Physiological and behavioral indices of emotion dysregulation as predictors of outcome from cognitive behavioral therapy and acceptance and commitment therapy for anxiety

Predictors and Moderators of Panic Disorder: Cognitive Behavioral Therapy vs. Acceptance and Commitment Therapy

BACKGROUND

Understanding variables that influence therapy outcomes can improve the results of interventions and reduce socio-health costs. The current study examined possible predictors and moderators of outcome (age, gender, duration of panic disorder, motivation to change, conscientiousness, and experiential avoidance) in Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT).

METHOD

Eighty participants with a diagnosis of panic disorder, 56 women and 24 men, with an average age of 38 years, received 12 group sessions of CBT or ACT. They were assessed with several measures at pre-treatment, post-treatment, and 3-month follow-up.

RESULTS

CBT outperformed ACT among older subjects, men, and those with a shorter duration of panic disorder. ACT outperformed CBT among younger subjects, women, and those with a long duration of panic disorder. In general, the greatest improvements in both CBT and ACT were in older subjects, women, those with a long duration of panic disorder, those in the contemplation stage, and those with high experiential avoidance.

CONCLUSIONS

Although future studies are necessary, there appear to be predictors and moderators of the effectiveness of CBT and ACT. Taking these variables into account can help improve treatment for people with panic disorder.

Emotion regulation and heart rate variability may identify the optimal posttraumatic stress disorder treatment: analyses from a randomized controlled trial

Introduction

High variability in response and retention rates for posttraumatic stress disorder (PTSD) treatment highlights the need to identify "personalized" or "precision" medicine factors that can inform optimal intervention selection before an individual commences treatment. In secondary analyses from a non-inferiority randomized controlled trial, behavioral and physiological emotion regulation were examined as non-specific predictors (that identify which individuals are more likely to respond to treatment, regardless of treatment type) and treatment moderators (that identify which treatment works best for whom) of PTSD outcome.

Methods

There were 85 US Veterans with clinically significant PTSD symptoms randomized to 6 weeks of either cognitive processing therapy (CPT; n = 44) or a breathing-based yoga practice (Sudarshan kriya yoga; SKY; n = 41). Baseline self-reported emotion regulation (Difficulties in Emotion Regulation Scale) and heart rate variability (HRV) were assessed prior to treatment, and self-reported PTSD symptoms were assessed at baseline, end-of-treatment, 1-month follow-up, and 1-year follow-up.

Results

Greater baseline deficit in self-reported emotional awareness (similar to alexithymia) predicted better overall PTSD improvement in both the short- and long-term, following either CPT or SKY. High self-reported levels of emotional response non-acceptance were associated with better PTSD treatment response with CPT than with SKY. However, all significant HRV indices were stronger moderators than all self-reported emotion regulation scales, both in the short- and long-term. Veterans with lower baseline HRV had better PTSD treatment response with SKY, whereas Veterans with higher or average-to-high baseline HRV had better PTSD treatment response with CPT.

Conclusions

To our knowledge, this is the first study to examine both self-reported emotion regulation and HRV, within the same study, as both non-specific predictors and moderators of PTSD treatment outcome. Veterans with poorer autonomic regulation prior to treatment had better PTSD outcome with a yoga-based intervention, whereas those with better autonomic regulation did better with a trauma-focused psychological therapy. Findings show potential for the use of HRV in clinical practice to personalize PTSD treatment.

Clinical trial registration

ClinicalTrials.gov identifier, NCT02366403.

Heart rate variability: Evaluating a potential biomarker of anxiety disorders

Establishing quantifiable biological markers associated with anxiety will increase the objectivity of phenotyping and enhance genetic research of anxiety disorders. Heart rate variability (HRV) is a physiological measure reflecting the dynamic relationship between the sympathetic and parasympathetic nervous systems, and is a promising target for further investigation. This review summarizes evidence evaluating HRV as a potential physiological biomarker of anxiety disorders by highlighting literature related to anxiety and HRV combined with investigations of endophenotypes, neuroimaging, treatment response, and genetics. Deficient HRV shows promise as an endophenotype of pathological anxiety and may serve as a noninvasive index of prefrontal cortical control over the amygdala, and potentially aid with treatment outcome prediction. We propose that the genetics of HRV can be used to enhance the understanding of the genetics of pathological anxiety for etiological investigations and treatment prediction. Given the anxiety-HRV link, strategies are offered to advance genetic analytical approaches, including the use of polygenic methods, wearable devices, and pharmacogenetic study designs. Overall, HRV shows promising support as a physiological biomarker of pathological anxiety, potentially in a transdiagnostic manner, with the heart-brain entwinement providing a novel approach to advance anxiety treatment development.

