The relationship between expressive suppression, therapeutic bond, and treatment outcomes of a positive affect intervention for adults with anxiety and/or depression

Expressive suppression (ES; reducing emotional expression) is linked with reduced social connectedness in individuals with anxiety or depression. One implication is that people who use ES may have difficulty establishing a bond with their therapist which may impede clinical improvement. We examined this hypothesis in 33 adults with clinically elevated anxiety or depression receiving treatment focused on enhancing positive thoughts, emotions, and behaviors. At baseline, participants rated ES for positive and negative emotions during a standardized conversation task designed to generate connectedness. They also rated measures of early (session 3) perceived therapeutic bond and treatment outcomes (i.e. positive affect and social connectedness). ES of positive (r = -.39, p = .018), but not negative (r = .06, p = .747), emotions was negatively associated with therapeutic bond. Therapeutic bond mediated the relationship between greater ES of positive emotions during affiliation and lower post-treatment positive affect, 95% bias-corrected bootstrap confidence interval [-0.021, -0.000], adjusted for pre-treatment positive affect, as well as lower post-treatment social connectedness [-0.397, -0.015]; however, the indirect effect was not significant when accounting for pre-treatment social connectedness (p > .05). ES of positive emotions may be an important factor in the development of therapeutic bond and therefore treatment outcomes for individuals with anxiety or depression.

Application of an egocentric social network approach to examine changes in social connections following treatment for anxiety and depression: A novel measurement tool for clinical trials research?

The epidemic of loneliness and social isolation has been recognized as a public health crisis warranting the same prioritization as other public health issues today, such as obesity, substance use disorders, and tobacco use. Social disconnection is particularly prevalent and disabling among individuals with anxiety and depression, yet it is inadequately evaluated and addressed in most clinical psychology treatment research. Studies generally employ global measures of perceived connectedness, loneliness, or relationship satisfaction, limiting understanding about elements of one's social network that may change with treatment. This study examined changes in the degree (number of people nominated) and quality of one's social network from pre-to post-treatment using an egocentric social network approach in 59 adults (mean age = 30.8 years, range = 18 to 54) with clinically elevated anxiety or depression who were randomized to a cognitive and behavioral positive valence treatment versus waitlist. Participants (egos) named people in their lives (alters) with whom they discussed important issues or spent free time. For each alter, participants rated how close they felt, how close they thought the alter felt to them, and how frequently they communicated. Linear regressions, which included treatment group as a predictor, revealed no group differences in changes in network degree, perceived alter feelings of closeness, or communication frequency, despite prior findings from this sample indicating larger increases in perceived global connectedness in the treatment group. Unexpectedly, the control group reported a greater increase in perceived closeness to alters. Post-hoc analyses revealed this was explained by the treatment group identifying more distal social ties (e.g., extended family, colleagues, roommates) as alters following treatment - an outcome positively associated with global improvements in connectedness. This proof-of-concept study suggests egocentric social network surveys may provide unique information on treatment-related changes in social functioning. Suggestions are provided for adaptations to facilitate application of social network surveys to mental health treatment research.

Amplification of positivity for depression and anxiety: Neural prediction of treatment response

Psychosocial treatments targeting the positive valence system (PVS) in depression and anxiety demonstrate efficacy in enhancing positive affect (PA), but response to treatment varies. We examined whether individual differences in neural activation to positive and negative valence incentive cues underlies differences in benefitting from a PVS-targeted treatment. Individuals with clinically elevated depression and/or anxiety (N = 88, ages 18 to 55) participated in one of two randomized, waitlist-controlled trials of Amplification of Positivity (AMP; NCT02330627, NCT03196544), a cognitive and behavioral intervention targeting the PVS. Participants completed a monetary incentive delay (MID) task during fMRI acquisition at baseline measuring neural activation to the possibility of gaining or losing money. Change in PA from before to after treatment was assessed using the Positive and Negative Affect Schedule. No significant associations were observed between baseline neural activation during gain anticipation and AMP-related changes in PA in regions of interest (striatum and insula) or whole-brain analyses. However, higher baseline striatal and insula activation during loss anticipation was associated with greater increases in PA post-AMP. This study provides preliminary evidence suggesting neural reactivity to negative valence cues may inform who stands to benefit most from treatments targeting the PVS.

Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Positive and negative affect change following psychotherapeutic treatment for anxiety-related disorders: A systematic review and meta-analysis

BACKGROUND

Anxiety-related disorders feature elevated negative affect (NA), and in some cases, diminished positive affect (PA). It remains unclear how well extant psychotherapies for anxiety-related disorders improve PA versus NA.

METHODS

We systematically searched the Cochrane Central Register of Controlled Trials, PubMed, PsychInfo, and Web of Science databases. Records included studies involving (1) patients with a principal or co-principal diagnosis of at least one anxiety-related disorder (i.e., generalized anxiety, social anxiety, panic, agoraphobia, health anxiety, specific phobia, obsessive-compulsive disorder, or posttraumatic stress disorder), and (2) pre- and post-treatment PA and NA scores or a change index between pre- and post-treatment PA and NA scores. Effect sizes were calculated for meta-analyses.

RESULTS

Fourteen studies with 1001 adults with an anxiety-related disorder were included. Psychotherapeutic interventions included cognitive behavioral, present-centered, and imagery-based approaches. Treatments reduced NA (g = -0.90; 95%CI [-1.19, -0.61]) to a greater extent than they improved PA (g = 0.27; 95%CI [0.05, 0.59]), Z = -5.26, p < .001. The limited number of studies available precluded analyses of the relationship between changes in affect and symptoms.

LIMITATIONS

Results should be considered with caution given the small number and heterogeneity of included studies.

CONCLUSIONS

Current psychotherapeutic interventions for anxiety-related disorders may not improve PA and NA to comparable levels.

Amplification of Positivity Treatment for Anxiety and Depression: A Randomized Experimental Therapeutics Trial Targeting Social Reward Sensitivity to Enhance Social Connectedness

BACKGROUND

Social disconnection is common and causes significant impairment in anxiety and depressive disorders, and it does not respond sufficiently to available treatments. The positive valence system supports social bond formation and maintenance but is often hyporesponsive in people with anxiety or depression. We conducted an experimental therapeutics trial to test the hypothesis that targeting positive valence processes through cognitive and behavioral strategies would enhance responsivity to social rewards, a core mechanism underlying social connectedness.

METHODS

Sixty-eight adults who endorsed clinically elevated anxiety and/or depression with social impairment were randomized 1:1:1 to 5 (n = 23) or 10 (n = 22) sessions of amplification of positivity (AMP) treatment or waitlist (n = 23). Pre- to posttreatment change in striatal activity (primary outcome) during social reward anticipation was measured using functional magnetic resonance imaging, and reactivity to a social affiliation task (secondary) and self-reported social connectedness (exploratory) were examined. Primary analyses compared AMP (doses combined) versus waitlist. A second aim was to compare the effects of different doses.

RESULTS

AMP engaged the hypothesized treatment target, leading to greater striatal activation during anticipation of social rewards versus waitlist (d = 1.01 [95% CI = 0.42-1.61]; largest striatal volume). AMP yielded larger improvements in positive affect and approach behavior during the affiliation task (but not other outcomes) and social connectedness. Larger striatal and social connectedness increases were observed for 5-session versus 10-session AMP (d range = 0.08-1.03).

CONCLUSIONS

Teaching people with anxiety or depression strategies to increase positive thoughts, behaviors, and emotions enhances activity in brain regions that govern social reward processing and promotes social connectedness. Social reward sensitivity may be a transdiagnostic target for remediating social disconnection.

Ecological Momentary Assessment of Social Approach and Avoidance Motivations in Serious Mental Illness: Connections to Suicidal Ideation and Symptoms

AIM

People with serious mental illness (SMI) are at an increased risk for suicide. Social approach and avoidance motivations are linked to social functioning, and social isolation is a risk factor for suicide. This study uses ecological momentary assessment (EMA) to understand social approach and avoidance motivations in relation to symptoms and suicidal ideation (SI).

METHODS

Participants (N = 128) diagnosed with schizophrenia, schizoaffective disorder, or a mood disorder with psychotic features completed assessments of SI and symptoms at baseline. They completed EMA surveys 3×/day for 10 days. EMA surveys included questions about approach and avoidance motivations and psychotic symptoms. Participants were split into four groups based on the median scores of approach and avoidance.

