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A Preliminary Investigation of Stimulus Control Training for Worry: Effects on Anxiety and Insomnia
Abstract
For individuals with generalized anxiety disorder, worry becomes associated with numerous aspects of life (e.g., time of day, specific stimuli, environmental cues) and is thus under poor discriminative stimulus control (SC). In addition, excessive worry is associated with anxiety, depressed mood, and sleep difficulties. This investigation sought to provide preliminary evidence for the efficacy of SC procedures in reducing anxiety-, mood-, and sleep-related symptoms. A total of 53 participants with high trait worry were randomly assigned to receive 2 weeks of either SC training (consisting of a 30-min time- and place-restricted worry period each day) or a control condition called focused worry (FW; consisting of instructions to not avoid naturally occurring worry so that worry and anxiety would not paradoxically increase). At post-training, SC was superior to FW in producing reductions on measures of worry, anxiety, negative affect, and insomnia, but not on measures of depression or positive affect. Moreover, SC was superior to FW in producing clinically significant change on measures of worry and anxiety. Results provide preliminary support for the use of SC training techniques in larger treatment packages for individuals who experience high levels of worry.
... With respect to psychopathology, habituation may be a component mechanism of several treatments, including flooding therapy and implosion therapy (C. E. Walker et al., 1981) and techniques that treat anxiety by having clients willfully worry during a restricted "worry period" that could last 30 min and occurs under controlled circumstances (McGowan & Behar, 2013). Although habituation is one of the most basic of cognitive processes and seems to have a central role in several clinical techniques, little is known about the nature and duration of the habituation of higher order cognitive processes. ...
... These undesired, debilitating involuntary cognitions (e.g., in rumination and obsessions) can be triggered by external stimuli (Meyer, 1966;Simpson & Hezel, 2019;Visser et al., 2020). The mechanisms underlying the potential habituation of these cognitions has been of interest for some time (Borkovec et al., 1983;McGowan & Behar, 2013;C. E. Walker et al., 1981). ...
... This observation has some implications for clinical interventions that involve habituation, such as flooding therapy, implosion therapy (C. E. Walker et al., 1981), and techniques that treat anxiety by having clients willfully worry during a restricted "worry period" (McGowan & Behar, 2013). We are cautious when generalizing our finding to the habituation of other mental phenomena. ...
Little is known about the habituation of higher order cognitive processes, a phenomenon whose study has implications for clinical interventions. Using a variant of the Reflexive Imagery Task (RIT), Bhangal et al. (2016) provided evidence of such habituation. In the basic version of the RIT, participants are presented with line drawings of objects and instructed not to think of the name of the objects. Involuntary object naming occurs often. To induce habituation, Bhangal et al. (2016) presented the same stimulus object (e.g., DOG) on 10 consecutive trials. From the first presentation to the tenth presentation of the same object, the likelihood of an RIT effect decreased systematically. The habituation effect was stimulus-specific: The presentation of a new stimulus eradicates it. The stimulus specificity observed in Bhangal et al. (2016) raises the question of whether habituation to a particular stimulus exists for some time and after other stimuli are presented, which would be a case of residual habituation. Knowledge of the duration, or the lack of any duration, of residual habituation would have implications for clinical techniques. In the present variant of Bhangal et al. (2016), participants experienced 10 instantiations of a stimulus and, later in the session and after the presentation of other stimuli, were presented again with that stimulus. We replicated the findings of Bhangal et al. (2016) with stimuli that included nonsense shapes (a methodological advance) and found no evidence of any residual habituation. We discuss the implications of this variant of the RIT for psychopathological phenomena and their treatments.
... Proverbs such as "You cannot prevent the birds of care and worry from flying over your head, but you can prevent them from building a nest in your head" may be helpful for clients to reflect on. Moreover, stimulus control strategies may treat sleep difficulties in GAD (McGowan & Behar, 2013). A number of studies testing this worry postponement procedure document that it can reduce daily worrying McGowan & Behar, 2013) and decrease somatic health complaints (e.g., Verkuil, Brosschot, Korrelboom, Reul-Verlaan, & Thayer, 2011). ...
... Moreover, stimulus control strategies may treat sleep difficulties in GAD (McGowan & Behar, 2013). A number of studies testing this worry postponement procedure document that it can reduce daily worrying McGowan & Behar, 2013) and decrease somatic health complaints (e.g., Verkuil, Brosschot, Korrelboom, Reul-Verlaan, & Thayer, 2011). The most recent study, however, conducted in a large sample via the internet, could not replicate these effects (Versluis, Verkuil, & Brosschot, 2016). ...
... Furthermore, without being targeted directly, negative meta-cognitions about worry (i.e., fearful cognitions that worrying could be debilitating [Wells, 1999]) were successfully reduced. While worry exposure was used as a singular treatment component in order to demonstrate its efficacy in isolation, overall treatment efficacy could possibly be increased by adding further empirically validated therapeutic interventions, such as worry postponement (McGowan & Behar, 2013). ...
Cognitive‐behavioral therapy (CBT) fundamentally aims to ameliorate generalized anxiety disorder (GAD) symptoms, which stem from habitual, inflexible, and spiraling systems of interaction between somatic, cognitive, and emotional responses to appraised threats. This chapter describes the core components of CBT often employed in clinical trials of GAD based on established manuals as well as recent treatment packages for GAD based on a CBT rationale such as metacognitive therapy, intolerance‐of‐uncertainty therapy, or emotion‐regulation therapy. It discusses the implementation of CBT by including self‐monitoring, relaxation training, progressive muscle relaxation, imagery training, meditation, applied relaxation, self‐control desensitization, stimulus control, worry exposure, and cognitive restructuring. Several studies have examined predictors of treatment outcome for GAD. Anxiety severity at baseline predicted higher severity post‐treatment as well as poorer follow‐up outcomes 10 to 14 years post‐treatment.
... A secondary aim was to examine whether these temporal relationships are static, or whether they change as symptoms change. We utilized data from a larger investigation of the efficacy of stimulus control training for worry (McGowan & Behar, 2013). In that investigation, participants assigned to a stimulus control training condition evidenced larger reductions in both worry and insomnia symptoms relative to participants assigned to a control condition. ...
... Neither intervention included any information regarding psychoeducation about sleep or any sleep-related treatment principles. For a more detailed description of the two interventions, see McGowan and Behar (2013). ...
... Additionally, it may be important to address and reduce worry experienced throughout the day in addition to worry prior to bedtime in order to reduce the effects of worry on sleep. We previously demonstrated that participants from this study evidenced significant reductions in insomnia symptoms after undergoing an intervention targeted at reducing worry (McGowan & Behar, 2013). Additionally, Bélanger et al. (2004) found that CBT for worry also significantly reduced insomnia symptoms. ...
There is growing evidence suggesting that worry and sleep are intimately linked. However, the relationship between these two phenomena over the course of a day remains largely unstudied. It is possible that (1) worry predicts sleep disturbance that night, (2) sleep disturbance predicts worry the following day, or (3) there is a bidirectional relationship between worry and sleep disturbance. The present study examined the daily relationship between worry (both during the day and immediately prior to sleep onset) and sleep in 50 high trait worriers who were randomly assigned to one of two interventions aimed at reducing worry as part of a larger study. A daily process approach was utilized wherein participants completed daily reports of sleep and worry during a 7-day baseline period followed by a 14-day intervention period. Results of repeated measures multilevel modeling analyses indicated that worry experienced on a particular day predicted increased sleep disturbance that night during both the baseline and intervention weeks. However, there was no evidence of a bidirectional relationship as sleep characteristics did not predict worry the following day. Additionally, the type of intervention that participants engaged in did not affect the daily relationship between worry and sleep. Results of the present study are consistent with the cognitive model of insomnia (Harvey, 2002) and highlight the importance of addressing and treating worry among individuals with high trait worry and sleep disturbance.
... Since Borkovec's initial study, worry postponement has been used in clinical practice to treat worry and insomnia (McGowan & Behar, 2013). It has also been incorporated in meta-cognitive therapy developed by Adrian Wells (Wells, 2002;Wells & Sembi, 2004b). ...
... It is also important to note that in this meta-analysis we only included peerreviewed studies that examined the effects of worry postponement on worry in daily life, in comparison to the mere registering of worries. We therefore had to exclude an interesting study by McGowan and Behar (2013), who compared worry postponement to a control intervention in which participants were instructed to worry as they normally do and to make this worry as intense as possible. The results were in line with this meta-analysis: the worry postponement intervention was associated with stronger reductions in worry, as measured with the PSWQ, and anxiety. ...
Worry postponement, also called stimulus control, is a simple and easy to administer intervention that often forms part of cognitive-behavioural treatments for worry. We conducted a meta-analysis to test if worry postponement is effective in reducing daily worry. Data from 7 randomized trials were included providing a total of 999 participants, of which 250 experienced worry as a burden and of which the majority was women. When comparing worry postponement to the mere registration of worries small effect sizes were observed for worry duration (d = 0.313) and for worry frequency (d = 0.189). Moderation analyses showed that the intervention yielded larger effect sizes in studies including more women. However, long-term follow-up studies are still lacking. Worry postponement, practiced between a week or a maximum of a month, was found to effectively reduce the frequency and duration of worry in daily life. This suggests that a simple intervention is available for people whose worries (temporarily) spiral out of control.
