Temporal relationship between dysfunctional beliefs, self-efficacy and panic apprehension in the treatment of panic disorder with agoraphobia

Feeling more confident to encounter negative emotions: The mediating role of distress tolerance on the relationship between self-efficacy and outcomes of exposure and response prevention for OCD

BACKGROUND

While exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD), up to half of patients do not effectively respond. In an effort to better understand the mechanisms behind ERP, the inhibitory learning model emphasizes the roles of increasing perceived self-efficacy and distress tolerance. While self-efficacy and distress tolerance have separately been shown to predict OCD symptoms and treatment outcomes, no studies have assessed their joint effects in ERP. The current study examined distress tolerance as a mediator of the relationship between self-efficacy and ERP outcomes.

METHODS

Patients in an intensive ERP-based treatment program (N = 116) completed weekly self-report measures.

RESULTS

Over the course of treatment, as OCD symptoms reduced, self-efficacy and distress tolerance both significantly increased. Importantly, increases in self-efficacy and distress tolerance mediated each other in explaining symptom reduction, suggesting a possible bi-directional effect.

LIMITATIONS

The temporal relationship between changes in self-efficacy and distress tolerance is worthy of further investigation. In addition, the current sample had limited racial diversity and might not be representative of patients receiving lower levels of care. Findings merit replication to be ascertained of their reliability.

CONCLUSIONS

Findings suggest that during ERP, patients gain confidence in their abilities both to cope with general challenges and to withstand distress, potentially helping them engage with exposures and overcome initial fears. These findings provide support for the inhibitory learning model and highlight the mechanistic roles of self-efficacy and distress tolerance in ERP. Clinical implications to target both in treatment are discussed.

One-year follow-up of the effectiveness and mediators of cognitive behavioural therapy among adults with attention-deficit/hyperactivity disorder: secondary outcomes of a randomised controlled trial

BACKGROUND

The long-term effectiveness of cognitive behavioural therapy (CBT) in medicated attention-deficit/hyperactivity disorder (ADHD) adults with residual symptoms needs to be verified across multiple dimensions, especially with respect to maladaptive cognitions and psychological quality of life (QoL). An exploration of the mechanisms underlying the additive benefits of CBT on QoL in clinical samples may be helpful for a better understanding of the CBT conceptual model and how CBT works in medicated ADHD.

METHODS

We conducted a secondary analysis of a randomised controlled trial including 98 medicated ADHD adults with residual symptoms who were randomly allocated to the CBT combined with medication (CBT + M) group or the medication (M)-only group. Outcomes included ADHD-core symptoms (ADHD Rating Scale), depression symptoms (Self-rating Depression Scale), maladaptive cognitions (Automatic Thoughts Questionnaire and Dysfunctional Attitude Scale), and psychological QoL (World Health Organization Quality of Life-Brief Version-psychological domain). Mixed linear models (MLMs) were used to analyse the long-term effectiveness at one-year follow-up, and structural equation modeling (SEM) was performed to explore the potential mechanisms of CBT on psychological QoL.

RESULTS

ADHD patients in the CBT + M group outperformed the M-only group in reduction of ADHD core symptoms (d = 0.491), depression symptoms (d = 0.570), a trend of reduction of maladaptive cognitions (d = 0.387 and 0.395, respectively), and improvement of psychological QoL (d = - 0.433). The changes in above dimensions correlated with each other (r = 0.201 ~ 0.636). The influence of CBT on QoL was mediated through the following four pathways: 1) changes in ADHD core symptoms; 2) changes in depressive symptoms; 3) changes in depressive symptoms and then maladaptive cognitions; and 4) changes firstly in depressive symptoms, maladaptive cognitions, and then ADHD core symptoms.

CONCLUSIONS

The long-term effectiveness of CBT in medicated ADHD adults with residual symptoms was further confirmed. The CBT conceptual model was verified in clinical samples, which would be helpful for a deeper understanding of how CBT works for a better psychological QoL outcome.

TRIAL REGISTRATION

ChiCTR1900021705 (2019-03-05).

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER)

BACKGROUND

Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation.

METHODS

We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews).

DISCUSSION

Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes.

TRIAL REGISTRATION

Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Refining the Analysis of Mechanism-Outcome Relationships for Anxiety Treatment: A Preliminary Investigation Using Mixed Models

Although efficacious treatments exist for anxiety disorders, issues remain regarding how best to conceptualize and measure purported change processes in clinical research. In the current study, we examined the relationship between treatment-specific (exposure therapy, attention bias modification [ABM]) as well as more general change processes with symptoms within a transdiagnostic sample using mixed models. Results indicated that slope of self-efficacy across treatment and between-session habituation across identical exposures was associated with slope of symptom change. Although slope of anxiety ratings within session was not associated with slope of symptom change, it did interact with other candidate exposure processes to predict symptoms. Purported ABM change processes were not associated with outcome. Our use of mixed models exemplifies an emerging trend in this research aimed at minimizing loss of data through aggregation, and our results highlight the utility of integrating treatment-specific as well as more general change processes in mechanistic research.

