Dr. Michel is clinical assistant professor in the Department of Psychiatry and Neurology at the Tulane University School of Medicine in New Orleans, Louisianna.

Dr. Willard is professor in the Departments of Psychiatry, and Neurology and Pediatrics at the Tulane University School of Medicine.

Disclosure: The authors report no financial, academic, or other support of this work.

Please direct all correspondence to: Deborah M. Michel, PhD, 824 Amethyst St, New Orleans, LA 70124; Tel: 504-282-7191; Fax: 504-282-7196; E-mail: dmarcon@tulane.edu


Focus Points

The role that family dynamics can potentially play in the development and maintenance of eating disorders is delineated.

Areas of inquiry for the assessment of family dynamics are presented.

The importance of family therapy in multidisciplinary treatment of eating disorders is discussed and a brief literature review of support for family treatment of eating disorders is provided.

Common issues that arise during the course of family treatment of eating disorders are outlined.



How is family treatment of eating disorders conducted and when is it warranted? This article briefly reviews the important role family dynamics can play in the development and maintenance of eating disorders and summarizes support for family treatment of eating disorders. The review presents areas for inquiry in the assessment of family dynamics and discusses the role of family therapy in multidisciplinary treatment. Common issues that arise in the course of therapy are also delineated.



The family dynamics of those with eating disorders, particularly anorexia, have been of interest to clinicians since the disorders were first described1,2 and well past the time that they were recognized as psychological problems.3 In particular, practitioners have noted the association between eating disorders and difficulty with individuation and separation from the family of origin. Peer relationships are vitally important during the developmental stage that occurs between childhood, during which family is the main source of support, and adulthood, when nonfamilial resources become paramount. During adolescence, it is imperative for friends to become of primary interest and for the family to recede to secondary status. If this phenomenon does not occur, the adolescent’s development of normal peer relationships may be inhibited, thus depriving the youngster of appropriate “growing up” experiences. Without a peer group, it is next to impossible to make the necessary transition from the family to the larger world.

The notion that dysfunctional family characteristics play a part in the development of eating disorders is controversial, as some clinicians believe that the observed family problems are a result rather than the cause of the stress associated with having a child with such a frightening illness.4 There is mounting evidence that genetics contribute to the development of eating disorders, although it is commonly believed that an interaction occurs between genetics and environmental stressors that spawns these disorders.5 What we do know is that the family represents the holding environment for the child and it is always necessary to look at which aspects of the family might relate to the occurrence and maintenance of the disease while remembering that it is never useful or appropriate to blame family members for the disease.3

The ways in which family dynamics may contribute to the development of an eating disorder vary. For example, the family may provide an atmosphere which hinders a youngster from establishing an identity, practicing effective communication skills, and/or learning adaptive coping strategies. Furthermore, within the context of the family, an eating disorder may help an adolescent establish a distinct and separate identity from the family, cope with stressors, distract from negative feelings, or provide what she or he considers to be a means of “safe” self expression in an environment that does not allow open self expression.3

We have noted6 that there have been many clinical accounts of the effectiveness of family therapy in the treatment of eating disorders, yet relatively few controlled studies. However, these few studies clearly show that family therapy is an effective modality for treating eating disorders, particularly in adolescents with anorexia. Investigations with families of bulimics also support the use of family treatment, although fewer studies have been conducted with this population compared to families of anorexics. Taken together, research and clinical experience has convinced us that family therapy is a critical part of treatment within a multidisciplinary team approach, and the need for family therapy from a biopsychosocial stance is now widely accepted.4 A more critical overview of the literature in this area is available in Eating Disorders.6


Assessment of Family Dynamics

The family therapy process begins with an assessment and is a continuous process throughout treatment.6,7 The assessment involves an evaluation of individual family members as well as the family unit as an interrelated system. Thus, the evaluation will necessarily include all family members living within the home. Other extended family members may also be asked to take part in the assessment if they have a significant relationship with the identified patient. The goal of the assessment is to determine if the familial environment played a role in the development and maintenance of the eating disorder and, if so, to identify the extent to which any problematic issues remain.8 The assessment also addresses how the eating disorder functions within the family system. During the evaluation, it is important to identify: (A) how the symptoms stabilize the family; (B) what role the family plays in stabilizing the symptoms; (C) around what themes the problem is organized; (D) what consequences will follow familial change; and (E) the therapeutic problem or dilemma.7

When conducting the evaluation, the practitioner should begin by obtaining standard psychosocial information for each family member including demographic data, current and previous living arrangements, psychiatric history, medical history, educational and occupational history, social history, and trauma history.6 It is also important to inquire about significant family events as well as family traditions. Gathering background information on each parent’s family of origin will promote identification of multigenerational patterns of relating and behaving.

As recommended by Anderson,9 there is a need to investigate other areas as well.6 First, interactional patterns should be evaluated including marital satisfaction, extent of spousal agreement on parenting, family satisfaction and companionship, patterns of communication, and the overall affective atmosphere of the family. Second, it is important to assess degree of flexibility in allowing family members to alter communication patterns and roles in response to situations and stressors. Third, clinicians should evaluate how sensitive family members are toward one another. Are they hypersensitive and overreactive, uninvolved and insensitive, or somewhere in between? Furthermore, it is suggested that supports and stresses be evaluated. More specifically, degree of support, or lack thereof, that family members afford one another should be assessed in addition to any significant sources of strengths and stressors both within and outside of the family.

Practitioners must also assess the age-appropriateness of rules and responsibilities that are assigned to family members, especially children and adolescents. Lastly, family knowledge of the eating disorder is a critical area of inquiry in terms of etiology, treatment, and recovery in addition to thoughts, feelings, and behaviors associated with it. Family attitudes and behaviors that may impede recovery need to be identified and resolved quickly,8 particularly preoccupations with weight and appearance which may undermine the identified patient’s efforts at recovery.10 Relatedly, it is important to obtain a family history of dieting, exercise, and eating disorders.3

To assist clinicians in family assessment, standardized, self-report measures are available such as the Family Adaptation and Cohesion Evaluation Scale11 and the Family Assessment Measure.12 These instruments examine the quality of familial relationships and familial interactions from an individual family members’ perspective.6 Although these instruments are subject to self-reporting bias, they can nevertheless be helpful secondary sources of information.


Treatment: A Multidisciplinary Approach

As we have written previously,6 recognition of the complexity of eating disorders, combined with the realization that no single healthcare professional can provide comprehensive care for these patients, led to the evolution of a multidisciplinary team approach.3 Family therapy is one arm of this approach. It is based on the tenet that the family is a system, or a group of interconnected parts which affect one another in a stable manner.13 Consequently, the psychotherapeutic focus is on the family system as a whole, instead of any individual member.6 We have stated3 that the family is the context out of which an eating disorder typically arises, and accordingly, necessitates change if an adolescent is to overcome the eating disorder in that environment. As a result, family therapy is often geared toward understanding the role that the identified patient has characteristically played within the family system and how he or she has contributed to maintaining whatever homeostasis has been achieved.

Homeostasis refers to the balance that occurs when all family members adhere to their given, often unspoken, rules of behavior. These rules can be quite rigid, thereby preventing family members from learning more adaptive, flexible coping mechanisms in response to life stressors. In some cases, patients do well in treatment without family participation, especially if the family exhibits a high degree of negative expressed emotion.14 Older patients who do not live with their families of origin may not need family therapy unless it is determined that the family continues to be a stimulating factor in the illness. These patients may be in family therapy with their spouses and children. When a patient still lives with her family, however, family therapy is usually recommended. Marital therapy may be suggested as an adjunctive treatment for those with spouses.3

Family therapy may evolve into marital therapy for the parents of the identified patient or individual therapy for one or both parents. In other cases, these psychotherapies may be recommended as adjunctive treatments. Furthermore, it is not unusual for one of the parents to be referred for individual therapy at the outset of treatment if it is clear that the primary family problem lies within that particular parent-child relationship.3

We have reported6 that family therapy conducted in conjunction with individual psychotherapy greatly improves prognosis10 and is recommended in the Practice Guideline for the Treatment of Patients with Eating Disorders.15 For theoretical or practical reasons, some practitioners treat both the identified patient and the family. We prefer a model using separate therapists for individual and family therapy on the following grounds3: (A) facilitation of the individuation-separation process; (B) less complicated management of confidentiality issues; and (C) division of therapeutic responsibilities.16 This model also addresses any family dysfunction on both an individual level, where it has been introjected, as well as on the present family level.17 Finally, there are some schools of family therapy that advocate parental control over the child’s eating and a professional, family-based treatment manual is available outlining one such method.6,18 It has been noted, however, that most clinicians do not follow this approach.19 In our experience, having a registered dietician (nutritional counselor) with expertise in eating disorders handle all food issues has been most beneficial. In this manner, the family and identified patient can relinquish battles surrounding food, strengthen familial relationships, and focus on relevant psychotherapeutic issues.6

At times, families may present obstacles to the assessment and treatment process.20 Potential difficulties include denial of a problem, minimization of the eating disorder, and/or denial of the psychological origins of the illness. Treatment resistance and lack of familial motivation to change may also be present. Family refusal to participate in treatment and/or to cooperate with treatment recommendations can have a devastating effect on the course of the illness and the potential for recovery.3 When family members refuse to take part in recommended treatment, the patient often feels that he/she alone is the one with “the problem” and is in some way defective. The aforementioned challenges must be confronted and resolved early in treatment so that a therapeutic alliance can be established, thereby enhancing the probability of a successful outcome.20

In response to familial disagreement with some aspect of treatment or treatment recommendations, the family therapist, and possibly the entire treatment team if appropriate, should meet with the family to work out those differences.3 Dealing with such problems in this manner models adaptive coping skills for the entire family and creates an atmosphere of mutual cooperation and respect in which healing can take place.


Common Issues

Although each case of an eating disorder develops for a variety of individualized reasons, that there are issues commonly encountered in family therapy.3,6 One such issue is difficulty with communication. This problem may be characterized by miscommunication, lack of communication, mixed or double messages, or failure to allow overt expression of feelings, either directly or indirectly. Another typical theme involves problems with the separation-individuation process and difficulties that the family has in allowing the child to become independent. Lack of appropriate parent-child boundaries (eg, failure to respect privacy), enmeshment (emotional overinvolvement), or disengagement (emotional distance), are also frequently seen. As mentioned earlier, the roles that family members play which contribute to the development and maintenance of the eating disorder must also be addressed. For example, a sick child might be the mediator between parents in a strained marriage. In addition, the family often has unrealistic expectations of individual members, such as the “superstar child.” Finally, issues of power and control within the family are likely to surface. For more detailed information on family therapy in the treatment of eating disorders, see the list of suggested readings.



Family therapy is an effective modality of treatment for eating disorders, particularly when used in conjunction with individual psychotherapy and nutritional counseling as part of multidisciplinary treatment. For younger patients still living with their families of origin, it is usually essential for recovery and requires the participation of all family members. If the family is highly defensive and critical, parent counseling or family therapy without the identified patient may be recommended. For older patients, family therapy may not be necessary unless the family is thought to play a role in the maintenance of the illness.

A careful and continuous assessment of family dynamics is warranted in order to ascertain the therapeutic needs of the family and to implement appropriate interventions. Family therapy can then be expected to surround common themes while also addressing individualized family concerns. At times, families may present challenges to the assessment and treatment process. These difficulties must be identified, addressed, and resolved early in treatment in order to increase the potential for a successful outcome.  PP



1. Gull WW. Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society of London. 1874;7:22-28.

2. Lasegue C. De l’anorexie hysterique. Archives Generales de Medecine. 1873;1:384-403. French

3. Michel DM, Willard SG. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, CT: Yale University Press; 2003.

4. Lemmon CR, Josephson, AM. Family therapy for eating disorders. Child Adolesc Psychiatr Clin N Am. 2001;10:519-542.

5. Klump K. A genetic link to anorexia. In: DeAngelis T, ed. Monitor on Psychology. 2002;33:34-36.

6. Michel DM, Willard SG. Family evaluation and therapy in anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton TD, ed. Eating Disorders. New York, NY: Marcel Dekker. In Press.

7. Vanderlinden J, Vandereycken W. Family therapy within the psychiatric hospital: indications, pitfalls, and specific interventions. In: Vandereycken W, Kog E, Vanderlinden J, eds. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York, NY: PMA Publishing; 1989:263-310.

8. Woodside DB, Shekter-Wolfson LF, Garfinkel PE, Olmsted MP. Family interactions in bulimia nervosa II: complex intrafamily comparisons and clinical significance. Int J Eat Disord. 1995;17:117-126.

9. Andersen AE. Practical Comprehensive Treatment of Anorexia Nervosa and Bulimia. Baltimore, MD: The Johns Hopkins University Press; 1985:135-148.

10.Pelch BL. Eating disordered families: issues between the generations. In: Lemberg R, Cohn L, eds. Eating Disorders: A Reference Sourcebook. Phoenix, AZ: Oryx Press; 1999:121-123.

11. Moos RH, Moos BS. Family Environment Scale Manual. 2nd ed. Palo Alto, CA: Consulting Psychologists Press; 1986.

12. Waller G, Slade P, Calam R. Family adaptabity and cohesion: relation to eating attitudes and disorders. Int J Eat Disord. 1990;9:225-228.

13. Foley VD. Family therapy. In: Corsini RJ. Current Psychotherapies. 3rd ed. Itasca, IL: FE Peacock Publishers; 1984:447-490.

14. Le Grange D, Eisler I, Dare C, Hodes M. Family criticism and self-starvation: a study of expressed emotion. J Fam Ther. 1992;14:177-192.

15. American Psychiatric Association Work Group on Eating Disorders. Practice guideline for the treatment of patients with eating disorders. Am J Psychiatry. 2000;57(suppl 1):1-39.

16. Brandes J. Outpatient family therapy for bulimia nervosa. In: Woodside DB, Shekter-Wolfson L, eds. Family Approaches in Treatment of Eating Disorders. Washington, DC: American Psychiatric Press; 1991:49-66.

17. Gowers S, Norton K, Halek C, Crisp AH. Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa. Int J Eat Disord. 1994;15:165-177.

18. Lock J, Le Grange D, Agras WS, Dare C. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York, NY: Guilford Press; 2002.

19. Goldner EM, Birminghan CL. Anorexia nervosa: methods of treatment. In: Alexander-Mott L, Lumsden DB, eds. Understanding Eating Disorders: Anorexia Nervosa, Bulimia Nervosa, and Obesity. Washington, DC: Taylor & Francis; 1994:135-157.

20. Michel DM. Psychological assessment as a therapeutic intervention in hospitalized patients with eating disorders. Prof Psychol Res Pract. 2002;33:470-477.

Suggested Readings

Dare C, Eisler I. Family therapy for anorexia nervosa. In: Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders. New York, NY: Guilford Press; 1997.

Le Grange D. Family therapy for adolescent anorexia nervosa. J Clin Psychiatry. 1999;55:727-739.

Lock J, Le Grange D, Agras WS, Dare C.
Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York, NY: Guilford Press; 2002.

Michel DM, Willard SG. Family evaluation and therapy in anorexia nervosa, bulimia nervosa, and binge eating disorder. In: Brewerton TD, ed.
Eating Disorders. New York, NY: Marcel Dekker. In Press.

