Specificity of autonomic arousal to DSM-IV panic disorder and posttraumatic stress disorder

The structure of mood and anxiety disorder symptoms in the perinatal period

BACKGROUND

The perinatal period is increasingly recognized as a vulnerable time for the development and exacerbation of psychiatric symptoms. Research has often focused on perinatal depression, with much less information on perinatal anxiety. This study examined the psychometric structure of all internalizing (anxiety and mood disorder symptoms) in the perinatal period.

METHODS

Participants were primarily community adults receiving prenatal care from an academic medical center (N = 246). Participants completed a structured clinical interview using the Interview for Mood and Anxiety Symptoms (IMAS) during pregnancy (28-32 weeks gestation) and the postpartum (6-8 weeks). Clinical interviews dimensionally assessed all current anxiety, mood, and obsessive-compulsive symptoms as well as lifetime psychiatric diagnoses.

RESULTS

Confirmatory factor analyses identified three latent factors onto which psychiatric symptoms loaded: Distress (depression, generalized anxiety, irritability, and panic symptoms), Fear (social anxiety, agoraphobia, specific phobia, and obsessive-compulsive symptoms), and Bipolar (mania and obsessive-compulsive symptoms) in both pregnancy and the postpartum. The fit statistics of the models indicated adequate to good fit in both models.

LIMITATIONS

The IMAS is validated against the DSM-IV-TR rather than the DSM-5 and assessments of psychiatric symptoms were focused only on the current pregnancy.

CONCLUSIONS

A three-factor model consisting of Distress, Fear and Bipolar latent factors was the best-fitting model in pregnancy and the postpartum period and showed stability across time. The structure of internalizing symptoms has important implications for future perinatal research and can be utilized to guide treatment by highlighting which psychiatric symptoms may be most similar during the perinatal period.

How a transdiagnostic approach can improve the treatment of emotional disorders: Insights from clinical psychology and neuroimaging

Multiple psychological treatments for emotional disorders have been developed and implemented, improving the quality of life of individuals. Nevertheless, relapse and poor response to psychotherapy are common. This article argues that a greater understanding of both the psychological and neurobiological mechanisms of change in psychotherapy is essential to improve treatment for emotional disorders. It aims to demonstrate how an understanding of these mechanisms provides a basis for (i) reconceptualizing some mental disorders, (ii) refining and establishing the evidence for existing therapeutic techniques and (iii) designing new techniques that precisely target the processes that maintain these disorders. Possible future directions for researchers and practitioners working at the intersection of neuropsychology and clinical psychology are discussed.

Unique Associations between Conditioned Cognitive and Physiological Threat Responses and Facets of Anxiety Symptomatology in Youth

This study examined associations between anxiety symptomatology and cognitive and physiological threat responses during threat learning in a large sample of children and adolescents. Anxiety symptomatology severity along different dimensions (generalized anxiety, separation anxiety, social anxiety, and panic symptoms) was measured using parental and self-reports. Participants completed differential threat acquisition and extinction using an age-appropriate threat conditioning task. They then returned to the lab after 7-10 days to complete an extinction recall task that also assessed threat generalization. Results indicated that more severe overall anxiety was associated with greater cognitive and physiological threat responses during acquisition, extinction, and extinction recall. During acquisition and extinction, all anxiety dimensions manifested greater cognitive threat responses, while panic, separation anxiety, and social anxiety symptoms, but not generalized anxiety, were related to heightened physiological threat responses. In contrast, when we assessed generalization of cognitive threat responses, we found only generalized anxiety symptoms were associated with greater threat response generalization. The study provides preliminary evidence of specificity in threat responses during threat learning across youth with different anxiety symptoms.

Women with Major Depressive Disorder, Irrespective of Comorbid Anxiety Disorders, Show Blunted Bilateral Frontal Responses during Win and Loss Anticipation

BACKGROUND

Electroencephalography (EEG) studies suggest that major depressive disorder (MDD) is associated with lower left than right frontal brain activity (asymmetry), a pattern appearing stronger in women than men, and when elicited during emotionally-relevant paradigms versus an uncontrolled resting state. However, it is unclear whether this asymmetry pattern generalizes to the common presentation of MDD with co-occurring anxiety. Moreover, asymmetry may differ for anxiety subtypes, wherein anxious apprehension (AnxApp: worry characteristic of generalized anxiety disorder) appears left-lateralized, but anxious arousal (AnxAro: panic characteristic of social anxiety, posttraumatic stress, and panic disorders) may be right-lateralized.

METHODS

This analysis attempted to replicate frontal EEG asymmetry patterns using functional magnetic resonance imaging (fMRI). Participants completed clinical interviews and a monetary incentive delay (MID) task during fMRI recording. We compared five groups of right-handed women from the Tulsa 1000 study, MDD (n=40), MDD-AnxApp (n=26), MDD-AnxAro (n=34), MDD-Both (with AnxApp and AnxAro; n=26), and healthy controls (CTL; n=24), as a function of MID anticipation condition (no win/loss, win, loss) and hemisphere on frontal blood oxygen-level-dependent (BOLD) signal.

RESULTS

CTL exhibited higher bilateral superior, middle, and inferior middle frontal gyrus BOLD signal than the four MDD groups for high arousal (win and loss) conditions. However, frontal attenuations were unrelated to current depression/anxiety symptoms, suggestive of a trait as opposed to a state marker.

LIMITATIONS

This was a cross-sectional analysis restricted to women.

CONCLUSIONS

Reduced prefrontal cortex recruitment during processing of both positively and negatively valenced stimuli is consistent with the emotion context insensitivity theory of MDD.

Distinct Risk Profiles in Social Anxiety Disorder

Using a factor mixture model (FMM) approach, this study examined if SAD could be subtyped by distinct risk profiles, and whether these subtypes predicted different manifestations of the disorder. We derived risk profiles from neurotic temperament (NT), positive temperament (PT), and autonomic arousability (AA), which are hypothesized to be important in the maintenance of anxiety disorders such as SAD. In our sample of 758 SAD outpatients, a two-class FMM solution fit the data best. Class 1 was characterized by very low PT whereas PT in Class 2 was substantially higher. The two classes differed to a lesser extent on NT, but were virtually equivalent on AA. Class 1 had significantly more males, individuals with depressive disorders, generalized SAD, and higher SAD severity. Class 2 had more individuals with performance subtype SAD. These findings provide initial support for distinct risk profiles within SAD that may be predictive of its clinical expression.

Time course of panic disorder and posttraumatic stress disorder onsets

PURPOSE

Posttraumatic stress disorder (PTSD) often co-occurs with panic disorder (PD), with some etiological models positing a causal role of panic reactivity in PTSD onset; however, data addressing the temporal ordering of these conditions are lacking. The aim of this study was to examine the bi-directional associations between PD and PTSD in a nationally representative, epidemiologic sample of trauma-exposed adults.

