Introduction to a special issue on the contrast avoidance model.

The current paper introduces the special issue on the Contrast Avoidance Model. The Contrast Avoidance Mmodel theorizes that chronic worriers are afraid of a sharp increase in negative emotion and/or sharp reduction in positive emotion (labeled negative emotional contrasts; NECs). They thus use perseverative thought as means to create and sustain negative emotion to prevent NECs if they were to experience negative events. Further, these individuals are uncomfortable with sustained positive emotion because it leaves them vulnerable to NECs. At the same time, worry increases the probability of positive emotional contrasts (PECs), or sharp increases in positive emotion or decreases in negative emotion when things turn out better than expected or positive events are experienced. Therefore, these individuals generate negative emotion via perseverative thought as a way to avoid NECs and increase the likelihood of PECs. The current special issue provides novel research on the model.

The Contrast Avoidance Model: Conclusion and synthesis of new research in the special issue.

In this special series, new research on the Contrast Avoidance Model (CAM) was presented, including studies on the role of CAM in the maintenance of chronic worry, the incremental validity of CAM, CAM as a mediator of the association between generalized anxiety disorder (GAD) and other variables, CAM as transdiagnostic, and interpersonal behaviors as a means to avoid negative emotional contrasts (NECs). Furthermore, the role of perseverative thought in relation to positive emotional contrasts (PECs) was explored. Studies indicated that higher worry was positively and negatively reinforced, a factor that is likely to contribute to the maintenance of GAD. Further, research demonstrated that CAM contributed unique variance to understanding GAD above and beyond other variables associated with GAD, such as intolerance of uncertainty and negative problem orientation. Additional research revealed the transdiagnostic nature of contrast avoidance, as well as the association between contrast avoidance and problem-solving deficits. In addition, both worry and rumination increased the likelihood of PECs. Further, data suggested that anxious individuals may use interpersonal strategies to avoid NECs. Finally, savoring positive emotions was found to reduce contrast avoidance, providing a novel intervention strategy to address contrast avoidance in individuals with GAD.

Perceptions of Social-Emotional Learning Among K-12 Teachers in the USA During the COVID-19 Pandemic.

Social-emotional learning (SEL) is the process of acquiring and applying knowledge, skills, and attitudes to achieve long-term relational and emotional goals. Teachers often implement SEL strategies in the classroom; however, shifting to online schooling during the COVID-19 pandemic may have impacted teachers' perceptions of their abilities to implement SEL. This study was designed to identify whether and how teachers' perceptions of SEL changed since the onset of the COVID-19 pandemic. Teachers (N = 637) in the USA completed a demographic questionnaire, the Depression, Anxiety, and Stress Scale (DASS-21), and rated their beliefs about SEL during the pandemic on a modified version of the Comfort and Culture subscales of the Teacher SEL Beliefs Scale. Data were collected between September 2020 and March 2021. Teachers indicated that they felt neutral to comfortable with SEL and that they felt neutral to supported by their school culture for SEL during the pandemic. Lower depression symptoms, greater school poverty, and perceived general support (not specific to SEL) from the administration were associated with higher teacher comfort with SEL. Further, greater general support from the district and colleagues was associated with greater school culture supporting SEL during COVID-19. Results suggest that addressing teachers' internalizing symptoms and fostering a supportive work environment is important in aiding teachers in SEL implementation.

Psychotherapeutic treatments for generalized anxiety disorder: cognitive and behavioral therapies, enhancement strategies, and emerging efforts.

INTRODUCTION: Generalized anxiety disorder (GAD) is common and disabling. Different versions of cognitive behavioral therapy (CBT) have been tested, but no treatment works for everyone. Therefore, researchers have attempted approaches to enhance CBT. AREAS COVERED: The current narrative review examines meta-analyses and individual trials of CBT-based treatments for GAD. We focus on CBT and its cognitive and behavioral components as well as efforts to enhance CBT and its dissemination and generalizability. Enhancement efforts included interpersonal and emotional processing therapy, mindfulness-based CBT, emotion regulation therapy, intolerance of uncertainty therapy, the unified protocol, metacognitive therapy, motivational interviewing, and contrast avoidance targeted treatment. Emerging strategies to enhance dissemination have focused on technologically based treatments. Attempts at generalizability have included examination of efficacy within diverse racial and ethnic groups. EXPERT OPINION: We conclude that CBT is efficacious, and a number of enhancement efforts have shown some promise in improving upon CBT in single trials. However, more research is needed, particularly efforts to determine which enhancements work best for which individuals and what are the mechanisms of change. Furthermore, few technological interventions have been compared to active treatments. Finally, much more attention needs to be paid to ethnic and racial diversity in randomized controlled trials.

