Mindfulness and Emotion Regulation Difficulties in Generalized Anxiety Disorder: Preliminary Evidence for Independent and Overlapping Contributions

Diminished levels of mindfulness (awareness and acceptance/nonjudgment) and difficulties in emotion regulation have both been proposed to play a role in symptoms of generalized anxiety disorder (GAD); the current studies investigated these relationships in nonclinical and clinical samples. In the first study, among a sample of 395 individuals at an urban commuter campus, self-reports of both emotion regulation difficulties and aspects of mindfulness accounted for unique variance in GAD symptom severity, above and beyond variance shared with depressive and anxious symptoms, as well as variance shared with one another. In the second study, individuals with GAD (n = 16) reported significantly lower levels of mindfulness and significantly higher levels of difficulties in emotion regulation than individuals in a nonanxious control group (n = 16). Results are discussed in terms of directions for future research and potential implications for treatment development.     

Group Cognitive Behavior Therapy for Chronic Posttraumatic Stress Disorder: An Initial Randomized Pilot Study

Individuals with posttraumatic stress disorder (PTSD) related to a serious motor vehicle accident were randomly assigned to either group cognitive behavioral treatment (GCBT) or a minimum contact comparison group (MCC). Compared to the MCC participants (n = 16), individuals who completed GCBT (n = 17) showed significant reductions in PTSD symptoms, whether assessed using clinical interview or a self-report measure. Among treatment completers, 88.3% of GCBT participants did not satisfy criteria for PTSD at posttreatment assessment, relative to 31.3% of the MCC participants. Examination of anxiety, depression, and pain measures did not show a unique advantage of GCBT. Treatment-related gains were maintained over a 3-month follow-up interval. Patients reported satisfaction with GCBT, and attrition from this treatment was comparable with individually administered CBTs. Results are discussed in light of modifications necessitated by the group treatment format, with suggestions for future study of this group intervention.     

Changes in Emotions Over the Course of Dialectical Behavior Therapy and the Moderating Role of Depression,Anxiety, and Posttraumatic Stress Disorder

Evidence-based borderline personality disorder (BPD) treatments such as dialectical behavior therapy (DBT) emphasize the acquisition and use of strategies to down regulate negative emotion. However, little research examines whether specific emotions change during DBT. Further, it is unclear if BPD-relevant comorbidities that involve heightened emotion—namely, depression, anxiety disorders, and posttraumatic stress disorder (PTSD)—moderate these outcomes. This study investigated which specific emotions (hostility/anger, fear, shame/guilt, and sadness) decrease during DBT, and whether comorbid depression, anxiety disorders, and PTSD moderate these outcomes. Individuals with BPD (N = 101) completed 6 months of standard DBT and provided measurements of specific emotions at every session and at pre-, mid-, and posttreatment. Generalized estimating equations revealed moderate effect-sized reductions in anger at major assessment time points. Anxiety disorders and PTSD moderated the effect of time on fear, shame, and guilt. PTSD also moderated the effect of time on sadness. For all moderating effects, individuals with the comorbidity exhibited greater reductions than those without. These findings corroborate that DBT reduces several specific emotions, and comorbid PTSD and anxiety disorders may facilitate this effect for fear, shame/guilt, and sadness (clinical trial registration number = NCT03123198).     

Emotional processing and panic

In this paper Rachman's concept of emotional processing was extended and a model highlighting the psychological operations underpinning processing was specified. Using this model, the aim was to investigate, by means of a questionnaire, whether patients with panic disorder (n=50) have more emotional processing difficulties than two samples of healthy controls (London, n=406; Aberdeen, n=125). The panic disorder group did have significantly more emotional processing difficulties than the control groups, showing a marked tendency to control feelings of anger, unhappiness and anxiety. Three emotional processing dimensions distinguished the panic from the control groups: greater control of emotional experiences ('smothering' or 'bottling up' emotions), greater awareness of feelings and more difficulties in labelling emotions. The authors hypothesise that emotional processing deficits act as a vulnerability factor for developing panic attacks.     

