The PTSD Checklist-Civilian Version: reliability, validity, and factor structure in a nonclinical sample.

OBJECTIVES: We examined the reliability, validity, and factor structure of the posttraumatic stress diorder (PTSD) Checklist-Civilian Version (PCL-C; Blanchard, Jones-Alexander, Buckley, & Forneris, 1996) among unselected undergraduate students. PARTICIPANTS: Participants were 471 undergraduate students at a large university in the Eastern United States and were not preselected based on trauma history or symptom severity. RESULTS: The PCL-C demonstrated good internal consistency and retest reliability. Compared with alternative measures of PTSD, the PCL-C showed favorable patterns of convergent and discriminant validity. In contrast to previous research using samples with known trauma exposure, we found support for both 1-factor and 2-factor models of PTSD symptoms. CONCLUSIONS: Overall, the PCL-C appears to be a valid and reliable measure of PTSD symptoms, even among nonclinical samples, and is superior to some alternative measures of PTSD. The factor structure among nonclinical samples may not reflect each of the PTSD symptom "clusters" (i.e., reexperiencing, avoidance/numbing, and hyperarousal).

The effects of verbal and imaginal worry on panic symptoms during an interoceptive exposure task.

Previous research has documented the inhibitory effects of worry on cardiovascular reactivity to subsequently presented fear-relevant stimuli. Although theoretical assertions point to the verbal-linguistic (as opposed to imagery-based) nature of worry as the cause of these inhibitory effects, extant research investigating the effects of worrisome thinking on subsequent anxiety-eliciting tasks has not isolated the verbal-linguistic nature of worry as the active ingredient in its suppressive effects on arousal. Furthermore, prior research has not examined the potential effects of worry on maintenance of panic symptoms. In this study, participants high in anxiety sensitivity were asked to engage in verbal worry, imaginal worry, or relaxation prior to each of three repeated presentations of an interoceptive exposure task. Relaxation was associated with lower initial subjective fear that remained low across repeated exposures, and related stable sympathetic arousal (and decreased heart rate) over time. Imagery-based worry was associated with moderate initial subjective fear that was sustained across repeated exposures, and sympathetic arousal (and heart rate) that was likewise stable over time. However, verbal worry was associated with high initial subjective fear that was sustained over time, but sympathetic arousal (and heart rate) that decreased across repeated exposures. Thus, verbal worry was uniquely associated with a lack of synchronous response systems and maintenance of anxious meaning over time. Theoretical and clinical implications are discussed.

Autonomic characteristics of generalized anxiety disorder and worry.

Autonomic characteristics of generalized anxiety disorder (GAD) and worry were examined using measures of heart period variability. The cardiorespiratory responses of 34 GAD clients and 32 nonanxious control subjects were recorded during resting baseline, relaxation, and worry periods. Results indicated differences between GAD subjects and controls as well as among baseline, relaxation, and worry periods. GAD clients exhibited shorter cardiac interbeat intervals (IBIs) and lower high frequency spectral power across all task conditions. Relative to baseline and relaxation conditions, worry was associated with (1) shorter IBIs, (2) smaller mean successive differences (MSD) of the cardiac IBIs, and (3) lower high frequency spectral power. These findings suggest that GAD and its cardinal feature (worry), are associated with lower cardiac vagal control. The findings of the present study provide evidence for the utility of further exploration of the role of autonomic nervous system activity in GAD.

Autonomic characteristics of nonclinical panic and blood phobia.

Autonomic characteristics of nonclinical panic and blood phobia were compared using spectral analysis of the electrocardiogram (EKG), as well as more conventional cardiovascular measures. The cardiovascular responses of 11 subjects who reported recent occurrence of frequent severe panic attacks, and 10 subjects who reported intense somatic reactions to the sight of blood (including episodes of syncope) were recorded during a variety of laboratory tasks (quiet rest, reaction time/shock avoidance, face immersion, and combined reaction time/face immersion). Results suggest distinct autonomic patterns in the groups. Panickers showed (a) higher heart rate and reduced heart-rate variability (b) aberrant associations among cardiovascular measures, and (c) dominant sympathetic control of heart rate coupled with diminished vagal tone. Blood phobics generally displayed an opposite pattern. The relevance of these findings to the etiology of panic and blood phobia, as well as to biological models of anxiety disorders in general, is discussed.

Psychotherapy for generalized anxiety disorder.

The present article describes the basic therapeutic techniques used in the cognitive-behavioral therapy (CBT) of generalized anxiety disorders and reviews the methodological characteristics and outcomes of 13 controlled clinical trials. The studies in general display rigorous methodology, and their outcomes are quite consistent. CBT has been shown to yield clinical improvements in both anxiety and depression that are superior to no treatment and nonspecific control conditions (and at times to either cognitive therapy alone or behavioral therapy alone) at both posttherapy and follow-up. CBT is also associated with low dropout rates, maintained long-term improvements, and the largest within-group and between-group effect sizes relative to all other comparison conditions.

