Andri S. Bjornsson

Age at onset and clinical correlates in body dysmorphic disorder.

OBJECTIVE Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD. METHODS Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD. RESULTS BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2. CONCLUSIONS BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Cognitive–behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: a randomized controlled trial

Objective: In this randomized controlled trial, cognitive–behavioral group therapy (CBGT) for social anxiety disorder (SAD) was compared to group psychotherapy (GPT), a credible, structurally equivalent control condition that included only nonspecific factors of group treatment (such as group dynamics). Methods: Participants were 45 college students at the University of Colorado with a primary diagnosis of SAD. Each treatment condition comprised eight group sessions lasting 2 hr each. Independent assessors (blind to treatment assignment) assessed participants at baseline and posttreatment with the Clinical Global Impression Scale (CGI) and the Liebowitz Social Anxiety Scale (LSAS). Results: Both treatments were found to be equally credible. There were five noncompleters in the CBGT condition (21.7%) and only one in the GPT condition (4.3%). There were no statistically significant differences posttreatment (controlling for pretreatment scores) between the two treatment conditions, and both treatments were found to be efficacious. Effect sizes for CBGT were similar to earlier studies, and adherence ratings revealed excellent adherence. Conclusions: Treatment of SAD appears to be moving toward individual CBT, partly because of high attrition rates and underutilization of group dynamics in group CBT. However, group therapy has unique therapeutic ingredients, and it may be too early to give up on group treatment altogether. Discussion of these findings included future directions with this treatment modality, especially whether these two types of group treatment could be combined and whether such combination might serve to decrease attrition, enhance efficacy, and facilitate dissemination. Depression and Anxiety, 2011.

Psychometric properties of the Liebowitz Social Anxiety Scale (LSAS) in a longitudinal study of African Americans with anxiety disorders

The Liebowitz Social Anxiety Scale (LSAS) is a widely used measure of social anxiety. However, no study has examined the psychometric properties of the LSAS in an African American sample. The current study examined the LSAS characteristics in 97 African Americans diagnosed with an anxiety disorder. Overall, the original LSAS subscales showed excellent internal consistency and temporal stability. Similar to previous reports, fear and avoidance subscales were so highly correlated that they yielded redundant information. Confirmatory factor analyses for three previously proposed models failed to demonstrate an excellent fit to our data. However, a four-factor model showed minimally acceptable fit. Overall, the LSAS performed similarly in our African American sample as in previous European American samples. Exploratory factor analyses are warranted to determine whether a better factor structure exists for African Americans.

Two-Year Course of Generalized Anxiety Disorder, Social Anxiety Disorder, and Panic Disorder in a Longitudinal Sample of African American Adults

OBJECTIVE Anxiety disorders are the most common group of psychiatric disorders in adults. In addition to high prevalence, anxiety disorders are associated with significant functional impairment, and published research has consistently found them to have a chronic course. To date, very little research has explored the clinical characteristics and prospective course of anxiety disorders in racial and ethnic minority samples. The aims of this article are to present clinical and demographic characteristics at intake and prospective 2-year course findings in a sample of African American adults. METHOD Data are presented from 152 African Americans diagnosed with generalized anxiety disorder (GAD, n = 94), social anxiety disorder (SAD, n = 85), and panic disorder with agoraphobia (PDA, n = 77) who are participating in the Harvard/Brown Anxiety Research Project-Phase II (HARP-II). HARP-II is an observational, prospective, longitudinal study of the course of anxiety disorders. Participants were interviewed at intake and annually for 2 years of follow-up. Probabilities of recovery over 2 years of follow-up were calculated using standard survival analysis methods. RESULTS AND CONCLUSIONS Survival analyses revealed a chronic course for all anxiety disorders, with rates of recovery of 0.23, 0.07, and 0.00 over 2 years for GAD, SAD, and PDA, respectively. These rates of recovery were lower than those reported in predominantly non-Latino White longitudinal samples, especially for SAD and PDA, suggesting that anxiety disorders may have a more chronic course for African Americans, with increased psychosocial impairment and high rates of comorbid Axis-I disorders. Clinical implications of these findings are discussed.

Barking up the wrong tree in attentional bias modification? Comparing the sensitivity of four tasks to attentional biases

BACKGROUND AND OBJECTIVES Attentional bias modification (ABM) is a potentially exciting new development in the treatment of anxiety disorders. However, reported therapeutic benefits have not always been replicated. To gauge the sensitivity of tasks used in ABM treatment and assessment, we used a counterbalanced within-subject design to measure their discriminant sensitivity to neutral and threatening facial expressions, comparing them with other well-known tasks that measure visual attention. METHODS We compared two tasks often used in the assessment and treatment of attention bias (the dot-probe and the spatial cueing paradigms) with two well-known visual attention tasks (the irrelevant singleton and attentional blink paradigms), measuring their sensitivity to processing differences between threatening and neutral expressions for non-clinical observers. RESULTS The dot-probe, spatial cueing and irrelevant singleton paradigms showed little or no sensitivity to processing differences between facial expressions while the attentional blink task proved very sensitive to such differences. Furthermore, the attentional blink task provided an intriguing picture of the temporal dynamics of attentional biases that the other paradigms cannot do. LIMITATIONS These results need to be replicated with larger samples, including a comparison of a group of individuals diagnosed with social anxiety disorder and normal controls. CONCLUSIONS Our results indicate that the sensitivity of putative attentional bias measures should be assessed experimentally for more powerful assessment and treatment of such biases. If the attentional blink task is indeed particularly sensitive to attentional biases, as our findings indicate, it is not unreasonable to expect that interventions based on this task may be more effective than those based on the tasks that are currently used.

The clinical course of body dysmorphic disorder in the Harvard/Brown Anxiety Research Project (HARP).

