The degree to which young children’s anxiety symptoms differentiate according to diagnostic groupings is under-studied, especially in children below the age of 4 years. Theoretical (confirmatory factor analysis, CFA) and statistical (exploratory factor analysis, EFA) analytical methods were employed to test the hypothesis that anxiety symptoms among 2–3-year-old children from a non-clinical, representative sample would differentiate in a manner consistent with current diagnostic nosology. Anxiety symptom items were selected from two norm-referenced parent-report scales of child behavior. CFA and EFA results suggested that anxiety symptoms aggregate in a manner consistent with generalized anxiety, obsessive–compulsive symptoms, separation anxiety, and social phobia. Multi-dimensional models achieved good model fit and fit the data significantly better than undifferentiated models. Results from EFA and CFA methods were predominantly consistent and supported the grouping of early childhood anxiety symptoms into differentiated, diagnostic-specific categories.
Anxiety; Preschool; Nosology; DSM; Factor analysis; Internalizing
The goal of this study was to characterize the contemporaneous and prognostic relationship between symptoms of separation anxiety disorder (SAD) and associated functional impairment. The sample comprised n=2067 8–16 year-old twins from a community-based registry. Juvenile subjects and their parents completed a personal interview on two occasions, separated by an average follow-up period of 18 months, about the subject’s current history of SAD and associated functional impairment. Results showed that SAD symptoms typically caused very little impairment but demonstrated significant continuity over time. Older youth had significantly more persistent symptoms than younger children. Prior symptom level independently predicted future symptom level and diagnostic symptom threshold, with and without impairment. Neither diagnostic threshold nor severity of impairment independently predicted outcomes after taking account of prior symptom levels. The results indicate that impairment may index current treatment need but symptom levels provide the best information about severity and prognosis.
separation anxiety; disorders; anxiety; DSM-IV; impairment; clinical significance criterion
Social anxiety disorder (SAD) and antisocial personality disorder (ASPD) are not often thought of as being comorbid. However, recent research suggests the existence of a SAD subtype with characteristics atypical of SAD but common to ASPD. Thus, we explored two competing hypotheses: 1) SAD and ASPD represent opposite ends of a single dimension, or 2) SAD and ASPD exist on two separate dimensions that may be positively correlated. Data were obtained from the National Epidemiological Survey on Alcohol and Related Conditions. SAD-ASPD was related to greater impairment and psychiatric comorbidity than either disorder alone. The SAD-ASPD group was also more likely to seek treatment for their SAD symptoms and to drink before/during antisocial acts than the SAD only group. The presence of SAD for individuals with ASPD (and vice versa) does not appear to provide any “protective benefits.” SAD and ASPD appear to be two separate but correlated disorders.
Social phobia; Social anxiety disorder; Antisocial personality disorder; Comorbidity
The present study applied latent class analysis to a sample of 810 participants residing in southern Mississippi at the time of Hurricane Katrina to determine if people would report distinct, meaningful PTSD symptom classes following a natural disaster. We found a four-class solution that distinguished persons on the basis of PTSD symptom severity/pervasiveness (Severe, Moderate, Mild, and Negligible Classes). Multinomial logistic regression models demonstrated that membership in the Severe and Moderate Classes was associated with potentially traumatic hurricane-specific experiences (e.g., being physically injured, seeing dead bodies), pre-hurricane traumatic events, co-occurring depression symptom severity and suicidal ideation, certain religious beliefs, and post-hurricane stressors (e.g., social support). Collectively, the findings suggest that more severe/pervasive typologies of natural disaster PTSD may be predicted by the frequency and severity of exposure to stressful/traumatic experiences (before, during, and after the disaster), co-occurring psychopathology, and specific internal beliefs.
Data suggest anxious drivers may engage in problematic behaviors that place themselves and others at increased risk of negative traffic events. Three domains of problematic behavior – exaggerated safety/caution, performance deficits, and hostile/aggressive behaviors – previously were identified during development of the Driving Behavior Survey (DBS), a novel measure of anxiety-related behavior. Extending this research, the current study examined the psychometric properties of DBS scores among individuals with posttraumatic stress disorder (PTSD) subsequent to motor vehicle trauma (N = 40). Internal consistencies and 12-week test-retest reliabilities for DBS scales ranged from good to excellent. Comparison of scores to normative student data indicated dose-response relationships for safety/caution and performance deficit subscales, with increased frequency of anxious behavior occurring within the PTSD sample. Associations with standard clinical measures provide additional evidence for anxiety-related driving behavior as a unique marker of functional impairment, distinct from both avoidance and disorder-specific symptoms.
