The increase in interest in GAD: Commentary on Asmundson & Asmundson

Examining the Effects of a Brief, Fully Self-Guided Mindfulness Ecological Momentary Intervention on Empathy and Theory-of-Mind for Generalized Anxiety Disorder: Randomized Controlled Trial

BACKGROUND

The utility of brief mindfulness ecological momentary interventions (EMIs) to improve empathy and theory-of-mind has been underinvestigated, particularly in generalized anxiety disorder (GAD).

OBJECTIVE

In this randomized controlled trial, we aimed to examine the efficacy of a 14-day, fully self-guided, mindfulness EMI on the empathy and theory-of-mind domains for GAD.

METHODS

Adults (aged ≥18 y) diagnosed with GAD were randomized to a mindfulness EMI (68/110, 61.8%) or self-monitoring app (42/110, 38.2%) arm. They completed the Interpersonal Reactivity Index self-report empathy measure and theory-of-mind test (Bell-Lysaker Emotion Recognition Task) at prerandomization, postintervention, and 1-month follow-up (1MFU) time points. Hierarchical linear modeling was conducted with the intent-to-treat principle to determine prerandomization to postintervention (pre-post intervention) and prerandomization to 1MFU (pre-1MFU) changes, comparing the mindfulness EMI to self-monitoring.

RESULTS

Observed effects were generally stronger from pre-1MFU than from pre-post intervention time points. From pre-post intervention time points, the mindfulness EMI was more efficacious than the self-monitoring app on fantasy (the ability to imagine being in others' shoes; between-intervention effect size: Cohen d=0.26, P=.007; within-intervention effect size: Cohen d=0.22, P=.02 for the mindfulness EMI and Cohen d=-0.16, P=.10 for the self-monitoring app). From pre-1MFU time points, the mindfulness EMI, but not the self-monitoring app, improved theory-of-mind (a window into others' thoughts and intentions through abstract, propositional knowledge about their mental states, encompassing the ability to decipher social cues) and the fantasy, personal distress (stress when witnessing others' negative experiences), and perspective-taking (understanding others' perspective) empathy domains. The effect sizes were small to moderate (Cohen d=0.15-0.36; P<.001 to P=.01) for significant between-intervention effects from pre-1MFU time points. Furthermore, the within-intervention effect sizes for these significant outcomes were stronger for the mindfulness EMI (Cohen d=0.30-0.43; P<.001 to P=.03) than the self-monitoring app (Cohen d=-0.12 to 0.21; P=.001 to P>.99) from pre-1MFU time points. No between-intervention and within-intervention effects on empathic concern (feeling affection, compassion, and care when observing others in distress, primarily attending to their emotional well-being) were observed from pre-post intervention and pre-1MFU time points.

CONCLUSIONS

The brief mindfulness EMI improved specific domains of empathy (eg, fantasy, personal distress, and perspective-taking) and theory-of-mind with small to moderate effect sizes in persons with GAD. Higher-intensity, self-guided or coach-facilitated, multicomponent mindfulness EMIs targeting the optimization of social relationships are likely necessary to improve the empathic concern domain in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04846777; https://clinicaltrials.gov/study/NCT04846777.

Current prevalence and determinants of generalized anxiety disorder from a nationally representative, population-based survey of India

Introduction

Generalized anxiety disorder (GAD) is one of the common anxiety disorders leading to impairment and burden. However, GAD remains the least studied anxiety disorder. There is a need for nationally representative epidemiological data of GAD to understand the current burden and plan the mental health policies and programs to attain their unmet needs. Hence, this study focuses on epidemiology, socio-demographic correlates, disability, and treatment gap of GAD from India's National Mental Health Survey (NMHS) 2016.

Materials and Methods

NMHS 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. NMHS is a multi-stage, stratified, random cluster sampling with random selection based on probability proportional to size at each stage. The Mini-International Neuropsychiatric Interview 6.0.0 used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of GAD was estimated. Association between GAD and socio-demographic factors was done using Firth's penalized logistic regression. The treatment gap and disability in GAD also calculated.

Results

The current weighted prevalence of GAD is 0.57%. The male gender and higher education groups have significantly lesser odds with current GAD. Urban metro and the married group have significantly higher odds with current GAD. The most common comorbid psychiatric disorders are depression (15.8%) followed by agoraphobia (9.4%). Among respondents with current GAD in the past 6 months across three domains, around 2/5th has mild and moderate disability, 1/10th has a severe disability, and 1/20th has an extreme disability. The overall treatment gap of current GAD is 75.7%.

Conclusion

NMHS 2016 has provided valuable insights into the epidemiology and burden of GAD among the general population. The available findings provide a glimpse of the current scenario in GAD to aid policymakers in targeting interventions.

