Mastery of Your Anxiety and Panic: Therapist GuideTherapist Guide
Abstract
This edition of the Mastery of Your Anxiety and Panic: Therapist Guide provides therapists with all the tools necessary to deliver effective treatment for panic disorder and agoraphobia. It provides step-by-step instructions for teaching clients the skills to overcome their fear of panic and panic attacks. The book also presents case vignettes as well as techniques for addressing atypical and problematic responses. The program, organized by skill, makes treatment able to be tailored to the individual. It also includes a chapter for adapting the treatment for effective delivery in six sessions within primary care or related settings. Although written for the client, the program is recommended to be carried out under the supervision of a mental health professional.
... The therapist begins by discussing the panic symptoms with the patient and highlights how the physiological, cognitive, and behavioral components interact within the CBT model of panic disorder. 19 The symptoms of panic (e.g., rapid heart rate, shortness of breath, and trembling) are explained as part of our body's natural defense system that prepares us for "fight or flight" in the presence of a real threat. When these symptoms arise in the context of a real danger, the response helps us to survive. ...
... For example, a review of the state of evidence for trichotillomania supports the behaviorally based treatment of habit reversal training, as well as enhancements with CT, DBT, and ACT. 44 Another issue in the field of cognitive-behavioral psychology is that there are two seemingly contradictory movements in the field-one toward developing more specialized treatments for specific disorders 19 and the other toward developing treatments that are more broadly applicable across different diagnostic categories, such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders. 45 The Unified Protocol is consistent with the initiative known as the Research Domain Criteria, which calls for researchers to conceptualize psychopathology in more dimensional ways through observable behavior and neurobiological measures. ...
... CBT is an empirically supported intervention and is the treatment of choice for patients with a wide variety of conditions. 19 More recent developments in CBT incorporate skills, such as mindfulness or values work, to address transdiagnostic processes. Despite its research support, CBT has not been widely adopted by community practitioners, primary care settings, or pharmacotherapists. ...
... Compared to no-treatment and treatment as usual, cognitive behavioral therapy (CBT) and other bona fide psychotherapeutic interventions are available to effectively treat individuals with GAD (e.g., Hanrahan, et al., 2013;van Dis et al., 2020). Moreover, the updated "Mastery of Your Anxiety and Worry" package (MAW-package; Zinbarg et al., 2006) is widely used for the treatment of GAD and was evaluated in randomized-controlled trial conditions (e.g., Avdagic et al., 2014;Flückiger, et al., 2016;Westra et al., 2016;Zinbarg et al., 2007). ...
... Using an ABAB crossed-therapist randomized clinical implementation trial design (see Figure A in the supplementary material), we contrast the following two implementation conditions (see study protocol : Flückiger et al., 2018): (a) State-Of-The-Art (SOTA) implementation, where the check-in phase at the beginning of each session primarily focuses on CBT session-agenda setting and review of last session's homework assignments that may cover a short exploration of changes; (b) Prolonged Focus on Change (PFC) implementation, where the check-in phase allows the therapist a more prolonged focus on collaboratively exploring the patient's change by a systematic intervention sequence (i.e., exploration of patient's behaviors, emotional states, helpful thoughts, changes in the generalized selfefficacy, and potential clinical implications of the change having occurred) Figure B in the supplementary material). The main difference between the two bona fide CBT implementation conditions lies in the attentional focus on and in the systematization of how the therapists explore occurring changes within the usually recommended session-structure (see Zinbarg et al., 2006). ...
... The MAW-package encompasses CBT interventions Zinbarg et al., 2006). This internationally well-known CBT-package for GAD typically consists of psychoeducation on generalized anxiety disorder, relaxation training (RT) and/or mindfulness exercises, cognitive restructuring (CR) and in vivo situational exposure for patients with overt behavioral avoidance. ...
Objective:
There is little evidence-based knowledge of how psychotherapists should handle both sudden gains and more gradual session-by-session changes, either in general or in individuals suffering from generalized anxiety disorder.
Methods:
Using an ABAB crossed-therapist randomized clinical implementation trial design (N = 80 patients and 20 therapists), we contrasted a Prolonged Focus on Change (PFC, N = 40) implementation with a State-Of-The-Art (SOTA, N = 40) implementation. Both implementations were based on a widely used cognitive behavioral therapy approach (Mastery of your Anxiety and Worry package) with the only difference that in the PFC implementation, the therapists were instructed to systematically explore eventual changes at the beginning of the therapy sessions.
Results:
Based on a 3-level hierarchical linear model, PFC implementation showed faster symptom reduction in worry over therapy (i.e., linear change) and a decelerated (quadratic) change until 12-month follow-up in comparison to the SOTA implementation.
Conclusion:
These findings provide clinically useful information about potential short-term and long-term effects of exploring occurring change in GAD populations. Randomized clinical implementation trial designs are a step forward allowing to experimentally investigate basic psychotherapeutic strategies in process-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... The following case study details the implementation of a traditional CBT manualized treatment for GAD while incorporating mindfulness-and acceptance-based principles in the treatment of a white, American male with GAD. Treatment involved use of the Mastery of Your Anxiety and Worry manual , an empirically supported CBT treatment for GAD (Zinbarg et al., 2006), while integrating mindfulness and acceptance components from Learning ACT: An Acceptance and Commitment Therapy Skills-Training Manual for Therapists (Luoma et al., 2007). Furthermore, this case study details the implementation of this treatment as it shifted from in-person to telehealth due to the COVID-19 pandemic. ...
... While he reported several depressive symptoms, given the overlap in his depressive symptoms with his GAD symptoms (e.g., difficulty sleeping, difficulty concentrating), assessment data, and the situational nature, a mood disorder diagnosis was not provided at intake nor during treatment. Fred's case conceptualization is based on the Mastery of Your Anxiety and Worry: Therapist Guide (Zinbarg et al., 2006) which is derived from the theoretical models by Barlow (2002) and Zinbarg (1998). Fred's developmental learning history reinforced a belief that he was "not good enough," "incompetent," and "bad." ...
Generalized Anxiety Disorder (GAD) can be chronic and impairing, highlighting the need for effective treatments. Although Cognitive Behavior Therapy (CBT) is an effective treatment for GAD, a number of patients continue to report GAD symptoms treatment. Integrating evidenced-based treatment components into CBT treatments, such as mindfulness- and acceptance-based treatment components found in Acceptance and Commitment Therapy (ACT), may help improve the efficacy of treatment. Emerging interventions and research suggest that the cognitive restructuring aspect of CBT and acceptance stance of ACT (e.g., cognitive defusion) can be implemented into treatment concurrently from a stance of increasing a patient’s coping skills repertoire and psychological flexibility. This systemic case analysis examined the efficacy and clinical utility of integrating ACT into a manualized CBT treatment for GAD. Furthermore, this study examined treatment efficacy and therapeutic alliance as the treatment rapidly and unexpectedly transitioned from in-person to telehealth due to the COVID-19 pandemic. Pre- to post-treatment and time-series analyses showed significant decreases in anxiety symptoms, worry, depressive symptoms, and emotion dysregulation. Although there was an initial increase in depressive and anxiety symptoms, worry, and emotion dysregulation following the switch from in-person to telehealth services, these quickly subsided and resumed a downward trend. The therapeutic relationship did not deteriorate during the transition to telehealth. This case study provides evidence of feasibility and efficacy of an integrated CBT/ACT approach in treating GAD. It also suggests that despite some temporary increase in symptoms, therapeutic alliance and treatment efficacy were not impacted by the switch to telehealth.
... Identifier: NCT03079336). Both conditions were based on the Mastery of your Anxiety and Worry package (MAW-package; Zinbarg et al., 2006), a widely used CBT approach. The MAW package for GAD typically comprises psychoeducation, relaxation training and/or mindfulness exercises, cognitive restructuring, and imagery and in vivo situational exposure. ...
... A total of 20 graduate-level psychologists were recruited from local postgraduate CBT training centers. Therapists and supervisors were trained according to the most recent version of the MAW package in an initial 16 h workshop presented by one of the MAW-package co-authors Zinbarg et al., 2006). Additionally, therapists participated in a 2 h study supervision in small groups on a biweekly basis. ...
