Effect of distraction and coping style on in vivo exposure for specific phobia of spiders.

Recent studies have generated mixed findings regarding the effects of distraction on exposure-based treatments. Results have also been inconsistent regarding the effects of monitoring and blunting coping styles on outcome. The present study attempted to integrate these two areas of research. We hypothesized that the effect of distraction on treatment outcome might depend on coping style. Specifically, we predicted that for blunters (i.e.. individuals who tend to avoid threat-related information), distraction would interfere with the effects of exposure. However, we predicted that distraction might benefit monitors (i.e., individuals who tend to seek out threat-related information). Sixty individuals with a specific phobia of spiders underwent a single, two-hour session of exposure treatment. During the first hour, half of the participants were distracted by listening to an audiotape and the other half underwent exposure without distraction. In the second hour, all participants underwent focused exposure. Based on measures of heart rate, subjective fear, and behavioral testing, participants improved after one hour of treatment, and improved further during the second hour. However, neither distraction, coping style, nor their interaction had a significant effect on outcome. The present study provides support for the benefits of behavioral treatment for specific phobias. However, our hypotheses regarding distraction and coping style were not confirmed.

Psychological features of subjects with idiopathic environmental intolerance.

OBJECTIVES: Idiopathic environmental intolerance (IEI) is associated with unexplained symptoms attributed to non-noxious levels of environmental substances. Clinically, some of the symptoms of IEI overlap with those of panic disorder (PD). We have recently reported a link between IEI and panic responses to a single inhalation of 35% carbon dioxide (CO(2)), a reliable panic induction challenge. This study assessed depression, stress, anxiety, and agoraphobic symptoms among IEI subjects from our previous study versus healthy controls. METHODS: Thirty-six IEI and 37 control subjects with no preexisting psychiatric history were compared on self-report psychological questionnaires. RESULTS: IEI subjects scored significantly higher than controls on the Agoraphobic Cognitions Questionnaire (ACQ), Depression Anxiety Stress Scales (DASS), and Mobility Inventory for Agoraphobia (MI) (Student's t, P<.05). CONCLUSIONS: IEI subjects represent a group with morbidity significantly higher than a control population but less than what would be expected for a clinical psychiatric population.

Clinical guidelines for the treatment of depressive disorders. VII. Comorbidity.

BACKGROUND: The Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments partnered to produce clinical guidelines for psychiatrists for the treatment of depressive disorders. METHODS: A standard guidelines development process was followed. Relevant literature was identified using a computerized Medline search supplemented by review of bibliographies. Operational criteria were used to rate the quality of scientific evidence, and the line of treatment recommendations included consensus clinical opinion. This section, on Axis I, Axis II, and Axis III comorbidity, is 1 of 7 articles that were drafted and reviewed by clinicians. Revised drafts underwent national and international expert peer review. RESULTS: Comorbid depression on Axis I is particularly prevalent in patients with anxiety disorders, substance use disorders, and eating disorders, but it also occurs in patients with schizophrenia, attention-deficit hyperactivity disorder (ADHD), and dementia. Depressive comorbidity has implications for assessment, management, and outcome. The relation between depression and personality disorders is complex. Patient with this comorbidity often require longer, more intense, and multimodal therapies. Depression is also prevalent in medical illnesses, requires careful diagnosis, and responds to standard antidepressant treatments. CONCLUSIONS: Comorbidity can influence the course and outcome of both associated conditions. Depression-specific psychotherapy and/or pharmacotherapy should be considered when comorbid depression is diagnosed.

Social anxiety in college students.

Individuals with social phobia often hold erroneous beliefs about the extent to which others experience symptoms of social anxiety and the ways in which others evaluate people who appear to be anxious. The purpose of this study was to: (a) provide normative data on the frequency with which individuals in a nonclinical sample experience particular symptoms of social anxiety (e.g., sweating, shaking, etc.); (b) to examine how the perception of anxiety in others influences participants' immediate impressions of various personal characteristics (e.g., intelligence, attractiveness, etc); and, (c) investigate the relationship between social anxiety and perceptions regarding others who appear to be anxious. Eighty-one undergraduate students completed self-report measures of social anxiety and social desirability, and then rated the degree to which their impressions of various personal characteristics were influenced when another individual was perceived to be anxious. Results suggested that the vast majority of individuals experience symptoms of anxiety in social situations from time to time. In addition, individuals who themselves reported elevated social anxiety were more likely than individuals less socially anxious to judge others who appear anxious to have less strength of character and to be less attractive and more compassionate compared to others who do not appear anxious. Clinical implications of these results are discussed.

Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study.

OBJECTIVE: The authors evaluated the efficacy, safety, and tolerability of sertraline, a selective serotonin reuptake inhibitor, in the treatment of generalized social phobia. METHOD: Adult outpatients with generalized social phobia (N=204) from 10 Canadian centers were randomly assigned to receive sertraline or placebo in a 2:1 ratio for a 20-week double-blind study following a 1-week, single-blind, placebo run-in. The initial dose of sertraline was 50 mg/day with increases of 50 mg/day every 3 weeks permitted after the fourth week of treatment (dosing was flexible up to a maximum of 200 mg/day). Primary efficacy assessments were the percentage of patients rated much or very much improved on the Clinical Global Impression (CGI) improvement item and the mean changes from baseline to study endpoint in total score on the social phobia subscale of the Marks Fear Questionnaire and total score on the Brief Social Phobia Scale. RESULTS: In intent-to-treat endpoint analyses of 203 of the patients, significantly more of the 134 patients given sertraline (N=71 [53%]) than of the 69 patients receiving placebo (N=20 [29%]) were considered responders according to their CGI improvement scores at the end of treatment. The mean reductions in the social phobia subscale of the Marks Fear Questionnaire and in the total score on the Brief Social Phobia Scale were 32.6% and 34.3% in the sertraline group and 10.8% and 18.6% in the placebo group, respectively. Analysis of covariance showed superiority of sertraline over placebo on all primary and secondary efficacy measures. Sertraline was well tolerated: 103 (76%) of the 135 sertraline-treated patients and 54 (78%) of the 69 placebo-treated patients completed the study. CONCLUSIONS: Sertraline is an effective treatment for patients with generalized social phobia.

Interpretations for anxiety symptoms in social phobia.

This study explored the ways in which people interpret visible physical symptoms of anxiety. A group of participants with social phobia (SP) and a nonclinical control (NCC) group completed either the Actor version or the Observer version of the Symptom Interpretation Scale (SIS), designed for the purposes of this study. The SIS asks participants to rate the extent to which each of eight interpretations is a likely explanation for a number of visible symptoms of anxiety. On the Actor version of the SIS, participants are asked to judge how their own anxiety symptoms are interpreted by others. On the Observer version of the SIS, participants are asked how they typically interpret anxiety symptoms that they notice in others. When participants were asked about anxiety symptoms that they themselves exhibit, people with social phobia were more likely than nonclinical controls to think that others interpreted these symptoms as being indicative of intense anxiety or a psychiatric condition and were less likely to think that others interpreted these symptoms as being indicative of a normal physical state. Data also suggested that people with social phobia have a more flexible cognitive style when asked to interpret anxiety symptoms exhibited by others than when asked about how others view their own anxiety symptoms. These findings are discussed in the context of recent psychological models of social anxiety and social phobia.

Prevention of relapse in generalized social phobia: results of a 24-week study in responders to 20 weeks of sertraline treatment.

The aim of this study was to evaluate the efficacy, tolerability, and effects on quality of life of sertraline, a selective serotonin reuptake inhibitor, in the prevention of relapse of generalized social phobia. Fifty adult outpatients with generalized social phobia who were rated much or very much improved on the Clinical Global Impression Scale of Improvement (CGI-I) after 20 weeks of sertraline treatment (50-200 mg/day) were randomly assigned in a one-to-one ratio to either continue double-blind treatment with sertraline or immediately switch to placebo for another 24 weeks. The initial 20-week study was placebo-controlled, and 15 responders to placebo also continued to receive double-blind placebo treatment in the continuation study. Eighty-eight percent of patients in the sertraline-continuation group and only 40% of patients in the placebo-switch and placebo-responder groups completed the study. In intent-to-treat endpoint analyses, 1 (4%) of 25 patients in the sertraline-continuation group and 9 (36%) of 25 patients in the placebo-switch group had relapsed at study endpoint (chi2 = 8.0, Fisher exact test, p = 0.01). The relative risk (hazards ratio) for relapse associated with placebo-switch relative to sertraline-continuation treatment was 10.2 (95% confidence interval, 1.3-80.7). Mean CGI-Severity, Marks Fear Questionnaire (MFQ) Social Phobia subscale, and Duke Brief Social Phobia Scale (BSPS) total scores were reduced by 0.07, 0.34, and 1.86 in the Sertraline-Continuation group and increased by 0.88, 4.09, and 5.99 in the Placebo-Switch group (all F > 5.3, p < 0.03), respectively. CGI-Severity, MFQ Social Phobia subscale, and BSPS scores also increased in the Placebo-Responder group. Discontinuations because of lack of efficacy were 4% in the sertraline-continuation group, 28% in the placebo-switch group (chi2 = 5.36, Fisher exact test, p = 0.049), relative to sertraline, and 27% in the placebo-responder group. Sertraline was effective in preventing relapse of generalized social phobia. Future research should assess whether improvements may be maintained or further increased by longer periods of treatment or through the addition of cognitive-behavioral techniques.

