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Timothy J Meeker,1,2 Mark I Saffer,1 Jodie Frost,1 Jui-Hong Chien,1 Roger J Mullins,1,2 Sean Cooper,1 O Joseph Bienvenu,3 Fred A Lenz1 1Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA; 2Department of Biology, Morgan State University, Baltimore, MD, USA; 3Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD, USACorrespondence: Timothy J Meeker, Department of Biology, Morgan State University, 1700 East Cold Spring Lane, Key Hall G51, Baltimore, MD, 21251, USA, Tel +1-443-885-3070, Email timothy.meeker@morgan.eduIntroduction: Pain is frequently accompanied by enhanced arousal and hypervigilance to painful sensations. Here, we describe our findings in an experimental vigilance task requiring healthy participants to indicate when randomly timed moderately painful stimuli occur in a long train of mildly painful stimuli.Methods: During a continuous performance task with painful laser stimuli (CPTpain), 18 participants rated pain intensity, unpleasantness, and salience. We tested for a vigilance decrement over time using classical metrics including correct targets (hits), incorrectly identified non-targets (false alarms), hit reaction time, and false alarm reaction time. We measured state anxiety and tense arousal before and after the task.Results: We found a vigilance decrement across four 12.5-minute blocks of painful laser stimuli in hits [F3,51=2.91; p=0.043; time block 1>block 4 (t=2.77; p=0.035)]. Both self-report state anxiety (tpaired,17=3.34; p=0.0039) and tense arousal (tpaired,17=3.20; p=0.0053) increased after the task. We found a vigilance decrement during our laser pain vigilance task consistent with vigilance decrements found in other stimulus modalities. Furthermore, state anxiety positively correlated with tense arousal.Discussion: CPTpain acutely increased tense arousal and state anxiety, consistent with previous results implicating the reciprocal interaction of state anxiety and acute painful sensations and the role of pain in augmenting tense arousal. These results may indicate a psychological process which predisposes the hypervigilant to developing greater acute pain, resulting in positive feedback, greater pain and anxiety.Keywords: continuous performance task, false alarms, pain, vigilance, salience

Up to 30% of patients with obsessive-compulsive disorder (OCD) exhibit an inadequate response to serotonin reuptake inhibitors (SRIs). To date, genetic predictors of OCD treatment response have not been systematically investigated using genome-wide association study (GWAS). To identify specific genetic variations potentially influencing SRI response, we conducted a GWAS study in 804 OCD patients with information on SRI response. SRI response was classified as 'response' (n=514) or 'non-response' (n=290), based on self-report. We used the more powerful Quasi-Likelihood Score Test (the MQLS test) to conduct a genome-wide association test correcting for relatedness, and then used an adjusted logistic model to evaluate the effect size of the variants in probands. The top single-nucleotide polymorphism (SNP) was rs17162912 (P=1.76 × 10(-8)), which is near the DISP1 gene on 1q41-q42, a microdeletion region implicated in neurological development. The other six SNPs showing suggestive evidence of association (P

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by intrusive thoughts and urges and repetitive, intentional behaviors that cause significant distress and impair functioning. The OCD Collaborative Genetics Association Study (OCGAS) is comprised of comprehensively assessed OCD patients with an early age of OCD onset. After application of a stringent quality control protocol, a total of 1065 families (containing 1406 patients with OCD), combined with population-based samples (resulting in a total sample of 5061 individuals), were studied. An integrative analyses pipeline was utilized, involving association testing at single-nucleotide polymorphism (SNP) and gene levels (via a hybrid approach that allowed for combined analyses of the family- and population-based data). The smallest P-value was observed for a marker on chromosome 9 (near PTPRD, P=4.13 × 10(-)(7)). Pre-synaptic PTPRD promotes the differentiation of glutamatergic synapses and interacts with SLITRK3. Together, both proteins selectively regulate the development of inhibitory GABAergic synapses. Although no SNPs were identified as associated with OCD at genome-wide significance level, follow-up analyses of genome-wide association study (GWAS) signals from a previously published OCD study identified significant enrichment (P=0.0176). Secondary analyses of high-confidence interaction partners of DLGAP1 and GRIK2 (both showing evidence for association in our follow-up and the original GWAS study) revealed a trend of association (P=0.075) for a set of genes such as NEUROD6, SV2A, GRIA4, SLC1A2 and PTPRD. Analyses at the gene level revealed association of IQCK and C16orf88 (both P

Genetic association studies of SLC6A4 (SERT) and obsessive-compulsive disorder (OCD) have been equivocal. We genotyped 1241 individuals in 278 pedigrees from the OCD Collaborative Genetics Study for 13 single-nucleotide polymorphisms, for the linked polymorphic region (LPR) indel with molecular haplotypes at rs25531, for VNTR polymorphisms in introns 2 and 7 and for a 381-bp deletion 3' to the LPR. We analyzed using the Family-Based Association Test (FBAT) under additive, dominant, recessive and genotypic models, using both OCD and sex-stratified OCD as phenotypes. Two-point FBAT analysis detected association between Int2 (P = 0.0089) and Int7 (P = 0.0187) (genotypic model). Sex-stratified two-point analysis showed strong association in females with Int2 (P

Rationale: Survivors of acute lung injury (ALI) frequently have substantial depressive symptoms and physical impairment, but the longitudinal epidemiology of these conditions remains unclear.Objectives: To evaluate the 2-year incidence and duration of depressive symptoms and physical impairment after ALI, as well as risk factors for these conditions.Methods: This prospective, longitudinal cohort study recruited patients from 13 intensive care units (ICUs) in four hospitals, with follow-up 3, 6, 12, and 24 months after ALI. The outcomes were Hospital Anxiety and Depression Scale depression score greater than or equal to 8 ("depressive symptoms") in patients without a history of depression before ALI, and two or more dependencies in instrumental activities of daily living ("impaired physical function") in patients without baseline impairment.Measurements and Main Results: During 2-year follow-up of 186 ALI survivors, the cumulative incidences of depressive symptoms and impaired physical function were 40 and 66%, respectively, with greatest incidence by 3-month follow-up; modal durations were greater than 21 months for each outcome. Risk factors for incident depressive symptoms were education 12 years or less, baseline disability or unemployment, higher baseline medical comorbidity, and lower blood glucose in the ICU. Risk factors for incident impaired physical function were longer ICU stay and prior depressive symptoms.Conclusions: Incident depressive symptoms and impaired physical function are common and long-lasting during the first 2 years after ALI. Interventions targeting potentially modifiable risk factors (e.g., substantial depressive symptoms in early recovery) should be evaluated to improve ALI survivors' long-term outcomes. [ABSTRACT FROM AUTHOR]

