Response of patients with panic disorder and symptoms of hypomania to cognitive behavior therapy for panic

How Our Caregivers Shape Who We Are: The Seven Dimensions of Attachment at the Core of Personality

Psychology defines personality as the stable traits of an individual, and cognitive research suggests that a set of core beliefs is at the root of these traits. From this perspective, two major questions remain unanswered: (1) What are the core beliefs that make up personality? (2) How are they acquired? An interesting answer is provided by attachment theory, according to which attachment is at the basis of personality. The current theoretical formulation, however, does not sufficiently clarify the relationship between the two. Adopting a cognitive-clinical approach, we put forward a novel version of attachment theory, arguing that it can better account for the relationship between attachment and personality, thereby providing more convincing answers to questions (1) and (2). In particular, we propose that: (A) attachment information is acquired over seven dimensions; (B) the acquisition of each dimension is induced by a specific caregiving feature and (C) realized through a specific acquisition mechanism - imprinting. In a nutshell, we propose an Attachment-Personality Model (APM) according to which seven attachment dimensions constitute the knowledge core of personality. We finally discuss the significant implications of the model, especially its clinical application in terms of conception, assessment, and treatment of mental disorders. The model can be empirically tested, and we suggest three ways to do that.

Comorbidity of bipolar and anxiety disorders: An overview of trends in research

Over the last three decades burgeoning research has shown that anxiety disorder comorbidity is not only highly prevalent in bipolar disorder (BD), but it also adversely impacts the course, outcome, and treatment of BD. The present review provides an overview of the current trends in research on comorbid anxiety and BDs based on prior reviews and meta-analyses (n = 103), epidemiological surveys, and large-scale clinical studies. The results reiterated the fact that at least half of those with BD are likely to develop an anxiety disorder in their lifetimes and a third of them will manifest an anxiety disorder at any point of time. All types of anxiety disorders were equally common in BD. However, there was a wide variation in rates across different sources, with most of this discrepancy being accounted for by methodological differences between reports. Comorbid anxiety disorders negatively impacted the presentation and course of BD. This unfavourable clinical profile led to poorer outcome and functioning and impeded treatment of BD. Despite the extensive body of research there was paucity of data on aetiology and treatment of anxiety disorder comorbidity in BD. Nevertheless, the substantial burden and unique characteristics of this comorbidity has important clinical and research implications.

A Lifetime Prevalence of Comorbidity Between Bipolar Affective Disorder and Anxiety Disorders: A Meta-analysis of 52 Interview-based Studies of Psychiatric Population

BACKGROUND

Bipolar affective disorder has a high rate of comorbidity with a multitude of psychiatric disorders and medical conditions. Among all the potential comorbidities, co-existing anxiety disorders stand out due to their high prevalence.

AIMS

To determine the lifetime prevalence of comorbid anxiety disorders in bipolar affective disorder under the care of psychiatric services through systematic review and meta-analysis.

METHOD

Random effects meta-analyses were used to calculate the lifetime prevalence of comorbid generalised anxiety disorder, panic disorder, social anxiety disorder, specific phobia, agoraphobia, obsessive compulsive disorder and posttraumatic stress disorder in bipolar affective disorder.

RESULTS

52 studies were included in the meta-analysis. The rate of lifetime comorbidity was as follows: panic disorder 16.8% (95% CI 13.7-20.1), generalised anxiety disorder 14.4% (95% CI 10.8-18.3), social anxiety disorder13.3% (95% CI 10.1-16.9), post-traumatic stress disorder 10.8% (95% CI 7.3-14.9), specific phobia 10.8% (95% CI 8.2-13.7), obsessive compulsive disorder 10.7% (95% CI 8.7-13.0) and agoraphobia 7.8% (95% CI 5.2-11.0). The lifetime prevalence of any anxiety disorders in bipolar disorder was 42.7%.

CONCLUSIONS

Our results suggest a high rate of lifetime concurrent anxiety disorders in bipolar disorder. The diagnostic issues at the interface are particularly difficult because of the substantial symptom overlap. The treatment of co-existing conditions has clinically remained challenging.

The effect of comorbid major depressive disorder or bipolar disorder on cognitive behavioral therapy for social anxiety disorder

BACKGROUND

Major depressive disorder (MDD) and bipolar disorder (BD) commonly co-occur in individuals with social anxiety disorder (SAD), yet whether these comorbidities influence the outcomes of cognitive behavioral therapy (CBT) for SAD is unclear.

