Chronicity, relapse, and illness--course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up

Sex differences in fear expression and persistence in an animal model of Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) is a complex psychiatric condition arising from traumatic experiences, marked by abnormal fear memories. Despite women are twice as likely as men to develop PTSD, the biological mechanisms underlying this disparity remain inadequately explored, particularly in preclinical studies involving female subjects. Previous research shows that female rats exhibit active fear responses, while males display passive behaviors. Additionally, sex differences in ultrasonic vocalizations (USVs) during fear conditioning have been observed, indicating varying emotional responses. Here, we validated a traumatic stress model consisting of footshock exposure paired with social isolation - originally developed in male rats - on females for the first time, focusing on sex differences in fear memory expression, retention and extinction. Our findings reveal that only during trauma exposure, males predominantly exhibited passive responses, whereas females demonstrated more active responses, despite both sexes emitting similar numbers of alarm USVs. Females also showed lower levels of freezing and USV emissions throughout extinction sessions and displayed a higher extinction rate compared to males. Notably, only males displayed a conditioned fear response when triggered by a single mild stressor. These findings highlight sex differences in trauma responses and fear memory processes. The study emphasizes the importance of incorporating 22-kHz USV evaluations along with other behavioral metrics for a comprehensive understanding of fear memory. This research contributes to the existing literature on traumatic stress models as well as underscores the necessity of including female subjects in preclinical studies to better inform treatment and prevention strategies tailored to both sexes.

Augmented Reality as an Aid to Behavior Therapy for Anxiety Disorders: A Narrative Review

Anxiety disorders are among the most common mental disorders worldwide. These conditions are characterized by excessive anxiety that is difficult to control. In most anxiety disorders, symptoms are triggered by exposure to specific objects or situations. This leads sufferers to avoid such exposures, leading to impaired social and occupational functioning and reduced quality of life. Therapies based on behavioral principles, either alone or in combination with cognitive techniques, are the most effective psychological interventions for anxiety disorders. However, the effectiveness of these therapies may be limited due to a lack of generalization from clinic to real-world settings. Augmented reality (AR) is a technology that provides an interactive experience by superimposing computer-generated content, often in multiple sensory modalities, on the real world. Emerging evidence suggests that AR may be useful in treating a broad range of mental disorders, including anxiety disorders. This review examines the evidence for the use of AR-based techniques as an aid to behavioral or cognitive-behavioral therapies for anxiety disorders. The available evidence suggests that this method may offer significant advantages over conventional therapies, particularly in the case of specific phobias, but also in social anxiety disorder. AR can also be combined with other novel technologies to monitor psychophysiological markers of anxiety and its reduction over the course of treatment. The advantages of AR could be related to its combination of real and simulated content, allowing for better generalization of the benefits of conventional exposure-based therapy. Though the safety, efficacy, and cost-effectiveness of this method need to be confirmed in larger samples, it could lead to a paradigm shift in the way behavioral therapies for anxiety disorders are conceptualized and delivered.

Cognitive behavioural therapy and third-wave approaches for anxiety and related disorders in older people

BACKGROUND

Cognitive behavioural therapy (CBT) is the most researched psychological therapy for anxiety disorders in adults, and known to be effective in this population. However, it remains unclear whether these results apply to older adults, as most studies include participants between 18 and 55 years of age. This systematic review aims to provide a comprehensive and up-to-date synthesis of the available evidence on CBT and third wave approaches for older adults with anxiety and related disorders.

OBJECTIVES

To assess the effects of Cognitive Behavioural Therapy (CT, BT, CBT and third-wave CBT interventions) on severity of anxiety symptoms compared with minimal management (not providing therapy) for anxiety and related disorders in older adults, aged 55 years or over. To assess the effects of CBT and related therapies on severity of anxiety symptoms compared with other psychological therapies for anxiety and related disorders in older adults, aged 55 years or over.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled studies Register (CCMDCTR), CENTRAL, Ovid MEDLINE, Ovid Embase and Ovid PsycINFO to 21 July 2022. These searches were updated on 2 February 2024. We also searched the international studies registries, including Clinicalstudies.gov and the WHO International Clinical Trials Registry Platform (ICTRP), to identify additional ongoing and unpublished studies. These sources were manually searched for studies up to 12 February 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in older adults (≥ 55 years) with an anxiety disorder, or a related disorder, including obsessive compulsive disorder (OCD), acute stress disorder and post-traumatic stress disorder (PTSD), that compared CBT to either minimal management or an active (non-CBT) psychological therapy. Eligible studies had to have an anxiety-related outcome.

DATA COLLECTION AND ANALYSIS

Several authors independently screened all titles identified by the searches. All full texts were screened for eligibility according to our prespecified selection criteria. Data were extracted and the risk of bias was assessed using the Cochrane tool for RCTs. The certainty of evidence was evaluated using GRADE. Meta-analyses were performed for outcomes with quantitative data from more than one study.

MAIN RESULTS

We included 21 RCTs on 1234 older people allocated to either CBT or control conditions. Ten studies focused on generalised anxiety disorder; others mostly included a mix of clinical diagnoses. Nineteen studies focused on the comparison between CBT and minimal management. Key issues relating to risk of bias were lack of blinding of participants and personnel, and participants dropping out of studies, potentially due to treatment preference and allocation. CBT may result in a small-to-moderate reduction of anxiety post-treatment (SMD -0.51, 95% CI -0.66 to -0.36, low-certainty evidence). However, compared to this benefit with CBT immediately after treatment, at three to six months post-treatment, there was little to no difference between CBT and minimal management (SMD -0.29, 95% CI -0.59 to 0.01, low-certainty evidence). CBT may have little or no effect on clinical recovery/ improvement post-treatment compared to minimal management, but the evidence is very uncertain (RR 1.56, 95% CI 1.20 to 2.03, very low-certainty evidence). Results indicate that five people would need to receive treatment for one additional person to benefit (NNTB = 5). Compared to minimal management, CBT may result in a reduction of comorbid depression symptoms post-treatment (SMD -0.57, 95% CI -0.74 to -0.40, low-certainty evidence). There was no difference in dropout rates post-treatment, although the certainty of the evidence was low (RR 1.19, 95% CI 0.80 to 1.78). Two studies reported adverse events, both of which related to medication in the control groups (very low-certainty evidence, no quantitative estimate). Only two studies compared CBT to other psychological therapies, both of which only included participants with post-traumatic stress disorder. Low-certainty evidence showed no difference in anxiety severity post-treatment and at four to six months post-treatment, symptoms of depression post-treatment, and dropout rates post-treatment. Other outcomes and time points are reported in the results section of the manuscript.

AUTHORS' CONCLUSIONS

CBT may be more effective than minimal management in reducing anxiety and symptoms of worry and depression post-treatment in older adults with anxiety disorders. The evidence is less certain longer-term and for other outcomes including clinical recovery/improvement. There is not enough evidence to determine whether CBT is more effective than alternative psychological therapies for anxiety in older adults.

