Rozprawy doktorskie na temat „Anxiety disorders”

Research indicates that eating disorders and anxiety disorders frequently co-occur. The prevalence of anxiety disorders amongst anorexia nervosa and bulimia nervosa samples has been reported in a number of investigations. Despite the significant number of research papers investigating the comorbidity between eating disorders and anxiety disorders, many are plagued by methodological problems, limiting the usefulness of findings. Furthermore, there is a significant lack of research examining the prevalence of eating disorders among anxiety patients, and as a result, the frequency of eating disorder pathology among patients presenting to specialty anxiety clinics is unclear. The current research investigated the prevalence of comorbid eating and anxiety disorders amongst 152 women presenting for either eating disorder treatment or anxiety disorder treatment. The prevalence of anxiety disorders was determined from a sample of 100 women presenting for inpatient and outpatient eating disorder treatment. The prevalence of eating disorders was determined from a sample of 52 women presenting for outpatient treatment of an anxiety disorder. The current study found that 65% of women with eating disorders also met criteria for at least one comorbid anxiety disorder. Furthermore, 69% reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, Social Phobia was most frequently diagnosed (42%) followed by PTSD (26%), GAD (23%), OCD (5%), Panic/Ag (3%) and Specific Phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. It is hoped that the present research will have significant etiological and therapeutic implications and further the understanding of the development and maintenance of eating disorder pathology.

Doctor of Philosophy(PhD)
Research indicates that eating disorders and anxiety disorders frequently co-occur. The prevalence of anxiety disorders amongst anorexia nervosa and bulimia nervosa samples has been reported in a number of investigations. Despite the significant number of research papers investigating the comorbidity between eating disorders and anxiety disorders, many are plagued by methodological problems, limiting the usefulness of findings. Furthermore, there is a significant lack of research examining the prevalence of eating disorders among anxiety patients, and as a result, the frequency of eating disorder pathology among patients presenting to specialty anxiety clinics is unclear. The current research investigated the prevalence of comorbid eating and anxiety disorders amongst 152 women presenting for either eating disorder treatment or anxiety disorder treatment. The prevalence of anxiety disorders was determined from a sample of 100 women presenting for inpatient and outpatient eating disorder treatment. The prevalence of eating disorders was determined from a sample of 52 women presenting for outpatient treatment of an anxiety disorder. The current study found that 65% of women with eating disorders also met criteria for at least one comorbid anxiety disorder. Furthermore, 69% reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, Social Phobia was most frequently diagnosed (42%) followed by PTSD (26%), GAD (23%), OCD (5%), Panic/Ag (3%) and Specific Phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. It is hoped that the present research will have significant etiological and therapeutic implications and further the understanding of the development and maintenance of eating disorder pathology.

This research applied ideas from the cognition-emotion literature to some of the theories in the OCD literature, and in so doing took'Va multi-dimensional approach to the understanding of OCD. The aim of the study was to explore the nature of 'emotionalcognitive profiles'^ of people with OCD,. and to compare these 'profiles' with those of people with other anxiety disorders and people from a non-clinical population. Participants from the three groups i.e. an OCD group, an anxiety group and a non-clinical group were asked to rate a number of appraisal dimensions, in response to four vignettes. There were 10 participants in each group (N=30). The vignettes were constructed to evoke feelings of anxiety, guilt, anger and pride. The responses of each group were then compared. The results showed that when anxiety is evoked, both people suffering with OCD and people suffering with other anxiety disorders, perceived more personal responsibility and more harm to self than the non-clinical group. The OCD group also seemed to perceive more personal responsiblity in the situation of guilt, which provoked discussion about the nature and role of guilt and responsibility in the aetiology and maintenance of this disorder. The results also led to some debate about the relationship between anxiety, depression and OCD and finally, a formulation of OCD was proposed. The formulation was an attempt to incorporate thinking from both cognitive and psychodynamic perspectives and to draw together some of the theories and models of OCD, which had been discussed in the study.

Book Summary: Psychopathology & Psychotherapy: DSM-5 Diagnosis, Case Conceptualization, and Treatment, Third Edition differs from other psychopathology and abnormal psychology books. While other books focus on describing diagnostic conditions, this book focus on the critical link between psychopathology and psychotherapy. More specifically, it links diagnostic evaluation, case conceptualization, and treatment selection to psychotherapy practice. Research affirms that knowledge and awareness of these links is essential in planning and providing highly effective psychotherapy. This third edition incorporates detailed case conceptualizations and treatment considerations for the DSM-5 diagnoses most commonly seen in everyday clinical practice. Extensive case studies illustrate the diagnostic, case conceptualization, and treatment process in a way that makes it come alive. Written by practicing clinicians with expertise in specific disorders, this book will be an invaluable resource to both novice and experienced clinicians.

