Examining the incremental contribution of behavioral inhibition to generalized anxiety disorder relative to other Axis I disorders and cognitive-emotional vulnerabilities

Underlying differences in resting-state activity metrics related to sensitivity to punishment

Reinforcement sensitivity theory (RST) of personality establishes the punishment sensitivity trait as a source of variation in defensive avoidance/approach behaviors. These individual differences reflect dissimilar sensitivity and reactivity of the fight-flight-freeze and behavioral inhibition systems (FFFS/BIS). The sensitivity to punishment (SP) scale has been widely used in personality research aimed at studying the activity of these systems. Structural and functional neuroimaging studies have confirmed the core biological correlates of FFFS/BIS in humans. Nonetheless, some brain functional features derived from resting-state blood-oxygen level-dependent (BOLD) activity and its association with the punishment sensitivity dimension remain unclear. This relationship would shed light on stable neural activity patterns linked to anxiety-like behaviors and anxiety predisposition. In this study, we analyzed functional activity metrics "at rest" [e.g., regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuation (fALFF)] and their relationship with SP in key FFFS/BIS regions (e.g., amygdala, hippocampus, and periaqueductal gray) in a sample of 127 healthy adults. Our results revealed a significant negative correlation between the fALFF within all these regions and the scores on SP. Our findings suggest aberrant neural activity (lower fALFF) within the brain's defense system in participants with high trait anxiety, which in turn could reflect lower FFFS/BIS activation thresholds. These neurally-located differences could lead to pathological fear/anxiety behaviors arising from the FFFS and BIS.

Toward Linguistic Recognition of Generalized Anxiety Disorder

Background

Generalized anxiety disorder (GAD) refers to extreme, uncontrollable, and persistent worry and anxiety. The disorder is known to affect the social functioning and well-being of millions of people, but despite its prevalence and burden to society, it has proven difficult to identify unique behavioral markers. Interestingly, the worrying behavior observed in GAD is argued to stem from a verbal linguistic process. Therefore, the aim of the present study was to investigate if GAD can be predicted from the language people use to put their anxious worries into words. Given the importance of avoidance sensitivity (a higher likelihood to respond anxiously to novel or unexpected triggers) in GAD, this study also explored if prediction accuracy increases when individual differences in behavioral avoidance and approach sensitivity are taken into account.

Method

An expressive writing exercise was used to explore whether GAD can be predicted from linguistic characteristics of written narratives. Specifically, 144 undergraduate student participants were asked to recall an anxious experience during their university life, and describe this experience in written form. Clinically validated behavioral measures for GAD and self-reported sensitivity in behavioral avoidance/inhibition (BIS) and behavioral approach (BAS), were collected. A set of classification experiments was performed to evaluate GAD predictability based on linguistic features, BIS/BAS scores, and a concatenation of the two.

Results

The classification results show that GAD can, indeed, be successfully predicted from anxiety-focused written narratives. Prediction accuracy increased when differences in BIS and BAS were included, which suggests that, under those conditions, negatively valenced emotion words and words relating to social processes could be sufficient for recognition of GAD.

Conclusions

Undergraduate students with a high GAD score can be identified based on their written recollection of an anxious experience during university life. This insight is an important first step toward development of text-based digital health applications and technologies aimed at remote screening for GAD. Future work should investigate the extent to which these results uniquely apply to university campus populations or generalize to other demographics.

Dialectical Thinking Is Linked With Smaller Left Nucleus Accumbens and Right Amygdala

Our current work examined the interface between thinking style and emotional experience at both the behavioral and neuropsychological levels. Thirty-nine Chinese participants completed the triad task, and we calculated the rate of individually selected relationship pairings to overall selections to represent their holistic thinking tendencies. In addition, participants in the top one-third of the ratio score were classified into the high holistic thinking group, while those in the bottom one-third of the ratio score were classified into the low holistic thinking group. We used the sensitivity to punishment and sensitivity to reward questionnaire (SPSRQ) to examine how people elicit positive and negative affective behaviors. Additionally, we examined the volume of the amygdala and nucleus accumbens and their functional connectivity in the resting-state. We found that high holistic thinkers were much less sensitive to rewards than low holistic thinkers. In other words, individuals with high holistic thinking are less likely to pursue behaviors that have positive emotional outcomes. Furthermore, their bilateral nucleus accumbens and right amygdala volumes were smaller than those of low holistic thinkers. Hierarchical regression analysis showed that holistic thinking tendency can negatively predict the volume of the left nucleus accumbens and right amygdala. Finally, resting-state functional connectivity results showed increased functional connectivity FC between left nucleus accumbens and bilateral amygdala in high holistic thinkers. These findings provide emotion-related manifestations of thinking styles at the behavioral and neural levels.