... The news media can be viewed as a stimulus that triggers a certain response (immediate fear, skewed beliefs). Since this stimulus is something that everyone does in fact have control over the recommended strategy is stimulus control (Borkovec et al. 1983;McGowan and Behar 2013): reduce or eliminate exposure to the stimulus to prevent the undesirable response. While one needs to be informed, watching or reading the news for approximately 30-60 min per day should be sufficient to keep up with the necessary information. ...
... We are often reinforced to check more often due to intermittent segments of uplifting news, or anticipation of positive news, even if the overall message conveyed is overly negative. As aforementioned, individuals are recommended to limit COVID-19 related news consumption to a specified amount (i.e., once a day for 30 min) and are urged to use accurate, non-sensationalized sources (Borkovec et al. 1983;McGowan and Behar 2013). Reappraisal of hopeless attitudes towards our current situation is also recommended as it is important to keep the reality in mind that for the most part these pandemic-related stressors are not permanent, although they may feel this way when one is in the midst of them. ...
The COVID-19 crisis has created a "mental health pandemic" throughout the world. Scientific data are not available to fully understand the nature of the resulting mental health impact given the very recent onset of the pandemic, nevertheless, there is a need to act immediately to develop psychotherapeutic strategies that may alleviate pandemic-related distress. The psychological distress, in particular fear and sadness, is a function of the pandemic's negative impact upon people's ability to meet their most basic needs (e.g., physical safety, financial security, social connection, participation in meaningful activities). This paper presents evidence-based cognitive behavioral strategies that should prove useful in reducing the emotional suffering associated with the COVID crisis.
... The news media can be viewed as a stimulus that triggers a certain response (immediate fear, skewed beliefs). Since this stimulus is something that everyone does in fact have control over the recommended strategy is stimulus control (Borkovec et al. 1983;McGowan and Behar 2013): reduce or eliminate exposure to the stimulus to prevent the undesirable response. While one needs to be informed, watching or reading the news for approximately 30-60 min per day should be sufficient to keep up with the necessary information. ...
... We are often reinforced to check more often due to intermittent segments of uplifting news, or anticipation of positive news, even if the overall message conveyed is overly negative. As aforementioned, individuals are recommended to limit COVID-19 related news consumption to a specified amount (i.e., once a day for 30 min) and are urged to use accurate, non-sensationalized sources (Borkovec et al. 1983;McGowan and Behar 2013). Reappraisal of hopeless attitudes towards our current situation is also recommended as it is important to keep the reality in mind that for the most part these pandemic-related stressors are not permanent, although they may feel this way when one is in the midst of them. ...
The COVID-19 crisis has created a “mental health pandemic” throughout the world. Scientific data are not available to fully understand the nature of the resulting mental health impact given the very recent onset of the pandemic, nevertheless, there is a need to act immediately to develop psychotherapeutic strategies that may alleviate pandemic-related distress. The psychological distress, in particular fear and sadness, is a function of the pandemic’s negative impact upon people’s ability to meet their most basic needs (e.g., physical safety, financial security, social connection, participation in meaningful activities). This paper presents evidence-based cognitive behavioral strategies that should prove useful in reducing the emotional suffering associated with the COVID crisis.
... The news media can be viewed as a stimulus that triggers a certain response (immediate fear, skewed beliefs). Since this stimulus is something that everyone does in fact have control over the recommended strategy is stimulus control (Borkovec et al. 1983;McGowan and Behar 2013): reduce or eliminate exposure to the stimulus to prevent the undesirable response. While one needs to be informed, watching or reading the news for approximately 30-60 min per day should be sufficient to keep up with the necessary information. ...
... We are often reinforced to check more often due to intermittent segments of uplifting news, or anticipation of positive news, even if the overall message conveyed is overly negative. As aforementioned, individuals are recommended to limit COVID-19 related news consumption to a specified amount (i.e., once a day for 30 min) and are urged to use accurate, non-sensationalized sources (Borkovec et al. 1983;McGowan and Behar 2013). Reappraisal of hopeless attitudes towards our current situation is also recommended as it is important to keep the reality in mind that for the most part these pandemic-related stressors are not permanent, although they may feel this way when one is in the midst of them. ...
As a result of this pandemic, we are all serving in an enormous social experiment thatwill allow researchers to determine the impact of chronic fear, countless losses, social isolation, andsignificant disruption of people’s day to day lives.We are concerned that if this is left unattended, themental health impact of these factors may be disastrous. The good news is that we have effectivestrategies to help individuals manage negative emotional states.All of the strategies that we are outlining in this document are taken from evidence-based psychologicaltreatments for individuals with anxiety disorders and depression. Thus, there is no reason to expect thatthese strategies cannot be equally useful for those suffering from similar emotional states secondary tothe challenges associated with the COVID crisis.Typically, when we produce a paper in academics, we spend months planning, writing, and reviewing itbefore making it available to others.Given the current rapidly evolving crisis we do not have time forthat.As a result, we are doing something highly unusual - releasing a work in progress that is likely todevelop over the next several months as we learn more about the impact of the COVID crisis on mentalhealth. The first version, released last week on 4/6/20, was produced in two days.The second versionwas produced in nine days. We know it is not perfect, but still believe it can be useful and thus is worthreleasing before it meets our standard -- but is too late.Please note that the second version has been substantially improved.Most of the areas covered in thefirst version have been edited, many new areas have been added (these are noted in the table ofcontents).And perhaps equally important, the document and website have
... Cognitive therapy, progressive muscle relaxation, and applied relaxation components have received research attention, [8][9][10][11][12] with self-control desensitization and stimulus control to a lesser degree. [6,13,14] Other techniques have gone virtually unexamined-though frequently used. ...
... These are promising results for worry outcome monitoring, especially when the brevity of the trial is considered. In clinical practice and RCTs, worry outcome monitoring is typically used continuously for approximately [8][9][10][11][12][13][14][15][16] weeks. Yet the current study shows significant, maintained improvement in worry after 10 days. ...
Background:
The efficacy of many cognitive behavioral component interventions has not been examined, with worry outcome monitoring among them.
Methods:
To address this issue, 51 participants with clinical levels of generalized anxiety disorder were randomly assigned to a treatment or control condition for 10 days. The treatment condition consisted of a brief ecological momentary intervention termed the Worry Outcome Journal (WOJ). WOJ participants recorded worries and tracked their outcomes, rating worry distress, interference, and expected outcome probabilities. Thought log (TL) control participants completed a record of their everyday thoughts and rated associated distress. All participants made four entries on paper each day when randomly prompted by text message. They then entered their paper contents online each night. After 30 days they reviewed their contents electronically and completed follow-up measures.
Results:
Primary results revealed significant reductions in worry for WOJ users compared to TL users at postintervention. A marginally significant difference was found at 20-day follow-up and treatment gains were maintained. Secondary analyses showed no harmful increases in worry beliefs for WOJ users, as well as preliminary evidence for decreases in beliefs about the uncontrollability of thoughts in both groups.
Conclusion:
The WOJ may be a viable therapist-independent treatment for reducing worry, even after only 10 days of use.
... Striving to reduce stimulus generalization and uncontrollable worry, patients are asked to postpone their worry to a predefined worry period at the same time and location every day. This approach has shown promis ing results with effects particularly on worry duration in kids and psychology students (Borkovec et al., 1983;Brosschot & van der Doef, 2006;Jellesma et al., 2009;McGowan & Behar, 2013;Verkuil et al., 2011). However, in a study with GAD patients (Tallon, 2019), WP showed no effect on worry or metacognitions compared to control conditions. ...
Background
Pathological worry is associated with appraisals of worrying as uncontrollable. Worry postponement (WP) with a stimulus control rationale appears to be effective in non-clinical samples. However, preliminary research in participants with generalized anxiety disorder (GAD) does not support its efficacy in reducing negative metacognitions or worry. The aim of this study was to investigate the efficacy of WP with a metacognitive rationale.
Method
Participants with GAD (n = 47) or hypochondriasis (HYP; n = 35) were randomly assigned to either an intervention group (IG) or waitlist (WL). The IG received a two-session long WP intervention aiming at mainly reducing negative metacognitions concerning uncontrollability of worrying. Participants were instructed to postpone their worry process to a predetermined later time during the six days between the two sessions. Participants completed questionnaires of negative metacognitions and worry at pre-assessment, post-assessment, and follow-up.
Results
We observed a significant Time*Group interaction for negative metacognitions and worry. Post-hoc analyses on the total sample and separately for GAD and HYP revealed significantly lower worry scores in the treated GAD sample compared to the WL, representing the only significant effect. In the GAD group, pre-post-effect sizes were small for negative metacognitions and large for worry. Effects persisted to a four-week follow-up.
Conclusion
WP with a metacognitive rationale seems to be effective in reducing worry in participants with GAD. The effectiveness for HYP seems limited, possibly due to the small sample size.
... As such, emotion regulation strategy use, particularly strategies aimed at reducing rumination, may be a good target for intervention to reduce SCCs in veteran populations. In order to address these difficulties, we created a 1-session treatment called "Worry Less, Remember More," integrating elements from Watkins's [24] rumination-focused cognitive-behavioral therapy for depression and Gilbert's [25] compassion-focused therapy (Multimedia Appendix 1 [24,26,27]). The psychoeducation portion consisted of concepts from evolutionary psychology as described by Gilbert [25], including an evolutionarily adapted attentional bias toward negative information, information about emotional regulation systems and their responses to trauma and stress, and attention as a limited resource that can be redirected. ...
