Anxiety Spectrum Research Articles

Characteristics of Telephone Calls in a Psychiatric Outpatient Practice

The goal of this study was to document the volume and characteristics of telephone calls from patients in an outpatient psychiatric clinic. Telephone calls from a psychiatric resident's patients were logged over a 6-month period. Information collected included sex of the caller, reason for the call, deemed importance of the call, primary psychiatric diagnosis, and insurance type. A total of 291 calls occurred during the 6-month period, with an average of 2.4 calls per work day. The physician deemed 1.5% of calls to be an emergency and 15% to be urgent. Of the resident's total case load of 115 patients over the 6 month period, 29% (n = 33) of patients never made physician-patient telephone contact. Female patients were significantly more likely to call than males. Requests for medication refills were the most frequent type of call (38%). The mean number of calls per patient in the caseload was significantly different across diagnostic groups, with patients with personality disorders and anxiety spectrum disorders making more calls than other groups. There was no significant difference in the volume of telephone calls between patients with private health insurance and those without. This study may be of particular interest to physicians and managed care systems who are interested in reimbursement for telephone psychiatry. This study confirms and extends the previously reported association between certain psychiatric disorders (personality disorders, anxiety spectrum disorders) and relative frequency of telephone calls to the physician. In addition, the high volume of calls for prescription refills is an important issue in telephone management.

Anxiety symptoms in clinically diagnosed bruxers

The present work was an attempt to investigate for the existence of an association between anxiety psychopathology and bruxism. The presence of bruxism was investigated according to validated clinical criteria in 98 subjects, who also filled out a self-report questionnaire (PAS-SR) for the assessment of panic-agoraphobic spectrum. 34.7% (n = 34) of participants were diagnosed as bruxers. The prevalence of anxiety psychopathology was similar between bruxers and non-bruxers, but Mann-Whitney U-test revealed significant differences in total PAS-SR (P = 0.026) score, indicating that subclinical symptoms of the anxiety spectrum might differentiate bruxers from controls. In particular, significant differences emerged in scores of domains evaluating panic (P = 0.039), stress sensitivity (P = 0.006) and reassurance sensitivity symptoms (P = 0.005) of panic-agoraphobic spectrum. Support to the existence of an association between bruxism and certain psychopathological symptoms has been provided.

Are We Overpathologizing the Socially Anxious? Social Phobia from a Harmful Dysfunction Perspective

Some social phobias are clearly genuine mental disorders. However, in just 2 decades, social phobia (or social anxiety disorder) went from rare (in the DSM-III) to common (1), amidst changing criteria and concern about caseness thresholds (2). The evidence suggests that social anxiety is a normal, species-typical, designed response to specific triggering situations, one that is roughly normally distributed in temperamental intensity (3,4). This raises the question, Is temperamentally high but nondisordered social anxiety being mislabelled a disorder? We argue that many, perhaps most, people whom the DSM-IV potentially classifies as suffering from social phobia are probably not disordered. Stein, a prolific writer on social phobia, asks the right question: Are we needlessly 'medicalising' a normal variant of temperament, performing cosmetic psychopharmacology to remove blemishes of the personality? (5). His answer: No. However, his reasons-that generalized social phobia is extreme on the social anxiety spectrum, undesired, and disabling in some social roles-also apply to many nondisordered features (for example, grief, homeliness, shortness, or selfishness). Moreover, roughly one-half of community diagnoses are nongeneralized cases. Further, neither biological differences between more and less anxious individuals nor findings that social anxiety runs in families show whether the more anxious are disordered or normal variants. Such correlates do not allow us to avoid the difficult conceptual question, When is social anxiety disordered? The harmful dysfunction analysis of disorder (6-8), used here, holds that disorders are dysfunctions that cause harm, with dysfunctions defined as failures of mental or physical mechanisms to perform biologically designed functions. Problematic mismatches between designed human nature and current social desirability are not disorders; for example, such negative but biologically designed conditions as adulterous longings, taste for fat and sugar, and male aggressiveness are not in themselves disordered. Also, the extremes of normally distributed features are not necessarily disorders; it depends on whether they involve dysfunctions. Judgments about normal and dysfunctional social anxiety remain at best plausible speculations. However, normal social anxiety is likely an adaptation preventing individuals from easily risking status in the group (9). In early environments, social groups were small and composed of familiars who cooperated but were nonetheless in competition for status and resources. Remaining an accepted group member despite such competition was critical to survival. A range of strategics balancing pursuit of status and avoidance of rejection-including some strategies involving high anxiety about placing oneself in social jeopardy and readiness for submission should jeopardy occur-likely had selective advantages. Moreover, normal social anxiety is exacerbated in our mass society, wherein we routinely negotiate new social hierarchies and, in some occupations, confront situations that tend to trigger anxiety by biological design. Our egalitarian society considers submissive displays that might reduce anxiety to be potentially embarrassing; consequently, they may be inhibited, further heightening anxiety. Substantial social anxiety under certain circumstances is thus compatible with normality. What, then, distinguishes social phobia from normal social anxiety? Social anxiety is uncomfortable and thus involves harm. Whether it is disordered depends on whether a dysfunction exists; that is, whether mechanisms that generate and regulate social anxiety fail to perform their function of minimizing risk while allowing social interaction. Such dysfunction involves greatly disproportionate anxiety intensity relative to the triggering situation: anxiety reaches debilitating levels in species-expectable tasks or remains intense when biologically plausible triggers are absent or minimal, for example, during interaction with family members or other nonthreatening familiars; or when engaging in basic functions, such as eating away from home; or in situations where there is no real social scrutiny or chance of losing status, such as sitting anonymously in a lecture hall. …

