The role of maladaptive beliefs in cognitive-behavioral therapy: Evidence from social anxiety disorder

Beliefs that are negatively biased, inaccurate, and rigid are thought to play a key role in the mood and anxiety disorders. Our goal in this study was to examine whether a change in maladaptive beliefs mediated the outcome of individual cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). In a sample of 47 individuals with SAD receiving CBT, we measured maladaptive interpersonal beliefs as well as emotional and behavioral components of social anxiety, both at baseline and after treatment completion. We found that (a) maladaptive interpersonal beliefs were associated with social anxiety at baseline and treatment completion; (b) maladaptive interpersonal beliefs were significantly reduced from baseline to treatment completion; and (c) treatment-related reductions in maladaptive interpersonal beliefs fully accounted for reductions in social anxiety after CBT. These results extend the literature by providing support for cognitive models of mental disorders, broadly, and SAD, specifically.     

Sleep-Related Safety Behaviors and Dysfunctional Beliefs Mediate the Efficacy of Online CBT for Insomnia: A Randomized Controlled Trial

Several trials have demonstrated the efficacy of online cognitive behavioral therapy (CBT) for insomnia. However, few studies have examined putative mechanisms of change based on the cognitive model of insomnia. Identification of modifiable mechanisms by which the treatment works may guide efforts to further improve the efficacy of insomnia treatment. The current study therefore has two aims: (1) to replicate the finding that online CBT is effective for insomnia and (2) to test putative mechanism of change (i.e., safety behaviors and dysfunctional beliefs). Accordingly, we conducted a randomized controlled trial in which individuals with insomnia were randomized to either online CBT for insomnia (n = 36) or a waiting-list control group (n = 27). Baseline and posttest assessments included questionnaires assessing insomnia severity, safety behaviors, dysfunctional beliefs, anxiety and depression, and a sleep diary. Three- and six-month assessments were administered to the CBT group only. Results show moderate to large statistically significant effects of the online treatment compared to the waiting list on insomnia severity, sleep measures, sleep safety behaviors, and dysfunctional beliefs. Furthermore, dysfunctional beliefs and safety behaviors mediated the effects of treatment on insomnia severity and sleep efficiency. Together, these findings corroborate the efficacy of online CBT for insomnia, and suggest that these effects were produced by changing maladaptive beliefs, as well as safety behaviors. Treatment protocols for insomnia may specifically be enhanced by more focused attention on the comprehensive fading of sleep safety behaviors, for instance through behavioral experiments.     

Intolerance of Uncertainty Mediates the Relation Between Generalized Anxiety Disorder Symptoms and Anger

Previous research has shown that individuals with generalized anxiety disorder (GAD) report elevated anger compared with nonanxious individuals; however, the pathways linking GAD and anger are currently unknown. We hypothesized that negative beliefs about uncertainty, negative beliefs about worry and perfectionism dimensions mediate the relationship between GAD symptoms and anger variables. We employed multiple mediation with bootstrapping on cross-sectional data from a student sample (N = 233) to test four models assessing potential mediators of the association of GAD symptoms to inward anger expression, outward anger expression, trait anger and hostility, respectively. The belief that uncertainty has negative personal and behavioural implications uniquely mediated the association of GAD symptoms to inward anger expression (confidence interval [CI] = .0034, .1845, P_M = .5444), and the belief that uncertainty is unfair and spoils everything uniquely mediated the association of GAD symptoms to outward anger expression (CI = .0052, .1936, P_M = .4861) and hostility (CI = .0269, .2427, P_M = .3487). Neither negative beliefs about worry nor perfectionism dimensions uniquely mediated the relation of GAD symptoms to anger constructs. We conclude that intolerance of uncertainty may help to explain the positive connection between GAD symptoms and anger, and these findings give impetus to future longitudinal investigations of the role of anger in GAD.     

Anxiety sensitivity in smokers with indicators of cardiovascular disease

There is growing recognition of the importance of understanding the nature of the associations between anxiety and cardiovascular disease (CVD), although limited research has examined mechanisms that may explain the anxiety-CVD link. Anxiety sensitivity (fear of anxiety-relevant somatic sensations) is a cognitive-affective risk factor implicated in the development of anxiety psychopathology and various behavioral risk factors for CVD, although has not been examined among individuals with CVD. Adult daily smokers (n = 619; 50.9% female; M_age = 44.0, SD = 13.67) completed an online survey that included the Anxiety Sensitivity Index-3 (ASI-3) and the Patient Health Questionnaire (PHQ). The presence of CVD was assessed via the presence of ≥1 of the following: heart attack, heart murmur, positive stress test, heart valve abnormality, angina, and heart failure. Smokers with CVD indicators (n = 66, 10.7%) had significantly higher scores on the ASI-3 (M = 33.5, SD = 22.15), relative to smokers without CVD (M = 22.0, SD = 17.92; Cohen’s d = .57). Those with CVD were significantly more likely to have moderate or high anxiety sensitivity (66.7%) relative to those without CVD (49.4%). Physical and social concerns about the meaning of somatic sensations were common among smokers with CVD.     

