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Domschke K, Ströhle A, Zwanzger P. [Treatment resistance in anxiety disorders-Definition and treatment options]. DER NERVENARZT 2024; 95:407-415. [PMID: 38436664 DOI: 10.1007/s00115-024-01627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
Treatment resistance in anxiety disorders represents a clinical challenge, contributes to the chronicity of the diseases as well as sequential comorbidities, and is associated with a significant individual and socioeconomic burden. This narrative review presents the operational definition of treatment resistance in anxiety disorders according to international consensus criteria (< 50% reduction in the Hamilton Anxiety Scale, HAM‑A, score or < 50% reduction in the Beck Anxiety Inventory, BAI, score or a clinical global impression-improvement, CGI‑I, score > 2). At least two unsuccessful guideline-based treatment attempts with pharmacological monotherapy or at least one unsuccessful treatment attempt with adequately delivered cognitive behavioral therapy are required. Pharmacotherapeutically, after excluding pseudo-resistance, switching the medication within one class or to another class and augmentation strategies with other antidepressants (mirtazapine, agomelatine), antipsychotics (quetiapine) or anticonvulsants (valproate) are recommended. Psychotherapeutically, third-wave therapies, psychodynamic therapy, systemic therapy and physical exercise can be considered for therapy resistance. In cases of no response to psychotherapy or pharmacotherapy, the respective other form of therapy or a combination of both should be offered. Compounds targeting the glutamatergic and endocannabinoid systems as well as neuropeptides are being tested as potential innovative pharmaceuticals for treatment-resistant anxiety disorders. There is an urgent need for further research to identify predictive markers and mechanisms as well as to develop innovative pharmacological and psychotherapeutic interventions for treatment-resistant anxiety disorders.
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Affiliation(s)
- Katharina Domschke
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hauptstr. 5, 79104, Freiburg, Deutschland.
- Deutsches Zentrum für Psychische Gesundheit (DZPG), Standort Berlin, Berlin, Deutschland.
| | - Andreas Ströhle
- Klinik für Psychiatrie und Psychotherapie, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Peter Zwanzger
- Fachbereich Psychosomatische Medizin, Kompetenzschwerpunkt Angst, kbo-Inn-Salzach-Klinikum, Wasserburg am Inn, Deutschland
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Schmalbach I, Witthöft M, Strauß B, Joraschky P, Petrowski K. The predictive value of cortisol in psychodynamic psychotherapy for social anxiety disorder: Extended results of the SOPHONET-Study. Transl Psychiatry 2024; 14:188. [PMID: 38605013 PMCID: PMC11009385 DOI: 10.1038/s41398-024-02882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Psychotherapy is an effective treatment for anxiety disorders (AD), yet a vast majority of patients do not respond to therapy, necessitating the identification of predictors to enhance outcomes. Several studies have explored the relationship between stress response and treatment outcome, as a potential treatment mechanism. However, the latter remains under-researched in patients with social anxiety disorder (SAD). We studied N = 29 patients undergoing psychodynamic psychotherapy (PDT) within the SOPHONET-Study. Stress reactivity (i.e., area under the curve with respect to the increase; AUCi) was induced by a standardized psychosocial stressor (Trier Social Stress Test; TSST) and assessed by means of adrenocorticotropic hormone (ACTH), blood and salivary cortisol samples before (t1) treatment. Samples of these biomarkers were taken -1 min prior stress exposure and six more blood samples were collected post-TSST ( + 1, + 10, + 20, + 30, + 45, + 60 min.). The participants were diagnosed with SAD based on the Structured Clinical Interview for DSM-IV (SCID) and completed the Liebowitz Social Anxiety Scale as well as the Beck Depression Inventory before (t1) and after psychotherapy (t2). Pre-treatment stress reactivity significantly predicted changes in depression (salivary p < 0.001 and blood cortisol p = 0.001), as well as in avoidance behavior (blood cortisol p = 0.001). None of the biomarkers revealed significant results in fear or in the total LSAS-scores, except for ACTH with a trend finding (p = 0.06). Regarding therapy success, symptoms of social anxiety (p = 0.005) and depression (p < 0.001) were significantly reduced from pre (t1) to post-treatment (t2). Our study showed that stress reactivity pre-treatment may serve as a predictor of psychotherapy outcome. In this regard, alterations in stress response relate to changes in symptoms of social anxiety and depression after PDT. This implies that patients with chronic stress might benefit from a targeted interventions during psychotherapy, especially to manage fear in social contexts.