Psychiatric Symptoms among Prospective Bariatric Surgery Patients: Rates of Prevalence and their Relation to Social Desirability, Pursuit of Surgery, and Follow-Up Attendance

There is a very limited empirical literature regarding the psychiatric status of prospective bariatric patients and no studies that examine potential social desirability effects on self-presentation for this patient population. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) was utilized to assess the prevalence of 13 DSM-IV Axis I disorders in a sample of 294 bariatric patients attending a presurgical psychological consultation. Marlowe-Crowne Social Desirability Scale (MCSD) was also included for 256 of these patients. Six-month follow-up data for a sub-sample of 64 patients was obtained to compare the extent of presurgical psychiatric symptoms between individuals who did versus did not pursue the surgery and those who attended versus failed to attend post-operative follow-up appointments. The results suggested the presence of an Axis I disorder among half of these patients, with comorbidity present in 29.9% of the sample. Highest prevalence rates were suggested for somatization (29.3%), social phobia (18%), hypochondriasis (15%), and obsessive-compulsive disorder (13.6%). Univariate analyses revealed that only MSCD scores were significantly and negatively related to total symptom levels. Analyses of the follow-up data indicated that patients who pursued the surgery had fewer total symptoms. Patients who attended all of their follow-up appointments tended to be older and weighed more at their presurgical evaluation. These findings suggest that significant psychopathology can be found among bariatric patients, and highlight the importance of attending to impression management issues and anxiety spectrum disorders in presurgical psychological evaluations.

Association studies of MAO-A, COMT, and 5-HTT genes polymorphisms in patients with anxiety disorders of the phobic spectrum

Recent studies provide evidence that anxiety disorders may be linked to malfunction of serotonin neurotransmission or impaired activity of enzymes metabolising the catecholamines. Functional polymorphisms in the MAO-A uVNTR promoter gene, the COMT gene (Val158Met) exon 4, and the 5-HTT promoter gene (44 bp ins/del) were investigated in 101 patients with phobic disorders of the anxiety spectrum and 202 controls matched to the patients for sex, age and ethnicity. There were no significant differences between controls and patients in the allele and genotype frequencies of the 5-HTT and COMT gene polymorphisms. The frequency of >3 repeat alleles of the MAO-A gene polymorphism was significantly higher in female patients suffering from anxiety disorders, specifically panic attacks and generalized anxiety disorder. There was also a trend for the more frequent presence of >3 repeat alleles in female patients with agoraphobia and specific phobia, in contrast to female patients with social phobia, who did not differ from controls. The results support a possible role of the MAO-A gene in anxiety disorders.

