A Case Study of a Woman with Obsessions Related to COVID-19.

This de-identified case study seeks to increase the understanding of the process and impact of modifying exposure and response prevention (ERP) to address obsessions associated with COVID-19. The case study presents the assessment, diagnosis, and treatment of obsessive-compulsive disorder via televideo utilizing ERP for a woman who presented with difficulty with contamination and harm obsessions related to COVID-19. Over the course of 7 months, including an initial evaluation, this client attended 24 treatment sessions via synchronous video telehealth. Psychoeducation, self-monitoring, in vivo and imaginal exposures, response prevention, and behavioral activation strategies were utilized. Following treatment, this client was successfully managing symptoms and her scores on the Yale Brown Obsessive-Compulsive Scale and Sheehan Disability Scale had decreased significantly.

A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder.

CONTEXT: Medication and cognitive behavioral treatment are the best-established treatments for social anxiety disorder, yet many individuals remain symptomatic after treatment. OBJECTIVE: To determine whether combined medication and cognitive behavioral treatment is superior to either monotherapy or pill placebo. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Research clinics at Columbia University and Temple University. PARTICIPANTS: One hundred twenty-eight individuals with a primary DSM-IV diagnosis of social anxiety disorder. INTERVENTIONS: Cognitive behavioral group therapy (CBGT), phenelzine sulfate, pill placebo, and combined CBGT plus phenelzine. MAIN OUTCOME MEASURES: Liebowitz Social Anxiety Scale and Clinical Global Impression (CGI) scale scores at weeks 12 and 24. RESULTS: Linear mixed-effects models showed a specific order of effects, with steepest reductions in Liebowitz Social Anxiety Scale scores for the combined group, followed by the monotherapies, and the least reduction in the placebo group (Williams test = 4.97, P < .01). The CGI response rates in the intention-to-treat sample at week 12 were 9 of 27 (33.3%) (placebo), 16 of 34 (47.1%) (CBGT), 19 of 35 (54.3%) (phenelzine), and 23 of 32 (71.9%) (combined treatment) (chi(2)(1) = 8.76, P < .01). Corresponding remission rates (CGI = 1) were 2 of 27 (7.4%), 3 of 34 (8.8%), 8 of 35 (22.9%), and 15 of 32 (46.9%) (chi(2)(1) = 15.92, P < .01). At week 24, response rates were 9 of 27 (33.3%), 18 of 34 (52.9%), 17 of 35 (48.6%), and 25 of 32 (78.1%) (chi(2)(1) = 12.02, P = .001). Remission rates were 4 of 27 (14.8%), 8 of 34 (23.5%), 9 of 35 (25.7%), and 17 of 32 (53.1%) (chi(2)(1) = 10.72, P = .001). CONCLUSION: Combined phenelzine and CBGT treatment is superior to either treatment alone and to placebo on dimensional measures and on rates of response and remission.

Efficacy of a manualized and workbook-driven individual treatment for social anxiety disorder.

Social anxiety disorder is a prevalent and impairing disorder for which viable cognitive-behavioral therapies exist. However, these treatments have not been easily packaged for dissemination and may be underutilized as a result. The current study reports on the findings of a randomized controlled trial of a manualized and workbook-driven individual cognitive-behavioral treatment for social anxiety disorder (Hope, Heimberg, Juster, & Turk, 2000; Hope, Heimberg, & Turk, 2006). This treatment package was derived from an empirically supported group treatment for social anxiety disorder and intended for broad dissemination, but it has not previously been subjected to empirical examination on its own. As a first step in that examination, 38 clients seeking treatment for social anxiety disorder at either the Adult Anxiety Clinic of Temple University or the Anxiety Disorders Clinic of the University of Nebraska-Lincoln were randomly assigned to receive either immediate treatment with this cognitive-behavioral treatment package or treatment delayed for 20 weeks. Evaluation at the posttreatment/postdelay period revealed substantially greater improvements among immediate treatment clients on interviewer-rated and self-report measures of social anxiety and impairment. Three-month follow-up assessment revealed maintenance of gains. Clinical implications and directions for future research are discussed.

Brooding and pondering: isolating the active ingredients of depressive rumination with exploratory factor analysis and structural equation modeling.

Depressive rumination, as assessed by Nolen-Hoeksema's Response Styles Questionnaire (RSQ), predicts the onset, chronicity, and duration of depressed mood. However, some RSQ items contain depressive content and result in a heterogeneous factor structure. After the a priori elimination of items potentially confounded with depressed item content, Treynor, Gonzalez, and Nolen-Hoeksema identified two factors within the remaining RSQ rumination sub-scale that were differentially related to depression: brooding and pondering. However, Treynor et al. used a nonstandard form and administration of the RSQ. The present study sought to address these methodological idiosyncrasies and replicate the factor structure of Treynor et al. through exploratory factor analysis and structural equation modeling. Findings support the brooding and pondering solution and demonstrate that brooding relates more strongly to depression and anxiety than does pondering.

