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Peer victimization and anxiety frequently co-occur and result in adverse outcomes in youth. Cognitive behavioural treatment is effective for anxiety and may also decrease children’s vulnerability to victimization.
This study aims to examine peer victimization in youth who have presented to clinical services seeking treatment for anxiety.
Following a retrospective review of clinical research data collected within a specialized service, peer victimization was examined in 261 children and adolescents (55.6% male, mean age 10.6 years, SD = 2.83, range 6–17 years) with a diagnosed anxiety disorder who presented for cognitive behavioural treatment. Youth and their parents completed assessments of victimization, friendships, anxiety symptoms, and externalizing problems.
High levels of victimization in this sample were reported. Children’s positive perceptions of their friendships were related to lower risk of relational victimization, while conduct problems were related to an increased risk of verbal and physical victimization. A subsample of these participants (n = 112, 57.1% male, mean age 10.9 years, SD = 2.89, range 6–17 years) had completed group-based cognitive behavioural treatment for their anxiety disorder. Treatment was associated with reductions in both self-reported anxiety and victimization. Results confirm the role of friendships and externalizing symptoms as factors associated with increased risk of victimization in youth with an anxiety disorder in a treatment-seeking sample.
Treatment for anxiety, whether in a clinic or school setting, may provide one pathway to care for young people who are victimized, as well as playing a role in preventing or reducing victimization.
Parenting has a strong influence on child development. However, there is minimal empirical evidence on why some parents use beneficial techniques, while others use harmful behaviours. Thus, there is a significant gap in the knowledge needed to address problematic parenting. Theories suggest that parental self-concept has a large influence on parenting behaviours. The aim of this study was to examine the relation between parent self-cognitions and parenting behaviours. One-hundred and four mothers of Grade 7 students completed questionnaires measuring their self-esteem, self-criticism, domain-specific self-concept, and parenting behaviours (support, behavioural control, and psychological control). Regression analyses demonstrated that self-cognitions largely predicted psychological control but support or behavioural control did not. These findings suggest that psychologically controlling behaviour in parents may be due to poor self-worth. With psychological control known to deeply damage children, these findings have major implications for interventions targeting harmful parenting.
Different and evolving conceptualisations of perfectionism have led to the development of numerous perfectionism measures in an attempt to capture the true representations of the construct. It is, therefore, important to ensure that these instruments are valid and reliable. The present systematic review examined the literature for the psychometric properties of the most commonly used general multidimensional trait perfectionism self-report measures. Relevant studies were identified by a systematic electronic search of academic databases. A total of 349 studies were identified, with 38 of these meeting inclusion criteria. The psychometric properties presented in each of these studies were subjected to assessment using a standardised protocol. All studies were evaluated by two reviewers independently. Results indicated that while none of the included measures demonstrated adequacy across all of the nine psychometric properties assessed, most were found to possess adequate internal consistency and construct validity. The absence of evidence to support adequate measurement properties over a number of domains for the measures included in this review may be attributed to the criteria of adequacy used, with some appearing overly strict and less relevant to perfectionism measures. Clinical and research relevance of the present findings and directions for future research are discussed.
In the past decade, network analysis (NA) has been applied to psychopathology to quantify complex symptom relationships. This statistical technique has demonstrated much promise, as it provides researchers the ability to identify relationships across many symptoms in one model and can identify central symptoms that may predict important clinical outcomes. However, network models are highly influenced by node selection, which could limit the generalizability of findings. The current study (N = 6850) tests a comprehensive, cognitive–behavioral model of eating-disorder symptoms using items from two, widely used measures (Eating Disorder Examination Questionnaire and Eating Pathology Symptoms Inventory).
We used NA to identify central symptoms and compared networks across the duration of illness (DOI), as chronicity is one of the only known predictors of poor outcome in eating disorders (EDs).
Our results suggest that eating when not hungry and feeling fat were the most central symptoms across groups. There were no significant differences in network structure across DOI, meaning the connections between symptoms remained relatively consistent. However, differences emerged in central symptoms, such that cognitive symptoms related to overvaluation of weight/shape were central in individuals with shorter DOI, and behavioral central symptoms emerged more in medium and long DOI.
Our results have important implications for the treatment of individuals with enduring EDs, as they may have a different core, maintaining symptoms. Additionally, our findings highlight the importance of using comprehensive, theoretically- or empirically-derived models for NA.