[Treatment resistance in anxiety disorders-Definition and treatment options]

Treatment resistance in anxiety disorders represents a clinical challenge, contributes to the chronicity of the diseases as well as sequential comorbidities, and is associated with a significant individual and socioeconomic burden. This narrative review presents the operational definition of treatment resistance in anxiety disorders according to international consensus criteria (< 50% reduction in the Hamilton Anxiety Scale, HAM‑A, score or < 50% reduction in the Beck Anxiety Inventory, BAI, score or a clinical global impression-improvement, CGI‑I, score > 2). At least two unsuccessful guideline-based treatment attempts with pharmacological monotherapy or at least one unsuccessful treatment attempt with adequately delivered cognitive behavioral therapy are required. Pharmacotherapeutically, after excluding pseudo-resistance, switching the medication within one class or to another class and augmentation strategies with other antidepressants (mirtazapine, agomelatine), antipsychotics (quetiapine) or anticonvulsants (valproate) are recommended. Psychotherapeutically, third-wave therapies, psychodynamic therapy, systemic therapy and physical exercise can be considered for therapy resistance. In cases of no response to psychotherapy or pharmacotherapy, the respective other form of therapy or a combination of both should be offered. Compounds targeting the glutamatergic and endocannabinoid systems as well as neuropeptides are being tested as potential innovative pharmaceuticals for treatment-resistant anxiety disorders. There is an urgent need for further research to identify predictive markers and mechanisms as well as to develop innovative pharmacological and psychotherapeutic interventions for treatment-resistant anxiety disorders.

Long-term remission rates and trajectory predictors in obsessive-compulsive disorder: Findings from a six-year naturalistic longitudinal cohort study

BACKGROUND

This naturalistic study, utilizing data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) cohort, investigated the long-term remission rates and predictors of different trajectories of obsessive-compulsive disorder (OCD) within a clinical population.

METHODS

A sample of 213 participants was classified into three illness trajectories: "Chronic," "Episodic, "and "Remitted-OCD." Long-term remission rates were calculated based on three follow-up measurements over a 6-year period. A multinomial logistic regression model, incorporating five selected predictors with high explanatory power and one covariate, was employed to analyze OCD trajectory outcomes.

RESULTS

The long-term full remission rates, calculated from all the measurements combined (14%), were significantly lower than what was observed in earlier studies and when compared to assessments at each individual follow-up (∼30%). Moreover, high baseline symptom severity and early age of onset were identified as significant risk factors for a chronic course of OCD, while male sex and younger age predicted a more favorable trajectory. Notably, the likelihood of an episodic course remained high even without identified risk factors.

LIMITATIONS

The bi-annual data collection process is unable to capture participants' clinical conditions between assessments. Additionally, no data was collected regarding the specific type and duration of psychological treatment received. Regarding the type of treatment participants received.

CONCLUSIONS

Results suggest that long-term remission rates may be lower than previously reported. Consequently, employing multiple assessment points in longitudinal studies is necessary for valid estimation of long-term full remission rates. The results emphasize the importance of personalized clinical care and ongoing monitoring and maintenance for most OCD cases.

Characteristics of patients with anxiety disorder without selective serotonin reuptake inhibitor prescription over a two-year period of pharmacotherapy

INTRODUCTION

Pharmacotherapy such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline reuptake inhibitors is recommended for the treatment of anxiety disorders. Although there are patients with persisted symptoms of anxiety disorders who are treated with monotherapy of benzodiazepine anxiolytics without SSRIs, the characteristics of these patients are unclear. In the present study, we investigated the characteristics of patients with persisted symptoms of anxiety disorder without SSRI prescription.

METHODS

From a prescription dataset covering 2018 and 2020, the prescriptions of 243 patients with anxiety disorder were analyzed. Patients were classified into two groups: SSRI non-prescription and prescription groups.

RESULTS

The SSRI non-prescription group had a higher ratio of females than did the SSRI prescription group (60.1% vs. 44.6%, respectively, p = 3.12 × 10-2 ), but statistically not significant after the Bonferroni correction. No significant differences in age, body mass index, or duration of outpatient visits were found between groups. Among the independent variables, sex (female) was the only variable identified that predicted SSRI non-prescription.

CONCLUSION

The present study showed that among patients with anxiety disorders, sex (female) was the only variable that predicted SSRI non-prescription.

Development of decision rules for an adaptive aftercare intervention based on individual symptom courses for agoraphobia patients

As other mental illnesses, agoraphobia is associated with a significant risk for relapse after the end of treatment. Personalized and adaptive approaches appear promising to improve maintenance treatment and aftercare as they acknowledge patients' varying individual needs with respect to intensity of care over time. Currently, there is a deficit of knowledge about the detailed symptom course after discharge from acute treatment, which is a prerequisite for the empirical development of rules to decide if and when aftercare should be intensified. Therefore, this study aimed firstly at the investigation of the naturalistic symptom course of agoraphobia after discharge from initial treatment and secondly at the development and evaluation of a data-driven algorithm for a digital adaptive aftercare intervention. A total of 56 agoraphobia patients were recruited in 3 hospitals. Following discharge, participants completed a weekly online monitoring assessment for three months. While symptom severity remained stable at the group level, individual courses were highly heterogeneous. Approximately two-thirds of the patients (70%) reported considerable symptoms at some time, indicating a need for medium or high-intense therapeutic support. Simulating the application of the algorithm to the data set resulted in an early (86% before week six) and relatively even allocation of patients to three groups (need for no, medium, and high-intense support respectively). Overall, findings confirm the need for adaptive aftercare strategies in agoraphobia. Digital, adaptive approaches may provide immediate support to patients who experience symptom deterioration and thus promise to contribute to an optimized allocation of therapeutic resources and overall improvement of care.

The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

The impact of physical exercise on the consolidation of fear extinction memories

Based on the mechanisms of fear extinction, exposure therapy is the most common treatment for anxiety disorders. However, extinguished fear responses can reemerge even after successful treatment. Novel interventions enhancing exposure therapy efficacy are therefore critically needed. Physical exercise improves learning and memory and was also shown to enhance extinction processes. This study tested whether physical exercise following fear extinction training improves the consolidation of extinction memories. Sixty healthy men underwent a differential fearconditioning paradigm with fear acquisition training on day 1 and fear extinction training followed by an exercise or resting control intervention on day 2. On day 3, retrieval and reinstatement were tested including two additional but perceptually similar stimuli to explore the generalization of exercise effects. Exercise significantly increased heart rate, salivary alpha amylase, and cortisol, indicating successful exercise manipulation. Contrary to our expectations, exercise did not enhance but rather impaired extinction memory retrieval on the next day, evidenced by significantly stronger differential skin conductance responses (SCRs) and pupil dilation (PD). Importantly, although conditioned fear responses were successfully acquired, they did not fully extinguish, explaining why exercise might have boosted the consolidation of the original fear memory trace instead. Additionally, stronger differential SCRs and PD toward the novel stimuli suggest that the memory enhancing effects of exercise also generalized to perceptually similar stimuli. Together, these findings indicate that physical exercise can facilitate both the long-term retrievability and generalization of extinction memories, but presumably only when extinction was successful in the first place.

A mixed-methods review and meta-synthesis of fears of recurrence and progression in people with mental health conditions

A fear that one's physical illness will recur or worsen has received substantial research attention over the past decade, most notably as fear of cancer recurrence. Indeed, such fear is known to be associated with poorer quality of life, adjustment, and psychopathology. However, fear of a recurrence or progression (FORP) of mental health conditions has received comparatively little study. The present review aimed to, 1) systematically review quantitative research on FORP in mental health regarding its association with age, gender, quality of life, mental health outcomes, and health behaviours, and 2) meta-synthesize qualitative research related to FORP to construct a transdiagnostic model. A qualitative meta-synthesis of 19 studies identified four subthemes underlying FORP (fear of symptoms, loss of progress, fear of death, and traumatic experiences). The three themes related to FORP were: inability to trust oneself, hypervigilance, and a low-risk low-reward lifestyle which was comprised of three subthemes (limiting relationships, limiting life goals, and fear of changing treatment). A quantitative systematic review of 15 studies found that FORP was strongly associated with worse quality of life, and greater depression, anxiety, psychotic symptoms, and medication adherence, but was not associated with age or gender. Hence, FORP can be understood transdiagnostically, and is generally associated with poorer mental health outcomes but may also predict adaptive health behaviours, such as appropriate medication adherence.

