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Background Despite the well-known association between anxiety and risk-avoidant decision making, it is unclear how pathological anxiety biases risk learning. We propose a Bayesian inference model with bias parameters of prior, learning, and perception during risk learning in individuals with pathological anxiety. Methods Patients with panic disorder (PD, n = 40) and healthy control subjects (n = 84) completed the balloon analog risk task (BART). By fitting our computational model of three bias parameters (prior belief, learning rate, and perceptual bias) to the participants' behavior, we estimated the degree of bias in risk learning and its relationship with anxiety symptoms. Results Relative to the healthy control subjects, the pathologically anxious participants exhibited a biased underestimation of perceptual evidence rather than differences in priors and learning rates. The degree of perceptual bias was correlated with the anxiety and depression symptom severity in the patients with PD. Furthermore, our proposed model was the winning model for BART data in an external data set from different patient groups. Conclusions Our results showed that individuals with pathological anxiety demonstrate perceptual bias in evidence accumulation, which may explain why patients with anxiety overestimate risk in their daily lives. This clarification highlights the importance of interventions focusing on perceptual bias, such as enhancing the clarity of favorable outcome probabilities.

Background Prospective cohorts have suggested that physical activity (PA) can decrease the risk of incident anxiety. However, no meta-analysis has been conducted. Aims To examine the prospective relationship between PA and incident anxiety and explore potential moderators. Methods Searches were conducted on major databases from inception to October 10, 2018 for prospective studies (at least 1 year of follow-up) that calculated the odds ratio (OR) of incident anxiety in people with high PA against people with low PA. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects meta-analysis was conducted and heterogeneity was explored using subgroup and meta-regression analysis. Results Across 14 cohorts of 13 unique prospective studies (N = 75,831, median males = 50.1%) followed for 357,424 person-years, people with high self-reported PA (versus low PA) were at reduced odds of developing anxiety (adjusted odds ratio [AOR] = 0.74; 95% confidence level [95% CI] = 0.62, 0.88; crude OR = 0.80; 95% CI = 0.69, 0.92). High self-reported PA was protective against the emergence of agoraphobia (AOR = 0.42; 95% CI = 0.18, 0.98) and posttraumatic stress disorder (AOR = 0.57; 95% CI = 0.39, 0.85). The protective effects for anxiety were evident in Asia (AOR = 0.31; 95% CI = 0.10, 0.96) and Europe (AOR = 0.82; 95% CI = 0.69, 0.97); for children/adolescents (AOR = 0.52; 95% CI = 0.29, 0.90) and adults (AOR = 0.81; 95% CI = 0.69, 0.95). Results remained robust when adjusting for confounding factors. Overall study quality was moderate to high (mean NOS = 6.7 out of 9). Conclusion Evidence supports the notion that self-reported PA can confer protection against the emergence of anxiety regardless of demographic factors. In particular, higher PA levels protects from agoraphobia and posttraumatic disorder.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-5) definition of agoraphobia (AG) as an independent diagnostic entity makes it timely to re-examine the epidemiology of AG. Study objective was to present representative data on the characteristics of individuals who meet DSM-IV criteria for AG (AG without a history of panic disorder [PD] and PD with AG) but not DSM-5 criteria, DSM-5 but not DSM-IV criteria, or both sets of criteria. METHODS: Population-based surveys from the World Mental Health Survey Initiative including adult respondents (n = 136,357) from 27 countries across the world. The Composite International Diagnostic Interview was used to assess AG and other disorders. RESULTS: Lifetime and 12-month prevalence estimates of DSM-5 AG (1.5% and 1.0%) were comparable to DSM-IV (1.4% and 0.9%). Of respondents meeting criteria in either system, 57.1% met criteria in both, while 24.2% met criteria for DSM-5 only and 18.8% for DSM-IV only. Severe role impairment due to AG was reported by a lower proportion of respondents who met criteria only for DSM-IV AG (30.4%) than those with both DSM-5 and DSM-IV AG (44.0%; χ 21 = 4.7; P = 0.031). The proportion of cases with any comorbidity was lower among respondents who met criteria only for DSM-IV AG (78.7%) than those who met both sets (92.9%; χ 21 = 14.5; P

1 BackgroundComorbid anxiety is common in bipolar disorder (BD) and associated with worse clinical outcomes including increased suicidality. Despite effective psychological treatments for anxiety, research into treating anxiety in BD is underdeveloped. This paper describes a novel psychological intervention to address anxiety in context of bipolar disorder (AIBD).2 MethodsAdults with BD and clinically significant anxiety symptoms were randomized to AIBD plus treatment as usual (TAU) or TAU alone. AIBD offered 10 sessions of psychological therapy using a formulation‐based approach. Feasibility and acceptability were evaluated through recruitment, retention, therapy attendance, alliance, fidelity, and qualitative feedback. Clinical outcomes were assessed at baseline, 16, 48, and 80 weeks: interim assessments of relapse at 32 and 64 weeks.3 ResultsSeventy‐two participants were recruited with 88% retention to 16 weeks and 74% to 80 weeks (similar between arms). Therapy participants attended urn:x-wiley:10914269:media:da22781:da22781-math-00017.7 (SD 2.8) sessions. Therapeutic alliance and therapy fidelity were acceptable. Qualitative interviews indicated that participants valued integrated support for anxiety with BD and coping strategies. Some suggested a longer intervention period. Clinical outcomes were not significantly different between arms up to 80 weeks follow‐up.4 ConclusionsAIBD is feasible and acceptable but lack of impact on clinical outcomes indicates that adaptations are required. These are discussed in relation to qualitative feedback and recent literature published since the trial completed.

BACKGROUND: No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD. METHODS: In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity. RESULTS: 37% and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). While there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (p = 0.007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost). CONCLUSIONS: PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

CONTEXT: The scarcity of cross-national reports and the changes in Diagnostic and Statistical Manual version 5 (DSM-5) regarding panic disorder (PD) and panic attacks (PAs) call for new epidemiological data on PD and PAs and its subtypes in the general population. OBJECTIVE: To present representative data about the cross-national epidemiology of PD and PAs in accordance with DSM-5 definitions. DESIGN AND SETTING: Nationally representative cross-sectional surveys using the World Health Organization Composite International Diagnostic Interview version 3.0. PARTICIPANTS: Respondents (n = 142,949) from 25 high, middle, and lower-middle income countries across the world aged 18 years or older. MAIN OUTCOME MEASURES: PD and presence of single and recurrent PAs. RESULTS: Lifetime prevalence of PAs was 13.2% (SE 0.1%). Among persons that ever had a PA, the majority had recurrent PAs (66.5%; SE 0.5%), while only 12.8% fulfilled DSM-5 criteria for PD. Recurrent PAs were associated with a subsequent onset of a variety of mental disorders (OR 2.0; 95% CI 1.8-2.2) and their course (OR 1.3; 95% CI 1.2-2.4) whereas single PAs were not (OR 1.1; 95% CI 0.9-1.3 and OR 0.7; 95% CI 0.6-0.8). Cross-national lifetime prevalence estimates were 1.7% (SE 0.0%) for PD with a median age of onset of 32 (IQR 20-47). Some 80.4% of persons with lifetime PD had a lifetime comorbid mental disorder. CONCLUSIONS: We extended previous epidemiological data to a cross-national context. The presence of recurrent PAs in particular is associated with subsequent onset and course of mental disorders beyond agoraphobia and PD, and might serve as a generic risk marker for psychopathology.