The interaction of distress tolerance and intolerance of uncertainty in the prediction of symptom reduction across CBT for social anxiety disorder

Distress tolerance (DT) and intolerance of uncertainty (IU) have been identified as transdiagnostic processes that predict symptom severity across a range of distinct anxiety disorders. However, the joint effect of these two variables on therapeutic outcome has not yet been examined. It is possible that DT and IU may both impact on treatment response to cognitive-behavioural therapy (CBT) in clients with anxiety, as clients with weak DT and strong IU may be less likely to engage in exposure and cognitive restructuring tasks across treatment due to their associated distress. The purpose of this study was to examine the interaction of DT and IU as predictors of post-treatment symptom severity and treatment response to group CBT in participants with primary DSM-IV-TR diagnosed social anxiety disorder (SAD). Participants (N = 95) with SAD completed 12 weeks of manualized group CBT. Results of multilevel longitudinal analysis demonstrated an interaction effect, such that lower DT and higher IU predicted higher SAD symptom severity across the course of therapy. The findings are discussed in terms of clinical implications for the disorder-specific and transdiagnostic treatment of anxiety disorders.     

The Role of Implicit Beliefs and Achievement Goals as Protective Factors in Youth Sport

This study explored whether implicit beliefs and 2 × 2 achievement goals were related to enjoyment in youth sport over 1 year and whether perceived changes in the coach–athlete relationship moderated these relationships. Indirect and conditional indirect effect analyses were conducted in a sample of 247 regular sport participants (M_age = 13.03 years). After adjusting for enjoyment at Time 1, incremental beliefs were indirectly related to Time 2 enjoyment via mastery-approach goals. However, this effect was evident only when the coach–athlete relationship was perceived to have deteriorated. Results highlight the protective value of adaptive implicit beliefs and achievement goals in youth sport.     

Examining the Panic Attack Specifier in Social Anxiety Disorder

Panic attacks (PAs) are characterized by overwhelming surges of fear and discomfort and are one of the most frequently occurring symptoms in psychiatric populations. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (i.e. DSM-5) allows for a panic attack (PA) specifier for all disorders, including social anxiety disorder (SAD). However, there is little research examining differences between individuals diagnosed with SAD with the PA specifier versus individuals diagnosed with SAD without the PA specifier. The current study examined social anxiety, mood, anxiety, and anxiety sensitivity social concerns, a risk factor for social anxiety in SAD-diagnosed individuals without (N = 52) and with (N = 14) the PA specifier. The groups differed only in somatic symptoms of anxiety. Result of the current study provides preliminary evidence that the presence of the PA specifier in social anxiety does not result in elevated levels of comorbidity or a more severe presentation of social anxiety.     

Work-anxiety-coping intervention improves work-coping perception while a recreational intervention leads to deterioration: Results from a randomized controlled trial

Work-anxieties are costly and need early intervention. The perception of being able to cope with work is a basic requirement for work ability. This randomized controlled trial investigates whether a cognitive behavioural, work-anxiety-coping group (WAG) intervention leads to better work-coping perception than an unspecific recreational group (RG). Heterogeneous people in medical rehabilitation, who were due to return to work, were interviewed concerning their work-anxieties, and either randomly assigned to a WAG (n = 85) or a RG (n = 95). The participants (with an average of 50 years old [range 23–64]; 51% women; 70% workers or employees, 25% academics, 5% unskilled) followed the group intervention for four or six sessions. The perceived work-coping was assessed by self-rating (Inventory for Job-Coping and Return Intention JoCoRi) after each group session. Although participants had a slight temporary decrease in work-coping after group session two (from M₁ = 2.47 to M₂ = 2.28, d_Cohen = ?.22), the WAG led to the improvement of perceived work-coping over the intervention course (from M₁ = 2.47 to M₆ = 2.65, d_Cohen = .18). In contrast, participants from the RG reported lower work-coping after six group sessions (from M₁ = 2.26 to M₆ = 2.02, d_Cohen = ?.18). It is considered that people with work-anxieties need training in work-coping. By focusing on recreation only, this may lead to deterioration of work-coping. Indeed, intervention designers should be aware of temporary deterioration (side effects) when confronting participants with work-coping.     