BackgroundPsychiatric conditions in which symptoms arise involuntarily (‘diseases’) might be assumed to be more heritable than those in which choices are essential (behavioral disorders). We sought to determine whether psychiatric ‘diseases’ (Alzheimer's disease, schizophrenia, and mood and anxiety disorders) are more heritable than behavioral disorders (substance use disorders and anorexia nervosa).MethodWe reviewed the literature for recent quantitative summaries of heritabilities. When these were unavailable, we calculated weighted mean heritabilities from twin studies meeting modern methological standards.ResultsHeritability summary estimates were as follows: bipolar disorder (85%), schizophrenia (81%), Alzheimer's disease (75%), cocaine use disorder (72%), anorexia nervosa (60%), alcohol dependence (56%), sedative use disorder (51%), cannabis use disorder (48%), panic disorder (43%), stimulant use disorder (40%), major depressive disorder (37%), and generalized anxiety disorder (28%).ConclusionsNo systematic relationship exists between the disease-like character of a psychiatric disorder and its heritability; many behavioral disorders seem to be more heritable than conditions commonly construed as diseases. These results suggest an error in ‘common-sense’ assumptions about the etiology of psychiatric disorders. That is, among psychiatric disorders, there is no close relationship between the strength of genetic influences and the etiologic importance of volitional processes. [ABSTRACT FROM AUTHOR]

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V. [ABSTRACT FROM AUTHOR]

BACKGROUND: Obsessive-compulsive disorder (OCD) is probably an etiologically heterogeneous condition. Many patients manifest other psychiatric syndromes. This study investigated the relationship between OCD and co-morbid conditions to identify subtypes. METHOD: Seven hundred and six individuals with OCD were assessed in the OCD Collaborative Genetics Study (OCGS). Multi-level latent class analysis was conducted based on the presence of eight co-morbid psychiatric conditions [generalized anxiety disorder (GAD), major depression, panic disorder (PD), separation anxiety disorder (SAD), tics, mania, somatization disorders (Som) and grooming disorders (GrD)]. The relationship of the derived classes to specific clinical characteristics was investigated. RESULTS: Two and three classes of OCD syndromes emerge from the analyses. The two-class solution describes lesser and greater co-morbidity classes and the more descriptive three-class solution is characterized by: (1) an OCD simplex class, in which major depressive disorder (MDD) is the most frequent additional disorder; (2) an OCD co-morbid tic-related class, in which tics are prominent and affective syndromes are considerably rarer; and (3) an OCD co-morbid affective-related class in which PD and affective syndromes are highly represented. The OCD co-morbid tic-related class is predominantly male and characterized by high conscientiousness. The OCD co-morbid affective-related class is predominantly female, has a young age at onset, obsessive-compulsive personality disorder (OCPD) features, high scores on the 'taboo' factor of OCD symptoms, and low conscientiousness. CONCLUSIONS: OCD can be classified into three classes based on co-morbidity. Membership within a class is differentially associated with other clinical characteristics. These classes, if replicated, should have important implications for research and clinical endeavors. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Individuals with obsessive-compulsive disorder (OCD) who have compulsive hoarding behavior are clinically different from other OCD-affected individuals. The objective of this study was to determine whether there are chromosomal regions specifically linked to compulsive hoarding behavior in families with obsessive-compulsive disorder. METHODS: The authors used multipoint allele-sharing methods to assess for linkage in 219 multiplex OCD families collected as part of the OCD Collaborative Genetics Study. The authors treated compulsive hoarding as the phenotype of interest and also stratified families into those with and without two or more relatives affected with compulsive hoarding. RESULTS: Using compulsive hoarding as the phenotype, there was suggestive linkage to chromosome 14 at marker D14S588 (Kong and Cox logarithm of the odds ratio [LOD] [KAC(all)=2.9]). In families with two or more hoarding relatives, there was significant linkage of OCD to chromosome 14 at marker C14S1937 (KAC(all)=3.7), whereas in families with fewer than two hoarding relatives, there was suggestive linkage to chromosome 3 at marker D3S2398 (KAC(all)=2.9). CONCLUSIONS: The findings suggest that a region on chromosome 14 is linked with compulsive hoarding behavior in families with OCD. [ABSTRACT FROM AUTHOR]

