Elsevier

Behavior Therapy

Volume 50, Issue 6, November 2019, Pages 1042-1052
Behavior Therapy

Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression

https://doi.org/10.1016/j.beth.2018.12.005Get rights and content

Highlights

  • The study employed time-lagged segment analyses of session-by-session measures

  • Decentering and reappraisal were explored as mediators of ERT

  • Decentering and reappraisal temporally preceded symptom reduction

  • The reverse direction, where mediators were predicted by outcomes, was nonsignificant

Abstract

Emotion Regulation Therapy (ERT) has demonstrated efficacy in both open and randomized trials for generalized anxiety disorder (GAD) with and without co-occurring depression. An important goal in ERT is to teach clients adaptive emotion regulation, including healthier metacognitive abilities such as decentering and cognitive reappraisal. A few studies thus far have demonstrated a mediating role for these metacognitive abilities in other cognitive behavioral therapies (CBTs) for GAD. However, a drawback to most of these has been the ability to demonstrate a causal role for improved metacognitive abilities in outcome. In the present study, we utilized multilevel time-lagged segment analyses to explore the temporal dynamics between session-by-session changes in metacognition and anxiety outcomes from ERT. Thirty-one young adults diagnosed with GAD with and without co-occurring depression received 16 sessions of ERT. Prior to each session, participants completed questionnaires pertaining to metacognition (i.e., decentering and cognitive reappraisal) and anxiety symptoms (i.e., worry, trait anxiousness, and generalized anxiety). Changes in decentering temporally preceded changes in worry and trait anxiousness of a medium to large magnitude, and changes in cognitive reappraisal temporally preceded changes in all three outcomes of a medium to large magnitude. The reverse direction, where mediators were predicted by outcomes, was nonsignificant. These findings support the notion that adaptive metacognitive emotion regulation is involved in reducing worry and anxiety in GAD. Having a clearer understanding of the temporal dynamics between metacognitive abilities and symptoms of anxiety can inform and improve not only ERT but other CBTs for GAD, as well.

Section snippets

Participants and Procedures

Participants (N = 31) were treatment-seeking young adults (age between 18 and 29 years old), enrolled in a large, urban, and diverse university in the northeastern United States. The main inclusion criterion was the presence of a GAD diagnosis (primary or secondary). Other comorbid mood and anxiety disorders were allowed. Current and lifetime diagnostic history was determined with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002).

Results

Participants’ mean age was 22.3 years old (SD = 2.5), the majority was female (n = 22, 71.0%), and demonstrated racial, ethnic, and sociodemographic diversity (for more details see Renna et al., 2018). Of the 31 participants in the study, 97% (n = 30) had a primary or co-primary diagnosis of GAD, and 3% (n = 1) had GAD as a secondary diagnosis. Co-primary MDD was present in 19% (n = 6) of participants, while 13 patients endorsed a secondary diagnosis of MDD. One participant was prescribed a

Discussion

Individuals with GAD demonstrate both excessive worry and lack of healthy metacognitive skills. Accordingly, CBTs for GAD include a variety of metacognitive components aimed at improving metacognitive abilities (Cuijpers et al., 2014, Hayes-Skelton et al., 2013, Mennin et al., 2018, Wells et al., 2010). However, although metacognitive skills are considered crucial in producing change in these treatments for GAD, much is yet to be understood in terms of how and why these treatments work.

Conflict of Interest Statement

The authors declare that there are no conflicts of interest.

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      Given the embedment of mediation studies in parent trials with the primary aim of establishing main effects, study designs often only include pre- and post-assessments of the putative mediators and outcome, which precludes the ability to establish temporal precedence. As an alternative to this, a recent open trial, investigating mediators of the effect of ERT on generalized anxiety disorder (GAD) with and without comorbid depression, employed so-called time-lagged segment models, where the mediator at sessionX, controlled for sessionX-1, predicts outcome at sessionX+1, controlled for outcome at sessionX (O'Toole, Renna, Mennin, & Fresco, 2019). With no overlap in time between segments, the study ensured temporal precedence and demonstrated how changes in decentering preceded changes in anxiety outcomes.

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      These findings suggest that future studies of decentering, as a beneficial trait, should consider the capacity for taking an observer perspective (including meta-awareness and disidentification from internal experience) separate from the capacity for regulating thought content. It is possible that differential associations with other outcomes, such as well-being or psychopathology, could be found as has been shown in previous research where individuals with general anxiety disorder whose improvements in the observer perspective aspect of decentering was associated with reductions in anxiety symptoms (O'Toole et al., 2019). Whilst transcendent life reflection did not align with the 3-process model of decentering (Bernstein et al., 2015), it was a factor represented by items from a measure that has been used to measure decentering.

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    David M. Fresco was supported by National Heart, Lung, and Blood Institute Grant R01HL119977, National Institute of Nursing Research Grant P30NR015326, and National Center for Complimentary and Integrative Health Grant 1R61AT009867.

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