International Journal of Cognitive Therapy

Published by Guilford Press
Online ISSN: 1937-1217
Print ISSN: 1937-1209
Change in Expectancy/Credibility from Session 4 to Session 7 of CBT.  
Relationship Between Expectancy and Symptom Severity over First Seven Sessions of CBT for GAD.  
Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-session cognitive and behavioral therapy for generalized anxiety disorder (GAD). In 76 adults with primary GAD, we predicted that expectancy/credibility would change significantly from sessions 4-7, that degree of change in expectancy/credibility would predict degree of reliable change at posttreatment, and that changes in expectancy/credibility would mediate the relationship between pretreatment severity and change at posttreatment. In support of the hypotheses, a latent growth model revealed significant increases in expectancy/credibility over the critical period. In addition, baseline GAD severity, expectancy/credibility intercept, and rate of change in expectancy/credibility all positively predicted degree of reliable change at posttreatment. Rate of change in expectancy/credibility during the critical period partially mediated the effect of baseline GAD severity, accounting for 38% of the variance in this relationship. This effect was not accounted for by preceding or concurrently changing anxiety levels.
In order to examine the benefit of adding pharmacotherapy to cognitive-behavioral therapy (CBT) for anxiety disorders, we searched for studies comparing CBT plus pharmacotherapy and CBT plus pill placebo for adults meeting DSM-III-R or DSM-IV diagnostic criteria for an anxiety disorder between the 1st available year and July 1, 2008. Of 874 studies that were initially considered, 11 studies were identified, representing 471 patients with post-acute completer data and 236 participants with follow-up completer data. CBT plus pharmacotherapy was generally more effective than CBT plus placebo at post-treatment for measures of anxiety disorder severity (Hedges' g = 0.59, 95% confidence interval: 0.29-0.90) and treatment response (OR: 1.95, 95% confidence interval: 1.25-3.03), but not at 6-month follow-up. Despite the relatively small number of studies, the fail-safe N suggested that the results are reliable. The largest effect sizes at post-treatment were found for panic disorder and generalized anxiety disorder. No differences were observed between self-report and clinician-administered measures. The reported effect sizes linearly decreased with publication year. In sum, there is preliminary evidence to suggest that adding pharmacotherapy to CBT is a useful short-term treatment strategy at least for some of the anxiety disorders.
Treatment Expectancy Ratings by Ethnic Group and Treatment Modality 
Studies suggest that ethnicity and socioeconomic factors may relate to differences in treatment expectancies and the attributions made for emotional or behavioral problems. We examined ethnic differences in (1) parents' attributions about the causes of adolescent behavioral and emotional problems and (2) treatment expectancies among 236 adolescent participants who enrolled in a 36-week randomized controlled trial for depression. Controlling for education and income, European American parents were more likely to endorse beliefs reflecting physical causes of depression than African American parents. There were no ethnic differences for beliefs reflecting external, familial, or community factors. Ethnic differences were observed in the treatment expectancies reported by parents, but not adolescents, with African American parents more likely than European Americans and Other minorities to endorse positive expectations for CBT. These findings may have implications for understanding discrepancies in mental health service use.
Effect of gender and diagnostic group on total dependent stress.  
Individuals with a history of depression experience more stress that is dependent in part on their own actions. However, it is unclear whether stress generation is a unique feature of depression, or a universal process that is also present in other types of psychopathology, such as anxiety disorders. The current study addressed this issue by comparing adolescents with a history of "pure" (i.e., non-comorbid) depressive disorders, pure anxiety disorders, comorbid depression and anxiety, and no disorder, on their levels of dependent and independent stress. Results indicated that adolescents with pure depression experienced more dependent stress than adolescents with pure anxiety, and adolescents with any internalizing diagnosis experienced more dependent stress than controls. Further, adolescents with comorbid depression and anxiety reported the highest levels of stress generation. The results suggest that while stress generation may be more strongly associated with depression than anxiety in adolescence, it is not unique to depression.
Strength of Association among independent Variables (N = 35) 
logistic regression Predicting Substance use Diagnosis (Alcohol/Cannabis) in Young Adulthood a 
Child Nonverbal iQ as a Mediator of the effects of Maternal Withdrawal on Substance use Disorder (SuD) Diagnosis (Alcohol/Cannabis)  
The relation between early mother-infant interaction and later socio-emotional development has been well established. The present study addresses the more recent interest in the impact of maternal caregiving on cognitive development and their role in decision-making in young adulthood. Using data from a prospective longitudinal study on attachment, prediction from early mother-infant interactions at age 18 months and from verbal and nonverbal cognitive skill at age 5 were examined as predictors of a substance use disorder (abuse/dependence) in young adulthood (age 20) on the Structured Clinical Interview for DSM-IV (SCID). Results reveal that the mother's withdrawal from interaction with the infant at age 18 months, coded using the AMBIANCE coding system (Atypical Maternal Behavior Instrument for Assessment and Classification), was associated with the child's lower nonverbal cognitive scores but not verbal cognitive scores at age 5. In addition, maternal withdrawal at 18 months predicted a clinical diagnosis of substance use disorder (alcohol/cannabis) at age 20. Finally, nonverbal reasoning at age 5 mediated the relationship between early maternal withdrawal and substance use disorder (alcohol/cannabis) in young adulthood. Findings indicate the need for further work examining how early maternal withdrawal affects nonverbal cognitive development by school entry, and how these nonverbal deficits further contribute to maladaptive coping strategies such as substance use by young adulthood.
