Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study

Psychological interventions for social anxiety disorder in children and adolescents: A systematic review and network meta-analysis

BACKGROUND

Social anxiety disorder (SAD) is a high-prevalence mental disorder among children and adolescents. The aim of this study is to compare and rank the effectiveness of several psychotherapies for SAD among children and adolescents.

METHODS

Only randomized controlled trials (RCTs) were utilized by searching PubMed, Embase, Cochrane Library, and Web of Science. We used network meta-analysis in the Bayesian framework to analyze the data. This study is registered with PROSPERO, number CRD42023476829.

RESULTS

In total, 30 RCTs with 1547 individuals were included, and nine psychotherapies with three control conditions were compared and ranked in this study. The findings revealed that internet-delivered cognitive behavioural therapy (surface under the cumulative ranking curve [SUCRA: 71.2 %]), group cognitive behavioural therapy (SUCRA: 68.4 %), and individual cognitive behavioural therapy (SUCRA: 66.0 %) significantly reduced social anxiety symptoms; internet-delivered cognitive behavioural therapy also significantly decreased depression symptoms in these patients (SUCRA: 92.2 %). In addition, group cognitive behavioural therapy can enhance functioning in these patients (SUCRA: 89.6 %).

CONCLUSION

These results suggest that internet-delivered cognitive behavioural therapy is the optimal type of psychotherapy for reducing social anxiety and depression symptoms in children and adolescents with SAD, internet-delivered parent-child interaction therapy and cognitive bias modification of interpretation have relatively poor treatment effects on social anxiety symptoms in children than other psychological interventions, and group cognitive behavioural therapy has better benefits in enhancing the functioning among children and adolescents with SAD. Further studies are needed to ascertain these results due to the limited number of included studies.

UK Medical Cannabis Registry: a case series analyzing clinical outcomes of medical cannabis therapy for generalized anxiety disorder patients

This study aims to analyze changes in health-related quality of life (HRQoL) and safety in patients with generalized anxiety disorder (GAD) prescribed a homogenous selection of cannabis-based medicinal products (CBMPs). Patients prescribed Adven CBMPs (Curaleaf International, UK) for GAD were identified from the UK Medical Cannabis Registry. Primary outcomes were changes in patient-reported outcome measures (PROMs) from baseline up to 12 months, including GAD-7, Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L. Adverse events were recorded using CTCAE version 4.0. A total of 120 patients were identified for inclusion, of which 38 (31.67%), 52 (43.33%), and 30 (25.00%) were prescribed oils, dried flower, and both formulations of CBMP. Associated improvements in GAD-7, SQS, and EQ-5D-5L at 1, 3, 6, and 12 months were observed compared to baseline ( P  < 0.010). There were 24 (20.00%) patients who reported 442 (368.33%) adverse events, most of which were mild (n = 184, 41.63%) and moderate (n = 197, 44.57%). This study reports an association between initiation of a homogeneous CBMP therapy and improvements in anxiety severity and HRQoL in individuals with GAD. Moreover, therapy was well-tolerated at 12 months follow-up. Further investigation through randomized controlled trials will ultimately be required to determine causation.

Fears of positive and negative evaluation and their within-person associations with emotion regulation in adolescence: A longitudinal analysis

Fear of positive evaluation (FPE) has recently emerged as an important aspect of social anxiety, alongside fear of negative evaluation. These evaluation fears peak during adolescence, a developmental stage that is also often accompanied by difficulties in emotion regulation, thereby increasing young individuals' vulnerability to mental disorders, such as social anxiety. We aimed to examine the longitudinal within-person associations between fears of evaluation, social anxiety, and three emotion regulation strategies (i.e., acceptance, suppression, rumination) in adolescents. Data were collected from a sample of 684 adolescents through an online survey three times over the course of 6 months and were analyzed using random intercept cross-lagged panel models. At the between-person level, FPE was linked to all three emotion regulation strategies, whereas fear of negative evaluation and social anxiety were associated with acceptance and rumination. At the within-person level, difficulties in accepting emotions predicted FPE, suppression predicted social anxiety, and social anxiety predicted rumination over time. These findings reveal complex interdependencies between emotion regulation, social anxiety, and evaluation fears, both reflecting individual differences and predicting changes within individuals, and further elucidate the developmental trajectory of social anxiety in adolescence.

Social Anxiety in Autistic People: Does the Clark and Wells Model fit?

PURPOSE

Cognitive behaviour therapy based on the Clark and Wells (1995) model is a first-line treatment for neurotypical people seeking support for social anxiety. While autistic people frequently report high social anxiety, it is unclear how appropriate the model is for this population.

METHODS

Over 300 autistic and non-autistic adults completed an online survey measuring key variables of the Clark and Wells model (socially-related negative thoughts, safety behaviours, self-focused attention). Using multiple regression and structural equation modelling, we assessed whether these variables accounted for the link between autism and social fears.

RESULTS

In multiple regression, autistic people experienced greater social fears than expected based on Clark and Wells variables, and safety behaviours were less predictive of social fears in autistic people. In structural equation modelling, Clark and Wells variables only mediated half the link between autistic traits and social fears. In exploratory analysis, we found that distress relating to uncertainty was an additional variable that needed to be taken into consideration in the relationship between autistic traits and social fears.

CONCLUSION

The Clark and Wells variables were relevant in autism, but did not fully explain elevated social fears in autistic people, which suggests that other factors are also important in accounting for social anxiety in autistic people. This means that therapy informed by the model may not be optimal for autistic people. We recommend further research developing adapted therapy for social anxiety in autistic people.

Specificity of attentional control deficits in predicting symptoms of social anxiety

BACKGROUND

The extent to which individuals can flexibly allocate their attention towards adaptive cues in the social environment may play an important role in the maintenance of social anxiety. Attentional control (AC) describes the top-down ability to regulate one's attention and cognitive resources. Although low AC has been linked to psychopathology broadly, the specific relation between AC and social anxiety disorder (SAD) remains poorly understood. The present study aimed to clarify the role of AC in SAD by examining unique associations between AC and several facets of social anxiety, above and beyond general psychological distress.

METHODS

Adults endorsing elevated SAD symptoms (n = 123) were assessed for levels of AC, inhibitory control, social anxiety severity, social anxiety sensitivity, social avoidance/safety behaviors, stress, and depression.

RESULTS

Partial correlations revealed that self-reported AC was negatively associated with all dimensions of SAD (rs = -0.20 to -0.29, ps < 0.05) after controlling for symptoms of stress and depression. Similarly, structural equation models showed that latent AC negatively predicted latent social anxiety (β = -0.21, p < .05), even after controlling for latent psychological distress.

LIMITATIONS

The study used a cross-sectional design, an analogue sample, and solely self-report measures in structural equation models.

CONCLUSIONS

Results converge to suggest that subjective (but not objective) deficits in AC have a unique relation with several mechanisms involved in the development and maintenance of SAD. These findings partially support the applicability of Attentional Control Theory to SAD and point to AC as a potential treatment target.

Psychiatric disorders and comorbidity in women with Turner Syndrome: a retrospective national cohort study

Turner syndrome (TS) is a genetic condition characterized by partial or complete monosomy X. A reduced life expectancy has been shown in TS, depending on an increased risk of aortic dissection, and ischemic heart disease. Studies covering the occurrence of psychiatric conditions are sparse within TS. Several case reports describe concomitant TS and neuropsychiatric abnormalities that may represent a pathogenetic link to genetics, as well as feature correlates of TS. The aim of this study was to determine the presence, and the frequency of psychiatric diagnosis in women with TS in a Swedish cohort followed during 25 years' time. Statistics from the entire female population in Sweden of corresponding age was used as reference. Data were retrieved from clinical examinations and validated from the National Board of Health and Welfare registries for women with TS (n = 487), aged 16 to 84 years, with respect to mental health disorders. The most common diagnoses in TS were mood and anxiety disorders. There was no increase in psychiatric diagnosis within the group with time, nor correlation to specific karyotype or somatic comorbidity as congenital heart disease and hypothyroidism, hormonal treatment, or childbirth. In addition, the frequency of psychiatric diagnosis in TS was lower than in the population-based data. Further investigations are needed in the view of the fact that women with Turner syndrome should not be burdened with more severe diagnoses.

