Cognitive-Behavioral Therapy for Insomnia Co-Morbid with Hearing Impairment: A Randomized Controlled Trial

The purpose of the current study was to examine the effects of cognitive behavior therapy (CBT-I) for insomnia on patients with insomnia co-morbid with hearing impairment. A randomized controlled design was used with a 3-month follow-up. Thirty-two patients with insomnia co-morbid with hearing impairment were randomized to either CBT-I or a waitlist condition (WLC). The primary outcome was insomnia severity. Secondary outcomes were sleep diary parameters, dysfunction, anxiety, and depression. Compared to WLC, CBT-I resulted in lower insomnia severity at post-treatment and at follow-up (d = 1.18–1.56). Relative to WLC, CBT-I also led, at both assessment points, to reduced total wake time (d = 1.39) and increased sleep restoration (d = 1.03–1.07) and sleep quality (d = 0.91–1.16). Both groups increased their total sleep time, but no significant group difference emerged. Compared to WLC, CBT-I resulted in higher function (d = 0.81–0.96) and lower anxiety (d = 1.29–1.30) at both assessment points. Neither CBT-I nor WLC led to improvement on depression. Based on the Insomnia Severity Index, more CBT-I (53–77%) than WLC participants (0–7%) were treatment responders. Also, more CBT-I (24%) than WLC participants (0%) remitted. In patients with insomnia co-morbid with hearing impairment, CBT-I was effective in decreasing insomnia severity, subjective sleep parameters, dysfunction, and anxiety. These findings are in line with previous results on the effects of CBT-I in other medical conditions.     

Worry and Pathological Worry in Patients with Psoriasis: Cross Sectional and Longitudinal Analyses of the Penn State Worry Questionnaire (PSWQ) in Four Samples of Patients

The purpose of the present study was to examine the psychometric properties of the Penn state Worry Questionnaire (PSWQ) in patients with psoriasis. A series of cross-sectional and longitudinal studies were undertaken to assess the reliability, stability and validity of the measure. Patients with psoriasis from four samples (consecutive attendees, anxious patients, depressed patients, and 6-month follow-up of consecutive attendees) completed the PSWQ and measures assessing related constructs of anxiety and depression (HADS) and coping (COPE). The clinical severity of patients psoriasis was also assessed by dermatologists using the Psoriasis Area and Severity Index (PASI). Exploratory factor analysis was undertaken and receiver operator characteristic (ROC) analyses were used to examine the clinical utility of the PSWQ cut-off score for normal and pathological worry. Exploratory factor analysis suggested that the PSWQ is essentially unidimensional in patients with psoriasis. Intraclass correlation demonstrated that, over a 6-month period, the reproducibility of the PSWQ total scale was good in patients with anxiety and moderate in patients with depression. ROC analysis suggested that the optimum cutoff differentiating pathological worry was > 60, which is commensurate with findings in adult mental health more generally. The PSWQ cutoff for pathological worry showed a lower specificity for depression than anxiety. The PSWQ is an appropriate measure of pathological worry in patients with psoriasis. The cutoff on the scale for pathological worry demonstrates appropriate conceptual overlap with subordinate distress categories of anxiety and depression.     

A pilot randomized trial of metacognitive therapy vs applied relaxation in the treatment of adults with generalized anxiety disorder

Metacognitive Therapy (MCT) and Applied Relaxation (AR) were compared in a pilot treatment trial of generalized anxiety disorder (GAD). Twenty outpatients meeting criteria for DSM-IV-TR GAD were assessed before treatment, after treatment and at 6 m and 12 m follow-up. The patients were randomized and treated individually for 8-12 weekly sessions. There was no drop-out from MCT and 10% at 6 m follow-up from AR. At post-treatment and at both follow-up points MCT was superior to AR. Standardized recovery rates for MCT at post-treatment were 80% on measures of worry and trait-anxiety compared with 10% following AR. At 6 m follow-up recovery rates for MCT were 70% on both measures compared with 10% and 20% for AR. At 12 m follow-up recovery rates for MCT were 80% (worry) and 60% (trait-anxiety) compared with 10% and 20% following AR. The recovery rates for MCT are similar to those obtained in an earlier uncontrolled trial (Wells & King, 2006). The effect sizes and standardized recovery rates for MCT suggest that it is a highly effective treatment.     