This report prospectively examines the course of body dysmorphic disorder (BDD) for up to 8 years in a sample of 514 participants in the Harvard/Brown Anxiety Research Project, a naturalistic, longitudinal study of anxiety disorders. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) BDD was assessed with a reliable semi-structured measure. For participants with BDD, severity of BDD symptoms was assessed with the Longitudinal Interval Follow-up Evaluation Psychiatric Status Rating scale. At the initial assessment, 17 participants (3.3%; 95% confidence interval = 1.8%–4.8%) had current BDD; 22 (4.3%; 95% confidence interval = 2.6%–6.1%) had lifetime BDD. Participants with BDD had significantly lower Global Assessment Scale scores than those without BDD, indicating poorer functioning. The probability of full recovery from BDD was 0.76, and probability of recurrence, once remitted, was 0.14 over the 8 years. In conclusion, among individuals ascertained for anxiety disorders, the probability of recovering from BDD was relatively high and probability of BDD recurrence was low.

Impact of stressful life events on the course of panic disorder in adults

BACKGROUND Panic disorder with/without agoraphobia (PD/PDA) is a prevalent anxiety disorder, associated with impairment in quality of life and functionality, as well as increased healthcare utilization. Extant research shows a relationship between stressful life events (SLEs) and the onset of panic attacks in adults who ultimately develop PD/PDA. However, limited attention has been paid to how SLEs might affect the severity of panic symptoms in individuals with PD/PDA. In this study, we examined the relationship between SLEs and panic symptom severity in adults with PD/PDA. METHODS Four hundred-eighteen adults with PD/PDA from the Harvard/Brown Anxiety Research Program (HARP), a long-term prospective longitudinal observational multicenter study of adults with a current or past history of anxiety disorders were included in this study. We examined occurrence of SLEs and their impact on panic symptom severity 12-weeks pre- and post-SLE. RESULTS A time-slope effect showed that participants had worsened panic symptoms over the course of the 12-weeks after family/friends/household and work SLEs. That is, their symptoms worsened progressively after the event, rather than immediately thereafter (i.e., significant symptom change within the same week of the event). LIMITATIONS The sample may not be representative of the general population. CONCLUSIONS These findings provide new insights into how SLEs affect panic symptoms in adults with PD/PDA in that household-related SLEs, such as serious family arguments, and work-related SLEs, such as being fired, put some adults at risk for worsened panic symptoms within 12-weeks of the event.

Personality Pathology Factors Predict Recurrent Major Depressive Disorder in Emerging Adults

OBJECTIVE Prior investigations consistently indicate that personality pathology is a risk factor for recurrence of major depressive disorder (MDD). Lack of emipircal support, however, for the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition organization of Axis II disorders supports the investigation of empirically derived factors of personality pathology as predictors of recurrence. METHOD A sample of 130 previously depressed emerging adults (80% female; aged 18 to 21 years) were assessed for personality disorder symptoms at baseline. Participants were then followed for 18 months to identify MDD recurrence during the first 2 years of college. RESULTS Based on a previous factor analysis of DSM personality disorder criteria, eight personality pathology factors were examined as predictors of MDD recurrence. Survival analysis indicated that factors of interpersonal hypersensitivity, antisocial conduct, and social anxiety were associated with increased risk of MDD recurrence. CONCLUSIONS These findings suggest that an empirically based approach to personality pathology organization may yield useful predictors of MDD recurrence during emerging adulthood.

Changes in body image and dieting among 16-19-year-old Icelandic students from 2000 to 2010

The aim of the study was to evaluate trends in body image and dieting among 16-19-year-old students in Iceland from 2000 to 2010. Data from four cross-sectional surveys conducted among Icelandic students in 26 junior colleges using four time points were compared to examine changes in body image and dieting. In total, 33,801 students with the mean age of 17.3 years participated. Body image became significantly more positive over the 10-year period for both genders. At all time points, females reported more negative body image than males and a higher proportion of dieters were females than males. There was a decrease in the frequency of dieting among females over time but an increase among males, resulting in a narrower gender gap in dieting. Further examination of these trends in body image and dieting may reveal differences in causal mechanisms behind negative body image and dieting between the genders.

Cued panic attacks in body dysmorphic disorder.

Background. Body dysmorphic disorder (BDD) is a common and often severe disorder. Clinical observations suggest that panic attacks triggered by BDD symptoms may be common. However, to our knowledge, no study has examined such panic attacks in BDD. We investigated the preva- lence, clinical features, and correlates of BDD- triggered panic attacks in individuals with this disorder. Methods. Panic attacks and other vari- ables were assessed using reliable and valid measures in 76 individuals with lifetime DSM-IV BDD. Results. 28.9% (95% CI, 18.5%–39.4%) of par- ticipants reported lifetime panic attacks trig- gered by BDD symptoms. The most common triggers of such attacks were feeling that others were looking at or scrutinizing the perceived appearance defects (61.9%), looking in the mirror at perceived defects (38.1%), and being in bright light where perceived defects would be more vis- ible (23.8%). The most common panic attack symptoms were palpitations (86.4%), sweating (66.7%), shortness of breath (63.6%), trembling or shaking (63.6%), and fear of losing control or going crazy (63.6%). Compared to participants without such panic attacks, those with BDD-trig- gered panic attacks had more severe lifetime BDD, social anxiety, and depressive symptoms, as well as poorer functioning and quality of life on a number of measures. They were also less likely to be employed and more likely to have been psy- chiatrically hospitalized and to have had suicidal ideation due to BDD. Conclusions. Panic attacks triggered by BDD-related situations appear com- mon in individuals with this disorder. BDD-trig- gered panic attacks were associated with greater symptom severity and morbidity. (Journal of Psychiatric Practice 2013;19:194–203)