Perseverative thought: a robust predictor of response to emotional challenge in generalized anxiety disorder and major depressive disorder

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) frequently co-occur, yet the reasons for their comorbidity remain poorly understood. In the present experiment, we tested whether a tendency to engage in negative, repetitive thinking constitutes a common risk process for the two disorders. A mixed sample of adults with comorbid GAD–MDD (n = 50), GAD only (n = 35), MDD only (n = 34), or no lifetime psychopathology (n = 35) was administered noncontingent failure and success feedback on consecutive performance tasks. Perseverative thought (PT), measured by negative thought intrusions during a baseline period of focused breathing, emerged as a powerful prospective predictor of responses to this experimental challenge. Participants reporting more frequent negative thought intrusions at baseline, irrespective of thought content or diagnostic status, exhibited a stronger negative response to failure that persisted even after subsequent success. Higher PT over the course of the experiment was associated with later behavioral avoidance, with negative affect and other traits closely linked to anxiety and depression, and with the presence and severity of GAD and MDD. These findings provide evidence for a broadly-defined PT trait that is shared by GAD and MDD and contributes to adverse outcomes in these disorders.     

Psychopathological Profile in Children with Chronic Tic Disorder and Co-existing ADHD: Additive Effects

The nature of the co-occurrence of chronic tic disorders (CTD) and attention deficit hyperactivity disorder (ADHD) is unclear. Especially in the field of psychopathology, the relationship of CTD and ADHD remains to be clarified. Thus, the aim of the present chart review study was to specify the contribution of CTD and/or ADHD to the psychopathological profile of the comorbid group (CTD+ADHD). The psychopathological profiles of four large groups (CTD-only (n=112), CTD+ADHD (n=82), ADHD-only (n=129), controls (n=144)) were measured by the eight subscales of the Child Behavior Checklist (CBCL) and analyzed by a 2×2 factorial design followed by contrasts. There were main effects of ADHD diagnosis on all but one subscale of the CBCL (Somatic Complaints). For CTD diagnosis, main effects were found for Attention Problems, Anxious/Depressed, Thought Problems, Social Problems and Somatic Complaints. The only interaction effect was seen for Somatic Complaints. While CTD and ADHD were both related to internalizing psychopathology of children in the CTD+ADHD group, ADHD had the largest effect on externalizing psychopathology in the comorbid group. At the level of psychopathology, an additive model for the co-occurrence of CTD and ADHD is strongly supported. In the comorbid group (CTD+ADHD), the ADHD diagnosis shows the strongest relation to externalizing psychopathology.     

The “Brightening” Effect: Reactions to Positive Events in the Daily Lives of Individuals With Major Depressive Disorder and Generalized Anxiety Disorder

Depressed individuals are less reactive than healthy individuals to positive stimuli in the laboratory, but accumulating evidence suggests that they are more emotionally reactive to positive events in their daily lives. The present study probed the boundaries of this curious “mood brightening” effect and investigated its specificity to major depressive disorder (MDD) vis-à-vis generalized anxiety disorder (GAD), its closest boundary condition. We used ecological momentary assessment to measure reactions to positive events over one week in individuals with MDD (n = 38), GAD (n = 36), comorbid MDD-GAD (n = 38), and no psychopathology (n = 33). Depressed individuals responded to positive events with larger changes in affect, cognition, reported withdrawal (but not approach) behavior, and symptoms than healthy controls. More severe depression assessed before the sampling week predicted greater brightening. Altered reactivity to positive events was relatively specific to MDD when compared with GAD, similar to patterns found for other positive emotional processes. The robustness, scope, and relative specificity of the brightening effect highlights the need to resolve conflicting findings across laboratory and non-laboratory studies to advance understanding of altered reactivity in emotional disorders.     

A Comparison of the Neuropsychological Profiles of the DSM-IV Subtypes of ADHD

Recent research on the DSM-IV subtypes of attention-deficit/hyperactivity disorder (ADHD) has demonstrated that the subtypes differ in demographic characteristics, types of functional impairment, and profiles of comorbidity with other childhood disorders. However, little research has tested whether the subtypes differ in underlying neuropsychological deficits. This study compared the neuropsychological profiles of children without ADHD (n = 82) and children who met symptom criteria for DSM-IV Predominantly Inattentive subtype (ADHD-IA; n = 67), Predominantly Hyperactive Impulsive subtype (ADHD-HI; n = 14), and Combined subtype (ADHD-C; n = 33) in the areas of processing speed, vigilance, and inhibition. We hypothesized that children with elevations of inattention symptoms (ADHD-IA and ADHD-C) would be impaired on measures of vigilance and processing speed, whereas children with significant hyperactivity/impulsivity (ADHD-HI and ADHD-C) would be impaired on measures of inhibition. Contrary to prediction, symptoms of inattention best predicted performance on all dependent measures, and ADHD-IA and ADHD-C children had similar profiles of impairment. In contrast, children with ADHD-HI were not significantly impaired on any dependent measures once subclinical symptoms of inattention were controlled. Our results do not support distinct neuropsychological deficits in ADHD-IA and ADHD-C children, and suggest that symptoms of inattention, rather than symptoms of hyperactivity/impulsivity, are associated with neuropsychological impairment.     