Context The scarcity of cross-national reports and the changes in Diagnostic and Statistical Manual version 5 (DSM-5) regarding panic disorder (PD) and panic attacks (PAs) call for new epidemiological data on PD and PAs and its subtypes in the general population. Objective To present representative data about the cross-national epidemiology of PD and PAs in accordance with DSM-5 definitions. Design and setting Nationally representative cross-sectional surveys using the World Health Organization Composite International Diagnostic Interview version 3.0. Participants Respondents (n = 142,949) from 25 high, middle, and lower-middle income countries across the world aged 18 years or older. Main outcome measures PD and presence of single and recurrent PAs. Results Lifetime prevalence of PAs was 13.2% (SE 0.1%). Among persons that ever had a PA, the majority had recurrent PAs (66.5%; SE 0.5%), while only 12.8% fulfilled DSM-5 criteria for PD. Recurrent PAs were associated with a subsequent onset of a variety of mental disorders (OR 2.0; 95% CI 1.8–2.2) and their course (OR 1.3; 95% CI 1.2–2.4) whereas single PAs were not (OR 1.1; 95% CI 0.9–1.3 and OR 0.7; 95% CI 0.6–0.8). Cross-national lifetime prevalence estimates were 1.7% (SE 0.0%) for PD with a median age of onset of 32 (IQR 20–47). Some 80.4% of persons with lifetime PD had a lifetime comorbid mental disorder. Conclusions We extended previous epidemiological data to a cross-national context. The presence of recurrent PAs in particular is associated with subsequent onset and course of mental disorders beyond agoraphobia and PD, and might serve as a generic risk marker for psychopathology.

Anxiety disorders are highly prevalent worldwide and engender substantial economic costs and disability. The World Health Organization is currently developing the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11), which represents the first opportunity to improve the validity, clinical utility, and global applicability of the classification in more than 25 years. This article describes changes in the organization and diagnostic guidelines for anxiety and fear-related disorders proposed by the ICD-11 Working Group on the Classification of Mood and Anxiety Disorders and the rationale and evidence base for the proposals. In ICD-11, anxiety and fear-related disorders that manifest across the lifespan are brought together under a new grouping, and are partly distinguished by their focus of apprehension. The focus of apprehension is the stimulus or situation that triggers the fear or anxiety and may be highly specific as in specific phobia or relate to a broader class of situations as in social anxiety disorder. The guidelines also clarify the relationship between panic disorder and agoraphobia and a qualifier is provided for panic attacks in the context of other disorders. A standardized format emphasizing essential features of anxiety disorders is intended to improve clinical utility. Guidelines will be further refined based on findings from two types of field studies: those using a case-controlled vignette methodology disseminated via the Internet to practitioners worldwide (http://gcp.network) and clinic-based field trials implemented globally at participating field study centers.

Background Cognitive behavioral therapy (CBT) and pharmacotherapy are efficacious for the short-term treatment of panic disorder. Less is known about the efficacy of these therapies for individuals who do not respond fully to short-term CBT. Method The current trial is a second-step stratified randomized design comparing two treatment conditions—selective serotonin reuptake inhibitor (SSRI; paroxetine or citalopram; n = 34) and continued CBT (n = 24)—in a sample of individuals classified as treatment nonresponders to an initial course of CBT for panic disorder. Participants were randomized to 3 months of treatment and then followed for an additional 9 months. Only treatment responders after 3 months were maintained on the treatment until 12-month follow-up. Data analysis focused on panic disorder symptoms and achievement of response status across the first 3 months of treatment. Final follow-up data are presented descriptively. Results Participants in the SSRI condition showed significantly lower panic disorder symptoms as compared to continued CBT at 3 months. Results were similar when excluding individuals with comorbid major depression or analyzing the entire intent-to-treat sample. Group differences disappeared during 9-month naturalistic follow-up, although there was significant attrition and use of nonstudy therapies in both arms. Conclusions These data suggest greater improvement in panic disorder symptoms when switching to SSRI after failure to fully respond to an initial course of CBT. Future studies should further investigate relapse following treatment discontinuation for nonresponders who became responders. Clinicaltrials.gov Identifier: NCT00000368; https://clinicaltrials.gov/show/NCT00000368

This is the peer reviewed version of the following article: Torvik, F.A., Rosenström, T.H., Gustavson, K.B., Ystrøm, E., Kendler, K.S., Bramness, J.G., Czajkowski, N.O. & Reichborn-Kjennerud, T. (2019). Explaining the association between anxiety disorders and alcohol use disorder: A twin study. Depression and Anxiety, 36(6), 522-532, which has been published in final form at https://doi.org/10.1002/da.22886. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. Background - It is unknown whether social anxiety disorder (SAD) has a unique association with alcohol use disorder (AUD) over and beyond that of other anxiety disorders, how the associations develop over time, and whether the associations are likely to be causal. Methods - Diagnoses of AUD, SAD, generalized anxiety disorder, panic disorder, agoraphobia, and specific phobias were assessed twice using the Composite International Diagnostic Interview among 2,801 adult Norwegian twins. The data were analyzed using logistic regression analyses and multivariate biometric structural equation modeling. Results - SAD had the strongest association with AUD, and SAD predicted AUD over and above the effect of other anxiety disorders. In addition, SAD was prospectively associated with AUD, whereas other anxiety disorders were not. AUD was associated with a slightly elevated risk of later anxiety disorders other than SAD. Biometric modeling favored a model where SAD influenced AUD compared to models where the relationship was reversed or due to correlated risk factors. Positive associations between AUD and other anxiety disorders were fully explained by shared genetic risk factors. Conclusions - Unlike other anxiety disorders, SAD plausibly has a direct effect on AUD. Interventions aimed at prevention or treatment of SAD may have an additional beneficial effect of preventing AUD, whereas interventions aimed at other anxiety disorders are unlikely to have a similar sequential effect on AUD.

BACKGROUND: Anxiety and depression display frequent comorbidity. Individuals with comorbid disorders also often have more extreme symptomatology than those with single disorders. This correlation between comorbidity and severity poses an interesting question: Are comorbid forms of anxiety and depression essentially just more severe versions of the pure disorders? METHODS: In a large major depression (MD) case-control sample of individuals from the China, Oxford and VCU Experimental Research on Genetic Epidemiology project, we examined the patterns of lifetime anxiety comorbidity (including generalized anxiety disorder-GAD, panic disorder, and five phobia subtypes) among MD cases (N = 5,864) in this population. Binary and multinomial logistic regression was used to estimate associations between risk factors and outcomes including MD as well as latent class membership, which were compared using continuation ratios. RESULTS: We found a five-class solution to fit best, and each resulting class had a distinct pattern of association with the tested risk factors. The use of continuation ratios suggests that a class characterized by high endorsement of GAD is comparable to a more severely affected "pure MD" group. The other three classes (characterized by agoraphobia, various specific phobias, and by high endorsement of all comorbid anxiety disorders, respectively) appear to differ meaningfully from MD alone. CONCLUSIONS: Risk for MD resulting from environmental and psychosocial factors may also predispose individuals to GAD, and less consistently, other anxiety disorders. Presentations of MD with certain phobias display distinguishably different patterns of risk, however, and are therefore likely qualitatively distinct. Language: en