Background
Subjective cognitive concerns (SCCs) entail perceived difficulties in thinking or memory, often reported without substantial objective evidence of cognitive impairment. These concerns are prevalent among individuals with a history of brain injuries, neurological conditions, or chronic illnesses, contributing to both psychological distress and functional limitations. They are increasingly considered to be a risk factor for future objective decline. A considerable number of individuals reporting SCCs also exhibit mental health symptoms, such as a history of trauma, depression, or anxiety. Interventions that address modifiable emotional and cognitive factors related to SCC could improve functioning and quality of life. Therefore, the use of emotion regulation strategies, especially those directed at minimizing rumination, could serve as a promising focus for interventions aimed at mitigating subjective cognitive concerns in veteran populations.
Objective
This pilot study explored the feasibility, acceptability, and preliminary efficacy of a brief, 1-session emotion regulation intervention called “Worry Less, Remember More.” The Worry Less, Remember More intervention was designed to reduce rumination and improve subjective cognitive functioning in veterans with subjective cognitive changes (N=15).
Methods
We randomized 15 veterans to either the active telehealth condition or waitlist control and completed the intervention. Participants were aged between 31 and 67 (mean 49.5, SD 10.1) years, and the sample was primarily male (12/15, 83%) and White (10/15, 67%). The most common diagnoses were posttraumatic stress disorder and depression. Following the intervention, veteran input was sought through semistructured interviews with a subset of 12 participants, examining feasibility, acceptability, and perceived efficacy. Preliminary efficacy was also measured using pre- and postintervention self-report measures.
Results
Veterans reported that this intervention was acceptable, with 92% (11/12) of the sample reporting that they benefited from the intervention and would recommend the intervention to others with similar difficulties. Semistructured interviews revealed difficulties with feasibility, including problems with the remote consenting process, forgetting appointments, and needing additional strategies to remember to consistently use the interventions. The intervention improved self-reported cognitive symptoms on quantitative measures but did not improve self-reported rumination.
Conclusions
This pilot study establishes the preliminary feasibility, acceptability, and efficacy of the Worry Less, Remember More intervention for veterans with subjective cognitive symptoms. Future iterations of the intervention may benefit from simplifying the electronic consent process, providing reminders for appointments, and incorporating compensatory cognitive strategies to assist with using the telehealth system, as well as applying the strategies learned in the intervention. While future research is needed with larger samples, including nonveteran populations, the intervention may also be a useful clinical tool to bridge care between neuropsychology clinics and mental health treatment.
... However, for individuals with a more pronounced dampening tendency, dampening may be implemented in an overgeneralized and maladaptive way irrespective of context elements (cf. process of poor discriminative stimulus control in generalised anxiety disorder; McGowan & Behar, 2013). Relatedly, positivity in general (vs. ...
Impaired episodic future thinking (EFT), as reflected in reduced specificity, low levels of detail and less use of mental imagery, has been associated with depressive symptomatology. The beneficial impact of Future Event Specificity Training (FEST) on impaired EFT has recently been demonstrated, as well as on anhedonia, the core symptom of depression reflecting low positive affect. The current study aimed to replicate these previous findings. In addition, this study is the first to examine the potential of FEST to reduce engagement in dampening, a maladaptive response style characterised by reducing the intensity and/or frequency of positive emotional states, which is linked to depressive symptoms and anhedonia. An RCT (FEST vs. waitlist control) was conducted in a large sample of Dutch‐speaking undergraduate students ( N = 155). In line with prior research, FEST resulted in significant improvements in EFT features. However, likely related to limited room for change detection, no significant changes were found in anhedonia and dampening. In the light of the positive impact of FEST on several EFT features, future studies should address methodological issues to create optimal conditions for potential change detection. Finally, further examination of the proposed theoretical change mechanisms aimed to reduce anhedonia and dampening is warranted.
... We are often reinforced to check more often due to intermittent segments of uplifting news, or anticipation of positive news, even if the overall message conveyed is overly negative. As aforementioned, individuals are recommended to limit COVID-19 related news consumption to a specified amount (i.e., once a day for 30 minutes) and are urged to use accurate, non-sensationalized sources (Borkovec, Wilkinson, Folensbee, Lerman, 1983;McGowan & Behar, 2013). Reappraisal of hopeless attitudes towards our current situation is also recommended as it is important to keep the reality in mind that for the most part these pandemic-related stressors are not permanent, although they may feel this way when one is in the midst of them. ...
The COVID-19 crisis has created a “mental health pandemic” throughout the world (Marques et al. 2020; Strakowski et al. 2020) as a result of its impact upon people’s day-to-day functioning. A recent survey by the Kaiser Family Foundation found that 56 percent of people reported that the worry or stress tied to COVID had a negative effect on their emotional well-being (Panchal et al. 2020), and as the duration of the pandemic increases, it is likely to lead to even more psychological distress.
Scientific data are not available to fully understand the nature of the resulting mental health impact given the recent onset of the pandemic, but there is a need to act immediately in order to develop strategies that may alleviate psychological distress. During the past two months we have identified the nature of pandemic-related distress by using our clinical observation skills to identify triggers and resultant psychological problems we were seeing in our patients, family, friends— and our own lives. Once we created this list we developed a self-help guide composed of strategies that allow those affected to manage their negative emotional states. The self-help guide is quite thorough and can be used in conjunction with the current paper in order to maximize the effectiveness of mental health professionals ability to reduce pandemic-related distress. Nearly all of the therapeutic techniques that we included were adopted from evidence-based cognitive behavioral treatments. We expect that these strategies will prove useful for those suffering the emotional challenges associated with the COVID crisis.
This paper also a discussion of a preliminary, scaleable consultation-oriented intervention that we developed (cf: Limowski et al. 2020) and are in the process of field-testing to determine if it is in fact feasible and effective in reducing pandemic-related psychological distress. Finally, we discuss the possibility of posttraumatic growth as a potential positive outcome that occurs when individuals are faced with negative circumstances.
... The authors note that positive affect regulation is an understudied phenomenon in relation to worry and GAD, and may yield fruitful and treatment-relevant insights. Similarly, in a treatment for chronic worry that was effective at reducing negative affect and worry, deficits in positive affect were unaffected (McGowan & Behar, 2013). While the study hypotheses focused on biases in the processing of negative stimuli, it seems surprising that worry but not rumination was associated with a diminished positivity bias. ...
Worry and rumination, two cardinal responses to emotional events, are key for maintaining negative emotion and have been implicated in the etiology and maintenance of anxiety and depressive disorders. Though worry and rumination are highly correlated with one another and people who engage in one often engage in both, they may differentially affect emotion. Specifically, previous work suggests that worry helps people avoid (intense) emotion, while rumination provokes it. Examining the ways in which these two forms of repetitive negative thinking (RNT) influence cognitive processing of emotional material may help us better understand the emotional sequelae of worry and rumination. This study examines visual attention to emotional information, since attending to certain types of information opens the door for further processing of it. The current study induced worry and rumination and then used eye tracking to compare how each form of RNT influenced the allocation of attention to emotional scenes. Participants induced to worry, compared with those induced to ruminate, spent less time viewing positive (vs. neutral) scenes and were the only group to preferentially maintain their attention on negative images when they were paired with positive images. These findings suggest that worry, compared with rumination, leads to the relative avoidance of positive information. Implications of these findings for research on mood and anxiety disorders are discussed.
... Worries occurring outside of this time are deliberately put off until the next designated worry period. This practice appears to reduce overall levels of worry (Borkovec, Wilkinson, Folensbee, & Lerman, 1983) and may itself reduce symptoms of insomnia (McGowan & Behar, 2013). ...
Insomnia is extremely common among adolescents with anxiety disorders, is associated with significant functional impairment, and may serve to maintain anxiety in this population. Despite this, insomnia is not a specific target of the most empirically supported psychosocial treatments for pediatric anxiety. In this article, we begin by reviewing evidence for the interrelatedness of insomnia and anxiety, as well as literature suggesting that treating insomnia directly may be necessary to optimize anxiety-related outcomes. We provide a basic overview for the use of cognitive behavioral therapy for insomnia with adolescents, including adaptations that may be required when working with anxious patients. We maintain that clinicians treating this population should regard insomnia as a critical target for intervention and that cognitive behavioral therapy for insomnia is a promising, brief treatment that is complementary to standard cognitive behavioral approaches to anxiety.
... Clients who have learned to worry pervasively in response to various internal or situational triggers present challenges with isolating the specific conditions under which worry is likely to occur. In the presence of poorly discriminated worry cues, stimulus control techniques can be instrumental in weakening and reducing the associations between worry and its triggers (Borkovec et al., 1983a;McGowan and Behar, 2013). Stimulus control involves designating a 30-minute worry period at a time and a location that is not associated with other routine or leisure activities. ...
Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders and is highly comorbid with other disorders. GAD is characterized by persistent, excessive and uncontrollable anxiety and worry about everyday life events. Additionally, GAD has been linked to inflexible patterns of cognitive, affective, physiological and neurobiological processes. Individuals with GAD are likely to present with interpersonal difficulties. Theoretical advances in the past two decades have facilitated improvements in treatment efficacy for GAD. Among different treatment approaches, cognitive-behavioral therapy (CBT) has been known to be the treatment of choice for GAD. CBT focuses on the alleviation of anxiety and worry in cognitive, affective and psychophysiological processes of GAD. Future therapy can benefit from treatment component analysis and development of new therapy techniques.
... Clients who have learned to worry pervasively in response to various internal or situational triggers present challenges with isolating the specific conditions under which worry is likely to occur. In the presence of poorly discriminated worry cues, stimulus control techniques can be instrumental in weakening and reducing the associations between worry and its triggers (Borkovec et al., 1983a;McGowan and Behar, 2013). Stimulus control involves designating a 30-minute worry period at a time and a location that is not associated with other routine or leisure activities. ...
Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders and is highly comorbid with other disorders. GAD is characterized by persistent, excessive and uncontrollable anxiety and worry about everyday life events. Additionally, GAD has been linked to inflexible patterns of cognitive, affective, physiological and neurobiological processes. Individuals with GAD are likely to present with interpersonal difficulties. Theoretical advances in the past two decades have facilitated improvements in treatment efficacy for GAD. Among different treatment approaches, cognitive-behavioral therapy (CBT) has been known to be the treatment of choice for GAD. CBT focuses on the alleviation of anxiety and worry in cognitive, affective and psychophysiological processes of GAD. Future therapy can benefit from treatment component analysis and development of new therapy techniques.
... As clients establish an association between worry and their zone while severing worry-cue ties throughout the day, worry becomes absent at the times and places in which it would most interfere. Stimulus control was effective at treating chronic worry and reducing anxiety and insomnia compared to a no-treatment condition (Borkovec, Wilkinson, Folensbee, & Lerman, 1983;McGowan & Behar, 2013). ...
This chapter differentiates components of theoretical models and treatments of generalized anxiety disorder (GAD) that have received substantial empirical support from those with less empirical support. It discusses the sequencing of individual treatment components, potential obstacles to the successful implementation of treatment, and ways to address the obstacles. Treatments based on theoretical models of GAD have been developed. Emotional/behavioral models include the emotion dysregulation model and the acceptance-based model. Treatments based on these models integrate cognitive behavioral therapy (CBT) techniques with novel methods derived from mindfulness and emotion regulation theory. Among interventions included in CBT programs, few would question that the two most studied and supported for GAD are cognitive therapy (CT) and relaxation training (RT). Only relaxation training and CBT have been noted as empirically supported treatments for GAD by the American Psychological Association.
... In addition to statistical effects, we analyzed clinically significant change by evaluating the percent of participants who improved on each variable by at least two standard deviations of the pretest scores (e.g., McGowan & Behar, 2012). In the SM+ group, 40.91% (ASRS), 22.73% (SSC), and 13.64% (GPA) of participants made clinically significant improvements. ...
Objective: There is a lack of empirically supported treatments for college students with ADHD and academic deficits. The current study evaluated self-monitoring, an intervention that may improve academics in children with ADHD, with a college sample diagnosed with ADHD. Method: Fifty-three participants were recruited, 41 of which completed the study and are included in the analyses. Participants were randomly assigned to a group that received study skills instruction, goal setting, and self-monitoring instruction (SM+ group; n = 22) or a group that received only study skills and goal setting (SM− group; n = 19). Results: Participants in the SM+ group demonstrated significant improvement in their ADHD symptoms, academic behavior, grade point averages (GPAs), and goal attainment. These improvements were not significant for the SM− group. Conclusion: These findings suggest that self-monitoring might be used to improve academic performance in college students with ADHD.
... Is it possible that the newer computerized attentional training procedures that have captured the scientific community's interest in recent years have effects that are in fact comparable to older behavioural interventions, such as SC training? It is interesting to note that the full clinical potential of SC training for worry, an intervention that has a strong theoretical foundation, has received very little empirical attention (McGowan & Behar, 2013). The reasons for this seem unclear. ...
La caractéristique essentielle du trouble d’anxiété généralisée (TAG) est une inquiétude excessive et incontrôlable et de l’anxiété, s’accompagnant de divers symptômes, y compris de la tension musculaire et de l’agitation. Les conséquences du TAG sont bien documentées, toutefois, ce trouble fait l’objet de moins de recherches que les autres troubles anxieux. De plus, les taux de rétablissement par suite d’un traitement révèlent qu’il y a bien du progrès à faire sur le plan des interventions actuelles. Bien que le grand besoin de recherche sur le TAG et les procédés qui le sous-tendent soit évident, il est aussi proposé que les praticiens bénéficieraient a) d’une synthèse plus explicite des connaissances, car certaines questions soulevées aujourd’hui l’ont déjà été par le passé, voire discutées; et b) d’une plus grande intégration des théories non cliniques dans les modèles conceptuels de l’inquiétude pathologique.
Opioid use disorder is associated with an elevated risk of most psychiatric disorders, as well as many health conditions. Among the most common co-occurring conditions are anxiety disorders and chronic pain. As opioids can provide potent relief of both negative affect and pain, the presence of these co-occurring conditions can complicate recovery from opioid use disorder. The objective of this chapter is to provide an overview of the co-occurrence of anxiety and pain among people with opioid use disorder and guidance on the application of cognitive-behavioral strategies for these conditions. Common mechanisms that can be targeted transdiagnostically are highlighted, as are possibilities for navigating potentially discrepant treatment elements (e.g., approach-oriented exposure techniques vs. avoidance-oriented environmental risk modification). Treatment principles are illustrated using with case examples of their application. Importantly, the treatment of this co-occurrence is understudies, and research on optimal treatment approaches for this population is needed.
Objective:
Evidence suggests that perseverative cognition (PC), the cognitive representation of past stressful events (rumination) or feared future events (worry), mediates the relationship between stress and physical disease. However, the experimental evidence testing methods to influence PC and the subsequent relationship with health outcomes has not been synthesized. Therefore, the current review addressed these gaps.
Method:
Studies randomly assigning participants to treatment and control groups, measuring PC and a physical and/or behavioral health outcome after exposure to a nonpharmacological intervention, were included in a systematic review. Key terms were searched in Medline, PsycINFO and CINAHL databases. Of the screened studies (k = 10,703), 36 met the eligibility criteria.
Results:
Random-effects meta-analyses revealed the interventions, relative to comparison groups, on average produced medium-sized effects on rumination (g = -.58), small-to-medium sized effects on worry (g = -.41) and health behaviors (g = .31), and small-sized effects on physical health outcomes (g = .23). Effect sizes for PC were negatively associated with effect sizes for health behaviors. (following outlier removal). Effect sizes for PC were significantly larger when interventions were delivered by health care professionals than when delivered via all other methods. No specific intervention type (when directly compared against other types) was associated with larger effect sizes for PC.
Conclusions:
Psychological interventions can influence PC. Medium-sized (negative) effect sizes for PC correspond with small (but positive) health behavior effect sizes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing. This meta-analysis of 419 randomized controlled trials found that various types of psychological interventions could improve mental wellbeing in clinical and non-clinical populations. Effect sizes tended to be small to moderate and were influenced by various moderators.
Rumination is theorized to be a cognitive avoidance process that is implicated in several manifestations of psychopathology. Few interventions directly target rumination as a core process maintaining emotional disorder symptoms. This pilot study compared the feasibility and preliminary efficacy of self-directed behavioral approaches for reducing rumination. Participants ( N = 60) with elevations in rumination were randomized to 3 weeks of self-directed interventions: (a) scheduled rumination time; (b) a strategy combining mindfulness, shaping, and disengagement strategies; or (c) self-monitoring control. Both active treatment conditions outperformed self-monitoring control on post-treatment depression scores. Scheduled rumination time significantly outperformed the other two conditions on measures of rumination and worry. No between-group differences emerged on the secondary outcome (i.e., anxiety symptoms). Brief, self-directed, behavioral interventions targeting rumination are feasible and demonstrate preliminary efficacy. Scheduled rumination time shows moderate to large effects. The use of a small, non-treatment seeking sample was the primary limitation.
School stress can be significant for adolescents. Improving stress-related coping skills and stress management can be very helpful. In this chapter brief strategies for reducing school stress are addressed. Emotion-focused coping can be taught. The avoidance that students with anxiety may use to cope can be decreased with brief interventions. Some of the more traditional approaches to stress reduction may not work as well as more current approaches such as stress reappraisal and a stress-is-enhancing mindset. The data to support the more current approaches is discussed. In addition, a personality can change mindset works in the same way as intelligence can change mindsets. Exciting interventions such as values affirmation have been demonstrated to reduce the racial/ethnic achievement gap, but they can be tricky to implement. If educators keep the information in mind that allows values affirmation to work, they will find the interventions very valuable.
This chapter provides a more historical background on the study of worry. It summarizes the theories and research that inspired Borkovec and colleagues’ foundational ideas. The chapter contrasts models of distal processes and models of proximal processes, a distinction that has been applied to other psychopathologies. At the heart of the cognitive avoidance model of generalized anxiety disorder (GAD) are the notions that individuals with GAD avoid mental imagery and the emotions associated with the imagery; and that worry is a behavior that facilitates this avoidance. The self‐regulatory executive function model (S‐REF) describes a pernicious processing mode called the cognitive attentional syndrome, which prevents the down‐regulation of negative thoughts and feelings by heightening self‐focused attention, activating unhelpful self‐beliefs and self‐appraisals, and causing less efficient cognitive functioning. The cognitive model of pathological worry aims to describe the causal mechanisms leading to and maintaining episodes of worry.
