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Negative or stressful life events are robust risk factors for depression and anxiety. Less attention has been paid to the positive aspects of events and whether positivity buffers the impact of the negative aspects of events. In this study, we examined the positivity and negativity of interpersonal and noninterpersonal episodic life events in predicting anxiety and depressive symptoms in a sample of 373 young adults. Regressions tested the main and interactive effects of positivity and negativity ratings of events in predicting symptom factors (fears, anhedonia-apprehension, general distress) relevant to anxiety and depression. A significant interaction demonstrated that positivity protected against high levels of negativity of noninterpersonal events in predicting general distress. A main effect of interpersonal negativity predicting higher anhedonia-apprehension was observed. Results for fears were nonsignificant. Findings suggest that the positivity of life events may buffer against negativity in predicting symptoms shared between anxiety and depression.

Disparities in treatment engagement and adherence based on ethnicity have been widely recognized but are inadequately understood. Few studies have examined treatment dropout among Latinx and non-Latinx White (NLW) individuals. Using Andersen's Behavioral Model of Health Service Use (A behavioral model of families' use of health services. 1968; J Health Soc Behav.1995; 36:1–10) as a framework, we examine whether pretreatment variables (categorized as predisposing, enabling, and need factors) mediate the relationship between ethnicity and premature dropout in a sample of Latinx and NLW primary care patients with anxiety disorders who participated in a randomized controlled trial (RCT) of cognitive behavioral therapy. Data from a total of 353 primary care patients were examined; 96 Latinx and 257 NLW patients participated. Results indicated that Latinx patients dropped out of treatment more often than NLW patients, resulting in roughly 58% of Latinx patients failing to complete treatment compared with 42% of NLW, and approximately 29% of Latinx patients dropping out before engaging in modules related to cognitive restructuring or exposure, relative to 11% of NLW patients. Mediation analyses suggest that social support and somatization partially explained the relationship between ethnicity and treatment dropout, highlighting the importance of these variables in understanding treatment disparities.

Individual responses to behavioral treatment of anxiety disorders vary considerably, which requires a better understanding of underlying processes. In this study, we examined the violation and change of threat beliefs during exposure. From 8,484 standardized exposure records of 605 patients with different anxiety disorders, learning indicators were derived: expectancy violation as mismatch between threat expectancy before exposure and threat occurrence, expectancy change as difference between original and adjusted expectancy after exposure, and prediction-error learning rate as extent to which expectancy violation transferred into change. Throughout sessions, high threat expectancy but low occurrence and adjusted expectancy indicated successful violation and change of threat beliefs by exposure. Expectancy violation, change, and learning rate substantially varied between patients. Not expectancy violation itself, but higher learning rate and expectancy change predicted better treatment outcome. Successful exposure thus requires expectancy violation to induce actual expectancy change, supporting learning from prediction error as transdiagnostic mechanism underlying successful exposure therapy.

Owing to high heterogeneity and comorbidity, the shared and unique neural mechanisms underlying the development of anxiety and major depressive disorders remain unclear. Using a dimensional model describing shared versus unique symptoms associated with anxiety and depression, this study investigated how longitudinal changes in symptom dimensions relate to threat neurocircuitry.

In this study, we examined how Big Five personality traits relate to outcome-based resilience in primarily female, upper-middle class, ethnically diverse U.S. adolescents (baseline N= 535; age range = 15–17) oversampled on elevated neuroticism. Cross-sectional, prospective-longitudinal, and dynamic analyses were performed with 8-year longitudinal data. Using a residualization approach, we approximated resilience as low stressor reactivity, calculated by regressing depression and anxiety diagnosis severity onto chronic stressor exposure over 1-year periods. Cross-sectional associations with stressor reactivity were observed for neuroticism (positive), extraversion (negative), openness (positive), and conscientiousness (negative). A positive prospective-longitudinal association with stressor reactivity was observed for neuroticism. In contemporaneous and lagged dynamic analyses, within-persons dynamics and mean levels of neuroticism (positive) and extraversion (negative) were associated with stressor reactivity. There were also unique associations with stressor reactivity for neuroticism (positive), extraversion (negative), and agreeableness (positive). Results indicate relevance of mean levels and intraindividual dynamics of personality, particularly neuroticism, for resilience in adolescents.

The amygdala is highly implicated in an array of psychiatric disorders but is not accessible using currently available noninvasive neuromodulatory techniques. Low-intensity transcranial focused ultrasound (TFUS) is a neuromodulatory technique that has the capability of reaching subcortical regions noninvasively.

