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.     

A transdiagnostic examination of intolerance of uncertainty across anxiety and depressive disorders

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N=218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.     

A Transdiagnostic Examination of Intolerance of Uncertainty Across Anxiety and Depressive Disorders

Intolerance of uncertainty (IU) has been identified as a potential maintaining factor for generalised anxiety disorder; however, there is a growing evidence to suggest that IU may contribute to other anxiety and depressive disorders. Moreover, certain components of IU (namely prospective and inhibitory IU) have been shown to be differentially associated with symptoms of emotional disorders. The aim of this study was to determine the extent to which individuals with various anxiety and depressive disorders endorsed IU, firstly as a trait variable (with prospective and inhibitory components) and secondly in reference to regularly occurring, diagnostically relevant situations (situation-specific IU). The degree to which diagnosis predicted IU was examined in a highly comorbid clinical sample (N = 218). Regardless of specific diagnoses, the degree of comorbidity emerged as a significant predictor of prospective IU and situation-specific IU. Conversely, specific diagnoses of social phobia, generalised anxiety disorder, depression, and obsessive compulsive disorder were uniquely related to inhibitory IU. These findings suggest that IU is a transdiagnostic construct and have implications for current diagnosis-specific and transdiagnostic theory and clinical practice.     

Secondary Transfer Effect of Intergroup Contact: The Role of Intergroup Attitudes,Intergroup Anxiety and Perspective Taking

We conducted a field study to investigate the secondary transfer effect of intergroup contact, consisting in the generalisation of the positive effects of intergroup contact to outgroups uninvolved in the contact situation. Italian secondary school students (N = 175) filled out a questionnaire; the effects of prior contact were statistically controlled. Results showed that contact with immigrants improved attitudes toward them. In turn, these attitudes generalised to attitudes toward two dissimilar outgroups not directly involved in contact: disabled and homosexuals. Notably, we found evidence for a secondary transfer effect of intergroup anxiety and perspective taking, which generalised from immigrants to the disabled and homosexuals. Evidence was found for the mediating role of intergroup attitudes, intergroup anxiety and perspective taking. The theoretical and practical implications of findings are discussed. Copyright © 2011 John Wiley & Sons, Ltd.     

Trait versus situation-specific intolerance of uncertainty in a clinical sample with anxiety and depressive disorders

Intolerance of uncertainty (IU) has been most heavily implicated in the development and maintenance of generalised anxiety disorder; however, recent research has supported the transdiagnostic conceptualisation of IU by demonstrating that IU contributes to a broad array of symptoms associated with multiple anxiety and depressive disorders. The aim of this study was to examine IU firstly as a trait variable and secondly in reference to a regularly occurring, diagnostically relevant situation in a large clinical sample (N = 218). A measure of situation-specific IU (the Intolerance of Uncertainty Scale-Situation-Specific Version; IUS-SS) is presented. The IUS-SS was found to have a unitary factor structure and high internal consistency. Participants reported significantly more situation-specific IU compared to trait IU. Discriminant validity was indicated by lack of significant relationships with measures of extraversion and alcohol use. Supporting the convergent validity and transdiagnostic nature of the scale, the IUS-SS was positively associated with neuroticism and symptoms of generalised anxiety disorder and social phobia, and explained unique variance in symptoms of depression and panic disorder above and beyond trait IU. Theoretical and clinical implications are discussed.     

Thought-action fusion and anxiety disorders symptoms in normal adolescents.

The present study examined thought-action fusion (TAF) in a large sample of normal adolescents (n=427). Participants completed the Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) and scales measuring trait anxiety, symptoms of obsessive-compulsive disorder, other anxiety disorders, and depression. Results showed that the TAFQ-A is a reliable instrument assessing two dimensions of TAF, viz. Morality (i.e., the belief that unacceptable thoughts are morally equivalent to overt actions) and Likelihood (i.e., the belief that thinking of an unacceptable or disturbing situation will increase the probability that that situation actually occurs). Furthermore, TAF was not only associated with symptoms of OCD, but also with symptoms of other anxiety disorders and depression. However, when controlling for levels of trait anxiety, most connections between TAF and anxiety disorders symptoms disappeared. Symptoms of OCD and generalised anxiety remained significantly related to TAF. Altogether, the data are supportive of the notion that TAF is involved in a broad range of anxiety disorders and in particular OCD.     