Reward dominance: Associations with anxiety,conduct problems,and psychopathy in children

The associations between children's behavior and their performance on a task with a steadily increasing ratio of punished to rewarded responses was investigated in a group of clinic-referred (n= 92) and normal control (n= 40) children between the ages of 6 and 13. Clinic-referred children with an anxiety disorder played significantly fewer trials than clinic-referred children without an anxiety disorder but the response style of the anxious children did not differ from that of a normal control group. Children with severe conduct problems who had no anxiety disorder played more trials than (a) children with severe conduct problems and a comorbid anxiety disorder, (b) nonanxious children with attention-deficit hyperactivity disorder, and (c) children in the normal control group. The strongest evidence for the reward dominant response style was for nonanxious subjects with elevations on a measure of psychopathic features, irrespective of whether they also had conduct problems and irrespective of whether they were clinic-referred. We would like to thank the staff of the Alabama School-Aged Assessment Service and the Tuscaloosa County School System for their help in data collection. We would like to especially acknowledge the help of John Gurley in data collection.     

The impact of borderline personality disorder and anxiety on neuropsychological performance in major depression

Previous studies of neuropsychological performance in borderline personality disorder (BPD) have exhibited mixed results. The high rate of co-occurring major depressive disorder (MDD) in BPD makes it difficult to specify whether neuropsychological deficits in BPD predominantly reflect co-occurring MDD or unique aspects of their psychopathology. To address this issue, 22 participants with borderline personality disorder and concurrent major depressive disorder (BPD-MDD) and 33 participants with MDD and no concurrent personality disorder were compared on a neuropsychological battery that assessed seven domains of performance: general intellectual functioning, motor skill, psychomotor speed, attention, memory, working memory, and executive function. Neuropsychological performance did not differ between BPD-MDD and MDD. However, BPD-MDD participants reported higher levels of anger, anxiety, and of overall emotional distress compared to MDD. When levels of anxiety were controlled, BPD-MDD participants exhibited superior general intellectual performance, psychomotor speed, and attention. Deficits found in previous BPD samples may reflect their susceptibility to co-occurring MDD. The impact of anxiety on neuropsychological performance in BPD, though, indicates a need for future experimental studies of the effects of mood on cognitive function to determine whether mood dysregulation, rather than core depressive symptoms, underlie cognition impairments in BPD.     

The mediating role of anxiety in self-reported somatic complaints of depressed adolescents

This study examined the mediating role of anxiety in the self-reports of somatic complaints in 96 depressed adolescent inpatients. Sixty-four subjects with major depressive episodes and comorbid anxiety disorders (MDE-A) determined from the Diagnostic Interview for Children and Adolescents-Revised (DICA-R) reported significantly more somatic complaints than 32 adolescents having major depressive episodes without comorbid anxiety (MDE). An analysis of covariance demonstrated that, with anxiety symptoms controlled, MDE and MDE-A groups did not differ significantly in somatic complaints. A hierarchical multiple-regression analysis revealed that, with demographic and anxiety symptoms controlled, depressive symptoms did not contribute to the explanation or prediction of somatic complaints. The results suggest that anxious, but not depressive symptoms, are independently associated with somatic complaints. The results are discussed in light of new affective models of psychopathology.     

