The reliability and validity of the Panic Disorder Self-Report: A new diagnostic screening measure of panic disorder

Psychotherapy utilization by United States college students

Objective: We studied current psychotherapy utilization rates among college students with mental health problems and identified characteristics associated with differential utilization. Participants: Nationwide online survey of students screening positive for at least one clinical mental health problem (N = 18,435). Methods: Rates and correlates of psychotherapy utilization were analyzed descriptively and with logistic regression. Results: Sample-wide, 19% reported receiving psychotherapy. Being male (vs. female), being Asian, Black or African American, or Multiracial (vs. White), greater financial difficulty, lower parent education, lower year in school, and attending a public (vs. private) institution were associated with lower utilization. Holding a gender minority (vs. female) identity and holding a sexual minority (vs. heterosexual) identity were associated with higher utilization. Utilization fell from Fall 2019 to Spring 2020, early during the COVID-19 pandemic, and subsequently rebounded. Conclusions: This study estimates current psychotherapy utilization among students with mental health problems and identifies possibly underserved populations.

The relationship of race, ethnicity, gender identity, sex assigned at birth, sexual orientation, parental education, financial hardship and comorbid mental disorders with quality of life in college students with anxiety, depression or eating disorders

BACKGROUND

Previous studies showed that comorbidity and demographic factors added to burden on health-related quality of life (HRQoL). Only one study explored the relationship between HRQoL and comorbidity in college students with mental disorders, leaving generalizability of findings uncertain. Less is known about the association of demographics on HRQoL. This study investigated HRQoL based on demographics and comorbidity among college students with mental disorders.

METHODS

Participants were students (N = 5535) across 26 U.S. colleges and universities who met criteria for depression, generalized anxiety, panic, social anxiety, post-traumatic stress, or eating disorders based on self-report measures. ANOVA and linear regressions were conducted.

RESULTS

Overall, female, minoritized (gender, sexual orientation, race, or ethnicity), and lower socioeconomic status students reported lower HRQoL than male, heterosexual, White, non-Hispanic, and higher socioeconomic status peers. After accounting for comorbidity, differences in physical HRQoL based on sex assigned at birth and gender were no longer significant. For mental HRQoL, only gender and sexual orientation remained significant. A greater number of comorbidities was associated with lower HRQoL regardless of demographic group.

LIMITATIONS

The non-experimental design limits causal inference. The study focused on univariable associations without examining potential interactions between demographic factors. Future research should explore structural factors like discrimination.

CONCLUSION

Results suggested that increased comorbidities placed an additional burden on HRQoL and that certain demographic groups were more vulnerable to HRQoL impairment among students with mental disorders. Findings suggest the need for prevention of disorders and their comorbidity and implementing tailored interventions for specific student subgroups with increased vulnerability.

Machine learning and Bayesian network analyses identifies associations with insomnia in a national sample of 31,285 treatment-seeking college students

BACKGROUND

A better understanding of the relationships between insomnia and anxiety, mood, eating, and alcohol-use disorders is needed given its prevalence among young adults. Supervised machine learning provides the ability to evaluate which mental disorder is most associated with heightened insomnia among U.S. college students. Combined with Bayesian network analysis, probable directional relationships between insomnia and interacting symptoms may be illuminated.

METHODS

The current exploratory analyses utilized a national sample of college students across 26 U.S. colleges and universities collected during population-level screening before entering a randomized controlled trial. We used a 4-step statistical approach: (1) at the disorder level, an elastic net regularization model examined the relative importance of the association between insomnia and 7 mental disorders (major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder, anorexia nervosa, and alcohol use disorder); (2) This model was evaluated within a hold-out sample. (3) at the symptom level, a completed partially directed acyclic graph (CPDAG) was computed via a Bayesian hill-climbing algorithm to estimate potential directionality among insomnia and its most associated disorder [based on SHAP (SHapley Additive exPlanations) values)]; (4) the CPDAG was then tested for generalizability by assessing (in)equality within a hold-out sample using structural hamming distance (SHD).

RESULTS

Of 31,285 participants, 20,597 were women (65.8%); mean (standard deviation) age was 22.96 (4.52) years. The elastic net model demonstrated clinical significance in predicting insomnia severity in the training sample [R2 = .44 (.01); RMSE = 5.00 (0.08)], with comparable performance in the hold-out sample (R2 = .33; RMSE = 5.47). SHAP values indicated that the presence of any mental disorder was associated with higher insomnia scores, with major depressive disorder as the most important disorder associated with heightened insomnia (mean |SHAP|= 3.18). The training CPDAG and hold-out CPDAG (SHD = 7) suggested depression symptoms presupposed insomnia with depressed mood, fatigue, and self-esteem as key parent nodes.

CONCLUSION

These findings provide insights into the associations between insomnia and mental disorders among college students and warrant further investigation into the potential direction of causality between insomnia and depression.

TRIAL REGISTRATION

Trial was registered on the National Institute of Health RePORTER website (R01MH115128 || 23/08/2018).

Internalizing psychopathology and its links to suicidal ideation, dysfunctional attitudes, and help-seeking readiness in a national sample of college students

BACKGROUND

Recent evidence suggests that multiple emotional disorders may be better assessed using dimensional models of psychopathology. The current study utilized a cross-sectional population survey of college students (N = 8613 participants) to examine the extent to which broad psychopathology factors accounted for specific associations between emotional problems and clinical and behavioral validators: suicidality, dysfunctional attitudes, and treatment seeking.

METHODS

Confirmatory factor models were estimated to identify the best structure of psychopathology. Models were then estimated to examine the broad and specific associations between each psychopathology indicator and the clinical and behavioral validators.

