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The efficacy of cognitive behavioral therapy (CBT) in the acute-phase treatment of panic disorder is well established. However, there are data to show CBT may not always be able to prevent recurrence after treatment. The central cognitive component of panic disorder psychopathology is thought to be hypersensitivity to physical sensations. The present study reports that some aspects of interoceptive hypersensitivity, gastrointestinal fears in particular, were predictive of the course of panic disorder after end of CBT. Clinically it is suggested that new interoceptive tasks related to gastrointestinal fears are needed.

Safety behavior (SB) and self-focused attention (SFA) have been posited as important maintenance factors in the cognitive model of social anxiety disorder (SAD). The present study reports the results of experiments to drop SB and SFA among clinically diagnosed patients with SAD employing their own idiosyncratic anxiety-provoking situations. The ratings for observable anxiety, belief in feared outcome and overall performance were better for role plays without SB and SFA than for role plays with them. The degree of drop in SFA predicted drop in observable anxiety and belief in feared outcome. Dropping SB and SFA, however, was unable to completely correct the cognitive distortion because the subjective ratings were still significantly worse than the objective ratings.

Conviction subtype Taijin-Kyofu (c-TK) is a subgroup of mental disorder characterized by conviction and strong fear of offending others in social situations. Although the concept of c-TK overlaps with that of social anxiety disorder (SAD), patients with c-TK often may not be diagnosed as such within the current Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria. We propose the Nagoya-Osaka criteria to amend this situation. This study examined the cross-cultural interrater reliability of the proposed criteria. Eighteen case vignettes of patients with a variety of complaints focused around social anxieties were collected from 6 different countries, and diagnosed by 13 independent raters from various nationalities according to the original DSM-IV and the expanded criteria. The average agreement ratio for the most frequent diagnostic category in each case was 61.5% with DSM-IV and 87.6% with the modified DSM-IV with Nagoya-Osaka criteria (p < 0.001). These findings indicate that the Nagoya-Osaka criteria for SAD can improve interrater reliability of SAD.

Objectives Electroconvulsive therapy (ECT) has been associated with memory and neuropsychological changes, but which features of ECT are associated with those changes have not been well investigated. The aim of this hypothesis-generation study was to examine correlations between ictal electroencephalographic (EEG) characteristics and cognitive side effects after ECT. Methods Eight patients with major depressive disorder were examined with the Wechsler Memory Scale-Revised (WMS-R), the Stroop test, the Trail Making Test, and verbal fluency before and after ECT treatment. Seven ictal EEG measurements (eg, slow-wave phase amplitude, postictal suppression) were manually rated by 3 independent psychiatrists. The correlations between ictal EEG measurements, changes in WMS-R subset scores, and non-memory-related neuropsychological assessments were examined with Spearman rank correlation. Results Verbal memory, general memory, attention/concentration, delayed memory of WMS-R subset scores, and the Stroop test scores improved significantly after ECT treatment. Postictal suppression and slow-wave amplitude correlated positively with delayed memory and visual/verbal discrepancy score. Slow-wave amplitude correlated negatively with letter fluency. The longer the polyspike wave duration, the higher the attention/concentration test results. Conclusions Certain ictal EEG measurements were associated with changes in several neuropsychological test results that had improved 2 weeks after the final ECT treatment. A hypothesis-testing study with a larger sample is needed to verify the relationships between EEG measurements and neuropsychological test performance.

Objective Oncology nurses are expected to play an important role in psychosocial care for cancer patients. The aim of this study was to examine whether a novel training program aimed at enhancing oncology nurses' ability to assess and manage common psychological problems in cancer patients would improve participants' self-reported confidence, knowledge, and attitudes regarding care of patients with common psychological problems (trial register: UMIN000008559). Methods Oncology nurses were assigned randomly to either the intervention group (N = 50) or the waiting list control group (N = 46). The intervention group received a 16-h program, the content of which focused on four psychological issues: normal reactions, clinically significant distress, suicidal thoughts, and delirium. Each session included a role-play exercise, group work, and didactic lecture regarding assessment and management of each problem. Primary outcomes were changes in self-reported confidence, knowledge, and attitudes toward the common psychological problems between pre-intervention and 3 months post-intervention. Secondary outcomes were job-related stress and burnout. Intervention acceptability to participants was also assessed. Results In the intervention group, confidence and knowledge but not attitudes were significantly improved relative to the control group. No significant intervention effects were found for job- related stress and burnout. A high percentage (98%) of participants considered the program useful in clinical practice. Conclusions This psycho-oncology training program improved oncology nurses' confidence and knowledge regarding care for patients with psychological problems. Copyright © 2015 John Wiley & Sons, Ltd.

