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Die Akzeptanz- und Commitment-Therapie (ACT) ist ein transdiagnostischer kognitiv-verhaltenstherapeutischer Ansatz, der darauf abzielt, Menschen zu vermitteln, emotionalen Problemen mit Achtsamkeit und Mitgefühl offen zu begegnen und gleichzeitig in ihrem Leben das zu verfolgen, was ihnen wirklich am Herzen liegt. Die Neubearbeitung des Bandes liefert eine Einführung in die Grundlagen und Methoden der ACT und stellt störungsübergreifende therapeutische Strategien praxisnah dar. In der ACT geht es nicht primär um die Beseitigung und Kontrolle von Symptomen, sondern darum, eine größere psychologische Flexibilität durch das Lernen von achtsamer Akzeptanz zu entwickeln. Anhand zahlreicher Beispiele beschreibt der Band, wie Klientinnen und Klienten lernen können, mit mehr Freundlichkeit auf ihr ungewolltes inneres Erleben zu reagieren, sanft mit ihren Gefühls- und Gedankenbarrieren umzugehen sowie den Fokus auf die Verfolgung von Lebenszielen zu konzentrieren, die bisher oft dem Management von Ängsten, Sorgen, Depressionen und anderen Belastungen zum Opfer gefallen sind. Dazu werden zahlreiche erfahrungsbezogene Übungen, Metaphern, Achtsamkeitstechniken und Methoden der Verhaltensaktivierung vorgestellt. Die Neuauflage des Bandes informiert über aktuelle Entwicklungen der ACT: So ist in den letzten Jahren die Evidenzbasis der ACT durch zahlreiche Studien enorm angewachsen, das Verständnis der Therapieprozesse hat sich insbesondere in Bezug auf die Beobachterperspektive vertieft und der therapeutische Fokus hat sich durch ein stärkeres Betonen des Beobachtens schwieriger Erlebensinhalte aus der Beobachterperspektive und durch die Integration von Techniken zur Förderung von Selbstmitgefühl erweitert.

Background Assessing in-session processes is important in psychotherapy research. The aim of the present study was to create and evaluate a short questionnaire capturing the patients’ view of the in-session realization of the six core components of Acceptance and Commitment Therapy (ACT). Method In two studies, psychotherapy patients receiving ACT (Study 1: n = 87) or Cognitive-Behavioral Therapy (CBT) (Study 2, Sample 1: n = 115; Sample 2: n = 156) completed the ACT session questionnaire (ACT-SQ). Therapists were n = 9 ACT therapists (Study 1) and n = 77 CBT trainee therapists (Study 2). Results Factor structure: Exploratory factor analyses suggested a one-factor solution for the ACT-SQ. Reliability: Cronbach’s alpha of the ACT-SQ was good (Study 1: α = .81; Study 2, Sample 1: α = .84; Sample 2: α = .88). Convergent validity: The ACT-SQ was positively correlated with validated psychotherapeutic change mechanisms (p < .05). Criterion validity: Higher ACT-SQ scores were associated with better treatment outcomes (p < .05). Conclusion The study provides preliminary evidence for the reliability and validity of the ACT-SQ to assess the in-session realization of the six core components of ACT in the patients’ view. Further validation studies and ACT-SQ versions for therapists and observers are necessary.

Background Psychological flexibility theory (PFT) suggests three key processes of change: increases in value-directed behaviors, reduction in struggle with symptoms, and reduction in suffering. We hypothesized that Acceptance and Commitment Therapy (ACT) would change these processes and that increases in valued action and decreases in struggle would precede change in suffering. Method Data were derived from a randomized clinical trial testing ACT (vs. waitlist) for treatment-resistant patients with primary panic disorder with/without agoraphobia (n = 41). Valued behavior, struggle, and suffering were assessed at each of eight sessions. Results Valued actions, struggle, and suffering all changed over the course of therapy. Overall changes in struggle and suffering were interdependent whereas changes in valued behavior were largely independent. Levels of valued behaviors influenced subsequent suffering, but the other two variables did not influence subsequent levels of valued action. Discussion This finding supports a central tenet of PFT that increased (re-)engagement in valued behaviors precedes reductions in suffering. Possible implications for a better understanding of response and non-response to psychotherapy are discussed.

Befreien Sie sich aus den Fangen der Angst, und beginnen Sie ein neues Leben >br> Machen wir uns doch nichts vor: An der Angst fuhrt kein Weg vorbei. Vielleicht stellt sie sich ein, wenn Sie morgens aufwachen, wenn Sie zur Arbeit fahren, wenn Sie in der Warteschlange an der Supermarktkasse stehen oder Partys und andere gesellschaftliche Events besuchen. Vielleicht halt die Angst Sie sogar davon ab, nachts einzuschlafen, und das fuhrt zu Erschopfung, Stress und noch mehr Angst. Kurz: Die Angst kann Ihr ganzes Leben in Beschlag nehmen, wenn Sie es zulassen. Tun Sie etwas dagegen! Dieser auserst hilfreiche kleine Ratgeber enthalt 52 unmittelbar anwendbare Achtsamkeitsstrategien, die Sie jederzeit und uberall nutzen konnen, um Ruhe und inneren Frieden zu kultivieren. Sie gehen Ihrer Angst auf den Grund, lernen, wieso das Vermeiden nicht funktioniert, und finden heraus, wie man Angstgedanken den Stachel nimmt. Schlieslich erfahren Sie, wie Sie Ihre Wertvorstellungen in den Fokus rucken konnen und so uber die Angst hinauswachsen - und zwar ein fur alle Mal.