METHODS

Participants were community-dwelling adults (62.6% women; Mage = 48.9, SD 16.3) with lifetime DSM-IV PTSD criterion A trauma exposure drawn from the 2001/2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and re-interviewed in 2004/5 (N = 12,467). Cox discrete-time proportional hazards models with time-varying covariates were used to investigate the bi-directional associations between lifetime PD and PTSD, accounting for demographic characteristics, trauma load, and lifetime history of major depression, generalized anxiety disorder, and social anxiety disorder.

RESULTS

PD was significantly associated with subsequent onset of PTSD (HR 1.210, 95%CI = 1.207-1.214, p < .001), and PTSD was significantly associated with onset of PD (HR 1.601, 95% CI 1.597-1.604, p < .001). The association between PTSD and subsequent PD was stronger in magnitude than that between PD and subsequent PTSD (Z = - 275.21, p < .01). Men evidenced stronger associations between PD and PTSD compared to women.

CONCLUSIONS

Results were consistent with a bidirectional pathway of risk, whereby PD significantly increased risk for the development of PTSD, and PTSD significantly increased risk for PD. Given the association between PTSD and subsequent PD, particularly among men, clinicians may consider supplementing PTSD treatment with panic-specific interventions, such as interoceptive exposure, to prevent or treat this disabling comorbidity.

PTSD symptoms are differentially associated with general distress and physiological arousal: Implications for the conceptualization and measurement of PTSD

BACKGROUND

The primary purpose of this study was to examine the place of posttraumatic stress disorder (PTSD) vis-à-vis the external dimensions of general distress and physiological arousal.

METHODS

Using data collected from veterans of the wars in Iraq and Afghanistan (N = 1350), latent variable covariance structure modeling was employed to compare correlations of PTSD symptom clusters and individual PTSD symptoms with general distress and physiological arousal.

RESULTS

Each PTSD symptom cluster, and 17 of 20 individual PTSD symptoms were more strongly associated with general distress than with physiological arousal. However, moderate to strong associations were also found between physiological arousal and both PTSD clusters and symptoms.

LIMITATIONS

Findings are based on self-reported data elicited from a single sample of veterans with substantial PTSD symptoms. Replication, particularly by clinician interview, is necessary. Generalizability to other traumatized populations is unknown.

CONCLUSIONS

Results offer support, with caveats, for viewing PTSD as a distress disorder. Findings are not consistent with the position that PTSD is a hybrid disorder with some features reflecting hyperarousal and others indicative of general distress. Results have implications for the conceptualization and measurement of PTSD.

The Multidimensional Emotional Disorder Inventory (MEDI): Assessing transdiagnostic dimensions to validate a profile approach to emotional disorder classification

There has been limited progress evaluating the validity of dimensional approaches to emotional disorder classification. This has occurred in part because of a lack of standardized assessment tools developed with the specific intent of studying dimensional classification. The goal of the current study was to develop and validate the Multidimensional Emotional Disorder Inventory (MEDI) to efficiently assess nine empirically supported transdiagnostic dimensions proposed in the Brown and Barlow (2009) profile approach to emotional disorder classification: neurotic temperament, positive temperament, depression, autonomic arousal, somatic anxiety, social anxiety, intrusive cognitions, traumatic reexperiencing, and avoidance. The MEDI factor structure, reliability, and convergent/discriminant validity was evaluated in outpatients with emotional disorders (pilot sample = 227; validation sample = 780). The final 9-factor solution fit the data well. Intercorrelations among MEDI factors were consistent with previous research, and all MEDI dimensions had acceptable reliability. Correlations with common self-report questionnaires and DSM-5 diagnoses supported the convergent/discriminant validity of all nine MEDI dimensions. Collectively, these results support the use of 49-item MEDI in clinical research samples. The MEDI should be used in future research to evaluate the validity of the Brown and Barlow (2009) approach to emotional disorder classification. Because it provides an efficient assessment of several well-established emotional disorder traits and phenotypes, the MEDI also may have utility for general research or clinical purposes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Anxious distress in depressed outpatients: Prevalence, comorbidity, and incremental validity

The goals of this study were to estimate the prevalence of the DSM-5 anxious distress specifier (AD) among depressed outpatients, to examine associations of AD with comorbid diagnoses, and to test the incremental validity of AD over comorbidity in predicting functional impairment and severity of anxiety and depression symptoms. The sample was 237 outpatients diagnosed with major depressive disorder (MDD) or persistent depressive disorder (PDD), with and without AD, using the Anxiety and Related Disorders Interview Schedule for DSM-5. Outpatients also completed self-report questionnaires assessing functional impairment and anxiety, stress, and depression symptom severity. Two-by-two contingency tables were used to examine the associations of AD with comorbidity. Two-thirds (66.2%) of outpatients were assigned AD, with similar rates among those with MDD and PDD. Outpatients with AD were significantly more likely than those without AD to have a comorbid GAD diagnosis (OR = 2.47). Hierarchical multiple regressions were used to test the incremental validity of AD in predicting functional impairment and symptom outcomes beyond comorbid disorders. Controlling for comorbid disorders, AD was significantly associated with more severe functional impairment, autonomic arousal, stress, panic, generalized anxiety, and depression. The strongest incremental association were observed between AD and autonomic arousal (f² = 0.12-0.18) and generalized anxiety (f² = 0.17). These findings add to a growing literature that AD is common among outpatients and associated with important clinical outcomes, suggesting that AD should be routinely assessed in patients with mood disorders.

Incidence and Clinical Features of Panic Related Posttraumatic Stress

The current study assessed the incidence and associated features of posttraumatic stress after the experience of panic. One hundred seventy-eight participants meeting diagnostic criteria for panic attacks (PAs) were assessed using standardized measures of posttraumatic symptoms and posttraumatic stress disorder (PTSD) in specific reference to their experience of panic. Sixty-three (35.4%) participants scored above the cutoff for PTSD in reference to the worst PA they had experienced. Adjusted means for the four PTSD symptom clusters indicate that panic-related posttraumatic symptoms are, on average, experienced "moderately" to "quite a bit." Panic-related posttraumatic symptoms and PTSD were best predicted by specific features of the panic experience itself, including subjective levels of distress, fear of losing control, chest pain, agoraphobia, and number of PAs experienced. These findings are discussed in terms of the diagnostic, prognostic, and treatment implications for a subset of individuals presenting with panic who may also have panic-related PTSD.

Adolescent clinical populations and associations between trauma and behavioral and emotional problems

OBJECTIVE

Trauma exposure is common during childhood and adolescence and is associated with youth emotional and behavioral problems. The present study adds to the current literature on trauma exposure among adolescent clinical populations by examining the association between trauma exposure and adolescent self-report of emotional and behavioral problems broadly, including internalizing and externalizing symptoms, in addition to the trauma-specific symptoms of posttraumatic stress disorder (PTSD).

