Cognitive analysis of specific threat beliefs and safety-seeking behaviours in generalised anxiety disorder: revisiting the cognitive theory of anxiety disorders.

BACKGROUND: Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM. Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive worry fail to explain when and why worry is excessive and when it is adaptive. AIMS: In this paper we propose a cognitive behavioural account of the difference between excessive and adaptive states of worry and explore the theme of threat and the function of safety-seeking behaviours as seen in GAD. Specifically, we incorporate the concept of inflated responsibility in a cognitive behavioural analysis of threat appraisal and safety-seeking behaviours in excessive worry and GAD. CONCLUSION: It is proposed that when worry is used as a strategy intended to increase safety from perceived social or physical threat then it should be conceptualised as a safety-seeking behaviour. However, when worry is used as a strategy to solve a problem which the person realistically can resolve or to deal explicitly with the feeling of anxiety then it functions as an adaptive coping behaviour. We also propose that the theme of threat in GAD centres on an inflated sense of responsibility for external everyday situations, and the function of safety-seeking behaviours is to attain certainty that responsibility has been fulfilled. The clinical implications of this cognitive behavioural analysis of excessive worry are discussed, as well as future research directions.

The mental health characteristics of pregnant women with depressive symptoms identified by the Edinburgh Postnatal Depression Scale.

OBJECTIVE: Few studies are available on the effectiveness of screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or the extent to which such tools may identify women with mental disorders other than depression. We therefore aimed to investigate the mental health characteristics of pregnant women who screen positive on the EPDS. METHOD: Consecutive women receiving antenatal care in primary care clinics (from November 2006 to July 2011) were invited to complete the EPDS in week 16 of pregnancy. All women who scored above 11 (screen positive) on the EPDS and randomly selected women who scored below 12 (screen negative) were invited to participate in a psychiatric diagnostic interview. RESULTS: 2,411 women completed the EPDS. Two hundred thirty-three women (9.7%) were screened positive in week 16, of whom 153 (66%) agreed to a psychiatric diagnostic interview. Forty-eight women (31.4%) were diagnosed with major depressive disorder according to DSM-IV criteria, 20 (13.1%) with bipolar disorder, 93 (60.8%) with anxiety disorders (including 27 [17.6%] with obsessive-compulsive disorder [OCD]), 8 (5.2%) with dysthymia, 18 (11.8%) with somatoform disorder, 3 (2%) with an eating disorder, and 7 (4.6%) with current substance abuse. Women who screened positive were significantly more likely to have psychosocial risk factors, including being unemployed (χ(2)(1) = 23.37, P ≤.001), lower educational status (χ(2)(1)= 31.68, P ≤ .001), and a history of partner violence (χ(2)(1) = 10.30, P ≤ 001), compared with the women who screened negative. CONCLUSIONS: Use of the EPDS early in the second trimester of pregnancy identifies a substantial number of women with potentially serious mental disorders other than depression, including bipolar disorder, OCD, and eating disorders. A comprehensive clinical assessment is therefore necessary following use of the EPDS during pregnancy to ensure that women who screen positive receive appropriate mental health management.

Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment.

STUDY OBJECTIVES: To assess the changes of insomnia symptoms among patients with obstructive sleep apnea (OSA) from starting treatment with positive airway pressure (PAP) to a 2-y follow-up. DESIGN: Longitudinal cohort study. SETTING: Landspitali--The National University Hospital of Iceland. PARTICIPANTS: There were 705 adults with OSA who were assessed prior to and 2 y after starting PAP treatment. INTERVENTION: PAP treatment for OSA. MEASUREMENTS AND RESULTS: All patients underwent a medical examination along with a type 3 sleep study and answered questionnaires on health and sleep before and 2 y after starting PAP treatment. The change in prevalence of insomnia symptoms by subtype was assessed by questionnaire and compared between individuals who were using or not using PAP at follow-up. Symptoms of middle insomnia were most common at baseline and improved significantly among patients using PAP (from 59.4% to 30.7%, P < 0.001). Symptoms of initial insomnia tended to persist regardless of PAP treatment, and symptoms of late insomnia were more likely to improve among patients not using PAP. Patients with symptoms of initial and late insomnia at baseline were less likely to adhere to PAP (odds ratio [OR] 0.56, P = 0.007, and OR 0.53, P < 0.001, respectively). CONCLUSION: Positive airway pressure treatment significantly reduced symptoms of middle insomnia. Symptoms of initial and late insomnia, however, tended to persist regardless of positive airway pressure treatment and had a negative effect on adherence. Targeted treatment for insomnia may be beneficial for patients with obstructive sleep apnea comorbid with insomnia and has the potential to positively affect adherence to positive airway pressure.

Insomnia in untreated sleep apnea patients compared to controls.

