Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.     

Rethinking the Role of Worry in Generalized Anxiety Disorder: Evidence Supporting a Model of Emotional Contrast Avoidance

The Contrast Avoidance model (Newman & Llera, 2011) proposes that individuals with generalized anxiety disorder (GAD) are hypersensitive to sharp upward shifts in negative emotion that typically accompany negative events, and use worry to maintain sustained intrapersonal negativity in an attempt to avoid these shifts. Although research shows that worry increases negative emotionality and mutes further emotional reactivity to a stressor when compared to the worry period (e.g., Llera & Newman, 2010), no study has tracked changes in negative emotionality from baseline to worry inductions followed by a range of emotional exposures. Further, no study has yet assessed participants’ subjective appraisals of prior worry on helping to cope with such exposures. The present study tested the main tenets of the Contrast Avoidance model by randomly assigning participants with GAD (n = 48) and nonanxious controls (n = 47) to experience worry, relaxation, and neutral inductions prior to sequential exposure to fearful, sad, and humorous film clips. Both physiological (nonspecific skin conductance responses [NS-SCRs]) and self-reported emotional changes were observed. Results indicated that worry boosted negative emotionality from baseline, which was sustained across negative exposures, whereas low negative emotionality during relaxation and neutral inductions allowed for sharp increases in response to exposures. Furthermore, GAD participants found worry to be more helpful than other conditions in coping with exposures, whereas control participants reported the opposite pattern. Results provide preliminary support for the Contrast Avoidance model. This suggests that treatment should focus on underlying avoidance patterns before attempting to reduce worry behavior.     

Theory of Mind Impairments in Social Anxiety Disorder

Social anxiety disorder (SAD) is a common psychiatric disorder characterized by a persistent, excessive fear and avoidance of social and performance situations. Research on cognitive biases indicates individuals with SAD may lack an accurate view of how they are perceived by others, especially in social situations when they allocate important attentional resources to monitoring their own actions as well as external threat. In the present study, we explored whether socially anxious individuals also have impairments in theory of mind (ToM), or the ability to comprehend others’ mental states, including emotions, beliefs, and intentions. Forty socially anxious and 40 non-socially-anxious comparison participants completed two ToM tasks: the Reading the Mind in the Eyes and the Movie for the Assessment of Social Cognition. Participants with SAD performed worse on ToM tasks than did non-socially-anxious participants. Relative to comparison participants, those with SAD were more likely to attribute more intense emotions and greater meaning to what others were thinking and feeling. These group differences were not due to interpretation bias. The ToM impairments in people with SAD are in the opposite direction of those in people with autism spectrum conditions whose inferences about the mental states of other people are absent or very limited. This association between SAD and ToM may have important implications for our understanding of both the maintenance and treatment of social anxiety disorder.     

Changes in Distress Intolerance and Treatment Outcome in a Partial Hospital Setting

Despite the well-established role of distress intolerance (DI) in a wide range of psychological disorders, few studies have examined whether DI improves during treatment and whether these changes are associated with symptom outcomes. Patients (N = 626) enrolled in a brief cognitive-behavioral partial hospital program completed pre- and posttreatment measures of DI. Results indicated that DI decreased significantly during treatment, with more than 30% of the sample exhibiting a reduction of more than 2 standard deviations from the sample mean. Women reported higher DI than men at baseline; however, there were no gender differences in changes in DI over time. Participants also completed a pre- and posttreatment measure of depression and a subset completed a measure of anxiety (n = 167). DI was associated with more severe depression and anxiety at pre- and posttreatment, with participants who reported a decrease in DI also reporting lower depression and anxiety symptoms at post-treatment. These results further highlight the transdiagnostic relevance of DI and suggest that DI may be a relevant factor in treatment outcome for depression and anxiety.     

Religiosity and Spirituality as Resiliency Resources: Moderation,Mediation, or Moderated Mediation?