METHOD

This study included 94 female (64%) and male (36%) adolescents, ages 13-19, representing 4 clinical populations: those seeking inpatient psychiatry, outpatient psychiatry, residential substance abuse, and outpatient medical services. Adolescents self-reported trauma history and internalizing, externalizing, and PTSD symptoms.

RESULTS

Most adolescents reported experiencing at least 1 traumatic event (83%; M = 2.28, SD = 1.83). Multiple regression analyses controlling for age, race/ethnicity, gender, and treatment setting indicated a greater number of types of trauma are associated with externalizing symptoms (β = .31, p < .01) and PTSD symptoms (β = .35, p < .01).

CONCLUSION

Trauma is a common experience among adolescents, particularly those presenting for behavioral health services, making trauma-informed care essential in these service delivery settings. Treatment that addresses adolescent risk behaviors and prevents recurrent trauma may be particularly important given the negative impact of multiple traumatic events on developing adolescents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Both anxiety and joint laxity determine the olfactory features in panic disorder

Previous research showed a high sensitivity in sensorial modalities in panic disorder (PD). This disorder has been consistently associated to the joint hypermobility syndrome (JHS). In non-clinical samples, this collagen alteration has been also related to an enhanced sensitivity in some sensorial modalities. The main aim of this study is to explore the olfactory functioning in PD in relation to JHS. Sixty patients with PD and sixty healthy controls performed the Sniffin' Sticks Test (SST) (threshold subtest), and completed the Affective Impact of Odors scale (AIO), the Relational Scale of Olfaction (EROL), and the Odor Awareness Scale (OAS). Clinical symptom rating scales and JHS assessment were also obtained. PD patients showed enhanced odor acuity, greater reactivity to smells and also increased odor awareness compared to the healthy controls. Within the patients group, those suffering from JHS displayed higher functioning in all olfactory domains compared to the non-JHS ones. The JHS and anxiety measures emerged as predictor variables of the olfactory function. The present findings highlight the importance of the olfactory function in PD and underline that both, JHS and anxiety, determine the olfactory characteristics in this disorder.

Effects of 35% carbon dioxide (CO2) inhalation in patients with post-traumatic stress disorder (PTSD): A double-blind, randomized, placebo-controlled, cross-over trial

BACKGROUND

In patients with post-traumatic stress disorder (PTSD) two open pilot studies about the effects of 35% carbon dioxide (CO₂) exist. One shows an augmented panicogenic and anxiogenic response (Muhtz et al., 2011), the other does not (Talesnik et al. 2007). We further characterized the CO₂ reactivity in PTSD using for the first time placebo-controlled and double-blind conditions.

METHODS

In 20 patients with PTSD we assessed panic, anxiety, dissociative and PTSD symptoms after a single vital capacity inhalation of 35% CO₂ compared to a placebo gas condition in a within-participant cross-over, placebo-controlled, double-blind and randomized design.

RESULTS

Inhalation of 35% CO₂ versus placebo provoked significantly increased panic, anxiety, dissociative and PTSD symptoms. The reaction to placebo gas was minimal. Order of inhalation, patients' sex or age did not influence the results. The panic and anxiety response under CO₂ was considerably higher in the PTSD patients than in healthy controls from our previous open study.

CONCLUSIONS

The results corroborate that our preceding findings of an increased CO₂ reactivity in patients with PTSD are not false positive due to the open design or the lack of placebo control. Replication in a larger number of PTSD patients and matched control subjects is needed. The potential role of childhood traumatisation, psychiatric comorbidity, psychotropic medication and trait dissociation in prior contradictory reports should be clarified.

The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders

BACKGROUND

Exposure to traumatic events and posttraumatic stress disorder (PTSD) are common among individuals with substance use disorders (SUDs). Although the presence of trauma exposure and/or PTSD among those with SUDs is associated with a range of negative outcomes, much remains to be understood about the factors contributing to these outcomes. Anxiety sensitivity (the tendency to respond fearfully to the signs and symptoms of anxiety) has been linked to greater PTSD symptoms and the use of substances to cope with PTSD symptoms, and is a promising factor for understanding the negative outcomes associated with co-occurring PTSD and SUDs.

METHODS

This study examined the association between anxiety sensitivity and trauma cue reactivity among 194 trauma-exposed patients with SUDs (27.3% met criteria for current PTSD). Participants completed ratings of negative affect and substance cravings prior to and after exposure to a personally-relevant trauma cue.

RESULTS

Results indicated that anxiety sensitivity was associated with greater emotional reactivity (but not craving reactivity) to the trauma cue; neither PTSD symptom severity nor PTSD diagnosis moderated these associations. PTSD symptom severity was associated with greater emotional and craving reactivity to the trauma cue.

CONCLUSIONS

Results highlight the potential utility of targeting anxiety sensitivity in treatments for trauma-exposed patients with SUDs with and without PTSD.

Fear and distress disorders as predictors of heart disease: A temporal perspective

OBJECTIVE

Few studies have been able to contrast associations of anxiety and depression with heart disease. These disorders can be grouped in fear and distress disorders. Aim of this study was to study the association between fear and distress disorders with subsequent heart disease, taking into account the temporal order of disorders.

METHODS

Twenty household surveys were conducted in 18 countries (n=53791; person years=2,212,430). The Composite International Diagnostic Interview assessed lifetime prevalence and age at onset of disorders, and respondents were categorized into categories based on the presence and timing of fear and distress disorders. Heart disease was indicated by self-report of physician-diagnosed heart disease or self-report of heart attack, together with year of onset. Survival analyses estimated associations between disorder categories and heart disease.

RESULTS

Most respondents with fear or distress disorders had either pure distress or pure fear (8.5% and 7.7% of total sample), while fear preceded distress in the large majority of respondents with comorbid fear and distress (3.8% of total sample). Compared to the "no fear or distress disorder" category, respondents with pure fear disorder had the highest odds of subsequent heart disease (OR:1.8; 95%CI:1.5-2.2; p<0.001) and compared to respondents with pure distress disorder, these respondents were at a significantly increased risk of heart disease (OR:1.3; 95%CI:1.0-1.6; p=0.020).

CONCLUSION

This novel analytic approach indicates that the risk of subsequent self-reported heart disease associated with pure fear disorder is significantly larger than the risk associated with distress disorder. These results should be confirmed in prospective studies using objective measures of heart disease.