Insomnia and obstructive sleep apnea (OSA) often coexist, but the nature of their relationship is unclear. The aims of this study were to compare the prevalence of initial and middle insomnia between OSA patients and controls from the general population as well as to study the influence of insomnia on sleepiness and quality of life in OSA patients. Two groups were compared, untreated OSA patients (n = 824) and controls ≥ 40 years from the general population in Iceland (n = 762). All subjects answered the same questionnaires on health and sleep and OSA patients underwent a sleep study. Altogether, 53% of controls were males compared to 81% of OSA patients. Difficulties maintaining sleep (DMS) were more common among men and women with OSA compared to the general population (52 versus 31% and 62 versus 31%, respectively, P < 0.0001). Difficulties initiating sleep (DIS) and DIS + DMS were more common among women with OSA compared to women without OSA. OSA patients with DMS were sleepier than patients without DMS (Epworth Sleepiness Scale: 12.2 versus 10.9, P < 0.001), while both DMS and DIS were related to lower quality of life in OSA patients as measured by the Short Form 12 (physical score 39 versus 42 and mental score 36 versus 41, P < 0.001). DIS and DMS were not related to OSA severity. Insomnia is common among OSA patients and has a negative influence on quality of life and sleepiness in this patient group. It is relevant to screen for insomnia among OSA patients and treat both conditions when they co-occur.

Comparative long-term adverse effects elicited by invasive group B and C meningococcal infections.

BACKGROUND: Given the identity between Neisseria meningitidis serogroup B (MenB) capsular polysaccharide (polysialic acid; PSA) and PSA found on neural cell adhesion molecules, it has been proposed that infection with MenB or vaccination with PSA may be associated with subsequent autoimmune or neurological disease. METHODS: We conducted 2 studies. The first was a retrospective nationwide study of invasive meningococcal disease (IMD) in Iceland (with 541 subjects) during the period 1975-2004, and we cross referenced this cohort with databases with respect to subsequent diagnosis of autoimmune disorders. A follow-up study involving 120 survivors of IMD was performed. The study included 70 patients with a history of MenB and 50 patients with N. meningitidis serogroup C (MenC) infection, who served as control subjects. Participants answered standardized questionnaires (Beck's Depression Inventory [BDI] II, Depression Anxiety Stress Scales [DASS], and Patient Health Questionnaire [PHQ]), and serum levels of immunoglobulin (Ig) G against MenB and MenC capsular polysaccharides were measured. RESULTS: The nationwide cohort had 9166 patient-years of follow up. No evidence of increased autoimmunity was found to be associated with MenB, compared with MenC. In the follow-up study, patients were evaluated 16.6 years after the infection, representing 2022 patient-years of observation. Comparable rates of most complications were recorded, but MenC infections were associated with arthritis (P = .008) and migraine headaches (P = .01) more frequently than were MenB infections. No difference was observed with respect to scores on BDI-II, DASS, or PHQ. IgG anti-MenB and anti-MenC capsular polysaccharide levels were not related to patient complaints. CONCLUSIONS: This study does not support the hypothesis that MenB infection may predispose to autoimmunity. MenC infections are associated with a higher prevalence of arthritis and migraine headaches. No evidence of antibody-associated pathology was detected at long-term follow-up.

Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) in adulthood is not fully treated by psychopharmacological treatment alone. The main aim of the current study was to evaluate a newly developed cognitive behaviour therapy (CBT) based group programme, the Reasoning and Rehabilitation for ADHD Youths and Adults (R&R2ADHD), using a randomized controlled trial. METHODS: 54 adults with ADHD already receiving psychopharmacological treatment were randomly allocated to an experimental (CBT/MED) treatment condition (n = 27) and a 'treatment as usual' (TAU/MED) control condition (n = 27) that did not receive the CBT intervention. The outcome measures were obtained before treatment (baseline), after treatment and at three month follow-up and included ADHD symptoms and impairments rated by independent assessors, self-reported current ADHD symptoms, and comorbid problems. RESULTS: The findings suggested medium to large treatment effects for ADHD symptoms, which increased further at three month follow-up. Additionally, comorbid problems also improved at follow-up with large effect sizes. CONCLUSIONS: The findings give support for the effectiveness of R&R2ADHD in reducing ADHD symptoms and comorbid problems, an improving functions associated with impairment. The implications are that the benefits of R&R2ADHD are multifaceted and that combined psychopharmacological and CBT based treatments may add to and improve pharmacological interventions. TRIAL REGISTRATION: ACTRN12611000533998 (http://www.ANZCTR.org.au/ACTRN12611000533998.aspx).

Trends in depressive symptoms, anxiety symptoms and visits to healthcare specialists: a national study among Icelandic adolescents.

AIMS: The aim of the study was to examine trends in adolescent depression and anxiety symptoms from 1997 to 2006, using four time-points (1997, 2000, 2003, and 2006), and adolescent mental health service use in the same period, using three time-points (1997, 2000, and 2006). METHODS: Four cross-sectional population-based samples of 14- and 15-year-old students, attending the compulsory 9th and 10th grades of the Icelandic secondary school system, completed questionnaires relating to mental health. In total, 21,245 students participated in the four studies. RESULTS: Anxiety symptoms increased significantly for both boys and girls, throughout the period from 1997 to 2006. Depressive symptoms increased significantly for girls, while there were no significant changes in depression among boys. During the same time period, the proportion of adolescents who visited healthcare specialists, i.e. psychiatrists, psychologists and social workers, increased significantly. The results revealed that regular visits (six times or more during 1 year) to psychiatrists and psychologists increased significantly over the same period among girls but not among boys. CONCLUSIONS: The findings show that symptoms of depression and anxiety have increased among adolescents in Iceland. Future work would benefit from further research into the trends in risk and protective factors associated with these outcomes. The findings call particular attention to the increasing risk for depression and anxiety symptoms among girls.