Mindfulness-based Cognitive Therapy for Generalized Anxiety Disorder: A Preliminary Evaluation

Listen to the Children: Elementary School Students' Perspectives on a Mindfulness Intervention

In recent years, mindfulness-based practices in grade schools have been associated with students' improved cognitive skills and general classroom behavior. In the majority of studies, however, only teacher and parent feedback are elicited, omitting a considerably significant voice - that of the students. Our study aims to fill this gap by exploring student opinions and perceptions regarding the implementation of a classroom-based mindfulness program. Elementary school students (N = 51) took part in teacher-facilitated mindfulness activities which were incorporated into their daily classroom routines. Over the course of the 8-week intervention period, students participated in focus groups about their perceptions of the program. Through qualitative content analysis, two major findings emerged from the focus group data: student opinions about the mindfulness program varied substantially and the mindfulness activities were not always liked and enjoyed. Critically, if students do not enjoy classroom-based mindfulness programs, they may be less motivated to engage in mindful activities and in turn may not experience the benefits that mindfulness has to offer. To maximize student engagement with mindfulness while addressing their concerns, the following recommendations are made: A balance between the entertaining and educational aspects of the program, flexible program delivery, and encouraging students to pursue mindful living outside of the classroom. This research is important to educational and clinical practitioners as student insight will benefit the development and modification of classroom-based mindfulness programs to ensure that students are better able to engage with and benefit from these programs.

When Mindfulness Becomes a Mental Health Risk: The Relevance of Emotion Regulation Difficulties and Need Frustration

Although a great deal of research has shown the positive effects of mindfulness on mental health, some studies have provided evidence that mindfulness can have negative consequences. However, not much is known about the conditions that can account for such negative effects. We examined the moderating roles of difficulties in emotion regulation and basic psychological need frustration in the relationship between mindfulness and psychological ill-being. Longitudinal data were collected at three points in time during a 6-month period from two adult samples in Turkey and Germany. Self-report measures were used to measure ill-being, mindfulness, emotion regulation difficulties, and need frustration. In the German sample, difficulties in emotion regulation and need frustration were related to ill-being, but there were no significant interactions. In the Turkish sample, need frustration predicted ill-being, and the interaction between mindfulness and difficulties in emotion regulation also predicted ill-being. Mindfulness was a protective factor among people with no major difficulties in emotion regulation, whereas it was a risk factor among those with emotion regulation difficulties. The findings suggest that the relationship between mindfulness and ill-being may be more complex than previously thought.

Cognitive Behavioral Therapy and Mindfulness-Based Cognitive Therapy for Depressive Disorders

Recently, the importance of cognitive behavioral therapy (CBT) in the treatment of depression is gradually emerging. Particularly, mindfulness meditation has various approaches related to dialectical behavioral therapy (DBT), acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), and evidence has been provided that they alleviate depressive symptoms. In particular, as MBCT increases the level of evidence in the treatment of repetitive depressive disorders, guidelines are being recommended to prevent recurrence. Mindfulness may also contribute to improving the patient's symptoms as well as improving the therapeutic relationship with the therapist. For both mindful patients and therapists, positive awareness of internal experiences can be a good way to enrich the mind and overcome depressive disorders.

Efficacy of an acceptance-based group behavioral therapy for generalized anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) shows the weakest treatment response among anxiety disorders. This study aimed at examining whether an acceptance-based group behavioral therapy (ABBT) for patients in a Brazilian anxiety disorders program, combining mindfulness and exposure strategies, can improve clinical outcome when compared with a standard nondirective supportive group therapy (NDST).

METHODS

Ninety-two individuals diagnosed with GAD were randomized to receive 10 sessions of either ABBT or NDST. Assessments at pretreatment, midtreatment, posttreatment, and 3-month follow-up comprised the following outcome measures: Hamilton Anxiety Rating Scale (HAM-A), Penn State Worry Questionnaire (PSWQ), Depression Anxiety and Stress Scale (DASS), and the Clinical Global Impressions (CGI). The World Health Organization Quality of Life (WHOQOL) was administered at pretreatment and posttreatment.

RESULTS

The mixed-effects regression models for DASS-stress, Hamilton Anxiety Interview, and CGI showed a significant effect for Time and the Time × Treatment effect, but not for the Treatment main effect. Similarly, there was a significant Time × Treatment effect for the PSWQ, but not main effects of Time or Treatment. Altogether, these data indicate that symptoms decreased in both conditions across treatment and follow-up, and that the rate of change was more rapid for those participants in the ABBT condition. We found no differences between groups from pretreatment to posttreatment in DASS-anxiety or any secondary outcome measure, but for the physical health domain of WHOQOL, which was faster in ABBT.

CONCLUSIONS

Both groups showed good clinical outcomes, but in general, participants of the ABBT group improved faster than those in the NDST group.

Relating mindfulness and executive function in children

Despite the important role of cognitions in mindful awareness, research on the cognitive processes underlying mindfulness in young populations is scarce. This study explores the association between the core executive functions (i.e. inhibition, working memory, and shifting) and mindfulness within the same model in a sample of children. Seventy-two parent-child dyads participated in the study. Difficulties with executive functioning and child mindfulness level were assessed. Inhibition, working memory, and shifting were significantly correlated with mindfulness. Furthermore, moderate to good fit was found in a model testing the association between mindfulness and the latent executive function variable composed by the three executive functions, and individual executive functions demonstrated significant loadings in relation to the latent variable. In a model relating mindfulness to each individual executive function, mindfulness was uniquely associated with inhibition, working memory, and shifting. The application of current theoretical models of mindfulness to child populations and clinical implications are discussed.