RESULTS

The hierarchical model of psychopathology with internalizing problems at the top, fear, and distress at the second level, and five specific symptom dimensions at the third level evidenced the best fit. The associations between symptom indicators of psychopathology and clinical and behavioral validators were relatively small and inconsistent. Instead, much of the association between clinical and behavioral validators and emotional problems operated at a higher-order level.

LIMITATIONS

The cross-sectional nature of the survey precludes the ability to make conclusions regarding causality.

CONCLUSIONS

Researchers should focus on investigating the shared or common components across emotional disorders, particularly concerning individuals presenting with higher rates of suicidal ideation dysfunctional attitudes, and help-seeking behavior. Using higher-order dimensions of psychopathology could simplify the complex presentation of multiple co-occurring disorders and suggest valid constructs for future investigations.

Machine Learning and Bayesian Network Analyses Identifies Psychiatric Disorders and Symptom Associations with Insomnia in a national sample of 31,285 Treatment-Seeking College Students

Background

A better understanding of the structure of relations among insomnia and anxiety, mood, eating, and alcohol-use disorders is needed, given its prevalence among young adults. Supervised machine learning provides the ability to evaluate the discriminative accuracy of psychiatric disorders associated with insomnia. Combined with Bayesian network analysis, the directionality between symptoms and their associations may be illuminated.

Methods

The current exploratory analyses utilized a national sample of college students across 26 U.S. colleges and universities collected during population-level screening before entering a randomized controlled trial. Firstly, an elastic net regularization model was trained to predict, via repeated 10-fold cross-validation, which psychiatric disorders were associated with insomnia severity. Seven disorders were included: major depressive disorder, generalized anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder, anorexia nervosa, and alcohol use disorder. Secondly, using a Bayesian network approach, completed partially directed acyclic graphs (CPDAG) built on training and holdout samples were computed via a Bayesian hill-climbing algorithm to determine symptom-level interactions of disorders most associated with insomnia [based on SHAP (SHapley Additive exPlanations) values)] and were evaluated for stability across networks.

Results

Of 31,285 participants, 20,597 were women (65.8%); mean (standard deviation) age was 22.96 (4.52) years. The elastic net model demonstrated clinical significance in predicting insomnia severity in the training sample [R2 = .449 (.016); RMSE = 5.00 [.081]), with comparable performance in accounting for variance explained in the holdout sample [R2 = .33; RMSE = 5.47). SHAP indicated the presence of any psychiatric disorder was associated with higher insomnia severity, with major depressive disorder demonstrated to be the most associated disorder. CPDAGs showed excellent fit in the holdout sample and suggested that depressed mood, fatigue, and self-esteem were the most important depression symptoms that presupposed insomnia.

Conclusion

These findings offer insights into associations between psychiatric disorders and insomnia among college students and encourage future investigation into the potential direction of causality between insomnia and major depressive disorder.

Trial registration

Trial may be found on the National Institute of Health RePORTER website: Project Number: R01MH115128-05.

Preferred treatment focus among college students with eating disorders and comorbid mental health problems in a digital cognitive-behavioral guided self-help program

OBJECTIVE

To examine the mental health problems that college students with eating disorders (EDs) and comorbid depression and/or anxiety disorders preferred to target first in a digital treatment program and explore correlates of preferred treatment focus.

METHODS

Four hundred and eighty nine college student users of a digital cognitive-behavioral guided self-help program targeting common mental health problems (76.7% female, Mage  = 20.4 ± 4.4, 64.8% White) screened positive for an ED and ≥one other clinical mental health problem (i.e., depression, generalized anxiety disorder, social phobia, and/or panic disorder). Students also reported on insomnia, post-traumatic stress, alcohol use, and suicide risk. Before treatment, they indicated the mental health problem that they preferred to target first in treatment. Preferred treatment focus was characterized by diagnostic profile (i.e., ED + Depression, ED + Anxiety, ED + Depression + Anxiety), symptom severity, and demographics.

RESULTS

58% of students with ED + Anxiety, 47% of those with ED + Depression, and 27% of those with ED + Depression + Anxiety chose to target EDs first. Across diagnostic profiles, those who chose to target EDs first had more severe ED symptoms than those who chose to target anxiety or depression (ps < .05). Among students with ED + Depression + Anxiety, those who chose to target EDs first had lower depression symptoms than those who chose to target depression, lower generalized anxiety than those who chose to target anxiety, and lower suicidality than those who chose to target anxiety or depression (ps < .01).

CONCLUSIONS

Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles. Research should explore specific symptom presentations associated with preferred treatment focus.

PUBLIC SIGNIFICANCE

Findings indicate that a sizable percentage of college students with depression/anxiety who also have EDs prefer to target EDs first in treatment, highlighting the importance of increasing availability of ED interventions to college students. Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles, and preference to target EDs was associated with greater ED psychopathology across diagnostic profiles.

Cognitive behavioural techniques reduce exercise anxiety and improve adherence to a resistance training program for people with anxiety-related disorders: A randomized controlled trial

Exercise is a cost-efficient alternative to other interventions for anxiety-related disorders (ARDs; e.g., psychotherapy, pharmaceutical) that is also associated with health benefits. Several exercise modalities, including resistance training (RT), have demonstrated efficacy at reducing symptoms of ARDs; however, there are challenges associated with effectively implementing such protocols, most notably, exercise avoidance or early discontinuation. Researchers have identified exercise anxiety as a contributor to exercise avoidance for people with ARDs. Exercise-based interventions for people with ARDs may need to include strategies for helping these individuals cope with exercise anxiety to facilitate long-term exercise engagement; however, research in this area is lacking. The primary purpose of this randomized controlled trial (RCT) was to examine the effects of combining cognitive behavioural techniques (CBT) with a RT program on changes in exercise anxiety, exercise frequency, disorder-specific anxiety symptoms, and physical activity for people with ARDs. A secondary purpose was to explore group differences in exercise motivation and exercise self-efficacy across time. A total of 59 physically inactive individuals with ARDs were randomized into either RT + CBT, RT, or waitlist (WL). Primary measures were assessed at baseline, weekly during the 4-week active phase, and at 1-week, 1-month, and 3-month follow-ups. Findings indicate both RT and RT + CBT can reduce exercise anxiety; however, the addition of CBT techniques may help facilitate improvements in exercise self-efficacy, reductions in disorder-specific anxiety, and increases in long-term exercise behaviour and vigorous physical activity. These techniques may be useful for researchers and clinicians alike in supporting individuals with ARDs interested in using exercise to cope with elevated anxiety.

