New Strategies for Combining Mindfulness with Integrative Cognitive Behavioral Therapy for the Treatment of Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) severely impacts social functioning, distress levels, and utilization of medical care compared with that of other major psychiatric disorders. Neither pharmacological nor psychotherapy interventions have adequately controlled cardinal symptoms of GAD: pervasive excessive anxiety and uncontrollable worry. Research has established cognitive behavioral therapy (CBT) as the most effective psychotherapy for controlling GAD; however, outcomes remain at only 50% reduction, with high relapse rates. Mindfulness has been integrated with CBT to treat people suffering from numerous psychiatric disorders, with mindfulness based stress reduction (MBSR) being the most researched. Preliminary evidence supports MBSR’s potential for controlling GAD symptoms and key researchers suggest mindfulness practices possess key elements for treating GAD. Classical mindfulness (CM) differs significantly from MBSR and possesses unique potentials for directly targeting process and state GAD symptoms inadequately treated by CBT. This article introduces the theory and practice of CM, its differences from MBSR, and a critical review of MBSR and CBT treatments for GAD. CM strategies designed to complement CBT targeting cardinal GAD symptoms are outlined with a case study illustrating its use.     

Test anxiety,anxiety disorders,and school-related wellbeing: Manifestations of the same or different constructs?

Previous studies have shown that highly test anxious persons are more likely to meet criteria for an anxiety disorder and report more frequent symptoms of anxiety disorders than their low test anxious counterparts. However, it is unclear whether test anxiety should be treated as distinct to, or a manifestation of, anxiety disorders. Furthermore, the Dual Factor Model of Mental Health proposes that high subjective wellbeing cannot be solely inferred from the absence of psychopathology. To date, no studies have examined the Dual Factor Model in relation to test anxiety. In the present study, we examined how test anxiety, two common anxiety disorders (i.e., generalized anxiety disorder [GAD] and panic disorder [PD]), and subjective wellbeing in the school domain (i.e., school-related wellbeing) were related in a sample of 918 adolescents (M age = 15.77 years) using network analysis and latent profile analysis. Results from the network analysis indicated that test anxiety, GAD, PD, and school-related wellbeing were represented as distinct constructs. Bridge nodes were identified that linked test anxiety with GAD, PD, and school-related wellbeing. The latent profile analysis identified three of the four profiles predicted by the Dual Factor Model, including (a) troubled (i.e., low school-related wellbeing, high test anxiety, GAD, and PD), (b) complete mental health (i.e., high school-related wellbeing, low test anxiety, GAD, and PD), and (c) symptomatic but content (i.e., average school-related wellbeing, test anxiety, GAD, and PD). We concluded that test anxiety was distinct from, rather than a manifestation of, GAD and PD. We found support for the Dual Factor Model, albeit not unequivocal, using test anxiety as an additional indicator of psychopathology to that of GAD and PD.     

Intelligence and emotional disorders: Is the worrying and ruminating mind a more intelligent mind?

Previous research has shown that anxiety and depression symptoms are negatively associated with measures of intelligence. However, this research has often not taken state distress and test anxiety into account, and recent findings indicate possible positive relationships between generalized anxiety disorder (GAD), worry, and intelligence. The present study examined the relationships between GAD, depression, and social anxiety symptoms, as well as their underlying cognitive processes of worry, rumination, and post-event processing, with verbal and non-verbal intelligence in an undergraduate sample (N = 126). While the results indicate that verbal intelligence has positive relationships with GAD and depression symptoms when test anxiety and state negative affect were taken into account, these relationships became non-significant when overlapping variance was controlled for. However, verbal intelligence was a unique positive predictor of worry and rumination severity. Non-verbal intelligence was a unique negative predictor of post-event processing. The possible connections between intelligence and the cognitive processes that underlie emotional disorders are discussed.     

Collaborating With Pediatric Gastroenterologists to Treat Co-Occurring Inflammatory Bowel Disease and Anxiety in Pediatric Medical Settings

Children and adolescents with inflammatory bowel disease (IBD) have distinct physical and emotional challenges that may place them at risk for developing anxiety and that may impede their receipt of mental health treatment. Only a handful of studies have applied empirically validated cognitive behavioral therapy (CBT) to IBD-related issues and no studies have examined the benefit of CBT for anxiety disorders in pediatric IBD. The aim of this paper is to describe a newly adapted cognitive behavioral treatment protocol, Treatment of Anxiety and Physical Symptoms related to IBD (TAPS + IBD), that has been tailored to concurrently address anxiety, including IBD-specific anxiety, and disease management in children and adolescents with IBD in pediatric medical offices. Two case studies are presented to demonstrate treatment implementation and preliminary assessment data. General considerations for health providers working with youth with comorbid anxiety and IBD from a multidisciplinary perspective and future research directions are provided.     

