Borderline Personality Traits Do Not Moderate the Relationship Between Depression, Beliefs, and Suicidal Thoughts and Behaviors.

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

Subscales of alexithymia show unique pathways through reappraisal and suppression to anxiety, depression and stress.

The goal of this work was to explore associations of constituent factors of alexithymia on mental health and potential mediating effects of emotion regulation strategies, specifically suppression and reappraisal. Data were collected through the crowd-sourcing platform Amazon Mechanical Turk (MTURK). Three hundred seventy-seven individuals completed questionnaires related to distress (Depression Anxiety Stress Scales [DASS]), emotion regulation (Emotion Regulation Questionnaire [ERQ]) and Alexithymia (Bermond-Vorst Alexithymia Questionnaire [BVAQ]). Three mediation models were constructed for depression, anxiety and stress, with BVAQ subscales (verbalizing, identifying, emotionalizing, fantasizing, and analyzing) as predictors and ERQ subscales (suppression and reappraisal) as mediators. Results indicated 37.3 % variance in depression, 25.2 % variance in anxiety, and 35.3 % variance in stress was explained by each model. Direct associations revealed emotionalizing and fantasizing were negatively associated with depression, anxiety, and stress, while verbalizing was additionally associated with depression, identifying was additionally associated with anxiety, and all four BVAQ subscales were associated with stress. BVAQ subscales demonstrated negative associations with reappraisal and positive associations with suppression that mediated anxiety and depression. However, suppression did not mediate relationships between BVAQ subscales with stress. Findings support the importance of examining multiple factors of alexithymia and associations with emotion regulation strategies and distress.

Uncovering the role of substance use in suicide attempts using a mixed-methods approach.

INTRODUCTION: Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts. METHODS: Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD. RESULTS: In Study 1, patients with co-occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method. CONCLUSIONS: Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans.

Changes in neural activity following a randomized trial of cognitive behavioral therapy for hoarding disorder.

OBJECTIVE: Cognitive behavioral therapy (CBT) is efficacious for hoarding disorder (HD), though results are modest. HD patients show an increase in activity in the dorsal anterior cingulate cortex (dACC) when making decisions. The aim of this study is to determine whether CBT's benefits follow improvements in dACC dysfunction or abnormalities previously identified in other brain regions. METHOD: In this randomized clinical trial of 64 treatment-seeking HD patients, patients received group CBT, delivered weekly for 16 weeks, versus wait list. Functional magnetic resonance imaging was used to examine neural activity during simulated decisions about whether to acquire and discard objects. RESULTS: During acquiring decisions, activity decreased in several regions, including right dorsolateral prefrontal, right anterior intraparietal area, both right and left medial intraparietal areas, left and right amygdala, and left accumbens. During discarding decisions, activity decreased in right and left dorsolateral prefrontal, right and left rostral cingulate, left anterior ventral insular cortex, and right medial intraparietal areas. None of the a priori brain parcels of interest significantly mediated symptom reduction. Moderation effects were found for left rostral cingulate, right and left caudal cingulate, and left medial intraparietal parcels. CONCLUSIONS: Therapeutic benefits of CBT for HD do not appear to be mediated by changes in dACC activation. However, pretreatment dACC activation predicts outcome. Findings suggest the need to re-evaluate emerging neurobiological models of HD and our understanding of how CBT affects the brain in HD, and perhaps shift focuses to new neural target discovery and target engagement trials. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Central and peripheral nervous system responses to chronic and paced hyperventilation in anxious and healthy subjects.

The aim of the present study was to examine self-report, peripheral nervous system, and central nervous system correlates of naturally-occurring, chronic hyperventilation (HV, assessed by hypocapnia or low resting state low end-tidal CO2), and to examine the additional effect of acute, experimentally-induced HV in anxious and healthy participants. By identifying the biomarkers of anxiety-related chronic HV and examining responses to acute HV, we hope to identify meaningful, mechanistic targets for further treatment development. Seventy anxious patients and 34 healthy control participants completed electroencephalogram (EEG) and peripheral nervous system recording at baseline and following a paced breathing task. Diagnosis x baseline hypnocapnia group analyses indicated that anxious/hypocapnic patients exhibited greater nonspecific skin conductance response amplitude than did anxious/normocapnic patients, and the anxious group reported greater HV-related symptoms and anxiety sensitivity than did the control group. However, no EEG abnormalities were noted as a function of anxiety group or baseline hypocapnia status. Following paced HV, anxious patients (but not controls) exhibited an increase in left-frontal alpha 1 power. Hypocapnic, but not normocapnic, participants exhibited an increase in skin conductance levels. Anxious patients reported an increase in negative cognitive appraisals of HV symptoms, and anxious/hypocapnic participants reported an increase in affective responses to HV. Thus, chronic HV is associated with greater arousal, and increased self-reported and physiological sensitivity to paced HV. Patients who chronically hyperventilate appear to be more sensitive to respiratory distress, responding with higher levels of anxiety and poorer tolerance of the physiological sensations accompanying acute HV.

