Depersonalization and individualism: the effect of culture on symptom profiles in panic disorder

Measuring distress in older population: Rasch analysis of the Kessler Psychological Distress Scale

OBJECTIVES

The 10-item Kessler Psychological Distress Scale (K-10) is a widely applied distress measure; however, its psychometric properties were not established with older populations using advanced methodology. The aim of this study was to examine psychometric properties of the K-10 through application of Rasch methodology and if possible, develop an ordinal-to-interval conversion to improve its reliability in older populations.

METHOD

The Partial Credit Rasch Model was applied to analyse K-10 scores of the sample including 490 participants (56.3 % females) aged 70 to 90 years and without dementia from the Sydney Memory and Ageing Study (MAS).

RESULTS

The initial analysis of the K-10 showed poor reliability and significant deviation from the expectations of the Rasch model. The best model fit was evident after correcting disordered thresholds and creating two testlet models to address local dependency between items (χ²(35) = 29.87, p = 0.71). The modified K-10 demonstrated strict unidimensionality, enhanced reliability and scale invariance across personal factors, such as sex, age, and education and permitted development of ordinal-to-interval transformation algorithms.

LIMITATIONS

Ordinal-to-interval conversion can only be applied for older adults with complete data.

CONCLUSIONS

The K-10 satisfied principles of fundamental measurement defined by Rasch model after minor modifications. Clinicians and researchers can transform K-10 raw scores into interval-level data using converging algorithms published here without altering the original scale response format, which increases reliability of the K-10.

Addressing Biases in Patient Care with The 5Rs of Cultural Humility, a Clinician Coaching Tool

Clinicians are called to care for patients with increasingly diverse backgrounds during vulnerable moments when gaining trust is imperative. Simultaneously, implicit or unconscious biases are omnipresent. Guidance for clinicians in addressing and curtailing implicit biases is a necessity to preserve provider resiliency while providing high-value, patient-centered care. However, tools to aid clinicians in this endeavor are unknown. The following article introduces The 5Rs of Cultural Humility (5Rs) as a coaching tool available to all clinicians, leaders, and administrators. It is a tool that brings awareness to the reality that everyone has implicit biases and provides a platform to address these biases through the use of cultural humility, mindfulness, and compassion. The tool encourages the clinician to become more aware of his or her decision-making and interactions with others. Each R includes an aim at reducing biases and a self-reflection question. The 5Rs are reflection, respect, regard, relevance, and resiliency. The framework of the 5Rs presents an approach for clinicians to explore more mindful interactions and enriching patient-provider interactions.

Lifestyle Behaviours Add to the Armoury of Treatment Options for Panic Disorder: An Evidence-Based Reasoning

This article presents an evidence-based reasoning, focusing on evidence of an Occupational Therapy input to lifestyle behaviour influences on panic disorder that also provides potentially broader application across other mental health problems (MHP). The article begins from the premise that we are all different. It then follows through a sequence of questions, examining incrementally how MHPs are experienced and classified. It analyses the impact of individual sensitivity at different levels of analysis, from genetic and epigenetic individuality, through neurotransmitter and body system sensitivity. Examples are given demonstrating the evidence base behind the logical sequence of investigation. The paper considers the evidence of how everyday routine lifestyle behaviour impacts on occupational function at all levels, and how these behaviours link to individual sensitivity to influence the level of exposure required to elicit symptomatic responses. Occupational Therapists can help patients by adequately assessing individual sensitivity, and through promoting understanding and a sense of control over their own symptoms. It concludes that present clinical guidelines should be expanded to incorporate knowledge of individual sensitivities to environmental exposures and lifestyle behaviours at an early stage.

