Anxiety Disorders: Feinstein A

Ameis SH, Feinstein A. · University of Toronto, Sunnybrook Health Sciences Center, 2075 Bayview, Avenue, Toronto, Ontario, M4N 3M5, Canada. · Expert Rev Neurother. · Pubmed #17078794 No free full text.

Abstract: This article reviews the treatment of behavioral disturbances associated with multiple sclerosis. Pharmacological and psychotherapeutic treatment data, when available, are presented for five discrete conditions: major depression, bipolar affective disorder, anxiety, psychosis, pseudobulbar affect and cognitive dysfunction. Despite the paucity of empirical treatment data that characterizes all of these conditions, with the exception of pseudobulbar affect, the message from open-label trials and anecdotal experience is that therapy is often successful, leading to improvements in quality of life for patients. Thus, all health professionals involved in the care of multiple sclerosis patients should have a good working knowledge of the neurotherapeutics of multiple sclerosis-related behavioral disorders.

Rapoport M, McCauley S, Levin H, Song J, Feinstein A. · Department of Psychiatry, Sunnybrook and Women's College Health Sciences Center, University of Toronto, Toronto, Ontario, Canada. · Neuropsychiatry Neuropsychol Behav Neurol. · Pubmed #12050475 No free full text.

Abstract: OBJECTIVE/BACKGROUND: To assess neurobehavioral outcome using the Neurobehavioral Rating Scale-Revised (NRS-R), an instrument with established specificity and validity in Traumatic Brain Injury (TBI) in a sample including the full spectrum of TBI severity 3 months after injury. METHOD: A cohort group of 102 subjects with mild TBI, 41 with moderate TBI, and 139 with severe TBI, from multiple academic trauma centers, were assessed using the NRS-R and the Glasgow Outcome Scale. RESULTS: Principal components analysis of the NRS-R resulted in a 3-factor model: (1) Cognitive, (2) Emotional, and (3) Hyperarousal. At 3 months, subjects with severe TBI show greater difficulties in cognitive and hyperarousal, but not emotional domains, than those with mild to moderate TBI. More than one third of subjects in all injury severity groups showed evidence of anxiety, depression, irritability, mental fatigability, and memory dysfunction. Scores on the NRS-R were related to outcome on the Glasgow Outcome Scale. CONCLUSIONS: Three months after injury, subjects with severe TBI have more dysfunction in cognitive and behavioral (but not emotional) domains than those with mild-to-moderate TBI. The NRS-R is a useful tool for assessing the full spectrum of neurobehavioral dysfunction at all ranges of TBI severity.

Feinstein A, Hershkop S, Ouchterlony D, Jardine A, McCullagh S. · Department of Psychiatry, Sunnybrook and Women's College Health Science Centre, Toronto, Ontario, Canada. · J Neuropsychiatry Clin Neurosci. · Pubmed #11884651 links to  free full text

Abstract: The relationship between posttraumatic amnesia (PTA) and symptoms of posttraumatic stress disorder (PTSD) was examined in 282 outpatients at a mean of 53 days after traumatic brain injury (TBI). Patients were assessed for TBI severity, intrusive and avoidant PTSD-type symptoms, and psychological distress, and were stratified into four comparison groups by duration of PTA. Levels of PTSD-type symptoms and psychological distress did not differ significantly between groups. Even patients with PTA >1 week reported intrusive and avoidant PTSD-type symptoms. However, when patients were stratified into those with PTA of <1 hour or >1 hour, the former were more likely to report such symptoms. TBI patients with brief PTA are more likely to experience PTSD-type reactions, but severe TBI with prolonged PTA is not incompatible with such reactions in a subset of patients. Possible mechanisms that could account for this finding are discussed.

Ghaffar O, Chamelian L, Feinstein A. · Neuropsychiatry Division, Dept. of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, FG08-2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada. · J Neurol. · Pubmed #18297331 No free full text.

Abstract: Pseudobulbar affect (PBA) is defined as episodes of involuntary crying, laughing, or both in the absence of a matching subjective mood state. This neuropsychiatric syndrome can be found in a number of neurological disorders including multiple sclerosis (MS). The aim of this study was to identify neuroanatomical correlates of PBA in multiple sclerosis (MS) using a case-control 1.5T MRI study. MS patients with (n = 14) and without (n = 14) PBA were matched on demographic, disease course, and disability variables. Comorbid psychiatric disorders including depressive and anxiety disorders were absent. Hypo- and hyperintense lesion volumes plus measurements of atrophy were obtained and localized anatomically according to parcellated brain regions. Between-group statistical comparisons were undertaken with alpha set at 0.01 for the primary analysis. Discrete differences in lesion volume were noted in six regions: Brainstem hypointense lesions, bilateral inferior parietal and medial inferior frontal hyperintense lesions, and right medial superior frontal hyperintense lesions were all significantly higher in the PBA group. A logistic regression model identified four of these variables (brainstem hypointense, left inferior parietal hyperintense, and left and right medial inferior frontal hyperintense lesion volumes) that accounted for 70% of the variance when it came to explaining the presence of PBA. In conclusion, MS patients with PBA have a distinct distribution of brain lesions when compared to a matched MS sample without PBA. The lesion data support a widely-dispersed neural network involving frontal, parietal, and brainstem regions in the pathophysiology of PBA.