自我决定动机对考试焦虑的影响：拖延行为的不同中介作用

我国约有一半的大学生经受着考试焦虑的困扰。结合国内外已有研究成果,本研究以624名大学生为被试,考察了自我决定动机的3种类型和拖延行为的2种类型对考试焦虑的忧虑性、情绪性的影响。结果发现：(1) 无动机对考试焦虑的2种类型都有正向的直接影响。(2) 唤起性拖延仅对情绪性有正向直接影响,而回避性拖延仅对忧虑性有正向直接影响。(3) 唤起性拖延在无动机影响考试焦虑的情绪性中起了重要的部分中介作用,而回避性拖延在无动机影响考试焦虑的忧虑性中起了重要的部分中介作用。     

Academic self-confidence effects on test anxiety among Nigerian university students

The study investigated academic self-confidence effects on test anxiety indicators of performance impairment and intrusive worry. Respondents were 206 Nigerian undergraduate students (mean age = 20.29, SD = 2. 22; female = 43.2%). The students took the Westside Test Anxiety Scale (Driscoll, 2004) and the Academic Self-confidence Scale (Jones, 2001). Data were analysed to predict performance impairment and intrusive worry from academic self-confidence, taking into account students’ year of study and gender. Results suggest that academic self-confidence influenced both performance impairment and intrusive worry dimensions of test anxiety. Students who were high in academic self-confidence reported lower performance impairment or intrusive worry. Also, first year students reported higher intrusive worry than those in second, third, or fourth year of study. High manifestation of academic self-confidence is an asset for coping with test anxiety.     

Cognitive Coping vs Emotional Disclosure in the Treatment of Anxious Children: A Pilot-Study

The present pilot-study was a first attempt to examine the effectiveness of the cognitive component of cognitive behaviour therapy for children with anxiety problems. A total of 24 highly anxious children were assigned to 1 of 2 intervention conditions: a Cognitive Coping intervention, which focussed primarily on the cognitive component of cognitive behaviour therapy, or an Emotional Disclosure intervention in which children were invited to write about their fears and anxious experiences. Children completed self-report questionnaires of anxiety disorders symptoms and worry at 3 points in time: (i) 6 weeks before treatment (i.e. baseline), (ii) at pre-treatment, and (iii) at post-treatment. The results showed, firstly, that levels of anxiety disorder symptoms and worry remained relatively stable over a 6-week waiting period and then decreased substantially after the interventions. This suggests that the children did not suffer from momentary anxiety and worry complaints and that treatments generally were effective in reducing these symptoms. Secondly, although within-group comparisons suggested that treatment effects were somewhat larger in the Cognitive Coping condition than in the Emotional Disclosure condition (effects sizes for anxiety disorders symptoms and worry were, respectively, 1.03 and 0.87 for Cognitive Coping vs 0.54 and 0.39 for Emotional Disclosure), statistical tests could not substantiate this impression, probably due to a lack of power as a result of the small numbers of children in both intervention conditions.     

Positive beliefs about worry: A psychometric evaluation of the Why Worry-II

Positive beliefs about worry are theorized to maintain excessive and uncontrollable worry, the hallmark of generalized anxiety disorder (GAD; American Psychiatric Association, 2013). The Why Worry-II (WW-II) is a 25-item revised questionnaire designed to measure five positive beliefs about worry. These five beliefs are that worry: (1) facilitates problem solving; (2) enhances motivation; (3) protects against negative emotions; (4) prevents negative outcomes; and (5) reflects a positive personality trait. The main goal of this study was to assess the WW-II’s psychometric properties, including its factor structure. Undergraduate participants (N = 309) completed the WW-II, and measures of worry, depression, anxiety, and positive and negative beliefs about worry. Overall, the results suggest that the five-factor model is a good fit to the data. The WW-II demonstrated excellent internal consistency, good test–retest reliability at six weeks, and evidence of convergent and divergent validity. The WW-II also uniquely predicted worry severity. Overall, our findings suggest that the WW-II has a five-factor structure congruent with theoretical predictions, sound psychometric properties, and a unique relationship to excessive worry. The theoretical and clinical implications of these findings are discussed.     