Die Akzeptanz- und Commitment-Therapie (ACT) gehort zu den prominentesten Weiterentwicklungen innerhalb der Verhaltenstherapie und wird zu den sog. „Dritte-Welle“-Ansatzen gezahlt. Die ACT ist in Grundlagen und Anwendungen empirisch fundiert, basiert auf einem prozessorientierten Modell und ist ein transdiagnostisches Verfahren. Aufbauend auf der Annahme, dass rigide Kontroll- und Vermeidungsbemuhungen inneren Erlebens den Verhaltensspielraum einschranken, ist das primare Ziel der ACT nicht die Symptomreduktion oder die Verbesserung von Erlebnisinhalten. Vielmehr liegt der Fokus in der ACT auf der Forderung von sechs Kernfertigkeiten zur Steigerung der allgemeinen psychischen Flexibilitat. Insbesondere anhand von Metaphern sowie erlebnis- und erfahrungsbasierten Vorgehensweisen soll ein intuitives Verstandnis der Verstarkerparadoxien erreicht werden, um den inneren Kampf mit unerwunschten und schmerzhaften Erfahrungen aufgeben zu konnen und stattdessen den Fokus auf die selbstbestimmte Verhaltensausrichtung nach eigenen Werten zu legen.

This chapter reviews somatic symptom disorders from the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) perspective highlighting the prevalence, nature, and the diagnostic validity of such diagnoses. It outlines how a dimensional perspective that focuses on key biobehavioral processes may be a more useful approach for understanding somatic disorders than the DSM’s categorical approach. The chapter discusses how a dimensional perspective and focus on dysfunctional processes related to illness behavior can be translated into treatments for somatic symptom disorders. It addresses some key vulnerability processes for somatic symptom disorders. DSM-5 distinguishes between five somatic symptom and related disorders: somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting other medical conditions, and factitious disorder. The overwhelming finding from cross-cultural studies is that the somatic manifestation and expression of emotional distress is universal, but the focus of somatic concern may vary in different cultures.

Summary Mental health promotion programs (MHP) seek to reduce sub-syndromal symptoms of mental distress and enhance positive mental health. This study evaluates the long-term effects of a mindfulness-based MHP program (‘Life Balance’) provided by health coaches in a multi-site field setting on mental distress, satisfaction with life and resilience. Using a controlled design, propensity score matching was used to select a control group for participants of the MHP. The total study sample (N = 3624) comprised 83% women, with a mean age of 50 years. Data was collected via mailings 1 year after study entry. Results suggest participants experience reduced emotional distress at 12-month follow-up, with a medium between-group effect size (d = 0.40) for those participants who showed clinically relevant symptoms of mental distress at study entry. The effects of the program were more pronounced in participants with higher initial distress scores. New cases of psychopathological symptoms were prevented in 1 of 16 participants. Satisfaction with life and resilience were enhanced significantly. Our data suggest ‘Life Balance’ shows long-term effectiveness and indicate it is possible to design MHP programs that serve as both primary and indicated prevention, and that these programs can be applied on a population basis.

Objective Evaluate the incremental effects of a computerized values clarification (VC) activity on anxiety symptomology and quality of life over and above establishment of a mindfulness meditation (MM) practice. Method Anxious participants (N = 120, Female = 86; Mage = 22.26) were randomly assigned to a 2-week, 10-min daily MM practice + control task or a 2-week, 10-min daily MM practice + VC task. Pre-assessments and post-assessments included well-established and ideographic self-report measures. Results Overall decreases in past week and past 24-h anxiety symptom frequency, as well as increased quality of life during the previous 24-h cycle only. VC did not have a demonstrable impact on outcomes. Conclusions Though findings are preliminary, brief VC exercises may not enhance outcomes that follow from mindfulness practice. Additional research is needed to isolate specific and shared impacts of mindfulness-based and values-based treatment strategies on anxiety symptoms and quality of life.

ZusammenfassungAkzeptanz- und Commitment-Therapie (ACT) ist ein therapeutischer Balance-ACT zwischen Akzeptanz und Veränderung. ACT ist transdiagnostisch und basiert auf den Ergebnissen zahlreicher Studien, die zeigen, dass ein Großteil psychischen Leidens Folge von Erlebensvermeidung ist. Kontrolle und Beseitigung unerwünschter Gedanken und Gefühle (Symptome) sind daher kein direktes Therapieziel. Anstatt mit unerwünschten schlecht zu kontrollierenden Gedanken und Gefühlen weiterhin zu kämpfen, lernen Patienten, (a) dass rigide unflexible Versuche aversives Erleben zu beseitigen keine Lösung, sondern das Problem sind; (b) zu unterscheiden, was sie eher kontrollieren und eher nicht kontrollieren können; (c) größere psychologische Flexibilität zu entwickeln durch das Praktizieren von achtsamer Akzeptanz, Bereitschaft und Defusion beim Auftauchen schwierigen Erlebens; (d) Lebensziele bzw. Werte zu identifizieren und in engagiertes Handeln umzusetzen und getroffene Vorsätze einzuhalten (commitment), (e) Erlebensbarrieren nicht zu bekämpfen, sondern sie freundlich mit auf den Weg zu nehmen. In der ACT stehen vor allem erlebensorientierte Methoden im Mittelpunkt (z. B. Ausspielen von Metaphern, Akzeptanzübungen). Eine ständig wachsende Zahl empirischer Untersuchungen unterstützt die Effektivität der ACT zur Behandlung eines breiten Spektrums psychischer Störungen.

