Aaron J. Fisher | University of California, Berkeley (original) (raw)

Papers by Aaron J. Fisher

Research paper thumbnail of Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

Behavior Therapy, 2010

The current study examined the impact of comorbidity on cognitive and behavioral therapies for ge... more The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.

Research paper thumbnail of NewmanFisher13

Research paper thumbnail of Mood-Reactive Self-Esteem and Depression Vulnerability: Person-Specific Symptom Dynamics via Smart Phone Assessment

PLOS ONE, 2015

Cognitive theories of depression suggest that mood-reactive self-esteem, a pattern of cognitive r... more Cognitive theories of depression suggest that mood-reactive self-esteem, a pattern of cognitive reactivity where low self-esteem is temporally dependent on levels of sadness, represents vulnerability for depression. Few studies have directly tested this hypothesis, particularly using intensive data collection methods (i.e., experience sampling) required to capture the temporal dynamics of sadness and self-esteem as they unfold naturally, over time. In this study we used participants' smartphones to collect multiple daily ratings of sadness and self-esteem over three weeks, in the real world. We then applied dynamic factor modeling to explore theoretically driven hypotheses about the temporal dependency of self-esteem on sadness (i.e., mood-reactive self-esteem) and its relationship to indices of depression vulnerability both contemporaneously (e.g., rumination, sad mood persistence) and prospectively (e.g., future symptomatology). In sum, individuals who demonstrated mood-reactive self-esteem reported higher levels of rumination at baseline, more persistent sad mood over three weeks, and increased depression symptoms at the end of three weeks above and beyond a trait-like index of self-esteem. The integration of smartphone assessment and person-specific analytics employed in this study offers an exiting new avenue to advance the study and treatment of depression.

Research paper thumbnail of Toward a Dynamic Model of Psychological Assessment: Implications for Personalized Care

Journal of Consulting and Clinical Psychology, 2015

The present article proposes a general framework and a set of specific methodological steps for c... more The present article proposes a general framework and a set of specific methodological steps for conducting person-specific dynamic assessments, which yield information about syndrome structures and states that can be used to provide actionable information for the formulation of personalized interventions. It is proposed that researchers should (a) determine the relevant constituent inputs for a diagnostic system; (b) measure these inputs with as much detail as possible; (c) assess the correlational structure of system inputs via factor-analytic methods within individuals; and (d) subject the individual-level, latent dimension time series to dynamic analyses such as the dynamic factor model (Molenaar, 1985) to discern the time-dependent, dynamic relationships within and between system components. An exemplar is provided wherein 10 individuals with clinically diagnosed generalized anxiety disorder completed surveys related to generalized anxiety disorder symptomatology for at least 60 consecutive days. These data were then subjected to person-specific exploratory and confirmatory factor analyses for the identification of latent symptom dimensions. Finally, dynamic factor models were used to model the dynamic interrelationships within and between symptom domains on a person-by-person basis. Person-specific factor analyses returned models with 3 (n = 8) or 4 (n = 2) latent factors, all with excellent fit. Dynamic factor modeling successfully revealed the contemporaneous correlations and time-lagged predictive relationships between factors, providing prescriptive information for the formulation of targeted interventions. The proposed approach has the potential to inform the construction and implementation of personalized treatments by delineating the idiosyncratic structure of psychopathology on a person-by-person basis. (PsycINFO Database Record

Research paper thumbnail of Personalized assessment and treatment of depression

Current Opinion in Psychology, 2015

The drive to personalize the delivery of psychosocial and pharmacologic treatments is embodied in... more The drive to personalize the delivery of psychosocial and pharmacologic treatments is embodied in Gordon Paul's (1967) famous question, "What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?" Traditionally, researchers have examined "what works for whom" via post hoc moderator analyses. However, these efforts have been largely unsuccessful, suffering from poor replication and statistical bias due a lack of random assignment. Recent advances in genetic and biological technologies and statistical methods have facilitated an explosion of research on the personalization of treatment for psychological disorders. The present review examines recent developments in the personalization of depression treatment. Page 3 of 23 A c c e p t e d M a n u s c r i p t Personalized assessment and treatment of depression 3 Highlights  We review recent developments in the personalization of depression assessment and treatment.

Research paper thumbnail of Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure

Journal of Consulting and Clinical Psychology, 2014

The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) ther... more The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD). Emotional processing theory of PTSD proposes that disconfirmation of erroneous cognitions associated with PTSD is a central mechanism in PTSD symptom reduction; but to date, the causal relationship between change in pathological cognitions and change in PTSD severity has not been established. Method: Female sexual or nonsexual assault survivors (N ϭ 64) with a primary diagnosis of PTSD received 10 weekly sessions of PE. Self-reported PTSD symptoms, depression symptoms, and PTSD-related cognitions were assessed at pretreatment, each of the 10 PE treatment sessions, and posttreatment. Results: Lagged mixed-effect regression models indicated that session-to-session reductions in PTSD-related cognitions drove successive reductions in PTSD symptoms. By contrast, the reverse effect of PTSD symptom change on change in cognitions was smaller and did not reach statistical significance. Similarly, reductions in PTSD-related cognitions drove successive reductions in depression symptoms, whereas the reverse effect of depression symptoms on subsequent cognition change was smaller and not significant. Notably, the relationships between changes in cognitions and PTSD symptoms were stronger than the relationships between changes in cognitions and depression symptoms. Conclusions: To our knowledge, this is the 1st study to establish change in PTSD-related cognitions as a central mechanism of PE treatment. These findings are consistent with emotional processing theory and have important clinical implications for the effective implementation of PE.

