Publications by authors named "Neil A Rector"

63 Publications

Technology supported mindfulness for obsessive compulsive disorder: The role of obsessive beliefs.

J Anxiety Disord 2021 Apr 15;81:102405. Epub 2021 Apr 15.

Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

The current study examined the association of OCD symptoms and OCD belief domains, for individuals engaged in Technology Supported Mindfulness training (TSM) using an EEG-based biofeedback device (called "Muse") that permits individuals to engage in home based mindfulness meditation practices. In this randomized controlled study, treatment-seeking participants with a principal DSM-5 diagnosis of OCD (N = 71) were randomly assigned to eight weeks of: 1) a meditation program involving daily use of the "Muse" device, or 2) wait list control. At weeks 1, 4, and 8, participants completed self-report measures of OCD symptoms (YBOCS: Yale-Brown Obsessive Compulsive Scale) and OCD beliefs (OBQ; OCCWG, 2005). Latent Difference Score (LDS) models indicated that there was no significant longitudinal relationship between OBQ "Responsibility/Threat" (OBQ R/T) scores and OCD symptoms. The analysis of OBQ "Perfectionism/Certainty" (OBQ P/C) and OCD symptoms demonstrated a significant reciprocal relationship between these two variables, in which OCD symptoms predicted subsequent increases in OBQ P/C and vice versa. The analysis of OBQ "Importance/Control of Thoughts" (OBQ I/C) and OCD symptoms demonstrated a significant reciprocal relationship between these two variables, in which OCD symptoms predicted subsequent increases in OBQ I/C and vice versa. The analysis of OBQ domains and EEG derived attentional changes demonstrated a significant association between OBQ P/C and Alpha band frequencies. These results clarify the association of OBQ belief domains, OCD symptom change and EEG derived indicators of attention during TSM.
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http://dx.doi.org/10.1016/j.janxdis.2021.102405DOI Listing
April 2021

A Brief Mindfulness-Based Cognitive Therapy (MBCT) Intervention as a Population-Level Strategy for Anxiety and Depression.

Int J Cogn Ther 2021 Apr 20:1-19. Epub 2021 Apr 20.

Department of Psychiatry, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario M4N 3M5 Canada.

Mindfulness-based interventions (MBIs) have emerged as clinically effective interventions for anxiety and depression although there are significant barriers to their access in the general population. The present study examined the effectiveness of a 5-week abbreviated mindfulness-based cognitive therapy (MBCT) intervention for a physician-referred, treatment-seeking, community sample ( = 54) with mood and/or anxiety symptom burden. Treatment effects demonstrated significant reductions in mood and anxiety symptom severity and significant increases in general well-being. Observed effect sizes were generally large, with high response and remission rates. The present study offers preliminary support that an abbreviated MBCT protocol can offer large treatment effects for decreasing mood and anxiety symptoms and could potentially offer an effective population-level strategy to improve cost-effectiveness and access to care.
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http://dx.doi.org/10.1007/s41811-021-00105-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057287PMC
April 2021

Technology supported mindfulness for obsessive compulsive disorder: Self-reported mindfulness and EEG correlates of mind wandering.

Behav Res Ther 2021 01 21;136:103757. Epub 2020 Oct 21.

Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

Cognitive Behavior Therapy (CBT) incorporating Exposure with Response Prevention (ERP) is the most efficacious treatment intervention for Obsessive Compulsive Disorder (OCD); however, there is a growing literature indicating that mindfulness based approaches can be beneficial in terms of managing OCD symptoms. The current study examined the potential benefits of using a consumer grade EEG-based biofeedback device (called "Muse") that permits individuals to engage in mindfulness meditation practices while at home. In this randomized controlled study, participants with a principal DSM-5 diagnosis of OCD (N = 71) were randomly assigned to eight weeks of: 1) a meditation program involving daily use of the "Muse" device, or 2) waitlist control. At weeks 1, 4, and 8, participants completed a five minute "open monitoring" practice while EEG data was recorded, and they completed self-report measures of mindfulness (FFMQ: Five Factor Mindfulness Questionnaire) and OCD symptoms (YBOCS: Yale-Brown Obsessive Compulsive Scale). Latent Difference Score (LDS) models demonstrated that the FFMQ "Non-Reactivity" facet and EEG-derived correlates of "Mind Wandering" (i.e., alpha, beta, but not delta or theta band power) were temporally associated with subsequent changes in YBOCS symptom scores. Participants in the Muse group (in comparison to the control group) experienced increased FFMQ "Non-Reactivity" and decreased mind wandering (increased alpha and beta band power), and in each case, these variables were associated with subsequent OCD symptom improvement. These results suggest that technology supported mindfulness training for OCD is associated with improvements in OCD symptoms, mindfulness and decreased mind wandering.
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http://dx.doi.org/10.1016/j.brat.2020.103757DOI Listing
January 2021

Excessive reassurance seeking in depression versus obsessive-compulsive disorder: Cross-sectional and cognitive behavioural therapy treatment comparisons.

J Anxiety Disord 2020 10 31;75:102280. Epub 2020 Jul 31.

Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Department of Psychiatry, Toronto, Ontario, Canada; University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada. Electronic address:

Excessive reassurance seeking (ERS) has been hypothesized as an important maintenance factor in depression and obsessive compulsive disorder (OCD). The present study examined the types of ERS in depression and OCD, the effects of CBT on ERS, predictors of ERS reduction, and the relation between ERS reduction and symptom change.

