Anxiety Disorders: Boston University

Culpepper L. · Boston Medical Center, 1 Boston Medical Center Place, Dowling 5, Boston, MA 02118, USA. · J Clin Psychiatry. · Pubmed #19371503 No free full text.

Abstract: Patients with generalized anxiety disorder (GAD) often have multiple medical comorbidities. The adrenal system and genetic and environmental factors are intermediaries between anxiety and medical illnesses such as chronic pain conditions and gastrointestinal, cardiovascular, endocrine, and respiratory disorders. Medical disorders associated with anxiety include migraine, rheumatoid arthritis, peptic ulcer disease, irritable bowel syndrome, coronary heart disease, hyperthyroidism, diabetes, asthma, and chronic obstructive pulmonary disorder. Compared to people with pain conditions without GAD, individuals with pain conditions and GAD experience and register pain differently; they also have increased awareness of symptoms. Comorbid medical illnesses may influence treatment choice for GAD. Treatment of anxiety in young patients with GAD needs to be long-term to decrease vulnerability to medical conditions.

Culpepper L. · Boston University School of Medicine, Boston, Massachusetts, USA. · CNS Spectr. · Pubmed #19317019 No free full text.

This publication has no abstract.

Fogler JM, Shipherd JC, Clarke S, Jensen J, Rowe E. · The Brookline Community Mental Center, Brookline, MA 02445, USA. · J Child Sex Abus. · Pubmed #19042605 No free full text.

Abstract: The literature on clergy-perpetrated sexual abuse suggests that there are two modal populations of survivors: boys and adult women. We review what is known about trauma and post-traumatic stress disorder following sexual abuse and explore the different treatment needs for these two survivor groups. For children, clergy-perpetrated sexual abuse can catastrophically alter the trajectory of psychosocial, sexual, and spiritual development. Depending on the age at which abuse occurred, adult clients may present with clinical issues that are more appropriate for a younger developmental stage. Additionally, the symptoms of traumatic stress may be misunderstood when clients conceptualize their abuse as an "affair" or "consensual" relationship. We discuss empirically supported treatments for post-traumatic stress disorder and potential adaptations for the needs of clergy-perpetrated sexual abuse survivors.

Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. · Boston University School of Medicine, Boston, MA 02118, USA. · J Altern Complement Med. · Pubmed #18803491 No free full text.

Abstract: OBJECTIVES: This paper seeks to explore the potential value of qigong and t'ai chi practice as a therapeutic intervention to aid in the treatment of survivors of torture and refugee trauma. DESIGN: The common effects of torture and refugee trauma are surveyed with a focus on post-traumatic stress disorder. An alternative theoretical framework for conceptualizing and healing trauma is presented. Evidence is reviewed from the scientific literature that describes how qigong and t'ai chi have been used in studies of the general population to alleviate symptoms that are also expressed in torture survivors. Observations are presented from a combined, simplified qigong and t'ai chi intervention with a convenience sample of four refugee survivors of torture. RESULTS: Preliminary observations from four cases and a review of the literature support the potential efficacy of incorporating qigong and t'ai chi into the treatment of survivors of torture and refugee trauma. CONCLUSIONS: The incorporation of qigong and t'ai chi into the treatment of torture survivors, within a new framework for healing trauma, merits further investigation.

Murray LK, Cohen JA, Ellis BH, Mannarino A. · Boston University School of Public Health, Center for International Health and Development, 85 E. Concord Street, 5th Floor, Boston, MA 02118, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #18558314 No free full text.

Abstract: The diverse clinical presentation of refugee children and adolescents after their traumatic experiences requires a treatment model that can mitigate a number of internalizing and externalizing symptoms. Refugee populations also require interventions that can adjust to the wide-ranging experiences likely encountered during preflight, flight, and resettlement. There is some evidence that immigration stressors or social stressors, such as discrimination, are associated with symptoms of posttraumatic stress disorder in refugee youth. Therefore refugee youth may benefit from multiple levels of services, ideally integrated. This article focuses on the mental and behavioral health component of services for refugee youth.

