David Rosenfield

Reducing anxiety sensitivity with exercise

Background: Exercise interventions repeatedly have been shown to be efficacious for the treatment of depression, and initial studies indicate similar efficacy for the treatment of anxiety conditions. To further study the potential beneficial role of prescriptive exercise for anxiety‐related conditions, we examined the role of exercise in reducing fears of anxiety‐related sensations (anxiety sensitivity). Methods: We randomly assigned 60 participants with elevated levels of anxiety sensitivity to a 2‐week exercise intervention, a 2‐week exercise plus cognitive restructuring intervention, or a waitlist control condition. Assessment of outcome was completed at pretreatment, midtreatment, 1‐week posttreatment, and 3‐week follow‐up. Results: We found that both exercise conditions led to clinically significant changes in anxiety sensitivity that were superior to the waitlist condition, representing a large controlled effect size (d=2.15). Adding a cognitive component did not facilitate the effects of the exercise intervention. Consistent with hypotheses, changes in anxiety sensitivity mediated the beneficial effects of exercise on anxious and depressed mood. Conclusions: We discuss these findings in terms of the potential role of exercise as an additional psychosocial intervention for conditions such as panic disorder, where anxiety sensitivity is a prominent component of pathology. Depression and Anxiety 25:689–699, 2008.

Cognitive Mechanisms of Social Anxiety Reduction: An Examination of Specificity and Temporality

Cognitive theories posit that exposure-based treatments exert their effect on social anxiety by modifying judgmental biases. The present study provides a conservative test of the relative roles of changes in judgmental biases in governing social anxiety reduction and addresses several limitations of previous research. Longitudinal, within-subjects analysis of data from 53 adults with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) social phobia diagnosis revealed that reductions in probability and cost biases accounted for significant variance in fear reduction achieved during treatment. However, whereas the reduction in probability bias resulted in fear reduction, the reduction in cost bias was merely a consequence of fear reduction. A potential implication is that exposure-based treatments for social anxiety might focus more attention on correcting faulty appraisals of social threat occurrence.

Preliminary Evidence for Cognitive Mediation During Cognitive–Behavioral Therapy of Panic Disorder

Cognitive-behavioral therapy (CBT) and pharmacotherapy are similarly effective for treating panic disorder with mild or no agoraphobia, but little is known about the mechanism through which these treatments work. The present study examined some of the criteria for cognitive mediation of treatment change in CBT alone, imipramine alone, CBT plus imipramine, and CBT plus placebo. Ninety-one individuals who received 1 of these interventions were assessed before and after acute treatment, and after a 6-month maintenance period. Multilevel moderated mediation analyses provided preliminary support for the notion that changes in panic-related cognitions mediate changes in panic severity only in treatments that include CBT.

D-Cycloserine Enhancement of Fear Extinction is Specific to Successful Exposure Sessions: Evidence from the Treatment of Height Phobia

BACKGROUND Whereas some studies have shown clear evidence for an augmentation effect of D-cycloserine (DCS) on exposure therapy for anxiety disorders, other studies have shown weak effects or no effect at all. Some preclinical data suggest that the DCS augmentation effect is moderated by the success of extinction learning. Therefore, we conducted a reanalysis of existing data to examine whether the effects of DCS on clinical outcome would vary as a function of response to the exposure session (i.e., exposure success). METHODS In a clinical trial, patients with height phobia received two sessions involving 30 minutes of virtual reality exposure therapy and were randomly assigned to a pill placebo (n = 14) or 50 mg of DCS (n = 15) immediately after each session. RESULTS Mixed-effects regression analysis showed that the effects of DCS administration on clinical improvement was moderated by the level of fear experienced just before concluding exposure sessions. Patients receiving DCS exhibited significantly greater improvement in symptoms relative to patients who received placebo when fear was low at the end of the exposure. In contrast, when end fear was still elevated, patients receiving DCS improved less compared with those receiving placebo. CONCLUSIONS D-cycloserine appears to enhance the benefits of exposure treatment when applied after a successful session, but it seems to have detrimental effects when administered after inadequate/unsuccessful exposure sessions.

Performance in the Interdependent Classroom: A Field Study

The present study was conducted in 5th and 6th grade classes to compare the performances of Anglos and minorities working in small interdependent learning groups with their performance in traditional, teacher-focused classrooms. A covariance analysis indicated that Anglos perform equally well in both interdependent and traditional classes. Minorities performed significantly better in interdependent classes than in traditional classes.

Respiratory and Cognitive Mediators of Treatment Change in Panic Disorder: Evidence for Intervention Specificity.

