Effects of positive interpretive bias modification in highly anxious individuals

Over the past 20 years evidence has accumulated that individuals suffering from anxiety tend to interpret ambiguous information as threatening. Considering the causal role of this interpretive bias in anxiety, it was recently established that modifying interpretive biases influences anxiety. This suggests that anxiety can be clinically treated by directly targeting this interpretive bias. The present study was designed to modify a negative interpretive bias in highly anxious individuals, and subsequently assess the hypothesized beneficial effects on clinical measures. High trait-anxious participants were randomly assigned to one of two conditions: a positive interpretational Cognitive Bias Modification (CBM-I) or a control condition (n = 2 × 17). The program was offered online for eight consecutive days. Upon completing the program, participants who had followed positive CBM-I were less state and trait-anxious compared to the control group. Additionally, positively trained participants scored lower on a measure of general psychopathology (SCL-90). No effects were observed on social anxiety and stress vulnerability. The mixed pattern of findings renders them rather inconclusive, leaving interpretations of the potential therapeutic merits of CBM-I open for future research.     

Training implicit social anxiety associations: An experimental intervention

The current study investigates an experimental anxiety reduction intervention among a highly socially anxious sample (N = 108; n = 36 per Condition; 80 women). Using a conditioning paradigm, our goal was to modify implicit social anxiety associations to directly test the premise from cognitive models that biased cognitive processing may be causally related to anxious responding. Participants were trained to preferentially process non-threatening information through repeated pairings of self-relevant stimuli and faces indicating positive social feedback. As expected, participants in this positive training condition (relative to our two control conditions) displayed less negative implicit associations following training, and were more likely to complete an impromptu speech (though they did not report less anxiety during the speech). These findings offer partial support for cognitive models and indicate that implicit associations are not only correlated with social anxiety, they may be causally related to anxiety reduction as well.     

Family environment as a moderator of the association between anxiety and suicidal ideation

The present study examined associations among anxiety symptoms, anxiety disorder diagnoses, perceptions of family support and conflict, and suicidal ideation (SI) in a clinical sample of psychiatrically hospitalized adolescents. Participants were 185 adolescents (72% female; 84% white, mean age = 15.02 years, SD = 1.33) hospitalized on an acute psychiatric inpatient unit. Results indicated that anxiety disorders and symptoms were positively associated with SI, even after controlling for mood disorder diagnoses and sex. Moreover, this relationship was stronger among youth who reported lower (versus higher) levels of family support. Family conflict was positively associated with SI but did not moderate the relationship between anxiety and SI. Results suggest that family support may represent an important intervention target to decrease suicide risk among anxious youth. Integrating positive parenting techniques (e.g., attending to positive behaviors, providing praise, emotion coaching) and effective parent-child communication into treatment with anxious youth may help achieve this aim.     

Effects of standard and explicit cognitive bias modification and computer-administered cognitive-behaviour therapy on cognitive biases and social anxiety

Background and objectivesThis study examines the effects of a single session of Cognitive Bias Modification to induce positive Interpretative bias (CBM-I) using standard or explicit instructions and an analogue of computer-administered CBT (c-CBT) program on modifying cognitive biases and social anxiety.MethodsA sample of 76 volunteers with social anxiety attended a research site. At both pre- and post-test, participants completed two computer-administered tests of interpretative and attentional biases and a self-report measure of social anxiety. Participants in the training conditions completed a single session of either standard or explicit CBM-I positive training and a c-CBT program. Participants in the Control (no training) condition completed a CBM-I neutral task matched the active CBM-I intervention in format and duration but did not encourage positive disambiguation of socially ambiguous or threatening scenarios.ResultsParticipants in both CBM-I programs (either standard or explicit instructions) and the c-CBT condition exhibited more positive interpretations of ambiguous social scenarios at post-test and one-week follow-up as compared to the Control condition. Moreover, the results showed that CBM-I and c-CBT, to some extent, changed negative attention biases in a positive direction. Furthermore, the results showed that both CBM-I training conditions and c-CBT reduced social anxiety symptoms at one-week follow-up.LimitationsThis study used a single session of CBM-I training, however multi-sessions intervention might result in more endurable positive CBM-I changes.ConclusionsA computerised single session of CBM-I and an analogue of c-CBT program reduced negative interpretative biases and social anxiety.     

