impulsivity Venturesomeness Empathy (IVE) Inventory, a self-harming behaviours checklist and scales measuring quality of life and the therapeutic relationship. The response criterion was a score of 3 or less on the CGI, associated with a Hopelessness Scale score of8.No patient committed suicide during the trial. Fifty-one patients were evaluated at week 24, 38 at week 52 and 21 at week 104. Cognitive therapy retained the patients in therapy for a longer time. The response criterion found no significant between-group differences at any measurement point in the completers. However, at week 24, CT was better than RST on the Hopelessness Scale, IVE scale and regarding the therapeutic relationship. At week 104, the CGI improvement (patient and evaluator) was significantly better in CT than in RST. High baseline depression and impulsivity predicted dropouts.CT retained the patients in therapy longer, showed earlier positive effects on hopelessness and impulsivity, and demonstrated better long-term outcomes on global measures of improvement.

Background: To date, there have been no studies comparing cognitive behavior therapy (CBT) with Rogerian therapy in post-traumatic stress disorder. Method: Sixty outpatients with DSM-IV chronic post-traumatic stress disorder were randomized into two groups for 16 weekly individual sessions of CBT or Rogerian supportive therapy (ST) at two centers. No medication was prescribed. Measures included the Post-Traumatic Stress Disorder Checklist Scale (PCLS), the Hamilton Anxiety Scale, Beck Depression Inventory, and Quality of Life. The general criterion of improvement (GCI) was a score of less than 44 on the PCLS. Results: Forty-two patients were evaluated at post-test, 38 at week 52 and 25 at week 104. At post-test, the rate of patients leaving the trial due to worsening or lack of effectiveness was significantly higher in the ST group (p = 0.004). At this point, no between-group difference was found on the GCI and any of the rating scales. Intent-to-treat analysis found no difference for the GCI, but patients in the CBT group showed greater improvement on the PCLS and Hamilton Anxiety Scale. Naturalistic follow-up showed sustained improvement without between-group differences at weeks 52 and 104. Conclusions: CBT retained significantly more patients in treatment than ST, but its effects were equivalent to those of ST in the completers. CBT was better in the dimensional intent-to-treat analysis at post-test.

This paper assesses the psychometric properties of the French version of the Obsessive Beliefs Questionnaire (OBQ-44) and investigates whether the questionnaire discriminates between obsessive-compulsive disorder (OCD), anxious control (AC), and non-clinical control (NCC) participants. A confirmatory factor analysis suggested a poor fit of the model. An exploratory factor analysis replicated the original factor structure. The subscales were moderately intercorrelated and highly correlated with the total score. There was partial support for convergent/divergent validity of the OBQ-44. In analyses of variance comparing the three samples, the participants in the OCD sample scored significantly higher than the participants in the AC and NCC samples on all of the OBQ-44 scores. In analyses of covariance comparing the OCD and NCC samples while controlling for general distress and age, the participants with OCD scored significantly higher than the NCC participants on all of the OBQ-44 scores. Implications of the current study are discussed.

The Obsessive Belief Questionnaire (OBQ) and the Interpretation of Intrusions Inventory (III) were designed to assess beliefs and appraisals considered critical to the pathogenesis of obsessions. In previous reports we have described the construction and psychometric properties of these measures. In this study a battery of questionnaires assessing anxiety, depression, and obsessive compulsive symptoms was completed by 410 outpatients diagnosed with obsessive compulsive disorder, 105 non-obsessional anxious patients, 87 non-clinical adults from the community, and 291 undergraduate students. Items from 6 theoretically derived subscales of the OBQ were submitted to factor analysis. Three factors emerged reflecting (1) Responsibility and threat estimation, (2) Perfectionism and intolerance for uncertainty, and (3) Importance and control of thoughts. A 44-item version (OBQ-44) composed of high-loading items from the 3 factors showed good internal consistency and criterion-related validity in clinical and non-clinical samples. Subscales showed less overlap than original scales. Factor analysis of the III yielded a single factor, suggesting the total score be used in lieu of the 3 rationally derived subscales. The scales performed well on tests of convergent validity. Discriminant validity was promising; hierarchical regression analyses indicated that the OBQ subscales and III generally predicted OC symptoms after controlling for general distress. A revision of the OBQ, the OBQ-44, is included in the appendix.

