Attenuated Psychophysiological Reactivity following Single-Session Group Imagery Rescripting versus Verbal Restructuring in Social Anxiety Disorder: Results from a Randomized Controlled Trial.

BACKGROUND: The effectiveness of psychotherapies for social anxiety disorder (SAD) is typically evaluated using self- and clinician-reported symptom change, while biomarkers of treatment response are rarely measured. The current study aimed to compare biomarkers of response following two brief group interventions for SAD. METHODS: This randomized controlled trial evaluated the effectiveness of single-session group interventions for SAD (n = 58) - imagery rescripting (IR) and verbal restructuring (VR) versus waitlist control (WC). The IR intervention guided participants to rescript autobiographical memories through visualization whilst the VR intervention focused on thought challenging. Trial outcomes included change in psychophysiological reactivity (heart rate variability (HRV) and electrodermal responding) to social stress, and symptom-based measures (social interaction anxiety, negative self-portrayal, cognitive avoidance, repetitive negative thinking, memory modification, anxious behaviors). RESULTS: Psychophysiological reactivity was selectively attenuated following IR treatment, compared to VR and WC groups. The specific influence of the imagery-based intervention in modulating autonomic reactivity was evident across HRV parameters, including the standard deviation of intervals between heartbeats (IR vs. WC, d = 0.67, p = 0.021; IR vs. VR, d = 0.58, p = 0.041), and high frequency power - an indicator of parasympathetically mediated emotion regulation (IR vs. WC, d = 0.75, p = 0.034; IR vs. VR, d = 0.95, p = 0.006). Few group differences were observed across self-report measures. CONCLUSION: The current study highlights the specificity of brief imagery-based interventions in influencing psychophysiological reactivity in SAD and establishes the sensitivity of objective markers of treatment response in quantifying change over symptom-based measurements.

Mechanisms of Change During Attention Training and Mindfulness in High Trait-Anxious Individuals: A Randomized Controlled Study.

The first aim of this study was to compare attention manipulation techniques deriving from metacognitive therapy (the Attention Training Technique; ATT) and mindfulness-based approaches (Mindfulness-Based Progressive Muscle Relaxation, MB-PMR) to a thought wandering control (TWC) condition, in terms of their impact on anxiety and four mechanisms: distancing, present-focused attention, uncontrollability and dangerousness, metacognitive beliefs, and cognitive flexibility (Stroop task). The second aim was to test indirect effects of the techniques on anxiety via the mechanism measures. High trait anxious participants (N = 81, Mage = 23.60, SDage = 7.66, 80% female) were randomized to receive ATT, MB-PMR, or the TWC condition. Measures of cognitive and somatic anxiety, distancing, present-focused attention, metacognitive beliefs, and cognitive flexibility were administered before or after the attention manipulation task. Compared to the TWC group, ATT and MB-PMR were associated with greater changes on cognitive (but not somatic) anxiety, present-focused attention, metacognitive beliefs, and uncorrected errors for threat-related words on the Stroop task. The pattern of means was similar for distancing, but this did not reach statistical significance, and Stroop speed increased equally for all conditions. Indirect effects models revealed significant effects of condition on state anxiety via distancing, metacognitive beliefs, and present-focused attention, but not via Stroop errors. ATT and MB-PMR were associated with changes on anxiety and the mechanism measures, suggesting that the mechanisms of change may be more similar than different across these techniques.

Thoughts, images, and appraisals associated with acting and not acting on the urge to self-injure.

