Intolerance of uncertainty predicts analogue posttraumatic stress following adverse life events

ABSTRACT

BACKGROUND AND OBJECTIVES: There is evidence that intolerance of uncertainty (IU) is associated with elevated post-traumatic stress (PTS) symptoms. There is a scarcity of research examining whether IU is prospectively related to PTS following exposure to negative life events. Using data from a Dutch student-sample, we examined the degree to which IU predicts post-traumatic stress symptoms associated with negative stressful life events (analogue posttraumatic stress (PTS)).

DESIGN: This was a prospective survey-study.

METHODS: A group of 193 undergraduate students completed self-report measures of Inhibitory IU, Prospective IU, and anxiety sensitivity (at Time 1, T1). One year later (at T2), participants rated adverse life-events experienced between T1 and T2, and completed a questionnaire tapping PTS associated with the most distressing event experienced in this time-frame. We hypothesized that pre-event Inhibitory IU and—to a lesser extent—Prospective IU would predict analogue PTS, after covarying for anxiety sensitivity.

RESULTS: As predicted, pre-event Inhibitory IU predicted post-event analogue PTS, even when controlling for anxiety sensitivity. With respect to distinct analogue PTS clusters, Inhibitory IU predicted PTS avoidance and PTS hyperarousal, but was unrelated to PTS reexperiencing.

CONCLUSIONS: This study confirm that IU, particularly Inhibitory IU, may convey risk for elevated PTS following adverse life events.     

Targeting avoidance via compound extinction

ABSTRACT

Avoidance towards innocuous cues is a key diagnostic criterion across anxiety-related disorders. Importantly, the most effective intervention for anxiety-related disorders, exposure therapy with response prevention, sometimes does not prevent the relapse of anxiety's symptomatology. We tested whether extinction effects, the experimental proxy of exposure, are enhanced by increasing the discrepancy between the prediction of an unpleasant event happening (shock presentation), and the actual event (shock omission). Forty-eight individuals first saw pictures of three stimuli. Two pictures (CSA, CSB) were followed by a shock (US) and one (CS-) was not. Next, participants learned to avoid the US by pressing a computer key. An extinction and response prevention procedure followed. In the first part of it, participants saw unreinforced presentations of all CSs. In the second part, the single group saw unreinforced presentations of the CSA and CS-. The compound group encountered compound unreinforced presentations of the CSA and CSB, and separate presentations of the CS-. Return of avoidance and fear was tested after unsignalled presentations of the US. Compound extinction resulted in comparable reduction of fear and avoidance compared to standard extinction. We discuss how future research could enhance extinction effects by adding costs to the avoidance behaviour.     

Shame-related social anxiety: Replicating a link with various social interaction measures

Abstract

In the present study, 182 young adults (131 men, 51 men: M age=20.2) completed self-report measures of shame and social avoidance/distress, anxiety, desirability, and negative social evaluation. Results supported Lewis (1985) in that shame-proneness was related to social avoidance/distress, interaction anxiety, and fear of negative social evaluation (even when controlling for social desirability). Social distress/avoidance and interaction anxiety also were significant predictors of shame-proneness. Results suggeste that attention to social anxiety may be valuable in the treatment of shameprone individuals.     

Safety Behaviour Enhances the Acceptability of Exposure

Compulsive washing and contamination fears are among the most common symptoms of obsessive-compulsive disorder (OCD). Research suggests that exposure and response prevention (ERP) is effective for OCD. However, ERP is prone to dropouts and refusals, and a substantial proportion of clients therefore do not receive the care they need. A proposed solution involves the judicious use of safety behaviour to enhance the acceptability of exposure-based interventions. The current study aimed to test this proposed solution. Participants were 70 undergraduate students who completed two exposure exercises for contamination fear, one with safety behaviour and one without. Participants then rated the acceptability of the two exercises. Exposure with safety behaviour (ESB) was rated as significantly more acceptable than ERP. Furthermore, subjective fear ratings were lower and behavioural approach to a series of contaminants was greater in the ESB condition. Results demonstrated the acceptability-enhancing potential of safety behaviour in exposure, and are discussed in terms of both theoretical and practical aspects of safety behaviour, exposure, and evidence-based interventions for anxiety disorders.     

