Laura Campbell-Sills

Acceptability and Suppression of Negative Emotion in Anxiety and Mood Disorders

The present study investigated perceived acceptability and suppression of negative emotion in participants with anxiety and mood disorders. Sixty participants with these disorders and 30 control participants watched an emotion-provoking film and completed self-report measures of their experience and regulation of emotions. The film elicited similar increases in negative emotion for clinical and nonclinical participants; however, clinical participants judged their resulting emotions as less acceptable and suppressed their emotions to a greater extent. The higher level of suppression in the clinical group was attributable to females in the clinical group suppressing their emotions more than females in the nonclinical group. For all participants, high levels of suppression were associated with increased negative emotion during the film and during a postfilm recovery period. Further analyses showed that appraising emotions as unacceptable mediated the relationship between negative emotion intensity and use of suppression in the clinical group. This study extends the literature on emotion regulation to a clinical sample and suggests that judging emotions as unacceptable and suppressing emotions may be important aspects of the phenomenology of emotional disorders.

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.

Psychometric Evaluation of the Behavioral Inhibition/Behavioral Activation Scales in a Large Sample of Outpatients With Anxiety and Mood Disorders.

The latent structure, reliability, and validity of the Behavioral Inhibition/Behavioral Activation Scales (BIS/BAS; C. L. Carver and T. L. White, 1994) were examined in a large sample of outpatients (N = 1,825) with anxiety and mood disorders. Four subsamples were used for exploratory and confirmatory factor analyses. In addition to generally upholding a latent structure found previously in nonclinical samples, results indicated measurement invariance of the BIS/BAS between genders and a higher order structure of the BAS scales. Convergent and discriminant validity of the BIS/BAS were supported by findings that the subscales correlated most strongly with measures of neighboring personality constructs (e.g., BIS with neuroticism, BAS with positive affect) than with measures of current anxiety and depression symptoms. Overall, the results support the psychometric properties of the BIS/BAS in this clinical sample.

Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings†

Objectives: This article describes a computer‐assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced‐based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary‐care settings. The purpose of the current report is to (1) present the structure and format of the computer‐assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. Methods: Thirteen clinicians using the computer‐assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert‐scale ratings and open‐ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected Results: Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. Conclusions: Computer‐assisted CBT programs provide a practice‐based system for disseminating evidence‐based mental health treatment in primary‐care settings while maintaining treatment fidelity, even in the hands of novice clinicians. Depression and Anxiety, 2009. Published 2009 Wiley‐Liss, Inc.

Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS)

BACKGROUND The Overall Anxiety Severity and Impairment Scale (OASIS) is a 5-item self-report measure that can be used to assess severity and impairment associated with any anxiety disorder or multiple anxiety disorders. A prior investigation with a nonclinical sample supported the reliability and validity of the OASIS; however, to date it has not been validated for use in clinical samples. METHODS The present study assessed the psychometric properties of the OASIS in a large sample (N=1036) of primary care patients whose physicians referred them to an anxiety disorders treatment study. Latent structure, internal consistency, convergent/discriminant validity, and cut-score analyses were conducted. RESULTS Exploratory and confirmatory factor analyses supported a unidimensional structure. The five OASIS items displayed strong loadings on the single factor and had a high degree of internal consistency. OASIS scores demonstrated robust correlations with global and disorder-specific measures of anxiety, and weak correlations with measures of unrelated constructs. A cut-score of 8 correctly classified 87% of this sample as having an anxiety diagnosis or not. LIMITATIONS Convergent validity measures consisted solely of other self-report measures of anxiety. Future studies should evaluate the convergence of OASIS scores with clinician-rated and behavioral measures of anxiety severity. CONCLUSIONS Overall, this investigation suggests that the OASIS is a valid instrument for measurement of anxiety severity and impairment in clinical samples. Its brevity and applicability to a wide range of anxiety disorders enhance its utility as a screening and assessment tool.

Genetic variation in 5HTTLPR is associated with emotional resilience

Emotional resilience can be defined as the ability to maintain healthy and stable levels of psychological functioning in the wake of stress and trauma. Although genes that contribute to psychopathology (often in interaction with environmental stressors) are being detected with increasing consistency, genes that influence resilience to stress have been less studied. In this study, 423 undergraduate college students completed a psychometrically sound 10‐item self‐report measure of resilience (CDRISC‐10) and provided blood for DNA. Linear and logistic regression analyses were used to model relationships between the serotonin transporter promoter polymorphism (5HTTLPR) and CDRISC‐10 scores and categories, respectively. CDRISC‐10 scores were normally distributed (mean 26.17, SD 5.88 [range 5–40]). In models adjusting for ancestry proportion scores (to mitigate confounding by population stratification) and other covariates, each copy of the “s” allele of 5HTTLPR was associated with ∼1‐point lower CDRISC‐10 score. Each copy of the “s” allele was associated with increased (adjusted OR = 1.53, 95% CI 1.06–2.21, P = 0.024) odds of being in the low resilient category (>1 SD below the mean), compared to being homozygous for the “l” allele. These findings suggest that variation in 5HTTLPR is associated with individual differences in emotional resilience, defined as an individuals ability to withstand and bounce back from stress. This relationship may explain the frequently observed interaction between 5HTTLPR and life stressors in predicting adverse mental health outcomes (e.g., depressive symptoms). Replication is needed, in concert with identification of other genes that influence emotional resilience and related phenotypes.