Thesis (PhD)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: The etiology of anxiety disorders remains incompletely understood. Clear evidence for a genetic component has been proposed; however, there is also an increasing focus on environmental factors and the interaction between these and the genetic components that may mediate (anxiety) disorder pathogenesis. No single gene or genetic component has been explicitly identified as being involved in the development of anxiety disorders. This is most likely due to a number of reasons, which include, for example, the heterogeneity of anxiety disorders, the contribution of environmental factors and methodological limitations (e.g. small sample size) of research studies. Until now, genetic association studies usually focused on one particular psychiatric disorder at a time. However, with the difficulty in identifying susceptibility genes and/or loci in heterogeneous disorders like obsessive-compulsive disorder and other conditions in the anxiety spectrum, it is perhaps timely to consider multivariate genetics and epidemiological studies in a number of disorders sharing a core characteristic – such as anxiety. In addition to genetic underpinnings, a number of environmental variables have also been identified as risk factors for pathological anxiety, including adverse life events like childhood physical and sexual abuse. The hypothesis for this project is that a pre-existing genetic vulnerability (or genetic risk) interacts with the impact of adverse life events to result in the development of one or more anxiety disorder(s). Considering phenotypic overlap amongst the anxiety disorders, it is likely that diverse networks of genes and/ or interacting pathways are responsible for the phenotypic manifestations observed. Sprague Dawley rats exhibiting behaviours indicative of anxiety in the context of environmental stressors (maternal separation and restraint stress) were used as model for the identification of novel susceptibility genes for anxiety disorders in humans. The striatum has previously been implicated as a candidate in the brain architecture of anxiety pathogenicity, and is also a site exhibiting a high degree of synaptic plasticity. The synaptic plasticity pathway was investigated using the dorsal striatum of the rat brain and several genes were identified to be aberrantly expressed in “anxious” rats relative to controls (Mmp9, Bdnf, Ntf4, Egr2, Egr4, Grm2 and Arc). In humans, it was found that the severity of early adversity was significantly and positively associated with the presence of an anxiety disorder in adulthood. When the human homologues of the susceptibility candidate genes that were identified using the animal model were screened in a human cohort of patients with obsessive-compulsive disorder (OCD), panic disorder (PD) or social anxiety disorder (SAD) (relative to controls), five single nucleotide polymorphisms (SNPs) were found to be significantly associated with these conditions. Four of these SNPs were also found to significantly interact with the severity of childhood trauma. Haplotype analysis of variants within the identified susceptibility candidates revealed novel haplotype associations, four of which are located in the MMP9 gene. Notably, this the first study to link these particular mutations in the MMP9 gene with anxiety disorders and this finding is consistent with previous work suggesting that MMP9 is involved in conditions like cardiovascular disease and cancer which have been associated with increased prevalence of anxiety disorders. In conclusion, this project yielded important findings pertaining to the etiology of anxiety disorders. The use of a combined anxiety disorders cohort (OCD, PD and SAD) may suggest that the associations found here may hold true for anxiety disorders in general and not only for a particular clinically delineated condition. Childhood trauma was confirmed as an increased susceptibility risk for anxiety disorders. Also, this research contributed several novel susceptibility genes (MMP9, EGR2, EGR4, NTF4, and ARC), five significant SNP associations, four significant SNP-environment interactions and five haplotype associations (within MMP9 and BDNF) as candidates for anxiety pathogenicity. The identified polymorphisms and haplotypes were demonstrated to be associated with susceptibility to anxiety disorders in a gene-environment correlation and gene-environment interaction.
AFRIKAANSE OPSOMMING: Die oorsake van angssteurings word steeds nie volledig verstaan nie. Daar is duidelike bewyse vir 'n genetiese komponent, maar daar is ook toenemende fokus op omgewingsfaktore en die interaksie tussen hierdie omgewingsfaktore en genetiese komponente by angssteurings. Geen enkele geen of genetiese komponent is al geïdentifiseer as diè wat betrokke is by die ontwikkeling van angssteurings nie. Dit is waarskynlik weens 'n aantal redes, wat byvoorbeeld, die heterogeneïteit van angssteurings, die bydrae van omgewingsfaktore en metodologiese beperkings (bv. klein steekproef) van die navorsingstudies, insluit. Verder het genetiese assosiasiestudies tot nou toe gewoonlik net op een spesifieke psigiatriese versteuring op 'n slag gefokus. Maar, gegewe die uitdaging om vatbaarheidsgene en / of loci in heterogene steurings soos obsessief – kompulsiewe steuring (OKV) en ander toestande op die angsspektrum te identifiseer, is dit tyd om genetiese en kliniese studies in ‘n aantal steurings - met ‘n oorvleuende kern-element soos angs -, gesamentlik te oorweeg. Bykomend tot die genetiese boustene, is ‘n aantal omgewingsveranderlikes soos traumatiese lewenservarings tydens die kinderjare as risikofaktore vir patologiese angs geidentifiseer. Die hipotese vir hierdie projek is dat daar 'n interaksie tussen genetiese kwesbaarheid (of genetiese risiko) en traumatiese lewensevarings is en dat dit tot die ontwikkeling van 'n / veelvoudige angssteuring(s) kan lei. Inaggenome die fenotipiese oorvleueling tussen die angssteurings, is dit waarskynlik dat diverse netwerke van gene en / of interaktiewe geen-paaie vir die manifestasie van hierdie toestande verantwoordelik is. Sprague Dawley-rotte met gedragswyses aanduidend van angs, in die konteks van omgewingstressore (d.i. skeiding van die ma-rot en bedwang-stres [restraint stress]), is as model gebruik vir die identifisering van nuwe vatbaarheidsgene vir angssteurings in mense. Die striatum is voorheen as ‘n kandidaat in die brein-argitektuur van patologiese angs voorgehou, en is ook ‘n plek met ‘n hoë mate van sinaptiese plastisiteit. Die sinaptiese plastisiteit is ondersoek deur te fokus op die dorsale striatum van die rotbrein en daar is verskeie gene gevind wat anders is in “angstige” rotte in vergelyking met kontroles (Mmp9, Bdnf, Ntf4, Egr2, Egr4, Grm2 en Arc). In mense is daar gevind dat die ernstigheidsgraad van vroeë trauma beduidend en positief met die teenwoordigheid van ‘n angssteuring tydens volwassenheid verband hou. Toe die menslike ekwivalente van die vatbaarheidsgene wat met die dieremodel geïdentifiseer is in ‘n mens-kohort met obsessief-kompulsiewe steuring (OKS), panieksteuring (PS) en sosiale angssteuring (SAS) ondersoek is, is gevind dat daar 5 enkele nukleotied polimorfismes (ENPs) is wat met die toestande verband hou. Daar is ook gevind dat vier van hierdie ENPs beduidend verband hou met die ernstigheidsgraad van trauma tydens die kinderjare. Haplotipe analise van variante binne die geïdentifiseerde vatbaarheidsgene het op nuwe haplotipe assosiasies – waarvan 4 op die MMP9-geen geleë is – gedui. Hierdie is dus die eerste studie wat gevind het dat dié spesifieke mutasies van die MMP9-geen met angssteurings verband hou. Hierdie bevinding strook met vorige werk wat daarop dui dat die MMP9-geen by toestande soos kardiovaskulêre siekte en kanker wat ook met verhoogde voorkoms van angssteurings verband hou, betrokke is. Ter afsluiting kan ons sê dat hierdie projek belangrike bevindinge oor die oorsake van angssteurings gemaak het. Die gebruik van ‘n gekombineerde angssteurings-kohort (OKS. PS en SAS) kan moontlik suggereer dat die assosiasies wat ons hier gevind het, waar is vir alle angssteurings en nie net vir ‘n spesifieke afgebakende toestand nie. Traumatiese ervarings tydens die kinderjare is ook bevestig as ‘n risiko vir die ontwikkeling van angssteurings. Hierdie navorsing het ook verskeie nuwe vatbaarheidsgene (MMP9, EGR2, EGR4, NTF4, en ARC), 5 beduidende ENP assosiasies, 4 beduidende ENP-omgewings-interaksies en 5 haplotipe assosiasies (by MMP9 en BDNF) geïdentifiseer as moontlike kandidate wat ‘n rol speel by die ontstaan van patologiese angs. Daar is ook gevind dat die geïdentifiseerde polimorfismes en haplotipes met vatbaarheid vir angssteurings in ‘n geen-omgewing- korrelasie en geen-omgewing- interaksie verband hou. Stellenbosch University http://scholar.sun.ac.za

Anxiety disorders are prevalent and debilitating. However, most affected individuals do not seek professional help. This treatment-seeking gap has been partly attributed to low levels of mental health literacy (MHL). Research into MHL for anxiety disorders is relatively immature and limited. To address this, this thesis examined key dimensions and predictors of MHL, for specific anxiety disorders. First, a review of the literature on MHL is presented. Second, a systematic review was conducted to comprehensively investigate two components of MHL for anxiety disorders; recognition and treatment beliefs. Findings showed that levels of recognition for all anxiety disorders were typically low, that treatment beliefs frequently differed from professional recommendations and that methodological inconsistencies were common. Third, an empirical study assessed recognition and treatment beliefs for specific anxiety disorders. A sample of 625 university students were presented with five case vignettes in an online survey, describing individuals with social anxiety disorder (SAD), generalised anxiety disorder (GAD), panic disorder (PD), major depressive disorder (MDD) and a life-stress scenario. Rates of recognition for all three anxiety disorders were significantly lower than those for depression, while professional help-seeking was recommended less frequently for SAD and GAD than for PD and MDD. Prior exposure to someone with a mental health condition consistently predicted disorder recognition, which in turn was a unique predictor of recommendations to seek professional help for SAD, GAD and MDD. Lastly, a discussion of findings and implications is presented. Research implications include the importance of theoretically based studies, with longitudinal and experimental designs and increased links between MHL and help-seeking behaviour. Clinical implications include greater focus on anxiety disorders in MHL interventions, with the inclusion of social contact initiatives.

Anxiety is a key component of respiratory disorders, which can exacerbate symptoms as well as impact upon treatment outcomes. This PhD offers an original contribution to knowledge by demonstrating the clinical effects of acupuncture on anxiety related to two chronic respiratory disorders, (hyperventilation syndrome (HVS) and chronic obstructive pulmonary disease (COPD)). This thesis contains findings from two novel trials that have examined the use of body acupuncture and ear acupuncture for the treatment of anxiety associated with respiratory disorders. These studies are linked through one research question: does acupuncture, offered as an adjunctive treatment to physiotherapy, reduce anxiety in patients with common chronic respiratory disorders? Previous research examining acupuncture for the treatment of anxiety has focused on the treatment of generalised anxiety disorder, or anxiety related to exposure to anxiety provoking situations. The research included within this thesis has examined the use of acupuncture in a population of individuals with respiratory disorders to assess the feasibility of using acupuncture for anxiety in this population, and to enhance our understanding of its efficacy and clinical benefits. No previous respiratory acupuncture studies have been identified that were designed with anxiety as a primary outcome. Study 1 is a three-arm single-blind randomised controlled trial (RCT) of acupuncture for HVS. In this trial acupuncture was used as an adjunct to standard physiotherapy (in the form of breathing retraining (BR)). Study 2 was a trial to examine the feasibility of using ear acupuncture as an adjunct to physiotherapy (in the form of pulmonary rehabilitation for COPD). Hypotheses were tested using anxiety data from the Hospital Anxiety and Depression Scale. The findings from both studies suggest that it is feasible to use acupuncture as an adjunct to physiotherapy in these patient groups. Within each trial, there were no statistically significant differences in anxiety between groups at outcome. However, following the interventions, there were clinically relevant reductions in anxiety in the acupuncture groups within both studies. In study 1 the reduction in mean anxiety scores in the acupuncture group took them to below the cut-off for clinically relevant anxiety. There were also statistically significant between-group differences in breathlessness associated with HVS. These findings indicate that both body acupuncture and ear acupuncture are feasible in patients with chronic respiratory disorders, when delivered as an adjunct to physiotherapy. They also suggest that acupuncture may have clinically significant benefits for anxiety associated with respiratory disorders, as well as for symptoms such as breathlessness. This knowledge will provide practitioners with some supportive evidence for the use of acupuncture within their clinical practice.