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.

The clinical construct of “anxiety neurosis” was broad and poorly defined, so that the delineation of specific anxiety disorders in the DSM‐III was an important advance. However, anxiety and related disorders are not only frequently comorbid, but each is also quite heterogeneous; thus diagnostic manuals provide only a first step towards formulating a management plan, and the development of additional decision support tools for the treatment of anxiety conditions is needed. This paper aims to describe systematically important domains that are relevant to the personalization of management of anxiety and related disorders in adults. For each domain, we summarize the available research evidence and review the relevant assessment instruments, paying special attention to their suitability for use in routine clinical practice. We emphasize areas where the available evidence allows the clinician to personalize the management of anxiety conditions, and we point out key unmet needs. Overall, the evidence suggests that we are becoming able to move from simply recommending that anxiety and related disorders be treated with selective serotonin reuptake inhibitors, cognitive‐behavioral therapy, or their combination, to a more complex approach which emphasizes that the clinician has a broadening array of management modalities available, and that the treatment of anxiety and related disorders can already be personalized in a number of important respects.

Dimensional models of anxiety and depression highlight common and distinct symptom clusters that are thought to reflect disruptions in underlying functional processes. The current study investigated how functioning of threat neurocircuitry relates to symptom dimensions of anxiety and depression. Participants were aged 18–19 years (n= 229, 158 female) and were selected to ensure a range of scores on symptom measures. Symptom dimensions of “General Distress” (common to anxiety disorders and depression), “Fears” (more specific to anxiety disorders), and “Anhedonia-apprehension” (more specific to depression) were evaluated. Participants underwent functional magnetic resonance imaging during a Pavlovian fear conditioning paradigm. Multilevel modeling analyses estimated relationships between symptom dimensions and activation in threat neural circuitry. Exploratory whole brain analyses were also conducted. Threat-related neural activity was not associated with General Distress or Fears. Anhedonia-apprehension was associated with activation of bilateral amygdala, anterior insula and dACC during late extinction. We found no evidence to support an association between symptom dimensions of General Distress or Fears with threat circuitry activation in a large sample of young adults. We did, however, find that the symptom dimension of Anhedonia-apprehension was significantly associated with threat-related neural activation during fear extinction. This effect requires replication in future work but may reflect anhedonic impairments in learning when contingencies are altered, possibly linked to the rewarding relief of an unexpectedly absent threat.

Anterior cingulate cortex (ACC) response during attentional control in the context of task-irrelevant emotional faces is a promising biomarker of cognitive behavioral therapy (CBT) outcome in patients with social anxiety disorder (SAD). However, it is unclear whether this biomarker extends to major depressive disorder (MDD) and is specific to CBT outcome. In the current study, 72 unmedicated patients with SAD (n= 39) or MDD (n= 33) completed a validated emotional interference paradigm during functional magnetic resonance imaging before treatment. Participants viewed letter strings superimposed on task-irrelevant threat and neutral faces under low perceptual load (high interference) and high perceptual load (low interference). Biomarkers comprised anatomy-based rostral ACC (rACC) and dorsal ACC (dACC) response to task-irrelevant threat (>neutral) faces under low and high perceptual load. Patients were randomly assigned to 12 weeks of CBT or supportive therapy (ST) (ClinicalTrials.gov identifier: NCT03175068). Clinician-administered measures of social anxiety and depression severity were obtained at baseline and every 2 weeks throughout treatment (7 assessments total) by an assessor blinded to the treatment arm. A composite symptom severity score was submitted to latent growth curve models. Results showed more baseline rACC activity to task-irrelevant threat>neutral faces under low, but not high, perceptual load predicted steeper trajectories of symptom improvement throughout CBT or ST. Post-hoc analyses indicated this effect was driven by subgenual ACC (sgACC) activation. Findings indicate ACC activity during attentional control may be a transdiagnostic neural predictor of general psychotherapy outcome.