Hofmann SG. · Department of Psychology, Boston University, Boston, MA 02215-2002, USA. · Cogn Behav Ther. · Pubmed #18049945 links to  free full text

Abstract: Social anxiety disorder (SAD) is a common, distressing and persistent mental illness. Recent studies have identified a number of psychological factors that could explain the maintenance of the disorder. These factors are presented here as part of a comprehensive psychological maintenance model of SAD. This model assumes that social apprehension is associated with unrealistic social standards and a deficiency in selecting attainable social goals. When confronted with challenging social situations, individuals with SAD shift their attention toward their anxiety, view themselves negatively as a social object, overestimate the negative consequences of a social encounter, believe that they have little control over their emotional response, and view their social skills as inadequate to effectively cope with the social situation. In order to avoid social mishaps, individuals with SAD revert to maladaptive coping strategies, including avoidance and safety behaviors, followed by post-event rumination, which leads to further social apprehension in the future. Possible disorder-specific intervention strategies are discussed.

Hofmann SG, Asmundson GJ. · Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215-2002, United States. · Clin Psychol Rev. · Pubmed #17904260 No free full text.

Abstract: Some contemporary theorists and clinicians champion acceptance and mindfulness-based interventions, such as Acceptance and Commitment Therapy (ACT), over cognitive-behavioral therapy (CBT) for the treatment of emotional disorders. The objective of this article is to juxtapose these two treatment approaches, synthesize, and clarify the differences between them. The two treatment modalities can be placed within a larger context of the emotion regulation literature. Accordingly, emotions can be regulated either by manipulating the evaluation of the external or internal emotion cues (antecedent-focused emotion regulation) or by manipulating the emotional responses (response-focused emotion regulation). CBT and ACT both encourage adaptive emotion regulation strategies but target different stages of the generative emotion process: CBT promotes adaptive antecedent-focused emotion regulation strategies, whereas acceptance strategies of ACT counteract maladaptive response-focused emotion regulation strategies, such as suppression. Although there are fundamental differences in the philosophical foundation, ACT techniques are fully compatible with CBT and may lead to improved interventions for some disorders. Areas of future treatment research are discussed.

Keane TM, Marshall AD, Taft CT. · VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts 02130, USA. · Annu Rev Clin Psychol. · Pubmed #17716068 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) results from exposure to a traumatic event that poses actual or threatened death or injury and produces intense fear, helplessness, or horror. U.S. population surveys reveal lifetime PTSD prevalence rates of 7% to 8%. Potential reasons for varying prevalence rates across gender, cultures, and samples exposed to different traumas are discussed. Drawing upon a conditioning model of PTSD, we review risk factors for PTSD, including pre-existing individual-based factors, features of the traumatic event, and posttrauma social support. Characteristics of the trauma, particularly peritraumatic response and related cognitions, and posttrauma social support appear to confer the greatest risk for PTSD. Further work is needed to disentangle the interrelationships among these factors and elucidate the underlying mechanisms. Based upon existing treatment outcome studies, we recommend use of exposure therapies and anxiety management training as first-line treatment for PTSD. Among psychopharmacological treatments, selective serotonin reuptake inhibitors evidence the strongest treatment effects, yet these effects are modest compared with psychological treatments.

Hofmann SG. · Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215-2002, USA. · Behav Res Ther. · Pubmed #17659253 links to  free full text

Abstract: Combining an effective psychological treatment with conventional anxiolytic medication is typically not more effective than unimodal therapy for treating anxiety disorders. However, recent advances in the neuroscience of fear reduction have led to novel approaches for combining psychological therapy and pharmacological agents. Exposure-based treatments in humans partly rely on extinction to reduce the fear response in anxiety disorders. Animal studies have shown that D-cycloserine (DCS), a partial agonist at the glycine recognition site of the glutamatergic N-methyl-D-aspartate receptor facilitates extinction learning. Similarly, recent human trials have shown that DCS enhances fear reduction during exposure therapy of some anxiety disorders. This article discusses the biological and psychological mechanisms of extinction learning and the therapeutic value of DCS as an augmentation strategy for exposure therapy. Areas of future research will be identified.

Hofmann SG. · Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215-2002, United States. · Clin Psychol Rev. · Pubmed #17532105 links to  free full text

Abstract: Anxiety disorders are highly prevalent. Fear conditioning and extinction learning in animals often serve as simple models of fear acquisition and exposure therapy of anxiety disorders in humans. This article reviews the empirical and theoretical literature on cognitive processes in fear acquisition, extinction, and exposure therapy. It is concluded that exposure therapy is a form of cognitive intervention that specifically changes the expectancy of harm. Implications for therapy research are discussed.

Morissette SB, Tull MT, Gulliver SB, Kamholz BW, Zimering RT. · Department of Psychiatry, Boston University School of Medicine, Boston, MA 02130, USA. · Psychol Bull. · Pubmed #17338599 No free full text.