Anxiety disorders, including social anxiety disorder (SAD) and posttraumatic stress disorder (PTSD) are common and disabling conditions. Largely based on animal and pharmacological studies, both the serotonergic and substance P/neurokinin-1 (SP/NK1) systems have been implicated in their underlying pathology. However, only few neuroimaging studies have directly assessed these neurotransmitter systems in human sufferers of anxiety disorders, and none have addressed possible between-systems relationships. The overall aim of this thesis was to study possible neurochemical alterations associated with anxiety disorders. To this end, three studies using positron emission tomography (PET) for in-vivo imaging of the brain serotonergic and SP/NK1 systems in patients with SAD and PTSD were conducted. The radiotracers [11C]5-HTP, [11C]DASB, and [11C]GR205171 were used to index serotonin synthesis rate, serotonin transporter (SERT) availability, and NK1 receptor availability respectively. In Study I, patients with SAD relative to controls exhibited enhanced serotonin synthesis rate and serotonin transporter availability. Serotonin synthesis rate in the amygdala was positively related to social anxiety symptom scores. Study II demonstrated increased NK1 receptor availability in the amygdala in patients with SAD relative to controls. In Study III, patients with PTSD showed elevated NK1 receptor availability in the amygdala as compared to controls. SERT availability in the amygdala was negatively related to PTSD symptom severity, a relationship that was moderated by NK1 receptor levels. The regional overlap between SERT and NK1 receptor expression was altered in patients with PTSD, with reduced overlap linked to more severe symptoms. Collectively, the findings are consistent with the view that serotonin in the amygdala induces rather than reduces anxiety and links exaggerated anxiety to an overactive presynaptic serotonin system. In addition, the involvement of the SP/NK1 system in stress and anxiety, as suggested by animal studies, was demonstrated in two common human anxiety disorders. Finally, PTSD symptomatology is better accounted for by interactions between the serotonergic and SP/NK1 systems in the amygdala than by each system separately. In conclusion, this thesis supports that both the serotonergic and SP/NK1 systems in and of themselves, but also interactively, may be important contributors to anxiety symptomatology.

Anxiety sensitivity is a cognitive, individual difference variable that is differentiated by an individual's fear of anxiety sensations and centred on the belief that such sensations result in harmful consequences. In order to test anxiety sensitivity, Reiss, Peterson, Gursky, and McNally (1986) developed the Anxiety Sensitivity Index (ASI). However, one contentious issue in the area concerns the factor analytic structure of anxiety sensitivity and this has important consequences for the construct. Numerous investigations have been conducted using the ASI, and the results have varied appreciably with some researchers arguing for a unidimensional construct. However the general consensus now is that anxiety sensitivity is multidimensional. It has been argued that the repeated attempts to clarify the dimensionality of anxiety sensitivity, using the 16-item ASI, is problematic because the scale was never designed to measure a multidimensional construct in the first instance. Thus, the objective of the dissertation was to critically examine the anxiety sensitivity construct by using an expanded, multidimensional measure of anxiety sensitivity referred to as the Anxiety Sensitivity Index - Revised ([ASI-R] Taylor & Cox, 1998) and establish the psychometric properties of the measure by conducting a series of empirical investigations to assess the clinical utility of the measure. A series of three empirical investigations are presented in the current dissertation. The first investigation aimed to critically examine the factor structure and psychometric properties of the ASI-R. Confirmatory factor analysis using a clinical sample of adults revealed that the ASI-R could be improved substantially through the removal of 15 problematic items in order to account for the most robust dimensions of anxiety sensitivity. The modified measure was re-named the 21-item Anxiety Sensitivity Index (21-item ASI) and re-analysed with a large sample of nonclinical adults, revealing configural and metric invariance across groups. Further, comparisons with other alternative models that also include comparisons with previous published ASI models indicated the 21-item ASI to be the best fitting model for both groups. There was also evidence of internal consistency, test-retest reliability, and construct validity for both samples. The aim of the second investigation was to critically examine differences between and within various anxiety classifications, a mood disorder classification, and a nonclinical control sample, with respect to both general and specific dimensions of anxiety sensitivity as identified by the 21-item ASI. In most instances, the results revealed that the differences between and within the diagnostic groups were consistent with theoretical expectations. Finally, the third investigation aimed to examine differences within each diagnostic category before and after cognitive behavioural therapy in order to provide a further test of validity for the revised 21-item ASI. The results revealed significant differences within all but one diagnostic group on the pre and post-treatment scores, using the global and specific dimensions of the 21-item ASI. The strengths, theoretical contribution, limitations, and directions for future research are discussed. It is concluded that the overall findings relating to the series of empirical investigations presented in the current dissertation make a significant and valid theoretical contribution to the field of anxiety sensitivity in particular, and anxiety research in general, by enhancing our understanding of anxiety sensitivity and how the 21-item ASI can be used to improve therapeutic interventions in clinical practice.

Anxiety sensitivity is a cognitive, individual difference variable that is differentiated by an individual's fear of anxiety sensations and centred on the belief that such sensations result in harmful consequences. In order to test anxiety sensitivity, Reiss, Peterson, Gursky, and McNally (1986) developed the Anxiety Sensitivity Index (ASI). However, one contentious issue in the area concerns the factor analytic structure of anxiety sensitivity and this has important consequences for the construct. Numerous investigations have been conducted using the ASI, and the results have varied appreciably with some researchers arguing for a unidimensional construct. However the general consensus now is that anxiety sensitivity is multidimensional. It has been argued that the repeated attempts to clarify the dimensionality of anxiety sensitivity, using the 16-item ASI, is problematic because the scale was never designed to measure a multidimensional construct in the first instance. Thus, the objective of the dissertation was to critically examine the anxiety sensitivity construct by using an expanded, multidimensional measure of anxiety sensitivity referred to as the Anxiety Sensitivity Index - Revised ([ASI-R] Taylor & Cox, 1998) and establish the psychometric properties of the measure by conducting a series of empirical investigations to assess the clinical utility of the measure. A series of three empirical investigations are presented in the current dissertation. The first investigation aimed to critically examine the factor structure and psychometric properties of the ASI-R. Confirmatory factor analysis using a clinical sample of adults revealed that the ASI-R could be improved substantially through the removal of 15 problematic items in order to account for the most robust dimensions of anxiety sensitivity. The modified measure was re-named the 21-item Anxiety Sensitivity Index (21-item ASI) and re-analysed with a large sample of nonclinical adults, revealing configural and metric invariance across groups. Further, comparisons with other alternative models that also include comparisons with previous published ASI models indicated the 21-item ASI to be the best fitting model for both groups. There was also evidence of internal consistency, test-retest reliability, and construct validity for both samples. The aim of the second investigation was to critically examine differences between and within various anxiety classifications, a mood disorder classification, and a nonclinical control sample, with respect to both general and specific dimensions of anxiety sensitivity as identified by the 21-item ASI. In most instances, the results revealed that the differences between and within the diagnostic groups were consistent with theoretical expectations. Finally, the third investigation aimed to examine differences within each diagnostic category before and after cognitive behavioural therapy in order to provide a further test of validity for the revised 21-item ASI. The results revealed significant differences within all but one diagnostic group on the pre and post-treatment scores, using the global and specific dimensions of the 21-item ASI. The strengths, theoretical contribution, limitations, and directions for future research are discussed. It is concluded that the overall findings relating to the series of empirical investigations presented in the current dissertation make a significant and valid theoretical contribution to the field of anxiety sensitivity in particular, and anxiety research in general, by enhancing our understanding of anxiety sensitivity and how the 21-item ASI can be used to improve therapeutic interventions in clinical practice.