Objective: Population-based studies of prevalence have been used to approximate the amount of need for treatment of mental disorders. This study aimed to estimate need for treatment of alcohol dependence, major depression, panic disorder, agoraphobia, and social phobia.Methods: Psychiatrists used the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) to assess individuals in a probability sample of the Baltimore Epidemiologic Catchment Area follow-up study for need for and use of mental health services. Population-based estimates were calculated with probability weights.Results: The SCAN sample included 816 participants who were interviewed between 1993 and 1999. Prevalence of need for mental health services in the general population was 28.7%+/-2.7%. Among the disorders studied, the greatest need was for treatment of alcohol dependence; 90% of the SCAN sample who met criteria for this diagnosis, or 13.6%+/-1.9% of the population, needed treatment. In the general population, 10.5%+/-2.1% needed treatment for major depression; 5.2%+/-.9%, for social phobia; 5.2%+/-1.6%, for panic disorder; and 3.2%+/-.9%, for agoraphobia. The highest needs for specific treatment modalities were self-help groups for alcohol dependence, talk therapy for depression, behavior modification for social phobia and agoraphobia, and antidepressant medications for panic disorder. Overall, less than 33% of needs were met. Social phobia and alcohol dependence were the two disorders with the highest proportion of unmet need.Conclusions: Prevalence of mental disorders is only an approximation of the need for treatment. There is a substantial need for mental health services in the general population. Most individuals who would benefit from treatment are not receiving any type of mental health services. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about the long-term outcome of personality disorder traits. The purpose of this study was to investigate, in a community-residing population, the longitudinal relationship between psychiatrist-assessed personality disorder scores and global functioning 13-18 years later. METHOD: A stratified random sample of residents of east Baltimore were examined by psychiatrists in 1981 and asssessed for DSM-III personality disorders using a semi-structured instrument, the Standardized Psychiatric Examination. A total of 292 persons were re-examined by different psychiatrists during 1994-1999 using the Schedules for the Assessment of Neuropsychiatry (SCAN). After completion of the SCAN, the subjects' functional status was evaluated using the Global Assessment of Functioning (GAF). The relationships between personality dimensions and follow-up GAF scores were evaluated using linear regression models. RESULTS: All of the personality disorder scales measured in 1981 were inversely related to functioning 13-18 years later, with the exception of narcissistic and compulsive scales. After controlling for Axis I disorders diagnosed contemporaneously with GAF assessment, schizoid, antisocial, borderline, histrionic, and avoidant personality disorder scores significantly predicted GAF scores. CONCLUSIONS: Most dimensions of DSM-III personality disorder traits were significantly associated with global functioning after an interval of 15 years. However, only schizoid, antisocial, borderline, histrionic, and avoidant personality disorder traits had long-term effects on functioning when Axis I disorders at follow-up were controlled. This suggests that the functional effect of the other personality disorder traits may be mediated through their relationship with Axis I disorders. Future research is needed using more specific and sensitive outcome measures. [ABSTRACT FROM AUTHOR]

How common is panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without a history of panic disorder in the USA?METHODSDesign: Cross sectional study.Setting: General population, USA; 2001-02.Population: 43 093 community dwelling adults aged over 18 years.Assessment: Participants were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule--DSM-IV version (AUDADIS-IV). People with organic or substance induced disorders were excluded.Outcomes: Diagnosis of panic disorder with agoraphobia, panic disorder without agoraphobia, or agoraphobia without panic disorder.Follow up: 81%.MAIN RESULTSThe overall 12 month and lifetime prevalence rates for panic disorder (with or without agoraphobia) were 2.1% and 5.1%. The 12 month and lifetime prevalence rates for panic disorder with agoraphobia were 0.6% and 1.1%, while the corresponding rates for panic disorder without agoraphobia were 1.6% and 4.0%. Agoraphobia without panic disorder was uncommon (12 month prevalence 0.05%; lifetime prevalence 0.17%). Panic disorder with or without agoraphobia was more common in women, middle-aged people, people with low incomes, and those who were widowed, separated or divorced (see http://www.ebmentalhealth.com/supplemental for table). Panic disorders were more common in Native Americans, and less common in Hispanic, black, or Asian/Pacific Islanders than in white people.CONCLUSIONSAbout one in 20 people in the USA have a lifetime diagnosis of panic disorder. Panic disorder is more common in women, Native Americans, the middle-aged, people with low incomes, and people who are widowed, separated, or divorced. [ABSTRACT FROM AUTHOR]

Background: Proactive psychiatric consultation services rapidly identify and assess medical inpatients in need of psychiatric care. In addition to more rapid contact, proactive services may reduce the length of stay and improve staff satisfaction. However, in some settings, it is impractical to integrate a proactive consultation service into every hospital unit; on-request and proactive services are likely to coexist in the future. Prior research has focused on changes in outcomes with the implementation of proactive services., Objective and Methods: This report describes differences between contemporary proactive and on-request services within the same academic medical center, comparing demographic and clinical data collected retrospectively from a 4-year period from the electronic medical record., Results: The proactive service saw patients over four times as many initial admissions (7592 vs. 1762), but transitions and handoffs between services were common, with 434 admissions involving both services, comprising nearly 20% of the on-request service's total contacts. The proactive service admissions had a shorter length of stay and a faster time to first psychiatric contact, and the patients seen were more likely to be female, of Black race, and to be publicly insured. There were over three times as many admissions to psychiatry from the proactive service. The on-request service's admissions had a longer length of stay, were much more likely to involve intensive care unit services, surgical services, and transfers among units, and the patients seen were more likely to die in the hospital or to be discharged to subacute rehabilitation., Conclusions: Overall, the results suggest that the two services fulfill complementary roles, with the proactive service's rapid screening and contact providing care to a high volume of patients who might otherwise be unidentified and underserved. Simultaneously, the on-request service's ability to manage patients in response to consult requests over a much larger area of the hospital provided important support and continuity for patients with complex health needs. Institutions revising their consultation services will likely need to consider the best balance of these differing functions to address perceived demand for services., (Copyright © 2024 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

