Emotional and interpersonal mechanisms in community SSRI treatment of social anxiety disorder.

BACKGROUND: Affective and interpersonal behavioural patterns characteristic of social anxiety disorder show improvement during treatment with serotonin agonists (e.g., selective serotonin reuptake inhibitors), commonly used in the treatment of social anxiety disorder. The present study sought to establish whether, during community psychopharmacological treatment of social anxiety disorder, changes in positive or negative affect and agreeable or quarrelsome behaviour mediate improvement in social anxiety symptom severity or follow from it. METHODS: Adults diagnosed with social anxiety disorder (n = 48) recorded their interpersonal behaviour and affect naturalistically in an event-contingent recording procedure for 1-week periods before and during the first 4 months of treatment with paroxetine. Participants and treating psychiatrists assessed the severity of social anxiety symptoms monthly. A multivariate latent change score framework examined temporally lagged associations of change in affect and interpersonal behaviour with change in social anxiety symptom severity. RESULTS: Elevated agreeable behaviour and positive affect predicted greater subsequent reduction in social anxiety symptom severity over the following month of treatment. Elevated negative affect, but not quarrelsome behaviour, predicted less subsequent reduction in symptom severity. LIMITATIONS: Limitations included limited assessment of extreme behaviour (e.g., violence) that may have precluded examining the efficacy of paroxetine because of the lack of a placebo control group. CONCLUSION: The present study suggests that interpersonal behaviour and affect may be putative mechanisms of action for serotonergic treatment of social anxiety disorder. Prosocial behaviour and positive affect increase during serotonergic treatment of social anxiety disorder. Specifically, modulating agreeable behaviour, positive affect and negative affect in individuals' daily lives may partially explain and refine clinical intervention.

Affect, interpersonal behaviour and interpersonal perception during open-label, uncontrolled paroxetine treatment of people with social anxiety disorder: a pilot study

Background: Laboratory-based research with community samples has suggested changes in affective, behavioural and cognitive processes as possible explanations for the effects of serotonergic medications. Examining the effects of serotonergic medications using an ecological momentary measure (such as event-contingent recording) in the daily lives of people with social anxiety disorder would contribute to establishing the effects of these medications on affect, behaviour and one form of cognition: perception of others' behaviour. Methods: The present study assessed changes in affect, interpersonal behaviour and perception of others' behaviour in adults with social anxiety disorder using ecological momentary assessment at baseline and over 4 months of a single-arm, uncontrolled, open-label trial of treatment with the selective serotonin reuptake inhibitor paroxetine. Results: Anxiety and concurrent depressive symptoms decreased. Participants also reported increased positive and decreased negative affect; increased agreeable and decreased quarrelsome behaviour; increased dominant and decreased submissive behaviour; and increased perception that others behaved agreeably toward them. Moreover, participants demonstrated reduced intraindividual variability in affect, interpersonal behaviour and perception of others' behaviour. Limitations: Limitations included the lack of a placebo group, the inability to identify the temporal order of changes and the restricted assessment of extreme behaviour. Conclusion: The results of the present study demonstrate changes during pharmacotherapy in the manifestation of affect, interpersonal behaviour and interpersonal perception in the daily lives of people with social anxiety disorder. Given the importance of interpersonal processes to social anxiety disorder, these results may guide future research seeking to clarify mechanisms of action for serotonergic medications.

Brain serotonin synthesis capacity in obsessive-compulsive disorder: effects of cognitive behavioral therapy and sertraline.

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[11C]methyl-L-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[11C]methyl-L-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

Assessing suitability for short-term cognitive-behavioral therapy in psychiatric outpatients with psychosis: a comparison with depressed and anxious outpatients.

OBJECTIVE: The Suitability for Short-Term Cognitive Therapy (SSCT) rating procedure has predicted outcome in depressed and anxious patients. This study examines its relevance in assessing patients with psychosis. METHOD: Outpatients with psychosis (n=56), depression (n=93), and anxiety (n=264) received cognitive- behavioral therapy in a university hospital teaching unit (mean number of sessions=16, SD=11). Demographic, clinical, and suitability variables were assessed as potential predictors of dropout and success as measured by the Reliable Change Index. RESULTS: Despite lower suitability scores in the psychosis group, dropout and success rates were similar across groups, although the magnitude of symptom reduction was less in the psychosis group. Across diagnoses, dropout was predicted by unemployment and by reluctance to take personal responsibility for change. In the psychosis group only, dropout was predicted by hostility. Success of completed therapy was predicted by higher baseline agoraphobic anxiety and "responsibility for change" scores. CONCLUSION: Attention to hostility early in therapy may reduce dropout in psychotic patients. Fostering acceptance of responsibility for change may improve both treatment retention and success across diagnoses. Agoraphobic fear is associated with success, possibly reflecting the effectiveness of behavioral interventions in psychosis and anxiety alike.

Brain regional α-[11C]methyl-L-tryptophan trapping in medication-free patients with obsessive-compulsive disorder.

