General, Specific and Unique Cognitive Factors Involved in Anxiety and Depressive Disorders.

Comorbidity among anxiety and depressive disorders is the rule rather than the exception. The Integrative Hierarchical Model proposes that each of these disorders contains general (common to all), specific (common to some) and unique components. However, research into this model is limited and hampered by small (clinical) sample sizes. The aim of the present study is to investigate the incremental validity of the cognitive constructs Anxiety Sensitivity, Pathological Worry and Cognitive Reactivity to sad mood over and above the personality traits neuroticism and extraversion. Symptomatic (N = 1,111) and remitted (N = 834) patients were selected from the 2,981 participants of the Netherlands Study of Depression and Anxiety (NESDA). Results revealed both specific and unique cognitive components of anxiety and depression. Across symptomatic and remitted groups, Anxiety Sensitivity was specific to social anxiety disorder and panic disorder, Aggression Reactivity was a unique component of dysthymia, and Rumination on Sadness was unique to major depressive disorder. We conclude that cognitive constructs have additional value in understanding anxiety and depressive disorders. Moreover, they prove to be more than mere epiphenomena of current disorders.

Serum levels of brain-derived neurotrophic factor in major depressive disorder: state-trait issues, clinical features and pharmacological treatment.

Recent evidence supports 'the neurotrophin hypothesis of depression' in its prediction that brain-derived neurotrophic factor (BDNF) is involved in depression. However, some key questions remain unanswered, including whether abnormalities in BDNF persist beyond the clinical state of depression, whether BDNF levels are related to the clinical features of depression and whether distinct antidepressants affect BDNF levels equally. We addressed these questions and investigated serum BDNF levels in 962 depressed patients, 700 fully remitted persons (≥6 months) and 382 healthy controls. We found serum BDNF levels to be low in antidepressant-free depressed patients relative to controls (P=0.007) and to depressed patients who were treated with an antidepressant (P=0.001). BDNF levels of fully remitted persons (whether unmedicated or treated with an antidepressant) were comparable to those of controls. Analyzing the sample of antidepressant-free depressed patients showed that BDNF levels were unrelated to the core clinical features of depression such as its severity or first versus a recurrent episode. The antidepressant associated upregulation of serum BDNF in depressed patients was confined to selective serotonin reuptake inhibitors (SSRIs) (P=0.003) and St John's wort (P=0.03). Our results suggest that low serum levels of BDNF are a state abnormality that is evident during depression and normalizes during remission. Increases in serum levels of BDNF during antidepressant treatment appear to be confined to some antidepressants and do not parallel clinical characteristics, such as the severity of depressive symptoms.

[Personality disorders in an institution for ambulatory mental health care. Prevalence, type and severity, treatment indication and drop out]. / Persoonlijkheidsstoornissen in een instelling voor tweedelijns geestelijke gezondheidszorg. Prevalentie, kenmerken, behandelindicatie en drop-out.

BACKGROUND: Personality disorders occur frequently. The presence of one or more personality disorders can influence the severity of the symptoms and can affect coping, treatment indication and drop out. AIM: To study the prevalence of personality disorders in an ambulatory health care centre and to investigate the influence of both the severity and the nature of personality disorders on the following: symptomatology, interpersonal behaviour, coping and defence mechanisms, personality traits, treatment indication and drop out. METHOD: We studied the prevalence of personality disorders in 100 patients using the International Personality Disorder Examination (IPDE), a semi-structured interview. Symptoms, interpersonal behaviour, coping and defence mechanisms and personality traits were assessed by means of self-reports. Patients were assigned to specific types of treatment by their own doctors, who were not aware of the assessment results. results Most of the patients suffered from a personality disorder. Patients with cluster-A-type personality disorders were all assigned to treatment. The majority of patients with cluster- B-type personality disorders were assigned to Axis-ii-type treatment but most patients with cluster-A-and cluster-C personality disorders were assigned to Axis-I-type treatment. The dropout percentage was higher among patients with a personality disorder than among those without. Among patients with personality disorders the drop-out percentage was highest in those from the A and C clusters. Patients with personality pathology from the A cluster were 13 times more likely to drop out than those without A cluster pathology, patients with C cluster pathology were 11 times more likely to drop out than those without C cluster pathology. CONCLUSION: In ambulatory mental health care more attention needs to be given to the diagnosis of personality disorders. Results suggest that in the treatment of patients with A and C cluster pathology much effort must be directed at fostering therapeutic alliance and compliance to treatment.

