An exploration of the nature and causes of distress in women attending gynecology outpatient clinics

This study evaluates the distress experienced by women attending gynecology outpatient clinics (GOCs). We investigate causes of this distress and explore women's own experience of their distress. A questionnaire survey of 197 women attending GOCs was carried out, both quantitative and qualitative analyses were undertaken. Thirty-five percent of women showed clinical levels of anxiety, 13% had clinically significant depression and half reported feeling distressed. A range of feelings was reported, though commonly mixed emotions were expressed. Women had a low sense of personal control and uncertainty in relation to their gynecologic problem. Both coincidental stress, such as life changes, and the direct consequences of the gynecologic problem were predictive of anxiety. Qualitative analysis suggested four ways in which women experienced their distress and the gynecologic problem: (i) gynecologic symptoms were a direct cause of distress, (ii) gynecologic symptoms caused distress indirectly through reactions to diagnosis and treatment, (iii) gynecologic symptoms caused distress because of their impact on relationships, social life and self identity, and (iv) distress was unrelated to the gynecologic symptoms. Results highlight diversity and complexity in women's experiences and support the need for a fuller understanding of distress in this group in order to meet their needs adequately and appropriately.

Predictive validity of an Implicit Association Test for assessing anxiety

The Implicit Association Test (IAT) was adapted to measure anxiety by assessing associations of self (vs. other) with anxiety-related (vs. calmness-related) words. Study 1 showed that the IAT-Anxiety exhibited good internal consistency and adequate stability. Study 2 revealed that the IAT-Anxiety was unaffected by a faking instruction. Study 3 examined the predictive validity of implicit and explicit measures and showed that the IAT-Anxiety was related to changes in experimenter-rated anxiety and performance decrements after failure. Study 4 found that several behavioral indicators of anxiety during a stressful speech were predicted by the IAT. Taken together, these studies show that the IAT-Anxiety is a reliable measure that is able to predict criterion variables above questionnaire measures of anxiety and social desirability.

Variables influencing anxiety of patients with abnormal cervical smears referred for colposcopy

The state anxiety scores of women with abnormal cervical smears referred for colposcopy were investigated to identify causes of anxiety, factors influencing anxiety and emotions involved with anxiety, in order to define strategies to reduce this anxiety. Forty-seven women were interviewed and completed a questionnaire and the Spielberger State and Trait Anxiety Inventory (STAI): 22 women prior to their intake consultation at the colposcopy clinic of the University Medical Center St Radboud, Nijmegen, and 25 women during their second visit before the actual colposcopy. The mean State anxiety score was 48.2, without significant differences between the intake and colposcopy consultation. The majority experienced anxiety because of a fear of cancer and/or the colposcopy. The mean State anxiety score was significantly higher in women who considered the level of information provided by the gynecologist/family practitioner insufficient, who experienced a long waiting time, who did not have a partner, and who experienced additional emotions like anger and sadness. In conclusion, patients referred for colposcopy after an abnormal cervical smear result have high levels of anxiety. High levels of anxiety may be reduced by uniform and explicit information about cervical smear results and colposcopy, by reduction of clinic waiting times, by stimulating social support, and by attention to emotions like anger and sadness.

Generalized anxiety disorder: comorbidity, comparative biology and treatment

Generalized anxiety disorder (GAD) is a severe and chronic anxiety disorder characterized by uncontrollable worrying and somatic anxiety (tension, insomnia and hypervigilance). It is a common condition, with lifetime prevalence rates for DSM-IV GAD in the general population of approx. 5-6% being reported. In addition, like other anxiety disorders, GAD also shows comorbidity with depression and most of the other anxiety disorders. This article reviews data on the prevalence of GAD, its comorbidity with depression, and its social and economic impact. Proposed neurobiological mechanisms for GAD are discussed, since an understanding of these may help in the development of future therapies. Finally, current pharmacological and non-pharmacological treatment options for GAD are reviewed, with particular attention being paid to published clinical-trial data.

[Mental disorders in patients with arterial hypertension with metabolic disturbances]

A battery of psychological tests has been used to study the psychic state and quality of life in 75 patients with mild and moderate arterial hypertension (AH) with or without (controls) different metabolic disturbances (diabetes mellitus, dyslipidaemia, obesity). Comparing to controls, the AH patients with metabolic disturbances suffered more frequently from different psychic disorders of neurotic register and their quality of life, general condition, activity and mood proved to be significantly worse. The authors conclude that psychological testing may be an important diagnostic tool in general hospital. It allows identification of the borderline mental disorders features, the correction of which appears to be of great importance for basic disease course and its therapy.

