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To establish the long-term effectiveness of 3 treatments for DSM-IV panic disorder with or without agoraphobia: cognitive-behavioral therapy (CBT), pharmacotherapy using a selective serotonin reuptake inhibitor (SSRI), or the combination of both (CBT + SSRI). As a secondary objective, the relationship between treatment outcome and 7 predictor variables was investigated.Patients were enrolled between April 2001 and September 2003 and were randomly assigned to treatment. Academic and nonacademic clinical sites participated. Each treatment modality lasted 1 year. Pharmacotherapists were free to choose between 5 SSRIs currently marketed in The Netherlands. Outcome was assessed after 9 months of treatment (posttest 1), after discontinuation of treatment (posttest 2), and 6 and 12 months after treatment discontinuation (follow-up 1 and follow-up 2).In the sample (N = 150), 48% did not suffer from agoraphobia or suffered from only mild agoraphobia, while 52% suffered from moderate or severe agoraphobia. Patients in each treatment group improved significantly from pretest to posttest 1 on the primary outcome measures of level of anxiety (P.001), degree of coping (P.001), and remitter status (P.001), as well as on the secondary outcome measures of depressive symptomatology (P.001), and from pretest to posttest 2 for health-related quality of life (P.001). Gains were preserved from posttest 2 throughout the follow-up period. Some superiority of CBT + SSRI and SSRI as compared with CBT was observed at posttest 1. However, at both follow-ups, differences between treatment modalities proved nonsignificant. Client satisfaction appeared to be high at treatment endpoint, while patients receiving CBT + SSRI appeared slightly (P.05) more satisfied than those receiving CBT only.No fall-off in gains was observed for either treatment modality after treatment discontinuation. SSRIs were associated with adverse events. Gains produced by CBT were slower to emerge than those produced by CBT + SSRI and SSRI, but CBT ended sooner.Netherlands Trial Register (www.trialregister.nl) Identifier: ISRCTN8156869.

Background: The importance of the therapist’s education and experience for the successful behavior treatment of obsessive-compulsive disorder (OCD) has not been investigated. Data on the relative effectiveness of self-controlled versus therapist-controlled in vivo exposure with response or ritual prevention (ERP) have yielded conflicting results. The present study compared the effectiveness of 4 different modes of delivery of ERP in a referred sample of OCD patients. Method: Of the 146 eligible OCD outpatients, 118 patients enrolled in this randomized controlled trial and were randomly assigned to (1) therapist-controlled ERP performed by experienced behavior therapists; (2) therapist-controlled ERP performed by master’s students of clinical psychology; (3) self-controlled ERP performed by experienced behavior therapists; and (4) self-controlled ERP performed by master’s students of clinical psychology. This trial was performed from January 1999 to January 2005. Results: Our analyses revealed no significant differences in clinical outcome between any of the different modes of delivery of ERP at posttreatment. The different ERP modes of delivery were associated with significant pretreatment to posttreatment improvement on all measurements, with large effect sizes on the primary outcome measure, the Yale-Brown Obsessive Compulsive Scale. Conclusions: Our results indicate that clinically inexperienced master’s students with no postgraduate training can be as capable as experienced and certified behavior therapists in treating OCD patients, as long as therapists adhere to a standardized treatment manual and adequate training and supervision is provided. In contrast to other studies, we did not find a supposed benefit of therapist-controlled ERP versus self-controlled ERP in patients with OCD.

Objective: This study tests a Stabilizing Group Treatment protocol, designed for the management of the long-term sequelae of child abuse, that is, Complex Posttraumatic Stress Disorder (Complex PTSD). Evidence-based treatment for this subgroup of PTSD patients is largely lacking. This stabilizing treatment aims at improving Complex PTSD using psycho-education and cognitive behavioral interventions. Method: Thirty-six patients with a history of childhood abuse, Complex PTSD and severe co-morbidity entered a 20-week treatment with pre-, post-, and follow-up-assessments. Results: Improvement was found for PTSD and borderline symptoms. Post-treatment 64% and after 6 months 78% of patients no longer met criteria for Complex PTSD. Conclusions: This open study indicates both the feasibility of investigating treatment outcome and the initial efficacy of stabilizing group treatment in severely ill patients with Complex PTSD related to childhood abuse. © 2010 Elsevier Ltd.

Objective: Disturbed sleep has a high impact on daily functioning and has been correlated with psychopathology. We investigated the extent to which insomnia and sleep duration were associated with both current and remitted depressive and anxiety disorders in a large-scale epidemiologic study, taking sociodemographics, health factors, and medication use into account. Method: Data of 2,619 individuals from the Netherlands Study of Depression and Anxiety (NESDA) were analyzed. Psychopathology was classified as no, current, or remitted DSM-IV-based diagnosis of major depressive or anxiety disorder. Outcome measures were insomnia (Women's Health Initiative Insomnia Rating Scale score >= 9) and sleep duration (

Background It was previously shown that antidepressants are associated with diminished vagal control over the heart. Longitudinal studies are needed to test the causality of this association further. Methods Longitudinal data were obtained in the Netherlands Study of Depression and Anxiety. At baseline and at 2-year follow-up, heart rate and cardiac vagal control as indexed by respiratory sinus arrhythmia were measured in 2114 subjects (mean age = 42.0 years; 66.2% female), who either used antidepressants at one or two time points (n = 603) or did not use antidepressants at any time point (n = 1511). Linear mixed-model analyses were conducted to compare changes in respiratory sinus arrhythmia and heart rate over time across antidepressant-naive subjects, subjects who started using an antidepressant during follow-up, subjects who stopped using an antidepressant, and persistent antidepressant users. Analyses were adjusted for demographics, health, and lifestyle factors. Results Compared with continuous nonusers, subjects who started the use of a tricyclic antidepressant or a serotonergic and noradrenergic antidepressant showed a significantly greater increase in heart rate and a decrease of respiratory sinus arrhythmia at 2 years. Subjects who started the use of selective serotonin reuptake inhibitors also showed a decrease in respiratory sinus arrhythmia, but their heart rate did not increase. Discontinuing antidepressants systematically caused opposite effects; levels returned in the direction of those observed among nonusers. Conclusions These 2-year longitudinal results indicate that all antidepressants cause a decrease in cardiac vagal control. After discontinuing antidepressants, autonomic function recovers, suggesting that the unfavorable effects are (partly) reversible. © 2010 Society of Biological Psychiatry.

