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Schopman SME, ten Have M, van Balkom AJ, de Graaf R, Batelaan NM. Course trajectories of anxiety disorders: Results from a 6-year follow-up in a general population study. Aust N Z J Psychiatry 2021; 55:1049-1057. [PMID: 33887978 PMCID: PMC8554495 DOI: 10.1177/00048674211009625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Little is known about the course of anxiety disorders in the general population. This study provides insights into the course of anxiety disorders in the general population taking into account transition to residual symptoms and to other diagnostic categories. METHODS Using data from three waves of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2; n = 6646), subjects with anxiety disorders (T0;n = 243) were divided into three mutually exclusive course trajectories according to their diagnostic status at 3-year (T1) and 6-year (T2) follow-up: remission group (no disorder at T2), intermittent course group (no disorder at T1 and disorder at T2) and chronic course group (disorder at all measurements). Transition to residual symptoms or other psychopathology were studied. In addition, predictors of course trajectories were assessed. RESULTS During 6-year follow-up, 77.8% of subjects achieved remission, 14.0% followed an intermittent course and 8.2% a chronic course. Of those in remission, residual anxiety symptoms remained in 46.6%, while 7.9% developed another disorder between T0 and T2. Compared with the remitting group, a chronic course was predicted by not living with a partner, multiple negative life events, neuroticism, lower mental functioning, severity of anxiety symptoms, use of mental health care and medication use. LIMITATIONS The intermittent and chronic course groups were small, limiting statistical power. As a result, certain predictors may not have reached significance. CONCLUSIONS In the general population at 6-year follow-up, 77.8% of subjects with anxiety disorders achieved remission. Because of transition to residual symptoms or another diagnostic category, only 52.4% of those subjects had a true favourable outcome.
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Affiliation(s)
- Simone ME Schopman
- Department of Psychiatry, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam and Amsterdam UMC, Amsterdam, The Netherlands,GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands,Simone M Schopman, Department of Psychiatry, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam and Amsterdam UMC, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands.
| | - Margreet ten Have
- Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Anton J van Balkom
- Department of Psychiatry, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam and Amsterdam UMC, Amsterdam, The Netherlands,GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands
| | - Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Neeltje M Batelaan
- Department of Psychiatry, Amsterdam Public Health Institute, Vrije Universiteit Amsterdam and Amsterdam UMC, Amsterdam, The Netherlands,GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands
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Muntingh A, Batelaan N, Scholten W, van Balkom AJ. To continue or discontinue antidepressants in anxiety disorders? A dilemma for patients and clinicians. J Psychiatry Neurosci 2021; 46:E388-E389. [PMID: 34077149 PMCID: PMC8327981 DOI: 10.1503/jpn.200099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Anna Muntingh
- From the Amsterdam UMC, VU University, Psychiatry, Amsterdam Public Health research institute, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom); and the GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom)
| | - Neeltje Batelaan
- From the Amsterdam UMC, VU University, Psychiatry, Amsterdam Public Health research institute, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom); and the GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom)
| | - Willemijn Scholten
- From the Amsterdam UMC, VU University, Psychiatry, Amsterdam Public Health research institute, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom); and the GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom)
| | - Anton J van Balkom
- From the Amsterdam UMC, VU University, Psychiatry, Amsterdam Public Health research institute, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom); and the GGZ inGeest Specialized Mental Health Care, Amsterdam, The Netherlands (Muntingh, Batelaan, Scholten, Van Balkom)
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Hendriks GJ, van Zelst WH, van Balkom AJ, Uphoff E, Robertson L, Keijsers GPJ, Oude Voshaar RC. Cognitive behavioural therapy and third wave approaches for anxiety and related disorders in older people. Hippokratia 2021. [DOI: 10.1002/14651858.cd007674.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gert-Jan Hendriks
- “Overwaal” Centre of Expertise for Anxiety Disorders, OCD and PTSD; Institute for Integrated Mental Health Care “Pro Persona; Nijmegen Netherlands
- Behavioural Science Institute; Radboud University; Nijmegen Netherlands
