Cognitive errors, symptom severity, and response to cognitive behavior therapy in older adults with generalized anxiety disorder.

OBJECTIVE: Recent research by Wetherell et al. investigating the differential response to group-administered cognitive behavior therapy (CBT) for generalized anxiety disorder (GAD) in older adults found that GAD severity, homework adherence, and psychiatric comorbidity predicted statistically significant improvement. The current study investigated whether the presence/absence of cognitive errors on separate domains of the Mini-Mental State Exam (MMSE) predicted baseline differences in symptom severity and improvement following CBT, above and beyond already established predictors. METHODS: Baseline characteristics were investigated in a sample of 208 older patients diagnosed with GAD. Predictors of treatment response were examined in a subsample of 65 patients who completed CBT and were included in a prior study by Wetherell et al. of response predictors. RESULTS: Results from the baseline sample indicated that only subjects who committed an error on the MMSE Working Memory domain exhibited increased severity in anxiety and depressive symptoms. Results from the treatment sample indicated that an error on the MMSE Orientation domain was a significant predictor of outcome at 6-month follow-up, while controlling for previously established predictors. Patients who committed at least one error in this domain showed decreased response relative to patients who committed no errors. CONCLUSION: In this sample of older adults diagnosed with GAD, poor performance on the MMSE Working Memory domain was associated with increased baseline anxiety and depression, while baseline performance differences on the MMSE Orientation domain predicted outcome six months after CBT intervention.

Specificity of Stroop interference in patients with pain and PTSD.

The authors investigated processing of threat words in motor vehicle accident survivors using a modified Stroop procedure. Three samples were included: 28 participants with comorbid posttraumatic stress disorder (PTSD) and pain, 26 participants with pain without PTSD, and 21 participants without pain or any psychiatric conditions. Four word categories were used: (a) accident words, (b) pain words, (c) positive words, and (d) neutral words. This study examined whether processing biases would occur to accident words only in participants with PTSD or if these biases would also be noted in the No PTSD/Pain sample. Additionally, this study examined whether processing biases would be noted to pain words in the 2 pain samples, irrespective of PTSD. Overall, color naming was significantly slower in the PTSD/Pain group in comparison with the other groups. As well, the PTSD/Pain sample showed significant response delays to both accident and pain-related words, whereas patients with No PTSD/Pain showed delays to pain stimuli only.

Response to repeated CO2 in individuals with elevated anxiety sensitivity: replication with 20% CO2.

The present report replicates and extends previous work examining response patterns to repeated presentation of CO2. In previous studies, two distinct response patterns to repeated presentation of 35% CO2 were noted, representing habituation and nonhabituation of anxiety. In this report, 21 participants who had never experienced a panic attack but who reported high levels of anxiety sensitivity were presented with 12 trials of 20% CO2, followed by a trial involving inhalation of room air (to examine dishabituation) and two more trials of 20% CO2. Results indicated that 67% of the sample reported habituation of anxiety. Reductions in anxiety across inhalations were paralleled by changes in tidal volume, perceived panic symptom severity, and feelings of panic. Notable dishabituation was observed in the nonhabituation sample. Results are discussed in the light of basic learning processes underlying the treatment of Panic Disorder (PD).

Worry content reported by older adults with and without generalized anxiety disorder.

This study investigated worry content in older adults with and without generalized anxiety disorder (GAD). This is an important topic of research, where findings may promote improved recognition and treatment of this disorder in late-life, as well as provide information about the nature of worry across the lifespan. Worry content was compared for 44 older adults diagnosed with GAD and 44 normal control (NC) volunteers matched for age, gender, and ethnicity. Results indicated that older adults with GAD reported a wider variety of worry topics than did NC participants. However, there were no differences in worry content patterns between older adults with and without GAD. These results suggest that pathological worry in later life is not uniquely defined by content, and implications of these findings for assessment and treatment of GAD in older adults are discussed. Worry content reported by older adults also was compared with previously published younger adult worry content data. Age differences in worry content were found in both the clinical and non-clinical groups in patterns that were generally consistent with common age-related developmental changes. Directions for future research of worry across the lifespan are proposed.