The experiences of lay health workers trained in task-shifting psychological interventions: a qualitative systematic review

Introduction

The prevalence of common mental disorders, such as depression and anxiety, is high and the demand for psychological interventions and talking therapies is increasing. In order to meet this need, it is necessary to explore alternative methods to deliver talking therapies. Training lay health workers (LHWs) to deliver psychological interventions might be one possible solution to address current gaps in service provision. A number of studies have successfully used this approach to deliver psychological interventions in order to meet the demand for mental health care. Despite increased interest in this area, the evidence has not been synthesised or systematically reviewed.

Methods

Electronic databases (MEDLINE, EMBBASE, PsycINFO and CINHAL) were systematically searched to specifically capture studies on task-shifting psychological interventions for common mental disorders. Data were extracted on the experiences of the lay-workers on training and therapy delivery. Thematic analysis was used to analyse the data. Themes and subthemes of LHWs views on receiving training, barriers and facilitators to therapy delivery, factors required to become a successful therapist and the impact of training and therapy delivery on the therapists are described.

Results

10 studies were eligible for inclusion. Key messages were: LHWs were satisfied with training but wanted more robust supervision; not enough time was given to training on understanding mental health problems; LHWs grew in confidence and this impacted on their personal relationships with others.

Conclusion

This is the first review to explore LHWs experiences in training and therapy delivery by synthesising existing qualitative research. A number of key messages derived out of this review can help in further improving the quality of the training programmes and highlighting the benefits that are available for the LHW in delivering psychological interventions.

All together now: utilizing common functional change principles to unify cognitive behavioral and mindfulness-based therapies

Cognitive behavior therapy (CBT) and mindfulness-based interventions (MBI) have made important contributions to resolving the global burden of mental illness. However, response rates are comparatively more modest for the distress disorders. Newer CBTs enriched with MBI components have emerged with promising findings for distress disorders but with a high degree of heterogeneity and, subsequently, an unclear path for determining the unique and synergistic contributions from CBTs and MBIs. We propose that one way to elucidate and improve upon this union is to identify common overarching principles (i.e. attention change; metacognitive change) that guide both approaches and to refine therapeutic processes to optimally reflect these common targets and their interplay (e.g. sequencing and dosing).

Evaluation of a Mindfulness-Based Intervention With and Without Virtual Reality Dialectical Behavior Therapy® Mindfulness Skills Training for the Treatment of Generalized Anxiety Disorder in Primary Care: A Pilot Study

Generalized Anxiety Disorder (GAD) is a very prevalent disorder in primary care (PC). Most patients with GAD never seek treatment, and those who do seek treatment often drop out before completing treatment. Although it is an understudied treatment, Mindfulness-Based Interventions (MBIs) indicate preliminary efficacy for the treatment of GAD symptoms, but many patients with GAD present other associated symptoms (e.g., attention deficits) that complicate the treatment. Virtual Reality DBT® Mindfulness Skills learning has recently been developed to make learning mindfulness easier for patients with emotion dysregulation who have trouble concentrating. Virtual Reality (VR) might serve as a visual guide for practicing mindfulness as it gives patients the illusion of "being there" in the 3D computer generated world. The main goal of this study was to evaluate the effect of two MBIs (a MBI in a group setting alone and the same MBI plus 10 min VR DBT® Mindfulness skills training) to reduce GAD symptoms. A secondary aim was to explore the effect in depression, emotion regulation, mindfulness, and interoceptive awareness. Other exploratory aims regarding the use of VR DBT® Mindfulness skills were also carried out. The sample was composed of 42 patients (roughly half in each group) with GAD attending PC visits. After treatment, both groups of patients showed significant improvements in General Anxiety Disorder measured by the GAD-7 using mixed regression models [MBI alone (B = -5.70; p < 0.001; d = -1.36), MBI+VR DBT® Mindfulness skills (B = -4.38; p < 0.001; d = -1.33)]. Both groups also showed significant improvements in anxiety, depression, difficulties of emotion regulation and several aspects of mindfulness and interoceptive awareness. Patients in the group that received additional 10 min VR DBT Mindfulness Skills training were significantly more adherent to the treatment than those receiving only standard MBI (100% completion rate in MBI + VR vs. 70% completion rate in MBI alone; Fisher = 0.020). Although randomized controlled studies with larger samples are needed, this pilot study shows preliminary effectiveness of MBI to treat GAD, and preliminary evidence that adjunctive VR DBT® Mindfulness Skills may reduce dropouts.