Treating PTSD in Patients With Psychosis: A Within-Group Controlled Feasibility Study Examining the Efficacy and Safety of Evidence-Based PE and EMDR Protocols

The present study uses a within-group controlled design to examine the efficacy and safety of two psychological approaches to posttraumatic stress disorder (PTSD) in 10 patients with a concurrent psychotic disorder. Patients were randomly assigned either to prolonged exposure (PE; N = 5) or eye movement desensitization and reprocessing (EMDR; N = 5). Before, during, and after treatment, a total of 20 weekly assessments of PTSD symptoms, hallucinations, and delusions were carried out. Twelve weekly assessments of adverse events took place during the treatment phase. PTSD diagnosis, level of social functioning, psychosis-prone thinking, and general psychopathology were assessed pretreatment, posttreatment, and at three-month follow-up. Throughout the treatment, adverse events were monitored at each session. An intention-to-treat analysis of the 10 patients starting treatment showed that the PTSD treatment protocols of PE and EMDR significantly reduced PTSD symptom severity; PE and EMDR were equally effective and safe. Eight of the 10 patients completed the full intervention period. Seven of the 10 patients (70%) no longer met the diagnostic criteria for PTSD at follow-up. No serious adverse events occurred, nor did patients show any worsening of hallucinations, delusions, psychosis proneness, general psychopathology, or social functioning. The results of this feasibility trial suggest that PTSD patients with comorbid psychotic disorders benefit from trauma-focused treatment approaches such as PE and EMDR.     

Post-Traumatic Stress Disorder as a Consequence of a Toxic Spill in Northern California

This study examined the development of post-traumatic stress disorder (PTSD) and associated features in residents of Dunsmuir, California, following a toxic spill. Classification of PTSD was based on a cutoff score from the Impact of Event Scale. It was predicted that greater exposure to the spill would increase the risk of PTSD and associated symptoms among spill residents; that those classified with PTSD would report more symptoms than would those without PTSD and controls; and that litigants would be classified with PTSD more than would nonlitigants. Results suggest that spill residents classified with PTSD had greater levels of tension, depression, anxiety, anger, fatigue, and confusion than did spill residents without PTSD and control residents with and without PTSD. Spill residents with PTSD reported more memory problems and sleep disorders than did those without PTSD and control residents with and without PTSD. Measures of physiological arousal showed that spill residents had higher systolic blood pressure several hours after a stressful interview than did control residents without PTSD. Pulse rates several hours after a stressful interview were higher for spill residents with and without PTSD than for control residents with PTSD. Results suggest that exposed residents are at risk for developing PTSD and associated symptoms.     

Anger and postcombat mental health: Validation of a brief anger measure with U.S. Soldiers postdeployed from Iraq and Afghanistan

The involvement of anger in the psychological adjustment of current war veterans, particularly in conjunction with combat-related posttraumatic stress disorder (PTSD), warrants greater research focus than it has received. The present study concerns a brief anger measure, Dimensions of Anger Reactions (DAR), intended for use in large sample studies and as a screening tool. The concurrent validity, discriminant validity, and incremental validity of the instrument were examined in conjunction with behavioral health data for 3,528 treatment-seeking soldiers who had been in combat in Iraq and Afghanistan. Criterion indices included multiple self-rated measures of psychological distress (including PTSD, depression, and anxiety), functional difficulties (relationships, daily activities, work problems, and substance use), and violence risk. Concurrent validity was established by strong correlations with single anger items on 4 other scales, and discriminant validity was found against anxiety and depression measures. Pertinent to the construct of anger, the DAR was significantly associated with psychosocial functional difficulties and with several indices of harm to self and to others. Hierarchical regression performed on a self/others harm index found incremental validity for the DAR, controlling for age, education, military component, officer rank, combat exposure, PTSD, and depression. The ability to efficiently assess anger in at-risk military populations can provide an indicator of many undesirable behavioral health outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A randomised controlled trial of the effectiveness of writing as a self-help intervention for traumatic injury patients at risk of developing post-traumatic stress disorder

The study investigated the effects of writing and self-help information on severity of psychological symptoms in traumatic injury patients at risk for developing post-traumatic stress disorder (PTSD). Patients attending Accident and Emergency (A & E), were screened for Acute Stress Disorder and randomised to an information control group (n = 36) or a writing and information group (n = 31). Participants in both groups received an information booklet one-month post-injury. Participants in the writing group also wrote about emotional aspects of their trauma during three 20-min sessions, five to six weeks post-injury. Psychological assessments were completed within one month and at three and six months post-injury. There were significant improvements on measures of anxiety, depression and PTSD over time. Differences between groups on these measures were not statistically significant. However, subjective ratings of the usefulness of writing were high. In conclusion, the results do not currently support the use of writing as a targeted early intervention technique for traumatic injury patients at risk of developing PTSD.     