This paper reviews the evidence-based literature concerning the efficacy and effectiveness of cognitive behavior therapy (CBT), drug treatment and their combination for obsessive compulsive disorder (OCD). After a brief outline of the seminal studies, the state of the art is presented with reference to the consensual recommendations proposed in the last 10 years. Management of OCD rests on potent selective serotonin reuptake inhibitors and CBT, used separately, sequentially, or concurrently. A hierarchical model for clinical decision-making is reported. With greater severity of OCD, it is recommended to add medications. However, the response rate is still too low in many patients, and some patients remain refractory to any kind of treatment. This stresses the importance of joint efforts of psychological and biological teams to develop new treatments.

Background: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. Methods: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. Results: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. Conclusions: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.

Studies on attentional processes in obsessive-compulsive disorder (OCD) have been inconsistent. The present study focused on the question of sustained attention in OCD, using the 'Degraded Stimulus Continuous Performance Test' (DS-CPT) sensitivity index over time. This study included 20 OCD patients and 25 control subjects, comparable in sex, age and educational level. All subjects had a neuropsychiatric structured diagnostic interview, as well as a psychometric battery. The DS-CPT evaluated sustained attention. The sensitivity decrement during DS-CPT was significant in both controls and OCD subjects. Contrary to our expectations, OCD patients did not show a greater decrease in sensitivity over time, compared to controls: thus, OCD patients presented a no more important attention decrease than controls. Controls and OCD subjects became more conservative in their response criteria throughout the DS-CPT test. Comparing OCD with and without pharmacological treatment did not reveal any difference in CPT outcome. Moreover, we observed, in OCD, a positive significant correlation between the Y-BOCS compulsion score and the CPT sensitivity index. A significant negative correlation of the Y-BOCS compulsive score with the CPT false alarm score was also found. In conclusion, OCD patients did not present any disturbance in sustained attention during a task requiring an increased processing load.

Panic attacks can be observed in a wide range of situations, but most common are those providing complex and unstructured stimulations, suggesting an impairment in attentional processing of visuo-spatial information. This study evaluated agoraphobics’ attentional processing of neutral (i.e., not anxiety-provoking) visuo-spatial stimulation. Twelve patients suffering from panic attacks with agoraphobia were compared with 22 normal controls on a computerized visual target discrimination task specifically designed for this study. Psychometric measures assessed the phobic avoidance, the level of depression and anxiety. The numbers of errors and reaction times were analysed with a three-way ANOVA (Group x target modality x number of stimulations). No between-group significant difference was found for the reaction time performance and the mean number of detection errors. However, an interaction effect was observed for this last variable depending on the target modality: agoraphobic patients made fewer omission errors than control subjects when the target was present among distractors, while they made more commission errors when the target was absent. Outcomes are discussed in terms of attentional hyperactivation related to anxiety and perseverative decision process in agoraphobic patients.

