Does the STIC measurement and feedback system improve multisystemic outcomes in individual, couple and family therapy? A randomized clinical trial

OBJECTIVE

In a randomized clinical trial, we evaluated whether the STIC (Systemic Therapy Inventory of Change) measurement and feedback system (MFS), the first MFS to explicitly integrate the family systems perspective, improved outcomes in individual, couple and family therapy.

METHOD

Nine hundred and seventy clients seeking individual, couple or family therapy, entered therapy with 93 therapists at four sites in the Chicago metropolitan area. All therapists were trained with the STIC and participated in both Treatment as Usual (TAU) and TAU with the STIC (STIC). After agreeing to participate, clients were randomly assigned to TAU or STIC. Therapists did not know the condition to which a case was assigned, until just prior to the first session. Therapy was not time-limited or constrained, except for the use of the STIC in the STIC condition. All clients were evaluated on a non-STIC multi-systemic battery of widely used outcome measures pre-and-post therapy.

RESULTS

STIC clients improved more than TAU clients regardless of treatment modality or outcome measure. Clinically significant change was also greater for STIC than TAU clients across outcome measures.

CONCLUSION

The STIC MFS holds promise for improving outcomes beyond TAU in individual, couple, and family therapy.

Insights from personalized models of brain and behavior for identifying biomarkers in psychiatry

A main goal in translational neuroscience is to identify neural correlates of psychopathology ("biomarkers") that can be used to facilitate diagnosis, prognosis, and treatment. This goal has led to substantial research into how psychopathology symptoms relate to large-scale brain systems. However, these efforts have not yet resulted in practical biomarkers used in clinical practice. One reason for this underwhelming progress may be that many study designs focus on increasing sample size instead of collecting additional data within each individual. This focus limits the reliability and predictive validity of brain and behavioral measures in any one person. As biomarkers exist at the level of individuals, an increased focus on validating them within individuals is warranted. We argue that personalized models, estimated from extensive data collection within individuals, can address these concerns. We review evidence from two, thus far separate, lines of research on personalized models of (1) psychopathology symptoms and (2) fMRI measures of brain networks. We close by proposing approaches uniting personalized models across both domains to improve biomarker research.

Association between reward-related functional connectivity and tri-level mood and anxiety symptoms

Depression and anxiety are associated with abnormalities in brain regions that process rewards including the medial orbitofrontal cortex (mOFC), the ventral striatum (VS), and the amygdala. However, there are inconsistencies in these findings. This may be due to past reliance on categorical diagnoses that, while valuable, provide less precision than may be required to understand subtle neural changes associated with symptoms of depression and anxiety. In contrast, the tri-level model defines symptom dimensions that are common (General Distress) or relatively specific (Anhedonia-Apprehension, Fears) to depression and anxiety related disorders, which provide increased precision. In the current study, eligibility was assessed by quasi-orthogonal screening questionnaires measuring reward and threat sensitivity (Behavioral Activation Scale; Eysenck Personality Questionnaire-Neuroticism). These participants were assessed on tri-level symptom severity and completed the Monetary Incentive Delay task during fMRI scanning. VS-mOFC and VS-amygdala connectivity were estimated during reward anticipation and reward outcome. Heightened General Distress was associated with lower VS-mOFC connectivity during reward anticipation (b = -0.064, p = 0.021) and reward outcome (b = -0.102, p = 0.014). Heightened Anhedonia-Apprehension was associated with greater VS-amygdala connectivity during reward anticipation (b = 0.065, p = 0.004). The present work has important implications for understanding the coupling between the mOFC and vS and the amygdala and the vS during reward processing in the pathophysiology of mood and anxiety symptoms and for developing targeted behavioral, pharmacological, and neuromodulatory interventions to help manage these symptoms.

Comparing a Computerized Digit Symbol Test to a Pen-and-Paper Classic

Background and Hypothesis

Processing speed dysfunction is a core feature of psychosis and predictive of conversion in individuals at clinical high risk (CHR) for psychosis. Although traditionally measured with pen-and-paper tasks, computerized digit symbol tasks are needed to meet the increasing demand for remote assessments. Therefore we: (1) assessed the relationship between traditional and computerized processing speed measurements; (2) compared effect sizes of impairment for progressive and persistent subgroups of CHR individuals on these tasks; and (3) explored causes contributing to task performance differences.

