Anxiety sensitivity moderates the painful effects of feeling burdensome to others

Perceived burdensomeness (PB), the perception of being a burden to others, is associated with pain and physical symptoms. Anxiety sensitivity (AS), the fear of arousal-related sensations, arising from beliefs that the sensations may have adverse personal consequences (physical, cognitive, and social), may increase risk for pain responding, particularly in anxiety-provoking (e.g. socially threatening) contexts. Accordingly, individuals high in AS may have a stronger pain response when experiencing PB than those low in AS. Undergraduate participants (n = 262) completed the Anxiety Sensitivity Index (ASI-3), and then were randomly assigned to re-live an experience when they were either burdensome to others (burdensome condition) or contributed equally to a group (control condition). Both social and physical self-reported pain were assessed post-manipulation. Those high in AS reported significantly higher pain ratings in the burdensome condition than the control condition; for those low in AS, pain did not change across conditions. In particular, being fearful of the physical repercussions of anxiety (AS physical concerns) while also feeling burdensome to others was associated with greater physical pain. AS may exacerbate the already painful effects of feeling burdensome to others, and may have important implications for the development of future suicide- and pain-related interventions.     

Direct and Mediating Effects of an Anxiety Sensitivity Intervention on Posttraumatic Stress Disorder Symptoms in Trauma-Exposed Individuals

Anxiety sensitivity (AS), or fear of anxious arousal, is a higher-order cognitive risk-factor for posttraumatic stress disorder (PTSD) composed of lower-order physical, cognitive, and social concerns regarding anxiety symptoms. Brief and effective interventions have been developed targeting AS and its constituent components. However, there is limited evidence as to whether an intervention aimed at targeting AS would result in reductions in PTS symptoms and whether the effects on PTS symptoms would be mediated by reductions in AS. Furthermore, there is no evidence whether these mediation effects would be because of the global or more specific components of AS. The direct and indirect effects of an AS intervention on PTS symptoms were examined in a sample of 82 trauma-exposed individuals (M age = 18.84 years, SD = 1.50) selected based on elevated AS levels (i.e., 1 SD above the mean) and assigned to either a treatment (n = 40) or an active control (n = 42) condition. Results indicated that the intervention led to reductions in Month 1 PTS symptoms, controlling for baseline PTS symptoms. Furthermore, this effect was mediated by changes in global AS and AS social concerns, occurring from intervention to Week 1. These findings provide an initial support for an AS intervention in amelioration of PTS symptoms and demonstrate that it is primarily reductions in the higher-order component of AS contributing to PTS symptom reduction.     

Emotion Beliefs and Cognitive Behavioural Therapy for Social Anxiety Disorder

Despite strong support for the efficacy of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), little is known about mechanisms of change in treatment. Within the context of a randomized controlled trial of CBT, this study examined patients' beliefs about the fixed versus malleable nature of anxiety—their ‘implicit theories’—as a key variable in CBT for SAD. Compared to waitlist (n = 29; 58% female), CBT (n = 24; 52% female) led to significantly lower levels of fixed beliefs about anxiety (M_baseline = 11.70 vs. M_Post = 7.08, d = 1.27). These implicit beliefs indirectly explained CBT-related changes in social anxiety symptoms (κ² = .28, [95% CI = 0.12, 0.46]). Implicit beliefs also uniquely predicted treatment outcomes when controlling for baseline social anxiety and other kinds of maladaptive beliefs (perceived social costs, perceived social self-efficacy, and maladaptive interpersonal beliefs). Finally, implicit beliefs continued to predict social anxiety symptoms at 12 months post-treatment. These findings suggest that changes in patients' beliefs about their emotions may play an important role in CBT for SAD.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

Anxiety at 13 and its effect on pain,pain-related anxiety,and pain-related disability at 17: An ALSPAC cohort longitudinal analysis