An experience sampling study on the links between daily teacher self-efficacy, need-supportive teaching and student intrinsic motivation

Introduction

Why are some teachers more successful at motivating students than others? We know from previous literature that teachers' self-efficacy relates to the extent in which they engage in need-supportive teaching in the classroom, which in turn relates to student intrinsic motivation. However, teachers' self-efficacy is hypothesized to be dependent on their previous mastery experiences, e.g., of engaging students in the classroom. This "feedback loop" where the teacher not only influences the student but also the other way around, in a process unfolding over time, can only be investigated empirically with an intensive longitudinal design. This is precisely what we did in the current study.

Methods

Secondary school teachers (n = 4) and students (n = 90) participated in an experience sampling study throughout one school year, resulting in a unique dataset with 48-59 repeated measurement points per class.

Results

Visual exploration of the time series revealed that teacher self-efficacy can vary substantially from lesson to lesson, with characteristic patterns of stabilization and de-stabilization. We conducted Vector Autoregressive Analysis (VAR) for each of the four cases to test whether, and how, the variables relate to each other over time. We found an "overspill effect" for student motivation, meaning that students' motivation in today's lesson predicts their motivation in tomorrow's lesson. Furthermore, in two cases we found that today's student motivation predicts tomorrow's teacher self-efficacy, but not the other way around.

Mechanisms of cognitive behavioral therapy vs. supportive psychotherapy in body dysmorphic disorder: An exploratory mediation analysis

Body dysmorphic disorder (BDD) is common, severe, and often chronic. Cognitive behavioral therapy (CBT) is the first-line psychosocial treatment for BDD, with well-established efficacy. However, some patients do not improve with CBT, and little is known about how CBT confers its effects. Neurocognitive processes have been implicated in the etiology and maintenance of BDD and are targeted by CBT-BDD treatment components. Yet, the malleability of these factors in BDD, and their potential role in mediating symptom improvement, are not well understood. Understanding how treatment works could help optimize treatment outcomes. In this secondary data analysis of a randomized clinical trial of CBT vs. supportive psychotherapy (SPT) in BDD (n = 120), we examined whether treatment-related changes in detail processing (Rey-Osterrieth Complex Figure test), maladaptive appearance beliefs (Appearance Schemas Inventory-Revised), and emotion recognition (Emotion Recognition Task) mediated treatment outcome. All constructs improved over time and were associated with symptom improvement. CBT was associated with greater improvements in maladaptive beliefs than SPT. None of the variables examined mediated symptom improvement. Findings suggest that with successful treatment, individuals with BDD demonstrate reduced neurocognitive deficits (detail processing, emotion recognition, maladaptive beliefs) and that CBT is more likely than SPT to improve maladaptive appearance beliefs. More work is needed to understand mechanisms of change and thus maximize treatment outcomes.

Within- and between-patients associations between self-efficacy, outcome expectation, and symptom change in cognitive behavioral therapy for generalized anxiety disorder

OBJECTIVES

There is limited information on how a change in patients' expectations over time results in symptom change in psychotherapy. This study aimed to investigate the changes in patients' expectations and symptoms during treatment and across follow-up as well as to determine the within- and between-patient relationships between two types of patient expectations, that is, self-efficacy and outcome expectation, and symptom change.

METHODS

Participants (80 participants × 6 repeated measures; 480 observations) with generalized anxiety disorder were treated using cognitive behavioral therapy and the within- and between-patient scores of self-efficacy and outcome expectation were evaluated in multilevel models as predictors of symptom change.

RESULTS

Patients' self-efficacy and outcome expectation increased, whereas severity of their symptoms reduced during and after treatment. At the within-patient (WP) level, an increase in self-efficacy was associated with a decrease in worry and depressive symptoms, and an increase in outcome expectation was associated with a decrease in depressive symptoms. The between-patient (BP) effect, however, was contrary to the WP effect, that is, self-efficacy was positively correlated with worry and outcome expectation was positively correlated with depressive symptoms CONCLUSION: These results highlight the importance of disaggregating the WP variability from BP variability in psychotherapy process-outcome research as they exhibit different associations at the within- and between-patient levels. Clinical Trial Registration: ClinicalTrial.gov (NCT03079336).

I Think I Can: The Role of Self-Efficacy in Exposure to Contamination

Introduction: Self-efficacy (SE) has been explored extensively within the field of psychology. Despite a rich literature demonstrating its positive effect on various behavioral outcomes, including psychological treatment outcomes, little is known about the impact of SE on outcomes related to obsessive-compulsive disorder. To fill this critical gap in the literature, this study aims to examine the relationship between SE beliefs and contamination-related approach behavior and to determine whether increasing SE may improve engagement in exposure-based interventions for contamination fears. Method: Participants (N = 120) were randomly assigned to complete a contamination-related behavioral approach task (CR-BAT) immediately following either a SE-boosting exercise or a non-SE related control. Results: Self-reported contamination-relevant SE was positively correlated with approach behavior during the CR-BAT. However, there were no differences between conditions in contamination-related SE or approach behavior during the CR-BAT. Nevertheless, participants in the SE-boosting condition reported lower levels of anxiety during the CR-BAT than did those in the control condition, suggesting that the manipulation was effective in reducing subjective distress. Discussion: Future research using more effective methods to manipulate SE is required to examine the causality of this relationship.

