Craig D. Marker

Automatic associations and panic disorder: Trajectories of change over the course of treatment

Cognitive models of anxiety and panic suggest that symptom reduction during treatment should be preceded by changes in cognitive processing, including modifying the anxious schema. The current study tested these hypotheses by using a repeated measures design to evaluate whether the trajectory of change in automatic panic associations over a 12-week course of cognitive behavior therapy (CBT) is related to the trajectory of change in panic symptoms. Individuals with panic disorder (N = 43) completed a measure of automatic panic associations--the Implicit Association Test (A. G. Greenwald, D. E. McGhee, & J. L. K. Schwartz, 1998), which reflects elements of the schema construct--every 3 weeks over the course of therapy and measures of panic symptoms each week. Dynamic bivariate latent difference score modeling not only indicated that automatic panic associations changed over the course of CBT for panic disorder but showed these changes were correlated with symptom reduction. Moreover, change in automatic panic associations was a significant predictor of change in panic symptom severity. These findings permit inferences about the temporality of change, suggesting that cognitive change does in fact precede and contribute to symptom change.

Attentional Disengagement Predicts Stress Recovery in Depression: An Eye-Tracking Study

Previous research has made significant progress elucidating the nature of cognitive biases in emotional disorders. However, less work has focused on the relation among cognitive biases and emotional responding in clinical samples. This study uses eye-tracking to examine difficulties disengaging attention from emotional material in depressed participants and to test its relation with mood reactivity and recovery during and after a stress induction. Participants diagnosed with Major Depressive Disorder (MDD) and never-disordered control participants (CTL) completed a novel eye-tracking paradigm in which participants had to disengage their attention from emotional material to attend to a neutral stimulus. Time to disengage attention was computed using a direct recording of eye movements. Participants then completed a stress induction and mood reactivity and recovery were assessed. MDD compared with CTL participants took significantly longer to disengage from depression-related stimuli (i.e., sad faces). Individual differences in disengagement predicted lower recovery from sad mood in response to the stress induction in the MDD group. These results suggest that difficulties in attentional disengagement may contribute to the sustained negative affect that characterizes depressive disorders.

In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders.

The study examined the shape of therapeutic alliance using latent growth curve modeling and data from multiple informants (therapist, child, mother, father). Children (n = 86) with anxiety disorders were randomized to family-based cognitive-behavioral treatment (FCBT; N = 47) with exposure tasks or to family education, support, and attention (FESA; N = 39). Children in FCBT engaged in exposure tasks in Sessions 9-16, whereas FESA participants did not. Alliance growth curves of FCBT and FESA youths were compared to examine the impact of exposure tasks on the shape of the alliance (between-subjects). Within FCBT, the shape of alliance prior to exposure tasks was compared with the shape of alliance following exposure tasks (within-subjects). Therapist, child, mother, and father alliance ratings indicated significant growth in the alliance across treatment sessions. Initial alliance growth was steep and subsequently slowed over time, regardless of the use of exposure tasks. Data did not indicate a rupture in the therapeutic alliance following the introduction of in-session exposures. Results are discussed in relation to the processes, mediators, and ingredients of efficacious interventions as well as in terms of the dissemination of empirically supported treatments.

The Reciprocal Relationship Between Alliance and Symptom Improvement Across the Treatment of Childhood Anxiety

This study examined changes in the therapeutic alliance and in self-reported anxiety over the course of 16 weeks of manual-based family treatment for child anxiety disorders. Eighty-six children (51.3% female; aged 7.15–14.44; 86.2% Caucasian, 14.8% minority) with a principal diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia, and their parents, received family treatment for anxiety disorders in youth. Child, therapist, and parent ratings of therapeutic alliance and child ratings of state anxiety were measured each session. Latent difference score growth modeling investigated the interacting relationship. Therapeutic alliance change, as rated by the mother and by the therapist, was a significant predictor (medium effect) of latter change in child anxiety (with greater therapeutic alliance leading to later reduction in anxiety). However, changes in child-reported anxiety also predicted latter change in father- and therapist-reported alliance (small-to-medium effect). Prospective relationships between child-reported therapeutic alliance and child-reported symptom improvement were not significant. Results provide partial support for a reciprocal model in which therapeutic alliance improves outcome, and anxiety reduction improves therapeutic alliance.

Maladaptive Self-Beliefs During Cognitive Behavioural Therapy for Social Anxiety Disorder: A Test of Temporal Precedence

Given the putative importance of maladaptive self-beliefs in cognitive models of social anxiety, there is growing interest in the construct’s influence on social anxiety reduction in treatment. The present study sought to examine whether maladaptive self-beliefs reduce over a 12-week course of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), and whether change in self-beliefs is an indicator of later change in social anxiety symptom severity within treatment. Participants were 77 individuals with SAD who completed measures of maladaptive self-beliefs every 2 weeks of the treatment protocol and measures of social anxiety each week. Using a dynamic bivariate latent difference score framework, results indicated that maladaptive self-beliefs reduced during CBT for SAD, and that change in maladaptive self-beliefs was a significant predictor of later change in social anxiety symptom severity. Reductions in social anxiety was not a significant predictor of later change in self-beliefs. Findings underscore the importance of maladaptive self-beliefs in the maintenance of social anxiety and in treatment for SAD. Moreover, they permit inferences about the temporal sequence of change processes in therapy and are consistent with CBT therapeutic models suggesting that cognitive change precedes symptom change.