Cognitive-Behavioral Therapy Enhancement Strategies.

We review the literature on various strategies to augment cognitive-behavioral therapy (CBT). Although traditional pharmacotherapy has only a small additive effect, research demonstrates that it is possible to select interventions that potentiate known mechanisms of CBT. D-cycloserine appears to potentiate activity at the N-methyl D-ethyl aspartate receptor and thereby facilitates fear extinction. Exercise may increase neural plasticity and thereby increase the efficacy of CBT for depression and anxiety. Noninvasive brain stimulation is thought to target the specific cortical regions needed for CBT response, but results have been mixed. Several other compounds appear promising but await controlled research before their efficacy as an augmentation strategy can be determined.

Reductions in Anxiety are Associated with Decreased Expressive Suppression and Increased Cognitive Reappraisal After Cognitive-Behavioral Treatment: A Naturalistic Study in Youth.

Broad deficits in emotion regulation skills have been observed in children with anxiety-related disorders. These deficits typically improve during cognitive-behavioral therapy (CBT), but few studies have examined changes in expressive suppression and cognitive reappraisal in youth with anxiety disorders and/or obsessive-compulsive disorder (OCD) during CBT, especially in real-world settings. In a naturalistic treatment-seeking sample, 123 youth completed measures of anxiety, depression, and emotion regulation strategy use before and after 15 sessions of CBT. For anxious youth, anxiety and expressive suppression decreased over treatment, while cognitive reappraisal increased. Reductions in expressive suppression and increases in cognitive reappraisal were significantly associated with improvements in anxiety and remained significantly associated with post-treatment anxiety after accounting for baseline anxiety and depression. Changes in expressive suppression and cognitive reappraisal over the course of treatment were not found for youth with primary OCD. Thus, CBT improves emotion regulation abilities in anxious youth, and these improvements are associated with anxiety reduction; improvements in emotion regulation do not appear to drive changes in OCD symptoms. Further research is needed to determine whether changes in emotion regulation strategies mediate changes in anxiety among youth receiving CBT.

Linking a latent variable trait-state-occasion model of emotion regulation to cognitive control.

Emotion dysregulation (ED) is a vulnerability factor for affective disorders that may originate from deficits in cognitive control (CC). Although measures of ED are often designed to assess trait-like tendencies, the extent to which such measures capture a time-varying (TV) or state-like construct versus a time-invariant (TI) or trait-like personality characteristic is unclear. The link between the TV and TI components of ED and CC is also unclear. In a 6-wave, 5-month longitudinal study, community participants (n = 1281) completed the Difficulties in Emotion Regulation Scale (DERS-16), a commonly used measure of ED and measures of CC. A latent variable (trait-state-occasion) model showed that the proportion of TI factor variance (.80) was greater than the TV factor variance (.19). Although TV factor stability was significant, the coefficients were small in magnitude. Furthermore, regression weights for the ED TI factor (average ß = -.62) were significant and larger than those for the TV factor (average ß = -.10) in predicting latent CC at each of the six-time points. These findings suggest that ED, as assessed by the DERS-16, is largely TI and this TI component is more strongly linked to CC than the TV component.

Psychometric properties of a daily obsessive-compulsive symptom scale for ecological momentary assessment.

Despite growing interest in ecological momentary assessment (EMA) in psychopathology and clinical observation of day-to-day fluctuations in obsessive-compulsive disorder (OCD) symptoms, there is not a standardized EMA measure of such symptoms that can guide systematic research. In the absence of such a measure, prior EMA research in OCD has utilized heterogeneous approaches to sampling momentary and daily OCD symptoms, which limits the ability to compare results between studies. The present study sought to examine the psychometric properties of a daily OCD symptom (d-OCS) measure that assesses common OCD symptom themes (e.g., contamination, checking, intrusive thoughts) in a sample of adults with OCD (n = 20), psychiatric controls (n = 27), and healthy controls (n = 27). Participants completed the d-OCS 3 times per day for 1 week. The d-OCS distinguished those with OCD from psychiatric controls and healthy controls. The d-OCS demonstrated good internal consistency, adequate test-retest reliability, and good convergent validity. These findings offer initial psychometric support for the use of the d-OCS in EMA research examining day-to-day fluctuations in symptoms of OCD. Additional investigation is needed to examine the discriminant validity of the d-OCS and generalize these findings to more diverse samples.