Michel DM, Willard SG. When Dieting Becomes Dangerous: A Guide to Understanding and Treating Anorexia and Bulimia. New Haven, CT: Yale University Press; 2003.

Minuchin S, Rosman BL, Baker L. Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, MA: Harvard University Press; 1978.

Root MPP, Fallon P, Friedrich WN. Bulimia: A Systems Approach to Treatment. New York, NY: W.W. Norton and Co.; 1986.

Schwartz RC, Barrett MJ, Saba G. Family therapy for bulimia. In: Garner DM, Garfinkel PE, eds.
Handbook of Treatment for Eating Disorders. New York, NY: Guilford Press; 1985.

Selvini-Palazzoli M, Aronson J. Self-Starvation. New York, NY: Jason Aronson; 1974.

Vandereycken W, Kog E, Vanderlinden MA. The Family Approach to Eating Disorders: Assessment and Treatment of Anorexia Nervosa and Bulimia. New York, NY: PMA Publishing; 1989. 

Woodside B, Shekter-Wolfson L, Brandes J, Lackstrom J. Eating Disorders and Marriage. New York, NY: Brunner/Mazel; 1993.

Woodside DB, Shekter-Wolfson L, eds. Family Approaches in Treatment of Eating Disorders. Washington, DC:?American Psychiatric Press; 1991.


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Kathryn J. Zerbe, MD

 Primary Psychiatry. 2003;10(6):76-78



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Sherry A. Falsetti, PhD

Primary Psychiatry. 2003;10(5):78­-83


Dr. Falsetti is director of behavioral sciences in the Department of Family and Community Medicine at the University of Illinois Family Health Center in Rockford, Illinois.

Disclosure: This work was supported in part by a treatment development grant from the National Institute of Mental Health (#MH53381-03).

Please direct all correspondence to: Sherry A. Falsetti, PhD, Family Health Center, 1221 East State St, Rockford, IL 61104; Tel: 815-972-1040; Fax: 815-972-1092; E-mail: falsetti@uic.edu


Focus Points

There are several effective cognitive-behavior treatments for posttraumtic stress disorder (PTSD).

The main components of effective treatment for PTSD include education, coping skills, exposure, and cognitive restructuring.

Relapse prevention can include predicting times that are high risk for a specific patient and discussing strategies to reduce risk.



Posttraumatic stress disorder (PTSD) is a common disorder that often occurs comorbid with depression and/or panic attacks. This article reviews the cognitive-behavioral treatment options for patients suffering from PTSD, including cognitive-processing therapy, stress inoculation training, prolonged exposure, and multiple-channel exposure therapy. A decision-making model for choosing treatment components that best meet each patients needs is presented. Phases of treatment, including psychoeducation, copings skills, cognitive restructuring, behavioral task scheduling, relapse prevention, and evaluation, are discussed.



Estimates of the prevalence of trauma and posttraumatic stress disorder (PTSD) in the general population indicate that both are significant problems in the United States.1,2 Lifetime trauma exposure estimates indicate that 70% to 90% of the general population have experienced at least one traumatic event.1,2 The current prevalence of PTSD is estimated to be as high as 14% in the general population,3 with lifetime estimates as high as 25%.4 Among certain disadvantaged groups, trauma exposure and PTSD may be even more prevalent.5 For example, in an urban mental health center it was found that 94% of the clients had a history of trauma exposure and 42% had a diagnosis of PTSD.6

There are currently several effective cognitive-behavioral treatment choices available for PTSD. Research has supported the efficacy of stress inoculation training (SIT),7-8 prolonged exposure (PE),9-10 cognitive-processing therapy (CPT),11-12 and multiple-channel exposure therapy (M-CET).13 Research on the efficacy of these treatments will be briefly reviewed and the components of these treatments will be explained. Finally, a model for decision making with regard to these treatments will be presented.


Components of Cognitive-Behavioral Treatment for PTSD

SIT consists of three treatment phases: education, skill building, and application. The education phase includes information about how the fear response develops, information about sympathetic nervous system arousal, and instruction in progressive muscle relaxation. The skill-building phase emphasizes the development of coping skills and includes diaphragmatic breathing, thought stopping, covert rehearsal, guided self-dialogue, and role playing. In the application phase of treatment, the goal is to have clients integrate and apply the skills they have learned and to use the following steps of stress inoculation: (1) assess the probability of feared event; (2) manage escape and avoidance behavior with thought stopping and the quieting reflex; (3) control self-criticism with guided self-dialogue; (4) engage in the feared behavior; and (5) self-reinforcement for using skills.

PE focuses on confronting the feared stimuli in imagination so that fear and anxiety decrease. This is similar to watching a frightening movie over and over. At first it may be very frightening, but by the 20th viewing it would not be as frightening. Analogously, replaying a frightening memory becomes less frightening as it is recounted numerous times in an objectively safe environment. Clients are also asked to confront fear cues that are not dangerous, but that may have been paired with danger at the time of the traumatic event. In vivo exposure to fear cues is used to extinguish the fear associated with these stimuli. This involves exposure to objects or situations in real life.

CPT, as described by Resick and Schnicke,14 includes education regarding basic feelings and how changes in self-statements can affect emotions. Clients are also taught how to identify the connections between actions, beliefs, and consequences, and are asked to write accounts of the traumatic event and read it repeatedly. In addition, several of the sessions focus on developing skills to analyze and confront maladaptive self-statements regarding the traumatic event. This is followed by a series of sessions which cover the impact of trauma on beliefs about safety, trust, esteem, power/competence, and intimacy.

M-CET includes psychoeducation about trauma, PTSD, and panic. Clients are taught to look at the evidence for their beliefs and to identify when they are overestimating the risk of a negative outcome, catastrophizing, overgeneralizing, basing their thoughts on feelings instead of facts, and disregarding important aspects of a situation. Exposure is conducted through having clients write about their trauma and developing hierarchies of feared activities. Exposure to panic symptoms is done by interoceptive exposure, which includes exercises such as stair stepping and head shaking that may bring on panic-like sensations.

The treatment packages described have many components in common, as well as some components that are unique to each treatment. All of these treatment packages have an educational component. Each of these treatment packages also has exposure components. SIT offers coping skills components that are unique to this treatment package. CPT and M-CET each have cognitive components that are not a part of prolonged exposure therapy or SIT.

Table 1 outlines the various components of these treatment packages that can be used to generate treatment alternatives to develop a treatment package that best meets each patient’s needs.


Guidelines for Treatment

The following guidelines are offered for the decision-making process of PTSD treatment. However, it should be cautioned that this process is based on clinical experience and is in need of empirical testing. First, as noted in Table 1, all of the PTSD treatments have a psychoeducational component. Which psychoeducational component is most appropriate can be determined by the patient’s diagnosis and any comorbid disorders. For example, if a patient suffers from PTSD with comorbid depression, then the CPT psychoeducational component would be the most appropriate fit because it provides information about both PTSD and depressive symptoms, whereas if the patient suffered from comorbid panic attacks, the psychoeducational component from M-CET would be most relevant. Table 2 presents a summary of the phases of treatment and the decision-making process.

After choosing the most appropriate educational component for treatment, the patient’s coping skills and overall level of distress need to be considered. If the patient has very few coping skills, or relies on dysfunctional coping skills such as overeating or substance abuse, providing positive coping skills, such as diaphragmatic breathing or guided self-dialogue, would be an appropriate next step. Furthermore, if the patient’s distress level is so high that he or she is having great difficulty disclosing any details about the traumatic event(s), cannot concentrate on what you are doing in session, or is in an acute crisis mode of functioning, then teaching coping skills from SIT before moving on to exposure-based work will assist in reducing anxiety enough that the exposure component may be better tolerated.

The coping skills of SIT can also be targeted to replace substance abuse if the patient is self-medicating. Of course, if there is an indication of physical dependence on a substance, then referring for detoxification and substance abuse treatment prior to trauma-focused treatment may be needed. In many cases, however, trauma victims have increased their substance abuse to lessen anxiety but are not physically dependent. In these cases, substituting healthier coping skills can result in a decrease in substance abuse.

The next component of treatment to be considered is the exposure component. If the patient experiences panic attacks, then conducting interoceptive exposure to the panic symptoms would be the first step in the exposure process. If the patient does not suffer from panic attacks, then prolonged imaginal exposure through either writing or verbal retelling of the event would be the next step to consider in treatment. These two forms of exposure have never been compared to determine if one is more effective than the other, or if one works better with certain types of patients. However, there are some common-sense considerations that may assist in choosing one over the other. For instance, finding out if the patient likes to write or if she or he has good imagery skills, as well as talking about both options with the patient, are important in deciding which form of exposure to implement.

In addition to education, coping skills, and exposure, correcting distorted cognitions is an important element of treatment for PTSD. How much of a focus this requires can be determined from our assessment of cognitions and symptomatology. Depression has been associated with cognitions of helplessness and hopelessness, which may need to be addressed if the patient experiences comorbid depressive symptoms. If the patient suffers from panic attacks, then addressing panic-related cognitive distortions in addition to trauma-related distortions should be an important component of treatment. CPT offers modules on safety, trust, power/competence, esteem, and intimacy specific to rape victims, that can be used to address trauma-related distortions on these issues. M-CET offers similar modules that are written for more general use with a wide range of civilian trauma victims.

The next step of treatment is behavioral task scheduling and in vivo exposure to trauma-related conditioned cues to further reduce any remaining avoidance behaviors. For patients with panic attacks, this would also include conducting in vivo exposure to panic-related situations. In vivo exposure can be conducted by having the patient choose three target behaviors. Together patient and therapist develop hierarchies for in vivo exposure to the chosen behaviors. Patients then work their way up the hierarchies beginning with the target behavior associated with the least amount of anxiety.

The relapse-prevention phase of treatment includes the tasks of predicting for the patient times that are high risk for relapse (times of high stress, confronting reminders, developmental phases) for the patient as well as discussing strategies to reduce risk (reviewing materials, implementing coping skills, booster sessions).


Evaluating the Effectiveness of Treatment

The effectiveness of treatment can be evaluated during treatment or after treatment is completed. M-CET offers the PTSD Daily Symptom Checklist15 that allows patients to indicate the number of PTSD symptoms experienced each day. This is averaged over the week and charted each week on a graph along with the number of panic attacks experienced each week. If panic attacks are a part of the symptom profile, the number of panic attacks each week can also be monitored and charted over the course of treatments. Subjective Units of Distress ratings are useful for interoceptive, imaginal, and in vivo exposure to evaluate progress. The PTSD Symptom Scale16 or the Modified PTSD Symptom Scale17 are also options; these assess symptoms for the 2 weeks prior to administration. The Beck Depression Inventory18 can be given periodically during the session to assess depressive symptoms during the course of treatment.

After treatment completion, a thorough evaluation of all relevant symptomatology, coping skills, and cognitions should be conducted. If the patient continues to suffer from significant symptoms, then additional treatment may be warranted. The decision-making process can be reactivated to again determine which components may be most relevant for any remaining symptoms. For example, a patient may no longer be suffering from any re-experiencing or arousal symptoms, but may still be quite avoidant. In this case, further in vivo exposure may be necessary. In other cases, PTSD symptoms may have decreased but perhaps depressive symptoms may not have significantly decreased. Further work with distorted cognitions or treatment that is more focused directly to the treatment of depression may be needed.

If CPT was used and the patient had difficulty doing homework, consider simplifying the homework to meet the patient’s needs. Falsetti and Resnick15 have simplified the cognitive worksheets for use in M-CET and find these to be effective in addressing distorted cognitions. If PE was used and the patient could not tolerate exposure, then the patient may need to learn coping skills to tolerate the high levels of affect and arousal before continuing with exposure. If the patient could not tolerate exposure due to fear of physical reactions, the use of education about panic attacks and interoceptive exposure should be considered. This will provide education and exposure to the physical sensations prior to trauma exposure, thereby making the physical arousal symptoms less fearful.


Empirical Findings

Veronen and Kilpatrick7 reported that SIT was effective in treating fear, anxiety, tension, and depression. They conducted a comparison, utilizing SIT, peer counseling, and systematic desensitization. They found that the clients who completed SIT had improved from pre- to posttreatment, but unfortunately no comparisons among treatments could be conducted.

Foa and colleagues9 compared SIT, PE, supportive counseling, and a no-treatment control group. The SIT approach in their study differed from that described by Kilpatrick and colleagues8 in that it did not include instructions for in vivo exposure to feared situations. Foa and colleagues9 reported that all of the treatments utilized led to some improvement in anxiety, depression, and PTSD. SIT was indicated to be the most effective treatment for PTSD at immediate follow-up, whereas at a 3.5-month follow-up, clients who had participated in the exposure treatment had fewer PTSD symptoms.

More recently, Foa and colleagues10 conducted another study comparing PE, SIT, and the combination in female assault victims. As in the previous study, SIT was modified by excluding the in-vivo exposure component, so as not to be confounded with PE. Results from the intent-to-treat sample indicated that PE was superior to SIT and PE-SIT on posttreatment anxiety and global social adjustment at follow-up and had larger effect sizes on PTSD severity, depression, and anxiety. SIT and PE-SIT did not differ significantly from each other on any outcome measure. Results using only treatment completers indicated that all three active treatments reduced PTSD and depression compared to women randomly assigned to a wait-list control group and that these gains were maintained at 3-, 6-, and 12-month follow-ups.

In addition to the comparison studies by Foa and colleagues,9,10 other researchers have also indicated the efficacy of flooding therapy. Marks and colleagues19 completed a controlled study comparing PE alone, cognitive restructuring alone, combined PE and cognitive restructuring, and relaxation without prolonged exposure or cognitive restructuring. They found that exposure alone, cognitive restructuring alone, and exposure plus cognitive restructuring all produced marked improvement and was generally superior to relaxation training alone. Therapists conducting the treatment reported that doing the combination treatment was more difficult than doing either alone. Interestingly, combining these two treatments did not appear to enhance treatment effects. However, similar to the study by Foa and colleagues,10 the combination treatment was given in the same amount of time as the other treatments alone, thus participants may not have had enough time to thoroughly integrate all they had learned.

Resick and colleagues20 compared six 2-hour group sessions of SIT, assertion training, and supportive psychotherapy plus information, and a wait-list control group. They reported that all three treatments were effective in reducing symptoms, with no significant differences between treatments. The clients on the wait list control did not improve. At a 6-month follow-up, improvement was maintained in relation to rape-related fears, but not on depression, self-esteem, and social fears.

Results of CPT, which is primarily a cognitive treatment for PTSD have been promising. Resick and Schnicke11 reported significant improvements with CPT on depression and PTSD measures pretreatment to 6 months post-treatment for 19 sexual assault survivors who were at least 3 months post-rape at the start of treatment. Therapy was conducted in group format over 12 weeks and a waiting list control group was also employed (n=20). Rates of PTSD went from a pretreatment rate of 90% to a posttreatment rate of 0%. Rates of major depression decreased from 62% to 42%. Further evaluation of the treatment indicates usefulness of both group and individual formats, with somewhat higher efficacy for treatment administered in individual sessions.14 More recently, Resick and colleagues12 compared CPT to PE and a wait-list control group. Results of this study indicated that both active treatments were efficacious and superior to the wait list.