A Taxometric Investigation of the Latent Structure of Worry: Dimensionality and Associations With Depression, Anxiety, and Stress

Worry has been described as a core feature of several disorders, particularly generalized anxiety disorder (GAD). The present study examined the latent structure of worry by applying 3 taxometric procedures (MAXEIG, MAMBAC, and L-Mode) to data collected from 2 large samples. Worry in the first sample (Study 1) of community participants (n = 1,355) was operationalized by worry engagement, absence of worry, and the worry feature of trait anxiety. Worry in the second sample (Study 2) of undergraduate participants (n = 1,171) was operationalized by the tendency to experience worry, intolerance of uncertainty, beliefs about worry, and symptoms of GAD. Results across both samples provided converging evidence that worry is best conceptualized as a dimensional construct, present to a greater or lesser extent in all individuals. Findings from Study 2 also indicated that the latent dimension of worry generally has an equal association with symptoms of depression, anxiety, and stress across the entire continuum. These findings are discussed in relation to the conceptualization and assessment of worry in GAD and related disorders.     

The Driving Behavior Survey as a Measure of Behavioral Stress Responses to MVA-Related PTSD

Numerous treatments are available that address the core symptoms of posttraumatic stress disorder (PTSD). However, there are a number of related behavioral stress responses that are not assessed with PTSD measures, yet these behavioral stress responses affect quality of life. The goal of the current study was to investigate whether a recently developed measure of behavioral stress response, the Driving Behavior Survey (DBS), was sensitive to change associated with treatment among a group of participants diagnosed with PTSD. The DBS indexes anxious driving behavior, which is frequently observed among individuals with motor vehicle accident-related PTSD. Participants (n = 40) were racially diverse adults (M age = 40.78, 63% women) who met diagnostic criteria for motor vehicle accident-related PTSD. Hierarchical linear modeling analyses indicated that participants who were assigned to a brief, exposure-based intervention displayed significant reductions on the DBS subscales relative to participants assigned to the wait-list control condition (r = .41–.43). Moreover, mediational analyses indicated that the observed reductions on the DBS subscales were not better accounted for by reductions in PTSD. Taken together, these findings suggest that the DBS subscales are sensitive to changes associated with PTSD treatment and can be used to augment outcome assessment in PTSD treatment trials.     

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.     

Can one’s temper be cooled? A role for Agreeableness in moderating Neuroticism’s influence on anger and aggression

The study followed from the idea that Neuroticism captures hot or facilitative vulnerabilities related to anger and aggression, whereas Agreeableness captures cool or inhibitory processes in relation to these same outcomes. As such, it was predicted that Neuroticism and Agreeableness should interact to predict anger and aggression according to hot/cool models of self-regulation. This hypothesis was systematically examined among three independent samples of participants (total N = 176). As predicted, Neuroticism and Agreeableness interacted to predict anger and aggression among all samples, and did so in a manner consistent with the hypothesis that Neuroticism–anger relations would be lower at high levels of Agreeableness. The results therefore highlight the distinct roles of Neuroticism and Agreeableness in predicting anger and aggression, while placing these traits in a common interactive self-regulatory framework.     

The impact of borderline personality disorder on process group outcome among women with posttraumatic stress disorder related to childhood abuse.

The outcome of a 12-week interpersonal process group therapy for women with postraumatic Stress Disorder (PTSD) related to childhood sexual abuse with and without borderline personality disorder (BPD) was assessed by comparing three naturally occurring treatment conditions: groups that did not have any members with borderline personality disorder (BPD-) (n = 18), groups in which at least one member carried the diagnosis (BPD+)(n = 16), and a 12-week waitlist (WL) (n = 15). PTSD, anger, depression, and other symptoms were significantly reduced in the BPD- groups. However, the BPD+ and WL conditions did not show any pre- to posttreatment improvements. Furthermore, the BPD+ condition showed a significant worsening on measures of anger. Analyses within the BPD+ condition indicated that women with and without the diagnosis experienced equal posttreatment increases in anger problems. These latter results suggest the presence of an anger "contagion" effect. That is, women without BPD did well in the BPD- groups but showed increased anger similar to the BPD+ women when treated in groups with them. Implications for client-treatment matching considerations in PTSD group therapy are discussed.     

