Post-traumatic stress disorder (PTSD) is associated with enhanced noradrenergic activity. Animal and human studies demonstrate that noradrenergic stimulation augments consolidation of fear learning. Retrieval of well-established memories by presenting a learned fear cue triggers reconsolidation processes during which memories may be updated, weakened, or strengthened. We previously reported that noradrenergic blockade in the rat amygdala impairs reconsolidation of fear memories. Here we investigated the effects of noradrenergic enhancement on reconsolidation of learned fear.
Using auditory fear conditioning in rats, we tested the effects of post-retrieval intra-amygdala infusion of the beta-adrenergic receptor agonist isoproterenol or the antagonist propranolol on conditioned fear in the amygdala.
A single intra-amygdala infusion of isoproterenol following retrieval of a well-consolidated memory enhanced fear memory elicited by the learned fear stimulus and impaired extinction of this memory forty-eight hours later. Intra-amygdala infusion of the beta-adrenergic receptor antagonist propranolol following a consecutive retrieval trial blocked the enhancing effects of isoproterenol on fear memory.
Postretrieval beta-adrenergic stimulation in the amygdala enhances reconsolidation of fear memories, making them resistant to extinction. Noradrenergic augmentation during retrieval of fear memories may thus contribute to persistence and severity of traumatic memories. Reconsolidation may be a useful tool in understanding the pathology of PTSD and may thus help in developing new and in modifying existing treatments of traumatic memories.
fear; anxiety; fear conditioning; amygdala; reconsolidation; extinction; isoproterenol; propranolol; posttraumatic stress disorder; PTSD; late-onset PTSD; beta-adrenergic receptor; norepinephrine
Generalized anxiety disorder (GAD) is a common, chronic condition that is relatively understudied compared to other psychiatric syndromes. Neuroimaging studies have begun to implicate particular neural structures and circuitry in its pathophysiology; however, no genetically-informative research has examined the potential sources of reported brain differences.
We acquired spectroscopic, volumetric, and diffusion tensor magnetic resonance imaging data from a pilot study of 34 female subjects selected from monozygotic twin pairs based upon their affection status for GAD and examined brain regions previously implicated in fear and anxiety for their relationship with affection status and genetic risk.
Lifetime GAD associated with increased creatine levels in the amygdala, smaller left hippocampal volume, and lower fractional anisotropy in the uncinate fasciculus which connects amygdala and frontal cortex. In addition, GAD genetic risk predicted increases in myo-inositol in the amygdala and, possibly, glutamate/glutamine/GABA alterations in the hippocampus. The association of lifetime GAD with smaller hippocampal volume was independent of major depression and might represent a common genetic risk marker for internalizing disorders.
These preliminary data suggest that GAD and its genetic risk factors are likely correlated with volumetric and spectroscopic changes in fear-related limbic structures and their connections with the frontal cortex.
Anxiety Disorders; Depressive Disorder; Twin Study; Magnetic Resonance Spectroscopy; Diffusion Tensor Imaging
Given the general population prevalence rates of obsessive compulsive disorder (OCD) and the affective disorders, one would expect the co-occurrence of these syndromes to be rare. Yet findings by our group and others have revealed extremely high rates of comorbidity in OCD with both depressive disorders (DD; 50%) and bipolar disorder (BPD; 10%). The current investigation sought to further clarify the role affective disorder comorbidity—particularly that with BPD—may play in the clinical expression of OCD.
A total of 605 individuals with OCD were evaluated with the Structured Clinical Interview for DSM-IV. The sample included three groups: BPD (bipolar I or II; N=79, 13.1%), DD (major depression or dysthymia; N=388, 64.1%), and NAD (no affective disorder comorbidity; N=138, 22.8%). Group-wise comparisons were conducted on comorbidity patterns, impairment measures, and clinical features of OCD. Results: Analyses revealed a graded severity pattern, with the BPD group as the most severe, followed by the DD group, and lastly the NAD group. Severity was reflected by the total number of Axis I disorders (p<0.01), the number of psychiatric hospitalizations (p<0.001), impairment measures (p’s<.05), and OCD symptoms (p<0.01). Of note, the impairment and OCD symptom severity findings were not attributable to the higher level of non-mood disorder comorbidities in the BPD and DD groups.