Patterns of Axis-II comorbidity in a Turkish OCD sample

OBJECTIVEObsessive–compulsive disorder (OCD) patients frequently present with Axis-II disorders, particularly Cluster C (anxiety spectrum) and Cluster A (schizophrenic spectrum) personality disorders. The present study examined patterns of Axis-II comorbidity in a Turkish OCD sample. In addition, we explored the impact of personality disorder symptoms on OCD-symptom severity and symptom profile.METHODStructured psychiatric interviews and self-report measures of OCD symptoms and Axis-II disorders were administered to patients with OCD and control subjects.RESULTSPatients with OCD obtained significantly higher scores on measures of Cluster A and Cluster C personality disorders. Patients with OCD also achieved significantly higher scores on the BPD Subscale; however, they did not obtain significantly higher scores on other Cluster B subscales. Group differences on measures of Cluster A and C disorders were marked.CONCLUSIONSFindings are consistent with prior work demonstrating an increased incidence of Axis-II disorders among patients with OCD.

Cross-sectional assessment of psychiatric disorders in renal transplantation patients in Turkey: a preliminary study

Background Psychiatric disorders such as depression and anxiety may be seen after a successful renal transplantation (RTx). The aim of this cross-sectional study was the assessment of psychiatric disorders after RTx in Turkey. The value of self-report scales in predicting depression and anxiety was also assessed. Patients and methods The study group consisted of 20 male and 20 female RTx patients (mean age 35.42 ± 10.09 years), with a mean duration of 61.65 ± 48.30 months of follow-up after transplantation. All patients were assessed with the validated Turkish versions of Structured Clinical Interview for the DSM-IV (SCID-I), Beck Depression Inventory (BDI), Hospital Anxiety Depression Scales (HADS), Spielberger Trait Anxiety Inventory (STAI-I), and Beck Hopelessness Scale (BHS). Results Twenty of the 40 patients warranted a DSM-IV psychiatric diagnosis with SCID-I evaluation. Major depression was observed in 25% of patients. The remaining diagnoses were within the affective and/or anxiety spectrum disorders. The set of age, gender, education, income, marital status, employment, type of transplantation, duration of illness, and duration after the transplantation was not significantly different between patients with or without psychiatric diagnoses. BDI, HADS, STAI-I, and BHS were significantly higher among patients with psychiatric diagnoses at P = .001 level using Student t test. Even after control of the variance explained by the set of demographic variables, hierarchical regression analysis revealed that HADS scores significantly predicted the psychiatric morbidity ( P = .003). Conclusion The frequency of psychiatric disorders is quite high in renal transplantation patients. Additionally, HADS, which significantly predicts depression and anxiety, may be used for screening purposes.

Modelling extracellular domains of GABA-A receptors: subtypes 1, 2, 3, and 5

GABA is the main inhibitory neurotransmitter in the mammalian central nervous system. When GABA binds to the ubiquitous GABA-A receptors on neurons, chloride channels are activated leading to a rapid increase in chloride conductance that depresses excitatory depolarization. The GABA-A receptors are targets for many clinically important drugs, such as the benzodiazepines, general anaesthetics, and barbiturates. All of these drugs enhance the chloride current activated by GABA. Of the GABA-A receptor family, the subtype 2 is critical for the treatment of anxiety spectrum disorders. To avoid unwanted side effects, it is necessary to find highly selective drugs that interact only with subtype 2 but not with the related receptors such as subtypes 1, 3, and 5. To realize such a goal, it is important to have not only the 3D (dimensional) structure of subtype 2 but also the 3D structures of subtypes 1, 3, and 5. In this study, the 3D structures of all the four subtypes of GABA-A receptors have been derived. The computer-modeled heteropentameric structures bear the following features: (1) each of the five subunits in the pentamer has an intrachain disulfide bond, a hallmark of ligand-gated pentameric channels; (2) those residues which are sensitive to the binding of the benzodiazepine site ligands are grouped around the α 1,2,3,5/ γ 2 interfaces; and (3) those residues which are sensitive to the binding of GABA molecules are grouped around the α 1,2,3,5/ β 2 interfaces. All these findings are fully consistent with experimental observations. Meanwhile, for those sensitive or key residues, a close look at their subtle difference among the four subtypes has been provided through a highlighted superposition picture. In addition to providing the atomic coordinates, the predicted structures have further clarified some ambiguities that could not been uniquely determined by the existing experimental data, such as the directionality of the subunit arrangement in the heteropentamers. The 3D models may provide a reasonable structural frame or footing for designing highly selective drugs. The present models might be also useful in understanding the basic mechanism of operation of the GABA-A receptors, stimulating novel strategies for developing more specific drugs and better treatments.

