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The present review aims to critically evaluate available literature on the use of acceptance and commitment therapy (ACT) to treat adult obsessive-compulsive disorder (OCD) and to draw conclusions about using ACT to reduce OCD symptoms in adults with OCD. Databases (PsycINFO, PsycARTICLES, MEDLINE, and PubMed), Google Scholar, and article references were used to identify relevant studies through October 10, 2020. This review includes both peer-reviewed, published articles (n = 15) and unpublished theses and dissertations (n = 2) to increase the breadth of the review as suggested by PRISMA guidelines. Reviewed articles utilized ACT and at least one measure of OCD symptom severity. Information on methodological, measurement, statistical, and analytical characteristics of the included studies were extracted to determine the quality of the available studies and to inform the conclusions of this review. Seventeen studies (n = 17) with 336 participants from three countries were evaluated. The current evidence suggests that ACT can be used to reduce symptoms of OCD in adults. A conclusion supporting the use of ACT to reduce OCD symptoms can be made because of several strengths within this body of literature (e.g., use of validated OCD symptom measures, inclusion of treatment manuals, use of multiple assessment points, etc.). However, because a majority of the included studies are quasi-experimental and single-subject studies, more stringent research (i.e., randomized controlled trials) with large, diverse samples is needed to strengthen this conclusion. Additionally, dismantling studies exploring the components of ACT that lead to OCD symptom improvement are needed., (Copyright © 2023 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

This study investigated the sustainability of a multi-agency 15-month Learning Collaborative (LC) for implementing trauma-informed care in 23 rural Pennsylvania counties. Provider agencies (N = 22) were assessed three years following completion of the LC. Sustained trauma-informed practices were assessed through criteria indicating organizational achievement as a trauma-informed care center. A theoretical model of clinical training was applied to determine the extent to which training- and skill-related factors were associated with sustained trauma-informed care. Three years after the LC, trauma symptom screening rates and staff training improvements were sustained, while staff confidence in delivering trauma-informed care worsened across time. Sustained trauma-informed care was associated with implementation milestone completion and third-party ratings of quality improvement skills during the LC. Building capacity for organizational change through training and skill development during active phases of implementation is important for sustained trauma informed care in behavioral health service., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To determine if intolerance of uncertainty, depression, anxiety, worry, or stress are related to post-op regret in otolaryngology patients., Methods: Adult patients or parents giving consent for pediatric patients meeting criteria for otolaryngologic surgery were recruited and completed the Intolerance of Uncertainty Scale (IUS-12), Penn State Worry Questionnaire (PSWQ), and Depression, Anxiety and Stress Scale-21 (DASS-21) preop and the Decisional Regret (DR) scale 1-month post-op. Pearson correlations were calculated., Results: The cohort included 109 patients, 73 (67%) males and 36 (33.3%) females. 43 (39.5%) were college graduates and 66 (60.9%) were not. Mean IUS-12 score was 22.9 (95% CI 21.0-24.8), mean PSWQ score was 46.9 (95% CI 44.5-49.3). DASS-21 mean score was 11.9 (95% CI 9.6-14.3). Mean DR score was 11.1 (95% CI 8.6-13.6). IUS-12 subscales Prospective Anxiety mean score was 14.2 (95% CI 12.8-15.5) and Inhibitory Anxiety mean score was 16.5 (95% CI 14.5-18.6). The Pearson correlation coefficient for post-op DR and total preop IUS was .188 ( P  = .027) and the correlation coefficient for post-op DR and preop Prospective Anxiety subscale of IUS score was .174 ( P  = .037). Correlations with PSWQ and DASS-21 scores and DR were not statistically significant., Conclusion: Intolerance of uncertainty is a psychological construct that is associated with post-op DR. More work is needed to determine whether screening for IU and behavior modification directed at IU for those with high levels would improve post-op decisional regret.

Given the increasing use of threat conditioning and generalization for clinical-translational research efforts, establishing test-retest reliability of these paradigms is necessary. Specifically, it is an empirical question whether the same participant evinces a similar generalization gradient of conditioned responses across two sessions with the identical contingencies and stimuli. Here, 46 human volunteers participated in an identical auditory threat acquisition and generalization protocol at two sessions separated by 1-to-2 weeks. Skin conductance responses (SCR) and trial-by-trial shock risk ratings served as primary measures. We used linear mixed effects modeling to test differential threat responses and generalization gradients, and Generalizability (G) theory coefficients as our primary formal assessment of test-retest reliability of intraindividual stability and change across time. Results showed largely invariant differential conditioning and generalization gradients across time. G coefficients indicated fair reliability for acquisition and generalization SCR. In contrast, risk rating reliabilities were mixed, and reliability was particularly low for acquisition risk ratings. Our findings generally support reliability of the threat conditioning and generalization paradigm for shorter test-retest intervals and highlight their utility for assessments of behavioral interventions in mental health research, but challenges remain and further work is needed. Threat conditioning and generalization tasks are increasingly used for translational efforts to improve behavioral interventions, and thus test-retest reliability for these tasks needs to be established. Our results support the test-retest reliability of threat conditioning and generalization over a relatively short (1-to-2 week) interval, but this depends on the measure used (physiological vs. self-report). Overall, these tasks could be appropriate for repeated testing over the course of a short-duration intervention study, but more research is needed, particularly in regard to longer-duration studies., (© 2022 Society for Psychophysiological Research.)