“You can do it!”: The role of parental encouragement of bravery in child anxiety treatment

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.     

Early maladaptive schemas and social anxiety in adolescents: The mediating role of anxious automatic thoughts

Cognitive models state that cognitions are organized hierarchically, so that the underlying schemas affect behavior via more automatic, superficial cognitive processes. This study aimed to demonstrate that early maladaptive schemas predict anxious automatic thoughts, and to show that such automatic thoughts act as mediators between schemas and prospective changes in social anxiety symptoms. The study also examined an alternative reverse model in which schemas acted as mediators between automatic thoughts and social anxiety. A total of 1052 adolescents (499 girls and 553 boys; M_age = 13.43; SD_age = 1.29) completed measures of early maladaptive schemas, socially anxious automatic thoughts, and social anxiety symptoms at Times 1, 2, and 3. The results revealed bidirectional longitudinal relationships among schemas and automatic thoughts that were consistent in content (e.g., the disconnection/rejection schemas and automatic thoughts of negative self-concept). Furthermore, the automatic thoughts of anticipatory negative evaluation by others at Time 2 mediated the relationship between the other-directedness schemas at Time 1 and social anxiety symptoms at Time 3. These findings are consistent with hierarchical cognitive models of social anxiety given that deeper schemas predict more surface-level thoughts. They also support that these more surface-level thoughts contribute to perpetuating schemas. Finally, results show that early maladaptive schemas of the other-directedness domain play a relevant role in the development and maintenance of social anxiety.     

Parenting practices,interpretive biases,and anxiety in Latino children

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.     

Post-event processing and memory bias for performance feedback in social anxiety

Despite predictions following from cognitive theories of anxiety, evidence for memory biases in social anxiety has been mixed. This study extends previous research by using stimuli relevant to participants’ concerns and allowing time for post-event processing. Participants high (n = 42) or low (n = 39) in social anxiety symptoms gave speeches and received standardized feedback on their and a confederate's performance. Participants then took recognition and recall tests for the feedback immediately after it was given and after a two-day delay. Results showed no recall biases. However, the hypothesized recognition biases were found: the high social anxiety group remembered the confederate's feedback more positively than their own, remembered their negative feedback as worse than the low group, and diminished positive feedback over time. Moreover, post-event processing mediated the relationship between social anxiety and memory for negative feedback. Results suggest that biased recognition of social feedback is linked to social anxiety.     

Parental Attitudes,Beliefs, and Understanding of Anxiety (PABUA): Development and psychometric properties of a measure

The Parental Attitudes, Beliefs, and Understanding of Anxiety (PABUA) was developed to assess parental beliefs about their child’s anxiety, parents’ perceived ability to cope with their child’s anxiety and to help their child manage anxious symptoms, and to evaluate parents’ understanding of various parenting strategies in response to their child’s anxiety. The study evaluated the PABUA in mother-child dyads (N = 192) seeking treatment for youth anxiety. Exploratory factor analysis yielded a three-factor solution and identified PABUA scales of Overprotection, Distress, and Approach (with Cronbach’s alpha ranging from .67 to .83). Convergent and divergent validity of PABUA scales was supported by the pattern of associations with measures of experiential avoidance, beliefs related to children’s anxiety, empathy, trait anxiety, and depressive symptoms; parent-reported family functioning; parent- and youth-reported anxiety severity; and parent-reported functional impairment (n = 83). Results provide preliminary support for the PABUA as a measure of parental attitudes and beliefs about anxiety, and future studies that investigate this measure with large and diverse samples are encouraged.     

