Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.     

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

ABSTRACT

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.     

Dissociating effects of subclinical anxiety and depression on cognitive control

Even at subclinical levels, anxiety and depression are associated with impaired cognitive control. It is unclear, though, to what extent these deficits reflect a common underlying dysfunction. Using a non-affective hybrid masked prime-Simon task, we obtained several measures of within- and between- trial inhibitory behavioral control in 80 young, healthy volunteers, together with measures of their anxiety and depression levels. Neither depression nor anxiety affected low-level within-trial control, or any of the between-trial control measures. However, increased levels of depression, but not of anxiety, were associated with impaired high-level within-trial control (increased Simon effect). Results indicate that depression, but not anxiety, impairs voluntary online response-control mechanisms independent of affective content.     

Text anxiety on cognitive ability test can result in differential predictive validity of academic performance

This paper investigates whether test anxiety leads to differential predictive validity in academic performance. Our results show that the predictive validity of a cognitive ability test, using final exam performance as a criterion, decreased a small amount as Worry (the cognitive aspect of anxiety) increased but was unaffected by Emotionality (the physiological aspect of anxiety). These results suggest that cognitive ability tests may be more useful as predictors of performance for low anxiety test-takers. These findings are discussed in the context of the interference and deficit perspectives of test anxiety.     

A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder

Objective: The aim of this study was to compare the effectiveness of cognitive behavior therapy with the combination of cognitive behavior therapy and interpersonal therapy on decreasing the excessiveness of pathological worry and increasing happiness of the individuals with generalized anxiety disorder.

Method: The sample consisted of 36 female undergraduate students who referred themselves to the Isfahan University Counseling Center and met the criteria for GAD. They were randomly assigned into three groups; namely, two experimental groups and one control group. Before receiving the interventions all of the groups completed Penn State Worry Questionnaire and Oxford Happiness Inventory. One of the experimental groups underwent cognitive behavior therapy and the other one received the integration of cognitive behavior therapy and interpersonal therapy. The control group received no intervention.

Result: The statistical analyses indicated that the differences between the CBT and CBT+ IPT groups on excessive worry and happiness in the post tests were not significant. But significant mean differences were observed in the follow-ups regarding pathological worry and happiness between two groups.

Conclusion: It can be concluded that the integration of cognitive behavior therapy and interpersonal therapy can be applied as an effective intervention for decreasing the rate of GADs’ relapses after cognitive behavior therapy.     

The impact of cognitive behavioral therapy on post event processing among those with social anxiety disorder

Individuals with social anxiety are prone to engage in post event processing (PEP), a post mortem review of a social interaction that focuses on negative elements. The extent that PEP is impacted by cognitive behavioral therapy (CBT) and the relation between PEP and change during treatment has yet to be evaluated in a controlled study. The current study used multilevel modeling to determine if PEP decreased as a result of treatment and if PEP limits treatment response for two types of cognitive behavioral treatments, a group-based cognitive behavioral intervention and individually based virtual reality exposure. These hypotheses were evaluated using 91 participants diagnosed with social anxiety disorder. The findings suggested that PEP decreased as a result of treatment, and that social anxiety symptoms for individuals reporting greater levels of PEP improved at a slower rate than those with lower levels of PEP. Further research is needed to understand why PEP attenuates response to treatment.     

Effects of impulsivity, reinforcement sensitivity, and cognitive style on Pathological Gambling symptoms among frequent slot machine players

Pathological Gambling (PG) is the inability to resist recurrent urges to gamble excessively despite harmful consequences to the gambler or others. A cognitive-behavioral Pathways Model of PG (Blaszczynski & Nower, 2002) suggests individual differences in rash impulsivity and reward sensitivity, together with a cognitive style that promotes poor decision making, as risk factors. These individual differences were examined in a community sample of experienced slot machine players (N = 100), who were classified into Low, Moderate, and Problem gambling groups according to the Problem Gambling Severity Index (Ferris & Wynne, 2001). There were significant group differences on rash impulsivity as measured by the Eysenck Impulsivity scale, and on reward sensitivity as measured by the BIS/BAS Drive scale. For cognitive style, there were differences on Actively Openminded Thinking (AOT), but not the Rational Experiential Inventory. Hierarchical regression analyses found that impulsivity and AOT predicted severity of PG, but that AOT mediated the effect of BAS Drive. A thinking style that promotes erroneous cognition may correlate with PG, but individual differences in rash impulsivity and reward-seeking play a more critical role in the etiology of PG. The individual characteristics of Pathological Gamblers are similar to those of people with Substance Use Disorders.     