Physical self-perceptions and self-esteem in adolescents participating in organized sports and religious groups

Drawing on the exercise and self-esteem model (EXSEM), the current study examined associations between sport activities and aspects of the self-system among adolescent members of sport groups. Youths attending religious groups were included in the study to allow for a test of generalization. Participants were 595 adolescents (sport groups: n = 355, M_age = 15.09 years, SD = 1.49, 54.6% female; religious groups: n = 240, M_age = 15.67 years, SD = 1.44, 53.8% female) who completed a series of paper and pencil measures detailing their involvement in sport activities (sport group only), their self-efficacy beliefs in the physical domain, perceived sport competence and attractiveness, as well as global self-esteem. A structural model was tested for sport youth, specifying an effect of sport activities on self-efficacy that, in turn, was expected to predict subjective sport competence and attractiveness. Finally, the model postulated effects of competence and attractiveness on self-esteem. The model test revealed a good fit. Multi-group models considering type of leisure group and sex pointed to parallel patterns in the associations of self-efficacy, competence, attractiveness, and self-esteem in the subgroups.     

Evaluating the role of anxiety sensitivity in barriers to cessation and reasons for quitting among smokers with asthma

The aim of the present study was to examine the unique predictive ability of anxiety sensitivity (AS) in terms of perceived barriers to cessation and smoking cessation motives among daily smokers with asthma (n = 125, 54% male, M_age = 37.7 years, SD = 12.1). As hypothesized, after controlling for the effects of race, asthma control, negative affect, and smoking rate, AS significantly predicted greater barriers to cessation, and reasons for quitting related to health concerns and self-control. Contrary to hypotheses, AS did not significantly predict external reasons for quitting. These findings suggest that smokers with asthma who are fearful of physiological arousal may be a particularly ‘at-risk’ population for smoking cessation difficulties due, in part, to greater perceived barriers to cessation. Interventions focused on enhancing intrinsic motivation for quitting and reducing AS may be most effective for this population.     

The Diagnostic Utility of Separation Anxiety Disorder Symptoms: An Item Response Theory Analysis

At present, it is not clear whether the current definition of separation anxiety disorder (SAD) is the optimal classification of developmentally inappropriate, severe, and interfering separation anxiety in youth. Much remains to be learned about the relative contributions of individual SAD symptoms for informing diagnosis. Two-parameter logistic Item Response Theory analyses were conducted on the eight core SAD symptoms in an outpatient anxiety sample of treatment-seeking children (N?=?359, 59.3 % female, M _Age?=?11.2) and their parents to determine the diagnostic utility of each of these symptoms. Analyses considered values of item threshold, which characterize the SAD severity level at which each symptom has a 50 % chance of being endorsed, and item discrimination, which characterize how well each symptom distinguishes individuals with higher and lower levels of SAD. Distress related to separation and fear of being alone without major attachment figures showed the strongest discrimination properties and the lowest thresholds for being endorsed. In contrast, worry about harm befalling attachment figures showed the poorest discrimination properties, and nightmares about separation showed the highest threshold for being endorsed. Distress related to separation demonstrated crossing differential item functioning associated with age—at lower separation anxiety levels excessive fear at separation was more likely to be endorsed for children ≥9 years, whereas at higher levels this symptom was more likely to be endorsed by children <9 years. Implications are discussed for optimizing the taxonomy of SAD in youth.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

The Developing Theory of Mental State Control: Changes in Beliefs about the Controllability of Emotional Experience from Elementary School through Adulthood

ABSTRACT

In everyday life, we use folk theories about the mind and behavior to understand ourselves and others. An important part of our folk theory of mind is our intuitions about the role of the self in mental functioning—namely, whether the self is able to control each mental operation. The current study explored beliefs about the nature of control over emotional aspects of mental experience from middle childhood through adulthood. Elementary school children (n = 46), middle schoolers (n = 46), 18-year-olds (n = 46), and adults (n = 104) were presented with vignettes depicting characters experiencing negative emotions. Participants evaluated the intentionality, changeability, and chronicity of the characters’ responses. Results showed that by elementary school, children share adults’ view that emotions are largely outside of volitional control. However, beliefs about the changeability and chronicity of emotions mature beyond middle childhood. Between elementary school and adulthood, participants decreased their endorsement of the ability to change one’s current negative emotions and increased their beliefs in the chronic, enduring nature of these responses. With age, these changeability and chronicity beliefs also came to differ depending on the emotional response (i.e., feeling grumpy, being nervous, acting mean). Together, these findings suggest that intuitions about the controllability of emotional experience become more differentiated and less optimistic across development.     