A Hierarchical Taxonomy of Psychopathology (HiTOP) Primer for Mental Health Researchers

Mental health research is at an important crossroads as the field seeks more reliable and valid phenotypes to study. Dimensional approaches to quantifying mental illness operate outside the confines of traditional categorical diagnoses, and they are gaining traction as a way to advance research on the causes and consequences of mental illness. The Hierarchical Taxonomy of Psychopathology (HiTOP) is a leading dimensional research paradigm that synthesizes decades of data on the major dimensions of psychological disorders. In this article, we demonstrate how to use the HiTOP model to formulate and test research questions through a series of tutorials. To boost accessibility, data and annotated code for each tutorial are included at OSF (https://osf.io/8myzw). After presenting the tutorials, we outline how investigators can use these ideas and tools to generate new insights in their own substantive research programs.

Characterizing eating disorder diagnosis and related outcomes by sexual orientation and gender identity in a national sample of college students

OBJECTIVE

In a national sample of college students, the current study aimed to: 1) examine differences in probable diagnoses of EDs (i.e., anorexia nervosa (AN), clinical/subthreshold bulimia nervosa (BN), or binge eating disorder (BED)) and weight and shape concerns by sexual orientation and gender identity, and 2) examine differences in ED chronicity and probable comorbid psychiatric diagnoses by sexual orientation and gender identity.

METHOD

Students across nine U.S. universities completed an online screener for DSM-5 clinical or subthreshold ED diagnoses, comorbid depression and anxiety disorders, and self-reported ED chronicity. Self-reported sexual orientation and gender identity were also collected. Tukey-corrected logistic and linear regressions examined differences in outcomes separately by sexual orientation and gender identity, adjusting for age, race, and ethnicity.

RESULTS

A total of 8,531 students (24% sexually diverse (SD); 2.7% gender diverse (GD)) were studied. Students who identified as bisexual or other sexual orientation reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to heterosexual students. Cisgender female students and GD students reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to cisgender male students. Some SD students and GD students who met criteria for probable EDs were also more likely to report chronic ED symptoms and probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively.

DISCUSSION

Some SGD students may be at heightened risk for EDs, highlighting the need to identify mechanisms that contribute to disparities.

College Mental Health Before and During the COVID-19 Pandemic: Results From a Nationwide Survey

Background

The COVID-19 pandemic could affect college students' mental health. We examined screening rates for psychological disorders before and during the pandemic.

Methods

Undergraduates were surveyed before (n = 3643) or during the pandemic (n = 4970). Logistic regression adjusting for participant demographics was conducted.

Results

Frequencies of depression [OR 1.32, 95% CI (1.17, 1.48)], alcohol use disorder [OR 1.70, 95% CI (1.50, 1.93)], bulimia nervosa/binge-eating disorder [OR 1.54, 95% CI (1.28, 1.85)], and comorbidity [OR 1.19, 95% CI (1.04, 1.35)] were greater during (vs. before) the pandemic. Frequencies of posttraumatic stress disorder were lower during the pandemic [OR 0.86, 95% CI (0.75, 0.98)]. The upward trend in alcohol use disorder was stronger among women than men [OR 1.47, 95% CI (1.18, 1.83)]. The upward trend in depression was stronger among Black students than White students [OR 1.72, 95% CI (1.19, 2.49)]. Anxiety disorders, insomnia, anorexia nervosa, and suicidality showed no significant trends.

Conclusions

Depression, alcohol use disorder, bulimia nervosa/binge-eating disorder, and comorbidity were higher, whereas posttraumatic stress disorder was lower during the pandemic. Women and Black students could face especially heightened risk for alcohol use disorder and depression, respectively, during the pandemic.

Harnessing mobile technology to reduce mental health disorders in college populations: A randomized controlled trial study protocol

About a third of college students struggle with anxiety, depression, or an eating disorder, and only 20-40% of college students with mental disorders receive treatment. Inadequacies in mental health care delivery result in prolonged illness, disease progression, poorer prognosis, and greater likelihood of relapse, highlighting the need for a new approach to detect mental health problems and engage college students in services. We have developed a transdiagnostic, low-cost mobile mental health targeted prevention and intervention platform that uses population-level screening to engage college students in tailored services that address common mental health problems. We will test the impact of this mobile mental health platform for service delivery in a large-scale trial across 20+ colleges. Students who screen positive or at high-risk for clinical anxiety, depression, or an eating disorder and who are not currently engaged in mental health services (N = 7884) will be randomly assigned to: 1) intervention via the mobile mental health platform; or 2) referral to usual care (i.e., campus health or counseling center). We will test whether the mobile mental health platform, compared to referral, is associated with improved uptake, reduced clinical cases, disorder-specific symptoms, and improved quality of life and functioning. We will also test mediators, predictors, and moderators of improved mental health outcomes, as well as stakeholder-relevant outcomes, including cost-effectiveness and academic performance. This population-level approach to service engagement has the potential to improve mental health outcomes for the millions of students enrolled in U.S. colleges and universities.