RESULTS

Participants with SI at baseline had higher mean social avoidance motivation, t(126) = 2.84, p = .003, and lower mean social approach motivation, t(126) = -2.44, p = .008, than participants without baseline SI. Greater baseline positive symptoms were related to greater mean avoidance, r = .231, p = .009, but not approach motivation. The low approach/high avoidance group had significantly higher current SI than those with high approach/low avoidance (p < .001). Overall, the low approach/high avoidance group reported more EMA-measured voices than the low approach/low avoidance group (p < .001) and the high approach/low avoidance group (p < .001). Similarly, the low approach/high avoidance group reported more EMA-measured suspiciousness than the low approach/low avoidance (p < .001) and the high approach/low avoidance groups (p < .001).

CONCLUSION

The results of this study point to the role of social approach and avoidance motivations in relation to SI and psychotic symptoms. Clinically, exposure therapies and cognitive behavioral therapies may help to address these social approach and avoidance processes linked to SI.

What good are positive emotions for treatment? A replication test of whether trait positive emotionality predicts response to exposure therapy for social anxiety disorder

BACKGROUND

Positive valence emotions serve functions that may facilitate response to exposure therapy - they encourage approach behavior, diminish perceived threat reactivity, and enhance assimilation of new information in memory. Few studies have examined whether positive emotions predict exposure therapy success and extant findings are mixed.

METHODS

We conducted a secondary analysis of an exposure therapy trial for social anxiety disorder to test the hypothesis that patients endorsing higher trait positive emotions at baseline would display the greatest treatment response. N = 152 participants enrolled in a randomized controlled trial of d-cycloserine augmentation completed five sessions of group exposure therapy. Pre-treatment positive emotionality was assessed using the NEO Five-Factor Inventory. Social anxiety symptoms were assessed throughout treatment by blinded evaluators using the Liebowitz Social Anxiety Scale.

RESULTS

Accounting for baseline symptom severity, multilevel growth curve models revealed that patients with higher pre-treatment positive emotionality displayed faster social anxiety symptom reductions and lower scores at 3-month follow-up. This predictive effect remained significant after controlling for baseline depression and extraversion (without the positive emotionality facet).

CONCLUSIONS

These findings add to emerging evidence suggesting that explicitly targeting and enhancing positive emotions during exposure to perceived threat may improve treatment outcomes for anxiety and fear-based disorders.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02066792https://clinicaltrials.gov/ct2/show/NCT02066792.

Social network size and personality traits independently and prospectively predict distress disorders and suicidal behavior in U.S. Army soldiers

BACKGROUND

Personality traits (e.g. neuroticism) and the social environment predict risk for internalizing disorders and suicidal behavior. Studying these characteristics together and prospectively within a population confronted with high stressor exposure (e.g. U.S. Army soldiers) has not been done, yet could uncover unique and interactive predictive effects that may inform prevention and early intervention efforts.

METHODS

Five broad personality traits and social network size were assessed via self-administered questionnaires among experienced soldiers preparing for deployment (N = 4645) and new soldiers reporting for basic training (N = 6216). Predictive models examined associations of baseline personality and social network variables with recent distress disorders or suicidal behaviors assessed 3- and 9-months post-deployment and approximately 5 years following enlistment.

RESULTS

Among the personality traits, elevated neuroticism was consistently associated with increased mental health risk following deployment. Small social networks were also associated with increased mental health risk following deployment, beyond the variance accounted for by personality. Limited support was found for social network size moderating the association between personality and mental health outcomes. Small social networks also predicted distress disorders and suicidal behavior 5 years following enlistment, whereas unique effects of personality traits on these more distal outcomes were rare.

CONCLUSIONS

Heightened neuroticism and small social networks predict a greater risk for negative mental health sequelae, especially following deployment. Social ties may mitigate adverse impacts of personality traits on psychopathology in some contexts. Early identification and targeted intervention for these distinct, modifiable factors may decrease the risk of distress disorders and suicidal behavior.

Examining Safety Behavior Subtypes Across Distinct Social Contexts in Social Anxiety Disorder and Major Depression

People with social anxiety disorder (SAD) use different types of safety behaviors that have been classified as avoidance vs. impression management. The current study investigated differences in safety behavior subtype use in 132 individuals with principal diagnoses of social anxiety disorder (SAD, n = 69), major depressive disorder (MDD, n = 30), and nonpatient controls (n = 33) across two social contexts: an interpersonal relationship-building task (social affiliation) and a speech task (social performance). We examined whether diagnostic groups differed in safety behavior subtype use and whether group differences varied by social context. We also explored relationships between avoidance and impression management safety behaviors, respectively, and positive and negative valence affective and behavioral outcomes within the social affiliation and social performance contexts. Safety behavior use varied by diagnosis (SAD > MDD > nonpatient controls). The effect of diagnosis on impression management safety behavior use depended on social context: use was comparable for the principal SAD and MDD groups in the social performance context, whereas the SAD group used more impression management safety behaviors than the MDD group in the social affiliation context. Greater use of avoidance safety behaviors related to higher negative affect and anxious behaviors, and lower positive affect and approach behaviors across contexts. Impression management safety behaviors were most strongly associated with higher positive affect and approach behaviors within the social performance context. These findings underscore the potential value of assessing safety behavior subtypes across different contexts and within major depression, in addition to SAD.

Randomized controlled trial of computerized approach/avoidance training in social anxiety disorder: Neural and symptom outcomes

Social anxiety is associated with diminished automatic approach toward positive social cues that may limit the ability to connect with others. This diminished approach bias may be a modifiable treatment target. We evaluated the effects of an approach avoidance training procedure on positive emotions, social relationship outcomes, clinical symptoms, and neural indices of social approach and reward processing. Forty-five individuals with social anxiety disorder were randomized (parallel 1:1 randomization) to complete computerized Approach Positive training (n = 21) or Balanced training(n = 24). Sessions included a standardized social interaction task. Participants were blind to training group. Participants completed clinical outcome measures and functional magnetic resonance imaging at baseline and post intervention with an MRI-compatible AAT and the social incentive delay task (SID). Both groups displayed significant improvements of similar magnitude on the primary outcome of social connectedness (between group post-treatment d = -0.21) but not positive affect (d = -0.09), from before to after treatment, persisting through follow-up. Groups demonstrated significant improvements on additional outcomes including anxiety, depression, and anhedonia symptoms. Participants in Approach Positive AAT demonstrated increased activation in the thalamus and medial prefrontal cortex during social versus neutral- approach relative to Balanced AAT during the fMRI AAT. Participants in Balanced AAT showed increased activation in regions within an a priori-defined striatum region of interest mask during anticipation of social reward (vs. baseline) in the SID relative to Approach Positive AAT. At a neural processing level AAT may influence the valuation and motivations associated with positive social cues regulated by the mPFC and thalamus. NCT02136212, NIMH R00MH090243.

Childhood Trauma Predicts Positive Expressive Suppression During Social Affiliation in Adults With Anxiety and/or Depression: Implications for Social Functioning

Experiencing childhood trauma (CT) can create barriers for developing relationships and is a risk factor for anxiety and depression. Expressive suppression (ES; i.e., reducing expression associated with experiencing emotions) might explain the link between CT and relationship formation difficulties. We examined the association between (1) CT and ES during a dyadic paradigm intended to facilitate connectedness between unacquainted partners and (2) ES and desire for future interaction (DFI). Individuals with an anxiety or depressive disorder diagnosis (N = 77) interacted with a trained confederate; partners answered a series of increasingly intimate questions about themselves. Participant ES for positive and negative emotions, and participant and confederate DFI were collected during the task. Participants completed global anxiety, depression, and CT measures. CT correlated with positive (r = .35, p = .002), but not negative, ES (r = .13, p = .273). In a multiple linear regression model, CT predicted positive ES beyond symptom variables and gender, β = .318, t = 2.59, p = .012. Positive ES correlated with participant (r = -.38, p = .001) and confederate DFI (r = -.40, p<.01); and predicted participant DFI beyond symptom variables and ethnicity, β = -.358, t = -3.18, p = .002, and confederate DFI, β = -.390, t = -3.51, p = .001, beyond symptom variables. Mediation analyses suggested positive ES accounted for the relationship between greater CT severity and less desire for future interaction from participants, 95%CI [-0.26, -0.02], and confederates, [-0.38, -0.01]. Positive ES may be an important factor in the reduced capacity to form new social relationships for individuals with a history of CT, anxiety, and depression.