Preliminary results from a controlled treatment outcome study comparing M-CET to a wait-list control group13 indicated that this may be an effective treatment for PTSD and panic attacks. Future research will need to be conducted to evaluate efficacy relative to other treatments for PTSD that have known efficacy, including prolonged exposure. In the initial study13 participants were randomly assigned either to 12 weeks of once-weekly M-CET group therapy (n=12) or a minimal attention group (n= 15) that received bimonthly supportive phone counseling. Participants reported a range of multiple traumatic events and the treatment groups were not restricted to those who had experienced one type of event. All participants were women who met criteria for current PTSD and panic attacks at least 3 months posttrauma.

At posttreatment, only 8.3% of subjects in the M-CET treatment condition met criteria for PTSD according to the Clinican Administered PTSD Scale21 compared to 66.7% of subjects in the minimal attention control group, indicating a significant difference at posttreatment between the treatment and comparison groups. Analyses also revealed that panic attacks and related symptoms decreased significantly. At the posttreatment evaluation, 93.3% of the minimal attention control group subjects reported experiencing at least one panic attack in the past month, compared to only 50% of the treatment group (c2 [1, N=25]=6.51, P<.01). Data also indicated that those in the treatment group reported significantly less frequent panic attacks compared to the control group over time as well as less fear of panic attacks and less interference with activities due to panic symptoms. Both groups improved significantly over time in terms of symptoms of depression.



There are now several effective cognitive-behavioral treatments available for PTSD and common comorbid disorders. These include SIT, CPT, PE, and M-CET. As always, it is important to first conduct a thorough assessment of trauma history, symptoms, coping skills, and cognitions before considering treatment options. However, there is very little empirical research that investigates matching client variables to treatment components. Until such research is conducted, using a decision-making model such as is illustrated here, can assist the therapist in choosing treatment components to fit each client’s needs. Future research testing the effectiveness of a decision-making model is needed.  PP



1. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen -Psychiatry. 1995;52:1048-1060.

2. Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community. Arch Gen Psychiatry. 1998;55:63.

3. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

4. Hidalgo RB, Davidson JRT. Posttraumatic stress disorder: epidemiology and health-related considerations. J Clin Psych. 2000;61(suppl 7):5-13.

5. Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma and posttraumatic stress disorder in severe mental illness. J Consult Clin Psych. 1998;66:493-499.

6. Switzer GE, Dew MA, Thompson K, Goycoolea JM, Derricott T, Mullins SD. Posttraumatic stress disorder and service utilization among urban mental health center clients. J Traum Stress. 1999;12:25-39.

7. Veronen LJ, Kilpatrick DG. Stress management for rape victims. In: Meichenbaum D, Jaremko ME, eds. Stress Reduction Prevention. York, NY: Plenum; 1983:341-374.

8. Kilpatrick DG, Veronen LJ, Resick PA. Psychological sequelae to rape: assessment and treatment strategies. In: Dolays DM, Meredith RL, eds. Behavioral Medicine: Assessment and Treatment Strategies. New York, NY: Plenum; 1982:473-497.

9. Foa EB, Rothbaum BO, Riggs DS, Murdock TB. Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling. J Consult Clin Psychol. 1991;59:715-723.

10. Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. J Consult Clin Psychol. 1999;67:194-200.

11. Resick PA, Schnicke MK. Cognitive processing therapy for sexual assault victims. J Consult Clin Psychol. 1992;60:748-756.

12. Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting list condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70:867-879.

13. Falsetti SA, Resnick HS, Davis J, Gallagher NG. Treatment of posttraumatic stress disorder with comorbid panic attacks: combining cognitive processing therapy with panic control techniques. Group Dynamics: Theory, Research and Practice. 2001;5:252-260.

14. Resick PA, Schnicke MK. Cognitive Processing Therapy for Rape Victims: A Treatment Manual. Newbury Park, CA: Sage; 1993.

15. Falsetti SA, Resnick HS. Multiple Channel Exposure Therapy: Patient and Therapist’s Manuals. Charleston, SC: National Crime Victims Research and Treatment Center; 1997.

16. Foa EB, Riggs DS, Dancu CV, Rothbaum BO. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Traum Stress. 1993;6:459-473.

17. Falsetti S, Resnick H, Resick P, Kilpatrick D. The modified PTSD symptom scale: a brief self-report measure of posttraumatic stress disorder. Behav Ther. 1993;16:161-162.

18. Beck AT, Ward CH, Mendelsohn M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.

19. Marks I, Lovell K, Noshirvani H, Livanou M, Thrasher S. Treatment of posttraumatic stress disorder by exposure and /or cognitive restructuring. Arch Gen Psychiatry. 1998;55:317-325.

20. Resick PA, Jordan CG, Girelli SA, Hutter CH, Marhoefer-Dvorak S. A comparative outcome study of behavioral group therapy for sexual assault victims. Behav Ther. 1988;19:385-401.

21. Blake D, Weathers F, Nagy L, et al. The Clinician Administered PTSD Scale (CAPS). Boston, MA: National Center for PTSD, Behavioral Sciences Division; 1990.


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Dean Schuyler, MD

Primary Psychiatry. 2003;10(5):31-32


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Anne Sheffield

Primary Psychiatry. 2003;10(5):89-94


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Dean Schuyler, MD

Primary Psychiatry. 2003;10(5):33-36


Dr. Schuyler is clinical associate professor of psychiatry at the Institute of Psychiatry at the Medical University of South Carolina in Charleston.

Disclosure: Dr. Schuyler has received honoraria from Forest, Pfizer, and Wyeth. No financial, academic, or other support was received for this work.

Please direct all correspondence to: Dean Schuyler, MD, Institute of Psychiatry, Medical University of South Carolina, 67 President Street, Charleston, SC 29425; Tel: 843-792-0037; Fax: 843-792-0048; E-mail: schuyled@musc.edu.


Focus Points

Cognitive therapy begins with a heightened awareness during the intake evaluation of clues to automatic thoughts relevant to the patient’s distress. 

In evaluating automatic thoughts, special attention is paid to their rationality and strategic worth.

A fundamental cognitive-therapy technique is “shift of set,” which seeks to teach the patient alternative options to distorted thoughts by means of analogy.


Does brief cognitive therapy work for depression? This article presents a step-by-step clinical approach to brief psychotherapy for the patient with depression. Cognitive therapy begins with the intake evaluation, followed by teaching the model to the patient, specifying a diagnosis, and establishing an agenda. Whether utilizing a structured or a more conversational approach, automatic thoughts relevant to the patient’s distress are identified. Disputation of the automatic thoughts typically features shift of set, along with a variety of techniques aimed at generating alternative cognitive options for the patient to consider. Two cases of brief cognitive therapy for major depression illustrate the approach.


Introduction: Cognitive Therapy for Depression

In 1967, Dr. Tim Beck published a chapter on the cognitive model in his textbook Depression: Clinical, Experimental and Theoretical Aspects.1 Two earlier articles by Beck2,3 had focused on cognitive changes in depression. A decade later, a workbook was published detailing how to treat a depressed patient with cognitive therapy.4 Depression represents the initial target for which the cognitive approach was proposed.

In 1991, A Practical Guide to Cognitive Therapy5 was written to provide an entry point for those students and clinicians interested in learning cognitive therapy, followed by an article6 applying these principles to chronically depressed (dysthymia) patients, and a clinical discussion7 covering issues of concern to the cognitive therapist treating the depressions. How the clinician can adapt the concepts of the cognitive model to best serve their depressed patients is a clinical issue that has been discussed over the past 2 decades.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition8 recognizes major depression, dysthymic disorder, and depressive disorder not otherwise specified as three forms of unipolar mood disorder. Adjustment disorder with depressed mood and bereavement belong somewhere on the spectrum of clinical problems associated with mood disorders. There is a separate categorization for bipolar disorders. This article will focus on major depressive disorder (MDD), but the remarks may be applied to a consideration of any of the other depressive disorders, with the exception of bipolar disorder.


The Cognitive Model

In the treatment of MDD, the application of cognitive principles begins in the first therapy session, which is typically devoted to an intake evaluation. During this session, the cognitive therapist learns the patient’s history and forms a diagnostic impression. However, if cognitive therapists orient themselves cognitively to the data gathering, there will be opportunities to inquire about meanings and gather data related to the beliefs associated with the patient’s distress. This inquiry acquaints the patient with an element of the cognitive model, and introduces an interaction likely to be repeated often during the psychotherapy.

Once the intake is accomplished, the next task is for the clinician to teach the model to the patient. This typically takes 5–10 minutes, and may be done with or without the visual aid of a blackboard. It associates situations, feelings, and thoughts in the patient’s mind, illustrated by means of the triple column technique in which patients write out their situations, feelings, and thoughts on a three-column chart. It presents the most readily modifiable element as the “cognitive (thinking) one.” If patients seek to change how they feel, or what they do, the vehicle for change will proceed through the channel of “thinking.”

With this association firmly established, one can teach a simple way of appraising identified meanings, or automatic thoughts. One can ask the patient: “Is your belief reasonable or rational? If so, does it have ‘strategic value’ (help you attain your goal)?”

To make sure that patients understand the concept of the automatic thought, one can utilize an example given by the patient in the intake session. The therapist can then describe and enumerate typical “cognitive errors.” These include polarization (thinking categorically, or in “black and white” terms), personalization (thinking exclusively of the self without considering others), and overgeneralization (thinking beyond the confines of the data at hand). These errors can be located in a fourth column on the triple column blackboard diagram expanding the chart to include situation, feeling, thoughts, and errors. (In later sessions, a fifth column for alternatives may be added).

Once the patient demonstrates a grasp of the conceptual model, the therapist and patient can proceed to formulate an agenda. At this point, the clinician’s approach may be highly structured in a series of steps:

(1) The patient describes the situation

(2) The patient describes distressing feelings associated with the situation

(3) The clinician and the patient engage in a discussion of relevant meanings of the situation and corresponding feelings.

(4) Three columns are drawn on a blackboard, and appropriate entries in the columns for situation, feelings, and thoughts are drawn.

(5) Automatic thoughts are “tested” and discarded or kept.

(6) Alternatives are considered. (An alternatives column may be added to the chart to record choices and their likely consequences).

With some patients, an unstructured approach may be more desirable. In this circumstance, there may be no blackboard, no triple columns, and the interaction may be highly conversational. The therapist’s contribution will consist largely of asking questions and requesting clarification. The goal is similar to the structured approach—to identify automatic thoughts relevant to the patient’s distress, and dispute them if they are found to be unhelpful.

It is at this point that the various cognitive techniques come into play. The most useful of these can be summarized as “shift of set.” The technique is derived from the observation that many patients have already unsuccessfully tried to problem-solve and find new approaches to their situations. There may be value, therefore, in changing the focus from that of the patient’s stated problem to that of a parallel situation. The goal is to help the patient find alternatives in the “new set” that he or she can apply to the problem area.

The most common technique for shifting set involves the therapist “telling a story.” The story should be free of identifiers, and may relate the plight of someone in an analogous situation. Successful stories often capitalize on the antics of children. They may be derived from the therapist’s own life experience (we then call them “self-disclosure”). Another form of shift of set involves wit or humor. The usual qualifiers apply here. If trainees of the model are witty or funny with friends, they ought to be able to find a way to incorporate this skill in a cognitive therapy. If they are “not funny,” they are urged to find another way to shift set.

Qualities for a successful story are engagement, relevance to the problem at hand, and brevity. Once the brief story is told, the patient must make the connection to his or her own situation. With some patients, the therapist may not play a role in the application of the story to the patient’s situation. The connection may be obvious to the patient at once, and he or she may say so. For others, the therapist may need to help the patient find the relevance in the story and apply it to the issue at hand.

Additional techniques involve designing an experiment to test the usefulness of a meaning or taking a survey to consider how others might view a situation or relationship. The application of the cognitive model to a couple of representative patients with MDD will now be illustrated in two of the author’s case studies.


Case 1: Charles

Charles was a 40-year-old chemical engineer when he called for an appointment because he was “not happy, isolated, in an unsatisfying marriage, and angry.” He had moved to town from Denver 5 years prior, where he and his wife Janet had married 10 years earlier. Janet was a poet who had sold several of her poems, but otherwise had never been a wage earner. Charles admired her talent, but acknowledged that “they lead separate lives.” He was the caretaker for his 75-year-old father; he and his wife had moved to their current location after his father became ill with complications of diabetes and hypertension.

Since he moved, work was not satisfying, and made worse by the memories of a stimulating job in Denver. Charles and Janet had no friends as a couple, and neither spent much time with colleagues or acquaintances. Charles visited his father daily. He was angry that Janet never wanted to have children, and that they had little in common, but he said little of this to her. He slept poorly, overate, did not exercise, and had gained weight. Charles complained of frequent headaches and stomachaches, which he ascribed to tension. He had been steadily sad for the past 2 years, and he felt trapped by his situation. His only sibling, a brother, had a severe alcohol problem and lived in Chicago. They visited each other only on rare occasions. There was no other history of emotional disorder in the family. He defined his goal for psychotherapy as: “finding a path worth taking in life.” Although he acknowledged being depressed, he did not want to take medication. The diagnosis made was MDD, with schizoid personality features.

During session 2, Charles told of buying and reading the treating clinician’s book, A Practical Guide to Cognitive Therapy.5 He believed he needed to “rethink situations and recalibrate the instrument.” He said that he used to have a dream, but that now it was lost. He discussed avoiding problems, feeling responsible for his wife, and placing himself last on his list of considerations. He was encouraged to identify the meanings he placed on his life situations to see if they were acceptable to him.

Several sessions were spent discussing Charles’ work situation and what he might do to “create a place for himself there.” He commented that his work orientation had rarely been one of “problem-solving.” At one point, the clinician described to him the leaderless confusion in his own department at work. The clinician told him of his own lengthy period of time in which he did nothing at work, and that once he became more assertive he actually uncovered several important opportunities. By session 5, Charles reported “being more proactive” at work and more willing to “express his wishes.”

When he next spoke of his marriage, he did so amid a striking devaluation of his own past achievements and general worth. He was asked to appraise himself more honestly, including voicing what he desired in a marriage partner. His initial description was distant from his portrayal of Janet. When asked why he stayed married to her, he replied that he was “responsible for her happiness,” and that she would be devastated if he left her. In several examples of their interaction, a shift from “content to process” was suggested, to gain a better idea of how the couple related to each other. Rather than focusing on what was said, the therapist directed the patient to consider the meaning behind what each partner said.

In session 6, Charles acknowledged having done “a lot of thinking about marital separation” and that he now felt ready to broach the issue with Janet. Charles and the treating clinician role-played how the conversation might go. He discussed sharing the cognitive method with several work colleagues, the first sign of any social interaction he had mentioned. He noted needing more “discriminant training with anger,” so he could better decide when to express it and when to dispute the relevant meanings. Charles and the clinician discussed choices and consequences, and re-focused on the issue of his responsibility for his wife.

Charles credited the cognitive method for paving the way for several work successes. He had taken the step of joining a gym and would have his initial appraisal by a trainer the following weekend. He told his wife that he would be moving in with his father, as a first step to finding some resolution for their marital incompatibility. Together with the clinician, Charles identified an approval need as one driving factor in his relationship with his wife, as well as with his boss at work.