driving anxiety; driving behavior; motor vehicle accident; posttraumatic stress disorder; assessment
Researchers and clinicians wishing to assess anxiety must choose from among numerous assessment options, many of which purport to measure the same or a similar construct. A common reporting metric would have great value, and can be achieved when similar instruments are administered to a single sample and then linked to each other to produce cross-walk score tables. Using item response theory (IRT), we produced cross-walk tables linking three popular “legacy” anxiety instruments – MASQ (N = 743), GAD-7 (N = 748), and PANAS (N = 1120) – to the anxiety metric of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®). The linking relationships were evaluated by resampling small subsets and estimating confidence intervals for the differences between the observed and linked PROMIS scores. Our results allow clinical researchers to retrofit existing data of three commonly-used anxiety measures to the PROMIS Anxiety metric and to compare clinical cut-off scores.
anxiety; linking; PROMIS; MASQ; GAD-7; PANAS
The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) after training. Therapists naïve to ET (N=181) were randomized to: (1) online training (OLT), (2) OLT plus motivational enhancement (ME), or (3) OLT + ME plus a learning community. Twelve weeks after training, self-reported use of ET in clinical practice was high (87.5%) and therapists demonstrated moderate clinical proficiency. Use of ET was predicted by therapist degree, self-efficacy, and knowledge. Clinical proficiency was predicted by therapist anxiety sensitivity, attitudes, and knowledge, as well as organizational and client barriers. Several of these effects were moderated by training condition, indicating that therapists who received more comprehensive training were less impacted by barriers and showed enhanced adoption in the presence of facilitating factors. Overall, these results suggest that the primary barriers to the adoption of ET are therapist, not organizational or client, factors.
Dissemination; Implementation; Online Training; Exposure Therapy; Anxiety Disorders
Effective exposure therapies for anxiety disorders have been available for half a century. Over that time we have made great strides increasing the potency of these powerful methods. Yet, most of us in practice still have a conversation like the following with our new patients: Therapist: “So what treatments have you had for your anxiety symptoms to date?” Patient: “I have seen numerous therapists over the last 10 years.” Therapist: “Great, so what did you do?” Patient: “We talked about things. And I learned relaxation and breathing techniques.” Therapist: “Did a therapist ever help you face your fears?” Patient: “What do you mean?” Therapist: “I mean did you directly confront feared situations, perhaps with your therapist outside the office?” Patient: “No, why, is that important?” This oft-repeated conversation highlights the disconnect between the well-established efficacy of exposure-based treatments for pathological anxiety and their inaccessibility to most anxious clients. This failure to successfully disseminate exposure-based empirically supported treatments is the motivation for this special issue. The articles that follow consider the causes of this dissemination failure, highlight areas of success, and offer constructive remedies for addressing this important public health problem.
Dissemination; Exposure therapy; Anxiety disorders; Special issue; Empirically supported treatments; Introduction
The central aim of this study is to estimate prevalence, ages of onset, severity, and associated disability of anxiety disorders among African Americans, Caribbean Blacks, and non-Hispanic whites in the U.S. Results indicated that whites were at elevated risk for generalized anxiety disorder, panic disorder, and social anxiety compared to Caribbean Blacks and African Americans. Black respondents were more likely to meet criteria for PTSD. When African American and Caribbean Black respondents met criteria for an anxiety disorder, they experienced higher levels of overall mental illness severity and functional impairment compared to whites. White respondents were at greater risk to develop generalized anxiety, social anxiety, and panic disorders late in life. Risk of developing PTSD endured throughout the life course for blacks whereas whites rarely developed PTSD after young adulthood. These results can be used to inform targeted interventions to prevent or remediate anxiety disorders among these diverse groups.
Race; Anxiety; Prevalence; Epidemiology; Ethnicity
Posttraumatic stress disorder (PTSD) is a moderately heritable anxiety disorder that may develop after exposure to trauma. However, only few genetic variants that relate to PTSD have been studied. This study examined the relationship between 12 single nucleotide polymorphisms (SNPs) in the corticotropin-releasing hormone receptor 1 gene (CRHR1) and post-disaster PTSD symptoms and diagnosis in adults exposed to 2004 Florida hurricanes. CRHR1 regulates the hypothalamic-pituitary-adrenal (HPA) axis; dysregulation of the HPA axis is characteristic of stress phenotypes. Final analyses were conducted in the European-American (EA) subsample (n=564) due to population stratification. After correction for multiple testing, rs12938031 and rs4792887 remained associated with post-hurricane PTSD symptoms. Additionally, rs4792887 was associated with post-hurricane diagnosis of PTSD. This study is the first to examine CRHR1 in relation to PTSD in adults, and provides evidence for the importance of CRHR1 variation in the etiology of PTSD. Although results are preliminary and require replication, they justify follow-up efforts to characterize how this gene relates to PTSD.