Beyond Positive Affect: Discrete Positive Emotions Differentiate Major Depression from Social Anxiety Disorder

Background

Social anxiety disorder (SAD) and major depressive disorder (MDD) are both associated with diminished global positive affect. However, little is known about which specific positive emotions are affected, and which positive emotions differentiate MDD from SAD.

Methods

Four groups of adults recruited from the community were examined (N = 272): control group (no psychiatric history; n = 76), SAD without MDD group (n = 76), MDD without SAD group (n = 46), and comorbid group (diagnoses of both SAD and MDD; n = 74). Discrete positive emotions were measured with the Modified Differential Emotions Scale, which asked about the frequency of 10 different positive emotions experienced during the past week.

Results

The control group had higher scores on all positive emotions compared to all three clinical groups. The SAD group had higher scores on awe, inspiration, interest, and joy compared to the MDD group, and higher scores on those emotions, as well as amusement, hope, love, pride, and contentment, than the comorbid group. MDD and comorbid groups did not differ on any positive emotions. Gratitude did not differ significantly between clinical groups.

Conclusion

Adopting a discrete positive emotion approach revealed shared and distinct features across SAD, MDD, and their comorbidity. We consider possible mechanisms underlying transdiagnostic vs. disorder-specific emotion deficits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10355-y.

Examining affective reactivity as a link between suicidality and social disconnection

The link between suicidality and social disconnection is well-established. We explored possible mechanisms that may account for this link using a positive and negative valence systems framework in a clinical sample with and without suicidality (i.e., suicidal ideation and/or behaviors in the past month). Participants (N = 228) interacted with a trained confederate during a controlled conversation task designed to generate social affiliation. Participant-rated positive affect (PA) and negative affect (NA) were collected during the task (baseline, anticipation, post). Participant-rated desire for future interaction was collected after the task. We tested if (1) groups with (n = 82) and without (n = 146) suicidality differed in affect during the task and (2) whether affect accounted for the link between suicidality and desire for future interaction. Results revealed that groups differed in PA, but not NA, throughout the task. Participants with suicidality reported no significant changes in PA over the task (ps > .05); and, experienced less PA at post-task compared to those without (p = .003, d = 0.38) whereas participants without suicidality reported increased PA at post-task compared to baseline and anticipation of the task, ps < .001. Mediation analysis suggested blunted post-task PA accounted for the relationship between suicidality and less desire for future interaction, 95%CI [-2.59,-0.51]. Diminished PA reactivity during social affiliation opportunities may help explain the link between suicidality and social disconnection. Preliminary findings highlight PA as a potential mechanistic target for improving social connection for individuals at risk for suicide, though prospective and experimental research is needed.

Amplification of Positivity Therapy for Co-occurring Alcohol Use Disorder with Depression and Anxiety Symptoms: Pilot Feasibility Study and Case Series

Positive valence system dysregulation is a relatively unexplored transdiagnostic mechanism and potential treatment target underpinning alcohol use and anxiety and depression symptoms. The current study examined the feasibility and potential benefit of a behavioral intervention focused on amplification of positivity (AMP) with eight adults (five female) diagnosed with alcohol use disorder and clinically significant depression or anxiety (ClinicalTrials.gov: NCT04278365). AMP for alcohol use (AMP-A) was delivered in 11 individual sessions involving positive activity interventions integrated alongside psychoeducation and alcohol use monitoring. Case descriptions are provided to illustrate treatment implementation. Treatment credibility and acceptability, participant endorsement of the therapy, and homework compliance were rated moderate to high. Exploratory, intent-to-treat analyses suggested medium to large effect sizes for post-treatment improvements in alcohol use, depression, anxiety, and positive affect. Results provide initial evidence of feasibility and acceptability of AMP-A and will be useful for informing future randomized clinical trials to examine clinical efficacy.

The Relationship Between Loneliness and Positive Affect in Older Adults

OBJECTIVE

To establish whether positive affect (PA) is uniquely associated with loneliness and other social functioning variables beyond negative affect (NA) among older adults.

METHODS

Four hundred and twenty-eight participants (aged 60+ years old, 82% White, and 48% female) were recruited using random digit-dialing and completed scales for loneliness (UCLA Loneliness Scale), companionship (PROMIS scale), satisfaction with discretionary social activities (PROMIS scale), PA (Center for Epidemiologic Studies [CES] Happiness Scale), and NA (CES-Depression scale and Brief Symptom Inventory-Anxiety Subscale).

RESULTS

Multiple linear regression models found PA to be a significant predictor of lower loneliness where the effect of PA on loneliness is dependent on the level of NA; a large effect size at the mean level of NA, which becomes attenuated when NA increases. Although the direction of effect of PA on loneliness will change for NA > 5.10, which is 5 standard deviations away from 0, based on the model estimates, the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with lower loneliness, however this effect is attenuated for larger NA. Similarly, multiple linear regression models found that companionship was associated with PA and NA where the effect of PA is dependent on the level of NA; a medium effect size at the mean level of NA, which becomes attenuated when NA increases. As in the case of loneliness, the direction of effect of PA on companionship will change for NA > 3.52, which is 3.5 standard deviation away from 0, based on the model estimates, but the percent of subjects with this large NA levels is practically 0. Thus, higher PA is associated with increased companionship, aand this effect is attenuated with greater NA. Satisfaction with social activities was associated with PA only (medium effect size).

CONCLUSION

Results suggest PA appears to be uniquely associated with social functioning among older adults. These findings support the potential for treatments that target PA to decrease loneliness among older adults, or vice versa.

Anhedonia in Anxiety Disorders

Humans, like other animals, are fundamentally motivated to pursue rewarding outcomes and avoid aversive ones. Anxiety disorders are conceptualized, defined, and treated based on heightened sensitivity to perceived aversive outcomes, including imminent threats as well as those that are uncertain yet could occur in the future. Avoidance is the central strategy used to mitigate anticipated aversive outcomes - often at the cost of sacrificing potential rewards and hindering people from obtaining desired outcomes. It is for these reasons that people are often motivated to seek treatment. In this chapter, we consider whether and how anhedonia - the loss of interest in pursuing and/or reduced responsiveness to rewarding outcomes - may serve as a barrier to recovering from clinically impairing anxiety. Increasingly recognized as a prominent symptom in many individuals with elevated anxiety, anhedonia is not explicitly considered within prevailing theoretical models or treatment approaches of anxiety. Our goal, therefore, is to review what is known about anhedonia within the anxiety disorders and then integrate this knowledge into a functional perspective to consider how anhedonia could maintain anxiety and limit treatment response. Our overarching thesis is that anhedonia disrupts the key processes that are central to supporting anxiety recovery. We end this chapter by considering how explicitly targeting anhedonia in treatment can optimize outcomes for anxiety disorders.

Association between neurocognitive functioning and suicide attempts in U.S. Army Soldiers

BACKGROUND

Suicide is a serious public health problem, including among U.S. Army personnel. There is great interest in discovering objective predictors of suicide and non-fatal suicidal behaviors. The current study examined the association between neurocognitive functioning and pre-military history of suicide attempts (SA) and post-enlistment onset of SA.

METHODS

New Soldiers reporting for Basic Combat Training (N = 38,507) completed a comprehensive computerized neurocognitive assessment battery and self-report questionnaires. A subset of Soldiers (n = 6216) completed a follow-up survey, including assessment of lifetime SA, 3-7 years later.

RESULTS

Six hundred eighty-nine Soldiers indicated lifetime SA at baseline and 210 Soldiers indicated new-onset SA at follow-up. Regression analyses, adjusted for demographic variables, revealed significant bivariate associations between neurocognitive performance on measures of sustained attention, impulsivity, working memory, and emotion recognition and lifetime SA at baseline. In a multivariable model including each of these measures as predictors, poorer impulse control and quicker response times on an emotion recognition measure were significantly and independently associated with increased odds of lifetime SA. A second model predicted new-onset SA at follow-up for Soldiers who did not indicate a history of SA at baseline. Poorer impulse control on a measure of sustained attention was predictive of new-onset SA.