Evidências de Validade da GAD-7 em Adolescentes Brasileiros

Resumo O objetivo deste estudo foi investigar evidências validade para a escala Generalized Anxiety Disorder (GAD-7) em adolescentes brasileiros, bem como validade concorrente para esta escala e apresentar a distribuição social do Transtorno de Ansiedade Generalizada (TAG). Participaram 302 adolescentes, com idades entre 15 e 19 anos, de ambos os sexos. Aplicou-se o questionário sociodemográfico, a GAD-7, a Hospital Anxiety and Depression Scale (HADS) e o Patient Health Questionnaire (PHQ-9). Os resultados da Análise Fatorial Exploratória (AFE) atestaram a unidimensionalidade da GAD-7 e indicaram consistência interna satisfatória. As evidências de validade concorrente apresentaram associações estatisticamente significativas e positivas entre a GAD-7 e as escalas PHQ-9 e HADS-A. Quanto à distribuição social, aproximadamente metade da amostra apresentou a ocorrência de sintomatologia positiva para TAG, sendo mais comum para o sexo feminino e em adolescentes mais jovens. Esses dados sugerem que a GAD-7 apresenta adequadas propriedades psicométricas para rastreamento de ansiedade em adolescentes.

Worry and Positive Episodes in the Daily Lives of Individuals With Generalized Anxiety Disorder: An Ecological Momentary Assessment Study

Worry is a central feature of generalized anxiety disorder (GAD). Although worry is related to anxiety and maintained by beliefs that worry is uncontrollable, there is scarce research on how individuals with GAD react to worry episodes in their daily life and how their positive experiences might impact reactions to worry episodes. The current study examined the level and variability of anxiety and controllability during high worry periods and positive experiences in GAD. Moreover, it investigated the influence of worry and positive experiences on later anxiety and perceived controllability within-persons. Finally, it examined change in anxiety level from previous to current episodes depending on previous episodes type. In the current study, 49 individuals with GAD (514 observations) registered their worry and positive episodes (i.e., episodes in which they had positive experiences) and reported on several variables during these episodes (i.e., anxiety and controllability of episodes and episode duration) using smartphone-based ecological momentary assessment for 7days. Results show anxiety and controllability differed by episode type (higher anxiety, lower controllability in worry episodes, and the opposite in positive episodes), and notable within-person variability in anxiety and controllability in both episode types. The time-lagged multilevel models showed episode type did not predict later anxiety during either episode type, although previous anxiety predicted current anxiety in worry episodes (but not positive episodes). Moreover, worry episodes did predict later controllability in worry episodes (but not positive episodes) and previous controllability predicted current controllability in both episode types. Furthermore, we obtained the increase in anxiety from t₀₋₁ to t₀ in a current worry episode to be significantly smaller when preceded by a worry (vs. positive) episode. Likewise, the reduction in anxiety from t₀₋₁ to t₀ in a current positive episode was significantly larger when preceded by a worry (vs. positive) episode. The novel findings in the current study that perceptions of controllability and anxiety vary within individuals with GAD, that greater controllability is experienced in positive episodes than worry episodes, and that worry may confer a sense of controllability at a later time could be seen as important contributions to the GAD literature.

Prevalence and correlates of generalized anxiety disorder in Singapore: Results from the second Singapore Mental Health Study

The aim of this paper is to report findings on the epidemiology of generalized anxiety disorder (GAD) using data from the Singapore Mental Health Study (SMHS) 2016, and draw comparisons with results from the first SMHS in 2010. Singapore residents aged 18 years and above participated in the household survey where the WHO Composite International Diagnostic Interview 3.0 was administered to assess the prevalence of GAD and other mental health conditions. The findings revealed that the lifetime prevalence of GAD was 1.6% among the Singapore general population in 2016, an increase from the 0.9% in 2010. More lifetime GAD cases were reported across several sociodemographic groups including age and employment status. Lifetime GAD was significantly associated with higher odds of several comorbid psychiatric conditions (OR = 3.8-9.3, p < 0.05). Treatment seeking behavior did not differ significantly when compared to SMHS 2010 and there was still a considerable treatment gap among individuals with GAD. Future intervention programs to reduce anxiety and encourage help-seeking behavior could be implemented at institutes of higher learning and workplace settings to reach the targeted audience.

Factorial invariance of a computerized version of the GAD-7 across various demographic groups and over time in primary care patients

BACKGROUND

The Generalized Anxiety Disorder 7-item scale (GAD-7) is commonly used by clinicians and researchers to screen for anxiety disorders and to monitor anxiety symptoms in primary care. However, findings regarding its factor structure are mixed, with most studies reporting a best-fitting for a one-factor structure, whereas others indicate a two-factor model. To be valid for comparisons, the GAD-7 should measure the same latent construct with the same structure across groups and over time. We aimed to examine the best-fit factor structure model of the GAD-7 among primary care patients and to evaluate its measurement invariance.

METHODS

A total of 1255 patients completed the computerized version of GAD-7 and a subsample of 238 cases was assessed at the 3-month follow-up. A confirmatory factor analysis (CFA) was performed and analyses of multiple-group invariance were also conducted to determine the extent to which the factor structure was comparable across various sociodemographic groups and over time.

