Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V

Psychometric properties of the dimensional anxiety scales for DSM-V in an unselected sample of German treatment seeking patients

BACKGROUND

Dimensional assessments are planned to be included as supplements to categorical diagnoses in DSM-V. The aim of this study was to examine the unidimensionality, reliability, validity, and clinical sensitivity of brief self-rated scales for specific anxiety disorders in an unselected German sample of consecutive attendees to a psychological clinic. These scales use a common template to assess core constructs of fear and anxiety.

METHODS

Dimensional scales for social anxiety disorder, specific phobia, agoraphobia, panic disorder, and generalized anxiety disorder were administered along with established scales to 102 adults seeking treatment for mental health problems at a German university outpatient clinic for psychotherapy. The computer-assisted clinical version of the Munich-Composite International Diagnostic Interview was used to assess mental disorders according to DSM-IV criteria. Dimensionality and scale reliability were examined using confirmatory factor analyses. Convergent and discriminant validity were examined by testing differences in the size of correlations between each dimensional anxiety scale and each of the previously validated scales. Each dimensional scale's ability to correctly differentiate between individuals with versus without an anxiety diagnosis was examined via the area under the curve.

RESULTS

Analyses revealed unidimensionality for each scale, high reliability, and convergent and discriminant validity. Classification performance was good to excellent for all scales except for specific phobia.

CONCLUSIONS

The application of the dimensional anxiety scales may be an effective way to screen for specific anxiety disorders and to supplement categorical diagnoses in DSM-V, although further evaluation and refinement of the scales (particularly the specific phobia scale) is needed.

Pediatric social anxiety disorder: predictors of response to pharmacological treatment

OBJECTIVE

Pediatric social anxiety disorder (SAD) is associated with an increased risk of comorbid mental disorders, with implications for prognosis and treatment strategy. The aim of this study is to explore predictors of treatment response, and the role of comorbidity in affecting refractoriness.

METHODS

One hundred and forty consecutive youths (81 males, 57.9%), ages 7-18 years (mean age 13.7 ± 2.5 years, mean age at onset of SAD 10.6 ± 2.7 years) met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for SAD as primary diagnosis, according to a structured clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]). All received a pharmacological treatment with serotonin reuptake inhibitors (SSRIs) targeted to SAD, associated with additional medications for comorbidities (mood stabilizers in 27.1%, antipsychotics in 12.8%) and 57.9% received an additional psychotherapy.

RESULTS

Eighty-nine patients (63.6%) responded to treatments after 3 months, namely 72.8% with psychotherapy plus medication and 50.8% with medication only. Nonresponders had more severe symptoms at baseline in terms of both clinical severity and functional impairment, and had more comorbid disruptive behavior disorders. The backward logistic regression indicated that clinical severity and functional impairment at baseline, comorbid disruptive behavior disorders, and bipolar disorders were predictors of nonresponse.

CONCLUSION

Our data suggest that SSRIs can be effective in pediatric SAD, but that the more severe forms of the disorder and those with heavier comorbidity are associated with poorer prognosis.

Developmental changes of rhesus monkeys in response to separation from the mother

The development of separation response behaviors in infant rhesus macaques across the first 6 months of life was assessed. Seventeen infants underwent a neonatal assessment at 7, 14, 21, and 30 days of age which included a brief period of social isolation. At 3 and 6 months of age these same monkeys and four additional subjects were again subjected to a period of brief social isolation and also exposed to a novel environment with their sedated mother. Results indicate a developmental increase followed by a steady decline in the frequency of separation vocalizations. A modest relationship between early-infancy locomotor profiles and separation responses was also observed at several time points suggesting a possible relationship between these measures. However, stable inter-individual measures of separation distress did not emerge until late in the infantile period. This could suggest that high levels of maternal contact-seeking behavior early in infancy are context specific and not a reliable index of enduring temperament.

Neurocircuitry of generalized anxiety disorder in adolescents: a pilot functional neuroimaging and functional connectivity study

BACKGROUND

Dysfunction of neural systems responsible for the processing of emotional stimuli is hypothesized to be involved in the pathophysiology of generalized anxiety disorder (GAD) in adolescents. We used standard fMRI and functional connectivity analyses to examine the functional neurocircuitry of GAD in adolescents.

METHODS

Ten adolescents with GAD and 10 healthy comparison subjects underwent fMRI while performing a continuous performance task with emotional and neutral distractors. Standard event-related voxel-wise fMRI and steady-state functional connectivity analyses were performed.

RESULTS

Increased activation was observed in the left medial prefrontal cortex and right ventrolateral prefrontal cortex (VLPFC) in response to emotional images compared to neutral imagines in youth with GAD. Connectivity analyses using the right VLPFC seed region suggested decreased connectivity between this region and the bilateral medial prefrontal cortex. Connectivity analyses using the right amygdala seed region revealed decreased correlation with the posterior cingulate cortex in adolescents with GAD. The left amygdala seed region demonstrated increased connectivity with the ipsilateral precuneus in youth with GAD compared to healthy subjects.

CONCLUSIONS

In addition to increased activation of the medial prefrontal cortex and right VLPFC, we observed altered connectivity between the amygdala or VLPFC and regions, which subserve mentalization (e.g. posterior cingulate cortex, precuneus, and medial prefrontal cortex). This suggests that structures that regulate emotion and affect interact abnormally with key structures that are involved in mentalization, a process known to be disrupted in GAD.

Bringing a developmental perspective to anxiety genetics

Despite substantial recent advancements in psychiatric genetic research, progress in identifying the genetic basis of anxiety disorders has been limited. We review the candidate gene and genome-wide literatures in anxiety, which have made limited progress to date. We discuss several reasons for this hindered progress, including small samples sizes, heterogeneity, complicated comorbidity profiles, and blurred lines between normative and pathological anxiety. To address many of these challenges, we suggest a developmental, multivariate framework that can inform and enhance anxiety phenotypes for genetic research. We review the psychiatric and genetic epidemiological evidence that supports such a framework, including the early onset and chronic course of anxiety disorders, shared genetic risk factors among disorders both within and across time, and developmentally dynamic genetic influences. We propose three strategies for developmentally sensitive phenotyping: examination of early temperamental risk factors, use of latent factors to model underlying anxiety liability, and use of developmental trajectories as phenotypes. Expanding the range of phenotypic approaches will be important for advancing studies of the genetic architecture of anxiety disorders.