POSTPARTUM BONDING DIFFICULTIES AND ADULT ATTACHMENT STYLES: THE MEDIATING ROLE OF POSTPARTUM DEPRESSION AND CHILDBIRTH‐RELATED PTSD

Despite decades of research demonstrating the role of adult attachment styles and early mother–infant bonding in parenting behaviors and maternal mental health, these constructs have seldom been studied together. The present study aimed to investigate the relationship between attachment styles and specific bonding difficulties of mothers. In addition, as postpartum depression and childbirth‐related posttraumatic stress symptoms have been associated with both constructs, we explored their possible mediation effect. One hundred fourteen mothers, 4 to 12 weeks’ postpartum, completed a demographic questionnaire, the Adult Attachment Style Questionnaire (M. Mikulincer, V. Florian, & A. Tolmacz, 1990), the Postpartum Bonding Questionnaire (L.F. Brockington, C. Fraser, & D. Wilson, 2006), the Modified Perinatal Posttraumatic Stress Disorder Questionnaire (J.L. Callahan, S.E. Borja, & M.T. Hynan, 2006), and the Edinburgh Postnatal Depression Scale (J.L. Cox, G. Chapman, D. Murray, & P. Jones, 1996), using an online survey system. As predicted, insecure attachment styles were associated with bonding difficulties wherein anxious/ambivalent attachment was associated with greater infant‐focused anxiety, mediated by postpartum depression but not childbirth‐related PTSD symptoms. In contrast, greater avoidant attachment style was associated with greater rejection and anger, mediated by childbirth‐related posttraumatic stress disorder (PTSD), but not depression symptoms. The current study confirmed the association of different attachment styles with bonding as well as the mediating roles of childbirth‐related PTSD and postpartum depression symptoms. Future psychological interventions may utilize such evidence to target interventions for bonding disorders in accordance with individual differences.     

Worry and the anxiety disorders: A meta-analytic synthesis of specificity to GAD

Although worry is central to the diagnosis of generalized anxiety disorder (GAD), it is also commonly observed in other anxiety disorders. In this meta-analytic review, we empirically evaluated the extent to which worry is specific to GAD relative to patients with other anxiety disorders, those with other psychiatric disorders, and nonpsychiatric controls. A total of 47 published studies (N = 8,410) were included in the analysis. The results yielded a large effect size indicating greater severity/frequency of worry, meta-worry, and domains of worry among anxiety disorder patients v. nonpsychiatric controls (d = 1.64). In contrast to the many differences emerging from comparisons between anxiety disordered patients and nonpsychiatric controls, when anxiety disordered patients were compared to people with other psychiatric disorders they differed only on severity/frequency and not on meta-worry or domains of worry. A large effect size indicating greater severity/frequency of worry, meta-worry, and domains of worry among patients with GAD v. nonpsychiatric controls was also found (d = 2.05). However, differences between GAD and those with other psychiatric disorders also emerged for severity/frequency of worry. GAD was associated with greater worry difficulties than other anxiety disorders, which generally did not differ from those with other psychiatric disorders and each other. The implications of these findings for conceptualizing worry in GAD and other anxiety disorders, and the potentially moderating effects of age and gender are discussed.     

Individual differences in disgust sensitivity and health-related avoidance: Examination of specific associations

This present study examined the specificity of disgust sensitivity in predicting health-related anxiety and behavioral avoidance. Participants (n = 60) completed self-report measures of disgust sensitivity, health anxiety, anxiety, and depression. They then completed three randomly presented health-related behavioral avoidance tasks (BATs) that consisted of potential exposure to the common cold, the flu, and mononucleosis. Results indicated that disgust sensitivity was significantly associated with anxious and avoidant responding to the health-related BATs. This association also remained largely intact after controlling for gender, anxiety, depression, and health anxiety. These findings indicate that disgust sensitivity has a specific and robust association with health-related anxiety and avoidance commonly observed among those with excessive health anxiety and obsessive compulsive disorder. The unique role of disgust sensitivity in relation to health anxiety is discussed in the context of a disease-avoidance model.     

