Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

Differentiating anxiety and depression in older adults with generalized anxiety disorder

To examine affect and cognition in differentiating anxiety and depression, 83 older participants with generalized anxiety disorder completed the Cognitive Checklist (CCL) and the Positive and Negative Affect Schedule (PANAS). A 3-factor solution was found for the PANAS: positive affect (PA), anxiety and anger (Negative Affect 1 [NA-1]), and guilt and shame (Negative Affect 2 [NA-2]). A 2-factor structure was noted for the CCL. Correlations with anxiety and depression measures suggested that the CCL Depression (CCL-D) subscale showed stronger correlations with depression, whereas the CCL Anxiety subscale did not uniquely correlate with anxiety. The NA-1 subscale correlated positively with measures of depression and anxiety, whereas the PA subscale showed negative correlations. Hierarchical regression suggested that the CCL-D subscale was a significant predictor of self-reported depression.     

Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa

This study examined the relationship between therapeutic alliance and primary symptom change (weight gain) during CBT for anorexia nervosa. The aims were threefold: (1) to establish the strength of the therapeutic alliance across the treatment, (2) to determine whether early therapeutic alliance is associated with the completion of CBT for this client group, and (3) to determine the direction of the relationship between therapeutic alliance and weight gain. Adult outpatients (N = 65) with a diagnosis of anorexia nervosa (or atypical anorexia nervosa) completed a measure of alliance at session six and at the end of treatment. Weight was recorded at the start of treatment, session six and at the end of treatment. The strength of the alliance was consistently high in the sample. However, early therapeutic alliance was not associated with either the likelihood of completing treatment or subsequent weight gain. In contrast, both early and later weight gain were associated with the strength of subsequent alliance. These findings indicate that it might be advisable to focus on techniques to drive weight gain rather than rely on the therapeutic alliance to bring about therapeutic change.     

Applied relaxation vs. cognitive therapy in the treatment of generalized anxiety disorder

The present study investigated the efficacy of a coping-technique, applied relaxation (AR) and cognitive therapy (CT), in the treatment of generalized anxiety disorder. Thirty-six outpatients fulfilling the DSM-III-R criteria for generalized anxiety were assessed with independent assessor ratings and self-report scales before and after treatment and at a 1 yr follow-up. The patients were randomized and treated individually for 12 weekly sessions. The results showed that both treatments yielded large improvements, which were maintained, or furthered at follow-up. There was no difference between AR and CT on any measure. The drop-out rate was 12% for AR and 5% for CT. The proportions of clinically significantly improved patients were 53 and 62% at post-treatment and 67 and 56% at follow-up for AR and CT, respectively. Besides affecting generalized anxiety the treatments also yielded marked and lasting changes on ratings of worry, cognitive and somatic anxiety and depression. The conclusion that can be drawn is that both AR and CT have potential as treatments for generalized anxiety disorder but they have to be developed further in order to increase the efficacy to the level usually seen in panic disorder, 80-85% clinically improved.     

A follow-up study of cognitive bias in generalized anxiety disorder

Patients with generalized anxiety disorder (GAD) without concurrent depression (n = 11) and normal controls (n = 17) were tested twice, about 2 months apart, on a modified Stroop colour-naming task, which presented anxiety-related, depression-related and neutral words in masked and unmasked exposure conditions. GAD patients received cognitive behaviour therapy in the test-retest interval, and were also retested at follow-up, about 20 months after initial testing. GAD patients showed interference in colour-naming negative words across both masked and unmasked conditions before treatment, but not post-treatment, compared with controls. Reduced interference effects of masked threat words over time correlated with reduced ratings of anxious thoughts at post-treatment, and at follow-up, in GAD patients. Thus, the preconscious bias for threat information in GAD appears to vary over time in association with changes in anxious thoughts and worries.     

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

Mindfulness-based stress reduction (MBSR) has been reported to reduce anxiety in a broad range of clinical populations. However, its efficacy in alleviating core symptoms of specific anxiety disorders is not well established. We conducted a randomized trial to evaluate how well MBSR compared to a first-line psychological intervention for social anxiety disorder (SAD). Fifty-three patients with DSM-IV generalized SAD were randomized to an 8-week course of MBSR or 12 weekly sessions of cognitive-behavioral group therapy (CBGT). Although patients in both treatment groups improved, patients receiving CBGT had significantly lower scores on clinician- and patient-rated measures of social anxiety. Response and remission rates were also significantly greater with CBGT. Both interventions were comparable in improving mood, functionality and quality of life. The results confirm that CBGT is the treatment of choice of generalized SAD and suggest that MBSR may have some benefit in the treatment of generalized SAD.     

Outcome predictors in guided and unguided self-help for social anxiety disorder

Internet-based self-help with therapist guidance has shown promise as an effective treatment and may increase access to evidence-based psychological treatment for social anxiety disorder (SAD). Although unguided self-help has been suggested primarily as a population-based preventive intervention, some studies indicate that patients with SAD may profit from unguided self-help. Gaining knowledge about predictors of outcome in guided and unguided self-help for SAD is important to ensure that these interventions can be offered to those who are most likely to respond. Utilizing a sample of 245 patients who received either guided or unguided self-help for SAD, the present study examined pre-treatment symptoms and program factors as predictors of treatment adherence and outcome. The results were in line with previous findings from the face-to-face treatment literature: namely, the intensity of baseline SAD symptoms, but not depressive symptoms, predicted treatment outcomes in both unguided and guided self-help groups. Outcomes were unrelated to whether a participant has generalized versus specific SAD. Furthermore, for the unguided self-help group, higher credibility ratings of the treatment program were associated with increased treatment adherence. The findings suggest that guided and unguided self-help may increase access to SAD treatment in a population that is more heterogeneous than previously assumed.     

Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles,social anxiety,and depression

Despite their apparent implications for social functioning, adult attachment styles have never been specifically explored among persons with social anxiety disorder. In the current study, a cluster analysis of the Revised Adult Attachment Scale (N. L. Collins, 1996) revealed that 118 patients with social anxiety were best represented by anxious and secure attachment style clusters. Members of the anxious attachment cluster exhibited more severe social anxiety and avoidance, greater depression, greater impairment, and lower life satisfaction than members of the secure attachment cluster. This pattern was replicated in a separate sample of 56 patients and compared with the pattern found in 36 control participants. Social anxiety mediated the association between attachment insecurity and depression. Findings are discussed in the context of their relevance to the etiology, maintenance, and cognitive-behavioral treatment of social anxiety disorder.     

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

ABSTRACT

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.     

Stress reactivity in social anxiety disorder with and without comorbid depression

Previous research on neuroendocrine responding to a psychological stressor in individuals with Social Anxiety Disorder (SAD) has provided inconsistent results. A recent meta-analysis concluded that Major Depressive Disorder (MDD), which is frequently comorbid with SAD, is associated with blunted stress reactivity. It is, thus, possible that comorbidity status contributes to the inconsistent findings in the SAD literature. In this study, salivary cortisol responses to a psychological stressor were examined in three groups: healthy controls (CTL), SAD, and SAD with comorbid MDD (COM). The SAD group differed from the other two groups in their cortisol stress reactivity. It is important to note that analyses combining participants with SAD with and without comorbid MDD obscured findings of cortisol reactivity. In addition, the differences in cortisol reactivity cannot be accounted for by participants' affective responses to the stressor. The current findings indicate that individuals with SAD exhibit distinct stress-related cortisol responses depending on their comorbidity statuses.     

Sleep quality and treatment of social anxiety disorder

Background and Objectives: Poor sleep is prevalent among individuals with social anxiety disorder (SAD) and may affect treatment outcome. We examined whether: (1) individuals with SAD differed from healthy controls (HCs) in sleep quality, (2) baseline sleep quality moderated the effects of treatment (Cognitive–behavioral group therapy [CBGT] vs. mindfulness-based stress reduction [MBSR] vs. waitlist [WL]) on social anxiety, (3) sleep quality changed over treatment, and (4) changes in sleep quality predicted anxiety 12-months post-treatment.

Design: Participants were 108 adults with SAD from a randomized controlled trial of CBGT vs. MBSR vs. WL and 38 HCs.

Methods: SAD and sleep quality were assessed pre-treatment and post-treatment; SAD was assessed again 12-months post-treatment.

Results: Participants with SAD reported poorer sleep quality than HCs. The effect of treatment condition on post-treatment social anxiety did not differ as a function of baseline sleep quality. Sleep quality improved in MBSR, significantly more than WL, but not CBGT. Sleep quality change from pre- to post-treatment in CBGT or MBSR did not predict later social anxiety.

Conclusions: MBSR, and not CBGT, improved sleep quality among participants. Other results were inconsistent with prior research; possible explanations, limitations, and implications for future research are discussed. ClinicalTrials.gov identifier: NCT02036658.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

Preliminary tests of a cognitive model of generalized anxiety disorder.

Although worry is the central feature of Generalised Anxiety Disorder (GAD), little is known about the factors that contribute to pathological or problematic worry. In a recent cognitive model of GAD, Wells, A. (1995) proposed that negative appraisal of worrying itself (meta-worry or type 2 worry) should be distinguished from other types of worrying (type 1 worry). A central feature of this model is the idea that individuals with GAD hold rigid positive beliefs about the usefulness of worrying as a coping strategy. However, these individuals also hold negative beliefs and appraise worrying as uncontrollable and dangerous. This combination of cognitions and associated responses leads to an increased frequency and generality of worrying, and thus to the pathological worry characteristic of GAD. This paper reports a preliminary test of the hypothesis that meta-worry contributes to problematic and pathological worrying, and this relationship is independent of the frequency of other types of worry. In testing for associations between worry dimensions we controlled for overlaps with Trait anxiety, and the controllability of worrying. Results of a series of regression analyses support the hypothesis that pathological worry is associated with meta-worry and this association is independent of Trait-anxiety and type 1 worry. The clinical implications of these data are briefly discussed.     

Investigating trajectories of change in psychological distress amongst patients with depression and generalised anxiety disorder treated with internet cognitive behavioural therapy

Internet based cognitive behavioural therapy (CBT) is efficacious for the treatment of anxiety and depression. The current study aimed to examine the effectiveness of internet based CBT prescribed by primary care clinicians for the treatment of depression and generalised anxiety disorder. Psychological distress data from 302 patients who completed an online CBT course for depression and 361 patients who completed an online CBT course for generalised anxiety disorder were subjected to growth mixture analysis. For both disorders psychological distress decreased across each lesson in a quadratic trend. Two classes of individuals were identified with different trajectories of change: a large group of individuals who responded well to the courses and a smaller group of individuals with a lower response. Both groups were similar with respect to socio-demographic characteristics however the Low Responders tended to have higher levels of symptom severity and psychological distress at baseline in comparison to the responders. For the majority of patients (75-80%) the internet CBT courses for depression and generalised anxiety disorder were effective. Further research is required to identify and effectively treat the smaller proportion of patients who did not improve during internet CBT.