Mega-analysis methods in ENIGMA: The experience of the generalized anxiety disorder working group.

The ENIGMA group on Generalized Anxiety Disorder (ENIGMA-Anxiety/GAD) is part of a broader effort to investigate anxiety disorders using imaging and genetic data across multiple sites worldwide. The group is actively conducting a mega-analysis of a large number of brain structural scans. In this process, the group was confronted with many methodological challenges related to study planning and implementation, between-country transfer of subject-level data, quality control of a considerable amount of imaging data, and choices related to statistical methods and efficient use of resources. This report summarizes the background information and rationale for the various methodological decisions, as well as the approach taken to implement them. The goal is to document the approach and help guide other research groups working with large brain imaging data sets as they develop their own analytic pipelines for mega-analyses.

Autistic Traits Moderate Reappraisal Success for Depression and Anxiety Symptoms.

Cognitive reappraisal is associated with reduced emotional distress; however, little is known about the nature of this relationship in autism. This study tested whether autistic traits moderate reappraisal success (i.e., the negative correlation between reappraisal use and emotional symptom severity). Emotional symptoms were assessed using measures of depression, anxiety, and stress. It was hypothesized that more severe autistic traits would be associated with weaker reappraisal success across all scales. Data were collected from 377 adults using an on-line survey. Structural equation models found moderation effects for depression and anxiety, but not stress. Contrary to hypotheses, more severe autistic traits were associated with stronger reappraisal success. These preliminary results support including reappraisal in emotion regulation treatments for individuals with autistic traits.

Cortical and subcortical brain structure in generalized anxiety disorder: findings from 28 research sites in the ENIGMA-Anxiety Working Group.

The goal of this study was to compare brain structure between individuals with generalized anxiety disorder (GAD) and healthy controls. Previous studies have generated inconsistent findings, possibly due to small sample sizes, or clinical/analytic heterogeneity. To address these concerns, we combined data from 28 research sites worldwide through the ENIGMA-Anxiety Working Group, using a single, pre-registered mega-analysis. Structural magnetic resonance imaging data from children and adults (5-90 years) were processed using FreeSurfer. The main analysis included the regional and vertex-wise cortical thickness, cortical surface area, and subcortical volume as dependent variables, and GAD, age, age-squared, sex, and their interactions as independent variables. Nuisance variables included IQ, years of education, medication use, comorbidities, and global brain measures. The main analysis (1020 individuals with GAD and 2999 healthy controls) included random slopes per site and random intercepts per scanner. A secondary analysis (1112 individuals with GAD and 3282 healthy controls) included fixed slopes and random intercepts per scanner with the same variables. The main analysis showed no effect of GAD on brain structure, nor interactions involving GAD, age, or sex. The secondary analysis showed increased volume in the right ventral diencephalon in male individuals with GAD compared to male healthy controls, whereas female individuals with GAD did not differ from female healthy controls. This mega-analysis combining worldwide data showed that differences in brain structure related to GAD are small, possibly reflecting heterogeneity or those structural alterations are not a major component of its pathophysiology.

Psychophysiological assessment of stress reactivity and recovery in anxiety disorders.

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder) and 28 healthy control (HC) participants underwent psychophysiological monitoring including electrocardiogram, respiration rate, electrodermal activity, gastrocnemius electromyograph, and end-tidal CO2 for a 3-min resting phase, a 6-min mild stressor phase, and a 3-min recovery phase. Anxious patients then went on to receive naturalistic cognitive-behavioral therapy (CBT) in a specialty outpatient clinic. Results for the reactivity phase indicated that compared to HCs, patients with social anxiety disorder exhibited heightened psychophysiological reactivity while patients with panic disorder and generalized anxiety disorder exhibited attenuated reactivity. Results for physiological recovery (return to baseline after the stressor was withdrawn) were mixed, but provided some support for slower autonomic recovery in patients with generalized anxiety disorder and panic disorder compared to HCs. Participants with all anxiety disorders exhibited diminished change in high frequency heart rate variability compared to HCs. Generally, psychophysiological reactivity and recovery were not associated with CBT outcome, though exploratory analyses indicated that greater respiration rate reactivity and stronger respiration rate recovery were associated with better CBT outcomes in patients with panic disorder.