The effect of SSRIs on unconditioned anxiety: a systematic review and meta-analysis of animal studies

RATIONALE

Selective serotonin reuptake inhibitors (SSRIs) are the first choice of treatment for anxiety-like disorders. However, which aspects of anxiety are affected by SSRIs is not yet fully understood.

OBJECTIVE

We aimed to systematically review the effect of six clinically effective SSRIs on four aspects of unconditioned anxiety: approach-avoidance behaviour (elevated plus maze), repetitive behaviour (marble burying), distress behaviour (ultrasonic vocalization), and activation of the autonomous nervous system (stress-induced hyperthermia).

METHODS

We identified publications by searching Medline and Embase databases and assessed the risk of bias. A random effects meta-analysis was performed and moderator effects were analysed with Bayesian penalized meta-regression.

RESULTS

Our search yielded 105 elevated plus maze, 63 marble burying, 11 ultrasonic vocalization, and 7 stress-induced hyperthermia articles. Meta-analysis suggested that SSRIs reduce anxiety-like behaviour in the elevated plus maze, marble burying and ultrasonic vocalization test and that effects are moderated by pre-existing stress conditions (elevated plus maze) and dose dependency (marble burying) but not by duration of treatment or type of SSRI. The reporting quality was low, publication bias was likely, and heterogeneity was high.

CONCLUSION

SSRIs seem to reduce a broad range of unconditioned anxiety-associated behaviours. These results should be interpreted with caution due to a high risk of bias, likely occurrence of publication bias, substantial heterogeneity and limited moderator data availability. Our review demonstrates the importance of including bias assessments when interpreting meta-analysis results. We further recommend improving the reporting quality, the conduct of animal research, and the publication of all results regardless of significance.

Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders

The temperamental trait behavioral inhibition (BI) is related to the development and maintenance of anxiety, particularly much so to social anxiety disorder. We investigated if BI and social anxiety disorder predicted cognitive behavioral therapy (CBT) outcomes for youth anxiety. Youth (N = 179; Mage = 11.6 years) were assessed 4 years following a randomized controlled CBT effectiveness trial. BI was measured by the parent-reported Behavioral Inhibition Questionnaire at baseline. The outcomes were diagnostic recovery, youth- and parent-reported anxiety symptoms, and clinical severity at post-treatment, 1-year, and 4-year follow-up. Having social anxiety disorder negatively predicted diagnostic recovery and predicted higher clinical severity at all assessment points and was the only significant predictor of outcomes at 4-year follow-up. Higher BI negatively predicted diagnostic recovery and predicted higher clinical severity and parent-reported symptom levels at post-treatment and 1-year follow-up, and predicted higher youth-reported anxiety levels at 1-year follow-up. Higher BI was the only predictor of youth- and parent-reported anxiety symptoms. BI and social anxiety disorder seem to be unique predictors of CBT outcomes among youth with anxiety disorders. CBT adaptations may be indicated for youth with high BI and social anxiety disorder.

If I Share With You, Will You Share With Me? A Quasi-Experimental Study on Social Anxiety and Self-Disclosure in Dictator Game

Social anxiety is characterized by a constant fear of negative evaluation, falling short of standards, low perceived likeability, and difficulties meeting social criteria. Using a quasi-experiment and a zero-acquaintance paradigm, this paper examines sharing behavior, which is represented by the willingness to give money in a Dictator Game. It explores gender and social anxiety differences related to this behavior, in terms of who is prone to receive more money. In addition to this, we investigated how the receiver's self-disclosure (positive or negative) influences the dictators' sharing behavior. Based on the original version of Dictator Game, involving a dictator and a receiver, one hundred and five adolescents aged 12-15, played Dictator Game in which they divided coins between themselves and the receiver. Our findings indicate that self-disclosure led to positive and gradual changes for non-anxious speakers. The anxious boy consistently achieved the highest money rate among all speakers, while the anxious girl received the lowest. However, her self-disclosure resulted in an increase in receiving. Across all situations, respondents reported slightly increased feelings of guilt and shame. Taken together, this study sheds light on adolescents' giving behavior by examining the interaction between adolescents' social traits and diverse social contexts throughout their developmental stages, ultimately influencing prosocial decision-making.

Alcohol sipping patterns, personality, and psychopathology in Children: Moderating effects of dorsal anterior cingulate cortex (dACC) activation

BACKGROUND

Alcohol, the most consumed drug in the United States, is associated with various psychological disorders and abnormal personality traits. Despite extensive research on adolescent alcohol consumption, the impact of early alcohol sipping patterns on changes in personality and mental health over time remains unclear. There is also limited information on the latent trajectory of early alcohol sipping, beginning as young as 9-10 years old. The dorsal anterior cingulate cortex (dACC) is crucial for cognitive control and response inhibition. However, the role of the dACC remains unclear in the relationship between early alcohol sipping and mental health outcomes and personality traits over time.

METHODS

Utilizing the large data from the Adolescent Brain Cognitive Development study (N = 11,686, 52% males, 52% white, mean [SD] age 119 [7.5] months, 9807 unique families, 22 sites), we aim to comprehensively examine the longitudinal impact of early alcohol sipping patterns on psychopathological measures and personality traits in adolescents, filling crucial gaps in the literature.

RESULTS

We identified three latent alcohol sipping groups, each demonstrating distinct personality traits and depression score trajectories. Bilateral dACC activation during the stop-signal task moderated the effect of early alcohol sipping on personality and depression over time. Additionally, bidirectional effects were observed between alcohol sipping and personality traits.

CONCLUSIONS

This study provides insights into the impact of early alcohol consumption on adolescent development. The key finding of our analysis is that poor response inhibition at baseline, along with increased alcohol sipping behaviors may accelerate the changes in personality traits and depression scores over time as individuals transition from childhood into adolescence.

Incidence Rates and Predictors of Recurrent Long-Term Mental Sickness Absence Due to Common Mental Disorders

PURPOSE

Several predictors have been identified for mental sickness absence, but those for recurrences are not well-understood. This study assesses recurrence rates for long-term mental sickness absence (LTMSA) within subgroups of common mental disorders (CMDs) and identifies predictors of recurrent LTMSA.

METHODS

This historical prospective cohort study used routinely collected data from 16,310 employees obtained from a nationally operating Dutch occupational health service (ArboNed). Total follow-up duration was 23,334 person-years. Overall recurrence rates were assessed using Kaplan-Meier estimators. Recurrence rates within subgroups of CMDs were calculated using person-years. Univariable and multivariable Cox proportional hazards models were used to identify predictors.

RESULTS

15.6% of employees experienced a recurrent LTMSA episode within three years after fully returning to work after a previous LTMSA episode. Highest recurrence rates for LTMSA were observed after a previous LTMSA episode due to mood or anxiety disorders. Mood or anxiety disorders and shorter previous episode duration were predictors of recurrent LTMSA. No associations were found for age, gender, company size, full-time equivalent and job tenure.

CONCLUSION

Employees should be monitored adequately after they fully returned to work after LTMSA. It is recommended to monitor high-risk employees (i.e. employees with mood or anxiety disorders and short LTMSA episode) more intensively, also beyond full return to work. Moreover, diagnosis of anxiety and depressive symptoms should be given a higher priority in occupational healthcare.

Limbic oxytocin receptor expression alters molecular signaling and social avoidance behavior in female prairie voles (Microtus ochrogaster)

Introduction

The social defeat paradigm is the most representative animal model to study social anxiety disorder (SAD) and its underlying neuronal mechanisms. We have previously reported that defeat progressively reduces oxytocin receptors (OXTR) in limbic regions of the brain over an eight-week period in female prairie voles (Microtus ochrogaster). Oxytocin receptors activate the mitogen-activated protein kinase (MAPK) pathway, which has been previously associated with the anxiolytic effects of oxytocin. Here, we assessed the functional significance of OXTR in stress-induced social avoidance and the response of the MAPK signaling pathway in the nucleus accumbens (NAc), anterior cingulate cortex (ACC), and basolateral amygdala (BLA) of female prairie voles.