Objective: Randomized comparisons of acceptance-based treatments with traditional cognitive behavioral therapy (CBT) for anxiety disorders are lacking. To address this gap, we compared acceptance and commitment therapy (ACT) to CBT for heterogeneous anxiety disorders. Method: One hundred twenty-eight individuals (52% female, mean age 38, 33% minority) with 1 or more DSM–IV anxiety disorders began treatment following randomization to CBT or ACT; both treatments included behavioral exposure. Assessments at pre-treatment, post-treatment, and 6- and 12-month follow-up measured anxiety-specific (principal disorder Clinical Severity Ratings [CSRs], Anxiety Sensitivity Index, Penn State Worry Questionnaire, Fear Questionnaire avoidance) and non-anxiety-specific (Quality of Life Index [QOLI], Acceptance and Action Questionnaire–16 [AAQ]) outcomes. Treatment adherence, therapist competency ratings, treatment credibility, and co-occurring mood and anxiety disorders were investigated. Results: CBT and ACT improved similarly across all outcomes from pre- to post-treatment. During follow-up, ACT showed steeper linear CSR improvements than CBT (p .05, d 1.26), and at 12-month follow-up, ACT showed lower CSRs than CBT among completers (p .05, d 1.10). At 12-month follow-up, ACT reported higher AAQ than CBT (p .08, d 0.42; completers: p .05, d 0.56), whereas CBT reported higher QOLI than ACT (p .05, d 0.42). Attrition and comorbidity improvements were similar; ACT used more non-study psychotherapy at 6-month follow-up. Therapist adherence and competency were good; treatment credibility was higher in CBT. Conclusions: Overall improvement was similar between ACT and CBT, indicating that ACT is a highly viable treatment for anxiety disorders.

Women and men diagnosed with infertility experience a variety of infertility-related stressors, including changes to their family and social networks, strain on their sexual relationship, and difficulties and unexpected challenges in their relationship. Infertility stress is linked with depression and psychological distress, and can lead to premature dropout from medical treatments and unresolved feelings of loss and grief. The current study examined the effectiveness of treating infertility stress using Acceptance and Commitment Therapy (ACT), a promising new behavior therapy that targets experiential avoidance through mindfulness, acceptance strategies, and value-directed action. This single-case study followed a couple experiencing infertility-related stress following a failed in vitro fertilization (IVF) procedure. The couple completed 6 self-report measures at 7 time points, including a second failed IVF attempt and a 1-year follow-up. Measures included both distress-focused instruments and therapy process-related questionnaires. The female participant reported higher pretreatment stress and depression scores compared to her partner. She reported significant decreases in global infertility stress, social infertility stress, sexual infertility stress, psychological distress, and depression from pretherapy to 1-year follow-up. She also reported a decrease in infertility stress following her second failed in vitro fertilization (IVF) attempt. The male participant reported significant decreases in sexual infertility stress. The study suggests that acceptance-based therapy shows promise in treating infertility stress in patients experiencing infertility who undergo medical treatments. The data from this preliminary case study also suggest that ACT may be helpful for couples following IVF treatment failure. Treatment gains were maintained 1-year posttherapy, indicating that an ACT approach to treating infertility has the potential to produce lasting change.

The goal of this paper is to familiarize clinicians with the use of Acceptance and Commitment Therapy (ACT) for problem anger by describing the application of ACT to a case of a 45-year-old man struggling with anger. ACT is an approach and set of intervention technologies that support acceptance and mindfulness processes linked with commitment and behavior change processes. Here, we outline an ACT model of problem anger, extend that analysis to a clinical case, and illustrate ACT intervention strategies and assessment considerations. As will be seen, ACT teaches individuals to “act on life, not an anger” by choosing and committing to live consistently with personal values rather than acting on anger feelings and associated behavioral impulses.

Acceptance and Commitment Therapy (ACT) is an innovative acceptance-based behavior therapy that has been applied broadly and successfully to treat a variety of clinical problems, including the anxiety disorders. Throughout treatment ACT balances acceptance and mindfulness processes with commitment and behavior change processes. As applied to anxiety disorders, ACT seeks to undermine excessive struggle with anxiety and experiential avoidance––attempts to down-regulate and control unwanted private events (thoughts, images, bodily sensations). The goal is to foster more flexible and mindful ways of relating to anxiety so individuals can pursue life goals important to them. This article describes in some detail a unified ACT protocol that can be adapted for use with persons presenting with any of the major anxiety disorders. To exemplify this approach, we present pre- and posttreatment data from three individuals with different anxiety disorders who underwent treatment over a 12-week period. The results showed positive pre- to posttreatment changes in ACT-relevant process measures (e.g., reductions in experiential avoidance, increases in acceptance and mindfulness skills), increases in quality of life, as well as significant reductions in traditional anxiety and distress measures. All three clients reported maintaining or improving on their posttreatment level of functioning.

