A family study of co-morbidity between generalized social phobia and generalized anxiety disorder in a non-clinic sample

Background: High rates of co-morbidity between Generalized Social Phobia (GSP) and Generalized Anxiety Disorder (GAD) have been documented. The reason for this is unclear. Family studies are one means of clarifying the nature of co-morbidity between two disorders. Methods: Six models of co-morbidity between GSP and GAD were investigated in a family aggregation study of 403 first-degree relatives of non-clinical probands: 37 with GSP, 22 with GAD, 15 with co-morbid GSP/GAD, and 41 controls with no history of GSP or GAD. Psychiatric data were collected for probands and relatives. Mixed methods (direct and family history interviews) were utilised. Results: Primary contrasts (against controls) found an increased rate of pure GSP in the relatives of both GSP probands and co-morbid GSP/GAD probands, and found relatives of co-morbid GSP/GAD probands to have an increased rate of both pure GAD and comorbid GSP/GAD. Secondary contrasts found (i) increased GSP in the relatives of GSP only probands compared to the relatives of GAD only probands; and (ii) increased GAD in the relatives of co-morbid GSP/GAD probands compared to the relatives of GSP only probands. Limitations: The study did not directly interview all relatives, although the reliability of family history data was assessed. The study was based on an all-female proband sample. The implications of both these limitations are discussed. Conclusions: The results were most consistent with a co-morbidity model indicating independent familial transmission of GSP and GAD. This has clinical implications for the treatment of patients with both disorders. (C) 2006 Elsevier B.V. All fights reserved.

Research into anxiety of childhood: playing catch-up (to Olympic standard)

This special issue is the culmination of an ESRC seminar series grant awarded to the authors of this editorial. We named the seminar series CATTS (Child Anxiety, Theory and Treatment Seminars) and it took the form of six highly stimulating, one-day seminars on the subject of child anxiety, with participants from clinical and academic backgrounds and from Great Britain, Europe, the USA and Australia. Most of the authors in this publication, and a sister special issue in Cognitions and Emotion (2008), participated in the CATTS series.

What does a transdiagnostic approach have to offer the treatment of anxiety disorders?

Purpose: The purpose of this paper is to review the rationale for 'transdiagnostic' approaches to the understanding and treatment of anxiety disorders. Methods: Databases searches and examination of the reference lists of relevant studies were used to identify papers of relevance. Results: There is increasing recognition that diagnosis-specific interventions for single anxiety-disorders are of less value than might appear since a large proportion of patients have more than one co-existing anxiety disorder and the treatment of one anxiety disorder does not necessarily lead to the resolution of others. As transdiagnostic approaches have the potential to address multiple co-existing anxiety disorders they are potentially more clinically relevant than single anxiety disorder interventions. They may also have advantages in ease of dissemination and in treating anxiety disorder not otherwise specified. Conclusions: The merits of the various transdiagnostic cognitive-behavioral approaches that have been proposed are reviewed. Such approaches have potential benefits, particularly in striking the balance between completely idiosyncratic formulations and diagnosis-driven treatments of anxiety disorders. However, caution is needed to ensure that transdiagnostic theories and treatments benefit from progress made by research on diagnosis-specific treatments, and further empirical work is needed to identify the shared maintaining processes that need to be targeted in the treatment of anxiety disorders.

Anticipatory activation in the amygdala and anterior cingulate in generalized anxiety disorder and prediction of treatment response

OBJECTIVE: The anticipation of adverse outcomes, or worry, is a cardinal symptom of generalized anxiety disorder. Prior work with healthy subjects has shown that anticipating aversive events recruits a network of brain regions, including the amygdala and anterior cingulate cortex. This study tested whether patients with generalized anxiety disorder have alterations in anticipatory amygdala function and whether anticipatory activity in the anterior cingulate cortex predicts treatment response. METHOD: Functional magnetic resonance imaging (fMRI) was employed with 14 generalized anxiety disorder patients and 12 healthy comparison subjects matched for age, sex, and education. The event-related fMRI paradigm was composed of one warning cue that preceded aversive pictures and a second cue that preceded neutral pictures. Following the fMRI session, patients received 8 weeks of treatment with extended-release venlafaxine. RESULTS: Patients with generalized anxiety disorder showed greater anticipatory activity than healthy comparison subjects in the bilateral dorsal amygdala preceding both aversive and neutral pictures. Building on prior reports of pretreatment anterior cingulate cortex activity predicting treatment response, anticipatory activity in that area was associated with clinical outcome 8 weeks later following treatment with venlafaxine. Higher levels of pretreatment anterior cingulate cortex activity in anticipation of both aversive and neutral pictures were associated with greater reductions in anxiety and worry symptoms. CONCLUSIONS: These findings of heightened and indiscriminate amygdala responses to anticipatory signals in generalized anxiety disorder and of anterior cingulate cortex associations with treatment response provide neurobiological support for the role of anticipatory processes in the pathophysiology of generalized anxiety disorder.

Infant-mother attachment and the growth of externalizing problems across the primary-school years

Background:  Some contend that attachment insecurity increases risk for the development of externalizing behavior problems in children. Method:  Latent-growth curve analyses were applied to data on 1,364 children from the NICHD Study of Early Child Care to evaluate the association between early attachment and teacher-rated externalizing problems across the primary-school years. Results:  Findings indicate that (a) both avoidant and disorganized attachment predict higher levels of externalizing problems but (b) that effects of disorganized attachment are moderated by family cumulative contextual risk, child gender and child age, with disorganized boys from risky social contexts manifesting increases in behavior problems over time. Conclusions:  These findings highlight the potentially conditional role of early attachment in children’s externalizing behavior problems and the need for further research evaluating causation and mediating mechanisms.