Those individuals with comorbid affective disorders, particularly BPD, represent a clinically severe group compared to those without such comorbidity. Clarifying the phenomenological features of OCD-affective disorder comorbidity has important etiological and treatment implications.
obsessive-compulsive disorder; comorbidity; bipolar disorder; depression; anxiety disorders
The ability to attend to relevant visual information in a proficient manner is central to most day-to-day tasks. Research suggests, however, that this ability is compromised by anxiety such that anxiety results in narrowing the focus of visual attention.
In the current study (N=58), we used the Attention Scope Task [1999: Gerontology 45:102–109] to examine the hypothesis that low-anxious individuals would be more proficient than high-anxious individuals in their scope of attention, that is, high-anxious individuals would have a larger scope of visual attention than low-anxious individuals. Additionally, we hypothesized that low-anxious individuals would be more proficient than high-anxious individuals in their ability to expand their scope of attention.
Results revealed that, compared to low-anxious individuals, high-anxious individuals were impaired only in their ability to expand their scope of attention from a small area to a larger one. Inclusion of a depressed control group in the study revealed that our findings are specific to the effect of anxiety and not depressive symptoms.
Thus, high-anxious individuals do not appear to have a smaller absolute scope of attention but instead seem to have difficulty expanding their attention scope dynamically. We discuss our results in relation to cognitive inflexibility in anxiety.
attention scope; attention; anxiety; attention narrowing; attention constriction
Childhood maltreatment has been associated with symptom severity, reduced quality of life, and impaired functioning in adults with social anxiety disorder (SAD). No study has investigated how childhood maltreatment impacts pharmacotherapy outcomes in this population, despite evidence for such a link in depression. The current study replicates previous work on childhood maltreatment within SAD and examines its impact on response to pharmacotherapy.
156 individuals seeking treatment for SAD completed the Childhood Trauma Questionnaire, which measures various types of abuse and neglect, along with measures of symptom severity, quality of life, and disability. Data from a subset of patients enrolled in a paroxetine trial (N=127) were analyzed to gauge the impact of childhood maltreatment on attrition and treatment response.
All types of maltreatment except for sexual abuse and physical abuse were related to greater symptom severity. Emotional abuse and neglect were related to greater disability, and emotional abuse, emotional neglect, and physical abuse were related to decreased quality of life. Emotional abuse significantly predicted attrition. A time by emotional abuse interaction suggests that for those who stayed the course, the impact of emotional abuse on severity of social anxiety weakened significantly over time.
Emotional maltreatment was most strongly linked to dysfunction in SAD, despite a tendency in the anxiety literature to focus on the effects of sexual and physical abuse. Additionally, individuals reporting emotional abuse were more likely to dropout from pharmacotherapy, but those who stayed the course displayed similar outcomes to those without such a history.
social anxiety disorder; social phobia; childhood maltreatment; pharmacotherapy; treatment outcome
Depression among women with sexual abuse histories is less treatment responsive than in general adult samples. One contributor to poorer treatment outcomes may be abused women’s difficulties in forming and maintaining secure relationships, as reflected in insecure attachment styles, which could also impede the development of a positive therapeutic alliance. The current study examines how attachment orientation (i.e., anxiety and avoidance) and development of the working alliance are associated with treatment outcomes among depressed women with histories of childhood sexual abuse.
Seventy women seeking treatment in a community mental health center who had Major Depressive Disorder and a childhood sexual abuse history were randomized to Interpersonal Psychotherapy or treatment as usual.
Greater attachment avoidance and weaker working alliance were each related to worse depression symptom outcomes; these effects were independent of the presence of comorbid Borderline Personality Disorder and Post-Traumatic Stress Disorder. The effect of avoidant attachment on outcomes was not mediated by the working alliance. Further, working alliance had a stronger effect on depression outcomes in the Interpersonal Psychotherapy group.