Methods

In experiment 1, Sexually naïve adult female prairie voles were defeated for three consecutive days and tested a week after for social preference/avoidance (SPA) test. Control subjects were similarly handled without defeat conditioning. In experiment 2, sexually and stress naïve adult female prairie voles were bilaterally injected into the NAc, ACC, or the BLA with a CRISPR/Cas9 virus targeting the Oxtr coding sequence to induce OXTR knockdown. Two weeks post-surgery, subjects were tested for SPA behavior. Viral control groups were similarly handled but injected with a control virus. A subgroup of animals from each condition in both experiments were similarly treated and euthanized without being tested for SPA behavior. Brains were harvested for OXTR autoradiography, western blot analysis of MAPK proteins and quantification of local oxytocin content in the NAc, BLA, ACC, and PVN through ELISA.

Results

Social defeat reduced OXTR binding in the NAc and affected MAPK pathway activity and oxytocin availability. These results were region-specific and sensitive to exposure to the SPA test. Additionally, OXTR knockdown in the NAc, ACC, and BLA induced social avoidance and decreased basal MAPK activity in the NAc. Finally, we found that OXTR knockdown in these regions was associated with less availability of oxytocin in the PVN.

Conclusion

Dysregulation of the oxytocin system and MAPK signaling pathway in the NAc, ACC, and BLA are important in social behavior disruptions in female voles. This dysregulation could, therefore, play an important role in the etiology of SAD in women.

Cannabidiol in anxiety disorders: Current and future perspectives

Anxiety disorders are highly prevalent psychiatric disorders, characterized by a chronic course and often accompanied by comorbid symptoms that impair functionality and decrease quality of life. Despite advances in basic and clinical research in our understanding of these disorders, currently available pharmacological options are associated with limited clinical benefits and side effects that frequently lead to treatment discontinuation. Importantly, a significant number of patients do not achieve remission and live with lifelong residual symptoms that limit daily functioning. Since the 1970s, basic and clinical research on cannabidiol (CBD), a non-psychotomimetic compound found in the Cannabis sativa plant, has indicated relevant anxiolytic effects, garnering attention for its therapeutic potential as an option in anxiety disorder treatment. This chapter aims to review the history of these studies on the anxiolytic effects of CBD within the current understanding of anxiety disorders. It highlights the most compelling current evidence supporting its anxiolytic effects and explores future perspectives for its clinical use in anxiety disorders.

Imagery rescripting and extinction: Effects on US expectancy, US revaluation, and the generalization of fear reduction

Exposure therapy consists of exposing patients to their fears and thereby diminishing their harm expectancies (i.e., extinction or expectancy learning). Although effective for many anxiety patients, its long-term success depends on the generalization of these harm expectancies to other stimuli. However, research shows that this generalization of extinction is limited. Besides decreasing harm expectancies, fear reduction may also be achieved by changing the meaning of an aversive memory representation (US revaluation). Imagery rescripting (ImRs) may be more successful in generalizing fear reduction because it allegedly works through US revaluation. The current experiment aimed to test working mechanisms for ImRs and extinction (revaluation and expectancy learning, respectively), and to examine generalization of fear reduction. In a fear conditioning paradigm, 113 healthy participants watched an aversive film clip that was used as the US. The manipulation consisted of imagining a script with a positive ending to the film clip (ImRs-only), extinction (extinction-only), or both (ImRs + extinction). Results showed enhanced US revaluation in ImRs + extinction. US expectancy decreased more strongly in the extinction conditions. Generalization of fear reduction was found in all conditions. Our results suggest different working mechanisms for ImRs and exposure. Future research should replicate this in (sub)clinical samples.

Early childhood anxiety disorders: continuity and predictors in adolescence

Anxiety disorders are among the most common disorders in early childhood. Although many older children and adolescents with anxiety disorders recover and remain well, little is known about the continuity of early childhood anxiety and the factors that predict persistence/recurrence in later childhood and adolescence. We followed 129 children who met anxiety disorder criteria at age 3 and/or 6 and determined how many continued to experience an anxiety disorder between age 7 and 15, as well as the continuity of specific anxiety disorders. We explored whether biological sex, number of anxiety disorders, early childhood persistence (i.e., anxiety diagnosis at both age 3 and 6), childhood comorbidities, temperamental behavioral inhibition, a maternal history of anxiety, and authoritarian and overprotective parenting predicted persistence/recurrence of an anxiety disorder from age 7 to 15. Sixty-five (50.4%) of the adolescents with an early childhood anxiety disorder met anxiety disorder criteria during the age 7-15 interval. Homotypic continuity from early childhood to school-age/mid-adolescence was observed for social anxiety disorder, separation anxiety disorder, and generalized anxiety disorder (GAD). Early childhood agoraphobia predicted school-age/mid-adolescent GAD and early childhood GAD predicted school-age/mid-adolescent specific phobia. In bivariate analyses, number of anxiety disorders, persistence of anxiety from age 3 to 6, and having a mother with a history of anxiety predicted the persistence/recurrence of anxiety disorders from age 7 to 15. Only early childhood persistence of anxiety uniquely predicted the persistence/recurrence of an anxiety disorder over and above the other predictors. Early intervention efforts should focus on identifying and intervening with young children who demonstrate a protracted course of anxiety.

Anxiety on the internet: Describing person, provider, and organization online posts

Anxiety is a pervasive phenomenon in contemporary society. With increased internet use in recent years, more people in the general population are seeking and providing help and participating in community online. The goal of our study was to evaluate the content of internet narratives among those who post about anxiety and determine what stakeholder groups are saying online. We used the bifurcated method; it is a multi-method (qualitative) approach with inductive, thematic analyses, and with quantification of content-related words via a computer program that crawls websites and counts the occurrences of specified terms (for cross-checking purposes). Themes of posts and webpages about anxiety were: using/reporting treatment strategies (83.3% saturation), providing help (77.8% saturation), telling personal stories (72.2% saturation), seeking help (61.1% saturation), and illustrating interpersonal impact (50% saturation). We argue that anxiety stakeholders may take part in health co-inquiry online (i.e., cooperating with others) in many of the same ways that they might collaborate in person. We recommend that clinicians query their clients about use of the internet in ways related to their anxiety (e.g., seeking information/treatment strategies, offering help to others, telling their personal stories, etc.) so that they might help them process what they experience online.

Pharmacotherapy and cognitive bias modification for the treatment of anxiety disorders

INTRODUCTION

Anxiety disorders are characterized by widespread and persistent anxiety or recurrent panic attacks. As a result of their high prevalence, chronicity, and comorbidity, patients' quality of life and functioning are severely compromised. However, several patients do not receive treatment.

AREAS COVERED

This review discusses the effectiveness, safety, and limitations of major medications and cognitive bias modification (CBM) for treating anxiety disorders. The possibility of combined treatment is also discussed in the literature. Furthermore, drawing on Chinese cultural perspectives, the authors suggest that anxiety can be recognized, measured, and coped with at three levels of skill (), vision (), and Tao ().

EXPERT OPINION

The combination of pharmacotherapy and CBM is possibly more effective in treating anxiety disorders than either treatment alone. However, clinicians and patients should participate in the joint decision-making process and consider comprehensive factors. Moderate anxiety has adaptive significance. In the coming years, by combining the downward analytical system of western culture with the upward integrative system of Chinese culture, a comprehensive understanding of anxiety and anxiety disorders should be established, rather than focusing only on their treatment.

