Kristina J. Korte

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.

The Fagerström Test for Nicotine Dependence: Do revisions in the item scoring enhance the psychometric properties?

Despite widespread use, considerable literature has shown that the Fagerström Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerström, 1991) has questionable psychometric properties, generally reflecting relatively poor properties of reliability and validity. One factor that may be affecting the psychometric qualities of the scale is the use of a dichotomous, forced-choice response format for certain items, in which respondents are asked to answer each question with a Yes or No response. This scoring approach is especially problematic when used to measure dimensional constructs, such as nicotine dependence, in which a dimensional construct is forced into a categorical construct. The purpose of the current study was to examine whether revising the response format utilized in the FTND would lead to an enhancement in the psychometric properties of this scale. This question was examined by removing the forced-choice response criteria on items 2, 5, and 6 of the FTND and revising the response options to reflect a 4-point Likert response set (0 = never, 1 = sometimes, 2 = most of the time, 3 = always). Participants consisted of 343 smokers from the community. Results revealed that the revised scoring approach resulted in a significant incremental improvement in scale reliability and enhanced convergent validity, showing a stronger association with smoking outcomes than the FTQ or FTND. Findings are discussed in terms of recommendations for scale revision and usage.

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.

Anxiety Sensitivity: A Potential Vulnerability Factor For Compulsive Hoarding

Compulsive hoarding is defined as the accumulation of and failure to discard a large number of possessions that appear to be useless or limited in value. Severe hoarding can result in illnesses due to unsanitary conditions, social isolation, work disability, and even death. Despite the severity of impairment associated with this clinical syndrome, research examining potential vulnerability factors is limited. Two independent studies have demonstrated that hoarding behaviors are significantly associated with anxiety sensitivity (AS), a well-known risk factor for anxiety pathology. However, the relationship between AS subfactors and hoarding behaviors is somewhat unclear. The primary aim of this investigation was to examine the relationships between hoarding and AS subfactors utilizing the anxiety sensitivity index-3, a measure designed to more accurately assess AS subfactors. Participants consisted of 279 college students, as well as 210 non-selected clinical participants. Consistent with initial predictions, hoarding behaviors were significantly associated with overall AS. Moreover, when looking at the relationships among hoarding behaviors and specific AS subfactors, hoarding was significantly associated with the physical concerns subscale. Finally, when examining the relationships among overall AS and specific hoarding facets, results indicated that the difficulty discarding subfactor of hoarding was associated with overall AS. Implications for future research and treatment are discussed.

Factor mixture modeling of anxiety sensitivity: a three-class structure.

Anxiety sensitivity (AS) is a multidimensional construct composed of several lower order factors and has been implicated in the development and maintenance of anxiety and depression symptoms and disorders. Recently, it has been suggested that AS is a dimensional-categorical construct, reflecting classes of individuals with different levels of and relations between AS factors. Factor mixture modeling was applied to examine the latent structure of AS in a sample of 1,151 college students (M age = 18.88, SD = 1.91). Results indicated that the best fitting model comprised three classes consisting of individuals with normative AS (n = 953), moderate AS (n = 124), and high AS (n = 74). Relations among the factors appeared to be different across groups, with the highest relations found in the normative AS class and the lowest relations found in the high AS class. There were significant differences in mean levels of anxiety and depression symptoms across classes, with the exception of social anxiety disorder symptoms. This study was the first to find and provide support for a third AS class. Implications for research and clinical utility are discussed, including the benefit of developing cut scores for AS classes based on this and similar studies.

Concurrent Treatment of Substance Use and PTSD.

Substance use disorders (SUD) and posttraumatic stress disorder (PTSD) are chronic, debilitating conditions that frequently co-occur. Individuals with co-occurring SUD and PTSD suffer a more complicated course of treatment and less favorable treatment outcomes compared to individuals with either disorder alone. The development of effective psychosocial and pharmacological interventions for co-occurring SUD and PTSD is an active and critically important area of investigation. Several integrated psychosocial treatments for co-occurring SUD and PTSD have demonstrated promising outcomes. While recent studies examining medications to treat co-occurring SUD and PTSD have yielded encouraging findings, there remain substantial gaps in the evidence base regarding the treatment of co-occurring SUD and PTSD. This review will summarize the findings from clinical trials targeting a reduction in SUD and PTSD symptoms simultaneously. These results may improve our knowledge base and subsequently enhance our ability to develop effective interventions for this complex comorbid condition.