Understanding the influence of attachment style and the working alliance on treatment outcomes can inform efforts to improve treatments for depressed women with a history of childhood sexual abuse.
Childhood Sexual Abuse; Attachment Orientation; Working Alliance; Depression Treatment; Interpersonal Psychotherapy
The co-occurrence of substance use disorder (SUD) and major depressive disorder (MDD) is common and is often thought to impair response to antidepressant therapy. These patients are often excluded from clinical trials, resulting in a significant knowledge gap regarding optimal pharmacotherapy for the treatment of MDD with concurrent SUD.
In the Combining Medications to Enhance Depression Outcomes study, 665 adult outpatients with chronic and/or recurrent MDD were prospectively treated with either escitalopram monotherapy (escitalopram and placebo) or an antidepressant combination (venalfaxine-XR and mirtazapine or escitalopram and bupropion-SR). Participants with MDD and concurrent SUD (13.1%) were compared to those without SUD (86.9%) on sociodemographic and clinical characteristics at baseline and treatment response at 12-week and 28-week endpoints.
The participants with MDD and SUD were more likely to be male and have current suicidal thoughts/plans, and had a greater lifetime severity and number of suicide attempts, and a higher number of concurrent Axis I disorders, particularly concurrent anxiety disorders. There were no significant differences between the MDD with or without SUD groups in terms of dose, time in treatment, response or remission at week 12 and 28. Furthermore, no significant differences in response or remission rates were noted between groups on the basis of the presence or absence of SUD and treatment assignment.
Although significant baseline sociodemographic and clinical differences exist, patients with MDD and concurrent SUD are as likely to respond and remit to a single or combination antidepressant treatment as those presenting without SUD.
major depressive disorder; substance use disorder; dual diagnosis; combination antidepressants; treatment outcome
Childhood abuse and neglect have been linked with increased risks of adverse mental health outcomes in adulthood and may moderate or predict response to depression treatment. In a small randomized controlled trial treating depression in a diverse sample of nontreatment-seeking, pregnant, low-income women, we hypothesized that childhood trauma exposure would moderate changes in symptoms and functioning over time for women assigned to usual care (UC), but not to brief interpersonal psychotherapy (IPT-B) followed by maintenance IPT. Second, we predicted that trauma exposure would be negatively associated with treatment response over time and at the two follow-up time points for women within UC, but not for those within IPT-B who were expected to show remission in depression severity and other outcomes, regardless of trauma exposure.
Fifty-three pregnant low-income women were randomly assigned to IPT-B (n = 25) or UC (n = 28). Inclusion criteria included≥18 years,>12 on the Edinburgh Postnatal Depression Scale, 10–32 weeks gestation, English speaking, and access to a phone. Participants were evaluated for childhood trauma, depressive symptoms/diagnoses, anxiety symptoms, social functioning, and interpersonal problems.
Regression and mixed effects repeated measures analyses revealed that trauma exposure did not moderate changes in symptoms and functioning over time for women in UC versus IPT-B. Analyses of covariance showed that within the IPT-B group, women with more versus less trauma exposure had greater depression severity and poorer outcomes at 3-month postbaseline. At 6-month postpartum, they had outcomes indicating remission in depression and functioning, but also had more residual depressive symptoms than those with less trauma exposure.
Childhood trauma did not predict poorer outcomes in the IPT-B group at 6-month postpartum, as it did at 3-month postbaseline, suggesting that IPT including maintenance sessions is a reasonable approach to treating depression in this population. Since women with more trauma exposure had more residual depressive symptoms at 6-month postpartum, they might require longer maintenance treatment to prevent depressive relapse.
childhood trauma; childhood maltreatment; perinatal depression; interpersonal psychotherapy; depression treatment
Previous studies demonstrate that anxiety is characterized by biased attention toward threats, typically measured by differences in motor reaction time to threat and neutral cues. Using eye-tracking methodology, the current study measured attention biases in anxious and nonanxious youth, using unrestricted free viewing of angry, happy, and neutral faces.