By session 10, Charles noted that he had moved into his father’s house, felt markedly better at work, and saw a “light at the end of the tunnel.” He reported a consistent elevation of mood, control of his eating, and regular exercise for the first time in memory. He felt that his problems were solvable now, and he suggested terminating his sessions with the option to continue later on if necessary.

Charles had another three-session course of psychotherapy 3 years later. He noted a new situation, with a return of depressive symptoms in that context. After two more meetings (and applying the cognitive model), he felt in good control and was asymptomatic.


Case 2: Regina

Regina was a 45-year-old white female, who complained of being “stuck, depressed, and apathetic.” Two months earlier, the youngest of her three children had left for college, she felt lost starting a job with a prestigious accounting firm, and she had the thought that she would “never know an intimate relationship again.” (She had been divorced for 6 years from her husband of 20 years). For 8 weeks prior, she had experienced disrupted sleep, poor appetite, little energy, easy fatigue, and a total loss of motivation. She was also increasingly nervous much of the time. She was feeling angry with her ex-husband for recently asking for and accepting her help, then suddenly announcing that he was planning to re-marry. She felt unprepared to have an intimate relationship with a man. She felt increasingly bad about herself. She was anxious about performance on her new, unfamiliar job.

Session 2 was spent helping Regina gain some perspective about the actions of her ex-husband. It seemed that he had taken advantage of her on multiple occasions during their marriage, and managed to do it yet again 6 years after their divorce. Her automatic thoughts focused on the need to protect herself, especially in close relationships with men. She typically gave a lot, receiving little.

While the treating clinician could have discussed various issues (her view of her husband’s actions, their consequences for her, how she determined her self-view) in a triple-column format, he decided to discuss these issues conversationally with her instead. Less structure was chosen over more structure, as her style and the evolving doctor-patient relationship seemed to fit better with a more informal version of cognitive therapy.

In a session dealing with choices and consequences, Regina noted how important approval was for her. She worked to form a more balanced (and realistic) view of her husband. Next, she focused on her self-view, in light of the legacy from her parents and her subsequent life experience. She and the clinician spoke of anger, fairness, honesty, and worth. She noted her rapidly growing familiarity in her new job and how positive her reception had been.

Achieving comfort in the workplace affected her overall self-worth in a very positive way. She decided she had let her husband’s view of her overwhelm her own. She said that she was capable of being proactive, and that her friends and new colleagues valued her. She reviewed her achievements and felt as though she had experienced many life successes. She discussed her view of her son and his sense of worth as an example of a “success story.” She called a friend who had not called her for 6 months, and was told how grateful the friend felt that she had thought to call. She had disputed (effectively) all the explanations she had come up with for no contact from the friend, and decided to act.

She felt that after six sessions (over a 2-month period) she had regained a major part of herself that she had lost. She was now sleeping well, and was hungry, energetic, and focused. Sessions ended with the option for another at her initiative.



The psychotherapy offered to each of the patients described was brief. In each case, distress was successfully relieved. The return of Charles for another (more brief) series of sessions was viewed as positive. His success and the value inherent in the relationship, evident during the initial sessions, laid the groundwork for his subsequent return. That the second therapy was shorter than the first, is typical.

The focus of each psychotherapy was in the here-and-now. No psychodynamic formulation was created in either case. Rather, both patients and their problems were understood cognitively. No role was assigned to the unconscious, and the concept of transference was not utilized. Although affect was expressed and behavior was discussed, the primary focus was on meanings (cognition). The format followed many of the principles of brief therapy: time-limited, goal-oriented, active therapist role, and rapid formation of the alliance.9 Homework is typically a feature of cognitive therapy. It may provide structure and encouragement for a patient’s cognitive work between sessions. As both of the cases presented represent more unstructured versions of the cognitive model, no homework was specifically assigned.

Although triple columns and the use of a blackboard to illustrate the patient’s thinking are similarly commonly employed, this approach was not taken in either case presented. The interaction was conversational, and the therapist’s contribution was chiefly one of posing questions. Self-disclosure played a part in Charles’ psychotherapy, but not in Regina’s. Shift of set was accomplished in each case by brief examples presented by the therapist, rather than by longer analogies. There was liberal use of humor with both patients, which took the form of occasional witty remarks rather than “jokes,” illustrating the beliefs to be examined.

Considerable attention was paid to engagement in each case, and the doctor-patient relationship seemed likely to have played a role in each patient’s success. Both patients were motivated for change, which is a crucial factor in treatment. Each psychotherapy could fairly be called a “collaborative dialogue,” and a deliberate attempt was made to harness each patient’s problem-solving skills. Some time was spent in both cases working on teaching the skill of assertiveness to two people whose prior approach to problems had been more passive.

Specific schemas, the rules that govern a person’s thinking and give rise to automatic thoughts, were not identified in either case. It is typical for longer-term cognitive approaches to work with schemas, and for brief therapy to focus on automatic thoughts.

The cognitive model allows considerable room for individual variation and creativity, a point stressed with trainees learning the model. As long as one honors its basic principles, two therapists may approach the same patient quite differently. Not all cognitive therapists would necessarily follow the same route as the one presented here.

It is important to note that each of the patients discussed here could have been treated with medication for MDD. They each gained far more from a brief cognitive therapy, and the time course for recovery was little different than it might have been for a drug. Recovery for each of them brought knowledge of a method they could utilize at any time to approach a new distressing situation.



This article has illustrated the application of the model of cognitive therapy to the treatment of MDD. A step-by-step approach that clinicians who are knowledgeable about the theoretical model can follow in their own offices was presented. The structure of intake, diagnosis, teaching the model, and forming an agenda for therapy is closely followed. Techniques for adding structure (triple column, use of a blackboard, assigning homework) are noted, and a more conversational (less structured) interaction is demonstrated in the cases presented.

The importance of shift of set in teaching the patient to seek alternatives to their meanings is emphasized. Techniques to shift set, such as stories, analogies, self-disclosure, and humor, are noted. Therapy was brief for both cases presented (ie, 10 sessions; 6 sessions). The common clinical outcome of the patient returning for another brief encounter is shown in one case. Both patients derived benefit from learning a model they could use and apply in the future to deal with distress.  PP



1. Beck AT. Depression: Clinical, Experimental and Theoretical Aspects. New York, NY: Harper and Row; 1967.

2. Beck AT. Thinking and depression: I. Idiosyncratic content and cognitive distortions. Arch Gen Psychiatry. 1963;9:324-333.

3. Beck AT. Thinking and depression: II. theory and therapy. Arch Gen Psychiatry. 1964;10:561-571.

4. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York, NY: Guilford Press; 1979.

5. Schuyler D. A Practical Guide to Cognitive Therapy. New York, NY: Norton; 1991.

6. Schuyler D. Short-term cognitive therapy shows promise for dysthymia. Curr Psychiatry. 2002;1:43-49.

7. Schuyler D, Basco M, Thase ME. Cognitive therapy for affective disorders. Psychiatric Update. 2002;22:1-9.

8. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

9. Budman S. Forms of Brief Therapy. New York, NY: Guilford Press; 1985.


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Paul Ritvo, PhD, M. David Lewis, MD, Jane Irvine, PhD, Laura Brown, MA, Andrew Matthew, MA, Brian F. Shaw, PhD

Primary Psychiatry. 2003;10(5):72-77


Dr. Ritvo is associate professor in the School of Kinesiology and Health Sciences and the Department of Psychology at York University, and in the Departments of Public Health Sciences, Family and Community Medicine, Psychiatry and Surgery, at the University of Toronto in Ontario.

Dr. Lewis is a consultant at Visions Teen Treatment Center in Malibu, California.

Dr. Irvine is associate professor in the Department of Psychology and the School of Kinesiology and Health Sciences at York University, and in the Departments of Psychiatry, Public Health Sciences, Family and Community Medicine and Surgery at the University of Toronto.

Ms. Brown is a research associate and Mr. Matthew is a research fellow at the University Health Network in Toronto.

Dr. Shaw is professor in the Departments of Psychiatry and Public Health Sciences at the University of Toronto.

Disclosure:The authors report no financial, academic, or other support of this work.

Please direct all correspondence to: Paul Ritvo, PhD, Division of Epidemiology, Biostatistics, and Behavioral Science, Ontario Cancer Institute, 610 University Ave, Toronto, ON M5G 2M9, Canada; Tel: 416-580-8021; Fax: 416-971-7554; E-mail: paul.ritvo@utoronto.ca

Focus Points

From the cognitive-behavioral therapy perspective, the most important components of addiction are distorted beliefs that drive unfortunate choices. 

The Challenge Achievement Learning Model (CALM) emphasizes challenges as a natural component of the desire to live productively.   

Failures to meet the challenges result in losses that reduce confidence, which explains why people sometimes dismiss challenges to follow well-known, controllable “grooves” that offer assured comforts. Some behavioral grooves are benign, while others are “slippery slopes” to addiction.  

CALM programming helps patients convert losses of confidence and addictive vulnerabilities to transformative paths of progress and satisfaction.


The Challenge Achievement Learning Model (CALM) applies cognitive-behavioral therapy (CBT) to addiction and relapse-prevention programs. Challenges are emphasized as a natural part of the universal desire to live productively and with more atisfaction. The CALM program identifies the role of challenge and achievement expectancies in successfully meeting challenges, especially in the influences they have on attention regulation and motivational processes. These roles are linked to the anxiety-provoking uncertainties involved in challenges and the failures that can have depressive effects. The CALM program addresses these vulnerabilities by proposing nine themes fundamental to the discovery of key cognitions that transform anxious-depressive experiences to performance-enhancing actions.


Introduction: The Cognitive-Behavioral Therapy Approach

From the perspective of cognitive-behavioral therapy (CBT), the most important components in addiction are the powerfully held, distorted beliefs that drive unfortunate choices. Briefly put, the reliance of people suffering from addiction on “substances” for joy, solace, and satisfaction directly relate to beliefs that these experiences are impossible when sober. These beliefs are supported by a network of mutually-reinforcing cognitions that lead people to give up in desperation and give in to addiction. From the CBT perspective, when these errant beliefs are modified, satisfactions can be found that substitute for addictive “highs” and give the individual alternative positive experiences.

It should be clarified at the outset that with the prevalence of addictive patterns in our society, many people rely on some “thing” for consolation when disappointed or troubled. In that regard, the 12-step approach1 is accurate in saying that “addictions misdirect our transformative capacities.” Instead of relying on a higher power for guidance in overcoming the disappointments of living, people regressively turn to material things. Instead of transcending and learning from problems, people seek solutions in addictions. While alcohol and drugs are the most obvious addictive substances, sex, gambling, money, and food are other examples. In fact, any behavioral interaction can be addictive if it offers temporary escape and distraction from real-life struggles.

The proposed method of applying CBT in the treatment of addictions is guided by the Challenge Achievement Learning Model (CALM).2 The CALM program emphasizes challenges as a natural part of the universal desire to live more productively and with more satisfaction. Thus, the CALM program applies equally well to assisting people in recovery and preventing relapse because responses to challenges are equally applicable to becoming clean and sober and staying clean and sober.

People take on challenges because they are vehicles to new and better places of learning and satisfaction. However, their transport is not assured. Challenging situations have, by definition, uncertain outcomes. They are not controllable and, in our attempts to meet them, there are no guarantees of success. As a result of the uncertainties, challenges are, by definition, anxiety and fear provoking.

Failures to meet challenges result in losses that affect confidence and, in some cases, are significant blows to self-esteem. These losses may be triggered and exacerbated by the added loss of missed opportunities. All losses are anxiety-provoking but they are also depressing when interpreted as indicating a helplessness in fulfilling aspirations. The CALM program takes into consideration success and failure in the course of confronting challenges, and the associated vulnerabilities experienced when reacting to failures and successes. Ultimately, the goal is to meet these vulnerabilities to anxiety and depression with key cognitions that evoke transformative experiences of new learning and new skill development.

Of course, we do not confront challenges during all of our waking hours. We sometimes turn away from them to follow well-known, controllable “grooves” that are, in essence, interactions offering assured outcomes and assured comforts. Some behavioral grooves are benign, while others are “slippery slopes” to addiction. Failure experiences can make the more addictive grooves particularly tempting, given their ever-present promotion in the market place.

The aims of CALM-based programming are to help individuals define and meet challenges and, along the way, find paths (preparatory activities) that build confidence and productivity. In these goals, two sets of expectancies are emphasized: challenge expectancies, which consider how difficult the challenge is, and achievement expectancies, which include the self-perceived strengths and resources the person will use to meet the challenge.

Predictably, when challenge expectancies are high and achievement expectancies are low, the individual experiences confidence deficits. As a result, the person may experience higher distress levels, sometimes to the point where practice and performance are impeded. This is why the CALM program additionally takes note of motivational processes and, in particular, the individual’s capacity to functionally regulate attention. All of these factors, in coordination, are important to successfully meeting challenges (Figure 1). Conversely, a problem in any of these factors predicts a poor outcome.


Case History: Dr. X

The following case history, a hypothetical construction based on the case experience of the authors, may be useful in explanation of the CBT approach to treatment of substance abuse.

Dr. X had a successful medical practice and was a devoted father of three children, although divorced for nearly a year. He was actively involved in his community and served on the boards of several charitable foundations. Dr. X, though a busy professional, also had a “secret life” involving several addictions including cocaine, gambling, and strip clubs. Although he appeared successful, he described himself as “empty,” “rotting at the core,” and a “total fraud.” He had no idea how he would get out of his “mess,” but found that one idea that kept coming up lately, was “dying young.”

In Dr. X’s case, he maintained a positive achievement expectancy about successfully continuing his medical practice. However, at first he was skeptical about being able to meet the challenge of overcoming addiction. His conception of the steep challenge involved dwarfed his capacities to achieve success. He doubted his ability to undertake even temporary cessations of addictive activity. At first he diverted attention away from confronting this challenge and was more motivated to seek sympathies than to confront the realities of getting “clean.” Initial sessions focused on building a therapeutic alliance through empathic discussions of the risks and stresses of living his dual lifestyle. He was supported in disclosing feelings of shame and guilt about his addicted life. All of these exchanges pointed to the centrality of the challenge of overcoming addiction. Meanwhile, a practical focus on the real alternatives for achieving sobriety in a stepwise manner, starting with an initial period of residential treatment, helped him focus attention on his challenge of getting clean and sober. With that focal attention came an increase in his achievement expectancies concerning overcoming addiction.


Pathways to Substance Abuse: Risk Factors for Depression and Anxiety

Like Dr. X, people with substantial abilitiesare no strangers to addictive behaviors. Why is this? As people rarely abuse substances in healthy states of mind, the slippery slope to addiction is often associated with psychological vulnerabilities which, while not necessarily diagnosable, share important features with diagnosable disorders. The most obvious vulnerabilities are to depression and anxiety.

Before discussing these vulnerabilities, it is important to clarify that cognition, in our use of the term, refers to the automatic thoughts and images that people generate in association with their moods (eg, sadness, fear, anger, guilt, shame). Because these cognitions arise repetitively (ie, automatically), key cognitions can be identified in relation to shifts in mood.3

Recent perspectives on depression, not surprisingly, focus on the cognitive reactions people have to their moods.4 According to the differential activation hypothesis,5 people who are vulnerable to depression react differently to negative moods, characteristically focusing on negative cognitions while maintaining a ruminative focus on self.6 The result is a cognitive-emotional spiral that intensifies to a cascade of negative feelings, thoughts, and body sensations that can impair problem solving. Once again, the key components are self-focused negative thinking and concurrent inabilities to resolve problems under the conditions of the downward emotional spiral.