Comparing Cognitive Behavioral Therapy and Systemic Therapy for Social Anxiety Disorder: Randomized Controlled Pilot Trial (SOPHO-CBT/ST)

This randomized controlled trial (RCT) aimed to pilot the newly developed manualized and monitored systemic therapy (ST) for social anxiety disorder (SAD), as compared to manualized and monitored cognitive behavioral therapy (CBT). We conducted a prospective multicenter, assessor-blind pilot RCT on 38 outpatients (ICD F40.1; Structured Clinical Interview for DSM (SCID); Liebowitz Social Anxiety Scale, LSAS-SR >30). The primary outcome was level of social anxiety (LSAS-SR) at the end of treatment. A total of 252 persons were screened, and 38 patients were randomized and started therapy (CBT: 20 patients; ST: 18 patients; age: M = 36 years, SD = 14). Within-group, simple-effect intent-to-treat analyses (ITT) showed significant reduction in LSAS-SR (CBT:d = 1.04; ST:d = 1.67), while ITT mixed-design ANOVA demonstrated the advantage of ST (d = 0.81). Per-protocol analyses supported these results. Remission based on reliable change indices also demonstrated significant difference (LSAS-SR: 15% in CBT; 39% in ST;h: 0.550), supported by blind diagnosticians’ ratings of those who completed therapy (SCID; 45% in CBT, 78% in ST,p = .083). No adverse events were reported. CBT and ST both reduced social anxiety, supporting patient improvement with the newly developed ST for SAD; this has yet to be verified in a subsequent confirmatory RCT.     

The latent structure of social anxiety disorder and the performance only specifier: a taxometric analysis

Social anxiety disorder (SAD) is often treated as a discrete diagnostic entity that represents a naturally occurring class, though empirical evidence largely supports a dimensional conceptualization of social fears. Further, the inclusion of a “performance only” specifier in the DSM-5 implies that individuals who experience intense social anxiety exclusively in performance situations are distinct from those with broader social fears. The purpose of the present research was to examine the latent structure of SAD and the DSM-5 “performance only” specifier in a large nonclinical sample (n = 2019). Three taxometric procedures (MAXCOV, MAMBAC, and L-Mode) were applied to indicators derived from two commonly used measures of social anxiety. Results yielded convergent evidence indicating that social anxiety exhibits a dimensional latent structure. Further, social performance anxiety demonstrates continuous relationships with milder social fears, suggesting that the “performance only” specifier may not represent a discrete entity. The implications of these findings for the assessment, diagnosis, classification, and treatment of social anxiety are discussed.     

Acculturative stress and experiential avoidance: relations to depression,suicide, and anxiety symptoms among minority college students

Although college campuses represent strategic locations to address mental health disparity among minorities in the US, there has been strikingly little empirical work on risk processes for anxiety/depression among this population. The present investigation examined the interactive effects of acculturative stress and experiential avoidance in relation to anxiety and depressive symptoms among minority college students (n = 1,095; 78.1% female; M_age = 21.92, SD = 4.23; 15.1% African-American (non-Hispanic), 45.3% Hispanic, 32.5% Asian, and 7.1% other races/ethnicities. Results provided empirical evidence of an interaction between acculturative stress and experiential avoidance for suicidal, social anxiety, and anxious arousal symptoms among the studied sample. Inspection of the significant interactions revealed that acculturative stress was related to greater levels of suicidal symptoms, social anxiety, and anxious arousal among minority college students with higher, but not lower, levels of experiential avoidance. However, in contrast to prediction, there was no significant interaction for depressive symptoms. Together, these data provide novel empirical evidence for the clinically-relevant interplay between acculturative stress and experiential avoidance in regard to a relatively wide array of negative emotional states among minority college students.     

Specificity of peer difficulties to social anxiety in early adolescence: categorical and dimensional analyses with clinical and community samples

Background and Objectives: We investigated the specificity of social difficulties to social anxiety by testing associations of social anxiety and other anxiety presentations with peer acceptance and victimization in community and treatment-seeking samples of adolescents aged 12–14 years.