Several lines of research have suggested a link between mania and creativity, The goal of the present study was to test whether positive affect moderated the relationship between risk for mania (assessed with the Hypomanic Personality Scale [HPS]) and a variable postulated to be a cognitive component of creativity: cognitive flexibility. Fifty-three undergraduate students were randomly assigned to either a neutral or positive mood induction condition. They then completed the Delis-Kaplan Executive Function System (DKEFS) Sorting Test as a measure of cognitive flexibility. Consistent with our hypothesis, higher HPS scores were associated with greater cognitive flexibility among participants in the positive mood induction condition. Covariate analyses revealed that results were not confounded by verbal intelligence or the presence of current depression symptoms. Our findings suggest a mood-dependent link between hypomanic personality and one potential component of creative cognition.
Recent psychosocial theories implicate disturbances in reward pursuit among individuals putatively at risk for mania. The present study examined associations of a measure of risk for mania (the Hypomanic Personality Scale; HPS) with both four trait positive emotions (joy, pride, compassion, and love) and ambitious life goals in five domains (fame, wealth, political influence, family, and friends) among 302 participants from two university settings. Findings indicated that higher HPS scores were related to reward (joy) and achievement-focused (pride) positive emotions, with weaker relations to prosocial (compassion, love) positive emotions. HPS scores were more robustly related to extrinsic (fame, politics) as compared to other-oriented (friends, family) ambitious life goals, with the exception of wealth. These effects were independent of current symptoms of mania and depression. Discussion focuses on the implications of elevated reward and achievement-related positive emotions and goals in understanding risk factors for mania.
Research into cognitive mechanisms in posttraumatic stress disorder (PTSD) typically comprises two types of studies. The first group of studies is conducted with survivors of traumatic events and assesses the association between PTSD and cognitive variables with questionnaires and/or information processing paradigms. In the second group of studies, healthy non-traumatized individuals are exposed to an analogue stressor (e.g., a stressful film) and cognitive variables of interest are usually experimentally manipulated to investigate their effects on analogue PTSD symptoms. This review illustrates how studies of trauma survivors and analogue studies with non-traumatized populations can be usefully combined. Two examples for this approach are presented: (1) research into the role of perceptual priming for trauma-related stimuli and (2) research into trauma-related rumination. The advantages and limitations of both types of studies are discussed and it is argued that a combination of both approaches is needed to investigate cognitive mechanisms in PTSD.
We conducted two studies to examine the Cognition Checklist for Mania-Revised (CCL-M-R; Beck, Colis, Steer, Madrak, & Goldberg, 2006). In the first, we gathered data in an undergraduate sample (N = 208) to examine the factor structure of the measure and the correlations of the subscales with the Hypomanic Personality Scale (HPS; Eckblad & Chapman, 1986). Factor analyses refined subscales, and three of the original four subscales developed by Beck and colleagues (2006) were retained. Persons with higher stores on the HPS were likely to endorse manic cognitions associated with overconfidence and excitement-seeking. In a second study, we gathered data from 61 persons diagnosed with bipolar I disorder, 38 with major depressive disorder (MDD), and 33 with no history of mood disorder. Excitement-seeking scores were robustly related to current manic symptoms, as measured by the Internal State Scale (ISS; Bauer et al., 1991). Thus, CCL-M-R excitement-seeking scores appear to be related to risk for mania and to current symptoms of mania within a clinical sample. Other findings, though, suggest that problems with interpersonal relationships (feeling thwarted by others) may emerge among those clinically diagnosed with bipolar I disorder, even though not endorsed among those at risk. Moreover, difficulties with interpersonal relationships and diminished confidence in those with bipolar I disorder paralleled the difficulties observed among those with MDD. Findings suggest that cognitive profiles associated with mania may depend on mood state and course of the disorder.
The present study investigated the efficacy of an 8-day, 6-session, intensive individual cognitive behavioral therapy protocol for social anxiety disorder using a multiple baseline across subjects design with 1, 2, and 3 months follow-up assessments. Participants were 5 outpatients with generalized social anxiety disorder. The intervention had variable effects on clinician-rated and self-report measures of anxiety and depression. The results question the efficacy of intensive psychotherapy as a general therapeutic strategy for social anxiety disorder. Directions for future research are discussed.
Individuals with body dysmorphic disorder (BDD) are excessively concerned about imagined or slight defects in their appearance (e.g., asymmetrical facial features). Cognitive-behavioral models of BDD propose that several factors, including dysfunctional appearance-related beliefs and life experiences, such as teasing, contribute to the avoidance behaviors or rituals (e.g., mirror checking, grooming) characteristic of BDD. Previous research has demonstrated an association between perceived teasing and body dissatisfaction. In the current study, we examined whether individuals with BDD (n=16) report to have been teased more often than do mentally healthy controls (n=17). The group comprising individuals with BDD reported more appearance- and competency-related teasing than did control participants. This study provides preliminary evidence for the association between perceived teasing and BDD.
The purpose of this study was to examine the moderating effects of cognitive risk factors in two mechanistically-distinct interventions. Forty-one patients with panic disorder and agoraphobia were randomly assigned to receive training aimed at altering respiration (Capnometry-assisted respiratory training, CART) or symptom appraisal (cognitive skill training, CT). Using a mixed effects regression model, we assessed whether reductions in panic symptom severity (PDSS) were moderated by the variables of interest. While improvement in PDSS did not differ among treatment modalities, moderating effects emerged. Individuals with greater initial levels of misappraisal showed smaller reduction in PDSS when receiving CT, but larger reduction when receiving CART. Greater lack of perceived control was predictive of worse outcome in CART, but better outcome in CT. Better homework compliance was related to greater reductions in PDSS irrespective of condition. The findings illustrate the complexity of moderating influences within and between distinct interventions.