Objective: To examine psychosocial predictors of successful pregnancy after recurrent spontaneous abortions (RSA). Method: We administered two waves of semi-structured interview and self-report questionnaire battery to a consecutive series of 46 couples who had had two RSAs (baseline before third pregnancy, and immediately after third pregnancy was ascertained), and followed them through their third pregnancy. Results: Of the 46 couples, four miscarried for karyotypal abnormalities and six without any known cause. When the latter six were compared with the remaining 36 women, they reported less social support satisfaction, a more stable attribution for the causes of past abortions, and more depressed mood in the preceding year. Taken altogether, this psychosocial model was able to predict 93% of the pregnancy outcomes correctly. Conclusion: Psychosocial variables (depression, attribution and social support) are robust predictors of the prospective pregnancy and suggest possible points of intervention in couples with RSA.

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.

We conducted a prospective study to determine whether systematic examinations and provision of explanation regarding the successful birth rates might improve mood or anxiety disorders among childless women with recurrent miscarriages. A total of 305 first-visit patients with a history of 2-12 miscarriages completed a first questionnaire battery, including: 'K6', a new screening instrument for mood and anxiety disorders, the 'Symptom Checklist-90 Revised' (SCL-90-R) and the 'Emotional Impact' questionnaire. Of these, 170 patients who underwent routine examinations and received an explanation about successful live birth rates responded to the second questionnaire. A total of 15.4% of the patients were estimated to suffer from diagnosable depression or anxiety disorders. Patients with high scores on K6 also showed elevated scores on all the subscales of SCL-90-R, including depression and anxiety. The K6 of patients with translocation was significantly higher than that of patients with antiphospholipid antibodies. The K6 and depression scores in the 2nd questionnaire survey were significantly lower than those in the 1st survey in the 170 patients. Improvement in depression was found in patients who underwent routine examination and received an explanation.

While randomized evidence appears to have established efficacy of cognitive-behavioral therapy (CBT) and some pharmacotherapy for social anxiety disorder (SAD), their real-world effectiveness has been called into question by long-term naturalistic cohort studies of patients with SAD as they show very low probability of recovery and sustained social dysfunctions despite some drug and psychological therapies.The present study examines the effectiveness of group CBT for SAD in real-world settings (n=62) by examining the course of patients' symptomatology and social functions through approximately 6 months on the waiting list, through 6 months receiving the manualized group CBT intervention consisting of 16 2-h sessions, and for 12 months after the treatment.We found: (i) that the patients with SAD changed little or possibly worsened through the 6 months on the waiting list, although two in three of them were on antidepressants, benzodiazepines or both; (ii) that both their symptomatology and social function improved significantly and substantively through the group CBT; and (iii) that this improvement was maintained through the 3- and 12-month follow ups.We can implement and must disseminate evidence-based, effective CBT for more patients with SAD to lessen their suffering and stop the perpetuation of their symptoms.

Brain metabolism activated studies have indicated associations between memory and the anterior cingulate cortex and hippocampus in patients with depression. The aim of the present study was therefore to investigate memory function, measured as performance on the Wechsler Memory Scale-Revised (WMS-R), and its relationship to brain perfusion using single-photon emission computed tomography (SPECT) at rest in patients with depression.The Hamilton Rating Scale for Depression (HAMD) and WMS-R were measured for 17 patients with depression by an independent clinical evaluation team. Voxel-based correlation analyses were performed with statistical parametric mapping at an extent threshold of 200 voxels. Associations were controlled for state and trait factors.WMS-R measurements of verbal, visual, and general memory were inversely correlated with brain perfusion in the right anterior cingulate cortex, left premotor cortices, and both regions, respectively. The HAMD directly correlated with brain perfusion in the right anterior cingulate cortex.Brain perfusion SPECT measurements of the anterior cingulate cortex at rest were associated with the severity of depression and immediate memory scores measured with the WMS-R.

