Incidence and temporal trends of co-occurring personality disorder diagnoses in immune-mediated inflammatory diseases.

AIMS: Although immune-mediated inflammatory diseases (IMID) are associated with multiple mental health conditions, there is a paucity of literature assessing personality disorders (PDs) in these populations. We aimed to estimate and compare the incidence of any PD in IMID and matched cohorts over time, and identify sociodemographic characteristics associated with the incidence of PD. METHODS: We used population-based administrative data from Manitoba, Canada to identify persons with incident inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) using validated case definitions. Unaffected controls were matched 5:1 on sex, age and region of residence. PDs were identified using hospitalisation or physician claims. We used unadjusted and covariate-adjusted negative binomial regression to compare the incidence of PDs between the IMID and matched cohorts. RESULTS: We identified 19 572 incident cases of IMID (IBD n = 6,119, MS n = 3,514, RA n = 10 206) and 97 727 matches overall. After covariate adjustment, the IMID cohort had an increased incidence of PDs (incidence rate ratio [IRR] 1.72; 95%CI: 1.47-2.01) as compared to the matched cohort, which remained consistent over time. The incidence of PDs was similarly elevated in IBD (IRR 2.19; 95%CI: 1.69-2.84), MS (IRR 1.79; 95%CI: 1.29-2.50) and RA (IRR 1.61; 95%CI: 1.29-1.99). Lower socioeconomic status and urban residence were associated with an increased incidence of PDs, whereas mid to older adulthood (age 45-64) was associated with overall decreased incidence. In a restricted sample with 5 years of data before and after IMID diagnosis, the incidence of PDs was also elevated before IMID diagnosis among all IMID groups relative to matched controls. CONCLUSIONS: IMID are associated with an increased incidence of PDs both before and after an IMID diagnosis. These results support the relevance of shared risk factors in the co-occurrence of PDs and IMID conditions.

Rising incidence of psychiatric disorders before diagnosis of immune-mediated inflammatory disease.

AIMS: After the diagnosis of immune-mediated inflammatory diseases (IMID) such as inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA), the incidence of psychiatric comorbidity is increased relative to the general population. We aimed to determine whether the incidence of psychiatric disorders is increased in the 5 years before the diagnosis of IMID as compared with the general population. METHODS: Using population-based administrative health data from the Canadian province of Manitoba, we identified all persons with incident IBD, MS and RA between 1989 and 2012, and cohorts from the general population matched 5 : 1 on year of birth, sex and region to each disease cohort. We identified members of these groups with at least 5 years of residency before and after the IMID diagnosis date. We applied validated algorithms for depression, anxiety disorders, bipolar disorder, schizophrenia, and any psychiatric disorder to determine the annual incidence of these conditions in the 5-year periods before and after the diagnosis year. RESULTS: We identified 12 141 incident cases of IMID (3766 IBD, 2190 MS, 6350 RA) and 65 424 matched individuals. As early as 5 years before diagnosis, the incidence of depression [incidence rate ratio (IRR) 1.54; 95% CI 1.30-1.84) and anxiety disorders (IRR 1.30; 95% CI 1.12-1.51) were elevated in the IMID cohort as compared with the matched cohort. Similar results were obtained for each of the IBD, MS and RA cohorts. The incidence of bipolar disorder was elevated beginning 3 years before IMID diagnosis (IRR 1.63; 95% CI 1.10-2.40). CONCLUSION: The incidence of psychiatric comorbidity is elevated in the IMID population as compared with a matched population as early as 5 years before diagnosis. Future studies should elucidate whether this reflects shared risk factors for psychiatric disorders and IMID, a shared final common inflammatory pathway or other aetiology.

Anxiety-related psychopathology and chronic pain comorbidity among public safety personnel.

