Article

What, Me Worry and Ruminate About DSM-5 and RDoC? The Importance of Targeting Negative Self-Referential Processing

Clinical Psychology Science and Practice (Impact Factor: 2.92). 02/2013; 20:259-268. DOI: 10.1111/cpsp.12038

ABSTRACT

Rumination, worry, and other forms of negative self-referential processing are familiar to everyone, as reflecting on the self is perhaps our most human characteristic. However, for a substantial subgroup of patients, negative self-referential processing (NSRP) arises in response to intense emotionality, worsening the clinical presentation and diminishing the treatment response. The combination of emotionality and NSRP likely reflects the endophenotype of complicated and treatment refractory patients who fail to achieve a satisfactory treatment response in our trials and our clinics. An important next step is to personalize treatments by deliberately targeting NSRPs within established treatment protocols or in as yet novel treatments. Enriching treatments with mindfulness meditation is one possible avenue for personalized care of patients with this hypothesized endophenotype.

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    • "Generalized anxiety disorder (GAD) is highly comorbid with unipolar depressive disorders (UDD) including major depressive disorder and dysthymia (Hoffman et al. 2008; Kessler et al. 2005). Efforts to differentiate transdiagnostic from disorder-specific features of GAD and UDD continue to represent a challenge for both research and clinical efforts; perhaps consequently, these disorders tend to be most disabling and refractory to treatment when they cooccur (Barrera and Norton 2009; Garcia et al. 2015; Mennin and Fresco 2013; Zimmerman and Chelminski 2003). Given considerable genotypic and phenotypic overlap in addition to lifetime and concurrent comorbidity, some scholars suggest that GAD and UDD are better subsumed under a broader category of 'distress disorders' within a hierarchical structure of arousal and positive and negative affect (e.g., Brown et al. 2001; Gorwood 2004; Watson 2005). "
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    ABSTRACT: Generalized anxiety disorder (GAD) and unipolar depressive disorders (UDD) have been shown to differ from each other in dimensions of affective functioning despite their high rates of comorbidity. We showed emotional film clips to a community sample (n = 170) with GAD, GAD with secondary UDD, or no diagnosis. Groups had comparable subjective responses to the clips, but the GAD group had significantly lower heart rate variability (HRV) during fear and after sadness, compared to controls. While HRV in the GAD and control groups rose in response to the sadness and happiness clips, it returned to baseline levels afterwards in the GAD group, potentially indicating lesser ability to sustain attention on emotional stimuli. HRV in the GAD + UDD group changed only in response to sadness, but was otherwise unvarying between timepoints. Though preliminary, these findings suggest comorbid UDD as a potential moderator of emotional responding in GAD.
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    • "Received: 12 September 2013; accepted: 12 September 2013; published online: 08 October 2013. Citation: Proudfit GH, Inzlicht M and Mennin DS (2013) Anxiety and error monitoring: the importance of motivation and emotion. Front. "

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    ABSTRACT: The transdiagnostic approach states that there are key cognitive and behavioral processes responsible for maintaining symptoms and these are shared across psychological disorders (Harvey, Watkins, Mansell, & Shafran, 2004). The first goal of this article is to justify the potential utility of a transdiagnostic perspective for theory, research and treatment using empirical evidence and clinical vignettes. We then take as an example one set of cognitive processes-attentional processes-to illustrate the approach. Evidence for three attentional processes is provided: vigilance to external concern-related stimuli; vigilance to internal concern-related stimuli (self-focused attention) and attentional avoidance. It is concluded that each of these attentional processes are transdiagnostic. We then discuss three possible resolutions to the question: How can a transdiagnostic perspective be valid when the different psychological disorders present so differently? The three proposals are: (1) variations in idiosyncratic current concerns; (2) variations in the degree of shared processes and (3) distinct processes for specific disorders or groups of disorders. The role of a transdiagnostic approach in supporting the development and testing of theories of psychopathology is highlighted and the need for future studies that incorporate multiple patient groups is discussed.
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Questions & Answers about this publication

  • David M Fresco added an answer in Abnormal Psychology:
    Can anyone advise me on papers about how high levels of neuroticism can be a barrier to therapeutic treatment? And how this is best prevented.
    Especially for individuals in treatment for social anxiety disorder and major depression.
    David M Fresco
    Here is a paper by Olatunji and colleagues that is a meta-analysis showing how neuroticism complicates treatment for mood and anxiety disoders:

    Olatunji, B. O., Cisler, J. M., & Tolin, D. F. (2010). A meta-analysis of the influence of comorbidity on treatment outcome in the anxiety disorders. Clinical Psychology Review, 30(6), 642–654. doi:10.1016/j.cpr.2010.04.008.