Design: Cross-sectional, quantitative survey.

Methods: Adolescents from the community (n?=?116) and a clinical setting (n?=?154) completed ratings of anxiety symptoms, perceived social acceptance, and peer victimization. Their parents also completed ratings of the adolescents’ anxiety and social acceptance.

Results: Social acceptance was lowest among adolescents with social anxiety disorder (SAD) and lower among adolescents with other anxiety disorders than in the community sample. Anxiety symptoms were negatively correlated with social acceptance, but these associations were not unique to social anxiety symptoms. Girls in the community sample reported more overt victimization than girls with SAD and with other anxiety diagnoses. Relational victimization was associated with social and nonsocial anxiety symptoms only in the community sample.

Conclusions: Our findings supplement recent laboratory-based observational studies on social functioning among adolescents with SAD and other anxiety disorders. Although social anxiety may be associated with unique social skill deficits and impairment, concerns about peer relations should also be considered among adolescents with other anxiety symptoms.     

Age and pre quit-day attrition during smoking cessation treatment

ABSTRACT

The present study aimed to replicate the finding that younger age predicts higher pre quit-day attrition. Our second aim was to explain this relation by examining empirically and theoretically informed age-related risk factors for low smoking cessation treatment engagement. 136 participants (M _age = 44.2 years, SD = 11.3 years; age = 22–64 years) were randomized to 15-weeks of either 1) an exercise intervention (n = 72) or 2) a wellness education control condition (n = 64). First, a logistic regression analysis was employed to test whether younger adults were more likely than older adults to drop prior to quit date. Next, we assessed whether smoking related health concerns, social expectancies, and/or perceived severity of craving affected the strength of the relation between age and attrition, by adding these three variables to the logistic regression along with age. The logistic regression model indicated that younger age and treatment condition were significantly related to the odds of dropping from treatment prior to the scheduled quit date. Further, health concerns, social expectancies, and/or perceived severity of cravings did not account for the effect of age on pre quit-day attrition. These findings highlight the importance of identifying empirically and theoretically informed variables associated with the pre quit-day attrition problem of young smokers.     

What can boys and girls do? Preschoolers’ perspectives regarding gender roles across domains of behavior

Previous research has examined at what age and in what contexts males and females develop gender-congruent stereotypes. Research indicates that social experience may provide a great influence on the presence of such stereotypes, but this is likely influenced by the development of gender schemas. The current study interviewed 99 children (3–6.5 years) in a sub-rural Midwestern university community. Females (N = 51, M _age = 4.6, SD = 0.73) and males (N = 48, M _age = 4.6, SD = 0.82) were individually asked who—boys, girls, or both—can do particular (1) occupations, (2) activities, (3) aggressive behaviors, and (4) prosocial behaviors. Generally, males tended to express holding no stereotypic beliefs, indicating gender-congruent expectations for only 2 items in one of the domains; however, females expressed multiple stereotypic beliefs for each of the four contexts. Social and cognitive explanations for these phenomena are discussed. The current study is an important addition to the existing literature in that preschool teachers and parents alike might be able to assist children to better develop activities and behavioral habits such that gender-related stereotypes fail to develop.     

Increased skills usage statistically mediates symptom reduction in self-guided internet-delivered cognitive–behavioural therapy for depression and anxiety: a randomised controlled trial

Cognitive–behavioural therapy (CBT) is an effective treatment for clinical and subclinical symptoms of depression and general anxiety, and increases life satisfaction. Patients’ usage of CBT skills is a core aspect of treatment but there is insufficient empirical evidence suggesting that skills usage behaviours are a mechanism of clinical change. This study investigated if an internet-delivered CBT (iCBT) intervention increased the frequency of CBT skills usage behaviours and if this statistically mediated reductions in symptoms and increased life satisfaction. A two-group randomised controlled trial was conducted comparing internet-delivered CBT (n = 65) with a waitlist control group (n = 75). Participants were individuals experiencing clinically significant symptoms of depression or general anxiety. Mixed-linear models analyses revealed that the treatment group reported a significantly higher frequency of skills usage, lower symptoms, and higher life satisfaction by the end of treatment compared with the control group. Results from bootstrapping mediation analyses revealed that the increased skills usage behaviours statistically mediated symptom reductions and increased life satisfaction. Although skills usage and symptom outcomes were assessed concurrently, these findings support the notion that iCBT increases the frequency of skills usage behaviours and suggest that this may be an important mechanism of change.