Canadian Public Safety Personnel (PSP; e.g., correctional service officers, dispatchers, firefighters, paramedics, police officers) regularly experience potentially traumatic, painful, and injurious events. Such exposures increase risk for developing mental disorders and chronic pain, which both involve substantial personal and social costs. The interrelationship between mental disorders and chronic pain is well-established, and both can be mutually maintaining; accordingly, understanding the relationship between mental health and chronic pain among PSP is important for improving health care. Unfortunately, the available research on such comorbidity for PSP is sparse. The current study was designed to provide initial estimates of comorbidities between mental disorders and chronic pain across diverse PSP. Participants included 5093 PSP (32% women) in six categories (i.e., Call Center Operators/Dispatchers, Correctional Workers, Firefighters, Municipal/Provincial Police, Paramedics, Royal Canadian Mounted Police) who participated in a large PSP mental health survey. The survey included established self-report measures for mental disorders and chronic pain. In the total sample, 23.1% of respondents self-reported clinically significant comorbid concerns with both mental disorders and chronic pain. The results indicated PSP who reported chronic pain were significantly more likely to screen positive for posttraumatic stress disorder (PTSD), major depressive disorder, generalized anxiety disorder, social anxiety disorder, and alcohol use disorder. There were differences between PSP categories; but, the most consistent indications of comorbidity were for chronic pain, PTSD, and major depressive disorder. Comorbidity between chronic pain and mental disorders among PSP is prevalent. Health care providers should regularly assess PSP for both symptom domains.

Insomnia, psychiatric disorders and suicidal ideation in a National Representative Sample of active Canadian Forces members.

BACKGROUND: Past research on the association between insomnia and suicidal ideation (SI) has produced mixed findings. The current study explored the relationship between insomnia, SI, and past-year mental health status among a large Canadian Forces (CF) sample. METHOD: Data was obtained from the 2013 Canadian Forces Mental Health Survey (CFMHS), and included a large representative sample of Canadian Regular Forces personnel (N = 6700). A series of univariate logistic regressions were conducted to test individual associations between past-year mental health status, insomnia, and potential confounds and SI. Mental health status included three groups: 0, 1, or two or more probable diagnoses of posttraumatic stress disorder (PTSD), major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD) and alcohol abuse/dependence. Stepwise multivariate logistic regression was used to assess the relationship between insomnia and SI with mental health status as a moderator. RESULTS: 40.8% of respondents reported experiencing insomnia. Both insomnia and number of mental health conditions incrementally increased the risk of SI. However, past-year mental health status was a significant moderator of this relationship, such that for CF personnel with either no (AOR = 1.61, 1.37-1.89) or only one past-year mental health condition (AOR = 1.39, 1.12-1.73), an incremental increase in insomnia was associated with an increased likelihood of SI. However, in personnel with two or more past-year mental health disorders, insomnia was no longer significantly associated with SI (AOR = 1.04, 0.81-1.33). CONCLUSIONS: Insomnia significantly increased the odds of SI, but only among individuals with no or one mental health condition. Findings highlight the importance of assessing insomnia among CF members in order to further suicide prevention efforts.

Chronic pain among public safety personnel in Canada.

Background: Chronic pain is highly prevalent in the general population and may be even higher among public safety personnel (PSP; e.g., correctional officers, dispatchers, firefighters, paramedics, police). Comprehensive data on chronic pain among diverse Canadian PSP are relatively sparse. Aims: The current study was designed to provide initial estimates of chronic pain frequency and severity among Canadian PSP. Methods: Estimates of chronic pain frequency and severity (i.e., intensity and duration) at different bodily locations were derived from self-reported data collected through an online survey. Participants included 5093 PSP (32.5% women) grouped into six categories (i.e., call center operators/dispatchers, correctional officers, firefighters, municipal/provincial police, paramedics, Royal Canadian Mounted Police [RCMP]). Results: Substantial proportions of participants reported chronic pain, with estimates ranging from 35.3% to 45.4% across the diverse PSP categories. Across PSP categories, chronic lower back pain was the most prevalent. For some pain locations, firefighters and municipal/provincial police reported lower prevalence, but paramedics reported lower intensity, and duration, than some other PSP groups. Over 50% of RCMP and paramedics reporting chronic pain indicated that the pain was associated with an injury related to active duty. Conclusions: Discrepancies emerged across PSP members with respect to prevalence, location, and severity. The current data suggest that additional resources and research are necessary to mitigate the development and maintenance of distressing or disabling chronic pain for Canadian PSP.