Background: Informal familial caregivers of stroke survivors experience uncertainty that begins at the time of the stroke event and continues into home-based care. The uncertainty faced by caregivers contributes to poor mental and physical health outcomes. Objective: This review details the factors associated with, impacts of, and coping skills used to manage uncertainty across the caregiving trajectory. By defining uncertainty reduction and tolerance recommendations, this review also builds upon the Stroke Caregiver Readiness Model to improve preparedness following the stroke event. Methods: A meta-ethnographic review was systematically conducted on thirteen qualitative studies with 218 participants from four countries. The Critical Appraisal Skills Programme (CASP) was used to assess study quality. Results: Following the stroke event, caregivers reported a lack of knowing (e.g., about the cause of the stroke event and survivor prognoses) as contributing to post-stroke uncertainty. As a result of this uncertainty, caregivers expressed concerns about their abilities to navigate caregiving responsibilities and how to plan for the future. Longer-term concerns (e.g., managing finances) and feelings of hopelessness occurred after discharge. Still, caregivers identified strategies to manage uncertainty. Caregiver coping skills included present-focused thinking, gratitude, faith, humor, and social support. Conclusions: The uncertainty faced by informal familial caregivers of stroke survivors is pervasive and changes across time. Uncertainty reduction and tolerance interventions can be used to build upon caregiver strengths and promote preparedness across the caregiving trajectory.

Studies with rodents and healthy humans suggest that replacing the expected threat with a novel outcome improves extinction and reduces the return of conditioned fear more effectively than threat omission alone. Because of the potential clinical implications of this finding for exposure-based anxiety treatments, this study tested whether the same was true in individuals with pathological anxiety (i.e., met DSM-5 diagnostic criteria for an anxiety disorder and/or obsessive-compulsive disorder (OCD). In this preliminary test of novelty-facilitated extinction, 51 unmedicated individuals with pathological anxiety were randomized to standard extinction ( n = 27) or novelty-facilitated extinction ( n = 24). Participants returned 24 h later to test extinction recall and fear reinstatement. Skin conductance responses (SCR) were the dependent measure of conditioned fear. Participants in both groups learned the fear association but variably extinguished it. Novelty did not facilitate extinction in this preliminary trial. Findings underscore the importance of translating paradigms from healthy humans to clinical samples, to ensure that new treatment ideas based on advances in basic neuroscience are relevant to patients., Competing Interests: In the past three years, HBS reports royalties from Cambridge University Press and UpToDate, Inc. and research support for an industry-sponsored trial of an investigational drug for obsessive-compulsive disorder from Biohaven. She also receives a stipend for her role as Associate Editor of JAMA Psychiatry. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Steinman, Dunsmoor, Gazman, Stovezky, Pascucci, Pomerenke, Phelps, Fyer and Simpson.)

Importance: Serotonin reuptake inhibitors (SRIs) are the only medications approved for obsessive-compulsive disorder (OCD), yet most patients taking SRIs exhibit significant symptoms. Adding exposure/response prevention (EX/RP) therapy improves symptoms, but it is unknown whether patients maintain wellness after discontinuing SRIs., Objective: To assess whether patients with OCD who are taking SRIs and have attained wellness after EX/RP augmentation can discontinue their SRI with noninferior outcomes compared with those who continue their SRI therapy., Design, Setting, and Participants: A 24-week, double-blind, randomized clinical trial was performed from May 3, 2013, to June 25, 2018. The trial took place at US academic medical centers. Participants included 137 adults with a principal diagnosis of OCD (≥1 year) who were taking an SRI (≥12 weeks), had at least moderate symptoms (defined as Yale-Brown Obsessive-Compulsive Scale [Y-BOCS] score ≥18 points), and received as many as 25 sessions of EX/RP therapy. Those who attained wellness (Y-BOCS score ≤14 points; 103 patients [75.2%]) were study eligible. Data were analyzed from June 29, 2019, to October 2, 2021., Intervention: Participants were randomly assigned either to receive taper to placebo (taper group) or to continue their SRI (continuation group) and monitored for 24 weeks., Main Outcome and Measures: The Y-BOCS score (range, 0-40 points) was the primary outcome; the Hamilton Depression Rating Scale (HDRS; range, 0-52 points) and the Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF; range, 0%-100%) scores were secondary outcomes. Outcomes were assessed at 8 time points by independent evaluators who were blinded to randomization. The taper regimen was hypothesized to be noninferior to continuation at 24 weeks using a 1-sided α value of .05., Results: A total of 101 patients (mean [SD] age, 31.0 [11.2] years; 55 women [54.5%]) participated in the trial: 51 patients (50.5%) in the taper group and 50 patients (49.5%) in the continuation group. At 24 weeks, patients in the taper group had noninferior results compared with patients in the continuation group (mean [SD] Y-BOCS score: taper group, 11.47 [6.56] points; continuation group: 11.51 [5.97] points; difference, -0.04 points; 1-sided 95% CI, -∞ to 2.09 points [below the noninferiority margin of 3.0 points]; mean [SD] HDRS score: taper group, 5.69 [3.84] points; continuation group, 4.61 [3.46] points; difference, 1.08 points; 1-sided 95% CI, -∞ to 2.28 points [below the noninferiority margin of 2.5 points]; mean [SD] Q-LES-Q-SF score: taper group, 68.01% [15.28%]; continuation group, 70.01% [15.59%]; difference, 2.00%; 1-sided 95% CI, -∞ to 6.83 [below the noninferiority margin of 7.75]). However, the taper group had higher rates of clinical worsening (23 of 51 [45%] vs 12 of 50 [24%]; P = .04)., Conclusions and Relevance: Results of this randomized clinical trial show that patients with OCD who achieve wellness after EX/RP therapy could, on average, discontinue their SRI with noninferior outcomes compared with those who continued their SRI. Those who tapered the SRI had higher clinical worsening rates. Future research should evaluate if SRI half-life alters these rates., Trial Registration: ClinicalTrials.gov Identifier: NCT01686087.