Although the field of couple therapy has made significant strides in recent years, there continues to be a need for theoretically sound and empirically supported treatments. The current case study examines whether Acceptance and Commitment Therapy (ACT), an experiential acceptance-based behavior therapy, can be effective in treating distressed couples. Although ACT has demonstrated effectiveness in treating a variety of disorders in individuals, it has not been systemically applied to the treatment of couple distress, and the current study is the first empirical examination of ACT for the treatment of couples. Two married couples participated in the study. A number of core ACT interventions were modified to treat couples in a conjoint format. Cognitive defusion exercises were used to help couples reduce their fusion with and the believability of negative thoughts and feelings related to the relationship. Mindfulness and acceptance techniques were used to help couples increase awareness of their reactions to negative relationship cycles. Finally, value-directed action was used to help partners act in ways consistent with relationship values even in the presence of unwanted thoughts and feelings. The results of this preliminary case study suggest that ACT may be effective in increasing marital adjustment and satisfaction, and in reducing interpersonal and psychological distress in couples. Future studies with larger samples and more controlled designs are needed to build on the results from this single-case study.

INTRODUÇÃO: É crescente a produção científica brasileira na adaptação de instrumentos internacionais para avaliar ansiedade. A tradução e adaptação transcultural de escalas é um primeiro passo na obtenção de instrumentos válidos que permitam a comparação de diferentes populações. O objetivo do presente estudo foi traduzir e avaliar a equivalência semântica do Cardiac Anxiety Questionnaire, realizando um estudo piloto na população brasileira de diferentes níveis de escolaridade. MÉTODO: O processo de adaptação transcultural envolveu duas traduções e retrotraduções realizadas por avaliadores independentes, avaliação das versões e elaboração de uma versão síntese. Também examinamos os comentários dos participantes sobre a versão preliminar do questionário, os quais foram usados no desenvolvimento da versão final. RESULTADOS: Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Os participantes com maior grau de escolaridade não apresentaram dificuldades na compreensão do instrumento, tendo apenas apresentado sugestões controversas acerca do item 5. Entretanto, os participantes apenas com escolaridade em nível fundamental relataram dificuldades com os itens 2, 4, 6, 7, 10, 11 e 14. Algumas alterações semânticas foram realizadas com o intuito de facilitar a compreensão do instrumento. CONCLUSÃO: A utilização de duas versões de tradução e retrotradução, discussão sobre a versão síntese e a interlocução com a população-alvo proporcionaram maior segurança ao processo de equivalência semântica da versão final brasileira.INTRODUCTION: There has been a growing interest in the cross-cultural application of psychological questionnaires to assess anxiety. The translation and cross-cultural adaptation of the original instrument is the first step in validating an instrument in a new population that will permit comparisons between different populations. The goals of this study were to translate the Cardiac Anxiety Questionnaire, assess its semantic equivalence, and perform a preliminary test with participants from the Brazilian population that were drawn from different educational backgrounds. METHOD: The cross-cultural adaptation process consisted of two translations and back translations performed by two independent evaluators; a critical evaluation of the two versions, and the development of a synthesized version. We also examined comments provided by participants on the preliminary version of the questionnaire and used them for the development of the final version. RESULTS: We report the results of the four stages for each item of the instrument. Participants with tertiary education had no difficulties comprehending the translated items of the questionnaire, only pointing item 5 as ambiguous. Participants from the lower educational level reported comprehension problems regarding items 2, 4, 6, 7, 10, 11 and 14. Some small changes were made in our first version to enhance comprehensibility. CONCLUSION: The use of two versions of translations, a critical examination of the two versions, and suggestions made by participants resulted in a final Brazilian version with a satisfactory degree of semantic accuracy and semantic equivalence with the original version.

INTRODUÇÃO: É crescente a produção científica brasileira na adaptação de instrumentos internacionais para avaliar ansiedade. A tradução e adaptação transcultural de escalas é um primeiro passo na obtenção de instrumentos válidos que permitam a comparação de diferentes populações. O objetivo do presente estudo foi traduzir e avaliar a equivalência semântica do Cardiac Anxiety Questionnaire, realizando um estudo piloto na população brasileira de diferentes níveis de escolaridade. MÉTODO: O processo de adaptação transcultural envolveu duas traduções e retrotraduções realizadas por avaliadores independentes, avaliação das versões e elaboração de uma versão síntese. Também examinamos os comentários dos participantes sobre a versão preliminar do questionário, os quais foram usados no desenvolvimento da versão final. RESULTADOS: Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Os participantes com maior grau de escolaridade não apresentaram dificuldades na compreensão do instrumento, tendo apenas apresentado sugestões controversas acerca do item 5. Entretanto, os participantes apenas com escolaridade em nível fundamental relataram dificuldades com os itens 2, 4, 6, 7, 10, 11 e 14. Algumas alterações semânticas foram realizadas com o intuito de facilitar a compreensão do instrumento. CONCLUSÃO: A utilização de duas versões de tradução e retrotradução, discussão sobre a versão síntese e a interlocução com a população-alvo proporcionaram maior segurança ao processo de equivalência semântica da versão final brasileira. INTRODUCTION: There has been a growing interest in the cross-cultural application of psychological questionnaires to assess anxiety. The translation and cross-cultural adaptation of the original instrument is the first step in validating an instrument in a new population that will permit comparisons between different populations. The goals of this study were to translate the Cardiac Anxiety Questionnaire, assess its semantic equivalence, and perform a preliminary test with participants from the Brazilian population that were drawn from different educational backgrounds. METHOD: The cross-cultural adaptation process consisted of two translations and back translations performed by two independent evaluators; a critical evaluation of the two versions, and the development of a synthesized version. We also examined comments provided by participants on the preliminary version of the questionnaire and used them for the development of the final version. RESULTS: We report the results of the four stages for each item of the instrument. Participants with tertiary education had no difficulties comprehending the translated items of the questionnaire, only pointing item 5 as ambiguous. Participants from the lower educational level reported comprehension problems regarding items 2, 4, 6, 7, 10, 11 and 14. Some small changes were made in our first version to enhance comprehensibility. CONCLUSION: The use of two versions of translations, a critical examination of the two versions, and suggestions made by participants resulted in a final Brazilian version with a satisfactory degree of semantic accuracy and semantic equivalence with the original version.