Social anxiety: an often silent disorder

Social anxiety disorder (SAD) is a chronic, often debilitating disorder with a high potential for comorbid conditions. Despite being among the most common of psychiatric disorders it is often under-recognized. This case illustrates the treatment of a patient who had initially presented for treatment of major depressive disorder, but was later discovered to also have SAD. Treatment of the SAD, which had predated the major depressive disorder, resulted in a markedly improved outcome. Discussions of treatment options including pharmacotherapy and psychotherapy are presented.

Achieving remission with venlafaxine and fluoxetine in major depression: its relationship to anxiety symptoms

Venlafaxine, a serotonin and norepinephrine reuptake inhibitor (SNRI), produces significantly higher remission rates in depressed patients than do the selective serotonin reuptake inhibitors (SSRIs). In this analysis of pooled data, we explored the relationship between differences in treatment efficacy, early improvement of symptoms, and severity of baseline anxiety in depressed patients treated with either venlafaxine or fluoxetine. A pooled analysis was performed on data from 1,454 outpatients with major depression from five double-blind, randomized studies comparing the 6-week efficacy of venlafaxine (542 patients) with fluoxetine (555 patients). The Hamilton rating scale for depression (HAM-D) total and item scores were analyzed at different treatment times up to 6 weeks. Venlafaxine and fluoxetine both produced statistically significant higher response and remission rates compared with placebo starting from week 2 for response and weeks 3 to 4 for remission. Venlafaxine was statistically significantly superior to fluoxetine from week 3 until week 6 in respect of response rate, and from week 2 until week 6 for remission rate. After 1 week of treatment, greater improvement in individual symptoms was observed in the depressed mood, suicide, and psychic anxiety items of the HAM-D scale for both venlafaxine- and fluoxetine-treated patients compared with placebo. Improvement in psychic anxiety was statistically significantly greater with venlafaxine than with fluoxetine. The presence of baseline psychic anxiety correlated significantly to treatment outcome when analyzing the remission rates. In depressed patients with moderate anxiety (HAM-D psychic anxiety score < or = 2), venlafaxine statistically significantly increased remission rates compared with placebo from week 4 until week 6, while a significant effect of fluoxetine on remission rates was observed starting at week 6. Remission rates in the severely anxious depressed patients (score > 2) were statistically significantly higher with venlafaxine than placebo starting from week 3 until the end of the study period, but no difference could be observed between fluoxetine and placebo. Baseline severity of psychic anxiety had a significant impact on remission rates after treatment of patients diagnosed with depression. Venlafaxine's superior remission rates in the more severely anxious patients and its ability to improve psychic anxiety as early as week 1 compared with fluoxetine suggest that venlafaxine's early efficacy on anxiety symptoms may be the basis for its superior efficacy in depression.

Social anxiety disorder and the neurobiology of social relationships

Social anxiety disorder (SAD) is a prevalent anxiety disorder with the potential for considerable impairment. A patient with SAD is presented and treatment options are discussed. Novel concepts guiding our understanding of the neurobiology of SAD are presented, including the concept of sensory maps of the body, which is used to speculate on the nature of internal representations of relationships and their potential role in triggering anxiety in SAD. Understanding the neural circuitry mediating social relationships and its role in the threat response in SAD may be important for the development of new treatments for this disorder.

Anxiety sensitivity and panic disorder

Anxiety sensitivity refers to fears of anxiety-related sensations. Most often measured by the Anxiety Sensitivity Index (ASI), anxiety sensitivity is a dispositional variable especially elevated in people with panic disorder. Regardless of diagnosis, ASI scores often predict panic symptoms in response to biological challenges (e.g., carbon dioxide inhalation) that provoke feared bodily sensations. Prospective longitudinal studies indicate that scores on the ASI predict subsequent spontaneous attacks, indicating that elevated anxiety sensitivity is a risk factor for panic and perhaps panic disorder. Cognitive behavioral treatment reduces anxiety sensitivity in panic patients, perhaps protecting against relapse. Imipramine likewise decreases anxiety sensitivity.

