Linking a latent variable trait-state-occasion model of emotion regulation to cognitive control.

Emotion dysregulation (ED) is a vulnerability factor for affective disorders that may originate from deficits in cognitive control (CC). Although measures of ED are often designed to assess trait-like tendencies, the extent to which such measures capture a time-varying (TV) or state-like construct versus a time-invariant (TI) or trait-like personality characteristic is unclear. The link between the TV and TI components of ED and CC is also unclear. In a 6-wave, 5-month longitudinal study, community participants (n = 1281) completed the Difficulties in Emotion Regulation Scale (DERS-16), a commonly used measure of ED and measures of CC. A latent variable (trait-state-occasion) model showed that the proportion of TI factor variance (.80) was greater than the TV factor variance (.19). Although TV factor stability was significant, the coefficients were small in magnitude. Furthermore, regression weights for the ED TI factor (average ß = -.62) were significant and larger than those for the TV factor (average ß = -.10) in predicting latent CC at each of the six-time points. These findings suggest that ED, as assessed by the DERS-16, is largely TI and this TI component is more strongly linked to CC than the TV component.

Altered bed nucleus of the stria terminalis and amygdala responses to threat in combat veterans with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) significantly impacts many veterans. Although PTSD has been linked to alterations in the fear brain network, the disorder likely involves alterations in both the fear and anxiety networks. Fear involves responses to imminent, predictable threat and is driven by the amygdala, whereas anxiety involves responses to potential, unpredictable threat and engages the bed nucleus of the stria terminalis (BNST). The BNST has been implicated in PTSD, but the role of the BNST in combat veterans with PTSD has yet to be examined. Identifying alterations in BNST responses to unpredictable threat could provide important new targets for treatment. The current study examined whether veterans with PTSD have altered BNST or amygdala responses (function and connectivity) to unpredictable and predictable threat. The fMRI task involved viewing predictable threat cues followed by threat images, predictable neutral cues followed by neutral images, and unpredictable threat cues followed by either a threat or neutral image. Participants included 32 combat-exposed veterans with PTSD and 13 combat-exposed controls without PTSD. Across all conditions, veterans with PTSD had heightened BNST activation and displayed stronger BNST and amygdala connectivity with multiple fear and anxiety regions (hypothalamus, hippocampus, insula, ventromedial prefrontal cortex) relative to controls. In contrast, combat controls showed a pattern of stronger connectivity during neutral conditions (e.g., BNST-vmPFC), which may suggest a neural signature of resilience to developing PTSD, ηp 2 = .087-.527, ps < .001. These findings have implications for understanding fear and anxiety networks that may contribute to the development and maintenance of PTSD.

Cognitive Behavioral Therapy for Anxiety Disorders in Youth: Efficacy, Moderators, and New Advances in Predicting Outcomes.

PURPOSE OF REVIEW: This review integrates recent systematic reviews and meta-analyses on the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders in children and adolescents. To inform personalized approaches to intervention, we also review recent research on moderators and predictors of outcomes. RECENT FINDINGS: Meta-analyses provide strong support for the efficacy of CBT for youth anxiety disorders, including with preschool-aged children using appropriate modifications. Furthermore, there is evidence that CBT is an effective adjunct treatment to psychopharmacological interventions, and the combination of treatments may be most effective for some youth. There is limited evidence of consistent demographic and clinical moderators of outcomes. Recent work in neuroscience has highlighted novel predictors of treatment outcomes that, with replication, may aid in more personalized approaches to youth anxiety treatment. CBT is efficacious for treating anxiety disorders in youth and lowering recurrence rates. CBT can also be an efficacious adjunct treatment for psychopharmacological interventions. Neuroimaging and psychophysiological measures of threat and motivational processing have shown initial promise in predicting symptom change with CBT, with potential implications for precision medicine.

The effects of worry proneness on diurnal anxiety: An ecological momentary assessment approach.