Interventions for Children's Anxiety Disorders

ABSTRACT

Anxiety problems represent common types of childhood disorders that can range from simple to complex, and are characterized as comprising cognitive, behavioral, physiological, and affective components. Current diagnostic nomenclature describes three types of childhood anxiety disorders: separation anxiety disorder, overanxious disorder, and avoidant anxiety disorder. Also, test anxiety may be manifested in school-aged children, in which concerns about performance contribute to lowered achievement. This article describes the nature of childhood anxiety disorders and test anxiety, and discusses interventions that may be effective in remediation efforts.     

The Treatment Acceptability/Adherence Scale: Moving Beyond the Assessment of Treatment Effectiveness

It is becoming more broadly recognized that beyond effectiveness, the acceptability of interventions for anxiety disorders is an important consideration for evidence-based practice. Although advances in treatments for anxious psychopathologies have demonstrated that cognitive-behavioural interventions are more desirable than other types of psychotherapy or pharmacotherapy, there continue to be problems with adherence and dropout. It has been suggested that low treatment acceptability may be partially responsible for high dropout rates. Although a number of preliminary investigations in this domain have been conducted, further progress is hampered by the absence of a single self-report measure that assesses both acceptability and anticipated adherence. Therefore, the current paper aimed to test the psychometric properties of the newly developed Treatment Acceptability/Adherence Scale (TAAS). In two studies of brief cognitive-behavioural interventions, the TAAS was administered immediately following the therapy session. In Study 1 (N = 120 non-clinical undergraduates), the therapy included two variants of an exposure-based intervention for contamination fear. In Study 2 (N = 27 individuals with obsessive-compulsive disorder), the therapy was a cognitively based intervention evaluating a novel treatment technique for checking compulsions. Measures of convergent and divergent validity were included. Results demonstrated that the TAAS exhibited sound psychometric properties across the two samples. It is hoped that this measure will help clinicians to predict and intervene when a treatment is not acceptable and/or when the client anticipates poor adherence to it. Furthermore, the TAAS may aid researchers in continuing to improve upon effective interventions for anxiety and related disorders.     

New Strategies for Combining Mindfulness with Integrative Cognitive Behavioral Therapy for the Treatment of Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) severely impacts social functioning, distress levels, and utilization of medical care compared with that of other major psychiatric disorders. Neither pharmacological nor psychotherapy interventions have adequately controlled cardinal symptoms of GAD: pervasive excessive anxiety and uncontrollable worry. Research has established cognitive behavioral therapy (CBT) as the most effective psychotherapy for controlling GAD; however, outcomes remain at only 50% reduction, with high relapse rates. Mindfulness has been integrated with CBT to treat people suffering from numerous psychiatric disorders, with mindfulness based stress reduction (MBSR) being the most researched. Preliminary evidence supports MBSR’s potential for controlling GAD symptoms and key researchers suggest mindfulness practices possess key elements for treating GAD. Classical mindfulness (CM) differs significantly from MBSR and possesses unique potentials for directly targeting process and state GAD symptoms inadequately treated by CBT. This article introduces the theory and practice of CM, its differences from MBSR, and a critical review of MBSR and CBT treatments for GAD. CM strategies designed to complement CBT targeting cardinal GAD symptoms are outlined with a case study illustrating its use.     

Does psychosocial stress exacerbate avoidant responses to cancer information in those who are afraid of cancer? A population-based survey among older adults in England

Objective: Communication of cancer information is an important element of cancer control, but cancer fear may lead to information avoidance, especially when coping is low. We examined the association between cancer fear and cancer information avoidance, and tested whether this was exacerbated by psychosocial stress.

Design: Cross-sectional survey of 1258 population-based adults (58–70 years) in England.

Main outcome measures: Cancer fear (intensity and frequency), perceived psychosocial stress and cancer information avoidance. Control variables were age, gender, ethnicity, marital status and education.