Background: The efficacy of cognitive behaviour therapy (CBT) in social phobia has been demonstrated in several controlled trials and meta-analyses, but no comparison of CBT with supportive therapy (ST) can be found in the literature. Method: The aim of the trial was to study the effectiveness of CBT versus ST carried out ‘as usual’. Sixty-seven DSM-4 social phobic patients (89% generalized subtype, most with avoidant personality) were randomly allocated into two groups. Group 1 (CBT) received 8 1-hour sessions of individual cognitive therapy (CT) for 6 weeks, followed by 6 2-hour sessions of social skills training (SST) in group weekly. Group 2 received ST for 12 weeks (6 half-hour sessions), then the patients were switched to CBT. All patients agreed not to take any medication during the whole trial. In group 1, 29 patients reached week 6, 27 reached week 12, and 24 weeks 36 and 60 (endpoint). In group 2, 29 patients reached week 6, 28 reached weeks 12 and 18, 26 week 24, and 23 reached weeks 48 and 72 (endpoint). Results: At week 6, after CT, group 1 was better than group 2 on the main social phobia measure. At week 12, after SST, group 1 was better than group 2 on most of the measures and demonstrated a significantly higher rate of responders. This finding was replicated after switching group 2 to CBT. Sustained improvement was observed in both groups at follow-up. Compliance with abstinence from medication increased over time. Conclusions: CBT was more effective than ST and demonstrated long-lasting effects. This may suggest that social phobia management requires more than a simple and inexpensive psychological intervention.

Background: The goal of the present study was to validate the French version of the Agoraphobic Cognitions Questionnaire (ACQ). Methods: Subjects consisted of 115 patients with panic disorder and agoraphobia, 54 obsessive-compulsive patients and 72 normal controls. Patients were referred for outpatient treatment. They filled in the questionnaire before and after entering treatment. The control group consisted of people taken from the general population. It was matched with the clinical groups on age, sex and education. Results: The ACQ appears to have a constant factor structure across US, Dutch and French samples. Results support the validity of the total score of the ACQ. Patients with panic disorder and agoraphobia scored significantly higher than obsessive-compulsive patients and control subjects. On the ACQ physical concerns subscale agoraphobic patients were significantly different from obsessive-compulsive patients and control subjects. On the social/behavioural subscale agoraphobic patients and obsessive-compulsive patients were significantly different from control subjects. The French translation of the ACQ was found to be stable over an interval of 15 days in the control group. The Cronbach coefficients of both subscales were also satisfactory. These results support the stability and the internal consistency of the questionnaire. In addition, the French translation of the ACQ was sensitive to changes with cognitive-behavioural therapy. Conclusions: These results support the findings of Chambless and Gracely [Cogn Ther Res 1989;13:9–20]. The ACQ physical concerns subscale is a specific feature for the anxiety status experienced by patients with panic disorder and agoraphobia. The ACQ social/behavioural subscale seems to be a more general feature of anxious patients.

Cognitive therapy (CT) has been studied in 78 controlled clinical trials from 1977 to 1996.The meta-analysis used Hedges and Olkin d+ and included 48 high-quality controlled trials. The 2765 patients presented non-psychotic and non-bipolar major depression, or dysthymia of mild to moderate severity.At post-test CT appeared significantly better than waiting-list, antidepressants (P0.0001) and a group of miscellaneous therapies (P0.01). But, CT was equal to behaviour therapy. As between-trial homogeneity was not met, the comparisons of CT with waiting-list or placebo, and other therapies should be taken cautiously. In contrast, between-trial homogeneity was high for the comparisons of CT with behaviour therapy and antidepressants. A review of eight follow-up studies comparing CT with antidepressants suggested that CT may prevent relapses in the long-term, while relapse rate is high with antidepressants in naturalistic studies.CT is effective in patients with mild or moderate depression.

Background: The change of psychopathological dimensions during treatment of panic disorder is attracting increasing interest. Methods: A population of subjects experiencing panic disorder with agoraphobia is evaluated with the French version of the factor structure of the Symptom Checklist 90 R (SCL 90 R). Two groups of patients are compared: a group receiving cognitive behaviour therapy (CBT) combined with buspirone and a group receiving cognitive behaviour therapy combined with placebo. Results: Comparative analysis of pre- and post-test changes between both groups completing treatment showed that the combination cognitive behaviour therapy plus buspirone provided better results than those in patients who had received cognitive behaviour therapy plus placebo. This difference between treatments did not persist at the 1-year follow-up, since, while results had been effectively maintained in the CBT plus buspirone group, the CBT plus placebo group continued to improve significantly for the target dimensions of treatment. Conclusions: Psychopathological dimensions on the SCL 90 R show that combination of buspirone and cognitive behaviour therapy accelerates the behaviour modification process only in the short term.