Cardiophobia, a clinical syndrome that affects hundreds of thousands of individuals in the USA, is characterized by abrupt, recurrent sensations and pain in the chest in the absence of physical pathology. This conceptual article seeks to address the significance of cardiophobia in western culture and to distinguish it from related disorders. In addition, a model of cardiophobia that highlights the role of heart-focused anxiety and interoceptive conditioning in the generation of limited-symptom panic attacks and acute chest pain is presented and vulnerability factors for cardiophobia are discussed. Future research directions relevant to the assessment and treatment of this clinically significant phenomenon are reviewed.

Rigorous evaluations of cognitive behavioral self-help books for anxiety in pure self-help contexts are lacking. The present study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT) self-help workbook for anxiety-related concerns, with no therapist contact, in an international sample. Participants (N=503; 94% mental health diagnosis) were randomized to an immediate workbook (n=256) or wait-list condition (n=247). Assessments at pretreatment, 12weeks, 6months, and 9months evaluated anxiety and related symptoms, quality of life, and ACT treatment processes (e.g., psychological flexibility). Participants in the wait-list arm crossed over to the workbook following the 12-week assessment. The workbook condition yielded significant improvements on all assessments from pre- to posttreatment relative to wait-list, and these gains were maintained at follow-ups. The pattern observed in the wait-list condition was virtually identical to the active treatment arm after receiving the workbook, but not before. Attrition was notable, but supplemental analyses suggested dropout did not influence treatment effects for all but one measure. Overall, findings provide preliminary support for the effectiveness of this self-help workbook and suggest ACT-based self-help bibliotherapy might be a promising low-cost intervention for people experiencing significant anxiety-related concerns.

Taxometric coherent cut kinetic analyses were used to test the latent structure of anxiety sensitivity in samples from North America (Canada and United States of America), France, Mexico, Spain, and The Netherlands (total n = 2741). Anxiety sensitivity was indexed by the 36-item Anxiety Sensitivity Index--Revised (ASI-R; [J. Anxiety Disord. 12(5) (1998) 463]). Four manifest indicators of anxiety sensitivity were constructed using the ASI-R: fear of cardiovascular symptoms, fear of respiratory symptoms, fear of publicly observable anxiety reactions, and fear of mental incapacitation. Results from MAXCOV-HITMAX, internal consistency tests, analyses of simulated Monte Carlo data, and a MAMBAC external consistency test indicated that the latent structure of anxiety sensitivity was taxonic in each of the samples. The estimated base rate of the anxiety sensitivity taxon differed slightly between nations, ranging from 11.5 to 21.5%. In general, the four ASI-R based manifest indicators showed high levels of validity. Results are discussed in relation to the conceptual understanding of anxiety sensitivity, with specific emphasis on theoretical refinement of the construct.

The present study describes the development of a short, general measure of experiential avoidance, based on a specific theoretical approach to this process. A theoretically driven iterative exploratory analysis using structural equation modeling on data from a clinical sample yielded a single factor comprising 9 items. A fully confirmatory factor analysis upheld this same 9-item factor in an independent clinical sample. The operational characteristics of the Acceptance and Action Questionnaire (AAQ) were then examined in 8 additional samples. All totaled, over 2,400 participants were studied. As expected, higher levels of experiential avoidance were associated with higher levels of general psychopathology, depression, anxiety, a variety of specific fears, trauma, and a lower quality of life. The AAQ related to more specific measures of avoidant coping and to self-deceptive positivity, but the relation to psychopathology could not be fully accounted for by these alternative measures. The data provide some initial support for the model of experiential avoidance based on Relational Frame Theory that is incorporated into Acceptance and Commitment Therapy, and provides researchers with a preliminary measure for use in population-based studies on experiential avoidance.

Change-oriented strategies such as problem-solving/communication training (PS/CT) and parental behavior management training (BMT) have been used to treat parent-adolescent conflict. Although several studies have documented the efficacy of these approaches relative to wait-list control conditions, clinically significant improvements have not been achieved for the majority of adolescents with significant behavioral problems such as comorbid ADHD/ODD. A similar pattern of findings was observed in earlier studies examining couple relationships. Extending the focus and scope of traditional couple therapy to an acceptance-based integrative approach has led to impressive treatment improvements in that area. In a similar vein, we propose an integrative family therapy and suggest enhancing more traditional change-oriented approaches such as PS/CT and BMT by integrating acceptance strategies into a values-centered family therapy. We discuss the role of experiential avoidance and values orientation within a family context and present examples of techniques adapted from traditionally adult- and couple-focused therapies. Finally, we discuss the balancing and sequencing of acceptance and change techniques and offer suggestions for future research and practice.

The present study compared the effects of creating an acceptance versus a control treatment context on the avoidance of aversive interoceptive stimulation. Sixty high anxiety sensitive females were exposed to two 10-min periods of 10% carbon dioxide enriched air, an anxiogenic stimulus. Before each inhalation period, participants underwent a training procedure aimed at encouraging them either to mindfully observe (acceptance context) or to control symptoms via diaphragmatic breathing (control context). A third group was given no particular training or instructions. We hypothesized that an acceptance rather than control context would be more useful in the reduction of anxious avoidance. Compared to control context and no-instruction participants, acceptance context participants were less avoidant behaviorally and reported less intense fear and cognitive symptoms and fewer catastrophic thoughts during the CO(2) inhalations. We discuss the implications of our findings for an acceptance-focused vs. control-focused context when conducting clinical interventions for panic and other anxiety disorders.

