Patient Expectations in Internet-Based Self-Help for Social Anxiety

A number of controlled trials have demonstrated the efficacy of Internet-based cognitive-behaviour therapy for treating social anxiety disorder (SAD). However, little is known about what makes those interventions work. The current trial focuses on patient expectations as one common mechanism of change. The study examines whether patients' expectancy predicts outcome, adherence, and dropout in an unguided Internet-based self-help programme for SAD. Data of 109 participants in a 10-week self-help programme for SAD were analysed. Social anxiety measures were administered prior to the intervention, at week 2, and after the intervention. Expectancy was assessed at week 2. Patient expectations were a significant predictor of change in social anxiety (β = - .35 to - .40, all p < .003). Patient expectations also predicted treatment adherence (β = .27, p = .02). Patients with higher expectations showed more adherence and better outcome. Dropout was not predicted by expectations. The effect of positive expectations on outcome was mediated by early symptom change (from week 0 to week 2). Results suggest that positive outcome expectations have a beneficial effect on outcome in Internet-based self-help for SAD. Furthermore, patient expectations as early process predictors could be used to inform therapeutic decisions such as stepping up patients to guided or face-to-face treatment options

Valence and agency influence striatal response to feedback in patients with major depressive disorder

BACKGROUND: Reduced sensitivity to positive feedback is common in patients with major depressive disorder (MDD). However, findings regarding negative feedback are ambiguous, with both exaggerated and blunted responses being reported. The ventral striatum (VS) plays a major role in processing valenced feedback, and previous imaging studies have shown that the locus of controls (self agency v. external agency) over the outcome influences VS response to feedback. We investigated whether attributing the outcome to one's own action or to an external agent influences feedback processing in patients with MDD. We hypothesized that depressed participants would be less sensitive to the feedback attribution reflected by an altered VS response to self-attributed gains and losses. METHODS: Using functional MRI and a motion prediction task, we investigated the neural responses to self-attributed (SA) and externally attributed (EA) monetary gains and losses in unmedicated patients with MDD and healthy controls. RESULTS: We included 21 patients and 25 controls in our study. Consistent with our prediction, healthy controls showed a VS response influenced by feedback valence and attribution, whereas in depressed patients striatal activity was modulated by valence but was insensitive to attribution. This attribution insensitivity led to an altered ventral putamen response for SA - EA losses in patients with MDD compared with healthy controls. LIMITATIONS: Depressed patients with comorbid anxiety disorder were included. CONCLUSION: These results suggest an altered assignment of motivational salience to SA losses in patients with MDD. Altered striatal response to SA negative events may reinforce the belief of not being in control of negative outcomes contributing to a cycle of learned helplessness.

Internet-based interpretation bias modification for social anxiety: A pilot study

BACKGROUND AND OBJECTIVES: The biased interpretation of ambiguous social situations is considered a maintaining factor of Social Anxiety Disorder (SAD). Studies on the modification of interpretation bias have shown promising results in laboratory settings. The present study aims at pilot-testing an Internet-based training that targets interpretation and judgmental bias. METHOD: Thirty-nine individuals meeting diagnostic criteria for SAD participated in an 8-week, unguided program. Participants were presented with ambiguous social situations, were asked to choose between neutral, positive, and negative interpretations, and were required to evaluate costs of potential negative outcomes. Participants received elaborate automated feedback on their interpretations and judgments. RESULTS: There was a pre-to-post-reduction of the targeted cognitive processing biases (d = 0.57-0.77) and of social anxiety symptoms (d = 0.87). Furthermore, results showed changes in depression and general psychopathology (d = 0.47-0.75). Decreases in cognitive biases and symptom changes did not correlate. The results held stable accounting for drop-outs (26%) and over a 6-week follow-up period. Forty-five percent of the completer sample showed clinical significant change and almost half of the participants (48%) no longer met diagnostic criteria for SAD. LIMITATIONS: As the study lacks a control group, results lend only preliminary support to the efficacy of the intervention. Furthermore, the mechanism of change remained unclear. CONCLUSION: First results promise a beneficial effect of the program for SAD patients. The treatment proved to be feasible and acceptable. Future research should evaluate the intervention in a randomized-controlled setting.