Results: A quarter (24%) of respondents avoided cancer information. Ordinal logistic regression analyses showed main effects of psychosocial stress (OR = 1.17, 95% CI 1.07–1.29) and cancer fear: cancer information avoidance was lowest in those with no cancer fear (13%), followed by those with moderate (24%; OR = 2.15, 95% CI: 1.49–3.12), and high cancer fear (35%; OR = 3.90, 95% CI: 2.65–5.73). In the adjusted model, the interaction between cancer fear and stress was significant (OR = 1.14, 95% CI 1.004–1.29, p < .05): 40% of those with high fear/high stress avoided cancer information compared with 29% with high fear/low stress.

Conclusion: Cancer fear and psychosocial stress interact to produce disengagement with cancer-related information, highlighting the importance of affective processes to cancer control efforts.     

A Review of Outcome Studies on Cognitive-Behavioral Therapy for Reducing Fear-Avoidance Beliefs Among Individuals With Chronic Pain

In the last two decades, emerging research has focused on advancing the explanations of how chronic pain becomes disabling. The fear-avoidance model of pain suggests that fear of reinjury in chronic pain patients leads to avoidance of certain movements that subsequently results in more pain and disability from that lack of movement. The literature supporting this model of pain and disability has allowed specific therapeutic interventions to be developed aimed at reducing pain-related fears in an attempt to reduce the physical symptoms and disability of chronic pain. Studies using cognitive-behavioral interventions to reduce fear-avoidance beliefs are reviewed and the treatments are evaluated based on the studies’ effectiveness. The author concludes that graded exposure in vivo appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance.     

Social anxiety and emotion regulation flexibility: considering emotion intensity and type as contextual factors

Background and objectives: Individuals with social anxiety disorder have often been considered inflexible in their emotion regulation. The aim of this study was to investigate emotion regulation flexibility in socially anxious individuals in response to two contextual factors, namely different levels of emotion intensity and emotion type.

Methods: A daily diary approach was employed, investigating emotion regulation (i.e., experiential avoidance, expressive suppression and cognitive reappraisal) in college students scoring high (N?=?62; HSA) and low (N?=?52; LSA) on social anxiety.

Results: Results revealed that HSAs were found to use more experiential avoidance than LSAs, especially at higher levels of negative intensity. The use of this emotion regulation strategy appeared to be driven by guilt, nervousness, and sadness. There were no between-group differences concerning the other strategies in response to varying levels of emotional intensity.

Conclusions: Together, the results provide evidence for inflexible emotion regulation in HSAs, reflected in an unwillingness to experience negative emotions.     

Real and virtual classrooms can trigger the same levels of stuttering severity ratings and anxiety in school-age children and adolescents who stutter

PurposeMany school-age children and adolescents who stutter experience the fear of public speaking. Treatment implications include the need to address this problem. However, it is not always possible to train repeatedly in front of a real audience. The present study aimed to assess the relevance of using a virtual classroom in clinical practice with school-age children and adolescents who stutter.MethodsTen children and adolescents who stutter (aged 9–17 years old) had to speak in three different situations: in front of a real audience, in front of a virtual class and in an empty virtual apartment using a head-mounted display. We aimed to assess whether the self-rated levels of anxiety while speaking in front of a virtual audience reflect the levels of anxiety reported while speaking in front of a live audience, and if the stuttering level while speaking to a virtual class reflects the stuttering level while speaking in real conditions.ResultsResults show that the real audience creates higher anticipatory anxiety than the virtual class. However, both the self-reported anxiety levels and the stuttering severity ratings when talking in front of a virtual class did not differ from those observed when talking to a real audience, and were significantly higher than when talking in an empty virtual apartment.ConclusionOur results support the feasibility and relevance of using a virtual classroom to expose school-age children and adolescents who stutter to a feared situation during cognitive behavioral therapy targeting the fear of public speaking.     

Psychotraumatic Stress and Anxiety

Abstract

A systematic review of all available treatment studies for music performance anxiety was undertaken. Interventions were categorised into psychological treatments and pharmacological treatments. Psychological treatments included behavioral, cognitive, cognitive-behavioral, combined treatments and other therapies. Issues such as the number of studies in each treatment modality, their sample sizes and the methodological quality of most of the studies reviewed precluded firm conclusions about the effectiveness of any of the treatments assessed for music performance anxiety. The field is in urgent need of larger scale, methodologically rigorous studies to assist the large minority of musicians who suffer from performance impairing music performance anxiety.     

