Treatment for Anhedonia: A Neuroscience Driven Approach.

Anhedonia, or loss of interest or pleasure in usual activities, is characteristic of depression, some types of anxiety, as well as substance abuse and schizophrenia. Anhedonia is a predictor of poor long-term outcomes, including suicide, and poor treatment response. Because extant psychological and pharmacological treatments are relatively ineffective for anhedonia, there is an unmet therapeutic need for this high-risk symptom. Current psychological and drug treatments for anxiety and depression focus largely on reducing excesses in negative affect rather than improving deficits in positive affect. Recent advances in affective neuroscience posit that anhedonia is associated with deficits in the appetitive reward system, specifically the anticipation, consumption, and learning of reward. In this paper, we review the evidence for positive affect as a symptom cluster, and its neural underpinnings, and introduce a novel psychological treatment for anxiety and depression that targets appetitive responding. First, we review anhedonia in relation to positive and negative valence systems and current treatment approaches. Second, we discuss the evidence linking anhedonia to biological, experiential, and behavioral deficits in the reward subsystems. Third, we describe the therapeutic approach for Positive Affect Treatment (PAT), an intervention designed to specifically target deficits in reward sensitivity.

Perceived social support mediates anxiety and depressive symptom changes following primary care intervention.

BACKGROUND: The current study tested whether perceived social support serves as a mediator of anxiety and depressive symptom change following evidence-based anxiety treatment in the primary care setting. Gender, age, and race were tested as moderators. METHODS: Data were obtained from 1004 adult patients (age M = 43, SD = 13; 71% female; 56% White, 20% Hispanic, 12% Black) who participated in a randomized effectiveness trial (coordinated anxiety learning and management [CALM] study) comparing evidence-based intervention (cognitive-behavioral therapy and/or psychopharmacology) to usual care in the primary care setting. Patients were assessed with a battery of questionnaires at baseline, as well as at 6, 12, and 18 months following baseline. Measures utilized in the mediation analyses included the Abbreviated Medical Outcomes (MOS) Social Support Survey, the Brief Symptom Index (BSI)-Somatic and Anxiety subscales, and the Patient Health Questionnaire (PHQ-9). RESULTS: There was a mediating effect over time of perceived social support on symptom change following treatment, with stronger effects for 18-month depression than anxiety. None of the mediating pathways were moderated by gender, age, or race. CONCLUSIONS: Perceived social support may be central to anxiety and depressive symptom changes over time with evidence-based intervention in the primary care setting. These findings possibly have important implications for development of anxiety interventions.

Experiencing core symptoms of anxiety and unipolar mood disorders in late adolescence predicts disorder onset in early adulthood.

BACKGROUND: Identification of youth at risk for anxiety and unipolar mood disorders (UMDs) can improve public health by targeting those who may warrant early or preventive intervention. This study examined whether endorsing core features of anxiety and UMDs predicted onset of later anxiety and UMDs across the next 7-9 years, and whether having subthreshold or subclinical manifestations of these disorders similarly predicted onset. METHODS: Data from this study come from the Youth Emotion Project (YEP), a two-site investigation of common and specific risk factors for emotional disorders. Endorsement of core features of a disorder and subclinical or subthreshold anxiety and UMD diagnoses were determined using data from the Structured Clinical Interview for DSM-IV (SCID) at the baseline assessment. Participants completed annual SCIDs over the course of the next 7-9 years (depending on cohort). RESULTS: Endorsement of panic attacks, obsessions and/or compulsions, and depression and/or anhedonia predicted onset of panic disorder, obsessive compulsive disorder, and major depressive disorder, respectively. When including all anxiety disorders in a model, only the presence of panic attacks uniquely predicted anxiety disorder onset. The presence of subclinical or subthreshold panic disorder, obsessive compulsive disorder, and social phobia at baseline predicted the full onset of these disorders over the follow-up period. CONCLUSIONS: Experiencing some symptoms of anxiety and UMDs in the absence of meeting diagnostic criteria is indicative of risk for later onsets of clinically significant DSM manifestations of these disorders. These individuals should be identified and targeted for prevention programs.

Superhero ideal, authenticity in relationships, and depressive symptoms: A multiple mediation analysis.