Differentiating high-functioning autism and social phobia

Both high-functioning autism (HFA) and social phobia (SP) involve profound social interaction deficits. Although these disorders share some similar symptoms, they are conceptualized as distinct. Because both HFA and SP are defined behaviorally, the degree of overlap between the two disorders may result in misinterpretation of symptoms. However, the deficits in each disorder differ, particularly in areas of social interaction, emotion recognition and expression, and communication. This paper reviews the literature that informs our current understanding of the behavioral overlaps and differences in HFA and SP. The review also addresses the implications of our current knowledge of these two disorders for differential diagnosis, treatment, and future research. Interdisciplinary, developmentally-oriented research may help extend current approaches to HFA and SP.

Reduced dorsal anterior cingulate cortical activity during emotional regulation and top-down attentional control in generalized social phobia, generalized anxiety disorder, and comorbid generalized social phobia/generalized anxiety disorder

BACKGROUND

Generalized social phobia (GSP) and generalized anxiety disorder (GAD) are both associated with emotion dysregulation. Research implicates dorsal anterior cingulate cortex in both explicit emotion regulation (EER) and top-down attentional control (TAC). Although studies have examined these processes in GSP or GAD, no work compares findings across the two disorders or examines functioning in cases comorbid for both disorders (GSP/GAD). Here we compare the neural correlates of EER and TAC in GSP, GAD, and GSP/GAD.

METHODS

Medication-free adults with GSP (EER n = 19; TAC n = 18), GAD (EER n = 17; TAC n = 17), GSP/GAD (EER n = 17; TAC n = 15), and no psychopathology (EER n = 18; TAC n = 18) participated. During EER, individuals alternatively viewed and upregulated and downregulated responses to emotional pictures. During TAC, they performed an emotional Stroop task.

RESULTS

For both tasks, significant group × condition interactions emerged in dorsal anterior cingulate cortex and parietal cortices. Healthy adults showed significantly increased recruitment during emotion regulation, relative to emotion-picture viewing. GAD, GSP, and GSP/GAD subjects showed no such increases, with all groups differing from healthy adults but not from each other. Evidence of emotion-related disorder-specificity emerged in medial prefrontal cortex and amygdala. This disorder-specific responding varied as a function of emotion content but not emotion-regulatory demands.

CONCLUSIONS

GSP and GAD both involve reduced capacity for engaging emotion-regulation brain networks, whether explicitly or via TAC. A reduced ability to recruit regions implicated in top-down attention might represent a general risk factor for anxiety disorders.

Associations between household and neighborhood income and anxiety symptoms in young adolescents

BACKGROUND

A better understanding of the role of both family- and neighborhood-level socioeconomic characteristics in the development of anxiety disorders is important for identifying salient target populations for intervention efforts. Little research has examined the question of whether associations between anxiety and socioeconomic status (SES) differ depending upon the level at which SES is measured or way in which anxiety manifests. We studied associations between both household- and neighborhood-level income and four different manifestations of anxiety in a community sample of young adolescents.

METHODS

We conducted a cross-sectional analysis of data on 498 subjects aged 11-13 from a cohort study of Seattle-area middle school students. Generalized estimating equations were used to examine the association between both annual household income and neighborhood median income and each of four anxiety subscale scores from the multidimensional anxiety scale for children (MASC): physical symptoms, harm avoidance, social anxiety, and separation/panic anxiety.

RESULTS

A negative association was found between household income and scores on two of the four MASC subscales--physical symptoms and separation/panic anxiety. In contrast, at equivalent levels of household income, adolescents living in higher income neighborhoods reported higher physical and harm avoidance symptom scores.

CONCLUSION

The role that SES plays in the development of childhood anxiety appears to be complex and to differ depending on the specific type of anxiety that is manifest and whether income is evaluated at the household or neighborhood level.

[Prevalence of Depressive and Anxious Symptomatology in 14-18 ys-old Students from a Private School in Medellin]

OBJECTIVE

This study describes prevalence of depressive and anxious symptoms together with family, environmental and personal risk factors in a group of adolescents between 14 and 18 years of age in a private school of Medellín.

METHODS

An analytic observational cross sectional study was performed in 152 adolescents, evaluating sociodemographic aspects and prevalence of depressive and anxious symptomatology, as established through BDI-II and BAI.

RESULTS

Average age was 15.4 ± 0.9 years old, with a 25% prevalence of anxiety symptoms and 25.7% of depressive symptoms. From the 38 (25%) students with BAI positive, 26 (68.4%) were BDI positive, and from the 39 (25.6%) students with BDI positive, 26 (66.7%) were BAI positive.

CONCLUSIONS

the risk factors for anxiety and depressive symptomatology were: being a woman, being a victim of bullying and abuse. Having friends was the protective factors for depressive symptomatology. There was a statistical association between self-report of depressive and anxiety symptomatology; between the anxiety self-report and the depressive symptomatology; as well as between depressive and anxiety symptomatology and parents' perception of such symptoms.

Psychometric Properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C)

Reliable and valid self-report questionnaires could be useful as initial screening instruments for social phobia in both clinical settings and general populations. The present study investigates the factor structure and psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C) in a sample of 228 children from the Italian general population aged 8 to 11. The children were asked to complete the Italian version of the SPAI-C and the Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire. Confirmatory factor analyses revealed that social phobia can be conceptualized as a unitary construct consisting of five distinct but interrelated symptom clusters named Assertiveness, General Conversation, Physical/Cognitive Symptoms, Avoidance, and Public Performance. Internal consistency of the SPAI-C total scores and two subscales was good; correlations between SPAI-C total scores and SCARED total scores/subscales ranged from moderate to high (Generalized Anxiety Disorder, for social phobia), with the SCARED Social Phobia subscale as the best predictor of SPAI-C total scores. The results indicate that the SPAI-C is a reliable and sensitive instrument suitable for identifying Social Phobia in the young Italian general population.