Method: Treatment-seeking participants diagnosed with a depressive disorder (N = 361) or OCD (N = 156) completed the Reassurance Seeking Scale (RSS) and symptom measures before and following CBT treatment. Measures of intolerance of uncertainty and distress tolerance were completed pre-treatment as potential predictors of ERS change.

Results: Individuals with depression demonstrated higher pre-treatment ERS related to social attachment compared to those with OCD. ERS significantly decreased over treatment in both groups and change in ERS predicted symptom change among both OCD and depression groups. Higher pre-treatment intolerance of uncertainty significantly predicted less ERS change regardless of diagnosis. Distress tolerance was not associated with ERS changes.

Conclusion: ERS is significantly related to symptom severity cross-sectionally as well as over treatment in depression and OCD, though types of ERS may differ. Higher intolerance of uncertainty may impede the reduction of ERS in CBT.
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http://dx.doi.org/10.1016/j.janxdis.2020.102280DOI Listing
October 2020

Preliminary Investigation of a Novel Cognitive Behavioural Therapy Curriculum on the Wellbeing of Middle Schoolers.

J Can Acad Child Adolesc Psychiatry 2020 May 1;29(2):66-75. Epub 2020 May 1.

Head, Mood and Anxiety Disorders Program, Department of Psychiatry, Sunnybrook Health Sciences Centre; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.

Objectives: A number of school-based interventions for preventing and attenuating symptoms of anxiety and depression in youth have been developed worldwide but evidence of their effectiveness is mixed. None of these curricula stem from existing children's literature, however, the Harry Potter (HP) series has been identified as potentially imparting Cognitive Behavioural Therapy concepts.

Methods: This study aimed to broadly capture, at an interim stage, the feasibility of a pilot HP curriculum aimed at imparting CBT skills to middle-schoolers in order to inform full development of the curriculum. The study design further included a non-randomized, Group (HP; Control) by Time (Baseline, Post-Intervention, Follow-up) mixed factorial approach retrospectively examining change in scores on a "Well-Being and Resiliency Survey" (WBRS) which assessed multiple symptomatic and social domains.

Results: In total, 232 grade seven and eight students participated in the curriculum over two years with no dropouts. Compared to 362 controls, there were no significant differences in WBRS scores between groups at post or one-year follow-up.

Conclusions: This pilot study demonstrated the feasibility of rapid and broad implementation of the intervention. Preliminary analyses showed no indication of effectiveness which may be the product of the intervention being in an interim stage during the study period and/or the retrospective design and limitations in data quality. Specifically, these results suggest that the WBRS may be a suboptimal instrument for measuring the effectiveness of this intervention. A prospective trial of the complete, revised curriculum with validated measures is required to provide an adequately assessment of its impact.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213921PMC
May 2020

Neuropsychological performance across symptom dimensions of obsessive-compulsive disorder: a comment on the state and critical review of the literature.

Expert Rev Neurother 2020 05 8;20(5):425-438. Epub 2020 Apr 8.

Anxiety Treatment and Research Clinic, St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.

: Obsessive-compulsive disorder (OCD) is a heterogeneous disorder, with multiple symptom presentations. Delineating the neuropsychological characteristics associated with previously identified symptom clusters may therefore be useful in assisting to better define symptom subtypes of OCD.: This review summarizes the existing literature on the assessment of neuropsychological performance in symptom-based dimensions of OCD. Results of 23 studies are described and the methodological issues and challenges present in this body of literature are discussed.: The current state of the literature precludes a meaningful meta-analysis of cognitive dysfunction across the breadth of symptom dimensions of OCD. This is due primarily to significant methodological differences observed between studies, both in terms of neuropsychological measures and symptom subtyping methods employed, and any resulting meta-analytic results would be biased by varying quality of evidence. Future studies addressing these limitations should include more consistent neuropsychology measures and methods of classifying OCD symptoms with the aim of reproducing the results of previous research to identify more concrete patterns of neuropsychological performance across dimensions; best practices and alternative approaches are discussed.
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http://dx.doi.org/10.1080/14737175.2020.1746644DOI Listing
May 2020

Filling the Gap for Obsessive-Compulsive Disorder Services in Canada: Implementing an Intensive Care Program.

J Nerv Ment Dis 2020 01;208(1):38-47

Frederick W. Thompson Anxiety Disorders Centre-OCD Intensive Treatment Services, Sunnybrook Health Sciences Centre.

Obsessive-compulsive disorder (OCD) is a significant psychiatric illness that can impact an individual in terms of their quality of life, functional abilities, and interpersonal relationships. Until recently, services for individuals with severe symptoms of OCD were limited within Canada. The Frederick W. Thompson Anxiety Disorders Centre at Sunnybrook Health Sciences Centre in Toronto, Canada, recently launched an intensive services program for individuals with severe symptoms of OCD. This article provides an overview of the steps that were taken to develop this program. Methods involved incorporation of information gathered from both service users and service providers of these models of treatment within North America and beyond. This article provides a potential treatment model for residential psychiatric treatment that can be applied to OCD and possibly other severe treatment refractory psychiatric illnesses in terms of methods used and generalizable key ingredients.
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http://dx.doi.org/10.1097/NMD.0000000000001075DOI Listing
January 2020

Effectiveness of intensive treatment services for obsessive compulsive disorder: outcomes from the first Canadian residential treatment program.

Int J Psychiatry Clin Pract 2020 Mar 31;24(1):59-67. Epub 2019 Oct 31.

Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Care Sciences, Toronto, Canada.

Obsessive-Compulsive Disorder (OCD) is a psychiatric illness that can result in debilitating symptoms and functional impairment. Until recently, individuals with severe OCD symptoms have not received appropriate services within the Canadian healthcare system. The Frederick W. Thompson Anxiety Disorders Centre launched an Intensive Services Residential treatment programme for OCD in July 2017 to meet the needs of the Canadian population. This paper sets out to demonstrate the effectiveness of this programme. This study incorporated quantitative and qualitative data collection. Quantitative data were analysed using paired sample -tests while qualitative data was transcribed and coded for emerging themes. Beneficial changes in symptomatology were found. Client narrative emphasised the importance of exposure response prevention (ERP), creation of an OCD community as well as enhanced functionality in clients' lives. Clients also commented on why they believed the treatment worked and points of potential improvement for discharge planning and programme organisation. This study adds to the growing body of evidence regarding the importance of intensive services for individuals experiencing severe symptoms of OCD. Enhancing accessibility to services and ensuring ongoing maintenance of gains will be important next steps in ensuring long-term recovery for individuals with severe symptoms of OCD.Key pointsIntensive services treatment for OCD has been found to be beneficial for clients and this paper demonstrates the first time this has been seen within a Canadian programme.Treatment provided decreased OCD severity and increased functionality and quality of life.Clients cited exposure and response prevention work as a key ingredient in their recovery.Our programme is always in an ongoing state of quality improvement, ensuring client engagement and satisfaction.
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http://dx.doi.org/10.1080/13651501.2019.1676450DOI Listing
March 2020

Reassurance seeking in the anxiety disorders and OCD: Construct validation, clinical correlates and CBT treatment response.

J Anxiety Disord 2019 Oct 22;67:102109. Epub 2019 Jun 22.

Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Suite F327, M4N 3M5, Toronto, Canada.

Background: Reassurance seeking has been hypothesized to be a key factor in the maintenance of anxiety and obsessive-compulsive disorders according to contemporary cognitive-behavioural therapy (CBT) approaches. The present study sought to examine the structure, clinical correlates, and malleability of reassurance seeking in the context of CBT treatment.

Methods: Treatment-seeking participants (N = 738) with DSM-IV-TR (American Psychiatric Association, 2000) panic disorder with agoraphobia (PD/A), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) completed the Reassurance Seeking Scale (RSS) with other symptom measures prior to and following CBT treatment.

Results: A confirmatory factor analysis supported a three factor solution: the need to seek excessive reassurance regarding decisions, attachment and the security of relationships, and perceived general threat and anxiety. The RSS was moderately correlated with general measures of anxiety and depression as well as disorder-specific symptom scales. Further, CBT was found to produce changes in reassurance seeking across CBT treatments and these reductions were significantly associated with disorder-specific clinical improvement.

Conclusion: Reassurance seeking appears to be a common factor across anxiety disorders and its reduction in CBT treatment is associated with improved clinical outcomes.
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http://dx.doi.org/10.1016/j.janxdis.2019.102109DOI Listing
October 2019

Changes in post-event processing during cognitive behavioural therapy for social anxiety disorder: A longitudinal analysis using post-session measurement and experience sampling methodology.

J Anxiety Disord 2019 08 19;66:102107. Epub 2019 Jun 19.

Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. Electronic address:

Purpose: Post-event processing (PEP) is posited to be an important factor in the maintenance of social anxiety symptoms. Previous research has demonstrated that general PEP tendencies are sensitive to treatment. However, it remains unclear how momentary PEP following social interactions changes over the course of treatment for social anxiety disorder. The purpose of the present study was to examine how both momentary and general PEP change over the course of treatment, and how such changes predict treatment outcome.

Method: Participants (N = 60) with social anxiety disorder were enrolled in group cognitive behavioural therapy. All participants completed measures of PEP and social anxiety symptom severity at five time points over treatment. A subset (N = 33) also completed repeated experience sampling measurements of PEP following social interactions across the course of treatment.

Results: Both general and momentary PEP decreased over the course of treatment. Decreases in both types of PEP predicted lower social anxiety symptom severity following treatment.

Conclusion: The results of the study demonstrate that momentary experiences of PEP can be influenced by treatment, and can in turn impact treatment outcome. The findings have significant clinical and theoretical implications.
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http://dx.doi.org/10.1016/j.janxdis.2019.102107DOI Listing
August 2019

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions.

Behav Ther 2019 01 6;50(1):87-100. Epub 2018 Apr 6.

Frederick W. Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto; University of Toronto.

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.
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http://dx.doi.org/10.1016/j.beth.2018.03.012DOI Listing
January 2019

A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes.

Arch Womens Ment Health 2019 10 6;22(5):543-556. Epub 2018 Dec 6.

Department of Psychiatry, Sunnybrook Health Sciences Centre and the University of Toronto, FG29 - 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.