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Affiliation(s)
- Ileana Schmalbach
- Department of Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Bernhard Strauß
- Institute for Psychosocial Medicine, Psychotherapy & Psychooncology, University Hospital Jena, Jena, Germany
| | - Peter Joraschky
- University Medical Center Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Katja Petrowski
- Department of Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Dresden University of Technology, Carl Gustav Carus Medical Faculty, Department of General Medicine/MK3, Dresden, Germany
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Fragkiadaki E, Katsanou L, Vartzoka F, Gravanis A, Pitsikas N. Effects of low doses of the novel dehydroepiandrosterone (DHEA) derivative BNN27 in rat models of anxiety. Psychopharmacology (Berl) 2024; 241:341-350. [PMID: 37917180 PMCID: PMC10806005 DOI: 10.1007/s00213-023-06490-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
RATIONALE Several lines of evidence indicate that the neurosteroid dehydroepiandrosterone (DHEA) is involved in anxiety. BNN27 is a new DHEA derivative lacking steroidogenic effects. The beneficial effects exerted by BNN27 in preclinical models of schizophrenia and memory disorders have been recently reported. OBJECTIVES The present study was designed to investigate the effects of this DHEA novel analog on anxiety-like behavior in rats. METHODS To this end, the light/dark box, the open field, the contextual fear conditioning, and the excessive self-grooming induced by the serotonin 5-HT2c receptor agonist mCPP tests were utilized. RESULTS Animals treated acutely with BNN27 (1, 3, and 6 mg/kg) dose dependently spent more time in the bright compartment of the light/dark box and in the central zone of the open field with respect to their vehicle-treated cohorts. Further, BNN27 reduced freezing behavior and weakened the mCPP-induced excessive self-grooming. CONCLUSIONS Our data indicate that BNN27 is a highly potent anxiolytic agent, as in all studied paradigms it showed anxiolytic-like effects in male rats.
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Affiliation(s)
- Evangelia Fragkiadaki
- Department of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Panepistimiou 3, 415-00, Larissa, Greece
| | - Lamprini Katsanou
- Department of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Panepistimiou 3, 415-00, Larissa, Greece
| | - Foteini Vartzoka
- Department of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Panepistimiou 3, 415-00, Larissa, Greece
| | - Achille Gravanis
- Department of Pharmacology, School of Medicine, University of Crete, Heraklion, Greece
| | - Nikolaos Pitsikas
- Department of Pharmacology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Panepistimiou 3, 415-00, Larissa, Greece.
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Domschke K, Seuling PD, Schiele MA, Bandelow B, Batelaan NM, Bokma WA, Branchi I, Broich K, Burkauskas J, Davies SJC, Dell'Osso B, Fagan H, Fineberg NA, Furukawa TA, Hofmann SG, Hood S, Huneke NTM, Latas M, Lidbetter N, Masdrakis V, McAllister-Williams RH, Nardi AE, Pallanti S, Penninx BWJH, Perna G, Pilling S, Pini S, Reif A, Seedat S, Simons G, Srivastava S, Steibliene V, Stein DJ, Stein MB, van Ameringen M, van Balkom AJLM, van der Wee N, Zwanzger P, Baldwin DS. The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline. World Psychiatry 2024; 23:113-123. [PMID: 38214637 PMCID: PMC10785995 DOI: 10.1002/wps.21177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.
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Affiliation(s)
- Katharina Domschke
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrik D Seuling
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Miriam A Schiele
- Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University Medical Center, Göttingen, Germany
| | - Neeltje M Batelaan
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Wicher A Bokma
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Igor Branchi
- Center for Behavioral Sciences and Mental Health, Istituto Superiore di Sanità, Rome, Italy
| | - Karl Broich
- Federal Institute for Drugs and Medical Devices, Bonn, Germany
| | - Julius Burkauskas
- Laboratory of Behavioral Medicine, Neuroscience Institute, Lithuanian University of Health Sciences, Palanga, Lithuania
| | - Simon J C Davies
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernardo Dell'Osso
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
- Department of Mental Health and Addictions, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Harry Fagan
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Naomi A Fineberg
- University of Hertfordshire & Hertfordshire Partnership, University NHS Foundation Trust, Hatfield, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Stefan G Hofmann
- Department of Clinical Psychology, Philipps University Marburg, Marburg, Germany
| | - Sean Hood
- Division of Psychiatry, Medical School, University of Western Australia, Perth, WA, Australia
| | - Nathan T M Huneke
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
| | - Milan Latas
- Clinic for Psychiatry, University Clinical Center of Serbia, Belgrade, Serbia
- Belgrade University School of Medicine, Belgrade, Serbia
| | | | - Vasilios Masdrakis
- First Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - R Hamish McAllister-Williams
