Cognitive biases in anxiety disorders and their effect on cognitive-behavioral treatment

How changes in depression severity and borderline personality disorder intensity are linked - a cohort study of depressed patients with and without borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is often complicated by comorbid major depressive episodes (MDEs), which can occur as part of major depressive disorder (MDD) or bipolar disorder (BD). Such comorbidity is related to worse outcomes in both disorders. Subsyndromal features of BPD are also common in depression. However, studies of simultaneous changes in BPD and depression severities are scarce, and their interactions are poorly understood.

AIMS

Studying the associations between changes in BPD and depression symptoms over the course of an MDE.

METHODS

In a 6-month naturalistic cohort study of MDE/BPD, MDE/MDD, and MDE/BD patients (N = 95), we measured change in BPD features between baseline and six months with the Borderline Personality Disorder Severity Index (BPDSI), an interviewer-rated instrument quantifying recent temporal frequency of BPD symptoms. We examined changes in BPD severity and their correlation with depression severity and other clinical measures and compared these across patient groups.

RESULTS

There were significant reductions in BPD severity, both in number of positive BPD criteria (-0.35, sd 1.38, p = 0.01672) and in BPDSI scores (-4.23, SD 6.74, p < 0.001), reflecting mainly a reduction in temporal frequency of symptoms. These were similar in all diagnostic groups. In multivariate regression models, changes in depression severity independently associated with changes in symptoms in the BDSI. This relationship was strongest in MDE/BPD patients but was not found in MDD patients without BPD.

CONCLUSIONS

In the six-month follow-up, BPD features in MDE patients alleviated mainly by decreasing temporal symptom frequency and intensity. In BPD patients with comorbid MDE, changes in both conditions are strongly correlated.

Influence of social support on cognitive reappraisal in young adults elevated on neuroticism

Social support offers protection from depression and anxiety, possibly through its beneficial effects upon cognitive reappraisal. The present study evaluates potential mechanisms of social support, utilizing a reappraisal task in 121 undergraduates elevated on neuroticism. Participants were instructed to reinterpret stressful images with (Social Condition) and without (Solo Condition) the reminder of a social support figure. Aversiveness, negative affect, and positive affect ratings, as well as written reappraisal responses, were collected trial-by-trial. Results indicated that participants reported lower aversiveness and negative affect and higher positive affect when reinterpreting images in the Social Condition compared to the Solo Condition. Analyses of adherence ratings of written reappraisals revealed that participants generated reinterpretations more in the Social Condition than in the Solo Condition. Exploratory mediation analyses indicated that Condition was indirectly associated with reappraisal efficacy as measured by aversiveness and affect ratings through reappraisal adherence. Results suggest that cognitive reappraisal with the influence of social support may be more effective than cognitive reappraisal without such social influence, and thus may be a suitable target for interventions for depression and anxiety.

Same same, but different: A psychometric examination of three frequently used experimental tasks for cognitive bias assessment in a sample of healthy young adults

Cognitive bias research draws upon the notion that altered information processing is key for understanding psychological functioning and well-being. However, little attention has been paid to the question of whether the frequently used experimental paradigms hold adequate psychometric properties. The present study examined the psychometric properties of three widely used cognitive bias tasks: the Approach-Avoidance Task (AAT), the visual dot-probe-task, and the Implicit Association Test (IAT). Approach, attentional, and association biases towards valenced stimuli were repeatedly measured at five different time points in a sample of 79 healthy young adults. Two different devices were used for assessment: a personal computer (PC) and a touchscreen-based tablet. Reliability estimates included internal consistency and temporal stability. Validity was inferred from convergence across different behavioral tasks and correlations between bias scores and self-reported psychological traits. Reliability ranged widely amongst tasks, assessment devices, and measurement time points. While the dot-probe-task appeared to be completely unreliable, bias scores obtained from the PC-based version of the AAT and both (PC and touchscreen) versions of the IAT showed moderate reliability. Almost no associations were found across information processing tasks or between implicit and explicit measures. Cognitive bias research should adopt a standard practice to routinely estimate and report psychometric properties of experimental paradigms, investigate feasible ways to develop more reliable tools, and use tasks that are suitable to answer the precise research question asked.