- Department of Psychiatry; Radboud University Medical Centre; Nijmegen Netherlands
| | - Willeke H van Zelst
- Department of Psychiatry; University Medical Centre Groningen; Groningen Netherlands
| | - Anton J van Balkom
- Department of Psychiatry and EMGO+ Institute; VU-University Medical Centre and GGZ inGeest; Amsterdam Netherlands
| | - Eleonora Uphoff
- Cochrane Common Mental Disorders; University of York; York UK
- Centre for Reviews and Dissemination; University of York; York UK
| | - Lindsay Robertson
- Cochrane Common Mental Disorders; University of York; York UK
- Centre for Reviews and Dissemination; University of York; York UK
| | - Ger PJ Keijsers
- Behavioural Science Institute; Radboud University; Nijmegen Netherlands
- Department of Clinical Psychological Sciences; Maastricht University; Maastricht Netherlands
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Abstract
BACKGROUND Recognition is growing that social anxiety disorder (SAnD) is a chronic and disabling disorder, and data from early trials demonstrate that medication may be effective in its treatment. This systematic review is an update of an earlier review of pharmacotherapy of SAnD. OBJECTIVES To assess the effects of pharmacotherapy for social anxiety disorder in adults and identify which factors (methodological or clinical) predict response to treatment. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR-Studies and CCMDCTR-References) to 17 August 2015. The CCMDCTR contains reports of relevant RCTs from MEDLINE (1950-), Embase (1974-), PsycINFO (1967-) and CENTRAL (all years). We scanned the reference lists of articles for additional studies. We updated the search in August 2017 and placed additional studies in Awaiting Classification, these will be incorporated in the next version of the review, as appropriate. SELECTION CRITERIA We restricted studies to randomised controlled trials (RCTs) of pharmacotherapy versus placebo in the treatment of SAnD in adults. DATA COLLECTION AND ANALYSIS Two authors (TW and JI) assessed trials for eligibility and inclusion for this review update. We extracted descriptive, methodological and outcome information from each trial, contacting investigators for missing information where necessary. We calculated summary statistics for continuous and dichotomous variables (if provided) and undertook subgroup and sensitivity analyses. MAIN RESULTS We included 66 RCTs in the review (> 24 weeks; 11,597 participants; age range 18 to 70 years) and 63 in the meta-analysis. For the primary outcome of treatment response, we found very low-quality evidence of treatment response for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (number of studies (k) = 24, risk ratio (RR) 1.65; 95% confidence interval (CI) 1.48 to 1.85, N = 4984). On this outcome there was also evidence of benefit for monoamine oxidase inhibitors (MAOIs) (k = 4, RR 2.36; 95% CI 1.48 to 3.75, N = 235), reversible inhibitors of monoamine oxidase A (RIMAs) (k = 8, RR 1.83; 95% CI 1.32 to 2.55, N = 1270), and the benzodiazepines (k = 2, RR 4.03; 95% CI 2.45 to 6.65, N = 132), although the evidence was low quality. We also found clinical response for the anticonvulsants with gamma-amino butyric acid (GABA) analogues (k = 3, RR 1.60; 95% CI 1.16 to 2.20, N = 532; moderate-quality evidence). The SSRIs were the only medication proving effective in reducing relapse based on moderate-quality evidence. We assessed tolerability of SSRIs and the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine on the basis of treatment withdrawal; this was higher for medication than placebo (SSRIs: k = 24, RR 2.59; 95% CI 1.97 to 3.39, N = 5131, low-quality evidence; venlafaxine: k = 4, RR 3.23; 95% CI 2.15 to 4.86, N = 1213, moderate-quality evidence), but there were low absolute rates of withdrawal for both these medications classes compared to placebo. We did not find evidence of a benefit for the rest of the medications compared to placebo.For the secondary outcome of SAnD symptom severity, there was benefit for the SSRIs, the SNRI venlafaxine, MAOIs, RIMAs, benzodiazepines, the antipsychotic olanzapine, and the noradrenergic and specific serotonergic antidepressant (NaSSA) atomoxetine in the reduction of SAnD symptoms, but most of the evidence was of very low quality. Treatment with SSRIs and RIMAs was also associated with a reduction in depression symptoms. The SSRIs were the only medication class that demonstrated evidence of reduction in disability across a number of domains.We observed a response to long-term treatment with medication for the SSRIs (low-quality evidence), for the MAOIs (very low-quality evidence) and for the RIMAs (moderate-quality evidence). AUTHORS' CONCLUSIONS We found evidence of treatment efficacy for the SSRIs, but it is based on very low- to moderate-quality evidence. Tolerability of SSRIs was lower than placebo, but absolute withdrawal rates were low.While a small number of trials did report treatment efficacy for benzodiazepines, anticonvulsants, MAOIs, and RIMAs, readers should consider this finding in the context of potential for abuse or unfavourable side effects.
