Vulnerabilities in social anxiety: Integrating intra- and interpersonal perspectives.

What are the major vulnerabilities in people with social anxiety? What are the most promising directions for translational research pertaining to this condition? The present paper provides an integrative summary of basic and applied translational research on social anxiety, emphasizing vulnerability factors. It is divided into two subsections: intrapersonal and interpersonal. The intrapersonal section synthesizes research relating to (a) self-representations and self-referential processes; (b) emotions and their regulation; and (c) cognitive biases: attention, interpretation and judgment, and memory. The interpersonal section summarizes findings regarding the systems of (a) approach and avoidance, (b) affiliation and social rank, and their implications for interpersonal impairments. Our review suggests that the science of social anxiety and, more generally, psychopathology may be advanced by examining processes and their underlying content within broad psychological systems. Increased interaction between basic and applied researchers to diversify and elaborate different perspectives on social anxiety is necessary for progress.

Telephone interpersonal counseling treatment for frequent attenders to primary care: Development and piloting.

BACKGROUND: Frequent attenders in primary care (FAs) consume a disproportionate amount of healthcare resources and often have depression, anxiety, chronic health issues, and interpersonal problems. Despite extensive medical care, they remain dissatisfied with the care and report no improvement in quality of life. OBJECTIVE: To pilot a Telephone-based Interpersonal Counseling intervention for Frequent Attenders (TIPC-FA) and assess its feasibility and efficacy in reducing symptoms and healthcare utilization. METHOD: Top 10% of primary care visitors were randomly assigned to TIPC-FA, Telephone Supportive Contact (Support), or Treatment as Usual (TAU). TIPC-FA and Support groups received six telephone sessions over twelve weeks, while the TAU group was interviewed twice. Multilevel regression tested for changes over time, considering patient and counselor variance. RESULTS: TIPC-FA and Support groups demonstrated reduced depressive symptoms, and the TIPC-FA group showed decreased somatization and anxiety. The TIPC-FA group demonstrated a trend towards less healthcare utilization than the TAU group. CONCLUSION: This pilot study suggests that IPC via telephone outreach is a feasible approach to treating FAs, achieving a reduction in symptoms not seen in other groups. Promising reduction in healthcare utilization in the TIPC-FA group warrants further exploration in larger-scale trials.

Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study.

BACKGROUND: Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT). OBJECTIVE: The aim of this study was to examine whether (1) the training protocol would increase clinicians' knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings. METHODS: A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time. RESULTS: Trainees' knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied). CONCLUSIONS: Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation.

The Impact of Surgery and Stored Red Blood Cell Transfusions on Nitric Oxide Homeostasis.

BACKGROUND: Cell-free hemoglobin (Hb) forms in stored red blood cells (RBCs) as a result of hemolysis. Studies suggest that this cell-free Hb may decrease nitric oxide (NO) bioavailability, potentially leading to endothelial dysfunction, vascular injury, and multiorgan dysfunction after transfusion. We tested the hypothesis that moderate doses of stored RBC transfusions increase cell-free Hb and decrease NO availability in postoperative surgical patients. METHODS: Twenty-six patients undergoing multilevel spine fusion surgery were studied. We compared those who received no stored RBCs (n = 9) with those who received moderate amounts (6.1 ± 3.0 units) of stored RBCs over 3 perioperative days (n = 17). Percent hemolysis (cell-free Hb), RBC-NO (heme-NO), and plasma nitrite and nitrate were measured in samples from the stored RBC bags and from patients' blood, before and after surgery. RESULTS: Posttransfusion hemolysis was increased approximately 3.5-fold over preoperative levels (P = 0.0002) in blood samples collected immediately after surgery but not on postoperative days 1 to 3. Decreases in both heme-NO (by approximately 50%) and plasma nitrite (by approximately 40%) occurred postoperatively, both in nontransfused patients (P = 0.036 and P = 0.026, respectively) and transfused patients (P = 0.0068 and P = 0.003, respectively) and returned to preoperative baseline levels by postoperative day 2 or 3. Postoperative plasma nitrite and nitrate were decreased significantly in both groups, and this change was slower to return to baseline in the transfused patients, suggesting that blood loss and hemodilution from crystalloid administration contribute to this finding. CONCLUSIONS: The decrease in NO metabolites occurred irrespective of stored RBC transfusions, suggesting this decrease may be related to blood loss during surgery and hemodilution rather than to scavenging of NO or inhibition of NO synthesis by stored RBC transfusions.