Latinx Individuals Who Smoke Daily with and without a Probable Anxiety Disorder: Differences in Smoking Behavior and Beliefs about Abstinence

There is a well-established relation between anxiety psychopathology and smoking in the general population. However, little work focuses on Latinx/Hispanic (hereafter Latinx) persons who smoke from this comorbidity perspective. The present investigation aimed to explore differences among English-speaking Latinx adults who live in the United States (US) and smoke cigarettes with and without a probable anxiety disorder in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) who identified as Latinx and were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with a probable anxiety disorder (compared to those without) were more likely to demonstrate higher levels of cigarette dependence, severity of problems when trying to quit, perceived barriers for quitting, and negative abstinence expectancies after adjusting for key variables linked to smoking and anxiety (e.g., hazardous drinking, education). The current findings are the first to document probable anxiety disorder status as a clinically relevant factor for a wide range of smoking variables and beliefs about abstinence among Latinx persons who smoke.

Biased Affective Forecasting: A Potential Mechanism That Enhances Resilience and Well-Being

According to a growing body of studies, people's ability to forecast future emotional experiences is generally biased. Nonetheless, the existing literature has mainly explored affective forecasting in relation to specific events, whereas little is still known about the ability to make general estimations of future emotional states. Based on existing evidence suggesting future-oriented disposition as a key factor for mental health, the aims of the current study were (1) to investigate the relationship between negative (NA) and positive (PA) affective forecasting biases and perceived psychological well-being, and (2) to explore whether positively biased predictions are associated with resilience and foster one's skills to cope with stressful events. To do so, we asked 85 undergraduate students to forecast PA and NA over 2 weeks, as well as to report their daily affect through a web-based Ecological Momentary Assessment. According to the results, positively biased PA forecasting (i.e., overestimating positive emotional states) was associated with greater perceived psychological well-being and higher resilience. When high levels of stress were experienced, participants holding an optimistic, yet biased, estimation of future PA were more likely to successfully manage stressors, thus maintaining lower levels of NA and higher levels of positive emotions. We suggest that positively biased PA forecasting is an adaptive cognitive distortion that boosts people's resilience and mental health, thus opening new avenues for the promotion of psychological well-being.

Affect Recall Bias: Being Resilient by Distorting Reality

Background

According to a growing body of literature, people are quite inaccurate in recalling past affective experiences. Nevertheless, the mechanism underlying this recall bias (i.e., the tendency to overestimate and/or underestimate positive or negative past emotional experiences) remains unclear, and its association with mental health has not been studied yet.

Methods

We adopted a smartphone-based Ecological Momentary Assessment to monitor daily affect (n = 92) and investigate the association between affect recall bias, mental health and resilience.

Results

While the tendency to overestimate negative affective experiences was observed in participants reporting mild depressive symptoms, positive affect (PA) overestimation as compared to PA underestimation was associated with better mental health (i.e. higher psychological well-being and lower depressive and anxiety symptoms) through the enhancement of resilience. Furthermore, positively biased participants (i.e. PA over estimators) benefited from greater well-being, even when compared to accurate individuals.

Conclusions

While people appear to use retrospective PA overestimation as a strategy to enhance well-being and resilience, they are not likely to underestimate past negative experiences to feel better. Accordingly, owning an optimistic vision of the past may represent an adaptive “distortion” of reality that fosters people’s mental health. The clinical implications of cultivating PA and learning strategies to regulate both negative and positive emotions are discussed.

Nurturing Our Better Nature: A Proposal for Cognitive Integrity as a Foundation for Autonomous Living

As we account for the genetic and environmental influences on morally-relevant character traits like intellectual honesty, industriousness, and self-control, do we risk becoming ever less accountable to ourselves? Behavioral genetic research suggests that about half the variance in such character traits is likely attributable to heredity, and a small fraction to the shared family environment. The remaining 40-60% is explained by neither genes nor family upbringing. This raises the question: how active a role can individuals play in shaping their own character? What, if anything, can and should one do to take responsibility for the kind of person one becomes? This paper sketches a novel theoretical proposal for addressing these questions, by drawing on several previously disparate lines of research within behavior genetics, philosophy, and experimental psychology. Our core proposal concerns the metacognitive capacity to engage in active, reality-based cognition, as opposed to passive, stimulus-driven processing or an active pretense at cognition (i.e., self-deception). We review arguments and evidence indicating that human beings both can and should exercise this capacity, which we have termed "cognitive integrity." We argue that doing so can in a certain sense "set us free" of our genetic and environmental influences-not by rendering them irrelevant, but by giving us the awareness and motivation to manage them more responsibly. This perspective has important implications for guiding the development of psychosocial interventions, and for informing how we direct ourselves more generally, both as individuals and as a society.

Cognitive Remediation and Bias Modification Strategies in Mood and Anxiety Disorders

PURPOSE OF REVIEW

Cognitive impairments and biases, which are prevalent in patients with mood and anxiety disorders, can affect quality of life and functioning. Traditional treatments are only insufficiently addressing these impairments and biases. We review the cognitive impairments and biases present in these disorders as well as treatments targeting these domains.