The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.

Feasibility, Acceptability and Preliminary Efficacy of Dialectical Behavior Therapy for Autistic Adults without Intellectual Disability: A Mixed Methods Study

Self-harm and suicidal behaviors are prevalent among autistic adults without intellectual disability (ID). Emotion dysregulation (ED), the difficulty in modulating emotions, has been identified as an important risk factor. Dialectical behavior therapy (DBT) has been proved effective to treat ED in disorders other than autism spectrum disorder. Our study aimed at assessing the feasibility, acceptability and preliminary efficacy of DBT in seven autistic adults without ID exhibiting self-harm and/or suicidal behaviors linked to severe ED. Our results suggest that DBT is feasible and highly acceptable to autistic adults without ID. Additionally, mean scores on the Difficulties in Emotion Regulation Scale decreased significantly post-treatment and at 4-month follow-up, suggesting that DBT might be efficacious in reducing ED in this population.

Association between spatial working memory and Re-experiencing symptoms in PTSD

BACKGROUND AND OBJECTIVES

Few studies have evaluated the link between working memory (WM) and post-traumatic stress disorder (PTSD). Further, it is unknown whether this relationship is accounted for by other relevant variables including negative affect, emotional dysregulation, or general non-WM-related cognitive control deficits, which are associated with PTSD. The purpose of this study was to determine the extent to which a computerized WM task could predict PTSD symptomology incrementally beyond the contribution of other relevant variables associated with PTSD.

METHODS

Thirty veterans were eligible to complete emotional symptom questionnaires, a heart-rate variability measure, and computerized tasks (i.e., emotional Stroop and automated complex span tasks). A three-stage hierarchical regression was conducted with the PCL-5 total score and symptom clusters (i.e., re-experiencing, avoidance, hyperarousal, and negative cognition/mood) as the dependent variable.

RESULTS

Results revealed that only the re-experiencing symptom cluster was significantly predicted by executive, verbal, and visuospatial WM tasks, which explained an additional 29.7% of the variance over and above other relevant variables. Most notably, the visuospatial task was the only WM task that significantly explained PCL-5 re-experiencing symptoms.

LIMITATIONS

This study was based on a small sample of veterans with PTSD and causality cannot be determined with this cross-sectional study.

CONCLUSIONS

Overall, the results suggest that deficits in visuospatial WM are significantly associated with PTSD re-experiencing symptoms after controlling for other relevant variables. Further research should evaluate whether an intervention to improve visuospatial WM capacity can be implemented to reduce re-experiencing symptoms.

Coping and Beliefs as Predictors of Functioning and Psychological Adjustment in Fibromyalgia Subgroups

Objectives

Research has pointed to two profiles of persons with fibromyalgia according to differences in functionality, thus distinguishing between functional and dysfunctional patients. The role of psychological factors underlying such clusters is unclear. This study aims to explore the contribution of pain beliefs and coping on fibromyalgia clustering.

Methods

A cluster analysis was performed to classify 238 women with fibromyalgia using the Fibromyalgia Impact Questionnaire and the Beck Depression Inventory as clustering variables. Cluster differences in physical functioning, depression, pain beliefs, coping, and age were then calculated (Student's t-test). Finally, a binary logistic regression was conducted to study the unique contribution of age, beliefs, and coping on cluster classification.

Results

Two clusters were revealed. Cluster 1 had a poor adaptation to fibromyalgia regarding physical functioning and depression. They generally embraced less adaptive beliefs (i.e., disability, harm, emotion, and requests) and coping strategies (i.e., guarding, resting, and asking for assistance). Cluster 2 showed a better adaptation to fibromyalgia and adopted more favorable beliefs (i.e., control) and coping strategies (i.e., exercise and task persistence). Cluster differences in age were significant but small. The backward binary logistic regression suggested a final model with six predictors (guarding, task persistence, harm, emotion, solicitude, and age) that explained 31% of the variance of group membership. Discussion. These results suggest that only a subset of psychological variables uniquely and independently contribute to functional/dysfunctional group membership. The results support the need to address psychological components in the management of fibromyalgia and point to a subset of preferred target beliefs and coping strategies.

