Andrea N. Niles

Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators

OBJECTIVE Cognitive behavioral therapy (CBT) is an empirically supported treatment for social phobia. However, not all individuals respond to treatment and many who show improvement do not maintain their gains over the long-term. Thus, alternative treatments are needed. METHOD The current study (N = 87) was a 3-arm randomized clinical trial comparing CBT, acceptance and commitment therapy (ACT), and a wait-list control group (WL) in participants with a diagnosis of social phobia based on criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). Participants completed 12 sessions of CBT or ACT or a 12-week waiting period. All participants completed assessments at baseline and posttreatment, and participants assigned to CBT and ACT also completed assessments 6 and 12 months following baseline. Assessments consisted of self-report measures, a public-speaking task, and clinician ratings. RESULTS Multilevel modeling was used to examine between-group differences on outcomes measures. Both treatment groups outperformed WL, with no differences observed between CBT and ACT on self-report, independent clinician, or public-speaking outcomes. Lower self-reported psychological flexibility at baseline was associated with greater improvement by the 12-month follow-up in CBT compared with ACT. Self-reported fear of negative evaluation significantly moderated outcomes as well, with trends for both extremes to be associated with superior outcomes from CBT and inferior outcomes from ACT. Across treatment groups, higher perceived control and extraversion were associated with greater improvement, whereas comorbid depression was associated with poorer outcomes. CONCLUSIONS Implications for clinical practice and future research are discussed.

Affect labeling enhances exposure effectiveness for public speaking anxiety

Exposure is an effective treatment for anxiety but many patients do not respond fully. Affect labeling (labeling emotional experience) attenuates emotional responding. The current project examined whether affect labeling enhances exposure effectiveness in participants with public speaking anxiety. Participants were randomized to exposure with or without affect labeling. Physiological arousal and self-reported fear were assessed before and after exposure and compared between groups. Consistent with hypotheses, participants assigned to Affect Labeling, especially those who used more labels during exposure, showed greater reduction in physiological activation than Control participants. No effect was found for self-report measures. Also, greater emotion regulation deficits at baseline predicted more benefit in physiological arousal from exposure combined with affect labeling than exposure alone. The current research provides evidence that behavioral strategies that target prefrontal-amygdala circuitry can improve treatment effectiveness for anxiety and these effects are particularly pronounced for patients with the greatest deficits in emotion regulation.

Randomized controlled trial of expressive writing for psychological and physical health: the moderating role of emotional expressivity

The current study assessed main effects and moderators (including emotional expressiveness, emotional processing, and ambivalence over emotional expression) of the effects of expressive writing in a sample of healthy adults. Young adult participants (N=116) were randomly assigned to write for 20 minutes on four occasions about deepest thoughts and feelings regarding their most stressful/traumatic event in the past five years (expressive writing) or about a control topic (control). Dependent variables were indicators of anxiety, depression, and physical symptoms. No significant effects of writing condition were evident on anxiety, depressive symptoms, or physical symptoms. Emotional expressiveness emerged as a significant moderator of anxiety outcomes, however. Within the expressive writing group, participants high in expressiveness evidenced a significant reduction in anxiety at three-month follow-up, and participants low in expressiveness showed a significant increase in anxiety. Expressiveness did not predict change in anxiety in the control group. These findings on anxiety are consistent with the matching hypothesis, which suggests that matching a persons naturally elected coping approach with an assigned intervention is beneficial. These findings also suggest that expressive writing about a stressful event may be contraindicated for individuals who do not typically express emotions.

Attentional bias and emotional reactivity as predictors and moderators of behavioral treatment for social phobia

Cognitive behavioral therapy (CBT) is a well-established treatment for anxiety disorders, and evidence is accruing for the effectiveness of acceptance and commitment therapy (ACT). Little is known about factors that relate to treatment outcome overall (predictors), or who will thrive in each treatment (moderators). The goal of the current project was to test attentional bias and negative emotional reactivity as moderators and predictors of treatment outcome in a randomized controlled trial comparing CBT and ACT for social phobia. Forty-six patients received 12 sessions of CBT or ACT and were assessed for self-reported and clinician-rated symptoms at baseline, post treatment, 6, and 12 months. Attentional bias significantly moderated the relationship between treatment group and outcome with patients slow to disengage from threatening stimuli showing greater clinician-rated symptom reduction in CBT than in ACT. Negative emotional reactivity, but not positive emotional reactivity, was a significant overall predictor with patients high in negative emotional reactivity showing the greatest self-reported symptom reduction.

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder. Method Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder. Results Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms. Conclusions Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.

Anxiety and depressive symptoms and medical illness among adults with anxiety disorders.

OBJECTIVE Anxiety is linked to a number of medical conditions, yet few studies have examined how symptom severity relates to medical comorbidity. PURPOSE The current study assessed associations between severity of anxiety and depression and the presence of medical conditions in adults diagnosed with anxiety disorders. METHOD Nine-hundred eighty-nine patients diagnosed with panic, generalized anxiety, social anxiety, and posttraumatic stress disorders reported on the severity of anxiety and depressive symptoms and on diagnoses of 11 medical conditions. RESULTS Severity of anxiety and depressive symptoms was strongly associated with having more medical conditions over and above control variables, and the association was as strong as that between BMI and disease. Odds of having asthma, heart disease, back problems, ulcer, migraine headache and eyesight difficulties also increased as anxiety and depressive symptom severity increased. Anxiety symptoms were independently associated with ulcer, whereas depressive symptoms were independently associated with heart disease, migraine, and eyesight difficulties. CONCLUSIONS These findings add to a growing body of research linking anxiety disorders with physical health problems and indicate that anxiety and depressive symptoms deserve greater attention in their association with disease.

