Description and Preliminary Outcomes of an In Vivo Exposure Group Treatment for Posttraumatic Stress Disorder.

Prolonged exposure (PE) therapy is traditionally delivered individually to patients. To engage more veterans in care, an in vivo exposure group treatment was developed in an urban VA medical center. This treatment represented a modification of the in vivo exposure portion of PE, with the addition of in-session, therapist-assisted in vivo exposures. Here, we describe this 12-week treatment and present preliminary outcome data. Demographics and pre- and posttreatment scores on the PTSD Checklist-Specific (PCL-S) and Beck Depression Inventory-II (BDI-II) were extracted from a program evaluation database. The sample included veterans with a diagnosis of posttraumatic stress disorder (PTSD) who participated in the in vivo exposure group between October 2010 and March 2014 and had available treatment outcome data (N = 43). The majority of participants in the sample were male (n = 41, 95.3%) and Black (n = 34, 79.1%). Participation in the in vivo group was associated with a significant decrease in PCL-S scores, with a medium-large effect size, t(42) = 5.35, p < .001, d = 0.73, and a significant decrease in BDI-II scores, with a small effect size, t(38) = 2.55, p = .015, d = 0.23. Previous participation in an evidenced-based treatment (EBT) was not associated with symptom change following the in vivo group. Findings suggest that in vivo exposure group therapy constitutes a promising intervention for individuals who decline EBTs or remain symptomatic after completing an EBT for PTSD. Further study of this treatment using a randomized controlled trial design is warranted.

Psychometric Properties of the Reconstructed Hamilton Depression and Anxiety Scales.

Although widely used, the Hamilton Rating Scale for Depression (HRSD) and Hamilton Anxiety Rating Scale (HARS) discriminate poorly between depression and anxiety. To address this problem, Riskind, Beck, Brown, and Steer (J Nerv Ment Dis. 175:474-479, 1987) created the Reconstructed Hamilton Scales by reconfiguring HRSD and HARS items into modified scales. To further analyze the reconstructed scales, we examined their factor structure and criterion-related validity in a sample of patients with major depressive disorder and no comorbid anxiety disorders (n = 215) or with panic disorder and no comorbid mood disorders (n = 149). Factor analysis results were largely consistent with those of Riskind et al. The correlation between the new reconstructed scales was small. Compared with the original scales, the new reconstructed scales correlated more strongly with diagnosis in the expected direction. The findings recommend the use of the reconstructed HRSD over the original HRSD but highlight problems with the criterion-related validity of the original and reconstructed HARS.

Shying away from a good thing: social anxiety in romantic relationships.

OBJECTIVES: To determine whether social anxiety covaries with satisfaction, social support, and intimacy in romantic relationships. METHOD: Undergraduates and their romantic partners (N = 163) completed self-report questionnaires. RESULTS: Higher social anxiety in women, but not men, was associated with wanting, receiving, and providing less support, based on self- but not partner-report measures. Women higher in social anxiety also reported being less satisfied in their romantic relationships and self-disclosing less to romantic partners than women lower in social anxiety. Further, self-reported received support mediated the relationship between social anxiety and romantic relationship satisfaction in women. In both sexes, higher social anxiety was related to perceiving intimacy as riskier and romantic relationships as less emotionally intimate. CONCLUSIONS: Together, results suggest that social anxiety is associated with interpersonal difficulty even in established romantic relationships.

Complicated grief symptoms in anxiety disorders: prevalence and associated impairment.

BACKGROUND: Previous research has identified high rates of comorbid anxiety disorders among individuals presenting with primary CG. In the present study, we examined the prevalence of comorbid CG in bereaved primary anxiety disorder (AD) patients compared to bereaved healthy controls. We also examined the impairment associated with comorbid CG in AD. METHODS: Participants were 242 bereaved adults (mean (SD) age = 41.5 (13.1), 44.2% women) with a primary AD diagnosis, including generalized anxiety disorder (GAD; n = 57), panic disorder (PD; n = 49), posttraumatic stress disorder (PTSD; n = 29), and generalized social anxiety disorder (GSAD; n = 107), as well as 155 bereaved healthy controls with no current DSM-IV Axis I diagnosis (mean (SD) age = 43.0 (13.6), 51.0% women). CG symptoms were measured using the 19-item inventory of complicated grief (ICG), with threshold CG defined as an ICG score of ≥30. Quality of life and functional impairment were assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Range of Impaired Functioning Tool (LIFE-RIFT), respectively. RESULTS: Participants with primary ADs had significantly higher rates of threshold CG symptoms than bereaved controls (12.0% vs. 0.65%; Fisher's Exact P < 0.001). Rates of threshold CG were significantly elevated for each AD when compared to bereaved controls. After adjustment for age, sex, education, and comorbid major depressive disorder, threshold CG was associated with lower quality of life (ß = -0.140, P = 0.023) and greater impairment (ß = 0.141, P = 0.035) among individuals with AD. CONCLUSIONS: Our findings suggest that threshold CG is of clinical relevance in bereaved individuals with a primary anxiety disorder. Screening for CG in patients with ADs may be warranted.

