Richard T. LeBeau

Homework Compliance Counts in Cognitive-Behavioral Therapy

Background: Prior research has demonstrated that there is some association between treatment engagement and treatment outcome in behavioral therapy for anxiety disorders. However, many of these investigations have been limited by weak measurement of treatment engagement variables, failure to control for potentially important baseline variables, and failure to consider various treatment engagement variables simultaneously. The purpose of the present study is to examine the relationship between two treatment engagement variables (treatment expectancy and homework compliance) and the extent to which they predict improvement from cognitive-behavioral therapy (CBT) for anxiety disorders. Methods: 84 adults with a DSM-IV-defined principal anxiety disorder took part in up to 12 sessions of CBT or acceptance and commitment therapy. Pre- and post-treatment disorder severity was assessed using clinical severity ratings from a semi-structured diagnostic interview. Participants made ratings of treatment expectancy after the first session. Homework compliance was assessed each session by the treating clinician. Results: Contrary to hypotheses, treatment expectancy and homework compliance were poorly correlated. Regression analyses revealed that homework compliance, but not treatment expectancy, predicted a significant portion of the variance in treatment outcome (10%). Conclusions: The present research suggests that although treatment expectation and homework compliance likely represent unique constructs of treatment engagement, homework compliance may be the more important treatment engagement variable for outcomes. The present research suggests that improvement of homework compliance has the potential to be a highly practical and effective way to improve clinical outcomes in CBT targeting anxiety disorders.

PSYCHOMETRIC PROPERTIES OF THE DIMENSIONAL ANXIETY SCALES FOR DSM‐V IN AN UNSELECTED SAMPLE OF GERMAN TREATMENT SEEKING PATIENTS

Dimensional assessments are planned to be included as supplements to categorical diagnoses in DSM‐V. The aim of this study was to examine the unidimensionality, reliability, validity, and clinical sensitivity of brief self‐rated scales for specific anxiety disorders in an unselected German sample of consecutive attendees to a psychological clinic. These scales use a common template to assess core constructs of fear and anxiety.

Dimensional anxiety scales for DSM-5: Sensitivity to clinical severity

PURPOSE Psychometric properties and clinical sensitivity of brief self-rated dimensional scales to supplement categorical diagnoses of anxiety disorders in the DSM-5 were recently demonstrated in a German treatment seeking sample of adults. The present study aims to demonstrate sensitivity of these scales to clinical severity levels. METHODS The dimensional scales were administered to 102 adults at a university outpatient clinic for psychotherapy. Diagnostic status was assessed using the Munich-Composite International Diagnostic Interview. To establish a wide range of clinical severity, we considered subthreshold (n=83) and threshold anxiety disorders (n=49, including Social Phobia, Specific Phobia, Agoraphobia, Panic Disorder, and Generalized Anxiety Disorder). RESULTS Individuals with either subthreshold or threshold anxiety disorder scored higher on all dimensional scales relative to individuals without anxiety. In addition, individuals with a threshold anxiety disorder scored higher on the dimensional scales than individuals with a subthreshold anxiety disorder (except for specific phobia). Disorder-related impairment ratings, global functioning assessments and number of panic attacks were associated with higher scores on dimensional scales. Findings were largely unaffected by the number of anxiety disorders and comorbid depressive disorders. CONCLUSION The self-rated dimensional anxiety scales demonstrated sensitivity to clinical severity, and a cut-off based on additional assessment of impairment and distress may assist in the discrimination between subthreshold and threshold anxiety disorders. Findings suggest further research in various populations to test the utility of the scales for use in DSM-5.

Test–retest reliability and sensitivity to change of the dimensional anxiety scales for DSM-5

OBJECTIVE This article reports on the test-retest reliability and sensitivity to change of a set of brief dimensional self-rating questionnaires for social anxiety disorder (SAD-D), specific phobia (SP-D), agoraphobia (AG-D), panic disorder (PD-D), and generalized anxiety disorder (GAD-D), as well as a general cross-cutting anxiety scale (Cross-D), which were developed to supplement categorical diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). METHODS The German versions of the dimensional anxiety scales were administered to 218 students followed up approximately 2 weeks later (Study 1) and 55 outpatients (23 with anxiety diagnoses) followed-up 1 year later (Study 2). Probable diagnostic status in students was determined by the DIA-X/M-CIDI stem screening-questionnaire (SSQ). In the clinical sample, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses were assessed at Time 1 using the DIA-X/M-CIDI. At Time 2, the patient-version of the Clinical Global Impression-Improvement scale (CGI-I) was applied to assess change. RESULTS Good psychometric properties, including high test-retest reliability, were found for the dimensional scales except for SP-D. In outpatients, improvement at Time 2 was associated with significant decrease in PD-D, GAD-D, and Cross-D scores. Discussion Major advantages of the scales include that they are brief, concise, and based on a consistent template to measure the cognitive, physiological, and behavioral symptoms of fear and anxiety. Further replication in larger samples is needed. Given its modest psychometric properties, SP-D needs refinement. CONCLUSION Increasing evidence from diverse samples suggests clinical utility of the dimensional anxiety scales.