The aim of the present study was to investigate the influence of anxiety at 13 years of age on the presence of chronic pain, pain-related anxiety, and pain-related disability at 17 years of age in a large longitudinal cohort. We hypothesized that mother-reported anxiety at 13 would be associated with the presence of chronic pain at 17 and an increase in pain-related anxiety using all available data from the longitudinal cohort. Further, we hypothesized that anxiety at 13 would predict pain-related disability in adolescents who reported chronic pain at 17 years of age. Participants were recruited from the Avon Longitudinal Study of Parents and Children based in the UK who attended a university research clinic at 17. Child anxiety (reported by the mother) was extracted at child age 13, and self-report of the presence of chronic pain, pain-related anxiety, and pain-related disability at 17. Analyses revealed that child anxiety at 13 was not significantly associated with the presence of chronic pain at 17 (n = 842). However, anxiety at 13 was significantly associated with pain-related anxiety at 17 (n = 1831). For the subsample of adolescents who reported chronic pain, anxiety at 13 was associated with pain-related disability at 17 (n = 393). Further analyses revealed that pain-related anxiety at 17 mediated the association between anxiety at 13 and pain-related disability at 17, suggesting that pain-related anxiety should be a target for treatment in adolescents with chronic pain, to reduce the impact of pain in later adolescence. General anxiety at 13 was unrelated to the presence of chronic pain at 17, but should be considered a risk factor for later pain-related anxiety and disability in a subset of adolescents who develop chronic pain.     

Differential Effects of Anxiety Sensitivity Components in the Relation Between Emotional Non-Acceptance and Post-traumatic Stress Symptoms Among Trauma-Exposed Treatment-Seeking Smokers

Anxiety sensitivity (AS), defined as the extent to which individuals believe anxiety and anxiety-related sensations have harmful consequences, may play an important explanatory role in the relation between emotional non-acceptance and the expression of traumatic stress symptoms among trauma-exposed smokers. This investigation examined whether lower-order dimensions of AS (cognitive, physical, and social concerns) differentially explain the relation between emotional non-acceptance and post-traumatic stress (PTS) symptom clusters (re-experiencing, avoidance, hyperarousal) among trauma-exposed daily smokers (N = 169, 46% female; M_age = 41, SD = 12.3). AS and its lower-order facets of cognitive and social concerns were found to mediate the relations between emotional non-acceptance and avoidance and hyperarousal PTS symptoms. Using a multiple mediation model, the mediational effect of AS cognitive concerns for the relation between emotional non-acceptance and post-traumatic avoidance symptoms was found to be uniquely evident relative to social and physical concerns. All observed AS effects were evident above and beyond the variance accounted for by gender, number of traumatic event exposure types, negative affectivity, number of cigarettes smoked per day, and alcohol use problems. The present findings suggest cognitive-based AS concerns may play a mechanistic role in the relation between emotional non-acceptance and certain PTS symptoms among trauma-exposed daily smokers.     

Anxiety sensitivity cognitive concerns drive the relation between anxiety sensitivity and symptoms of depression

Depression is typically treated as a homogeneous construct despite evidence for distinct cognitive, affective, and somatic symptom dimensions. Anxiety sensitivity (AS; the fear of consequences of anxiety symptoms) is a cognitive risk factor implicated in the development of depressive symptoms. However, it is unclear how lower order AS dimensions (i.e. physical, cognitive, and social concerns) relate to depressive symptom factors. Confirmatory factor analysis, followed by structural equation modeling, were conducted to examine the factor structure of depression and to then examine the relations between these factors and the lower order factors of AS. This study was conducted in a sample of 374 adults (M age = 35.5, 54.3% female) with elevated levels of psychopathology (89.2% meeting criteria for at least one DSM-5 diagnosis, 25.6% primary depressive disorder). In this study a two-factor model of depression, composed of Cognitive and Affective/Somatic factors, was superior to one- and three-factor solutions. AS cognitive concerns were related to both cognitive and affective/somatic symptoms of depression. Neither of the other AS dimensions was related to depression symptom dimensions. These findings provide a better understanding of the relations between AS and depression symptoms.     

Pain-Related Anxiety and Marijuana Use Motives: A Pilot Test Among Active Marijuana-Using Young Adults

The present investigation examined pain-related anxiety in regard to marijuana use motives among a sample of young adult marijuana users (N = 180; 45% women; M _age = 21.11 years, SD = 6.41). Hierarchical multiple regression analyses were used to determine the relations between pain-related anxiety and marijuana use motives. After controlling for current marijuana use frequency (past 30 days), daily cigarette smoking rate, current rate of alcohol consumption, level of bodily pain (current), and other marijuana use motives, pain-related anxiety was significantly and uniquely associated with coping and conformity motives for marijuana use. Pain-related anxiety was not significantly related to other marijuana use motives. These results offer novel empirical insight pertaining to a relation between pain-related anxiety and coping as well as conformity motives for marijuana use among active users.     