We examined concurrent and prospective associations of self-focused cognitive styles with bipolar spectrum disorders. Controlling for depressive and hypomanic/manic symptoms, 125 individuals with bipolar spectrum disorders scored higher than 149 demographically similar normal controls on the rumination scale of the Response Styles Questionnaire (RSQ) and the private self-consciousness subscale of the Self-Consciousness Scale (SCS). The two groups did not differ on the distraction scale of the RSQ or the public self-consciousness and social anxiety subscales of the SCS. In addition, among the bipolar individuals, controlling for initial depressive and hypomanic/manic symptoms, rumination predicted the number, but not the likelihood of onset, of depressive episodes, whereas private self-consciousness predicted the likelihood of onset, but not the number, of hypomanic/manic episodes over a 3.5-year follow-up.
We conducted a two-phase study to develop and evaluate the psychometric properties of an instrument to identify barriers to Cognitive Behavioral Therapy (CBT) homework completion in a depressed sample. In Phase I, we developed an item pool by interviewing 20 depressed patients and 20 CBT therapists. In Phase II, we created and administered a draft instrument to 56 people with depression. Exploratory Factor Analysis revealed a 2-factor oblique solution of "Patient Factors" and "Therapy/Task Factors." Internal consistency coefficients ranged from .80 to .95. Temporal stability was demonstrated through Pearson correlations of .72 (for the therapist/task subscale) to .95 (for the patient subscale) over periods of time that ranged from 2 days to 3 weeks. The patient subscale was able to satisfactorily classify patients (75 to 79 %) with low and high adherence at both sessions. Specificity was .66 at both time points. Sensitivity was .80 at sessions B and .77 at session C. There were no consistent predictors of assignment compliance when measured by the Assignment Compliance Rating Scale (Primakoff, Epstein, & Covi, 1986). The Rating Scale and subscale scores did, however, correlate significantly with assignment non-compliance (.32 to .46).
The literatures examining disgust's role in information processing biases and evidence for memory biases in anxiety disorders are both mixed, suggesting small or fragile effects. Thus, to maximize power and reliability, a mega-analytic approach was used to examine data across two studies to determine whether a memory bias for spider-relevant information exists under conditions when disgust is elevated and if the bias is specific to highly fearful individuals. Disgust was manipulated by having a large tarantula present or absent (at encoding and/or at recall) when individuals high (N=158) or low (N=108) in spider fear completed a free recall task. Results indicated that, as expected, the spider's presence was related to enhanced recall of spider information. However, this bias was driven by the presence of the spider during encoding only (as opposed to during recall), and high trait spider fear was not necessary for the memory bias to be expressed. Finally, there was a small effect for individual differences in trait and state disgust to predict spider recall, but this effect disappeared when anxiety was also included as a predictor, suggesting only a limited role for disgust in memory biases related to specific fears.
Study 1 IFES Scores at Two Separate Timepoints -Means and Standard Deviations 
We define intrusive prospective imagery as the experience of mental imagery of events that may happen in the future and which come to mind involuntarily. This everyday phenomenon may be exacerbated in psychological disorders such as bipolar disorder (Holmes, Geddes, Colom, & Goodwin, 2008) although specific measures to assess this have been lacking. We recently developed the Impact of Future Events Scale (IFES; Deeprose & Holmes, 2010), which is further examined in the current paper. In Study 1, adults volunteers (N=50) completed the IFES on two occasions, with 1-week between measurements. This revealed acceptable test-rest reliability. In Study 2, (N=90) IFES showed good internal consistency and confirmed two predictions. First, in the total sample risk for bipolar disorder (MDQ; Hirschfield et al., 2000) and IFES Total Score correlated positively. Second, when the sample was split into high (MDQ ≥ 7) and low (MDQ ≤ 6) bipolarity risk groups, higher IFES Total Scores were observed in the high risk group. We conclude that 1) IFES presents a useful measure for assessing intrusive prospective imagery with acceptable test-retest reliability and good internal consistency and 2) risk for bipolar disorder is associated with elevated IFES Total Scores with potentially important clinical implications.
Group Comparisons Using MaNCOVa 
Sample Demographic and Clinical Characteristics 
Specificity of Diagnostic Group by Measure Informed From ROC Contrasts 
Although previous research has identified cognitive styles that distinguish individuals with bipolar disorder (BD), individuals with major depressive disorder (MDD), and individuals without mood disorders from one another, findings have been inconsistent. The current study included 381 participants classified into a BD group, a MDD group, and a no mood disorder group. To differentiate between these groups, this study evaluated cognitive styles with a battery of traditional and more recently-developed measures. Receiver operating characteristics (ROC) analyses were used to determine the discriminate ability of variables with significant between group differences. Results supported that BD and MDD may be characterized by distinct cognitive styles. Given work showing that interventions for MDD may not be effective at treating BD, it is important to directly compare individuals with these disorders. By clarifying the overlapping and divergent cognitive styles characterizing BD and MDD, research can not only improve diagnostic validity, but also provide more efficacious and effective interventions.
Specificity of brooding rumination as a cognitive vulnerability for anxiety and depression was examined using the tripartite theory as a framework. The three factors of the tripartite theory (negative affect, positive affect, and physiological hyperarousal) were included in the same structural equation model (latent growth curves) to test three competing hypotheses: brooding rumination as a depression-specific vulnerability (i.e., brooding uniquely predicts shared negative affect + specific positive affect), anxiety-specific vulnerability (i.e., brooding predicts shared negative affect + specific physiological hyperarousal), or shared risk vulnerability (i.e., brooding predicts negative affect, the shared tripartite component common to both anxiety and depression). Data from children in 2nd through 7th grades (N = 303) were collected in three waves over two years. Results revealed brooding to be uniquely associated with initial levels of negative affect and physiological hyperarousal, thus providing support for the anxiety-specific vulnerability. Results from the multigroup analysis confirmed that the relationship among these variables did not differ across sex. Longitudinal associations between brooding and the tripartite factors are also discussed.