Posttraumatic stress disorder; CRHR1; HPA axis; disasters; trauma
Social anxiety disorder and body dysmorphic disorder are considered nosologically distinct disorders In contrast, some cognitive models suggest that social anxiety disorder and body dysmorphic disorder share similar cognitive maintenance factors. The aim of this study was to examine the effects of psychological treatments for social anxiety disorder on body dysmorphic disorder concerns. In Study 1, we found that 12 weekly group sessions of cognitive-behavioral therapy led to significant decreases in body dysmorphic symptom severity. In Study 2, we found that an attention retraining intervention for social anxiety disorder was associated with a reduction in body dysmorphic concerns, compared to a placebo control condition. These findings support the notion that psychological treatments for individuals with primary social anxiety disorder improve co-occurring body dysmorphic disorder symptoms.
social anxiety disorder; body dysmorphic disorder; attention bias; cognitive bias modification
Anxiety sensitivity (AS) has been conceptualized as trait-like vulnerability and maintenance factor for PTSD. Although recent literature has demonstrated its malleability during treatment, few have examined its influence on and effect from PTSD treatment. Using multilevel regression analyses we examined: a) changes in AS during treatment, and b) whether pre-treatment AS predicted PTSD treatment response, in sample of female victims of interpersonal trauma receiving one of three treatments (Cognitive Processing Therapy, Cognitive Processing Therapy-Cognitive, and Written Accounts). Participants exhibited reductions in total ASI scores from pre- to post-treatment. Growth curve modeling revealed slightly different trajectories of PTSD symptoms as a function of pre-treatment AS, and overall decreases in PTSD symptoms during treatment were not associated with pretreatment AS. Pretreatment AS dimensions impacted PTSD total scores and symptoms clusters differentially. Clinical and theoretical implications for these results are discussed.
Anxiety Sensitivity; Posttraumatic Stress Disorder; Treatment; Cognitive Therapy
Preliminary evidence supports the role of emotion-related deficits in generalized anxiety disorder (GAD), including heightened emotional intensity, poor understanding of emotion, negative cognitive reactivity to emotions, and maladaptive emotion management. However, questions remain concerning the specificity of these emotion-related deficits compared to highly comorbid conditions such as social anxiety disorder (SAD). In the current study, 113 undergraduate students were administered measures of GAD, SAD, and emotion-related factors in order to clarify relationships among these variables. In univariate analyses, presence of SAD did not significantly impact the association between GAD and the emotion-related measures. Further, a discriminant function analysis revealed that emotional intensity and impaired regulation strategies provided the greatest discrimination between groups and best predicted a diagnosis of GAD (regardless of SAD comorbidity). Although their discriminatory ability was weaker, poor emotional understanding best predicted a diagnosis of SAD (regardless of GAD comorbidity), and non-acceptance of emotions best predicted comorbid GAD and SAD.
Generalized anxiety disorder; Social phobia; Comorbidity; Emotion; Emotion dysregulation; Emotion regulation
To better understand the development and exacerbation of late-life anxiety, we tested a risk model positing that trait negative affect (NA) characteristics would interact with cognitive functioning, thereby increasing some older adults’ risk for increased anxiety symptoms. The moderator-mediator model consisted of measures of NA, cognitive functioning, and their interaction, as predictors of later Hamilton Anxiety Rating Scale scores (HARS) via a mediational process, subjective memory concerns (SMCs). Older adults (aged 65-years and over; Mage = 76.7 years, SD = 6.90 years) completed evaluations four times over approximately 18 months. A latent growth curve model including Anxiety Sensitivity Index total score (ASI), Mattis Dementia Rating Scale-2 (DRS) total raw score, the ASI x DRS interaction, a SMC measure as mediator, HARS intercept (scores at times 3 and 4), and HARS slope provided good fit The ASI x DRS-2 interaction at Time 1 predicted HARS slope score (β = −.34, p <.05). When ASI score was high, stronger cognitive functioning was associated with fewer anxiety symptoms. The indirect effect of ASI score predicting HARS score 18-months later through the SMC mediator was statistically significant (β = .08, p < .05). Results suggest that the cognitive functioning changes associated with aging might contribute to the development of anxiety symptoms in older adults with specific NA traits. Implications for predicting and preventing late life anxiety disorders are discussed.