RESULTS

The results showed that both a one- and two-factor structure (representing somatic and cognitive-affective components) were invariant across sociodemographic groups and over time. The two-factor structure provided the best model fit.

LIMITATIONS

Results cannot be generalized to all primary care patients, as only patients whose general practitioners consider them to suffer emotional disorders were included.

CONCLUSIONS

Our study supports the reliability and validity of the one- and two-factor model of the GAD-7, both for screening purposes and for monitoring response to treatment.

Probabilistic Learning by Positive and Negative Reinforcement in Generalized Anxiety Disorder

This experiment examined learning tendencies in generalized anxiety disorder (GAD) using reinforcement feedback for probabilistic outcomes. One hundred sixty-six GAD and 105 non-GAD participants were randomized to a computerized probabilistic learning task that used either negative or positive reinforcement. Participants chose between stimuli with specific probabilities of reinforcement to learn which of each pair had the highest probability. Reinforced choices either removed an angry face (negative reinforcement) or made a happy face appear (positive reinforcement). Results showed that those with GAD learned the correct probabilistic choices at a slower rate over time and to a lesser degree than control participants regardless of reinforcement type. Estimations of the likelihood of receiving a good outcome posttask were also more inaccurate for those with GAD, especially when true likelihoods were high. Furthermore, compared with control participants, those with GAD reported lower perceived reinforcement sensitivity, higher behavioral inhibition sensitivity, and higher undesirable feelings toward probabilistic learning.

Enhanced cognitive control over task-irrelevant emotional distractors in generalized anxiety disorder versus obsessive-compulsive disorder

Generalized anxiety disorder (GAD) is defined in part by excessive and uncontrollable worry. However, little is known about cognitive control abilities in adults with GAD. The present study examined cognitive control over negative and neutral material in a mixed clinical sample of adults with GAD and/or obsessive-compulsive disorder and a comparison healthy control sample. Participants completed a novel emotional variant of the AX-CPT (eAX-CPT) to index proactive and reactive cognitive control in the presence of negative and neutral distractor stimuli. Participants with GAD demonstrated enhanced cognitive control specifically over negative emotional distractors, relative to neutral distractors (within-subjects) and relative to OCD and controls (between-subjects). Findings were specific to GAD versus trait worry; however, higher trait worry predicted better cognitive control in GAD only. These findings are inconsistent with deficit-based cognitive models of GAD and may be better accounted for by models that conceptualize worry as an intentional (albeit maladaptive) cognitive control or emotion regulation strategy that is actively maintained by individuals with GAD in order to avoid engaging with more distressing emotional information.

Cognitive functions in young adults with generalized anxiety disorder

Background:

Anxiety and worry are central symptoms of Generalized Anxiety Disorder (GAD) that have been theorized to negatively impact cognitive functions. However, most of the research has focused on threat-related or emotionally-charged stimuli, and a surprisingly small number of investigations examined ‘cold’ cognitive functions using classic neuropsychological tests. Such investigations are particularly important given that some theoretical models suggest compensatory mechanisms associated with anxiety that in certain circumstances may result in intact performance. The aim of the present study is to assess the neuropsychological profile associated with GAD, using a comprehensive neuropsychological battery.

Methods:

A sample of 23 college students meeting criteria for DSM-5 GAD and 20 control participants completed a psychometrically valid comprehensive computerized neuropsychological battery and clinical questionnaires.

Results:

The GAD sample presented with significantly elevated symptomatic rates of anxiety, worry, depression and stress. However, no significant differences were found on any neuropsychological outcome measures or domain indexes. Effect sizes were small, some of which favored the GAD sample.

Conclusion:

Despite substantial psychopathological burden, GAD exhibited intact cognitive functioning. These results support the Cognitive Control Theory of Anxiety, suggesting that elevated primary anxiety may not impact ‘cold’ cognitive functions in the absence of threat or substantial cognitive load. Given that this is one of the only studies employing a comprehensive neuropsychological battery in GAD, more research is needed in this population to replicate these results and to examine the impact of anxiety on cognitive functions at varying degrees of cognitive load in this population.

Are anxiety disorders publications continuing on a trajectory of growth? A look at Boschen's (2008) predictions and beyond

The relative health of a field of research can be approximated by assessing peer-reviewed journal publication trends for articles pertinent to that field. The most recent comprehensive assessment of publication trends in the anxiety disorders indicated that the field was on a continuing trajectory of growth (Boschen, 2008). We conducted an updated search of Medline for publications on each of the anxiety disorders from 2006 to 2016. Results indicated that there was continuing growth in anxiety disorders research overall and, particularly, for posttraumatic stress disorder, social anxiety disorder, generalized anxiety disorder, and obsessive compulsive disorder. Publication trends observed in Medline were also reflected in the focus of papers published in the Journal of Anxiety Disorders over the past 3 years; yet, a substantive number of papers in the journal also dealt with multiple anxiety disorders, anxiety-related constructs, transdiagnostic issues, and conditions with significant overlap with the anxiety disorders. Observed publication trends, shifts in the focus of research attention, and probable future research directions are discussed briefly.