Risky play and children's safety: balancing priorities for optimal child development

Injury prevention plays a key role in keeping children safe, but emerging research suggests that imposing too many restrictions on children’s outdoor risky play hinders their development. We explore the relationship between child development, play, and conceptions of risk taking with the aim of informing child injury prevention. Generational trends indicate children’s diminishing engagement in outdoor play is influenced by parental and societal concerns. We outline the importance of play as a necessary ingredient for healthy child development and review the evidence for arguments supporting the need for outdoor risky play, including: (1) children have a natural propensity towards risky play; and, (2) keeping children safe involves letting them take and manage risks. Literature from many disciplines supports the notion that safety efforts should be balanced with opportunities for child development through outdoor risky play. New avenues for investigation and action are emerging seeking optimal strategies for keeping children “as safe as necessary,” not “as safe as possible.” This paradigm shift represents a potential for epistemological growth as well as cross-disciplinary collaboration to foster optimal child development while preserving children’s safety.

Pre-adoption adversity and self-reported behavior problems in 7 year-old international adoptees

To further investigate the long-term impact of pre-adoption adversity on international adoptees, externalizing and internalizing symptoms were assessed using a self-report measure at school-age in addition to mothers' reports. The sample consisted of 95 adopted children and their mothers. Children's health and developmental status were assessed soon after arrival in their adoptive family. At age 7, the Dominic Interactive, a self-report measure, was used to evaluate externalizing and internalizing symptoms while mothers completed the CBCL. Children's self-reports were compared to their non-adopted peers'. Adopted children reported more symptoms of specific phobia than their peers. A significant correlation was found between mothers' and children's reports but only for externalizing symptoms. Self-reported symptoms were related to indices of nutritional and psychosocial deprivation at arrival, such as low height/age and weight/height ratios. Our results emphasize the importance of considering international adoptees' perception of their psychological adjustment and the long-term impact of early risk factors.

Developmental epidemiology of anxiety disorders

This review focuses on developmental aspects in the epidemiology of anxiety disorders including prevalence, onset, natural course, longitudinal outcome, and correlates and risk factors, with focus on childhood through young adulthood. Anxiety disorders are frequent and early-emerging conditions. They may remit spontaneously; however, the same or other mental disorders often recur. Although risk factors have been identified, more work is needed to identify the most powerful predictors for onset and the progression to more complex forms of psychopathology and to understand the underlying mechanisms and interactions. This identification is crucial to facilitate research prevention, early interventions, and treatment programs.

Psychopharmacologic treatment of children and adolescents with anxiety disorders

Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.

Panic disorder and school refusal

This article provides clinical and research information about panic disorder, agoraphobia, and school refusal. Proposed changes to the definition of panic disorder and agoraphobia for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition are outlined. Treatment of panic disorder, and school refusal in children and adolescents is also discussed.

Duplication of GTF2I results in separation anxiety in mice and humans

Duplication (dup7q11.23) and deletion (Williams syndrome) of chromosomal region 7q11.23 cause neurodevelopmental disorders with contrasting anxiety phenotypes. We found that 30% of 4- to 12-year-olds with dup7q11.23 but fewer than 5% of children with WS or in the general population met diagnostic criteria for a separation-anxiety disorder. To address the role of one commonly duplicated or deleted gene in separation anxiety, we compared mice that had varying numbers of Gtf2i copies. Relative to mouse pups with one or two Gtf2i copies, pups with additional Gtf2i copies showed significantly increased maternal separation-induced anxiety as measured by ultrasonic vocalizations. This study links the copy number of a single gene from 7q11.23 to separation anxiety in both mice and humans, highlighting the utility of mouse models in dissecting specific gene functions for genomic disorders that span many genes. This study also offers insight into molecular separation-anxiety pathways that might enable the development of targeted therapeutics.

Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder

Generalized anxiety disorder (GAD) is associated with significant morbidity in children and adolescents, yet only recently have the neuropharmacology and neurophysiology of this condition been studied in youth. Accumulating data suggest structural and functional abnormalities within the brain's fear networks in youth with GAD. Additionally, seven studies examined the efficacy of medications that modulate this system and, in some cases, the direct effects of these medications on structures within these networks (e.g. amygdala, ventrolateral prefrontal cortex [VLPFC]). In this review, we summarize the extant functional, functional connectivity, and structural neuroimaging data in children and adolescents with GAD. In addition, data concerning selective serotonin reuptake inhibitors (SSRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), atypical anxiolytics, benzodiazepines, and psychotherapy are reviewed in the context of the neurophysiology of pediatric GAD. The existing data suggest abnormal activity within the amygdala, VLPFC, and anterior cingulate cortex, as well as the possibility of impaired connectivity among these brain regions. In addition to numerous cognitive behavioral therapy (CBT) trials, five randomized, controlled psychopharmacologic trials primarily in youth with GAD suggest that SSRIs and SSNRIs are effective for this condition. These findings also raise the possibility that functional activity within the amygdala and VLPFC may be altered following successful treatment.

Anxiety disorder symptoms in children and adolescents: differences by age and gender in a community sample

INTRODUCTION

Anxiety symptoms in childhood and adolescence are an important risk factor for developing anxiety disorders in subsequent development stages. This study examines the frequency and characteristics of the symptoms of the principal anxiety disorders in children and adoloscents using a self-report questionnaire based on the diagnostic categories of the American Psychiatric Association (APA) manual.

MATERIAL AND METHODS

A cross-sectional, non-interventional study was conducted on 2522 children and adolescents form 8 to 17 years (49% males), enrolled from different schools in the Province of Alicante who completed the Spence Children's Anxiety Scale.

RESULTS

The mean score obtained on the scale (range: 0-114) was 25.15 (standard deviation (SD)=13.54). More than one in four (26.41%) of the children and adolescents showed high scores in any anxiety disorder. The anxiety symptoms due to separation were the most frequent in the sample (5.5%), followed by physical fears (5.1%). Girls scored significantly higher in all disorders (P<.001), except in obsessive-compulsive disorder. Differences were found as regards age in all disorders, except physical fears, but the effect sizes were only in anxiety due to separation, which decreased with age, and generalised anxiety, which was higher in adolescents than in children.