Eighteen anxious and 15 nonanxious youth (8–17 years old) passively viewed angry-neutral and happy-neutral face pairs for 10 s while their eye movements were recorded.
Anxious youth displayed a greater attention bias toward angry faces than nonanxious youth, and this bias occurred in the earliest phases of stimulus presentation. Specifically, anxious youth were more likely to direct their first fixation to angry faces, and they made faster fixations to angry than neutral faces.
Consistent with findings from earlier, reaction-time studies, the current study shows that anxious youth, like anxious adults, exhibit biased orienting to threat-related stimuli. This study adds to the existing literature by documenting that threat biases in eye-tracking patterns are manifest at initial attention orienting.
anxiety; threat-bias; orienting; eye tracking
The number of individuals looking for health information on the Internet continues to expand. The purpose of the study was to understand the prevalence of major depression, among English-speaking individuals worldwide looking for information on depression online.
An automated online Mood Screener website was created and advertised via Google AdWords, for one year. Participants (N = 24,965) completed a depression screening measure and received feedback based on their results. Participants were then invited to participate in a longitudinal mood screening study.
Of the 24,965 who completed the screening, 66.6% screened positive for current major depression, 44.4% indicated current suicidality, and 7.8% reported a recent (past two weeks) suicide attempt. Of those consenting to participate in the longitudinal study (n = 1,327, from 86 countries), 77.4% screened positive for past depression, 64.6% reported past suicidality, and 17.5% a past suicide attempt. Yet, only 25% of those screening positive for current depression, and only 37.2% of those reporting a recent suicide attempt are in treatment.
Many of the consumers of Internet health information may genuinely need treatment and are not “cyberchondriacs”. Online screening, treatment, and prevention efforts may have the potential to serve many currently untreated clinically depressed and suicidal individuals.
depression rates; cyberchondriasis; major depression; internet screening; telecare
Nervios (PNRV) and ataque de nervios (ATQ) are culture-bound syndromes with overlapping symptoms of anxiety, depression, and dissociation, shown to have inconsistent associations to psychiatric disorder. Few studies test the basic assumption that PNRV and ATQ are uniformly linked to distress outcomes across Latina/o immigrant groups. This study examined: (a) the extent to which acculturative stress, Latino/U.S. American acculturation, and anxious predisposition were associated with lifetime history of ATQ and PNRV, and (b) the extent to which ATQ and PNRV add incremental validity in explaining acculturative stress and psychological distress beyond measures of anxious predisposition.
Participants (n = 82) included Mexican mothers who completed surveys on acculturation, trait anxiety, anxiety sensitivity, lifetime ATQ/PNRV, psychological distress, and acculturative stress.
Lifetime PNRV, but not lifetime ATQ, was significantly predictive of psychological distress. PNRV was also linked to trait anxiety. Psychometric measures of anxious predisposition (trait anxiety, anxiety sensitivity) were more robust predictors of distress outcomes than lifetime history of ATQ/PNRV.
Inquiry into lifetime history of nervios may be a useful point of entry in talking to Mexican immigrant mothers about stress and distress. However, standard tools for assessing anxiety sensitivity and trait anxiety appear most useful in identifying and explaining presence of psychological distress. Further research is needed to determine the cross-cultural relevance of trait anxiety and anxiety sensitivity, and its implications for the development of anxiety treatments that are effective across cultures.
anxiety sensitivity; culture-bound syndrome; nervios; Latinos; clinical utility
The ability to process a death, and the ability to remain optimistic and look beyond the loss, are both thought to be effective means of coping with loss and other aversive events. Recently, these seemingly contrary dimensions have been integrated into the idea of coping flexibility.
In this study we assessed the ability of married and bereaved individuals in the US and Hong Kong to use both coping approaches as operationalized by the trauma-focused and forward-focused coping scales of a previously validated questionnaire. We also calculated a single flexibility score.