Memory of childhood trauma before and after long-term psychological treatment of borderline personality disorder.

The present study investigated the consistency of self-reports of childhood traumatic events in a sample of 50 patients with a borderline personality disorder (BPD) before and after 27 months of intensive treatment with schema focused therapy or transference focused psychotherapy. The mean number of reported sexual, physical and emotional traumatic events did not change following treatment. Test-retest correlations of the trauma-interview also indicated high stability of the total number of sexual, physical and emotional events reported. The majority of the patients, however, did no longer report at least one of the 33 listed events after psychotherapy, and the majority reported at least one event that they had not mentioned before the start of treatment. These findings were not related to type of treatment or changes in suppression, intrusions, avoidance of intrusions, dissociative symptoms, depressive symptoms, and borderline symptoms.

Maladaptive core beliefs and eating disorder symptoms.

This study compared maladaptive core beliefs of eating-disordered groups (full and subthreshold syndrome) and healthy controls and investigated the association between eating disorder symptoms and core beliefs. Participants were compared on self-report measures of core beliefs (YSQ) and eating disorder psychopathology (BITE). Anorexia nervosa (AN; both subtypes) and bulimia nervosa (BN) patients had significantly more core beliefs than healthy controls. Binge eating disorder (BED) patients had intermediate scores between AN and BN on the one hand and healthy controls on the other hand. No correlation was found between core beliefs and frequency of binge eating. Frequency of vomiting, laxative misuse and fasting was positively associated with all domains of core beliefs. Patients with eating disorders have some core beliefs which are not directly related to eating, weight or shape. Frequency of purging and fasting behaviors is associated with more severe maladaptive core beliefs. Our data demonstrate the importance of identifying purging and fasting as significant clinical markers.

Psychiatric comorbidity in epilepsy.

Many studies on psychiatric comorbidity in epilepsy have been performed using many different patient groups and diagnostic instruments. This methodological heterogeneity complicates comparison of the findings. In this article, psychiatric disorders in epilepsy are reviewed from the perspective of the DSM classification system. The empirical findings of axis I clinical disorders and axis II personality disorders are described separately. Furthermore, the existence and specificity of conditions such as interictal dysphoric disorder, interictal behavior syndrome, and psychosis of epilepsy are discussed. From the many studies that have been performed on this topic it can be learned that there is a need for well-controlled studies using representative patient groups and valid and standardized diagnostic instruments. So far, the majority of the studies have concerned axis I disorders; relatively little research has been performed on axis II personality disorders. More research on personality disorders, as well as on the relative contributions of the different (brain- and non-brain-related) factors to the relationship between epilepsy and psychiatric disorders, is recommended.

Blood glucose awareness training in Dutch type 1 diabetes patients: one-year follow-up.

BACKGROUND: American studies have shown positive effects of Blood Glucose Awareness Training (BGAT) on the recognition of hypoglycaemia. We evaluated the effects of BGAT among Dutch patients, and compared individual training with training in the original group format. METHODS: Fifty-nine type 1 diabetes patients participated in BGAT in either a group (n = 37) or an individual (n = 22) setting. Before and one year after training they performed up to 70 measurements, two to four a day, at home on a handheld computer. During each measurement they estimated their blood glucose (BG), indicated whether they would be participating in traffic and raised their BG on the basis of their estimation, and then measured their BG. The incidence of severe hypoglycaemia and traffic accidents was also assessed. RESULTS: BGAT had positive effects on hypoglycaemic awareness, decisions not to drive and to raise the blood glucose during hypoglycaemia, severe hypoglycaemic episodes and traffic accidents. The accuracy of BG estimations only improved after group training, while after individual training patients tended to measure more or more extremely high BG values. CONCLUSION: The training improved awareness of hypoglycaemia, and seems worthy of implementation in The Netherlands.

