Predicting birth weight in fetuses with gastroschisis.

OBJECTIVE: To determine the accuracy of commonly utilized ultrasound formulas for estimating birth weight (BW) in fetuses with gastroschisis. STUDY DESIGN: A retrospective review was conducted of all inborn pregnancies with gastroschisis within the five institutions of the University of California Fetal Consortium (UCfC) between 2007 and 2012. Infants delivered at ⩾28 weeks who had an ultrasound within 21 days before delivery were included. Prediction of BW was evaluated for each of the five ultrasound formulas: Hadlock 1 (abdominal circumference (AC), biparietal diameter (BPD), femur length (FL) and head circumference (HC)) and Hadlock 2 (AC, BPD and FL), Shepard (AC and BPD), Honarvar (FL) and Siemer (BPD, occipitofrontal diameter (OFD), and FL) using Pearson's correlation, mean difference and percent error and Bland-Altman analysis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the ultrasound diagnosis of intrauterine growth restriction (IUGR) were assessed. RESULTS: We identified 191 neonates born with gastroschisis within the UCfC, with 111 neonates meeting the inclusion criteria. The mean gestational age at delivery was 36.3±1.7 weeks and the mean BW was 2448±460 g. Hadlock (1) formula was found to have the best correlation (r=0.81), the lowest mean difference (8±306 g) and the lowest mean percent error (1.4±13%). The Honarvar and Siemer formulas performed significantly worse when compared with Hadlock 1, with a 13.7% (P<0.001) and 3.9% (P=0.03) difference, respectively, between estimated and actual BW. This was supported by Bland-Altman plots. For Hadlock 1 and 2, sensitivity was 80% with a NPV of 91%. CONCLUSION: The widely used Hadlock (1) and (2) formulas provided the best estimated BW in infants with gastroschisis despite its inclusion of abdominal circumference. Furthermore, this formula performs well with diagnosis of IUGR.

Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive-compulsive disorder.

BACKGROUND: Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment. METHOD: Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification. RESULTS: Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%). CONCLUSIONS: This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.

Evaluation of the clinical global impression scale among individuals with social anxiety disorder.

BACKGROUND: The clinical Global Impression Scale (CGI) is commonly used as a primary outcome measure in studies evaluating the efficacy of treatments for anxiety disorders. The current study evaluated the psychometric properties and predictors of clinicians' ratings on an adapted version of the CGI among individuals with social anxiety disorders. METHOD: An independent assessor administered the CGI Severity of Illness and Improvement ratings to 123 patients at baseline and the subset of treated patients again mid- and post-treatment. RESULTS: Improvement ratings were strongly related to both concurrent Severity of Illness and changes in Severity of Illness ratings from baseline. Additionally, both CGI ratings were positively correlated with both self-report and clinician-administered measures of social anxiety, depression, impairment and quality of life. Measures of social anxiety symptoms accounted for a large portion of the variance in Severity of Illness ratings, with significant additional variance accounted for by measures of impairment and depression. Changes in social anxiety symptoms from baseline accounted for significant variance in Improvement ratings, but no significant additional variance was accounted for by changes in impairment and depressive symptoms. CONCLUSIONS: Our findings support the utility of the CGI as an index of global severity and symptom-specific improvement among individuals with social anxiety disorder.

The psychometric properties of the Interpersonal Sensitivity Measure in social anxiety disorder.

The Interpersonal Sensitivity Measure (IPSM) was developed to assess hypersensitivity to interpersonal rejection, a suggested trait of depression-prone personality (Aust NZ J Psychiatry 23 (1989) 341). Although studies of the IPSM and interpersonal rejection sensitivity have primarily been conducted in depressed populations, it is important to investigate interpersonal rejection sensitivity as a relevant construct in the assessment of social anxiety. This study examined the psychometric properties of the IPSM in treatment-seeking individuals with social anxiety disorder. The results of this investigation support the convergent and divergent validity and internal consistency of the IPSM in socially anxious individuals. An exploratory factor analysis of the scale was also conducted after the original factor and subscale structure was shown to be a poor fit for the present data. Three factors emerged (Interpersonal Worry and Dependency, Low Self-Esteem, and Unassertive Interpersonal Behavior), and 29 items were retained. Because they demonstrated negative factor loadings on Factor 2, it is suggested that the scoring for four items of the original IPSM be reversed. In summary, the revised IPSM assesses three aspects of interpersonal rejection sensitivity and appears to be a valid and reliable instrument for its assessment in social anxiety disorder.

Neuroendocrine predictors of response to intravenous clomipramine therapy for refractory obsessive-compulsive disorder.

