Search

Objectives Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder, often complicated with comorbidities. Social phobia (SP) is the most frequent co-occurring anxiety disorder in OCD, associated with increased clinical severity. However, no study had examined the relevance of interpersonal processes in this comorbidity, which are at the core of SP. This study characterized the clinical (i.e., symptom profile, age of onset, chronicity, and comorbidity), vulnerability (i.e., childhood trauma, negative life events), and interpersonal (attachment style, expressed emotion, and social support) correlates of comorbid SP in a large sample of OCD patients. Methods We analysed the data of 382 OCD patients participating in the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. We examined the correlates of SP in OCD using self-report questionnaires and structured clinical interviews. In addition, data of 312 non-OCD SP patients were drawn from the Netherlands Study of Depression and Anxiety (NESDA), to compare the age of onset of SP between groups. Descriptive univariate analyses were followed by backward stepwise logistic regression analyses. Results Social phobia was present among approximately 20% of OCD patients. Social phobia in OCD was associated with increased depression severity and decreased ratings of secure attachment style. Among OCD patients, SP had a significantly earlier age onset as compared to SP in non-OCD patients. Conclusion Social phobia in OCD might render a vulnerable clinical picture, characterized with early onset of SP symptoms, insecure attachment style, and increased depressive symptoms. Future studies should use prospective designs to better understand the nature of comorbid SP in OCD. Practitioner points Approximately one fifth of OCD patients were diagnosed with comorbid social phobia in a large representative clinical sample. OCD patients with comorbid social phobia presented with a vulnerable clinical picture, characterized with increased depression severity and decreased ratings of secure attachment style. Social phobia in OCD was associated with an earlier AOO as compared to the AOO of social phobia without OCD. The findings are limited by a cross-sectional design; thus, causality could not be assessed. Research is needed to further examine the mechanisms of comorbid social phobia in OCD.

Background Anxiety disorders are highly prevalent and cause substantial economic burden. Blended cognitive-behavioural therapy (bCBT), which integrates Internet-based CBT and face-to-face CBT (ftfCBT), is an attractive and potentially cost-saving treatment alternative to conventional CBT for patients with anxiety disorders in specialised mental health care. However, little is known about the effectiveness of bCBT in routine care. We examined the acceptability, effectiveness and cost-effectiveness of bCBT versus ftfCBT in outpatient specialised care to patients with panic disorder, social anxiety disorder and generalised anxiety disorder. Methods and findings Patients with anxiety disorders were randomised to bCBT (n = 52) or ftfCBT (n = 62). Acceptability of bCBT and ftfCBT were evaluated by assessing treatment preference, adherence, satisfaction and therapeutic alliance. Costs and effects were assessed at post-treatment and one-year follow-up. Primary outcome measure was the Beck Anxiety Inventory (BAI). Secondary outcomes were depressive symptoms, general psychopathology, work and social adjustment, quality of life and mastery. Incremental cost-effectiveness ratios (ICERs) were computed from societal and healthcare perspectives by calculating the incremental costs per incremental quality-adjusted life year (QALY). No significant differences between bCBT and ftfCBT were found on acceptability or effectiveness measures at post-treatment (Cohen’s d between-group effect size on BAI = 0.15, 95% CI −0.30 to 0.60) or at one-year follow-up (d = −0.38, 95% CI −0.84 to 0.09). The modelled point estimates of societal costs (bCBT €10945, ftfCBT €10937) were higher and modelled point estimates of direct medical costs (bCBT €3748, ftfCBT €3841) were lower in bCBT. The acceptability curves showed that bCBT was expected to be a cost-effective intervention. Results should be carefully interpreted due to the small sample size. Conclusions bCBT appears an acceptable, clinically effective and potentially cost-saving alternative option for treating patients with anxiety disorders. Trials with larger samples are needed to further investigate cost-effectiveness. Trial registration Netherlands Trial Register: NTR4912.

Contains fulltext : 200709.pdf (Publisher’s version ) (Closed access) Aims: The aim of this study was to elicit the preference of patients with an anxiety disorder regarding treatment modalities. Understanding patients' preferences could help optimize treatment uptake and adherence to therapeutic interventions. Materials and methods: A discrete-choice experiment was used to elicit patients' preferences with regard to four treatment characteristics: waiting time until first treatment, intensity of treatment, face-to-face vs digital treatment, and group size. In 12 choice sets, participants were asked to choose between two treatment alternatives. A random parameters logit model was used to analyse the data. Results: A total of 126 participants, aged 18 years and older, currently or in the previous year in treatment for an anxiety disorder, completed the survey. Respondents preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment and a treatment intensity of one session per week rather than two sessions per week or one session every two weeks. Waiting time and treatment intensity were substantially less important to patients than level of digitalization and group size. Heterogeneity in preference was significant for each attribute, and sub-group analyses revealed this was partly related to education level and age. Limitations: The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity. Conclusions: This study demonstrated how different treatment components for anxiety disorders affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for age and education. Incorporating patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for anxiety disorders. 9 p.

Contains fulltext : 221419.pdf (Publisher’s version ) (Open Access) Stepped-care (SC) models for anxiety disorders are implemented on a large scale and are assumed to be as effective for the greater majority of patients as more intensive treatment schemes. To compare the outcomes of SC and international guideline-based treatment (Treatment as Usual: TAU) for panic disorder, a total of 128 patients were randomized to either SC or TAU (ratio 2: 1, respectively) using a computer generated algorithm. They were treated in four mental health care centres in the Netherlands after therapists had been trained in SC by a senior expert therapist. SC comprised 10-week guided self-help (pen-and-paper version) followed, if indicated, by 13-week manualized face-to-face cognitive behavioural therapy (CBT), with medication- if prescribed- kept constant. TAU consisted of 23-week regular face-to-face CBT (RCBT) with medication -when prescribed- also kept constant. The means of the attended sessions in the SC condition was 5.9 (SD = 4.8) for ITT and 9.6 (SD = 9.6) for the RCBT condition. The difference in the number of attended sessions between the conditions was significant (t(126) = -3.87, p < .001). Remission rates between treatment conditions did not differ significantly (SC: 44.5%; RCBT: 53.3%) and symptom reduction was similar. Stepping up SC treatment to face-to-face CBT showed a minimal additional effect. Importantly, drop-out rates differed significantly for the two conditions (SC: 48.2%; RCBT: 26.7%). SC was effective in the treatment of panic disorder in terms of symptom reduction and remission rate, but dropout rates were twice as high as those seen in RCBT, with the second phase of SC not substantially improving treatment response. However, SC required significantly less therapist contact time compared to RCBT, and more research is needed to explore predictors of success for guided self-help interventions to allow treatment intensity to be tailored to patients' needs and preferences. 15 p.

BackgroundMajor depressive disorder (MDD) represents a leading cause of disability. This study examines the course of disability in patients with chronic, recurrent and remitting MDD compared to healthy controls and identifies predictors of disability in remitting MDD.MethodsWe included 914 participants from the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV MDD and WHO DAS II disability were assessed at baseline and at 2, 4 and 6 years. Six-year total and domain-specific disability were analysed and compared in participants with chronic (n = 57), recurrent (n = 120), remitting (n = 127) MDD and in healthy controls (n = 430). Predictors of residual disability were identified using linear regression analysis.ResultsAt baseline, most disability was found in chronic MDD, followed by recurrent MDD, remitting MDD and healthy controls. Across diagnostic groups, most disability was found in household activities, interpersonal functioning, participation in society and cognition. A chronic course was associated with chronic disability. Symptom remission was associated with a decrease in disability, but some disability remained. In remitting MDD, higher residual disability was predicted by older age, more severe avoidance symptoms, higher disability at baseline and late symptom remission. Severity of residual disability correlated with the severity of residual depressive symptoms.ConclusionsSymptomatic remission is a prerequisite for improvements in disability. However, disability persists despite symptom remission. Therefore, treatment of MDD should include an explicit focus on disability, especially on the more complex domains. To this end, treatments should promote behavioural activation and address subthreshold depressive symptoms in patients with remitted MDD.

