Shari A. Steinman

Automaticity in anxiety disorders and major depressive disorder

In this paper we examine the nature of automatic cognitive processing in anxiety disorders and Major Depressive Disorder (MDD). Rather than viewing automaticity as a unitary construct, we follow a social cognition perspective (Bargh, 1994) that argues for four theoretically independent features of automaticity: unconscious (processing of emotional stimuli occurs outside awareness), efficient (processing emotional meaning uses minimal attentional resources), unintentional (no goal is needed to engage in processing emotional meaning), and uncontrollable (limited ability to avoid, alter or terminate processing emotional stimuli). Our review of the literature suggests that most anxiety disorders are characterized by uncontrollable, and likely also unconscious and unintentional, biased processing of threat-relevant information. In contrast, MDD is most clearly typified by uncontrollable, but not unconscious or unintentional, processing of negative information. For the anxiety disorders and for MDD, there is no sufficient evidence to draw firm conclusions about efficiency of processing, though early indications are that neither anxiety disorders nor MDD are characterized by this feature. Clinical and theoretical implications of these findings are discussed and directions for future research are offered. In particular, it is clear that paradigms that more directly delineate the different features of automaticity are required to gain a more comprehensive and systematic understanding of the importance of automatic processing in emotion dysregulation.

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.

Anxiety-linked expectancy bias across the adult lifespan

Anxiety is characterised by a negative expectancy bias, such that anxious individuals report negatively distorted expectations about the future. Contrary to anxiety, ageing is characterised by a positivity effect, such that ageing is associated with a tendency to attend to and remember positive information, relative to negative information. The current study integrates these literatures to examine anxiety- and age-linked biases when thinking about the future. Participants (N=1,109) completed a procedure that involved reading valenced scenarios (positive, negative, or ambiguous) and then rating the likelihood of future valenced events occurring. Results suggest that ageing and anxiety have independent and opposing effects. Heightened anxiety was associated with a reduced expectancy for positive events, regardless of the scenarios’ current emotional valence, whereas increased age was associated with an inflated expectancy for positive events, which was strongest when individuals were processing socially relevant or negative scenarios.

Reaching new heights: comparing interpretation bias modification to exposure therapy for extreme height fear.

OBJECTIVE Cognitive models of anxiety disorders posit that biases in interpretation maintain, and potentially cause, anxiety. This study tested whether it is possible to decrease height fear symptoms through cognitive bias modification for interpretations (CBM-I). Additionally, the clinical utility of CBM-I was tested by comparing it to an already established treatment: exposure therapy. METHOD Extremely height fearful individuals (N = 110) participated in the study. Acrophobic symptoms were measured before and after 2 sessions of CBM-I and were compared to the standard treatment for acrophobia (exposure therapy), a combination of CBM-I and exposure therapy, and a Control condition. RESULTS In line with hypotheses, participants in the 3 active conditions showed greater response to treatment than the Control condition in height-relevant interpretation bias, symptoms, and behavioral avoidance on a height stressor, with few differences between the active conditions. Further, symptom change was mediated by change in interpretation bias. CONCLUSIONS Overall, findings suggest that different pathways to fear reduction (exposure vs. shifting interpretations) can lead to similar reductions in height fear. This study provides the first evidence that directly shifting cognitive processing, even with no therapist involvement, can reduce symptoms as effectively as the gold standard, therapist-directed exposure therapy.

Cognitive processing and acrophobia: validating the Heights Interpretation Questionnaire.

Three studies were conducted to examine the psychometric properties of a new scale: the Heights Interpretation Questionnaire (HIQ). This scale was designed to measure height fear-relevant interpretation bias to help assess the relationship between biased interpretations and acrophobia symptoms. Studies 1 (N=553) and 2 (N=308) established the scales factor structure and convergent and discriminant validity among two large undergraduate samples. Study 3 (N=48) evaluated the predictive validity of the HIQ by examining how well the scale predicted subjective distress and avoidance on actual heights. Factor analysis resulted in four distinct factors, and results suggest that each of the factors, along with the full HIQ, have good reliability and validity. Additionally, the scale predicts subjective distress and avoidance on heights beyond self-reported acrophobia symptoms. Overall, the HIQ shows promise as a new tool to investigate cognitive processing biases in acrophobia.