Prevalence and correlates of cannabis use among individuals with DSM-5 social anxiety disorder: Findings from a nationally representative sample

Cannabis use disorder (CUD) and frequency of use are highly related to social anxiety disorder (SAD). With updates to diagnostic criteria of psychiatric disorders and recent changes in cannabis laws, the present study sought to explore the relationships between cannabis use, CUD, and social anxiety in a large nationally representative sample of individuals with lifetime (N = 1255) and past-year SAD (N = 980). Notably, we found that at the symptom level, at least weekly cannabis use was significantly related to fear or avoidance of social situations interfering with relationships in both samples. Weekly + cannabis use and CUD were significantly associated with lifetime SAD symptom severity, but only weekly + cannabis use was related to SAD severity in the past-year sample. We also found that weekly + cannabis use but not CUD was related to greater odds of seeking treatment for SAD and suicide attempt history. Overall, these data provide an updated examination of cannabis use and SAD using DSM-5 criteria and a large nationally representative sample and also highlight the importance of weekly + cannabis use as a marker of severity and suicide risk in individuals with SAD.

Long-term benefits of mindfulness on white matter tracts underlying the cortical midline structures in panic disorder: A 2-year longitudinal study

AIMS

We aimed to examine the long-term benefits of mindfulness-based cognitive therapy (MBCT) on white matter plasticity in the cortical midline structures (CMS) for a period of 2 years in patients with panic disorder and the relationships between white matter changes in the CMS and severity of state and trait symptoms.

METHODS

Seventy-one participants were enrolled and underwent diffusion tensor imaging at baseline and after 2 years (26 who received MBCT as an adjunct to pharmacotherapy [MBCT+PT], 20 treated with pharmacotherapy alone [PT-alone], and 25 healthy controls [HCs]). The severity of symptoms and fractional anisotropy (FA) in white matter regions underlying the CMS were assessed at baseline and 2-year follow-up.

RESULTS

The MBCT+PT group showed better outcomes after 2 years than the PT-alone group. The groups showed different FA changes: the MBCT+PT group showed decreased FA in the left anterior cingulate cortex (ACC); the PT-alone group showed increased FA in the bilateral dorsomedial prefrontal cortex, posterior cingulate cortex (PCC), and precuneus. Decreased white matter FA in the ACC, PCC, and precuneus was associated with improvements in the severity of state and trait symptoms in patients with panic disorder.

CONCLUSION

Alleviation of excessive white matter connectivity in the CMS after MBCT leads to improvements in clinical symptoms and trait vulnerability in patients with panic disorder. Our study provides new evidence for the long-term benefits of MBCT on white matter plasticity and its clinical applicability as a robust treatment for panic disorder.

Integrating Mindfulness and Acceptance Into Traditional Cognitive Behavioral Therapy During the COVID-19 Pandemic: A Case Study of an Adult Man With Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be chronic and impairing, highlighting the need for effective treatments. Although Cognitive Behavior Therapy (CBT) is an effective treatment for GAD, a number of patients continue to report GAD symptoms treatment. Integrating evidenced-based treatment components into CBT treatments, such as mindfulness- and acceptance-based treatment components found in Acceptance and Commitment Therapy (ACT), may help improve the efficacy of treatment. Emerging interventions and research suggest that the cognitive restructuring aspect of CBT and acceptance stance of ACT (e.g., cognitive defusion) can be implemented into treatment concurrently from a stance of increasing a patient's coping skills repertoire and psychological flexibility. This systemic case analysis examined the efficacy and clinical utility of integrating ACT into a manualized CBT treatment for GAD. Furthermore, this study examined treatment efficacy and therapeutic alliance as the treatment rapidly and unexpectedly transitioned from in-person to telehealth due to the COVID-19 pandemic. Pre- to post-treatment and time-series analyses showed significant decreases in anxiety symptoms, worry, depressive symptoms, and emotion dysregulation. Although there was an initial increase in depressive and anxiety symptoms, worry, and emotion dysregulation following the switch from in-person to telehealth services, these quickly subsided and resumed a downward trend. The therapeutic relationship did not deteriorate during the transition to telehealth. This case study provides evidence of feasibility and efficacy of an integrated CBT/ACT approach in treating GAD. It also suggests that despite some temporary increase in symptoms, therapeutic alliance and treatment efficacy were not impacted by the switch to telehealth.

The influence of cross unconditional stimulus reinstatement on electrodermal responding and conditional stimulus valence in differential fear conditioning

We examined whether the inhibitory Conditional Stimulus (CS)-no Unconditional Stimulus (US) association formed during extinction can be triggered by a novel US during the reinstatement of conditional electrodermal responding and self-reported CS valence in human differential fear conditioning. Participants were trained with either a shock or an aversive scream US before undergoing extinction. Participants then received either the same (i.e., shock_shock or scream_scream) or a different US during reinstatement (i.e., shock_scream, scream_shock). Differential conditioning across all indices was stronger when a shock US was used during acquisition. After reinstatement, electrodermal responding to both the CS+ and the CS- increased regardless of the type of US used during reinstatement (non-differential reinstatement). Differential CS valence evaluations were larger after reinstatement in the groups that received the same US during acquisition and reinstatement (differential reinstatement), but differential evaluations did not increase in the groups receiving a different US at reinstatement. This dissociation suggests that the reinstatement of negative stimulus valence and the reinstatement of expectancy learning may differ.

Emotions in social anxiety disorder: A review

Extant cognitive behavioral models of social anxiety disorder (SAD) have primarily focused on cognitions and behaviors that maintain the disorder. Emotional aspects of SAD have been investigated but have not been sufficiently integrated into current models. To facilitate such integration, we reviewed the literature on emotional constructs (emotional intelligence, emotional knowledge, emotional clarity, emotion differentiation, and emotion regulation), and discrete emotions (anger, shame, embarrassment, loneliness, guilt, pride, and envy) in SAD and social anxiety. We present the studies conducted on these constructs, summarize the main findings, suggest areas for future research, discuss the findings in the context of existing models of SAD and attempt to integrate the findings into these existing models of the disorder. Clinical implications of our findings are also discussed.

HDAC1-mediated regulation of GABA signaling within the lateral septum facilitates long-lasting social fear extinction in male mice

Social anxiety disorder (SAD) is caused by traumatic social experiences. It is characterized by intense fear and avoidance of social contexts, which can be robustly mimicked by the social fear conditioning (SFC) paradigm. The extinction phase of the SFC paradigm is akin to exposure therapy for SAD and requires learning to disassociate the trauma with the social context. Learning-induced acetylation of histones is critical for extinction memory formation and its endurance. Although class I histone deacetylases (HDACs) regulate the abovementioned learning process, there is a lack of clarity in isoforms and spatial specificity in HDAC function in social learning. Utilizing the SFC paradigm, we functionally characterized the role of HDAC1, specifically in the lateral septum (LS), in regulating the formation of long-term social fear extinction memory. We measured a local increase in activity-inducing HDAC1 phosphorylation at serine residues of social fear-conditioned (SFC⁺) mice in response to the extinction of social fear. We also found that LS-HDAC1 function negatively correlates with acute social fear extinction learning using pharmacological and viral approaches. Further, inhibition of LS-HDAC1 enhanced the expression of the GABA-A receptor β1 subunit (Gabrb1) in SFC⁺ mice, and activation of GABA-A receptors facilitated acute extinction learning. Finally, the facilitation of extinction learning by HDAC1 inhibition or GABA-A receptor activation within the LS led to the formation of long-lasting extinction memory, which persisted even 30 days after extinction. Our results show that HDAC1-mediated regulation of GABA signaling in the LS is crucial for the formation of long-lasting social fear extinction memory.