Clinical syndromes, personality disorders, and neurocognitive differences in male and female inmates

This study examined clinical syndromes, personality disorders, and neurocognitive problems in adult male (n = 523) and female inmates (n = 523) and a sample of unincarcerated adult women (n = 523). Inmates were administered the Coolidge Correctional Inventory (CCI), and the unincarcerated sample was given an identical test, the Coolidge Axis II Inventory. Although there were significant differences between the two inmate groups on a majority of the 32 CCI scales, only two scales achieved a medium effect size. The two inmate groups were found to be highly similar in a comparison of ranked personality disorder prevalence rates. Consistent with previous literature, male inmates had a significantly higher prevalence of antisocial personality disorder than female inmates (24% vs. 18%). Female inmates had double the prevalence of male inmates on the borderline and histrionic personality disorder scales. Female inmates also reported significantly more general neuropsychological dysfunction, specifically memory problems and neurosomatic symptoms, than male inmates. Female inmates also reported significantly higher levels of anxiety, depression, symptoms of schizophrenia, post-traumatic stress disorder, attention deficit hyperactivity disorder, and depersonalization than male inmates. Overall, the findings support previous research of high levels of psychological and neuropsychological problems in inmates, regardless of gender, and reinforces the need for comprehensive mental health screening of offender populations. Copyright © 2011 John Wiley & Sons, Ltd.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

Attentional Performance in Children and Adolescents with Tic Disorder and Co-Occurring Attention-Deficit/Hyperactivity Disorder: New Insights from a 2 × 2 Factorial Design Study

The aim of the present study was to investigate the effect of both tic disorder (TD) and attention-deficit/hyperactivity disorder (ADHD) on attentional functions. N = 96 children and adolescents participated in the study, including n = 21 subjects with TD, n = 23 subjects with ADHD, n = 25 subjects with TD+ADHD, and n = 27 controls. Attentional performance was tested based on four computerized attention tasks (sustained attention, divided attention, go/nogo and set shifting). The effect of TD as well as ADHD on attentional performance was tested using a 2 × 2 factorial approach. A diagnosis of TD had no negative impact on attentional functions but was associated with improved performance in the set shifting task. By contrast, regardless of a diagnosis of TD, subjects with ADHD were found to perform worse in the sustained attention, divided attention and go/nogo task. No interaction effect between the factors TD and ADHD was revealed for any of the attention measures. Our results add to findings from other areas of research, showing that in subjects with TD and ADHD, ADHD psychopathology is often the main source of impairment, whereas a diagnosis of TD has little or no impact on neuropsychological performance in most cases and even seems to be associated with adaptive mechanisms.     

Prognostic value of implicit and explicit self-associations for the course of depressive and anxiety disorders

Dysfunctional self-beliefs are assumed to play an important role in maintaining depression and anxiety. Current dual-process models emphasize the relevance of differentiating between implicit and explicit self-beliefs. Therefore, this study tested the prognostic value of automatic and explicit self-associations for the naturalistic course of depressive and anxiety disorders over two years follow-up. Both self-depressed and self-anxious associations were measured in unipolar depressed patients (n = 313), anxious patients (n = 566), and patients with comorbid depressive and anxiety disorders (n = 577) as part of the Netherlands Study of Depression and Anxiety. Outcomes showed that in single predictor models specifically automatic self-anxious associations were related to a reduced chance of remission from anxiety, whereas automatic self-depressed associations were related to a reduced chance of remission from depression. Explicit self-anxious associations and fearful avoidance behaviour showed independent predictive validity for remission from anxiety, whereas explicit self-depressed associations and having both major depressive disorder and dysthymia showed independent predictive validity for remission from depression. These findings are not only consistent with the view that both implicit and explicit dysfunctional self-associations are related to the course of anxiety and unipolar depressive disorders, but also suggest that both types of self-beliefs are proper targets for therapeutic interventions.     

Role of Comorbid Depression and Co-occurring Depressive Symptoms in Outcomes for Anxiety-Disordered Youth Treated with Cognitive-Behavioral Therapy

This study examined the role of comorbid depressive disorders (major depressive disorder or dysthymic disorder) and co-occurring depressive symptoms in treatment outcome and maintenance for youth (N = 72, aged 7–14) treated with cognitive-behavioral therapy for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Hierarchical linear modeling examined treatment outcome and maintenance in terms of severity of the principal anxiety disorder. Results indicated that higher levels of child-reported depressive symptoms predicted less favorable treatment outcome. Higher levels of mother-reported depressive symptoms predicted less favorable treatment maintenance at a 1-year follow-up. Results suggest that co-occurring depressive symptoms play a role in effective treatment for anxiety-disordered youth and support the merits of treatment adaptations for these youth.     