Contains fulltext : 80327.pdf (Publisher’s version ) (Closed access) OBJECTIVE: This study aimed to evaluate the success of implementing outpatient schema focused therapy (ST) for borderline patients in regular mental healthcare and to determine the added value of therapist telephone availability outside office hours in case of crisis (TTA). METHODS: To enhance the implementation, the following adaptations regarding the original ST protocol were applied: a reduction in the frequency and duration of the therapy; training therapists of eight regular healthcare centers in ST with a structured and piloted program supported by a set of films (DVDs) with examples of ST techniques; training and supervision given by Dutch experts. Telephone availability outside office hours was randomly allocated to 50% of the therapists of each treatment center. Patient's outcome measures were assessed with a semi-structured interview and self-report measures on BPD, quality of life, general psychopathology and an ST questionnaire, before, during and after treatment. RESULTS: Data on 62 DSM-IV defined BPD patients were available. Intention-to-treat analyses showed that after 1.5 years of ST 42% of the patients had recovered from BPD. No added value of therapist telephone availability (TTA) was found on the BPDSI score nor on any other measure after 1.5 years of ST. CONCLUSIONS: ST for BPD can be successfully implemented in regular mental healthcare. Treatment results and dropout were comparable to a previous clinical trail. No additional effect of extra crisis support with TTA outside office hours ST was found.

Dysfunctional self-schemas are assumed to play an important role in suicidal ideation. According to recent information-processing models, it is important to differentiate between 'explicit' beliefs and automatic associations. Explicit beliefs stem from the weighting of propositions and their corresponding 'truth' values, while automatic associations reflect more simple associations in memory. Both types of associations are assumed to have different functional properties and both may be involved in suicidal ideation. Thus far, studies into self-schemas and suicidal ideation focused on the more explicit, consciously accessible traces of self-schemas and predominantly relied on self-report questionnaires or interviews. To complement these 'explicit' findings and more directly tap into self-schemas, this study investigated automatic self-associations in a large scale community sample that was part of the Netherlands Study of Depression and Anxiety (NESDA). The results showed that automatic self-associations of depression and anxiety were indeed significantly related to suicidal ideation and past suicide attempt. Moreover, the interactions between automatic self-depressive (anxious) associations and explicit self-depressive (anxious) beliefs explained additional variance over and above explicit self-beliefs. Together these results provide an initial insight into one explanation of why suicidal patients might report difficulties in preventing and managing suicidal thoughts. © 2009 The Author(s).

Contains fulltext : 81152.pdf (Publisher’s version ) (Closed access) OBJECTIVE: Three studies were conducted to prepare for the implementation of Schema Therapy (ST) for Borderline Personality Disorder (BPD) in general mental healthcare settings. Two were surveys to detect promoting and hindering factors, one was a preliminary test of a training program in ST. METHODS: In 2004, a diagnostic analysis of factors promoting and hindering implementation of a new treatment for BPD was conducted among both managers (n = 23) and therapists (n = 49) of 29 Dutch mental healthcare institutes through a written survey (Study 1). Next, a training program, including a set of DVDs displaying the major therapeutic techniques, was developed and tested among eight therapists. The training program was evaluated by the participants. After the training, three independent raters evaluated therapists' adherence and competence, viewing videos of the therapists completing structured role-plays (Study 2). In 2008, a second written survey was conducted in 22 mental health institutes to study factors for future nationwide implementation of ST (Study 3). RESULTS: Both surveys indicated that the situation in most institutes was favorable for implementing a new effective treatment, as participants were not satisfied with the existing treatments, had suitable professional backgrounds, worked in settings with (B)PD-oriented care programs, and expressed a need for change. The surveys yielded clear results for promoting or hindering successful implementation of ST. Promoting factors included scientific evidence for the effectiveness of the treatment, structural changes in the patient's personality, rapidly noticeable effects for the patient, low drop-out rates and a favorable cost-effectiveness. Possible barriers included implementation mandated unilaterally by management, choosing ST based on financial or organizational needs, extending implementation over a lengthy period of time and providing telephone support by therapists beyond office hours. The eight-day training program received very positive ratings. After the training, therapists were rated as sufficiently adherent and competent applying ST to treat BPD patients, with peer supervision and supervision recommended as a supplement to the training. CONCLUSION: This study showed that the situation in 2005 was advantageous to start implementation of ST. Evaluation of the training and the achieved competence scores of trainees concluded that the training program was a good basis for training therapists in ST. Outcome of the survey in 2008 demonstrated that there was a clear interest for implementation of ST for BPD patients in the future.

Context: It has been hypothesized that depression is associated with lower heart rate variability and decreased cardiac vagal control. This may play an important role in the risk of cardiovascular diseaseamongdepressed individuals. Objective: To determine whether heart rate variability was lower in depressed individuals than in healthy controls in a large adult sample. Design: Cross-sectional analyses from a large depression cohort study. Setting: The Netherlands Study of Depression and Anxiety. Participants: Two thousand three hundred seventy-three individuals (mean age, 41.8 years; 66.8% female) who participated in the Netherlands Study of Depression and Anxiety. Included were 524 controls, 774 individuals with a diagnosis of major depressive disorder (MDD) earlier in life (remitted MDD), and 1075 individuals with current MDD based on the Composite International Diagnostic Interview. This sample was sufficiently powered to examine the confounding effects of lifestyle, comorbid anxiety, and antidepressants. Main Outcome Measures: The standard deviation of normal-to-normal beats (SDNN) and cardiac vagal control, as indexed by respiratory sinus arrhythmia (RSA), were measured during 11/2 hours of ambulatory recording of electrocardiograms and thorax impedance. Multivariate analyses were conducted to compare SDNN and RSA across depression groups after adjustment for demographics, health, lifestyle, comorbid anxiety, and psychoactive medication. Results: Individuals with remitted and current MDD had a lower mean SDNN and RSA compared with controls (SDNN, 3.1-5.7 milliseconds shorter, P ≤ .02; RSA, 5.1-7.1 milliseconds shorter, P < .001; effect size, 0.125-0.269). Comorbid anxiety and lifestyle did not reduce these associations. However, accounting for psychoactive medication removed the association with SDNN and strongly attenuated the association with RSA. Depressed individuals who were using selective serotonin reuptake inhibitors, tricyclic antidepressants, or other antidepressants had significantly shorter SDNNs and RSAs (effect size, 0.207-0.862) compared with controls and depressed individuals not taking medication. Conclusions: This study shows that depression is associated with significantly lowered heart rate variability. However, this association appears to be mainly driven by the effect of antidepressants. ©2008 American Medical Association. All rights reserved.

