M. Katherine Shear

Overactive Action Monitoring in Obsessive-Compulsive Disorder Evidence From Functional Magnetic Resonance Imaging

The anterior cingulate cortex (ACC) in patients with obsessive-compulsive disorder (OCD) has been found to be hyperactive at rest, during symptom provocation, and after commission of errors in cognitive tasks. This hyperactivity might reflect an abnormality in conflict detection, a hypothesized basic mechanism for the action-monitoring function of the ACC. This hypothesis was tested using functional magnetic resonance imaging, by scanning 11 OCD patients and 13 matched control subjects while they performed a version of the continuous-performance task with four trial types that induced graded levels of response conflict. Although a behavioral index of conflict (i.e., accuracy) was similar for patients and control subjects, the ACC activation was increased in patients during high-conflict trials. The error-related activity in the same brain region was also higher in patients, consistent with previous electrophysiological findings. Both conflict- and error-related activity showed trends for positive correlations with severity of OCD symptoms, but not with anxiety. These findings suggest that as part of an overactive action-monitoring system, the ACC is more directly involved in the pathophysiology of OCD than previously thought.

Reliability and validity of the Panic Disorder Severity scale: replication and extension

UNLABELLEDnThe Panic Disorder Severity Scale (PDSS) is a recently developed seven-item instrument to rate overall severity of Panic Disorder. The scale has previously shown good psychometric properties in a sample of Panic Disorder patients with no more than mild agoraphobia. The purpose of this paper is to confirm reliability and validity, to provide an estimate of a cut-score discriminating the presence or absence of current DSM-IV Panic Disorder, and to determine the factor structure of the instrument.nnnPROCEDURESn104 psychiatric outpatients, including 54 with current Panic Disorder, underwent structured diagnostic assessment and the PDSS interview. The PDSS was repeated within 3-17 days.nnnRESULTSnwe confirmed reliability and validity of the instrument and found a one-factor solution fit the data. A cut-off score of eight identifies patients with current panic with a sensitivity of 83.3%, and a specificity of 64%.nnnCONCLUSIONnthe PDSS is a simple, reliable instrument for use in Panic Disorder studies. A cut-score of eight may be useful as a tool to screen patients in settings such as primary care, for diagnosis-level symptoms.

Therapists, Therapist Variables, and Cognitive-Behavioral Therapy Outcome in a Multicenter Trial for Panic Disorder

The relationship between therapists and treatment outcome was examined in 14 highly trained therapists who participated in the Multicenter Collaborative Study for the Treatment of Panic Disorder. Overall, therapists yielded positive outcomes in their caseloads; yet, therapists significantly differed in the magnitude of change among caseloads. Effect sizes for therapist impact on outcome measures varied from 0% to 18%. Overall experience in conducting psychotherapy was related to outcome on some measures, whereas age, gender, gender match, and experience with cognitive-behavioral therapy (CBT) were not. Therapists with above- and below-average outcomes were rated similarly on measures of adherence and competency. The results suggest that therapists make a contribution to outcome in CBT for panic disorder, even when patients are relatively uniform, treatment is structured, and outcome is positive. Implications for future clinical outcome studies and for training clinicians are discussed.

Generalized Anxiety Disorder in Late Life: Lifetime Course and Comorbidity With Major Depressive Disorder

OBJECTIVEnGeneralized anxiety disorder (GAD) in elderly persons is highly prevalent, but little is known about its course, age at onset, and relationship to comorbid major depressive disorder (MDD). The authors assessed the course and comorbidity of late-life GAD and MDD.nnnMETHODSnAuthors assessed elderly subjects in anxiety or depression intervention studies who had a lifetime history of GAD, with current MDD (N=57) or without (N=46). Subjects lifetime course of illness was charted retrospectively.nnnRESULTSnThe 103 subjects had a mean age of 74.1 years, and a mean age at onset of GAD of 48.8 years; 46% were late-onset. GAD episodes were chronic, and 36% were longer than 10 years. Of the comorbid GAD-MDD patients, most had different times of onset and/or offset of the disorders; typically, GAD preceded MDD.nnnCONCLUSIONSnElderly subjects with GAD tended to have chronic symptoms lasting years-to-decades, without interruption, and many have late onset. Elderly persons with lifetime GAD and MDD tend to have different onset and offset of the two disorders. Findings characterize late-life GAD as a chronic disorder distinct from MDD.

Physician office visits of adults for anxiety disorders in the United States, 1985–1998

OBJECTIVE: To determine the number of physician office visits by adults in which an anxiety disorder diagnosis was recorded and rates of treatment during these visits.DESIGN: We used data from the 1985, 1993, 1994, 1997, and 1998 National Ambulatory Medical Care Surveys, which is a nationally representative series of surveys of office-based practice employing clustered sampling.SETTING: Office-based physician practices in the United States.PARTICIPANTS: A systematically sampled group of office-based physicians.RESULTS: The number of office visits with a recorded anxiety disorder diagnosis increased from 9.5 million in 1985 to 11.2 million per year in 1993–1994 and 12.3 million per year in 1997–1998, representing 1.9%, 1.6%, and 1.5% of all office visits in 1985, 1993–1994, and 1997–1998, respectively. The majority of recorded anxiety disorder diagnoses were not for specific disorders, with 70% of anxiety disorder visits to primary care physicians coded as “anxiety state, unspecified.” Visits to primary care physicians accounted for 48% of all anxiety disorder visits in 1985 and 1997–1998. Treatment for anxiety was offered in over 95% of visits to psychiatrists but in only 60% of visits to primary care physicians. Primary care physicians were less likely to offer treatment for anxiety when specific anxiety disorders were diagnosed than when “anxiety state, unspecified” was diagnosed (54% vs 62% in 1997–1998). Prescriptions for medications to treat anxiety disorders increased between 1985 and 1997–1998 while use of psychotherapy decreased over the same time period in visits to both primary care physicians and psychiatrists.CONCLUSIONS: Although there is a large number of office visits with a recorded anxiety disorder diagnosis, under-recognition and under-treatment appear to be a continuing problem, especially in the primary care sector. Medication is being substituted for psychotherapy in visits to both psychiatrists and primary care physicians over time.