Ethnic variation in whether dissociation mediates the relation between traumatic life events and attenuated positive psychotic symptoms

The present study sought to determine whether dissociative experiences mediated the relationship between traumatic life events and attenuated positive psychotic symptoms in a non-treatment-seeking sample of racial and ethnic minority young adults. Participants (n = 549) completed a self-report inventory for psychosis risk (i.e., the Prodromal Questionnaire; R. L. Loewy, C. E. Bearden, J. K. Johnson, A. Raine, & T. D. Cannon, 2005), from which a total number of attenuated positive psychotic symptoms was assessed. Participants also completed a checklist of potentially traumatic life events and a traumatic dissociation scale. Hierarchical linear regression models and bootstrapping results indicated that dissociation mediated the relationship between traumatic life events and attenuated positive psychotic symptoms. Stratified analyses of Black, Asian, and Hispanic subgroups revealed that full mediation was only evident in the Black subgroup of young adults. Partial mediation was found among the Hispanic group, and no mediation occurred in the Asian subgroup. For the latter, traumatic life events were not significantly associated with dissociative experiences. A dissociative response style may be particularly relevant to trauma-exposed Black young adults exhibiting subclinical psychotic experiences and less so for Asian young adults. Trauma-induced dissociative experiences should be assessed further in clinical high-risk studies, especially among Black traumatized youth.

Symptom profiles in depersonalization and anxiety disorders: an analysis of the Beck Anxiety Inventory

BACKGROUND

Depersonalization disorder (DPD) entails distressing alterations in self-experiencing. However, it has long been recognized that depersonalisation symptoms occur in other disorders, particularly anxiety and panic. One strand of research proposes that depersonalization phenomenology arises through altered autonomic arousal in response to stress.

SAMPLING AND METHODS

We sought to examine profiles of anxiety symptoms through a secondary data analysis of individual items and factor subscales on the Beck Anxiety Inventory (BAI), comparing two relatively large patient samples with DPD or with a variety of anxiety conditions, respectively. The DPD sample (n = 106) had a lower overall BAI score than the combined anxiety disorders group (n = 525).

RESULTS

After controlling for this as well as for potential confounders such as age and gender, the DPD group presented significantly lower scores on the panic subscale, marginally lower scores on the autonomic subscale and significantly higher scores on the neurophysiological subscale of the BAI.

CONCLUSIONS

These differences imply similarities between the cognitive components of DPD and anxiety disorders while physiological experiences diverge. The findings encourage future research looking at direct physiological measures and longitudinal designs to confirm the mechanisms underlying different clinical manifestations of anxiety.

Two-phase survey to determine social anxiety and gender differences in Omani adolescents

INTRODUCTION

There is a lack of studies examining the effectiveness of some of the commonly used instruments to elicit the presence of social anxiety disorder (SAD) in Arab-speaking populations, such as those in Oman. The aim of this study was to establish the influence of social anxiety and the role of gender among Omani adolescents.

METHODS

A two-phase protocol was used, entailing the psychometric properties of the Arabic version of the Liebowitz Social Anxiety Scale (LSAS) against the gold standard, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

RESULTS

According to DSM and LSAS, the prevalence of social phobia among Omani students was generally higher compared to what has been reported in other parts of the world and the crosstabs analysis showed a significant correlation between gender and SAD.

DISCUSSION

The Arabic version of LSAS proved to be an effective tool for assessing and quantifying the presence of SAD. This study discusses the sociocultural factors affecting social phobia in Omani society.

Depersonalization disorder and anxiety: a special relationship?

A significant association between anxiety and depersonalization has been found in healthy controls and psychiatric patients irrespective of underlying conditions. Although patients with depersonalization disorder (DPD) often have a history of severe anxiety symptoms, clinical observations suggest that the relation between anxiety and depersonalization is complex and poorly understood. Using relevant rating scales, levels of anxiety and depersonalization were assessed in 291 consecutive DPD cases. 'High' and 'low' depersonalization groups, were compared according to anxiety severity. Correlation and multivariate regression analyses were also used to assessed the contribution of anxiety to the phenomenology and natural course of depersonalization. A low but significant association between depersonalization and anxiety (as measured by Beck's Anxiety Inventory) was only apparent in those patients with low intensity depersonalization, but not in those with severe depersonalization. Levels of anxiety did not seem to make specific contributions to the clinical features of depersonalization itself, although DPD patients with high anxiety seem characterised by additional non-specific perceptual symptoms. The presence of a 'statistical dissociation' between depersonalization and anxiety adds further evidence in favour of depersonalization disorder being an independent condition and suggests that its association with anxiety has been overemphasized.

