Sources of stress and worry in the development of stress-related mental health problems: A longitudinal investigation from early- to mid-adolescence.

BACKGROUND AND OBJECTIVES: Stress and stress-related mental health complaints are common and increasing among adolescents, especially girls. Identifying typical sources of stress as well as central intervention targets is an important effort in the development of effective prevention and treatment protocols. This study investigated worry as potential mediator in the development of mental health problems in response to common stressors in adolescence. We also examined to what sources adolescents ascribe their stress over the years from the 7th through the 9th grade. DESIGN: Prospective cohort study. METHODS: Self-reported subjective stressor load, worry, anxiety and depressive symptoms were assessed in a sample of Swedish 7th graders (N = 1137; 46% girls, mean age 13.2) with follow-up assessments one and two years later. RESULTS: School was the most common source of stress across all time-points, with girls reporting considerable more stress than boys. Worry mediated the relationship between overall stressor load and depressive symptoms and anxiety over time and was not moderated by gender. CONCLUSIONS: Worry may be an important target in stress prevention and efforts to prevent stress-related problems would benefit from focusing on early adolescence as especially school stress is already relatively common in grade 7.

Too tired for school? The effects of insomnia on absenteeism in adolescence.

OBJECTIVES: Sleep has important consequences for a person's daytime functioning. Numerous studies have shown that insomnia predicts work absenteeism and work disability in adults, but only a few studies have examined this association in adolescents. This study aims to explore whether symptoms of insomnia in adolescents predict school absenteeism 1 year later, over and above known psychological risk factors for absenteeism. DESIGN: The study used a longitudinal design with 2 measurement points over 1 year. SETTING: The students completed questionnaires during school hours at baseline and again at follow-up. PARTICIPANTS: Students in the 10th to 12th grades in a Swedish upper secondary school were followed prospectively for 1 year (age, 16-20 years; N = 353; 48.1% girls). MEASUREMENTS AND RESULTS: We used logistic regression analyses, controlling for the known effects of psychological factors, and arrived at a model elucidating the role of insomnia. That is, besides symptoms of insomnia, the model included previous absenteeism, alcohol intoxication, school-related social phobia, social anxiety, depressive symptoms, somatic symptoms, and bully victimization. Symptoms of insomnia predicted school absenteeism 1 year later, over and above known risk factors for absenteeism. Adolescents reporting severe symptoms of insomnia were almost 3 times more likely than adolescents reporting no or low symptoms to report problematic absenteeism 1 year later. We did not find any gender difference. CONCLUSIONS: Our findings underscore the importance of sleep problems on adolescents' daytime functioning as measured by school absenteeism. Therefore, sleep may be an important target for preventive interventions with adolescents.

Randomized trial of Internet-based relapse prevention for partially remitted depression.

OBJECTIVE: To investigate whether Internet-based cognitive behaviour therapy (CBT) can prevent relapse in persons with partially remitted major depression after previous treatment. METHOD: Seventy-one women and 13 men (N = 84) with partially remitted major depression after treatment were randomly assigned to either 10 weeks of Internet-based CBT or to a control group. Self-help material was used in combination with e-mail contact with a personal therapist. Monthly self-ratings of depressive symptoms were made, and diagnostic interviews were conducted before and after the treatment period, as well as 6 months later. RESULTS: Significantly fewer participants in the CBT group experienced relapse (4/38 or 10.5%) compared with those in the control group (14/37 or 37.8%). The difference in relapse rates between groups occurred early in the study period and was still apparent after 6 months. A trend towards a larger reduction in depressive symptoms was observed at post-treatment in the participants who received CBT compared with controls. Reduction in depressive symptoms reduced the risk of relapse. A trend towards a higher remission rate was found in the CBT group at the 6 month follow-up. CONCLUSION: Internet-based CBT seems promising in preventing relapse in persons with partially remitted major depression after previous treatment.

Cerebral blood flow in subjects with social phobia during stressful speaking tasks: a PET study.

OBJECTIVE: The central nervous system representation of social phobia (social anxiety disorder) is largely unknown. The aim of this study was to examine brain activity during symptom provocation in social phobics. METHOD: Positron emission tomography with the use of (15)O water was used to measure regional cerebral blood flow (rCBF) in 18 subjects with DSM-IV-defined social phobia and a nonphobic comparison group while they were speaking in front of an audience and in private. Heart rate and subjective anxiety were also recorded. RESULTS: During public versus private speaking, subjective anxiety increased more in the social phobics than in the comparison group. Increased anxiety was accompanied by enhanced rCBF in the amygdaloid complex in the social phobics relative to the comparison subjects. Cortically, brain blood flow decreased in the social phobics and increased in the comparison subjects more during public than private speaking in the orbitofrontal and insular cortices as well as in the temporal pole and increased less in the social phobics than in the comparison group in the parietal and secondary visual cortices. Furthermore, rCBF increased in the comparison group, but not in the social phobics, in the perirhinal and retrosplenial cortices. CONCLUSIONS: An rCBF pattern of relatively increased cortical rather than subcortical perfusion was observed in the nonphobic subjects, indicating that cortical evaluative processes were taxed by public performance. In contrast, the social phobia symptom profile was associated with increased subcortical activity. Thus, the functional neuroanatomy of social phobia involves the activation of a phylogenetically older danger-recognition system.

Dispositional pessimism and amygdala activity: a PET study in healthy volunteers.

The present study used scores from Seligman's Attribution Style Questionnaire and [15O] water positron emission tomographic measurements of regional cerebral blood flow (rCBF) to investigate the relation between individual differences in dispositional pessimism and amygdala activity. During scanning 13 healthy non-snake-phobic females passively viewed a snake videotape. Using one-tailed tests, significant negative correlations were evident between pessimism scores, with low scores reflecting relatively more pessimism, and right (r=-0.60; p=0.014) and left amygdala rCBF (r=-0.53; p=0.032). These results extend previous neuroimaging findings in healthy subjects indicating a role for the amygdala in transient negative emotional states, and suggest that this multimodal brain region also is involved in more durable negative affects such as dispositional pessimism.

