Sleep Quality Improvement During Cognitive Behavioral Therapy for Anxiety Disorders.

Despite the ubiquity of sleep complaints among individuals with anxiety disorders, few prior studies have examined whether sleep quality improves during anxiety treatment. The current study examined pre- to posttreatment sleep quality improvement during cognitive behavioral therapy (CBT) for panic disorder (PD; n = 26) or generalized anxiety disorder (GAD; n = 24). Among sleep quality indices, only global sleep quality and sleep latency improved significantly (but modestly) during CBT. Sleep quality improvement was greater for treatment responders, but did not vary by diagnosis. Additionally, poor baseline sleep quality was independently associated with worse anxiety treatment outcome, as measured by higher intolerance of uncertainty. Additional intervention targeting sleep prior to or during CBT for anxiety may be beneficial for poor sleepers.

Common and disorder-specific neural responses to emotional faces in generalised anxiety, social anxiety and panic disorders.

BACKGROUND: Although evidence exists for abnormal brain function across various anxiety disorders, direct comparison of neural function across diagnoses is needed to elicit abnormalities common across disorders and those distinct to a particular diagnosis. AIMS: To delineate common and distinct abnormalities within generalised anxiety (GAD), panic and social anxiety disorder (SAD) during affective processing. METHOD: Fifty-nine adults (15 with GAD, 15 with panic disorder, 14 with SAD, and 15 healthy controls) underwent functional magnetic resonance imaging while completing a facial emotion matching task with fearful, angry and happy faces. RESULTS: Greater differential right amygdala activation to matching fearful v. happy facial expressions related to greater negative affectivity (i.e. trait anxiety) and was heightened across all anxiety disorder groups compared with controls. Collapsing across emotional face types, participants with panic disorder uniquely displayed greater posterior insula activation. CONCLUSIONS: These preliminary results highlight a common neural basis for clinical anxiety in these diagnoses and also suggest the presence of disorder-specific dysfunction.

Risk for suicidal behaviors associated with alcohol and energy drink use in the US Army.

PURPOSE: Suicidal behaviors have increased in the US Army since 2005. To identify potential interventions for suicide risk, we examined the relationship between alcohol and energy drink use, independently and in combination, and rates of seriously considering and/or attempting suicide in US Army soldiers. METHODS: This study used the DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD HRB), which sampled 10,400 Army soldiers, with 5,927 responses representing 508,088 soldiers. Use of energy drinks in combination with alcohol (A/ED) and average daily amount of alcohol consumption over the past 30 days and history of seriously considering and/or attempting suicide in the past year were assessed via self-report questions. RESULTS: Six percent of Army service members reported either seriously considering and/or attempting suicide in the past year. Twenty-six percent of soldiers reported A/ED. Those who reported the highest level of alcohol use were more likely to have seriously considered and/or attempted suicide. Soldiers who reported daily A/ED were over three times more likely to have reported suicidal ideation or attempts, and even after adjusting for overall alcohol consumption and energy drink use alone remained approximately two times (OR = 1.99) more likely to report suicidality. CONCLUSIONS: Combination alcohol and energy drink use and heavy alcohol use contribute to suicidality and may be targets for potential intervention to address suicide risk.

Screening for adolescent anxiety disorders in a pediatric emergency department.

OBJECTIVES: Adolescence is a time of increasing risk for some anxiety disorders. Scant data exist on adolescent anxiety in emergency department (ED) settings. We sought to characterize select clinical characteristics and health care use associated with anxiety disorders in a pediatric ED. METHODS: We screened a convenience sample of 100 adolescent-parent dyads presenting to the ED for the presence of child anxiety disorders using the 5-item Screen for Child Anxiety Related Emotional Disorders, parent (SCARED-P) and child (SCARED-C) versions. Additional demographic and clinical data were also collected. RESULTS: The SCARED-P and SCARED-C screens identified probable anxiety disorder(s) in 26% to 33% of adolescent participants, respectively. Correlates of positive SCARED-C screens were female sex, asthma, presenting complaint involving headache or migraine, and school absenteeism due to physical problems. Correlates of positive SCARED-P screens were lower parental educational level, presenting complaint involving headache or migraine, and more medical specialty and total medical visits. Few anxious adolescents had received mental health services in the past 6 months. In multivariate models, female sex was independently associated with SCARED-C total score, and presenting complaint involving headache or migraine was independently associated with SCARED-P total score. CONCLUSIONS: The current pilot data suggest that anxiety disorders are more prevalent among adolescent ED patients than among the general population but largely untreated. Several demographic and clinical variables may help to identify occult anxiety disorders. Greater awareness of anxiety disorders in this population may assist in redirecting a pattern of low use of mental health services but higher overall health care use.