OBJECTIVE There are numerous theories of panic disorder, each proposing a unique pathway of change leading to treatment success. However, little is known about whether improvements in proposed mediators are indeed associated with treatment outcomes and whether these mediators are specific to particular treatment modalities. Our purpose in this study was to analyze pathways of change in theoretically distinct interventions using longitudinal, moderated mediation analyses. METHOD Forty-one patients with panic disorder and agoraphobia were randomly assigned to receive 4 weeks of training aimed at altering either respiration (capnometry-assisted respiratory training) or panic-related cognitions (cognitive training). Changes in respiration (PCO₂, respiration rate), symptom appraisal, and a modality-nonspecific mediator (perceived control) were considered as possible mediators. RESULTS The reductions in panic symptom severity and panic-related cognitions and the improvements in perceived control were significant and comparable in both treatment groups. Capnometry-assisted respiratory training, but not cognitive training, led to corrections from initially hypocapnic to normocapnic levels. Moderated mediation and temporal analyses suggested that in capnometry-assisted respiratory training, PCO₂ unidirectionally mediated and preceded changes in symptom appraisal and perceived control and was unidirectionally associated with changes in panic symptom severity. In cognitive training, reductions in symptom appraisal were bidirectionally associated with perceived control and panic symptom severity. In addition, perceived control was bidirectionally related to panic symptom severity in both treatment conditions. CONCLUSION The findings suggest that reductions in panic symptom severity can be achieved through different pathways, consistent with the underlying models.

Response rates for CBT for anxiety disorders: Need for standardized criteria.

Full appreciation of the effectiveness of cognitive behavioral therapy (CBT) requires both effect size data and individual rates of positive response. Response rates are particularly helpful for clinicians when choosing among treatment options. However, systematic reviews on cross-study response rates have not been conducted, possibly due to the absence of a standardized metric for calculating response rates. We conducted a systematic review of the treatment outcome literature to determine overall response rates to CBT for anxiety disorders and whether current methods of defining treatment response influence overall response rates. Our database search (2000-2014) resulted in 87 studies that reported response rates and included at least one CBT condition. Results showed that overall treatment response rates across anxiety disorders averaged 49.5% at post-treatment and 53.6% at follow-up. Response rates varied significantly as a function of the properties used to define them. Measures that incorporated more than one criterion, the combination of a reliable change index with a clinical cutoff (a clinically significant change), and intent-to-treat samples yielded lower response rates at post-treatment. Blinded independent assessors yielded higher response rates than unblinded assessors. Based on previous empirical and theoretical work, we recommend that future studies use a clinically significant change index, in an intent-to-treat analysis (using a mixed-model approach), reflecting multiple modalities, and assessed by independent blinded assessors. Our results indicate that such measures are likely to reduce response rates, but may result in a less biased and more accurate representation of improvement and achievement of normative functioning.

Prolonged Exposure vs Supportive Counseling for Sexual Abuse–Related PTSD in Adolescent Girls: A Randomized Clinical Trial

IMPORTANCE Evidence-based treatments for posttraumatic stress disorder (PTSD) have not been established for adolescents despite high prevalence of PTSD in this population. OBJECTIVE To examine the effects of counselor-delivered prolonged exposure therapy compared with supportive counseling for adolescents with PTSD. DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial of 61 adolescent girls with PTSD using a permuted block design. Counselors previously naive to prolonged exposure therapy provided the treatments in a community mental health clinic. Data collection lasted from February 2006 through March 2012. INTERVENTIONS Participants received fourteen 60- to 90-minute sessions of prolonged exposure therapy (n = 31) or supportive counseling (n = 30). MAIN OUTCOMES AND MEASURES All outcomes were assessed before treatment, at mid-treatment, and after treatment and at 3-, 6-, and 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed by the Child PTSD Symptom Scale-Interview (range, 0-51; higher scores indicate greater severity). Secondary outcomes were presence or absence of PTSD diagnosis assessed by the DSM-IV Schedule for Affective Disorders and Schizophrenia for School-Age Children and functioning assessed by the Childrens Global Assessment Scale (range, 1-100; higher scores indicate better functioning). Additional secondary measures, PTSD severity assessed by the Child PTSD Symptom Scale-Self-Report (range, 0-51; higher scores indicate greater severity) and depression severity assessed by the Childrens Depression Inventory (range, 0-54; higher scores indicate greater severity), were also assessed weekly during treatment. RESULTS Data were analyzed as intent to treat. During treatment, participants receiving prolonged exposure demonstrated greater improvement on the PTSD symptom severity scale (difference between treatments in improvement, 7.5; 95% CI, 2.5-12.5; P < .001) and on all secondary outcomes (loss of PTSD diagnosis: difference, 29.3%, 95% CI, 20.2%-41.2%; P = .01; self-reported PTSD severity: difference, 6.2; 95% CI, 1.2-11.2; P = .02; depression: difference, 4.9; 95% CI, 1.6-8.2; P = .008; global functioning: difference, 10.1; 95% CI, 3.4-16.8; P = .008). These treatment differences were maintained through the 12-month follow-up: for interviewer-assessed PTSD (difference, 6.0; 95% CI, 1.6-10.4; P = .02), loss of PTSD diagnosis (difference, 31.1; 95% CI, 14.7-34.8; P = .01), self-reported PTSD (difference, 9.3; 95% CI, 1.2-16.5; P = .02), depression (difference, 7.2; 95% CI, 1.4-13.0; P = .02), and global functioning (difference, 11.2; 95% CI, 4.5-17.9; P = .01). CONCLUSION AND RELEVANCE Adolescents girls with sexual abuse-related PTSD experienced greater benefit from prolonged exposure therapy than from supportive counseling even when delivered by counselors who typically provide supportive counseling. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00417300.