LIMITATIONS

Effect sizes are small and of unlikely clinical predictive utility.

CONCLUSIONS

We simultaneously examined multiple neurocognitive domains as predictors of SA in a large, representative sample of new Army Soldiers. Impulsivity most strongly predicted past and future SA over and beyond other implicated cognitive-emotional domains.

Age-dependent brain morphometry in Major Depressive disorder

BACKGROUND

Major depressive disorder (MDD) is a complex disorder that affects nearly 264 million people worldwide. Structural brain abnormalities in multiple neuroanatomical networks have been implicated in the etiology of MDD, but the degree to which MDD affects brain structure during early to late adulthood is unclear.

METHODS

We examined morphometry of brain regions commonly implicated in MDD, including the amygdala, hippocampus, anterior cingulate gyrus, lateral orbitofrontal gyrus, subgenual cortex, and insular cortex subregions, from early to late adulthood. Harmonized measures for gray matter (GM) volume and cortical thickness of each region were estimated cross-sectionally for 305 healthy controls (CTLs) and 247 individuals with MDD (MDDs), collated from four research cohorts. We modeled the nonlinear associations of age with GM volume and cortical thickness using generalized additive modeling and tested for age-dependent group differences.

RESULTS

Overall, all investigated regions exhibited smaller GM volume and thinner cortical measures with increasing age. Compared to age matched CTLs, MDDs had thicker cortices and greater GM volume from early adulthood until early middle age (average 35 years), but thinner cortices and smaller GM volume during and after middle age in the lateral orbital gyrus and all insular subregions. Deviations of the MDD and CTL models for both GM volume and cortical thickness in these regions started as early as age 18.

CONCLUSIONS

The analyses revealed that brain morphometry differences between MDDs and CTLs are dependent on age and brain region. The significant age-by-group interactions in the lateral orbital frontal gyrus and insular subregions make these regions potential targets for future longitudinal studies of MDD.

Long-term prognostic value of non-invasive lesion-specific hemodynamic index

Background

With advancement in computational fluid dynamics (CFD) technology, novel lesion-specific hemodynamic parameters can be estimated non-invasively. However, their long-term prognostic implications have not been fully defined.

Purpose

We sought to investigate the ten-year outcomes of lesion-specific hemodynamic indices derived-from coronary CT angiography (CCTA).

Methods

A total of 145 vessels (95 patients) with stable coronary artery disease who underwent fractional flow reserve (FFR) derived by coronary computed tomographic angiography (FFRCT) and invasive FFR measurement was included from the first-in-human study of FFRCT. Study participants were enrolled from October 2009 to January 2011 and were followed up until December 2020. A total of 340 lesions with % diameter stenosis ≥30% were identified, and wall shear stress (WSS) and change FFRCT across the lesion (ΔFFRCT) were obtained using CFD techniques by an independent core laboratory. The optimal cut-off for WSS and ΔFFRCT was applied for outcome analysis. The primary endpoint was target lesion failure (TLF) including cardiovascular death, target vessel myocardial infarction, and target lesion revascularization at 10 years.

Results

The median WSS and ΔFFRCT was 183.3 [112.8; 273.9] and 0.06 [0.03; 0.13]. WSS and ΔFFRCT was mildly correlated with FFRCT (r=−0.18, P=0.001 for WSS; r=−0.36, P&lt;0.001 for ΔFFRCT). Of 179 lesions with deferral of revascularization at the index procedure of FFR measurement, TLF occurred in 16 (8.9%) lesions. In prediction of 10-year TLF, % diameter stenosis (per-lesion) ≥50%, FFRCT ≤0.80, WSS ≥256.1 dyn/cm2, and ΔFFRCT ≥0.06 were significant predictors. However, in multivariate analyses with those predictors, % diameter stenosis (per-lesion) ≥50%, FFRCT ≤0.80 became insignificant, and lesion-specific hemodynamic indices were only predictive of 10-year TLF (adjusted hazard ratio [aHR] 2.66, 95% confidence interval [CI] 0.98–7.22, P=0.055 for WSS ≥256.1 dyn/cm2; aHR 5.88, 95% CI 1.10–33.25, P=0.045 for ΔFFRCT ≥0.06). WSS ≥256.1 dyn/cm2 and ΔFFRCT ≥0.06 had higher information gain in predicting outcomes than % diameter stenosis (per-lesion) ≥50% and FFRCT ≤0.80, and both improved predictability for 10-year TLF risk of the model with % diameter stenosis (per-lesion) ≥50% and FFRCT ≤0.80 (P=0.068 for WSS ≥256.1 dyn/cm2; P=0.011 for ΔFFRCT ≥0.06) (Figure).

Conclusions

Non-invasive lesion-specific hemodynamic indices (i.e., high WSS and high ΔFFRCT) were the robust predictors of 10-year outcomes of a target lesion with incremental predictability over anatomical severity and low FFRCT. Clinical application of non-invasive hemodynamic indices will provide better long-term risk stratification over the current prognostication scheme before an invasive procedure.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott, Philips, HeartFlow

Randomized, Placebo-Controlled Trial of the Angiotensin Receptor Antagonist Losartan for Posttraumatic Stress Disorder

BACKGROUND

Evidence-based pharmacological treatments for posttraumatic stress disorder (PTSD) are few and of limited efficacy. Previous work suggests that angiotensin type 1 receptor inhibition facilitates fear inhibition and extinction, important for recovery from PTSD. This study tests the efficacy of the angiotensin type 1 receptor antagonist losartan, an antihypertensive drug, repurposed for the treatment of PTSD.

METHODS

A randomized controlled trial was conducted for 10 weeks in 149 men and women meeting DSM-5 PTSD criteria. Losartan (vs. placebo) was flexibly titrated from 25 to 100 mg/day by week 6 and held at highest tolerated dose until week 10. Primary outcome was the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) change score at 10 weeks from baseline. A key secondary outcome was change in CAPS-5 associated with a single nucleotide polymorphism of the ACE gene. Additional secondary outcomes included changes in the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9, and proportion of responders with a Clinical Global Impressions-Improvement scale of "much improved" or "very much improved."

RESULTS

Both groups had robust improvement in PTSD symptoms, but there was no significant difference on the primary end point, CAPS-5 measured as week 10 change from baseline, between losartan and placebo (mean change difference, 0.9, 95% confidence interval, -3.2 to 5.0). There was no significant difference in the proportion of Clinical Global Impressions-Improvement scale responders for losartan (58.6%) versus placebo (57.9%), no significant differences in changes in PTSD Checklist for DSM-5 or Patient Health Questionnaire-9, and no association between ACE genotype and CAPS-5 improvement on losartan.

CONCLUSIONS

At these doses and durations, there was no significant benefit of losartan compared with placebo for the treatment of PTSD. We discuss implications for failure to determine the benefit of a repurposed drug with strong a priori expectations of success based on preclinical and epidemiological data.

The Association between Age and Experienced Emotions in Hoarding Disorder

Objectives: Hoarding disorder (HD) is conceptualized as a fear-based disorder and exposure to sorting/discarding possessions is a core part of treatment. However, there has been no investigation of age-related differences in emotional reaction to sorting. The objective of this study was to explore the association between age and affective response during a sorting task.Methods: Forty-nine adults with HD completed a standardized sorting task. Participants reported their current emotion before and after the sorting task and reported their subjective distress throughout the task.Results: Older participants reported significantly lower distress ratings. Only 43% of participants reported fear prior to the task and 22% reported fear after the task. The probability of reporting fear before and after the task decreased significantly with age.Conclusions: Fear may not be the emotion experienced when discarding items, particularly for older adults with HD. Future work should focus on mechanisms of action in HD treatment.Clinical Implications: Clinicians should not assume fear or anxiety to be the primary emotional response in older adults with HD when engaged in an exposure to sorting/discarding. Older hoarding patients with a more fear-oriented aversion to sorting possessions may require a treatment emphasis on increasing the percentage of items discarded.

Failure to Identify Robust Latent Variables of Positive or Negative Valence Processing Across Units of Analysis

BACKGROUND

The heterogeneous nature of mood and anxiety disorders highlights a need for dimensionally based descriptions of psychopathology that inform better classification and treatment approaches. Following the Research Domain Criteria approach, this investigation sought to derive constructs assessing positive and negative valence domains across multiple units of analysis.

