Trauma exposure, PTSD and psychotic-like symptoms in post-conflict Timor Leste: an epidemiological survey.

BACKGROUND: Studies in developed countries indicate that psychotic-like symptoms are prevalent in the community and are related to trauma exposure and PTSD. No comparable studies have been undertaken in low-income, post-conflict countries. This study aimed to assess the prevalence of psychotic-like symptoms in conflict-affected Timor Leste and to examine whether symptoms were associated with trauma and PTSD. METHODS: The Psychosis Screening Questionnaire and the Harvard Trauma Questionnaire (assessing trauma exposure and PTSD) were administered in an epidemiological survey of 1245 adults (response rate 80.6%) in a rural and an urban setting in Timor Leste. We defined PSQ screen-positive cases as those people reporting at least one psychotic-like symptom (paranoia, hallucinations, strange experiences, thought interference, hypomania). RESULTS: The prevalence of PSQ screen-positive cases was 12 percent and these persons were more disabled. PSQ cases were more likely to reside in the urban area, experienced higher levels of trauma exposure and a greater prevalence of PTSD. PTSD only partially mediated the relationship between trauma exposure and psychotic-like symptoms. CONCLUSIONS: Psychotic-like symptoms may be prevalent in countries exposed to mass conflict. The cultural and contextual meaning of psychotic-like symptoms requires further inquiry in low-income, post-conflict settings such as Timor Leste.

Adult separation anxiety disorder: a disorder comes of age.

This article explores accruing evidence supporting the occurrence of an adult form of separation anxiety disorder (ASAD), a category yet to be recognized by international classification systems. ASAD can have its first onset in adulthood, although in a portion of cases, it represents a persistence or recurrence of the childhood-onset type. Recent large-scale clinic studies have suggested that ASAD is associated with high levels of disability. In addition, the presence of ASAD in individuals with anxiety disorders seems to signal a poor outcome to cognitive-behavioral therapy. The existing evidence suggests possible grounds for removing the childhood-onset requirement for the category of separation anxiety disorder, thereby allowing for first onset in adulthood. There is a pressing need to design and test appropriate treatments for ASAD and to educate clinicians to identify and manage the condition.

The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic.

BACKGROUND: Adult separation anxiety disorder (ASAD) has been identified recently, but there is a paucity of data about its prevalence and associated characteristics amongst anxiety patients. This study assessed the prevalence and risk factor profile associated with ASAD in an anxiety clinic. METHODS: Clinical psychologists assigned 520 consecutive patients to DSM-IV adult anxiety subcategories using the SCID. We also measured demographic factors and reports of early separation anxiety (the Separation Anxiety Symptom Inventory and a retrospective diagnosis of childhood separation anxiety disorder). Other self-report measures included the Adult Separation Anxiety Symptom Questionnaire (ASA-27), the Depression, Anxiety, Stress Scales (DASS-21), personality traits measured by the NEO PI-R and the Work and Social Adjustment Scale. These measures were included in three models examining for overall differences and then by gender: Model 1 compared the conventional SCID anxiety subtypes (excluding PTSD and OCD because of insufficient numbers); Model 2 divided the sample into those with and without ASAD; Model 3 compared those with ASAD with the individual anxiety subtypes in the residual group. RESULTS: Patients with ASAD had elevated early separation anxiety scores but this association was unique in females only. Except for social phobia in relation to some comparisons, those with ASAD recorded more severe symptoms of depression, anxiety and stress, higher neuroticism scores, and greater levels of disability. CONCLUSIONS: Patients with ASAD attending an anxiety clinic are highly symptomatic and disabled. The findings have implications for the classification, clinical identification and treatment of adult anxiety disorders.

Adult separation anxiety disorder among war-affected Bosnian refugees: comorbidity with PTSD and associations with dimensions of trauma.

