Lindsey B. DeBoer

Augmentation of exposure therapy with post-session administration of d-cycloserine

BACKGROUND Pre-session administration of d-cycloserine (DCS) has been found to augment exposure therapy outcomes in a variety of anxiety disorders. To be able to enhance learning only for successful exposure sessions, it would be beneficial to have the option of administering DCS after rather than before the session, a strategy encouraged by pre-clinical work. We believe the present study is the first published report on the efficacy of post-session administration of DCS in humans. METHOD Adults (N = 29) with a DSM-IV diagnosis of acrophobia were randomized to receive two sessions of virtual reality exposure therapy (VRE) in combination with placebo or 50 mg of DCS. Instead of administering the pill prior to each of the sessions, as has been done in extant work, we administered the pill immediately following each session. Measures of acrophobia severity were collected at baseline, at each treatment session, 1-week post-treatment, and at 1-month follow-up. RESULTS Mixed-effects repeated-measures ANOVAs and GLMMs revealed significant improvement in all outcome measures over time, but no between-group differences were observed. At post-treatment, 63.5% of patients in the placebo condition vs. 60.0% of those in the DCS condition were in remission. At 1-month follow up, 63.4% of those in the placebo condition vs. 66.6% of those in the DCS condition were in remission. CONCLUSIONS These findings do not support the application of post-session DCS administration for augmenting the efficacy of exposure-based treatments. Possible reasons for these findings are discussed. TRIAL REGISTRY The Trial is registered at ClinicalTrials.gov (NCT01102803).

Exploring exercise as an avenue for the treatment of anxiety disorders

Anxiety disorders constitute a significant public health problem. Current gold standard treatments are limited in their effectiveness, prompting the consideration of alternative approaches. In this review, we examine the evidence for exercise as an intervention for anxiety disorders. This evidence comes from population studies, studies of nonclinical anxiety reduction, as well as a limited number of studies of clinically anxious individuals. All of these studies provide converging evidence for consistent beneficial effects of exercise on anxiety, and are consistent with a variety of accounts of the mechanism of anxiety reduction with exercise. Further study of clinical populations is encouraged, as are studies of the mechanism of change of exercise interventions, which have the potential to help refine exercise intervention strategies. Likewise, studies that identify moderators of treatment efficacy will assist clinicians in deciding how and for whom to prescribe exercise.

D-Cycloserine Augmentation of Cognitive Behavioral Group Therapy of Social Anxiety Disorder: Prognostic and Prescriptive Variables

OBJECTIVE The aim of the current study was to identify individual characteristics that (a) predict symptom improvement with group cognitive behavioral therapy (CBT) for social anxiety disorder (SAD; i.e., prognostic variables) or (b) moderate the effects of d-cycloserine (DCS) versus placebo augmentation of CBT for SAD (i.e., prescriptive variables). METHOD Adults with SAD (N = 169) provided Liebowitz Social Anxiety Scale scores in a trial evaluating DCS augmentation of group CBT. Rate of symptom improvement during therapy and posttreatment symptom severity were evaluated using multilevel modeling. As predictors of these 2 parameters, we selected the range of variables assessed at baseline (demographic characteristics, clinical characteristics, personality traits). Using step-wise analyses, we first identified prognostic and prescriptive variables within each of these domains and then entered these significant predictors simultaneously in 1 final model. RESULTS African American ethnicity and cohabitation status were associated with greater overall rates of improvement during therapy and lower posttreatment severity. Higher initial severity was associated with a greater improvement during therapy but also higher posttreatment severity (the greater improvement was not enough to overcome the initial higher severity). DCS augmentation was evident only among individuals low in conscientiousness and high in agreeableness. CONCLUSIONS African American ethnicity, cohabitation status, and initial severity are prognostic of favorable CBT outcomes in SAD. DCS augmentation appears particularly useful for patients low in conscientiousness and high in agreeableness. These findings can guide clinicians in making decisions about treatment strategies and can help direct research on the mechanisms of these treatments.

