An evaluation of a specialist service model for treating Body Dysmorphic Disorder (BDD): application of the National Institute for Health and Clinical Excellence Guidelines for BDD (NICE, 2006).

Body dysmorphic disorder (BDD) is still poorly recognised with a dearth of research into treatment. This is the only known study to date to evaluate the implementation of the National Institute for Health and Clinical Excellence (NICE) guidelines recommended treatment for BDD in clinical practice as well as providing qualitative data of both patients and clinicians (NICE, 2006). The study aims to evaluate current recommended treatments for Body Dysmorphic Disorder utilised in a specialist service for BDD. In addition the study elicits the experiences of patients receiving treatment and the clinicians providing the treatment. This provides a basis to assess if refinements are to be made to treatment protocols for BDD in this specialist service. A mixed methods approach was employed with quantitative data from patients treated for BDD collated from the Trust’s database and examined with intention to treat analysis. Thematic Analysis (TA) was used to analyse data from semi-structured interviews conducted with clinical staff and patients to elicit their experiences of respectively providing and receiving treatment. The clinical data indicated impairment in patients’ functioning plus high risks and substance misuse. Treatment outcomes of NICE recommended CBT and medication (Selective Serotonergic Reuptake Inhibitors and augmentation) produced significant improvements in BDD symptoms in patients with severe symptoms at baseline. Patients also showed significant improvements in depression and overall functioning. However despite improvements symptoms were not completely eliminated and one group treated by the service (Level 6 outpatients) showed minimal to no improvement on all symptom measures. Both clinician and patient participants expressed dissatisfaction with the lack of sufficient knowledge and expertise for treating BDD. Both groups also placed high value on the therapeutic relationship. However clinicians interviewed indicated a higher dissatisfaction with current treatment options for BDD than patients. The experiences of patients provided a different perspective to the findings in the quantitative phase. Their view of improvements was based on their functioning and overall quality of life. Clinicians’ perspectives provided insight into other options for treatment which are lacking and could provide substantial support for current recommendations. Given the evidence base for recommended treatments is still limited, it is essential to include qualitative data in evaluating effectiveness of treatment and in developing services that respond to patient needs and choice

The safety case and the lessons learned for the reliability and maintainability case

This paper examine the safety case and the lessons learned for the reliability and maintainability case

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a modern type of short-term psychotherapy that integrates cognitive and behavioral theories. The CBT approach is effective in the treatment of a wide range of mental issues and conditions, such as generalized anxiety disorders, general or post-traumatic stress, panic attacks, depression, eating and sleep dysfunctions, obsessive–compulsive disorders, and substance dependence. CBT is also effective as an intervention for psychotic, personality, and bipolar disorders or to approach fatigue and chronic pain conditions especially if associated with distress. This book explains both theoretical and practical aspects of CBT, along with case examples, and contains useful tools and specific interventions for different psychological situations

Cybersecurity issues in software architectures for innovative services

The recent advances in data center development have been at the basis of the widespread success of the cloud computing paradigm, which is at the basis of models for software based applications and services, which is the "Everything as a Service" (XaaS) model. According to the XaaS model, service of any kind are deployed on demand as cloud based applications, with a great degree of flexibility and a limited need for investments in dedicated hardware and or software components. This approach opens up a lot of opportunities, for instance providing access to complex and widely distributed applications, whose cost and complexity represented in the past a significant entry barrier, also to small or emerging businesses. Unfortunately, networking is now embedded in every service and application, raising several cybersecurity issues related to corruption and leakage of data, unauthorized access, etc. However, new service-oriented architectures are emerging in this context, the so-called services enabler architecture. The aim of these architectures is not only to expose and give the resources to these types of services, but it is also to validate them. The validation includes numerous aspects, from the legal to the infrastructural ones e.g., but above all the cybersecurity threats. A solid threat analysis of the aforementioned architecture is therefore necessary, and this is the main goal of this thesis. This work investigate the security threats of the emerging service enabler architectures, providing proof of concepts for these issues and the solutions too, based on several use-cases implemented in real world scenarios

Urban Land Markets as Spatial Justice

A common view is that urban land markets subtract from, or subvert, spatial justice in cities, with spatial justice thus a definable outcome of market functions. This article explores urban land markets as spatial justice, which is multi-dimensional and subjective and integral to the functioning of markets. Seen from this perspective, urban land markets present a very particular way in which the ‚happening‘ of spatial justice unfolds. Thinking of urban land markets in this way offers considerable value to being able to grasp the ways in which they both configure and constitute spatial justice, and thus broadens our understanding of their emancipatory or conservative potential in urban development. While a distributional understanding of justice represents a fundamental tenet of much progressive thinking, in which the fairness of outcome is seen as fundamentally more important than that of the process, we argue that there is considerable benefit in viewing spatial justice as a process of the struggle to lay claim to place or space. Viewed this way, urban land markets represent a key context within which that struggle occurs, but interventions designed to improve spatial justice must focus on the social relations that inform that struggle as much or more than on land markets themselves

