Abnormal optokinetic and perceptual span parameters in cerebellar-vestibular dysfunction and related anxiety disorders

As prior studies indicated abnormal cerebellar-vestibular-based sensorimotor mechanisms and neurological and ENG diagnostic parameters in anxiety disorders and because ocular fixation and sequential scanning are cerebellar-vestibular-modulated, it appeared reasonable to measure these and related ocular functions in matched samples of anxiety-disordered and control subjects. In this study, the optokinetically-determined fixation, sequential scanning, and perceptual span capacities obtained by means of a newly revised blurring-speed method were significantly lower or impaired in 70 anxiety-disordered patients vs 70 controls. Such data supported further the hypothesis that there may be cerebellar-vestibular predispositions to anxiety disorders and the optokinetically-based tracking method may prove useful in separating a diverse array of CV-determined or related anxiety symptoms from those of other origins. However, independent validation as well as additional studies of anxiety disorders using larger samples vs random or "normal" controls are required before conclusions are justified.     

Predicting response to anxiety management in patients with generalised anxiety disorders

This paper describes the analysis of predictive factors in a group of generally anxious patients treated with anxiety management. Evidence for three reliable predictors is presented. It is argued these reflect anxiety, demoralisation and depression. The same three variables contributed to prediction of outcome after treatment and 6 months later, and their pre-treatment values classified 80% of the patients correctly into good or poor responders. Lower initial levels of anxiety and demoralisation together with higher depression rated by the assessor predicted a better outcome. Predictions were more accurate for patients with a mild degree of depression than for those who were not depressed.     

Psychopathology in anxiety disorders

Complaints of anxiety, often meetingDiagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III), criteria for anxiety disorder, are among the most common problems presenting to health practitioners. In spite of the frequency of anxiety and anxiety disorders, little is known about the basic psychopathology of these conditions that would lead to the development of more efficient and effective treatments and possible preventive efforts. Recently, there has been an increase in research on the psychopathology of anxiety disorders from biological, psychological, and social perspectives. The National Institute of Mental Health's Clinical Research Branch sponsored a 2-day workshop of investigators representing diverse research approaches to discuss emerging issues and research practices within the anxiety disorders. Discussions centered on a review of the general areas of classification, phenomenology, and etiology. A selective summary of this workshop is presented along with recommendations for specific research directions.     

Treatment for anxiety disorders: Efficacy to effectiveness to implementation

Anxiety disorders are common, costly and debilitating, and yet often unrecognized or inadequately treated in real world, primary care settings. Our group has been researching ways of delivering evidence-based treatment for anxiety in primary care settings, with special interest to preserving the fidelity of the treatment while at the same time promoting its sustainability once the research is over. In this paper, we describe the programs we have developed and our directions for future research. Our first study evaluated the efficacy of CBT and expert pharmacotherapy recommendations for panic disorder in primary care, using a collaborative care model of service delivery (CCAP). Symptom, disability and mental health functioning measures were superior for the intervention group compared to treatment as usual both in the short term and the long term, although also more costly. In our ongoing CALM study, we have extended our population to include panic disorder, social anxiety disorder, generalized anxiety disorder and posttraumatic disorder, while at the same time utilizing clinicians with limited mental health care experience. In addition to pharmacotherapy management, we developed a computer-assisted CBT that guides both novice clinician and patient, thereby contributing to sustainability once the research is over. We have also incorporated a measurement based approach to treatment planning, using a web-based tracking system of patient status. To date, the computer-assisted CBT program has been shown to be acceptable to clinicians and patients. Clinicians rated the program highly, and patients engaged in the program. Future directions for our research include dissemination and implementation of the CALM program, testing potential alternations to the CALM program, and distance delivery of CALM.     