Emotion regulation among individuals classified with and without generalized anxiety disorder.

Generalized anxiety disorder (GAD) has been conceptualized as being characterized by the experience of intense emotion, limited understanding of the emotional experience, poor ability to adaptively modulate emotions, and an aversive response to emotions [Mennin, D. S., Turk, C. L., Heimberg, R. G., & Carmin, C. N. (2004). Focusing on the regulation of emotion: a new direction for conceptualizing and treating generalized anxiety disorder. In: M. A. Reinecke, & D. A. Clark (Eds.), Cognitive therapy over the lifespan: theory, research and practice (pp. 60-89). New York: Wiley]. In order to test aspects of this model, participants completed daily diaries and a questionnaire measuring emotion regulation strategies. As hypothesized, relative to controls, individuals classified as having GAD reported more intense daily emotional experiences. Contrary to predictions and previous research, those with GAD did not show poor emotion differentiation and used several emotion regulation strategies more often than control participants. The implications for both the emotion dysregulation model and treatment of GAD are discussed.

Memory bias for threat in generalized anxiety disorder: the potential importance of stimulus relevance.

Information processing models propose that anxious individuals are characterized by memory biases for mood-congruent threat information. However, evidence for memory biases in generalized anxiety disorder (GAD) has been mixed at best. Given the heterogeneity of concerns in GAD, previous use of nomothetic stimulus sets may have precluded detection of memory biases. Therefore, in order to guarantee the relevance of the stimuli used, in the current study individuals with GAD each individually selected words that were of personal relevance to them. Using these idiographically selected words with 23 individuals with DSM-IV GAD and 23 non-anxious controls (NACs), results showed an implicit memory bias for threat words in individuals with GAD compared with NACs. Furthermore, there was additional evidence that individuals with GAD may also be characterized by explicit memory bias for threat words. The magnitude of group differences for explicit recall of threat words was similar to those previously observed in panic disorder. Limitations and future directions are discussed.

Impairment and quality of life in individuals with generalized anxiety disorder.

Once considered to be a disorder associated with minimal impairment, the link between generalized anxiety disorder (GAD) and impairment across a broad constellation of domains is now well established. However, less is known about how comorbidity affects these relationships or how GAD impacts one's perceived life satisfaction or quality of life. To investigate these questions, data from 52 treatment-seeking individuals with GAD (33 with comorbid Axis I diagnoses) were compared to data from 55 nonanxious controls. Individuals with GAD reported more impairment at work and in their social functioning than they did with home and family responsibilities. They also reported lower quality of life than nonanxious controls, particularly in regard to self-esteem, goals and values, money, work, play, learning, creativity, friends, and relatives. Trait worry was positively correlated with impairment and inversely related to life satisfaction within the clinical sample. Individuals with GAD, with and without comorbid Axis I diagnoses, showed few differences on measures of impairment (differing only on impairment in social functioning). However, individuals with GAD and comorbid disorders perceived their lives as less satisfying than did individuals with GAD without comorbid diagnoses.

Social anxiety, alcohol expectancies, and self-efficacy as predictors of heavy drinking in college students.

Burke and Stephens (1999) [Burke, R.S., Stephens, R.S. Social anxiety and drinking in college students: A social cognitive theory analysis. Clinical Psychology Review, 19, (1999) 513-530.] proposed a social cognitive theory of heavy drinking in college students. According to this theory, alcohol expectancies for social facilitation and self-efficacy for refusing heavy drinking in anxiety-producing social situations moderate the relationship between social anxiety and drinking. In the current study, a significant three-way interaction was observed among social anxiety, expectancies, and self-efficacy when amount and frequency of drinking was the dependent variable. As predicted by the model, socially anxious college students with low self-efficacy for avoiding heavy drinking in social situations and high positive expectancies for social facilitation reported more alcohol consumption than other socially anxious individuals.

Preliminary evidence for an emotion dysregulation model of generalized anxiety disorder.

Three studies provide preliminary support for an emotion dysregulation model of generalized anxiety disorder (GAD). In study 1, students with GAD reported heightened intensity of emotions, poorer understanding of emotions, greater negative reactivity to emotional experience, and less ability to self-soothe after negative emotions than controls. A composite emotion regulation score significantly predicted the presence of GAD, after controlling for worry, anxiety, and depressive symptoms. In study 2, these findings were largely replicated with a clinical sample. In study 3, students with GAD, but not controls, displayed greater increases in self-reported physiological symptoms after listening to emotion-inducing music than after neutral mood induction. Further, GAD participants had more difficulty managing their emotional reactions. Implications for GAD and psychopathology in general are discussed.

Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder.

The Brief Fear of Negative Evaluation Scale (BFNE; M. R. Leary, 1983a) is often used to assess fear of negative evaluation, the core feature of social anxiety disorder. However, few studies have examined its psychometric properties in large samples of socially anxious patients. Although the BFNE yields a single total score, confirmatory factor analysis indicated a 2-factor solution to be more appropriate, with the 1st factor consisting of all straightforwardly worded items (BFNE-S) and the 2nd of all reverse-scored items (BFNE-R). Support was obtained for the convergent and discriminant validity of the BFNE and BFNE-S, but not the BFNE-R. These results suggest that standard scoring of the BFNE may not be optimal for patients with social anxiety disorder.

Level of emotional awareness as a differentiating variable between individuals with and without generalized anxiety disorder.

Using Mennin, Heimberg, Turk, and Fresco's [Emotion regulation deficits as a key feature of generalized anxiety disorder: Testing a theoretical model, submitted for publication] conceptualization of generalized anxiety disorder (GAD) as a syndrome involving emotion dysregulation and an overuse of cognitive control strategies, this study sought to differentiate individuals with GAD from controls by offering differences in emotional awareness as one of the central distinctions between these groups. This study employs the Levels of Emotional Awareness Scale (LEAS) [Lane et al., 1990Lane, R. D., Quinlan, D. M., Schwartz, G. E., Walker, P. A., & Zeitlin, S. B. (1990). The Levels of Emotional Awareness Scale: a cognitive-developmental measure of emotion. Journal of Personality Assessment, 55, 124-134] a rater-coded measure, to assess level of emotional awareness, a methodological improvement over previous tests of the model, which relied upon self-report. Individuals with GAD scored significantly higher than controls on emotional awareness. These findings are discussed in light of the theoretical implications for GAD.

Psychometric properties of disability measures among patients with social anxiety disorder.

BACKGROUND: Although recognition of the importance of disability as a construct has increased in recent years, there has been little examination of the reliability and validity of disability measures. METHODS: This study examined three disability measures, the Liebowitz Self-Rated Disability Scale (LSRDS), the clinician-rated Disability Profile (DP), and the Sheehan Disability Scale (SDS) among patients with a primary diagnosis of social anxiety disorder. RESULTS: The disability measures correlated strongly with each other, as well as with measures of social anxiety, depressive symptoms, and patients' subjectively-evaluated quality of life. The LSRDS and DP were more internally consistent than the SDS Total Score. All measures discriminated between patients with generalized and non-generalized social anxiety disorder. However, the LSRDS and DP also showed greater sensitivity to ecological indicators of distress than the SDS. Social anxiety symptoms accounted for significant variance in disability, above and beyond that accounted for by depressive symptoms. CONCLUSIONS: Overall, the LSRDS, DP, and SDS appear to be valid tools in the study of disability in social anxiety disorder, although the LSRDS and the DP appear to be somewhat more sensitive to the experiences of socially anxious patients.

The Internet: home to a severe population of individuals with social anxiety disorder?

The current study sought to understand better the psychological characteristics of socially anxious individuals who seek information on the internet about social anxiety disorder and its treatment. Participants were 434 individuals who responded to an internet-based survey linked to the website of an anxiety specialty clinic. Using established cut-off scores, 92% of the sample met criteria for social anxiety disorder. Internet survey respondents who met these criteria reported greater severity of and impairment due to social anxiety than a treatment-seeking sample of persons with social anxiety disorder. Nevertheless, only about one-third of these internet respondents reported having received psychotherapy, and a similar percentage reported having received pharmacotherapy. Those with the most severe social interaction anxiety and who spent the most time interacting on the internet endorsed positive effects of internet use. However, a significant number of negative effects also were endorsed.

The path from initial inquiry to initiation of treatment for social anxiety disorder in an anxiety disorders specialty clinic.

Efficacious treatments for social anxiety disorder have become increasingly available, with approximately three-quarters of treatment completers showing significant improvement [Arch. Gen. Psychiatry 55 (1998) 1133.]. However, very few individuals with social anxiety disorder access these services. The present study reports on the path to initiation of treatment for social anxiety disorder among individuals contacting an anxiety disorder specialty clinic. Of 395 initial telephone inquiries, only 60 individuals (15%) started treatment. Three "critical points" associated with high pretreatment attrition were identified: scheduling an initial interview, attending a scheduled initial interview, and initiating a treatment program after receiving a principal diagnosis of social anxiety disorder. Several demographic variables (e.g., level of education, race) were related to attendance at the initial interview. However, no differences were found between those who did and did not initiate treatment on demographic variables, symptom severity, or quality of life. Given that most individuals who complete treatment for social phobia experience significant benefit, results of the current study suggest that future efforts should be devoted to increasing number of patients who access these services.

