The impact of an 8-day intensive treatment for adolescent panic disorder and agoraphobia on comorbid diagnoses

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Impact of personality disorders on treatment outcome for female assault survivors with chronic posttraumatic stress disorder

This study examined the impact of comorbid personality disorders on the outcome of cognitive behavioral treatment for women with chronic posttraumatic stress disorder (PTSD). Seventy-five adult women with PTSD resulting from rape or nonsexual assault in adulthood or sexual abuse in childhood were treated with prolonged exposure with or without cognitive restructuring. Assessment of personality disorders found that 39% of participants met DSM-IV criteria for some personality disorder diagnosis. No difference was found between women with and without personality disorders on the prevalence of PTSD at the end of treatment. Participants with a personality disorder were less likely to attain good end-state functioning, but this may be attributable to the fact that they started off slightly worse than those without personality disorders. Finally, the comorbid patients treated by community therapists fared as well or better than those treated by cognitive behavioral treatment experts in posttreatment prevalence of PTSD and end-state functioning.     

Anxiety and Related Disorders and Concealment in Sexual Minority Young Adults

Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress places sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.     

Clinical Effectiveness of an Intensive Outpatient Program for Integrated Treatment of Comorbid Substance Abuse and Mental Health Disorders

Comorbid substance use disorders (SUDs) and mental health disorders are a pervasive problem among post-9/11 veterans and service members. Treatment of SUD and comorbid disorders has historically occurred separately and sequentially, and when treated concurrently has been primarily done in a weekly outpatient setting, which has high rates of dropout. The current study describes an integrated 2-week intensive outpatient treatment (IOP) using cognitive-behavioral therapy, including prolonged exposure for posttraumatic stress disorder (PTSD), unified protocol for anxiety and mood disorders, and relapse prevention for SUD. Forty-two patients completed the comorbid treatment program. Results indicated that self-reported substance use, PTSD, and depression symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that comorbid SUD and mental health disorders can be effectively treated in a 2-week intensive outpatient program.     

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.     

Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.     

Comorbid anxiety and mood disorders among persons with social anxiety disorder.

Axis I comorbidity is associated with greater severity of social anxiety disorder. However, the differential effects of comorbid mood and anxiety disorders on symptom severity or treatment outcome have not been investigated. We evaluated 69 persons with uncomplicated social anxiety disorder, 39 persons with an additional anxiety disorder, and 33 persons with an additional mood disorder (with or without additional anxiety disorders). Those with comorbid mood disorders reported greater duration of social anxiety than those with uncomplicated social anxiety disorder. They were also judged, before and after 12 weeks of cognitive-behavioral group treatment and at follow-up, to be more severely impaired than those with no comorbid diagnosis. In contrast, persons with comorbid anxiety disorders were rated as more impaired than those with no comorbid diagnosis on only a single measure. Type of comorbid diagnosis did not result in differential rates of improvement of social anxiety disorder.     

Diagnostic issues,multiple paraphilias,and comorbid disorders in sexual offenders: Their incidence and treatment

This paper critically appraises the criteria for DSM diagnoses of the paraphilias relevant to sexual offenders. It is concluded that these criteria leave a lot to be desired and that a more helpful approach would be to rate the features of each type of sexual offender along dimensions ranging from normal to seriously problematic. Next consideration is given to the evidence on the incidence of multiple paraphilias and comorbid disorders. It is not yet completely clear from this evidence that sexual offenders typically have multiple sexual outlets although some obviously do. What is clear is that incidence of comorbid disorders is sufficiently high to warrant concerns about how to effectively address these additional disordered aspects of sexual offenders in treatment. Finally, suggestions are offered about how to address in treatment both multiple paraphilic offenders and those with associated comorbid disorders.     

Killing Two Birds With One Stone: Exposure Simultaneously Addressing Panic Disorder and Obsessive-Compulsive Disorder

Massed exposure has gained acceptance as an effective method to treat anxiety disorders. When using this intervention in patients presenting with more than one anxiety disorder, specific treatment options need to be discussed. Should exposure be applied in sequential order for each of the comorbid disorders? Or can exposure sessions also be designed to simultaneously target both problem areas? We report on the cognitive-behavioral treatment of a 28-year-old woman with obsessive-compulsive disorder (OCD) and severe panic disorder with agoraphobia (PDA). A series of behavioral experiments based on prolonged exposure was planned. Due to the fact that avoided situations elicited both agoraphobic and contamination fears, we decided to combine exposure for PDA and OCD to optimize therapeutic transfer. Twelve sessions of this exposure resulted in a long-term reduction of both PDA and OCD symptoms. The case illustrates that two comorbid conditions can be effectively combined under one therapeutic rationale. Capabilities and limitations of the method and implications for current theoretical debates on exposure therapy are discussed.     

