Respiratory Interoception and Pathological Illness Anxiety: Disentangling Bias

OBJECTIVE

Biased interoception decoupled from physiology might be relevant in the etiology of pathological illness anxiety (PIA). Empirical evidence for interoceptive deviations in illness anxiety is scarce but potentially informative to optimize treatments. We hypothesized that persons with PIA differ fundamentally in the classification of bodily sensations from those without PIA.

METHODS

In a respiratory categorization task, participants breathed into a pulmonary training device. Inspiration effort was varied by eight resistive loads. The lower/higher four loads were introduced as belonging to arbitrary categories "A"/"B," respectively. Participants memorized respiratory sensations in a first experimental block and were asked to label the resistances in a second block. We calculated the sensitivity of resistance classification according to category and response bias in terms of categorical misclassification. Data of 39 participants with PIA and 35 controls were compared with regard to sensitivity and response bias by group, resistive load, and their interaction in a multiple regression.

RESULTS

With similar sensitivity, patients more often labeled loads above the categorical border erroneously as belonging to category A, thus underestimating their resistance ( β = -0.06, p = .001; η2 = 0.02).

CONCLUSIONS

Individuals with PIA showed a systematic "wait and see" approach. Altered respiroception in PIA might stem from biased perception during training phase, the recognition phase, biased memory, or a combination of these. Its exact characteristics remain unknown, and future research must address the challenge of developing reliable and valid paradigms accounting for the variability of interoceptive biases.

REGISTRATION

This work was preregistered on OSF ( https://osf.io/9shcw ).

Vagally-mediated heart rate variability and depression in children and adolescents - A meta-analytic update

BACKGROUND

Depression is one of the most common mental disorders and a leading cause of disability worldwide. In adults, depression is characterized by decreased vagal activity (vagally-mediated heart rate variability; vmHRV), while vmHRV is inversely correlated with depressive symptoms. In children/adolescents, a 2016 synthesis (4 studies, 259 individuals) found similarly decreased vmHRV in clinical depression, but no significant association between depressive symptoms and vmHRV (6 studies, 2625 individuals). Given the small number of studies previously considered for synthesis and the rapidly growing evidence base in this area, a meta-analytic update was warranted.

METHOD

A previous review was updated by a systematic literature search to identify studies that (a) compared vmHRV in clinically depressed children/adolescents with non-depressed controls and (b) reported associations between vmHRV and depression severity.

RESULTS

The search update identified 5 additional studies for group comparison (k = 9 studies in total, n = 608 individuals in total) and 15 additional studies for correlational meta-analysis (k = 21 studies in total, n = 4224 individuals in total). Evidence was found for lower resting-state vmHRV in clinically depressed children/adolescents compared to healthy controls (SMD = -0.593, 95 % CI [-1.1760; -0.0101], I2 = 90.92 %) but not for a significant association between vmHRV and depressive symptoms (r = -0.053, 95 % CI [-0.118; 0.012], I2 = 65.77 %). Meta-regression revealed a significant association between depressive symptoms and vmHRV as a function of sex.

LIMITATIONS

The samples considered are highly heterogeneous. Data on the longitudinal association between vmHRV and depression are currently lacking.

CONCLUSION

The present findings support the use of vmHRV as a biomarker for clinical depression in children/adolescents.

[Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan]

Metacognitions and interoceptive sensibility in the perception of premonitory urges in tic disorders across the lifespan Abstract. Objective: Depending on contextual factors, the prevalence of premonitory urges (PU) in patients with tic disorders (TD) increases with age and varies both intra- and interindividually. In youth, PUs correlate with metacognitions. In both youth and adults, interoceptive sensibility is altered compared to healthy controls. We examined the relationship between PUs, tics, metacognitions, and interoceptive sensibility across the lifespan regarding tic severity. Method: In an online survey, 53 participants reported their PUs on the Premonitory Urge for Tics Scale (PUTS) and tic severity on the Symptom Checklist for Tic Disorders (SBB-TIC). We assessed interoceptive sensibility via the Body Perception Questionnaire (BPQ-A) and metacognitions regarding tics with the Belief About Tics Scale (BATS). Results: Adults scored higher on the PUTS than youth. In youth, interoceptive sensibility increased with age; interoceptive sensibility correlated with PUTS. Metacognitions and interoceptive sensibility explained a significant amount of variance in premonitory urges, even after controlling for tic severity and age. Conclusions: The presumed cause of age-dependent development of PUs in youth lies in their neurophysiological maturing processes. However, negative metacognitions and interoceptive abilities also play an important role in the development and maintenance of PU and might be of therapeutic use in the treatment of TD.

Interoception and premonitory urges in children and adolescents with tic disorders

Background

Compared to healthy controls (HCs), adult Tic Disorder (TD) patients exhibit a lower interoceptive accuracy (IAcc) in heartbeat perception. Since the lower IAcc is not evident in children, the age at which tics develop, but in adults only (Pile et al., 2018, https://doi.org/10.1007/s10803-018-3608-8), lower IAcc may reflect a pathological mechanism relevant with regard to tics, premonitory urges (PUs) or the resulting impairment. Although tics are a motor phenomenon, up to date, IAcc has been assessed only with a heartbeat-counting task. This study aims at comparing cardiac and muscular IAcc using two different paradigms and investigates how IAcc is related to premonitory urges in youth.

Method

Interoceptive measures (heartbeat-counting task, muscle tension paradigm) of 28 youth with TD were compared to 23 control participants and related to self-rated premonitory urges and tic symptoms.

Results

TD patients did not differ from HCs in any IAcc measures. However, within TD patients, IAcc explained additional variance in PUs when controlling for tic severity. Muscular IAcc in TD patients is related to urges and tics, but the direction of this association is unclear. IAcc is lower in TD patients than in HCs, indicating imprecise sensory input which is more easily overcome by priors within the predictive coding framework.

Conclusions

Muscle tension feedback tasks could extend interoceptive trainings aimed at improving IAcc to improve accuracy of urge perception (more precise sensory input) to foster the ability to control tics via HRT. Longitudinal studies could provide further insights in causal relationships between IAcc, premonitory urges and tics.

Temperature Perception in the Blushing Region

Abstract. Background: Individuals with social phobia are characterized by a heightened sensitivity for physical symptom such as blushing. Objectives: We exploratorily examined whether blushing-fearful individuals with / without social phobia were more sensitive to perceiving facial temperature increases compared to healthy controls. Methods: 50 participants were tested using an adaptive two-alternative forced-choice task. A Peltier element was attached to the cheek and repeatedly warmed up in one of two phases. The participants’ task was to indicate in which of the two phases the temperature had increased. Results: Contrary to our hypothesis, blushing-fearful individuals with social phobia ( n = 11) were less sensitive to facial temperature increases, i. e., exhibited higher temperature perception threshold, than the subclinical group ( n = 14) and healthy controls ( n = 23). Limitations: The preliminary nature of our study should be noted, and replication in a larger sample is warranted. Conclusions: The findings may be best understood within a predictive coding framework: Individuals with social phobia may rely on priors when assessing their physical symptoms to form an impression of their public self in social situations.