Study Design

Participants included 92 CHR individuals and 60 healthy controls who completed clinical interviews, the Brief Assessment of Cognition in Schizophrenia Symbol Coding test, the computerized TestMyBrain Digit Symbol Matching Test, a finger-tapping task, and a self-reported motor abilities measure. Correlations, Hedges' g, and linear models were utilized, respectively, to achieve the above aims.

Study Results

Task performance was strongly correlated (r = 0.505). A similar degree of impairment was seen between progressive (g = -0.541) and persistent (g = -0.417) groups on the paper version. The computerized task uniquely identified impairment for progressive individuals (g = -477), as the persistent group performed similarly to controls (g = -0.184). Motor abilities were related to the computerized version, but the paper version was more related to symptoms and psychosis risk level.

Conclusions

The paper symbol coding task measures impairment throughout the CHR state, while the computerized version only identifies impairment in those with worsening symptomatology. These results may be reflective of sensitivity differences, an artifact of existing subgroups, or evidence of mechanistic differences.

Worry and Positive Episodes in the Daily Lives of Individuals With Generalized Anxiety Disorder: An Ecological Momentary Assessment Study

Worry is a central feature of generalized anxiety disorder (GAD). Although worry is related to anxiety and maintained by beliefs that worry is uncontrollable, there is scarce research on how individuals with GAD react to worry episodes in their daily life and how their positive experiences might impact reactions to worry episodes. The current study examined the level and variability of anxiety and controllability during high worry periods and positive experiences in GAD. Moreover, it investigated the influence of worry and positive experiences on later anxiety and perceived controllability within-persons. Finally, it examined change in anxiety level from previous to current episodes depending on previous episodes type. In the current study, 49 individuals with GAD (514 observations) registered their worry and positive episodes (i.e., episodes in which they had positive experiences) and reported on several variables during these episodes (i.e., anxiety and controllability of episodes and episode duration) using smartphone-based ecological momentary assessment for 7days. Results show anxiety and controllability differed by episode type (higher anxiety, lower controllability in worry episodes, and the opposite in positive episodes), and notable within-person variability in anxiety and controllability in both episode types. The time-lagged multilevel models showed episode type did not predict later anxiety during either episode type, although previous anxiety predicted current anxiety in worry episodes (but not positive episodes). Moreover, worry episodes did predict later controllability in worry episodes (but not positive episodes) and previous controllability predicted current controllability in both episode types. Furthermore, we obtained the increase in anxiety from t₀₋₁ to t₀ in a current worry episode to be significantly smaller when preceded by a worry (vs. positive) episode. Likewise, the reduction in anxiety from t₀₋₁ to t₀ in a current positive episode was significantly larger when preceded by a worry (vs. positive) episode. The novel findings in the current study that perceptions of controllability and anxiety vary within individuals with GAD, that greater controllability is experienced in positive episodes than worry episodes, and that worry may confer a sense of controllability at a later time could be seen as important contributions to the GAD literature.

Rumination and worry as putative mediators explaining the association between emotional disorders and alcohol use disorder in a longitudinal study

INTRODUCTION

The high rate of comorbidity between alcohol use and emotional disorders is well demonstrated, but the mechanisms underlying their relationship remain largely unidentified. One possibility is maladaptive responding to negative affect, such as worry and rumination. The present study sought to examine worry and rumination as putative mediators explaining the link between emotional disorders and alcohol use disorders. Methods Mediational analyses were conducted using a sample (n = 232) derived from a larger late adolescence/early adulthood longitudinal dataset (Youth Emotion Project; Zinbarg et al., 2010). Results A significant indirect effect was observed for emotional disorder severity on alcohol use disorder severity via rumination, but not via worry or the shared variance between worry and rumination. Conclusions These findings suggest that rumination may specifically confer risk for the development of alcohol use disorder for individuals with emotional disorders. Further, ruminative thinking may serve as a specific treatment target to reduce vulnerability to alcohol use disorder.