Research paper thumbnail of Validating the Rapid Responder Construct Within a Practice Research Network

Journal of Clinical Psychology, 2014

Research paper thumbnail of Motivation and Changes in Depression

Cognitive Therapy and Research, 2013

This study evaluated the capacity of the Willingness Scale (WS) to predict changes in depression ... more This study evaluated the capacity of the Willingness Scale (WS) to predict changes in depression over the course of a brief inpatient admission. Two cohorts (N = 160) of adult inpatients completed the Willingness Scale along with a measure of depression following admission. Depression severity was assessed approximately 4 days later, prior to discharge. Data were evaluated using structural equation modeling. Higher WS scores predicted greater reductions in depression in both cohorts, and the magnitude of this effect was large. The fits of the models were outstanding, with no significant differences in any parameter estimates across the two cohorts. The WS predicts changes in depression, even within a brief inpatient admission where the treatment is predominantly biological. These results replicate results of previous studies in outpatient populations where CBT was the primary treatment and suggest motivational factors may play an important role in causation and recovery from depression.

Research paper thumbnail of The Self-Rating of the Effects of Alcohol Questionnaire as a Predictor of Alcohol-Related Outcomes in 12-Year-Old Subjects

Alcohol and Alcoholism, 2008

Aims: A low level of response (LR), or low sensitivity, to alcohol as established by alcohol chal... more Aims: A low level of response (LR), or low sensitivity, to alcohol as established by alcohol challenges has been shown to predict future heavier drinking, alcohol-related problems and alcohol use disorders. To date, only one study has evaluated the predictive validity of a second measure of LR as determined by the Self-Report of the Effects of Alcohol (SRE) Questionnaire. The current analyses evaluate the ability of SRE scores as determined at age 12 to predict heavier drinking and alcohol-related problems 2 years later in a sample from the United Kingdom. Methods: The subjects were 156 boys (54.5%) and girls from the Avon Longitudinal Study of Parents and Children (ALSPAC) who had reported consuming one or more standard drinks by age 12 and who were followed up 2 years later. Results: The age 12 SRE scores correlated with the number of drinks per week, maximum drinks and the number of alcohol problems both at baseline and at age 14 follow-ups. In these evaluations, a larger number of drinks required for effects on the SRE (i.e. a lower LR per drink consumed) related to heavier intake and alcohol-related difficulties. Simultaneous entry multiple regression analyses revealed that the age 12 SRE score maintained a significant relationship with age 14 higher number of drinks per week and the number of alcohol problems even when the age 12 values for alcohol intake and problems were used as covariates. Conclusion: The SRE scores appear to have value in predicting future heavier drinking and alcohol problems in 12-year olds that go beyond the information offered by the earlier drinking pattern alone.

Research paper thumbnail of The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression

Journal of Consulting and Clinical Psychology, 2013

Objective: This study tested whether the quality of the patient-rated working alliance, measured ... more Objective: This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP). Method: 395 adults (57% female; M age ϭ 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16 -20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change. Results: A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) ϭ 62.48, p Ͻ .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) ϭ 8.31, p ϭ .004. Conclusions: The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies.

Research paper thumbnail of Evaluating the impact of depression, anxiety & autonomic function on health related quality of life, vocational functioning and health care utilisation in acute coronary syndrome patients: the ADVENT study protocol

BMC Cardiovascular Disorders, Dec 2, 2013

Background: Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome ... more Background: Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome patients. Somatic and cognitive subtypes of depression and anxiety in acute coronary syndrome have been shown to be associated with mortality although their association with patient outcomes is unknown, as are the mechanisms that underpin these associations. We are conducting a prospective cohort study which aims to examine in acute coronary syndrome patients: (1) the role of somatic subtypes of depression and anxiety as predictors of health related quality of life outcomes; (2) how somatic subtypes of depression and anxiety relate to long term vocational functioning and healthcare utilisation; and (3) the role of the autonomic nervous system assessed by heart rate variability as a moderator of these associations.

Research paper thumbnail of Cardiac stability at differing levels of temporal analysis in panic disorder, post-traumatic stress disorder, and healthy controls

Psychophysiology

The panic disorder (PD) literature provides evidence for both physiologic rigidity and instabilit... more The panic disorder (PD) literature provides evidence for both physiologic rigidity and instability as pathognomonic features of this disorder. This ambiguity may be a result of viewing PD at differential levels of temporal analysis. We assessed cardiac variability across three levels of temporal scale in PD patients, post-traumatic stress disorder (PTSD) patients, and healthy controls. Sixteen healthy controls, 14 PD patients, 23 PTSD patients, and 16 PTSD + PD patients presented for a polysomnogram. Differences were assessed in respiratory sinus arrhythmia (RSA), autoregressive stability of heart rate (HR), and the number of nonspecific accelerations in HR over the night. No differences in RSA were found between groups; however, PD patients exhibited significantly lower autoregressive HR stability, and all patients had significantly more HR accelerations than controls. These data reinforce prior findings demonstrating physiologic instability in PD and indicate that prior equivocalities regarding physiologic variability in PD may be due to limited temporal scaling of measurements.