Die Bedeutung des Vorgefühls bei Tic-Störungen

Zusammenfassung. Theoretischer Hintergrund: Die Funktion des Vorgefühls in der Pathogenese und Aufrechterhaltung von Tic-Störungen (TS) wird in den letzten Jahren verstärkt erforscht. Die mögliche funktionelle Bedeutung der Vorgefühle wird aber noch nicht ausreichend verstanden. Methode: Im vorliegenden Review wird der Kenntnisstand zu Vorgefühlen entlang eines integrativen funktionalen Störungsmodells zusammengefasst. Ergebnisse: Im Vergleich zum Jugendalter nehmen Tic-Symptome bei Tic-Störungen im Erwachsenenalter ab, während immer mehr Betroffene ein Vorgefühl berichten. Hierbei kann zwischen einem allgemeinen Vorgefühl (trait) und dem Drang, Tics auszuführen (state) unterschieden werden. Das Vorgefühl als trait ist abhängig von der Interozeptionsfähigkeit. An den Drang, Tics auszuführen, kann habituiert werden, moderiert von Aufmerksamkeits- und Attributionsprozessen. Durch das Auflösen des Vorgefühl-Tic-Reizreaktionsmusters reduzieren sich die Tic-Symptome. Schlussfolgerung: Für weitere Erkenntnisse in Bezug auf die Bedeutung von Vorgefühl und den Drang, Tics auszuführen, sollten zukünftige Forschungsansätze Drang und allgemeine Vorgefühle in therapeutischen Interventionsstudien berücksichtigen, weitere Interozeptionsparadigmen einbeziehen und die Entwicklung von allgemeinem Vorgefühl und Drang über die Lebensspanne hinweg untersuchen.

Screening and assessment for cancer patients' psychosocial support needs: Development and validation of the psychosocial risk questionnaire

PURPOSE

Psychosocial factors can negatively influence the ability to cope with cancer-specific therapy. To identify high-risk patients and to offer need-based care concerning social issues, valid, reliable, and economic instruments are needed. This study aims to develop a tool assessing psychosocial support needs and analyze its psychometric properties.

METHODS

Based on an extensive literature search, items for the scale of psychosocial risks (PSR) were developed to assess the need for psychosocial support. Overall, N = 343 participants with cancer took part in the study to investigate the psychometric properties of the PSR. The factor structure was examined by using a principal component analysis. Correlations with criteria-related constructs determined the convergent validity. Cut-off scores for the PSR were selected based on receiver-operating characteristics and the calculation of Youden indices.

RESULTS

The principal component analysis suggests a two-factor structure: (1) Psychosocial support need to ensure medical and social care services, and (2) Support need for coping with problems. The predicted correlations confirm the convergent validity. Both scales showed excellent internal consistency (Ensure medical and social care services: Omega = 0.94) and (Coping with problems: Omega = 0.90).

CONCLUSION

The newly developed scale can provide helpful information regarding psychosocial support needs to professionals (psychotherapists, psychologists, physicians, and social workers) in the psycho-oncological field. Based on this information, specific and personalized interventions for cancer patients can be offered. The PSR is appropriate for assessing specific psychosocial needs to support cancer patients.

Psychometric evaluation of the Positive Mental Health (PMH) scale using item response theory

BACKGROUND

The investigation of patient-reported outcomes and psycho-oncological interventions mainly focuses on psychological distress or psychopathology. However, the recognition of the equal importance of positive mental health (PMH) has increased lately. The PMH-scale is a brief questionnaire allowing to assess well-being in individuals in the general population and in patients. Previous studies evaluated the psychometric properties of the PMH-scale using classical test theory (CTT). This study is the first to investigate the PMH-scale in patients with cancer using item analysis according to the Rasch model.

METHODS

In total, N = 357 cancer patients participated in the study. A Rasch analysis of the PMH-scale was conducted including testing of unidimensionality, local independence, homogeneity and differential item functioning (DIF) with regard to age, gender, type of cancer, the presence of metastases, psycho-oncological support, and duration of disease. Additionally, the ordering of the item thresholds as well as the targeting of the scale were investigated.

RESULTS

After excluding one misfitting item and accounting for local dependence by forming superitems, a satisfactory overall fit to the Rasch model was established (χ² = 30.34, p = 0.21). The new PMH-8 scale proved to be unidimensional, and homogeneity of the scale could be inferred. All items showed ordered thresholds, there was no further item misfit. DIF was found for age, but as the impact of DIF was not substantial, no adjustment related to the age-DIF had to be made. The Person Separation Index (PSI = 0.89) was excellent, indicating excellent discriminatory power between different levels of positive mental health. Overall, the targeting of the PMH-8 was good for the majority of the present sample. However, at both ends of the scale item thresholds are missing as indicated by a slight floor effect (1.4%) and a considerable ceiling effect (9.8%).

CONCLUSIONS

Overall, the results of the analysis according to the Rasch model support the use of the revised PMH-scale in a psycho-oncological context.

Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Background

The annual incidence of new cancer cases has been increasing worldwide for many years, and is likely to continue to rise. In Germany, the number of new cancer cases is expected to increase by 20% until 2030. Half of all cancer patients experience significant emotional and psychosocial distress along the continuum of their disease, treatment, and aftercare, and also as long-term survivors. Consequently, in many countries, psycho-oncological programs have been developed to address this added burden at both the individual and population level. These programs promote the active engagement of patients in their cancer therapy, aftercare and survivorship planning and aim to improve the patients' quality of life.

In Germany, the “new form of care isPO” (“nFC-isPO”; integrated, cross-sectoral psycho-oncology/integrierte, sektorenübergreifende Psycho-Onkologie) is currently being developed, implemented and evaluated. This approach strives to accomplish the goals devised in the National Cancer Plan by providing psycho-oncological care to all cancer patients according to their individual healthcare needs. The term “new form of care" is defined by the Innovation Fund (IF) of Germany's Federal Joint Committee as “a structured and legally binding cooperation between different professional groups and/or institutions in medical and non-medical care”.

The nFC-isPO is part of the isPO project funded by the IF. It is implemented in four local cancer centres and is currently undergoing a continuous quality improvement process. As part of the isPO project the nFC-isPO is being evaluated by an independent institution: the Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Germany.

The four-year isPO project was selected by the IF to be eligible for funding because it meets the requirements of the federal government's National Cancer Plan (NCP), in particular, the “further development of the oncological care structures and quality assurance" in the psycho-oncological domain. An independent evaluation is required by the IF to verify if the new form of care leads to an improvement in cross-sectoral care and to explore its potential for permanent integration into the German health care system.

Methods

The nFC-isPO consists of six components: a concept of care (C1), care pathways (C2), a psycho-oncological care network (C3), a care process organization plan (C4), an IT-supported documentation and assistance system (C5) and a quality management system (C6). The two components concept of care (C1) and care pathways (C2) represent the isPO clinical care program, according to which the individual cancer patients are offered psycho-oncological services within a period of 12 months after program enrolment following the diagnosis of cancer. The remaining components (C3-C6) represent the formal-administrative aspects of the nFC-isPO that are intended to meet the legally binding requirements of patient care in the German health care system. With the aim of systematic development of the nFC-isPO while at the same time enabling the external evaluators to examine its quality, effectiveness and efficiency under conditions of routine care, the project partners took into consideration approaches from translational psycho-oncology, practice-based health care research and program theory. In order to develop a structured, population-based isPO care program, reference was made to a specific program theory, to the stepped-care approach, and also to evidence-based guideline recommendations.

