Emotion regulation difficulties associated with the experience of uncued panic attacks: evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity

Emotion regulation difficulties among nonclinical uncued panickers were examined in two studies. In Study 1, participants with a recent history of uncued panic attacks (n  =  91), compared to a nonpanic sample (n  =  91), reported significantly greater levels of experiential avoidance, lack of emotional acceptance, and lack of emotional clarity. In Study 2, a subset of uncued panickers and nonpanickers from Study 1 (n = 17 per group) viewed positive and negative emotion-eliciting film clips. Despite comparable levels of self-reported distress and physiological arousal, panickers reported using more emotionally avoidant regulation strategies during both film clips. Panic participants also responded with greater negative emotion to the positive emotion-eliciting clip. Results are discussed in terms of their research and clinical implications.     

Change in Dysfunctional Beliefs About Sleep in Behavior Therapy,Cognitive Therapy,and Cognitive-Behavioral Therapy for Insomnia

As part of a larger randomized controlled trial, 188 participants were randomized to behavior therapy (BT), cognitive therapy (CT), or cognitive-behavioral therapy (CBT) for insomnia. The aims of this study were threefold: (a) to determine whether change in dysfunctional beliefs about sleep was related to change in sleep, insomnia symptoms, and impairment following treatment; (b) to determine whether BT, CT, and CBT differ in their effects on dysfunctional beliefs; and (c) to determine whether the treatments differ in their effects on particular kinds of dysfunctional beliefs. Beliefs, sleep, insomnia symptoms, and sleep-related psychosocial impairment were assessed at pretreatment, posttreatment, and 6- and 12-month follow-up. Greater change in dysfunctional beliefs occurring over the course of BT, CT, or CBT was associated with greater improvement in insomnia symptoms and impairment at posttreatment and both follow-ups. All groups experienced a significant decrease in dysfunctional beliefs during treatment, which were sustained through 6- and 12-month follow-up. Compared with the BT group, a greater proportion of participants in the CT and/or CBT groups endorsed dysfunctional beliefs below a level considered clinically significant at posttreatment and 12-month follow-up. The results demonstrate the importance of targeting dysfunctional beliefs in insomnia treatment, suggest that beliefs may be significantly modified with BT alone, and indicate that cognitive interventions may be particularly powerful in enhancing belief change.     

Treatment with medications affecting dopaminergic and serotonergic mechanisms: effects on fluency and anxiety in persons who stutter

Medications with dopamine antagonist properties, such as haloperidol, and those with serotonin reuptake inhibitor properties, such as clomipramine, have been shown to improve fluency. To examine the degree to which each of these two pharmacological mechanisms might independently affect fluency, a selective serotonin reuptake inhibitor, paroxetine, and a selective dopamine (D-2) antagonist, pimozide, were evaluated. Both types of medications also affect mood and anxiety, factors that could influence fluency levels. Therefore, we also evaluated the medications’ effects on generalized and speech-related anxiety and the relationships between changes in anxiety and changes in fluency in 11 subjects with a history of developmental stuttering. The randomized, double blind, placebo-controlled crossover study that was designed had to be terminated prior to completion due to severe side effects following withdrawal from paroxetine. Even with a reduced sample size (n = 6), significant improvement in percent fluent speaking time (p = 0.02) was found using a telephone task between baseline and pimozide (n = 6), with average duration of dysfluencies significantly shorter (p = 0.04) but no significant difference in the estimated number of dysfluencies per minute. This significant improvement was associated with non-significant increases in generalized anxiety, but non-significant decreases in speech-related anxiety. No significant differences were found in fluency between baseline and paroxetine (n = 5). These preliminary results suggest that fluency improvement is more likely to be mediated by dopaminergic rather than serotonergic mechanisms. Due to its side effects, however, pimozide may be considered a risk for treatment of stuttering.

Educational objectives: As a result of reading this paper the reader will describe and explain: (1) how medications may affect fluency and the rationale for selecting medications for treatment trials; (2) the interrelationship between fluency and anxiety; and (3) factors important in developing clinical trials using medications.     

A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania

This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.     