Research paper thumbnail of Heart rate and autonomic response to stress after experimental induction of worry versus relaxation in healthy, high-worry, and generalized anxiety disorder individuals.

Biological Psychology

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Research paper thumbnail of The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.

Journal of Consulting and Clinical Psychology, 2013

Research paper thumbnail of Mediated moderation in combined cognitive behavioral therapy versus component treatments for generalized anxiety disorder.

Journal of Consulting and Clinical Pscyhology

Objective: This study examined a) duration of generalized anxiety disorder (GAD) as a moderator o... more Objective: This study examined a) duration of generalized anxiety disorder (GAD) as a moderator of cognitive behavioral therapy (CBT) versus its components (cognitive therapy and self-control desensitization) and b) increases in adaptive order of anxious symptoms during the course of psychotherapy as a mediator of this moderation. Adaptive order (degree of dynamic flexibility in daily symptoms) was quantified as the inverse of spectral power due to daily to intra-daily oscillations in fourfold-daily diary data (Fisher, Newman, & Molenaar, 2011). Method: This was a secondary analysis of Borkovec, Newman, Pincus, & Lytle (2002). Seventy-six participants with a principle diagnosis of GAD were assigned randomly to combined CBT (n = 24), cognitive therapy (n = 25) or self-control desensitization (n = 27). Results: Duration of GAD moderated outcome such that those with longer duration showed greater reliable change from component treatments than they showed from CBT, whereas those with shorter duration fared better in response to CBT. Decreasing predictability in daily and intradaily oscillations during therapy reflected less rigidity and more flexible responding. Increases in flexibility over the course of therapy fully mediated the moderating effect of GAD duration on condition, indicating a mediated moderation process. Conclusions: Individuals with longer duration of GAD may respond better to more focused treatments whereas those with shorter duration of GAD may respond better to a treatment that offers more coping strategies. Importantly, the mechanism by which this moderation occurs appears to be the establishment of flexible responding during treatment.

Research paper thumbnail of Proposed Specific Factors for Generalized Anxiety Disorder Within the Integrative Hierarchical Model of Anxiety and Depression

Since its first appearance in the third edition of the Diagnostic and Statistical Manual of Menta... more Since its first appearance in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980), generalized anxiety disorder (GAD) has provided challenges to the discriminative validity of the mood and anxiety disorders. Although the removal of autonomic symptoms from the diagnostic criteria for GAD in DSM-IV helped to increase the diagnostic reliability from a range of .27 to . 56 (Williams et al., 1992) based on DSM-III-R criteria and .67 based on DSM-IV criteria (Brown, Di Nardo, Lehman, & Campbell, 2001), some researchers have expressed concern that this distinction further confuses the boundary between GAD and mood disorders Brown et al., 1995). It has been argued that though the removal of these symptoms from the diagnostic criteria improved the overall reliability of GAD, as well as the discriminative validity of GAD in relation to the other anxiety disorders, the overlap with depressive disorders and the discriminative difficulties therein still remain. Research based on DSM-IV criteria has shown that GAD shares a closer relationship to the mood disorders than it does to other anxiety disorders . Clark and Watson (1991) developed the tripartite model, in which depression and anxiety share a common factor of negative affectivity, depression is indicated by low positive affectivity (PA) and anxiety by high autonomic arousal (AA). Mineka, Watson, and Clark expanded on this model with the integrative hierarchical model, within which each anxiety disorder is indicated by an idiosyncratic predictor. has made the argument that this model can and should be extended to new taxonomic systems, including the approaching DSM-V. However, a specific factor remains to be determined for GAD within this model.

Research paper thumbnail of A quantitative method for the analysis of nomothetic relationships between idiographic structures: Dynamic patterns create attractor states for sustained posttreatment  …

Journal of consulting and …, Jan 1, 2011

ObjectiveThe present article aimed to demonstrate that the establishment of dynamic patterns duri... more ObjectiveThe present article aimed to demonstrate that the establishment of dynamic patterns during the course of psychotherapy can create attractor states for continued adaptive change following the conclusion of treatmentMethodThis study is a secondary analysis of T. D. Borkovec and E. Costello (1993). Of the 55 participants in the original study, 33 were retained for the present analysis due to the homogeneity of psychotherapy outcome among these participants. Of these 33, the majority were White (88%) and female (70%), and the average age was 35.44 years (SD = 14.46). Participants participated in 12 weeks of either cognitive behavioral therapy or applied relaxation. Daily diary entries from the treatment period were subjected to time series analyses in order to determine the degree of order versus disorder present within individual dynamic systems. These idiographic data were then aggregated for nomothetic analysis of treatment outcome via linear mixed effect models.ResultsSpectral power due to daily to intradaily oscillations in thrice-daily diary data significantly moderated reliable change over posttreatment follow-up such that lesser power predicted increases in reliable change over the 1-year follow-up period. Additionally, residual variance for dynamic factor models significantly moderated the slope for change over the follow-up period, such that lesser variance—and thus greater order in dynamic systems—predicted increases in reliable change.ConclusionsThe degree of order in dynamic systems established during therapy acted as an adaptive attractor state, promoting continued positive gains 1 year after the conclusion of therapy. The present study represents an important innovation in the study of dynamic systems in psychotherapy.