Relationships between the anxiety sensitivity index, the suffocation fear scale, and responses to CO2 inhalation.

Interest in documenting ways to predict anxious responding in panic disorder (PD) patients has proliferated recently in the literature. In the current study, two self-report measures were assessed to determine their relative utility in predicting responses to a panicogenic challenge. The Anxiety Sensitivity Index (ASI) and the Suffocation Fear Scale (SFS) were evaluated by correlating scores on these measures with reactions to inhalation of 35% carbon dioxide (CO2), assessed via anxiety ratings, panic symptom intensity, tidal volume (VT) and respiratory rate (RR). A sample of 14 PD patients and 14 matched control (MC) participants demonstrated that the relationship between ASI scores and responses to 35% CO2 were stronger than the relationship between SFS scores and responses to CO2. Specifically, both respiratory responses (VT and RR) and self-reported reactions (anxiety and symptom intensity) were significantly correlated with scores on the ASI. In contrast, scores on the SFS were significantly correlated with only one measure of respiratory change (VT). Although preliminary, these data indicate that the ASI may be a more useful tool than the SFS in predicting self-reported and respiratory responses to CO2 challenges.

Assessing older adults with generalized anxiety: a replication and extension.

Anxiety is a major health problem for older adults. The cornerstone for further work in this area is research that establishes the psychometric utility of standardized measurement strategies to characterize anxiety in older adults. The goals of the current study were to replicate and extend prior research addressing the psychometric properties of five self-report measures of anxiety in a sample of 57 older adults with generalized anxiety disorder (GAD). Data addressed the descriptive characteristics, internal consistency, test-retest reliability, interrelation of subscales, and convergent and divergent validity of the Penn state worry questionnaire (PSWQ), worry scale (WS), Spielberger state-trait anxiety inventory - Form Y (STAI), and two versions of the fear questionnaire (FQ). Descriptive data generally replicated prior findings, with some increased state and trait anxiety in the current sample. Measures were internally consistent, with evidence that a revised version of the FQ that focuses on severity of fear irrespective of associated avoidance demonstrated greater internal consistency than the original version. Measures of content-specific fears and worries (WS, FQ) were stable over time and demonstrated convergent validity. Evidence of convergent validity also was evident for measures of worry and general anxiety (WS, PSWQ, STAI-Trait), but two of these measures (PSWQ, STAI) were not reliable over time. Only the PSWQ showed evidence of divergent validity with respect to self-report measures of depression.

Do panic symptom profiles influence response to a hypoxic challenge in patients with panic disorder? A preliminary report.

OBJECTIVE: This study examined how panic symptom profiles affect response to a hypoxic laboratory challenge in patients with panic disorder. METHODS: Seven patients whose naturally occurring panic attacks were characterized by prominent respiratory symptoms (Resp subgroup) were compared and contrasted with seven patients who did not report respiratory symptoms during panic attacks (NonResp subgroup). All were administered a novel 12% O2 challenge and assessed with measures of tidal volume, respiratory rate, end-tidal CO2, anxiety, and panic symptoms. RESULTS: Although the Resp and NonResp subgroups showed equivalent increases in anxiety and panic symptoms, the Resp subgroup showed greater fluctuation in tidal volume during and after the challenge as well as overall lower levels of end-tidal CO2. CONCLUSIONS: Our results suggest the importance of panic symptom profiles in determining respiratory responses to a hypoxic challenge in patients with panic disorder. These findings are discussed in light of current theories of panic disorder, with particular attention to respiratory disturbances in this disorder.

Anxiety disorders.

Research has only recently begun to address the nature and treatment of anxiety in later life. Prevalence rates suggest that anxiety disorders occur more than twice as frequently as depression among older adults, with the highest rates reported for generalized anxiety disorder and phobias. However, relatively little is known about the psychopathology and treatment of these and other anxiety disorders. In this review, recent clinical advances in this area are summarized. Particular attention is given to the prevalence and nature of late-life anxiety and its overlap with related conditions, psychometric properties of assessment tools for evaluating anxiety in older adults, and treatment outcome literature in both pharmacological and psychosocial domains. Directions for future research are provided throughout and summarized in a final section with the goal of stimulating additional empirical work in the area.