Neuroticism mediates the relationship between childhood adversity and adult sleep quality.

This study investigated the relationship of childhood adversity and adult sleep quality in 327 college students (91 males), with a mean age of 18.9 years (SD = 2.1) and also examined whether neuroticism significantly mediated the observed association. Regression findings indicate that the relationship between childhood adversity and adult sleep quality is significant, and that there is a stronger association in men. Furthermore, a bootstrapping approach to testing the significance of the indirect effect (i.e., mediation) indicated that neuroticism mediated this relationship in both men and women. These data suggest that otherwise healthy young adults with a history of childhood adversity are at increased risk for sleep disturbance. Neuroticism may represent a potential target for change in future insomnia interventions, particularly in adults with a history of childhood adversity.

Anxiety sensitivity as a predictor of the clinical course of panic disorder: a 1-year follow-up study.

BACKGROUND: There is evidence that negative affect (NA) and anxiety sensitivity (AS) predict the development of anxiety disorders, particularly panic disorder (PD). The main purpose of this study was to examine whether NA and AS will also predict the clinical course of PD. METHODS: Participants were 136 individuals with a DSM-III-R diagnosis of PD (with or without agoraphobia) enrolled in a naturalistic and longitudinal study of anxiety disorders, the Harvard/Brown Anxiety Research Project (HARP). Participants were administered the Anxiety Sensitivity Index and the Negative Affect Scales of the Positive and Negative Affect Schedule-Expanded Form (PANAS-X-NA) and their percentage of time in PD episode was followed for 1 year after the administration of the measures. RESULTS: Multiple regression analyses indicated that AS, but not NA, was a significant predictor of percentage of time in PD episode after controlling for previous time in PD episodes, comorbid depression, other anxiety disorders, and exposure to psychopharmacological and behavioral treatments. As expected, the Physical Concerns subscale of the Anxiety Sensitivity Index had a significant independent contribution in predicting the course of the disorder. CONCLUSIONS: Overall, these findings suggest that AS, as a unique construct, may be predictive of the amount of time patients are in episode of PD.

Single-Subject Anxiety Treatment Outcome Prediction using Functional Neuroimaging.

This corrects the article DOI: 10.1038/npp.2013.328.

What good are positive emotions for treatment? Trait positive emotionality predicts response to Cognitive Behavioral Therapy for anxiety.

OBJECTIVE: Cognitive behavioral therapy (CBT) is empirically supported for the treatment of anxiety disorders; however, not all individuals achieve recovery following CBT. Positive emotions serve a number of functions that theoretically should facilitate response to CBT - they promote flexible patterns of information processing and assimilation of new information, encourage approach-oriented behavior, and speed physiological recovery from negative emotions. We conducted a secondary analysis of an existing clinical trial dataset to test the a priori hypothesis that individual differences in trait positive emotions would predict CBT response for anxiety. METHOD: Participants meeting diagnostic criteria for panic disorder (n = 28) or generalized anxiety disorder (n = 31) completed 10 weekly individual CBT sessions. Trait positive emotionality was assessed at pre-treatment, and severity of anxiety symptoms and associated impairment was assessed throughout treatment. RESULTS: Participants who reported a greater propensity to experience positive emotions at pre-treatment displayed the largest reduction in anxiety symptoms as well as fewer symptoms following treatment. Positive emotions remained a robust predictor of change in symptoms when controlling for baseline depression severity. CONCLUSIONS: Initial evidence supports the predictive value of trait positive emotions as a prognostic indicator for CBT outcome in a GAD and PD sample.

Association of Childhood Anxiety Disorders and Quality of Life in a Primary Care Sample.

UNLABELLED: Anxiety disorders are associated with measurable deficits in quality of life (QOL) in adult samples. However, this association has largely been unexplored in pediatric samples. In this study, we examined relationships between child anxiety-including number of anxiety disorders (comorbidity), symptom severity, and subtypes of anxiety-and QOL in a pediatric primary care sample. RESULTS: Anxiety comorbidity was common in the current sample (n = 73), with 3-quarters being diagnosed with more than one anxiety disorder. QOL in the current sample did not vary significantly by age, gender, or race/ethnicity. Both greater comorbidity and higher total anxiety symptom severity were inversely associated with QOL across multiple domains, although anxiety comorbidity did not reach significance in multivariate models adjusted for gender, income, and externalizing symptoms. On the anxiety severity subscales, both physical symptoms and social anxiety had independent associations with QOL. CONCLUSIONS: Anxiety-related outcomes, as measured by anxiety comorbidity, symptom severity, and type of anxiety, are associated with significantly worse QOL in a pediatric sample. Providers should be aware that QOL is impacted by both severity and type of anxiety-related conditions, particularly social anxiety and somatic-related anxiety.

Single-subject anxiety treatment outcome prediction using functional neuroimaging.

The possibility of individualized treatment prediction has profound implications for the development of personalized interventions for patients with anxiety disorders. Here we utilize random forest classification and pre-treatment functional magnetic resonance imaging (fMRI) data from individuals with generalized anxiety disorder (GAD) and panic disorder (PD) to generate individual subject treatment outcome predictions. Before cognitive behavioral therapy (CBT), 48 adults (25 GAD and 23 PD) reduced (via cognitive reappraisal) or maintained their emotional responses to negative images during fMRI scanning. CBT responder status was predicted using activations from 70 anatomically defined regions. The final random forest model included 10 predictors contributing most to classification accuracy. A similar analysis was conducted using the clinical and demographic variables. Activations in the hippocampus during maintenance and anterior insula, superior temporal, supramarginal, and superior frontal gyri during reappraisal were among the best predictors, with greater activation in responders than non-responders. The final fMRI-based model yielded 79% accuracy, with good sensitivity (0.86), specificity (0.68), and positive and negative likelihood ratios (2.73, 0.20). Clinical and demographic variables yielded poorer accuracy (69%), sensitivity (0.79), specificity (0.53), and likelihood ratios (1.67, 0.39). This is the first use of random forest models to predict treatment outcome from pre-treatment neuroimaging data in psychiatry. Together, random forest models and fMRI can provide single-subject predictions with good test characteristics. Moreover, activation patterns are consistent with the notion that greater activation in cortico-limbic circuitry predicts better CBT response in GAD and PD.

Cognitive-behavioral therapy for generalized anxiety disorder is associated with attenuation of limbic activation to threat-related facial emotions.

BACKGROUND: The neural processes underlying the benefits of cognitive behavioral treatment (CBT) for generalized anxiety disorder (GAD) are not well understood. METHODS: Twenty-one (n=21) adults with a principal diagnosis of GAD and eleven (n=11) non-anxious healthy controls (HC) underwent functional magnetic resonance imaging while completing a facial emotion processing task. Responses to threat-related emotionality (i.e., the contrast of fear and angry vs. happy faces) were assessed at pretreatment and again following 10 sessions of CBT in the GAD group and a comparable waiting period in the HC group. RESULTS: At pretreatment, GAD participants displayed blunted responses in the amygdala, insula, and anterior cingulate to the happy face-processing comparison condition, and greater amygdalo-insular connectivity. CBT was associated with attenuated amygdalar and subgenual anterior cingulate activation to fear/angry faces and heightened insular responses to the happy face comparison condition, but had no apparent effects on connectivity. Pre-treatment abnormalities and treatment-related changes were not associated with symptoms of worry. LIMITATIONS: There was no active control condition (e.g., treatment waitlist) for comparison of treatment effects. CONCLUSIONS: Taken together, these results provide evidence for a dual-process psychotherapeutic model of neural systems changes in GAD in which cingulo-amygdalar reactivity to threat-cues is attenuated while insular responses to positive facial emotions are potentiated. Future work is needed to determine the clinical implications of these changes and their specificity to CBT.