Existing theoretical models and empirical evidence suggest that worry proneness is associated with anxious responding. However, it is unknown how worry proneness may influence the experience of anxiety throughout the day. The present study addresses this gap in the literature by employing an ecological momentary assessment design to examine the impact of worry proneness on diurnal changes in anxiety reported in the morning, afternoon, and evening for one week in a sample of unselected adults (N = 136). Results indicated a significant reduction in anxiety from morning to evening. Further, this effect was moderated by worry proneness, such that a diurnal decline in anxiety was detectable among those with low and moderate levels of worry proneness, whereas those high in worry proneness reported increased momentary anxiety which was sustained throughout the day. These results replicate previous studies indicating anxiety is highest in the morning and lowest in the evening. Further, these findings suggest that worry proneness may override normative diurnal changes in anxiety and thereby maintain anxiety at elevated and consistent levels. The implications of these findings for the development and treatment of disorders characterized by excessive worry are discussed.

Circadian Rhythms in Obsessive-Compulsive Disorder: Recent Findings and Recommendations for Future Research.

PURPOSE OF REVIEW: Circadian rhythms are a topic of growing interest in mental health, particularly in obsessive-compulsive disorder. However, the consistency of this link has not been carefully examined. Thus, the present review integrates findings from the past 5 years in order to determine the strength of such a relationship and identify areas for clarification and extension. RECENT FINDINGS: Findings revealed inconsistent evidence for a link between circadian rhythms and OCD. Chronotype is unrelated to OCD symptoms in adolescents but predicts OCD symptoms in adults. Results on delayed sleep timing are equivocal. Circadian rhythm disorders predict OCD treatment outcome. Preliminary evidence implicates decreased light exposure and diurnal symptom variability in OCD. The relationship between circadian rhythms and OCD may vary by age, diagnostic status, and assessment method. Recent findings are limited by an overreliance on convenience samples and singular self-report methods. Recommendations for future research on the role of circadian rhythms in OCD are discussed.

Anger Rumination is not Uniquely Characteristic of Obsessive-Compulsive Disorder.

Although anger has been observed in obsessive-compulsive disorder (OCD), it remains unclear if rumination about anger is characteristic and/or unique to OCD. The present study examines whether types of anger rumination are endorsed more strongly by OCD patients compared to clinical and nonclinical controls. Patients with OCD (n = 30), generalized anxiety disorder (GAD; n = 29), and non-clinical controls (NCC; n = 30) completed measures of OCD symptoms, anger rumination, and trait anxiety. Patients with OCD and GAD significantly differed from NCC's (all ps < .001), but not each other (all ps > .10), in anger afterthoughts, thoughts of revenge, angry memories, and understanding causes of anger. However, the group differences were no longer significant when controlling for trait anxiety. A dimensional approach revealed that OCD symptoms were correlated with anger rumination domains overall. However, these associations were also no longer significant after controlling for trait anxiety. These findings suggest that anger rumination may emerge in OCD largely as an artifact of trait anxiety/negative affect that is associated with but not unique to the disorder. The implications of these findings for conceptualizing emotion and its regulation in OCD are discussed.

Enhancing Inhibitory Learning: The Utility of Variability in Exposure.

Exposure therapy has strong empirical support as a treatment for anxiety and related disorders, yet not all participants see clinically meaningful reduction in symptoms, and some experience return of fear. In this review, we examine the theoretical models of exposure therapy, from early precursors to the contemporary inhibitory learning model. The inhibitory learning model is applied to examine one potential method of improving outcomes in exposure therapy: increasing variability in the progression of the exposure hierarchy. We explore mechanisms that support the use of variability in exposure, including the violation of expectancies to enhance learning. In addition, the role of intolerance of uncertainty in anxiety is examined; variable exposure therapy could target this transdiagnostic mechanism in anxiety and related disorders. Suggestions for future research are then offered.

Disgust in Anxiety and Obsessive-Compulsive Disorders: Recent Findings and Future Directions.

