The self-assessment of resilience and anxiety: psychometric properties

This report describes the psychometric properties of the Self-Assessment of Resilience and Anxiety (SARA) scale within the context of a study of kava for generalized anxiety. This eight-item, patient-rated scale includes questions designed to measure calmness, mental clarity, confidence, physical well being, sociability, and resilience. The SARA scale was administered during a clinical trial of kava versus placebo in 38 subjects diagnosed with generalized anxiety disorder (GAD). Validation of the SARA scale was assessed against the Hamilton Rating Scale for Anxiety, Hospital Anxiety and Depression Scale, Penn State Worry Questionnaire, Sheehan Disability Scale, Arizona Sexual Experience scale, and Clinical Global Impression of Illness Improvement scale. Good test-retest reliability, internal consistency, convergent validity, and sensitivity to treatment were identified, and factor analyses revealed a three-factor internal structure. The SARA scale was responsive to symptom change over time and correlated with comparable GAD symptom measures. The SARA scale demonstrates solid psychometric properties and may serve as a reliable and valid measure in the use of kava or related medicinal herbs.     

St. John's Wort: clinical status in psychiatry

Depression and anxiety are among the top 10 health problems for which complementary and alternative therapies (CATs) are most frequently used, and medicinal herbs are among the most popular of these treatments. St. John's wort (Hypericum perforatum) is a perennial herb that has become a widely used depression therapy. Extracts of hypericum have shown affinity for receptors within multiple neurochemical systems. The primary active substance responsible for the antidepressant effect is not well defined, but most work has concentrated specifically on the hypericin and hyperforin components. Although hypericum has demonstrated significant antidepressant and antianxiety effects in multiple studies, there are several recent studies that do not support the previous evidence. In all reported studies, hypericum extracts have been well tolerated. In addition, new psychiatric uses for hypericum in obsessive-compulsive disorder, generalized anxiety disorder, menopausal symptoms, and alcohol dependence have been reported. Because patients are choosing to pursue CAT as a first-line therapy, psychiatrists will need to have a better understanding of phytomedicines used for treating depression and anxiety, and thus be better prepared to serve as effective allies of their patients.     

Randomized controlled trial of false safety behavior elimination therapy: a unified cognitive behavioral treatment for anxiety psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.     

Safety Behaviors in Adults With Social Anxiety: Review and Future Directions

Safety behaviors are considered an important factor in the maintenance of social anxiety disorder (SAD). Safety behaviors are typically employed by socially anxious individuals to reduce anxiety in feared social situations. However, by preventing individuals with social anxiety from gathering evidence that would disconfirm their maladaptive beliefs about social situations, the use of safety behaviors ultimately maintains social anxiety over time. Twenty years ago, Wells and colleagues (1995) demonstrated that use of safety behaviors diminishes the efficacy of exposure treatment for SAD, suggesting that reduction in the use of safety behaviors during exposure can enhance treatment response. Research on safety behaviors has expanded considerably since Wells et al.’s seminal publication, and our understanding of the role safety behaviors may play in the maintenance of social anxiety has grown in breadth and depth. In this paper, we present a detailed review of the published research on safety behaviors relevant to social anxiety and social-anxiety-related processes. Finally, we evaluate the impact of safety behaviors on the outcome of treatment for SAD, and we look to the literature on safety behaviors in other anxiety disorders to inform our understanding of use of safety behaviors during exposure and to facilitate future research in SAD.     

Putting the client in control: The perception of control in the behavioral treatment of anxiety

Traditional explanations of anxiety reduction through behavioral interventions such as extinction, habituation, reciprocal inhibition, and counterconditioning do not adequately account for all instances and aspects of anxiety reduction and clinical methods employed in contemporary behavior therapy. This article examines the role of an additional process — the alterations of perceptions of control — believed to be operative in anxiety reduction. We discuss three targets for establishing control in behavioral treatments of anxiety: (1) control over one's physiological responding while in an anxiety-producing situation, (2) control over the anxiety-producing stimulus or situation itself, and (3) control over the conduct of exposure. These three types of control perceptions are differentially important for different types of anxiety disorders. Implications for the conduct of behavioral treatments and possibilities for increasing client perceptions of control in anxiety treatment programs are outlined. We also recommend that client perceptions of control should be systematically assessed in order to relate them to treatment successes and failures.     

