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BACKGROUND: Co-morbidity within anxiety disorders, and between anxiety disorders and depression, is common. According to the theory of Gray and McNaughton, this co-morbidity is caused by recursive interconnections linking the brain regions involved in fear, anxiety and panic and by heritable personality traits such as neuroticism. In other words, co-morbidity can be explained by one disorder being an epiphenomenon of the other and by a partly shared genetic etiology. The aim of this paper is to evaluate the theory of Gray and McNaughton using the results of genetic epidemiological studies. METHOD: Twenty-three twin studies and 12 family studies on co-morbidity are reviewed. To compare the outcomes systematically, genetic and environmental correlations between disorders are calculated for the twin studies and the results from the family studies are summarized according to the method of Klein and Riso. RESULTS: Twin studies show that co-morbidity within anxiety disorders and between anxiety disorders and depression is explained by a shared genetic vulnerability for both disorders. Some family studies support this conclusion, but others suggest that co-morbidity is due to one disorder being an epiphenomenon of the other. CONCLUSIONS: Discrepancies between the twin and family studies seem partly due to differences in used methodology. The theory of Gray and McNaughton that neuroticism is a shared risk factor for anxiety and depression is supported. Further research should reveal the role of recursive interconnections linking brain regions. A model is proposed to simultaneously investigate the influence of neuroticism and recursive interconnections on co-morbidity. [ABSTRACT FROM AUTHOR]

Background. Dissociation, defined as a disruption in usually integrated mental functions, is found not only in DSM-IV dissociative disorders, but also in post-traumatic stress disorder and eating disorders. Dissociative phenomena are also common in the general population, and may reflect a constitutionally determined cognitive style rather than a pathological trait acquired through experiencing adverse life events. In pathological dissociation, evidence has been presented for episodic memory dysfunction. In contrast, in high-dissociative subjects increased performance has been found for episodic memory and dual task performance. These findings have been linked to changes in working memory capacity.Method. In the present study, the authors sought to extend these findings by using functional magnetic resonance imaging during performance of two parametric working memory tasks. We tested 21 healthy low- and high-dissociative participants.Results. High-dissociative participants performed slightly better during both tasks. Imaging data showed that both groups activated similar networks for both tasks, i.e. (bilateral) dorsolateral (DL) and ventrolateral prefrontal cortex (PFC), parietal cortex, and supplementary motor area. GroupOEtask interactions were found in the high-dissociative group in L DLPFC and L parietal cortex; in the low-dissociative group in R fusiform gyrus. The differences in the high-dissociative group were independent from performance differences, implying that high-dissociative subjects generally recruit this network to a greater extent.Conclusions. These results confirm earlier findings using a verbal WM task in high-dissociative participants, and are compatible with the conceptualization of non-pathological dissociation as an information-processing style, characterized by distinct attentional and mnemonic abilities. [ABSTRACT FROM AUTHOR]

Background: Little research has been done on the uniqueness of risk profiles for depression and anxiety in late life.Aims: Delineating risk factors for the decline of mental health in older persons, comparing risk profiles for developing symptoms of pure depression, pure anxiety and both anxiety and depression in a prospective design.Method: Self-report data on depression and anxiety were collected from community-dwelling older respondents (> or = 55 years) on two occasions, 3 years apart. Data from emotionally healthy respondents (n=1810) were used to investigate the effects of long-standing vulnerability factors and stressful life events.Results: After 3 years 9% of the subjects had scored beyond the thresholds for symptoms. Vulnerability for depression and anxiety was quite similar, but life events differed: onset of depression was predicted by death of a partner or other relatives; onset of anxiety was best predicted by having a partner who developed a major illness. No support for moderator effects between vulnerability factors and stress was found; the effects were purely additive.Conclusions: Depression and anxiety have many risk factors in common, but specific risk factors also were found, especially in subjects developing both depression and anxiety. [ABSTRACT FROM AUTHOR]

Sixty agoraphobics were treated by behavioural therapy (self-exposure in vivo) either with their partner involved in all aspects of treatment or without their partner. The two treatment formats were about equally effective. Behavioural treatment directed at the agoraphobia resulted in improvement irrespective of marital quality and partner involvement in the therapy. The effects of treatment led neither to a deterioration of the marriage nor to adjustment problems in the partner. Avoidance behaviour, intropunitivity and overprotection were found to predict treatment response. The partners of agoraphobics were not found to have psychological problems themselves. [ABSTRACT FROM AUTHOR]

A response by E. R. S. Nijenhuis and R. van Dyck to a commentary about their article "The development and the psychometric characteristics of the Somatoform Dissociation Questionnaire."

A letter to the editor is presented about dissociative pathology that discriminates between bipolar mood disorder and dissociative disorder.