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle, UK
| | - Antonio E Nardi
- Panic & Respiration Laboratory, Institute of Psychiatry, Medical School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stefano Pallanti
- Institute of Neuroscience, Florence, Italy
- Albert Einstein College of Medicine, New York, NY, USA
| | - Brenda W J H Penninx
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Giampaolo Perna
- Department of Biological Sciences, Humanitas University, Milan, Italy
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational & Health Psychology, University College London, London, UK
| | - Stefano Pini
- University of Pisa School of Medicine, Pisa, Italy
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Goethe University Frankfurt, Frankfurt am Main, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology, Frankfurt am Main, Germany
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gemma Simons
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
| | | | - Vesta Steibliene
- Neuroscience Institute and Clinic of Psychiatry, Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dan J Stein
- South African Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Murray B Stein
- Department of Psychiatry and School of Public Health, University of California San Diego, San Diego, CA, USA
| | - Michael van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Anton J L M van Balkom
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Nic van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Peter Zwanzger
- Clinical Center for Psychiatry, Psychotherapy and Psychosomatic Medicine, Kbo-Inn-Salzach Hospital, Wasserburg am Inn, Germany
- Department of Psychiatry and Psychotherapy, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - David S Baldwin
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- South African Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
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Therapeutic Implications of microRNAs in Depressive Disorders: A Review. Int J Mol Sci 2022; 23:ijms232113530. [PMID: 36362315 PMCID: PMC9658840 DOI: 10.3390/ijms232113530] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
MicroRNAs are hidden players in complex psychophysical phenomena such as depression and anxiety related disorders though the activation and deactivation of multiple proteins in signaling cascades. Depression is classified as a mood disorder and described as feelings of sadness, loss, or anger that interfere with a person’s everyday activities. In this review, we have focused on exploration of the significant role of miRNAs in depression by affecting associated target proteins (cellular and synaptic) and their signaling pathways which can be controlled by the attachment of miRNAs at transcriptional and translational levels. Moreover, miRNAs have potential role as biomarkers and may help to cure depression through involvement and interactions with multiple pharmacological and physiological therapies. Taken together, miRNAs might be considered as promising novel therapy targets themselves and may interfere with currently available antidepressant treatments.
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Pitsikas N. The role of nitric oxide (NO) donors in anxiety. Lights and shadows. Nitric Oxide 2018; 77:6-11. [DOI: 10.1016/j.niox.2018.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 12/28/2022]
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Ociskova M, Prasko J, Vrbova K, Kasalova P, Holubova M, Grambal A, Machu K. Self-stigma and treatment effectiveness in patients with anxiety disorders - a mediation analysis. Neuropsychiatr Dis Treat 2018; 14:383-392. [PMID: 29416340 PMCID: PMC5790087 DOI: 10.2147/ndt.s152208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
GOAL The goal of this study was to explore the impact of self-stigma on the treatment outcomes in patients with anxiety disorders and to find possible mediators of this relationship. METHOD Two hundred and nine patients with anxiety disorders, who were hospitalized in a psychotherapeutic department, attended the study. The average age was 39.2±12.4 years; two-thirds were women. Most of the patients used a long-term medication. The participants underwent either cognitive behavioral therapy (CBT) or short psychodynamic therapy. The selection to the psychotherapy was not randomized. All individuals completed several scales - Beck Depression Inventory, the second edition (BDI-II), Beck Anxiety Inventory (BAI), Dissociative Experience Scale (DES), Sheehan Disability Scale (SDS), subjective Clinical Global Impression (subjCGI), and The Internalized Stigma of Mental Illness Scale (ISMI). A senior psychiatrist filled out the objective CGI (objCGI). RESULTS The patients significantly improved in the severity of anxiety (BAI), depression (BDI-II), and overall severity of the mental disorder (objCGI). The self-stigma predicted a lower change of the objCGI, but not a change of the anxiety and depressive symptoms severity. Anxiety, depressive symptoms, dissociation, and disability were assessed as possible mediators of the relationship between the self-stigma and the treatment change. None of them were significant. CONCLUSION Self-stigma lowers the effectiveness of the combined treatment of anxiety disorders. Future research should explore other possible mediators influencing this relationship.
