Search

Objectives Women's greater prevalence of anxiety disorders compared to men is widely assumed to be partly due to gender differences in cognitive and behavioural factors that perpetuate anxiety, such as repetitive negative thinking (RNT) and avoidance. However, past studies assessing this assumption have not controlled for gender differences in baseline symptom severity, the type of stressful life experiences against which RNT and avoidance are measured, or emotional reactivity to these experiences. Design Using a two-group design, the present study controlled for these confounds by comparing avoidance and RNT in relation to a controlled symptom provocation task in spider phobic men and women with equivalent spider fear severity on the Fear of Spiders Questionnaire. Methods Participants engaged in a behavioural approach test (BAT) involving a live spider, during which they were assessed for avoidance (physical proximity to the spider) and subjective distress. Two weeks later, participants reported on their levels of negative affect and RNT experienced during the preceding weeks in relation to the BAT. Results Women exhibited greater avoidance and reported greater RNT than men, despite reporting comparable distress and negative affect. Gender remained a significant predictor of avoidance when accounting for distress and also remained a significant predictor of RNT when accounting for depressive symptoms and negative affect. Conclusions These results provide in vivo evidence that heightened avoidance and RNT may perpetuate anxiety symptoms in women independently of gender differences in symptom severity, daily experiences, or emotional reactivity. Practitioner points Following symptom provocation, men and women with spider phobia differ in cognitive and behavioural coping responses. Women exhibit greater avoidance and repetitive negative thinking than men, and these differences are not attributable to gender differences in symptom severity or emotional reactivity. These findings provide novel evidence for gender differences in maintaining factors that perpetuate anxiety disorders whilst accounting for confounding factors present in prior research.

Repetitive negative thinking (RNT) is a transdiagnostic feature of psychiatric disorders. Women report greater RNT than do men, yet the association between uniquely female characteristics, such as fluctuating sex hormones during the menstrual cycle, and RNT has not been established. Here we examined changes in RNT and anxiety symptoms across the menstrual cycle in women with ( n = 40) and without ( n = 41) generalized anxiety disorder (GAD). Women with GAD reported an increase in RNT and negative affect from the follicular phase to the luteal phase; unexpectedly, this was not associated with changes in anxiety symptoms, estradiol, or progesterone. Nonanxious women reported no changes in RNT or anxiety symptoms over the menstrual cycle, but higher within-participants progesterone was associated with reduced RNT and negative affect. These results indicate that uniquely female biological processes may influence core cognitive processes that underlie anxiety disorders, but further investigations to determine the implications for symptom severity are required.

In vivo exposure therapy for specific phobia is an effective treatment, yet up to 80% of individuals with specific phobia go untreated. This appears to be due to an unwillingness to confront the fe...

Exposure therapy is the preferred treatment for specific phobia (SP), with evidence supporting its efficacy whether delivered over multiple sessions or as a single session, such as One-Session Treatment. In this meta-analysis, we compared the efficiency and effectiveness of single- and multi-session exposure for SP. PsycINFO, Embase, MEDLINE, and Cochrane were systematically searched for peer-reviewed articles reporting the effects of multi-session (k = 30) and/or single-session (k = 55) in vivo exposure on SP symptoms in clinical populations (n = 1758 participants). A random-effects model was used to synthesise and compare the pre-post treatment effects (Hedges' g) on approach behaviour and self-reported SP symptoms. Mean total treatment time was significantly longer for multi-session exposure than for single-session. There were no significant differences in the pooled effect sizes of single-session and multi-session exposure at post-treatment and follow-up assessments; effect sizes were large for all outcomes. Phobia subtype significantly moderated the effect size for both treatment approaches, although the direction of association differed according to the outcome measures. Results suggest no evidence for differences in the effectiveness of single- and multi-session exposure, but single-session is more time efficient. These outcomes suggest that policies to facilitate access to single-session exposure would be beneficial.