To systematically review and meta-analyze research investigating the association between maternal anxiety during pregnancy and outcomes for mother and baby following the immediate delivery period. MEDLINE, Medline In-Process & Other Non-Indexed Citations, PsycINFO, Embase, CINAHL, and the Cochrane library were searched. English-language, prospective studies providing data on outcomes following delivery in women with and without antenatal anxiety (defined by clinical diagnosis or score on validated scale) were included. Three-hundred-fifty-eight articles were retrieved and 13 were included. Titles and abstracts were screened; two reviewers independently reviewed full text articles, conducted quality assessments, extracted, and checked the data. Where available for > 2 studies, random effect meta-analysis was conducted and heterogeneity was quantified. Subanalyses explored moderators, regardless of heterogeneity, including type of anxiety assessment and timing, among others. There were two outcomes that were amenable to meta-analysis. Antenatal anxiety was significantly associated with postpartum depression (PPD) measured within 6 months postpartum (pooled odds ratio [OR] = 2.64, 95% CI 2.02-3.46; 8 studies), regardless of restricting analyses to those studies controlling for prenatal depression (2.45, 1.77-3.39; 6 studies). Associations were also significant when PPD was measured at 1-3 months (2.57, 1.94-3.40; 7 studies) and 6-10 months (4.42, 1.45-13.49; 3 studies). Maternal anxiety was also associated with reduced odds of breastfeeding (0.63, 0.53-0.74; 5 studies). Antenatal anxiety is associated with PPD up to the first 10 months, independent of prenatal depression, and with lower odds of breastfeeding.
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http://dx.doi.org/10.1007/s00737-018-0930-2DOI Listing
October 2019

Maternal Anxiety During Pregnancy and the Association With Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis.

J Clin Psychiatry 2018 09 4;79(5). Epub 2018 Sep 4.

Department of Psychiatry, Sunnybrook Health Sciences Centre, and the University of Toronto, Toronto, Ontario, Canada.

Objective: This systematic review and meta-analysis examined the association between maternal antenatal anxiety (AA) and a range of perinatal outcomes.

Data Sources: Ovid MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched to May 31, 2016, using controlled vocabulary and keywords (eg, prenatal, anxiety, preterm).

Study Selection: Perinatal outcomes of women with and without AA (diagnosed or self-reported using validated scale) derived from English language, prospectively collected data were included. 1,458 abstracts were reviewed, 306 articles were retrieved, and 29 articles were included.

Data Extraction: Two independent reviewers extracted data and assessed quality. Random-effects models were utilized for outcomes (≥ 3 studies). Subanalyses examined potential effect moderators including study quality and diagnostic versus self-reported anxiety among others.

Results: Antenatal anxiety was associated with increased odds for preterm birth (pooled odds ratio [OR] = 1.54; 95% confidence interval [CI], 1.39 to 1.70, 16 studies) and spontaneous preterm birth (OR = 1.41; 95% CI, 1.13 to 1.75), lower mean birth weight (mean difference = -55.96 g; 95% CI, -93.62 to -18.31 g), increased odds for low birth weight (OR = 1.80; 95% CI, 1.48 to 2.18), earlier gestational age (mean difference = -0.13 wk; 95% CI, -0.22 to -0.04 wk), increased odds for being small for gestational age (OR = 1.48; 95% CI, 1.26 to 1.74), and smaller head circumference (mean difference = -0.25 cm; 95% CI, -0.45 to -0.06 cm). Heterogeneity between studies was not significant for most outcomes. Subanalyses for birth weight found women with diagnosed anxiety had infants with significantly lower birth weight (P < .03) compared to those identified with rating scales (although both subanalyses were significant [P < .01]). Associations between anxiety and preeclampsia, cesarean delivery, and Apgar scores were nonsignificant.

Conclusions: Antenatal anxiety is associated with multiple adverse perinatal outcomes and is not benign. The impact of treating anxiety on these associations is unknown.
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http://dx.doi.org/10.4088/JCP.17r12011DOI Listing
September 2018

Does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? A randomized controlled trial in a community setting.

Br J Clin Psychol 2019 Mar 8;58(1):1-18. Epub 2018 Jul 8.

Centre for Addiction and Mental Health, Toronto, Ontario, Canada.

Objectives: Exposure and response prevention (ERP) remains the most empirically supported psychological treatment for obsessive compulsive disorder (OCD). Clinical guidelines recommend the addition of cognitive approaches to ERP although the presumed additive benefits have not been directly tested. The aim of this was to compare a treatment that integrated cognitive therapy with ERP (ERP + CT) to traditional, manualized ERP to test the additive benefits.

Design: A longitudinal, randomized control trial design was used.

Methods: Participants (N = 127) with OCD were randomly assigned to receive individual outpatient ERP or ERP + CT. Obsessive-compulsive symptom severity measures were completed pre- and post-treatment and at 6-month follow-up.

Results: While both conditions led to significant symptom and obsessive belief reduction, ERP + CT led to significantly greater symptom and belief reduction as compared to ERP across all main symptom presentations of OCD. Based on a priori definitions of effectiveness, more patients in ERP + CT compared to the ERP group were also deemed treatment responders.

Conclusions: The results of this study suggest that cognitive therapy can be readily integrated with ERP to improve clinical outcomes beyond ERP alone.

Practitioner Points: Both ERP and ERP + CT were effective, however a course of ERP + CT was significantly more effective at reducing symptoms of OCD than the ERP treatment condition. Significantly more participants who received ERP + CT experienced clinically significant change in OCD symptoms compared to those who received ERP. OCD symptom dimension did not significantly impact response to either ERP or ERP + CT treatments.
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http://dx.doi.org/10.1111/bjc.12188DOI Listing
March 2019

The interaction of distress tolerance and intolerance of uncertainty in the prediction of symptom reduction across CBT for social anxiety disorder.

Cogn Behav Ther 2017 Nov 22;46(6):459-477. Epub 2017 Jun 22.

b Department of Psychiatry , University of Toronto , Toronto , Ontario , Canada.