RECENT FINDINGS

Interventions aimed at improving cognitive impairments and biases may help improve cognitive deficits and overall functioning in patients with mood and anxiety disorders. Direct comparisons of treatments for cognitive impairments or biases versus more traditional psychosocial interventions have produced diverse results.

SUMMARY

Overall, treatments for cognitive impairments and cognitive biases warrant additional study in clinical trials. Future research should explore cognitive remediation and cognitive bias modification adjunctive to psychosocial treatments to optimize patient outcomes in mood and anxiety disorders.

An attentional bias for thin bodies and its relation to body dissatisfaction

Research suggests that humans have an attentional bias for the rapid detection of emotionally valenced stimuli, and that such a bias might be shaped by clinical psychological states. The current research extends this work to examine the relation between body dissatisfaction and an attentional bias for thin/idealized body shapes. Across two experiments, undergraduates completed a gender-consistent body dissatisfaction measure, and a dot-probe paradigm to measure attentional biases for thin versus heavy bodies. Results indicated that men (n=21) and women (n=18) show an attentional bias for bodies that correspond to their own gender (Experiment 1), and that high body dissatisfaction among men (n=69) and women (n=89) predicts an attentional bias for thin same-gender bodies after controlling for body mass index (BMI) (Experiment 2). This research provides a new direction for studying the attentional and cognitive underpinnings of the relation between body dissatisfaction and eating disorders.

Countering fear renewal: changes in the UCS representation generalize across contexts

After treatment of anxiety disorders, fear often returns. Analogue studies show that outside the extinction context the conditional stimulus (CS) activates the acquisition memory (CS predicts unconditional stimulus; UCS), rather than the extinction memory (CS does not predict UCS). Conditioning theory postulates that fear also diminishes after a reduction in the subjective cost of the UCS, which can occur in absence of any changes in the CS-UCS association. We hypothesized that fear reduction via "UCS deflation" generalizes across context. Healthy students underwent acquisition in context A with neutral CSs and 100dB white noise as UCS. One group received post-conditioning UCS exposure, in which UCS intensity decreased over time ("ABAdefl"). Another group received UCS presentations at equal intensity ("ABActrl"). Two groups did a filler task ("ABB"; "ABA"). Then, all groups underwent extinction in context B and were retested in context A (ABA-groups) or B (ABB-group). During each CS participants rated UCS expectancy and UCS cost. Results showed the typical increase in UCS expectancy following the context switch from extinction to test phase. In contrast, UCS deflation caused a reduction in cost ratings that was maintained after the context change. Findings suggest that UCS deflation techniques may reduce fear renewal.

The role of anxiety sensitivity, behavioral inhibition, and cognitive biases in anxiety symptoms: structural equation modeling of direct and indirect pathways

OBJECTIVE(S)

Limited research has examined how temperamental (i.e., behavioral inhibition, anxiety sensitivity) and cognitive (i.e., interpretive and judgment biases) risks for the development anxiety covary to influence anxiety symptoms. Thus, the present study aimed to advance understanding of the direct and indirect links between anxiety sensitivity, behavioral inhibition, and interpretive biases, and judgment biases (in the form of perceived control) to anxiety outcomes (i.e., worry and trait anxiety symptoms).

METHOD

842 emerging adults (mean = 18.75 years, standard deviation = 1.05; age range = 18-24; 70% women) recruited from a university in the northeast participated in this study. Participants completed a battery of self-report measures assessing risk factors and anxiety outcomes of interest.

RESULTS

Structural equation modeling revealed anxiety sensitivity and behavioral inhibition were directly linked with anxiety outcomes. Anxiety sensitivity and behavioral inhibition were also indirectly linked with anxiety outcomes through interpretive and judgment biases. The hypothesized model was partially invariant across high-risk and low-risk groups for anxiety disorders.

CONCLUSIONS

Results of this study provide preliminary support for theoretical models hypothesizing a developmental progression from temperamental to cognitive risks and culminating in the expression of anxiety symptoms. Limitations and clinical implications of this research are discussed.