Infant Attachment Security and the Timing of Puberty: Testing an Evolutionary Hypothesis

Life-history theories of the early programming of human reproductive strategy stipulate that early rearing experience, including that reflected in infant-parent attachment security, regulates psychological, behavioral, and reproductive development. We tested the hypothesis that infant attachment insecurity, compared with infant attachment security, at the age of 15 months predicts earlier pubertal maturation. Focusing on 373 White females enrolled in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, we gathered data from annual physical exams from the ages of 9½ years to 15½ years and from self-reported age of menarche. Results revealed that individuals who had been insecure infants initiated and completed pubertal development earlier and had an earlier age of menarche compared with individuals who had been secure infants, even after accounting for age of menarche in the infants’ mothers. These results support a conditional-adaptational view of individual differences in attachment security and raise questions about the biological mechanisms responsible for the attachment effects we discerned.

The significance of insecure attachment and disorganization in the development of children's externalizing behavior: A meta-analytic study

This study addresses the extent to which insecure and disorganized attachments increase risk for externalizing problems using meta-analysis. From 69 samples (N = 5,947), the association between insecurity and externalizing problems was significant, d = 0.31 (95% CI: 0.23, 0.40). Larger effects were found for boys (d = 0.35), clinical samples (d = 0.49), and from observation-based outcome assessments (d = 0.58). Larger effects were found for attachment assessments other than the Strange Situation. Overall, disorganized children appeared at elevated risk (d = 0.34, 95% CI: 0.18, 0.50), with weaker effects for avoidance (d = 0.12, 95% CI: 0.03, 0.21) and resistance (d = 0.11, 95% CI: −0.04, 0.26). The results are discussed in terms of the potential significance of attachment for mental health.

Interpretation of ambiguity in children: a prospective study of associations with anxiety and parental interpretations

Interpretation of ambiguity is consistently associated with anxiety in children, however, the temporal relationship between interpretation and anxiety remains unclear as do the developmental origins of interpretative biases. This study set out to test a model of the development of interpretative biases in a prospective study of 110 children aged 5–9 years of age. Children and their parents were assessed three times, annually, on measures of anxiety and interpretation of ambiguous scenarios (including, for parents, both their own interpretations and their expectations regarding their child). Three models were constructed to assess associations between parent and child anxiety and threat and distress cognitions and expectancies. The three models were all a reasonable fit of the data, and supported conclusions that: (i) children’s threat and distress cognitions were stable over time and were significantly associated with anxiety, (ii) parents’ threat and distress cognitions and expectancies significantly predicted child threat cognitions at some time points, and (iii) parental anxiety significantly predicted parents cognitions, which predicted parental expectancies at some time points. Parental expectancies were also significantly predicted by child cognitions. The findings varied depending on assessment time point and whether threat or distress cognitions were being considered. The findings support the notion that child and parent cognitive processes, in particular parental expectations, may be a useful target in the treatment or prevention of anxiety disorders in children.

Feasibility of guided CBT self-help for childhood anxiety disorders in primary care

Anxiety disorders in childhood are common, disabling and run a chronic course. Cognitive Behaviour Therapy (CBT) effective but is expensive and trained therapists are scarce. Guided self-help treatments may be a means of widening access to treatment. This study aimed to examine the feasibility of guided CBT self-help for childhood anxiety disorders in Primary Care, specifically in terms of therapist adherence, patient and therapist satisfaction and clinical gain. Participants were children aged 5-12 years referred to two Primary Child and Adolescent Mental Health Services (PCAMHSs) in Oxfordshire, UK, who met diagnostic criteria for a primary anxiety disorder. Of the 52 eligible children, 41 anxious children were assessed for anxiety severity and interference before and after receiving CBT self-help, delivered via the parent (total therapy time= 5 hours) by Primary Mental Health Workers (PMHWs). Therapy sessions were rated for treatment adherence and patients and PMHWs completed satisfaction questionnaires after treatment completion. Over 80% of therapy sessions were rated at a high level of treatment adherence. Parents and PMHWs reported high satisfaction with the treatment. 61% of the children assessed no longer met criteria for their primary anxiety disorder diagnosis following treatment, and 76% were rated as ‘much’/’very much’ improved on the Clinician’s Global Impression-Improvement scale. There were significant reductions on parent and child report measures of anxiety symptoms, interference, and depression. Preliminary exploration indicated that parental anxiety was associated with child treatment outcome. The findings suggest that guided CBT self-help represents a promising treatment for childhood anxiety in primary care.

Parental incarceration, attachment and child psychopathology

Theory and evidence relating parental incarceration, attachment, and psychopathology are reviewed. Parental incarceration is a strong risk factor for long-lasting psychopathology, including antisocial and internalizing outcomes. Parental incarceration might threaten children's attachment security because of parent-child separation, confusing communication about parental absence, restricted contact with incarcerated parents, and unstable caregiving arrangements. Parental incarceration can also cause economic strain, reduced supervision, stigma, home and school moves, and other negative life events for children. Thus, there are multiple possible mechanisms whereby parental incarceration might increase risk for child psychopathology. Maternal incarceration tends to cause more disruption for children than paternal incarceration and may lead to greater risk for insecure attachment and psychopathology. Children's prior attachment relations and other life experiences are likely to be of great importance for understanding children's reactions to parental incarceration. Several hypotheses are presented about how prior insecure attachment and social adversity might interact with parental incarceration and contribute to psychopathology. Carefully designed longitudinal studies, randomized controlled trials, and cross-national comparative research are required to test these hypotheses.