Heterogeneity in Autonomic Arousal Level in Perseverative Worry: The Role of Cognitive Control and Verbal Thought

One puzzle in high worry and generalized anxiety disorder (GAD) is the heterogeneity in the level of autonomic arousal symptoms seen among affected individuals. While current models agree that worry persists, in part, because it fosters avoidance of unpleasant internal experiences, they disagree as to whether worry does so by suppressing activation of autonomic arousal or by fostering persistent autonomic hyperarousal. Our Cognitive Control Model predicts that which pattern of autonomic arousal occurs depends on whether or not a worrier has sufficient cognitive control capacity to worry primarily in a verbal versus imagery-based manner. Because this model has been supported by only one study to date, the present study sought to replicate and extend that study’s findings. Results from an online survey in an unselected sample of over 900 college students provide further support for our model’s central tenet and initial support for its prediction that higher effortful control is associated with a higher percentage of verbal thought during worry. Finally, we report tentative evidence that autonomic arousal symptoms in worry and GAD vary as a function of individual differences in cognitive control capacity because higher capacity is linked to a greater predominance of verbal thought during worry.

Post-traumatic stress disorder and depression co-occurrence: Structural relations among disorder constructs and trait and symptom dimensions

OBJECTIVES

Post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) in response to trauma co-occur at high rates. A better understanding of the nature of this co-occurrence is critical to developing an accurate conceptualization of the disorders. This study examined structural relations among the PTSD and MDD constructs and trait and symptom dimensions within the framework of the integrative hierarchical model of anxiety and depression.

DESIGN

Study participants completed clinician-rated and self-report measures during a pre-treatment assessment.

METHODS

The sample consisted of 200 treatment-seeking individuals with a primary DSM-IV PTSD diagnosis. Structural equation modelling was used to examine the relationship between the constructs.

RESULTS

The trait negative affect/neuroticism construct had a direct effect on both PTSD and MDD. The trait positive affect/extraversion construct had a unique, negative direct effect on MDD, and PTSD had a unique, direct effect on the physical concerns symptoms construct. An alternative model with the PTSD and MDD constructs combined into an overall general traumatic stress construct produced a decrement in model fit.

CONCLUSIONS

These findings provide a clearer understanding of the relationship between co-occurring PTSD and MDD as disorders with shared trait negative affect/neuroticism contributing to the overlap between them and unique trait positive affect/extraversion and physical concerns differentiating them. Therefore, PTSD and MDD in response to trauma may be best represented as two distinct, yet strongly related constructs.

PRACTITIONER POINTS

In assessing individuals who have been exposed to trauma, practitioners should recognize that co-occurring PTSD and MDD appears to be best represented as two distinct, yet strongly related constructs. Negative affect may be the shared vulnerability directly influencing both PTSD and MDD; however, in the presence of both PTSD and MDD, low positive affect appears to be more specifically related to MDD and fear of physical sensations to PTSD, which is information that could be used by practitioners in the determination of treatment approach. Overall, these findings are clinically relevant in that they may inform assessment, treatment planning, and ultimately diagnostic classification.

The structure and intensity of self-reported autonomic arousal symptoms across anxiety disorders and obsessive-compulsive disorder

BACKGROUND

Heightened autonomic arousal symptoms (AAS) are assumed to be a central feature of anxiety disorders. However, it is unclear whether the magnitude and profile of AAS vary across anxiety disorders and whether heightened AAS characterises obsessive-compulsive disorder (OCD).

AIMS

We sought to determine whether the intensity and structure of AAS varied across anxiety disorders and OCD.

METHOD

A sample of 459 individuals with a primary anxiety disorder or OCD were administered the Symptom Checklist-90R. Nine items referring to prototypic AAS were included in a latent class analysis.

RESULTS

A 2-class solution (high and low AAS classes) best fitted the data. Participants comprising the high AAS class scored uniformly high across all assessed AAS symptoms. Older age and the presence of panic disorder, social anxiety disorder and generalized anxiety disorder predicted membership in the high AAS class. No OCD symptom dimension was significantly associated with membership in the high AAS class.

LIMITATION

AAS were assessed using a self-report measure and replication is needed using other methodologies.

CONCLUSIONS

These findings suggest that OCD may be sufficiently distinct from anxiety disorders and do not support subtyping of anxiety disorders on the basis of the predominant type of AAS. Therapeutic approaches that target AAS might best be applied in the treatment of panic disorder, social anxiety disorder and generalized anxiety disorder.

Posttraumatic Stress in Parents of Children Diagnosed with Cancer: Hyperarousal and Avoidance as Mediators of the Relationship between Re-Experiencing and Dysphoria

Background

Increased understanding of the relationships between different symptom clusters involved in posttraumatic stress symptoms (PTSS) could guide empirical research and clinical practice. The objective of the present study was to investigate whether hyperarousal and avoidance mediated the relationship between re-experiencing and dysphoria in parents of children diagnosed with cancer.

Methods

Longitudinal data from parents of children receiving cancer therapy were used. PTSS were assessed using the PTSD Checklist Civilian Version at one week (T1), two (T2) and four months (T3) after diagnosis. Mediation analyses for multiple mediators were conducted for mothers (n = 122) and fathers (n = 121), respectively. The mediation model tested the assumption that the PTSS symptom clusters hyperarousal and avoidance mediated the relationship between re-experiencing and dysphoria.

Results

For fathers, none of the hypothesized mediators were significant. For mothers, hyperarousal mediated the relationship between re-experiencing and dysphoria, but avoidance did not.

Conclusions

Results suggest that hyperarousal is important for the development of dysphoria in mothers, supporting use of interventions targeting such symptoms in the early and ongoing period following the child’s diagnosis.

Prevalence and Predictors of Prescription Sleep Aid Use among Individuals with DSM-5 Insomnia: The Role of Hyperarousal

STUDY OBJECTIVES

Despite mounting evidence for the overuse of prescription sleep aids (PSA), reliable data on PSA use among insomniacs are unavailable. Current studies focus on trends in PSA use at the general population level, and thus do not distinguish between transient sleep disturbance and insomnia disorder. Therefore, we prospectively examined the prevalence and predictors of baseline and chronic PSA use in a well-defined sample of individuals with insomnia.

METHODS

We analyzed longitudinal data from an urban, community-based cohort of 649 adults (48.1 ± 11.6 y; 69.3% female) with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)-based insomnia disorder. Participants completed standardized measures of sleep disturbance, daytime alertness, depression, and anxiety at baseline and follow-up 1 y later. They also reported whether and with what frequency they used PSA at both time points.

RESULTS

Approximately 19% of the sample used PSA at baseline, the majority (69.4%) of whom continued use 1 y later. Anxiety and daytime alertness were the only independent predictors of both acute and chronic PSA use. An increase of 1 standard deviation (SD) in alertness was associated with a 33% increase in the odds of chronic PSA use (χ(2) = 4.98; odds ratio [OR] = 1.33; 95% confidence interval [CI]: 1.04-1.72; P < 0.05), and a 1-SD increase in anxiety was associated with a 41% increase (χ(2) = 6.95; OR = 1.41; 95% CI: 1.09-1.82; P < 0.05). Chronic PSA users did not report any significant improvements in sleep from baseline to follow-up relative to nonusers.

