Aaron M. Norr

Randomized Controlled Trial of False Safety Behavior Elimination Therapy: A Unified Cognitive Behavioral Treatment for Anxiety Psychopathology

We tested the efficacy of a unified cognitive-behavioral therapy protocol for anxiety disorders. This group treatment protocol, termed false safety behavior elimination therapy (F-SET), is a cognitive-behavioral approach designed for use across various anxiety disorders such as panic disorder (PD), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). F-SET simplifies, as well as broadens, key therapeutic elements of empirically validated treatments for anxiety disorders to allow for easier delivery to heterogeneous groups of patients with anxiety psychopathology. Patients with a primary anxiety disorder diagnosis (N=96) were randomly assigned to F-SET or a wait-list control. Data indicate that F-SET shows good efficacy and durability when delivered to mixed groups of patients with anxieties (i.e., PD, SAD, GAD) by relatively inexperienced clinicians. Findings are discussed in the context of balancing treatment efficacy and clinical utility.

Evaluating the unique contribution of intolerance of uncertainty relative to other cognitive vulnerability factors in anxiety psychopathology

BACKGROUND Intolerance of uncertainty (IU) is a cognitive vulnerability factor associated with a wide range of anxiety psychopathology. Other cognitive vulnerabilities such as anxiety sensitivity (AS), distress tolerance (DT), and discomfort intolerance (DI) have also been investigated as constructs of interest across anxiety disorders. As researchers increasingly uncover viable transdiagnostic vulnerabilities to anxiety, it becomes important to determine the degree of overlap between these constructs. METHODS The present studies examined the unique relationships between IU, other vulnerability factors (AS, DT, and DI) and social anxiety, obsessive-compulsive, and worry symptoms across two nonclinical samples (n=217, n=241). RESULTS Findings were highly consistent across samples. IU was significantly associated with anxiety symptoms in all analyses, even when accounting for other transdiagnostic risk variables. Anxiety sensitivity, was uniquely related to social anxiety and obsessive-compulsive symptoms in all analyses, but was related to worry in only one study. Distress tolerance was only uniquely associated with worry. Discomfort intolerance was not uniquely related to the anxiety symptoms in any analyses. LIMITATIONS Future research should attempt to replicate the findings in a clinical population and utilize a longitudinal design. CONCLUSIONS The robust and incremental relationships between IU and anxiety symptoms suggests the potential benefit of targeting IU in the context of transdiagnostic anxiety treatments.

Distress tolerance and anxiety sensitivity cognitive concerns: testing the incremental contributions of affect dysregulation constructs on suicidal ideation and suicide attempt

Empirical work has suggested relationships among suicide-related outcomes and several constructs related to affect dysregulation, notably anxiety sensitivity (AS) and distress tolerance (DT). However, important questions remain, including the relative contributions of these affect regulation variables as well as the direct contribution of DT on suicidal ideation and prior attempts. The current study sought to better elucidate the nature of these relationships by examining AS, DT, and suicidal ideation and attempt in a clinical sample (N=192). Consistent with prior work and prediction, findings revealed a significant relationship between the AS cognitive concerns subfactor and suicidal ideation and suicide attempt history after accounting for the effects of DT, gender, and depressive symptoms. In addition, depressive symptoms significantly moderated the relationship between the AS cognitive concerns subfactor and suicidal ideation. After accounting for the influence of AS, analyses revealed that DT approached significance in predicting suicidal ideation, but did not significantly predict suicide attempt history. These results suggest that elevated AS cognitive concerns are particularly relevant to suicide in the context of depressive symptoms. Clinicians may benefit from implementing AS reduction strategies with individuals who endorse elevated suicide risk as well as elevated AS cognitive concerns.