METHODS

The present study examined the degree to which individuals with SAD and comorbid MDD (SAD+MDD; n=76), comorbid BD (SAD+BD; n=19), a comorbid anxiety disorder (SAD+ANX; n=27), or no comorbid diagnoses (SAD+NCO; n=41) benefitted from CBT for SAD. Individuals were screened using the Structured Clinical Interview for DSM-IV and then completed the Social Phobia Inventory and the Depression Anxiety Stress Scales before and after 12-weeks of group CBT for SAD.

RESULTS

At pretreatment the SAD+MDD and SAD+BD groups reported higher social anxiety symptoms than the SAD+ANX and SAD+NCO groups. All groups reported large and significant improvement in social anxiety with CBT. However, at posttreatment the SAD+MDD and SAD+BD groups continued to have higher social anxiety symptoms than the SAD+NCO group, and the SAD+ANX group did not differ in social anxiety symptoms from any group. The sample also showed small and statistically significant improvement in depressive symptoms with CBT for SAD.

LIMITATIONS

Information about medication was not collected in the present study, and we did not assess the long-term effects of CBT.

CONCLUSION

Our results suggest that CBT for SAD is an effective treatment even in the presence of comorbid mood disorders in the short-term, although extending the course of treatment may be helpful for this population and should be investigated in future research.

Effects of comorbid anxiety disorders on the longitudinal course of pediatric bipolar disorders

OBJECTIVE

To examine the longitudinal effects of comorbid anxiety disorders in youth with bipolar spectrum disorder (BP).

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, who were 7 through 17 years or age and who met criteria for DSM-IV BP-I (n = 244), BP-II (n = 28), and operationally defined bipolar disorder not otherwise specified (BP-NOS) (n = 141) were included. Subjects were followed on average 5 years using the Longitudinal Interval Follow-up Evaluation. Effects of anxiety on the time to mood recovery and recurrence and percentage of time with syndromal and subsyndromal mood symptomatology during the follow-up period were analyzed.

RESULTS

At intake and during the follow-up, 62% of youth with BP met criteria for at least 1 anxiety disorder. About 50% of the BP youth with anxiety had ≥2 anxiety disorders. Compared to BP youth without anxiety, those with anxiety had significantly more depressive recurrences and significantly longer median time to recovery. The effects of anxiety on recovery disappeared when the severity of depression at intake was taken into account. After adjusting for confounding factors, BP youth with anxiety, particularly those with ≥2 anxiety disorders, spent significantly less follow-up time asymptomatic and more time with syndromal mixed/cycling and subsyndromal depressive symptomatology compared to those without anxiety.

CONCLUSIONS

Anxiety disorders are common and adversely affect the course of BP in youth, as characterized by more mood recurrences, longer time to recovery, less time euthymic, and more time in mixed/cycling and depressive episodes. Prompt recognition and the development of treatments for BP youth with anxiety are warranted.

Psychotherapies for comorbid anxiety in bipolar spectrum disorders

BACKGROUND

Comorbid anxiety disorders are highly prevalent in bipolar disorder and have been shown to have serious negative impacts on the course of illness. The pharmacological treatment of anxiety can interact with the bipolar disorder and has not been proven effective. As such, many have recommended the psychological treatment of anxiety. This paper reviews the literature on psychological treatments for anxiety comorbid to bipolar disorder.

METHOD

The Medline, PsychInfo and Web of Science databases were thoroughly examined for relevant treatment studies.

RESULTS

Despite frequent recommendations in the literature, surprisingly few have studied the psychological treatment of comorbid anxiety in bipolar disorders. Nevertheless, preliminary results suggest that comorbid anxiety disorders can be effectively treated in a bipolar clientele using cognitive-behavioral therapy, mindfulness-based cognitive-behavioral therapy or relaxation training. In contrast, interpersonal, family therapy and psychoeducation alone would not seem to be beneficial treatment alternatives for anxiety. Cognitive-behavioral therapy appears to reduce the symptoms of obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder and general symptoms of anxiety among patients with bipolar disorder. However, the long-term maintenance of anxiety treatment effects may be somewhat reduced and adaptations may be called for to augment and sustain benefits.

CONCLUSIONS

There is an urgent need for randomized controlled trials of different forms of psychotherapy for anxiety disorders comorbid to bipolar disorder. Until such trials are available, the most promising approach would appear to be the sequential or modular CBT-based treatment of the anxiety disorder.