Computerized Assessment of Psychosis Risk

Early detection and intervention with young people at clinical high risk (CHR) for psychosis is critical for prevention efforts focused on altering the trajectory of psychosis. Early CHR research largely focused on validating clinical interviews for detecting at-risk individuals; however, this approach has limitations related to: (1) specificity (i.e., only 20% of CHR individuals convert to psychosis) and (2) the expertise and training needed to administer these interviews is limited. The purpose of our study is to develop the computerized assessment of psychosis risk (CAPR) battery, consisting of behavioral tasks that require minimal training to administer, can be administered online, and are tied to the neurobiological systems and computational mechanisms implicated in psychosis. The aims of our study are as follows: (1A) to develop a psychosis-risk calculator through the application of machine learning (ML) methods to the measures from the CAPR battery, (1B) evaluate group differences on the risk calculator score and test the hypothesis that the risk calculator score of the CHR group will differ from help-seeking and healthy controls, (1C) evaluate how baseline CAPR battery performance relates to symptomatic outcome two years later (i.e., conversion and symptomatic worsening). These aims will be explored in 500 CHR participants, 500 help-seeking individuals, and 500 healthy controls across the study sites. This project will provide a next-generation CHR battery, tied to illness mechanisms and powered by cutting-edge computational methods that can be used to facilitate the earliest possible detection of psychosis risk.

Reciprocal effects of neuroticism and life stress in adolescence

BACKGROUND

Stressful life experiences and personality can influence one another. Personality may contribute to the amount and type of stress individuals experience, which is referred to as a selection effect. Life stress may also impact one's personality, which is referred to as a socialization effect. It was hypothesized that neuroticism would predict increased chronic and episodic stress (selection effect) and that chronic and episodic stress would predict increased neuroticism (socialization effect).

METHODS

The current study investigated selection and socialization effects of neuroticism and life stress over a three-year period in 627 adolescents. Life stress data were examined in terms of duration (chronic versus episodic) and type (interpersonal versus non-interpersonal). Episodic stress data were examined as dependent or independent.

RESULTS

The results from ten cross-lagged panel models provided some evidence for significant selection and socialization effects depending on stress type. Over three years, we observed that neuroticism increases interpersonal chronic stress and non-interpersonal stressful events (selection effects) and that dependent non-interpersonal stressful events and chronic stress increase neuroticism (socialization effects).

LIMITATIONS

Study limitations include a lack of a lifespan perspective and a statistical approach that does not differentiate between- from within-person variance.

CONCLUSIONS

Findings suggest the value of attending to stress response as well as targeting neuroticism in prevention and intervention approaches in adolescents.

Extraversion and interpersonal support as risk, resource, and protective factors in the prediction of unipolar mood and anxiety disorders

Whereas there is extensive research on factors that contribute to vulnerability for depression and anxiety, research on how to promote mental health or offset risk effects in individuals likely to develop these disorders is lacking. Resilience models focus on risk, resource, and protective factors and their relationships. The current longitudinal study evaluated whether extraversion and interpersonal support functioned in resource or protective roles in relation to unipolar mood disorder (UMD), anxiety disorder (AD), and comorbid diagnoses. Data from 534 adolescents over a 3-year period were examined in a series of survival analyses to predict future disorder onset. The linear effect of extraversion significantly interacted with neuroticism predicting UMD diagnoses with extraversion conferring protection and introversion conferring risk at high levels of neuroticism. The quadratic effect of extraversion significantly interacted with neuroticism predicting AD and comorbid diagnoses such that extraversion escalated risk for diagnoses at high levels of neuroticism. The quadratic effect of extraversion was significant in comorbidity models, demonstrating increased risk as one progresses from slight extraversion to extreme introversion, independent of neuroticism. Interpersonal support significantly predicted UMD, AD, and comorbid diagnoses in an approximately linear fashion. Specificity tests indicated that these effects remained when including the other diagnosis in each model. Findings suggest the value of attending to extraverted traits and encouraging social connection regardless of risk status in prevention and treatment approaches. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Reliability of BOLD signals in chronic stroke-induced aphasia

