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Recent research: two studies on panic, two on attention training for anxiety disorders, and three on the effects of child abuse

Here are seven recent papers on panic, attention training, and the effects of childhood sexual abuse (all details & abstracts to these studies are listed further down this blog post).  Pfaltz & colleagues report on a novel ambulatory respiratory monitoring system that seems to demonstrate that panic sufferers are not routinely suffering from breathing abnormalities (e.g. hyperventilation) when they go about their daily lives.  The CBT theory of panic disorder would go along with this - panic being seen as due, in part, to catastrophizing about the meaning of experienced physical sensations rather than due to simply having unusual physical sensations.  Shelby et al's paper extends this understanding concluding that with sufferers from non-cardiac chest pain (NCCP) "Chest pain and anxiety were directly related to greater disability and indirectly related to physical and psychosocial disability via pain catastrophizing. Efforts to improve functioning in patients with NCCP should consider addressing pain catastrophizing."

Amir & colleagues report on a different way of treating anxiety - by tackling selective attention to threat.  In a fascinating study (that used a computer programme to train social anxiety disorder sufferers to attend to neutral, rather than threatening, faces), they showed very significant improvements in social phobia both at the end of treatment and at four months follow-up.  In a further paper they begin to show similar potential benefits using an attention training programme with generalized anxiety disorder sufferers as well.  In a loose way, this links with ACT (Acceptance & Commitment Therapy) with its emphasis on having people focus on value-driven activity rather than attending to catastrophizing and rumination - see the "Bus driver metaphor" for more on this.

Bebbington et al investigated links between childhood sexual abuse and subsequent adult suicide attempts in over 8,000 British adults.  They estimated that approximately 28% of adult female suicide attempts and 7% of adult male suicide attempts were linked to earlier abuse.  They concluded "Sexual abuse is a significant antecedent of suicidal behavior, particularly among women. In identifying suicidal behavior, it is important to consider the possibility of sexual abuse, since it implies a need for focused treatment."  In a linked editorial Fullilove discusses these findings, stating " ... a history of childhood sexual abuse was strongly associated with suicide attempts and suicide intent. The odds ratio, which the team used to look at the strength of the association, was higher for women than men but remarkably high in both groups (9.6 and 6.7, respectively) ... affective disturbance at the time of the interview (was) found ... to be a mediator of the relationship between childhood sexual abuse and suicide attempts and suicide intent ... Bebbington and colleagues point out the need for clinicians to hear a report of suicide attempt/intent as a clue to ask about childhood sexual abuse. This is an excellent suggestion ... "  

Finally, still on the subject of child abuse, Wegman & Stetler's meta-analysis showed that "Experiencing child abuse was associated with an increased risk of negative physical health outcomes in adulthood ... Neurological and musculoskeletal problems yielded the largest effect sizes, followed by respiratory problems, cardiovascular disease, gastrointestinal and metabolic disorders ... Child abuse is associated with an increased risk of poor physical health in adulthood. The magnitude of the risk is comparable to the association between child abuse and poor psychological outcomes." 

Pfaltz, M. C., T. Michael, et al. (2009). "Respiratory Pathophysiology of Panic Disorder: An Ambulatory Monitoring Study." Psychosom Med 71(8): 869-876.  [Abstract/Full Text]
Objective: To assess the external validity of laboratory baselines in panic disorder (PD), frequently associated with respiratory pattern abnormalities like increased respiratory variability and sighing, implying a stable pathophysiologic trait characteristic. Methods: Physical activity and a variety of breath-by-breath volumetric, timing, and variability measures of respiration were recorded in the daily life of 26 patients with PD and 26 healthy controls (HC), using a novel ambulatory monitoring system optimized for reliable assessment of respiratory pattern. Data were stratified for physical activity to eliminate its confounding effects. Results: Groups showed strong and consistent diurnal patterns in almost all respiratory variables. However, patients with PD did not differ from HC regarding any of the respiratory timing, volumetric and variability measures, with negligible group effect sizes for all measures. Patients with fewer self-reported respiratory symptoms of anxiety exhibited more pronounced rapid shallow breathing as well as diminished total breath time and its variability. Conclusions: Despite state-of-the-art ambulatory assessment and sufficient statistical power to detect respiratory alterations previously observed in the laboratory, we found no evidence for such alterations in PD patients' daily life. Neither the total PD group nor patients with particularly pronounced respiratory symptomatology displayed increased respiratory variability. These results caution against interpreting results from laboratory baselines in PD as reflecting a stable trait characteristic. Rather, they likely represent a state-trait interaction due to enhanced reactivity of PD patients to novel environments. These results challenge aspects of respiratory theories of PD that were based on laboratory findings.