Research paper thumbnail of Expectancy/Credibility Change as a Mediator of Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Mechanism of Action or Proxy for Symptom  …

International journal of cognitive therapy, Jan 1, 2010

Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-sessio... more Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-session cognitive and behavioral therapy for generalized anxiety disorder (GAD). In 76 adults with primary GAD, we predicted that expectancy/ credibility would change significantly from sessions 4-7, that degree of change in expectancy/credibility would predict degree of reliable change at posttreatment, and that changes in expectancy/credibility would mediate the relationship between pretreatment severity and change at posttreatment. In support of the hypotheses, a latent growth model revealed significant increases in expectancy/credibility over the critical period. In addition, baseline GAD severity, expectancy/credibility intercept, and rate of change in expectancy/credibility all positively predicted degree of reliable change at posttreatment. Rate of change in expectancy/credibility during the critical period partially mediated the effect of baseline GAD severity, accounting for 38% of the variance in this relationship. This effect was not accounted for by preceding or concurrently changing anxiety levels.

Research paper thumbnail of Sympathetic arousal moderates self-reported physiological arousal symptoms at baseline and physiological flexibility in response to a stressor in generalized anxiety  …

Biological psychology, Jan 1, 2010

Research paper thumbnail of A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal  …

Journal of Consulting …, Jan 1, 2011

Objective: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintain... more Objective: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. Method: This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age ϭ 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n ϭ 40) or to CBT plus interpersonal and emotional processing therapy (n ϭ 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T.

Research paper thumbnail of Diagnostic Comorbidity in Adults With Generalized Anxiety Disorder: Impact of Comorbidity on Psychotherapy Outcome and Impact of Psychotherapy on Comorbid Diagnoses

Behavior Therapy, 2010

The current study examined the impact of comorbidity on cognitive and behavioral therapies for ge... more The current study examined the impact of comorbidity on cognitive and behavioral therapies for generalized anxiety disorder (GAD) as well as the impact of these therapies on diagnoses comorbid to GAD. Seventy-six treatment-seeking adults with principal diagnoses of GAD received 14 sessions of therapy. Most (n = 46; 60.5%) of the sample had at least one comorbid diagnosis. Although the presence of comorbid diagnoses was associated with greater severity of GAD symptoms at pretreatment, greater severity of comorbid major depression, simple phobia, and social phobia was associated with greater change in symptoms of GAD in response to treatment, with no effect on maintenance of gains during a 2-year follow-up. Further, psychotherapy for principal GAD led to a reduction in number of comorbid diagnoses and in severity of social phobia, simple phobia, and major depression at posttreatment. At 2-year follow-up severity of social and simple phobia remained below pretreatment levels, whereas severity of depression was no longer significantly below pretreatment levels. These results suggest that although people with comorbid disorders enter treatment with more severe GAD symptomatology, they demonstrate greater change, and therefore such comorbidity does not diminish the efficacy of cognitive and behavioral therapies for GAD. In addition, the impact of these treatments for GAD may generalize to reduced severity of simple phobia, social phobia, and major depression; however, gains in severity of major depression are not maintained.

Research paper thumbnail of NewmanFisher13

Research paper thumbnail of Mood-Reactive Self-Esteem and Depression Vulnerability: Person-Specific Symptom Dynamics via Smart Phone Assessment

PLOS ONE, 2015

Cognitive theories of depression suggest that mood-reactive self-esteem, a pattern of cognitive r... more Cognitive theories of depression suggest that mood-reactive self-esteem, a pattern of cognitive reactivity where low self-esteem is temporally dependent on levels of sadness, represents vulnerability for depression. Few studies have directly tested this hypothesis, particularly using intensive data collection methods (i.e., experience sampling) required to capture the temporal dynamics of sadness and self-esteem as they unfold naturally, over time. In this study we used participants' smartphones to collect multiple daily ratings of sadness and self-esteem over three weeks, in the real world. We then applied dynamic factor modeling to explore theoretically driven hypotheses about the temporal dependency of self-esteem on sadness (i.e., mood-reactive self-esteem) and its relationship to indices of depression vulnerability both contemporaneously (e.g., rumination, sad mood persistence) and prospectively (e.g., future symptomatology). In sum, individuals who demonstrated mood-reactive self-esteem reported higher levels of rumination at baseline, more persistent sad mood over three weeks, and increased depression symptoms at the end of three weeks above and beyond a trait-like index of self-esteem. The integration of smartphone assessment and person-specific analytics employed in this study offers an exiting new avenue to advance the study and treatment of depression.