Objectives:
There is limited information on how a change in patients' expectations over time results in symptom change in psychotherapy. This study aimed to investigate the changes in patients' expectations and symptoms during treatment and across follow-up as well as to determine the within- and between-patient relationships between two types of patient expectations, that is, self-efficacy and outcome expectation, and symptom change.
Methods:
Participants (80 participants × 6 repeated measures; 480 observations) with generalized anxiety disorder were treated using cognitive behavioral therapy and the within- and between-patient scores of self-efficacy and outcome expectation were evaluated in multilevel models as predictors of symptom change.
Results:
Patients' self-efficacy and outcome expectation increased, whereas severity of their symptoms reduced during and after treatment. At the within-patient (WP) level, an increase in self-efficacy was associated with a decrease in worry and depressive symptoms, and an increase in outcome expectation was associated with a decrease in depressive symptoms. The between-patient (BP) effect, however, was contrary to the WP effect, that is, self-efficacy was positively correlated with worry and outcome expectation was positively correlated with depressive symptoms CONCLUSION: These results highlight the importance of disaggregating the WP variability from BP variability in psychotherapy process-outcome research as they exhibit different associations at the within- and between-patient levels. Clinical Trial Registration: ClinicalTrial.gov (NCT03079336).
... The CBT treatments were based on the "Mastery of Your Anxiety and Worry" protocol (MAW; Craske & Barlow, 2006;Zinbarg, Craske & Barlow, 2006). The treatment included psychoeducation about worry and GAD, mindfulness and/or relaxation exercises, cognitive restructuring, and either imaginary exposure (for patients with subtle experiential avoidance behaviors) or in vivo exposure (for patients with open behavioral avoidance). ...
... The CBT treatments were based on the "Mastery of Your Anxiety and Worry" protocol (MAW; Craske & Barlow, 2006;Zinbarg, Craske & Barlow, 2006). The treatment included psychoeducation about worry and GAD, mindfulness and/or relaxation exercises, cognitive restructuring, and either imaginary exposure (for patients with subtle experiential avoidance behaviors) or in vivo exposure (for patients with open behavioral avoidance). ...
Objective:
This study aimed to investigate the effects of changes in interpersonal cognitions on outcome during cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) and how these effects are moderated by patients' interpersonal problems at intake.
Method:
A sample of 80 adult patients diagnosed with GAD who were undergoing CBT within a randomized controlled trial completed a questionnaire concerning interpersonal problems at baseline as well as measures of changes in interpersonal and self-related cognitions and in worry severity session by session. We conducted dynamic structural equation modeling to estimate cross-lagged within-patient effects of changes in interpersonal cognitions on worry, adjusting for the effects of self-related cognitions. Furthermore, we included interpersonal problems as a moderator of the effects of changes in interpersonal cognitions.
Results:
We found significant cross-lagged effects of changes in both interpersonal cognitions and self-related cognitions on subsequent worry levels. Greater changes in interpersonal cognitions and self-related cognitions in a given session were associated with lower worry levels at the beginning of the next session. When adjusting for self-related cognitions, the effects of changes in interpersonal cognitions on subsequent worry remained significant. However, there were no interactive effects of changes in interpersonal cognitions by patients' interpersonal problems on worry severity.
Conclusions:
The results present evidence supporting changes in interpersonal cognitions and self-related cognitions as relevant change mechanisms in CBT for GAD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... All therapy sessions were videotaped, and each session lasted for up to 90 minutes (some of the sessions were held partially or entirely outside the laboratory to perform exposure). Treatment was based on the protocol of Barlow et al. (2007) for treating PD with additions (Huppert and Baker-Morisette, 2003). All components of the protocol were implemented except those of the breathing and relaxation exercises because of the lack of empirical basis of effectiveness (Craske et al., 1997;Schmidt et al., 2000). ...
... The CBTPS is based on a number of principles. First, it is based on the ideas underlying the protocol of Barlow et al. (2007) for treating PD. The treatment focuses on re-evaluating situations by understanding the nature of the disorder, identifying and challenging biased thoughts (particularly of probability over-estimation and catastrophizing), and coping with fear by being exposed to anxiety-provoking triggers and situations (interoceptive and in vivo). ...
Background
Research has long investigated the cognitive processes in the treatment of depression, and more recently in panic disorder (PD). Meanwhile, other studies have examined patients’ cognitive therapy skills in depression to gain insight into the link between acquiring such skills and treatment outcome.
Aims
Given that no scale exists to examine in-session patient use of panic-related cognitive behavioural therapy (CBT) skills, the aim of this study was to develop a new measure for assessing patients’ cognitive and behavioural skills in CBT for PD.
Method
This study included 20 PD patients who received 12 weekly individual therapy sessions. The Cognitive Behavioral Therapy Panic Skills (CBTPS) rating system was developed. Three independent raters coded tapes of therapy sessions at the beginning and end of treatment.
Results
The coefficient alphas and inter-rater reliability were high for the cognitive and behavioural subscales. Improvement in the patients’ CBTPS scores on both subscales indicated overall symptom improvement, above improvement in anxiety sensitivity.
Conclusion
To our knowledge, this is the first study examining the impact of patient acquisition of CBT PD skills on treatment outcome. A new measure was developed based on the observations and was deemed reliable and valid. The measure facilitates the examination of the mechanisms of change in treatment for PD. An in-depth examination of the CBTPS may refine our understanding of the impact of each skill on PD treatment outcome. Further research relating to acquiring CBT skills could shed light on the mechanisms of change in treatment.
... Fortunately, cognitive behavioral therapy (CBT) has emerged as a supported treatment for adolescent PDA. Specifically, a developmental adaptation of Panic Control Treatment (PCT; Barlow, Craske, Cerny, & Klosko, 1989;Craske & Barlow, 2006), a wellestablished cognitive-behavioral intervention for PDA in adults, has shown considerable efficacy in the treatment of adolescent PDA (Hoffman & Mattis, 2000;Pincus, May, Whitton, Mattis & Barlow, 2010). Results of a randomized control trial (RCT) demonstrated that youth receiving the adolescent version of the treatment, PCT-A, showed significantly greater reductions in panic frequency and severity relative to youth in a waitlist control condition (Pincus et al., 2010). ...
... Silverman & Albano, 1997) emphasize a thorough evaluation of the extent of a child's fear and avoidance to inform PDA diagnostic impressions and decisions about clinical severity. Moreover, in the evidence-based treatment of PDA, fear and avoidance are central treatment targets for both adults (Barlow & Craske, 2000;Craske & Barlow, 2006) and children (Pincus, Ehrenreich, Mattis, & Barlow, 2008), and are addressed through the development of a fear and avoidance hierarchy that subsequently provides a roadmap for exposures across treatment. Given the centrality of fear and avoidance in the identification and treatment of youth with PDA, it is possible that heterogeneity across children's baseline levels of fear and avoidance are meaningfully linked to heterogeneity in treatment response. ...
Background
Research supports the efficacy of intensive cognitive behavioral therapy (CBT) for the treatment of adolescent panic disorder with or without agoraphobia (PDA). However, little is known about the conditions under which intensive treatment is most effective. The current investigation examined the moderating roles of baseline fear and avoidance in the intensive treatment of adolescent PDA.Methods
Adolescents with PDA (ages 11–17; N = 54) were randomized to either an intensive CBT treatment (n = 37) or a waitlist control condition (n = 17). PDA diagnosis, symptom severity, and number of feared and avoided situations were assessed at baseline and 6-week posttreatment/postwaitlist. Hierarchical regression analyses examined the relative contributions of treatment condition, number of baseline feared or avoided situations, and their interactions in the prediction of posttreatment/waitlist PDA symptoms.ResultsThe main effect of intensive CBT on posttreatment PDA symptoms was not uniform across participants, with larger treatment effects found among participants with lower, relative to higher, baseline levels of fear and avoidance.Conclusions
Findings help clarify which adolescents suffering with PDA may benefit most from an intensive treatment format.
... CBT therapies were grounded in the "Mastery of Your Anxiety and Worry" protocol (MAW; Zinbarg et al., 2006). As the primary intervention, treatments included (i) psychoeducation regarding generalized anxiety disorder and worry overall, (ii) cognitive restructuring, (iii) relaxation and/or mindfulness exercises, and (iv) exposure (either imaginary or in vivo). ...
