We sought to examine psychological mechanisms of treatment outcomes of a mindfulness meditation intervention for generalized anxiety disorder (GAD). We examined mindfulness and decentering as two potential therapeutic mechanisms of action of GAD symptom reduction in patients randomized to receive either mindfulness-based stress reduction (MBSR) or an attention control class (N = 38). Multiple mediation analyses were conducted using a non-parametric cross product of the coefficients approach that employs bootstrapping. Analyses revealed that change in decentering and change in mindfulness significantly mediated the effect of MBSR on anxiety. When both mediators were included in the model, the multiple mediation analysis revealed a significant indirect effect through increases in decentering, but not mindfulness. Furthermore, the direct effect of MBSR on decrease in anxiety was not significant, suggesting that decentering fully mediated the relationship. Results also suggested that MBSR reduces worry through an increase in mindfulness, specifically by increases in awareness and nonreactivity. Improvements in GAD symptoms resulting from MBSR are in part explained by increased levels of decentering.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Paradoxical effects of thought suppression: A meta-analysis of controlled studies. Clinical Psychology Review, 21(5), 683–703.
Baer, R. A., Carmody, J., & Hunsinger, M. (2012). Weekly change in mindfulness and perceived stress in a mindfulness-based stress reduction program. Journal of Clinical Psychology,. doi:10.1002/jclp.21865.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27–45. doi:10.1177/1073191105283504.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893–897.
Bieling, P. J., Hawley, L. L., Bloch, R. T., Corcoran, K. M., Levitan, R. D., Young, L. T., et al. (2012). Treatment-specific changes in decentering following mindfulness-based cognitive therapy versus antidepressant medication or placebo for prevention of depressive relapse. Journal of Consulting and Clinical Psychology, 80(3), 365–372. doi:10.1037/a0027483.
Bishop, S. R. B., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., et al. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241.
Brannan, A. M., Heflinger, C. A., & Bickman, L. (1997). The Caregiver Strain Questionnaire: Measuring the impact on the family of living with a child with serious emotional disturbance. Journal of Emotional and Behavioral Disorders, 5(4), 212–222. doi:10.1177/106342669700500404.
Carmody, J., Baer, R. A., Lykins, E. L. B., & Olendzki, N. (2009). An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program. Journal of Clinical Psychology, 65(6), 613–626. doi:10.1002/jclp.20579.
Dobkin, P. L., & Zhao, Q. (2011). Increased mindfulness—the active component of the mindfulness-based stress reduction program? Complementary Therapies in Clinical Practice, 17(1), 22–27. doi:10.1016/j.ctcp.2010.03.002.
First, M. B., Spitzer, R. L. G. M., & Williams, J. B. W. (2002). Structured clinical interview for DSM-IV-TR Axis I disorders-patient edition (SCID-I/P, 11/2002 revision). New York, NY: Biometrics Research Department, New York State Psychiatric Institute.
Fisak, B., & von Lehe, A. C. (2012). The relation between the five facets of mindfulness and worry in a non-clinical sample. Mindfulness, 3(1), 15–21. doi:10.1007/s12671-011-0075-0.
Fresco, D. M., Mennin, D. S., Heimberg, R. G., & Ritter, M. (2013). Emotion regulation therapy for generalized anxiety disorder. Cognitive and Behavioral Practice, 20(3), 282–300. doi:10.1016/j.cbpra.2013.02.001.
Fresco, D. M., Moore, M. T., van Dulmen, M. H., Segal, Z. V., Ma, S. H., Teasdale, J. D., et al. (2007a). Initial psychometric properties of the experiences questionnaire: Validation of a self-report measure of decentering. Behavior Therapy, 38(3), 234–246. doi:10.1016/j.beth.2006.08.003.
Fresco, D. M., Segal, Z. V., Buis, T., & Kennedy, S. (2007b). Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression. Journal of Consulting and Clinical Psychology, 75(3), 447–455. doi:10.1037/0022-006X.75.3.447.
Goldin, P., Ziv, M., Jazaieri, H., & Gross, J. J. (2012). Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: Effects on the self-referential brain network in social anxiety disorder. Frontiers in Human Neuroscience, 6, 295. doi:10.3389/fnhum.2012.00295.
Hayes, A. F. (2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76(4), 408–420.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2012). Decentering as a common mechanism across two behavioral treatments for generalized anxiety disorder. In: SA Hayes-Skelton (Chair), Processes and mechanisms of action in a randomized controlled trial of two behavioral therapies for generalized anxiety disorder. Paper presented at the Presented as the annual meeting of the Society for Psychotherapy Research, Virginia Beach, VA.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169–183. doi:10.1037/a0018555.
Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., et al. (2013). Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: Effects on anxiety and stress reactivity. Journal of Clinical Psychiatry, 74(8), 786–792. doi:10.4088/JCP.12m08083.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4(1), 33–47.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Dell.