Purpose: Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short- and long-term morbidity and mortality. However, there are limited data on mental health sequelae that survivors experience following discharge., Methods: We conducted a retrospective, population-based cohort study in Ontario, Canada of critically ill adult (≥ 18 years) survivors of AMI-CS, admitted to hospital between April 1, 2009 and March 31, 2019. We compared these patients to AMI survivors without shock. We captured outcome data using linked health administrative databases. The primary outcome was a new mental health diagnosis (a composite of mood, anxiety, or related disorders; schizophrenia/psychotic disorders; and other mental health disorders) following hospital discharge. We secondarily evaluated incidence of deliberate self-harm and death by suicide. We compared patients using overlap propensity score-weighted, cause-specific proportional hazard models., Results: We included 7812 consecutive survivors of AMI-CS, from 135 centers. Mean age was 68.4 (standard deviation (SD) 12.2) years, and 70.3% were male. Median follow-up time was 767 days (interquartile range (IQR) 225-1682). Incidence of new mental health diagnosis among AMI-CS survivors was 109.6 per 1,000 person-years (95% confidence interval (CI) 105.4-113.9), compared with 103.8 per 1000 person-years (95% CI 102.5-105.2) among AMI survivors without shock. After propensity score adjustment, there was no difference in the risk of new mental health diagnoses following discharge [hazard ratio (HR) 0.99 (95% CI 0.94-1.03)]. Factors associated with new mental health diagnoses following AMI-CS included female sex, pre-existing mental health diagnoses, and discharge to a long-term hospital or rehabilitation institute., Conclusion: Survivors of AMI-CS experience substantial mental health morbidity following discharge. Risk of new mental health diagnoses was comparable between survivors of AMI with and without shock. Future research on interventions to mitigate psychiatric sequelae after AMI-CS is warranted., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Delirium is common in hospitalised patients, and there is currently no specific treatment. Identifying and treating underlying somatic causes of delirium is the first priority once delirium is diagnosed. Several international guidelines provide clinicians with an evidence-based approach to screening, diagnosis and symptomatic treatment. However, current guidelines do not offer a structured approach to identification of underlying causes. A panel of 37 internationally recognised delirium experts from diverse medical backgrounds worked together in a modified Delphi approach via an online platform. Consensus was reached after five voting rounds. The final product of this project is a set of three delirium management algorithms (the Delirium Delphi Algorithms), one for ward patients, one for patients after cardiac surgery and one for patients in the intensive care unit., Competing Interests: DISCLOSURES The authors have no conflicts of interest to disclose.

Background: Little is known about specific obsessive-compulsive clinical features associated with lifetime history of suicide attempt in individuals with obsessive-compulsive disorder (OCD) and major depression., Methods: The study sample included 515 adults with OCD and a history of major depression. In exploratory analyses, we compared the distributions of demographic characteristics and clinical features in those with and without a history of attempted suicide and used logistic regression to evaluate the association between specific obsessive-compulsive clinical features and lifetime suicide attempt., Results: Sixty-four (12%) of the participants reported a lifetime history of suicide attempt. Those who had attempted suicide were more likely to report having experienced violent or horrific images (52% vs. 30%; p < 0.001). The odds of lifetime suicide attempt were more than twice as great in participants with versus without violent or horrific images (O.R. = 2.46, 95%, CI = 1.45-4.19; p < 0.001), even after adjustment for other risk correlates of attempted suicide, including alcohol dependence, post-traumatic stress disorder, parental conflict, excessive physical discipline, and number of episodes of depression. The association between violent or horrific images and attempted suicide was especially strong in men, 18-29 year olds, those with post-traumatic stress disorder, and those with particular childhood adversities., Conclusions: Violent or horrific images are strongly associated with lifetime suicide attempts in OCD-affected individuals with a history of major depression. Prospective clinical and epidemiological studies are needed to elucidate the basis of this relationship., Competing Interests: Declaration of competing interest The authors have no conflict of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk., Research Question: What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm?, Study Design and Methods: Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge., Results: We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide., Interpreation: Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Psychiatric comorbidity is defined as the joint occurrence of two or more mental or substance use disorders. Widespread psychiatric comorbidity has been reported in treatment and population-based studies. The aim of this study was to measure the extent and impact of psychiatric comorbidity in a cohort of the Baltimore Epidemiologic Catchment Area study., Methods: We examined the comorbidity burden of 16 mental disorders in a cohort of 847 participants using both established and novel analytical approaches The Comorbidity to Diagnosis Inflation Ratio (CDIR), is a statistical instrument that quantifies impact of pairwise comorbid associations, both on the whole sample, as well as on each specific disorder., Results: Most anxiety disorders had substantial co-occurrence with each other, as well as with Major Depressive Disorder (MDD). In addition, mood disorders had a high degree of comorbidity with Alcohol Dependence (AD). The CDIR for the whole sample was 1.32, indicating a ratio of 132 comorbidities per 100 diagnoses. The conditions with high sample prevalence were relatively less comorbid than the low prevalence conditions. Obsessive Compulsive Disorder had a comorbidity burden that was 89% greater than the overall sample., Conclusion: Anxiety disorders are highly interrelated, as well as highly comorbid with depression. The comorbidity phenomenon is linked to the differential prevalence of the analyzed conditions. Comorbidity frequency (most prevalent comorbid condition) appears mutually exclusive to comorbidity burden (most widely interrelated condition). While AD and MDD were the most frequently diagnosed disorders; low prevalence conditions as OCD and GAD were the most widely interrelated., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Importance: Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients, but little is known regarding long-term psychiatric sequelae among survivors after ECMO., Objective: To investigate the association between ECMO survivorship and postdischarge mental health diagnoses among adult survivors of critical illness., Design, Setting, and Participants: Population-based retrospective cohort study in Ontario, Canada, from April 1, 2010, through March 31, 2020. Adult patients (N=4462; age ≥18 years) admitted to the intensive care unit (ICU), and surviving to hospital discharge were included., Exposures: Receipt of ECMO., Main Outcomes and Measures: The primary outcome was a new mental health diagnosis (a composite of mood disorders, anxiety disorders, posttraumatic stress disorder; schizophrenia, other psychotic disorders; other mental health disorders; and social problems) following discharge. There were 8 secondary outcomes including incidence of substance misuse, deliberate self-harm, death by suicide, and individual components of the composite primary outcome. Patients were compared with ICU survivors not receiving ECMO using overlap propensity score-weighted cause-specific proportional hazard models., Results: Among 642 survivors who received ECMO (mean age, 50.7 years; 40.7% female), median length of follow-up was 730 days; among 3820 matched ICU survivors who did not receive ECMO (mean age, 51.0 years; 40.0% female), median length of follow-up was 1390 days. Incidence of new mental health conditions among survivors who received ECMO was 22.1 per 100-person years (95% confidence interval [CI] 19.5-25.1), and 14.5 per 100-person years (95% CI, 13.8-15.2) among non-ECMO ICU survivors (absolute rate difference of 7.6 per 100-person years [95% CI, 4.7-10.5]). Following propensity weighting, ECMO survivorship was significantly associated with an increased risk of new mental health diagnosis (hazard ratio [HR] 1.24 [95% CI, 1.01-1.52]). There were no significant differences between survivors who received ECMO vs ICU survivors who did not receive ECMO in substance misuse (1.6 [95% CI, 1.1 to 2.4] per 100 person-years vs 1.4 [95% CI, 1.2 to 1.6] per 100 person-years; absolute rate difference, 0.2 per 100 person-years [95% CI, -0.4 to 0.8]; HR, 0.86 [95% CI, 0.48 to 1.53]) or deliberate self-harm (0.4 [95% CI, 0.2 to 0.9] per 100 person-years vs 0.3 [95% CI, 0.2 to 0.3] per 100 person-years; absolute rate difference, 0.1 per 100 person-years [95% CI, -0.2 to 0.4]; HR, 0.68 [95% CI, 0.21 to 2.23]). There were fewer than 5 total cases of death by suicide in the entire cohort., Conclusions and Relevance: Among adult survivors of critical illness, receipt of ECMO, compared with ICU hospitalization without ECMO, was significantly associated with a modestly increased risk of new mental health diagnosis or social problem diagnosis after discharge. Further research is necessary to elucidate the potential mechanisms underlying this relationship.