BackgroundThis multicentre study compared a 16-week buspirone treatment with placebo in patients presenting with panic disorder with agoraphobia and also receiving cognitive behaviour therapy (CBT).MethodDouble-blind testing was maintained until week 68, but not tested; 91 patients were included; 14 placebo-responders excluded; 77 patients randomised; 48 reached week 16 and 41 reached week 68.ResultsAt week 16, within-group analysis showed significant improvements in agoraphobia, panic attacks, and depression in both groups. Generalised anxiety improved only in CBT + buspirone. Between-group comparisons showed buspirone to have an effect on generalised anxiety and agoraphobia. Changes in degree of agoraphobia and depression were correlated in subjects on CBT + buspirone only. A significantly higher proportion of women, and of subjects showing high avoidance dropped out. Positive expectations regarding medication predicted success in both groups. At week 68, improvement was retained without significant buspirone effect.ConclusionBuspirone enhanced the effects of cognitive behaviour therapy on generalised anxiety and agoraphobia in the short term.

Memory processes were compared in 26 patients presenting DSM-III-R obsessive-compulsive disorder (OCD) with 20 sex-, age- and education-matched normal controls. A significant between-group difference was found: visual memory was significantly lower in OCD, whereas no significant between-group differences in verbal memory were observed. A subsample of 17 OCD were also compared with the 20 control subjects on an explicit-memory free-recall task and an implicit-memory completion task using neutral, obsessive and guilt-responsibility words to test the effects of an emotional verbal input on memory functioning. No between-group difference was found, suggesting that emotionally laden word processing did not modify implicit and explicit memory performances.

Sixty outpatients with obsessive-compulsive disorder (OCD, 22 men, 38 women) were randomized to receive 6 months of antiexposure therapy with fluvoxamine (group F), exposure therapy with fluvoxamine (group Fe), or exposure therapy with placebo (group Pe). Patients in group F did not comply with antiexposure therapy, so it was in fact a neutral condition. Patients began with depressed mood (mean Hamilton depression score = 19). Fifty patients were reevaluated at week 8, 44 at week 24 (posttest), 37 at week 48, and 33 at 18 months, 1 year posttreatment (group F, n = 10; group Fe, n = 12; group Pe, n = 11). The three groups improved on rituals and depression. There was a drug effect on rituals at week 8 and on depression at week 24; both these effects disappeared at week 48. The 33 18-month completers had been comparable at baseline to those not followed up, apart from having more severe behavioral avoidance. At 18-month followup, patients as a whole remained improved with no between-group differences; over 80% of the Fe and Pe patients versus 40% of the F patients were not receiving antidepressant treatment (Fe vs. F: p < 0.04; Pe vs. F: p = 0.053; Fe vs. Pe: NS). In OCD fluvoxamine and exposure therapy were synergistic in the short term, and exposure reduced subsequent need for antidepressants in the followup year after they had been stopped.

We commend the authors of this paper for theirhonest acknowledgement of the limitations of theirown re-analysis of our 1998 meta-analysis:i) The small number of trials included in their re-analysis is a considerable inconvenient.ii) The small number of studies included did notpermit investigation of sources of the hetero-geneity between trials.A recent review by Butler (1) with the recenttrials could help in developing a new point ofview. Too limited meta-analyses could producemisleading and⁄or out of date conclusions. Thatis the reason why we included as many trials aspossible in our study from 1998 even unpub-lished. We only know too well that negativetrials are under represented in scientific journals,especially about antidepressants effects (2, 3):grey literature is indeed literature for meta-analysis.Nevertheless, we acknowledge that our modestmeta-analysis (4) was far from perfect and we areglad to see it became a conversation piece amongdistinguished researchers.Jean CottrauxFomer Head Anxiety Disorder UnitUniversity Lyon 1LyonFranceE-mail: cottraux@univ-lyon1.fr