Cognitive behavior therapy vs exposure in vivo in the treatment of panic disorder with agoraphobia (corrected from agrophobia)

Seventy-three psychiatric outpatients with DSM-IV diagnosis of panic disorder with agoraphobia were assessed with a battery of independent assessor, self-observation, self-report and behavioral measures before and after therapy, and at a 1-yr follow-up. They were randomly assigned to Exposure in vivo (E; n = 25), Cognitive Behavior Therapy (CBT; n = 26), or a Wait-list control (WLC; n = 22) and received 12-16 individual therapy sessions, once weekly. The treatments yielded significant improvements, both on panic/agoraphobia measures and on measures of general anxiety, depression, social adjustment and quality of life, which were maintained at follow-up. However, there were no significant differences between E and CBT. The three criteria of clinically significant improvement were achieved by 67% of the E-patients and 79% of the CBT-patients at post-treatment, and 74% and 76%, respectively, at follow-up. The conclusion that can be drawn is that adding cognitive therapy to exposure did not yield significantly better results than for exposure alone.     

Generalized Worry in Patients With Chronic Fatigue Syndrome Following Cognitive Behavioral Therapy: A Prospective Cohort Study in Secondary Care

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = −3.42, p < .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.     

Persecutory delusions and catastrophic worry in psychosis: developing the understanding of delusion distress and persistence

In a recent theoretical account of persecutory delusions, it is suggested that anxiety and worry are important factors in paranoid experience [Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., & Bebbington, P. E. (2002). A cognitive model of persecutory delusions. British Journal of Clinical Psychology, 41(4), 331-347]. In emotional disorders worry has been understood in terms of catastrophising. In the current study, the concept of catastrophising is applied for the first time with persecutory delusions. Thirty individuals with current persecutory delusions and 30 non-clinical controls participated in a cross-sectional study. The group with persecutory delusions was also followed up at 3 months to assess predictors of delusion persistence. At its most severe, 21% of individuals with persecutory delusions had clinical worry, 68% had levels of worry comparable with treatment seeking GAD patients. Further, high levels of anxiety, worry and catastrophising were associated with high levels of persecutory delusion distress and with the persistence of delusions over 3 months. If future research replicates these findings, worry reduction interventions for individuals with persecutory delusions may be warranted.     

Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders

ObjectiveTo compare a mindfulness-based intervention with cognitive behavioral therapy (CBT) for the group treatment of anxiety disorders.MethodOne hundred five veterans (83% male, mean age = 46 years, 30% minority) with one or more DSM-IV anxiety disorders began group treatment following randomization to adapted mindfulness-based stress reduction (MBSR) or CBT.ResultsBoth groups showed large and equivalent improvements on principal disorder severity thru 3-month follow up (ps < .001, d = ?4.08 for adapted MBSR; d = ?3.52 for CBT). CBT outperformed adapted MBSR on anxious arousal outcomes at follow up (p < .01, d = .49) whereas adapted MBSR reduced worry at a greater rate than CBT (p < .05, d = .64) and resulted in greater reduction of comorbid emotional disorders (p < .05, d = .49). The adapted MBSR group evidenced greater mood disorders and worry at Pre, however. Groups showed equivalent treatment credibility, therapist adherence and competency, and reliable improvement.ConclusionsCBT and adapted MBSR were both effective at reducing principal diagnosis severity and somewhat effective at reducing self-reported anxiety symptoms within a complex sample. CBT was more effective at reducing anxious arousal, whereas adapted MBSR may be more effective at reducing worry and comorbid disorders.     

The effects of active worrying on working memory capacity

According to the attentional control theory, worry, a crucial component of anxiety, impairs task performance through its direct effect on working memory capacity (WMC) by using up the limited resources available for performance thus reducing attentional control. We tested this hypothesis in the current study by examining the causal influence of active worrying on WMC in a sample of undergraduate university students (n?=?64) assigned either to a worry condition or to a non-worry control condition. Participants performed a change detection task before and after the worry/control manipulation. Mediation analyses showed that the level of self-reported worry mediated the effects of condition on change in WMC as demonstrated by the significant indirect effect of worry and the resulting non-significant direct effect of condition on change in WMC. Similar results were obtained when using state anxiety measures as mediating factors. Results of the current study are amongst the first to demonstrate that worry impairs WMC and as such have important implications for understanding the impact of worry.     