Research paper thumbnail of Toward a Dynamic Model of Psychological Assessment: Implications for Personalized Care

Journal of Consulting and Clinical Psychology, 2015

The present article proposes a general framework and a set of specific methodological steps for c... more The present article proposes a general framework and a set of specific methodological steps for conducting person-specific dynamic assessments, which yield information about syndrome structures and states that can be used to provide actionable information for the formulation of personalized interventions. It is proposed that researchers should (a) determine the relevant constituent inputs for a diagnostic system; (b) measure these inputs with as much detail as possible; (c) assess the correlational structure of system inputs via factor-analytic methods within individuals; and (d) subject the individual-level, latent dimension time series to dynamic analyses such as the dynamic factor model (Molenaar, 1985) to discern the time-dependent, dynamic relationships within and between system components. An exemplar is provided wherein 10 individuals with clinically diagnosed generalized anxiety disorder completed surveys related to generalized anxiety disorder symptomatology for at least 60 consecutive days. These data were then subjected to person-specific exploratory and confirmatory factor analyses for the identification of latent symptom dimensions. Finally, dynamic factor models were used to model the dynamic interrelationships within and between symptom domains on a person-by-person basis. Person-specific factor analyses returned models with 3 (n = 8) or 4 (n = 2) latent factors, all with excellent fit. Dynamic factor modeling successfully revealed the contemporaneous correlations and time-lagged predictive relationships between factors, providing prescriptive information for the formulation of targeted interventions. The proposed approach has the potential to inform the construction and implementation of personalized treatments by delineating the idiosyncratic structure of psychopathology on a person-by-person basis. (PsycINFO Database Record

Research paper thumbnail of Personalized assessment and treatment of depression

Current Opinion in Psychology, 2015

The drive to personalize the delivery of psychosocial and pharmacologic treatments is embodied in... more The drive to personalize the delivery of psychosocial and pharmacologic treatments is embodied in Gordon Paul's (1967) famous question, "What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?" Traditionally, researchers have examined "what works for whom" via post hoc moderator analyses. However, these efforts have been largely unsuccessful, suffering from poor replication and statistical bias due a lack of random assignment. Recent advances in genetic and biological technologies and statistical methods have facilitated an explosion of research on the personalization of treatment for psychological disorders. The present review examines recent developments in the personalization of depression treatment. Page 3 of 23 A c c e p t e d M a n u s c r i p t Personalized assessment and treatment of depression 3 Highlights  We review recent developments in the personalization of depression assessment and treatment.

Research paper thumbnail of Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure

Journal of Consulting and Clinical Psychology, 2014

The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) ther... more The goal of the current study was to examine mechanisms of change in prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD). Emotional processing theory of PTSD proposes that disconfirmation of erroneous cognitions associated with PTSD is a central mechanism in PTSD symptom reduction; but to date, the causal relationship between change in pathological cognitions and change in PTSD severity has not been established. Method: Female sexual or nonsexual assault survivors (N ϭ 64) with a primary diagnosis of PTSD received 10 weekly sessions of PE. Self-reported PTSD symptoms, depression symptoms, and PTSD-related cognitions were assessed at pretreatment, each of the 10 PE treatment sessions, and posttreatment. Results: Lagged mixed-effect regression models indicated that session-to-session reductions in PTSD-related cognitions drove successive reductions in PTSD symptoms. By contrast, the reverse effect of PTSD symptom change on change in cognitions was smaller and did not reach statistical significance. Similarly, reductions in PTSD-related cognitions drove successive reductions in depression symptoms, whereas the reverse effect of depression symptoms on subsequent cognition change was smaller and not significant. Notably, the relationships between changes in cognitions and PTSD symptoms were stronger than the relationships between changes in cognitions and depression symptoms. Conclusions: To our knowledge, this is the 1st study to establish change in PTSD-related cognitions as a central mechanism of PE treatment. These findings are consistent with emotional processing theory and have important clinical implications for the effective implementation of PE.

Research paper thumbnail of Validating the Rapid Responder Construct Within a Practice Research Network

Journal of Clinical Psychology, 2014

Research paper thumbnail of Motivation and Changes in Depression

Cognitive Therapy and Research, 2013

This study evaluated the capacity of the Willingness Scale (WS) to predict changes in depression ... more This study evaluated the capacity of the Willingness Scale (WS) to predict changes in depression over the course of a brief inpatient admission. Two cohorts (N = 160) of adult inpatients completed the Willingness Scale along with a measure of depression following admission. Depression severity was assessed approximately 4 days later, prior to discharge. Data were evaluated using structural equation modeling. Higher WS scores predicted greater reductions in depression in both cohorts, and the magnitude of this effect was large. The fits of the models were outstanding, with no significant differences in any parameter estimates across the two cohorts. The WS predicts changes in depression, even within a brief inpatient admission where the treatment is predominantly biological. These results replicate results of previous studies in outpatient populations where CBT was the primary treatment and suggest motivational factors may play an important role in causation and recovery from depression.

