The fear of Alzheimer's disease: mediating effects of anxiety on subjective memory complaints.

Objectives: To determine if the fear of developing Alzheimer's disease (FDAD) construct, in combination with similar psychoemotional factors, could help elucidate the nature of older adults' subjective memory complaints (SMCs) and subsequent objective memory performance.Methods: One hundred ninety-three healthy older adults (aged 65-93) were administered clinician and self-report measures of depression, worry, anxiety, illness attitudes, and memory, and each rated their concern with developing AD.Results: Self-reported FDAD was not associated with objective memory performance (p > .05). FDAD, trait anxiety, general anxiety, and general and illness-related worry were independently associated with subjective memory report (ps < .05). The relationship between FDAD and subjective memory report was mediated by measures of general trait and state anxiety, but not general worry or illness-specific worry.Conclusions: FDAD was not associated with objective memory functioning, suggesting AD concerns were not reflective of memory pathology. The mediating effect of anxiety on the relationship between FDAD and subjective memory report suggests that assessment of anxiety, beyond AD fear, may help identify older adults at risk for developing negative perceptions of memory and related distress.

Task-Based Attentional Control: The Role of Anxiety and Age.

OBJECTIVE: Attentional Control Theory (ACT) posits that anxiety impacts cognitive functioning through interference in working memory and processing efficiency, resulting in performance deficits in set-shifting and inhibition. Few studies have examined the effects of anxiety on set-shifting and inhibition in clinical samples or how these relationships might be affected by age. The current study tested whether increased age, elevated anxiety, and their interaction were associated with reduced performance on measures of set-shifting and inhibition. METHOD: Symptom and neuropsychological testing data were obtained from outpatient participants presenting at an academic medical center (N = 521; mean age = 50.39 years, SD = 22.35, range = 18-90; 47.4% female; 78.3% White). The Trail Making Test Difference score was used to assess set-shifting and the Stroop Color-Word Test Interference score was used to assess inhibition. RESULTS: After controlling for demographic variables, ADHD diagnosis, depression symptoms, and Mild Cognitive Impairment (MCI), both age and anxiety were significant predictors of set-shifting (ß = 0.45 and ß = 0.18, respectively, ps < 0.001) and inhibition (ß = -0.37, p < 0.001 and ß = -0.19, p = 0.001, respectively). No interaction was found between age and anxiety in the prediction of set-shifting or inhibition. CONCLUSION: Congruent with ACT, anxiety was associated with worse performance on measures of set-shifting and inhibition. Older age was an independent predictor of worse set-shifting and inhibition but did not moderate the relationship between anxiety and attentional control, suggesting that anxiety adversely affected working memory and processing efficiency equivalently across the adult lifespan. The results highlight the importance of anxiety assessment in neuropsychological evaluation in patients of all ages.

Combining physical therapy and cognitive behavioral therapy techniques to improve balance confidence and community participation in people with unilateral transtibial amputation who use lower limb prostheses: a study protocol for a randomized sham-control clinical trial.

BACKGROUND: Low balance confidence is a prevalent yet overlooked issue among people who use lower limb prostheses (LLP) that can diminish community integration and quality of life. There is a critical need to develop rehabilitation programs that specifically target balance confidence in people who use LLP. Previous research has shown that multicomponent interventions including cognitive-behavioral therapy (CBT) techniques and exercise are feasible and effective for improving balance confidence in older adults. Therefore, a cognitive behavioral-physical therapy (CBPT) intervention was developed to target balance confidence and increase community integration in people who use LLP. METHODS/DESIGN: This randomized control trial will recruit 60 people who use LLP with low balance confidence. Participants will be randomized to the CBPT intervention condition or control condition. DISCUSSION: The trial is designed to test the effects of the CBPT intervention on balance confidence and functional mobility in lower limb prosthesis users by examining self-reported and objective measures of community integration and quality of life. The trial will also examine the relationship between changes in balance confidence and changes in community integration following participation in CBPT intervention. Additionally, through participant feedback, researchers will identify opportunities to improve intervention efficacy. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03411148. Registration date: January 26, 2018.

The moderating role of negative affect on objective verbal memory performance and subjective memory complaints in healthy older adults.

