Brief report: sudden gains in cognitive-behavioral group therapy and group psychotherapy for social anxiety disorder among college students.

The present study examined sudden gains (SGs; large symptom improvements between adjacent treatment sessions) and its association with treatment outcome in a randomized-controlled trial comparing cognitive-behavioral group therapy (CBGT) versus group psychotherapy (GPT; designed to incorporate only non-specific factors) for social anxiety disorder (SAD). SAD symptoms were assessed after each treatment session in a sample of 45 college students. Independent assessors evaluated symptom severity at baseline, post-treatment and follow-up. A total of 10 (22.2%) participants experienced SGs during treatment. No differences were found in symptom improvement at post-treatment or follow-up between individuals with and without SGs. SGs appeared at similar rates across both treatments but were associated with greater improvements at post-treatment and follow-up in GPT compared to CBGT. Majority of SGs in CBGT occurred early in treatment before the provision of specific treatment techniques. These results suggest that non-specific treatment factors may be important in promoting SGs.

Personality pathology factors predict recurrent major depressive disorder in emerging adults.

OBJECTIVE: Prior investigations consistently indicate that personality pathology is a risk factor for recurrence of major depressive disorder (MDD). Lack of emipircal support, however, for the Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition organization of Axis II disorders supports the investigation of empirically derived factors of personality pathology as predictors of recurrence. METHOD: A sample of 130 previously depressed emerging adults (80% female; aged 18 to 21 years) were assessed for personality disorder symptoms at baseline. Participants were then followed for 18 months to identify MDD recurrence during the first 2 years of college. RESULTS: Based on a previous factor analysis of DSM personality disorder criteria, eight personality pathology factors were examined as predictors of MDD recurrence. Survival analysis indicated that factors of interpersonal hypersensitivity, antisocial conduct, and social anxiety were associated with increased risk of MDD recurrence. CONCLUSIONS: These findings suggest that an empirically based approach to personality pathology organization may yield useful predictors of MDD recurrence during emerging adulthood.

Age at onset and clinical correlates in body dysmorphic disorder.

OBJECTIVE: Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD. METHODS: Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD. RESULTS: BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2. CONCLUSIONS: BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Appraisals of Social Trauma and Their Role in the Development of Post-Traumatic Stress Disorder and Social Anxiety Disorder.

Cognitive theories of post-traumatic stress disorder (PTSD) feature appraisal of trauma as a critical factor in the development and maintenance of the disorder. Here we explored appraisals of social trauma (severe rejection or humiliation). Participants were outpatients with social anxiety disorder (SAD) and clinically significant PTSD symptoms (PTSS) after social trauma (n = 15); two clinical control groups of either SAD (n = 32) or obsessive-compulsive disorder (OCD; n = 13); and a control group with no diagnoses (n = 38). Measures included a clinical interview to assess social trauma and related open-ended appraisals and the Posttraumatic Cognitions Inventory (PTCI). Raters blind to group assignment performed content analyses of appraisals. Results showed that the PTSS group scored significantly higher than either clinical group on the PTCI SELF subscale. Only the SELF subscale predicted a diagnosis of both PTSS and SAD. All but one PTSS participant reported primarily negative beliefs about their social trauma, and the most common categories were flawed self and others are critical or cruel. Post-traumatic appraisals implicated in the course of PTSD are significant in how individuals respond to social trauma, with negative self-cognitions linked to both PTSS and SAD.

Cognitive-behavioral group therapy versus group psychotherapy for social anxiety disorder among college students: a randomized controlled trial.

OBJECTIVE: In this randomized controlled trial, cognitive-behavioral group therapy (CBGT) for social anxiety disorder (SAD) was compared to group psychotherapy (GPT), a credible, structurally equivalent control condition that included only nonspecific factors of group treatment (such as group dynamics). METHODS: Participants were 45 college students at the University of Colorado with a primary diagnosis of SAD. Each treatment condition comprised eight group sessions lasting 2 hr each. Independent assessors (blind to treatment assignment) assessed participants at baseline and posttreatment with the Clinical Global Impression Scale (CGI) and the Liebowitz Social Anxiety Scale (LSAS). RESULTS: Both treatments were found to be equally credible. There were five noncompleters in the CBGT condition (21.7%) and only one in the GPT condition (4.3%). There were no statistically significant differences posttreatment (controlling for pretreatment scores) between the two treatment conditions, and both treatments were found to be efficacious. Effect sizes for CBGT were similar to earlier studies, and adherence ratings revealed excellent adherence. CONCLUSIONS: Treatment of SAD appears to be moving toward individual CBT, partly because of high attrition rates and underutilization of group dynamics in group CBT. However, group therapy has unique therapeutic ingredients, and it may be too early to give up on group treatment altogether. Discussion of these findings included future directions with this treatment modality, especially whether these two types of group treatment could be combined and whether such combination might serve to decrease attrition, enhance efficacy, and facilitate dissemination.

