Anxious children who received treatment grow -up: An 8-to-13 year follow-up study

This dissertation examined the long-term efficacy (8-to-13 years, M = 9.54, SD = 1.689) of exposure-based cognitive-behavioral therapy (CBT) for phobic and anxiety disorders in youths. Long-term efficacy was examined in terms of diagnostic recovery, symptom reductions, and clinically significant change. This dissertation also examined predictors of long-term efficacy (e.g., age, gender, and other clinical characteristics) as well as the relative long-term efficacy of CBT for Hispanic/Latino and European American youth. ^ Participants consisted of 67 youth (age range 15–26 years; M = 19.43, SD = 3.02 years at time of follow-up assessment), (47.8% females, 37.3% Hispanic/Latino) who had participated in one of two clinical trials (Silverman et al., 1999a, b). After providing informed consent to participate in the long term follow-up, youths completed a diagnostic interview and a battery of questionnaires. Results indicated that treatment gains were maintained about 9.5 years after treatment was completed. Maintenance of treatment gains was evident in terms of diagnostic recovery, symptom reductions, and clinically significant change. Long-term treatment gains extended to both ethnic groups and the two ethnic groups were functionally equivalent along most indices examined. Analyses of predictors of long-term outcome showed that parent self-reported pre-treatment depression, youth-reported pre-treatment depression, and youths retrospective reports of negative life events were significantly associated with less favorable long-term gains in terms of total symptoms of anxiety at long-term follow-up. In terms of long-term sequelae, youths with less successful post-treatment outcomes reported seeking-out additional treatment as well as using/abused substances and substance dependence significantly more than youths with successful post-treatment outcomes. Results are discussed in terms of the contribution of the present study to knowledge base about the long-term efficacy of exposure-based CBT procedures for phobic and anxiety disorders in youth. Findings also are discussed in terms of the need to modify CBT procedures to target youths with less successful post-treatment outcomes. Limitations and future directions are presented. ^

The differential impact of oxytocin receptor (OXTR) genotypes on the risk of autism spectrum disorder (ASD) and resulting social communication deficits

Background: Autism spectrum disorder (ASD) is multifactorial and is likely the result of complex interactions between multiple environmental and genetic factors. Recently, it has been suggested that each symptom cluster of the disorder, such as poor social communication, may be mediated by different genetic influences. Genes in the oxytocin pathway, which mediates social behaviours in humans, have been studied with single nucleotide polymorphisms (SNPs) in the oxytocin receptor gene (OXTR) being implicated in ASD. This thesis examines the presence of different oxytocin receptor genotypes, and their associations with ASD and resulting social communication deficits. Methods: The relationship between four OXTR variants and ASD was evaluated in 607 ASD simplex (SPX) families. Cases were compared to their unaffected siblings using a conditional logistic approach. Odds ratios and associated 95 percent confidence intervals were obtained. A second sample of 235 individuals with a diagnosis of ASD was examined to evaluate whether these four OXTR variants were associated with social communication scores on the Autism Diagnostic Interview – Revised (ADI-R). Parameter estimates and associated 95 percent confidence intervals were generated using a linear regression approach. Multiple testing issues were addressed using false discovery adjustments. Results: The rs53576 AG genotype was significantly associated with a lower risk of ASD (OR = 0.707, 95% CI: 0.512-0.975). A single genotype (AG) provided by the rs2254298 marker was found to be significantly associated with higher social communication scores (Parameter estimate = 1.833, SE = 0.762, p = 0.0171). This association was also seen in a Caucasian only and mothers as the respondent samples. No association was significant following false discovery rate adjustments. Conclusion: The findings from these studies provide limited support for the role of OXTR SNPs in ASD, especially in social communication skills. The clinical significance of these associations remains unknown, however, it is likely that these associations do not play a role in the severity of symptoms associated with ASD. Rather, they may be important in the appearance of social deficits due to the rs2254298 markers association with enlarged amygdalas.