BackgroundObsessive-compulsive disorder (OCD) has a lifetime prevalence of 2–3% and is a leading cause of global disability. Brain circuit abnormalities in individuals with OCD have been identified, but important knowledge gaps remain. The goal of the new global initiative described in this paper is to identify robust and reproducible brain signatures of measurable behaviors and clinical symptoms that are common in individuals with OCD. A global approach was chosen to accelerate discovery, to increase rigor and transparency, and to ensure generalizability of results.MethodsWe will study 250 medication-free adults with OCD, 100 unaffected adult siblings of individuals with OCD, and 250 healthy control subjects at five expert research sites across five countries (Brazil, India, Netherlands, South Africa, and the U.S.). All participants will receive clinical evaluation, neurocognitive assessment, and magnetic resonance imaging (MRI). The imaging will examine multiple brain circuits hypothesized to underlie OCD behaviors, focusing on morphometry (T1-weighted MRI), structural connectivity (Diffusion Tensor Imaging), and functional connectivity (resting-state fMRI). In addition to analyzing each imaging modality separately, we will also use multi-modal fusion with machine learning statistical methods in an attempt to derive imaging signatures that distinguish individuals with OCD from unaffected siblings and healthy controls (Aim #1). Then we will examine how these imaging signatures link to behavioral performance on neurocognitive tasks that probe these same circuits as well as to clinical profiles (Aim #2). Finally, we will explore how specific environmental features (childhood trauma, socioeconomic status, and religiosity) moderate these brain-behavior associations.DiscussionUsing harmonized methods for data collection and analysis, we will conduct the largest neurocognitive and multimodal-imaging study in medication-free subjects with OCD to date. By recruiting a large, ethno-culturally diverse sample, we will test whether there are robust biosignatures of core OCD features that transcend countries and cultures. If so, future studies can use these brain signatures to reveal trans-diagnostic disease dimensions, chart when these signatures arise during development, and identify treatments that target these circuit abnormalities directly. The long-term goal of this research is to change not only how we conceptualize OCD but also how we diagnose and treat it.

Contains fulltext : 219241.pdf (Publisher’s version ) (Closed access) INTRODUCTION: Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder where most patients do not reach full symptomatic remission. Identifying predictors of course can improve patients' care by informing clinicians on prognosis and enhancing treatment strategies. Several predictors associated with improved outcome of OCD were identified. However, research focused mainly on clinical, illness-related predictors of the course of OCD. This study examined the contribution of environmental and interpersonal predictors on the long-term outcome of OCD, in addition to the previously identified clinical indicators. METHODS: We used the baseline, two and four-year data of 382 adult OCD patients participating in the naturalistic cohort study of the Netherlands Obsessive Compulsive Disorder Association (NOCDA). Remission was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Predictors of outcome were assessed at baseline, via clinician-rated and self-report instruments. RESULTS: Remission at two and at four-year follow-up ranged from 11% to 26%. Early age of onset and the presence of childhood trauma predicted a worse four-year course. Secure attachment style emerged as a protective predictor of improved outcome. LIMITATIONS: The naturalistic design of our study did not enable a systematic estimation the effect of treatments received during the follow-up period. Furthermore, age of onset and childhood trauma were assessed retrospectively, which may contribute to recall bias. CONCLUSION: Results coincide with previous prediction research and stress the importance of adaptive interpersonal functioning in the course of OCD. Clinical implications and future research directions are discussed. 9 p.

Background Depressive and anxiety disorders have shown to be associated to premature or advanced biological aging and consequently to adversely impact somatic health. Treatments with antidepressant medication or running therapy are both found to be effective for many but not all patients with mood and anxiety disorders. These interventions may, however, work through different pathophysiological mechanisms and could differ in their impact on biological aging and somatic health. This study protocol describes the design of an unique intervention study that examines whether both treatments are similarly effective in reducing or reversing biological aging (primary outcome), psychiatric status, metabolic stress and neurobiological indicators (secondary outcomes). Methods The MOod Treatment with Antidepressants or Running (MOTAR) study will recruit a total of 160 patients with a current major depressive and/or anxiety disorder in a mental health care setting. Patients will receive a 16-week treatment with either antidepressant medication or running therapy (3 times/week). Patients will undergo the treatment of their preference and a subsample will be randomized (1:1) to overcome preference bias. An additional no-disease-no-treatment group of 60 healthy controls without lifetime psychopathology, will be included as comparison group for primary and secondary outcomes at baseline. Assessments are done at week 0 for patients and controls, and at week 16 and week 52 for patients only, including written questionnaires, a psychiatric and medical examination, blood, urine and saliva collection and a cycle ergometer test, to gather information about biological aging (telomere length and telomerase activity), mental health (depression and anxiety disorder characteristics), general fitness, metabolic stress-related biomarkers (inflammation, metabolic syndrome, cortisol) and genetic determinants. In addition, neurobiological alterations in brain processes will be assessed using structural and functional Magnetic Resonance Imaging (MRI) in a subsample of at least 25 patients per treatment arm and in all controls. Discussion This intervention study aims to provide a better understanding of the impact of antidepressant medication and running therapy on biological aging, metabolic stress and neurobiological indicators in patients with depressive and anxiety disorders in order to guide a more personalized medicine treatment. Trial registration Trialregister.nl Number of identification: NTR3460, May 2012.

Although effective treatments for obsessive compulsive disorder (OCD) are increasingly available, a considerable percentage of patients fails to respond or relapses. Predictors associated with improved outcome of OCD were identified. However, information on interpersonal determinants is lacking. This study investigated the contribution of attachment style and expressed emotion to the outcome of exposure and response prevention (ERP), while accounting for previously documented intrapersonal (i.e., symptom severity and personality pathology) predictors. Using logistic regression analyses and multi-level modeling, we examined predictors of treatment completion and outcome among 118 adult OCD patients who entered ERP. We assessed outcome at post treatment, and at four and 13 months from treatment completion. OCD baseline severity and fearful attachment style emerged as the main moderators of treatment outcome. Severe and fearfully attached patients were more likely to dropout prematurely. The improvement of fearful clients was attenuated throughout treatment and follow-up compared to non-fearful clients. However, their symptom worsening at the long-term was also mitigated. Severe OCD patients had a more rapid symptom reduction during treatment and at follow-up, compared to less severe clients. The findings suggest that both baseline OCD severity and fearful attachment style play a role in the long-term outcome of ERP.

Background: : Psychiatric disorders are associated with overweight/obesity. Obsessive-compulsive disorder (OCD) may be an exception, as anecdotal evidence suggests lower BMI in OCD. Additionally, depression is associated with elevated BMI, but effects of comorbid secondary depression are unknown. The aim of the present study was to assess BMI and risk for overweight/obesity in OCD and to assess the effect of comorbid depression on BMI. Methods: : BMI, demographics, and clinical status were assessed in large samples of individuals with OCD, anxiety disorders, depressive disorders, comorbid anxiety/depressive disorders, and non-clinical controls (NCC). Results: : Although no initial differences were found between the samples on BMI, the non-depressed OCD subsample had significantly lower BMI and risk for overweight/obesity compared to all other clinical samples. NCC were nearly twice as likely to be overweight compared to non-depressed OCD. Limitations: : Eating disorders were excluded in the OCD sample, but BMI < 17 was used as an exclusion criterion in the clinical control groups in lieu of screening for Anorexia. Group differences on demographics were controlled for. Recruitment methodology differed between samples. Conclusions: : OCD is associated with significantly lower rates of obesity and overweight, but this relationship was not found when comorbid depression was present. This suggests that the purer the phenotype of OCD, the more substantial protective factor against overweight/obesity emerges compared to other clinical samples and NCC. An OCD-specific reward/anhedonia model, previously offered to elucidate lower smoking rates in OCD, may account for lower BMI in OCD. These results warrant careful clinical attention to the negative impact of comorbid depression on OCD that spans from increasing risk for obesity and cigarette smoking, to hindering treatment response.