The clinical course of body dysmorphic disorder in the Harvard/Brown Anxiety Research Project (HARP).

This report prospectively examines the course of body dysmorphic disorder (BDD) for up to 8 years in a sample of 514 participants in the Harvard/Brown Anxiety Research Project, a naturalistic, longitudinal study of anxiety disorders. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) BDD was assessed with a reliable semi-structured measure. For participants with BDD, severity of BDD symptoms was assessed with the Longitudinal Interval Follow-up Evaluation Psychiatric Status Rating scale. At the initial assessment, 17 participants (3.3%; 95% confidence interval = 1.8%-4.8%) had current BDD; 22 (4.3%; 95% confidence interval = 2.6%-6.1%) had lifetime BDD. Participants with BDD had significantly lower Global Assessment Scale scores than those without BDD, indicating poorer functioning. The probability of full recovery from BDD was 0.76, and probability of recurrence, once remitted, was 0.14 over the 8 years. In conclusion, among individuals ascertained for anxiety disorders, the probability of recovering from BDD was relatively high and probability of BDD recurrence was low.

Body Dysmorphic Disorder and Major Depressive Episode Have Comorbidity-Independent Associations With Suicidality in an Acute Psychiatric Setting.

(Appeared originally in Journal of Affective Disorders 2019; 259:266-270).

Iceland screens, treats, or prevents multiple myeloma (iStopMM): a population-based screening study for monoclonal gammopathy of undetermined significance and randomized controlled trial of follow-up strategies.

Monoclonal gammopathy of undetermined significance (MGUS) precedes multiple myeloma (MM). Population-based screening for MGUS could identify candidates for early treatment in MM. Here we describe the Iceland Screens, Treats, or Prevents Multiple Myeloma study (iStopMM), the first population-based screening study for MGUS including a randomized trial of follow-up strategies. Icelandic residents born before 1976 were offered participation. Blood samples are collected alongside blood sampling in the Icelandic healthcare system. Participants with MGUS are randomized to three study arms. Arm 1 is not contacted, arm 2 follows current guidelines, and arm 3 follows a more intensive strategy. Participants who progress are offered early treatment. Samples are collected longitudinally from arms 2 and 3 for the study biobank. All participants repeatedly answer questionnaires on various exposures and outcomes including quality of life and psychiatric health. National registries on health are cross-linked to all participants. Of the 148,704 individuals in the target population, 80 759 (54.3%) provided informed consent for participation. With a very high participation rate, the data from the iStopMM study will answer important questions on MGUS, including potentials harms and benefits of screening. The study can lead to a paradigm shift in MM therapy towards screening and early therapy.

Body dysmorphic disorder.

Body dysmorphic disorder (BDD) is a relatively common disorder that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance. BDD is commonly considered to be an obsessive-compulsive spectrum disorder, based on similarities it has with obsessive-compulsive disorder. It is important to recognize and appropriately treat BDD, as this disorder is associated with marked impairment in psychosocial functioning, notably poor quality of life, and high suicidality rates. In this review, we provide an overview of research findings on BDD, including its epidemiology, clinical features, course of illness, comorbidity, psychosocial functioning, and suicidality. We also briefly review recent research on neural substrates and cognitive processing. Finally, we discuss treatment approaches that appear efficacious for BDD, with a focus on serotonin-reuptake inhibitors and cognitive-behavioral therapy.

Foraging with Anne Treisman: Features versus conjunctions, patch leaving and memory for foraged locations.