In-situation safety behaviors play an important role in the maintenance of anxiety because they prevent patients from experiencing unambiguous disconfirmation of their unrealistic beliefs about feared catastrophes. Strategies for identifying particular safety behaviors, however, have not been sufficiently investigated. The aims of the present study were to (i) develop a comprehensive list of safety behaviors seen in panic disorder and to examine their frequency; and (ii) correlate the safety behaviors with panic attack symptoms, agoraphobic situations and treatment response.The subjects consisted of 46 consecutive patients who participated in group cognitive behavioral treatment (CBT) for panic disorder. All the patients completed a Safety Behavior List that was developed based on experiences with panic disorder patients.Carrying medications, distracting attention, carrying a plastic bottle, and drinking water were reported by more than half of the patients. The strongest correlations between panic symptoms and safety behaviors were found between symptoms of derealization and listening to music with headphones, paresthesia and pushing a cart while shopping, and nausea and squatting down. The strongest association between agoraphobic situations and safety behaviors was found between the fear of taking a bus or a train alone and moving around. Staying still predicted response to the CBT program, while concentrating on something predicted lack of response.An approximate guideline has been developed for identifying safety behaviors among patients with panic disorder and should help clinicians use CBT more effectively for these patients.

The present study aimed to examine how video feedback can affect perceived performance and anticipatory anxiety in various naturalistic social anxiety-provoking situations among clinical patients diagnosed with social anxiety disorder (SAD) and to examine predictors that might influence response to video feedback. Participants were 52 consecutive patients with DSM-IV SAD who participated in a group-based CBT program. Our results demonstrated that video feedback was associated with a decrease in the underestimation of own performance as well as the perception of feared outcomes. Moreover, anticipatory anxiety decreased after video feedback combined with peer feedback. Male sex, comorbidity with other anxiety disorders, and benzodiazepine prn, as well as patients' initial anxiety and avoidance were negative predictors of the effect of video feedback.

Aim: The aim of this paper is to report the outcomes and follow-up data of our cognitive behavioral therapy program for Japanese patients with panic disorder and to examine the baseline predictors of their outcomes. Methods: Seventy outpatients with panic disorder with or without agoraphobia were treated with manualized group cognitive behavioral therapy. Results: Fourteen patients (20%) did not complete the program. Among the completers, the average Panic Disorder Severity Scale score fell from 12.8 at baseline to 7.1 post-therapy (44.7% reduction). This effectiveness was sustained for 1 year. While controlling for the baseline severity, the duration of illness and the baseline social dysfunction emerged as significant predictors of the outcome. Conclusions: Our data suggest that group cognitive behavioral therapy for panic disorder can bring about as much symptom reduction among Japanese patients with panic disorder as among Western patients.

Background A number of studies have provided strong evidence for the use of cognitive behavior therapy (CBT) in the treatment of social anxiety disorder (SAD). However, all of the previous reports were from Europe and North America and it is unknown whether Western psychological therapies are effective for SAD in non-Western cultures. The present pilot study aimed to evaluate CBT program for SAD which was originally developed for Western patients, among Japanese patients. Methods Fifty-seven outpatients who participated in group CBT for SAD were evaluated using eight self-reported and one clinician-administered questionnaires to measure various aspects of SAD symptomatology at the beginning and at the end of the program. Pre- and post-treatment scores were compared and the magnitude of treatment effect was quantified as well based once on the intention-to-treat (ITT) and once among the completers only. We also examined baseline predictors of the CBT outcomes. Results Seven patients (12%) did not complete the program. For the ITT sample, the percentage of reduction was 20% to 30% and the pre to post treatment effect sizes ranged from 0.37 to 1.01. Among the completers, the respective figures were 20% to 33% and 0.41 to 1.19. We found no significant pretreatment predictor of the outcomes. Conclusion Group CBT for SAD is acceptable and can bring about a similar degree of symptom reduction among Japanese patients with SAD as among Western patients.

Background Cognitive model of panic disorder have proposed that panic attacks result from the catastrophic misinterpretation of certain bodily sensations. Cognitive-Behavioral Therapy (CBT) for panic disorder aims to change these catastrophic cognitions. CBT intervention successfully caused reduction of catastrophic cognitions and symptomatic improvement in the majority of cases. However there are some patients who fail to modify their catastrophic cognitions or rather experience an increase in them during CBT treatment. It is clinically and theoretically important to understand about cognitive sensitization of panic disorder during CBT sessions. The purpose of the present study is 1) to clarify the baseline characteristics of panic patients who would experience sensitization of their catastrophic cognitions through the CBT treatment, and 2) to examine the course of symptomatic changes for them. Methods Of ninety-five outpatients with panic disorder started the group CBT program for treatment of panic disorder, seventy-nine completer were classified as "cognitively sensitized (CS)" or "cognitive responding (CR)" or "no-responder" according to the difference of the Agoraphobic Cognitions Questionnaire score across treatment. We compared the CS and CR patients in terms of their baseline clinical characteristics. Then we assessed the symptomatic and functional changes for both groups. Results At the start of the CBT program, despite of the same degree of panic disorder severity, CS scored significantly lower on ACQ score than CR. CS also showed significantly lower score on anticipatory anxiety compared to CR. At the end of treatment CS showed significant improvement in severity of panic disorder, although the degree of improvement was smaller than that for CR. Then CS would progressively reduce their agoraphobic fear and avoidance, and would improve their functional impairment up to three month of follow-up. Conclusion Panic patients who would experience sensitization of their catastrophic cognitions through the CBT treatment could nonetheless gradually improve. They showed a relatively low level of catastrophic cognition and anticipatory anxiety before starting the CBT program. We might conclude that temporary sensitization of catastrophic cognition may be necessary before improvement especially among those with initially low catastrophic body sensation fears and that we need not be concerned too much with temporary increase in catastrophic cognition in the process of CBT for panic disorder.