„Comorbidity“ among mental disorders is commonly observed in both clinical and epidemiological samples. The robustness of this observation is rarely questioned; however, what is at issue is its meaning. Is comorbidity „noise“ – nuisance covariance that researchers should eliminate by seeking „pure“ cases for their studies – or a „signal“ – an indication that current diagnostic systems are lacking in parsimony and are not „carving nature at its joints?“ (Krueger, p. 921). With these words, Krueger started a discussion on the structure of mental disorders, which suggested that a 3-factor model of common mental disorders existed in the community. These common factors were labeled „anxious-misery,“ „fear“ (constituting facets of a higher-order internalizing factor), and „externalizing.“ Along with similar evidence from personality research and psychometric explorations and selective evidence from genetic and psychopharmacologic studies, Krueger suggested that this model might not only be phenotypically relevant, but might actually improve our understanding of core processes underlying psychopathology. Since then, this suggestion has become an influential, yet also controversial topic in the scientific community, and has received attention particularly in the context of the current revision process of the Manual of Mental Disorders (Fifth Edition) (DSM-V) and the International Classification of Diseases, 11th Revision (ICD-11). Focusing on anxiety disorders, this article critically discusses the methods and findings of this work, calls into question the model’s developmental stability and utility for clinical use and clinical research, and challenges the wide-ranging implications that have been linked to the findings of this type of exploration. This critical appraisal is intended to flag several significant concerns about the method. In particular, the concerns center around the tendency to attach wide-ranging implications (eg, in terms of clinical research, clinical practice, public health, diagnostic nomenclature) to the undoubtedly interesting statistical explorations.

„Comorbidity“ among mental disorders is commonly observed in both clinical and epidemiological samples. The robustness of this observation is rarely questioned; however, what is at issue is its meaning. Is comorbidity „noise“ – nuisance covariance that researchers should eliminate by seeking „pure“ cases for their studies – or a „signal“ – an indication that current diagnostic systems are lacking in parsimony and are not „carving nature at its joints?“ (Krueger, p. 921). With these words, Krueger started a discussion on the structure of mental disorders, which suggested that a 3-factor model of common mental disorders existed in the community. These common factors were labeled „anxious-misery,“ „fear“ (constituting facets of a higher-order internalizing factor), and „externalizing.“ Along with similar evidence from personality research and psychometric explorations and selective evidence from genetic and psychopharmacologic studies, Krueger suggested that this model might not only be phenotypically relevant, but might actually improve our understanding of core processes underlying psychopathology. Since then, this suggestion has become an influential, yet also controversial topic in the scientific community, and has received attention particularly in the context of the current revision process of the Manual of Mental Disorders (Fifth Edition) (DSM-V) and the International Classification of Diseases, 11th Revision (ICD-11). Focusing on anxiety disorders, this article critically discusses the methods and findings of this work, calls into question the model’s developmental stability and utility for clinical use and clinical research, and challenges the wide-ranging implications that have been linked to the findings of this type of exploration. This critical appraisal is intended to flag several significant concerns about the method. In particular, the concerns center around the tendency to attach wide-ranging implications (eg, in terms of clinical research, clinical practice, public health, diagnostic nomenclature) to the undoubtedly interesting statistical explorations.

Psychology
Ph.D.
Objective: This study examined whether overt and relational peer victimization were associated with the severity of Social Phobia (SoP) symptoms and whether frequent victimization was more common among youth with SoP as compared to youth with other anxiety disorders. In addition, the study examined whether self-esteem, peer beliefs, and emotional lability were linked to internalizing symptoms above and beyond overt and relational victimization severity. Method: Participants were 90 youth (47 boys, 43 girls; M age = 11.06 years; SD = 3.09) and their parents. Youth had been referred to an outpatient child and adolescent anxiety disorders clinic. Measures included (a) a semi-structured diagnostic interview, (b) youth self-report forms assessing peer victimization, anxiety, depressive symptoms, loneliness, and global self-worth, and (c) parent-report forms assessing anxiety and emotion regulation. Results: Results showed a concurrent positive association between peer victimization and self-reported social anxiety, with relational victimization providing unique information above and beyond overt victimization. Peer victimization was not associated with a specific diagnosis, but was related to multiple internalizing problems (negative beliefs about the peer group accounted for some of this relation). Conclusions: Peer victimization is important to assess for and consider in the treatment of childhood and adolescent anxiety disorders. Peer victimization is associated with social anxiety symptoms, and relational victimization, in particular, is associated with internalizing problems among youth with anxiety disorders. Victimization appears to be associated with symptomatology rather than diagnosis.
Temple University--Theses

Background: Symptoms of anxiety and depression in patients with restless legs syndrome (RLS) have been observed. However, it is unclear whether rates of threshold depression and anxiety disorders according to DSM-IV criteria in such patients are also elevated. Methods: 238 RLS patients were assessed with a standardized diagnostic interview (Munich- Composite International Diagnostic Interview for DSM-IV) validated for subjects aged 18–65 years. Rates of anxiety and depressive disorders were compared between 130 RLS patients within this age range and 2265 community respondents from a nationally representative sample with somatic morbidity of other types. Results: RLS patients revealed an increased risk of having 12-month anxiety and depressive disorders with particularly strong associations with panic disorder (OR=4.7; 95% CI=2.1–10.1), generalized anxiety disorder (OR=3.5; 95% CI= 1.7–7.1), and major depression (OR=2.6; 95% CI=1.5–4.4). In addition, lifetime rates of panic disorder and most depressive disorders as well as comorbid depression and anxiety disorders were considerably increased among RLS patients compared with controls. Conclusions: The results suggest that RLS patients are at increased risk of having specific anxiety and depressive disorders. Causal attributions of patients suggest that a considerable proportion of the excess morbidity for depression and panic disorder might be due to RLS symptomatology.

Anxiety disorders are very common and the primary feature is abnormal or inappropriate anxiety. Fear and anxiety is often mediated by the amygdala, a brain structure rich in substance P (SP) and neurokinin 1 (NK1) receptors. To learn more about how the human amygdala is modulated by fear and anxiety in event-triggered anxiety disorders and to investigate if the SP/NK1 receptor system is affected, regional cerebral blood flow (rCBF) ([15O]-water; Study I and II) and the SP/NK1 receptor system ([11C]GR205171; Study III and IV) were studied with positron emission tomography (PET). In Study I we investigated the neural correlates of affective startle modulation in persons with specific phobia by measuring rCBF during exposure to fearful and non-fearful pictures, paired and unpaired with acoustic startle stimuli. Fear-potentiated startle was associated with activation of the affective part of the anterior cingulate cortex and the left amygdaloid–hippocampal area. In Study II short-term drug treatment effects on rCBF in patients diagnosed with social phobia was evaluated, comparing the NK1 receptor antagonist GR205171 to the selective serotonin reuptake inhibitor citalopram and placebo. Social anxiety and neural activity in the medial temporal lobe including the amygdala was significantly reduced by both drugs but not placebo. In Study III we investigated if activity in the SP/NK1 receptor system in the amygdala would be affected by fear provocation in individuals with specific snake or spider phobia. Fear provocation was associated with a decreased uptake of the NK1 antagonist [11C]GR205171 in the amygdala, possibly explained by an increase in endogenous SP release occupying the NK1 receptors. Study IV was conducted to explore the resting state NK1 receptor availability in PTSD patients as compared to healthy controls. Increased resting state binding of the tracer [11C]GR205171 in the amygdala of patients with PTSD suggested an increased amount of available receptors. In summary, fear and fear-potentiated startle modulates the human amygdala, possibly through the SP/NK1 receptor system.

The proposed study examined the relationship between parental anxiety, measured both subjectively (via self-report questionnaires) and objectively (via salivary cortisol) and the child's feeding progress. Children diagnosed with a feeding disorder were recruited with their parents at Our Children's House at Baylor (n=19; 11 females, 8 males). The patients and their parents were housed in the clinic for an eight-week intensive multidisciplinary pediatric feeding disorder treatment program. Calorie intake was recorded daily as outcome measures of treatment progression. Parental anxiety was measured by the Pediatric Inventory for Parents (PIP), state anxiety on the State Trait Anxiety Inventory (STAI), and by salivary cortisol at three different time points. The present study attempted to examine whether parental feeding (phase three of treatment program) would continue to cause a decrease in the child's caloric intake. In averaging ten meals prior to parental feeding in comparison to the average of ten meals following parental feeding, there was no significant difference as measured by a t-test. Paired t-tests examined parental anxiety from time one to time two and found that salivary cortisol increased significantly t(15) = -6.07, p = .000 from Time 1 (M = 2.30, SD = 1.64) to Time 2 (M = 5.24, SD = 2.58). This demonstrated that while parental anxiety increased as measured by salivary cortisol, the children continued to make improvements. This may be the result of the multidisciplinary feeding program which encompassed a strong behavioral component and parent training. Even though the current results did not demonstrate a direct relationship between parental stress and caloric intake, parental stress as measured by salivary cortisol did increase.