Threat interpretation bias as a vulnerability factor in childhood anxiety disorders

The present study examined threat interpretation biases in children 7-12 years of age with separation, social and generalised anxiety disorders (N=15), non-anxious offspring at risk due to parental anxiety (N=16) and non-anxious controls of non-anxious parents (N=14). Children provided interpretations of ambiguous situations to assess cognitive, emotional and behavioural responses. In comparison with non-anxious control children and at-risk children who did not differ from each other, anxious children reported stronger negative emotion and less ability to influence ambiguous situations. These results suggest that threat interpretation bias may be a cognitive factor associated with ongoing childhood anxiety but not a vulnerability factor associated with parental anxiety.     

Humanistic‐experiential therapies in the treatment of generalised anxiety: A perspective

This study discusses the current status of evidence‐based psychological therapies for generalised anxiety disorder (GAD). It points to the dominance of cognitive‐behavioural therapies (CBTs) and compares this dominance with the position of humanistic‐experiential therapies (HEPs) in this area. The paper hypothesises several reasons for this situation, including historical developments as well as HEPs’ ambivalence around embracing mainstream mental health classification systems, and corresponding types of research. The paper then highlights some recent developments in HEPs for anxiety disorders (particularly emotion‐focused therapy; EFT); developments that are breaking new conceptual grounds while also generating new outcome research.     

The effects of cognitive load on attention control in subclinical anxiety and generalised anxiety disorder

Poor regulation of emotions may involve impaired attention control. In the current paper, we report the results of two studies examining the interaction of anxiety, attention control and cognitive load. In Study I, using a performance-based task to assess attention control, we examined whether anxiety is associated with impaired attention control, and whether these effects are influenced by working memory load. In Study II, we examined these effects in patients with a diagnosis of generalised anxiety disorder (GAD) compared to non-anxious control (NAC) participants. Results of Study I showed that high anxiety was associated with increased attention control, that is decreased interference from distractors, but only under high cognitive load. These results were replicated in Study II such that individuals with GAD showed increased attention control relative to NACs, but only under high cognitive load. These results help clarify previous predictions regarding the effect of anxiety on attention control.     

Electrodermal lability in anxiety disorders

Twenty-eight anxiety patients, aged below 50 years, were diagnosed according to DSM-III-R criteria (panic disorder with and without agoraphobia, generalised anxiety disorder, and anxiety disorder not otherwise specified). The patients were characterised by high levels of state and trait anxiety and neuroticism, compared with the controls. However, there were no differences between patients and controls in electrodermal habituation rate, non-specific activity, or skin resistance level. When the patients were divided into electrodermally labile and stable subjects, significant differences were found between patients and controls in both electrodermal activity and Eysenck's personality dimensions. The labile patients were more introverted and attained higher psychoticism scores than either the stable patients or controls. Duration of anxiety symptoms removed the difference found in extroversion, but not in any other variable. The results are discussed in relation to the utility of electrodermal measurements in validation of diagnostic entities. It is concluded, that from the psychophysiological point of view, anxiety disorders may be examined within a dimensional framework.     

Need for closure and anxiety in delusions: a longitudinal investigation in early psychosis

This study investigated the role of need for closure (NFC) and anxiety in delusions. The Need For Closure Scale (NFCS) and measures of trait and state anxiety were administered to an early psychosis group with current delusions, a clinical (generalised anxiety disorder--GAD) control group and a non-clinical control group. The battery of questionnaires was repeated at follow-up one year later. The NFCS did not meet criteria for a unidimensional scale and two sub-scales were removed from all further analyses. At baseline the deluded and GAD groups scored significantly higher on the reduced NFCS (NFCS-R) than the control group. Trait anxiety was related to NFCS-R in the GAD and non-clinical control groups, but not in the deluded group. At follow-up all groups scored significantly lower on the NFCS-R, perhaps suggesting a practice effect, although the two clinical groups continued to have higher scores than the non-clinical control group. The recovered and non-recovered deluded groups did not differ on the NFCS-R one year later, unlike in the GAD group where recovered participants had significantly lower scores than the non-recovered. Change scores on the NFCS-R and trait anxiety were correlated at trend level in the GAD and non-clinical control groups, but not in the deluded group. These findings suggest that whilst NFC and trait anxiety are related in non-psychotic groups, NFC may be implicated in the formation of delusions, independently of anxiety, in psychotic individuals.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Social phobic interoception: effects of bodily information on anxiety, beliefs and self-processing