Electrodermal lability in anxiety disorders

Twenty-eight anxiety patients, aged below 50 years, were diagnosed according to DSM-III-R criteria (panic disorder with and without agoraphobia, generalised anxiety disorder, and anxiety disorder not otherwise specified). The patients were characterised by high levels of state and trait anxiety and neuroticism, compared with the controls. However, there were no differences between patients and controls in electrodermal habituation rate, non-specific activity, or skin resistance level. When the patients were divided into electrodermally labile and stable subjects, significant differences were found between patients and controls in both electrodermal activity and Eysenck's personality dimensions. The labile patients were more introverted and attained higher psychoticism scores than either the stable patients or controls. Duration of anxiety symptoms removed the difference found in extroversion, but not in any other variable. The results are discussed in relation to the utility of electrodermal measurements in validation of diagnostic entities. It is concluded, that from the psychophysiological point of view, anxiety disorders may be examined within a dimensional framework.     

Issues in diagnosing anxiety disorders

Research progress in the anxiety disorders is predicated on a useful classification system. In this paper, we review the reliability and validity data for theDiagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III) anxiety disorders and discuss the salient issues associated with both the conceptualization of anxiety disorders and the diagnostic criteria offered in the DSM-III. It is concluded that the diagnostic reliability for these disorders is, overall, satisfactory. A dearth of validity data, however, hinders progress in both the diagnosis and the treatment of the anxiety disorders. Nevertheless, the DSM-III work group has proposed several changes in the diagnostic criteria for the anxiety disorders. We find some of these proposed changes helpful in that they clarify current diagnostic criteria; changes in diagnostic criteria that alter the basic classification schema, however, seem to be premature.Preparation of this paper was supported in part by MIMH Research Grant 1368.On sabbatical leave from Indiana State University.     

The role of glutamate in anxiety and related disorders

Anxiety, stress, and trauma-related disorders are a major public health concern in the United States. Drugs that target the gamma-aminobutyric acid or serotonergic system, such as benzodiazepines and selective serotonin reuptake inhibitors, respectively, are the most widely prescribed treatments for these disorders. However, the role of glutamate in anxiety disorders is becoming more recognized with the belief that drugs that modulate glutamatergic function through either ionotropic or metabotropic glutamate receptors have the potential to improve the current treatment of these severe and disabling illnesses. Animal models of fear and anxiety have provided a method to study the role of glutamate in anxiety. This research has demonstrated that drugs that alter glutamate transmission have potential anxiolytic action for many different paradigms including fear-potentiated startle, punished responding, and the elevated plus maze. Human clinical drug trials have demonstrated the efficacy of glutamatergic drugs for the treatment of obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social phobia. Recent data from magnetic resonance imaging studies provide an additional link between the glutamate system and anxiety. Collectively, the data suggest that future studies on the mechanism of and clinical efficacy of glutamatergic agents in anxiety disorders are appropriately warranted.     

Explicit memory in anxiety disorders

Two experiments were conducted to study selective memory bias favoring anxiety-relevant materials in patients with anxiety disorders. In the 1st experiment, 32 patients with generalized anxiety disorder (GAD), 30 with social phobia (speaking anxiety), and 31 control participants incidentally learned GAD-relevant words, speech anxiety-relevant words, strongly pleasant words, and words with a neutral valence. Participants did not show any explicit memory bias for threatening materials. Thirty patients suffering from panic disorder (PD) with agoraphobia and 30 controls took part in the 2nd experiment. The design was similar to the 1st experiment. This time a highly specific selective memory bias for threatening words was found. Words describing symptoms of anxiety were better recalled by PD patients. Results are consistent with previous findings but are inexplicable by existing theories.     

Health anxiety, hypochondriasis, and the anxiety disorders

Although clinical observations suggest that health-related anxiety is present, to some extent, in a number of anxiety disorders, this relationship has not been examined empirically. The present study therefore utilized the Short Health Anxiety Inventory (SHAI) to elucidate the structure of such symptoms among patients with anxiety disorders and to empirically investigate the presence of health anxiety in various anxiety disorders. Confirmatory factor analysis yielded equivalent support for either a 2-factor or 3-factor model of the SHAI's latent structure. The measure demonstrated good reliability, convergent validity, and discriminant validity. Comparison of SHAI scores across groups of patients with various anxiety disorders revealed elevated levels of health anxiety among patients with hypochondriasis and panic disorder relative to those with other anxiety disorders. Receiver operating characteristic analyses supported the utility of the SHAI as a diagnostic tool for screening patients with hypochondriasis utilizing empirically derived cut scores. Findings are discussed in terms of cognitive-behavioral models of anxiety disorders.     