Health anxiety and hypochondriasis in the light of DSM-5

Background: In the DSM-5, the diagnosis of hypochondriasis was replaced by two new diagnositic entities: somatic symptom disorder (SSD) and illness anxiety disorder (IAD). Both diagnoses share high health anxiety as a common criterion, but additonal somatic symptoms are only required for SSD but not IAD. Design: Our aim was to provide empirical evidence for the validity of these new diagnoses using data from a case–control study of highly health-anxious (n = 96), depressed (n = 52), and healthy (n = 52) individuals. Results: The individuals originally diagnosed as DSM-IV hypochondriasis predominantly met criteria for SSD (74%) and rarely for IAD (26%). Individuals with SSD were more impaired, had more often comorbid panic and generalized anxiety disorders, and had more medical consultations as those with IAD. Yet, no significant differences were found between SSD and IAD with regard to levels of health anxiety, other hypochondriacial characteristics, illness behavior, somatic symptom attributions, and physical concerns, whereas both groups differed significantly from clinical and healthy controls in all of these variables. Conclusion: These results do not support the proposed splitting of health anxiety/hypochondriasis into two diagnoses. Further validation studies with larger samples and additional control groups are warranted to prove the validity of the new diagnoses.     

Frontal brain asymmetry in depression with comorbid anxiety: a neuropsychological investigation

The approach-withdrawal model posits that depression and anxiety are associated with a relative right asymmetry in frontal brain activity. Most studies have tested this model using measures of cortical brain activity such as electroencephalography. However, neuropsychological tasks that differentially use left versus right frontal cortical regions can also be used to test hypotheses from the model. In two independent samples (Study 1 and 2), the present study investigated the performance of currently depressed individuals with or without a comorbid anxiety disorder and healthy controls on neuropsychological tasks tapping primarily left (verbal fluency) or right (design fluency) frontal brain regions. Across both samples, results indicated that comorbid participants performed more poorly than depressed only and control participants on design fluency, while all groups showed equivalent performance on verbal fluency. Moreover, comorbid participants showed "asymmetrical" performance on these two tasks (i.e., poorer design [right frontal] relative to verbal [left frontal] fluency), whereas depressed only and control participants showed approximately symmetrical profiles of performance. Results from these two samples suggest an abnormal frontal asymmetry in neurocognitive performance driven primarily by right frontal dysfunction among anxious-depressed individuals and highlight the importance of considering comorbid anxiety when examining frontal brain functioning in depression.     

Verbal Memory Dysfunction in Depressed Outpatients With and Without Borderline Personality Disorder

This study contrasts memory functions with emotional words between two groups of patients presenting with symptoms of major depressive disorder (MDD)—20 patients with a comorbid diagnosis of borderline personality disorder (BPD) and 20 patients without BPD—and a group of 20 community adult controls. BPD patients showed poorer recall and recognition memory performances than controls, while MDD patients and controls did not differ significantly on these tasks. BPD patients showed a lower accuracy of recognition memory than MDD patients, despite negligible differences between the two patient groups in the severity of depressive symptoms and in the general level of psychopathology. Controls and BPD patients showed positive word selectivity in recall, while MDD patients showed nonsignificant selectivity differences. These findings provide additional data regarding memory disturbances specific to MDD versus BPD. The selectivity differences are consistent with theories of mood-congruent memory in depression and may serve as a cognitive marker for differentiating BPD from prototypical MDD.     

Correlation between cortisol level and serotonin uptake in patients with chronic stress and depression

In a recent study (Tafet, Toister-Achituv, & Shinitzky, 2001), we demonstrated that cortisol induces an increase in the expression of the gene coding for the serotonin transporter, associated with a subsequent elevation in the uptake of serotonin. This stimulatory effect, produced upon incubation with cortisol in vitro, was observed in peripheral blood lymphocytes from normal subjects. In the present work we investigated the cortisol-induced increase in serotonin uptake in lymphocytes from hypercortisolemic patients, including subjects with major depressive disorder (n = 8), and subjects with generalized anxiety disorder (n = 12), in comparison with a control group of normal healthy subjects (n = 8). A significant increase in serotonin uptake (+37%+14, M + SD) was observed in the control group, whereas neither the generalized anxiety disorder nor the major depression group exhibited changes in serotonin uptake upon incubation with cortisol. It is likely that under chronic stress or depression, the capacity for increase in serotonin transporter has reached its limit due to the chronically elevated blood cortisol level. The physiological and diagnostic implications of this observation are discussed.     