Subjective memory complaints (SMCs) are part of the diagnostic criteria for Mild Cognitive Impairment (MCI), yet little is known about their etiology. In some previous studies, no direct relation has been found between SMCs and objective memory performance, yet significant correlations have been identified between SMCs and psychological factors such as depression and anxiety. In the current study, we examined whether negative affect moderated the relation between objective memory functioning and SMCs in a sample of healthy, non-demented participants aged 65 and older. As predicted, several negative affect measures moderated the relationship between objective cognitive functioning and SMCs. In the absence of objective memory impairment as indexed by the Rey Auditory Verbal Learning Test (RAVLT) and the Dementia Rating Scale-2nd Edition (DRS-2), higher levels of negative affect were associated with increased levels of SMCs. Moreover, a lower order negative affect factor, anxiety sensitivity, significantly moderated the relation between objective memory functioning and SMCs, after controlling for higher order measures of general negative affectivity. Findings suggest that negative affect, particularly anxiety sensitivity, distorts the subjective appraisal of one's own memory, such that people high on negative affect factors report more episodes of forgetting, even in the absence of objective cognitive impairments.

Implicit learning, thought-focused attention and obsessive-compulsive disorder: a replication and extension.

Although significant empirical support exists for both cognitive and neurobiological models of obsessive-compulsive disorder (OCD), there have been few efforts to integrate findings. In this investigation, we attempted to link models by examining relationships between performance on information processing tasks posited to be markers of OCD-related neuropathology and a self-report measure of excessive thought-focused attention (cognitive self-consciousness; CSC). Congruent with predictions and prior research, OCD patients' performance was impaired in comparison to an anxious control group on the Serial Reaction Time (SRT) Task, a measure of implicit procedural learning. Following completion of the SRT, participants' awareness of the embedded stimulus pattern was assessed. As predicted, participants with OCD demonstrated superior performance on this task. Scoring on a measure of CSC correlated with performance on both tasks, although the amount of variance accounted for was modest. Evaluation of OCD symptom subgroups revealed greater procedural learning impairment in a hoarding subgroup. Implications for theory and treatment are discussed.

Anxiety sensitivity and obsessive--compulsive disorder.

Anxiety sensitivity (AS), a cognitive risk factor for anxiety disorders, was evaluated in a homogeneous obsessive-compulsive disorder (OCD) sample. A total of 280 individuals with OCD completed measures. Evaluation of the Anxiety Sensitivity Index revealed a latent structure that was congruent with previous studies showing a single higher order and three lower order factors, although greater variance was accounted for by the general factor than in a previous study. AS was significantly associated with OCD symptom severity after controlling for other putative cognitive risk factors, although the additional variance explained was small. Variability in the relationship of AS to OCD symptom severity was found across OCD symptom subgroups. Results suggest that AS might be an important aspect of OCD-relevant cognition for specific OCD subgroups, and the need for experimental evaluation is discussed.

Dysfunctional belief-based obsessive-compulsive disorder subgroups.

An attempt was made to identify obsessive-compulsive disorder (OCD) subgroups based on differences in OCD related beliefs. OCD patients (N=367) were assessed with the Obsessional-Beliefs Questionnaire prior to treatment. Individuals' scores on measures of inflated personal responsibility and the tendency to overestimate threat, perfectionism and intolerance of uncertainty, and over-importance and over-control of thoughts were subjected to cluster analysis. Support for both a simple and complex subgroup model was found (2-subgroup and 5-subgroup taxonomies). A low-beliefs subgroup was identified in both taxonomies. The low-beliefs subgroups reported scores on belief measures equivalent to scores reported for non-OCD comparison groups in earlier studies. Additional analyses were conducted to determine relations between belief-based and symptom subgroups. Significant relationships were found (e.g., Symmetry symptom subgroup membership was associated with membership in the Perfectionism/Certainty beliefs subgroup), although the shared variance was modest. Implications for understanding OCD heterogeneity and for cognitive theory are discussed.

Cognitive self-consciousness, implicit learning and obsessive-compulsive disorder.

The negative appraisal of commonly experienced intrusive thoughts is posited to play an important role in obsessive-compulsive disorder (OCD), although why some people focus on thought experiences and have difficulties dismissing intrusions is not well understood. To elucidate how intrusive thoughts might become obsessional problems, relations between thought-focused attention (cognitive self-consciousness; CSC), implicit sequence learning and OCD were evaluated in individuals with OCD (n=43) and in a nonclinical comparison group (n=41). Impaired performance on a serial reaction time test, but enhanced recognition of the embedded stimulus pattern, was predicted for the OCD group based on hypothesized nonconscious processing differences. Predicted differences were found and CSC score predicted reaction time and pattern recognition. CSC might be a consequence of conscious processing gating problems that increase thought salience and the likelihood of the negative appraisal of intrusive thoughts. Implications for theory and treatment are discussed.