Pathological worry is characterized by an inability to distract or disengage from worry, and this uncontrollability is the defining feature of Generalized Anxiety Disorder (GAD). The present study assessed a novel computerized strategy that targets these attention difficulties. Worry Disengagement Training (WDT), which involves alternating between writing about one's worry and positive topics, was evaluated in a sample with elevated worry (N = 50), most of whom met for GAD diagnosis (66%). Compared to waitlist, WDT led to increased ability to disengage from in vivo worry on a breath focus task, resulting in fewer negative intrusions (β = − 0.29, p = .02; sr² = 0.08). Relative to waitlist, WDT also led to lower self-reported general worry (β = − 0.36, p = .001, sr² = 0.14) and depressive symptoms (β = − 0.25, p = .02, sr² = 0.07). These effects remained in the subset of participants meeting criteria for GAD. WDT did not impact anxious arousal, suggesting some specificity of effects. These findings provide preliminary support for WDT as an effective strategy to increase disengagement ability and reduce worry and depression. Limitations and future directions are discussed.
Objective: To assess whether worry and rumination differ in predicting nighttime sleep disturbance versus daytime sleep-related impairment, as assessed using short forms from the Patient Reported Outcomes Measurement Information System (PROMIS).
Participants: Adults recruited from the United States population (N = 459) via an online crowdsourcing service.
Methods: Factor analysis explored whether items comprising validated measures of worry and rumination loaded onto separate factors. Hierarchical multiple regression models entered worry and rumination in a stepwise fashion to assess their relative strength in predicting PROMIS sleep disturbance and sleep-related impairment, after controlling for 17 covariates. All analyses were run twice using sleep-specific and general measures of worry and rumination.
Results: Worry and rumination items loaded onto separate factors. In the regression analysis of sleep-specific cognition, only worry entered the model predicting sleep disturbance, whereas rumination entered after worry in the model predicting sleep-related impairment. In the analysis of general cognition, both cognitive process variables significantly predicted the PROMIS outcomes. Worry was the stronger predictor of sleep disturbance, whereas rumination was the stronger predictor of sleep-related impairment.
Conclusions: Worry and rumination were observed to be distinct constructs that separately contributed to predicting daytime sleep-related impairment. Future studies should more closely examine how cognitive processes relate to insomnia symptomology during the day.
Several socio-cultural factors complicate mental health care in the ultra-Orthodox Jewish population. These include societal stigma, fear of the influence of secular ideas, the need for rabbinic approval of the method and provider, and the notion that excessive concern with the self is counter-productive to religious growth. Little is known about how the religious beliefs of this population might be employed in therapeutic contexts. One potential point of convergence is the Jewish philosophical tradition of introspection as a means toward personal, interpersonal, and spiritual growth. We reviewed Jewish religious-philosophical writings on introspection from antiquity (the Babylonian Talmud) to the Middle Ages (Duties of the Heart), the eighteenth century (Path of the Just), the early Hasidic movement (the Tanya), and modernity (Alei Shur, Halakhic Man). Analysis of these texts indicates that: (1) introspection can be a religiously acceptable reaction to existential distress; (2) introspection might promote alignment of religious beliefs with emotions, intellect and behavior; (3) some religious philosophers were concerned about the demotivating effects of excessive introspection and self-critique on religious devotion and emotional well-being; (4) certain religious forms of introspection are remarkably analogous to modern methods of psychiatry and psychology, particularly psychodynamic psychotherapy and cognitive-behavioral therapy. We conclude that homology between religious philosophy of emotion and secular methods of psychiatry and psychotherapy may inform the choice and method of mental health care, foster the therapist-patient relationship, and thereby enable therapeutic convergence.
Insomnia is a common feature among individuals with anxiety disorders. Studies of cognitive behavioral therapy (CBT) for anxiety report moderate effects on concomitant insomnia symptoms, but further research is still needed especially toward understanding how CBT for anxiety renders beneficial effects on insomnia. The current study examined changes in insomnia symptoms reported by 51 Veterans who participated in a group-based transdiagnostic CBT for anxiety intervention. In addition, insomnia symptoms were examined in relation to symptoms of general distress (GD), anhedonic depression (AD), and anxious arousal (AA) pre- to post-treatment. Results revealed a small, though statistically significant (p < .05) beneficial effect on insomnia symptoms. When changes in GD, AD, and AA were simultaneously examined in relation to changes in insomnia, change in AA was the only significant predictor of insomnia symptoms. The current study highlights the role of AA in the relationship between anxiety disorders and insomnia and demonstrates that reductions in insomnia during transdiagnostic CBT for anxiety can be largely attributed to changes in AA.
Stress is a concept that all of us, with or without diabetes, can relate to. Coined less than sixty years ago by Hans Selye (1956), in our Western world the term has quickly become an ingrained part of both our vocabulary and our daily existence. It is a catch-all description for many of the everyday worries in our modern day lives - family challenges, work demands, health difficulties, relationship conflicts and so on. For the individuals we care for, there are the additional diabetes and lifestyle-related stressors to contend with. This article outlines the impact of stress on diabetes, and offers some practical suggestions and a strategy that non-psychologist clinicians can use to support people with diabetes who are experiencing diabetes-related stress.
This chapter discusses the relationship between sleep and emotional functioning in the absence of psychopathology. Research evaluating the impact of sleep on emotional functioning supports associations between deficient sleep and reduced positive affect, increased negative affect, and increased difficulties with emotion regulation. Research evaluating the impact of emotions on sleep suggests that the negative valence and high arousal dimensions of emotion are similarly associated with increased sleep latency and fragmentation and decreased sleep quality and total sleep time. However, negative valence and high arousal potentially have unique effects on sleep architecture, with high arousal being associated with reductions in slow-wave sleep and negative valence being associated with disruptions to REM sleep. Moreover, individual differences in emotion regulation also impact sleep parameters, above and beyond the influence of current emotions. The chapter discusses implications of this research, highlighting future directions for improving our understanding of the dynamic relationship between sleep and emotional functioning.
Comorbid diagnoses were examined in 55 principal generalized anxiety disorder (GAD) clients, and the effect of treatment for the principal disorder on those conditions was evaluated. High rates of comorbid diagnoses were present at pretherapy, with social and simple phobia being most common. The presence of additional diagnoses declined dramatically from pretherapy to follow-up and was significantly greater among clients for whom the GAD therapy had been successful than among clients for whom GAD outcome had been ambiguous. This was generally true regardless of whether clients reported at follow-up that they had received further therapy since the posttherapy assessment.
Using outpatients with anxiety and mood disorders (N = 350), the authors tested several models of the structural relationships of dimensions of key features of selected emotional disorders and dimensions of the tripartite model of anxiety and depression. Results supported the discriminant validity of the 5 symptom domains examined (mood disorders; generalized anxiety disorder, GAD; panic disorder; obsessive-compulsive disorder; social phobia). Of various structural models evaluated, the best fitting involved a structure consistent with the tripartite model (e.g., the higher order factors, negative affect and positive affect, influenced emotional disorder factors in the expected manner). The latent factor, GAD, influenced the latent factor, autonomic arousal, in a direction consistent with recent laboratory findings (autonomic suppression); Findings are discussed in the context of the growing literature on higher order trait dimensions (e.g., negative affect) that may be of considerable importance to the understanding of the pathogenesis, course, and co-occurrence of emotional disorders.
In recent studies of the structure of affect, positive and negative affect have consistently emerged as two dominant and relatively independent dimensions. A number of mood scales have been created to measure these factors; however, many existing measures are inadequate, showing low reliability or poor convergent or discriminant validity. To fill the need for reliable and valid Positive Affect and Negative Affect scales that are also brief and easy to administer, we developed two 10-item mood scales that comprise the Positive and Negative Affect Schedule (PANAS). The scales are shown to be highly internally consistent, largely uncorrelated, and stable at appropriate levels over a 2-month time period. Normative data and factorial and external evidence of convergent and discriminant validity for the scales are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
Community norms are reported for the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, G. Brown, & R. A. Steer, 1988), Fear Questionnaire (FQ; I. M. Marks & A. Mathews, 1979), Penn State Worry Questionnaire (PSWQ; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990), and Social Phobia and Anxiety Inventory (SPAI; S. M. Turner, D. C. Beidel, C. V. Dancu, & M. A. Stanley, 1989). The demographic profile of the samples closely matched the 1990 U.S. national census. On the SPAI, women scored higher than men on the Agoraphobia subscale, and the lowest income group scored higher than higher income participants on the Difference and Social Phobia subscales. Participants under 45 years of age exceeded those aged 45–65 on the BAI, the PSWQ, and FQ Social Phobia, Blood/Injury, and Total Phobia scores. Percentile scores are provided for all measures, as well as discussion of their usefulness for assessing clinical significance of therapy outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Between-group outcome research is a scientific approach to evaluating the effectiveness of psychotherapy and the mechanisms of change associated with those treatments for psychological disorders. This area of research is replete with important methodological issues that need to be considered in order for investigators to draw the strongest, most specific cause-and-effect conclusions about the active components of treatments, human behavior, and the effectiveness of therapeutic interventions. In this chapter, we present the various methodological considerations associated with these experiments. The chapter begins with a description of the different experimental designs from which investigators may choose in designing a therapy outcome study. These designs include the no-treatment and common factors comparison designs, as well as the dismantling, additive, catalytic, and parametric designs. We also present the methodological, client/participant, and therapist concerns that must be taken into account in the design stage of a treatment outcome investigation. Following this, we discuss the measurement of change, starting with the considerations surrounding dependent variables and ending with methods of analyzing data and assessing clinically significant change. Finally, after a presentation on small-N experimental designs, we discuss the importance of scientific research in naturalistic settings.
