Social anxiety disorder: what are we losing with the current diagnostic criteria?

Objective: To assess the rate of comorbidities and the functional impairment associated with the social anxiety disorder (SAD), with an emphasis on the so-called subthreshold clinical signs and symptoms. Method: Psychiatric comorbidities and psychosocial functioning were evaluated in 355 volunteers (college students) who had been diagnosed as SAD (n = 141), Subthreshold SAD (n = 92) or Controls (n = 122). Results: The rate of comorbidities was 71.6% in the SAD group and 50% in subjects with Subthreshold SAD, both significantly greater than Controls (28.7%). Concerning psychosocial functioning, the SAD group had higher impairment than the other two groups in all domains evaluated, and subjects with Subthreshold SAD presented intermediate values. Conclusion: The rates of psychiatric comorbidities and the impairment of psychosocial functioning increase progressively along the spectrum of social anxiety. The fact that Subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of the diagnostic criteria.

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.

Interpretation bias in preschool children at risk for anxiety: a prospective study

A story-stem paradigm was used to assess interpretation bias in preschool children. Data were available for 131 children. Interpretation bias, behavioural inhibition (BI) and anxiety were assessed when children were aged between 3 years 2 months and 4 years 5 months. Anxiety was subsequently assessed 12-months, 2-years and 5-years later. A significant difference in interpretation bias was found between participants who met criteria for an anxiety diagnosis at baseline, with clinically anxious participants more likely to complete the ambiguous story-stems in a threat-related way. Threat interpretations significantly predicted anxiety symptoms at 12-month follow-up, after controlling for baseline symptoms, but did not predict anxiety symptoms or diagnoses at either 2-year or 5- year follow-up. There was little evidence for a relationship between BI and interpretation bias. Overall, the pattern of results was not consistent with the hypothesis that interpretation bias plays a role in the development of anxiety. Instead, some evidence for a role in the maintenance of anxiety over relatively short periods of time was found. The use of a story-stem methodology to assess interpretation bias in young children is discussed along with the theoretical and clinical implications of the findings.

Self-ratings and observer-ratings of social skill: a manipulation of state social anxiety in anxious and non-anxious children

The role of state and trait anxiety on observer ratings of social skill and negatively biased self-perception of social skill was examined. Participants were aged between 7 and 13 years (mean=9.65; sd=1.77; N=102), 47 had a current anxiety diagnosis and 55 were non-anxious controls. Participants were randomly allocated to a high or low anxiety condition and asked to complete social tasks. Task instructions were adjusted across conditions to manipulate participants’ state anxiety. Observers rated anxious participants as having poorer social skills than non-anxious controls but there was no evidence that anxious participants exhibited a negative self-perception bias, relative to controls. However, as participants’ ratings of state anxiety increased, their perception of their performance became more negatively biased. The results suggest that anxious children may exhibit real impairments in social skill and that high levels of state anxiety can lead to biased judgements of social skills in anxious and non-anxious children.

Clinical predictors of response to cognitive-behavioural therapy in pediatric anxiety disorders: the Genes for Treatment (GXT) Study

Objective The Genes for Treatment study is an international, multisite collaboration exploring the role of genetic, demographic, and clinical predictors in response to cognitive-behavioral therapy (CBT) in pediatric anxiety disorders. The current article, the first from the study, examined demographic and clinical predictors of response to CBT. We hypothesized that the child’s gender, type of anxiety disorder, initial severity and comorbidity, and parents’ psychopathology would significantly predict outcome. Method A sample of 1,519 children 5 to 18 years of age with a primary anxiety diagnosis received CBT across 11 sites. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each time point (posttreatment, 3-, 6-, and/or 12-month follow-up) and analyzed using linear and logistic mixed models. Separate analyses were conducted using data from posttreatment and follow-up assessments to explore the relative importance of predictors at these time points. Results Individuals with social anxiety disorder (SoAD) had significantly poorer outcomes (poorer response and lower rates of remission) than those with generalized anxiety disorder (GAD). Although individuals with specific phobia (SP) also had poorer outcomes than those with GAD at posttreatment, these differences were not maintained at follow-up. Both comorbid mood and externalizing disorders significantly predicted poorer outcomes at posttreatment and follow-up, whereas self-reported parental psychopathology had little effect on posttreatment outcomes but significantly predicted response (although not remission) at follow-up. Conclusion SoAD, nonanxiety comorbidity, and parental psychopathology were associated with poorer outcomes after CBT. The results highlight the need for enhanced treatments for children at risk for poorer outcomes.

