Refining the Analysis of Mechanism-Outcome Relationships for Anxiety Treatment: A Preliminary Investigation Using Mixed Models.

Although efficacious treatments exist for anxiety disorders, issues remain regarding how best to conceptualize and measure purported change processes in clinical research. In the current study, we examined the relationship between treatment-specific (exposure therapy, attention bias modification [ABM]) as well as more general change processes with symptoms within a transdiagnostic sample using mixed models. Results indicated that slope of self-efficacy across treatment and between-session habituation across identical exposures was associated with slope of symptom change. Although slope of anxiety ratings within session was not associated with slope of symptom change, it did interact with other candidate exposure processes to predict symptoms. Purported ABM change processes were not associated with outcome. Our use of mixed models exemplifies an emerging trend in this research aimed at minimizing loss of data through aggregation, and our results highlight the utility of integrating treatment-specific as well as more general change processes in mechanistic research.

Investigating the psychometric properties of the Suicide Stroop Task.

Behavioral measures are increasingly used to assess suicidal thoughts and behaviors. Some measures, such as the Suicide Stroop Task, have yielded mixed findings in the literature. An understudied feature of these behavioral measures has been their psychometric properties, which may affect the probability of detecting significant effects and reproducibility. In the largest investigation of its kind, we tested the internal consistency and concurrent validity of the Suicide Stroop Task in its current form, drawing from seven separate studies (N = 875 participants, 64% female, aged 12 to 81 years). Results indicated that the most common Suicide Stroop scoring approach, interference scores, yielded unacceptably low internal consistency (rs = -.09-.13) and failed to demonstrate concurrent validity. Internal consistency coefficients for mean reaction times (RTs) to each stimulus type ranged from rs = .93-.94. All scoring approaches for suicide-related interference demonstrated poor classification accuracy (AUCs = .52-.56) indicating that scores performed near chance in their ability to classify suicide attempters from nonattempters. In the case of mean RTs, we did not find evidence for concurrent validity despite our excellent reliability findings, highlighting that reliability does not guarantee a measure is clinically useful. These results are discussed in the context of the wider implications for testing and reporting psychometric properties of behavioral measures in mental health research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Enhancement of Self-Conducted Exposure for OCD Using Cognitive Bias Modification: A Case Study.

The psychological treatment of choice for obsessive-compulsive disorder (OCD) is exposure and response prevention (ERP). However, the training required for practitioners to be proficient in delivering ERP is not readily available, thereby rendering the treatment inaccessible to most patients. Self-directed ERP (sERP) programs designed to increase the accessibility of ERP have not proven effective, perhaps because patients find it difficult to comply with exposure exercises without the guidance of a clinician. Research on cognitive bias modification (CBM) suggests that CBM may help individuals approach feared situations. In this case study, a patient with OCD completed a 7-week treatment program that combines sERP with CBM. Treatment led to a significant decrease in OCD symptoms and functional impairment. Results suggest that this novel treatment, which requires only an initial couple of sessions with a clinician trained in ERP, has the potential to increase the accessibility of ERP for patients with OCD.

Testing the Efficacy of Attention Bias Modification for Suicidal Thoughts: Findings From Two Experiments.

This study explores whether four sessions of attention bias modification (ABM) decreases suicide-specific attentional bias. We conducted two experiments where suicide ideators completed either a Training or Control version of ABM, a computer-based intervention intended to target attentional bias. Suicide-specific attentional bias was measured using adapted Stroop and probe discrimination tasks. The first experiment with community-based suicide ideators did not show that ABM impacts attentional bias or suicidal ideation. The second experiment with clinically severe suicidal inpatients yielded similar results. Post-hoc findings suggest that the type of attentional bias targeted by the current intervention may differ from the type that marks suicide risk. There remains little to no evidence that the ABM intervention changes suicide-specific attentional bias or suicidal ideation.

Cognitive behaviour therapy for specific phobia of vomiting (Emetophobia): A pilot randomized controlled trial.