Linking repetitive negative thinking and insomnia symptoms: A longitudinal trait-state model.

Sleep disturbance is highly debilitating, and an abundance of research suggests that repetitive negative thinking (i.e., rumination, worry) may contribute to the development and maintenance of maladaptive sleep patterns, such as insomnia symptoms. Although repetitive negative thinking is often conceptualized as a 'trait' risk factor for anxiety-related disorders, it is unclear if it consists of time-varying (TV) or state-like features versus time-invariant (TI) or trait-like characteristics. Furthermore, it is unclear if it is the TV or TI components of repetitive negative thinking that contribute to insomnia symptoms that is commonly observed in anxiety-related disorders. In a 6-wave, 5-month longitudinal study, community participants (N = 1219) completed measures of rumination, worry, transdiagnostic repetitive negative thinking, and insomnia symptoms. A latent variable (trait-state-occasion) model was applied to the measures of repetitive negative thinking. The results showed that although estimates of TI factor variance and TV factor variance were both significant for latent repetitive negative thinking, worry, and rumination, the proportion of TI factor variance (0.82-0.89) was greater than the amount of TV factor variance (0.11-0.19). Although TV factor stability was statistically significant for latent repetitive negative thinking, rumination, and worry, the magnitude of the coefficients was small. Furthermore, regression weights for the latent repetitive negative thinking, rumination, and worry TI factor were significant and larger than those for the TV factor in predicting insomnia symptoms at each of the six time points. These findings suggest that repetitive negative thinking is largely TI, and it is this TI component that contributes to insomnia symptoms. Implications for conceptualizations of repetitive negative thinking as a predisposing and perpetuating factor in insomnia for anxiety and related disorders are discussed.

Facing Uncertainty: A Comparison of Hierarchical and Variable Exposure Interventions for Contamination Fear.

Consistent with the inhibitory retrieval approach, one proposed modification to improve the effectiveness of exposure-based interventions is to maximize variability by not proceeding linearly up an exposure hierarchy. Accordingly, the present study compares hierarchical and variable exposure interventions for contamination-fearful individuals and examines the role of uncertainty to predict intervention outcomes. Participants (N=73) were randomly assigned to complete a single-session exposure intervention using a standard hierarchy or a variable exposure intervention in which hierarchy items were randomly presented. Participants completed a behavioral approach task (BAT) at baseline and two follow-up visits over a two-week period. Both interventions resulted in a significant decrease in anxiety and disgust as well as more BAT steps completed but did not differ from one another. However, individuals in the variable exposure condition reported less variability in uncertainty during exposure compared to those in the standard condition, d=.78. Furthermore, lower levels of variability in uncertainty predicted greater reductions in anxiety and disgust post-intervention. Consistent with previous studies, variable exposure did not convey additional benefit over standard, hierarchical exposure. The experience of uncertainty during exposure is an important yet understudied process that warrants additional investigation.

Mechanisms of Action in Exposure Therapy.

PURPOSE OF REVIEW: Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness. RECENT FINDINGS: Recent studies have examined mechanisms of exposure-based interventions across multiple levels of analysis, from cognitive and behavioral changes that occur during treatment to the neurobiological mechanisms underlying fear extinction. Belief change and reductions in safety behaviors and avoidance mediate symptom improvements during exposure therapy, suggesting plausible cognitive and behavioral mechanisms. On the neural level, increased activation of prefrontal regions during extinction learning is a likely mechanism of exposure. Improved understanding of the biological mechanisms of exposure have led to exciting developments in clinical research, including pharmacological augmentation, though clinical translation of basic research has produced mixed results. Though still in development, such translational research is a promising future direction for exposure-based interventions.

Linking the Estimation of Threat and COVID-19 Fear and Safety Behavior Use: Does Intolerance of Uncertainty Matter?