Facets of Mindfulness in Adults with Generalized Anxiety Disorder and Impact of Co-occurring Depression

Anxiety and depressive symptoms are associated with lower levels of mindfulness, yet few studies to date have examined facets of mindfulness in adults with Generalized Anxiety Disorder (GAD). In this study, we examined differences in mindfulness between individuals with GAD with and without concurrent Major Depressive Disorder (MDD) and/or Dysthymic Disorder (DD). We also examined the associations of anxiety and depressive symptoms with facets (subscales) of mindfulness. We hypothesized that individuals with primary GAD and co-occurring MDD/DD would exhibit lower mindfulness than those without a concurrent depressive disorder. We also hypothesized that mindfulness would be negatively correlated with worry and depressive symptom severity. Subjects were 140 adults (M (SD) age = 33.4 (12.9); 73% female) with a primary diagnosis of GAD; 30.8% (n = 43) also met criteria for current MDD/DD as determined by a structured clinical interview for DSM-IV. Current worry and depressive symptoms were assessed using self-report measures at baseline of a 12-week treatment study. Individuals with GAD and co-occurring MDD/DD exhibited significantly lower mindfulness than those without a depressive disorder diagnosis and specifically lower scores on the Awareness sub-scale compared to individuals with primary GAD and no comorbid depression. In terms of the dimensional impact of worry and depression ratings, depression symptoms independently predicted lower Awareness scores and worry independently predicted lower levels of Nonreacting and Nonjudging sub-scales. This may have direct treatment implications.

Feasibility study of mindfulness-based cognitive therapy for anxiety disorders in a Japanese setting

Objective

Mindfulness-based cognitive therapy (MBCT) could be a treatment option for anxiety disorders. Although its effectiveness under conditions of low pharmacotherapy rates has been demonstrated, its effectiveness under condition of high pharmacotherapy rate is still unknown. The aim of the study was to evaluate effectiveness of MBCT under the context of high pharmacotherapy rates.

Results

A single arm with pre-post comparison design was adopted. Those who had any diagnosis of anxiety disorders, between the ages of 20 and 74, were included. Participants attended 8 weekly 2-hour-long sessions followed by 2 monthly boosters. Evaluation was conducted at baseline, in the middle, at end of the intervention, and at follow-up. The State-Trait Anxiety Inventory (STAI)-state was set as the primary outcome. Pre-post analyses with mixed-effect models repeated measures were conducted. Fourteen patients were involved. The mean age was 45.0, and 71.4% were female. The mean change in the STAI-state at every point showed statistically significant improvement. The STAI-trait also showed improvement at a high significance level from the very early stages. The participants showed significant improvement at least one point in some other secondary outcomes.

Trial registration Retrospectively registered at the University Hospital Medical Information Network on 1st August 2013 (ID: UMIN000011347)

Mindfulness-Based Treatment for Bipolar Disorder: A Systematic Review of the Literature

Despite the increasing number of studies examining the effects of mindfulness interventions on symptoms associated with Bipolar Disorder (BD), the effectiveness of this type of interventions remains unclear. The aim of the present systematic review was to (i) critically review all available evidence on Mindfulness Based Cognitive Therapy (MBCT) as a form of intervention for BD; (ii) discuss clinical implications of MBCT in treating patients with BD; and (iii) provide a direction for future research. The review presents findings from 13 studies (N = 429) that fulfilled the following selection criteria: (i) included BD patients; (ii) presented results separately for BD patients and control groups (where a control group was available); (iii) implemented MBCT intervention; (iv) were published in English; (v) were published in a peer reviewed journal; and (vi) reported results for adult participants. Although derived from a relatively small number of studies, results from the present review suggest that MBCT is a promising treatment in BD in conjunction with pharmacotherapy. MBCT in BD is associated with improvements in cognitive functioning and emotional regulation, reduction in symptoms of anxiety depression and mania symptoms (when participants had residual manic symptoms prior to MBCT). These, treatment gains were maintained at 12 month follow up when mindfulness was practiced for at least 3 days per week or booster sessions were included. Additionally, the present review outlined some limitations of the current literature on MBCT interventions in BD, including small study sample sizes, lack of active control groups and idiosyncratic modifications to the MBCT intervention across studies. Suggestions for future research included focusing on factors underlying treatment adherence and understanding possible adverse effects of MBCT, which could be of crucial clinical importance.

The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder

Research with non-clinical and clinical samples has examined how mindfulness concepts relate to psychological symptom presentations. However, there is less clarity when examining treatment-seeking patients who experience DSM-diagnosed anxiety and obsessional disorders - both cross-sectionally, and following empirically-supported treatments. The Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) conceptualizes mindfulness as consisting of five facets: Observing, Describing, Acting with Awareness, Nonreactivity, and Nonjudging. The current study examines the factor structure and predictive validity of the FFMQ in a large sample of treatment-seeking individuals with obsessive compulsive disorder (OCD), panic disorder with or without agoraphobia (PD/A), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). Confirmatory factor analyses (CFA) established that both four and five-factor models (i.e., with and without inclusion of the Observing factor) provided an acceptable representation of the underlying FFMQ structure, but did not support a one-factor solution. For each of these diagnostic groups, hierarchical regression analyses clarified the association between specific FFMQ facets and diagnosis specific symptom change during CBT treatment. These findings are discussed in the context of the possible transdiagnostic relevance of specific mindfulness facets, and how these facets are differentially associated with diagnosis specific symptom alleviation during CBT.

Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial

BACKGROUND

Research suggests that an 8-week mindfulness-based cognitive therapy (MBCT) course may be effective for generalised anxiety disorder (GAD).