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Affiliation(s)
- Marie Ociskova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Jan Prasko
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Kristyna Vrbova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Petra Kasalova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Michaela Holubova
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Ales Grambal
- Department of Psychiatry, Faculty of Medicine and Dentistry, Palacky University, University Hospital, Olomouc
| | - Klara Machu
- Department of Psychology, Faculty of Arts, University of Ostrava, Ostrava, The Czech Republic
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Garcia R. Neurobiology of fear and specific phobias. ACTA ACUST UNITED AC 2017; 24:462-471. [PMID: 28814472 PMCID: PMC5580526 DOI: 10.1101/lm.044115.116] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 06/02/2017] [Indexed: 01/01/2023]
Abstract
Fear, which can be expressed innately or after conditioning, is triggered when a danger or a stimulus predicting immediate danger is perceived. Its role is to prepare the body to face this danger. However, dysfunction in fear processing can lead to psychiatric disorders in which fear outweighs the danger or possibility of harm. Although recognized as highly debilitating, pathological fear remains insufficiently treated, indicating the importance of research on fear processing. The neurobiological basis of normal and pathological fear reactions is reviewed in this article. Innate and learned fear mechanisms, particularly those involving the amygdala, are considered. These fear mechanisms are also distinguished in specific phobias, which can indeed be nonexperiential (implicating innate, learning-independent mechanisms) or experiential (implicating learning-dependent mechanisms). Poor habituation and poor extinction are presented as dysfunctional mechanisms contributing to persistence of nonexperiential and experiential phobias, respectively.
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Affiliation(s)
- René Garcia
- Institut de Neurosciences de la Timone, UMR7289, Aix Marseille Université & Centre National de la Recherche Scientifique, 13385 Marseille, France
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Santos P, Herrmann AP, Benvenutti R, Noetzold G, Giongo F, Gama CS, Piato AL, Elisabetsky E. Anxiolytic properties of N -acetylcysteine in mice. Behav Brain Res 2017; 317:461-469. [DOI: 10.1016/j.bbr.2016.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/01/2016] [Accepted: 10/06/2016] [Indexed: 12/21/2022]
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Abstract
Systems for subtyping individuals with social anxiety disorder have been the focus of much research attention as a means to improve assessment and treatment of the disorder. This article highlights recent revisions to social anxiety disorder (SAD) subtypes from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to DSM-V, reviewing empirical evidence that served as the impetus for the revisions. Recent research examining the validity of the DSM-V system and alternative subtyping systems is reviewed. Overall, there appears to be greater empirical support for a dimensional subtyping system. Concerns therefore remain with the DSM-V system, which retained a categorical system but replaced the previous subtypes with a subtype of individuals fearing only performance situations. Recommendations for future research are discussed, as well as alternate options for capturing the variability in SAD presentations, including the possibility of eliminating subtyping altogether.
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Affiliation(s)
- Catherine D'Avanzato
- Rhode Island Hospital, Providence, RI, USA.
- Alpert Medical School of Brown University, Providence, RI, USA.
- , 593 Eddy Street, Potter Building 2nd floor, Providence, RI, 02903, USA.
| | - Kristy L Dalrymple
- Rhode Island Hospital, Providence, RI, USA
- , 593 Eddy Street, Potter Building 2nd floor, Providence, RI, 02903, USA
- , 146 West River Street, Suite 11B, Providence, RI, 02906, USA
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Pitsikas N. Constituents of Saffron (Crocus sativus L.) as Potential Candidates for the Treatment of Anxiety Disorders and Schizophrenia. Molecules 2016; 21:303. [PMID: 26950102 PMCID: PMC6273654 DOI: 10.3390/molecules21030303] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/10/2016] [Accepted: 02/29/2016] [Indexed: 02/07/2023] Open
Abstract
Anxiety disorders and schizophrenia are common public health issues. The dried stigma of the plant Crocus sativus L., (C. sativus) commonly known as saffron are used in folk medicine for various purposes. Several lines of evidence suggest that C. sativus, crocins and safranal are implicated in anxiety and schizophrenia. Here, I intend to critically review advances in research of these emerging molecules for the treatment of anxiety and schizophrenia, discuss their advantages over currently used anxiolytics and neuroleptics, as well remaining challenges. Current analysis shows that C. sativus and its components might be a promising class of compounds for the treatment of the above mentioned psychiatric diseases.
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Affiliation(s)
- Nikolaos Pitsikas
- Department of Pharmacology, School of Medicine, Faculty of Health Sciences, University of Thessaly, Panepistimiou 3 (Biopolis), Larissa 41500, Greece.