DSM-3 obsessive-compulsive out-patients were randomly assigned to fluvoxamine with antiexposure (F), fluvoxamine with exposure (Fe), or placebo with exposure (Pe) for 24 weeks. Of 65 patients offered treatment 60 entered the trial, 50 reached week 8, 44 completed treatment to week 24, and 37 reached follow up to week 48. On average the patient had depressed mood (mean Hamilton depression rating scale = 19). Drop-out numbers, clinical status and behavioural measures were comparable across groups. Most F patients did not do antiexposure, but Fe and Pe patients complied in doing exposure. All three groups improved in rituals and depression from week 0 to week 24 and 48, with a slight but non-significant superiority for combined treatment up to week 24. At week 8 there was a drug between-group effect on rituals, but not on depression. At week 24 there was a drug between-group effect on depression, but not on rituals. The drug superiority was short-lived. At week 48 there was no between-group difference in rituals or depression. Depression was related to ritual outcome at week 24 in F, and tended to be so in Fe.

Although psychological stress is known to favor ventricular arrhythmic events, there is no evidence that stress management intervention decreases ventricular electrical instability in implantable cardioverter-defibrillator (ICD) patients. The aim of the study was to determine whether cognitive behavioral therapy (CBT) results in a decrease of arrhythmic events requiring ICD intervention through an improvement in sympathovagal balance.Of 253 consecutive ICD patients (age 59 +/- 10 years, 64 men), 70 were randomly assigned to CBT (n = 35) or conventional medical care (n = 35). Measures of heart rate variability, psychological well-being, and quality of life were assessed at baseline, 3 months, and 1 year. The primary outcome was appropriate ICD shock.Although, it was not statistically different, the number of patients requiring shocks was less in the CBT group than in the conventional treatment group. At 3 months, among patients without antiarrhythmic drugs, none of the subjects in the CBT group had experienced arrhythmic events requiring ICD intervention, as compared with 4 in the control group (P.05). At 12 months, there was no difference in the number of arrhythmic events requiring therapy between the CBT group versus the control group. Among heart rate variability indexes, daytime pNN 50 and nocturnal SDNN improved significantly in the CBT group, as compared with the control group.By decreasing anxiety and possibly improving sympathovagal balance, cognitive behavior therapy may decrease the propensity for ventricular arrhythmias in ICD patients. However, these effects appear to be limited over time.

Five hundred and fifty-eight cigarette smokers (mean 31 cigarettes/day) were randomized in four groups: Acupuncture, Behaviour Therapy, Placebo Medication and Waiting-list Control. The life-table analysis of smoking cessation showed, at a 12-month follow-up, no difference between Acupuncture, Behaviour Therapy and Placebo. Differences appeared only in an analysis of the abstinent subjects at each data point. Behaviour Therapy and Acupuncture accounted for significantly more abstinent subjects than Placebo at the end of the 2-week therapeutic phase. However at 9 and 12 months Acupuncture had a statistically-significant greater number of abstinent subjects than Behaviour Therapy, but there was no difference between Acupuncture and Placebo. The percentage decrease in smoking from baseline appeared significantly greater at 12 months in the first three groups than in the Control conditions. However, as in most smoking-cessation studies, the overall effect was small and non-specific. The results reflect the importance of maintenance programmes and of the prevention of addiction.

The dexamethasone suppression test (DST) was administered after baseline cortisol measurements in 20 patients (10 males, 10 females) who met DSM-III criteria for obsessive-compulsive disorder (OCD). Six patients (30%) showed an abnormal escape from dexamethasone suppression. DST suppressors vs. DST nonsuppressors showed no differences in age, rate of secondary depressive disorders, or scores on the Hamilton Rating Scale for Depression, the Minnesota Multiphasic Personality Inventory D scale, or OCD rating scales. Surprisingly, there was a trend for suppressors to have a stringer family history of depressive disorders, and for nonsuppressors to include an excess of male subjects. Moreover, there was a significant correlation between levels of cortisol before and after DST. In five of six nonsuppressors, both depressive symptoms and obsessive- compulsive behaviors showed a diminution in response to antidepressant therapy combined, in one case, with intensive behavior therapy. The relationships between OCD and endogenous depression, as well as the specificity of the DST, are discussed.