Introduction: Pregnancy presents health challenges related to well-being, physical activity, dietary regulation, and body image. There is evidence to support the use of guided imagery to address these concerns during pregnancy. The purpose of this study was to analyze the use and short-term outcomes of a multiple-behavior guided imagery intervention delivered through a mobile health (mHealth) application for pregnant women., Methods: A single-arm, 5-week feasibility trial was conducted, and participants were instructed to listen to an audio file every day for 35 days on an mHealth application. Measurements included ongoing assessments of the participants' use of the guided imagery audio files and pre- and post-test measures of depression, anxiety, stress, physical activity, food cravings, and body image. Postintervention qualitative interviews were conducted to assess whether participants would continue to use guided imagery., Results: Fifty-eight participants (mean age, 28.5 years) were enrolled from January to June of 2018. Cloud analytics data showed an average of 4.96 audio downloads per week with the Sleep and Relaxation file being the most widely used (mean weekly usage, 5.67) and reported favorite during follow-up interviews. Paired-sample t tests from pre- to post-test showed significant reductions in depression, anxiety, and stress, increased physical activity, and sedentary behavior along with some changes in body image., Discussion: Future scalable guided imagery interventions are justified to test for efficacy. Guided imagery may also be delivered in person by health care providers or by using widely available technologies., (© 2021 by the American College of Nurse-Midwives.)

Practice guidelines for adults with obsessive-compulsive disorder (OCD) recommend augmenting serotonin reuptake inhibitors (SRIs) with exposure and ritual prevention (EX/RP). However, fewer than half of patients remit after a standard 17-session EX/RP course. We studied whether extending the course increased overall remission rates and which patient factors predicted remission. Participants were 137 adults with clinically significant OCD (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score ≥18) despite an adequate SRI trial (≥12 weeks). Continuing their SRI, patients received 17 sessions of twice-weekly EX/RP (standard course). Patients who did not remit (Y-BOCS ≤12) received up to 8 additional sessions (extended course). Of 137 entrants, 123 completed treatment: 49 (35.8%) remitted with the standard course and another 46 (33.6%) with the extended course. Poorer patient homework adherence, more Obsessive-Compulsive Personality Disorder (OCPD) traits, and the Brain-Derived Neurotrophic Factor (BDNF) Val66MET genotype were associated with lower odds of standard course remission. Only homework adherence differentiated non-remitters from extended course remitters. Extending the EX/RP course from 17 to 25 sessions enabled many (69.3%) OCD patients on SRIs to achieve remission. Although behavioral (patient homework adherence), psychological (OCPD traits), and biological (BDNF genotype) factors influenced odds of EX/RP remission, homework adherence was the most potent patient factor overall., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: To assess the relationship between depression, anxiety, stress, worry, intolerance of uncertainty (IU), and shared decision making (SDM) in parents of pediatric otolaryngology surgical patients with their perceptions of decisional conflict (DC)., Study Design: Cross-sectional., Setting: Academic pediatric otolaryngology outpatient clinic., Methods: Participants were legal guardians of pediatric patients who met criteria for otolaryngologic surgery. Participants completed a demographic survey as well as validated Decisional Conflict Scale (DCS); Shared Decision-Making Scale (SDMS); Depression, Anxiety and Stress Scale-21 (DASS-21); Penn State Worry Questionnaire (PSWQ); and short form of the Intolerance of Uncertainty Scale (IUS-12)., Results: A total of 114 participants were enrolled. Respondents were predominantly female (93.0%) and married (60.5%). Most guardians had not consented previously for otolaryngologic surgery for their child (69.3%). Participants reported low levels of DC and depression as well as moderate levels of anxiety and stress. DC scores were not significantly correlated to DASS-21, PSWQ, or SDM. IUS-12 Total and subscale IUS-12 prospective negatively correlated with Total DC. DC was not related to age, sex, education level, previous otolaryngologic surgery, or type of surgery recommended., Conclusion: In this group, an association was found between IU and DC. Clinicians should be aware that DC is not modified by previous surgical experience. Interventions aimed at addressing parental IU related to surgery may reduce DC. Further research efforts could help us understand how mental health relates to surgical decision making.