Review of Perioperative Music Medicine: Mechanisms of Pain and Stress Reduction Around Surgery

Clinical-experimental considerations and an approach to understanding the autonomic basis of improved surgical outcomes using Perioperative Music Medicine (PMM) are reviewed. Combined surgical, psycho-physiological, and experimental perspectives on Music Medicine (MM) and its relationship to autonomic nervous system (ANS) function are discussed. Considerations are given to the inter-related perioperative effects of MM on ANS, pain, and underlying vagal and other neural circuits involved in emotional regulation and dysregulation. Many surgical procedures are associated with significant pain, which is routinely treated with post-operative opioid medications, which cause detrimental side effects and delay recovery. Surgical trauma shifts the sympathetic ANS to a sustained activation impairing physiological homeostasis and causing psychological stress, as well as metabolic and immune dysfunction that contribute to postoperative mortality and morbidity. In this article, we propose a plan to operationalize the study of mechanisms mediating the effects of MM in perioperative settings of orthopedic surgery. These studies will be critical for the implementation of PMM as a routine clinical practice and to determine the potential limitations of MM in specific cohorts of patients and how to improve the treatment.

Heart rate variability: A biomarker of selective response to mindfulness-based treatment versus fluoxetine in generalized anxiety disorder

BACKGROUND

Mindfulness-based interventions (MBIs) are effective for some, but not all patients with anxiety disorders, but no clinical features have been consistently able to differentiate which patients are more likely to respond. In this study, we tested heart rate variability (HRV), a proposed correlate of regulated emotional response, as a moderator of treatment response to an MBI compared with pharmacotherapy.

METHODS

Seventy-seven patients with GAD had HRV data collected before randomization to pharmacological treatment with fluoxetine or Body-in-Mind Training (an MBI focused on bodily movement attention). HRV was used to predict treatment response measured by the Hamilton anxiety rating scale at 0 (baseline), 5, and 8 weeks (end of the intervention).

RESULTS

The HF (nu) index of HRV was a strong moderator of treatment response between BMT and fluoxetine (estimate = 4.27 95%CI [1.19, 8.19]). Although fluoxetine was overall slightly superior to BMT in this study, no differences were found between groups in patients with high HF (nu) scores (estimate = -1.85 CI95% [-9.21, 5.52]). In contrast, patients with low HF (nu) achieved lower anxiety rating scores with fluoxetine treatment when compared with BMT (estimate = -10.29, 95% CI [-17.59, -2.99]).

LIMITATIONS

A relatively small sample of patients was included.

CONCLUSIONS

HRV was able to identify a subgroup for which MBI was less effective than pharmacotherapy and is a promising candidate as a selective biomarker for treatment response between an MBI and fluoxetine.

"Third-wave" cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry

For decades, cognitive and behavioral therapies (CBTs) have been tested in randomized controlled trials for specific psychiatric syndromes that were assumed to represent expressions of latent diseases. Although these protocols were more effective as compared to psychological control conditions, placebo treatments, and even active pharmacotherapies, further advancement in efficacy and dissemination has been inhibited by a failure to focus on processes of change. This picture appears now to be evolving, due both to a collapse of the idea that mental disorders can be classified into distinct, discrete categories, and to the more central attention given to processes of change in newer, so-called "third-wave" CBTs. Here we review the context for this historic progress and evaluate the impact of these newer methods and models, not as protocols for treating syndromes, but as ways of targeting an expanded range of processes of change. Five key features of "third-wave" therapies are underlined: a focus on context and function; the view that new models and methods should build on other strands of CBT; a focus on broad and flexible repertoires vs. an approach to signs and symptoms; applying processes to the clinician, not just the client; and expanding into more complex issues historically more characteristic of humanistic, existential, analytic, or system-oriented approaches. We argue that these newer methods can be considered in the context of an idiographic approach to process-based functional analysis. Psychological processes of change can be organized into six dimensions: cognition, affect, attention, self, motivation and overt behavior. Several important processes of change combine two or more of these dimensions. Tailoring intervention strategies to target the appropriate processes in a given individual would be a major advance in psychiatry and an important step toward precision mental health care.