While dialectical behaviour therapy (DBT) appears efficacious in reducing suicidal and self-harming behaviour, it is unclear whether DBT reduces emotion regulation (ER) difficulties, a purported mechanism of change of treatment. This review aims to investigate and evaluate the current evidence to understand the effectiveness of DBT in improving ER difficulties. A qualitative synthesis of studies investigating the effectiveness of DBT on self-reported ER difficulties as measured by the Difficulties in Emotion Regulation Scale (DERS) was performed, identifying eligible studies using PsycINFO, PubMed, MEDLINE and EMBASE databases. Fourteen studies were identified. Current evidence indicates that DBT does not show consistent benefits relative to existing psychological treatments in improving ER difficulties. The literature is compromised by significant methodological limitations increasing risk of bias across study outcomes. Furthermore, high variability across DBT programs and a lack of investigation regarding adherence and participant engagement within interventions was observed. Further research is needed in order to conclude regarding the effectiveness of DBT in improving ER difficulties. Consistent use of active treatment conditions, greater standardisation of DBT-based interventions, in addition to further examination of participant engagement level in DBT-based interventions in the long term may assist understanding as to whether DBT improves ER difficulties.
There is a need for ecological approaches to guide global mental health programmes that can appropriately address the personal, family, social and cultural needs of displaced populations. A transactional ecological model of adaptation to displacement was developed and applied to the case of Syrian refugees living in Jordan.
Syrian and Jordanian psychosocial workers (n = 29) supporting the Syrian refugee community in Jordan were interviewed in three waves (2013–2016). A grounded-theory approach was used to develop a model of key local concepts of distress. Emergent themes were compared with the ecological model, including the five ADAPT pillars identified by Silove (2013).
The application of the ecological concept of niche construction demonstrated how the adaptive functions of a culturally significant concept of dignity (karama) are moderated by gender and displacement. This transactional concept brought to light the adaptive capacities of many Syrian women while highlighting the ways that stigma may restrict culturally sanctioned opportunities for others, in particular men. By examining responses to potentially traumatic events at the levels of individual, family/peers, society and culture, adaptive responses to environmental change can be included in the formulation of distress. The five ADAPT pillars showed congruence with the psychosocial needs reported in the community.
The transactional concepts in this model can help clinicians working with displaced people to consider and formulate a broader range of causal factors than is commonly included in individualistic therapy approaches. Researchers may use this model to develop testable hypotheses.
The experience of paediatric asthma is associated with increased stress and emotional difficulties for both the child and family. The current study aimed to qualitatively explore parents’ views of their child's asthma experience, from initial diagnosis onwards, to enhance our understanding of how families emotionally adjust and adapt to the diagnosis and management of asthma. Semi-structured interviews were conducted with 17 parents of children (<18 years) with physician-diagnosed asthma. Questionnaires were used to capture demographic information and anxiety symptom status of parents (State Trait Anxiety Inventory — Form Y [STAI-Y1/Y2]) and children (Spence Children's Anxiety Scale — Parent reported [SCAS-P]). Grounded theory was used to analyse the results. Analysis saw three themes emerge as important in understanding the impact of asthma on the family: (1) the experience of obtaining an asthma diagnosis, (2) parents’ belief in their competence to manage asthma, and (3) parents’ behaviour in response to the asthma. A model was developed that posits adaptive parental adjustment to asthma is determined in part by the circumstances around the time of diagnosis, the level of knowledge and skills, and the controllability of the asthma. This model can guide medical and allied health professionals to specific areas where intervention may reduce stress and emotional difficulties associated with asthma and its management for affected families.
Anxiety disorders occur at an increased rate in children with asthma; however, there is only a small evidence base to support specific psychological treatments for these children. The current study evaluated the efficacy of a pilot cognitive behavioural treatment (CBT) group intervention for children with asthma and a comorbid anxiety disorder in a case series design. Five children (aged 8–11 years old) with asthma and a comorbid anxiety disorder and their mothers took part in eight 1-hour group treatment sessions. Primary outcomes measures were anxiety diagnosis and asthma-related quality of life. Secondary outcome measures were asthma symptom control and parent quality of life associated with caring for a child with asthma. Three of the participants no longer met diagnostic criteria for an anxiety disorder following treatment and three different participants reported a reliable improvement in asthma-related quality of life. Two participants reported a reliable improvement in asthma symptom control. Three mothers reported an improvement in caregiver quality of life. The findings provide preliminary proof of concept evidence for the efficacy of a CBT intervention for children with asthma and clinical anxiety.