Developmental brain alterations in 17 year old boys are related to antenatal maternal anxiety

ObjectiveTo assess the association between maternal anxiety during pregnancy and the brain activity of 17 year old adolescents performing two cognitive control tasks.MethodsTwenty-three 17 year old boys of mothers whose level of anxiety was measured during pregnancy were investigated using ERP while performing a Go/Nogo paradigm assessing exogenous cognitive control and a Gambling paradigm requiring endogenous cognitive control.ResultsNo effects of antenatal maternal anxiety were observed in the Go/Nogo paradigm. However, in the Gambling paradigm adolescents of the high anxiety group (n = 8) showed a less efficient pattern of decision making compared to the adolescents in the low-average anxiety group (n = 15). Moreover, only for this task the ERP data showed an enlarged early frontal P2a component in the high anxiety group.ConclusionsThe brain activity of adolescents during an endogenous cognitive control task is associated to the level of anxiety experienced by their mother during pregnancy. This association was not observed during an exogenous cognitive control task.SignificanceThis study indicates that a child’s brain functionality is related to its mother’s anxiety during pregnancy. Endogenous cognitive control is regarded the cognitive function most affected by the level of antenatal maternal anxiety.     

BDNF Val66Met,stress, and positive mothering: Differential susceptibility model of adolescent trait anxiety

Etiological research has indicated the gene–environment interaction (G × E) on adolescent anxiety. This study aimed to examine how the BDNF Val66Met polymorphism interacted with stressful life events and positive mothering to influence youth trait anxiety. The study sample included 780 community adolescents of Chinese Han ethnicity (M = 13.6, 51.3% females). Participants’ trait anxiety, exposure to stressful life events, and mother's warmth-reasoning were assessed by self-reported questionnaires. We found that BDNF Val66Met polymorphism significantly moderated the influences of stressful life events and mother's warmth-reasoning on adolescent anxiety. The influences were significantly greater in adolescents carrying one or two Val allele than those with Met/Met genotype. Moreover, the G × E interactions were more consistent with the differential susceptibility than the diathesis–stress model. Adolescents carrying Val allele who were more susceptible to adversity were also more likely to benefit from supportive experiences. These findings provide novel evidence for the role of BDNF Val66Met as a genetic susceptibility modulating the influences of stressful life events and mother's warmth-reasoning on adolescent anxiety. We speculate that BDNF Val66Met may moderate anxious youths’ responses to mindfulness-based stress reduction program and family-based treatment targeting the enhancement of positive parenting.     

Cognitive behavioral therapy for youth with social anxiety: Differential short and long-term treatment outcomes

This study examined social anxiety symptoms and/or diagnosis as a predictor of differential short- and long-term cognitive-behavioral treatment (CBT) outcomes. Ninety-one anxiety-disordered youth participated in a randomized clinical trial of CBT. Semi-structured interviews provided dimensional clinical severity ratings (CSRs) for children's principal anxiety disorder at pretreatment, posttreatment, 1-year and 7.4-year follow-up assessments for youth with versus without pretreatment social anxiety. Thirty-nine youth presented with either principal (n = 17), secondary (n = 11), or tertiary social phobia diagnoses (n = 7) or subclinical social anxiety symptoms (n = 4). Hierarchal linear modeling (HLM) indicated that youth made similar gains from pretreatment to posttreatment and 1-year follow-up regardless of their social anxiety symptoms or diagnosis; however, youth with social anxiety symptoms or diagnosis were significantly less improved at 7.4-year follow-up. This pattern was distinct from that of youth with the most severe (CSR = 4) principal anxiety disorders at pretreatment. Though initially responsive to CBT, children who present with social anxiety diagnoses or symptoms may require an enhanced or extended treatment to maintain their gains into young adulthood whether or not social anxiety is considered their principal childhood difficulty.     