Objective:
This study explores in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) to what degree therapists' perceptions of their patients as interpersonally challenging (IC) is explained by the therapist or patient effects, if baseline patients' characteristics predict IC, and if IC is related to outcome.
Method:
Eighty patients diagnosed with GAD and treated by 20 therapists with 16 sessions of CBT were randomized to two different implementation conditions. Patients completed baseline measures of depression, anxiety, interpersonal problems, and interpersonal strengths. The therapists completed a single-item assessing IC session-by-session. As an outcome, patients completed a worry measure at baseline, session 5, session 10, and posttreatment.
Results:
Multilevel models showed meaningful therapist effects, explaining 18% of IC variance. Interpersonal strengths were the only baseline predictor significantly and negatively associated with IC during treatment. Structural equation models showed significant negative IC effects on subsequent patient worry during therapy.
Conclusions:
IC might represent a risk factor for psychotherapy outcome. Patient interpersonal strengths at baseline may buffer therapists perceiving their patients as ICs. The therapist effects on IC suggest that CBT clinicians treating GAD might benefit from identifying cases that are interpersonally challenging for them and reflecting about what might trigger that perception.
... The Hyperventilation Challenge is a validated measure tapping into anxiety sensitivity. Hyperventilation is a standard interoceptive exposure exercise in CBT for anxiety disorders, particularly panic disorder (Craske & Barlow, 2006;Schmidt & Trakowski, 2005), and it induces panic-and anxiety-related interoceptive sensations. After a demonstration by the assessor and a 10-sec "practice trial" of fast breathing, participants were asked to "overbreathe" with a metronome set to 80 bpm for an undisclosed 60 s. ...
Introduction
Cannabis use disorder (CUD) is a growing public health concern, and is highly comorbid with negative affective conditions such as anxiety and depression. Late adolescence and early adulthood represents a time of rapid emotion regulation development, as well as the onset of anxiety, mood, and substance use disorders, especially CUD. Maladaptive cognitive, behavioral, and emotional responding to one's own negative affect (in an effort to eliminate it) is associated with substance use, and represents a novel treatment target to improve outcomes of treatment for substance misuse. Method: After development of a manual for a novel intervention, Affect Management Treatment (AMT) for CUD, a pilot randomized clinical trial was conducted in 18–25 year-old participants with CUD to evaluate the impact of this approach on negative affect, constructs (e.g., distress intolerance) representing maladaptive reactivity to negative affect, and cannabis use. Participants (N = 52) received either 12 sessions of standard cognitive behavioral therapy (CBT) for CUD or 12 sessions of AMT and were assessed on measures of negative affect, reactivity to negative affect, cannabis use, and cannabis use problems at baseline, throughout treatment, post-treatment, and 6-mo follow-up. Results: AMT outperformed CBT in reducing negative affect and reactivity to negative affect, and it had a significant impact on cannabis use and cannabis use problems. There were no statistically significant between-group differences on cannabis outcomes. Conclusions: AMT offers a novel, successful approach to the treatment of CUD.
... CBT. Treatment was adapted from several evidence-based protocols (e.g., Zinbarg et al., 2006), and emphasized psychoeducation around anxiety and worry, progressive muscle relaxation, self-monitoring, cognitive restructuring, and behavioral strategies (e.g., behavioral experiments, imaginal exposure). Procedures for CBT-consistent management of homework noncompliance from the literature were used and made explicit (e.g., Beck, 2005;Kazantzis & Shinkfield, 2007). ...
Objective
Although therapist supportive, rather than directive, strategies have been particularly indicated during client resistance, little systematic research has examined how therapists responsively navigate resistance in different therapy approaches and how this responsiveness is related to outcome.
Method
In the context of disagreement episodes in cognitive–behavioral therapy (CBT) for generalized anxiety disorder (GAD; Westra, H. A., Constantino, M. J., & Antony, M. M. Integrating motivational interviewing with cognitive–behavioral therapy for severe generalized anxiety disorder: An allegiance-controlled randomized clinical trial. Journal of Consulting and Clinical Psychology, 84(9), 768–782. https://doi.org/10.1037/ccp0000098, 2016), the present study examined (1) the degree to which therapist management of resistance differed between therapists trained in CBT integrated with motivational interviewing (MI-CBT; i.e., training centered on the responsive management of resistance) and therapists trained in CBT-alone, and (2) the impact of specific therapist behaviors during disagreement on client worry outcomes immediately posttreatment and 1-year posttreatment. Episodes of disagreement were rated used the Structural Analysis of Social Behavior (Benjamin, L. S. Structural analysis of social behavior. Psychological Review, 81(5), 392–425. https://doi.org/10.1037/h0037024, 1974).
Results
Therapists trained in MI-CBT were found to exhibit significantly more affiliative and fewer hostile behaviors during disagreement compared to those trained in CBT-alone; both of these, in turn, were found to mediate client 1-year posttreatment outcomes, such that increased affiliation during disagreement was associated with improved outcomes.
Conclusion
This study highlights the value of training therapists in the responsive detection and management of resistance, as well as the systematic integration of MI into CBT.
... procedure Participants randomized to the SDP condition received one of the following treatment protocols: Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach (Hope et al., 2006(Hope et al., , 2010, Mastery of Your Anxiety and Panic, (Craske & Barlow, 2007), Mastery of Your Anxiety and Worry (Zinbarg et al., 2006), and Treating Your Obsessive-Compulsive Disorder With Exposure and Response (Ritual) Prevention Therapy (Foa et al., 2012). The SDPs varied in content and number of sessions focused on a given therapeutic strategy, but each SDP included psychoeducation, exposure, and relapse prevention-with the exception of the OCD SDP-all SDPs also included cognitive restructuring. ...
Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. Better understanding when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examine dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.
... Mastery of Your Anxiety and Worry, second edition [8]; Treating Your Obsessive-Compulsive Disorder With Exposure and Response (Ritual) Prevention Therapy, second edition [9]; and Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach, second edition [10]. ...
Objective
To examine whether the Unified Protocol (UP) remains equivalent to single-disorder protocols (SDPs) in the treatment of anxiety disorders at 12-month follow-up.
Method
We report results from the 12-month follow-up of a recent randomized equivalence trial [1]. Data are from 179 participants (55.31% female sex, 83.24% White, average age 30.66) who met criteria for a principal anxiety disorder and were randomized to either the UP or SDP conditions. Consistent with the parent trial, the primary outcome was principal diagnosis clinician severity rating (CSR) from the Anxiety Disorder Interview Schedule (ADIS). Secondary outcomes included anxiety, depression, and impairment. Missing data were accommodated using multiple imputation (10,000 imputed data sets) under a missing at random assumption. Equivalence between the UP and SDPs was tested using slope difference scores from latent growth models and 95% confidence interval of between-condition effect sizes.
Results
The results indicated that the UP and SDP conditions remained equivalent with regard to principal diagnosis clinician severity rating at 12-month follow-up. In addition, there were no significant differences between conditions on secondary outcomes at 12-month follow-up.
Conclusions
The UP continues to yield outcomes comparable to SDPs at 12-month follow-up, and therefore provides a single intervention that can be used to treat the most commonly occurring psychiatric disorders with durable effects.
... The treatment was adapted from established, evidence-based CBT protocols (e.g. Zinbarg, Craske, & Barlow, 2006). The treatment involved progressive muscle relaxation, self-monitoring training, psychoeducation regarding worry and anxiety, cognitive restructuring, and behavioural interventions. ...
Client characteristics are widely understood to influence alliance development. However, few studies have examined the role of client ambivalence about therapeutic change. Building on past research demonstrating associations between ambivalence and therapy relationship variables, such as resistance, this study examined whether greater ambivalence was associated with poorer alliance quality. Further, it examined whether motivational interviewing (MI), which involves strategies for managing ambivalence, moderated this relationship. Using data from a randomised controlled trial of cognitive‐behavioural therapy (CBT) for 71 individuals who completed treatment for generalised anxiety disorder, this study tested whether ambivalence, operationalised as observed motivational language against change (counter‐change talk; CCT), in session 1 was related to client‐rated alliance quality over time, and whether this relationship varied between two treatments: MI integrated with CBT (MI‐CBT) or CBT alone. CCT predicted lower client alliance ratings at the early, middle and late stages of therapy. At the late stage, treatment group was a significant moderator, such that CCT was associated with poorer alliances for CBT alone, but not for MI‐CBT. Results suggest that early ambivalence can predict early and middle phase alliance problems in both treatments and that, without explicit strategies for managing ambivalence, early CCT is strongly associated with poorer alliances during the late stage of CBT treatment. This research highlights the importance for clinician responsivity to early motivational markers.
