Efficacy of problem-solving training and cognitive exposure in the treatment of generalized anxiety disorder: A case replication series

Written Imaginal Exposure for Hoarding Disorder: A Preliminary Pilot Study

ABSTRACT

Hoarding disorder (HD) is marked by difficulty discarding possessions. Many refuse treatment or drop out, which may be due to treatment's incorporation of in-home decluttering, which is feared and avoided. Thus, strategies to prepare patients for decluttering/discarding are needed. Imaginal exposure (IE), or imagining one's worst fears about discarding, could be one such strategy. This pilot preliminarily tested a short-duration IE intervention compared with a control intervention. Over 3 days, adults diagnosed with HD (n = 32) were randomly assigned to either write about and imagine their worst fears about discarding (IE condition) or a neutral topic (control writing [CW] condition). The IE condition showed significant improvements in HD symptoms from preintervention to 1-week follow-up, with medium to large effects; however, the CW condition did as well. Comparing change scores between conditions, the IE condition's improvements were not significantly different than the CW condition's. Overall, IE was helpful in improving HD symptoms, but this pilot did not indicate that it was more helpful than CW. This raises important questions about possible demand characteristics, placebo effects, or regression to the mean, and it has implications for the design and methodology of other studies assessing IE's utility.

Social problem-solving attitudes and performance as a function of differences in trait and state worry

BACKGROUND AND OBJECTIVES

This study investigated problem-solving attitudes and state-dependent, performance-based problem-solving abilities of individuals with high trait worry as compared to those low in trait worry. Secondary objectives involved investigating the relationship between problem-solving effectiveness and processes hypothesized to influence worry and problem-solving (i.e., working memory, attentional control, emotional dysregulation, and concreteness of thought).

METHODS

A 2 (group: high worry, n = 68, vs. low worry, n = 66) X 2 (induction type: worry vs. neutral mentation) factorial design was employed to investigate the differential effects of state worry, and neutral mentation for comparison, on performance-based problem-solving effectiveness. Independent samples t-tests tested for group differences in self-reported problem-solving attitudes. Multiple regression analyses were used to investigate if aforementioned processes predict problem-solving effectiveness.

RESULTS

Previous findings that individuals with high trait worry endorse greater tendencies to self-report unconstructive problem-solving attitudes were replicated. Contrary to predictions, there were no significant within or between group differences on problem-solving performance. Concreteness of problem solutions was the only consistent predictor of problem-solving effectiveness.

LIMITATIONS

Study did not directly assess problem-solving for personal problems.

CONCLUSIONS

Disparities in self-appraisal may account for lack of worry-related performance differences. Findings suggest that when employing problem-solving interventions with a high worry population, emphasis should be placed on changing maladaptive problem attitudes. Nonclinical and clinical populations alike may benefit from incorporating training in concreteness in problem-solving therapy.

Focus on and venting of negative emotion mediates the 18-year bi-directional relations between major depressive disorder and generalized anxiety disorder diagnoses

BACKGROUND

Myriad emotion regulation and coping theories have proposed that avoidant/emotion-oriented coping is a cause and consequence of anxiety and depression. However, few studies have investigated potential mechanisms underlying the prospective anxiety-depression disorder relation. The current study examined various coping strategies (i.e., denial, focus on and venting of emotion (FOAVE), and behavioral disengagement) as potential longitudinal mediators between generalized anxiety disorder (GAD) and major depressive disorder (MDD).

METHODS

In a nationally representative sample of adults (N = 3,294), MDD and GAD were assessed at Time 1 (T1) and Time 3 (T3) (Composite International Diagnostic Interview - Short-Form), and avoidant coping strategies (denial, behavioral disengagement, and FOAVE) were measured at Time 2 (T2) (Coping Questionnaire). Assessments occurred over 18 years, each spaced approximately 9 years apart. Structural equation modeling mediation analyses examined whether T1 MDD predicted T3 GAD (and vice versa), and if T2 avoidant coping mediated these relations, above and beyond baseline comorbidity.

RESULTS

FOAVE mediated the T1 MDD-T3 GAD association, and vice versa. Presence of T1 MDD and GAD predicted more T2 FOAVE, and greater T2 FOAVE forecasted T3 MDD and GAD, accounting for 16-21% of the longitudinal MDD-GAD relations. However, behavioral disengagement and denial did not mediate the prospective MDD-GAD relations. Also, T1 MDD and GAD forecasted greater T2 behavioral disengagement.

CONCLUSIONS

The use of FOAVE, may be a mechanism by which MDD earlier in life may lead to GAD 18 years later, and vice versa. Theoretical and potential clinical implications are discussed.

