The cortisol awakening response predicts major depression: predictive stability over a 4-year follow-up and effect of depression history.

BACKGROUND: The cortisol awakening response (CAR) has been shown to predict major depressive episodes (MDEs) over a 1-year period. It is unknown whether this effect: (a) is stable over longer periods of time; (b) is independent of prospective stressful life events; and (c) differentially predicts first onsets or recurrences of MDEs. METHOD: A total of 270 older adolescents (mean age 17.06 years at cortisol measurement) from the larger prospective Northwestern-UCLA Youth Emotion Project completed baseline diagnostic and life stress interviews, questionnaires, and a 3-day cortisol sampling protocol measuring the CAR and diurnal rhythm, as well as up to four annual follow-up interviews of diagnoses and life stress. RESULTS: Non-proportional person-month survival analyses revealed that higher levels of the baseline CAR significantly predict MDEs for 2.5 years following cortisol measurement. However, the strength of prediction of depressive episodes significantly decays over time, with the CAR no longer significantly predicting MDEs after 2.5 years. Elevations in the CAR did not significantly increase vulnerability to prospective major stressful life events. They did, however, predict MDE recurrences more strongly than first onsets. CONCLUSIONS: These results suggest that a high CAR represents a time-limited risk factor for onsets of MDEs, which increases risk for depression independently of future major stressful life events. Possible explanations for the stronger effect of the CAR for predicting MDE recurrences than first onsets are discussed.

Neuroticism as a common dimension in the internalizing disorders.

BACKGROUND: Several theories have posited a common internalizing factor to help account for the relationship between mood and anxiety disorders. These disorders are often co-morbid and strongly covary. Other theories and data suggest that personality traits may account, at least in part, for co-morbidity between depression and anxiety. The present study examined the relationship between neuroticism and an internalizing dimension common to mood and anxiety disorders. METHOD: A sample of ethnically diverse adolescents (n=621) completed self-report and peer-report measures of neuroticism. Participants also completed the Structured Clinical Interview for DSM-IV (SCID). RESULTS: Structural equation modeling showed that a single internalizing factor was common to lifetime diagnosis of mood and anxiety disorders, and this internalizing factor was strongly correlated with neuroticism. Neuroticism had a stronger correlation with an internalizing factor (r=0.98) than with a substance use factor (r=0.29). Therefore, neuroticism showed both convergent and discriminant validity. CONCLUSIONS: These results provide further evidence that neuroticism is a necessary factor in structural theories of mood and anxiety disorders. In this study, the correlation between internalizing psychopathology and neuroticism approached 1.0, suggesting that neuroticism may be the core of internalizing psychopathology. Future studies are needed to examine this possibility in other populations, and to replicate our findings.

Anxiety sensitivity, panic, and depressed mood: a reanalysis teasing apart the contributions of the two levels in the hierarchial structure of the Anxiety Sensitivity Index.

Anxiety sensitivity (AS) has been defined as the fear of anxiety and anxiety-related sensations, and evidence suggests that AS plays an important role in the psychopathology of panic. It is entirely unclear whether the relation between AS and panic should be attributed to one (or more) of the AS group factors, the general AS factor, or to factors at both levels of the AS hierarchy. The authors reanalyzed data presented earlier by R. M. Rapee, T. A. Brown, M. A. Antony, and D. H. Barlow (1992) to tease apart the contributions of the different levels of the AS hierarchy to fear responses to hyperventilation and 5.5% carbon dioxide challenges. The results demonstrated that AS-Physical Concerns is the only one of the three AS group factors that contributes to relations with fear responses to these two challenges. However, AS-Mental Incapacitation Concerns had a stronger positive linear association with depressed mood than did AS-Physical Concerns.

The structure and correlates of anxiety sensitivity in older adults.