Although a number of recent studies have shown that panic disorder is associated with deterioration in quality of life and social dysfunctions, details of these impairments and their correlates have not been well studied. The present study aims to examine which aspects of quality of life and social functioning were particularly impaired in patients with panic disorder and to search for their clinical correlates. Fifty patients with panic disorder with or without agoraphobia who participated in our group cognitive-behavioral treatment program were administered the Medical Outcomes Study Short-Form Health Survey and the Work, Home and Leisure Activities Scale. Their panic disorder symptomatology was assessed with the Panic Disorder Severity Scale and Fear Questionnaire. Compared with the population mean, the patients reported less than average quality of life in both physical and mental domains, especially in the latter domain. They also reported substantial social dysfunctions, especially in work and social leisure activities. Different aspects of patients' psychopathology were associated with these impairments. While agoraphobia appeared as a consistent predictor for most of the aspects examined, social phobia emerged as a strong predictor for mental quality of life and for work and social leisure functions. The findings suggest that we need to remain sensitive to different aspects of functional impairments of patients with panic disorder and that we may need to pay more attention to the role of social anxiety in their treatment.

Background There have been only a limited number of cross-cultural studies of social anxiety disorder (SAD), especially as diagnosed with modern operationalized diagnostic criteria and as measured with recently developed assessment instruments. We examined the symptomatological structure and clinical subtypes of patients with DSM-IV SAD among the Japanese clinical population. Methods We performed confirmatory and exploratory factor analyses of the joint Social Interaction Anxiety Scale and Social Phobia Scale [Mattick, R.P., Clarke, J.C., 1998. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav. Res. Ther. 36, 455–470.] from 149 psychiatric patients diagnosed with SAD. Based on the derived symptom factors, we further ran cluster analysis to identify patient subgroups. Results Factor analyses revealed three factors which were named “scrutiny fears”, “conversation fears” and “relationship fears”. The first two appeared common to Western clinical populations but the third appeared unique to the Japanese. Cluster analysis based on these three factor scores yielded three subgroups, which were externally validated and which overall corresponded with mild, moderate and pervasive subtypes of social phobia. Limitations Both factor analysis and cluster analysis employed in the present study are exploratory in nature. Further empirical examination in different settings and cultures is necessary to provide definitive answers. Conclusions It is suggested that we may need three symptom subscales and three subtypes in order to better account for cultural variations in the presentation of SAD.

Until now most of the research on social support has concentrated on general support in relationship to the whole group of people around each individual. In contrast, only a few studies have dealt with individual-specific support (i.e. social support from a particular individual relationship). The Quality of Relationship Inventory (QRI) is a recently developed questionnaire to measure individual-specific social support. We developed the Japanese version by means of back translation and ascertained its reliability and validity among the Japanese women who had had two recurrent spontaneous abortions without known organic etiologies. Factor analysis revealed that the Japanese QRI had a two-factor structure, representing supportive and conflictual aspects of a particular relationship (named Factor-S and Factor-C, respectively). Each factor showed satisfactory reliability with Cronbach's alphas of 0.95 and 0.89. When the QRI scores were compared with the scales from the Social Support Questionnaire, a measure of general social support, the Factor-C of the former with respect to the mother correlated negatively with the Social Support Satisfaction of the latter (r = - 0.40; 95% confidence interval (CI) - 0.64 to - 0.09). Childhood experiences with parents also showed expected correlations with the QRI: care received from the parent before age 16 years strongly predicted Factor-S with that parent (r = 0.50, 95% CI 0.21-0.71 in the case of the mother; r = 0.54, 95% CI 0.27-0.73 in the case of the father). Although we still need to examine the Japanese QRI with different populations, it appears to be a promising measure of individual-specific relationship for the Japanese population.

