Ethan E. Gorenstein

Standard and Enhanced Cognitive–Behavior Therapy for Late-Life Generalized Anxiety Disorder: Two Pilot Investigations

OBJECTIVE Although cognitive-behavior therapy (CBT) is an efficacious treatment for generalized anxiety disorder (GAD) in younger adults, little is known about its efficacy in older patients. Investigations to date have tested group-format or otherwise nonstandard versions of CBT. The studies described here are, to our knowledge, the first to test the efficacy of individual-format CBT administered in a mental health clinic for treatment of late-life GAD. METHODS Study 1 tested a standard version, and Study 2 tested an enhanced version (ECBT) that included learning and memory aids designed to make the therapy more effective with elderly patients (e.g., homework reminder and troubleshooting calls, weekly review of all concepts and techniques). RESULTS Study 1 CBT participants showed significant improvement on GAD severity ratings. Study 2 ECBT participants showed significant improvement on two self-report measures, rates of posttreatment GAD, and GAD severity ratings. ECBT resulted in improvement on more measures and yielded larger effect sizes than standard CBT, when each was compared against a wait-list control group. CONCLUSION Results of these pilot studies suggest that standard individual-format CBT may not be optimally effective for treating late-life GAD; thus, ECBT should be tested further in randomized trials.

Failure to delay gratification following septal lesions in rats: Implications for an animal model of disinhibitory psychopathology

Abstract It has been proposed that dysfunction within a neural system composed of the medial septum, the posterior hippocampus and the orbito-frontal cortex (SHF system) may constitute the physiological basis of several disinhibitory syndromes in humans—psychopathy, hyperkinesis, alcoholism and extraversion. Consequently, the syndrome produced by lesions of the SHF system in animals is offered as a tentative behavioral model that may elucidate basic psychological components of human disinhibitory psychopathology. As predicted from this model, rats with septal lesions, like disinhibited humans, were less likely to delay gratification than controls when given a choice between waiting 10 sec for an assured reinforcement and an immediately available, though infrequently delivered, reinforcement. Inquiry into the nature of this deficit suggested that these rats are subject to an interference effect, such that the influence of future rewards on behavior could be disrupted or ‘eclipsed’ by the presence of more immediate, prominent, motivationally significant cues. The possibility that various disinhibitory syndromes in humans may also be due to a similar rigid focus of attention upon the most immediate or prominent motivationally significant event was briefly discussed.

Cardiac Autonomic Control and Treatment of Hostility: A Randomized Controlled Trial

Objective: To test whether reduction in hostility increases autonomic regulation of the heart. Methods: In this randomized controlled trial, participants were 158 healthy adults, aged 20 years to 45 years, who were 1 standard deviation (SD) above national norms on the Cook-Medley Hostility and the Spielberger Trait Anger Indices. Participants also were interviewed, using the Interpersonal Hostility Assessment Technique (IHAT). They were randomly assigned to a 12-week cognitive behavior therapy program for hostility reduction or a wait-list control condition. The main outcome measure was cardiac autonomic modulation, measured as RR interval variability (RRV) derived from 24-electrocardiographic recordings. Results: In a multivariate analysis of variance assessing psychological outcomes of hostility, anger, and IHAT scores, there was a significant treatment effect with an average reduction across the three outcomes that was approximately 0.7 SD (ES = 0.685, SE = 0.184, p < .001) greater for the intervention group than for the control group. In contrast, the change in heart rate was −0.14 beat/min (95% Confidence Interval [CI] = −2.43, 2.14) in treatment participants and −1.36 beat/min (95% CI = −3.28, 0.61) in wait-list participants. High-frequency RRV, an index of cardiac parasympathetic modulation, increased by 0.07 ln ms2 (95% CI = −0.10, 0.24) for participants in the treatment condition and decreased by 0.04 ln ms2 (95% CI = −0.18, 0.10) for participants in the wait-list condition. These differences were not significant. The findings for other indices of RRV were similar. Conclusions: Reduction of hostility and anger was not accompanied by increases in cardiac autonomic modulation. These findings raise questions about the status of disordered autonomic nervous system regulation of the heart as a pathophysiological mechanism underlying the hostility-heart disease relationship and about whether hostility itself is a mechanism or merely a marker of elevated risk of heart disease. SD = standard deviation; CBT = cognitive behavior therapy; RRV = RR interval variability; ECG = electrocardiogram; HR = heart rate; HF = high frequency; ln = natural log; CI = confidence interval; ANS = autonomic nervous system; STAXI = State Trait Anger Expression Inventory; SDRR = standard deviation of normal to normal RR intervals; ES = effective size; SE = standard error; LF = low frequency; CHD = coronary heart disease.

Cognitive-behavioral therapy for management of anxiety and medication taper in older adults.

OBJECTIVE The authors hypothesized that patients with late-life anxiety undergoing cognitive-behavioral therapy plus medical management for medication taper (CBT-MM) would realize greater reduction in medication use and greater improvement in psychological symptoms than a control group undergoing medical management alone (MM). METHODS Forty-two patients (age >60) who wanted to reduce anxiolytic medication were allocated to the two groups (CBT-MM versus MM), using a randomization plus difference-minimization procedure (to equate for medication use). RESULTS CBT-MM completers significantly reduced medication use, but not at a greater rate than MM completers. At the same time, CBT-MM completers experienced significantly greater alleviation of psychological symptoms than did MM completers. Some, but not all, treatment gains were maintained at 6-month follow-up. Intention-to-treat analyses using the mixed-effects model showed similar, but weaker, treatment effects than completer analyses. CONCLUSIONS Cognitive-behavioral therapy can alleviate psychological symptoms in elderly patients with anxiety even as patients reduce anxiolytic medication.