Emotional reactivity to daily events in youth with anxiety disorders

Background: Although research supports associations between anxiety and emotional reactivity in adults (Cisler, J. M., Olatunji, B. O., Feldner, M. T., &; Forsyth, J. P. (2010). Emotion regulation and the anxiety disorders: an integrative review. Journal of Psychopathology and Behavioral Assessment, 32(1), 68–82.), few studies have examined emotional reactivity in anxious youth (e.g., Carthy et al., 2010; Tan, P. Z., Forbes, E. E., Dahl, R. E., Ryan, N. D., Siegle, G. J., Ladouceur, C. D., &; Silk, J. S. (2012). Emotional reactivity and regulation in anxious and nonanxious youth: a cell-phone ecological momentary assessment study. Journal of Child Psychology and Psychiatry, 53(2), 197–206.). Methods: Using daily diary methodology, this study examined both negative affect (NA) and positive affect (PA) reactivity to daily events in youth diagnosed with anxiety (N?=?68; 60% female; 78% non-Hispanic White; M age?=?11.18 years, SD?=?3.17). We also examined whether parent-reported emotion regulation would predict emotional reactivity. Results: Participants reported more NA on days they experienced more negative parent and teacher events and less PA on days that they experienced more negative peer events. Additionally, better emotion regulation was associated with less NA reactivity to negative teacher events and to both negative and positive academic events. Conclusions: Interpersonal events have a salient effect on daily affect for anxious youth. Youth anxiety therapists should target emotion regulation associated with negative events involving adults and address barriers to developing and maintaining positive peer relationships.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Comorbidity of test anxiety and other anxiety disorders in children

Elementary school children with clinically significant test anxiety, as determined by self-report and a clinical interview, were assessed for the incidence of other fears and anxiety. The results indicated that test-anxious children reported more fears and general worries than their non-test-anxious peers. As expected, the test-anxious children experienced more negative cognitions and subjective distress when taking a test. Furthermore, the fear of negative evaluation was not limited to an actual test, since these children also reported identical symptoms when engaged in a second social-evaluative task. Finally, 60% of the testanxious sample met DSM-III criteria for an anxiety disorder. The results are discussed in terms of the relationship of text anxiety to more complex social-evaluative dysfunctions, more pervasive anxiety conditions, DSM-III anxiety disorders, and the utility of test anxiety as an indicator of the presence of these more pervasive anxiety states.This research is based on a dissertation conducted by the first author under the direction of the second author. Thanks are expressed to Stephen B. Manuck, Scott M. Monroe, Sharon Nelson-LeGall, and Saul Shiffman, who served as committee members. This study was supported in part by National Institute of Mental Health Grants No. 30915 and No. 16804, and a grant to the first author from the Sigma Xi Foundation.     

Irrational beliefs and the anxiety disorders

This study investigated the levels of irrationality reported by a clinical sample of anxiety disorder patients, including simple and social phobics, panic disorder patients, agoraphobics, and obssessive compulsive patients. The levels of irrationality were compared between these groups and a group of normal control subjects, using the Rational Behavior Inventory (RBI). Agoraphobic patients were significantly less rational than control subjects on six of the RBI's subfactors and the total score of the Inventory. Patients in all diagnostic categories except simple phobia were significantly different from control subjects on the projected misfortune subfactor, and patients in all categories except simple phobia and panic disorder were significantly different from controls on the total RBI score. There were only four instances where patients in anxiety disorder categories significantly differed from each other in levels of irrationality. The implications of these findings, methodological limitations, and directions for future research are discussed.Joseph A. Himle, ACSW is a Clinical Social Worker at the Anxiety Disorders Program, Department of Psychiatry, University of Michigan. David P. Himle, Ph.D. is an Associate Professor of Social Work at the University of Michigan. Bruce A. Thyer, Ph.D. is an Associate Professor of Social Work, University of Georgia and Faculty Fellow at the University Affiliated Program. He is also an Associate Clinical Professor at the Department of Psychiatry and Health Behavior, Medical College of Georgia.