Background Social anxiety disorder (SAD) is one of the most common anxiety disorders. The efficacy of cognitive behaviour therapy (CBT) has been examined but to date its effects on Quality of Life (QoL) have not been appropriately evaluated especially in the long term. The study aimed to examine, in the long term, what aspects of Quality of Life (QoL) changed among social anxiety disorder (SAD) patients treated with group cognitive behaviour therapy (CBT) and what predictors at baseline were associated with QoL. Methods Outpatients diagnosed with SAD were enrolled into group CBT, and assessed at follow-ups for up to 12 months in a typical clinical setting. QoL was evaluated using the Short Form 36. Various aspects of SAD symptomatology were also assessed. Each of the QoL domains and scores on symptomatology were quantified and compared with those at baseline. Baseline predictors of QoL outcomes at follow-up were investigated. Results Fifty-seven outpatients were enrolled into group CBT for SAD, 48 completed the whole program, and 44 and 40 completed assessments at the 3-month and 12-month follow-ups, respectively. All aspects of SAD symptomatology and psychological subscales of the QoL showed statistically significant improvement throughout follow-ups for up to 12 months. In terms of social functioning, no statistically significant improvement was observed at either follow-up point except for post-treatment. No consistently significant pre-treatment predictors were observed. Conclusions After group CBT, SAD symptomatology and some aspects of QoL improved and this improvement was maintained for up to 12 months, but the social functioning domain did not prove any significant change statistically. Considering the limited effects of CBT on QoL, especially for social functioning, more powerful treatments are needed.

Background Interoceptive exposure has been validated as an effective component of cognitive behavioral therapy (CBT) for the treatment of panic disorder but has hitherto received little research attention. We examined the effectiveness of various interoceptive exposure exercises using the Body Sensations Questionnaire (BSQ) (Chambless et al., 1984). Methods We first performed an exploratory principal factor analysis of all the items contained in the BSQ to obtain meaningful dimensions of interoceptive fears. Next, we examined the correlations between each interoceptive exposure task's degree of similarity to panic attacks and each BSQ factor and then examined whether the BSQ factor scores decreased in comparison with the baseline values when the corresponding exposure tasks were successfully completed by the subjects. Results The factor analyses revealed four factors, which we named "pseudoneurological fears", "gastrointestinal fears", "cardiorespiratory fears" and "fears of dissociative feelings." Among the nine interoceptive exposure tasks, 'hyperventilation', 'shaking head', 'holding breath' and 'chest breathing' were considered to reproduce pseudoneurological symptoms, 'breathing through a straw' was considered to reproduce gastrointestinal symptoms, and 'spinning' was considered to reproduce both pseudoneurological and dissociative symptoms; none of the interoceptive exercises were found to reproduce cardiorespiratory symptoms. Among each group of patients for whom 'hyperventilation', 'holding breath', 'spinning' or 'chest breathing' was effective, a significant improvement in the BSQ pseudoneurological fears factor scores was observed. On the other hand, no significant difference between the baseline and endpoint values of the BSQ gastrointestinal fears or the BSQ fears of dissociative feelings factor scores were observed among the patients for whom 'spinning' or 'breathing through a straw' was effective. Conclusion Several interoceptive exposure tasks were particularly effective in reducing pseudoneurological fears. New interoceptive tasks, especially tasks related to cardiorespiratory and dissociative feelings, are needed.

BACKGROUND: Unexplained miscarriage is speculated to be due to a Th1/Th2 cytokine imbalance at the feto– maternal interface and immunological functions are known to be under the influence of various psychological factors. Indeed, the psycho–neuro–immuno–endocrine network has been proposed to contribute to miscarriage. To assess whether psychological disorders might induce spontaneous abortion we carried out a prospective study to determine if any psychological parameter influenced risk in those patients with a history of recurrent miscarriages. METHODS: A prospective study was carried out on 61 patients with a history of two consecutive first-trimester miscarriages. A battery of self-report questionnaires including Symptom Checklist-90 Revised and the NEO Five Factor Index and semi-structured interviews were conducted before a subsequent pregnancy. We investigated whether or not these parameters predicted subsequent miscarriages. RESULTS: Ten (22.2%) of the 45 patients who conceived miscarried again. Baseline depressive symptoms influenced subsequent miscarriage (P 0.004). This statistically significant effect remained when we corrected with Bonfferoni adjustment (P 0.036). CONCLUSIONS: A high depression scale is associated with a high miscarriage rate in those patients suffering recurrent miscarriage.