Anxiety and error-related brain activity

Error-related negativity (ERN/Ne) is a component of the event-related brain potential (ERP) associated with monitoring action and detecting errors. It is a sharp negative deflection that generally occurs from 50 to 150 ms following response execution and has been associated with anterior cingulate cortex (ACC) activity. An enhanced ERN has been observed in patients with obsessive-compulsive disorder (OCD)—reflecting abnormal ACC activity hypothesized as part of the pathophysiology of OCD. We recently reported that the ERN is also enhanced in a group of college students with OC characteristics. The present study extended these findings by measuring the ERN in college undergraduates who scored high on either the Penn State Worry Questionnaire (PSWQ) or a combined version of the Snake (SNAQ) and Spider (SPQ) Questionnaires. Results indicate that, like OC subjects, subjects who score high on a measure of general anxiety and worry have enhanced error-related brain activity relative to both phobic and non-anxious control subjects. The enhanced ERN was found to generalize beyond OCD within the anxiety spectrum disorders but also shows some specificity within these disorders.

Successful educators: a practical guide for understanding children's learning problems and mental health issues

Introduction Four-Component Model: Factors that Can Explain Why a Student Is Not Succeeding in School Paying Attention Characteristics of Attention Deficit Hyperactivity Disorder (ADHD) Identification of ADHD Treatment of ADHD The Ability Component How to Identify and Describe Skill Deficits How to Treat Skill Deficits Effort Component The Connection Between Your Expectations and Your Students' Efforts Using Positive Communication to Improve Student Effort The Impact of Depression and Bipolar Disorder on a Student's Effort The Impact of Disorders within the Anxiety Spectrum on Student Effort The Impact of Behavioral Disorders on Student Effort Organization and Study Skills Component Communicating Your Knowledge with Parents References Suggested Reading Internet Resources

Anxiolytic profile of the antiepileptic drug levetiracetam in the Vogel conflict test in the rat

The novel antiepileptic drug levetiracetam has been shown to reverse anxiogenic effects of benzodiazepine withdrawal in mice tested in an elevated plus-maze without altering the behaviour of normal mice in this model. This could suggest that the effect of levetiracetam is dependent upon the level of stress/anxiety of the animals. Levetiracetam was therefore further examined in another widely used animal model of anxiety, the Vogel conflict test. In the first experiment, water-deprived rats were submitted to a free drinking period (habituation) in a chamber equipped with a bottle of water. Twenty-four hours later, animals were returned to the same chamber but the licks to the water bottle were then punished with a foot shock (0.5 mA, 90 ms). In the second experiment, the procedure was modified by administering a foot shock at the end of the habituation period in order to induce a state of stress/anxiety (conditioned fear/ anticipatory anxiety) for subsequent testing. Levetiracetam (17 and 54 mg/kg) and chlordiazepoxide (5 mg/kg) were administered via the intraperitoneal route. The results indicated that in the first experiment only chlordiazepoxide showed a statistically significant anxiolytic effect. In contrast, in the second experiment, where the shock was given at the end of the habituation period, levetiracetam (54 mg/kg) revealed significant anxiolytic activity similar to chlordiazepoxide. This suggests that levetiracetam may have potential anxiolytic effects and may provide therapeutic benefits to individual with anxiety spectrum disorders.

Brief Interventions for Anxiety Disorders: Clinical Outcome Studies

While the number of well-designed controlled clinical outcome studies is not large, brief psychotherapeutic interventions appear to play a useful role in the treatment of anxiety spectrum disorders. Such interventions not only appear to be effective in their own right, but also add a significant component to the benefits of medication. This article summarizes and describes the time-limited interventions and outcomes of more than 50 studies, including a number that measured the effectiveness of crisis intervention and brief therapy approaches with post-traumatic stress disorder (PTSD) precipitated by gunshot injuries, sexual assaults, terrorist attacks, vehicular accidents, and violent crimes. [Brief Treatment and Crisis Intervention 2:325–339 (2002)]

Social anxiety spectrum: gender differences in Italian high school students.