The relationship between challenging parenting behaviour and childhood anxiety disorders

Background: This research investigates the relationship between challenging parenting behaviour and childhood anxiety disorders proposed by Bögels and Phares (2008). Challenging parenting behaviour involves the playful encouragement of children to go beyond their own limits, and may decrease children’s risk for anxiety (Bögels & Phares, 2008). Method: Parents (n = 164 mothers, 144 fathers) of 164 children aged between 3.4 and 4.8 years participated in the current study. A multi-method, multi-informant assessment of anxiety was used, incorporating data from diagnostic interviews as well as questionnaire measures. Parents completed self-report measures of their parenting behaviour (n = 147 mothers, 138 fathers) and anxiety (n = 154 mothers, 143 fathers). Mothers reported on their child’s anxiety via questionnaire as well as diagnostic interview (n = 156 and 164 respectively). Of these children, 74 met criteria for an anxiety disorder and 90 did not. Results: Fathers engaged in challenging parenting behaviour more often than mothers. Both mothers’ and fathers’ challenging parenting behaviour was associated with lower report of child anxiety symptoms. However, only mothers’ challenging parenting behaviour was found to predict child clinical anxiety diagnosis. Limitations: Shared method variance from mothers confined the interpretation of these results. Moreover, due to study design, it is not possible to delineate cause and effect. Conclusions: The finding with respect to maternal challenging parenting behaviour was not anticipated, prompting replication of these results. Future research should investigate the role of challenging parenting behaviour by both caregivers as this may have implications for parenting interventions for anxious children.

Separation anxiety disorder in adult patients with obsessive-compulsive disorder: prevalence and clinical correlates

Objective: Individuals with obsessive-compulsive disorder (OCD) and separation anxiety disorder (SAD) tend to present higher morbidity than do those with OCD alone. However, the relationship between OCD and SAD has yet to be fully explored.Method: This was a cross-sectional study using multiple logistic regression to identify differences between OCD patients with SAD (OCD + SAD, n = 260) and without SAD (OCD, n = 695), in terms of clinical and socio-demographic variables. Data were extracted from those collected between 2005 and 2009 via the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders project.Results: SAD was currently present in only 42 (4.4%) of the patients, although 260 (27.2%) had a life-time diagnosis of the disorder. In comparison with the OCD group patients, patients with SAD + OCD showed higher chance to present sensory phenomena, to undergo psychotherapy, and to have more psychiatric comorbidities, mainly bulimia.Conclusion: In patients with primary OCD, comorbid SAD might be related to greater personal dysfunction and a poorer response to treatment, since sensory phenomena may be a confounding aspect on diagnosis and therapeutics. Patients with OCD + SAD might be more prone to developing specific psychiatric comorbidities, especially bulimia. Our results suggest that SAD symptom assessment should be included in the management and prognostic evaluation of OCD, although the psychobiological role that such symptoms play in OCD merits further investigation. (C) 2014 Elsevier Masson SAS. All rights reserved.