The current study examines the neuroendocrine response to intravenous clomipramine (IV CMI) in oral CMI-resistant obsessive-compulsive disorder (OCD) patients on day 1 and day 14 of treatment to identify predictors of response. Forty-four OCD patients with an inadequate response or poorly tolerant to oral CMI were begun at 25 mg IV CMI, increasing to 250 mg by day 10, and continuing on that dose to day 14. On day 1, plasma levels of prolactin (PRL), growth hormone (GH), and cortisol were obtained immediately before the 25 mg IV infusion, and at five 30-minute time points after the infusion. On day 14, hormonal samples were obtained in a similar fashion. Response was assessed by the Clinical Global Impressions (CGI). Low PRL(MAX) to IV CMI and low cortisol levels overall on day 1 were both significantly associated with clinical response at day 14. An overall increase in growth hormone (GH) secretion during the day 14 testing was associated with positive response. A pronounced PRL response to IV CMI on day 14 was exhibited by the nonresponders, whereas a smaller and later but significant increase in PRL was noted in the responders. The findings suggest that in this sample of oral CMI-resistant patients with OCD, neuroendocrine measures derived from pharmacological challenge with IV CMI are capable of distinguishing IV CMI treatment responders from nonresponders. The limitations of IV CMI as a specific probe of serotonin function are discussed.

A controlled study of cognitive deficits in children with chronic Lyme disease.

Although neurologic Lyme disease is known to cause cognitive dysfunction in adults, little is known about its long-term sequelae in children. Twenty children with a history of new-onset cognitive complaints after Lyme disease were compared with 20 matched healthy control subjects. Each child was assessed with measures of cognition and psychopathology. Children with Lyme disease had significantly more cognitive and psychiatric disturbances. Cognitive deficits were still found after controlling for anxiety, depression, and fatigue. Lyme disease in children may be accompanied by long-term neuropsychiatric disturbances, resulting in psychosocial and academic impairments. Areas for further study are discussed.

Serum leptin levels increase following acute myocardial infarction.

Leptin is secreted into the circulation and communicates the peripheral nutritional status to specific hypothalamic centers. Recent studies suggest that leptin may be involved in the acute response to stress, and that its interaction with the hypothalamo-pituitary-adrenal axis and the inflammatory cytokine system may be of clinical importance. Since these systems are activated during acute myocardial infarction (AMI), we studied leptin and cortisol levels during hospitalization in 30 consecutive patients admitted for AMI. The results show that leptin reached its peak on the second day of hospitalization, with a 2-fold increase from its baseline level on admission (p < 0.02). On day 3, leptin levels declined, and were 46%, 9%, and 6% above baseline on days 3, 4 and 5, respectively. The mean cortisol level was elevated on day 1 and decreased toward normal levels thereafter (p < 0.001). The cortisol level did not correlate with leptin concentration throughout the study. These findings suggest that leptin may have a role in the metabolic changes taking place during the first days after an AMI.

The Liebowitz Social Anxiety Scale: a comparison of the psychometric properties of self-report and clinician-administered formats.

BACKGROUND: The clinician-administered version of the Liebowitz Social Anxiety Scale (LSAS-CA) is a commonly used assessment device for the evaluation of social anxiety disorder and has been shown to have strong psychometric characteristics. Because of its apparently straightforward rating format and potential savings in time and effort, interest in the use of the LSAS as a self-report (LSAS-SR) measure has increased, and the LSAS-SR has been used in a number of studies. However, the psychometric properties of the LSAS-SR have not been well established. METHODS: This study examined the psychometric properties of the LSAS-SR in comparison to the LSAS-CA in a sample of 99 individuals with a primary diagnosis of social anxiety disorder and 53 individuals with no current psychiatric disorder. RESULTS: There was little difference between the two versions of the LSAS on any scale or subscale score. Both forms were internally consistent and the subscale intercorrelations for the two forms were essentially identical. Correlations of each LSAS-SR index with its LSAS-CA counterpart were all highly significant. Finally, the convergent and discriminant validity of the two forms of the LSAS was shown to be strong. CONCLUSION: Results of this study suggest that the self-report version of the LSAS compares well to the clinician-administered version and may be validly employed in the assessment of social anxiety disorder.

Social anxiety disorder: recent findings in the areas of epidemiology, etiology, and treatment.

Social anxiety disorder is a common and chronic disorder that leads to substantial psychosocial impairment. The disorder occurs early in childhood, and is frequently comorbid with a variety of other psychiatric diagnoses like depression, other anxiety disorders, substance abuse, and eating disorders. Given these serious implications of social anxiety disorder, early effective treatment is extremely important. Pharmacotherapy, with a selective serotonin reuptake inhibitor, and cognitive behavioral therapy are the first choice of treatments for social anxiety disorder. This paper reviews recent findings on the epidemiology, etiology, and treatment for social anxiety disorder, and highlights areas where future research should be directed.

