The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium.

BACKGROUND: Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs. METHOD: General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure. RESULTS: Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types - witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury - accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events. CONCLUSIONS: Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.

The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication.

Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication, a nationally representative survey of US adults. A subsample of 2073 respondents was assessed for lifetime Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) OCD. More than one quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale, is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early onset cases in men, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.

Mental disorders as risk factors for later substance dependence: estimates of optimal prevention and treatment benefits.

BACKGROUND: Although mental disorders have been shown to predict subsequent substance disorders, it is not known whether substance disorders could be cost-effectively prevented by large-scale interventions aimed at prior mental disorders. Although experimental intervention is the only way to resolve this uncertainty, a logically prior question is whether the associations of mental disorders with subsequent substance disorders are strong enough to justify mounting such an intervention. We investigated this question in this study using simulations to estimate the number of substance disorders that might be prevented under several hypothetical intervention scenarios focused on mental disorders. METHOD: Data came from the National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey that retrospectively assessed lifetime history and age of onset of DSM-IV mental and substance disorders. Survival analysis using retrospective age-of-onset reports was used to estimate associations of mental disorders with subsequent substance dependence. Simulations based on the models estimated effect sizes in several hypothetical intervention scenarios. RESULTS: Although successful intervention aimed at mental disorders might prevent some proportion of substance dependence, the number of cases of mental disorder that would have to be treated to prevent a single case of substance dependence is estimated to be so high that this would not be a cost-effective way to prevent substance dependence (in the range 76-177 for anxiety-mood disorders and 40-47 for externalizing disorders). CONCLUSIONS: Treatment of prior mental disorders would not be a cost-effective way to prevent substance dependence. However, prevention of substance dependence might be considered an important secondary outcome of interventions for early-onset mental disorders.

Implications of modifying the duration requirement of generalized anxiety disorder in developed and developing countries.

BACKGROUND: A number of western studies have suggested that the 6-month duration requirement of generalized anxiety disorder (GAD) does not represent a critical threshold in terms of onset, course, or risk factors of the disorder. No study has examined the consequences of modifying the duration requirement across a wide range of correlates in both developed and developing countries. METHOD: Population surveys were carried out in seven developing and 10 developed countries using the WHO Composite International Diagnostic Interview (total sample=85,052). Prevalence and correlates of GAD were compared across mutually exclusive GAD subgroups defined by different minimum duration criteria. RESULTS: Lifetime prevalence estimates for GAD lasting 1 month, 3 months, 6 months and 12 months were 7.5%, 5.2%, 4.1% and 3.0% for developed countries and 2.7%, 1.8%, 1.5% and 1.2% for developing countries, respectively. There was little difference between GAD of 6 months' duration and GAD of shorter durations (1-2 months, 3-5 months) in age of onset, symptom severity or persistence, co-morbidity or impairment. GAD lasting >or=12 months was the most severe, persistently symptomatic and impaired subgroup. CONCLUSIONS: In both developed and developing countries, the clinical profile of GAD is similar regardless of duration. The DSM-IV 6-month duration criterion excludes a large number of individuals who present with shorter generalized anxiety episodes which may be recurrent, impairing and contributory to treatment-seeking. Future iterations of the DSM and ICD should consider modifying the 6-month duration criterion so as to better capture the diversity of clinically salient anxiety presentations.

Psychotherapy for generalized anxiety disorder.

The present article describes the basic therapeutic techniques used in the cognitive-behavioral therapy (CBT) of generalized anxiety disorders and reviews the methodological characteristics and outcomes of 13 controlled clinical trials. The studies in general display rigorous methodology, and their outcomes are quite consistent. CBT has been shown to yield clinical improvements in both anxiety and depression that are superior to no treatment and nonspecific control conditions (and at times to either cognitive therapy alone or behavioral therapy alone) at both posttherapy and follow-up. CBT is also associated with low dropout rates, maintained long-term improvements, and the largest within-group and between-group effect sizes relative to all other comparison conditions.

Informing the continuity controversy: a taxometric analysis of depression.

