Quality of Life in Heterogeneous Anxiety Disorders: Changes Across Cognitive-Behavioral Treatments.

Quality of life is lower among individuals with anxiety disorders; however, this construct is rarely a focus in treatment research. This study explores changes in quality of life in a randomized, controlled trial of several cognitive-behavioral treatments (CBTs) for anxiety disorders. Adults with heterogeneous anxiety disorders (N = 223) were randomly assigned to (a) unified protocol for transdiagnostic treatment of emotional disorders, (c) a single-disorder protocol targeting their principal diagnosis, or (c) a waitlist control condition, and assessed at baseline, posttreatment, and 6-month follow-up. At baseline, the sample evidenced deficits in quality of life, with no significant differences in quality of life across diagnoses or condition. Results suggest improved quality of life among participants in treatment, at similar rates across treatment condition and diagnostic category, and at levels significantly higher than the waitlist. Improvements were maintained through 6-month follow-up. This study supports CBT as effective in promoting quality of life.

Attentional Bias Modification for Social Anxiety Disorder: What do Patients Think and Why does it Matter?

BACKGROUND: In the past decade, a great deal of research has examined the efficacy and mechanisms of attentional bias modification (ABM), a computerized cognitive training intervention for anxiety and other disorders. However, little research has examined how anxious patients perceive ABM, and it is unclear to what extent perceptions of ABM influence outcome. AIMS: To examine patient perceptions of ABM across two studies, using a mixed methods approach. METHOD: In the first study, participants completed a traditional ABM program and received a hand-out with minimal information about the purpose of the task. In the second study, participants completed an adaptive ABM program and were provided with more extensive rationale and instructions for changing attentional biases. RESULTS: A number of themes emerged from qualitative data related to perceived symptom changes and mechanisms of action, acceptability, early perceptions of the program, barriers/facilitators to engagement, and responses to adaptive features. Moreover, quantitative data suggested that patients' perceptions of the program predicted symptom reduction as well as change in attentional bias. CONCLUSIONS: Our quantitative data suggest that it may be possible to quickly and inexpensively identify some patients who may benefit from current ABM programs, although our qualitative data suggest that ABM needs major modifications before it will be an acceptable and credible treatment more broadly. Although the current study was limited by sample size and design features of the parent trials from which these data originated, our findings may be useful for guiding hypotheses in future studies examining patient perceptions towards ABM.

The unique and conditional effects of interoceptive exposure in the treatment of anxiety: A functional analysis.

Interoceptive exposure (IE; exposure focused on anxiety about somatic sensations) is a well-established component of treatments for panic disorder (PD), but little is known about the specificity of its effects or individual response patterns resulting from this intervention. This study investigated the utility of IE in the treatment of PD with claustrophobia, examining its mechanisms in isolation and in combination with situational exposure. Ten adults with PD and claustrophobia were treated with a flexible single-case approach. Participants received up to 6 sessions of IE; nonresponders received up to 6 additional sessions of IE combined with situational exposure. Hypotheses were: 1) Reductions in anxiety sensitivity (AS) and fearful expectancies would coincide with the introduction of IE and reach clinical significance by the end of the IE phase; 2) Reductions in claustrophobic avoidance would coincide with the introduction of situational exposure; 3) Fear extinction and distress habituation would occur in both intervention phases. Hypothesis 1 was not supported: Five participants experienced a reduction in AS and six participants experienced reduced expectancies of feared outcomes, but this did not reliably coincide with introduction of IE. Hypothesis 2 was supported: Claustrophobic avoidance improved more after the addition of situational exposure. Hypothesis 3 was supported: Habituation and fear extinction, whereby distress and expectancies of feared outcomes decreased and fear tolerance increased, were observed in response to IE delivered alone and in combination with situational exposure. IE appeared more helpful to participants who were fearful of the physical consequences of somatic sensations (e.g., heart attack) vs. other consequences (e.g., embarrassment). The observed variability in response to IE suggests a need for individualized implementation of this intervention.

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders.

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Compared With Diagnosis-Specific Protocols for Anxiety Disorders: A Randomized Clinical Trial.