BACKGROUND: The chronotype, being a morning or an evening type, can influence an individual's psychological health. Studies have shown a link between depressed mood and being an evening type; however, most studies have used symptom scales and not diagnostic criteria, and confounding factors such as sleep patterns and somatic health factors have often not been considered. This study aims to examine the association between chronotype and depressive (major depressive disorder (MDD), dysthymia) and anxiety (generalized anxiety disorder, panic disorder, agoraphobia, and social phobia) disorders diagnosed using clinical interviews, while taking into account relevant sociodemographic, clinical, somatic health, and sleep parameters. METHODS: Data from a large cohort, the Netherlands Study of Depression and Anxiety were used (n = 1,944), which included 676 currently depressed and/or anxious patients, 831 remitted patients, and 437 healthy controls. Chronotype was assessed using the Munich Chronotype Questionnaire. RESULTS: Our results showed that current depressive and/or anxiety disorders were associated with a late chronotype (β =.10, P =.004) even when adjusting for sociodemographic, somatic health, and sleep-related factors (β =.09, P =.03). When examining each type of disorder separately, MDD only, but not dysthymia or specific anxiety disorders, was associated with the late chronotype. The late chronotype also reported significant diurnal mood variation (worse mood in the morning). CONCLUSIONS: Our findings show a clear association between MDD and late chronotype (being an evening type), after controlling for a range of pertinent factors. A late chronotype is therefore associated with a current status of MDD and deserves the relevant clinical attention when considering treatments. Language: en

Background In DSM-5, the agoraphobia core symptom criterion has been revised to require fear about multiple situations from across at least two distinct domains in which escape might be difficult or panic-like symptoms might develop. The present study examined patterns and correlates of the recent change in a sample of anxious youth with symptom presentations consistent with the DSM-IV agoraphobia definition and/or specific phobia (SP) to consider how the recent diagnostic change impacts the prevalence and composition of agoraphobia in children and adolescents. Method Analyses (N = 151) evaluated impairment and correlates of agoraphobic youth who no longer meet the DSM-5 agoraphobia criteria relative to agoraphobic youth who do meet the new DSM-5 criteria. Secondary analyses compared agoraphobic youth not meeting DSM-5 criteria to SP youth. Results One-quarter of youth with symptom presentations consistent with the DSM-IV agoraphobia definition no longer met criteria for DSM-5 agoraphobia, but showed comparable severity and impairment across most domains to youth who do meet criteria for DSM-5 agoraphobia. Further, these youth showed higher levels of anxiety sensitivity and internalizing psychopathology relative to youth with SP. Conclusions A substantial proportion of impaired youth with considerable agoraphobic symptom presentations have been left without a specified anxiety diagnosis by the DSM-5, which may affect their ability to receive and/or get coverage for services and their representation in treatment evaluations. Future DSM iterations may do well to include a “circumscribed” agoraphobia specifier that would characterize presentations of fear or anxiety about multiple situations, but that do not span across at least two distinct situational domains.

Background Physical activity has been discussed as a therapeutic alternative or add-on for the treatment of anxiety disorders. We studied whether aerobic exercise compared to physical activity with low impact can improve the effect of cognitive behavioral therapy (CBT) in patients with panic disorder (PD) with/without agoraphobia. Methods Forty-seven patients received group CBT treatment over 1 month, which was augmented with an 8-week protocol of either aerobic exercise (three times/week, 30 min, 70% VO(2) max; n = 24) or a training program including exercises with very low intensity (n = 23) in a randomized controlled double-blind design. The primary outcome measure was the total score on the Hamilton Anxiety Scale (Ham-A). A 2 × 3 analysis of covariance (ANCOVA) with baseline value as a covariate was conducted for data analysis. Results Time × group interaction for the Ham-A revealed a significant effect (P = .047, η(2) p = .072), which represented the significant group difference at a 7-month follow-up. For the other clinical outcome measures no statistical significance emerged, although improvement was more sustained in the exercise group. Conclusions For patients with PD, regular aerobic exercise adds an additional benefit to CBT. This supports previous results and provides evidence about the intensity of exercise that needs to be performed.

Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive-behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults.A total of 172 patients with PDA (DSM-IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18-60 years) and older (? 60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions.Attrition rates were 2/31 (6%) for the over-60s and 31/141 (22%) for the under-60s group (?(2) = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate-to-large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age-related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P-values

BACKGROUND: Older adults with panic disorder and agoraphobia (PDA) are underdiagnosed and undertreated, while studies of cognitive-behavioral therapy (CBT) are lacking. This study compares the effectiveness of CBT for PDA in younger and older adults. METHODS: A total of 172 patients with PDA (DSM-IV) received manualized CBT. Primary outcome measures were avoidance behavior (Mobility Inventory Avoidance scale) and agoraphobic cognitions (Agoraphobic Cognitions Questionnaire), with values of the younger (18-60 years) and older (≥ 60 years) patients being compared using mixed linear models adjusted for baseline inequalities, and predictive effects of chronological age, age at PDA onset and duration of illness (DOI) being examined using multiple linear regressions. RESULTS: Attrition rates were 2/31 (6%) for the over-60s and 31/141 (22%) for the under-60s group (χ(2) = 3.43, df = 1, P = .06). Patients in both age groups improved on all outcome measures with moderate-to-large effect sizes. Avoidance behavior had improved significantly more in the 60+ group (F = 4.52, df = 1,134, P = .035), with agoraphobic cognitions showing no age-related differences. Baseline severity of agoraphobic avoidance and agoraphobic cognitions were the most salient predictors of outcome (range standardized betas 0.59 through 0.76, all P-values < .001). Apart from a superior reduction of agoraphobic avoidance in the 60+ participants (β = -0.30, P = .037), chronological age was not related to outcome, while in the older patients higher chronological age, late-onset type and short DOI were linked to superior improvement of agoraphobic avoidance. CONCLUSIONS: CBT appears feasible for 60+ PDA-patients, yielding outcomes that are similar and sometimes even superior to those obtained in younger patients.

The recently published DSM-5 contains a number of changes pertinent to panic disorder and agoraphobia. These changes include separation of panic disorder and agoraphobia into separate diagnoses, the addition of criteria and guidelines for distinguishing agoraphobia from specific phobia, the addition of a 6-month duration requirement for agoraphobia, the addition of panic attacks as a specifier to any DSM-5 diagnosis, changes to descriptors of panic attack types, as well as various changes to the descriptive text. It is crucial that clinicians and researchers working with individuals presenting with panic attacks and panic-like symptoms understand these changes. The purpose of the current paper is to provide a summary of the main changes, to critique the changes in the context of available empirical evidence, and to highlight clinical implications and potential impact on mental health service utilization. Several of the changes have the potential to improve access to evidence-based treatment; yet, although certain changes appear justified in that they were based on converging evidence from different empirical sources, other changes appear questionable, at least based on the information presented in the DSM-5 text and related publications. Ongoing research of DSM-5 panic disorder and agoraphobia as well as application of the new diagnostic criteria in clinical contexts is needed to further inform the strengths and limitations of DSM-5 conceptualizations of panic disorder and agoraphobia.