The criterion validity of the Center for Epidemiological Studies Depression Scale (CES-D) in a sample of self-referred elders with depressive symptomatology.

BACKGROUND: The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression. METHODS: Paper-and-pencil administration of the CES-D to 318 elders (55-85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (MINI), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore the characteristics of true versus false positives were analyzed. RESULTS: For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes. CONCLUSIONS: The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi-clinical sample of elders. Subjects scoring >/=25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment.

Autobiographical memory in depressed and non-depressed patients with borderline personality disorder.

OBJECTIVES: The present study investigated the specificity of autobiographical memories among depressed and non-depressed borderline patients, compared with depressed patients and controls. The influence of childhood trauma, intrusions of traumatic events, avoidance of intrusions, dissociation and depression on memory specificity was also studied. METHOD: The Autobiographical Memory Test (AMT), a trauma interview and self-report measures of intrusions, avoidance, depression and dissociation were administered to 83 borderline outpatients, 26 depressed outpatients and 30 controls. RESULTS: Depressed borderline patients and depressed patients reported fewer specific memories than controls. Depressed patients generated fewer specific memories than non-depressed borderline patients. Neither trauma nor traumatic intrusions, avoidance of intrusions or dissociation were related to the specificity of memories. Level of depressive symptoms (BDI) was also not related, but the presence of a depression was. CONCLUSION: In this large sample of outpatients with borderline personality disorder, only the subgroup with a co-morbid diagnosis of depression had trouble remembering specific events from the past. Trauma, intrusions, avoidance of intrusions and dissociation seem to be unrelated to the specificity of autobiographical memories in borderline personality disorder.

Personality disorder traits in patients with epilepsy.

OBJECTIVE AND METHODS: The Questionnaire on Personality Traits (VKP: Vragenlijst voor Kenmerken van de Persoonlijkheid) was used to investigate personality disorder (PD) traits in 203 patients with epilepsy and a control group of 332 subjects from the general population. Furthermore, the association of PD traits with epilepsy-related variables was studied, as well as the association between PD traits and level of psychopathology. RESULTS: The results showed that, compared with the control group, patients with epilepsy had higher dimensional VKP scores for several Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and International Classification of Diseases (ICD-10) PDs. Associations were found between PD traits and age at onset of epilepsy, duration of epilepsy, seizure frequency and number of anti-epileptic drugs. Anxiety and depression were not associated with PD traits. CONCLUSION: It is likely that suffering from epileptic seizures negatively influences personality development and can result in the development of maladaptive PD traits. The results also support the idea that PD traits are not (completely) covered by axis I psychopathology and therefore should be separately investigated.

Evidence for associations among somatoform dissociation, psychological dissociation and reported trauma in patients with chronic pelvic pain.

This study investigates somatoform as well as psychological dissociation, somatization and reported trauma among patients with chronic pelvic pain (CPP). Women with CPP (n = 52) who were newly referred to a gynecology department, or whose pain had resisted treatment, completed standardized self-report questionnaires and received a structured interview for DSM-IV dissociative disorders. The prevalence of dissociative disorders in the sample was very low. As hypothesized, self-reported somatoform dissociation was positively correlated with self-reported psychological dissociation and features of DSM-IV dissociative disorders; women who reported more serious psychic trauma, in particular sexual and physical abuse, experienced more somatoform and psychological dissociation than women reporting less trauma, or no trauma at all; and the association of somatoform dissociation and reported trauma was stronger than the association of psychological dissociation and trauma. Physical abuse/life threat posed by a person predicted somatoform dissociation best. The results are consistent with findings among psychiatric patients, and, therefore, strengthen the thesis that somatoform dissociation, (features of) dissociative disorder, and reported trauma are strongly intercorrelated phenomena.

Psychopathologies in patients with nonepileptic seizures with and without comorbid epilepsy: how different are they?

The underlying psychopathology in patients with nonepileptic seizures (NES) is diverse and poorly understood. The prevalence of epilepsy in NES patients is higher than in the general population, so epilepsy can be understood as a risk factor for NES. The question emerges if psychopathology differs in NES patients with and without epilepsy. Retrospective data concerning psychopathology and personality in both groups show two differences: (1) somatoform disorders are more prevalent in NES-only patients and (2) personality disorders are more typical in NES patients with epilepsy and resemble the pattern of psychopathology found in epilepsy-only patients. If true, then NES in epilepsy patients may be associated with an epilepsy condition. Consequently, in studies of psychopathology in epilepsy patients, patients with comorbid nonepileptic seizures have to be included.

The influence of depressive state features on trait measurement.

BACKGROUND: Certain personality characteristics may change during depression, reflecting temporary states, while others remain stable. This study investigates the stability of personality during depression. Identification of depression-sensitive personality traits may help to elucidate the mechanisms that influence course and outcome of depression. METHODS: For 42 ambulatory and 38 day care patients with a depressive disorder, depression severity and personality characteristics were measured repeatedly during a 12 week-period. The total HDRS score was indicative of depression severity, while the NEO-FFI was used for measurement of basic personality traits and the IPS for depression-specific traits. RESULTS: In 12 weeks, depression severity significantly decreased for both patient groups. The Big Five traits Neuroticism and Extraversion and all but one aspect of Interpersonal sensitivity showed depression-related changes towards the normal range. Openness, Altruism and Conscientiousness remained stable. LIMITATIONS: The number of patients excluded from the study due to missing data is substantial. Furthermore, it was not possible to control for treatment influence due to a double-blind design. CONCLUSIONS: Neuroticism, Extraversion and Interpersonal sensitivity scores are likely to reflect state components during a depression, while the stability of Openness, Conscientiousness and Altruism scores indicates pure personality traits.

Blood Glucose Awareness Training in Dutch Type 1 diabetes patients. Short-term evaluation of individual and group training.

AIMS: The aims of the present study were: (i) to evaluate the effects of a Dutch translation and adaptation of Blood Glucose Awareness Training (BGAT-III) on blood glucose (bg) perception, glycaemic control, and decisions not to drive or to raise the bg during hypoglycaemia; (ii) to compare the effects of individual and group BGAT. METHODS: Fifty-nine patients with Type 1 diabetes participated in BGAT in either a group or an individual setting. Before and after BGAT, 39 (66%) of them completed 30-70 measurements on a hand-held computer (hhc). During every measurement, they estimated their bg, indicated whether they would drive or raise their bg on the basis of their estimation, and then measured their bg. RESULTS: Individual and group BGAT did not have significantly different effects (P = 0.35-0.98). Overall, BGAT did not significantly affect bg perception (P = 0.11-0.65). Before BGAT patients recognized a mean of 32% of their hypoglycaemic episodes, after BGAT a mean of 39% (P = 0.12). After BGAT, patients more often decided not to drive when their bg was low (P = 0.03). They tended to decide more often to raise their bg during hypoglycaemia (P = 0.09). CONCLUSIONS: The effects of BGAT were smaller than expected. Possible reasons for this negative outcome may be the adapted version of BGAT (shorter in duration), a lack of statistical power, or a difference between American and European samples in their reaction to BGAT.

Prevalence of Psychopathology in Dutch Epilepsy Inpatients: A Comparative Study.

The purpose of this study was to determine the prevalence of psychiatric disorders in Dutch patients with epilepsy in comparison with epidemiological data on a representative sample of the Dutch population. The Composite International Diagnostic Interview (CIDI) was used to determine the prevalence of psychiatric disorders in 209 epilepsy patients and compared with findings in the general Dutch population. The prevalence in temporal lobe epilepsy (TLE) and extra-temporal lobe epilepsy (extra-TLE) was also compared. Psychiatric disorders most frequently found in patients with epilepsy were anxiety and mood disorders. The last-year prevalence of these disorders was 25% for anxiety disorders and 19% for mood disorders. Compared with the general Dutch population, the prevalence of these disorders was significantly higher in epilepsy. No differences were found between patients with TLE and extra-TLE. It can be concluded that patients with epilepsy admitted to a tertiary epilepsy center suffer more often from mood and anxiety disorders than the general population.