Search

The authors examine the relationship of the two signature injuries experienced by military personnel serving in Afghanistan and Iraq: posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mild TBI). Studies show that a substantial minority of those serving develop persistent emotional sequelae (such as PTSD and other psychological health problems) and/or somatic or cognitive sequelae (postconcussive symptoms) of traumatic exposure. Remarkably, the mechanism (emotional versus biomechanical) and locus (head versus other regions) of injury are weak determinants of whether an individual develops PTSD, persistent postconcussive symptoms, or both. Preexisting or traumatically acquired cognitive dysfunction can increase the risk for these syndromes, probably by reducing cognitive reserve. Structural and functional neuroimaging studies can be interpreted to explain part of the shared symptomatic and functional variance in these syndromes, but this literature is far from consistent and serves mainly to raise new, challenging questions about mutual pathophysiology. The frequent confluence of PTSD and persistent postconcussive symptoms in military personnel strains the bounds of these constructs. New studies are needed to improve our understanding of how emotional and biomechanical stressors can yield these adverse outcomes and how such outcomes can be prevented and treated.

Objective: Increased amygdala reactivity during processing of certain types of emotional stimuli (e.g., fear, anger) has been observed in patients with anxiety disorders such as social phobia and posttraumatic stress disorder (PTSD). It is uncertain whether this heightened amygdala reactivity is specific to treatment-seeking patients with anxiety disorders or is a general feature of individuals with increased anxiety-related temperamental traits. Method: Thirty-two physically healthy subjects 18-21 years old were recruited from a large pool of college students. Of these, 16 were chosen on the basis of scoring in the upper-15th percentile on a measure of trait anxiety (anxiety-prone group), and 16 were chosen on the basis of scoring in the normative range (40th-60th percentile). Subjects participated in functional magnetic resonance imaging (fMRI) during an emotion face assessment task that has been shown to reliably en gage amygdala and associated limbic structures. Results: Anxiety-prone subjects had significantly greater bilateral amygdala and insula activation to emotional faces than did the anxiety-normative comparison subjects. Higher scores on several measures assessing anxiety proneness (e.g., neuroticism, trait anxiety, and anxiety sensitivity) were associated with greater activation of the amygdala (predominantly left-sided) and the anterior insula (bilateral). Conclusions: Increased amygdala and insula reactivity to certain types of emotional processing is seen in young adults with increased anxiety-related temperamental traits. Therefore, this brain emotion-processing profile may be a functional endophenotype for proneness to (certain kinds of) anxiety disorders.

Objective: Few studies have focused on the natural course of posttraumatic stress disorder (PTSD) and its determinants in samples of the general population. The authors examined determinants of remission and chronicity of PTSD and associations with other disorders in a prospective community sample. Method: The data were drawn from a prospective, longitudinal epidemiological study of adolescents and young adults (age 14-24 years) in Munich, Germany (N=2,548). The course of PTSD from baseline to follow-up 34-50 months later was studied in 125 respondents with DSM-IV PTSD or subthreshold PTSD at baseline. Results: Although 52% of the PTSD cases remitted during the follow-up period, 48% showed no significant remission of PTSD symptoms. Respondents with a chronic course were more likely to experience new traumatic event(s) during follow-up (odds ratio-5.21, 95% confidence interval [CI]=1.95-13.92), to have higher rates of avoidant symptoms at baseline (odds ratio=10.16, 95% CI=1.73-59.51), and to report more help seeking (odds ratio=5.50, 95% CI=1.04-29.05), compared to respondents with remission. Rates of incident somatoform disorder (odds ratio=4.24, 95% CI=1.60-11.19) and other anxiety disorders (odds ratio=4.07, 95% CI=1.15-14.37) were also significantly associated with a chronic course. Conclusions: PTSD is often a persistent and chronic disorder. Specific symptom clusters--especially avoidant symptoms--might be associated with the course of PTSD. In addition, the occurrence of new traumatic events differentiates PTSD cases with a chronic course from those with remission.