2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion.

BACKGROUND: Stored red blood cells (RBCs) are deficient in 2,3-diphosphoglycerate (2,3-DPG), but it is unclear how autologous salvaged blood (ASB) compares with stored blood and how rapidly 2,3-DPG levels return to normal after transfusion. Therefore, we compared levels of 2,3-DPG in stored versus ASB RBCs and in patients' blood after transfusion. METHODS: Twenty-four patients undergoing multilevel spine fusion surgery were enrolled. We measured 2,3-DPG and the oxyhemoglobin dissociation curve (P50) in samples taken from the ASB and stored blood bags before transfusion and in blood samples drawn from patients before and after transfusion. RESULTS: The mean storage duration for stored RBCs was 24 ± 8 days. Compared with fresh RBCs, stored RBCs had decreased 2,3-DPG levels (by approximately 90%; P < 0.0001) and a decreased P50 (by approximately 30%; P < 0.0001). However, ASB RBCs did not exhibit these changes. The mean 2,3-DPG concentration decreased by approximately 20% (P < 0.05) in postoperative blood sampled from patients who received 1 to 3 stored RBC units and by approximately 30% (P < 0.01) in those who received ≥4 stored RBC units. 2,3-DPG was unchanged in patients who received no stored blood or ASB alone. After surgery, 2,3-DPG levels recovered gradually over 3 postoperative days in patients who received stored RBCs. CONCLUSIONS: Stored RBCs, but not ASB RBCs, have decreased levels of 2,3-DPG and a left-shift in the oxyhemoglobin dissociation curve. Postoperatively, 2,3-DPG levels remain below preoperative baseline levels for up to 3 postoperative days in patients who receive stored RBCs but are unchanged in those who receive only ASB RBCs.

Oxidative stress and rheologic properties of stored red blood cells before and after transfusion to surgical patients.

BACKGROUND: The loss of structural and functional integrity of red blood cells (RBCs) during storage, collectively referred to as "storage lesion," has been implicated in reduced oxygen delivery after transfusion. RBCs are highly susceptible to oxidative damage from generation of reactive oxygen species by autoxidation of hemoglobin. Therefore, we examined whether increased oxidative stress (OS) in stored RBCs is associated with impaired cell membrane deformability before or after transfusion. STUDY DESIGN AND METHODS: Thirty-four patients undergoing multilevel spine fusion surgery were enrolled. OS in RBCs was assessed by the presence of fluorescent heme degradation products and methemoglobin, which were measured with fluorimetric and spectrophotometric methods, respectively. Deformability and aggregation were determined by ektacytometry in stored RBCs, autologous salvaged RBCs, and posttransfusion blood samples. RESULTS: OS in stored RBCs was significantly increased with longer storage (R = 0.54, p = 0.032) and significantly higher than that in fresh RBCs (9.1 ± 1.3 fluorescent arbitrary units vs. 7.7 ± 0.9 fluorescent arbitrary units, p < 0.001). Deformability decreased (R = -0.60, p = 0.009) with increasing storage duration. OS was elevated (p < 0.05) and deformability was decreased (p < 0.05) in postoperative blood from patients who had undergone moderate (≥4 RBC units) but not minimal or no transfusion. Neither the decrease in deformability of RBCs nor the aggregation changes were correlated with OS. CONCLUSIONS: Although stored RBCs show signs of increased OS and loss of cell membrane deformability, these changes were not directly correlated and were only evident after moderate but not lower dose transfusion in postoperative surgical patients. These findings suggest that factors other than OS may contribute to impaired rheology with stored RBCs in the clinical setting.