Contains fulltext : 200729.pdf (Publisher’s version ) (Open Access) Background: Anxiety and depressive disorders are common mental disorders. A substantial part of patients does not achieve symptomatic remission after treatment in specialized services. Current care as usual (CAU) for these patients consists of long-term supportive contacts. Termination of CAU is often not considered to be an option due to persistent symptoms, a low level of functioning, and the absence of further treatment options. A new intervention, ZemCAD, offers a program focused on rehabilitation and self-management, followed by referral back to primary care. Methods: This multicenter randomized controlled trial was carried out in twelve specialized outpatient mental health care services in the Netherlands. Consenting and eligible patients were invited for the MINI interview and the baseline questionnaire. Assessments were done at 6 (T1), 12 (T2) and 18 (T3) months post baseline. We used linear mixed model analysis (LMM) to ascertain the effectiveness of the ZemCAD group relative to the CAU group on quality of life, symptom severity and empowerment. Results: In total 141 patients were included. The results at 18-month follow-up regarding to quality of life and symptom severity, showed no significant differences between the ZemCAD group and the CAU group, except on the 'social relationships'-domain (d = 0.37). With regard to empowerment a significant difference between both groups was observed in the total empowerment score and one empowerment dimension (d = 0.45 and d = 0.39, respectively). After the ZemCAD intervention, more patients went from specialized outpatient mental health services back to a less specialized health care setting with less intensive treatment, such as primary care. Conclusion: The findings in this study suggest that patients with chronic and treatment-resistant anxiety and depression using the ZemCAD intervention improve on empowerment but not on symptom severity or quality of life. Since little is known about the effects of rehabilitation and self-management in patients with chronic and treatment resistant anxiety and depressive disorders, this is a first attempt to provide a proof-of-concept study in this under-researched but important field. Trial registration: Netherlands Trial Register: NTR3335, registered 7 March 2012. 16 p.

Background: Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.Objective: This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.Methods: We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.Results: We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.Conclusions: iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

BackgroundAnxiety and depressive disorders are increasingly being viewed as chronic conditions with fluctuating symptom levels. Relapse prevention programmes are needed to increase self-management and prevent relapse. Fine-tuning relapse prevention programmes to the needs of patients may increase uptake and effectiveness.Materials and methodsA discrete choice experiment (DCE) was conducted amongst patients with a partially or fully remitted anxiety or depressive disorder. Patients were presented 20 choice tasks with two hypothetical treatment scenarios for relapse prevention, plus a "no treatment" option. Each treatment scenario was based on seven attributes of a hypothetical but realistic relapse prevention programme. Attributes considered professional contact frequency, treatment type, delivery mode, programme flexibility, a personal relapse prevention plan, time investment and effectiveness. Choice models were estimated to analyse the data.ResultsA total of 109 patients with a partially or fully remitted anxiety or depressive disorder completed the DCE. Attributes with the strongest impact on choice were high effectiveness, regular contact with a professional, low time investment and the inclusion of a personal prevention plan. A high heterogeneity in preferences was observed, related to both clinical and demographic characteristics: for example, a higher number of previous treatment episodes was related to a preference for a higher frequency of contact with a professional, while younger age was related to a stronger preference for high effectiveness.ConclusionsThis study using a DCE provides insights into preferences for a relapse prevention programme for anxiety and depressive disorders that can be used to guide the development of such a programme.

Objective: Despite the frequent occurrence of depressive symptoms in obsessive-compulsive disorder (OCD), little is known about the reciprocal influence between depressive and obsessive-compulsive symptoms during the course of the disease. The aim of the present study is to investigate the longitudinal relationship between obsessive-compulsive and depressive symptoms in OCD patients. Method: We used the baseline and 1-year follow-up data of the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. In 276 patients with a lifetime diagnosis of obsessive-compulsive disorder, depressive and obsessive-compulsive symptoms were assessed at baseline and at one-year follow-up with the Beck Depression Inventory (BDI) and the Yale-Brown Obsessive Compulsive Symptom (Y-BOCS) scale. Relations were investigated using a cross-lagged panel design. Results: The association between the severity of depressive symptoms at baseline and obsessive-compulsive symptoms at follow7up was significant (beta=0.244, p

Background: Despite increasing evidence for the diagnostic instability between and within depressive and anxiety disorders, most studies report solely on the recurrence rates of the specific index disorders. Neglecting this evidence has an inherent risk of underestimating recurrence rates of depressive and anxiety disorders. This study investigates the impact of diagnostic instability of recurrence rates in depression and anxiety.Methods: Data were derived from the Netherlands Study of Depression and Anxiety (NESDA). The sample of 656 participants had a panic disorder with or without agoraphobia, agoraphobia, social phobia, generalized anxiety disorder, major depressive disorder or dysthymia, and a subsequent remission. Recurrence rates of index disorders (diagnostically stable recurrence) and newly arisen anxiety or depressive disorders (diagnostically unstable recurrence), were calculated over a 4-year follow-up period.Results: In anxiety disorders (n=281), the recurrence rate is more than doubled, from 23.8% with a stable recurrence, to 54.8%, when diagnostically unstable recurrences are included. In depressive disorders (N=173) the recurrence rate increases from 37.6% to 49.7%, and in comorbid anxiety and depressive disorders (N=202) the diagnostically unstable recurrences increase from 54.0% to 66.3%.Limitations: Attrition during follow up may have biased the results; remission was defined as absence of symptoms for 1 month; very short-term remission and recurrence patterns were not assessed.Conclusions: Diagnostically unstable recurrences have a significant impact on recurrence rates, with the greatest instability for anxiety disorders. When only diagnostically stable recurrences are assessed, recurrence rates are highly underrated and provide biased estimates of the true course of these disorders. (C) 2016 Elsevier B.V. All rights reserved.

Objective: In recent years there has been some ambiguity about the way hoarding and OCD are related to each other. The present study examines the differences between persons with OCD/hoarding and OCD/non-hoarding and examines which characteristics are associated with the OCD/hoarding group. Information is established about prevalences, socio-demographical characteristics, OCD and related characteristics, OCD subtypes, comorbidity (depression, anxiety disorders and PTSD) and personality traits. Methods: Data from baseline assessment of The Netherlands Obsessive Compulsive Disorder Association (NOCDA) study are used. The NOCDA sample consists of 419 participants between 18 and 79 years of age, including participants with current or remitted full DSM-IV-TR criteria for OCD. Results: Results show that 58 persons (14.3%) are classified as persons with OCD/hoarding and 349 persons (85,7%) are classified as persons with OCD/non-hoarding. OCD/hoarding is independently associated with severity of autism symptoms (p

BackgroundThis study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions.MethodsData were derived from the ‘Netherlands Mental Health Survey and Incidence Study-2’ (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning.ResultsThe three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning.LimitationsCourse analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed.ConclusionsSubthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden.