Social intelligence mediates the protective role of resting-state brain activity in the social cognition network against social anxiety

Background

Social intelligence refers to an important psychosocial skill set encompassing an array of abilities, including effective self-expression, understanding of social contexts, and acting wisely in social interactions. While there is ample evidence of its importance in various mental health outcomes, particularly social anxiety, little is known on the brain correlates underlying social intelligence and how it can mitigate social anxiety.

Objective

This research aims to investigate the functional neural markers of social intelligence and their relations to social anxiety.

Methods

Data of resting-state functional magnetic resonance imaging and behavioral measures were collected from 231 normal students aged 16 to 20 years (48% male). Whole-brain voxel-wise correlation analysis was conducted to detect the functional brain clusters related to social intelligence. Correlation and mediation analyses explored the potential role of social intelligence in the linkage of resting-state brain activities to social anxiety.

Results

Social intelligence was correlated with neural activities (assessed as the fractional amplitude of low-frequency fluctuations, fALFF) among two key brain clusters in the social cognition networks: negatively correlated in left superior frontal gyrus (SFG) and positively correlated in right middle temporal gyrus. Further, the left SFG fALFF was positively correlated with social anxiety; brain-personality-symptom analysis revealed that this relationship was mediated by social intelligence.

Conclusion

These results indicate that resting-state activities in the social cognition networks might influence a person's social anxiety via social intelligence: lower left SFG activity → higher social intelligence → lower social anxiety. These may have implication for developing neurobehavioral interventions to mitigate social anxiety.

An investigation of treatment return after psychological therapy for depression and anxiety

BACKGROUND

Some patients return for further psychological treatment in routine services, although it is unclear how common this is, as scarce research is available on this topic.

AIMS

To estimate the treatment return rate and describe the clinical characteristics of patients who return for anxiety and depression treatment.

METHOD

A large dataset (N=21,029) of routinely collected clinical data (2010-2015) from an English psychological therapy service was analysed using descriptive statistics.

RESULTS

The return rate for at least one additional treatment episode within 1-5 years was 13.7%. Furthermore, 14.5% of the total sessions provided by the service were delivered to treatment-returning patients. Of those who returned, 58.0% continued to show clinically significant depression and/or anxiety symptoms at the end of their first treatment, while 32.0% had experienced a demonstrable relapse before their second treatment.

CONCLUSIONS

This study estimates that approximately one in seven patients return to the same service for additional psychological treatment within 1-5 years. Multiple factors may influence the need for additional treatment, and this may have a major impact on service activity. Future research needs to further explore and better determine the characteristics of treatment returners, prioritise enhancement of first treatment recovery, and evaluate relapse prevention interventions.

A cohort study comparing the effects of medical cannabis for anxiety patients with and without comorbid sleep disturbance

BACKGROUND

Research on cannabis-based medicinal products (CBMPs) in anxiety remains inconclusive due to a paucity of high-quality evidence. Studies indicate a bidirectional relationship between generalized anxiety disorder (GAD) and sleep disruption, but it is unclear how this affects CBMP treatment outcomes. This study aims to compare the patient-reported outcome measures (PROMs) of patients prescribed CBMPs for GAD, with and without impaired sleep.

METHODS

Changes in PROMs were recorded from baseline to 1, 3, 6, and 12 months between those with impaired or unimpaired sleep. Multivariate logistic regression was applied to compare factors associated with a clinically significant improvement in GAD-7 at 12 months. Secondary outcomes included adverse event incidence and frequency.

RESULTS

Of the 302 patients that fit the inclusion criteria, mean GAD-7, single-item sleep quality, and EQ-5D-5L index values improved at all time points (p < 0.001). A relationship between sleep impairment and clinically significant changes in GAD-7 at 1 and 3 months was identified (p ≤ 0.01). On multivariate regression, only baseline GAD severity was associated with an increased likelihood of observing a clinically significant improvement in anxiety (p < 0.001). Seven hundred and seven (234%) adverse events were reported by 55 (18.21%) participants.

CONCLUSIONS

This study observed an association between CBMP treatment and improvements in anxiety in patients with GAD. While patients with comorbid sleep disruption had greater improvements in anxiety, the differences were not maintained in a multivariate analysis. Baseline anxiety severity may be a predictor for CBMP treatment outcomes.

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

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

Facing ambiguity: Social threat sensitivity mediates the association between peer victimization and adolescent anxiety

Peer victimization is a developmentally salient stressor that elevates adolescents' risk for anxiety disorders. However, modifiable mechanisms that explain this link and can be targeted via therapeutic interventions remain poorly understood. Drawing from psychobiological models implicating aberrant threat sensitivity in the development and maintenance of psychopathology, the current study investigated sensitivity to peer-related social threats as a mechanism underlying the association between peer victimization and anxiety. A sample of 197 dyads of early adolescents (M age = 12.02; 46% female) and parents/guardians (M age = 41.46; 90% female) completed online surveys assessing peer victimization, sensitivity to potential (i.e., ambiguous) social threats, and anxiety. Controlling for potentially confounding demographic and psychosocial factors, both self- and parent-reported peer victimization were positively associated with adolescent anxiety symptoms. Additionally, there were significant indirect effects from self- and parent-reported peer victimization to anxiety via social threat sensitivity. Supplemental analyses indicated unique effects of covert, but not overt, peer victimization on social threat sensitivity and anxiety. The findings provide initial evidence that peer victimization experiences lower adolescents' threshold for interpreting threats in ambiguous social situations, which contributes to heightened anxiety. These results implicate social threat sensitivity as a potential therapeutic target for interrupting links from peer victimization to psychological distress.

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

BACKGROUND

Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how 'recurrence' of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

METHODS

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

RESULTS

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

CONCLUSION

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

Status after Hospital Discharge: An Observational Study of the Progression of Patients' Mental Health Symptoms Six Weeks after Hospital Discharge

(1) Background: Transitioning from mental health inpatient care to community care is often a vulnerable time in the treatment process where additional risks and anxiety may arise. We collected data for this study as part of a pragmatic cluster-randomized, longitudinal approach in Alberta. As the first phase of the ongoing innovative supportive program, this paper assessed the progression of mental health symptoms in patients six weeks after hospital discharge. Factors that may contribute to the presence or absence of anxiety and depression symptoms, as well as well-being, following return to the community were investigated. This provides evidence and baseline data for future phases of the project. (2) Methods: An observational study design was adopted for this study. Data on a variety of sociodemographic and clinical factors were collected at discharge and six weeks after via REDCap. Anxiety, depression, and well-being symptoms were assessed using the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the World Health Organization-Five Well-Being Index (WHO-5), respectively. Descriptive, chi-square, independent t-tests, and multivariate regression analyses were conducted. (3) Result: The survey was completed by 88 out of 306 participants (28.8% response rate). The chi-square/Fisher exact test and independent t-test revealed no significant change in the mental health conditions from baseline to six weeks after discharge. It was found that the only significant factor predicting symptoms six weeks after discharge from inpatient treatment was the baseline symptoms in all three logistic regression models. It was four times more likely for those who experienced anxiety and depression at baseline to experience anxiety and depression symptoms six weeks after discharge (OR = 4.27; 95% CI: 1.38-13.20) (OR = 4.04; 95% CI: 1.25-13.05). Those with poor baseline well-being were almost 12 times more likely to experience poor well-being six weeks after discharge (OR = 11.75; 95% CI: 3.21-42.99). (4) Conclusions: Study results found no significant change in mental health conditions in the short term following hospital discharge. It is essential that researchers and policymakers collaborate in order to implement effective interventions to support and maintain the mental health conditions of patients following discharge.