A Brief Mindfulness Meditation Training Increases Pain Threshold and Accelerates Modulation of Response to Tonic Pain in an Experimental Study.

OBJECTIVE: Research shows that mindfulness meditation (MM) affects pain perception; however, studies have yet to measure patterns of change over time. We examined effects of MM on perception of experimental heat pain using multiple psychophysical indices, including pattern of change in response to tonic painful stimuli. We also tested the potential moderating role of baseline mindfulness. METHOD: Forty participants were randomly assigned to a brief MM training or control group. We assessed: a) heat pain threshold (HPT), b) temperature which induces pain at a fixed, target intensity level, and c) response pattern over time to tonic heat pain. RESULTS: Compared to control group, the MM group showed increased HPT and more rapid attenuation of pain intensity for tonic pain stimuli. Moderation analyses indicated that baseline mindfulness moderated effects of MM on HPT. CONCLUSIONS: A brief MM intervention appears to affect perception of experimental pain both by increasing pain threshold and accelerating modulation of response. Findings may help elucidate mechanisms of MM for chronic pain.

A 10-year prospective study of respiratory disease and depression and anxiety in adulthood.

BACKGROUND: Several cross-sectional studies have found an association between respiratory disease and increased mood or anxiety disorders among adults. Little is known about the nature of these associations over time or the role of potential confounders in these links. OBJECTIVES: To investigate the association between respiratory disease and incident and persistent depression or anxiety disorders 10 years later and to examine potential pathways of these associations. METHODS: Data were drawn from the Midlife Development in the United States survey, a representative sample of adults in the United States ages 18 to 74 years. Participants (N = 2,101) were interviewed on a range of health domains at baseline at wave 1 (1994) and again at wave 2 (2005). RESULTS: Respiratory disease was associated with increased odds of depression and anxiety disorders cross-sectionally at both time points. Respiratory disease at wave 1 was not associated with incident depression or anxiety disorders at wave 2. Respiratory disease at wave 1 was associated with increased odds of persistent depression or anxiety disorders 10 years later among those with depression or anxiety disorders at wave 1. Associations were not explained by differences in demographic characteristics, secondhand smoke exposure, cigarette smoking, or history of exposure to childhood maltreatment. CONCLUSION: Findings shed new light on the association between respiratory disease and depression or anxiety disorders. Individuals with respiratory disease appear to have higher prevalence of concurrent depression or anxiety disorders and persistent depression or anxiety disorders compared with those without respiratory disease. However, a history of respiratory disease does not appear to confer increased risk of new onset of depression or anxiety disorders.

Anxiety disorders and risk of self-reported ulcer: a 10-year longitudinal study among US adults.

OBJECTIVE: Previous epidemiologic studies have documented a link between anxiety disorders and ulcer among adults. Few studies have examined these associations over time and little is understood about the pathways underlying these relationships. METHOD: Data were drawn from n = 2101 adult participants in the Midlife Development in the United States I and II. Data on ulcer diagnoses were collected through self-report: among participants in the current sample, 38 reported ulcer at Waves 1 and 2 (prevalent ulcer), and 18 reported ulcer at Wave 2 but not at Wave 1 (incident ulcer). Panic attacks and generalized anxiety disorder at Wave 1 (1994) were examined in relation to prevalent (past 12 months) and incident ulcer approximately 10 years later at Wave 2 (2005). RESULTS: Anxiety disorders at Wave 1 were associated with increased prevalence of ulcer [odds ratio (OR) = 4.1, 95% confidence interval (CI) = 2.0-8.4], increased risk of incident ulcer at Wave 2 (OR = 4.1, 95% CI = 1.4-11.7) and increased risk of treated ulcer at Wave 2 (OR = 4.7, 95% CI = 2.3-9.9) compared with those without anxiety. CONCLUSIONS: In this large population sample of adults, anxiety disorders were associated with an increased risk of ulcer over a 10-year period. These relationships do not appear to be explained by confounding or mediation by a wide range of factors. Future studies should address potential mechanisms underlying the relationship between anxiety and ulcer.

