The influence of comorbidity on treatment outcome for children and adolescents with anxiety disorders

There have been a growing number of studies showing that cognitive behavioural treatment packages for children with anxiety disorders are highly effective. Clinically, it is often assumed that treatment outcome is less successful, or that treatment needs to be altered when faced with the existence of comorbid conditions. To date, only one study has directly addressed this question in the child anxiety literature. The present study compared the treatment outcome and maintenance following a brief, group program for the reduction of child and adolescent anxiety disorders in anxious children with versus without comorbid disorders. There was no significant difference in response to treatment at the end of the program and few differences at 12-month follow-up. The only indication of an impact of comorbidity was a suggestion that children with a comorbid condition did not do as well at follow-up. However, this result was only shown on some parent-report measures and not on self-report measures. Overall, the results indicate that treatment for child and adolescent anxiety disorders produces broadly comparable results regardless of the existence of comorbid disorders.     

Axis I anxiety and mental health disorders among stuttering adolescents

PurposeThe purpose of this study was to evaluate anxiety and psychological functioning among adolescents seeking speech therapy for stuttering using a structured, diagnostic interview and psychological questionnaires. This study also sought to determine whether any differences in psychological status were evident between younger and older adolescents.MethodParticipants were 37 stuttering adolescents seeking stuttering treatment. We administered the Computerized Voice Version of the Diagnostic Interview Schedule for Children, and five psychometric tests. Participants were classified into younger (12–14 years; n = 20) and older adolescents (15–17 years; n = 17).ResultsThirty-eight percent of participants attained at least one diagnosis of a mental disorder, according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 2000), with the majority of these diagnoses involving anxiety. This figure is double current estimates for general adolescent populations, and is consistent with our finding of moderate and moderate–severe quality of life impairment. Although many of the scores on psychological measures fell within the normal range, older adolescents (15–17 years) reported significantly higher anxiety, depression, reactions to stuttering, and emotional/behavioral problems, than younger adolescents (12–14 years). There was scant evidence that self-reported stuttering severity is correlated with mental health issues. There are good reasons to believe these results are conservative because many participants gave socially desirable responses about their mental health status.DiscussionThese results reveal a need for large-scale, statistically powerful assessments of anxiety and other mental disorders among stuttering adolescents with reference to control populations.Educational Objectives: The reader will be able to: (a) explain the clinical importance of assessing for mental health with stuttering adolescents, (b) state the superior method for adolescent mental health assessment and (c) state a major issue with determining the genuineness of stuttering adolescent responses to psychological assessment.     

A model for the treatment of eating disorders of adolescents in a specialized centre in The Netherlands

Treatment of adolescent patients with eating disorders has to take into account that these patients differ in age, their stage of development, and the constellation and functioning of their family life. Our treatment model takes these factors into account and is family and cognitive behaviourally orientated. The work has developed and changed in recent years, based on our experiences over the past ten years, as well as in combination with ideas we picked up from the experiences of colleagues elsewhere, be they via oral reports or written papers. Our approach is flexible; yet it also offers a structured containment for the patient, both by the treatment team and the parents. We aim, as much as possible, to let the family members carry out the treatment, providing them with the environment and the tools they need. Including the family members actively in the treatment of their ill daughter and teaching the parents how to help their child at home is the core of our philosophy, and we believe that this prevents prolonged inpatient stays or readmissions. This paper describes the different ways and settings in which we try to carry out our work.     

A multiple group psychotherapy approach to adolescents with psychiatric and substance abuse comorbidity.

Multiple group psychotherapy was employed as the primary treatment modality in a day-treatment program as an innovative multifaceted approach to treating adolescents comorbid for psychiatric and substance abuse diagnoses. The concurrent educational program included a high school on site. The groups included Substance Abuse Group, which promoted the 12-step model; Health Group; Psychotherapy Group; Leisure Time Group; Self-Awareness Group; and Multiple Family Group. The effect of the multiple groups was to provide a variety of experiences focusing on varied aspects of normal and dysfunctional adolescent development. Together the combination of groups served to strengthen the participants' cohesiveness, communicating skills, and hopefulness.     