Maladaptive emotion regulation and dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning are characteristic of depression and anxiety. However, little research examines whether and how emotion regulation affects HPA axis functioning. We utilized an experience sampling methodology to examine associations between three emotion regulation strategies (problem solving, disengagement, and emotional expression/support seeking) and diurnal cortisol rhythms and reactivity in everyday life. Participants were young adults with current, past, or no history of internalizing disorders (depression or anxiety; N= 182). Across participants, problem solving was associated with an elevated cortisol awakening response (CAR), whereas disengagement was associated with a steeper cortisol slope. Only for individuals with internalizing disorders was momentary problem solving and emotional expression/support seeking associated with higher cortisol reactivity and emotional expression/support seeking associated with a flatter diurnal slope and blunted CAR. Results provide insight into associations between emotion regulation and day-to-day HPA axis functioning.

Neuroticism has been associated with depression and anxiety both cross-sectionally and longitudinally. Interpretive bias has been associated with depression and anxiety, primarily in cross-sectional and bias induction studies. The purpose of the current study was to examine the role of interpretive bias as a prospective risk factor and a mediator of the relation between neuroticism and depressive and anxious symptoms in young adults assessed longitudinally. Neuroticism significantly predicted a broad general-distress dimension but not intermediate fears and anhedonia-apprehension dimensions or a narrow social-fears dimension. Neuroticism also significantly predicted negative interpretive bias for social scenarios. Negative interpretive bias for social scenarios did not significantly predict dimension scores, nor did it mediate the relation between neuroticism and general distress or social fears. These results suggest that although neuroticism relates to negative interpretive bias, its risk for symptoms of depression and anxiety is at most weakly conferred through negative interpretive bias.

This paper provides a methodological description of a multi-site, randomized controlled trial (RCT) of a cognitive-behavioral intervention for enhancing employment success among unemployed persons whose employment efforts have been undermined by social anxiety disorder (SAD). SAD is a common and impairing condition, with negative impacts on occupational functioning. In response to these documented employment-related impairments, in a previous project, we produced and tested an eight-session work-related group cognitive-behavioral therapy provided alongside vocational services as usual (WCBT+VSAU). WCBT is delivered by vocational service professionals and is designed in a context and style that overcomes accessibility and stigma-related obstacles with special focus on employment-related targets. Our previous project found that WCBT+VSAU significantly improved social anxiety, depression, and a range of employment-related outcomes compared to a control group of socially anxious job-seekers who received vocational services as usual without WCBT (VSAU-alone). Participants in this study were all homeless, primarily African American job-seekers with high levels of psychiatric comorbidity and limited education and employment histories. The present, two-region study addresses whether WCBT+VSAU enhances job placement, job retention and mental health outcomes in a larger sample assessed over an extended follow-up period. In addition, this trial evaluates whether the effects of WCBT+VSAU generalize to a new population of urban-based, racially diverse job-seekers with vocational and educational histories that differ from our original sample. This study also investigates the system-effects of WCBT+VSAU in a new site that will be informative for broad implementation of WCBT+VSAU. Finally, this project involves a refined, technology-assisted form of WCBT+VSAU designed to be delivered more easily by vocational services professionals.

Research has demonstrated that stressors play a critical role in the development of generalized anxiety disorder (GAD), social anxiety disorder (SAD), and major depressive disorder (MDD). Separately, deficits in positive affect (PA) have been identified in GAD, SAD, and MDD. Whereas previous research has linked the buffering effects of PA in chronic illness, such effects have yet to be investigated for chronic stressors and emotional disorder–related symptom severity. The purpose of the present study was to examine PA as a moderator of chronic interpersonal and noninterpersonal stress on GAD, SAD, and MDD symptom severity. Using a multilevel statistical approach with a sample of adolescents and young adults (N= 463), PA was found to moderate significantly the relationship between chronic interpersonal stress and symptom severity for MDD and SAD. Findings suggest that in times of chronic interpersonal stress, higher PA may serve as a buffer from development of SAD and MDD symptoms.

•Anxiety and PTSD show disrupted amygdala-vmPFC functioning during fear conditioning.•There is limited investigation of disruptions in fear conditioning in depression.•Psychological treatments alter activity and connectivity in survival circuitry.•Future work should consider dimensional assessments and role of reward circuitry.

The antihypertensive drug losartan has been shown to improve memory in humans as well as learning and fear extinction in rodent models, highlighting its potential to have similar synergistic effects on exposure-based cognitive behavioral therapy for anxiety disorders. This study investigated the effect of losartan on neural correlates of processing threat versus safety stimuli in highly anxious individuals to identify potential pathways of how the drug might facilitate psychological treatment.