Fear,worry, and ritualistic behaviour in childhood: developmental trends and interrelations

Previous studies of childhood fear, worry, and ritualistic behaviour have been limited by restricted age ranges, narrow ranges of anxiety phenomena, non‐comparable methodologies, and assessment of typical behaviour within a pathological context. Content and intensity of fear, worry, and ritualistic behaviour, and associations among these variables, were assessed through a semi‐structured interview individually administered to 142 children aged 7–16 years. Common themes in the content of fear, worry, and ritualistic behaviour varied predictably with age. Intensity ratings for all three phenomena decreased with age, although this decline was only significant between 7 and 10 years. Levels were higher in girls than boys. Fear and worry were positively related, and the regular performance of rituals was related to anxiety across the age range. Worry was more strongly related than fear to engagement in ritualistic behaviour. We consider implications for the understanding of anxiety and ritualistic behaviour in typical and atypical development. Copyright © 2009 John Wiley & Sons, Ltd.     

Worry spreads: Interpersonal transfer of problem-related anxiety

This paper distinguishes processes potentially contributing to interpersonal anxiety transfer, including object-directed social appraisal, empathic worry, and anxiety contagion, and reviews evidence for their operation. We argue that these anxiety-transfer processes may be exploited strategically when attempting to regulate relationship partners’ emotion. More generally, anxiety may serve as either a warning signal to other people about threat (alerting function) or an appeal for emotional support or practical help (comfort-seeking function). Tensions between these two interpersonal functions may account for mutually incongruent interpersonal responses to expressed anxiety, including mistargeted interpersonal regulation attempts. Because worry waxes and wanes over time as a function of other people's ongoing reactions, interpersonal interventions may help to alleviate some of its maladaptive consequences.     

Daytime functioning in older patients suffering from chronic insomnia: treatment outcome in a randomized controlled trial comparing CBT with Zopiclone

The paper presents data from a randomized controlled trial comparing treatment effects of cognitive behavioural therapy (CBT), hypnotic treatment (Zopiclone), and placebo in a sample of insomnia patients. Data from the same trial have already demonstrated that CBT was more efficient in improving sleep than Zopiclone. The novel outcomes that are reported here concern daytime functioning.

Forty-six older patients (age55) qualifying for a diagnosis of primary insomnia were recruited to participate. Assessments were completed at baseline, post-treatment, and at a 6-months follow-up, and measures of worry, anxiety, depression, interpersonal relationships, subjective alertness, vigilance, and quality of life were used.

The participants in both treatment conditions scored within the normal range on the outcome measures at baseline with the exception of reporting less alertness, relative to a group of good sleepers. One interaction effect indicated that subjective alertness improved more in the Zopiclone group than the CBT group from baseline to post-treatment, and another that CBT was more effective than Zopiclone in reducing trait anxiety from baseline to follow-up.

It was concluded that the treatments yielded only minor effects on the measures of daytime functioning, and that none of them was clearly superior to the other.     

Resistance and outcome expectations in cognitive‐behavioural therapy for generalised anxiety disorder

Greater client resistance has been consistently found to be negatively associated with outcome in psychotherapy. However, the pathways through which resistance impacts such outcomes are underexplored. Given that client outcome expectation (OE) has been identified as an important common factor in psychotherapy, the goals of the present study were to examine: (a) the impact of resistance on subsequent client and therapist OE (COE & TOE, respectively); and (b) whether COE and/or TOE mediate the relationship between resistance and outcome. These relationships were tested among 44 clients with severe generalised anxiety disorder treated with cognitive‐behavioural therapy in the context of a randomised controlled trial (Westra, Constantino, & Antony, 2016). Resistance was measured at a mid‐treatment session, and COE and TOE were assessed at baseline and immediately after the resistance session. Treatment outcome was measured via client‐rated worry severity at post‐treatment. As predicted, higher resistance was associated with lower subsequent COE and TOE; B = ?.73, p < .001 and B = ?.46, p < .001, respectively. In turn, lower post‐resistance COE predicted higher post‐treatment worry (B = ?.5, p < .001), indicating mediation. In contrast, TOE did not mediate the relationship between resistance and outcome (B = ?.02, p = .876). These results suggest that resistance can be demoralising to both clients and therapists. However, only lower client morale may be detrimental to therapy outcome. This study contributes to understanding outcome pathways through two common therapy processes.     