Results

The basic version, nFC-isPO, was created over the first year after the start of the isPO project in October 2017, and has since been subject to a continuous quality improvement process. In 2019, the nFC-isPO was implemented at four local psycho-oncological care networks in the federal state North Rhine-Westphalia, in Germany. The legal basis of the implementation is a contract for "special care" with the German statutory health insurance funds according to state law (§ 140a SCB V; Social Code Book V for the statutory health insurance funds). Besides the accompanying external evaluation by the IMVR, the nFC-isPO is subjected to quarterly internal and cross-network quality assurance and improvement measures (internal evaluation) in order to ensure continuous quality improvement process. These quality management measures are developed and tested in the isPO project and are to be retained in order to ensure the sustainability of the quality of nFC-isPO for later dissemination into the German health care system.

Discussion

Demands on quality, effectiveness and cost-effectiveness of in the German health care system are increasing, whereas financial resources are declining, especially for psychosocial services. At the same time, knowledge about evidence-based screening, assessment and intervention in cancer patients and about the provision of psychosocial oncological services is growing continuously. Due to the legal framework of the statutory health insurance in Germany, it has taken years to put sound psycho-oncological findings from research into practice. Ensuring the adequate and sustainable financing of a needs-oriented, psycho-oncological care approach for all newly diagnosed cancer patients, as required by the NCP, may still require many additional years. The aim of the isPO project is to develop a new form of psycho-oncological care for the individual and the population suffering from cancer, and to provide those responsible for German health policy with a sound basis for decision-making on the timely dissemination of psycho-oncological services in the German health care system.

Trial registration

The study was pre-registered at the German Clinical Trials Register (https://www.drks.de/DRKS00015326) under the following trial registration number: DRKS00015326; Date of registration: October 30, 2018.

Interoceptive accuracy does not predict emotion perception in daily life

Peripheral emotion theories suggest a crucial role of interoception for emotion perception, which in turn facilitates emotion regulation. Laboratory studies found positive relations between interoceptive accuracy and perceived emotion intensity and arousal. Studies in natural settings are largely missing, but seem important by virtue of emotional experience and regulation diversity.

On hundred seven participants underwent a cardiovascular interoceptive accuracy task. Afterwards, participants provided detailed information on perceived emotions and emotion regulation strategies in an ecological momentary assessment (EMA). Multilevel models were calculated. In consideration of valence, emotion intensity, arousal, intensity of body sensations and, emotion regulation success were modeled as a function of centered interoceptive accuracy.

Interoceptive accuracy did not predict any emotion perception criterion. Lower accuracy was related to a slightly stronger decrease of perceived arousal after regulation.

Differences in emotion categories, intensity, and sample collection might explain divergences to laboratory studies.

Linking Depression with Negative Alcohol-Related Consequences: A Structural Equation Model Among a Clinically Depressed Population

Background and Objectives: Previous research suggests that rumination acts as a mediating mechanism in the association between depression and drinking motives, particularly drinking to cope, as well as negative alcohol-related consequences. In this study, we tested the connections between depressive symptoms, rumination, drinking motives, alcohol consumption, and alcohol-related problems in a clinically depressed population (N = 209). Methods: Structural equation modeling was used to test the models. Specifications were based on the results of a previously evaluated model in a sample of college students. Results: The complex model showed a significant positive association between depressive symptoms and rumination. Drinking motives (enhancement and coping) were linked to more negative alcohol-related consequences. In a simplified model, pronounced depressive symptoms were associated with both increased ruminative thinking and more negative alcohol-related problems. Rumination was connected with stronger drinking motives (combined in one general factor), which were again associated with alcohol consumption and alcohol-related problems. Limitations: The use of self-report measures to determine diagnostic validity. Conclusions: In a clinically depressed sample, depressive symptoms were linked to increased negative alcohol-related consequences. This association was partially explained by rumination and drinking motives. However, rumination was less relevant than previous studies suggested.

Behavioural and functional evidence revealing the role of RBFOX1 variation in multiple psychiatric disorders and traits

Common variation in the gene encoding the neuron-specific RNA splicing factor RNA Binding Fox-1 Homolog 1 (RBFOX1) has been identified as a risk factor for several psychiatric conditions, and rare genetic variants have been found causal for autism spectrum disorder (ASD). Here, we explored the genetic landscape of RBFOX1 more deeply, integrating evidence from existing and new human studies as well as studies in Rbfox1 knockout mice. Mining existing data from large-scale studies of human common genetic variants, we confirmed gene-based and genome-wide association of RBFOX1 with risk tolerance, major depressive disorder and schizophrenia. Data on six mental disorders revealed copy number losses and gains to be more frequent in ASD cases than in controls. Consistently, RBFOX1 expression appeared decreased in post-mortem frontal and temporal cortices of individuals with ASD and prefrontal cortex of individuals with schizophrenia. Brain-functional MRI studies demonstrated that carriers of a common RBFOX1 variant, rs6500744, displayed increased neural reactivity to emotional stimuli, reduced prefrontal processing during cognitive control, and enhanced fear expression after fear conditioning, going along with increased avoidance behaviour. Investigating Rbfox1 neuron-specific knockout mice allowed us to further specify the role of this gene in behaviour. The model was characterised by pronounced hyperactivity, stereotyped behaviour, impairments in fear acquisition and extinction, reduced social interest, and lack of aggression; it provides excellent construct and face validity as an animal model of ASD. In conclusion, convergent translational evidence shows that common variants in RBFOX1 are associated with a broad spectrum of psychiatric traits and disorders, while rare genetic variation seems to expose to early-onset neurodevelopmental psychiatric disorders with and without developmental delay like ASD, in particular. Studying the pleiotropic nature of RBFOX1 can profoundly enhance our understanding of mental disorder vulnerability.

The modulating impact of cigarette smoking on brain structure in panic disorder: a voxel-based morphometry study

Cigarette smoking increases the likelihood of developing anxiety disorders, among them panic disorder (PD). While brain structures altered by smoking partly overlap with morphological changes identified in PD, the modulating impact of smoking as a potential confounder on structural alterations in PD has not yet been addressed. In total, 143 PD patients (71 smokers) and 178 healthy controls (62 smokers) participated in a multicenter magnetic resonance imaging (MRI) study. T1-weighted images were used to examine brain structural alterations using voxel-based morphometry in a priori defined regions of the defensive system network. PD was associated with gray matter volume reductions in the amygdala and hippocampus. This difference was driven by non-smokers and absent in smoking subjects. Bilateral amygdala volumes were reduced with increasing health burden (neither PD nor smoking > either PD or smoking > both PD and smoking). As smoking can narrow or diminish commonly observed structural abnormalities in PD, the effect of smoking should be considered in MRI studies focusing on patients with pathological forms of fear and anxiety. Future studies are needed to determine if smoking may increase the risk for subsequent psychopathology via brain functional or structural alterations.