One means by which Intolerance of Uncertainty (IU) purports to contribute to anxiety is by increasing Threat Perception (TP). This process was examined by comparing two different definitions of uncertainty: ambiguity versus unpredictability. N = 104 participants were measured for IU and then made worry and TP estimates for four different scenario types: Ambiguous Scenarios (where an outcome could be interpreted as threatening), Unpredictable Positive Scenarios (where a surprising and positive outcome was anticipated), as well as Positive and Negative Scenarios (with certain outcome). Both Ambiguous and Unpredictable Positive Scenarios more strongly predicted the relationship between IU and worry scores than (certain) Positive or Negative Scenarios. The relationship between IU and ‘ambiguous worry’ was largely explained by TP estimates, whereas the relationship between IU and ‘Unpredictable Positive Worry’ was largely independent of TP. Results suggest ambiguity and unpredictability are differentially explained by TP such that they produce different types of response. The authors argue ambiguity and unpredictability are explanatory components within IU.
Effective treatments for common anxiety and mood disorders exist, yet epidemiological studies reveal that the unmet need for treatment in the community remains high. This study investigates the significance of the initial delay to first seek professional help in this unmet need for treatment in an Australian sample. Help-seeking history was retrospectively reported by 273 new referrals to a specialist anxiety treatment clinic who had a primary diagnosis of an anxiety (78%) or mood disorder (22%). Clinical, demographic and attitudinal variables were tested as potential predictors of length of the delay. Average help-seeking delay was 8.2 years (range 0–72 years). Younger age at symptom onset and slower problem recognition were associated with delayed help-seeking, and older people were more likely to report longer delays. We conclude that delays to first seek treatment are long and contribute significantly to the unmet need for treatment for anxiety and mood disorders, and that lack of problem recognition is a significant barrier to help-seeking.
In Australia, acculturating adolescents from a non-English speaking background (NESB) face two important challenges: developing a cultural identity and establishing a set of cultural values. These challenges are achieved by balancing a native and Australian orientation. It was expected that NESB adolescents who did not achieve these tasks would experience poor mental health. This study focused on adolescents because a significant relationship between cultural identity, cultural values and mental health in this group will highlight a need for sensitivity to such cultural and developmental issues. Two hundred and sixty-three NESB adolescents completed questionnaires that assessed cultural identity (Australian and native), cultural values (individualism and collectivism), state mental health (depression, anxiety and stress) and trait mental health (positive affectivity [PA] and negative affectivity [NA]). Results indicated that high Australian pride and high native pride are associated with lower depression, anxiety, stress and NA, and higher PA. Results also indicated that adolescents high on individualism and collectivism reported lower depression and stress, and higher PA. Furthermore, adolescents with a separated cultural identity (high native pride and low Australian pride) reported the highest levels of depression, but adolescents with separated cultural values (high collectivism and low individualism) reported the lowest levels of depression and anxiety. We concluded that cultural identity and cultural values are differentially related to mental health, and such relationships, albeit moderate, emerge during adolescence.
The present chapter aims to guide clinicians in the principles of treatment and the use of the treatment Manual, as well as highlight some of the more common problems encountered in therapy. fihile further studies are needed to identify the active components of effective treatment for generalized anxiety disorder, it appears that two core elements are:
•An underlying rationale, based on the ‘coping skills’ model of cognitive
behavioral therapy, where patients are taught skills to manage their anxiety and
to take responsibility for change and control over their thoughts, feelings, and
•Cognitive therapy with the goal of bringing the process of worry under the
Relaxation training, usually a form of progressive muscle relaxation, is a useful adjunct to treatment, particularly where the effects of chronic and high levels of muscle tension trouble an individual.