Analysis of 'natural' and vaccine-induced haemophilus influenzae type B capsular polysaccharide serum antibodies for 3H1, a V3-23-associated idiotope.

The variable (V-) region repertoire of antibodies (Abs) to Haemophilus influenzae capsular polysaccharide (Hib PS) has been extensively studied in individuals vaccinated against the microbe, but to a lesser extent in subjects who generated such Abs in response to a 'natural' encounter with this microbe or its antigenic mimics. To gain an insight into the repertoire of Hib PS-reactive Abs in vaccinated and non-vaccinated individuals, we used a monoclonal Ab, 3H1, which detects an idiotypic marker associated with an Ab V-region gene, V3-23. We show here that Hib PS-reactive Abs with detectable 3H1 idiotope can be quantified by an indirect inimunoezymatic assay in serum samples of non-vaccinated healthy adults as well as of recently vaccinated healthy infants. The percentage of Abs that was simultaneously Hib PS-reactive and 3H1-positive ranged widely (from 0 to 68%) among individual serum samples from both groups of subjects. No dramatic differences in the expression of 3H1 idiotope on Hib PS-reactive Abs were found between vaccinated and non-vaccinated individuals. Our results are consistent with the hypothesis that the utilization of V-region genes in Hib PS-reactive Abs that individuals generate after a 'natural' encounter with Hib PS or its mimics is similar to that in these Abs elicited by Hib PS conjugate vaccines.

Posttraumatic stress disorder in older adults: a conceptual review.

Issues that are salient in understanding posttraumatic stress disorder (PTSD) in older adults are examined in this review. Although this issue has received scattered attention in the literature since introduction of the diagnosis of PTSD to the Diagnostic and Statistical Manual (DSM) in 1980, it is clear that numerous conceptual and defining questions exist in our understanding of the aftermath of trauma exposure in older adults. In approaching this issue, studies pertaining to diagnostic status as well as broader dimensions of psychosocial functioning are examined. Concerns that are unique to older adults are highlighted throughout, with particular attention to areas where additional research is warranted.

Measures of depression in older adults with generalized anxiety disorder: a psychometric evaluation.

Generalized anxiety disorder (GAD) is the most common of the pervasive anxiety disorders among older adults, with lifetime prevalence estimates of 6%. Because of this high prevalence rate, it is important to establish the utility of assessment tools with this population. Preliminary data exist with regard to the use of anxiety measures with older anxious adults; however, no similar information is available for self-report measures of depression in this population. This study examined the psychometric properties of the Beck Depression Inventory (BDI) and the Geriatric Depression Scale (GDS) with a sample of 54 older adults diagnosed with GAD, 22 of whom were diagnosed with a coexistent depressive disorder. Internal consistency, convergent and divergent validity, construct validity, and discriminative validity of the BDI and the GDS were examined. Overall, the results support the reliability and validity of these self-report measures of depressive symptoms in a sample of older anxious adults.

Cognitive interference for trauma cues in sexually abused adolescent girls with posttraumatic stress disorder.

Investigated cognitive processing of fear-relevant information in sexually abused adolescent girls with posttraumatic stress disorder (PTSD) using a modified Stroop procedure (MSP). Participants were 20 sexually abused girls with PTSD, 13 sexually abused girls without PTSD, and 20 nonvictimized girls who served as controls, 11 to 17 years old. Word conditions included abuse-related threat, developmentally relevant (related to the experience of sexual abuse, e.g., trust, secrecy, and intimacy), general threat, positive, and neutral. Girls with PTSD were expected to show cognitive interference for trauma-related words as well as for developmentally relevant words, relative to adolescents without PTSD. Overall color naming was significantly slower in the PTSD group than in the nonabused controls. Contrary to expectation, all participants demonstrated cognitive interference for trauma-related words. Relevant theoretical and methodological issues are highlighted.