Transfer of exposure therapy effects to a threat context not considered during treatment in patients with panic disorder and agoraphobia: Implications for potential mechanisms of change

Further developments of exposure-based therapy (EBT) require more knowledge about transfer of treatment to non-trained everyday contexts. However, little is known about transfer effects of EBT. Using a standardized EBT protocol in 275 patients with panic disorder and agoraphobia we investigated the transfer of EBT to a highly standardized context during a Behavioral Avoidance Test (BAT; being entrapped in a small and dark test chamber) and not part of the exposure sessions. Patients of a treatment group underwent the BATs before treatment (t1), after a preparatory treatment phase (t2), and after an agoraphobic exposure phase (t3) and were compared with wait-list control patients, who repeated BAT assessments across the same time period. We found stronger reductions in avoidance behavior, reported fear, and autonomic arousal during the BAT from t1 to t3 in the treatment group patients who were anxious during t1 relative to the anxious but untreated patients. Fear reduction was related to treatment outcome indicating the contribution of transfer effects to successful EBT. Interestingly, reduction varied for different fear response systems suggesting different processes to may be involved in transfer effects. Importantly, final BAT assessment still evoked residual fear in the treatment group as compared to BAT non-anxious control patients, suggesting limited transfer effects - one possible reason for the return of symptoms in new situations.

Cardiac interoception: A novel signal detection approach and relations to somatic symptom distress

Interoception is essential for the maintenance of physical and mental health. Paradigms assessing cardioceptive accuracy do not separate sensitivity from bias or are very demanding. We present the piloting (study 1; N = 60) and psychometric evaluation and validation (study 2; N = 84) of a novel task for the assessment of cardiac interoceptive perception following the principles of signal detection theory. By disentangling sensitivity and response bias, we demonstrate that the previously used interoceptive accuracy score of the heartbeat mental tracking task represents an amalgam of sensitivity and response bias. The new task demonstrated adequate test-retest reliabilities for sensitivity (d') and response bias (c). Sensitivity was inversely related (β = -.36) to somatic symptom distress after statistically controlling for response bias. The novel cardiovascular signal detection task is easy to implement, feasible, and promising in terms of unraveling the role of (cardiac) interoceptive perception in psychopathology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Therapygenetic effects of 5-HTTLPR on cognitive-behavioral therapy in anxiety disorders: A meta-analysis

There is a recurring debate on the role of the serotonin transporter gene linked polymorphic region (5-HTTLPR) in the moderation of response to cognitive behavioral therapy (CBT) in anxiety disorders. Results, however, are still inconclusive. We here aim to perform a meta-analysis on the role of 5-HTTLPR in the moderation of CBT outcome in anxiety disorders. We investigated both categorical (symptom reduction of at least 50%) and dimensional outcomes from baseline to post-treatment and follow-up. Original data were obtained from ten independent samples (including three unpublished samples) with a total of 2,195 patients with primary anxiety disorder. No significant effects of 5-HTTLPR genotype on categorical or dimensional outcomes at post and follow-up were detected. We conclude that current evidence does not support the hypothesis of 5-HTTLPR as a moderator of treatment outcome for CBT in anxiety disorders. Future research should address whether other factors such as long-term changes or epigenetic processes may explain further variance in these complex gene-environment interactions and molecular-genetic pathways that may confer behavioral change following psychotherapy.

Somatosensory Illusions Elicited by Sham Electromagnetic Field Exposure: Experimental Evidence for a Predictive Processing Account of Somatic Symptom Perception

OBJECTIVE

According to the predictive processing theory of somatic symptom generation, body sensations are determined by somatosensory input and central nervous predictions about this input. We examined how expectations shape predictions and consequently bodily perceptions in a task eliciting illusory sensations as laboratory analogue of medically unexplained symptoms.

METHODS

Using the framework of signal detection theory, the influence of sham Wi-Fi on response bias (c) and somatosensory sensitivity (d') for tactile stimuli was examined using the somatic signal detection task (SSDT). A healthy student sample (n = 83) completed the SSDT twice (sham Wi-Fi on/off) in a randomized order after watching a film that promoted adverse health effects of electromagnetic fields.

RESULTS

When expecting a Wi-Fi signal to be present, participants showed a significantly more liberal response bias c (p = .010, ηp2 = 0.08) for tactile stimuli in the SSDT as evidence of a higher propensity to experience somatosensory illusions. No significant alteration of somatosensory sensitivity d' (p = .76, ηp2 < 0.002) was observed.

CONCLUSIONS

Negative expectations about the harmfulness of electromagnetic fields may foster the occurrence of illusory symptom perceptions via alterations in the somatosensory decision criterion. The findings are in line with central tenets of the predictive processing account of somatic symptom generation. This account proposes a decoupling of percept and somatosensory input so that perception becomes increasingly dependent on predictions. This biased perception is regarded as a risk factor for somatic symptom disorders.

Interoceptive Sensibility, Alexithymia, and Emotion Regulation in Individuals Suffering from Fibromyalgia

INTRODUCTION

People suffering from fibromyalgia syndrome report various difficulties in emotional processing, possibly resulting from changes in bodily perception (interoception). In our study, we investigated the relationships between interoceptive sensibility (IS) and two disease-relevant emotional components (alexithymia and emotion regulation) in fibromyalgia sufferers compared to healthy individuals.

METHODS

Fifty-five fibromyalgia sufferers and 55 healthy individuals, matched with regard to age and gender, participated in our cross-sectional study. All participants completed the following self-report measures: the Multidimensional Assessment of Interoceptive Awareness, the Toronto Alexithymia Scale, and the Emotion Regulation Skills Questionnaire. Depression and anxiety scores served as confounding variables.

RESULTS

Fibromyalgia sufferers reported a stronger tendency to note as well as to avoid (unpleasant) body sensations. IS and psychopathology each explained about thirty percent of the variance in emotion regulation in fibromyalgia sufferers. Alexithymia was related to IS and emotion regulation in controls but not in fibromyalgia sufferers.

CONCLUSION

Disturbances in interoception could be seen as the starting point of emotional difficulties in people with fibromyalgia. Following the fear-avoidance-model, experiential avoidance may restrict patients' ability to adaptively regulate emotional states, possibly initiating a vicious cycle of psychological distress and pain.

An investigation of genetic variability of DNA methyltransferases DNMT3A and 3B does not provide evidence for a major role in the pathogenesis of panic disorder and dimensional anxiety phenotypes

While DNA methylation patterns have been studied for a role in the pathogenesis of anxiety disorders, the role of the enzymes establishing DNA methylation-DNA methyltransferases (DNMTs)-has yet to be investigated. In an effort to investigate DNMT genotype-specific effects on dimensional anxiety traits in addition to the categorical phenotype of panic disorder, 506 panic disorder patients and 3112 healthy participants were assessed for anxiety related cognition [Agoraphobic Cognitions Questionnaire (ACQ)], anxiety sensitivity [Anxiety Sensitivity Index (ASI)] as well as pathological worry [Penn State Worry Questionnaire (PSWQ)] and genotyped for five single nucleotide polymorphisms (SNPs) in the DNMT3A (rs11683424, rs1465764, rs1465825) and DNMT3B (rs2424932, rs4911259) genes, which have previously been found associated with clinical and trait-related phenotypes. There was no association with the categorical phenotype panic disorder. However, a significant association was discerned between DNMT3A rs1465764 and PSWQ scores in healthy participants, with the minor allele conveying a protective effect. In addition, a marginally significant association between questionnaire scores (PSWQ, ASI) in healthy participants and DNMT3B rs2424932 was detected, again with the minor allele conveying a protective effect. The present results suggest a possible minor role of DNMT3A and DNMT3B gene variation in conveying resilience towards anxiety disorders. As the observed associations indicated a protective effect of two SNPs particularly with pathological worry, future studies are proposed to explore these variants in generalized anxiety disorder rather than panic disorder.