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Affiliation(s)
- Taryn Williams
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Coenie J Hattingh
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Catherine M Kariuki
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Sean A Tromp
- University of Cape TownFaculty of Health Sciences4 Roughmoor Rd, MowbrayCape TownWestern CapeSouth Africa7700
| | - Anton J van Balkom
- VU‐University Medical Centre and GGZ inGeestDepartment of Psychiatry and EMGO+ InstituteA.J. Ernststraat 887AmsterdamNetherlands1081 HL
| | - Jonathan C Ipser
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
| | - Dan J Stein
- University of Cape TownDepartment of Psychiatry and Mental HealthEducation Centre, Valkenberg HospitalPrivate Bage X1, ObservatoryCape TownSouth Africa7925
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Rickelt J, Viechtbauer W, Lieverse R, Overbeek T, van Balkom AJ, van Oppen P, van den Heuvel OA, Marcelis M, Eikelenboom M, Tibi L, Schruers KR. The relation between depressive and obsessive-compulsive symptoms in obsessive-compulsive disorder: Results from a large, naturalistic follow-up study. J Affect Disord 2016; 203:241-247. [PMID: 27310102 DOI: 10.1016/j.jad.2016.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/28/2016] [Accepted: 06/03/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Despite the frequent occurrence of depressive symptoms in obsessive-compulsive disorder (OCD), little is known about the reciprocal influence between depressive and obsessive-compulsive symptoms during the course of the disease. The aim of the present study is to investigate the longitudinal relationship between obsessive-compulsive and depressive symptoms in OCD patients. METHOD We used the baseline and 1-year follow-up data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. In 276 patients with a lifetime diagnosis of obsessive-compulsive disorder, depressive and obsessive-compulsive symptoms were assessed at baseline and at one-year follow-up with the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Symptom (Y-BOCS) scale. Relations were investigated using a cross-lagged panel design. RESULTS The association between the severity of depressive symptoms at baseline and obsessive-compulsive symptoms at follow-up was significant (β=0.244, p<0.001), while the association between the severity of obsessive-compulsive symptoms at baseline and depressive symptoms at follow-up was not (β=0.097, p=0.060). Replication of the analyses in subgroups with and without current comorbid major depressive disorder (MDD) and subgroups with different sequence of onset (primary versus secondary MDD) revealed the same results. LIMITATIONS There may be other factors, which affect both depressive and obsessive-compulsive symptoms that were not assessed in the present study. CONCLUSION The present study demonstrates a relation between depressive symptoms and the course of obsessive-compulsive symptoms in OCD patients, irrespective of a current diagnosis of MDD and the sequence of onset of OCD and MDD.
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Affiliation(s)
- Judith Rickelt
- Department of Psychiatry & Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Institute for Mental Health Care Eindhoven (GGzE), Eindhoven, The Netherlands.
| | - Wolfgang Viechtbauer
- Department of Psychiatry & Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Ritsaert Lieverse
- Department of Psychiatry & Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Mondriaan Mental Health Center, Maastricht, The Netherlands
| | - Thea Overbeek
- Mondriaan Mental Health Center, Maastricht, The Netherlands
| | - Anton J van Balkom
- Department of Psychiatry, VU University Medical Center (Vumc), Amsterdam, The Netherlands; EMGO+, VU University Medical Center (Vumc), Amsterdam, The Netherlands; GGZ inGeest, Amsterdam, The Netherlands
| | - Patricia van Oppen
- Department of Psychiatry, VU University Medical Center (Vumc), Amsterdam, The Netherlands; EMGO+, VU University Medical Center (Vumc), Amsterdam, The Netherlands; GGZ inGeest, Amsterdam, The Netherlands
| | - Odile A van den Heuvel
- Department of Psychiatry, VU University Medical Center (Vumc), Amsterdam, The Netherlands; Department of Anatomy & Neurosciences, VUmc, Neuroscience Campus Amsterdam (NCA), VU/VUmc, Amsterdam, The Netherlands
| | - Machteld Marcelis
- Department of Psychiatry & Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Institute for Mental Health Care Eindhoven (GGzE), Eindhoven, The Netherlands
| | - Merijn Eikelenboom
- Department of Psychiatry, VU University Medical Center (Vumc), Amsterdam, The Netherlands; EMGO+, VU University Medical Center (Vumc), Amsterdam, The Netherlands
| | - Lee Tibi
- Psychology Department, Ben Gurion University, Be'er-Sheva, Israel