Do Spirituality and Faith Make a Difference? Report from the Southern European Psycho-Oncology Study Group

OBJECTIVE: In the last decade, some attention has been given to spirituality and faith and their role in cancer patients' coping. Few data are available about spirituality among cancer patients in Southern European countries, which have a big tradition of spirituality, namely, the Catholic religion. As part of a more general investigation (Southern European Psycho-Oncology Study--SEPOS), the aim of this study was to examine the effect of spirituality in molding psychosocial implications in Southern European cancer patients. METHOD: A convenience sample of 323 outpatients with a diagnosis of cancer between 6 to 18 months, a good performance status (Karnofsky Performance Status > 80), and no cognitive deficits or central nervous system (CNS) involvement by disease were approached in university and affiliated cancer centers in Italy, Spain, Portugal, and Switzerland (Italian speaking area). Each patient was evaluated for spirituality (Visual Analog Scale 0-10), psychological morbidity (Hospital Anxiety and Depression Scale--HADS), coping strategies (Mini-Mental Adjustment to Cancer--Mini-MAC) and concerns about illness (Cancer Worries Inventory--CWI). RESULTS. The majority of patients (79.3%) referred to being supported by their spirituality/faith throughout their illness. Significant differences were found between the spirituality and non-spirituality groups (p ≤ 0.01) in terms of education, coping styles, and psychological morbidity. Spirituality was significantly correlated with fighting spirit (r = -0.27), fatalism (r = 0.50), and avoidance (r = 0.23) coping styles and negatively correlated with education (r = -0.25), depression (r = -0.22) and HAD total (r = -0.17). SIGNIFICANCE OF RESULTS: Spirituality is frequent among Southern European cancer patients with lower education and seems to play some protective role towards psychological morbidity, specifically depression. Further studies should examine this trend in Southern European cancer patients.

Personality traits and behavioural and psychological symptoms in patients with mild cognitive impairment.

BACKGROUND AND AIMS: Both personality changes and behavioural and psychological symptoms (BPS) may be associated with mild cognitive impairment (MCI) in later life and help identify incipient dementia. We wished to investigate the links between personality and BPS in MCI. METHOD: We studied premorbid personality traits as estimated 5 years back and their changes in 83 control subjects and 52 MCI patients using the revised NEO Personality Inventory for the Five-Factor Model completed by a proxy. Information on BPS was obtained using the Neuropsychiatric Inventory (NPI). Analyses were controlled for current depression and anxiety. RESULTS: Premorbid neuroticism and openness to experience were associated with the total NPI score. The changes in neuroticism, extraversion, openness to experiences, and conscientiousness were associated with apathy and affective symptoms. CONCLUSIONS: Personality changes and BPS occur in MCI. The occurrence of affective BPS and apathy is associated with both premorbid personality traits and their changes.

La structure du sommeil et l’activité cardiaque nocturne chez les adolescents ayant un trouble anxieux