This is the first randomised controlled trial to evaluate a protocol for cognitive behaviour therapy (CBT) for a Specific Phobia of Vomiting (SPOV) compared with a wait list and to use assessment scales that are specific for a SPOV. METHOD: 24 participants (23 women and 1 man) were randomly allocated to either 12 sessions of CBT or a wait list. RESULTS: At the end of the treatment, CBT was significantly more efficacious than the wait list with a large effect size (Cohen's d=1.53) on the Specific Phobia of Vomiting Inventory between the two groups after 12 sessions. Six (50%) of the participants receiving CBT achieved clinically significant change compared to 2 (16%) participants in the wait list group. Eight (58.3%) participants receiving CBT achieved reliable improvement compared to 2 (16%) participants in the wait list group. CONCLUSIONS: A SPOV is a condition treatable by CBT but further developments are required to increase efficacy.

Preliminary Evidence for the Enhancement of Self-Conducted Exposures for OCD using Cognitive Bias Modification.

Exposure and Response Prevention (ERP) is the most effective treatment for OCD but it is not accessible to most patients. Attempts to increase the accessibility of ERP via self-directed ERP (sERP) programs such as computerized delivery and bibliotherapy have met with noncompliance, presumably because patients find the exposure exercises unacceptable. Previous research suggests that Cognitive Bias Modification (CBM) interventions may help individuals approach feared situations. The goal of the current study was to test the efficacy of a treatment program for OCD that integrates sERP with CBM. Twenty-two individuals meeting diagnostic criteria for OCD enrolled in our 7-week treatment program. Results suggest that sERP with CBM led to significant reduction of OCD symptoms and functional impairment. Indeed, the magnitude of the effect of this novel treatment, that requires only an initial session with a clinician trained in ERP for OCD, was comparable to that of the gold standard clinician-administered ERP. Moreover, preliminary evidence suggests that CBM interventions targeting interpretation bias may be most effective, whereas those targeting attention and working memory bias may not be so.

The effects of cognitive load on attention control in subclinical anxiety and generalised anxiety disorder.

Poor regulation of emotions may involve impaired attention control. In the current paper, we report the results of two studies examining the interaction of anxiety, attention control and cognitive load. In Study I, using a performance-based task to assess attention control, we examined whether anxiety is associated with impaired attention control, and whether these effects are influenced by working memory load. In Study II, we examined these effects in patients with a diagnosis of generalised anxiety disorder (GAD) compared to non-anxious control (NAC) participants. Results of Study I showed that high anxiety was associated with increased attention control, that is decreased interference from distractors, but only under high cognitive load. These results were replicated in Study II such that individuals with GAD showed increased attention control relative to NACs, but only under high cognitive load. These results help clarify previous predictions regarding the effect of anxiety on attention control.

Hoarding disorder in older adulthood.

OBJECTIVE: Hoarding disorder (HD) is a chronic condition associated with moderate to severe impairment in health and functioning. HD has been primarily studied in midlife adults, and there is limited research on HD in late life. METHODS: In this review, we summarize research on the presentation and characteristics of HD and hoarding symptoms in older adults, including evidence for associated impairment in daily functioning, physical health, and cognitive function. Finally, we review the evidence available for intervention outcomes for treating HD in older adults. RESULTS: Geriatric HD is characterized by severe functional impairment, medical and psychiatric comorbidities, and cognitive dysfunction. CONCLUSION: There is a lack of randomized controlled trials investigating evidence-based treatments for geriatric HD.

Interpretation of Ambiguity in Individuals with Obsessive-Compulsive Symptoms.

In two experiments we examined the psychometric properties of a new measure of interpretation bias in individuals with obsessive-compulsive symptoms (OCs). In Experiment 1, 38 individuals high in OC symptoms, 34 individuals high in anxiety and dysphoric symptoms, and 31 asymptomatic individuals completed the measure. Results revealed that the Word Sentence Association Test for OCD (WSAO) can differentiate those with OC symptoms from both a matched anxious/dysphoric group and a non-anxious/non-dysphoric group. In a second experiment, we tested the predictive validity of the WSAO using a performance-based behavioral approach test of contamination fears, and found that the WSAO was a better predictor of avoidance than an established measure of OC washing symptoms (Obsessive Compulsive Inventory-Revised, washing subscale). Our results provide preliminary evidence for the reliability and validity of the WSAO as well as its usefulness in predicting response to behavioral challenge above and beyond OC symptoms, depression, and anxiety.