How Do Elements of a Reduced Capacity to Withstand Uncertainty Relate to the Severity of Health Anxiety?

Intolerance of uncertainty (IU)—a multidimensional cognitive vulnerability factor—is associated with a variety of anxiety disorders and health anxiety (HA). To date, few studies have assessed whether IU dimensions (prospective and inhibitory IU) are differentially associated with HA and whether their contributions are independent of anxiety sensitivity (AS). This study addressed these issues using independent community (n = 155; 81% women) and undergraduate (n = 560; 86% women) samples. Results indicated that prospective IU, but not inhibitory IU, had significant positive associations with HA in community dwellers and undergraduate students. AS somatic and cognitive concerns were also significant predictors among both samples. In addition, severity of IU dimensions among individuals reporting elevated HA were compared against individuals diagnosed with generalized anxiety disorder, social anxiety disorder, panic disorder, and obsessive–compulsive disorder. Results indicated minimal differences between those with elevated HA and each of the anxiety disorder diagnoses. Findings lend support to the unique transdiagnostic nature of IU and support commonalities between HA and anxiety disorders.     

Nature and Role of Change in Anxiety Sensitivity During NRT-Aided Cognitive-Behavioral Smoking Cessation Treatment

This study evaluated the associations between change in anxiety sensitivity (AS; fear of the negative consequences of anxiety and related sensations) and lapse and relapse during a 4-week group NRT-aided cognitive-behavioral Tobacco Intervention Program. Participants were 67 (44 women; M _age = 46.2 years, SD = 10.4) adult daily smokers. Results indicated that participants who maintained high levels of AS from pretreatment to 1 month posttreatment, compared to those who demonstrated a significant reduction in AS levels during this time period, showed a significantly increased risk for lapse and relapse. Further inspection indicated that higher continuous levels of AS physical and psychological concerns, specifically among those participants who maintained elevated levels of AS from pre- to posttreatment, predicted significantly greater risk for relapse. Findings are discussed with respect to better understanding change in AS, grounded in an emergent taxonic-dimensional factor mixture model of the construct, with respect to lapse and relapse during smoking cessation.     

Efficacy of brief guided self-help cognitive behavioral treatment for perfectionism in reducing perinatal depression and anxiety: a randomized controlled trial

Perfectionism has been proposed as a transdiagnostic process that maintains depression and anxiety through shared cognitive and behavioral processes. The purpose of this study was to investigate the efficacy of a brief, guided cognitive behavioral treatment (CBT) for perfectionism delivered via a self-help booklet in reducing perfectionism and symptoms of depression and anxiety during the antenatal period. Pregnant women in their third trimester were randomly allocated to self-help (n = 30) or waitlist control (n = 30). There were significant reductions in perfectionism and symptoms for participants who received CBT for perfectionism from pre- to post-treatment, which were maintained at 3-month follow-up, while the waitlist control group demonstrated no significant changes. Path analysis demonstrated a significant indirect effect of treatment condition on post-treatment depression and anxiety scores via perfectionism, controlling for pre-treatment scores, suggesting changes in perfectionism were associated with decreases in symptoms. The findings suggest that it would be useful for future research with larger samples to further investigate the efficacy of CBT for perfectionism for perinatal depression and anxiety.     

Multimethod assessment of treatment process in chronic low back pain: comparison of reported pain-related anxiety with directly measured physical capacity

Although cognitive behavioural treatments (CBT) have proven efficacy in improving symptom management, pain-related distress, physical performance and return to work. few studies have examined the relationship between changes in behavioural process variables during treatment and improvement in outcome variables following treatment. We designed a multimethod assessment strategy to test the relative contribution of changes in physical capacity and pain-related anxiety to treatment outcome variables. Low back pain patients (n = 59) were treated with an intensive programme of physical exercise and CBT. Comparisons from pre- to post-treatment showed significant improvement in pain severity, interference, affective distress, activity level, and depression. Improvements in pain-related anxiety were associated with improvements in all outcome variables except interference. Of three physical capacity composite scores, improvement in only one (lumbar extension and flexion capacity) was associated with improvements in all outcome variables except interference. Further analyses demonstrated that the relationship between changes in pain-related anxiety and treatment outcome were independent of changes in physical capacity performance. Changes during treatment in pain-related anxiety may be more important than changes during treatment in physical capacity when predicting the effect of treatment on behavioural outcome measures. These results are discussed in the context of how to improve assessment of the chronic pain patient and improve the effectiveness of multidisciplinary CBT.     