Challenges and early experiences in the development of an anxiety clinic in the public health sector

This paper argues the importance of establishing specialist anxiety clinics within the public sector of the Australian health system. It describes the development of such a service and summarizes the characteristics of the first 1000 clients. Factors such as staffing, utilization trends, referral patterns, assessment and treatment procedures, and the clinical and demographic characteristics of the first 1000 cases are reviewed and discussed. The model of the clinic, which operates in partnership with community mental health and an academic research unit, has proven itself to be a suitable, cost-effective and efficient prototype in the treatment of anxiety disorders. Anxiety disorders exact a high social and economic cost. At a time of global funding cuts and savings in the mental health system, it is vital to think ethically as well as cost-efficiently, considerations that require that we offer the most efficient treatment to the greatest number of people.

Cognition in childhood anxiety: conceptual, methodological, and developmental issues

Anxiety disorders are one of the most common psychiatric disorders in the general child population and can have significant impact on immediate and long-term functioning. Despite the common use of cognitive-behavioral interventions that target specific, negative thoughts in anxious children, it is unclear that the extant literature clearly documents cognitive aberrations among these children. In this review, conceptual and methodological issues related to the assessment of cognition in anxious children are highlighted and empirical data addressing these areas are evaluated. Furthermore, data addressing cognitive change as a function of treatment outcome is examined, and the impact of cognitive development as a moderating variable is discussed. Finally, areas for future research are presented.

Psychotropic prescription in non-psychiatric hospital settings

A study was conducted to assess differences in psychotropic prescription (PP) in various non-psychiatric hospital settings. After adjustment for demographic, medical and psychological status, rates of PP were significantly lower for surgical, intensive care and outpatients and higher for geriatric patients than for patients in other settings, suggesting inadequate consideration of psychiatric problems in certain contexts, in particular intensive care units.

[Tolerance of ambiguity, art therapy and psychiatric illness]

Tolerance of ambiguity means the ability to tolerate contradictory and incalculable informations. There is the hypothesis that a high degree of tolerance of ambiguity correlates with creativity. It is unclear how various psychiatric illnesses and psychopathological conditions affect tolerance of ambiguity. Therefore we carried out a study concerning the tolerance of ambiguity: 154 persons were systematically investigated with a standardized questionnaire (31 schizophrenic in-patients, 41 neurotic in-patients, 49 members of the staff as control group, 33 artists as control group). In addition we examined the degree of depression in the neurotic group, the anancasm score and the well-being in general. In the schizophrenic group we assessed psychotic symptoms, the positive and negative symptoms, medication, anancasm and depression. Tolerance of ambiguity decreased in the following sequence: artists - members of the staff - neurotic in-patients - schizophrenic in-patients. It became evident that in the schizophrenic group negative symptoms negatively correlates with tolerance of ambiguity. The results seem to confirm the hypothesis that there is a positive correlation between tolerance of ambiguity and creativity. In addition, the higher degree of intolerance of ambiguity in schizophrenic patients may represent a protective mechanism. Intolerance of ambiguity possibly protects from too many contradictory informations. Furthermore the necessity is confirmed that creative therapy methods should be carefully chosen to avoid irritation on the one hand and not to neglect the required training of creative basic functions on the other hand. Although our results weaken the thesis that psychiatric illness is generally associated with an increase of creativity they don't exclude that highly creative performances in some individuals are possible who are especially talented in spite of or even because of their emotional suffering.

Residual symptoms and comorbidity in panic disorder

BACKGROUND

The aim of this study was to assess the outcome of the comorbid conditions of panic disorder after 1 year of treatment, emphasizing the detection of residual symptoms and their relationship to other clinical variables.

METHODS

Subjects (N = 64) were assessed by the Structured Clinical Interview for DSM-III-R and the Eysenck Personality Questionnaire. Comorbidity with other disorders, scores on Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were assessed at baseline and after 12 months. Criteria for residual anxiety/somatic symptoms were defined.

RESULTS

Reduction in generalized anxiety disorder rates accounted for a significant decrease in comorbidity at 1-year follow-up, with regard to baseline assessment. When the more severe symptoms of the disorder had remitted, a third of the patients referred physical symptoms with some concern over a fluctuating state of anxiety. The said symptoms were neither a recurrence of panic disorder nor did they account for other anxiety or somatoform disorders. Lower scores on extraversion predict higher risk of residual symptoms.

DISCUSSION

The persistence of residual anxiety/somatic symptoms in a third of the patients who apparently achieved a good response to treatment of panic disorder might characterize a minor form of chronic persistence of this condition.