    Here are a couple of papers that we have published that offer a theoretical account from an affect science perspective as to how and why:

    https://www.researchgate.net/publication/256419569_Emotion_Regulation_Therapy?ev=prf_pub

    https://www.researchgate.net/publication/248391117_What_me_worry_and_ruminate_about_DSM-5_and_RDoC_The_importance_of_targeting_negative_self-referential_processing?ev=prf_pub
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      ABSTRACT: Generalized anxiety disorder and major depression (often termed “distress disorders”; see Watson, 2005) are commonly comorbid and appear to be characterized by temperamental features that reflect heightened sensitivity to underlying motivational systems related to threat/safety and reward/loss. Further, individuals with these disorders tend to perseverate (i.e., worry, ruminate) as a way to manage this motivationally relevant distress and often utilize these self-conscious processes to the detriment of engaging new contextual learning. Emotion Regulation Therapy integrates principles from traditional and contemporary cognitive behavioral treatments (e.g., skills training & exposure) with basic and translational findings from affect science to offer a blueprint for improving intervention by focusing on the motivational responses and corresponding regulatory characteristics of individuals with distress disorders. This emphasis on affect science permits identification of candidate mechanisms of treatment in terms of core disruptions of normative cognitive, emotional, and motivational systems, which in turn, helps generate more targeted solutions for clients to utilize adaptive ways to cope or compensate for these core deficits. In essence, contrasting a client’s difficulties with what we understand as normative functioning allows us to generate theory-driven hypotheses that form that basis of our case conceptualization and treatment planning. Outcome and mechanism data provide preliminary support for the use of ERT to treat distress disorders.
      Full-text · Chapter · Dec 2013

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  • David M Fresco added an answer in Psychiatry:
    Which type of treatment is more effective for a generalized anxiety disorder, pharmacotherapy or psychotherapy?
    Which type of treatment is more effective for a generalized anxiety disorder, pharmacotherapy or psychotherapy?
    David M Fresco
    As much as I am a fan of mindfulness enriched treatments, and the one that I have worked on, emotion regulation therapy, contains a heavy dose of mindfulness, and has shown impressive efficacy for GAD and anxious depression, I hesitate to make blanket statements about mindfulness interventions without explaining some rationale for how and why they are likely to positively impact a condition such as GAD. The Evans et al implementation of MBCT for GAD, for instance was efficacious, but not more so than most CBTs. The Roemer and Orsillo ABBT treatment is quite promising and has some mindfulness elements, but not so much sitting practice, more mindfulness of every day life. Our ERT has formal sitting practice, which to the best of my knowledge is the first acute treatment to have that. Our trial papers need to find their way through the peer review process before I feel comfortable making claims, but we have published a couple of preliminary papers on ERT. https://www.researchgate.net/publication/235510892_Emotion_Regulation_Therapy_for_Generalized_Anxiety_Disorder?ev=prf_pub As for mechanisms, my rationale for mindfulness enriched treatments for GAD is that they may an especially well suited intervention to help overcome negative self-referential processing, which is quite common in GAD https://www.researchgate.net/publication/248391117_What_me_worry_and_ruminate_about_DSM-5_and_RDoC_The_importance_of_targeting_negative_self-referential_processing?ev=prf_pub
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      ABSTRACT: Despite the success of cognitive behavioral therapies (CBT) for emotional disorders, a sizable subgroup of patients with complex clinical presentations, such as patients with generalized anxiety disorder, fails to evidence adequate treatment response. Emotion Regulation Therapy (ERT) integrates facets of traditional and contemporary CBTs, mindfulness, and emotion-focused interventions within a framework that reflects basic and translational findings in affect science. Specifically, ERT is a mechanism-targeted intervention focusing on patterns of motivational dysfunction while cultivating emotion regulation skills. Open and randomized controlled psychotherapy trials have demonstrated considerable preliminary evidence for the utility of this approach as well as for the underlying proposed mechanisms. This article provides an illustration of ERT through the case of “William.” In particular, this article includes a case-conceptualization of William from an ERT perspective while describing the flow and progression of the ERT treatment approach.
      Full-text · Article · Feb 2013 · Cognitive and Behavioral Practice

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