AIMS

To compare changes in anxiety levels among participants with GAD randomly assigned to MBCT, cognitive-behavioural therapy-based psychoeducation and usual care.

METHOD

In total, 182 participants with GAD were recruited (trial registration number: CUHK_CCT00267) and assigned to the three groups and followed for 5 months after baseline assessment with the two intervention groups followed for an additional 6 months. Primary outcomes were anxiety and worry levels.

RESULTS

Linear mixed models demonstrated significant group × time interaction (F(4,148) = 5.10, P = 0.001) effects for decreased anxiety for both the intervention groups relative to usual care. Significant group × time interaction effects were observed for worry and depressive symptoms and mental health-related quality of life for the psychoeducation group only.

CONCLUSIONS

These results suggest that both of the interventions appear to be superior to usual care for the reduction of anxiety symptoms.

Cognitive Hypnotherapy for Accessing and Healing Emotional Injuries for Anxiety Disorders

Although anxiety disorders on the surface may appear simple, they often represent complex problems that are compounded by underlying factors. For these reasons, treatment of anxiety disorders should be individualized. This article describes cognitive hypnotherapy, an individual comprehensive treatment protocol that integrates cognitive, behavioral, mindfulness, psychodynamic, and hypnotic strategies in the management of anxiety disorders. The treatment approach is based on the self-wounds model of anxiety disorders, which provides the rationale for integrating diverse strategies in the psychotherapy for anxiety disorders. Due to its evidence-based and integrated nature, the psychotherapy described here provides accuracy, efficacy, and sophistication in the formulation and treatment of anxiety disorders. This model can be easily adapted to the understanding and treatment of other emotional disorders.

AN OPEN TRIAL OF EMOTION REGULATION THERAPY FOR GENERALIZED ANXIETY DISORDER AND COOCCURRING DEPRESSION

BACKGROUND

Although CBT is efficacious for a wide variety of psychiatric conditions, relatively fewer GAD patients achieve high endstate functioning as compared to patients receiving CBTs for other disorders. Moreover, GAD trials that utilized patient samples without prominent depression have tended to report that effect sizes for depressive outcomes were small or diminished to pretreatment levels in the follow-up period. Emotion regulation therapy (ERT) integrates principles from traditional and contemporary cognitive behavioral treatments with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on motivational, regulatory, and contextual learning mechanisms.

METHOD

The purpose of this investigation was to provide initial support for the efficacy of ERT in an open trial of patients with GAD and cooccurring depressive symptoms. Twenty-one patients received a 20-session version of ERT delivered in weekly individual sessions. Standardized clinician ratings and self-report measures were assessed at pre-, mid-, and posttreatment as well as at three- and nine-month follow-ups. Intent-to-treat analyzes were utilized.

RESULTS

GAD patients, half with comorbid major depression, evidenced statistically, and clinically meaningful improvements in symptom severity, impairment, quality of life, and in model-related outcomes including emotional/motivational intensity, mindful attending/acceptance, decentering, and cognitive reappraisal. Patients maintained gains across the three and nine month follow-up periods.

CONCLUSIONS

These findings, although preliminary, provide additional evidence for the role of emotion dysregulation in the onset, maintenance, and now treatment of conditions such as GAD and cooccurring depressive symptoms.

Group mindfulness based cognitive therapy vs group support for self-injury among young people: study protocol for a randomised controlled trial

BACKGROUND

Non-suicidal self-injury (NSSI) is a transdiagnostic behaviour that can be difficult to treat; to date no evidence based treatment for NSSI exists. Mindfulness Based Cognitive Therapy (MBCT) specifically targets the mechanisms thought to initiate and maintain NSSI, and thus appears a viable treatment option. The aims of the current study are to test the ability of MBCT to reduce the frequency and medical severity of NSSI, and explore the mechanisms by which MBCT exerts its effect.

METHODS/DESIGN

We will conduct a parallel group randomised controlled trial of Mindfulness Based Cognitive Therapy (MBCT) versus Supportive Therapy (ST) in young people aged 18-25 years. Computerised block randomisation will be used to allocate participants to groups. All participants will meet the proposed DSM-5 criteria for NSSI (i.e. five episodes in the last twelve months). Participants will be excluded if they: 1) are currently receiving psychological treatment, 2) have attempted suicide in the previous 12 months, 3) exhibit acute psychosis, 4) have a diagnosis of borderline personality disorder, or 5) have prior experience of MBCT. Our primary outcome is the frequency and medical severity of NSSI. As secondary outcomes we will assess changes in rumination, mindfulness, emotion regulation, distress tolerance, stress, and attentional bias, and test these as mechanisms of change.

DISCUSSION

This is the first randomised controlled trial to test the efficacy of MBCT in reducing NSSI. Evidence of the efficacy of MBCT for self-injury will allow provision of a brief intervention for self-injury that can be implemented as a stand-alone treatment or integrated with existing treatments for psychiatric disorders.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number ACTRN12615000023550 . Registered 16 January 2015.