Clinician Maladaptive Anxious Avoidance in the Context of Implementation of Evidence-Based Interventions: A Commentary

This paper posits that a clinician's own anxious reaction to delivering specific evidence-based interventions (EBIs) should be better accounted for within implementation science frameworks. A key next step for implementation science is to delineate the causal processes most likely to influence successful implementation of evidence-based interventions (EBIs). This is critical for being able to develop tailored implementation strategies that specifically target mechanisms by which implementation succeeds or fails. First, we review the literature on specific EBIs that may act as negatively valenced stimuli for clinicians, leading to a process of clinician maladaptive anxious avoidance that can negatively impact EBI delivery. In the following sections, we argue that there are certain EBIs that can cause emotional distress or discomfort in a clinician, related to either: (1) a clinicians' fear of the real or predicted short-term distress the EBI can cause patients, or (2) fears that the clinician will inadvertently cause the patient harm and/or face liability. This distress experienced by the clinician can perpetuate a cycle of maladaptive anxious avoidance by the clinician, contributing to lack of or suboptimal EBI implementation. We illustrate how this cycle of maladaptive anxious avoidance can influence implementation by providing several examples from leading EBIs in the psychosocial literature. To conclude, we discuss how leveraging decades of treatment literature aimed at mitigating maladaptive anxious avoidance can inform the design of more tailored and effective implementation strategies for EBIs that are negatively valenced.

Extending the vulnerability-stress model of mental disorders: three-dimensional NPSR1 × environment × coping interaction study in anxiety

BACKGROUND

The general understanding of the 'vulnerability-stress model' of mental disorders neglects the modifying impact of resilience-increasing factors such as coping ability.

AIMS

Probing a conceptual framework integrating both adverse events and coping factors in an extended 'vulnerability-stress-coping model' of mental disorders, the effects of functional neuropeptide S receptor gene (NPSR1) variation (G), early adversity (E) and coping factors (C) on anxiety were addressed in a three-dimensional G × E × C model.

METHOD

In two independent samples of healthy probands (discovery: n = 1403; replication: n = 630), the interaction of NPSR1 rs324981, childhood trauma (Childhood Trauma Questionnaire, CTQ) and general self-efficacy as a measure of coping ability (General Self-Efficacy Scale, GSE) on trait anxiety (State-Trait Anxiety Inventory) was investigated via hierarchical multiple regression analyses.

RESULTS

In both samples, trait anxiety differed as a function of NPSR1 genotype, CTQ and GSE score (discovery: β = 0.129, P = 3.938 × 10-8; replication: β = 0.102, P = 0.020). In A allele carriers, the relationship between childhood trauma and anxiety was moderated by general self-efficacy: higher self-efficacy and childhood trauma resulted in low anxiety scores, and lower self-efficacy and childhood trauma in higher anxiety levels. In turn, TT homozygotes displayed increased anxiety as a function of childhood adversity unaffected by general self-efficacy.

CONCLUSIONS

Functional NPSR1 variation and childhood trauma are suggested as prime moderators in the vulnerability-stress model of anxiety, further modified by the protective effect of self-efficacy. This G × E × C approach - introducing coping as an additional dimension further shaping a G × E risk constellation, thus suggesting a three-dimensional 'vulnerability-stress-coping model' of mental disorders - might inform targeted preventive or therapeutic interventions strengthening coping ability to promote resilient functioning.

Videoconferencing Psychotherapy for Panic Disorder and Agoraphobia: Outcome and Treatment Processes From a Non-randomized Non-inferiority Trial

BACKGROUND

In the context of the COVID-19 pandemic, legislations are being modified around the world to allow patients to receive mental health services through telehealth. Unfortunately, there are no large clinical trial available to reliably document the efficacy of delivering videoconferencing psychotherapy (VCP) for people with panic disorder and agoraphobia (PDA) and whether basic psychotherapeutic processes are altered.

METHODS

This 2-arm intent-to-treat non-inferiority study reports on a clinical trial on VCP and documents how therapeutic working alliance and motivation toward psychotherapy are associated to treatment outcome. We hypothesized that VCP would not be inferior to standard face-to-face (FF) cognitive behavior therapy for PDA. No specific hypothesis was stated to address working alliance and treatment mechanisms. VCP was compared to a gold-standard psychotherapy treatment for PDA, which was delivered either in person or in videoconference, with a strict tolerance criterion of about 2 points on the primary outcome measure. Seventy one adult patients were recruited. Measures of working alliance were collected after the first, fifth, and last session. Motivation toward therapy at pre-treatment and working alliance after the fifth therapy session were used as predictors of treatment outcome and compared with change in dysfunctional beliefs toward bodily sensations.