Recent views about anxiety vulnerabilities assume some suppression of those past experiences7-9 that are perceived as aversive and beyond control. These experiences are actively avoided, which consumes energy while the related anxieties, paradoxically, are fueled by it.10,11 The “avoidant space” ultimately becomes a “hot spot” of anxiety, with the cognitively-mediated avoidance leading to distortions of associated cognitions. The avoidant space further becomes a place of personal impoverishment, as the content and its surrounding cognitive-emotional environment is neither nurtured nor nourished. The whole process becomes a negative engine that drains confidence and turns the grief often associated with the anxious experience into personalized shame and guilt.

Dr. X’s marital break-up was the significant trauma that precipitated his addictive behaviors, as he found anxieties about being “unlovable” and “left alone” intolerable. He had trouble understanding how his workaholic behavior contributed to the communication breakdown with his ex-wife, leaving her in a resentful state. Rather than face his anxieties about his past and future relationships in progressive attempts to initiate another serious relationship, he took regressive refuge in the “high” experienced from cocaine and the “easy comraderie” found in being the “big spender” at the strip club. Although these experiences provided him with a ready escape from core anxieties, he simultaneously felt impoverished by having to get high, risk arrest, and spend money indiscriminantly.

Part of this avoidant process, as in Dr. X’s case, is funneled into an intensification of everyday worries as the “thinking” dominance, characterizing worry, prevents the processing of the fearful imagery associated with traumatic emotion.12 This short-term prevention perpetuates the original disturbance by reinforcing and strengthening anxious meanings. Evidence indicates that worrying has a stabilizing effect on the individual psychophysiologically, as worriers do not report intense affect, rather they report low-level discomforts. Worrying also rigidly restricts the range of responding to middle-ranges, permitting a far narrower range of positive excitement as well as negative emotion.13,14 For example, people with generalized anxiety disorder show reductions in imagery and increases in negatively-valued thought and, more convincingly, after therapy, demonstrate returns of normal ratios of thoughts to images and negative and positive thoughts.15

Overall, this evidence-based perspective on anxiety vulnerability accentuates a core of event-related anxiety repressed from awareness and surrounded by a periphery of avoidant worry that reinforces fear and constricts positive experiences, including anticipations of enjoyment and satisfaction. In the case of Dr. X, his everyday worries centered on whether people suspected his “dual existence” and whether he was as respected and esteemed in the community as he was before his marriage dissolved. Once again, these worries diverted him from dealing with his core anxiety about eventually being left unloved and alone.

Given that such anxiety-based and depressive vulnerabilities are some of the “slippery slopes” leading to substance use, what does the CALM program offer in terms of guidance to couselors and their clients?


CALM as the Antidote to Psychological Vulnerabilities

CALM programming focuses on helping the vulnerable client find the key cognitions (thoughts, images) that convert addictive vulnerabilities to transformative paths of progress and satisfaction. This includes helping clients to precisely process regressive and transformative experiences by itemizing automatic thoughts and reappraisals (ie, rational responses) in an ongoing method called the “cognitive workout.” CALM programs also specifically aim to transform the “negativized,” distorted experiences of self to a self-transformative focus, changing distortions to more realistic cognitions that carry the reinforcing “ring” of personal truth. This includes strategies to transform the ruminative self-focus to more balanced reflections on self and other, and strategies that counteract the negative cognitive-affective barrages via the self care of one’s capacity for change. Programming assists clients in actualizing these strategies in graduated sets of challenges that build confidence and establish feedback cycles of achievement and satisfaction.

In relating to the anxiety vulnerability, the counseling goal is transforming the avoidant space to a locus of shared courage and support, first by establishing an alliance that supports cognitive-emotional disclosures that turn grief outward in expressions that reduce the associated shame and guilt. By releasing suppressions and reducing avoidance, the counselor helps release tension and, subsequently, helps clients feel revitalized (invigorated with more available energy) and more confident.

With Dr. X, this meant confronting the avoidance of his experience of rejection by his wife and disclosing his grief about “blowing it” in the relationship. With his self-disclosure of grief came the clarity of understanding that his view that the break-up was all his fault did not take into consideration the behaviors of his wife, which had eroded his affection. He began seeing that he had taken refuge in his work and in charitable activities, missing and avoiding the nourishment of shared intimacy. As he explored and understood more of his trauma with the break-up, he began to see that he could possibly find intimacy without resorting to addictive “highs.”


The Thematic Structuring of Transformative Challenges

Like other CBT-oriented clinicians, we believe central cognitive structures underlie vulnerabilities to depression and anxiety, and, ultimately, addictive behavior.16 The identification of these structures is useful in directing self-transformative efforts. In contrast to labeling these structures “schemas,”15 we see these structures as “themes.” We view schemas as pseudobiological structures that cannot be empirically verified while themes can be validated using qualitative interview analyses17 as well as quantitative psychometrics.

We have further developed a conviction that each vulnerability theme is joined with a theme of transformation. In fact, we believe this dual-structure is present whenever people confront challenges. When individuals struggle with challenge conditions, they frequently “shuttle” back and forth between the key cognitions of vulnerability/transformation themes.

The nine dual-themes are each associated with personalized obstacle thoughts so-named because they comprise the mental obstacles between challenges and achievements, ie, between aspirations and goals. Obstacle thoughts are not all dysfunctional since knowing what one is up against helps one plan and gather assistance. But obstacle thoughts frequently go beyond thinking about difficulty to become hardened beliefs about impossibility and hopelessness. In that case, instead of rising to challenges we spiral downwards, only to find that the paths to success seem more distant and steep. Simply put, obstacle thoughts are mainly concerned with challenge expectancies, although they sometimes also focus on discounting resources, and, in this way, refer to achievement expectancies.

We move from obstacle thoughts to inspiring thoughts via cognitions that focus on transforming the obstacles between aspirations and satisfactions. In this way the “stumbling block” of the obstacle becomes the “stepping stone” of transformation. Each of us has a unique repertoire of transformative thoughts and the interactions of our unique obstacle and transformative thoughts make the major difference in our ongoing mental states.

It should be reaffirmed that these transformative cognitions cannot be reduced to positive versus negative thinking, as positive thinking sometimes functions as obstacle thinking, and negative thinking sometimes operates as transformative thinking. This can be illustrate with the following nine themes.


Theme 1: Aptitude Versus Ineptness

Whenever challenged, we first question the fundamental soundness of our resources for meeting the challenge. Sometimes we have high estimations of our mental/physical soundness and the aptitudes brought to specific challenging tasks. Our abilities and the design of our lives seem to “fit” well. At other times, we feel inept. At our base of being, we find flaws that are difficult to correct and that impede us from successfully meeting our challenges. However, we call upon transformative cognitions that focus on the soundness of our resources to “transform” this negative momentum. These thoughts focus on the “fit” of our competencies with certain tasks. One need not believe in universal soundness, just in specific abilities that fit well with certain tasks, boiling down to the realistic assessments about what we can do well and what skills can be further developed.


Theme 2: Function Versus Dysfunction

Theme 2 builds on some degree of confidence in basic resources to center on the obstacle of learning to optimally use them. When faced with opportunities to use our natural equipment, our performance can be deficient. In fact, because trial and error is fundamental, faulty performances are inevitable. Unfortunately, we can become rapidly irrational about them and find ourselves stuck in guilt/grief cycles linked to past experiences of failure. We can carry erroneous assumptions that our mistakes were avoidable and that, through sloppiness or laziness, we “chose” the path to dysfunction. This theme and related cognitions are linked to the brittleness of perfectionism.

Self-forgiveness is the start of the transformative thinking linked to Theme 2, but key cognitions furthermore center on becoming effective through the correction of errors and improvements in performance. This thinking often accommodates a “darkest before dawn” pattern because errors become increasingly conscious and obvious before new skills emerge.


Theme 3: Resilience Versus Vulnerability

Theme 3 builds on two levels of confidence. First, in basic resources and second, in capacities to learn from errors. The obstacle thinking in Theme
3 relates to our vulnerabilities to adverse events that cause chaos. Whether these experiences are external or internal, they disrupt “normality” such that the obstacles of Theme 3 do not concern routine performance but the stresses that weaken our usual competencies. This thinking, not surprisingly, often follows traumatic events.

The transformative cognitions crucial in Theme 3 revolve around resilience, to the specific resources and know-how that permit people to rebound from personal adversities, to sustained and sturdy performances.


Theme 4: Autonomy Versus Dependency

Theme 4 builds on confidence in basic resources and on capacities for both improving performance and manifesting resilience. The obstacle thinking of Theme 4 revolves around dependency. Being able to deal with adversity requires support which causes us to confront the well-known difficulties of finding support that is well-timed, regulated, and consistent.

Whenever we have difficulties getting needs met, dependency issues arise along with the dual questions of how to successfully obtain what you need and/or proceed without it. Accordingly, the obstacles revolve around anxieties about dependency, with the obstacle thinking often focusing on one’s own inadequacies with obtaining support.

Transformative thinking in this theme focuses on autonomy, the key to mutual regulation, whether actions are aimed at gaining more support or tolerating less, or eliciting better matches. Autonomy, at core, is the temporary detachment from contact, the stepping back, which allows coregulation and reorganization.


Theme 5: Disclosure Versus Emotional Deficit

Theme 5 builds on the confidence derived from the first four themes. It revolves around the obstacle of emotional deficit and constricted expression. These are deficits that lead to impoverishment and low energy, or to tension and volatile fluctuations between high and low energy states. The obstacle thinking associated with emotional deficit centers on the danger of expression, in terms of explosiveness and the humiliation or conflict to which it can lead. The obstacle thinking of Theme 5 obscures healthy expression and reinforces suppression rather than expression.

Transformative thinking in this theme centers on the necessity of emotional disclosure and its enrichment of relationships. Such thinking does not whitewash the “ups” and “downs” of emotional expression but acknowledges the pain of release of negative emotions as well as the expression of positive emotions that are unreciprocated. Nonetheless, the transformative thinking in this theme focuses on the necessity of emotional expression in personal health, and the varieties of disclosures that lead to healthier states of mind and body, and enriched intimacy.


Theme 6: Compassion Versus Social Emission

Theme 6 relates to social exclusion with the obstacle thinking revolving around the social need to create boundaries, ie, inclusions and exclusions. Boundary-making, when optimal, creates unique relationships in explicit roles (eg, teacher-student, parent-child, psychotherapist-client) and in implicit ones that foster growth and adjustment. Boundary-making, when defensive, however, can be inadvertently or deliberately destructive of relationships.

Although every individual is continually making boundary decisions, some people are consistently bothered by obstacle thoughts about exclusion. Not only do these thoughts project the bulk of decision-making onto others, they accent the negative dynamic of exclusion. Often the social groups from whom we are excluded motivate the wish for entry and inclusion. While entry, as a social transition, often marks positive progress, it is also true that people become addicted to desires to enter some circles solely because entry has previously eluded them.

The transformative thoughts in this theme revolve around the compassion that is operative in an inclusive world view. In these world views, there are no ultimate exclusions in providing service. They emphasize the readiness to serve, without exclusion, and the acceptance of outcomes related to service, without attachment to a particular one.

Aside from the established organizations that promote compassion, the transformative thinking of Theme 6 applies to personal situations involving family members and friends. Each person can be of some help to others, however simple that help may be. It is also true that there is always someone who needs help. Therefore, there is no need to feel excluded from meaningful relationships, given the willingness to serve.


Theme 7: Respect Versus Abuse

Theme 7 focuses on the obstacle thinking associated with the many forms of abuse that occur in relationships. A wide range of abusive behavior, from subtle to major, is addressed with only the extreme end of the spectrum qualifying for clinical “abuse.” The logic of abuse, however, holds true for the whole continuum as first steps usually begin with subtle shifts of which both partners in a relationship may not be wholly aware.

Once again, abuse is only possible in established relationships, and typically in relationships with cohesion and magnetism. Accordingly, the obstacle thinking of abuse revolves around the inability to view self and others as separate. Without an acceptance of basic separateness, no one can be seen as inherently possessing inalienable rights.

Thus, this obstacle thinking differs from that of other themes. It is typically positive, defending the “positives” of abusive relationships. The key negative component is the defense of a compromised individuality for the relationship’s greater good. Notwithstanding the fact that some self-sacrifice is inevitable, the crucial ingredient of this obstacle thinking is a lack of balance, a “skew” that defends volatile one-sided domination.

The transformative thinking in this theme centers on the concept of respect that implies a boundary, a separateness, and an acknowledgement that boundary-crossings require permission. While obstacle thinking assumes respect encumbers the progress of relationships, transformative thinking values respect. When people see their individual welfare respected within a relationship, there is a “freeing up” of energy and a relief from strain. Respectful relationships are the foundation for productive synergy, transformative and even spiritual in dimension.


Theme 8: Humility Versus Merciless Judgement

The last two themes concern managing success, as success is seen as opening doors, psychologically, to new challenges. This perspective helps us understand Theme 8 and the obstacle thinking associated with merciless judgment—a central pattern in achievement-addiction. While being addicted to achievement might seem positive, as with other addictions it carries the automatic reactions that culminate in excess and imbalance.

Achievement-addiction originates with the valuing of “goal” over “person.” Whenever this happens, personal experience is devalued. The belief that it does not matter what one feels or thinks as long as one reaches a goal, directly undermines self worth and is experienced as immediate impoverishment. It is one of the failures of our culture and our educational system, particularly, that we are persuaded to believe that one has to trade sensitivity for achievement.

One never needs to make the trade, because the meaningful assimilation of experience is the fuel for sustained, sustainable achievement. While one may delay coming to this insight, the valuing of goal over self can become so habitual and dominant that accomplishments have little actual effect. The extreme form of this pattern is the “imposter” syndrome where the devaluing of self reaches an extreme point such that the individual feels unworthy of achievements attained. There is such a discrepancy, such a cut-off, between the relationship with self and achievement, that the individual comes to believe that accomplishments were just lucky or, worse, the result of faulty judgment.

Merciless self-judgments are the cause and the result of achievement-addiction. In a merciless judgment, the absence of success is intolerable and judgment thus leaves no room for error.

The transformative thinking associated with this theme centers on humility, especially in pursuing satisfaction and happiness. This kind of humility does not reject achievement as a component of satisfaction but places it in proportion as one of several pathways. Furthermore, personal development is viewed realistically as the transformative process of surmounting obstacles via persistent, incremental progress. The ultimate test of progress is also seen as one’s relationships with self and intimate others, regardless of losses or gains publicly experienced.


Theme 9: Reciprocity Versus Privilege

Theme 9 refers to the situations of apparent mastery that bring privilege. These privileges may be people to delegate to and other perquisites of wealth, like travel, and expert or celebrity status. All privileges are distinguishing and, in some circumstances, persuade people to cease identifying with the common man and the common good.

When so persuaded, however, the resulting obstacle thinking is subtle, but quickly problematic. The common people with whom you cease identifying may be distant. However, the obstacle thinking involved centers on a breakdown of reciprocity that quickly extends to intimates. The ultimate result of the breakdown of reciprocity is narcissistic isolation.