METHODS

Adults with clinically impairing mood and anxiety symptoms (N = 225) completed comprehensive assessments across several units of analysis. Self-report assessments included nine questionnaires that assess mood and anxiety symptoms and traits reflecting the negative and positive valence systems. Behavioral assessments included emotional reactivity and distress tolerance tasks, during which skin conductance and heart rate were measured. Neuroimaging assessments included fear conditioning and a reward processing task. The latent variable structure underlying these measures was explored using sparse Bayesian group factor analysis.

RESULTS

Group factor analysis identified 11 latent variables explaining 31.2% of the variance across tasks, none of which loaded across units of analysis or tasks. Instead, variance was best explained by individual latent variables for each unit of analysis within each task. Post hoc analyses 1) showed associations with small effect sizes between latent variables that were derived separately from functional magnetic resonance imaging and self-report data and 2) showed that some latent variables are not directly related to individual valence system constructs.

CONCLUSIONS

The lack of latent structure across units of analysis highlights challenges of the Research Domain Criteria approach and suggests that while dimensional analyses work well to reveal within-task features, more targeted approaches are needed to reveal latent cross-modal relationships that could illuminate psychopathology.

Changes in neural reward processing following Amplification of Positivity treatment for depression and anxiety: Preliminary findings from a randomized waitlist controlled trial

Positive valence system (PVS) deficits are increasingly recognized as important treatment targets for depression and anxiety. Emerging behavioral treatments designed to upregulate the PVS show initial promise; however, neural mechanisms underlying these approaches remain unknown. This study investigated neural reward-processing-related changes following Amplification of Positivity (AMP)-a treatment designed to enhance positive thinking, emotions and behaviors through positive activity interventions (Clinicaltrials.gov: NCT02330627). Individuals with depression and/or anxiety (N = 29) were randomized to 10 sessions of AMP (n = 16) or waitlist (WL; n = 13). Participants completed a monetary incentive delay task during fMRI at baseline and post-assessment. Hypothesis-driven region of interest (ventral striatum, insula, anterior cingulate) and exploratory whole-brain activation and connectivity analyses evaluated pre-to-post changes for AMP vs. WL when anticipating potential monetary gain or loss. No between-group brain activation changes emerged in regions of interest or whole-brain analyses. Increased neural connectivity from pre-to-post-treatment was observed in AMP vs. WL, including ventral striatum, anterior insula, and anterior cingulate connectivity with prefrontal, limbic, occipital and parietal regions-predominantly during loss anticipation. This preliminary study is the first to examine neural mechanisms of positive activity interventions in depression and anxiety and suggests that AMP may strengthen brain connectivity in reward processing, attention, and emotion regulation networks.

Computer-delivered behavioural activation and approach-avoidance training in major depression: Proof of concept and initial outcomes

OBJECTIVES

Individuals with major depressive disorder (MDD) have problems with engaging in approach behaviour to potentially rewarding encounters, which contributes to the maintenance of depressive symptoms. Approach-avoidance training (AAT) retrains implicit approach tendencies, and behavioural activation (BA) promotes explicit approach behaviour in MDD. As a novel MDD treatment strategy, this study aimed to implement a brief, computerized version of BA integrated with implicit AAT.

DESIGN

Adults with a principal diagnosis of MDD (N = 25) were randomly assigned to complete one of two versions of AAT - approach-positive faces (n = 12) or balanced approach of positive and neutral faces (n = 13) - concurrently with self-guided BA twice weekly for 2 weeks.

METHODS

Outcomes included treatment completion rates; bias scores for automatic approach towards positive social cues; and symptom scales for depression, positive affect, social relationship functioning, anhedonia, and anxiety.

RESULTS

Feasibility and acceptability of computerized BA + AAT were supported by moderate pre-treatment credibility and expectancy ratings and 80% treatment completion. Participants across both conditions displayed significant and large sized reductions in depression from pre- to post-assessment (Cohen's d = -1.23) that maintained three months later, as well as decreased anxiety and anhedonia and increased positive affect and social relationship functioning (medium to large effects).

CONCLUSION

Results support the feasibility and potential efficacy of brief, computerized BA + AAT. Research is needed to determine whether AAT is additive to BA, and what AAT parameters best enhance treatment outcomes.

PRACTITIONER POINTS

Brief, computerized behavioral activation plus approach/avoidance training (BA + AAT) may be acceptable and beneficial for some patients with moderate-to-severe major depression. Computer-delivered BA + AAT can be implemented as a largely self-guided program for MDD and could be administered remotely and/or with minimal clinician interaction. As this was a small proof of concept study, it cannot be determined which treatment components - AAT, BA, or both - contributed to positive clinical outcomes. Because BA + AAT was implemented in a research clinic, it remains unknown what treatment engagement and response would look like in community settings.

Characterizing the time course of automatic action tendencies to affective facial expressions and its dysregulation in social anxiety disorder

Affective facial expressions elicit automatic approach or avoidance action tendencies, which are dysregulated in Social Anxiety Disorder (SAD). However, research has not dissociated the initiation and execution phases of automatic action tendencies, which may be distinctly modulated by affective faces and SAD. In Study 1, fifty adults completed a modified Approach-Avoidance Task (AAT) that characterized the time course of automatic approach or avoidance actions elicited by affective faces. In the initiation phase, happy faces elicited greater automatic approach tendencies compared to angry faces, an effect that linearly weakened across the execution phase. In Study 2, 44 adults with a principal diagnosis of SAD and 22 healthy comparison (HC) adults completed a similar AAT. Compared to the HC group, the SAD group exhibited an inconsistent time course of automatic action tendencies to neutral faces. Specifically, SAD was characterized by relatively weak initiation of automatic approach tendencies, but relatively stronger execution of automatic approach tendencies. In contrast, the HC group exhibited relatively similar initiation and execution of automatic approach tendencies to neutral faces. Together, these results demonstrate that the initiation and execution of automatic action tendencies are differentially modulated by affective faces and SAD.

Higher affective congruency in the approach-avoidance task is associated with insular deactivation to dynamic facial expressions

Individuals exhibit a natural bias to approach positive social cues (e.g., smiling face) and to avoid negative ones, which may be altered in psychiatric conditions. Computerized approach/avoidance training to promote affectively congruent behavior has proven useful in modulating such biases. Here, we investigate how exposure to a higher rate of congruency impacts neural processing of social-affective cues. While undergoing functional magnetic resonance imaging (fMRI), twenty-four individuals completed two versions of the approach-avoidance task (AAT), in which they had to approach or avoid dynamic facial expressions of either happiness or disgust. In the high congruency condition, congruent responses (i.e. approaching happy faces, avoiding disgusted faces) were more frequent. The balanced condition had equal amounts of congruent and incongruent responses. Processing of congruent approach-avoidance actions towards social cues was associated with lower recruitment of the right anterior insula in the congruency-intensive relative to the balanced condition. Differential activation between the high congruency and balanced condition in the right hippocampus was negatively related to individuals' trait avoidance tendency. These findings are consistent with reduced affective neural processing of social cues when being exposed to congruent AAT contexts. These neural foci could be important targets when assessing the effectiveness of affective congruency training protocols.

Disentangling temporal dynamics in attention bias from measurement error: A state-space modeling approach

Temporal dynamics in attention bias (AB) have gained increasing attention in recent years. It has been proposed that AB is variable over trials within a single test session of the dot-probe task, and that the variability in AB is more predictive of psychopathology than the traditional mean AB score. More important, one of the dynamics indices has shown better reliability than the traditional mean AB score. However, it has been also suggested that the dynamics indices are unable to uncouple random measurement error from true variability in AB, which questions the estimation precision of the dynamics indices. To clarify and overcome this issue, the current article introduces a state-space modeling (SSM) approach to estimate trial-level AB more accurately by filtering random measurement error. The estimation error of the extant dynamics indices versus SSM were evaluated by computer simulations with different parameter settings for the temporal variability and between-person variance in AB. Throughout the simulations, SSM showed robustly lower estimation error than the extant dynamics indices. We also applied these indices to real data sets, which revealed that the dynamics indices overestimate within-person variability relative to SSM. Here SSM indicated less temporal dynamics in AB than previously proposed. These findings suggest that SSM might be a better alternative to estimate trial level AB than the extant dynamics indices. However, it is still unclear whether AB has meaningful in-session variability that is predictive of psychopathology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Diagnostic and dimensional evaluation of implicit reward learning in social anxiety disorder and major depression

OBJECTIVE

Increasing evidence supports the presence of an anhedonic endophenotype in major depressive disorder (MDD), characterized by impairments in various components of reward processing, particularly incentive motivation, effort-based decision making, and reward learning. In addition to its prominent role in MDD, reward processing dysregulation has been proposed as a transdiagnostic risk and/or maintenance factor for a range of other forms of psychopathology. Individuals with social anxiety disorder (SAD)-a condition that frequently co-occurs with MDD-demonstrate low trait positive affectivity and altered processing of rewards and positively valenced information. However, no studies to date have directly tested reward learning-the ability to modulate behavior in response to rewards-in this population.