RESULTS

Panic disorder, agoraphobia, fear of sensations and depressed mood all showed significant improvements and large effect-sizes from pre to post-treatment. Gains were maintained at follow-up. No significant differences were found between VCP and FF, and effect sizes were trivial for three of the four outcome measures. Non-inferiority tests confirmed that VCP was no less effective than FF therapy on the primary outcome measure and two of the three secondary outcome measures. Working alliance was very strong in VCP and did not statistically differ from FF. Working alliance and motivation did not predict treatment outcome, which was significantly predicted by the reduction in dysfunctional beliefs. The strength of the therapeutic bond was correlated with change in dysfunctional beliefs.

CONCLUSION

Mental health professionals can use VCP to provide services to patients with PDA. Building and maintaining a sound working alliance should not be a source concern. Practical recommendations are formulated.

ISRCTN TRIAL REGISTRATION NUMBER

ISRCTN76456442.

Low Perceived Self-Efficacy Impedes Discriminative Fear Learning

Perceived self-efficacy refers to a subject’s expectation about the outcomes his/her behavior will have in a challenging situation. Low self-efficacy has been implicated in the origins and maintenance of phobic behavior. Correlational studies suggest an association between perceived self-efficacy and learning. The experimental manipulation of perceived self-efficacy offers an interesting approach to examine the impact of self-efficacy beliefs on cognitive and emotional functions. Recently, a positive effect of an experimentally induced increased self-efficacy on associative learning has been demonstrated. Changes in associative learning constitute a central hallmark of pathological fear and anxiety. Such alterations in the acquisition and extinction of conditioned fear may be related to cognitive and neurobiological factors that predict a certain vulnerability to anxiety disorders. The present study builds on previous own work by investigating the effect of an experimentally induced low perceived self-efficacy on fear acquisition, extinction and extinction retrieval in a differential fear conditioning task. Our results suggest that a negative verbal feedback, which leads to a decreased self-efficacy, is associated with changes in the acquisition of conditioned fear. During fear acquisition, the negative verbal feedback group showed decreased discrimination of fear responses between the aversive and safe conditioned stimuli (CS) relative to a group receiving a neutral feedback. The effects of the negative verbal feedback on the acquisition of fear discrimination learning were indexed by an impaired ability to discriminate the probability of receiving a shock during acquisition upon presentation of the aversive (CS+) relative to the safe stimuli (CS−). However, the effects of low self-efficacy on discrimination learning were limited to fear acquisition. No differences between the groups were observed during extinction and extinction retrieval. Furthermore, analysis of other outcome measures, i.e., skin conductance responses and CS valence ratings, revealed no group differences during the different phases of fear conditioning. In conclusion, lower perceived self-efficacy alters cognitive/expectancy components of discrimination during fear learning but not evaluative components and physiological responding. The pattern of findings suggests a selective, detrimental role of low(er) self-efficacy on the subject’s ability to learn the association between ambiguous cues and threat/safety.

Self-efficacy as a predictor of treatment outcome in an outpatient eating disorder program

This prospective pilot study examined the relationship between self-efficacy and treatment outcome in an adult outpatient eating disorder program. Data from 59 eating disorder outpatients were collected, including measures of self-efficacy, eating disorder symptom severity, negative emotions (depression, anxiety, and stress), body mass index, and duration of illness. Hierarchical regression was used to examine the impact of baseline self-efficacy, and early treatment changes in self-efficacy (i.e., baseline to 6 weeks), on end-of-treatment (EoT) eating disorder symptom severity and treatment dropout. Early change in self-efficacy during the course of treatment was found to predict EoT symptom severity when controlling for confounding variables. Furthermore, baseline self-efficacy was found to predict treatment dropout, but not end-of-treatment symptom severity. This is the first study (using a validated scale) to show that self-efficacy, and early changes in self-efficacy, may be an important predictor of treatment outcome for eating disorder outpatients. Implications and suggestions for future research are discussed.

[What do virtual reality tools bring to child and adolescent psychiatry?]