BACKGROUND Digital, self-guided cognitive behavioural therapy (CBT) interventions circumvent many barriers to in-person therapy for young people; although adherence to these interventions is low. The absence or insufficient disclosure of recommendations or instructions for appropriate use may account for this. OBJECTIVE This systematic review synthesizes the literature on digital CBT interventions for depression and anxiety in young people to describe (i) how appropriate use has been defined and communicated to users as instructions for use; (ii) how adherence has been measured; and (iii) to determine the associations between adherence and treatment outcomes. METHODS A systematic review was conducted with two reviewers extracting data independently. Four electronic databases (Embase, Medline, PsycINFO and The Cochrane library) were searched in April 2021 for studies that met the following inclusion criteria: participants aged between 12-24 years, evaluated a digital CBT intervention targeting depression or anxiety, and reported instructions or recommendations for use or measures of adherence. Studies that evaluated non-CBT interventions or cognitive- or behavioural-only interventions were excluded. Methodological quality was assessed using the using the Cochrane Risk of Bias Tool (ROB) and the Integrated Quality Criteria for the Review of Multiple Study designs (ICROMS). RESULTS There were 32 manuscripts that met inclusion criteria, of which 28 were unique studies (total N=16 578 youth). Definitions of appropriate use varied between the different interventions in terms of intended recipients, duration and frequency of use, and the features employed to support engagement and adherence to appropriate use definitions. Reporting of appropriate use definitions in studies were inconsistent with no study systematically describing components of appropriate use nor providing information on how recommendations for use were relayed to users. Most often definitions of appropriate use were derived from the study protocol and descriptions of intervention features. Adherence was mostly operationalized as the degree of intervention completion; however, reporting of adherence data was heterogeneous. There was little evidence of an association between degree of use and outcomes in the nine studies that examined this. CONCLUSIONS Definitions of appropriate use are unique to each digital CBT intervention. Yet, statements of appropriate use are not systematically reported in the literature. Further, the extent to which recommendations for use are communicated to users is not routinely reported. Despite unique definitions of appropriate use, adherence was most often generically operationalized as the degree of intervention completion and was not consistently associated with outcomes. We propose a framework to promote systematic reporting of definitions of appropriate use for digital interventions to provide guidance to users and to assist the development of appropriate and nuanced measures of adherence. CLINICALTRIAL This protocol was registered with PROSPERO [CRD42020208668].

Fatigue is a prominent symptom of Generalized Anxiety Disorder (GAD). However, the pathways contributing to elevated fatigue in GAD are poorly understood. Sleep disturbance, also prominent in GAD, only partially explains elevated fatigue in GAD. Repetitive negative thinking (RNT) is a cognitive feature of both GAD and sleep disturbance, and RNT has recently also been associated with elevated fatigue. Therefore, this study assessed whether elevated fatigue in GAD is accounted for by a combination of sleep quality and RNT.Between-group, correlational design in 64 primarily university-educated women with and without a GAD diagnosis.Women completed self-report questionnaires assessing RNT experienced in the past few days, previous night's sleep quality, and current physical and mental fatigue. Hierarchical linear regressions were conducted to assess whether the relationship between GAD status and fatigue is accounted for by RNT and sleep quality.Women with GAD reported lower sleep quality, and higher RNT and physical and mental fatigue, compared to women without GAD. Sleep quality partly accounted for group differences in both types of fatigue (β's -0.4), whereas RNT fully accounted for group differences in both types of fatigue (β's 0.29). The relationship between RNT and both types of fatigue was fully accounted for by sleep quality (β's -0.39).These findings indicate that heightened RNT amongst women with GAD may be associated with elevated physical and mental fatigue via its detrimental effects on sleep quality. Interventions that reduce RNT may help to alleviate fatigue symptoms in women with GAD.Women with Generalized Anxiety Disorder (GAD) have elevated fatigue and repetitive negative thinking (RNT), and poorer self-reported sleep quality, relative to women without GAD. Whereas sleep quality only partially accounts for elevated fatigue in GAD, RNT fully accounts for elevated fatigue, and the relationship between RNT and fatigue is fully accounted for by sleep quality. These findings provide novel evidence that women with GAD may have elevated fatigue because of the detrimental effects of RNT on sleep. These findings suggest that targeting RNT in treatment for GAD may help to reduce fatigue in GAD, by improving sleep quality.