Foraging tasks are increasingly used to investigate human visual attention as they may provide a more dynamic and multifaceted picture of attentional orienting than more traditionally used visual search tasks. A common way of assessing foraging performance involves measuring when foragers decide to move to a new "patch" with a higher yield. We assessed this using Anne Treisman's famous feature versus conjunction manipulation in an iPad foraging task. We measured how well patch leaving accorded with the predictions of the marginal value theorem that describes how foragers may optimize their foraging by leaving a patch once the average yield within a patch drops below the average yield in the whole environment. Human foraging in our paradigm deviated from the predictions of such optimal foraging conceptions, and our participants kept on foraging within the same patch for longer than expected. Patch leaving and intertarget times differed surprisingly little between feature and conjunction foraging, especially in light of the dramatic differences typically seen between performance on feature and conjunction visual search tasks. Other aspects of foraging performance (run number and switch costs) differed strongly between feature and conjunction foraging, however. We conclude that human foraging is probably influenced by too many factors to be captured with a relatively simple mathematical model.

Measuring Biases of Visual Attention: A Comparison of Four Tasks.

: Attention biases to stimuli with emotional content may play a role in the development and maintenance of anxiety disorders. The most commonly used tasks in measuring and treating such biases, the dot-probe and spatial cueing tasks, have yielded mixed results, however. We assessed the sensitivity of four visual attention tasks (dot-probe, spatial cueing, visual search with irrelevant distractor and attentional blink tasks) to differences in attentional processing between threatening and neutral faces in 33 outpatients with a primary diagnosis of social anxiety disorder (SAD) and 26 healthy controls. The dot-probe and cueing tasks revealed no differential processing of neutral and threatening faces between the SAD and control groups. The irrelevant distractor task showed some sensitivity to differential processing for the SAD group, but the attentional blink task was uniquely sensitive to such differences in both groups, and revealed processing differences between the SAD and control groups. The attentional blink task also revealed interesting temporal dynamics of attentional processing of emotional stimuli and may provide a uniquely nuanced picture of attentional response to emotional stimuli. Our results therefore suggest that the attentional blink task is more suitable for measuring preferential attending to emotional stimuli and treating dysfunctional attention patterns than the more commonly used dot-probe and cueing tasks.

Body dysmorphic disorder is associated with risk for suicidality and inpatient hospitalization: A replication study.

In a previous study, body dysmorphic disorder (BDD) was shown to have comorbidity-independent associations with suicidality among patients in a partial hospital program. Here, we replicated and extended this study in an independent cohort (N = 1612) from the same program using a different measure of suicidality. Semi-structured interviews were used to assess psychiatric diagnoses and suicide risk. We also documented inpatient hospitalization during treatment. BDD was associated with suicide risk and inpatient hospitalization even after adjusting for age, gender and other psychiatric disorders. The results suggest that BDD is associated with risk for suicidality and clinical deterioration in acute psychiatric settings.

Social trauma and its association with posttraumatic stress disorder and social anxiety disorder.

The key characteristic of a traumatic event as defined by the Diagnostic and Mental Manual of Mental Disorders (DSM) seems to be a threat to life. However, evidence suggests that other types of threats may play a role in the development of PTSD and other disorders such as social anxiety disorder (SAD). One such threat is social trauma, which involves humiliation and rejection in social situations. In this study, we explored whether there were differences in the frequency, type and severity of social trauma endured by individuals with a primary diagnosis of SAD (n = 60) compared to a clinical control group of individuals with a primary diagnosis of obsessive compulsive disorder (OCD, n = 19) and a control group of individuals with no psychiatric disorders (n = 60). The results showed that most participants in this study had experienced social trauma. There were no clear differences in the types of experiences between the groups. However, one third of participants in the SAD group (but none in the other groups) met criteria for PTSD or suffered from clinically significant PTSD symptoms in response to their most significant social trauma. This group of SAD patients described more severe social trauma than other participants. This line of research could have implications for theoretical models of both PTSD and SAD, and for the treatment of individuals with SAD suffering from PTSD after social trauma.

Body dysmorphic disorder and major depressive episode have comorbidity-independent associations with suicidality in an acute psychiatric setting.