BACKGROUND: Bereavement following disasters is a devastating experience for family members. The aim of this study was to examine the long-term mental health effects of losing a loved one in a natural disaster. METHODS: Ninety-four Norwegians aged 18-80 years who lost close family members in the 2004 Southeast Asian tsunami were evaluated 2 and 6 years after the disaster. The participants were either staying in an affected area at the time of the disaster (i.e., directly exposed) or not (i.e., not directly exposed). The prevalence of psychiatric disorders was assessed by the MINI International Neuropsychiatric Interview (M.I.N.I). Prolonged grief disorder (PGD) was self-reported using the Inventory of Complicated Grief (ICG), and functional impairment was self-reported using the Work and Social Adjustment Scale (WSAS). RESULTS: We did not identify a significant decrease in the prevalence of PGD, posttraumatic stress disorder (PTSD), or major depressive disorder (MDD) from 2 to 6 years. Approximately, one-third of the bereaved (36%) had a psychiatric disorder 6 years after the tsunami. The most common disorder was PGD (12%) followed by general anxiety disorder (GAD, 11%), agoraphobia (11%), and MDD (10%). The prevalence of PTSD and MDD was higher among family members who were directly exposed to the disaster compared to those who were not (21 vs. 0%, and 25 vs. 3%). PGD was associated with functional impairment independent of other disorders. CONCLUSIONS: Loss of a close family member in a natural disaster can have a substantial adverse long-term effect on mental health and everyday functioning. Language: en

Background We examined the adequacy of pharmacotherapy and psychotherapy received by primary care patients with anxiety disorders over up to 5 years of follow-up. Method Five hundred thirty-four primary care patients at 15 US sites, who screened positive for anxiety symptoms, were assessed for anxiety disorders. Those meeting anxiety disorder criteria were offered participation and interviewed again at six and 12 months postintake, and yearly thereafter for up to 5 years. We utilized existing definitions of appropriate pharmacotherapy and created definitions of potentially adequate psychotherapy/cognitive-behavioral therapy (CBT). Results At intake, of 534 primary care participants with anxiety disorders, 19% reported receiving appropriate pharmacotherapy and 14% potentially adequate CBT. Overall, 28% of participants reported receiving potentially adequate anxiety treatment, whether pharmacotherapy, psychotherapy, or both. Over up to five years of follow-up, appropriate pharmacotherapy was received by 60% and potentially adequate CBT by 36% of the sample. Examined together, 69% of participants received any potentially adequate treatment during the follow-up period. Over the course of follow-up, primary care patients with MDD, panic disorder with agoraphobia, and with medicaid/medicare were more likely to receive appropriate anxiety treatment. Ethnic minority members were less likely to receive potentially adequate care. Conclusions Potentially adequate anxiety treatment was rarely received by primary care patients with anxiety disorders at intake. Encouragingly, rates improved over the course of the study. However, potentially adequate CBT remained much less utilized than pharmacotherapy and racial-ethnic minority members were less likely to received care, suggesting much room for improved dissemination of quality treatment.

BACKGROUND: Research suggests that suicidal behavior in individuals with anxiety disorders is attributable to cooccurring risk factors, such as depression. We argue that these conclusions are founded primarily in statistical adjustments that may obscure independent associations. We explored independent associations between specific anxiety disorders and suicide attempts and ideation by means of propensity score matching, a process that simulates a case-control study by creating matched groups that differ in group status (e.g., diagnosis of a specific anxiety disorder) but that are statistically equivalent on observed covariates. METHODS: We made use of the National Comorbidity Survey Replication (NCS-R) and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), which include a total of 43,935 adults. Diagnoses included agoraphobia without panic disorder, generalized anxiety disorder, panic disorder with or without agoraphobia, posttraumatic stress disorder, social anxiety disorder, and specific phobia. RESULTS: Each anxiety disorder was (95% confidence intervals) associated with increased odds of lifetime suicide attempts (odds ratios 3.57-6.64 [NCS-R], 3.03-7.00 [NESARC]) and suicidal ideation (odds ratios 2.62-4.87 [NCS-R], 3.34-10.57 [NESARC]). Odds ratios for each disorder remained statistically significant after matching on diagnostic status of dysthymia, major depressive disorder, alcohol abuse/dependence, substance abuse/dependence, bipolar disorder I, bipolar disorder II, all other anxiety disorders, and on sociodemographic variables. CONCLUSIONS: This is the first report to present evidence that each anxiety disorder is associated with suicide ideation and suicide attempts beyond the effects of cooccurring mental disorders. These findings warrant consideration in assessment, intervention, and related policies. Language: en

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are highly prevalent, disabling conditions associated with considerable personal and societal burden.(1) Because MDD and GAD have high symptom overlap(2) and often co-occur,(3) there is considerable controversy regarding their separation as distinct diagnostic entities. Some studies and meta-analyses have suggested that MDD and several anxiety disorders have a modest familial aggregation and moderate levels of cross heritability,(4) but other studies have found mixed evidence for shared familial risk.(5) Other studies have found distinguishable patterns of comorbidity between GAD and MDD,(6) although whether co-occurrence of MDD and GAD has any influence on these differences is unknown. Several twin studies have also examined the relationship between MDD and GAD in large population samples.(7) The Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (VATSPSUD) found that the correlation for environmental risk factors between MDD and GAD was 0.51, indicating that environmental risk factors for these disorders are moderately correlated. The VATSPSUD estimated the genetic correlation between MDD and GAD to be 1, indicating a very strong relationship between the genetic risk factors for both disorders.(7) Data from the Australian and Dutch Twins and Siblings Study also suggest considerable overlap in genetic risk factors for GAD and MDD,(8) and data from the Swedish Twin Registry(9) indicate that GAD and MDD share the same genetic factors but their environmental determinants are mostly distinct. Three large prospective epidemiological studies have also indicated that the developmental risk factors for GAD and MDD do not fully overlap,(10-12) suggesting that despite their similarities, the etiological pathways of these two disorders may differ. Application of latent variable techniques to three large community surveys in which psychiatric diagnoses were used as indicators have suggested that MDD and GAD may be part of an underlying factor named “anxious misery”,(13-16) but other studies have found divergent results.(17) In addition, a recent meta-analysis of the relationship between anxiety sensitivity and internalizing disorders found that anxiety sensitivity is more strongly correlated with agoraphobia, GAD and posttraumatic stress than with depression, raising new questions regarding the relationship between GAD and MDD.(18) The present study seeks to build on existing knowledge by examining data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large, nationally representative sample of US adults. The specific goals of our study were: 1) to compare the sociodemographic characteristics and comorbidity patterns of individuals with GAD, MDD, and those with both disorders (GAD-MDD); and, 2) to determine the factor structure of the individual DSM-IV criteria for GAD and MDD.

In this review, the role of hypnosis and related psychotherapeutic techniques are discussed in relation to the anxiety disorders. In particular, anxiety is addressed as a special form of mind/body problem involving reverberating interaction between mental and physical distress. The history of hypnosis as a therapeutic discipline is reviewed, after which neurobiological evidence of the effect of hypnosis on modulation of perception in the brain. Specific brain regions involved in hypnosis are reviewed, notably the dorsal anterior cingulate gyrus and the dorsolateral prefrontal cortex. The importance of hypnotizability as a trait, stable variability in hypnotic responsiveness, is discussed. Analogies between the hypnotic state and dissociative reactions to trauma are presented, and the uses of hypnosis in treating posttraumatic stress disorder, stressful situations, and phobias as well as outcome data are reviewed. Effects of hypnosis on control of somatic processes are discussed, and then effects of psychosocial support involving Supportive-Expressive Group Therapy and hypnosis on survival time for cancer patients are evaluated. The evidence indicates an important role for hypnosis in managing anxiety disorders and anxiety related to medical illness.