... The treatment manual was derived from several evidence-based protocols of CBT for GAD (e.g. Coté & Barlow, 1992;Zinbarg, Craske, & Barlow, 2006), and included psychoeducation regarding anxiety and worry, progressive muscle relaxation, training in self-monitoring, cognitive restructuring (i.e. with a focus on probability overestimation and catastrophic thinking) and one or more additional behavioural strategies (e.g. behavioural experiments, reduction of worry behaviours, imaginary exposure to feared outcomes). ...
Greater client resistance has been consistently found to be negatively associated with outcome in psychotherapy. However, the pathways through which resistance impacts such outcomes are underexplored. Given that client outcome expectation (OE) has been identified as an important common factor in psychotherapy, the goals of the present study were to examine: (a) the impact of resistance on subsequent client and therapist OE (COE & TOE, respectively); and (b) whether COE and/or TOE mediate the relationship between resistance and outcome. These relationships were tested among 44 clients with severe generalised anxiety disorder treated with cognitive‐behavioural therapy in the context of a randomised controlled trial (Westra, Constantino, & Antony, 2016). Resistance was measured at a mid‐treatment session, and COE and TOE were assessed at baseline and immediately after the resistance session. Treatment outcome was measured via client‐rated worry severity at post‐treatment. As predicted, higher resistance was associated with lower subsequent COE and TOE; B = −.73, p < .001 and B = −.46, p < .001, respectively. In turn, lower post‐resistance COE predicted higher post‐treatment worry (B = −.5, p < .001), indicating mediation. In contrast, TOE did not mediate the relationship between resistance and outcome (B = −.02, p = .876). These results suggest that resistance can be demoralising to both clients and therapists. However, only lower client morale may be detrimental to therapy outcome. This study contributes to understanding outcome pathways through two common therapy processes.
... While emotional reactivity can be adaptive to some extent, excessive negative anticipation may affect the development and maintenance of psychiatric symptoms (Galli et al., 2014). Sustained anticipatory anxiety, for instance, constitutes one core symptom of generalized anxiety disorder further facilitating the development and maintenance of anxiety symptoms (Zinbarg et al., 2006). Previous research on sustained anticipatory anxiety in rodents and healthy adults points to a neural dissociation of phasic and sustained brain responses to threat anticipation (Davis et al., 2010;Herrmann et al., 2016). ...
... The CBT condition involved psychoeducation, self-monitoring, cognitive strategies, progressive muscle relaxation, and additional behavioral interventions. Specifically, treatment was adapted from evidence-based protocols by Barlow and colleagues (e.g., Coté & Barlow, 1992;Zinbarg, Craske, & Barlow, 2006) that were based on Borkovec's work (e.g., Borkovec & Costello, 1993;Borkovec et al., 1987). Treatment targeted the core features of GAD such as excessive worry, positive beliefs about the utility of worry, catastrophic thinking patterns, and avoidance of emotional material. ...
Clients with generalized anxiety disorder (GAD) that demonstrate observer-coded treatment ambivalence benefit from the addition of motivational interviewing (MI) to cognitive behavioral therapy (CBT; Button, Westra, Constantino, & Antony, 2016). While observer-coded assessment of ambivalence and readiness for change is resource-intensive, the present study investigates the use of more efficient self-report measures to predict treatment outcomes. Participants ( N = 85) with GAD received CBT or MI-CBT and completed self-report measures of readiness for change (Change Questionnaire, Miller & Johnson, 2008) and ambivalence (Treatment Ambivalence Questionnaire, Purdon, Rowa, Gifford, McCabe, & Antony, 2012). Greater self-reported baseline readiness for change was associated with lower posttreatment worry and symptom severity and faster reduction in worry. Self-reported ambivalence was not associated with outcomes. Patients with less concern about adverse consequences of treatment who received CBT experienced greater increases in readiness for change than those receiving MI-CBT. We discuss implications for using these measures in clinical settings.
... The CBT framework takes a much more didactic approach than dynamic treatment, using techniques such as psychoeducation, cognitive re-framing, and exposure, including interoceptive exposure and in vivo exposure. In the process, CBT aims to impart patients with a new and improved knowledge of skills to be implemented in the face of panic symptoms including interpersonal problems (e.g., avoidance of social interactions), thus allowing for improved functioning (Zinbarg et al. 2006). ...
Objective:
To investigate whether (a) baseline levels of panic-specific reflection function (PSRF; i.e. patients' capacity to reflect on their panic symptoms) and improvement in this capacity over treatment; (b) baseline borderline personality disorder (BPD) traits and pre-post treatment improvement in BPD traits predict change in patients' quality of object relations.
Method:
A subsample of 102 patients diagnosed with panic disorder from a larger randomized controlled trial received either Cognitive-Behavioral Therapy or Panic-Focused Psychodynamic Psychotherapy. We investigated whether baseline levels and change in both PSRF and BPD traits (as measured by the SCID-II) predicted pre-post change in quality of object relations (QOR), while controlling for pre-post treatment change in panic symptoms assessed by the Panic Disorder Severity Scale.
Results:
In both treatments, higher baseline levels of PSRF and lower levels of BPD traits, as well as pre-post decrease in BPD traits, predicted improvement in QOR when controlling for symptomatic change.
Conclusions:
The findings suggest that reduction in comorbid BPD traits can facilitate improvement in patients' quality of object relations even in brief symptom-focused psychotherapies. Additionally, patients with higher baseline levels of symptom-focused reflective function and lower BPD traits are more likely to demonstrate interpersonal change over the course of psychotherapy for panic disorder. Finally, our study highlights the importance of examining therapeutic change beyond reduction in symptoms, particularly in domains of interpersonal functioning.
... Substantial research implicates safety behaviors in the development and maintenance of clinical anxiety (Helbig-Lang & Petermann, 2010). Accordingly, safety behaviors are traditionally eliminated as soon as possible during cognitive-behavioral therapy (CBT) for anxiety and related disorders (e.g., Abramowitz & Jacoby, 2015;Antony, Craske, & Barlow, 1995;Craske & Barlow, 2007;Foa, Hembree, & Rothbaum, 2007). Although experts have offered multiple explanations for safety behaviors' deleterious effects on CBT outcome (for a review, see Blakey & Abramowitz, 2016), safety behaviors are primarily thought to prevent the correction of mistaken/maladaptive beliefs. ...
People with anxiety-related disorders often engage in safety behaviors: overt or covert actions performed to prevent the occurrence of a feared outcome and/or reduce associated distress. Although clinical experience and conceptual models of posttraumatic stress disorder (PTSD) underscore the deleterious long-term effects of such strategies on PTSD symptoms, little empirical research has specifically examined safety behaviors in the context of posttraumatic stress. The current multi-site study was designed to identify common posttraumatic safety behaviors and examine their relation to symptom severity. Interview and self-report data were collected from adults residing in the Western United States (U.S.) reporting ongoing distress related to a lifetime traumatic event (n = 89) as well as from adults with a current PTSD diagnosis residing in the Southeastern U.S. (n = 47). Results showed that posttraumatic safety behaviors were not only common in both groups, but significantly correlated with trauma-related cognitions (rs ranged .39-.45), self-reported PTSD symptoms (rs ranged .56-.72), and interviewer-rated PTSD symptoms (rs ranged .32-.51). Findings point to specific posttraumatic coping strategies that would be important to consider in a clinical context.
© 2019, American Psychological Association. This paper is not the copy of record and may not exactly replicate the final, authoritative version of the article. Please do not copy or cite without authors' permission. The final article will be available, upon publication, via its DOI: 10.1037/trm0000205
... For example, numerous disorder-specific protocols, all classified as cognitive-behavioral therapies (CBTs), have been developed to address a wide array of psychopathologies, including PTSD, anxiety disorders, SUD, and depression (Back et al., 2015;Beck, 2011;Craske & Barlow, 2007;Epstein & McCrady, 2009;Foa, Hembree, & Rothbaum, 2007;Foa, Yadin, & Lichner, 2012;Hope, Heimberg, & Turk, 2000;Martell, Dimidjian, & Herman-Dunn, 2010). Each of these CBTs employs similar treatment techniques. ...