OBJECTIVE Sudden gains are robust predictors of outcome in psychotherapy. However, previous attempts at predicting sudden gains have yielded inconclusive findings. The aim of the present study was to examine a novel, transdiagnostic, transtherapeutic predictor of sudden gains that would replicate in different settings and populations. Specifically, we examined intraindividual variability in symptoms. METHOD We examined data from a randomized controlled trial (RCT) of prolonged exposure therapy for posttraumatic stress disorder (PTSD) in children and adolescents (n = 63), an RCT of cognitive and behavioral therapies for obsessive-compulsive disorder (OCD) in adults (n = 91), and psychodynamic therapy delivered under routine clinical conditions in a naturalistic setting for diverse disorders (n = 106). In all 3 data sets, we examined whether a measure of variability in symptoms occurring during the first sessions could predict sudden gains. RESULTS Variability in symptoms was found to be independent of total change during treatment. Variability in symptoms significantly predicted sudden gains in all 3 data sets and correctly classified 81.0%, 69.2%, and 76.9% of individuals to sudden gain or nonsudden gain status, respectively. CONCLUSIONS The present study represents the first examination of variability in symptoms as a predictor of sudden gains. Findings indicated that sudden gains are significantly predicted by intraindividual variability in symptoms, in diverse settings, contexts, and populations. Advantages of this predictor, as well as clinical and research implications are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background The cognitive theory of obsessive-compulsive disorder (OCD) ascertains that catastrophic (mis)interpretations of normally occurring intrusive thoughts are related to the maintenance of OCD. Nonetheless, findings supporting the relationship between cognitive biases and OCD symptoms are largely inconsistent. In the present study we examined the relationship between OCD cognitions and symptoms among 382 OCD patients participating in the longitudinal Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. Methods OCD cognitions and OC, anxiety and depressive symptoms were assessed using self-report questionnaires at baseline and at two-year follow-up. Baseline multiple regression analyses assessed the specificity of OC cognitions to OCD symptoms. Cross-lagged analyses examined whether cognitions predict OCD symptoms at two-year follow up. Results Baseline analyses demonstrated significant relationships between comorbid anxiety, depressive severity and OC cognitions, adjusted for OCD symptoms (β =.283, p

BackgroundThe course of illness in obsessive–compulsive disorder (OCD) varies significantly between patients. Little is known about factors predicting a chronic course of illness. The aim of this study is to identify factors involved in inducing and in maintaining chronicity in OCD.MethodsThe present study is embedded within the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, an ongoing multicenter naturalistic cohort study designed to identify predictors of long-term course and outcome in OCD. For this study, 270 subjects with a current diagnosis of OCD were included. Chronicity status at 2-year follow-up was regressed on a selection of baseline predictors related to OCD, to comorbidity and to stress and support.ResultsPsychotrauma [odds ratio (OR) 1.98, confidence interval (CI) 1.22–3.22,p= 0.006], recent negative life events (OR 1.42, CI 1.01–2.01,p= 0.043), and presence of a partner (OR 0.28, CI 0.09–0.85,p= 0.025) influenced the risk of becoming chronic. Longer illness duration (OR 1.46, CI 1.08–1.96,p= 0.013) and higher illness severity (OR 1.09, CI 1.03–1.16,p= 0.003) increased the risk of remaining chronic.ConclusionsExternal influences increase the risk of becoming chronic, whereas the factors involved in maintaining chronicity are illness-related. As the latter are potentially difficult to modify, treatment should be devoted to prevent chronicity from occurring in the first place. Therapeutic strategies aimed at alleviating stress and at boosting social support might aid in achieving this goal.

Age of onset is a marker of clinically relevant subtypes in various medical and psychiatric disorders. Past research has also reported that age of onset in generalized anxiety disorder (GAD) is clinically significant; but, in research to date, arbitrary cut-off ages have been used. In the present study, admixture analysis was used to determine the best fitting model for age of onset distribution in GAD. Data were derived from 459 adults with a diagnosis of GAD who took part in the Netherlands Study of Depression and Anxiety (NESDA). Associations between age of onset subtypes, identified by admixture analysis, and sociodemographic, clinical, and vulnerability factors were examined using univariate tests and multivariate logistic regression analyses. Two age of onset distributions were identified: an early-onset group (24 years of age and younger) and a late-onset group (greater than 24 years of age). Multivariate analysis revealed that early-onset GAD was associated with female gender (OR 2.1 (95%CI 1.4–3.2)), higher education (OR 1.1 (95%CI 1.0–1.2)), and higher neuroticism (OR 1.4 (95%CI 1.1–1.7)), while late-onset GAD was associated with physical illnesses (OR 1.3 (95%CI 1.1–1.7)). Study limitations include the possibility of recall bias given that age of onset was assessed retrospectively, and an inability to detect a possible very-late-onset GAD subtype. Collectively, the results of the study indicate that GAD is characterized by a bimodal age of onset distribution with an objectively determined early cut-off at 24 years of age. Early-onset GAD is associated with unique factors that may contribute to its aetiology; but, it does not constitute a more severe subtype compared to late-onset GAD. Future research should use 24 years of age as the cut-off for early-onset GAD to when examining the clinical relevance of age of onset for treatment efficacy and illness course.

Background: Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care. Methods: In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months. Results: We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC was superior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55]. Conclusions: CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD.

This study aimed to identify course trajectories of anxiety disorder using a data-driven method and to determine the incremental predictive value of clinical and psychological variables over and above diagnostic categories. 703 patients with DSM-IV panic disorder with or without agoraphobia, agoraphobia, social phobia, or generalized anxiety disorder were selected from a prospective cohort study. Latent Growth Mixture Modeling was conducted, based on symptoms of anxiety and avoidance as assessed with the Life Chart Interview covering a 6-year time period. In 44% of the participants symptoms of anxiety and avoidance improved, in 24% remained stable, in 25% slightly increased, and in 7% severely increased. Identified course trajectories were predicted by baseline DSM-IV anxiety categories, clinical variables (i.e., severity and duration and level of disability) and psychological predictors (i.e., neuroticism, extraversion, anxiety sensitivity, worry, and rumination). Clinical variables better predicted unfavorable course trajectories than psychological predictors, over and above diagnostic categories. (C) 2016 Elsevier Ltd. All rights reserved.

Objective Anxiety and/or Depressive Disorders (ADDs) and Chronic Somatic Diseases (CSDs) are associated with substantial levels of health-related disability and work impairment. However, it is unclear whether comorbid ADDs and CSDs additively affect functional outcomes. This paper examines the impact of ADDs, CSDs, and their comorbidity on disability, work absenteeism and presenteeism. Methods Baseline data from the Netherlands Study of Depression and Anxiety (n = 2371) were used. We assessed presence of current ADDs (using psychiatric interviews, CIDI) and presence of self-reported CSDs. Outcome measures were disability scores (WHO-DAS II questionnaire, overall and domain-specific), work absenteeism (≤ 2 weeks and > 2 weeks; TiC-P) and presenteeism (reduced and impaired work performance; TiC-P). We conducted multivariate regression analyses adjusted for socio-demographics. Results Both ADDs and CSDs significantly and independently impact total disability, but the impact was substantially larger for ADDs (main effect unstandardized β = 20.1, p

Tourette syndrome (TS) and obsessive-compulsive disorder (OCD) both are neuropsychiatric disorders associated with abnormalities in dopamine neurotransmission. Aims of this study were to quantify striatal D2/3 receptor availability in TS and OCD, and to examine dopamine release and symptom severity changes in both disorders following amphetamine challenge. Changes in [(11)C]raclopride binding potential (BP(ND)) were assessed using positron emission tomography before and after administration of d-amphetamine (0.3 mg kg(-1)) in 12 TS patients without comorbid OCD, 12 OCD patients without comorbid tics, and 12 healthy controls. Main outcome measures were baseline striatal D2/3 receptor BP(ND) and change in BP(ND) following amphetamine as a measure of dopamine release. Voxel-based analysis revealed significantly decreased baseline [(11)C]raclopride BP(ND) in bilateral putamen of both patient groups vs. healthy controls, differences being more pronounced in the TS than in the OCD group. Changes in BP(ND) following amphetamine were not significantly different between groups. Following amphetamine administration, tic severity increased in the TS group, which correlated with BP(ND) changes in right ventral striatum. Symptom severity in the OCD group did not change significantly following amphetamine challenge and was not associated with changes in BP(ND). This study provides evidence for decreased striatal D2/3 receptor availability in TS and OCD, presumably reflecting higher endogenous dopamine levels in both disorders. In addition, it provides the first direct evidence that ventral striatal dopamine release is related to the pathophysiology of tics.

