Megan M. Kelly

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive–compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive–compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or “chapter”) in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM‐V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM‐V Research Planning Conference on Obsessive–Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC‐spectrum grouping of disorders be included in DSM‐V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of “Anxiety and Obsessive–Compulsive Spectrum Disorders.” These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM‐V. Depression and Anxiety, 2010.

Emotional avoidance and panicogenic responding to a biological challenge procedure

Healthy undergraduates high (n = 27) and low (n = 27) in experiential avoidance underwent twelve 20 s inhalations of 20% carbon dioxide-enriched air, while physiological (e.g., skin conductance, heart rate, EMG, and end-tidal CO2) and subjective (e.g., subjective units of distress, evaluative ratings, number and severity of panic symptoms endorsed) reactions were continuously monitored. Individuals high in experiential avoidance endorsed more panic symptoms, more severe cognitive symptoms, and more fear, panic, and uncontrollability than their less avoidant counterparts. Magnitude of autonomic response did not discriminate between groups, nor were the observed effects accounted for by other risk factors for challenge-induced panic such as anxiety sensitivity. Results are discussed in terms of the pathoplastic relation between emotional avoidance and exacerbation of unpleasant emotional responses and the view that emotional avoidance may constitute a risk factor in the development and maintenance of anxiety disorders.

Childhood maltreatment and adult personality disorder symptoms: Influence of maltreatment type

The present study examines the effects of different types of childhood maltreatment on personality disorder symptoms in a sample of adults with no Axis I psychopathology. Participants reporting a history of moderate to severe maltreatment on the Childhood Trauma Questionnaire (n = 70) were grouped by type of abuse and compared with a non-abused group (n = 35) with regard to the number of personality disorder symptoms endorsed. Physical/sexual abuse and emotional abuse/neglect each were associated with elevated symptoms of all three personality disorder clusters. Elevated symptoms of several specific personality disorders were also seen, including paranoid, borderline, avoidant, dependent, obsessive-compulsive, and depressive personality disorder. There were no significant differences between the maltreatment groups. These findings indicate that emotional abuse/neglect and physical/sexual abuse are risk factors for a broad array of personality outcomes in a non-clinical sample.

Dex/CRH test cortisol response in outpatients with major depression and matched healthy controls.

BACKGROUND The dexamethasone/corticotropin releasing hormone (Dex/CRH) test has been proposed as a potential tool for identifying endophenotypes relevant to mood disorders. An exaggerated cortisol response to the test during major depressive episodes has been demonstrated for inpatients with melancholic or psychotic features. A diminished hormone response has been observed in chronically depressed outpatients. METHODS Following a battery of self-report and interview assessments, 68 adults completed the Dex/CRH test. Thirty-four met structured interview criteria for current major depressive disorder and 34 age- and sex-matched control subjects had no current or lifetime DSM-IV depressive disorder. Effect of diagnosis on cortisol response to the Dex/CRH test was examined in a repeated measures general linear model. RESULTS The matched groups were equivalent with regard to childhood adversity. Cortisol response to the Dex/CRH test among subjects with current MDD was not significantly different from that seen in matched healthy controls. Independent of diagnosis, an exploratory analysis showed a trend-level association between maltreatment history and diminished cortisol response; no interactive effects with depression diagnosis were detected. CONCLUSIONS The results do not support the hypothesis that elevated cortisol response to the Dex/CRH test represents a marker for major depressive episodes.

Effects of military trauma exposure on women veterans' use and perceptions of Veterans Health Administration care.

BackgroundFew studies have addressed how military trauma exposure, particularly sexual assault and combat exposure, affects women veterans’ use and perceptions of Veterans Health Administration (VHA) care.ObjectiveThe aim of the present study was to evaluate the effects of military sexual assault and combat exposure on women veterans’ use and perceptions of different aspects of VHA care.DesignCross-sectional telephone survey of a national sample of women veterans.ParticipantsWomen from the VA’s National Registry of Women Veterans.MeasurementsSociodemographic characteristics, VHA care utilization, perceptions of care.ResultsWomen veterans with histories of military sexual assault reported more use of VHA services, but less satisfaction, poorer perceptions of VHA facilities and staff, and more problems with VHA services compared to women veterans without histories of sexual assault. Combat exposure was related to more problems with VHA staff, although few other differences were observed for women with and without histories of combat exposure.ConclusionsFindings provide information on areas that can be targeted with respect to caring for women veterans exposed to military sexual trauma and combat exposure, including improving interactions with VHA staff and the ease of using VHA services.

Social anxiety and its relationship to functional impairment in body dysmorphic disorder.