Negative life events and cognitive vulnerability to depression: Informant effects and sex differences in the prediction of depressive symptoms in middle childhood

While diathesis-stress models of cognitive vulnerability to depression (CVD) in childhood have been tested, few studies have included both parent- and child-reported negative life events, despite the fact that they provide unique information on events that may be relevant to depression risk in boys and girls. It was hypothesized that different types of stress may show moderation of CVD for boys and girls; specifically, we predicted that parent-reported stressors may moderate boys’ CVD, and that self-reported stress may play a more critical moderating role for girls. A community sample of 182 eight-year-olds completed measures of CVD at baseline, and child- and parent-reported measures of stress were collected at follow-up, one year later. Support for diathesis-stress models of CVD varied depending on child sex and the source of information on stress. Results highlight the importance of collecting multiple measures of stress in testing diathesis-stress models of CVD in middle childhood.     

Evaluating the cognitive avoidance model of generalised anxiety disorder: Impact of worry on threat appraisal, perceived control and anxious arousal

Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry. According to the cognitive avoidance theory of GAD, worry may function as an affective dampening strategy motivated by intolerance of negative emotional states. By facilitating avoidance of more distressing cognitions and associated affect, worry is said to preclude modification of the fear representation in memory, maintaining threat associations and perpetuating further anxiety and worry. The present study evaluated these assumptions in a treatment-seeking GAD sample. Sixty-one participants were randomly allocated to conditions in which they were instructed to worry, imaginally process or relax in response to an anxiety trigger. Results supported the detrimental impact of worry, showing maintained threat expectancies and decreased control perceptions compared to other modes of processing. However, skin conductance level increased as a function of worry and there was no suggestion that worry suppressed affective responding. These findings highlight the need for clarification of the mechanisms involved in the maintenance of threat associations and worry in GAD.     

Negative self-focused cognitions mediate the effect of trait social anxiety on state anxiety

The cognitive model of social anxiety predicts that negative self-focused cognitions increase anxiety when anticipating social threat. To test this prediction, 36 individuals were asked to anticipate and perform a public-speaking task. During anticipation, negative self-focused cognitions or relaxation were experimentally induced while self-reported anxiety, autonomic arousal (heart rate, heart rate variability, skin conductance level), and acoustic eye-blink startle response were assessed. As predicted, negative self-focused cognitions mediated the effects of trait social anxiety on self-reported anxiety and heart rate variability during negative anticipation. Furthermore, trait social anxiety predicted increased startle amplitudes. These findings support a central assumption of the cognitive model of social anxiety.     

Look before you leap: the role of negative urgency in appraisals of ambiguous and unambiguous scenarios in individuals high in generalized anxiety disorder symptoms

Negative interpretation bias, the propensity to make threatening interpretations of ambiguous information, is associated with symptoms of generalized anxiety disorder (GAD). Apart from its relationship with intolerance of uncertainty (IU), little is known about what explains the presence of this cognitive bias in GAD. One factor may be negative urgency (NU), the tendency to take rash action when distressed, which is related to GAD symptoms and to cognitive biases in nonclinical populations. The aim of the present study was to examine the relationship between NU and interpretation bias in individuals high in GAD symptoms (N = 111). IU, trait anxiety, and other forms of impulsivity were examined concurrently as competing correlates of interpretation bias. Greater NU and IU were found to be unique correlates of greater threatening interpretations of ambiguous scenarios. Greater NU was also a unique correlate of greater threatening interpretations of negative and positive scenarios. No other forms of impulsivity were uniquely related to interpretation bias. The findings suggest that greater NU may have a role in the tendency for individuals high in GAD symptoms to make threatening interpretations in response to ambiguous scenarios, overtly threatening situations, and situations without indication of threat or danger. Theoretical implications of these findings are discussed.     

