Elsevier

General Hospital Psychiatry

Volume 61, November–December 2019, Pages 111-115
General Hospital Psychiatry

Changes in positive affect in cognitive-behavioral treatment of anxiety disorders

https://doi.org/10.1016/j.genhosppsych.2019.06.008Get rights and content

Abstract

Objective

This study evaluated changes in positive affect within cognitive-behavioral treatments (CBT) for anxiety disorders. It was hypothesized that there would be significantly greater increases in positive affect in CBT conditions compared to the waitlist, and particularly higher in the Unified Protocol (UP) than the single disorder protocols (SDP) given the UP's focus on emotions (including positive emotions) rather than symptoms.

Method

Patients with heterogeneous anxiety disorders (N = 223) were randomly assigned to the UP, SDP or waitlist. Linear mixed model regression (intent to treat) analyses were used to compare change in positive affect, quality of life, and savoring between patients in the treatment conditions (UP and SDP) versus waitlist conditions. Between condition effect sizes were calculated to assess the magnitude of difference within conditions at post-treatment.

Results

Results indicated a significant Group (treatment vs. waitlist) × Time (pre- post-treatment) interaction (F(1, 154.36) = 6.75; p = .01) for positive affect in which the treatment group showed significant improvements in positive affect pre- to post-treatment (ESsg = 0.37, SEsg = 0.09, 95% CI [0.20: 0.54]) and the waitlist condition did not. There were no differences between UP and SDP conditions in positive affect at baseline or at post-treatment.

Conclusions

These results suggest CBT, which typically focuses on reductions in negative affect, may also improve positive affect. The importance of future research evaluating, targeting, and improving positive affect in CBT trials is discussed.

Clinicaltrials.gov Identifier: NCT01243606

Introduction

While negative affect has been widely studied in relation to the development and treatment of emotional disorders (i.e., anxiety, mood, and related disorders [1]), the role of positive affect in connection to these conditions remains under-studied [2]. In general, positive affect refers to pleasant states of emotion, including joy, enthusiasm, confidence, and love [3]. Of note, positive affect is not simply the opposite of negative affect, but rather an independent construct not always inversely correlated with negative affect [[4], [5], [6]], although this has historically been debated in the literature with others considering them to be bipolar ends of the same dimension [7], and still others integrating these perspectives within a hierarchical model [8].

Positive affect has been associated with many health-related benefits in clinical and non-clinical populations. For instance, research suggests it may increase stress resilience and overall mental health and well-being [2,9,10]. In addition, positive affect has been associated with improved immune system functioning and reductions in pain levels [11,12]. Furthermore, more frequent instances of positive affect have been linked to improvements in overall functioning, such as an increase in problem-solving skills [13,14] and goal attainment [15], and academic achievement [16] .

Emotional disorders are associated with deficits in positive emotions [17,18], over and above the contributions of negative affectivity [1]. This finding may be due to positive emotion dysregulation [2,19], specifically through excessive dampening of positive emotional experiences when they occur [20]. Theoretical accounts have postulated treatments aimed at enhancing positive affect may hold many benefits, such as decreasing the impact of negative emotional experiences, enhancing overall functioning [21,22], and potentially even offsetting risk of relapse [19]. Further, preliminary research has demonstrated that explicitly targeting positive affect in treatment through the addition of therapeutic strategies or modules, such as well-being therapy [23], quality of life therapy [24], positive psychotherapy [25], and a positive emotion regulation augmentation [26] can lead to improvements in positive affect. Taken together, literature suggests there is a benefit to increasing positive affect in treatment.

Despite the advantages of addressing positive affect for both emotional and physical health, the majority of psychotherapy interventions continue to focus on targeting negative affect. Correspondingly, most studies of leading treatments for emotional disorders remain focused on evaluating outcomes of reduced symptoms of negative affectivity [2], rather than increased positive affectivity. The question remains if and how existing treatments for emotional disorders change positive affect even though it is not their central focus. Cognitive-behavioral therapies (CBT) might be well-suited for enhancing positive affect [19], as specifically changing thought patterns and/or behavioral responses may lead to more positive interpretations and a willingness to approach, or even savor experiences previously considered negative. For a detailed review of cognitive-behavioral strategies aimed at enhancing positive emotion regulation, see Carl et al. [19].

Transdiagnostic treatments (e.g., the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders [UP]; [27,28], which focus on the broad range of emotions rather than symptoms associated with a specific disorder, may be particularly helpful as they provide a platform to specifically discuss the range of emotions (including positive) across diagnoses. In the emotional disorder framework, an individual attempts to escape or avoid the aversive experience of frequent and intense negative emotions, which often backfires, resulting in continuation of this pattern [29]. This framework extends to positive emotions as well; some individuals find the experience of positive emotions distressing (e.g., worry about what might happen if one let's their down and feels happy, feel that they don't deserve to feel joy, feelings of happiness reminds them of times they felt happier) and engage in efforts to dampen or avoid such experiences. The UP then targets these patterns with each core skill (understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotion exposures) aimed at changing the maintenance cycle of one's emotional experience its aversive associations, rather than an often disorder-specific context [27]. This emotion-focused approach coupled with the integration of many traditional CBT skills in one unified intervention makes the UP a potential treatment for addressing deficits in positive affect.

The present study aims to explore changes in positive affect within a large randomized controlled trial comparing various CBT protocols to a waitlist control condition. It was hypothesized 1) there would be significantly greater increases in positive affect amongst those in the treatment conditions compared to the waitlist condition and 2) these increases in positive affect would be higher in the UP condition than the single disorder protocol (SDP) condition (given the UP's explicit focus on emotions, rather than symptoms). Additionally, we predicted 3) increases in positive affect would be associated with decreases in anxiety, depression, negative affect, and clinical severity, as well as increases in quality of life and savoring beliefs, amongst those in treatment conditions.

Section snippets

Participants

Participants (N = 223) were enrolled in a treatment trial and met criteria for a principal (most interfering and distressing) diagnosis of panic disorder, generalized anxiety disorder, social anxiety disorder, or obsessive-compulsive disorder. On average patients were 31.06 (SD = 10.99) years old and the majority (n = 124) identified as female and Caucasian (n = 186). Additional inclusion/exclusion criteria and details of the sample have been described elsewhere (see Barlow et al. [23]).

Procedure

Once

Statistical analyses

Analyses were conducted in SPSS 20.0. Independent samples t-test were conducted to assess for differences across study conditions. Correlations were used to examine the associations between positive affect and related constructs at baseline within the full sample. Correlational analyses were also used to examine associations between change in positive affect and change in these related constructs. Linear mixed model regression (intent to treat) analyses were used to compare change in positive

Results

At baseline, the sample evidenced significant deficits in positive affect (M = 28.70, SD = 7.26), falling a standard deviation below non-clinical norms (M = 35.0, SD = 6.4; [38]). There were no significant differences between UP (M = 31.56, SD = 8.41) and SDP (M = 31.99, SD = 7.16) conditions on levels of positive affect at baseline (t(174) = 0.71, p = .48) and post-treatment (t(117) = −0.30, p = .76), therefore data were collapsed across UP and SDP conditions for all further analyses in order

Discussion

The present studied evaluated change in positive affect within a randomized controlled trial comparing cognitive behavioral therapies to a waitlist control condition. Results suggest, consistent with study hypotheses, that those who received CBT showed significant improvements in positive affect pre- to post-treatment, while significant changes were not observed amongst those in the waitlist condition. Furthermore, change in positive affect was significantly associated with related constructs

Acknowledgements

This study was funded by grant R01 MH090053 from the National Institute of Mental Health.

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