Predictors of benzodiazepine self -administration behavior in anxious patients

The purpose of this study was to examine factors that may be associated with benzodiazepine (BZ) self-administration and risks of dependence in anxious patients. Preliminary work included examination of psychosocial characteristics and subjective drug response as potential predictors of medication use. Fifty-five M, F patients with generalized anxiety or panic disorder participated in a 3-week outpatient Choice Procedure in which they self-medicated “as needed” with alprazolam (Alz) and placebo. Findings showed that a large amount of variance in alprazolam preference, frequency, and quantity of use could be predicted by measures of anxiety, drug liking, and certain personality characteristics. The primary study extended this work by examining whether individual differences in Alz sensitivity also predict patterns of use. Twenty anxious patients participated in the study, which required 11 weekly clinic visits. Ten of these also participated in a baseline assessment of HPA-axis function that involved 24-hour monitoring of cortisol and ACTH levels and a CRH Stimulation Test. This assessment was conducted on the basis of prior evidence that steroid metabolites exert neuromodulatory effects on the GABA A receptor and that HPA-axis function may be related to BZ sensitivity and long-term disability in anxious patients. Patients were classified as either HIGH or LOW users based on their p.r.n. patterns of Alz use during the first 3 weeks of the study. They then participated in a 4-week dose response trial in which they received prescribed doses of medication (placebo, 0.25, 0.5, and 1.0mg Alz), each taken TID for 1 week. The dose response trial was followed by a second 3-week Choice Procedure. Findings were not indicative of biological differences in Alz sensitivity between the HIGH and LOW users. However, the HIGH users had higher baseline anxiety and greater anxiolytic response to Alz than the LOW users. Anxiolytic benefits of p.r.n. and prescribed dosing were shown to be comparable, and patients' conservative patterns of p.r.n. medication use were not affected by the period of prescribed dosing. Although there was not strong evidence to suggest relationships between HPA-axis function and Alz use or sensitivity, interesting findings emerged about the relationship between HPA-axis function and anxiety. ^

Evaluation of a brief child-focused group-based intervention for anxiety-disordered children

This paper presents a pilot study of a brief, group-based, cognitive-behavioural intervention for anxiety-disordered children. Five children (aged 7 to 13 years) diagnosed with a clinically significant anxiety disorder were treated with a recently developed 6-session, child-focused, cognitive-behavioural intervention that was evaluated using multiple measures (including structured diagnostic interview, self-report questionnaires and behaviour rating scales completed by parents) over four follow-up occasions (posttreatment, 3-month follow-up, 6-month follow-up and 12-month follow-up). This trial aimed to (a) evaluate the conclusion suggested by the research of Cobham, Dadds, and Spence (1998) that anxious children with non-anxious parents require a child-focused intervention only in order to demonstrate sustained clinical gains; and (b) to evaluate a new and more cost-effective child-focused cognitive-behavioural intervention. Unfortunately, the return rate of the questionnaires was poor, rendering this data source of questionable value. However, diagnostic interviews (traditionally the gold standard in terms of outcome in this research area) were completed for all children at all follow-up points. Changes in diagnostic status indicated that meaningful treatment-related gains had been achieved and were maintained over the full follow-up period. The results would thus seem to support the principle of participant-intervention matching proposed by Cobham et al. (1998), as well as the utility of the more brief intervention evaluated.

Screening for anxiety in mild cognitvely impaired individuals

Anxiety disorders are one of the most common psychiatric complaints across aU age cohorts, including older adults over age 65 (Regier et al., 1988; Regier, Narrow & Rae, 1990). Despite being a common complaint among older adults, anxiety remains underreported by patients and under diagnosed by health professionals (Stanley & Beck, 2000). Anxiety disorders have been less well studied in older adults than depression, both in terms of the assessment as well as treatment. While several anxiet)' inventories have normative data available for older populations, few anxiet)' measures have been specifically designed to be used with older populations. The primar)' aim of this pilot project was to evaluate the utility of a new anxiety screen specifically designed for older adults, the Geriatric Anxiet)' Inventor)' (GAI) on an older cohort with mild cognitive deficits.

Ansiedade na infância

Dissertação para obtenção do grau de Mestre em Design da Comunicação, apresentada na Universidade de Lisboa - Faculdade de Arquitetura.

Personality disorders in the community: a report from the Australian national survey of mental health and wellbeing

Background: The first set of aims of the present study was to determine the prevalence of personality disorders (PDs) in a nation, and gender differences in the types and numbers of PDs endorsed. The second set of aims was to establish the relationship of PD to other, non-PD disorders, physical conditions, and disability. Method: Data were obtained from the Australian National Survey of Mental Health and Wellbeing, conducted between May and August 1997. A stratified random sample of households was generated, from which all those aged 18 or over were considered potential interviewees. There were 10,641 respondents to the survey, and this represented a response rate of 78%. Each interviewee was asked 59 questions indexing specific ICD-10 PD criteria. Results: Of the total survey sample, 704 persons had at least one PD. Using weighted replicate weights, it was estimated that approximately 6.5% of the adult population of Australia have one or more PDs (lifetime prevalence). Persons with PD were more likely to be younger, male, and not married, and to have an anxiety disorder, an affective disorder, a substance use disorder, or a physical condition. They were also more likely to have greater disability than those without PD. Conclusion: The study is the first nationwide survey of mental disorders conducted within Australia. It provides an estimate of the prevalence of the various types of PD. The survey has considerable limitations, however, and these are discussed.