Psychophysiological assessment of stress reactivity and recovery in anxiety disorders

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder) and 28 healthy control (HC) participants underwent psychophysiological monitoring including electrocardiogram, respiration rate, electrodermal activity, gastrocnemius electromyograph, and end-tidal CO₂ for a 3-min resting phase, a 6-min mild stressor phase, and a 3-min recovery phase. Anxious patients then went on to receive naturalistic cognitive-behavioral therapy (CBT) in a specialty outpatient clinic. Results for the reactivity phase indicated that compared to HCs, patients with social anxiety disorder exhibited heightened psychophysiological reactivity while patients with panic disorder and generalized anxiety disorder exhibited attenuated reactivity. Results for physiological recovery (return to baseline after the stressor was withdrawn) were mixed, but provided some support for slower autonomic recovery in patients with generalized anxiety disorder and panic disorder compared to HCs. Participants with all anxiety disorders exhibited diminished change in high frequency heart rate variability compared to HCs. Generally, psychophysiological reactivity and recovery were not associated with CBT outcome, though exploratory analyses indicated that greater respiration rate reactivity and stronger respiration rate recovery were associated with better CBT outcomes in patients with panic disorder.

Anterior prefrontal brain activity during emotion control predicts resilience to post-traumatic stress symptoms

Regulating social emotional actions is essential for coping with life stressors and is associated with control by the anterior prefrontal cortex (aPFC) over the amygdala. However, it remains unclear to what extent prefrontal emotion regulation capacities contribute to resilience against developing post-traumatic stress disorder (PTSD) symptoms. Here, 185 police recruits who experienced their core trauma in the line of duty participated in a prospective longitudinal study. Pre- and post-trauma, they performed a well-established functional magnetic resonance imaging (fMRI) approach-avoidance task, mapping impulsive and controlled emotional actions. Higher baseline aPFC, dorsal and medial frontal pole activity was related to lower PTSD symptoms after trauma exposure. aPFC activity predicted symptom development over and above self-reported and behavioural measures. Trauma exposure, but not trauma symptoms, predicted amygdala activation at follow-up. These findings suggest that prefrontal emotion regulation activity predicts increased resilience against developing post-traumatic stress symptoms and may provide fruitful starting points for prediction and intervention studies.

Heart rate and heart rate variability as outcomes and longitudinal moderators of treatment for pain across follow-up in Veterans with Gulf War illness

AIMS

Accumulating evidence suggests Gulf War illness (GWI) is characterised by autonomic nervous system dysfunction (higher heart rate [HR], lower heart rate variability [HRV]). Yoga - an ancient mind-body practice combining mindfulness, breathwork, and physical postures - is proposed to improve autonomic dysfunction yet this remains untested in GWI. We aimed to determine (i) whether HR and HRV improve among Veterans with GWI receiving either yoga or cognitive behavioural therapy (CBT) for pain; and (ii) whether baseline autonomic functioning predicts treatment-related pain outcomes across follow-up.

MAIN METHODS

We present secondary analyses of 24-hour ambulatory cardiac data (mean HR, square root of the mean squared differences between successive R-R intervals [RMSSD], high frequency power [HF-HFV], and low-to-high frequency ratio [LF/HF] extracted from a 5-min window during the first hour of sleep) from our randomised controlled trial of yoga versus CBT for pain among Veterans with GWI (ClinicalTrials.govNCT02378025; N = 75).

KEY FINDINGS

Veterans who received CBT tended towards higher mean HR at end-of-treatment. Better autonomic function (lower mean HR, higher RMSSD/HF-HRV) at baseline predicted greater reductions in pain across follow-up, regardless of treatment group. Better baseline autonomic function (mid-range-to-high RMSSD/HF-HRV) also predicted greater pain reductions with yoga, while worse baseline autonomic function (higher mean HR, lower RMSSD/HF-HRV) predicted greater pain reductions with CBT.

SIGNIFICANCE

To our knowledge, this is the first study to suggest that among Veterans with GWI, HR may increase with CBT yet remain stable with yoga. Furthermore, HR and HRV moderated pain outcome across follow-up for yoga and CBT.

Behavioral Test (BAT-Back): Preliminary Evidence for a Successful Predictor of Treatment Outcome After Exposure Treatment for Chronic Low Back Pain

OBJECTIVES

Although several questionnaires assessing fear of movement exist, it is still a challenge to identify individuals who might benefit more from exposure for chronic pain than from other psychological approaches and vice versa. Psychological approaches to chronic pain cannot advance toward the often called-for "tailored approaches" because of limited knowledge about treatment predictors. Our aim was to evaluate the additional predictive value of avoidance behavior based on behavioral observation.

METHODS

This study examined pretreatment self-report and behavioral measures as predictors of treatment outcome for n=43 patients experiencing disabling chronic low back pain, who took part in a randomized controlled trial in which they received 10 to 15 sessions of exposure treatment. Only patients with elevated fear avoidance based on self-report measures were included. Data were analyzed using regression analyses and classification and regression trees.