From efficacy to implementation : applying internet-delivered cognitive behavioural therapy in the treatment of OCD

Background: Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) are closely related psychiatric conditions associated with functional impairment across various life domains, an increased risk of suicide, and a significant societal and economic burden. If left untreated, these disorders often become chronic. While Cognitive Behavioural Therapy (CBT) and medication with selective serotonin reuptake inhibitors (SSRIs) are first-line treatments recommended for both OCD and BDD, the availability of CBT is limited in most parts of the world. Aims: The overall aim of this thesis was to extend previous evaluations of internetdelivered CBT (ICBT) for OCD and BDD, in order to demonstrate the applicability and effectiveness of the treatments and to reach out to a broader spectrum of patients suffering from these disorders. More specifically, the aims of each study were: Study I, to investigate whether therapist-guided and unguided ICBT were non-inferior and costeffective compared to face-to-face CBT; Study II, to evaluate the effectiveness of ICBT for OCD and BDD when implemented in the Swedish health care system; Study III, to examine the clinical characteristics of incompleteness and to use it to predict treatment outcome with ICBT for OCD. Methods: Study I was a randomised controlled non-inferiority trial that enrolled 120 participants. The participants were randomly assigned to receive 14 weeks of either face-to-face CBT, therapist-guided ICBT, or unguided ICBT for OCD. The primary outcome measure was the clinician rated Yale Brown Obsessive-Compulsive Scale (YBOCS) and the non-inferiority margin was set to 3 points on the Y-BOCS. Symptom severity was measured pre, bi-weekly, post, 3-month (primary end-point) as well as 12 months after treatment. Study II was an effectiveness study with repeated measures (pre, weekly, posttreatment). The RE-AIM implementation framework was used to measure implementation variables according to the elements of reach, effectiveness, adoption, implementation and maintenance. Four-hundred and thirty-four participants were included and received ICBT for OCD (OCD-NET) and 163 participants were included and received ICBT for BDD (BDD-NET). The primary outcome measures for effectiveness were the clinician-rated Y-BOCS and the Y-BOCS for BDD (BDD-YBOCS). Study III used a subsample (n= 167) of participants from Study II who received ICBT for OCD. Baseline incompleteness (feelings of something being not just right or incomplete) was measured with the Obsessive-Compulsive Trait Core Dimensions Questionnaire (OCTCDQ). The primary outcome measure was the clinician rated Y-BOCS and participants were measured pre-, weekly and post-treatment. Results: In Study I, both therapist-guided and unguided ICBT were found to be costeffective compared to face-to-face CBT. However, the non-inferiority results were inconclusive because the confidence intervals crossed the pre-specified non-inferiority margin of 3 points on the Y-BOCS at the primary endpoint (therapist-guided ICBT, mean Y-BOCS difference= 2.10 points, [90% CI, −0.41 to 4.61]; p= 0.17; unguided ICBT, mean YBOCS difference= 5.35 points [90% CI, 2.76 to 7.94]; p < .001). In Study II, OCD-NET and BDD-NET led to significant reductions in OCD and BDD symptom severity (mean YBOCS reduction= -8.8 points; mean BDD-YBOCS reduction= -11.4 points) and large within-group effect sizes posttreatment (OCD-NET, d= 1.94; BDD-NET, d= 2.07). Eightyseven percent of participants receiving OCD-NET and 78% of participants receiving BDD-NET were treatment completers and participants in both treatment groups reported a high treatment satisfaction at posttreatment (OCD-NET= 87%, BDD-NET= 79%). The implementation also influenced treatment delivery at the clinic and dramatically decreased (by 60-70%) the mean number of patients waiting to receive face-to-face treatment options. In Study III, the underlying emotional construct of incompleteness was positively associated with OCD severity and a higher degree of comorbidity at baseline as well as with symmetry/ordering symptoms. Furthermore, elevated levels of incompleteness predicted worse treatment outcomes with ICBT (B= 0.13, SE= 0.04, [95% CI 0.05 to 0.21], p= 0.002) assessed with the clinician-rated YBOCS. Participants with a high degree of incompleteness had lower probabilities than individuals who scored low on incompleteness of being classified as responders (39% vs. 52%) and remitters (10% vs. 34%). Conclusions: The results suggest that therapist-guided and unguided ICBT are costeffective alternatives to face-to-face CBT in the treatment of OCD. Future research should focus on investigating the effects and cost-effectiveness of a stepped-care approach to deliver ICBT. The findings further indicate that ICBT for OCD and BDD are effective, acceptable, and safe treatments that can be successfully implemented within the Swedish healthcare system. More research is needed to explore the effectiveness of ICBT in a less specialised implementation context, such as primary care. Incompleteness seems to be an important clinical characteristic in OCD that deserves further investigation and higher levels of incompleteness were found to predict a worse treatment outcome with ICBT