CONCLUSIONS

From the mental health perspective, it is important to be able to detect anxiety symptoms in children from 8 years onwards, in order to intervene early and prevent the development of anxiety disorders in later life.

Juvenile neurogenesis makes essential contributions to adult brain structure and plays a sex-dependent role in fear memories

Postnatal neurogenesis (PNN) contributes neurons to olfactory bulb (OB) and dentate gyrus (DG) throughout juvenile development, but the quantitative amount, temporal dynamics and functional roles of this contribution have not been defined. By using transgenic mouse models for cell lineage tracing and conditional cell ablation, we found that juvenile neurogenesis gradually increased the total number of granule neurons by approximately 40% in OB, and by 25% in DG, between 2 weeks and 2 months of age, and that total numbers remained stable thereafter. These findings indicate that the overwhelming majority of net postnatal neuronal addition in these regions occurs during the juvenile period and that adult neurogenesis contributes primarily to replacement of granule cells in both regions. Behavioral analysis in our conditional cell ablation mouse model showed that complete loss of PNN throughout both the juvenile and young adult period produced a specific set of sex-dependent cognitive changes. We observed normal hippocampus-independent delay fear conditioning, but excessive generalization of fear to a novel auditory stimulus, which is consistent with a role for PNN in psychopathology. Standard contextual fear conditioning was intact, however, pre-exposure dependent contextual fear was impaired suggesting a specific role for PNN in incidental contextual learning. Contextual discrimination between two highly similar contexts was enhanced; suggesting either enhanced contextual pattern separation or impaired temporal integration. We also observed a reduced reliance on olfactory cues, consistent with a role for OB PNN in the efficient processing of olfactory information. Thus, juvenile neurogenesis adds substantively to the total numbers of granule neurons in OB and DG during periods of critical juvenile behavioral development, including weaning, early social interactions and sexual maturation, and plays a sex-dependent role in fear memories.

Relationship of obsessive-compulsive disorder to age-related comorbidity in children and adolescents with Tourette syndrome

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are the 2 most frequent psychiatric disorders co-occurring with Tourette syndrome (TS). Both usually cause greater impairment in psychosocial functioning than the tics themselves. In a previous study, we examined the relationship of attention-deficit/hyperactivity disorder to other comorbid conditions in TS. The relationship of OCD to other comorbidities in TS still remains unclear and is the focus of the present study.

METHODS

Pearson's χ tests and logistic regressions (year-wise) were used to examine a cross-sectional sample of children and adolescents (n = 5060) diagnosed with TS, taken from the Tourette Syndrome International Database Consortium. We explored the relationship of OCD to other comorbid conditions in TS across different age groups.

RESULTS

In children (ages 5-10 y) with TS, higher rates of comorbidities were found in the presence compared with the absence of OCD. Adolescents (ages 11-17 y) with TS + OCD showed higher rates of internalizing (i.e., anxiety and mood) disorders when compared with those with TS - OCD. A year-wise increase of coexisting mood disorders was found for subjects with TS with and without OCD.

CONCLUSIONS

Overall, children and adolescents with TS + OCD showed higher rates of comorbid disorders compared with those with TS - OCD. This underlines the necessity for a comprehensive assessment of additional comorbidities even if the 2 disorders (TS + OCD) have already been diagnosed.

Parent and child perspectives on the nature of anxiety in children and young people with autism spectrum disorders: a focus group study

Anxiety disorders are common among children and young people with autism spectrum disorders (ASD). Despite growing knowledge about the prevalence, phenomenology and treatment of anxiety disorders, relatively little is understood about the nature and impact of anxiety in this group and little is known about autism-specific factors that may have a role in the increased prevalence of anxiety disorders. In this exploratory study, we report on a series of five focus groups with 17 parents of children and adolescents with ASD and anxiety. Across groups, parents gave strikingly similar descriptions of the triggers and behavioural signs associated with anxiety. Another consistent finding was that many parents reported that their children had great difficulty expressing their worries verbally and most showed their anxiety through changes in their behaviour. The impact of anxiety was reported to often be more substantial than the impact of ASD itself. The implications of the focus group findings are discussed in relation to existing literature.

Empirically derived subtypes of lifetime anxiety disorders: developmental and clinical correlates in U.S. adolescents

OBJECTIVE

The current study examined the sex- and age-specific structure and comorbidity of lifetime anxiety disorders among U.S. adolescents.

METHOD

The sample consisted of 2,539 adolescents (1,505 females and 1,034 males) from the National Comorbidity Survey-Adolescent Supplement who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]) lifetime anxiety disorders (American Psychiatric Association, 2000). Adolescents ranged in age from 13 to 18 years (M = 15.2 years, SE = 0.08 years) and were 39% non-White. Multiple-group latent class analysis was conducted by adolescent sex and age to identify subgroups of adolescents with similar anxiety disorder profiles. Developmental and clinical correlates of empirically derived classes were also examined to assess the nomological validity of identified subgroups.

RESULTS

A 7-class solution provided the best fit to the data, with classes defined primarily by one rather than multiple anxiety disorders. Results also indicated that classes displayed similar diagnostic profiles across age, but varied by sex. Classes characterized by multiple anxiety disorders were consistently associated with a greater degree of persistence, clinical severity, impairment, and comorbidity with other DSM-IV-TR psychiatric disorders.

CONCLUSIONS

The presentation of lifetime anxiety disorders among adolescents and the observation of unique correlates of specific classes provide initial evidence for the utility of individual DSM-IV-TR anxiety disorder categories. Although findings of the present study should be considered preliminary, results emphasize the potential value of early intervention and gender-specific conceptualization and treatment of anxiety disorders.

Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder, but, to our knowledge, no studies examined the course of anxiety disorders in youth and adults with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, ages 7 to 17 years who met criteria for Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) bipolar I disorder (n = 244), bipolar II disorder (n = 28), and operationally defined bipolar disorder not otherwise specified (n = 141) were recruited primarily from outpatient clinics. Subjects were followed on average for 5 years using the Longitudinal Interval Follow-Up Evaluation. We examined factors associated with the persistence (> 50% of the follow-up time) and onset of new anxiety disorders in youth with bipolar disorder.