Keywords:
design;
methodology;
naturalistic;
outcome;
psychotherapy;
therapy
Research on relationships between anxiety and depression has proceeded at a rapid pace since the 1980s. The similarities and differences between these two conditions, as well as many of the important features of the comorbidity of these disorders, are well understood. The genotypic structure of anxiety and depression is also fairly well documented. Generalized anxiety and ma-jor depression share a common genetic diathesis, but the anxiety disorders themselves are genetically hetergeneous. Sophisticated phenotypic models have also emerged, with data converging on an integrative hierarchical model of mood and anxiety disorders in which each individual syndrome contains both a common and a unique component. Finally, considerable progress has been made in understanding cognitive aspects of these disor-ders. This work has focused on both the cognitive content of anxiety and de-pression and on the effects that anxiety and depression have on information processing for mood-congruent material.
The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Worry exposure (WE) is a core element of cognitive-behavioral treatment for generalized anxiety disorder (GAD). Its efficacy as a stand-alone treatment method (without further cognitive-behavioral therapy interventions) has never been tested.We aimed to examine whether WE alone is as efficacious as the empirically supported stand-alone treatment for GAD, applied relaxation (AR).
In a randomized controlled study, 73 outpatients meeting DSM-IV criteria for GAD as primary diagnosis were allocated to either WE or AR or a waiting list control group; in a 2nd randomization procedure the waiting list subjects were reallocated to WE or AR. The treatment was manualized (15 sessions with WE or AR), included 6-month and 1-year follow-ups, as well as last observation carried forward and completer analyses, and was controlled for allegiance effects.The Hamilton Anxiety Rating Scale and the State-Trait Anxiety Scale were used as primary outcome measures. Self-report scales of anxiety, worrying and depression including negative metacognition about worrying and thought suppression served as secondary outcome measures.
The dropout rate was moderate. The pre-/posttreatment effects were high for the Hamilton Anxiety Rating Scale (standardized mean difference >1) and for the State-Trait Anxiety Inventory (standardized mean difference >0.87). The proportion of patients reaching high end state functioning was 48% (WE) and 56% (AR). WE and AR did not differ with regard to dropout rate or treatment effects. The treatment effects were stable at 6 month and 1 year follow-up.
This is the first study to show that a stand-alone exposure in sensu technique--WE--is efficacious in the treatment of GAD. Both AR and WE seem to represent effective principles of change in GAD.
Generalized anxiety disorder (GAD) is a chronic anxiety disorder, associated with comorbidity and impairment in quality of life, for which improved psychosocial treatments are needed. GAD is also associated with reactivity to and avoidance of internal experiences. The current study examined the efficacy of an acceptance-based behavioral therapy aimed at increasing acceptance of internal experiences and encouraging action in valued domains for GAD. Clients were randomly assigned to immediate (n = 15) or delayed (n = 16) treatment. Acceptance-based behavior therapy led to statistically significant reductions in clinician-rated and self-reported GAD symptoms that were maintained at 3- and 9-month follow-up assessments; significant reductions in depressive symptoms were also observed. At posttreatment assessment 78% of treated participants no longer met criteria for GAD and 77% achieved high end-state functioning; these proportions stayed constant or increased over time. As predicted, treatment was associated with decreases in experiential avoidance and increases in mindfulness.
In a controlled clinical trial, 57 Ss meeting DSM-III-R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4-12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.
In 1984, Jacobson, Follette, and Revenstorf defined clinically significant change as the extent to which therapy moves someone outside the range of the dysfunctional population or within the range of the functional population. In the present article, ways of operationalizing this definition are described, and examples are used to show how clients can be categorized on the basis of this definition. A reliable change index (RC) is also proposed to determine whether the magnitude of change for a given client is statistically reliable. The inclusion of the RC leads to a twofold criterion for clinically significant change.
In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is defined as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individual’s responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.
Comorbid diagnoses were examined in 55 principal generalized anxiety disorder (GAD) clients, and the effect of treatment for the principal disorder on those conditions was evaluated. High rates of comorbid diagnoses were present at pretherapy, with social and simple phobia being most common. The presence of additional diagnoses declined dramatically from pretherapy to follow-up and was significantly greater among clients for whom the GAD therapy had been successful than among clients for whom GAD outcome had been ambiguous. This was generally true regardless of whether clients reported at follow-up that they had received further therapy since the posttherapy assessment.
Literature on temperament, personality, and mood and anxiety disorders is reviewed. The review is organized primarily around L. A. Clark and D. Watson's (1991b) tripartite model for these disorders, but other influential approaches are also examined. Negative affectivity (or neuroticism) appears to be a vulnerability factor for the development of anxiety and depression, indicates poor prognosis, and is itself affected by the experience of disorder. Positive affectivity (or extraversion) is related more specifically to depression, may be a risk factor for its development, suggests poor prognosis, and also may be affected by the experience of disorder. Other personality dimensions (e.g., anxiety sensitivity, attributional style, sociotropy or dependence, autonomy or self-criticism, and constraint) may constitute specific vulnerability factors for particular disorders. More longitudinal and measurement-based research that jointly examines anxiety and depression is needed.
Nondirective (ND), applied relaxation (AR), and cognitive behavioral (CBT) therapies for generalized anxiety disorder (GAD) were compared. The latter 2 conditions were generally equivalent in outcome but superior to ND at postassessment. The 3 conditions did not differ on several process measures, and ND created the greatest depth of emotional processing. Follow-up results indicated losses in gains in ND, maintained gains in the other 2 conditions, especially CBT, and highest endstate functioning for CBT. AR and CBT thus contain active ingredients in the treatment of GAD; support exists for further development of imagery exposure methods or cognitive therapy because of their likely role in promoting maintenance of change with this disorder. Expectancy for improvement was also associated with outcome, suggesting the need for further research on this construct for understanding the nature of GAD and its amelioration.
The similarities and distinctions between the constructs of worry and anxiety were examined in a sample of 189 university students. Three worry scales and four measures of anxiety were compared in relation to measures of negative affect, personal control, and problem-solving style. Although measures of worry and anxiety were highly correlated, negative affect (e.g. depression, confusion) tended to be more closely related to anxiety than to worry, whereas problem-solving style tended to be more closely related to worry than to anxiety. Personal control did not show a differential relationship to anxiety or worry. When the definition of anxiety was restricted to somatic anxiety, however, negative affect, perceived problem-solving abilities, and personal control were more strongly related to worry than to anxiety. Implications of these results are discussed in light of current definitions and measurement of these constructs.
Background: Insomnia is a prevalent health complaint that is often difficult to evaluate reliably. There is an important need for brief and valid assessment tools to assist practitioners in the clinical evaluation of insomnia complaints.Objective: This paper reports on the clinical validation of the Insomnia Severity Index (ISI) as a brief screening measure of insomnia and as an outcome measure in treatment research. The psychometric properties (internal consistency, concurrent validity, factor structure) of the ISI were evaluated in two samples of insomnia patients.Methods: The first study examined the internal consistency and concurrent validity of the ISI in 145 patients evaluated for insomnia at a sleep disorders clinic. Data from the ISI were compared to those of a sleep diary measure. In the second study, the concurrent validity of the ISI was evaluated in a sample of 78 older patients who participated in a randomized-controlled trial of behavioral and pharmacological therapies for insomnia. Change scores on the ISI over time were compared with those obtained from sleep diaries and polysomnography. Comparisons were also made between ISI scores obtained from patients, significant others, and clinicians.Results: The results of Study 1 showed that the ISI has adequate internal consistency and is a reliable self-report measure to evaluate perceived sleep difficulties. The results from Study 2 also indicated that the ISI is a valid and sensitive measure to detect changes in perceived sleep difficulties with treatment. In addition, there is a close convergence between scores obtained from the ISI patient's version and those from the clinician's and significant other's versions.Conclusions: The present findings indicate that the ISI is a reliable and valid instrument to quantify perceived insomnia severity. The ISI is likely to be a clinically useful tool as a screening device or as an outcome measure in insomnia treatment research.
Clients with generalized anxiety disorder (GAD) received either (a) applied relaxation and self-control desensitization, (b) cognitive therapy, or (c) a combination of these methods. Treatment resulted in significant improvement in anxiety and depression that was maintained for 2 years. The large majority no longer met diagnostic criteria; a minority sought further treatment during follow-up. No differences in outcome were found between conditions; review of the GAD therapy literature suggested that this may have been due to strong effects generated by each component condition. Finally, interpersonal difficulties remaining at posttherapy, measured by the Inventory of Interpersonal Problems Circumplex Scales (L. E. Alden, J. S. Wiggins, & A. L. Pincus, 1990) in a subset of clients, were negatively associated with posttherapy and follow-up improvement, suggesting the possible utility of adding interpersonal treatment to cognitive-behavioral therapy to increase therapeutic effectiveness.