Relapse Prevention Techniques in the Treatment of Childhood Anxiety Disorders: A Case Example

Research has shown that cognitive behavioral therapy (CBT) is an efficacious treatment for children and adolescents with anxiety disorders. CBT incorporates techniques such as cognitive restructuring and exposure, which foster symptom reduction. While these components promote sustained fear reduction, greater attention to relapse prevention (RP) may be warranted, particularly given the comorbidity associated with anxiety disorders. A case example demonstrates a comprehensive relapse prevention (RP) component. Specifically, parental involvement was emphasized as well as the creation of a bound book that consolidated skills and provided a concrete resource for potential future anxious episodes.     

Targeting Common Factors Across Anxiety and Depression Using the Unified Protocol for the Treatment of Emotional Disorders in Adolescents

Clinical approaches to mood and anxiety disorders in children and adolescents have historically been confined to either diagnosis- [e.g., for obsessive–compulsive disorder vs. generalized anxiety disorder (GAD), etc.] or domain-specific (e.g., for anxiety disorders vs. depressive disorders) treatments. However, as conceptualizations of mental illness shift towards a more dimensional model [e.g., the recent Research Domain Criteria (RDoC) from the National Institutes of Health], transdiagnostic treatments, such as the unified protocol for the treatment of emotional disorders in adolescents (UP-A; Ehrenreich et al. in Child Fam Behav Ther 31(1):20–37, 2008), are gaining support in the empirical literature. This paper reviews the common treatment targets across three emotional disorders commonly found in adolescence: GAD, social anxiety disorder, and major depressive disorder. In particular, similarities and differences across potential treatment mechanisms, including cognitive and information processing deficits, problem-solving difficulties, and avoidance strategies are examined. Finally, the case of 17-year-old “Andrea” is presented to demonstrate how transdiagnostic approaches like the UP-A can be effective in treating a range of emotional disorders in youth.     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

Verhaltenstherapie bei Kindern und Jugendlichen mit Angststörungen

Research into anxiety disorders of children and adolescents have been neglected for a long time. Current work on the prevalence and on the course of anxiety disorders of children and adolescents impressively substantiates that (1) anxiety disturbances are the most frequent mental disorders of children and adolescents and, (2) represent important factors of risk for the development of anxiety disorders, depression and substance dependence/abuse in adulthood. The recent developments in behavior therapy on anxiety disorders with children and adolescents are presented first and the results of a meta-analysis of behavior therapy studies are summarized. The results of the meta-analysis show that anxiety disorders can be treated successfully in children and adolescents with behavior therapy. The follow up data show that therapy successes remain stable over a timespan of several years. In comparison of individual and group therapy as well as child and family-based therapy, there are no important differences with regard to therapy success.     

Strategies included in cognitive behavioral therapy programs to treat internalized disorders: a systematic review

This review aimed to identify the strategies used in programs based on cognitive behavioral therapy (CBT) to prevent and treat symptoms of anxiety, depression, and internalized behaviors of children and adolescents. Based on an online search (ERIC, PsycInfo, Virtuose UQAM, and Google Scholar), 61 studies describing different cognitive behavioral programs were selected. Results showed that 40 strategies were implemented in at least one program. However, none of the strategies were systematically present in all programs, and only few were reported in more than 50% of the studies. Cognitive restructuring and problem-solving were the most popular strategies to treat depressive symptoms, whereas anxiety programs also generally included relaxation and exposure. Furthermore, six strategies were identified in a single anxiety program, whereas nine strategies were implemented in only one depression program. These results suggest that in anxiety and depression programs designed for children and adolescents, the label “CBT” encompasses a wide variety of programs with only few similar strategies. Such findings highlight the need to define a common basis for CBT programs, in order to better reflect CBT theory and to identify the effectiveness of the strategies included in these programs.     

Verbal and practical intelligence in general anxiety,obsessive compulsive and major depression disorders