Reduction of anxiety sensitivity in relation to nicotine withdrawal symptoms during smoking cessation: an examination among successful quitters

Anxiety sensitivity has been implicated as a potential risk factor for post-quit withdrawal symptoms. The present study examined relations between the extent of change in anxiety sensitivity and the course of nicotine withdrawal symptoms experienced during the initial two weeks of a quit attempt among treatment-seeking smokers. The sample consisted of 29 adult daily smokers (34% female; M_age = 47.7, SD = 13.1) who successfully quit and maintained their abstinence. After adjusting for the effects of gender, treatment condition, use of nicotine replacement therapy, nicotine dependence, alcohol use problems, baseline levels of anxiety sensitivity, and reductions in negative affect, greater reductions in anxiety sensitivity were related to faster decreases in withdrawal symptoms. The current data suggest that there may be merit to employ anxiety sensitivity reduction methods for the management of emergent withdrawal symptoms in smoking cessation treatment.     

Generalized anxiety disorder: acute and chronic treatment

Clinical and epidemiological data suggest that generalized anxiety disorder (GAD) is a chronic illness causing patients to suffer for many years leading to significant distress in daily life functioning. The literature suggests the several conclusions. GAD is a disorder in need of appropriate treatment and often has a chronic course with comorbid conditions, such as major depression and other anxiety disorders. Benzodiazepines, while effective anxiolytic agents acutely, when prescribed for >4 weeks cause rebound anxiety and following prolonged therapy may lead to withdrawal symptoms. Antidepressants cause significant anxiety relief compared with placebo and for psychosocial treatment cognitive-behavioral therapy is an efficacious psychosocial treatment. Many GAD patients are in need of long-term medication management. Furthermore, there is limited data for patients diagnosed with GAD the treatment outcome with the combination of medication and psychotherapy both acutely and long-term; how to best sequence these treatments; for those patients who do not meet remission criteria what is the ideal approach for augmentation; and for patients with treatment-refractory GAD the empirical evidence is lacking on medication switching and augmentation strategies. Research is needed in the area of developing treatment strategies for patients suffering from treatment-refractory GAD. There is still an urgent need to explore treatment combinations and duration strategies in the management of patients suffering with GAD.     

Migräne und Botulinumtoxin Typ A

A chronic migraine occurs significantly less frequently than an episodic migraine, with a prevalence of approximately 0.5 to 2.2?%. Based on the scientific data of an extensive study program, Botox® has been permitted for use as a prophylaxis in Austria since 2012. Most other forms of medicinal prophylaxis are of limited effectiveness and are associated with significant side-effects. Successful prophylaxis and therapy require patient compliance and withdrawal treatment for the frequent accompanying headache caused by the overuse of analgesics.     

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.     

Childhood Anxiety/Withdrawal, Adolescent Parent–Child Attachment and Later Risk of Depression and Anxiety Disorder

Previous research has shown that children with high levels of early anxiety/withdrawal are at increased risk of later anxiety and depression. It has also been found that positive parent–child attachment reduces the risk of these disorders. The aim of this paper was to examine the extent to which positive parent–child attachment acted to mitigate the risk of later internalising disorders amongst children with high levels of early anxiety/withdrawal using data from a 30 years longitudinal study of a New Zealand birth cohort. The findings of this study showed that: (a) increasing rates of early anxiety/withdrawal were associated with an increased risk of later anxiety and depression; (b) positive parent–child attachment in adolescence was associated with a decline in the risk of later anxiety and depression; and (c) these associations persisted even after controlling for confounding factors. The implications of these findings for the role of parent–child attachment in mitigating the adverse effects of early anxiety/withdrawal are discussed. It is concluded that positive parent–child attachment in adolescence may act as a compensatory factor which buffers the adverse effects of childhood anxiety/withdrawal on risks of developing later anxiety and depression.     

LISTENING TO SMOKING RESEARCHERS:

Abstract— The work of Baker and his colleagues indicates that a broadened view of withdrawal that recognizes its probable affective bases will suggest new treatment strategies for the treatment of smoking and, by extension, drug dependence. This commentary briefly reviews the current status of treating drug dependence by addressing negative affect and emphasizes that clinical research which allows for building more complex models, of individual change over time holds promise for clearer understanding of the role of negative affect among drug abusers and thus more effective treatments. Although clinical treatments for drug dependence have long recognized the significance of negative affect we are far from a thorough understanding of the role of negative affect in withdrawal, craving, and relapse to drug use.     