Sleep laboratory and epidemiological studies indicate that insomnia is a frequent finding in patients with psychiatric disorders. In this respect, insomnia associated with a major depression or an anxiety disorder, mainly generalized anxiety disorder (GAD), is the most prevalent diagnosis. According to available evidence, the sleep disturbance associated with mild-to-moderate GAD is a sleep-maintenance insomnia, and to a lesser extent a sleep-onset insomnia. Insomnia associated with mild-to-moderate GAD generally responds to psychological treatments and anxiolytic benzodiazepines. Moreover, concomitant administration of hypnotic medication can be contemplated in patients with severe GAD.
After providing background information on the definition and nature of generalized anxiety disorder, this article describes cognitive-behavioral therapy (CBT) methods that have been empirically supported in the treatment of this disorder. Subsequent to this description, relevant outcome literature is briefly reviewed, along with evidence that the addition of other techniques beyond traditional CBT methods may be necessary to maximize clinical outcome. A description is then provided of an integrated interpersonal/emotional processing therapy that the authors have recently added to their CBT protocol. CBT with and without this integrated treatment is currently being evaluated in an experimental trial.
The present article presents and reviews the model of psychopathology and treatment underlying Acceptance and Commitment Therapy (ACT). ACT is unusual in that it is linked to a comprehensive active basic research program on the nature of human language and cognition (Relational Frame Theory), echoing back to an earlier era of behavior therapy in which clinical treatments were consciously based on basic behavioral principles. The evidence from correlational, component, process of change, and outcome comparisons relevant to the model are broadly supportive, but the literature is not mature and many questions have not yet been examined. What evidence is available suggests that ACT works through different processes than active treatment comparisons, including traditional Cognitive-Behavior Therapy (CBT). There are not enough well-controlled studies to conclude that ACT is generally more effective than other active treatments across the range of problems examined, but so far the data are promising.
Studies using fear-conditioning paradigms have found that anxiety patients are more conditionable than individuals without these disorders, but these effects have been demonstrated inconsistently. It is unclear whether these findings have etiological significance or whether enhanced conditionability is linked only to certain anxiety characteristics. To further examine these issues, the authors assessed the predictive significance of relevant subsyndromal characteristics in 72 healthy adults, including measures of worry, avoidance, anxious mood, depressed mood, and fears of anxiety symptoms (anxiety sensitivity), as well as the dimensions of Neuroticism and Extraversion. Of these variables, the authors found that the combination of higher levels of subsyndromal worry and lower levels of behavioral avoidance predicted heightened conditionability, raising questions about the etiological significance of these variables in the acquisition or maintenance of anxiety disorders. In contrast, the authors found that anxiety sensitivity was more linked to individual differences in orienting response than differences in conditioning per se.
Chapter 14 explores insomnia, its cognitive models and key cognitive constructs. Behavioural experiments are proposed to address unhelpful beliefs about sleep and tiredness, worry, monitoring, thoughts leading to safety behaviours, and investigate distorted perceptions.
In a controlled clinical trial, 57 Ss meeting DSM—III—R criteria for generalized anxiety disorder, and fulfilling an additional severity criterion, were randomly allocated to cognitive behavior therapy (CBT), behavior therapy (BT), or a waiting-list control group. Individual treatment lasted 4—12 sessions; independent assessments were made before treatment, after treatment, and 6 months later, and additional follow-up data were collected after an interval of approximately 18 months. Results show a clear advantage for CBT over BT. A consistent pattern of change favoring CBT was evident in measures of anxiety, depression, and cognition. Ss were lost from the BT group, but there was no attrition from the CBT group. Treatment integrity was double-checked in England and in Holland, and special efforts were made to reduce error variance. Possible explanations for the superiority of CBT are discussed.
• Data for this report come from a nationally representative probability sample survey of noninstitutionalized adults, aged 18 to 79 years. The survey, conducted in 1979, found that insomnia afflicts 35% of all adults during the course of a year; about half of these persons experience the problem as serious. Those with serious insomnia tend to be women and older, and they are more likely than others to display high levels of psychic distress and somatic anxiety, symptoms resembling major depression, and multiple health problems. During the year prior to the survey, 2.6% of adults had used a medically prescribed hypnotic. Typically, use occurred on brief occasions, one or two days at a time, or for short durations of regular use lasting less than two weeks. The survey also found a small group of hypnotic users (11% of all users; 0.3% of all adults) who reported using the medication regularly for a year or longer. If we include anxiolytics and antidepressants, 4.3% of adults had used a medically prescribed psychotherapeutic drug that was prescribed for sleep; 3.1% had used an over-the-counter sleeping pill. The majority of serious insomniacs (85%) were untreated by either prescribed or over-the-counter medications.
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
A theory of emotional imagery is described which conceives the image in the brain to be a conceptual network, controlling specific somatovisceral patterns, and constituting a prototype for overt behavioral expression. Evidence for the hypothesis that differentiated efferent activity is associated with type and content of imaginal activity is considered. Recent work in cognitive psychology is described, which treats both the generation of sensory imagery and text comprehension and storage as examples of the processing of propositional information. A similar propositional analysis is applied to emotional imagery as it is employed in the therapeutic context. Experiments prompted by this view show that the conceptual structure of the image and its associated efferent outflow can be modified directly through instructions and through shaping of reports of image experience. The implications of the theory for psychopathology are considered, as well as its relevance to therapeutic behavior change.
The ability to suppress unwanted thoughts was investigated in patients with Generalized Anxiety Disorder (GAD; n = 29), Speech Phobics (n = 25), and nonanxious controls (n = 28). All participants spent 5 minutes thinking aloud about anything that came to mind while trying not to think of white bears. In another task, they thought aloud for 5 minutes while trying not to think of their main worry. Intrusions of unwanted thoughts were signaled by button presses and recorded on tape. In accordance with the disorder’s definition and complaints of the GAD patients, they showed more intrusions of their main worry than of white bears. The opposite was true for other participants. Compared to a baseline measure, all participant groups were unable to reduce duration of main worry thoughts when trying to suppress them.
In this paper a cognitive model of Generalized Anxiety Disorder (GAD) is described. Evidence for the model is briefly reviewed and the specific form of cognitive therapy (metacognitive therapy) derived from the model is outlined. The model accounts for the disappointing effects of existing cognitive-behavioural treatments of GAD in terms of a failure to focus on key beliefs concerning worry itself. The model asserts that pathological worry in GAD is maintained by positive and negative metacognitive beliefs concerning the advantages and the dangers of worrying. Individuals with GAD tend to use internal information such as a felt sense that they will be able to cope as a signal to terminate worrying. Although worrying is used as a means of coping with anticipated threats, it becomes the object of negative beliefs and appraisals. Several feedback cycles maintain the problem. When worrying is appraised as dangerous anxiety increases and it is difficult for the individual to obtain an internal state signalling that it is safe to stop worrying. Unhelpful behavioural strategies such as avoidance of situations that trigger worry, thought control strategies characterized by a lack of attempts to interrupt ongoing worry sequences, and attempts to suppress thoughts that trigger worrying maintain maladaptive metacognitions and anxiety. Specific strategies for conceptualizing GAD cases, and for modifying key metacognitions are presented. Copyright © 1999 John Wiley & Sons, Ltd.
A sample of physician-referred chronic insomniacs was randomly allocated to either progressive relaxation, stimulus control, paradoxical intention, placebo or no treatment conditions. Treatment process and outcome were investigated in terms of mean and standard deviation (night to night variability) measures of sleep pattern and sleep quality. Only active treatments were associated with significant improvement, but the nature of treatment gains varied. In particular, stimulus control improved sleep pattern, whereas relaxation affected perception of sleep quality. All improvements were maintained at 17 month follow-up. Results are discussed with reference to previous research and guidelines are given for clinical practice.
The purpose of this article is to suggest some new directions for the presentation and reporting of data in psychotherapy outcome research. Statistical comparisons based on group means provide no information on the variability of treatment outcome, and statistical significance tests do not address clinical significance. Although psychotherapy research has begun to address these issues, it has done so unsystematically. New standards and conventions are needed to serve as criteria for classifying therapy subjects into categories of improved, unimproved, and deteriorated based on response to treatment. A two-fold criterion for determining improvement in a client is recommended, based on both statistical reliability and clinical significance. Statistical procedures for determining whether or not these criteria have been met are discussed.
The first wave of behavior therapy countered the excesses and scientific weakness of existing nonempirical clinical traditions through empirically studied first-order change efforts linked to behavioral principles targeting directly relevant clinical targets. The second wave was characterized by similar direct change efforts guided by social learning and cognitive principles that included cognitive in addition to behavioral and emotive targets. Various factors seem to have set the stage for a third wave, including anomalies in the current literature and philosophical changes. Acceptance and Commitment Therapy (ACT) is one of a number of new interventions from both behavioral and cognitive wings that seem to be moving the field in a different direction. ACT is explicitly contextualistic and is based on a basic experimental analysis of human language and cognition, Relational Frame Theory (RFT). RFT explains why cognitive fusion and experiential avoidance are both ubiquitous and harmful. ACT targets these processes and is producing supportive data both at the process and outcome level. The third-wave treatments are characterized by openness to older clinical traditions, a focus on second order and contextual change, an emphasis of function over form, and the construction of flexible and effective repertoires, among other features. They build on the first- and second-wave treatments, but seem to be carrying the behavior therapy tradition forward into new territory.
Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.
Four hundred and fifty college students rated the credibility of the rationales and procedural descriptions of two therapy, three placebo, and one component-control procedure frequently used in analogue outcome research. The rating scale was designed to assess both the credibility and the expectancy for improvement generated by the rationales. The results indicated that the control conditions were, in general, less credible than the therapy conditions. Implications for outcome research are briefly discussed.
This randomized controlled trial compared the effectiveness of metacognitive therapy (MCT) and intolerance-of-uncertainty therapy (IUT) for generalized anxiety disorder (GAD) in an outpatient context. Patients with GAD (N = 126) consecutively referred to an outpatient treatment center for anxiety disorder were randomly allocated to MCT, IUT, or a delayed treatment (DT) condition. Patients were treated individually for up to 14 sessions. Assessments were conducted before treatment (pretreatment), after the last treatment session (posttreatment), and six months after treatment had ended (follow-up). At posttreatment and follow-up assessments, substantial improvements were observed in both treatment conditions across all outcome variables. Both MCT and IUT, but not DT, produced significant reductions in GAD-specific symptoms with large effect sizes (ranging between 0.94 and 2.39) and high proportions of clinically significant change (ranging between 77% and 95%) on various outcome measures, and the vast majority of the patients (i.e., 91% in the MCT group, and 80% in the IUT group) no longer fulfilled the diagnostic criteria for GAD. Results further indicate that MCT produced better results than IUT. This was evident on most outcome measures, and also reflected in effect sizes and degree of clinical response and recovery.
With the advent of DSM-III-R, the diagnostic criteria for generalized anxiety disorder (GAD) shifted in emphasis from the autonomic arousal to the cognitive component of the disorder, namely worry. The Penn State Worry Questionnaire was developed to assess the trait of worry and has proven to be a reliable and valid measure in a series of studies largely based on college student samples. The purpose of the present study was to assess the psychometric properties and utility of the PSWQ in a clinical sample of 436 anxiety disorder patients and 32 normal controls. Factor analysis indicated that the PSWQ assesses a unidimensional construct. Furthermore, the PSWQ evidenced quite favorable internal consistency using GAD patients and each of the other anxiety disorder groups and normal controls. The validity of the PSWQ was supported by an analysis indicating that the measure distinguished. GADs from each of the other anxiety disorder groups including those with obsessive-compulsive disorder. Moreover, correlations between the PSWQ and measures of anxiety, depression, and emotional control supported the convergent and discriminant validity of the measure. Collectively, the findings speak favorably to the use of the PSWQ in research examining the nature and treatment of GAD and the processes of normal and pathological worry.
The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.
Revisions to DSM-III cite apprehensive expectation or 'worry' as a defining feature of generalized anxiety disorder (GAD). The quality and focus of worry reported by groups of GAD patients (n = 19), and nonanxious 'controls' (n = 26) were examined using self-monitored data. Content categorizations by independent raters showed that GAD patients worried more about illness, health and injury issues and displayed a tendency to worry more about miscellaneous 'minor' issues. These descriptor ratings differentiated the worries of GAD patients from those of non-anxious controls: perceived control over worrying, the extent to which the worry was considered realistic, and perceived success with which worry was alleviated using corrective/preventative actions. The data are related to the DSM-III-R criteria for GAD and to conceptualizations of the nature of excessive worry.
One-hundred and twenty-eight subjects underwent inductions of emotions designed to elicit worrisome, depressed, somatically anxious, or neutral emotional states, and then they completed the Multiple Affect Adjective Checklist. Induction of worry was found to produce (a) moderate degrees of both anxiety and depression, (b) emotional profiles more highly correlated with those of depression and somatic anxiety than the correlation of depression and somatic anxiety profiles with each other, and (c) a subjective state containing no unique emotional features separate from that induced in depression and somatic anxiety. Whereas a discriminant function analysis correctly classified 70-85% of the subjects in the other three conditions, subjects who underwent the induction of worry were correctly classified at only chance level.
Sleep-maintenance insomniacs received either a stimulus-control (n = 7) or a credible placebo treatment (n = 8), administered in small groups for 4 weeks. Self-reports of time awake after sleep onset, total number of arousals and number of arousals exceeding 10 min were collected at baseline, at termination of treatment (post-treatment), and at a 3-month follow-up. Results showed a statistically- and clinically-significant reduction on all three dependent measures from baseline to post-treatment for both groups; these gains were maintained through the follow-up period. However, the results achieved with stimulus-control procedures were not significantly different from reductions found with a credible placebo condition. These findings compare favorably with other reports of behavioral treatments of both onset and maintenance insomnia.
As an internal, self-generated event, worrisome cognitive activity can occur under a wide variety of environmental conditions. The contiguity of the activity and diverse cues would suggest that poor discriminative control is established, and, conversely, that subject-initiated restriction of the temporal and environmental cues for the occurrence of the activity may reduce its frequency during the day. Two experiments are reported wherein self-labeled worriers received either no-treatment or a 4-week trial of stimulus control instructions designed to effect such a restriction. Daily worry reports were found to decline significantly among treated subjects relative to controls.
The present paper reports two questionnaire studies and an experimental investigation of worrying. Worry correlated more highly than general tension reports with a variety of affect scales and was characterized by: (a) feelings of anxiety, tension and apprehension; (b) moderate awareness of somatic cues including muscle tension and upset stomach; and (c) concerns over future rather than past or present situations. Self-labeled worriers were most distinguished from non-worriers by their reported uncontrollability of cognitive intrusions once worrying was initiated. In the experimental study, worriers and non-worriers were assessed for their ability to focus their attention on a monotonous (breathing) stimulus before and after 0, 15 or 30 min of worrying. Worriers reported significantly higher anxiety. depression and hostility, a lower frequency of focused attention and a greater frequency of negative thought intrusions than did non-worriers prior to the worry period. For both worriers and non-worriers. 15 min of worry resulted in an apparent incubation of negative cognitive intrusions on the subsequent attention-focusing task.
This study examined the relationships among anxiety, nocturnal sleep, and daytime restedness over a 1-week period, using the Spielberger State-Trait Anxiety Inventory and daily sleep logs. Among both insomniacs and controls, between-subjects correlations showed a significant negative relationship between state anxiety at bedtime and restedness during the day. Neither variable was related to nocturnal sleep variables. Within-subject correlations showed similar relationships between state anxiety and restedness the following day. For insomniacs, but not for normal sleepers, bedtime state anxiety was also significantly correlated with sleep latency. The authors hypothesize that anxiety, not sleep deprivation, may be responsible for the insomniac's complaint of daytime fatigue.
A sample of 21 medicated and 20 nonmedicated insomniacs participated in a sleep medication withdrawal program that provided education about sleep medication and a gradual medication withdrawal schedule. Ten medicated participants received stimulus control treatment and the withdrawal program, and 11 medicated participants served as a control group that received only the withdrawal program. Half of the nonmedicated participants received stimulus control, and the remaining nonmedicated participants served as a wait-list control condition. Medicated participants significantly reduced sleep medication use without significant deterioration on sleep, anxiety, or depression measures from baseline to 8-week follow-up. Stimulus control participants, unlike control group participants, showed significant improvement at follow-up for total sleep time, sleep efficiency, and sleep quality. Stimulus control participants also reported less daytime sleepiness than control participants after treatment. Nonmedicated participants exhibited a more positive response to stimulus control than medicated participants.
This study evaluates the efficacy of a cognitive-behavioral treatment for generalized anxiety disorder (GAD) that addresses two types of worries: (a) those about situations that are amenable to problem solving, and (b) those about situations that are not. The treatment's goal is to help patients become more tolerant of uncertainty by discriminating between both types of worry and applying the correct strategy to each type. A multiple baseline design was used and subjects were 4 adults with a primary diagnosis of GAD. Treatment outcome was assessed with daily self-monitoring, self-report questionnaires, and standardized clinician ratings. At posttest and 6-month follow-up, 3 of 4 subjects no longer met diagnostic criteria for GAD and had attained high end-state functioning. At 12-month follow-up, none of the subjects met GAD diagnostic criteria but end-state functioning was variable. The results also show that treatment outcome was highly related to change in intolerance of uncertainty.
Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.
The present study examined the usefulness of the Penn State Worry Questionnaire (PSWQ) as a means of screening for generalized anxiety disorder (GAD). Using receiver operating characteristic analyses, the accuracy of the PSWQ in screening for GAD was examined in both clinical and analogue diagnosed GAD samples. Given high comorbidity between GAD and other emotional disorders, we also investigated the usefulness of the PSWQ in selecting non-cases of GAD that were also free of PTSD, social phobia, or depression versus non-cases of GAD that met criteria for one of these conditions. The overall usefulness of the PSWQ as a screening device is discussed.
Little is known about lifetime prevalence or age of onset of DSM-IV disorders.
To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication.
Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview.
Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older.
Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders.
Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups.
About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.