Prefrontal modulation of anxiety through a lens of noradrenergic signaling

Anxiety disorders are the most common class of mental illness in the U.S., affecting 40 million individuals annually. Anxiety is an adaptive response to a stressful or unpredictable life event. Though evolutionarily thought to aid in survival, excess intensity or duration of anxiogenic response can lead to a plethora of adverse symptoms and cognitive dysfunction. A wealth of data has implicated the medial prefrontal cortex (mPFC) in the regulation of anxiety. Norepinephrine (NE) is a crucial neuromodulator of arousal and vigilance believed to be responsible for many of the symptoms of anxiety disorders. NE is synthesized in the locus coeruleus (LC), which sends major noradrenergic inputs to the mPFC. Given the unique properties of LC-mPFC connections and the heterogeneous subpopulation of prefrontal neurons known to be involved in regulating anxiety-like behaviors, NE likely modulates PFC function in a cell-type and circuit-specific manner. In working memory and stress response, NE follows an inverted-U model, where an overly high or low release of NE is associated with sub-optimal neural functioning. In contrast, based on current literature review of the individual contributions of NE and the PFC in anxiety disorders, we propose a model of NE level- and adrenergic receptor-dependent, circuit-specific NE-PFC modulation of anxiety disorders. Further, the advent of new techniques to measure NE in the PFC with unprecedented spatial and temporal resolution will significantly help us understand how NE modulates PFC function in anxiety disorders.

An interdisciplinary multimodal integrative healthcare program for somatic symptom disorder, with predominant (spinal) pain

OBJECTIVE

Although multimodal interventions are generally recommended in patients with long-term somatic symptom disorders (SSD), available evidence is limited. The current study evaluates the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for patients with SSD and predominant (spinal) pain.

METHOD

The healthcare program consisted of two active treatment phases: main 20-week program and a 12-month relapse prevention program. Participants were 4453 patients diagnosed with SSD. The primary outcome was health-related quality of life (HRQoL) assessed using the RAND-36 (i.e., mental/physical component summary) and secondary outcomes included physical and psychological symptoms assessed using the Brief Symptom Inventory (BSI) and RAND-36 subscales. Mixed linear models were used to examine the effects of the multimodal healthcare program on primary/secondary outcomes over four time points: before start 20-week program (T0), halfway 20-week program (T1), end of 20-week program (T2) and end of relapse prevention program (T3).

RESULTS

Significant improvements were found from T0 to T2 for all primary variables (i.e., mental/physical component summary) and secondary variables (i.e., BSI/RAND-36 subscales), which were maintained until the end of the relapse prevention program (T3).

CONCLUSION

An interdisciplinary multimodal integrative treatment for SSD is effective for improving HRQoL and reducing physical and psychological symptoms.

Personalised app-based relapse prevention of depressive and anxiety disorders in remitted adolescents and young adults: a protocol of the StayFine RCT

INTRODUCTION

Youth in remission of depression or anxiety have high risks of relapse. Relapse prevention interventions may prevent chronicity. Aim of the study is therefore to (1) examine efficacy of the personalised StayFine app for remitted youth and (2) identify high-risk groups for relapse and resilience.

METHOD AND ANALYSIS

In this Dutch single-blind parallel-group randomised controlled trial, efficacy of app-based monitoring combined with guided app-based personalised StayFine intervention modules is assessed compared with monitoring only. In both conditions, care as usual is allowed. StayFine modules plus monitoring is hypothesised to be superior to monitoring only in preventing relapse over 36 months. Participants (N=254) are 13-21 years and in remission of depression or anxiety for >2 months. Randomisation (1:1) is stratified by previous treatment (no treatment vs treatment) and previous episodes (1, 2 or >3 episodes). Assessments include diagnostic interviews, online questionnaires and monitoring (ecological momentary assessment with optional wearable) after 0, 4, 12, 24 and 36 months. The StayFine modules are guided by certified experts by experience and based on preventive cognitive therapy and ingredients of cognitive behavioural therapy. Personalisation is based on shared decision-making informed by baseline assessments and individual symptom networks. Time to relapse (primary outcome) is assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia-lifetime version diagnostic interview. Intention-to-treat survival analyses will be used to examine the data. Secondary outcomes are symptoms of depression and anxiety, number and duration of relapses, global functioning, and quality of life. Mediators and moderators will be explored. Exploratory endpoints are monitoring and wearable outcomes.

ETHICS, FUNDING AND DISSEMINATION

The study was approved by METC Utrecht and is funded by the Netherlands Organisation for Health Research and Development (636310007). Results will be submitted to peer-reviewed scientific journals and presented at (inter)national conferences.

TRIAL REGISTRATION NUMBER

NCT05551468; NL8237.

Patients' symptoms and strengths as predictors of long-term outcomes of CBT for generalized anxiety disorder - A three-level, multi-predictor analysis

Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual's symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients' strengths for clinical practice.

Neuroimmune mechanisms in fear and panic pathophysiology

Panic disorder (PD) is unique among anxiety disorders in that the emotional symptoms (e.g., fear and anxiety) associated with panic are strongly linked to body sensations indicative of threats to physiological homeostasis. For example, panic attacks often present with feelings of suffocation that evoke hyperventilation, breathlessness, or air hunger. Due to the somatic underpinnings of PD, a major focus has been placed on interoceptive signaling and it is recognized that dysfunctional body-to-brain communication pathways promote the initiation and maintenance of PD symptomatology. While body-to-brain signaling can occur via several pathways, immune and humoral pathways play an important role in communicating bodily physiological state to the brain. Accumulating evidence suggests that neuroimmune mediators play a role in fear and panic-associated disorders, although this has not been systematically investigated. Currently, our understanding of the role of immune mechanisms in the etiology and maintenance of PD remains limited. In the current review, we attempt to summarize findings that support a role of immune dysregulation in PD symptomology. We compile evidence from human studies and panic-relevant rodent paradigms that indicate a role of systemic and brain immune signaling in the regulation of fear and panic-relevant behavior and physiology. Specifically, we discuss how immune signaling can contribute to maladaptive body-to-brain communication and conditioned fear that are relevant to spontaneous and conditioned symptoms of PD and identify putative avenues warranting future investigation.

Integrative systemic and family therapy for social anxiety disorder: Manual and practice in a pilot randomized controlled trial (SOPHO-CBT/ST)

Social anxiety disorders (SAD) are among the most prevalent mental disorders (lifetime prevalence: 7-12%), with high impact on the life of an affected social system and its individual social system members. We developed a manualized disorder-specific integrative systemic and family therapy (ISFT) for SAD, and evaluated its feasibility in a pilot randomized controlled trial (RCT). The ISFT is inspired by Helm Stierlin's concept of related individuation developed during the early 1980s, which has since continued to be refined. It integrates solution-focused language, social network diagnostics, and genogram work, as well as resource- and problem orientation for both case conceptualization and therapy planning. Post-Milan symptom prescription to fluidize the presented symptoms is one of the core interventions in the ISFT. Theoretically, the IFST is grounded in radical constructivism and "Cybern-Ethics," multi-directional partiality, and a both/and attitude toward a disorder-specific vs. non-disorder-specific therapy approach. SAD is understood from the viewpoint of social systems theory, especially in adaptation to a socio-psycho-biological explanatory model of social anxiety. In a prospective multicenter, assessor-blind pilot RCT, we included 38 clients with SAD (ICD F40.1; Liebowitz Social Anxiety Scale, LSAS-SR > 30): 18 patients participated in the ISFT, and 20 patients in Cognitive Behavioral Therapy (CBT; age: M = 36 years, SD = 14). Within-group, simple-effect intention-to-treat analyses showed significant reduction in social anxiety (LSAS-SR; ISFT: d = 1.67; CBT: d = 1.04), while intention-to-treat mixed-design ANOVA demonstrated the advantage of ISFT (d = 0.81). Per-protocol analyses supported these results. The remission rate based on blind diagnosticians' ratings was good to satisfactory (Structured Clinical Interview, SCID; 78% in ST, 45% in CBT, p = 0.083); this has yet to be verified in a subsequent confirmatory RCT. The article will present the ISFT rationale and manual, including a special focus on multi-person settings, and the central findings from our pilot RCT.

