3.

Semantic Priming and Disorder Bias in Social Anxiey

Cogn Ther Res (2014) 38:2332 DOI 10.1007/s10608-013-9582-8
Published online: 19 September 2013
Springer Science+Business Media New York 2013
Baland Jalal Nader Amir - J oint Doctoral Program in Clinical Psychology, San Diego
State
University/University of California at San Diego, 6386 Alvarado
Ct, Suite 301, San Diego, CA 92120, USA
Abstract
Cognitive models of social anxiety posit that recurrent interpretation of ambiguous information
as threatening is involved in maintaining symptoms of social anxiety. Researchers have used
several methodologies to assess interpretation bias in social anxiety, including homographs (i.e.,
words with two meanings, e.g., chicken-poultry and chicken-scared). In the current study, we
examined the effects of priming in 21 individuals with social anxiety disorder and 21 non-
anxious control partic-ipants. All participants completed a homograph priming paradigm. In this
task, participants see a fixation cross followed by a homograph prime. This homograph is then
followed by related or unrelated neutral, physical, or social threat target words examining the
priming effect of the homograph on the target. As hypothesized, for non-threat targets, we
obtained the typical priming effect in all participants. Moreover, we found that individuals with
social anxiety disorder were slower to respond to related social threat targets compared to
unrelated social threat targets when these targets were preceded by socially relevant homographs.
These data suggest that individuals with social anxiety disorder inhibit social threat meaning of
ambiguous primes perhaps due to a vigilance-avoidance pattern of threat relevant information.
Introduction
Both classic as well as more recent cognitive models of social anxiety stress that recurrent
interpretation of ambiguous information as threatening plays a pivotal role in maintaining
anxiety (e.g., Clark and Wells 1995; Hof-mann 2007; Rapee and Heimberg 1997; Roth et al.
2001; Stopa and Clark 2000; Laposa et al. 2010). One such example is a recent comprehensive
maintenance model of social anxiety disorder (SAD) (Hofmann 2007) which posits that social
apprehension in SAD is associated with unrealistic social standards, for instance overestimation
of negative consequences of a social encounter. Consistent with these models, a number of
studies have found that individuals with SAD display an interpretation bias (Amir et al. 1998a, b;
Foa et al. 1996; Huppert et al. 2007) for threat-relevant information.
As interpretation bias is driven by automatic thoughts, self-report measures may have limited
utility in assessing them. Therefore, researchers have devised alternative methodologies to assess
automatic interpretation bias in anxious individuals (e.g., homographs, homophones, rank
ordering and scenarios; Amir et al. 2005, 1998a, b; Math-ews et al. 1989; Constans et al. 1999).
One such paradigm is the homograph task that examines the effects of inter-pretation on priming.
A definition of a homograph is a word with at least two different meanings (e.g., chicken-poultry
and chicken-scared).
For example, in a seminal study, Richards and French (1992) examined semantic activation in
response to ambiguous homograph primes in anxious and non-anxious individuals. These
homographs had one threat and one non-threat meaning and were then followed by targets related
to either their threat or their non-threat meaning, or by unrelated targets (we will refer to
non-threat/neutral meanings of homograph primes as non-threat). Partici-pants performed a
lexical decision task (deciding whether a letter string is a word or a non-word) on the target letter
strings. The reaction time to decide whether the letter string was a word or non-word indexed the
interpretation of the homograph primes.
The targets in Richards and Frenchs study were: (1) related to the threat meaning of the
homograph (arms-weapons), (2) related to the non-threat meaning of the homograph (arms-legs),
(3) unrelated and non-threat tar-gets (arms-wind), or (4) unrelated and threat targets (arms-
stress). The authors only analyzed correctly identified words and discarded non-word trials. The
time between the presentation of the homograph prime and the target, stim-ulus onset
asynchronies (SOAs), was 500, 750, or 1250 ms.
As hypothesized, both the high and low anxious groups showed facilitation for both the threat
meaning and non-threat meaning of the homograph when compared to unrelated primes at 500
ms SOA. At 750 ms SOA, however, only anxious individuals displayed significant priming
effects for the threat-related meanings of the homograph primes; a similar trend emerged at 1250
ms SOA. Overall these results suggest that anxious individ-uals appear to lock on to a
threatening interpretation if one is available (Richards and French 1992, p. 519). Thus, anxious
individuals seem to demonstrate an interpretative bias in the processing of threat related
homographs.