This case study describes the treatment of a middle-aged, Caucasian male for alcohol dependence. Treatment focused on using the valued directions component of Acceptance and Commitment Therapy (ACT), a relatively new and promising intervention for substance use disorders. Rather than merely setting a treatment goal to “stop drinking,” we helped the client identify valued life directions that promote an environment to support sobriety and put a plan into action for the client to “start living.” Treatment resulted in improved quality of life and near 100% sobriety. The positive results of this clinical case complement the preliminary findings of a randomized clinical trial currently conducted to evaluate ACT in the treatment of polysubstance abuse. We discuss our treatment approach in relation to existing cognitive-behavioral interventions for alcohol dependence.

The present cross-sectional study sought to examine the extent to which heart-focused anxiety is associated with the co-occurrence of coronary artery disease (CAD) and a history of regular smoking in a sample of 148 postangiography patients from a cardiology unit. Individuals with CAD who regularly smoked demonstrated significantly greater heart-focused attention, but no greater degree of avoidance and fear of heart-focused sensations, than did nonsmoking persons with CAD and smokers without CAD. We also found evidence that heart-focused attention and fear incrementally predicted (above and beyond demographic variables and body mass index) intensity of average chest pain. Overall, this study provides some of the first empirical evidence that the co-occurrence of regular smoking and CAD is associated with specific dimensions of health anxiety. We discuss these findings in relation to models of panic pathology and anxious responding to bodily sensations.

Despite the widespread use of metaphors to teach relaxation, there is no research to explore whether children prefer and/or respond better to metaphorical compared to literal instructions. Thus, our primary goal was to investigate preference for and compliance with literal versus metaphorical instructions commonly used to teach relaxation to children. We exposed 33 non-clinical preschool children to both literal (e.g., squeeze your shoulders up to your ears) and metaphorical (e.g., pretend you are a turtle going into its shell) instructions. We assessed preferences by asking children to identify their “favorite” exercise(s), and coded compliance with instructions. Our results show that all children preferred metaphors to literal instructions. Although there was no overall difference in compliance to either set of instructions, compliance was high with both sets of instructions, and boys were more compliant with whichever instruction set was administered first. Our findings also suggest that inter...

Anxiety-related responding and skill deficits historically are associated with performance-based problems such as mathematics anxiety, yet the relative contribution of these variables to substandard performance remains poorly understood. Utilizing a 7% carbon dioxide (CO2) gas to induce anxiety, the present study examined the impact of anxious responding on two performance tasks, mental arithmetic and lexical decision. Independent variables included math anxiety group, gender, and gas condition. Dependent variables included task performance and physiological and self-report indices of anxiety. A total of 64 university undergraduate students participated. Physiological and verbal-report measures of anxiety supported the utility of 7% carbon dioxide-enriched air as an anxiety-inducing stimulus. Behavioral disruption on performance tasks, however, did not differ as a function of carbon dioxide inhalation. Performance did differ as a function of math anxiety. High math anxious individuals generally exhibited higher error rates on mathematical tasks, particularly on tasks designed to measure advanced math skill and those requiring working memory resources. These findings are discussed with reference to processing efficiency theory, discordance among anxiety response systems, and the intricacies associated with skill measurement.

Background: Nonresponsiveness to therapy is generally acknowledged, but only a few studies have tested switching to psychotherapy. This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy (ACT). Methods: This was a randomized controlled trial that included 43 patients diagnosed with primary panic disorder and/or agoraphobia (PD/A) with prior unsuccessful state-of-the-art treatment (mean number of previous sessions = 42.2). Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months. They were randomized to immediate treatment (n = 33) or a 4-week waiting list (n = 10) with delayed treatment (n = 8). Treatment consisted of eight sessions, implemented twice weekly over 4 weeks. Primary outcomes were measured with the Panic and Agoraphobia Scale (PAS), the Clinical Global Impression (CGI), and the Mobility Inventory (MI). Results: At post-treatment, patients who received ACT reported significantly more improvements on the PAS and CGI (d = 0.72 and 0.89, respectively) than those who were on the waiting list, while improvement on the MI (d = 0.50) was nearly significant. Secondary outcomes were consistent with ACT theory. Follow-up assessments indicated a stable and continued improvement after treatment. The dropout rate was low (9%). Conclusions: Despite a clinically challenging sample and brief treatment administered by novice therapists, patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list, with medium-to-large effect sizes that were maintained for at least 6 months. These proof-of-principle data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients. Further work on switching to psychotherapy for nonresponders is clearly needed.

Acceptance and Commitment Therapy (ACT) is a cognitive-behavioral treatment that targets ineffective control strategies and experiential avoidance—the unwillingness to accept negative thoughts, feelings, and emotions. Although ACT has been suggested as an effective treatment for panic, substance use, pain, and mood disorders, there are no published reports on the use of ACT for treating adolescent disorders such as anorexia nervosa. This case summarizes the successful adoption of ACT techniques in the treatment of a 15-year-old female with anorexia nervosa. It also shows how ACT techniques can be successfully combined with, and set the stage for, more standard cognitive-behavioral interventions.