Relationship between adjunctive medications for anxiety and time spent ill in patients with bipolar disorder

Objective. Many patients with bipolar disorder take adjunctive medications for anxiety. Using naturalistic data, we investigated the relationship between the use of adjunctive anxiolytics and the time spent in episodes or with subsyndromal mood symptoms. Methods. This was a post-hoc analysis of 310 patients with bipolar disorder who previously recorded mood and medications daily for 5 months using ChronoRecord software. One hundred patients were taking adjunctive anxiolytics for at least 50% of days; 210 were not. Of the 100 patients, 73 were taking a benzodiazepine. All patients taking anxiolytics were also receiving treatments for bipolar disorder. Results. Patients with bipolar disorder who were taking adjunctive medications for anxiety spent more time ill. Comparing patients who were taking or not taking anxiolytics, the mean days spent either in any episode or with subsyndromal symptoms was 45.6 vs. 29.6%, respectively (P<0.001), the mean days in any episode was 17.1 vs. 9.2%, respectively (P=0.016), and the mean days with subsyndromal depression was 26.4 vs. 16.2%, respectively (P=0.004). Conclusion. While this methodology cannot determine causality, these findings highlight the need for controlled studies of the long-term impact of adjunctive medications for anxiety on mood symptoms in patients being treated for bipolar disorder.

Implementing clinical guidelines for bipolar disorder

PURPOSE

To critically review the evidence concerning the implementation of clinical guidelines for bipolar disorder.

METHODS

A Medline search was made of the literature on the implementation of guidelines in bipolar disorder and mental health. The implementation of non-pharmacological treatments from the 2006 NICE Guideline for Bipolar Disorder was then used as a case example. May's model of normalization of complex interventions was then applied to the NICE guideline recommendations for bipolar disorder.

RESULTS

The effective local implementation of guidelines requires a detailed understanding of local barriers to their implementation. Some recommendations in the NICE Guideline on advanced directives and management of anxiety disorder in bipolar disorder appear to follow the existing trends in practice and are more likely to be implemented. Interventions concerning the psychological management of bipolar depression and maintenance psychological treatments are going to be the most difficult to implement because of shortages of skilled staff, the absence of specific training and supervision, the requirements for staff to adopt practices that are quite different from what they are used to, and some uncertainty about whether these interventions are effective in the most severe patients.

CONCLUSIONS

Without a detailed local understanding of the barriers to implementation and the resources and will to overcome them, there is likely to be a considerable local variation in the implementation of guidelines for bipolar disorder. Recommendations that require little change to working practices and resources are most likely to be implemented.

Self-rated importance of religion predicts one-year outcome of patients with panic disorder

Cognitive-behavioral therapy and medication are efficacious treatments for panic disorder, but individual attributes such as coping and motivation are important determinants of treatment response. A sample of 56 patients with panic disorder, treated with group cognitive-behavioral therapy, were reassessed 6 months and 12 months after initial assessment. We studied the effect of self-rated importance of religion, perceived stress, self-esteem, mastery, and interpersonal alienation on outcome as measured by the General Severity Index of the Brief Symptom Inventory (BSI.GSI). Importance of religion was a predictor of BSI.GSI symptom improvement at 1 year. Over time, improvement was seen for the religion is very important subgroup in the BSI.GSI and Perceived Stress Scales. This study suggests that one mechanism by which high importance of religion reduces psychiatric symptoms is through reducing perceived stress.

Randomized trial results of quality of life comparing whole abdominal irradiation and combination chemotherapy in advanced endometrial carcinoma: A gynecologic oncology group study

OBJECTIVE

To prospectively compare quality of life (QOL) outcomes in patients with advanced endometrial cancer treated with whole abdominal irradiation (WAI) or doxorubicin-cisplatin (AP) chemotherapy.

METHODS

Using the Fatigue Scale (FS), Assessment of Peripheral Neuropathy (APN), Functional Alterations due to Changes in Elimination (FACE), and Functional Assessment of Cancer Therapy-General (FACT-G), QOL was measured at: pre-treatment, end of treatment (EOT), and 3 and 6 months post-treatment.

RESULTS

317 of 396 eligible patients provided a baseline QOL assessment. The AP arm produced a statistically significant survival benefit along with greater toxicities, including peripheral neuropathy persisting up to 6 months. WAI patients reported worse FS (p < 0.001) and FACE (p < 0.001) scores at EOT and poorer FACE scores 3 months post-treatment (p = 0.004) compared to AP patients. APN scores were significantly worse among AP patients at EOT, and 3 and 6 months post-treatment (p < 0.001 for all). There is no indication that FACT-G scores differed between the two arms at any assessment point.

CONCLUSIONS

The trade-off for increased survival with AP is its potential for clinically significant peripheral neuropathy. This should be discussed with patients, particularly those who work with their hands or on their feet, in weighing therapeutic choices. Further research is needed to manage side effects having an enduring impact on QOL.