The Interaction of Extraversion and Anxiety Sensitivity on Social Anxiety: Evidence of Specificity Relative to Depression

Neuroticism and extraversion have been linked to the etiologies and course of anxiety and mood disorders, such that neuroticism is broadly associated with numerous disorders and extraversion is most strongly associated with social anxiety and depression. While previous research has established the broad associations between temperament and emotional disorders, less is known about the specific, proximal factors that are associated with them, and very few studies have situated these risk factors into a larger etiological model that specifies how they may relate to one another. The current study examined the interaction of extraversion and anxiety sensitivity (AS) in predicting social anxiety symptoms in a large, diagnostically diverse clinical sample (N = 826). Symptoms were assessed with self-report and dimensional interview measures, and regression analyses were performed examining the main effects and interaction of extraversion and AS (examining both total and lower-order components) on social anxiety. Results showed that at higher levels of AS, the inverse relationship between extraversion and social anxiety was stronger, and the social concerns component of AS is responsible for this effect. This interaction was also observed with regard to depression symptoms, but the interaction was not present after accounting for shared variance (i.e., comorbidity) between depression and social anxiety symptoms. Clinical and theoretical implications of the results are discussed.     

Cognitive risk factors explain the relations between neuroticism and social anxiety for males and females

The hierarchical model of vulnerabilities to emotional distress contextualizes the relation between neuroticism and social anxiety as occurring indirectly through cognitive risk factors. In particular, inhibitory intolerance of uncertainty (IU; difficulty in uncertain circumstances), fear of negative evaluation (FNE; fear of being judged negatively), and anxiety sensitivity (AS) social concerns (fear of outwardly observable anxiety) are related to social anxiety. It is unclear whether these risk factors uniquely relate to social anxiety, and whether they account for the relations between neuroticism and social anxiety. The indirect relations between neuroticism and social anxiety through these and other risk factors were examined using structural equation modeling in a sample of 462 individuals (M age = 36.56, SD = 12.93; 64.3% female). Results indicated that the relations between neuroticism and social anxiety could be explained through inhibitory IU, FNE, and AS social concerns. No gender differences were found. These findings provide support for the hierarchical model of vulnerabilities to emotional distress disorders, although the cognitive risk factors accounted for variance beyond their contribution to the relation between neuroticism and social anxiety, suggesting a more complex model than that expressed in the hierarchical model of vulnerabilities.     

Parent and Child Anxiety Sensitivity: Relationship in a Nonclinical Sample

Little is known about the relationship between parent and child anxiety sensitivity (AS), particularly in nonclinical samples. The present study examined this association in 207 healthy parent-child pairs including 244 children (mean age = 12.3 years, 103 girls) and 226 parent figures (175 mothers). Sequential multiple linear regression revealed that parent AS was significantly associated with child AS in girls, but not in boys. Parent AS accounted for 9% of incremental variance in child AS, after controlling for child age, parent depression, and parent anxiety. Analyses of parent AS dimensions indicated that the social concerns dimension accounted for 14% of incremental variance in child AS in girls only. Parent anxiety and depression showed no association with child AS, once parent AS was taken into account. The findings indicate that parent AS, especially AS social concerns, demonstrates a significant relationship with child AS in this nonclinical sample of girls.     

Tendency to Catastrophize Somatic Sensations: Pain Catastrophizing and Anxiety Sensitivity in Predicting Headache

General catastrophic thinking styles about uncomfortable bodily sensations may predispose the development of common health pathologies, such as persistent headache. The purpose of this research was to explore the relationships between the Pain Catastrophizing (PC) Scale and Anxiety Sensitivity (AS) Index, which measure tendencies to catastrophize pain‐ and anxiety‐related somatic sensations, respectively. A non‐clinical sample completed the PC Scale, AS Index, and health outcome questionnaires regarding headache (n = 1018). Results revealed that: (i) AS and PC are empirically separate constructs; (ii) the overlap between PC and AS lies within the domain of fearing physical catastrophe; (iii) AS independently predicts weekly headache, headache pain intensity, and the number of a wide range of physical symptoms associated with headache; and (iv) PC independently predicts the presence of weekly headache. Limitations and implications of this research, as well as recommendations for future research directions are discussed.     