Axis I and II comorbidity in adults with ADHD

Ongoing debate over the validity of the attention-deficit/hyperactivity disorder (ADHD) construct in adulthood is fueled in part by uncertainty regarding implications of potentially extensive yet incompletely described comorbid Axis I and II psychopathology. Three hundred sixty-three adults ages 18 to 37 completed semistructured clinical interviews; informants were also interviewed, and best estimate diagnoses were obtained. Results were as follows: First, ADHD combined type (ADHD-C) had an excess of externalizing and internalizing Axis I disorders, suggesting a gradient-of-severity relationship between it and ADHD inattentive type (ADHD-I). Second, ADHD-C and ADHD-I did not differ in frequency of Axis II disorders. Third, however, ADHD overall was associated with increased rates of Axis II disorders, compared with rates in non-ADHD control participants, including both Cluster B (primarily borderline personality disorder) and Cluster C disorders. Fourth, ADHD incrementally accounted for clinician-rated global assessment of functioning scores above and beyond comorbid conditions or symptoms on either Axis I or Axis II. Results further inform nosology of ADHD in adults.     

The structure of axis II disorders in adolescents: a cluster- and factor-analytic investigation of DSM-IV categories and criteria

The aim of this study was to ascertain whether the structure of personality disorder (PD) symptoms in adolescents assessed using DSM-IV diagnoses and diagnostic criteria resembles the structure intended for the diagnosis of PDs in adults. A national sample of clinicians rated DSM-IV Axis II criteria on 294 adolescent patients in treatment for enduring maladaptive personality patterns. Cluster analysis replicating procedures used in an adult sample by Morey (1988) identified considerable similarity between adult and adolescent PDs, as did exploratory factor analysis of ratings of diagnostic criteria, which yielded ten empirically derived factors that resembled the ten DSM-IV PDs. Cluster analysis and confirmatory factor analysis with indicators of Axis II symptoms produced mixed results in replicating the DSM-IV hierarchical structure of PDs (Clusters A, B, and C), although hierarchical models generally fared better than models specifying only first-order factors or clusters. The structure of personality pathology as assessed by Axis II criteria in adolescents resembles that outlined in DSM-IV Axis II for adults, suggesting that PDs can be assessed in adolescents as in adults. Whether this is an optimal way of diagnosing personality pathology in adolescence, however, requires further investigation.     

Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study

This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs. exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt.     

Electroencephalographic asymmetries in adolescents with major depression: influence of comorbidity with anxiety disorders

This study examined whether adolescents with major depressive disorder (MDD) display the abnormal electroencephalographic (EEG) alpha asymmetries found in depressed adults. Resting EEG was recorded in 25 right-handed female outpatients (19 with MDD, 11 of whom also had a current anxiety disorder; 6 with anxiety disorders only) and 10 non-ill controls. In contrast to the non-ill controls, adolescents having MDD but no anxiety disorder showed alpha asymmetry indicative of less activation over right than over left posterior sites. Within the MDD patient group, comorbid anxiety disorders reduced the posterior alpha asymmetry, supporting the potential importance of evaluating anxiety in studies of regional brain activation in adolescent MDD. These preliminary findings are similar to those from adult studies that suggest that MDD is associated with right parietotemporal hypoactivation.     

Outpatient group psychotherapy following day treatment for patients with personality disorders

This prospective, naturalistic study evaluated the practice and effectiveness of an outpatient group therapy program following day treatment for patients with personality disorders (PDs). One hundred and eighty-seven patients (86% patients with PDs and 14% with no PDs), were treated in outpatient psychodynamic group therapy. Outcome was assessed by Global Assessment of Functioning, Symptom Check List 90-R, and Inventory of Interpersonal Problems-Circumplex, short version, at admission and discharge from day treatment, and at the end of outpatient group therapy. Average length of outpatient therapy was 24 months. Forty-three percent terminated in an irregular manner. Outcome of the continuation therapy was satisfactory for patients without PDs. For PD patients, the improvement from the day treatment was maintained during outpatient therapy, but further improvements were modest for symptoms and interpersonal distress, somewhat better for global functioning. Implications for further treatment development are discussed.     

Using item response theory to understand comorbidity among anxiety and unipolar mood disorders

The authors hypothesized that anxiety and unipolar mood disorders are often comorbid because each disorder indicates a broad, higher order factor. In a clinical subsample of the nationally representative National Comorbidity Survey participants (N = 251), a one-factor model fit the correlations among 7 dichotomous anxiety and unipolar mood diagnoses. Following the lead provided by literature on the structure of emotional and behavioral problems in children, we labeled this factor internalizing. Item response theory was used to explore how each diagnosis mapped onto the internalizing factor. The test information function derived from the 7 diagnoses suggested that they measure primarily the higher end of the factor. In addition, very high scores on internalizing (meeting criteria for 6-7 disorders) were associated with increased social costs, a phenomenon not well captured by the "comorbidity" concept. The results underscore the need to develop clinical assessment instruments that span the full range of the internalizing factor and measure both the shared and distinctive features of anxiety and unipolar mood disorders in a graded, continuous fashion.     