RESULTS

Of the 170 youth who had anxiety at intake, 80.6% had an anxiety disorder at any time during the follow-up. Most of the anxiety disorders during the follow-up were of the same type as those present at intake. About 50% of the youth had persistent anxiety, particularly generalized anxiety disorder (GAD). Persistence was associated with multiple anxiety disorders, less follow-up time in euthymia, less conduct disorder, and less treatment with antimanic and antidepressant medications (all P values ≤ .05). Twenty-five percent of the sample who did not have an anxiety disorder at intake developed new anxiety disorders during follow-up, most commonly GAD. The onset of new anxiety disorders was significantly associated with being female, lower socioeconomic status, presence of attention-deficit/hyperactivity disorder and substance use disorder, and more follow-up time with manic or hypomanic symptoms (all P values ≤ .05)

CONCLUSIONS

Anxiety disorders in youth with bipolar disorder tend to persist, and new-onset anxiety disorders developed in a substantial proportion of the sample. Early identification of factors associated with the persistence and onset of new anxiety disorders may enable the development of strategies for treatment and prevention.

[Guidelines of the Brazilian Medical Association for the diagnosis and differential diagnosis of social anxiety disorder]

OBJECTIVE

Social anxiety disorder is the most common anxiety disorder. The condition has a chronic course usually with no remission and is frequently associated with significant functional and psychosocial impairment. The Brazilian Medical Association, with the project named Diretrizes ('Guidelines', in English), endeavors to develop diagnostic and treatment protocols for the most common disorders. This work presents the most relevant findings regarding the guidelines of the Brazilian Medical Association concerning the diagnosis and differential diagnosis of social anxiety disorder.

METHOD

We used the methodology proposed by the Brazilian Medical Association for the Diretrizes project. The search was performed on the online databases Medline (PubMed), Scopus, Web of Science, and Lilacs, with no time restraints. Searchable questions were structured using PICO format (acronym for "patient or population"; "intervention, indicator or exposition"; "control or comparison" and; "outcome or ending").

RESULTS

We present data regarding the clinical manifestations of social anxiety disorder, impairments and implications related to the condition, differences between the generalized and specific subtypes, and the relationship with depression, drug dependence and abuse, and other anxiety disorders. Additionally, the main differential diagnoses are discussed.

CONCLUSION

The guidelines are intended to serve as references to the general practitioner and the specialist as well, facilitating the diagnosis of social anxiety disorder.

Caveats of chronic exogenous corticosterone treatments in adolescent rats and effects on anxiety-like and depressive behavior and hypothalamic-pituitary-adrenal (HPA) axis function

BACKGROUND

Administration of exogenous corticosterone is an effective preclinical model of depression, but its use has involved primarily adult rodents. Using two different procedures of administration drawn from the literature, we explored the possibility of exogenous corticosterone models in adolescence, a time of heightened risk for mood disorders in humans.

METHODS

In experiment 1, rats were injected with 40 mg/kg corticosterone or vehicle from postnatal days 30 to 45 and compared with no injection controls on behavior in the elevated plus maze (EPM) and the forced swim test (FST). Experiment 2 consisted of three treatments administered to rats from postnatal days 30 to 45 or as adults (days 70 to 85): either corticosterone (400 μg/ml) administered in the drinking water along with 2.5% ethanol, 2.5% ethanol or water only. In addition to testing on EPM, blood samples after the FST were obtained to measure plasma corticosterone. Analysis of variance (ANOVA) and alpha level of P < 0.05 were used to determine statistical significance.

RESULTS

In experiment 1, corticosterone treatment of adolescent rats increased anxiety in the EPM and decreased immobility in the FST compared to no injection control rats. However, vehicle injected rats were similar to corticosterone injected rats, suggesting that adolescent rats may be highly vulnerable to stress of injection. In experiment 2, the intake of treated water, and thus doses delivered, differed for adolescents and adults, but there were no effects of treatment on behavior in the EPM or FST. Rats that had ingested corticosterone had reduced corticosterone release after the FST. Ethanol vehicle also affected corticosterone release compared to those ingesting water only, but differently for adolescents than for adults.

CONCLUSIONS

The results indicate that several challenges must be overcome before the exogenous corticosterone model can be used effectively in adolescents.

Social phobia and subtypes in the national comorbidity survey-adolescent supplement: prevalence, correlates, and comorbidity

OBJECTIVE

Social phobia typically develops during the adolescent years, yet no nationally representative studies in the United States have examined the rates and features of this condition among youth in this age range. The objectives of this investigation were to: (1) present the lifetime prevalence, sociodemographic and clinical correlates, and comorbidity of social phobia in a large, nationally representative sample of U.S. adolescents; and (2) examine differences in the rates and features of social phobia across the proposed DSM-5 social phobia subtypes.

METHOD

The National Comorbidity Survey Replication-Adolescent Supplement is a nationally representative face-to-face survey of 10,123 adolescents 13 to 18 years of age in the continental United States.

RESULTS

Approximately 9% of adolescents met criteria for any social phobia in their lifetime. Of these adolescents, 55.8% were affected with the generalized subtype and 44.2% exhibited nongeneralized social phobia. Only 0.7% met criteria for the proposed DSM-5 performance-only subtype. Generalized social phobia was more common among female adolescents and risk for this subtype increased with age. Adolescents with generalized social phobia also had a younger age of onset, higher levels of disability and clinical severity, and a greater degree of comorbidity relative to adolescents with nongeneralized forms of the disorder.

CONCLUSIONS

This study indicates that social phobia is a highly prevalent, persistent, and impairing psychiatric disorder among adolescent youth. Results of this study also provide evidence for the clinical utility of the generalized subtype and highlight the importance of considering the heterogeneity of social phobia in this age group.

Influence of early stress on social abilities and serotonergic functions across generations in mice

Exposure to adverse environments during early development is a known risk factor for several psychiatric conditions including antisocial behavior and personality disorders. Here, we induced social anxiety and altered social recognition memory in adult mice using unpredictable maternal separation and maternal stress during early postnatal life. We show that these social defects are not only pronounced in the animals directly subjected to stress, but are also transmitted to their offspring across two generations. The defects are associated with impaired serotonergic signaling, in particular, reduced 5HT1A receptor expression in the dorsal raphe nucleus, and increased serotonin level in a dorsal raphe projection area. These findings underscore the susceptibility of social behaviors and serotonergic pathways to early stress, and the persistence of their perturbation across generations.