Extracellular serotonin level in the basolateral nucleus of the amygdala and dorsal periaqueductal gray under unconditioned and conditioned fear states: An in vivo microdialysis study

Serotonin (5-HT) plays a key role in the neural circuitry mediating unconditioned and conditioned fear responses related to panic and generalized anxiety disorders. The basolateral nucleus of the amygdala (BLA) and the dorsal periaqueductal gray (dPAG) appear to be mainly involved in these conditions. The aim of this study was to measure the extracellular level of 5-HT and its metabolite 5-hydroxyindolacetic acid (5-HIAA) in the BLA and dPAG during unconditioned and conditioned fear states using in vivo microdialysis procedure. Thus, for the unconditioned fear test, animals were chemically stimulated in the dPAG with semicarbazide, an inhibitor of the gamma-aminobutyric acid-synthesizing enzyme glutamic acid decarboxylase. For the conditioned fear test, animals were subjected to a contextual conditioned fear paradigm using electrical footshock as the unconditioned stimulus. The results show that the 5-HT and 5-HIAA level in the BLA and dPAG did not change during unconditioned fear, whereas 5-HT concentration, but not 5-HIAA concentration, increased in these brain areas during conditioned fear. The present study showed that the 5-HT system was activated during conditioned fear, whereas it remained unchanged during unconditioned fear, supporting the hypothesis that 5-HT has distinct roles in conditioned and unconditioned fear (dual role of 5-HT in anxiety disorders). (C) 2009 Elsevier B.V. All rights reserved.

5-HT1A receptors in the dorsal hippocampus mediate the anxiogenic effect induced by the stimulation of 5-HT neurons in the median raphe nucleus

We evaluated the involvement of dorsal hippocampus (DH) 5-HT1A receptors in the mediation of the behavioral effects caused by the pharmacological manipulation of 5-HT neurons in the median raphe nucleus (MRN). To this end, we used the rat elevated T-maze test of anxiety. The results showed that intra-DH injection of the 5-HT1A/7 agonist 8-OH-DPAT facilitated inhibitory avoidance, an anxiogenic effect, without affecting escape. Microinjection of the 5-HT1A antagonist WAY-100635 was ineffective. In the elevated T-maze, inhibitory avoidance and escape have been related to generalized anxiety and panic disorders, respectively. Intra-MRN administration of the excitatory aminoacid kainic acid, which non-selectively stimulates 5-HT neurons in this brain area facilitated inhibitory avoidance and impaired escape performance, but also affected locomotion. Intra-MRN injection of WAY-100635, which has a disinhibitory effect on the activity of 5-HT neurons in this midbrain area, only facilitated inhibitory avoidance. Preadministration of WAY-100635 into the DH blocked the behavioral effect of intra-MRN injection of WAY-100635, but not of kainic acid. These results indicate that DH 5-HT1A receptors mediate the anxiogenic effect induced by the selective stimulation of 5-HT neurons in the MRN. (c) 2007 Elsevier B.V. and ECNP. All rights reserved.

The lateral habenula regulates defensive behaviors through changes in 5-HT-mediated neurotransmission in the dorsal periaqueductal gray matter

Chemical stimulation of the lateral nucleus of the habenula (LHb), an area implicated in the regulation of serotonergic activity in raphe nuclei, affects the acquisition of inhibitory avoidance and escape expression of rats submitted to the elevated T-maze test of anxiety. Here, we investigated whether facilitation of 5-HT-mediated neurotransmission in the dorsal periaqueductal gray (dPAG) accounts for the behavioral consequences in the elevated T-maze induced by chemical stimulation of the LHb. The dPAG in the midbrain, which is innervated by 5-HT fibers originating from the dorsal raphe nucleus (DRN), has been consistently implicated in the genesis/regulation of anxiety- and fear-related defensive responses. The results showed that intra-dPAG injection of WAY-100635 or ketanserin, 5-HT(1A) and 5-HT(2A/2C) receptor antagonists, respectively, counteracted the anti-escape effect caused by bilateral intra-LHb injection of kainic acid (60 pmol/0.2 mu l). Ketanserin, but not WAY-100635, blocked kainic acid`s facilitatory effect on inhibitory avoidance acquisition. Overall, the results suggest that the pathway connecting the LHb to the DRN is involved in the control of 5-HT release in the dPAG, and facilitation of 5-HT-mediated neurotransmission in the latter area distinctively impacts upon the expression of anxiety- and fear-related defensive behaviors. While stimulation of 5-HT(1A) receptors selectively affects escape performance, 5-HT(2A/2C) receptors modulate both inhibitory avoidance and escape. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Evaluation of the psychometric properties of the Social Phobia Inventory in university students