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Ociskova M, Prasko J, Latalova K, Kamaradova D, Grambal A. Psychological factors and treatment effectiveness in resistant anxiety disorders in highly comorbid inpatients. Neuropsychiatr Dis Treat 2016; 12:1539-51. [PMID: 27445474 PMCID: PMC4928674 DOI: 10.2147/ndt.s104301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Anxiety disorders are a group of various mental syndromes that have been related with generally poor treatment response. Several psychological factors may improve or hinder treatment effectiveness. Hope has a direct impact on the effectiveness of psychotherapy. Also, dissociation is a significant factor influencing treatment efficiency in this group of disorders. Development of self-stigma could decrease treatment effectiveness, as well as several temperamental and character traits. The aim of this study was to explore a relationship between selected psychological factors and treatment efficacy in anxiety disorders. SUBJECTS AND METHODS A total of 109 inpatients suffering from anxiety disorders with high frequency of comorbidity with depression and/or personality disorder were evaluated at the start of the treatment by the following scales: the Mini-International Neuropsychiatric Interview, the Internalized Stigma of Mental Illness scale, the Adult Dispositional Hope Scale, and the Temperament and Character Inventory - revised. The participants, who sought treatment for anxiety disorders, completed the following scales at the beginning and end of an inpatient-therapy program: Clinical Global Impression (objective and subjective) the Beck Depression Inventory - second edition, the Beck Anxiety Inventory, and the Dissociative Experiences Scale. The treatment consisted of 25 group sessions and five individual sessions of cognitive behavioral therapy or psychodynamic therapy in combination with pharmacotherapy. There was no randomization to the type of group-therapy program. RESULTS Greater improvement in psychopathology, assessed by relative change in objective Clinical Global Impression score, was connected with low initial dissociation level, harm avoidance, and self-stigma, and higher amounts of hope and self-directedness. Also, individuals without a comorbid personality disorder improved considerably more than comorbid patients. According to backward-stepwise multiple regression, the best significant predictor of treatment effectiveness was the initial level of self-stigma. CONCLUSION The initial higher levels of self-stigma predict a lower effectiveness of treatment in resistant-anxiety-disorder patients with high comorbidity with depression and/or personality disorder. The results suggest that an increased focus on self-stigma during therapy could lead to better treatment outcomes.
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Affiliation(s)
- Marie Ociskova
- Department of Psychiatry, Olomouc University Hospital, Faculty of Medicine and Dentistry, Palacký University Olomouc, Czech Republic
| | - Jan Prasko
- Department of Psychiatry, Olomouc University Hospital, Faculty of Medicine and Dentistry, Palacký University Olomouc, Czech Republic
| | - Klara Latalova
- Department of Psychiatry, Olomouc University Hospital, Faculty of Medicine and Dentistry, Palacký University Olomouc, Czech Republic
| | - Dana Kamaradova
- Department of Psychiatry, Olomouc University Hospital, Faculty of Medicine and Dentistry, Palacký University Olomouc, Czech Republic
| | - Ales Grambal
- Department of Psychiatry, Olomouc University Hospital, Faculty of Medicine and Dentistry, Palacký University Olomouc, Czech Republic
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Pitsikas N. The metabotropic glutamate receptors: potential drug targets for the treatment of anxiety disorders? Eur J Pharmacol 2013; 723:181-4. [PMID: 24361306 DOI: 10.1016/j.ejphar.2013.12.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/11/2013] [Accepted: 12/12/2013] [Indexed: 01/14/2023]
Abstract
Anxiety-related disorders are a common public health issue. Several lines of evidence suggest that altered glutamatergic neurotransmission underlies anxiety. Thus, novel molecules targeting glutamatergic neurotransmission, such as ligands of the metabotropic glutamate receptors (mGlurs) might be promising candidates for the treatment of anxiety disorders. To date, several ligands selective for each mGlu receptor (mGlur) have been synthesized, and pharmacological significances of these compounds have been demonstrated mainly in animal models. Here we critically review advances in research of these emerging molecular targets for the treatment of anxiety, discuss their advantages over currently used anxiolytics as well as remaining challenges.
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Affiliation(s)
- Nikolaos Pitsikas
- Department of Pharmacology, School of Medicine, University of Thessaly, Mezourlo, P.O. Box 1400, 411-10 Larissa, Greece.
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Yoshinaga N, Ohshima F, Matsuki S, Tanaka M, Kobayashi T, Ibuki H, Asano K, Kobori O, Shiraishi T, Ito E, Nakazato M, Nakagawa A, Iyo M, Shimizu E. A preliminary study of individual cognitive behavior therapy for social anxiety disorder in Japanese clinical settings: a single-arm, uncontrolled trial. BMC Res Notes 2013; 6:74. [PMID: 23448435 PMCID: PMC3602169 DOI: 10.1186/1756-0500-6-74] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2012] [Accepted: 02/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cognitive behavior therapy (CBT) is regarded as an effective treatment for social anxiety disorder (SAD) in Europe and North America. Individual CBT might be acceptable and effective for patients with SAD even in non-Western cultures; therefore, we conducted a feasibility study of individual CBT for SAD in Japanese clinical settings. We also examined the baseline predictors of outcomes associated with receiving CBT. METHODS This single-arm trial employed a 14-week individual CBT intervention. The primary outcome was the self-rated Liebowitz Social Anxiety Scale, with secondary measurements of other social anxiety and depressive severity. Assessments were conducted at baseline, after a waiting period before CBT, during CBT, and after CBT. RESULTS Of the 19 subjects screened, 15 were eligible for the study and completed the outcome measures at all assessment points. Receiving CBT led to significant improvements in primary and secondary SAD severity (ps < .001). The mean total score on the Liebowitz Social Anxiety Scale improved from 91.8 to 51.7 (before CBT to after CBT), and the within-group effect size at the end-point assessment was large (Cohen's d = 1.71). After CBT, 73% of participants were judged to be treatment responders, and 40% met the criteria for remission. We found no significant baseline predictors of those outcomes. CONCLUSION Despite several limitations, our treatment-which comprises a 14-week, individual CBT program-seems feasible and may achieve favorable treatment outcomes for SAD in Japanese clinical settings. Further controlled trials are required in order to address the limitations of this study. TRIAL REGISTRATION UMIN-CTR UMIN000005897.