The authors examined whether motivations for drinking alcohol are associated with the anxietyrelated dispositional tendencies of anxiety sensitivity, experiential avoidance, and alexithymic coping. The authors administered the Anxiety Sensitivity Index, Experiential Avoidance Scale, 20-item Toronto Alexithymia Scale, Revised Drinking Motives Questionnaire, and a demographics questionnaire to 182 university drinkers. In multiple regressions, the dispositional factors significantly predicted the risky drinking motives of coping, enhancement, and conformity. Coping and enhancement motives were significantly predicted by experiential avoidance. Conformity motives were significantly and independently predicted by anxiety sensitivity and alexithymia. The process of experiential avoidance mediated the bivariate correlation between anxiety sensitivity and coping-motivated drinking to a greater extent than did the process of alexithymic coping. The authors discuss the observed relations in regard to the psychological functions of drinking behavior that may portend the development of heavy drinking and alcohol problems in dispositionally vulnerable individuals. They also review implications for refinements of behavior therapy for problem drinkers.

Although multicenter clinical trials have impressively attested to the efficacy of psychological interventions for common psychological disorders, some individual patients still do not profit from treatment. In this article, we present a theoretical model and some supportive results to explain this unsatisfactory state. Apart from early treatment dropout, some patients are not engaged in treatment and lack the prerequisite behavior (“patient basic behavior”) for successfully applying protocol-specified intervention techniques. According to the dual model of therapy, therapists have two tasks: to apply treatment techniques/procedures and to motivate patients for treatment by strengthening patient basic behavior if necessary. Our results show that therapists attend and react to therapeutic process problems by changing from a method-oriented treatment strategy to a process- or patient-oriented strategy. This change, however, occurs too soon, too often, and occasionally for the wrong reason. We must therefore develop empirically based criteria to inform therapists when to react, what to look for, and what to do to motivate the patient. We conclude that treatment outcome research and process research are both valuable and complementary aspects of psychotherapy research.

The present investigation evaluated affective style in terms of anxiety sensitivity, emotional reactivity, and distress tolerance in heavy smokers. Specifically, heavy smokers (≥20 cigarettes per day) were partitioned into those who were able to quit for at least 7 days ( n =10) and those who were able to quit for less than 7 days ( n =12). All participants completed measures of anxiety sensitivity and maximum breath-holding duration and then were exposed to a 20% carbon dioxide-enriched air challenge. Results indicated that heavy smokers who had not been able to remain abstinent from smoking for at least 1 week during a quit attempt demonstrated significantly greater cognitive-affective reactivity to the challenge relative to their counterparts but did not differ at a physiological level of analysis. Contrary to our hypotheses, neither anxiety sensitivity scores nor maximum breath-holding duration significantly differed between the groups. These findings are discussed in relation to better understanding affective style among heavy smokers.

The present study explored psychological predictors of response to a series of three 25 second inhalations of 20% carbon dioxide-enriched air in 60 nonclinical participants. Multiple regression analyses indicated that only anxiety sensitivity physical concerns predicted self-reported fear, whereas both physical anxiety sensitivity concerns and behavioural inhibition sensitivity independently predicted affective ratings of emotional arousal. In contrast, the psychological concerns anxiety sensitivity dimension predicted ratings of emotional displeasure (valence), and both psychological anxiety sensitivity concerns and behavioural inhibition sensitivity independently predicted emotional dyscontrol. No variables significantly predicted heart rate. These data are in accord with current models of emotional reactivity that highlight the role of cognitive variables in the production of anxious and fearful responding to somatic perturbation, and help further clarify the particular predictors of anxiety-related re...

We examined whether certain “risky” drinking motives mediate the previously established relation between elevated anxiety sensitivity (AS) and increased drinking behavior in college student drinkers (n=109 women, 73 men). Specifically, we administered the Anxiety Sensitivity Index (ASI), Revised Drinking Motives Questionnaire, and a quantity-frequency measure of typical drinking levels. Participants were parceled according to high (n=30), moderate (n=29), and low (n=34) AS levels. As expected, high AS participants reported a higher typical weekly drinking frequency than the low and moderate AS students regardless of gender. Similarly, high AS participants (particularly high AS men) reported a higher yearly excessive drinking frequency than low AS students. Only the negative reinforcement motives of Coping and Conformity were found to independently mediate the relations between AS and increased drinking behavior in the total sample. High AS women's greater drinking behavior was largely explained by their elevated Coping Motives, while heightened Conformity Motives explained the increased drinking behavior of high AS men. Finally, associations between AS and increased drinking behavior in university students were largely attributable to the “social concerns” component of the ASI. We discuss the observed relations with respect to the psychological functions of drinking behavior that may portend the development of alcohol problems in young adult high AS men and women.

Closed-cell aluminum foam offers a unique combination of properties such as low density, high stiffness, strength and energy absorption that can be tailored through design of the microstructure. During ballistic impact, the foam exhibits significant non-linear deformation and stress wave attenuation. Composite structural armor panels containing closed-cell aluminum foam are impacted with 20-mm fragment-simulating projectiles (FSP). One-dimensional plane strain finite element analysis (FEA) of stress wave propagation is performed to understand the dynamic response and deformation mechanisms. The FEA results correlate well with the experimental observation that aluminum foam can delay and attenuate stress waves. It is identified that the aluminum foam transmits an insignificant amount of stress pulse before complete densification. The ballistic performance of aluminum foam-based composite integral armor (CIA) is compared with the baseline integral armor of equivalent areal-density by impacting panels with 20-mm FSP. A comparative damage study reveals that the aluminum foam armor has finer ceramic fracture and less volumetric delamination of the composite backing plate as compared to the baseline. The aluminum foam armors also showed less dynamic deflection of the backing plate than the baseline. These attributes of the aluminum foam in integral armor system add a new dimension in the design of lightweight armor for the future armored vehicles.

