Scott L. Rauch

What is an anxiety disorder

Initiated as part of the ongoing deliberation about the nosological structure of DSM, this review aims to evaluate whether the anxiety disorders share features of responding that define them and make them distinct from depressive disorders, and/or that differentiate fear disorders from anxious‐misery disorders. The review covers symptom self‐report as well as on‐line indices of behavioral, physiological, cognitive, and neural responding in the presence of aversive stimuli. The data indicate that the anxiety disorders share self‐reported symptoms of anxiety and fear; heightened anxiety and fear responding to cues that signal threat, cues that signal no threat, cues that formerly signaled threat, and contexts associated with threat; elevated stress reactivity to aversive stimuli; attentional biases to threat‐relevant stimuli and threat‐based appraisals of ambiguous stimuli; and elevated amygdala responses to threat‐relevant stimuli. Some differences exist among anxiety disorders, and between anxiety disorders and depressive disorders. However, the differences are not fully consistent with proposed subdivisions of fear disorders vs. anxious misery disorders, and comparative data in large part are lacking. Given the high rates of co‐morbidity, advances in our understanding of the features of responding that are shared across vs. unique to anxiety and depressive disorders will require dimensional approaches. In summary, the extant data help to define the features of responding that are shared across anxiety disorders, but are insufficient to justify revisions to the DSM nosology at this time. Depression and Anxiety, 2009.

OBSESSIVE-COMPULSIVE DISORDER: A REVIEW OF THE DIAGNOSTIC CRITERIA AND POSSIBLE SUBTYPES AND DIMENSIONAL SPECIFIERS FOR DSM-V

Background: Since the publication of the DSM‐IV in 1994, research on obsessive–compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility. Methods: The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies. Results: This review presents a number of options and preliminary recommendations to be considered for DSM‐V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions (criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered “time‐consuming” for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a “general medical condition”; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to “poor insight,” and adding “tic‐related OCD”); and (7) highlighting in the DSM‐V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions). Conclusions: A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM‐V process progresses. Depression and Anxiety, 2010.

Should OCD be classified as an anxiety disorder in DSM‐V?

In DSM‐III, DSM‐III‐R, and DSM‐IV, obsessive–compulsive disorder (OCD) was classified as an anxiety disorder. In ICD‐10, OCD is classified separately from the anxiety disorders, although within the same larger category as anxiety disorders (as one of the “neurotic, stress‐related, and somatoform disorders”). Ongoing advances in our understanding of OCD and other anxiety disorders have raised the question of whether OCD should continue to be classified with the anxiety disorders in DSM‐V. This review presents a number of options and preliminary recommendations to be considered for DSM‐V. Evidence is reviewed for retaining OCD in the category of anxiety disorders, and for moving OCD to a separate category of obsessive–compulsive (OC)‐spectrum disorders, if such a category is included in DSM‐V. Our preliminary recommendation is that OCD be retained in the category of anxiety disorders but that this category also includes OC‐spectrum disorders along with OCD. If this change is made, the name of this category should be changed to reflect this proposed change. Depression and Anxiety, 2010.

Amygdala activation in response to facial expressions in pediatric obsessive-compulsive disorder

Background: Exaggerated amygdala activation to threatening faces has been detected in adults and children with anxiety disorders, compared to healthy comparison (HC) subjects. However, the profile of amygdala activation in response to facial expressions in obsessive–compulsive disorder (OCD) may be a distinguishing feature; a prior study found that compared with healthy adults, adults with OCD exhibited less amygdala activation to emotional and neutral faces, relative to fixation [Cannistraro et al. (2004). Biological Psychiatry 56:916–920]. Methods: In the current event‐related functional magnetic resonance imaging (fMRI) study, a pediatric OCD sample (N=12) and a HC sample (N=17) performed a gender discrimination task while viewing emotional faces (happy, fearful, disgusted) and neutral faces. Results: Compared to the HC group, the OCD group showed less amygdala/hippocampus activation in all emotion and neutral conditions relative to fixation. Conclusions: Like previous reports in adult OCD, pediatric OCD may have a distinct neural profile from other anxiety disorders, with respect to amygdala activation in response to emotional stimuli that are not disorder specific. Depression and Anxiety, 2010.