Anxiety and compulsion patterns in the maintenance of bingeing/purging behaviours by individuals with bulimia nervosa

Bulimia nervosa, if not treated or if treated unsuccessfully, can develop into a severe and enduring eating disorder. Analysis of self-management of Seed-BN indicates that individuals frequently experience significant negative mental health issues and a complex relationship with medication management. Two discrete patterns of coping strategies to prevent deterioration in distressing symptoms were in evidence, controlled vomiting, which was related to the management of anxiety, and uncontrolled vomiting due to more dominant self-management of compulsive acts. The implications for nursing revolve around accurate assessment of vomiting and subsequent engagement by the individual with their coping strategies in relation to perceived deterioration in distressing symptoms. This paper reports on the results of a study into the self-reported coping strategies employed by a small sample (n = 12) of individuals diagnosed with bulimia nervosa purging sub-type, severe and enduring eating disorder (Seed-BN), referred to an outpatient clinic for psychotherapy. Data collection focused on the vomiting activities of participants through analysis of their self-management from diary extracts, which recorded vomiting patterns. Participants all experienced significant mental health issues, had complex histories of BN over a prolonged period, difficulties maintaining relationships, and many had an additional history of substance misuse including dependence on prescription drugs. The study findings indicated two different self-management strategies, anxiety containment and compulsion maintenance. There was a clear association between anxiety and controlled weekly vomiting patterns compared with compulsion and daily vomiting patterns. The implications for nursing practice relate to the potential for assessment of differences in vomiting patterns to indicate self-management status and subsequent interventions focusing on either anxiety or compulsive patterns.

The role of emotion and emotion regulation in social anxiety disorder

Many psychiatric disorders involve problematic patterns of emotional reactivity and regulation. In this review, we consider recent findings regarding emotion and emotion regulation in the context of social anxiety disorder (SAD). We first describe key features of SAD which suggest altered emotional and self-related processing difficulties. Next, we lay the conceptual foundation for a discussion of emotion and emotion regulation and present a common framework for understanding emotion regulation, the process model of emotion regulation. Using the process model, we evaluate the recent empirical literature spanning self-report, observational, behavioral, and physiological methods across five specific families of emotion regulation processes-situation selection, situation modification, attentional deployment, cognitive change, and response modulation. Next, we examine the empirical evidence behind two psychosocial interventions for SAD: cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR). Throughout, we present suggestions for future directions in the continued examination of emotion and emotion regulation in SAD.

CALM Pregnancy: results of a pilot study of mindfulness-based cognitive therapy for perinatal anxiety

Many women experience anxiety during pregnancy with potential negative effects on maternal, birth, and child outcomes. Because of potential risks of fetal exposure to psychotropic medications, efficacious non-pharmacologic approaches are urgently needed. However, no published studies of psychotherapeutic treatments for anxiety in pregnancy exist. Mindfulness-based cognitive therapy (MBCT) may substantially reduce anxiety and co-morbid symptoms in people with anxiety disorders. Coping with Anxiety through Living Mindfully (CALM) Pregnancy is an adaptation of MBCT designed to address anxiety in pregnant women. This study examined the feasibility, acceptability, and clinical outcomes of the CALM Pregnancy intervention in pregnant women anxiety. Twenty-four pregnant women with generalized anxiety disorder (GAD) or prominent symptoms of generalized anxiety participated in an open treatment trial of the CALM Pregnancy group intervention. Psychiatric diagnoses were determined by structured clinical interview, and self-report measures of anxiety, worry, depression, self-compassion, and mindfulness were completed at baseline and post-intervention. Qualitative feedback was elicited via questionnaire. Twenty-three participants completed the intervention with high attendance and good compliance with home practice. Completers showed statistically and clinically significant improvements in anxiety, worry, and depression, and significant increases in self-compassion and mindfulness. Of the 17 participants who met GAD criteria at baseline, only one continued to meet criteria post-intervention. Participants regarded their experience in the intervention to be overwhelmingly positive. MBCT in the form of the CALM Pregnancy intervention holds potential to provide effective, non-pharmacological treatment for pregnant women with anxiety. These promising findings warrant further testing of the intervention with a randomized controlled trial.

Mindfulness and acceptance-based behavioral therapies for anxiety disorders

This article presents a brief conceptual overview of acceptance-based behavioral therapies (ABBTs) for anxiety disorders, followed by a review and summary of the recent efficacy studies of ABBTs for anxiety and comorbid disorders. We discuss clinical implications, including the importance of targeting reactivity and experiential avoidance in interventions for anxiety disorders through the use of mindfulness and other acceptance-based strategies, as well the encouragement of engagement in meaningful activities or valued action. We also address future directions for research, such as expanding research to include more randomized control trials comparing ABBTs for specific anxiety disorders to other active treatments, examining mechanisms of change, exploring adaptations in different care-delivery contexts, as well as determining the applicability of these approaches to clients from marginalized or non-dominant statuses.

Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders

OBJECTIVE

To compare a mindfulness-based intervention with cognitive behavioral therapy (CBT) for the group treatment of anxiety disorders.

METHOD

One hundred five veterans (83% male, mean age=46 years, 30% minority) with one or more DSM-IV anxiety disorders began group treatment following randomization to adapted mindfulness-based stress reduction (MBSR) or CBT.