Consensus statement on generalized anxiety disorder from the International Consensus Group on Depression and Anxiety.

OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in generalized anxiety disorder (GAD) and guide clinical practice with recommendations on the appropriate treatment strategy. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R.T. Davidson, Yves Lecrubier, and David J. Nutt. Four additional faculty members invited by the chair were Karl Rickels, Hans-Ulrich Wittchen, Dan J. Stein, and Thomas D. Borkovec. EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSIONS: GAD is the most common anxiety disorder in primary care and is highly debilitating. Furthermore, it is frequently comorbid with depression and other anxiety disorders, which exacerbates functional impairment. Antidepressants (serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and nonsedating tricyclic antidepressants) are generally the most appropriate first-line pharmacotherapy for GAD, since they are also effective against comorbid psychiatric disorders and are suitable for long-term use. Cognitive-behavioral therapy is the preferred form of psychotherapy for GAD, although when GAD is comorbid with depression, pharmacotherapy is increasingly indicated.

Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder.

Nondirective (ND), applied relaxation (AR), and cognitive behavioral (CBT) therapies for generalized anxiety disorder (GAD) were compared. The latter 2 conditions were generally equivalent in outcome but superior to ND at postassessment. The 3 conditions did not differ on several process measures, and ND created the greatest depth of emotional processing. Follow-up results indicated losses in gains in ND, maintained gains in the other 2 conditions, especially CBT, and highest endstate functioning for CBT. AR and CBT thus contain active ingredients in the treatment of GAD; support exists for further development of imagery exposure methods or cognitive therapy because of their likely role in promoting maintenance of change with this disorder. Expectancy for improvement was also associated with outcome, suggesting the need for further research on this construct for understanding the nature of GAD and its amelioration.

What is the scientific meaning of empirically supported therapy?

It is important to define precisely what is and is not meant by "empirically supported treatments," rigorously based on what is actually known about the nature of experimental therapy research. The criteria for empirically supported treatments merely allow conclusions about whether treatments cause any change beyond the causative effect of such factors as placebo or the passage of time. Applied implications are limited, due to external validity and to the fact that applied decisions are influenced by cost-benefit analyses. Creating increasingly effective therapies through between-group designs is best done by controlled trials specifically aimed at basic questions about the nature of psychological problems and the nature of therapeutic change mechanisms. Naturalistic research is important for external validity but is valuable only if it uses scientifically valid methods to address basic knowledge questions.

Effects of psychotherapy on comorbid conditions in generalized anxiety disorder.

Comorbid diagnoses were examined in 55 principal generalized anxiety disorder (GAD) clients, and the effect of treatment for the principal disorder on those conditions was evaluated. High rates of comorbid diagnoses were present at pretherapy, with social and simple phobia being most common. The presence of additional diagnoses declined dramatically from pretherapy to follow-up and was significantly greater among clients for whom the GAD therapy had been successful than among clients for whom GAD outcome had been ambiguous. This was generally true regardless of whether clients reported at follow-up that they had received further therapy since the posttherapy assessment.

A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems.

Clients with generalized anxiety disorder (GAD) received either (a) applied relaxation and self-control desensitization, (b) cognitive therapy, or (c) a combination of these methods. Treatment resulted in significant improvement in anxiety and depression that was maintained for 2 years. The large majority no longer met diagnostic criteria; a minority sought further treatment during follow-up. No differences in outcome were found between conditions; review of the GAD therapy literature suggested that this may have been due to strong effects generated by each component condition. Finally, interpersonal difficulties remaining at posttherapy, measured by the Inventory of Interpersonal Problems Circumplex Scales (L. E. Alden, J. S. Wiggins, & A. L. Pincus, 1990) in a subset of clients, were negatively associated with posttherapy and follow-up improvement, suggesting the possible utility of adding interpersonal treatment to cognitive-behavioral therapy to increase therapeutic effectiveness.

Effects of suppressing thoughts about emotional material.

Concurrent and subsequent effects of suppressing versus expressing emotional (anxious and depressing) and neutral material were investigated. Subjects either suppressed or expressed thoughts about an anxious, depressing, or neutral target situation during an initial thought period. During the subsequent period, all subjects expressed thoughts about the same target situation. Analyses of thought content revealed that attempts to suppress the thought did not eliminate its occurrence. During the subsequent expression period, subjects in the initial expression condition displayed a significant decrease in statements about the target situation, indicating habituation, whereas subjects in the initial suppression condition showed an increase. Variations in this general pattern were observed on the basis of the different emotional valences of the target situations.