Gender differences in the social anxiety spectrum and their correlation with other psychopathological features were analyzed in 520 students by using two questionnaires: the Social Anxiety Spectrum Self-Report (SHY-SR), which explores social anxiety spectrum, and the General Spectrum Measure (GSM), which explores panic-agoraphobia, mood, obsessive-compulsive, and eating-behavior features. Mean SHY-SR total score was significantly higher in women than in men, and gender differences were particularly pronounced for interpersonal sensitivity domain. Likewise, GSM scores were higher in women, except for the manic section. The SHY-SR domains correlated significantly with all GSM sections, except for the manic section. In conclusion, women reported more symptoms than men (who belonged to different psychopathologic dimensions) and displayed a profile of social anxiety spectrum that differs quantitatively but not qualitatively from the men's profile. The correlation between social anxiety spectrum and other psychopathological features mirrors previous findings concerning the high comorbidity of axis-I social anxiety disorder.

Altered dopamine D 2 receptor function in fibromyalgia patients: a neuroendocrine study with buspirone in women with fibromyalgia compared to female population based controls

Background: To what extent fibromyalgia belongs to affective spectrum disorders or anxiety spectrum disorders remains disputed. Buspirone induces a hypothermic response, which most likely is due to 5-HT 1A autoreceptor stimulation, and growth hormone (GH) release, which probably is related to postsynaptic 5-HT 1A receptor stimulation. The prolactin response to buspirone has been suggested to be mediated through dopamine (DA) antagonistic effects. Objectives: Based on the assumption that fibromyalgia is more strongly related to stress and anxiety than affective spectrum disorders, we hypothesized that compared to population controls, fibromyalgia patients should demonstrate an increased prolactin response (DA sensitivity) to buspirone challenge test, but no difference in hypothermic response or GH release (5HT sensitivity). Method: A 60-mg dose of buspirone was given orally to 22 premenopausal women with fibromyalgia and 14 age and sex matched healthy control subjects. Core body temperature, growth hormone and prolactin levels were analyzed at baseline and after 60, 90, and 150 min. Results: Fibromyalgia patients showed an augmented prolactin response to buspirone compared to controls. Temperature and growth hormone responses did not differ from controls. Conclusions: Dopaminergic rather than serotonergic neurotransmission is altered in fibromyalgia, suggesting increased sensitivity or density of dopamine D 2 receptors in fibromyalgia patients. Stress and anxiety is an important modulator of dopaminergic neurotransmission. Our results suggest that fibromyalgia is related to anxiety and associated with disturbance in the stress response systems.

Personality traits in social phobia

The purpose was to assess personality traits in subjects with a DSM-IV diagnosis of social phobia. Thirty-two subjects were administered the Structured Clinical Interview for DSM-IV for Axes I and II disorders (SCID I and II). Personality traits were assessed by means of the Karolinska Scales of Personality (KSP). Current and lifetime axis I co-morbidity was diagnosed in 28% and 53% of the subjects, respectively. In total, 59% had at least one personality disorder and 47% were diagnosed with an avoidant personality disorder. The social phobics scored significantly higher than a Swedish normative sample on the KSP measuring anxiety proneness, irritability, detachment, and indirect aggression but lower on the scales for socialisation and social desirability. The presence as compared to absence of avoidant personality disorder in the social phobics was associated with significantly higher psychic anxiety and inhibition of aggression. In addition, symptom severity was higher in social phobics with an avoidant personality disorder. Generally, the results support the view that social phobia and avoidant personality disorder reflect different aspects of a social anxiety spectrum.

Structural issues and policy in the management of depressive illness: Overview and expert panel commentary

Opening with an overview of the current state of knowledge regarding management of depression and anxiety spectrum disorders, this paper then reports commentary from the expert panel on the question: When there are effective treatments, why are optimal outcomes not achieved in clinical practice?