Post-traumatic stress disorder (PTSD) is associated with impaired memory performance coupled with functional changes in brain areas involved in declarative memory and emotion regulation. It is not yet clear how symptom severity and comorbidity affect neurocognitive functioning in PTSD. We performed a functional magnetic resonance imaging (fMRI) study with an emotional declarative memory task in 28 Complex PTSD patients with comorbid depressive and personality disorders, and 21 healthy nontrauma-exposed controls. In Complex PTSD patients-compared to controls-encoding of later remembered negative words vs baseline was associated with increased blood oxygenation level dependent (BOLD) response in the left ventral anterior cingulate cortex (ACC) and dorsal ACC extending to the dorsomedial prefrontal cortex (dmPFC) together with a trend for increased left hippocampus activation. Patients tended to commit more False Alarms to negative words compared to controls, which was associated with enhanced left ventrolateral prefrontal and orbitofrontal cortex (vlPFC/OFC) responses. Severity of child abuse was positively correlated with left ventral ACC activity and severity of depression with (para) hippocampal and ventral ACC activity. Presented results demonstrate functional abnormalities in Complex PTSD in the frontolimbic brain circuit also implicated in fear conditioning models, but generally in the opposite direction, which may be explained by severity of the trauma and severity of comorbid depression in Complex PTSD.©The Author (2011). Published by Oxford University Press.

BackgroundAntidepressant use is often prolonged in patients with anxiety and/or depressive disorder(s) compared with recommendations in treatment guidelines to discontinue after sustained remission.AimTo unravel the motivations of patients and GPs causing long-term antidepressant use and to gain insight into possibilities to prevent unnecessary long-term use.Design and settingQualitative study using semi-structured, in-depth interviews with patients and GPs in the Netherlands.MethodPatients with anxiety and/or depressive disorder(s) (n = 38) and GPs (n = 26) were interviewed. Innovatively, the interplay between patients and their GPs was also investigated by means of patient-GP dyads (n = 20).ResultsThe motives and barriers of patients and GPs to continue or discontinue antidepressants were related to the availability of supportive guidance during discontinuation, the personal circumstances of the patient, and considerations of the patient or GP. Importantly, dyads indicated a large variation in policies of general practices around long-term use and continuation or discontinuation of antidepressants. Dyads further indicated that patients and GPs seemed unaware of each other's (mismatching) expectations regarding responsibility to initiate discussing continuation or discontinuation.ConclusionAlthough motives and barriers to antidepressant continuation or discontinuation were related to the same themes for patients and GPs, dyads indicated discrepancies between them. Discussion between patients and GPs about antidepressant use and continuation or discontinuation may help clarify mutual expectations and opinions. Agreements between a patient and their GP can be included in a patient-tailored treatment plan.

Background: To study the clinical relevance of type of comorbidity and number of comorbid disorders in anxiety disorders. Four groups were compared according to sociodemographic-, vulnerability- and clinical factors: single anxiety disorder, anxiety-anxiety comorbidity, anxiety-depressive comorbidity and "double" comorbidity (i.e. anxiety and depressive comorbidity).Methods: Data were obtained from the Netherlands Study of Anxiety and Depression (NESDA). A sample of 1004 participants with a current anxiety disorder was evaluated.Results: As compared with single anxiety, anxiety-anxiety comorbidity was associated with higher severity, greater chronicity and more treatment. Anxiety-anxiety comorbidity was associated with an earlier age of onset and a more chronic course compared with anxiety-depressive comorbidity, while anxiety-depressive comorbidity was associated with more severe symptoms and more impaired functioning than anxiety-anxiety comorbidity. "Double" comorbidity was associated with higher severity, greater chronicity, more treatment and increased disability. Sociodemographic and vulnerability factors were comparable among the four groups.LimitationsA prospective design would be more appropriate to study the outcome. In this study no distinction was made between whether depression or anxiety disorder preceded the current anxiety disorder.Conclusions: It is clinical relevant to diagnose and treat comorbidity among anxiety disorders as it is associated with higher severity and more chronicity. Whereas anxiety-anxiety comorbidity has an earlier age of onset and a more chronic course, anxiety-depressive comorbidity leads to more treatment and impaired functioning. "Double" comorbidity leads to even more severity, chronicity and impairment functioning compared with both anxiety-anxiety and anxiety-depressive comorbidity. (C) 2011 Elsevier B.V. All rights reserved.

Objective: This study aimed to evaluate the criterion validity and the diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) regarding the identification of depressive and anxiety disorders in an insurance medicine setting. Participants: Our sample consisted of 230 individuals who applied for a work disability benefit due to mental health problems. Methods: Depressive and anxiety disorders were assessed using the 4DSQ and the Composite International Diagnostic Interview (CIDI). Internal consistency was determined by calculating Cronbach's alpha values. Criterion validity was evaluated by regression techniques. A Receiver Operating Characteristic (ROC) analysis was performed to evaluate diagnostic accuracy. Results: Of the 230 participants 109 (47.4%) had a current DSM-IV depressive disorder and 146 (63.5%) an anxiety disorder. The 4DSQ scales showed an excellent internal consistency. The depression scale of the 4DSQ had specific sensitivity for major depressive disorder. The anxiety scale was also sensitive for the anxiety disorders. The area under the ROC curve (AUC) indicated good diagnostic accuracy of the 4DSQ for assessing depressive and/or anxiety disorders: AUC-value 0.81 for both depression and anxiety. Conclusions: Although the 4DSQ shows good criterion validity and diagnostic accuracy with respect to depressive and anxiety disorders in applicants for a work disability benefit due to mental health problems, the feasibility of the 4DSQ as a screening measure for depressive and anxiety disorders is limited due to the high prevalence of depressive and anxiety disorders. © 2012 - IOS Press and the authors. All rights reserved.

Objective: Complex posttraumatic stress disorder (PTSD) involves a variety of personality disturbances presumed to result from repeated interpersonal trauma such as child abuse. As Complex PTSD patients are a heterogeneous population, we searched for clinically relevant personality-based subtypes. Method: This study used a cluster analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Axis II features within a sample of 71 female outpatients with systematically assessed child abuse-related Complex PTSD. Results: Two main subtypes were found: adaptive and nonadaptive. The latter was further differentiated into withdrawn, alienated, suffering, and aggressive subtypes, characterized by different levels of introversion and disinhibition. Among the nonadaptive subtypes, the severity of Complex PTSD symptoms was lowest in the withdrawn (introverted only) subtype. The subtypes differed in their level of dissociation and depression but did not differ regarding PTSD symptoms, trauma history, or parental bonding characteristics. Conclusion: Confirming earlier findings, our study found personality-based Complex PTSD subtypes, which could implicate differential treatment needs and results. © 2012 Copyright Taylor and Francis Group, LLC.