Objectives: Anxiety and depression are common mental disorders in adults admitted to the ICU. Although depression increases postsurgical delirium and anxiety does not, their associations with ICU delirium in critically ill adults remain unclear. We evaluated the association between ICU baseline anxiety and depression and ICU delirium occurrence., Design: Subgroup analysis of a prospective cohort study., Setting: Single, 36-bed mixed ICU., Patients: Nine-hundred ninety-one ICU patients admitted with or without delirium between July 2016 and February 2020; patients admitted after elective surgery or not assessed for anxiety/depression were excluded., Intervention: None., Measurements and Main Results: The Hospital Anxiety and Depression Scale questionnaire was administered at ICU admission to determine baseline anxiety and depression. All patients were assessed with the Confusion Assessment Method for the ICU (CAM-ICU) q8h; greater than or equal to 1 +CAM-ICU assessment and/or scheduled antipsychotic use represented a delirium day. Multivariable logistic and Quasi-Poisson regression models, adjusted for ICU days and nine delirium risk variables ("Pre-ICU": age, Charlson Comorbidity Index, cognitive impairment; "ICU baseline": Acute Physiology and Chronic Health Evaluation-IV, admission type; "Daily ICU": opioid and/or benzodiazepine use, Sequential Organ Failure Assessment score, coma), were used to evaluate associations between baseline anxiety and/or depression and ICU delirium. Among the 991 patients, 145 (14.6%) had both anxiety and depression, 78 (7.9%) had anxiety only, 91 (9.2%) had depression only, and 677 (68.3%) had neither. Delirium occurred in 406 of 991 total cohort (41.0%) patients; in the baseline anxiety and depression group, it occurred in 78 of 145 (53.8%), in the anxiety only group, 37 of 78 (47.4%), in the depression only group, 39 of 91 (42.9%), and in the group with neither in 252 of 677 (37.2%). Presence of both baseline anxiety and depression was associated with greater delirium occurrence (adjusted odds ratio, 1.99; 95% CI, 1.10-3.53; p = 0.02) and duration (adjusted risk ratio, 1.62; 95% CI, 1.17-2.23; p < 0.01)., Conclusions: Baseline anxiety and depression are associated with increased ICU delirium occurrence and should be considered when delirium risk reduction strategies are being formulated., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

The COVID-19 pandemic within the United States of America resulted in over 800,000 deaths as of February 2022 and has been addressed by social distancing or stay-at-home measures. Collective prolonged multimodal trauma on this scale is likely to elicit symptomatology in the general population consistent with post-traumatic stress disorder (PTSD), somatization, anxiety, and stress. The psychological component of this response contributes substantially to the burden of this disease worldwide. This cross-sectional study examines the relationship between COVID-19-related concern, anxiety, and perceived stress on PTSD-like symptomatology over the course of the COVID-19 pandemic. Participants were recruited via social media within the United States of America between 8th May 2020 and 11th August 2021 to complete an internet questionnaire including mood, personality, and COVID-19-specific scales. General anxiety and PTSD-like symptomatology were above the screening cutoffs for most respondents. These measures increased in severity over the pandemic, with the change point of our Concern scale preceding that of the other significant measures. Measures of COVID-19-related concern, generalized anxiety, and PTSD-like symptomatology were strongly correlated with each other. Anxiety, perceived stress, and PTSD-like symptomatology are strongly interrelated, increase with pandemic length, and are linked to reported levels of concern over COVID-19. These observations may aid future research and policy as the pandemic continues.

Corticosteroids are used for a multitude of indications in palliative patients. In this narrative review, we aim to review literature on the treatment and prevention of neuropsychiatric complications of steroids. For prevention, only lamotrigine had a positive effect in a small number of studies. For treatment, olanzapine appears to be nearly universally effective at low doses, but randomized trial evidence is lacking. Further randomized clinical trials are necessary to elucidate data-driven guidelines for prevention and treatment of corticosteroid-induced neuropsychiatric symptoms. Until further data are available, it is reasonable to consider low dose olanzapine for any patient taking 40 mg of prednisone or its equivalent, especially those with a history of depression or neuropsychiatric symptoms.