Although separation anxiety disorder appears to be common among children exposed to disasters, there are no data focusing on the impact of trauma on adult separation anxiety disorder. The present exploratory study examined the relationship of adult separation anxiety disorder with other psychological reactions (posttraumatic stress disorder [PTSD], complicated grief, depression) and dimensions of trauma among 126 war-affected Bosnian refugees resettled in Australia. Adult separation anxiety disorder was associated with PTSD, but not with complicated grief or depression. Although adult separation anxiety disorder was weakly linked with traumatic losses, this association was nonspecific. Further research is needed to clarify the pathogenic pathways leading to the comorbid PTSD-adult separation anxiety disorder pattern and its clinical implications.

Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder.

OBJECTIVE: Attachment theory suggests that anxious attachment styles are associated with risk to psychiatric disorder, especially anxiety disorders. Separation anxiety would appear to be a core form of anxiety that is associated with anxious attachment. Nevertheless, as yet no research has examined the relationship of attachment styles to adult separation anxiety disorder, a condition that has only recently been fully recognized. METHOD: The Attachment Style Questionnaire was used to examine attachment styles among 83 consecutive anxiety clinic patients diagnosed with panic disorder with agoraphobia and those re-assigned from that category to adult separation anxiety disorder. RESULTS: Dimensional associations showed strong correlations with scales measuring anxious attachment and separation anxiety. Patients assigned to the separation anxiety group scored significantly higher than those in the panic disorder group on the scales of Need for Approval and Preoccupation with Relationships. CONCLUSIONS: The findings finally dispel the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder. Possible implications for treatment are considered.

Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis.

CONTEXT: Uncertainties continue about the roles that methodological factors and key risk factors, particularly torture and other potentially traumatic events (PTEs), play in the variation of reported prevalence rates of posttraumatic stress disorder (PTSD) and depression across epidemiologic surveys among postconflict populations worldwide. OBJECTIVE: To undertake a systematic review and meta-regression of the prevalence rates of PTSD and depression in the refugee and postconflict mental health field. DATA SOURCES: An initial pool of 5904 articles, identified through MEDLINE, PsycINFO and PILOTS, of surveys involving refugee, conflict-affected populations, or both, published in English-language journals between 1980 and May 2009. STUDY SELECTION: Surveys were limited to those of adult populations (n > or = 50) reporting PTSD prevalence, depression prevalence, or both. Excluded surveys comprised patients, war veterans, and civilian populations (nonrefugees/asylum seekers) from high-income countries exposed to terrorist attacks or involved in distal conflicts (> or = 25 years). DATA EXTRACTION: Methodological factors (response rate, sample size and design, diagnostic method) and substantive factors (sociodemographics, place of survey, torture and other PTEs, Political Terror Scale score, residency status, time since conflict). DATA SYNTHESIS: A total of 161 articles reporting results of 181 surveys comprising 81,866 refugees and other conflict-affected persons from 40 countries were identified. Rates of reported PTSD and depression showed large intersurvey variability (0%-99% and 3%-85.5%, respectively). The unadjusted weighted prevalence rate reported across all surveys for PTSD was 30.6% (95% CI, 26.3%-35.2%) and for depression was 30.8% (95% CI, 26.3%-35.6%). Methodological factors accounted for 12.9% and 27.7% PTSD and depression, respectively. Nonrandom sampling, small sample sizes, and self-report questionnaires were associated with higher rates of mental disorder. Adjusting for methodological factors, reported torture (Delta total R(2) between base methodological model and base model + substantive factor [DeltaR(2)] = 23.6%; OR, 2.01; 95% CI, 1.52-2.65) emerged as the strongest factor associated with PTSD, followed by cumulative exposure to PTEs (DeltaR(2) = 10.8%; OR, 1.52; 95% CI, 1.21-1.91), time since conflict (DeltaR(2) = 10%; OR, 0.77; 95% CI, 0.66-0.91), and assessed level of political terror (DeltaR(2) = 3.5%; OR, 1.60; 95% CI, 1.03-2.50). For depression, significant factors were number of PTEs (DeltaR(2) = 22.0%; OR, 1.64; 95% CI, 1.39-1.93), time since conflict (DeltaR(2) = 21.9%; OR, 0.80; 95% CI, 0.69-0.93), reported torture (DeltaR(2) = 11.4%; OR, 1.48; 95% CI, 1.07-2.04), and residency status (DeltaR(2) = 5.0%; OR, 1.30; 95% CI, 1.07-1.57). CONCLUSION: Methodological factors and substantive population risk factors, such as exposure to torture and other PTEs, after adjusting for methodological factors account for higher rates of reported prevalence of PTSD and depression.

Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders--a pilot group randomized trial.

A group randomized trial of adding a home-based walking program to a standard group cognitive behavioral therapy (GCBT+EX) was compared with groups receiving GCBT and educational sessions (GCBT+ED). The study was implemented in an outpatient clinic providing GCBT for clients diagnosed with panic disorder, generalized anxiety disorder or social phobia. Pre- and post-treatment measures included the self-report depression, anxiety, and stress scale (DASS-21) and measures of physical activity. From January 2004 to May 2005, six groups were allocated to GCBT+EX (n=38) and five to GCBT+ED (n=36). Analysis of covariance for completed cases (GCBT+EX, n=21; GCBT+ED, n=20), adjusting for the group design, baseline DASS-21 scores, and anxiety diagnosis showed significant effect for GCBT+EX on depression, anxiety, and stress (regression coefficients=-6.21, -3.41, and -5.14, respectively, p<0.05) compared to the GCBT+ED. The potential of exercise interventions as adjunct to GCBT for anxiety disorder needs to be further explored.

Development of the "Recovery from Eating Disorders for Life" Food Guide (REAL Food Guide) - a food pyramid for adults with an eating disorder.

BACKGROUND: There is limited evidence to inform nutrition and dietetic interventions for individuals with eating disorders even though it is recommended as an essential part of multidisciplinary management. There is minimal guidance, an absence of standardised nutrition educational material, and no research on how best to educate patients on healthy eating and how to achieve nutrition adequacy. Therefore the REAL Food Guide was developed. METHODS: The REAL Food Guide is a pyramid with four layers and key nutrition messages beside each layer that was conceived to address gaps in nutrition education and intervention for individuals with eating disorders. Written and verbal consumer feedback was obtained from consumers receiving treatment regarding the acceptability and usefulness of the REAL Food Guide. A unique database was developed to reflect the types of foods and realistic portion sizes that patients are likely to select. This database was used for nutrition modelling to assess the nutrition adequacy of three meal patterns (meat containing, vegetarian and semi-vegan) for both weight maintenance and weight regain. Each meal pattern was compared to the Nutrient Reference Values for Australia and New Zealand. RESULTS: Nutritional analysis demonstrated nutritional adequacy of meal patterns for energy, macronutrients and most micronutrients when the recommended number of serves from the REAL Food Guide were assessed. All meal patterns were adequate in micronutrients except for the semi-vegan meal pattern that was inadequate in vitamin D. Feedback from individuals with eating disorders demonstrates the nutrition education tool was acceptable to them as they felt it was more helpful for their recovery than general nutrition guidelines. CONCLUSION: The REAL Food Guide is a comprehensive and user-friendly guide that clinicians can use to educate patients about components of a balanced and healthy diet. The guide can educate all eating disorder clinicians, including those who are new to the field, about the basics of nutrition. Clinicians using the guide can be confident that, if followed, patient's energy and nutritional requirements will be met and important nutrition education messages are reinforced, that are tailored to the beliefs and concerns of individuals with eating disorders.

Delays in referral of patients with social phobia, panic disorder and generalized anxiety disorder attending a specialist anxiety clinic.

Individuals with anxiety disorders experience substantial delays in obtaining treatment, but little is known about whether people with specific anxiety subcategories are differentially affected. The present study used a modified Encounter Form to examine the cause and length of delays in reaching primary care and specialist services amongst patients with panic disorder (PD/PD-Ag), social phobia (SP), and generalized anxiety disorder (GAD). Participants were 142 consecutive patients attending a specialist anxiety clinic in South Western Sydney. On average, participants with SP took much longer to consult a primary health care provider. Primary care assessments of those with SP often failed to detect anxiety as the key problem, and subsequently, those with SP reported longer delays in reaching specialist care (>9 years). It is not possible to extrapolate the findings to all individuals with SP, as the study was based on specialist service attenders. Nevertheless, the data supports previous findings in suggesting that SP may not be well-recognized as a disorder needing treatment, either by the patient or the primary health care provider. Appropriate educational programs seem warranted to ensure appropriate treatment for this condition.