BackgroundSchema-focused therapy (SFT) and transference-focused psychotherapy (TFP) for borderline personality disorder were recently compared in a randomised multicentre trial.AimsTo assess the societal cost-effectiveness of SFT v. TFP in treating borderline personality disorder.MethodCosts 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).ResultsMean 4-year bootstrapped costs were $37826 for SFT and $46 795 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 $90457 for one QALY loss.ConclusionsDespite 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.

Van Boeijen CA, Van Oppen P, Van Balkom AJLM, Visser S, Kempe PT, Blankenstein N, Van Dyck R. Angststoornissen in de eerste lijn vaak goed te behandelen. Een gerandomiseerd gecontroleerd onderzoek. Huisarts Wet 2007;50(7):315-20. Achtergrond Angststoornissen komen in de eerstelijnszorg frequent voor. Psychologische behandeling is effectief maar tijdrovend en bovendien zijn er wachtlijsten voor tweedelijnszorg. De ontwikkeling van richtlijnen voor een behandeling die haalbaar is in de eerstelijnszorg is daarom gewenst. Doelstelling Het vergelijken van de effectiviteit en toepasbaarheid van begeleide zelfhulp, de NHG-Standaard Angststoornissen en cognitieve gedragstherapie (CGT). Onderzoeksopzet Gerandomiseerd gecontroleerd onderzoek van twaalf weken behandeling met een vervolgmeting na drie en negen maanden voor eerstelijnszorgpatienten met paniekstoornis en/of gegeneraliseerde angststoornis. Methode De eerste twee behandelingen werden uitgevoerd door 46 huisartsen, die de ene of de andere behandeling willekeurig toegewezen kregen. CGT werd uitgevoerd door cognitieve gedragstherapeuten in een psychiatrische polikliniek. De deelnemers (n = 154) werden willekeurig ingedeeld voor een van de drie behandelvormen. De hoofduitkomstmaat was de state-subschaal van de Spielberger Anxiety Inventory. Resultaten De drie behandelingen gaven significante verbeteringen tussen voormeting en nameting, en deze verbetering bleef stabiel tussen nameting en de vervolgmetingen. De resultaten van de drie behandelvormen verschilden op termijn niet significant. De toepasbaarheid van de NHG-Standaard Angststoornissen was gering vergeleken met die van begeleide zelfhulp. Conclusies Onze resultaten geven aan dat eerstelijnszorgpatienten met angststoornissen voor wie de huisarts doorverwijzing niet noodzakelijk acht, op bevredigende wijze behandeld kunnen worden door de huisarts. Doorverwijzing naar een psychiatrische polikliniek levert bij deze patienten geen betere resultaten op. Begeleide zelfhulp is gemakkelijker uit te voeren door huisartsen dan een minder goed gestructureerde behandeling zoals vastgelegd in de NHG-Standaard Angststoornissen.

The aim of this pilot study was to test the effectiveness and feasibility of a new, guided self-help program in five selected primary care patients with panic disorder (PD) or generalized anxiety disorder (GAD). Most patients achieved a clinically relevant improvement after 12 weeks of treatment with large effect sizes (Cohen's d) on all measures. Two patients could be considered as recovered according to the criteria of Jacobson and Truax (1991). Although all of the patients appeared to improve on all outcome measures, PD was easier to treat than GAD. These results suggest that a guided self-help manual treatment is an effective treatment possibility for PD and GAD in primary care. When these results can be replicated in a controlled trial in a larger sample, guided self-help treatment may be a first-line treatment in general practice in a step-by-step care approach of PD and GAD.

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.

In a long-standing fear-of-flying program, persons with fear of flying (N=150) were after a diagnostic assessment and individual preparation phase randomly assigned to either a 1-day behavioral group treatment (BGT) program, a 2-day cognitive-behavioral group treatment (CBGT) program or a waiting list (WL) control group. A post-treatment flight on a commercial airline measured participants' ability to fly. Different self-report flight anxiety questionnaires were completed before, during and after treatment at 3-, 6- and 12-month follow-up. Results indicated that both treatments were superior to the WL, and equally effective on the flying test and later independent flying, but also that the 2-day CBGT program was significantly more effective than the 1-day BGT program on subjective measures of fear and self-efficacy.

Summary: Purpose: This study was performed to investigate the relation between symptoms of interictal depression, anxiety, personality traits, and psychological dissociation with the localization and lateralization of the epileptogenic zone in patients with partial epilepsy. Methods: All patients were diagnosed according to the localization-related concept of the 1989 International League Against Epilepsy (ILAE) Classification of Epilepsies and Epileptic Syndromes, and the localization and lateralization of the epileptogenic zone was established by using the clinical criteria for noninvasive presurgical evaluation. This resulted in 67 patients with temporal lobe epilepsy (TLE) and 64 patients with extra-TLE. All patients were assessed on the various aspects of psychopathology by using a comprehensive battery of standardized diagnostic instruments. Results: We did not find the hypothesized excess of psychiatric symptoms in patients with (mesial) TLE in comparison with patients with extra-TLE. We also found no differences between patients with the lateralization of epilepsy in the left versus the right hemisphere. Conclusions: TLE per se cannot be considered a risk factor in developing more or more severe symptoms of psychopathology in patients with partial epilepsy. Concomitant factors, such as the duration of epilepsy, seizure frequency, and frontal lobe dysfunction may play an additional role. Our findings support the hypothesis of a multifactorial explanation for the psychiatric symptoms in patients with epilepsy.

CONTEXT: Borderline personality disorder is a severe and chronic psychiatric condition, prevalent throughout health care settings. Only limited effects of current treatments have been documented.OBJECTIVE: To compare the effectiveness of schema-focused therapy (SFT) and psychodynamically based transference-focused psychotherapy (TFP) in patients with borderline personality disorder.DESIGN: A multicenter, randomized, 2-group design.SETTING: Four general community mental health centers.PARTICIPANTS: Eighty-eight patients with a Borderline Personality Disorder Severity Index, fourth version, score greater than a predetermined cutoff score.INTERVENTION: Three years of either SFT or TFP with sessions twice a week.MAIN OUTCOME MEASURES: Borderline Personality Disorder Severity Index, fourth version, score; quality of life; general psychopathologic dysfunction; and measures of SFT/TFP personality concepts. Patient assessments were made before randomization and then every 3 months for 3 years.RESULTS: Data on 44 SFT patients and 42 TFP patients were available. The sociodemographic and clinical characteristics of the groups were similar at baseline. Survival analyses revealed a higher dropout risk for TFP patients than for SFT patients (P = .01). Using an intention-to-treat approach, statistically and clinically significant improvements were found for both treatments on all measures after 1-, 2-, and 3-year treatment periods. After 3 years of treatment, survival analyses demonstrated that significantly more SFT patients recovered (relative risk = 2.18; P = .04) or showed reliable clinical improvement (relative risk = 2.33; P = .009) on the Borderline Personality Disorder Severity Index, fourth version. Robust analysis of covariance (ANCOVA) showed that they also improved more in general psychopathologic dysfunction and measures of SFT/TFP personality concepts (PCONCLUSIONS: Three years of SFT or TFP proved to be effective in reducing borderline personality disorder-specific and general psychopathologic dysfunction and measures of SFT/TFP concepts and in improving quality of life; SFT is more effective than TFP for all measures.