Srrmmary.-A muluple-baseline design with counterdemands instructions was used to evaluate the efficacy of cognitive therapy in five depressed patients. Depression measures (LMMPI, Hamilton, and Beck Depression Inventory) showed that all the patients were improved at the end of treatment and therapeutic benefits were maintained at a l-yr. follow-up. These resula conf~rmed the beneficial effects for depressive patients of cognitive therapy with scrlogent methodological controls. Since the seminal study of Rush, Beck, Kovacs, and Hollon (1977), several researchers concluded that cognitive behavioral therapy was effective in depression (Beck, Sha~, Rush, & Emery, 1979; Blackburn & Bishop, 1981; Christie, 1981; Murphy, Simons, Wetzel, & Lustma, 1984; Shaw, 1977; Taylor & Marshall, 1977; Teasdale, Fennell, Hibbert, & Amies, 1984; Williams, 1984; Wilson, Goldin, & Charbonneau-Powis, 1983). However, no study has ever evaluated the effects of such therapy associated with negative expectancies or counterdemand instructions. If patients showed an improvement despite these expectancies, it would further confirm the efficacy of cognitive therapy. In the present smdy, French depressive out-patients were given cognitive therapy in a multiple baseline-design associated with positive and negative therapeutic instructions.

SummaryOf 15 patients with writer's cramp (4 females, 11 males, mean age 36, range 23–50, mean duration 3.6 years), 13 entered a behavioural treatment. Nine received a multimodal treatment, and four EMG feedback alone. Four patients dropped out during the treatment phase. Nine patients were considered as improved at a follow-up between 1 and 9 months. A stress-coping model is put forward to account for the therapeutic effectiveness, and to explain the drop-outs. Writer's cramp seems to be related to stressful situations at work. The existence of personality and biological factors remains to be demonstrated.

To the Editor.— Psychiatrists and psychologists in several countries have helped to compose this letter, which critiques recent reports (in the May 1988Archives, pp 407-443) by Klerman, 1 Ballenger et al, 2 Noyes et al, 3 Pecknold et al, 4 and Lesser et al. 5 The evaluation of treatment outcome is a complex process, and the same data can lead different observers to contrasting conclusions, as is highlighted by this large trial reported by respected researchers. All five articles claim that alprazolam is "effective," a claim made without qualification in the abstract of Klerman's article. 1 Pecknold et al 4 even recommend in their abstract that the administration of medication should last at least 6 months, with subsequent taper of at least 8 weeks. This claim of "efficacy" is misleading given the arguable interpretation of the data presented and that busy clinicians often have to rely on abstracts more

The association of some antigens of the HLA system with numerous diseases has been demonstrated repeatedly in the last 10 years. Good evidence exists that panic disorders and agoraphobia with panic attacks are a familial disease (Pauls et al. 1980; Crowe 1983). However, ~e~s~iation of anxiety with HLA remains a relatively neglected area of investigation. A report by Surman et al. (1983) suggested that an association between panic disorder and the major histocompatibility complex may exist. B 14 antigen was present in two sets of genotypic identical siblings pairs, all concordant for panic disorder, and in one relative suffering from social phobia. Crowe et al. (1987) recently presented a study of panic disorder in 26 families. The finding that Bf, a locus of the complement system located in the HLA re~on,h~a~sitiveLOD~su~e~~~A locus might be a relevant place to look for an association with panic attacks. The present study is the first investigation on the association of HLA antigens in a relatively large group of patients with panic snacks, with or without ago~phobia.