Aaron J. Fisher

A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal therapies.

OBJECTIVE Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. METHOD This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age = 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n = 40) or to CBT plus interpersonal and emotional processing therapy (n = 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990; Hamilton Anxiety Rating Scale; M. Hamilton, 1959; assessor severity rating; State-Trait Anxiety Inventory-Trait Version; C. D. Spielberger, R. L. Gorsuch, R. Lushene, P. R. Vagg, & G. A. Jacobs, 1983) as well as with indices of clinically significant change. RESULTS Mixed models analysis of all randomized participants showed very large within-treatment effect sizes for both treatments (CI = [-.40, -.28], d = 1.86) with no significant differences at post (CI = [-.09, .07], d = .07) or 2-year follow-up (CI = [-.01, .01]), d = .12). There was also no statistical difference between compared treatments on clinically significant change based on chi-square analysis. CONCLUSIONS Interpersonal and emotional processing techniques may not augment CBT for all GAD participants. Trial Registry name: Clinical Trials.gov, Identifier: NCT00951652.

AN OPEN TRIAL OF INTEGRATIVE THERAPY FOR GENERALIZED ANXIETY DISORDER

Cognitive- behavioral therapy (CBT), although effective, has the lowest average effect size for generalized anxiety disorder (GAD), when compared to effect sizes of CBT for other anxiety disorders. Additional basic and applied research suggests that although interpersonal processes and emotional avoidance may be maintaining GAD symptomatology, CBT has not sufficiently addressed interpersonal issues or emotion avoidance. This study aimed to test the feasibility and preliminary efficacy of an integrative psychotherapy, combining CBT with techniques to address interpersonal problems and emotional avoidance. Eighteen participants received 14 sessions of CBT plus interpersonal emotional processing therapy and three participants (for training and feasibility purposes) received 14 sessions of CBT plus supportive listening. Results showed that the integrative therapy significantly decreased GAD symptomatology, with maintenance of gains up to 1 year following treatment. In addition, comparisons with extant literature suggested that the effect size for this new GAD treatment was higher than the average effect size of CBT for GAD. Results also showed clinically significant change in GAD symptomatology and interpersonal problems with continued gains during the 1-year follow-up. Implications of these results are discussed.

Change in Negative Cognitions Associated with PTSD Predicts Symptom Reduction in Prolonged Exposure

OBJECTIVE The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD). Emotional processing theory of PTSD proposes that disconfirmation of erroneous cognitions associated with PTSD is a central mechanism in PTSD symptom reduction; but to date, the causal relationship between change in pathological cognitions and change in PTSD severity has not been established. METHOD Female sexual or nonsexual assault survivors (N = 64) with a primary diagnosis of PTSD received 10 weekly sessions of PE. Self-reported PTSD symptoms, depression symptoms, and PTSD-related cognitions were assessed at pretreatment, each of the 10 PE treatment sessions, and posttreatment. RESULTS Lagged mixed-effect regression models indicated that session-to-session reductions in PTSD-related cognitions drove successive reductions in PTSD symptoms. By contrast, the reverse effect of PTSD symptom change on change in cognitions was smaller and did not reach statistical significance. Similarly, reductions in PTSD-related cognitions drove successive reductions in depression symptoms, whereas the reverse effect of depression symptoms on subsequent cognition change was smaller and not significant. Notably, the relationships between changes in cognitions and PTSD symptoms were stronger than the relationships between changes in cognitions and depression symptoms. CONCLUSIONS To our knowledge, this is the 1st study to establish change in PTSD-related cognitions as a central mechanism of PE treatment. These findings are consistent with emotional processing theory and have important clinical implications for the effective implementation of PE.