L’objectif de la présente thèse était de caractériser le sommeil d’un groupe clinique d’enfants et d’adolescents ayant un trouble d’anxiété comme diagnostic primaire et le comparer à un groupe témoin. Dans un premier temps, nous avons vérifié si le profil de la fréquence cardiaque nocturne des enfants et des adolescents pouvait être regroupé selon le diagnostic. Pour ce faire, la fréquence cardiaque nocturne de 67 adolescents anxieux et 19 sujets non anxieux a été enregistrée à l’aide d’un équipement ambulatoire. Les résultats de cette étude montrent que le profil de la fréquence cardiaque nocturne chez les enfants anxieux varie selon le diagnostic. Alors que les adolescents non anxieux montrent un profil de la fréquence cardiaque nocturne plat, on retrouve les associations suivantes chez les adolescents ayant un trouble anxieux : a) un profil croissant de la fréquence cardiaque chez les adolescents ayant un trouble d’anxiété de séparation; b) un profil décroissant de la fréquence cardiaque chez les adolescents ayant un trouble d’anxiété généralisé; c) un profil en forme de U chez les adolescents ayant un trouble d’anxiété sociale. De plus, une association significative a été observée entre le diagnostic et la présence de fatigue matinale. L’association d’un profil de la fréquence cardiaque nocturne avec un diagnostic d’anxiété suggère la présence d’une dysrégulation de la modulation chronobiologique du système nerveux autonome. Étant donné que le profil de la fréquence cardiaque nocturne s’exprime différemment selon le diagnostic, qu’en est-il de l’architecture du sommeil? Dans un deuxième temps, nous avons enregistré le sommeil en laboratoire d’un groupe clinique de 19 jeunes ayant un trouble d’anxiété comme diagnostic primaire, avec comorbidités et médication et comparé à 19 jeunes non anxieux. Les résultats de cette étude ont montré que les participants du groupe anxieux ont une latence au sommeil plus longue, une latence au sommeil paradoxal plus longue et une durée d’éveil plus longue lorsque comparé au groupe témoin. L’évaluation subjective de la qualité du sommeil chez le groupe d’adolescents anxieux montre que leur auto-évaluation reflète les valeurs enregistrées en laboratoire. Nous avons également observé chez le groupe anxieux une fréquence cardiaque moyenne plus élevée et un index plus élevé d’apnée-hypopnée, bien que non pathologique. Nous avons également observé une association positive entre l’anxiété de trait et l’indice d’apnée-hypopnée et la latence au sommeil, ainsi qu’une association positive entre l’anxiété manifeste et la latence au sommeil paradoxal. Ces résultats suggèrent que le sommeil chez cette population est altéré, que des signes d’hypervigilance physiologique sont présents et qu'une association existe entre ces deux paramètres. Finalement, dans la troisième étude de cette thèse, nous avons analysé l’activité cardiaque pendant le sommeil en utilisant les paramètres temporels et fréquentiels de la variabilité cardiaque chez un groupe clinique de dix-sept enfants et adolescents ayant un trouble d’anxiété comme diagnostic primaire avec comorbidité et médication, et comparé à un groupe non anxieux. Les résultats ont montré que les participants du groupe anxieux, lorsque comparés au groupe non anxieux, présentent des intervalles interbattements plus courts, un indice temporel de la variabilité cardiaque représentant la branche parasympathique moindre, une activité des hautes fréquences normalisées moindre et un ratio basse fréquence sur haute fréquence augmenté. Plusieurs corrélations ont été observées entre les mesures cliniques de l’anxiété et les mesures de la variabilité cardiaque. Ces résultats viennent ajouter à la littérature actuelle un volet descriptif clinique à ce jour non documenté, soit l’impact de l’anxiété pathologique chez un groupe clinique d’enfants et d’adolescents sur le processus normal du sommeil et sur la régulation de la fréquence cardiaque. En résumé, les résultats de ces trois études ont permis de documenter chez un groupe clinique d’enfants et d’adolescents ayant de l’anxiété pathologique, la présence d’une altération circadienne du profil de la fréquence cardiaque, d’une architecture altérée du sommeil ainsi qu’une dysrégulation du système nerveux contrôlant l’activité cardiaque.

Le rôle de la sérotonine sur le développement de traits anxieux : une étude de trajectoire longitudinale

Certains gènes, modulant la sérotonine (5-hydroxytryptamine, 5-HT), ont été associés aux tempéraments liés à l'anxiété. Une limitation dans la plupart de ces études est que les études sont de nature transversale et l'anxiété a été évaluée à un seul point dans le temps. De plus, seules quelques études ont été réalisées chez les enfants. Le but de la présente étude était d'étudier le rôle des gènes HTR2A et TPH2 dans le développement des trajectoires d’anxiété durant l’enfance. Les associations entre ces gènes, ces trajectoires, le diagnostic d’anxiété à l'âge adulte et les différences entre les sexes ont été examinées dans l'Étude Longitudinale des Enfants de Maternelle au Québec, composée de 3185 enfants recrutés en 1986-1987. Leur anxiété a été cotée par leur professeur annuellement entre 6 et 12 ans. Ces cotes ont été modélisées en trajectoires comportementales. Les données genotypées de 5-HT, disponibles pour 1068 personnes, ont été analysées en utilisant les statistiques du Chi-carré, des régressions logistiques et des analyses de variance. Sur les 37 polymorphismes étudiés, plusieurs ont été associés à la trajectoire de forte anxiété, tels le 5-HTR2A (rs1328684, rs95534511, rs1745837, rs7984966, 7330636) et TPH2 (rs11179050, rs11179052, rs1386498). Bien que les trajectoires d’anxiété en enfance n’aient pas prédit le diagnostic d'anxiété à 21 ans, les relations ont été trouvées entre ce diagnostic, HTR2A et les polymorphismes du nucléotide simple (PNS) de TPH2. On remarque que les PNS associés à l’anxiété durant l’enfance et l’âge adulte ne sont pas les mêmes. La force d'association entre les gènes étudiés et l'anxiété diffère entre les garçons et les filles. Cette étude est la première à identifier une association entre les variantes TPH2, 5-HTR2A et les trajectoires d’anxiété en enfance. Les études futures devraient reproduire les résultats dans d'autres échantillons, enquêter sur l'interaction avec les facteurs de stress, et étudier la pertinence fonctionnelle de la PNS.