Cognitive inhibition and interference in dissociative identity disorder: the effects of anxiety on specific executive functions

Using an experimentally based, computer-presented task, this study assessed cognitive inhibition and interference in individuals from the dissociative identity disorder (DID; n=12), generalized anxiety disorder (GAD; n=12) and non-clinical (n=12) populations. Participants were assessed in a neutral and emotionally negative (anxiety provoking) context, manipulated by experimental instructions and word stimuli. The DID sample displayed effective cognitive inhibition in the neutral but not the anxious context. The GAD sample displayed the opposite findings. However, the interaction between group and context failed to reach significance. There was no indication of an attentional bias to non-schema specific negative words in any sample. Results are discussed in terms of the potential benefit of weakened cognitive inhibition during anxious arousal in dissociative individuals.     

An investigation of the interaction between cognitive style and context reinstatement on the memory performance of eyewitnesses

The power of context reinstatement to improve recall is well established, but the degree of effect obtained varies widely between studies. Exploring possible causes for this variation, this paper examines the relationship between cognitive style and the efficacy of context reinstatement in improving free and cued recall in an eyewitness paradigm. Experiment 1, using a live staged event and a 1 week delay, indicated a significant improvement in free recall with the reinstatement of context and, as expected, no such improvement in cued recall. However, analysis of the data according to field dependency, as measured by Witkin, Oltman, Raskin, and Karp's [A manual for the Embedded Figures Test (1971) Palo Alto, CA: Consulting Psychologists Press] Group Embedded Figures Test (GEFT) revealed that, in free recall, field dependent witnesses' scores improved significantly with context reinstatement, whilst the scores of field independent witnesses did not. In cued recall, however, the field independent witnesses scored significantly higher overall than field dependent witnesses. Experiment 2 sought replication of these findings again utilised the GEFT and the Riding [Cognitive Styles analysis (1991) Birmingham: Learning and Training Technology] Cognitive Styles Analysis (CSA). Analysis of the data according to the Wholist-Analytic (W-A) dimension of the CSA, indicated no interaction with either context reinstatement or memorial performance. However the GEFT analysis produced similar results to that obtained in Experiment 1. The meaning of the interaction between the GEFT and both free and cued recall, and the failure of the CSA to similarly interact are discussed, together with the implication of these findings for establishing the value of reinstating context for individual eyewitnesses.     

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.     

Moderating effects of the valence of social interaction on the dysfunctional consequences of perseverative cognition: an ecological study in major depression and social anxiety disorder

Background and Objectives: Major depression disorder (MDD) and social anxiety disorder (SAD) are characterized by the use of perseverative cognition (PC) as a dysfunctional coping strategy. We sought to investigate the dysfunctional physiological and psychological consequences of PC and how the valence of social interactions moderates such consequences in these psychopathological conditions.

Design/Methods: The study combined 24-hour heart rate variability (HRV) and ecological momentary assessments in 48 individuals with MDD, SAD, and sex-matched controls.

Results: In all participants, PC was associated with mood worsening and reduced ability of the parasympathetic nervous system, mainly the vagus, to inhibit sympathetic arousal (i.e., reduced HRV). Individuals with SAD had the highest frequency of daily PC, while those with MDD reported that PC interfered more with their ongoing activities. In SAD, daily PC was associated with significantly lower HRV after negative social interactions. Individuals with MDD reported higher levels of sadness during PC irrespective of the valence of the preceding social interaction but higher levels of anxiety and efforts to inhibit PC following positive interactions.

Conclusions: Results highlight the need to account for important moderators like the valence of social interaction when looking at the physiological consequences of maladaptive emotion regulation strategies.     

Interactive effects of generalized and situational expectancies on the arousal of cognitive and emotional components of social anxiety

This study examined the arousal of social anxiety in an interview setting as a function of anticipated self-disclosure. Of 88 college students who completed the Social Avoidance and Distress (SAD) scale and other measures of social anxiety, self-disclosure, need to affiliate, and interpersonal trust, 24 volunteered for the interview. During the interview, both components of anxiety (worry and emotionality) were affected by expectancy conditions, and emotionality was higher for high- than for low-SAD subjects. The prediction of an interaction between SAD level and expectancy condition on worry was confirmed: only high-SAD subjects exposed to the negative-expectancy condition experienced significant elevations in worry. Though social anxiety and self-disclosure measures correlated negatively, anxiety did not affect self-disclosure during the interview.