Toward a Dynamic Model of Psychological Assessment: Implications for Personalized Care

OBJECTIVE The present article proposes a general framework and a set of specific methodological steps for conducting person-specific dynamic assessments, which yield information about syndrome structures and states that can be used to provide actionable information for the formulation of personalized interventions. It is proposed that researchers should (a) determine the relevant constituent inputs for a diagnostic system; (b) measure these inputs with as much detail as possible; (c) assess the correlational structure of system inputs via factor-analytic methods within individuals; and (d) subject the individual-level, latent dimension time series to dynamic analyses such as the dynamic factor model (Molenaar, 1985) to discern the time-dependent, dynamic relationships within and between system components. METHOD An exemplar is provided wherein 10 individuals with clinically diagnosed generalized anxiety disorder completed surveys related to generalized anxiety disorder symptomatology for at least 60 consecutive days. These data were then subjected to person-specific exploratory and confirmatory factor analyses for the identification of latent symptom dimensions. Finally, dynamic factor models were used to model the dynamic interrelationships within and between symptom domains on a person-by-person basis. RESULTS Person-specific factor analyses returned models with 3 (n = 8) or 4 (n = 2) latent factors, all with excellent fit. Dynamic factor modeling successfully revealed the contemporaneous correlations and time-lagged predictive relationships between factors, providing prescriptive information for the formulation of targeted interventions. CONCLUSIONS The proposed approach has the potential to inform the construction and implementation of personalized treatments by delineating the idiosyncratic structure of psychopathology on a person-by-person basis.

A Quantitative Method for the Analysis of Nomothetic Relationships Between Idiographic Structures: Dynamic Patterns Create Attractor States for Sustained Posttreatment Change

OBJECTIVE The present article aimed to demonstrate that the establishment of dynamic patterns during the course of psychotherapy can create attractor states for continued adaptive change following the conclusion of treatment. METHOD This study is a secondary analysis of T. D. Borkovec and E. Costello (1993). Of the 55 participants in the original study, 33 were retained for the present analysis due to the homogeneity of psychotherapy outcome among these participants. Of these 33, the majority were White (88%) and female (70%), and the average age was 35.44 years (SD = 14.46). Participants participated in 12 weeks of either cognitive behavioral therapy or applied relaxation. Daily diary entries from the treatment period were subjected to time series analyses in order to determine the degree of order versus disorder present within individual dynamic systems. These idiographic data were then aggregated for nomothetic analysis of treatment outcome via linear mixed effect models. RESULTS Spectral power due to daily to intradaily oscillations in thrice-daily diary data significantly moderated reliable change over posttreatment follow-up such that lesser power predicted increases in reliable change over the 1-year follow-up period. Additionally, residual variance for dynamic factor models significantly moderated the slope for change over the follow-up period, such that lesser variance--and thus greater order in dynamic systems--predicted increases in reliable change. CONCLUSIONS The degree of order in dynamic systems established during therapy acted as an adaptive attractor state, promoting continued positive gains 1 year after the conclusion of therapy. The present study represents an important innovation in the study of dynamic systems in psychotherapy.

Mediated Moderation in Combined Cognitive Behavioral Therapy Versus Component Treatments for Generalized Anxiety Disorder

OBJECTIVE This study examined (a) duration of generalized anxiety disorder (GAD) as a moderator of cognitive behavioral therapy (CBT) versus its components (cognitive therapy and self-control desensitization) and (b) increases in dynamic flexibility of anxious symptoms during the course of psychotherapy as a mediator of this moderation. Degree of dynamic flexibility in daily symptoms was quantified as the inverse of spectral power due to daily to intradaily oscillations in four-times-daily diary data (Fisher, Newman, & Molenaar, 2011). METHOD This was a secondary analysis of the data of Borkovec, Newman, Pincus, and Lytle (2002). Seventy-six participants with a principle diagnosis of GAD were assigned randomly to combined CBT (n = 24), cognitive therapy (n = 25), or self-control desensitization (n = 27). RESULTS Duration of GAD moderated outcome such that those with longer duration showed greater reliable change from component treatments than they showed from CBT, whereas those with shorter duration fared better in response to CBT. Decreasing predictability in daily and intradaily oscillations of anxiety symptoms during therapy reflected less rigidity and more flexible responding. Increases in flexibility over the course of therapy fully mediated the moderating effect of GAD duration on condition, indicating a mediated moderation process. CONCLUSIONS Individuals with longer duration of GAD may respond better to more focused treatments, whereas those with shorter duration of GAD may respond better to a treatment that offers more coping strategies. Importantly, the mechanism by which this moderation occurs appears to be the establishment of flexible responding during treatment.