Researchers and practitioners have long debated the structural nature of mental disorders. Until recently, arguments favoring categorical or dimensional conceptualizations have been based primarily on theoretical speculation and indirect empirical evidence. Within the depression literature, methodological limitations of past studies have hindered their capacity to inform this important controversy. Two studies were conducted using MAXCOV and MAMBAC, taxometric procedures expressly designed to assess the underlying structure of a psychological construct. Analyses were performed in large clinical samples with high base rates of major depression and a broad range of depressive symptom severity. Results of both studies, drawing on 3 widely used measures of depression, corroborated the dimensionality of depression. Implications for the conceptualization, investigation, and assessment of depression are discussed.

A taxometric investigation of the latent structure of worry.

Researchers have described 2 types of worriers, normal and pathological, who differ in the frequency, intensity, and controllability of their worry experiences. Although normal and pathological worry are generally treated as separate though related phenomena, no study has tested for separateness against the alternative hypothesis that all worry exists along a single dimension. In the present study, worry ratings of 1,588 college students were submitted to taxometric procedures designed to evaluate latent structure. Results provided evidence for the dimensionality of worry. These findings suggest that generalized anxiety disorder (GAD), whose central feature is worry, may also be quantitatively rather than qualitatively different from normal functioning. The authors argue that a focus on normal and pathological extremes has constrained the study of worry phenomena and that dimensional conceptualization of worry may significantly enhance understanding of both worry and GAD.

Predicting the child-rearing practices of mothers sexually abused in childhood.

OBJECTIVE: Although empirical investigations have established a relationship between childhood sexual abuse and numerous long-term consequences, surprisingly little research has addressed the possible effects of childhood victimization on the later child-rearing practices of adult survivors. The present study examined hypothesized predictors of three parenting styles among adult survivors of sexual abuse as compared with adult children of alcoholic parents. METHOD: Forty-five clinical outpatients completed a questionnaire battery assessing experiences of childhood abuse, current economic and social resources, and parenting attitudes and practices. The child-rearing practices of participants were compared with those reported by a community sample of 717 mothers. Additional analyses examined the extent to which sexual abuse and its adult sequelae predicted the parenting behaviors reported by the present sample. RESULTS: Both sexual abuse survivors and children of alcoholics reported significantly higher rates of permissive parenting practices than mothers in the community sample. Multiple regression analyses further revealed unique relationships between sexual abuse and parenting, over and above the variance explained by physical abuse, current socioeconomic status, and the experience of growing up in an alcoholic home. Mothers' sexual abuse severity, social support satisfaction, and dysfunctional parenting attitudes moderated several of these relationships. CONCLUSIONS: The present findings suggest that sexual abuse and its adult sequelae may have negative consequences for the parenting practices of survivors, particularly for survivors' ability to provide their children with appropriate structure, consistent discipline, and clear behavioral expectations. Implications for the psychosocial development of survivors' children are discussed.

Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication.

BACKGROUND: Despite heightened awareness of the clinical significance of social phobia, information is still lacking about putative subtypes, functional impairment, and treatment-seeking. New epidemiologic data on these topics are presented from the National Comorbidity Survey Replication (NCS-R). METHOD: The NCS-R is a nationally representative household survey fielded in 2001-2003. The World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) was used to assess 14 performance and interactional fears and DSM-IV social phobia. RESULTS: The estimated lifetime and 12-month prevalence of social phobia are 12.1% and 7.1% respectively. Performance and interactional fears load onto a single latent factor, and there is little evidence for distinct subtypes based either on the content or the number of fears. Social phobia is associated with significant psychiatric co-morbidity, role impairment, and treatment-seeking, all of which have a dose-response relationship with number of social fears. However, social phobia is the focus of clinical attention in only about half of cases where treatment is obtained. Among non-co-morbid cases, those with the most fears were least likely to receive social phobia treatment. CONCLUSIONS: Social phobia is a common, under-treated disorder that leads to significant functional impairment. Increasing numbers of social fears are associated with increasingly severe manifestations of the disorder.