Increased neural error monitoring, as measured by the error-related negativity (ERN), is a transdiagnostic neurobiological marker of anxiety. To date, little is known about whether the ERN can inform the choice between first-line anxiety disorder treatments and whether the ERN changes following treatment completion. The aim of the study was to therefore assess whether the ERN is a treatment moderator and index of symptom change during cognitive-behavioral therapy (CBT) or selective serotonin reuptake inhibitors (SSRIs). Participants included adult volunteers (Mage=25.8±8.5; 67% female) with principal anxiety disorders (n=60) or no lifetime history of Axis I psychopathology (ie, healthy controls; n=26). A flanker task was used to elicit the ERN at baseline and 12 weeks later, following either CBT or SSRIs in the patient sample. Results indicated that baseline ERN was a significant treatment moderator such that a more enhanced baseline ERN was associated with greater reduction in anxiety symptoms within individuals who received CBT but not SSRIs. Results also revealed that the ERN increased pre- to post-treatment among patients randomized to SSRIs, but remained stable among patients randomized to CBT and healthy controls. Together, these novel findings highlight that ERN may help guide treatment decisions regarding engagement in CBT or SSRIs, especially among individuals with an enhanced ERN. The findings also suggest that SSRIs have the capacity to alter individual differences in the ERN, providing evidence that the ERN is not entirely static in patients with anxiety disorders.

Maternal postnatal depression occurs following 10–15% of births and is associated with a range of negative child outcomes. Risks to children are particularly increased when postnatal depression is persistent. We aimed to examine whether a parenting video-feedback therapy (VFT) intervention versus a control treatment of progressive muscle relaxation (PMR), both added to cognitive behavioural therapy (CBT) for persistent postnatal depression, would lead to improved child outcomes at age 2 years.

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions—including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal—is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.(Reprinted and permission from Lancet2016; 388: 3048-59)

Background:Many patients with anxiety disorders remain symptomatic after receiving evidence-based treatment, yet research on treatment-resistant anxiety is limited. We evaluated effects of cognitive behavioral therapy (CBT) on outcomes of patients with medication-resistant anxiety disorders using data from the Coordinated Anxiety Learning and Management (CALM) trial.Methods:Primary care patients who met study entry criteria (including DSM-IVdiagnosis of generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or social anxiety disorder) despite ongoing pharmacotherapy of appropriate type, dose, and duration were classified as medication resistant (n= 227). Logistic regression was used to estimate effects of CALM's CBT program (CALM-CBT; chosen by 104 of 117 medication-resistant patients randomized to CALM) versus usual care (UC; n= 110) on response [≥ 50% reduction of 12-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptom score] and remission (BSI-12 < 6) at 6,12, and 18 months. Within-group analyses examined outcomes by treatment choice (CBT vs. CBT plus medication management) and CBT dose.Results:Approximately 58% of medication-resistant CALM-CBT patients responded and 46% remitted during the study. Relative to UC, CALM-CBT was associated with greater response at 6 months (AOR = 3.78, 95% CI 2.02-7.07) and 12 months (AOR = 2.49, 95% CI 1.36-4.58) and remission at 6,12, and 18 months (AORs = 2.44 to 3.18). Patients in CBT plus medication management fared no better than those in CBT only. Some evidence suggested higher CBT dose produced better outcomes.Conclusions:CBT can improve outcomes for patients whose anxiety symptoms are resistant to standard pharmacotherapy.(Reprinted with permission From Depression and Anxiety2016; 33: 1099–1106)

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions—including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal—is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin–noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Neuroticism and several other traits have been proposed to confer vulnerability for unipolar mood disorders (UMDs) and anxiety disorders (ADs). However, it is unclear whether the associations of these vulnerabilities with these disorders are attributable to a latent variable common to all vulnerabilities, more narrow latent variables, or both. In addition, some researchers have suggested that neuroticism predicts UMDs, ADs, and substance use disorders (SUDs) with comparable strength, whereas other researchers have hypothesized that neuroticism is more strongly related to UMDs and ADs. We tested hypotheses about the factor structure of several vulnerabilities and the prospective associations of these latent variables with initial onsets of UMDs, ADs, and SUDs during a 3-year period in 547 participants recruited as high school juniors. Although a general neuroticism factor predicted SUDs, it predicted UMDs and ADs more strongly and especially predicted comorbid UMDs and ADs. There was also mixed support for specific associations involving more narrow latent vulnerabilities.