Bereaved participants reported greater trauma-focused coping ability than did married participants. However, bereaved participants meeting criteria for complicated grief (CG) reported less forward-focused coping than both asymptomatic bereaved and married participants. The CG group also showed less overall coping flexibility than the asymptomatic bereaved and married groups. Country was not a factor.
Findings suggest that deficits in coping flexibility are indicative of pathology in bereaved individuals, and that this relationship extends across cultures. Limitations of the study and directions for future research are discussed.
Coping Skills; Grief; Cross-Cultural Comparison; Social Adjustment; Life Stress
Prior research, predominantly with adults, has shown that the serotonin transporter gene (5-HTTLPR) interacts with stress (GxE) to predict depressive symptoms; however, few GxE studies have been conducted with youth using rigorous methods, particularly a prospective design and contextual interview to assess stress. The current study examined the interaction between 5-HTTLPR and stress, both chronic and episodic, to predict longitudinal change in depressive symptoms among children and adolescents.
A general community sample of youth (N=200; 57% girls; mean age: 12.09 years old) were genotyped for 5-HTTLPR (rs 25531) at baseline. They were interviewed via contextual stress procedures to ascertain chronic family stress and episodic stressors and completed depressive symptoms questionnaires at baseline and 6 months later.
A significant GxE showed that chronic family stress predicted prospective increases in depressive symptoms over 6 months among youth possessing the high risk S allele. This GxE was not found for episodic stressors occurring in the last 6 months. There was no moderation by sex or pubertal status.
These findings advance knowledge on GxE effects in depression among youth. This is the first study to show that chronic family stress, but not episodic stressors, when ascertained by rigorous stress interview, interacts with 5-HTTLPR to prospectively predict depressive symptoms among children and adolescents.
children; adolescents; depression; genetics; environment; serotonin
Posttraumatic stress disorder (PTSD) patients show heightened fear responses to trauma reminders and an inability to inhibit fear in the presence of safety reminders. Brain imaging studies suggest that this is in part due to amygdala over-reactivity as well as deficient top-down cortical inhibition of the amygdala. Consistent with these findings, previous studies, using fear-potentiated startle (FPS), have shown exaggerated startle and deficits in fear inhibition in PTSD participants. However, many PTSD studies using the skin conductance response (SCR) report no group differences in fear acquisition.
The study included 41 participants with PTSD and 70 without PTSD. The fear conditioning session included a reinforced conditioned stimulus (CS+, danger cue) paired with an aversive airblast, and a nonreinforced CS (CS−, safety cue). Acoustic startle responses and SCR were acquired during the presentation of each CS.
The results showed that fear conditioned responses were captured in both the FPS and SCR measures. Furthermore, PTSD participants had higher FPS to the danger cue and safety cue compared to trauma controls. However, SCR did not differ between groups. Finally, we found that FPS to the danger cue predicted re-experiencing symptoms, whereas FPS to the safety cue predicted hyper-arousal symptoms. However, SCR did not contribute to PTSD symptom variance.
Replicating earlier studies, we showed increased FPS in PTSD participants. However, although SCR was a good measure of differential conditioning, it did not differentiate between PTSD groups. These data suggest that FPS may be a useful tool for translational research.
Fear-potentiated startle; skin conductance response; trauma; posttraumatic stress disorders; psychophysiology
There is growing evidence suggesting that early adversity may be a marker for a distinct pathway to major depressive disorder (MDD). We examined associations between childhood adversity and a broad variety of clinical characteristics and response to pharmacotherapy in a large sample of patients with chronic forms of MDD.
Subjects included 808 patients with chronic forms of MDD (chronic MDD, double depression, or recurrent MDD with incomplete recovery between episodes and a total continuous duration of >2 years) who were enrolled in a 12-week open-label trial of algorithm-guided pharmacotherapy. Baseline assessments included a semi-structured diagnostic interview, and clinician- and self-rated measures of depressive symptoms, social functioning, depressotypic cognitions, and personality traits, and childhood adversity. Patients were re-evaluated every 2 weeks.