Distress tolerance (DT) and intolerance of uncertainty (IU) have been identified as transdiagnostic processes that predict symptom severity across a range of distinct anxiety disorders. However, the joint effect of these two variables on therapeutic outcome has not yet been examined. It is possible that DT and IU may both impact on treatment response to cognitive-behavioural therapy (CBT) in clients with anxiety, as clients with weak DT and strong IU may be less likely to engage in exposure and cognitive restructuring tasks across treatment due to their associated distress. The purpose of this study was to examine the interaction of DT and IU as predictors of post-treatment symptom severity and treatment response to group CBT in participants with primary DSM-IV-TR diagnosed social anxiety disorder (SAD). Participants (N = 95) with SAD completed 12 weeks of manualized group CBT. Results of multilevel longitudinal analysis demonstrated an interaction effect, such that lower DT and higher IU predicted higher SAD symptom severity across the course of therapy. The findings are discussed in terms of clinical implications for the disorder-specific and transdiagnostic treatment of anxiety disorders.
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http://dx.doi.org/10.1080/16506073.2017.1334087DOI Listing
November 2017

The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder.

J Anxiety Disord 2017 Jun 14;49:65-75. Epub 2017 Mar 14.

Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada. Electronic address:

Research with non-clinical and clinical samples has examined how mindfulness concepts relate to psychological symptom presentations. However, there is less clarity when examining treatment-seeking patients who experience DSM-diagnosed anxiety and obsessional disorders - both cross-sectionally, and following empirically-supported treatments. The Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) conceptualizes mindfulness as consisting of five facets: Observing, Describing, Acting with Awareness, Nonreactivity, and Nonjudging. The current study examines the factor structure and predictive validity of the FFMQ in a large sample of treatment-seeking individuals with obsessive compulsive disorder (OCD), panic disorder with or without agoraphobia (PD/A), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). Confirmatory factor analyses (CFA) established that both four and five-factor models (i.e., with and without inclusion of the Observing factor) provided an acceptable representation of the underlying FFMQ structure, but did not support a one-factor solution. For each of these diagnostic groups, hierarchical regression analyses clarified the association between specific FFMQ facets and diagnosis specific symptom change during CBT treatment. These findings are discussed in the context of the possible transdiagnostic relevance of specific mindfulness facets, and how these facets are differentially associated with diagnosis specific symptom alleviation during CBT.
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http://dx.doi.org/10.1016/j.janxdis.2017.03.003DOI Listing
June 2017

Social Anxiety and Fear of Causing Discomfort to Others: Diagnostic Specificity, Symptom Correlates and CBT Treatment Outcome.

Behav Cogn Psychother 2017 Jul 6;45(4):382-400. Epub 2017 Mar 6.

University of Toronto and Sunnybrook Health Sciences Centre,Toronto.

Background: Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears.

Aims: To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety-Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD.

Method: In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes.

Results: In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores.

Conclusions: These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.
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http://dx.doi.org/10.1017/S135246581700008XDOI Listing
July 2017

Examining the dynamic relationships between exposure tasks and cognitive restructuring in CBT for SAD: Outcomes and moderating influences.

J Anxiety Disord 2016 Apr 4;39:10-20. Epub 2016 Feb 4.

Department of Psychiatry, University of Toronto, Toronto, Canada; Centre for Addiction and Mental Health, 100 Stokes St., Toronto, Ontario, Canada.

Meta-analyses indicate that cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) leads to substantial symptom alleviation. Although there is an emphasis on engaging in exposure and cognitive restructuring during treatment, the longitudinal relationship between skill use and symptom alleviation is not well understood. Furthermore, treatment response may be attenuated by pre-existing patient vulnerabilities. This study examined the longitudinal association of skill use (i.e. exposure (EX), thought record use (TR)), symptom reduction and the potential moderating influence of perfectionism during a 12-session, manual-based CBT for SAD intervention for 100 patients (51% female) meeting DSM-IV criteria for SAD. Results obtained from Latent Difference Score (LDS) models indicated that the frequency of both EX and TR skill use led to subsequent symptom alleviation; however, this varied based on the type of skill used. Further, although both EX and TR interventions were associated with subsequent symptom reduction, the association of EX and subsequent symptom alleviation was greater than the association of TR and subsequent symptom alleviation. Finally, higher pre-treatment perfectionism was associated with greater initial skill use, followed by significantly reduced skill use in later sessions. These preliminary results suggest that perfectionistic individuals demonstrate differential engagement in EX and TR interventions during treatment.
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http://dx.doi.org/10.1016/j.janxdis.2016.01.010DOI Listing
April 2016

Can I Really Do This? An Examination of Anticipatory Event Processing in Social Anxiety Disorder.

J Cogn Psychother 2016 1;30(2):94-104. Epub 2016 Jan 1.

Sunnybrook Health Sciences Centre, University of Toronto, Canada.