... Also, the processes targeted by each intervention (e.g., intolerance of uncertainty, experiential avoidance) changed in a similar manner across groups. This study, however, focused only on group therapy and compared ACT with CBT following the protocol of Zinbarg, Craske, Barlow, and O'Leary (1993), which is closer to the beckian approach. ...
Objective
Cognitive‐behavior therapy (CBT) is considered the “golden standard” psychotherapy for generalized anxiety disorder (GAD) but, at this point, we have little information about differences among various CBT approaches.
Method
We conducted a randomized controlled trial to compare three CBT protocols for GAD: (a) Cognitive Therapy/Borkovec's treatment package; (b) Rational Emotive Behavior Therapy, and (c) Acceptance and Commitment Therapy/Acceptance‐based behavioral therapy. A number of 75 patients diagnosed with GAD, aged between 20 and 51 (m = 27.13; standard deviation = 7.50), 60 women and 11 men, were randomized to the three treatment arms.
Results
All treatments were associated with large pre‐post intervention reductions in GAD symptoms and dysfunctional automatic thoughts, with no significant differences between groups. Correlation analyses showed similar associations between changes in symptoms and changes in dysfunctional automatic thoughts.
Conclusions
All three approaches appear to be similarly effective. Implications for the theoretical models underlying each of the three cognitive‐behavior therapy approaches are discussed.
... The first, second, and fourth authors developed a list of criteria by which the content of the commercially available applications would be reviewed. These criteria were designed to be trans-theoretical and reflect empirically supported content domains of existing cognitive-behavioral treatments for depression, anxiety disorders, PTSD, and alcohol use disorders (Foa et al. 2007;Zinbarg et al. 2006;Epstein and McCrady 2009;Gilson et al. 2009), and are consistent with similar work conducted on applications designed for anxiety and worry (Kertz et al. 2017). Broad domains for the criteria included (a) correct psychoeducation about symptoms, the disorder, and/or its treatment; (b) self-monitoring of symptoms, moods, thoughts, or behaviors; (c) personalized feedback or recommendations following an assessment of the consumer's symptoms; (d) cognitive techniques such as cognitive restructuring, mindfulness training, motivational enhancement, and identifying values or high-risk situations (in the case of alcohol use disorder); and (e) behavioral techniques such a guided relaxation/breathing, exposure exercises, behavioral activation, development of coping plans, goal setting, contingency management, or building social support. ...
Link to full article: https://rdcu.be/bA3W7
Objective: The primary objectives of this paper were to 1) review empirical support for existing self-help smartphone applications for depression, anxiety, PTSD, and alcohol use disorders; 2) and evaluate whether commercially available self-help applications offer, or were derived from, empirically supported approaches; and 3) provide a framework for evaluating applications for use in the absence of existing empirical support.
Methods: We performed a systematic review of existing applications via PubMed and performed a content analysis, based on theoretically-grounded evidence-based review criteria, on each commercially available application retrieved from Google Play and Apple Store searches. Seventeen academic papers met inclusion criteria and were evaluated; only four empirically supported applications were available commercially. Of the commercial applications, one was found via the PubMed search.
Results: While the majority of the smartphone applications evaluated in the content analysis included at least one empirically-supported component, there was great variability in how comprehensive the integrated tools were, and a significant proportion included non-evidence-based tools.
Conclusions: In this study, we found that evidence-based applications are often not available to the general public and those that are available offer varying degrees of empirically-derived tools. These findings unveil a new “research-practice gap” at the intersection of mental health and emergent technology-based interventions. As research attempts to keep pace with emergent intervention technologies, we provide suggestions to consumers and clinicians for reviewing these applications, and for future research in the service of reducing the “research-practice gap.”
... All participants were assigned one principal diagnosis after administration of a diagnostic interview (see Measures below); if randomized to the SDP condition, the principal diagnosis determined which SDP the participant received. SDPs included: 1) SAD: Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach -2nd edition (MSA-II; Hope et al., 2006;Hope et al., 2000); 2) PD/A: Mastery of Your Anxiety and Panic -4th edition (MAP-IV; Barlow and Craske, 2007;Craske and Barlow, 2007); 3) GAD: Mastery of Your Anxiety and Worry -2nd edition (MAW-II; Craske and Barlow, 2006;Zinbarg et al., 2006); and 4) OCD: Treating Your OCD with Exposure and Response (Ritual) Prevention Therapy -2nd edition ( Foa et al., 2012;Yadin et al., 2012). ...
... In the case of panic disorder, common expectations concerning the negative outcome of exposure to feared physical sensations (such as dizziness, heartbeat, faintness, sweating etc.) are that one may become crazy, suffer a heart attack, faint, or suffer from other forms of physical collapse. Typically, most CBT protocols for the treatment of panic disorder combine different forms of exposure (Barlow & Craske, 2007;Clark et al., 1994). One important form is interoceptive exposure, which means exposure to inner sensations, that is, unpleasant physical sensations associated with anxiety. ...
A three-session therapist-guided exposure treatment was tested in a consecutive series of eight primary health care patients suffering from panic attacks who specifically used distraction techniques as their primary safety behavior. The Panic Disorder Severity Scale Self-Report (PDSS-SR) was administered at baseline (1-3 weeks before the first session), and 1, 2, and 3 weeks after treatment. Weekly ratings on the Body Sensations Questionnaire (BSQ) and the Agoraphobic Cognitions Questionnaire (ACQ) during treatment were undertaken to explore when reliable change took place on these measures. The results showed a large within-group effect size on PDSS-SR ( d = 1.63); six of the eight patients were classified as responders, and four of them showed remission. Large effect sizes ( ds between 1.17 and 3.00) were seen also on BSQ and ACQ, as well as on agoraphobic avoidance, general level of anxiety, and depression. The results on BSQ and ACQ suggest that the fear of body sensations in most cases was reduced before a change occurred in agoraphobic cognitions. These results indicate that a brief three-session exposure-based treatment may be sufficient for this subgroup of panic patients. The findings need to be replicated under controlled conditions with larger samples and different therapists before more firm conclusions can be drawn. Future research should also focus on the relevance of dividing patients into subgroups based on type of safety behavior.
... images and the anxious arousal they may evoke may be helpful (van der Heider & ten Broeke, 2009;Zinbarg, Craske, & Barlow, 2006). The solution, according to the EPT, is for people to stay with their anxiety long enough for it to reduce on its own. ...
Past research has found that experiential avoidance (EA) is a type of avoidance that is common in individuals who report distress associated with traumatic events. No treatment studies to date have evaluated potential changes in EA associated with prolonged exposure therapy (PE), an empirically supported treatment for traumatic distress. This case series presents outcomes associated with treatment by PE for five adults who presented with posttraumatic stress disorder (PTSD), comorbid generalized anxiety disorder (GAD), and problematic EA. PTSD, GAD, depression, and EA symptoms were monitored at baseline, post-treatment, and 1-month follow-up. The five participants reported decreases in PTSD to below clinical cutoff criteria at post-treatment, all five participants reported decreases in depression at post-treatment, and four of the participants showed decreases in GAD and EA at post-treatment. In comparing pre-treatment to 1-month follow-up scores, all the participants reported decreases in PTSD, GAD, depression, and all but one participant reported a decrease in EA. The findings of this study suggest that PE may be a helpful treatment for individuals reporting EA.
... Nowadays, many treatments have been proposed to treat the generalized anxiety disorder. Given this, the mindfulness-based stress reduction program was considered the most common method and it was delivered in the form of stress reduction and relaxation training programs (Kabat-Zinn, 1989, 1990). Vollestad, Sivertsen & Nielsen (2011) found that the mindfulness-based stress reduction treatment program alleviated the symptoms of anxiety, worry and state-trait anxiety in patients with anxiety disorders. ...