MATERIALS AND METHODS

The current study evaluated reward learning in MDD, SAD, and healthy control subjects (N = 90) using a well-validated signal detection task. Given increasing data supporting transdiagnostic features of psychopathology, we also evaluated associations between anhedonia and task performance transdiagnostically in the patient sample.

RESULTS

Contrary to expectations, results indicated no significant group differences in response bias in the full sample, suggesting no diagnostic differences in reward learning. However, dimensional analyses revealed that higher self-reported anhedonia (but not general distress or anxious arousal) was associated with worse reward learning in both the MDD and SAD groups explaining about 11% of the variance.

CONCLUSION

Deficits in implicit reward learning are associated with anhedonia but not necessarily with major depressive disorder as a diagnosis, which supports the use of transdiagnostic approaches to understanding psychopathology.

Regulation of glycolysis by the hypoxia-inducible factor (HIF): implications for cellular physiology

Under conditions of hypoxia, most eukaryotic cells can shift their primary metabolic strategy from predominantly mitochondrial respiration towards increased glycolysis to maintain ATP levels. This hypoxia-induced reprogramming of metabolism is key to satisfying cellular energetic requirements during acute hypoxic stress. At a transcriptional level, this metabolic switch can be regulated by several pathways including the hypoxia inducible factor-1α (HIF-1α) which induces an increased expression of glycolytic enzymes. While this increase in glycolytic flux is beneficial for maintaining bioenergetic homeostasis during hypoxia, the pathways mediating this increase can also be exploited by cancer cells to promote tumour survival and growth, an area which has been extensively studied. It has recently become appreciated that increased glycolytic metabolism in hypoxia may also have profound effects on cellular physiology in hypoxic immune and endothelial cells. Therefore, understanding the mechanisms central to mediating this reprogramming are of importance from both physiological and pathophysiological standpoints. In this review, we highlight the role of HIF-1α in the regulation of hypoxic glycolysis and its implications for physiological processes such as angiogenesis and immune cell effector function.

Examining the link between positive affectivity and anxiety reactivity to social stress in individuals with and without social anxiety disorder

BACKGROUND

Positive affect (PA) attenuates negative reactivity to stress; however, this adaptive function of PA is seldom studied in psychiatric conditions characterized by more extreme forms of affective responding. We tested distinct associations of PA and negative affect (NA) with anxiety reactivity in participants with social anxiety disorder (SAD)-a condition characterized by heightened NA and diminished PA-and non-SAD control subjects.

METHOD

Adults with a principal diagnosis of SAD (n = 71) and those without a psychiatric history (n = 36) rated their PA and NA during the past week, and were exposed to a laboratory stressor wherein they delivered a video-recorded speech on a controversial topic. Anxiety reactivity was assessed in terms of anticipatory anxiety prior to the speech, and observer-rated anxiety-related behavior during the speech.

RESULTS

Across all participants, higher PA significantly predicted lower anticipatory anxiety and less anxiety-related behavior, beyond level of NA; lower NA significantly predicted attenuated anticipatory anxiety, but not anxiety-related behavior, beyond level of PA. The association between PA and stress reactivity was diminished for individuals with especially elevated NA, as well as for individuals with SAD compared to those without.

CONCLUSIONS

PA may be protective against negative reactivity to social stress; however, theoretical models and clinical applications should consider possible interactive effects of PA and NA in modulating stress reactivity.

Enhancing Social Connectedness in Anxiety and Depression Through Amplification of Positivity: Preliminary Treatment Outcomes and Process of Change

Background

Anxiety and depressive disorders are often characterized by perceived social disconnection, yet evidence-based treatments produce only modest improvements in this domain. The well-established link between positive affect (PA) and social connectedness suggests that directly targeting PA in treatment may be valuable.

Method

A secondary analysis of a waitlist-controlled trial (N=29) was conducted to evaluate treatment response and process of change in social connectedness within a 10-session positive activity intervention protocol-Amplification of Positivity (AMP)-designed to increase PA in individuals seeking treatment for anxiety or depression (ClinicalTrials.gov Identifier: NCT02330627). Perceived social connectedness and PA/negative affect (NA) were assessed throughout treatment. Time-lagged multilevel mediation models examined the process of change in affect and connectedness throughout treatment.

Results

The AMP group displayed significantly larger improvements in social connectedness from pre- to post-treatment compared to waitlist; improvements were maintained through 6-month follow-up. Within the AMP group, increases in PA and decreases in NA both uniquely predicted subsequent increases in connectedness throughout treatment. However, experiencing heightened NA throughout treatment attenuated the effect of changes in PA on connectedness. Improvements in connectedness predicted subsequent increases in PA, but not changes in NA.

Conclusions

These preliminary findings suggest that positive activity interventions may be valuable for enhancing social connectedness in individuals with clinically impairing anxiety or depression, possibly through both increasing positive emotions and decreasing negative emotions.

Facial Affect and Interpersonal Affiliation: Displays of Emotion During Relationship Formation in Social Anxiety Disorder

Social anxiety disorder (SAD) often involves difficulty developing relationships. Facial expressions are important in relationship formation, but data are limited regarding facial display production among persons with SAD during social interaction. The current study compared facial displays of individuals diagnosed with SAD (n=41) to control participants (n=24) as they interacted with a confederate; confederates and observers then rated their desire for future interaction with participants. Automated software used the Facial Action Coding System (FACS; Ekman & Friesen, 1978) to classify displays. During portions of the interaction that involved listening to partners, the SAD group smiled less frequently and less intensely than controls, and lower smiling was associated with others' lower desire for future interaction with participants. Diminished positive facial affect in response to interaction partners may disrupt relationship formation in SAD and may serve as an effective treatment target.

Preliminary evidence that computerized approach avoidance training is not associated with changes in fMRI cannabis cue reactivity in non-treatment-seeking adolescent cannabis users

BACKGROUND

Cognitive Bias Modification (CBM) has garnered interest as a potential addiction treatment. CBM interventions such as Approach Avoidance Training (AAT) are designed to alter automatic tendencies to approach drugs or drug-related cues. In our previous work, the cannabis AAT (CAAT) reduced cannabis approach bias, which was related to reduced cannabis use, among 80 non-treatment-seeking cannabis-using youth (Jacobus et al., 2018). In this preliminary examination, a subsample of these youth underwent neuroimaging to explore CAAT's effect on cannabis cue-related neural activation.

METHODS

Sub-study participants were 41 cannabis-using youth ages 17-21 (mean age = 18.83; 47.5% female). Participants completed a cannabis cue-reactivity task during a functional MRI scan pre- and post CAAT-training or CAAT-sham to examine CAAT-related neural changes.

RESULTS

Thirty-seven youth completed all six CAAT (n = 19) or CAAT-sham (n = 18) training sessions and had usable neuroimaging data. The group*time interaction on cannabis approach bias reached trend-level significance (p = .055). Change in approach bias slopes from pre-to post-treatment was positive for CAAT-sham (increased approach bias) and negative for CAAT-training (change to avoidance bias), consistent with the larger study. No significant changes emerged for cannabis cue-induced activation following CAAT-training or CAAT-sham in whole brain or region of interest analyses. However, active CAAT-training was associated with small-to-medium decreases in amygdala (Cohen's d_z = 0.36) and medial prefrontal cortex (Cohen's d_z = 0.48) activation to cannabis cues.