Objective: This study evaluated quality of care for primary care patients with anxiety disorders in university-affiliated outpatient clinics in Los Angeles, San Diego, and Seattle. Method: Three hundred sixty-six primary care outpatients who were diagnosed with panic disorder, generalized anxiety disorder, social phobia, and/or posttraumatic stress disorder (with or without major depression) were surveyed about care received in the prior 3 months. Quality indicators were mental health referral, anxiety counseling, and use of appropriate antianxiety medication during the previous 3 months. Results: Approximately one-third of patients with anxiety disorders had received counseling from their primary care provider in the prior 3 months. Fewer than 10% had receiving counseling from a mental health professional that included multiple elements of cognitive behavior therapy. Approximately 40% had received appropriate antianxiety medications in the previous 3 months, although only 25% had received them at a minimally adequate dose and duration. Overall, fewer than one in three patients had received either psychotherapy or pharmacotherapy that met a criterion for quality care. In multivariate analyses, patients with comorbid depression and/or medical illness were more likely--and patients from ethnic minorities were less likely--to receive appropriate antianxiety medications. Conclusions: Rates of quality care for anxiety disorders are moderate to low in university-affiliated primary care practices. Although an appropriate type of pharmacotherapy was frequently used, it was often of inadequate duration. Cognitive behavior therapy was markedly underused. These findings emphasize the need for practice guidelines and implementation of quality improvement programs for anxiety disorders in primary care.

Objective: Social phobia is a common, sometimes disabling, fear of situations that might entail scrutiny by others. Several anxiety disorders, including social phobia, are genetically influenced. Genetic linkage analysis can provide the means to identify genomic locations harboring susceptibility loci for genetically influenced disorders. Identifying loci for social phobia was the goal of this study. Method: The authors conducted a genome-wide linkage scan, i.e., tested enough genetic markers to query the entire genome, in 17 American pedigrees (163 subjects) ascertained through pro-bands with panic disorder. Several anxiety disorders segregate in these families; diagnoses were based on structured interviews. A total of 422 markers (404 autosomal, 18 on the X chromosome) with an average spacing of less than 10 centimorgans were genotyped. Multipoint lod score and nonparametric (Zlr score) linkage analyses for social phobia were completed with Allegro and Genehunter X software. Results: Evidence for linkage to social phobia for chromosome 16 markers was identified. A Zlr score of 3.41 was observed for chromosome 16 near marker D16S415. The maximum observed lod score was 2.22, also for chromosome 16, between D16S415 and D16S503 (under a model of recessive inheritance). Additional areas of interest were identified on chromosomes 9, 14, and 18. Conclusions: These findings meet conservative criteria for 'suggestive' linkage. The gene encoding the norepinephrine transporter protein (SLC6A2) maps to this broad region, making SLC6A2 both a positional and physiological candidate for influencing social phobia risk. To the authors' knowledge, this is the first complete linkage genome scan for this disorder.

Objective: Posttraumatic stress disorder (PTSD) develops in only a subset of persons exposed to traumatic stress, suggesting the existence of stressor and individual differences that influence risk. In this study the authors examined the heritability of trauma exposure and PTSD symptoms in male and female twin pairs of nonveteran volunteers. Method: Scores on a traumatic events inventory and a DSM-IV PTSD symptom inventory were examined in 222 monozygotic and 184 dizygotic twin pairs. Biometrical model fitting was conducted by using standard statistical methods. Results: Additive genetic, common environmental, and unique environmental effects best explained the variance in exposure to assaultive trauma (e.g., robbery, sexual assault), whereas exposure to nonassaultive trauma (e.g., motor vehicle accident, natural disaster) was best explained by common and unique environmental influences. PTSD symptoms were moderately heritable, and the remaining variance was accounted for by unique environmental experiences. Correlations between genetic effects on assaultive trauma exposure and on PTSD symptoms were high. Conclusions: Genetic factors can influence the risk of exposure to some forms of trauma, perhaps through individual differences in personality that influence environmental choices. Consistent with symptoms in combat veterans, PTSD symptoms after noncombat trauma are also moderately heritable. Moreover, many of the same genes that influence exposure to assaultive trauma appear to influence susceptibility to PTSD symptoms in their wake. (Am J Psychiatry 2002; 159:1675-1681)