Worry is the hallmark feature of the anxiety disorders in children and adolescents. Little information, however, is available on childhood worry, and when worry may lead to functional impairment. The number, frequency, intensity, and areas of worry were examined in a clinic sample of children with anxiety disorders (n=59) using a structured data gathering procedure. Findings revealed that number of worry increased with age; severity decreased with age. An interaction between age and gender was also found. No differences were found for frequency or intensity. The most common areas of worry were School, Health, and Personal Harm. A link between worry and anxiety was also established as children with Overanxious Disorder (which is characterized by excessive worry) scored higher on all worry parameters relative to children with other types of anxiety disorders. The theoretical and clinical implication of these finding are discussed.

Psychology
Ph.D.
Objective: This study examined (a) the distribution of physical symptoms in youth with specific primary anxiety disorders (i.e. separation anxiety disorder [SAD], generalized anxiety disorder [GAD], and social phobia [SP]) and (b) their response to treatment with cognitive-behavioral therapy (CBT; 14 sessions of CBT over the course of 12 weeks), medication, combination therapy (CBT + medication), or pill placebo in a sample. Method: Anxiety disordered youth (N = 488, age 7-17) who met criteria for a primary diagnosis of GAD, SAD, and/or SP as part of the Child/Adolescent Anxiety Multimodal Study (CAMS; Walkup et al. 2008) were included in this study. The sample was diverse and included children with comorbid secondary diagnoses. Results: The most common somatic complaints were headache, stomach pain or aches, feeling drowsy or too sleepy, head cold or sniffles, and sleeplessness. The distribution of these complaints did not differ across diagnostic groups. The number and severity of physical symptoms decreased over the course of treatment. Treatment condition, including placebo, was unrelated to the number and severity of physical symptoms posttreatment. Conclusions: Treatment of anxiety leads to a decrease in the number and severity of physical symptoms experienced in anxiety-disordered youth, irrespective of treatment type.
Temple University--Theses

