Claudia Zayfert

Health functioning impairments associated with posttraumatic stress disorder, anxiety disorders, and depression.

Although anxiety disorders have been associated with impairments in self-reported health functioning, the relative effect of various anxiety disorders has not been studied. We compared health functioning of patients with a principal diagnosis of posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), and major depressive disorder (MDD). Patients with PTSD and MDD were equally impaired on overall mental health functioning, and both were significantly worse than patients with PD and GAD. PTSD was associated with significantly worse physical health functioning relative to PD, GAD, and MDD. Hierarchical regression showed that the association of PTSD with physical health functioning was unique and was not caused by the effects of age, depression, or comorbid anxiety disorders. Both PTSD and comorbid anxiety accounted for unique variance in mental functioning. These results highlight the association of PTSD with impaired physical and mental functioning and suggest that effective treatment of PTSD may affect overall health.

Integrating DBT-based techniques and concepts to facilitate exposure treatment for PTSD

While considerable evidence supports the use of exposure-based treatment for PTSD, its utilization in clinical practice remains limited. This article presents a systematic and empirically grounded approach to the flexible application of PTSD treatment research in a “true” clinical setting. High rates of attrition, suicidality, dissociation, destructive impulsivity, and chaotic life problems are reasons cited by clinicians for abandoning empirically supported exposure treatment. Linehans dialectical behavior therapy (DBT), designed to address many of these issues, offers useful strategies for addressing the needs of patients considered poor candidates for exposure therapy. This article offers a model for integrating DBT-based theory, concepts, and skills with manualized exposure-based cognitive-behavior therapy for PTSD in order to improve patient (and therapist) tolerance of this treatment.

Psychophysiological reactivity in female sexual abuse survivors

This study examined psychophysiological reactivity in 37 female childhood sexual abuse (CSA) survivors. After assessment of posttraumatic stress disorder (PTSD), psychiatric comorbidity, and trauma history, we conducted a psychophysiological assessment of forehead muscle tension, electrodermal activity, and heart rate during a mental arithmetic task and 4 script-driven imagery tasks (neutral, consensual sex, pleasant, and trauma). PTSD symptom severity correlated positively with psychophysiologic changes and negative emotions during the trauma imagery task. During mental arithmetic, PTSD symptom severity correlated negatively with autonomic changes and positively with negative emotions. These results extend earlier PTSD research showing trauma-specific increased psychophysiological reactivity related to CSA in women with PTSD. They further suggest a negative association between PTSD severity and autonomic reactions to mental arithmetic.

Comorbid anxiety disorders in civilians seeking treatment for posttraumatic stress disorder

Research indicates that posttraumatic stress disorder (PTSD) is associated with high rates of comorbid psychiatric diagnoses. Yet, it remains unknown whether PTSD is associated with greater comorbidity relative to patients with other anxiety disorders. This study examined prevalence of comorbid anxiety disorders with PTSD relative to other disorders among a treatment-seeking population. Patients with PTSD (n = 83) evidenced greater overall comorbidity as compared to patients with other anxiety (n = 151) or Axis I (n = 73) disorders. Compared to patients with panic disorder, patients with PTSD were more likely to be diagnosed with depression and social phobia, but not other anxiety disorders. Extent of anxiety disorder comorbidity was not related to PTSD severity. These findings are discussed in terms of their relevance for treatment of PTSD.

Eating disorder symptoms among female anxiety disorder patients in clinical practice: the importance of anxiety comorbidity assessment.

This exploratory study investigated the relationship between anxiety disorders, anxiety comorbidity, and eating disorder (ED) symptoms in clinical practice, and examined the naturalistic detection of ED when diagnoses were based on the Anxiety Disorders Interview Schedule (ADIS). Two hundred and fifty-seven female patients completed an ED questionnaire and were assessed with the ADIS. Although ED frequency did not differ among anxiety disorder diagnoses, regression analyses revealed that social phobia (SP) and posttraumatic stress disorder (PTSD) accounted for unique variance in eating pathology. Questionnaire results indicated that almost 12% of patients met criteria for a possible ED. Clinicians using the ADIS evidenced good specificity but were not sensitive to detecting ED, missing 80% of possible cases. Results support possible links between ED, social phobia and PTSD and highlight the importance of assessing anxiety comorbidity when examining the relationship between ED and anxiety disorders. Results also suggest that formal screening for ED among female anxiety patients may be warranted.

Factors associated with insomnia among civilians seeking treatment for PTSD: an exploratory study.