Objective Past studies have found that various psychiatric symptoms fluctuate over the menstrual cycle. Sleep disturbance is a transdiagnostic feature of psychiatric conditions and is associated with several symptoms that exhibit menstrual fluctuations. Although some evidence indicates that subjective sleep quality changes over the menstrual cycle in healthy women, no studies have investigated whether sleep fluctuates over the menstrual cycle in psychiatric populations, other than premenstrual dysphoric disorder. Methods The present study used a mixed between- within-groups design to compare self-reported sleep characteristics (sleep onset latency, number and duration of night-time awakenings, and total sleep time), sleep quality, insomnia symptoms, and daytime sleepiness in women with (n = 31) and without (n = 32) generalized anxiety disorder (GAD) at two time points within a single menstrual cycle – the early-follicular (low ovarian hormones) and mid-luteal (high ovarian hormones) phases. Results Women with GAD reported lower sleep quality, more insomnia symptoms, and more daytime sleepiness (ηp2 = 0.13–0.14), but comparable sleep characteristics, compared to women without GAD. In both groups, sleep variables remained stable over the menstrual phases examined. Within-person changes in estradiol and progesterone between the two menstrual phases were mostly not associated with within-person changes in sleep variables, except that larger increases in estradiol were associated with a reduction in the number of night-time awakenings from the early-follicular to mid-luteal phases (β = −0.26). Conclusion These findings indicate that subjective sleep disturbance, unlike other psychiatric symptoms, may not be modulated by the menstrual cycle and ovarian hormones during the phases examined in this study.

ObjectiveThere has been significant disruption to the lives and mental health of adolescents during the COVID-19 pandemic, but the exact nature of the effects is not known. The purpose of this study was to assess the psychological and lifestyle impact of the pandemic on Australian adolescents, using an online survey, administered during and after the peak of the outbreak (June-July 2020).MethodSelf-report surveys were administered online to a sample of 760 Australian adolescents aged 12-18 years old. Surveys assessed worry about contracting COVID-19, behavioral change in response to the pandemic, impact on education, peer and family relationships, lifestyle factors including exercise, technology use and sleep, as well as mental health outcomes including psychological distress, loneliness, health anxiety and wellbeing.ResultsOverall, young people expressed significant concern and worry about contracting the virus, and most (>85%) engaged in behaviors to reduce the risk of transmission. Three quarters of the sample reported a worsening of their mental health since the pandemic began, with negative impacts reported by most respondents on learning, friendships and family relationships. More than 40% of young people reported a decrease in exercise and 70% reported an increase in technology use since the outbreak. There were high levels of uncertainty about the future reported by respondents, and their scores on validated measures indicated higher levels of sleep disturbance, psychological distress and health anxiety, and lower levels of wellbeing, relative to normative samples. Reponses on the Kessler Psychological Distress Scale indicated that 48.3% of the sample were experiencing distress consistent with a probable mental illness, which is much higher than pre-pandemic prevalence rates. Effects on mental health were worse among those who reported a previous diagnosis of depression and/or anxiety relative to those without a history of depression and/or anxiety.ConclusionThese results indicate high levels of disruption and psychological distress experienced by adolescents during the current COVID-19 pandemic. Adolescents are already vulnerable to the onset of mental illness at this developmental stage, and the current research underscores the need to find rapid and accessible ways to support adolescent mental health during times of crisis. There is a need for longitudinal research to evaluate the enduring effects of the pandemic on adolescents.