Abstract: Smoking is highly prevalent across most anxiety disorders. Tobacco use increases risk for the later development of certain anxiety disorders, and smokers with anxiety disorders have more severe withdrawal symptoms during smoking cessation than smokers without anxiety disorders. The authors critically examined the relationships among anxiety, anxiety disorders, tobacco use, and nicotine dependence and reviewed the existing empirical literature. Future research is needed to better understand the interrelationships among these variables, including predictors, moderators, and mechanisms of action. Increased knowledge in these areas should inform prevention efforts as well as the development and improvement of smoking cessation programs for those with anxiety and other psychiatric disorders.

Hofmann SG, Pollack MH, Otto MW. · Department of Psychology, Center for Anxiety and Related Disorders, Boston University, Boston, Massachusetts 02215, USA. · CNS Drug Rev. · Pubmed #17227287 links to  free full text

Abstract: Anxiety disorders are among the most common mental disorders. One of the most effective strategies to treat anxiety disorders is exposure therapy with or without cognitive intervention. Fear reduction in exposure therapy is similar to extinction learning. Preclinical studies suggest that extinction learning can be blocked by antagonists at the glutamatergic N-methyl-D-aspartate (NMDA) receptor, and facilitated with D-cycloserine (DCS), a partial agonist at the glycine recognition site of the NMDA receptor in the amygdala. DCS is an established antibiotic drug for the chronic treatment of tuberculosis in humans, but has only recently been investigated as an augmentation therapy for psychological treatment procedures. The review of the literature provides preliminary support for the use of acute dosing of DCS as an adjunctive intervention to exposure therapy for anxiety disorders, including specific phobia and social anxiety disorder. Negative results have recently been reported in the treatment of subclinical fears of animals. These studies suggest that DCS needs to be administered on an acute rather than a chronic dosing schedule, include sufficient time for memory consolidation, and be administered together with psychological treatment that leaves sufficient room for further improvement. It remains to be seen whether these highly promising findings represent reliable pharmacological strategies to enhance exposure therapy of anxiety disorders.

King LA, King DW, McArdle JJ, Saxe GN, Doron-Lamarca S, Orazem RJ. · Department of Psychiatry, Boston University and VA Boston Healthcare System, Boston, MA, USA. · J Trauma Stress. · Pubmed #17195976 No free full text.

Abstract: In this article, the authors introduce a latent difference score (LDS) approach to analyzing longitudinal data in trauma research. The LDS approach accounts for internal sources of change in an outcome variable, including the influence of prior status on subsequent levels of that variable and the tendency for individuals to experience natural change (e.g., a natural decrease in posttraumatic stress disorder [PTSD] symptoms over time). Under traditional model assumptions, the LDSs are maximally reliable and therefore less likely to introduce biases into model testing. The authors illustrate the method using a sample of children who experienced significant burns or other injuries to examine potential influences (i.e., age of child-adolescent at time of trauma and ongoing family strains) on PTSD symptom severity over time.

Otto MW, Basden SL, Leyro TM, McHugh RK, Hofmann SG. · Center for Anxiety and Related Disorders, Department of Psychology, Boston University, Boston, MA 02215, USA. · CNS Spectr. · Pubmed #17192764 links to  free full text

Abstract: In a particular success for translational research agendas, characterization of the neuronal circuits underlying fear extinction, and basic research in animal extinction paradigms, has led to intervention studies examining the use of D-cycloserine (DCS) to enhance therapeutic learning from exposure-based cognitive-behavioral therapy (CBT). In this article, we review these intervention studies, and discuss DCS augmentation of CBT relative to more traditional combination-treatment strategies in the treatment of anxiety disorders. We offer an accounting, based on evidence for internal context effects, of current limitations in the combination of antidepressant or benzodiazepine medications with CBT and discuss the advantages of isolated-dosing strategies with DCS relative to these limitations. This strategy is contrasted with the chronic-dosing applications of DCS for schizophrenia and Alzheimer's disease, and future directions for isolated-dosing strategies are discussed.

Culpepper L. · Department of Family Medicine, Boston University School of Medicine, Boston, MA 02118-2393, USA. · J Clin Psychiatry. · Pubmed #17092194 No free full text.