Measuring Within-Session and Between-Session Compliance in Hoarding Disorder: A Preliminary Investigation of the Psychometric Properties of the CBT Compliance Measure (CCM) and Patient Exposure/Response Prevention Adherence Scale for Hoarding (PEAS-H).

Hoarding disorder (HD) is a new psychiatric diagnosis in Diagnostic and Statistical Manual of Mental Disorders-Fifth edition and preliminary evidence suggests that cognitive-behavioral treatments are effective in treating this condition. However, it has been demonstrated that individuals with HD generally display poor compliance during treatment, which may lead to poor outcomes. Treatment compliance can be conceptualized as either within-session or between-session compliance, but currently there are no validated measures of within-session or between-session compliance specifically for HD. The aim of this study was to provide an initial validation of the CBT Compliance Measure and the Patient Exposure/Response Prevention Adherence Scale for Hoarding in a sample of participants with HD who were undergoing group cognitive behavioral therapy (CBT) for HD (N = 70). Both measures, which were administered at each relevant treatment session, demonstrated a unidimensional structure, good reliability, as well as predictive validity, and are thus promising in the measurement of within-session and between-session compliance with CBT for HD.

Moving Beyond the Negative: Contributions of Positive and Negative Affect on Quality of Life in Patients With Generalized Anxiety Disorder.

Individuals with generalized anxiety disorder (GAD) report poorer quality of life (QOL) than do nonanxious controls. Further, although positive affect (PA) and negative affect (NA) have been shown to predict QOL, no previous literature has tested this relationship in the context of individuals with GAD. In the present study, we evaluated the unique and interactive contributions of PA and NA on QOL within a sample of individuals diagnosed with GAD (N = 50). Specifically, a hierarchical regression was conducted to evaluate the unique contributions of PA, NA, and their interaction on QOL, over and above symptoms of depression. PA and depression symptoms were both significant predictors of QOL, whereas neither the main effect for NA nor the PA × NA interaction was statistically significant. Results suggest that, for those with GAD, PA uniquely contributes to QOL. Strategies to upregulate PA may be a useful treatment target for increasing QOL in individuals with GAD.

The dose-response curve in cognitive-behavioral therapy for anxiety disorders.

Previous studies examining the dose-response curve in psychotherapy have suggested that 11-19 sessions may be necessary for at least 50% of individuals to show clinically significant improvement. However, this curve has not been examined specifically for cognitive-behavioral therapy (CBT) for anxiety disorders, for which a more rapid recovery curve may be expected. Survival analysis was used to assess the dose-response curve for 201 patients with anxiety disorders who received weekly CBT at an anxiety specialty clinic. The primary outcome measure was the Outcome Questionnaire-45.2, which patients completed prior to each treatment session. Sixty-four percent of the sample achieved reliable change, and this response occurred in approximately five sessions on average. Fifty percent of the sample achieved clinically significant improvement, which occurred in approximately eight sessions on average. The findings suggest that earlier response may be expected in CBT for anxiety disorders, and are discussed in terms of potential ways to further improve response rates for this treatment.

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory.

OBJECTIVES: Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth. METHOD: Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples. RESULTS: Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore. DISCUSSION: Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.

"Cold" Cognitive Control and Attentional Symptoms in Anxiety: Perceptions Versus Performance.

Clinically significant anxiety is associated with an array of attentional symptoms (e.g., difficulty concentrating; unwanted thought) that are subjectively experienced as severe. However, neuropsychological findings are mixed with respect to the presence of cognitive deficits that can account for these symptoms. Contextualizing predictions from established clinical theories (e.g., Attentional Control Theory) within contemporary, neurobiologically derived models of cognitive control (Dual Mechanisms of Control Theory), the present study investigated the relationship between "cold" proactive and reactive cognitive control, task effort, and subjective attentional symptoms (difficulty concentrating; unwanted thought) in a mixed clinical sample of individuals with generalized anxiety disorder (GAD) and/or obsessive-compulsive disorder (OCD) and a comparison sample of healthy controls. Clinical status moderated the relationship between attentional symptoms (attentional focusing and trait worry) and proactive cognitive control response time. Clinical status also moderated the relationship between trait worry and task effort. Higher trait worry was associated with slower proactive control and lower effort in healthy participants, but faster proactive control in clinical participants. Self-reported attentional focusing showed differential validity vis-à-vis proactive control response time in clinical versus healthy participants. Post-hoc conditional effects analysis suggested more accurate self-appraisals in healthy controls, but was not significant after correction for multiple comparisons. Preliminary evidence suggested that differences in task effort in anxious versus healthy adults may relate to subjective attentional symptoms in GAD and OCD.

