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Recent research: a mixed bag of six papers on anxiety

Here are half a dozen papers with anxiety relevance.  The first couple are about the interaction between genetic vulnerability (or resilience) and childhood experience.  The Stevens et al paper is an update on the large body of research looking at psychological genetic vulnerability/resilience in macaque monkeys and how this interacts with parenting quality to lead, or not lead, to emotional and neurophysiological disturbances in adulthood.  The Battaglia paper particularises this gene/environment investigation by looking at the connections between early human childhood separation anxiety, loss of a parent, and panic disorder in adulthood.  

There are then a couple of papers on treatment.  MacGregor and colleagues report encouraging results for an internet-based CBT programme for panic and phobic anxiety.  Exploring the pluses and minuses of delivering psychological treatment via computer and the internet is exciting and important work.  There is a huge amount of psychological suffering that goes largely unhelped.  If the internet can make good treatment much more widely available this would be tremendous.  As they say "It's important to keep an open mind, but not so open that your brains fall out."  As with drugs and other interventions, there are commercial pressures that are contributing strongly to the push to sell some of these treatments more widely.  The current findings in depression (Gellatly, Bower et al. 2007) seem to be that therapist-guided self-help is considerably more effective than self-help attempted simply on one's own.  In other words, optimal self-help allows therapists to be more effective in their use of time, but doesn't dispense with them altogether.  It also seems that computer-delivered and book-delivered self-help materials are about equally effective - with some people preferring one medium and some the other.  The other treatment paper - by Bugg et al - showed high user satisfaction with a therapeutic writing intervention after trauma, but no statistically significant improvement over treatment as usual in their assessments of anxiety, depression and PTSD.

Finally there are a couple of papers on anxiety's effects and associations.  The first, by Tolman et al, highlights that social anxiety disorder - which is sometimes claimed to be a "non-diagnosis" - has very real and distressing consequences.  In their study on women claiming welfare benefit, they found "Analyses demonstrated that compared with respondents without social anxiety disorder, those with this disorder worked fewer months. The impact of social anxiety disorder was independent of and more striking than the effects of depression."  The authors went on to conclude "By undermining efforts to obtain or maintain employment, social anxiety disorder poses a significant, unrecognized impediment to efforts to reduce welfare reliance and to help recipients achieve economic self-sufficiency. Because recipients may lose benefits if they fail to enter the workforce rapidly and if they exceed time limits for support, those with social anxiety disorder are at risk of extreme economic hardship. Improved access to effective treatments in this population could have significant public health and economic benefits."  The last study is described by Arehart-Treichel and it looked at the association between anxiety and irritable bowel syndrome (IBS).  "The investigators focused on 357 individuals who had come to an anxiety-disorder clinic for help with anxiety problems. They found that 17 percent of them had IBS. They also found the syndrome in a large number of subjects with generalized anxiety disorder or panic disorder, but in fewer with social anxiety disorder or obsessive-compulsive disorder and in none with a specific phobia. The syndrome was prevalent and severe among subjects with generalized anxiety disorder." 

Stevens, H. E., J. F. Leckman, et al. (2009). "Risk and Resilience: Early Manipulation of Macaque Social Experience and Persistent Behavioral and Neurophysiological Outcomes." Journal of Amer Academy of Child & Adolescent Psychiatry 48(2): 114-127.  [Abstract/Full Text
Objective: To review the contributions of research on nonhuman primates, specifically macaque monkeys, to the understanding of early social stress and its effects on behavior and neurophysiology. Method: Review and synthesis of two bodies of work on macaque monkeys and early social manipulation: peer rearing and variable foraging demands. The literature was searched with Medline using key terms macaque, variable foraging, and peer rearing. The reference lists of these articles were also used to generate potential studies for review. Results: Nonhuman primate macaques show similarities to humans in their social development and functioning. Peer rearing of young macaques and rearing of young macaques with mothers experiencing variable foraging conditions both result in increased anxious, impulsive, and aggressive temperament and behavior; more reactive stress physiology; altered neurotransmitter functioning; and immune and metabolic changes. Functional variants of specific genes that code for neuromodulators are mediators of these effects. Conclusions: Disrupted social relations during macaque rearing contribute to the risk for developing emotional and neurophysiological disturbance. In the face of such disruption, certain genotypes contribute to resilience. This can be alternately stated that, for animals of high-risk genotypes, resilience is conferred by quality relationships during rearing. This interaction of genetics with early social environment also applies to child mental health, implicating biological mediators identified in macaques as contributing to more complex outcomes in humans.