Study Objectives: Trauma exposure likely contributes to poor sleep, but relatively few studies have empirically tested this, instead focusing on posttraumatic stress disorder. Moreover, little is known about sex differences in sleep after trauma. The current study used a cross-sectional and retrospective design to test hypotheses that trauma exposure would be associated with subsequent insomnia symptoms, particularly among women, even after accounting for important covariates., Method: Data from Wave 3 (1993-1996) of the Baltimore Epidemiologic Catchment Area Study (N = 1920) were used to examine associations between remote (prior to past year) and recent (past year) trauma and current sleep disturbance (insomnia, hypersomnia symptoms) in the total sample (M age = 55, 63.2% women, 57.7% white), and separately in men and women. Sensitivity analyses were conducted among individuals with no pretrauma sleep disturbance to examine incident sleep disturbance., Results: Among all participants, both remote (odds ratio [OR] = 1.95, 95% confidence interval [CI] [1.34, 2.85]) and recent (OR = 1.94, 95% CI [1.31, 2.87]) trauma exposure were associated with increased odds of insomnia (OR = 2.41, 95% CI [1.54, 3.76]) but not hypersomnia. Associations between trauma and insomnia were particularly strong among women, but null among men. The relationship between trauma exposure and insomnia symptoms persisted among individuals with no pretrauma history of insomnia., Conclusion: Results suggest women may be vulnerable to insomnia symptoms as sequelae of trauma. Future research should examine prospective associations between trauma and sleep in larger samples and how assessment and treatment of insomnia among women trauma survivors reduces the public health impact of trauma and poor sleep., (Copyright © 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The interplay between critical illness and mental disorders is poorly understood. The purpose of this study is to measure both the treated prevalence of mental disorders and psychotropic medication use before and after hospitalization and the impact of intensive care unit (ICU) admission on these outcomes., Methods: Using a population-based administrative database in Manitoba, Canada, 49,439 ICU patients admitted between 2000 and 2012 were compared to two matched comparison groups (hospitalized; n = 146,968 and general population; n = 141,937). Treated prevalence of mental disorders and psychotropic medication prescriptions were measured in the 5-year periods before and after the hospitalization. Multivariable models compared adjusted prevalence ratios (APRs) between populations., Results: The 5-year treated mental disorder prevalence in the ICU population increased from 41.5% pre-hospitalization to 55.6% post-hospitalization. Compared to non-ICU hospitalized patients, the adjusted treated mental disorder prevalence in ICU patients was lower prior to hospitalization (1-year APR 0.94, 95% CI 0.92-0.97, p < 0.0001; 5-year APR 0.99, 95% CI 0.98-1.00, p = 0.1), but higher following discharge (1-year APR 1.08, 95% CI 1.05-1.11, p < 0.0001, 5-year APR 1.03, 95% CI 1.01-1.05, p < 0.0001). A high proportion of ICU patients received antidepressant, anxiolytic and sedative-hypnotic prescriptions before and after their hospitalization. In multivariable analyses, ICU exposure was associated with an increase in mood, anxiety and psychotic disorders, and sedative-hypnotics use (p < 0.0001 for all Time × Group interactions)., Conclusions: During the 5 years after admission to ICU, there is a significant increase in treated prevalence of mental disorders and psychotropic medication use compared to the 5 years prior to ICU and compared to general population and hospital cohorts. Prevention and intervention programs that identify and treat mental disorders among survivors of critical illness warrant further study., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Although general anxiety has increased markedly since the onset of the COVID-19 pandemic, little has been reported about the demographic distribution of COVID-19 related worry, its relationship with psychological features, and its association with depression symptoms in the United States (US)., Methods: 2117 participants, selected to represent the age, gender, and race/ethnic distributions of the US population, completed an online survey. Analysis of variance and correlation analyses were used to assess relationships between the COVID-19 related worry score and demographic characteristics, past psychiatric diagnoses, personality dimensions, and current psychological symptoms. Logistic regression was used to evaluate the association between the COVID-19 worry score and depression symptoms., Results: The COVID-19 worry score was markedly higher in younger (18-49 year-olds) than older participants, and moderately higher in men, those who were married or cohabiting, with post-college education, and/or living in large urban areas. The COVID-19 worry score also was markedly higher in those who reported having been diagnosed with a psychiatric disorder. The COVID-19 worry score correlated with neuroticism, current psychological symptoms, and COVID-19 risk and COVID-19 behavior scores. The COVID-19 worry score was associated with current depression symptoms (OR = 1.10, 95% CI = 1.09-1.11; p < 0.001) in univariable models and remained significant after adjustment for other correlates of depression, including COVID-19 risk., Conclusions: In this US sample, the COVID-19 worry score was inversely related to age, strongly related to psychological symptoms, and independently associated with depression symptoms. These findings have implications for the community mental health response to the COVID-19 pandemic in the US., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The intensive care unit (ICU) within a hospital is typically thought of as a place for the provision of patient care for a life-threatening emergency. Less frequently do we consider it an integral part of disaster response. The COVID-19 pandemic is a public health disaster that has caused surges of critically ill patients requiring treatment in intensive care units (ICUs). However, it is important to bear in mind that survival of a critical illness can come at a cost, including to mental health. Being critically ill and requiring life-saving treatments is extremely stressful, and survivors frequently have substantial decrements in physical functioning, cognition, and emotional health. Remarkably, one in five critical illness survivors has clinically significant symptoms of posttraumatic stress disorder (PTSD). Risk factors, or markers of risk, include prior anxiety and depression, high doses of sedative medications in the intensive care unit (ICU), memories of nightmare-like experiences in the ICU, and emotional distress in early recovery. As with PTSD in other contexts, social support is a protective factor. ICU follow-up clinics, in-ICU psychological interventions, ICU diaries, post-ICU telephonic and computer-based cognitive-behavioral interventions, and virtual reality interventions all show promise in preventing long-term PTSD in critical illness survivors, perhaps particularly in those with substantial emotional distress in early recovery. However, awareness regarding this problem is still growing, as are changes to post-ICU care delivery. Hopefully, improved awareness on the part of the psychiatric community will help with recovery from the COVID-19 pandemic disaster.