Physiological and behavioral indices of emotion dysregulation as predictors of outcome from cognitive behavioral therapy and acceptance and commitment therapy for anxiety

BACKGROUND AND OBJECTIVES Identifying for whom and under what conditions a treatment is most effective is an essential step toward personalized medicine. The current study examined pre-treatment physiological and behavioral variables as predictors and moderators of outcome in a randomized clinical trial comparing cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for anxiety disorders. METHODS Sixty individuals with a DSM-IV defined principal anxiety disorder completed 12 sessions of either CBT or ACT. Baseline physiological and behavioral variables were measured prior to entering treatment. Self-reported anxiety symptoms were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-up from baseline. RESULTS Higher pre-treatment heart rate variability was associated with worse outcome across ACT and CBT. ACT outperformed CBT for individuals with high behavioral avoidance. Subjective anxiety levels during laboratory tasks did not predict or moderate treatment outcome. LIMITATIONS Due to small sample sizes of each disorder, disorder-specific predictors were not tested. Future research should examine these predictors in larger samples and across other outcome variables. CONCLUSIONS Lower heart rate variability was identified as a prognostic indicator of overall outcome, whereas high behavioral avoidance was identified as a prescriptive indicator of superior outcome from ACT versus CBT. Investigation of pre-treatment physiological and behavioral variables as predictors and moderators of outcome may help guide future treatment-matching efforts.

Avoidant decision-making in social anxiety disorder: A laboratory task linked to in vivo anxiety and treatment outcome

Recent studies on reward-based decision-making in the presence of anxiety-related stimuli demonstrated that approach-avoidance conflicts can be assessed under controlled laboratory conditions. However, the clinical relevance of these decision conflicts has not been demonstrated. To this end, the present study investigated avoidant decisions in treatment-seeking individuals with social anxiety disorder (SAD). In a gambling task, advantageous choices to maximize gains were associated with task-irrelevant angry faces and disadvantageous choices with happy faces. The clinical relevance of avoidant decisions for in vivo anxiety in a social stress situation (public speaking) were examined (n = 44). In a subsample (n = 20), the predictive value for a reduction of avoidance following behavioral therapy was also evaluated. Results indicated a close link between more frequent avoidant decisions and elevated in vivo anxiety. Moreover, individuals who showed a deficit in the goal-directed adjustment of their decisions also showed higher and sustained distress during the social stressor and reported less decrease of avoidance following treatment. The findings highlight the importance of an avoidant decision-making style for the experience of acute distress and the maintenance of avoidance in SAD. Assessing avoidant decision-making may help to predict the response to behavioral treatments.

Demographic, Medical, and Psychosocial Predictors of Pregnancy Anxiety

BACKGROUND Pregnancy anxiety is associated with risk of preterm birth and an array of other birth, infant, and childhood outcomes. However, previous research has not helped identify those pregnant women at greatest risk of experiencing this specific, contextually-based affective condition. METHODS We examined associations between demographic, medical, and psychosocial factors and pregnancy anxiety at 24-26 weeks of gestation in a prospective, multicentre cohort study of 5271 pregnant women in Montreal, Canada. RESULTS Multivariate analyses indicated that higher pregnancy anxiety was independently related to having an unintended pregnancy, first birth, higher medical risk, and higher perceived risk of complications. Among psychosocial variables, higher pregnancy anxiety was associated with lower perceived control of pregnancy, lower commitment to the pregnancy, more stressful life events, higher perceived stress, presence of job stress, lower self-esteem and more social support. Pregnancy anxiety was also higher in women who had experienced early income adversity and those who did not speak French as their primary language. Psychosocial variables explained a significant amount of the variance in pregnancy anxiety independently of demographic and medical variables. CONCLUSIONS Women with pregnancy-related risk factors, stress of various kinds, and other psychosocial factors experienced higher pregnancy anxiety in this large Canadian sample. Some of the unique predictors of pregnancy anxiety match those of earlier US studies, while others point in new directions. Screening for high pregnancy anxiety may be warranted, particularly among women giving birth for the first time and those with high-risk pregnancies.

Anxiety treatment improves physical functioning with oblique scoring of the SF-12 Short Form Health Survey

OBJECTIVE No studies have found a positive effect of anxiety treatment on physical functioning, but recent investigations of the 12-item Short Form Health Questionnaire (SF-12), which is frequently used to assess physical functioning, have suggested that orthogonal scoring of the summary measure may distort representations of physical health. The current study reanalyzes whether anxiety treatment improves physical functioning using oblique scoring in the Coordinated Anxiety Learning and Management (CALM) randomized clinical trial for the treatment of anxiety disorders. Replication was tested in reanalysis of data from the earlier Collaborative Care for Anxiety and Panic (CCAP) randomized clinical trial for the treatment of panic disorder. METHOD The CALM study included 1004 primary care patients with panic, social anxiety, generalized anxiety or posttraumatic stress disorders. Patients received usual care (UC) or an evidence-based intervention (cognitive behavioral therapy, psychotropic medication or both; ITV). Physical functioning (SF-12v2) was assessed at baseline and at 6, 12 and 18 months. Oblique and orthogonal scoring methods for the physical functioning aggregate measure from SF-12 scale items were compared. RESULTS In CALM, physical functioning improved to a greater degree in ITV than UC for oblique but not orthogonal scoring. Findings were replicated in the CCAP data. CONCLUSIONS Evidence-based treatment for anxiety disorders in primary care improves physical functioning when measured using oblique scoring of the SF-12. Due to this scoring issue, effects of mental health treatment on physical functioning may have been understated.