RESULTS

Regression analyses showed that higher avoidance behavior at pretreatment as measured by the Behavioral Avoidance Test-Back Pain (BAT-Back) significantly predicted reduction in global disability (with a small to medium effect), but not in specific disability. Self-report measures failed to predict treatment success for both outcome measures. Classification and regression trees divide subgroups who might benefit from exposure treatment through a BAT-Back score of >22 for Pain Disability Index.

DISCUSSION

There is some preliminary evidence that pretreatment avoidance behavior might be an indicator for reduction in global disability after exposure treatments in patients experiencing disabling chronic low back pain and elevated fear avoidance. We identified preliminary cutoff scores that need further investigation.

Psychological inflexibility and somatization in nonepileptic attack disorder

BACKGROUND

There is no clear understanding of what causes and maintains nonepileptic attack (NEA) disorder (NEAD), or which psychological therapies may be helpful. The relationships between variables of psychological inflexibility: experiential avoidance (EA), cognitive fusion (CF), mindfulness, and key outcome variables in NEAD: somatization, impact upon life, and NEA frequency were investigated.

METHOD

Two hundred eighty-five individuals with NEAD completed validated measures online. Linear regression was used to explore which variables predicted somatization and impact upon life. Ordinal regression was used to explore variables of interest in regard to NEA frequency.

RESULTS

Mindfulness, EA, CF, somatization, and impact upon life were all significantly correlated. Mindfulness uniquely predicted somatization when considered in a model with EA and CF. Higher levels of somatization increased the odds of experiencing more NEAs. Individuals who perceived NEAD as having a more significant impact upon their lives had more NEAs, more somatic complaints, and more EA.

CONCLUSIONS

Higher levels of CF and EA appear to be related to lower levels of mindfulness. Lower levels of mindfulness predicted greater levels of somatization, and somatization predicted NEA frequency. Interventions that tackle avoidance and increase mindfulness, such as, acceptance and commitment therapy, may be beneficial for individuals with NEAD. Future directions for research are suggested as the results indicate more research is needed.

Emotional Dysregulation in Adolescents: Implications for the Development of Severe Psychiatric Disorders, Substance Abuse, and Suicidal Ideation and Behaviors

Well-tuned emotional regulation is fundamental for human life and psychological well-being. Negative physiological emotions are counterbalanced by positive ones, and this equilibrium is the mainstay of human physiological affective states. However, this mechanism may sometimes become dysfunctional when negative emotions are not correctly counterbalanced, causing maladaptive behaviors, especially during adolescence. A very interesting review by Young et al. was recently published (Brain Sci.2019, 9(4), 76) and stimulated us to reflect on this topic. The screening for emotional disturbances and dysregulation in adolescents must be included in all the preventive and interventional programs aimed to achieve both physical and psychological well-being of the population and early intervention should be provided in order to avoid progression toward clinically relevant psychiatric disorders in late adolescence and adulthood.

Brain and Physiological Markers of Autonomic Function Are Associated With Treatment-Related Improvements in Self-Reported Autonomic Dysfunction in Veterans With Gulf War Illness: An Exploratory Pilot Study

BACKGROUND

Gulf War Illness (GWI) is a poorly understood condition characterized by a constellation of mood, cognitive, and physical symptoms. A growing body of evidence demonstrates autonomic nervous system (ANS) dysfunction. Few published treatment studies exist for GWI.

METHOD

We recently completed a randomized controlled trial comparing a 10-week group yoga intervention to 10-week group cognitive behavioral therapy (CBT) for veterans with GWI. Here, we present exploratory data on ANS biomarkers of treatment response from a small pilot exploratory neurophysiological add-on study (n = 13) within that larger study.

RESULTS

Findings suggest that veterans with GWI receiving either yoga or CBT for pain improved following treatment and that changes in biological ANS-especially for the yoga group-moved in the direction of healthy profiles: lower heart rate, higher square root of the mean squared differences between successive R-R intervals (RMSSD), greater parasympathetic activation/dominance (increased high-frequency heart rate variability [HF-HRV], decreased low-frequency/high-frequency [LF/HF] ratio), reduced right amygdala volume, and stronger amygdala-default mode/amygdala-salience network connectivity, both immediately posttreatment and at 6-month follow-up. Biological mechanisms of CBT appeared to underlie improvements in more psychologically loaded symptoms such as self-reported fatigue and energy. Higher tonic arousal and/or more sympathetic dominance (higher skin conductance, lower RMSSD, lower HF-HRV, higher LF/HF ratio) pretreatment predicted greater treatment-related improvements in self-reported ANS for both the yoga and CBT group.