Objective: The authors determined the costs associated with generalized social anxiety disorder in a managed care setting. Method: A three-phase mail and telephone survey was conducted from July to October 1998 in two outpatient clinics of a large health maintenance organization (HMO). The survey assessed direct costs, indirect costs, health-related quality of life, and clinical severity associated with generalized social anxiety disorder, both alone and with comorbid psychopathology. Results: The weighted prevalence rate of current generalized social anxiety disorder was 8.2%. In the past year, only 0.5% of subjects with generalized social anxiety disorder had been accurately diagnosed. Yet 44.1% had a mental health specialty visit or had been prescribed an antidepressant, and psychiatric comorbidity was found in 43.6%. Noncomorbid generalized social anxiety disorder was associated with significantly lower health-related quality of life, work productivity, and earnings and greater utilization of health services; generalized social anxiety disorder with comorbid psychopathology was even more disabling. Suicide was attempted by 21.9% of subjects with noncomorbid generalized social anxiety disorder. Persons with average-severity generalized social anxiety disorder had probabilities of graduating from college that were 10 percentage points lower, earned wages that were 10% lower, and had probabilities of holding a technical, professional, or managerial job that were 14 percentage points lower than the comparison group. Conclusions: In a community cohort of HMO members, generalized social anxiety disorder was rarely diagnosed or treated despite being highly prevalent and associated with significant direct and indirect costs, comorbid depression, and impairment. (Am J Psychiatry 2001; 158:1999-2007)

Objective: Quality-of-life indices have been used in medical practice to estimate the impact of different diseases on functioning and well-being and to compare outcomes between different treatment modalities. An integrated view of the issue of quality of life in patients with anxiety disorders can provide important information regarding the nature and extent of the burden associated with these disorders and may be useful in the development of strategies to deal with it. Method: A review of epidemiological and clinical studies that have investigated quality of life (broadly conceptualized) in patients with panic disorder, social phobia, posttraumatic stress disorder, generalized anxiety disorder, and obsessive-compulsive disorder was conducted by searching MEDLINE and Psyc-LIT citations from 1984 to 1999. A summary of the key articles published in this area is presented. Results: The studies reviewed portray an almost uniform picture of anxiety disorders as illnesses that markedly compromise quality of life and psychosocial functioning. Significant impairment can also be found in individuals with subthreshold forms of anxiety disorders. Effective pharmacological or psychotherapeutic treatment has been shown to improve the quality of life for patients with panic disorder, social phobia, and posttraumatic stress disorder. Limitations in current knowledge in this area are identified, and suggestions for needed future research are provided. Conclusions: It is expected that a more thorough understanding of the impact on quality of life will lead to increased public awareness of anxiety disorders as serious mental disorders worthy of further investment in research, prevention, and treatment.

Objective: The purpose of this study was to determine the efficacy of fluvoxamine for the treatment of social phobia (social anxiety disorder). Method: In a 12-week multicenter, double-blind, randomized, placebo-controlled trial, 92 patients with social phobia were treated with the selective serotonin reuptake inhibitor fluvoxamine; 91.3% of the patients had the generalized subtype of the disorder. The primary criterion for response was a rating of 'much improved' or 'very much improved' on the Clinical Global Impression of Improvement scale. Secondary response criteria were changes on three specialized rating scales for social phobia symptoms: the Brief Social Phobia Scale, the Social Phobia Inventory, and the Liebowitz Social Anxiety Scale. Psychosocial impairment was assessed in three domains (disruption of work, social life, and home/family life) by using the Sheehan Disability Scale. Results: The mean daily dose of fluvoxamine was 202 mg (SD = 86). At study end or with the last observation carried forward, within the evaluable subjects (N = 86) there was a significantly higher proportion of responders in the fluvoxamine group (42.9%, N = 18) than in the placebo group (22.7%, N = 10). Similarly, fluvoxamine was superior to placebo on all social phobia rating scales at week 8 and beyond. Fluvoxamine also resulted in significantly greater decreases in measures of psychosocial disability than did placebo. Overall, fluvoxamine was well tolerated and safe. Conclusions: These findings indicate that fluvoxamine is efficacious in the pharmacologic management of serious forms of social phobia.

