Lauren S. Hallion

A Meta-Analysis of the Effect of Cognitive Bias Modification on Anxiety and Depression.

Cognitive biases have been theorized to play a critical role in the onset and maintenance of anxiety and depression. Cognitive bias modification (CBM), an experimental paradigm that uses training to induce maladaptive or adaptive cognitive biases, was developed to test these causal models. Although CBM has generated considerable interest in the past decade, both as an experimental paradigm and as a form of treatment, there have been no quantitative reviews of the effect of CBM on anxiety and depression. This meta-analysis of 45 studies (2,591 participants) assessed the effect of CBM on cognitive biases and on anxiety and depression. CBM had a medium effect on biases (g = 0.49) that was stronger for interpretation (g = 0.81) than for attention (g = 0.29) biases. CBM further had a small effect on anxiety and depression (g = 0.13), although this effect was reliable only when symptoms were assessed after participants experienced a stressor (g = 0.23). When anxiety and depression were examined separately, CBM significantly modified anxiety but not depression. There was a nonsignificant trend toward a larger effect for studies including multiple training sessions. These findings are broadly consistent with cognitive theories of anxiety and depression that propose an interactive effect of cognitive biases and stressors on these symptoms. However, the small effect sizes observed here suggest that this effect may be more modest than previously believed.

Perseverative thought: A robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD-MDD (n=50), GAD only (n=35), MDD only (n=34), or no lifetime psychopathology (n=35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.

Rumination Predicts Heightened Responding to Stressful Life Events in Major Depressive Disorder and Generalized Anxiety Disorder

Although studies have documented heightened stress sensitivity in major depressive disorder (MDD) and generalized anxiety disorder (GAD), the mechanisms involved are poorly understood. One possible mechanism is the tendency to ruminate in response to stress. We used ecological momentary assessment to study ruminative thoughts after stressful events in 145 adults with MDD, GAD, comorbid MDD-GAD, or no psychopathology. Diagnosed individuals reported more event-related rumination than controls, even after adjusting for event stressfulness. Rumination was equally common in MDD and GAD and was especially severe among comorbid cases. More rumination immediately after the event predicted poorer affect, more maladaptive behavior, and more MDD and GAD symptoms at the next signal, even when pre-event levels of these variables were controlled. Rumination mediated, but did not moderate, the association of stress with affect and with symptoms. Stress-related rumination was more deleterious for diagnosed than healthy individuals, more intense for more severe clinical cases, and more persistent for cases with a greater temperamental vulnerability for emotional disorders. These results implicate rumination as a mechanism of stress sensitivity and suggest pathways through which it may maintain depression and anxiety in everyday life.

Trauma as a Predictive Indicator of Clinical Outcome in Residential Treatment

The present study was conducted to identify predictors of residential treatment outcome for youth. Data were collected and analyzed on multiple variables including each subjects psychiatric diagnoses, previous treatment attempts and success or failure in these respective settings, length of stay in prior treatment settings, past psychiatric hospitalizations, medication usage, trauma history, short-term and long-term treatment goals, and presenting symptomatology at admission to residential treatment. For this sample, analysis of outcomes data indicated that exposure to a variety of types of trauma was the single greatest predictor of improvement or deterioration in residential treatment.

Psychometric Properties of a Structured Diagnostic Interview for DSM-5 Anxiety, Mood, and Obsessive-Compulsive and Related Disorders:

Three hundred sixty-two adult patients were administered the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND). Of these, 121 provided interrater reliability data, and 115 provided test–retest reliability data. Participants also completed a battery of self-report measures that assess symptoms of anxiety, mood, and obsessive-compulsive and related disorders. Interrater reliability of DIAMOND anxiety, mood, and obsessive-compulsive and related diagnoses ranged from very good to excellent. Test–retest reliability of DIAMOND diagnoses ranged from good to excellent. Convergent validity was established by significant between-group comparisons on applicable self-report measures for nearly all diagnoses. The results of the present study indicate that the DIAMOND is a promising semistructured diagnostic interview for DSM-5 disorders.