| | - Koen Rj Schruers
- Department of Psychiatry & Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, The Netherlands; Mondriaan Mental Health Center, Maastricht, The Netherlands; Department of Health Psychology, University of Leuven, Belgium
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Visser HA, van Megen H, van Oppen P, Eikelenboom M, Hoogendorn AW, Kaarsemaker M, van Balkom AJ. Inference-Based Approach versus Cognitive Behavioral Therapy in the Treatment of Obsessive-Compulsive Disorder with Poor Insight: A 24-Session Randomized Controlled Trial. Psychother Psychosom 2016; 84:284-93. [PMID: 26278470 DOI: 10.1159/000382131] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/07/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Obsessive-compulsive disorder (OCD) with poor insight has severe consequences for patients; nonetheless, no randomized controlled trial has ever been performed to evaluate the effectiveness of any treatment specifically for poor-insight OCD. A new psychotherapy for OCD, the inference-based approach (IBA), targets insight in OCD by strengthening normal sensory-driven reality testing. The goal of the present study is to compare the effectiveness of this new treatment to the effectiveness of cognitive behavior therapy (CBT) for patients with OCD with poor insight. METHOD A randomized controlled trial was conducted, in which 90 patients with OCD with poor insight received either 24 CBT sessions or 24 IBA sessions. The primary outcome measure was the Yale-Brown Obsessive Compulsive Scale (YBOCS). Secondary outcome measures were level of insight, anxiety and depressive symptoms, and quality of life. Mixed-effects models were used to determine the treatment effect. RESULTS In both conditions, a significant OCD symptom reduction was reached, but no condition effects were established. Post hoc, in a small subgroup of patients with the worst insight (n = 23), it was found that the patients treated with the IBA reached a significantly higher OCD symptom reduction than the patients treated with CBT [estimated marginal mean = -7.77, t(219.45) = -2.4, p = 0.017]. CONCLUSION Patients with OCD with poor insight improve significantly after psychological treatment. The results of this study suggest that both CBT and the IBA are effective treatments for OCD with poor insight. The IBA might be more promising than CBT for patients with more extreme poor insight.
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Affiliation(s)
- Henny A Visser
- Innova Research Centre, Mental Health Care Institute GGZ Centraal, Ermelo, The Netherlands
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Visser HA, van Minnen A, van Megen H, Eikelenboom M, Hoogendoorn AW, Kaarsemaker M, van Balkom AJ, van Oppen P. The relationship between adverse childhood experiences and symptom severity, chronicity, and comorbidity in patients with obsessive-compulsive disorder. J Clin Psychiatry 2014; 75:1034-9. [PMID: 25006863 DOI: 10.4088/jcp.13m08825] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Accepted: 01/17/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Studies on the relationship between adverse childhood experiences (ACEs) and obsessive-compulsive disorder (OCD) symptom severity are scarce. Available studies leave a considerable degree of uncertainty. The present study examines the relationship between ACEs and symptom severity, chronicity, and comorbidity in a sample of patients with OCD. METHOD Baseline data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, in which 382 referred patients with DSM-IV-diagnosed OCD participated, were analyzed. ACEs (physical abuse, sexual abuse, witnessing interparental violence, maternal dysfunction, paternal dysfunction, and early separation from a parent) were measured using a structured interview. Data were collected between September 2005 and November 2009. RESULTS None of the ACEs were related to OCD symptom severity or chronicity, nor was there a dose-response relationship between ACEs and OCD severity or chronicity, but results of linear regression analysis revealed that ACEs were related to comorbidity in patients with OCD (P < .001), in particular to comorbid affective disorders (P < .01), substance use disorders (P < .01), and eating disorders (P < .01), but not to comorbid anxiety disorders. CONCLUSIONS Results of the study suggest that unlike in other psychiatric disorders, ACEs play no significant role in symptom severity and chronicity of OCD. This study was the first to reveal evidence for a relationship between ACEs and comorbidity in patients with OCD. Conclusions about trauma-relatedness of OCD based on studies finding higher trauma rates or severity among patients with OCD than among healthy controls, should be critically reconsidered, since presence of comorbidity might account for these differences.