Social avoidance and testosterone enhanced exposure efficacy in women with social anxiety disorder: A pilot investigation

Social avoidance has been associated with more persistent social anxiety disorder (SAD) symptoms and low testosterone levels in individuals with SAD. We tested whether pre-treatment avoidance tendencies moderate the efficacy of testosterone-augmented exposure therapy. Fifty-five females with SAD received two exposure sessions during which fear levels were assessed. Session 1 was augmented with testosterone (0.50 mg) or placebo. Avoidance tendencies and symptom severity were assessed pre- and post-exposure. Participants showed stronger avoidance for social versus non-social stimuli and this tendency remained stable over time. Stronger pretreatment avoidance tendencies were associated with larger fear reduction in the testosterone but not the placebo condition. This effect did not transfer to the second non-enhanced session or symptom severity. The findings support the hypothesis that individuals suffering from SAD with relatively stronger pretreatment avoidance tendencies benefit more from testosterone-augmentation, pointing to a potential behavioral marker for testosterone enhancement of exposure therapy.

Generalized Anxiety Disorder in Canadian Adults: to what Extent Might Social Support Subdomains and Negative Social Interactions Predict Psychological Distress?

Generalized anxiety disorder (GAD) may involve persistent and unwarranted anxiety, fear, and rumination, combined with various somatic symptoms (e.g., fatigue, dizziness, muscle tension, and nausea) which may compel many to withdraw socially. While studies report an inverse relationship between social support and psychological distress among adults with GAD, those that assess the distinct influence of negative social relations, particularly by sex are limited. The primary aims of this study were to (a) assess and compare respondents with a lifetime of GAD in terms of levels of perceived social support (using the Social Provisions Scale - 10 Items (SPS-10) Scale), negative social interactions (using the Negative Social Interaction (NSI) Scale) and psychological distress (using the Kessler Psychological Distress Scale (K10)), and (b) determine whether SPS-10 subdomains and NSIs predict psychological distress. Compared with a matched sample without GAD, respondents with GAD were more likely to be single, divorced, and have lower incomes. Respondents with GAD also had lower overall SPS-10 scores, and lower scores for each subdomain (i.e., 'guidance', 'reliable alliance', 'reassurance of worth', 'attachment', and 'social integration'), and higher NSI and K10 scores. Although no difference in psychological distress was observed between men and women with GAD, men had lower SPS-10 scores (overall and for each subdomain), while women had higher NSIs scores. A subsequent hierarchical regression for respondents with GAD revealed that 'social integration' and 'reassurance of worth' predicted lower psychological distress, while higher NSI scores predicted higher psychological distress. Finding implications and future research are discussed.

Panic disorder: Epidemiology, disability, and treatment gap from nationally representative general population of India

Introduction

Panic disorder (PD) is one of the most common and debilitating anxiety disorder. Individuals with PD seek frequent healthcare and emergency services leading to frequent work absenteeism and economic burden. However, its prevalence patterns in the Indian context are poorly understood. Hence, this article discusses the epidemiology, disability, and treatment gap from India's National Mental Health Survey 2016.

Materials and Methods

National Mental Health Survey 2016 was a nationally representative epidemiological survey of adult respondents from 12 states of India. Mini International Neuropsychiatric Interview 6.0.0 is used to diagnose psychiatric disorders. Sheehan disability scale was used to assess the disability. The current weighted prevalence of PD was estimated. Association between PD and its sociodemographic correlates was done using Firth penalized logistic regression. The treatment gap and disability in PD were also calculated.

Results

The lifetime and current weighted prevalence of PD was 0.5% (95% confidence interval 0.49-0.52) and 0.3% (95% confidence interval 0.28-0.41), respectively. The male gender and unemployed have significantly lesser odds with current PD. The elderly, Urban metro, and the married/separated group have significantly higher odds with current PD. The most common comorbid psychiatric disorder is agoraphobia (42.3%) and depression (30.9%) followed by Generalized Anxiety Disorder (10%). Among respondents with current PD in the past 1 month across three domains, around 80% had a disability of any severity and 20%-25% had marked disability. The overall treatment gap of current PD is 71.7%.

Conclusion

It is the first study reporting prevalence from a nationally representative sample from the general population of India. The survey has shed light on the epidemiology and the challenges faced by those with PD which emphasizes the urgency of bridging the treatment gap. These findings are paramount to the development of more inclusive and effective mental health policies and interventions to tackle the current burden due to PD.

Induced interpretation bias affects free recall and episodic memory bias in social anxiety

The combined effect of each cognitive bias, interpretation, attention, and memory bias, is known to play a causal role in the etiology and maintenance of social anxiety. However, little is known about how each type of bias (i.e., interpretation, memory bias) acts during social anxiety. The present study aimed to investigate whether experimentally induced interpretation bias using the cognitive bias modification (CBM) paradigm would influence free recall and episodic memory biases in a Korean sample. A total of 61 participants were randomly assigned to either a positive (n = 30) or negative (n = 31) CBM group. The study used CBM scenarios that were auditory-specific and focused on social anxiety symptoms. The results showed that interpretation biases could be induced, and they resulted in training congruent state mood and memory biases on both free-recall memory and autobiographical memory, which partly confirmed the combined cognitive biases hypothesis proposed by Hirsch, Clark (1).

Altered Low Frequency Heart Rate Variability Associated with Agoraphobia in Panic Disorder: A Retrospective Study

PURPOSE

This study aimed to compare the clinical features of panic disorder (PD) with comorbid agoraphobia to those of PD alone. We focused on autonomic nervous system (ANS) alterations reflected in heart rate variability (HRV) and executive function deficits reflected in the Stroop test.

MATERIALS AND METHODS

We retrospectively compared psychometric features, Stroop test results, and resting-state HRV across three groups: a subclinical group with anxiety attack history, a PD group without agoraphobia, and a PD group with agoraphobia. The subclinical group included 10 male and 34 female, the PD without agoraphobia group included 17 male and 19 female, and the PD with agoraphobia group included 11 male and 18 female.

RESULTS

The PD with agoraphobia group had higher Symptom Checklist-95 scores than the other groups. Both PD groups had longer reaction times in the Stroop test than the subclinical group. There were no significant differences in HRV parameters between the PD groups with and without agoraphobia. Compared with the subclinical group, the PD with agoraphobia group showed significantly lower values of the natural logarithm of low-frequency HRV.

CONCLUSION

Our results do not support that executive function deficits and ANS alterations are more pronounced with comorbid agoraphobia among PD groups. However, PD with agoraphobia patients showed more complex and severe clinical symptoms in their self-reports. Compared with the subclinical group, PD patients with agoraphobia showed specific features in the natural logarithm of low-frequency HRV. Our findings suggest that agoraphobia comorbidity should be considered when evaluating or treating patients with PD.

The effect of SSRIs on fear learning: a systematic review and meta-analysis

RATIONALE

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line medication for anxiety-like disorders such as panic disorder, generalized anxiety disorder, and post-traumatic stress disorder. Fear learning plays an important role in the development and treatment of these disorders. Yet, the effect of SSRIs on fear learning are not well known.

OBJECTIVE

We aimed to systematically review the effect of six clinically effective SSRIs on acquisition, expression, and extinction of cued and contextual conditioned fear.

METHODS

We searched the Medline and Embase databases, which yielded 128 articles that met the inclusion criteria and reported on 9 human and 275 animal experiments.

RESULTS

Meta-analysis showed that SSRIs significantly reduced contextual fear expression and facilitated extinction learning to cue. Bayesian-regularized meta-regression further suggested that chronic treatment exerts a stronger anxiolytic effect on cued fear expression than acute treatment. Type of SSRI, species, disease-induction model, and type of anxiety test used did not seem to moderate the effect of SSRIs. The number of studies was relatively small, the level of heterogeneity was high, and publication bias has likely occurred which may have resulted in an overestimation of the overall effect sizes.

CONCLUSIONS

This review suggests that the efficacy of SSRIs may be related to their effects on contextual fear expression and extinction to cue, rather than fear acquisition. However, these effects of SSRIs may be due to a more general inhibition of fear-related emotions. Therefore, additional meta-analyses on the effects of SSRIs on unconditioned fear responses may provide further insight into the actions of SSRIs.