Long-Term Management of Generalised Anxiety Disorder with Low-Dose Continuous Infusions of Flumazenil: A Case Series

Background: Generalised anxiety disorder (GAD) is a common anxiety disorder associated with social and occupational impairment. Recently, a theory was postulated that dysfunctional gamma aminobutyric acid type A receptors (GABAA) are implicated in anxiety symptomology, which could be corrected by flumazenil, an antagonist at the benzodiazepine binding site on the GABAA receptor. Method: Participants had a primary diagnosis of GAD and were treated initially with an eight-day continuous low-dose flumazenil infusion (total 32 mg at a rate of 4 mg/24 h). Some participants were re-treated with a further four- or eight-day infusion. Treatment response was measured as a 50% reduction in anxiety or stress scores on the Depression Anxiety Stress Scale—21 (DASS-21). Remission was measured as scores ≤3 or ≤7 on the anxiety and stress subscales of the DASS-21, respectively. Results: Eight cases are reported. All cases met the criteria for treatment response on the anxiety and stress subscale of the DASS-21. Remission was achieved in seven participants on the anxiety subscale and in five on the stress subscale. No changes in hepatic, renal, or haematological function were likely attributed to flumazenil. Conclusion: Data suggest that low-dose continuous flumazenil infusion manages GAD symptoms and is safe. Although these results are promising, future randomised control trials are required to confirm these results.

Long-term Effectiveness and Predictors of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Emotional Disorders in Specialized Care: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Transdiagnostic internet-delivered cognitive behavioral therapy (iCBT) for emotional disorders has been shown to be effective in specialized care in the short term. However, less is known about its long-term effects in this specific setting. In addition, predictors of long-term effectiveness may help to identify what treatments are more suitable for certain individuals.

OBJECTIVE

This study aimed to analyze the long-term effectiveness of transdiagnostic iCBT compared with that of treatment as usual (TAU) in specialized care and explore predictors of long-term effectiveness.

METHODS

Mixed models were performed to analyze the long-term effectiveness and predictors of transdiagnostic iCBT (n=99) versus TAU (n=101) in public specialized mental health care. Outcomes included symptoms of depression and anxiety, health-related quality of life (QoL), behavioral inhibition and behavioral activation, comorbidity, and diagnostic status (ie, loss of principal diagnosis) from baseline to 1-year follow-up. Sociodemographic characteristics (sex, age, and education) and clinical variables (principal diagnosis, comorbidity, and symptom severity at baseline) were selected as predictors of long-term changes.

RESULTS

Compared with baseline, transdiagnostic iCBT was more effective than TAU in improving symptoms of depression (b=-4.16, SE 1.80, 95% CI -7.68 to -0.67), health-related QoL (b=7.63, SE 3.41, 95% CI 1.00-14.28), diagnostic status (b=-0.24, SE 0.09, 95% CI -1.00 to -0.15), and comorbidity at 1-year follow-up (b=-0.58, SE 0.22, 95% CI -1.00 to -0.15). From pretreatment assessment to follow-up, anxiety symptoms improved in both transdiagnostic iCBT and TAU groups, but no significant differences were found between the groups. Regarding the predictors of the long-term effectiveness of transdiagnostic iCBT compared with that of TAU, higher health-related QoL at follow-up was predicted by a baseline diagnosis of anxiety, male sex, and the use of psychiatric medication; fewer comorbid disorders at follow-up were predicted by older age and higher baseline scores on health-related QoL; and fewer depressive symptoms at follow-up were predicted by baseline diagnosis of depression. However, this pattern was not observed for baseline anxiety diagnoses and anxiety symptoms.

CONCLUSIONS

The results suggest that transdiagnostic iCBT is more effective than TAU to target depressive symptoms among patients with emotional disorders. Anxiety symptoms remained stable at 1-year follow-up, with no differences between the groups. Results on predictors suggest that some groups of patients may obtain specific gains after transdiagnostic iCBT. Specifically, and consistent with the literature, patients with baseline depression improved their depression scores at follow-up. However, this pattern was not found for baseline anxiety disorders. More studies on the predictor role of sociodemographic and clinical variables in long-term outcomes of transdiagnostic iCBT are warranted. Future studies should focus on studying the implementation of transdiagnostic iCBT in Spanish public specialized mental health care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668.

Childhood inhibition predicts adolescent social anxiety: Findings from a longitudinal twin study

An enduring issue in the study of mental health is identifying developmental processes that explain how childhood characteristics progress to maladaptive forms. We examine the role that behavioral inhibition (BI) has on social anxiety (SA) during adolescence in 868 families of twins assessed at ages 8, 13, and 15 years. Multimodal assessments of BI and SA were completed at each phase, with additional measures (e.g., parenting stress) for parents and twins. Analyses were conducted in several steps: first, we used a cross-lagged panel model to demonstrate bidirectional paths between BI and SA; second a biometric Cholesky decomposition showed that both genetic and environmental influences on childhood BI also affect adolescent SA; next, multilevel phenotypic models tested moderation effects between BI and SA. We tested seven potential moderators of the BI to SA prediction in individual models and included only those that emerged as significant in a final conditional model examining predictors of SA. Though several main effects emerged as significant, only parenting stress had a significant interaction with BI to predict SA, highlighting the importance of environmental moderators in models examining temperamental effects on later psychological symptoms. This comprehensive assessment continues to build the prototype for such developmental psychopathology models.

Robust group- but limited individual-level (longitudinal) reliability and insights into cross-phases response prediction of conditioned fear

Here, we follow the call to target measurement reliability as a key prerequisite for individual-level predictions in translational neuroscience by investigating (1) longitudinal reliability at the individual and (2) group level, (3) internal consistency and (4) response predictability across experimental phases. One hundred and twenty individuals performed a fear conditioning paradigm twice 6 months apart. Analyses of skin conductance responses, fear ratings and blood oxygen level dependent functional magnetic resonance imaging (BOLD fMRI) with different data transformations and included numbers of trials were conducted. While longitudinal reliability was rather limited at the individual level, it was comparatively higher for acquisition but not extinction at the group level. Internal consistency was satisfactory. Higher responding in preceding phases predicted higher responding in subsequent experimental phases at a weak to moderate level depending on data specifications. In sum, the results suggest that while individual-level predictions are meaningful for (very) short time frames, they also call for more attention to measurement properties in the field.

Enhanced top-down sensorimotor processing in somatic anxiety

Functional neuroimaging research on anxiety has traditionally focused on brain networks associated with the psychological aspects of anxiety. Here, instead, we target the somatic aspects of anxiety. Motivated by the growing appreciation that top-down cortical processing plays a crucial role in perception and action, we used resting-state functional MRI data from the Human Connectome Project and Dynamic Causal Modeling (DCM) to characterize effective connectivity among hierarchically organized regions in the exteroceptive, interoceptive, and motor cortices. In people with high (fear-related) somatic arousal, top-down effective connectivity was enhanced in all three networks: an observation that corroborates well with the phenomenology of anxiety. The anxiety-associated changes in connectivity were sufficiently reliable to predict whether a new participant has mild or severe somatic anxiety. Interestingly, the increase in top-down connections to sensorimotor cortex were not associated with fear affect scores, thus establishing the (relative) dissociation between somatic and cognitive dimensions of anxiety. Overall, enhanced top-down effective connectivity in sensorimotor cortices emerges as a promising and quantifiable candidate marker of trait somatic anxiety.