The significance of the Interpersonal-Psychological Theory of Suicide in an oncological context-A scoping review

OBJECTIVES

Since individuals afflicted with cancer are at an elevated risk of dying by suicide, understanding suicide-related ideation and behaviours is critical in identifying vulnerable patients. The interpersonal theory of suicide (IPTS) provides a framework to research risk factors for suicide and has been validated in different samples. The aim of this scoping review is to study literature related to IPTS and cancer patients.

METHODS

This scoping review was registered with the OPEN Science Framework (osf.io/92465). The databases PsycINFO, Web of Science, PubMed and PubMed Central were searched. Eligible research needed to use a minimum of one psychometric element to measure at least one of the factors of the IPTS in individuals with cancer.

RESULTS

Ninety-six studies were identified and screened. Eligible research included individuals with cancer and the use of at least one measurement of at least one of the factors of the IPTS. Overall, four articles met the inclusion criteria and three studies found significant associations of components of the IPTS and suicidal ideation/behaviour.

CONCLUSION

While these initial findings support the notion that the IPTS is relevant for individuals with cancer as well, a direct validation of the IPTS in cancer patients is needed.

Critical consideration of assessment methods for clinically significant changes of mental distress after psycho-oncological interventions

OBJECTIVES

Considering the heterogeneity of cancer entities and the associated disease progression, personalized care of patients is increasingly emphasized in psycho-oncology. This individualization makes the use of measurements of individual clinically significant change important when studying the efficacy and effectiveness of psycho-oncological care. Two conceptualizations for the measurement of clinical significance are critically contrasted in this study: the Reliable Change Index (RCI) and the Minimal Important Difference (MID) method.

METHODS

In total, 2,121 cancer patients participated in the study and a subsample of 708 patients was reassessed about 4 months later. Psychological distress was measured using the Hospital Anxiety and Depression Scale. We evaluated two measures of clinical significance (RCI, MID) by comparing the respective numbers of improved, unimproved, and deteriorated patients.

RESULTS

Individually significant changes were observed with both methods; however, determined rates of improvement differed substantially: MID (66.67%) and RCI (48.23%). Most importantly, according to MID, 17.93% of patients were identified as being improved, although their respective improvements were not statistically significant and thus unreliable.

CONCLUSIONS

The benefits of RCI outweigh MID, and therefore, the RCI is recommended as a measure to assess change.

Cyberchondriasis

Abstract. Studies show a rising trend that individuals who worry about their health regularly search the internet. Recently, potentially negative effects of doing so have been highlighted. Illness anxiety and negative affectivity may influence these effects. We tested if searching the internet about a personal symptom leads to increased health concerns and if these traits have an impact. Data from 79 students were collected. Participants were asked to name and evaluate a symptom of personal concern and to research that symptom using the Internet for 5 min. Searching the internet resulted in a significant increase in health concerns and this was significantly moderated by negative affectivity but not by illness anxiety. A replication of these findings, possibly with an older sample scoring higher on illness anxiety will help to better understand the relations described above, and to point consumers and health professionals into the right direction regarding media usage.

Association of rs7688285 allelic variation coding for GLRB with fear reactivity and exposure-based therapy in patients with panic disorder and agoraphobia

The gene coding for glycine receptor β subunits (GLRB) has been found to be related to panic disorder and agoraphobia (PD/AG) and to be associated with altered insular BOLD activation during fear conditioning, as an intermediate phenotype of defensive system reactivity in healthy subjects. In a multicenter clinical trial on PD/AG patients we investigated in three sub-samples whether GLRB allelic variation (A/G; A-allele identified as «risk») in the single nucleotide polymorphism rs7688285 was associated with autonomic (behavioral avoidance test BAT; n = 267 patients) and neural (differential fear conditioning; n = 49 patients, n = 38 controls) measures, and furthermore with responding towards exposure-based cognitive behavioral therapy (CBT, n = 184 patients). An interaction of genotype with current PD/AG diagnosis (PD/AG vs. controls; fMRI data only) and their modification after CBT was tested as well. Exploratory fMRI results prior to CBT, revealed A-allele carriers irrespective of diagnostic status to show overall higher BOLD activation in the hippocampus, motor cortex (MC) and insula. Differential activation in the MC, anterior cingulate cortex (ACC) and insula was found in the interaction genotype X diagnosis. Differential activation in ACC and hippocampus was present in differential fear learning. ACC activation was modified after treatment, while no overall rs7688285 dependent effect on clinical outcomes was found. On the behavioral level, A-allele carriers showed pronounced fear reactivity prior to CBT which partially normalized afterwards. In sum, rs7688285 variation interacts in a complex manner with PD/AG on a functional systems level and might be involved in the development of PD/AG but not in their treatment.

Contingent biofeedback outperforms other methods to enhance the accuracy of cardiac interoception: A comparison of short interventions

BACKGROUND AND OBJECTIVES

Deviations in interoception might contribute to the development and maintenance of mental disorders. The improvement of interoceptive accuracy (IA) is desirable but assessment and training methods remain controversial. For instance, it was assumed that performance increases in heartbeat counting paradigms after cardiac feedback were due to an improvement of knowledge with regard to heart rate rather than due to an actual improvement in IA.

METHODS

Here, we examined effects of contingent cardiac feedback training, non-contingent cardiac feedback, mindfulness practice, and a waiting period with external attentional focus on IA. 100 healthy participants underwent a mental tracking paradigm before and after 20 min of training or waiting.

RESULTS

Results revealed a significant increase of IA in the contingent feedback condition (d = 1.21, p ≤ .001) and no significant changes after non-contingent feedback, mindfulness practice or waiting (d ≤ 0.37; p ≥ .06). Furthermore, IA increase was significantly higher after the contingent feedback training compared to all other conditions, including non-contingent feedback.

LIMITATIONS

Future studies need to replicate these findings in clinical samples and examine time dependent effects.

CONCLUSIONS

The results provide evidence for the trainability of heartbeat perception. IA improvements may reduce the symptom burden in people suffering from mental disorders and psychophysiological conditions that have been linked to lower interoceptive accuracy such as depression, somatic symptom disorder, chronic pain, and functional somatic syndromes. Consequently, exploration of biofeedback training procedures shall be continued with the aim of identifying relevant mediators of beneficial effects and future implementation in clinical practice.

A genome-wide association meta-analysis of prognostic outcomes following cognitive behavioural therapy in individuals with anxiety and depressive disorders

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (rg ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h2SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h2SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

The impact of depressive comorbidity on neural plasticity following cognitive-behavioral therapy in panic disorder with agoraphobia

BACKGROUND

Depressive disorders are a frequent comorbidity of panic disorder with agoraphobia (PD/AG). Cognitive-behavioral therapy (CBT) for PD/AG effectively reduces anxiety and depressive symptoms, irrespective of comorbidities. However, as depressive comorbidities can confound fear circuitry activation (i.e. amygdalae, insulae, anterior cingulate cortex) in PD/AG, we investigated whether comorbid depressive disorders alter neural plasticity following CBT.