PURPOSE OF REVIEW: In the past 20 years, the role of disgust in anxiety disorders and obsessive-compulsive disorder (OCD) has been investigated with increasing precision. In this review, we examine recent evidence implicating disgust in anxiety and OCD, highlighting recent measurement and methodological improvements. Specific emphasis is placed on understanding the mechanisms that may account for the role of disgust in OCD and related disorders. RECENT FINDINGS: Recent developments include clarification of the role of distinct disgust-relevant vulnerabilities in the etiology of anxiety and OCD, an improved understanding of the neurobiology of disgust processing in OCD, and an increased focus on disgust-related mechanisms that contribute to psychopathology, such as disgust-based learning and emotion regulation. Disgust proneness is increasingly linked with symptoms of anxiety and OCD. However, further examination of the mechanisms that account for the roles of distinct disgust-relevant vulnerabilities is needed, and studies that directly examine disgust during the course of treatment are limited. Increasingly, the field has moved toward experimental investigation of specific disgust-relevant mechanisms that influence the etiology and treatment of OCD and related anxiety disorders.

Responsibility/Threat Overestimation Moderates the Relationship Between Contamination-Based Disgust and Obsessive-Compulsive Concerns About Sexual Orientation.

Disgust has been shown to perform a "disease-avoidance" function in contamination fears. However, no studies have examined the relevance of disgust to obsessive-compulsive (OC) concerns about sexual orientation (e.g., fear of one's sexual orientation transforming against one's will, and compulsive avoidance of same-sex and/or gay or lesbian individuals to prevent that from happening). Therefore, we investigated whether the specific domain of contamination-based disgust (i.e., evoked by the perceived threat of transmission of essences between individuals) predicted OC concerns about sexual orientation, and whether this effect was moderated/amplified by obsessive beliefs, in evaluation of a "sexual orientation transformation-avoidance" function. We recruited 283 self-identified heterosexual college students (152 females, 131 males; mean age = 20.88 years, SD = 3.19) who completed three measures assessing disgust, obsessive beliefs, and OC concerns about sexual orientation. Results showed that contamination-based disgust (ß = .17), responsibility/threat overestimation beliefs (ß = .15), and their interaction (ß = .17) each uniquely predicted OC concerns about sexual orientation, ts = 2.22, 2.50, and 2.90, ps < .05. Post hoc probing indicated that high contamination-based disgust accompanied by strong responsibility/threat overestimation beliefs predicted more severe OC concerns about sexual orientation, ß = .48, t = 3.24, p < .001. The present study, therefore, provided preliminary evidence for a "sexual orientation transformation-avoidance" process underlying OC concerns about sexual orientation in heterosexual college students, which is facilitated by contamination-based disgust, and exacerbated by responsibility/threat overestimation beliefs. Treatment for OC concerns about sexual orientation should target such beliefs.

Sleep Disturbance in Posttraumatic Stress Disorder: Epiphenomenon or Causal Factor?

PURPOSE OF REVIEW: The goal of this review is to integrate recent findings on sleep disturbance and PTSD, examine sleep disturbance as a causal factor in the development of PTSD, and identify future directions for research, treatment, and prevention. RECENT FINDINGS: Recent research highlights a relationship between both objective and subjective sleep disturbance and PTSD across diverse samples. Sleep disturbance also predicts PTSD over time. Finally, treatments targeting sleep disturbance lead to decreased PTSD symptoms, while standard PTSD treatments conclude with residual sleep disturbance. Sleep disturbance may be more than a mere epiphenomenon of PTSD. Future research examining the causal role of sleep disturbance in the development of PTSD, as well as the utility of targeting sleep disturbance in prevention and treatment, is necessary to fully understand the likely bidirectional relationship between sleep disturbance and PTSD.

Emotion regulation of fear and disgust: differential effects of reappraisal and suppression.