Differentiation of Axis I and Axis II disorders

The revised 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987) distinguishes between Axis I and Axis II disorders: Axis II includes personality (and developmental) disorders, and all others are on Axis I. This distinction is often useful, but the reification of Axis I and II constructs through diagnostic criteria sets that demarcate categorically distinct entities is at times problematic. We review the issues of differentiating personality from Axis I disorders, specifically illustrated by schizotypal and schizophrenic disorders, borderline and mood disorders, antisocial and substance use disorders, and avoidant personality from social phobia. The options for addressing their differentiation include adding exclusion criteria, shifting the placement of disorders, deleting overlapping criteria, adding differentiating criteria, and converting to a dimensional format.     

Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior

In the context of a school-based prevention of conduct disorder program, 7,231 first- through fourth-grade children were screened for cross-setting disruptive behavior. Frequencies of DSM-III-R psychiatric disorders and patterns of comorbidity were assessed. We also examined the association of psychiatric diagnosis with child and parent characteristics to determine differential risk based on diagnostic subgroups. Attention deficit hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) were the most frequent diagnoses. Mood and anxiety disorders were infrequent as single diagnoses. Patterns of comorbidity demonstrated that both externalizing and internalizing disorders commonly cooccurred with ADHD. More severe degrees of psychopathology and psychosocial risk accrued to the subgroup of youths with ADHD plus a comorbid externalizing disorder.This study was supported by grant MN-46584 from the National Institute of Mental Health.     

Personality disorders associated with substance use among American and Greek adolescents

A study was conducted to investigate the association between personality disorder (PD) symptomatology and substance use among adolescents in community settings in the United States and Greece. The Structured Clinical Interview for DSM-IV Personality Disorders and the Adolescent Health Behavior Survey were completed by 37 male and 84 female adolescents, ages 15 to 18, who were recruited from an adolescent medical clinic and schools in and near New York City (n = 71) and Heraklion, Greece (n = 50). Results indicated that: (1) adolescents with PDs reported more frequent alcohol consumption during the past year than did those without PDs; (2) adolescents with borderline PD reported more cigarette smoking and heavy alcohol consumption than did those without borderline PD; (3) adolescents with antisocial PD symptomatology reported greater alcohol, cigarette, and illicit drug use than did those without antisocial PD symptomatology; and (4) although more American (30%) than Greek (4%) adolescents reported illicit substance use, differences were not observed in the prevalence of alcohol use, cigarette use, or personality disorders as a function of nationality.     

Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive-compulsive personality disorder

The aim of this study was to examine the pattern of comorbidity among obsessive-compulsive personality disorder (OCPD) and other personality disorders (PDs) in a sample of 400 psychiatric inpatients. PDs were assessed using the Semistructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Odds ratios (ORs) were calculated to determine significant comorbidity among OCPD and other axis II disorders. The most elevated odds ratios were found for the cooccurrence of OCPD with cluster A PDs (the "odd" PDs, or paranoid and schizoid PDs). These results are consistent with those of previous studies showing a higher cooccurrence of OCPD with cluster A than with cluster C ("anxious") PDs. In light of these observations, issues associated with the nosologic status of OCPD within the Diagnostic and Statistical Manual of Mental Disorders clustering system remain unsettled.     

High-risk behavior among gay adolescents: implications for treatment and support

This article contrasts the experiences of most adolescents during social and psychological development with the special challenges faced by those developing an awareness of their homosexuality. Emphasis is placed upon the interplay between societal prejudices and discrimination toward homosexuality and personal development and risk-taking behavior in gay adolescents. The implications of these life stressors for gay adolescents are also discussed in terms of their consequences for mental health policy and treatment.     

青少年饮食失调：同伴的表现形式及作用机制

饮食失调在青少年群体中非常普遍, 同伴被认为是一种重要的影响因素。梳理其作用机制, 对青少年饮食失调的预防和干预有重要意义。研究表明, 同伴对青少年饮食失调具有消极影响, 主要表现为感知到的同伴行为、实际的同伴行为、身体不满意的中介作用、以及同伴质量的影响。研究者从直接、间接的角度就同伴对青少年饮食失调的作用机制及影响进行了阐释。未来的研究应深化研究内容, 如增加关于同伴影响的长期效应、同伴属性划分、影响路径作用大小以及同伴与饮食失调的其它社会影响因素间的交互作用等方面的研究。