Background Dimensional assessments are planned to be included as supplements to categorical diagnoses in DSM-V. The aim of this study was to examine the unidimensionality, reliability, validity, and clinical sensitivity of brief self-rated scales for specific anxiety disorders in an unselected German sample of consecutive attendees to a psychological clinic. These scales use a common template to assess core constructs of fear and anxiety. Methods Dimensional scales for social anxiety disorder, specific phobia, agoraphobia, panic disorder, and generalized anxiety disorder were administered along with established scales to 102 adults seeking treatment for mental health problems at a German university outpatient clinic for psychotherapy. The computer-assisted clinical version of the Munich-Composite International Diagnostic Interview was used to assess mental disorders according to DSM-IV criteria. Dimensionality and scale reliability were examined using confirmatory factor analyses. Convergent and discriminant validity were examined by testing differences in the size of correlations between each dimensional anxiety scale and each of the previously validated scales. Each dimensional scale's ability to correctly differentiate between individuals with versus without an anxiety diagnosis was examined via the area under the curve. Results Analyses revealed unidimensionality for each scale, high reliability, and convergent and discriminant validity. Classification performance was good to excellent for all scales except for specific phobia. Conclusions The application of the dimensional anxiety scales may be an effective way to screen for specific anxiety disorders and to supplement categorical diagnoses in DSM-V, although further evaluation and refinement of the scales (particularly the specific phobia scale) is needed.

Background Controversy surrounds the question of whether agoraphobia (AG) exists as an independent diagnostic entity apart from panic. In favor of this position, AG without panic disorder (PD) in parents was found being unrelated to offsprings’ risk for AG or PD, albeit it may enhance the familial transmission of PD (Nocon et al., Depress Anxiety 2008;25:422–434). However, a recent behavioral genetic analysis (Mosing et al., Depress Anxiety 2009;26:1004–1011) found an increased risk for both PD and AG in siblings of those with AG without PD, casting doubt on whether AG exists independently of PD. Convincing evidence for either position notably requires considering also other anxiety disorders to establish the position of AG relative to the panic/anxiety spectrum. Methods Familial transmission of panic attacks (PAs), PD, and AG was examined in a 10-year prospective-longitudinal community study of 3,021 adolescents and young adults including completed direct and indirect information on parental psychopathology. Standardized diagnostic assessments using the Munich-Composite International Diagnostic Interview allowed generating exclusive diagnostic groups independent from diagnostic hierarchy rules. Results Parental PD without AG was associated with an increased risk for PA and PD+AG, but not for PD without AG or AG without PD in offspring. Parental AG without PD was unrelated to the offsprings’ risk for PA, exclusive PD or AG, or PD+AG. Findings were largely unaffected by adjustment for other offspring or parental anxiety disorders. Conclusions Findings provide further evidence for the independence of AG apart from the PD spectrum.

Guided by the diagnostic nosology, anxiety patients are expected to show defensive hyperarousal during affective challenge, irrespective of the principal phenotype. In the current study, patients representing the whole spectrum of anxiety disorders (i.e., specific phobia, social phobia, panic disorder with or without agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder(PTSD)), and healthy community control participants, completed an imagery-based fear elicitation paradigm paralleling conventional intervention techniques. Participants imagined threatening and neutral narratives as physiological responses were recorded. Clear evidence emerged for exaggerated reactivity to clinically relevant imagery—most pronounced in startle reflex responding. However, defensive propensity varied across principal anxiety disorders. Disorders characterized by focal fear and impairment (e.g., specific phobia) showed robust fear potentiation. Conversely, for disorders of long-enduring, pervasive apprehension and avoidance with broad anxiety and depression comorbidity (e.g., PTSD secondary to cumulative trauma, GAD), startle responses were paradoxically diminished to all aversive contents. Patients whose expressed symptom profiles were intermediate between focal fearfulness and broad anxious-misery in both severity and chronicity exhibited a still heightened but more generalized physiological propensity to respond defensively. Importantly, this defensive physiological gradient—the inverse of self-reported distress—was evident not only between but also within disorders. These results highlight that fear circuitry could be dysregulated in chronic, pervasive anxiety, and preliminary functional neuroimaging findings suggest that deficient amygdala recruitment could underlie attenuated reflex responding. In summary, adaptive defensive engagement during imagery may be compromised by long-term dysphoria and stress—a phenomenon with implications for prognosis and treatment planning. Depression and Anxiety 29:264–281, 2012.

High comorbidity between panic disorder with/without agoraphobia (PD/A) and irritable bowel syndrome (IBS) has been identified in the literature. These findings have resulted in the recent development of neurobiological models to explain their overlapping symptoms and related origins. This study was a preliminary investigation of the influence of cognitive behavioral therapy (CBT) for PD/A on PD/A patients with and without comorbid IBS.All patients completed a thorough intake assessment, brief waitlist period, and a 12-week CBT group for PD/A.The results demonstrated significant reductions in the symptoms of anxiety, depression, and overall impairment in both patient groups (ts2.3; Ps.05). In addition, PD/A patients with comorbid IBS also experienced reductions in the disability and distress associated with their gastrointestinal symptoms of IBS (ts1.9; Ps.07).Although additional research still is needed, these preliminary findings suggest that CBT for PD/A can be used to simultaneously treat comorbid symptoms of PD/A and IBS. Implications for the neurobiological models for these comorbid conditions were discussed.

Background: A history of separation anxiety disorder (SAD) is frequently reported by patients with obsessive–compulsive disorder (OCD). The purpose of this study was to determine if there are clinical differences between OCD-affected individuals with, versus without, a history of SAD. Methods: Using data collected during the OCD Collaborative Genetic Study, we studied 470 adult OCD participants; 80 had a history of SAD, whereas 390 did not. These two groups were compared as to onset and severity of OCD, lifetime prevalence of Axis I disorders, and number of personality disorder traits. Results: OCD participants with a history of SAD were significantly younger than the non-SAD group (mean, 34.2 versus 42.2 years; P

Background: Previous work has suggested that anxiety disorders are associated with suicide attempts. However, many studies have been limited by lack of accounting for factors that could influence this relationship, notably personality disorders. This study aims to examine the relationship between anxiety disorders and suicide attempts, accounting for important comorbidities, in a large nationally representative sample. Methods: Data came from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2. Face-to-face interviews were conducted with 34,653 adults between 2004 and 2005 in the United States. The relationship between suicide attempts and anxiety disorders (panic disorder, agoraphobia, social phobia, specific phobia, generalized anxiety disorder, posttraumatic stress disorder (PTSD)) was explored using multivariate regression models controlling for sociodemographics, Axis I and Axis II disorders. Results: Among individuals reporting a lifetime history of suicide attempt, over 70% had an anxiety disorder. Even after adjusting for sociodemographic factors, Axis I and Axis II disorders, the presence of an anxiety disorder was significantly associated with having made a suicide attempt (AOR=1.70, 95% confidence interval (CI): 1.40-2.08). Panic disorder (AOR=1.31, 95% CI: 1.06-1.61) and PTSD (AOR=1.81, 95% CI: 1.45-2.26) were independently associated with suicide attempts in multivariate models. Comorbidity of personality disorders with panic disorder (AOR=5.76, 95% CI: 4.58-7.25) and with PTSD (AOR=6.90, 95% CI: 5.41-8.79) demonstrated much stronger associations with suicide attempts over either disorder alone. Conclusion: Anxiety disorders, especially panic disorder and PTSD, are independently associated with suicide attempts. Clinicians need to assess suicidal behavior among patients presenting with anxiety problems. Language: en