Results of an Italian school-based expressive writing intervention trial focused on peer problems

This study investigated the effectiveness of an expressive writing intervention in a sample of Italian early adolescents on internalizing and post-traumatic stress symptoms and coping strategies. Participants were 153 Italian adolescents (48% male), attending 7th grade (M = 12.24 yrs, SD = 0.47). Youth were randomly assigned either to write about personal emotional events related to problems they recently experienced with peers, or trivial topics. Data were collected before and 2 months following the intervention. Analyses revealed no overall intervention effects on symptoms. However, level of peer victimization moderated the effects of the intervention on coping strategies, such that victimized youth in the intervention showed increases in cognitive restructuring and avoidance coping, relative to other groups. Thus, expressive writing affected coping strategies but not internalizing problems in our early adolescent sample.     

Attention allocation and social worries predict interpretations of peer-related social cues in adolescents

Adolescence is a sensitive period for increases in normative but also debilitating social fears and worries. As the interpretation of interpersonal cues is pertinent to social anxiety, investigating mechanisms that may underlie biases in social cue appraisal is important.Fifty-one adolescents from the community aged 14–19 were presented with self- and other-relevant naturalistic social scenes for 5 s and then required to rate either a negative or a positive interpretation of the scene. Eye-tracking data were collected during the free viewing period to index attentional deployment. Individual differences in social worries were measured via self-report.Social anxiety levels significantly predicted biases in interpretation ratings across scenes. Additionally, cumulative attentional deployment to peer cues also predicted these interpretation biases: participants who spent more time on facial displays perceived more threat, i.e. endorsed more negative and less positive interpretations. Self-relevant scenes yielded greater tendencies to draw negative interpretations. Finally, older adolescents also selected more benign interpretations.Social anxiety is associated with a bias in interpreting social cues; a cognitive bias that is also influenced by attentional deployment. This study contributes to our understanding of the possible attention mechanisms that shape cognitions relevant to social anxiety in this at-risk age group.     

Modifying interpretations among individuals high in anxiety sensitivity

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.     

A meta-analysis and scoping review of social cognition performance in social phobia,posttraumatic stress disorder and other anxiety disorders

Social cognition deficits are observed in a variety of psychiatric illnesses. However, data concerning anxiety disorders are sparse and difficult to interpret. This meta-analysis aims at determining if social cognition is affected in social phobia (SP) or posttraumatic stress disorder (PTSD) compared to non-clinical controls and the specificity of such deficits relatively to other anxiety disorders. The scoping review aims to identify research gaps in the field. Forty studies assessing mentalizing, emotion recognition, social perception/knowledge or attributional style in anxiety disorders were included, totalizing 1417 anxious patients and 1321 non-clinical controls. Results indicate distinct patterns of social cognition impairments: people with PTSD show deficits in mentalizing (effect size d = −1.13) and emotion recognition (d = −1.6) while other anxiety disorders including SP showed attributional biases (d = −0.53 to d = −1.15). The scoping review identified several under investigated domains of social cognition in anxiety disorders. Some recommendations are expressed for future studies to explore the full range of social cognition in anxiety disorders and allow direct comparisons between different disorders.     

Group cognitive behavioural treatment of youth anxiety in community based clinical practice: Clinical significance and benchmarking against efficacy

The efficacy of a group cognitive behavioural therapy (CBT) programme (Cool Kids) of youth anxiety has been demonstrated at university clinics in Australia and Denmark and similar CBT programmes have been found effective within community settings in other countries. However, most effectiveness studies of CBT for youth anxiety have either used a mixture of CBT guidelines, or translated protocols not previous tested in an efficacy trial. This study used a benchmarking strategy to compare outcomes from the same CBT programme used at a university research clinic (N = 87) and community centres (N = 82). There was a significant reduction on both clinical and self-report measures of youth anxiety over time with medium to large effect sizes within both samples. Treatment effects on self-report measures of youth anxiety were significantly larger within the university sample, while changes in clinical measures of youth anxiety were similar in the two samples. Overall these findings suggest that an efficacious CBT group treatment programme developed within research contexts is transportable to community centres. Despite being effective within the community, the results indicate that the treatment may lose some of its efficacy when disseminated to the community.     