Abstract: Generalized social anxiety disorder (SAD) is a disabling yet unrecognized condition for many individuals visiting primary care physicians. Social anxiety disorder carries a high risk of developing additional anxiety and mood disorders, including those with suicidal behaviors, as comorbidities, leading to a severe course. Screening and case-finding tools are available and can lead to the recognition of affected individuals. Once symptoms are recognized, an initial assessment will help to differentiate from other anxiety disorders and conditions that can be misdiagnosed as SAD. The primary care physician can manage treatment of SAD, which might require involving mental health professionals. Both pharmacotherapy, involving selective serotonin reuptake inhibitors, and psychotherapy, preferably with cognitive-behavioral therapy, can be effective. Long-term support strategies to monitor relapses or the development of additional psychiatric disorders or to provide anticipatory guidance at times of significant life transitions are additional primary care-based activities that can be helpful to the patient with SAD.

Culpepper L, Judd CR, Moller MD, Nemeroff CB, Rapaport MH, Ciraulo DA. · Department of Family Medicine, Boston University School of Medicine, MA, USA. · JAAPA. · Pubmed #16999330 No free full text.

Abstract: Primary-care practitioners confront myriad issue in managing their patients with depression and/or anxiety. Understanding the scope and epidemiology of these disorders is essential to understanding their shared characteristics. Do we always recognize these patients in practice? What are the barriers to diagnosis and treatment, and how can they overcome? What are the treatment options of these sometimes life-altering conditions, and how do we choose from among the many that exist?

van der Kolk BA. · Boston University School of Medicine, 1269 Beacon Street, Brookline, MA 02446, USA. · Ann N Y Acad Sci. · Pubmed #16891578 No free full text.

Abstract: The research showing how exposure to extreme stress affects brain function is making important contributions to understanding the nature of traumatic stress. This includes the notion that traumatized individuals are vulnerable to react to sensory information with subcortically initiated responses that are irrelevant, and often harmful, in the present. Reminders of traumatic experiences activate brain regions that support intense emotions, and decrease activation in the central nervous system (CNS) regions involved in (a) the integration of sensory input with motor output, (b) the modulation of physiological arousal, and (c) the capacity to communicate experience in words. Failures of attention and memory in posttraumatic stress disorder (PTSD) interfere with the capacity to engage in the present: traumatized individuals "lose their way in the world." This article discusses the implications of this research by suggesting that effective treatment needs to involve (a) learning to tolerate feelings and sensations by increasing the capacity for interoception, (b) learning to modulate arousal, and (c) learning that after confrontation with physical helplessness it is essential to engage in taking effective action.

King DW, King LA, McArdle JJ, Grimm K, Jones RT, Ollendick TH. · Boston University and VA Boston Healthcare System, USA. · J Trauma Stress. · Pubmed #16612827 links to  free full text

Abstract: Despite the proliferation of longitudinal trauma research, careful attention to timing of assessments is often lacking. Patterns in timing of assessments, alternative time structures, and the treatment of time as an outcome are discussed and illustrated using trauma data.

Spinazzola J, Blaustein M, van der Kolk BA. · The Trauma Center, Boston University School of Medicine, National Child Traumatic Stress Network, Boston, Massachusetts 02446, USA. · J Trauma Stress. · Pubmed #16281240 No free full text.

Abstract: The authors review sample composition and enrollment data for 34 studies cited in the International Society for Traumatic Stress Studies (ISTSS) 2000 Practice Guidelines as meeting the Level A U.S. Agency for Health Care Policy and Research (AHCPR) classification for treatment of adult posttraumatic stress disorder (PTSD), and compare data from more recent research. Findings reveal that many published reports omitted vital data including exclusion criteria and rates, demographics, and trauma exposure history. Moreover, severe comorbid psychopathology, a common feature of treatment-seeking individuals with PTSD, emerged as the predominant reason for exclusion across studies. Subsequently published studies exhibited improved reporting of sample characteristics and demonstrated comparable outcomes despite inclusion of more diverse trauma exposure samples. Findings indicate the need for future efficacy research to adopt more comprehensive reporting requirements and to test the applicability of validated treatments to individuals suffering from as yet unstudied combinations of PTSD and prevalent comorbid disorders.

Barlow DH. · Center for Anxiety and Related Disorders, Boston University, Boston, MA 02215-2013, USA. · Psychol Assess. · Pubmed #16262456 No free full text.

Abstract: A clear consensus has emerged around the world concerning the desirability and even the urgency of basing health care delivery systems on evidence. Among behavioral health care providers such as psychologists, evidence-based practice (EBP) has been focused largely on interventions. Psychologists have long emphasized a scientifically based psychometric approach to the development of assessment procedures. Nevertheless, the era of evidence-based assessment highlights 2 somewhat different issues. First, sophisticated assessment is closely integrated with our emerging conceptions of psychopathology, rather than standing separate from these conceptions. Second, broad-based ongoing outcomes assessment systems are increasingly required for EBP on the part of governments and health care policymakers. This article summarizes these developments and looks to the future.