Virtual reality is a relatively new technology that enables individuals to immerse themselves in a virtual world. It offers several advantages including a more realistic, lifelike environment that may allow subjects to "forget" they are being assessed, allow a better participation and an increased generalization of learning. Moreover, the virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, and can also be used to evaluate the patient's multimodal integration and to aid rehabilitation of cognitive abilities. The use of virtual reality to treat various psychiatric disorders in adults (phobic anxiety disorders, post-traumatic stress disorder, eating disorders, addictions…) and its efficacy is supported by numerous studies. Similar research for children and adolescents is lagging behind. This may be particularly beneficial to children who often show great interest and considerable success on computer, console or videogame tasks. This article will expose the main studies that have used virtual reality with children and adolescents suffering from psychiatric disorders. The use of virtual reality to treat anxiety disorders in adults is gaining popularity and its efficacy is supported by various studies. Most of the studies attest to the significant efficacy of the virtual reality exposure therapy (or in virtuo exposure). In children, studies have covered arachnophobia social anxiety and school refusal phobia. Despite the limited number of studies, results are very encouraging for treatment in anxiety disorders. Several studies have reported the clinical use of virtual reality technology for children and adolescents with autistic spectrum disorders (ASD). Extensive research has proven the efficiency of technologies as support tools for therapy. Researches are found to be focused on communication and on learning and social imitation skills. Virtual reality is also well accepted by subjects with ASD. The virtual environment offers the opportunity to administer controlled tasks such as the typical neuropsychological tools, but in an environment much more like a standard classroom. The virtual reality classroom offers several advantages compared to classical tools such as more realistic and lifelike environment but also records various measures in standardized conditions. Most of the studies using a virtual classroom have found that children with Attention Deficit/Hyperactivity Disorder make significantly fewer correct hits and more commission errors compared with controls. The virtual classroom has proven to be a good clinical tool for evaluation of attention in ADHD. For eating disorders, cognitive behavioural therapy (CBT) program enhanced by a body image specific component using virtual reality techniques was shown to be more efficient than cognitive behavioural therapy alone. The body image-specific component using virtual reality techniques boots efficiency and accelerates the CBT change process for eating disorders. Virtual reality is a relatively new technology and its application in child and adolescent psychiatry is recent. However, this technique is still in its infancy and much work is needed including controlled trials before it can be introduced in routine clinical use. Virtual reality interventions should also investigate how newly acquired skills are transferred to the real world. At present virtual reality can be considered a useful tool in evaluation and treatment for child and adolescent disorders.

Anxiety Disorder-Specific Predictors of Treatment Outcome in the Coordinated Anxiety Learning and Management (CALM) Trial

Identifying baseline characteristics associated with treatment outcome in generalized anxiety disorder, panic disorder, social anxiety disorder (SAD) or post-traumatic stress disorder. We performed two secondary analyses of the Coordinated Anxiety Learning and Management trial. Baseline characteristics and their interactions with treatment assignment were analyzed via stepwise logistic regression models and receiver-operating criterion analyses by disorder predicting remission and response for each disorder. Predictors for poor outcome across diagnoses were comorbid depression and low socioeconomic status. Good outcome was associated with positive treatment expectancy and high self-efficacy expectancy. SAD had the lowest rate of remission and response compared to the other anxiety disorders, and differed in respect to its predictors of treatment outcome. Perceived social support predicted treatment outcome in SAD. The special role of SAD among the other anxiety disorders requires further study both because of its worse prognosis and its more specific treatment needs.

Increased perceived self-efficacy facilitates the extinction of fear in healthy participants

Self-efficacy has been proposed as an important element of a successful cognitive behavioral treatment (CBT). Positive changes in perceived self-efficacy have been linked to an improved adaptive emotional and behavioral responding in the context of anxiety-provoking situations. Furthermore, a positive influence of increased self-efficacy on cognitive functions has been confirmed. The present study examined the effect of verbal persuasion on perceived self-efficacy and fear extinction. Healthy participants were subjected to a standardized differential fear conditioning paradigm. After fear acquisition, half of the participants received a verbal persuasion aimed at increasing perceived self-efficacy. The extinction of fear was assessed immediately thereafter on both the implicit and explicit level. Our results suggest that an increased perceived self-efficacy was associated with enhanced extinction, evidenced on the psychophysiological level and accompanied by more pronounced decrements in conditioned negative valence. Changes in extinction were not due to a decrease in overall emotional reactivity to conditioned stimuli (CS). In addition, debriefing participants about the false positive feedback did not affect the processing of already extinguished conditioned responses during a subsequent continued extinction phase. Our results suggest that positive changes in perceived self-efficacy can be beneficial for emotional learning. Findings are discussed with respect to strategies aimed at increasing extinction learning in the course of exposure-based treatments.

Ecological Momentary Assessments and Automated Time Series Analysis to Promote Tailored Health Care: A Proof-of-Principle Study

BACKGROUND

Health promotion can be tailored by combining ecological momentary assessments (EMA) with time series analysis. This combined method allows for studying the temporal order of dynamic relationships among variables, which may provide concrete indications for intervention. However, application of this method in health care practice is hampered because analyses are conducted manually and advanced statistical expertise is required.

OBJECTIVE

This study aims to show how this limitation can be overcome by introducing automated vector autoregressive modeling (VAR) of EMA data and to evaluate its feasibility through comparisons with results of previously published manual analyses.

METHODS

We developed a Web-based open source application, called AutoVAR, which automates time series analyses of EMA data and provides output that is intended to be interpretable by nonexperts. The statistical technique we used was VAR. AutoVAR tests and evaluates all possible VAR models within a given combinatorial search space and summarizes their results, thereby replacing the researcher's tasks of conducting the analysis, making an informed selection of models, and choosing the best model. We compared the output of AutoVAR to the output of a previously published manual analysis (n=4).

RESULTS

An illustrative example consisting of 4 analyses was provided. Compared to the manual output, the AutoVAR output presents similar model characteristics and statistical results in terms of the Akaike information criterion, the Bayesian information criterion, and the test statistic of the Granger causality test.