Acute exercise effects on worry,state anxiety,and feelings of energy and fatigue among young women with probable Generalized Anxiety Disorder: A pilot study

BackgroundLittle is known about the acute effects of exercise among individuals with clinical or subclinical Generalized Anxiety Disorder (GAD).PurposeThus, this study examined worry, state anxiety, and feelings of energy and fatigue responses to acute aerobic exercise and quiet rest, and explored potential moderators of response among young adult women with worry scores indicative of GAD.MethodsSeventeen young women with Penn State Worry Questionnaire scores ≥45 (60 ± 8) completed 30-min treadmill running at 65%–85% heart rate reserve (%HRR) and 30-min seated quiet rest in counterbalanced order. Outcomes included worry, state anxiety, and feelings of energy and fatigue. Two condition X two time repeated measures ANOVA examined differences across condition and time. Hedges’ d effect sizes (95%CI) were calculated to quantify and compare the magnitude of change. Independent-samples t-tests explored potential moderators of outcome response.ResultsTotal exercise time was 35.8 ± 3.4min with a mean 30.3 ± 0.16 in-zone minutes (65%-85%HRR); participants exercised at ∼72.9 ± 0.03 %HRR (range 66%–79%). Compared with quiet rest, acute exercise significantly improved worry engagement, state anxiety, and feelings of energy and fatigue (all p ≤ 0.031). Moderate-to-large (d = 0.44 to 1.69) reductions in state anxiety and feelings of fatigue and improvements in feelings of energy were found. Exercise-induced reductions in worry engagement were significantly larger among non-high trait anxious participants. Compared to normal sleepers, quiet rest significantly increased feelings of fatigue among poor sleepers.ConclusionFindings provide support for the positive effects of acute aerobic exercise on worry, state anxiety, and feelings of energy and fatigue among young women with worry indicative of GAD.     

Augmenting In Vivo Exposure With Fear Antagonistic Actions: A Preliminary Test

The current study investigated the efficacy of an exposure augmentation strategy in which the phobic individual is encouraged to enact actions that are in direct opposition to the fear action tendencies associated with acrophobia. Participants (N = 88) meeting DSM-IV criteria for specific phobia (acrophobia) were randomized to (a) exposure with oppositional actions (E + OA), (b) exposure only (EO), (c) a credible placebo consisting of pulsed audio-photic stimulation (APS), or (d) a waitlist control (WLC). Treatment consisted of six, 6-min exposure trials. Participants were assessed with questionnaire, behavioral, and physiologic measures at pre- and posttreatment, and at a 1-month follow-up session. Participants receiving E + OA showed significantly greater improvement on behavioral and questionnaire measures than those in the other 3 conditions at both posttreatment and follow-up. Further, whereas treatment improvement generalized to an untrained context for those receiving E + OA, such was not the case for EO- and APS-treated participants. Findings suggest augmenting exposure with oppositional actions may enhance treatment outcome and thus warrant additional investigation with clinical samples.     

A Pilot Randomized Clinical Trial of a Novel,Culturally Adapted,Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.     

Repetitive Thought and Self-Reported Sleep Disturbance

Repetitive thought has been focused upon as a transdiagnostic risk factor for depression, anxiety, and poor physical health. Among the forms of repetitive thought, rumination and worry are considered to play important roles in the onset and maintenance of insomnia. However, there have been few attempts to clarify the similarities, differences, and interaction between the functions of rumination and worry in sleep problems. Furthermore, no study has investigated the prospective relationships between these two forms of repetitive thought and sleep disturbance. In the present study, we examined the prospective associations between repetitive thought and subjective sleep quality, measured by a self-report questionnaire. A total of 208 undergraduates participated in a 2-wave longitudinal survey with an interval of 3 weeks between assessments. Hierarchical multiple regression analyses showed that baseline rumination predicted reduction in the follow-up assessment of subjective sleep quality, controlling for levels of depressive and anxious symptoms. This main effect of rumination was qualified by the levels of worry; for individuals with higher levels of worry, rumination was associated with greater reduction in subjective sleep quality. These results suggest that both rumination and worry have unique associations with sleep and that their interaction is especially important in sleep problems.