Cross-sectional Comparison of the Epidemiology of DSM-5 Generalized Anxiety Disorder Across the Globe

Importance Generalized anxiety disorder (GAD) is poorly understood compared with other anxiety disorders, and debates persist about the seriousness of this disorder. Few data exist on GAD outside a small number of affluent, industrialized nations. No population-based data exist on GAD as it is currently defined in DSM-5. Objective To provide the first epidemiologic data on DSM-5 GAD and explore cross-national differences in its prevalence, course, correlates, and impact. Design, Setting, and Participants Data come from the World Health Organization World Mental Health Survey Initiative. Cross-sectional general population surveys were carried out in 26 countries using a consistent research protocol and assessment instrument. A total of 147 261 adults from representative household samples were interviewed face-to-face in the community. The surveys were conducted between 2001 and 2012. Data analysis was performed from July 22, 2015, to December 12, 2016. Main Outcomes and Measures The Composite International Diagnostic Interview was used to assess GAD along with comorbid disorders, role impairment, and help seeking. Results Respondents were 147 261 adults aged 18 to 99 years. The surveys had a weighted mean response rate of 69.5%. Across surveys, DSM-5 GAD had a combined lifetime prevalence (SE) of 3.7% (0.1%), 12-month prevalence of 1.8% (0.1%), and 30-day prevalence of 0.8% (0). Prevalence estimates varied widely across countries, with lifetime prevalence highest in high-income countries (5.0% [0.1%]), lower in middle-income countries (2.8% [0.1%]), and lowest in low-income countries (1.6% [0.1%]). Generalized anxiety disorder typically begins in adulthood and persists over time, although onset is later and clinical course is more persistent in lower-income countries. Lifetime comorbidity is high (81.9% [0.7%]), particularly with mood (63.0% [0.9%]) and other anxiety (51.7% [0.9%]) disorders. Severe role impairment is common across life domains (50.6% [1.2%]), particularly in high-income countries. Treatment is sought by approximately half of affected individuals (49.2% [1.2%]), especially those with severe role impairment (59.4% [1.8%]) or comorbid disorders (55.8% [1.4%]) and those living in high-income countries (59.0% [1.3%]). Conclusions and Relevance The findings of this study show that DSM-5 GAD is more prevalent than DSM-IV GAD and is associated with substantial role impairment. The disorder is especially common and impairing in high-income countries despite a negative association between GAD and socioeconomic status within countries. These results underscore the public health significance of GAD across the globe while uncovering cross-national differences in prevalence, course, and impairment that require further investigation.

Should uncontrollable worry be removed from the definition of GAD? A test of incremental validity.

In its current instantiation in DSM-IV, a diagnosis of generalized anxiety disorder (GAD) requires the presence of excessive and uncontrollable worry. It has been proposed that the uncontrollability criterion be removed from future editions of the DSM, primarily on the basis of empirical and conceptual overlap between excessiveness and uncontrollability and a relative lack of research on uncontrollability. However, no research has directly investigated the incremental validity of the uncontrollability criterion-that is, the extent to which uncontrollability predicts important clinical information over and above excessiveness. This question was examined in a community sample of 126 adults diagnosed with GAD. After controlling for excessiveness, uncontrollability explained a significant proportion of additional variance in a variety of relevant clinical measures, including GAD severity, clinician-rated anxiety, number and severity of comorbid disorders, and use of psychotropic medication and psychotherapy. The results remained statistically significant even when other features of GAD were controlled. By contrast, excessiveness did not significantly predict any clinical measure over and above uncontrollability. These findings suggest that uncontrollability contributes to the validity of the GAD diagnosis and should be retained as a core feature of pathological worry.

Repetitive transcranial magnetic stimulation for generalised anxiety disorder: a pilot randomised, double-blind, sham-controlled trial.