Investigating the neurobiology of language impairment and treatment in chronic stroke aphasia using fMRI requires an understanding of measurement variability within and between participants. In this multicenter study, we evaluated the scan-rescan reliability of an auditory and visual (written) story comprehension paradigm in stroke participants with aphasia (N = 65) and healthy controls (N = 22). The multi-modal task was conducted twice (~1 week apart) on separate visits upon study enrolment and twice again at completion three months later. A non-language visuomotor task was studied in the aphasia group only, which was conducted once per time point (3 months apart). While participants were asked to make responses during the comprehension task, these in-scanner responses were not recorded. Reliability was assessed using intraclass correlation coefficient (ICC) at both group and individual participant levels. The visual story comprehension condition had higher reliability than the auditory condition in both groups, with participants with aphasia exhibiting lower reliability than controls in both conditions (stroke ICC = .43, healthy ICC = .81). Differences in reliability within the group of participants with aphasia were found to be partially explained by overall language impairment as well as greater head motion. In the participants with aphasia, the visuomotor paradigm was found to have greater reliability than the story comprehension task at equivalent interscan intervals (visuomotor = 0.50, comprehension = 0.34), and its reliability was not associated with language impairment. This work highlights the importance of considering the reliability of fMRI tasks in aphasia research, provides strategies to improve reliability and has potential implications for the field of clinical neuroimaging in general.

Factor Analysis of Negative Symptom Items in the Structured Interview for Prodromal Syndromes

BACKGROUND

Negative symptoms occur early in the clinical high risk (CHR) state and indicate increased risk of conversion to psychotic disorder and poor functional outcome. However, while the negative symptom domain has shown to be parsimoniously explained by a 2-factor construct in schizophrenia, there has yet to be an established factor structure of negative symptoms in CHR.

METHODS

214 individuals meeting the Structured Interview for Psychosis-Risk Syndromes (SIPS) criteria for CHR were recruited through 3 active research programs in the United States. Exploratory Factor Analysis was conducted on the 6 negative symptom items of the SIPS, and factors were evaluated with respect to functional outcome and depression.

RESULTS

Factor analysis indicated a 2-factor hierarchical model with 2 negative symptom dimensions reflecting volition (Occupational Functioning and Avolition) and emotion (Expression of Emotion, Experience of Emotion and Social Anhedonia). Linear Regression showed that the emotion factor was associated with poor social function, and the volition factor was associated with poor role function and depression.

CONCLUSIONS

Similar to factor solutions identified in adults diagnosed with psychotic disorders, results indicated that the SIPS negative symptom subscale is not a unidimensional construct. Rather, the SIPS negative subscale has 2 distinct factors that have different associations with clinical outcome and should be interpreted independently. Results have significant relevance for informing the valid assessment and conceptual interpretation of early clinical phenomenology in the psychosis prodrome.

Reduced autobiographical memory specificity affects general distress through poor social support

Sharing specific autobiographical events is likely to influence the support people give us; a person who shares little detail of their lives may be unlikely to attract social support and this may in turn contribute towards anxious and depressive symptoms. Participants (N = 142) reported memories evoked by negative and positive cue words and these memories were coded for whether or not they referred to a specific event lasting less than 24 h. At this time (T1) and one year later (T2), participants also completed the UCLA Life Stress Interview (LSI), which includes a measure of social support, and measures of depression and anxiety comprising a general distress latent construct. The tendency to recall fewer specific memories was associated with lower social support given by friends and romantic partners and this was in turn associated with elevated general distress at T2, even when accounting for T1 social support and general distress. Our findings contribute to the literature regarding the social function of memory and suggest another route via which reduced specificity contributes to emotional disorders.

Emotional content impacts how executive function ability relates to willingness to wait and to work for reward

Research has demonstrated that better value-based decision making (e.g., waiting or working for rewards) relates to greater executive function (EF) ability. However, EF is not a static ability, but is influenced by the emotional content of the task. As such, EF ability in emotional contexts may have unique associations with value-based decision making, in which costs and benefits are explicit. Participants (N = 229) completed an EF task (with both negative and neutral task conditions) and two value-based decision-making tasks. Willingness to wait and to work were evaluated in separate path models relating the waiting and working conditions to the EF conditions. Willingness to wait and willingness to work showed distinct relationships with EF ability: Greater EF ability on a negative, but not on a neutral, EF task was related to a willingness to wait for a reward, whereas greater EF ability across both EF tasks was related to a greater willingness to work for a reward. EF ability on a negative EF task showed an inverted-U relationship to willingness to wait for reward, and was most related to willingness to wait at a 6-month delay. Greater EF, regardless of whether the task was negative or neutral, was related to a greater willingness to work when reward was uncertain (50%) or was likely (88%), but not when reward was unlikely (12%). This study suggests that the emotional content of value-based decisions impacts the relationship between EF ability and willingness to wait or to work for reward.