Thesis (MSc)--University of Stellenbosch, 2001.
ENGLISH ABSTRACT: SEPARATION STUDY Traumatic experiences during childhood can have a negative impact on behaviour later in life. Kendier et al. (1992) found that the loss of a parent during childhood increased the risk to develop major anxiety disorders and could also lead to depressive-like behaviour (Furukawa et al., 1999). Methods: We subjected rat pups to maternal separation and determined the effects thereof on adult behaviour. We removed rat pups from their mothers for 3 hours daily from postnatal day 2 to 14. On day 60, the behaviours of the rats were tested using the elevated plus-maze and the open field test. Controls were reared normally. Behaviours: Amount of time spent and the number of entries into the arms of the maze were noted on the elevated plus-maze, while the total time spent in each zone (inner versus outer) and the number of zone crossings were noted for each rat on the open field arena. The latency to move from the initial placement in the outer zone to the inner zone as well as the number of quadrant crossings was also determined. Defecation, freezing, rearing and grooming behaviours were also noted. Neurotransmitter levels: Noradrenaline, serotonin and their metabolites were evaluated in maternally separated rats and compared to controls. Their concentrations at basal level, immediately after restraint stress and 15 minutes after restraint stress, were also determined. A HPLC method was followed in these determinations. ACTH Determinations: All rats were subjected to restraint stress for a lO-minute period. Trunk blood was collected for basal, as well as 15 and 60 minutes postrestraint stress for ACTH determinations. Results: Behaviours: The amount of entries was significantly reduced in the separated animals, indicating decreased locomotion. They spent significantly more time in the closed maze arms. A significant increase in defecation frequency and rearing behaviour was noted. These observations are typical of anxious behaviour. In the open field test, the behavioural results were less convincing. Only a significant increase in defecation frequency and a significant decrease in rearing behaviour in separated animals, were observed. Neurotransmitter levels: No significant differences were noted between separated animals and controls with respect to basal monoamine levels. However, noradrenaline levels were significantly decreased in the frontal cortex 15 minutes after restraint stress and immediately after restraint stress in the hypothalamus and hippocampus in separated animals. MHPG levels were significantly decreased in the frontal cortex immediately after restraint stress. No significant differences were found with respect to serotonin levels. However, significant increases were found in 5HIAA levels in the frontal cortex and hippocampus of separated rats, 15 minutes after restraint stress. The basal turnover ratios of serotonin (5HIAA/5HT) and noradrenaline (MHPGINA) did not yield significant results. However, immediately after restraint stress, a significant increase was found in serotonin turnover in the hypothalamus of separated rats when compared to controls. This turnover rate was also increased in separated rats, 15 minutes after restraint stress in the frontal cortex and hypothalamus. ACTH Determinations: Basal ACTH levels were significantly higher in separated animals. At 15 minutes post-restraint stress, the levels were significantly lower than controls, indicating a blunted stress response. Our results therefore showed that maternal separation could lead to anxious behaviours in adult life. These behavioural abnormalities were associated with alterations in the central nervous and neuroendocrinological systems, particularly in response to stressful situations. CRF STUDY The maternal separation study indicated that elevated CRF levels could possibly be causally related to abnormalities observed in the anxious animals. We therefore hypothesised that adverse development factors, such as maternal separation, predisposes individuals to develop psychopathologies later in life and that this process was driven by a presence of high CRF levels. Methods: Cannulas were implanted into the left lateral ventricles of normal rats, making use of stereotaxic procedures. CRF (3 flg/fll) was injected into the ventricles daily for 5 days. Saline controls were handled similarly, but only injected with saline for the same time period. Both groups of animals were then compared to naïve controls. Histology was performed to determine the correct placement of the cannulas. Behaviours: The Elevated Plus-maze was employed to determine whether their behaviours were anxious. The number of entries into the various arms of the maze as well as the amount of time spent in the open and closed arms was accumulated. Rearing, freezing, defecation and grooming were also noted. ACTH Determinations: The ACTH levels ofCRF-injected, saline-injected and naïve rats were determined 15 minutes after restraint stress. Results: Behaviours: A decrease in the number of entries into the closed arms of the maze was noted in the CRF-injected rats when compared to naïve controls. No significant differences were found between the groups with respect to the amount of time spent in the various arms and the behaviours noted during the experiment. ACTH Determinations: A decrease in ACTH levels was noted in CRF-injected rats 15 minutes after restraint stress when compared to naïve controls. Therefore, although the CRF injections did not alter the behaviour of the rat, they did exhibit a blunted stress response to the stressor. Conclusion: Our experiments led us to conclude that early adverse experiences, such as maternal separation, can lead to the development of psychopathologies later in life. CRF, however, is not pivotal in the development of these abnormalities; rather it seems that the neurochemical abnormalities (serotonin and noradrenaline) play a more important role in the development of these mental disturbances. Finally, we hypothesise that combination drug therapy that targets both the noradrenergic and serotonergic neurotransmitter systems could be preferred above those aimed at rectifying the individual neurotransmitter systems in the treatment of psychopathologies, such as anxiety disorders.
AFRIKAANSE OPSOMMING: MOEDERLIKE SKEIDINGS STUDIE Traumatiese gebeurtenisse wat gedurende kinderjare ervaar word, kan 'n negatiewe impak op die gedrag van dieselfde individue hê, as hulle volwassenheid bereik het. Kendier et al. (1992) het waargeneem dat die verlies van 'n ouer tydens die kinderjare, die risiko om angssteumisse te ontwikkel, dramaties verhoog en kan ook lei tot 'n depressiewe gemoedtoestand (Furukawa et al., 1999). Metodes: Ons het neonatale rotte aan moederlike skeiding blootgestel en die effekte daarvan op gedrag tydens hul volwasse lewe beoordeel. Ons het daagliks die moeders vir 3 ure van die kleintjies afweggeneem, vanafpostnatale dag 2 tot 14. Op dag 60, het ons die gedrag van die diere op die "elevated plus-maze" en die" open field test" getoets. Kontrole rotte het onder normale omstandighede opgegroei. Gedrag parameters: Die hoeveelheid tyd en aantal kere wat die rotte in die verskillende arms van die "elevated plus-maze" gespandeer het, was waargeneem. Die totale tyd in die "open field" toets se binneste ofbuitenste sones, die hoeveelheid kruisings tussen die twee sones, die tyd wat dit neem om beweging in die binneste sone te inisiëer, sowel as die hoeveelheid kwadrante wat gekruis was, is genotuleer. Defekasie, botstilstande, steiering, en versorgingsgedragte was ook waargeneem terwyl die rotte in die doolhowe was. Neurochemiese oordragstowwe: Die hippokampus, hipotalamus en frontale korteks van moerderlik-geskeide rotte en kontroles, was uit hul brein gedissekteer om die vlakke van noradrenalien, serotonien en hul metaboliete daarin te bepaal. Basale vlakke sowel as hul konsentrasies onmiddelik na stres en 15 minute na stres, was gedetermineer. 'n HPLC metode was gebruik vir hierdie bepalings. ACTH bepalings: Rotte, moederlik-geskei en kontroles, was onderwerp aan beperkingstres vir 'n tydsduur van 10 minute. Bloed was op die volgende tydsintervalle gekollekteer vir die bepaling van ACTH vlakke, naamlik basaal, 15 minute en 60 minute na die einde van stresperiode. Resultate: Gedrag: Op die "elevated plus-maze" was moederlik-geskeide rotte minder beweeglik omdat hul aanmerklik minder die arms van die doolhowe binne gegaan het. Hulle het ook baie meer tyd in die geslote arms gespandeer. Verder het die eksperimentele rotte meer defekasie bolusse uitgeskei en was die aantal steieringe uitgevoer, ook aanmerklik verhoog. Hierdie patroon van gedrag is tipies die van angstigheid. Neurochemiese oordragstowwe: Daar was geen betekenisvolle verskil tussen die basale neurotransmitter vlakke van moederlik-geskeide rotte en hul kontroles. Daarenteen was die vlakke van noradrenalien in die frontale korteks dramaties verhoog by die 15 minute tydsinterval na die stres, asook onmiddelik na die stres in die hipotalamus en hippokampus. MHPG vlakke was egter aanmerklik verlaag in die frontale korteks onmiddelik na die stres. Terwyl daar geen noemenswaardige verskil in serotonien vlakke waargeneem is nie, was die vlakke van 5HlAA betekenisvol verhoog in die frontale korteks en hippokampus van moederlik-geskeide rotte, 15 minute na die beperkingstres. Geen verskil in die omsettingsverhoudinge van basale serotonien (5HlAA/5HT) ofnoradrenalien (MHPGINA) vlakke is gevind nie. Daar was egter 'n betekenisvolle verhoging in die serotonien omset in die hipotalamus van moerdlik-geskeide rotte, onmiddelik na beperkingstres. Hierdie verskil het ook voorgekom 15 minute na die stresperiode in die hipotalamus, sowel as in die frontale korteks. ACTH bepalings: Rotte wat onderwerp was aan moederlike skeiding het verhoogde basale konsentrasies van ACTH getoon. Die ACTH vlakke was egter aanmerklik laer 15 minute na stres toe dit met kontrole groepe vergelyk is. Ons resultate toon dus dat moerderlike-skeiding wel tot angstige gedrag tydens die volwasse lewe kan lei. Hierdie afwyking in gedrag was geassosieër met abnormaliteite in die sentrale senuwee sisteem sowel as die neuroendokrienologiese sisteem van die dier, veralonder toestande van stres. Na gelang van ons bevindinge in die moerderlike skeidingstudie, het dit geblyk dat CRF 'n belangrike rol speel tot daarstelling van angstige gedrag. Daarom het ons in die tweede deel van ons studie gaan kyk ofverhoogde vlakke van CRF in die brein moontlik die gedrag van die rot kon verander. CRF STUDIE Metodes: Kannules was in die linker ventrikel van die breine van normale rotte geïmplanteer deur gebruik te maak van stereotaktiese prosedures. CRF (3 Ilg/IlI) was daagliks vir 5 dae aan die rotte toegedien. Rotte wat presies dieselfde gehanteer was het 'n fisiologiese soutoplossing ontvang. Hierdie rotte was met naïewe rotte vergelyk. Die korrekte plasing van kannules was met histologiese metodes bevestig. Gedrag: Die "elevated plus-maze" was gebruik om te bepaal of angstige gedragte by behandelde rotte ontlok was. Die aantal kere wat 'n rot die verskillende arms van die doolhofbinne gaan, sowel as die tyd wat die dier op elke arm deurbring was genotuleer. Die aantal steierings, botstilstande, defekasies en versorgingsbewegings was weereens waargeneem. ACTH bepalings: Die vlakke van ACTH was bepaal in al die rotgroepe, 15 minute nadat hulle aan 10 minute beperkingstres onderwerp was. Resultate: Gedrag: Rotte wat met CRF toegedien was, het op minder geleenthede die toe arms van die "elevated plus-maze" binne gegaan toe hulle met die naïewe groep rotte vergelyk was. Hierdie verskil was betekenisvol. Daar was geen ander noemenswaardige verskille ten opsigte van die ander gedragsparameter nie. ACTH bepalings: Daar was 'n afname in die ACTH vlakke, 15 minute na die stres toegedien was in rotte wat CRF ontvang het, in vergelyking tot die naïewe kontrole groep. Hierdie resultate dui daarop dat die toediening van CRF in die brein nie die rot se gedrag, maar wel die dier se respons op stres, beïnvloed het. Gevolgtrekking: In die lig van die voorafgaande resultate verky, blyk dit dat moederlike-skeiding tydens die vroeë kinderjare wel kan aanleiding gee tot angstige gedrag tydens volwassenheid. Ons studies dui ook aan dat CRF nie die primêre bron van hierdie gedrags afwykings is nie, maar dat abnormaliteite in die neurochemiese oordragstowwe (serotonien en noradrenalien) eerder die bepalende faktore is. Ten slotte, ons beveel aan dat geneesmiddels wat geskoei is om die serotonerge sowel as die noradrenerge sisteme aan te spreek, voordeel moet geniet in die behandeling van gedragstoomisse, soos angs.

The current study examined relations among perceptual bias, measured by comparing self performance ratings to those of an independent rater, and gender and comorbid Oppositional Defiant Disorder and Anxiety Disorder (ODD/AD) status in school-aged children with primary diagnoses of ODD. Specifically, perceptual bias of boys (N=61) and girls (N=39) with ODD with (N=43) and without comorbid AD (N=57) were examined after completing a problem solving activity with their parent(s). Measures of global functioning, executive functioning, and severity of the disorders were also examined. Based on previous findings, it was predicted that boys with ODD without AD would exhibit the greatest positive perceptual bias, followed by girls with ODD without AD, boys with ODD and AD, and, finally, girls with ODD and AD. No significant group differences emerged on the related dimensions of global functioning, executive functioning, or severity of behavioral problems. However, systematic differences in age, ADHD diagnosis, and intellectual ability were revealed among the groups, consequently they were controlled for in the final analyses. Overall, children in all groups displayed positive perceptual bias when compared to observer ratings. However, the main hypotheses were not supported. That is, children with ODD evaluated their performance higher than that of observers, independent of comorbid anxiety and gender, when controlling for the effects of age, ADHD, and intellectual ability. Implications and future directions in examining perceptual bias are discussed.
Master of Science

This paper examined the links between selective attention, memory bias, interpretive bias, and anxiety problems in a community sample of 81 children (38 females) aged 9-17 years. Cognitive biases were assessed using a word and picture Dot Probe Discrimination task to assess selective attention, a memory task to assess a memory bias, and the CNCEQ to assess interpretive bias. Childhood anxiety was assessed using the parent and child versions of the RCMAS and RCADS. Significant associations were found between the three cognitive biases and childhood anxiety problems. In addition, selective attention was found to be associated with the selective abstraction subscale of the CNCEQ. The results did not support the mediation of selective attention and interpretive bias by memory bias. Finally, the results supported a cognitive model that posited that interpretive bias may be predictive of childhood anxiety problems beyond what is predicted by selective attention and memory bias.