Contexte : La prévalence de la douleur chronique est élevée parmi la population en général et pourrait être encore plus élevée chez le personnel de la sécurité publique (ex.: agents correctionnels, répartiteurs, pompiers, ambulanciers, policiers). Il y a relativement peu de données exhaustives sur la douleur chronique chez le personnel de sécurité publique canadien.But : Cette étude visait à estimer la fréquence et la gravité de la douleur chronique chez le personnel de sécurité publique canadien.Méthodes : Des estimations de la fréquence et de la gravité de la douleur chronique (i.e. intensité et durée) à différents endroits du corps ont été tirées de données autodéclarées receuillies par le truchement d'un questionnaire en ligne. Les 5 093 participants (32,5 % de femmes) ont été regroupés en six catégories (i.e. opérateurs et répartiteurs en centre d'appel, agents correctionnels, pompiers, policiers au niveau municipal ou provincial, ambulanciers, Gendarmerie royale du Canada.)Résultats : Une proportion importante de participants a déclaré souffrir de douleur chronique, avec des estimations allant de 35,3 % à 45,4 % pour toutes les catégories de personnel de sécurité. La douleur au bas du dos présentait la prévalence la plus élevée dans toutes les catégories de personnel de sécurité. Les ambulanciers ont déclaré une plus faible prévalence de l'intensité et de la durée de la douleur à ressentie à certains endroits, comparativement aux autres groupes de personnel de la santé publique. Plus de 50 % des agents de la Gendarmerie royale du Canada et des ambulanciers qui ont déclaré souffrir de douleur chronique ont affirmé que la douleur était associée à une blessure subie pendant qu'ils étaient en service.Conclusions : Des différences ont été relevées entre les membres du personnel de la sécurité publique en ce qui concerne la prévalence, la localisation et la gravité de la douleur. Les données actuelles suggèrent que des ressources et des études additionnelles sont nécessaires pour atténuer l'apparition et la persistance de la douleur chronique éprouvante ou invalidante chez le personnel de la sécurité publique canadien.

Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis.

BACKGROUND: Depression and anxiety are common in persons with multiple sclerosis (MS), and adversely affect fatigue, medication adherence, and quality of life. Though effective treatments for depression and anxiety exist in the general population, their applicability in the MS population has not been definitively established. OBJECTIVE: To determine the overall effect of psychological and pharmacological treatments for depression or anxiety in persons with MS. METHODS: We searched the Medline, EMBASE, PsycINFO, PsycARTICLES Full Text, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and Scopus databases using systematic review methodology from database inception until March 25, 2015. Two independent reviewers screened abstracts, extracted data, and assessed risk of bias and strength of evidence. We included controlled clinical trials reporting on the effect of pharmacological or psychological interventions for depression or anxiety in a sample of persons with MS. We calculated standardized mean differences (SMD) and pooled using random effects meta-analysis. RESULTS: Of 1753 abstracts screened, 21 articles reporting on 13 unique clinical trials met the inclusion criteria. Depression severity improved in nine psychological trials of depression treatment (N=307; SMD: -0.45 (95%CI: -0.74, -0.16)). The severity of depression also improved in three pharmacological trials of depression treatment (SMD: -0.63 (N=165; 95%CI: -1.07, -0.20)). For anxiety, only a single trial examined psychological therapy for injection phobia and reported no statistically significant improvement. CONCLUSION: Pharmacological and psychological treatments for depression were effective in reducing depressive symptoms in MS. The data are insufficient to determine the effectiveness of treatments for anxiety.

Development and validation of a risk prediction algorithm for the recurrence of suicidal ideation among general population with low mood.

BACKGROUND: Suicidal ideation is one of the strongest predictors of recent and future suicide attempt. This study aimed to develop and validate a risk prediction algorithm for the recurrence of suicidal ideation among population with low mood METHODS: 3035 participants from U.S National Epidemiologic Survey on Alcohol and Related Conditions with suicidal ideation at their lowest mood at baseline were included. The Alcohol Use Disorder and Associated Disabilities Interview Schedule, based on the DSM-IV criteria was used. Logistic regression modeling was conducted to derive the algorithm. Discrimination and calibration were assessed in the development and validation cohorts. RESULTS: In the development data, the proportion of recurrent suicidal ideation over 3 years was 19.5 (95% CI: 17.7, 21.5). The developed algorithm consisted of 6 predictors: age, feelings of emptiness, sudden mood changes, self-harm history, depressed mood in the past 4 weeks, interference with social activities in the past 4 weeks because of physical health or emotional problems and emptiness was the most important risk factor. The model had good discriminative power (C statistic=0.8273, 95% CI: 0.8027, 0.8520). The C statistic was 0.8091 (95% CI: 0.7786, 0.8395) in the external validation dataset and was 0.8193 (95% CI: 0.8001, 0.8385) in the combined dataset. LIMITATIONS: This study does not apply to people with suicidal ideation who are not depressed. CONCLUSIONS: The developed risk algorithm for predicting the recurrence of suicidal ideation has good discrimination and excellent calibration. Clinicians can use this algorithm to stratify the risk of recurrence in patients and thus improve personalized treatment approaches, make advice and further intensive monitoring.