Enhanced cognitive control over task-irrelevant emotional distractors in generalized anxiety disorder versus obsessive-compulsive disorder.

Generalized anxiety disorder (GAD) is defined in part by excessive and uncontrollable worry. However, little is known about cognitive control abilities in adults with GAD. The present study examined cognitive control over negative and neutral material in a mixed clinical sample of adults with GAD and/or obsessive-compulsive disorder and a comparison healthy control sample. Participants completed a novel emotional variant of the AX-CPT (eAX-CPT) to index proactive and reactive cognitive control in the presence of negative and neutral distractor stimuli. Participants with GAD demonstrated enhanced cognitive control specifically over negative emotional distractors, relative to neutral distractors (within-subjects) and relative to OCD and controls (between-subjects). Findings were specific to GAD versus trait worry; however, higher trait worry predicted better cognitive control in GAD only. These findings are inconsistent with deficit-based cognitive models of GAD and may be better accounted for by models that conceptualize worry as an intentional (albeit maladaptive) cognitive control or emotion regulation strategy that is actively maintained by individuals with GAD in order to avoid engaging with more distressing emotional information.

Efficacy and mediators of a group cognitive-behavioral therapy for hoarding disorder: A randomized trial.

OBJECTIVE: Hoarding disorder (HD) is a common and potentially debilitating psychiatric disorder. Thus far, psychological treatments have yielded modest effects and/or were time-consuming and costly to deliver. The aim of the present study was to test the efficacy of a brief group cognitive-behavioral therapy (CBT) for adults with HD and to test hypothesized mediators of treatment outcome. METHOD: Eighty-seven adults with a primary diagnosis of HD were randomized to either immediate CBT or wait list. CBT consisted of 16 weekly, 90-min group sessions that emphasized in-session practice of discarding and refraining from acquiring, decision-making and problem-solving training, emotional distress tolerance, motivational interviewing strategies, and contingency management. Participants were assessed at pretreatment, midtreatment, and posttreatment by an independent evaluator unaware of treatment condition. RESULTS: CBT was efficacious for the symptoms of HD compared with wait list. Saving-related cognitions, but not subjective cognitive impairment, partially mediated treatment outcomes. CONCLUSION: Brief Group CBT is an efficacious and feasible treatment for adults with HD, and is partially mediated by reductions in maladaptive beliefs about possessions. Superiority trials comparing CBT to active treatments, and additional research into mechanisms of treatment outcome, are warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Psychometric Properties of the Difficulties in Emotion Regulation Scale (DERS) and Its Short Forms in Adults With Emotional Disorders.

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

Resting-State Functional Connectivity in Generalized Anxiety Disorder and Social Anxiety Disorder: Evidence for a Dimensional Approach.

Generalized anxiety disorder (GAD) and social anxiety disorder (SAD) are currently considered distinct diagnostic categories. Accumulating data suggest the study of anxiety disorders may benefit from the use of dimensional conceptualizations. One such dimension of shared dysfunction is emotion regulation (ER). The current study evaluated dimensional (ER) and categorical (diagnosis) neurocorrelates of resting-state functional connectivity (rsFC) in participants with GAD and SAD and healthy controls (HC). Functional magnetic resonance imaging (fMRI) rsFC was estimated between all regions of the default mode network (DMN), salience network (SN), and bilateral amygdala (N = 37: HC-19; GAD-10; SAD-8). Thereafter, rsFC was predicted by both ER, (using the Difficulties in Emotion Regulation Scale [DERS]), and diagnosis (DSM-5) within a single unified analysis of covariance (ANCOVA). For the ER dimension, there was a significant association between impaired ER abilities and anticorrelated rsFC of amygdala and DMN (L.amygdala-ACC: p = 0.011, beta = -0.345), as well as amygdala and SN (L.amygdala-posterior cingulate cortex [PCC]: p = 0.032, beta = -0.409). Diagnostic status was significantly associated with rsFC differences between the SAD and HC groups, both within the DMN (PCC-MPFC: p = 0.009) and between the DMN and SN (R.LP-ACC: p = 0.010). Although preliminary, our results exemplify the potential contribution of the dimensional approach to the study of GAD and SAD and support a combined categorical and dimensional model of rsFC of anxiety disorders.

Low pre-treatment end-tidal CO2 predicts dropout from cognitive-behavioral therapy for anxiety and related disorders.

Recent clinical trial research suggests that baseline low end-tidal CO2 (ETCO2, the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO2 among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO2, and respiration rate (the first minute was analyzed). Lower ETCO2 was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO2 significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO2 significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO2 patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO2 is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO2 might benefit from additional intervention that targets respiratory abnormality.