A Case Report of Problem Solving Therapy for Reducing Suicide Risk in Older Adults with Anxiety Disorders

Objectives: Suicide is a global public health problem among older adults. Problem-solving therapy (PST) has demonstrated promise in reducing late-life suicide risk, chiefly in secondary analyses of studies on late-life depression. PST mitigates negative beliefs about one's problem-solving abilities and maladaptive problem-solving styles, which suicidal older adults report. The effects of PST on suicide risk in older adults with primary anxiety disorder diagnoses have not been examined. Anxiety is a risk factor for suicide, but it is less studied in research on suicide compared to depression. This paper describes two cases of older individuals with anxiety disorders and suicidal ideation who completed six sessions of PST. Methods: Assessments of suicide risk, anxiety, depressive symptoms, and problem-solving ability were administered. Results: Both cases exhibited a clinically significant reduction in suicide risk, along with reductions in anxiety, worry, and depressive symptoms by posttreatment. Conclusions & Clinical Implications: Findings highlight the potential for PST as a psychotherapeutic intervention for reducing suicide risk in older adults with anxiety disorders.

Coping strategies and their relationship with emotional intelligence in patients with epilepsy referred to Isfahan Epilepsy Society in 2017

INTRODUCTION

Epilepsy is a common neurological disorder, and the patients with epilepsy are heavily influenced by the psychological and social aspects of the illness. Therefore, patients try to use coping strategies to control their stress and tension in this situation. Given the importance of the issue of adaptation and coping with stress in patients with epilepsy, as well as the different factors affecting coping strategies in these patients, the present study aimed to investigate the relationship between coping strategies and emotional intelligence in patients with epilepsy.

METHODS

This descriptive-analytic study conducted on 134 male and female patients with epilepsy referred to the Epilepsy Society of Isfahan, Iran. The consecutive sampling method was applied in this study. The data collection tool included a three-section questionnaire: the Demographic information, the Coping Inventory for Stressful Situations (CISS), and the Bar-On Emotional Quotient Inventory (EQ-i).

RESULTS

The emotion-focused coping strategy was mostly used by 53.7% of the samples. The mean and standard deviation of the total score of emotional intelligence was 285.6 ± 39.5. Moreover, Pearson correlation test showed a significant difference between emotional intelligence variables and coping strategies (p < 0.001).

CONCLUSION

According to the relationship between emotional intelligence and coping strategies, it is suggested to consider ways to improve the emotional intelligence of patients with epilepsy in order to use more adaptive coping strategies.

A Feasibility Open Trial of a Brief Internet-Delivered Written Exposure Therapy for Worry

Background: Cognitive exposure, a treatment of choice for hypothetical fears, involves listening repeatedly to a recorded scenario of one's worst hypothetical fear. A major limitation, however, is that the script cannot be easily modified. Aims: The current study assessed the feasibility of a brief guided internet-based written exposure therapy (iWET) for hypothetical fears, Mind at Peace. Method: Fifty-three adults presenting clinical levels of anxiety (GAD-7 ≥ 8) and worry (PSWQ ≥ 45) were recruited. A single group pre-test/post-test design including a 3-month follow-up was used. Mind at Peace is a 6-week iWET consisting of psychoeducation and five 30-minute weekly writing exposure sessions. Feasibility outcome measures included treatment adherence, attrition, treatment acceptability and preliminary efficacy. Primary outcome measures were the Generalized Anxiety Disorder-7 (GAD-7) and the Penn State Worry Questionnaire (PSWQ). Results: Attrition was higher (57%) and adherence lower (28%) than expected. Intent-to-treat repeated measures ANOVAs revealed significant and large improvements on the GAD-7 (ƞp2 = 0.36) and the PSWQ (ƞp2 = 0.23) with similar findings among study completers. Remission rates were higher on the GAD-7 than on the PSWQ, suggesting that Mind at Peace may primarily target general symptoms of generalized anxiety. Rates of acceptability varied, but nearly all study completers reported that they would recommend this treatment to a friend. Conclusions: This study provided valuable information on Mind at Peace. Methodological changes are proposed to improve its feasibility. A more definitive trial incorporating suggested methodological improvements is recommended.

Prolonged Exposure Therapy for Experiential Avoidance: A Case-Series Study

Past research has found that experiential avoidance (EA) is a type of avoidance that is common in individuals who report distress associated with traumatic events. No treatment studies to date have evaluated potential changes in EA associated with prolonged exposure therapy (PE), an empirically supported treatment for traumatic distress. This case series presents outcomes associated with treatment by PE for five adults who presented with posttraumatic stress disorder (PTSD), comorbid generalized anxiety disorder (GAD), and problematic EA. PTSD, GAD, depression, and EA symptoms were monitored at baseline, post-treatment, and 1-month follow-up. The five participants reported decreases in PTSD to below clinical cutoff criteria at post-treatment, all five participants reported decreases in depression at post-treatment, and four of the participants showed decreases in GAD and EA at post-treatment. In comparing pre-treatment to 1-month follow-up scores, all the participants reported decreases in PTSD, GAD, depression, and all but one participant reported a decrease in EA. The findings of this study suggest that PE may be a helpful treatment for individuals reporting EA.

Systematic review and meta-analysis of dropout rates in individual psychotherapy for generalized anxiety disorder

BACKGROUND

Despite being a relatively prevalent and debilitating disorder, Generalized Anxiety Disorder (GAD) is the second least studied anxiety disorder and among the most difficult to treat. Dropout from psychotherapy is concerning as it is associated with poorer outcomes, leads to service inefficiencies and can disproportionately affect disadvantaged populations. No study to date has calculated a weighted mean dropout rate for GAD and explored associated correlates.