Research paper thumbnail of The Self-Rating of the Effects of Alcohol Questionnaire as a Predictor of Alcohol-Related Outcomes in 12-Year-Old Subjects

Alcohol and Alcoholism, 2008

Aims: A low level of response (LR), or low sensitivity, to alcohol as established by alcohol chal... more Aims: A low level of response (LR), or low sensitivity, to alcohol as established by alcohol challenges has been shown to predict future heavier drinking, alcohol-related problems and alcohol use disorders. To date, only one study has evaluated the predictive validity of a second measure of LR as determined by the Self-Report of the Effects of Alcohol (SRE) Questionnaire. The current analyses evaluate the ability of SRE scores as determined at age 12 to predict heavier drinking and alcohol-related problems 2 years later in a sample from the United Kingdom. Methods: The subjects were 156 boys (54.5%) and girls from the Avon Longitudinal Study of Parents and Children (ALSPAC) who had reported consuming one or more standard drinks by age 12 and who were followed up 2 years later. Results: The age 12 SRE scores correlated with the number of drinks per week, maximum drinks and the number of alcohol problems both at baseline and at age 14 follow-ups. In these evaluations, a larger number of drinks required for effects on the SRE (i.e. a lower LR per drink consumed) related to heavier intake and alcohol-related difficulties. Simultaneous entry multiple regression analyses revealed that the age 12 SRE score maintained a significant relationship with age 14 higher number of drinks per week and the number of alcohol problems even when the age 12 values for alcohol intake and problems were used as covariates. Conclusion: The SRE scores appear to have value in predicting future heavier drinking and alcohol problems in 12-year olds that go beyond the information offered by the earlier drinking pattern alone.

Research paper thumbnail of The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression

Journal of Consulting and Clinical Psychology, 2013

Objective: This study tested whether the quality of the patient-rated working alliance, measured ... more Objective: This study tested whether the quality of the patient-rated working alliance, measured early in treatment, predicted subsequent symptom reduction in chronically depressed patients. Secondarily, the study assessed whether the relationship between early alliance and response to treatment differed between patients receiving cognitive behavioral analysis system of psychotherapy (CBASP) vs. brief supportive psychotherapy (BSP). Method: 395 adults (57% female; M age ϭ 46; 91% Caucasian) who met criteria for chronic depression and did not fully remit during a 12-week algorithm-based, open-label pharmacotherapy trial were randomized to receive either 16 -20 sessions of CBASP or BSP in addition to continued, algorithm-based antidepressant medication. Of these, 224 patients completed the Working Alliance Inventory-Short Form at Weeks 2 or 4 of treatment. Blind raters assessed depressive symptoms at 2-week intervals across treatment using the Hamilton Rating Scale for Depression. Linear mixed models tested the association between early alliance and subsequent symptom ratings while accounting for early symptom change. Results: A more positive early working alliance was associated with lower subsequent symptom ratings in both the CBASP and BSP, F(1, 1236) ϭ 62.48, p Ͻ .001. In addition, the interaction between alliance and psychotherapy type was significant, such that alliance quality was more strongly associated with symptom ratings among those in the CBASP treatment group, F(1, 1234) ϭ 8.31, p ϭ .004. Conclusions: The results support the role of the therapeutic alliance as a predictor of outcome across dissimilar treatments for chronic depression. Contrary to expectations, the therapeutic alliance was more strongly related to outcome in CBASP, the more directive of the 2 therapies.

Research paper thumbnail of Evaluating the impact of depression, anxiety & autonomic function on health related quality of life, vocational functioning and health care utilisation in acute coronary syndrome patients: the ADVENT study protocol

BMC Cardiovascular Disorders, Dec 2, 2013

Background: Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome ... more Background: Depression and anxiety are highly prevalent and co-morbid in acute coronary syndrome patients. Somatic and cognitive subtypes of depression and anxiety in acute coronary syndrome have been shown to be associated with mortality although their association with patient outcomes is unknown, as are the mechanisms that underpin these associations. We are conducting a prospective cohort study which aims to examine in acute coronary syndrome patients: (1) the role of somatic subtypes of depression and anxiety as predictors of health related quality of life outcomes; (2) how somatic subtypes of depression and anxiety relate to long term vocational functioning and healthcare utilisation; and (3) the role of the autonomic nervous system assessed by heart rate variability as a moderator of these associations.

Research paper thumbnail of Cardiac stability at differing levels of temporal analysis in panic disorder, post-traumatic stress disorder, and healthy controls

Psychophysiology

The panic disorder (PD) literature provides evidence for both physiologic rigidity and instabilit... more The panic disorder (PD) literature provides evidence for both physiologic rigidity and instability as pathognomonic features of this disorder. This ambiguity may be a result of viewing PD at differential levels of temporal analysis. We assessed cardiac variability across three levels of temporal scale in PD patients, post-traumatic stress disorder (PTSD) patients, and healthy controls. Sixteen healthy controls, 14 PD patients, 23 PTSD patients, and 16 PTSD + PD patients presented for a polysomnogram. Differences were assessed in respiratory sinus arrhythmia (RSA), autoregressive stability of heart rate (HR), and the number of nonspecific accelerations in HR over the night. No differences in RSA were found between groups; however, PD patients exhibited significantly lower autoregressive HR stability, and all patients had significantly more HR accelerations than controls. These data reinforce prior findings demonstrating physiologic instability in PD and indicate that prior equivocalities regarding physiologic variability in PD may be due to limited temporal scaling of measurements.

Research paper thumbnail of Heart rate and autonomic response to stress after experimental induction of worry versus relaxation in healthy, high-worry, and generalized anxiety disorder individuals.