older adults; aging; risk factors; anxiety symptoms; cognitive functioning; memory complaints
Understanding differences in responses following attempts to suppress versus simply monitor intrusive thoughts is important given the established relationship between intrusive thinking and numerous forms of psychopathology. Moreover, these differences may vary as a function of age. Because of the links between aging and both enhancement in emotion regulation skills and decline in inhibition skills, older and younger adults were expected to differ in their responses (e.g., experience of negative affect and thought recurrence) to attempts at suppressing intrusive thoughts. This study examined whether efforts to suppress thought content that varied in valence and age-relevance differentially affected older (N = 40, aged 66–92) and younger (N = 42, aged 16–25) adults’ ability to inhibit intrusive thought recurrence and their resulting negative affect. Interestingly, older adults experienced less recurrence for most thoughts than younger adults. Also, for several dependent variables (negative affect and perceived difficulty suppressing intrusive thoughts), older adults showed less decline in their magnitude of response across thinking periods (i.e., from suppression to monitoring) than did younger adults. These age effects were not generally moderated by level of trait anxiety, though higher anxiety did predict intrusive thought responding in expected directions, such as greater negative affect. These findings point to independent influences of age and anxiety, and suggest a complex mix of risk and protective factors for older adults’ responses to intrusive thoughts.
aging; intrusive thoughts; thought suppression; emotion regulation; older
Attentional biases are known to play a contributing, and perhaps even causal role in the etiology of anxiety and other negative affective states. The prevalence of anxiety disorders in the older cohort is growing, and there are both theoretical and empirical reasons to suspect that age-related factors could moderate attentional bias effects in the context of late-life anxiety. The current study included one of the most widely-used measures of attentional bias, the dot-probe task (Mathews & MacLeod, 1985). Participants were older adults who were either nonanxious or diagnosed with generalized anxiety disorder. The patient subsample also completed cognitive behavior therapy (CBT) or an equivalent wait list condition, after which the dot probe was administered a second time. Results showed that clinical anxiety had no particular importance for the deployment of attention, casting doubt on the universality of biased attention in older anxiety patients. Although there were no maladaptive biases detected toward either threat or depression words at pretreatment, there was nevertheless a marginally significant differential reduction in bias towards threat words following CBT. This reduction did not occur among those in the wait list condition. Implications are discussed.
attentional bias; dot probe; generalized anxiety disorder; aging; older adults
Information processing bias was evaluated in a sample of 25 older adults with generalized anxiety disorder (GAD) over the course of 12 weeks of escitalopram pharmacotherapy. Using the CANTAB Affective Go/No Go test, treatment response (as measured by the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, and Generalized Anxiety Disorder Severity Scale) was predicted from a bias score (i.e., difference score between response latencies for negative and positive words) using mixed-models regression. A more positive bias score across time predicted better response to treatment. Faster responses to positive words relative to negative words were associated with greater symptomatic improvement over time as reflected by scores on the GADSS. There was a trend towards significance for PSWQ scores and no significant effects related to HAMA outcomes. These preliminary findings offer further insights into the role of biased cognitive processing of emotional material in the manifestation of late-life anxiety symptoms.
Generalized Anxiety Disorder; Aging; Attention; Information Processing Bias; Escitalopram
Most functional neuroimaging studies of panic disorder (PD) have focused on the resting state, and have explored PD in relation to healthy controls rather than in relation to other anxiety disorders. Here, PD patients, Posttraumatic stress disorder (PTSD) patients, and healthy control subjects were studied with functional magnetic resonance imaging utilizing an instructed fear conditioning paradigm incorporating both Threat and Safe conditions. Relative to PTSD and control subjects, PD patients demonstrated significantly less activation to the Threat condition and increased activity to the Safe condition in the subgenual cingulate, ventral striatum and extended amygdala, as well as in midbrain periaquaeductal grey, suggesting abnormal reactivity in this key region for fear expression. PTSD subjects failed to show the temporal pattern of activity decrease found in control subjects.
anxiety disorders; panic disorder; posttraumatic stress disorder; subgenual cingulate cortex; ventral striatum; extended amygdala; brainstem; neuroimaging
The primary goal of this study was to investigate the specificity of the social versus nonsocial components of self-reported behavioral inhibition during childhood with young adults’ current symptoms of anhedonic depression, social anxiety, and anxious arousal. As hypothesized, the social component of BI demonstrated some specificity for symptoms of social anxiety versus other internalizing disorders. Furthermore, results support the hypothesis that the relationship between BI and depressive symptoms is mediated by levels of social anxiety and anxious arousal.