A meta-analysis of the relationship between anxiety and telomere length

Background and objectives: Telomeres are protective caps at the ends of chromosomes, and shorter telomeres are associated with poor physical health. The present study set out to consolidate the varying effect sizes found so far in studies of anxiety and telomere length.

Design and methods: A meta-analytic investigation of the relationship between anxiety and telomere length used information from 17 different samples comprising a total of 19,424 participants.

Results: The results showed a small but significant association, r?=??.06, between higher anxiety and shorter telomeres. Studies comparing individuals diagnosed with an anxiety disorder with other individuals had a significant effect size, and studies that did not use this comparison threshold did not have a significant effect size.

Conclusions: Anxiety is associated with an important biomarker related to health. Future experimental studies that examine the impact of interventions intended to reduce anxiety in conjunction with measurement of telomere length can further clarify the impact of anxiety on telomere length.     

Social emotions and social cognition in the development of social anxiety disorder

ABSTRACT

Social anxiety disorder (SAD) is one of the most prevalent mental disorders with serious individual impairments and societal costs. Little is known about the mechanisms involved in SAD development. Here, I propose that dysregulated social emotions (social fear and shyness) are crucial for SAD development and that these dysregulated social emotions originate in the disturbances in socio-cognitive abilities. The research from our lab confirmed this. It showed that behavioural and physiological indices of social fear contribute to the development of SAD in toddlerhood and early childhood. Later in childhood, between ages 4.5 and 7.5, we found a new risk factor for SAD―dysregulated shyness. Specifically, we found that negative shy expressions and prolonged physiological blushing (temperature increase) contribute to SAD development. Whereas elevated fear may be rooted in deficits in socio-cognitive skills, dysregulated shyness may be rooted in advanced socio-cognitive abilities. These findings imply that dysregulated social emotions play an important role in SAD and should be explicitly targeted in clinical treatments of SAD.     

Associations between emotional avoidance,anxiety sensitivity,and reactions to an observational fear challenge procedure

Research has shown that emotional avoidance and anxiety sensitivity are associated with more self-reported fear and distress in response to laboratory fear challenge procedures. The present study aimed to expand upon this work and examined how emotional avoidance and anxiety sensitivity are related to emotional and physiological responses to an observational fear challenge procedure. To accomplish this aim, a carefully screened, non-clinical sample (N = 43) was administered the Acceptance and Action Questionnaire (AAQ), a measure of emotional avoidance, and the Anxiety Sensitivity Index (ASI). Participants then engaged in an observational fear challenge paradigm. During the fear challenge, participants watched mock panic attacks while emotional (e.g., fear and panic) and skin conductance levels were assessed. Consistent with expectation, emotional avoidance and anxiety sensitivity were positively associated with more self-reported fear and more severe panic symptoms to the challenge procedure. However, anxiety sensitivity was more highly associated with self-reported fear and panic symptoms in response to the challenge procedure than emotional avoidance. Emotional avoidance and anxiety sensitivity were not associated with levels of physiological arousal to the observational fear challenge procedure. Discussion focuses on the interplay between emotional avoidance, anxiety sensitivity, and the development of vicarious fear responses and how these constructs may contribute to the pathogenesis of anxiety disorders.     

Recalling safety: cooperative functions of the ventromedial prefrontal cortex and the hippocampus in extinction

Anxiety disorders are commonly treated with exposure-based therapies that rely on extinction of conditioned fear. Persistent fear and anxiety following exposure therapy could reflect a deficit in the recall of extinction learning. Animal models of fear learning have elucidated a neural circuit for extinction learning and recall that includes the amygdala, ventromedial prefrontal cortex (vmPFC), and hippocampus. Whereas the amygdala is important for extinction learning, the vmPFC is a site of neural plasticity that allows for the inhibition of fear during extinction recall. We suggest that the vmPFC receives convergent information from other brain regions, such as contextual information from the hippocampus, to determine the circumstances under which extinction or fear will be recalled. Imaging studies of human fear conditioning and extinction lend credence to this extinction network. Understanding the neural circuitry underlying extinction recall will lead to more effective therapies for disorders of fear and anxiety.     