CONCLUSION

These exploratory pilot data provide preliminary support for the suggestion that treatment (yoga, CBT) is associated with improvements in both biological and self-reported ANS dysfunctions in GWI. The major limitation for these findings is the small sample size. Larger and more controlled studies are needed to replicate these findings and directly compare biomarkers of yoga versus CBT.

Treatment Integrity and Social Validity of the FRIENDS for Life Programme in a Northeastern Canadian School System

The FRIENDS for Life (FFL) programme, a school-based anxiety prevention programme, targets anxiety reduction and resiliency development in elementary school-aged children (Barrett, Sonderegger & Xenos, 2003). In the context of equivocal effectiveness findings regarding FFL in Canadian schools, the present study assessed pre–post changes in anxiety, self-esteem, and prosocial behaviour in a school system in Northeastern Canada. To yield further insight to the potential sources of equivocal FFL effectiveness findings, we also evaluated FFL treatment integrity (TI) and social validity (SV). Few studies have assessed FFL TI at the level of identifying which programme sessions, or within-session content, have or have not been adhered to (Higgins & O'Sullivan S, 2015). Similarly, few studies have provided detailed programme SV data or perceived programme benefits by children and parents. TI and SV can provide programme data beyond anxiety reduction, which is key in prevention programming research, as pre–post changes are challenging to detect in ‘healthy’ samples (Durlak & Wells, 1997). Treatment outcome, TI, and SV data were collected from classrooms across 10 elementary schools administering FFL. The sample included 210 child and 108 parent participants; post-testing occurred 1 week following FFL programme completion. Findings indicated significant decreases from pre- to post-test in child-reported anxiety and self-esteem but no changes in prosocial behaviours. Findings suggest that low TI ratings may have impacted anxiety, self-esteem, and prosocial behaviour results, and that child-reported SV may be more related to programme outcomes than parent-reported SV. Implications for FFL programme developers and future FFL evaluation studies are discussed.

A Randomized Controlled Trial in Routine Clinical Practice Comparing Acceptance and Commitment Therapy with Cognitive Behavioral Therapy for the Treatment of Major Depressive Disorder

BACKGROUND

Since current therapies for depression are effective but not for all patients alike, we need to further improve available treatments. Existing research suggests that acceptance and commitment therapy (ACT) may effectively treat major depressive disorder (MDD). We compared ACT with cognitive behavioral therapy (CBT) for depression, testing the hypothesis that CBT would outperform ACT.

METHODS

We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before and after treatment and at the 6-month follow-up, assessing diagnosis, symptom levels of depression, and quality of life.

RESULTS

After treatment, the rates of remission from depression were 75 and 80% for the ACT and CBT conditions, respectively. Patients in both conditions further reported significant and large reductions in depressive symptoms and improvement in quality of life from before to after treatment as well as at the follow-up. Our findings indicated no significant differences between the two intervention groups.

CONCLUSION

Our results indicate that CBT is not more effective in treating depression than ACT. Further research is needed to investigate whether ACT and CBT work differently for different groups of patients with depression.

Empirically supported psychological treatments and the Research Domain Criteria (RDoC)

BACKGROUND

The Research Domain Criteria (RDoC) has been developed as an alternative approach to studying psychiatric disorders. The RDoC constructs and units of analysis, from genes up through paradigms, are intended to describe a hierarchy of priority measurements. Several of these have been investigated in the context of empirically-supported treatments, as either moderators or mediators of outcome.

METHOD

This review considers the available research on the moderating and mediating role of genes, molecules, circuits and physiology in cognitive-behavior therapy (CBT) outcome studies for negative valence system conditions.

FINDINGS

Based on the review, research has aspired to identify candidate genes, molecules, circuits and physiological moderators or mediators of treatment, but no definitive tests have been conducted. Instead, several candidate variables have been found that deserve further investigation.

LIMITATIONS

The available research is based on diagnoses from the DSM, whereas the RDoC initiative endeavors to determine empirically valid taxonomic signs.

CONCLUSIONS

The results of this review are discussed in the joint context of developments in empirically-supported psychological therapy and the specific aims of the RDoC initiative, and conclude with recommendations for future research.