The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.
Social anxiety disorder; Social phobia; Emotion regulation; Generalized expectancies for mood; regulation
Individual cognitive-behavioral therapy (CBT) provides anxious youth with skills and experiences to increase “brave” behavior in the face of feared situations. This study addresses whether parental encouragement of bravery during an anxiety provoking and potentially avoidable naturalistic speech task (a) differs between parents of youth (ages 9–13) with anxiety disorders (N=47) and parents of healthy non-anxious controls (N=20); (b) influences response to treatment; and (c) changes during treatment for anxious youth randomized to receive CBT (N=30) or Child-Centered Therapy (CCT; a non-directive active comparison treatment; N=17). Parent-child dyads were videotaped during a discussion of whether or not the child should complete an optional speech task. Parents of anxious youth showed less encouragement of bravery than parents of controls. Encouragement of bravery increased from pre- to post-treatment for youth who received CBT but not CCT, and pre-treatment encouragement of bravery predicted a better response to treatment, particularly for youth receiving CBT.
child anxiety; avoidance; approach; cognitive behavioral therapy; parenting; parent-child interaction
Cognitive theorists propose that attentional biases for threatening information play an important role in the development and maintenance of anxiety disorders. If attentional biases for threat figure in the maintenance of anxiety, then the experimental reduction of the bias for threat (attention training) should reduce anxiety. We randomly assigned 41 spider-fearful individuals to receive either attention training (n = 20) or control procedures (n = 21). We used a modified dot-probe discrimination paradigm with photographs of spiders and cows to train attention. Training reduced attentional bias for spiders, but only temporarily. Although both groups declined in spider fear and avoidance, reduction in attentional bias did not produce significantly greater symptom reduction in the training group than in the control group. However, reduction in attentional bias predicted reduction in self-reported fear for the training group. The reduction in attentional bias for threat may have been insufficiently robust to produce symptom reduction greater than that produced by exposure to a live spider and spider photographs alone. Alternatively, attention training may be an unsuitable intervention for spider fear.
attention training; cognitive bias modification; attentional bias; spider phobia; dot-probe paradigm
Accumulating evidence suggests that social anxiety is associated with biased processing of positive social information. However, it remains to be determined whether those biases are simply correlates of, or play a role in maintaining social anxiety. The current study examined whether diminished attentional allocation for positive social cues mediates the link between social anxiety and anxiety reactivity to a social-evaluative task. Forty-three undergraduate students ranging in severity of social anxiety symptoms completed a baseline measure of attentional bias for positive social cues (i.e., modified probe detection task) and subsequently delivered an impromptu videotaped speech. Mediation analyses revealed that the tendency to allocate attention away from positive social stimuli mediated the effect of social anxiety on change in state anxiety in response to the stressor. The current findings add to a nascent empirical literature suggesting that aberrant processing of positive social information may contribute to the persistence of excessive social anxiety.
Social anxiety; attention; positive; anxiety vulnerability; information processing
This study examined the influence of trauma history and PTSD symptoms on the behavior of veterans and their intimate partners (287 couples; N = 574) observed during conflict discussions and coded using the Rapid Marital Interaction Coding System (Heyman, 2004). Dyadic structural equation modeling analyses showed that PTSD was associated with more frequent displays of hostility and psychological abuse and fewer expressions of acceptance and humor in both veterans and their partners. Findings provide new insight into the social and emotional deficits associated with PTSD and emphasize the importance of addressing the trauma histories and PTSD of both partners when treating veteran couples with relationship disturbance.
A number of factors are believed to confer risk for anxiety development in children; however, cultural variation of purported risk factors remains unclear. We examined relations between controlling and rejecting parenting styles, parental modeling of anxious behaviors, child interpretive biases, and child anxiety in a mixed clinically anxious (n = 27) and non-clinical (n = 20) sample of Latino children and at least one of their parents. Families completed discussion-based tasks and questionnaires in a lab setting. Results indicated that child anxiety was: linked with parental control and child interpretative biases; associated with parental modeling of anxious behaviors at a trend level; and not associated with low parental acceptance. Findings that controlling parenting and child interpretive biases were associated with anxiety extend current theories of anxiety development to the Latino population. We speculate that strong family ties may buffer Latino children from detrimental effects of perceived low parental acceptance.
children; anxiety; culture; Latino; Hispanic; parenting; modeling; cognitive bias