Are Older Adults Unique? Examining Presenting Issues and Changes in Therapy Across the Life Span

With the urgent need to increase and improve mental health care of the growing population of older adults in the United States, clinical research is warranted to further the knowledge and improve the relevant training for mental health professionals working with older adults. This study drew from two diverse clinical samples of adults ages 18 years to 80 years to examine whether and how initial clinical presentations and changes over time in individual, family-of-origin, and relational measures differed across the life span. Results indicated a variety of linear and curvilinear associations between individual, family-of-origin, and relational measures at intake and age, with some moderation by gender. There were no significant results between the amount of change on those measures and age, indicating that older adults may change in similar fashion to middle-aged and younger adults in psychotherapy. Relevant clinical implications are provided.

Intrahemispheric Perfusion in Chronic Stroke-Induced Aphasia

Stroke-induced alterations in cerebral blood flow (perfusion) may contribute to functional language impairments and recovery in chronic aphasia. Using MRI, we examined perfusion in the right and left hemispheres of 35 aphasic and 16 healthy control participants. Across 76 regions (38 per hemisphere), no significant between-subjects differences were found in the left, whereas blood flow in the right was increased in the aphasic compared to the control participants. Region-of-interest (ROI) analyses showed a varied pattern of hypo- and hyperperfused regions across hemispheres in the aphasic participants; however, there were no significant correlations between perfusion values and language abilities in these regions. These patterns may reflect autoregulatory changes in blood flow following stroke and/or increases in general cognitive effort, rather than maladaptive language processing. We also examined blood flow in perilesional tissue, finding the greatest hypoperfusion close to the lesion (within 0-6 mm), with greater hypoperfusion in this region compared to more distal regions. In addition, hypoperfusion in this region was significantly correlated with language impairment. These findings underscore the need to consider cerebral perfusion as a factor contributing to language deficits in chronic aphasia as well as recovery of language function.

The Effects of Childhood and Adolescent Adversity on Substance Use Disorders and Poor Health in Early Adulthood

Childhood and adolescent adversity have been shown to predict later mental and physical health outcomes. Understanding which aspects and developmental timings of adversity are important, and the mechanisms by which they have their impact may help guide intervention approaches. A large subset of adolescents (N = 457; Female 68.9 %) from the 10-year longitudinal Youth Emotion Project was examined to better understand the associations among childhood/adolescent adversity, substance use disorder, and later health quality. Adolescent (but not childhood) adversities were associated with poorer health in late adolescence/early adulthood, adolescent adversities were associated with subsequent onset of substance use disorder, and adolescent adversities continued to be associated with poorer health in late adolescence/early adulthood after accounting for the variance explained by substance use disorder onset. These associations were observed after statistically accounting for emotional disorders and socioeconomic status. Specific domains of adversity uniquely predicted substance use disorder and poorer health outcomes. In contrast with current recent research, our findings suggest the association between childhood/adolescent adversity and poorer health outcomes in late adolescence and emerging adulthood are not entirely accounted for by substance use disorder, suggesting efforts to curtail family-based adolescent adversity may have downstream health benefits.

Experiencing core symptoms of anxiety and unipolar mood disorders in late adolescence predicts disorder onset in early adulthood

BACKGROUND

Identification of youth at risk for anxiety and unipolar mood disorders (UMDs) can improve public health by targeting those who may warrant early or preventive intervention. This study examined whether endorsing core features of anxiety and UMDs predicted onset of later anxiety and UMDs across the next 7-9 years, and whether having subthreshold or subclinical manifestations of these disorders similarly predicted onset.

METHODS

Data from this study come from the Youth Emotion Project (YEP), a two-site investigation of common and specific risk factors for emotional disorders. Endorsement of core features of a disorder and subclinical or subthreshold anxiety and UMD diagnoses were determined using data from the Structured Clinical Interview for DSM-IV (SCID) at the baseline assessment. Participants completed annual SCIDs over the course of the next 7-9 years (depending on cohort).