It has been suggested that body-state information influences self-perception and negative thinking in social phobia [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope & F. R. Schneier (Eds.), Social phobia: diagnosis, assessment and treatment (pp. 69-93). New York: Guilford Press.]. This study explored the effects of body-state information on anxiety and cognition in patients with generalised social phobia during a feared social interaction. It was hypothesised that information concerning an increase in pulse rate would lead to increments in anxiety, negative beliefs and self-processing whilst information concerning a decrease in pulse rate would have the opposite effect. The results of this study were generally consistent with the hypotheses. These findings are important as they may help to account for fluctuations in anxiety, negative beliefs and self-processing in social situations that do not present objective social threat. In particular, social anxiety appears to be modulated by body-state information. The implications of the present findings for cognitive therapy of social phobia are briefly discussed.     

Is Time Perspective a Predictor of Anxiety and Perceived Stress? Some Preliminary Results from Greece

In the current studies, we explore the relationship between anxiety / perceived stress and time perspectives. Study 1 tested the relationship between the dimensions of the Zimbardo Time Perspective Inventory (ZTPI) and anxiety in a male sample. Study 2 examined the relationship between time perspectives and perceived stress in a sample of students. Both studies considered the Deviation of the Balanced Time Perspective (DBTP). In Study 1 psychiatrists of the Mental Health Centre of the Armed Forces in Athens diagnosed generalised anxiety in a number of male participants of the overall sample (n?=?204). All participants completed a validated Greek translation of the ZTPI. In Study 2 a sample of students (n?=?71) of Panteion University completed the Greek translations of the ZTPI and the Perceived Stress Scale (PSS-14 items). In Study 1 a negative correlation between Future orientation and anxiety was found. The DBTP was higher in persons with anxiety. In Study 2 the Past Negative and Present Fatalistic orientations correlated with high-perceived stress as assumed. Furthermore, high-perceived stress was associated with a higher DBTP. The ZTPI is particularly important for the explanation of perceived stress. DBTP, Past Negative and Present Fatalistic perspectives are important factors of influence. The measurement of anxiety should be re-examined.     

How does thought suppression impact upon beliefs about uncontrollability of worry?

According to Wells’ metacognitive model of generalised anxiety disorder (GAD; [Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320]), GAD patients attempt to suppress intrusions that trigger worry. Wells postulates that these attempts are rarely effective and may increase the frequency of worry triggers. These apparent failures are interpreted as evidence for loss of mental control, thereby exacerbating beliefs about worry uncontrollability. The current study tested these predictions. Sixty-two high worriers completed a naturalistic experiment comprising two sessions separated by 1 week. In Session 1, participants recorded their beliefs about worry in general, including its uncontrollability. They then selected a current worry and recorded how often it came to mind over the following week. The Suppression group (N=32) suppressed their chosen worry during the week. The Mention group (N=30) simply monitored its occurrence. In Session 2, Session 1 measures were repeated. Contrary to prediction, the Suppression group reported a significant increase in worry controllability in general. No shift was demonstrated by the Mention group. In addition, relative to the Mention group, the Suppression group reported more success at suppressing their chosen worries, spent less time thinking about them, and found them more controllable and less distressing. Findings are discussed within the context of Wells’ model.     

Cognitions related to anxiety: a pilot study of treatment

In general, where anxiety appears to have a specific external focus, such as the situations which are avoided by phobic patients, treatment involving systematic exposure to those situations seems to be effective. This is less appropriate, or even impossible, where anxiety is not dependent on any external circumstance, but is described by the patient as occurring at any time or place, either chronically over long periods, or acutely in the form of ‘panic attacks’. These patients with ‘generalised’ anxiety often describe internal cues for anxiety either in the form of thoughts (e.g. worry over a current problem) or somatic (e.g. chest sensations interpreted as possible heart disease). Beck et al. (1974) has suggested that on interview, all patients diagnosed as suffering from diffuse or generalised anxiety can report specific ideas or other cognitive cues which are associated with anxiety. These usually concern possible traumatic events, such as illness and death, or social rejection. Clearly Beck has in mind the possibility that these cognitions have the effect of inducing anxiety, although even if the validity of the subjective reports were to be accepted, the problem remains of whether the relationship between mood state and cognitions is causal and if so, in which direction it operates. Obviously a causal relationship may also operate in both directions simultaneously, to form a ‘vicious circle’ in which each exacerbates the other. To establish whether there is a sense in which particular cognitions contribute causally to anxious mood, it would be necessary to find a method of manipulating the type or frequency of cognitions thought to be operating in this way.