The effect of modifying automatic action tendencies on overt avoidance behaviors.

We used the Approach-Avoidance Task (AAT) to examine the role of automatic action tendencies. We hypothesized that, after manipulation of automatic action tendencies, participants would be more likely to approach feared objects when compared with participants in a control condition. Participants were instructed to push or pull a joystick, resulting in contamination-related and neutral pictures moving progressively away from or toward them, respectively. We manipulated approach by building a contingency between the arm movement and the picture type in the active condition but not in the control condition. Consistent with our hypothesis, participants in the active manipulation group showed facilitated automatic approach tendencies and reduced avoidance tendencies for contamination-related stimuli and completed more steps approaching their feared objects in a behavioral approach test compared with participants in the control group. Our results suggest that automatic action tendencies may play an important role in the maintenance of fear-related behavioral avoidance.

Image Generation in Individuals with Generalized Social Phobia.

Individuals with social phobia report experiencing recurrent negative images of themselves in social situations. However, research on the role of visual imagery in social phobia has relied exclusively on self-report measures. In the first study, we used a visual image generation task with social-threat and neutral stimuli to test the hypothesis that individuals with Generalized Social Phobia (GSP, n = 32) are more efficient at generating images related to social-threat words than are non-anxious-controls (NACs, n = 28). We found that, contrary to our hypothesis, the GSP and NAC groups did not differ in speed of generating images related to social-threat words. However, the GSP group was significantly slower than the NAC group at generating images related to neutral words. To further examine the generation of neutral images, we conducted a second study using a well-validated neutral image generation task, and found that the GSP group (n = 24) was slower to generate neutral images than were the NAC (n = 21) and anxious-control (AC, n = 15) groups, which did not differ from each other. Taken together, findings from the two studies suggest that social phobia is characterized by less efficient generation of neutral images.

Attentional impairment in anxiety: inefficiency in expanding the scope of attention.

BACKGROUND: The ability to attend to relevant visual information in a proficient manner is central to most day-to-day tasks. Research suggests, however, that this ability is compromised by anxiety such that anxiety results in narrowing the focus of visual attention. METHOD: In the current study (N = 58), we used the Attention Scope Task [1999: Gerontology 45:102-109] to examine the hypothesis that low-anxious individuals would be more proficient than high-anxious individuals in their scope of attention, that is, high-anxious individuals would have a larger scope of visual attention than low-anxious individuals. Additionally, we hypothesized that low-anxious individuals would be more proficient than high-anxious individuals in their ability to expand their scope of attention. RESULTS: Results revealed that, compared to low-anxious individuals, high-anxious individuals were impaired only in their ability to expand their scope of attention from a small area to a larger one. Inclusion of a depressed control group in the study revealed that our findings are specific to the effect of anxiety and not depressive symptoms. CONCLUSION: Thus, high-anxious individuals do not appear to have a smaller absolute scope of attention but instead seem to have difficulty expanding their attention scope dynamically. We discuss our results in relation to cognitive inflexibility in anxiety.

Executive control of attention in individuals with contamination-related obsessive-compulsive symptoms.

BACKGROUND: In this study, we examined executive control of attention in individuals with contamination-related obsessive-compulsive (OC) symptoms using a modified version of the Eriksen flanker task. The task indexes one's ability to resolve attentional conflict between different responses and to ignore task distracters. METHODS: For this study, we modified the original flanker task using affective words to examine the effect of threat-relevant stimuli on executive control of attention. Consistent with research on information processing biases in individuals with OC symptoms, we hypothesized that the flanker interference effect (i.e., difference in response latencies between incongruent and congruent flanker trials) will be greater for threat-related flankers in individuals with OC symptoms (n=32), relative to a control group (n=36). RESULTS: Results of our study were consistent with our hypothesis: The interference effect for threat flankers was greater in individuals with OC symptoms than in those low in symptoms. Moreover, there was no differential interference effect in the low and high symptom groups for neutral flankers. CONCLUSIONS: These findings suggest that the presence of threat-relevant distracters disrupts executive control of attention in individuals with contamination-related OC symptoms. These results are consistent with extant research on attentional biases in individuals with clinical and subclinical symptoms of OCD.