Means, Standard Deviations, and bivariate Associations Among Primary Variables in Study 1 
Means, Standard Deviations, and Correlations Among Primary Variables in Study 2 
Study 2 regressions Predicting Concurrent Depressive and general Anxiety Symptoms from erS and rumination (Controlling for Comorbid Symptoms) 
Study 2 regressions Predicting Prospective Depressive and general Anxiety Symptoms from erS and rumination (Controlling for baseline and Comorbid Symptoms) 
Recent research investigating cognitive and interpersonal models of depression have conceptualized rumination and excessive reassurance seeking (ERS) as vulnerabilities for the etiology of depression. However, research testing the vulnerability hypothesis for these constructs among youth is lacking. Additionally, the specificity of rumination and excessive reassurance seeking to depression is unclear. Two studies investigated associations between these constructs to depression and anxiety. In Study 1, concurrent associations between these constructs and depressive and anxious arousal were examined among 194 minority, underserved youth. Study 2 examined concurrent and longitudinal associations between both constructs and depressive and general anxiety symptoms in a community sample of 402 youth. Results from both studies supported rumination as a specific vulnerability for depressive symptoms, whereas ERS appeared to be a concomitant of negative affect common to depressive and anxiety symptoms. Findings inform cognitive and interpersonal theories of depression by advancing knowledge of how rumination and ERS relate to aspects of internalizing problems among diverse populations of youth.
It has become increasingly clear that mental health is more than just the absence of psychopathology and that there is clinical utility in examining positive aspects of mental health. The present study examined the effects of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders on quality of life in a randomized controlled trial that included individuals with a diverse range of emotional disorders. Results indicated that the Unified Protocol produced significant increases in quality of life when examining both within-individual effect sizes and between-conditions effect sizes compared to a waitlist condition. Furthermore, results indicated that post-treatment levels of quality of life predicted levels of functional impairment independently of diagnostic severity. These results provide further evidence of the importance of examining indicators of mental health in conjunction with markers of psychopathology and provide promising evidence that the Unified Protocol may promote improved mental health in addition to treating psychopathology.
The COVID-19 pandemic may exacerbate common symptoms of obsessive-compulsive disorder, such as fears of contamination or causing harm to others. To investigate the potential impact of COVID-19 on obsessive-compulsive (OC) symptoms, we utilized a frequent sampling prospective design to assess changes in OC symptoms between April 2020 and January 2021. We examined in a broad clinical and non-clinical sample whether baseline risk (e.g., emotion dysregulation, anxiety sensitivity, intolerance of uncertainty) and protective (e.g., resilience) factors would predict OC symptom changes, and whether coping strategies would mediate week-to-week changes in COVID-19 impact and OC symptoms. Emotion dysregulation was associated with greater likelihood of OC symptom worsening, whereas resilience was associated with lower likelihood. Longitudinal mediation analyses revealed that coping strategies were not significant mediators; however, changes in adaptive coping were associated with subsequent-week OC symptom reductions. Regardless of perceived COVID-19 impact, implementing adaptive coping strategies may prospectively reduce OC symptoms. Supplementary information: The online version contains supplementary material available at 10.1007/s41811-021-00128-4.
The COVID-19 pandemic has resulted in increased distress and uncertainty. Understanding the progression of mental health and factors underlying the perpetuation of distress during the pandemic is pivotal in informing interventions and public health messaging. This current study examined longitudinal effects of two cognitive vulnerabilities, looming cognitive style, and intolerance of uncertainty, as well as coping styles on anxiety and depression through online questionnaires at two time points in the pandemic, May 2020 (N = 1520) and August 2020 (N = 545). Depression, but not anxiety, significantly increased across time, which was moderated by coping style. Serial mediation modeling using path analysis demonstrated a significant pathway illustrating increased looming cognitive style in the beginning of the pandemic leads to increased intolerance of uncertainty, avoidant coping, and anxiety later in the pandemic. Results suggest a novel model in conceptualizing anxiety during the pandemic, namely highlighting looming cognitive style as an underlying cognitive vulnerability factor and antecedent of intolerance of uncertainty and illuminating the temporal directionality between looming cognitive style and intolerance of uncertainty. These findings provide important implications regarding intervention and public health messaging with modifiable behavioral and cognitive factors to improve mental health during a pandemic.
The COVID-19 pandemic triggered increased rates of depression, especially among college students. Due to social distancing guidelines, loneliness has been suspected as a prominent factor in depression during the pandemic. Research is needed to identify possible mechanisms through which loneliness conveys risk for pandemic-era depression. Two potential mechanisms are boredom and repetitive negative thinking (RNT). This study examined cross-sectional associations between depression, loneliness, boredom, and RNT in a sample of college students (N = 199) in April 2020 immediately following campus closure. Results showed a serial indirect effect of loneliness on depression through boredom then RNT. Moreover, specific indirect effects of loneliness on depression were found through boredom and RNT, individually. Though limited by the cross-sectional design, these data align with cognitive-behavioral theory and identify boredom and RNT as possible mechanisms of the association between loneliness and depression in college students during the COVID-19 pandemic.
Research on the psychosocial impact of COVID-19 has found significant levels of distress among the general population, and among those especially vulnerable due to chronic social or health challenges. Among these are individuals aging with HIV infection, who are encountering COVID-19 as a new infectious threat to their health and wellbeing. In a longitudinal observational study of the psychosocial impact of COVID-19 in middle-aged and older people living with HIV, we identified a subset of participants who expressed heightened levels of distress and were referred for clinical intervention. This paper describes the supportive and contemporary cognitive-behavioral interventions that were provided and presents data on changes in distress in this case series. This work provides a model for identifying people in at-risk groups in acute need of psychological intervention and for implementing an individualized clinical response that can be safely delivered in the context of COVID-19 and future crisis situations.