Background: Social Phobia (SP) is a prevalent disorder in primary-care settings. To date, few researchers have examined the natural course of SP in primary care. We examined the natural course and predictors of recovery in a large sample of primary-care patients. Methods: Data are obtained from the Primary Care Anxiety Project, a naturalistic, longitudinal study of anxiety disorders in primary-care patients. This report pertains to 182 patients with SP at intake. We examined intake demographic and clinical variables as predictors of recovery within the 5 years of follow-up. Results: The probability of recovery from SP during the 5-year follow-up period was .40. At intake, a longer duration of SP episode, comorbid Panic Disorder with Agoraphobia, and lower psychosocial functioning predicted lower rates of recovery. Conclusions: These findings highlight the chronicity of SP, as well as factors that may affect its naturalistic course. It is imperative that primary-care physicians and mental health specialists assess for and treat SP in their practices. Future research is warranted to further examine the effect of medical and psychiatric comorbidity on SP course. Depression and Anxiety, 2010. © 2010 Wiley-Liss, Inc.

Background: Both depression and anxiety have been implicated as influencing survival following an acute coronary syndrome (ACS). Studies evaluating the contribution of anxiety have produced varying results, perhaps reflecting the use of dimensional self-report measures of state anxiety and failure to control for co-morbid depression. We sought to assess the impact of anxiety on outcome in ACS patients using DSM-IV diagnoses, in addition to self-report measures, controlling for effects of concurrent depressive diagnosis as well as medical and socio-demographic variables. Methods: Some 489 patients hospitalized with an ACS were assessed for lifetime and current DSM-IV anxiety disorders using both Composite International Diagnostic Interview (CIDI) decisions and such decisions complemented by clinical judgments of impairment. Patients were re-interviewed over the next 12 months to assess cardiac outcome (ACS readmission and cardiac mortality). Results: Univariate analyses revealed a trend for those with a lifetime history of agoraphobia to experience poorer cardiac outcome and for those with a lifetime diagnosis of generalized anxiety disorder (GAD) to experience a superior cardiac outcome. After controlling for post-ACS depression and key medical and demographic covariates, agoraphobia was a significant predictor of poorer cardiac outcome while the trend for those with a history of GAD to experience a superior cardiac outcome remained. Conclusions: Any impact of “anxiety” on post-ACS outcome appears to be influenced by the clinical sub-type. The seemingly paradoxical finding that GAD might improve outcome may reflect “apprehensive worrying” being constructive, by improving self-management of the individual's cardiac problems. Depression and Anxiety, 2010. © 2009 Wiley-Liss, Inc.

The present review was conducted in order to evaluate the current diagnostic criteria for specific phobia (SP) in light of the empirical evidence gathered since DSM-IVand to propose changes to DSM-V where change is clearly and reliably indicated by the evidence. In response to questions put forth by the DSM-V Anxiety, OC Spectrum, Posttraumatic, and Dissociative Disorder Work Group, four primary areas were determined for this review: the accuracy and utility of the current SP type classification system, the validity of test anxiety as a type of SP, the boundary between agoraphobia and SP, and the reliability and utility of the diagnostic criteria for SP. Developmental issues are addressed within each area. Literature reviews examining academic findings published between 1994 and 2009 were carried out and the results are included herein. The review presents a number of options and preliminary recommendations to be considered for DSM-V. All of these recommendations should be considered tentative as they await the field trials and expert consensus necessary prior to their inclusion in the DSM-V. The present review also reveals a great need for future research in the area of SP and directions for such research is provided. Depression and Anxiety 27:148–167, 2010. r 2010 Wiley-Liss, Inc.

Contains fulltext : 90464.pdf (Publisher’s version ) (Closed access) Background: This study is aimed to evaluate the role of two vulnerability factors, health anxiety and fear of :Par in the prediction of the onset of panic disorder/agoraphobia (PDA) relative to a comparison anxiety disorder Methods: Young women, aged between 18 and 24 years, were investigated at baseline and, 17 months later using the Anxiety Disorders Interview Schedule-Lifetime and measures of health anxiety and fear of bodily sensations (subscale disease phobia of the Whiteley Index, and total score of the Body Sensations Questionnaire). First, 22 women with current PDA were compared to 81 women with current social phobia and 1,283 controls. Second, 24 women with an incidence of PDA were compared to 60 women with an incidence of social phobia and 1,036 controls. Results: Multiple logistic regression analyses adjusted for history of physical diseases, somatic symptoms, and other psychological disorders revealed that (a) fear of bodily sensations was elevated for women with PDA vs. controls as well as women with social phobia, and (b) health anxiety (and history of physical diseases) was elevated in women who developed PDA vs. controls and vs. women who developed social phobia. Conclusions: These results suggest that health anxiety, as well as history of physical diseases, may be specific vulnerability factors for the onset of PDA relative to social phobia. Whereas fear of bodily sensations was not found to be a risk factor for the onset of panic disorder/agoraphobia, it was a specific marker of existing PDA relative to social phobia. 8 p.

Background: The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) specifies that generalized anxiety disorder (GAD) should not be diagnosed if it occurs exclusively during an episode of a major depressive disorder (MDD) or another mood disorder. This hierarchy rule was intended to promote diagnostic parsimony, but may result in the loss of important clinical information. The goal of this study was to compare individuals with MDD, comorbid MDD and GAD, and GAD within the course of MDD at intake and 12-month follow-up on self-report measures, clinician ratings, and rates of comorbidity. Methods: Participants were divided into three diagnostic groups: MDD without GAD (n=124), comorbid MDD and GAD (n=59), and GAD within the course of MDD (n=166). All the participants completed a semi-structured clinical interview and self-report measures assessing psychopathology, temperament, and functional impairment. A subset of the total sample completed a follow-up assessment of 12 months postintake. Results: Individuals with comorbid MDD and GAD and GAD within the course of MDD reported more psychopathology, negative affect, and functional impairment at intake than individuals with MDD only. The presence of GAD at intake, however, did not differentially predict symptom severity, functional impairment, or the presence of comorbidity at 12-month follow-up. Conclusions: Cross-sectional findings indicate that individuals with GAD within the course of MDD experience levels of psychopathology, functional impairment, and comorbidity similar to those found in individuals with comorbid GAD and MDD. Preliminary longitudinal findings, however, suggest that the presence of GAD in patients with MDD does not have prognostic significance. Depression and Anxiety, 2009. © 2009 Wiley-Liss, Inc.