Although excessive fear has been central to traditional conceptualisations of the anxiety disorders, recent research suggests that disgust may also play a role in the development of some anxiety disorders. While dysregulation of emotion may confer risk for the development of anxiety disorders, it remains unclear if there are differences in the extent to which fear and disgust can be effectively regulated. To fill this important gap in the literature, unselected participants (N = 95) experienced fear or disgust via video exposure, and they were instructed to employ either reappraisal or suppression to regulate their emotional experience while viewing the videos. For those exposed to fear-relevant content, change in emotional distress did not significantly differ between those that suppressed and those that reappraised. However, significantly less emotional distress was observed for those that reappraised compared to those that suppressed when exposed to disgust-relevant content. Although physiological arousal varied over time as a function of the emotional content of the videos, it did not vary as a function of emotion regulation strategy employed. These findings suggest that reappraisal may be especially effective in regulating verbal distress when exposed to disgusting cues in the environment. The implications of these findings for the treatment of anxiety disorders that are characterised by excessive disgust reactions will be discussed.

Linking attentional control and PTSD symptom severity: the role of rumination.

Although deficits in attentional control have been linked to posttraumatic stress disorder (PTSD), the mechanism that may account for this association has not been fully elucidated. The present study examined rumination as a mediator of the relationship between attentional control and PTSD symptoms. Veterans with PTSD and trauma-exposed veterans without PTSD completed measures of attentional control, rumination, and PTSD symptom severity. As predicted, the findings showed that veterans with PTSD reported significantly lower levels of attentional control than veterans without PTSD. Veterans with PTSD also reported significantly higher levels of rumination than veterans without PTSD. Subsequent analysis of the total sample revealed that the relationship between attentional control and PTSD symptom severity was accounted for by excessive rumination. Attentional control may contribute to PTSD symptoms through excessive rumination. Attentional control and rumination may be important targets for PTSD interventions.

Further Psychometric Evaluation of the Child Disgust Scale.

This study evaluated the psychometric properties of the Child Disgust Scale (CDS) among 457 youth (ages 8-17, M = 14.77 ± 1.98 years) initiating residential treatment for obsessive-compulsive disorder and anxiety disorders. Confirmatory factor analysis supported a bifactor model with two distinct factors of Disgust Avoidance and Disgust Affect, in addition to an overall General Disgust factor. Strong internal consistency was observed for the CDS total and factor scores. In addition, CDS scores demonstrated generally modest and positive correlations with child-reported obsessive-compulsive and anxiety symptoms, weaker correlations with parent-reported anxiety and child-rated impairment, and non-significant correlations with parent-rated impairment. Findings suggest that the CDS displays strong psychometric properties and is developmentally appropriate for use in pediatric clinical populations with obsessive-compulsive and anxiety disorders.

Is disgust sensitive to classical conditioning as indexed by facial electromyography and behavioural responses?

Earlier studies provided preliminary support for the role of classical conditioning as a pathway of disgust learning, yet this evidence has been limited to self-report. This study included facial electromyographical (EMG) measurements (corrugator and levator muscles) and a behavioural approach task to assess participants' motivation-to-eat the actual food items (conditioned stimuli, CS). Food items served as CS and film excerpts of a woman vomiting served as unconditioned stimuli (US). Following acquisition the CS+ (neutral CS paired with US disgust) was rated as more disgusting and less positive. Notably, the conditioned response was transferred to the actual food items as evidenced by participants' reported lowered willingness-to-eat. Participants also showed heightened EMG activity in response to the CS+ which seemed driven by the corrugator indexing a global negative affect. These findings suggest that classical conditioning as a pathway of disgust learning can be reliably observed in subjective but not in disgust-specific physiological responding.

Effects of disgust priming and disgust sensitivity on moral judgement.