The present study investigated whether scores on the Autobiographical Memory Test (AMT) in 55 patients with borderline personality disorder (BPD) were modified after long-term psychotherapy and whether the pretreatment AMT scores would predict improvement in depression severity or BPD symptom severity at the end of treatment. In addition, it was analysed whether changes in ratings of mood, thought suppression, dissociation, and BPD symptom severity following treatment were associated with changes in AMT scores. Only patients with BPD and a comorbid diagnosis of depression at time 1, generated significantly more specific memories and fewer categoric memories after 15 months of therapy. Moreover, these changes were unrelated to type of therapy and changes in depression severity, borderline symptom severity, dissociation, or thought suppression. The AMT scores at initial assessment did not predict depression severity at 15 months. The percentage of negative specific memories tended to predict BPD symptom severity.

Aims: Despite claims that comorbid anxiety disorders tend to lead to a poor outcome in the treatment of alcohol dependence, the few studies on this topic show conflicting results. Objective: To test whether the out come of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder is worse than that of similar patients without a comorbid phobic disorder. Methods: The probabilities of starting to drink again and of relapsing into regular heavy drinking in (i) a group of 81 alcohol-dependent patients with comorbid social phobia or agoraphobia were compared with those in (ii) a group of 88 alcohol-dependent patients without anxiety disorders in a naturalistic follow-up using Cox regression analysis. Results: Adjusted for initial group differences, the hazard ratio for the association of phobic disorders with resumption of drinking was 1.05 (95% CI, 0.85-1.30, P = 0.66) and the adjusted hazard ratio for the association of phobic disorders with a relapse into regular heavy drinking was 1.02 (95% CI, 0.78-1.33, P = 0.89). Conclusion: The findings of this study do not confirm the idea that alcohol-dependent patients who have undergone alcohol-dependence treatment are at greater risk of a relapse if they have a comorbid anxiety disorder. No differences were found in abstinence duration or time to relapse into regular heavy drinking between patients with and without comorbid phobic disorders.

Objective: This study is the first to investigate the relative effectiveness of cognitive-behavioral therapy (CBT) compared with a selective serotonin reuptake inhibitor (SSRI; sertraline) in a randomized, controlled trial on the treatment of anxiety disorders in older adults. Method: Eighty-four patients 60 years of age and over with a principal diagnosis of generalized anxiety disorder, panic disorder, agoraphobia, or social phobia were randomly assigned to one of three conditions: 15 sessions of CBT, pharmacologie treatment with an SSRI (sertraline; maximum dosage 150 mg), or a waitlist control group. Participants completed measures of primary outcome (anxiety) and coexistent worry and depressive symptoms at baseline, posttreatment, and at three-month follow up. Results: Attrition rates were high in both treatment groups. Consequently, findings are based on a relatively small sample of completers (N = 52). Although both CBT and sertraline led to significant improvement in anxiety, worry, and depressive symptoms both at posttreatment and at three-month follow up, sertraline showed superior results on worry symptoms. Effect size estimates for CBT were in the small to medium range both at posttreatment (mean d = 0.42) and at three-month follow up (mean d= 0.35), whereas effect sizes for sertraline fell into the large range (posttreatment mean d = 0.94 and three-month follow up mean d = 1.02). The waitlist condition showed virtually no effects (posttreatment mean d = .03). Conclusions: Our findings strongly suggest that the pharmacologie treatment of late-life anxiety with SSRIs has not been given the proper attention in research to date. © 2006 American Association for Geriatric Psychiatry.

Objective: Major depressive disorder has been associated with changes in the hypothalamus–pituitary–thyroid (HPT) axis and with hypercortisolism. However, the changes reported have been at variance, probably related to in- or outpatient status, the use of antidepressant medication and the heterogeneity of depression. We therefore conducted a controlled study in unipolar depressed outpatients who had been free of antidepressants for at least 3 months. Design: We assessed endocrine parameters in 113 depressed outpatients and in 113 sex- and age-matched controls. Methods: Patients were included if they had a major depression according to a Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM), fourth edition (SCID-IV) and if they had a 17-item Hamilton rating scale for depression (HRSD) score of ≥16. Endocrine parameters contained serum concentrations of TSH, (free) thyroxine, tri-iodothyronine, cortisol, thyroid peroxidase (TPO) antibody titre and 24-h urinary excretion of cortisol. Results: The serum concentration of TSH was slightly higher in depressed patients as compared with controls (P < 0.001), independent of the presence of subclinical hypothyroidism and/or TPO antibodies (n = 28). All other HPT axis parameters were similar in both groups. The 24-h urinary cortisol excretion was similar in patients and controls. In atypical depression, serum cortisol was lower than in non-atypical depression (P = 0.01). Patients with neither melancholic depression nor severe depression (HRSD ≥23) had altered endocrine parameters. Finally, serum TSH values could not be related to cortisol values. Conclusion: When compared with matched control subjects, outpatients with major depression had slightly higher serum TSH, while urinary cortisol levels were similar. Furthermore, we observed lower serum cortisol in atypical depression than in non-atypical depression.

Objective: Evidence has emerged which indicates that the post-treatment relapse rate for alcohol-dependent patients with a comorbid anxiety disorder is higher than for alcohol-dependent patients without a comorbid anxiety disorder. The question raised by this evidence is whether the relapse rate in these dually diagnosed patients could be reduced if they were given additional treatment for the comorbid anxiety disorder. We attempted to answer this question by conducting a trial among patients with a double diagnosis of alcohol dependence and agoraphobia or social phobia. Method: We conducted a 32-week randomized controlled trial among 96 abstinent patients with a primary diagnosis of alcohol dependence and a comorbid anxiety disorder involving agoraphobia or social phobia. The patients were randomly assigned to an intensive psychosocial relapse-prevention program on its own (n = 49) or in combination with an anxiety treatment program comprising cognitive behavioral therapy (CBT) and optional pharmacotherapy consisting of an SSRI (n = 47). The primary outcome measure was the percentage of patients who suffered an alcohol relapse during a 32-week period. The secondary outcome measures were total abstinence, a reduction in the days of heavy drinking, and less severe anxiety symptoms. Results: Although the additional therapy clearly reduced the anxiety symptoms, it had no significant effect on the alcohol relapse rates. Conclusion: Anxiety treatment for alcohol-dependent patients with a comorbid anxiety disorder can alleviate anxiety symptoms, but it has no significant effect on the outcome of alcohol treatment programs.