Illness-Death Model as a Framework for Chronic Disease Burden Projection: Application to Mental Health Epidemiology

Introduction

Estimates of future disease burden supports public health decision-making. Multistate modeling of chronic diseases is still limited despite a long history of mathematical modeling of diseases. We introduce a discrete time approach to the illness-death model and a recursion formula, which can be utilized to project chronic disease burden. We further illustrate an example of the technique applied to anxiety disorders in Germany.

Materials and Equipment

The illness-death model is a multistate model that relates prevalence, incidence, mortality, and remission. A basic recursion formula that considers prevalence, incidence, mortality among the susceptible, and mortality among the diseased can be applied to irreversible chronic diseases such as diabetes. Among several mental disorders, remission plays a key role and thus an extended recursion formula taking remission into account is derived.

Methods

Using the Global Burden of Disease Study 2019 data and population projections from the Federal Statistical Office of Germany, a total number of individuals with anxiety disorders by sex in Germany from 2019 to 2030 was projected. Regression models were fitted to historical data for prevalence and incidence. Differential mortality risks were modeled based on empirical evidence. Remission was estimated from prevalence, incidence, and mortality, applying the extended recursion formula. Sex- and age-specific prevalence of 2019 was given as the initial value to estimate the total number of individuals with anxiety disorders for each year up to 2030. Projections were also made through simple extrapolation of prevalence for comparison.

Results

From 2019 to 2030, we estimated a decrease of 52,114 (-1.3%) individuals with anxiety disorders among women, and an increase of 166,870 (+8.5%) cases among men, through the illness-death model approach. With prevalence extrapolation, an increase of 381,770 (+9.7%) among women and an increase of 272,446 (+13.9%) among men were estimated.

Discussion

Application of the illness-death model with discrete time steps is possible for both irreversible chronic diseases and diseases with possible remissions, such as anxiety disorders. The technique provides a framework for disease burden prediction. The example provided here can form a basis for running simulations under varying transition probabilities.

Premature death and causes of death among patients with panic disorder and comorbid psychiatric disorders: A nationwide cohort study

OBJECTIVES

Panic disorder (PD) is associated with high psychiatric and physical comorbidity, but the cause of mortality has not been well studied. This study investigated mortality rates and causes of death in an Asian cohort with PD.

METHODS

We enrolled a nationwide retrospective cohort of 298,466 persons diagnosed with PD from January 1, 2001, to December 31, 2016. Each cohort member was matched with a comparison one randomly selected from the general population with the same sex, age at entry, and birth year. The data of both the PD cohort and the comparison group were linked with the national mortality database to obtain each individual's mortality status. We used mortality rate ratios (MRRs) to compare mortality risks between the patients with PD and the general population. Stratified analysis of mortality risks was performed based on sex and psychiatric comorbidities.

RESULTS

PD was associated with a slightly increased mortality risk (MRR, 1.14 [99% CI, 1.11-1.17]). The risk of unnatural death (MRR, 2.83 [99% CI, 2.59-3.10]) was significantly higher among the individuals with PD than among the general population, whereas the risk of overall natural death across all categories was not (MRR, 1.01 [99% CI, 0.98-1.04]). The mortality risk was the highest for suicide (MRR, 4.94 [99% CI, 4.32-5.72]) and was higher in women (MRR, 6.37 [99% CI, 5.25-7.96]) than in men (MRR, 3.77 [99% CI, 3.14-4.64]). Comorbid substance use disorders increased the risk of mortality from natural (MRR, 3.23 [99% CI, 2.59-4.14]) and unnatural (MRR, 9.45 [99% CI, 6.29-17.85]) causes.

CONCLUSION

PD was associated with increased all-cause mortality, especially suicide. Substance use further increased mortality risk in persons with PD. Targeted treatment for substance use and suicide prevention are essential among persons with PD.

Heightened false alarms of conditioned threat predict longitudinal increases in GAD and SAD symptoms over the first year of college

Lab-based fear-conditioning studies have repeatedly implicated exaggerated threat reactivity to benign (unreinforced) stimuli as concurrent markers of clinical anxiety, but little work has examined the strength of false alarms as a longitudinal predictor of anxiety problems. As such, we tested whether heightened false alarms of conditioned threat assessed in participants' first semester of college predicted second-semester symptoms of generalized anxiety disorder (GAD) and social anxiety disorder (SAD) - two anxiety conditions that are common in college students, have been associated with excessive false alarms, and have yet to be assessed with longitudinal conditioning designs. Here, we focused on the predictive effects of behavioral threat responses (threat expectancy, subjective anxiety, avoidance) given their greater potential for translation to the clinic. Results implicate conditioning-related increases in anxiety to safe stimuli resembling the danger-cue as prospective predictors of GAD. In contrast, SAD was predicted by non-specific elevations in anxiety to a broad set of safe stimuli, as well as by increased threat expectancy toward cues least resembling the conditioned danger cue. These findings suggest that risk for GAD and SAD are captured by distinct, behavioral indicators of false-alarms that may be more feasibly collected in clinical settings compared to alternative experimental anxiety measures like psychophysiological responses.

Strategies to improve access to cognitive behavioral therapies for anxiety disorders: A scoping review

Background

Strategies to improve access to evidence-based psychological treatments (EBPTs) include but are not limited to implementation strategies. No currently available framework accounts for the full scope of strategies available to allow stakeholders to improve access to EBPTs. Anxiety disorders are common and impactful mental conditions for which EBPTs, especially cognitive-behavioral therapies (CBT), are well-established yet often hard to access.

Objective

Describe and classify the various strategies reported to improve access to CBT for anxiety disorders.

Methods

Scoping review with a keyword search of several databases + additional grey literature documents reporting on strategies to improve access to CBT for anxiety disorders. A thematic and inductive analysis of data based on grounded theory principles was conducted using NVivo.

Results

We propose to classify strategies to improve access to CBT for anxiety disorders as either "Contributing to the evidence base," "Identifying CBT delivery modalities to adopt in practice," "Building capacity for CBT delivery," "Attuning the process of access to local needs," "Engaging potential service users," or "Improving programs and policies." Each of these strategies is defined, and critical information for their operationalization is provided, including the actors that could be involved in their implementation.

Implications

This scoping review highlights gaps in implementation research regarding improving access to EBPTs that should be accounted for in future studies.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BACKGROUND

The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.

METHODS/DESIGN

We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.

STATISTICAL ANALYSIS

Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.

DISCUSSION

This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Does the time-span of conditioning affect spontaneous recovery after extinction?

Gold-standard psychological treatments such as exposure therapy are significantly undermined by high relapse rates. Although exposure-based treatments are capable of extinguishing maladaptive behaviours, these behaviours often spontaneously re-emerge over time - a phenomenon known in experimental research as spontaneous recovery. Understanding the factors that underlie this process is essential to improving long-term treatment outcomes. One factor that is yet to be properly examined is the effect of the total span of time across which behaviours are learned. To date, only one study by Gallistel & Papachristos (2020) has explored this in mice. Their findings suggest that long spans of acquisition learning result in greater spontaneous recovery compared to short spans. We investigated the effect of conditioning span across 5 experiments using rats. Contrary to Gallistel & Papachristos, our results found no difference in recovery between rats conditioned over a long span versus a short span, following short, intermediate and long delay intervals. This suggests that the span of conditioning does not affect the magnitude of recovery, nor the rate at which recovery emerges. Unexpectedly, conditioning span did appear to influence the strength of responding during acquisition, such that longer conditioning spans led to higher levels of responding. This finding could indicate that the learning process operates over a long time period beyond the original training episode. However, further research is needed to establish whether conditioning span influences the strength of what is learned, or instead the performance of a conditioned response.