Enhancing the Personalization of Psychotherapy With Dynamic Assessment and Modeling

Clinicians have long recognized the importance of tailoring psychotherapy interventions to the needs and characteristics of the individual patient. However, traditional approaches to clinical assessment, service delivery, and intervention research have not been conducive to such personalization. Contrary to traditional nomothetic approaches, idiographic assessment and modeling of intraindividual dynamic processes holds tremendous promise for tailoring the implementation of psychotherapy to the individual patient. In this article, we (a) present an argument for assessing person-specific dynamics, (b) provide a detailed description of a method that harnesses person-specific dynamic assessment and modeling for use in routine psychotherapy, (c) present exemplar clinical cases illustrating these methods, and (d) discuss how these methods can be translated into routine clinical assessment and psychotherapy.

Cardiac stability at differing levels of temporal analysis in panic disorder, post-traumatic stress disorder, and healthy controls

The panic disorder (PD) literature provides evidence for both physiologic rigidity and instability as pathognomonic features of this disorder. This ambiguity may be a result of viewing PD at differential levels of temporal analysis. We assessed cardiac variability across three levels of temporal scale in PD patients, post-traumatic stress disorder (PTSD) patients, and healthy controls. Sixteen healthy controls, 14 PD patients, 23 PTSD patients, and 16 PTSD + PD patients presented for a polysomnogram. Differences were assessed in respiratory sinus arrhythmia (RSA), autoregressive stability of heart rate (HR), and the number of nonspecific accelerations in HR over the night. No differences in RSA were found between groups; however, PD patients exhibited significantly lower autoregressive HR stability, and all patients had significantly more HR accelerations than controls. These data reinforce prior findings demonstrating physiologic instability in PD and indicate that prior equivocalities regarding physiologic variability in PD may be due to limited temporal scaling of measurements.

Exploring the Idiographic Dynamics of Mood and Anxiety via Network Analysis

Individual variation is increasingly recognized as important to psychopathology research. Concurrently, new methods of analysis based on network models are bringing new perspectives on mental (dys)function. This current work analyzed idiographic multivariate time series data using a novel network methodology that incorporates contemporaneous and lagged associations in mood and anxiety symptomatology. Data were taken from 40 individuals with generalized anxiety disorder (GAD), major depressive disorder (MDD), or comorbid GAD and MDD, who answered questions about 21 descriptors of mood and anxiety symptomatology 4 times a day over a period of approximately 30 days. The model provided an excellent fit to the intraindividual symptom dynamics of all 40 individuals. The most central symptoms in contemporaneous systems were those related to positive and negative mood. The temporal networks highlighted the importance of anger to symptomatology, while also finding that depressed mood and worry—the principal diagnostic criteria for GAD and MDD—were the least influential nodes across the sample. The method’s potential for analysis of individual symptom patterns is demonstrated by 3 exemplar participants. Idiographic network-based analysis may fundamentally alter the way psychopathology is assessed, classified, and treated, allowing researchers and clinicians to better understand individual symptom dynamics.

Validating the rapid responder construct within a practice research network.

OBJECTIVE The present study was a replication and extension of prior work (Stulz, Lutz, Leach, Lucock, & Barkham, ) that identified multiple groups of clients in treatment with high-symptom severity and markedly different recovery trajectories (rapid/early response vs. little or no response). METHOD Using data collected through repeated administrations of the Depression subscale of the Treatment Outcome Package (n = 147), growth mixture modeling was employed to determine whether clients fell into discrete groups of response trajectories during 15 sessions of psychotherapy. Additionally, logistic regressions were conducted to assess possible predictors of group membership. RESULTS Three separate groups of treatment responders were identified: 2 high-symptom groups-rapid responders and nonresponders-and 1 low-symptom group of nonresponders. Elevated social conflict and suicidality predicted increased likelihood of membership in the high-symptom nonresponder group. Increased feelings of interpersonal hostility and better sexual functioning predicted increased likelihood of membership in the rapid responder group. CONCLUSION Replication of earlier results provides further evidence for the usefulness of modeling change during psychotherapy using multiple trajectories. Predictors of group membership indicate the influence of functional impairment on recovery, and support the importance of multidimensional measurement of client problems.