Understanding Pain Catastrophizing: Putting Pieces Together

The present narrative review addresses issues concerning the defining criteria and conceptual underpinnings of pain catastrophizing. To date, the concept of pain catastrophizing has been extensively used in many clinical and experimental contexts and it is considered as one of the most important psychological correlate of pain chronicity and disability. Although its extensive use, we are still facing important problems related to its defining criteria and conceptual understanding. At present, there is no general theoretical agreement of what catastrophizing really is. The lack of a consensus on its definition and conceptual issues has important consequences on the choice of the pain management approaches, defining and identifying problems, and promoting novel research. Clinical and research work in absence of a common theoretical ground is often trivial. It is very surprising that clinical and experimental work has grown extensively in the past years, without a common ground in the form of a clear definition of pain catastrophizing and overview of its conceptual basis. Improving the efficacy and efficiency of pan catastrophizing related treatments requires an understanding of the theoretical construct. So far, most interventions have only demonstrated modest effects in reducing pain catastrophizing. Therefore, clarifying the construct may be an important precursor for developing more targeted and effective interventions, thereby easing some of the burden related to this aspect of pain. In our review, we have extracted and de-constructed common elements that emerge from different theoretical models with the aim to understand the concept of catastrophizing, which components can be modulated by psychological interventions, and the general role in pain processing. The analysis of the literature has indicated essential key elements to explain pain catastrophizing: emotional regulation, catastrophic worry (as repetitive negative thinking), rumination, behavioral inhibition and behavioral activation (BIS/BAS) systems, and interoceptive sensitivity. The present paper attempts to integrate these key elements with the aim to re-compose and unify the concept within a modern biopsychosocial interpretation of catastrophizing.

Development of the Response to Fearful Situations Scale

BACKGROUND

Most measures of anxious avoidance are limited to disorder-specific mechanisms and ignore the measurement of courage/approach responding in confronting fearful situations.

AIMS

The purpose of the present study was to construct and validate a self-report assessment of the tendency towards avoidant or approach responding in fearful situations, the Response to Fearful Situations Scale (RFSS).

METHOD AND RESULTS

In Study 1 (n = 241), exploratory factor analysis resulted in two factors, avoidance and approach. Study 2 (n = 423) replicated the two-factor structure and established test-re-test reliability. In Study 3 (n = 44), the RFSS demonstrated predictive validity on a behavioural avoidance task. In Studies 4 (n = 253) and 5 (n = 256), the RFSS was associated with clinical symptoms above existing measures of avoidance.

DISCUSSION

These results validate the use of the RFSS as a transdiagnostic measure of avoidance and approach.

Reinforcement sensitivity, depression and anxiety: A meta-analysis and meta-analytic structural equation model

Reinforcement Sensitivity Theory (RST) posits that individual differences in reward and punishment processing predict differences in cognition, behavior, and psychopathology. We performed a quantitative review of the relationships between reinforcement sensitivity, depression and anxiety, in two separate sets of analyses. First, we reviewed 204 studies that reported either correlations between reinforcement sensitivity and self-reported symptom severity or differences in reinforcement sensitivity between diagnosed and healthy participants, yielding 483 effect sizes. Both depression (Hedges' g = .99) and anxiety (g = 1.21) were found to be high on punishment sensitivity. Reward sensitivity negatively predicted only depressive disorders (g = -.21). More severe clinical states (e.g., acute vs remission) predicted larger effect sizes for depression but not anxiety. Next, we reviewed an additional 39 studies that reported correlations between reinforcement sensitivity and both depression and anxiety, yielding 156 effect sizes. We then performed meta-analytic structural equation modeling to simultaneously estimate all covariances and control for comorbidity. Again we found punishment sensitivity to predict depression (β = .37) and anxiety (β = .35), with reward sensitivity only predicting depression (β = -.07). The transdiagnostic role of punishment sensitivity and the discriminatory role of reward sensitivity support a hierarchical approach to RST and psychopathology.