The transformative thinking associated with this theme revolves around the principle of reciprocity. Embracing reciprocity requires accepting that the relationship one has with “other” is fundamentally the relationship one has with “self.” No amount of privilege permits escape from this reality, even though privilege is the primary means for attempting such escape.

The transformative thinking surrounding reciprocity is, when realistic, also dynamic, pragmatic, consistent, and incremental. Personal productivity and creativity becomes implicitly service-oriented rather than privilege-based and extends to a dynamic world of cause and effect, contributing to or detracting from the common good, thus, every act has purpose and meaning beyond immediate situations.

For Dr. X, the key themes were 1, 2, 3, 5, and 8. Not only did he feel lacking in the fundamental capacities (Theme 1) to sustain intimacy, he felt he had “blown” his marriage with specific dysfunctional behaviors (Theme 2). He was still vulnerable to the shock and stress of his wife leaving him (Theme 3) and unable, before counseling, to disclose the emotional bitterness he felt (Theme 5) about trying so hard as good husband and provider only to fail. Lastly, this inability to disclose grief was reinforced by his visiting merciless judgments (Theme 8) on himself for his part in the relationship failure.

He was eventually able to see that he did possess the capacity for intimacy (Theme 1—soundness) and could learn from the mistakes he had made in his marriage (Theme 2—functionality) as well as bounce back from the shock of dissolution (Theme 3—resilience). Eventually, he was able to disclose his emotional grief (Theme 5—disclosure) and to cease judging himself harshly in realizing that many people find intimacy difficult (Theme 8—humility) and that he was not alone in struggling with the challenge of intimate relations.



The CALM program emphasizes challenge situations as the key transformative experiences in life to which we bring challenge expectancies and achievement expectancies and real capacities to sustain motivation and attention (Figure 2). Inevitably, we meet some challenges and fail with others, with failures accompanied by losses of confidence, self-esteem, and opportunity. At such times, in contrast to challenges, we find the predictive, comforting, controllable “grooves” of life tempting. For some of us, some of these grooves are slippery slopes to addiction.

CALM-based CBT programming assists clients in their recovery by guiding them through their vulnerabilities to depression and anxiety, using the nine themes as the relevant foci for transformation. This permits a “honing in” on key transformative cognitions that are direct antidotes to the obstacle cognitions identified between aspirations and goal attainments. The nine themes are not just vehicles relevant to escapes from crisis, they are structures which the recovered individual can use to find a path of challenge and meaningful satisfaction. We believe the best approach to relapse prevention is derived from a structure that guides people to meet challenges relevant to their ongoing growth and satisfaction. In Dr. X’s case, he was able to withdraw from cocaine and stop frequenting strip clubs even though he realized that his life was not “fixed.” He had aligned himself with the challenge of finding authentic intimacy and felt that with assistance he had a good chance of successfully meeting this new challenge.

The ultimate aim of CALM-based CBT is the discovery of a path of healthy challenges and of resources that provide vehicles for new learning, new satisfaction, and new confidence.  PP



1. Alcoholics Anonymous–Big Book. 4th ed. New York, NY: Alcoholics Anonymous World Services, Inc.; 2001.

2. Ritvo, P, Irvine, J, Katz, J, Shaw BF. Cognitive-behavioral group therapy with medical patients. In: White JR, Freeman AS, eds. Cognitive-Behavioral Group Therapy for Specific Problems and Populations. Washington, DC: American Psychological Association; 2000:263-281.

3. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy for Depression. New York, NY: Guilford Press; 1979.

4. Segal ZV, Ingram RE. Mood priming and construct activation in tests of cognitive vulnerability to unipolar depression. Clin Psychol Rev. 1994:14:663-695.

5. Teasdale JD. Cognitive vulnerability to persistent depression. Cognition and Emotion. 1988:2:247-274.

6. Nolen-Hoeksma S, Morrow JA. Prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. J Pers Soc Psychol. 1991;61:115-121.

7. Berry D, Pennebaker JW. Nonverbal and verbal emotional expression and health. Psychother Psychosom. 1993;59:11-19.

8. Pennebaker JW. Putting stress into words: health, linguistic and therapeutic implications. Behav Res Ther. 1993;31:539-548.

9. Pennebaker JW, Mayne T, Francis M. Linguistic predictors of adaptive bereavement. J Pers Soc Psychol. 1997;72:863-871.

10. Beck A, Emery G. Anxiety Disorders and Phobias. New York, NY: Basic Books; 1985.

11. Salkovskis, PM. The cognitive approach to anxiety: threat beliefs, safety seeking behavior, and the special case of health anxiety and obsessions. In: Salkovskis P, ed. Frontiers of Cognitive Therapy. New York, NY: Guilford Press; 1997.

12. Borkovec TD, Roemer L, Kinyon J.Disclosure and worry: opposite sides of the emotional processing coin. In: Pennebaker J, ed. Emotion, Disclosure and Health. Washington, DC: 9American Psychological Association; 2002.

13. Hoehn-Saric R, McLeod DR. The peripheral sympathetic nervous system: Its role in normal and pathological anxiety. Psychiatr Clin North Am. 1988;11:375-386.

14. Lyonfields JD. Borkovec TD, Thayer JF. Vagal tone in generalized anxiety disorder and the effects of aversive imagery and worrisome thinking. Behav Ther. 2003.In press.

15. Borkovec TD, Inz J. The nature of worry in generalized anxiety disorder: A predominance of thought activity. Behav Res Ther. 1990;28:153.

16. Young JE, Klosko JS. Reinventing Your Life. New York, NY: Plume/Penguin Books; 1994.

17. Tashakkori A, Teddlie C. Mixed Methodology. Thousand Oaks, CA: Sage Publications; 1998.


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Monica Ramirez Basco, PhD, Megan Merlock, Noelle McDonald

Primary Psychiatry. 2003;10(5):65-71


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Andrew Adesman, MD

Primary Psychiatry. 2003;10(4):55-60


Dr. Adesman is director of Developmental and Behavioral Pediatrics at Schneider Children’s Hospital in New Hyde Park, NY.

Disclosure: Dr. Adesman is a consultant for, advisor to, and on the speaker’s bureau for Eli Lilly, McNeil, Novartis, and Shire.

Please direct all correspondence to: Andrew Adesman, MD, Suite 130, 1983 Marcus Avenue, Lake Success, NY 11042.


Attention-deficit/hyperactivity disorder (ADHD), if not effectively treated, is associated with considerable morbidity. Behavioral interventions and medication management remain the cornerstones of effective ADHD therapy. The National Institute of Mental Health’s Multimodal Treatment of ADHD (MTA) study demonstrated that stimulant medication, when prescribed carefully and monitored closely, is the single most effective treatment for ADHD. The MTA study likewise documented that a comprehensive behavior therapy program was also effective, albeit less so than medication. A multimodal program that combined medication and behavioral interventions resulted in the greatest overall improvement. Nonetheless, a combined approach may not be required for all patients with ADHD. Clinicians must be aware that current community approaches to medication management do not result in an optimal response. Important differences in the approach to medication management are discussed. The MTA study reinforces the need for close monitoring of clinical response to medication. Compared to children medicated in the community, the MTA-medicated children were generally treated for 12 hours (not 8 hours), were seen more frequently for follow-up (with mandated frequent teacher communication), were treated at somewhat higher doses of medication, and had their medication adjusted more frequently. In addition to elaborating on the MTA study results, this article reviews some of the other implications and limitations of the MTA for clinicians. Lastly, several of the most recently approved stimulant and nonstimulant medications for treatment of ADHD are described.



Attention-deficit/hyperactivity disorder (ADHD), if not effectively treated, is associated with considerable morbidity. Children and adolescents with ADHD are at increased risk for academic failure, social rejection, behavior problems at home and school, and ultimately, low self-esteem. Although effective clinical interventions cannot eliminate the risks for academic and psychosocial impairment, delayed or ineffective treatment will almost certainly increase these risks.

Behavioral interventions and medication management remain the cornerstones of effective ADHD therapy and is the focus of this article. This article focuses primarily on the lessons to be learned from the recent Multimodal Treatment of ADHD (MTA) study and briefly reviews some of the newest medication options in treating children and adolescents with ADHD.


The MTA Study

The National Institute of Mental Health-sponsored MTA study represents the most extensive, well-designed prospective evaluation of different treatment approaches for children with combined type ADHD.1 The MTA study was initiated in 1994 and conducted by experienced researchers at six sites. Children 7–9 years of age with combined type ADHD, including those with comorbid anxiety and/or disruptive behavior disorders, were included in the study. Subjects were randomized to one of four treatment groups: medication management (MedMgt), behavior therapy (Behav), combined medication management and behavior therapy (Comb), and a community control (CC) group. The treatment protocols for the MedMgt and Behav groups reflected “best practice” and were provided by clinical research personnel over a 14-month period. Children in the CC group did not receive any services through the MTA study, but were encouraged to seek any services in their community which they felt their child needed.

The MTA study indisputably demonstrates that medication, when carefully prescribed and closely monitored, is the single most effective treatment of ADHD. Although the results of the MTA study cannot be fully reviewed here,2-7 there are several lessons worth noting. First of all, children in the MedMgt and Comb groups showed the greatest improvement, whereas those in the CC group experienced the least improvement. Given that two thirds (68%) of the children in the CC group were treated with medication by their local physicians, it is essential to appreciate that the act of prescribing medication for a child with ADHD does not insure an optimal outcome. The MedMgt, Comb, and CC groups were comparable with respect to ADHD severity, but there were the following key differences in the approach to medication management3,4:

12-hour dosing: One of the most significant differences between the MTA-treated children and the community-treated children was in the medication regimen itself. Children in the MedMgt and Comb groups of the MTA protocol generally received medication on a BID regimen (mean=2.9 methylphenidate doses/day) whereas those children medicated in the CC group generally received only two doses per day (mean=2.1 doses/day). To the extent that all of the children in the MTA study met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition8 criteria for ADHD, combined type, and therefore had some impairment in the home setting (not just in school), it is not surprising that treatment with medication for 12 hours was associated (along with many other factors) with a superior clinical response.

Follow-up frequency/intensity: There were significant qualitative and quantitative differences in the approach to medical follow-up of children in the MTA protocol who received medication. Medical follow-up visits for children receiving MTA-delivered medication were significantly longer than those provided in the community—30 minutes versus 18 minutes. Similarly, children in the MedMgt and Comb groups were seen much more frequently for medication follow-up than were those in the CC group—8.8 visits/year versus 2.3 visits/year.

Teacher communication: In addition to more frequent and longer medication follow-up visits, there was also more frequent teacher communication in the MedMgt and Comb groups. For the MTA-delivered medication subjects, a pharmacotherapist called each child’s teacher monthly to gain insight into the child’s functioning and thus guide medication adjustments. Clinicians in a private practice setting do not speak regularly with the teacher of a child with ADHD.

Total daily dose: The total methylphenidate dose was higher in the MTA-treated subjects than in those children treated in the community—32.8 mg/day versus 18.7 mg/day. When adjusted per dose, the mean methylphenidate dose in the MTA-treated children was 11.3 mg, whereas the average dose for children treated by community physicians was 21% lower, at 8.9 mg.

Tolerability: When carefully adjusted and closely monitored, treatment with stimulant medication was not only very effective, but it was also very well tolerated. At the conclusion of the 14-month study, 73.4% of the MTA-medicated subjects were taking methylphenidate, and an additional 10.4% were taking amphetamine; only 13.1% were not taking any medication. (A very small percentage of patients were on either pemoline, bupropion, haloperidol, or imipramine.) Of the 198 children for whom methylphenidate was the optimal treatment (based on placebo-controlled titration trial at the outset), 88% were still taking methylphenidate at the end of the 13-month maintenance period. Despite the fact that the MedMgt children generally received a 12-hour regimen at a higher dose than the CC children, they remained on medication significantly longer (9.9 months versus 5.5 months; P<.001), suggesting that stimulant therapy, when optimized and closely monitored, is also well tolerated.


Additional Lessons From the MTA Study

Optimal Medication Regimens

Result of the MTA study show that optimal medication regimens require periodic readjustment. There were many differences in medication dosage and monitoring between children in the CC group and those in the MedMgt and Comb groups. Although the aggregate data cited above highlights significant differences in the dosing regimen, one must also consider to what extent children required subsequent titration or medication changes.

Despite the fact that placebo-controlled dose titrations were conducted at the outset, many children required several further additional dose adjustments. For example, of the 230 children for whom an optimal treatment regimen was established (using the titration trial), only 17% remained on the same medication dosage throughout the study. The overwhelming majority of children needed a change in dose and some required a change in medication. In most instances, a dose increase was required, though some children needed a dose reduction instead. When comparing the titration dose versus the end-of-maintenance dose, the mean MPH dose increased from 30.5 mg/day (.97 mg/kg/day) to 34.4 mg/day (1.09 mg/kg/day). Not surprisingly, children who were started on a low dose following titration (<15 mg/day) were most likely to require a dose increase, whereas those who were started on a high dose initially (>35 mg/day) were more likely to experience a dose reduction over time.

The mean number of medication changes per child was 2.18 (±1.8 SD), though one child required 10 medication dosage adjustments. More than half of the children treated with medication required a medication change within 3 months into the maintenance period, and the average time interval to the first change was 4.7 months. Although dosage adjustments were made 1 month earlier in the MedMgt group than in the Comb group (4.1 months versus 5.1 months, P<.05), this was likely a protocol artifact in that changes in the behavior therapy plan had to precede any medication change, thus delaying medication changes for children in the Comb group.

Medication adjustments were not limited to the initial months of the maintenance period. Approximately 20% of children required modifications in the medication regimen at 9 months and 12% required changes at 12 months. These data collectively suggest the need to regularly monitor and adjust medication response based on frequent parent and teacher feedback.


Response to Stimulants

Overall, 90% (231/256) of the children who completed the titration trial responded well to either methylphenidate (79%) or dextroamphetamine (11%), indicating that most children with ADHD respond well to stimulants. This 90% overall response rate is comparable with previously cited response rates to stimulants when two different medications are tried. Dextroamphetamine was found to be helpful in approximately half of the children for whom methylphenidate was not considered appropriate at the end of the titration (12/26). Interestingly, 6 of the 26 initial methylphenidate nonresponders were later successfully treated with methylphenidate. For these children, the titration trials were considered “false negatives.” Although not common, this observation suggests that clinicians may occasionally need to revisit previously tried (and failed) medications.


Stimulants and Anxious ADHD Children

Investigators have previously tried to identify which children with ADHD are most likely to respond to stimulant medication. Preschool children, autistic children, and children with a comorbid anxiety disorder seem to be less likely to respond well to stimulant therapy. Although the MTA excluded preschool children and autistic children, a significant number of the children in the MTA had a comorbid anxiety disorder by parent report. During the titration trial, the children with both ADHD and
anxiety responded well to stimulant therapy.5 Although earlier studies have likewise suggested that anxious ADHD children do indeed respond to stimulants, the MTA methodology was methodologically superior to many of these other studies.


