The National Institute of Clinical Excellence (NICE) guidelines for anxiety (Panic and Generalized Anxiety Disorder) and depression were finally launched in December 2004, after much delay (see www.nice.org.uk). Given that these were such important documents, it might seem surprising that the launch went almost entirely unnoticed. Why was it surprising? Because the recommendations were ground breaking. CBT was identified as the first line treatment pretty much across the board, with huge resource implications. It is not the business of NICE to comment on resources (or the lack of these). However, it was noted in the anxiety guidelines that CBT should be available promptly from appropriately trained and supervised therapists. In many (if not most) areas, this strongly implies a huge change in emphasis in the delivery of psychological therapies. The (implicit) implications are staggering. With the honourable exception of Interpersonal Therapy in depression, other psychological therapies were not advocated – at all. In anxiety, combination treatment (medication and CBT) was not recommended as a first or second line treatment. Some medication (antipsychotic) was ruled out. Guided self-help (based on CBT principles) was “third choice”. So the explicit recommendation is that good quality, empirically grounded psychotherapies (CBT, CBT and IPT in depression) should be widely and promptly available, whereas therapies without an empirical basis were not recommended.

We examined beliefs about depression in patients and their partners and explored the impact of beliefs on perceptions of marital functioning, level of distress and caregiving in partners, and clinical outcome of major depression. Fifteen patients meeting criteria for major depressive disorder and their co-habiting spouses were interviewed at baseline using the Reasons for Depression Questionnaire (Addis, Truax and Jacobson, 1995) and measures of symptom severity, distress, caregiver consequences and marital satisfaction. Outcome was assessed at 6 months. Identifying biological reasons for depression was significantly associated with patient severity of depression and with caregiver burden. Caregiver distress was significantly associated with endorsement of interpersonal reasons for depression. Concordance in reason giving between patients and partners was significantly associated with a good outcome. This is the first study to show that beliefs about depression held by patients and their partners may have an impact on the clinical outcome of major depression.

There is active, current speculation about the relationship between trauma and psychosis. However, little is known about the information-processing mechanisms underlying the development of trauma-related intrusions in this area. Our account highlights the role of contextual integration, i.e. the need for experiential information to be effectively integrated into a temporal and spatial context in order to facilitate voluntary recall. Drawing on existing models of both posttraumatic stress disorder (PTSD) and psychosis (Brewin, 2001; Ehlers and Clark, 2000; Garety et al., 2001; Morrison, 2001), we propose a contextual integration account of trauma-related intrusions. It is argued that the strength of contextual integration, which occurs during encoding, influences the frequency and nature of subsequent intrusive experiences. Consequently, individual differences in schizotypal personality traits, which are known to be associated with levels of contextual integration, are also related to the phenomenology of trauma-related intrusions. Whilst intrusions can be seen to occur within a range of disorders, it is argued that contextual integration may be one key variable in understanding the relationship between an experienced trauma and any consequent psychiatric symptomatology. Implications for clinical interventions aimed at trauma-related psychosis are discussed, along with research aimed at developing the empirical basis for such interventions.

This study reports the development of a self-report measure to assess metacognitive beliefs about paranoia in non-patients. We aimed to test the specific hypotheses that positive beliefs about paranoia would predict frequency of paranoia, and that negative beliefs about paranoia would predict distress associated with delusional ideation. Three-hundred and seventeen non-patient participants were asked to complete questionnaires assessing beliefs about paranoia, paranoia, dimensions of delusional ideation and trait anxiety. The results showed that four empirically distinct subscales were measured by the beliefs about paranoia scale (negative beliefs about paranoia, beliefs about paranoia as a survival strategy, general positive beliefs and normalising beliefs). The scales possessed acceptable internal consistency and were associated with the measures of paranoia, delusional ideation and anxiety. Consistent with predictions, it was found that beliefs about paranoia as a survival strategy were associated with frequency of paranoia, and negative beliefs were associated with distress associated with delusional ideation. These findings suggest that a metacognitive approach to the conceptualization of paranoia as a strategy for managing interpersonal threat may have some utility. The clinical implications of the findings are also discussed.

It has now been established in several randomized controlled trials that specialist cognitive-behavioural therapy (CBT) is an effective treatment for severe and persistent health anxiety (diagnostically, “Hypochondriasis”). It has not yet been established whether or not such results will generalize from academic research centres to routine clinical settings. The present study was designed to address the issue of generalization by evaluating the outcome of a consecutive series of patients meeting diagnostic criteria for hypochondriasis, treated using CBT in a non-academic clinic in Copenhagen, Denmark. The delivery of the treatment was adapted to fit with the practice of the clinic, so that the later components of therapy were delivered in a group therapy setting. Therapists participated in a brief training course, which was subsequently supplemented by expert clinical and peer supervision. Patients received the same amount of treatment used in previous clinical trials. Results indicate that the degree of improvement obtained in this study was significant and compared well with those obtained in the previous trials. These results support the use of dissemination of new treatments using a specialist training model.

Safety-seeking behaviours are seen as playing a key role in the maintenance of various anxiety disorders. This article examines their role in panic disorder and social phobia and suggests that, whilst there are clear theoretical differences between safety-seeking behaviours and adaptive coping strategies, the difficult issue in clinical practice is being able to distinguish between the two. It builds on previous work by Salkovskis and colleagues and provides a detailed discussion of the problems in distinguishing between safety-seeking behaviours (direct avoidance, escape and subtle avoidance) and adaptive coping strategies in clinical practice. The suggestion is made that topology can only be a guide to categorizing the two types of responses and they can only be fully distinguished by taking into account the intention of the individual and their perceived function to that individual in the specific context. It is suggested that further analysis of the use of safety-seeking behaviours aimed at avoiding a variety of outcomes at differing levels of catastrophe may provide useful information that would clarify our understanding of the role of such behaviours in maintaining anxiety disorders.