Symptom fluctuation over the menstrual cycle in anxiety disorders, PTSD, and OCD: a systematic review

Anxiety disorders are more prevalent and severe in women than men. Extant research suggests that the menstrual cycle modulates the severity and expression of anxiety symptoms across a range of disorders. The aims of this systematic review were to synthesise the existing literature investigating menstrual phase-related fluctuations in symptoms of anxiety disorders, and related conditions PTSD and OCD, in menstruating women, and to evaluate the methodologies used. PsycINFO and PubMed were searched through to April 2021 for studies that measured and compared symptoms of a diagnosed anxiety disorder, PTSD, or OCD, between at least two menstrual phases. Fourteen studies meeting inclusion criteria were identified. The review revealed evidence for exacerbation of a broad range of symptoms in panic disorder, PTSD, social anxiety disorder, and generalised anxiety disorder, around the weeks prior to and post menses onset, coincident with elevated but declining ovarian hormones, and low hormone levels, respectively. Effects were heterogenous between individuals and different symptom types. Key methodological weaknesses included sub-optimal and inconsistent means of defining and identifying menstrual phases, low sample representativeness, and small sample sizes. Menstrual fluctuations in anxiety symptoms appear to be a feature of anxiety disorders, PTSD, and OCD, but likely only occur in a subset of women. Future research in this field could better manage and account for such heterogeneity by using group-based trajectory modelling in larger sample sizes and using pre-screening to recruit women with known histories of menstrual fluctuation in anxiety symptoms.

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity

BACKGROUND

Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life.

METHODS

A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points.

RESULTS

Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up.

CONCLUSIONS

Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

Sex is a defining feature of neuroimaging phenotypes in major brain disorders

Sex is a biological variable that contributes to individual variability in brain structure and behavior. Neuroimaging studies of population-based samples have identified normative differences in brain structure between males and females, many of which are exacerbated in psychiatric and neurological conditions. Still, sex differences in MRI outcomes are understudied, particularly in clinical samples with known sex differences in disease risk, prevalence, and expression of clinical symptoms. Here we review the existing literature on sex differences in adult brain structure in normative samples and in 14 distinct psychiatric and neurological disorders. We discuss commonalities and sources of variance in study designs, analysis procedures, disease subtype effects, and the impact of these factors on MRI interpretation. Lastly, we identify key problems in the neuroimaging literature on sex differences and offer potential recommendations to address current barriers and optimize rigor and reproducibility. In particular, we emphasize the importance of large-scale neuroimaging initiatives such as the Enhancing NeuroImaging Genetics through Meta-Analyses consortium, the UK Biobank, Human Connectome Project, and others to provide unprecedented power to evaluate sex-specific phenotypes in major brain diseases.

The 9-year clinical course of depressive and anxiety disorders: New NESDA findings

BACKGROUND

In longitudinal research, switching between diagnoses should be considered when examining patients with depression and anxiety. We investigated course trajectories of affective disorders over a nine-year period, comparing a categorical approach using diagnoses to a dimensional approach using symptom severity.

METHOD

Patients with a current depressive and/or anxiety disorder at baseline (N = 1701) were selected from the Netherlands Study of Depression and Anxiety (NESDA). Using psychiatric diagnoses, we described 'consistently recovered,' 'intermittently recovered,' 'intermittently recurrent', and 'consistently chronic' at two-, four-, six-, and nine-year follow-up. Additionally, latent class growth analysis (LCGA) using depressive, anxiety, fear, and worry symptom severity scores was used to identify distinct classes.

RESULTS

Considering the categorical approach, 8.5% were chronic, 32.9% were intermittently recurrent, 37.6% were intermittently recovered, and 21.0% remained consistently recovered from any affective disorder at nine-year follow-up. In the dimensional approach, 66.6% were chronic, 25.9% showed partial recovery, and 7.6% had recovered.

LIMITATIONS

30.6% of patients were lost to follow-up. Diagnoses were rated by the interviewer and questionnaires were completed by the participant.

CONCLUSIONS

Using diagnoses alone as discrete categories to describe clinical course fails to fully capture the persistence of affective symptoms that were observed when using a dimensional approach. The enduring, fluctuating presence of subthreshold affective symptoms likely predisposes patients to frequent relapse. The commonness of subthreshold symptoms and their adverse impact on long-term prognoses deserve continuous clinical attention in mental health care as well further research.

Validation of the Acceptance and Action Questionnaire-II in the general Spanish population

Acceptance and Commitment Therapy states that Experiential Avoidance contributes to the development of psychological issues. The Acceptance and Action Questionnaire-II measures Experiential Avoidance. The objective of the current study is to perform a validation of the Acceptance and Action Questionnaire-II in the general Spanish population. A sample of 964 participants from all over Spain was used (M = 43.43 years; SD = 15.27). The psychometric properties of the questionnaire were examined according to Classical Test Theory. In addition, assessments were made of participants’ personality, Emotional Intelligence, Anxiety, and Depression, and the influence of sex and age on Experiential Avoidance was examined. The Acceptance and Action Questionnaire-II is a unidimensional instrument, with excellent reliability (α = .93) and adequate evidence of validity. Differences were observed based on sex, with women scoring higher, and based on age, with lower scores in the older age groups. The Acceptance and Action Questionnaire-II is a valid, reliable instrument for use in the general Spanish population.

Optimal well-being in the aftermath of anxiety disorders: A 10-year longitudinal investigation

BACKGROUND

Although preliminary research has explored the possibility of optimal well-being after depression, it is unclear how rates compare to anxiety. Using Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) as exemplars of anxiety, we tested the rates of optimal well-being one decade after being diagnosed with an anxiety disorder. Based on reward deficits in depression, we pre-registered our primary hypothesis that optimal well-being would be more prevalent after anxiety than depression as well as tested two exploratory hypotheses.

METHOD

We used data from the Midlife in the United States (MIDUS) study, which contains a nationally representative sample across two waves, 10 years apart. To reach optimal well-being, participants needed to have no symptoms of GAD, PD, or major depressive disorder (MDD) at the 10 year follow-up and exceed cut-offs across nine dimensions of well-being.

RESULTS

The results failed to support our primary hypothesis. Follow-up optimal well-being rates were highest for adults previously diagnosed with MDD (8.7%), then PD (6.1%), and finally GAD (0%). Exploratory analyses revealed optimal well-being was approximately twice as prevalent in people without anxiety or depression at baseline and provided partial support for baseline well-being predicting optimal well-being after anxiety. Results were largely replicated across different classifications of optimal well-being.

LIMITATIONS

Findings are limited by the somewhat unique measurement of anxiety in the MIDUS sample as well as the relatively high rate of missing data.

CONCLUSIONS

We discuss possible explanations for less prevalent optimal well-being after anxiety vs. depression and the long-term positivity deficits from GAD.

Work-focused therapy for common mental disorders: A naturalistic study comparing an intervention group with a waitlist control group

BACKGROUND:

Common mental disorders (CMD) are leading causes of sickness absence. Treatments for CMD that both reduce symptoms and support work participation urgently need to be developed.