Background: The Multidimensional Anxiety Scale for Children (MASC) is a widely used self-report questionnaire for the assessment of anxiety symptoms in children and adolescents. Methods: This study used receiver operating characteristic analyses to investigate the predictive value of the MASC total and scale scores for DSM-IV anxiety diagnoses in a referred sample. Eight- to 18-year-olds (n=212) were assessed with the MASC and Anxiety Disorders Interview Schedule for Children (ADIS-C). Results: The MASC total score did not exceed the threshold for being judged as fair in predicting any ADIS-C/DSM-IV anxiety diagnosis. The Separation Anxiety scale and the Physical Symptoms scale predicted Panic Disorder (PAD) and Agoraphobia fairly accurately. The Social Anxiety scale predicted Social Phobia, and the Separation Anxiety scale predicted PAD to a moderate degree. The MASC scale Harm Avoidance did not predict any ADIS-C/DSM-IV diagnosis. Conclusions: These results suggest that the MASC may not be a valid screening instrument for DSM-IV diagnoses. Depression and Anxiety, 2008. © 2008 Wiley-Liss, Inc.

Two inter-related studies evaluated the measurement model and construct validity of body vigilance, as indexed by the body vigilance scale [BVS; Schmidt et al., 1997: J Consulting Clin Psychol 65:214–220]. Confirmatory factor analyses (CFA) and convergent, discriminant, and incremental tests of validity of body vigilance were conducted among separate nonclinical samples from the United States (US) (study 1) and Spain (study 2). In both the US and Spanish samples, poor fit for the four-item unidimensional measurement model of body vigilance was observed; good fit, however, was found for a unidimensional, three-item measurement model. Subsequent analyses demonstrated both theoretically predicted as well as a number of unexpected associations between body vigilance and a variety of theoretically relevant external criterion variables. Results are discussed in terms of their clinical implications for advancing assessment of body vigilance and theoretical implications for better understanding the nomological nature of the construct. Depression and Anxiety, 2008. Published 2007 Wiley-Liss, Inc.

To examine the familial liability of panic disorder (PD) and agoraphobia (AG) in a community sample, namely the effect of parental PD and AG on the offspring's risk to develop either or both conditions in adolescence or adulthood. A representative community sample of N=3,021 adolescents and young adults aged 14-24 years at baseline was followed up over a period of 10 years in up to four waves. Family information was assessed by either direct interviews with at least one parent or by using subjects' family history information at either wave (N=3,014). Diagnoses and selected symptoms were assessed in both, parents and subjects, by using a standardized diagnostic interview (DSM-IV M-CIDI) with its respective family history module. (1) Parental panic attacks (PA), PD, and AG were all shown to be associated with an increased risk of offspring to also develop PA, PD, and AG. (2) Associations of parental PD were present irrespective of parental AG, whereas parental AG without PD was not associated with an increased offspring risk. (3) Outcome risk was particularly elevated in offspring of parents with PD+AG. (4) Parental PD or AG was not associated with an earlier age of onset of any syndrome in the offspring. We confirmed and expanded previous results from clinical samples that comorbid PD and AG aggregate in families. AG without PD is not familial, but it might enhance the familial transmission of PD.

Recognition of facially expressed emotions is essential in social interaction. For patients with social phobia, general anxiety disorders, and comorbid anxiety, deficits in their emotion recognition and specific biases have already been reported. This is the first study to investigate facial emotion recognition patterns in patients with panic disorder [PD]. We assumed a general performance deficit in patients with PD. Exploratory analyses should have revealed recognition patterns and specific types of errors. Additionally, we checked the influence of depression and anxiety symptoms, per se, on recognition. A carefully selected group of 37 patients with PD without agoraphobia [DSM-IV 300.01] and no psychiatric comorbidity was compared to 43 controls matched for age and sex. We assessed emotion recognition with the FEEL Test [Facially Expressed Emotion Labeling], using faces displaying fear, anger, sadness, happiness, disgust, and anger. Recognition of emotions in patients with PD was significantly worse than that of controls, specifically, sadness and anger. They also showed a tendency to interpret nonanger emotions as anger. Interestingly, in patients with PD, depressive symptoms were more strongly related to emotion recognition than were anxiety symptoms, and recognition differences between patients and controls disappeared when we controlled for depression. This effect is discussed in the context of previous studies reporting emotion recognition deficits of depressed patients.

This investigation evaluated the association between physical inactivity and emotional vulnerability in panic disorder. Participants were 39 adults (69% females) with a primary diagnosis of panic disorder (with or without agoraphobia), recruited through the community. Consistent with prediction, current physical inactivity was significantly associated with greater levels of anxiety sensitivity and severity of panic disorder. Results are discussed in relation to the importance of better understanding the role of physical inactivity in panic disorder.

Our purpose in this study was to compare the prevalence and pattern of Axis I and II comorbidities between patients with and without nocturnal panic (NP) attacks. One hundred and sixteen subjects with panic disorder (PD; according to DSM-IV criteria) were included: We assessed Axis I and II comorbidities using the Structured Clinical Interview for DSM-IV Axis I and II disorders, respectively. Of the sample, 27.6% of subjects had recurrent nocturnal panic attacks (NP group). Subjects with NP did not differ from those without in any sociodemographic or clinical characteristics. In the sample (94 subjects), 81% had at least one lifetime comorbid Axis I disorder, without significant differences between subjects with and without nocturnal panic even when considering comorbidity rates for single disorders; a trend toward significance was found for anorexia nervosa and somatization disorder, which both were more frequent among subjects with NP. Concerning Axis II disorders, 49.1% of the sample (57 subjects) met the criteria for at least one personality disorder, without significant differences between patients with and without NP. No significant differences were detected in comorbidity rates for any single Axis II personality disorder. Personality might play a relevant role in influencing treatment approaches to PD, but it does not appear to be a differential focus of concern in patients with compared to those without NP.

Panic disorder (PD) is prevalent, impairing, under-recognized, and often mistreated. Previous surveys in Chinese communities indicate very low prevalence estimates and provide limited information about its clinical characteristics. A random telephone survey of the general population (age range, 15-60 years) in Hong Kong was conducted using a questionnaire that generated the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-based diagnosis of PD, its symptom profile, help-seeking behavior, and health visit expenditure. Of 3,004 interviews successfully completed, 3.89% of participants (n=117) met criteria of PD in the previous 6 months. Their demographic and clinical profile resembled that of their Western counterparts. Excessive physical investigations and under-treatment were common. Participants with subthreshold PD (14.9%; n=449) exhibited a similar but attenuated clinical profile. We conclude that PD may be more common in Chinese people than what previous epidemiological surveys suggest. The present study is limited by the lack of clinical reappraisal, examination of comorbidity, and a low overall response rate. Nonetheless, it suggests that telephone interviews may provide a cost-effective alternative to large-scale epidemiological surveys for communities with limited resources for mental health research and high unmet needs for treatment.

Dyspnea is a key symptom in panic attacks. This study investigated different types of dyspnea induced by the 35% CO2 challenge test given to patients with panic disorder (PD). The types of dyspnea provide room for possible conjectures on neurophysiological pathways involved in the experience of breathing discomfort in PD and in the panic-respiration connection. Factor analysis applied to the Dyspnea Questionnaire identified three main factors: breathing effort, sense of suffocation, and rapid breath. Factor scores for breathing effort and sense of suffocation significantly discriminated between patients who did and those who did not report CO2-induced panic attacks. Factor scores for breathing effort significantly discriminated between patients whose reaction resembled their unexpected panic attacks and those whose reaction did not. A dissociation between an increased central respiratory command and a decreased mechanical efficiency of the respiratory response in patients with PD may underlie the breathing effort factor during the CO2 challenge. The sense of suffocation factor was found to be linked to chemosensitivity. Although involved in CO2 reactivity, it may not be a central factor in unexpected panic attacks. Depression and Anxiety 00:000–000, 2004. © 2004 Wiley-Liss, Inc.