Research has shown threat overestimation is significantly associated with intolerance of uncertainty (IU), and both processes predict higher anxiety and safety behavior usage. However, the extent to which threat overestimation predicts subsequent COVID-19-related distress may vary as a function of IU. The present study examined IU as a moderator of the relationship between COVID-19 threat estimation and subsequent COVID-19 fear and safety behavior use. Between February 27 and March 26, 2020, participants (N = 57) completed a self-report measure of IU and estimated the number of people they believed had died from COVID-19. Four weeks later, participants completed measures of COVID-19 fear and safety behavior use. Results revealed IU significantly predicted subsequent COVID-19 fear and safety behavior use. IU also moderated the effect of threat estimation on COVID-19 fear such that those who underestimated threat and experienced low to moderate levels of IU reported experiencing lower levels of COVID-19 fear 1 month later.

Obsessive-Compulsive Disorder and Illness Anxiety: Examining Commonalities and Comorbidity.

Obsessive-compulsive disorder (OCD) and illness anxiety disorder (IAD) often co-occur. Cognitive-behavioral models of both disorders overlap and include maladaptive attentional processes, misinterpretation of thoughts and physical sensations, and engagement in repetitive behaviors in an attempt to reduce associated distress. Given commonalities in their presentation and their common co-occurrence, it is important to understand how illness anxiety affects the presentation and treatment of OCD. In this article, theoretical conceptualizations of OCD and IAD and their comorbid presentation are outlined, and assessment and differential diagnosis of these conditions are discussed. Despite shared cognitive vulnerabilities and behavioral patterns, well-validated symptom measures, along with careful functional analysis, can be used to distinguish between OCD, IAD, and comorbid presentations. Best practices for the cognitive-behavioral treatment of these co-occurring conditions are also presented, with suggestions based on both the empirical literature and detailed case studies. Finally, recommendations for future research on co-occurring OCD and IAD and their treatment are explored.

Time-Varying and Time-Invariant Dimensions in Intolerance of Uncertainty: Specificity in the Prediction of Obsessive-Compulsive Symptoms.

Intolerance of uncertainty (IU) is the tendency to respond negatively toward uncertain situations. IU consists of a Prospective factor (desire for predictability) and an Inhibitory factor (uncertainty paralysis) and is central to theoretical approaches to obsessive-compulsive disorder (OCD). However, time-invariant (TI) and time-varying (TV) components of IU and their association with OCD symptoms are not yet understood. The present study examined the association between TI and TV components of IU and OCD symptoms in community adults (N = 1,280) over a 5-month period. Latent variable models were fit to the data to examine the relative impact of TI and TV components of IU on OCD symptoms. As a test of specificity, models examining the association between TI and TV components of IU and depressive symptoms were also examined. The results showed that IU consists of significant TI and TV components, although the TI component accounted for most of the variance (76-84%) and was more strongly associated with OCD and depressive symptoms than the TV component. Furthermore, the TI component of IU was strongly associated with OCD symptoms when controlling for depressive symptoms, and the TI component of IU was strongly associated with depressive symptoms when controlling for OCD symptoms. A consistent pattern was observed for both Prospective and Inhibitory IU factors, with stable TI components demonstrating stronger relations with OCD and depressive symptoms than TV components. These findings have implications for conceptualizing the TI component of IU as a risk for OCD and other emotional disorders.

A longitudinal trait-state model of attentional control: Implications for repetitive negative thinking.

BACKGROUND: Attentional control refers to the ability to direct, focus, and shift attention voluntarily, and poor attentional control may confer risk for various affective disorders by increasing repetitive negative thinking. Although attentional control has been described as a trait, it is unclear if it is a time-varying (TV) or state-like factor versus a time-invariant (TI) or trait-like personality characteristic. METHODS: In a 6-wave, 5-month longitudinal study, community participants (n = 1,251) completed the Attentional Control Scale (Derryberry & Reed, 2002), the most commonly used measure of attentional control that includes two components: Focusing and Shifting. A latent variable (trait-state-occasion) model was applied to the two components. RESULTS: The results showed that although estimates of TI factor variance and TV factor variance were both significant for Focusing and Shifting, the proportion of TI factor variance (0.81, 0.77) was significantly greater than the amount of TV factor variance (0.18, 0.22). Furthermore, although TV factor stability was statistically significant for Focusing and Shifting, the size of the coefficients was small to moderate in magnitude. In predicting latent repetitive negative thinking at each of the six time points, regression weights for the attentional control TI factor were significant and larger than those for the TV factor (which were generally not significant). LIMITATIONS: Relatively short timeframe of 5 months and exclusive reliance on self-report measures. CONCLUSIONS: These findings suggest that self-reported attentional control is largely TI and that it is this TI component that predicts repetitive negative thinking.