Sexual differentiation of neural mechanisms of stress sensitivity during puberty

Anxiety disorders are a major public health concern and current treatments are inadequate for many individuals. Anxiety is more common in women than men and this difference arises during puberty. Sex differences in physiological stress responses may contribute to this variability. During puberty, gonadal hormones shape brain structure and function, but the extent to which these changes affect stress sensitivity is unknown. We examined how pubertal androgens shape behavioral and neural responses to social stress in California mice (Peromyscus californicus), a model species for studying sex differences in stress responses. In adults, social defeat reduces social approach and increases social vigilance in females but not males. We show this sex difference is absent in juveniles, and that prepubertal castration sensitizes adult males to social defeat. Adult gonadectomy does not alter behavioral responses to defeat, indicating that gonadal hormones act during puberty to program behavioral responses to stress in adulthood. Calcium imaging in the medioventral bed nucleus of the stria terminalis (BNST) showed that social threats increased neural activity and that prepubertal castration generalized these responses to less threatening social contexts. These results support recent hypotheses that the BNST responds to immediate threats. Prepubertal treatment with the nonaromatizable androgen dihydrotestosterone acts in males and females to reduce the effects of defeat on social approach and vigilance in adults. These data indicate that activation of androgen receptors during puberty is critical for programming behavioral responses to stress in adulthood.

Enhancing panic disorder treatment with mobile-aided case management: an exploratory study based on a 3-year cohort analysis

Background

Individuals with panic disorder frequently face ongoing symptoms, suboptimal treatment adherence, and increased relapse rates. Although mobile health interventions have shown promise in improving treatment outcomes for numerous mental health conditions, their effectiveness, specifically for panic disorder, has yet to be determined.

Objective

This study investigates the effects of a mobile-aided case management program on symptom reduction and quality of care among individuals with panic disorder.

Methods

This 3-year cohort study enrolled 138 participants diagnosed with panic disorder. One hundred and eight participants joined the mobile-aided case management group and 30 in the treatment-as-usual group. Data were collected at baseline, 3-month, 6-month, and 12-month treatment checkpoints using self-report questionnaires, in-depth interviews, direct observation, and medical record analysis.

Results

During the maintenance treatment phase, the mobile-assisted case management group decreased both panic severity (p = 0.008) and state anxiety (p = 0.016) more than the control group at 6 months. Participants who underwent case management experienced enhanced control over panic symptoms, heightened self-awareness, and elevated interpersonal support.

Conclusion

The mobile-aided case management is beneficial in managing panic disorder, especially maintenance treatment.

Assessing the Anxiety and Knowledge about Monkeypox Virus: A Cross-Sectional Cohort Study

Introduction Recent cases of human monkeypox virus (MPXV) infections have raised global health concerns, as sporadic instances have occurred in various regions, prompting investigations into the potential for increased transmission. This underscores the importance of effective communication strategies in addressing the emerging challenges associated with this viral ailment. The study was conducted to understand public anxiety and knowledge related to MPXV infection, particularly in the context of emerging infectious diseases. Our aims included assessing anxiety levels and knowledge about monkeypox infection among the Saudi population, as well as their willingness to receive vaccinations if available. Methods A cross-sectional cohort study among the adult Saudi population was conducted. A questionnaire with four sections, including demographic data and disease knowledge, comprised optimized questions of the standard generalized anxiety disorder assessment (GAD-7) as well as questions related to acceptance of getting the vaccine if it could be afforded. Results Out of a total of 5298 participants, 927 (17.5%) showed different degrees of GAD-7 anxiety. Females showed a significantly higher rate of anxiety (487/2189, 22.2%) than males (440/3109, 14.2%). People aged 46 to 55 and >55 years old showed significantly higher rates of anxiety (30.7% and 27.2%). There is an overall decrease in knowledge and awareness about the MPXV. Interestingly, 59% of the participants admitted that they would get the MPXV vaccine if it were made available. There was a positive correlation between the anxiety level and the response of people toward the MPXV vaccine if it were available. Conclusion Our study underscores a significant level of anxiety and a notable lack of awareness concerning MPXV infection. Although a substantial number of participants expressed their willingness to receive an MPXV vaccine, our findings emphasize the pressing need for improved public education and awareness campaigns to alleviate anxiety levels and enhance understanding of this infectious disease. This effort is crucial for mitigating health concerns and facilitating well-informed decision-making among the Saudi population.

Congruency of multimodal data-driven personalization with shared decision-making for StayFine: individualized app-based relapse prevention for anxiety and depression in young people

Tailoring interventions to the individual has been hypothesized to improve treatment efficacy. Personalization of target-specific underlying mechanisms might improve treatment effects as well as adherence. Data-driven personalization of treatment, however, is still in its infancy, especially concerning the integration of multiple sources of data-driven advice with shared decision-making. This study describes an innovative type of data-driven personalization in the context of StayFine, a guided app-based relapse prevention intervention for 13- to 21-year-olds in remission of anxiety or depressive disorders (n = 74). Participants receive six modules, of which three are chosen from five optional modules. Optional modules are Enhancing Positive Affect, Behavioral Activation, Exposure, Sleep, and Wellness. All participants receive Psycho-Education, Cognitive Restructuring, and a Relapse Prevention Plan. The personalization approach is based on four sources: (1) prior diagnoses (diagnostic interview), (2) transdiagnostic psychological factors (online self-report questionnaires), (3) individual symptom networks (ecological momentary assessment, based on a two-week diary with six time points per day), and subsequently, (4) patient preference based on shared decision-making with a trained expert by experience. This study details and evaluates this innovative type of personalization approach, comparing the congruency of advised modules between the data-driven sources (1-3) with one another and with the chosen modules during the shared decision-making process (4). The results show that sources of data-driven personalization provide complementary advice rather than a confirmatory one. The indications of the modules Exposure and Behavioral Activation were mostly based on the diagnostic interview, Sleep on the questionnaires, and Enhancing Positive Affect on the network model. Shared decision-making showed a preference for modules improving positive concepts rather than combating negative ones, as an addition to the data-driven advice. Future studies need to test whether treatment outcomes and dropout rates are improved through personalization.

More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder

BACKGROUND

Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time.

METHODS

102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test.

RESULTS

CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test.

CONCLUSIONS

When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.

Efficacy of high-intensity versus low-intensity psychoanalytically oriented long-term treatments and determinants of outcome: individual participant data Meta-analysis of Long-term Analytic treatment Studies (MeLAS)

INTRODUCTION

Long-term psychodynamic/psychoanalytic psychotherapy (LTPP) is a prevalent treatment option for complex mental disorders. Yet, little is known about the role of treatment intensity in LTPP. We present a study protocol for a systematic review and individual participant data (IPD) meta-analysis aggregating and analysing individual data from randomised and quasi-experimental trials by meta-analysis. The purpose is to (1) determine the treatment effectiveness of LTPP with low versus high intensity (up to 2 weekly sessions vs three or more), (2) compare their joint effectiveness to shorter therapies and treatments as usual, (3) identify predictors and moderators of treatment outcomes and (4) determine reciprocal relationships between different outcome domains (symptomatic and structural/personality change) over the courses of LTPP.

METHODS AND ANALYSIS

We include studies from (randomised controlled trial, RCT) and quasi-experimental trials, where at least one condition was LTPP of high or low frequency. Long-term treatment is defined as ≥1 year or ≥50 sessions. To be eligible studies must include a standardised outcome measure of symptoms (global or disorder specific) with at least one proof of reliability. The primary outcome is symptom reduction (global or specific), secondary outcome criteria are reliable change, remission, functional capacities, personality, personality functioning and interpersonal pathology. Relevant studies will mainly be identified by searching relevant databases: PubMed, PsycINFO (via EBSCO), Web of Science (via Elsevier), Chochrane's Central Register of Controlled Trials (via Wiley). Risk of bias will be evaluated in line with the Cochrane assessments tools for quasi-experimental trials and RCTs, respectively.

ETHICS AND DISSEMINATION

Aggregation of data from primary trials collected based on ethics votes. Dissemination into clinical practice via open access publications of findings.

PROSPERO REGISTRATION NUMBER

CRD42022304982; Pre-results.