The diagnostic threshold of generalized anxiety disorder in the community: a developmental perspective

Discussion surrounds the question as to whether criteria for generalized anxiety disorder (GAD) should change, particularly in youth. This study examines the effects of possible criteria changes on GAD prevalence and clinical correlates. DSM-IV GAD was assessed using the M-CIDI in a community sample of adolescents and young adults. Diagnostic thresholds were modified in two age spans (9-20 and 21-34 years) using a person-by-year data file (N = 38,534 cases). Relaxing the duration or excessiveness criteria led to the most pronounced changes in GAD prevalence, while relaxing frequency, uncontrollability, or associated-symptom criteria had smaller effects. A lower duration requirement increased rates more in older than younger age spans. Opposite effects occurred for changes in associated-symptoms or clinical-significance criteria. Broader GAD definitions identified cases in both age spans that appeared mostly milder than DSM-IV cases but that still differed from non-GAD cases in various clinical factors and validators. Developmental aspects require stronger consideration in future diagnostic systems.

Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions

Restoring sleep is strongly associated with a better physical, cognitive, and psychological well-being. By contrast, poor or disordered sleep is related to impairment of cognitive and psychological functioning and worsened physical health. These associations are well documented not only in adults but also in children and adolescents. Importantly, adolescence is hallmarked by dramatic maturational changes in sleep and its neurobiological regulation, hormonal status, and many psychosocial and physical processes. Thus, the role of sleep in mental and physical health during adolescence and in adolescent patients is complex. However, it has so far received little attention. This review first presents contemporary views about the complex neurobiology of sleep and its functions with important implications for adolescence. Second, existing complex relationships between common adolescent somatic/organic, sleep-related, and psychiatric disorders and certain sleep alterations are discussed. It is concluded that poor or altered sleep in adolescent patients may trigger and maintain many psychiatric and physical disorders or combinations of these conditions, which presumably hinder recovery and may cross into later stages of life. Therefore, timely diagnosis and management of sleep problems appear critical for growth and development in adolescent patients.

The multidimensional evaluation and treatment of anxiety in children and adolescents: rationale, design, methods and preliminary findings

OBJECTIVE: This study aims to describe the design, methods and sample characteristics of the Multidimensional Evaluation and Treatment of Anxiety in Children and Adolescents - the PROTAIA Project. METHOD: Students between 10 and 17 years old from all six schools belonging to the catchment area of the Primary Care Unit of Hospital de Clínicas de Porto Alegre were included in the project. It comprises five phases: (1) a community screening phase; (2) a psychiatric diagnostic phase; (3) a multidimensional assessment phase evaluating environmental, neuropsychological, nutritional, and biological factors; (4) a treatment phase, and (5) a translational phase. RESULTS: A total of 2,457 subjects from the community were screened for anxiety disorders. From those who attended the diagnostic interview, we identified 138 individuals with at least one anxiety disorder (apart from specific phobia) and 102 individuals without any anxiety disorder. Among the anxiety cases, generalized anxiety disorder (n = 95; 68.8%), social anxiety disorder (n = 57; 41.3%) and separation anxiety disorder (n = 49; 35.5%) were the most frequent disorders. CONCLUSION: The PROTAIA Project is a promising research project that can contribute to the knowledge of the relationship between anxiety disorders and anxiety-related phenotypes with several genetic and environmental risk factors.

Functional impairment related to painful physical symptoms in patients with generalized anxiety disorder with or without comorbid major depressive disorder: post hoc analysis of a cross-sectional study

BACKGROUND

Generalized anxiety disorder (GAD) is the most frequent anxiety disorder in primary care patients. It is known that painful physical symptoms (PPS) are associated with GAD, regardless the presence of comorbid major depressive disorder (MDD). However the specific role of such symptoms in patients' functional impairment is not well understood. The objective of the present study is to assess functional impairment related to the presence of PPS in patients with GAD.

METHODS

This is a post hoc analysis of a cross-sectional study. Functioning, in the presence (overall pain score >30; Visual Analog Scale) or absence of PPS, was assessed using the Sheehan Disability Scale (SDS) in three groups of patients; 1) GAD and comorbid MDD (GAD+MDD+), 2) GAD without comorbid MDD (GAD+MDD-), 3) controls (GAD-MDD-). ANCOVA models were used.

RESULTS

Of those patients with GAD+MDD+ (n = 559), 436 (78.0%) had PPS, compared with GAD+MDD- (249 of 422, 59%) and controls (95 of 336, 28.3%). Functioning worsened in both GAD groups in presence of PPS (SDS least squares mean total score: 16.1 vs. 9.8, p < 0.0001, GAD+MDD+; 14.3 vs. 8.2, p < 0.0001, GAD+MDD-). The presence of PPS was significantly associated with less productivity.

CONCLUSIONS

Functional impairment related to the presence of PPS was relevant. Clinical implications should be considered.

Is there room for 'development' in developmental models of information processing biases to threat in children and adolescents?

Clinical and experimental theories assume that processing biases in attention and interpretation are a causal mechanism through which anxiety develops. Despite growing evidence that these processing biases are present in children and, therefore, develop long before adulthood, these theories ignore the potential role of child development. This review attempts to place information processing biases within a theoretical developmental framework. We consider whether child development has no impact on information processing biases to threat (integral bias model), or whether child development influences information processing biases and if so whether it does so by moderating the expression of an existing bias (moderation model) or by affecting the acquisition of a bias (acquisition model). We examine the extent to which these models fit with existing theory and research evidence and outline some methodological issues that need to be considered when drawing conclusions about the potential role of child development in the information processing of threat stimuli. Finally, we speculate about the developmental processes that might be important to consider in future research.

Social fear and social phobia types among community youth: differential clinical features and vulnerability factors

OBJECTIVE

To compare different social fears and social phobia subtypes with regard to clinical (age of onset, avoidance, impairment, comorbidities) and vulnerability factors (behavioural inhibition (BI), parental psychopathology and parental rearing) among community youth.