Enhancing exposure-based therapy from a translational research perspective

Combining an effective psychological treatment with conventional anxiolytic medication is typically not more effective than unimodal therapy for treating anxiety disorders. However, recent advances in the neuroscience of fear reduction have led to novel approaches for combining psychological therapy and pharmacological agents. Exposure-based treatments in humans partly rely on extinction to reduce the fear response in anxiety disorders. Animal studies have shown that D-cycloserine (DCS), a partial agonist at the glycine recognition site of the glutamatergic N-methyl-D-aspartate receptor facilitates extinction learning. Similarly, recent human trials have shown that DCS enhances fear reduction during exposure therapy of some anxiety disorders. This article discusses the biological and psychological mechanisms of extinction learning and the therapeutic value of DCS as an augmentation strategy for exposure therapy. Areas of future research will be identified.     

The natural course of anxiety symptoms in early adolescence: factors related to persistence

Background and objectives: Anxiety disorders are the most common mental health problems during childhood and adolescence. This study examined the course of anxiety symptoms in early adolescents from the general population over three phases.

Design: Prospective cohort study.

Methods: Two hundred and forty-two participants (mean-age of 13.52) from a baseline sample of 1514 (mean-age of 10.23) were followed up three times. Of the 1514 children, those with emotional risk and controls without risk constituted the second-phase sample (n?=?562; mean-age of 11.25). The Screen for Child Anxiety Related Emotional Disorders-SCARED was administered in all three phases.

Results: Fifty-six percent and 32% of respondents showed total scores above the SCARED cutoff point at one and three years follow-up, respectively. Eight percent showed fluctuating symptoms. Fifty-five percent of respondents showed high scores for any subtype of anxiety over three years. Social phobia and generalized anxiety symptoms were the most prevalent and persistent. Participants with persistent separation anxiety showed the highest co-occurrence with symptoms of other psychopathological disorders. Participants with persistent anxiety showed lower academic performance. Being male was a protective factor against persistence.

Conclusions: The data support anxiety maintenance during early adolescence. Early adolescence is a critical period which may involve other serious academic, social, and family problems.     

Cycles of Understanding and Hope: Toward an Integrative Model of Therapeutic Change in Child Psychotherapy*

ABSTRACT

This article presents an integrative theory of pathological development in childhood and an inclusive model of therapeutic change, based on a contemporary understanding of children's emotions. In this model, effective therapies for children and adolescents, whether through empathy and understanding or through active efforts to change patterns of thought and behavior, arrest malignant emotional processes, especially vicious cycles of painful emotions and pathogenic family interactions. Our most successful interventions then set in motion positive cycles of healthy emotional and interpersonal experiences - increased confidence and engagement in life and more affirming interactions between parents and children. Over time, successful therapy strengthens in children and adolescents a more encouraging, less critical inner voice and, perhaps most profoundly, more positive expectations for their future - a new sense of what is possible in their lives.     

Post-extinction conditional stimulus valence predicts reinstatement fear: Relevance for long-term outcomes of exposure therapy

Exposure therapy for anxiety disorders is translated from fear conditioning and extinction. While exposure therapy is effective in treating anxiety, fear sometimes returns after exposure. One pathway for return of fear is reinstatement: unsignaled unconditional stimuli following completion of extinction. The present study investigated the extent to which valence of the conditional stimulus (CS+) after extinction predicts return of CS+ fear after reinstatement. Participants (N = 84) engaged in a differential fear conditioning paradigm and were randomised to reinstatement or non-reinstatement. We hypothesised that more negative post-extinction CS+ valence would predict higher CS+ fear after reinstatement relative to non-reinstatement and relative to extinction retest. Results supported the hypotheses and suggest that strategies designed to decrease negative valence of the CS+ may reduce the return of fear via reinstatement following exposure therapy.