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Affiliation(s)
- Henny A Visser
- GGZ Centraal, lokatie Veldwijk, Afdeling Marina de Wolf Centrum, Postbus 1000, 3853 BA, Ermelo, the Netherlands
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Batelaan NM, Rhebergen D, Spinhoven P, van Balkom AJ, Penninx BWJH. Two-year course trajectories of anxiety disorders: do DSM classifications matter? J Clin Psychiatry 2014; 75:985-93. [PMID: 24912140 DOI: 10.4088/jcp.13m08837] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Anxiety disorders have been shown to differ in their course, but it is unknown whether DSM-categories represent clinically relevant course trajectories. We aim to identify anxiety course trajectories using a data-driven method and to examine whether these course trajectories correspond to DSM-categories or whether other clinical indicators better differentiate them. METHOD 907 patients with panic disorder with agoraphobia, panic disorder without agoraphobia , agoraphobia, social phobia, or generalized anxiety disorder according to DSM-IV criteria were derived from a prospective cohort study (Netherlands Study of Depression and Anxiety). Baseline data were collected between September 2004 and February 2007; follow-up data, between October 2006 and March 2009. Latent class growth analysis was conducted, based on symptoms of anxiety and avoidance assessed with the Life Chart Interview covering a 2-year time period. Identified course trajectories were compared with DSM-IV diagnoses and a wider set of predictors. RESULTS We identified a class with minimal symptoms over time (41.7%), a moderately severe chronic class (42.8%), and a severe chronic class (15.4%). Panic disorder with agoraphobia (OR = 2.14; 95% CI, 1.48-3.09) and social phobia (OR = 1.97; 95% CI, 1.46-2.68) predicted moderately severe chronicity; panic disorder with agoraphobia (OR = 2.70; 95% CI, 1.66-4.40), social phobia (OR = 2.46; 95% CI, 1.62-3.74), and generalized anxiety disorder (OR = 1.86; 95% CI, 1.23-2.82) predicted a severe chronic course. However, baseline severity, duration of anxiety, and disability better predicted severe chronic course trajectories than DSM-categories. Additionally, partner status, age at onset, childhood trauma, and comorbid depressive disorder predicted chronic courses. CONCLUSIONS Course of anxiety was pleomorphic with over 40% having a favorable course, thereby questioning the common notion of chronicity of anxiety disorders. Severity, duration of anxiety, and disability were able to better identify severe chronic course trajectories as compared with DSM-IV categories. These findings facilitate the identification of chronic course trajectories of anxiety disorders in clinical care and support current debates on staging and profiling of mental disorders.
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Affiliation(s)
- Neeltje M Batelaan
- Department of Psychiatry, VU University Medical Center Amsterdam and GGZ inGeest, AJ Ernststraat 1187, 1081 HL Amsterdam, The Netherlands
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Thomaes K, Dorrepaal E, Draijer N, Jansma EP, Veltman DJ, van Balkom AJ. Can pharmacological and psychological treatment change brain structure and function in PTSD? A systematic review. J Psychiatr Res 2014; 50:1-15. [PMID: 24321592 DOI: 10.1016/j.jpsychires.2013.11.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 11/18/2022]
Abstract
While there is evidence of clinical improvement of posttraumatic stress disorder (PTSD) with treatment, its neural underpinnings are insufficiently clear. Moreover, it is unknown whether similar neurophysiological changes occur in PTSD specifically after child abuse, given its enduring nature and the developmental vulnerability of the brain during childhood. We systematically reviewed PTSD treatment effect studies on structural and functional brain changes from PubMed, EMBASE, PsycINFO, PILOTS and the Cochrane Library. We included studies on adults with (partial) PTSD in Randomized Controlled Trials (RCT) or pre-post designs (excluding case studies) on pharmacotherapy and psychotherapy. Risk of bias was evaluated independently by two raters. Brain coordinates and effect sizes were standardized for comparability. We included 15 studies (6 RCTs, 9 pre-post), four of which were on child abuse. Results showed that pharmacotherapy improved structural abnormalities (i.e., increased hippocampus volume) in both adult-trauma and child abuse related PTSD (3 pre-post studies). Functional changes were found to distinguish between groups. Adult-trauma PTSD patients showed decreased amygdala and increased dorsolateral prefrontal activations post-treatment (4 RCTs, 5 pre-post studies). In one RCT, child abuse patients showed no changes in the amygdala, but decreased dorsolateral prefrontal, dorsal anterior cingulate and insula activation post-treatment. In conclusion, pharmacotherapy may reduce structural abnormalities in PTSD, while psychotherapy may decrease amygdala activity and increase prefrontal, dorsal anterior cingulate and hippocampus activations, that may relate to extinction learning and re-appraisal. There is some evidence for a distinct activation pattern in child abuse patients, which clearly awaits further empirical testing.