Biological Psychology

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Research paper thumbnail of The relationship between the therapeutic alliance and treatment outcome in two distinct psychotherapies for chronic depression.

Journal of Consulting and Clinical Psychology, 2013

Research paper thumbnail of Mediated moderation in combined cognitive behavioral therapy versus component treatments for generalized anxiety disorder.

Journal of Consulting and Clinical Pscyhology

Objective: This study examined a) duration of generalized anxiety disorder (GAD) as a moderator o... more Objective: This study examined a) duration of generalized anxiety disorder (GAD) as a moderator of cognitive behavioral therapy (CBT) versus its components (cognitive therapy and self-control desensitization) and b) increases in adaptive order of anxious symptoms during the course of psychotherapy as a mediator of this moderation. Adaptive order (degree of dynamic flexibility in daily symptoms) was quantified as the inverse of spectral power due to daily to intra-daily oscillations in fourfold-daily diary data (Fisher, Newman, & Molenaar, 2011). Method: This was a secondary analysis of Borkovec, Newman, Pincus, & Lytle (2002). Seventy-six participants with a principle diagnosis of GAD were assigned randomly to combined CBT (n = 24), cognitive therapy (n = 25) or self-control desensitization (n = 27). Results: Duration of GAD moderated outcome such that those with longer duration showed greater reliable change from component treatments than they showed from CBT, whereas those with shorter duration fared better in response to CBT. Decreasing predictability in daily and intradaily oscillations during therapy reflected less rigidity and more flexible responding. Increases in flexibility over the course of therapy fully mediated the moderating effect of GAD duration on condition, indicating a mediated moderation process. Conclusions: Individuals with longer duration of GAD may respond better to more focused treatments whereas those with shorter duration of GAD may respond better to a treatment that offers more coping strategies. Importantly, the mechanism by which this moderation occurs appears to be the establishment of flexible responding during treatment.

Research paper thumbnail of Proposed Specific Factors for Generalized Anxiety Disorder Within the Integrative Hierarchical Model of Anxiety and Depression

Since its first appearance in the third edition of the Diagnostic and Statistical Manual of Menta... more Since its first appearance in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980), generalized anxiety disorder (GAD) has provided challenges to the discriminative validity of the mood and anxiety disorders. Although the removal of autonomic symptoms from the diagnostic criteria for GAD in DSM-IV helped to increase the diagnostic reliability from a range of .27 to . 56 (Williams et al., 1992) based on DSM-III-R criteria and .67 based on DSM-IV criteria (Brown, Di Nardo, Lehman, & Campbell, 2001), some researchers have expressed concern that this distinction further confuses the boundary between GAD and mood disorders Brown et al., 1995). It has been argued that though the removal of these symptoms from the diagnostic criteria improved the overall reliability of GAD, as well as the discriminative validity of GAD in relation to the other anxiety disorders, the overlap with depressive disorders and the discriminative difficulties therein still remain. Research based on DSM-IV criteria has shown that GAD shares a closer relationship to the mood disorders than it does to other anxiety disorders . Clark and Watson (1991) developed the tripartite model, in which depression and anxiety share a common factor of negative affectivity, depression is indicated by low positive affectivity (PA) and anxiety by high autonomic arousal (AA). Mineka, Watson, and Clark expanded on this model with the integrative hierarchical model, within which each anxiety disorder is indicated by an idiosyncratic predictor. has made the argument that this model can and should be extended to new taxonomic systems, including the approaching DSM-V. However, a specific factor remains to be determined for GAD within this model.

Research paper thumbnail of A quantitative method for the analysis of nomothetic relationships between idiographic structures: Dynamic patterns create attractor states for sustained posttreatment  …

Journal of consulting and …, Jan 1, 2011

ObjectiveThe present article aimed to demonstrate that the establishment of dynamic patterns duri... more ObjectiveThe present article aimed to demonstrate that the establishment of dynamic patterns during the course of psychotherapy can create attractor states for continued adaptive change following the conclusion of treatmentMethodThis study is a secondary analysis of T. D. Borkovec and E. Costello (1993). Of the 55 participants in the original study, 33 were retained for the present analysis due to the homogeneity of psychotherapy outcome among these participants. Of these 33, the majority were White (88%) and female (70%), and the average age was 35.44 years (SD = 14.46). Participants participated in 12 weeks of either cognitive behavioral therapy or applied relaxation. Daily diary entries from the treatment period were subjected to time series analyses in order to determine the degree of order versus disorder present within individual dynamic systems. These idiographic data were then aggregated for nomothetic analysis of treatment outcome via linear mixed effect models.ResultsSpectral power due to daily to intradaily oscillations in thrice-daily diary data significantly moderated reliable change over posttreatment follow-up such that lesser power predicted increases in reliable change over the 1-year follow-up period. Additionally, residual variance for dynamic factor models significantly moderated the slope for change over the follow-up period, such that lesser variance—and thus greater order in dynamic systems—predicted increases in reliable change.ConclusionsThe degree of order in dynamic systems established during therapy acted as an adaptive attractor state, promoting continued positive gains 1 year after the conclusion of therapy. The present study represents an important innovation in the study of dynamic systems in psychotherapy.