Psychologic sequelae after critical illness, part of the postintensive care syndrome, significantly decrease quality of life. A robustly effective treatment intervention is currently lacking. Virtual reality has beneficial effects on several non-ICU-related psychologic disorders. The aim of this study was to explore patient-related determinants of ICU-specific virtual reality, such as the timing of patients' self-reported readiness to initiate virtual reality and the number of desired sessions and safety, and to explore the effects of ICU-specific virtual reality on mental health., Design: A multicenter, randomized controlled feasibility study., Setting: ICU at a university teaching hospital and a secondary care hospital in Rotterdam, The Netherlands., Patients: Consecutive mechanically ventilated patients with sepsis or septic shock., Interventions: Patients were randomly assigned (1:1) to receive ICU-specific virtual reality (ICU-specific virtual reality group) or exposure to a nature virtual reality environment (control virtual reality group)., Measurement and Main Results: Explorative outcomes were feasibility, in terms of patient-related determinants, and safety. The effects of ICU-specific virtual reality on the psychologic components of postintensive care syndrome and quality of life were additionally studied. Fifty patients (median age: 61 yr; 21 [42%] female) were included. Patients in the ICU-specific virtual reality group felt ready to initiate the virtual reality intervention 10 days (median, 95% range, 5-21 d) after ICU discharge, and one session (median, 95% range, 1-6) was desired. ICU-specific virtual reality patients experienced higher immersion, cybersickness scores were low, and no changes in vital signs were observed. They also reported reduced posttraumatic stress disorder and depression scores and better mental health from 2 days until 1 month after initial exposure (Short Form-12 Mental Component Scale: ICU-specific virtual reality, 57 [36-67] vs control virtual reality, 47 [26-63]; p < 0.01). Six months after exposure, this effect was still present for posttraumatic stress disorder and depression, but not for mental quality of life., Conclusions: ICU-specific virtual reality is a feasible and acceptable novel intervention that could be used during recovery from an episode of critical illness in the ICU. A future, adequately powered study should confirm whether virtual reality is able to improve mental health and quality of life., Competing Interests: The authors have disclosed that they do not have any conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: As the science of consultation-liaison psychiatry advances, the Academy of Consultation-Liaison Psychiatry's Guidelines and Evidence-Based Medicine Subcommittee reviews articles of interest to help academy members remain familiar with the latest in evidence-based practice., Objective: We identify the 10 most important articles for clinical practice in consultation-liaison psychiatry from 2020 using the new Importance and Quality instrument for assessing scientific literature., Methods: The subcommittee published annotated abstracts for 97 articles on the academy website in 2020. Reviewers then rated all articles on clinical importance to practice and quality of scholarship using the Importance and Quality instrument. We describe the 10 articles with the highest aggregate scores and analyze the reliability of Importance and Quality instrument., Results: Twenty-four raters identified the top 10 scoring articles of 2020. These articles provide practical guidance on key areas of consultation-liaison psychiatry including management of COVID-19, lithium treatment for complex patients, medical risks among patients with severe mental illness, and substance use disorders in medical settings. The assessment instrument demonstrated good to excellent interrater reliability., Conclusion: These articles offer valuable guidance for consultation-liaison psychiatrists regardless of their practice area. Collaborative literature reviews with standardized assessments help clinicians deliver evidence-based care and foster a high standard of practice across the specialty., (Copyright © 2021 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.)

To quantify short- and long-term psychologic distress, that is, symptoms of posttraumatic stress disorder, anxiety, and depression, and the health-related quality of life in coronavirus disease 2019 ICU survivors., Design: A prospective, observational cohort study., Setting: Postcoronavirus disease 2019 clinics of three hospitals in Rotterdam, the Netherlands., Patients: Adult patients admitted for coronavirus disease 2019 to the ICU, who visited the postcoronavirus disease 2019 follow-up clinic., Measures and Main Results: The primary outcomes were psychologic distress and overall and mental health-related quality of life, assessed using the Impact of Event Scale-Revised, Hospital Anxiety and Depression Scale, Short-Form 36, and European Quality of Life 5D, 6 weeks, 3 months, and 6 months post hospital discharge. Second, we compared 3-month psychologic and mental health-related quality of life outcomes with a historical critical illness survivor cohort and overall and mental health-related quality of life with the Dutch population. We included 118 patients with a median age of 61 years (95% range, 36-77 yr) of whom 79 (68%) were male. At 6 weeks, 13 patients (23%) reported psychologic distress, copresence of probable psychiatric disorders was common, and no decline in psychologic distress was observed throughout follow-up. Coronavirus disease 2019 patients tend to suffer less from posttraumatic stress disorder and reported less severe symptoms of anxiety (Hospital Anxiety and Depression Scale Anxiety Score: 3 [0-17] vs 5 [0-16]; estimated mean difference 2.3 [95% CI, 0.0-4.7]; p = 0.05) and depression (Hospital Anxiety and Depression Scale Depression Score: 3 [0-15] vs 5 [0-16]; estimated mean difference 2.4 [95% CI, 0.1-2.4]; p = 0.04) than the historical critical illness cohort. Overall and mental health-related quality of life increased over time. Coronavirus disease 2019 ICU survivors reported better mental health-related quality of life than our historical cohort, but overall and mental health-related quality of life was still poorer than the Dutch population., Conclusions: Psychologic distress was common in coronavirus disease 2019 ICU survivors and remained similar until 6 months after hospital discharge. Health-related quality of life increased over time and was higher than in a historical cohort, but was lower than in the Dutch population. Our findings highlight that coronavirus disease 2019 ICU survivors should be monitored after ICU treatment to detect possible psychologic distress., Competing Interests: The authors have disclosed that they do not have any conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Obsessive-compulsive disorder (OCD) affects 1-2% of the population, and, as with other complex neuropsychiatric disorders, it is thought that rare variation contributes to its genetic risk. In this study, we performed exome sequencing in the largest OCD cohort to date (1,313 total cases, consisting of 587 trios, 41 quartets and 644 singletons of affected individuals) and describe contributions to disease risk from rare damaging coding variants. In case-control analyses (n = 1,263/11,580), the most significant single-gene result was observed in SLITRK5 (odds ratio (OR) = 8.8, 95% confidence interval 3.4-22.5, P = 2.3 × 10 -6 ). Across the exome, there was an excess of loss of function (LoF) variation specifically within genes that are LoF-intolerant (OR = 1.33, P = 0.01). In an analysis of trios, we observed an excess of de novo missense predicted damaging variants relative to controls (OR = 1.22, P = 0.02), alongside an excess of de novo LoF mutations in LoF-intolerant genes (OR = 2.55, P = 7.33 × 10 -3 ). These data support a contribution of rare coding variants to OCD genetic risk., (© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Background: Persistent motor or vocal tic disorder (PMVT) has been hypothesized to be a forme fruste of Tourette syndrome (TS). Although the primary diagnostic criterion for PMVT (presence of motor or vocal tics, but not both) is clear, less is known about its clinical presentation., Objective: The goals of this study were to compare the prevalence and number of comorbid psychiatric disorders, tic severity, age at tic onset, and family history for TS and PMVT., Methods: We analyzed data from two independent cohorts using generalized linear equations and confirmed our findings using meta-analyses, incorporating data from previously published literature., Results: Rates of obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD) were lower in PMVT than in TS in all analyses. Other psychiatric comorbidities occurred with similar frequencies in PMVT and TS in both cohorts, although meta-analyses suggested lower rates of most psychiatric disorders in PMVT compared with TS. ADHD and OCD increased the odds of comorbid mood, anxiety, substance use, and disruptive behaviors, and accounted for observed differences between PMVT and TS. Age of tic onset was approximately 2 years later, and tic severity was lower in PMVT than in TS. First-degree relatives had elevated rates of TS, PMVT, OCD, and ADHD compared with population prevalences, with rates of TS equal to or greater than PMVT rates., Conclusions: Our findings support the hypothesis that PMVT and TS occur along a clinical spectrum in which TS is a more severe and PMVT a less severe manifestation of a continuous neurodevelopmental tic spectrum disorder. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society., (© 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.)

Background: Contamination-prevention behaviors such as mask wearing and physical distancing are crucial to reduce coronavirus transmission during the COVID-19 pandemic. We hypothesized that engagement in these behaviors could provoke obsessions and phobias in vulnerable individuals in the community., Methods: A total of 2117 participants, systematically selected to represent the age, gender, and race distributions of the US population, completed an online survey that assessed demographic characteristics, clinical features, COVID-19 risks, and COVID-19 contamination-prevention behaviors. Logistic regression was used to estimate the magnitude of the relationships between the COVID-19 behavior score and clinically significant contamination obsessions, contamination compulsions, and pre-COVID-19 to current change in obsessive-compulsive symptom scores., Results: The COVID-19 behavior score was significantly associated with contamination obsessions (odds ratio (OR) = 1.15, 95% CI = 1.12-1.16; p < 0.001) and contamination phobias (OR = 1.14, 95% CI = 1.12-1.16; p < 0.001). The COVID-19 behavior score also was associated with pre-pandemic to current increase in the overall obsessive-compulsive symptom score (OR = 1.16, 95% CI = 1.09-1.23; p < 0.001), as well as increase in obsessive-compulsive symptom score excluding washing items (OR = 1.13, 95% CI = 1.07-1.19; p < 0.001). The magnitude of these relationships did not appreciably change, after adjustment for other variables associated with the outcomes. Moreover, the relationship was significant in those with or without OCD, and in individuals with different levels of doubt and COVID-19 risk., Conclusions: Contamination safety measures are critical for reducing the spread of COVID-19 in the community. However, they may be related to the development of contamination-related symptoms and OCD in vulnerable individuals, complicating the diagnosis and treatment of mental disorders during this period., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: How personality traits, anxiety, and depressive disorders relate longitudinally has implications for etiologic research and prevention. We sought to determine how neuroticism and extraversion relate to first-onset anxiety and depressive disorders in young adults., Design: An inception cohort of 489 university freshmen was followed for 6 years., Method: Participants self-reported personality traits using the Eysenck Personality Questionnaire. Anxiety and depressive disorders were assessed using the Diagnostic Interview Schedule., Results: Baseline neuroticism predicted first-onset panic disorder, agoraphobia, generalized anxiety disorder (GAD), and major depressive disorder (MDD), while introversion predicted first-onset agoraphobia (moderate-large effects). Participants who developed panic disorder, agoraphobia, GAD, or MDD had increases in neuroticism if the disorder was current at follow-up (moderate-large effects). Participants who developed MDD but were in remission by follow-up had a moderate increase in neuroticism., Conclusions: High neuroticism in young adulthood is either a true risk factor, or marker of risk, for first-onset anxiety and depressive disorders, as is low extraversion for agoraphobia. The current data suggest large neuroticism "state" effects for panic disorder, agoraphobia, and MDD, and moderate "scar" effects from MDD. Though many clinicians and researchers regard personality traits simply as "vulnerability" factors, longitudinal analyses suggest additional complexity.

A pathological increase in vigilance, or hypervigilance, may be related to pain intensity in some clinical pain syndromes and may result from attention bias to salient stimuli mediated by anxiety. During a continuous performance task where subjects discriminated painful target stimuli from painful nontargets, we measured detected targets (hits), nondetected targets (misses), nondetected nontargets (correct rejections), and detected nontargets (false alarms). Using signal detection theory, we calculated response bias, the tendency to endorse a stimulus as a target, and discriminability, the ability to discriminate a target from nontarget. Owing to the relatively slow rate of stimulus presentation, our primary hypothesis was that sustained performance would result in a more conservative response bias reflecting a lower response rate over time on task. We found a more conservative response bias with time on task and no change in discriminability. We predicted that greater state and trait anxiety would lead to a more liberal response bias. A multivariable model provided partial support for our prediction; high trait anxiety related to a more conservative response bias (lower response rate), whereas high state anxiety related to a more liberal bias. This inverse relationship of state and trait anxiety is consistent with reports of effects of state and trait anxiety on reaction times to threatening stimuli. In sum, we report that sustained attention to painful stimuli was associated with a decrease in the tendency of the subject to respond to any stimulus over time on task, whereas the ability to discriminate target from nontarget remains unchanged. NEW & NOTEWORTHY During a series of painful stimuli requiring subjects to respond to targets, we separated response willingness from ability to discriminate targets from nontargets. Response willingness declined during the task, with no change in subjects' ability to discriminate, consistent with previous vigilance studies. High trait anxious subjects were less willing to respond and showed slower reaction times to hits than low anxious subjects. This study reveals an important role of trait anxiety in pain vigilance.