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Affiliation(s)
- Naoki Yoshinaga
- Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
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15
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A review on predictors of treatment outcome in social anxiety disorder. BRAZILIAN JOURNAL OF PSYCHIATRY 2012. [DOI: 10.1016/s1516-4446(12)70016-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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16
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Abstract
Given the enormous contribution of anxiety disorders to the burden of disease, it is key to optimize their prevention and treatment. In this critical review we assess advances in the pharmacotherapy of anxiety disorders, as well as remaining challenges, in recent decades, the field has seen rigorous clinical trial methods to quantify the efficacy and safety of serendipitously discovered agents, more focused development of medications with selective mechanisms of action, and the gradual translation of insights from laboratory research into proof-of-principle clinical trials. On the positive side, a considerable database of studies shows efficacy and relative tolerability of the selective serotonin reuptake inhibitors in the major anxiety disorders, and secondary analyses of such datasets have informed questions such as optimal definition of response and remission, optimal dose and duration, and comparative efficacy of different agents. Significant challenges in the field include barriers to appropriate diagnosis and treatment of anxiety disorders, failure of a significant proportion of patients to respond to first-line pharmacotherapy agents, and a limited database of efficacy or effectiveness studies to guide treatment in such cases.
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Affiliation(s)
- Nastassja Koen
- Department of Psychiatry and Mental Health, University of Cape Town, South Africa
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17
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Mululo SCC, de Menezes GB, Vigne P, Fontenelle LF. A review on predictors of treatment outcome in social anxiety disorder. BRAZILIAN JOURNAL OF PSYCHIATRY 2012; 34:92-100. [DOI: 10.1590/s1516-44462012000100016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 09/03/2011] [Indexed: 12/16/2022]
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18
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Harvey BH, Shahid M. Metabotropic and ionotropic glutamate receptors as neurobiological targets in anxiety and stress-related disorders: Focus on pharmacology and preclinical translational models. Pharmacol Biochem Behav 2012; 100:775-800. [DOI: 10.1016/j.pbb.2011.06.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 05/24/2011] [Accepted: 06/09/2011] [Indexed: 11/29/2022]
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19
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Schutters SIJ, van Megen HJGM, Van Veen JF, Schruers KRJ, Westenberg HGM. Paroxetine augmentation in patients with generalised social anxiety disorder, non-responsive to mirtazapine or placebo. Hum Psychopharmacol 2011; 26:72-6. [PMID: 23055414 DOI: 10.1002/hup.1165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 12/29/2010] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The aim of the study was to investigate if combination of mirtazapine with paroxetine causes a greater therapeutic effect and less sexual side effects than paroxetine monotherapy in social anxiety disorder (SAD). METHODS Twenty one patients with generalised SAD, non-responsive to a 12 week trial with mirtazapine and 22 patients, non-responsive to placebo received paroxetine (20-40 mg) in addition to their double-blind treatment with mirtazapine or placebo for another 12 weeks. The Liebowitz Social Anxiety Scale (LSAS) and the Clinical Global Impression-Improvement (CGI-I) scale were used to measure efficacy. Sexual functioning was assessed by the Arizona Sexual Experiences Scale (ASEX). RESULTS Both treatments showed a significant LSAS reduction and their response rates (based on LSAS reduction ≥ 40% and CGI-I ≤ 2) were similar (paroxetine and mirtazapine: 52.4%, paroxetine and placebo: 59.1%). Sexual dysfunction (based on ASEX ≥ 19) was found in half of patients treated with paroxetine and placebo, and in 38% of patients treated with paroxetine and mirtazapine. CONCLUSION The present study did not find support for a greater efficacy of combination pharmacotherapy in SAD, however results suggest that combination of paroxetine with mirtazapine might cause less sexual dysfunction than treatment with paroxetine alone.
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Affiliation(s)
- Sara I J Schutters
- Department of Psychiatry, University Medical Centre Utrecht, The Netherlands.