MTA: Interpretive Pitfalls

The results of the MTA study are somewhat complex, and media reports have at times inadvertently oversimplified or distorted their findings. By extension, some clinicians may also not fully understand or appreciate all of the results and may potentially misinterpret the lessons from these data. Professionals who treat children with ADHD must be aware of the many potential “false lessons” from the MTA.


Neccesity of the Multimodal Approach

Although some may be tempted to conclude from the MTA that there is no benefit to a multimodal approach, this inference is likely as simplistic as it is incorrect. Admittedly, there was no statistical or clinical difference between the MedMgt group and the Comb group when solely considering ADHD core symptom outcomes. However, some differences were suggested for other functional outcomes, such as oppositional/aggressive symptoms, internalizing symptoms, social skills, parent-child relations, and academic functioning.6 The MTA investigators describe these differences as small but likely real. An effect size of 0.27 (when comparing Comb group with MedMgt and Behav groups) did not achieve statistical significance because of design limitations of the MTA protocol. Sample-size calculations for the MTA study were predicated on 80% power to detect effect sizes of 0.4 or greater. Many critics and proponents of the MTA study have noted that focusing on the reduction of ADHD core symptoms may be too myopic, and that long-term outcome is more likely related to social skills and these other functional outcome measures.

A more powerful argument in support of the value of a multimodal approach is derived from a comparison of aggregate measures of improvement. Using factor analysis, a single composite measure of treatment outcome was developed based on the sum of the scores on 17 of the standardized baseline assessments. The Comb treatment group did significantly better than all other treatment groups, with the smallest difference noted when compared to the MedMgt group (effect size 0.28) and the greatest difference when compared to the CC group (effect size 0.70).

Two other modest advantages have been identified for the multimodal approach compared to medication alone. In the MTA trial, children in the Comb group ended treatment on a somewhat lower dose of methylphenidate than did children in the MedMgt group (31.1 mg/day versus 38.1 mg/day). It is unclear to what extent this modest dose differential (methylphenidate 7 mg) conferred any clinical advantages with respect to medication-related adverse events or overall tolerability/compliance. Also, parent ratings of satisfaction with treatment were highest for the two groups that received behavioral intervention. Satisfaction ratings were greater in the Comb treatment group than the MedMgt group. Ironically, satisfaction ratings were higher for the Behav group than the MedMgt group, despite the fact that the latter group had a more substantial clinical response to treatment.


The Multimodal Approach as Optimal for all Children With ADHD

Although the data suggest that children in the Comb group did have the best overall outcome, that does not necessarily mean that all children with ADHD should receive a multimodal approach. Some ADHD patients may benefit more from such a comprehensive treatment approach than others. For example, secondary analyses from the MTA study indicate that children with ADHD plus two comorbid conditions benefited more from a combined approach than did others.

Of the 579 subjects in the MTA sample, 68% had one or more comorbid conditions; 33% had a comorbid anxiety disorder, 40% had oppositional defiant disorder, 14% had conduct disorder, 4% had an affective disorder, and 10% also had a tic disorder. A quarter of the total cohort (24.7%) had both a comorbid anxiety disorder and disruptive behavior disorder; this subgroup seemed to benefit most from the multimodal approach.

Although the MTA’s multimodal treatment protocol was clearly superior to behavior therapy alone, there were only modest benefits to a multimodal approach compared to the MedMgt group. On clinical grounds alone, treatment with medication may be more than sufficient for many children with ADHD. When MTA investigators looked at a qualitative outcome measure of success (that incorporated both parent and teacher ratings of ADHD and oppositional defiant disorder symptoms at completion of treatment), 68% of the Comb children and 56% of the MedMgt children were in the normal range (compared to 34% and 25% for the Behav and CC groups respectively). Even smaller differences between the Comb and MedMgt groups were noted at the study conclusion with respect to what proportion no longer met full criteria for ADHD, combined type (90% and 88% respectively).


Results of a Community-Based Multimodal Approach 

Many would assume that a community-based multimodal approach would achieve the same results as in the MTA protocol. However, just as there were substantial differences in outcome for the children medicated in the community compared to those treated as part of the MedMgt or Comb groups, there will likely be substantial differences between a community-initiated multimodal approach and that provided through the MTA protocol.

Although the behavioral treatment interventions were standardized and manualized (thus permitting replication), it is unlikely that many families would be able to obtain the same package of services locally.7 Parents of children in the Behav treatment group received 8 individual and 27 group sessions that focused on behavior management techniques and how to coordinate their child’s care with the school. In addition, children in this group attended an 8-week, 5 days/week (9 hours/day) Summer treatment program. Besides sports skills, this summer program included a consistency management program, timeout from reinforcement, social reinforcement, modeling, group problem-solving, social skills training, and individualized academic skills practice. During the school year, a part-time behavioral aide was in the classroom for 12 weeks to work with the child and provide feedback to the parents using a daily report card.

Lastly, a behavior consultant provided the child’s teacher with 10–16 sessions focusing on classroom behavior management strategies. Unfortunately, health insurance plans often do not cover this extensive array of services, school districts are generally unable to provide this intensity of behavioral supports, and many communities do not have professionals with the proper training and availability to provide these intensive interventions even if funding were available. Thus, in many ways, the behavioral interventions in the MTA study were optimal, but not likely attainable for most families.

The multimodal approach in the MTA was interdisciplinary, not just multidisciplinary. There was close collaboration between the pharmacotherapist and the behavioral therapist from both a logistical and clinical standpoint. Medication management follow-up visits were scheduled to coincide with behavioral therapy sessions, and there was frequent clinical communication between the staff overseeing the medical and behavioral interventions. Although generally desired, achieving such close collaboration among professionals in a community setting is often quite difficult.


Efficacy of Behavior Therapy

Many are under the assumption that behavior therapy does not work. Children treated in the MTA protocol with behavior therapy showed a comparable response to those children treated with medication in the community with respect to ADHD outcomes. Although behavior therapy did not have the most robust treatment effect as a single modality, it was included as a treatment modality specifically because of the multiple prior studies that have demonstrated its efficacy.

In the MTA study, parent report of “parent-child relations” was higher in the Behav group than the CC group. When moderator variables were examined to determine if select subgroups had a differential response to the interventions provided, it was noted that in children with a comorbid anxiety disorder, behavior therapy was essentially as effective as medication management, and that the combined therapy group responded significantly better than either treatment alone.


Generalization of the MTA Findings

Clinicians must remember that the MTA study focused exclusively on children with ADHD, combined type, and should not be generalized to all ADHD patients. Children with ADHD, Inattentive type, were not included in this study. Children with ADHD, inattentive type typically have fewer difficulties with social functioning and are often able to focus better in a quiet home environment than in a classroom with 25 other children. Thus, whereas the MTA study clearly suggests that children with ADHD, combined type, should generally be treated with medication for school and homework (eg, 12-hour duration), the decision to treat a child with ADHD, innattentive type with medication during the after-school period should be determined on a case-by-case basis. To the extent that a significant percentage of children with ADHD also have a learning disability, clinicians’ questions to parents about a child’s difficulty completing homework should delineate between distractibility due to ADHD and learning difficulties due to an associated learning disability.


Medication Management

In recent years, several new medications have been approved for treatment of children with ADHD.9 Although many of these newer medications are simply improved, longer-acting preparations of familiar stimulants, these extended-release preparations do confer several advantages. With effective long-acting preparations, children with ADHD should no longer need to go to their school nurse for a mid-day dose of medication. This means that children will not have gaps in coverage in between doses, and some of the sharp daytime blood level peaks and troughs should be eliminated. Since the longer-acting stimulants (methylphenidate and mixed amphetamine salts) work beyond the 7–8 hour school day, these once-a-day dosing preparations better enable ADHD children to do their homework after school without subsequent re-dosing. This is an especially big advantage for “latchkey kids,” who will no longer need to assume responsibility for self-medication, further reducing potential for problems with adherence or diversion. In addition to improved long-acting preparations, the Food and Drug Administration has recently also approved two other medications for treatment of ADHD (dexmethylphenidate and atomoxetine), and several other preparations are currently in development.


Choosing a Stimulant

Methylphenidate, dextroamphetamine, and mixed amphetamine salt preparations are generally equally effective. Approximately 75% of children with ADHD respond well to any one specific stimulant medication, and 90% respond well to stimulants when more than one is tried. Although many children with ADHD respond equally well to different stimulants, some children respond better to methylphenidate than amphetamines, and for others, it is the reverse. Unfortunately, medication response cannot be predicted a priori. Thus, as in the MTA titration protocol, if a patient with ADHD does not respond well to one stimulant preparation despite adjustments in the medication regimen (eg, timing, dose), a second stimulant should be tried. Although some physicians chose amphetamine preparations as their first-line stimulant, the amphetamines do have a higher side-effect rate than methylphenidate. For this reason, it may be best to start patients on a long-acting methylphenidate preparation and switch to an amphetamine product if methylphenidate is ineffective or poorly tolerated.

Since once-a-day dosing is best for every child whenever possible, patients should be started on long-acting preparations to streamline the titration phase and to maximize confidentiality, convenience, and adherence. Some clinicians choose to start patients on short-acting preparations to minimize side effects and allow greatest dosing flexibility. Once stable, the patient should be switched to a longer-acting preparation. If a patient has a need for after-school medication coverage (all children with ADHD, combined type, and some patients with ADHD, inattentive type), a 12-hour methylphenidate stimulant preparation is recommended. If a child functions well after school (eg, many children with ADHD, inattentive type), an 8-hour extended-release methylphenidate preparation may be sufficient. Titration is often necessary, and clinicians may occasionally choose to give a child both an 8-hour and a 12-hour preparation if, for example, the child needs 12-hour coverage but less medication after school than in school.

The two main amphetamine preparations, dextroamphetamine and mixed amphetamine salts, appear to be comparable in efficacy, though there have been very few studies directly comparing the two agents. Both are available in short- and long-acting preparations: dextroamphetamine in preparations of 4 hours and 8 hours and amphetamine salts in preparations of 5–6 hours and 10–11 hours. Mixed amphetamine salts extended-release capsules are available in many different strengths (5, 10, 15, 20, 25, 30 mg) and can be given as a sprinkle, further facilitating dose titration.

Whereas all of the previously available methylphenidate preparations include methylphenidate in its racemic form (both the “d” and “I” stereoisomers), clinical studies suggest that methylphenidate’s biological activity resides with the “d” isomer. Dexmethylphenidate is a novel methylphenidate preparation in that it is only comprised of the “d” isomer. Preliminary studies suggest that dexmethylphenidate may have a somewhat longer duration of benefit and superior clinical effect compared to immediate-release racemic methylphenidate. However, it is not yet available in a long-acting preparation.



Atomoxetine was recently approved by the FDA for the treatment of ADHD in children (>6 years of age), adolescents, and adults.10 This medication is a selective norepinephrine reuptake inhibitor, though it has been shown in animals to also have dopaminergic activity in the prefrontal cortex. Unlike stimulants, where there is a relatively close relationship between half-life and clinical duration of action, there is a sharp dissociation between atomoxetine’s pharmacokinetic and pharmacodynamic profile.

Atomoxetine is metabolized by the 2D6 pathway of the cytochrome P450 system. The drug’s half-life is approximately 5 hours in patients who are “extensive metabolizers” (94% of the general population), but much longer (20.4 hours) in the small percentage of individuals who are “poor metabolizers.” Interestingly, the clinical duration of benefit is substantially longer than the half-life.

In several double-blind, placebo-controlled trials with atomoxetine, improvement was noted compared to placebo on school teacher ratings as well as on parent questionnaires. Benefit was noted by parents not only after school but also, to some extent, in the evening and the following morning (prior to the next day’s medication). In children, gastrointestinal side effects, such as decreased appetite, stomach ache, and vomiting, are most common. These side effects may be minimized if given with a meal or if the daily dose is divided into two doses (eg, breakfast and dinner).

It is recommended that patients treated with atomoxetine be started on a low dose, and titrated to the target dose after at least 3 days. The recommended dose is generally based on weight. In children and adolescents who weigh under 70 kg, the starting dose is 0.5 mg/kg/day and the target dose is 1.2 mg/kg/day. For individuals who weigh >70 kg, the starting dose is 40 mg and the target dose is 80 mg. The total daily dose in children and adolescents should not exceed 1.4 mg/kg/day or 100 mg/day, whichever is less. Some clinical benefit is likely to be seen within a few days of starting the medication. However, full clinical response may take several weeks.

Atomoxetine appears to have several potential advantages compared to the stimulants. Nonetheless, it is premature to consider it a preferred first-line medication for youth with ADHD. To begin with, although atomoxetine is FDA-approved as a “once-a-day” therapy for children and adolescents with ADHD, there are limited data specifically looking at its efficacy and tolerability when prescribed in that manner. Atomoxetine is said to have a 70% response rate (when including QD and BID studies together). Although this response rate is similar to the stimulants when considered individually, it is much lower than the stimulants collectively. More importantly, there have been no well-designed direct comparisons between any of the stimulants and atomoxetine. Although atomoxetine is said to have a comparable effect size to the stimulants (0.7 s.d.), well-controlled double-blind trials are needed to assess the relative efficacy and tolerability of this new medication.

If children or adolescents with ADHD do not respond well to treatment with stimulants or atomoxetine, other medications may be helpful. Although not approved for the treatment of ADHD, clinical studies have shown bupropion, a2-agonists (clonidine, guanfacine), and tricyclic antidepressants to be effective in some youths with ADHD. In general, these medications do not have as robust an effect size as the stimulants. These medications are sometimes used in conjunction with the stimulants as well, although there are very few studies evaluating the safety and efficacy of combining medications for treatment of ADHD. For example, there have been a few cases of sudden death reported in children taking clonidine and stimulants concurrently. However, these were rare events and atypical clinical cases, so it is unclear to what extent these medications can be used together safely.



Effective treatment of ADHD is essential. Medication, when prescribed carefully and monitored closely, is the single most effective treatment for ADHD. Clinicians must be mindful of their prescribing practices and the extent to which their medication management routines deviate from those followed in the MTA protocol. Children in the MTA study were more likely to be on a 12-hour medication regimen with close follow-up and titration as needed. Community physicians in the MTA study did not communicate with the teachers as regularly and did not meet with the family as frequently.

In the MTA study, behavioral interventions were not as effective as medication when optimized. However, the addition of behavior therapy to medication not only led to increased parent satisfaction with the treatment protocol, but also resulted in some additional benefits beyond the core symptoms of ADHD. Unfortunately, many factors preclude families from receiving a multimodal treatment approach as provided in the MTA study. Nonetheless, the availability of new long-acting stimulants and the recent release of other medications should enable concerned and caring physicians to provide children and adolescents with effective treatment of ADHD.  PP



1. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56:1073-1086.

2. Jensen PS, Hinshaw SP, Swanson JM, Greenhill LL, Conners CK. Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. Dev Behav Pediatrics. 2001;22:60-73.

3. Vitiello B, Severe JB, Laurence MS, Greenhill L, Arnold LE. Methylphenidate dosage for children with ADHD over time under controlled conditions: lessons from the MTA. J Am Acad Child Adolesc Psychiatry. 2001;40:188-196.

4. Greenhill LL, Abikoff H, Arnold LE, Cantwell D, Conners CK. Medication treatment strategies in the MTA study: relevance to clinicians and researchers. J Am Acad Child Adolesc Psychiatry. 1996;35:1304-1313.