Risk for suicidal behaviors associated with PTSD, depression, and their comorbidity in the U.S. Army.

BACKGROUND: Suicide rates have risen considerably in the United States Army in the past decade. Suicide risk is highest among those with past suicidality (suicidal ideation or attempts). The incidence of posttraumatic stress disorder (PTSD) and depressive illnesses has risen concurrently in the U.S. Army. We examined the relationship of PTSD and depression, independently and in combination, and rates of past-year suicidality in a representative sample of U.S. Army soldiers. METHODS: This study used the DoD Survey of Health Related Behaviors Among Active Duty Military Personnel (DoD HRB) (N=5927). Probable PTSD and depression were assessed with the PTSD Checklist (PCL) and the 10-item short form of the Center for Epidemiologic Studies Depression Scale (CES-D), respectively. Past-year suicidality was assessed via self-report. RESULTS: Six percent of Army service members reported suicidality within the past year. PTSD and MDD were each independently associated with past-year suicidality. Soldiers with both disorders were almost three times more likely to report suicidality within the past year than those with either diagnosis alone. Population-attributable risk proportions for PTSD, depression, and both disorders together were 24%, 29%, and 45%, respectively. LIMITATIONS: The current study is subject to the limitations of a cross-sectional survey design and the self-report nature of the instruments used. CONCLUSIONS: PTSD and depression are each associated with suicidality independently and in combination in the active duty component of the U.S. Army. Soldiers presenting with either but especially both disorders may require additional outreach and screening to decrease suicidal ideation and attempts.

Age of onset, clinical characteristics, and 15-year course of anxiety disorders in a prospective, longitudinal, observational study.

BACKGROUND: Age of onset is rarely studied in the anxiety disorders literature. The current study examined age of onset as it relates to clinical characteristics and course of anxiety disorders using a prospective, longitudinal, observational design. METHODS: Fifteen-year follow-up data were examined for participants with panic disorder with (PDA) or without (PD) agoraphobia, social phobia (SP), and/or generalized anxiety disorder (GAD) at baseline. Logistic regression analyses were conducted to determine whether age of onset was associated with demographic or clinical variables at baseline. Cox regression analyses were conducted to examine longitudinal course (time to recurrence and recovery, respectively) for each diagnostic group. RESULTS: At baseline, PD participants with early onset (i.e., < age 20) were more likely to have comorbid MDD, GAD, and SP relative to late-onset participants (≥ age 20). For PDA, early-onset participants were less likely to be married, and more likely to have both GAD and SP at baseline. With respect to longitudinal course, earlier onset was associated with an increased likelihood of recurrence in participants with PDA. No other models reached significance. LIMITATIONS: The sample sizes for some disorders were comparatively small in relation to PDA, and all participants were treatment-seeking, which may limit generalizability. CONCLUSIONS: For some anxiety disorders, earlier age of onset appears to be associated with greater severity and worse course, as evidenced by increased risk of recurrence over 15years of follow-up. Early interventions focused on children and adolescents may alleviate some of the public health burden associated with anxiety disorders.

Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda.

The current review describes the phenomenology of several common anxiety disorders in children and adolescents as they present in medical settings. Anxiety disorders and associated features in children are described, along with epidemiology, functional impairment, common somatic complaints, medical comorbidity, health care utilization, and presentation in general and in specialty pediatric medical settings. Recommendations for clinical management in pediatric settings are presented, and evidence-based interventions and emerging treatments for pediatric anxiety disorders are described. The review concludes with a discussion of future research directions that may lead to increased recognition and improved management of anxiety disorders in pediatric medical settings.

Relationship of anxiety disorders, sleep quality, and functional impairment in a community sample.