Cognitive Behavioral Treatment of Panic Disorder and Agoraphobia in a Multiethnic Urban Outpatient Clinic: Initial Presentation and Treatment Outcome

Few studies examine the effectiveness of panic control treatment across diverse ethnic groups. In this paper we present data on 40 patients (African American, n = 24; Caucasian, n = 16) with panic disorder and comorbid agoraphobia who presented at an anxiety disorder clinic in an inner-city area. On initial assessment both groups were similar on psychometric measures, and both groups moderately improved with treatment though significant residual symptoms remained. We illustrate, through case examples, a variety of clinical issues that need to be addressed when providing treatment to multiethnic African American clients with panic disorder and agoraphobia.     

Perceived teasing experiences in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about imagined or slight defects in their appearance (e.g., asymmetrical facial features). Cognitive-behavioral models of BDD propose that several factors, including dysfunctional appearance-related beliefs and life experiences, such as teasing, contribute to the avoidance behaviors or rituals (e.g., mirror checking, grooming) characteristic of BDD. Previous research has demonstrated an association between perceived teasing and body dissatisfaction. In the current study, we examined whether individuals with BDD (n = 16) report to have been teased more often than do mentally healthy controls (n = 17). The group comprising individuals with BDD reported more appearance- and competency-related teasing than did control participants. This study provides preliminary evidence for the association between perceived teasing and BDD.     

Characteristics of stuttering-like disfluencies in Dutch-speaking children

The purpose of this study was to compare the characteristics of stuttering-like disfluencies in a group of native Dutch-speaking children who stutter (n = 693), with a group of normally fluent children (n = 79). Methods involved the observation of stuttering-like disfluencies in participants’ conversational speech samples (total 77,200 words), particularly the frequency, duration and physical tension of instances of stuttering. Findings indicate that stuttering-like disfluencies exhibited by children who stutter are significantly more frequent, longer in duration and involve more physical tension when compared to those of normally fluent children. Furthermore, applying a criterion of 3% stuttering-like disfluencies to distinguish stuttering from normally fluent children resulted in a high degree of sensitivity (0.9452) and specificity (0.9747). Results were taken to suggest that characteristics of stuttering-like disfluencies of Dutch-speaking children are similar to those of English-speaking children and that talker group membership criteria for childhood stuttering can reasonably be extrapolated from the Dutch to the English language and vice versa.

Educational objectives: The reader will be able to: (1) describe characteristics of stuttering-like disfluencies, (2) define properties such as frequency, duration and physical tension for stuttering children and normally fluent children, and (3) make use of data on sensitivity and specificity of the criterion of 3% stuttering-like disfluencies to distinguish stuttering and normally fluent children.     

Behavioural treatment of trichotillomania: two-year follow-up results

Post-treatment evaluation studies of behaviour therapy (BT) for trichotillomania (TTM) have shown that BT is successful in reducing symptoms in this impulse-control disorder. The present study was aimed at investigating gain maintenance at long-term follow-up. TTM-related symptoms and other symptom characteristics were evaluated in 28 patients suffering from TTM before and after brief BT and at a 3-month and 2-year follow-up. The manual-based BT consisted of self-control procedures offered in six sessions. Pre-post effect sizes for TTM symptoms at post-treatment evaluation and at the two follow-ups were 2.91, 1.47, and .87. Compared to the post-treatment effects, the 3-month and 2-year follow-up effect sizes had decreased by 49% and 70%, respectively. Better 2-year follow-up results were associated with lower pre-treatment levels of depressive symptoms and with complete abstinence from hair pulling immediately after treatment.     

Behavioral Activation as an Early Intervention for Posttraumatic Stress Disorder and Depression Among Physically Injured Trauma Survivors

This paper describes an adaptation of behavioral activation (BA) for the early intervention of posttraumatic stress disorder (PTSD) and depression among physically injured survivors of traumatic injury, and presents pilot data on a small randomized effectiveness trial (N = 8). The application of BA to PTSD is based on the theory that increases in guided activity may break patterns of avoidance that can maintain PTSD. Compared to treatment as usual (TAU), those who received BA showed improvement in PTSD symptom severity from pre- to posttreatment, and there was a trend for the BA group to score better than the TAU group on physical functioning. Contrary to expectation, this brief adaptation did not have an impact on depression. Implications of these results for the effective early intervention after trauma are discussed.     