Critical review of outcome research on interpersonal psychotherapy for anxiety disorders.

BACKGROUND: Interpersonal psychotherapy (IPT) has demonstrated efficacy in treating mood and eating disorders. This article critically reviews outcome research testing IPT for anxiety disorders, a diagnostic area where cognitive behavioral therapy (CBT) has dominated research and treatment. METHODS: A literature search identified six open and five controlled trials of IPT for social anxiety disorder (SAD), panic disorder, and posttraumatic stress disorder. RESULTS: Studies were generally small, underpowered, and sometimes methodologically compromised. Nonetheless, minimally adapted from its standard depression strategies, IPT for anxiety disorders yielded positive results in open trials for the three diagnoses. In controlled trials, IPT fared better than waiting list (N = 2), was equipotent to supportive psychodynamic psychotherapy (N = 1), but less efficacious than CBT for SAD (N = 1), and CBT for panic disorder (N = 1) in a methodologically complicated study. IPT equaled CBT in a group residential format (N = 1). CONCLUSIONS: IPT shows some promise for anxiety disorders but has thus far shown no advantages in controlled trials relative to other therapies. Methodological and ecological issues have complicated testing of IPT for anxiety disorders, clouding some findings. The authors discuss difficulties of conducting non-CBT research in a CBT-dominated area, investigator bias, and the probable need to further modify IPT for anxiety disorders. Untested therapies deserve the fairest possible testing.

Does parental response to children's pain moderate the association between pain severity and functional disability? An examination of noncardiac chest pain.

OBJECTIVE: We sought to examine whether parental responses to children's noncardiac chest pain moderate the relationship between child's pain severity and functional disability. METHODS: 77 children (ages 8-18 years) with noncardiac chest pain and their parents were recruited from pediatric cardiology clinics in Israel. Children completed measures assessing pain (intensity/frequency) and functioning. Parents and children completed measures assessing parental responses to children's pain. RESULTS: Parental protective responses (parent and child report) moderated the relationship between child's pain intensity and frequency and functional disability. Parental encouraging/monitoring responses (child report only) moderated the relationship between child's pain intensity and functional disability. As expected, the association between pain and disability was greater for children and adolescents whose parents were higher in these behaviors. CONCLUSIONS: Parental protective and encouraging/monitoring behavior may exacerbate the impact of pain on functioning. Interventions that promote more adaptive responses to children's pain may help reduce disability in youth with pain.

Mechanisms of change in interpersonal therapy (IPT).

Although interpersonal therapy (IPT) has demonstrated efficacy for mood and other disorders, little is known about how IPT works. We present interpersonal change mechanisms that we hypothesize account for symptom change in IPT. Integrating relational theory and insights based on research findings regarding stress, social support, and illness, IPT highlights contextual factors thought to precipitate and maintain psychiatric disorders. It frames therapy around a central interpersonal problem in the patient's life, a current crisis or relational predicament that is disrupting social support and increasing interpersonal stress. By mobilizing and working collaboratively with the patient to resolve this problem, IPT seeks to activate several interpersonal change mechanisms. These include: 1) enhancing social support, 2) decreasing interpersonal stress, 3) facilitating emotional processing, and 4) improving interpersonal skills. We hope that articulating these mechanisms will help therapists to formulate cases and better maintain focus within an IPT framework. Here we propose interpersonal mechanisms that might explain how IPT's interpersonal focus leads to symptom change. Future work needs to specify and test candidate mediators in clinical trials. We anticipate that pursuing this more systematic strategy will lead to important refinements and improvements in IPT and enhance its application in a range of clinical populations.

Panic disorder in children and adolescents with noncardiac chest pain.

