Objective-Identifying mediators of therapeutic change is important to the development of interventions and augmentation strategies. Threat reappraisal is considered a key mediator underlying the effects of cognitive-behavioral therapy for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis.Method-In our review we included studies that: (1) investigated the threat reappraisal mediation hypothesis; (2) included adults with an anxiety disorder diagnosis; (3) employed a longitudinal design; and (4) did not report on previously published findings (to avoid the inclusion of multiple reports of the same data). After data extraction, we made review-specific quality judgments for each study using the following a priori criteria informed by mediation theory: (1) demonstrated statistical mediation; (2) demonstrated that CBT caused threat reappraisal; (3) demonstrated that threat reappraisal caused anxiety reduction; and (4) demonstrated specificity of the threat reappraisal-anxiety reduction relation.Results-Of the 2,296 studies we identified, 25 met inclusion criteria. Of these studies, 56% tested and 52% established statistical mediation, 52% tested and 28% established CBT as a cause of threat reappraisal, 28% tested and 24% established threat reappraisal as a cause of anxiety reduction, and 44% tested and 36% established specificity of the threat reappraisal-anxiety reduction relation.Conclusions-While threat reappraisal is related to anxiety symptom improvement with CBT, there are few extant studies that meet most of the criteria necessary to conclusively demonstrate that it causes symptom improvement in CBT and that it is not a proxy for other third variables.Recommendations for future research in this area are discussed.
KeywordsAnxiety disorders; cognitive-behavioral treatment; mediation; treatment mechanisms; systematic reviewThe last three decades have seen a tremendous amount of research focusing on the development of cognitive behavioral treatments (CBT) for the anxiety disorders. These efforts have paid off; CBT has demonstrated clear efficacy for the anxiety disorders (Barlow, Gorman, Shear, & Woods, 2000;Borkovec & Costello, 1993;Bryant, Moulds, Guthrie, & Nixon, 2005;Davidson et al., 2004;Foa et al., 2005;Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010;Powers, Sigmarsson, & Emmelkamp, 2008; WolitzkyTaylor, Horowitz, Powers, & Telch, 2008), offering clinically meaningful advantages over Correspondence can be addressed to Jasper Smits, Ph.D., Department of Psychology, Southern Methodist University, jsmits@smu.edu.
NIH Public AccessAuthor Manuscript J Consult Clin Psychol. Author manuscript; available in PMC 2013 August 01.
NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript psychological placebo conditions (Hofmann & Smits, 2008), and showing improvements in symptoms comparable to established pharmacotherapies (Norton & Price, 2007;Otto, Smits, & Reese, 2004). Although efficacious for the treatment of anxiet...