Objective: In attempting to explain the familial predisposition to panic disorder, most studies have focused on the heritability of physiologic characteristics (e.g., [CO.sub.2] sensitivity). A heretofore unexplored possibility is that a psychological characteristic that predisposes to panic - anxiety sensitivity - might be inherited. In this study, the authors examined the heritability of anxiety sensitivity through use of a twin group. Method: Scores on the Anxiety Sensitivity Index were examined in a group of 179 monozygotic and 158 dizygotic twin pairs. Biometrical model fitting was conducted through use of standard statistical methods. Results: Broad heritability estimate of the Anxiety Sensitivity Index as a unifactorial construct was 45%. Additive genetic effects and unique environmental effects emerged as the primary influences on anxiety sensitivity. There was no evidence of genetic discontinuity between normal and extreme scores on the Anxiety Sensitivity Index. Conclusions: This study suggests that one psychological risk factor for the development of panic disorder - anxiety sensitivity - may have a heritable component. As such, anxiety sensitivity should be considered in future research on the heritability of panic disorder.

Objective: This article presents epidemiologic data on the distinction between social phobia characterized by pure speaking fears and that characterized by other social fears. Method: The data come from the National Comorbidity Survey (N = 8,098). Social phobia was assessed with a revised version of the Composite International Diagnostic Interview. Results: Latent class analysis showed that the brief set of social fears assessed in the survey can be disaggregated into a class characterized largely by speaking fears and a second class characterized by a broader range of social fears. One-third of the people with lifetime social phobia exclusively reported speaking fears, while the other two-thirds also had at least one of the other social fears assessed. The vast majority of the latter had multiple social fears including, in most cases, both performance and interactional fears. The two subtypes were similar in age at onset distribution, family history, and certain sociodemographic correlates. However, the social phobia characterized by pure speaking fears was less persistent, less impairing, and less highly comorbid with other DSM-III-R disorders than was social phobia characterized by other social fears. Conclusions: Further general population research assessing more performance and interaction fears is needed to determine whether social phobia subtypes can be refined and whether the subtypes are better conceptualized as distinct disorders. In the meantime, people who have social phobia with multiple fears, some of which are nonspeaking fears, appear to have the most impairment and should be the main focus of prevention and intervention efforts.

In a study of the prevalence of panic and other anxiety disorders in persons with complaints of dizziness, 87 patients referred to a clinic for vestibular disorders completed self-rating measures of anxiety and depression; 32 also underwent a structured diagnostic interview. Thirteen (14.9%) of the patients met the DSM-III-R criteria for panic disorder, agoraphobia, or both. They rated themselves as much more disabled by their dizziness than the patients with no psychiatric disorder. Panic disorder was equally prevalent among patients with and without vestibular disease. In some cases panic disorder may provide an explanation for the dizziness, whereas in others it may be a comorbid condition compounding the disability attributable to the vestibular disorder.

Objective: The goal of this study was to gain a broader perspective on social anxiety in the community than has been achieved by epidemiologic surveys to date. Method: The authors conducted a telephone survey of social anxiety among 526 randomly selected respondents in a medium-sized Canadian city. Results: Sixty-one percent of the respondents reported being much or somewhat more anxious than other people in at least one of the seven social situations surveyed. Speaking to a large audience (i.e., public speaking) was the most frequently feared situation (endorsed by 55.0% of the respondents), followed by speaking to a small group of familiar people (24.9%), dealing with people in authority (23.3%), attending social gatherings (14.5%), speaking to strangers or meeting new people (13.7%), and eating (7.1%) or writing (5.1%) in front of others. When the threshold for caseness was systematically modified - by altering the required level of psychosocial interference or distress or by including or excluding subjects with pure public speaking phobia - the rate of 'social anxiety syndrome' in the community varied from 1.9% to 18.7%; 7.1% was the prevalence when the criteria were set to conform with DSM-III-R. Conclusions: Social anxiety is common in the community, but precise delineation of the prevalence of 'social phobia' depends heavily on where the diagnostic threshold is set. If DSM-III-R criteria had been applied in previous epidemiologic studies, it is likely that those studies would have documented prevalences of social phobia that are several times as high as the currently accepted rates.