CONCLUSIONS

Despite reducing cannabis use in the larger sample, CAAT-training did not alter neural cannabis cue-reactivity in the sub-study compared to CAAT-sham. More research is needed to understand neural mechanisms underlying AAT-related changes in substance use.

Intolerance of uncertainty in hoarding disorder

BACKGROUND

Intolerance of uncertainty (IU) has been proposed as a transdiagnostic risk and maintenance factor underlying various forms of psychopathology. Few studies, however, have examined IU in hoarding disorder (HD)-a condition characterized by excessive urges to acquire and difficulties discarding possessions-core symptoms that may be fueled by inflated IU. We examined cross-sectional relationships between IU and different symptom facets of HD, controlling for anxiety and depression severity, and explored whether pre-treatment levels of IU predicted response to exposure-based treatment for HD.

METHOD

Fifty-seven individuals seeking treatment for HD completed baseline measures of hoarding symptoms, IU, anxiety and depression. Participants then completed 26 sessions of group exposure-based treatment for HD with or without compensatory cognitive training. Hoarding symptoms were assessed following the final treatment session to index treatment response.

RESULTS

IU was positively and significantly associated with greater urges to acquire and greater difficulties discarding possessions, beyond shared variance accounted for by anxiety and depression. IU was not significantly related to clutter symptom severity. Higher pre-treatment IU predicted increased odds of treatment non-response.

CONCLUSIONS

Elevated IU is associated with specific hoarding symptom clusters and may be an important target for HD treatment.

A multi-site proof-of-concept investigation of computerized approach-avoidance training in adolescent cannabis users

BACKGROUND

Few effective treatment options exist for cannabis-using youth. This pilot study aimed to test Approach-Avoidance Training to reduce cannabis use with non-treatment-seeking adolescents.

METHODS

Eighty cannabis-using non-treatment-seeking adolescents (average age 19) were recruited from San Diego, California and Charleston, South Carolina, and randomized to complete either six sessions of Cannabis Approach-Avoidance Task Training (CAAT-training) designed to reduce automatic approach biases for cannabis cues or CAAT-sham training. Change in two primary outcome variables was examined: 1) cannabis approach bias and 2) percent cannabis use days over study enrollment. Change in percent alcohol use days over study enrollment was explored as a secondary outcome.

RESULTS

A mixed models repeated measures analysis confirmed the group by time interaction effect for approach bias failed to reach statistical significance (p = .06). Significant group by time interaction effects (ps < 0.05) predicted percent days of cannabis and alcohol use over study enrollment. Participants randomized to the avoid cannabis condition (CAAT-training) reported 7% fewer days of cannabis use compared to 0% change for sham; unexpectedly, those in the avoid cannabis condition reported 10% percent more alcohol use days compared to 3% more for sham.

CONCLUSIONS

Computerized cognitive bias modification paradigms may have utility in reducing adolescent cannabis use. Future work should consider developing a paradigm that addresses both cannabis and alcohol, as well as alternative computerized approaches for coping with addictive behavior in conjunction with bias modification.

Predictive validity and correlates of self-assessed resilience among U.S. Army soldiers

BACKGROUND

Self-assessment of resilience could prove valuable to military and other organizations whose personnel confront foreseen stressors. We evaluated the validity of self-assessed resilience among U.S. Army soldiers, including whether predeployment perceived resilience predicted postdeployment emotional disorder.

METHODS

Resilience was assessed via self-administered questionnaire among new soldiers reporting for basic training (N = 35,807) and experienced soldiers preparing to deploy to Afghanistan (N = 8,558). Concurrent validity of self-assessed resilience was evaluated among recruits by estimating its association with past-month emotional disorder. Predictive validity was examined among 3,526 experienced soldiers with no lifetime emotional disorder predeployment. Predictive models estimated associations of predeployment resilience with incidence of emotional disorder through 9 months postdeployment and with marked improvement in coping at 3 months postdeployment. Weights-adjusted regression models incorporated stringent controls for risk factors.

RESULTS

Soldiers characterized themselves as very resilient on average [M = 14.34, SD = 4.20 (recruits); M = 14.75, SD = 4.31 (experienced soldiers); theoretical range = 0-20]. Demographic characteristics exhibited only modest associations with resilience, while severity of childhood maltreatment was negatively associated with resilience in both samples. Among recruits, resilience was inversely associated with past-month emotional disorder [adjusted odds ratio (AOR) = 0.65, 95% CI = 0.62-0.68, P < .0005 (per standard score increase)]. Among deployed soldiers, greater predeployment resilience was associated with decreased incidence of emotional disorder (AOR = 0.91; 95% CI = 0.84-0.98; P = .016) and increased odds of improved coping (AOR = 1.36; 95% CI = 1.24-1.49; P < .0005) postdeployment.

CONCLUSIONS

Findings supported validity of self-assessed resilience among soldiers, although its predictive effect on incidence of emotional disorder was modest. In conjunction with assessment of known risk factors, measurement of resilience could help predict adaptation to foreseen stressors like deployment.

Changes in marijuana use symptoms and emotional functioning over 28-days of monitored abstinence in adolescent marijuana users

RATIONALE

Advancing marijuana prevention and intervention efforts are important given the decreasing perception of harm among adolescents and increasing marijuana legalization.

OBJECTIVES

This study evaluates how a monitored abstinence protocol may contribute to emotional functioning and changes in marijuana problems that can enhance successful outcomes for non-treatment-seeking adolescent marijuana users.

METHODS

Adolescent marijuana users (n = 26) and demographically matched controls (n = 30) completed 28 days of monitored abstinence confirmed by biweekly urine toxicology. Participants were given measures of emotional functioning, marijuana use symptoms, and reward sensitivity during monitored abstinence.

RESULTS

All participants (n = 56) completed the protocol, and 69% of marijuana users (n = 18 of 26) were confirmed abstinent for 28 days, with all users showing decreasing marijuana use. Reductions in subsyndromal depression, positive marijuana use expectancies, and poor sleep quality were observed by the end of the monitored abstinence period (n = 26, p values < .05). Marijuana users also reported more attentional impulsivity and less responsiveness to reward stimuli during the second week of abstinence compared to controls. Later age of onset of regular marijuana use and more cumulative lifetime use were associated with a greater degree of emotional change and increased recognition of the negative effects of marijuana use.

CONCLUSIONS

Monitored abstinence programs may be beneficial in reducing marijuana use, subsyndromal emotional distress symptoms, and changing beliefs about marijuana use. Future prevention and intervention efforts may consider targeting reward sensitivity and impulsivity, in addition to marijuana use, expectancies, and emotional functioning.

Neural mechanisms of interference control in working memory capacity

The extent to which one can use cognitive resources to keep information in working memory is known to rely on (1) active maintenance of target representations and (2) downregulation of interference from irrelevant representations. Neurobiologically, the global capacity of working memory is thought to depend on the prefrontal and parietal cortices; however, the neural mechanisms involved in controlling interference specifically in working memory capacity tasks remain understudied. In this study, 22 healthy participants completed a modified complex working memory capacity task (Reading Span) with trials of varying levels of interference control demands while undergoing functional MRI. Neural activity associated with interference control demands was examined separately during encoding and recall phases of the task. Results suggested a widespread network of regions in the prefrontal, parietal, and occipital cortices, and the cingulate and cerebellum associated with encoding, and parietal and occipital regions associated with recall. Results align with prior findings emphasizing the importance of frontoparietal circuits for working memory performance, including the role of the inferior frontal gyrus, cingulate, occipital cortex, and cerebellum in regulation of interference demands.

Group Cognitive Rehabilitation and Exposure/Sorting Therapy: A Pilot Program

While cognitive-behavioral therapy for hoarding disorder (HD) has resulted in significant reductions in symptoms, most individuals continue to have significant hoarding symptoms following treatment. This investigation sought to extend the literature on the behavioral treatments for hoarding by examining (1) group cognitive rehabilitation and exposure/sorting therapy (CREST) and (2) group exposure therapy (ET) for hoarding. Participants in both studies reported significant decreases in hoarding symptom severity from baseline to post-treatment on all primary outcome measures using mixed-effects linear regression models with the intent to treat sample. Participants who received group CREST reported statistically significant reductions in anxiety, depression, and overall severity at post-treatment, while participants who received group ET did not. Results provide preliminary evidence for both group CREST and group ET as effective treatments for hoarding disorder.