Open trial of nefazodone among Hispanics with major depression: efficacy, tolerability, and adherence issues.

The efficacy and tolerability of nefazodone in the treatment of major depression among Spanish-monolingual Hispanics was examined and compared to historical controls among English-speaking, predominantly non-Hispanic subjects. Fifty monolingual Hispanic outpatients with major depression and a HAM-D17 score > or = 18 were treated with nefazodone in a flexible-dose 8-week open-label protocol. Sixty-three percent of the intent-to-treat (ITT) sample with > or = 1 efficacy visit were considered responders according to CGI-I criteria, falling within the range of response rates (58-69%) reported in six prior nefazodone trials with non-Hispanic subjects. Significant improvement was found for the ITT and completer samples in HAM-D17, HAM-D28, and SCL-90 scores and in two measures of psychosocial functioning. Endpoint mean dose in the ITT sample was 379 mg/day (SD = 170), also within the range of previous trials (321-472 mg/day). Adverse effects were not elevated, with only dry mouth (8%) reported by > 6% of subjects. However, 42% of the sample dropped out of treatment before study termination, usually because of side effects or due to family or work difficulties, a higher rate than previously reported for nefazodone (21-33%). This open trial finds nefazodone to be an efficacious treatment for major depression among monolingual Hispanics, with comparable efficacy to previous controlled trials among non-Hispanic subjects. Double-blind studies are required to confirm this comparable efficacy. Mean endpoint doses and adverse effect rates similar to previous trials do not support the need for reduced doses of nefazodone among Hispanics. However, an elevated rate of treatment discontinuation threatens treatment efficacy among this population. Causes for this elevated rate require explanation, given the apparently unremarkable pattern of adverse effect reports.

Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles, social anxiety, and depression.

Despite their apparent implications for social functioning, adult attachment styles have never been specifically explored among persons with social anxiety disorder. In the current study, a cluster analysis of the Revised Adult Attachment Scale (N. L. Collins, 1996) revealed that 118 patients with social anxiety were best represented by anxious and secure attachment style clusters. Members of the anxious attachment cluster exhibited more severe social anxiety and avoidance, greater depression, greater impairment, and lower life satisfaction than members of the secure attachment cluster. This pattern was replicated in a separate sample of 56 patients and compared with the pattern found in 36 control participants. Social anxiety mediated the association between attachment insecurity and depression. Findings are discussed in the context of their relevance to the etiology, maintenance, and cognitive-behavioral treatment of social anxiety disorder.

An empirical approach to subtype identification in individuals with social phobia.

BACKGROUND: The present study used cluster analysis procedures to identify empirically subgroups of patients with social phobia in a large clinical sample. METHOD: The Liebowitz Social Anxiety Scale (LSAS) was administered to 382 patients from several studies of the treatment of social phobia. LSAS fear ratings were summed into four subscale scores (social interaction, public speaking, observation by others, eating and drinking in public) based on a previous factor analytical study of the LSAS. In order to produce a stable and robust solution, these factor scores were submitted to a two-stage clustering procedure consisting of an agglomerative-hierarchical clustering method followed by an iterative non-hierarchical clustering method. RESULTS: Three patient subgroups were identified based on their pattern of feared social situations on the LSAS. These groups were labelled: (1) pervasive social anxiety; (2) moderate social interaction anxiety; and (3) dominant public speaking anxiety. Clusters differed significantly on age and age of social phobia onset, as well as on measures of social anxiety, general anxiety and depressive symptomatology. Clusters also differed in the percentage of assigned patients who met criteria for the generalized subtype of social phobia and avoidant personality disorder. CONCLUSIONS: The results provide empirical support for the existence of three subgroups in a clinical sample of individuals with social phobia and contribute to the growing evidence for the heterogeneity of social phobia. Further study of the conceptual, clinical and aetiological significance of these subgroups is needed.

Symptom provocation alters behavioral ratings and brain electrical activity in obsessive-compulsive disorder: a preliminary study.

Regional brain activity was measured using quantitative electroencephalography (EEG) in six patients with obsessive-compulsive disorder (OCD) during live and imaginal exposure to feared contaminants. OCD symptoms increased significantly from baseline levels during live and imaginal exposures. However, live exposure provoked significantly more OCD symptoms than imaginal exposure. There was a significant change in the anterior-to-posterior scalp distribution of alpha power during live exposure. These preliminary results suggest that: (1) live exposure is more effective than imaginal exposure in altering behavioral and electrophysiological measures; and (2) live exposure is associated with regional EEG changes in OCD.

Ataque de nervios and history of childhood trauma.