Objective: The aim of the study was to study the psychometric properties of the Social Phobia Inventory (SPIN) in its version for the context of Brazilian adults. Methods: A sample of Brazilian university students from the general population (n = 2314) and a sample of university students identified as cases (n = 88) and noncases (n = 90) of social phobia were assessed, using as a parameter the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The different instruments were applied individually in the presence of a rater. Results: The SPIN showed adequate internal consistency (.63-.90) and concurrent validity with different instruments of auto- and hetero-evaluation of social phobia. Discriminative validity showed 0.84 to 0.86 sensitivity and 0.84 to 0.87 specificity for cutoff notes between 19 and 21. Factorial analysis showed the presence of a variable number of factors as a function of the different samples. Conclusions: The version of the SPIN studied is quite adequate for use in the context of Brazilian university students, favoring the screening of social phobia. However, further studies using more diverse samples are needed. (C) 2010 Elsevier Inc. All rights reserved.

Further Study of the Psychometric Qualities of a Brief Screening Tool for Social Phobia (MINI-SPIN) Applied to Clinical and Nonclinical Samples

PURPOSE. The purpose of this study was to further assess the psychometric qualities of the Mini-Social Phobia Inventory (MS) to screen for social anxiety disorder (SAD). DESIGN AND METHODS. The MS and other self- and clinician-rated scales for anxiety and social anxiety were applied in 2,314 university students and in samples of SAD patients (n = 88) and nonpatients (n = 90). FINDINGS. The MS revealed adequate discriminative validity, internal consistency (alpha = 0.49-0.73), convergent validity with the Social Phobia Inventory, Brief Social Phobia Scale, and Self-Statements During Public Speaking Scale and convergent and divergent validity with the Beck Anxiety Inventory. PRACTICE IMPLICATIONS. The MS has shown to be a fast and efficient screening instrument for SAD in different cultures and contexts.

Study of the psychometric qualities of the Brief Social Phobia Scale (BSPS) in Brazilian university students

Purpose: To perform a psychometric analysis of the Brazilian version of the Brief Social Phobia Scale (BSPS). Materials and methods: Hundred and seventy-eight university students of both genders aged on average 21.2 years and identified as Social Anxiety Disorder (SAD) cases and non-cases was studied, with the structured clinical interview for DSM-IV being used as a parameter. The different instruments were applied in an individual manner in the presence of a rater and of an observer. Results: The BSPS showed adequate internal consistency (0.48-0.88) and concurrent and divergent validity with the Beck Anxiety Inventory (BAI) (0.21-0.62), Social Phobia Inventory (0.24-0.82) and Self Statements During Public Speaking Scale (SSPS) (0.23-0.31). Discriminative validity revealed a sensitivity of 0.88-0.90 and a specificity of 0.81(0.83 for cut-off notes of 18/19. Factorial analysis demonstrated the presence of six factors that jointly explained 71.79% of data variance. Construct validity indicated some limits of the scale regarding the diagnosis of SAD. Inter-rater reliability was strong (0.86-1.00, p < 0.001). Conclusions: The BSPS is adequate for use with university students, although further studies in different cultures, samples and contexts are still necessary. (C) 2009 Elsevier Masson SAS. All rights reserved.

5-HT2C receptor regulation of defensive responses in the rat dorsal periaqueductal gray

Activation of 5-HT2C receptors in limbic structures such as the amygdala and hippocampus increases anxiety. Indirect evidence obtained with non-selective 5-HT2C-interacting drugs suggests that the same may occur in the dPAG, a brainstem region consistently implicated in the genesis/regulation of panic attacks. In this study we used more selective agonists and antagonists to unveil the role played by dPAG 5-HT2C receptors in the regulation of anxiety- and panic-related defensive behaviors. Our results showed that intra-dPAG microinjection of the endogenous agonist 5-HT (20 nmol) or the 5-HT2C receptor agonists MK-212 (1 and 10 nmol) and RO-600175 (40 nmol) significantly increased inhibitory avoidance acquisition in rats tested in the elevated T-maze, suggesting an anxiogenic effect. 5-HT, but not the two 5-HT2C receptor agonists, inhibited escape performance. In the elevated T-maze, inhibitory avoidance and escape responses have been related to generalized anxiety and panic attacks, respectively. The behavioral effects caused by 5-HT and MK-212 were fully blocked by previous local microinjection of the 5-HT2C receptor antagonist SB-242084. Intra-dPAG injection of MK-212 also failed to affect escape expression in another test relating this behavior to panic, the electrical stimulation of the dPAG. Overall, the results indicate that 5-HT2C receptors in the dPAG are preferentially involved in the regulation of defensive behaviors related to anxiety, but not panic. This finding extends to the dPAG the prominent role that has been attributed to 5-HT2C receptors in anxiety generation. (C) 2010 Elsevier Ltd. All rights reserved.