Dissociative style is mostly studied as a risk factor for dissociative pathology, but it may also reflect a fundamental characteristic of healthy information processing. Due to the close link between attention and working memory and the previous finding of enhanced attentional abilities with a high dissociative style, a positive relationship was also expected between dissociative style and verbal working memory span. In a sample of 119 psychology students, it was found that the verbal span of the high-dissociative group was about half a word larger than of the medium and low-dissociative groups. It is suggested that dissociative style may be one of only very few individual differences that is directly relevant to consciousness research.

Background: Patients with a double diagnosis of alcohol dependence and phobic disorders are a common phenomenon in both alcohol and anxiety disorder clinics. If we are to provide optimum treatment we need to know more about the clinical characteristics of this group of comorbid patients. Objective: To answer the following questions. (1) What are the clinical characteristics of treatment-seeking alcohol-dependent patients with a comorbid phobic disorder? (2) Are alcohol dependence and other clinical characteristics of comorbid patients different from those of 'pure' alcohol-dependent patients? (3) Are the anxiety symptoms and other clinical characteristics of comorbid patients different from those of 'pure' phobic patients? Method: Three groups of treatment-seeking patients were compared on demographic and clinical characteristics: alcohol dependent patients with a comorbid phobic disorder (n = 110), alcohol-dependent patients (n = 148) and patients with social phobia or agoraphobia (n = 106). In order to diagnose the comorbid disorders validly, the assessment took place at least 6 weeks after detoxification. Results: Comorbid patients have high scores on depressive symptoms and general psychopathology: 25% of patients have a current and 52% a lifetime depressive disorder. The majority have no partner and are unemployed, they have a high incidence of other substance use (benzodiazepine, cocaine, cannabis) and a substantial proportion of comorbid patients have been emotionally, physically and sexually abused. They do not have a more severe, or different type of alcohol dependence or anxiety disorder than 'pure' alcohol-dependent patients and phobic patients respectively. Conclusion: Comorbid patients constitute a complex part of the treatment-seeking population in alcohol clinics and psychiatric hospitals. These findings should be taken into account when diagnosing and treating alcohol-dependent patients with a comorbid phobic disorder.

Patients' preferences in the treatment of depression are important in clinical practice and in research. Antidepressant medication is often prescribed, but adherence is low. This may be caused by patients preferring psychotherapy, which is often not available in primary care. In randomized clinical trials, patients' preferences may affect the external validity. The aim of this article is to study patients' preferences regarding psychotherapy and antidepressant medication and the impact of these preferences on treatment outcome. A systematic review of the literature was performed. The majority of patients preferred psychotherapy in all available studies. Antidepressants were often regarded as addictive and psychotherapy was assumed to solve the cause of depression. Discussing and supporting preferences as part of a quality improvement program of depression care, resulted in more patients receiving the treatment that was most suitable to them. In two patient-preference trials, preferences did not influence treatment outcome. It can be concluded that a substantial percentage of well-informed patients prefer psychotherapy. Patients with strong preferences, mostly for psychotherapy, are likely not to enter antidepressant treatment or randomized clinical trials if their preferences are not supported.

There is evidence that thyroid hormone T-3 increases serotonergic neurotransmission. Therefore, T-3 addition to antidepressants may improve treatment response in major depression. In nonrefractory depression, T-3 addition to tricyclic antidepressants indeed accelerates treatment response. Current therapeutic practice favors selective serotonin reuptake inhibitors. This is the first study to investigate the efficacy of T-3 addition to paroxetine in major depression. One hundred thirteen patients with major depressive disorder were randomly assigned to 8 wk of double-blind outpatient treatment with low-dose T-3 (25 mug), high-dose T-3 (25 mug twice daily), or placebo in addition to paroxetine 30 mg daily. A total of 106 patients started treatment and were included in the outcome analysis. Response rate after 8 wk ( reduction of Hamilton Rating Scale for Depression score greater than or equal to 50%) was 46% in all three treatment arms (P = 0.99). T-3 addition did not accelerate clinical response to paroxetine, nor was an effect of T-3 found when only women were analyzed. Patients on T-3 addition reported more adverse events than patients on placebo comedication. In conclusion, these results do not support a role for T-3 addition to selective serotonin reuptake inhibitors in the treatment of nonrefractory major depressive disorder. On the contrary, more adverse reactions occurred in T-3-treated patients

Interpersoonlijke psychotherapie (ipt) is een kortdurende psychotherapie die bij depressieve ouderen goed toepasbaar is en waarvan het effect bewezen is. Binnen ipt wordt de depressie als ziekte benoemd. Bij de kenmerkende behandelstrategieen staat de wisselwerking tussen de depressie en de interpersoonlijke context centraal. Alhoewel er goede argumenten zijn om ipt in het vaste behandelaanbod voor depressieve ouderen op te nemen, is de beschikbaarheid van getrainde therapeuten een knelpunt. Dit geldt zeker ook in de eerste lijn, waar de meeste depressieve patienten terechtkomen. Uit een lopend onderzoeksproject in Amsterdam en omstreken naar het toepassen van ipt door hulpverleners uit de geestelijke gezondheidszorg in de huisartsenpraktijk, blijkt dat de betrokkenen (patienten, therapeuten, huisartsen) voornamelijk positief zijn over de ipt-werkwijze. Implementatie van ipt in de eerste lijn is haalbaar als therapeuten een trainingstraject volgen waarin individuele supervisie over een aantal therapieen is opgenomen.

Aims: It has been repeatedly stated that comorbid anxiety disorders predict poor outcome of alcoholism treatment. This statement is based on the high comorbidity of alcohol use disorders and anxiety disorders, and the negative influence of other comorbid psychiatric disorders on the outcome of treatment of alcohol dependence. This review focuses on outcome results of alcohol-dependent patients with a comorbid anxiety disorder. We try to answer the question whether anxiety disorders should be treated in alcohol-dependent patients to improve outcome results in alcoholism treatment. Methods: In a search through Pubmed, Psychinfo and Cochrane, we found only 12 articles on this subject. We distinguished three perspectives: (1) studies on the predictive value of comorbid anxiety disorders on the outcome of alcoholism treatment; (2) studies on the improvement of abstinence rates and anxiety symptoms by offering pharmacological treatment for comorbid anxiety disorders; (3) studies on psychotherapeutic treatment. Results: Most studies showed methodological limitations. Only one high quality study showed that comorbid anxiety disorders predict poor outcome of the treatment of alcohol dependence. Conclusions: We cannot conclude that comorbid anxiety disorders in alcohol-dependent patients need a specific treatment to prevent relapse. However, medication and perhaps cognitive behavioural therapy can be useful in alcohol-dependent patients with a comorbid anxiety disorder to reduce anxiety symptoms. Methodological implications for further research are discussed.