Objective: Obsessive-compulsive disorder (OCD) is phenomenologically heterogeneous, and findings of underlying structure classification based on symptom grouping have been ambiguous to date. Variable-centered approaches, primarily factor analysis, have been used to identify homogeneous groups of symptoms; but person-centered latent methods have seen little use. This study was designed to uncover sets of homogeneous groupings within 1611 individuals with OCD based on symptoms.Method: Latent class analysis models using 61 obsessive-compulsive symptoms collected from the Yale-Brown Obsessive-Compulsive Scale were fit. Relationships between latent class membership and treatment response, sex, symptom severity, and comorbid tic disorders were tested for relationship to class membership.Results: Latent class analysis models of best fit yielded 3 classes. Classes differed only in frequency of symptom endorsement. Classes with higher symptom endorsement were associated with earlier age of onset, being male, higher Yale-Brown Obsessive-Compulsive Scale symptom severity scores, and comorbid tic disorders. There were no differences in treatment response between classes.Conclusions: These results provide support for the validity of a single underlying latent OCD construct, in addition to the distinct symptom factors identified previously via factor analyses. (C) 2011 Elsevier Inc. All rights reserved.

Background: Although panic disorder is generally considered to be a chronic condition, little is known about the natural history of panic attacks and the factors predicting the prognosis of panic. It is expected that data derived from the community show more variation in the prognosis of panic and that subjects with less severe, 'subthreshold panic disorder' have a better prognosis. Methods: Using a large, representative population-based study, the 2-year course of panic attacks and its predictors were investigated among 155 subjects with panic disorder and subthreshold panic disorder. Presence and frequency of attacks were studied using structured interviews. Putative risk-indicators of chronicity included socio-demographics, psychobiological, environmental, psychiatric and panic-related factors. Results: Thirty-nine percent of those with panic disorder and 17% of those with subthreshold panic disorder reported panic episodes during more than 75% of the observed time periods in the Life Chart Interview. Forty-three percent of those with panic disorder and 14% of those with subthreshold panic disorder reported over 24 attacks per 3-month period. Male gender, severity of panic and agoraphobia predicted a high proportion of time spent in panic episodes. Low self-esteem, limited positive life events and severity of panic predicted highly frequent attacks. Limitations: The sample size was small, thereby limiting statistical power. The reported outcome may have overestimated chronicity. Conclusions: As was expected, the 2-year prognosis of panic was more varied than is often found in clinical studies. Although subthreshold panic disorder had a more favourable prognosis than full-blown panic disorder, a sizeable proportion of those with subthreshold panic disorder had an unfavourable prognosis. © 2009 Elsevier B.V. All rights reserved.

Objective: This study tests a Stabilizing Group Treatment protocol, designed for the management of the long-term sequelae of child abuse, that is, Complex Posttraumatic Stress Disorder (Complex PTSD). Evidence-based treatment for this subgroup of PTSD patients is largely lacking. This stabilizing treatment aims at improving Complex PTSD using psycho-education and cognitive behavioral interventions. Method: Thirty-six patients with a history of childhood abuse, Complex PTSD and severe co-morbidity entered a 20-week treatment with pre-, post-, and follow-up-assessments. Results: Improvement was found for PTSD and borderline symptoms. Post-treatment 64% and after 6 months 78% of patients no longer met criteria for Complex PTSD. Conclusions: This open study indicates both the feasibility of investigating treatment outcome and the initial efficacy of stabilizing group treatment in severely ill patients with Complex PTSD related to childhood abuse. © 2010 Elsevier Ltd.

INTRODUCTION: This study investigated the psychometric properties of the first clinician-administered semi-structured interview for assessing the severity of hypochondriacal symptoms. The Hypochondriasis Yale-Brown Obsessive-Compulsive Scale (H-YBOCS) consisted of three a priori dimensions: hypochondriacal obsessions, compulsions and avoidance. METHODS: The 16-item interview was conducted with 112 participants with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, hypochondriasis. We analysed factor analytic structure, reliability, construct validity and sensitivity to change. RESULTS: Factor analysis supported a three-factor model similar to the a priori dimensions. Internal consistency ranged from satisfactory to good. Inter-rater reliability was excellent. The construct validity was low to moderate. The H-YBOCS was sensitive for measuring changes in symptom severity. CONCLUSION: The H-YBOCS is a (factorially) valid and coherent interview with a high level of agreement across different raters. The relatively low discriminant validity could be due to co-morbid anxiety and depressive disorders. Overall, the H-YBOCS seems to be a promising contribution to the assessment of hypochondriasis. KEY PRACTITIONER MESSAGE: *The hypochondriasis Y-BOCS is a feasible clinician rated interview to assess the severity of hypochondriacal complaints

To gain insight into memory disturbances in Complex Posttraumatic Stress Disorder (Complex PTSD), we investigated declarative memory function and medial temporal lobe activity in patients and healthy non-traumatized controls. A case-control study was performed in nine patients with Complex PTSD and nine controls. All respondents performed a declarative memory task with neutral and emotional, negative words during functional magnetic resonance imaging. Memory performance of neutral words was impaired in Complex PTSD with a relative conservation of recall of negative words. Deep encoding of later remembered negative words, as well as correct recognition of negative words and false alarms, was associated with an enhanced Blood Oxygenation Level Dependent (BOLD) response in the left hippocampus extending into the parahippocampal gyrus of Complex PTSD patients compared with controls. Post-hoc volumetric comparisons did not reveal significant anatomical differences in the medial temporal lobe between Complex PTSD patients and controls. We conclude that in Complex PTSD preferential recall of negative words is associated with increased activation in the left hippocampus and parahippocampal gyrus during both successful and false recall. These findings support a model of an abnormally functioning hippocampus in Complex PTSD. (C) 2008 Elsevier Ireland Ltd. All rights reserved

Background Age of onset is an important epidemiological indicator in characterizing disorders׳ subtypes according to demographic, clinical and psychosocial determinants. While investigated in various psychiatric conditions, age of onset and related characteristics in agoraphobia have yet to be examined. In light of the new diagnostic status in the DSM-5 edition of agoraphobia as independent from panic disorder, research on agoraphobia as a stand-alone disorder is needed. Methods Admixture analysis was used to determine the best-fitting model for the observed ages at onset of 507 agoraphobia patients participating in the Netherlands Study of Depression and Anxiety (age range 18–65). Associations between agoraphobia age of onset and different demographic, clinical and psychosocial determinants were examined using multivariate logistic regression analysis. Results Admixture analyses identified two distributions of age of onset, with 27 as the cutoff age (≤27; early onset, >27; late onset). Early onset agoraphobia was only independently associated with family history of anxiety disorders (p Limitations Age of onset was assessed retrospectively, and analyses were based on cross-sectional data. Conclusion The best distinguishing age of onset cutoff of agoraphobia was found to be 27. Early onset agoraphobia might constitute of a familial subtype. As opposed to other psychiatric disorders, early onset in agoraphobia does not indicate for increased clinical severity and/or disability.

Objective This study assesses the feasibility and outcome of the implementation of a screening program for classifying panic disorder (PD) in patients presenting with noncardiac chest pain (NCCP 1 1Noncardiac chest pain.), when integrated in routine cardiac emergency department (CED 2 2Cardiac emergency department.) care. Methods Barrier analyses were made during the pilot phase and implementation period. NCCP patients aged 18–70 years presenting at the CED ( n =252) were eligible for screening with the Hospital Anxiety and Depression Scale (HADS). Those scoring above cutoff on the HADS were referred to the psychiatric department and received the Composite International Diagnostic Interview. Results Screening was initiated in 60 patients (23.8%), of whom nine refused participation. Staff adherence remained low despite implementing several improvements in the screening procedure. In total, 39 patients completed the program; 8 were diagnosed with a psychiatric disorder, including 2 patients with PD. Conclusion Feasibility of implementation of this screening program for PD in NCCP patients in routine CED care was limited because offering screening frequently conflicted with provision of acute care and because patients showed relatively high refusal rates. Contrasting our assumption, various other psychiatric disorders besides PD were classified.