This study examined gender differences in anxiety-related personality traits in patients with panic disorder with or without agoraphobia (PD+/-AG). Outpatients (101 total) with SCID confirmed PD+/-AG completed the Anxiety Sensitivity Index (ASI), the Trait form of the State-Trait Anxiety Inventory (STAI-T), the NEO Personality Inventory Revised (NEO PI-R), and the Retrospective Self-Report of Inhibition (RSRI) as part of their assessment. Significant gender differences were not detected for the total ASI scores. Females scored significantly higher than males on the Physical Concerns subscale of the ASI, whereas males scored significantly higher than women on the Social Concerns subscale. Women scored higher than men on the Extraversion scale of the NEO PI-R as well as on certain subscales of this domain. Although a significant gender difference was not detected on the Neuroticism subscale, men scored higher on the angry hostility and depression facets of this trait. Significant gender differences were not found for the STAI-T or the RSRI. These findings suggest that gender differences exist among patients with PD+/-AG in the feared consequences of anxiety symptoms as well as in the personality characteristics of extraversion.

The Panic Disorder Severity Scale (PDSS) [Shear et al., 1997] is rapidly gaining world-wide acceptance as a standard global severity measure of panic disorder, however, its cross-cultural validity and reliability have not been reported yet. We developed the Japanese version of the PDSS and examined its factor structure, internal consistency and inter-rater reliability and concurrent validity among Japanese patients with panic disorder with or without agoraphobia. We also established rules of thumb for interpreting PDSS total scores, taking the Clinical Global Impression severity scale as the anchoring criterion. The identical one-factor structure of the PDSS was confirmed among the Japanese patients as among the United States patients. Both internal and inter-rater reliability was excellent (Cronbach's alpha was 0.86, and ANOVA ICCs were all above 0.90). Concurrent validity of the PDSS items with self-report questionnaires tapping similar or overlapping domains was satisfactory (Pearson correlation coefficients were mostly above 0.5). Using the anchor-based approach, the following interpretative guides are suggested: among those with established panic disorder diagnosis, PDSS total scores up to 10 correspond with "mild," those between 11 and 15 with "moderate," and those at or above 16 correspond with "severe" panic disorder. The present findings support the cross-cultural generalizability of panic disorder symptomatology and of the PDSS, in particular.

Experimental evidence suggests that panic disorder is characterized by abnormalities in the balance system function and that these abnormalities might be related to the severity of agoraphobic avoidance. Since the balance system can be modulated by the serotonergic system, we investigated the effect of a 6-week treatment with citalopram on the balance system function in patients with panic disorder. Fifteen patients with panic disorder with/without agoraphobia underwent static posturography on days 0 and 42. Static posturography and clinical assessments were carried out by different investigators who were blind to each other. Static posturography showed high percentages of abnormal scores. Patients with no or low agoraphobic avoidance showed less abnormal posturographic measures than those with moderate to severe agoraphobia. After 6 weeks of treatment with citalopram there was a significant decrease of four out of six posturography measures in eyes-closed and neck extension conditions, whereas no significant effect was found in the eyes-open condition. This is the first report that suggests that the modulation of the serotonergic system can improve the balance system function in patients with panic disorder, particularly when visual information is lacking. In addition, our findings confirm the observation that many patients with panic disorder have abnormalities in their balance system function, supporting the idea that these abnormalities are mainly related to agoraphobic avoidance. (C) 2003 Wiley-Liss, Inc.

We investigated the prevalence of anxiety disorders in a sample of individuals with chronic schizophrenia, controlling for anxiety symptoms that may be related to delusions and hallucinations, and the possible differences in clinical variables between the groups. Individuals with a diagnosis of schizophrenia and able to give informed consent were recruited from the community. The Mini International Neuropsychiatric Interview (MINI) was administered to both confirm the DSM-IV diagnosis of schizophrenia and screen for comorbid anxiety disorders. If a comorbid anxiety disorder was found, its relation to the individual's delusions and hallucinations was examined. Clinical rating scales for schizophrenia were administered as well as rating scales for specific anxiety disorders where appropriate. Overall, anxiety disorders ranged from 0% [ for Post Traumatic Stress Disorder (PTSD)] to 26.7% [ for generalized anxiety disorder (GAD) and agoraphobia without panic] with lower rates when controlled for anxiety symptoms related to delusions and hallucinations. In investigating clinical variables, the cohort was initially divided into schizophrenics with no anxiety disorders and those with an anxiety disorder; with further analyses including schizophrenics with anxiety disorders related to delusions and hallucinations and those with anxiety disorders not related to delusions and hallucinations. The most consistent difference between all the groups was on the PANSS-G subscale. No significant differences were found on the remaining clinical variables. Comorbid anxiety disorders in schizophrenia can be related to the individual's delusions and hallucinations, though anxiety disorders can occur exclusive of these positive symptoms. Clinicians must be aware that this comorbidity exists in order to optimize an individual's treatment.

The match-mismatch model of panic states that panic disorder patients tend to overestimate the probability of panic prior to engaging in a fear-provoking situation. Furthermore, patients are expected to become more accurate in predicting panic over subsequent occasions of exposure. We tested the model with naturally occurring panic attacks. Patients rated the probability of a panic attack in the morning, and these ratings were compared to the actual occurrence of panic that day. Ratings were collected daily in a baseline period before treatment, during treatment, and again for 2 weeks after treatment. The results confirmed that panic disorder patients tend to overpredict the likelihood of panic. However, patients did not become more accurate in their predictions over time. In fact, overprediction bias increased because expectancy of panic remained stable, in spite of the decline of the frequency of panic from pre- to post-test. Thus, over a short course of therapy panic patients tend to persist in overestimating the chance that panic may occur. At baseline, expectancy of panic and the tendency to overpredict were not associated with other aspects of the symptomatology. Neither expectancy nor overprediction bias was predictive of treatment outcome. Finally, improvement in treatment was not associated with a decreased expectancy of panic.

To determine the generalizability and population-based correlates of clinically derived panic attack subtypes among adults in the community. Data were drawn from the National Comorbidity Survey (n = 8,098), a representative sample of adults of age 18-54 years in the United States. Sociodemographic characteristics, psychiatric comorbidity, and panic symptomotology associated with three clinically derived panic subtypes (early-onset, agoraphobia, and dyspnea) were compared using two-way ANOVA and multivariate logistic regression analyses. Among those with panic attacks in the community, 51.2% had early-onset, 32.6% had agoraphobia, and 64.4% had dysthymia. Significant differences in sociodemographic characteristics, psychiatric comorbidity, and panic symptomotology emerged between the three groups. Early-onset panic was associated with significantly increased likelihood of bipolar disorder and substance dependence but was not distinguished from the other two subtypes by panic symptoms. Panic attack with agoraphobia was associated with significantly higher odds of several comorbid anxiety disorders, and panic with dyspnea was more common among married females with less education and high levels of comorbid alcohol and depressive disorders. These data suggest that clinically derived panic subtypes are generalizable and may be associated with several unique sociodemographic and psychiatric correlates in the general population. Observed differences between these subtypes may influence results from clinical samples.