Vagal influence during worry and cognitive challenge.

The primary foci of the study were exploration of the linkage between cognitive and autonomic inflexibility of worry and generalized anxiety disorder (GAD) and examination of the effects of an analog cognitive restructuring task on this relationship. Cardiac responses of GAD and non-GAD participants were measured to examine the sympathetic and parasympathetic effects of worry and cognitive challenge. Diagnostic groups of undergraduate students were determined via administration of a structured interview, yielding a GAD group (n=16) and a control group (n=19) of individuals without GAD, depression, or panic disorder diagnoses. Cardiac autonomic responses were acquired via electrocardiogram during rest, worry, and cognitive challenge conditions by an experimenter blind to diagnosis. Metrics were compared between the two groups and across the three conditions. Individuals diagnosed with GAD did not differ significantly from controls on autonomic indices. Worry was associated with significantly decreased parasympathetic influence and increased sympathetic activity. Cognitive challenge did not result in significant increased cardiac responsivity. The results indicate that worry behavior is associated with decreased vagal activity, suggest a linkage between autonomic and cognitive inflexibility, and provide further suggestions for improving protocols to assess the autonomic effects of cognitive therapy techniques.

Detection of change in threat-related and innocuous scenes among snake-fearful and snake-tolerant participants: data from the flicker task.

Visual change detection mirrors conscious attention. In the flicker task, pairs of scenes are presented rapidly; the second scene differs from the first, and the participant identifies the change. Change occurs in either a central-interest region or marginal-interest region of the scene. Detecting change in a marginal-interest region requires that attention be disengaged from the central-interest region. In two flicker experiments the dependent variable was the number of scene-pair repetitions before the change was identified. The independent variables were snake-fearful versus snake-tolerant participants, presence versus absence of a snake in the scene, and a change within a central-interest versus marginal-interest region. Snake-fearful participants took longer than snake-tolerant participants to identify changes in scenes without a snake. The explanation is offered that snake-fearful participants took longer than snake-tolerant participants to disengage attention from scenes in which a snake was present; delayed disengagement from scenes that included a snake impeded the detection of change in scenes that did not.

Component fears of claustrophobia associated with mock magnetic resonance imaging.

A conceptualization of claustrophobia [Rachman, S., & Taylor, S. (1993). Analyses of claustrophobia. Journal of Anxiety Disorders, 7, 281-291] was evaluated in the context of magnetic resonance imaging. One hundred eleven students responded to questionnaires that quantified fear of suffocation, fear of restriction, and sensitivity to anxiety symptoms. Sixty-four of them were then exposed to a mock magnetic resonance imaging assessment; maximum subjective fear during the mock assessment was self-reported, behavioral reactions to the mock assessment were characterized, and heart rates before and during the assessment were recorded. Scores for fear of suffocation, fear of restriction, and anxiety sensitivity were used to predict subjective, behavioral, and cardiac fear. Subjective fear during the mock assessment was predicted by fears of suffocation and public anxiousness. Behavioral fear (escape/avoidance) was predicted by fears of restriction and suffocation, and sensitivity to symptoms related to suffocation. Cardiac fear was predicted by fear of public anxiousness. The criterion variance predicted was impressive, clearly sufficient to legitimize both the research preparation and the conceptualization of claustrophobia that was evaluated.

Comment on the status of systematic desensitization.

Articles about systematic desensitization that appeared in mainstream behavior therapy journals between the years 1970 and 2002 were counted. Graphic displays of the data point to a sudden and lasting decline of interest in systematic desensitization among academics and researchers. A questionnaire concerning clinical use of orthodox systematic desensitization was mailed to 310 selected providers. Returns from 171 of those providers show that use of systematic desensitization has declined but continues to be fairly widespread. The decline of interest in systematic desensitization is explained: arguments are offered that revitalized interest would be beneficial but is not likely to occur.

Specific and nonspecific treatment factors in the experimental analysis of behavioral treatment efficacy.