The Generalized Anxiety Disorder (GAD) is one of the most chronic and detrimental disorders and it is considered a common disorder in childhood and adolescence. Furthermore, this disorder is associated with many problems in the health domain. As such, this study attempted to gauge the impact of mindfulness-based stress reduction on intolerance of uncertainty and anxiety sensitivity among students with generalized anxiety disorder. Therefore, it was attempted to run a quasi-experimental research, including a pre-test, a post-test and a control group, among high schools of Robat Karim in Tehran province. Having used the purposive sampling method, 30 students diagnosed with generalized anxiety disorder, intolerance of uncertainty and high anxiety sensitivity were selected. Then, they were randomly assigned to experimental (15 students) and control groups (15 students). Consequently, the mindfulness program was introduced to the experimental group in 8 sessions and the control group received no treatment. It should be noted that groups were assessed before and after treatment with generalized anxiety scale, anxiety sensitivity and intolerance of uncertainty. The results of analysis of covariance showed that mindfulness-based stress reduction programs significantly reduced the symptoms of generalized anxiety disorder, anxiety sensitivity and intolerance of uncertainty. Since mindfulness reduces the levels of two key components of generalized anxiety disorder, namely intolerance of uncertainty and anxiety sensitivity, it seems appropriate to make use of this program in the treatment of generalized anxiety disorder.
... The following section will briefly review contemporary cognitive and behavioral (CBT) therapeutic techniques that have built upon the legacy of Lang's early work, which include: (a) imaginal exposure, (b) the direct modification of the content of aversive imagery-based thoughts, (c) the promotion of adaptive imagery, (d) metacognitive reappraisal of imagery, and (e) imagery-based cognitive modification of maladaptive thinking habits. Imaginal exposure (IE) treatments are still widely used in contemporary clinical practice, with a strong evidence base for treating anxiety disorders ranging from specific phobias (Craske, Antony, & Barlow, 2006), obsessive-compulsive disorder (Abramowitz, Franklin, & Foa, 2002), generalized anxiety disorder (Zinbarg, Craske, & Barlow, 2006), to PTSD (Foa et al., 2007). Seminal advances in mechanistic understandings of fear extinction learning and habituation have been informed by the legacy of Lang's bio-informational theory and experimental work (e.g., Lang, Melamed, & Hart, 1970 ). ...
This article pays tribute to the seminal paper by Peter J. Lang (1977; this journal) on “Imagery in therapy: Information-processing analysis of fear”. We review research and clinical practice developments in the past five decades with reference to key insights from Lang’s theory and experimental work on emotional mental imagery. First, we summarize and recontextualize Lang’s bio-informational theory of emotional mental imagery (1977; 1979) within contemporary theoretical developments on the function of mental imagery. Second, Lang’s proposal that mental imagery can evoke emotional responses is evaluated by reviewing empirical evidence that mental imagery has a powerful impact on negative as well as positive emotions at neurophysiological and subjective levels. Third, we review contemporary cognitive and behavioral therapeutic practices that use mental imagery and consider points of extension and departure from Lang’s original investigation of mental imagery in fear-extinction behavior change. Fourth, Lang’s experimental work on emotional imagery is revisited in light of contemporary research on emotional psychopathology-linked individual differences in mental imagery. Finally, key insights from Lang’s experiments on training emotional response during imagery are discussed in relation to how specific techniques may be harnessed to enhance adaptive emotional mental imagery training in future research.
... Methods to reduce arousal in bed that are included in the VA CBT-I protocol include: relaxation techniques (e.g., progressive muscle relaxation [PMR], diaphragmatic breathing, meditation, and positive imagery), creating a pre-sleep buffer to allow for unwinding before going to bed, and techniques to address intrusive thoughts in bed (e.g., "worry time," a technique used in evidence-based therapies for generalized anxiety disorder 27 ). ...
Study objectives:
This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (N = 138) and use of it two years after it was released (N = 176).
Methods:
VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released.
Results:
Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (β = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (β = 0.286, p < 0.01), compatibility with their own needs and values (β = 0.307, p < 0.01), and expectations about the complexity of the app (β = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes.
Conclusions:
Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.
... Results of each assessment were reviewed with me before participants were invited to enroll in the study. Eligible participants were enrolled in a two-phase feasibility trial in which Phase 1 required the completion of daily surveys (described later) and Phase 2 was a 10-to 12-week cognitive– behavioral therapy for GAD at no cost to participants (Zinbarg, Craske, & Barlow, 2006). Phase 2 was employed both as a means to compensate participants for their efforts, as well as to help mitigate their clinically severe worry and anxiety. ...
The present article proposes a general framework and a set of specific methodological steps for conducting person-specific dynamic assessments, which yield information about syndrome structures and states that can be used to provide actionable information for the formulation of personalized interventions. It is proposed that researchers should (a) determine the relevant constituent inputs for a diagnostic system; (b) measure these inputs with as much detail as possible; (c) assess the correlational structure of system inputs via factor-analytic methods within individuals; and (d) subject the individual-level, latent dimension time series to dynamic analyses such as the dynamic factor model (Molenaar, 1985) to discern the time-dependent, dynamic relationships within and between system components.
An exemplar is provided wherein 10 individuals with clinically diagnosed generalized anxiety disorder completed surveys related to generalized anxiety disorder symptomatology for at least 60 consecutive days. These data were then subjected to person-specific exploratory and confirmatory factor analyses for the identification of latent symptom dimensions. Finally, dynamic factor models were used to model the dynamic interrelationships within and between symptom domains on a person-by-person basis.
Person-specific factor analyses returned models with 3 (n = 8) or 4 (n = 2) latent factors, all with excellent fit. Dynamic factor modeling successfully revealed the contemporaneous correlations and time-lagged predictive relationships between factors, providing prescriptive information for the formulation of targeted interventions.
The proposed approach has the potential to inform the construction and implementation of personalized treatments by delineating the idiosyncratic structure of psychopathology on a person-by-person basis. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
This study explores the usefulness of Adlerian psychotherapy, specifically the use of early recollections (ERs), in treating panic attacks. The research is based on a case study involving 50 sessions with a patient presenting panic disorder. The paper is structured in three parts: (1) a literature review examining panic attacks, the Adlerian approach to psychological symptoms, and the use of ERs; (2) a case formulation including patient information and symptomatology, followed by an analysis of the therapeutic process centered on 12 ERs that emerged during therapy; and (3) a critical discussion of the Adlerian interpretation of symptoms and principal treatment outcomes. This case study contributes to the understanding of treatment for panic attacks, offering insights into the potential effectiveness of Adlerian psychotherapy and the role of ERs in addressing panic symptoms. The findings suggest that Adlerian therapy, particularly the use of ERs, may be a valuable approach in treating panic attacks.
This chapter discusses key transdiagnostic cognitive, behavioral, and physiological features of anxiety disorders and how these may be targeted using exposure therapy. Benefits of transdiagnostic and disorder-specific approaches to treating anxiety disorders are discussed, as well as considerations for when one may want to use each approach. Guidelines for how to deviate from typical disorder-specific approaches are provided, in the context of both individual and group treatments for anxiety disorders. A brief review of the literature is provided, as well as a case example to illustrate the application of transdiagnostic exposure therapy for comorbid anxiety disorders.
Objectives:
The current study aims to investigate the indirect associations between experiential avoidance (EA) and burnout, wellbeing, and productivity loss (PL) via the mediating role of positive and negative emotions among police officers.
Methods:
Data were collected on 187 officers (84% male) aged 21-64 years between 2019 and 2020. Participants completed online self-report measures.
Results:
EA was indirectly associated with burnout via positive and negative affect. EA was indirectly associated with wellbeing through positive affect, positive affect and burnout, and negative affect and burnout. Finally, EA was indirectly associated with PL via positive affect and burnout, and negative affect and burnout.
Conclusion:
Results provide support for the role of EA in officers' wellbeing and job performance via increasing negative affect and decreasing positive affect. This highlights the importance of interventions, such as acceptance and commitment therapy that target acceptance and psychological flexibility.