A taxometric investigation of the latent structure of worry.

Researchers have described 2 types of worriers, normal and pathological, who differ in the frequency, intensity, and controllability of their worry experiences. Although normal and pathological worry are generally treated as separate though related phenomena, no study has tested for separateness against the alternative hypothesis that all worry exists along a single dimension. In the present study, worry ratings of 1,588 college students were submitted to taxometric procedures designed to evaluate latent structure. Results provided evidence for the dimensionality of worry. These findings suggest that generalized anxiety disorder (GAD), whose central feature is worry, may also be quantitatively rather than qualitatively different from normal functioning. The authors argue that a focus on normal and pathological extremes has constrained the study of worry phenomena and that dimensional conceptualization of worry may significantly enhance understanding of both worry and GAD.

The nature of worry in generalized anxiety disorder: a predominance of thought activity.

Indirect evidence suggests that worry primarily involves thought, rather than imaginal, activity, a distinction within cognitive process that is potentially crucial to some theories of anxiety maintenance and modification. The present study contrasted the frequencies of reporting the presence of thoughts and images among generalized anxiety disorder clients and matched, nonanxious control subjects during a self-relaxation period and a worry period. Repetition of the assessment was conducted with clients after they completed 12 sessions of therapy. Sampling of mentation during these periods revealed that (a) during relaxation, nonanxious subjects reported a predominance of imagery whereas clients show equal amounts of thought and imagery, (b) nonanxious subjects shifted to a predominance of thought during worry, and (c) clients showed a normalization of thought and image frequencies after successful therapy. This combination of results suggests that worry is principally thought-like in content. The speculation is offered that worry may function as motivated avoidance of emotional imagery and its attendant somatic sensations.

Experience and appraisal of worry among high worriers with and without generalized anxiety disorder.

Recent research has revealed that a large number of highly worried individuals do not qualify for a diagnosis of generalized anxiety disorder (GAD). This raises the intriguing question of why some high worriers are more impaired and distressed by their worrying than others, particularly when the severity of their worry is the same. The present investigation sought to address this question by examining whether GAD and non-GAD high worriers differ in their actual worry experiences, their subjective appraisals of worry experiences, or both experiences and appraisals of worry. GAD and non-GAD worriers, selected for matching levels of trait worry severity, completed an attention-focus task with thought sampling before and after a brief worry induction. They also completed questionnaires assessing their experiences during and after the worry induction, as well as their general beliefs about worry. GAD worriers experienced less control over negative intrusive thoughts immediately after worrying, reported greater somatic hyperarousal following worry, and endorsed several negative beliefs about worry more strongly than their worry-matched controls. Results suggest that GAD is associated with unique experiences and appraisals that distinguish it from other forms of severe worry.

The effect of worry on cardiovascular response to phobic imagery.

Cardiovascular response to phobic exposures has been shown to reflect the degree of emotional processing of phobic material and relates in important ways to outcome in exposure therapy. The present study investigated the effect of worry on such processing. Speech anxious subjects visualized a phobic scene for 10 trials. Three groups differed according to whether they engaged in relaxed, neutral, or worrisome thinking just prior to each scene presentation. Although the three types of thinking had no effect on cardiovascular activity during the thinking periods, subjects in the worry group displayed significantly less heart rate response to the phobic image than those in the neutral condition who had significantly less response than the relaxed condition. However, the worry group showed significantly greater subjective fear to the images than the neutral condition, with the relaxed group near to the level of the worry group and not significantly different from either of the other two conditions. The results suggest that worry may inhibit emotional processing and thus preserve cognitive/affective fear structure, and are discussed in terms of Gray's (Behavioral and Brain Sciences, 5, 469-534, 1982) theory of the behavioral inhibition system and semantic satiation effects in cognitive psychology.

Interpretive cues and ambiguity in generalized anxiety disorder.

The current study investigated whether generalized anxiety disorder (GAD) individuals rely on antecedent information to interpret ambiguity and whether reliance on such preceding cues persists in the absence of potential threat. Twenty-six GAD and 23 nonanxious control college students performed a lexical decision task, using homographs (i.e. words with multiple meanings) as ambiguous primes. In half the trials, a homograph prime that possessed both threat-related, as well as neutral meanings was followed by a target word related to one of these two meanings. In addition, each ambiguous prime was immediately preceded by a series of four antecedent words that were either: (a) associated with the threatening meaning of the prime; (b) associated with the neutral meaning of the prime; or (c) unrelated to either meaning of the homograph, as well as the target. Homographs for which both meanings were neutral in valence comprised the other half of the trials. Effect size statistics suggest that GAD participants utilized the antecedent words to interpret the homograph primes with threat-related meanings, unlike their nonanxious counterparts (p<0.06). When both meanings of the homograph prime were neutral in valence, the GAD group appeared deficient in the use of preceding information to interpret the ambiguous prime.