Intolerance of uncertainty as a vulnerability factor for hoarding behaviors

BACKGROUND Intolerance of uncertainty (IU) has been identified as a key vulnerability factor among numerous anxiety related conditions. It has been suggested that individuals engage in uncertainty-motivated behaviors such as avoidance, as a way to cope with ambiguous and potentially distressing situations. Patterns of behavioral avoidance have also been observed in a substantial number of hoarding patients and are thought to directly contribute to the avoidance of discarding. However, no studies to date have examined the potential relationship between IU and hoarding. The primary aim of the current investigation was to examine the association between IU and hoarding behaviors. METHOD Participants consisted of 279 college students from a large southern university. RESULTS Results revealed that IU was a significant predictor of hoarding severity after controlling for relevant covariates. Moreover, when looking at the relationships among IU subfactors and hoarding, results indicated that Factor 1 was significantly associated with hoarding severity whereas Factor 2 was not. LIMITATIONS Future research should attempt to replicate the findings within clinical populations. Additionally, due to the cross sectional nature of the study, future work should utilize a longitudinal design. CONCLUSIONS The current study provides additional evidence that IU is an important individual difference variable associated with various anxiety related conditions. Moreover, our findings revealed that IU is a unique and robust predictor of hoarding behaviors. Increasing our knowledge of vulnerability factors in compulsive hoarding has important implications for the classification of this disorder within DSM-V. Additionally, this information could inform future research and treatment programs.

Direct and Interactive Effects of Distress Tolerance and Anxiety Sensitivity on Generalized Anxiety and Depression

Anxiety sensitivity and distress tolerance are both hypothesized risk factors for generalized anxiety disorder (GAD) and major depressive disorder (MDD). However, it is unclear whether these factors synergistically influence GAD and MDD and related symptoms. Using latent variable methods, direct and interactive relations between anxiety sensitivity and distress tolerance with worry and depressive symptoms and with GAD and MDD diagnoses were examined in 347 outpatients. Interactive effects of anxiety sensitivity and distress tolerance were found for worry and GAD/MDD. The interactions generally suggested that anxiety sensitivity confers a greater risk for worry and GAD/MDD at higher levels of distress tolerance, and that distress tolerance confers a greater risk for worry and GAD/MDD at lower levels of anxiety sensitivity. Given the interactive effects of anxiety sensitivity and distress tolerance for GAD/MDD, interventions targeting both risk factors may prove more efficacious than targeting each individually.

A randomized clinical trial targeting anxiety sensitivity for patients with suicidal ideation.

Objective: Anxiety sensitivity (AS) is a well-established transdiagnostic risk factor for anxiety and mood psychopathology including suicide. A variety of interventions using cognitive–behavioral skills as well as cognitive bias modification (CBM) suggest that AS can be quickly and effectively reduced in nonclinical and nontreatment seeking samples. However, it is unclear whether AS reduction protocols will have efficacy for more severe clinical samples. Moreover, the combination of cognitive–behavioral techniques with CBM focused on changing interpretation bias (CBM-I) related to AS has not been evaluated. Method: A patient sample with co-occurring anxiety psychopathology and active suicidal ideation (N = 74) was randomly assigned to a brief 1-session computerized treatment including: (a) psychoeducation and interoceptive exposure (i.e., cognitive anxiety sensitivity treatment [CAST]) plus CBM-I for AS; or (b) health information condition plus sham CBM for AS. Participants were assessed immediately after the 1-hr intervention as well as at 1- and 4-month follow-ups. Results: Consistent with hypotheses, participants in the active treatment showed significantly greater AS reduction that was maintained through follow-up (effect sizes ranged from medium to large for the overall AS and the AS subscales). Mediation analyses suggested that changes in AS mediated suicide outcomes. Conclusions: In sum, these are the first findings to suggest that brief AS reduction protocols have efficacy both in terms of risk and symptom outcomes in patient samples showing active suicidal ideation.

Identification of anxiety sensitivity classes and clinical cut-scores in a sample of adult smokers: Results from a factor mixture model

Anxiety sensitivity (AS), a multidimensional construct, has been implicated in the development and maintenance of anxiety and related disorders. Recent evidence suggests that AS is a dimensional-categorical construct within individuals. Factor mixture modeling was conducted in a sample of 579 adult smokers (M age=36.87 years, SD=13.47) to examine the underlying structure. Participants completed the Anxiety Sensitivity Index-3 and were also given a Structured Clinical Interview for DSM-IV-TR. Three classes of individuals emerged, a high AS (5.2% of the sample), a moderate AS (19.0%), and a normative AS class (75.8%). A cut-score of 23 to identify high AS individuals, and a cut-score of 17 to identify moderate-to-high AS individuals were supported in this study. In addition, the odds of having a concurrent anxiety disorder (controlling for other Axis I disorders) were the highest in the high AS class and the lowest in the normative AS class.