In the present study, we sought to investigate which brain structures are recruited in planning tasks of increasing complexity. For this purpose, a parametric self-paced pseudo-randomized event-related functional MRI version of the Tower of London task was designed. We tested 22 healthy subjects, enabling assessment of imaging results at a second (random effects) level of analysis. Compared with baseline, planning activity was correlated with increased blood oxygenation level-dependent (BOLD) signal in the dorsolateral prefrontal cortex, striatum, premotor cortex, supplementary motor area, and visuospatial system (precuneus and inferior parietal cortex). Task load was associated with increased activity in these same regions. In addition, increasing task complexity was correlated with activity in the left anterior prefrontal cortex, a region supposed to be specifically involved in third-order higher cognitive functioning.

In 1986, the traditional psychiatric hospital where 70% of Amsterdam's intramural treatment took place, was closed down. The progress of two groups of long-stay patients was followed by longitudinal cohort research for five years after their transferral to new small-scale facilities in Amsterdam. The ADL-functioning of the most severely handicapped clients improved and their psychiatric symptoms decreased, while no improvement was seen in the functioning of the more independent and less handicapped clients. Now, thirteen years after closure of the old hospital, the use of the psychiatric facilities by these clients is being evaluated. This evaluation makes clear that the improvement of the severely disabled patients depends on the intensity of care given. Apparently, the improvement in the new facilities is no guarantee for a further development into a less care-intensive environment. The less handicapped and more independent clients, however, could more easily be transferred to less care-intensive facilities.

General practitioners (GPs) are recommended to use DSM-IV criteria to diagnose major depression in daily clinical practice. This implies the assessment of nine depressive symptoms and four additional criteria. A short structured interview has been developed to assess these symptoms and criteria, and a study was carried out to investigate the reliability and validity with which GPs can assess these symptoms and criteria and the DSM-IV diagnosis of major depression. In 14 general practices, 52 patients with symptoms of distress and depression were interviewed twice by their GP, with an interval of one to four days. Furthermore, the patients filled out three depression questionnaires. The reproducibility of eight symptoms and three additional criteria was moderate to good (kappa >0.40). The reproducibility of the depressive symptom count, that is necessary to arrive at a diagnosis of major depression, was such that in 75 percent of the patients the test-retest difference did not exceed one symptom. The reproducibility of the diagnosis of major depression was good (kappa 0.63). The validity of the diagnosis of major depression assessed by the GPs, as compared to results of the self-report depression questionnaires, was satisfactory (r 0.35-0.61). Diagnosing major depression in patients with depressive symptomatology just above or below the threshold of major depression warrants a certain amount of caution in general practice. (C) 2002 Elsevier Science Inc. All rights reserved.

This paper has two objectives. The first is to describe a multimodal, standardized treatment program used by the VALK Foundation, an agency that specializes in the treatment of patients with fear of flying. The second is to present the results of an evaluation of this program, particularly with regard to the effectiveness of a 2-day cognitive-behavioral group treatment program and a 1-day behavioral group treatment program for flying phobics. On the basis of individualized assessment, patients (N = 1,026) were nonrandomly assigned to 1 of the 2 group treatment modalities. Self-report data and behavioral indicators for fear of flying were collected at pretreatment and at 3-, 6-, and 12-month follow-ups. Complete data were obtained from 757 participants. Results showed that both treatment programs produced statistically significant, clinically relevant decreases in self-reported anxiety and behavioral anxiety indices. This paper explains the procedures and outcomes of a well-established clinical program. Limitations of the study are discussed and future research suggested.

Background: Dissociative reactions and alexithymia are two strategies that have been put forward as coping mechanisms to alleviate painful emotions. It is the clinical impression that dissociation is related to certain alexithymia features. In line with the coping hypothesis, it was predicted that the relationship between dissociative tendencies and alexithymia would be partly mediated by current levels of stress and/or by past traumatic experiences. Furthermore, dissociation may also be related to enhanced fantasizing, although alexithymia has traditionally been associated with an incapacity to fantasize. Methods: Data were obtained from 833 nonclinical participants on dissociative tendencies, alexithymia, childhood abuse, current stress and socially desirable behavior. Correlation analyses followed by multiple regression were performed. Results: Dissociative tendencies appeared to be especially related to one alexithymic feature: a difficulty in identifying feelings. This relationship was partially mediated by levels of current stress. A history of trauma did not predict dissociation measures. Furthermore, highly dissociative participants were more fantasy prone than low-dissociative participants. Conclusions: The results of this study support the idea that in a nonclinical group dissociation may provide a way to cope with current stressful events, and that this is associated with a difficulty in identifying feelings. It is argued that two types of dissociation may exist, one trait-like type of dissociation that is associated with fantasy proneness and other related factors, and a trauma-related type of dissociation that is more apparent within the clinical range.

This chapter argues that real progress in the management of anxiety disorders will depend on a further understanding of etiological processes. It focuses mainly on biological and psychopharmacological aspects of anxiety research. In order to make further advances, a major effort to clarify etiology of anxiety disorders is needed. Since 2006 it has been possible to perform genome-wide association (GWA) studies, in which single nucleotide polymorphisms (SNPs) are genotyped across the whole genome of an individual and subsequently associated to a disorder. GWA studies have changed the view on how genetic factors influence complex traits, such as psychiatric disorders. The field of anxiety disorders research will gain from better translation from clinical phenotype (early signs, symptom differentiation, comorbidity, and end-stage profiles) and treatment response profiles to biomarkers derived from genetic and brain imaging research, and vice versa. A multidisciplinary approach will be the most fruitful.

The placebo response forms a growing problem in randomized, placebo-controlled clinical trials in psychiatry. Research into the placebo response is on the increase, but remains very limited in relation to social phobia. Together with the dropout rate, the placebo effect is an important factor limiting the discriminative properties of any study. In this study, we reviewed 15 placebo-controlled studies in social phobia, focussing on patients and study characteristics. In social phobia, the placebo effect has turned out to be moderately large and has shown no increase over the past decade. Placebo response was highest in large, multicentred trials and was independent of study duration. No validation for a placebo run-in was found. Taking into account both response to placebo and active drug, as well as dropout rate, the most discriminative results are probably to be expected in a sample of patients who are moderately to severely impaired. More research in the field of the placebo response is needed.