Reliability, validity and cut-off score of the Chinese version of the panic disorder severity scale self-report form in patients with panic disorder

BACKGROUND

Panic disorder (PD) is often undiagnosed, misdiagnosed, or untreated in non-psychiatric clinical settings. Therefore, a cost-effective, accurate and easy-to-administer instrument for PD assessment is still needed. For that reason, the self-report version of the Panic Disorder Severity Scale (PDSS-SR) has been developed and suggested to be a reliable and useful tool in clinical and research settings. The current study aims to evaluate the reliability and validity of the Chinese version of the PDSS-SR and determine the cut-off score of the PDSS-SR.

METHODS

A total of 133 patients with PD in Shanghai were assessed by the PDSS-SR, PDSS and Hamilton Anxiety Rating Scale (HAMA). Moreover, 117 patients with non-PD anxiety and 51 healthy subjects also completed the PDSS-SR to construct a receiver operating characteristic (ROC) curve with the scores of PD patients.

RESULTS

The internal consistency (Cronbach's α) of the PDSS-SR was 0.72-0.80, and the interrater correlation coefficient was 0.78. The results of principal component analysis and varimax rotation indicated that the PDSS-SR had a two-factor structure, with all seven items having salient loadings. The cut-off score was 4, which was associated with high sensitivity (96.03%) and specificity (61.31%).

CONCLUSIONS

The findings demonstrate that these items and the total score of the PDSS-SR have acceptable reliability and validity in patients with PD and that the PDSS-SR can be used by general doctors for clinical screening in China.

Evidence that Relationship Quality, Social Support, and SSRI Use Do Not Account for the Shared Underlying Relationships among Symptoms of Depression, Anxiety, and Female Sexual Dysfunction

Recent research has suggested that the shared characteristics and co-occurrence among depression, anxiety, and female sexual dysfunction may represent a shared underlying liability (i.e., the internalizing spectrum, which traditionally accounts for the overlap between depression and anxiety in psychopathology research). To date, however, whether common covariates shared by these symptom domains might instead account for the interrelationships has not been examined. Three such potential confounders include intimate relationship quality, social support, and selective serotonin reuptake inhibitor (SSRI) use. We therefore aimed to examine whether and to what extent controlling for these covariates affects the structure of an internalizing spectrum model that includes sexual problems. Participants (n = 525, mean [SD] age = 32 [11.1]) were women who participated in an online self-report survey and were in a current intimate relationship. Hierarchical exploratory structural equation models of the internalizing spectrum were compared before and after controlling for relationship quality, social support, and SSRI use and were markedly similar, indicating that the model was robust. This study provides further evidence that the internalizing spectrum can account for the relationships among depression, anxiety, and low sexual function in women, which has potential implications for diagnosis and treatment.

Identification and medical utilization of newly diagnosed panic disorder: A Nationwide case-control study

OBJECTIVE

Ascertaining comorbid illnesses and patterns of medical utilization early in the course of psychiatric illness can help identify patients with panic disorder. We investigated how such cases were diagnosed and the comorbidities associated with newly diagnosed panic disorder in a nationwide database.

METHODS

We enrolled a large representative cohort of the general population in Taiwan (N = 1000,000) and selected 9759 cases of panic disorder from January 1, 2000 to December 31, 2013. The distribution of the departments in which the cases were identified and the medical utilization 12 months before diagnosis were analyzed. Based on a nested case-control study, four controls were randomly selected for each case and matched for sex, age, and incidence year. Conditional logistic regression was used to explore the factors associated with newly-diagnosed panic disorder such as demographic factors, concomitant medications, and physical and psychiatric comorbidities.

RESULTS

Most (58.5%) cases of panic disorder were diagnosed in the psychiatry department, whereas only 3.7% were identified in the emergency department. Before diagnosis, the patients frequently visited the departments of internal medicine, family practice, and Chinese herbal medicine. A multivariate analysis revealed a higher number of physical and psychiatric comorbidities before diagnosis in the cases compared with the controls, especially depressive disorder and other anxiety disorders.

CONCLUSIONS

Individuals with certain comorbidities and patterns of medical utilization are more likely to be diagnosed with panic disorder. We suggest providing more training to general practitioners and emergency physicians for the early diagnosis of panic disorder.

Screening for perinatal anxiety disorders: Room to grow

BACKGROUND

The anxiety and their related disorders (AD) are the most prevalent of all mental health conditions, disproportionately affecting women. The value of perinatal AD screening is well established but there is very limited evidence to support the applicability of existing anxiety screening instruments. To our knowledge, no previous studies have evaluated an AD screening instrument in a perinatal population using full gold standard methodology.

OBJECTIVE

To assess the accuracy of the most commonly used and/or recommended screening tools for perinatal AD (i.e., the Edinburgh Postnatal Depression Scale (EPDS) and its anxiety subscale (EPDS-3A), and the Generalized Anxiety Disorder 7 and 2-item Scales (GAD-7 and GAD-2) alongside a clinically derived alternative; the Anxiety Disorder - 13 (AD-13).

METHODS

310 Canadian women completed mood and anxiety questionnaires at approximately 3-months postpartum. Those scoring at/above cut-off on one or more questionnaire completed a diagnostic interview for depression and all AD (n = 115). The accuracy of each scale was assessed via ROC analyses.

RESULTS

Only the AD-13 met the standard of a clinically useful screening measure, with an area under the curve (AUC) above 0.8. This was achieved with and without the inclusion of the related disorders. No other measure demonstrated an AUC above 0.8, either including or excluding the related disorders.

CONCLUSIONS

Neither the EPDS/EPDS 3-A, nor the GAD-7/GAD-2 can be recommended for widespread use as a perinatal AD screening tool. The high performance of the AD-13 is a good indication that an effective alternative is well within reach.