Autobiographical memory in posttraumatic stress disorder before and after treatment

Although overgeneral retrieval of autobiographical memories has been repeatedly demonstrated in posttraumatic stress disorder (PTSD), no studies have indexed overgeneral retrieval before and after treatment of PTSD. Autobiographical memory was assessed in PTSD participants (n=20) prior to commencing cognitive behaviour therapy and 6 months after therapy completion. Fifteen participants completed both assessments. Improvement in PTSD symptoms was significantly associated with improved retrieval of specific memories and decreased retrieval of categoric memories in response to positive cues. These data suggest that symptom reduction during treatment of PTSD leads to greater access to specific memories of positive experiences.     

A meta-analytic review of cognitive processing therapy for adults with posttraumatic stress disorder

Numerous studies have demonstrated the efficacy of cognitive processing therapy (CPT) for treating posttraumatic stress disorder (PTSD). Two prior meta-analyses of studies are available but used approaches that limit conclusions that can be drawn regarding the impact of CPT on PTSD outcomes. The current meta-analysis reviewed outcomes of trials that tested the efficacy of CPT for PTSD in adults and evaluated potential moderators of outcomes. All published trials comparing CPT against an inactive control condition (i.e. psychological placebo or wait-list) or other active treatment for PTSD in adults were included, resulting in 11 studies with a total of 1130 participants. CPT outperformed inactive control conditions on PTSD outcome measures at posttreatment (mean Hedges’ g = 1.24) and follow-up (mean Hedges’ g = 0.90). The average CPT-treated participant fared better than 89% of those in inactive control conditions at posttreatment and 82% at follow-up. Results also showed that CPT outperformed inactive control conditions on non-PTSD outcome measures at posttreatment and follow-up and that CPT outperformed other active treatments at posttreatment but not at follow-up. Effect sizes of CPT on PTSD symptoms were not significantly moderated by participant age, number of treatment sessions, total sample size, length of follow-up, or group versus individual treatment; but, older studies had larger effect sizes and percent female sex moderated the effect of CPT on non-PTSD outcomes. These meta-analytic findings indicate that CPT is an effective PTSD treatment with lasting benefits across a range of outcomes.     

Phoneme monitoring in silent naming and perception in adults who stutter

The present study investigated phonological encoding skills in persons who stutter (PWS). Participants were 10 PWS (M = 31.8 years, S.D. = 5.9) matched for age, gender, and handedness with 12 persons who do not stutter (PNS) (M = 24.3 years, S.D. = 4.3). The groups were compared in a phoneme monitoring task performed during silent picture naming. The phonological complexity of the target items in the task was varied such that participants monitored either compound words or noun phrases. Performance in this task was compared to phoneme monitoring performed on aurally presented target words to investigate whether any differences observed in silent naming were also evident in perception. Analysis of the response time data, in milliseconds, indicated that PWS were significantly slower as compared to PNS in phoneme monitoring during silent naming; group differences were not obtained in the perception task. The groups were also comparable in the response time to phoneme monitoring within compound words and noun phrases in both silent naming and perception. The findings suggested that PWS were slower in the encoding of segmental, phonological units during silent naming. Furthermore, absence of such differences in perception ruled out a general monitoring deficit in PWS. Findings are interpreted within the context of the psycholinguistic theories of stuttering that postulate phonological encoding and/or monitoring as a causal variable in stuttering.

Educational objectives: As a result of this activity, the participant should: (1) describe relevant literature on phonological encoding skills in children and adults who stutter, (2) identify paradigms that can be used to investigate phonological processing in PWS, and (3) discuss the role of phonological encoding in speech production.     

Isolating the Effects of Mindfulness Training Across Anxiety Disorder Diagnoses in the Unified Protocol