Do dysfunctional beliefs play a role in all types of obsessive-compulsive disorder?

Some but not all models of obsessive-compulsive disorder (OCD) emphasize the role of dysfunctional beliefs in the etiology and maintenance of this disorder. Clinical observations suggest that some OCD patients have prominent dysfunctional beliefs associated with their obsessions and compulsions, while other patients do not show this pattern. It is possible that dysfunctional beliefs play a role in only a subgroup of cases of OCD and, by extension, that different models might apply to different subtypes of the disorder. To examine this issue, patients with OCD (N = 244) completed measures of dysfunctional OC-related beliefs, along with measures of OC symptoms and demographics. These measures were also completed by three comparison groups; anxious (N = 103), student (N = 284), and community (N = 86) controls. Cluster analysis revealed two OCD clusters: low versus high scores on beliefs (OC-low, OC-high). Belief scores for OC-low were in the range of scores for the comparison groups, which were all significantly lower than those of OC-high. Thus, a cluster of OCD patients was identified who did not have elevated scores on measures of dysfunctional beliefs. OC-low and OC-high did not differ on some OC measures (contamination, checking, grooming), but OC-high had higher scores on measures of harming obsessions. These results are consistent with the view that dysfunctional beliefs may play a role in only some types of OCD.

Does cognitive self-consciousness link older adults' cognitive functioning to obsessive-compulsive symptoms?

To elucidate how obsessional symptoms might develop or intensify in late-life, we tested a risk model. We posited that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, would increase reactivity to aging-related cognitive changes and mediate the relationship between cognitive functioning and obsessive-compulsive disorder (OCD) symptoms. Older adults (Mage = 76.7 years) completed the Dementia Rating Scale-2 (DRS-2), a CSC measure, and an OCD symptom measure up to four times over 18 months. A model that included DRS-2 age and education adjusted total score as the indicator of cognitive functioning fit the data well, and CSC score change mediated the relationship between initial cognitive functioning and changes in OCD symptoms. In tests of a model that included DRS-2 Initiation/Perseveration (I/P) and Conceptualization subscale scores, the model again fit the data well. Conceptualization scores, but not I/P scores, were related to later OCD symptoms, and change in CSC scores again mediated the relationship. Lower scores on initial cognitive functioning measures predicted increases in CSC scores over time, which in turn predicted increases in OCD symptoms over the 18 months of the study. Implications for understanding late-life obsessional problems are discussed.

A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms.

Recently, experts have suggested that obsessive-compulsive disorder (OCD), a highly heterogeneous condition, is actually composed of distinct subtypes. Research to identify specific subtypes of OCD has focused primarily on symptom presentation. Subtype models have been proposed using factor analyses that yield dimensional systems of symptom categories, but not necessarily distinct subtypes. Other empirical work has considered the role of neuropsychological functioning and comorbidity as part of a comprehensive scheme for subtyping OCD. The identified dimensions from all of these studies have implications for the treatment of OCD. In this article, we review the research on subtypes of OCD, focusing on subtype schemes based upon overt symptom presentation and neuropsychological profiles. We also review research pertinent to alternative subtyping schemes, both conceptually and methodologically. The research is critically examined and implications for treatment are discussed. Recommendations for future investigations are offered.

Psychopathy is related to negative affectivity but not to anxiety sensitivity.

Although the hypothesis that psychopathic individuals are characterized by a reduced capacity for experiencing anxiety is central to many theories of psychopathy, most prior studies have examined anxiety and fear measures generally considered outdated in the literature. Moreover, prior findings are mixed, with several studies reporting no relationships between psychopathy and anxiety, and others suggesting negative relationships for the affective, interpersonal aspects of the disorder and positive relationships for the antisocial behavior dimension. To examine whether psychopathy dimensions are associated with contemporary measures of anxiety, the Anxiety Sensitivity Index and State Trait Anxiety Inventory-Trait scale were administered to 157 male inmates. Participants also completed the MMPI-derived Welsh Anxiety Scale (WAS), commonly used in psychopathy studies. Analyses provide no evidence for a negative relationship between psychopathy's affective, interpersonal factor and anxiety sensitivity after controlling for trait anxiety. Trait anxiety and WAS scores were positively associated with the antisocial behavior dimension of psychopathy. Findings do replicate prior relationships between the WAS and psychopathy, suggesting the WAS may measure aspects of negative affectivity that differ from anxiety.