Interest in the empirical demonstration of the clinical efficacy of psychosocial treatments has been rekindled by societal concerns over accountability and cost-effectiveness in the delivery of mental health services. Behavior therapy has had a long history of experimental research on treatment efficacy and enjoys a visible presence in contemporary mental health practice. The demonstration of behavioral treatment efficacy, however, requires experimental evidence that shows the efficacy of prescriptive structured procedures beyond nonspecific factors in delivery of such procedures. The authors provide an analysis of the nature of nonspecific treatment factors and nonspecific effects and suggest experimental procedures testing the incremental validity of specific treatments. They examine two widely promoted, prescriptive structured treatments to analyze the specificity of their clinical efficacy: eye movement desensitization and reprocessing for anxiety disorders and cognitive-behavioral treatment of generalized anxiety disorder. They conclude that the treatments show different levels of efficacy and different degrees of specificity.

Fear responses to mock magnetic resonance imaging among college students: toward a prototype experiment.

Two hundred randomly selected student participants (139 females, 61 males) responded initially to questionnaires that quantified variables such as state and trait anxiety, anxiety sensitivity, claustrophobia, and panic/agoraphobia. Later they were informed that a mock magnetic resonance imaging (MRI) procedure was upcoming, and were prompted to provide self-efficacy ratings vis-à-vis completing the procedure. Finally, the participants' behavioral reactions to a mock MRI procedure were characterized; their heart beats were recorded and ratings of fearfulness were acquired. One purpose of the research was simply to tally numbers of participants who responded fearfully in various ways: 7 failed the procedure behaviorally, 7 others completed the procedure but did so fearfully, 17 others completed the procedure but manifested excessive heart-rate responsivity. A second purpose of the research was to "predict" subjects' fear-response categorization psychometrically and/or with self-efficacy ratings: psychometric data related to claustrophobia predicted subjects' fear-response categorization as did self-efficacy ratings. According to these results mock MRI assessment among college students provides a promising context for research on claustrophobia.

Heavy drinking among college students is influenced by anxiety sensitivity, gender, and contexts for alcohol use.

In order to quantify relationships between anxiety sensitivity and situational antecedents to heavy alcohol consumption, 245 university student drinkers completed the anxiety sensitivity index-revised (ASI-R) and the inventory of drinking situations (IDS-42). The observed correlations indicated that anxiety sensitivity is related to negatively reinforced drinking, positively reinforced drinking, and temptation-motivated drinking. However, anxiety sensitivity is most clearly implicated as a factor in negatively reinforced drinking, i.e., drinking followed by "tension reduction." Additionally, the relationship between anxiety sensitivity and negatively reinforced drinking is stronger among males than among females. The results point to anxiety sensitivity and gender as interacting individual difference variables that influence incidence of negatively reinforced heavy drinking among college students.

Epidemiological evaluation of known and suspected cardiovascular risk factors in chronic renal impairment.

Patients with chronic renal impairment (CRI) are at greatly increased risk for premature vascular disease; however, little is known about its evolution. This paper describes a cohort of patients with CRI and reports study design, baseline demographic and biochemical data, and comparisons with two contemporaneous age- and sex-matched control groups, one with established coronary artery disease and the other without overt vascular disease. Among 369 individuals (median age, 63 years; range, 18 to 88 years; 67% men) with CRI, 34% had a history of vascular disease and 21% had electrocardiographic left ventricular hypertrophy (LVH). Even in those with mild renal impairment (serum creatinine < 2.1 mg/dL), approximately one third had vascular disease and 12% had LVH. A history of hypertension was present in 76% of the CRI group, but as compared with controls, systolic and diastolic blood pressures were not elevated. Low-density lipoprotein (LDL) cholesterol concentration also was not elevated, but CRI was associated with elevated serum triglyceride and plasma homocysteine levels and reduced high-density lipoprotein (HDL) cholesterol, hemoglobin, and serum albumin concentrations. Across the spectrum of CRI, more severe renal dysfunction was associated with lower levels of diastolic blood pressure, LDL and HDL cholesterol, albumin, and hemoglobin, but increased levels of plasma homocysteine. This cross-sectional analysis shows that vascular disease is common in individuals with mild CRI attending a nephrology program and also suggests trends in the levels of a number of potential vascular risk factors with respect to severity of renal dysfunction. These results will be further quantified in a prospective biennial follow-up.

