Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: A systematic review
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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 (CBT) for anxiety disorders. The present study systematically reviewed the evidence for the threat reappraisal mediation hypothesis. METHOD: In our review, we included studies that (a) investigated the threat reappraisal mediation hypothesis; (b) included adults with an anxiety disorder diagnosis; (c) used a longitudinal design; and (d) 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: (a) demonstrated statistical mediation; (b) demonstrated that CBT caused threat reappraisal; (c) demonstrated that threat reappraisal caused anxiety reduction; and (d) 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.
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Research on reappraisal has been lacking in generalized anxiety disorder.
“In terms of reappraisal, although widely studied within the context of other anxiety disorders (e.g., threat reappraisal; Smits, Julian, Rosenfield, Powers, & Smits, 2012), this research has been lacking in terms of GAD.”
From Changes in Decentering and Reappraisal Temporally Precede Symptom Reduction During Emotion Regulation Therapy for Generalized Anxiety Disorder With and Without Co-Occurring Depression. (2019) · cites this paper as Smits et al., 2012
The randomized design allowed experimental control of the effect of Internet-based CBT on the mediator, an important criterion for mediation.
“The randomized design of the study made it possible to have experimental control of the effect of Internet-based CBT on the mediator, which has been suggested to be an important criterion for mediation by Smits et al. [35].”
From Mediators in Internet-Based Cognitive Behavior Therapy for Severe Health Anxiety (2013) · cites this paper as [35]
Improvements in threat cognitive reappraisal are associated with reductions in anxiety symptom severity.
“and that these improvements are associated with reductions in anxiety symptom severity (Smits et al., 2012).”
From Which emotion regulation strategies are mediating the outcome of acceptance and commitment therapy compared to cognitive-behaviour therapy in the treatment of anxiety symptoms? (2025) · cites this paper as Smits et al., 2012
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“Among other therapeutic change processes that are potentially important to exposure therapy outcome, increased implementation of emotion regulation strategies such as cognitive reappraisal may be important to consider in future studies that aim to enhance the understanding of why DCS may only exert positive effects wh…”
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- Authors
- Smits, J. A. J., Julian, K., Rosenfield, D., & Powers, M. B.
- Affiliations
- Southern Methodist University (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2012
- Volume
- 80
- Issue
- 4
- Pages
- 624-635
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC3404225
- OpenAlex
- W1986592878
- Cited by
- 162
- References
- 85
- Citations by year
- 2026: 8 · 2025: 11 · 2024: 12 · 2023: 14 · 2022: 11 · 2021: 22 · 2020: 12 · 2019: 12 · 2018: 11 · 2017: 11 · 2016: 6 · 2015: 8 · 2014: 11 · 2013: 11 · 2012: 1
- FWCI
- 1.45
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Funders
- National Institute of Health (R01DA027533 and R34DA031038)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Keywords
- cognitive behavioral therapy, anxiety disorders, mediation, symptom change, anxiety reduction, therapeutic mechanisms
- MeSH terms
- Adult, Anxiety, Anxiety Disorders, Humans, Cognitive Behavioral Therapy, Treatment Outcome
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