It is assumed that before the commencement of treatment, a clinical assessment will have ruled out comorbid diagnoses in need of immediate specific treatment, such as a major depressive episode. fihere depression is present, it becomes the treatment priority and the need for further treatment of anxiety symptoms reviewed when the depression is resolved. Given the phenomenological similarities between the two disorders, it is often necessary to establish from historical information whether GAD existed before the onset of a major depressive episode, or to assess whether a GAD continues to exist following effective treatment of the depressive disorder.
fihile patients with a primary diagnosis of GAD will not always meet criteria for another diagnosis, they will often have concerns and behaviors that are characteristic of other anxiety disorders. Panic attacks, social anxiety, phobic avoidance, obsessions, and illness anxiety are common. The treating clinician will therefore need to be able to recognize these different features and address these in the course of treatment. For example, some time can be spent focusing specifically on fears of scrutiny and negative evaluation or fears that a physical sensation is really a sign of a serious, life-threatening illness within the framework of the cognitive behavioral approach. The use of a slow-breathing exercise (possibly due to its meditation-like features) can provide temporary control over acute episodes of high anxiety for many individuals. Hence patients can be relatively quickly provided with an increased sense of control that allows them to recognize the triggers of their anxiety and implement cognitive strategies.
The aims of treatment are symptom reduction and improved function. Elimination of all anxiety is unlikely (and unnecessary), and the therapist has a role in helping the patient to set realistic goals for therapy. Psychological and pharmacological treatments are available for social phobia. The treatments for which there is most evidence of efficacy are cognitive and exposure-based treatments, social skills training packages, antidepressant medication and benzodiazepine anxiolytics. In general, outcome is related to severity of symptoms at pretreatment. Psychological treatments for social phobia
Social skills training
The role of social skills training in the treatment of social phobia continues to be debated. Prior to the publication of DSM-III, social skills training had demonstrated clinical utility in heterogeneous populations of psychiatric outpatients with social skills difficulties or anxieties (Stravynski et al., 1982;filazlo et al., 1990). Hence it was proposed that these techniques be applied to the treatment of social phobia. Reviewers agree that few of the early studies that examined social skills treatments were methodologically sound (Marks, 1985;Heimberg, 1989; Stravynski and Greenberg, 1989;Mattick et al., 1995); in particular, only rarely was a control condition in evidence. Diagnostic groups were often heterogeneous or poorly defined. No differentiation was made between those with and those without avoidant personality disorder (APD). In addition, strategies referred to as social skills training often included explicit instructions more consistent with exposure therapies, e.g., to regularly confront their fears and to persist in the situation until anxiety diminished (filazlo et al., 1990).
Part of the argument over the role of social skills training centers on whether apparently poor social skills are the result of actual skills deficits, or really due to inhibition of skills expression due to anxiety. Turner et al. (1986) examined thesocial skills of patients with social phobia, comparing those with and without avoidant personality disorder. They found that patients with social phobia alone felt anxious, and perceived that others found them anxious and inadequate, but in fact had appropriate social skills. Those with APD were found to be markedly lacking in social skills. However, the authors were unable to exclude profound inhibition in social situations as the underlying cause giving rise to the appearance of skills deficits: in APD, severe anxiety related to a core schema that social error will lead to rejection can result in profound social inhibition and avoidance.
Survivors of trauma who do not recover independently, and who go on to develop longer-term problems as a result of their experiences, may require formal treatment. There is also a mounting body of research suggesting that early interventions with high risk survivors may facilitate the recovery process and reduce the prevalence of subsequent PTSD. The purpose of this chapter is to provide a brief overview of common interventions used in the treatment of acute stress disorder (ASD) and PTSD, and to discuss their application as a preventive strategy.
Aims of treatment
It is reasonable to assume that virtually all human beings will experience a psychological reaction to very frightening or upsetting events. This raises questions about what constitutes an adaptive psychological response to trauma and, as a corollary, what are reasonable treatment goals. Severe traumatic events profoundly affect survivors’ views of themselves and the world. In most cases, it is reasonable to suggest that the survivor will never be the same person again. Equally, those changes need not all be bad. Recovery from trauma can result in personal growth, with the development of improved coping strategies and more adaptive models of the self and the world.
Ideally, treatment would serve to eliminate all the symptoms of PTSD and return the survivor to pretrauma levels of functioning. In reality, that will not always be possible. As with other disorders, factors such as the severity of the condition, chronicity, and comorbidity (particularly in the form of axis II disorders) are likely to affect treatment efficacy. In acute cases of PTSD with few complications, it is reasonable to expect a high degree of success with relatively few sessions (6 to 10). In such cases, elimination of PTSD symptoms, a return to prior functioning, and low risk of relapse would be achievable goals. (Importantly, this is not to imply that the person will never again experience distressing memories of the event but, rather, that such intrusive phenomena will be infrequent and manageable). On the other hand, treatment goals for affietnam veteran with, forexample, a 30-year history of PTSD, high levels of comorbid alcohol abuse, and poor social and occupational functioning, would be more conservative. It may be a question of helping that person to manage the symptoms more effectively, reducing their impact on quality of life, relationships, and general functioning.