The Unified Protocol for Transdiagnostic Treatment (UP; Barlow et al., 2011) has recently demonstrated statistically equivalent therapeutic effects compared to leading cognitive behavioral therapy (CBT) protocols for anxiety disorders designed to address disorder-specific symptoms (i.e., single-disorder protocols [SDP]); Barlow et al., 2017). Although all treatment protocols included similar evidence-based CBT elements, investigation of those related to symptom improvement in the UP is warranted. Because the UP is unique from the SDPs for its inclusion of mindfulness, the present study evaluated mindfulness as a primary treatment element. We explored whether UP participants, compared to SDP, demonstrated greater improvements in mindfulness from pre- to posttreatment, and whether these improvements predicted posttreatment severity across anxiety disorder diagnoses. Participants were individuals with a principle anxiety disorder (N = 179) randomized to receive either the UP or SDP. Results indicated significant improvements pre- to posttreatment in mindfulness for participants receiving either the UP or SDP. However, at posttreatment, mindfulness scores were significantly greater for the UP condition. At the diagnosis level, posttreatment scores in mindfulness were significantly greater in the UP condition than the respective SDP conditions for principal Generalized Anxiety Disorder (GAD) and Social Anxiety Disorder (SOC). Moreover, results suggest that change in mindfulness is related to posttreatment severity, when moderated by treatment condition, but only for participants with principal GAD. Taken together, the UP is effective in improving mindfulness in a sample with heterogeneous anxiety disorders, but this change seems particularly relevant for reduction in symptom severity for individuals with principal GAD.     

Behavioral Therapy Teams for Obsessive-Compulsive Disorder: Lessons Learned From a Pilot Randomized Trial in a Community Mental Health Center

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.     

An investigation of the relationship between cognitive reactivity and rumination

Teasdale’s (Teasdale, J.D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2, 247–274) differential activation hypothesis refers to the ease with which maladaptive cognitive processes are triggered by mild dysphoria as cognitive reactivity. Supporting this model is evidence of a differential association between sad mood and dysfunctional cognitions in formerly depressed and never-depressed individuals and the finding that cognitive reactivity predicts depression recurrence in remitted depressives. The Leiden Index of Depression Sensitivity–Revised (LEIDS-R; Van der Does, A.J.W., Williams, J.M.G. (2003). Leiden Index of Depression Sensitivity–Revised (LEIDS-R). Retrieved September 4, 2007, from http://www.dousa.nl/publications_depression.htm#LEIDS) is a recently developed self-report measure that provides clinicians and researchers with a time-efficient means by which to assess cognitive reactivity. This study investigated the relationship between cognitive reactivity (indexed by the LEIDS-R) and depressive rumination in a nonclinical sample (N = 324). As predicted, partial correlations between the LEIDS-R (subscale and Total scores) and the Ruminative Response Scale (RRS; Nolen-Hoeksema, S., and Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake. Journal of Personality and Social Psychology, 61, 115–121) were significant after controlling for current depressive symptoms. A subsample of participants (n= 130) was administered a structured interview to determine current and past depression diagnostic status. Recovered depressed individuals scored more highly on the LEIDS-R Total and LEIDS-R Rumination subscale; however, the groups did not differ on the remaining subscales. Regression analyses indicated that (across all participants) LEIDS-R Total made a unique contribution to the prediction of depression over and above trait level of depressive rumination. Overall, the LEIDS-R is a time-efficient self-report index of cognitive reactivity that demonstrates promise in distinguishing recovered and never-depressed individuals.     

Taxometric Investigation of PTSD: data from two nationally representative samples

Current psychiatric nosology depicts posttraumatic stress disorder (PTSD) as a discrete diagnostic category. However, only one study has examined the latent structure of PTSD, and this study suggested that PTSD may be more accurately conceptualized as an extreme reaction to traumatic life events rather than a discrete clinical syndrome. To build on the existing literature base, the present research examined the latent structure of posttraumatic stress reactions by applying three taxometric procedures (MAXEIG, MAMBAC, and L-Mode) to data collected from large nationally representative samples of women (ns = 2684 and 3033) and adolescents (n = 3775). Results consistently provided evidence for a dimensional PTSD solution across samples and statistical procedures. These findings have important implications for the theory, assessment, and investigation of posttraumatic stress reactions.     