Striving for high achievement across multiple domains to achieve an unrealistic ideal may predict adolescents' depressive symptoms, and this relation may be explained by authenticity in meaningful relationships. This is the first known study to examine the relation between internalization of the superhero ideal, defined as the socially prescribed desire for achievement across personal and professional domains, and depressive symptoms, and to examine authenticity in relationships as a mediator in the relation between the superhero ideal and depressive symptoms. Participants were 163 adolescents (ages 12-14). Multiple mediation results utilizing cross-sectional data indicated that the superhero ideal was related to depressive symptoms and that authenticity in relationships with peers and parents partially mediated this relation. These results identify a possible explanation for understanding the relation between the superhero ideal and depressive symptoms.

Measuring the suicidal mind: implicit cognition predicts suicidal behavior.

Suicide is difficult to predict and prevent because people who consider killing themselves often are unwilling or unable to report their intentions. Advances in the measurement of implicit cognition provide an opportunity to test whether automatic associations of self with death can provide a behavioral marker for suicide risk. We measured implicit associations about death/suicide in 157 people seeking treatment at a psychiatric emergency department. Results confirmed that people who have attempted suicide hold a significantly stronger implicit association between death/suicide and self than do psychiatrically distressed individuals who have not attempted suicide. Moreover, the implicit association of death/suicide with self was associated with an approximately 6-fold increase in the odds of making a suicide attempt in the next 6 months, exceeding the predictive validity of known risk factors (e.g., depression, suicide-attempt history) and both patients' and clinicians' predictions. These results provide the first evidence of a behavioral marker for suicidal behavior and suggest that measures of implicit cognition may be useful for detecting and predicting sensitive clinical behaviors that are unlikely to be reported.

Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia.

OBJECTIVE: Loss of pleasure or interest in activities (i.e., anhedonia) is a risk factor for suicidality, treatment nonresponse, and relapse. Extant treatments that focus on reducing negative affect have limited effects upon positive affect (a core feature of anhedonia). We investigated whether a novel intervention aimed at increasing reward sensitivity was more efficacious for positive affect than a cognitive-behavior treatment aimed at reducing threat sensitivity, in individuals with clinically severe symptoms of depression or anxiety, and functional impairment. METHOD: The Treatment for Affective Dimensions trial was offered in a 2-site randomized study at outpatient treatment centers in Los Angeles and Dallas. Ninety-six patients were randomized to 15 weekly, individual sessions of Positive Affect Treatment (PAT) or Negative Affect Treatment (NAT). The primary outcome was improvement in positive affect (Positive and Negative Affect Schedule-Positive) from pretreatment to 6-month follow-up (6MFU). Secondary outcomes were improvements in negative affect (Positive and Negative Affect Schedule-Negative), suicidal ideation, and symptoms (Depression Anxiety Stress Scales). RESULTS: PAT resulted in greater improvements in positive affect, p = .009, d = .52, and higher positive affect at 6MFU, p = .002, d = .67, than NAT. Participants in PAT also reported lower negative affect, p = .033, d = .52, and lower symptoms of depression, p = .035, d = .34, anxiety, p < .018, d = .30, and stress, p = .006, d = .43 at 6MFU. Finally, probability of suicidal ideation at 6MFU was lower in PAT than NAT (1.7% vs. 12.0%), p < .001. CONCLUSIONS: Compared to NAT, PAT demonstrated better outcomes (at 6MFU) on positive affect, depression, anxiety, stress, and suicidal ideation, for patients with symptomatic pretreatment levels of these outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Positive valence reduces susceptibility to return of fear and enhances approach behavior.

BACKGROUND AND OBJECTIVES: Although exposure therapy is highly efficacious for anxiety disorders, many individuals do not respond. Drawing from the science of fear extinction and reinstatement, the current study evaluated whether a training designed to increase valence of the feared stimulus improved the longevity of treatment outcomes. METHODS: Participants were 61 undergraduate students with fear of spiders (>10 on Spider Phobia Questionnaire, M = 20.45, SD = 3.98) who were randomized to receive positive valence training or control training. Participants completed exposure over two days, with training conditions at the end of the first day. Tests of spontaneous recovery and reinstatement were conducted one week later. RESULTS: Compared to control, the Positive Valence Training group demonstrated significantly less subjective fear at test of spontaneous recovery and less behavioral avoidance after reinstatement. Change in valence predicted subjective fear at spontaneous recovery and after reinstatement but did not predict behavioral avoidance after reinstatement. LIMITATIONS: Due to the relatively small size and homogeneity of the sample, as well as the limited methods of training (i.e., film clips only) and outcome measurement (i.e., self-report and behavioral measures), current results should be interpreted with caution. CONCLUSIONS: Adjunct positive valence training may enhance the longevity of exposure treatment.