Kalisch, R., Wiech, K., Critchley, H. D., Seymour, B., O’Doherty, J. P., Oakley, D. A., et al. (2005). Anxiety reduction through detachment: Subjective, physiological, and neural effects. Journal of Cognitive Neuroscience, 17(6), 874–883. doi:10.1162/0898929054021184.
Linehan, M. M. (1993). Skills for training manual for treating borderline personality disorder. New York: Guilford Press.
MacKinnon, D. P., Krull, J. L., & Lockwood, C. M. (2000). Equivalence of the mediation, confounding and suppression effect. Prevention Science, 1(4), 173–181.
Marino, T. L., Lunt, R. A., & Negy, C. (2008). Thought-action fusion: A comprehensive analysis using structural equation modeling. Behaviour Research and Therapy, 46(7), 845–853. doi:10.1016/j.brat.2008.03.005.
McCracken, L. M., Gutierrez-Martinez, O., & Smyth, C. (2013). “Decentering” reflects psychological flexibility in people with chronic pain and correlates with their quality of functioning. Health Psychology, 32(7), 820–823. doi:10.1037/a0028093.
Mennin, D. S., Fresco, D. M., Heimberg, R. G., & Ritter, M. (Under Review). An open trial of emotion regulation therapy for generalized anxiety disorder and comorbid depression.
Mor, N., & Winquist, J. (2002). Self-focused attention and negative affect: A meta-analysis. Psychological Bulletin, 128(4), 638–662.
Nyklicek, I., & Kuijpers, K. F. (2008). Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: Is increased mindfulness indeed the mechanism? Annals of Behavioral Medicine, 35(3), 331–340. doi:10.1007/s12160-008-9030-2.
Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods, Instruments, & Computers, 36(4), 717–731.
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40(3), 879–891.
Roemer, L., Lee, J. K., Salters-Pedneault, K., Erisman, S. M., Orsillo, S. M., & Mennin, D. S. (2009). Mindfulness and emotion regulation difficulties in generalized anxiety disorder: Preliminary evidence for independent and overlapping contributions. Behavior Therapy, 40(2), 142–154. doi:10.1016/j.beth.2008.04.001.
Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083–1089. doi:10.1037/a0012720.
Roemer, L., Williston, S. K., Eustis, E. H., & Orsillo, S. M. (2013). Mindfulness and acceptance-based behavioral therapies for anxiety disorders. Current Psychiatry Reports, 15(11), 410. doi:10.1007/s11920-013-0410-3.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press.
Splevins, K., Smith, A., & Simpson, J. (2009). Do improvements in emotional distress correlate with becoming more mindful? A study of older adults. Aging and Mental Health, 13(3), 328–335. doi:10.1080/13607860802459807.
Stober, J., & Bittencourt, J. (1998). Weekly assessment of worry: An adaptation of the Penn State Worry Questionnaire for monitoring changes during treatment. Behaviour Research and Therapy, 36(6), 645–656.
Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology, 70(2), 275–287.
Vollestad, J., Sivertsen, B., & Nielsen, G. H. (2011). Mindfulness-based stress reduction for patients with anxiety disorders: Evaluation in a randomized controlled trial. Behaviour Research and Therapy, 49(4), 281–288. doi:10.1016/j.brat.2011.01.007.
Watkins, E., Teasdale, J. D., & Williams, R. M. (2000). Decentring and distraction reduce overgeneral autobiographical memory in depression. Psychological Medicine, 30(4), 911–920.
This study was primarily supported by Grant K23AT4432 from the National Center on Complementary and Alternative Medicine, National Institutes of Health (Hoge, P.I.). The Highland Street Foundation provided additional support to Drs. Simon and Bui.
Conflict of interest
Authors E. Hoge, E. Bui, E. Goetter, D. Robinaugh, R. Ojserkis, and D. Fresco state that they have no financial or other relationships which would create a conflict of interest with regard to this manuscript. Author N. Simon lists the following financial relationships: Consulting: MGH Psychiatry Academy. Research Grants: American Cancer Society, American Foundation for Suicide Prevention, Department of Defense, Highland Street Foundation. Equity (Spouse only): Elan, Dandreon, G Zero, Gatekeeper.
Consent was obtained by study staff before the beginning of study procedures, and the Partners Human Research Committee approved the study before initiation. Additional informed consent was obtained from any subjects for whom identifying information appears in this paper.
No animal studies were carried out by the authors for this article.
About this article
Cite this article
Hoge, E.A., Bui, E., Goetter, E. et al. Change in Decentering Mediates Improvement in Anxiety in Mindfulness-Based Stress Reduction for Generalized Anxiety Disorder. Cogn Ther Res 39, 228–235 (2015). https://doi.org/10.1007/s10608-014-9646-4
- Mindfulness-based stress reduction
- Mindfulness meditation
- Generalized anxiety disorder