A randomized double-blind placebo-controlled trial of the effect of homocysteine-lowering therapy with folic acid on endothelial function in patients with coronary artery disease.

OBJECTIVES: This study was designed to determine the effects of folic acid therapy on endothelial function in patients with coronary artery disease (CAD). BACKGROUND: Hyperhomocysteinemia, a risk factor for CAD, may cause atherosderosis by oxidative endothelial injury. Folic acid reduces plasma homocysteine, but the effect on adverse vascular events is unknown. METHODS: In a double-blind placebo-controlled trial, 90 patients (mean age [range] 63 [46 to 79] years, 79 men) with CAD were randomized to either folic acid 5 mg or placebo daily for 12 weeks. Endothelial function was assessed by measuring: 1) flow-mediated endothelium-dependent dilation (EDD) of the brachial artery; 2) combined serum nitrite/nitrate (NOx) concentrations and; 3) plasma von Willebrand factor (vWF) concentration. RESULTS: At the end of the study, plasma homocysteine was lower in the folic acid group compared with the placebo group (mean [95% confidence interval] 9.3 (8.5 to 10.1) vs. 12.3 [11.3 to 13.4] micromol/l, p < 0.001). Although there were no significant differences in EDD, serum NOx or plasma vWF between the two groups, there was a greater increase in EDD from baseline in the folic acid group compared to placebo (1.2 [0.7 to 1.8] vs. 0.4 [-0.3 to 1.1]%, p = 0.07). CONCLUSIONS: Folic acid reduced plasma homocysteine and was associated with a trend toward improved endothelial function in patients with CAD. The absence of an unequivocally positive result may have been due to inadequate sample size or chance. This reinforces the need for the results of large randomized controlled trials before the implementation of routine folic acid supplementation.

Does folic acid decrease plasma homocysteine and improve endothelial function in patients with predialysis renal failure?

BACKGROUND: Considerable evidence suggests that hyperhomocysteinemia is an independent vascular risk factor that promotes atherosclerosis by inducing endothelial dysfunction. Although folic acid reduces hyperhomocysteinemia, the effect on adverse vascular events is unknown. We hypothesized that in patients with chronic renal failure, a condition associated with both hyperhomocysteinemia and atherosclerosis, treatment with folic acid would improve endothelial function. METHODS AND RESULTS: In a prospective, double-blind protocol, 100 patients (mean age 62 years, 67 men) with predialysis chronic renal failure were randomized to 5 mg folic acid or placebo daily for 12 weeks. Endothelial function was assessed by measuring (1) endothelium-dependent dilation of the brachial artery, (2) combined serum nitrite/nitrate concentrations, and (3) plasma von Willebrand factor concentration. Baseline characteristics of the 2 groups were similar. At the end of the study, both serum and red cell folate concentrations were greater in the folic acid group than the placebo group [mean (95% CI) 39.0 (29.8 to 51.0) versus 7.7 (6.6 to 8.9) microg/L and 739 (613 to 891) versus 220 (184 to 262) microg/L, respectively; both P<0.001]. Despite a reduction in hyperhomocysteinemia in the folic acid group compared with the placebo group [15.1 (14.1 to 16.2) versus 20.1 (18.2 to 22.2) micromol/L; P<0.001], there were no significant differences in endothelium-dependent dilation, combined serum nitrite/nitrate concentrations, or plasma von Willebrand factor concentration between the 2 groups. CONCLUSIONS: High-dose folic acid lowers but fails to normalize hyperhomocysteinemia in patients with predialysis chronic renal failure. This was not accompanied by an improvement of endothelial function and suggests that treatment with folic acid may not reduce the burden of vascular disease in uremia.

Research on posttreatment return of claustrophobic fear, arousal, and avoidance using mock diagnostic imaging.