Predictors of posttraumatic stress in children following injury: The influence of appraisals, heart rate, and morphine use

Prospective studies of posttraumatic stress disorder (PTSD) in children that investigate simultaneously both cognitive and biological or psychophysiological predictors are rare. The present research reports on the impact of cognitive factors (trauma-related appraisals) and biological indicators (heart rate, morphine use) in predicting PTSD and depression symptoms following single-incident trauma. Children and adolescents (N = 48) were assessed within 4 weeks of an injury that led to hospital treatment and followed up 6-months later. While morphine did not predict initial PTSD severity, it was associated with lower levels of PTSD at follow-up. Reductions in PTSD symptoms (change scores) between assessments were similarly associated with morphine dosage. Trauma-related appraisals also contributed to PTSD and depression symptom severity. While slightly different patterns of results were obtained depending on whether static or change scores were examined, as a whole the study adds to a growing literature that morphine has the potential to reduce PTSD symptoms severity. Likewise the relationship between unhelpful trauma appraisals and posttrauma psychopathology was replicated.     

A Randomized Trial of Attention Training for Generalized Social Phobia: Does Attention Training Change Social Behavior?

The use of attention training protocols for the treatment of generalized social anxiety disorder (SAD) is undergoing increased examination. Initial investigations were positive but more recent investigations have been less supportive of the treatment paradigm. One significant limitation of current investigations is overreliance on self-report. In this investigation, we expanded on initial investigations by using a multimodal assessment of patient functioning (i.e., including behavioral assessment). Patients with a primary diagnosis of SAD (n = 31) were randomly assigned to eight sessions of attention training (n = 15) or placebo/control (n = 16). Participants were assessed at pre- and posttreatment via self- and clinician-report of social anxiety as well as anxious and behavioral response to two in vivo social interactions. Results revealed no differences between groups at posttreatment for all study outcome variables, suggesting a lack of effect for the attention training condition. The results are concordant with recent investigations finding a lack of support for the use of attention training as an efficacious treatment for patients with SAD.     

Cognitive Processing Therapy Versus Supportive Counseling for Acute Stress Disorder Following Assault: A Randomized Pilot Trial

The study tested the efficacy and tolerability of cognitive processing therapy (CPT) for survivors of assault with acute stress disorder. Participants (N = 30) were randomly allocated to CPT or supportive counseling. Therapy comprised six individual weekly sessions of 90-min duration. Independent diagnostic assessment for PTSD was conducted at posttreatment. Participants completed self-report measures of posttraumatic stress, depression, and negative trauma-related beliefs at pre-, posttreatment, and 6-month follow-up. Results indicated that both interventions were successful in reducing symptoms at posttreatment with no statistical difference between the two; within and between-group effect sizes and the proportion of participants not meeting PTSD criteria was greater in CPT. Treatment gains were maintained for both groups at 6-month follow-up.     

Assaultive violence and the risk of posttraumatic stress disorder following a subsequent trauma

Breslau, Peterson, and Shultz (2008) reported that prior trauma alone, in the absence of PTSD, did not predict an increased PTSD risk, relative to no prior trauma. Only prior trauma that resulted in PTSD predicted an increased PTSD risk following a subsequent trauma. Recently, Cougle, Resnick, and Kilpatrick (2009) proposed that the effect of prior trauma might vary by type of prior trauma, a possibility not considered in Breslau et al. They report that childhood sexual or physical assault, in the absence of PTSD, increased the PTSD risk following a subsequent trauma. This report examines the PTSD effects of prior assaultive violence, using data from Breslau et al. (1998). The study assessed PTSD in relation to up to three events. Analysis was performed on the subset with PTSD assessment for two distinct events, the earliest trauma and a subsequent trauma (n = 967), using as reference persons with no prior trauma (n = 972). Neither prior assaultive violence nor other prior traumas, in the absence of PTSD, influenced the subsequent risk of PTSD. In contrast, prior PTSD increased considerably the PTSD risk of a subsequent trauma. The limitations in Cougle et al. (2009) and in this study and future research directions are discussed.