Functioning of Neural Systems Supporting Emotion Regulation in Anxiety-Prone Individuals

Previous neuroimaging studies suggest that prefrontal cortex (PFC) modulation of the amygdala and related limbic structures is an underlying neural substrate of effortful emotion regulation. Anxiety-prone individuals experience excessive negative emotions, signaling potential dysfunction of systems supporting down-regulation of negative emotions. We examined the hypothesis that anxious individuals require increased recruitment of lateral and medial PFC to decrease negative emotions. An emotion regulation task that involved viewing moderately negative images was presented during functional magnetic resonance imaging (fMRI). Participants with elevated trait anxiety scores (n=13) and normal trait anxiety scores (n=13) were trained to reduce negative emotions using cognitive reappraisal. Blood oxygenation level-dependent (BOLD) changes were contrasted for periods when participants were reducing emotions versus when they were maintaining emotions. Compared to healthy controls, anxious participants showed greater activation of brain regions implicated in effortful (lateral PFC) and automatic (subgenual anterior cingulate cortex) control of emotions during down-regulation of negative emotions. Left ventrolateral PFC activity was associated with greater self-reported reduction of distress in anxious participants, but not in healthy controls. These findings provide evidence of altered functioning of neural substrates of emotion regulation in anxiety-prone individuals. Anxious participants required greater engagement of lateral and medial PFC in order to successfully reduce negative emotions.

Disorder-Specific Impact of Coordinated Anxiety Learning and Management Treatment for Anxiety Disorders in Primary Care

CONTEXT Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. OBJECTIVE To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). DESIGN A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. SETTING Seventeen US primary care clinics. PATIENTS Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. INTERVENTIONS CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. MAIN OUTCOME MEASURES Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. RESULTS CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CONCLUSIONS CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

Prefrontal dysfunction during emotion regulation in generalized anxiety and panic disorders

BACKGROUND The mechanisms that contribute to emotion dysregulation in anxiety disorders are not well understood. Two common disorders, generalized anxiety disorder (GAD) and panic disorder (PD), were examined to test the hypothesis that both disorders are characterized by hypo-activation in prefrontal cortex (PFC) during emotion regulation. A competing hypothesis that GAD in particular is characterized by PFC hyper-activation during emotion regulation (reflecting overactive top-down control) was also evaluated. Method Twenty-two medication-free healthy control (HC), 23 GAD, and 18 PD participants underwent functional magnetic resonance imaging (fMRI) during a task that required them to reappraise (i.e. reduce) or maintain emotional responses to negative images. RESULTS GAD participants reported the least reappraisal use in daily life, and reappraisal use was inversely associated with anxiety severity and functional impairment in these participants. During fMRI, HCs demonstrated greater activation during both reappraisal and maintenance than either GAD or PD participants (who did not differ) in brain areas important for emotion regulation (e.g. dorsolateral and dorsomedial PFC). Furthermore, across all anxious participants, activation during reappraisal in dorsolateral and dorsomedial PFC was inversely associated with anxiety severity and functional impairment. CONCLUSIONS Emotion dysregulation in GAD and PD may be the consequence of PFC hypo-activation during emotion regulation, consistent with insufficient top-down control. The relationship between PFC hypo-activation and functional impairment suggests that the failure to engage PFC during emotion regulation may be part of the critical transition from dispositionally high anxiety to an anxiety disorder.

Single-Subject Anxiety Treatment Outcome Prediction using Functional Neuroimaging

The possibility of individualized treatment prediction has profound implications for the development of personalized interventions for patients with anxiety disorders. Here we utilize random forest classification and pre-treatment functional magnetic resonance imaging (fMRI) data from individuals with generalized anxiety disorder (GAD) and panic disorder (PD) to generate individual subject treatment outcome predictions. Before cognitive behavioral therapy (CBT), 48 adults (25 GAD and 23 PD) reduced (via cognitive reappraisal) or maintained their emotional responses to negative images during fMRI scanning. CBT responder status was predicted using activations from 70 anatomically defined regions. The final random forest model included 10 predictors contributing most to classification accuracy. A similar analysis was conducted using the clinical and demographic variables. Activations in the hippocampus during maintenance and anterior insula, superior temporal, supramarginal, and superior frontal gyri during reappraisal were among the best predictors, with greater activation in responders than non-responders. The final fMRI-based model yielded 79% accuracy, with good sensitivity (0.86), specificity (0.68), and positive and negative likelihood ratios (2.73, 0.20). Clinical and demographic variables yielded poorer accuracy (69%), sensitivity (0.79), specificity (0.53), and likelihood ratios (1.67, 0.39). This is the first use of random forest models to predict treatment outcome from pre-treatment neuroimaging data in psychiatry. Together, random forest models and fMRI can provide single-subject predictions with good test characteristics. Moreover, activation patterns are consistent with the notion that greater activation in cortico-limbic circuitry predicts better CBT response in GAD and PD.