CONTEXT: The hypothesis of a serotonin (5-hydroxytryptamine [5-HT]) dysfunction in obsessive-compulsive disorder (OCD) stems largely from the clinical efficacy of 5-HT reuptake inhibitors. Serotonergic abnormalities in the unmedicated symptomatic state, however, remain to be fully characterized. OBJECTIVE: To investigate brain regional 5-HT synthesis, as indexed by positron emission tomography and the α-[(11)C]methyl-L-tryptophan trapping constant (K*), in treatment-free adults meeting criteria for OCD. DESIGN: Between-group comparison. SETTING: Department of Psychiatry and Montreal Neurological Institute, McGill University, and Department of Psychology, McGill University Health Centre, Quebec, Canada. PARTICIPANTS: Twenty-one medication-free patients with OCD (15 men with a mean [SD] age of 33.2 [9.3] years and 6 women with a mean [SD] age of 35.8 [7.1] years) and 21 healthy controls matched for age and sex (15 men with a mean [SD] age of 32.9 [10.1] years and 6 women with a mean [SD] age of 36.5.5 [8.6] years). Main Outcome Measure The α-[(11)C]methyl-L-tryptophan brain trapping constant K*, which was analyzed with Statistical Parametric Mapping (SPM8) and with proportional normalization (extent threshold of 100 voxels with a peak threshold of P ≤ .005). RESULTS: Compared with healthy controls, the patients with OCD exhibited significantly greater α-[(11)C]methyl-L-tryptophan trapping in the right hippocampus and left temporal gyrus (Brodmann area 20). In the larger subsample of all men, these same differences were also evident, as well as higher K* values in the caudate nucleus. Individual differences in symptom severity correlated positively with K* values sampled from the caudate and temporal lobe of the patients with OCD, respectively. There were no regions where the patients exhibited abnormally low K* values. Volumetric analyses found no morphometric alterations that would account for the group differences. CONCLUSION: The results support previous reports of greater striatal and temporal lobe activity in patients with OCD than in healthy controls and suggest that these disturbances include a serotonergic component. Previously reported glucose metabolic disturbances in OCD involving the orbitofrontal and cingulate cortices, in comparison, might reflect postsynaptic changes in the serotonergic system.

Social behaviour and mood in everyday life: the effects of tryptophan in quarrelsome individuals.

OBJECTIVE: We hypothesized that increasing brain serotonin in healthy individuals with high scores on 2 self-report measures of trait quarrelsomeness would reduce quarrelsome behaviours and enhance agreeable behaviours when measured ecologically using an event-contingent recording method. METHODS: We conducted a double-blind crossover study, in which participants took tryptophan (3 g/d) and placebo for 15 days each and recorded how they behaved, felt and perceived others during everyday social interactions. RESULTS: Tryptophan significantly decreased quarrelsome behaviours and increased agreeable behaviours and perceptions of agreeableness. Men also behaved less dominantly, whereas both men and women perceived others as more dominant. CONCLUSION: Tryptophan's effects on behaviours and perceptions, while more marked in the men, were generally positive and accompanied by improved affect. Increasing serotonin in quarrelsome people may not only reduce behaviours associated with a predisposition to various mental and physical disorders but also enhance socially constructive behaviours and improve social perceptions.

Public awareness about depression: the effectiveness of a patient guideline.

OBJECTIVE: To evaluate the effectiveness of a patient guideline for educating the public in the recognition and treatment of depression. METHOD: Lay subjects were interviewed regarding their knowledge and beliefs about depression through the use of a semi-structured questionnaire. They were asked to "think aloud" while evaluating two clinical scenarios about depression, both with and without the use of a patient guideline. All interviews were audio taped, transcribed, and analyzed for subjects' thought processes and accuracy of responses in the presence and absence of the guideline. RESULTS: Subjects with no prior history of depression identified fewer symptoms of depression listed in the patient guideline than did subjects with a history of depression. In the absence of the guideline, only 50% and 38% of subjects provided accurate diagnosis of depression for the simple and complex problems respectively. In the presence of the guideline, 92% and 83% of subjects provided an accurate diagnosis of depression for the simple and complex problems respectively. CONCLUSIONS: Lay people have a limited knowledge of depression and its treatment, and are less able to recognize symptoms of depression without the help of patient guideline. The guideline primes lay people to better recognize these symptoms and their relationship to diagnosis. This level of understanding about depression by lay people will facilitate improved communication between physicians and their patients.

Treatment seeking for obsessive-compulsive disorder: role of obsessive-compulsive disorder symptoms and comorbid psychiatric diagnoses.

Previous research has indicated that individuals afflicted with obsessive-compulsive disorder (OCD) have a very low rate of seeking help from mental health professionals. From standardized psychiatric interviews of 7,214 residents of Edmonton, Canada, we identified 172 subjects with a lifetime diagnosis of OCD; 63 (36.6%) had consulted a doctor about their symptoms. Total number of OCD symptoms (odds ratio [OR] = 2.23) and severe obsessions of violence and other unpleasant thoughts (OR = 2.52) were significantly associated with treatment seeking in multivariate analysis. The absence of association between compulsions and treatment seeking was corroborated by a very low prevalence of treatment seeking (17.3%) in individuals suffering from compulsions only. Our findings suggest that there is a need to teach the public about compulsions, and such a strategy may enhance future public health education programs.

Tryptophan, serotonin and human social behavior.

Animals research suggests that increasing serotonin can decrease aggression, increase affiliative behaviors and increase dominant behaviors. We tested the relevance of these data to humans by giving 100 healthy people tryptophan (1 g after each meal) and placebo, each for 12 days in a double-blind cross-over study. Social behaviors were studied using an event sampling method in which subjects filled in a one page questionnaire about their behaviors after each social interaction lasting at least 5 minutes. Tryptophan caused a significant decrease in quarrelsome behaviors and a significant increase in dominant behaviors.