One obvious possibility is that of ‘thought-stopping’: that is, patients could be taught to identify thoughts which are associated with anxiety and stop them in the usual way (Wolpe, 1973, p. 211) e.g. by' shouting stop, and substituting an alternative thought. The present study was planned as a pilot experiment to determine (i) if appropriate anxiety related cognitions could be elicited from a series of patients with generalised anxiety, (ii) if the reported frequency of such thoughts could be modified by a thought-stopping technique, and (iii) if any changes in thought frequency were associated with improvements in mood.

Clearly there are many ‘non-specific’ features involved in thought-stopping which could also have therapeutic effects on mood. For this reason it was necessary to include an alternative procedure, not directed at reducing thought frequency, but having the same degree of plausibility to patients, and preferably to therapists. The control procedure chosen for this purpose was modelled on desensitisation, in which patients were encouraged to allow the supposedly anxiety-provoking thoughts into their mind and tolerate them, rather than attempt to stop them. In summary, the study employed a relaxation training phase as a base-line, followed by a cross-over design in which the two treatment phases of thought-stopping and ‘cognitive desensitisation’ were given to each patient, in balanced order.     

Limited generalisation of changes in attentional bias following attentional bias modification with the visual probe task

Although attentional bias modification (ABM) can change anxiety, recent studies failed to replicate such effects, possibly because the visual probe ABM failed to induce changes in attentional bias (AB). We investigated whether visual probe ABM generalised to different measures of AB besides the visual probe task (VPT), and thus whether ABM genuinely changes attentional processing. We trained participants (N?=?60) to either attend towards or away from angry facial expressions, and we examined training effects on the dot probe task, the exogenous cueing task, and the visual search task. We found a small change in AB in the VPT, but this effect did not transfer to the exogenous cueing task or the visual search task. Our study shows that ABM does not necessarily lead to generalised effects on AB. This finding can be explained by the poor psychometric properties of the AB measures.     

Anxiety,depression, and the suicidal spectrum: a latent class analysis of overlapping and distinctive features

ABSTRACT

Anxiety and depression diagnoses are associated with suicidal thoughts and behaviours. However, a categorical understanding of these associations limits insight into identifying dimensional mechanisms of suicide risk. This study investigated anxious and depressive features through a lens of suicide risk, independent of diagnosis. Latent class analysis of 97 depression, anxiety, and suicidality-related items among 616 psychiatric outpatients indicated a 3-class solution, specifically: (1) a higher suicide-risk class uniquely differentiated from both other classes by high reported levels of depression and anxious arousal; (2) a lower suicide-risk class that reported levels of anxiety sensitivity and generalised worry comparable to Class 1, but lower levels of depression and anxious arousal; and (3) a low to non-suicidal class that reported relatively low levels across all depression and anxiety measures. Discriminants of the higher suicide-risk class included borderline personality disorder; report of worthlessness, crying, and sadness; higher levels of anxious arousal and negative affect; and lower levels of positive affect. Depression and anxiety diagnoses were not discriminant between higher and lower suicide risk classes. This transdiagnostic and dimensional approach to understanding the suicidal spectrum contrasts with treating it as a depressive symptom, and illustrates the advantages of a tripartite model for conceptualising suicide risk.     

Linguistic correlates of social anxiety disorder

The goal of this study was to examine the linguistic correlates of social anxiety disorder (SAD). Twenty-four individuals with SAD (8 of them with a generalised subtype) and 21 non-anxious controls were asked to give speeches in front of an audience. The transcribed speeches were examined for the frequency of negations, I-statements, we-statements, negative emotion words, and positive emotion words. During their speech, individuals with either SAD subtype used positive emotion words more often than controls. No significant differences were observed in the other linguistic categories. These results are discussed in the context of evolutionary and cognitive perspectives of SAD.