Treatment histories of patients with three anxiety disorders.

The current study sought to examine the extent to which empirically supported psychological and pharmacological treatments were used by individuals with panic disorder (n = 41), social phobia (n = 34), or obsessive compulsive disorder (n = 21). Participants were recruited from an anxiety disorders clinic and completed a questionnaire about previous treatment and contact with a variety of professionals. Results indicated that the types of pharmacological treatment received by patients were more often consistent with findings from the empirical literature than were the psychological treatments received by patients. Cognitive and behavioral treatments had been tried by fewer than half of participants (between 19 and 44% of participants). Results were fairly consistent across the anxiety disorders. Possible explanations for the discrepancy between the types of psychological treatments that have received empirical support and those that are typically provided to patients are provided.

Increased left posterior parietal-temporal cortex activation after D-fenfluramine in women with panic disorder.

It is unclear whether the functional changes found in panic disorder reflect disturbed physiology of particular neurotransmitters. One method of investigating altered neurotransmission is to assess regional brain activations in response to agonist challenges. D-Fenfluramine is a medication that induces neuronal release of serotonin. Using ¿15OH(2)O and positron emission tomography (PET), measurements of regional cerebral blood flow (rCBF) were done at t=-20, -5, +20 and +35 relative to the IV D-fenfluramine injection (t=0) in nine panic-disordered and 18 healthy subjects. Subjects were otherwise healthy, right-handed, non-smoking and not taking psychotropic medication. ¿15OH(2)O PET scans were assessed with Statistical Parametric Mapping using individual global cerebral blood flow as a covariate. Comparisons of the (baseline) first two scans between healthy and panic-disordered subjects showed a decreased rCBF in the left posterior parietal-superior temporal cortex in the patient group. Fenfluramine-induced increases as defined by the last two scans minus the first two scans were compared between groups and a significantly greater increase in the same left posterior parietal-superior temporal region was found in panic-disordered subjects. Consistent with this finding, differences between the last two scans (post-fenfluramine) of the healthy and panic-disordered subjects showed an increased rCBF in the left superior temporal cortex in panic-disordered subjects. Functional pathology in the left parietal-superior temporal cortex in panic disorder may be related to abnormal modulation by serotonin.

Is self-criticism unique for depression? A comparison with social phobia.

BACKGROUND: This study further examined the diagnostic specificity of the self-critical personality dimension, as measured by the Depressive Experiences Questionnaire (DEQ; Blatt et al., 1976. The Depressive Experiences Questionnaire. Yale University Press, New Haven). METHODS: Patients with major depression (n=26) were compared to social phobia patients (n=32). RESULTS: Depressed patients scored significantly higher on the DEQ Self-Criticism dimension. However, when current level of depressed mood was controlled for, self-criticism was not a significant predictor of diagnostic status. Further, the level of DEQ self-criticism reported by patients with social phobia was almost three times greater than the level reported in an earlier diagnostic specificity study with panic disorder patients [Bagby et al., 1992. Diagnostic specificity of the dependent and self-critical personality dimensions in major depression. J. Affect. Disord. 26, 59-64]. LIMITATIONS: Only one measure of self-criticism was used in this study, and the research design was cross-sectional rather than prospective. CONCLUSIONS: Self-criticism is not unique to major depression, and this personality dimension may be implicated in other forms of psychopathology [Blatt, 1991. A cognitive morphology of psychopathology. J. Nerv. Ment. Dis. 179, 449-458]. Some cognitive features believed to play an important role in depression may also be salient in persons with social phobia.