Risk of suicide and suicide attempts associated with physical disorders: a population-based, balancing score-matched analysis.

BACKGROUND: The association between physical disorders and suicide remains unclear. The aim of this study was to examine the relationship between physical disorders and suicide after accounting for the effects of mental disorders. METHOD: Individuals who died by suicide (n = 2100) between 1996 and 2009 were matched 3:1 by balancing score to general population controls (n = 6300). Multivariate conditional logistic regression compared the two groups across physician-diagnosed physical disorders [asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease, hypertension, diabetes, cancer, multiple sclerosis and inflammatory bowel disease], adjusting for mental disorders and co-morbidity. Secondary analyses examined the risk of suicide according to time since first diagnosis of each physical disorder (1-90, 91-364, ⩾ 365 days). Similar analyses also compared individuals with suicide attempts (n = 8641) to matched controls (n = 25 923). RESULTS: Cancer was associated with increased risk of suicide [adjusted odds ratio (AOR) 1.40, 95% confidence interval (CI) 1.03-1.91, p < 0.05] even after adjusting for all mental disorders. The risk of suicide with cancer was particularly high in the first 90 days after initial diagnosis (AOR 4.10, 95% CI 1.71-9.82, p < 0.01) and decreased to non-significance after 1 year. Women with respiratory diseases had elevated risk of suicide whereas men did not. COPD, hypertension and diabetes were each associated with increased odds of suicide attempts in adjusted models (AORs ranged from 1.20 to 1.73). CONCLUSIONS: People diagnosed with cancer are at increased risk of suicide, especially in the 3 months following initial diagnosis. Increased support and psychiatric involvement should be considered for the first year after cancer diagnosis.

Health anxiety disorders in older adults: conceptualizing complex conditions in late life.

Health anxiety disorders (e.g., hypochondriasis) are prevalent but understudied in older adults. Existing research suggests that severe health anxiety has a late age of onset, perhaps because of comorbidity with physical health conditions that are more likely to occur with aging. Despite being under diagnosed in later life due to a lack of age-appropriate diagnostic criteria, significant positive associations with age suggest that health anxiety disorders are more prevalent in older than younger adults. Preliminary research also highlights the complexity of these disorders in older adults and the potential importance of medical morbidity as a risk factor. This review explores the complexities of health anxiety disorders in later life with a focus on understanding defining features, prevalence rates, correlates, assessment, diagnosis, and treatment. We offer a theoretical model of the development of severe health anxiety among older adults to encourage further research on this important and under-studied topic.

Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel.

BACKGROUND: Although it has been posited that exposure to adverse childhood experiences (ACEs) increases vulnerability to deployment stress, previous literature in this area has demonstrated conflicting results. Using a cross-sectional population-based sample of active military personnel, the present study examined the relationship between ACEs, deployment related stressors and mood and anxiety disorders. METHOD: Data were analyzed from the 2002 Canadian Community Health Survey-Canadian Forces Supplement (CCHS-CFS; n = 8340, age 18-54 years, response rate 81%). The following ACEs were self-reported retrospectively: childhood physical abuse, childhood sexual abuse, economic deprivation, exposure to domestic violence, parental divorce/separation, parental substance abuse problems, hospitalization as a child, and apprehension by a child protection service. DSM-IV mood and anxiety disorders [major depressive disorder, post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic attacks/disorder and social phobia] were assessed using the composite international diagnostic interview (CIDI). RESULTS: Even after adjusting for the effects of deployment-related traumatic exposures (DRTEs), exposure to ACEs was significantly associated with past-year mood or anxiety disorder among men [adjusted odds ratio (aOR) 1.34, 99% confidence interval (CI) 1.03-1.73, p < 0.01] and women [aOR 1.37, 99% CI 1.00-1.89, p = 0.01]. Participants exposed to both ACEs and DRTEs had the highest prevalence of past-year mood or anxiety disorder in comparison to those who were exposed to either ACEs alone, DRTEs alone, or no exposure. CONCLUSIONS: ACEs are associated with several mood and anxiety disorders among active military personnel. Intervention strategies to prevent mental health problems should consider the utility of targeting soldiers with exposure to ACEs.