Korostil M, Feinstein A. · Department of Psychiatry, Sunnybrook Health SciencesCentre, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5. · Mult Scler. · Pubmed #17294613 No free full text.

Abstract: OBJECTIVE: To assess prevalence rates and clinical correlates of anxiety disorders in patients with multiple sclerosis (MS). METHODS: Demographic and neurological data were collected on 140 consecutive clinic attendees, and their lifetime and point prevalences of anxiety disorders were determined with the Structured Clinical Interview for DSM-IV disorders (SCID-IV). All subjects completed the self-report Hospital Anxiety and Depression Scale (HADS). Suicidal intent was rated with the Beck Suicide Scale (BSS), psychosocial stressors and supports were quantified with Social Stress and Support Interview (SSSI), and cognition assessed with Neuropsychological Screening Battery for MS. RESULTS: The lifetime prevalence of any anxiety disorder was 35.7%, with panic disorder (10%), obsessive compulsive disorder (8.6%), and generalized anxiety disorder (18.6%), the most common diagnoses obtained. Subjects with an anxiety disorder were more likely to be female, have a history of depression, drink to excess, report higher social stress and have contemplated suicide. The diagnosis of an anxiety disorder had been missed in the majority of subjects, therefore, they had not received treatment. A discriminant function analysis identified a series of variables that correctly classified 75% of patients with an anxiety disorder. CONCLUSION: Anxiety disorders are common in patients with MS, but are frequently overlooked and under-treated. Risk factors include being female, a co-morbid diagnosis of depression, and limited social support. Clinicians should evaluate all MS subjects for anxiety disorders, as they represent a treatable cause of disability in MS.

Feinstein A, Nicolson D. · Department of Psychiatry, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada. · J Trauma Stress. · Pubmed #16281204 No free full text.

Abstract: The current war in Iraq saw an alliance between the media and the military, a process called embedded journalism. The aim of this study was to explore whether this process affected the journalists' vulnerability to psychological distress. Eighty-five of 100 journalists approached agreed to participate; 38 (44.7%) were embedded. There were no differences between embedded and unilateral (non-embedded) journalists on demographic measures or in their exposure to traumatic events. Similarly, the two groups did not differ on indices of posttraumatic stress disorder, depression, psychological distress, and substance use. Based on General Health Questionnaire scores, one third of all journalists were psychologically distressed. There is no evidence from the recent war in Iraq suggesting that embedded journalists are at increased risk for psychological problems.

Quesnel S, Feinstein A. · Department of Psychiatry, University of Toronto and Sunnybrook and Women's College Health Science Centre, 2075 Bayview Ave, Ontario, Canada, M4N 3M5. · Mult Scler. · Pubmed #15124767 No free full text.

Abstract: Multiple sclerosis (MS) patients are known to be at increased risk from mood disorders and suicidal ideation. Although these are often associated with alcohol disorders, the drinking habits of MS patients have not been well studied to date. Our study assessed drinking patterns in 140 MS patients, focusing on a possible link between problem drinking and mood and anxiety disorders. Lifetime psychiatric diagnoses were ascertained using the Structured Clinical Interview for DSM-IV disorders (SCID-IV). Results demonstrate that one in six MS patients drink to excess over the course of their lifetime. Those with a history of problem drinking display a higher lifetime prevalence of anxiety (P = 0.006), but not mood disorders. There were also significant associations between problem drinking and a lifetime prevalence of suicidal ideation (P = 0.006), substance abuse (P = 0.001), and a family history of mental illness (P = 0.008). Clinicians should be aware of the possibility of problem drinking in MS patients, and how this may complicate the course of their disease. Clues to problem drinking in MS patients are the presence of a positive family history of mental illness and prominent anxiety.

Feinstein A. · Department of Psychiatry, University of Toronto and Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. · Neurology. · Pubmed #12221156 No free full text.

Abstract: OBJECTIVE: To examine neurologic and psychiatric correlates of suicidal intent in a community sample of 140 patients with MS. METHODS: Patients with (28.6%) and without lifetime suicidal intent were compared across MS disease-related and psychiatric variables. All subjects were interviewed with 1) the Structured Clinical Interview for DSM-IV Axis 1 disorders (SCID-IV) to determine lifetime prevalence of major depression and anxiety disorders; and 2) the Social Stress and Support Interview to assess psychological stressors. Suicidal intent was documented with questions from the SCID-IV and Beck Suicide Scale. Patients also completed the Hospital Anxiety and Depression Scale and cognitive testing. RESULTS: Suicidal patients were significantly more likely to live alone, have a family history of mental illness, report more social stress, and have lifetime diagnoses of major depression, anxiety disorder, comorbid depression-anxiety disorder, and alcohol abuse disorder. By logistic regression analysis, the severity of major depression, alcohol abuse, and living alone had an 85% predictive accuracy for suicidal intent. A third of suicidal patients had not received psychological help. Two-thirds of subjects with current major depression, all suicidal, had not received antidepressant medication. CONCLUSIONS: Suicidal intent, a potential harbinger for suicide, is common in MS and is strongly associated with major depression, alcohol abuse, and social isolation. Suicidal intent is a potentially treatable cause of morbidity and mortality in MS.