Public speaking avoidance as a treatment moderator for social anxiety disorder

BACKGROUND AND OBJECTIVES

Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) have both garnered empirical support for the effective treatment of social anxiety disorder. However, not every patient benefits equally from either treatment. Identifying moderators of treatment outcome can help to better understand which treatment is best suited for a particular patient.

METHODS

Forty-nine individuals who met criteria for social anxiety disorder were assessed as part of a randomized controlled trial comparing 12 weeks of CBT and ACT. Pre-treatment avoidance of social situations (measured via a public speaking task and clinician rating) was investigated as a moderator of post-treatment, 6-month follow-up, and 12-month follow-up social anxiety symptoms, stress reactivity, and quality of life.

RESULTS

Public speaking avoidance was found to be a robust moderator of outcome measures, with more avoidant individuals generally benefitting more from CBT than ACT by 12-month follow-up. In contrast, clinician-rated social avoidance was not found to be a significant moderator of any outcome measure.

LIMITATIONS

Results were found only at 12-month follow-up. More comprehensive measures of avoidance would be useful for the field moving forward.

CONCLUSIONS

Findings inform personalized medicine, suggesting that social avoidance measured behaviorally via a public speaking task may be a more robust factor in treatment prescription compared to clinician-rated social avoidance.

Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement

Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.

Intervening variables in group-based acceptance & commitment therapy for severe health anxiety

OBJECTIVE

The present study is based on a previously reported successful randomized controlled trial (RCT) on Acceptance and Commitment Group therapy (ACT-G) for severe health anxiety (HA) and investigates intervening variables of ACT for HA. The process primarily targeted by ACT is psychological flexibility (PF). No randomized study has yet examined the possible intervening variables of ACT for HA.

METHODS

126 patients diagnosed with severe HA were enrolled in the RCT of which 107 were included in the analyses. The outcome measure was illness worry (Whiteley Index) and included process variables were PF and facets of mindfulness.

RESULTS

Statistically significant indirect effects (IE) of ACT-G on the outcome of illness worry 6 months after treatment were found for PF (IE = -5.5, BCa 99% CI -12.3;-1.2) and one mindfulness subscale, namely 'non-react' (IE = -6.5 BCa 99% CI -15.3: 1.0).

CONCLUSION

In line with the ACT model of change, PF may have a small to moderate IE on decrease in illness worry. Of the mindfulness scales, only 'non-react' showed a significant IE. Although tentative, due to no active comparison control condition, these results support that PF is a intervening variable in ACT treatment aimed at reducing illness worry in patients with severe HA.

Low pre-treatment end-tidal CO2 predicts dropout from cognitive-behavioral therapy for anxiety and related disorders

Recent clinical trial research suggests that baseline low end-tidal CO₂ (ETCO₂, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO₂ among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO₂, and respiration rate (the first minute was analyzed). Lower ETCO₂ was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO₂ significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO₂ significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO₂ patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO₂ is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO₂ might benefit from additional intervention that targets respiratory abnormality.

The Bodymind Model: A platform for studying the mechanisms of change induced by art therapy

This paper introduces the Bodymind model of Art Therapy and delineates the processes through which it has salutary effects on individuals coping with a variety of health related challenges. The goal of this model is to articulate how activation, reorganization, growth and reintegration of the self can emerge from bodymind processes activated by art therapy. It provides a framework for the conduct of research that will test the key theoretical mechanisms through which art therapy benefits clients. We expect this model to be a spring board for discussion, debate and development of the profession of art therapy. Furthermore, we hope readers can use this model to conduct sound mechanistic studies. This paper can inform social scientists and medical professionals on the manner in which art making can contribute to health.

Affect, emotion dysregulation and sleep quality among low-income women

OBJECTIVES

To examine the underlying mechanisms through which steady state emotions, specifically affect and emotion regulation, influence sleep quality among young adult low-income women.

DESIGN

Cross-sectional.

SETTING

Stress and Health Study (2006-2012) in southeast Texas.

PARTICIPANTS

A subgroup (n=392) of racially and ethnically diverse young adult women ages 18-31.

MEASUREMENTS

Participants provided measures of positive and negative affect, difficulties in emotion regulation, and sleep quality. Structural equation models were designed to identify differential mediating roles of emotion dysregulation in the association between both positive and negative affect and sleep quality.

RESULTS

The relationship between positive affect and improved sleep quality operated completely through domains of emotion regulation (β= -0.054, 95% CI: -0.08 to -0.03), whereas the adverse effects of negative affect exhibited both direct (β= 0.142, 95% CI: 0.06 to 0.23) and indirect (β= 0.124, 95% CI: 0.08 to 0.16) effects on poor sleep. Negative affect was associated with poor sleep quality via two pathways-it directly influenced sleep quality and it indirectly influenced sleep quality among women experiencing difficulties in emotion regulation.