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Affiliation(s)
- Kathleen Thomaes
- GGZ InGeest/Dept. of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; Neuroscience Campus, Amsterdam, The Netherlands.
| | - Ethy Dorrepaal
- GGZ InGeest/Dept. of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; EMGO Institute, VUmc, Amsterdam, The Netherlands; PsyQ, Parnassia Bavo Group, Den Haag, The Netherlands
| | - Nel Draijer
- GGZ InGeest/Dept. of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; EMGO Institute, VUmc, Amsterdam, The Netherlands
| | | | - Dick J Veltman
- GGZ InGeest/Dept. of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; Neuroscience Campus, Amsterdam, The Netherlands; AMC Academic Psychiatric Center, AIAR, Amsterdam, The Netherlands
| | - Anton J van Balkom
- GGZ InGeest/Dept. of Psychiatry, VU University Medical Center (VUmc), Amsterdam, The Netherlands; EMGO Institute, VUmc, Amsterdam, The Netherlands
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Visser HA, van Oppen P, van Megen HJ, Eikelenboom M, van Balkom AJ. Obsessive-compulsive disorder; chronic versus non-chronic symptoms. J Affect Disord 2014; 152-154:169-74. [PMID: 24084621 DOI: 10.1016/j.jad.2013.09.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 09/05/2013] [Accepted: 09/05/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Understanding chronicity in OCD is hampered by contradictory findings arising from dissimilar definitions of chronic OCD. The purpose of this study was to investigate the magnitude of chronicity in OCD and to examine if chronic OCD is critically different from non-chronic OCD, using a chronicity definition that reflects empirical findings. METHOD Baseline data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, in which 379 OCD patients participated, were analyzed. Chronic OCD was defined as "continuous presence of at least moderately severe OCD symptoms during at least two years", and was assessed retrospectively using a Life-Chart Interview. RESULTS Application of the chronicity criterion resulted in two groups with highly distinguishable course patterns. The majority of the sample (61.7%) reported a chronic course. Patients with a chronic course reported significantly more severe OCD symptoms, more illness burden, more comorbidity, an earlier OCD onset and more contamination and washing - and symmetry and ordering symptoms. Multivariable logistic regression analysis revealed that chronic OCD was independently associated with more OCD-subtypes (p<0.001), contamination and washing symptoms (p<0.001), earlier OCD onset (p=0.05) and higher severity of compulsions (p<.01). LIMITATIONS The findings are based on a cross-sectional survey. Furthermore course was assessed retrospectively, implying the possibility of overestimation of persistence and severity of symptoms. CONCLUSION Chronicity is the rule rather than the exception in OCD in clinical samples. Chronic OCD is critically different from non-chronic OCD. Further attempts to break down the heterogeneity of OCD in homogeneous course subtypes should be made to allow for a more precise determination of the pathogenesis of OCD and better treatment.
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Affiliation(s)
- Henny A Visser
- Innova Research Centre, Mental Health Care Institute GGZ Centraal, Ermelo, The Netherlands.
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Hofmeijer-Sevink MK, van Oppen P, van Megen HJ, Batelaan NM, Cath DC, van der Wee NJA, van den Hout MA, van Balkom AJ. Clinical relevance of comorbidity in obsessive compulsive disorder: the Netherlands OCD Association study. J Affect Disord 2013; 150:847-54. [PMID: 23597943 DOI: 10.1016/j.jad.2013.03.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 03/18/2013] [Accepted: 03/18/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study describes lifetime and current rates of comorbidity, its onset and its consequences in a large clinical sample of patients with obsessive compulsive disorder (OCD). A wide range of risk factors and clinical characteristics were also examined to determine whether pure OCD is different from OCD with current comorbidity. Finally, the temporal sequencing of the disorders was examined. METHOD Data were obtained from the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. A sample of 382 participants with current OCD (during the past month) was evaluated. RESULTS Current comorbidity occurred in 55% of patients with OCD, while 78% suffered from lifetime comorbidity. Comorbidity is associated with more severe OCD, anxiety and depressive symptoms and more negative consequences on daily life. Multiple comorbid disorders often precede OCD and influence both its course and severity. Childhood trauma and neuroticism are vulnerability factors for the development of multiple comorbid disorders in OCD. LIMITATIONS It should be noted that causal inferences about the association between risk factors and OCD are precluded since our results were based on cross-sectional data. CONCLUSION (Multiple) comorbidity in OCD is clinically relevant since it is associated with a specific pattern of vulnerability, with greater chronicity, with more severe OCD and more negative consequences on daily life. This indicates that the diagnosis and treatment of all comorbid disorders is clinically relevant, and clinicians should be especially aware of multiple disorders in cases of childhood trauma and high levels of neuroticism. Primary OCD has a different developmental and comorbidity pattern compared to secondary OCD.