Investigating behavior inhibition in obsessive-compulsive disorder: Evidence from eye movements

We investigated the role of inhibition failure in Obsessive Compulsive Disorder (OCD) through an eye tracking experiment. Twenty-five subjects with OCD were recruited, as well as 25 with Generalized Anxiety Disorder (GAD) and 25 healthy controls. A 3 (group: OCD group, GAD group and control group) × 2 (target eccentricity: far and near) × 2 (saccade task: prosaccade and antisaccade) mixed design was used, with all participants completing two sets of tasks involving both prosaccade (eye movement towards a target) and antisaccade (eye movement away from a target). The main outcome was the eye movement index, including the saccade latency (the time interval from the onset of the target screen to the first saccade) and the error rate of saccade direction. The antisaccade latency and antisaccade error rates for OCDs were much higher than those for GADs and healthy controls. OCDs had longer latency and error rates for antisaccades than for prosaccades, and for far-eccentricity rather than near-eccentricity stimuli. These results suggest that OCDs experience difficulty with behavior inhibition, and that they have higher visual sensitivity to peripheral stimuli. In particular, they show greatest difficulty in inhibiting behavior directed towards peripheral stimuli.

Linking personality and brain anatomy: a structural MRI approach to Reinforcement Sensitivity Theory

Reinforcement Sensitivity Theory (RST) proposes a widely used taxonomy of human personality linked to individual differences at both behavioral and neuropsychological levels that describe a predisposition to psychopathology. However, the body of RST research was based on animal findings, and little is known about their anatomical correspondence in humans. Here we set out to investigate MRI structural correlates (i.e. voxel-based morphometry) of the main personality dimensions proposed by the RST in a group of 400 healthy young adults who completed the Sensitivity to Punishment and Sensitivity to Reward Questionnaire (SPSRQ). Sensitivity to punishment scores correlated positively with the gray matter volume in the amygdala, whereas sensitivity to reward scores correlated negatively with the volume in the left lateral and medial prefrontal cortex. Moreover, a negative relationship was found between the striatal volume and the reward sensitivity trait, but only for male participants. The present results support the neuropsychological basis of the RST by linking punishment and reward sensitivity to anatomical differences in limbic and frontostriatal regions, respectively. These results are interpreted based on previous literature related to externalizing and internalizing disorders, and they highlight the possible role of SPSRQ as a measure of proneness to these disorders.

Towards precision medicine in generalized anxiety disorder: Review of genetics and pharmaco(epi)genetics

Generalized anxiety disorder (GAD) is a prevalent and chronic mental disorder that elicits widespread functional impairment. Given the high degree of non-response/partial response among patients with GAD to available pharmacological treatments, there is a strong need for novel approaches that can optimize outcomes, and lead to medications that are safer and more effective. Although investigations have identified interesting targets predicting treatment response through pharmacogenetics (PGx), pharmaco-epigenetics, and neuroimaging methods, these studies are often solitary, not replicated, and carry several limitations. This review provides an overview of the current status of GAD genetics and PGx and presents potential strategies to improve treatment response by combining better phenotyping with PGx and improved analytical methods. These strategies carry the dual benefit of delivering data on biomarkers of treatment response as well as pointing to disease mechanisms through the biology of the markers associated with response. Overall, these efforts can serve to identify clinical, genetic, and epigenetic factors that can be incorporated into a pharmaco(epi)genetic test that may ultimately improve treatment response and reduce the socioeconomic burden of GAD.

Mediating Effect of Trait Emotional Intelligence Between the Behavioral Activation System (BAS)/Behavioral Inhibition System (BIS) and Positive and Negative Affect

Gray (1970, 1981, 1987) proposed a behavioral motivation theory (Reinforcement Sensitivity Theory, RST), which describes the Behavioral Activation/Approach System (BAS) and the Behavioral Inhibition System (BIS). Some studies relate higher activation of BAS to positive affect, whereas BIS activation is linked to negative affect, particularly to high levels of anxiety and depression. Research data suggests that greater Trait Emotional Intelligence (TEI) influences optimal development of well-being and psychological adjustment, such as positive affective states. However, a recent study relates the motivational BIS/BAS systems with TEI, showing that high TEI is characterized by sensitivity to reward (BAS), and low TEI due to activation of the BIS system. The aim of this study was to explore how TEI may mediate the relationship between BIS/BAS sensitivity and positive and negative affect. Four-hundred and sixty-seven undergraduate students (385 females) were evaluated. TEI was evaluated with the Trait Meta-Mood Scale (TMMS). Affective states were measured with the Positive (PA) and Negative Affect (NA) Schedule, and BIS/BAS sensitivity was measured with The Sensitivity to Punishment (SP) and Sensitivity to Reward (SR) Questionnaire. The results reveal the influence of the two motivational systems on affective states, and show how this relationship is modified by and better explained through TEI. That is, a stronger approach to appetitive stimuli produces more positive affect, but a belief that one [does not] understand unpleasant emotions or that one analyzes them, or thinks that one cannot regulate or control emotions will reduce that positive state. Greater activation of inhibitory behaviors will produce greater negative affect, and this will increase when one perceives that one attends excessively to one's feelings or does not understand them or feels incapable of regulating them. Accordingly, although motivators could be a focus of interest for intervention, this study shows that the efficiency and profitability of these practical applications increases by adding TEI.