Importance: Transdiagnostic interventions have been developed to address barriers to the dissemination of evidence-based psychological treatments, but only a few preliminary studies have compared these approaches with existing evidence-based psychological treatments. Objective: To determine whether the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is at least as efficacious as single-disorder protocols (SDPs) in the treatment of anxiety disorders. Design, Setting, and Participants: From June 23, 2011, to March 5, 2015, a total of 223 patients at an outpatient treatment center with a principal diagnosis of panic disorder with or without agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, or social anxiety disorder were randomly assigned by principal diagnosis to the UP, an SDP, or a waitlist control condition. Patients received up to 16 sessions of the UP or an SDP for 16 to 21 weeks. Outcomes were assessed at baseline, after treatment, and at 6-month follow-up. Analysis in this equivalence trial was based on intention to treat. Interventions: The UP or SDPs. Main Outcomes and Measures: Blinded evaluations of principal diagnosis clinical severity rating were used to evaluate an a priori hypothesis of equivalence between the UP and SDPs. Results: Among the 223 patients (124 women and 99 men; mean [SD] age, 31.1 [11.0] years), 88 were randomized to receive the UP, 91 to receive an SDP, and 44 to the waitlist control condition. Patients were more likely to complete treatment with the UP than with SDPs (odds ratio, 3.11; 95% CI, 1.44-6.74). Both the UP (Cohen d, -0.93; 95% CI, -1.29 to -0.57) and SDPs (Cohen d, -1.08; 95% CI, -1.43 to -0.73) were superior to the waitlist control condition at acute outcome. Reductions in clinical severity rating from baseline to the end of treatment (ß, 0.25; 95% CI, -0.26 to 0.75) and from baseline to the 6-month follow-up (ß, 0.16; 95% CI, -0.39 to 0.70) indicated statistical equivalence between the UP and SDPs. Conclusions and Relevance: The UP produces symptom reduction equivalent to criterion standard evidence-based psychological treatments for anxiety disorders with less attrition. Thus, it may be possible to use 1 protocol instead of multiple SDPs to more efficiently treat the most commonly occurring anxiety and depressive disorders. Trial Registration: clinicaltrials.gov Identifier: NCT01243606.

Improvement in quality of life and sexual functioning in a comorbid sample after the unified protocol transdiagnostic group treatment.

Patients with multiple mental disorders often experience sexual dysfunction and reduced quality of life. The unified protocol (UP) is a transdiagnostic treatment for emotional disorders that has the potential to improve quality of life and sexual functioning via improved emotion management. The present study evaluates changes in quality of life and sexual functioning in a highly comorbid sample treated with the UP in a group format. Forty-eight patients were randomly assigned to either a UP active-treatment group or a medication-only control group. Treatment was delivered in 14 sessions over the course of 4 months. Symptoms of anxiety and depression were assessed using the Beck Anxiety Inventory and Beck Depression Inventory. Sexual functioning was assessed by the Arizona Sexual Experience Scale (ASEX), and quality of life was assessed by the World Health Organization Quality of Life-BREF scale (WHOQOL-BREF). Quality of life, anxiety and depression all significantly improved among participants treated with the UP. Some improvement in sexual functioning was also noted. The results support the efficacy of the UP in improving quality of life and sexual functioning in comorbid patients.

Current Definitions of "Transdiagnostic" in Treatment Development: A Search for Consensus.

Research in psychopathology has identified psychological processes that are relevant across a range of Diagnostic and Statistical Manual (DSM) mental disorders, and these efforts have begun to produce treatment principles and protocols that can be applied transdiagnostically. However, review of recent work suggests that there has been great variability in conceptions of the term "transdiagnostic" in the treatment development literature. We believe that there is value in arriving at a common understanding of the term "transdiagnostic." The purpose of the current paper is to outline three principal ways in which the term "transdiagnostic" is currently used, to delineate treatment approaches that fall into these three categories, and to consider potential advantages and disadvantages of each approach.

Origins and outlook of interoceptive exposure.

BACKGROUND AND OBJECTIVES: Interoceptive exposure (IE) is a behavioral intervention that reduces anxiety sensitivity and distress associated with somatic sensations. In this discussion, we describe the history, current applications and additional clinical potential of IE. METHOD: We review the origins of IE and its historical application to panic disorder, as well as the accumulating evidence for transdiagnostic application to other disorders including post-traumatic stress disorder, social anxiety disorder, specific phobias and physical disorders. Then, we discuss ways in which IE could contribute to the treatment of additional disorders. RESULTS: IE is well-established in the treatment of panic disorder and increasingly used to target anxiety-provoking physical sensations in other disorders. Research and clinical evidence suggests that anxiety sensitivity is present across a range of disorders, and may actually be one variation on a broader phenomenon of interoceptive sensitivity, or anxiety focused on physical sensations that have been conditioned to unpleasant emotional states. Moreover, somatic symptoms are central to the experience of most emotions and may contribute to avoidant coping, a maintenance factor for disorders of emotion. IE has potential as a transdiagnostic intervention targeting interoceptive sensitivity in disorders such as depression and eating disorders. Nevertheless, IE is underutilized by clinicians in practice. Recent research in inhibitory learning and extinction suggests strategies for maximizing the effectiveness of IE. LIMITATIONS: This review is not exhaustive in nature, and systematic research on transdiagnostic applications of IE remains scarce. CONCLUSIONS: IE is a potentially powerful yet understudied transdiagnostic intervention.