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Thomaes K, Dorrepaal E, Draijer N, de Ruiter MB, Elzinga BM, Sjoerds Z, van Balkom AJ, Smit JH, Veltman DJ. Increased anterior cingulate cortex and hippocampus activation in Complex PTSD during encoding of negative words. Soc Cogn Affect Neurosci 2013; 8:190-200. [PMID: 22156722 PMCID: PMC3575721 DOI: 10.1093/scan/nsr084] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 11/01/2011] [Indexed: 12/15/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) is associated with impaired memory performance coupled with functional changes in brain areas involved in declarative memory and emotion regulation. It is not yet clear how symptom severity and comorbidity affect neurocognitive functioning in PTSD. We performed a functional magnetic resonance imaging (fMRI) study with an emotional declarative memory task in 28 Complex PTSD patients with comorbid depressive and personality disorders, and 21 healthy non-trauma-exposed controls. In Complex PTSD patients--compared to controls--encoding of later remembered negative words vs baseline was associated with increased blood oxygenation level dependent (BOLD) response in the left ventral anterior cingulate cortex (ACC) and dorsal ACC extending to the dorsomedial prefrontal cortex (dmPFC) together with a trend for increased left hippocampus activation. Patients tended to commit more False Alarms to negative words compared to controls, which was associated with enhanced left ventrolateral prefrontal and orbitofrontal cortex (vlPFC/OFC) responses. Severity of child abuse was positively correlated with left ventral ACC activity and severity of depression with (para) hippocampal and ventral ACC activity. Presented results demonstrate functional abnormalities in Complex PTSD in the frontolimbic brain circuit also implicated in fear conditioning models, but generally in the opposite direction, which may be explained by severity of the trauma and severity of comorbid depression in Complex PTSD.
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Affiliation(s)
- Kathleen Thomaes
- Department of Psychiatry, GGZ InGeest/VU University Medical Center, Amsterdam, The Netherlands.
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Thomaes K, Dorrepaal E, Draijer N, de Ruiter MB, van Balkom AJ, Smit JH, Veltman DJ. Reduced anterior cingulate and orbitofrontal volumes in child abuse-related complex PTSD. J Clin Psychiatry 2010; 71:1636-44. [PMID: 20673548 DOI: 10.4088/jcp.08m04754blu] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 07/07/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Classic posttraumatic stress disorder (PTSD) is associated with smaller hippocampus, amygdala, and anterior cingulate cortex (ACC) volumes. We investigated whether child abuse-related complex PTSD--a severe form of PTSD with affect dysregulation and high comorbidity--showed similar brain volume reductions. METHOD We used voxel-based morphometry to measure gray matter concentrations in referred outpatients with child abuse-related complex PTSD (n = 31) compared to matched healthy nontraumatized controls (n = 28). Complex PTSD was diagnosed using the Structured Clinical Interview for DSM-IV-TR and the Structured Clinical Interview for Disorders of Extreme Stress. All respondents were scanned on a 1.5-T magnetic resonance system at the VU Medical Center, Amsterdam, The Netherlands, between September 2005 and February 2006. RESULTS As was hypothesized, patients with child abuse-related complex PTSD showed reductions in gray matter concentration in right hippocampus (P(SVC corrected) = .04) and right dorsal ACC (P(SVC corrected) = .02) compared to controls. In addition, a reduction in gray matter concentration in the right orbitofrontal cortex (OFC) was found. Severity of child abuse and PTSD-hyperarousal correlated negatively with ACC volume. Impulsivity correlated negatively with hippocampus volume, and anger, with hippocampus and OFC volume. Comorbidity of borderline personality disorder--compared to comorbid cluster C personality disorder--accounted for more extensive reductions in the ACC and OFC volume. CONCLUSIONS In complex PTSD, not only the hippocampus and the ACC but also the OFC seem to be affected, even in the absence of comorbid borderline personality disorder. These results suggest that neural correlates of complex PTSD are more severe than those of classic PTSD.