Emotional distress tolerance (EDT)-or the ability to withstand negative emotional states-is considered a transdiagnostic risk factor for psychopathology. Although EDT is theorized to play a role in anxiety development and maintenance, research aiming to delineate the relationship between anxiety and EDT is lacking. The current study tested whether self-reported EDT predicted self-reported and actual avoidance in the presence of feared stimuli using a heights-fearful sample. Moreover, the study tested whether EDT predicted other in-the-moment fear responses, such as peak anxiety, anxious cognitions, and bodily sensations. Participants (N = 128) completed questionnaires assessing fear of heights, negative affect, anxious cognitions, and bodily sensations, as well as two heights behavioral avoidance tasks (BATs). Results demonstrated that EDT did not predict actual avoidance or other in-the-moment fear responses, except for peak anxiety in one BAT. However, EDT predicted self-reported avoidance of heights beyond fear of heights and negative affect. Taken together, results suggest that perception of ability to tolerate emotional distress predicts perception of avoidance of heights, but not actual avoidance of heights or reactions to heights (with the exception of peak anxiety in one BAT). Given these findings, self-reported EDT may not adequately predict how individuals react in anxiety-provoking situations., (Copyright © 2021. Published by Elsevier Ltd.)

Abstract: Although awareness of postpartum depression (PPD) has increased, postpartum anxiety disorders (PPA) remain overlooked. Understanding women's knowledge of PPA and their effective treatments is needed given the underutilization of treatment and associated negative health outcomes. Two internet-based studies (OSF [https://osf.io/3fjvr] preregistered follow-up) were conducted to identify women's knowledge and familiarity with PPD and PPA and knowledge of cognitive behavioral therapy (CBT). Study 1 revealed that women who were planning to become pregnant, pregnant, or recently postpartum (N = 218) were less familiar with PPA than PPD and had limited familiarity with CBT. Women also reported low screening rates for PPA and low perceived treatment seeking for women with PPA and PPD. Study 2 (N = 290) revealed that recently postpartum women recognized fewer symptoms and recommended treatment less often for PPA than PPD and had limited CBT knowledge. Overall, results indicate limited knowledge of PPA compared with PPD, indicating a need for targeted information to perinatal women., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Brief computerized programs that train less threatening interpretations (termed Cognitive Bias Modification for Interpretations, or CBM-I) can shift interpretation biases and subsequent anxiety symptoms. However, results have been inconsistent, particularly for studies conducted over the Internet., Methods: The current exploratory study tests 13 variations of a single brief session of CBM-I, a non-CBM-I cognitive flexibility condition, a neutral condition, and a no task control condition in an analogue sample with moderate to severe anxiety., Results: Results suggest that all conditions, except the neutral scenarios condition and the alternative way to improve cognitive flexibility, led to changes in interpretations (when compared to the no task control condition). Only conditions geared toward increasing imagery during CBM-I and targeting flexibility related to emotional material differed from the no task control condition on other post-training measures., Conclusions: Presenting valenced interpretations of ambiguous information during brief CBM-I, regardless of the format, can lead to changes in interpretation bias. However, most conditions did not differ from the no task control condition on other post-training assessments (and differences that did occur may be due to chance). Future trials should consider further testing of CBM-I that targets flexibility related to emotional material, and should include an increased number of sessions and trials.

The Mnemonic Similarity Task (MST) measures mnemonic discrimination, or the ability to correctly identify new stimuli from highly similar, old stimuli. Poor mnemonic discrimination is a potential risk or maintenance factor for anxiety, and recent studies suggest state affect may moderate relations between mnemonic discrimination and trait anxiety. No studies have evaluated mnemonic discrimination in specific subtypes of anxiety or with clinically relevant stressors. This preregistered study evaluated the role of social anxiety and the anticipation of a future speech on MST performance. Participants with high ( n  = 66) and low ( n  = 64) levels of social anxiety were randomly assigned to a stressor condition or a control condition prior to the MST. State anxiety was measured throughout the study. Results did not indicate significant effects of trait (high vs. low social anxiety) or state anxiety (stressor condition vs. control condition) on mnemonic discrimination. Results are compared with previous research and implications and future directions are discussed.

The tendency for individuals to interpret ambiguous information in a threatening way is theorised to maintain anxiety disorders. Recent findings suggest that positive and negative interpretation biases may have unique effects. This study tested the relationships between threat and benign biases with state and trait anxiety and quality of life, and whether individual differences moderate these relationships. N  = 699 individuals with elevated trait anxiety symptoms completed web-based measures of interpretation bias, trait anxiety, state anxiety, and quality of life. Results demonstrated that threat interpretations predicted state anxiety, trait anxiety, and quality of life. Benign interpretations also predicted quality of life. However, benign interpretations only weakly (or not at all) predicted state and trait anxiety. Individual differences (e.g. gender, race, ethnicity, age) did not moderate findings. Results emphasise the need to consider benign and threat biases separately, both in cognitive models of anxiety and experimental designs.