Incidence and Clinical Features of Panic Related Posttraumatic Stress

The current study assessed the incidence and associated features of posttraumatic stress after the experience of panic. One hundred seventy-eight participants meeting diagnostic criteria for panic attacks (PAs) were assessed using standardized measures of posttraumatic symptoms and posttraumatic stress disorder (PTSD) in specific reference to their experience of panic. Sixty-three (35.4%) participants scored above the cutoff for PTSD in reference to the worst PA they had experienced. Adjusted means for the four PTSD symptom clusters indicate that panic-related posttraumatic symptoms are, on average, experienced "moderately" to "quite a bit." Panic-related posttraumatic symptoms and PTSD were best predicted by specific features of the panic experience itself, including subjective levels of distress, fear of losing control, chest pain, agoraphobia, and number of PAs experienced. These findings are discussed in terms of the diagnostic, prognostic, and treatment implications for a subset of individuals presenting with panic who may also have panic-related PTSD.

The efficacy of aerobic exercise and resistance training as transdiagnostic interventions for anxiety-related disorders and constructs: A randomized controlled trial

Evidence supports exercise as an intervention for many mental health concerns; however, randomized controlled investigations of the efficacy of different exercise modalities and predictors of change are lacking. The purposes of the current trial were to: (1) quantify the effects of aerobic exercise and resistance training on anxiety-related disorder (including anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder) status, symptoms, and constructs, (2) evaluate whether both modalities of exercise were equivalent, and (3) to determine whether exercise enjoyment and physical fitness are associated with symptom reduction. A total of 48 individuals with anxiety-related disorders were randomized to aerobic exercise, resistance training, or a waitlist. Symptoms of anxiety-related disorders, related constructs, and exercise enjoyment were assessed at pre-intervention and weekly during the 4-week intervention. Participants were further assessed 1-week and 1-month post-intervention. Both exercise modalities were efficacious in improving disorder status. As well, aerobic exercise improved general psychological distress and anxiety, while resistance training improved disorder-specific symptoms, anxiety sensitivity, distress tolerance, and intolerance of uncertainty. Physical fitness predicted reductions in general psychological distress for both types of exercise and reductions in stress for aerobic exercise. Results highlight the efficacy of different exercise modalities in uniquely addressing anxiety-related disorder symptoms and constructs.

The prevalence and incidence of perinatal anxiety disorders among women experiencing a medically complicated pregnancy

Over 20% of pregnancies involve medical difficulties that pose some threat to the health and well-being of the mother, her developing infant, or both. We report on the first comparison of the prevalence and incidence of maternal anxiety disorders (AD) in pregnancy and the postpartum, across levels of medical risk in pregnancy. Pregnant women (N = 310) completed postnatal screening measures for anxiety. Women who scored at or above cutoff on one or more of the screening measures were administered a diagnostic interview (n = 115) for AD. Pregnancies were classified into low, moderate, or high risk based on self-report and contact with high-risk maternity clinics. The incidence of AD in pregnancy was higher among women classified as experiencing a medically moderate or high-risk pregnancy, compared with women classified as experiencing a medically low-risk pregnancy. Across risk groups, there were no differences in AD prevalence or in the incidence of AD in the postpartum. Demographic characteristics and parity did not contribute meaningfully to outcomes. Pregnancies characterized by medical risks are associated with an increased likelihood of new onset AD. Women experiencing medically complex pregnancies should be screened for anxiety and offered appropriate treatment.

False Safety Behavior Elimination Therapy: A randomized study of a brief individual transdiagnostic treatment for anxiety disorders

In response to the ever-growing number of CBT based therapy protocols, transdiagnostic approaches to anxiety treatment, based on models of anxiety emphasizing common elements across anxiety disorders, have been increasingly explored. The aim of the current study was to test the efficacy of an individually administered, brief (5-session) transdiagnostic treatment for anxiety disorders. The current treatment (called F-SET) focuses chiefly on the elimination of anxiety maintaining behaviors and cognitive strategies (so-called "safety" aids) among individuals suffering from a range of anxiety disorders including generalized anxiety disorder (GAD), social anxiety disorder (SAD) and panic disorder (PD). Patients (N=28; mean age=28.5years; 75% female; 71% White) were randomly assigned to F-SET or waitlist control conditions. Participants were assessed prior to, immediately after, and 1-month following treatment. In addition to independent assessments of diagnostic status, standardized self-report measures and assessor ratings of severity and distress associated with anxiety symptoms were used. Participants in the F-SET condition experienced significantly less anxiety (Cohen's d=2.01) and depression (Cohen's d=2.16) than those in the WL condition. Mediational analysis showed that change in avoidance strategies mediated the group changes in anxiety symptoms. The results from the current study are an important first step in identifying a simpler, focused form of CBT that can be delivered with minimal therapist training, at a low cost and with minimal client contact time.

Developmental risk factors in generalized anxiety disorder and panic disorder

BACKGROUND

There is a lack of clarity regarding specific risk factors discriminating generalized anxiety disorder (GAD) from panic disorder (PD).

GOAL

This study investigated whether GAD and PD could be discriminated through differences in developmental etiological factors including childhood parental loss/separation, psychological disorders, and maternal and paternal attachment.

METHOD

Twenty people with adult generalized anxiety disorder (GAD), 20 with adult panic disorder (PD), 11 with adult comorbid GAD and PD, and 21 adult non-anxious controls completed diagnostic interviews to assess symptoms of mental disorders in adulthood and childhood. Participants also reported on parental attachment, loss and separation.

RESULTS

Childhood diagnoses of GAD and PD differentiated clinical groups from controls as well as from each other, suggesting greater likelihood for homotypic over heterotypic continuity. Compared to controls, specific phobia was associated with all three clinical groups, and childhood depression, social phobia, and PTSD were uniquely associated with adult GAD. Both maternal and paternal attachment also differentiated clinical groups from controls. However, higher levels of subscales reflecting maternal insecure avoidant attachment (e.g., no memory of early childhood experiences and balancing/forgiving current state of mind) emerged as more predictive of GAD relative to PD. There were no group differences in parental loss or separation.