On the other hand, similar studies that have examined the role of ambiguity and processing of
threat relevant information in anxiety have used alternative applications of the homograph
paradigm. For example, Hazlett-Ste-vens and Borkovec (2004) who used a modified version of
Richards and Frenchs (1992) homograph paradigm found that participants with GAD relied on
the antecedent words to interpret the homograph primes with threat-related meanings as opposed
to non-anxious controls. Amir et al. (2005), who used a modified version of Simpson and Kangs
(1994) homograph paradigm, on the other hand found that non-anxious controls, unlike socially
anxious participants, displayed faster reaction times naming a target primed by a homograph
with the same meaning activated in two successive trials than naming a target primed by an
unrelated word, suggesting faulty learning mechanisms in social anxiety. Unlike Richards and
Frenchs (1992) use of the homograph paradigm, these cited studies have elaborated on the basic
use of this paradigm by introducing additional cues or relying on multiple trials.
While Richards and Frenchs (1992) results are consistent with current models of anxiety
suggesting a facilitation for threat related information, a number of issues remain regarding the
clinical utility of this paradigm. First, Richards and French used anxious undergraduates to
examine the role of interpretation bias in anxiety. However, it is essential to also examine these
information processing biases in clinical samples. For example, a vigilance-avoidance pattern of
information processing has been found in clinical samples (e.g., Amir et al. 2001; Amir et al.
1998a, b; Mogg et al. 1987). This two-stage model of information processing proposes that
anxiety is maintained by an initial faster detection (i.e., automatic hypervigi-lance) of threat
relevant information followed by an enhanced strategic avoidance of such information (Mogg et
al. 1997). For example, Amir et al. (2001) found using the retrieval practice paradigm that
individuals with SAD do not learn threat-related information as well as NACs indicating that
clinically anxious individuals may strate-gically be inhibiting threatening information once made
available. Similarly, Amir et al. (1998a, b), found that individuals with generalized social anxiety
disorder showed initial activation of inappropriate meanings of socially relevant homographs
followed by later inhibition of these meanings. On the other hand, Mogg et al. (1997) failed to
find support for this vigilance-avoidance model of anxiety in non-clinically anxious participants,
which led the authors to conclude that vigilance-avoidance pattern of processing, may pertain
primarily to clinical levels of anxiety. (p. 302).
In the current study, we examined the effect of priming in individuals with SAD and NACs
using Richards and Frenchs (1992) homograph paradigm. Moreover, in addi-tion to extending
Richards and Frenchs study from a college student population to a clinical population, we also
included a category of homographs that had either a socially threatening meaning or a non-threat
meaning, thus allowing us to examine semantic activation in face of both physical and social
threat. We hypothesized that both the SAD and NAC group respectively would show facilitation
for related versus unrelated targets of non-threat homo-graph primes thus displaying a basic
priming effect. Moreover, in line with Richards and French (1992) we hypothesized that
individuals with SAD would be faster to respond to related social threat words compared to unre-
lated social threat words when preceded by social homographs.
Discussion
As expected, for non-threat words we obtained a priming effect for both the SAD and NAC
group respectively. That is, the SAD and NAC group showed facilitation for related versus
unrelated targets of non-threat homograph primes. This finding is not surprising in that
regardless of level of anxiety the prime is used to direct resources to a particular memory
representation, and when presented with a semantically unrelated target, time is consequently
needed for redirection of cognitive resources. The finding that the SAD group responded faster
to related versus unrelated targets of homographs with non-threat meanings further suggests that
when individuals with SAD are presented with homograph primes that do not carry any
inherently threatening meanings, their spread of automatic activation is not subject to cognitive
biases that would cause them to otherwise inhibit the semantically related meaning and favor the
unrelated meaning.
In the current study, we found that individuals with SAD were slower to respond to related social
threat words compared to unrelated social threat words when preceded by social homographs.
In summary, our results suggest that the tendency for individuals with SAD to negatively
skew judgments of ambiguous information may stem from strategic avoidance of this
information in the first place. This avoidance of potentially socially threatening information may
lead to partial recollection in memory (e.g., of a blind dates yawn), partial recollection that are
later subject of negative interpretation bias (Amir et al. 2001).

4. Emotion Differentiation and Emotion Regulation in High and Low Socially
Anxious Individuals: An Experience-Sampling Study
Cogn Ther Res
DOI 10.1007/s10608-014-9611-2
Springer Science+Business Media New York 2014 - Published online: 13 March 2014
Mia Skytte OToole Morten Berg Jensen Hanne Nrr Fentz Robert Zachariae Esben
Hougaard

Abstract
The present study explored when and how emotional difficulties and poor quality of life arise in
the everyday lives of socially anxious individuals. 264 fresh-men-year college students
completed an online survey for 11 consecutive days. Comparing individuals high (HSA) and low
in social anxiety, results revealed that irrespective of daily positive emotion differentiation
ability, HSAs engaged daily emotion suppression strategies, pointing to inflexible emotion
regulation. Furthermore, HSAs with poor daily negative emotion differentiation used the least
daily cognitive reappraisal. Finally, both expressive suppression and cognitive reappraisal
showed group-specific effects on daily positive affect. Daily expressive suppression was more
strongly associated with diminished daily positive affect in HSAs, and HSAs benefited less in
terms of daily positive affect from daily use of cognitive reappraisal. Based on these findings,
emotion differentiation ability and emotion regulation appear relevant clinical targets for
individuals with social anxiety disorder
Interaction Effects
Further regarding cognitive reappraisal, as indicated by a statistically significant two-way
interaction term of a small to medium magnitude, negative emotion differentiation ability may
play a role in explaining the mixed results regarding cognitive reappraisal. Trait social anxiety
and negative emotion differentiation interacted in the predic-tion of daily cognitive reappraisal.
