Efficacy of self-administered treatments for pathological academic worry: A randomized controlled trial

Research on treatments for reducing pathological worry is limited. In particular, academic worry is a common theme in generalized anxiety disorder (GAD) samples as well as non-clinical student samples. Given the high cost of anxiety disorders to society, research is needed to examine the efficacy of self-administered treatments designed to reduce pathological worry. The primary goal of this study was to investigate the benefits of three self-administered interventions for reducing academic worry. College students (N = 113) experiencing clinically significant academic worry were randomized to either: (a) worry exposure (WE); (b) expressive writing (EW); (c) relaxation consisting of pulsed audio-photic stimulation (APS); or (d) waitlist control (WLC). Participants were instructed to practice their interventions three times per week for one month and completed home practice logs online to track treatment adherence. Academic worry, general anxiety, and perceived stress were assessed at baseline and post-treatment. Academic worry and general anxiety were also assessed at a three-month follow-up. Those assigned to the WE and APS conditions showed significant improvement relative to EW and WLC at post-treatment. All treatment conditions showed continued improvement by follow-up, with no between-group differences. Treatment and public health implications are discussed.     

Perceived attachment: relations to anxiety sensitivity, worry, and GAD symptoms

This investigation examined the relation between perceived alienation from parents and peers, anxiety sensitivity (AS), and current worry and generalized anxiety disorder (GAD) symptoms with the goal of expanding the knowledge base on factors that may contribute to the development of AS and its role in worry. The mediating role of AS between perceptions of alienation and current worry and GAD symptoms was also examined. Ninety-four non-clinical worriers completed self-report questionnaires assessing their perceptions of attachment, AS levels, and worry and GAD symptoms. Even after controlling for worry and GAD symptoms, greater perceptions of alienation from mothers and peers were significantly associated with higher AS symptoms. AS as a unitary construct mediated the relation between perceptions of alienation from mothers and peers and worry and GAD symptoms. The facets fear of publicly observable symptoms and fear of cognitive dyscontrol also mediated this relation. The role of alienation in relation to AS, worry, and GAD symptoms is discussed along with directions for future research.     

The role of executive functioning in CBT: a pilot study with anxious older adults

Cognitive behavior therapy (CBT) is an effective treatment for late life anxiety and depression. The successful use of CBT is assumed to rely on cognitive skills known as executive functions (EF; e.g., hypothesis generation, allocation of attention, self-monitoring) governed by the prefrontal cortex. Because older adults sometimes have executive deficits as a consequence of normal aging, EF may be a mediator of CBT outcome in older samples. The current pilot study tested the hypothesis that older adults with executive deficits (as measured by neuropsychological tests) would show decreased therapeutic benefit from CBT for generalized anxiety disorder, as compared to a group with intact EF. Results indicated differential response to CBT within the dysfunction group depending on the stability (and possibly, the etiology) of executive deficits from pre- to posttreatment. Those whose EF scores remained low from pre- to posttreatment did not respond to CBT, while those whose scores improved responded quite well, similar to an Intact EF group. Results indicate that some, but not all, older adults with executive dysfunction show decreased benefit from CBT, and are consistent with the assumption that executive skills are important for the successful use of CBT. However, some participants may show improvement on both mood and cognitive skills during treatment, which is discussed further.     

Inflated responsibility and the use of stop rules for catastrophic worrying

The present paper reports the results of two experiments designed to test some predictions from a mood-as-input explanation of catastrophic worrying (). In particular, these experiments attempted to identify whether worriers possess characteristics that would contribute to the use of relatively strict 'as many as can' closure rules for catastrophising. Experiment 1 demonstrated that high worriers begin a catastrophising task with higher self-reported levels of responsibility towards fully considering all issues involved, than low worriers. Experiment 2 suggested that inflated responsibility has a causal effect on perseveration at the catastrophising task (rather than being a simple non-causal by-product of excessive worrying), and that inflated responsibility exacerbates catastrophising only in conjunction with negative mood. This suggests a relatively complex relationship between responsibility and mood, where there are mood conditions in which high responsibility does not generate greater persistence than low responsibility. These findings are consistent with predictions from a mood-as-input account of catastrophic worrying, and provide evidence for a putative mechanism that mediates the influence of variables such as inflated responsibility on perseveration.     

The Nature of Generalized Anxiety in Older Primary Care Patients: Preliminary Findings

Clinical features of older primary care patients with GAD (PC-GAD; n = 22) were examined relative to older patients with GAD recruited for two academic clinical trials (M. A. Stanley, J. G. Beck, et al., 2003; J. L. Wetherell, M. Gatz, & M. G, Craske, 2003) and to a sample of older primary care patients without psychiatric diagnoses (No Dx; n = 10). Comparisons revealed similar levels of worry, anxiety, depressive symptoms, quality of life, and functional status between the PC-GAD subsample and patients recruited for academic trials, although primary care patients were older, less well educated, and more ethnically diverse. The PC-GAD subgroup, however, reported greater symptom severity, reduced quality of life, and poorer perceived general health, mental health, and vitality than the No Dx subgroup (² = .23–.43). Service utilization was not different between PC-GAD and No Dx subgroups, with the exception of psychotropic medication use. The Penn State Worry Questionnaire (PSWQ) and an abbreviated version of this measure may be useful for identifying late-life GAD in primary care. Cutoff scores of 50 and 22 on the full and abbreviated versions of the PSWQ, respectively, demonstrated excellent specificity, sensitivity, and positive predictive value. Negative predictive value was less impressive, probably as a result of high base rates for GAD in this sample.     