BACKGROUND Insomnia and sleep disturbance are pervasive and debilitating conditions affecting up to 40% of adolescents. Women and girls are at greater risk of insomnia, yet differences in treatment responsiveness between genders have not been adequately investigated. Additionally, while women report greater symptom severity and burden of illness than men, this discrepancy requires further examination in adolescents. OBJECTIVE The purpose of this study was to examine gender differences in sleep symptom profiles and treatment response in adolescents. METHODS Digital cognitive behavioral therapy for insomnia (CBT-I) treatment responsiveness, as indexed by changes in Insomnia Severity Index (ISI) and Global Pittsburgh Sleep Quality Index (PSQI) scores, was compared in boys and girls (aged 12-16 years; N=49) who participated in a pilot evaluation of the Sleep Ninja smartphone app. Gender differences in self-reported baseline insomnia symptom severity (ISI), sleep quality (PSQI), and sleep characteristics derived from sleep diaries were also examined. RESULTS Compared with boys, we found that girls reported greater symptom severity (P=.04) and nighttime wakefulness (P=.01 and P=.04) and reduced sleep duration (P=.02) and efficiency (P=.03), but not poorer sleep quality (P=.07), more nighttime awakenings (P=.16), or longer time to get to sleep (P=.21). However, gender differences in symptom severity and sleep duration were accounted for by boys being marginally younger in age. Treatment response to CBT-I was equivalent between boys and girls when comparing reductions in symptom severity (P=.32); there was a trend showing gender differences in improvements in sleep quality, but this was not statistically significant (P=.07). CONCLUSIONS These results demonstrate the presence of gender differences in insomnia symptoms and severity in adolescents and suggest further research is required to understand gender differences in insomnia symptom profiles to inform the development of gender-specific digital interventions delivered to adolescents.

Preclinical studies have demonstrated that conditioned fear extinction is impaired in females with low endogenous levels of the sex hormone estradiol, due to menstrual fluctuations or hormonal contraceptive use. As fear extinction is a laboratory model of exposure therapy for anxiety and trauma disorders, here we assessed the hypothesis that treatment outcomes may be diminished when exposure therapy occurs during periods of low estradiol. 90 women with spider phobia (60 cycling and 30 using hormonal contraceptives) underwent a one-session exposure treatment for spider phobia, following which, serum estradiol levels were assessed. A median split in estradiol level was used to divide cycling participants into two groups; lower and higher estradiol. Behavioral avoidance and self-reported fear of spiders were measured pre-treatment, post-treatment, and at a 12 week follow-up assessment. Women using hormonal contraceptives exhibited a significantly slower rate of improvement across treatment, greater behavioral avoidance at post-treatment and follow-up, and fewer self-initiated post-treatment exposure tasks, relative to both groups of cycling women, who did not differ. No group differences in self-reported fear were evident. Correlational analyses revealed that across the whole sample, lower estradiol levels were associated with slower rates of improvement across treatment, and greater self-reported fear and behavioral avoidance at post-treatment, but not follow-up. These results provide the first evidence of an association between endogenous estradiol, hormonal contraceptive use, and exposure therapy outcomes in spider phobic women. Hormonal profile may partly account for variability in responsiveness to psychological treatments for anxiety and trauma disorders in women.

The present study assessed the circumstances under which size estimation biases in spider phobia occur, and whether such biases are modifiable by treatment. Women with (n = 67) and without (n = 33) spider phobia approached a spider during a behavioral approach test (BAT). They provided size estimates of the spider both during and shortly after the BAT (with the spider in view, or not in view, respectively). Phobic women then received cognitive therapy or a placebo treatment and one week later they underwent a second BAT and provided size estimates of the same spider during and after the BAT. Phobic women reported larger size estimates than non-phobic women after, but not during, the BAT. Size estimates after, but not during, the BAT correlated with self-reported fear but not avoidance. Size estimates after, but not during, the BAT reduced from the first to second BAT in phobic women; an effect evident in both the cognitive therapy and placebo treatment conditions. Changes in size estimates were not associated with treatment-induced reductions in fear or avoidance. These results suggest that estimation biases in spider phobia are likely driven by non-perceptual processes. The clinical utility of size estimation measures is discussed.