A Double-Blind, Randomized, Controlled Pilot Trial of N-Acetylcysteine in Veterans With Posttraumatic Stress Disorder and Substance Use Disorders.

OBJECTIVE The antioxidant N-acetylcysteine is being increasingly investigated as a therapeutic agent in the treatment of substance use disorders (SUDs). This study explored the efficacy of N-acetylcysteine in the treatment of posttraumatic stress disorder (PTSD), which frequently co-occurs with SUD and shares impaired prefrontal cortex regulation of basal ganglia circuitry, in particular at glutamate synapses in the nucleus accumbens. METHODS Veterans with PTSD and SUD per DSM-IV criteria (N = 35) were randomly assigned to receive a double-blind, 8-week course of N-acetylcysteine (2,400 mg/d) or placebo plus cognitive-behavioral therapy for SUD (between March 2013 and April 2014). Primary outcome measures included PTSD symptoms (Clinician-Administered PTSD Scale, PTSD Checklist-Military) and craving (Visual Analog Scale). Substance use and depression were also assessed. RESULTS Participants treated with N-acetylcysteine compared to placebo evidenced significant improvements in PTSD symptoms, craving, and depression (β values < -0.33; P values < .05). Substance use was low for both groups, and no significant between-group differences were observed. N-acetylcysteine was well tolerated, and retention was high. CONCLUSIONS This is the first randomized controlled trial to investigate N-acetylcysteine as a pharmacologic treatment for PTSD and SUD. Although preliminary, the findings provide initial support for the use of N-acetylcysteine in combination with psychotherapy among individuals with co-occurring PTSD and SUD. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02499029.

Factor mixture modeling of the Penn State Worry Questionnaire: Evidence for distinct classes of worry

Worry, the anticipation of future threat, is a common feature of anxiety and mood psychopathology. Considerable research has examined the latent structure of worry to determine whether this construct reflects a dimensional or taxonic structure. Recent taxometric investigations have provided support for a unidimensional structure of worry; however, the results of these studies are limited in that taxometric approaches are unable to assess for the presence of more than two classes of a given construct. Given the complex nature of worry, it is possible that worry may actually reflect a latent structure comprised of multiple classes that cannot be assessed through taxometric approaches. Thus, it is important to utilize newer statistical techniques, such as factor-mixture modeling (FMM), which allow for a more nuanced assessment of the latent structure of a given psychological construct. The aim of the current study was to examine the latent structure of worry using FMM. It was predicted that worry would reflect a three-class structure comprised of (1) a class of low, normative levels of worry, (2) a class of moderate, subclinical worry, and (3) a class of high, pervasive worry. The latent class structure of worry was assessed using FMM in a sample of 1337 participants recruited from the community through a research clinic. Results revealed a three-class structure of the PSWQ comprising low, moderate-high, and high classes of worry. We also provided convergent and discriminant validity of the worry classes by demonstrating that the high worry class was most associated with GAD and that the low worry class was the least associated with GAD. The clinical utility of the worry classes, including the creation of empirically based cut-scores, and the implications for future research are discussed.

Safety aid use and social anxiety symptoms: The mediating role of perceived control

The use of safety aids, cognitive or behavioral strategies used to reduce or cope with anxiety, has emerged as a key construct of interest in anxiety disorders due to their role in the development and maintenance of anxiety symptoms. It has been suggested that individuals with anxiety engage in safety aid use to reduce their anxiety and feel more in control of a situation; however, no studies to date have examined the association between perceived control, that is, perceived level of control over internal events in anxiety provoking situations, and the use of safety aids. The purpose of the present study was to examine the association of perceived control, the use of safety aids, and symptoms of social anxiety. It was predicted that the association between safety aid use and social anxiety symptoms would be mediated by perceived control. This prediction was examined in a large sample of 281 participants. As predicted, perceived control was a significant mediator of the association between the use of safety aids and social anxiety symptoms. This effect remained significant after running a multiple mediation model with distress tolerance added as a competing mediator. Implications for future research are discussed.

Panic Disorder and Agoraphobia Considerations for DSM-V

With the upcoming release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) there has been a necessary critique of the DSM-IV including questions regarding how to best improve the next iteration of the DSM classification system. The aim of this article is to provide commentary on the probable direction the DSM-V is headed with regard to panic attacks, panic disorder (PD), and agoraphobia (AG). The DSM-V Work Group’s recommendations for panic attacks, PD, and AG are reviewed, and important diagnostic questions and concerns are raised. Future research directions are discussed that will hopefully help improve our understanding of anxiety and our ability to accurately diagnose and classify these conditions.