Effects of Postpartum Fatigue and Depressive Cognitions on Life Satisfaction and Quality of Life in Arab Postpartum Women: The Intervening Role of Resourcefulness.

The purpose of this study is to explore the relationships among postpartum fatigue (PPF), depressive cognitions, resourcefulness, quality of life, and life satisfaction in Arab postpartum mothers. A conceptual framework is used in this study based on the middle range theory of resourcefulness, which Zauszniewski developed in 2006. The study is a cross-sectional descriptive design with 123 postpartum women who had given birth within the past six months. used WhatsApp and Facebook for recruitment. developed the self-administered online survey in Qualtrics and collected data from 6 January 2017, to 6 February 2017. Correlation analysis is used to address the research aim and used the P value of 0.05 to determine the significance of the results. There were significant correlations among depressive cognitions and resourcefulness, life satisfaction, and quality of life; there were also significant correlations between PPF and life satisfaction, as well as among resourcefulness, quality of life, and life satisfaction. The results of this study emphasized the importance of assessing depressive symptoms and PPF in mothers early in the postpartum period. The results may contribute to designing future intervention studies aimed toward decreasing the risk of mothers with PPF developing more serious depressive symptoms.

The increase in interest in GAD: Commentary on Asmundson & Asmundson.

Generalized Anxiety Disorder (GAD) is one of the most common anxiety disorders. It is associated with functional impairment and is unlikely to spontaneously remit. As identified by Asmundson and Asmundson (2018), published research studies on GAD have increased in number over the last decade. We propose that this is due to the high prevalence of the diagnosis and symptoms, interest in transdiagnostic processes, such as worry, increased interest in emotion dysregulation as a principle underlying diagnoses, and new methods of treating and disseminating treatment that may be particularly well suited to GAD. Despite the increase in research articles on GAD, GAD still remains one of the least studied anxiety disorders. We propose that this is due to the misconception that GAD does not lead to severe impairment, despite data showing otherwise. Future research should continue to examine the phenomenology, mechanisms, and treatment of GAD in order to better understand this common anxiety disorder.

Meta-worry in adolescents: examination of the psychometric properties of the meta-worry questionnaire in an adolescent sample.

BACKGROUND: Meta-worry is considered a central component of the Metacognitive Model of Generalized Anxiety Disorder. Although initial research provides support for the applicability of this model to adolescent samples, the construct of meta-worry has yet to be examined in adolescents. AIMS: The purpose of this study was to examine the psychometric properties of the Meta-Worry Questionnaire (MWQ), a measure designed to assess negative beliefs about worry, in an adolescent sample, and to examine the degree to which meta-worry is associated with pathological worry in adolescents. METHOD: A non-referred sample of 175 adolescents completed a modified version of the MWQ along with the Meta-Cognitions Questionnaire-Children (MCQ-C) and the Penn State Worry Questionnaire for Children (PSWQ-C). RESULTS: The MWQ was found to exhibit strong psychometric properties. Most noteworthy, the MWQ was found to be a particularly robust predictor of scores on the PSWQ-C, and incremental validity was also demonstrated. CONCLUSIONS: Overall, the current findings provide support for the reliability and validity of the MWQ in adolescents and support for meta-worry as a predictor of worry symptoms in adolescents.

A randomized controlled trial of ecological momentary intervention plus brief group therapy for generalized anxiety disorder.

Momentary intervention has been proposed as a cost-effective, generalizable, and ecologically valid method to increase the efficiency of face-to-face cognitive-behavioral therapy (CBT). The purpose of the current pilot study was to evaluate the efficacy of a six-session palmtop computer-assisted Group CBT for generalized anxiety disorder (GAD) (CAGT6) in comparison with a six-session Group CBT for GAD without the computer (CBGT6) and typical (12 session) Group CBT for GAD (CBGT12) in a randomized controlled trial. Thirty-four individuals with a primary diagnosis of GAD were randomized to one of the three conditions and completed measures of GAD and anxiety before therapy, after therapy, and at 6-, and 12-month follow-ups. Results indicated that CAGT6 was superior to CBGT6 at posttreatment, but not significantly different from CBGT12. At 6- and 12-month follow-ups, CAGT6 was neither significantly different from CBGT6, nor from CBGT12. Percentages of individuals achieving reliable change on two of the three GAD measures favored CAGT6 over CBGT6 at posttreatment, suggesting promise for the added value of the mobile technology.