Characteristics of Vietnamese patients attending an anxiety clinic in Australia and perceptions of the wider Vietnamese community about anxiety.

This article examined the causes underlying low utilization of mental health services by Vietnamese immigrants in Australia. Study 1 examined cases of Vietnamese patients who had attended an anxiety disorders clinic, while Study 2 surveyed Vietnamese people in the community on their knowledge and attitudes towards common mental problems. Results from Study 1 showed that Vietnamese patients had significantly higher attrition rates, and presented with a larger number of nonanxiety disorders than their Australian-born counterparts. Study 2 results indicated that many Vietnamese people did not differentiate clearly between the terms 'stress', 'anxiety' and 'depression'. Additionally, many participants felt that there was a generally negative cultural attitude towards people suffering from these problems and the mental health system itself. These outcomes suggest the importance of education for ethnic communities regarding available mental health facilities and treatments offered, as well as specific information on mental illness to help remove stigma.

The global prevalence of common mental disorders: a systematic review and meta-analysis 1980-2013.

BACKGROUND: Since the introduction of specified diagnostic criteria for mental disorders in the 1970s, there has been a rapid expansion in the number of large-scale mental health surveys providing population estimates of the combined prevalence of common mental disorders (most commonly involving mood, anxiety and substance use disorders). In this study we undertake a systematic review and meta-analysis of this literature. METHODS: We applied an optimized search strategy across the Medline, PsycINFO, EMBASE and PubMed databases, supplemented by hand searching to identify relevant surveys. We identified 174 surveys across 63 countries providing period prevalence estimates (155 surveys) and lifetime prevalence estimates (85 surveys). Random effects meta-analysis was undertaken on logit-transformed prevalence rates to calculate pooled prevalence estimates, stratified according to methodological and substantive groupings. RESULTS: Pooling across all studies, approximately 1 in 5 respondents (17.6%, 95% confidence interval:16.3-18.9%) were identified as meeting criteria for a common mental disorder during the 12-months preceding assessment; 29.2% (25.9-32.6%) of respondents were identified as having experienced a common mental disorder at some time during their lifetimes. A consistent gender effect in the prevalence of common mental disorder was evident; women having higher rates of mood (7.3%:4.0%) and anxiety (8.7%:4.3%) disorders during the previous 12 months and men having higher rates of substance use disorders (2.0%:7.5%), with a similar pattern for lifetime prevalence. There was also evidence of consistent regional variation in the prevalence of common mental disorder. Countries within North and South East Asia in particular displayed consistently lower one-year and lifetime prevalence estimates than other regions. One-year prevalence rates were also low among Sub-Saharan-Africa, whereas English speaking counties returned the highest lifetime prevalence estimates. CONCLUSIONS: Despite a substantial degree of inter-survey heterogeneity in the meta-analysis, the findings confirm that common mental disorders are highly prevalent globally, affecting people across all regions of the world. This research provides an important resource for modelling population needs based on global regional estimates of mental disorder. The reasons for regional variation in mental disorder require further investigation.

Overlap of symptom domains of separation anxiety disorder in adulthood with panic disorder-agoraphobia.