The role of glutamate in anxiety and related disorders

Anxiety, stress, and trauma-related disorders are a major public health concern in the United States. Drugs that target the gamma-aminobutyric acid or serotonergic system, such as benzodiazepines and selective serotonin reuptake inhibitors, respectively, are the most widely prescribed treatments for these disorders. However, the role of glutamate in anxiety disorders is becoming more recognized with the belief that drugs that modulate glutamatergic function through either ionotropic or metabotropic glutamate receptors have the potential to improve the current treatment of these severe and disabling illnesses. Animal models of fear and anxiety have provided a method to study the role of glutamate in anxiety. This research has demonstrated that drugs that alter glutamate transmission have potential anxiolytic action for many different paradigms including fear-potentiated startle, punished responding, and the elevated plus maze. Human clinical drug trials have demonstrated the efficacy of glutamatergic drugs for the treatment of obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social phobia. Recent data from magnetic resonance imaging studies provide an additional link between the glutamate system and anxiety. Collectively, the data suggest that future studies on the mechanism of and clinical efficacy of glutamatergic agents in anxiety disorders are appropriately warranted.     

Guided Internet-Based CBT for Common Mental Disorders

The Internet has become a part of most people’s lives in many parts of the world. Since the late 1990s there has been an intensive research activity in which psychological treatments, such as cognitive behavior therapy (CBT), have been found to be effective when delivered via the Internet. Most research studies indicate that the effects are larger when some form of guidance is provided from a therapist, and unguided treatments tend to lead to more dropout and smaller effects. Guided Internet treatments often consists of book length text materials, but can also include other components such as audio files and video clips. Homework assignment is often included and feedback is given for completed homework. Guided Internet-based CBT (iCBT) has been found to work for problems such as depression, panic-, social anxiety-, and generalized anxiety disorders. There are many research trials in which participants have been recruited via media, and there has been less research conducted in representative clinical settings. Most research has been conducted on adults and in university settings with nationwide recruitment. There is a need for treatments and studies on older adults, children and adolescents. In conclusion, dissemination of the research findings on guided iCBT to regular clinical settings is warranted.     

The extent and characteristics of driving anxiety

Research over the last two decades has resulted in improved understandings of the nature and characteristics of driving anxiety. However, we still do not know the extent of driving anxiety in the general population, as most studies have focused on clinical or vehicle accident samples, and the only population study is of older adults. The present study addressed this gap in knowledge using data from 441 people who responded to a survey sent to a random sample of 1500 adults recruited from the compulsory voting register in New Zealand. While 31% reported no driving anxiety, 52% endorsed mild driving anxiety and 16% reported moderate to severe driving anxiety. There were small but significant differences in the average age at which participants in these three groups started to learn to drive, but there were no differences in driving-related accidents and incidents over the past 12 months. Those with higher driving anxiety endorsed more anxiety about road rage, lower feelings of safety while driving, and more driving-related avoidance and negative cognitions than the less anxious participants. However, levels of helpseeking were low, and suggest the need to develop online self-help packages that are more accessible and acceptable to those experiencing driving anxiety.     

Safety behaviour does not necessarily interfere with exposure therapy

There has been much recent controversy regarding whether or not the use of safety and other neutralizing behaviour interferes with exposure-based therapy. The aim of this study was to examine the role of safety behaviour in the treatment of specific phobia. Sixty-two snake-fearful participants were randomized to a 45-min exposure session with or without the use of safety gear, such as gloves and goggles. During the treatment, participants in the safety behaviour group were able to achieve a significantly closer initial distance of approach to the snake compared to controls. When tested post-treatment without any safety gear, both groups demonstrated comparable treatment gains involving significant reductions in fearful cognitions and subjective anxiety, as well as significant improvements in distance of approach. Results suggest that reliance on safety behaviour during exposure therapy for anxiety disorders may not interfere with treatment outcome.     

Cigarette Smoking, Anxiety, and Depression

This review provides a detailed analysis of anxiety and depression as they relate to each stage of the cigarette smoking cycle: initiation, maintenance, and cessation with an emphasis on nicotine withdrawal. An analysis of the literature confirms that cigarette smoking is highly comorbid with anxiety disorders and clinical depression, and that this relationship appears to be moderated by factors such as age of the smoker, type of disorder, and level of nicotine dependence. Studies also offer evidence to suggest a relationship between smoking and both subclinical anxiety and depression. Research findings have not revealed whether common factors influence the development of anxiety, depression, and smoking, whether anxiety and depression lead to smoking, or whether the reverse is true. Nevertheless, a current understanding of the links among smoking, anxiety, and depression confirms current prevention and cessation techniques, as well as suggests new directions for research and clinical practice.     