Subsyndromal depression in the United States: prevalence, course, and risk for incident psychiatric outcomes.

BACKGROUND: Subsyndromal depression (SD) may increase risk for incident major depressive and other disorders, as well as suicidality. However, little is known about the prevalence, course, and correlates of SD in the US general adult population. Method Structured diagnostic interviews were conducted to assess DSM-IV Axis I and II disorders in a nationally representative sample of 34 653 US adults who were interviewed at two time-points 3 years apart. RESULTS: A total of 11.6% of US adults met study criteria for lifetime SD at Wave 1. The majority (9.3%) had <5 total symptoms required for a diagnosis of major depression; the remainder (2.3%) reported ⩾5 symptoms required for a diagnosis of major depression, but denied clinically significant distress or functional impairment. SD at Wave 1 was associated with increased likelihood of developing incident major depression [odds ratios (ORs) 1.72-2.05], as well as dysthymia, social phobia, and generalized anxiety disorder (GAD) at Wave 2 (ORs 1.41-2.92). Among respondents with SD at Wave 1, Cluster A and B personality disorders, and worse mental health status were associated with increased likelihood of developing incident major depression at Wave 2. CONCLUSIONS: SD is prevalent in the US population, and associated with elevated rates of Axis I and II psychopathology, increased psychosocial disability, and risk for incident major depression, dysthymia, social phobia, and GAD. These results underscore the importance of a dimensional conceptualization of depressive symptoms, as SD may serve as an early prognostic indicator of incident major depression and related disorders, and could help identify individuals who may benefit from preventive interventions.

Common mental disorder diagnosis and need for treatment are not the same: findings from a population-based longitudinal survey.

BACKGROUND: Controversy exists regarding whether people in the community who meet criteria for a non-psychotic mental disorder diagnosis are necessarily in need of treatment. Some have argued that these individuals require treatment and that policy makers need to develop outreach programs for them, whereas others have argued that the current epidemiologic studies may be diagnosing symptoms of distress that in many cases are self-limiting and likely to remit without treatment. All prior studies that have addressed this issue have been cross-sectional. We examined the longitudinal outcomes of individuals with depressive, anxiety and substance use (DAS) disorder(s) who had not previously received any treatment. Method Data came from a nationally representative US sample. A total of 34 653 non-institutionalized adults (age ≥20 years) were interviewed at two time points, 3 years apart. DAS disorders, mental health service use and quality of life (QoL) were assessed at both time points. RESULTS: Individuals with a DAS disorder who had not previously received any treatment were significantly more likely than those who had been previously treated to have remission of their index disorder(s) without subsequent treatment, to be free of co-morbid disorder(s) and not to have attempted suicide during the 3-year follow-up period (50.7% v. 33.0% respectively, p < 0.05). At wave 2, multiple linear regression demonstrated that people with a remission of their baseline DAS disorder(s) had levels of functioning similar to those without a DAS disorder. CONCLUSIONS: Individuals with an untreated DAS disorder at baseline have a substantial likelihood of remission without any subsequent intervention.

Predictors of 1-year outcomes of major depressive disorder among individuals with a lifetime diagnosis: a population-based study.