CONCLUSIONS

Hyperarousal, as indexed by daytime alertness and anxiety, is a strong determinant of PSA use among individuals with insomnia. These findings are consistent with emerging data showing that insomnia is not just a nocturnal sleep disorder, but one characterized by 24-h arousal. Though current research targets sleep disturbance, this study highlights the role of the arousal system in pharmacological treatment seeking.

The structure of negative emotional states in a postpartum inpatient sample

BACKGROUND

Depression and anxiety disorders exhibit comorbidity, and the same relationships have been observed in postpartum samples. The tripartite model posits that anxiety and depression overlap due to shared and unique symptom components. The present study tested whether a one-factor model, or a three-factor model consistent with the tripartite model, provided a better fit to anxiety and depression symptoms in a postpartum sample.

METHODS

The sample consisted of 663 postpartum psychiatric inpatients who completed self-reported questionnaires assessing symptoms of anxiety and depression.

RESULTS

Confirmatory factor analysis revealed that a three-factor model consistent with the tripartite model provided a good fit to anxiety/depression data. This model consisted of three factors: positive affect, negative affect, and autonomic arousal. Positive affect was related to depressive diagnoses and negatively related to anxiety diagnoses; autonomic arousal was related to anxiety diagnoses; and negative affect was uniquely related to mixed anxiety-depressive diagnoses.

LIMITATIONS

The sample consisted of postpartum psychiatric inpatients and the generalisability of results to other postpartum samples is not known.

CONCLUSIONS

Postpartum anxiety and depression appear to be characterised by three differentiable symptom clusters. Postpartum anxiety, depression, and mixed anxiety-depressive diagnoses are differentially associated with these symptom clusters. These findings suggest that the tripartite model may be useful in guiding assessment, differentiation, and treatment of postpartum emotional disorders.

Metabolic decoupling in daily life in patients with panic disorder and agoraphobia

Various studies have assessed autonomic and respiratory underpinnings of panic attacks, yet the psychophysiological functioning of panic disorder (PD) patients has rarely been examined under naturalistic conditions at times when acute attacks were not reported. We hypothesized that emotional activation in daily life causes physiologically demonstrable deviations from efficient metabolic regulation in PD patients. Metabolic coupling was estimated as within-individual correlations between heart rate (HR) and indices of metabolic activity, i.e., physical activity (measured by 3-axial accelerometry, Acc), and minute ventilation (Vm, measured by calibrated inductive plethysmography, as proxy for oxygen consumption). A total of 565 daytime hours were recorded in 19 PD patients and 20 healthy controls (HC). Pairwise cross-correlations of minute-by-minute averages of these metabolic indices were calculated for each participant and then correlated with several indices of self-reported anxiety. Ambulatory HR was elevated in PD (p = .05, d = 0.67). Patients showed reduced HR-Acc (p < .006, d = 0.97) and HR-Vm coupling (p < .009, d = 0.91). Combining Vm and Acc to predict HR showed the strongest group separation (p < .002, d = 1.07). Discriminant analyses, based on the combination of Vm and Acc to predict HR, classified 77% of all participants correctly. In PD, HR-Acc coupling was inversely related to trait anxiety sensitivity, as well as tonic and phasic daytime anxiety. The novel method that was used demonstrates that anxiety in PD may reduce efficient long-term metabolic coupling. Metabolic decoupling may serve as physiological characteristic of PD and might aid diagnostics for PD and other anxiety disorders. This measure deserves further study in research on health consequences of anxiety and psychosocial stress.

Anxiety sensitivity and post-traumatic stress reactions: Evidence for intrusions and physiological arousal as mediating and moderating mechanisms

A growing body of research has implicated anxiety sensitivity (AS) and its dimensions in the development of post-traumatic stress disorder (PTSD). However, the mechanism(s) that may account for the association between AS and PTSD remains unclear. Using the "trauma film paradigm," which provides a prospective experimental tool for investigating analog intrusion development, the present study examines the extent to which intrusions mediate the association between AS and the development of posttraumatic stress reactions. After completing a measure of AS and state mood, unselected participants (n = 45) viewed a 10 min film of graphic scenes of fatal traffic accidents and then completed a second assessment of state mood. Participants then kept a daily diary to record intrusions about the film for a one-week period. Post-traumatic stress reactions about the film were then assessed after the one-week period. The results showed that general AS and physical and cognitive concerns AS predicted greater post-traumatic stress reactions about the film a week later. Furthermore, the number of intrusions the day after viewing the traumatic film, but not fear and disgust in response to the trauma film, mediated the association between general AS (and AS specifically for physical and cognitive concerns) and post-traumatic stress reactions a week later. Subsequent analysis also showed that physiological arousal during initial exposure to the traumatic film moderated the association between general AS and the number of intrusions reported the day after viewing the film. The implications of these analog findings for conceptualizing the mechanism(s) that may interact to explain the role of AS in the development of PTSD and its effective treatment are discussed.

Olfactory functioning in panic disorder

BACKGROUND

The olfactory function in panic disorder (PD) has been scarcely approached in the literature. The purpose of this paper is to study this question by focusing on the olfactory sensitivity (i.e. detection threshold), the reactivity to odors, and the odor awareness in patients suffering from PD.

METHODS

41 patients with PD and 41 healthy controls performed Sniffin׳ Sticks Test (threshold subtest) and completed the Affective Impact of Odors scale (AIO), the Relational Scale of Olfaction (EROL) and the Odor Awareness Scale (OAS). Clinical symptoms rating scales were concurrently obtained.

RESULTS

PD patients showed lower olfactory detection thresholds (i.e. higher sensitivity) along with an enhanced reactivity to odors as well as a greater olfactory awareness compared to the healthy controls. The severity of PD was significantly associated with the olfactory questionnaires ratings, but not with the detection ability. Olfactory measures were intercorrelated in most cases.

LIMITATIONS

i) The results of the olfactory sensitivity are limited to one odorant (phenyl ethyl alcohol) and thus may not be generalizable to other odorants. ii) As comorbid Axis II disorders were not screened, it is not possible to exclude the influence of personality traits in our results. iii) The involvement of the medications in some olfactory outcomes cannot be ruled out.

CONCLUSION

The current findings highlight the importance of the olfactory function in PD as patients appeared to be highly sensitive, reactive and aware of odors. These results are discussed in the light of the common neural substrates involved in the olfactory processing and in the pathophysiology of PD, and also related to the clinical features of this disorder.