Latent variable analysis of positive and negative valence processing focused on symptom and behavioral units of analysis in mood and anxiety disorders

BACKGROUND

Mood and anxiety disorders are highly heterogeneous and their underlying pathology is complex. The Research Domain Criteria (RDoC) approach seeks to establish dimensionally and neuroscience-based descriptions of psychopathology that may inform better classification and treatment approaches. The current investigation sought to determine the latent variables underlying positive and negative valence processing in terms of symptoms and behavioral units of analysis.

METHOD

As part of an ongoing study, individuals with mood and anxiety problems were recruited largely from primary care clinics at UCLA (n=62) and UCSD (n=58). These participants underwent a comprehensive symptomatic and behavioral assessment. An implicit approach avoidance task and a modified dot probe detection task were used to measure positive and negative valence processing.

RESULTS

Principal components analysis with varimax rotation identified four symptom components, three behavioral components for the dot probe task, and two behavioral components for the implicit approach avoidance task. These components yielded two meta-components consisting of: negative valence symptoms, negative approach bias, and high sustained, selective attention; and positive valence symptoms, positive approach bias, and slow selective or sustained attention. The components did not differ between males and females, nor by age or medication status.

LIMITATIONS

The limitations are: (1) relatively small sample, (2) exploratory analysis strategy, (3) no test/re-test data, (4) no neural circuit analysis, and (5) limited reliability of behavioral data.

CONCLUSIONS

These preliminary data show that positive and negative valence processing domains load on independent dimensions. Taken together, multi-level assessment approaches combined with advanced statistical analyses may help to identify distinct positive and negative valence processes within a clinical population that cut across traditional diagnostic categories.

What good are positive emotions for treatment? Trait positive emotionality predicts response to Cognitive Behavioral Therapy for anxiety

OBJECTIVE

Cognitive behavioral therapy (CBT) is empirically supported for the treatment of anxiety disorders; however, not all individuals achieve recovery following CBT. Positive emotions serve a number of functions that theoretically should facilitate response to CBT - they promote flexible patterns of information processing and assimilation of new information, encourage approach-oriented behavior, and speed physiological recovery from negative emotions. We conducted a secondary analysis of an existing clinical trial dataset to test the a priori hypothesis that individual differences in trait positive emotions would predict CBT response for anxiety.

METHOD

Participants meeting diagnostic criteria for panic disorder (n = 28) or generalized anxiety disorder (n = 31) completed 10 weekly individual CBT sessions. Trait positive emotionality was assessed at pre-treatment, and severity of anxiety symptoms and associated impairment was assessed throughout treatment.

RESULTS

Participants who reported a greater propensity to experience positive emotions at pre-treatment displayed the largest reduction in anxiety symptoms as well as fewer symptoms following treatment. Positive emotions remained a robust predictor of change in symptoms when controlling for baseline depression severity.

CONCLUSIONS

Initial evidence supports the predictive value of trait positive emotions as a prognostic indicator for CBT outcome in a GAD and PD sample.

A Preliminary Investigation of the Measurement of Object Interconnectedness in Hoarding Disorder

A defining feature of hoarding disorder (HD) is excessive attachment to possessions. Several existing self-report measures assess emotional attachment to items but do not explicitly assess the level of interconnectedness between the individual and their items. The current study investigated a new self-report measure of object attachment based on a measure of interconnectedness among individuals. The visual nature of this measure may be especially useful in HD patients since hoarding is often characterized by low insight. Participants completed the Relationship between Self and Items (RSI) measure and measures of hoarding severity, clutter, anxiety, and depression. HD participants reported significantly higher scores on the RSI than did community controls. The RSI was positively associated with hoarding symptoms, but was not significantly correlated with symptoms of anxiety or depression. Results also suggested that the RSI is sensitive to change from pre to post-treatment. This brief, one-item measure may be useful as a screen for HD and to provide further clinical data on level of interconnectedness to possessions.

Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention

BACKGROUND

Research suggests that the positive affect system may be an important yet underexplored treatment target in anxiety and depression. Existing interventions primarily target the negative affect system, yielding modest effects on measures of positive emotions and associated outcomes (e.g., psychological well-being). The objective of the present pilot study was to evaluate the efficacy of a new transdiagnostic positive activity intervention (PAI) for anxiety and depression.

METHOD

Twenty-nine treatment-seeking individuals presenting with clinically impairing symptoms of anxiety and/or depression were randomly allocated to a 10-session protocol comprised of PAIs previously shown in nonclinical samples to improve positive thinking, emotions, and behaviors (e.g., gratitude, acts of kindness, optimism; n = 16) or a waitlist (WL) condition (n = 13). Participants were assessed at pre- and posttreatment, as well as 3- and 6-month follow-up, on measures of positive and negative affect, symptoms, and psychological well-being. ClinicalTrials.gov Identifier: NCT02330627 RESULTS: The PAI group displayed significantly larger improvements in positive affect and psychological well-being from pre- to posttreatment compared to WL. Posttreatment and follow-up scores in the PAI group were comparable to general population norms. The PAI regimen also resulted in significantly larger reductions in negative affect, as well as anxiety and depression symptoms, compared to WL. Improvements across all outcomes were large in magnitude and maintained over a 6-month follow-up period.

CONCLUSIONS

Targeting the positive affect system through a multicomponent PAI regimen may be beneficial for generating improvements in positive emotions and well-being, as well as reducing negative affect and symptoms, in individuals with clinically impairing anxiety or depression.

Attentional control moderates the relationship between social anxiety symptoms and attentional disengagement from threatening information

BACKGROUND AND OBJECTIVES

Social anxiety is characterized by biased attentional processing of social information. However, heterogeneity of extant findings suggests that it may be informative to elucidate individual difference factors that modulate the processing of emotional information. The current study examined whether individual differences in components of attentional control (AC--shifting and focusing) moderated the link between social anxiety and attentional engagement and disengagement biases for threat-relevant cues.

METHODS

Seventy-five undergraduate students completed well-established measures of social anxiety symptoms, AC, and attentional bias for social threat information (modified probe detection task).

RESULTS

Moderation analyses revealed that at low levels of AC-shifting, increased social anxiety was associated with slower disengagement from threat-relevant compared to neutral social cues. In contrast, at high levels of AC-shifting, social anxiety was associated with faster disengagement from threat-relevant compared to neutral stimuli. Individual differences in AC-focusing did not moderate the social anxiety-attentional bias link.

LIMITATIONS

Causal inferences cannot be made given the cross-sectional study design. The sample comprised individuals displaying a range of self-reported social anxiety symptoms; thus, generalizability to clinical samples remains to be established. The measurement of AC relied on subjective participant report.

CONCLUSIONS

The current findings underscore the importance of AC processes in understanding the nature of attentional bias mechanisms in anxiety.

Structural connectivity of neural reward networks in youth at risk for substance use disorders

BACKGROUND

Having a positive family history of alcohol use disorders (FHP), as well as aberrant reward circuitry, has been implicated in the initiation of substance use during adolescence. This study explored the relationship between FHP status and reward circuitry in substance naïve youth to better understand future risky behaviors.

METHODS

Participants were 49 FHP and 45 demographically matched family history negative (FHN) substance-naïve 12-14 year-olds (54 % female). Subjects underwent structural magnetic resonance imaging, including diffusion tensor imaging. Nucleus accumbens and orbitofrontal cortex volumes were derived using FreeSurfer, and FSL probabilistic tractography probed structural connectivity and differences in white matter diffusivity estimates (e.g. fractional anisotropy, and mean, radial, and axial diffusivity) between fiber tracts connecting these regions.

RESULT

FHP and FHN youth did not differ on nucleus accumbens or orbitofrontal cortex volumes, white matter tract volumes, or percentages of streamlines (a proxy for fiber tract count) connecting these regions. However, within white matter tracts connecting the nucleus accumbens to the orbitofrontal cortex, FHP youth had significantly lower mean and radial diffusivity (ps < 0.03) than FHN youth.

DISCUSSION

While white matter macrostructure between salience and reward regions did not differ between FHP and FHN youth, FHP youth showed greater white matter coherence within these tracts than FHN youth. Aberrant connectivity between reward regions in FHP youth could be linked to an increased risk for substance use initiation.