METHODS

A systematic review was conducted using PsycINFO, Medline and Embase databases, identifying studies investigating individual psychotherapies for adults with GAD. Forty-five studies, involving 2224 participants, were identified for meta-analysis.

RESULTS

The weighted mean dropout rate was 16.99% (95% confidence interval 14.42%-19.91%). The Q-statistic indicated significant heterogeneity among studies. Moderator analysis and meta-regressions indicated no statistically significant effect of client age, sex, symptom severity, comorbidity, treatment type, study type (randomized trial or not), study quality, number of sessions or therapist experience.

CONCLUSIONS

In research investigating psychotherapy for GAD, approximately one in six clients can be expected to drop out of treatment. Dropout rate was not significantly moderated by the client, therapist or treatment variables investigated. Future research should specify the definition of dropout, reasons for dropout and associated correlates to assist the field's progression.

Internet-Based Extinction Therapy for Worry: A Randomized Controlled Trial

Worry is a common phenotype in both psychiatric patients and the normal population. Worry can be seen as a covert behavior with primary function to avoid aversive emotional experiences. Our research group has developed a treatment protocol based on an operant model of worry, where we use exposure-based strategies to extinguish the catastrophic worry thoughts. The aim of this study was to test this treatment delivered via the Internet in a large-scale randomized controlled trial. We randomized 140 high-worriers (defined as > 56 on the Penn State Worry Questionnaire [PSWQ]) to either Internet-based extinction therapy (IbET) or to a waiting-list condition (WL). Results showed that IbET was superior to WL with an overall large between-group effect size of d = 1.39 (95% confidence interval [1.04,1.73]) on the PSWQ. In the IbET group, 58% were classified as responders. The corresponding figure for WL participants was 7%. IbET was also superior to the WL on secondary outcome measures of anxiety, depression, meta-cognitions, cognitive avoidance, and quality of life. Overall treatment results were maintained for the IbET group at 4- and 12-month follow-up. The results from this trial are encouraging as they indicate that worry can be targeted with an accessible and novel intervention for worry. Replication trials with active control group are needed.

Testing a procedural variant of written imaginal exposure for generalized anxiety disorder

This experiment examined the degree to which it is more beneficial for individuals with generalized anxiety disorder (GAD) to engage in repeated exposure to mental imagery of the same feared scenario versus varying the exposure content. On three consecutive days, individuals with GAD (N=57) spent 20min writing about: (1) the same worst case scenario (consistent exposure; CE), (2) variations of their worst case scenario (varied exposure; VE), or (3) a neutral topic (neutral control; NC). Participants in the CE condition displayed significant decreases in worry, acute cognitive avoidance, and intolerance of uncertainty from baseline to 1-week follow-up; participants in the VE and NC conditions did not. Initial activation of self-reported anxiety (observed in the CE and VE conditions) and between-session reduction in anxiety (observed in the CE condition only) were associated with improvement in worry. Including more references to negative emotion and writing in the present tense were also associated with greater improvement in worry in the CE condition. These findings suggest that writing repeatedly about the same worst case scenario may benefit people with GAD. The study also provides information on potential mechanisms of change.

Helping highly anxious clients embrace chaos and career uncertainty using cognitive behavioural techniques

A primary tenet of Pryor and Bright’s Chaos Theory of Careers is that our world is full of change and unpredictability. When it comes to career development, rather than relying solely on good planning, one should accept and embrace unexpected changes and think creatively about possibilities. Although the Chaos Theory of Careers approach to counselling is logical and relevant to the real world, it may not be applied easily to clients with high levels of anxiety and low tolerance of uncertainty. The current paper explores the challenges of providing chaos career counselling to highly anxious clients. Borrowing concepts from a cognitive behavioural theory model for generalized anxiety disorder, this paper suggests several techniques from the cognitive behavioural theory literature that may facilitate chaos career counselling for anxious clients.

[Comorbidity in generalized anxiety disorder: prevalence and course after cognitive-behavioural therapy]

OBJECTIVE

To evaluate the prevalence and course of Axis I concurrent disorders in a population of patients who underwent cognitive-behavioural therapy (CBT) to treat their generalized anxiety disorder (GAD).

METHOD

This study is a secondary analysis combining patients from 3 treatment studies done at Université Laval. A total of 90 patients with a DSM-IV consistent GAD diagnosis received from 12 to 16 CBT sessions to treat GAD. Symptomatology was assessed at pretest, posttest, and 6 months after treatment, with the Anxiety Disorders Interview Schedule, a structured diagnostic interview.

RESULTS

Seventy-three per cent of patients had both GAD and a concurrent diagnosis. The most common diagnoses were simple phobia, social phobia, panic disorder, and major depression. CBT applied to GAD decreases the number of concurrent diagnoses. A panic disorder or a greater number of concurrent diagnoses at pretest is associated with a less efficient treatment at follow-up 6 months later.

CONCLUSION

Patients with GAD have a high comorbidity rate with other Axis I disorders, but these significantly decrease after a short CBT aimed at GAD. Implications for GAD treatment and mechanisms that might explain these findings are discussed.