Research paper thumbnail of Expectancy/Credibility Change as a Mediator of Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Mechanism of Action or Proxy for Symptom  …

International journal of cognitive therapy, Jan 1, 2010

Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-sessio... more Examined the mediating effect of changes in expectancy/credibility from sessions 4-7 of 14-session cognitive and behavioral therapy for generalized anxiety disorder (GAD). In 76 adults with primary GAD, we predicted that expectancy/ credibility would change significantly from sessions 4-7, that degree of change in expectancy/credibility would predict degree of reliable change at posttreatment, and that changes in expectancy/credibility would mediate the relationship between pretreatment severity and change at posttreatment. In support of the hypotheses, a latent growth model revealed significant increases in expectancy/credibility over the critical period. In addition, baseline GAD severity, expectancy/credibility intercept, and rate of change in expectancy/credibility all positively predicted degree of reliable change at posttreatment. Rate of change in expectancy/credibility during the critical period partially mediated the effect of baseline GAD severity, accounting for 38% of the variance in this relationship. This effect was not accounted for by preceding or concurrently changing anxiety levels.

Research paper thumbnail of Sympathetic arousal moderates self-reported physiological arousal symptoms at baseline and physiological flexibility in response to a stressor in generalized anxiety  …

Biological psychology, Jan 1, 2010

Research paper thumbnail of A randomized controlled trial of cognitive-behavioral therapy for generalized anxiety disorder with integrated techniques from emotion-focused and interpersonal  …

Journal of Consulting …, Jan 1, 2011

Objective: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintain... more Objective: Recent models suggest that generalized anxiety disorder (GAD) symptoms may be maintained by emotional processing avoidance and interpersonal problems. Method: This is the first randomized controlled trial to test directly whether cognitive-behavioral therapy (CBT) could be augmented with the addition of a module targeting interpersonal problems and emotional processing. Eighty-three primarily White participants (mean age ϭ 37) with a principle diagnosis of GAD were recruited from the community. Participants were assigned randomly to CBT plus supportive listening (n ϭ 40) or to CBT plus interpersonal and emotional processing therapy (n ϭ 43) within a study using an additive design. Doctoral-level psychologists with full-time private practices treated participants in an outpatient clinic. Using blind assessors, participants were assessed at pretreatment, posttreatment, 6-month, 1-year, and 2-year follow-up with a composite of self-report and assessor-rated GAD symptom measures (the Penn State Worry Questionnaire; T.

Research paper thumbnail of Within-sample temporal instability in cross- sectional estimates

Proceedings of the National Academy of Sciences, 2019

We offer our sincere gratitude to Hamaker and Ryan (1) for their comment. As we note in our manus... more We offer our sincere gratitude to Hamaker and Ryan (1) for their comment. As we note in our manuscript (2), we believe the generalization issue in question to be a key problem in human subject research methodology. This challenge requires effort from all quarters to resolve. We also agree "that we should interpret measures in terms of what they are meant to represent." This is perhaps the most important point to be taken from our paper-that understanding individuals requires measuring and analyzing individuals. Thus, it may be fair to argue that comparisons between idio-graphic and nomothetic data structures offer limited value. To this end, we do not diverge from Hamaker and Ryan's position. However, we should clarify that the repeated sampling paradigm we used explicitly avoids the problem of an asymptotically error-free estimate under infinite sampling conditions. As Hamaker and Ryan (1) note, our cross-sectional samples were not independent. Specifically, we resampled the same population, in its entirety, multiple times. As a result, the variability around the cross-sectional correlation estimate is the degree to which that estimate varies within the sampled population over time. Taken to the extreme, measuring a bivariate correlation in the entire human population at one time point would return a cross-sectional estimate without error. However, measuring the same bivariate correlation in the entire human population repeatedly would produce a distribution of estimates with a central tendency and a non-zero SD-the degree to which each measurement varied from the average across time points. Consequently , our estimate is not a proxy for the SE of the cross-sectional correlation estimate or for within-individual correlations, but a third representation, which estimates within-sample temporal instability in cross-sectional estimates. As Hamaker and Ryan (1) would likely agree, this third representation is fundamentally not a representation of within-subject processes over time. Moreover , it is also fair to acknowledge that it likely does not reflect the true measure of the variability (i.e., temporal instability) of the cross-sectional estimate over time. Although the repeated sampling of any population will produce variation around the mean, some of this variation will no doubt be due to within-individual variance over time. This intrasubject variation might further include important stochastic, nonlinear, and phase information. We believe that for group-derived statistical estimates to generalize to individuals, these estimates must hold true over time (and likewise correspond with temporal dynamics at the individual level). Given that human physiology and phenomenology unfold in time, quantifications of human experience must apply over repeated intervals. However, the variability that a single individual exhibits in behavior over repeated assessments is fundamentally different from the variability that a cross-sectional estimate exhibits from repeated testing. Thus, it may be inappropriate to use one estimate to represent or draw inferences about the other (3). Like Hamaker and Ryan (1), we advocate for statistical practices that distinguish group and individual effects, as these illustrate the difference between understanding people and claims about groups, which may or may not extrapolate to their constituent individuals.