Research has shown threat overestimation is significantly associated with intolerance of uncertainty (IU), and both processes predict higher anxiety and safety behavior usage. However, the extent to which threat overestimation predicts subsequent COVID-19-related distress may vary as a function of IU. The present study examined IU as a moderator of the relationship between COVID-19 threat estimation and subsequent COVID-19 fear and safety behavior use. Between February 27 and March 26, 2020, participants (N = 57) completed a self-report measure of IU and estimated the number of people they believed had died from COVID-19. Four weeks later, participants completed measures of COVID-19 fear and safety behavior use. Results revealed IU significantly predicted subsequent COVID-19 fear and safety behavior use. IU also moderated the effect of threat estimation on COVID-19 fear such that those who underestimated threat and experienced low to moderate levels of IU reported experiencing lower levels of COVID-19 fear 1 month later.
Suicide is a public health concern which warrants considerable attention, especially with the onset of the COVID-19 pandemic. The current study sought to examine the relationship between behavioral, psychological, and economic impacts of COVID-19 on suicidal ideation severity in a sample of 90 undergraduate students who completed a comprehensive survey on mental health in January 2020 and were re-assessed in April, June, and July of 2020. Multiple regression analyses showed that changes in experience of loneliness, loneliness due to social distancing, pandemic-related concerns, COVID contagion anxiety, and quarantining alone positively and significantly correlated with peri-pandemic suicidal ideation severity after accounting for pre-pandemic suicidal ideation and sexual orientation, while time spent talking to romantic partner and time spent talking to friends and family were negatively correlated. Findings provide insights into the psychological and behavioral effects of social distancing measures and the pandemic, but further research is needed to generalize findings. Supplementary information: The online version contains supplementary material available at 10.1007/s41811-022-00140-2.
As the COVID-19 outbreak peaks, millions of individuals are losing their income, and economic anxiety is felt worldwide. In three different countries (the USA, the UK, and Israel: N = 1200), the present study addresses four different sources of anxiety: health-related anxiety, economic-related anxiety, daily routine-change anxiety, and anxiety generated by social isolation. We hypothesized that, economic anxiety would have a similar or greater effect, compared to health anxiety. Results show that in all three countries, the levels of economic and health anxiety were essentially equal, and both surpassed routine-change and isolation anxiety. Although the COVID-19 crisis originated in the health field, this study emphasizes the need to move from a generalized concept of anxiety to specific types of distress, most notably economic anxiety. Economic anxiety results in serious mental and physical health problems and should be attended to by clinical professionals and by policy makers.
The novel coronavirus disease 2019 (COVID-19) rapidly spread, becoming a global pandemic with significant health, economic, and social impacts. COVID-19 has caused widespread anxiety, which at healthy levels leads to adaptive, protective behavioral changes. For some individuals, a pandemic outbreak can lead to excessive, maladaptive levels of anxiety, particularly among those with obsessive-compulsive disorder (OCD) and health anxiety. In the present paper, we review past research studies that examined anxiety in response to other disease outbreaks (including Swine Flu, Zika, and Ebola) to serve as a guide for expectable responses to COVID-19. Our review focused on the role of belief-based cognitive variables (obsessive beliefs, contamination cognitions), transdiagnostic processes (disgust sensitivity, anxiety sensitivity, an intolerance of uncertainty), social factors, and environmental/situational variables as contributing factors to excessive concerns about past pandemics. These factors in combination with unique characteristics of the virus (disease, behavioral, social and economic factors) and media consumption might enhance vulnerability to excessive anxiety about COVID-19, in line with a diathesis-stress model. COVID-19 is also unique from past pandemics due to its severity, easy transmissibility, and the nature of prescribed behavioral responses (i.e., hand washing and social distancing). We therefore discuss the ways in which COVID-19 may disproportionately affect individuals with OCD and health anxiety. We conclude with important topics for clinical and research attention to help mental health professionals respond in this time of crisis.
This article presents a panel discussion on the development of the therapeutic relationship element of collaborative empiricism in Beckian Cognitive Therapy, or Cognitive Behavior Therapy (CBT). The panel comprised experts in research and practice who had been invited as keynote presenters for the 7th International Congress of Cognitive Psychotherapy held in Istanbul, Turkey in 2011. The experts responded to questions about the definition of collaborative empiricism, the role for case conceptualization in collaborative empiricism, how collaborative empiricism contributes to central CBT change mechanisms, and what issues emerge in CBTtraining and supervision. Additional themes arising from the discussion concerned how the relational element of collaborative empiricism is embedded throughout the use of CBT techniques, and highlighted a need for process research on collaborative empiricism in CBT.
Depression and anxiety are common following acquired brain injury (ABI) and can be effectively treated using cognitive behaviour therapy (CBT) that has been adapted to compensate for cognitive difficulties (CBT-ABI). Training clinicians to deliver CBT-ABI is a crucial step in effective translation into clinical practice. This study evaluated the outcome of didactic and skill-based training on competencies in delivering CBT-ABI. Participants were 39 registered psychologists who attended a day-long workshop on using CBT-ABI to treat anxiety and depression after ABI, which included knowledge and skill-based content. Fourteen participants completed three additional supervision sessions reviewing audio recordings of their use of CBT-ABI with clients. Training outcomes were measured using surveys rating the usefulness of the various workshop components, a checklist of competencies in CBT-ABI on which participants rated themselves pre-workshop and post-workshop and post-supervision, and the Cognitive Therapy Scale (CTS), used by supervisors and a blinded expert to evaluate supervisees’ skills. Participant-rated competencies in CBT-ABI significantly improved following workshop training, with no further change after supervision. CTS ratings of the supervisor, but not the blinded expert, showed significant improvement after short-term supervision. At 16-month follow-up, self-rated competency gains were maintained, and therapist confidence and competence were no longer major barriers to using CBT-ABI in the workplace. These findings suggest targeted training is important for clinical translation of this evidence-based intervention.