CONCLUSIONS

Results suggest that automated analysis and interpretation of times series is feasible. Compared to a manual procedure, the automated procedure is more robust and can save days of time. These findings may pave the way for using time series analysis for health promotion on a larger scale. AutoVAR was evaluated using the results of a previously conducted manual analysis. Analysis of additional datasets is needed in order to validate and refine the application for general use.

Mechanisms of change in cognitive therapy for obsessive compulsive disorder: role of maladaptive beliefs and schemas

The present study aimed to identify mechanisms of change in individuals with moderately severe obsessive-compulsive disorder (OCD) receiving cognitive therapy (CT). Thirty-six adults with OCD received CT over 24 weeks. At weeks 0, 4/6, 12, 16/18, and 24, independent evaluators assessed OCD severity, along with obsessive beliefs and maladaptive schemas. To examine mechanisms of change, we utilized a time-varying lagged regression model with a random intercept and slope. Results indicated that perfectionism and certainty obsessive beliefs and maladaptive schemas related to dependency and incompetence significantly mediated (improved) treatment response. In conclusion, cognitive changes in perfectionism/certainty beliefs and maladaptive schemas related to dependency/incompetence precede behavioral symptom reduction for OCD patients. Targeting these mechanisms in future OCD treatment trials will emphasize the most relevant processes and facilitate maximum improvement.

Changes in self-efficacy and outcome expectancy as predictors of anxiety outcomes from the CALM study

BACKGROUND

Although self-efficacy (SE) and outcome expectancy (OE) have been well researched as predictors of outcome, few studies have investigated changes in these variables across treatments. We evaluated changes in OE and SE throughout treatment as predictors of outcomes in a large sample with panic disorder, generalized anxiety disorder, social anxiety disorder, or posttraumatic stress disorder. We hypothesized that increases in SE and OE would predict reductions in anxiety and depression as well as improvement in functioning.

METHODS

Participants (mean age = 43.3 years, SD = 13.2, 71.1% female, 55.5% white) were recruited from primary care centers throughout the United States and were randomized to receive either Coordinated Anxiety Learning and Management (CALM) treatment - composed of cognitive behavioral therapy, psychotropic medication, or both - or usual care. SE and OE ratings were collected at each session for participants in the CALM treatment (n = 482) and were entered into a structural equation model as predictors of changes in Brief Symptom Inventory, Anxiety Sensitivity Index, Patient Health Questionnaire (PHQ), and Sheehan Disability Scale outcomes at 6, 12, and 18 months after baseline.

RESULTS

The best-fitting models predict symptom levels from OE and SE and not vice versa. The slopes and intercept of OE significantly predicted change in each outcome variable except PHQ-8. The slope and intercept of SE significantly predicted change in each outcome variable.

CONCLUSION

Over and above absolute level, increases in SE and OE were significant predictors of decreases in symptoms and increases in functioning. Implications for treatment are discussed, as well as future directions of research.

The mediational role of panic self-efficacy in cognitive behavioral therapy for panic disorder: a systematic review and meta-analysis

Cognitive models of panic disorder (PD) with or without agoraphobia have stressed the role of catastrophic beliefs of bodily symptoms as a central mediating variable of the efficacy of cognitive behavioral therapy (CBT). Perceived ability to cope with or control panic attacks, panic self-efficacy, has also been proposed to play a key role in therapeutic change; however, this cognitive factor has received much less attention in research. The aim of the present review is to evaluate panic self-efficacy as a mediator of therapeutic outcome in CBT for PD using descriptive and meta-analytic procedures. We performed systematic literature searches, and included and evaluated 33 studies according to four criteria for establishing mediation. Twenty-eight studies, including nine randomized waitlist-controlled studies, showed strong support for CBT improving panic self-efficacy (criterion 1); ten showed an association between change in panic self-efficacy and change in outcome during therapy (criterion 2); three tested, and one established formal statistical mediation of panic self-efficacy (criterion 3); while four tested and three found change in panic self-efficacy occurring before the reduction of panic severity (criterion 4). Although none of the studies fulfilled all of the four criteria, results provide some support for panic self-efficacy as a mediator of outcome in CBT for PD, generally on par with catastrophic beliefs in the reviewed studies.

Mechanisms of change in cognitive behavioral therapy for panic disorder: the unique effects of self-efficacy and anxiety sensitivity

The present study examined temporal dependencies of change of panic symptoms and two promising mechanisms of change (self-efficacy and anxiety sensitivity) during an 11-session course of cognitive-behavior therapy (CBT) for Panic Disorder (PD). 361 individuals with a principal diagnosis of PD completed measures of self-efficacy, anxiety sensitivity, and PD symptoms at each session during treatment. Effect size analyses indicated that the greatest changes in anxiety sensitivity occurred early in treatment, whereas the greatest changes in self-efficacy occurred later in treatment. Results of parallel process latent growth curve models indicated that changes in self-efficacy and anxiety sensitivity across treatment uniquely predicted changes in PD symptoms. Bivariate and multivariate latent difference score models indicated, as expected, that changes in anxiety sensitivity and self-efficacy temporally preceded changes in panic symptoms, and that intraindividual changes in anxiety sensitivity and self-efficacy independently predicted subsequent intraindividual changes in panic symptoms. These results provide strong evidence that changes in self-efficacy and anxiety sensitivity during CBT influence subsequent changes in panic symptoms, and that self-efficacy and anxiety sensitivity may therefore be two distinct mechanisms of change of CBT for PD that have their greatest impact at different stages of treatment.

