Evaluating symptom burden in kidney transplant recipients: validation of the revised Edmonton Symptom Assessment System for kidney transplant recipients - a single-center, cross-sectional study.

We assessed the validity of the Edmonton Symptom Assessment System (ESAS-r) in kidney transplant recipients (KTR). A cross-sectional sample of 252 KTR was recruited. Individual ESAS-r symptom scores and symptom domain scores were evaluated. Internal consistency, convergent validity, and construct validity were assessed with Cronbach's α, Spearman's rank correlations, and a priori-defined risk group comparisons. Mean (SD) age was 51 (16), 58% were male, and 58% Caucasian. ESAS-r Physical, Emotional, and Global Symptom Scores demonstrated good internal consistency (α > 0.8 for all). ESAS-r Physical and Global Symptom Scores strongly correlated with PHQ-9 scores (0.72, 95% CI: 0.64-0.78 and 0.74, 95% CI: 0.67-0.80). For a priori-defined risk groups, individual ESAS-r symptom score differed between groups with lower versus higher eGFR [pain: 1 (0-3) vs. 0 (0-2), delta = 0.18; tiredness: 3 (1-5) vs. 1.5 (0-4), delta = 0.21] and lower versus higher hemoglobin [tiredness: 3 (1-6) vs. 2 (0-4), delta = 0.27]. ESAS-r Global and Physical Symptom Scores differed between groups with lower versus higher hemoglobin [13 (6-29) vs. 6.5 (0-18.5), delta = 0.3, and 9 (2-19) vs. 4 (0-13), delta = 0.24] and lower versus higher eGFR [11 (4-20) vs. 6.5 (2-13), delta = 0.21, and 7 (2-16) vs. 3 (0-9), delta = 0.26]. These data support reliability and construct validity of ESAS-r in KTR. Future studies should explore its clinical utility for symptom assessment among KTR.

Post-extinction conditional stimulus valence predicts reinstatement fear: relevance for long-term outcomes of exposure therapy.

Exposure therapy for anxiety disorders is translated from fear conditioning and extinction. While exposure therapy is effective in treating anxiety, fear sometimes returns after exposure. One pathway for return of fear is reinstatement: unsignaled unconditional stimuli following completion of extinction. The present study investigated the extent to which valence of the conditional stimulus (CS+) after extinction predicts return of CS+ fear after reinstatement. Participants (N = 84) engaged in a differential fear conditioning paradigm and were randomised to reinstatement or non-reinstatement. We hypothesised that more negative post-extinction CS+ valence would predict higher CS+ fear after reinstatement relative to non-reinstatement and relative to extinction retest. Results supported the hypotheses and suggest that strategies designed to decrease negative valence of the CS+ may reduce the return of fear via reinstatement following exposure therapy.

The neural correlates of persuasion: a common network across cultures and media.

Persuasion is at the root of countless social exchanges in which one person or group is motivated to have another share its beliefs, desires, or behavioral intentions. Here, we report the first three functional magnetic resonance imaging studies to investigate the neurocognitive networks associated with feeling persuaded by an argument. In the first two studies, American and Korean participants, respectively, were exposed to a number of text-based persuasive messages. In both Study 1 and Study 2, feeling persuaded was associated with increased activity in posterior superior temporal sulcus bilaterally, temporal pole bilaterally, and dorsomedial prefrontal cortex. The findings suggest a discrete set of underlying mechanisms in the moment that the persuasion process occurs, and are strengthened by the fact that the results replicated across two diverse linguistic and cultural groups. Additionally, a third study using region-of-interest analyses demonstrated that neural activity in this network was also associated with persuasion when a sample of American participants viewed video-based messages. In sum, across three studies, including two different cultural groups and two types of media, persuasion was associated with a consistent network of regions in the brain. Activity in this network has been associated with social cognition and mentalizing and is consistent with models of persuasion that emphasize the importance of social cognitive processing in determining the efficacy of persuasive communication.

Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V.

The present review was conducted in order to evaluate the current diagnostic criteria for specific phobia (SP) in light of the empirical evidence gathered since DSM-IV and to propose changes to DSM-V where change is clearly and reliably indicated by the evidence. In response to questions put forth by the DSM-V Anxiety, OC Spectrum, Posttraumatic, and Dissociative Disorder Work Group, four primary areas were determined for this review: the accuracy and utility of the current SP type classification system, the validity of test anxiety as a type of SP, the boundary between agoraphobia and SP, and the reliability and utility of the diagnostic criteria for SP. Developmental issues are addressed within each area. Literature reviews examining academic findings published between 1994 and 2009 were carried out and the results are included herein. The review presents a number of options and preliminary recommendations to be considered for DSM-V. All of these recommendations should be considered tentative as they await the field trials and expert consensus necessary prior to their inclusion in the DSM-V. The present review also reveals a great need for future research in the area of SP and directions for such research is provided.

Culture and the anxiety disorders: recommendations for DSM-V.

BACKGROUND: The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM-IV-TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent "over-specification" of disorders, the post-DSM-III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross-cultural limitations in DSM-IV-TR anxiety disorder criteria. METHODS: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity-related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders. RESULTS: Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10-minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM-V validators that could help clarify the cross-cultural applicability of criteria. CONCLUSIONS: On the basis of the available data, options and preliminary recommendations for DSM-V are put forth that should be further evaluated and tested.

Extinction theory & anorexia nervosa: Deepening therapeutic mechanisms.

By virtue of adopting the core symptomatic fear (i.e., a fear of weight gain) as a primary treatment target, the treatment of AN centrally involves exposure-driven processes. However, exposure trials targeting the fear of weight gain in AN have been sparse, yielding mixed results to date. In translating extinction theory to the treatment of AN, it is likely that the absence of a clear distinction between what constitutes the core feared cue and the core feared outcome has stymied the application of exposure treatments in AN. This review considers several configurations of the core fear association in AN, noting distinct therapeutic strategies which may allow for more precise efforts in violating fear-based expectancies. Specific guidance is offered in the clinical decision making process as to which strategies might best promote inhibitory learning, and a clinical case is discussed, in which treatment was adjusted to specifically violate the core underlying fear association.

A comparison of the nature and correlates of panic attacks in the context of Panic Disorder and Social Anxiety Disorder.

UNLABELLED: Panic attacks occurring outside of Panic Disorder are not well-understood despite their inclusion as a diagnostic specifier in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). This study compares panic attacks in the context of Panic Disorder compared to social anxiety in terms of their symptom frequency, severity, and clinical correlates. METHOD: Participants (n=404) were interviewed using the Anxiety Disorders Interview Schedule (ADIS-IV-L; Brown et al., 1994), from which we analyzed interviewer ratings of panic attacks and panic attack symptoms, as well as other demographic and clinical characteristics. RESULTS: Panic attacks in the context of Panic Disorder were characterized by a greater number and severity of symptoms compared to panic attacks in the context of Social Anxiety Disorder, and were associated with a history of traumatization, inpatient psychiatric treatment, and benzodiazepine use. Social anxiety panic attacks were associated with reduced physical health concerns. Cognitive panic attack symptoms were more prevalent in Panic Disorder and were associated with a variety of poor clinical correlates. CONCLUSIONS: Panic attacks in the context of Panic Disorder are more severe than those in social anxiety, and this may be driven by cognitive disturbances during those attacks.

Human fear conditioning and extinction: timing is everything or is it?

A differential fear conditioning paradigm was used with 107 healthy undergraduate participants to evaluate the effect of conditioned stimulus (CS) temporal properties on fear acquisition and extinction. Two minute duration CSs were used for Day 1 fear acquisition. Participants were randomized to receive either 1, 2, or 4min CS durations during Day 2 extinction. Extinction re-test was examined on Day 3 using the original acquisition CS duration (2min). Findings indicated that participants who were aware of the CS+/unconditioned stimulus (US) contingency (n=52) develop a temporal expectation about when the unconditioned stimulus will be delivered. Although the shorter duration CS resulted in greater fear reduction during extinction, cessation of fear responding at re-test was the same for CS extinction durations ranging from half the CS acquisition duration to twice the CS acquisition duration. Thus, extinction performance did not predict extinction at re-test, which could have important implications for optimizing exposure therapy for anxiety disorders.

Dimensional indicators of generalized anxiety disorder severity for DSM-V.

For DSM-V, simple dimensional measures of disorder severity will accompany diagnostic criteria. The current studies examine convergent validity and test-retest reliability of two potential dimensional indicators of worry severity for generalized anxiety disorder (GAD): percent of the day worried and number of worry domains. In study 1, archival data from diagnostic interviews from a community sample of individuals diagnosed with one or more anxiety disorders (n = 233) were used to assess correlations between percent of the day worried and number of worry domains with other measures of worry severity (clinical severity rating (CSR), age of onset, number of comorbid disorders, Penn state worry questionnaire (PSWQ)) and DSM-IV criteria (excessiveness, uncontrollability and number of physical symptoms). Both measures were significantly correlated with CSR and number of comorbid disorders, and with all three DSM-IV criteria. In study 2, test-retest reliability of percent of the day worried and number of worry domains were compared to test-retest reliability of DSM-IV diagnostic criteria in a non-clinical sample of undergraduate students (n = 97) at a large west coast university. All measures had low test-retest reliability except percent of the day worried, which had moderate test-retest reliability. Findings suggest that these two indicators capture worry severity, and percent of the day worried may be the most reliable existing indicator. These measures may be useful as dimensional measures for DSM-V.