Clustering of temperamental and cognitive risk factors for anxiety in a college sample of late adolescents

Temperamental vulnerabilities (e.g., behavioral inhibition, anxiety sensitivity) and cognitive biases (e.g., interpretive and judgment biases) may exacerbate feelings of stress and anxiety, particularly among late adolescents during the early years of college. The goal of the present study was to apply person-centered analyses to explore possible heterogeneity in the patterns of these four risk factors in late adolescence, and to examine associations with several anxiety outcomes (i.e., worry, anxiety symptoms, and trait anxiety). Cluster analyses in a college sample of 855 late adolescents revealed a Low-Risk group, along with four reliable clusters with distinct profiles of risk factors and anxiety outcomes (Inhibited, Sensitive, Cognitively-Biased, and Multi-Risk). Of the risk profiles, Multi-Risk youth experienced the highest levels of anxiety outcomes, whereas Inhibited youth experienced the lowest levels of anxiety outcomes. Sensitive and Cognitively-Biased youth experienced comparable levels of anxiety-related outcomes, despite different constellations of risk factors. Implications for interventions and future research are discussed.

Risk indicators of anxiety throughout adolescence: the TRAILS study

BACKGROUND

The aim was to identify risk indicators from preadolescence (age period 10-12) that significantly predict unfavorable deviations from normal anxiety development throughout adolescence (age period 10-17 years).

METHODS

Anxiety symptoms were assessed in a community sample of 2,220 boys and girls at three time-points across a 5-year interval. Risk indicators were measured at baseline and include indicators from the child, family, and peer domain. Associations with anxiety were measured with multilevel growth curve analyses.

RESULTS

A stable difference in anxiety over adolescence was found between high and low levels of a range of child factors (frustration, effortful control), family factors (emotional warmth received from parents, lifetime parental internalizing problems), and peer factor (victims of bullying) (P <.001). In contrast, the difference in anxiety between high and low levels of factors, such as self-competence, unfavorable parenting styles, and bully victims, decreased over adolescence (P <.001). For other family factors, associations were weaker (.05 <P <.001). Associations with parental education and family composition were not significant. Adjustment for concurrent depressive symptoms attenuated the associations, but those that were significant at P <.001 remained to be so. Specificity for anxiety subtypes (generalized anxiety, separation anxiety, social phobia, panic, and obsessive-compulsive symptoms) was reported for each association.

CONCLUSIONS

Several child, family, and peer factors measured in preadolescence were risk indicators of high levels of anxiety symptoms throughout adolescence. Some factors (such as rejective parenting) were vulnerability indicators for anxiety in early adolescence only, whereas other factors (such as peer victimization) were indicators of long-term elevated anxiety levels.

[Generalized anxiety disorder: recognizing it and understanding its impact on the cognitive functioning]

Since the appearance of Generalized Anxiety Disorder (GAD) in the 1980 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the definition and the comprehension of this disorder have largely evolved. The present article is an overview of the principal aspects of GAD in the literature such as the history, the prevalence, the socioeconomic characteristics, the comorbidity, the differential diagnosis and its evolution, while considering the litigious questions concerning its classification. This article also presents a report of the recent studies about the cognitive profile of patients, from a perspective of cognitive experimental psychology and neuropsychology. The consequences on cognitive functioning are discussed in the second part of the article, as well as precautions relatively to functioning clinicians have to consider.

Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder

OBJECTIVE

Cognitive models of panic disorder suggest that change in catastrophic misinterpretations of bodily sensations will predict symptom reduction. To examine change processes, we used a repeated measures design to evaluate whether the trajectory of change in misinterpretations over the course of 12-week cognitive behavior therapy is related to the trajectory of change in a variety of panic-relevant outcomes.

METHOD

Participants had a primary diagnosis of panic disorder (N = 43; 70% female; mean age = 40.14 years). Race or ethnicity was reported as 91% Caucasian, 5% African American, 2.3% biracial, and 2.3% "other." Change in catastrophic misinterpretations (assessed with the Brief Body Sensations Interpretation Questionnaire; Clark et al., 1997) was used to predict a variety of treatment outcomes, including overall panic symptom severity (assessed with the Panic Disorder Severity Scale [PDSS]; Shear et al., 1997), panic attack frequency (assessed with the relevant PDSS item), panic-related distress/apprehension (assessed by a latent factor, including peak anxiety in response to a panic-relevant stressor-a straw breathing task), and avoidance (assessed by a latent factor, which included the Fear Questionnaire-Agoraphobic Avoidance subscale; Marks & Mathews, 1979).

RESULTS

Bivariate latent difference score modeling indicated that, as expected, change in catastrophic misinterpretations predicted subsequent reductions in overall symptom severity, panic attack frequency, distress/apprehension, and avoidance behavior. However, change in the various symptom domains was not typically a significant predictor of later interpretation change (except for the distress/apprehension factor).

CONCLUSIONS

These results provide considerable support for the cognitive model of panic and speak to the temporal sequence of change processes during therapy.

Anxiety disorders in children and adolescents

Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.