RESULTS

Endorsement of panic attacks, obsessions and/or compulsions, and depression and/or anhedonia predicted onset of panic disorder, obsessive compulsive disorder, and major depressive disorder, respectively. When including all anxiety disorders in a model, only the presence of panic attacks uniquely predicted anxiety disorder onset. The presence of subclinical or subthreshold panic disorder, obsessive compulsive disorder, and social phobia at baseline predicted the full onset of these disorders over the follow-up period.

CONCLUSIONS

Experiencing some symptoms of anxiety and UMDs in the absence of meeting diagnostic criteria is indicative of risk for later onsets of clinically significant DSM manifestations of these disorders. These individuals should be identified and targeted for prevention programs.

Elevated responding to safe conditions as a specific risk factor for anxiety versus depressive disorders: evidence from a longitudinal investigation

The current study evaluated the degree to which startle reflexes (SRs) in safe conditions versus danger conditions were predictive of the onset of anxiety disorders. Specificity of these effects to anxiety disorders was evaluated in comparison to unipolar depressive disorders and with consideration of level of neuroticism. A startle paradigm was administered at baseline to 132 nondisordered adolescents as part of a longitudinal study examining risk factors for emotional disorders. Participants underwent a repetition of eight safe-danger sequences and were told that delivery of an aversive stimulus leading to a muscle contraction of the arm would occur only in the late part of danger conditions. One aversive stimulus occurred midway in the safe-danger sequences. Participants were assessed for the onset of anxiety and unipolar depressive disorders annually over the next 3 to 4 years. Larger SR magnitude during safe conditions following delivery of the aversive stimulus predicted the subsequent first onset of anxiety disorders. Moreover, prediction of the onset of anxiety disorders remained significant above and beyond the effects of comorbid unipolar depression, neuroticism, and subjective ratings of intensity of the aversive stimulus. In sum, elevated responding to safe conditions following an aversive stimulus appears to be a specific, prospective risk factor for the first onset of anxiety disorders.

Neuroticism and introversion are associated with salivary cortisol patterns in adolescents

Previous studies have yielded equivocal findings on the relationship between personality and cortisol activity. The present study examined associations between personality and cortisol activity in a large, diverse adolescent sample, while partialling the effects of relevant demographic and health-related covariates. A subsample of 230 participants (57% of whom reported elevated neuroticism) was selected from a larger sample of 16-18-year olds involved in a study on risk factors for emotional disorders. Subsample participants completed a battery of personality questionnaires, and saliva collection was requested several months later on three consecutive days at six time points per day, from wakeup to bedtime. Associations between personality and cortisol rhythms were examined using multilevel growth curve modeling. Neuroticism (N) and introversion (I) were significantly and differentially associated with features of diurnal cortisol patterns. Specifically, a significant N x gender interaction was observed, demonstrating flatter cortisol rhythms across the waking day among male participants with higher N. Elevated I, however, was associated with lower cortisol awakening responses for both male and female participants, and higher cortisol at the time of waking for male participants only. The present study supports personality as a significant predictor of diurnal cortisol patterns in late adolescence, after accounting for the effects of demographic and health covariates, and suggests that gender plays a role in moderating associations between personality and cortisol.

Factorial and construct validity of the revised short form integrative psychotherapy alliance scales for family, couple, and individual therapy

The Integrative Psychotherapy Alliance model brought an interpersonal and systemic perspective to bear on theory, research, and practice on the psychotherapeutic alliance. Questions have been raised about the independence of the theoretical factors in the model and their operationalization in the Individual, Couple, and Family Therapy Alliance Scales. This paper presents results of a confirmatory factor analysis of the scales that delineated at least three distinct interpersonal factors as well as shorter versions of the three scales to facilitate their use in research and practice. The paper also presents the results of a study testing each factor's association with client retention and progress over the first eight sessions in individual and couple therapy. At least two of the interpersonal factors were uniquely associated with progress in individual and couple functioning. Implications of the results for theory, research, practice, and training in individual, couple, and family therapy are elaborated.

A contemporary learning theory perspective on the etiology of anxiety disorders: it's not what you thought it was

The authors describe how contemporary learning theory and research provide the basis for perspectives on the etiology and maintenance of anxiety disorders that capture the complexity associated with individual differences in the development and course of these disorders. These insights from modern research on learning overcome the shortcomings of earlier overly simplistic behavioral approaches, which sometimes have been justifiably criticized. The authors show how considerations of early learning histories and temperamental vulnerabilities affect the short- and long-term outcomes of experiences with stressful events. They also demonstrate how contextual variables during and following stressful learning events affect the course of anxiety disorder symptoms once they develop. This range of variables can lead to a rich and nuanced understanding of the etiology and course of anxiety disorders.