BACKGROUND: Anxiety disorders and insomnia are each prevalent, impairing, and highly comorbid. However, little is known about whether specific types of sleep complaints are associated with specific anxiety disorders, and whether poor sleep has an additive effect on functional impairment in anxiety disorders. METHOD: Data from the German Health Survey (GHS; N = 4181; ages 18-65) were utilized to examine relationships among anxiety disorders, sleep quality (assessed by the Pittsburgh Sleep Quality Inventory; PSQI), and functional impairment (assessed by the Medical Outcomes Scale Short Form; SF-36; and past-month disability days due to physical and emotional problems, respectively). RESULTS: Most anxiety disorders were significantly associated with global PSQI scores. Social phobia (AOR 3.95, 95% CI 1.73-9.04) and GAD (AOR 3.94, 95% CI 1.66-9.34) had the strongest relationships with global PSQI scores. Daytime dysfunction was the PSQI subscale most strongly associated with anxiety disorders, particularly GAD. Having a comorbid anxiety disorder and poor sleep was associated with significantly lower Mental Component Scores on the SF-36 than having an anxiety disorder alone (40.87 versus 43.87, p = .011) and with increased odds of one or more disability days due to emotional problems (AOR 2.72, 95% CI 1.35-5.48), even after controlling for sociodemographic factors and past-month mood and substance use disorders. CONCLUSIONS: Most anxiety disorders are moderately associated with reduced sleep quality. Individuals with anxiety disorders and poor sleep experience significantly worse mental health-related quality of life and increased disability relative to those with anxiety disorders alone.

Risk factors for isolated sleep paralysis in an African American sample: a preliminary study.

Isolated sleep paralysis (ISP) is a temporary period of involuntary immobility that can occur at sleep onset or offset. It has previously been reported in association with both panic disorder (PD) and posttraumatic stress disorder (PTSD). The current study examined the association between ISP and several possible risk factors--anxiety sensitivity, trauma exposure, life stress, and paranormal beliefs--in a sample of African American participants with and without a history of ISP. Significant between-group differences were found for PD and PTSD diagnoses, anxiety sensitivity, life stress, and certain aspects of paranormal belief, with the ISP group being higher on all of these indices. No differences were found with regard to trauma exposure. Hierarchical regression analyses indicated that PD, anxiety sensitivity, and life stress each contributed unique variance to ISP cognitive symptoms, whereas PTSD and paranormal beliefs did not. These results provide preliminary support for an association between ISP and anxiety sensitivity and corroborate previous reports of ISP's association with PD and life stress. The current trauma/PTSD findings are mixed, however, and warrant future research.

Quality of life following simultaneous placement of penile prosthesis with radical prostatectomy.

PURPOSE: The present study examined erectile functioning, frequency of sexual contact, psychological functioning, partner/marital satisfaction and overall quality of life (QOL) after immediate sexual rehabilitation for prostate cancer via simultaneous placement of a penile prosthesis at radical retropubic prostatectomy (RP). MATERIALS AND METHODS: Questionnaire packets were sent to and received from 51 men who had undergone simultaneous implantation of a penile prosthesis at the time of RP (PP+) and from a comparison group of 47 men who undergone RP alone (PP-) matched by age and year of surgery. Questionnaires included the Erectile Dysfunction Inventory of Treatment Satisfaction, the Depression Anxiety Stress Scales, the Dyadic Adjustment Scale and a prostate specific European Organization for the Research and Treatment of Cancer (EORTC) QOL questionnaire. Further comparisons were performed for a PP- subgroup consisting of 15 patients who had undergone nerve sparing RP. RESULTS: Higher Erectile Dysfunction Inventory of Treatment Satisfaction, EORTC Sexual Functioning, EORTC Total scores and more frequent sexual contact were reported by the PP+ group compared with the PP- group. The PP+ group also had better outcomes that approached but did not reach statistical significance compared with the nerve sparing subgroup with regard to Depression Anxiety Stress Scales and EORTC Emotional Functioning scores. CONCLUSIONS: Men who chose simultaneous placement of a penile prosthesis with RP reported greater overall QOL, erectile function and more frequent sexual contact than a comparison group of men who underwent RP alone. Placement of penile prosthesis at the time of RP may be a desirable option for men with prostate cancer in whom a nerve sparing procedure may not be ideal. These results underscore the importance of sexual function for men undergoing prostate cancer treatment.