Functional MRI study of specific animal phobia using an event-related emotional counting stroop paradigm

Background: Emotional interference tasks may be useful in probing anterior cingulate cortex (ACC) function to understand abnormal attentional study in individuals with specific phobia. Methods: In a 3u2009T functional MRI study, individuals with specific phobias of the animal subtype (SAP, n=12) and healthy comparison (HC) adults (n=12) completed an event‐related emotional counting Stroop task. Individuals were presented phobia‐related, negative, and neutral words and were instructed to report via button press the number of words displayed on each trial. Results: Compared to the HC group, the SAP group exhibited greater rostral ACC activation (i.e., greater response to phobia‐related words than neutral words). In this same contrast, HCs exhibited greater right amygdala and posterior insula activations as well as greater thalamic deactivation than the SAP group. Both groups exhibited anterior cingulate, dorsomedial prefrontal cortex, inferior frontal gyrus/insula, and amygdala activations as well as thalamic deactivation. Psychophysiological interaction analysis highlighted a network of activation in these regions in response to phobia‐related words in the SAP group. Conclusions: Taken together, these findings implicate a circuit of dysfunction, which is linked to attention abnormalities in individuals with SAP. Depression and Anxiety, 2009. Published 2009 Wiley‐Liss, Inc.

Anxiety sensitivity correlates with two indices of right anterior insula structure in specific animal phobia

Background: Anxiety sensitivity (AS) is a dispositional trait involving fear of anxiety‐related symptoms. Functional imaging research suggests that the activity of the anterior insular cortex, particularly the right insula, may both mediate AS and play a role in the pathophysiology of phobias. However, no imaging studies have examined whether AS relates to insula morphology. We examined whether AS was significantly correlated with right anterior insula volume and thickness among adults with specific animal phobia (SAP) and healthy comparison (HC) subjects. Methods: Nineteen adults with SAP and 20 demographically group‐matched HC subjects underwent magnetic resonance imaging at 3u2009Tesla. Subjects also completed the Anxiety Sensitivity Index (ASI). Regression and correlation analyses examined ASI scores in relation to anterior and posterior insular cortex volume and thickness within and across subject groups. Results: SAP subjects had significantly higher ASI scores than HC, but did not differ in terms of insula volumes or thickness. ASI scores predicted right anterior insula thickness in SAP but not HC subjects, and right anterior insula volume in the sample as a whole. Correlations of ASI scores with the anterior and posterior insula volume and thickness were not significant in either group. Conclusions: These findings suggest that the right anterior insular cortex size is a neural substrate of AS within specific phobia, rather than an independent diagnostic marker of the disorder. Future investigations should examine whether heightened AS represents a shared intermediate phenotype across anxiety disorders, manifesting functionally as increased insular reactivity and clinically as a fear of anxiety symptoms. Depression and Anxiety, 2010.

Neural correlates of anxiety sensitivity during masked presentation of affective faces

Background: Anxiety Sensitivity (AS), the tendency to fear the thoughts, symptoms, and social consequences associated with the experience of anxiety, is associated with increased risk for developing anxiety disorders. Some evidence suggests that higher scores on the Anxiety Sensitivity Index (ASI), a measure of the AS construct, are associated with activation of the anterior insular cortex during overt emotion perception. Although the ASI provides subscale scores measuring Physical, Mental Incapacitation, and Social Concerns of AS, no study has examined the relationship between these factors and regional brain activation during affect processing. We hypothesized that insular responses to fear‐related stimuli would be primarily related to the Physical Concerns subscale of the ASI, particularly for a sample of subjects with specific phobias. Methods: Adult healthy controls (HC; n = 22) and individuals with specific phobia, small animal subtype (SAP; n = 17), completed the ASI and underwent functional magnetic resonance imaging while engaged in a backward‐masked affect perception task that presents emotional facial stimuli below the threshold of conscious perception. Results: Groups did not differ in ASI, state or trait anxiety scores, or insula activation. Total ASI scores were positively correlated with activation in the right middle/anterior insula for the combined sample and for the HC and SAP groups separately. Multiple regression analysis revealed that the relationship between AS and insular activation was primarily accounted for by Physical Concerns only. Conclusions: Findings support the hypothesized role of the right anterior insula in the visceral/interoceptive aspects of AS, even in response to masked affective stimuli. Depression and Anxiety 28:243–249, 2011. u2003u2003© 2011 Wiley‐Liss, Inc.

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER: EVIDENCE FOR TWO DIMENSIONS.

To determine possible dimensions that underlie obsessive–compulsive personality disorder (OCPD) and to investigate their clinical correlates, familiality, and genetic linkage.