Abstract The primary aim of the current study was to examine social anxiety symptoms in high-functioning children and adolescents, ages eight to 17 years old with autism (HFA) or Asperger syndrome (AS). The second aim was to study emotion recognition skills in children and adolescents with HFA/AS. In addition, two internationally used social anxiety questionnaires (The Social Phobia and Anxiety Inventory for Children and; The Social Anxiety Scale for Children -revised) were translated into Finnish, and psychometric analyses were performed in order assess the research and clinical utility of these measures as novel tools for the study of child social anxiety in Finland. Results suggest that adolescents, in particular, with HFA/AS experience a greater number of social anxiety symptoms and have increased rates of clinically relevant social anxiety disorder (SAD) than do their control counterparts. Parents reported higher levels of anxiety symptoms in their children with HFA/AS regardless of the child’s age; however, individuals with HFA/AS self-reported anxiety symptoms increased later in their development (i.e., adolescence). In addition, overall facial emotion recognition increased with age in the HFA/AS group. Despite this, the HFA/AS group did not reach the higher ability level attained by the typically developing adolescents regardless of age. Specifically, when the facial emotion expressed a combination of both surprise and fear, participants with HFA/AS labelled the facial expression as “fear” statistically significantly more often than did controls. Moreover, control participants interpreted faces which blended sadness and neutral emotions as neutral more often than HFA/AS participants. Results suggest that social anxiety is clinically important to assess in children and adolescents with HFA/AS. Clinical interventions which enhance emotion recognition skills and reduce social anxiety symptoms in individuals with HFA/AS may be warranted
Tiivistelmä Tutkimuksen päätarkoituksena oli selvittää sosiaalista ahdistuneisuutta 8–17-vuotiailla hyvätasoisilla lapsilla ja nuorilla, joilla on autismi (HFA) tai Aspergerin oireyhtymä (AS). Tutkimuksen toinen tarkoitus oli selvittää, miten HFA- ja AS-lapset ja nuoret kykenevät tunnistamaan tunteita kasvonilmeistä. Tutkimus arvioi myös kahden kansainvälisesti tunnetun, sosiaalista ahdistuneisuutta mittaavan kyselylomakkeen (The Social Phobia and Anxiety Inventory for Children ja The Social Anxiety Scale for Children -revised) toimivuutta suomalaisessa väestössä. Tavoitteena oli antaa uusia työvälineitä suomalaiselle lastenpsykiatrialle tutkimus- ja kliiniseen työhön. Tutkimustulokset osoittivat HFA- ja AS-nuorten kokevan muita nuoria useammin sosiaalista ahdistuneisuutta. Vanhemmat havaitsevat HFA- ja AS-lastensa sosiaalisen ahdistuneisuuden oireet lapsen iästä riippumatta, kun lapset itse kertoivat oireistaan vasta nuoruusiässä. Tutkimus osoitti myös, että HFA:ta tai AS:ää sairastavien kyky tunnistaa tunteita paranee iän myötä. Se ei kuitenkaan saavuta tavalliseen tapaan kehittyvien lasten taitotasoa nuoruusikään mennessä. HFA- ja AS-lapset ja nuoret tulkitsevat ikätovereitaan useammin kasvojen ilmeen peloksi silloin, kun kasvojenilme on sekoitus pelko-yllättyneisyyttä. Tavalliseen tapaan kehittyneet lapset ja nuoret tulkitsevat kasvojenilmeen useammin neutraaliksi kuin HFA tai AS diagnoosin saaneet, jos kasvojenilme on sekoitus surullinen-neutraalia. Tutkimustulosten perusteella tulee HFA:ta tai AS:ää sairastavia lapsia ja nuoria hoidettaessa ottaa huomioon sosiaalinen ahdistuneisuus. Heille tulisi nykyistä useammin tarjota tilaisuus myös kuntouttaa kykyä tunnistaa toisten ihmisten tunteita

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

Aus der Einleitung: A wide range of epidemiological community studies worldwide converge on several incontrovertible facts regarding anxiety disorders: they occur frequently, begin at an early age, significantly impair multiple areas of development and life, and are associated with numerous adverse correlates and consequences. Furthermore, evidence clearly points to the fact that the majority of patients who have anxiety disorders still go undetected and undertreated, despite considerable efforts over the last two decades to improve this situation. Less than half receive any treatment at all and only a fraction of those receive what can be considered even "minimally adequate treatment."

Childhood anxiety disorders are highly prevalent, cause significant distress and functional impairment, are risk factors for depression, suicidal ideation and attempts, substance abuse and smoking, yet often go unrecognized and untreated. As a result, effective prevention and early intervention have become policy and research priorities. This study evaluated the effectiveness of a universal school-based cognitive behavioural intervention in decreasing anxiety symptoms experienced by early adolescents during the transition from elementary to middle or secondary school. The role of gender, coping style, geographic location, and timing of the intervention were also assessed. Participants were 722 grade 7 and 8 students (11 – 14 years) from 41 classrooms in 20 randomly selected public schools in British Columbia. Schools were randomly assigned to either the FRIENDS for Youth program provided within regular classrooms, one hour weekly for 10 weeks or to a waitlist control group. Self-reported anxiety, depression and coping, and parent and teacher assessed difficulties were assessed at pre-, post, and six month follow-up. Results were examined universally and for children who scored above the clinical cut-off for anxiety at pre-test. Results indicate students, including those “at risk”, who participated in the FRIENDS for Youth program had lower anxiety than those in the control group at 6-month follow-up. Gender differences in self-reported anxiety as well as in response to the intervention were found, with girls, including those “at risk” reporting higher anxiety scores than boys, and intervention group girls reporting significantly lower anxiety scores at post-intervention and at 6-month follow-up compared to the control group. Teachers assessed girls as having lower difficulties scores than boys, and intervention group girls reporting significantly lower difficulties scores at post-intervention than the control group. Grade 7 elementary students had significantly lower anxiety scores than middle school students and grade 7 students in the intervention group had significantly lower anxiety scores at post-intervention than the control group. Overall, intervention effects on anxiety were small. For “at risk” participants and for girls, however, the intervention was effective. Results demonstrated a prevention effect with significantly fewer “at risk” students at 6-month follow-up in the intervention group than the control group.

The present study examined the social skills and social acceptance of children with SAD (n=20), children with GAD (n=18), and typically developing (TD) children (n=20). A multimodal assessment paradigm was employed to address three study objectives: (a) to determine whether social skills deficits are unique to children with SAD or extend to children with GAD, (b) to assess whether skills vary as a function of social context (in vivo peer interaction Wii Task versus hypothetical Social Vignette Task) and (c) to examine the relationship between anxiety diagnosis and social acceptance. Parent questionnaire data indicated that both youth with SAD and GAD experienced difficulties with assertiveness, whereas children with SAD experienced a broader range of social skills difficulties. Blinded observers' ratings during the behavioral assessment social tasks indicated that compared to children with GAD and TD children, children with SAD have deficits in social behaviors and social knowledge across settings, including speech latency, a paucity of speech, few spontaneous comments, questions and exclamations, and ineffective social responses. In addition, vocal analysis revealed that children with SAD were characterized by anxious speech patterns. By comparison, children with GAD exhibited non-anxious speech patterns and did not differ significantly from TD youth on social behaviors, with the exception of fewer spontaneous comments and questions. Lastly, children with SAD were perceived as less likeable and less socially desirable by their peers than both children with GAD and TD children. Clinical implications of these findings are discussed.
Ph.D.
Doctorate
Psychology
Sciences
Psychology; Clinical Psychology

Dental anxiety is a common and disabling problem for individuals with autism spectrum disorders (ASD). Little is known about the causes of dental anxiety in ASD but the literature suggests it may be related to sensory sensitivity (Stein et al., 2011) and having high rates of anxiety in general (White et al., 2009). The purpose of this research is to examine the factors that predict dental anxiety in children with ASD. The first two qualitative studies were designed to identify relevant factors in dental anxiety using a bottom-up approach. Interviews were carried out with parents of children with ASD and individuals with ASD. The second study interviewed dentists with varying expertise in ASD. Both sets of interviews were analysed using content analysis. Findings from the qualitative studies suggest that dental anxiety is related to parental anxiety, sensory sensitivity, worries about pain, and negative experiences. In the third study 45 children with ASD aged (11 to 17) and their parents, and a comparison group of 50 Typically Developing (TD) children and their parents, completed measures examining dental anxiety and associated factors. The results demonstrate that children with ASD have higher rates of dental anxiety related to their higher overall anxiety level. Correlations show that dental anxiety is related to other forms of anxiety: unusual sensory processing, cognition, past experiences at the dentist, parents’ dental anxiety, and the number of visits that a child has had to the dentist. Regression analysis shows that dental anxiety in children with ASD is determined by their worries about treatment and the number of dental visits. In TD children, dental anxiety was only predicted by their worries about treatment. Nevertheless, despite the aforementioned small differences, this third study showed that children with ASD and TD children are more alike than different, which is an interesting finding that requires further investigation. Overall, this research helps us understand the underlying causes of dental fear in children with ASD and gives insight into interventions to support them with oral care.