CONCLUSIONS

These results support differentiation of GAD and PD based on developmental risk factors. Recommendations for future research and implications of the findings for understanding the etiology and symptomatology of GAD and PD are discussed.

Perinatal anxiety disorder prevalence and incidence

BACKGROUND

Anxiety and related disorders (AD) disproportionately affect women, and are the most prevalent of all mental health conditions. The current research represents the first study of maternal postpartum AD prevalence in which all of the AD are assessed, and one of few studies of this type in which maternal prenatal AD incidence is assessed.

METHODS

A Canadian sample of pregnant women (N=310) was recruited from a defined geographical area between November 2007 and November 2010. Participants were first administered postnatal mood and anxiety screening measures. Those who scored at or above cutoff on one or more of these measures were administered a diagnostic interview for depression and anxiety at approximately three months postpartum (n=115). Findings from the diagnostic interview were used to estimate the prevalence and incidence of mood and AD in pregnancy, as well as at and during the first three months postpartum. Period prevalence and incidence estimates were obtained retrospectively from interview data collected postnatally.

RESULTS

The prevalence of AD during pregnancy and the early postpartum period (15.8% and 17.1% respectively) exceeded that of depression (3.9% and 4.8% respectively). The prevalence of OCD in our sample exceeded that of OCD among adults aged 18-64. Parity was unrelated to AD prevalence. Slightly less than 5% of participants were comorbid for both AD, and depression.

LIMITATIONS

This study is limited by a relatively small sample size for a prevalence study, and non-random sample selection. As only women who scored above cutoff on one or more screening measures were interviewed, prevalence estimates are conservative. Finally, prenatal prevalence estimates are based on retrospective report provided postpartum.

CONCLUSIONS

This study provides evidence that, as a group, anxiety and related conditions affect a significant proportion of postpartum women, and are more prevalent than is postpartum depression.

Emotional distress tolerance across anxiety disorders

Emotional distress tolerance (EDT) has increasingly been recognized as a transdiagnostic vulnerability factor. However, research assessing EDT in anxiety disorder populations is lacking. The current study addressed this gap in the literature by examining EDT in a sample of outpatients with panic, social anxiety, generalized anxiety, or obsessive compulsive disorders (n=674), and by assessing its relationship to symptom severity and impairment. Results showed that poor EDT was common across diagnostic groups. However, correlation and regression analyses suggested that although EDT was associated with symptom severity and impairment, it did not account for unique variance in scores beyond the effect of negative affect, stress, intolerance of uncertainty (IU) and anxiety sensitivity (AS). IU and AS had a stronger relationship with overall symptom severity and impairment in the regression models. Together, findings suggest that although EDT may be transdiagnostic, IU and AS are more relevant to our understanding of anxiety disorders.

Anxiety and Related Disorders and Concealment in Sexual Minority Young Adults

Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress places sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.

The Feasibility, Acceptability, and Efficacy of Delivering Internet-Based Self-Help and Guided Self-Help Interventions for Generalized Anxiety Disorder to Indian University Students: Design of a Randomized Controlled Trial

BACKGROUND

Generalized anxiety disorder (GAD) is one of the most common mental disorders among university students; however, many students go untreated due to treatment costs, stigma concerns, and limited access to trained mental health professionals. These barriers are heightened in universities in India, where there are scant mental health care services and severe stigma surrounding help seeking.

OBJECTIVE

To evaluate the feasibility, acceptability, and efficacy of Internet-based, or "online," cognitive behavioral therapy (CBT)-based unguided and guided self-help interventions (using the programs GAD Online and Lantern, respectively) to reduce GAD symptoms in students with clinical and subthreshold GAD and, ultimately, reduce the prevalence and incidence of GAD among the student population.

METHODS

Students will be recruited via 3 colleges in Hyderabad, India, and referred for a campus-wide online screening. Self-report data will be collected entirely online. A total of 300 qualifying students will be randomized in a 1:1:1 ratio to receive GAD Online, Lantern, or to be in a wait-list control condition, stratified by clinical and subthreshold GAD symptomatology. Students will complete a postintervention assessment after 3 months and a follow-up assessment 6 months later, at which point students in the wait-list control condition will receive one of the programs. The primary outcome is GAD symptom severity at 3 months postintervention. Secondary outcomes include GAD caseness at 9 months, other anxiety and depression symptoms, self-efficacy, and functional measures (eg, sleep, social functioning) at 3 and 9 months, respectively. Primary analyses will be differences between each of the intervention groups and the wait-list control group, analyzed on an intention-to-treat (ITT) basis using mixed-design ANOVA.

RESULTS

The study commenced in February 2015. The sample was recruited over a 3-week period at each college. The trial is expected to end in December 2015.

CONCLUSIONS

This trial will be the first to evaluate the use of Internet-based CBT programs compared with a wait-list control group for the treatment of GAD among students in Indian universities. If effective, these programs have the potential to reduce the mental health care treatment gap by providing readily accessible, private, and cost-effective evidence-based care to students with GAD who do not currently receive the treatment they need.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02410265 http://clinicaltrials.gov/ct2/show/NCT02410265 (Archived by WebCite at http://www.webcitation.org/6ddqH6Rbt).

Depression and anxiety during the perinatal period

BACKGROUND

Mood and anxiety and related disorders (AD) account for a significant proportion of mental health conditions, with close to 30 % of the population (28.8 %) suffering from an AD at some time in their life, and over fifteen percent (16.2 %) suffering from a mood disorder. The existing empirical literature leaves a number of important gaps with respect to our understanding of mood, anxiety and stress related difficulties among pregnant and postpartum women. The objective of this research is to address these.