Comparability between telephone and face-to-face Structured Clinical Interview for DSM-IV in assessing social anxiety disorder

PURPOSE. This article evaluates the comparability of the telephone and in-person Structured Clinical Interview for DSM-IV (SCID) interviews in assessing patients with social anxiety disorder (SAD) as an independent anxiety diagnosis. DESIGN AND METHODS. One hundred subjects were randomly selected and interviewed with the SCID, once by telephone and once in person (1-3 months later). FINDINGS. The prevalence of SAD assessed with the telephone interviews was 56%, whereas the in-person prevalence was 52%, with no statistically significant difference. The test-retest kappa for the 200 interviews was .84, indication of excellent agreement. PRACTICE IMPLICATIONS. These findings, along with the existing evidence of their validity, should encourage the use of SCID by telephone for SAD diagnostic interviews.

Validity and applicability of the Mini International Neuropsychiatric Interview administered by family medicine residents in primary health care in Brazil

Objective: To evaluate the validity and applicability of the Mini International Neuropsychiatric Interview (MINI) used by family medicine residents in primary health care (PHC) in Brazil. Methods: Training for administrating the MINI was given as part of a broad psychiatry education program. Interviews were held with 120 PHC patients who were at least 15 years old. MINI was administered by 25 resident physicians, while the Structured Clinical Interview for Diagnosis (SCID) was administered by a psychiatrist blind to patients` results on the MINI, and the diagnoses on both interviews were compared. The resident physicians answered questions on the applicability of the MINI. Results: Concordance levels for any mental disorder, the broader current diagnostic categories and the most common specific diagnoses were analyzed. Kappa coefficients ranged between 0.65 and 0.85; sensitivity, between 0.75 and 0.92; specificity, between 0.90 and 0.99; positive predictive values (PPV), between 0.60 and 0.86; negative predictive values (NPV), between 0.92 and 0.99; and accuracy, between 0.88 and 0.98. The resident physicians considered MINI comprehensibility and clinical relevance satisfactory. Conclusions: These good psychometric results in a real-world setting may be related to a special training program, which is more frequent, intensive and diversified. In these conditions, the MINI is a useful tool for general practitioners. (c) 2008 Elsevier Inc. All rights reserved.

Validity of the Brazilian Portuguese version of the bipolar spectrum diagnostic scale

OBJECTIVE: Bipolar spectrum disorders (BSDs) are prevalent and frequently unrecognized and undertreated. This report describes the development and validation of the Brazilian version of the bipolar spectrum diagnostic scale (B-BSDS), a screening instrument for bipolar disorders, in an adult psychiatric population. METHOD: 114 consecutive patients attending an outpatient psychiatric clinic completed the B-BSDS. A research psychiatrist, blind to the B-BSDS scores, interviewed patients by means of a modified version of the mood module of the Structured Clinical Interview for DSM-IV ("gold standard"). Subthreshold bipolar disorders were defined as recurrent hypomania without a major depressive episode or with fewer symptoms than those required for threshold hypomania. RESULTS: The internal consistency of the B-BSDS evaluated with Cronbach's alpha coefficient was 0.89 (95% CI; 0.86-0.91). On the basis of the modified SCID, 70 patients (61.4%) of the sample received a diagnosis of BSDs. A B-BSDS screening score of 16 or more items yielded: sensitivity of 0.79 (95% CI; 0.72-0.85), specificity of 0.77 (95% CI; 0.70-0.83), a positive predictive value of 0.85 (95% CI; 0.78-0.91) and a negative predictive value of 0.70 (95% CI; 0.63-0.75). CONCLUSION: The present data demonstrate that the B-BSDS is a valid instrument for the screening of BSDs.

Inter-informant agreement and prevalence estimates for substance use disorders: direct interview versus family history method.