Relationship of cognitions and symptoms of agoraphobia in Hong Kong Chinese: a combined quantitative and qualitative study

OBJECTIVES

The aim of this study was to explore and describe the subjective experiences of agoraphobia in Hong Kong Chinese.

METHOD

This was a cross-sectional descriptive study, using a combined qualitative-quantitative approach. In the qualitative part, two focus groups were held with nine participants suffering from DSM-IV panic disorder with agoraphobia, followed up in a regional hospital in Hong Kong. The audiotaped

MATERIAL

was transcribed and analysed into four main categories and 13 subcategories based on a grounded theory approach. One subcategory ('Fear of making others worried and being a burden to others') was identified as a novel, culture-specific concept in agoraphobia that was not reported in Western literature. In the quantitative part, this subcategory was redefined and measured by a two-item, self-rated questionnaire survey in another 35 participants suffering from DSM-IV defined panic disorder with agoraphobia.

RESULTS

Qualitative data showed that the clinical manifestations of agoraphobia were specifically related to the underlying corresponding catastrophic cognitions. An individual's agoraphobic cognitions and symptoms were highly related to the identity of the surrounding people during panic attacks in agoraphobic situations, which reflected the characteristic structure of the Chinese interpersonal network. Participants preferred reliance on self to cope with the anxiety first, then turned to their family members for help due to higher interpersonal trust. Participants also expressed fear of affecting others due to their illness. A new sub-theme of agoraphobia ('Fear of making others worried and being a burden to others') was extracted from the qualitative data. Its validity was confirmed by the quantitative description of this new theme using a self-rated questionnaire as a methodological triangulation.

CONCLUSIONS

The central theme to emerge from the qualitative data was that agoraphobia is a clinical condition that has a close relationship to Chinese cultural factors. 'Fear of making others worried and being a burden to others' is a new concept in agoraphobia worthy of further study.

Prevalence and childhood antecedents of depersonalization syndrome in a UK birth cohort

PURPOSE

Depersonalization syndrome is characterised by a sense of unreality about the self [depersonalization (DP)] and/or the outside world [derealization (DR)]. Prevalence estimates vary widely. Little is known about childhood antecedents of the disorder although emotional abuse is thought to play a role.

METHODS

Longitudinal data from 3,275 participants of a UK population-based birth cohort (the MRC National Survey of Health and Development) were used to: (1) assess the prevalence of DP syndrome at age 36, measured by the Present State Examination (PSE); and (2) examine the effects of a range of socio-demographic, childhood adversity and emotional responses as potential risk factors for DP.

RESULTS

Thirty three survey members were classified with DP, yielding a prevalence of 0.95% [95% confidence intervals (CI) 0.56-1.34]. There were no associations with socio-economic status, parental death or divorce; self-reported accidents, childhood depression, tendency to daydream or reactions to criticism. However, teacher-estimated childhood anxiety was a strong independent predictor of adult depersonalization, and there were strong cross-sectional relationships between DP and anxiety and depression caseness.

CONCLUSIONS

To our knowledge this is the first study assessing nationwide prevalence of the DP syndrome and uses longitudinal data to explore childhood risk factors for adult DP. The prevalence of adult DP was slightly lower than reported by other surveys. The study found that childhood anxiety was the only significant predictor of the adult DP syndrome, supporting the view that depersonalisation disorder forms part of the spectrum of responses to anxiety.

Cross-cultural variations in the prevalence and presentation of anxiety disorders

Considerable cross-cultural variation exists in the prevalence and presentation of the anxiety disorders as defined by the fourth edition of the Diagnostic and Statistical Manual. Researchers debate whether this variation represents cultural differences in the phenomenology of universal disorders or the existence of unique culturally constructed disorders. This article reviews recent literature on the prevalence and presentation of five anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, specific phobia and post-traumatic stress disorder, both across countries and within the USA. This article indicates that certain anxiety disorders (e.g., generalized anxiety disorder and panic disorder) may vary greatly in rate across cultural groups. It indicates that the clinical presentation of anxiety disorders, with respect to symptom presentation and the interpretation of symptoms, varies across cultures. A difference in catastrophic cognitions about anxiety symptoms across cultures is hypothesized to be a key aspect of cross-cultural variation in the anxiety disorders. Future research directions are suggested.