METHODS

Within a randomized, controlled clinical trial on exposure-based CBT, forty-two PD/AG patients including fifteen (35.7%) with a comorbid depressive disorder (PD/AG + DEP) participated in a longitudinal functional magnetic resonance imaging (fMRI) study. A differential fear conditioning task was used as probe of interest. A generalized psycho-physiological interaction analysis (gPPI) served to study functional connectivity patterns.

RESULTS

After CBT, only PD/AG patients without comorbid depressive disorders (PD/AG-DEP) showed reduced activation in the left inferior frontal gyrus (IFG) extending to the insula. While PD/AG-DEP patients showed enhanced functional connectivity (FC) between the left IFG and subcortical structures (anterior cingulate cortex, thalamus and midbrain), PD/AG + DEP patients exhibited increased FC between the left IFG and cortical structures (prefrontal, parietal regions). In both groups, FC decreased following CBT.

LIMITATIONS

Primary depressed and medicated patients were excluded. Major depression and dysthymia were collapsed.

CONCLUSIONS

Reduced activation in the left IFG, as previously shown in PD/AG, appears to be a specific substrate of CBT effects in PD/AG-DEP patients only. Differential patterns of FC pertaining to fear circuitry networks in patients without depression vs. cognitive networks in patients with comorbid depression may point towards different pathways recruited by CBT as a function of comorbidity.

Orexin in the anxiety spectrum: association of a HCRTR1 polymorphism with panic disorder/agoraphobia, CBT treatment response and fear-related intermediate phenotypes

Preclinical studies point to a pivotal role of the orexin 1 (OX₁) receptor in arousal and fear learning and therefore suggest the HCRTR1 gene as a prime candidate in panic disorder (PD) with/without agoraphobia (AG), PD/AG treatment response, and PD/AG-related intermediate phenotypes. Here, a multilevel approach was applied to test the non-synonymous HCRTR1 C/T Ile408Val gene variant (rs2271933) for association with PD/AG in two independent case-control samples (total n = 613 cases, 1839 healthy subjects), as an outcome predictor of a six-weeks exposure-based cognitive behavioral therapy (CBT) in PD/AG patients (n = 189), as well as with respect to agoraphobic cognitions (ACQ) (n = 483 patients, n = 2382 healthy subjects), fMRI alerting network activation in healthy subjects (n = 94), and a behavioral avoidance task in PD/AG pre- and post-CBT (n = 271). The HCRTR1 rs2271933 T allele was associated with PD/AG in both samples independently, and in their meta-analysis (p = 4.2 × 10^-7), particularly in the female subsample (p = 9.8 × 10^-9). T allele carriers displayed a significantly poorer CBT outcome (e.g., Hamilton anxiety rating scale: p = 7.5 × 10^-4). The T allele count was linked to higher ACQ sores in PD/AG and healthy subjects, decreased inferior frontal gyrus and increased locus coeruleus activation in the alerting network. Finally, the T allele count was associated with increased pre-CBT exposure avoidance and autonomic arousal as well as decreased post-CBT improvement. In sum, the present results provide converging evidence for an involvement of HCRTR1 gene variation in the etiology of PD/AG and PD/AG-related traits as well as treatment response to CBT, supporting future therapeutic approaches targeting the orexin-related arousal system.

Effects of Cognitive Behavioral Therapy on Neural Processing of Agoraphobia-Specific Stimuli in Panic Disorder and Agoraphobia

BACKGROUND

Patients suffering from panic disorder and agoraphobia are significantly impaired in daily life due to anxiety about getting into a situation due to apprehension about experiencing a panic attack, especially if escape may be difficult. Dysfunctional beliefs and behavior can be changed with cognitive behavioral therapy; however, the neurobiological effects of such an intervention on the anticipation and observation of agoraphobia-specific stimuli are unknown.

METHODS

We compared changes in neural activation by measuring the blood oxygen level-dependent signal of 51 patients and 51 healthy controls between scans before and those after treatment (group by time interaction) during anticipation and observation of agoraphobia-specific compared to neutral pictures using 3-T fMRI.

RESULTS

A significant group by time interaction was observed in the ventral striatum during anticipation and in the right amygdala during observation of agoraphobia-specific pictures; the patients displayed a decrease in ventral striatal activation during anticipation from pre- to posttreatment scans, which correlated with clinical improvement measured with the Mobility Inventory. During observation, the patients displayed decreased activation in the amygdala. These activational changes were not observed in the matched healthy controls.

CONCLUSIONS

For the first time, neural effects of cognitive behavioral therapy were shown in patients suffering from panic disorder and agoraphobia using disorder-specific stimuli. The decrease in activation in the ventral striatum indicates that cognitive behavioral therapy modifies anticipatory anxiety and may ameliorate abnormally heightened salience attribution to expected threatening stimuli. The decreased amygdala activation in response to agoraphobia-specific stimuli indicates that cognitive behavioral therapy can alter the basal processing of agoraphobia-specific stimuli in a core region of the fear network.

Interoception in pathological health anxiety

According to cognitive-behavioral models, pathological health anxiety is triggered and maintained by the perception of mostly mild and benign bodily sensations that are misinterpreted as signs of illness. Arguably, abnormalities in interoception may account for this misguided preoccupation with somatic sensations. Using a multimethod approach, the current study investigated possible abnormalities in interoception in patients with pathological health anxiety (PHA; n = 51) and healthy participants (n = 56). Different types of interoception were assessed with a heartbeat-tracking task and a signal-detection task for nonspecific skin conductance fluctuations (NSCFs task). Patients compared with healthy participants showed a more liberal interoceptive response bias for NSCFs, t(79) = 2.32, p = .02, d = 0.53, 95% confidence interval (CI) (0.30, 0.68). Specifically, patients with a comorbid anxiety disorder compared with healthy participants exhibited a significantly higher interoceptive sensitivity for NSCFs, t(57) = 3.12, p < .01, d = 0.89, 95% CI (0.54, 1.12). No evidence for higher interoceptive sensitivity in PHA (neither in the heartbeat mental tracking task nor in the NSCF task) was observed after accounting for comorbid anxiety disorders. The findings suggest that higher interoceptive sensitivity might not be specific to health anxiety, but rather associated with factors shared with the anxiety disorders. Biased (i.e., more liberal) interoceptive processing appears more specific to health anxiety, but further studies using larger sample sizes and a multimethod approach for the assessment of interoception are needed to more completely unravel the role of interoception in health anxiety. (PsycINFO Database Record

Weibliche Homosexualität, Maskulinität und Körperzufriedenheit

Zusammenfassung. Theoretischer Hintergrund: Homosexuelle Frauen sind zufriedener mit ihrem Körper als heterosexuelle Frauen. Homosexualität ist folglich möglicherweise ein Schutzfaktor vor Körperunzufriedenheit. Unklar bleibt der zugrundeliegende Mechanismus für diesen Schutzfaktor. Fragestellung: Es wird untersucht, ob die höhere Körperzufriedenheit auf unterschiedliche Geschlechtsrollen, insbesondere Maskulinität, rückführbar ist. Methode: Diese Frage wurde an einer Stichprobe von N = 478 Frauen mittels einer Mediatoranalyse beantwortet. Ergebnisse: Homosexuelle Frauen waren zufriedener mit ihrem Körper als Heterosexuelle und erreichten höhere Werte für Maskulinität. Maskulinität mediierte den Unterschied bezüglich Körperzufriedenheit. Schlussfolgerungen: Teilweise vermittelt über Maskulinität, kann weibliche Homosexualität als Schutzfaktor vor Körperunzufriedenheit angesehen werden.