Cognitive style, alprazolam plasma levels, and treatment response in panic disorder

This study investigated an anxiety-prone cognitive style (measured by the Anxious Thoughts and Tendencies Questionnaire, AT&T) as a predictor of the acute response to increasing alprazolam plasma levels in panic disorder. Panic disorder patients (n=26) were treated with escalating doses of alprazolam for 4 weeks, then a fixed dose of 1 mg four times a day for 4 weeks. At 0, 1, 2, 3, 4, 6, and 8 weeks, trough alprazolam plasma levels; clinical, self-report, and performance measures; and vital signs were assessed. Panic attack data were from daily diaries. The repeated response measures were analyzed in relation to alprazolam plasma levels using SAS GENMOD, with patients classified as high or low on the baseline AT&T. Panic attacks, anticipatory anxiety, fear, avoidance, overall agoraphobia, the Hamilton Anxiety Rating Scale, and clinicians' global ratings improved with increasing alprazolam plasma levels. Hopkins Symptom Checklist-90 Anger-Hostility; Profile of Mood States Vigor, Confusion, and Friendliness; and speed and accuracy of performance worsened. Patients with high AT&T scores were worse throughout the study on situational panics, fear, avoidance, overall agoraphobia, the Hamilton Anxiety Rating Scale, the Hamilton Rating Scale for Depression, and Clinical Global Improvement; most Hopkins Symptom Checklist-90 clusters; Profile of Mood States Anxiety, Depression, and Confusion; and Continuous Performance Task omissions. We conclude that in panic disorder: (1) alprazolam has a broad spectrum of clinical activity related to plasma levels in individual patients; (2) sedation, disinhibition, and performance deficits may persist for at least a month after dose escalation ends; (3) marked anxiety-prone cognitions predict more symptoms throughout treatment, but do not modify the response to alprazolam and therefore should not influence the choice of alprazolam as treatment.

Attentional retraining: a randomized clinical trial for pathological worry

OBJECTIVE

Research has consistently shown that highly anxious individuals tend to show an attentional bias in favor of threat cues (i.e., a threat bias). Further, recent evidence suggests that it is possible to modify patterns of attention allocation for such stimuli and the resulting changes in attention allocation alter affective responses to stress. However, to date such changes in patterns of attention have been shown only over brief time intervals and only in non-anxious individuals who lack a pre-existing attentional bias. In contrast, the present study tested the efficacy of such attentional training in a sample of severe worriers over an extended period of time using psychometrically validated measures of anxiety and depression.

METHOD

Twenty-four adult participants reporting severe worry were randomly assigned to receive five sessions of either computer-delivered attentional retraining or sham training. The study was conducted from January to August 2001 and June to August 2002.

RESULTS

Significant Treatment Group X Time interactions were found for both threat bias (p=001) and a composite measure of anxious and depressive symptoms (p=.002). Compared to sham-training, the active retraining program produced significant reductions in both threat bias and symptoms.

CONCLUSIONS

These data support the view that an attentional bias in favor of threat cues is an important causal factor in generalized anxiety and suggest that a computer-based attentional retraining procedure may be an effective component of treatment.

Anxiety disorders in youth

Anxiety disorders are one of the most prevalent categories of childhood and adolescent psychopathology. Due to their distressing, time-consuming, and/or debilitating nature, impairments in academic, social, and family functioning are often substantial. This article reviews the nature, etiology, assessment, and treatment of anxiety disorders in youth. We conclude by reviewing implications for nurses involved in the care of youth with anxiety disorders.

Links between eating disorder symptom severity and psychiatric comorbidity

Patients with eating disorders (ED) frequently exhibit additional psychiatric disorders. This study aimed to examine whether psychiatric comorbidity in ED patients is associated with increased severity of ED symptoms in a sample of 277 women with a current ED (84 anorexia nervosa, 152 bulimia nervosa, 41 eating disorders not otherwise specified). Psychiatric comorbidity of Axes I and II was determined using the Structured Clinical Interview (SCID) for DSM-IV. Severity of ED-related symptoms was assessed using interviewer-rated scales from the Structured Interview for Anorexia and Bulimia Nervosa (SIAB). Affective and anxiety-related disorders of both axes were linked with increased intensity of weight- and appearance-related fears and concerns. Frequency of binge-eating and frequency of purging both were associated with Axis I anxiety disorders, substance-related disorders, and Cluster B personality disorders. Frequency of dieting was related to anxiety disorders on both axes. Multivariate analyses revealed that Axis I anxiety disorders were more closely linked with severity of ED symptoms than affective or substance-related disorders. The results showed that psychiatric comorbidity of both axes is linked with increased severity of ED symptoms and that there are associations between specific ED symptoms and specific forms of comorbidity.