A growing body of literature indicates a modestly positive association between religiosity and spirituality as predictors of psychological health (anxiety and depression), suggesting they serve as personal resiliency factors. The purpose of this study was to expand our understanding of the relationships among these constructs. Using Lazarus's Transactional Model of Stress as a theoretical framework, we examined: (a) the extent to which spirituality and religiosity mediated and/or moderated the association between perceived stress and psychological health and (b) whether there was a moderated (religiosity) mediation (spirituality) between stress and health. The Perceived Stress Scale, Daily Spiritual Experiences Scale, Religious Commitment Inventory, and Hospital Anxiety and Depression Scale were administered to measure the following constructs: stress, spirituality, religiosity, and psychological health. This study utilized a nonexperimental, quantitative, correlational, cross‐sectional, moderated‐mediation design, and included a convenience sample of 331 research participants. Both spirituality and religiosity moderated stress and health. However, only spirituality partially mediated the relationship. In addition, religiosity did not moderate the mediating effects of spirituality. Overall, this study confirmed the role of both religiosity and spirituality as effective resiliency resources.     

On ‘the fear of death’ as the primary anxiety: How and why Klein differs from Freud

It is well known that Melanie Klein held the view that ‘fear of death’ is the primary source of anxiety and that her position is explicitly opposed to that of Sigmund Freud, who maintained that that fear cannot in any way or form be a source of anxiety. In a previous article on Freud's Inhibitions, Symptoms and Anxiety (Blass, 2013), the author argued that, counter to what is commonly portrayed in the literature, Freud's considerations for rejecting the fear of death as a source of anxiety were based on relational and experiential factors that are usually associated with Kleinian psychoanalysis. In light of this affinity of Freud with Klein a question arises as to the actual source of their differences in this context. The present paper offers an answer to this question. The author first presents some of her earlier findings on what led Freud to reject the fear of death as a source of anxiety and then turns to investigate Klein's considerations for accepting it. This takes us beyond her explicit statements on this matter and sheds new light on the relationship of her views regarding death and anxiety and those of Freud. In turn this deepens the understanding of the relationship of Freud and Klein's conceptualizations of the psyche and its internal object relations, pointing to both surprising common ground and foundational differences.     

The moderating role of attachment insecurities in the association between social and physical pain

We examined the effects of social exclusion and attachment insecurities (anxiety, avoidance) on physical pain sensitivity, hypothesizing that anxiety would predict greater physical pain sensitivity only following social exclusion. Participants were either included in or excluded from a computer-based ball-tossing game and then completed a coldpressor task. Anxious men showed greater physical pain sensitivity when excluded, but not when included. Moreover, individuals (men and women) high on both anxiety and avoidance showed greater physical pain sensitivity when excluded, but not when included. Conclusions: Anxious individuals’ heightened physical pain sensitivity following exclusion is a manifestation of hyperactivation of their attachment systems, and when threatened, avoidant individuals who are also high in anxiety are less successful in deactivating their attachment systems.     

Infant face interest is associated with voice information and maternal psychological health

Early infant interest in their mother's face is driven by an experience based face processing system, and is associated with maternal psychological health, even within a non clinical community sample. The present study examined the role of the voice in eliciting infants’ interest in mother and stranger faces and in the association between infant face interest and maternal psychological health.Infants aged 3.5-months were shown photographs of their mother's and a stranger's face paired with an audio recording of their mother's and a stranger's voice that was either matched (e.g., mother's face and voice) or mismatched (e.g., mother's face and stranger's voice). Infants spent more time attending to the stranger's matched face and voice than the mother's matched face and voice and the mismatched faces and voices. Thus, infants demonstrated an earlier preference for a stranger's face when given voice information than when the face is presented alone. In the present sample, maternal psychological health varied with 56.7% of mothers reporting mild mood symptoms (depression, anxiety or stress response to childbirth). Infants of mothers with significant mild maternal mood symptoms looked longer at the faces and voices compared to infants of mothers who did not report mild maternal mood symptoms. In sum, infants’ experience based face processing system is sensitive to their mothers’ maternal psychological health and the multimodal nature of faces.     

The Impact of Trait Anxiety on Self‐frame and Decision Making

The present study investigated how trait anxiety influenced the formation of a self‐frame and decision making. Participants (N = 1044) responded to the Trait Anxiety Inventory. Those with trait anxiety scores ±1 Z score from the sample mean (N = 328) were recalled to respond to the self‐frame questionnaire. The results suggested that trait anxiety differences could result in differences in the editing of decision‐making information, thereby influencing the risky choice. Compared with the low trait anxiety group, participants from the high trait anxiety group showed a greater tendency to use negative vocabulary to construct their self‐frame and tended to choose conservative plans. Self‐frame suppressed the influence of trait anxiety on decision making. These results further confirmed the hypothesis that individual differences in personality traits might influence the processing of information in a framed decision task. Copyright © 2013 John Wiley & Sons, Ltd.