Fear of bodily sensations has received extensive attention in relation to panic disorder, and more recently, other types of anxiety pathology and chronic pain problems. Extending this work, the present study examined fear of bodily sensations and its underlying dimensions in emergency room patients with Noncardiac Chest Pain (NCCP; n = 63). We posited a “differential specificity” hypothesis, expecting that specific cardiopulmonary fears would be more strongly associated with NCCP symptoms relative to other bodily fears. As hypothesized, participants reported cardiopulmonary sensations as significantly more fear-provoking than numbness, dissociation, and gastrointestinal sensations. Additionally, regression analysis indicated that after accounting for theoretically relevant demographic variables and health status, cardiopulmonary fear was the best predictor of a composite index of cardiac complaints intensity, even after removing variance related to the absolute number of cardiac complaints. We discuss these findings in relation to the specific role for the fear of cardiopulmonary sensations in chest pain complaints, with implications for better understanding the underlying psychological processes involved in NCCP.

Anxiety-related responding and skill deficits have historically been associated with performance-based anxiety disorders such as social phobia. Prominent cognitive-behavioral models of social phobia have typically deemphasized skill deficits and focused more on the effects of negative cognition on social performance. Considering that empirical accounts of the relation between social skill and social performance are generally modest, the impact of skill deficits on the development and maintenance of performance inadequacies may be relatively neglected in theoretical paradigms in this area. A second problem that has plagued social skill research is the misuse of the term skill deficit as a synonym for performance deficit. In response to these issues, we utilize the multilevel framework of psychological behaviorism to offer a more parsimonious account of the relation between anxiety and skill in social phobia. We argue that this integrated model assimilates contemporary accounts of social phobia and uniquely expands upon them by delineating the unique and cumulative effects of skill and anxiety on social performance. We further suggest that this model resolves existing theoretical incompatibilities, facilitates improved patient-treatment matching, and shows promise as a guiding framework for empirical research.

This study evaluated whether a diminished perception of control over environmental and interoceptive events differentially predicted interpretive biases for threat for ambiguous scenarios. The sample had 95 participants without a history of psychopathology. Results indicated that the internal dimension of the Anxiety Control Questionnaire (ACQ; R. M. Rapee, M. G. Craske, T. A. Brown, & D. H. Barlow, 1996) was predictive of interpretive biases for internal scenarios above and beyond demographic variables, subclinical panic attack history, and state anxiety; the external control subscale of the ACQ also was predictive of internal rank-ordered responses. The ACQ external dimension was predictive of interpretive responses for external scenarios beyond the effects accounted for by the other predictor variables, including perceived control for internal events. These findings provide initial correlational evidence consistent with cognitive–behavioral accounts of panic disorder that posit a perceived lack of control over aversive events may exacerbate an interpretive bias for threat.

Predictability, or lack thereof, is believed to play a critical role in the development and maintenance of anxiety, with unpredictability being associated with heightened levels of anxious and fearful responding. Despite the potential importance of predictability in theoretical accounts of emotional dysregulation, currently no standardized assessment instrument exists to assess predictability perceptions for anxiety-related events. The present series of four investigations report on an initial attempt to develop a self-report instrument (i.e., Perceived Predictability Index, PPI) that can measure predictability perceptions for the occurrence, duration, and termination of anxiety-related events. Initial item selection and factor structure of the instrument was based on a large sample of participants and yielded a two-factor solution: (1) prediction of anxiety-related environmental events and (2) prediction of internal events. Our subsequent studies show that the PPI possesses adequate levels of internal consistency and temporal stability over time. Additionally, the PPI demonstrated adequate divergent and convergent validity relative to other standard anxiety and fear measures. The internal dimension of the scale also demonstrated predictive validity for emotional responding during a biological challenge test. We discuss these findings in relation to the role of perceived predictability in the study of anxious and fearful responding, and offer directions for future research.

Prediction and/or control of threatening events generally results in less pronounced anxiety-related responding compared to when those same events are unpredictable or uncontrollable. For this reason, researchers have suggested that predictability and controllability may modulate anxiety-related responding, thereby serving an important role in the development and progression of anxiety pathology. Despite the recognized importance of prediction and control for anxiety, these variables have not been defined or operationalized in a uniform and unambiguous manner. In this article, we propose an operational definition that defines and distinguishes prediction and control in terms of the onset and offset of an aversive event. This operationalization is aimed at facilitating experimental-based efforts to explore the independent and interactive effects of the prediction and control on anxious responding.

The increasing recognition that panic attacks are heterogeneous phenomena necessitates better and more objective criteria to define and examine what constitutes a panic attack. The central aim of the present study was to classify subtypes of panic attacks (i.e. prototypic, cognitive, and non-fearful) in a nonclinical sample (N = 96) based on the concordance/discordance between subjective and physiological responding to multiple inhalations of 20 and 13% CO2-enriched air. Results show that a substantial proportion of this nonclinical sample (55.2%) responded to the CO2 challenge in a manner consistent with clinical and research definitions of different subtypes of panic attacks. The implications of this dimensional approach for discriminating subtypes of panic in the laboratory are discussed as a means to better understand the phenomenology and nature of panic attacks.