METHODS

Fears of 6 social situations and Social Phobia (SP), along with their clinical features, were assessed using the Munich-Composite International Diagnostic Interview (DIA-X/M-CIDI) in a population-based sample of N = 3021 14-24 year olds that were followed up for 10 years. BI and parental rearing were assessed using self-report questionnaires. Parental psychopathology was assessed directly in parents via DIA-X/M-CIDI, supplemented by offsprings' family history reports.

RESULTS

In the total sample, 20.0%, 11.6%, 11.7% reported fear of 1, 2, 3 or more social situations, respectively; rates were 24.2%, 18.7%, and 57.1% in SP-cases (6.6% of the total sample). Exploring the factorial structure indicated rather unidimensionality of social fears than mutual distinction of social fears by interaction vs. performance situations. Except for fear of taking tests and public speaking, social fears rarely occurred in isolation. Social fears of both interaction and performance situations were associated with severe avoidance (vs. fear of either situation; Odds Ratios, OR = 1.5, 95%CI: 1.1-1.9) and impairment (OR = 3.6, 95%CI: 2.6-4.9), and more comorbid anxiety and depressive disorders (OR range 3.2-5.8, p > .001). Fear of interaction situations was associated with higher BI (vs. performance-related fears, OR range 1.2-2.1, p < .05). Associations with parental psychopathology and unfavourable parental rearing were less consistent, albeit stronger for fear of interaction situations (vs. performance-related fears). Interactions with time indicated an earlier onset of SP for higher BI, but not for parental psychopathology or unfavourable parental rearing.

CONCLUSIONS

Interaction-related social fears differ in their clinical and vulnerability factors from performance-related social fears. The current DSM-IV specifier of "generalized" SP may fall short of adequately denoting these differences. Fear of taking tests appears to be conceptually and, possibly, etiologically distinct from other social fears, and may be better placed in another category (e.g., as a type of specific phobia).

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.

Comorbidity of Anxiety and Depression in Youth: Implications for Treatment and Prevention

The high level of concurrent and sequential comorbidity between anxiety and depression in children and adolescents may result from (a) substantial overlap in both the symptoms and items used to assess these putatively different disorders, (b) common etiological factors (e.g., familial risk, negative affectivity, information processing biases, neural substrates) implicated in the development of each condition, and (c) negative sequelae of anxiety conferring increased risk for the development of depression. Basic research on their various common and unique etiological mechanisms has guided the development of efficacious treatments for anxiety and depressive disorders in youth. Potential processes through which the successful treatment of childhood anxiety might prevent subsequent depression are described.

Comorbid anxiety in children and adolescents with bipolar spectrum disorders: prevalence and clinical correlates

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder. We aimed to examine the prevalence and correlates of comorbid anxiety disorders among youth with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 446 youth, ages 7 to 17 years, who met DSM-IV criteria for bipolar I disorder (n = 260) or bipolar II disorder (n = 32) or met operationalized criteria for bipolar disorder not otherwise specified (n = 154) were included. Subjects were evaluated for current and lifetime Axis I psychiatric disorders at intake using the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime version, and standardized instruments were used to assess functioning and family history.

RESULTS

Forty-four percent (n = 194) of the sample met DSM-IV criteria for at least 1 lifetime anxiety disorder, most commonly separation anxiety (24%) and generalized anxiety disorders (16%). Nearly 20% met criteria for 2 or more anxiety disorders. Overall, anxiety disorders predated the onset of bipolar disorder. Subjects with bipolar II disorder were more likely than subjects with bipolar I disorder or bipolar disorder not otherwise specified to have a comorbid anxiety disorder. After adjusting for confounding factors, youth with bipolar disorder with anxiety were more likely to have bipolar II disorder; longer duration of mood symptoms; more severe ratings of depression; and family history of depression, hopelessness, and somatic complaints during their worst lifetime depressive episode than those without anxiety.

CONCLUSIONS

Comorbid anxiety disorders are common in youth with bipolar disorder, and they most often predate bipolar disorder onset. Bipolar II disorder, a family history of depression, and more severe lifetime depressive episodes distinguish youth with bipolar disorder with comorbid anxiety disorders from those without. Careful consideration should be given to the assessment of comorbid anxiety in youth with bipolar disorder.

[Psychiatric emergencies in childhood and adolescence]

OBJECTIVE

The prevalence of psychiatric disorders in childhood/adolescence is of 10-15%.The most frequent causes of psychiatric emergence attendances in this age are: behavioral disturbances, suicidal behavior, and depression.The objective of this study is to present the most relevant clinical issues and to guide the initial procedures of psychiatric emergencies in childhood/adolescence.

METHOD

Non-systematic review.

RESULTS

Relevant clinical issues for psychiatric emergency evaluation of children/adolescents are presented. Clinical presentations are divided in relevant groups of symptoms, due to its frequency and to its impact to patients and their families. Therefore, the following syndromes are presented: aggressive behavior, intoxication, suicidal behavior, psychoses, anxiety disorders, eating disorders, maltreatment against children/adolescents. The initial procedures recommended for each of these conditions are described.

CONCLUSION

Psychiatric emergencies in childhood/adolescence can be the re-agudization or a first crisis of a psychiatric disorder. The emergency evaluation's objectives are: to identify the diagnosis, the risks for the child/adolescent, the triggering and maintaining factors, and the presence of familiar and social support.

Is there room for 'development' in developmental models of information processing biases to threat in children and adolescents?

Clinical and experimental theories assume that processing biases in attention and interpretation are a causal mechanism through which anxiety develops. Despite growing evidence that these processing biases are present in children and, therefore, develop long before adulthood, these theories ignore the potential role of child development. This review attempts to place information processing biases within a theoretical developmental framework. We consider whether child development has no impact on information processing biases to threat (integral bias model), or whether child development influences information processing biases and if so whether it does so by moderating the expression of an existing bias (moderation model) or by affecting the acquisition of a bias (acquisition model). We examine the extent to which these models fit with existing theory and research evidence and outline some methodological issues that need to be considered when drawing conclusions about the potential role of child development in the information processing of threat stimuli. Finally, we speculate about the developmental processes that might be important to consider in future research.

Anxiety disorders before birth and self-perceived distress during pregnancy: associations with maternal depression and obstetric, neonatal and early childhood outcomes

BACKGROUND

Maternal perinatal mental health has been shown to be associated with adverse consequences for the mother and the child. However, studies considering the effect of DSM-IV anxiety disorders beyond maternal self-perceived distress during pregnancy and its timing are lacking.

AIMS

To examine the role of maternal anxiety disorders with an onset before birth and self-perceived distress during pregnancy for unfavourable maternal, obstetric, neonatal and childhood outcomes.

STUDY DESIGN

DSM-IV mental disorders and self-perceived distress of 992 mothers as well as obstetric, neonatal and childhood outcomes of their offspring were assessed in a cohort sampled from the community using the Munich-Composite International Diagnostic Interview. Logistic regression analyses revealed associations (odds ratios) between maternal anxiety disorders and self-perceived distress during pregnancy with maternal depression after birth and a range of obstetric, neonatal and childhood psychopathological outcomes.

RESULTS

Lifetime maternal anxiety disorders were related to offspring anxiety disorders, but not to offspring externalizing disorders. Analyses focussing on maternal DSM-IV anxiety disorders before birth yielded associations with incident depression after birth. In addition, self-perceived distress during pregnancy was associated with maternal depression after birth, preterm delivery, caesarean section, separation anxiety disorder, ADHD, and conduct disorder in offspring.

CONCLUSION

Findings confirm the transmission of anxiety disorders from mother to offspring. Apart from maternal anxiety, self-perceived distress during pregnancy also emerged as a putative risk factor for adverse outcomes. The finding that maternal anxiety disorders before birth yielded less consistent associations, suggests that self-perceived distress during pregnancy might be seen as a putative moderator/mediator in the familial transmission of anxiety.

The role of genes and environment in shaping co-occurrence of DSM-IV defined anxiety dimensions among Italian twins aged 8-17

This study investigated the ultimate causes of co-variation between symptoms of four common DSM-IV anxiety dimensions - Generalized Anxiety, Panic, Social Phobia and Separation Anxiety disorder - assessed with the Italian version of the Screen for Child Anxiety-Related Emotional Disorders questionnaire in a sample of 378 twin pairs aged 8-17 from the population-based Italian Twin Register. Genetic and environmental proportions of covariance between the targeted anxiety dimensions were estimated by multivariate twin analyses. Genetic influences (explaining from 58% to 99% of covariance) and unique environmental factors were the sole sources of co-variation for all phenotypes under study. Genetic influences associated with different anxiety dimensions coincide remarkably, as indicated by genetic correlations ranging from 0.40 to 0.61, while unique environmental overlap is less substantial. Thus, while additive genetic effects are important in explaining why children report symptoms from multiple anxiety disorders, environmental idiosyncratic factors seem to play a marginal role in shaping the co-occurrence of different anxiety dimensions in childhood.

Anxiety disorders in children and adolescents

Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.

Anxiety disorders in older adults: a comprehensive review

This review aims to address issues unique to older adults with anxiety disorders in order to inform potential changes in the DSM-V. Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed. Overall, the current literature suggests: (a) anxiety disorders are common among older age individuals, but less common than in younger adults; (b) overlap exists between anxiety symptoms of younger and older adults, although there are some differences as well as limitations to the assessment of symptoms among older adults; (c) anxiety disorders are highly comorbid with depression in older adults; (d) anxiety disorders are highly comorbid with a number of medical illnesses; (e) associations between cognitive decline and anxiety have been observed; (f) late age of onset is infrequent; and (g) both pharmacotherapy and CBT have demonstrated efficacy for older adults with anxiety. The implications of these findings are discussed and recommendations for the DSM-V are provided, including extending the text section on age-specific features of anxiety disorders in late life and providing information about the complexities of diagnosing anxiety disorders in older adults.

Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V

The present review was conducted in order to evaluate the current diagnostic criteria for specific phobia (SP) in light of the empirical evidence gathered since DSM-IV and to propose changes to DSM-V where change is clearly and reliably indicated by the evidence. In response to questions put forth by the DSM-V Anxiety, OC Spectrum, Posttraumatic, and Dissociative Disorder Work Group, four primary areas were determined for this review: the accuracy and utility of the current SP type classification system, the validity of test anxiety as a type of SP, the boundary between agoraphobia and SP, and the reliability and utility of the diagnostic criteria for SP. Developmental issues are addressed within each area. Literature reviews examining academic findings published between 1994 and 2009 were carried out and the results are included herein. The review presents a number of options and preliminary recommendations to be considered for DSM-V. All of these recommendations should be considered tentative as they await the field trials and expert consensus necessary prior to their inclusion in the DSM-V. The present review also reveals a great need for future research in the area of SP and directions for such research is provided.

The structure of common mental disorders: a replication study in a community sample of adolescents and young adults

Previous research suggests that patterns of comorbidity of common mental disorders among adults are best reflected by a hierarchical three-factor structure with two correlated factors ('anxious-misery' and 'fear') summarized in a second-order 'internalizing' factor and one 'externalizing' factor. This three-factor structure has not been examined yet in a sample of adolescents and young adults.A representative sample of 3021 adolescents and young adults (baseline age 14-24) were prospectively followed over 10 years. Mental disorders were assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) by using the standardized Munich Composite International Diagnostic Interview. Ten mental disorders (major depressive episode, dysthymia, generalized anxiety disorder, social phobia, specific phobia, agoraphobia, panic disorder, alcohol dependence, drug dependence, antisocial personality) were fitted to a series of Confirmatory Factor Analysis models using: (1) 12-month data, and (2) lifetime data from a person-year data set.The three-factor model showed good fit to the observed data in our sample both when 12-month diagnoses and lifetime-to-date diagnoses from a person-year data file were used; yet the higher-order 'internalizing' factor summarizing 'anxious misery' and 'fear' had to be omitted.The three-factor model could be replicated in a sample of adolescents and young adults with the exception that the second-order 'internalizing' factor was not consistent with the data. Further research is necessary to provide more complete insight into the structure of mental disorders by examining the stability of the structure of mental disorders in different developmental stages (ages) and by using a more extensive set of mental disorders.