Eighty-two patients with social phobia were randomly assigned to cognitive therapy or double-blind drug treatment with moclobemide (300–600 mg per day) or placebo. After 15 weeks of active treatment, a 2-month treatment-free follow-up as well as a 15-month naturalistic follow-up were scheduled. At post-test, cognitive therapy was significantly superior to moclobemide, but not to placebo, on a composite social phobia measure. At 2-month follow-up, cognitive therapy was superior to both moclobemide and placebo. Treatment gains were maintained in cognitive therapy during 2-month and 15-month follow-up, however, most patients (66%) who completed the study needed additional cognitive and/or behavioural treatment. Moclobemide proved not superior to placebo at post-test as well as at 2-month follow-up. As most patients from the medication conditions were treated with cognitive and/or behavioural treatment during the naturalistic follow-up period, at the 15-month assessment no between-group differential effects were found to remain. These results indicate that cognitive therapy is an effective treatment for social phobia in both the short and long term. As the results from previous studies on the efficacy of moclobemide in social phobia were inconclusive, our data tip the scales in the direction that there is no place for moclobemide in the treatment of social phobia. Copyright © 2001 John Wiley & Sons, Ltd.

BackgroundLittle research has been done on the uniqueness of risk profiles for depression and anxiety in late life.AimsDelineating 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.MethodSelf-Report data on depression and anxiety were collected from community-dwelling older respondents (⩾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.ResultsAfter 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.ConclusionsDepression and anxiety have many risk factors in common, but specific risk factors also were found, especially in subjects developing both depression and anxiety.

Objective: The purpose of this study was to examine the comorbidity of and communality of risk factors associated with major depressive disorder and anxiety disorders in later life. Method: A random age- and sex-stratified community-based sample (N=3,056) of the elderly (age 55-85 years) in the Netherlands was studied. A two-stage screening design was used, with the Center for Epidemiologic Studies Depression Scale as a screening instrument and the National Institute of Mental Health Diagnostic Interview Schedule as a criterion instrument. Risk factors were measured with well-validated instruments and represented a broad range of vulnerability and stress-related factors associated with anxiety and depression. Multivariate analyses examined risk factors associated with pure major depressive disorder, pure anxiety disorders, and comorbid conditions. Results: Comorbidity was highly prevalent: 47.5% of those with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorder. While the only variables associated with pure major depressive disorder were younger age and external locus of control, risk factors representing a wide range of both vulnerability and stress were associated with pure anxiety disorders. External locus of control was the only common factor. The group with anxiety disorders plus major depressive disorder had a distinct risk factor profile and may represent those with a more severe disorder. Conclusions: Although high levels of comorbidity between major depressive disorder and anxiety disorders were found, comparing risk factors associated with pure major depressive disorder and pure anxiety disorders revealed more differences than similar ties. Anxiety disorders in later life merit separate study.

This article presents the development of and data on the dimensional structure, reliability, and validity of 2 new inventories for assessing different aspects of fear of flying: the Flight Anxiety Situations questionnaire (FAS), which assesses anxiety related to flying experienced in different situations, and the Flight Anxiety Modality questionnaire (FAM), which measures symptom modalities in which anxiety in flight situations is expressed. Two initial questionnaires were constructed from multiple sources. Factor analytic studies were conducted to assess their internal structure, and the final versions were examined in a sample of 746 patients who experienced fear of flying. A principal-components analysis investigated the optimal dimensional structure in 2 randomly created subsamples. A 3-factor solution for the FAS and a 2-factor solution for the FAM Were revealed. The internal consistency and test-retest reliability were good to excellent. Moderately strong correlations between the subscales suggest sufficient factorial specificity and convergent validity. The subscales were sensitive to change.

De klinische effectiviteit van zogenaamde ‘evidence based’ behandelingen voor paniekstoornis met agorafobie werd onderzocht aan de hand van gegevens over het lange-termijneffect en aanvullende behandeling na deelname aan een gecontroleerde effectstudie. Twee jaar na afsluiting van de onderzoeksbehandeling werden de patienten thuis ondervraagd over hun klachten en over de mate waarin zij aanvullende behandeling hadden ontvangen. De uitkomst onmiddellijk na de protocollaire onderzoeksbehandeling had uitgewezen dat alle behandelingen tot een afname van klachten hadden geleid. Verder bleek medicatie (fluvoxamine) gecombineerd met exposure in vivo effectiever dan placebo met exposure, ademtraining met exposure of alleen exposure. De lange-termijnresultaten lieten geen verschil meer zien in klachtniveau tussen de oorspronkelijke groepen: de afname van klachten in de fluvoxamine plus exposure patienten was in stand gebleven en patienten van de andere groepen waren verder vooruitgegaan. De verdere vooruitgang was te danken aan aanvullende behandeling, die vooral was gegeven aan patienten van de laatste drie groepen. De hoeveelheid nabehandeling die nodig bleek oversteeg ruimschoots het aantal zittingen van de oorspronkelijke behandeling. Deze resultaten geven aan dat kortdurende protocollaire behandelingen weliswaar werkzaam zijn, in de zin dat ze klachten doen afnemen, maar ook dat ze bij lange na niet afdoende zijn. Maar weinig patienten hebben geen aanvullende behandeling meer nodig, de meeste worden nog lang doorbehandeld. Ten slotte wordt de toevoegende waarde van medicatie aan gedragstherapie besproken. Medicatie bespoedigde het gunstige effect van gedragstherapie: patienten hadden minder klachten onmiddellijk na de behandeling en kregen ook minder aanvullende therapie. Een deel van de patienten gebruikte echter nog steeds medicatie bij de follow-up. Op de lange duur was de gedragstherapie, in de aanvullende behandeling vaak gecombineerd met cognitieve therapie, even effectief. Dat kostte wel een aanzienlijke extra inspanning in de vorm van aanvullende therapie.