CONCLUSIONS

The subgroup of patients with residual symptoms would not be detectable by follow-up studies, which focus on the assessment of relapse of panic disorder by means of strictly defined diagnostic criteria.

Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: a 3-month double-blind study

BACKGROUND

The prevalence of generalized anxiety disorder (GAD) represents an important public health issue. Hydroxyzine, an antagonist of histamine receptors, showed both efficacy and safety in previous short-term double-blind studies over placebo in this pathology. The aim of the current study was to confirm those positive results over a 3-month period in adult outpatients.

METHOD

This multicenter, parallel (hydroxyzine [50 mg/day]; bromazepam [6 mg/day]), randomized, double-blind, placebo-controlled trial included 2 weeks of single-blind run-in placebo, 12 weeks of double-blind randomized treatment, and 4 weeks of single-blind run-out placebo. Three hundred thirty-four of 369 selected outpatients with a diagnosis of GAD according to DSM-IV criteria and a Hamilton Rating Scale for Anxiety (HAM-A) total score >/= 20 were randomized before entering the double-blind period. The primary outcome criterion was the change in the HAM-A score from baseline to 12 weeks of double-blind treatment with hydroxyzine compared with placebo.

RESULTS

In the intent-to-treat analysis, the mean +/- SD change in HAM-A scores from baseline to endpoint was -12.16 +/- 7.74 for hydroxyzine and -9.64 +/- 7.74 for placebo (p =.019). Results at endpoint for percentage of responders (p =.003) and remission rates (p =.028), Clinical Global Impressions-Severity scale score (p =.001), maintenance of efficacy (p =.022), and Hospital Anxiety and Depression scale score on day 84 (p =.008) also confirmed the efficacy of hydroxyzine over placebo. The study showed no statistically significant difference between hydroxyzine and bromazepam. Except for drowsiness, which was more frequent with bromazepam, safety results were comparable in the 3 groups.

CONCLUSION

Hydroxyzine showed both efficacy and safety in the treatment of GAD and appears to be an effective alternative treatment to benzodiazepine prescription.

DSM-IV-defined anxiety disorder symptoms in South African children

OBJECTIVE

To examine -defined anxiety disorder symptoms in a large sample of normal South African schoolchildren.

METHOD

Children completed two self-report questionnaires: the Spence Children's Anxiety Scale (SCAS) and the 41-item version of the Screen for Child Anxiety Related Emotional Disorders (SCARED).

RESULTS

Psychometric properties of the SCAS and the SCARED were moderate (convergent validity) to sufficient (reliability). Factor analyses yielded evidence for the presence of a number of hypothesized anxiety categories (i.e., social phobia, panic disorder, fears, and generalized anxiety disorder). Furthermore, anxiety levels of South African children were higher than those of Western (i.e., Dutch) children. Differences were found with regard to the content of prevalent anxiety symptoms among South African and Western children.

CONCLUSION

Although psychometric properties of the SCAS and the SCARED in South African children somewhat deviated from those obtained in Western countries, both scales seem to be useful for assessing childhood anxiety symptoms in this country.

Relationship between fluid intelligence and ability to benefit from cognitive-behavioural therapy in older adults: a preliminary investigation

OBJECTIVE

The aim of this study was to conduct a preliminary evaluation of the hypothesis that fluid intelligence in older adults is associated with the ability to benefit from cognitive-behavioural therapy (CBT), but unrelated to the ability to benefit from non-directive supportive counselling (SC).

METHOD

A sample of 32 older adults who had completed a randomized controlled trial course of either CBT (N = 16) or SC (N = 16) for anxiety disorders took part in the study. The Raven's Coloured Progressive Matrices (RCPM) test was used to assess fluid intelligence. The Beck Anxiety Inventory change scores between pre-treatment and post-treatment were used as an index of ability to benefit from therapy. A measure of depressive symptomatology was also administered to control statistically for the effects of depression on intellectual functioning.

RESULTS

The results for the SC group showed a significant and positive association between fluid intelligence scores and anxiety change scores, such that older adults with higher levels of fluid intelligence demonstrated the most benefit from this intervention. In contrast, there was no significant association between level of fluid intelligence and ability to benefit from therapy in the CBT group.

CONCLUSION

CBT for anxiety disorders is suitable for older adults, irrespective of their fluid intelligence, while the nature of SC may render it more sensitive to level of fluid intelligence.