Social Anxiety Disorder and Perceived Criticism in Intimate Relationships: Comparisons With Normal and Clinical Control Groups.

Individuals with social anxiety disorder (SAD) have difficulties in their romantic relationships, including decreased satisfaction and intimacy, but the reasons for these difficulties are poorly understood. Because fear of negative evaluation is a cardinal feature of SAD, perceived criticism from a romantic partner may play a central role in socially anxious individuals' relationships. In the present study, we compared levels of perceived, expressed, and observed criticism and reactions to criticism among individuals with SAD and their partners (n = 21), individuals with other anxiety disorders and their partners (n = 35), and couples free of psychopathology (n = 30). Participants rated both global criticism and criticism during a 10-minute problem-solving task, which was also coded for criticism by observers. Individuals with anxiety disorders showed elevated levels of interaction-specific perceived criticism, expressed criticism, and upset and stress due to criticism relative to normal controls; they also reported that the interaction was more stressful. However, there were no group differences on global measures of criticism, and the two anxious groups did not differ on any measures. Findings suggest that the high levels of criticism anxious individuals perceive and their corresponding negative reactions to criticism, though not specific to SAD, may account for some of the relationship difficulties that have been identified in SAD. Results also indicate that anxious individuals may contribute to their relationship difficulties by being highly critical themselves. Overall, our findings point to the need for a clinical focus on decreasing perceived criticism among individuals with anxiety disorders.

Attributions and perceptions of criticism: An examination of patients with anxiety and normal control participants.

Perceived criticism from relatives predicts poor clinical outcomes for patients with a variety of psychological disorders. Research indicates the attributions individuals make about motives for relatives' criticism are linked to perceived criticism from this relative. Accordingly, attributions may be an important target of intervention to reduce perceived criticism and improve clinical outcomes, but this association requires testing in a clinical sample. We examined relationships among attributions of criticism, perceived criticism, and upset due to criticism among individuals with anxiety disorders (n = 53) and with no psychopathology (n = 52). Participants completed measures of global attributions, perceived criticism, and upset due to criticism regarding criticism from a romantic partner/spouse or parent. After a 10-min problem-solving interaction with their relative, they completed measures of attributions, perceived criticism, and upset with regard to this relative's critical behavior during the interaction, and observers reliably coded interactions for relatives' criticism. Results showed that negative attributions were related to greater perceived criticism and upset for both global and interaction-specific measures. In analyses of interaction-specific measures, negative attributions added to prediction of perceived criticism and upset over and above the contribution of observed criticism. Positive attributions were not significantly related to global or interaction-specific upset in any analyses. Relationships were consistent across patients and normal controls. Our findings suggest that negative attributions of relatives' motives for their criticism are important predictors of perceived criticism and upset. Thus, interventions targeting these attributions may be helpful in mitigating the negative effect of perceived criticism for individuals with psychopathology. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Social Anxiety and Social Support in Romantic Relationships.

Little is known about the quality of socially anxious individuals' romantic relationships. In the present study, we examine associations between social anxiety and social support in such relationships. In Study 1, we collected self-report data on social anxiety symptoms and received, provided, and perceived social support from 343 undergraduates and their romantic partners. One year later couples were contacted to determine whether they were still in this relationship. Results indicated that men's social anxiety at Time 1 predicted higher rates of breakup at Time 2. Men's and women's perceived support, as well as men's provided support, were also significantly predictive of breakup. Social anxiety did not interact with any of the support variables to predict breakup. In Study 2, a subset of undergraduate couples with a partner high (n=27) or low (n=27) in social anxiety completed two 10-minute, lab-based, video-recorded social support tasks. Both partners rated their received or provided social support following the interaction, and trained observers also coded for support behaviors. Results showed that socially anxious individuals received less support from their partners during the interaction according to participant but not observer report. High and lower social anxiety couples did not differ in terms of the target's provision of support. Taken together, results suggest that social anxiety is associated with difficulties even in the context of established romantic relationships. Clinical implications are discussed.

Criticism in the Romantic Relationships of Individuals With Social Anxiety.