A comparison of the relative efficacy of self-control therapy and a behavioral problem-solving therapy for depression in children

Twenty-nine children 9 to 12 years old who were identified as moderately to severely depressed using the Children's Depression Inventory were randomly assigned to either a self-control, behavioral problem-solving, or waiting list condition. The self-control treatment focused on teaching children self-management skills. The behavioral problem-solving therapy consisted of education, self-monitoring of pleasant events, and group problem solving directed toward improving social behavior. Subjects were assessed pre-and posttreatment and at 8-week follow-up with multiple assessment procedures and from multiple perspectives. At posttreatment, subjects in both active treatments reported significant improvement on self-report and interview measures of depression while subjects in the waiting list condition reported minimal change. Results were maintained at follow-up. The general success of the experimental treatments was discussed and recommendations for further treatment components were provided.Second authorship on this article is shared by Drs. Reynolds and Kaslow. The authors would like to thank Mr. Ed Guzwieski, Principal, and the teachers of Oregon Middle School for their cooperation with this study. The authors also would like to thank Mary Wysopal for conducting the posttreatment and follow-up interviews, and Carol Fairbanks for rating the audiotapes.     

Exposure-based cognitive behavior therapy for atopic dermatitis: an open trial

Atopic dermatitis (AD) is a common and debilitating inflammatory dermatological disorder and is marked by itch and inflamed skin. Scratching, sleep loss, and avoidance of situations associated with more AD symptoms are central hypothesized mechanisms that perpetuate the disorder and cause reduced quality of life. We developed an exposure-based cognitive behavioral treatment (CBT) that entailed mindfulness practice as a means to increase tolerance for aversive experiences during exposure. The aim of the present study was to test the treatment’s acceptability and preliminary efficacy in adults with AD. We used an uncontrolled pretest-posttest design and recruited participants (N = 9) from a university hospital dermatological clinic. The treatment comprised 10 weekly sessions over 10 weeks and assessments of AD symptoms as well as psychiatric symptoms and quality of life were conducted at baseline, posttreatment and 6-month follow-up. The results showed significant and large baseline to posttreatment improvements on self-reported measures of AD symptoms (p = .020) and general anxiety (p = .005), but there was no significant improvement in depression or quality of life. Treatment satisfaction was high and a majority of participants (67%) completed the treatment. We conclude that exposure-based CBT for adult AD can be feasible, acceptable, and potentially efficacious.     

Accuracy of the DIBELS Oral Reading Fluency Measure for Predicting Third Grade Reading Comprehension Outcomes

We evaluated the validity of DIBELS (Dynamic Indicators of Basic Early Literacy Skills) ORF (Oral Reading Fluency) for predicting performance on the Florida Comprehensive Assessment Test (FCAT-SSS) and Stanford Achievement Test (SAT-10) reading comprehension measures. The usefulness of previously established ORF risk-level cutoffs [Good, R.H., Simmons, D.C., and Kame’enui, E.J. (2001). The importance and decision-making utility of a continuum of fluency-based indicators of foundational reading skills for third-grade high-stakes outcomes. Scientific Studies of Reading, 5, 257–288.] for third grade students were evaluated on calibration (n_S1 = 16,539) and cross-validation (n_S2 = 16,908) samples representative of Florida's Reading First population. The strongest correlations were the third (February/March) administration of ORF with both FCAT-SSS and SAT-10 (r_S = .70–.71), when the three tests were administered concurrently. Recalibrated ORF risk-level cut scores derived from ROC (receiver-operating characteristic) curve analyses produced more accurate identification of true positives than previously established benchmarks. The recalibrated risk-level cut scores predict performance on the FCAT-SSS equally well for students from different socio-economic, language, and race/ethnicity categories.     

Parent-child interaction therapy for Mexican Americans: results of a pilot randomized clinical trial at follow-up

We examined treatment effects over a 6- to 24-month period posttreatment for 3 different interventions for externalizing behavior problems in young Mexican American (MA) children: a culturally modified version of Parent–Child Interaction Therapy (PCIT), called Guiando a Niños Activos (GANA), standard PCIT, and treatment as usual (TAU). Fifty-eight MA families with a 3- to 7-year-old child with clinically significant behavior problems were randomly assigned to GANA, standard PCIT, or TAU. As previously reported, all three treatment approaches produced significant pre-post improvement in conduct problems across a wide variety of parent-report measures, and those effects remained significant over the follow-up period. GANA produced results that were significantly superior to TAU on 6 out of 10 parent-report measures 6 to 24 months posttreatment, and GANA significantly outperformed PCIT on child internalizing symptoms. However, PCIT and TAU did not differ significantly from one another. These data suggest that both PCIT and GANA produce treatment gains that are maintained over time, and that GANA continues to outperform TAU over the long term.