Clark and Wells (1995) posit that anticipatory processing before a social situation serves to maintain social anxiety. More specifically, ruminative processes similar to post-event processing (PEP) may occur in anticipation of anxiety provoking social events, and in this article, we have labelled this type of anticipatory rumination (AnEP). Participants ( = 75) with social anxiety disorder (SAD) completed measures of anticipatory event processing, trait anxious rumination, social anxiety, state anxiety, and PEP, in the context of completing videotaped exposures twice as part of manual-based group cognitive behavioral therapy. AnEP was significantly positively associated with trait anxious rumination and social anxiety and was associated with state anxiety during the first videotaping. AnEP at the two time points was significantly correlated and decreased across the two taped exposures. Greater AnEP at the first taping was associated with greater PEP the following week. PEP after the first videotaped exposure then significantly related to AnEP for the second videotaped exposure several weeks later. Discussion focuses on the similarities between PEP and AnEP as well as implications for cognitive models and treatment of SAD.
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http://dx.doi.org/10.1891/0889-8391.30.2.94DOI Listing
January 2016

Interactions between childhood maltreatment and brain-derived neurotrophic factor and serotonin transporter polymorphisms on depression symptoms.

Psychiatry Res 2015 Sep 29;229(1-2):609-12. Epub 2015 May 29.

Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada.

This study represents the first replication of the BDNF Val66Met ⁎ 5-HTTLPR ⁎ childhood maltreatment effect on self-reported depression symptoms using a rigorous maltreatment interview. Participants included a community sample of 339 adolescents/young adults (age 12-33; 265 female). In the context of childhood neglect, among BDNF Met-carriers, s-allele carriers of 5-HTTLPR reported significantly higher depression than l/l homozygotes, whereas a differential relation of 5-HTTLPR genotype to depression was not seen among BDNF Val/Val homozygotes.
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http://dx.doi.org/10.1016/j.psychres.2015.04.040DOI Listing
September 2015

Distress tolerance in OCD and anxiety disorders, and its relationship with anxiety sensitivity and intolerance of uncertainty.

J Anxiety Disord 2015 Jun 22;33:8-14. Epub 2015 Apr 22.

University of Toronto, Department of Psychiatry, Toronto, Ontario, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

There is a growing interest in the role of distress tolerance (i.e., the capacity to withstand negative emotions) in the onset and maintenance of anxiety. However, both empirical and theoretical knowledge regarding the role of distress tolerance in the anxiety disorders is relatively under examined. Accumulating evidence supports the relationship between difficulties tolerating distress and anxiety in nonclinical populations; however, very few studies have investigated distress tolerance in participants with diagnosed anxiety disorders. Individuals with social anxiety disorder (SAD), generalized anxiety disorder (GAD), panic disorder with and without agoraphobia (PD/A) and obsessive-compulsive disorder (OCD) completed measures of distress tolerance (DT), conceptually related measures (i.e., anxiety sensitivity (AS), intolerance of uncertainty (IU)), and anxiety symptom severity. Results showed that DT was negatively associated with AS and IU. DT was correlated with GAD, SAD and OCD symptoms, but not PD/A symptoms, in individuals with those respective anxiety disorders. DT was no longer a significant predictor of OCD or anxiety disorder symptom severity when AS and IU were also taken into account. There were no between group differences on DT across OCD and the anxiety disorder groups. Implications for the role of distress tolerance in anxiety pathology are discussed.
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http://dx.doi.org/10.1016/j.janxdis.2015.04.003DOI Listing
June 2015

A Pilot Test of the Additive Benefits of Physical Exercise to CBT for OCD.

Cogn Behav Ther 2015 4;44(4):328-40. Epub 2015 Mar 4.

a Sunnybrook Health Sciences Centre , 2075 Bayview Ave., Toronto , Ontario , Canada M4N 3M5.

The majority of "responders" to first-line cognitive-behavioural therapy (CBT) and pharmacological treatments for obsessive-compulsive disorder (OCD) are left with residual symptoms that are clinically relevant and disabling. Therefore, there is pressing need for widely accessible efficacious alternative and/or adjunctive treatments for OCD. Accumulating evidence suggests that physical exercise may be one such intervention in the mood and anxiety disorders broadly, although we are aware of only two positive small-scale pilot studies that have tested its clinical benefits in OCD. This pilot study aimed to test the feasibility and preliminary efficacy of adding a structured physical exercise programme to CBT for OCD. A standard CBT group was delivered concurrently with a 12-week customized exercise programme to 11 participants. The exercise regimen was individualized for each participant based on peak heart rate measured using an incremental maximal exercise test. Reports of exercise adherence across the 12-week regimen exceeded 80%. A paired-samples t-test indicated very large treatment effects in Yale-Brown Obsessive-Compulsive Scale scores from pre- to post-treatment in CBT group cohorts led by expert CBT OCD specialists (d = 2.55) and junior CBT clinician non-OCD specialists (d = 2.12). These treatment effects are very large and exceed effects typically observed with individual and group-based CBT for OCD based on leading meta-analytic reviews, as well as previously obtained treatment effects for CBT using the same recruitment protocol without exercise. As such, this pilot work demonstrates the feasibility and significant potential clinical utility of a 12-week aerobic exercise programme delivered in conjunction with CBT for OCD.
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http://dx.doi.org/10.1080/16506073.2015.1016448DOI Listing
March 2016

Childhood emotional and sexual maltreatment moderate the relation of the serotonin transporter gene to stress generation.

J Abnorm Psychol 2015 May 2;124(2):275-87. Epub 2015 Feb 2.

Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto.

Emerging evidence suggests that the tendency to generate stressful life events may be, at least in part, genetically determined. However, the role of the early environment in shaping responses to later stressors is crucial to fully specifying biogenetic models of stress generation. The current study examined the moderating role of childhood emotional, physical, and sexual maltreatment on the relation of the serotonin-transporter-linked promoter region (5-HTTLPR) polymorphism of the serotonin transporter gene to proximal independent, dependent, and dependent-interpersonal life events. This question was tested in a cross-sectional community sample of 297 adolescents and young adults. Childhood maltreatment history and proximal life events were assessed with state-of-the-art interviews that provide independent and standardized ratings of the environmental context. Consistent with the stress generation hypothesis, individuals with the risk s-allele of the serotonin transporter gene reported significantly higher rates of dependent and dependent-interpersonal life events than those homozygous for the l-allele, but only in the context of a history of maternal emotional maltreatment or sexual maltreatment. Neither serotonin transporter gene polymorphisms or childhood maltreatment, or their interaction, were associated with reports of independent life events. The current results demonstrate the importance of considering specificity in the early environmental context when examining the relation of genetic factors to the generation of proximal stress.
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http://dx.doi.org/10.1037/abn0000034DOI Listing
May 2015

Is post-event processing a social anxiety specific or transdiagnostic cognitive process in the anxiety spectrum?

Behav Cogn Psychother 2014 Nov;42(6):706-17

University of Toronto,and Sunnybrook Health Sciences Centre,Canada.

Background: Research on post-event processing (PEP), where individuals conduct a post-mortem evaluation of a social situation, has focused primarily on its relationship with social anxiety.

Aims: The current study examined: 1) levels of PEP for a standardized event in different anxiety disorders; 2) the relationship between peak anxiety levels during this event and subsequent PEP; and 3) the relationship between PEP and disorder-specific symptom severity.

Method: Participants with primary DSM-IV diagnoses of social anxiety disorder (SAD), obsessive compulsive disorder (OCD), panic disorder with/without agoraphobia (PD/A), or generalized anxiety disorder (GAD) completed diagnosis specific symptom measures before attending group cognitive behavioural therapy (CBT) specific to their diagnosis. Participants rated their peak anxiety level during the first group therapy session, and one week later rated PEP in the context of CBT.

Results: The results indicated that all anxiety disorder groups showed heightened and equivalent PEP ratings. Peak state anxiety during the first CBT session predicted subsequent level of PEP, irrespective of diagnostic group. PEP ratings were found to be associated with disorder-specific symptom severity in SAD, GAD, and PD/A, but not in OCD.

Conclusions: PEP may be a transdiagnostic process with relevance to a broad range of anxiety disorders, not just SAD.
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http://dx.doi.org/10.1017/S135246581300074XDOI Listing
November 2014

The expanding cognitive-behavioural therapy treatment umbrella for the anxiety disorders: disorder-specific and transdiagnostic approaches.

Can J Psychiatry 2014 Jun;59(6):301-9

Research Coordinator, Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario.

Cognitive-behavioural therapy (CBT) is an empirically supported treatment for anxiety disorders. CBT treatments are based on disorder-specific protocols that have been developed to target individual anxiety disorders, despite that anxiety disorders frequently co-occur and are comorbid with depression. Given the high rates of diagnostic comorbidity, substantial overlap in dimensional symptom ratings, and extensive evidence that the mood and anxiety disorders share a common set of psychological and biological vulnerabilities, transdiagnostic CBT protocols have recently been developed to treat the commonalities among the mood and anxiety disorders. We conducted a selective review of empirical developments in the transdiagnostic CBT treatment of anxiety and depression (2008-2013). Preliminary evidence suggests that theoretically based transdiagnostic CBT approaches lead to large treatment effects on the primary anxiety disorder, considerable reduction of diagnostic comorbidity, and some preliminary effects regarding the impact on the putative, shared psychological mechanisms. However, the empirical literature remains tentative owing to relatively small samples, limited direct comparisons with disorder-specific CBT protocols, and the relative absence of the study of disorder-specific compared with shared mechanisms of action in treatment. We conclude with a treatment conceptualization of the new transdiagnostic interventions as complementary, rather than contradictory, to disorder-specific CBT.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079149PMC
http://dx.doi.org/10.1177/070674371405900603DOI Listing
June 2014

Acceptance and commitment therapy: empirical considerations.

Authors:
Neil A Rector

Behav Ther 2013 Jun 25;44(2):213-7. Epub 2011 May 25.

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

Cognitive-behavioral therapy (CBT), including behavior therapy, cognitive therapy, and their integration, has evolved over the past four decades to become the most empirically supported psychological treatment for a range of psychiatric conditions, spanning the preponderance of Axis I disorders, selected Axis II disorders, and a range of associated clinical-health problems. The evolution of cognitive-behavioral theory and treatment has followed a coherent scientific framework, first introduced in the cognitive-behavioral modeling and treatment of depression, to include: (a) systematic clinical observations, (b) definition and psychometric operationalization of key disorder-specific cognitive, emotional and behavioral constructs, (c) laboratory investigation of operationalized disorder-specific processes, (d) development of comprehensive CBT treatment interventions to target the processes of empirically tested disorder-specific models, (e) progression from early noncontrolled clinical outcome studies to the development of sophisticated, large-scale randomized controlled trials testing disorder-specific CBT interventions, (f) examination of disorder-specific moderators and mediators of change in CBT treatment, and (g) openness to refinements and elaborations based on empirical updates from experimental and clinical investigations.
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http://dx.doi.org/10.1016/j.beth.2010.07.007DOI Listing
June 2013

Cognitive behavioral therapy for schizophrenia: an empirical review.