Angsterkrankungen stellen mit einer 12-Monats-Prävalenz von 14% die häufigsten psychischen Erkrankungen in der westlichen Gesellschaft dar. Angesichts der hohen querschnittlichen wie sequentiellen Komorbidität von Angsterkrankungen, der ausgeprägten individuellen Einschränkungen sowie der hohen ökonomischen Belastung für das Gesundheitssystem ist neben therapeutischen Behandlungsansätzen die Entwicklung von kurzzeitigen, kostengünstigen und leicht zugänglichen Präventionsmaßnahmen von großer Bedeutung und steht zunehmend im Fokus des gesundheitspolitischen Interesses, um die Inzidenz von Angsterkrankungen zu reduzieren. Voraussetzung für die Entwicklung von gezielten und damit den effektivsten Präventionsmaßnahmen sind valide Risikofaktoren, die die Entstehung von Angsterkrankungen begünstigen. Ein Konstrukt, das in der Literatur als subklinisches Symptom in Form einer kognitiven Vulnerabilität für Angsterkrankungen und damit als Risikofaktor angesehen wird, ist die sogenannte Angstsensitivität (AS). AS umfasst die individuelle Tendenz, angstbezogene körperliche Symptome generell als bedrohlich einzustufen und mit aversiven Konsequenzen zu assoziieren. Das Ziel der vorliegenden Arbeit war daher die Etablierung und Validierung eines Präventionsprogramms zur Reduktion der AS an einer nicht-klinischen Stichprobe von 100 Probanden (18-30 Jahre) mit einer erhöhten AS (Anxiety Sensitivity Index [ASI-3] ≥17) sowie die Rekrutierung von 100 alters- und geschlechtsangeglichenen Probanden mit niedriger Angstsensitivität (ASI-3 <17). In einem randomisiert-kontrollierten Studiendesign durchliefen die Probanden mit hoher AS entweder das über fünf Wochen angelegte „Kognitive Angstsensitivitätstraining“ (KAST) als erste deutschsprachige Übersetzung des Computer-basierten „Cognitive Anxiety Sensitivity Treatment“ (CAST) von Schmidt et al. (2014) oder wurden der Wartelisten-Kontrollgruppe zugeteilt. Das KAST Training bestand aus einer einmaligen Vermittlung kognitiv-behavioraler Psychoedukation zum Thema Stress und Anspannung sowie deren Auswirkungen auf den Körper und der Anleitung von zwei interozeptiven Expositionsübungen (‚Strohhalm-Atmung‘ und ‚Hyperventilation‘), die über den anschließenden Zeitraum von fünf Wochen in Form von Hausaufgaben wiederholt wurden. Es konnte gezeigt werden, dass die Teilnehmer des KAST-Programms nach Beendigung des Trainings (T1) eine signifikant niedrigere AS-Ausprägung im Vergleich zur Wartelisten-Kontrollgruppe aufwiesen und diese Reduktion auch über den Katamnese-Zeitraum von sechs Monaten (T2) stabil blieb. Ergänzend wurde auch die Targetierbarkeit weiterer intermediärer Risikomarker wie der Trennungsangst (TA), des Index der kardialen Sensitivität sowie der Herzratenvariabilität (HRV) untersucht, die jedoch nicht durch das KAST-Training direkt verändert werden konnten. Im Vergleich der Subgruppen von Probanden mit hoher AS und gleichzeitig hoher TA (Adult Separation Anxiety Questionnaire [ASA-27] ≥22) und Probanden mit hoher AS, aber niedriger TA (ASA-27 <22) zeigte sich, dass die AS-TA-Hochrisikogruppe ebenfalls gut von der KAST-Intervention profitieren und eine signifikante Reduktion der AS erzielen konnte, indem sie sich bei T1 dem Niveau der Gruppe mit niedriger TA anglich. Zudem korrelierte die prozentuale Veränderung der Einstiegswerte der inneren Anspannung während der Strohhalm-Atmungsübung positiv mit der prozentualen Veränderung der dimensionalen TA bei T1. Zusammenfassend weisen die Ergebnisse der vorliegenden Arbeit erstmalig auf die Wirksamkeit der deutschsprachigen Übersetzung des CAST-Programms (Schmidt et al., 2014), eines Computer-basierten, und damit leicht zu implementierenden sowie kostengünstigen Programms, in Bezug auf die Reduktion der AS sowie indirekt der TA hin und können damit zur indizierten und demnach besonders effektiven Prävention von Angsterkrankungen in Hochrisikogruppen beitragen.
Background
Neuroticism is associated with the onset and maintenance of a number of mental health conditions, as well as a number of deleterious outcomes (e.g. physical health problems, higher divorce rates, lost productivity, and increased treatment seeking); thus, the consideration of whether this trait can be addressed in treatment is warranted. To date, outcome research has yielded mixed results regarding neuroticism's responsiveness to treatment, perhaps due to the fact that study interventions are typically designed to target disorder symptoms rather than neuroticism itself. The purpose of the current study was to explore whether a course of treatment with the unified protocol (UP), a transdiagnostic intervention that was explicitly developed to target neuroticism, results in greater reductions in neuroticism compared to gold-standard, symptom focused cognitive behavioral therapy (CBT) protocols and a waitlist (WL) control condition.
Method
Patients with principal anxiety disorders ( N = 223) were included in this study. They completed a validated self-report measure of neuroticism, as well as clinician-rated measures of psychological symptoms.
Results
At week 16, participants in the UP condition exhibited significantly lower levels of neuroticism than participants in the symptom-focused CBT ( t(218) = −2.17, p = 0.03, d = −0.32) and WL conditions( t(207) = −2.33, p = 0.02, d = −0.43), and these group differences remained after controlling for simultaneous fluctuations in depression and anxiety symptoms.
Conclusions
Treatment effects on neuroticism may be most robust when this trait is explicitly targeted.
Bright light (BL) therapy is clinically utilized for treatment of sleep–wake disorders through the manipulation of circadian oscillation. It is also extended to depressive disorders including seasonal affective disorder through emotional regulation. Recently, it has been suggested that BL facilitates memory encoding and consolidation via another psychophysiological mechanism of perceptual information processing in the brain. In particular, BL can help to alleviate stress associated with processing of fear memories. In this study, we explored a potential application of BL for treatment of stress-induced and fear circuitry disorders in patients receiving exposure-based cognitive behavioral therapy (CBT). Fourteen patients with panic disorder (PD) or posttraumatic stress disorder (PTSD) were enrolled in a single-blind, randomized control trial to assess BL exposure (8000-lux, 30 min, 9 times, 2 weeks apart) compared to sham light (SL) exposure (800-lux, the same duration and frequency), while patients were concurrently receiving exposure-based CBT. The State Trait Anxiety Index (STAI) and the self-rating version of Montgomery–Åsberg Depression Rating Scale (MADRS-S) assessed anxiety-related severity scores before and after therapy. After dropouts, 10 participants remained. STAI and MADRS-S scores showed a significantly greater reduction in the BL group than in the SL group. BL may be an effective augmentative therapy when used with exposure-based CBT for PD and PTSD patients. Future trials with larger sample sizes that are adequately statistically powered are required to confirm these preliminary findings.
Despite the substantial evidence that supports the efficacy of cognitive-behavioral therapy for the treatment of anxiety and related disorders, our understanding of mechanisms of change throughout treatment remains limited. The goal of the current study was to examine changes in experiential avoidance across treatment in a sample of participants (N = 179) with heterogeneous anxiety disorders receiving various cognitive-behavioral therapy protocols. Univariate latent growth curve models were conducted to examine change in experiential avoidance across treatment, followed by parallel process latent growth curve models to examine the relationship between change in experiential avoidance and change in anxiety symptoms. Finally, bivariate latent difference score models were conducted to examine the temporal precedence of change in experiential avoidance and change in anxiety. Results indicated that there were significant reductions in experiential avoidance across cognitive-behavioral treatment, and that change in experiential avoidance was significantly associated with change in anxiety. Results from the latent difference score models indicated that change in experiential avoidance preceded and predicted subsequent changes in anxiety, whereas change in anxiety did not precede and predict subsequent changes in experiential avoidance. Taken together, these results provide additional support for reductions in experiential avoidance as a transdiagnostic mechanism in cognitive-behavioral therapy.