METHODS

Participants were 660 English-speaking pregnant women. Participants for the portion of the research estimating the prevalence/incidence of perinatal mood disorders and AD (N = 347) were recruited proportionally from a geographically defined area. All participants were recruited via prenatal clinic visits at hospitals, physician offices and midwifery clinics, and via community outreach at events and through word of mouth. Recruitment took place between November 9, 2007 and November 12, 2010. Participants were administered questionnaires prenatally at two time points (approximately 24 and 33 weeks gestation) and again at 4-6 weeks' postpartum and 6-months postpartum. Prevalence/incidence study participants who screened above cut-off on one or more of the 4-6 week mood and anxiety questionnaires were also administered a diagnostic interview for mood disorders and AD at approximately 8-12 weeks postpartum.

DISCUSSION

This research addresses a number of gaps in our understanding of mood, anxiety and stress among pregnant and postpartum women. Specifically, gaps in our knowledge regarding the prevalence and incidence of (a) AD and mood disorders, and (b) anxiety and stress among women experiencing a medically high-risk pregnancy, interest in stress management training in pregnancy, mental health treatment barriers and access and screening for anxiety among pregnant and postpartum women are addressed. The findings from this series of studies have the potential to improve screening, assessment and treatment of mood and anxiety problems suffered by pregnant and postpartum women.

Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: translating evidence into clinical practice

This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n=112), depression (n=83), or panic (n=26). At baseline, midpoint and post-treatment, patients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d=.65-.78), and improvements in quality of life (d=.48-.66). Improvements in primary symptoms were large (d=.91-1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.

Psychometric properties of the primary care behavioral health screen

The Primary Care Behavioral Health Screen (PCBHS) is a self-report instrument developed to screen for behavioral health problems in primary care settings. The present paper describes development of the PCBHS and reports findings from item analyses and studies examining the instrument's convergent validity and test-retest reliability. Results suggest the PCBHS is a useful and valid method for screening a variety of behavioral health problems in a busy primary care practice. Recommendations for further research on the PCBHS are provided.

"The Sound of Fear": assessing vocal fundamental frequency as a physiological indicator of social anxiety disorder

The relationship between vocal pitch and social anxiety disorder (SAD) has been examined with encouraging initial results, highlighting increased fundamental frequency (F0) as a physiological indicator of SAD. The present series of studies examined the relationship between F0 emitted during social threat and SAD symptoms. Two independent samples of SAD patients, and a sample of demographically-equivalent non-socially anxious controls (NSACs), completed varying social threat tasks which involved speech. Mean F0 emitted throughout the tasks was examined. Male SAD patients emitted greater F0 in comparison to NSACs across studies. For females, this relationship was significant only when examined in patients with SAD of the generalized subtype, and in response to in vivo social exposures. Furthermore, gender-specific thresholds for overall F0 emitted during social threat were identified which demonstrated excellent differentiation between patients with generalized SAD and NSACs. These results provide additional support for increased F0 as a physiological indicator of SAD.

Comprehension of self-report evidence-based measures of anxiety

BACKGROUND

Given their applicability in diverse settings and for a wide range of purposes, the generalizability of self-report symptom measures is particularly important. An understudied factor in the development and validation of self-report measures is the degree to which they are difficult to comprehend. This study evaluated the difficulty of self-report measures of anxiety with respect to several domains, including formatting, length, and linguistic problems.

METHODS

Ninety-two evidence based measures of anxiety were evaluated for comprehension level.

RESULTS

The majority of anxiety measures included challenging elements of formatting, linguistic ability, and readability. Measures of obsessive-compulsive disorder were associated with the highest level of comprehension (i.e., greatest difficulty).

CONCLUSIONS

The validity of self-report measures relies on the ability of respondents to understand the instructions and measure items. Factors related to the comprehension of self-report measures should be included among the basic psychometric properties in measure development and validation. Future research on the development of self-report measures that can be more broadly applicable across levels of education and literacy are of particular importance to research, clinical, and public health agendas.

Computerized progress notes for chronic pain patients receiving opioids; the Prescription Opioid Documentation System (PODS)

OBJECTIVE

We herein provide a description of a health information technology tool using computer-assisted survey instruments as a methodology for documentation during long-term opioid therapy.

DESIGN

We report our experience using the Prescription Opioid Documentation and Surveillance (PODS) System, a medical informatics tool that utilizes validated questionnaires to automate the assessment of opioid prescribing for chronic nonmalignant pain.

SETTING AND PATIENTS

Chronic pain patients answered questions that were presented on a computer terminal prior to each appointment in a Department of Veterans Affairs Pain Clinic.

MEASURES

Pain levels, activities of daily living, and screening for common psychological disorders were sought at each visit. Results were tabulated with some information gathered sequentially permitting evaluation of progress. Following a face-to-face interview, the clinician added additional comments to the medical record.

RESULTS

By deploying a systematic series of questions that are recalled by the computer, PODS assures a comprehensive assessment.

CONCLUSIONS

The PODS fulfills medicolegal requirements for documentation and provides a systematic means of determining outcomes. This process facilitates the determination of the appropriate intervals between clinic visits by stratifying patients into high, moderate, and low risk.