Anxiety and safety behavior usage during the COVID-19 pandemic: The prospective role of contamination fear.

The coronavirus (COVID-19) pandemic has broadly increased anxiety and changed individual behavior. However, there is limited research examining predictors of pandemic-related changes, and the majority of existing research is cross-sectional in nature, which limits causal inference. Given functional links with disease avoidance processes, individual differences in contamination fear may be especially relevant in predicting responses to COVID-19. Accordingly, the present study prospectively examines contamination fear and obsessive-compulsive washing symptoms as predictors of anxiety and safety behaviors in response to COVID-19 in a student sample (N = 108). To examine specificity, anxiety and safety behaviors in response to seasonal influenza are also examined. In the early stages of the pandemic (March 2020), coronavirus-related anxiety was higher than flu-related anxiety (d = 1.38). Obsessive-compulsive washing symptoms also increased from before the pandemic (d = 0.4). Although baseline contamination fear and obsessive-compulsive washing symptoms did not significantly predict coronavirus-related anxiety, contamination fear did significantly predict safety behavior usage in response to both COVID-19 and influenza. The specificity of the prospective association between contamination fear and the use of safety behaviors are discussed in the context of the global COVID-19 pandemic and the broader literature on the role of safety behaviors in anxiety.

Specificity of trait anxiety in anxiety and depression: Meta-analysis of the State-Trait Anxiety Inventory.

The State-Trait Anxiety Inventory - Trait version (STAI-T) was developed to measure an individual's tendency to experience anxiety, but it may lack discriminant evidence of validity based on strong observed relationships with measures of depression. The present series of meta-analyses compares STAI-T scores among individuals with depressive disorders, anxiety disorders, and nonclinical comparison groups, as well as correlations with measures of anxiety and depressive symptom severity, in order to further examine discriminant and convergent validity. A total of 388 published studies (N = 31,021) were included in the analyses. Individuals with an anxiety disorder and those with a depressive disorder displayed significantly elevated scores on the STAI-T compared to nonclinical comparison groups. Furthermore, anxiety and depressive symptom severity were similarly strongly correlated with the STAI-T (mean r = .59 - .61). However, individuals with a depressive disorder had significantly higher STAI-T scores than individuals with an anxiety disorder (Hedges's g = 0.27). Given these findings, along with previous factor analyses that have observed a depression factor on the STAI-T, describing the scale as a measure of 'trait anxiety' may be a misnomer. It is proposed that the STAI-T be considered a non-specific measure of negative affectivity rather than trait anxiety per se.

Enhancing Inhibitory Learning: The Utility of Variability in Exposure.

Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.

Cognitive mechanisms of disgust in the development and maintenance of psychopathology: A qualitative review and synthesis.

A growing body of research has implicated disgust in various psychopathologies, especially anxiety-related disorders. Although the observed role of disgust in many disorders is robust, the mechanisms that may explain this role are unclear. Cutting-edge research in cognitive science has the potential to elucidate such mechanisms and consequently improve our understanding of how disgust contributes to the etiology and maintenance of psychopathology. In this qualitative review, we systematically assess cognitive bias mechanisms that have been linked to disgust and its disorders. This review suggests that disgust-related biases may be observed in memory, interpretation, judgment of expectancies, and attention, as well as at implicit levels. Of these cognitive domains, the most robust bias appears to be observed at the level of attention. However, reliable moderators of attentional biases for disgust have not yet been identified, and this bias has not been systematically linked to other levels of analysis. Despite these limitations, the available research indicates that attentional avoidance rather than orienting or maintenance may be the most characteristic of disgust. Attentional avoidance of disgust may have important implications for etiological and treatment models of disorders characterized by excessive disgust reactions. The implications for advancing such models are discussed in the context of a combined cognitive bias hypothesis.

Anger Rumination is not Uniquely Characteristic of Obsessive-Compulsive Disorder.