A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self-rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self-criticism were each associated with multiple forms of childhood adversity. A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing the 12-week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission.
These findings indicate that a history of childhood adversity is associated with an especially chronic form of MDD that is less responsive to antidepressant pharmacotherapy.
major depression; mood disorders; childhood maltreatment; clinical features; treatment response
Selective serotonin reuptake inhibitors (SRIs) relieve irritability within days in women with premenstrual dysphoric disorder (PMDD); however, the effects on other affective symptoms in PMDD remain to be demonstrated.
We performed hourly ratings in women with PMDD to test the specificity of the therapeutic effects of SRIs and to determine whether the kinetics of these effects differ from those of the symptom offset accompanying menses. Twelve women with PMDD received fluoxetine (20 mg daily) during the luteal phase of the menstrual cycle. Twelve other women with PMDD received no treatment. Outcome measures included a visual analogue scale completed hourly before and after either the start of SRIs or at menses-onset in the untreated women and the premenstrual tension syndrome (PMTS) scale completed daily. Data were analyzed by ANOVA-R.
Hourly VAS scores significantly improved after SRI in irritability as well as sadness, anxiety, and mood swings. Compared with the symptomatic pretreatment baseline, PMTS scores significantly improved on the second day after the start of SRI (p < .01). An identical time course of symptom improvement occurred after both SRI and menses-onset.
Conclusion and Discussion
These data document that the rapid response to SRI was not limited to irritability. The similar kinetics in the remission of PMDD after SRIs and after menses-onset suggest both a phenotype reflecting the relative capacity to rapidly change affective state, and a possible therapeutic mechanism by which SRIs recruit this endogenous capacity to change state, normally expressed around menses-onset in women with PMDD.
premenstrual dysphoric disorder; fluoxetine; selective serotonin reuptake inhibitors; treatment response
Prenatal serotonin reuptake inhibitor (SRI) exposure has been related to adverse newborn neurobehavioral outcomes; however these effects have not been compared to those that may arise from prenatal exposure to maternal major depressive disorder (MDD) without SRI treatment. This study examined potential effects of MDD with and without SRI treatment on newborn neurobehavior.
This was a prospective, naturalistic study. Women were seen at an outpatient research center twice during pregnancy (26–28 and 36–38 weeks gestational age (GA)). Psychiatric diagnoses were assessed using the Structured Clinical Interview for the DSM-IV; medication use was measured with the Timeline Follow-Back instrument. Three groups were established based upon MDD diagnosis and SRI use: Control (N=56), MDD (N=20) or MDD+SRI (N=36). Infants were assessed on a single occasion within 3 weeks of birth with the NICU Network Neurobehavioral Assessment Scale (NNNS). Generalized Linear Modeling was used to examine neurobehavioral outcomes by exposure group and infant age at assessment.
Full-term infants exposed to MDD+SRIs had a lower GA than CON or MDD-exposed infants and, controlling for GA, had lower quality of movement and more central nervous system stress signs. In contrast, MDD-exposed infants had the highest quality of movement scores, while having lower attention scores than CON and MDD+SRI-exposed infants.
MDD+SRI-exposed infants appear to have a different neurobehavioral profile than MDD-exposed infants in the first three weeks after delivery; both groups may have different neurobehavioral profiles with increasing age from birth.
infant; motor quality; central nervous system; depression; pregnancy; treatment
We explored whether clinical outcomes differ by treatment strategy following initial antidepressant treatment failure among patients with and without clinically relevant symptom clusters.
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial was used to examine depression remission and response in patients with coexisting anxiety, atypical features, insomnia, and low energy. We applied propensity scoring to control for selection bias that precluded comparisons between augmentation and switch strategies in the original trial. Binomial regressions compared the likelihood of remission or response among patients with and without symptom clusters for switch versus augmentation strategies (n=269 per arm); augmentation strategy type (n=565); and switch strategy type (n=727).