HSAs with relatively poor negative emotion differentiation were less likely to use cognitive
reappraisal than HSAs with good negative emotion differentiation, although this difference was
larg-est for LSAs. Thus, where the between-group analyses showed no differences between
HSAs and LSAs in their overall daily use of cognitive reappraisal, there was a between-group
difference when taking negative emotion differentiation ability into account. The same
interaction term did not predict the other emotion regulation strategies, indicating similar
associations between negative emotion differentiation and both external and internal suppression
in the two groups.
Daily positive emotion differentiation interacted with trait social anxiety in the prediction of
expressive suppres-sion. Results revealed that positive emotion differentiation ability was not
associated with expressive suppression in HSAs. However, in the LSA group, individuals
engaged in less expressive suppression when they reported better positive emotion differentiation
ability. Thus, the ability to differentiate between positive emotions did not predict less emotion
suppression in HSAs. One reason may be that HSAs or individuals with SAD have been
described as being inflexible in their emotion regulation (Kashdan and Collins 2010), in that they
persistently engage in emotion suppression (e.g. Dalrymple and Herbert 2007; Turk et al. 2005;
Werner et al. 2011), possibly doing this irrespective of a relative greater awareness of positive
emotions..
None of the interaction terms predicted daily social satisfaction, which indicates that although
HSAs in general experienced less daily social satisfaction than LSAs, the association between
daily use of the investigated emotion regulation strategies and daily social satisfaction did not
differ between the two groups. Conclusions
In conclusion,
The present study may contribute to our understanding of when social anxiety leads to
difficulties with emotion regulation and poor quality of life. Positive and negative emotion
differentiation ability had a different influence on emotion regulation in the two groups. Irre-
spective of positive emotion differentiation ability, HSAs engaged expressive suppression,
pointing to inflexible emotion regulation. Furthermore, although the ability to differentiate
between negative emotions made the largest difference for LSAs, HSAs with poor negative
emotion differentiation used less cognitive reappraisal. Both expressive suppression and
cognitive reappraisal showed group-specific effects on positive effect. Daily expressive
suppression was more strongly associated with less daily positive affect in the HSAs, and HSAs
benefitted less in terms of daily positive affect from using daily use of cognitive reappraisal. The
detected associations need to be replicated in a formal clinical sample of individuals with SAD,
however, the present study points to several aspects of the emotional life of HSAs that may also
be relevant in a clinical setting..
5. Perceived Control is a Transdiagnostic Predictor of Cognitive
Behavior Therapy Outcome for Anxiety Disorders
Cogn Ther Res (2014) 38:1022 DOI 10.1007/s10608-013-9587-3
Published online: 15 October 2013Springer Science+Business Media New York (outside the
USA) 2013
Matthew W. Gallagher Behavioral Science Division, National Center for PTSD
(116B-2), VA Boston Healthcare System, 150 South Huntington
Avenue, Boston, MA 02130-4817, USA
Kristin Naragon-Gainey University at Buffalo, The State University of New York,
Buffalo, NY, USA
Timothy A. Brown
Center for Anxiety and Related Disorders, Boston University,
Boston, MA, USA

Abstract
Perceived control has been proposed to be a general psychological vulnerability factor that
confers an elevated risk for developing anxiety disorders, but there is limited research examining
perceived control during cog-nitive-behavioral therapies (CBT). The present study examined
whether treatment resulted in improvements in perceived control, and the indirect effects of CBT
on changes in symptoms of obsessive-compulsive disorder, social phobia, generalized anxiety
disorder, and panic disorder via changes in perceived control. Participants (n 606) were a
large clinical sample presenting for treatment at an outpatient anxiety disorders clinic. Partic-
ipants completed a series of self-report questionnaires and a structured clinical interview at an
intake evaluation and at two follow-up assessments 12 and 24 months later, with the majority of
participants initiating CBT between the first two assessments. Results of latent growth curve
models indicated that individuals initiating CBT subsequently reported large increases in
perceived control and significant indirect effects of treatment on intraindividual changes in each
of the four anxiety disorders examined via intraindividual changes in perceived control. These
results suggest that the promotion of more adaptive perceptions of control is associated with
recovery from anxiety disorders. Fur-thermore, the consistent finding of indirect effects across
the four anxiety disorders examined underscores the transdiagnostic importance of perceived
control in pre-dicting CBT outcomes.