Social anxiety is associated with difficulties in intimate relationships. Because fear of negative evaluation is a cardinal feature of social anxiety disorder, perceived criticism and upset due to criticism from partners may play a significant role in socially anxious individuals' intimate relationships. In the present study, we examine associations between social anxiety and perceived, observed, and expressed criticism in interactions with romantic partners. In Study 1, we collected self-report data from 343 undergraduates and their romantic partners on social anxiety symptoms, perceived and expressed criticism, and upset due to criticism. One year later couples reported whether they were still in this relationship. Results showed that social anxiety was associated with being more critical of one's partner, and among women, being more upset by criticism from a partner. Social anxiety was not related to perceived criticism, nor did criticism variables predict relationship status at Time 2. In Study 2, undergraduate couples with a partner high (n = 26) or low (n = 26) in social anxiety completed a 10-minute, video-recorded problem-solving task. Both partners rated their perceived and expressed criticism and upset due to criticism following the interaction, and observers coded interactions for criticism. Results indicated that social anxiety was not significantly related to any of the criticism variables, but post hoc analyses cast doubts upon the external validity of the problem-solving task. Results are discussed in light of known difficulties with intimacy among individuals with social anxiety.

Prediction and moderation of improvement in cognitive-behavioral and psychodynamic psychotherapy for panic disorder.

OBJECTIVE: To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients. METHOD: Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS). RESULTS: Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment. CONCLUSIONS: Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

A systematic review of predictors and moderators of improvement in cognitive-behavioral therapy for panic disorder and agoraphobia.

BACKGROUND: Despite the considerable efficacy of cognitive-behavioral therapy (CBT) for panic disorder (PD) and agoraphobia, a substantial minority of patients fail to improve for reasons that are poorly understood. OBJECTIVE: The aim of this study was to identify consistent predictors and moderators of improvement in CBT for PD and agoraphobia. DATA SOURCES: A systematic review and meta-analysis of articles was conducted using PsycInfo and PubMed. Search terms included panic, agoraphobi*, cognitive behavio*, CBT, cognitive therapy, behavio* therapy, CT, BT, exposure, and cognitive restructuring. STUDY SELECTION: Studies were limited to those employing semi-structured diagnostic interviews and examining change on panic- or agoraphobia-specific measures. DATA EXTRACTION: The first author extracted data on study characteristics, prediction analyses, effect sizes, and indicators of study quality. Interrater reliability was confirmed. SYNTHESIS: 52 papers met inclusion criteria. Agoraphobic avoidance was the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology. Other variables were consistently unrelated to improvement in CBT, understudied, or inconsistently related to improvement. LIMITATIONS: Many studies were underpowered and failed to report effect sizes. Tests of moderation were rare. CONCLUSIONS: Apart from agoraphobic avoidance, few variables consistently predict improvement in CBT for PD and/or agoraphobia across studies.

Avoidant personality disorder in individuals with generalized social anxiety disorder: what does it add?

Avoidant personality disorder (AvPD) has a high level of symptom overlap and comorbidity with generalized social anxiety disorder (GSAD). We examined whether the presence of comorbid AvPD adds significant clinically relevant information for individuals seeking treatment for GSAD. Results suggested that AvPD was significantly associated with poorer quality of life and greater disability in univariate, but not multivariate analyses. Endorsement of more AvPD symptoms was associated with increased disability, increased risk of intimacy, and lower social support, even after covariate adjustment. Specifically, AvPD item 3, hard to be "open" even with people you are close to, was most strongly correlated with quality of life and disability. A binary diagnosis of AvPD alone adds little beyond a marker of greater GSAD severity and depression among patients with GSAD, while a specific feature of AvPD not captured by the GSAD diagnosis, namely emotional guardedness, may be associated with greater impairment.

Mood regulation and quality of life in social anxiety disorder: an examination of generalized expectancies for negative mood regulation.

The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.

Anchoring the Panic Disorder Severity Scale.

The Panic Disorder Severity Scale (PDSS) is a clinician-administered measure of panic disorder symptom severity widely used in clinical research. This investigation sought to provide clinically meaningful anchor points for the PDSS both in terms of clinical severity as measured by the Clinical Global Impression-Severity Scale (CGI-S) and to extend its clinical meaningfulness by examining its association with quality of life. A total of 63 individuals with a primary diagnosis of panic disorder were assessed on completion of a 6- or 8-week psychotherapy or pharmacotherapy trial for the treatment of panic disorder. As expected, the PDSS was correlated with both the CGI-S and quality of life. These results provide further support for the validity and clinical utility of the PDSS and provide simple anchors to help guide the potential use of the PDSS scale to measure treatment progress in clinical practice.