Obsessive-Compulsive Disorder and Anxiety Spectrum in Children

Obsessive-compulsive disorder (OCD) is now recognized as a frequent and disabling disorder among children and adolescents. The phenomenology is similar to adult OCD, but several reports have indicated that compulsions are more prominent in children and that children are more inclined than adults to include their family surroundings in ritualistic behavior. It is also clear that young children engage in a significant amount of repetitive, ritualistic compulsive activity that appears to be a normal part of their behavioral repertoire.Although the cause of childhood-onset OCD is unknown, many factors are likely to contribute to the heterogenous clinical phenotypes, including both genetic and environmental factors. The neurobiological circuitry involved in childhood-onset OCD is likely to involve alterations to the same cortico-striatothalamic circuitry implicated in adult OCD, but the develop-mental differences have yet to be fully delineated. The treatment response patterns of adults and children are generally inconsis-tent with each other, and specific OCD subtypes may also respond differentially.Phenotypic characterization can be undertaken either categorically, as seen with traditional diagnostic categories, or dimensionally. Extended phenotypes can be defined in terms of symptoms and course of the illness, or neuroimaging and neurobiologic study findings, or treatment responses. Phenotypic characterization must also reflect an understanding of the rituals and repetitive behaviors that are associated with normal development. (A proposed categorization of OCD subtypes appears in the “Table library.”)

Modern epidemiology of anxiety: results of the Zurich cohort study

The Zurich cohort study investigated a general population sample of 591 males and females, enriched by risk cases, through five interviews carried out between the ages of 20 and 35. The total prevalence rate for the anxiety spectrum (consisting of panic, general anxiety disorders (GAD) and recurrent brief anxiety states (RBA)) was 22 per cent. Panic and RBA were highly associated (odds ratio 12·3). Complex panic syndromes (panic+GAD, panic+RBA) were shown to be much more severe than pure panic in terms of impairment, treatment and suicide attempt rates. Pure panic, DSM-III GAD and RBA showed comparable validity. For the definition of GAD, a duration of two or four weeks is probably preferable to the 6-months currently required by DSM-IV and ICD-10. The marked longitudinal associations and diagnostic changes between the three anxiety states support the hypothesis of an anxiety spectrum. Copyright © 1999 John Wiley & Sons, Ltd.

Heteromeric complexes of alpha 5 and/or alpha 7 subunits. Effects of calcium and potential role in nicotine-induced presynaptic facilitation.

Nicotine alters a broad spectrum of behaviors, including attention, arousal, anxiety, and memory. The cellular physiology of nicotine is comparably diverse: nicotine interacts with an array of ionotropic receptors whose gating can lead to direct depolarization of neurons or to an indirect modulation of neuronal excitability by presynaptic facilitation. Furthermore, as many laboratories have shown, the alpha- and beta-type subunits that comprise neuronal nicotinic acetylcholine receptors (nAChRs) are encoded by multiple, homologous genes, yielding at least seven alpha and three beta subunits, distinct in primary sequence. nAChRs that differ in subunit composition differ in pharmacology, conductance, and kinetics as well as in their permeability to and modulation by calcium. We will first discuss recent studies on the biophysics of a special (peculiar?) subset of nAChRs, focusing on heteromeric nAChRs comprised of alpha 4 beta 2 +/- alpha 5 or alpha 7 +/- beta 2 and alpha 5. These nAChR channel subtypes are potently and differentially modulated by changes in intracellular calcium ([Ca]). Thus, the Po, tau o, and desensitization kinetics of alpha 4 beta 2 channels are altered by changes in [Ca]int from 0 to 50 microM; nAChRs that include the alpha 5 subunit are oppositely regulated. Mutagenesis of specific residues within the M1 and M2 domain of alpha 4, beta 2, and alpha 5 suggest a possible Ca binding "pocket." The assembly of functional nAChRs that include alpha 5 and/or alpha 7 and the potential role of these novel heteromeric complexes in presynaptic facilitation will also be presented.

The spectrum of generalised anxiety in clinical practice: the role of short-term, intermittent treatment∗

DSM-IV generalised anxiety disorder (GAD) has a high lifetime prevalence, but subthreshold anxiety states are even more common, particularly in family practice. Generalized anxiety is conceptualised as a spectrum of disorders, with transient anxiety at one end and GAD at the other. Based on long-term experience with family practice patients, the authors suggest that most anxious patients, wherever on this continuum they are placed, could be treated with short-term, possibly intermittent, rather than chronic anxiolytic therapy. Data are presented which show that 50% of chronic GAD patients are only in need of such short-term intermittent therapy. Further clinical research is needed to refine short-term, intermittent treatments for anxiety spectrum disorders, to make effective treatments available to those suffering from anxiety but falling short of diagnostic criteria for GAD, and to target more effectively the different treatment strategies.