BACKGROUND: This study sought to examine whether mood, anxiety, and obsessive-compulsive spectrum disorders have unique (comorbidity-independent) associations with suicidal thoughts and behaviors in an acute psychiatric population. METHODS: Patients (N = 498) were evaluated during admission to a partial hospital. Semi-structured interviews were used to assess current psychiatric diagnoses and past-month suicidal ideation and suicidal behaviors (e.g., suicide attempts). RESULTS: After adjusting for age, gender and other psychiatric disorders, body dysmorphic disorder (BDD) had a significant association with suicidal ideation (odds ratio [OR] = 6.62; 95% CI, 1.92-22.79) and suicidal behaviors (OR = 2.45; 95% CI, 1.05-5.71). Similarly, major depressive episode was associated with suicidal ideation (OR = 3.00; 95% CI, 1.95-4.63) and suicidal behaviors (OR = 2.11; 95% CI, 1.12-3.98). When unipolar and bipolar depression were analyzed separately, unipolar depression was associated with suicidal ideation (OR = 1.82; 95% CI, 1.20-2.74), but not suicidal behaviors, whereas, bipolar depression was associated with suicidal ideation (OR = 2.71; 95% CI, 1.36-5.40) and marginally with suicidal behaviors (OR = 2.02; 95% CI, 0.99-4.13). Anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder were unrelated to suicidality in this sample after controlling for comorbid disorders. LIMITATIONS: Cross-sectional design and a relatively small sample for analyses of low base-rate conditions. CONCLUSIONS: Major depressive episode and BDD are unique markers of suicidality in an acute psychiatric setting. BDD is a common but often underdiagnosed condition, and clinicians should be aware of high rates of suicidality among these patients.

Posttraumatic stress disorder in African American and Latinx adults: Clinical course and the role of racial and ethnic discrimination.

Research has suggested that African American and Latinx adults may develop posttraumatic stress disorder (PTSD) at higher rates than White adults, and that the clinical course of PTSD in these minority groups is poor. Factors that may contribute to higher prevalence and poorer outcome in these groups are sociocultural factors and racial stressors, such as experiences with discrimination. To date, however, no research has explored the relationship between experiences with discrimination and risk for PTSD, and very little research has examined the course of illness for PTSD in African American and Latinx samples. The present study examined these variables in the only longitudinal clinical sample of 139 Latinx and 152 African American adults with anxiety disorders, the Harvard/Brown Anxiety Research Project-Phase II. Over 5 years of follow-up, remission rates for African Americans and Latinx adults with PTSD in this sample were 0.35 and 0.15, respectively, and reported frequency of experiences with discrimination significantly predicted PTSD diagnostic status in this sample, but did not predict any other anxiety or mood disorder. These findings demonstrate the chronic course of PTSD in African American and Latinx adults, and highlight the important role that racial and ethnic discrimination may play in the development of PTSD among these populations. Implications for an increased focus on these sociocultural stressors in the assessment and treatment of PTSD in African American and Latinx individuals are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Barking up the wrong tree in attentional bias modification? Comparing the sensitivity of four tasks to attentional biases.

BACKGROUND AND OBJECTIVES: Attentional bias modification (ABM) is a potentially exciting new development in the treatment of anxiety disorders. However, reported therapeutic benefits have not always been replicated. To gauge the sensitivity of tasks used in ABM treatment and assessment, we used a counterbalanced within-subject design to measure their discriminant sensitivity to neutral and threatening facial expressions, comparing them with other well-known tasks that measure visual attention. METHODS: We compared two tasks often used in the assessment and treatment of attention bias (the dot-probe and the spatial cueing paradigms) with two well-known visual attention tasks (the irrelevant singleton and attentional blink paradigms), measuring their sensitivity to processing differences between threatening and neutral expressions for non-clinical observers. RESULTS: The dot-probe, spatial cueing and irrelevant singleton paradigms showed little or no sensitivity to processing differences between facial expressions while the attentional blink task proved very sensitive to such differences. Furthermore, the attentional blink task provided an intriguing picture of the temporal dynamics of attentional biases that the other paradigms cannot do. LIMITATIONS: These results need to be replicated with larger samples, including a comparison of a group of individuals diagnosed with social anxiety disorder and normal controls. CONCLUSIONS: Our results indicate that the sensitivity of putative attentional bias measures should be assessed experimentally for more powerful assessment and treatment of such biases. If the attentional blink task is indeed particularly sensitive to attentional biases, as our findings indicate, it is not unreasonable to expect that interventions based on this task may be more effective than those based on the tasks that are currently used.

