Decoding rumination: A machine learning approach to a transdiagnostic sample of outpatients with anxiety, mood and psychotic disorders.

OBJECTIVE: To employ machine learning algorithms to examine patterns of rumination from RDoC perspective and to determine which variables predict high levels of maladaptive rumination across a transdiagnostic sample. METHOD: Sample of 200 consecutive, consenting outpatient referrals with clinical diagnoses of schizophrenia, schizoaffective, bipolar, depression, anxiety disorders, obsessive compulsive and post-traumatic stress. Machine learning algorithms used a range of variables including sociodemographics, serum levels of immune markers (IL-6, IL-1ß, IL-10, TNF-α and CCL11) and BDNF, psychiatric symptoms and disorders, history of suicide and hospitalizations, functionality, medication use and comorbidities. RESULTS: The best model (with recursive feature elimination) included the following variables: socioeconomic status, illness severity, worry, generalized anxiety and depressive symptoms, and current diagnosis of panic disorder. Linear support vector machine learning differentiated individuals with high levels of rumination from those ones with low (AUC = 0.83, sensitivity = 75, specificity = 71). CONCLUSIONS: Rumination is known to be associated with poor prognosis in mental health. This study suggests that rumination is a maladaptive coping style associated not only with worry, distress and illness severity, but also with socioeconomic status. Also, rumination demonstrated a specific association with panic disorder.

Interpersonal Subtypes of Anxiety Disorder Patients: Relationship to Assessment and Treatment Variables.

We attempted to replicate earlier findings of interpersonal subtypes in patients with anxiety disorder (Psychotherapy. 2011;48:304-310) and examine whether these subtypes are characterized by different types of pathology and respond differently to treatment. Interpersonal problems were measured by the Inventory of Interpersonal Problems (Inventory of Interpersonal Problems Manual. San Antonio, TX: Psychological Cooperation; 2000) in a sample of 31 patients with anxiety disorder. Results demonstrated the existence of 4 interpersonal subtypes. The subtypes did not differ in severity of anxiety and global levels of symptoms at pretreatment or in Reliable Change Index of anxiety symptoms over the course of treatment. However, they were significantly different in terms of overall interpersonal problems (p = 0.004). Regarding treatment variables, half of the patients in the nonassertive cluster discontinued treatment prematurely. The number of psychotherapy sessions attended was significantly different across the 4 clusters (p = 0.04), with socially avoidant patients attending significantly greater number of sessions.

[ADHD: Burden of Disease According to Subtypes in Adult Patients]. / Der Einfluss des ADHS-Subtyps auf den Leidensdruck bei erwachsenen ADHS-Patienten.

OBJECTIVES: In consideration of ADHD subtype we assessed burden of disease of adult ADHD patients and neuroticism. METHODS: 511 adult ADHD patients were enrolled in the study. We measured ADHD symptoms categorically and dimensionally by the "Homburger ADHS-Skalen für Erwachsene (HASE)". All participants rated their ADHD associated level of suffering. To assess personality traits, the psychometric instrument NEO-PI-R was used. RESULTS: In patients with higher levels of neuroticism, there was no significant difference in the level of suffering between the ADHD subtypes. In the group of ADHD patients which scored low on the neuroticism scale, ADHD combined patients are significant more affected compared to the predominantly hyperactive-impulsive or the predominantly inattentive type. CONCLUSIONS: These results underline the hypothesis that the burden of disease is not only related to the level of ADHD symptoms and subtype but also moderated by neuroticism.

Classification models for subthreshold generalized anxiety disorder in a college population: Implications for prevention.

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders on college campuses and often goes unidentified and untreated. We propose a combined prevention and treatment model composed of evidence-based self-help (SH) and guided self-help (GSH) interventions to address this issue. To inform the development of this stepped-care model of intervention delivery, we evaluated results from a population-based anxiety screening of college students. A primary model was developed to illustrate how increasing levels of symptomatology could be linked to prevention/treatment interventions. We used screening data to propose four models of classification for populations at risk for GAD. We then explored the cost considerations of implementing this prevention/treatment stepped-care model. Among 2489 college students (mean age 19.1 years; 67% female), 8.0% (198/2489) met DSM-5 clinical criteria for GAD, in line with expected clinical rates for this population. At-risk Model 1 (subthreshold, but considerable symptoms of anxiety) identified 13.7% of students as potentially at risk for developing GAD. Model 2 (subthreshold, but high GAD symptom severity) identified 13.7%. Model 3 (subthreshold, but symptoms were distressing) identified 12.3%. Model 4 (subthreshold, but considerable worry) identified 17.4%. There was little overlap among these models, with a combined at-risk population of 39.4%. The efficiency of these models in identifying those truly at risk and the cost and efficacy of preventive interventions will determine if prevention is viable. Using Model 1 data and conservative cost estimates, we found that a preventive intervention effect size of even 0.2 could make a prevention/treatment model more cost-effective than existing models of "wait-and-treat."