Ethical issues in the clinical application of fMRI: factors affecting the validity and interpretation of activations

The ability of functional magnetic resonance imaging (fMRI) to localize activations in a single patient, along with the safety and widespread availability of this methodology, has lead to an increasing use of fMRI for clinical purposes such as pre-surgical planning. As methodology continues to improve and more experience with fMRI in the clinical setting is acquired, clinical functional neuroimaging will likely have an increasing influence over patient care. Therefore, ethical use of fMRI, as with other medical techniques, requires understanding the factors impacting the interpretation of the methodology. Issues affecting the validity and interpretation of clinical functional neuroimaging, including effects of altered hemodynamic response function, head motion, and structural changes in the brain, are reviewed. The distinction between correlated and necessary activation in a clinical context is discussed. Different types of statistical errors in fMRI analysis are described, along with their consequences to the patient. Finally, for the future of clinical fMRI development, the need for normative patient data, as well as standardized tasks, scan protocols, and data analyses, is discussed.     

Innovations in the treatment of anxiety psychopathology: introduction

Behavioral and cognitive interventions have an established history of efficacy for the treatment of anxiety disorders. The majority of patients receiving these empirically supported interventions for anxiety exhibit improvement and these changes tend to be maintained following treatment. Moreover, emerging data suggest that cognitive-behavioral protocols can be effectively transferred to real-world settings such as primary care practices. On the other hand, historical reviews indicate that the relative efficacy of treatments for anxiety have not substantially improved over time. A further concern is that there are relatively few innovations in the treatment of anxiety during the past 20years. Thus, we appear to have reached somewhat of a plateau with regard to treatment response, which would suggest a need to consider novel methods and approaches. This special series will describe new and innovative approaches to the treatment of anxiety psychopathology.     

Internalizing behavior problems and scholastic achievement in children: cognitive and behavioral pathways as mediators of outcome.

Examined a conceptual model in which dual developmental pathways (behavioral and cognitive) are hypothesized to account for the relation among internalizing behavior problems, intelligence, and later scholastic achievement using a cross-sectional sample of 325 children. Classroom behavior and select aspects of cognitive functioning (vigilance, short-term memory) were hypothesized to mediate the relations among internalizing problems, IQ, and long-term scholastic achievement. Hierarchical tests applied to a nested series of models demonstrated that (a) individual differences in measured intelligence among children are associated with variations in classroom performance and cognitive functioning, (b) classroom performance and cognitive functioning make unique contributions to prediction of later achievement over and above the influence of intelligence, (c) anxious/depressive features are correlated but separable constructs, and (d) anxiety/depression and withdrawal contribute to prediction of classroom performance and cognitive functioning over and above the effects of intelligence. Classroom performance and cognitive functioning thus appear to mediate the effects of internalizing behaviors as well as intelligence. Particular attention to the presence and potential impact of social withdrawal on children's functioning, both alone and concomitant with anxiety/depression, appears warranted during the course of clinical evaluations owing to the strong continuity among these variables.     

The tell-tale heart: physiological reactivity during resolution of ambiguity in youth anxiety

In the past decade, cognitive biases and physiological arousal have each been proposed as mechanisms through which paediatric anxiety develops and is maintained over time. Preliminary studies have found associations between anxious interpretations of ambiguity, physiological arousal, and avoidance, supporting theories that link cognition, psychophysiology, and behaviour. However, little is known about the relationship between youths’ resolutions of ambiguity and physiological arousal during acute stress. Such information may have important clinical implications for use of verbal self-regulation strategies and cognitive restructuring during treatments for paediatric anxiety. In this brief report, we present findings suggesting that anxious, but not typically developing, youth select avoidant goals via non-threatening resolution of ambiguity during a stressor, and that this resolution of ambiguity is accompanied by physiological reactivity (heart rate, heart rate variability, and respiratory sinus arrhythmia). We propose future empirical research on the interplay between interpretation bias, psychophysiology, and child anxiety, as well as clinical implications.