Depersonalization and personality in panic disorder

BACKGROUND

Prevalence and clinical correlates of depersonalization symptoms have been associated with panic disorder. Personality traits might increase the likelihood of experiencing depersonalization symptoms or depersonalization disorder in panic patients.

AIMS

The objectives of this study are to establish the prevalence of depersonalization symptoms during the panic attack and in depersonalization disorder and to examine the personality factors associated with the presence of depersonalization in patients with panic disorder.

METHODS

The sample comprised 104 consecutive adult outpatients with panic disorder, diagnosed according to the Semistructured Clinical Interview for DSM-IV (Axis I/II disorders). Participants were assessed with the Cambridge Depersonalization Scales, the Temperament and Character Inventory, and the Panic and Agoraphobia Scale.

RESULTS

Forty-eight percent of the sample had depersonalization symptoms during the panic attack, whereas 20% of patients had a depersonalization disorder. Women presented more depersonalization disorders than did men (P = .036). Patients with panic disorder with depersonalization disorder had a more severe panic disorder (P = .002). Logistic regression analysis showed that self-transcendence trait (odds ratio, 1.089; 95% confidence interval, 1.021-1.162; P = .010) and severity of panic (odds ratio, 1.056; 95% confidence interval, 1.005-1.110; P = .032) were independently associated with depersonalization disorder.

CONCLUSIONS

A high prevalence of depersonalization symptoms and depersonalization disorder was confirmed in patients with panic disorder, supporting a dosage effect model for understanding depersonalization pathology. Self-transcendence trait and severity of panic disorder were reported as risk factors for depersonalization disorder.

Culture and the anxiety disorders: recommendations for DSM-V

BACKGROUND

The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM-IV-TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent "over-specification" of disorders, the post-DSM-III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross-cultural limitations in DSM-IV-TR anxiety disorder criteria.

METHODS

Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity-related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders.

RESULTS

Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10-minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM-V validators that could help clarify the cross-cultural applicability of criteria.

CONCLUSIONS

On the basis of the available data, options and preliminary recommendations for DSM-V are put forth that should be further evaluated and tested.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V

This review covers the literature since the publication of DSM-IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

Cognitive-affective neuroscience of depersonalization

Depersonalization disorder (DPD) is characterized by a subjective sense of detachment from one's own being and a sense of unreality. An examination of the psychobiology of depersonalization symptoms may be useful in understanding the cognitive-affective neuroscience of embodiment. DPD may be mediated by neurocircuitry and neurotransmitters involved in the integration of sensory processing and of the body schema, and in the mediation of emotional experience and the identification of feelings. For example, DPD has been found to involve autonomic blunting, deactivation of sub-cortical structures, and disturbances in molecular systems in such circuitry. An evolutionary perspective suggests that attenuation of emotional responses, mediated by deactivation of limbic structures, may sometimes be advantageous in response to inescapable stress.

Prevalence, correlates, and predictors of depersonalization experiences in the German general population

The survey aimed to investigate the prevalence of depersonalization (DP) experiences, its sociodemographic characteristics and its associations with medical conditions, illness behavior, and potential etiologic factors. A representative face-to-face household survey was conducted. The sample consists of n = 1,287 participants aged 14 to 90 years. Sociodemographic variables, medical conditions, current mental disorders, health care utilization, and childhood adversities were assessed. A total of 1.9% participants scored in the range of clinically significant DP (DP-C) and 9.7% reported at least some impairment through DP (DP-I). DP-C/DP-I were strongly associated with depression and anxiety. After adjustment for depression and anxiety, DP-C and DP-I were independently associated with hypertension, diabetes mellitus, chronic pulmonary disease, severe pain, and childhood adversities. We conclude that DP is common, it can not be reduced to a negligible variant of depression or anxiety and that more awareness about DP with respect to detection and research is urgently required.

[Depersonalisation/derealization - clinical picture, diagnostics and therapy]

The present state of knowledge about depersonalization (DP) and derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.