We conducted a meta-analysis to update the knowledge of long-term efficacy of different treatments in panic disorder with or without agoraphobia. Included were 68 studies pertaining to 106 treatment conditions and 1346 patients. Effect sizes Cohen's d were calculated within the treatment conditions at posttest and at follow-up for panic and agoraphobia. A comparison was made between six treatments: high-potency benzodiazepines, antidepressants, psychological panic management, exposure in vivo, antidepressants combined with exposure, and psychological panic management combined with exposure in vivo. The mean (+/- SD) duration of the follow-up period was 62 +/- 89 weeks. In the majority of the studies (84%), follow-up had a naturalistic character. The lack of information about treatments received between posttest and follow-up limits the interpretation of the results. For all conditions, the treatment gains at posttest were maintained during the follow-up period. The mean (+/- SD) d for panic was 1.11 +/- 0.70 at posttest and 1.28 +/- 0.61 at follow-up; for agoraphobia, the mean d at posttest was 1.36 +/- 1.10 and at follow-up it was 1.41 +/- 0.82. Significant differences were found in efficacy on agoraphobic measures at follow-up between the combination of antidepressants and exposure in vivo versus psychological panic management, exposure in vivo, and the combination of psychological panic management and exposure. Overall, the data suggest that different treatment options for panic disorder with or without agoraphobia are effective at both posttest and follow-up. Research on long-term treatment, discontinuation of therapies, and interventions between posttest and follow-up need more attention, for pharmacotherapy as well as psychotherapy.

In de discussie over herinneringen aan traumatische ervaringen staan twee geheugenfenomenen centraal, te weten traumatische herinneringen en dissociatieve amnesie. Deze verschijnselen worden vaak beschreven als dissociatieve geheugenproblemen. In dit artikel wordt allereerst nagegaan in hoeverre geheugenmechanismen zoals geidentificeerd in experimenteel onderzoek toereikend zijn bij het verklaren van herinneringen aan traumatische ervaringen. De stelling zal worden verdedigd, dat het beschikbare laboratorium onderzoek met name dissociatieve geheugenproblemen niet afdoende kan verklaren. In aansluiting hierop worden enige neuro-psychologische en cognitief-psychologische modellen van dissociatieve geheugenproblemen besproken. Geconcludeerd wordt dat verder gemeenschappelijk onderzoek van experimentele geheugenonderzoekers en clinici naar dit omstreden onderwerp wenselijk en mogelijk is.

Volgens de 19de-eeuwse Franse psychiatrie heeft dissociatie betrekking op psychologische aspecten van ervaringen, reacties en functies zoals amnesie en identiteitsfragmentering, alsook op lichamelijke of somatoforme aspecten, zoals anesthesie en motorische stoornissen. Bij de hernieuwde interesse voor dissociatie en dissociatieve stoornissen bestaat er te weinig belangstelling voor somatoforme dissociatie. Zoals we toelichten aan de hand van een casus, zijn er klinische aanwijzingen dat dissociatieve stoornissen samenhangen met de somatoforme dissociatieve symptomen die 19de-eeuwse patienten met hysterie kenmerkten. Daarna beschrijven we de ontwikkeling van een zelf-rapportage-vragenlijst die de ernst van somatoforme dissociatie meet. Zowel het oorspronkelijke onderzoek als het herhalingsonderzoek wees uit dat deze Somatoform Dissociation Questionnaire (SDQ-20) over uitstekende psychometrische eigenschappen beschikt. De items bleken in sterke mate schaalbaar te zijn op een unidimensionele latente schaal. De betrouwbaarheid van de schaal was hoog. Hoge correlaties met de DIS-Q, die psychologische manifestaties van dissociatie meet, ondersteunen de convergente validiteit van de SDQ-20. Hogere scores van patienten met een dissociatieve identiteitsstoornis vergeleken met patienten met een dissociatieve stoornis nao of depersonalisatiestoornis wijzen op criterium-gerelateerde validiteit. De SDQ-20 items betreffen negatieve en positieve dissociatieve verschijnselen, die in de 19de-eeuwse Franse psychiatrie bekend waren als de essentiele kenmerken van hysterie.

Three controversies about Dissociative Identity Disorder are discussed. First, is DID an artefact due to iatrogenic influences? The empirical evidence does not support such a conclusion, although iatrogenic influences may play a considerable part in the presentation of this disorder. Second, how adequate are the present diagnostic criteria? It is argued that the DSM-IV may elicit overdiagnosis and that the use of structured clinical interviews is mandatory. The third controversy concerns memory processes of DID patients. Does psychogenic amnesia for sexual abuse exist, or are the so-called repressed memories of sexual abuse false memories (unintentionally) induced by overzealous therapists? Clinical data and experimental laboratory findings do not converge in this. The massive amnesia for traumatic events that is clinically reported in dissociative disorders, has not been replicated in laboratory studies, whereas memory research has shown that some false memories can be created in the laboratory. © 1998 John Wiley & Sons, Ltd.

The authors hypothesized that there would be a similarity between animal defensive responses to variable predatory imminence and injury and certain somatoform dissociative symptoms of trauma-reporting patients who have dissociative disorder. As a first test of this hypothesis, 12 somatoform symptom clusters consisting of clinically observed somatoform dissociative phenomena were constructed. All clusters discriminated between patients with dissociative disorders (n = 50) and patients with other psychiatric diagnoses (n = 50). Those expressive of the hypothesized similarity--freezing, anesthesia-analgesia, and disturbed eating--belonged to the 5 most characteristic symptoms of dissociative disorder patients. Anesthesia-analgesia, urogenital pain, and freezing symptom clusters independently contributed to predicted presence of dissociative disorder. Using an independent sample, it appeared that anesthesia-analgesia best predicted presence of dissociative disorder after controlling for symptom severity. The results were largely consistent with the hypothesized similarity.

The hypothesis was investigated that more accurate perception of heartbeats by patients with panic disorder is an artefact of arousal. Twenty-three patients with panic disorder, 16 patients with a mood disorder and 21 normal controls were tested. There were more panic patients who accurately perceived their heart rates ( N =7) than depressed patients ( N =0) or normals ( N =2). The nine accurate perceivers had higher scores on questionnaires measuring the cognitions associated with panic. For non-accurate perceivers, perceived heart rates were unrelated to actual heart rates, unrelated to cognitive factors, but significantly related to arousal. It is concluded that the accurate perception of heartbeats by patients with panic disorder is both fact and artefact: some patients are accurate perceivers, but the majority are not.

The objective of this study was to examine sociodemographic and clinical characteristics of 419 patients who were self-referred to a treatment agency because of fear of flying. With the use of homogeneity analyses to explore the association between flight-anxiety and different types of phobia, four specific subtypes of flying phobics were identified. The subtypes differed in terms of flight-anxiety level, age, sex, complaints like “fear of aircraft accidents, the need to have control over the situation, fear of losing control over themselves,” and phobias underlying their fear of flying, such as claustrophobia, acrophobia, social phobia, and symptoms of panic attacks. It is argued that the typology identified could have implications for the selection of treatment components.