Obsessive-compulsive disorder subtypes: an attempted replication and extension of a symptom-based taxonomy.

A symptom-based subgroup taxonomy for obsessive-compulsive disorder (OCD) was evaluated and refined. The Yale-Brown Obsessive-Compulsive Scale symptom checklist was scored and cluster analysis was conducted with a sample of OCD patients (N = 114). Results were compared to Calamari et al.'s (Behaviour Research and Therapy 37 (1999) 113) five subgroup model. Rules for determining the number of subgroups supported a more complex model. In between sample comparisons, a stable contamination subgroup was found in both a five and seven subgroup taxonomy. Between sample stability was not as strong for Harming, Obsessionals, Symmetry, and Certainty subgroups. Hoarding, as a distinctive subgroup, was unstable in separate samples. When the Calamari et al. sample and the present sample were combined (N = 220), we found a reliable Hoarding subgroup. More interpretable and stable models emerged with the combined samples suggesting that large clinical samples are needed to identify OCD subgroups. Greater support was found for a seven subgroup taxonomy based subgroup interpretability and validation measure differences. The potential utility of symptom-based subgroup models of OCD and alternative approaches are discussed. Identification of reliable and valid OCD subtypes may advance theory and treatment.

Too much thinking about thinking?: Metacognitive differences in obsessive-compulsive disorder.

Negative appraisals of intrusive thoughts and beliefs about the importance of thoughts are considered core mechanisms in cognitive models of obsessive-compulsive disorder (OCD). In refinements of cognitive theory, differences in metacognitive processes have been emphasized. Cartwright-Hatton and Wells [J. Anxiety Disord. 37 (1997) 279-296] found that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, was the only metacognitive dimension that differentiated OCD patients from patients with generalized anxiety disorder. To evaluate the relative importance of different cognitive processes to OCD, we administered an expanded CSC scale and two state-of-the-art measures of thought appraisals and beliefs. Scores on the CSC scale reliably differentiated OCD patients (n=30), from an anxious comparison group (OAD, n=25) after controlling for scores on the two cognition measures. The tendency to excessively reflect upon one's cognitive processes may increase opportunities for negative appraisals of intrusive thoughts, foster over-importance of thought beliefs, and increase the likelihood of developing OCD.

Assessing Older Adults' Obsessive-Compulsive Disorder Symptoms: Psychometric Characteristics of the Obsessive Compulsive Inventory-Revised.

The lack of Obsessive-Compulsive disorder (OCD) symptom measures validated for use with older adults has hindered research and treatment development for the age group. We evaluated the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) with participants aged 65 and older (N = 180) to determine if the measure was an effective tool for evaluating obsessional symptoms. Participants completed the OCI-R and a comprehensive assessment battery up to four times over approximately 18 months. Results supported the well-replicated latent structure of the OCI-R (i.e., Washing, Checking, Ordering, Obsessing, Hoarding, and Neutralizing.). OCI-R total score was robustly associated with OCD symptoms assessed 18 months later by clinical interview, while scores on self-report measures of worry, general anxiety, and depression were not. Results indicate the OCI-R is an effective OCD symptom measure for older adults, although replication with additional older adult samples is needed.

The sense of incompleteness as a motivator of obsessive-compulsive symptoms: an empirical analysis of concepts and correlates.