Controlled respiration is one of the oldest and certainly the single, most efficient acute intervention for the mitigation and treatment of excessive stress. Any clinician treating patients who manifest excessive stress syndromes should consider controlled respiration as a potentially suitable intervention for virtually all patients. The purpose of this chapter is to discuss the uses of voluntary control of respiration patterns in the treatment of excessive stress. As used in this text, this term refers to the process by which the patient exerts voluntary control over his or her breathing pattern—in effect, breath control. There are hundreds of diverse patterns of controlled respiration; we examine several that we feel have particular introductory utility for the clinician concerned with the treatment of the stress response. The exercises presented in this chapter are by no means inclusive. We have simply chosen several patterns that are simple to learn and effective. Again, the goal of voluntary, controlled respiration in the treatment of excessive stress is to have the patient voluntarily alter his or her rhythmic pattern of breathing to create a more relaxed state.
This chapter introduces the idea of integrated treatment. It reviews how Cognitive behavioral group therapy (CBGT) for generalized anxiety disorder (GAD) can benefit from formally integrating a mindfulness component. The chapter describes a pure CBGT approach to GAD, and examines how to integrate components of mindfulness training. It explores how CBGT for perinatal depression becomes enriched by including elements from interpersonal therapy (IPT). GAD involves excessive anxiety and worry for more days than not for a period of at least 6 months about a number of present or future events or activities. Novel approach to GAD is mindfulness. The chapter sketches what it looks like to integrate aforementioned Dugas and Robichaud CBGT approach with mindfulness. The chapter shows how basic CBGT can be enriched by integrating other therapy approaches that are likely to make the group format more attractive and engaging and thus improve individual group members' outcomes.
Angststörungen zählen zu den häufigsten psychischen Störungen in der Allgemeinbevölkerung. Die Lebenszeitprävalenz liegt insgesamt bei 15–20 %. Diagnostisch werden folgende Untergruppen unterschieden: Panikstörung, die generalisierte Angststörung, die Agoraphobie, die soziale Phobie und die spezifischen Phobien. Ursache und Entstehung sind multifaktoriell bedingt. Angststörungen neigen häufig zu einem chronischen Krankheitsverlauf und gehen mit einer bedeutsamen psychosozialen Behinderung einher. Es existieren differenzierte störungsbezogene Ansätze von Pharmako- und Psychotherapie mit hohem Evidenz- und Empfehlungsgrad. Häufig ist auch eine Kombinationsbehandlung notwendig.
In these contemporary times education practices have become more encompassing of globalised standards of best teaching practice. Thus providing new ideas of teaching that call for a variety of teachers with diverse backgrounds and perspectives. If the outdoor education profession is to keep up with these changes in the field of education then it must first address issues like the dropout rate of females from the profession. Grounded in cultural nature theories of human development, this chapter examines a study on the effect of an experiential program on the development of pedagogy in female outdoor education pre-service teachers learning to teach. This chapter elucidates the plight of capable female outdoor education teachers as they face their fears and negative attitudes from the dominant discourses of the profession. The notion of feeling fear when teaching an activity that has risk involved was gleaned from the study, female pre-service outdoor education teachers (POETs) experienced fear when teaching activities that contained elements of risk in the outdoors. Thus providing an example of a situation where female POETs seriously considered dropping out of the teacher preparation program. The final part of this chapter discusses fear and explores an argument in support of the need to champion highly capable female outdoor educators to support them in the profession.
Objective:
We tested the relation of perceived criticism (PC) from a parent or spouse/romantic partner to outcome of psychotherapy for panic disorder (PD).
Method:
Participants were 130 patients with PD (79% with agoraphobia) who received 24 twice-weekly sessions of panic-focused psychodynamic psychotherapy, cognitive-behavioral therapy, or applied relaxation therapy. Patients were predominantly White (75%), female (64%), and non-Hispanic (85%). At baseline, Week 5 of treatment, termination, and at 6- and 12-month follow-up, patients rated PC from the relative with whom they lived. Independent evaluators assessed the severity of PD at baseline, Weeks 1, 5, and 9 of treatment, termination, and the 2 follow-up points. Data were analyzed with piecewise (treatment phase, follow-up phase) latent growth curve modeling.
Results:
The latent intercept for PC at baseline predicted the latent slope for panic severity in the follow-up (p = .04) but not the active treatment phase (p = .50). In contrast, the latent intercept for PD severity at baseline did not predict the latent slope on PC in either phase (ps ≥ .29). Nor did the slopes of PC and PD severity covary across treatment (p = .31) or follow-up (p = .13). Indeed, PC did not change significantly across treatment (p = .45), showing the stability of this perception regardless of significant change in severity of patients' PD (p < .001).
Conclusions:
Because PC predicts worse long-term treatment outcome for PD, study findings argue for interventions to address perceived criticism in treatment. (PsycINFO Database Record
This chapter focuses on the psychological treatment of panic attacks and panic disorder as denned by DSM-III-R diagnostic criteria (American Psychiatric Association [APA]). In this chapter, current available psychological treatments of panic disorder and evidence for their efficacy are reviewed. A brief discussion of developments in conceptualization and in the treatment of panic disorder as well as recent epidemiological data are presented before describing specific treatment procedures and their efficacies. Directions for future research are suggested in the conclusion.
Controlled respiration is one of the oldest and certainly the single, most efficient acute intervention for the mitigation and treatment of excessive stress. Any clinician treating patients who manifest excessive stress syndromes should consider controlled respiration as a potentially suitable intervention for virtually all patients. The purpose of this chapter is to discuss the uses of voluntary control of respiration patterns in the treatment of excessive stress. As used in this text, this term refers to the process by which the patient exerts voluntary control over his or her breathing pattern—in effect, breath control. There are hundreds of diverse patterns of controlled respiration; we examine several that we feel have particular introductory utility for the clinician concerned with the treatment of the stress response. The exercises presented in this chapter are by no means inclusive. We have simply chosen several patterns that are simple to learn and effective. Again, the goal of voluntary, controlled respiration in the treatment of excessive stress is to have the patient voluntarily alter his or her rhythmic pattern of breathing to create a more relaxed state.
The application of randomized clinical trial (RCT) research to psychotherapy, involving head-to-head comparisons of treatments for specified conditions, led to a proliferation of published and empirically supported treatment manuals. The large-scale NIMH Treatment of Depression Collaborative Treatment Program (TCRCP; Elkin et al., 1989) introduced the methodological innovation of treatment manuals as a way to make treatment comparisons (Beutler, Clarkin, & Bongar, 2000; Beutler et al., 2004; Lambert & Ogles, 2004). Manualized treatments are tools that investigators may utilize to aid in the identification of the signal or active ingredients within treatments and separate these specific treatment elements from the general therapeutic qualities of the therapists delivering the treatment. Unfortunately, the relatively small cadre of therapists used in the TCRCP did not allow investigators to confidently disentangle therapist effects from treatment effects.
In the present study we examined the relationship between depressive symptoms and generalized anxiety symptoms during intensive cognitive-behavioral and pharmacological treatment.
Individuals (n=157) with major depressive disorder (MDD; n=83), generalized anxiety disorder (GAD; n=29) and their combination (n=45) who attended an intensive partial hospital treatment program, completed daily self-report measures of depression and generalized anxiety. Treatment included empirically-based cognitive-behavioral interventions in both individual and group format, as well as pharmacotherapy.
Multilevel linear modeling indicated that for all diagnostic groups, changes in depressive symptoms led to changes in generalized anxiety symptoms to a greater extent than vice versa during treatment. Moreover, changes in depressive symptoms fully mediated changes in generalized anxiety symptoms, whereas changes in generalized anxiety symptoms only partially mediated the changes in depressive symptoms.
Partial hospital setting.
Our results suggest that depressive symptoms may play a prominent role in the process of change in both MDD and GAD. This has implications for the classification of GAD as well as for choosing early treatment targets for individuals with comorbid MDD and GAD.
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Although ADHD in adolescents is an impairing and prevalent condition, with community prevalence estimates between 2% and 6%, psychosocial treatments for adolescents compared to younger children are relatively understudied. Our group has successfully developed an evidence base for cognitive-behavioral therapy (CBT) for ADHD in medication-treated adults with ADHD with clinically significant symptoms. In the current paper, we describe an adaptation of this treatment to adolescents, and provide case reports on 3 adolescents who participated in an open pilot trial. The results suggest that the treatment approach was well tolerated by the adolescents and that they experienced clinical benefit. This early report of the approach in adolescents is promising and requires further efficacy testing.
Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist-client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.
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