Assessment of social anxiety in first episode psychosis using the Liebowitz Social Anxiety scale as a self-report measure.

OBJECTIVE: Social anxiety is a common problem in psychotic disorders. The Liebowitz Social Anxiety Scale, Self-Rating version (LSAS-SR) is a widely used instrument to capture different aspects of social anxiety, but its psychometric properties have not been tested in this patient group. The aims of the present study were to evaluate the psychometric properties of the LSAS-SR in patients with first episode psychosis, to investigate whether it differentiated between active and passive social withdrawal and to test which clinical factors contributed to current level of social anxiety. METHOD: A total of 144 first episode psychosis patients from the ongoing Thematically Organized Psychosis (TOP) study were included at the time of first treatment. Diagnoses were set according to the Structured Clinical Interview (SCID-1) for DSM-IV. A factor analysis was carried out and the relationship of social anxiety to psychotic and general symptomatology measured by the Positive and Negative Syndrome Scale (PANSS) was evaluated. Possible contributors to social anxiety were analyzed using multiple hierarchic regression analysis. RESULTS: The factor analysis identified three subscales: public performance, social interaction and observation. All three subscales showed satisfactory psychometric properties, acceptable convergent and discriminate properties, and confirmed previous findings in social anxiety samples. Self-esteem explained a significant amount of the variance in social anxiety, even after adjusting for the effects of delusions, suspiciousness and depression. CONCLUSION: The study shows that the LSAS-SR can be used in this patient group, that social anxiety is strongly related to both behavioral social avoidance and to self-esteem. The results support the use of this measure in assessment of social anxiety in both clinical settings and in research.

DSM-5 proposals for mood disorders: a cost-benefit analysis.

PURPOSE OF REVIEW: The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 revision is underway. The review examines draft proposals for changes in mood disorders (posted February 2010 on DSM-5 web site), explains their rationale, and considers relative costs vs. benefits. RECENT FINDINGS: Proposals covered include recommendation for a comorbid anxiety dimension; addition of a new disorder, mixed anxiety depression; replacement of mixed manic episodes with a 'mixed features' specifier applicable to manic, hypomanic, and major depressive episodes; addition of severity dimensions for manic and major depressive episodes; and removal of the bereavement exclusion in major depressive episode. Although some proposals (particularly the anxiety dimension and the use of Patient Health Questionnaire-9 (PHQ-9) as depression severity dimension) may improve clinical and research utility, others have a high potential for false positives (e.g., addition of mixed anxiety depression, removal of bereavement exclusion), unclear clinical utility (e.g., mixed features specifier for depressive episodes), or problematic implementation (e.g., use of Clinical Global Impression (CGI), which requires prior experience of treating bipolar patients, for rating manic episode severity). SUMMARY: A cost-benefit analysis of mood proposals yields mixed results, with some having significant benefits and others carrying the risk of significant problems. Only proposals in which benefits outweigh costs should be included in the final DSM-5.

Social skills and social phobia: an investigation of DSM-IV subtypes.

Social phobia is characterized as pervasive social timidity in social settings. Although much is known about this disorder, aspects of its clinical presentation remain unexplored, in particular characteristics that distinguish the generalized and non-generalized subtypes. For example, it remains unclear whether patients with the non-generalized subtype display social skills deficits in social interactions, and if so, are these deficits clinically, as well as statistically, significant? In this study, adults with either the non-generalized (NGSP; n=60) or generalized (GSP; n=119) subtype of social phobia and adults with no psychological disorder (n=200) completed an extensive behavioral assessment of social skill and social anxiety. As expected, adults with NGSP and GSP reported equal distress and displayed similar rates of avoidance during an Impromptu Speech Task when compared to adults with no disorder. In contrast, the three groups were distinctly different when interacting with another person in various social situations. Adults with NGSP displayed social skill deficits when compared to individuals with no disorder, but they had fewer deficits than the GSP subtype. However, the identified skill deficits were clinically as well as statistically significant only for the GSP subtype. The results are discussed in terms of the contribution of skill deficits to the conceptualization and treatment of social phobia.