Identifying Patterns in Complex Field Data

Abstract. Ambulatory assessment methods are well suited to examine how patients with panic disorder and agoraphobia (PD/A) undertake situational exposure. But under complex field conditions of a complex treatment protocol, the variability of data can be so high that conventional analytic approaches based on group averages inadequately describe individual variability. To understand how fear responses change throughout exposure, we aimed to demonstrate the incremental value of sorting HR responses (an index of fear) prior to applying averaging procedures. As part of their panic treatment, 85 patients with PD/A completed a total of 233 bus exposure exercises. Heart rate (HR), global positioning system (GPS) location, and self-report data were collected. Patients were randomized to one of two active treatment conditions (standard exposure or fear-augmented exposure) and completed multiple exposures in four consecutive exposure sessions. We used latent class cluster analysis (CA) to cluster heart rate (HR) responses collected at the start of bus exposure exercises (5 min long, centered on bus boarding). Intra-individual patterns of assignment across exposure repetitions were examined to explore the relative influence of individual and situational factors on HR responses. The association between response types and panic disorder symptoms was determined by examining how clusters were related to self-reported anxiety, concordance between HR and self-report measures, and bodily symptom tolerance. These analyses were contrasted with a conventional analysis based on averages across experimental conditions. HR responses were sorted according to form and level criteria and yielded nine clusters, seven of which were interpretable. Cluster assignment was not stable across sessions or treatment condition. Clusters characterized by a low absolute HR level that slowly decayed corresponded with low self-reported anxiety and greater self-rated tolerance of bodily symptoms. Inconsistent individual factors influenced HR responses less than situational factors. Applying clustering can help to extend the conventional analysis of highly variable data collected in the field. We discuss the merits of this approach and reasons for the non-stereotypical pattern of cluster assignment across exposures.

Die Relevanz der Ausbildung für den späteren Einsatz von Expositionsverfahren in der therapeutischen Praxis

Zusammenfassung. Theoretischer Hintergrund: Obwohl empirische Belege für Expositionsmethoden sprechen, werden diese in der Praxis zu wenig eingesetzt. Fragestellung: Es wurden Faktoren auf individueller und institutioneller Ebene identifiziert, welche für eine spätere Anwendung von Expositionsmethoden in der Praxis relevant sind und im deutschen Ausbildungssystem untersucht. Methode: Insgesamt wurden 20 Ausbildungsinstitute und 398 Absolvent_innen befragt. Mit einer Multilevelanalyse wurde die Relevanz verschiedener Faktoren geprüft. Ergebnisse: Auf individueller Ebene waren Ausbildungstyp (KiJu vs. Erwachsene) und inhaltliche Aspekte (z. B. die Einstellung zu Expositionsmethoden) für den späteren Expositionseinsatz wichtig. Auf institutioneller Ebene war eine universitäre Anbindung der Ausbildungsinstitute relevant. Schlussfolgerungen: Innerhalb der Ausbildung trägt die vermehrte Vermittlung von sowohl störungs- als auch methodenspezifischem Wissen zur Verwendung von Expositionsverfahren bei. Absolventen und deren spätere Patienten profitieren von praktischer Übung der Methodik, vor allem dann, wenn realistische Überzeugungen hinsichtlich der Wirksamkeit und Umsetzbarkeit der Methode entwickelt werden.

Pathologisches Hautzupfen/-quetschen (Skin Picking)

Zusammenfassung. Theoretischer Hintergrund: Pathologisches Hautzupfen/-quetschen (Dermatillomanie) ist mit der Aufnahme in das DSM-5 eine anerkannte psychische Störung. Fragestellung: Die Arbeit überprüft zwei Messinstrumente auf ihre psychometrische Güte: Die modifizierte deutsche Übersetzung der Skin Picking Scale (mSPS-D) und die Skin Picking Impact Scale (SPIS-D). Methode: Mittels einer Online-Erhebung wurden die Fragebögen an einer von Dermatillomanie betroffenen Stichprobe psychometrisch und faktorenanalytisch untersucht. Ergebnisse: Für die mSPS-D wurden für drei Subskalen sowie die Gesamtskala gute bis sehr gute Reliabilitätswerte (α = .76 – .81) ermittelt. Für den SPIS-D konnte die Faktorenstruktur der Kurzversion repliziert werden (α = .81). Beide Fragebögen können damit als reliable, valide und ökonomische Messinstrumente zur Erfassung von Pathologischem Hautzupfen/-quetschen gelten. Schlussfolgerungen: Die Messinstrumente bieten eine gute Grundlage für die weitere Erforschung des Pathologischen Hautzupfen/-quetschens.

Support Vector Machine Analysis of Functional Magnetic Resonance Imaging of Interoception Does Not Reliably Predict Individual Outcomes of Cognitive Behavioral Therapy in Panic Disorder with Agoraphobia

BACKGROUND

The approach to apply multivariate pattern analyses based on neuro imaging data for outcome prediction holds out the prospect to improve therapeutic decisions in mental disorders. Patients suffering from panic disorder with agoraphobia (PD/AG) often exhibit an increased perception of bodily sensations. The purpose of this investigation was to assess whether multivariate classification applied to a functional magnetic resonance imaging (fMRI) interoception paradigm can predict individual responses to cognitive behavioral therapy (CBT) in PD/AG.

METHODS

This analysis is based on pretreatment fMRI data during an interoceptive challenge from a multicenter trial of the German PANIC-NET. Patients with DSM-IV PD/AG were dichotomized as responders (n = 30) or non-responders (n = 29) based on the primary outcome (Hamilton Anxiety Scale Reduction ≥50%) after 6 weeks of CBT (2 h/week). fMRI parametric maps were used as features for response classification with linear support vector machines (SVM) with or without automated feature selection. Predictive accuracies were assessed using cross validation and permutation testing. The influence of methodological parameters and the predictive ability for specific interoception-related symptom reduction were further evaluated.

RESULTS

SVM did not reach sufficient overall predictive accuracies (38.0-54.2%) for anxiety reduction in the primary outcome. In the exploratory analyses, better accuracies (66.7%) were achieved for predicting interoception-specific symptom relief as an alternative outcome domain. Subtle information regarding this alternative response criterion but not the primary outcome was revealed by post hoc univariate comparisons.

CONCLUSION

In contrast to reports on other neurofunctional probes, SVM based on an interoception paradigm was not able to reliably predict individual response to CBT. Results speak against the clinical applicability of this technique.

The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients' interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists' adherence (r=0.54) and therapeutic alliance (r=0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients' interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r=0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.

Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia

INTRODUCTION

Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment-specific effects on symptoms and neurofunctional correlates.

EXPERIMENTAL PROCEDURES

We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29).

RESULTS

Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups.

DISCUSSION

This study demonstrates that therapist-guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment.