Social anxiety appears to be a prominent characteristic of body dysmorphic disorder (BDD). However, few previous studies have examined social anxiety and its facets (i.e., physiological arousal, fear and avoidance of social situations) and their relationship to psychosocial functioning in BDD. The present study aimed to fill these gaps by examining (a) social anxiety and its facets in BDD, and b) cross-sectional and prospective relationships between social anxiety symptoms and functional impairment in BDD. Individuals with DSM-IV BDD without comorbid social phobia (N=108) completed measures of social anxiety and psychosocial functioning at study intake (T1). Psychosocial functioning was also assessed at a 12-month follow-up interview (T2). Severity of social anxiety (i.e., due to BDD or any other source) was rated with the Social Phobia Inventory (SPIN). In addition, participants were interviewed with the Duke Brief Social Phobia Scale (BSPS) to assess social anxiety independent of BDD. At T1, participants endorsed high levels of social anxiety on the SPIN and subclinical levels of social anxiety on the BSPS. Greater social anxiety was associated with poorer psychosocial functioning in cross-sectional and prospective analyses, particularly fear and avoidance of social situations. These results suggest that certain aspects of social anxiety, especially social fear and avoidance, may be significant contributing factors to functional impairment in individuals with BDD.

Observational fear conditioning in the acquisition and extinction of attentional bias for threat : An experimental evaluation

Anxious persons show automatic and strategic attentional biases for threatening information. Yet, the mechanisms and processes that underlie such biases remain unclear. The central aim of the present study was to elucidate the relation between observational threat learning and the acquisition and extinction of biased threat processing by integrating emotional Stroop color naming tasks within an observational differential fear conditioning procedure. Forty-three healthy female participants underwent several consecutive observational fear conditioning phases. During acquisition, participants watched a confederate displaying mock panic attacks (UCS) paired with a verbal stimulus (CS+), but not with a second nonreinforced verbal stimulus (CS-). As expected, participants showed greater magnitude electrodermal and verbal-evaluative (e.g., distress, fear) conditioned responses to the CS+ over the CS- word. Participants also demonstrated slower color-naming latencies to CS+ compared to the CS- word following acquisition and showed attenuation of this preferential processing bias for threat following extinction. Findings are discussed broadly in the context of the interplay between fear learning and processing biases for threat as observed in persons suffering from anxiety disorders.

Neuroendocrine Predictors of Emotional and Behavioral Adjustment in Boys: Longitudinal Follow-Up of a Community Sample

BACKGROUND Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis has been observed in adults and children with mood and anxiety disorders and is thought to be involved in the pathogenesis of these disorders. We recently studied a diverse community sample of boys and found associations of behavioral problems, including symptoms of depression and anxiety, with basal and stress-induced cortisol concentrations. Here we examine cortisol-emotional/behavioral associations at a two-year follow-up and test whether initial cortisol is predictive of worsening emotional/behavioral problems two years later. METHOD Seventy-eight 10-14-year-old boys and their mothers completed a battery of psychosocial assessments, provided morning and afternoon saliva samples, and participated in a home visit involving mildly stressful tasks and saliva collection for cortisol assay during a two-year follow-up assessment. RESULTS Consistent with the findings from our time 1 assessment, greater declines in cortisol across the home-visit challenge task were significantly associated with internalizing and externalizing behaviors as well as attention problems and social problems at the two-year follow-up. In addition, morning and afternoon cortisol concentrations at the initial assessment were significant positive predictors of the later development of child depressive symptoms at follow-up after controlling for initial depressive symptoms. CONCLUSION These findings demonstrate that children in the community with internalizing and externalizing behavior problems have altered patterns of HPA axis stress reactivity. In addition, our prospective findings suggest that elevated cortisol concentrations may influence the later development of emotional/behavioral problems in boys.

Associations between emotional avoidance, anxiety sensitivity, and reactions to an observational fear challenge procedure

Research has shown that emotional avoidance and anxiety sensitivity are associated with more self-reported fear and distress in response to laboratory fear challenge procedures. The present study aimed to expand upon this work and examined how emotional avoidance and anxiety sensitivity are related to emotional and physiological responses to an observational fear challenge procedure. To accomplish this aim, a carefully screened, non-clinical sample (N=43) was administered the Acceptance and Action Questionnaire (AAQ), a measure of emotional avoidance, and the Anxiety Sensitivity Index (ASI). Participants then engaged in an observational fear challenge paradigm. During the fear challenge, participants watched mock panic attacks while emotional (e.g., fear and panic) and skin conductance levels were assessed. Consistent with expectation, emotional avoidance and anxiety sensitivity were positively associated with more self-reported fear and more severe panic symptoms to the challenge procedure. However, anxiety sensitivity was more highly associated with self-reported fear and panic symptoms in response to the challenge procedure than emotional avoidance. Emotional avoidance and anxiety sensitivity were not associated with levels of physiological arousal to the observational fear challenge procedure. Discussion focuses on the interplay between emotional avoidance, anxiety sensitivity, and the development of vicarious fear responses and how these constructs may contribute to the pathogenesis of anxiety disorders.

Behavioral Adjustment in a Community Sample of Boys: Links with Basal and Stress-Induced Salivary Cortisol Concentrations

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis has been observed in association with internalizing symptoms and is thought to be involved in the pathogenesis of depression and some anxiety disorders. This study examined basal and stress-induced cortisol concentrations in relation to internalizing and externalizing symptoms in a racially mixed community sample of 102 8-11-year-old boys. Afternoon basal cortisol concentrations were positively correlated with measures of internalizing behavior problems, social problems, and emotionality. Greater change in cortisol across a home-visit challenge task was also significantly associated with internalizing behaviors and social problems, as well as attention and thought problems. The implications of these findings and how they may relate to the pathogenesis of emotional and behavioral problems are discussed.