Carbon dioxide inhalation challenges in idiopathic environmental intolerance.

BACKGROUND: Idiopathic environmental intolerance (IEI) is associated with unexplained physical symptoms, which overlap considerably with those of panic disorder (PD). OBJECTIVE: This study tested the hypothesis that patients with symptoms to suggest IEI exhibit features of PD in response to nonnoxious environmental stimuli. METHODS: A single-blind, case-control 35% carbon dioxide inhalation challenge was conducted at a university-based occupational health unit with the use of standardized psychologic questionnaires involving 36 patients with IEI and 37 healthy control subjects. The main outcome measures included panic attack symptoms and scores on the Anxiety Sensitivity Index, a measure of panic-related anxiety. RESULTS: Patients with IEI scored significantly higher on the Anxiety Sensitivity Index than control subjects did (P <.05). Significantly more patients with IEI (71%) than control subjects (26%) fulfilled panic attack criteria after carbon dioxide (P <.001). Physiologic responses to the challenge were not significantly different between groups. CONCLUSIONS: Results suggest that, similar to patients with PD, patients with IEI display high anxiety sensitivity and in response to carbon dioxide inhalation tend to experience heightened anxiety and panic attacks.

Negative priming for obsessive-compulsive checkers and noncheckers.

Negative priming--the slowing of a response to an item that was recently ignored--was investigated in three groups: obsessive-compulsive disorder (OCD) checkers, OCD noncheckers, and nonclinical control participants. All groups performed both a standard negative priming task, selecting targets based on a perceptual feature (i.e., color), and a modified negative priming task, selecting targets based on a semantic feature (i.e., referent size). All three groups demonstrated significant negative priming in both tasks, although the negative priming was much larger in the novel, semantic task than in the common, perceptual one. The findings suggest that patients with OCD do not demonstrate impairments in negative priming, contrary to earlier claims (Enright & Beech, 1990, 1993a, 1993b; Enright, Beech, & Claridge, 1995).

Symptom structure in obsessive-compulsive disorder: a confirmatory factor-analytic study.

Although obsessive-compulsive disorder (OCD) has long been a unitary diagnosis, there is much recent interest in its potential heterogeneity, as manifested by symptom subgroups. This study evaluated existing models of symptom structure in a sample of 203 individuals with OCD. Using confirmatory factor analysis, we examined the ability of each model to account for two levels of data: a priori symptom groupings (second-order) and individual symptoms, identified by the Yale-Brown Obsessive Compulsive Scale symptom checklist. Four models were examined: a single-factor, a two-factor (i.e., obsessions and compulsions), and two multidimensional models, comprising three and four factors. Adequate fit was found solely for the four-factor model--specifying obsessions/checking, symmetry/ordering, contamination/cleaning, and hoarding--but only at the second-order level; it did not account for relationships among discrete symptoms. Parameter estimates showed within-factor heterogeneity, as well as overlap between factors, most notably the two representing checking and contamination-related symptoms. The implications of these findings are discussed. Results provide evidence for the multidimensionality of OCD symptoms, but suggest that a comprehensive model has yet to be identified. They also point to the inadequacy of groupings based solely upon overt behavioural similarities (e.g., 'checking'). Recommendations are made for future research.

Psychometric properties of the frost multidimensional perfectionism scale in a clinical anxiety disorders sample.

The purpose of this study was to examine the factor structure of the Frost Multidimensional Perfectionism Scale (MPS-F; Frost, Marten, Laharte, & Rosenblate, 1990). Although perfectionism is thought to contribute to the development of psychopathology and the MPS-F is gaining popularity for use in assessing perfectionism in clinical samples, to date the factor structure has not been examined in a clinical sample. Three hundred and twenty-two individuals diagnosed with an anxiety disorder using the SCID for DSM-IV and 49 nonclinical controls completed the MPS-F as well as a measure of perfectionism (MPS-H) developed by Hewitt and Flett ( 1991 ). Analyses suggested that the MPS-F has similar psychometric properties in clinical samples to those in nonclinical samples, and factors very similar to those observed by Frost et al. (1990) could be extracted. A 3-factor solution appeared more appropriate for statistical reasons, and the 3 scales based on these factors distinguished among diagnostic groups in a manner similar to scales based on the 6-factor solution in past research. Results were discussed in terms of the potential utility of a 3-factor solution and in terms of the general construct of perfectionism and the distinction between nonpathological high performance standards and neurotic perfectionism.