Health psychology is multidisciplinary, with researchers, practitioners, and policy makers finding themselves needing at least some level of competency in a variety of areas from psychology to physiology, public health, and others. Given this multidisciplinary ontology, prior attempts have been made to establish a framework for understanding the role of biological, psychological, and socio-environmental constructs in disease development, maintenance, and treatment. Other models, however, do not explain how factors may interact and develop over time. The aim here was to apply and adapt the 3P model, originally developed and used in the treatment of insomnia, to couch the biopsychosocial model in a way that explains how diseases develop, are maintained, and can be treated. This paper outlines the role of predisposing, precipitating, and perpetuating factors in disease states and conditions (the 3Ps) and provides examples of how this model may be adapted and applied to a number of health-related diseases or disorders including chronic pain, gastrointestinal disorders, oral disease, and heart disease. The 3P framework can aid in facilitating a multidisciplinary, theoretical approach and way of conceptualizing the study and treatment of diseases in the future., (Copyright © 2019 Wright, Tiani, Billingsley, Steinman, Larkin and McNeil.)

Background and Objectives: People who are afraid of heights may have a perceptual bias, such that they see heights as higher than they truly are. The current study tested if there is a causal relationship between treatments for height fear and changes in perceptual bias., Methods: Specifically, the effects on perceptual bias following three height fear interventions (exposure, cognitive bias modification for interpretations, and a combination of exposure and cognitive bias modification) and a control condition were examined in individuals with an extreme fear of heights (N = 107)., Results: Results provided preliminary evidence that some height fear interventions reduce perceptual bias. Specifically, participants that completed exposure had a significant decrease in perceptual bias, and participants in the cognitive bias modification and combination conditions had decreases in perceptual bias at the level of non-significant trends, while no reduction occurred for the control condition., Limitations: Limitations of this study include that the hypothesis was largely informed by data from a parent study and that the effect sizes were small; thus, replicating these results is warranted., Conclusions: These findings suggest that there may be a causal relationship between height fear treatments and altered perception of heights., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: The Difficulties in Emotion Regulation Scale (DERS) is a widely used self-report measure of subjective emotion ability, as defined by a prominent clinically derived model of emotion regulation (Gratz and Roemer, 2004). Although the DERS is often used in treatment and research settings for adults with emotional (i.e., anxiety, mood, obsessive-compulsive, or trauma-related) disorders, its psychometric properties are not well-characterized in this population. Method: We examined the psychometric properties of the DERS and three popular short forms (DERS-16; DERS-18; and DERS-SF) in a large ( N = 427) sample of treatment-seeking adults with one or more DSM-5 emotional disorders. Results: For the original DERS, internal consistency was strong for all subscales except Awareness. A bifactor structure consisting of one general emotion dysregulation factor and five uncorrelated specific factors corresponding to the original DERS subscales (excluding Awareness) provided the best fit. A series of structural equation models (SEMs) demonstrated unique incremental contributions of the general factor and several specific factors to explaining concurrent clinical severity. The general factor and one specific factor (Goals) also prospectively predicted treatment outcome following a naturalistic course of outpatient cognitive-behavioral therapy (CBT) in a subset of participants ( n = 202) for whom discharge data were available. Specifically, more severe emotion dysregulation at intake predicted better CBT response, while more severe impairment in goal-directed activity when distressed predicted worse CBT response. All three short forms showed a robust bifactor structure and good internal consistency and convergent validity vis-à-vis the original measure, albeit with a slight decrement in incremental utility (1-3% less variance explained in clinical severity). Conclusion: With the Awareness items excluded, the DERS showed good internal consistency and a robust bifactor latent structure. The general factor and several specific factors incrementally and prospectively predicted clinical severity and treatment outcome, which suggests that the DERS may have clinical and predictive utility in treatment-seeking adults with emotional disorders. Additional research is needed to establish convergent and discriminant validity in this population. The use of a short form in lieu of the full DERS may be sufficient for many general clinical and research purposes, particularly when participant burden is a concern.

Difficulty concentrating is one of the most common diagnostic criteria across DSM-5 categories, especially within the emotional (mood- and anxiety-related) disorders. A substantial literature has characterized cognitive functioning in emotional disorders using objective (behavioral) computerized cognitive tasks. However, diagnoses are typically formed on the basis of subjective (self-reported; clinician-rated) assessments of symptoms, and little is known about difficulty concentrating as a symptom. These questions are particularly important for generalized anxiety disorder (GAD), which has long been the subject of nosological debates, and for which several theoretical models that suggest a central role for cognitive impairments (including difficulty concentrating) in the maintenance of psychopathology have been proposed. The present study evaluated the incremental utility of difficulty concentrating and its relationship to worry and other symptoms in 175 GAD-diagnosed adults. Clinician-assessed difficulty concentrating incrementally predicted clinician-rated GAD, anxiety, and depression severity even after other GAD symptoms were controlled. Consistent with theoretical models of GAD that propose a direct relationship between worry and cognitive impairment, difficulty concentrating mediated the relationship between trait worry and clinical severity. These findings suggest that difficulty concentrating has value as a diagnostic criterion and is a potential mechanism by which worry increases distress and impairment., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Three hundred sixty-two adult patients were administered the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND). Of these, 121 provided interrater reliability data, and 115 provided test-retest reliability data. Participants also completed a battery of self-report measures that assess symptoms of anxiety, mood, and obsessive-compulsive and related disorders. Interrater reliability of DIAMOND anxiety, mood, and obsessive-compulsive and related diagnoses ranged from very good to excellent. Test-retest reliability of DIAMOND diagnoses ranged from good to excellent. Convergent validity was established by significant between-group comparisons on applicable self-report measures for nearly all diagnoses. The results of the present study indicate that the DIAMOND is a promising semistructured diagnostic interview for DSM-5 disorders.