Research conducted over the past decade indicates that difficulties in emotion regulation are more prevalent among those who have been abused than in individuals with no such experiences. Emotional Schema Therapy (EST), which is an integration of cognitive and metacognitive models as well as acceptance-based approaches, specifically targets content of beliefs about emotions and dysfunctional coping strategies to deal with difficult emotions. This study provides an initial evaluation of the efficacy of EST in addressing difficulties in six dimensions of emotion regulation in women with a history of child abuse or neglect. The statistical population consisted of all female residents of Isfahan, Iran, aged above 18 years. Five hundred volunteer women responded to a Child Abuse and Neglect questionnaire. Individuals who had higher scores on this questionnaire were invited to participate in the research project. Thirty volunteer participants were randomly assigned into experimental and control groups (n1 = n2 = 15). The intervention was a 15-session group therapy consisting of cognitive, behavioral, experiential, and mindfulness techniques. Participants completed the Difficulties in Emotion Regulation Scale (DERS) 2 weeks before and after the treatment and at 2 months follow-up. The same assessments were conducted with the control group. Data were analyzed by Mann-Whitney U Test, Friedman Test, and Wilcoxon Signed-Rank Test. Results showed that EST significantly improved acceptance of emotional responses, goal-directed behaviors, impulse control, and adaptive emotion regulation strategies in both post-test and follow-up assessments in the experimental group. In contrast, the control group did not have any significant changes on these variables. Significant changes were not detected for lack of emotional awareness and lack of emotional clarity in both groups. These findings indicate that EST is a potential effective treatment to improve aspects of emotion regulation in women with a history of child abuse and neglect.
Session by session WSAS scores in the arms
ACT competency ratings
Process and clinical measure scores at assessment, termination, and follow-up Arm of the study N Assessment mean (SD) Termination mean (SD) Follow-up mean (SD)
The comparative clinical utility of the components of the psychological flexibility model of acceptance and commitment therapy (ACT) have not been equally evaluated. This study therefore conducted a feasibility and pilot two-arm dismantling trial by quarantining the self-as-context component. Sixteen participants were randomised to either 8 sessions of protocol-based ACT (Full-ACT) or 8 sessions of protocol-based ACT minus self-as-context (ACT-SAC). Process measures (flexibility and decentring) were taken at start of treatment, end of treatment, and at 6-week follow-up. Clinical outcome measures (functioning, anxiety, and depression) were collected on a session-by-session basis. Randomisation was well tolerated, all measures were completed, both interventions were competently delivered, and one adverse effect occurred in the full-ACT arm. Ten participants attended all 8 sessions creating a dropout rate of 37.50%. Clinical change appeared linear in both treatments and that treatment gains were maintained. Findings suggest that a full trial is possible and sample size calculations and methodological improvements are provided for this.
Whereas some theories of cognitive behavioral therapies (CBT) propose that acceptance and reappraisal conflict with one another, we propose that one component of acceptance, self-acceptance of negative emotions (being nonjudgmental of oneself for experiencing negative emotions), and reappraisal may facilitate one another. We hypothesized that emotion regulation (self-efficacy and frequency of suppression and reappraisal) would be associated with a stronger correlation between self-acceptance and more positive/less negative affect. We also examined whether self-acceptance is associated with a stronger correlation between emotion regulation and affect. Participants (n = 267) completed measures of self-acceptance, affect , and emotion regulation. Use of emotion regulation strategies was associated with stronger relationships between self-acceptance and affect, and self-acceptance was associated with stronger relationships between emotion regulation and affect. This suggests that self-acceptance and emotion regulation can facilitate, rather than conflict with one another. Clinically, self-acceptance may improve outcomes when integrated into CBT in addition to reappraisal.
While symptom accommodation has been examined within obsessive-compulsive disorder (OCD) and anxiety disorders, this concept has yet to be studied as it applies to depression. This study provided an initial examination of the nature, incidence, clinical correlates, and predictors of symptom accommodation among adults with depression, and validated a self-report measure of symptom accommodation related to depression, the Symptom Accommodation Scale–Depression–Patient Version (SAS-D-PV). Sixty-nine adults who were diagnosed with a mood disorder upon entry to a residential treatment program completed the SAS-D-PV along with measures of depression severity, anxiety, and anger outbursts. An exploratory factor analysis yielded a six-item scale with two factors (frequency and impact), with good internal consistency for the total score, Frequency subscale, and Impact subscale (α = .81, .87, and .85, respectively). Participants reported accommodation behaviors taking place on average two to three times over the past week. Symptom accommodation was associated with greater depression severity, anxiety sensitivity, social anxiety, and anger outbursts. Depression severity emerged as a significant predictor of symptom accommodation. These results suggest that symptom accommodation does apply to depression. Additional research is warranted to determine the impact accommodation has on symptom course and treatment outcome.
Doing AN Mode: Body State and Cognitive Feedback Loops Regenerate a Schematic Model of " Self in Extreme Control, " with Attention Being Predominantly Directed at Propositional Meanings. The Content of Information Flowing between Subsystems Differs from Depression, with a Greater Emphasis on Control of Eating, Shape, and Weight, as Opposed to Worthlessness or Failure in the Cognitive Loop and a Highly Influential Role of Extreme Somatic States in the Body State Feedback Loop. Note. The image and buffered process, where attention is directed, are shown in black. Unattended components and processes are shown in grey. Propositional Subsystem (attended to): Specific thoughts focus on striving for extreme control of eating, weight and/or shape. These thoughts form the basis of rumination about, e.g., planning eating, calorie consumption and exercise routines. Implicational Schematic Model (unattended): Recurrent synthesis of multimodal inputs generates anorexigenic schematic model supporting a sense of safety, agency an extreme control. Body-State (unattended): Somatic correlates of starvation, e.g., interoceptive information on stomach emptiness, altered tastes and smells, pressure or tightness of clothing; bodily feedback form ritualized physical over-activity.  