Personality traits in social phobia.

The purpose was to assess personality traits in subjects with a DSM-IV diagnosis of social phobia. Thirty-two subjects were administered the Structured Clinical Interview for DSM-IV for Axes I and II disorders (SCID I and II). Personality traits were assessed by means of the Karolinska Scales of Personality (KSP). Current and lifetime axis I co-morbidity was diagnosed in 28% and 53% of the subjects, respectively. In total, 59% had at least one personality disorder and 47% were diagnosed with an avoidant personality disorder. The social phobics scored significantly higher than a Swedish normative sample on the KSP measuring anxiety proneness, irritability, detachment, and indirect aggression but lower on the scales for socialisation and social desirability. The presence as compared to absence of avoidant personality disorder in the social phobics was associated with significantly higher psychic anxiety and inhibition of aggression. In addition, symptom severity was higher in social phobics with an avoidant personality disorder. Generally, the results support the view that social phobia and avoidant personality disorder reflect different aspects of a social anxiety spectrum.

Social phobia and avoidant personality disorder as related to parental history of social anxiety: a general population study.

Using a validated and DSM-IV compatible questionnaire, the present study related family history of excessive social anxiety to social phobia and avoidant personality disorder (APD) in epidemiologically identified probands in the general population. Probands met diagnostic criteria for social phobia with or without APD and APD with or without social phobia. A two- to three-fold increased relative risk of social anxiety was observed for all diagnostic groups. Increasing severity in probands by varying diagnostic criteria did not affect the relative risk. Because familial aggregation of social anxiety was not modulated by Axis I or II diagnosis or diagnostic cut-off levels, data imply that social phobia and APD may represent a dimension of social anxiety rather than separate disorders. Thus, having an affected family member is associated with a two- to three-fold risk increase for both social phobia and APD.

Social phobia subtypes in the general population revealed by cluster analysis.

BACKGROUND: Epidemiological data on subtypes of social phobia are scarce and their defining features are debated. Hence, the present study explored the prevalence and descriptive characteristics of empirically derived social phobia subgroups in the general population. METHODS: To reveal subtypes, data on social distress, functional impairment, number of social fears and criteria fulfilled for avoidant personality disorder were extracted from a previously published epidemiological study of 188 social phobics and entered into an hierarchical cluster analysis. Criterion validity was evaluated by comparing clusters on the Social Phobia Scale (SPS) and the Social Interaction Anxiety Scale (SIAS). Finally, profile analyses were performed in which clusters were compared on a set of sociodemographic and descriptive characteristics. RESULTS: Three clusters emerged, consisting of phobics scoring either high (generalized subtype), intermediate (non-generalized subtype) or low (discrete subtype) on all variables. Point prevalence rates were 2.0%, 5.9% and 7.7% respectively. All subtypes were distinguished on both SPS and SIAS. Generalized or severe social phobia tended to be over-represented among individuals with low levels of educational attainment and social support. Overall, public-speaking was the most common fear. CONCLUSIONS: Although categorical distinctions may be used, the present data suggest that social phobia subtypes in the general population mainly differ dimensionally along a mild moderate-severe continuum, and that the number of cases declines with increasing severity.

Regional cerebral blood flow during tinnitus: a PET case study with lidocaine and auditory stimulation.

Brain imaging of tinnitus has suggested central correlates of tinnitus perception. This study presents positron emission tomographic (PET) measurements of regional cerebral blood flow (rCBF) in a female tinnitus patient with bilateral left dominant tinnitus. Lidocaine infusion (75 mg during 5 min (0.2 mg/kg/min)) resulted in a 75% reduction of tinnitus and a temporary abolition of the dominant tinnitus in her left ear. Regional CBF was measured in four conditions: i) at rest while concentrating on tinnitus, ii) following maximum effect of lidocaine, iii) during sound stimulation, and iv) the following day at rest while concentrating on tinnitus. Subtraction analyses showed that tinnitus was associated with increased rCBF in the left parieto-temporal auditory cortex, including the primary and secondary auditory cortex with a focus in the parietal cortex (Brodmann areas 39, 41, 42, 21, 22). Activations were also found in right frontal paralimbic areas (Brodmann areas 47, 49 and 15). Sound stimulation resulted in bilateral activation of auditory areas. It is suggested that tinnitus is processed in primary, secondary and integrative auditory cortical areas. Tinnitus perception may involve areas related to auditory attention, while emotional processing relates to temporofrontal paralimbic areas.

Social phobia in the general population: prevalence and sociodemographic profile.

BACKGROUND: The present study examined the prevalence of social phobia in the Swedish general population and demographic characteristics associated with this anxiety disorder. METHODS: Data were obtained by means of a postal survey administrated to 2000 randomly selected adults. A questionnaire, validated against clinical interviews and established social phobia scales, was used to assess social distress in a broad range of phobic situations, as well as the diagnostic criteria for social phobia corresponding to DSM-IV. Interpretable questionnaires were obtained from 1202 respondents (60.1%). RESULTS: The point prevalence of social phobia was estimated at 15.6%, but prevalence rates varied between 1.9 and 20.4% across the different levels of distress and impairment used to define cases. Public speaking was the most common social fear. Social phobia was associated with female gender, low educational attainment, psychiatric medication use, and lack of social support. CONCLUSIONS: Although the exact diagnostic boundaries for social phobia are difficult to determine, it can be concluded that social anxiety is a distressing problem for a considerable proportion of the general population.