Shelby, R. A., T. J. Somers, et al. (2009). "Pain Catastrophizing in Patients with Noncardiac Chest Pain: Relationships With Pain, Anxiety, and Disability." Psychosom Med 71(8): 861-868.  [Abstract/Full Text] 
Objective: To examine the contributions of chest pain, anxiety, and pain catastrophizing to disability in 97 patients with noncardiac chest pain (NCCP) and to test whether chest pain and anxiety were related indirectly to greater disability via pain catastrophizing. Methods: Participants completed daily diaries measuring chest pain for 7 days before completing measures of pain catastrophizing, trait anxiety, and disability. Linear path model analyses examined the contributions of chest pain, trait anxiety, and catastrophizing to physical disability, psychosocial disability, and disability in work, home, and recreational activities. Results: Path models accounted for a significant amount of the variability in disability scales (R2 = 0.35 to 0.52). Chest pain and anxiety accounted for 46% of the variance in pain catastrophizing. Both chest pain ({beta} = 0.18, Sobel test Z = 2.58, p < .01) and trait anxiety ({beta} = 0.14, Sobel test Z = 2.11, p < .05) demonstrated significant indirect relationships with physical disability via pain catastrophizing. Chest pain demonstrated a significant indirect relationship with psychosocial disability via pain catastrophizing ({beta} = 0.12, Sobel test Z = 1.96, p = .05). After controlling for the effects of chest pain and anxiety, pain catastrophizing was no longer related to disability in work, home, and recreational activities. Conclusions: Chest pain and anxiety were directly related to greater disability and indirectly related to physical and psychosocial disability via pain catastrophizing. Efforts to improve functioning in patients with NCCP should consider addressing pain catastrophizing.

Amir, N., C. Beard, et al. (2009). "Attention training in individuals with generalized social phobia: A randomized controlled trial." J Consult Clin Psychol 77(5): 961-73.  [PubMed]
The authors conducted a randomized, double-blind placebo-controlled trial to examine the efficacy of an attention training procedure in reducing symptoms of social anxiety in 44 individuals diagnosed with generalized social phobia (GSP). Attention training comprised a probe detection task in which pictures of faces with either a threatening or neutral emotional expression cued different locations on the computer screen. In the attention modification program (AMP), participants responded to a probe that always followed neutral faces when paired with a threatening face, thereby directing attention away from threat. In the attention control condition (ACC), the probe appeared with equal frequency in the position of the threatening and neutral faces. Results revealed that the AMP facilitated attention disengagement from threat from pre- to postassessment and reduced clinician- and self-reported symptoms of social anxiety relative to the ACC. The percentage of participants no longer meeting Diagnostic and Statistical Manual (4th ed.) criteria for GSP at postassessment was 50% in the AMP and 14% in the ACC. Symptom reduction in the AMP group was maintained during 4-month follow-up assessment. These results suggest that computerized attention training procedures may be beneficial for treating social phobia.

Amir, N., C. Beard, et al. (2009). "Attention modification program in individuals with generalized anxiety disorder." J Abnorm Psychol 118(1): 28-33.  [PubMed]
Research suggests that individuals with generalized anxiety disorder (GAD) show an attention bias for threat-relevant information. However, few studies have examined the causal role of attention bias in the maintenance of anxiety and whether modification of such biases may reduce pathological anxiety symptoms. In the present article, the authors tested the hypothesis that an 8-session attention modification program would (a) decrease attention bias to threat and (b) reduce symptoms of GAD. Participants completed a probe detection task by identifying letters (E or F) replacing one member of a pair of words. The authors trained attention by including a contingency between the location of the probe and the nonthreat word in one group (Attention Modification Program; AMP) and not in the other (attention control condition; ACC). Participants in the AMP showed change in attention bias and a decrease in anxiety, as indicated by both self-report and interviewer measures. These effects were not present in the ACC group. These results are consistent with the hypothesis that attention plays a causal role in the maintenance of GAD and suggest that altering attention mechanisms may effectively reduce anxiety.