Adults with panic disorder (PD) often present to medical settings with noncardiac chest pain (NCCP), but less is known about children and adolescents with this complaint. We sought to characterize PD in youth with NCCP and compare features with PD in youth in psychiatric outpatient settings. Using a semi-structured diagnostic interview we evaluated 132 youth (ages 8-17) with NCCP recruited from two medical settings. Twenty-seven (20.5 %) met full DSM-IV criteria for PD, eleven of which were children (<13 years). Most frequent panic symptoms were somatic complaints, although cognitive symptoms were also common. Only 14.8 % had clinically significant agoraphobia. Comorbid anxiety disorders and major depression were common. Overall, clinical features of PD among youth with NCCP are similar to PD in psychiatric settings. Interventions for PD may benefit youth who present initially with NCCP. Systematic psychiatric screening could increase detection of PD and improve care for this population.

Do mindfulness-based interventions reduce pain intensity? A critical review of the literature.

BACKGROUND: Mindfulness-based interventions (MBIs) emphasizing a nonjudgmental attitude toward present moment experience are widely used for chronic pain patients. Although changing or controlling pain is not an explicit aim of MBIs, recent experimental studies suggest that mindfulness practice may lead to changes in pain tolerance and pain intensity ratings. OBJECTIVE: The objective of this review is to investigate the specific effect of MBIs on pain intensity. METHODS: A literature search was conducted using the databases PUBMED and PsycINFO for relevant articles published from 1960 to December 2010. We additionally conducted a manual search of references from the retrieved articles. Only studies providing detailed results on change in pain intensity ratings were included. RESULTS: Sixteen studies were included in this review (eight uncontrolled and eight controlled trials). In most studies (10 of 16), there was significantly decreased pain intensity in the MBI group. Findings were more consistently positive for samples limited to clinical pain (9 of 11). In addition, most controlled trials (6 of 8) reveal higher reductions in pain intensity for MBIs compared with control groups. Results from follow-up assessments reveal that reductions in pain intensity were generally well maintained. CONCLUSIONS: Findings suggest that MBIs decrease the intensity of pain for chronic pain patients. We discuss implications for understanding mechanisms of change in MBIs.

[Fever phobia in the ultra-religious community in Israel].

INTRODUCTION: Fever phobia has been described for over 30 years without significant prevalence change. NevertheLess, there is only minimal data about this phenomenon in IsraeL and within its varied sub-populations. The study goal was to examine the prevalence of this phobia among parents seeking care for their febrile child in an urgent care center (UCC), especialLy Charedi (ultra-religious) parents. The working hypothesis was that as the Charedi parents tended to be younger, and have Less formal education, they would be more LikeLy to have greater rates of fever phobia. METHODS: Site: Two UCCs in Jerusalem and Modiin. INSTRUMENT: A structured 38-item interview was conducted encompassing the original fever phobia questionnaire, demographic information, and knowledge and beliefs regarding fever. PARTICIPANTS: Parents of children who visited a UCC with a febrile child aged between 2 months and 10 years. RESULTS: A total of 349 interviews were conducted; 90% of the parents felt that fever could cause damage; 33% were very worried when their child has fever; 55% worried and 12% were not worried. It was found that there was lack of knowledge and false assumptions existed. For example, 1/3 of the parents defined fever < 37.7 degrees C as fever and 1/2 of the parents start treatment for fever < 38 degrees C. n contrast to the working hypothesis, the Charedi parents were less worried. The larger the family, the less likely the parents were to be worried. CONCLUSIONS: There continues to be both lack of knowledge and incorrect assumptions regarding fever in parents using UCC. Charedi parents are less worried, perhaps secondary to larger family size.

Haven't we met somewhere before? The effects of a brief Internet introduction on social anxiety in a subsequent face to face interaction.