Part of this book has been quite conventional. The reviews of the syndromes and treatments in relation to panic and agoraphobia, social phobia, specific phobias, obsessive–compulsive disorder, generalized anxiety disorder and posttraumatic stress disorder are brief, succinct overviews designed for busy clinicians. The discussion of general issues in the etiology and treatment of the anxiety disorders is also essential information for the practicing clinician. The Clinician Guides and the Patient Treatment Manuals are, however, quite unusual. These Guides and Manuals need to be placed in context.
There is an art and a science to good medical practice. Because the science tends to predominate, the art of treatment is seldom discussed, either at a general or a specific level. Elsewhere, we have called attention to the need for the elements of good clinical care to be made explicit. Good clinical care needs to be taught to trainee psychiatrists and clinical psychologists for use with patients for whom there is no specific remedy immediately applicable to their disorder (Andrews, 1993a). This book is different. It is about treating persons with chronic anxiety disorders who, if expertly treated with specific remedies, can be expected to recover. This recovery has been made possible by the scientific advances that have occurred in our understanding of the treatment of the anxiety disorders. Much of this book is focused on the cognitive behavioral treatments simply because the instructions for prescribing medications are relatively simple and, courtesy of advertising by the pharmaceutical industry, do not need repeating in a book on the treatment of anxiety disorders. The cognitive behavioral treatments are less well known and, being both nonproprietary and not for profit, are neither as widely promoted nor as readily available as are the drug therapies.
There is a greater problem. The amount of evidence for the efficacy of psychotherapy is less plentiful than the evidence that is routinely provided by the pharmaceutical industry to the national regulatory authorities in each country. This evidence is provided as part of the process of having products cleared for marketing and, in many countries, for subsidy. In the first edition of this book, much of the evidence about the efficacy of cognitive behavioral therapy came from trials in which the progress of treated groups were compared to their own pretreated status, or else were compared to the progress of wait-list or no treatment control groups.
After formal diagnosis and assessment, two issues must be addressed before treatment is planned. First, the clinician, by conducting a thorough behavioral analysis, must identify the factors that trigger and maintain the panic attacks and the avoidance behavior. Second, the clinician must consider the eVects of comorbid disorders on treatment.
The general principles and practice of behavioral analysis have been outlined elsewhere (Kirk, 1989;Schulte, 1997). However, in panic disorder and agoraphobia there are unique details to be considered. In terms of the antecedents of panic attacks, it is necessary to evaluate the physical and psychological triggers. These typically include situations previously associated with panic, certain physical sensations, and particular worrying thoughts (e.g., “Oh no! fihat if I had a panic attack right now?”). In addition, panic attacks will be more likely to occur when the person has been made more physically aroused as a result of being anxious, stressed, hot, smoking, drinking alcohol, taking stimulant drugs (e.g., coffee), and so on. In addition, panic attacks appear more likely when the individual is “run down”, perhaps because of illness (e.g., flu), physical and psychological stress (e.g., childbirth), or sleep deprivation. Once a listing of antecedents has been made, the consequences of panic attacks need to be identified. The consequences can be divided into three categories. First, individuals may respond to panic attacks with avoidance behavior. Commonly avoided agoraphobic situations have been described earlier, but for present purposes it is worth noting that identifying the cognitive link between panic attacks and avoidance will facilitate cognitive behavioral treatment (e.g., “I avoid crowded trains because the air may run out when everyone is breathing it”). Second, the subtle avoidance strategies (e.g., the use of safety signals) need to be identified. Finally, the social consequences of avoidance need to be evaluated. For instance, individuals with dependent traits may welcome the increased support given as a consequence of panic attacks and become more dependent. Such behavioral patterns need to be identified to ensure they do not inhibit progress in treatment.
Management of comorbid disorders
The most frequently comorbid axis I disorders are the other anxiety disorders, especially social phobia (Sanderson et al., 1990). One advantage of cognitive behavioral interventions is their applicability to all the anxiety disorders, in that each disorder responds to various combinations of anxiety-management and exposure strategies.