OBJECTIVES: The aim of this study was to examine the frequency, content, and appraisals of thoughts and images occurring during urges to engage in non-suicidal self-injury (NSSI). METHOD: Undergraduates (N = 154) with a history of NSSI completed an online survey of their thoughts, images, and appraisals when they acted on urges to engage in NSSI as well as when they resisted urges to self-injure. RESULTS: Most (>90%) participants reported experiencing both thoughts and images during urges to engage in NSSI. During urges that resulted in self-injury, self-critical and hopeless thoughts were most distressing, and thoughts about relief from emotional distress were most comforting. Images of the anticipated injury were most common. During urges that did not result in self-injury themes of the futility of NSSI, positive self-talk, and the impact on others were most common. Images were most frequently of the negative impact on self and others, and the anticipated injury. Appraisals encouraging NSSI occurred when individuals did and did not act on their urges, but concurrent strong discouraging appraisals appeared to be protective on occasions when urges did not result in self-injury. LIMITATIONS: Retrospective self-report was used to assess cognitive content. Generalisability of findings to non-student samples needs to be assessed. CONCLUSIONS: Findings from this study may inform comprehensive assessment of thoughts and images associated with urges to engage in NSSI. NSSI interventions may need to promote thoughts, imagery and appraisals that discourage NSSI whilst simultaneously modifying cognitions that encourage NSSI.

The power of positive thinking: Pathological worry is reduced by thought replacement in Generalized Anxiety Disorder.

Worry in Generalized Anxiety Disorder (GAD), takes a predominantly verbal form, as if talking to oneself about possible negative outcomes. The current study examined alternative approaches to reducing worry by allocating volunteers with GAD to conditions in which they either practiced replacing the usual form of worry with images of possible positive outcomes, or with the same positive outcomes represented verbally. A comparison control condition involved generating positive images not related to worries. Participants received training in the designated method and then practiced it for one week, before attending for reassessment, and completing follow-up questionnaires four weeks later. All groups benefited from training, with decreases in anxiety and worry, and no significant differences between groups. The replacement of worry with different forms of positive ideation, even when unrelated to the content of worry itself, seems to have similar beneficial effects, suggesting that any form of positive ideation can be used to effectively counter worry.

Delineating the Role of Negative Verbal Thinking in Promoting Worry, Perceived Threat, and Anxiety.

Worry is characterized by streams of verbal thoughts about potential negative outcomes. Individuals with high levels of worry (and particularly those with generalized anxiety disorder) find it very difficult to control worry once it has started. What is not clear is the extent to which verbal negative thinking style maintains worry. Our study aimed to disentangle the effects of verbal versus imagery based thinking, and negative versus positive worry-related content on subsequent negative intrusive thoughts. High worriers were trained to engage in imagery or verbal processing, focusing on either negative or positive outcomes of their current main worry. Both thinking style and valence of worry content influenced later negative intrusive thoughts that play a role in initiating worry episodes. In contrast, only valence influenced subjective ratings of worry outcomes (i.e., cost, concern, and ability to cope, although not probability), with positive valence leading to lower ratings, irrespective of thinking style.

Are attentional control resources reduced by worry in generalized anxiety disorder?

This is the first study to examine attentional control capacities in generalized anxiety disorder (GAD). GAD is characterized by uncontrollable worry. Individuals diagnosed with GAD and healthy participants (HPs) performed a random key-pressing task while thinking about a worrisome or a positive future event, to assess the extent to which attentional control resources are used by worry. Attentional control was also assessed when participants were not instructed to think about a specific topic using the N-back task, which varies in task difficulty, and therefore is sensitive to subtle differences in ability to handle increasing demands on attentional control within the same paradigm. GAD participants (but not HPs) were less random while worrying than thinking about a positive event during the key-pressing task, suggesting that worry consumed more attentional control resources in this population. During the N-Back task, GAD participants performed worse than HPs during the high load conditions only, indicating greater difficulty in sustaining focus on conditions requiring a higher degree of attentional control, even without concurrent task activity. Poor attentional control might underpin the difficulty of GAD individuals to stop worrying and switch to thinking more benign information. Further research could investigate whether worry consumes attentional control resources in other psychological disorders with high rates of worry (e.g., panic disorder, psychosis), as well as the extent to which attentional control is used by other forms of repetitive thinking, such as depressive rumination.

Characteristics of worry in generalized anxiety disorder.