Cognitive features of social phobia.

New cognitive models of social phobia have been developed based, in part, on a growing number of studies suggesting that people with social phobia process information related to social threat differently than people who are not socially anxious and, in some cases, differently than individuals with other anxiety disorders. In addition to providing an overview of recent models of social phobia, this paper reviews the research literature to date on the following aspects of cognition in social phobia: attention, memory, attributions and appraisals, imagery and perspective, and perfectionism.

Investigation of dopamine system genes in obsessive-compulsive disorder.

Evidence from anatomical, pharmacological, and animal studies on the involvement of the dopamine system in obsessive-compulsive disorder (OCD) is mounting. This, along with evidence for a genetic diathesis provided by family and twin studies, prompted us to conduct genetic association studies of dopamine system genes in OCD. We genotyped OCD patients (n > 100) and matched controls for four loci: (1) a 40-base-pair repeat in the dopamine transporter gene; (2) the TaqIA polymorphism and the serine/cysteine variation in the D2 dopamine receptor gene; (3) an MscI polymorphism in the D3 dopamine receptor gene; and (4) a 48-base-pair repeat in the D4 dopamine receptor gene. Significant differences in allele frequencies were found between patients and controls for the D4 receptor gene, although replication is required with family-based controls before any conclusions can be entertained. This study represents the first comprehensive assessment of the roles of dopamine system genes in OCD.

Dimensions of perfectionism across the anxiety disorders.

To explore the role of perfectionism across anxiety disorders, 175 patients with either panic disorder (PD), obsessive compulsive disorder (OCD), social phobia, or specific phobia, as well as 49 nonclinical volunteers, completed two measures [Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R., (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449-468; Hewitt, P. L., & Flett, G. L., (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456-470.] that assess a total of nine different dimensions of perfectionism. Relative to the other groups, social phobia was associated with greater concern about mistakes (CM), doubts about actions (DA), and parental criticism (PC) on one measure and more socially prescribed perfectionism (SP) on the other measure. OCD was associated with elevated DA scores relative to the other groups. PD was associated with moderate elevations on the CM and DA subscales. The remaining dimensions of perfectionism failed to differentiate among groups. The clinical implications of these findings are discussed.

The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.

Although the State-Trait Anxiety Inventory (STAI) is a popular measure of anxiety, some previous research suggests that the trait scale may assess depression, as well as anxiety. The factor structure of the trait items was initially examined using factor analytic procedures. Confirmatory factor analytic methods suggested that a hierarchical solution best fit the data, with one overall factor and two lower order factors. The lower order subscales created from this factor solution were examined in a sample of individuals diagnosed with an anxiety disorder. Overall, the results offered good support for the notion that the trait scale of the STAI assesses depression, as well as anxiety. One set of items appeared to assess anxiety and worry, whereas the other assessed sadness and self-deprecation. The two subscales correlated differentially with other measures of anxiety and depression in a manner that was consistent with their content. Finally, diagnostic groups and controls could be meaningfully distinguished on these subscales. Implications for the use of this measure are discussed.

A comparison of social phobia outcome measures in cognitive-behavioral group therapy.

This article reports the effects of a cognitive-behavioral group therapy program for social phobia (N = 25 outpatients) on several psychometric measures. It is the first study to simultaneously examine three newer and promising social-phobia measures: the Social Phobia Scale (SPS) and accompanying Social Interaction Anxiety Scale (SIAS), the Social Phobia and Anxiety Inventory (SPAI), and the Liebowitz Social Anxiety Scale (LSAS). More traditional measures of social phobia were also included, along with measures of anxious and depressed mood. Among the newer scales, the SPAI and SPS/SIAS were found to have good sensitivity to treatment. There was limited support for the LSAS. Intercorrelations among all of the outcome measures are presented both before and after cognitive-behavioral therapy. Strengths and weakness of each of the newer social-phobia measures are discussed.