BACKGROUND: Examining predictors of the outcomes of major depressive disorder (MDD) is important for clinical practice and population health. There are few population-based longitudinal studies on this topic. The objectives of this study were to (1) estimate the proportions of persistent and recurrent MDD among those with MDD over 1 year, and (2) identify demographic, socio-economic, workplace psychosocial and clinical factors associated with the outcomes. METHOD: From a population-based longitudinal study of the working population, participants with a lifetime diagnosis of MDD were selected (n=834). They were classified into two groups: those with and those without current MDD. The proportions of 1-year persistence and recurrence of MDD were estimated. MDD was assessed by the World Health Organization (WHO) Composite International Diagnostic Interview, CIDI-Auto 2.1, by telephone. RESULTS: The proportions of persistent and recurrent MDD in 1 year were 38.5% [95% confidence interval (CI) 31.1-46.5] and 13.3% (95% CI 10.2-17.1) respectively. Long working hours, negative thinking and having co-morbid social phobia were predictive of persistence of MDD. Perceived work-family conflict, the severity of a major depressive episode and symptoms of depressed mood were significantly associated with the recurrence of MDD. CONCLUSIONS: Clinical and psychosocial factors are important in the prognosis of MDD. The factors associated with persistence and recurrence of MDD may be different. More large longitudinal studies on this topic are needed so that clinicians may predict potential outcomes based on the clinical profile and provide interventions accordingly. They may also take clinical action to change relevant psychosocial factors to minimize the chance of persistence and/or recurrence of MDD.

Associations between use of cocaine, amphetamines, or psychedelics and psychotic symptoms in a community sample.

OBJECTIVE: To investigate the association between use of cocaine, amphetamines, or psychedelics and psychotic symptoms. METHOD: Cumulated lifetime data from a prospective, longitudinal community study of 2588 adolescents and young adults in Munich, Germany, were used. Substance use at baseline, 4-year and 10-year follow-up and psychotic symptoms at 4-year and 10-year follow-up were assessed using the Munich-Composite International Diagnostic Interview. Data from all assessment waves were aggregated, and multinomial logistic regression analyses were performed. Additional analyses adjusted for sociodemographics, common mental disorders, other substance use, and childhood adversity (adjusted odds ratios, AOR). RESULTS: After adjusting for potential confounders, lifetime experience of two or more psychotic symptoms was associated with lifetime use of cocaine (AOR 1.94; 95% CI 1.10-3.45) and psychedelics (AOR 2.37; 95% CI 1.20-4.66). Additionally, when mood or anxiety disorders were excluded, lifetime experience of two or more psychotic symptoms was associated with use of psychedelics (AOR 3.56; 95% CI 1.20-10.61). CONCLUSION: Associations between psychotic symptoms and use of cocaine, and/or psychedelics in adolescents and young adults call for further studies to elucidate risk factors and developmental pathways.

Happy but not so approachable: the social judgments of individuals with generalized social phobia.

BACKGROUND: We examined social approachability judgments in a psychiatric population that frequently experiences interpersonal difficulties and reduced social satisfaction, individuals with generalized social phobia (gSP). METHODS: Our objective was to broaden the understanding of the social cognitive tendencies of individuals with gSP by systematically investigating their interpretation of positive facial expressions. We hypothesized that approachability ratings would be lower for positive as well as negative emotional faces in the gSP group compared to the healthy comparison group. Each participant evaluated 24 emotional faces presented on a computer screen. Participants first labeled the faces as either happy, disgust, or angry in emotional expression, and then they rated each face's approachability. Analysis of variance and post hoc analyses were used to identify group, emotion, and group by emotion rating differences. RESULTS: Happy face approachability ratings were higher than disgust and anger in both groups. The central finding was that individuals with gSP rated happy faces as less approachable than the healthy participants and that degree of social anxiety was associated with lower approachability ratings within the gSP sample. Explicit approachability judgments of negative faces did not differ as predicted. CONCLUSIONS: Consistent with earlier indirect evidence of interpretation biases of positive social emotional information, this study reveals that individuals with gSP demonstrate explicit, subjective social interpretation biases of overtly positive social feedback. The therapeutic relevance of these results is discussed.

Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication.

BACKGROUND: Despite heightened awareness of the clinical significance of social phobia, information is still lacking about putative subtypes, functional impairment, and treatment-seeking. New epidemiologic data on these topics are presented from the National Comorbidity Survey Replication (NCS-R). METHOD: The NCS-R is a nationally representative household survey fielded in 2001-2003. The World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) was used to assess 14 performance and interactional fears and DSM-IV social phobia. RESULTS: The estimated lifetime and 12-month prevalence of social phobia are 12.1% and 7.1% respectively. Performance and interactional fears load onto a single latent factor, and there is little evidence for distinct subtypes based either on the content or the number of fears. Social phobia is associated with significant psychiatric co-morbidity, role impairment, and treatment-seeking, all of which have a dose-response relationship with number of social fears. However, social phobia is the focus of clinical attention in only about half of cases where treatment is obtained. Among non-co-morbid cases, those with the most fears were least likely to receive social phobia treatment. CONCLUSIONS: Social phobia is a common, under-treated disorder that leads to significant functional impairment. Increasing numbers of social fears are associated with increasingly severe manifestations of the disorder.