Posttraumatic stress disorder in African Americans: a two year follow-up study.

The present study was a prospective, naturalistic, longitudinal investigation of the two year course of posttraumatic stress disorder (PTSD) in a sample of African Americans with anxiety disorders. The study objectives were to examine the two year course of PTSD and to evaluate differences between African Americans with PTSD and anxiety disorders and African Americans with anxiety disorders but no PTSD with regard to comorbidity, psychosocial impairment, physical and emotional functioning, and treatment participation. The participants were 67 African Americans with PTSD and 98 African Americans without PTSD (mean age 41.5 years, 67.3% female). Individuals with PTSD were more likely to have higher comorbidity, lower functioning, and they were less likely to seek treatment than those with other anxiety disorders but no PTSD. The rate of recovery from PTSD over two years was 0.10 and recovery from comorbid Major Depressive Disorder was 0.55. PTSD appears to be persistent over time in this population. The rates of recovery were lower than what has been reported in previous longitudinal studies with predominantly non-Latino Whites. It is imperative to examine barriers to treatment and factors related to treatment engagement for this population.

Two-year course of generalized anxiety disorder, social anxiety disorder, and panic disorder with agoraphobia in a sample of Latino adults.

OBJECTIVE: It is imperative to study the clinical course of anxiety disorders among Latinos, given the implications for culturally sensitive treatment in this population. The current study is the first prospective, observational, longitudinal study of anxiety disorders among Latinos. METHOD: Data are reported on 139 adult Latinos (M age = 34.65 years, SD = 10.98, 70.5% female) diagnosed with social anxiety disorder (SAD; n = 86), generalized anxiety disorder (GAD; n = 90), or panic disorder with agoraphobia (PDA; n = 62). The participants were interviewed with standardized clinical interviews at intake and annually over 2 years of follow-up. Probabilities of recovery were calculated using standard survival analysis methods. RESULTS: The 2-year recovery rates in this study were 0.07 for SAD, 0.14 for GAD, 0.03 for PDA, and 0.50 for major depressive disorder (MDD). Overall functioning, social adjustment, and life satisfaction in this sample were poor. CONCLUSIONS: The recovery rates for anxiety disorders in this Latino sample were markedly low. Although caution must be used in comparing these data with prior longitudinal studies, these recovery rates seem to be much lower than in non-Latino White samples. However, the clinical course of MDD in this sample was similar to its course among non-Latino Whites, invoking the pressing question of whether there is something about the experience of anxiety disorders (but not MDD) among Latinos that makes them more impairing and persistent. The answer to that question should inform future treatment development for this population.

Cued panic attacks in body dysmorphic disorder.

BACKGROUND: Body dysmorphic disorder (BDD) is a common and often severe disorder. Clinical observations suggest that panic attacks triggered by BDD symptoms may be common. However, to our knowledge, no study has examined such panic attacks in BDD. We investigated the prevalence, clinical features, and correlates of BDD- triggered panic attacks in individuals with this disorder. METHODS: Panic attacks and other variables were assessed using reliable and valid measures in 76 individuals with lifetime DSM-IV BDD. RESULTS: 28.9% (95% CI, 18.5%-39.4%) of participants reported lifetime panic attacks triggered by BDD symptoms. The most common triggers of such attacks were feeling that others were looking at or scrutinizing the perceived appearance defects (61.9%), looking in the mirror at perceived defects (38.1%), and being in bright light where perceived defects would be more visible (23.8%). The most common panic attack symptoms were palpitations (86.4%), sweating (66.7%), shortness of breath (63.6%), trembling or shaking (63.6%), and fear of losing control or going crazy (63.6%). Compared to participants without such panic attacks, those with BDD-triggered panic attacks had more severe lifetime BDD, social anxiety, and depressive symptoms, as well as poorer functioning and quality of life on a number of measures. They were also less likely to be employed and more likely to have been psychiatrically hospitalized and to have had suicidal ideation due to BDD. CONCLUSIONS: Panic attacks triggered by BDD-related situations appear com- mon in individuals with this disorder. BDD-triggered panic attacks were associated with greater symptom severity and morbidity.