Cognitive and personality characteristics of worriers.

Worriers and nonworriers from a college population were compared on the Imaginal Processing Inventory, the Self-Consciousness scale, and the Sandler-Hazari Obsessionality Inventory. Subjects from both groups also engaged in either brief relaxing or stressful imagery. Before the imagery task, measures of cognitive activity were obtained from periods of relaxed wakefulness, focused attention and anagram performance. After the imagery task, focused attention and anagrams measures were repeated. Worriers reported a more negative daydreaming style, greater difficulty with attentional control, and greater obsessional symptoms, public self-consciousness and social anxiety. On thought sampling measures obtained during relaxed wakefulness periods and rated by objective judges, and on self-report measures obtained during the focused attention task, worriers evidenced significantly more negatively affect-laden cognitive intrusions. No differences were found on anagram performance, and imagery condition did not influence any measure, suggesting that instructed fear images are insufficient to initiate worrisome episodes.

The role of worrisome thinking in the suppression of cardiovascular response to phobic imagery.

Speech-fearful subjects repeatedly imagined a phobic image while heart rate and subjective reports of fear were monitored. Subject groups differed according to the type of mental activity that preceded each image. One group thought about a relaxing situation (Relaxation) and one group engaged in worrisome thinking (General-Worry). Three other groups were pre-trained to worry during their pre-image mentation periods with an emphasis on: (a) the thoughts; (b) the images; or (c) the affect experienced during worry. Cardiovascular effects occurred only on the first image presentation. Thought-Worry produced significantly less heart rate response than did Relaxation; the other worry conditions fell nonsignificantly between these two groups. Within-group correlations between heart rate response to the image and the reported predominance of thought relative to imagery during the preceding mentation period showed that: (a) greater worrisome thinking in General-Worry was related to less cardiovascular response; and (b) greater relaxed thinking in Relaxation was associated with greater cardiovascular response. These results support the hypothesis that it is the worrisome thinking aspect of worry that may inhibit the emotional processing of phobic material and that Gray's mismatch theory of anxiety elicitation may account for these effects.

Development and validation of the Penn State Worry Questionnaire.

The present report describes the development of the Penn State Worry Questionnaire to measure the trait of worry. The 16-item instrument emerged from factor analysis of a large number of items and was found to possess high internal consistency and good test-retest reliability. The questionnaire correlates predictably with several psychological measures reasonably related to worry, and does not correlate with other measures more remote to the construct. Responses to the questionnaire are not influenced by social desirability. The measure was found to significantly discriminate college samples (a) who met all, some, or none of the DSM-III-R diagnostic criteria for generalized anxiety disorder and (b) who met criteria for GAD vs posttraumatic stress disorder. Among 34 GAD-diagnosed clinical subjects, the worry questionnaire was found not to correlate with other measures of anxiety or depression, indicating that it is tapping an independent construct with severely anxious individuals, and coping desensitization plus cognitive therapy was found to produce significantly greater reductions in the measure than did a nondirective therapy condition.

Efficacy of Eye Movement Desensitization in the treatment of cognitive intrusions related to a past stressful event.

Much of the Eye Movement Desensitization and Reprocessing (EMDR) efficacy research has been widely criticized, limiting scientific understanding of its therapeutic components. The present investigation of Eye Movement Desensitization (EMD) effectiveness included undergraduate students reporting current intrusive cognitions conceming a traumatic event. Forty-five participants received a single treatment session of either: (a) EMD, as described by Shapiro [J. Behav. Ther. Exp. Psychiatry 20 (1989b) 211], (b) an identical procedure which employed eye fixation on a stationary target, or (c) non-directive counseling. Standardized self-report, subjective rating, Daily Diary, and intrusive thought sampling measures were collected before and after treatment. Results indicated that participants in the eye fixation group reported marginally (p < .052) fewer cognitive intrusions than the non-directive group 1 week following treatment. No significant differences between the EMD and non-directive conditions or between the EMD and eye fixation conditions on this measure were found. During the treatment session, both desensitization groups were superior to the non-directive group in reducing reported vividness of the mental image of the original event. However, the non-directive group improved to the level of the two other groups by the following week. Rapid saccadic eye movements were therefore unrelated to immediate treatment effects for this sub-clinical sample, and non-directive treatment largely yielded eventual outcomes equivalent to the two desensitization conditions.