Suicide and self-injury are difficult to predict because at-risk individuals are often unable or unwilling to report their intentions. Therefore, tools to reliably assess risk without reliance on self-report are critically needed. Prior research suggests that people who engage in suicidal and nonsuicidal self-injury (NSSI) often implicitly (i.e., outside conscious control) associate themselves with self-harm and death, indicating that self-harm-related implicit cognition may serve as a useful behavioral marker for suicide risk. However, earlier studies left several critical questions about the robustness, sensitivity, and specificity of self-harm-related implicit associations unaddressed. We recruited a large sample of participants (N = 7,015) via a public web-based platform called Project Implicit Mental Health (PIMH) to test several hypotheses about self-harm-related implicit associations using the Implicit Association Test (IAT). Participants were randomly assigned to complete 1 of 3 self-harm IATs (Self + Cutting using picture stimuli, Self + Suicide using word stimuli, Self + Death using word stimuli). Results replicated prior studies demonstrating that self-harm-related implicit associations were stronger among individuals with (vs. without) a history of suicide attempt and NSSI. Results also suggested that self-harm-related implicit associations are robust (based on internal replication), are sensitive to recency and severity of self-harm history (e.g., stronger associations for more recent and more lethal prior suicide attempts), and correlate with specific types of self-harm behaviors. These findings clarify the nature of self-harm-related implicit cognition and highlight the IAT's potential to track current risk for specific types of self-harm in ways that more fixed risk factors cannot. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Exposure and response prevention (EX/RP) is an evidence-based treatment for obsessive-compulsive disorder (OCD), yet not all patients achieve wellness with EX/RP. The degree to which patients adhere to EX/RP procedures outside of sessions has been found to predict therapy outcomes, including who achieves post-treatment wellness. We sought to investigate which components of treatment adherence most relate to outcome and to develop adherence benchmarks to identify who does and does not become well to provide clinicians with prognostic tools. Adherence data came from 37 adult patients with DSM-IV OCD who received 17 sessions of EX/RP as part of a randomized controlled trial of augmentation strategies for incomplete response to serotonin reuptake inhibitors (SRIs). Therapists rated between-session patient adherence at each exposure session by quantifying: 1) the quantity of homework exposures attempted; 2) the quality of attempted exposures; and 3) the degree of success with response prevention. Each adherence item significantly correlated with post-treatment OCD severity. Success with response prevention proved particularly strongly linked to therapy outcome. Time course analysis of this item accurately identified, relatively early in treatment, who would achieve post-treatment wellness. These data provide an efficient method for differentiating between those patients who will and will not achieve wellness after EX/RP augmentation of SRIs. Limitations and clinical implications of the current findings are discussed., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background and Objectives: Implicit associations are relatively uncontrollable associations between concepts in memory. The current investigation focuses on implicit associations in four mental health domains (alcohol use, anxiety, depression, and eating disorders) and how these implicit associations: a) relate to explicit associations and b) self-reported clinical symptoms within the same domains, and c) vary based on demographic characteristics (age, gender, race, ethnicity, and education)., Methods: Participants (volunteers over age 18 to a research website) completed implicit association (Implicit Association Tests), explicit association (self + psychopathology or attitudes toward food, using semantic differential items), and symptom measures at the Project Implicit Mental Health website tied to: alcohol use (N = 12,387), anxiety (N = 21,304), depression (N = 24,126), or eating disorders (N = 10,115)., Results: Within each domain, implicit associations showed small to moderate associations with explicit associations and symptoms, and predicted self-reported symptoms beyond explicit associations. In general, implicit association strength varied little by race and ethnicity, but showed small ties to age, gender, and education., Limitations: This research was conducted on a public research and education website, where participants could take more than one of the studies., Conclusions: Among a large and diverse sample, implicit associations in the four domains are congruent with explicit associations and self-reported symptoms, and also add to our prediction of self-reported symptoms over and above explicit associations, pointing to the potential future clinical utility and validity of using implicit association measures with diverse populations., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Deficits in sensorimotor gating have been hypothesized to underlie the inability to inhibit repetitive thoughts and behaviors. To test this hypothesis, this study assessed prepulse inhibition (PPI), a measure of sensorimotor gating, across three psychiatric disorders (obsessive-compulsive disorder [OCD], social anxiety disorder [SAD], and anorexia nervosa [AN]) whose clinical presentations include repetitive thoughts and behaviors, Methods: We tested acoustic PPI in unmedicated individuals with OCD (n = 45), SAD (n = 37), and AN (n = 26), and compared their results to matched healthy volunteers (n = 62). All participants completed a structured clinical interview and a clinical assessment of psychiatric symptom severity., Results: Percent PPI was significantly diminished in females with OCD compared to healthy female volunteers (P = .039). No other differences between healthy volunteers and participants with disorders (male or female) were observed. Percent PPI was not correlated with severity of obsessions and compulsions, as measured by the Yale-Brown Obsessive Compulsive Scale., Conclusions: This is the first study to assess PPI in participants with SAD or AN, and the largest study to assess PPI in participants with OCD. We found PPI deficits only in females with OCD, which suggests that the cortico-striato-pallido-thalamic and pontine circuitry (believed to underlie PPI) differs between males and females with OCD. Given that PPI deficits were only present in females with OCD and not related to repetitive thoughts and behaviors, our results do not support the hypothesis that sensorimotor gating deficits, as measured by PPI, underlie the inability to inhibit repetitive thoughts and behaviors in individuals with OCD, SAD, and AN., (© 2016 Wiley Periodicals, Inc.)