Distinguishing generalized anxiety disorder, panic disorder, and mixed anxiety states in older treatment-seeking adults

Eighty treatment-seeking adults age 60 or over with panic disorder, generalized anxiety disorder, and mixed anxiety states (generalized anxiety with panic attacks, panic disorder with secondary generalized anxiety) completed a clinical assessment and battery of self report measures. Several hypotheses were tested from the domains of distinguishing symptoms, associated features, and rates of comorbidity with other disorders. Greater between- than within-group variance was found on a subset of measures suggesting that the distinction between GAD and PD is generally valid in the older adult population. Higher scores on measures of sympathetic arousal, agoraphobic avoidance, and rates of comorbid somatization disorder and alcohol dependence distinguished those with PD from those with GAD. Higher scores on measures of depression and hostility, but not trait anxiety or worry, distinguished the GAD group. Results indicate that distinguishing features of GAD and PD in older treatment-seeking adults may be fewer and slightly different from those of younger adults.

Cognitive behavioral treatment of anxiety in later life

Anxiety can be a significant problem in later life (i.e., after age 65). To cope, a substantial proportion of elderly individuals take benzodiazepine medication, as prescribed by their primary-care physician. Unfortunately, the use of benzodiazepines for the long-term management of anxiety in the elderly carries certain risks, including cognitive impairment, motor impairment, respiratory depression, and addiction. Cognitive behavior therapy, a proven treatment for anxiety in younger individuals, might offer a safe and effective alternative to medication in the older population. We describe the rationale and implementation of a 13-session cognitive-behavioral treatment protocol, currently in use at Columbia-Presbyterian Medical Center. The protocol is designed to address several aspects of anxiety that we have encountered in elderly patients: excessive worry (especially about aging and related health matters); reduced structure of daily life; anxiety over symptoms of autonomic arousal; benzodiazepine dependence; realistic fears; and insomnia.

The Association of Cigarette Smoking With High-frequency Heart Rate Variability: An Ecological Momentary Assessment Study

Objective Evidence from both laboratory and observational studies suggests that acute and chronic smoking leads to reduced high-frequency heart rate variability (HF-HRV), a measure of cardiac vagal regulation. We used ecological momentary assessment (EMA) to study the effect of smoking on concurrent HF-HRV in a trial measuring the effects of hostility reduction and compared 24-hour HF-HRV in smokers and nonsmokers. Method Ambulatory electrocardiogram data were collected before randomization from 149 healthy individuals with high hostility levels (20–45 years, body mass index ⩽ 32 kg/m2) and paired with concurrent EMA ratings of smoking and physical position during waking hours. A multilevel mixed model was estimated associating ln(HF-HRV) from smoking status (between-person factor) and person-centered momentary smoking (within-person factor, treated as a random effect), adjusting for momentary physical position, medication use, and consumption of alcohol and caffeine. Results Thirty-five smokers and 114 nonsmokers provided both EMA and HF-HRV data. Within smokers, ln HF-HRV was reduced by 0.31 millisecond2 (p = .04) when participants reported having recently smoked cigarettes, compared with when they had not. The 24-hour HF-HRV was significantly lower in smokers (M [SD] = 5.24 [0.14] milliseconds2) than nonsmokers (5.63 ± 0.07 milliseconds2, p = .01). Conclusions In healthy smokers with high hostility levels used as their own controls during daily living, smoking acutely reduced HF-HRV. HF-HRV was also reduced in smokers as compared with nonsmokers. Although limited by a small sample of individuals with high hostility levels, these findings nonetheless provide additional evidence that cardiac vagal regulation is lowered by cigarette smoking, which may be one of the numerous pathophysiological effects of smoking.

The Effect of Hostility Reduction on Autonomic Control of the Heart and Vasculature: A Randomized Controlled Trial.

Objective Hostility is associated with coronary artery disease. One candidate mechanism may be autonomic nervous system (ANS) dysregulation. In this study, we report the effect of cognitive behavioral treatment on ANS regulation. Methods Participants were 158 healthy young adults, high in hostility measured by the Cook-Medley Hostility and Spielberger Trait Anger scales. Participants were also interviewed using the Interpersonal Hostility Assessment Technique. They were randomized to a 12-week cognitive behavioral treatment program for reducing hostility or a wait-list control group. The outcome measures were preejection period, low-frequency blood pressure variability, and high-frequency heart rate variability measured at rest and in response to and recovery from cognitive and orthostatic challenge. Linear-mixed models were used to examine group by session and group by session by period interactions while controlling for sex and age. Contrasts of differential group and session effects were used to examine reactivity and recovery from challenge. Results After Bonferroni correction, two-way and three-way interactions failed to achieve significance for preejection period, low-frequency blood pressure variability, or high-frequency heart rate variability (p > .002), indicating that hostility reduction treatment failed to influence ANS indices. Conclusions Reduction in anger and hostility failed to alter ANS activity at rest or in response to or recovery from challenge. These findings raise questions about whether autonomic dysregulation represents a pathophysiological link between hostility and heart disease.