Variation in the CD38 gene, which regulates secretion of the neuropeptide oxytocin, has been associated with several social phenotypes. Specifically, rs3796863 Aallele carriers have demonstrated increased social sensitivity. In 400 older adolescents, we used trait-state-occasion modeling to investigate how rs3796863 genotype, baseline ratings of chronic interpersonal stress, and their gene–environment (G×E) interaction predicted trait social anxiety and depression symptoms over 6 years. We found significant G×E effects for CD38 A-carrier genotypes and chronic interpersonal stress at baseline predicting greater social anxiety and depression symptoms. A significant G×E effect of smaller magnitude was also found for C/Cgenotype and chronic interpersonal stress predicting greater depression; however, this effect was small compared with the main effect of chronic interpersonal stress. Thus, in the context of chronic interpersonal stress, heightened social sensitivity associated with the rs3796863 Aallele may prospectively predict risk for social anxiety and (to a lesser extent) depression.

Psychobiological research with adolescent populations tends to focus on negative mood, stress, and psychopathology, but the role of positive emotions is insufficiently understood. The current study examines the relative contributions of both negative and positive affective experiences to the basal activity of the hypothalamic-pituitary-adrenal axis, measured by levels of cortisol across the waking day.

Although exposure therapy is an effective treatment for anxiety disorders, fear sometimes returns following successful therapy. The Rescorla–Wagner model predicts that presenting two fear-provoking stimuli simultaneously (compound extinction) will maximize learning during exposure and reduce the likelihood of relapse. Participants were presented with either single extinction trials only or single extinction trials followed by compound extinction trials. In addition, participants within each extinction group were randomized to caffeine or placebo ingestion prior to extinction to investigate the mechanism by which compound extinction may maximize learning (enhanced associative change or enhanced responding). Participants presented with compound trials demonstrated significantly less fear responding at spontaneous recovery compared with participants who received single extinction trials only. Ingestion of caffeine also provided some protection from spontaneous recovery (as measured by valence ratings). At the reinstatement test, only compound extinction trials predicted less fear responding; caffeine ingestion prior to extinction did not attenuate reinstatement effects.

ObjectiveThis article reports on the test–retest reliability and sensitivity to change of a set of brief dimensional self-rating questionnaires for social anxiety disorder (SAD-D), specific phobia (SP-D), agoraphobia (AG-D), panic disorder (PD-D), and generalized anxiety disorder (GAD-D), as well as a general cross-cutting anxiety scale (Cross-D), which were developed to supplement categorical diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).MethodsThe German versions of the dimensional anxiety scales were administered to 218 students followed up approximately 2 weeks later (Study 1) and 55 outpatients (23 with anxiety diagnoses) followed-up 1 year later (Study 2). Probable diagnostic status in students was determined by the DIA-X/M-CIDI stem screening-questionnaire (SSQ). In the clinical sample, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses were assessed at Time 1 using the DIA-X/M-CIDI. At Time 2, the patient-version of the Clinical Global Impression—Improvement scale (CGI-I) was applied to assess change.ResultsGood psychometric properties, including high test–retest reliability, were found for the dimensional scales except for SP-D. In outpatients, improvement at Time 2 was associated with significant decrease in PD-D, GAD-D, and Cross-D scores.DiscussionMajor advantages of the scales include that they are brief, concise, and based on a consistent template to measure the cognitive, physiological, and behavioral symptoms of fear and anxiety. Further replication in larger samples is needed. Given its modest psychometric properties, SP-D needs refinement.ConclusionIncreasing evidence from diverse samples suggests clinical utility of the dimensional anxiety scales.

Meta-analytic evidence has supported a gene-environment interaction between life stress and the serotonin transporter–linked polymorphism (5-HTTLPR) on depression, but few studies have examined factors that influence detection of this effect, despite years of inconsistent results. We propose that the candidate environment (akin to a candidate gene) is key. Theory and evidence have implicated major stressful life events (SLEs)—particularly major interpersonal SLEs—as well as chronic family stress. A total of 400 participants from the Youth Emotion Project (which began with 627 high school juniors oversampled for high neuroticism) completed up to five annual diagnostic and stress interviews and provided DNA samples. A significant gene-environment effect for major SLEs and S-carrier genotype was accounted for significantly by major interpersonal SLEs but not significantly by major noninterpersonal SLEs. S-carrier genotype and chronic family stress also significantly interacted. Identifying such candidate environments may facilitate future gene-environment research in depression and psychopathology more broadly.