Background and Objectives: Cognitive Bias Modification to reduce threat interpretations (CBM-I) trains individuals to resolve ambiguous scenarios via completion of word fragments that assign benign meanings to scenarios. The current study tested: 1) whether Internet-based CBM-I can shift interpretations to be more positive/less negative, and 2) whether varying the number of letters missing in the word fragments (assumed to increase task difficulty) moderates CBM-I's effects., Methods: Participants (N = 350) completed a brief online version of CBM-I, followed by assessments of interpretation bias, fear of negative evaluation, and anticipatory anxiety. Participants were randomly assigned to 1 of 5 conditions: control (half of scenarios ended positively, half negatively), or 4 positive conditions (all scenarios ended positively, but word fragments varied on number of letters missing, from 0 to 3)., Results: Relative to the control condition, all positive conditions led to more positive/less negative interpretations. When analyses were re-run with only a highly socially anxious subset of the sample (n = 100), conditions in which the final word of scenarios was missing 0, 1, or 2 letters led to more positive/less negative interpretations compared to the control condition, but the condition missing 3 letters did not differ from the control condition. There were no differences between conditions on other outcome measures., Limitations: Training was brief, and an unselected sample was used., Conclusions: Results suggest a brief Internet-based CBM-I paradigm can shift interpretation bias, but not necessarily other anxiety-relevant outcomes. Making the task too difficult may blunt effects for highly socially anxious individuals., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Anxiety and related disorders are highly prevalent and costly to society. Fortunately, a large number of randomized controlled trials have demonstrated the efficacy of cognitive behavioral therapy (CBT) in the treatment of anxiety and related disorders. A smaller number of effectiveness studies have also demonstrated that similar outcomes to randomized controlled trials can be obtained in "real-world" settings. There is minimal research, however, into long-term outcomes in effectiveness research. This study describes the outcomes of 98 individuals with anxiety and related disorders treated in an outpatient, fee-for-service setting using a case formulation CBT approach. Participants were followed up each year after their discharge, for a period of 3 years. The results indicate that patients maintained their treatment gains, with large effect sizes obtained from pre-treatment to each follow-up time point (d=1.11-1.60). The results provide preliminary evidence to suggest that individuals treated with CBT in "real-world" settings maintain their treatment gains in the long-term., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Although it is well documented that anxious individuals have negative expectations about the future, it is unclear what cognitive processes give rise to this expectancy bias. Two studies are reported that use the Expectancy Task, which is designed to assess expectancy bias and illuminate its basis. This task presents individuals with valenced scenarios (Positive Valence, Negative Valence, or Conflicting Valence), and then evaluates their tendency to expect subsequent future positive relative to negative events. The Expectancy Task was used with low and high trait anxious (Study 1: n = 32) and anxiety sensitive (Study 2: n = 138) individuals. Results suggest that in the context of physical concerns, both high anxious samples display a less positive expectancy bias. In the context of social concerns, high trait anxious individuals display a negative expectancy bias only when negatively valenced information was previously presented. Overall, this suggests that anxious individuals display a less positive expectancy bias, and that the processes that give rise to this bias may vary by type of situation (e.g., social or physical) or anxiety difficulty.

Objective: Cognitive models of anxiety disorders posit that biases in interpretation maintain, and potentially cause, anxiety. This study tested whether it is possible to decrease height fear symptoms through cognitive bias modification for interpretations (CBM-I). Additionally, the clinical utility of CBM-I was tested by comparing it to an already established treatment: exposure therapy., Method: Extremely height fearful individuals (N = 110) participated in the study. Acrophobic symptoms were measured before and after 2 sessions of CBM-I and were compared to the standard treatment for acrophobia (exposure therapy), a combination of CBM-I and exposure therapy, and a Control condition., Results: In line with hypotheses, participants in the 3 active conditions showed greater response to treatment than the Control condition in height-relevant interpretation bias, symptoms, and behavioral avoidance on a height stressor, with few differences between the active conditions. Further, symptom change was mediated by change in interpretation bias., Conclusions: Overall, findings suggest that different pathways to fear reduction (exposure vs. shifting interpretations) can lead to similar reductions in height fear. This study provides the first evidence that directly shifting cognitive processing, even with no therapist involvement, can reduce symptoms as effectively as the gold standard, therapist-directed exposure therapy., (PsycINFO Database Record (c) 2014 APA, all rights reserved.)