Anxiety sensitivity (AS) has been defined as the fear of symptoms of anxiety and panic, and is most frequently assessed with the Anxiety Sensitivity Index (Peterson & Reiss, 1987). To investigate the nature and structure of AS in an older sample, data were collected from a sample of 322 adults aged 65 to 97, with mean age 75. Confirmatory factor analysis indicated a hierarchical structure with three group factors (physical concerns, mental incapacitation concerns, and social concerns), as well as a general factor, consistent with previous investigations. Results suggest that the nature and structure of the AS trait in older adults are highly similar to those of younger adults.

Individual differences in the acquisition of affectively valenced associations.

Two studies were conducted to test the predictions derived from the behavioral activation system and behavioral inhibition system theory of personality that trait anxiety is positively related to the speed of acquisition of punishment expectancies and impulsivity is positively related to the speed of acquisition of reward expectancies. Both studies used a standard approach-avoidance discrimination task with self-report measures of expectancies. Both studies found support for the hypothesized relation between trait and acquisition of punishment expectancies but not for the hypothesized relation between impulsivity and acquisition of reward expectancies. Study 2 suggested that the relation between trait anxiety and punishment expectancy is affected by the type of incentive and the type of trait anxiety measure used. The results suggest that highly trait anxious individuals are more susceptible to developing new sources of anxiety than others.

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents.

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.

Discriminating between generalized anxiety disorder and anxiety disorder not otherwise specified in a Hispanic population: is it only a matter of worry?

One hundred and two Hispanic persons who presented for treatment at a specialized anxiety disorders clinic were evaluated at intake using the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo and Barlow [1988] Albany: Center for Stress and Anxiety Disorders, State University of New York at Albany). Results indicated that 14% of these patients suffered from anxiety and/or affective disorders that were not adequately captured by our current diagnostic system. Given that the majority of these cases were characterized by predominantly anxious features, further investigation was undertaken to determine the degree of overlap between these patients (anxiety disorder, not otherwise specified; NOS) and those with generalized anxiety disorder (GAD). The two groups differed only with regard to the number of excessive worries they reported and not in terms of somatic symptomatology, psychosocial stressors, or demographic variables. These data suggest that excessive worry may be a discriminating factor between the GAD and NOS groups, providing support for the notion of GAD as a disorder of chromic worry. Future research is needed to tease apart the relative influences of culture and socioeconomic status on our findings.

Sexual victimization, generalized perception of control, and posttraumatic stress disorder symptom severity.

We examined the relations among various characteristics of sexual victimization, posttraumatic stress disorder (PTSD) symptom severity, and generalized perception of control. Our main focus lay in testing three predictions derived from the animal model of PTSD articulated by Foa, Zinbarg, and Olasov-Rothbaum (1992) based on the effects of uncontrollable and/or unpredictable aversive events. A sample of 117 female undergraduates participated and completed self-report measures of past experience with child sexual abuse, adult sexual victimization, PTSD symptom severity, and locus of control. The results showed that child sexual abuse experienced on multiple occasions was associated with diminished generalized perception of control and that diminished generalized perception of control is associated with greater PTSD symptom severity following adult sexual victimization when experienced on a single occasion or involving force. These results provide partial support for the uncontrollability/unpredictability model of PTSD. Further research is necessary, however, to firmly establish the direction of causality involved in these associations.

Structure of anxiety and the anxiety disorders: a hierarchical model.

The authors used a semistructured clinical interview and a self-report battery of questionnaires to measure key features of the anxiety disorders in a large sample of patients seeking treatment at an outpatient anxiety disorders clinic and in a no mental disorder group. Results were consistent with hierarchical models of anxiety and the anxiety disorders such as the model implicit in American Psychiatric Association (1987, 1994) and trait models positing a trait diathesis common to all the anxiety disorders. A higher order general factor differentiated each of the patient groups from the no mental disorder group. Several lower order factors provided the basis for differentiation among the patient groups. Conclusions regarding the degree to which models predicting a hierarchical structure of anxiety and the anxiety disorders are empirically supported must await replication of these results with additional samples.

Subsyndromal ("mixed") anxiety--depression in primary care.

OBJECTIVE: To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses. DESIGN: Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff. SETTING: Five primary care sites in the United States, France, and Australia. PATIENT: Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up. METHODS: Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers. RESULTS: After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders. CONCLUSION: The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment.