This study explored relationships between insomnia (as measured by Item 13 of the Clinician-Administered PTSD [Posttraumatic Stress Disorder] Scale) and other PTSD symptoms, comorbidity, and measures of depression, worry, and panic in a mixed-trauma sample of 143 treatment-seeking civilians with PTSD (median age 39.4 years, 83% female, 96% White). Regression analyses showed that, adjusting for sleep medication use, severity of nightmares and diminished interest in pleasurable activities accounted for unique variance in insomnia severity level. Severity of nightmares and depression accounted for unique variance in the presence of severe insomnia. Findings support a role for conditioning related to nightmares in the etiology of PTSD-related insomnia.

Comorbid PTSD and social phobia in a treatment-seeking population: an exploratory study.

The purpose of this study was to examine patterns of comorbidity of posttraumatic stress disorder (PTSD) and social phobia (SP) and explore factors associated with the etiology and effect of this comorbidity. The sample consisted of 443 patients seeking treatment of PTSD, SP, or both. Of 240 patients with principal PTSD, 43% had comorbid SP, whereas only 7% of 57 with principal SP had comorbid PTSD. Patients with principal PTSD and comorbid SP were more likely to meet criteria for major depression and other anxiety disorders, and reported worse depression, anxiety, and physical, mental, and social functioning, than those with only PTSD or SP, regardless of other anxiety comorbidity. PTSD patients with SP reported more trauma-related guilt and higher frequency of childhood abuse than those without SP. The results are discussed in terms of implications for treatment of the comorbid presentation and directions for future research.

Specificity of the Social Interaction Self-Statement Test in Social Phobia

The specificity of the Social Interaction Self-Statement Test (SISST) was evaluated in sample of 277 patients seeking treatment for anxiety. Both the positive and negative scales significantly discriminated between patients diagnosed with social phobia and other anxiety disorder patients. Patients with social phobia scored significantly higher on the negative scale and significantly lower on the positive scale as compared with other treatment-seeking anxiety disorder patients. Negative SISST scores were significantly correlated with the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI). The positive scale was significantly correlated with the BDI. Despite this relationship, differences in BAI and BDI scores did not account for SISST findings. The present study provides further support for the use of the SISST with clinical populations.

A Psychometric Study of the Fear of Sleep Inventory-Short Form (FoSI-SF)

STUDY OBJECTIVES Fear of sleep may play a significant role in sleep disturbances in individuals with posttraumatic stress disorder (PTSD). This report describes a psychometric study of the Fear of Sleep Inventory (FoSI), which was developed to measure this construct. METHODS The psychometric properties of the FoSI were examined in a non-clinical sample of 292 college students (Study I) and in a clinical sample of 67 trauma-exposed adults experiencing chronic nightmares (Study II). Data on the 23 items of the FoSI were subjected to exploratory factor analyses (EFA) to identify items uniquely assessing fear of sleep. Next, reliability and validity of a 13-item version of the FoSI was examined in both samples. RESULTS A 13-item Short-Form version (FoSI-SF) was identified as having a clear 2-factor structure with high internal consistency in both the non-clinical (α = 0.76-0.94) and clinical (α = 0.88-0.91) samples. Both studies demonstrated good convergent validity with measures of PTSD (0.48-0.61) and insomnia (0.39-0.48) and discriminant validity with a measure of sleep hygiene (0.19-0.27). The total score on the FoSI-SF was significantly higher in the clinical sample (mean = 17.90, SD = 12.56) than in the non-clinical sample (mean = 4.80, SD = 7.72); t(357) = 8.85 p < 0.001. CONCLUSIONS Although all items are recommended for clinical purposes, the data support the use of the 13-item FoSI-SF for research purposes. Replication of the factor structure in clinical samples is needed. Results are discussed in terms of limitations of this study and directions for further research.

Resolving Treatment Complications Associated with Comorbid Eating Disorders

Eating disorders (EDs) represent an interesting challenge for the anxiety clinician. ED treatment often is viewed as a distinct specialty; thus, many anxiety clinicians have minimal background in the treatment of EDs. In addition, EDs often are difficult to treat even with extensive experience, and the substantial medical comorbidity and high mortality rate associated with them can make ED patients anxiety-provoking and ethically challenging for providers. Finally, individuals with EDs often are reluctant to disclose or change their ED behaviors. In this chapter we will (a) summarize findings on the co-occurrence of EDs in anxiety patients; (b) discuss how to assess for EDs in anxiety patients; (c) review empirically supported and promising treatments for EDs; (d) describe a case formulation approach for treating anxiety patients with comorbid EDs; (e) provide illustrative case examples using this approach; and (f) explore the issue of ordering of treatments for this population.