IntroductionPrevious researches have shown that anxiety symptoms are negatively associated with measures of intelligence. However, recent findings indicate possible positive relationships between Generalized Anxiety Disorders (GAD) and intelligence. Also, Obsessive Compulsive Disorder (OCD) is associated with a moderate degree of underperformance on cognitive tests, including deficient processing. There are inconsistent results to present the relationship between Major Depression Disorder (MDD) and IQ. The present study has three main aims. The first aim of this study is to investigate the difference between IQ in individuals with GAD, OCD and major depressive disorder, and normal group. The second purpose is to perform a comparative study between the GAD, OCD and MDD groups on verbal and non-verbal intelligence. The third aim of this study is to examine the relationships between GAD, OCD and MDD as well as their underlying cognitive processes, including worry, rumination, and post-event processing, with verbal and non-verbal intelligence.ObjectiveThe present study is performed on four groups of participants including those with GAD, OCD, MDD and Healthy Volunteer (HV) group consisting of individuals without psychiatric disorders.MethodThe number of 50 healthy volunteers as the control group, 45 patients with GAD, 20 patients with OCD and 25 patients with MDD (n = 140) were selected as the case-referent groups. The present study was a cross-sectional type and the research was performed based on the causal-comparative method. Verbal and non-verbal intelligence was measured with the Wechsler Adult Intelligence Scale-3rd edition (WAIS-III). Rumination and post-event processing were measured by PSWQ, RRS-BR, and PEPQ, respectively.ResultsThe results indicate that Verbal Intelligence and Verbal Comprehension Index in GAD patients have significant differences in comparison to the OCD, MDD and control groups. While, the value of the Working Memory Index (WMI) in the normal group is higher than the value of the same index in the GAD, OCD and MDD groups. Also, the values of the Processing Speed Index (PSI) in normal and GAD groups are higher than the OCD and MDD groups. The worry, rumination, and post-event processing in patients with GAD are positively correlated with general and verbal intelligence. But, verbal and non-verbal intelligence had a negative correlation with worry, rumination and post-event processing in healthy volunteers.ConclusionInvestigation of the possible connections between intelligence and the cognitive processes underlying emotional disorders can provide therapeutic strategies for smart individuals who are at risk for GAD.     

Improving the Transportability of CBT for Internalizing Disorders in Children

Research provides strong support for the efficacy and effectiveness of cognitive behavioral therapy (CBT) for the treatment of childhood internalizing disorders. Given evidence for limited dissemination and implementation of CBT outside of academic settings, efforts are underway to improve its transportability so that more children with mental health needs may benefit from treatment. Creative modifications to existing treatments aim to deliver CBT for anxiety disorders and depression in a more transportable format. Notable progress has been made within the areas of computerized CBT, camp-based CBT, school-based CBT, and CBT delivered through primary care settings. These approaches are discussed within the context of key elements of transportability that are particularly germane to the dissemination and implementation of child treatments.     

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

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

Commentary: Expanding the Research Agenda on Interventions for Child and Adolescent Anxiety Disorders

The articles in this series describe complementary programs of research and innovative approaches to extend evidence-based interventions for youth with anxiety in several important directions: to extend the target age range [Pincus, D. B., Santucci, L. C., Ehrenreich, J. T., & Eyberg, S. M. (2008-this issue). Treating separation anxiety disorder in young children: Exploring the additive impact of exposure on PCIT treatment outcome. Cognitive and Behavioral Practice, 15]; to extend interventions to more broadly defined target populations, including youth with co-occurring psychiatric symptoms [Weersing, V. R., Gonzalez, A., Campo, J. V., & Lucas, A. N. (2008-this issue). Brief CBT for pediatric anxiety and depression: Piloting an integrated treatment approach. Cognitive and Behavioral Practice, 15] and somatic symptoms [Reigada, L. C., Fisher, P. H., Cutler, C., & Masia Warner, C. (2008-this issue). An innovative treatment approach for children with anxiety disorders and medically unexplained somatic complaints. Cognitive and Behavioral Practice, 15]; to extend access in specific community-practice settings [Ginsburg, G. S., Becker, K., Kingery, J., & Nichols, T. (2008-this issue). Transporting CBT for childhood anxiety disorders into inner city school-based mental health clinics. Cognitive and Behavioral Practice, 15; Reigada, L. C., Fisher, P. H., Cutler, C., & Masia Warner, C. (2008-this issue). An innovative treatment approach for children with anxiety disorders and medically unexplained somatic complaints. Cognitive and Behavioral Practice, 15; Weersing, V. R., Gonzalez, A., Campo, J. V., & Lucas, A. N. (2008-this issue). Brief CBT for pediatric anxiety and depression: Piloting an integrated treatment approach. Cognitive and Behavioral Practice, 15]; and to extend access to these evidence-based approaches, in general [Khanna, M. S., & Kendall, P. C. (2008-this issue). Computer assisted CBT for child anxiety: The Coping Cat CD. Cognitive and Behavioral Practice, 15]. This commentary addresses how, collectively, these programs of research illustrate promising approaches to intervention adaptation and testing. The discussion also explores potential directions that might facilitate future research, including potential directions for broadening the interventions research agenda to help ensure that high-quality, evidence-based interventions are ultimately available to children and adolescents with anxiety.     

A Comparison of Interactions Among Children,Parents, and Therapists in Cognitive Behavior Therapy for Anxiety Disorders in Australia and Japan

Despite growing attention to the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at posttreatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.     