A deeper understanding of the cognitive-affective mechanisms maintaining anorexia nervosa (AN) is required to develop more effective interventions. Clinical challenges posed by AN are reviewed and a novel model of AN is offered to account for these phenomena, framed within an established cognitive architecture (Interacting Cognitive Subsystems). It is proposed that AN is maintained by oscillations between two extreme yet mutually reinforcing states of mind. In "doing" mode there is a focus on specific conceptual meanings about the control of eating, shape, and weight, with a neglect of broader emotional meaning and bodily states associated with starvation. When control cannot be maintained, individuals move into "mindless bodily emoting" mode. Here attention flips between aversive bodily sensations and emotional beliefs, resulting in feeling out of control, afraid, and selfdisgusted. Novel implications for course, recovery, and treatment of AN following directly from this theoretical analysis are discussed in a separate sequel paper.
Model of the relationship among gender, RNT dimensions, and symptom outcomes. Note. Significant SEM model paths: *p < .05; **p < .01
Analysis of the indirect effects within the SEM explanatory model
Rumination and worry are vulnerability factors involved in the early development of depression and anxiety during adolescence, particularly in girls. Current views conceptualize rumination and worry as transdiagnostic forms of repetitive negative thinking (RNT). However, most of research has analyzed them separately, without considering gender differences. We analyzed common and specific roles of rumination and worry in accounting for depressive and anxiety symptom levels overall and as a function of gender in adolescents (N = 159). Rumination and worry items were loaded into separate RNT factors. Girls showed a higher use of rumination and worry and higher levels of depression and anxiety than boys. Structural equation modeling supported that both RNT factors accounted for gender differences in symptom levels: rumination was the strongest mediator for depression and worry the strongest mediator for anxiety. Our findings support both general and specific contributions of RNT to account for affective symptomatology during adolescence, particularly in girls. Supplementary information: The online version contains supplementary material available at 10.1007/s41811-022-00133-1.
The purpose of this series of experiments was to determine the necessary conditions for eliciting depressive realism in a contingency judgment task and to compare the explanatory power of divergent theoretical accounts for this phenomenon. Across a series of experiments, groups of dysphoric and non-dysphoric undergraduate students (n1 = 46; n2 = 60) completed contingency judgment tasks, after which they estimated their control over the task. Depressive realism was elicited when the method of responding to the task was manipulated. Only when participants faced a choice between a "pressing" response option and a "not pressing" response option did dysphoric participants make more accurate judgments of control than nondysphoric participants, F(1, 59) = 11.24, p < .05. The evidence for a boundary condition identified in the current paper suggests important attentional differences between dysphoric and non-dysphoric individuals that must be explained by any theoretical account of depressive realism.
Sample Characteristics by Euthymic and Depressed Mood Groups
Effects of repeated checking on memory accuracy, confidence, vividness , and detail by mood group at Visit 1.  
Studies show that repeated checking leads to memory distrust in healthy controls. Additionally, the extent of this reduction in memory confidence has been associated with executive control. Utilizing a 2 × 2 design, we examine the role of mood and cognitive training targeting executive control on memory distrust following repeated checking. Participants were 69 individuals with depressed (n = 32) or euthymic (n = 37) mood. Memory distrust following a repeated checking task was assessed before and after 3 sessions of a computerized cognitive training program or a control task. Consistent with previous studies, participants reported reduced meta-memory following repeated checking. Although participants with depressed mood reported lower overall cognitive confidence at a trend level, the effect of repeated checking on memory distrust was not potentiated by depressed mood in our study. A reduction in memory distrust following repeated checking was found over time; however, this effect was not dependent on cognitive training condition, mood status, or their interaction.
Although cognitive behavioral therapy (CBT) is an established and efficient treatment for a variety of common mental disorders, a considerable number of patients do not respond to treatment or relapse after successful CBT. Recent findings and approaches from neuroscience could pave the way for clinical developments to enhance the outcome of CBT. Herein, we will present how neuroscience can offer novel perspectives to better understand (a) the biological underpinnings of CBT, (b) how we can enrich CBT with neuroscience-informed techniques (augmentation of CBT), and (c) why some patients may respond better to CBT than others (predictors of therapy outcomes), thus paving the way for more personalized and effective treatments. We will introduce some key topics and describe a selection of findings from CBT-related research using tools from neuroscience, with the hope that this will provide clinicians and clinical researchers with a brief and comprehensible overview of the field.
Intercorrelations among Per fectionism Measures
Correlations Between Per fectionism Measures and Symptoms Across Clinical Groups
Summary of Hierarchical Regression Analyses: Per fectionism Measures Predicting DASS Symptom Severity Across Clinical Groups
We investigated perfectionism in clinical samples using new measures of maladap-tive cognitive-personality dimensions—the Evaluative Concerns Perfectionism Scale (ECPS) and Self-Critical Perfectionism Scale (SCPS), as well as the Frost (FMPS) and the Hewitt and Flett (HMPS) Multidimensional Perfectionism Scales. Outpatients (N = 190) with a principal diagnosis of social anxiety disorder (SAD), panic disorder with or without agoraphobia (PDA), obsessive-compulsive disorder (OCD), or predominantly major depressive disorder were compared to non-psychiatric con-trols. Patients with depression and SAD had similar or significantly higher scores than the controls, and patients with PDA and/or OCD on many perfectionism measures. OCD patients were also higher than controls and those with PDA on many scales. PDA patients were similar to controls on all but a few measures. The SCPS was the only consistent unique positive predictor of variance on the Depres-sion Anxiety Stress Scale (DASS) in a combined patient group.