Neurotrophic gene polymorphisms and response to psychological therapy

Therapygenetics, the study of genetic determinants of response to psychological therapies, is in its infancy. Here, we investigate whether single-nucleotide polymorphisms in nerve growth factor (NGF) (rs6330) and brain-derived neutrotrophic factor (BDNF) (rs6265) genes predict the response to cognitive behaviour therapy (CBT). Neurotrophic genes represent plausible candidate genes: they are implicated in synaptic plasticity, response to stress, and are widely expressed in brain areas involved in mood and cognition. Allelic variation at both loci has shown associations with anxiety-related phenotypes. A sample of 374 anxiety-disordered children with white European ancestry was recruited from clinics in Reading, UK, and in Sydney, Australia. Participants received manualised CBT treatment and DNA was collected from buccal cells using cheek swabs. Treatment response was assessed at post-treatment and follow-up time points. We report first evidence that children with one or more copies of the T allele of NGF rs6330 were significantly more likely to be free of their primary anxiety diagnosis at follow-up (OR=0.60 (0.42–0.85), P=0.005). These effects remained even when other clinically relevant covariates were accounted for (OR=0.62 (0.41–0.92), P=0.019). No significant associations were observed between BDNF rs6265 and response to psychological therapy. These findings demonstrate that knowledge of genetic markers has the potential to inform clinical treatment decisions for psychotherapeutic interventions.

Evaluating the external validity of comorbid disorders in youth using rating scales and behavior observations

To evaluate the theoretical underpinnings of current categorical approaches to classify childhood psychopathological conditions, this dissertation examined whether children with a single diagnosis of an anxiety disorder (ANX only) and children with an anxiety diagnosis comorbid with other diagnoses (i.e., anxiety + anxiety disorder [ANX + ANX], anxiety + depressive disorder [ANX + DEP], and anxiety + disruptive disorder [ANX + EXT]) could be differentiated using external validation criteria of clinical phenomenology (i.e., levels of anxiety, depression, and internalizing, externalizing and total behavior problems). This study further examined whether the four groups could be differentiated in terms of their interaction patterns with their parents and peers, respectively. The sample consisted of 129 youth and their parents who presented to the Child Anxiety and Phobia Program (CAPP) housed within the Child and Family Psychosocial Research Center at Florida International University, Miami. Youth were between the ages of 8 and 14 years old. A battery of questionnaires was used to assess participants' clinical presentation in terms of levels of anxiety, depression, and internalizing and externalizing symptoms. Family and peer interaction were evaluated through rating scales and through behavior observation tasks. Statistics based on the parameter estimates of the structured equation models indicated that all the comorbid groups were significantly different from the pure anxiety disorder group when it came to depression indices of clinical phenomenology. Further, significant differences appeared mainly in terms of the ANX + DEP comorbid group relative to the other comorbid groups. In terms of Parent-child interaction the ANX + EXT and the ANX + DEP comorbid groups were differentiated from the pure anxiety disorder and ANX + ANX comorbid group when it came to the appraisal of the parent/child relationship by the parent, and the acceptance subscale according to the mother report. In terms of peer-child interaction the ANX + EXT and the ANX + DEP comorbid groups were statistically significantly different from the pure anxiety disorder only when it came to the positive interactions and the social skills as rated by mother. Limitations and future research recommendations are discussed.

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.