RESULTS

Both groups showed large and equivalent improvements on principal disorder severity thru 3-month follow up (ps<.001, d=-4.08 for adapted MBSR; d=-3.52 for CBT). CBT outperformed adapted MBSR on anxious arousal outcomes at follow up (p<.01, d=.49) whereas adapted MBSR reduced worry at a greater rate than CBT (p<.05, d=.64) and resulted in greater reduction of comorbid emotional disorders (p<.05, d=.49). The adapted MBSR group evidenced greater mood disorders and worry at Pre, however. Groups showed equivalent treatment credibility, therapist adherence and competency, and reliable improvement.

CONCLUSIONS

CBT and adapted MBSR were both effective at reducing principal diagnosis severity and somewhat effective at reducing self-reported anxiety symptoms within a complex sample. CBT was more effective at reducing anxious arousal, whereas adapted MBSR may be more effective at reducing worry and comorbid disorders.

Mindfulness-based stress reduction for comorbid anxiety and depression: case report and clinical considerations

Growing research literature has documented the effectiveness of mindfulness-based interventions for anxiety and depressive disorders. Mindfulness-based stress reduction (MBSR) teaches a series of mindfulness meditation and yoga practices, delivered in a group format during eight weekly sessions plus one full-day session. This case report demonstrates how MBSR was associated with dramatic clinical improvement of an individual with symptoms of panic, generalized anxiety, and depression. Scores on clinical assessment measures suggested clinically severe levels of anxious arousal, generalized anxiety, worry, fear of negative evaluation, and depression at the beginning of the intervention. The scores on all these measures fell well within normal limits 7 weeks later at the end of the intervention, and no remaining symptoms were reported afterward. Increased life satisfaction and quality of life were documented as well. This case illustrates the potential benefit of MBSR as an alternative or adjunctive treatment for comorbid anxiety and depressive disorder symptoms.

Psychological and neural mechanisms of trait mindfulness in reducing depression vulnerability

Mindfulness-based interventions are effective for reducing depressive symptoms. However, the psychological and neural mechanisms are unclear. This study examined which facets of trait mindfulness offer protection against negative bias and rumination, which are key risk factors for depression. Nineteen male volunteers completed a 2-day functional magnetic resonance imaging study. One day utilized a stress-induction task and the other day utilized a mindful breathing task. An emotional inhibition task was used to measure neural and behavioral changes related to state negative bias, defined by poorer performance in inhibiting negative relative to neutral stimuli. Associations among trait mindfulness [measured by the Five Facet Mindfulness Questionnaire (FFMQ)], trait rumination, and negative bias were examined. Non-reactivity scores on the FFMQ correlated negatively with rumination and negative bias following the stress induction. Non-reactivity was inversely correlated with insula activation during inhibition to negative stimuli after the mindful breathing task. Our results suggest non-reactivity to inner experience is the key facet of mindfulness that protects individuals from psychological risk for depression. Based on these results, mindfulness could reduce vulnerability to depression in at least two ways: (i) by buffering against trait rumination and negative bias and (ii) by reducing automatic emotional responding via the insula.

A randomized trial of MBSR versus aerobic exercise for social anxiety disorder

OBJECTIVE

Effective treatments for social anxiety disorder (SAD) exist, but additional treatment options are needed for nonresponders as well as those who are either unable or unwilling to engage in traditional treatments. Mindfulness-based stress reduction (MBSR) is one nontraditional treatment that has demonstrated efficacy in treating other mood and anxiety disorders, and preliminary data suggest its efficacy in SAD as well.

METHOD

Fifty-six adults (52% female; 41% Caucasian; age mean [M] ± standard deviation [SD]: 32.8 ± 8.4) with SAD were randomized to MBSR or an active comparison condition, aerobic exercise (AE). At baseline and post-intervention, participants completed measures of clinical symptoms (Liebowitz Social Anxiety Scale, Social Interaction Anxiety Scale, Beck Depression Inventory-II, and Perceived Stress Scale) and subjective well-being (Rosenberg Self-Esteem Scale, Satisfaction with Life Scale, Self-Compassion Scale, and UCLA-8 Loneliness Scale). At 3 months post-intervention, a subset of these measures was readministered. For clinical significance analyses, 48 healthy adults (52.1% female; 56.3% Caucasian; age [M ± SD]: 33.9 ± 9.8) were recruited. MBSR and AE participants were also compared with a separate untreated group of 29 adults (44.8% female; 48.3% Caucasian; age [M ± SD]: 32.3 ± 9.4) with generalized SAD who completed assessments over a comparable time period with no intervening treatment.

RESULTS

A 2 (Group) x 2 (Time) repeated measures analyses of variance (ANOVAs) on measures of clinical symptoms and well-being were conducted to examine pre-intervention to post-intervention and pre-intervention to 3-month follow-up. Both MBSR and AE were associated with reductions in social anxiety and depression and increases in subjective well-being, both immediately post-intervention and at 3 months post-intervention. When participants in the randomized controlled trial were compared with the untreated SAD group, participants in both interventions exhibited improvements on measures of clinical symptoms and well-being.

CONCLUSION

Nontraditional interventions such as MBSR and AE merit further exploration as alternative or complementary treatments for SAD.