OBJECTIVES: Family studies typically use multiple sources of information on each individual including direct interviews and family history information. The aims of the present study were to: (1) assess agreement for diagnoses of specific substance use disorders between direct interviews and the family history method; (2) compare prevalence estimates according to the two methods; (3) test strategies to approximate prevalence estimates according to family history reports to those based on direct interviews; (4) determine covariates of inter-informant agreement; and (5) identify covariates that affect the likelihood of reporting disorders by informants. METHODS: Analyses were based on family study data which included 1621 distinct informant (first-degree relatives and spouses) - index subject pairs. RESULTS: Our main findings were: (1) inter-informant agreement was fair to good for all substance disorders, except for alcohol abuse; (2) the family history method underestimated the prevalence of drug but not alcohol use disorders; (3) lowering diagnostic thresholds for drug disorders and combining multiple family histories increased the accuracy of prevalence estimates for these disorders according to the family history method; (4) female sex of index subjects was associated with higher agreement for nearly all disorders; and (5) informants who themselves had a history of the same substance use disorder were more likely to report this disorder in their relatives, which entails the risk of overestimation of the size of familial aggregation. CONCLUSION: Our findings have important implications for the best-estimate procedure applied in family studies.

Inter-informant agreement and prevalence estimates for mood syndromes: Direct interview vs. family history method.

BACKGROUND: The use of the family history method is recommended in family studies as a type of proxy interview of non-participating relatives. However, using different sources of information can result in bias as direct interviews may provide a higher likelihood of assigning diagnoses than family history reports. The aims of the present study were to: 1) compare diagnoses for threshold and subthreshold mood syndromes from interviews to those relying on information from relatives; 2) test the appropriateness of lowering the diagnostic threshold and combining multiple reports from the family history method to obtain comparable prevalence estimates to the interviews; 3) identify factors that influence the likelihood of agreement and reporting of disorders by informants. METHODS: Within a family study, 1621 informant-index subject pairs were identified. DSM-5 diagnoses from direct interviews of index subjects were compared to those derived from family history information provided by their first-degree relatives. RESULTS: 1) Inter-informant agreement was acceptable for Mania, but low for all other mood syndromes. 2) Except for Mania and subthreshold depression, the family history method provided significantly lower prevalence estimates. The gap improved for all other syndromes after lowering the threshold of the family history method. 3) Individuals who had a history of depression themselves were more likely to report depression in their relatives. LIMITATIONS: Low proportion of affected individuals for manic syndromes and lack of independence of data. CONCLUSIONS: The higher likelihood of reporting disorders by affected informants entails the risk of overestimation of the size of familial aggregation of depression.

Introduction d'un questionnaire de dépistage de l'Etat de stress post traumatique (ESPT) : quel impact sur le diagnostic dans une unité d'urgence psychiatrique ambulatoire ?

Contexte: Impression clinique que l'Etat de Stress Post-traumatique (ESPT) est sous-diagnostiqué dans la prise en charge des patients qui sont évalués dans le cadre d'une urgence psychiatrique. Objectifs: (i) identifier la prévalence de l'ESPT dans une unité d'urgence psychiatrique au moyen d'un instrument diagnostic et la comparer avec le diagnostic clinique retenu dans un échantillon historique (ii) évaluer la perception des cliniciens quant à l'utilisation systématique d'un instrument diagnostic Méthodes: la prévalence de l'ESPT a été évaluée chez des patients consécutifs (N = 403) qui ont bénéficié d'une consultation par des psychiatres de l'Unité urgence-crise du Service de Psychiatrie de Liaison (PLI) du CHUV, en utilisant le module J du Mini Mental Neuropsychologic Interview (MINI 5.0.0, version CIM-10). Ce résultat a été comparé avec la prévalence de l'ESPT mentionné comme diagnostic dans les dossiers (N = 350) d'un échantillon historique. La perception des médecins-assistants de psychiatrie quant au dépistage systématique de l'ESPT avec un instrument a été étudiée en se basant sur la conduite d'un focus group d'assistants travaillant dans l'Unité urgence-crise du PLI. Résultats: Parmi les patients (N = 316) évalués à l'aide de l'instrument diagnostic, 20,3% (n = 64) réunissaient les critères de l'ESPT. Cela constitue un taux de prévalence significativement plus élevé que la prévalence d'ESPT documentée dans les dossiers de l'échantillon historique (0,57%). Par ailleurs, la prévalence de l'ESPT est significativement plus élevée parmi les groupes socio- économiques précarisés, tels que réfugiés et sans papiers (50%), patients venant d'un pays à histoire de guerre récente (47,1%), patients avec quatre (44,4%) ou trois comorbidités psychiatriques (35,3%), migrants (29,8%) et patients sans revenus professionnels (25%). Le focus groupe composé de 8 médecins-assistants a révélé que l'utilisation systématique d'un outil- diagnostic ne convenait pas dans le setting d'urgence psychiatrique, notamment parce que l'instrument a été considéré comme non adapté à une première consultation ou jugé avoir un impact négatif sur l'entretien clinique. Toutefois, après la fin de l'étude, les médecins-assistants estimaient qu'il était important de rechercher activement l'ESPT et continuaient à intégrer les éléments principaux du questionnaire dans leur travail clinique. Conclusion et perspectives: cette étude confirme que l'ESPT est largement sous-diagnostiqué dans le contexte des urgences psychiatriques, mais que l'usage systématique d'un outil diagnostic dans ce cadre ne satisfait pas les praticiens concernés. Pour améliorer la situation et au vu du fait qu'un instrument diagnostic est considéré comme non-adapté dans ce setting, il serait peut-être bénéfique d'envisager un dépistage ciblé et/ou de mettre en place une stratégie de formation institutionnelle.

Diagnostic profile of inpatients as a determinant of length of stay in a general hospital psychiatric unit

The aim of this study was to determine if the diagnostic profile of inpatients of a psychiatric unit in a general hospital influences the length of stay. The results of a retrospective survey comprising the first 16 years of operation of the Psychiatric Unit of the Ribeirão Preto General Hospital (PURP) showed that the progressive increase observed in the length of stay correlated with the increase in percentage of schizophrenia diagnosis, after the 8th year of hospital operation, and of affective disorders, after the 12th year. The length of hospitalization kept increasing until the 16th year, even though there was no change in the diagnostic profile of the patients admitted to the unit. In a prospective study encompassing the next six months, 61 inpatients were evaluated with the Structured Clinical Interview for DSM-III-R and the Brief Psychiatric Rating Scale (BPRS). The results showed that 82% of the inpatients fulfilled the diagnostic criteria for the schizophrenic or affective disorder spectrum at admission, with a discharge rate slower than for other diagnoses, although the length of hospitalization did not significantly differ among diagnostic categories. The results further demonstrated that in every diagnostic category more than 50% of the patients stayed in hospital for more than one week after reaching a BPRS score equal to 6, indicative of discharge. Overall, these data suggest that the increase in length of hospitalization may be due to a higher percentage of patients with a diagnosis of schizophrenia and affective disorder admitted to the PURP. In addition, patients with low symptomatic levels remained in hospital longer than they should have.

Momentary stress moderates procoagulant reactivity to a trauma-specific interview in patients with posttraumatic stress disorder caused by myocardial infarction

Hypercoagulability of the blood might partially explain the increased cardiovascular disease risk in posttraumatic stress disorder (PTSD) and is also triggered by anticipatory stress. We hypothesized exaggerated procoagulant reactivity in patients with PTSD in response to a trauma-specific interview that would be moderated by momentary stress levels. We examined 23 patients with interviewer-diagnosed PTSD caused by myocardial infarction (MI) and 21 post-MI patients without PTSD. A second diagnostic (i.e., trauma-specific) interview to assess posttraumatic stress severity was performed after a median follow-up of 26 months (range 12-36). Before that interview patients rated levels of momentary stress (Likert scale 0-10) and had blood collected before and after the interview. The interaction between PTSD diagnostic status at study entry and level of momentary stress before the follow-up interview predicted reactivity of fibrinogen (P=0.036) and d-dimer (P=0.002) to the PTSD interview. Among patients with high momentary stress levels, PTSD patients had greater fibrinogen (P=0.023) and d-dimer (P=0.035) reactivity than non-PTSD patients. Among patients with low momentary stress levels, PTSD patients had less d-dimer reactivity than non-PTSD patients (P=0.024); fibrinogen reactivity did not significantly differ between groups. Momentary stress levels, but not severity of posttraumatic stress, correlated with d-dimer reactivity in PTSD patients (r=0.46, P=0.029). We conclude that momentary stress levels moderated the relationship between PTSD and procoagulant reactivity to a trauma-specific interview. Procoagulant reactivity in post-MI patients with PTSD confronted with their traumatically experienced MI was observed if patients perceived high levels of momentary stress before the interview.

Treatment of hyperactive children: increased efficiency through modifications of homeopathic diagnostic procedure

BACKGROUND: The rigorous test to which homeopathy was subject in our recent double-blind clinical trail of homeopathic treatment of attention deficit hyperactivity disorder (ADHD) necessitated optimized treatment meeting the highest standards. METHODS: Optimization was performed in three steps: (1) In successfully treated children, prescriptions leading to an insufficient response were analysed by a general questionnaire to identify unreliable symptoms. (2) Polarity analysis, a further development of Bönninghausen's concept of contraindications, was introduced in response to the frequently one-sided symptoms. This enabled us to use few but specific symptoms to identify the medicine whose genius symptoms exhibit the closest match to the patient's characteristic symptoms. (3) We investigated the influence of the primary perception symptoms on the result of the repertorization. Perception symptoms are not normally recorded during a patient interview even though they are among the most reliable facts related by the patients. At the same time we were able to improve the continuity of improvement of ADHD symptoms using liquid Q-potencies. RESULTS: Introducing the questionnaire, polarity analysis, and including perception symptoms, lead to an improvement in the success rate of the first prescription from 21% to 54%, of the fifth prescription from 68% to 84%.

Patterns of diagnostic comorbidity in children and adolescents with anxiety

Comorbidity is defined as the co-occurrence of two or more psychological disorders and has been identified as one of the most pressing issues facing child psychologists today. Unfortunately, research on comorbidity in anxious children is rare. The purpose of this research was to examine how specific comorbid patterns in children and adolescents referred with anxiety disorders affected clinical presentation. In addition, the effects of gender, age and total number of diagnoses were also examined.^ Three hundred fifty-five children and adolescents (145 girls and 210 boys, hereafter referred to as "children") aged 6 to 17 who presented to the Child Anxiety and Phobia Program during the years 1987 through 1996 were assessed through a structured clinical interview administered to both the children and their families. Based on information from both children and parents, children were assigned up to five DSM diagnoses. Global ratings of severity were also obtained. While children were interviewed, parents completed a number of questionnaires pertaining to their child's overall functioning, anxiety, thoughts and behaviors. Similarly, while parents were interviewed, children completed a number of self-report questionnaires concerning their own thoughts, feelings and behaviors.^ In general, children with only anxiety disorders were rated as severe as children who met criteria for both anxiety and externalizing disorders. Children with both anxiety and externalizing disorders were mostly young (i.e. age 6 through 11) and mostly male. These children tended to rate themselves (and be rated by their parents) equally as anxious as children with only anxiety disorders. Global ratings of severity tended to be associated with the type of comorbid pattern versus the number of diagnoses assigned to a child. The theoretical, development and clinical implications of these findings will be discussed. ^

Evaluation of the internal structural validity of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) anxiety disorders in children and adolescents

The purpose of the present dissertation was to evaluate the internal validity of symptoms of four common anxiety disorders included in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (text revision) (DSM-IV-TR; American Psychiatric Association, 2000), namely, separation anxiety disorder (SAD), social phobia (SOP), specific phobia (SP), and generalized anxiety disorder (GAD), in a sample of 625 youth (ages 6 to 17 years) referred to an anxiety disorders clinic and 479 parents. Confirmatory factor analyses (CFAs) were conducted on the dichotomous items of the SAD, SOP, SP, and GAD sections of the youth and parent versions of the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV: C/P; Silverman & Albano, 1996) to test and compare a number of factor models including a factor model based on the DSM. Contrary to predictions, findings from CFAs showed that a correlated model with five factors of SAD, SOP, SP, GAD worry, and GAD somatic distress, provided the best fit of the youth data as well as the parent data. Multiple group CFAs supported the metric invariance of the correlated five factor model across boys and girls. Thus, the present study’s finding supports the internal validity of DSM-IV SAD, SOP, and SP, but raises doubt regarding the internal validity of GAD.^

Evidências de validade do Millon Behavioral Medicine Diagnostic: avaliação de indicadores de adesão ao tratamento em pacientes com hipertensão

Systemic Arterial Hypertension – SAH – is defined as the syndrome which its main feature is the presence of high tensional levels, associated with alterations of functional or structural levels in the organs that it strikes. Its specific causes are not very well bounded and have an asymptomatic character. Due to its chronicity it requires adherence to the treatment plan in a systematic and permanent manner, implicating in lifestyle changes, combined or not with the use of medication. The personality inventories have been largely used in the lineation of indicative traits of difficulties with the adherence to the treatment. In this sense, developed by Theodore Millon, the Millon Behavioural Medicine Diagnostic – MBMD is an instrument made from the consensus among healthcare professionals, aiming at identifying psychological factors that may compromise medical treatment so that they can be conducted in a way to enable a better adherence. Objective: evaluation of the evidence of validity of the Millon Behavioural Medicine Diagnostic – MBMD for a public of patients with hypertension, aiming at investigating the indicators implicated in the adherence or not to the anti-hypertensive treatment. Method: there was a group of 200 participants in a university hospital in the city of Natal/RN, males and females, ranging from 20 to 70 years old. An interview protocol was administered in order to obtain information about socio-demographic data, clinical history, healthcare habits and way of conducting treatment, and after, the administration of the MBMD followed. Results: by means of Factor Analysis it was verified that the organization proposed by the factors is favorable and it adjusts to the theory, allowing the visualization of other underlying constructs to the scales, with adequate adjustment indexes and satisfactory Cronbach’s alpha indicators. Besides, the MBMD revealed itself sensitive to the intragroup differences relative to the sex, age, schooling, marital status, profession, income, SAH history, diagnostic time, medication use, comorbidity presence, hyposodic diet, social support and adherence criteria variables. The utilization of such instrument in the evaluation of the adherence to the anti-hypertensive treatment show, therefore, indicators of validity.

High Diagnostic Accuracy And Reproducibility Of Fine-needle Aspiration Cytology For Diagnosing Salivary Gland Tumors: Cytohistologic Correlation In 182 Cases.

The purpose of this study was to assess the efficacy and reproducibility of the cytologic diagnosis of salivary gland tumors (SGTs) using fine-needle aspiration cytology (FNAC). The study aimed to determine diagnostic accuracy, sensitivity, and specificity and to evaluate the extent of interobserver agreement. We retrospectively evaluated SGTs from the files of the Division of Pathology at the Clinics Hospital of São Paulo and Piracicaba Dental School between 2000 and 2006. We performed cytohistologic correlation in 182 SGTs. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 94%, 100%, 100%, 100%, and 99%, respectively. The interobserver cytologic reproducibility showed significant statistical concordance (P < .0001). FNAC is an effective tool for performing a reliable preoperative diagnosis in SGTs and shows high diagnostic accuracy and consistent interobserver reproducibility. Further FNAC studies analyzing large samples of malignant SGTs and reactive salivary lesions are needed to confirm their accuracy.