Contemporary models of obsessive-compulsive disorder emphasize the importance of harm avoidance (HA) and related dysfunctional beliefs as motivators of obsessive-compulsive (OC) symptoms. Recently, there has been a resurgence of interest in Janet's (1908) concept of incompleteness (INC) as another potentially important motivator. Contemporary investigators define INC as the sense that one's actions, intentions, or experiences have not been properly achieved. Janet defined INC more broadly to include alexithymia, depersonalization, derealization, and impaired psychological mindedness. We conducted two studies to address four issues: (a) the clinical correlates of INC; (b) whether INC and HA are distinguishable constructs; (c) whether INC predicts OC symptoms after controlling for HA; and (d) the relative merits of broad versus narrow conceptualizations of INC. Study 1 was a meta-analysis of the clinical correlates of narrowly defined INC (16 studies, N=5,940). INC was correlated with all types of OC symptoms, and was more strongly correlated with OC symptoms than with general distress. Study 2 (N=534 nonclinical participants) showed that (a) INC and HA were strongly correlated but factor analytically distinguishable; (b) INC statistically predicted all types of OC symptoms even after controlling for HA; and (c) narrow INC was most strongly correlated with OC symptoms whereas broad INC was most strongly correlated with general distress. Although the findings are limited by being correlational in nature, they support the hypothesis that INC, especially in its narrow form, is a motivator of OC symptoms.

Do negative affect characteristics and subjective memory concerns increase risk for late life anxiety?

To better understand the development and exacerbation of late-life anxiety, we tested a risk model positing that trait negative affect (NA) characteristics would interact with cognitive functioning, thereby increasing some older adults' risk for increased anxiety symptoms. The moderator-mediator model consisted of measures of NA, cognitive functioning, and their interaction, as predictors of later Hamilton Anxiety Rating Scale scores (HARS) via a mediational process, subjective memory concerns (SMCs). Older adults (aged 65-years and over; M(age)=76.7 years, SD=6.90 years) completed evaluations four times over approximately 18 months. A latent growth curve model including Anxiety Sensitivity Index total score (ASI), Mattis Dementia Rating Scale-2 (DRS) total raw score, the ASI×DRS interaction, a SMC measure as mediator, HARS intercept (scores at times 3 and 4), and HARS slope provided good fit. The ASI×DRS-2 interaction at Time 1 predicted HARS slope score (ß=-.34, p<.05). When ASI score was high, stronger cognitive functioning was associated with fewer anxiety symptoms. The indirect effect of ASI score predicting HARS score 18-months later through the SMC mediator was statistically significant (ß=.08, p<.05). Results suggest that the cognitive functioning changes associated with aging might contribute to the development of anxiety symptoms in older adults with specific NA traits. Implications for predicting and preventing late life anxiety disorders are discussed.

Anxiety as a context for understanding associations between hypochondriasis, obsessive-compulsive, and panic attack symptoms.

In the context of the integrative model of anxiety and depression, we examined whether the essential problem of hypochondriasis is one of anxiety. When analyzed, data from a large nonclinical sample corresponded to the integrative model's characterization of anxiety as composed of both broad, shared and specific, unique symptom factors. The unique hypochondriasis, obsessive-compulsive, and panic attack symptom factors all had correlational patterns expected of anxiety with the shared, broad factors of negative emotionality and positive emotionality. A confirmatory factor analysis showed a higher-order, bifactor model was the best fit to our data; the shared and the unique hypochondriasis and anxiety symptom factors both contributed substantial variance. This study provides refinements to an empirically based taxonomy and clarifies what hypochondriasis is and, importantly, what it is not.

What do low-dysfunctional beliefs obsessive-compulsive disorder subgroups believe?

Obsessive-compulsive disorder (OCD) heterogeneity research identified a patient subgroup that endorsed few of the dysfunctional beliefs posited to be important to development of obsessional disorders. Because of the clinical and theoretical importance of such heterogeneity, we attempted to elucidate the concerns of a low-beliefs OCD subgroup. We evaluated specific metacognitive beliefs and monitoring tendencies assessed on the Metacognitions Questionnaire (MCQ-30; Wells & Cartwright-Hatton, 2004), and feelings of incompleteness ("not just right experiences" [NJREs]) believed to reflect an inability to use emotional experience and sensory feedback to guide behavior (Summerfeldt, 2007). Low (OCD-L) and high dysfunctional beliefs (OCD-H) OCD patient subgroups, and anxious and student comparison groups, completed measures. Scoring on the MCQ-30 differentiated OCD subgroups, although evaluations of differences and correlations with OCD symptom measures indicated that these metacognitive beliefs more so characterized the thinking of the OCD-H subgroup. Scoring on NJREs measures also differentiated OCD subgroups. NJREs scores were consistently related to OCD symptoms only for the OCD-L subgroup. Results are congruent with theoretical formulations positing that harm avoidance and feelings of incompleteness are important and distinct motivations that underlie specific variants of OCD.