There is a need to explain the high level of comorbidity between separation anxiety disorder (SAD) in adulthood and panic disorder with agoraphobia (Pd-Ag). One possibility is that inadequate specification of symptom domains and/or diagnostic questions accounts for some of the comorbidity. The present anxiety clinic study examined responses of adult patients (n = 646) with SAD and/or Pd-Ag on eight symptom domains based on a previous factor analysis of a commonly used separation anxiety measure, the ASA-27, as well as on the Anxiety Sensitivity Index. We also examined questionnaire items that did not load on the factor structure. All separation anxiety domains distinguished strongly between SAD and Pd-Ag. Comparisons across three groups (SAD alone, Pd-Ag alone and comorbid SAD/Pd-Ag) revealed that two symptom domains (anxiety about embarking on trips, and sleep disturbances) showed some overlap between Pd-Ag and SAD. Two of the items of the ASA-27 that did not load with other items in the factor analysis also showed overlap with Pd-Ag, with both referring to anxieties about leaving home. Patients with SAD (with or without Pd-Ag) returned higher scores on anxiety sensitivity than those with Pd-Ag alone. The findings support the distinctiveness of the construct of SAD and the capacity of the ASA-27 to discriminate between that disorder and Pd-Ag. SAD appears to be a more severe form of anxiety than Pd-Ag. There may be a need to refine items to include the reasons for avoiding leaving home, reluctance to sleep alone and to embark on trips, to ensure accurate discrimination between Pd-Ag and SAD in adulthood.

Predicting the impact of the 2011 conflict in Libya on population mental health: PTSD and depression prevalence and mental health service requirements.

BACKGROUND: Mental disorders are likely to be elevated in the Libyan population during the post-conflict period. We estimated cases of severe PTSD and depression and related health service requirements using modelling from existing epidemiological data and current recommended mental health service targets in low and middle income countries (LMIC's). METHODS: Post-conflict prevalence estimates were derived from models based on a previously conducted systematic review and meta-regression analysis of mental health among populations living in conflict. Political terror ratings and intensity of exposure to traumatic events were used in predictive models. Prevalence of severe cases was applied to chosen populations along with uncertainty ranges. Six populations deemed to be affected by the conflict were chosen for modelling: Misrata (population of 444,812), Benghazi (pop. 674,094), Zintan (pop. 40,000), displaced people within Tripoli/Zlitan (pop. 49,000), displaced people within Misrata (pop. 25,000) and Ras Jdir camps (pop. 3,700). Proposed targets for service coverage, resource utilisation and full-time equivalent staffing for management of severe cases of major depression and post-traumatic stress disorder (PTSD) are based on a published model for LMIC's. FINDINGS: Severe PTSD prevalence in populations exposed to a high level of political terror and traumatic events was estimated at 12.4% (95%CI 8.5-16.7) and was 19.8% (95%CI 14.0-26.3) for severe depression. Across all six populations (total population 1,236,600), the conflict could be associated with 123,200 (71,600-182,400) cases of severe PTSD and 228,100 (134,000-344,200) cases of severe depression; 50% of PTSD cases were estimated to co-occur with severe depression. Based upon service coverage targets, approximately 154 full-time equivalent staff would be required to respond to these cases sufficiently which is substantially below the current level of resource estimates for these regions. DISCUSSION: This is the first attempt to predict the mental health burden and consequent service response needs of such a conflict, and is crucially timed for Libya.

Brief report--associations of personality disorder with early separation anxiety in patients with adult separation anxiety disorder.

A recent study has suggested a link between early separation anxiety and personality disorder. It is possible that this relationship is mediated or confounded by the presence of adult separation anxiety disorder (ASAD). In a clinic study of 397 anxiety patients, we found that ASAD patients with heightened early separation anxiety had higher rates of any Cluster C personality disorder compared to ASAD patients without elevated early separation anxiety, and higher rates of any Cluster B or C personality disorder compared to anxiety patients with low early separation anxiety and no ASAD. Although cross-sectional in design, the study supports a direct link between early separation anxiety and some adult personality disorders, irrespective of the type of adult anxiety disorder present, including ASAD.

Separation anxiety in adulthood: dimensional or categorical?

Recent evidence suggests that a clinical form of separation anxiety can be observed in adults. An important question of relevance to defining the construct of adult separation anxiety is whether there is discontinuity between that constellation and other forms of anxiety. In the present study, 2 taxometric procedures - Mean Above Minus Below a Cut and Maximum Eigenvalue - were used to assess whether adult separation anxiety conformed primarily to a categorical or a dimensional pattern. The data were derived from a separation anxiety symptom questionnaire completed by 840 consecutive adult patients attending an anxiety disorders clinic. Although some results of the analysis were ambiguous, the overall findings suggested a dimensional pattern. The relevance of the finding to the status of adult separation anxiety is discussed.