d-Cycloserine as an Augmentation Strategy With Cognitive-Behavioral Therapy for Social Anxiety Disorder

OBJECTIVE The authors examined whether D-cycloserine, a partial agonist at the glutamatergic N-methyl-d-aspartate receptor, augments and accelerates a full course of comprehensive cognitive-behavioral therapy (CBT) in adults with generalized social anxiety disorder. METHOD This was a multisite randomized placebo-controlled efficacy study with 169 medication-free adults with generalized social anxiety disorder, of whom 144 completed the 12-week treatment and 131 completed the three follow-up assessments. Patients were randomly assigned to receive 50 mg of D-cycloserine or placebo 1 hour before each of five exposure sessions that were part of a 12-session cognitive-behavioral group treatment. Response and remission status was determined at baseline, throughout treatment, at end of treatment, and at 1-, 3-, and 6-month follow-up assessments by assessors who were blind to treatment condition. RESULTS D-Cycloserine-augmented and placebo-augmented CBT were associated with similar completion rates (87% and 82%), response rates (79.3% and 73.3%), and remission rates (34.5% and 24.4%) at the posttreatment assessment; response and remission rates were largely maintained at the follow-up assessments. Although D-cycloserine was associated with a 24%-33% faster rate of improvement in symptom severity and remission rates relative to placebo during the treatment phase, the groups did not differ in response and remission rates. CONCLUSIONS D-Cycloserine did not augment a full course of comprehensive CBT for social anxiety disorder.

D-cycloserine Enhancement of Exposure Therapy for Social Anxiety Disorder Depends on the Success of Exposure Sessions

OBJECTIVE The evidence for the efficacy of D-cycloserine (DCS) for augmenting cognitive behavioral therapy (CBT) for anxiety disorders has been mixed. Guided by preclinical research and initial findings from a small-scale study involving humans, we tested the hypothesis that DCS enhancement of exposure therapy would be specific to successful exposure sessions. METHOD Medication-free adults with generalized social anxiety disorder (N = 145) received 50 mg of DCS or placebo 1 h before each of 5 exposure sessions that were part of a standardized 12-session group CBT protocol. Participants provided fear ratings at the beginning and just before the end of exposure exercises. Independent raters, blind to group assignment, administered the clinical global impression improvement and severity scales at each session and at posttreatment. RESULTS Mixed-effects analyses revealed that, among patients who reported low fear at the end of an exposure session, those who had received DCS evidenced significantly greater clinical improvement at the next session, relative to those who had received placebo. In contrast, when exposure end fear was high, patients receiving DCS exhibited less clinical improvement at the following session than patients receiving placebo. Similarly, patients who had received DCS evidenced lower clinical severity at posttreatment, relative to patients who had received placebo, only when their average end fear for medication-augmented sessions had been in the low to moderate range. Finally, these moderating effects of exposure success as indexed by end fear were not better accounted for by within-session extinction. CONCLUSIONS The efficacy of DCS for augmenting exposure-based CBT depends on the success of exposure sessions. These findings may help guide the development of an algorithm for the effective use of DCS for augmenting exposure-based CBT. TRIAL REGISTRY http://www.ClinicalTrials.gov, ID# NCT00633984, http://www.clinicaltrials.gov/ct2/show/NCT00633984.