Background Ovarian hormones have been implicated as a potential source of variability in the effectiveness of exposure therapy for anxiety disorders in women. Additionally, preclinical studies in healthy women indicate that ovarian hormones are related to cognitive modes of emotion regulation, like cognitive restructuring. The purpose of the current study was to determine whether a relationship exists between endogenous ovarian hormones and the outcomes of cognitive restructuring in clinically anxious women. Methods Ninety women with spider phobia received training in cognitive restructuring or a control task and provided a blood sample for the measurement of serum estradiol and progesterone levels. Behavioral avoidance, using a behavioral approach task with a live spider, and self-reported fear of spiders were measured at baseline and 1-week post-treatment. Results The results indicated that heightened levels of progesterone, but not estradiol, at the time of cognitive restructuring predicted greater post-treatment reductions in behavioral avoidance, but not self-reported fear, amongst women who received cognitive restructuring but not those in the control group. Limitations As menstrual cycle phase was not assessed; the present study provides information regarding how the benefits of cognitive therapy are predicted by between-person individual differences in absolute hormone levels, but does not examine the relationship between within-person fluctuations in hormone levels and outcomes. Conclusions These results suggest the effectiveness of cognitive therapy for anxiety disorders in women may differ depending on endogenous levels of progesterone, and raise the possibility that progesterone could be a useful pharmacological adjunct to cognitive therapy.

Subjective, disabling fatigue is a common complaint and a key feature of numerous medical conditions, and is a transdiagnostic feature of psychiatric disorders. Despite physical and mental fatigue being associated with functional impairment and reduced quality of life, little is understood about its underlying mechanisms or modulating factors. Women commonly experience exacerbation of other (non-fatigue related) psychiatric symptoms during the luteal phase of the menstrual cycle, and report greater fatigue prevalence compared to men. It is therefore plausible that subjective fatigue may similarly fluctuate across the menstrual cycle. Here we compared physical and mental fatigue in the early-follicular (lower ovarian hormones) and mid-luteal (higher ovarian hormones) phases of a single menstrual cycle, while controlling for sleep disruption, in women with (n = 18) and without (non-anxious; n = 20) generalised anxiety disorder (GAD). As expected, women with GAD reported greater physical and mental fatigue than healthy women. Further, although there were no changes in physical fatigue from the early-follicular to mid-luteal phases in both groups, mental fatigue in non-anxious women increased to levels equivalent to those experienced by their GAD counterparts in the mid-luteal phase. Although salivary levels of estradiol and progesterone increased from the early-follicular to mid-luteal phase, hormones did not significantly predict fatigue in either phase. These findings are consistent with the exacerbations of state anxiety and mood disturbance recognised to occur in the luteal phase of the menstrual cycle. We speculate that increased mental fatigue in the luteal phase may represent a vulnerable period for the development and maintenance of psychiatric disorders, potentially via compromised emotional regulation.