The Relation of Severity and Comorbidity to Treatment Outcome with Cognitive Behavioral Therapy for Childhood Anxiety Disorders

The present study investigated the impact of comorbidity over and above the impact of symptom severity on treatment outcome of Cognitive Behavioral Therapy for children with anxiety disorders. Children (aged 8–12, n = 124) diagnosed with an anxiety disorder were treated with a short-term CBT protocol. Severity was assessed with a composite measure of parent-reported behavior problems. Two approaches to comorbidity were examined; “total comorbidity” which differentiated anxiety disordered children with (n = 69) or without (n = 55) a co-occurring disorder and “non-anxiety comorbidity’ which differentiated anxious children with (n = 22) or without a non-anxiety comorbid disorder (n = 102). Treatment outcome was assessed in terms of Recovery, represented by post-treatment diagnostic status, and Reliable Change, a score reflecting changes in pre- to post-treatment symptom levels. Severity contributed to the prediction of (no) Recovery and (more) Reliable Change in parent-reported internalizing and externalizing symptoms and self-reported depressive symptoms. Total and non-anxiety comorbidity added to the prediction of diagnostic recovery. Non-anxiety comorbidity added to the prediction of Reliable Change in parent reported measures by acting as a suppressor variable. Non-anxiety comorbidity operated as a strong predictor that explained all of the variance associated with severity for self-reported depressive symptoms. The results support the need for further research on mechanisms by which treatment gains in children with higher symptom severity and non-anxiety comorbidity can be achieved.     

Transdiagnostic group CBT for anxiety disorders: the unified protocol in mental health services

Comorbidity among the anxiety disorders is common and may negatively impact treatment outcome. Potentially, transdiagnostic cognitive-behavioral treatments (CBT) deal more effectively with comorbidity than standard CBT. The present study tested the effectiveness of The Unified Protocol (UP) applied to Mental Health Services. Pre-post-treatment effects were examined for psychiatric outpatients with anxiety disorders receiving UP treatment in groups. Forty-seven patients (mean-age = 34.1 (SD = 9.92), 77% females) with a principal diagnosis of anxiety were included. We found significant and clinically meaningful changes in the primary outcomes Clinical Global Impression Severity Scale (CGI-S; d = 1.36), Hamilton Anxiety Scale (HARS; d = .71), and WHO-5 Well-being Index (WHO-5; d = .54). Also, comorbid depressive symptoms and levels of positive and negative affect changed significantly after treatment. Patients with high levels of comorbidity profited as much as patients with less comorbidity; however, these patients had higher scores after treatment due to higher symptom burden at onset. Patients with comorbid depression profited more from treatment than patients without comorbid depression. The treatment effects found in the present study correspond to treatment effects of other TCBT studies, other UP group studies, and effectiveness studies on standard CBT for outpatients. The results indicate that the UP can be successfully applied to a MHS group setting, demonstrating positive effects on anxiety and depressive symptoms for even highly comorbid cases.     

Psychosocial correlates of eczema in a non-treatment-seeking population

Data from the Vietnam Experience Study were used to examine psychosocial correlates of eczema. Based upon the results of dermatologic examinations, three groups of male veterans were identified: (a) subjects with eczema (n = 80), (b) subjects with tinea (n = 282), and (c) subjects with no medical diagnosis (n = 176). These three groups were compared on measures of anxiety, depression, hostility, and social support. The Diagnostic Interview Schedule (Version III-A) was used to determine diagnoses of anxiety and depression and level of social support. MMPI Scales 2 and 7, the Wiggins content scale of Depression, and the Cook-Medley Hostility Scale were used to assess anxiety, depression, and hostility. Eczema subjects did not differ from tinea or no-disease control groups on dependent measures. These results are contrasted with previous studies of treatment-seeking patients, which showed greater prevalence of anxiety and depression among individuals with eczema. Directions for future research are suggested.This paper is taken from the first author's dissertation.     

Irrational Beliefs in Employees with an Adjustment,a Depressive,or an Anxiety Disorder: a Prospective Cohort Study

It remains unclear if patients with different types of common mental disorders, such as adjustment, anxiety and depressive disorders, have the same irrational ideas. The aim of this prospective cohort study (n = 190) is to investigate differences in level and type of irrational beliefs among these groups and to examine whether a change in irrational beliefs is related to symptom recovery. Irrational beliefs (IBI) and symptoms were measured at four points in time: at baseline, after 3, 6 and 12 months. Results showed that diagnostic groups differed in their level of irrational beliefs and this effect remained over time. Highest levels of irrationality were observed in the double diagnosis group, followed by the anxiety disorder group and the depression group. Participants with adjustment disorders showed the lowest levels of irrationality, comparable to a community sample. We did not find differences in the type of irrational beliefs between diagnostic groups. The level of irrationality declined over time for all diagnostic groups. No differences in decrease were observed between diagnostic groups. The magnitude and direction of change in irrational beliefs were related to the magnitude of recovery of depressive, anxiety and stress symptoms over time. These results support the application of general cognitive interventions, especially for patients with a depressive or an anxiety disorder.