BACKGROUND Repetitive transcranial magnetic stimulation (rTMS) holds promise for treating generalised anxiety disorder (GAD) but has only been studied in uncontrolled research. AIMS This is the first randomised controlled trial (clinicaltrials.gov: NCT01659736) to investigate the efficacy and neural correlates of rTMS in GAD. METHOD Twenty five participants (active n = 13; sham, n = 12) enrolled. rTMS was targeted at the right dorsolateral prefrontal cortex (DLPFC, 1 Hz, 90% resting motor threshold). RESULTS Response and remission rates were higher in the active v. sham groups and there were significant group × time interactions for anxiety, worry and depressive symptoms, favouring active v. sham. In addition, right DLPFC activation during a decision-making gambling task increased at post-treatment for active rTMS only, and changes in neuroactivation correlated significantly with changes in worry symptoms. CONCLUSIONS Findings provide preliminary evidence that rTMS may improve GAD symptoms in association with modifying neural activity in the stimulation site.

Cognitive Control in Generalized Anxiety Disorder: Relation of Inhibition Impairments to Worry and Anxiety Severity

Cognitive models of generalized anxiety disorder (GAD) propose that cognitive control, broadly construed, and inhibition specifically, play a role in the maintenance of GAD symptoms. However, few studies have explicitly investigated inhibition, and in particular “cold” (non-emotional) inhibition, and its relation to worry and anxiety severity in GAD. Adults with GAD (n = 35) and healthy controls (n = 21) completed computerized Stroop and Go/NoGo tasks, two widely-used tests of inhibition. GAD status predicted significantly worse (slower and less accurate) performance on the Stroop but not the Go/NoGo task. Clinician-rated anxiety severity predicted slower and less accurate Stroop performance over and above the effect of GAD diagnosis but did not predict Go/NoGo performance. Trait worry did not incrementally predict performance on either task. These findings provide qualified support for theoretical models of inhibition impairments in GAD and suggest that inhibition could be a promising target for novel neurocognitive interventions.

Psychometric Properties of the Difficulties in Emotion Regulation Scale (DERS) and Its Short Forms in Adults With Emotional Disorders

Objective: The Difficulties in Emotion Regulation Scale (DERS) is a widely used self-report measure of subjective emotion ability, as defined by a prominent clinically derived model of emotion regulation (Gratz and Roemer, 2004). Although the DERS is often used in treatment and research settings for adults with emotional (i.e., anxiety, mood, obsessive-compulsive, or trauma-related) disorders, its psychometric properties are not well-characterized in this population. Method: We examined the psychometric properties of the DERS and three popular short forms (DERS-16; DERS-18; and DERS-SF) in a large (N = 427) sample of treatment-seeking adults with one or more DSM-5 emotional disorders. Results: For the original DERS, internal consistency was strong for all subscales except Awareness. A bifactor structure consisting of one general emotion dysregulation factor and five uncorrelated specific factors corresponding to the original DERS subscales (excluding Awareness) provided the best fit. A series of structural equation models (SEMs) demonstrated unique incremental contributions of the general factor and several specific factors to explaining concurrent clinical severity. The general factor and one specific factor (Goals) also prospectively predicted treatment outcome following a naturalistic course of outpatient cognitive-behavioral therapy (CBT) in a subset of participants (n = 202) for whom discharge data were available. Specifically, more severe emotion dysregulation at intake predicted better CBT response, while more severe impairment in goal-directed activity when distressed predicted worse CBT response. All three short forms showed a robust bifactor structure and good internal consistency and convergent validity vis-à-vis the original measure, albeit with a slight decrement in incremental utility (1–3% less variance explained in clinical severity). Conclusion: With the Awareness items excluded, the DERS showed good internal consistency and a robust bifactor latent structure. The general factor and several specific factors incrementally and prospectively predicted clinical severity and treatment outcome, which suggests that the DERS may have clinical and predictive utility in treatment-seeking adults with emotional disorders. Additional research is needed to establish convergent and discriminant validity in this population. The use of a short form in lieu of the full DERS may be sufficient for many general clinical and research purposes, particularly when participant burden is a concern.