Anxiety symptomatology: the association with distress tolerance and anxiety sensitivity

Research focused on psychological risk factors for anxiety psychopathology has led to better conceptualization of these conditions as well as pointed toward preventative interventions. Anxiety sensitivity (AS) has been well-established as an anxiety risk factor, while distress tolerance (DT) is a related construct that has received little empirical exploration within the anxiety psychopathology literature. The current investigation sought to extend the existing literature by examining both DT and the relationship between DT and AS across a number of anxiety symptom dimensions, including panic, generalized anxiety, social anxiety, and obsessive-compulsive anxiety. Participants (N=418) completed a number of measures that assessed DT, AS, anxiety symptomatology, and negative affect. Findings indicated that DT was uniquely associated with panic, obsessive compulsive, general worry, and social anxiety symptoms, but that DT and AS were not synergistically associated with each of these symptom dimensions. These findings indicate that an inability to tolerate emotional distress is associated with an increased vulnerability to experience certain anxiety symptoms.

The Disqualification of Positive Social Outcomes Scale: a novel assessment of a long-recognized cognitive tendency in social anxiety disorder

Socially anxious individuals frequently tend to disqualify positive social experiences and outcomes. However, no formal measure of Disqualificationof Positive Social Outcome (DPSO)-related tendencies has yet been reported. The purpose of the present series of studies was to develop the Disqualification ofPositive Social Outcomes Scale (DPSOS) and examine its psychometric profile across several independent samples, including a large (n=585) undergraduate sample; a clinical sample of individuals diagnosed with social anxiety disorder (n=14), and a demographically-equivalent sample of non-socially anxious control participants (n=14). The factorial validity, internal consistency, and construct validity of the DPSOS subscales were examined. Results provide preliminary support for the psychometric properties of the DPSOS. Implications of DPSO as to assessment and treatment of social anxiety disorder are discussed.

Suppressing the White Bears interacts with Anxiety Sensitivity in the prediction of Mood and Anxiety Symptoms

Suppression is a commonly used strategy to manage unwanted thoughts by attempting to actively remove them from awareness. However, research has shown that this cognitive strategy often results in the paradoxical effect of increasing the frequency of unwanted thoughts. While the association between thought suppression and mood and anxiety symptoms has been repeatedly demonstrated, relations between this cognitive strategy and other anxiety risk factors such as anxiety sensitivity (AS) are unexplored. Using a nonclinical sample of young adults (N = 414), the current investigation sought to more thoroughly investigate the association between AS and thought suppression as well as explore their synergistic effect on anxiety symptomatology. As hypothesized, thought suppression and AS were positively associated. Moreover, AS and thought suppression interacted to predict elevated levels of panic and obsessive compulsive symptomatology.

Web-based therapist-assisted cognitive behavioral treatment of panic symptoms: a randomized controlled trial with a three-year follow-up

BACKGROUND

Internet-delivered treatment may reduce barriers to care in those unwilling or unable to access traditional forms of treatment.

OBJECTIVE

To assesses the efficacy of web-based therapist-assisted cognitive behavioral treatment (web-CBT) of panic symptoms.

DESIGN

A randomized waiting-list controlled trial with an uncontrolled three-year follow-up.

PARTICIPANTS

A community sample of 58 participants with chronic panic symptoms of varying severity (immediate treatment: n=27, waiting-list control: n=31).

OUTCOME MEASURES

The primary outcome measures were a one-week Panic Diary and the Panic Disorder Severity Scale - Self-Report (PDSS-SR); secondary measures were the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ), the Mobility Inventory - Alone subscale (MI-AAL), and the Depression Anxiety Stress Scales (DASS-42).

RESULTS

In the RCT, 54 participants (93%) completed posttest measurements. With regard to the primary outcome measures, intention-to-treat ANCOVAs revealed that participants in the treatment condition improved more than the participants in the waiting-list control condition (p<.03), with a pooled between-group effect size of d=.7. After three years (n=47; 81% study compliance), effects were more pronounced.

CONCLUSION

The results demonstrate the efficacy of therapist-assisted web-CBT in the treatment of panic symptoms.

An examination of recent non-clinical panic attacks, panic disorder, anxiety sensitivity, and emotion regulation difficulties in the prediction of generalized anxiety disorder in an analogue sample

Both non-clinical panic attacks and panic disorder (PD) have been found to be associated with generalized anxiety disorder (GAD). This study examined a proxy risk factor model of the relationship between non-clinical panic attacks, PD, and GAD. Specifically, it was proposed that non-clinical panic attacks and PD predict GAD only due to their shared association with anxiety sensitivity (AS) and difficulties in emotion regulation. Results demonstrated that emotion regulation difficulties reliably predicted GAD above and beyond the experience of non-clinical panic attacks and PD. However, although PD lost strength as a predictor, it remained significantly associated with GAD in the full model, providing only partial support for the proposed proxy risk factor model. Findings speak to the underlying role of emotion regulation difficulties in GAD, and suggest that it may be the shared relationship of these difficulties with both PD and GAD that partially explain the association of these disorders.

Exploring the relationship between fear of positive evaluation and social anxiety

Cognitive-behavioral theorists have proposed that fear of negative evaluation is the core feature of social anxiety [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In: R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). New York: Guilford Press; Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in social phobia. Behavior Research and Therapy, 35, 741-756]. However, we have previously hypothesized that fear of evaluation in general is important in social anxiety, including fears of positive as well as negative evaluation, and we developed the Fear of Positive Evaluation Scale (FPES; Weeks, J. W., Heimberg, R. G., & Rodebaugh, T. L. (2007). The Fear of Positive Evaluation Scale: Assessing a proposed cognitive component of social anxiety disorder. Manuscript submitted for review.) to test this hypothesis. The present paper reviews several studies conducted for the purpose of extending the empirical examination of the construct of fear of positive evaluation (FPE). Consistent with hypothesis, FPE was positively associated with discomfort in response to receipt of positive social feedback and negatively associated with perceived accuracy of the feedback received. Furthermore, the FPES correlated significantly with several measures related to social anxiety, and lower correlations with measures of other constructs provided evidence of discriminant validity. Thus, findings from the present series of studies add to the developing support for the hypothesis that fear of positive evaluation is important in social anxiety.