Background and Objectives: Cognitive-behavioral therapies are currently the gold standard for panic disorder treatment, with well-documented treatment response. However, following interventions, some individuals continue to improve, while others experience a return of symptoms. The field lacks reliable ways to predict follow-up symptomatology. In the current study, a cluster analysis with a repeated measures design was conducted to examine change patterns over 12 weeks of cognitive behavioral group therapy for panic disorder. The central aim of the study was to evaluate if change patterns predict level of panic symptom severity at a six month follow-up in this sample., Methods: Individuals with panic disorder (N = 36) completed a measure of panic symptoms (Panic Disorder Severity Scale) at the outset of every therapy session and at a six month follow-up., Results: Results revealed three patterns of change in this specific trial, which significantly predicted level of panic symptoms six months post-treatment, beyond initial or final level of panic symptoms, and beyond total symptom change., Limitations: Given the relatively small, lab-based sample, replications in other settings and samples will be important., Conclusions: Overall, results provide initial evidence that change patterns are meaningful predictors of panic symptom severity well after the final session of treatment., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Anxiety is characterised by a negative expectancy bias, such that anxious individuals report negatively distorted expectations about the future. Contrary to anxiety, ageing is characterised by a positivity effect, such that ageing is associated with a tendency to attend to and remember positive information, relative to negative information. The current study integrates these literatures to examine anxiety- and age-linked biases when thinking about the future. Participants (N=1,109) completed a procedure that involved reading valenced scenarios (positive, negative, or ambiguous) and then rating the likelihood of future valenced events occurring. Results suggest that ageing and anxiety have independent and opposing effects. Heightened anxiety was associated with a reduced expectancy for positive events, regardless of the scenarios' current emotional valence, whereas increased age was associated with an inflated expectancy for positive events, which was strongest when individuals were processing socially relevant or negative scenarios.

In this paper we examine the nature of automatic cognitive processing in anxiety disorders and Major Depressive Disorder (MDD). Rather than viewing automaticity as a unitary construct, we follow a social cognition perspective (Bargh, 1994) that argues for four theoretically independent features of automaticity: unconscious (processing of emotional stimuli occurs outside awareness), efficient (processing emotional meaning uses minimal attentional resources), unintentional (no goal is needed to engage in processing emotional meaning), and uncontrollable (limited ability to avoid, alter or terminate processing emotional stimuli). Our review of the literature suggests that most anxiety disorders are characterized by uncontrollable, and likely also unconscious and unintentional, biased processing of threat-relevant information. In contrast, MDD is most clearly typified by uncontrollable, but not unconscious or unintentional, processing of negative information. For the anxiety disorders and for MDD, there is no sufficient evidence to draw firm conclusions about efficiency of processing, though early indications are that neither anxiety disorders nor MDD are characterized by this feature. Clinical and theoretical implications of these findings are discussed and directions for future research are offered. In particular, it is clear that paradigms that more directly delineate the different features of automaticity are required to gain a more comprehensive and systematic understanding of the importance of automatic processing in emotion dysregulation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Three studies were conducted to examine the psychometric properties of a new scale: the Heights Interpretation Questionnaire (HIQ). This scale was designed to measure height fear-relevant interpretation bias to help assess the relationship between biased interpretations and acrophobia symptoms. Studies 1 (N=553) and 2 (N=308) established the scale's factor structure and convergent and discriminant validity among two large undergraduate samples. Study 3 (N=48) evaluated the predictive validity of the HIQ by examining how well the scale predicted subjective distress and avoidance on actual heights. Factor analysis resulted in four distinct factors, and results suggest that each of the factors, along with the full HIQ, have good reliability and validity. Additionally, the scale predicts subjective distress and avoidance on heights beyond self-reported acrophobia symptoms. Overall, the HIQ shows promise as a new tool to investigate cognitive processing biases in acrophobia., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

To examine the causal relationship between cognitive biases and anxiety, a bias modification paradigm was used to reduce negative interpretation biases in participants with high anxiety sensitivity (AS). Participants (N=75) were assigned to a Positive training condition or to one of two Control conditions (Neutral or No training). During training, participants imagined themselves in ambiguous scenarios related to AS. Positive training required participants to resolve the scenarios' ambiguity positively and was hypothesized to result in more positive and less negative subsequent interpretations related to AS, fewer self-reported AS symptoms, and less emotional vulnerability on AS stressors (compared to the Control conditions). As expected, Positive training shifted interpretations of novel scenarios and self-reported AS symptoms in the anticipated direction. Evidence was mixed for the effect of Positive training on emotional vulnerability (small effect for less fear, but not for avoidance). Findings support the causal premise underlying cognitive models of anxiety.