[F45.41: chronic pain disorder with somatic and psychological factors : a coding aid]. / F45.41 Chronische Schmerzstörung mit somatischen und psychischen Faktoren : Eine Kodierhilfe.

In 2009, the German version of ICD-10 (ICD-10 GM version 2009) introduced the diagnosis of "chronic pain disorder with somatic and psychological factors", because current ICD-10 diagnoses did not address the biopsychosocial character of chronic pain adequately. For most patients, a dichotomous classification into psychologically versus biomedically caused pain is inappropriate and does not reflect current knowledge on pain. The new code F45.41 addresses the relevance of psychological factors for chronic pain persistence and chronic pain treatment, even in those conditions with a clear biomedical cause at the beginning. This guideline describes how to use this new diagnosis, which boundaries have to be considered, and how comorbid and associated conditions can be classified. The distinction of this new diagnosis from other pain-associated diagnoses and recommendations for the coding of comorbid conditions are presented. The differentiation of everyday pain symptoms from pain disorders is outlined. Finally, contextual factors of the classification process, as well as problems in integrating this new diagnosis into diagnosis-related group (DRG) systems of financial reimbursement are discussed.

A proposal for a dimensional classification system based on the shared features of the DSM-IV anxiety and mood disorders: implications for assessment and treatment.

A wealth of evidence attests to the extensive current and lifetime diagnostic comorbidity of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) anxiety and mood disorders. Research has shown that the considerable cross-sectional covariation of DSM-IV emotional disorders is accounted for by common higher order dimensions such as neuroticism/behavioral inhibition (N/BI) and low positive affect/behavioral activation. Longitudinal studies indicate that the temporal covariation of these disorders can be explained by changes in N/BI and, in some cases, initial levels of N/BI are predictive of the temporal course of emotional disorders. The marked phenotypal overlap of the DSM-IV anxiety and mood disorders is a frequent source of diagnostic unreliability (e.g., temporal overlap in the shared features of generalized anxiety disorder and mood disorders, situation specificity of panic attacks in panic disorder and specific phobia). Although extant dimensional proposals may address some drawbacks associated with the DSM nosology (e.g., inadequate assessment of individual differences in disorder severity), these proposals do not reconcile key problems in current classification, such as modest reliability and high comorbidity. This article considers an alternative approach that emphasizes empirically supported common dimensions of emotional disorders over disorder-specific criteria sets. Selection and assessment of these dimensions are discussed along with how these methods could be implemented to promote more reliable and valid diagnosis, prognosis, and treatment planning. For instance, the advantages of this system are discussed in context of transdiagnostic treatment protocols that are efficaciously applied to a variety of disorders by targeting their shared features.

Depression, anxiety, and somatoform disorders: vague or distinct categories in primary care? Results from a large cross-sectional study.

OBJECTIVE: Depression, anxiety, and somatization are the most frequently observed mental disorders in primary health care. Our main objective was to draw on the often neglected general practitioners' (GPs) perspective to investigate what characterizes these three common mental diagnoses with regard to creating more suitable categories in the DSM-V and ICD-11. METHODS: We collected independent data from 1751 primary care patients (participation rate=77%) and their 32 treating GPs in Germany. Patients filled out validated patient self-report measures for depression (PHQ-9), somatic symptom severity (PHQ-15), and illness anxiety (Whiteley-7), and questions regarding coping and attribution of illness. GPs' clinical diagnoses and associated features were assessed. RESULTS: Patients diagnosed by their GPs with depression, anxiety, and/or somatoform disorders were significantly older, less educated, and more often female than the reference group not diagnosed with a mental disorder. They had visited the GP more often, had a longer duration of symptoms, and were more often under social or financial stress. Among the mental disorders diagnosed by the GPs, depression (OR=4.4; 95% CI=2.6 to 7.5) and comorbidity of somatoform, depressive, and anxiety disorders (OR=9.5; 95% CI=4.6 to 19.4) were associated with the largest degrees of impairment compared to the reference group. Patients diagnosed as having a somatoform/functional disorder only had mildly elevated impairment on all dimensions (OR=2.0; 95% CI=1.4 to 2.7). Similar results were found for the physicians' attribution of psychosocial factors for cause and maintenance of the disease, difficult patient-doctor relationship, and self-assessed mental disorder. CONCLUSION: In order to make the DSM-V and ICD-11 more suitable for primary care, we propose providing appropriate diagnostic categories for (1) the many mild forms of mental syndromes typically seen in primary care; and (2) the severe forms of comorbidity between somatoform, depressive, and/or anxiety disorder, e.g., with a dimensional approach.

[Assessment of posttraumatic stress disorders]. / Diagnostik posttraumatischer Belastungsstörungen.

Trauma, traumatization, Acute stress reaction, Posttraumatic stress disorder and other disorders following exposure to traumatic stress are described. Classification according to ICD and DSM are presented and critically valued. The complex Posttraumatic Stress disorder is introduced in its symptoms and with a proposal for a classification. Problems in assessing traumatized individuals are referred and recommendations for interviews and testing procedure are presented. Structured interviews and tests in german language are described. Due to control stress load by the process of assessing the economic choice of instruments is recommended.

[Anxiety level and addiction to first-time prescriptions of anxiolytics: a psychometric study]. / Niveau d'anxiété et de dépendance des primoconsommants d'anxiolytiques: une étude de psychométrie.

CONTEXT: The anxiety epidemic and its corollary, the widespread prescription of anxiolytics, present a public health problem in view of the risk of addiction to these drugs. OBJECTIVE: To assess the level of anxiety and addiction in the borderline population at risk of addiction. DESIGN: The study analyzed a series of patients in the third month of their first prescription for anxiolytics. It used two validated scales: the Hospital Anxiety and Depression scale (HAD), and a French scale measuring addiction (the "Echelle Cognitive d'Attachement aux Benzodiazepines" or ECAB). RESULT: 83% of patients were still anxious at the third month of treatment. 23% had become addicted. DISCUSSION: There is a contradiction between the prolonged prescription and use of anxiolytics, which are associated with a risk of addiction, and professional guidelines that recommend short treatment for outpatients using these drugs for the first time.

Supplementary dimensional assessment in anxiety disorders.

Anxiety disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), comprise a relatively heterogeneous group of clinical conditions that range from specific phobias to obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). The grouping under one heading refers to the fact that these seemingly heterogeneous disorders share a number of common psychopathological features and also share at least some common principles in treatment. Among the shared elements are broadly defined prototypical anxiety reactions, panic attacks, anticipatory anxiety, avoidance behaviour, a predominantly early onset, and relatively high persistence rates over time. Many of the shared diagnostic features of anxiety disorders are by their nature dimensional, and hundreds of psychometric scales have been developed to measure these diagnostic constructs across anxiety disorder and for specific diagnostic classes. This paper explores different types of dimensional approaches used in the literature and discusses how an integrated categorical/dimensional strategy might enhance the usefulness of the DSM-V. We suggest the use of cross-cutting dimensional ratings that might ultimately lead to an improved classification model. We also suggest that a staging approach to illness, based upon supplementary dimensional rating could provide useful information for clinical and research purposes.

The global burden of anxiety and mood disorders: putting the European Study of the Epidemiology of Mental Disorders (ESEMeD) findings into perspective.

This article compares the preliminary, descriptive European Study of The Epidemiology of Mental Disorders (ESEMeD) findings reported in this supplement with 8 broad patterns of results found in previous psychiatric epidemiologic surveys. It is a systematic review of the literature on community epidemiologic surveys of anxiety and mood disorders. It concludes that the ESEMeD findings are broadly consistent with the patterns found in previous surveys but faults the preliminary ESEMeD analyses for failing to distinguish cases by severity and to consider the effects of severity on need for treatment. The fact that the ESEMeD surveys collected much richer data than previous psychiatric epidemiologic surveys on role impairment, symptom severity, and episode duration makes it possible to develop more useful classifications of clinical severity in future analyses. Elaborations that feature such distinctions have the potential to substantially increase the relevance of the ESEMeD findings for European health care policy.

An overview of SSRI and SNRI therapies for depression.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine re-uptake inhibitors (SNRIs) are used widely to treat mood and anxiety disorders. Indications, pharmacologic characteristics, and dosing and administration are outlined. Because more patients receive SSRIs in general medical versus psychiatric settings, this chapter includes information relevant to both.

Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders.

BACKGROUND: The present paper describes a component of a large population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder). METHOD: Outcome was calculated as averted 'years lived with disability' (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997-8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs. RESULTS: Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at dollar 400 million, resulting in a cost per YLD averted ranging from dollar 7761 for generalized anxiety disorder to dollar 34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to < dollar 20 000 for all disorders. CONCLUSIONS: Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.