Temporal patterns of change in panic disorder during cognitive behaviour therapy: an Indian study

BACKGROUND

CBT has been proven to be effective in the treatment of panic disorder; however, attempts to study the process of change are limited.

AIM

The study evaluated the temporal patterns of change in the panic symptoms, cognitions, behaviours, and anxiety sensitivity in subjects with panic disorder being treated with CBT.

METHOD

Thirty subjects with panic disorder were allocated to two groups: Cognitive Behaviour Therapy (CBT, n = 15) and Behaviour Therapy (BT, n = 15). Assessments were carried out weekly for five consecutive weeks using the Semi-Structured Interview Schedule, the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire, and the Texas Panic Attack Record Form. The CBT group received comprehensive CBT and the BT group received psycho-education and Applied Relaxation.

RESULTS

Following intervention the change was continuous and gradual on all the variables in the CBT group and the scores reduced to a functional range after 4-5 weeks of therapy. Such a change was not evident in the BT group. Significant change was evident in cognitive domains following the introduction of the exposure and cognitive restructuring within the CBT group. Both cognitive and behavioural techniques contributed to the overall change.

CONCLUSION

CBT had an impact on the cognitive domains and significant changes were evident corresponding to the addition of cognitive restructuring and exposure techniques in the 3rd to 5th week. Both cognitive and behavioural components are therefore crucial for overall improvement to occur.

Mechanisms of change in cognitive behaviour therapy for panic disorder: the role of panic self-efficacy and catastrophic misinterpretations

The efficacy of cognitive behavioural therapy (CBT) for panic disorder with or without agoraphobia (PD) is well-established; however, little is known about the underlying change processes of clinical improvement during therapy. According to cognitive theories, CBT for PD primarily works by changing catastrophic misinterpretations of bodily symptoms and panic attacks. However, panic self-efficacy, i.e. the perceived ability to cope with panic attacks, has also been suggested as an important change mechanism in CBT for PD. The aim of the study was to investigate if change in catastrophic misinterpretations and panic self-efficacy mediated change in the level of anxiety during the course of thirteen sessions of group CBT for PD. Forty-five participants completed weekly self-report measures of the possible cognitive mediators and the level of anxiety throughout therapy. The results indicated that within-person change in panic self-efficacy in one session, but not in catastrophic misinterpretations, predicted within-person level of anxiety symptoms the following week. However, in a reversed analysis, prior change in level of anxiety symptoms also predicted change in panic self-efficacy the following session. These results support panic self-efficacy as a mediator of change in CBT for PD, although a reciprocal causal relationship between panic self-efficacy and level of anxiety seems to be implied.

Cognitive mediation of cognitive-behavioural therapy outcomes for anxiety-based school refusal

BACKGROUND

Cognitive-behavioural therapy (CBT) has proven to be effective for anxiety-based school refusal, but it is still unknown how CBT for school refusal works, or through which mechanisms.

AIMS

Innovative statistical approaches for analyzing small uncontrolled samples were used to investigate the role of self-efficacy in mediating CBT outcomes for anxiety-based school refusal.

METHOD

Participants were 19 adolescents (12 to 17 years) who completed a manual-based cognitive-behavioural treatment. Primary outcomes (school attendance; school-related fear; anxiety) and secondary outcomes (depression; internalizing problems) were assessed at post-treatment and 2-month follow-up.

RESULTS

Post-treatment increases in school attendance and decreases in fear about attending school the next day were found to be mediated by self-efficacy. Mediating effects were not observed at 2-month follow-up.

CONCLUSIONS

These findings provide partial support for the role of self-efficacy in mediating the outcome of CBT for school refusal. They contribute to a small body of literature suggesting that cognitive change enhances CBT outcomes for young people with internalizing problems. Regarding methodology, the product of coefficient test appears to be a valuable way to study mediation in outcome studies involving small samples.

Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: a systematic review

OBJECTIVE

Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Threat reappraisal is considered a key mediator underlying the effects of cognitive-behavioral therapy (CBT) for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis.

METHOD

In our review, we included studies that (a) investigated the threat reappraisal mediation hypothesis; (b) included adults with an anxiety disorder diagnosis; (c) used a longitudinal design; and (d) did not report on previously published findings (to avoid the inclusion of multiple reports of the same data). After data extraction, we made review-specific quality judgments for each study using the following a priori criteria informed by mediation theory: (a) demonstrated statistical mediation; (b) demonstrated that CBT caused threat reappraisal; (c) demonstrated that threat reappraisal caused anxiety reduction; and (d) demonstrated specificity of the threat reappraisal-anxiety reduction relation.