OBJECTIVE: Ataque de nervios is a common, self-labeled Hispanic folk diagnosis. It typically describes episodic, dramatic outbursts of negative emotion in response to a stressor, sometimes involving destructive behavior. Dissociation and affective dysregulation during such episodes suggested a link to childhood trauma. We therefore assessed psychiatric diagnoses, history of ataque, and childhood trauma in treatment-seeking Hispanic outpatients (N = 70). Significantly more subjects with an anxiety or affective disorder plus ataque reported a history of physical abuse, sexual abuse, and/or or a substance-abusing caretaker than those with psychiatric disorder but no ataque. In some Hispanic individuals, ataque may represent a culturally sanctioned expression of extreme affect dysregulation associated with childhood trauma. Patients with ataque de nervios should receive a thorough traumatic history assessment.

Childhood trauma and dissociative symptoms in panic disorder.

OBJECTIVE: Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. The authors hypothesized that among individuals with a primary diagnosis of panic disorder, those experiencing depersonalization/derealization during panic attacks would be more likely to have a history of childhood trauma. METHOD: Rates of traumatic events were compared between panic disorder patients with (N=34) and without (N=40) prominent depersonalization/derealization during panic attacks. Symptom severity in the two groups was also examined. RESULTS: Contrary to the authors' hypothesis, no evidence was found that depersonalization/derealization during panic attacks was associated with childhood trauma. Minimal differences in severity of illness were found between patients with dissociative symptoms and those without such symptoms. CONCLUSIONS: This finding is consistent with a multifactorial model of dissociation. Factors other than childhood trauma and general psychopathology may underlie vulnerability to dissociative symptoms in panic disorder.

Low dopamine D(2) receptor binding potential in social phobia.

OBJECTIVE: This study compared dopamine D(2) receptor binding potential in patients with social phobia and healthy comparison subjects. METHOD: Dopamine D(2) receptor binding potential was assessed in 10 unmedicated subjects with generalized social phobia and no significant lifetime psychiatric comorbidity and 10 healthy comparison subjects matched for age and sex. Binding potential was measured in the striatum by using single photon emission computerized tomography and constant infusion of the D(2) receptor radiotracer [(123)I]iodobenzamide ([(123)I]IBZM). RESULTS: Mean D(2) receptor binding potential was significantly lower in the subjects with social phobia than in the comparison subjects. Within the social phobia group, there was a nonsignificant correlation of binding potential with the Liebowitz Social Anxiety Scale score. CONCLUSIONS: Generalized social phobia may be associated with low binding of [(123)I]IBZM to D(2) receptors in the striatum.

Disability and quality of life in pure and comorbid social phobia. Findings from a controlled study.

Social phobia is increasingly recognized as a prevalent and socially impairing mental disorder. However, little data is available regarding the general and disease-specific impairments and disabilities associated with social phobia. Furthermore, most studies have not controlled for the confounding effects of comorbid conditions. This study investigates: (a) the generic quality of life; (b) work productivity; and, (c) various other disorder-specific social impairments in current cases with pure (n = 65), comorbid (n = 51) and subthreshold (n = 34) DSM-IV social phobia as compared to controls with no social phobia (subjects with a history of herpes infections). Social phobia cases reported a mean illness duration of 22.9 years with onset in childhood or adolescence. Current quality of life, as assessed by the SF-36, was significantly reduced in all social phobia groups, particularly in the scales measuring vitality, general health, mental health, role limitations due to emotional health, and social functioning. Comorbid cases revealed more severe reductions than pure and subthreshold social phobics. Findings from the Liebowitz self-rated disability scale indicated that: (a) social phobia affects most areas of life, but in particular education, career, and romantic relationship; (b) the presence of past and current comorbid conditions increases the frequency and severity of disease-specific impairments; and, (c) subthreshold social phobia revealed slightly lower overall impairments than comorbid social phobics. Past-week work productivity of social phobics was significantly diminished as indicated by: (a) a three-fold higher rate of unemployed cases; (b) elevated rates of work hours missed due to social phobia problems; and (c) a reduced work performance. Overall, these findings underline that social phobia in our sample of adults, whether comorbid, subthreshold, or pure was a persisting and impairing condition, resulting in considerable subjective suffering and negative impact on work performance and social relationships. The current disabilities and impairments were usually less pronounced than in the past, presumably due to adaptive behaviors in life style of the respondents. Data also confirmed that social phobia is poorly recognized and rarely treated by the mental health system.

Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome.

UNLABELLED: To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitive-behavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment-free follow-up phases. EXPERIMENTAL DESIGN: Responders to an acute trial contrasting PZ and CBGT entered a six-month maintenance phase. Patients who continued to respond through the maintenance phase entered a six-month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study. PRINCIPAL OBSERVATIONS: PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment-free follow-up. There was a greater relapse among patients with generalized social phobia with phenelzine. CONCLUSIONS: PZ and cognitive-behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment-free follow-up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long-term efficacy of combined PZ and CBGT.