Generalized anxiety disorder in older adults: examining the relation between clinician severity ratings and patient self-report measures.

Generalized anxiety disorder (GAD) is the most prevalent of the chronic anxiety disorders for older adults. Although a variety of self-report measures are beginning to be utilized to assess anxiety and related symptoms in older adults, there is a paucity of data regarding the convergence of self-report measures with clinician ratings of symptom severity. This situation is problematic in that interpretability of assessment data is limited, as is our broader understanding of the construct of GAD in an older adult population. To address these issues, we examined convergence across assessment modalities among 64 older adults who met diagnostic criteria for GAD. In addition to two Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) interviews conducted by independent raters, participants completed four self-report measures (Penn State Worry Questionnaire [PSWQ], Worry Scale [WS], State-Trait Anxiety Inventory [STAI], Beck Depression Inventory [BDI]) as part of a more extensive pretreatment assessment battery. Results revealed significant correlations between clinician-rated GAD severity and the BDI, STAI, and PSWQ. Regression analyses indicated that the BDI (r2 = .15) and the PSWQ (r2 = .07) were particularly useful predictors of clinician-rated GAD severity. A comorbid mood disorder, however, was identified as an important mediator of these relations. Specifically, presence of coexistent depression accounted for 17% of the variance in clinician severity ratings (CSR; P < .01), with individuals diagnosed with a comorbid mood disorder receiving higher clinician severity ratings. The only self-report measure that accounted for additional significant variance was the PSWQ (7%). The study highlights the need to address coexistent psychological conditions when examining convergence between assessment modalities, and expands upon the relatively neglected area of anxiety assessment in older individuals. Specifically, the BDI and the PSWQ are identified as particularly useful screening instruments that may be helpful in conceptualizing GAD severity within an older adult population.

Response patterns to repeated CO2 inhalation in individuals with high anxiety sensitivity.

The present report extends previous work which has documented two distinct response patterns to repeated presentation of interoceptive cues (using CO2 inhalation) in PD patients [Beck, J. G. & Shipherd, J. C. (1997). Repeated exposure to interoceptive cues: does habituation of fear occur in panic disorder patients? Behaviour Research and Therapy, 35, 551-557]. We were interested in determining if these two patterns of fear habituation and sensitization would be noted in panic-naive individuals who reported high levels of Anxiety Sensitivity. A second aspect of this report examined whether attention to bodily sensations versus to neutral material would impact fear habituation and sensitization. Participants included 43 panic-naive individuals who scored at least 1 standard deviation above norms on the Anxiety Sensitivity Index. Results indicated that 37% of the sample reported habituation of fear, 47% reported fear sensitization and 16% demonstrated relatively stable fear levels across 12 inhalations of CO2 during session 1. The attentional manipulation did not exert a pronounced influence on anxiety, panic symptom severity, skin conductance, or heart rate in either Habituators or Sensitizers during session 2. These results are discussed in light of their relevance in understanding fundamental psychopathological processes underlying Panic Disorder.

Exaggerated anxiety is not unique to CO2 in panic disorder: a comparison of hypercapnic and hypoxic challenges.

Current biological models of panic disorder (PD) assert that this disorder is maintained by hypersensitivity to carbon dioxide (CO2) and related asphyxia cues, which is manifested as an exaggerated suffocation alarm (D. Klein, 1993). Because suffocation can result from both increased CO2 (hypercapnia) and decreased oxygen (O2; hypoxia), this study examined respiratory responding and anxiety during 5% CO2 (a hypercapnic challenge) and 12% O2 (a hypoxic challenge) in 14 PD patients and 14 matched controls (MC). Results demonstrate that irrespective of the source of suffocation, PD patients respond with increased anxiety relative to MC participants. Significant group differences were observed in respiratory functioning, with the PD patients showing higher respiratory rates in response to both challenges. The MC sample demonstrated the expected respiratory responses to both hypercapnia and hypoxia. The findings indicate that PD patients are hypersensitive to alterations in breathing and that this reactivity is not specific to CO2.

The effects of suppressing trauma-related thoughts on women with rape-related posttraumatic stress disorder.