RESULTS

Of the 2,296 studies we identified, 25 met inclusion criteria. Of these studies, 56% tested and 52% established statistical mediation, 52% tested and 28% established CBT as a cause of threat reappraisal, 28% tested and 24% established threat reappraisal as a cause of anxiety reduction, and 44% tested and 36% established specificity of the threat reappraisal-anxiety reduction relation.

CONCLUSIONS

While threat reappraisal is related to anxiety symptom improvement with CBT, there are few extant studies that meet most of the criteria necessary to conclusively demonstrate that it causes symptom improvement in CBT and that it is not a proxy for other third variables. Recommendations for future research in this area are discussed.

Coping skills and exposure therapy in panic disorder and agoraphobia: latest advances and future directions

Although cognitive-behavioral treatments for panic disorder have demonstrated efficacy, a considerable number of patients terminate treatment prematurely or remain symtpomatic. Cognitive and biobehavioral coping skills are taught to improve exposure therapy outcomes but evidence for an additive effect is largely lacking. Current methodologies used to study the augmenting effects of coping skills test the degree to which the delivery of coping skills enhances outcomes. However, they do not assess the degree to which acquisition of coping skills and their application during exposure therapy augment outcomes. We examine the extant evidence on the role of traditional coping skills in augmenting exposure for panic disorder, discuss the limitations of existing research, and offer recommendations for methodological advances.

Respiratory and cognitive mediators of treatment change in panic disorder: evidence for intervention specificity

OBJECTIVE

There are numerous theories of panic disorder, each proposing a unique pathway of change leading to treatment success. However, little is known about whether improvements in proposed mediators are indeed associated with treatment outcomes and whether these mediators are specific to particular treatment modalities. Our purpose in this study was to analyze pathways of change in theoretically distinct interventions using longitudinal, moderated mediation analyses.

METHOD

Forty-one patients with panic disorder and agoraphobia were randomly assigned to receive 4 weeks of training aimed at altering either respiration (capnometry-assisted respiratory training) or panic-related cognitions (cognitive training). Changes in respiration (PCO₂, respiration rate), symptom appraisal, and a modality-nonspecific mediator (perceived control) were considered as possible mediators.

RESULTS

The reductions in panic symptom severity and panic-related cognitions and the improvements in perceived control were significant and comparable in both treatment groups. Capnometry-assisted respiratory training, but not cognitive training, led to corrections from initially hypocapnic to normocapnic levels. Moderated mediation and temporal analyses suggested that in capnometry-assisted respiratory training, PCO₂ unidirectionally mediated and preceded changes in symptom appraisal and perceived control and was unidirectionally associated with changes in panic symptom severity. In cognitive training, reductions in symptom appraisal were bidirectionally associated with perceived control and panic symptom severity. In addition, perceived control was bidirectionally related to panic symptom severity in both treatment conditions.

CONCLUSION

The findings suggest that reductions in panic symptom severity can be achieved through different pathways, consistent with the underlying models.

Cognitive mediation of panic reduction during an early intervention for panic

OBJECTIVE

This study investigated cognitive mediation of improvement in panic disorder (PD) symptomatology during and after an early intervention for panic symptoms in subthreshold and mild PD.

METHOD

We executed a pragmatic, pre-post, two-group, multi-site, randomized trial of an early intervention for panic symptoms, based on cognitive-behavioural therapy, vs. a wait-list control group in a sample of 217 participants with subthreshold PD or mild PD.

RESULTS

First, two of the three subscales of the mediator variable Panic Appraisal Inventory (PAI-anticipation and PAI-coping) significantly mediated residual change in PD symptomatology on the PD Severity Scale-Self Report. Second, preintervention to postintervention PAI-anticipation and PAI-coping change scores significantly predicted postintervention to follow-up change in PD symptomatology after controlling for other change scores. However, the converse association was also significant.

CONCLUSION

The results suggest that changes in cognitions may mediate changes in PD symptomatology and that the process of change is circular.

Cognitive behavioural therapy and applied relaxation for generalized anxiety disorder: a time series analysis of change in worry and somatic anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.

Treatment of panic disorder: recent developments and current status

Panic disorder is a commonly encountered condition in general medical practice and in various medical settings. It is important for all medical practitioners to be able to recognize this disorder, provide patients with basic information and medical advice, and depending on the specific circumstances, to refer patients for appropriate treatment by primary care physicians, psychiatrists and/or clinical psychologists. This article reviews the developments in the treatment of panic disorder, focusing on the major treatment modalities of pharmacotherapy and cognitive-behavior therapy, as well as their combinations. In addition to providing information on current treatments for panic disorder and the main underlying treatment issues, the article identifies areas where improvements need to be made and areas where much research has been conducted in recent years. These include simplified modes of delivery of cognitive-behavior therapy, optimal ways of combining medications with cognitive-behavior therapy, and minimizing the risk of recurrence after the cessation of treatment.