title: Cognitive-behavior therapy resolves implicit fear associations in generalized anxiety disorder.
abstract: BACKGROUND
  Cognitive schema theories postulate that anxiety disorders are associated with excessive fear associations in memory. For generalized anxiety disorder (GAD), it has been shown that patients not only exhibit negative implicit evaluations of clearly negative worry words (e.g., cancer), but also a generalization of this effect to neutral words (e.g., diagnosis). This study assessed the sensitivity of this bias, which has been interpreted as an indicator of a pathologically broadened fear structure, to cognitive-behavioral therapy (CBT).
  
  
  METHODS
  An Extrinsic Affective Simon task was used to measure implicit associations with idiosyncratic neutral and negative worry words in 23 GAD patients and 25 healthy controls (HC). Patients were tested before and after CBT, and half of them were additionally tested while waiting for treatment. Clinical symptoms were measured before and after treatment, and at 6-months follow-up.
  
  
  RESULTS
  CBT normalized bias for neutral words, and the extent of bias reduction during treatment predicted the extent of additional symptom improvement during the 6 months following intervention. Furthermore, the amplitude of pre-treatment bias predicted the onset of CBT response, with lower bias predicting immediate symptom improvement at the end of treatment, and higher bias predicting delayed treatment effects during the 6 months follow-up.
  
  
  CONCLUSIONS
  Biased implicit evaluation of neutral worry targets does not represent an enduring vulnerability factor for the development of GAD but is related to heightened levels of state worry. Furthermore, the normalization of this bias might be a crucial factor in the therapeutic action of CBT.
authors.affiliation: University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK. andrea.reinecke@psych.ox.ac.uk
authors.forename: Andrea
authors.initials: A
authors.lastname: Reinecke
authors.forename: Mike
authors.initials: M
authors.lastname: Rinck
authors.forename: Eni S
authors.initials: ES
authors.lastname: Becker
authors.forename: Jürgen
authors.initials: J
authors.lastname: Hoyer
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D001008:Anxiety Disorders / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D001244:Association; D001288:Attention; D016022:Case-Control Studies; D015928:Cognitive Behavioral Therapy; D003863:Depression / Q000175:diagnosis; D005239:Fear / Q000523:psychology*; D005260:Female; D005500:Follow-Up Studies; D005793:Generalization, Psychological; D006801:Humans; D008297:Male; D011569:Psychiatric Status Rating Scales; D012044:Regression Analysis; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014936:Word Association Tests