Separating depressive comorbidity from panic disorder: A combined functional magnetic resonance imaging and machine learning approach

BACKGROUND

Depression is frequent in panic disorder (PD); yet, little is known about its influence on the neural substrates of PD. Difficulties in fear inhibition during safety signal processing have been reported as a pathophysiological feature of PD that is attenuated by depression. We investigated the impact of comorbid depression in PD with agoraphobia (AG) on the neural correlates of fear conditioning and the potential of machine learning to predict comorbidity status on the individual patient level based on neural characteristics.

METHODS

Fifty-nine PD/AG patients including 26 (44%) with a comorbid depressive disorder (PD/AG+DEP) underwent functional magnetic resonance imaging (fMRI). Comorbidity status was predicted using a random undersampling tree ensemble in a leave-one-out cross-validation framework.

RESULTS

PD/AG-DEP patients showed altered neural activation during safety signal processing, while +DEP patients exhibited generally decreased dorsolateral prefrontal and insular activation. Comorbidity status was correctly predicted in 79% of patients (sensitivity: 73%; specificity: 85%) based on brain activation during fear conditioning (corrected for potential confounders: accuracy: 73%; sensitivity: 77%; specificity: 70%).

LIMITATIONS

No primary depressed patients were available; only medication-free patients were included. Major depression and dysthymia were collapsed (power considerations).

CONCLUSIONS

Neurofunctional activation during safety signal processing differed between patients with or without comorbid depression, a finding which may explain heterogeneous results across previous studies. These findings demonstrate the relevance of comorbidity when investigating neurofunctional substrates of anxiety disorders. Predicting individual comorbidity status may translate neurofunctional data into clinically relevant information which might aid in planning individualized treatment. The study was registered with the

ISRCTN

ISRCTN80046034.

5HTT is associated with the phenotype psychological flexibility: results from a randomized clinical trial

Adaption to changing environments is evolutionarily advantageous. Studies that link genetic and phenotypic expression of flexible adjustment to one's context are largely lacking. In this study, we tested the importance of psychological flexibility, or goal-related context sensitivity, in an interaction between psychotherapy outcome for panic disorder with agoraphobia (PD/AG) and a genetic polymorphism. Given the established role of the 5HTT-LPR polymorphism in behavioral flexibility, we tested whether this polymorphism (short group vs. long group) impacted therapy response as a function of various endophenotypes (i.e., psychological flexibility, panic, agoraphobic avoidance, and anxiety sensitivity). Patients with PD/AG were recruited from a large multicenter randomized controlled clinical trial on cognitive-behavioral therapy. Pre- to post-treatment changes by 5HTT polymorphism were analyzed. 5HTT polymorphism status differentiated pre- to post-treatment changes in the endophenotype psychological flexibility (effect size difference d = 0.4, p < 0.05), but none of the specific symptom-related endophenotypes consistently for both the intent-to-treat sample (n = 228) and the treatment completers (n = 194). Based on the consistency of these findings with existing theory on behavioral flexibility, the specificity of the results across phenotypes, and the consistency of results across analyses (i.e., completer and intent to treat), we conclude that 5HTT polymorphism and the endophenotype psychological flexibility are important variables for the treatment of PD/AG. The endophenotype psychological flexibility may help bridge genetic and psychological literatures. Despite the limitation of the post hoc nature of these analyses, further study is clearly warranted.

Metacognitions, worry and sleep in everyday life: Studying bidirectional pathways using Ecological Momentary Assessment in GAD patients

BACKGROUND

The metacognitive model of generalized anxiety disorder proposes that negative metacognitive beliefs are crucial in the maintenance of excessive worry. Furthermore, according to the cognitive model of insomnia, worry leads to problems falling or staying asleep and poor sleep quality. In order to test the assumed causal relationships, the present study examined the time-dependent course of negative metacognition and worry as well as worry and sleep quality, using Ecological Momentary Assessment (EMA).

METHOD

Negative metacognitions, worry and sleep were assessed by self-report questionnaires as well as EMA in 56 GAD patients who carried a portable device for 1 week and logged sleep quality, negative metacognition and worry processes four times a day.

RESULTS

Metacognitions, worry and sleep were significantly correlated. Structural equation modeling using multilevel analyses showed a unidirectional relationship of negative metacognitions leading to prolonged worry processes and a bidirectional relationship of worry and sleep quality.

CONCLUSIONS

These findings support the theoretically derived assumptions on the relationship between negative metacognitions, worry and sleep. Implications for further research as well as clinical implications are discussed.

Dimensional structure of bodily panic attack symptoms and their specific connections to panic cognitions, anxiety sensitivity and claustrophobic fears

BACKGROUND

Previous studies of the dimensional structure of panic attack symptoms have mostly identified a respiratory and a vestibular/mixed somatic dimension. Evidence for additional dimensions such as a cardiac dimension and the allocation of several of the panic attack symptom criteria is less consistent. Clarifying the dimensional structure of the panic attack symptoms should help to specify the relationship of potential risk factors like anxiety sensitivity and fear of suffocation to the experience of panic attacks and the development of panic disorder.

METHOD

In an outpatient multicentre study 350 panic patients with agoraphobia rated the intensity of each of the ten DSM-IV bodily symptoms during a typical panic attack. The factor structure of these data was investigated with nonlinear confirmatory factor analysis (CFA). The identified bodily symptom dimensions were related to panic cognitions, anxiety sensitivity and fear of suffocation by means of nonlinear structural equation modelling (SEM).

RESULTS

CFA indicated a respiratory, a vestibular/mixed somatic and a cardiac dimension of the bodily symptom criteria. These three factors were differentially associated with specific panic cognitions, different anxiety sensitivity facets and suffocation fear.

CONCLUSIONS

Taking into account the dimensional structure of panic attack symptoms may help to increase the specificity of the associations between the experience of panic attack symptoms and various panic related constructs.

Oxytocin receptor gene methylation: converging multilevel evidence for a role in social anxiety

Social anxiety disorder (SAD) is a commonly occurring and highly disabling disorder. The neuropeptide oxytocin and its receptor (OXTR) have been implicated in social cognition and behavior. This study-for the first time applying a multilevel epigenetic approach-investigates the role of OXTR gene methylation in categorical, dimensional, and intermediate neuroendocrinological/neural network phenotypes of social anxiety. A total of 110 unmedicated patients with SAD and matched 110 controls were analyzed for OXTR methylation by direct sequencing of sodium bisulfite-converted DNA extracted from whole blood. Furthermore, OXTR methylation was investigated regarding SAD-related traits (Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS)), salivary cortisol response during the Trier social stress test (TSST), and amygdala responsiveness to social phobia related verbal stimuli using fMRI. Significantly decreased OXTR methylation particularly at CpG Chr3: 8 809 437 was associated with (1) the categorical phenotype of SAD (p<0.001, Cohen's d=0.535), (2) increased SPS and SIAS scores (p<0.001), (3) increased cortisol response to the TSST (p=0.02), and (4) increased amygdala responsiveness during social phobia-related word processing (right: p(corr)<0.001; left: p(corr)=0.005). Assuming that decreased OXTR methylation confers increased OXTR expression, the present finding may reflect a compensatory upregulation for pathologically reduced oxytocin levels or a causally relevant increased OXTR activation in SAD and related traits. OXTR methylation patterns might thus serve as peripheral surrogates of oxytocin tone and aid in establishing accessible biomarkers of SAD risk allowing for indicated preventive interventions and personalized treatment approaches targeting the oxytocin system.