The experience of disability and quality of life in social anxiety disorder.

Although disability is a concept most often associated with role dysfunction, and quality of life is most often associated with life satisfaction, these terms are frequently used interchangeably in the literature. In contrast, this study proposes that disability and quality of life are independent but related constructs. Additionally, we propose that disability partially mediates the relationship between symptoms and quality of life. That is, greater symptoms are associated with more impairment, which is, in turn, associated with less satisfaction with one's life. Ninety-six individuals with social anxiety disorder were given measures of social anxiety symptoms, disability, and quality of life. The results of the study suggest that disability and quality of life are, in fact, distinct concepts, and the experience of disability partially mediates the relationship between a patient's experience of symptoms and his or her perceived life satisfaction.

Using the Penn State Worry Questionnaire to identify individuals with generalized anxiety disorder: a receiver operating characteristic analysis.

We report on the use of the Penn State Worry Questionnaire (PSWQ) to identify individuals with generalized anxiety disorder (GAD). Fifty individuals with primary or secondary GAD and 114 individuals with social anxiety disorder (without GAD) completed the PSWQ. In receiver operating characteristic analyses, a score of 65 simultaneously optimized sensitivity and specificity in discriminating individuals with GAD from individuals with social anxiety disorder. Results support the use of the PSWQ in screening individuals likely to meet criteria for GAD who present for treatment at an anxiety disorders specialty clinic.

A brief telephone intervention targeting treatment engagement from a substance abuse program wait list.

This study compares three brief participant-initiated telephone interventions aimed at enhancing treatment engagement of individuals on a substance abuse treatment wait list. Policies requiring that wait list members call at least every other week in order to remain eligible for treatment remained in place for the standard and enhanced conditions but not for the voluntary condition. The standard condition was a minimal intervention, providing information on the program. The enhanced condition focused on client motivation for treatment and recovery. If individuals in the voluntary condition called, they were provided information about current wait list number and approximate remaining wait time. The rate of treatment engagement was the same among treatment conditions. The best predictor of engagement was the number of calls placed to the program while waiting. Treatment condition was a positive predictor of call frequency; presence of a comorbid psychiatric diagnosis was a negative predictor. The article also discusses future directions.

Confirmatory factor analysis of the Penn State Worry Questionnaire.

Worry is often assessed with the 16-item Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990. Behaviour Research and Therapy, 28, 487-495), but the factor structure of the PSWQ is not well articulated. Three factor analyses of the PSWQ have been conducted, with two (Brown, Antony, & Barlow, 1992. Behaviour Research and Therapy, 30, 33-37; van Rijsoort, Emmelkamp, & Vervaeke, 1999) retaining a unifactorial solution and one (Stöber, 1995) retaining a two-factor solution. We sought to determine the relative strengths of these solutions. Seven hundred eighty-eight undergraduates completed the PSWQ and measures of depression and anxiety. Confirmatory factor analyses indicated that the two-factor solution provided a better fit to the data. There was also evidence for a higher order worry factor. Multiple regression analyses revealed that factor 1 (Worry Engagement) explained the majority of the variance in the symptom measures. The higher order worry factor also accounted for variance in some measures. Compared to the PSWQ total score, Worry Engagement demonstrated slightly higher internal consistency and significantly stronger correlations with most measures of depression and anxiety. Factor 2 (Absence of Worry) demonstrated moderate negative correlations with Worry Engagement and the PSWQ Total Score but only modest correlations with depression and anxiety.

Effects of emotion on pain reports, tolerance and physiology.

The effects of specific emotional states on a laboratory pain task were tested by examining the behavioural, verbal and psychophysiological responses of 80 student volunteers (50% female). Participants were assigned to one of four Velten-style emotion-induction conditions (ie, anxiety, depression, elation or neutral). The sexes of experimenters were counterbalanced. Overt escape behaviour (ie, pain tolerance), pain threshold and severity ratings, verbal reports of emotion and physiological measures (ie, electrocardiogram, corrugator and trapezium electromyogram) were recorded. A pressure pain task was given before and after the emotion induction. As predicted, those who participated in the anxiety or depression condition showed reduced pain tolerance after induction of these negative emotions; pain severity ratings became most pronounced in the depression condition. Emotion induction did not have a discernable effect on pain tolerance or severity ratings in the elation condition. A pattern of participant and experimenter sex effects, as well as trials effects, was seen in the physiological data. The influence of negative affective states (ie, anxiety and depression) on acute pain are discussed along with the unique contributions of behavioural, verbal and physiological response systems in understanding the interactions of pain and emotions.