Sarah A. Hayes-Skelton

A Randomized Clinical Trial Comparing an Acceptance Based Behavior Therapy to Applied Relaxation for Generalized Anxiety Disorder

OBJECTIVE To examine whether an empirically and theoretically derived treatment combining mindfulness- and acceptance-based strategies with behavioral approaches would improve outcomes in generalized anxiety disorder (GAD) over an empirically supported treatment. METHOD This trial randomized 81 individuals (65.4% female, 80.2% identified as White, average age 32.92) diagnosed with GAD to receive 16 sessions of either an acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Assessments at pretreatment, posttreatment, and 6-month follow-up included the following primary outcome measures: GAD clinician severity rating, Structured Interview Guide for the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Depression Anxiety Stress Scale, and the State-Trait Anxiety Inventory. Secondary outcomes included the Beck Depression Inventory-II, Quality of Life Inventory, and number of comorbid diagnoses. RESULTS Mixed effect regression models showed significant, large effects for time for all primary outcome measures (ds = 1.27 to 1.61) but nonsignificant, small effects for condition and Condition × Time (ds = 0.002 to 0.20), indicating that clients in the 2 treatments improved comparably over treatment. For secondary outcomes, time was significant (ds = 0.74 to 1.38), but condition and Condition × Time effects were not (ds = 0.004 to 0.31). No significant differences emerged over follow-up (ds = 0.03 to 0.39), indicating maintenance of gains. Between 63.3 and 80.0% of clients in ABBT and 60.6 and 78.8% of clients in AR experienced clinically significant change across 5 calculations of change at posttreatment and follow-up. CONCLUSION ABBT is a viable alternative for treating GAD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Development and initial psychometric properties of the Computer Assisted Maltreatment Inventory (CAMI): A comprehensive self-report measure of child maltreatment history

OBJECTIVES The present study reports on the development and initial psychometric properties of the Computer Assisted Maltreatment Inventory (CAMI), a web-based self-report measure of child maltreatment history, including sexual and physical abuse, exposure to interparental violence, psychological abuse, and neglect. METHODS The CAMI was administered to a geographically diverse sample of college students (N=1398). For validation purposes, participants also completed a widely used measure of maltreatment (Childhood Trauma Questionnaire) as well as measures of social desirability. To examine test-retest reliability, a subset of participants (n=283) completed the CAMI a second time 2-4 weeks after the initial administration. RESULTS Short-term test-retest reliability of the CAMI subscales was good to strong, as was internal consistency on applicable scales. Criterion-related validity of the CAMIs composite abuse severity scores was supported through predicted discriminative correlations with subscales of the CTQ. The CAMI subscales showed comparable or weaker associations with measures of social desirability than did the CTQ. Although both measures were more strongly associated with a need for approval than other aspects of social desirability, these correlations were still rather low in magnitude and in a range typical of many clinical measures. CONCLUSIONS The present findings as well as the rich descriptive data and flexibility offered by computer administration suggest that the CAMI is a promising instrument for the comprehensive assessment of maltreatment history from adults.

Decentering as a common link among mindfulness, cognitive reappraisal, and social anxiety.

BACKGROUND The tendency to employ both cognitive reappraisal and mindfulness are associated with reduced trait social anxiety; however, it is unclear whether reappraisal and mindfulness are associated with social anxiety through the same mechanisms. It has been proposed that decentering, or the process of seeing thoughts or feelings as objective events in the mind rather than personally identifying with them, may be a key mechanism underlying both cognitive reappraisal and mindfulness. AIMS To examine the relationships between reappraisal, mindfulness, decentering, and social anxiety. METHOD This study utilized structural equation modeling to examine the relationships among cognitive reappraisal, mindfulness, decentering, and social anxiety in a large cross-sectional study. RESULTS Results indicate that the relationship between mindfulness and social anxiety is partially accounted for by decentering, whereas the relationship between cognitive reappraisal and social anxiety is more fully accounted for by decentering. CONCLUSIONS These results imply that decentering may be a common mechanism underlying both cognitive reappraisal and mindfulness, although mindfulness may also affect social anxiety through additional mechanisms. However, given the cross-sectional nature of these findings, results should be considered preliminary, with future research being needed to further elucidate these relationships.

What happens in session does not stay in session: changes within exposures predict subsequent improvement and dropout.

Previous exposure therapy research has suggested potential differences in emotional processing at different points in treatment (Hayes, Hope, & Heimberg, 2008). For example, indicators of emotional processing may be more related to outcome during the later exposure sessions than during the initial session. This is consistent with a growing body of psychotherapy research highlighting the importance of timing and change processes across therapy. The current study examined whether the learning-but-not-benefiting hypothesis is observed in a group based intervention for clients with a range of anxiety disorders. It was hypothesized that activation and within session habituation during later, but not the initial exposure session, would be related to outcome, whereas activation and within session habituation during the first session would be related to dropout status. Results revealed that lower activation and less habituation during the first exposure was associated with increased treatment discontinuation. Second, lower peak and, to a lesser extent greater activation and habituation, during exposures were generally associated with better treatment outcomes. These findings highlight the importance of examining the complexities and timing of the exposure process.