Prospective Evaluation of the Effect of an Anxiety Sensitivity Intervention on Suicidality among Smokers

Recent empirical work has revealed a significant relationship between anxiety sensitivity (AS), particularly the AS cognitive concerns subfactor, and suicidality among cigarette smokers. The current study prospectively tested whether an intervention targeting AS (i.e. an AS-augmented smoking cessation program) would predict lower suicidality in a population known to be at increased risk for death by suicide (i.e. cigarette smokers). Participants (N = 169) were randomly assigned to a standard cognitive behavioral smoking intervention or a cognitive behavioral smoking intervention with an AS reduction component. Findings indicate that the participants who received the AS-augmented intervention had lower suicidality compared to those in the standard intervention, even accounting for baseline suicidality, substance use disorder diagnosis, current depression, current anxiety, and current smoking status. As the first examination of the effect of an AS reduction program on suicidality, this study provides initial support for the hypothesis that reducing AS may lead to lower suicidality. Future work should include testing an AS intervention in a sample with elevated suicidality, as well as specifically targeting AS cognitive concerns, which has a stronger and more consistent relationship with suicidality than global AS.

Effects of anxiety sensitivity on alcohol problems: evaluating chained mediation through generalized anxiety, depression and drinking motives

AIMS To test whether the relations between anxiety sensitivity (AS), a transdiagnostic risk factor, and alcohol problems are explained by chained mediation models, from AS through anxiety or depressive symptoms then drinking motives in an at-risk sample. It was hypothesized that AS would influence alcohol problems through generalized anxiety or depression symptoms and then through negatively reinforced drinking motives (i.e. drinking to cope with negative affect and drinking to conform). DESIGN Cross-sectional single- and chained-mediation models were tested. SETTING Self-report measures were completed in clinics at Florida State University and the University of Vermont, USA. PARTICIPANTS Participants consisted of 523 adult daily cigarette smokers [mean age = 37.23, standard deviation (SD) = 13.53; 48.6% female]. MEASUREMENTS As part of a larger battery of self-report measures, participants completed self-report measures of AS, generalized anxiety, depression, drinking motives and alcohol problems. FINDINGS Chained mediation was found from AS to alcohol problems through generalized anxiety then through drinking to cope with negative affect [B = 0.04, 90% confidence interval (CI) = 0.004, 0.10)]. Chained mediation was also found from AS to alcohol problems through depression then through drinking to cope with negative affect (B = 0.11, 90% CI = 0.05, 0.21) and, separately, through socially motivated drinking (B = 0.05, 90% CI = 0.003, 0.11). CONCLUSIONS Anxiety sensitivity and alcohol problems are indirectly related through several intervening variables, such as through generalized anxiety or depression and then through drinking to cope with negative affect.

Validation of the Cyberchondria Severity Scale (CSS): Replication and extension with bifactor modeling

Internet help seeking behaviors are increasingly common. Despite the positives associated with technology, cyberchondria, or the process of increased anxiety in response to internet medical information seeking, is on the rise. The Cyberchondria Severity Scale (CSS) was recently developed to provide a valid measure of cyberchondria across multiple dimensions. The current study sought to extend previous work on the CSS factor structure by examining a bifactor model. Participants (N=526) from a community sample completed the CSS via online crowd sourcing. Results revealed that the bifactor model of the CSS provided superior fit to the data, suggesting that it is useful to conceptualize the CSS as containing a General Cyberchondria factor that is orthogonal to its subfactors. Similar to previous work, the CSS Mistrust factor does not appear to be necessary to this construct. Finally, results revealed unique relations between General and Specific Cyberchondria factors with lower-order health anxiety dimensions.