Performance of retarded adolescents and nonretarded children on one- and two-bit logical problems

Groups of adolescents of retarded and borderline intelligence, ranging in IQ from 44 to 80 and in mean MA (mental age) from 8 to 12 yr, and groups of nonretarded children ranging in mean MA from 6 to 12 yr, were given logical problem solving tasks. In the nonretarded groups, on a one-bit problem only the kindergarten children (mean MA = 6 yr) failed to perform above chance, and were not tested further. On a two-bit problem, only the first graders (mean MA = 7 yr) failed to perform above chance.Conversely, in the low IQ groups, only the borderline group (mean MA = 12 yr) performed reliably above chance on the one-bit problem, and none performed above chance on the two-bit problem. There is a profound deficiency in low IQ individuals on certain tasks requiring logic and foresight, and MA markedly over-estimates their performance relative to the performance of nonretarded individuals.     

Anxiety Disorders in Late Life: Considerations for Assessment and Cognitive-Behavioral Treatment

Anxiety disorders are among the most frequently diagnosed mental disorders in late life. As older adults comprise a growing segment of the population, evidence-based treatments for anxiety disorders in late life have come into sharper focus. Cognitive-behavioral therapy (CBT) for anxiety disorders in late life has received less empirical attention and widespread dissemination relative to other age groups. Increasing older adults’ access to timely assessment and effective treatment can help reduce the personal and societal costs of anxiety disorders. The purpose of this review paper is to discuss important considerations for the assessment of anxiety disorders in older adults and offer adaptations to CBT treatment for this population. As part of assessment considerations, we discuss how physical health conditions, cognitive impairment, and functional limitations can impact anxiety disorder diagnoses with older adults. We also outline validated self-report measures of anxiety disorder symptoms for older adults and highlight the importance of assessing older adults’ suitability for CBT. Several recommendations for adapting CBT protocols for older adults with anxiety disorders are described, such as extending psychoeducation, altered treatment pacing, use of content aids, and medical contraindications for interoceptive exposure. A case study is included that illustrates helpful assessment and treatment adaptions for an older woman with panic disorder. We highlight the pressing need to increase research and dissemination of CBT for anxiety disorders for older adults to meet the needs of an increasing segment of the population worldwide.     

Unexpected improvement, decline, and stasis: a prediction confidence perspective on achievement success and failure

The authors hypothesized that reactions to performance feedback depend on whether one's lay theory of intelligence is supported or violated. In Study 1, following improvement feedback, all participants generally exhibited positive affect, but entity theorists (who believe that intelligence is fixed) displayed more anxiety and more effort to restore prediction confidence than did incremental theorists (who believe that intelligence is malleable). Similarly, when performance declined, entity theorists displayed more anxiety and compensatory effort than incremental theorists. However, when performance remained rigidly static despite a learning opportunity, incremental theorists evinced more anxiety and compensatory effort than entity theorists. In Study 2, this pattern was replicated when the entity and incremental theories were experimentally manipulated. Study 3 demonstrated that for both groups, theory violation impairs subsequent task performance. Taken together, these studies provide evidence that lay theory violation and damaged prediction confidence have significant and measurable effects on emotion and motivation. The authors discuss the implications of these findings for the literature on achievement success and failure.     

Anxiety Levels in Children with Autism Spectrum Disorder: A Meta-Analysis

The aim of the current study was to meta-analytically examine whether anxiety levels in children with autism spectrum disorders (ASD) are elevated. A total of 83 articles were selected from a systematic literature search and were included in the meta-analyses. Results demonstrated that children with ASD had higher anxiety levels compared to typically developing children, and this difference increased with IQ. Youth with ASD also tended to have higher anxiety levels compared to clinically referred children, and this difference increased with age. Children with ASD had higher anxiety levels compared to youth with externalizing or developmental problems, but not when compared to youth with internalizing problems. The study findings highlight the importance of more research in order to fully understand the nature and development of anxiety in children with ASD. More specifically, the results suggest that especially high-functioning adolescents with ASD may be at risk for developing anxiety disorders. Therefore, it seems important to carefully follow and monitor children with ASD transcending to adolescence.     

The influence of gender,age, Psychological resilience and family interaction factors upon anxiety and depression in non-autism spectrum disorder siblings of children with an autism spectrum disorder

The influence of gender, age, Psychological resilience and family interaction factors upon generalised anxiety disorder (GAD) and major depressive disorder (MDD) was investigated in 75 non-autism spectrum disorder (NASD) siblings who had a brother or sister with an autism spectrum disorder (ASD). GAD and MDD were much more prevalent than in comparable age group samples, and adolescent females had the highest MDD rates. Several Psychological resilience skills were significantly associated with lower GAD and MDD, particularly being able to recognise mistakes in their thinking (for children) and being able to remain in control of their anger (for adolescents). Suggestions are made for ways of encouraging NASD siblings to develop skills that may assist them in avoiding these disorders.