Elevated responding to safety cues in the context of threat is associated with anxiety disorder onset, but pathways underlying such responding remain unclear. In this study, we examined whether childhood/adolescent adversity was associated with larger startle reflexes during safe phases of a fear-potentiation startle paradigm (following delivery of an aversive stimulus) that predict anxiety disorders. Participants (N= 104) came from the Youth Emotion Project, a longitudinal study of risk factors for emotional disorders. Participants with no baseline psychopathology underwent a startle-modulation protocol and assessment for childhood and adolescent adversities using a validated interview. Adolescent adversity was associated with larger startle reflexes during the safe phases following an aversive stimulus. Neither child adversities nor adolescent adversities were associated with responding during any other phase of the protocol. These findings suggest a pathway between adolescent adversity and a risk factor for anxiety disorders in which adolescent adversity contributes to impaired responding to safety cues.

To evaluate the effects of medical comorbidity on anxiety treatment outcomes.

There will be several changes to the diagnosis of obsessive–compulsive and related disorders (OCRDs) in DSM-5. Several disorders, including body dysmorphic disorder (BDD), hoarding disorder (HD), trichotillomania (hair-pulling disorder) (TTM), and excoriation (skin-picking) disorder (SPD), will be included alongside obsessive compulsive disorder (OCD) in a distinct diagnostic category of OCRDs. Also, dimensional assessments of psychopathology will be included to supplement traditional categorical diagnoses. The DSM-5 subworkgroup on obsessive–compulsive spectrum disorders developed a set of brief self-rated scales for BDD, HD, TTM, and SPD that are consistent in content and structure, reflect DSM-5 criteria, and can be used by clinicians to help generate a dimensional severity rating for the disorders. In the present paper, we discuss the scales’ creation and examine their psychometric properties in a large non-clinical sample (n=296). The scales each demonstrated a single factor structure, strong internal consistency (α=.80–.89), convergent validity (rs=.74–.92), and significantly higher total scores in individuals who indicated the presence of the respective disorder’s core symptom on a binary diagnostic screener (Cohen’s d=0.57–2.18). The results provide support for further evaluation of these scales in clinical samples and take an important step toward the integration of standardized dimensional measurement into DSM-5.

Large racial disparities in the use of mental health care persist. Differences in treatment preferences could partially explain the differences in care between minority and nonminority populations. We compared beliefs about mental illness and treatment preferences between adult African-Americans, Hispanics, Asian Americans, Native Americans, and White Americans with diagnosed anxiety disorders. Measures of beliefs about mental illness and treatment were drawn from the National Comorbidity Survey Replication and from our previous work. There were no significant differences in beliefs between the African-Americans and the White Americans. The beliefs of the Hispanics and the Native Americans were most distinctive, but the differences were small in magnitude. Across raceethnicity, the associations between beliefs and service use were generally weak and statistically insignificant. The differences in illness beliefs and treatment preferences do not fully explain the large, persistent racial disparities in mental health care. Other crucial barriers to quality care exist in our health care system and our society as a whole.

To examine a large sample of patients with anxiety and the association between types of complementary and alternative treatments that were used, demographic variables, diagnostic categories, and treatment outcomes.

This case study of combined anxiety with both alcohol and benzodiazepine dependence illustrates key issues in presentation, differential diagnosis and management. The case is discussed from a biopsychosocial perspective with each of the discussants focusing on their particular area of experience and expertise, then the treatment package is presented in an integrated fashion. Of particular interest is how social anxiety disorder may become a significant barrier to engagement and retention, and thus outcome in persons presenting for addiction treatment, and how a treatment plan for such patients can be built.

Anxiety disorders commonly occur among those with substance use disorders. This article reviews the literature describing the prevalence and patterns of this comorbidity in epidemiological and clinical samples and theoretical models explaining this comorbidity, and reviews the effects of anxiety disorders on substance use outcomes and data from clinical trials that target comorbid anxiety disorders to examine the effects of treating anxiety disorders on substance use outcomes. Next, this review outlines evidence-based pharmacological and psychological treatments for anxiety disorders and provides treatment recommendations for those treating this comorbid population. Finally, a discussion of treatment-delivery issues is presented to address the important issues that arise when treating anxiety disorders in typical addictions-treatment settings.