Comorbidity of phobic disorders with alcoholism in a Canadian community sample.

OBJECTIVES: To examine the relation between phobic disorders and alcoholism in a Canadian community sample. METHOD: Data came from the Mental Health Supplement of the Ontario Health Survey. The University of Michigan revision of the Composite International Diagnostic Interview (UM-CIDI) was used to diagnose DSM-III-R psychiatric disorders in 8116 Canadian respondents between ages 15 and 64 years. Since the cross-system agreement (ICD-10 and DSM-III-R or DSM-IV) on the diagnosis of alcohol abuse is much lower than that for alcohol dependence, we also examined a WHO category, "hazardous alcohol use." Logistic regression controlling for age and sex was used to determine odds ratios (ORs) for phobic disorders and alcohol-use diagnoses. RESULTS: Individuals with lifetime alcohol abuse or dependence had two- to threefold increased odds of having a phobic disorder. Simple phobia and social phobia with multiple fears were significantly associated (ORs 1.5 to 2) with hazardous alcohol use (which had a prevalence of approximately 10%). CONCLUSIONS: Given the early onset of most phobic disorders, the findings suggest that these are a risk factor for hazardous patterns of alcohol use.

Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation.

OBJECTIVES: The personality of medical students may have an important impact on both their academic performance and emotional adjustment during medical school. There has been little systematic study of the impact of perfectionism on medical students. The present study sought to compare the perfectionism profile of medical students with that of a general arts student group and to examine the relationship among perfectionism, distress symptoms and academic expectations and satisfaction. DESIGN: Medical students (n=96) and arts students (n=289) completed a baseline assessment including two multidimensional perfectionism scales. The medical students also completed measures of distress symptoms, personality (neuroticism, conscientiousness) and questions about their perceptions of their academic performance. Of the medical students, 58 completed a second set of questionnaires 6 months later (time 2). SUBJECTS: First-, second- and third year medical students and first-year arts students. RESULTS: In comparison with arts students, the perfectionism profile of medical students showed higher personal standards, lower doubts about actions and lower maladaptive perfectionism scores. In the medical students adaptive perfectionism (achievement striving) was significantly correlated with baseline academic performance expectations and conscientiousness and was predictive of dissatisfaction with academic performance at time 2. Maladaptive perfectionism (excessive evaluative concerns) was significantly correlated with baseline distress symptoms and neuroticism and was predictive of symptoms of depression and hopelessness at time 2. CONCLUSIONS: Perfectionism in medical students differs systematically from perfectionism in general arts students. Distinguishing adaptive and maladaptive aspects of perfectionism is important in understanding the cross-sectional and longitudinal implications of perfectionism for medical students.

Pindolol potentiation of paroxetine for generalized social phobia: a double-blind, placebo-controlled, crossover study.

OBJECTIVE: The effectiveness of pindolol as an adjunctive treatment to boost response to selective serotonin reuptake inhibitors (SSRIs) in patients with generalized social phobia was tested. METHOD: A double-blind, placebo-controlled, crossover design was used to compare addition of 5 mg of pindolol t.i.d. or placebo for 4 weeks to a steady paroxetine dose. Subjects were 14 patients with generalized social phobia who were less than "very much improved" on the Clinical Global Impression scale after at least 10 weeks of treatment with a maximally tolerated dose of paroxetine. Changes on the Liebowitz Social Anxiety Scale and the Social Phobia Inventory scores were compared across the two crossover periods. RESULTS: Pindolol was not significantly superior to placebo for augmenting the effects of paroxetine on social anxiety symptoms. None of the 14 subjects was deemed a responder to the pindolol arm of the crossover. CONCLUSIONS: Pindolol was no more effective than placebo in augmenting the effects of SSRI treatment for generalized social phobia.