Topiramate as a treatment for pain in multisomatoform disorder patients: an open trial

Multisomatoform disorder (MSD), defined as 3 or more medically unexplained, currently distressing physical symptoms in addition to a long (> or =2 years) history of somatization, is a prevalent and disabling disorder in which few pharmacological trials have been referred to in the literature. Thirty-five MSD patients from the Somatoform Disorders Unit of the Miguel Servet University Hospital, Zaragoza, Spain, with pain of more than 3 months as the main symptom, were treated with topiramate in doses ranging from 300-400 mg/day. Patients were assessed at baseline and at one and six-months follow-up with the McGill Pain Questionnaire (MPQ), Pain Visual Analogue Scale (PVAS), Clinical Global Impresión (CGI), Global Assessment Functioning (GAF) and Hospital Anxiety Depression Scale (HADS). Eight patients (22.8%) dropped from the study, 3 due to side-effects and the other 5 because of lack of efficacy. All the outcome measures showed significant improvements at one-month except the ratings on the Hospital Anxiety Depression Scale. At six-months follow-up, clinician-rated assessments (CGI and GAF) still showed significant differences with baseline but less significant than at one-month follow-up. However, patient-rated assessments (MPQ and PVAS) did not present significant differences with baseline. Despite limitations of the study, topiramate seems to be effective in treating multisomatoform disorder patients with pain as the main symptom and a controlled randomized trial in these patients appears warranted. A possible "decay effect" in patient-rated assessments with any drug in somatoform disorder patients is discussed.

[Anxiety disorders in private practice psychiatric out-patients: prevalence, comorbidity and burden (DELTA study)]

Few data are currently available on the prevalence and associated characteristics of anxiety disorders in psychiatric out-patients in France, in particular in the private health-care. However, this represents one of the principal systems of care for patients suffering from anxiety disorders, with a possible direct access and several types of treatments available (pharmacotherapy but also different kinds of psychotherapy). The aim of our study was to describe the prevalence of anxiety disorders in a large sample of patients consulting in the private sector, and in addition to study the comorbidity, the severity of the disorders, their consequences on quality of life and health care consumption. The studied patients were included and assessed by 501 psychiatrists from all the country, at the time of a first visit. Inclusions were to be made in a consecutive way, but with the exclusion of psychotic disorders and dementia. A sample of 1 955 patients was obtained, and all subjects had a standardized diagnostic assessment with the Mini International Neuropsychiatric Interview (MINI) and with various dimensional scales of symptomatology severity, quality of life, and health care consumption. On the whole, at least one current anxiety disorder was found in 64.3% of the patients, while 55% had a depressive disorder. Individually, the prevalence rates are 29.4% for generalized anxiety disorder, 25.9% for agoraphobia, 19.2% for panic disorder, 15.3% for social phobia, 11.4% for obsessive-compulsive disorder, and 5.4% for post-traumatic stress disorder (PTSD). A history of suicide attempts was found in 12-20% of patients, and an elevated suicide risk was found for example in 25% of PTSD patients. The scores of the symptomatic scales, adaptation and quality of life measure show a very significant anxious symptomatology, with serious functional consequences. Approximately 75% of patients had another medical consultation during the three previous months, and 9% have been hospitalized. An interruption of work was found in 25% of the patients during the last three months, in average for 35 days. Concerning drug consumption before the visit by anxiety disorders patients, the preponderance of anxiolytic use is notable (85 to 98% according to categories of anxiety disorders) when compared to that of antidepressants (20 to 40%). Moreover, 38.4% of the whole sample took an anxiolytic once a day for at least three months and about 40% of them had dependence symptoms. In conclusion, this study showed the quantitative importance of anxiety disorders among psychiatric out-patients in the private practice sector in France, all the categories of anxiety being represented, and the high level of severity and burden of these disorders. Compared to some data published before, the prevalence rates of these anxiety disorders seem to be increasing.

No evidence for overgeneral memories in borderline personality disorder

The hypothesis that borderline personality disorder (BPD) is related to overgeneral memories was tested in a mixed sample of 39 patients. A memory test with emotional cue words and the instruction to produce specific autobiographical memories was used. Specificity was judged by an independent rater. Regression analyses indicated that age and major depressive disorder were related to the production of less specific memories, whereas educational level and presence of personality disorder were positivily related to number of specific memories. Borderline personality disorder, anxiety disorders and childhood traumas were not related to number of specific memories.