The Continuing Evolution of Biopsychosocial Interventions for Chronic Pain

In the last several decades, great strides have been made in the treatment of persistent painful conditions. The scope of treatment has shifted from purely biomedical, including approaches built upon cognitive, behavioral, and social psychological principles. This article reports and discusses several key paradigm shifts that fueled this revolutionary change in the management of chronic pain. The progressive development of theoretical metamodels and treatment conceptualizations is presented. Cognitive behavioral therapy (CBT) is the most widely accepted biopsychosocial treatment for chronic pain and is founded upon a rich theoretical tradition. The CBT rationale, and empirical evidence to support its efficacy, is presented. The emergence and promise of mindfulness-based and acceptance-based interventions is also discussed. The article concludes with the assertion that future treatment outcome research should focus on understanding the treatment-specific and common factors associated with efficacy.

Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis

PURPOSE

Mindfulness- and acceptance-based interventions (MABIs) are receiving increasing attention in the treatment of mental disorders. These interventions might be beneficial for patients with anxiety disorders, but no prior reviews have comprehensively investigated the effects of this family of interventions on clinical samples. The aim of this study was to review and synthesize extant research on MABIs for patients with diagnoses of anxiety disorders.

METHODS

We conducted a systematic search of relevant databases according to pre-defined criteria. Studies were eligible for inclusion if they employed MABIs for patients diagnosed with anxiety disorders.

RESULTS

Nineteen eligible studies were found. Meta-analysis of within-group pre- to post-treatment effects yielded overall Hedges'g effect sizes of 1.08 for anxiety symptoms and 0.85 for depression symptoms. For controlled studies, overall between-group Hedges'g was 0.83 for anxiety symptoms and 0.72 for depression symptoms. Moderator analyses examined whether intervention type, design, treatment dosage, or patient sample was associated with systematic variation in effect sizes. No significant moderating effects were found on the variables examined, apart from an observed superiority in effect size for clinical trials on samples of patients with mixed anxiety disorders. However, differential effect sizes indicated benefits of adding specific psychotherapeutic content to mindfulness training, as well as an advantage of individual over group treatment.

CONCLUSIONS

MABIs are associated with robust and substantial reductions in symptoms of anxiety and comorbid depressive symptoms. More research is needed to determine the efficacy of MABIs relative to current treatments of choice, and to clarify the contribution of processes of mindfulness and acceptance to observed outcome.

Anger regulation in traumatized Cambodian refugees: the perspectives of Buddhist monks

Recent research has highlighted the importance of traditional methods of healing in relation to the treatment of psychological distress in non-Western populations. This pilot study, conducted in Massachusetts, investigates what Buddhist Cambodian monks consider to be the causes, phenomenology and appropriate intervention strategies for anger among Cambodian refugees. Six monks were interviewed at four major temples in Massachusetts. Findings suggested that anger was common in the Cambodian community, was frequently triggered by marital discord, and commonly resulted in verbal and physical violence and, sometimes, suicidality. Buddhist-based anger management strategies identified as useful by the monks included education about Buddhist doctrines, mindfulness meditation practices, and the use of herbal medication and holy water. These anger regulation strategies and treatments are discussed in the context of Buddhist beliefs and Western psychological interventions.

Effects of mindfulness on psychological health: a review of empirical studies

Within the past few decades, there has been a surge of interest in the investigation of mindfulness as a psychological construct and as a form of clinical intervention. This article reviews the empirical literature on the effects of mindfulness on psychological health. We begin with a discussion of the construct of mindfulness, differences between Buddhist and Western psychological conceptualizations of mindfulness, and how mindfulness has been integrated into Western medicine and psychology, before reviewing three areas of empirical research: cross-sectional, correlational research on the associations between mindfulness and various indicators of psychological health; intervention research on the effects of mindfulness-oriented interventions on psychological health; and laboratory-based, experimental research on the immediate effects of mindfulness inductions on emotional and behavioral functioning. We conclude that mindfulness brings about various positive psychological effects, including increased subjective well-being, reduced psychological symptoms and emotional reactivity, and improved behavioral regulation. The review ends with a discussion on mechanisms of change of mindfulness interventions and suggested directions for future research.

Mindfulness based cognitive therapy for psychiatric disorders: a systematic review and meta-analysis

Mindfulness- based Cognitive Therapy (MBCT) is a meditation program based on an integration of Cognitive behavioural therapy and Mindfulness-based stress reduction. The aim of the present work is to review and conduct a meta-analysis of the current findings about the efficacy of MBCT for psychiatric patients. A literature search was undertaken using five electronic databases and references of retrieved articles. Main findings included the following: 1) MBCT in adjunct to usual care was significantly better than usual care alone for reducing major depression (MD) relapses in patients with three or more prior depressive episodes (4 studies), 2) MBCT plus gradual discontinuation of maintenance ADs was associated to similar relapse rates at 1year as compared with continuation of maintenance antidepressants (1 study), 3) the augmentation of MBCT could be useful for reducing residual depressive symptoms in patients with MD (2 studies) and for reducing anxiety symptoms in patients with bipolar disorder in remission (1 study) and in patients with some anxiety disorders (2 studies). However, several methodological shortcomings including small sample sizes, non-randomized design of some studies and the absence of studies comparing MBCT to control groups designed to distinguish specific from non-specific effects of such practice underscore the necessity for further research.

