Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Killing Two Birds With One Stone: Exposure Simultaneously Addressing Panic Disorder and Obsessive-Compulsive Disorder

Massed exposure has gained acceptance as an effective method to treat anxiety disorders. When using this intervention in patients presenting with more than one anxiety disorder, specific treatment options need to be discussed. Should exposure be applied in sequential order for each of the comorbid disorders? Or can exposure sessions also be designed to simultaneously target both problem areas? We report on the cognitive-behavioral treatment of a 28-year-old woman with obsessive-compulsive disorder (OCD) and severe panic disorder with agoraphobia (PDA). A series of behavioral experiments based on prolonged exposure was planned. Due to the fact that avoided situations elicited both agoraphobic and contamination fears, we decided to combine exposure for PDA and OCD to optimize therapeutic transfer. Twelve sessions of this exposure resulted in a long-term reduction of both PDA and OCD symptoms. The case illustrates that two comorbid conditions can be effectively combined under one therapeutic rationale. Capabilities and limitations of the method and implications for current theoretical debates on exposure therapy are discussed.     

A transdiagnostic examination of intolerance of uncertainty across anxiety and depressive disorders

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N=218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.     

A Transdiagnostic Examination of Intolerance of Uncertainty Across Anxiety and Depressive Disorders

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N = 218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

An open trial of a transdiagnostic cognitive-behavioral group therapy for anxiety disorder

Transdiagnostic models of anxiety, and cognitive-behavioral treatments based on these models, have been gaining increased attention in recent years. Preliminary efficacy studies generally suggest strong treatment effects, although few of these studies have examined to what extent treatment effects are similar across clients with different anxiety disorders. The purpose of the current study was to examine the efficacy of a 12-week transdiagnostic group cognitive-behavioral therapy for anxiety disorders and compare outcome across diagnoses. Mixed-effect regression modeling of data from 52 participants with anxiety disorders (predominantly panic disorder and social phobia) participating in an open outcome trial indicated that participants tended to improve over treatment, with no differential outcome for any primary or comorbid disorders. The results of this study add to the growing evidence base for transdiagnostic anxiety treatment models and provide preliminary support for the assumption that individuals with different anxiety diagnoses can be treated equally within the same treatment protocol.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Comorbidity and the Treatment of Principal Anxiety Disorders in a Naturalistic Sample

This study examined the impact of comorbidity on treatment outcome and the effects of cognitive behavioral therapy (CBT) for anxiety and depressive disorders on comorbid disorders in a naturalistic sample of 150 patients presenting to an anxiety disorders clinic. The following results were observed across principal (i.e., most severe) diagnoses. Patients with comorbid anxiety and depressive disorders presented for treatment with higher severity of their principal disorder than patients without comorbidity. However, the presence of comorbidity did not predict dropout or poor treatment response, and patients demonstrated significant improvement in their principal disorders regardless of comorbidity. The frequency of clinically severe and subclinical (i.e., not severe enough to meet diagnostic criteria) comorbid conditions decreased significantly over the course of treatment. The implication of these findings for the classification and treatment of emotional disorders is discussed.     

Treatment of Adolescent Panic Disorder: A Nonrandomized Comparison of Intensive Versus Weekly CBT

This study compared the relative efficacy of intensive versus weekly panic control treatment (PCT) for adolescent panic disorder with agoraphobia (PDA). Twenty-six adolescents participated in weekly sessions and 25 received intensive treatment involving daily sessions. Both groups demonstrated significant and comparable reductions in panic disorder severity and general anxiety symptoms, which maintained over time. Participants receiving weekly treatment showed significant decreases in depressive symptoms, whereas those in the intensive program reported no change. Findings support the efficacy of the intensive approach for adolescent PDA, but suggest that adolescents receiving intensive treatment may benefit from a brief course of additional weekly sessions.     

Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders

Comorbid substance use disorders (SUDs) and mental health disorders are a pervasive problem among post-9/11 veterans and service members. Treatment of SUD and comorbid disorders has historically occurred separately and sequentially, and when treated concurrently has been primarily done in a weekly outpatient setting, which has high rates of dropout. The current study describes an integrated 2-week intensive outpatient treatment (IOP) using cognitive-behavioral therapy, including prolonged exposure for posttraumatic stress disorder (PTSD), unified protocol for anxiety and mood disorders, and relapse prevention for SUD. Forty-two patients completed the comorbid treatment program. Results indicated that self-reported substance use, PTSD, and depression symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that comorbid SUD and mental health disorders can be effectively treated in a 2-week intensive outpatient program.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Comparison of bulimics, obese binge eaters, social phobics, and individuals with panic disorder on comorbidity across DSM-III-R anxiety disorders.

Eighty-two women, presenting as normal-weight bulimics, obese binge eaters, social phobics, and individuals with panic disorder, were compared on anxiety, depression, and substance abuse. All were administered the Anxiety Disorder Interview Schedule-Revised and completed the Michigan Alcohol Screening Test, Drug Abuse Screening Test, and Self-Consciousness Scale. A striking proportion of eating disorder subjects were comorbid for one or more anxiety disorders, the most frequent diagnoses being generalized anxiety disorder and social phobia. The results suggest that the place of anxiety in bulimia nervosa goes beyond that discussed within the context of the anxiety reduction model. Conflicting comorbidity findings among this and prior investigations are noted, however, and discussed in terms of the issue of differential diagnosis between eating and anxiety disorders.     

Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.     

Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.     

Role of Comorbid Depression and Co-occurring Depressive Symptoms in Outcomes for Anxiety-Disordered Youth Treated with Cognitive-Behavioral Therapy

This study examined the role of comorbid depressive disorders (major depressive disorder or dysthymic disorder) and co-occurring depressive symptoms in treatment outcome and maintenance for youth (N = 72, aged 7–14) treated with cognitive-behavioral therapy for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Hierarchical linear modeling examined treatment outcome and maintenance in terms of severity of the principal anxiety disorder. Results indicated that higher levels of child-reported depressive symptoms predicted less favorable treatment outcome. Higher levels of mother-reported depressive symptoms predicted less favorable treatment maintenance at a 1-year follow-up. Results suggest that co-occurring depressive symptoms play a role in effective treatment for anxiety-disordered youth and support the merits of treatment adaptations for these youth.     

Associations Among Anxiety Disorders and Non-anxiety Disorders,Functional Impairment and Medication in Children and Adolescents

This is a study of comorbid anxiety disorders and how they affect the clinical picture of comorbid cases. The sample consisted of 576 Spanish children aged 8 to 17 years receiving psychiatric outpatient consultation that were evaluated using a semi-structured diagnostic interview for both parents and children. A specific association of homotypic comorbidity among anxiety disorders that was independent of the presence of other disorders was found. There was heterotypic comorbidity between anxiety and depressive disorders, ADHD, anorexia and tic disorders. Relationships between non-anxiety disorders were, in general, independent of anxiety, but anxiety moderated the relationship between ADHD-Conduct disorder and Conduct disorder-enuresis. Comorbid anxiety increased difficulties in social interaction, was related with higher global impairment and had an impact on consultation and medication. Anxiety disorder comorbidity should be well recognized in order not to disregard the treatment of all present disorders.     

Cognitive Behavioral Treatment of Comorbid Anxiety Disorders and Social Difficulties in Children with High-Functioning Autism: A Case Report

A substantial proportion of children with high-functioning autism (HFA) or Asperger syndrome (AS) have one or more comorbid anxiety disorders. Because anxiety disorders exacerbate the social difficulties and other functional impairments caused by an autism spectrum disorder (ASD), there is a need for efficacious treatments to address the clinical needs of youth with this comorbid presentation. This article describes an evidence-based cognitive behavioral therapy (CBT) treatment manual enhanced to address the unique characteristics and clinical needs of children with ASD. A case study is presented in which CBT was utilized in the successful treatment of an 11-year-old girl with HFA. The intervention was effective in reducing anxiety and improving social and adaptive functioning. These findings suggest that an enhanced CBT approach may be a viable intervention for children with comorbid HFA and anxiety disorders that should be further evaluated.     

An Open Trial Investigation of a Transdiagnostic Group Treatment for Children With Anxiety and Depressive Symptoms

The current study investigates the feasibility and preliminary outcomes associated with a transdiagnostic emotion-focused group protocol for the treatment of anxiety disorders and depressive symptoms in youth. Twenty-two children (ages 7 to 12; M = 9.79) with a principal anxiety disorder and varying levels of comorbid depressive symptoms were enrolled in an open trial of the Emotion Detectives Treatment Protocol (EDTP; Ehrenreich-May & Bilek, 2009), an intervention adapted from existent unified protocols for the treatment of emotional disorders among adults and adolescents. Results indicate that participants experienced significant improvements in clinician-rated severity of principal anxiety disorder diagnoses (d = 1.38), the sum of all anxiety and depressive disorder severity ratings (d = 1.07), and child-reported anxiety (d = 0.47) and parent-reported depressive symptoms (d = 0.54) at the posttreatment assessment. EDTP had good retention rates and reports of high satisfaction. Thus, preliminary evidence suggests that EDTP is a feasible and potentially efficacious treatment of youth anxiety disorders and co-occurring depressive symptoms. Children experiencing a range of internalizing symptoms may benefit from this more generalized, emotion-focused treatment modality, as it offers flexibility to families and the mental health clinician, while maintaining a concurrent focus on the provision of cognitive-behavioral treatment skills vital to the amelioration of anxiety and depressive disorder symptoms in youth.     

Drinking motives in alcohol use disorder patients with and without social anxiety disorder

The high comorbidity of alcohol use disorders (AUD) and social anxiety disorder (SAD) is often explained by excessive drinking in social situations to self-medicate social anxiety. Indeed, the motive to drink alcohol to lower social fears was found to be elevated in socially anxious persons. However, this social anxiety specific motive has not been directly investigated in primarily alcohol dependent individuals. We explored social anxiety, the motivation to drink alcohol in order to cope with social fears, and social anxiety as a consequence of drinking in AUD with and without comorbid SAD. Male AUD inpatients with (AUD+SAD group, N=23) and without comorbid SAD (N=37) completed a clinical interview and a questionnaire assessment. AUD+SAD patients reported higher levels of depression and an elevated motive to drink due to social anxiety but did not experience more social fears as a consequence of drinking. Previous results concerning alcohol drinking motives in order to relieve social fears could be replicated in a clinical AUD sample. Additionally, our findings suggest comorbid AUD+SAD patients to be more burdened regarding broader psychopathological symptoms. Thus, accessibility to SAD-specific screening and treatment procedures may be beneficial for primary AUD patients.