A hallmark symptom of posttraumatic stress disorder (PTSD) is the presence of intrusive thoughts that come to mind against an individual's will and are frequently accompanied by considerable distress. This investigation examined the effects of deliberate suppression of rape-related thoughts on female sexual assault survivors, in order to explore this facet of PTSD. Seventeen women with chronic PTSD following a sexual assault were contrasted with nineteen survivors without PTSD, using a thought suppression paradigm (e.g. [Wegner, Schneider, Carter, & White (1987) Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53 5-13]). Results indicated that PTSD participants experienced a rebound in the frequency of rape-related thoughts following deliberate suppression, whereas non-PTSD participants did not experience a rebound. Reported level of perceived controllability over rape-related thoughts for the PTSD participants was significantly lower during the suppression phase (as compared with the expression phase) relative to the non-PTSD participants. PTSD participants were significantly more anxious, depressed and distressed throughout the procedure relative to non-PTSD participants, although mood changes did not parallel the rebound effect found with rape-related thoughts in the PTSD group. Results are discussed in light of the role that intrusive thoughts may play in the maintenance of PTSD.

The utility of the Fear Survey Schedule-III: an extended replication.

This investigation examined the factor structure of the Fear Survey Schedule-III in patients with specific anxiety disorders, including patients with panic disorder, agoraphobia without panic, generalized anxiety disorder, social phobia, specific phobia, obsessive compulsive disorder, post traumatic stress disorder, and anxiety disorder NOS. Four factors were obtained, reflecting a similar structure as has been noted in other studies. However, the ability of the obtained factors to discriminate among patients with panic disorder, social phobia, and specific phobia was not high. Future directions are highlighted.

Worry versus anxiety. Is there really a difference?

The similarities and distinctions between the constructs of worry and anxiety were examined in a sample of 189 university students. Three worry scales and four measures of anxiety were compared in relation to measures of negative affect, personal control, and problem-solving style. Although measures of worry and anxiety were highly correlated, negative affect (e.g. depression, confusion) tended to be more closely related to anxiety than to worry, whereas problem-solving style tended to be more closely related to worry than to anxiety. Personal control did not show a differential relationship to anxiety or worry. When the definition of anxiety was restricted to somatic anxiety, however, negative affect, perceived problem-solving abilities, and personal control were more strongly related to worry than to anxiety. Implications of these results are discussed in light of current definitions and measurement of these constructs.

Repeated exposure to interoceptive cues: does habituation of fear occur in panic disorder patients? A preliminary report.

In order to explore the mechanism of action of interoceptive exposure, 12 Panic Disorder (PD) patients were presented with two sessions of repeated CO2 inhalation. Two distinct patterns of responding were noted. The first pattern was described as habituation of fear (n = 6). These patients showed decrements in pre- and post-inhalation anxiety during both sessions (with more rapid decline during session 2), as well as spontaneous recovery of fear at the onset of session 2. The second pattern indicated fear sensitization. These patients showed relatively low levels of anticipatory anxiety preceding CO2 inhalation during both sessions but reported robust increases in fear following gas inhalation. The extent of this increase was slightly less during session 2 relative to session I and did not appear to be mediated by cardiovascular arousal, as both groups showed rapid HR habituation during both sessions. Results are discussed in light of current theories of PD and its treatment.

How does interoceptive exposure for panic disorder work? An uncontrolled case study.

To examine the influence of interoceptive exposure (IE) when used alone in the treatment of Panic Disorder (PD), 17 PD patients were presented with six IE sessions, using 35% CO2 as the exposure medium. The data indicate that IE alone is effective in reducing panic, panic-related fears, and general anxiety. However, the positive effects of IE do not appear to extend to agoraphobia, related fears, or depressed mood. Two distinct within-session patterns of fear response to IE were noted, one indicating habituation and the other indicating a lack of fear reduction. Although both patterns were associated with reductions in panic and anxiety following IE, the Habituators appeared to have a more positive outcome, which occurred more rapidly. These data suggest that IE may operate via two different pathways. Implications for understanding fear reduction are discussed, along with directions for future study.