Previous research has indicated that individuals with Parkinson's disease are at higher risk for psychiatric disorders. Depression and dementia (impaired cognitive function), in particular, have been associated with victims of Parkinson's disease. Drugs that are typically prescribed for this disorder include compounds that influence brain chemistry and may result in psychiatric symptoms such as delirium and psychosis. Twenty-four patients with Parkinson's disease but no symptoms of dementia participated in this study. Clinical data were obtained and the prevalence of previous psychiatric disorders in these individuals was assessed. Thirty-eight percent (nine individuals) of the patients were diagnosed with an anxiety disorder that was considered clinically significant. This was greater than the five to 15 percent incidence of anxiety disorders estimated in the general population. Lifetime prevalence of social phobia or panic disorder was also higher in the study group. Three general explanations were suggested to account for these results. Anxiety disorders may be the result of a reaction by the individual to having a chronic debilitating illness; psychiatric symptoms may also be a side effect of the drug treatments given for this disease - L-dopa, in particular, is know to cause increased motor fluctuations; and finally, anxiety disorders may be a direct result of the progression of Parkinson's disease, the causal mechanism of which is currently unknown. Because the results of this trial have raised additional questions concerning Parkinson's disease, more research is recommended. (Consumer Summary produced by Reliance Medical Information, Inc.)

Objective: Posttraumatic stress disorder (PTSD), particularly in combat veterans with chronic illness, is often refractory to standard pharmacological interventions. There is a need to test adjunctive treatments to boost response. Method: Subjects were 19 patients with PTSD who were minimally responsive to 12 weeks of treatment with a selective serotonin reuptake inhibitor (SSRI) at maximum tolerated dose. Outcomes were compared among subjects whose treatment was augmented with 8 weeks of double-blind olanzapine or placebo administration. Results: Olanzapine augmentation was associated with statistically significantly greater reduction than placebo in specific measures of posttraumatic stress, depressive, and sleep disorder symptoms. Clinician-rated global response rates did not, however, significantly differ between groups. Conclusions: This is most likely the first double-blind, placebo-controlled study of an adjunct to SSRIs for PTSD. Despite the small group size, the findings suggest a role for olanzapine or other atypical antipsychotics in treating SSRI-resistant PTSD. Sleep symptoms may especially benefit. (Am J Psychiatry 2002; 159:1777-1779)

The authors compared the maximal duration of voluntary breath-holding in patients with panic disorder (N = 23), patients with generalized social phobia (N = 10), and healthy subjects (N = 26). Patients with panic disorder had significantly shorter breath-holding durations than either comparison group. Groups did not otherwise differ in physiologic response to the breath-holding. Implications for a false suffocation alarm in panic disorder are discussed.

Depression has long been associated with panic disorders and agoraphobia, fear of being in places or situations from which escape might be difficult or where help may not be available if a panic attack occurs. Between 25 and 75 percent of patients with panic disorders also have a problem with depression. Another condition related to panic disorder is social phobia, a persistent fear of situations where there is the possibility of scrutiny by others or where the individual may be embarrassed or humiliated. Thus far, there is little research on the relationship between social phobia and panic disorder, but some studies have indicated that there is an overlap between the two conditions. The extent and incidence of depression were examined in 63 patients with social phobia and in 54 patients with panic disorder. The data were derived from diagnostic interviews that were conducted at an anxiety clinic, and individuals were selected on the basis of criteria in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R). No significant differences in gender, martial status, or age were found. However, panic disorder was associated with a higher incidence of depression than was social phobia. Sixty-three percent (34 individuals) of the patients with panic disorders had experienced major depression, whereas only 35 percent (22 patients) with social phobia had experienced at least one major episode of depression. These results indicate that rates of major depression vary among anxiety disorders; this may also be related to the degree of functional impairment that the anxiety disorder causes. The clinical implications of these findings are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)