Web recruitment and internet use and preferences reported by women with postpartum depression after pregnancy complications.

Nearly one million women each year have pregnancy complications that cause antepartum and postpartum anxiety and depression. This exploratory study determined 1) feasibility of using social media to recruit women with depressive symptoms following high risk pregnancy, 2) women's barriers to treatment, 3) use of online resources for assistance with PPD, and 4) preferences for internet treatment. Among a national sample of 53 women, nearly 70% had major depression. Common barriers were lack of time and stigma. Over 90% of women would use the internet to learn coping strategies for PPD. Women expressed interest in web-based PPD treatment and identified desired characteristics of an intervention.

Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment.

Generalized anxiety disorder (GAD) is associated with substantial personal and societal cost yet is the least successfully treated of the anxiety disorders. In this review, research on clinical features, boundary issues, and naturalistic course, as well as risk factors and maintaining mechanisms (cognitive, biological, neural, interpersonal, and developmental), are presented. A synthesis of these data points to a central role of emotional hyperreactivity, sensitivity to contrasting emotions, and dysfunctional attempts to cope with strong emotional shifts via worry. Consistent with the Contrast Avoidance model, evidence shows that worry evokes and sustains negative affect, thereby precluding sharp increases in negative emotion. We also review current treatment paradigms and suggest how the Contrast Avoidance model may help to target key fears and avoidance tendencies that serve to maintain pathology in GAD.

Maternal and child expressed emotion as predictors of treatment response in pediatric obsessive-compulsive disorder.

Expressed emotion (EE) is associated with symptoms and treatment outcome in various disorders. Few studies have examined EE in pediatric OCD and none of these has assessed the child's perspective. This study examined the relationship among maternal and child EE, child OCD severity, and OCD-related functioning pre- and post-treatment. At pre-treatment, mothers completed speech samples about the child with OCD and an unaffected sibling. Children with OCD completed speech samples about parents. There were low rates of high maternal EE (child with OCD: 16.1%; sibling: 2.6%) and high child EE about parents (mothers: 11.9%; fathers: 10.2%). High EE was primarily characterized by high criticism, not high overinvolvement. High maternal EE and child EE regarding fathers were associated with pre-treatment child OCD severity but not post-treatment severity. High child and maternal EE were predictive of post-treatment OCD-related functioning. EE may be an important child and maternal trait associated with pre-treatment OCD severity and generalization of treatment gains.

Interpersonal pathoplasticity in individuals with generalized anxiety disorder.

Recent theories of generalized anxiety disorder (GAD) have emphasized interpersonal and personality functioning as important aspects of the disorder. We examined heterogeneity in interpersonal problems in 2 studies of individuals with GAD (n = 47 and n = 83). Interpersonal subtypes were assessed with the Inventory of Interpersonal Problems-Circumplex (Alden, Wiggins, & Pincus, 1990). Across both studies, individuals with GAD exhibited heterogeneous interpersonal problems, and cluster analyses of these patients' interpersonal characteristics yielded 4 replicable clusters, identified as intrusive, exploitable, cold, and nonassertive subtypes. Consistent with our pathoplasticity hypotheses, clusters did not differ with GAD severity, anxiety severity, or depression severity. Clusters in Study 2 differed on rates of personality disorders, including avoidant personality disorder, further providing support for the validity of interpersonal subtypes. The presence of interpersonal subtypes in GAD may have important implications for treatment planning and efficacy.

A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: is human contact necessary for therapeutic efficacy?

Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders. The present article reviews the literature published before 2010 on these treatments for anxiety and depression using self-help and decreased therapist-contact interventions. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of anxiety disorders, it is concluded that self-administered and predominantly self-help interventions are most effective for motivated clients. Conversely, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses when accounting for both attrition and compliance. Additionally, predominantly self-help computer-based cognitive and behavioral interventions are efficacious in the treatment of subthreshold mood disorders. However, therapist-assisted treatments remain optimal in the treatment of clinical levels of depression. Although the most efficacious amount of therapist contact varies by disorder, computerized treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems.