5. March JS, Swanson JM, Arnold LE, Hoza B, Conners CK. Anxiety as a predictor and outcome variable in the Multimodal Treatment Study of Children with ADHD (MTA). J Abnorm Child Psychol. 2000;28:527-541.

6. Conners CK, Epstein JN, March JS, Angold A, Wells KC. Multimodal treatment of ADHD in the MTA: an alternative outcome analysis. J Am Acad Child Adolesc Psychiatry. 2001;40:159-167.

7. Barkley R. Commentary on the Multimodal Treatment Study of Children with ADHD. J Abnorm Child Psychol. 2000;29:595-599.

8. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC. American Psychiatric Association; 1994.

9. Adesman A. New medications for treatment of children with attention-deficit/hyperactivity disorder: review and commentary. Pediatr Ann. 2002;31:514-522.

10. Strattera [package insert]. Indianapolis, IN: Eli Lilly; 2002.


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Karen Pierce, MD

Primary Psychiatry. 2003;10(4):77-80


Dr. Pierce is assistant professor of psychiatry in the Department of Psychiatry at Northwestern University and medical director of the Children’s Partial Hospitalization Program at Children’s Memorial Hospital in Chicago, IL.

Disclosure: Dr. Pierce is on the speaker’s bureau for Eli Lilly, Novartis, and Ortho-McNeil.

Please direct all correspondence to: Karen Pierce, MD, Children’s Memorial Hospital, Box 10, 2300 Children’s Plaza, Chicago, IL 60614; Tel: 773-525-1218; Fax: 773-525-8925; E-mail: kpierce@childrensmemorial.org


Attention-deficit/hyperactivity disorder (ADHD) is being recognized as prevalent in adulthood. However, there is a lack of extensive research and thorough physician training of adult ADHD. The recent awareness of the chronicity of childhood symptoms of ADHD continuing throughout the lifespan makes this an important topic. This disorder is complicated by the fact that comorbid psychiatric problems accompany the ADHD symptoms. Physicians often overlook symptoms of inattention, distractibility, and impulsivity in adulthood. This article reviews prevalence of ADHD in adults as well as diagnosis and treatment options.



With increased awareness of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents, research1and clinical experience has indicated that many young people with ADHD continue to have symptoms as adults. An increasing number of adults present to clinics with symptoms of ADHD.2Recognition of this disorder in adults can be complex due to the difficulty of obtaining and understanding the impact of ADHD symptoms in one’s life and the coexistence of other psychiatric conditions. Obtaining an accurate past history of symptoms is difficult and often misleading. The limitation of a strict adherence to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)3 definition of ADHD adds to the frustration. This article highlights the incidence and prevalence of adult ADHD, provides information on how to diagnose the disorder, and reviews effective treatments.



ADHD is common among adults. Estimates of occurrence of ADHD in adulthood range from 1% to 6%.4 Occurrence of adult ADHD can be difficult to study as some of the core symptoms of ADHD remit with age. Although the rate of hyperactivity and impulsivity declines with age, inattention symptoms often remain. In adult epidemiology studies, the incidence of ADHD is approximately 4.7%.5,6 The lowest incidence of adult ADHD was reported by Heiligenstein and Keeling7 at 4.0%.

Several predictors of persistence for ADHD into adulthood include positive family history of ADHD, psychosocial adversity, and comorbid disorders such as conduct disorder, oppositional defiant disorder, and mood/anxiety disorders.8 Another reason that adult ADHD is often overlooked may be due to the way we define remission and categorize the symptoms. Adults may not have the required number of DSM-IV symptoms to meet full criteria but may have enough disability to be functionally impaired.3 Longitudinal studies of children with ADHD have revealed that 60% no longer meet diagnostic criteria (syndromatic remission), 30% continue to have symptomatic remission (subthreshold symptoms), and only 10% achieve full functional remission.2

An interesting discussion by Biederman and colleagues9 explored the curious data showing that ADHD in adults have a more equal gender distribution than in childhood. In children the gender ratio of ADHD favors males at 4:1 to females at 9:1. Biederman and colleagues9 postulated that since boys have a greater tendency to demonstrate disruptive behavior disorders than girls, the disorder is diagnosed more in boys during childhood. Further studies in females at younger ages are required to fully understand this phenomenon. Perhaps by diagnosing more adult women with ADHD, we can better calculate the prevalence of the disorder in young girls.



ADHD carries great impact as indicated in recent studies.6 Nonmedicated adults with ADHD often suffer from the cumulative effects of a lifetime of ADHD-associated behaviors. Pomerleau and colleagues10 studied 71 adults with ADHD (55 males, 16 females; mean age=34 years) and found higher rates of smoking compared with controls. Results of the study suggest that smokers with ADHD find exceptional difficulty quitting (despite numerous attempts to quit) compared with the general population. In addition, individuals with untreated ADHD are more prone to abuse substances.11 Children with ADHD?who are untreated typically begin drinking 3 years earlier than their peers.11 Adults with ADHD are at risk for increased medical costs, increases job changes, and are more often self-employed.12 They have jobs with lower status and fail to achieve or be promoted. They struggle with vocational, academic, or social demands. Barkley and colleagues12 demonstrated increase in traffic accidents in adults and adolescents with ADHD not related to knowledge about driving rules or safety in a driving lab.

ADHD is a heterogeneous condition that has a heritable component. The genetic basis for the etiology of ADHD has a heritability of .75%.13 Often, adults first get diagnosed when their children are diagnosed with the disorder and receive intervention.14 Completing ADHD symptom checklists on their child reveals that they, too, suffer with many of the same problems. The pathophysiology of ADHD shown by both anatomic and functional studies may lie within the frontosubcortical system.15 Structural neuroimaging studies reveal problems in the frontal cortex, prefrontal cortex, corpus collosum, globus pallidus, vermis of the cerebellum, and the caudate nucleus.15 Functional imaging continues to investigate and validate these findings and show decreased cerebral metabolism. These tests are for research purposes only and do not help to confirm the diagnosis.


Making the Diagnosis

An ADHD diagnosis is made by a clinical exam. There are no laboratory tests or psychological tests that confirm a clinical presentation. Since ADHD is a performance-based disability, the procedure to assess this can be subjective. Can a medical student or an intern attain that level of education and suddenly develop ADHD? How about a second-time mother who gets overwhelmed, distracted, and first presents with symptoms after having no symptoms with the first child? Many adults with ADHD were able to get by until multi-level high performance tasks needed to be juggled and completed. A thorough interview becomes important with specific questions about impairment. In assessment of ADHD, one needs to carefully observe the person’s motor activity and their attention when not directly engaged. Planning to be engaged in paperwork during the interview can expose inattention and distractibility. There are adult rating scales for ADHD available to confirm a diagnosis.16

There are 18 symptoms defined by DSM-IV to diagnose ADHD.3 Adults may present these symptoms differently than children.3,7 Adults tend to be self-referred, rarely presenting to the clinician with behavior that disrupts others the way many children present. Spouses and employment personnel note less productivity, missing deadlines, being late for work, poor financial management, or forgetfulness. Interpersonal skills suffer as impatience, being quick to become angry, and excessive talking interfere with the reciprocal nature of relationships.

The inattention in adults may manifest as inattention to details. They may make lists and then forget to check what is on it and miss the task.14 Many adults with ADHD can read a magazine or brief article but not a whole novel. They may regularly read the encyclopedia because the entries are concise. Adult ADHD patients report inner restlessness and becoming easily overwhelmed. Over-commitment to activities and poor time management may round out the picture. In adolescents and adults, symptoms of hyperactivity can take the form of restless feelings and difficulty engaging in quiet or sedentary activities. Adults can be extremely fidgety but in a socially acceptable way, like wiggling their toes or drumming their fingers quietly. Shifts in sitting and walking around the consulting room are also signs of ADHD. Other symptoms may include impulsive job changes, driving too fast, traffic violations, or an excess of smoking or caffeine consumption.

For a diagnosis of ADHD, symptoms must occur frequently, persist for at least 6 months, and be inconsistent with the developmental level.3 Careful history including job performances, academic achievement, and the pattern of relationships can establish the chronicity of the symptoms. An adult with ADHD may be fortunate to have kept one job but when asked about the job it becomes obvious that the duties are changed frequently (eg, an emergency room physician). It is important to ask about the person’s work and conduct an assessment of their performance within the job. One may deny symptoms of ADHD until it becomes obvious; for example, when the secretary is on vacation, inattention, disorganization, and forgetfulness may become more apparent.

Perhaps the most difficult DSM-IV criteria to establish in adults is that the symptoms must cause impairment prior to 7 years of age.3 Retrospective history is often inaccurate, as adults have trouble remembering childhood symptoms. There is no evidence that 7 years of age is the magic number for the onset of the disorder, but rather represents the long-standing nature of the illness and its impact on functioning. Gathering old report cards or communicating with the parents to establish history and chronicity can be helpful. ADHD symptoms may present later when the task complexity increases such as in college or in professional school. One DSM-IV criteria for ADHD is some impairment from the symptoms in two or more settings, such as school, work, or home.3 To establish problems functioning in two or more areas, reports from spouses, children, and work relations can be helpful both to establish the diagnosis and to enlist help during the treatment phase.

The DSM-IV states that impairment is required in order to make a psychiatric diagnosis. There must be evidence of impairment in social, academic, or occupational functioning.3 This can create controversy, and good clinical judgment is helpful. However, it is not always easy to judge what constitutes impairment. For example, a gifted student may achieve B’s and C’s in college, or a busy housewife may forgets her errands and have to go to the store three to four times a day to complete a task. Both of these individuals are significantly achieving below the individual’s expectation and would meet the impairment criteria. This should be carefully documented before treatment begins as these symptoms will be markers for treatment interventions.

Another DSM-IVcriteria is the exclusionary diagnosis.3 More often in adults, ADHD is not considered in the presence of coexisting conditions. Frontal lobe functioning is impaired in many diseases and psychiatric diagnoses. Often, the ADHD symptoms are missed because focus is on the other disease state.

The three subtypes of ADHD are defined in DSM-IV as the inattentive type, hyperactive-impulsive type, and the combined type.3 Most often, adults present with the inattentive subtype. Those with the combined type usually have a strong history of symptoms throughout their childhood, with little remission. Impulsive irritability and hyperactivity still occur in adults but may present in a more socially acceptable way than the disruptive behaviors of childhood.



Comorbidity is commonplace in people with ADHD. Studies in children show increased rates of anxiety, depression, and substance use. Adults must be screened for ADHD symptoms and other psychiatric disorders. Among patients with ADHD, antisocial personality disorder occurs in 12% to 27%, alcohol and drug dependence in 27% to 46%, major depressive disorders in 17% to 31%, and anxiety disorders in 32% to 50%.17 Often when depression or an anxiety disorder in an adult clears, underlying issues with executive functioning and attention can be found. Demoralization from the underachievement that a chronic attention disorder presents is common. Feelings of inadequacy, a sense of failure, and underachievement can lead to depressive symptoms. Not being able to read a book because of inattention, distractibility, or missing deadlines can be humiliating. This should be differentiated from depression. In addition, substance abuse must be treated and understood as a separate disorder or possibly a way to self-medicate symptoms of ADHD.



Treatment of ADHD should improve the patient’s functional outcomes. As ADHD is a chronic disorder, impairment will be very individualized and so should treatment. Before a treatment plan is undertaken, care must be taken to identify target symptoms and measure severity. Developing a list of symptoms to be treated or using a standardized rating scale of severity is a way to establish treatment markers.

There are three components for treatment of adult ADHD: (1) education of patients and caregivers to create a framework for understanding and managing behavior; (2) psychosocial interventions to improve socialization and interpersonal interactions; and (3) pharmacologic interventions to treat physiologic manifestations of the disorder.

Education is the first step to easing miscommunications and misconceptions of adult ADHD. Referral to support groups or national organizations can be helpful. Often, newly diagnosed adult patients need to reframe their lives and their past with the new knowledge that has been gained. Understanding the disorder and its impact can provide great relief to the patient.


Psychosocial Intervention

Psychosocial interventions with a person’s support group are beneficial. There are no studies on psychosocial treatment of adults, but any of the management techniques used with children may be helpful. Adults can set up a reward system for each task that is completed. Employers, spouses, and significant others benefit from knowledge that is gained about the chronicity of the disorder and the impact on one’s life. Systems to improve organization such as computer systems or lists can be mainstays of treatment.

Behavioral treatment works when it is constantly implemented. Like pharmacotherapy, when behavior treatment ends, so does the symptom relief. Employers can insist on weekly meetings to keep things on track. A very successful businessman with ADHD may flounder when his boss stops their weekly phone reports, and improve once the procedure is reinstated. Simple plans to keep things in the same place or to dedicate daily time to organization are also beneficial.

A recent development in ADHD is the concept of coaching. Coaches establish working relationships with clients to help promote organization and time management. The concept of coaching is to help individuals with ADHD set goals, accept limitations, acknowledge strengths, develop social skills, and create strategies that help to manage their lives. Coaches have varied educational and professional backgrounds and should be screened and interviewed. The American Coaching Association is an organization that can partner a person with ADHD with a coach.18


Pharmacologic Intervention

Pharmacologic treatment studies in adults have been limited (Table).19-31 Stimulants have been the standard treatment for an adult with ADHD. Studies have shown that stimulants work on core symptoms in adult ADHD.19-23

The two classes of stimulants that come in both short-acting and long-acting forms are methylphenidate23 and amphetamines.30 The advantages of the stimulants are their effectiveness in reducing core symptoms such as impulsivity, and increasing patient compliance. Stimulants have been used for a long time to treat ADHD and safety and efficacy data is established.19-31 They may also improve social functioning and academic performance. The limitations include the lack of continuous relief, diversion and abuse potential, and tolerability and safety. The adverse effects of stimulants are similar for all but there is individual variation between patients and agents. Side effects occur most frequently during initiation of therapy and with dosage increases. Side effects such as headache, abdominal pain, and decreased appetite tend to decrease over time. With adults, monitoring blood pressure and pulse is important as these agents may increase heart rate and blood pressure.17

The dosage range for adults varies and can be assessed with rating scales and feedback from the patient. The methylphenidate dose is about 15–20 mg every 4 hours during the period that the symptoms should be treated. The dose ranges from 60–80 mg/day depending on the symptom list. Some patients want pharmacology during the work day while others want their social time under control with medication. The long-acting stimulants methylphenidate HCl, and amphetamine extended release, have been shown to be efficacious in adults.17

A new medication that has been studied in adults is atomoxetine, a norepinephrine reuptake inhibitor that has been shown to alleviate symptoms of ADHD.32 The side-effect profile of atomoxetine is similar to the stimulants but these side effects are usually transient. The dosage range for atomoxetine for adults is 80–100 mg.32

Other medications which have been tried with adults include tricyclic antidepressants, bupropion, and venlafaxine. These are not approved by the Food and Drug Administration for use in ADHD and studies of these agents are limited and inconclusive.



ADHD is a chronic disorder, not only for children and adolescents but adults as well. With continuing symptoms into adult life,33 impairment may impact the functioning of an adult with attention symptoms. Careful screening for this disorder in adults will lead to proper intervention and an improved quality of life in those who suffer from ADHD.  PP



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