Bebbington, P. E., C. Cooper, et al. (2009). "Suicide Attempts, Gender, and Sexual Abuse: Data From the 2000 British Psychiatric Morbidity Survey." Am J Psychiatry 166(10): 1135-1140.  [Abstract/Full Text]  
OBJECTIVE: The purpose of this study was to utilize data from the 2000 British National Survey of Psychiatric Morbidity, a randomized cross-sectional survey of the British population that included questions relating to the phenomena of suicidality and sexual abuse, to test the hypothesis that suicide attempts in women are significantly associated with a history of sexual abuse. METHOD: Participants were male and female volunteers, ages 16 to 74 years old (N=8,580), interviewed in the 2000 British National Survey of Psychiatric Morbidity. RESULTS: Sexual abuse was strongly associated with a history of suicide attempts as well as of suicidal intent and was more common in women. The population attributable risk fraction was considerably greater in female respondents (28%) than in male respondents (7%), which is consistent with more prevalent exposure to sexual abuse among women. The effect of sexual abuse on suicidal attempts and suicidal intent was reduced by controlling for affective symptoms, suggesting that the effect of the former was likely to be mediated by affective changes. CONCLUSIONS: Sexual abuse is a significant antecedent of suicidal behavior, particularly among women. In identifying suicidal behavior, it is important to consider the possibility of sexual abuse, since it implies a need for focused treatment.

Fullilove, M. T. (2009). "Toxic Sequelae of Childhood Sexual Abuse." Am J Psychiatry 166(10): 1090-1092.  [Free Full Text] 
In this issue of the Journal, Bebbington and colleagues (1) report findings from the 2000 British National Survey of Psychiatric Morbidity, which indicated that a history of childhood sexual abuse was strongly associated with suicide attempts and suicide intent. The odds ratio, which the team used to look at the strength of the association, was higher for women than men but remarkably high in both groups (9.6 and 6.7, respectively). The population attributable risk factor (the proportion of suicide attempts linked to childhood sexual abuse) was 27.8% for women and 6.9% for men. The authors used the Clinical Interview Schedule-Revised to examine affective disturbance at the time of the interview and found this measure to be a mediator of the relationship between childhood sexual abuse and suicide attempts and suicide intent ... Bebbington and colleagues point out the need for clinicians to hear a report of suicide attempt/intent as a clue to ask about childhood sexual abuse. This is an excellent suggestion, although not as straightforward to implement as one might wish. My colleagues examined the implementation of trauma-informed treatment and found that mandating inquiry about trauma did not lead to incorporating that information in a treatment plan. There was all too little change on follow-up 10 years later. This means that we have to ask, "What prevents clinicians from acting?" Of course, as I just noted, clinicians' actions can lead to secondary traumatization; a sensitivity to possible harm is to be lauded. Another major problem is the paucity of well-established treatments.  However, these limitations should not be used as an excuse not to act but rather as spur to greater engagement in containing and defusing the effects of this noxious agent. Based on their findings from a study of childhood sexual abuse in China, Luo and colleagues pointed out the following: "The findings suggest a need for increasing public awareness of child sexual abuse through open discussions of various abusive behaviors and the potential impact of these behaviors lingering into adulthood. The findings are consistent with a need for public health campaigns that tackle the stigma...[and] new efforts to alleviate the negative long-term impact of childhood sexual abuse by following up on the victims and to address their needs."

Wegman, H. L. and C. Stetler (2009). "A Meta-Analytic Review of the Effects of Childhood Abuse on Medical Outcomes in Adulthood." Psychosom Med 71(8): 805-812.  [Abstract/Full Text] 
Objective: To summarize the relationship between abuse during childhood and physical health outcomes in adulthood and to examine the role of potential moderators, such as the type of health outcome assessed, gender, age, and the type of abuse. Studies using self-report assessment methods were compared with studies using objective or independently verifiable methods. Method: The current study is a quantitative meta-analysis comparing results from 78 effect sizes across 24 studies including 48,801 individuals. Results: Experiencing child abuse was associated with an increased risk of negative physical health outcomes in adulthood (effect size d = 0.42, 95% Confidence Interval = 0.39-0.45). Neurological and musculoskeletal problems yielded the largest effect sizes, followed by respiratory problems, cardiovascular disease, gastrointestinal and metabolic disorders. Effect sizes were larger when the sample was exclusively female and when the abuse was assessed via self-report rather than objective, independently verifiable methods. Conclusions: Child abuse is associated with an increased risk of poor physical health in adulthood. The magnitude of the risk is comparable to the association between child abuse and poor psychological outcomes. However, studies often fail to include a diverse group of participants, resulting in a limited ability to draw conclusions about the population of child abuse survivors as a whole. Important methodological improvements are also needed to better understand potential moderators.

 

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