Discriminating between generalized anxiety disorder and anxiety disorder not otherwise specified in a Hispanic population: is it only a matter of worry?

One hundred and two Hispanic persons who presented for treatment at a specialized anxiety disorders clinic were evaluated at intake using the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo and Barlow [1988] Albany: Center for Stress and Anxiety Disorders, State University of New York at Albany). Results indicated that 14% of these patients suffered from anxiety and/or affective disorders that were not adequately captured by our current diagnostic system. Given that the majority of these cases were characterized by predominantly anxious features, further investigation was undertaken to determine the degree of overlap between these patients (anxiety disorder, not otherwise specified; NOS) and those with generalized anxiety disorder (GAD). The two groups differed only with regard to the number of excessive worries they reported and not in terms of somatic symptomatology, psychosocial stressors, or demographic variables. These data suggest that excessive worry may be a discriminating factor between the GAD and NOS groups, providing support for the notion of GAD as a disorder of chromic worry. Future research is needed to tease apart the relative influences of culture and socioeconomic status on our findings.

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.

Subsyndromal ("mixed") anxiety--depression in primary care

OBJECTIVE

To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses.

DESIGN

Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff.

SETTING

Five primary care sites in the United States, France, and Australia.

PATIENT

Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up.

METHODS

Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers.

RESULTS

After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders.

CONCLUSION

The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment.

Uncontrollability and unpredictability in post-traumatic stress disorder: an animal model

The disturbances observed in animals subjected to unpredictable and uncontrollable aversive events resemble post-traumatic stress disorder (PTSD) symptoms and thus may constitute an animal model of this disorder. It is argued that the similarity between animals' symptoms and those of trauma victims may reflect common etiological factors. Relevant experiments in which animals exhibit generalized fear and arousal, discrete fear of a conditioned stimulus (CS), analgesia, and avoidance are reviewed with the view that these manifestations may be analogous to the PTSD symptom clusters of persistent arousal, reexperiencing, numbing, and avoidance, respectively. Finally, animal paradigms are suggested to test the validity of the model and specific hypotheses are derived from the animal literature regarding trauma variables that are predictive of particular PTSD symptom clusters.

Personality and conditioning: a test of four models

Four experiments were conducted to test hypotheses derived from 4 alternative models of individual differences in instrumental conditioning. A standard go--no-go discrimination learning task was used in each of the 4 experiments. The results indicate that individual differences in performance of this discrimination are more consistently and strongly associated with impulsivity and anxiety than with extraversion and neuroticism. In each of the experiments, high anxiety hindered the learning of a go--no-go discrimination more among high impulsive Ss than among low impulsive Ss, and in 2 of the experiments high anxiety actually facilitated learning among low impulsive Ss. These findings are incompatible with Eysenck's and Gray's hypotheses regarding extraversion but are not inconsistent with Newman's. Aspects of these results do support Spence's and Gray's models of anxiety and instrumental conditioning. However, both of these models were contradicted by other trends in the data. A modification of Gray's model of impulsivity and anxiety that emphasizes the role of expectancies was proposed to fit these data.

Personality and conditioning: A test of four models

Four experiments were conducted to test hypotheses derived from 4 alternative models of individual differences in instrumental conditioning. A standard go--no-go discrimination learning task was used in each of the 4 experiments. The results indicate that individual differences in performance of this discrimination are more consistently and strongly associated with impulsivity and anxiety than with extraversion and neuroticism. In each of the experiments, high anxiety hindered the learning of a go--no-go discrimination more among high impulsive Ss than among low impulsive Ss, and in 2 of the experiments high anxiety actually facilitated learning among low impulsive Ss. These findings are incompatible with Eysenck's and Gray's hypotheses regarding extraversion but are not inconsistent with Newman's. Aspects of these results do support Spence's and Gray's models of anxiety and instrumental conditioning. However, both of these models were contradicted by other trends in the data. A modification of Gray's model of impulsivity and anxiety that emphasizes the role of expectancies was proposed to fit these data.