Contextual learning induces an increase in the number of hippocampal CA1 neurons expressing high levels of BDNF

We examined behaviorally induced expression of brain-derived neurotrophic factor (BDNF) in area CA1 of the hippocampus. Sprague-Dawley rats were trained in a contextual fear conditioning (CFC) task, sacrificed 4h later, and their brains were processed for immunohistochemistry. We found distinctively high levels of BDNF immunoreactivity in a small number ( approximately 1%) of CA1 neurons in untrained animals. The number of these exceptional neurons, which are identified as BDNF(++) in this study, was increased by up to approximately 3% after CFC. This increase was blocked in the presence of a memory-impairing dose of a NMDA receptor antagonist (MK801 0.3 mg/kg, i.p.) given 30 min prior to training. The BDNF signal intensity in BDNF(++) neurons correlated with that of surrounding glutamic acid decarboxylase (GAD) 65. This correlation between GAD65 and BDNF signal intensities suggests that BDNF upregulation was associated with increased signaling via inhibitory GABAergic synapses that would lessen further intervening neuronal activity. Our observation that neurons which upregulate BDNF expression following a learning experience are rich in GAD65-enriched afferent synapses suggests that these neurons may have distinct roles in memory consolidation.     

The contributory role of worry in emotion generation and dysregulation in generalized anxiety disorder

The role of worry in generalized anxiety disorder (GAD) has been posited to serve as an avoidance of emotional experience, and emotion regulation deficits in GAD have been found in several previous studies. It remains unclear whether those with GAD experience more dysregulated emotions during periods of euthymia and positive affect or whether these deficits occur only during periods of worry. Individuals with GAD (with and without co-occurring dysphoria) and non-anxious controls were randomly assigned to receive a worry, neutral, or relaxation induction. Following the induction, all participants viewed a film clip documented to elicit sadness. Intensity of emotions and emotion regulation were examined following the induction period and film clip. The results revealed that, regardless of co-occurring dysphoria, individuals with GAD in the worry condition experienced more intense depressed affect than GAD participants in the other conditions and controls participants. In contrast, presence of worry appeared to have less impact on indices of emotion dysregulation, which were greater in participants with GAD compared to controls, but largely insensitive to contextual effects of worry or of relaxation. Following film viewing, both GAD participants with and without dysphoria displayed poorer understanding, acceptance, and management of emotions than did controls. However, acceptance and management deficits were most pronounced in individuals with both GAD and co-occurring dysphoria. Implications for the role of emotions in conceptualization and treatment of GAD are discussed.     

Attentional control in OCD and GAD: specificity and associations with core cognitive symptoms

Obsessive–compulsive disorder (OCD) and generalized anxiety disorder (GAD) are both defined by excessive negatively-valenced cognitions. Although obsessional thoughts are considered essential to OCD and perseverative worry is considered essential to GAD, these excessive cognitions have been found to co-occur in both disorders. Accordingly, a common diathesis may influence the emergence of excessive thoughts in both disorders. The present study examined deficits in attentional control as a cognitive vulnerability that may contribute to both obsessional thought and perseverative worry. Patients with OCD (n = 30), GAD (n = 29), and non-clinical controls (NCC; n = 29) completed measures of obsessional thoughts, perseverative worry, and attentional control. Deficits in self-reported attentional control were found in both OCD and GAD relative to the NCC. However, attentional control was only related to excessive cognition in the GAD patient group, where deficits were associated with increased perseverative worry. Mediational modeling suggested that trait anxiety mediated the relationship between attentional control and perseverative worry in GAD. Implications of these findings for conceptualizing the role of attentional control in the genesis of excessive cognitions in OCD and GAD are discussed.     

Evaluating the cognitive avoidance model of generalised anxiety disorder: Impact of worry on threat appraisal, perceived control and anxious arousal

Generalised anxiety disorder (GAD) is characterised by persistent and uncontrollable worry. According to the cognitive avoidance theory of GAD, worry may function as an affective dampening strategy motivated by intolerance of negative emotional states. By facilitating avoidance of more distressing cognitions and associated affect, worry is said to preclude modification of the fear representation in memory, maintaining threat associations and perpetuating further anxiety and worry. The present study evaluated these assumptions in a treatment-seeking GAD sample. Sixty-one participants were randomly allocated to conditions in which they were instructed to worry, imaginally process or relax in response to an anxiety trigger. Results supported the detrimental impact of worry, showing maintained threat expectancies and decreased control perceptions compared to other modes of processing. However, skin conductance level increased as a function of worry and there was no suggestion that worry suppressed affective responding. These findings highlight the need for clarification of the mechanisms involved in the maintenance of threat associations and worry in GAD.     

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.