Characterization of different types of anxiety disorders in relation to structural integration of personality and adverse and protective childhood experiences in psychotherapy outpatients - a cross-sectional study

BACKGROUND

Current research has emphasized the role of structural integration of personality and childhood experiences for the understanding of anxiety disorders. In this study, we examined the relationship between anxiety disorders (generalized anxiety disorder vs. panic disorder vs. phobic disorders), the level of structural integration of personality, and negative and protective childhood experiences at the beginning of outpatient psychodynamic psychotherapy treatment. Differences were characterized in comparison to patients with no anxiety disorders.

METHODS

The sample included a total of 1646 outpatient psychodynamic psychotherapy treatments, of which 695 treatments included the diagnosis of at least one anxiety disorder. Levels of structural integration of personality were assessed according to the Operationalized Psychodynamic Diagnosis (OPD-2) system. Self-reported negative and protective childhood experiences were examined by using the Questionnaire for the Assessment of Adverse and Protective Childhood Experiences (APC). Associations were tested using single factor ANOVAs.

RESULTS

Patients with anxiety disorders showed lower levels of structural integration of personality and reported more adverse childhood experiences than patients with no anxiety disorders. Regarding the subscales of structural integration of personality, phobic disorders were associated with impaired external communication, whereas for generalized anxiety disorder, an (uncorrected) association with impaired self-regulation was found. Also, generalized anxiety disorder was associated with sexual abuse and other traumatization (accidents etc.) during childhood, while panic disorder and phobic disorders were associated with emotional neglect, abuse, and fewer protective childhood experiences.

CONCLUSIONS

Our findings emphasize the need of considering structural integration of personality and childhood experiences in order to understand and treat various types of anxiety disorders.

Sudden gains in face-to-face and internet-based cognitive therapy for social anxiety disorder

Sudden gains are large and stable decreases in clinical symptoms between consecutive therapy sessions. This work examined the frequency and possible determinants of sudden gains in Cognitive Therapy for Social Anxiety Disorder, comparing face-to-face (CT) and internet-based (iCT) formats of treatment delivery. Data from 99 participants from a randomised controlled trial were analysed. The frequency of sudden gains was high: 64% and 51% of participants experienced a sudden gain in CT and iCT respectively. Having a sudden gain was associated with lower social anxiety symptoms at posttreatment and follow-up. There was evidence of reductions in negative social cognitions and self-focused attention immediately prior to the sudden gain, contrasting with no prior reductions in depression symptoms. Ratings of session videotapes in CT showed that clients' statements indicated greater generalised learning in sessions immediately prior to gains, compared to control sessions. This may suggest a role for generalised learning in facilitating these large symptom reductions. There were no significant differences in results between the CT and iCT treatment formats, suggesting that the therapy content appears to play a more important role in determining participants' large symptom improvements than the medium of treatment delivery.

[Anxiety and substance abuse disorders-Focus on alcohol and cannabis]

Anxiety disorders are frequent, with a 12-month prevalence of 14%, tend to be chronic, and display a high comorbidity with substance abuse disorders. Anxiety and substance abuse disorders are associated with a pronounced individual as well as socioeconomic burden. This article reviews the epidemiological, etiological, and clinical aspects of the dual diagnosis of anxiety and substance abuse disorders, with a particular focus on alcohol and cannabis. The treatment comprises nonpharmacological strategies, mainly cognitive behavioral therapy combined with elements of motivational interviewing (MI) and pharmacological management with antidepressants; however, the use of selective serotonin reuptake inhibitors (SSRI)/serotonin and noradrenaline reuptake inhibitors (SNRI) is not unreservedly recommended. The use of gabapentinoids requires careful risk-benefit consideration because of their potential for abuse and dependence in substance abuse disorders. Benzodiazepines are reserved exclusively for crisis management. Rapid diagnosis and treatment initiation targeting both disorders are essential for successful treatment of comorbid anxiety and substance abuse disorders.

Randomized evaluation of a school-based, trauma-informed group intervention for young women in Chicago

This study explores whether a school-based group counseling program for adolescent girls, implemented at scale, can mitigate trauma-related mental health harms. In a randomized trial involving 3749 Chicago public high school girls, we find that participating in the program for 4 months induces a 22% reduction in posttraumatic stress disorder symptoms and find significant decreases in anxiety and depression. Results surpass widely accepted cost-effectiveness thresholds, with estimated cost-utility well below $150,000 per quality adjusted life year. We find suggestive evidence that effects persist and may even increase over time. Our results provide the first efficacy trial of such a program specifically designed for girls, conducted in America's third largest city. These findings suggest the promise of school-based programs to mitigate trauma-related harms.

Toward a reliable detection of arachnophobia: subjective, behavioral, and neurophysiological measures of fear response

Introduction

The administration of questionnaires presents an easy way of obtaining important knowledge about phobic patients. However, it is not well known how these subjective measurements correspond to the patient's objective condition. Our study aimed to compare scores on questionnaires and image evaluation to the objective measurements of the behavioral approach test (BAT) and the neurophysiological effect of spiders extracted from fMRI measurements. The objective was to explore how reliably subjective statements about spiders and physiological and behavioral parameters discriminate between phobics and non-phobics, and what are the best predictors of overall brain activation.

Methods

Based on a clinical interview, 165 subjects were assigned to either a "phobic" or low-fear "control" group. Finally, 30 arachnophobic and 32 healthy control subjects (with low fear of spiders) participated in this study. They completed several questionnaires (SPQ, SNAQ, DS-R) and underwent a behavioral approach test (BAT) with a live tarantula. Then, they were measured in fMRI while watching blocks of pictures including spiders and snakes. Finally, the respondents rated all the visual stimuli according to perceived fear. We proposed the Spider Fear Index (SFI) as a value characterizing the level of spider fear, computed based on the fMRI measurements. We then treated this variable as the "neurophysiological effect of spiders" and examined its contribution to the respondents' fear ratings of the stimuli seen during the fMRI using the redundancy analysis (RDA).

Results

The results for fear ranks revealed that the SFI, SNAQ, DS-R, and SPQ scores had a significant effect, while BAT and SPQ scores loaded in the same direction of the first multivariate axis. The SFI was strongly correlated with both SPQ and BAT scores in the pooled sample of arachnophobic and healthy control subjects.

Discussion

Both SPQ and BAT scores have a high informative value about the subject's fear of spiders and together with subjective emotional evaluation of picture stimuli can be reliable predictors of spider phobia. These parameters provide easy and non-expensive but reliable measurement wherever more expensive devices such as magnetic resonance are not available. However, SFI still reflects individual variability within the phobic group, identifying individuals with higher brain activation, which may relate to more severe phobic reactions or other sources of fMRI signal variability.

Gender differences in anxiety and depressive symptomatology determined by network analysis in panic disorder

BACKGROUND

It has been suggested that gender differences in anxiety and depressive symptoms characterize panic disorder (PD) in terms of vulnerability to stressful life events, anxiety, depressive symptom patterns, and brain structure. However, few studies have investigated the gender differences in PD using a network approach.

METHODS

This study included 619 participants with PD (313 men). The Panic Disorder Severity Scale, Albany Panic and Phobia Questionnaire, and Beck Depression Inventory-II were used to evaluate symptomatology. To investigate the PD-related white matter (WM) neural correlates, tract-based spatial statistics were used. The PD-related clinical scales and WM neural correlates were included in the network analysis to identify associations between variables. To evaluate network differences between genders, network comparison tests were conducted.

RESULTS

Our findings revealed that agoraphobia in men was the strongest central symptom. In addition, loss of pleasure, and not anxiety or panic symptoms, was the strongest central symptom in women with PD. The network comparison test revealed that the bridge strength score was higher in agoraphobia and tiredness in men and in self-criticalness in women. Furthermore, in the network that includes neural correlates of WM, the bridge strength score was higher in the cingulate gyrus WM in men and the cingulum hippocampus in women.