A review of technology-assisted self-help and minimal contact therapies for drug and alcohol abuse and smoking addiction: is human contact necessary for therapeutic efficacy?

Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for addictive disorders, such as nicotine, alcohol, and drug abuse and addiction. The present article reviews the literature published before 2010 on computerized treatments for drug and alcohol abuse and dependence and smoking addiction. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of substance use and abuse it is concluded that self-administered and predominantly self-help computer-based cognitive and behavioral interventions are efficacious, but some therapist contact is important for greater and more sustained reductions in addictive behavior.

Diagnostic comorbidity in adults with generalized anxiety disorder: impact of comorbidity on psychotherapy outcome and impact of psychotherapy on comorbid diagnoses.

The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n=46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.

Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach.

OBJECTIVE: To examine the relative efficacy of family-based cognitive-behavioral therapy (CBT) versus family-based relaxation treatment (RT) for young children ages 5 to 8 years with obsessive-compulsive disorder (OCD). METHOD: Forty-two young children with primary OCD were randomized to receive 12 sessions of family-based CBT or family-based RT. Assessments were conducted before and after treatment by independent raters blind to treatment assignment. Primary outcomes included scores on the Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Improvement. RESULTS: For the intent-to-treat sample, CBT was associated with a moderate treatment effect (d = 0.53), although there was not a significant difference between the groups at conventional levels. For the completer sample, CBT had a large effect (d = 0.85), and there was a significant group difference favoring CBT. In the intent-to-treat sample, 50% of children in the CBT group achieved remission as compared to 20% in the RT group. In the completer sample, 69% of children in the CBT group achieved a clinical remission compared to 20% in the RT group. CONCLUSIONS: Results indicate that children with early-onset OCD benefit from a treatment approach tailored to their developmental needs and family context. CBT was effective in reducing OCD symptoms and in helping a large number of children achieve a clinical remission.

Resolving ambiguity: the effect of experience on interpretation of ambiguous events in generalized social phobia.

The authors examined the effect of learning on multiple encounters with sources of social ambiguity in individuals with generalized social phobia (GSP). The authors modified G. B. Simpson and H. Kang's (1994) paradigm and presented prime-target word pairs to individuals with GSP and nonanxious controls (NACs) to prime threat and nonthreat meanings of homographs and examine the effect of this priming on later encounters with that homograph. Consistent with previous research, NACs showed faster response latencies naming a target primed by a homograph with the same meaning activated in two successive trials than naming the same target primed by an unrelated word. Furthermore, NACs showed slower response latencies naming a target when a different meaning of the homograph prime was activated in successive trials than naming a target primed by an unrelated word. GSP participants did not show this pattern in learning a nonthreat meaning of a homograph. These results support the hypothesis that a faulty learning mechanism may be involved in social anxiety.

Palmtop computer-assisted group therapy for social phobia.

This article describes the application of group computer-assisted therapy for social phobia. The computer program includes a diary function for ongoing self-monitoring of anxiety as well as guidance on the practice of relaxation, cognitive restructuring, and self-control desensitization. Although the program was originally designed to treat individuals with generalized anxiety disorder (GAD), it was hypothesized that the program also would be effective for individuals with social phobia; therefore, it was implemented in a group of individuals with a primary diagnosis of GAD or social phobia. We present the case of a client with social phobia who received six sessions of group therapy and who carried the ambulatory computer throughout this treatment. Outcome data suggest that the treatment was highly effective for this client as well as others with a diagnosis of social phobia or GAD.

Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy?

Self-help materials, brief therapies, and treatments involving minimal therapist contact have all been proposed as effective and low-cost interventions for anxiety disorders. However, research also suggests that the therapeutic alliance is a central predictor of therapy outcome. Interestingly, amounts of therapist contact within and across "self-help" interventions vary greatly. It is therefore unclear how much therapist contact is necessary for a positive anxiety disorder treatment outcome. The present article reviews the literature on anxiety disorder treatments using self-help, self-administered, and decreased therapist-contact interventions. Treatment studies are grouped together by anxiety diagnosis as well as amount of therapist contact. It is concluded that self-administered treatments are most effective for motivated clients seeking treatment for simple phobias. Predominantly self-help therapies are efficacious for panic disorder and mixed anxiety samples. On the other hand, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses.