Case-series Evaluating a Transdiagnostic Cognitive-behavioral Treatment For Co-occurring Anxiety Disorders.

Background. Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioral interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating cooccurring anxiety disorders. Aims. To evaluate the efficacy of a transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders. Methods. An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13 session modular transdiagnostic cognitive-behavioral intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD. Results. Five of the six participants completed treatment. At post-treatment assessment the five treatment completers achieved diagnostic and symptomatic change with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the three-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre- to post-intervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at three-month follow-up. Conclusions. Results suggest that transdiagnostic cognitive behavioral interventions can be of benefit to patients with co-occurring anxiety disorders.

Is social phobia characterized by a distinct interpersonal pattern?

Traditionnellement, le construit de la phobie sociale a été défini selon une vision intrapersonnelle, en tant que trouble de l’anxiété. Une autre conception se propose de la définir d’un point de vue interpersonnel, comme un pattern global d’autoprotection. L’objectif principal de cette thèse est de tester des hypothèses tirées du modèle interpersonnel de la phobie sociale. Deux études, présentées sous forme d’articles, ont permis d’examiner si des patterns spécifiques d’autoprotection, tels que l’impuissance et la soumission, caractérisent le mode de fonctionnement des phobiques sociaux. Les études ont également évalué si l’autoprotection et l’anxiété sont interreliées. Pour la première étude, les patterns interpersonnels de 132 phobiques sociaux, évalués à l’aide d’une mesure dérivée du Circumplex interpersonnel, ont été comparés à ceux de 85 individus célibataires ayant une dysfonction sexuelle et 105 sujets normaux. La relation entre les patterns d’autoprotection, l’anxiété sociale, la détresse générale et le fonctionnement social a également été examinée chez les phobiques sociaux. La seconde étude a permis d’examiner l’évolution des patterns d’autoprotection ainsi que de l’anxiété sociale, de la détresse générale et du fonctionnement social, chez 85 phobiques sociaux à quatre moments : avant et après un traitement d’approche interpersonnelle, ainsi qu’aux relances de six mois et d’un an. L’étude a également comparé les participants en rémission et ceux satisfaisant les critères de la phobie sociale un an suivant la fin du traitement. Les résultats suggèrent que les patterns d’impuissance et de soumission sont caractéristiques de la phobie sociale. Plus précisément, ces patterns décrivent davantage les comportements des phobiques sociaux plutôt que ceux des groupes de comparaison. De plus, une réduction significative de l’autoprotection a été notée au post-traitement et maintenue jusqu’au suivi d’un an, surtout chez les participants en rémission.En outre, une relation entre l’autoprotection, l’anxiété sociale et la détresse générale a été mise en évidence chez les phobiques sociaux. Une amélioration de l’anxiété, de la détresse subjective et du fonctionnement social cohérente avec la dissolution des patterns d’autoprotection a également été obtenue au post-traitement. En conclusion, les résultats des deux études appuient une conception interpersonnelle de la phobie sociale.

The effects of maternal social phobia on mother-infant interactions and infant social responsiveness

Background: Social phobia aggregates in families. The genetic contribution to intergenerational transmission is modest, and parenting is considered important. Research on the effects of social phobia on parenting has been subject to problems of small sample size, heterogeneity of samples and lack of specificity of observational frameworks. We addressed these problems in the current study.Methods: We assessed mothers with social phobia (N = 84) and control mothers (N = 89) at 10 weeks in face-to-face interactions with their infants, and during a social challenge, namely, engaging with a stranger. We also assessed mothers with generalised anxiety disorder (GAD) (N = 50). We examined the contribution to infant social responsiveness of early infant characteristics (neonatal irritability), as well as maternal behaviour. Results: Mothers with social phobia were no less sensitive to their infants during face-to-face interactions than control mothers, but when interacting with the stranger they appeared more anxious, engaged less with the stranger themselves, and were less encouraging of the infant's interaction with the stranger; infants of index mothers also showed reduced social responsiveness to the stranger. These differences did not apply to mothers with GAD and their infants. Regression analyses showed that the reduction in social responsiveness in infants of mothers with social phobia was predicted by neonatal irritability and the degree to which the mother encouraged the infant to interact with the stranger.Conclusions: Mothers with social phobia show specific parenting difficulties, and their infants show early signs of reduced social responsiveness that are related to both individual infant differences and a lack of maternal encouragement to engage in social interactions.

Parenting by anxious mothers: effects of disorder subtype, context and child characteristics

Background:  There has been increasing research interest in parenting by anxious adults; however, little is known about anxiety-subtype effects, or effects of the context in which parenting is assessed. Methods:  Two groups of anxious mothers, social phobia (N = 50), generalised anxiety disorder (N = 38), and nonanxious controls (N = 62) were assessed with their 4.9-year-old children in three tasks: two presented threat specifically relevant to each maternal disorder, namely, a social threat task where the child had to give a speech, and a nonsocial threat task where the child had to explore potentially scary objects; the third was a nonthreat task (playing with play dough). Seven parenting dimensions were scored. Effects on parenting of maternal anxiety subgroup and task, and their interactions, were examined, as were effects of earlier child behavioural inhibition and currently manifest anxiety. Results:  There were no parenting differences between maternal groups in the nonthreat play-dough task; parenting difficulties in the two anxious groups were principally evident in the disorder-specific challenge. Parenting differences between nonanxious and anxious mothers occurred independently of child characteristics. There was little evidence for particular forms of parenting difficulty being unique to maternal disorder. Conclusions:  Anxious mothers’ parenting difficulties emerge when occurring under challenge, especially when this is disorder-specific. These effects should be considered in research and clinical practice.

Cortisol levels in response to starting school in children at increased risk for social phobia

Background: Research on depression has identified hyperactivity of the HPA axis as a potential contributory factor to the intergenerational transmission of affective symptoms. However, this has not yet been examined in the context of social phobia. The current study compared HPA axis activity in response to a universal social stressor (starting school) in children of 2 groups of women: one with social phobia and one with no history of anxiety (comparison group). To determine specificity of effects of maternal social phobia, a third group of children were also examined whose mothers had generalised anxiety disorder (GAD). Method: Children provided salivary cortisol samples in the morning, afternoon and at bedtime across 3 time-blocks surrounding the school start: a month before starting school (baseline), the first week at school (stress response), and the end of the first school term (stress recovery). Child behavioural inhibition at 14 months was also assessed to explore the influence of early temperament on later stress responses. Results: All children displayed an elevation in morning and afternoon cortisol from baseline during the first week at school, which remained elevated until the end of the first term. Children in the social phobia group, however, also displayed an equivalent elevation in bedtime cortisol, which was not observed for comparison children or for children of mothers with GAD. Children in the social phobia group who were classified as 'inhibited' at 14 months displayed significantly higher afternoon cortisol levels overall. Summary: A persistent stress response to school in the morning and afternoon is typical for all children, but children of mothers with social phobia also display atypical elevations in evening cortisol levels when at school - signalling long-term disruption of the circadian rhythm in HPA axis activity. This is the first study to report HPA axis disruption in children at risk of developing social phobia, and future research should aim to determine whether this represents a pathway for symptom development, taking early temperament into account.

Doll Play narratives about starting school in children of socially anxious mothers, and their relation to subsequent child school-based anxiety

Background: Child social anxiety is common, and predicts later emotional and academic impairment. Offspring of socially anxious mothers are at increased risk. It is important to establish whether individual vulnerability to disorder can be identified in young children. Method: The responses of 4.5 year-old children of mothers with social phobia (N = 62) and non-anxious mothers (N = 60) were compared, two months before school entry, using a Doll Play (DP) procedure focused on the social challenge of starting school. DP responses were examined in relation to teacher reports of anxious-depressed symptoms and social worries at the end of the child’s first school term. The role of earlier child behavioral inhibition and attachment, assessed at 14 months, was also considered. Results: Compared to children of non-anxious mothers, children of mothers with social phobia were significantly more likely to give anxiously negative responses in their school DP (OR = 2.57). In turn, negative DP predicted teacher reported anxious-depressed and social worry problems. There were no effects of infant behavioral inhibition or attachment. Conclusion: Vulnerability in young children at risk of anxiety can be identified using Doll Play narratives.

Serotonin transporter [corrected] methylation and response to cognitive behaviour therapy in children with anxiety disorders

Anxiety disorders that are the most commonly occurring psychiatric disorders in childhood, are associated with a range of social and educational impairments and often continue into adulthood. Cognitive behaviour therapy (CBT) is an effective treatment option for the majority of cases, although up to 35-45% of children do not achieve remission. Recent research suggests that some genetic variants may be associated with a more beneficial response to psychological therapy. Epigenetic mechanisms such as DNA methylation work at the interface between genetic and environmental influences. Furthermore, epigenetic alterations at the serotonin transporter (SERT) promoter region have been associated with environmental influences such as stressful life experiences. In this study, we measured DNA methylation upstream of SERT in 116 children with an anxiety disorder, before and after receiving CBT. Change during treatment in percentage DNA methylation was significantly different in treatment responders vs nonresponders. This effect was driven by one CpG site in particular, at which responders increased in methylation, whereas nonresponders showed a decrease in DNA methylation. This is the first study to demonstrate differences in SERT methylation change in association with response to a purely psychological therapy. These findings confirm that biological changes occur alongside changes in symptomatology following a psychological therapy such as CBT.

Predictors of onset of depression and anxiety in the year after diagnosis of breast cancer

Background Depression and anxiety are common after diagnosis of breast cancer. We examined to what extent these are recurrences of previous disorder and, controlling for this, whether shame, self-blame and low social support after diagnosis predicted onset of depression and anxiety subsequently. Method Women with primary breast cancer who had been treated surgically self-reported shame, self-blame, social support and emotional distress post-operatively. Psychiatric interview 12 months later identified those with adult lifetime episodes of major depression (MD) or generalized anxiety disorder (GAD) before diagnosis and onset over the subsequent year. Statistical analysis examined predictors of each disorder in that year. Results Of the patients, two-thirds with episodes of MD and 40% with episodes of GAD during the year after diagnosis were experiencing recurrence of previous disorder. Although low social support, self-blame and shame were each associated with both MD and GAD after diagnosis, they did not mediate the relationship of disorder after diagnosis with previous disorder. Low social support, but not shame or self-blame, predicted recurrence after controlling for previous disorder. Conclusions Anxiety and depression during the first year after diagnosis of breast cancer are often the recurrence of previous disorder. In predicting disorder following diagnosis, self-blame and shame are merely markers of previous disorder. Low social support is an independent predictor and therefore may have a causal role.

Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000

Objective: There is little information about obsessive-compulsive disorder in large representative community samples. The authors aimed to establish obsessive-compulsive disorder prevalence and its clinical typology among adults in private households in Great Britain and to obtain generalizable estimates of impairment and help-seeking.Method: Data from the British National Psychiatric Morbidity Survey of 2000, comprising 8,580 individuals, were analyzed using appropriate measurements. The study compared individuals with obsessive-compulsive disorder, individuals with other neurotic disorders, and a nonneurotic comparison group. ICD-10 diagnoses were derived from the Clinical Interview Schedule-Revised.Results: the authors identified 114 individuals (74 women, 40 men) with obsessive-compulsive disorder, with a weighted 1-month prevalence of 1.1%. Most individuals (55%) in the obsessive-compulsive group had obsessions only. Comorbidity occurred in 62% of these individuals, which was significantly greater than the group with other neuroses (10%). Co-occurring neuroses were depressive episode (37%), generalized anxiety disorder (31%), agoraphobia or panic disorder (22%), social phobia (17%), and specific phobia (15%). Alcohol dependence was present in 20% of participants, mainly men, and drug dependence was present in 13%. Obsessive-compulsive disorder, compared with other neurotic disorders, was associated with more marked social and occupational impairment. One-quarter of obsessive-compulsive disorder participants had previously attempted suicide. Individuals with pure and comorbid obsessive-compulsive disorder did not differ according to most indices of impairment, including suicidal behavior, but pure individuals were significantly less likely to have sought help (14% versus 56%).Conclusions: A rare yet severe mental disorder, obsessive-compulsive disorder is an atypical neurosis, of which the public health significance has been underestimated. Unmet need among individuals with pure obsessive-compulsive disorder is a cause for concern, requiring further investigation of barriers to care and interventions to encourage help-seeking.

BODY DYSMORPHIC DISORDER IN PATIENTS WITH OBSESSIVE-COMPULSIVE DISORDER: PREVALENCE and CLINICAL CORRELATES

Background The prevalence, sociodemographic aspects, and clinical features of body dysmorphic disorder (BDD) in patients with obsessivecompulsive disorder (OCD) have been previously addressed in primarily relatively small samples. Methods We performed a cross-sectional demographic and clinical assessment of 901 OCD patients participating in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. We used the Structured Clinical Interview for DSM-IV Axis I Disorders; Yale-Brown Obsessive-Compulsive Scale; Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS); Brown Assessment of Beliefs Scale; Clinical Global Impression Scale; and Beck Depression and Anxiety Inventories. Results The lifetime prevalence of BDD was 12.1%. The individuals with comorbid BDD (OCD-BDD; n = 109) were younger than were those without it. In addition, the proportions of single and unemployed patients were greater in the OCD-BDD group. This group of patients also showed higher rates of suicidal behaviors; mood, anxiety, and eating disorders; hypochondriasis; skin picking; Tourette syndrome; and symptoms of the sexual/religious, aggressive, and miscellaneous dimensions. Furthermore, OCD-BDD patients had an earlier onset of OC symptoms; greater severity of OCD, depression, and anxiety symptoms; and poorer insight. After logistic regression, the following features were associated with OCD-BDD: current age; age at OCD onset; severity of the miscellaneous DY-BOCS dimension; severity of depressive symptoms; and comorbid social phobia, dysthymia, anorexia nervosa, bulimia nervosa, and skin picking. Conclusions Because OCD patients might not inform clinicians about concerns regarding their appearance, it is essential to investigate symptoms of BDD, especially in young patients with early onset and comorbid social anxiety, chronic depression, skin picking, or eating disorders. Depression and Anxiety 29: 966-975, 2012. (C) 2012 Wiley Periodicals, Inc.