Although prior research suggests that disgust results in more severe moral judgements, the extent to which awareness of disgust cues influences moral judgements remains unclear. To address this gap in the literature, participants in this study were randomised to subliminal or conscious awareness of disgust and neutral images prior to the description and evaluation of moral transgressions. No differences were found in moral severity ratings for transgressions that were presented after neutral and disgust images in the subliminal condition. However, moral severity ratings for moderate transgressions that were presented after neutral images were significantly higher than morality ratings of transgressions presented after disgust images in the conscious condition. Subsequent analysis also revealed a significant relationship between individual differences in disgust propensity and perceived immorality of moderate transgressions, especially in the conscious condition. The finding of higher moral severity ratings for moderate transgressions presented after neutral images in the conscious condition is inconsistent with research showing that disgust uniquely influences moral judgements. This research highlights the importance of further research examining the role of methodological considerations that may moderate the influence of disgust on moral judgements.

EFFECTS OF HOMEWORK COMPLIANCE ON COGNITIVE-BEHAVIORAL THERAPY WITH D-CYCLOSERINE AUGMENTATION FOR CHILDREN WITH OBSESSIVE COMPULSIVE DISORDER.

BACKGROUND: The present study examined the effects of homework compliance on outcome from cognitive behavioral therapy (CBT) for children with obsessive-compulsive disorder (OCD) and the extent to which these effects differ as a function of augmentation of CBT with D-cycloserine (DCS). METHODS: Twenty-seven youth with OCD were randomized to either 50 mg DCS or placebo (PBO) administered immediately after each of 10 CBT sessions, primarily consisting of exposure and ritual prevention (ERP). Independent evaluators assessed OCD severity using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at the start of each session. Compliance with between-session ERP assignments was also assessed at the start of each session using the Patient ERP Adherence Scale (PEAS). RESULTS: Greater homework compliance between the previous session and the current session was related to lower CY-BOCS at the current session. However, the relation between homework compliance and CY-BOCS varied by treatment condition. Higher homework compliance was related to lower CY-BOCS for participants in the DCS condition, but not for participants in the PBO condition. Furthermore, participants receiving DCS were estimated to have significantly lower CY-BOCS than those given PBO among those with the highest levels of homework compliance. CONCLUSIONS: DCS may more effectively facilitate the effects of CBT for youth with OCD when patients are compliant with prescribed homework. Theoretical and clinical implications are discussed.

Selective effects of excessive engagement in health-related behaviours on disgust propensity.

The present study examined the extent to which engagement in health-related behaviours modulate disgust propensity, a purportedly stable personality trait. Participants were randomised into a health behaviour (n = 30) or control condition (n = 30). After a baseline period, participants in the health behaviour condition spent one week actively engaging in a clinically representative array of health-related behaviours on a daily basis, followed by a second week-long baseline period. Participants in the control condition monitored their normal use of health behaviours. Compared to control participants, those in the health behaviour condition reported significantly greater increases in disgust propensity after the health behaviour manipulation. This effect was most robust for contamination disgust propensity and remained significant when controlling for changes in health anxiety and disease fear. In contrast, self-disgust and anxiety sensitivity did not significantly differ between the two groups as a function of the health behaviour manipulation. Mediational analyses were consistent with the hypothesis that changes in the frequency of health-related behaviours, but not changes in health anxiety and disease fear, mediated the effects of the experimental manipulation on changes in contamination disgust propensity. These findings suggest that the purportedly stable personality trait of disgust propensity can be modulated by excessive engagement in health-related behaviours.

Specific emotion regulation difficulties and executive function explain the link between worry and subsequent stress: A prospective moderated mediation study.