Physical activity as a moderator of the association between anxiety sensitivity and binge eating

Individuals with elevated anxiety sensitivity (AS; i.e., fear of somatic arousal) may binge eat to reduce emotional distress. Because physical activity reduces stress reactivity, we predicted that: (1) the relation between AS and binge eating would be moderated by physical activity and (2) coping motives for eating would mediate the association between AS and binge eating such that the relation would be stronger for those low in physical activity. Participants (N=167) completed online self-report measures. Regression analyses revealed that moderate-intensity physical activity (MPA) moderated the relation between AS and binge eating such that AS was not related to binge eating among those who frequently engaged in MPA but was related to binge eating among those who did not report engaging in MPA. Vigorous-intensity physical activity (VPA) moderated in the opposite direction such that the relation between AS and binge eating was significant among persons reporting high levels of VPA but less strong among persons reporting low levels of VPA. The mediation model was also significant, but was not moderated by MPA or VPA. Theoretical and clinical implications are discussed.

The efficacy of vigorous-intensity exercise as an aid to smoking cessation in adults with elevated anxiety sensitivity: study protocol for a randomized controlled trial

BackgroundAlthough cigarette smoking is a leading cause of death and disability in the United States (US), over 40 million adults in the US currently smoke. Quitting smoking is particularly difficult for smokers with certain types of psychological vulnerability. Researchers have frequently called attention to the relation between smoking and anxiety-related states and disorders, and evidence suggests that panic and related anxiety vulnerability factors, specifically anxiety sensitivity (AS or fear of somatic arousal), negatively impact cessation. Accordingly, there is merit to targeting AS among smokers to improve cessation outcome. Aerobic exercise has emerged as a promising aid for smoking cessation for this high-risk (for relapse) group because exercise can effectively reduce AS and other factors predicting smoking relapse (for example, withdrawal, depressed mood, anxiety), and it has shown initial efficacy for smoking cessation. The current manuscript presents the rationale, study design and procedures,and design considerations of the Smoking Termination Enhancement Project (STEP).MethodsSTEP is a randomized clinical trial that compares a vigorous-intensity exercise intervention to a health and wellness education intervention as an aid for smoking cessation in adults with elevated AS. One hundred and fifty eligible participants will receive standard treatment (ST) for smoking cessation that includes cognitive behavioral therapy (CBT) and nicotine replacement therapy (NRT). In addition, participants will be randomly assigned to either an exercise intervention (ST+EX) or a health and wellness education intervention (ST+CTRL). Participants in both arms will meet 3 times a week for 15 weeks, receiving CBT once a week for the first 7 weeks, and 3 supervised exercise or health and wellness education sessions (depending on randomization) per week for the full 15-week intervention. Participants will be asked to set a quit date for 6 weeks after the baseline visit, and smoking cessation outcomes as well as putative mediator variables will be measured up to 6 months following the quit date.DiscussionThe primary objective of STEP is to evaluate whether vigorous-intensity exercise can aid smoking cessation in anxiety vulnerable adults. If effective, the use of vigorous-intensity exercise as a component of smoking cessation interventions would have a significant public health impact. Specifically, in addition to improving smoking cessation treatment outcome, exercise is expected to offer benefits to overall health, which may be particularly important for smokers. The study is also designed to test putative mediators of the intervention effects and therefore has the potential to advance the understanding of exercise-anxiety-smoking relations and guide future research on this topic.Clinical trials registryClinicalTrials.gov, NCT01065506, http://clinicaltrials.gov/ct2/show/NCT01065506