Aus der Einleitung: A wide range of epidemiological community studies worldwide converge on several incontrovertible facts regarding anxiety disorders: they occur frequently, begin at an early age, significantly impair multiple areas of development and life, and are associated with numerous adverse correlates and consequences. Furthermore, evidence clearly points to the fact that the majority of patients who have anxiety disorders still go undetected and undertreated, despite considerable efforts over the last two decades to improve this situation. Less than half receive any treatment at all and only a fraction of those receive what can be considered even "minimally adequate treatment."

Background: Comorbid anxiety disorders in psychotic illness are reported in the international literature as highly prevalent and have a significant negative impact on patient outcomes. Local literature describing such comorbidity in the South African population is limited and clinically, anxiety symptoms are seldom recognised or treated in patients with psychotic disorders. More data on prevalence rates across psychotic disorder diagnoses, as well as sociodemographic correlates would aid recognition, diagnosis, and treatment, and potentially improve clinical outcomes in this population. Method: We performed a secondary analysis of an existing database which comprised data from participants of three previous studies. The sample was made up of patients from Valkenberg Hospital and healthcare facilities in its catchment area. All patients had a diagnosis of a psychotic disorder. Socio-demographic information was collected using a structured questionnaire. Clinical information and diagnosis was determined using the Structured Clinical Interview for DSM (SCID-I). Rates of comorbid anxiety disorders were compared across various sociodemographic categories. Results: The overall prevalence of any anxiety disorder in the entire sample (N=226) was 14.6% (n=33), 95% CI [10.27-19.89%]. The most common anxiety disorder comorbidities were, in descending order, panic disorder (n=12, 5.31%; 95% CI [2.77-9.09%]), PTSD (n=9, 3.98%; 95% CI [1.84-7.42%]), specific phobia (n=7, 3.10%; 95% CI [1.25-6.28%]), anxiety disorder not otherwise specified (n=7, 3.10%; 95% CI [1.25-6.28%]), social phobia (n=4, 1.77%; 95% CI [0.48%-4.47%]), generalised anxiety disorder (n=4, 1.77%; 95% CI [0.48-4.47%]), substance-induced anxiety disorder (n=4, 1.77%; 95% CI [0.48-4.47%]) and obsessive compulsive disorder (n=2, 0.88%; 95% CI [0.11-3.16%]). There was a significant association between diagnosis and the presence of post-traumatic stress disorder (PTSD), with the schizoaffective disorder group having a higher rate of PTSD (13.3% vs. 3.3% in schizophrenia, 3.2% in substance-induced mood/psychotic disorder and 0% in bipolar I disorder) (Fisher's exact test, p=0.039). In turn, there was a trend level association between diagnosis and the presence of panic disorder (PD), with schizoaffective disorder patients having higher rates of PD (16.6% vs. 4.1% in schizophrenia spectrum, 3.2% in substance-induced mood/psychotic disorder and 2.2% in bipolar I disorder) (Fisher's exact test, p=0.052). A significant association was found between level of education and the presence of PTSD, with higher rates of PTSD in patients with seven or less years of education (8.8%) compared to lower rates in those with 8-12 years of education (5.3%) and > 12years of education (0%) (Fisher's exact test, p=0.020). Conclusion: The overall prevalence of anxiety disorders in psychotic illness was lower than what has been described in previous literature. Prevalence rates of individual anxiety disorders were also lower than previously published literature. Possible reasons for this include use of the SCID which utilises a strict diagnostic hierarchy, that the majority of the sample were in-patients, no use of self-report questionnaires or other anxiety-specific diagnostic instruments, or possible geographical and/or ethnic differences in South African patients. The most frequent comorbid anxiety disorders in our study were panic disorder and PTSD. This is out of keeping with other literature which has mostly found obsessive compulsive disorder and social anxiety disorder to be the most common anxiety comorbidities in psychotic illness. Further research into comorbid anxiety in psychotic disorders is needed, particularly amongst South African populations.

The aim of this thesis was to provide research to understand and treat anxiety in children with asthma. Specifically, the aims were to: (1) investigate the parent and cognitive factors associated with anxiety in children with asthma; and (2) evaluate a cognitive behavioural treatment (CBT) specifically developed for children in this population. The rationale behind this research was the identification of a higher prevalence of anxiety disorders in children with asthma compared to healthy children, yet very little understanding about the factors which may underlie this relationship. This poor understanding has translated into a lack of evidence-based treatments for this population. The research comprises of five empirical studies, including a meta-analysis, two cross-sectional empirical studies, a case series analysis of treatment and a qualitative study. The findings of this thesis highlight that some parenting behaviours, namely parental control, and child cognitions, namely avoidant coping, whilst understandable in the context of a chronic illness, may – in fact – also confer risk for anxiety in these children. The results also showed promise for the efficacy of a group CBT intervention for a small number of participants with asthma and a comorbid anxiety disorder, however critically a large number of eligible participants declined to take part. It appears that a number of barriers to treatment engagement exist, which relate specifically to parent beliefs and understanding about the link between asthma and anxiety. Additional research is needed with larger samples in order to further explicate the role of parent and cognitive factors in the development and maintenance of anxiety in children with asthma, and establish CBT as an evidence-based treatment for this population.

Although theoretical arguments would suggest little comorbidity between Separation Anxiety Disorder (SAD) and Oppositional Defiant Disorder (ODD), epidemiological studies find otherwise. I examined whether ambiguous symptoms and negative halo effects contribute to this comorbidity. In Study 1, 72 mothers read scenarios of children displaying either SAD or ODD behaviors. The SAD scenarios included behaviors considered by judges to be pure exemplars of SAD, as well as behaviors considered to be ambiguous representations of the disorder. ODD scenarios also included both pure and ambiguous behaviors. After each scenario, mothers rated the child on the behaviors presented in the scenario, as well as behaviors of the alternate disorder, and somatic symptoms. Mothers endorsed the ambiguous behaviors presented in the scenarios significantly less than the pure behaviors; and rated the ambiguous behaviors of the non-presented disorder significantly more often than the pure behaviors of the non-presented disorder. This suggests that some comorbidity between SAD and ODD may be explained by the presence of ambiguous items representing the two disorders. For the SAD scenarios, mothers also endorsed non-presented somatic symptoms, suggesting a general negative halo bias in maternal ratings of anxious children. Study 2 used a clinical sample of parents (N = 201) and youth (N = 177) and examined whether using only nonambiguous, or pure, items from commonly used rating scales would decrease the degree of relatedness between SAD and ODD symptoms. Pure anxiety and oppositional scales were created from the Child Behavior Checklist (CBCL) and Youth Self-Report (YSR). In general, the relationship between these pure scales was compared to the relationship between the commonly used, empirically-derived and DSM-oriented scales assessing anxiety and oppositionality on the CBCL and YSR. The pure scales were significantly less related than the empirical or DSM-oriented scales. Thus, the relatedness of the disorders was decreased by assessing only pure exemplars. In sum, the results of these studies suggest that the comorbidity of SAD and ODD observed in epidemiological studies may be partially due to the inclusion of ambiguous items on commonly used rating scales. Implications for clinical assessment and theory are discussed.
Arts, Faculty of
Psychology, Department of
Graduate