Background: It is unclear whether altered hypothalamic-pituitary-adrenal (HPA) axis regulation, which frequently accompanies depression and anxiety disorders, represents a trait rather than a state factor., Aims: To examine whether HPA axis dysregulation represents a biological vulnerability for these disorders, we compared cortisol levels in unaffected people with and without a parental history of depressive or anxiety disorders. We additionally examined whether possible HPA axis dysregulations resemble those observed in participants with depression or anxiety disorders., Method: Data were from the Netherlands Study of Depression and Anxiety. Within the participants without a lifetime diagnoses of depression or anxiety disorders, three groups were distinguished: 180 people without parental history, 114 with self-reported parental history and 74 with CIDI-diagnosed parental history. These groups were additionally compared with people with major depressive disorder or panic disorder with agoraphobia (n = 1262). Salivary cortisol samples were obtained upon awakening, and 30, 45 and 60 min later., Results: As compared with unaffected participants without parental history, unaffected individuals with diagnosed parental history of depression or anxiety showed a significantly higher cortisol awakening curve (effect size (d) = 0.50), which was similar to that observed in the participants with depression or anxiety disorders. Unaffected people with self-reported parental history did not differ in awakening cortisol levels from unaffected people without parental history., Conclusions: Unaffected individuals with parental history of depression or anxiety showed a higher cortisol awakening curve, similar to that of the participants with depression or anxiety disorders. This suggests that a higher cortisol awakening curve reflects a trait marker, indicating an underlying biological vulnerability for the development of depressive and anxiety disorders.

Background: Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders., Methods: Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established., Results: Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants., Conclusions: Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Background: Schema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial., Aims: To assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder., Method: Costs were assessed by interview. Health-related quality of life was measured using EQ-5D. Outcomes were costs per recovered patient (recovery assessed with the Borderline Personality Disorder Severity Index) and costs per quality-adjusted life-year (QALY)., Results: Mean 4-year bootstrapped costs were euro37 826 for SFT and euro46 795 for TFP (95% uncertainty interval for difference -21 775 to 3546); QALYs were 2.15 for SFT and 2.27 for TFP (95% UI -0.51 to 0.28). The percentages of patients who recovered were 52% and 29% respectively. The SFT intervention was less costly and more effective than TFP (dominant), for recovery; it saved euro90 457 for one QALY loss., Conclusions: Despite the initial slight disadvantage in QALYs, there is a high probability that compared with TFP, SFT is a cost-effective treatment for borderline personality disorder.

Background: Memory functioning has been highlighted as a central issue in pathological dissociation. In non-pathological dissociation, evidence for enhanced working memory has been found, together with greater task-load related activity. So far, no imaging studies have investigated working memory in dissociative patients., Method: To assess working memory in dissociative patients functional magnetic resonance imaging was used during performance of a parametric, verbal working-memory task in patients with a dissociative disorder (n=16) and healthy controls (n=16)., Results: Imaging data showed that both groups activated brain regions typically involved in working memory, i.e. anterior, dorsolateral and ventrolateral prefrontal cortex (PFC), and parietal cortex. Dissociative patients showed more activation in these areas, particularly in the left anterior PFC, dorsolateral PFC and parietal cortex. In line with these findings, patients made fewer errors with increasing task load compared to controls, despite the fact that they felt more anxious and less concentrated during task performance., Conclusions: These results extend findings in non-pathological high dissociative individuals, suggesting that trait dissociation is associated with enhanced working-memory capacities. This may distinguish dissociative patients from patients with post-traumatic stress disorder, who are generally characterized by impaired working memory.

The aim of this study was to investigate familial influences and their dependence on sex for panic disorder and/or agoraphobia, social phobia, generalized anxiety disorder and major depression. Data from Australian (N = 2287) and Dutch (N = 1185) twins and siblings who were selected for a linkage study and participated in clinical interviews to obtain lifetime Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) diagnoses were used. In a liability model, tetrachoric correlations were estimated in sibling pairs and sex differences between sibling correlations were tested. For each diagnosis, the sibling correlations could be constrained to be equal across the Australian and Dutch samples. With the exception of panic disorder and/or agoraphobia, all sibling correlations were the same for brother, sister and opposite-sex sibling pairs and were around .20. For panic disorder and/or agoraphobia, the correlation was .23 in brother and sister pairs, but absent in opposite-sex sibling pairs. From these results it can be concluded that upper heritability estimates, based on twice the correlations in the sibling pairs, vary between 36% (major depression) and 50% (social phobia). Furthermore, different genetic risk factors appear to contribute to the vulnerability for panic disorder and/or agoraphobia in men and women. No other sex differences were found.

Background: Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources., Methods: Data of a large community-based random probability sample (N = 659) of older subjects (55-85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables., Results: Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low., Conclusions: Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.

The research on anxiety disorders of the department of psychiatry of the Vrije Universiteit is briefly reviewed. Studies have included comparisons between pharmacotherapy and cognitive behaviour therapy and combination treatments of panic disorder and of obsessive-compulsive disorder. Also, the hyperventilation model of panic disorder could be rejected as a result of an ambulatory monitoring study. Provocation studies with adrenalin in panic disorder have shown less support for a psychological model of panic than expected. Recommendations for future research include studies on anxiety in the very young and in the elderly, studies on comorbidity in anxiety, especially with alcoholism and depression and the development of treatment manuals for general practice. The issue is raised whether investing in neuroimaging studies will critically advance our knowledge in the near future.