Anxiety and depressive symptoms and medical illness among adults with anxiety disorders.

OBJECTIVE: Anxiety is linked to a number of medical conditions, yet few studies have examined how symptom severity relates to medical comorbidity. PURPOSE: The current study assessed associations between severity of anxiety and depression and the presence of medical conditions in adults diagnosed with anxiety disorders. METHOD: Nine-hundred eighty-nine patients diagnosed with panic, generalized anxiety, social anxiety, and posttraumatic stress disorders reported on the severity of anxiety and depressive symptoms and on diagnoses of 11 medical conditions. RESULTS: Severity of anxiety and depressive symptoms was strongly associated with having more medical conditions over and above control variables, and the association was as strong as that between BMI and disease. Odds of having asthma, heart disease, back problems, ulcer, migraine headache and eyesight difficulties also increased as anxiety and depressive symptom severity increased. Anxiety symptoms were independently associated with ulcer, whereas depressive symptoms were independently associated with heart disease, migraine, and eyesight difficulties. CONCLUSIONS: These findings add to a growing body of research linking anxiety disorders with physical health problems and indicate that anxiety and depressive symptoms deserve greater attention in their association with disease.

Sudden gains as a long-term predictor of treatment improvement among children in community mental health organizations.

OBJECTIVE: Sudden gains have been described as rapid, sizeable changes observed between treatment sessions and have been associated with improved treatment outcome in adults. The current study examined weekly sudden gains among children seeking treatment in the community mental health setting. METHOD: Participants were 161 children (age M = 10.58, SD = 1.73; 69.6% male; 47.8% Caucasian) and their parents who were randomized to one of three treatment modalities and were administered weekly and quarterly assessments throughout treatment. RESULTS: When idiographic (youth- and parent-identified "top problems") and nomothetic measures (standardized checklists) were used to calculate sudden gains (i.e., gain must be large: in absolute terms, relative to prior session, and relative to changes in prior and subsequent sessions), 20-42% of participants experienced at least one sudden gain during treatment. Most sudden gains occurred early in treatment, and session content of relaxation was associated with sudden gain presence. Using a modified Bonferonni correction, sudden gains predicted overall symptom levels at final assessment (i.e., last assessment obtained following post-treatment) even after controlling for pre-treatment symptom levels and magnitude of the overall gain from pre- to post-treatment. CONCLUSIONS: Suddenness of gains may have a direct effect on long-term treatment outcome among children in the community.

The interaction between the superhero ideal and maladaptive perfectionism as predictors of unhealthy eating attitudes and body esteem.

Unhealthy eating attitudes and poor body esteem often lead to adverse outcomes (e.g., eating disorders). Prior research has identified two risk factors for these outcomes--endorsement of the superhero ideal and maladaptive perfectionism--and has suggested that these factors may interact to predict unhealthy eating attitudes and body esteem. The current study examined the interaction between the superhero ideal and maladaptive perfectionism as predictors of unhealthy eating attitudes and body esteem among 161 12- to 14-year-olds (74 males, 87 females). Maladaptive perfectionism moderated the relation between endorsement of the superhero ideal and unhealthy eating attitudes for girls only, such that endorsement of the superhero ideal was significantly associated with unhealthy eating attitudes only for adolescents with high levels of maladaptive perfectionism. The moderation model was not significant for body esteem. Prevention strategies should focus on reducing endorsement of the superhero ideal when there are high levels of maladaptive perfectionism.

Evidence for an emotion-cognition interaction in the statistical prediction of suicide attempts.

Suicidal behavior is a prevalent problem among adolescents and young adults. Although most theoretical models of suicide suggest that this behavior results from the interaction of different risk factors, most prior studies have tested only bivariate associations between individual risk factors and suicidal behaviors. The current study was designed to address this limitation by testing the effect of an emotion-cognition interaction on suicide attempts among youth. Specifically, we hypothesized that the interaction of emotion reactivity and problem-solving skills would statistically predict the probability of a recent suicide attempt among 87 adolescents and young adults. Results revealed a significant interaction, such that emotion reactivity was strongly associated with the probability of a suicide attempt among those with poor problem-solving skills, moderately associated among those with average problem-solving skills, and not significantly associated among those with good problem-solving skills. The next generation of studies on suicidal behavior should continue to examine how risk factors interact to predict this dangerous outcome.