BACKGROUND: Worry is a transdiagnostic risk factor for stress-related mental health complaints such as anxiety, depression, and insomnia. Although worry may function as a form of avoidance of unwanted emotions and accordingly interfere with adaptive emotion regulation, the specific domains of emotion regulation that are perturbed by excessive worry to confer risk for stress-related symptoms are unclear. Further, it is unknown if cognitive control mechanisms that underlie successful emotion regulation influence the effect of worry on stress. The present study addressed these gaps in the literature by examining specific emotion regulation difficulties as mediators of the relationship between worry and subsequent stress, as well as executive function as a moderator of the mediated effects. METHOD: 656 community adults were assessed for trait worry, emotion dysregulation, stress, and executive dysfunction once per month for three months (time 1 - time 3). RESULTS: The effect of worry (time 1) on subsequent stress (time 3) was partially mediated by difficulties with emotional clarity and difficulty engaging in goal-directed behavior when upset (time 2) after controlling for age, gender, and baseline stress. Moderated mediation models revealed that the indirect effect of worry on stress via difficulty with goal-directed behavior was significantly moderated by executive dysfunction, such that fewer executive function difficulties acted as a buffer against the harmful effects of worry. LIMITATIONS: Limitations include reliance on self-report measures, lack of experimental manipulation, and a nonclinical sample. CONCLUSIONS: Findings point to specific domains of emotion regulation as treatment targets for individuals with high worry proneness.

Examining reciprocal relations between disgust proneness and OCD symptoms: A four-wave longitudinal study.

BACKGROUND AND OBJECTIVES: Although disgust proneness has been implicated in the development of obsessive-compulsive disorder (OCD), available studies have largely employed cross-sectional designs and the prospective and potentially reciprocal association between disgust proneness and OCD symptoms remains unclear. The present study employs cross lagged panel analysis to examine the prospective and reciprocal association between disgust proneness and OCD symptoms. METHOD: A community sample of adults (N = 307) completed symptom measures of disgust proneness and OCD symptoms at four time points with 1 month intervals. RESULTS: The results showed that the cross-lagged paths from disgust proneness to OCD symptoms were significant (average ß = 0.07, p's < 0.001) when controlling for depression. However, the paths from total OCD symptoms to disgust proneness were not significant. In contrast, the cross-lagged paths from disgust proneness to washing OCD symptoms were not significant. However, the paths from washing OCD symptoms to disgust proneness were significant (average ß = 0.05, p's < 0.01) when controlling for depression. LIMITATIONS: The study is limited is limited by exclusive reliance on self-report in a nonclinical sample. CONCLUSIONS: The findings offer preliminary evidence suggesting that disgust proneness may be a cause and consequence of OCD depending on the nature of the symptoms. Thus, the longitudinal relation between disgust proneness and OCD may be transactional where one influences the effect of the other.

Is disgust more resistant to extinction than fear? A meta-analytic review of laboratory paradigms.

Disgust can be acquired via evaluative conditioning; a process by which a neutral stimulus (conditioned stimulus; CS) comes to be evaluated as disgusting due to its pairing with an inherently disgusting stimulus (unconditioned stimulus; US). Research has shown that conditioned disgust responses are resistant to extinction which may have implications for disorders (i.e., contamination-based obsessive-compulsive disorder, specific phobias, and post-traumatic stress disorder) in which heightened disgust has been implicated. Importantly, extinction is the primary mechanism by which exposure therapies are thought to achieve symptom reduction for these disorders. Exposure therapies were originally modeled on fear extinction, whereas disgust extinction was largely overlooked until recently. Accordingly, differences in the degree to which learned disgust and fear can be attenuated via extinction learning remains unclear. The present investigation was a meta-analysis directly comparing the degree of extinction of conditioned disgust (n = 14) and conditioned fear (n = 14) in laboratory paradigms. Extinction was operationalized as the standardized mean difference (SMD) in evaluative ratings between the CS+ (the CS paired with the US) and CS- (the unpaired CS) after extinction training. Results of a subgroup analysis indicated that disgust (SMD = 0.52) was significantly more resistant to extinction than fear (SMD = 0.37). Additionally, a series of meta-regression analyses indicated that extinction was not influenced by important study characteristics (e.g., sex, age, number of conditioning and extinction trials). The findings suggest that extinction-based approaches may be less effective at attenuating learned disgust and research is needed to better optimize treatments for disgust-related disorders.