The successful treatment of extreme shape concern in patients with eating disorders has been shown to be important for their sustained recovery. This case series reports a preliminary investigation of the effects of a new brief cognitive-behavioural intervention for extreme shape concern. The intervention, which is implemented in a single 2-hour session, addresses four mechanisms hypothesized to contribute to the maintenance of extreme shape concern and is designed to be suitable as an adjunct to existing treatments for eating disorders. Participants were five women with extreme shape concern and three female patients with eating disorders. The results indicate that the intervention was effective to various degrees in each participant, and suggest that the intervention warrants further investigation. In particular, methods of increasing the potency of the intervention should be investigated, and its efficacy tested in a larger controlled study.

In two linked studies we examined children's performance on tasks required for participation in cognitive therapy. In Study 1 we piloted some new tasks with children aged 5 to 11 years. In study 2 the effects of IQ, age and educational experience were examined in children aged 5 to 7 years. In study 1, 14 children aged 5 to 11 completed three tasks related to cognitive therapy; generating post-event attributions, naming emotions, and linking thoughts and feelings. Study 2 used a between-subjects design in which 72 children aged 5, 6, or 7 years from two primary schools completed the three tasks and the Block Design and Vocabulary sub-tests from the WISC III or WPPSI-R. Children were tested individually during the school day. All measures were administered on the same occasion. In study 2 administration order of the cognitive therapy task and the WISC III/WPPSI-R were randomized. The majority of children demonstrated some ability on each of the three tasks. In study 2, performance was associated with school and with IQ but not with age. There were no gender differences. Children attending a school with an integrated thinking skills programme and those with a higher 1Q were more successful on the cognitive therapy tasks. These results suggest that many young children could engage in cognitive therapy given age-appropriate materials. The effects of training in relevant meta-cognitive skills on children's ability to use concepts in CBT may warrant further research.

This study describes the development and initial evaluation of a cognitive schema questionnaire for children. The Schema Questionnaire for Children (SQC) was designed to capture the 15 early maladaptive schemas proposed by Young (1990). Face validity of the questionnaire items as assessed by a group of CBT experts (n=16) was good. Concurrent validity was assessed by asking 47 school children aged 11–16 years of age to complete both the (SQC) and a British version of the 75 item Young's Schema Questionnaire short form (YSC-S). Significant correlations were obtained for 10 of the 15 schemas, with a further two approaching statistical significance. Although some of the correlations were modest, these initial results suggest that the SQC may be a valid quick and developmentally appropriate way of assessing Young's maladaptive schema in children.

We assessed the efficacy of cognitive behaviour therapy (CBT) delivered by general practitioners (GPs) to fatigued employees on sick leave. CBT had no substantial effect on clinical outcomes. In the present study, we aim to describe the treatment protocol and present an analysis of the delivery of the intervention. To assess protocol execution, GPs used standardized registration forms in each treatment session. A quality check was performed to assess whether CBT was completed according to protocol. Of the 71 patients starting CBT, 51 patients completed the intervention. There were no striking differences in protocol execution between those who recovered after CBT and those who did not recover. Although there were differences in the performance and delivery of CBT, there was no association between protocol execution and treatment results of individual GPs. Despite the lack of efficacy, the intervention received a positive evaluation from both patients and GPs. CBT completers who recovered did not receive a clearly different treatment than those who did not recover. In addition, successful GPs did not deliver a clearly different treatment than less successful GPs. The lack of efficacy can at least partly be attributed to the inadequacy of the intervention, whether it is the intervention itself or its delivery by GPs.

This project reports on the effective delivery of a behavioural coping skills programme with a repetitive deliberately self-harming young woman. A simple single case A-B design was employed to evaluate the intervention due to the applied nature of the project and ethical considerations. An assessment period prior to the intervention phase constituted an extended baseline. Data concerning the primary dependent variable, deliberate self-harm, were collected for a 3-month follow-up period.

Childhood anxiety disorders often have a poor prognosis. Despite this, there are currently no published treatment protocols for young children with anxiety difficulties. Individually focused therapies (e.g. CBT) are useful for older children, but likely to be less so for this group. This paper describes a pilot investigation of a new CBT based parenting intervention for the treatment of children aged 9 years and under. Sixteen parents of 11 anxious children took part in a 10-week intervention, completing the Child Behaviour Checklist at three time points. The intervention was based on a new cognitively enhanced parenting package, with an emphasis on coping with internalizing symptoms, and with additional modules on the specific skills needed for managing anxiety. All children were reported to experience substantial decreases in their internalizing symptoms by the end of the study. Parents' satisfaction with the intervention was high. This is a promising new intervention for the treatment of a currently neglected group.

Affective symptoms are often present and under-treated in schizophrenia. This case study reports the effect of treatment of a specific phobia and associated avoidance on the psychotic symptoms of a patient with medication resistant schizophrenia. The treatment of the specific phobia and agoraphobia followed a traditional systematic desensitization procedure. The successful treatment of the phobias led to improvements in psychotic symptoms. Previously, the client had only a limited response to a number of antipsychotic medications including clozapine but responded well to a traditional systematic desensitization program that produced positive consequences for the psychotic symptomatology. The clinical and theoretical aspects of this case are discussed.