Implicit and explicit memory for catastrophic associations to bodily sensation words in panic disorder

This study investigated explicit (cued recall) and implicit memory (word completion) memory bias for catastrophic associations among individuals with panic disorder (n=24), clinician controls (n=24), and normal controls (n=24). Compared to both control groups, the panic disorder group showed biased explicit and implicit memory for catastrophic associations to bodily sensation words (e.g., palpitation-coronary) compared to positive (e.g., smiles-elation) and neutral (e.g., groceries-coupons) word pairs of equal relatedness. These results support cognitive formulations of panic disorder which suggest that individuals with panic disorder have biased memory for

Comorbid anxiety disorders in late-life depression

We examined the prevalence and correlates of comorbid anxiety disorders in two groups of older depressed patients assessed at the University of Pittsburgh. A total of 336 older outpatients and inpatients with major depression were comprehensively evaluated with several instruments including the Hamilton Depression Rating Scale, and either the SADS-L or the SCID for DSM-III-R. These patients presented with major depression, associated with a wide range of functional, cognitive, and medical impairment. One-third to one-half of them also presented with severe symptomatic anxiety. However, only a small proportion (less than 5%) met diagnostic criteria for lifetime or current panic, obsessive-compulsive, or phobic disorders. At baseline, lifetime comorbid anxiety disorders were associated with a higher rate of alcoholism and higher symptomatic anxiety. Lifetime comorbid anxiety disorders did not affect the rate of response of depression, but they were associated with a higher use of benzodiazepines and a 50% increase in the time outpatients needed to respond. These findings suggest that, even in psychiatric patients with major depression, the lifetime prevalence of anxiety disorders is lower in late life, but that it has important clinical and therapeutic implications.

Anxiety among widowed elders: Is it distinct from depression and grief?

The purpose of this study was to test the validity and utility of distinguishing symptoms of anxiety from those of depression and grief in recently spousally bereaved elders. We also examined pathways from baseline (six months or less post-spousal death) to follow-up (12 and 18 months post-death) levels of anxiety, depression and grief-related symptoms. Baseline and follow-up data were available from 56 recently widowed elderly subjects recruited for an investigation of physiological changes in bereavement. Confirmatory factor analyses indicated that a model in which anxiety was specified as a third factor, apart from depression and grief factors, fit the data well and significantly better than either the one or two factor models. Path analyses revealed that both baseline severity of grief and anxiety had significant lagged effects and predicted follow-up severity of depression. Symptoms of anxiety appeared distinct from those of depression and grief, and the anxiety, depression and grief factors differentially predicted subsequent symptomatology. These findings suggest a need for more specific identification and treatment of anxiety, depression and grief symptoms within the context of late-life spousal bereavement.

CONCEPTUAL UNDERPINNINGS AND EMPIRICAL SUPPORT FOR THE MOOD SPECTRUM

This article presents an overview of the conceptual basis and empirical support for a unitary view of mood disturbance. The authors consider this general conceptualization of psychiatric disturbance as consisting of an array of related symptoms and behavioral features that define the spectrum of each disorder. They discuss how this conceptual framework aids in overcoming what they believe to be the false dichotomy between unipolar and bipolar mood disorders and in evaluating subthreshold and unusual presentations. They also describe the structured clinical interview and self-report instrument that they have developed to facilitate systematic assessment of the proposed mood spectrum. Finally, they summarize the clinical utility of such an approach to the description and assessment of patients with mood disorders.

Panic-agoraphobic spectrum: reliability and validity of assessment instruments

DSM IV is a simple, reliable diagnostic system with many advantages. However, DSM diagnostic criteria may not provide sufficient characterization of clinically significant symptoms. We have undertaken a project to assess an array (spectrum) of clinical features associated with different DSM Disorders. The purpose of this paper is to report on reliability of assessment instruments for Panic-Agoraphobic Spectrum (PAS), to document convergent validity of PAS symptom groupings, and to confirm the relationship between PAS and DSM IV Panic Disorder (PD). We studied 22 normal controls and 95 outpatients who met criteria for Panic Disorder with and without lifetime Major Depression, and Major Depression or Obsessive Compulsive Disorder without lifetime Panic Disorder. Assessment instruments had excellent reliability and there was good concordance between interview and self-report formats. PAS scores were highest in subjects with PD, followed by outpatients without PD, and were lowest in normal controls. PAS scores varied among PD patients, and a subgroup of patients without PD scored high on PAS. We conclude that PAS can be reliably assessed, and that it describes a valid, coherent constellation of features associated with DSM IV Panic Disorder, but providing additional important clinical information.