There is considerable overlap in symptomatology between Tourette's syndrome (TS) and obsessive-compulsive disorder (OCD). Increased rates of tics are found in OCD and up to 60% obsessive-compulsive symptoms in TS. However, in OCD obsessive-compulsive symptoms are more often anxiety-related and, as a consequence, aimed at anxiety-reduction, whereas in TS these symptoms are more stimulus-bound. Therefore, it is of clinical interest to study whether these phenomenological differences are reflected in differences between dysfunctional cognitions accompanying OC symptoms in OCD with or without tics and TS. Current cognitive theory of OCD ascertains that specific dysfunctional beliefs are important in the etiology and maintenance of OCD. To assess these beliefs, the obsessive-compulsive beliefs questionnaire-87 (OBQ-87) has been developed. In the present study, OBQ-87 scores of OCD patients without tics, OCD with tics, and TS (without OCD) patients were compared to those of normal controls. Results: OCD without tic patients exhibited higher OBQ-87 scores than TS patients. No differences were found between OCD with or without tic patients on any of the OBQ-87 subscales. These results suggest that: (1) dysfunctional beliefs have no discriminative power with respect to OCD with or without tic patients; (2) the direct relationship between types of OC symptoms and specific dysfunctional beliefs is questionable. Therefore, one can doubt the specificity of cognitive theory of OCD to explain specific OC behavior. © 2005 Elsevier Ltd. All rights reserved.

Anxiety has been linked to onset of cardiovascular disease. This study examines the differential impact of types of anxiety (panic, phobia and worry) on 3-year onset of non-fatal cardiovascular disease (CVD). By investigating anxiety disorders as opposed to anxiety symptoms and by using a reliable diagnostic instrument to assess anxiety, limitations of previous studies are considered. 5149 persons at risk for CVD were interviewed using the Composite International Diagnostic Interview. The panic-type included panic disorder and panic attacks; the phobic-type included agoraphobia and social phobia, and the worry-type included generalized anxiety disorder. CVD was self-reported and required treatment or monitoring by a doctor. Analyses were adjusted for sociodemographics, behavioral variables, and comorbid somatic and psychiatric disorders. During follow-up, 62 persons (1.2%) developed CVD. Baseline generalized anxiety disorder was strongly associated with onset of CVD (adjusted OR: 3.39). Further research should replicate findings and focus on biological underpinnings of this association.

Purpose: Mental health services increasingly incorporate the vision of recovery. This qualitative study analysed and compared experiences of recovery on prevocational services, in order to assess if users make progress towards recovery, relative to a staged recovery model. Method: Data were collected through semi-structured interviews with participants on care farms (n=14), work (n=7) and creative projects (n=5). Results: The transition from past to current lives was described as a progressive, non-linear process, with different stages guided by different goals. Participants on creative projects lacked clear goals, presented less interest in peers and high need for emotional support. Participants on work projects aimed for occupational rehabilitation, but struggled with the patient culture of the peer community. Participants on care farms aimed for daytime occupations and closer contact with society. They experienced care farms as open, real-life work settings where they could exercise responsibility and connect with people. Conclusions: Participants progressed towards recovery, as care farms, work- and creative projects empowered them to leave behind inactive, isolated or disorganized living. In day centres, users focused on self-reflection and personal development (creative projects) or on occupational performance (work projects), whereas on care farms, users fulfilled worker roles in a real-life, open community environment.Implications for RehabilitationOrganized as open communities in real-life settings, care farms facilitate the reflection on personal and social responsibility, and therefore have the potential to help users internalize worker identities and improve their motivation to progress towards recovery.Supervisors on care farms are regarded by users as close contacts within the social networks they develop on the service, a position that allows supervisors to actively engage and promote users' progress towards recovery.Elements of the farm environment (such as the "normal life", presence of family members and visitors, and nature) can serve as anchors for supporting the progress towards recovery. © 2014 Informa UK Ltd.

Past research demonstrated that age at onset might account for different clinical and etiological characteristics in panic disorder (PD). However, prior research relied on arbitrary choices of age cut-offs. Using a data-driven validated method, this study aimed to examine differences between early and late onset PD in various determinants. Admixture analysis was used to determine the best fitting model of age at onset distribution in PD. Data was collected from 511 individuals (ages 18-65) with PD diagnoses, who participated in the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV comorbidities and various measures of childhood adversities, suicidal behavior, anxiety and depressive symptoms were assessed. The best fitting cut-off score between early and late age at onset groups was 27 years (early age at onset≤27 years). Univariate tests showed that participants with early onset PD were younger and more likely to be female. Early onset PD was associated with agoraphobia, higher frequency of childhood trauma and life events, and higher rates of suicide attempts as compared to late onset PD. Multivariate logistic regression analysis demonstrated that only current age, childhood trauma and agoraphobia remained significantly associated with early onset PD. Findings suggest that 27 years marks two onset groups in PD, which are slightly distinct. Early onset PD is independently associated with exposure to childhood trauma and increased avoidance. This highlights the importance of subtyping age of onset in PD. Clinical implications are further discussed. © 2013 Elsevier Ltd.

Background This study describes lifetime and current rates of comorbidity, its onset and its consequences in a large clinical sample of patients with obsessive compulsive disorder (OCD). A wide range of risk factors and clinical characteristics were also examined to determine whether pure OCD is different from OCD with current comorbidity. Finally, the temporal sequencing of the disorders was examined. Method Data were obtained from the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. A sample of 382 participants with current OCD (during the past month) was evaluated. Results Current comorbidity occurred in 55% of patients with OCD, while 78% suffered from lifetime comorbidity. Comorbidity is associated with more severe OCD, anxiety and depressive symptoms and more negative consequences on daily life. Multiple comorbid disorders often precede OCD and influence both its course and severity. Childhood trauma and neuroticism are vulnerability factors for the development of multiple comorbid disorders in OCD. Limitations It should be noted that causal inferences about the association between risk factors and OCD are precluded since our results were based on cross-sectional data. Conclusion (Multiple) comorbidity in OCD is clinically relevant since it is associated with a specific pattern of vulnerability, with greater chronicity, with more severe OCD and more negative consequences on daily life. This indicates that the diagnosis and treatment of all comorbid disorders is clinically relevant, and clinicians should be especially aware of multiple disorders in cases of childhood trauma and high levels of neuroticism. Primary OCD has a different developmental and comorbidity pattern compared to secondary OCD.

ObjectiveThe need for symmetry and ordering objects related to a “just right”-feeling is a common symptom in Tourette's syndrome (TS) and resembles symmetry behavior in obsessive-compulsive disorder, but its pathophysiology is unknown. We used a symptom provocation paradigm to investigate the neural correlates of symmetry behavior in TS and hypothesized the involvement of frontal-striatal and limbic brain areas.MethodsPictures of asymmetrically and symmetrically arranged objects were presented in randomized blocks (4 blocks of each condition) to 14 patients with TS and 10 matched healthy controls (HC). A H215O positron emission tomography scan was acquired during each stimulus block, resulting in 8 scans per subject. After each scan, state anxiety and symmetry behavior (the urge to rearrange objects) were measured using a visual analogue scale.ResultsDuring the asymmetry condition, TS patients showed increased regional cerebral blood flow (rCBF) in the anterior cingulate cortex, supplementary motor area, and inferior frontal cortex, whereas HC showed increased rCBF in the visual cortex, primary motor cortex, and dorsal prefrontal cortex. Symmetry ratings during provocation correlated positively with orbitofrontal activation in the TS group and sensorimotor activation in the HC group, and negatively with dorsal prefrontal activity in HC.ConclusionsResults suggest that both motor and limbic circuits are involved in symmetry behavior in TS. Motor activity may relate to an urge to move or perform tics, and limbic activation may indicate that asymmetry stimuli are salient for TS patients. In contrast, symmetry provocation in HC resulted in activation of brain regions implicated in sensorimotor function and cognitive control.

Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder characterized by intrusive thoughts and behaviors that dominate daily living, like an itch patients cannot ignore. Deficits in executive functioning are common in OCD and are thought to be related to dysfunctional frontal-striatal systems. One of those executive functions is cognitive flexibility, defined as the ability to rapidly switch response strategies following changes in task-relevant information. The temporal stability of cognitive flexibility impairments in OCD has been incompletely investigated since previous studies have suggested both state and trait dependency. In this study, 16 OCD patients performed a functional magnetic resonance imaging version of a task-switching paradigm twice, intervened by a follow-up period of on average 6 months. Results show that functional abnormalities in the dorsal frontal-striatal circuit and anterior cingulate cortex at baseline normalized at follow-up. This change in the recruitment of task-related brain circuits correlated with change in disease severity. These results support the view that the imbalance between the dorsal and ventral frontal-striatal circuits is at least partly state-dependent, and is associated with a reduction in symptom severity.

Background Anxiety disorders are highly prevalent in primary care and cause a substantial burden of disease. Screening on risk status, followed by preventive interventions in those at risk may prevent the onset of anxiety disorders, and thereby reduce the disease burden. The willingness to participate in screening and interventions is crucial for the scope of preventive strategies, but unknown. This feasibility study, therefore, investigated participation rates of screening and preventive services for anxiety disorders in primary care, and explored reasons to refrain from screening. Methods In three general practices, screening was offered to individuals visiting their general practitioner (total n = 2454). To assess risk status, a 10-item questionnaire was followed by a telephone interview (including the CIDI) when scoring above a predefined threshold. Preventive services were offered to those at risk. Participation rates for screening and preventive services for anxiety disorders were assessed. Those not willing to be screened were asked for their main reason to refrain from screening. Results Of all individuals, 17.3% participated in initial screening, and of those with a possible risk status, 56.0% continued screening. In 30.1% of those assessed, a risk status to develop an anxiety disorder was verified. Of these, 22.6% already received some form of mental health treatment and 38.7% of them agreed to participate in a preventive intervention and were referred. The most frequently mentioned reasons to refrain from screening were the emotional burden associated with elevated risk status, the assumption not to be at risk, and a lack of motivation to act upon an elevated risk status by using preventive services. Conclusions Screening in general practice, followed by offering services to prevent anxiety disorders in those at risk did not appear to be a feasible strategy due to low participation rates. To enable the development of feasible and cost-effective preventive strategies, exploring the reasons of low participation rates, considering involving general practitioners in preventive strategies, and looking at preventive strategies in somatic health care with proven feasibility may be helpful.

Young immigrant women in the Netherlands demonstrate disproportionate rates of suicidal behavior. This study investigated the origins of suicidal behavior in South Asian-Surinamese, Turkish, and Moroccan immigrant young women in order to identify ethnic- and gender-specific patterns of suicidal behavior. Based on life story interviews of women who had been enrolled in mental health care, we constructed five typical patterns in which social, cultural, and personal factors were interconnected. Suicidal behavior was influenced by the ability and right to act autonomously with regard to strategic life choices, as well as by the questioning of cultural values of self-sacrifice and protection of honor. © 2012 The Author(s).

Background Many OCD patients present with comorbid conditions, and major depression is one of the most frequent comorbidities observed. OCD patients with comorbid depression exhibit functional disability and poor quality of life. However, it is unclear whether depressive symptoms are predictive of treatment response, and debate remains whether they should be targeted in the treatment of comorbid patients. The current study aimed at assessing the predictive value of depression and OCD symptoms in the long term outcome of OCD treatment. Methods In the current study, relations between OCD and depressive symptoms were systematically investigated in a group of 121 OCD patients who received 16 sessions of behavior or cognitive therapy either alone or with fluvoxamine. Results Depression (either as a continuous or categorical variable) was not predictive of treatment response in any of the treatment modalities for up to 5 years of follow-up. Changes in OCD symptoms largely predicted changes in depressive symptoms but not vice versa. Limitations Subsequent to participation in the RCT, almost two-thirds of the participants received some form of additional treatment (either pharmacological or psychological), and as a result, it is impossible to determine interaction effects with additional treatment received after the trial. Conclusions Treatment of OCD with comorbid depression should focus on amelioration of OCD symptoms. When OCD treatment is successful, depressive symptoms are likely to ameliorate as well.

Background: Behavior therapy [exposure and response prevention (ERP)] and cognitive therapy (CT) have proven effective in the treatment of obsessive-compulsive disorder. Direct comparisons between these treatment modalities have exposed no differences in efficacy. However, very little research has been conducted into the differences between the change processes in ERP and CT. This investigation is a first attempt to study change by measuring scores on a weekly basis rather than at specific stages in the treatment and follow-up. Methods: We used the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at weekly intervals to rate and compare the severity of the obsessions and compulsions of 61 completers of either CT or ERP. The aim was to ascertain whether the process of change in CT is different from the process of change in ERP. We expected that ERP would primarily affect behavior, thus reducing compulsions first, while CT would primarily affect thought, thus reducing obsessions first. Results: Firstly, no differences were found between ERP and CT with respect to the change process for obsessions and compulsions. Secondly, it emerged that changes in compulsions predicted all treatment effects better than changes in obsessions. Conclusions: These results suggest that reduction of compulsions is the process through which both ERP and CT affect change.

Background. There is increasing evidence that subthreshold forms of psychopathology are both common and clinically relevant. To enable classification of these subthreshold forms of psychopathology, it may be useful to distinguish not only a threshold for illness but also for health. Our aim was to investigate this with regard to panic.Method. Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), which is based on a large representative sample of the adult general population (18–65 years) of The Netherlands (n=7076). The Composite International Diagnostic Interview was used as a diagnostic instrument. By defining two thresholds, three groups were formed: panic disorder, subthreshold panic disorder and no-panic. These groups were compared using multinomial regression analysis, χ2 and analysis of variance.Results. The 12-month prevalence of panic disorder was 2·2% while that of subthreshold panic disorder was 1·9%. Symptom profiles and risk indicators associated with panic disorder and subthreshold panic disorder were similar, and half of the risk indicators were more strongly associated with panic disorder than with subthreshold panic disorder. Subthreshold panic disorder occupied an intermediate position between panic disorder and no-panic with regard to the number of symptoms, the percentage of subjects with co-morbidity, and functioning.Conclusions. Subthreshold panic disorder is common, and seems clinically relevant, but is milder than panic disorder. These results thus support the use of a double threshold in panic. Further research should focus on the positioning of the thresholds, the course of subthreshold panic disorder and its treatment options.

This randomised controlled trial was conducted to compare zolpidem to an equivalent dose of temazepam with respect to subjective rebound insomnia after cessation of 4 weeks of treatment in chronic insomnia (zolpidem 10 mg, n=79; temazepam 20 mg, n=84). Both agents improved total sleep time (TST) as well as sleep onset latency (SOL) significantly during the 4 treatment weeks. Prevalence rates for rebound insomnia, defined as a worsening of TST or SOL of more than 40% compared to baseline, were 27% for TST and 53% for SOL in the Zolpidem condition and 26% and 58%, respectively, in the temazepam condition. No significant differences were found between both agents with respect to rebound insomnia, nor with respect to their efficacy or safety. We conclude that in clinical practice zolpidem has no advantages over temazepam with respect to rebound insomnia.