LIMITATIONS

Since this is a cross-sectional network study of PD patients, the causal relationship between interactions in this network analysis for both genders may not be accurately determined.

CONCLUSION

Network structures of anxiety and depressive symptomatology and related WM neural correlates can differ according to gender in PD patients.

An exploratory investigation of schema modes in social anxiety disorder: Empirical findings and case conceptualization

BACKGROUND

Current "gold standard" treatments for social anxiety disorder (SAD) are limited by the limited emphasis of key etiological factors in conceptualization, and many individuals with SAD experience residual symptoms posttreatment. Hence, the novel application of the Schema Therapy Mode Model may provide a helpful framework for extending clinical understanding and treatment options for SAD. This exploratory study aimed to investigate the presence and pattern of schema modes among SAD individuals.

METHOD

Forty individuals with SAD completed questionnaire measures of symptomatology, social anxiety-relevant cognitions, schema modes, childhood trauma, and parental style.

RESULTS

Key maladaptive schema modes identified in SAD were Vulnerable Child, Punitive Critic, Demanding Critic, Compliant Surrender, and Detached Self-Soother.

CONCLUSION

Outcomes provide the basis for a proposed schema mode case conceptualization for SAD and are hoped to provide a rationale for testing the applicability of Schema Therapy as a novel treatment for SAD. Key limitations are discussed.

Bidirectional relationships between interpretation biases, safety behaviors, and social anxiety

Theoretical models of social anxiety (SA) propose bidirectional relationships between SA, interpretation biases, and safety behaviors (Safe-B). However, longitudinal studies evaluating these bidirectional relationships are scarce. The main objective of this study was to analyze the bidirectional relationships between interpretation biases (from ambiguous situations and ambiguous faces), Safe-B, and SA. A two-time longitudinal study was carried out with the participation of 575 vocational training students (M = 19.49, SD = 2.41). Both the interpretation biases measured through ambiguous situations and ambiguous faces and the Safe-B predicted higher levels of SA in the second time. In turn, a bidirectional relationship was found between SA and Safe-B. However, no bidirectional relationships were found between interpretation biases and Safe-B and between biases and SA. Among others, the limitations of the study include the high attrition rate (30.4%) and the high proportion of male students (62.1%). The findings highlight the role of interpretation bias and Safe-B in SA. In turn, as a new initiative, the study supports the bidirectional relationship between Safe-B and SA. Implications are discussed throughout the manuscript.

Clinical Markers of Panic and Generalized Anxiety Disorder: Overlapping Symptoms, Different Course and Outcome

Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) share underlying neurobiological mechanisms and several clinical features which, with medical comorbidities, may increase misdiagnosis and delay proper treatment. The aim of the study was to evaluate the association between clinical/socio-demographic markers and GAD/PD diagnosis. Outpatients (N = 290) with PD or GAD were identified in mental health services in Monza and Milan (Italy). Descriptive analyses and a binary logistic regression model were performed. Post-onset psychiatric (p = 0.05) and medical (p = 0.02) multiple co-morbidities were associated with GAD; treatment with selective serotonin reuptake inhibitors (SSRIs) was associated with PD, while GAD diagnosis was associated with treatment with atypical antipsychotics or GABAergic drugs (p = 0.03), as well as psychodynamic psychotherapy (p < 0.01). Discontinuation of the last pharmacological treatment was associated with GAD diagnosis rather than the PD one (p = 0.02). GAD patients may have a worse prognosis than PD patients because of more frequent multiple co-morbidities, relapses and poorer treatment compliance. The different treatment approaches were consistent with the available literature, while the association between GAD and psychodynamic psychotherapy is an original finding of our study. Further studies on larger samples are necessary to better characterize clinical factors associated with GAD or PD.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

OBJECTIVE

Depression and anxiety cause a high burden of disease and have high relapse rates (39%-72%). This meta-analysis systematically examined effectiveness of relapse prevention strategies on risk of and time to relapse in youth who remitted.

METHOD

PubMed, PsycInfo, Embase, Cochrane, and ERIC databases were searched up to June 15, 2021. Eligible studies compared relapse prevention strategies to control conditions among youth (mean age 13-25 years) who were previously depressed or anxious or with ≥30% improvement in symptoms. Two reviewers independently assessed titles, abstracts, and full texts; extracted study data; and assessed risk of bias and overall strength of evidence. Random-effects models were used to pool results, and mixed-effects models were used for subgroup analyses. Main outcome was relapse rate at last follow-up (PROSPERO ID: CRD42020149326).

RESULTS

Of 10 randomized controlled trials (RCTs) that examined depression, 9 were eligible for analysis: 4 included psychological interventions (n = 370), 3 included antidepressants (n = 80), and 2 included combinations (n = 132). No RCTs for anxiety were identified. Over 6 to 75 months, relapse was half as likely following psychological treatment compared with care as usual conditions (k = 6; odds ratio 0.56, 95% CI 0.31 to 1.00). Sensitivity analyses including only studies with ≥50 participants (k = 3), showed similar results. Over 6 to 12 months, relapse was less likely in youth receiving antidepressants compared with youth receiving pill placebo (k = 3; OR 0.29, 95% CI 0.10 to 0.82). Quality of studies was suboptimal.

CONCLUSION

Relapse prevention strategies for youth depression reduce risk of relapse, although adequately powered, high-quality RCTs are needed. This finding, together with the lack of RCTs on anxiety, underscores the need to examine relapse prevention in youth facing these common mental health conditions.

Recurrence of anxiety disorders and its predictors in the general population

BACKGROUND

Anxiety disorders frequently recur in clinical populations, but the risk of recurrence of anxiety disorders is largely unknown in the general population. In this study, recurrence of anxiety and its predictors were studied in a large cohort of the adult general population.

METHODS

Baseline, 3-year and 6-year follow-up data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). Respondents (N = 468) who had been in remission for at least a year prior to baseline were included. Recurrence was assessed at 3 and 6 years after baseline, using the Composite International Diagnostic Interview version 3.0. Cumulative recurrence rates were estimated using the number of years since remission of the last anxiety disorder. Furthermore, Cox regression analyses were conducted to investigate predictors of recurrence, using a broad range of putative predictors.

RESULTS

The estimated cumulative recurrence rate was 2.1% at 1 year, 6.6% at 5 years, 10.6% at 10 years, and 16.2% at 20 years. Univariate regression analyses predicted a shorter time to recurrence for several variables, of which younger age at interview, parental psychopathology, neuroticism and a current depressive disorder remained significant in the, age and gender-adjusted, multivariable regression analysis.

CONCLUSIONS

Recurrence of anxiety disorders in the general population is common and the risk of recurrence extends over a lengthy period of time. In clinical practice, alertness to recurrence, monitoring of symptoms, and quick access to health care in case of recurrence are needed.

Burden and risk factors of anxiety disorders among Arabic pediatric population: A systematic review

<b>Aim:</b> In the general population, where 6 to 20% of individuals experience anxiety disorders, children also experience a higher burden of anxiety. We undertook a systematic review In order to examine and summarize the results from studies that estimated the prevalence of anxiety and/or its associated risk factors in the pediatric populations of Arab nations, primarily the gulf countries.<br /> <b>Methods:</b> Any study that focused on the pediatric population and completed in Arab nations to determine the incidence of anxiety and/or its risk factors among children under the age of 18. The review had 13 articles were included.<br /> <b>Results:</b> The results of the systematic review found that there was a wide variation in the prevalence of anxiety among children. At least 30.2% of the children were found to suffer from anxiety and the prevalence could go up to 60% in some countries with a higher prevalence among girls than boys. Associated factors of anxiety were diverse including exposure to environmental tobacco smoke, parenting style, living with parents suffering from mental disorders, school type, and being female.<br /> <b>Conclusion:</b> The findings of the review demonstrate the higher prevalence of anxiety among children as almost at least one-third of children suffer from anxiety in the Gulf countries. The program managers and the respective government of these Arab countries need to devise some strategies and interventions that not only focus on the children but also their environment.