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Affiliation(s)
- Kathleen Thomaes
- GGZ Ingeest, Department of Psychiatry, VU University Medical Center, A J Ernststraat 887, 1081 HL Amsterdam, The Netherlands.
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Thomaes K, Dorrepaal E, Draijer NPJ, de Ruiter MB, Elzinga BM, van Balkom AJ, Smoor PLM, Smit J, Veltman DJ. Increased activation of the left hippocampus region in Complex PTSD during encoding and recognition of emotional words: a pilot study. Psychiatry Res 2009; 171:44-53. [PMID: 19081708 DOI: 10.1016/j.pscychresns.2008.03.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 12/20/2007] [Accepted: 03/04/2008] [Indexed: 12/20/2022]
Abstract
To gain insight into memory disturbances in Complex Posttraumatic Stress Disorder (Complex PTSD), we investigated declarative memory function and medial temporal lobe activity in patients and healthy non-traumatized controls. A case-control study was performed in nine patients with Complex PTSD and nine controls. All respondents performed a declarative memory task with neutral and emotional, negative words during functional magnetic resonance imaging. Memory performance of neutral words was impaired in Complex PTSD with a relative conservation of recall of negative words. Deep encoding of later remembered negative words, as well as correct recognition of negative words and false alarms, was associated with an enhanced Blood Oxygenation Level Dependent (BOLD) response in the left hippocampus extending into the parahippocampal gyrus of Complex PTSD patients compared with controls. Post-hoc volumetric comparisons did not reveal significant anatomical differences in the medial temporal lobe between Complex PTSD patients and controls. We conclude that in Complex PTSD preferential recall of negative words is associated with increased activation in the left hippocampus and parahippocampal gyrus during both successful and false recall. These findings support a model of an abnormally functioning hippocampus in Complex PTSD.
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Affiliation(s)
- Richard C Oude Voshaar
- University Medical Centre Groningen; Department of Psychiatry; Hanzeplein 1 PO Box 30.001 Groningen Netherlands 9700 RB
| | - G J Hendriks
- Forum GGZ Nijmegen; Department of Anxiety Disorders 'Overwaal'; PO Box 7049 GM Nijmegen Netherlands 6503
| | - G Keijsers
- Radboud University Nijmegen; Department of Clinical Psychology; PO Box 9104 HE Nijmegen Netherlands 6500
| | - Anton J van Balkom
- VU-University Medical Centre VU-MC/GGZ inGeest; Department of Psychiatry and Institute for Research in Extramural Medicine; A.J. Ernststraat 887 Amsterdam Netherlands 1081 HL
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Voshaar RCO, Gorgels WJ, Mol AJ, van Balkom AJ, Mulder J, van de Lisdonk EH, Breteler MH, Zitman FG. Predictors of long-term benzodiazepine abstinence in participants of a randomized controlled benzodiazepine withdrawal program. Can J Psychiatry 2006; 51:445-52. [PMID: 16838826 DOI: 10.1177/070674370605100706] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify predictors of resumed benzodiazepine use after participation in a benzodiazepine discontinuation trial. METHOD We performed multiple Cox regression analyses to predict the long-term outcome of a 3-condition, randomized, controlled benzodiazepine discontinuation trial in general practice. RESULTS Of 180 patients, we completed follow-up for 170 (94%). Of these, 50 (29%) achieved long-term success, defined as no use of benzodiazepines during follow-up. Independent predictors of success were as follows: offering a taper-off program with group therapy (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.5 to 3.9) or without group therapy (HR 2.9; 95% CI, 1.8 to 4.8); a lower daily benzodiazepine dosage at the start of tapering off (HR 1.5; 95% CI, 1.2 to 1.9); a substantial dosage reduction by patients themselves just before the start of tapering off (HR 2.1; 95% CI, 1.4 to 3.3); less severe benzodiazepine dependence, as measured by the Benzodiazepine Dependence Self-Report Questionnaire Lack of Compliance subscale (HR 2.4; 95%CI, 1.1 to 5.2); and no use of alcohol (HR 1.7; 95% CI, 1.2 to 2.5). Patients who used over 10 mg of diazepam equivalent, who had a score of 3 or more on the Lack of Compliance subscale, or who drank more than 2 units of alcohol daily failed to achieve long-term abstinence. CONCLUSIONS Benzodiazepine dependence severity affects long-term taper outcome independent of treatment modality, benzodiazepine dosage, psychopathology, and personality characteristics. An identifiable subgroup needs referral to specialized care.
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