OBJECTIVE:

Determine the potential effects of work-focused therapy combining work interventions with either meta cognitive therapy or cognitive behavioural therapy (W-MCT/CBT) for patients with CMD on sick leave.

METHODS:

Naturalistic study with a quasi-experimental approach. Pre- and post-scores (return to work, symptoms, return-to-work self-efficacy, clinical recovery from depression and anxiety) were compared between the intervention group (n = 87) who received immediate treatment over an average of 10.40 sessions (SD = 3.09) and the non-randomized waitlist control group (n = 95) that had waited an average of 11.18 weeks (SD = 2.29).

RESULTS:

Significantly more patients returned fully to work in the intervention group (41.4%) than the control group (26.3%). Effect sizes for self-efficacy scores, depression and anxiety were large in the intervention group (d = 1.28, 1.01, 1.58), and significantly lower in the control group (d = 0.60, 0.14, 0.45). Significantly more patients in the treatment group than control group recovered from depression (54.1% vs. 12.8%) and anxiety (50.0% vs.10.6%).

CONCLUSIONS:

W-MCT/CBT may be an effective intervention for patients on sick leave due to CMD.

Stress in obstructive sleep apnea

People with obstructive sleep apnea (OSA) often have psychological symptoms including depression and anxiety, which are commonly treated with anti-depression or anti-anxiety interventions. Psychological stress is a related symptom with different intervention targets that may also improve mental state, but this symptom is not well characterized in OSA. We therefore aimed to describe stress in relation to other psychological symptoms. We performed a prospective cross-sectional study of 103 people, 44 untreated OSA (mean ± s.d. age: 51.2 ± 13.9 years, female/male 13/31) and 57 healthy control participants (age: 46.3 ± 13.8 years, female/male 34/23). We measured stress (Perceived Stress Scale; PSS), excessive daytime sleepiness (Epworth Sleepiness Scale; ESS), depressive symptoms (Patient Health Questionnaire; PHQ-9), and anxiety symptoms (General Anxiety Disorder; GAD-7). We compared group means with independent samples t-tests and calculated correlations between variables. Mean symptom levels were higher in OSA than control, including PSS (mean ± s.d.: OSA = 15.3 ± 6.9, control = 11.4 ± 5.5; P = 0.002), GAD-7 (OSA = 4.8 ± 5.0, control = 2.1 ± 3.9; P = 0.02), PHQ-9 (OSA = 6.9 ± 6.1, control = 2.6 ± 3.8; P = 0.003) and ESS (OSA = 8.1 ± 5.3, control = 5.0 ± 3.3; P = 0.03). Similar OSA-vs-control differences appeared in males, but females only showed significant differences in PHQ-9 and ESS, not PSS or GAD-7. PSS correlated strongly with GAD-7 and PHQ-9 across groups (R = 0.62–0.89), and moderately with ESS. Perceived stress is high in OSA, and closely related to anxiety and depressive symptoms. The findings support testing stress reduction in OSA.

Feasibility and acceptability of an enhanced cognitive behavioural therapy programme for parent-child dyads with anxiety disorders: a mixed-methods pilot trial protocol

BACKGROUND

Cognitive behavioural therapy (CBT) is the most widely recognised and efficacious psychological therapy for the treatment of anxiety disorders in children and adults. However, suboptimal remission rates indicate room for improvement in treatments, particularly when both children and their parents have anxiety disorders. Bidirectional transmission and maintenance of anxiety within parent-child dyads could be better targeted by CBT, to improve treatment outcomes for children and parents with anxiety disorders. This study aimed to develop and evaluate the feasibility and acceptability of a concurrent parent-child enhanced CBT intervention that targets the individual's anxiety disorder(s), as well as the bidirectional factors that influence and maintain anxiety in the dyad.

METHODS

Feasibility and acceptability of the proposed CBT protocol will be evaluated in an open-label pilot trial of the intervention utilising qualitative and quantitative data collection. Ten parent-child dyad participants (n = 20) with anxiety disorders will be recruited for the proposed intervention. The intervention is based on an empirically supported 10-week CBT programme for anxiety disorders in adults, adapted to be delivered to parent-child dyads concurrently, and to target anxious modelling and overprotective behaviours through joint observational exposures. Intervention feasibility will be explored by pre-post symptom change on a range of clinician- and self-report measures to determine preliminary indications of participants' intervention response and effect size calculations to estimate sample size for a future definitive randomised controlled trial (RCT). Additional feasibility measures will include recruitment rates, completion rates, and adherence to programme requirements. To explore participant acceptability of the intervention, qualitative interviews will be conducted with five parent-child dyads who complete the intervention (n = 10), along with five parent-child dyads with anxiety symptoms who express interest in the intervention (n = 10). Acceptability measures will include prospective and retrospective quantitative self-report and qualitative interview data.

DISCUSSION

This pilot trial will utilise a mixed-methods design to determine the feasibility and acceptability of delivering an enhanced CBT intervention for the concurrent treatment of parent-child dyads with anxiety disorders. The results of this trial will inform the development and implementation of a future definitive randomised clinical trial to evaluate intervention efficacy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ANZCTR1261900033410 . Prospectively registered: pre-results. Registered 04 March 2019.

Predictors of persistence of anxiety disorders across the lifespan: a systematic review

Despite the substantial disease burden of anxiety disorders, physicians have a poor understanding of factors that predict their typical persistent course. This systematic review of predictors of persistent anxiety disorders covered 48 studies with 29 690 patients diagnosed with an anxiety disorder that were published in PubMed, PsycINFO, and Web of Science between Jan 1, 1980 (introduction of DSM-III), and Dec 1, 2019. We also compared predictors between children, adolescents, adults, and older adults (ie, ≥55 years). A persistent course was primarily predicted by clinical and psychological characteristics, including having panic attacks, co-occurring personality disorders, treatment seeking, poor clinical status after treatment, higher severity and longer duration of avoidance behaviour, low extraversion, higher anxiety sensitivity, and higher behavioural inhibition. Unlike disorder onset, sociodemographic characteristics did not predict persistence. Our results outline a profile of patients with specific clinical and psychological characteristics who are particularly vulnerable to anxiety disorder persistence. Clinically, these patients probably deserve additional or more intensive treatment to prevent development of chronicity.

It's all about who you know: Memory retention of a rat's cagemates during infancy negatively predicts adulthood hippocampal FGF2

Recent research has demonstrated that individual differences in infant fear memory positively predict adulthood anxiety-like behavior and conditioned fear expression. However, the physiological mechanisms underlying this relationship and the effect of environmental (e.g., social) influences on the stability of this relationship have not been explored. In the present study, we examined whether individual differences in infant fear memory predict levels of endogenous fibroblast growth factor-2 (FGF2; a biomarker of fear/anxiety) in adulthood, and whether the mean memory retention of a rat's cagemates predicts conditioned fear expression and FGF2 in adulthood. We conditioned infant rats to associate a white noise with shock, and tested their memory of the association 1 week later. They were then weaned and randomly assigned to cage/cagemates. In adulthood, rats received weak context conditioning (i.e., a single shock) and were tested for fear of the context the following day. Rats were then euthanized and their brains extracted to measure levels of hippocampal FGF2 protein. Across 2 experiments, an individual rat's fear memory during infancy positively predicted their own fear expression in adulthood, but the mean memory retention of their cagemates did not predict fear expression. In contrast, the mean memory retention of a rat's cagemates during infancy negatively predicted hippocampal FGF2 protein in adulthood, but an individual rat's memory retention did not predict their own levels of FGF2. These data support the idea that variations in the fearfulness of a rat's cagemates predict individual differences on physiological measures in adulthood.

Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol

About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.