The looming vulnerability model proposes that individual differences in anxiety are related to variations in the tendencies to generate anticipatory mental simulations in which threats are intensifying or fast approaching. Research has demonstrated that a looming cognitive style is found across anxiety disorders. The purpose of this study was to determine how CBT impacts looming appraisals and to examine how changes in looming appraisals predict general changes in anxiety across many disorders and changes in a specific disorder (GAD). Participants from a heterogeneous anxiety disorder sample (N = 66) completed measures of looming and anxiety symptoms before and after standard group CBT. A subset of participants with GAD (n = 23) also completed a measure of worry at baseline and post-treatment. Results indicated that CBT leads to significant reductions in dysfunctional looming appraisals, and these reductions predict post-treatment anxiety symptom ratings in an anxiety sample and post-treatment worry symptoms within a specific disorder.
We investigated whether panic disorder (PD), obsessive-compulsive disorder (OCD), and social anxiety disorder (SAD) patients differ in the perception of their illnesses and whether these differences can be ascribed to levels of anxiety sensitivity. We performed a cross-sectional study comparing responses from 36 PD patients, 38 OCD, and 34 SAD patients in the Illness Perception Questionnaire-Mental Health (IPQ-MH). A MANCOVA model with the diagnostic group as the fixed factor, the IPQ-MH items as dependent variables, and the Anxiety Sensitivity Index-Revised (ASI-R) score as a covariate, was created. Significant differences were observed between the groups with respect to illness perception. PD patients showed significantly higher levels of anxiety sensitivity than other groups. However, after controlling for anxiety sensitivity as a covariate, patients with PD had significant lower scores in “personal control” and “treatment control” than patients with SAD. OCD patients did not differ significantly from both groups. PD, OCD, and SAD patients have both common and different perceptions regarding their illnesses. Differences between PD and SAD are related to controllability of symptoms, but seem not to be mediated by anxiety sensitivity. Future studies should investigate whether illness perceptions in OCD and anxiety disorders have therapeutic implications.
The transdiagnostic approach states that there are key cognitive and behavioral processes responsible for maintaining symptoms and these are shared across psychological disorders (Harvey, Watkins, Mansell, & Shafran, 2004). The first goal of this article is to justify the potential utility of a transdiagnostic perspective for theory, research and treatment using empirical evidence and clinical vignettes. We then take as an example one set of cognitive processes-attentional processes-to illustrate the approach. Evidence for three attentional processes is provided: vigilance to external concern-related stimuli; vigilance to internal concern-related stimuli (self-focused attention) and attentional avoidance. It is concluded that each of these attentional processes are transdiagnostic. We then discuss three possible resolutions to the question: How can a transdiagnostic perspective be valid when the different psychological disorders present so differently? The three proposals are: (1) variations in idiosyncratic current concerns; (2) variations in the degree of shared processes and (3) distinct processes for specific disorders or groups of disorders. The role of a transdiagnostic approach in supporting the development and testing of theories of psychopathology is highlighted and the need for future studies that incorporate multiple patient groups is discussed.
Since the development of acceptance and commitment therapy as a therapy model, there has been much debate about the similarities and differences between it and ‘second wave’ cognitive-behavioural practices (i.e. cognitive therapy, rational emotive behaviour therapy). This article builds on these discussions, discussing the underlying theoretical constructs relevant to the philosophy and practice of ACT and ‘second wave’ CBT models. Ultimately, this results in the conclusion that there are more similarities than differences between the two. Many of the espoused differences between them appear to be due to the implicit versus explicit attentional foci of the different models, and due to the development of idiosyncratic language by the different authors. As a result, it would appear that there is more to be gained by bringing these models together, to solidify the cognitive-behavioural framework and its application to therapy.
Thought-Action Fusion (TAF) has been consistently identified as an important cognitive construct in Obsessive-Compulsive Disorder (OCD). However, some recent studies have highlighted other variables such as negative affect (Abramowitz, Whiteside, Lynam, & Kalsy, 2003) and magical ideation (Einstein & Menzies, 2004a) that may be important in further understanding this construct. The aim of this study was to determine the relationship between negative affect, magical thinking, thought-action fusion, and obsessive compulsive symptomatology. One hundred and thirty seven participants completed four questionnaires pertaining to the variables of interest. Both TAF and magical ideation were significantly related to obsessive compulsive symptomatology, with magical ideation having the stronger relationship. Negative affect was found to be a partial mediator for the relationship between both magical ideation and TAF with OC symptomatology. Results suggest that magical thinking may be an important cognitive variable in OCD and future studies with clinical samples should further examine its relationship along with related variables such as TAF.
The present study investigated automatic/implicit and controlled/explicit processes in snacking behavior. Participants who were bothered by their habit of eating snacks were compared to participants with another habit. A reaction time task was used to assess implicit action tendencies in which participants had to pull or push a joystick in reaction to food and neutral stimuli on the screen. With regard to appetitive action tendencies, compared to the controls, participants who were bothered by snack eating were slower to push food stimuli. On a semantic priming task to assess implicit evaluations, they exhibited less interference between positive self-control targets and food stimuli, suggesting a weaker association between self-control and food. No group differences were found in food-taste associations or explicit taste ratings. Results suggest that snacking behavior seems to be due to both implicit appetitive action tendencies and weak associations with self-control. However, they also indicate that explicit tastiness evaluations of food do not seem to affect snacking behavior.
Top-cited authors
Stefan G Hofmann
  • Philipps University of Marburg
Robert L Leahy
  • Weill Cornell Medical College
Golan Shahar
  • Ben-Gurion University of the Negev
Malka Margalit
  • Tel Aviv University
Liad Bareket-Bojmel
  • Peres Academic Center