Motivational Sensitivities Linked to Impulsive Motor Errors in Parkinson's Disease

OBJECTIVES

We investigated how broad motivational tendencies are related to the expression and suppression of action impulses in Parkinson's disease (PD).

METHODS

Sixty-nine participants with PD completed a Simon response conflict task and Behavioral Inhibition System (BIS) and Behavioral Activation System (BAS) scales based on Gray's (1987) reinforcement sensitivity theory. Analyses determined relationships between BIS, BAS, and the susceptibility to making impulsive action errors and the proficiency of inhibiting interference from action impulses.

RESULTS

BIS scores correlated positively with rates of impulsive action errors, indicating that participants endorsing low BIS tendencies were much more susceptible to acting on strong motor impulses. Analyses of subgroups with high versus low BIS scores confirmed this pattern and ruled out alternative explanations in terms of group differences in speed-accuracy tradeoffs. None of the scores on the BIS or BAS scales correlated with reactive inhibitory control.

CONCLUSIONS

PD participants who endorse diminished predilection toward monitoring and avoiding aversive experiences (low BIS) show much greater difficulty restraining fast, impulsive motor errors. Establishing relationships between motivational sensitivities and cognitive control processes may have important implications for treatment strategies and positive health outcomes in participants with PD, particularly those at risk for falling and driving difficulties related to impulsive reactions. (JINS, 2018, 24, 128-138).

Behavioral approach and orbitofrontal cortical activity during decision-making in substance dependence

Behavioral approach, defined as behavior directed toward a reward or novel stimulus, when elevated, may increase one's vulnerability to substance use disorder. Behavioral approach has been associated with relatively greater left compared to right frontal activity; behavioral inhibition may be associated with relatively greater right compared to left frontal brain activity. We hypothesized that substance dependent individuals (SDI) would have higher behavioral approach than controls and greater prefrontal cortical activity during decision-making involving reward. We hypothesized that behavioral approach would correlate with left frontal activity during decision-making and that the correlation would be stronger in SDI than controls. 31 SDI and 21 controls completed the Behavioral Inhibition System/Behavioral Approach System (BIS/BAS) scales and performed a decision-making task during fMRI. Orbitofrontal (OFC) and dorsolateral prefrontal activity were correlated with BIS and BAS scores. Compared to controls, SDI had higher BAS Fun Seeking scores (p<0.001) and worse decision-making performance (p=0.004). BAS Fun Seeking correlated with left OFC activity during decision-making across group (r=0.444, p<0.003). The correlation did not differ by group. There was no correlation between BIS and right frontal activity. Left OFC may play a role in reward-related decision-making in substance use disorder especially in individuals with high behavioral approach.

Clinical anxiety promotes excessive response inhibition

BACKGROUND

Laboratory tasks to delineate anxiety disorder features are used to refine classification and inform our understanding of etiological mechanisms. The present study examines laboratory measures of response inhibition, specifically the inhibition of a pre-potent motor response, in clinical anxiety. Data on associations between anxiety and response inhibition remain inconsistent, perhaps because of dissociable effects of clinical anxiety and experimentally manipulated state anxiety. Few studies directly assess the independent and interacting effects of these two anxiety types (state v. disorder) on response inhibition. The current study accomplished this goal, by manipulating state anxiety in healthy and clinically anxious individuals while they complete a response inhibition task.

METHOD

The study employs the threat-of-shock paradigm, one of the best-established manipulations for robustly increasing state anxiety. Participants included 82 adults (41 healthy; 41 patients with an anxiety disorder). A go/nogo task with highly frequent go trials was administered during alternating periods of safety and shock threat. Signal detection theory was used to quantify response bias and signal-detection sensitivity.

RESULTS

There were independent effects of anxiety and clinical anxiety on response inhibition. In both groups, heightened anxiety facilitated response inhibition, leading to reduced nogo commission errors. Compared with the healthy group, clinical anxiety was associated with excessive response inhibition and increased go omission errors in both the safe and threat conditions.

CONCLUSIONS

Response inhibition and its impact on go omission errors appear to be a promising behavioral marker of clinical anxiety. These results have implications for a dimensional view of clinical anxiety.