Expectancy bias in anxious samples.

Although it is well documented that anxious individuals have negative expectations about the future, it is unclear what cognitive processes give rise to this expectancy bias. Two studies are reported that use the Expectancy Task, which is designed to assess expectancy bias and illuminate its basis. This task presents individuals with valenced scenarios (Positive Valence, Negative Valence, or Conflicting Valence), and then evaluates their tendency to expect subsequent future positive relative to negative events. The Expectancy Task was used with low and high trait anxious (Study 1: n = 32) and anxiety sensitive (Study 2: n = 138) individuals. Results suggest that in the context of physical concerns, both high anxious samples display a less positive expectancy bias. In the context of social concerns, high trait anxious individuals display a negative expectancy bias only when negatively valenced information was previously presented. Overall, this suggests that anxious individuals display a less positive expectancy bias, and that the processes that give rise to this bias may vary by type of situation (e.g., social or physical) or anxiety difficulty.

Suicide and self-injury-related implicit cognition: A large-scale examination and replication.

Suicide and self-injury are difficult to predict because at-risk individuals are often unable or unwilling to report their intentions. Therefore, tools to reliably assess risk without reliance on self-report are critically needed. Prior research suggests that people who engage in suicidal and nonsuicidal self-injury (NSSI) often implicitly (i.e., outside conscious control) associate themselves with self-harm and death, indicating that self-harm-related implicit cognition may serve as a useful behavioral marker for suicide risk. However, earlier studies left several critical questions about the robustness, sensitivity, and specificity of self-harm-related implicit associations unaddressed. We recruited a large sample of participants (N = 7,015) via a public web-based platform called Project Implicit Mental Health (PIMH) to test several hypotheses about self-harm-related implicit associations using the Implicit Association Test (IAT). Participants were randomly assigned to complete 1 of 3 self-harm IATs (Self + Cutting using picture stimuli, Self + Suicide using word stimuli, Self + Death using word stimuli). Results replicated prior studies demonstrating that self-harm-related implicit associations were stronger among individuals with (vs. without) a history of suicide attempt and NSSI. Results also suggested that self-harm-related implicit associations are robust (based on internal replication), are sensitive to recency and severity of self-harm history (e.g., stronger associations for more recent and more lethal prior suicide attempts), and correlate with specific types of self-harm behaviors. These findings clarify the nature of self-harm-related implicit cognition and highlight the IAT’s potential to track current risk for specific types of self-harm in ways that more fixed risk factors cannot.

Do patterns of change during treatment for panic disorder predict future panic symptoms

BACKGROUND AND OBJECTIVES Cognitive-behavioral therapies are currently the gold standard for panic disorder treatment, with well-documented treatment response. However, following interventions, some individuals continue to improve, while others experience a return of symptoms. The field lacks reliable ways to predict follow-up symptomatology. In the current study, a cluster analysis with a repeated measures design was conducted to examine change patterns over 12 weeks of cognitive behavioral group therapy for panic disorder. The central aim of the study was to evaluate if change patterns predict level of panic symptom severity at a six month follow-up in this sample. METHODS Individuals with panic disorder (N = 36) completed a measure of panic symptoms (Panic Disorder Severity Scale) at the outset of every therapy session and at a six month follow-up. RESULTS Results revealed three patterns of change in this specific trial, which significantly predicted level of panic symptoms six months post-treatment, beyond initial or final level of panic symptoms, and beyond total symptom change. LIMITATIONS Given the relatively small, lab-based sample, replications in other settings and samples will be important. CONCLUSIONS Overall, results provide initial evidence that change patterns are meaningful predictors of panic symptom severity well after the final session of treatment.

Prepulse inhibition deficits only in females with obsessive-compulsive disorder

Deficits in sensorimotor gating have been hypothesized to underlie the inability to inhibit repetitive thoughts and behaviors. To test this hypothesis, this study assessed prepulse inhibition (PPI), a measure of sensorimotor gating, across three psychiatric disorders (obsessive–compulsive disorder [OCD], social anxiety disorder [SAD], and anorexia nervosa [AN]) whose clinical presentations include repetitive thoughts and behaviors

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.