Clinical features of tic-related obsessive-compulsive disorder: results from a large multicenter study

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Early onset obsessive-compulsive disorder with and without tics

Introduction: Research suggests that obsessive-compulsive disorder (OCD) is not a unitary entity, but rather a highly heterogeneous condition, with complex and variable clinical manifestations. Objective: The aims of this study were to compare clinical and demographic characteristics of OCD patients with early and late age of onset of obsessive-compulsive symptoms (OCS); and to compare the same features in early onset OCD with and without tics. The independent impact of age at onset and presence of tics on comorbidity patterns was investigated. Methods: Three hundred and thirty consecutive outpatients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for OCD were evaluated: 160 patients belonged to the early onset group (EOG): before 11 years of age, 75 patients had an intermediate onset (IOG), and 95 patients were from the late onset group (LOG): after 18 years of age. From the 160 EOG, 60 had comorbidity with tic disorders. The diagnostic instruments used were: the Yale-Brown Obsessive Compulsive Scale and the Dimensional Yale-Brown Obsessive Compulsive Scale (DY-BOCS), Yale Global Tics Severity Scale; and Structured Clinical Interview for DSM-IV Axis I Disorders-patient edition. Statistical tests used were: Mann-Whitney, full Bayesian significance test, and logistic regression. © MBL Communications Inc.

Clinical features of pure obsessive-compulsive disorder

Objective Psychiatric comorbidity is the rule in obsessive-compulsive disorder (OCD); however, very few studies have evaluated the clinical characteristics of patients with no co-occurring disorders (non-comorbid or pure OCD). The aim of this study was to estimate the prevalence of pure cases in a large multicenter sample of OCD patients and compare the sociodemographic and clinical characteristics of individuals with and without any lifetime axis I comorbidity. Method A cross-sectional study with 955 adult patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC). Assessment instruments included the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, The USP-Sensory Phenomena Scale and the Brown Assessment of Beliefs Scale. Comorbidities were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders. Bivariate analyses were followed by logistic regression. Results Only 74 patients (7.7%) presented pure OCD. Compared with those presenting at least one lifetime comorbidity (881, 92.3%), non-comorbid patients were more likely to be female and to be working, reported less traumatic experiences and presented lower scores in the Y-BOCS obsession subscale and in total DY-BOCS scores. All symptom dimensions except contamination-cleaning and hoarding were less severe in non-comorbid patients. They also presented less severe depression and anxiety, lower suicidality and less previous treatments. In the logistic regression, the following variables predicted pure OCD: sex, severity of depressive and anxious symptoms, previous suicidal thoughts and psychotherapy. Conclusions Pure OCD patients were the minority in this large sample and were characterized by female sex, less severe depressive and anxious symptoms, less suicidal thoughts and less use of psychotherapy as a treatment modality. The implications of these findings for clinical practice are discussed. © 2013 Elsevier Inc. All rights reserved.

Panic Disorder and Agoraphobia in OCD patients: Clinical profile and possible treatment implications

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Clinical features of tic-related obsessive-compulsive disorder: results from a large multicenter study

Objective. To evaluate the clinical features of obsessive-compulsive disorder (OCD) patients with comorbid tic disorders (TD) in a large, multicenter, clinical sample. Method. A cross-sectional study was conducted that included 813 consecutive OCD outpatients from the Brazilian OCD Research Consortium and used several instruments of assessment, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Yale Global Tic Severity Scale (YGTSS), the USP Sensory Phenomena Scale, and the Structured Clinical Interview for DSM-IV Axis I Disorders. Results. The sample mean current age was 34.9 years old (SE 0.54), and the mean age at obsessive-compulsive symptoms (OCS) onset was 12.8 years old (SE 0.27). Sensory phenomena were reported by 585 individuals (72% of the sample). The general lifetime prevalence of TD was 29.0% (n=236), with 8.9% (n=72) presenting Tourette syndrome, 17.3% (n=5141) chronic motor tic disorder, and 2.8% (n=523) chronic vocal tic disorder. The mean tic severity score, according to the YGTSS, was 27.2 (SE 1.4) in the OCD1TD group. Compared to OCD patients without comorbid TD, those with TD (OCD1TD group, n=236) were more likely to be males (49.2% vs. 38.5%, p<005) and to present sensory phenomena and comorbidity with anxiety disorders in general: separation anxiety disorder, social phobia, specific phobia, generalized anxiety disorder, post-traumatic stress disorder, attention-deficit hyperactivity disorder, impulse control disorders in general, and skin picking. Also, the "aggressive," "sexual/religious," and "hoarding" symptom dimensions were more severe in the OCD+TD group. Conclusion. Tic-related OCD may constitute a particular subgroup of the disorder with specific phenotypical characteristics, but its neurobiological underpinnings remain to be fully disentangled.