Fear sometimes returns after attenuation via exposure. Return of fear is poorly understood due to conflicting results from diverse experiments. This article reports on two experiments in which claustrophobic fear during mock diagnostic imaging was attenuated and allowed to return so the experiments could be evaluated and return of fear studied. Attentional focus versus distraction during exposure was a between-subjects independent variable. Attempts were made to predict return of fear, return of heart-rate responsivity, and behavioral avoidance using levels of fear and heart-rate during initial mock diagnostic imaging as predictor variables. One third of participants displayed return of fear, heart-rate response, or avoidance 1 week after fear reduction. Heart-rate response during initial mock imaging predicted posttreatment return-of-fear classification; level of fear during initial imaging did not. Neither initial heart rate nor initial fear predicted return of heart-rate reactivity or avoidance. The experiments are offered as models for programmatic research.

Abnormalities of endothelial function in patients with predialysis renal failure.

BACKGROUND: Endothelial dysfunction plays an important role in the development of atherosclerotic vascular disease, which is the leading cause of mortality in patients with chronic renal failure. OBJECTIVE: To examine the relation between predialysis renal failure and endothelial function. DESIGN: Two groups were studied: 80 patients with non-diabetic chronic renal failure and 26 healthy controls, with similar age and sex distributions. Two indices of endothelial function were assessed: high resolution ultrasonography to measure flow mediated endothelium dependent dilatation of the brachial artery following reactive hyperaemia, and plasma concentration of von Willebrand factor. Endothelium independent dilatation was also assessed following sublingual glyceryl trinitrate. The patients were divided into those with and without overt atherosclerotic vascular disease. RESULTS: Although patients with chronic renal failure had significantly impaired endothelium dependent dilatation compared with controls (median (interquartile range), 2.6% (0.7% to 4.8%) v 6.5% (4.8% to 8.3%); p < 0.001) and increased von Willebrand factor (254 (207 to 294) v 106 (87 to 138) iu/dl; p < 0.001), there was no difference between renal failure patients with and without atherosclerotic vascular disease. Within the chronic renal failure group, endothelium dependent dilatation and von Willebrand factor were similar in patients in the upper and lower quartiles of glomerular filtration rate (2.7% (0.7% to 6.7%) v 2.8% (1.1% to 5.0%); and 255 (205 to 291) v 254 (209 to 292) iu/dl, respectively). Endothelium independent dilatation did not differ between the renal failure or control groups and was also similar in patients with renal failure irrespective of the degree of renal failure or the presence of atherosclerotic vascular disease. CONCLUSIONS: Endothelial function is abnormal in chronic renal failure, even in patients with mild renal insufficiency and those without atherosclerotic vascular disease, suggesting that uraemia may directly promote the development of atherosclerosis early in the progression of chronic renal failure.

Relaxation training inhibits fear and arousal during in vivo exposure to phobia-cue stimuli.

Twenty carefully selected snake phobics were exposed to a caged snake for eight trials via a conveyor apparatus. During the first and eighth trials the subjects brought the snake toward themselves as closely as tolerable; records were kept of the end-of-trial distances remaining between the subject and the snake. For the six intervening trials the experimenter placed the snake a standard distance away; records were kept of the subjects' heart rates and skin-conductance levels before and during the exposures, and of their self-reported fear intensities after the exposures. Half of the subjects had received six sessions of progressive relaxation training before the exposures occurred. The results for subjects who had received relaxation training versus subjects who had not received relaxation training showed clearly that the training served to attenuate arousal and fear in the context of in vivo exposure. The results showed also that relaxation worked by lowering arousal throughout the course of exposure, not by hastening or facilitating arousal decrement during exposure. Some implications of the results are discussed.

Pelvic gliomatosis within foci of endometriosis.

The third reported case of pelvic gliomatosis found within foci of endometriosis is documented 16 years after the removal of a benign cystic teratoma. Grossly at laparoscopy the lesions appear as typical deep fibrotic endometriotic implants.

Toward a standard experiment for studying post-treatment return of fear.