The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: a systematic review and meta-analysis

BACKGROUND

Mindfulness-based cognitive therapy (MBCT) is a group-based clinical intervention program designed to reduce relapse or recurrence of major depressive disorder (MDD) by means of systematic training in mindfulness meditation combined with cognitive-behavioral methods.

OBJECTIVE

By means of a meta-analysis to evaluate the effect of MBCT for prevention of relapse or recurrence among patients with recurrent MDD in remission.

METHOD

Electronic databases were searched and researchers were contacted for further relevant studies. Studies were coded for quality. Meta-analyses were performed by means of the Cochrane Collaboration Review Manager 5.1.

RESULTS

Six randomized controlled trials with a total of 593 participants were included in the meta-analysis. MBCT significantly reduced the risk of relapse/recurrence with a risk ratio of 0.66 for MBCT compared to treatment as usual or placebo controls, corresponding to a relative risk reduction of 34%. In a pre-planned subgroup analysis the relative risk reduction was 43% for participants with three or more previous episodes, while no risk reduction was found for participants with only two episodes. In two studies, MBCT was at least as effective as maintenance antidepressant medication.

CONCLUSION

Results of this meta-analysis indicate that MBCT is an effective intervention for relapse prevention in patients with recurrent MDD in remission, at least in case of three or more previous MDD episodes.

Mindfulness-based cognitive therapy for nonremitted patients with bipolar disorder

INTRODUCTION

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, many individuals with bipolar disorder continue to experience substantial residual mood symptoms that often lead to the recurrence of mood episodes.

AIMS

This study explored whether a new mindfulness-based cognitive therapy (MBCT) for bipolar disorder would increase mindfulness, reduce residual mood symptoms, and increase emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning. Following a baseline clinical assessment, 12 individuals with DSM-IV bipolar disorder were treated with 12 group sessions of MBCT.

RESULTS

At the end of treatment, as well as at the 3 months follow-up, participants showed increased mindfulness, lower residual depressive mood symptoms, less attentional difficulties, and increased emotion-regulation abilities, psychological well-being, positive affect, and psychosocial functioning.

CONCLUSIONS

These findings suggest that treating residual mood symptoms with MBCT may be another avenue to improving mood, emotion regulation, well-being, and functioning in individuals with bipolar disorder.

The empirical status of the "new wave" of cognitive behavioral therapy

This article reviews the current state of empirical research on the purported "new wave" of cognitive behavioral therapy (CBT). A particular emphasis is given to mindfulness-based treatments and acceptance and commitment therapy (ACT). Mindfulness-based approaches and ACT are evaluated with regard to their efficacy and comparison with traditional CBT. Deviations from CBT are explained within the context of theory, specifically in terms of the role of cognitions. These differences, however, are not irreconcilable in requiring a separate classification of "new wave" treatments. While subtle and important differences on the theoretical and procedural level might exist, available data do not favor one treatment over another, and do not suggest differential mechanisms of action that warrant a dramatic separation from the CBT family of approaches. Instead, the "new wave" treatments are consistent with the CBT approach, which refers to a family of interventions rather than a single treatment. Thus, the term "new wave" is potentially misleading because it is not an accurate reflection of the contemporary literature.

Treating chronic worry: Psychological and physiological effects of a training programme based on mindfulness

The present study examines psychological and physiological indices of emotional regulation in non-clinical high worriers after a mindfulness-based training programme aimed at reducing worry. Thirty-six female university students with high Penn State Worry Questionnaire scores were split into two equal intervention groups: (a) mindfulness, and (b) progressive muscle relaxation plus self-instruction to postpone worrying to a specific time of the day. Assessment included clinical questionnaires, daily self-report of number/duration of worry episodes and indices of emotional meta-cognition. A set of somatic and autonomic measures was recorded (a) during resting, mindfulness/relaxation and worrying periods, and (b) during cued and non-cued affective modulation of defence reactions (cardiac defence and eye-blink startle). Both groups showed equal post-treatment improvement in the clinical and daily self-report measures. However, mindfulness participants reported better emotional meta-cognition (emotional comprehension) and showed improved indices of somatic and autonomic regulation (reduced breathing pattern and increased vagal reactivity during evocation of cardiac defense). These findings suggest that mindfulness reduces chronic worry by promoting emotional and physiological regulatory mechanisms contrary to those maintaining chronic worry.

Newer variations of cognitive-behavioral therapy: behavioral activation and mindfulness-based cognitive therapy

Recent innovations in the treatment and prevention of depression that build on the foundation of cognitive-behavioral therapy represent promising directions for clinical practice and research. Specifically, behavioral activation and mindfulness-based cognitive therapy have been a recent focus of attention. Behavioral activation is a brief, structured approach to treating acute depression that seeks to alleviate depression by promoting an individual's contact with sources of reward through increasing activation, improving problem solving, and decreasing avoidance and other barriers to activation. Mindfulness-based cognitive therapy is a brief group intervention that seeks to prevent depressive relapse by promoting mindful attention, acceptance, and skillful action to help individuals interrupt habitual cognitive and affective patterns associated with risk of relapse. Each approach is supported by at least two large-scale, randomized clinical trials; however, many important questions remain. We examine current research on both approaches by addressing the robustness of findings, the extension to novel populations, and the processes by which clinical benefit is achieved.