Battaglia, M., P. Pesenti-Gritti, et al. (2009). "A Genetically Informed Study of the Association Between Childhood Separation Anxiety, Sensitivity to CO2, Panic Disorder, and the Effect of Childhood Parental Loss." Arch Gen Psychiatry 66(1): 64-71.  [Abstract/Full Text]
Context Childhood separation anxiety disorder can predate panic disorder, which usually begins in early adulthood. Both disorders are associated with heightened sensitivity to inhaled CO2 and can be influenced by childhood parental loss. Objectives To find the sources of covariation between childhood separation anxiety disorder, hypersensitivity to CO2, and panic disorder in adulthood and to measure the effect of childhood parental loss on such covariation. Design Multivariate twin study. Participants Seven hundred twelve young adults from the Norwegian Institute of Public Health Twin Panel, a general population cohort. Main Outcome Measures Personal direct assessment of lifetime panic disorder through structured psychiatric interviews, history of childhood parental loss, and separation anxiety disorder symptoms. Subjective anxiety response to a 35% CO2/65% O2 inhaled mixture compared with compressed air (placebo). Results Our best-fitting solution yielded a common pathway model, implying that covariation between separation anxiety in childhood, hypersensitivity to CO2, and panic disorder in adulthood can be explained by a single latent intervening variable influencing all phenotypes. The latent variable governing the 3 phenotypes' covariation was in turn largely (89%) influenced by genetic factors and childhood parental loss (treated as an identified element of risk acting at a family-wide level), which accounted for the remaining 11% of covariance. Residual variance was explained by 1 specific genetic variance component for separation anxiety disorder and variable-specific unique environmental variance components. Conclusions Shared genetic determinants appear to be the major underlying cause of the developmental continuity of childhood separation anxiety disorder into adult panic disorder and the association of both disorders with heightened sensitivity to CO2. Inasmuch as childhood parental loss is a truly environmental risk factor, it can account for a significant additional proportion of the covariation of these 3 developmentally related phenotypes.

MacGregor, A. D., L. Hayward, et al. (2009). "Empirically Grounded Clinical Interventions Clients' and Referrers' Perceptions of Computer-Guided CBT (FearFighter)." Behavioural and Cognitive Psychotherapy 37(01): 1-9.  [Abstract/Full Text]
Background: Computer-guided CBT has been shown to be a potentially useful way of closing the gap between the demand and supply for CBT. Moreover, this approach has additional benefits in terms of less travel times for treatment, accessibility in remote and unusual locations, increased confidentiality, easier disclosure of sensitive information, and more egalitarian therapist-client interactions. Research on computerized CBT has concentrated on clinical outcomes, but the views of clients on this treatment approach have been relatively neglected. Aims: The aims were to assess client satisfaction, professionals' views, and ease of programme use after completion of treatment via an internet-based CBT programme for panic and phobic anxiety (FearFighter). Method: A feasibility and effectiveness study of FearFighter was conducted in remote and rural areas of Scotland. Treatment data are available for 35 clients at post-treatment, of whom 29 completed an 18-item set of rating scales designed to assess satisfaction, including ease of use, accessibility, how far needs were met, whether changes to the programme were required, the benefits and drawbacks of not having a therapist, and quality of support. Open-ended questions were included. Referring agencies were also asked to rate their views on FearFighter. Results: Clients reported moderate to high levels of improvement and of overall satisfaction; very few difficulties in logging on to and using the programme were encountered. Similar levels of satisfaction with the programme were reported by referrers. Conclusions: It is concluded that computer-guided CBT is acceptable to clients and to professionals, and that it could play a valuable part in a system of delivering CBT.