Anxiety and Disordered Eating

Empirical accounts of a relation between anxiety and eating disorders date as far back as 1950 (e.g., Keys, Brožek, Henschel, Mickelsen, & Taylor, 1950). Investigations into this relation, particularly studies conducted over the past 20 years, have confirmed that individuals with eating disorders are at significantly elevated risk for generalized anxiety disorder, specific phobias, social phobia, obsessive compulsive disorder, and post-traumatic stress disorder (Pallister & Waller, 2008; Reyes-Rodriguez et al., 2011). Approximately 65% of patients with eating disorders meet criteria for at least one anxiety disorder, which tends to predate and to persist beyond remission of the eating disorder (Adambegan et al., 2012; Godart et al., 2003; Kaye, Bulik, Thornton, Barbarich, & Masters, 2004; Klump et al., 2004; Swinbourne et al., 2012; Swinbourne & Touyz, 2007). Anxiety has thus come to be considered a possible predisposing risk factor for eating disorders, whereas eating disorders may represent more complex manifestations of underlying anxiety vulnerability. Improving adherence to and outcomes of eating disorder interventions remain important goals, and patients with comorbid anxiety disorders appear especially in need of enhanced interventions as they tend to have poorer illness courses and outcomes (Dellava et al., 2010; Herpertz-Dahlmann et al., 2001; Thornton, Dellava, Root, Lichtenstein, & Bulik, 2011; Yackobovitch-Gavin et al., 2009). The purpose of this special series is to highlight some of the latest work on the relation between anxiety and disordered eating, with the overarching goal of identifying promising areas of research that may ultimately lead to better interventions. To this end, we invited submissions reporting on the interplay among specific anxiety-related vulnerabilities and disordered eating symptoms and risk processes. The eight manuscripts in this special series collectively investigate a range of anxiety and disordered eating constructs, are guided by various theoretical models, and employ complementary research designs and analytic approaches. By analyzing hypothesized relations at multiple levels and by testing theoretically-relevant interactions among variables of interest, these papers help move forward the literature in terms of refining contemporary accounts of the anxiety-disordered eating relation. Below, we provide a brief overview of each article along with a discussion as to how they relate to the theme of this special series. The first two papers in the series build on extant evidence that genetic vulnerability for anxiety may increase risk for eating pathology and help to explain the high rates of anxiety-eating disorder comorbidity (Bellodi et al., 2001; Halmi et al., 1991; Lilenfeld et al, 1998; Strober et al., 2007). Goddard and Treasure (2013) present data suggesting that trait anxiety may be an intermediate phenotype of eating disorders, particularly anorexia nervosa (AN), which comprised the majority of eating disorder diagnoses in their sample. Taborelli and collagues (2013) found that mothers’ anxiety levels while pregnant, as well as maternal overprotection, differentiated between their daughters with and without AN. Importantly, this study highlights that genetic and early environmental influences may be specific to particular eating disorder diagnoses, as these patterns did not emerge for women with bulimia nervosa (BN). Together, these two studies provide support for a potential shared genetic vulnerability for anxiety and AN. The remaining papers in this series explore specific cognitive vulnerability factors common to both anxiety and disordered eating. In one of two papers exploring the interplay among anxiety, eating pathology, and perfectionism, Egan and colleagues (2013) found that anxiety partially mediated the association between eating disorders and self-oriented perfectionism and suggested that treating perfectionism, a plausible transdiagnostic factor, may enhance treatment for both eating and anxiety disorders. In the other study, Menatti, Weeks, Levinson, & McGowan (2013) showed that maladaptive self-evaluative perfectionism, which has been related to core components of social anxiety disorder (Heimberg et al., 2010), mediated the relation between bulimic symptoms and fear of public scrutiny and social interaction anxiety, two important components of social anxiety disorder, over and above distorted body-related thoughts. Related to these two studies, DeBoer and colleagues (2013) examined the role of fear of negative evaluation in the progression of college sorority women’s eating disorder risk factors over time. In this study, fear of negative evaluation predicted subsequent body dissatisfaction and eating disorder symptoms. Thin-ideal internalization was also predicted by prior levels of fear of negative evaluation, but only among women with BMIs that were relatively high (although still within the normal range) for their peer group. Fear of negative evaluation was itself predicted by prior levels of the majority of risk factors included in the dual-pathway etiological model of BN (Stice & Agras, 1998). This study represents an initial attempt at establishing temporal precedence in anxiety and eating symptom amelioration in response to intervention. Two papers in this series highlight specific dimensions of anxiety sensitivity, a risk factor for anxiety- and panic-related disorders more broadly, in eating pathology. Using both cross-sectional and experimental data, Hearon and colleagues (2013) found that anxiety sensitivity was positively associated with self-reports of emotional eating, coping motives for eating, and expectancies that eating leads to loss of control. They also found that body mass index (BMI) interacted with fear of loss of mental control (a sub-dimension of anxiety sensitivity) and the belief that eating leads to feeling out of control to predict overeating. Although anxiety sensitivity appears to be a risk factor for eating pathology (Anestis et al., 2008; DeBoer et al., 2012), and both eating disorders and anxiety sensitivity are risk factors for suicidality (Capron et al., 2012a, b), elevated sensitivity to somatic anxiety symptoms may actually protect women with elevated ED symptomology against suicidality, as less aversion to physical pain is associated with acquired capability for suicide (Fink et al., 2013). These two studies represent an important direction for anxiety-eating disorder comorbidity research in their efforts to tease apart the relative risk conferred by specific sub-components of anxiety vulnerability constructs. Bardone-Cone and colleagues’ (2013) contribution to this issue suggests that anxiety’s associations with various facets of eating pathology may be strongest among women who tend to derive their self-worth from their physical appearance. Their results also suggest that the extent to which one’s social group values physical appearance, as reflected by the frequency of appearance-focused conversations, independently moderates the association between anxiety and binge eating. Such personal and cultural emphases on appearance and thinness may be particularly common in certain Western subcultures. As noted by DeBoer and colleagues (2013), associations among anxiety and eating disorder symptoms may be stronger among women with high BMIs relative to their peer group (even if in a healthy range) if they have low self-esteem and are also embedded in an environment that emphasizes physical appearance (Cashel, Cunningham, Landeros, Cokley, & Muhammad, 2003). The findings from these six manuscripts suggest that perfectionism, fear of negative evaluation, anxiety sensitivity, and appearance-related self-worth may be worthwhile targets for eating disorder prevention and intervention. Additionally, it appears that the influence of some anxiety variables (i.e., fear of negative evaluation and anxiety sensitivity) and may be more pronounced for women with relatively high BMIs. We hope that this issue will: (1) inform readers of the theoretical importance and clinical significance of this area of research; (2) highlight the various constructs currently thought to be most pertinent to the anxiety-eating disorder relation; and (3) identify promising directions for future investigation. As demonstrated by the eight contributions to this issue, our understanding of the nature of anxiety-eating disorder comorbidity has grown remarkably since 1950. As such high-quality empirical work continues to accumulate, the field will become better able to quickly identify at-risk individuals and to enhance interventions for both anxiety and eating disorders.