Although anger has been observed in obsessive-compulsive disorder (OCD), it remains unclear if rumination about anger is characteristic and/or unique to OCD. The present study examines whether types of anger rumination are endorsed more strongly by OCD patients compared to clinical and nonclinical controls. Patients with OCD (n = 30), generalized anxiety disorder (GAD; n = 29), and non-clinical controls (NCC; n = 30) completed measures of OCD symptoms, anger rumination, and trait anxiety. Patients with OCD and GAD significantly differed from NCC's (all ps < .001), but not each other (all ps > .10), in anger afterthoughts, thoughts of revenge, angry memories, and understanding causes of anger. However, the group differences were no longer significant when controlling for trait anxiety. A dimensional approach revealed that OCD symptoms were correlated with anger rumination domains overall. However, these associations were also no longer significant after controlling for trait anxiety. These findings suggest that anger rumination may emerge in OCD largely as an artifact of trait anxiety/negative affect that is associated with but not unique to the disorder. The implications of these findings for conceptualizing emotion and its regulation in OCD are discussed.

Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans.

OBJECTIVE: Comorbidity is the rule and not the exception among veterans with posttraumatic stress disorder (PTSD). Examining comorbidities in a veteran population allows us to better understand veterans' symptoms and recognize when mental health treatment may need to be tailored to other co-occurring issues. This article evaluates comorbid mood and anxiety disorders and PTSD symptom severity in a large sample of veterans from multiple eras of service, including the recent wars in Iraq and Afghanistan. METHOD: The current study used data from veterans who sought treatment for PTSD at a VA PTSD Clinical Team from 2005 to 2013. Veterans were assessed for PTSD, mood, and anxiety disorders using a structured clinical interview and completed self-report symptom measures as part of the PTSD clinic intake procedure. A total of 2,460 veterans were evaluated, and 867 met diagnostic criteria for PTSD. RESULTS: Veterans with PTSD were significantly more likely than those without PTSD to be diagnosed with social anxiety disorder and obsessive-compulsive disorder, but significantly less likely to be diagnosed with depression. In addition, veterans who had at least one comorbid diagnosis in addition to PTSD reported significantly higher PTSD symptom severity than veterans with PTSD alone. PTSD symptom severity also varied by era of service. CONCLUSION: These results suggest that among veterans seeking treatment for PTSD, comorbid mood and anxiety disorders may be associated with greater severity of PTSD symptoms. Future work is needed to determine the impact of specific comorbidities on trauma-focused treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Disgust in Anxiety and Obsessive-Compulsive Disorders: Recent Findings and Future Directions.

PURPOSE OF REVIEW: In the past 20 years, the role of disgust in anxiety disorders and obsessive-compulsive disorder (OCD) has been investigated with increasing precision. In this review, we examine recent evidence implicating disgust in anxiety and OCD, highlighting recent measurement and methodological improvements. Specific emphasis is placed on understanding the mechanisms that may account for the role of disgust in OCD and related disorders. RECENT FINDINGS: Recent developments include clarification of the role of distinct disgust-relevant vulnerabilities in the etiology of anxiety and OCD, an improved understanding of the neurobiology of disgust processing in OCD, and an increased focus on disgust-related mechanisms that contribute to psychopathology, such as disgust-based learning and emotion regulation. Disgust proneness is increasingly linked with symptoms of anxiety and OCD. However, further examination of the mechanisms that account for the roles of distinct disgust-relevant vulnerabilities is needed, and studies that directly examine disgust during the course of treatment are limited. Increasingly, the field has moved toward experimental investigation of specific disgust-relevant mechanisms that influence the etiology and treatment of OCD and related anxiety disorders.

Is disgust proneness sensitive to treatment for OCD among youth?: Examination of diagnostic specificity and symptom correlates.

Although disgust proneness has been implicated in obsessive-compulsive disorder (OCD), there is a paucity of research examining change in disgust proneness during treatment as well as the correlates of such change, especially in children. This study examined the relationship between changes in disgust proneness and disorder-specific symptoms during residential treatment among youth with OCD, anxiety, and mood disorders. Youth ages 12-18 (n=472) completed pre- and post-outcome measures of OCD, anxiety, and mood symptoms and disgust proneness. Results indicate that although disgust proneness decreases during treatment for youth with OCD, anxiety, and mood disorders, youth with primary OCD experienced the greatest decrease in disgust proneness over the course of treatment. Reductions in disgust proneness during treatment were significantly correlated with reductions in multiple symptom measures, with the strongest correlations between reductions in disgust proneness and OCD symptoms. Implications and directions for future research are discussed.