Anxiety sensitivity and fear of pain in patients with recurring headaches.

Anxiety sensitivity (AS) plays an important role in the cognitive, affective and behavioral profiles of patients with chronic pain related to musculoskeletal injury. However, investigators have not considered whether these findings extend to patients with other classes of chronic pain. The primary purpose of this investigation was to address this issue in 72 patients with recurring headaches who completed a self-report questionnaire inventory during a treatment visit to an outpatient neurology clinic. The mean ASI score for the group (mean = 24; SD = 11) was relatively high. When patients were classified on the basis of ASI scores, 20 (28%) met criteria for high, 41 (57%) for medium and 11 (15%) for low AS. Multivariate analysis of variance confirmed that these groups differed on specific aspects of their cognitive, affective, and behavioral profiles. High AS patients reported greater depression, trait anxiety, pain-related escape/avoidance behavior and fearful appraisals of pain than did patients with medium or low AS. High AS patients also indicated greater cognitive disruption in response to pain than did patients with low AS. Groups did not differ in headache severity, physiological reactivity, change in lifestyle, anger, nor did they differ in use of over-the-counter or prescribed analgesics. Multiple regression analysis identified AS, pain-related cognitive disruption, and sensory pain experience as significant predictors of fear of pain. Lifestyle changes attributed to headache were, on the other hand, predicted by headache severity, physiological and cognitive anxiety and escape/avoidance behavior. These results provide further evidence of the important association between AS and fear responses of patients with chronic pain syndromes. Implications and future directions are discussed.     

Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People With HIV: A Clinical Case Study

Despite high rates of co-occurring tobacco use and anxiety symptoms and disorders among persons with HIV, evidence-based interventions for these individuals are not yet available. The present study sought to evaluate an integrated treatment model addressing smoking cessation and anxiety sypmtoms among HIV-positive smokers. Treatment was an 8-week intervention integrating a standard smoking cessation protocol (i.e., cognitive-behavioral therapy [CBT], nicotine replacement therapy) with CBT for anxiety. Inclusion criteria were 18–65 years of age, ≥ 10 cigarettes/day, State–Trait Anxiety Inventory [STAI-T] score of > 39, and moderate motivation (i.e., ≥ 5 out of 10 on a 10-point Likert scale) to quit smoking. Primary outcomes included scores on the Anxiety Sensitivity Index (ASI) and cigarettes smoked per day. Self-reported abstinence was biochemically verified by carbon monoxide breath analysis. Three male participants (mean age 49.3, SD = 9.1) completed through 2-month follow-up. At baseline all participants reported smoking an average of 20 cigarettes per day. Two participants quit smoking and maintained abstinence by the 2-month follow-up, and demonstrated a reduction in ASI scores. Participant 3 continued to smoke but at a reduced rate. Participants’ response to cognitive and behavioral strategies (e.g., creating balanced thoughts, interoceptive exposures) will be discussed. Clinical lessons learned include use of a flexible approach to cognitive restructuring, use of imaginal and in vivo exposures in session to better prepare patients for homework practice, and flexibility in delivering the treatment in an individual or group format. This clinical presentation provides preliminary support for the feasibility and initial effectiveness of an integrated treatment to reduce anxiety symptoms and aid in smoking cessation in anxious, HIV-positive smokers.     

The interaction of distress tolerance and intolerance of uncertainty in the prediction of symptom reduction across CBT for social anxiety disorder

Distress tolerance (DT) and intolerance of uncertainty (IU) have been identified as transdiagnostic processes that predict symptom severity across a range of distinct anxiety disorders. However, the joint effect of these two variables on therapeutic outcome has not yet been examined. It is possible that DT and IU may both impact on treatment response to cognitive-behavioural therapy (CBT) in clients with anxiety, as clients with weak DT and strong IU may be less likely to engage in exposure and cognitive restructuring tasks across treatment due to their associated distress. The purpose of this study was to examine the interaction of DT and IU as predictors of post-treatment symptom severity and treatment response to group CBT in participants with primary DSM-IV-TR diagnosed social anxiety disorder (SAD). Participants (N = 95) with SAD completed 12 weeks of manualized group CBT. Results of multilevel longitudinal analysis demonstrated an interaction effect, such that lower DT and higher IU predicted higher SAD symptom severity across the course of therapy. The findings are discussed in terms of clinical implications for the disorder-specific and transdiagnostic treatment of anxiety disorders.