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20
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Mirtazapine in generalized social anxiety disorder: a randomized, double-blind, placebo-controlled study. Int Clin Psychopharmacol 2010; 25:302-4. [PMID: 20715300 DOI: 10.1097/yic.0b013e32833a4d71] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study is aimed at investigating the efficacy and tolerability of mirtazapine in a generalized social anxiety disorder. Sixty patients with generalized social anxiety disorder were randomly allocated to receive mirtazapine (30-45 mg/day) (n= 30) or placebo (n= 30) for 12 weeks in a double-blind study design. Primary efficacy was assessed by the Liebowitz Social Anxiety Scale (LSAS) and response to treatment was defined as a reduction of 40% on the LSAS and an improvement on the Clinical Global Impression scale of 'much or very much improved'. An intent-to-treat analysis showed no difference between mirtazapine and placebo on the absolute LSAS scores with a mean decrease of 13.5 +/- 16.9 and 11.2 +/- 17.8 respectively, and on the number of responders, 13 and 13%, respectively. In conclusion, mirtazapine (30-45 mg/day) failed to be effective in the generalized social anxiety disorder.
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Common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. Int Clin Psychopharmacol 2009; 24:1-18. [PMID: 19060722 DOI: 10.1097/yic.0b013e32831db2d7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study is to summarize available knowledge about common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. A literature search was carried out by using MEDLINE and references of selected articles. The search included articles published up to March 2008. The main genetic finding concerns the serotonin transporter gene promoter polymorphisms, the long variant of which seems to be related to a positive response to therapy in mood disorders and could also have a role in the treatment of anxiety disorders. Among other predictors, the main factors common to both classes of disorder are comorbid axis II disorders and early onset of illness, which are related to a worse response to therapy and concomitant good physical conditions, absence of earlier treatments, early administration and response to therapies, and higher self- directedness, which is related to a better outcome. Many common predictors have been identified and these seem to be related to features covering the totality of patients that go beyond specific characteristics of single disorders. Possible limitations and suggestions for future research based on a more integrated vision of human complexity are discussed.
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Menezes GBD, Fontenelle LF, Mululo S, Versiani M. Resistência ao tratamento nos transtornos de ansiedade: fobia social, transtorno de ansiedade generalizada e transtorno do pânico. BRAZILIAN JOURNAL OF PSYCHIATRY 2007; 29 Suppl 2:S55-60. [DOI: 10.1590/s1516-44462007000600004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJETIVOS: Os transtornos de ansiedade são condições psiquiátricas prevalentes que determinam importante prejuízo funcional, piora na qualidade de vida do indivíduo e um enorme custo social. Embora diversas medicações eficazes para os transtornos de ansiedade encontrem-se disponíveis, um número significativo de pacientes não responde adequadamente ao tratamento e muitos permanecem com sintomas residuais clinicamente significativos. O objetivo deste estudo é rever aspectos relacionados à resistência ao tratamento e estratégias farmacológicas no manejo dos transtornos de ansiedade resistentes ao tratamento. MÉTODO: Revisão narrativa. RESULTADOS: São discutidos os diversos aspectos conceituais relacionados à resistência ao tratamento, os possíveis preditores de resistência e, finalmente, algumas estratégias a serem utilizadas no manejo dos transtornos de ansiedade (incluindo transtorno de ansiedade social, transtorno de ansiedade generalizada e transtorno do pânico) que não respondem às abordagens terapêuticas convencionais. CONCLUSÃO: A resistência ao tratamento ainda é um desafio para a prática clínica que começa em conceitos não operacionalizados de resposta e resistência e termina na escassez de estudos controlados sobre estratégias de tratamento nesse último cenário clínico.
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Affiliation(s)
| | | | - Sara Mululo
- Universidade Federal do Rio de Janeiro, Brasil
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Pallanti S, Quercioli L. Resistant social anxiety disorder response to Escitalopram. Clin Pract Epidemiol Ment Health 2006; 2:35. [PMID: 17166264 PMCID: PMC1769378 DOI: 10.1186/1745-0179-2-35] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Accepted: 12/13/2006] [Indexed: 11/21/2022]
Abstract
Background Social Anxiety Disorder (SAD) is a common disorder and its high prevalence and lifelong chronicity are such that it represents a substantial public health problem. The observation that serotonergic agents appear to be effective for its treatment suggests that patients may have abnormal serotonergic neurotransmission within the central nervous system. We investigated the efficacy of Escitalopram in treatment resistant patients with SAD. Method Twenty-nine adult outpatients participated in a 12-week open-label trial of escitalopram. All the subjects had a primary diagnosis of SAD and had failed at least one previous adequate trial of paroxetine. Escitalopram was orally administered starting with a dose of 10 mg/day following a 1-week titration. Results The escitalopram treatment was characterized by good tolerability (drop-out rate due to intolerance: 10.3%), and 24 subjects completed the study trial. At the end of the 12-week treatment period, 14 subjects (48.3%) were considered as responders on the basis of the Clinical Global Impression-Improvement (CGI-I) (much or very much improved) scale and the Liebowitz Scale for Social Anxiety (LSAS) (reduction >35% compared to baseline). We observed a significant mean reduction in the Sheehan Disability Scale Work (p < .05) and Social (p < .05) subscores, but not in the Family subscore. Conclusion These data suggest escitalopram has a role in the treatment of resistant SAD, especially in view of the favourable tolerability profile observed in the patients. Controlled studies are required to further investigate these findings and to compare escitalopram with other treatments for this disorder.