This study's aim was to prospectively examine and identify a model of demographic, clinical, and attitudinal variables that impact improvement among patients with panic disorder. Subjects were 232 primary care patients meeting criteria for DSM-IV panic disorder. Eligible patients were randomly assigned to a collaborative care intervention or to treatment as usual. Assessments occurred at 3-month intervals during the course of 1 year. In final multivariate logistic regression models, patients with higher anxiety sensitivity and higher neuroticism scores at baseline were less likely to show clinical improvement (using a criterion of 20 or less on the Anxiety Sensitivity Index) at 3 months. Those who were non-white, had higher anxiety sensitivity, and higher overall phobic avoidance at baseline were less likely to show clinical improvement at 12 months. A greater understanding of these predictors may help clinicians identify who is at greatest risk for persistent panic-related symptoms and to plan the intensity of interventions accordingly.

Early life adversity (ELA) has been linked to higher depression risk across the lifespan, as well as chronic inflammatory conditions that contribute to earlier mortality. In the present study we characterized innate immune responses to acute social stress in a community sample of adolescents (mean age 13.9±1.6; 46.4% female) as a potential pathway linking ELA and depression pathogenesis.

Pavlovian learning processes are central to the etiology and treatment of anxiety disorders. Anhedonia and related perturbations in reward processes have been implicated in Pavlovian learning. Associations between anhedonia symptoms and neural indices of Pavlovian learning can inform transdiagnostic associations among depressive and anxiety disorders.

Accumulating psychobiological data implicate reward disturbances in the persistence of anorexia nervosa (AN). Evidence suggests that individuals with AN demonstrate decision-making deficits similar to those with mood and anxiety disorders that cause them to under-respond to many conventionally rewarding experiences (e.g., eating, interacting socially). In contrast, unlike individuals with other psychiatric disorders, individuals with AN simultaneously over-respond to rewards associated with eating-disorder behaviors (e.g., restrictive eating, exercising). This pattern of reward processing likely perpetuates eating-disorder symptoms, as the rewards derived from eating-disorder behaviors provide temporary relief from the anhedonia associated with limited responsivity to other rewards. Positive Affect Treatment (PAT) is a cognitive-behavioral intervention designed to target reward deficits that contribute to anhedonia in mood and anxiety disorders, including problems with reward anticipation, experiencing, and learning. PAT has been found to promote reward responsivity and clinical improvement in mood and anxiety disorders. This manuscript will: (1) present empirical evidence supporting the promise of PAT as an intervention for AN; (2) highlight nuances in the maintaining processes of AN that necessitate adaptations of PAT for this population; and (3) suggest future directions in research on PAT and other reward-based treatments that aim to enhance clinical outcomes for AN.

Visceral hypersensitivity and symptom severity in Irritable Bowel Syndrome (IBS) are both exacerbated by stress. The eye-blink startle response represents a noninvasive measure of central defensive responding. Evidence for central hyperexcitability was studied in IBS patients by examining potentiation of the startle reflex to a nociceptive threat.

The objective of this study was to examine the relative impact of anxiety disorders and major depression on functional status and health-related quality of life of primary care outpatients.

Studies have documented the increasing use of complementary and alternative medicine over the last decade, especially in distressed individuals with symptoms of anxiety, depression, and pain. Herbal medicine is a specific form of complementary and alternative medicine often used by individuals seeing traditional medical practitioners and, hence, has the potential to interact with other medically prescribed treatments. The study examined the use of herbal medicine in a group of primary care patients with symptoms of anxiety and depression. The rate of use of herbal medicines was 11%, and use was selectively associated with a diagnosis of major depression, higher education, and a lower burden of medical illness. Use was not associated with receipt of pharmacotherapy or psychotherapy for anxiety or depression.

Effects of structured worry interviews were examined among analog-GAD and nonanxious college students. Thirty-four analog-GAD and 29 nonanxious control participants generated sequences of possible catastrophic outcomes for each of six worry topics using the Catastrophizing Interview Technique (Vasey and Borkovec, 1992). Threat ratings for each topic were collected, and ratings of subjective distress, likelihood of the feared outcome, and perceived control over the feared outcome were obtained immediately following each interview. Results indicated that the analog-GAD group rated the worry topics of achievement, social relations, and economics as more threatening than their nonanxious counterparts. The analog-GAD group also generated more catastrophizing steps and reported higher levels of negative mood following the worry interviews. In addition, the eventual fear underlying each worry was determined by coding the content of the final outcome step from each interview. Results from the coded interview responses indicated that fears of negative emotion and of failure were the most frequently coded categories in each of the six topical domains for the analog-GAD group. Although there was no difference in the proportion of negative emotion codes between analog-GAD and nonanxious groups, the analog-GAD group did receive a greater proportion of failure codes than the nonanxious control group. Results largely replicated the findings of Vasey and Borkovec in an analog-GAD sample. In addition, results suggest that fear of negative emotion underlies worry in general, regardless of diagnostic status, while fears of failure or ineffectiveness are more specific to GAD.

Nocturnal panic (NP), or waking from sleep in a state of panic, occurs in 18 to 45 of panic disorder patients. This relatively common phenomenon, however, is not well understood. In this study, the authors tested the hypotheses that NP represents a more severe form of panic disorder or is a manifestation of heightened vulnerability to sleep disturbance. Patients with NP (N51) were compared with patients with panic disorder without a history of NP (N41) on measures of panic disorder severity, comorbidity, interpersonal functioning, and sleep disturbance. There was no evidence for more severe psychopathology and only weak evidence for more sleep disturbance. Instead, patients with NP showed less agoraphobic avoidance, perhaps suggesting that they are less likely to associate panic with situational factors. The authors conclude that NP may be a specific version of panic disorder characterized by fearful associations with sleep and sleeplike states.

In this commentary we review the theoretical positions of Roemer and Orsillo and identify several key issues. First, the specificity of their arguments to generalized anxiety disorder (CAD) compared to the other anxiety disorders are explored. For example, the proposed distinctions between worry in CAD and worry associated with the other anxiety disorders are examined in light of available empirical evidence. Second, the proposed disjunctions between mental content and both actual experience and emotional/physiological responding are placed in the context of current theoretical and empirical work. Finally, possible therapeutic mechanisms of change for mindfulness/acceptance‐based treatments and the roles of control and predictability in anxiety disorder treatment are discussed.

While undergoing fMRI, six patients with DSM IV diagnosis of panic disorder and six normal controls performed directed imagery of neutral, moderate and high anxiety situations based on an individually determined behavioral hierarchy. Brain activity was compared during high vsneutral anxiety blocks for each group of subjects using SPM99b. Panic patients showed increased activity in inferior frontal cortex, hippocampus and throughout the cingulate both anterior and posterior, extending into the orbitofrontal cortex and encompassing both hemispheres. These areas may constitute the important circuit in the psychopathology of panic disorder. We propose that this pattern of activity may enhance the encoding and retrieval of strong emotional events, facilitating the recapitulation of traumatic experiences and leading to panic disorder in vulnerable individuals.

Anxiety disorders are among the most prevalent of all psychological disorders and are potentially amenable to early intervention and prevention. In this article, we review the various costs associated with anxiety disorders that make early prevention a valuable endeavor. Also, we considered extant data regarding risk factors for anxiety disorders, as knowledge of risk factors permits the targeting of a select group of the population considered to be most likely to develop anxiety disorders. Existing efficacy research on prevention for anxiety disorders is promising, but an overarching model to guide further research and development is lacking. We propose such models to guide high-risk sample selection including the content and format of prevention efforts.

Worry, the cognitive enumeration and anticipation of potential future negative events, is associated with autonomic dysregulation, which may in turn have implications for the immune system. People endorsing high (n= 7) and normal levels of trait worry (n= 8) were briefly exposed to a phobic stimulus and the autonomic and immune responses and recovery were assessed. A time-matched control group (n= 6) was not exposed to any stimulus. Both worry groups showed increased heart rate and skin conductance in response to phobic fear. However, only the normal worry group showed a concomitant increase in natural killer cells in peripheral blood. Patterns of change during the follow-up period suggested that phobic fear had disrupted a normal circadian increase in natural killer cells. Adrenergic and hypothalamus–pituitary–adrenal mechanisms may be responsible for the differences between high and normal worry groups in their natural killer cell response to and recovery from phobic fear.

In this review, we conceptualize exposure‐based treatment as a learning experience. With this approach, optimizing treatment is a matter of optimizing memory for new learning. Given that perspective, we discuss the implications of a “new theory of disuse,” proposed by Bjork and Bjork (1992) to capture the storage and retrieval dynamics that characterize human memory. The theory distinguishes between the storage strength and retrieval strength of learned representations and provides a framework from which we derive a number of manipulations that have the potential to improve the long‐term effectiveness of cognitive behavioral therapy. Implications for treatment of specific fears are described in detail, with additional discussion regarding treatment for other emotional disorders.