Feinstein A, Owen J, Blair N. · Department of Psychiatry, University of Toronto, Sunnybrook and Women's College Health Sciences Centre, Ont., Canada. · Am J Psychiatry. · Pubmed #12202279 links to  free full text

Abstract: OBJECTIVE: War journalists often confront situations of extreme danger in their work. Despite this, information on their psychological well-being is lacking. METHOD: The authors used self-report questionnaires to assess 140 war journalists, who recorded symptoms of posttraumatic stress disorder (PTSD) (with the Impact of Event Scale-Revised), depression (with the Beck Depression Inventory-II), and psychological distress (with the 28-item General Health Questionnaire). To control for stresses generic to all journalism, the authors used the same instruments to assess 107 journalists who had never covered war. A second phase of the study involved interviews with one in five journalists from both groups, using the Structured Clinical Interview for Axis I DSM-IV Disorders. RESULTS: The rates of response to the self-report questionnaires were approximately 80% for both groups. There were no demographic differences between groups. Both male and female war journalists had significantly higher weekly alcohol consumption. The war journalists had higher scores on the Impact of Event Scale and the Beck Depression Inventory. Their lifetime prevalence of PTSD was 28.6%, and the rates were 21.4% for major depression and 14.3% for substance abuse. War journalists were not, however, more likely to receive treatment for these disorders. CONCLUSIONS: War journalists have significantly more psychiatric difficulties than journalists who do not report on war. In particular, the lifetime prevalence of PTSD is similar to rates reported for combat veterans, while the rate of major depression exceeds that of the general population. These results, which need replicating, should alert news organizations that significant psychological distress may occur in many war journalists and often goes untreated.

Feinstein A, Stergiopoulos V, Fine J, Lang AE. · Department of Psychiatry, University of Toronto, Sunnybrook and Women's College Health Science Center, Ontario, Canada. · Neuropsychiatry Neuropsychol Behav Neurol. · Pubmed #11513100 No free full text.

Abstract: OBJECTIVE: To assess psychiatric outcome in patients with an established diagnosis of a hyperkinetic (i.e. tremor, dystonia, myoclonus) psychogenic movement disorder. BACKGROUND: Longitudinal studies of patients with psychogenic movement disorders (PMD) have to date suffered from small sample size, lack of sample homogeneity (psychogenic movements grouped with other somatoform disorders, mixed hyper and hypokinetic movements), the absence of structured psychiatric interviews, and a failure to adequately address the extent of psychiatric co-morbidity by adopting a hierarchical approach to diagnosis. METHODS: A sample of 88 patients with documented PMD according to the criteria of Fahn and Williams were followed up on average 3.2 years (sd = 2.2; range 1-7 years) after first being assessed at a tertiary referral clinic for patients with movement disorders. The detailed psychiatric assessment included the Structured Clinical Interview for Axis (SCID-I) and Axis II (SCID-II) DSM-IV disorders which generated diagnoses with respect to major mental illness (SCID-I) and personality disorders (SCID-II) respectively. RESULTS: Of 88 subjects initially seen in clinic, three had died (one by suicide), two were in nursing homes (Alzheimers disease, terminal cancer) and three had emigrated. Of the remaining 80 subjects, 42 (52.5%) agreed to be interviewed. There were no demographic or illness-related differences between those who agreed or refused participation. At follow-up, the mean age of subjects was 48.6 (13.3) years, 62.7% were female and 75% were unemployed. An Axis I diagnosis of mental illness was made in 40 (95.3%) subjects. The PMD had remitted in four subjects, but had been replaced in two of them by a different mental disorder. Thirty-eight percent of subjects with PMD had developed additional unexplained medical symptoms at follow-up. Point and lifetime prevalence rates for other Axis I diagnoses were: major depression 19.1% and 42.9%; anxiety disorders 38.2% and 61.9%; co-morbid major depression and anxiety disorders 11.9% and 28.6%. Personality disorders were present in 45% of the sample. No subject viewed their PMD as primarily psychiatric in origin. Poor outcome with respect to the abnormal movements was associated with long duration of symptoms, insidious onset of movements and psychiatric co-morbidity on Axis I diagnoses. CONCLUSIONS: Follow-up data of patients with PMD revealed a persistence in abnormal movements in more than 90% of subjects. Prevalence rates of mental illness in excess of those found in the general population and in neurologic disorders plus an inability to acknowledge the essentially psychologic nature of their condition characterized the outcome picture and carries a poor longer term prognosis.