A Transdiagnostic Temperament-Phenotype Profile Approach to Emotional Disorder Classification: An Update

Although the emotional disorders (EDs) have achieved favorable reliability in the Diagnostic and Statistical Manual of Mental Disorders (DSM), accumulating evidence continues to underscore limitations in ED diagnostic validity. In particular, taxometric, comorbidity, and other descriptive psychopathology studies of transdiagnostic phenotypes studies suggest that the EDs may be best conceptualized as dimensional entities that are more similar than different. Despite optimism that the fifth edition of the DSM (DSM-5) would constitute a meaningful shift toward dimensional ED assessment and diagnosis, most changes contribute little movement in that direction. In the present report, we summarize past and anticipate persisting (i.e., in DSM-5) limitations of a purely categorical approach to ED diagnosis. We then review our alternative dimensional-categorical profile approach to ED assessment and classification, including preliminary evidence in support of its validity and presentation of two ED profile case examples using our newly developed Multidimensional Emotional Disorder Inventory. We end by discussing the transdiagnostic treatment implications of our profile approach to ED classification and directions for future research.

Initial interpretation and evaluation of a profile-based classification system for the anxiety and mood disorders: Incremental validity compared to DSM-IV categories

Limitations in anxiety and mood disorder diagnostic reliability and validity due to the categorical approach to classification used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) have been long recognized. Although these limitations have led researchers to forward alternative classification schemes, few have been empirically evaluated. In a sample of 1,218 outpatients with anxiety and mood disorders, the present study examined the validity of Brown and Barlow's (2009) proposal to classify the anxiety and mood disorders using an integrated dimensional-categorical approach based on transdiagnostic emotional disorder vulnerabilities and phenotypes. Latent class analyses of 7 transdiagnostic dimensional indicators suggested that a 6-class (i.e., profile) solution provided the best model fit and was the most conceptually interpretable. Interpretation of the classes was further supported when compared with DSM diagnoses (i.e., within-class prevalence of diagnoses, using diagnoses to predict class membership). In addition, hierarchical multiple regression models were used to demonstrate the incremental validity of the profiles; class probabilities consistently accounted for unique variance in anxiety and mood disorder outcomes above and beyond DSM diagnoses. These results provide support for the potential development and utility of a hybrid dimensional-categorical profile approach to anxiety and mood disorder classification. In particular, the availability of dimensional indicators and corresponding profiles may serve as a useful complement to DSM diagnoses for both researchers and clinicians.

Bayesian Analysis of Current and Lifetime Comorbidity Rates of Mood and Anxiety Disorders In Individuals with Posttraumatic Stress Disorder

Although posttraumatic stress disorder (PTSD) is no longer considered an anxiety disorder in DSM-5, previous research has indicated high rates of comorbid anxiety and mood disorders in individuals with PTSD. The goal of the present study was to build upon previous examinations of diagnostic comorbidity by using Bayesian methods of estimating current and lifetime comorbidity rates to determine more precise estimates of the proportion of individuals in a clinical sample with PTSD that also meet criteria for various emotional disorders. Two hundred and fifty three individuals with a current or lifetime diagnosis of PTSD underwent a comprehensive assessment of current and lifetime emotional disorders. Bayesian statistical techniques were then used to calculate credibility intervals for the current and lifetime comorbidity rates of emotional disorders. The Bayesian analyses used informative priors based on previous comorbidity findings. The median number of current emotional disorders was two and the median number of lifetime comorbid emotional disorders was three. Credibility intervals indicated that social phobia and major depressive disorder were the most common current and lifetime comorbid emotional disorders. The proportion of individuals with lifetime comorbidity rates were very high for both any lifetime anxiety disorder (.91, 95% CI .88: .94) and any lifetime depressive disorder (.90, 95% CI .86: .93). Together these results indicate that despite the separation from the anxiety disorders in DSM-5, the vast majority of individuals with PTSD will present with one or more emotional disorders. Implications for the assessment and treatment of PTSD are discussed.

Longitudinal course of anxiety sensitivity and PTSD symptoms in cognitive-behavioral therapies for PTSD

Anxiety sensitivity (AS) has been conceptualized as trait-like vulnerability and maintenance factor for PTSD. Although recent literature has demonstrated its malleability during treatment, few have examined its influence on and effect from PTSD treatment. Using multilevel regression analyses we examined: (a) changes in AS during treatment and (b) whether pre-treatment AS predicted PTSD treatment response, in sample of female victims of interpersonal trauma receiving one of three treatments (cognitive processing therapy, cognitive processing therapy-cognitive, and written accounts). Participants exhibited reductions in total ASI scores from pre- to post-treatment. Growth curve modeling revealed slightly different trajectories of PTSD symptoms as a function of pre-treatment AS, and overall decreases in PTSD symptoms during treatment were not associated with pretreatment AS. Pretreatment AS dimensions impacted PTSD total scores and symptoms clusters differentially. Clinical and theoretical implications for these results are discussed.

Reexperiencing symptoms, dissociation, and avoidance behaviors in daily life of patients with PTSD and patients with panic disorder with agoraphobia

Panic attacks are frequently perceived as life threatening. Panic disorder (PD) patients may therefore experience symptoms of posttraumatic stress disorder (PTSD). The authors explored this in 28 healthy controls, 17 PTSD patients, and 24 PD patients with agoraphobia who completed electronic diaries 36 times during 1 week. Patient groups frequently reported dissociation as well as thoughts, memories, and reliving of their trauma or panic attacks. PTSD patients reported more trauma/panic attack thoughts (incidence rate ratio [IRR] = 2.9) and memories (IRR = 2.8) than PD patients. Patient groups relived their trauma or panic attacks equally frequently, and reported comparable bodily reactions and distress associated with trauma or panic attack memories. Clinical groups avoided trauma or panic attack reminders more often than healthy controls (avoidance of trauma- or panic attack-related thoughts (IRR = 8.0); avoidance of things associated with the trauma or panic attack (IRR = 40.7). PD patients avoided trauma or panic attack reminders less often than PTSD patients (avoidance of trauma- or panic attack-related thoughts [IRR = 2.5]; avoidance of things associated with the trauma or panic attack [IRR = 4.1]), yet these differences were nonsignificant when controlling for functional impairment. In conclusion, trauma-like symptoms are common in PD with agoraphobia and panic attacks may be processed similarly as trauma in PTSD.

Randomized controlled trial: Multimodal Anxiety and Social Skill Intervention for adolescents with autism spectrum disorder

Anxiety is common among adolescents with autism spectrum disorders (ASD) and may amplify the core social disability, thus necessitating combined treatment approaches. This pilot, randomized controlled trial evaluated the feasibility and preliminary outcomes of the Multimodal Anxiety and Social Skills Intervention (MASSI) program in a sample of 30 adolescents with ASD and anxiety symptoms of moderate or greater severity. The treatment was acceptable to families, subject adherence was high, and therapist fidelity was high. A 16 % improvement in ASD social impairment (within-group effect size = 1.18) was observed on a parent-reported scale. Although anxiety symptoms declined by 26 %, the change was not statistically significant. These findings suggest MASSI is a feasible treatment program and further evaluation is warranted.

A psychophysiological investigation of threat and reward sensitivity in individuals with panic disorder and/or major depressive disorder

Heightened sensitivity to threat and reduced sensitivity to reward are potential mechanisms of dysfunction in anxiety and depressive disorders, respectively. However, few studies have simultaneously examined whether these mechanisms are unique or common to these disorders. In this study, sensitivity to predictable and unpredictable threat (measured by startle response during threat anticipation) and sensitivity to reward (measured by frontal electroencephalographic [EEG] asymmetry during reward anticipation) were assessed in 4 groups (N = 191): those with (1) panic disorder (PD) without a lifetime history of depression, (2) major depression (MDD) without a lifetime history of an anxiety disorder, (3) comorbid PD and MDD, and (4) controls. General distress/negative temperament (NT) was also assessed via self-report. Results indicated that PD (with or without comorbid MDD) was uniquely associated with heightened startle to predictable and unpredictable threat, and MDD (with or without comorbid PD) was uniquely associated with reduced frontal EEG asymmetry. Both psychophysiological measures of threat and reward sensitivity were stable on retest approximately 9 days later in a subsample of participants. Whereas the comorbid group did not respond differently on the tasks relative to the PD-only and MDD-only groups, they did report greater NT than these 2 groups (which did not differ from each other). Results suggest that heightened sensitivity to threat and reduced sensitivity to reward may be specific components of PD and MDD, respectively. In addition, relative to noncomorbid depression and PD, comorbid MDD and PD may be characterized by heightened NT, but not abnormal levels of these "specific" components.

A preliminary investigation of the new and revised symptoms of posttraumatic stress disorder in DSM-5

BACKGROUND

Research has shown that posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. The DSM-5 marks an opportunity to increase the differential diagnosis of PTSD by emphasizing symptoms that are specific to PTSD and deemphasizing symptoms that are common to many mental disorders. This study analyzes the new and revised PTSD symptom criteria proposed for DSM-5 by examining their relations with diagnoses and measures of PTSD. In addition, we report the specificity of DSM-5 symptoms with PTSD compared to depressive disorders and substance use.

METHODS

This study utilized pre- and postdeployment data collected from a sample of 213 National Guard Brigade Combat Team soldiers who were deployed to Iraq. Questionnaire data were collected pre- and postdeployment and interview data were collected postdeployment. Scales to measure the DSM-5 symptoms were created using structural analyses and were correlated with interview and self-report measures of PTSD, depression, and substance use.

RESULTS

The DSM-5 symptom of anger shows the most increase from pre- to postdeployment in participants diagnosed with PTSD. In addition, this scale showed the strongest relation to PTSD and showed some evidence of specificity. Other symptom scales, including those measuring negative expectations and aggressive behaviors, showed equivalent correlations with PTSD, depression, and substance use.

CONCLUSIONS

It will be important to continue studying the specificity of anger with PTSD. Several of the other new and revised DSM-5 symptoms appear to be nonspecific, and it is unlikely that their inclusion in the diagnostic criteria for PTSD will improve differential diagnosis.

Understanding the latent structure of the emotional disorders in children and adolescents

Investigators are persistently aiming to clarify structural relationships among the emotional disorders in efforts to improve diagnostic classification. The high co-occurrence of anxiety and mood disorders, however, has led investigators to portray the current structure of anxiety and depression in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, APA 2000) as more descriptive than empirical. This study assesses various structural models in a clinical sample of youths with emotional disorders. Three a priori factor models were tested, and the model that provided the best fit to the data showed the dimensions of anxiety and mood disorders to be hierarchically organized within a single, higher-order factor. This supports the prevailing view that the co-occurrence of anxiety and mood disorders in children is in part due to a common vulnerability (e.g., negative affectivity). Depression and generalized anxiety loaded more highly onto the higher-order factor than the other disorders, a possible explanation for the particularly high rates of comorbidity between the two. Implications for the taxonomy and treatment of mood and anxiety disorders for children and adolescents are discussed.

Clarifying domains of internalizing psychopathology using neurophysiology

Current initiatives such as the National Institute of Mental Health's Research Domain Criteria project aim to reorganize classification of mental disorders along neurobiological lines. Here, we describe how consideration of findings from psychiatric research employing two physiological measures with distinct neural substrates--the startle blink reflex and the error-related negativity (ERN)--can help to clarify relations among disorders entailing salient anxiety or depressive symptomatology. Specifically, findings across various studies and reviews reveal distinct patterns of association for both the startle blink reflex and the ERN with three key domains of psychopathology: (1) Fear (or phobic) disorders (distinguished by increased startle to unpleasant stimuli, but normal-range ERN). (2) Non-phobic anxiety disorders and negative affect (associated with increased ERN, increased startle across all types of emotional stimuli and increased baseline startle) and, more tentatively (3) Major depression (for which patterns of response for both startle and ERN appear to vary, as a function of severity and distinct symptomatology). Findings from this review point to distinct neurobiological indicators of key psychopathology domains that have been previously demarcated using personality and diagnostic data. Notably, these indicators exhibit more specificity in their relations with these three domains than has been seen in quantitative-dimensional models. Implications of these findings are discussed.

The structure of posttraumatic psychopathology in veterans attending primary care

This study attempted to extend research indicating that posttraumatic stress disorder (PTSD) factors of Re-experiencing, Avoidance and Hyperarousal are more related to Fear/phobic disorders, while PTSD Dysphoria is more related to Anxious-Misery disorders. Trauma exposure, PTSD and comorbidity data for 668 veteran patients were analysed using confirmatory factor analyses and relative strengths of the relationships between PTSD factors and the Fear and Anxious-Misery factors were assessed. Combining Simms, Watson, and Doebbeling's (2002) model of PTSD symptoms and Krueger's (1999) Fear/Anxious Misery model of mood and anxiety disorders fit the data well. Contrary to previous research, PTSD Re-experiencing, Avoidance and Hyperarousal did not correlate more with the Fear factor; nor did PTSD Dysphoria correlate more with Anxious-Misery. Hyperarousal was more closely related to Fear than was Re-experiencing; however, Avoidance was not. Dysphoria was more closely related to the Anxious-Misery factor than all other PTSD factors.

Understanding the relationship between co-occurring PTSD and MDD: symptom severity and affect

How to best understand theoretically the nature of the relationship between co-occurring PTSD and MDD (PTSD+MDD) is unclear. In a sample of 173 individuals with chronic PTSD, we examined whether the data were more consistent with current co-occurring MDD as a separate construct or as a marker of posttraumatic stress severity, and whether the relationship between PTSD and MDD is a function of shared symptom clusters and affect components. Results showed that the more severe depressive symptoms found in PTSD+MDD as compared to PTSD remained after controlling for PTSD symptom severity. Additionally, depressive symptom severity significantly predicted co-occurring MDD even when controlling for PTSD severity. In comparison to PTSD, PTSD+MDD had elevated dysphoria and re-experiencing - but not avoidance and hyperarousal - PTSD symptom cluster scores, higher levels of negative affect, and lower levels of positive affect. These findings provide support for PTSD and MDD as two distinct constructs with overlapping distress components.

An examination of the structure of posttraumatic stress disorder in relation to the anxiety and depressive disorders

The nature and structure of posttraumatic stress disorder (PTSD) has been the subject of much interest in recent times. This research has been represented by two streams, the first representing a substantive body of work which focuses specifically on the factor structure of PTSD and the second exploring PTSD's relationship with other mood and anxiety disorders. The present study attempted to bring these two streams together by examining structural models of PTSD and their relationship with dimensions underlying other mood and anxiety disorders. PTSD, anxiety and mood disorder data from 989 injury survivors interviewed 3-months following their injury were analyzed using a series of confirmatory factor analyses (CFA) to identify the optimal structural model. CFA analyses indicated that the best fitting model included PTSD's re-experiencing (B1-5), active avoidance (C1-2), and hypervigilance and startle (D4-5) loading onto a Fear factor (represented by panic disorder, agoraphobia and social phobia) and the PTSD dysphoria symptoms (numbing symptoms C3-7 and hyperarousal symptoms D1-3) loading onto an Anxious Misery/Distress factor (represented by depression, generalized anxiety disorder and obsessive compulsive disorder). The findings have implications for informing potential revisions to the structure of the diagnosis of PTSD and the diagnostic algorithm to be applied, with the aim of enhancing diagnostic specificity.

Acute panicogenic, anxiogenic and dissociative effects of carbon dioxide inhalation in patients with post-traumatic stress disorder (PTSD)

BACKGROUND

Increased anxiety and panic to inhalation of carbon dioxide (CO(2)) has been described in patients with anxiety disorders, especially panic disorder, compared to healthy subjects. Post-traumatic stress disorder (PTSD) has been hypothesised to resemble panic disorder and is currently classified as an anxiety disorder in DSM-IV. However, there are only very few data available about the sensitivity of patients with PTSD to CO(2).

METHODS

In 10 patients with PTSD, 10 sex- and age-matched healthy subjects and 8 patients with panic disorder we assessed anxiety, panic, dissociative and PTSD symptoms before and after a single vital capacity inhalation of 35% CO(2).

RESULTS

Patients with PTSD showed an increased anxiety, panic and dissociative reaction to the inhalation of 35% CO(2) compared to healthy participants. PTSD subjects' responses were indistinguishable from those of panic patients. Additionally, PTSD-typical symptoms like post-traumatic flashbacks were provoked in patients with PTSD after the inhalation of CO(2).

CONCLUSIONS

In our sample, PTSD was associated with an increased CO(2) reactivity, pointing to an increased susceptibility of PTSD patients to CO(2) challenge.

Worry, worry attacks, and PTSD among Cambodian refugees: a path analysis investigation

Among traumatized Cambodian refugees, this article investigates worry (e.g., the types of current life concerns) and how worry worsens posttraumatic stress disorder (PTSD). To explore how worry worsens PTSD, we examine a path model of worry to see whether certain key variables (e.g., worry-induced somatic arousal and worry-induced trauma recall) mediate the relationship between worry and PTSD. Survey data were collected from March 2010 until May 2010 in a convenience sample of 201 adult Cambodian refugees attending a psychiatric clinic in Massachusetts, USA. We found that worry was common in this group (65%), that worry was often about current life concerns (e.g., lacking financial resources, children not attending school, health concerns, concerns about relatives in Cambodia), and that worry often induced panic attacks: in the entire sample, 41% (83/201) of the patients had "worry attacks" (i.e., worry episodes that resulted in a panic episode) in the last month. "Worry attacks" were highly associated with PTSD presence. In the entire sample, generalized anxiety disorder was also very prevalent, and was also highly associated with PTSD. Path analysis revealed that the effect of worry on PTSD severity was mediated by worry-induced somatic arousal, worry-induced catastrophic cognitions, worry-induced trauma recall, inability to stop worry, and irritability. The final model accounted for 75% of the variance in PTSD severity among patients with worry. The public health and treatment implications of the study's findings that worry may have a potent impact on PTSD severity in severely traumatized populations are discussed: worry and daily concerns are key areas of intervention for these worry-hypersensitive (and hence daily-stressor-hypersensitive) populations.

Stress controversies: post-traumatic stress disorder, hippocampal volume, gastroduodenal ulceration*

Stress in mammals triggers a neuroendocrine response mediated by the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. Increased activity of these two systems induces behavioural, cardiovascular, endocrine and metabolic cascades that enable the individual to fight or flee and cope with the stress. Our understanding of stress and stress-response mechanisms is generally robust. Here, however, we review three themes that remain controversial and perhaps deserve further scrutiny and investigation before they achieve canonical status. The themes are, first, hypocortisolaemia in post-traumatic stress disorder (PTSD). A reduction rather than a stress-induced increase in adrenal glucocorticoid levels, as seen in major depressive disorder (MDD), is puzzling and furthermore is not a consistent feature of PTSD. Overall, studies on PTSD show that glucocorticoid levels may be normal or higher or lower than normal. The second theme concerns the reduction in volume of the hippocampus in MDD attributed to the neurotoxicity of hypercortisolaemia. Again, as for hypocortisolaemia in PTSD, reduced hippocampal volume in MDD has been found in some but not all studies. Third, the discovery of a causal association between Helicobacter pylori and peptic ulcers apparently brought to an end the long-held view that peptic ulceration was caused predominantly by stress. However, recent studies suggest that stress can cause peptic ulceration in the absence of H. pylori. Predictably, the aetiological pendulum of gastric and duodenal ulceration has swung from 'all stress' to 'all bacteria' followed by a sober realisation that both factors may play a role. This raises the question as to whether stress and H. pylori interact, and if so how? All three controversies are of clinical significance, pose fundamental questions about stress mechanisms and offer important areas for future research.

Treating Panic in a Veteran With Comorbid Combat-Related Posttraumatic Stress Disorder

Research indicates that psychiatric comorbidity can limit the effectiveness of evidence-based psychotherapy interventions. Panic disorder (PD) can be effectively treated with panic control treatment. However, the effectiveness of this intervention with comorbid posttraumatic stress disorder (PTSD) is not well established. This case is about a 57-year-old Vietnam Veteran diagnosed with PD with agoraphobia and comorbid PTSD and depression. The veteran participates in 10 sessions of panic control treatment after limited success with pharmacotherapy. He completed a structured clinical interview and self-report measures at pretreatment, 1-week posttreatment and 3-month follow-up. The veteran’s panic attacks were eliminated prior to completing the protocol. He remained panic free at posttreatment and follow-up but continued to meet criteria for PTSD and depression. These findings indicate that comorbid PTSD and depression do not limit the success of panic control treatment for PD. However, treatment effects do not generalize across anxiety disorders. Implications and recommendations are presented.