Otto MW, Powers MB, Fischmann D. · Boston University Center for Anxiety and Related Disorders, 648 Beacon Street-Sixth Floor, Boston, MA 02215, USA. · Clin Psychol Rev. · Pubmed #15967554 No free full text.

Abstract: In this article, we review research on the nature and treatment of panic disorder, and apply these findings to a discussion of the role of internal cue exposure in the treatment of substance use disorders (SUDs). Two features of panic treatment were used as a model for interventions for SUDs: exposure to internal (interoceptive) cues rather than reliance on external (environmental) exposure alone, and use of cue exposure to try to inoculate individuals against future maladaptive patterns. Specifically, we emphasized the role of exposure to internal, largely emotional cues, as a way to enhance resilience to cues for relapse in individuals with SUDs. Hypothesized moderators and mediators of this treatment approach were discussed, as were similarities between this research agenda and an increasing focus on the role of emotional acceptance/tolerance in cognitive-behavioral treatments.

Meuret AE, Ritz T, Wilhelm FH, Roth WT. · Center for Anxiety and Related Disorders, Boston University, USA. · Clin Psychol Rev. · Pubmed #15792851 No free full text.

Abstract: Hyperventilation has numerous theoretical and empirical links to anxiety and panic. Voluntary hyperventilation (VH) tests have been applied experimentally to understand psychological and physiological mechanisms that produce and maintain anxiety, and therapeutically in the treatment of anxiety disorders. From the theoretical perspective of hyperventilation theories of anxiety, VH is useful diagnostically to the clinician and educationally to the patient. From the theoretical perspective of cognitive-behavior therapy, VH is a way to expose patients with panic disorder to sensations associated with panic and to activate catastrophic cognitions that need restructuring. Here we review panic disorder treatment studies using breathing training that have included VH. We differentiate the roles of VH in diagnosis, education about symptoms, training of breathing strategies, interoceptive exposure, and outcome measurement--discussing methodological issues specific to these roles and VH test reliability and validity. We propose how VH procedures might be standardized in future studies.

Otto MW, Bruce SE, Deckersbach T. · Department of Psychology and Center for Anxiety and Related Disorders, Boston University, Boston, MA 02215, USA. · J Clin Psychiatry. · Pubmed #15762818 No free full text.

Abstract: Cognitive-behavioral therapy (CBT) is effective in the treatment of anxiety disorders when used in conjunction with benzodiazepine pharmacotherapy and when used as a monotherapy. Patients using CBT alone have dropout rates similar to or lower than those patients undergoing other forms of therapy, including benzodiazepines. CBT also works well with patients who do not respond adequately to pharmacotherapy. Combined CBT and benzodiazepine treatment has additive effects when compared with benzodiazepine monotherapy; however, patients receiving combined therapy who subsequently discontinue benzodiazepine treatment experience a loss of efficacy compared with CBT and placebo, perhaps due to fear extinction being context dependent. To avoid this loss of efficacy, CBT may be administered alone or as a bridge between benzodiazepine use and discontinuation during a medication taper. The case report upon which this supplement is based questions the value of CBT for patients experiencing cognitive impairment due to an anxiety disorder, benzodiazepine medication, substance abuse, or a combination of these factors. This article addresses this concern and asserts that CBT is a valuable treatment option in these cases.

Brief DJ, Bollinger AR, Vielhauer MJ, Berger-Greenstein JA, Morgan EE, Brady SM, Buondonno LM, Keane TM, Anonymous00258. · Boston University School of Medicine, Boston, MA, USA. · AIDS Care. · Pubmed #15736824 No free full text.

Abstract: Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

Landon TM, Barlow DH. · Center for Anxiety and Related Disorders, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215, USA. · J Psychiatr Pract. · Pubmed #15552543 No free full text.

Abstract: Is cognitive behavioral treatment (CBT) appropriate for panic disorder with or without agoraphobia (PDA) in children, adolescents, and adults? Are its effects durable? In this review, we survey various psychological approaches to the treatment of PDA and examine the relative efficacy and clinical utility of each. A growing body of research demonstrates that CBT is well-tolerated, cost-effective, and produces substantial treatment gains for individuals with PDA over the short- and long-term. Nevertheless, not everyone benefits and there is room for improvement among those who do. We address these shortcomings and consider recent developments.