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Affiliation(s)
- Stefano Pallanti
- Mount Sinai School of Medicine, New York, USA
- Department of Neurological and Psychiatric Sciences, University of Florence, Italy
- Istituto di Neuroscienze, Viale Ugo Bassi 1, 50137 Florence, Italy
| | - Leonardo Quercioli
- Assistant Psychiatrist, Istituto di Neuroscienze, Florence, Italy
- Department of Neurological and Psychiatric Sciences, University of Florence, Italy
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Smits JAJ, Powers MB, Buxkamper R, Telch MJ. The efficacy of videotape feedback for enhancing the effects of exposure-based treatment for social anxiety disorder: A controlled investigation. Behav Res Ther 2006; 44:1773-85. [PMID: 16488388 DOI: 10.1016/j.brat.2006.01.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 12/14/2005] [Accepted: 01/06/2006] [Indexed: 11/26/2022]
Abstract
Correcting patients' faulty beliefs concerning social evaluative threats is the hallmark of cognitive-behavioral treatment of social anxiety disorder. The current study examined the efficacy of two videotape feedback procedures as adjuncts to exposure-based treatment. Participants suffering from social phobia (N=77) were randomly assigned to one of four conditions: (a) credible placebo treatment (PLA); (b) exposure + no feedback (EXP); (c) exposure + videotape feedback of performance (PER); or (d) exposure + videotape feedback of audience responses (AUD). Contrary to prediction, the videotape feedback procedures did not enhance the effects of exposure-based treatment. Clinical and theoretical implications are discussed.
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Affiliation(s)
- Jasper A J Smits
- Department of Psychology, Southern Methodist University, Dedman College, P.O. Box 750442, Dallas, TX 75275, USA.
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Abstract
Anxiety, stress, and trauma-related disorders are a major public health concern in the United States. Drugs that target the gamma-aminobutyric acid or serotonergic system, such as benzodiazepines and selective serotonin reuptake inhibitors, respectively, are the most widely prescribed treatments for these disorders. However, the role of glutamate in anxiety disorders is becoming more recognized with the belief that drugs that modulate glutamatergic function through either ionotropic or metabotropic glutamate receptors have the potential to improve the current treatment of these severe and disabling illnesses. Animal models of fear and anxiety have provided a method to study the role of glutamate in anxiety. This research has demonstrated that drugs that alter glutamate transmission have potential anxiolytic action for many different paradigms including fear-potentiated startle, punished responding, and the elevated plus maze. Human clinical drug trials have demonstrated the efficacy of glutamatergic drugs for the treatment of obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social phobia. Recent data from magnetic resonance imaging studies provide an additional link between the glutamate system and anxiety. Collectively, the data suggest that future studies on the mechanism of and clinical efficacy of glutamatergic agents in anxiety disorders are appropriately warranted.
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Affiliation(s)
- Bernadette M Cortese
- Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Abstract
Although treatment with different compounds such as tricyclic antidepressants, selective serotonin reuptake inhibitors, high-potency benzodiazepines, and monoamine oxidase inhibitors has been proven effective in anxiety disorders, 20% to 40% of patients are nonresponders. Given the limited efficacy, the delayed onset of response (it takes several weeks before a clinical effect can be seen for most of these drugs), and the occurrence of side effects associated with pharmacotherapy, predicting response in anxiety disorders would be immensely valuable. This review surveys the literature over the past years on predictors of response to pharmacotherapy in obsessive-compulsive disorder, social anxiety disorder, panic disorder, and posttraumatic stress disorder. Prediction of treatment response may be founded on demographic and clinical variables, neurochemical and electrophysiologic parameters, imaging studies, and genetic markers.
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Affiliation(s)
- Damiaan Denys
- Rudolf Magnus Institute of Neuroscience, Department of Psychiatry, University Medical Center, 3508 GA Utrecht, The Netherlands.
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