Dimensional assessment of posttraumatic stress disorder in DSM-5

The present paper describes the development of the National Stressful Events Survey for PTSD-Short Scale (NSESSS-PTSD), a new self-report scale for PTSD that is brief (9 items), free of copyright restrictions, and consistent with DSM-5 diagnostic criteria. Study 1 describes the development of the NSESSS-PTSD scale items, which were reduced from a larger pool of items that were administered to a subsample of individuals with probable DSM-5 PTSD diagnoses from a large national sample. The resultant scale included items from each criterion and demonstrated high internal consistency. Study 2 evaluates the psychometric properties of the NSESSS-PTSD in a trauma-exposed non-clinical sample. Strong psychometric properties were observed in the sample, including convergent validity (through comparison to the DSM-IV Posttraumatic Stress Disorder Checklist), internal consistency, and the presence of a single dominant factor. Limitations of the present studies are discussed and specific recommendations for the next steps in the validation process are provided.

Associative learning versus fear habituation as predictors of long-term extinction retention

ABSTRACT Violation of unconditioned stimulus (US) expectancy during extinction training may enhance associative learning and result in improved long-term extinction retention compared to within-session habituation. This experiment examines variation in US expectancy (i.e., expectancy violation) as a predictor of long-term extinction retention. It also examines within-session habituation of fear-potentiated startle (electromyography, EMG) and fear of conditioned stimuli (CS) throughout extinction training as predictors of extinction retention. Participants (n = 63) underwent fear conditioning, extinction and retention and provided continuous ratings of US expectancy and EMG, as well as CS fear ratings before and after each phase. Variation in US expectancy throughout extinction and habituation of EMG and fear was entered into a regression as predictors of retention and reinstatement of levels of expectancy and fear. Greater variation in US expectancy throughout extinction training was significantly predictive of enhanced extinction performance measured at retention test, although not after reinstatement test. Slope of EMG and CS fear during extinction did not predict retention of extinction. Within-session habituation of EMG and self-reported fear is not sufficient for long-term retention of extinction learning, and models emphasizing expectation violation may result in enhanced outcomes.

Dimensional indicators of generalized anxiety disorder severity for DSM-V.

For DSM-V, simple dimensional measures of disorder severity will accompany diagnostic criteria. The current studies examine convergent validity and test-retest reliability of two potential dimensional indicators of worry severity for generalized anxiety disorder (GAD): percent of the day worried and number of worry domains. In study 1, archival data from diagnostic interviews from a community sample of individuals diagnosed with one or more anxiety disorders (n = 233) were used to assess correlations between percent of the day worried and number of worry domains with other measures of worry severity (clinical severity rating (CSR), age of onset, number of comorbid disorders, Penn state worry questionnaire (PSWQ)) and DSM-IV criteria (excessiveness, uncontrollability and number of physical symptoms). Both measures were significantly correlated with CSR and number of comorbid disorders, and with all three DSM-IV criteria. In study 2, test-retest reliability of percent of the day worried and number of worry domains were compared to test-retest reliability of DSM-IV diagnostic criteria in a non-clinical sample of undergraduate students (n = 97) at a large west coast university. All measures had low test-retest reliability except percent of the day worried, which had moderate test-retest reliability. Findings suggest that these two indicators capture worry severity, and percent of the day worried may be the most reliable existing indicator. These measures may be useful as dimensional measures for DSM-V.

Experimental Psychopathology and Clinical Psychology: An Integrative Model to Guide Clinical Science and Practice

Experimental psychopathology has elucidated mechanisms underlying various forms of psychopathology and has contributed to the continuous updating and generation of mechanistically-focused and evidence-based psychological treatments. Clinical psychology is an applied field of psychology concerned with the assessment and treatment of psychological disorders and behavioral problems. Despite the notable commonality in their focus upon psychological dysfunction, conceptual frameworks that guide their integration are surprisingly scarce. Clinical science and practice would benefit greatly from the combined strengths of each discipline. In this review, we begin by defining experimental psychopathology and clinical psychology, we present arguments for greater integration between them, and we propose a model to guide the integration of experimental psychopathology-informed science into clinical practice, illustrating the relevance of the model by drawing upon the seminal research on fear conditioning and extinction and other experimental paradigms.

Sensing emotion in voices: Negativity bias and gender differences in a validation study of the Oxford Vocal ('OxVoc') sounds database.

Emotional expressions are an essential element of human interactions. Recent work has increasingly recognized that emotional vocalizations can color and shape interactions between individuals. Here we present data on the psychometric properties of a recently developed database of authentic nonlinguistic emotional vocalizations from human adults and infants (the Oxford Vocal ‘OxVoc’ Sounds Database; Parsons, Young, Craske, Stein, & Kringelbach, 2014). In a large sample (n = 562), we demonstrate that adults can reliably categorize these sounds (as ‘positive,’ ‘negative,’ or ‘sounds with no emotion’), and rate valence in these sounds consistently over time. In an extended sample (n = 945, including the initial n = 562), we also investigated a number of individual difference factors in relation to valence ratings of these vocalizations. Results demonstrated small but significant effects of (a) symptoms of depression and anxiety with more negative ratings of adult neutral vocalizations (R2 = .011 and R2 = .008, respectively) and (b) gender differences in perceived valence such that female listeners rated adult neutral vocalizations more positively and infant cry vocalizations more negatively than male listeners (R2 = .021, R2 = .010, respectively). Of note, we did not find evidence of negativity bias among other affective vocalizations or gender differences in perceived valence of adult laughter, adult cries, infant laughter, or infant neutral vocalizations. Together, these findings largely converge with factors previously shown to impact processing of emotional facial expressions, suggesting a modality-independent impact of depression, anxiety, and listener gender, particularly among vocalizations with more ambiguous valence.

Public speaking avoidance as a treatment moderator for social anxiety disorder.

BACKGROUND AND OBJECTIVES Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient. METHODS Forty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life. RESULTS Public speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure. LIMITATIONS Results were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward. CONCLUSIONS Findings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance.