Mechanisms of improvement in generalized anxiety disorder: A mediation and moderated mediation analysis from a randomized controlled trial.

Publisher: Wiley-Blackwell Country of Publication: England NLM ID: 8105533 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 0144-6657 (Print) Linking ISSN: 01446657 NLM ISO Abbreviation: Br J Clin Psychol Subsets: MEDLINE

Publication: 2011- : West Sussex, England : Wiley-Blackwell
Original Publication: Letchworth, Herts, [England] : The Society, c1981-

Mediation Analysis* ; Mindfulness*/methods; Humans ; Quality of Life ; Anxiety Disorders/therapy ; Anxiety ; Treatment Outcome

Background: Generalized anxiety disorder (GAD) is associated with the lowest treatment response rate among all anxiety disorders. Understanding mechanisms of improvement may help to develop more effective and personalized treatments.
Aim: The objective of the study was to investigate different improvement mechanisms in the treatment of individuals diagnosed with GAD.
Design: We reported data from a randomized controlled trial that evaluated three different GAD treatments (mindfulness-based intervention, BMT; fluoxetine, FLX; and an active comparison group, QoL) for 8 weeks.
Method: Mediation analyses were performed evaluating the association between worry symptoms at baseline and anxiety scoring at the endpoint, considering self-compassion or mindfulness or its dimensions at mid-treatment as mediators for the whole sample (assessing GAD improvement mechanism) and the different interventions as moderators.
Results: Contrary to mindfulness state scoring (C = .06; 95% CI = -.05 to .20), self-compassion (C = .11; 95% CI = .01 to .28) and non-judgement of inner experience (C = .10; 95% CI = .004 to .21) mediated the association between worry symptoms at baseline and anxiety at the endpoint. When comparing BMT to FLX, the intervention modality did not moderate these associations.
Conclusion: Self-compassion and non-judgement of inner experience seem to be essential targets in GAD treatment, contrary to the mindfulness state itself. Although no difference was found considering the intervention modality, future research may assess how to boost these dimensions in specific treatments for GAD.
(© 2022 British Psychological Society.)

Arch, J. J., Brown, K. W., Dean, D. J., Landy, L. N., Brown, K. D., & Laudenslager, M. L. (2014). Self-compassion training modulates alpha-amylase, heart rate variability, and subjective responses to social evaluative threat in women. Psychoneuroendocrinology, 42, 49-58. https://doi.org/10.1016/j.psyneuen.2013.12.018.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45. https://doi.org/10.1177/1073191105283504.
Barros, V. V., Kozasa, E. H., Souza, I. C. W., & Ronzani, T. M. (2014). Validity evidence of the Brazilian version of the five facet mindfulness questionnaire (FFMQ). Psicologia: Teoria e Pesquisa, 30(3), 317-327. https://doi.org/10.1590/S0102-37722014000300009.
Beck, J. S., Beck, A. T., Knapp, P., Meyer, E., & da Rosa, S. M. (2013). Terapia cognitivo-comportamental: Teoria e prática (2a edição). Artmed.
Behar, E., DiMarco, I. D., Hekler, E. B., Mohlman, J., & Staples, A. M. (2009). Current theoretical models of generalized anxiety disorder (GAD): Conceptual review and treatment implications. Journal of Anxiety Disorders, 23(8), 1011-1023. https://doi.org/10.1016/j.janxdis.2009.07.006.
Bergen-Cico, D., & Cheon, S. (2014). The mediating effects of mindfulness and self-compassion on trait anxiety. Mindfulness, 5(5), 505-519. https://doi.org/10.1007/s12671-013-0205-y.
Bishop, S. R. (2002). What do we really know about mindfulness-based stress reduction? Psychosomatic Medicine, 64(1), 71-83. https://doi.org/10.1097/00006842-200201000-00010.
Bomyea, J., Ramsawh, H., Ball, T. M., Taylor, C. T., Paulus, M. P., Lang, A. J., & Stein, M. B. (2015). Intolerance of uncertainty as a mediator of reductions in worry in a cognitive behavioral treatment program for generalized anxiety disorder. Journal of Anxiety Disorders, 33, 90-94. https://doi.org/10.1016/j.janxdis.2015.05.004.
Borkovec, T. D., Alcaine, O. M., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. In Generalized anxiety disorder: Advances in research and practice (pp. 77-108). The Guilford Press.
Borkovec, T. D., & Roemer, L. (1995). Perceived functions of worry among generalized anxiety disorder subjects: Distraction from more emotionally distressing topics? Journal of Behavior Therapy and Experimental Psychiatry, 26(1), 25-30. https://doi.org/10.1016/0005-7916(94)00064-s.
Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. The Journal of Clinical Psychiatry, 62(Suppl. 11), 37-42; discussion 43-45.
Castillo, C., Macrini, L., Cheniaux, E., & Landeira-Fernandez, J. (2010). Psychometric properties and latent structure of the Portuguese version of the Penn State worry questionnaire. The Spanish Journal of Psychology, 13(1), 431-443.
Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. Journal of Alternative and Complementary Medicine, 15(5), 593-600. https://doi.org/10.1089/acm.2008.0495.
Costa, M. A., D'Alò de Oliveira, G. S., Tatton-Ramos, T., Manfro, G. G., & Salum, G. A. (2019). Anxiety and stress-related disorders and mindfulness-based interventions: A systematic review and multilevel meta-analysis and meta-regression of multiple outcomes. Mindfulness, 10(6), 996-1005. https://doi.org/10.1007/s12671-018-1058-1.
Costa, M. A., Gonçalves, F. G., Tatton-Ramos, T., Fonseca, N. K. O., Schwinn, J. K., Alves, S. G., Salum, G. A., & Manfro, G. G. (2020). A three-arm randomized clinical trial comparing the efficacy of a mindfulness-based intervention with an active comparison group and fluoxetine treatment for adults with generalized anxiety disorder. Psychotherapy and Psychosomatics, 90, 269-279. https://doi.org/10.1159/000511880.
Curtiss, J., & Klemanski, D. H. (2014). Teasing apart low mindfulness: Differentiating deficits in mindfulness and in psychological flexibility in predicting symptoms of generalized anxiety disorder and depression. Journal of Affective Disorders, 166, 41-47. https://doi.org/10.1016/j.jad.2014.04.062.
de Souza, L. K., & Hutz, C. S. (2016). Adaptation of the self-compassion scale for use in Brazil: Evidences of construct validity. Temas Em Psicologia, 24(1), 159-172. https://doi.org/10.9788/TP2016.1-11.
Dekker, J. M., Schouten, E. G., Klootwijk, P., Pool, J., Swenne, C. A., & Kromhout, D. (1997). Heart rate variability from short electrocardiographic recordings predicts mortality from all causes in middle-aged and elderly men: The Zutphen study. American Journal of Epidemiology, 145(10), 899-908. https://doi.org/10.1093/oxfordjournals.aje.a009049.
Ellard, K. K., Barlow, D. H., Whitfield-Gabrieli, S., Gabrieli, J. D. E., & Deckersbach, T. (2017). Neural correlates of emotion acceptance vs worry or suppression in generalized anxiety disorder. Social Cognitive and Affective Neuroscience, 12(6), 1009-1021. https://doi.org/10.1093/scan/nsx025.
Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52-60. https://doi.org/10.1016/j.cpr.2017.10.011.
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psychology Review, 37, 1-12. https://doi.org/10.1016/j.cpr.2015.01.006.
Hamilton, M. (1959). The assessment of anxiety states by rating. The British Journal of Medical Psychology, 32(1), 50-55.
Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a potential common mechanism across two therapies for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 83(2), 395-404. https://doi.org/10.1037/a0038305.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183. https://doi.org/10.1037/a0018555.
Hoge, E. A., Bui, E., Goetter, E., Robinaugh, D. J., Ojserkis, R. A., Fresco, D. M., & Simon, N. M. (2015). Change in decentering mediates improvement in anxiety in mindfulness-based stress reduction for generalized anxiety disorder. Cognitive Therapy and Research, 39(2), 228-235. https://doi.org/10.1007/s10608-014-9646-4.
Hoge, E. A., Hölzel, B. K., Marques, L., Metcalf, C. A., Brach, N., Lazar, S. W., & Simon, N. M. (2013). Mindfulness and self-compassion in generalized anxiety disorder: Examining predictors of disability. Evidence-based Complementary and Alternative Medicine, 2013, 1-7. https://doi.org/10.1155/2013/576258.
Iani, L., Lauriola, M., Cafaro, V., & Didonna, F. (2017). Dimensions of mindfulness and their relations with psychological well-being and neuroticism. Mindfulness, 8(3), 664-676. https://doi.org/10.1007/s12671-016-0645-2.
Introduction to Mediation, Moderation, and Conditional Process Analysis. (n.d.). Andrew F. Hayes, Ph.D. Retrieved April 25, 2020, from http://afhayes.com/introduction-to-mediation-moderation-and-conditional-process-analysis.html.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10(2), 144-156. https://doi.org/10.1093/clipsy.bpg016.
Kemp, A. H., Brunoni, A. R., Santos, I. S., Nunes, M. A., Dantas, E. M., Carvalho de Figueiredo, R., Pereira, A. C., Ribeiro, A. L. P., Mill, J. G., Andreão, R. V., Thayer, J. F., Benseñor, I. M., & Lotufo, P. A. (2014). Effects of depression, anxiety, comorbidity, and antidepressants on resting-state heart rate and its variability: An ELSA-brasil cohort baseline study. American Journal of Psychiatry, 171(12), 1328-1334. https://doi.org/10.1176/appi.ajp.2014.13121605.
Kemppainen, J., Johnson, M. O., Phillips, J. C., Sullivan, K. M., Corless, I. B., Reid, P., Iipinge, S., Chaiphibalsarisdi, P., Sefcik, E., Chen, W.-T., Kirksey, K., Voss, J., Rivero-Méndez, M., Tyer-Viola, L., Dawson Rose, C., Webel, A., Nokes, K., Portillo, C., Holzemer, W. L., … Beamon, E. R. (2013). A multinational study of self-compassion and human immunodeficiency virus-related anxiety. International Nursing Review, 60(4), 477-486. https://doi.org/10.1111/inr.12056.
Keng, S.-L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041-1056. https://doi.org/10.1016/j.cpr.2011.04.006.
Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., Chapleau, M.-A., Paquin, K., & Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33(6), 763-771. https://doi.org/10.1016/j.cpr.2013.05.005.
Leary, M. R., Tate, E. B., Adams, C. E., Allen, A. B., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treating oneself kindly. Journal of Personality and Social Psychology, 92(5), 887-904. https://doi.org/10.1037/0022-3514.92.5.887.
Lee, J. K., & Orsillo, S. M. (2014). Investigating cognitive flexibility as a potential mechanism of mindfulness in generalized anxiety disorder. Journal of Behavior Therapy and Experimental Psychiatry, 45(1), 208-216. https://doi.org/10.1016/j.jbtep.2013.10.008.
Ludwig, D. S. (2008). Mindfulness in medicine. JAMA, 300(11), 1350. https://doi.org/10.1001/jama.300.11.1350.
Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in Neuroscience, 7, 1-11. https://doi.org/10.3389/fnins.2013.00008.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State worry questionnaire. Behaviour Research and Therapy, 28(6), 487-495.
Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and Identity, 2(3), 223-250. https://doi.org/10.1080/15298860309027.
Newman, M. G., Llera, S. J., Erickson, T. M., Przeworski, A., & Castonguay, L. G. (2013). Worry and generalized anxiety disorder: A review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment. Annual Review of Clinical Psychology, 9, 275-297. https://doi.org/10.1146/annurev-clinpsy-050212-185544.
Russell, T. (2011). Body in mind training: Mindful movement for severe and enduring mental illness. British Journal of Wellbeing, 2(4), 13-16. https://doi.org/10.12968/bjow.2011.2.4.13.
Russell, T. (2015). Mindfulness in motion: Unlock the secrets of mindfulness in motion. Watkins Publishing.
Russell, T. A., & Tatton-Ramos, T. (2014). Body in mind training: Mindful movement for the clinical setting. Neuro-Disability and Psychotherapy, 2, 108-136.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62(3), 373-386. https://doi.org/10.1002/jclp.20237.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(Suppl 20), 22-33; quiz 34-57.
Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097. https://doi.org/10.1001/archinte.166.10.1092.
Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based interventions for people diagnosed with a current episode of an anxiety or depressive disorder: A meta-analysis of randomised controlled trials. PLoS One, 9(4), e96110. https://doi.org/10.1371/journal.pone.0096110.
Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness training and problem formulation. Clinical Psychology: Science and Practice, 10(2), 157-160. https://doi.org/10.1093/clipsy.bpg017.
Van Dam, N. T., Sheppard, S. C., Forsyth, J. P., & Earleywine, M. (2011). Self-compassion is a better predictor than mindfulness of symptom severity and quality of life in mixed anxiety and depression. Journal of Anxiety Disorders, 25(1), 123-130. https://doi.org/10.1016/j.janxdis.2010.08.011.
Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based interventions for anxiety disorders: A systematic review and meta-analysis. The British Journal of Clinical Psychology/the British Psychological Society, 51(3), 239-260. https://doi.org/10.1111/j.2044-8260.2011.02024.x.
Werner, A. M., Tibubos, A. N., Rohrmann, S., & Reiss, N. (2019). The clinical trait self-criticism and its relation to psychopathology: A systematic review - Update. Journal of Affective Disorders, 246, 530-547. https://doi.org/10.1016/j.jad.2018.12.069.

Keywords: antidepressant; anxiety; generalized anxiety disorder; mechanism; mindfulness

Date Created: 20221130 Date Completed: 20230209 Latest Revision: 20230209

20231215

10.1111/bjc.12402

36447332