The majority (76.2 %) of participants chose to initiate CBT treatment at CARD following the
initial assessment. The CBT treatment provided at CARD consisted of a time-limited course
(typically a maximum of 16 sessions) of a specific CBT protocol for individuals principal
diagnosis (e.g., Mastery of your anxiety and panic, Barlow and Craske 2006, for individuals with
panic disorder). This treatment was delivered by a mix of predoctoral and postdoctoral therapists,
with the majority of treatment delivered in individual sessions. Individuals who initiated
treatment at CARD were asked about the use of specific techniques during treatment at the 12-
month follow-up (T2) assess-ment. 23.1 % reported the use of relaxation, 32.3 % reported the
use of breathing control techniques (e.g., dia-phragmatic breathing), 72.0 % reported the use of
cognitive restructuring techniques, 58.4 % reported the use of situa-tional exposure exercises,
11.3 % reported the use of interoceptive exposure exercises, 10.7 % reported the use of imaginal
exposure exercises, and 16.7 % reported the use of strategies to prevent safety behaviors. The
remaining 144 (23.8 %) of participants did not initiate CBT at CARD and were included in our
analyses as a control condition.
Discussion
There is extensive research demonstrating the importance of perceived control as a
transdiagnostic vulnerability factor for anxiety disorders (Barlow 2002; Gallagher et al. 2013).
Consistent with our hypotheses, previous research, and the triple vulnerabilities model, we found
moderate to large associations between perceived control and the four anxiety disorder constructs
examined at the initial evalua-tion. These findings support the notion that perceived control
regarding emotional experiences is an important, transdiagnostic predictor of symptom severity
across the anxiety disorders.
The present study also builds upon previous research by longitudinally examining the
associations between per-ceived control and anxiety disorders following the initia-tion of CBT.
Previous research has examined the role of perceived control during CBT for panic disorder
(Meuret et al. 2010), but the present study is the first to examine the role of perceived control
during the treatment of multiple anxiety disorders. Our results indicate that, in a large,
diagnostically diverse clinical sample of patients present-ing to an anxiety disorders specialty
clinic, those individ-uals who initiate a course of CBT subsequently report more adaptive
perceptions of control. Although the absence of repeated assessments of perceived control during
treatment precludes more definitive conclusions regarding the timing of change, our results are
nevertheless promising. As hypothesized, intraindividual changes in perceived control across 2
years of follow-up assessments were robust pre-dictors of intraindividual changes in symptoms
of OCD, PDA, SOC, and GAD. Also as hypothesized, our results demonstrated indirect effects
of CBT treatment on intra-individual changes in symptoms of OCD, PDA, SOC, and GAD via
intraindividual changes in perceived control. The most noteworthy aspects of these findings were
the con-sistency of the evidence of indirect effects across the four anxiety disorders examined
and the very large magnitude of the observed effects of changes in perceived control on changes
in anxiety symptoms.
The strengths of the present study include the use of a large and diverse clinical sample and
the use of assess-ment procedures that involved both self-report and clini-cian-rated measures of
anxiety. These characteristics strengthen conclusions regarding the relevance of
perceived control as a transdiagnostic predictor of CBT outcomes, as the reported effects are
unlikely to be artifi-cially inflated by method effects and do not appear to be unique to a
particular anxiety disorder.
Conclusions
There have been increasing efforts in recent years to identify mechanisms of change of
empirically supported treatments as it has become clear that, although we have extensive
evidence of efficacy for many treatments, rela-tively little is known about how or why our
treatments produce change (Kazdin 2007). The present study provides promising evidence that, in
addition to playing an important role in the development of anxiety disorders, perceived control
may play an important role in CBT for anxiety disorders. Although the present study did not
include any examination of the effects of specific treatment protocols on perceived control, our
results are consistent with recent trends in the development of treatment protocols for anx-iety
disorders. There is promising recent evidence of the utility of transdiagnostic treatment protocols
for anxiety disorders such as the Unified Protocol (UP; Barlow et al. 2011; Ellard et al. 2010;
Farchione et al. 2012). The UP was designed to target shared etiological factors such as
perceived control and neuroticism that are thought to play an important role across emotional
disorders (Allen et al. 2008). Our results are consistent with the theoretical framework of the UP
that emphasizes commonalities across the anxiety disorders, and also demonstrate the utility of
focusing on constructs with transdiagnostic rele-vance such as perceived control.