J Nerv Ment Dis 2012 Oct;200(10):832-9

Centre for Addiction and Mental Health, Clarke Institute of Psychiatry and Department of Psychiatry, University of Toronto, Ontario, Canada.

Early case studies and noncontrolled trial studies focusing on the treatment of delusions and hallucinations have laid the foundation for more recent developments in comprehensive cognitive behavioral therapy (CBT) interventions for schizophrenia. Seven randomized, controlled trial studies testing the efficacy of CBT for schizophrenia were identified by electronic search (MEDLINE and PsychInfo) and by personal correspondence. After a review of these studies, effect size (ES) estimates were computed to determine the statistical magnitude of clinical change in CBT and control treatment conditions. CBT has been shown to produce large clinical effects on measures of positive and negative symptoms of schizophrenia. Patients receiving routine care and adjunctive CBT have experienced additional benefits above and beyond the gains achieved with routine care and adjunctive supportive therapy. These results reveal promise for the role of CBT in the treatment of schizophrenia although additional research is required to test its efficacy, long-term durability, and impact on relapse rates and quality of life. Clinical refinements are needed also to help those who show only minimal benefit with the intervention.
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http://dx.doi.org/10.1097/NMD.0b013e31826dd9afDOI Listing
October 2012

Examination of the trait facets of the five-factor model in discriminating specific mood and anxiety disorders.

Psychiatry Res 2012 Sep 15;199(2):131-9. Epub 2012 May 15.

Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Structural models of the mood and anxiety disorders postulate that each disorder has a shared component that can account for comorbidity and its own unique component that distinguishes it from others. The principal aim of the current study was to determine the extent to which the 30 facets of the Five-Factor Model (FFM), as measured by the Revised NEO Personality Inventory (NEO PI-R), contribute to the identification of the unique component in mood and anxiety disorders in treatment-seeking clinical samples. Participants (N=610) were psychiatric outpatients with principal DSM-IV diagnoses (Diagnostic and Statistical Manual-IV; American Psychiatric Association, 1994) diagnoses of major depressive disorder (MDD), post-traumatic stress disorder (PTSD), generalized social phobia (GSP), panic disorder with/without agoraphobia (PD; PD/A) or obsessive-compulsive disorder (OCD). Results suggest that approximately half of the variance in differences between these diagnoses is associated with specific characteristics represented by the FFM facets. Unique personality profiles for the MDD, GSP, PTSD and, to a lesser extent, OCD groups emerged. Broad traits of the FFM, when broken into more narrow components at the facet level, contribute significantly to the identification of unique aspects associated with specific mood and anxiety disorders. The integration of lower and higher levels of structural examination of the mood and anxiety disorders is discussed.
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http://dx.doi.org/10.1016/j.psychres.2012.04.027DOI Listing
September 2012

Disgust recognition in obsessive-compulsive disorder: diagnostic comparisons and posttreatment effects.

Can J Psychiatry 2012 Mar;57(3):177-83

Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario.

Objective: To examine whether disgust recognition deficits are present and specific to obsessive-compulsive disorder (OCD), and the extent to which this deficit, if present, can be reduced in cognitive-behavioural therapy (CBT).

Method: Responses to the Pictures of Facial Affect (POFA) were examined in patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosed OCD (n = 20), panic disorder with agoraphobia (PDA; n = 15), and generalized social phobia (GSP; n = 15) and a second, independent OCD sample of treatment responders to CBT (n = 11).

Results: There were significant and statistically large disgust recognition differences between the OCD group and comparison PDA and GSP groups. However, patients with OCD treated with CBT showed disgust recognition scores that were equivalent to the PDA and GSP groups, significantly better than the untreated OCD sample, and equivalent to scores from the original POFA nonaffected standardization sample.

Conclusions: These results provide support for the presence of disgust recognition impairment in OCD, and provide preliminary evidence that disgust recognition impairments may improve with treatment.
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http://dx.doi.org/10.1177/070674371205700307DOI Listing
March 2012

The CANMAT task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders.

Ann Clin Psychiatry 2012 Feb;24(1):6-22

Mood and Anxiety Disorders Program, Sunnybrook Health Sciences Centre, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

Background: Comorbid mood and anxiety disorders are commonly seen in clinical practice. The goal of this article is to review the available literature on the epidemiologic, etiologic, clinical, and management aspects of this comorbidity and formulate a set of evidence- and consensus-based recommendations. This article is part of a set of Canadian Network for Mood and Anxiety Treatments (CANMAT) Comorbidity Task Force papers.

Methods: We conducted a PubMed search of all English-language articles published between January 1966 and November 2010. The search terms were bipolar disorder and major depressive disorder, cross-referenced with anxiety disorders/symptoms, panic disorder, agoraphobia, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Levels of evidence for specific interventions were assigned based on a priori determined criteria, and recommendations were developed by integrating the level of evidence and clinical opinion of the authors.

Results: Comorbid anxiety symptoms and disorders have a significant impact on the clinical presentation and treatment approach for patients with mood disorders. A set of recommendations are provided for the management of bipolar disorder (BD) with comorbid anxiety and major depressive disorder (MDD) with comorbid anxiety with a focus on comorbid posttraumatic stress disorder, use of cognitive-behavioral therapy across mood and anxiety disorders, and youth with mood and anxiety disorders.

Conclusions: Careful attention should be given to correctly identifying anxiety comorbidities in patients with BD or MDD. Consideration of evidence- or consensus-based treatment recommendations for the management of both mood and anxiety symptoms is warranted.
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February 2012