Gaining insight into adolescent vulnerability for social anxiety from developmental cognitive neuroscience

Social anxiety disorder (SAD) markedly impairs daily functioning. For adolescents, SAD can constrain typical development precisely when social experiences broaden, peers' opinions are highly salient, and social approval is actively sought. Individuals with extreme, impairing social anxiety fear evaluation from others, avoid social interactions, and interpret ambiguous social cues as threatening. Yet some degree of social anxiety can be normative and non-impairing. Furthermore, a temperament of behavioral inhibition increases risk for SAD for some, but not all adolescents with this temperament. One fruitful approach taken to understand the mechanisms of social anxiety has been to use neuroimaging to link affect and cognition with neural networks implicated in the neurodevelopmental social reorientation of adolescence. Although initial neuroimaging studies of adolescent SAD and risk for SAD underscored the role of fear-processing circuits (e.g., the amygdala and ventral prefrontal cortex), recent work has expanded these circuits to include reward-processing structures in the basal ganglia. A growing focus on reward-related neural circuitry holds promise for innovative translational research needed to differentiate impairing from normative social anxiety and for novel ways to treat adolescent SAD that focus on both social avoidance and social approach.

The Behavioural Inhibition System, anxiety and hippocampal volume in a non-clinical population

Background

Animal studies have suggested that the hippocampus may play an important role in anxiety as part of the Behavioural Inhibition System (BIS), which mediates reactivity to threat and punishment and can predict an individual’s response to anxiety-relevant cues in a given environment. The aim of the present structural magnetic resonance imaging (MRI) study was to examine the relationship between individual differences in BIS and hippocampal structure, since this has not received sufficient attention in non-clinical populations. Thirty healthy right-handed participants with no history of alcohol or drug abuse, neurological or psychiatric disorders, or traumatic brain injury were recruited (16 male, 14 female, age 18 to 32 years). T1-weighted structural MRI scans were used to derive estimates of total intracranial volume, and hippocampal and amygdala gray matter volume using FreeSurfer. To relate brain structure to Gray’s BIS, participants completed the Sensitivity to Punishment questionnaire. They also completed questionnaires assessing other measures potentially associated with hippocampal volume (Beck Depression Inventory, Negative Life Experience Survey), and two other measures of anxiety (Spielberger Trait Anxiety Inventory and the Beck Anxiety Inventory).

Results

We found that high scores on the Sensitivity to Punishment scale were positively associated with hippocampal volume, and that this phenomenon was lateralized to the right side. In other words, greater levels of behavioural inhibition (BIS) were positively associated with right hippocampal volume.

Conclusions

Our data suggest that hippocampal volume is related to the cognitive and affective dimensions of anxiety indexed by the Sensitivity to Punishment, and support the idea that morphological differences in the hippocampal formation may be associated with behavioural inhibition contributions to anxiety.

The adherence/resource priming paradigm--a randomised clinical trial conducting a bonafide psychotherapy protocol for generalised anxiety disorder

BACKGROUND

Bonafide psychotherapy is an effective treatment for generalised anxiety disorder compared to no-treatment. Rather than creating increasing numbers of new overall treatment-packets within a medical meta-model, an additional approach to investigating clinical research designs may be to increase the understanding of already effective psychotherapies. Treatment manuals and protocols allow a relatively high degree of freedom for the way therapists implement the overall treatment manuals. There is a systematic lack of knowledge on how therapists should customise these overall protocols. The present study experimentally examines three ways of conducting a bonafide psychotherapy based on a 15 session time-limited cognitive-behavioural therapy (CBT) protocol and their relation to the therapists' protocol adherence and treatment efficacy.

METHODS/DESIGN

This trial will investigate three different methods of customising a bonafide CBT-protocol using dyadic peer-tutoring methodology (primings). The individuals with GAD will be randomly assigned to one of three priming conditions (resource priming, supportive resource priming, or adherence priming). The participant treatment allocation will be performed randomly. Therapists will be assigned to a peer-tutoring partner and priming condition based on a mutual agreement. Treatment outcomes will be assessed at the following times: observer based in-session outcomes, session-by-session post-session outcomes, treatment outcome at post assessment and treatment outcome at 6-month follow-up.

DISCUSSION

The proposed trial addresses the clinically relevant question of how to customise a bonafide psychotherapy protocol using tandem peer-tutoring methodology (three priming conditions). Through the development and testing of the proposed priming procedures, this study describes levels of adherence and how to conduct an overall treatment protocol in a more systematised way.

TRIAL REGISTRATION

From ClinicalTrials.gov Identifier: NCT02039193.