The influence of endophenotypic,disease-specific,and environmental variables on the expression of anxiety in pediatric epilepsy

Children and adolescents with epilepsy often show higher rates of anxiety, which carries an increased risk for reduced health-related quality of life (HRQOL). The current study assessed the role of parental psychiatric history (i.e., anxiety, depression, and/or bipolar disorder) on the rate of anxiety features in youth seen in a tertiary epilepsy clinic. Data included parental ratings on the Behavior Assessment System for Children (BASC-2) and the Quality of Life in Childhood Epilepsy (QOLCE) questionnaire for 180 children and adolescents (mean age = 11.40, SD = 3.98). Our results identified clinically elevated anxiety ratings in nearly half the sample (47%) with previous psychiatric history endorsed by 48% of parents. The effect of parental psychiatric history on youth anxiety was found to be significant and associated with a threefold increase in the rate of youth anxiety features. This risk increased to fourfold in refractory epilepsy, and the impact of family psychiatric history is greater in adolescent females and in families that report higher levels of stress. In those families who reported no psychiatric history, anxiety was best predicted by epilepsy-specific factors above and beyond sociodemographic factors. Parental psychiatric history was also identified as a significant risk factor for diminished patient HRQOL, even after accounting for seizure control. These findings highlight the impact of family and epilepsy factors on psychological functioning and offer further support for the strong relationship between parental adjustment and child outcome in pediatric epilepsy.     

Trying to fall asleep while catastrophising: what sleep-disordered adolescents think and feel

ObjectiveCatastrophising is a repetitive cognitive process related to sleep disturbance in adult insomnia patients. More recently catastrophising has been associated with increased sleep disturbances in community samples of children and adolescents, with this association mediated by anxiety and depression. However, there currently is no evidence of these processes outside of community samples; impeding our ability to draw clinical conclusions. Knowledge on such dysfunctional cognitive processes in adolescents experiencing sleep disturbance would be clinically beneficial in aetiology and intervention. Our research examined the link between catastrophising, anxiety, depression and sleep latency in a sample of sleep-disordered adolescents. We also explored specific catastrophising themes which may impact the sleep latency of these adolescents.MethodForty adolescents (age = 15.1 ± 1.5 years, 53% boys) diagnosed with delayed sleep phase disorder completed a 7-day sleep diary, along with measures of anxiety and depression and a catastrophising interview with a trained sleep therapist.ResultsSeveral catastrophisation themes were generated, the most common concerning interpersonal and performance aspects of school. Bootstrapping analyses showed depression did not mediate the relationship between catastrophising and sleep; however, an indirect relationship was found between catastrophising, anticipatory anxiety, and sleep latency.ConclusionThese findings have implications for the role of dysfunctional thinking in prolonging sleep onset for adolescents and providing a clinical framework for health professionals when assessing and treating adolescents with delayed sleep timing.     

A School Nurse-Delivered Intervention for Anxious Children: An Open Trial

Anxiety disorders are common in children and severely impair their functioning. Because a hallmark symptom of anxiety is somatic complaints, anxious youth often seek help from their school nurse. Thus, school nurses are in an ideal position to identify anxious children and intervene early. This study assessed the feasibility of a brief nurse-administered intervention (CALM—Child Anxiety Learning Modules) based on cognitive behavioral strategies to reduce anxiety symptoms and improve academic functioning. Nine elementary school nurses completed a one-day training and administered the CALM intervention to 11 children with elevated symptoms of anxiety (M age: 8.09; range 5–11; 54% male; 91% White). Feasibility of the intervention was assessed using several indicators (e.g., training satisfaction, intervention satisfaction/helpfulness). Pre-post intervention child outcomes were collected from evaluators, parents, children, and teachers. Results indicated that the majority of nurses were highly satisfied with the training and reported the intervention was feasible. Paired t tests on pre-post outcome measures revealed significant reductions in anxiety, somatic symptoms, and concentration problems. Nurses (70%), parents (81%), and children (50%) reported that the intervention was either somewhat or very helpful. Preliminary results identified barriers to implementation but also suggest that the intervention is feasible and helpful. A sufficiently powered randomized controlled trial is needed to assess the intervention’s efficacy.