Bugg, A., G. Turpin, et al. (2009). "A randomised controlled trial of the effectiveness of writing as a self-help intervention for traumatic injury patients at risk of developing post-traumatic stress disorder." Behaviour Research and Therapy 47(1): 6-12.  [Abstract/Full Text
The study investigated the effects of writing and self-help information on severity of psychological symptoms in traumatic injury patients at risk for developing post-traumatic stress disorder (PTSD). Patients attending Accident and Emergency (A & E), were screened for Acute Stress Disorder and randomised to an information control group (n = 36) or a writing and information group (n = 31). Participants in both groups received an information booklet one-month post-injury. Participants in the writing group also wrote about emotional aspects of their trauma during three 20-min sessions, five to six weeks post-injury. Psychological assessments were completed within one month and at three and six months post-injury. There were significant improvements on measures of anxiety, depression and PTSD over time. Differences between groups on these measures were not statistically significant. However, subjective ratings of the usefulness of writing were high. In conclusion, the results do not currently support the use of writing as a targeted early intervention technique for traumatic injury patients at risk of developing PTSD.

Tolman, R. M., J. Himle, et al. (2009). "Impact of Social Anxiety Disorder on Employment Among Women Receiving Welfare Benefits." Psychiatr Serv 60(1): 61-66.  [Abstract/Full Text]
OBJECTIVE: Studies in clinical and community samples have documented that social anxiety disorder is common, disabling, and costly. It reduces educational attainment and job success, and thus it may undermine economic self-sufficiency. The authors examined whether social anxiety disorder was an obstacle to successful employment in a longitudinal epidemiological study of women receiving welfare in an urban Michigan county. The hypothesis that social anxiety disorder would predict reduced work attainment was examined. METHODS: Psychiatric diagnoses were established with the Composite International Diagnostic Interview-Short Form. The authors conducted a linear fixed-effects regression analysis for survey data with 609 respondents who completed at least the third wave of the Women's Employment Study in order to explore obstacles to employment among mothers on welfare. RESULTS: Analyses demonstrated that compared with respondents without social anxiety disorder, those with this disorder worked fewer months. The impact of social anxiety disorder was independent of and more striking than the effects of depression. CONCLUSIONS: By undermining efforts to obtain or maintain employment, social anxiety disorder poses a significant, unrecognized impediment to efforts to reduce welfare reliance and to help recipients achieve economic self-sufficiency. Because recipients may lose benefits if they fail to enter the workforce rapidly and if they exceed time limits for support, those with social anxiety disorder are at risk of extreme economic hardship. Improved access to effective treatments in this population could have significant public health and economic benefits.

Arehart-Treichel, J. (2009). "Two Anxiety Disorder Types Linked to G.I. Illness." Psychiatr News 44(2): 15-.  [Free Full Text]  
People with generalized anxiety disorder or panic disorder are more likely to have comorbid irritable bowel syndrome than those with some other anxiety disorders.  Clinicians who treat patients with generalized anxiety disorder or panic disorder should assess patients for symptoms of irritable bowel syndrome (IBS), according to the authors of a recent study headed by Daniel Gros, Ph.D., an assistant professor of psychiatry at the Medical University of South Carolina. It is in press with the Journal of Anxiety Disorders.  The investigators focused on 357 individuals who had come to an anxiety-disorder clinic for help with anxiety problems. They found that 17 percent of them had IBS. They also found the syndrome in a large number of subjects with generalized anxiety disorder or panic disorder, but in fewer with social anxiety disorder or obsessive-compulsive disorder and in none with a specific phobia. The syndrome was prevalent and severe among subjects with generalized anxiety disorder. 

 

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