Background Insomnia and sleep disturbance are pervasive and debilitating conditions affecting up to 40% of adolescents. Women and girls are at greater risk of insomnia, yet differences in treatment responsiveness between genders have not been adequately investigated. Additionally, while women report greater symptom severity and burden of illness than men, this discrepancy requires further examination in adolescents. Objective The purpose of this study was to examine gender differences in sleep symptom profiles and treatment response in adolescents. Methods Digital cognitive behavioral therapy for insomnia (CBT-I) treatment responsiveness, as indexed by changes in Insomnia Severity Index (ISI) and Global Pittsburgh Sleep Quality Index (PSQI) scores, was compared in boys and girls (aged 12-16 years; N=49) who participated in a pilot evaluation of the Sleep Ninja smartphone app. Gender differences in self-reported baseline insomnia symptom severity (ISI), sleep quality (PSQI), and sleep characteristics derived from sleep diaries were also examined. Results Compared with boys, we found that girls reported greater symptom severity (P=.04) and nighttime wakefulness (P=.01 and P=.04) and reduced sleep duration (P=.02) and efficiency (P=.03), but not poorer sleep quality (P=.07), more nighttime awakenings (P=.16), or longer time to get to sleep (P=.21). However, gender differences in symptom severity and sleep duration were accounted for by boys being marginally younger in age. Treatment response to CBT-I was equivalent between boys and girls when comparing reductions in symptom severity (P=.32); there was a trend showing gender differences in improvements in sleep quality, but this was not statistically significant (P=.07). Conclusions These results demonstrate the presence of gender differences in insomnia symptoms and severity in adolescents and suggest further research is required to understand gender differences in insomnia symptom profiles to inform the development of gender-specific digital interventions delivered to adolescents.

Summary Increased prevalence, severity, and burden of anxiety, trauma-related and stress-related disorders in women compared with men has been well documented. Evidence from a variety of fields has emerged suggesting that sex hormones, particularly oestradiol and progesterone, play a significant part in generation of these sex differences. In this Series paper, we aim to integrate the literature reporting on the effects of sex hormones on biological, behavioural, and cognitive pathways, to propose two broad mechanisms by which oestradiol and progesterone influence sex differences in anxiety disorders: augmentation of vulnerability factors associated with anxiety disorder development; and facilitation of the maintenance of anxious symptoms post-development. The implications for future research, along with novel approaches to psychological and pharmacological treatment of anxiety disorders, are also considered.

Many people with traumatic brain injury (TBI) have poor emotion recognition, with negative emotions more frequently impaired. They can also display abnormal affective responses to emotionally charged material, however, the mechanisms underpinning such deficits are unclear. This study examined whether affective responsivity can be improved by focusing attention and whether responsivity is associated with perception accuracy. Eighteen adults with moderate-to-severe TBI and 18 control participants viewed facial expressions while skin conductance (SCR) and evoked cardiac deceleration (ECD) (used as indices of orientation) and skin conductance levels (SCL) (used as an index of phasic arousal) were monitored. They viewed two blocks of faces (8 angry and 8 happy per block), passively in the first block and with the instruction to identify the emotional expression in the second. No differences between conditions, emotions or groups were found using SCR. Both groups demonstrated increasing ECD for the attend condition relative to the passive condition. For the passive task the control group showed increasing SCL (sensitisation) over trials when viewing angry faces and decreasing SCL (habituation) to happy faces. No differences between emotions were shown for the TBI group who rapidly habituated to both expressions. For the attend task, there was no evidence of habituation for either expression for either the control or TBI participants. Physiological measures did not correlate to accuracy in recognising emotions. The results suggest that increasing attentional demands improves orientation and emotional engagement (arousal) to emotional faces following TBI. However, the relationship to this and emotion perception accuracy remains unclear.

A series of experiments studied the effects of the interval between extinction trials on the loss of context conditioned freezing responses. Rats were shocked in one context (A) but not in another (B) and subjected to extinction trials in context A. In Experiment 1, massed trials produced more rapid loss than spaced trials. A shift from spaced to massed trials maintained this loss, but the shift from massed to spaced trials restored lost responses. Experiments 2-5 examined this effect of massed trials on responding across spaced trials. They provided evidence that (a) a single trial was as effective as multiple daily massed trials, (b) learning occurred on the first of the massed trials but not on later ones, and (c) the first trial reduced the amount learned across subsequent massed trials. Finally, alternating extinction trials in A and B produced more response loss across spaced trials than blocks of trials in A and B. The results were discussed in terms of the role accorded to self-generated priming in the models developed by A. R. Wagner (1978, 1981).