CONCLUSIONS

Therapies targeting improvement and maintenance of healthy emotion regulation domains, while delineating the positive affect state from the negative affect state, may lessen the burden of poor sleep quality among low-income women.

How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms

BACKGROUND

Acceptance and Commitment Therapy (ACT) has been demonstrated to be effective in reducing depressive symptoms. However, little is known how and for whom therapeutic change occurs, specifically in web-based interventions. This study focuses on the mediators, moderators and predictors of change during a web-based ACT intervention.

METHODS

Data from 236 adults from the general population with mild to moderate depressive symptoms, randomized to either web-based ACT (n = 82) or one of two control conditions (web-based Expressive Writing (EW; n = 67) and a waiting list (n = 87)), were analysed. Single and multiple mediation analyses, and exploratory linear regression analyses were performed using PROCESS and linear regression analyses, to examine mediators, moderators and predictors on pre- to post- and follow-up treatment change of depressive symptoms.

RESULTS

The treatment effect of ACT versus the waiting list was mediated by psychological flexibility and two mindfulness facets. The treatment effect of ACT versus EW was not significantly mediated. The moderator analyses demonstrated that the effects of web-based ACT did not vary according to baseline patient characteristics when compared to both control groups. However, higher baseline depressive symptoms and positive mental health and lower baseline anxiety were identified as predictors of outcome across all conditions. Similar results are found for follow-up.

CONCLUSIONS

The findings of this study corroborate the evidence that psychological flexibility and mindfulness are distinct process mechanisms that mediate the effects of web-based ACT intervention. The results indicate that there are no restrictions to the allocation of web-based ACT intervention and that web-based ACT can work for different subpopulations.

TRIAL REGISTRATION

Netherlands Trial Register NTR2736 . Registered 6 February 2011.

Stress reactivity predicts symptom improvement in children with anxiety disorders

BACKGROUND

We examined the longitudinal associations of autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis rest and reactivity measures with anxiety and depressive symptoms at one-year follow-up in children with anxiety disorders.

METHODS

In a clinical sample of 152 children with a primary DSM-IV anxiety disorder, aged 8 to 12 years, anxiety and depressive symptoms were assessed with the Multidimensional Anxiety Scale for Children and the Children's Depression Inventory at pre-treatment baseline and one year later, after treatment with cognitive behavioral therapy. At baseline, children participated in a 70min stress task. Salivary cortisol was measured directly prior to and 20min post stress task. Skin conductance level (SCL), heart rate and high frequency heart rate variability (HRV) were continuously measured during rest and the stress task. To investigate if rest or reactivity measures predicted anxiety and depressive symptoms at one year follow-up, linear regression analyses were conducted for rest and reactivity measures of SCL, heart rate, HRV and cortisol separately.

RESULTS

Higher SCL reactivity predicted less decrease of anxiety symptoms at one-year follow-up. Cortisol reactivity showed a weak association with depressive symptoms at one-year follow-up: lower cortisol reactivity predicted less decrease in depressive symptoms.

LIMITATIONS

Only self-reported anxiety and depressive symptoms were used. However, all predictors were objective biological measures, hence there is no risk of shared method variance bias.

CONCLUSIONS

These findings suggest that pre-treatment HPA and ANS responsiveness to stress are predictive biomarkers for a lack of symptom improvement in children with a clinical anxiety disorder.

Affect labeling enhances exposure effectiveness for public speaking anxiety

Exposure is an effective treatment for anxiety but many patients do not respond fully. Affect labeling (labeling emotional experience) attenuates emotional responding. The current project examined whether affect labeling enhances exposure effectiveness in participants with public speaking anxiety. Participants were randomized to exposure with or without affect labeling. Physiological arousal and self-reported fear were assessed before and after exposure and compared between groups. Consistent with hypotheses, participants assigned to Affect Labeling, especially those who used more labels during exposure, showed greater reduction in physiological activation than Control participants. No effect was found for self-report measures. Also, greater emotion regulation deficits at baseline predicted more benefit in physiological arousal from exposure combined with affect labeling than exposure alone. The current research provides evidence that behavioral strategies that target prefrontal-amygdala circuitry can improve treatment effectiveness for anxiety and these effects are particularly pronounced for patients with the greatest deficits in emotion regulation.