Distributed and condensed versions of a cognitive dissonance programme: comparative effects on eating disorder risk factors and symptoms

Research regarding different learning schedules is equivocal. Learning theory suggests that distributed learning may better facilitate long-term maintenance of behaviour change [Bouton, M. (2000). A learning theory perspective on lapse, relapse, and the maintenance of behavior change. Health Psychology: Special Issue: Maintenance of Behavior Change in Cardiorespiratory Risk Reduction, 19, 57–63]. Alternatively, some research suggests that massed-intensive content delivery can be as beneficial as distributed delivery [e.g. Rogojanski, J., & Rego, S. A. (2013). Advances and controversies in the application of a modified version of cognitive behavior therapy for social anxiety disorder. Pragmatic Case Studies in Psychotherapy, 9(3), 337–346]. The present study compared two versions of a cognitive dissonance (CD)-based eating disorders (EDs) prevention programme. CD interventions target ED risk factors via an interactive format with content spread over multiple sessions, and have demonstrated both efficacy and effectiveness across numerous trials. We randomised female undergraduates (N = 73) to either four 1-hour sessions over four weeks (4SV), or two 2-hour sessions over two weeks (2SV). The versions were identical in content and total intervention time. Results indicated that both conditions showed similar rates of improvement in ED risk factors and symptoms through a 12-month follow-up, with the exception of thin-ideal internalisation, where results suggested a possible advantage of the 4SV for long-term, but not short-term, gain. Therefore, findings suggest that entities implementing CD are able to select the format that best fits their needs without significantly compromising the positive impact of the programme. Implications regarding the dissemination benefits of a flexible programme format that maintains effectiveness are discussed.