A Transdiagnostic Temperament-Phenotype Profile Approach to Emotional Disorder Classification: An Update.

Although the emotional disorders (EDs) have achieved favorable reliability in the Diagnostic and Statistical Manual of Mental Disorders (DSM), accumulating evidence continues to underscore limitations in ED diagnostic validity. In particular, taxometric, comorbidity, and other descriptive psychopathology studies of transdiagnostic phenotypes studies suggest that the EDs may be best conceptualized as dimensional entities that are more similar than different. Despite optimism that the fifth edition of the DSM (DSM-5) would constitute a meaningful shift toward dimensional ED assessment and diagnosis, most changes contribute little movement in that direction. In the present report, we summarize past and anticipate persisting (i.e., in DSM-5) limitations of a purely categorical approach to ED diagnosis. We then review our alternative dimensional-categorical profile approach to ED assessment and classification, including preliminary evidence in support of its validity and presentation of two ED profile case examples using our newly developed Multidimensional Emotional Disorder Inventory. We end by discussing the transdiagnostic treatment implications of our profile approach to ED classification and directions for future research.

Effect of cognitive-behavioral therapy for anxiety disorders on quality of life: a meta-analysis.

OBJECTIVE: Although cognitive-behavioral therapy (CBT) is effective for treating anxiety disorders, little is known about its effect on quality of life. To conduct a meta-analysis of CBT for anxiety disorders on quality of life, we searched for relevant studies in PubMed, PsycINFO, and the Cochrane Library and conducted manual searches. METHOD: The search identified 44 studies that included 59 CBT trials, totaling 3,326 participants receiving CBT for anxiety disorders. We estimated the controlled and within-group random effects of the treatment changes on quality of life. RESULTS: The pre-post within-group and controlled effect sizes were moderately strong (Hedges's g = 0.54 and Hedges's g = 0.56, respectively). Improvements were greater for physical and psychological domains of quality of life than for environmental and social domains. The overall effect sizes decreased with publication year and increased with treatment duration. Face-to-face treatments delivered individually and in groups produced significantly higher effect sizes than Internet-delivered treatments. CONCLUSION: CBT for anxiety disorders is moderately effective for improving quality of life, especially in physical and psychological domains. Internet-delivered treatments are less effective than face-to-face treatments in improving quality of life.

Effect of pharmacotherapy for anxiety disorders on quality of life: a meta-analysis.

PURPOSE: Pharmacotherapy is an effective treatment for anxiety disorders, but its effects on quality of life (QOL) have not been examined systematically. Our objective was to conduct an effect size analysis of pharmacological interventions on QOL outcomes in patients with DSM-IV anxiety disorders. METHODS: Manual and electronic searches using PubMed, PsycINFO, and the Cochrane Library were conducted for records from the first available date through May 1, 2013 for trials of pharmacological interventions in patients with anxiety disorders, which had measures of QOL before and after treatment. Of 1,865 entries, 93 studies were identified as potentially relevant and 32 met inclusion criteria, of which results were examined from 22 studies reporting 27 distinct pharmacological trials, representing data from 4,344 anxiety disorder patients. Data were extracted independently by multiple observers to estimate within-group and placebo-controlled random effects of the treatment changes on QOL. We hypothesized that pharmacotherapy improves QOL, which is associated with improvement in anxiety symptoms. RESULTS: Pharmacological interventions effectively improved QOL from before to after treatment (Hedges' g = 0.59), although the controlled effect size is smaller among those trials with placebo interventions (Hedges' g = 0.32). These effect sizes were robust, increased with publication year, and increased with reductions in anxiety symptoms. CONCLUSIONS: Pharmacological therapy is effective for improving QOL in anxiety disorders, and larger symptom reductions are associated with greater improvement in QOL.

D-Cycloserine as an augmentation strategy for cognitive behavioral therapy of anxiety disorders.

The goal of this review is to examine the clinical studies on d-cycloserine, a partial glutamatergic N-methyl-D-aspartate agonist, as an augmentation strategy for exposure procedures during cognitive behavioral therapy for anxiety disorders. Although cognitive behavioral therapy and anxiolytic medications are more effective than placebo for treating anxiety disorders, there is still considerable room for further improvement. Traditional combination strategies typically yield disappointing results. However, recent studies based on translational research have shown promise to augment the neural circuitry underlying fear extinction with pharmacological means. We discuss the current state of the literature, including inconsistencies of findings and issues concerning the drug mechanism, dosing, and dose timing. D-cycloserine is a promising combination strategy for cognitive behavioral therapy of anxiety disorders by augmenting extinction learning. However, there is also evidence to suggest that d-cycloserine can facilitate reconsolidation of fear memory when exposure procedures are unsuccessful.