Social anxiety occurs in a range of social situations, the salience of which is influenced by prevailing modes of social contact. The emergence of computer mediated communication (CMC), buoyed by the recent explosion of social networks, has changed the way many people make and maintain social contacts. We randomly assigned 30 socially anxious and 30 low social anxiety participants to a brief internet chat introduction or a control internet surfing condition followed by a standardized face to face (FTF) interaction. We hypothesized that for socially anxious participants the chat introduction would reduce anxiety of and preference to avoid the subsequent FTF interaction. Results supported hypotheses for most indices. Findings suggest that, at least for the common situation in which internet chat precedes FTF interaction with the same person, such contact may reduce social anxiety. It is not known whether this decrease would generalize to FTF contact in other contexts. It is suggested that CMC might be construed as a particularly useful form of safety behavior that may help in the allocation of attentional resources to process new information relevant for disconfirmation of negative beliefs maintaining social anxiety. Potential clinical implications are discussed.

Therapist adherence to interpersonal vs. supportive therapy for social anxiety disorder.

We assessed therapist adherence to interpersonal therapy (IPT) and supportive therapy (ST) in a controlled trial for social anxiety disorder. Raters blindly scored n = 133 videotapes from 53 participants using the Collaborative Study Psychotherapy Rating Scale (CSPRS). Results reveal statistical differences across groups, but higher than expected overlap. Greater use of IPT in beginning sessions predicted better outcome in both therapies. Suboptimal adherence may be due to the crossed design in which the same therapists delivered both IPT and ST. Since switching between different approaches is a clinical reality for integrative psychotherapists, these findings may have important clinical implications.

Psychiatric disorders in youth with medically unexplained chest pain versus innocent heart murmur.

OBJECTIVE: To examine the prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders in youth with chest pain compared with a control sample with innocent heart murmur. STUDY DESIGN: We assessed youth ages 8 to 17 years who were examined in cardiology settings for medically unexplained chest pain (n=100) or innocent heart murmur (n=80). We conducted semi-structured interviews and assessed medical history, quality of life, and disability. RESULTS: Youth with chest pain had a higher prevalence of psychiatric disorders compared with youth with murmur (74% versus 47%, χ(2)=13.3; P<.001). Anxiety disorders predominated, although major depression was also more common in the chest pain group (9% versus 0%; Fisher exact tests; P<.01). Onset of psychiatric disorders generally preceded chest pain. Patterns were similar for boys and girls and for children and adolescents. Chest pain was associated with poorer quality of life and with pain-related disability for youth with co-morbid psychiatric disorder. CONCLUSIONS: In childhood and adolescence, medically unexplained chest pain is associated with a high prevalence of psychiatric disorders. Systematic mental health screening may improve detection and enhance treatment of these patients.

Depressive symptoms, risk factors and sleep in asthma: results from a national Israeli health survey.

OBJECTIVE: The objective was to assess the association between asthma and depressive symptoms (DS) and to evaluate the relationship between DS and risk factors [smoking, physical inactivity, body mass index (BMI) and sleep duration] in asthmatic individuals. METHODS: We analyzed data from the Israeli National Health Interview Survey, conducted among 9509 participants aged ≥21 years in 2003-2004. Data on sociodemographic factors, chronic respiratory disorders, DS and risk factors were obtained through telephone interviews. DS were measured using Short Form 36 mental health items. Analyses were performed using multivariate logistic regression models. RESULTS: A total of 393 participants (4.2%) reported chronic asthma in the 12 months previous to the interview. Of those, 37.4% had DS, compared with 21.8% of nonasthmatic participants [odds ratio (OR), 1.84; 95% confidence interval (CI), 1.47-2.30; P<.001]. DS in asthmatic individuals were significantly associated with physical inactivity [adjusted OR (AOR), 2.01; 95% CI, 1.12-3.61; P=.02], with smoking (AOR 1.80; 95% CI, 1.04-3.12; P=.04) and with less sleep (AOR, 1.81; 95% CI, 1.03-3.19; P=.04). DS in asthmatic participants were not associated with BMI. CONCLUSIONS: DS are common in asthmatic individuals and are significantly associated with physical inactivity, with smoking and with less hours of sleep. Such health-related risk factors may impact on the course of asthma and on overall health.