Fear sometimes returns after successful fear attenuation via in vivo exposure to fear signals. Post-treatment return of fear is of considerable interest both practically and theoretically, but factors associated with return of fear are poorly understood due to conflicting results from procedurally diverse experiments. This paper reports two very similar experiments in which fear of animal specimens was weakened then allowed to return so that factors associated with return of fear could be studied. In each experiment attentional focus versus distraction during exposure served as a between-subjects independent variable. In each case, attempts also were made to predict return of fear via several nonmanipulated variables: initial fear, initial avoidance during voluntary exposure, initial heart rate during voluntary exposure, and speed of fear reduction during repeated exposure trials. With the sample sizes used there was only suggestive evidence that return of fear was associated with distraction during exposure, and with relatively rapid fear decline during exposure. More importantly, the experiments are offered as standard, replicable models for research that will permit procedurally homogeneous investigations of variables with which return of fear is associated.

Effects of relaxation training on fear and arousal during in vivo exposure to a caged snake among DSM-III-R simple (snake) phobics.

Eight pairs of DSM-III-R snake phobic subjects (Ss) were exposed to a caged snake while seated in front of a package-conveyor apparatus during eight 4-minute trials. Heart rates and skin-conductance levels were recorded before and during each of the eight trials. Self-reports of fear were obtained after each trial. One S in each pair controlled the conveyor on alternating trials. One subject (S) in each pair had received a representative regimen of relaxation training beforehand. Heart-rate decreased more in Ss controlling the conveyor than in their yoked partners. Ss who had received relaxation training showed lower heart-rate change, lower skin-conductance change, and lower self-reports of fear after the exposure trials. Relaxed Ss also moved the snake closer to themselves than did unrelaxed subjects on some trials.

Control and attention during exposure influence arousal and fear among insect phobics.

Heart beats, skin conductance, and subjective fear levels were recorded among eight pairs of DSM-III-R spider-phobic subjects (Experiment 1) and among eight pairs of DSM-III-R cockroach-phobic subjects (Experiment 2) who were exposed simultaneously to an approaching specimen during eight 4-minute trials. Control over the approach of the specimen alternated between subjects over trials. On different trials, both subjects were instructed either to attend closely to the features of the specimen or to attend closely to their bodily fear reactions. Among spider-phobic subjects (Experiment 1), Self-Control over the specimen produced higher skin conductance during exposure than did Partner-Control over the specimen; instructions to attend closely to the features of the specimen produced higher skin-conductance than did instructions to attend closely to one's bodily fear reactions. Among cockroach-phobic subjects (Experiment 2), Self-Control over the specimen produced higher skin conductance and higher self-reported fear than did Partner-Control over the specimen during the early exposures. Instructions to attend closely to the specimen produced higher skin conductance and higher self-reported fear throughout the experiment and higher heart rates early during the experiment than did instructions to attend to one's bodily reactions. Empirical generalizations based on these data are intended as contributions toward a fund of experimental information that, in due course, will be used to conceptualize the means by which exposure to feared stimuli leads to fear reduction.

Ovarian Preservation at Hysterectomy for Endometriosis

Traditionally, definitive treatment for symptomatic endometriosis has been total abdominal hysterectomy with bilateral salpingo-oophorectomy. However, aggressive excision of all endometriotic implants at the time of hysterectomy with preservation of one or both ovaries may be an acceptable alternative. All hysterectomies performed between 1988 and 1993 were retrospectively reviewed. Fifty-two women underwent laparoscopic hysterectomy for pelvic pain from advanced stage endometriosis with preservation of at least one ovary. The majority of women had significant to total relief of pelvic pain postoperatively. Average follow-up was 36 months. This series suggests that ovarian preservation at the time of hysterectomy can be considered in women with endometriosis. Patient benefits include avoidance of symptoms of surgical castration and subsequent exogenous hormone replacement.

Laparoscopic tubal anastomosis.

We conducted a retrospective chart review of 22 laparoscopic tubal anastomoses performed between May 1987 and May 1991. The procedures were modeled after the two-stitch technique of Swolin. Overall fertility rates were disappointing in this small series, although the first live birth has occurred. The two-stitch method and available laparoscopic suture needles and needle holders limited the surgical results. Modifications of technique and instrumentation should improve fertility outcome.