Beziehungsgewalt

The objective of our questionnaire study was to investigate posttraumatic stress disorders of abused women and to analyze differences between affected women suffering from high versus low symptom strain with respect to the duration and intensity of the abuse and to victimization incidences in their childhood. We collected data on characteristics of the abuse relationship, kind and frequency of experienced violence, symptoms of posttraumatic stress disorder (PTSD, PCL-C according to DSM-IV), and comorbid complaints (SCL-90-R). Participants were 71 women with a mean age of 43 years. On average, they had lived in an abusive relationship for 11 years. Two thirds had experience with psychotherapy. All provided information on abuse that may be considered traumatic. 62% suffered from injuries necessitating medical treatment at least once, and half sustained lasting physical damage. With respect to all SCL-90-R scales, the research participants were under significantly higher strain than the normed female sample. PTSD was diagnosed in 58%. Compared to women without PTSD, women with PTSD reported very serious assault, comorbid symptoms as well as physical and sexual victimization in their childhood significantly more often.     

Pharmacotherapeutic options in the treatment of comorbid depression and anxiety

Although anxiety and mood disorders are listed as separate disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, they frequently coexist. They may be expressed phenotypically as comorbidities or as the provisional entity mixed anxiety-depressive disorder. Patients with both anxiety and depression are more symptomatic, use more health care resources, and have a worse prognosis than those with a single disorder. Recognizing and treating these patients are challenges for physicians because the symptoms of the two disorders often overlap. Administration of effective treatment, comprising both anxiolytic and antidepressant effects, can reduce patient distress and disability, as well as inappropriate utilization of medical services. Medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors, nefazodone, venlafaxine XR (extended release) and mirtazapine, are highly effective in treating comorbid depression and anxiety. These newer agents now represent the pharmacotherapeutic treatments of choice for the comorbid conditions.     

Psychiatric Comorbidity in Children with Autism Spectrum Disorders: A Comparison with Children with ADHD

The present study was conducted with the aim to identify comorbid psychiatric disorders in children with autism spectrum disorders (ASD) (n = 40) and to compare those comorbidity rates to those in children with attention deficit hyperactivity disorder (ADHD) (n = 40). Participants were clinically referred children aged 7–18 years. DSM-IV classifications were used for the primary diagnosis (ASD/ADHD), while comorbid psychiatric disorders were assessed using a structured diagnostic interview, the structured clinical interview for DSM-IV, childhood diagnoses (KID-SCID). Twenty-three children with ASD (57.5 %) had at least one comorbid disorder, whereas 16 children with ADHD (40.0 %) were classified as having at least one comorbid disorder. No group differences were found with respect to this comorbidity rate or for the rate of comorbid externalizing disorders (ODD and/or CD). However, children with ASD had more comorbid internalizing disorders compared to children with ADHD. More specifically, children with ASD had higher rates of anxiety disorders, but not mood disorders. No associations between comorbidity and age or between comorbidity and the intelligence quotient was found. It is important for clinicians to always be aware of, and screen for, comorbidity, and to consider treatment for these comorbid disorders. In addition, research should focus on establishing valid and reliable screening tools as well as effective treatment options for these comorbid disorders.     

Cognitive behavioral therapy for panic disorder and comorbidity: more of the same or less of more?

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

Comorbid depression and heart rate variability as predictors of aggressive and hyperactive symptom responsiveness during inpatient treatment of conduct‐disordered,ADHD boys

The primary objective of the present study was to assess the utility of (1) comorbid depression and (2) parasympathetic influence on cardiac function as markers for treatment response among aggressive preadolescent males. Inpatient records of 53 patients with conduct disorder and attention deficit hyperactivity disorder (17 with a comorbid depressive disorder) were examined, including an intake electrocardiogram and daily tallies of several indices of aggressive behavior across 3 weeks of stay. The relations of comorbid depression, heart rate variability, and residualized heart rate (primarily of sympathetic origin) to treatment response were assessed through analyses of linear growth functions. Significant vagal tone by diagnostic status interactions were obtained for both frequency and duration indices of aggression, whereby nondepressed patients with high vagal tone deteriorated and depressed patients with high vagal tone improved during hospitalization. No such relation was found for attention deficit hyperactivity disorder symptoms. Patients in the comorbid group also exhibited greater heart rate variability than their nondepressed counterparts. Furthermore, residualized heart rate was predictive of maternal substance use and paternal incarcerations. These findings suggest complex relations among treatment response, comorbid depression, and emotion regulation in male preadolescents with severe behavior disorders. Additionally, the differential prediction afforded by vagal tone and residualized heart rate underscores the importance of assessing both parasympathetic and sympathetic indices of cardiac function as distinct physiological markers. Aggr. Behav. 26:425–441, 2000. © 2000 Wiley‐Liss, Inc.     