Decentering as a Potential Common Mechanism across Two Therapies for Generalized Anxiety Disorder

OBJECTIVE The purpose of this study was to examine decentering as a potential mechanism of action across 2 treatments for generalized anxiety disorder: an acceptance-based behavioral therapy (ABBT) and applied relaxation (AR). METHOD Sixty-four individuals who completed at least half of the 16 total sessions of either ABBT or AR (65.6% female; 79.7% identified as White; average age = 34.41 years) completed measures of decentering (Experiences Questionnaire) and of symptoms of anxiety (Depression Anxiety Stress Scale-Stress subscale) at 5 time points over the course of therapy, and a measure of worry (Penn State Worry Questionnaire) at pre- and posttreatment. RESULTS Initial growth curve models showed that decentering increased significantly over therapy (z = 7.09), and this increase was associated with a decrease in worry symptoms (Penn State Worry Questionnaire) at posttreatment (z = -8.51). The rate of change did not significantly vary across treatments, Δχ2/Δdf = 0.16/1, p = .69. Further, a series of bivariate latent difference score models indicated that the best-fitting model was one in which decentering was a leading indicator of change in symptoms (DASS-Stress). Allowing this coupling to vary across treatments did not significantly improve the fit of the model, Δχ2/Δdf = 0.71/1, p = .40. CONCLUSIONS In this sample, results suggest that increased decentering was associated with decreases in anxiety and that changes in decentering appear to precede changes in symptoms within both ABBT and AR, indicating that decentering may be an important common mechanism of action. (PsycINFO Database Record

A contemporary view of applied relaxation for generalized anxiety disorder.

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.

Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder

Objective: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. Method: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. Results: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. Conclusions: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.

Surviving and Thriving During Stress: A Randomized Clinical Trial Comparing a Brief Web-Based Therapist-Assisted Acceptance-Based Behavioral Intervention Versus Waitlist Control for College Students

The high rates of anxiety in college students and the many barriers to accessing evidence-based care in communities and on campuses indicate a clear need to explore ways to increase access to evidence-based treatments. Web-based interventions and preventions are one way to bridge this gap; they hold the potential to decrease mental health disparities and enhance student functioning. The current RCT examined the acceptability and efficacy of a 3-session web-based therapist-assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress) for college students versus a waitlist (WL) control condition, in a sample of racially and ethnically diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-effects regression models (MRMs) were run in SPSS to examine the effects of time, condition, and Condition × Time on outcomes and hypothesized mechanisms. Significant Condition × Time interactions for general anxiety, depression, and quality of life (QOL) emerged, suggesting that SATDS participants reported significantly greater changes on these outcomes from pre- to posttreatment versus WL. However, interaction effects were nonsignificant for anxious arousal and social anxiety. MRMs examining hypothesized mechanisms revealed significant Condition × Time interactions for experiential avoidance, decentering, and values-based living. However, interaction effects were nonsignificant for mindfulness. All significant gains were maintained at 1-month follow-up, with the exception of QOL. Results contribute to the growing literature on the acceptability and efficacy of web-based approaches, and suggest these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care.

What's in a Face? How Face Gender and Current Affect Influence Perceived Emotion

Faces drive our social interactions. A vast literature suggests an interaction between gender and emotional face perception, with studies using different methodologies demonstrating that the gender of a face can affect how emotions are processed. However, how different is our perception of affective male and female faces? Furthermore, how does our current affective state when viewing faces influence our perceptual biases? We presented participants with a series of faces morphed along an emotional continuum from happy to angry. Participants judged each face morph as either happy or angry. We determined each participant’s unique emotional ‘neutral’ point, defined as the face morph judged to be perceived equally happy and angry, separately for male and female faces. We also assessed how current state affect influenced these perceptual neutral points. Our results indicate that, for both male and female participants, the emotional neutral point for male faces is perceptually biased to be happier than for female faces. This bias suggests that more happiness is required to perceive a male face as emotionally neutral, i.e., we are biased to perceive a male face as more negative. Interestingly, we also find that perceptual biases in perceiving female faces are correlated with current mood, such that positive state affect correlates with perceiving female faces as happier, while we find no significant correlation between negative state affect and the perception of facial emotion. Furthermore, we find reaction time biases, with slower responses for angry male faces compared to angry female faces.

Changes in Decentering Across Cognitive Behavioral Group Therapy for Social Anxiety Disorder

To further improve treatments, we need to better understand potential common treatment mechanisms, such as decentering, or the ability to observe thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990). Therefore, this study examined whether 12 sessions of Cognitive Behavioral Group Therapy (CBGT) for 63 clients (57.6% female, 50.8% White) diagnosed with social anxiety disorder led to increases in decentering and whether increased decentering was associated with improved outcome. Furthermore, this study examined whether decentering was associated with outcome over and above a competing mechanism-cognitive reappraisal. Overall, results indicated that CBGT in this study led to similar outcomes compared to previous studies and decentering increased over CBGT (ds from 0.81 to 2.23). Change in decentering predicted improvement on most, but not all, measures of outcome and those who no longer met criteria for social anxiety disorder at posttreatment had significantly greater change in decentering across therapy and significantly higher decentering scores at post-treatment compared to those who retained a social anxiety disorder diagnosis at posttreatment. Finally, changes in decentering predicted outcome over and above changes in reappraisal on all outcome measures. These results largely support the role of decentering in CBGT for social anxiety; however, the implications of the inconsistencies in results based on which outcome measure was used are discussed.