Attentional bias toward suicide-related stimuli predicts suicidal behavior.

A long-standing challenge for scientific and clinical work on suicidal behavior is that people often are motivated to deny or conceal suicidal thoughts. The authors proposed that people considering suicide would possess an objectively measurable attentional bias toward suicide-related stimuli and that this bias would predict future suicidal behavior. Participants were 124 adults presenting to a psychiatric emergency department who were administered a modified emotional Stroop task and followed for 6 months. Suicide attempters showed an attentional bias toward suicide-related words relative to neutral words, and this bias was strongest among those who had made a more recent attempt. Importantly, this suicide-specific attentional bias predicted which people made a suicide attempt over the next 6 months, above and beyond other clinical predictors. Attentional bias toward more general negatively valenced words did not predict any suicide-related outcomes, supporting the specificity of the observed effect. These results suggest that suicide-specific attentional bias can serve as a behavioral marker for suicidal risk, and ultimately improve scientific and clinical work on suicide-related outcomes.

Automatic avoidance tendencies in individuals with contamination-related obsessive-compulsive symptoms.

We used an approach-avoidance task (AAT) to examine response to threatening stimuli in 20 individuals high in contamination-related obsessive-compulsive symptoms (HCs) and 21 individuals low in contamination-related obsessive-compulsive symptoms (LCs). Participants were instructed to respond to contamination-related and neutral pictures by pulling a joystick towards themselves or by pushing it away from themselves. Moving the joystick changed the size of the image to simulate approaching or distancing oneself from the object. Consistent with our hypothesis, the HC group was significantly slower in pulling contamination-related pictures than in pulling neutral pictures, whereas in the LC group there was no difference between speed of pulling contamination-related pictures and neutral pictures. Contrary to our hypothesis, we did not find support for faster pushing away of contamination-related pictures than neutral pictures by the HC group. Moreover, the degree of avoidance of contamination-related stimuli when pulling - but not when pushing - was significantly correlated with self-reported contamination-related obsessive-compulsive symptoms. These results suggest a biased behavioral response for threatening objects in individuals high in contamination fears only when inhibiting the prepotent response to avoid threatening stimuli and not when performing a practiced avoidance response. Thus, our results validate the use of the AAT as a measure of inhibited and uninhibited automatic avoidance reactions to emotional information in individuals with contamination-related obsessive-compulsive symptoms.

Attention training for reducing spider fear in spider-fearful individuals.

Cognitive theorists propose that attentional biases for threatening information play an important role in the development and maintenance of anxiety disorders. If attentional biases for threat figure in the maintenance of anxiety, then the experimental reduction of the bias for threat (attention training) should reduce anxiety. We randomly assigned 41 spider-fearful individuals to receive either attention training (n=20) or control procedures (n=21). We used a modified dot-probe discrimination paradigm with photographs of spiders and cows to train attention. Training reduced attentional bias for spiders, but only temporarily. Although both groups declined in spider fear and avoidance, reduction in attentional bias did not produce significantly greater symptom reduction in the training group than in the control group. However, reduction in attentional bias predicted reduction in self-reported fear for the training group. The reduction in attentional bias for threat may have been insufficiently robust to produce symptom reduction greater than that produced by exposure to a live spider and spider photographs alone. Alternatively, attention training may be an unsuitable intervention for spider fear.

The effect of attention training on a behavioral test of contamination fears in individuals with subclinical obsessive-compulsive symptoms.

In the current study, we evaluated the effectiveness of attention training in individuals with subclinical obsessive-compulsive symptoms. We hypothesized that after completing attention training, participants would be more likely to complete steps in a hierarchy approaching their feared contaminant compared with participants in the control condition. Participants completed a probe detection task by identifying letters replacing one member of a pair of words (neutral or contamination related). We trained attention by building a contingency between the location of the contamination-related word in the active condition and not in the control condition. Participants in the active group showed a significant reduction in attention bias for threat and completed significantly more steps when approaching their feared objects compared with participants in the control group. Our results suggest that attention disengagement training may facilitate approaching feared objects in individuals with obsessive-compulsive symptoms.

Learning the futility of the thought suppression enterprise in normal experience and in obsessive compulsive disorder.

BACKGROUND: The belief that we can control our thoughts is not inevitably adaptive, particularly when it fuels mental control activities that have ironic unintended consequences. The conviction that the mind can and should be controlled can prompt people to suppress unwanted thoughts, and so can set the stage for the intrusive return of those very thoughts. An important question is whether or not these beliefs about the control of thoughts can be reduced experimentally. One possibility is that behavioral experiments aimed at revealing the ironic return of suppressed thoughts might create a lesson that could reduce unrealistic beliefs about the control of thoughts. AIMS: The present research assessed the influence of the thought suppression demonstration on beliefs about the control of thoughts in a non-clinical sample, and among individuals with obsessive-compulsive disorder (OCD). METHOD: In Study 1, we assessed the effect of the thought suppression demonstration on beliefs about the control of thoughts among low and high obsessive individuals in the non-clinical population (N = 62). In Study 2, we conducted a similar study with individuals with OCD (N = 29). RESULTS: Results suggest that high obsessive individuals in the non-clinical population are able to learn the futility of suppression through the thought suppression demonstration and to alter their faulty beliefs about the control of thoughts; however, for individuals with OCD, the demonstration may be insufficient for altering underlying beliefs. CONCLUSIONS: For individuals with OCD, the connection between suppressing a neutral thought in the suppression demonstration and suppressing a personally relevant obsession may need to be stated explicitly in order to affect their obsessive beliefs.

Maternal attitudinal inflexibility: longitudinal relations with mother-infant disrupted interaction and childhood hostile-aggressive behavior problems.

OBJECTIVE: : The Personal Attitude Scale (PAS; Hooley, 2000) is a method that is under development for identifying individuals high in Expressed Emotion based on personality traits of inflexibility, intolerance, and norm-forming. In the current study, the goal was to measure the association between this maternal attitudinal inflexibility, early hostile or disrupted mother-infant interactions, and hostile-aggressive behavior problems in the child. METHODS: In a prospective longitudinal study of 76 low-income mothers and their infants, it was predicted that maternal PAS scores, assessed at child age 20, would be related to difficulties in early observed mother-infant interaction and to hostile-aggressive behavioral difficulties in the child. RESULTS: Results indicated that maternal difficulties in interacting with the infant in the laboratory were associated with maternal PAS scores assessed 20 years later. Hostile-aggressive behavior problems in the child at age five were also predictive of PAS scores of mothers. However, contrary to prediction, these behavior problems did not mediate the association between mother-infant interaction difficulties and maternal PAS scores, indicating that the child's hostile-aggressive behavior problems did not produce the link between quality of early interaction and later maternal attitudinal inflexibility. CONCLUSIONS: The current results validate the PAS against observable mother-child interactions and child hostile-aggressive behavior problems and indicate the importance of future work investigating the maternal attitudes that are associated with, and may potentially precede, parent-infant interactive difficulties. PRACTICE IMPLICATIONS: These findings regarding the inflexible attitudes of mothers whose interactions with their infants are also disrupted have important clinical implications. First, once the stability of the PAS has been established, this measure may offer a valuable screening tool for the prenatal identification of parents at risk for difficult interactions with their children. Second, it suggests routes for more cognitive interventions around helping less flexible parents shift perspectives to better take account of their child's outlooks and needs.

Managing unwanted intrusive thoughts in obsessive-compulsive disorder: relative effectiveness of suppression, focused distraction, and acceptance.

Suppression is one of various mental control techniques that people may use to manage unwanted thoughts. Evidence suggests that it is at best unsustainable and at worst counterproductive. This leads to the question: If suppression is a futile way to respond to unwanted, intrusive thoughts, what is a more effective alternative? In the current study, we evaluated the relative effectiveness of suppression and two alternative mental control techniques-focused distraction and acceptance-on the frequency of intrusions and distress associated with them. Results support the claim that suppression is a counterproductive technique for dealing with unwanted, intrusive thoughts in OCD. However, the harmfulness of suppression was reflected primarily in the magnitude of distress and not in intrusion frequency. Focused distraction and acceptance were the more effective techniques for managing clinically significant intrusive thoughts. We discuss implications for the cognitive treatment for OCD.