BACKGROUND & OBJECTIVES: Groups of clients and community volunteers with Generalized Anxiety Disorder (GAD) and clients with Panic Disorder were compared to a group with elevated worry but without GAD on a range of measures, to identify individual differences beyond a high propensity to worry. METHOD: Participants completed standardised questionnaires and a behavioural worry task that assesses frequency and severity of negative thought intrusions. RESULTS: Relative to high worriers, clients with GAD had higher scores on trait anxiety, depression, more negative beliefs about worry, a greater range of worry topics, and more frequent and severe negative thought intrusions. Relative to community volunteers with GAD, clients in treatment reported poorer attentional control. Compared to clients with Panic Disorder, clients with GAD had higher trait anxiety, propensity to worry, negative beliefs and a wider range of worry content. CONCLUSIONS: Results confirmed expectations of group differences based on GAD diagnostic criteria, but also revealed other differences in mood, characteristics of worry, and perceived attentional control that may play a role in the decision to seek treatment.

The extent and nature of imagery during worry and positive thinking in generalized anxiety disorder.

Clients in treatment for Generalized Anxiety Disorder (GAD) were compared to a control group to assess the extent and nature of imagery during worry or while thinking about a personally relevant positive future event. Two methods were used to assess mentation and were completed in counter balanced order within the worry and positive conditions. One method assessed the occurrence of imagery by requiring participants to categorize their mentation as verbal thoughts or images every 10 s. The other method involved participants estimating the duration of any imagery that occurred in the previous 10 s. Imagery during worry occurred less often than while thinking about a positive event for both groups, but GAD clients had a more pronounced deficit of imagery during worry than the control group. Images that occurred were briefer during worry than while thinking about a positive future event and were briefer in the GAD than the control group for both worry and positive conditions. The results thus confirmed that imagery is less common during worry in clients with GAD but also demonstrated that the imagery that does occur in GAD is briefer.

The contribution of attentional bias to worry: distinguishing the roles of selective engagement and disengagement.

This study investigated the effect on worry of biased attentional engagement and disengagement. Variants of a novel attention modification paradigm were developed, designed to induce a group difference either in participants' tendency to selectively engage with, or disengage from, threatening meanings. An index of threat bias, reflecting relative speeding to process threat word compared to non-threat word content, confirmed that both procedures were effective in inducing differential attentional bias. Importantly, when the induced group difference in attentional bias followed the procedure designed to influence selective engagement with threat meanings, it also gave rise to a corresponding group difference in worry. This was not the case when it was induced by the procedure designed to influence selective disengagement from threat meanings. These findings suggest that facilitated attentional engagement with threat meanings may causally contribute to variability in worry.

Facilitating a benign attentional bias reduces negative thought intrusions.

The causal role of biased attention in worry was investigated in an experiment in which high worriers were assigned either to a condition requiring attention to nonthreatening words and text while ignoring worry-related material or to a mixed-attention control condition. The former procedure led to fewer negative thought intrusions in a worry test (as rated by both participants and an assessor) than did the control condition. These findings suggest that attentional bias plays a causal role in worry and that its modification can reduce excessive worry.

The effects of modifying interpretation bias on worry in generalized anxiety disorder.

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.

Looking on the bright side: accessing benign meanings reduces worry.

This research investigated whether increasing access to benign outcomes of ambiguous events decreases excessive worry. Participants reporting high levels of worry were assigned either to practice in accessing benign meanings of threat-related homographs and emotionally ambiguous scenarios or to a control condition in which threatening or benign meanings were accessed with equal frequency. Results were assessed by use of a breathing focus task that involved categorizing the valence of thought intrusions before and after an instructed worry period and a test of working memory capacity available to participants while worrying. In comparison with the control group, the benign group reported fewer negative thought intrusions (as rated by both participants and an assessor) and less anxiety during the breathing focus task and showed greater residual working memory capacity while worrying. These findings suggest that enhancing access to benign outcomes is an effective method of reducing both the persistence of worry and its detrimental consequences.

Restriction of working memory capacity during worry.

The authors report the first direct assessment of working memory capacity when people engage in worry. High and low worriers performed a random key-press task while thinking about a current worry or a positive personally relevant topic. High (but not low) worriers showed more evidence of restricted capacity during worry than when thinking about a positive topic. These findings suggest that high worriers have less residual working memory capacity when worrying than when thinking about other topics and, thus, have fewer attentional resources available to redirect their thoughts away from worry.