The DSM-IV field trial for mixed anxiety-depression.

OBJECTIVE: This field trial was designed to answer four questions. First, are patients presenting with anxious or depressed symptoms that are associated with significant impairment but do not meet DSM-III-R definitional thresholds for axis I anxiety or mood disorders? Second, is the impairment experienced by these patients simply the consequence of the severity of their medical conditions? Third, what percent of these patients present with depressive symptoms only, anxious symptoms only, and a mixture of both? Fourth, how should the operational criteria for the syndrome(s) presented by these patients be defined? METHOD: A total of 666 patients from five primary care medical sites and two outpatient mental health sites were administered a semistructured psychiatric interview. RESULTS: Patients presenting with affective symptoms that did not meet definitional thresholds for DSM-III-R axis I disorders were at least as common as patients with several of the already established anxiety and mood disorders in each of the seven sites, and their disorders were associated with significant distress or impairment. A nonspecific pattern of anxious and depressed symptoms was the modal presentation among these patients with currently subdefinitional threshold disorders, and they could be significantly differentiated in terms of current symptoms from patients presenting with a principal diagnosis of generalized anxiety disorder, major depressive episode, or panic disorder with agoraphobia. CONCLUSIONS: The authors recommend that a mixed anxiety-depression category be included in the DSM-IV appendix for proposed diagnostic categories that need further study. A criteria set is proposed.

Information processing and classical conditioning: implications for exposure therapy and the integration of cognitive therapy and behavior therapy.

This article reviews Wagner's standard operating procedures (SOP) model, an information processing model of conditioning, and some of its supporting evidence. The implications of this model for behavior therapy are explored. Applying the SOP model to the anxiety reduction technique of exposure, it is predicted that: (1) rehearsal and attention-focusing should facilitate whereas distraction should attenuate the long-term benefits of exposure; and (2) successful exposure therapy should be associated with a demonstrable allocation of cognitive processing resources and indications of enhanced elaborative processing of the feared stimuli. At a more general level, the SOP model may provide a bridge between traditional behavior therapy techniques and the principles that underly cognitive therapy. That is, the SOP model suggests that even those behavior therapy techniques which represent the most straightforward applications of conditioning procedures can be seen as being mediated by information processing mechanisms.

Uncontrollability and unpredictability in post-traumatic stress disorder: an animal model.

The disturbances observed in animals subjected to unpredictable and uncontrollable aversive events resemble post-traumatic stress disorder (PTSD) symptoms and thus may constitute an animal model of this disorder. It is argued that the similarity between animals' symptoms and those of trauma victims may reflect common etiological factors. Relevant experiments in which animals exhibit generalized fear and arousal, discrete fear of a conditioned stimulus (CS), analgesia, and avoidance are reviewed with the view that these manifestations may be analogous to the PTSD symptom clusters of persistent arousal, reexperiencing, numbing, and avoidance, respectively. Finally, animal paradigms are suggested to test the validity of the model and specific hypotheses are derived from the animal literature regarding trauma variables that are predictive of particular PTSD symptom clusters.

Personality and conditioning: a test of four models.

Four experiments were conducted to test hypotheses derived from 4 alternative models of individual differences in instrumental conditioning. A standard go--no-go discrimination learning task was used in each of the 4 experiments. The results indicate that individual differences in performance of this discrimination are more consistently and strongly associated with impulsivity and anxiety than with extraversion and neuroticism. In each of the experiments, high anxiety hindered the learning of a go--no-go discrimination more among high impulsive Ss than among low impulsive Ss, and in 2 of the experiments high anxiety actually facilitated learning among low impulsive Ss. These findings are incompatible with Eysenck's and Gray's hypotheses regarding extraversion but are not inconsistent with Newman's. Aspects of these results do support Spence's and Gray's models of anxiety and instrumental conditioning. However, both of these models were contradicted by other trends in the data. A modification of Gray's model of impulsivity and anxiety that emphasizes the role of expectancies was proposed to fit these data.