We found no statistically significant difference in remission or response rates between augmentation or switch strategies. However, symptom clusters did distinguish among augmentation and switch strategies, respectively. For patients with low energy, augmentation with buspirone was less likely to produce remission than augmentation with bupropion (remission Risk Ratio [RR]:0.54, 95% CI: 0.35–0.85, response RR:0.67, 95% CI 0.43, 1.03). Also, for patients with low energy, switching to venlafaxine or bupropion was less likely to produce remission than switching to sertraline (RR: 0.59, 95% CI: 0.36–0.97; RR: 0.63, 95% CI: 0.38–1.06, respectively).
Remission and response rates following initial antidepressant treatment failure did not differ by treatment strategy for patients with coexisting atypical symptoms or insomnia. However, some second-step treatments for depression may be more effective than others in the presence of coexisting low energy. Subsequent prospective testing is necessary to confirm these initial findings.
Depression; Antidepressant; Propensity Score; Symptom Cluster; Medication Selection
Cognitive Bias Modification (CBM) is a promising treatment for Social Anxiety Disorder (SAD). However, previous randomized trials have not systematically examined the combination of CBM for attention (CBM-A) and interpretation (CBM-I), or the credibility and acceptability of these protocols.
We conducted a randomized, double-blind placebo-controlled trial (N = 32) to examine the efficacy of a CBM treatment called Attention and Interpretation Modification (AIM) for SAD. AIM comprised eight, twice weekly computer sessions with no therapist contact. During AIM, participants (1) completed a dot probe task in which probes always followed neutral faces when paired with a disgust face, thereby directing attention away from threat and (2) completed a word-sentence association task in which they received positive feedback for making benign interpretations of word-sentence pairs and negative feedback for making negative interpretations. We also assessed participants’ perceived credibility of and satisfaction with AIM.
Participants receiving AIM reported significantly reduced self-reported (Liebowitz Social Anxiety Scale) symptoms of social anxiety relative to the placebo. These gains were also evident on a behavioral measure (performance on an impromptu speech). AIM met our benchmarks for credibility and acceptability in this community sample, although credibility ratings were modest. Participants reported that CBM-I was more helpful than CBM-A.
A combined CBM treatment produced medium to large effects on social anxiety. Participants rated AIM as moderately credibly and acceptable. Should these findings be replicated in larger samples, AIM has the potential to be a widely accessible and efficacious treatment for SAD.
social anxiety; cognitive bias modification; treatment; attention bias; interpretation bias
Exposure and response prevention (ERP) for obsessive–compulsive disorder (OCD) is underutilized, in part because of costs and time requirements. This study extends pilot work investigating the use of a stepped care ERP administration, in which patients are first given a low-intensity, low-cost treatment and the more costly intervention is reserved for those who do not respond to the first intervention.
Thirty adults with OCD were randomized to receive stepped care ERP or standard ERP. Those receiving stepped care started with three sessions over 6 weeks of low-intensity counseling with ERP bibliotherapy; patients failing to meet strict responder criteria after 6 weeks were given the more traditional treatment of therapist-administered ERP (17 sessions twice weekly). Those receiving standard ERP received the therapist-administered ERP with no lower-intensity lead-in.
The two treatments were equally efficacious, with 67% of stepped care completers and 50% of standard treatment completers meeting criteria for clinically significant change at posttreatment. Similarly, no differences in client satisfaction ratings were obtained between the two groups. Examination of treatment costs, however, revealed that stepped care resulted in significantly lower costs to patients and third-party payers than did standard ERP, with large effect sizes.
These results suggest that stepped care ERP can significantly reduce treatment costs, without evidence of diminished treatment efficacy or patient satisfaction. Additional research is needed to determine the long-term efficacy and costs of stepped care for OCD, and to examine the financial and therapeutic impact of implementing stepped care in community settings.
obsessive–compulsive disorder; stepped care; exposure and response prevention; behavior therapy; cost-effectiveness; health economics
Recent research has highlighted the prevalence and harmful consequences of hoarding, and investigators have proposed inclusion of hoarding disorder in DSM-5. An unanswered question about the proposed disorder is whether people who hoard animals would meet diagnostic criteria for it. This paper discusses the similarities and differences between object and animal hoarding. People who hoard animals appear to meet the basic diagnostic criteria for hoarding disorder. Their homes are cluttered, disorganized, and dysfunctional. They have great difficulty relinquishing animals to people who can more adequately care for them, and they form intense attachments (urges to save) that result in significant impairment. However, they differ from people who hoard objects in several ways. These differences are significant enough to warrant comment in the text description accompanying the diagnostic criteria and consideration as a subtype of hoarding disorder. More research is necessary to determine the exact relationship between object and animal hoarding.
hoarding disorder; animal hoarding; DSM-5
Obsessive-compulsive disorder (OCD) is a chronic and debilitating anxiety disorder associated with significant impairment in quality of life and functioning. Research examining the differences in clinical correlates and treatment response associated with different obsessions in OCD has yielded important findings underscoring the heterogeneous nature of this disorder. To date, most of this research has focused on differences associated with primary obsessions, and little attention has been paid to the clinical utility of studying how compulsive symptoms affect clinical course. Virtually no systematic research has explored the clinical characteristics of one understudied symptom presentation, mental rituals, and what impact this primary symptom has on severity and course of illness. Mental rituals, or compulsions without overt signs, represent unique clinical challenges but often go understudied for numerous methodological and clinical reasons.
In the present study, we explored the impact of primary mental rituals on clinical severity and chronicity in a large, longitudinal sample of OCD patients (N = 225) over 4 years.
Mental rituals were a primary presenting symptom for a sizable percentage of the sample (12.9%). Primary mental rituals were associated with greater clinical severity and lower functioning at intake, as well as a more chronic course of illness, as participants with primary mental rituals spent nearly 1 year longer in full DSM-IV criteria episodes over the 4-year follow-up interval than OCD patients without mental rituals.
These results suggest that mental rituals are uniquely impairing and highlight the need for further empirical exploration and consideration in treatment.
obsessive-compulsive disorder; mental rituals; longitudinal; chronicity; anxiety
Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM-5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large-scale study (n=217) of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. The HD sample was compared to 96 participants meeting criteria for OCD without HD. High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition-related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition-related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). These findings form important base rates for developing research and treatments for hoarding disorder.
compulsive hoarding; clutter; saving; difficulty discarding; psychiatric diagnosis
Empirical evidence suggests that there is a significant genetic influence in the development of posttraumatic stress disorder (PTSD). The serotonin transporter (5-HTT) gene (SLC6A4) has been identified as a prime candidate for the development of the disorder, as 5-HTT is a working target for selective serotonin reuptake inhibitors (SSRIs), first line treatment agents for PTSD. Several studies have reported associations between 5-HTT-linked promoter region (5-HTTLPR) polymorphism variants and increased rates of PTSD in civilian samples. This study investigated the role of the 5-HTTLPR polymorphism, triallelically classified, in a sample of combat veterans with and without PTSD.
Rates of PTSD were examined across three genotypes in a sample of 388 combat veterans. The short/long polymorphism of 5-HTTLPR and the A-G polymorphism within the 5-HTTLPR (rs25531) were genotyped, and statistical analyses were conducted.
There were significant intergroup (PTSD versus non-PTSD) differences in the genotype frequencies of 5-HTTLPR/rs25531 (χ2[1, n=388]=16.23, P=5.62×10−5). The 5-HTTLPR S′/S′ (low transcriptionally efficient) genotype was also associated with the PTSD severity score in the 228 participants who had combat severity data (r=.15, P=0.03).
The findings are consistent with previous research among civilian populations that have indicated that the low transcriptionally efficient S′/S′ genotype of 5-HTTLPR is a risk factor for the development of PTSD after trauma exposure. Our findings are the first to examine this polymorphism and PTSD in a military sample. Additional large-scale investigations are needed to replicate these findings.
post traumatic stress disorder; 5-HTTLPR; combat trauma; genetic risk; 5-HTTLPR genotypes; combat veteran