A structured interview for the assessment of the Five-Factor Model of personality: facet-level relations to the axis II personality disorders

The Structured Interview for the Five-Factor Model (SIFFM; Trull & Widiger, 1997) is an 120-item semistructured interview that assesses both adaptive and maladaptive features of the personality traits included in the five-factor model of personality, or "Big Five." In this article, we evaluate the ability of SIFFM scores to predict personality disorder symptomatology in a sample of 232 adults (46 outpatients and 186 nonclinical college students). Personality disorder symptoms were assessed using the Personality Diagnostic Questionnaire-Revised (PDQ-R; Hyler & Rider, 1987). Results indicated that many of the predicted associations between lower-order personality traits and personality disorders were supported. Further, many of these associations held even after controlling for comorbid personality disorder symptoms. These findings may help inform conceptualizations of the personality disorders, as well as etiological theories and treatment.     

Brain structure abnormalities in young women who presented conduct disorder in childhood/adolescence

The phenotype and genotype of antisocial behavior among females are different from those among males. Previous studies have documented structural brain alterations in males with antisocial behavior, yet little is known about the neural correlates of female antisocial behavior. The present study examined young women who had presented conduct disorder (CDW) prior to age 15 to determine whether brain abnormalities are present in adulthood and whether the observed abnormalities are associated with comorbid disorders or maltreatment that typically characterize this population. Using magnetic resonance imaging and voxel-based morphometry, we compared gray matter volumes (GMV) of 31 women who presented CD by midadolescence and 25 healthy women (HW), age, on average, 23 years. Participants completed structured, validated interviews to diagnose mental disorders, and validated questionnaires to document physical and sexual abuse. Relative to HW, CDW presented increased GMV in the left superior temporal gyrus that was associated with past alcohol and drug dependence, current use of alcohol and drugs, and current anxiety and depression symptoms and maltreatment. Additionally, CDW displayed reduced GMV in lingual gyrus, hippocampus, and anterior cingulate cortex that was associated with past comorbid disorders, current alcohol and drugs use, current anxiety and depression symptoms, and maltreatment. The CDW also presented reduced total GMV that was associated with past comorbid disorders and current anxiety/depression symptoms. Alterations of brain structure were observed among young adult females with prior CD, relative to HW, all of which were associated with internalizing and externalizing disorders and maltreatment that typically accompany CD.     

Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?

Individuals with obsessive-compulsive disorder (OCD) commonly experience comorbid mood disturbances such as major depressive disorder (MDD). Previous studies that have compared OCD patients with and without MDD have revealed differences in demographic characteristics, clinical severity, and symptom presentation between these two patient groups. Previous studies have not, however, examined whether there are differences with respect to cognitive processes. The present study therefore aimed to address this gap in the literature. Eighty patients with OCD and no unipolar mood disorders were compared with 34 OCD patients with comorbid major depression on measures of OCD symptoms, cognitions, and insight, as well as on measures of depression and functional impairment. Whereas depressed OCD patients evidenced higher scores than non-depressed OCD patients on semi-idiographic measures of OCD symptoms and cognitions, this was not the case for nomothetic measures. Functional impairment and the tendency to misinterpret innocuous intrusive thoughts as significant emerged as unique predictors of depression within the entire sample of OCD patients. Results are discussed in terms of (a) the importance of semi-idiographic assessment of OCD, (b) possible explanations for the relationship between OCD symptoms, depression, and cognitive processes, and (c) the psychological treatment of comorbid OCD and MDD.     

Cognitive Behavioral Treatment of PTSD with Comorbid Panic Attacks

Many individuals that experience traumatic events such as sexual and physical assault develop posttraumatic stress disorder (PTSD). More recently, research has indicated that a significant proportion of PTSD sufferers may also have comorbid panic attacks. Although there are several effective treatments that focus on alleviating PTSD symptoms, until now there were no treatments that focused on also treating comorbid panic attacks. Multiple channel exposure therapy (M-CET) is the first treatment developed to specifically treat comorbid PTSD and panic attacks. It is also unique in that it has been used to treat women who have multiple trauma histories as well as a wide range of different types of traumatic event exposure in a group format. This treatment is described in a session by session format and special considerations in implementing the treatment are discussed.