Anxiety Disorders: Harvard University

Allgulander C, Bandelow B, Hollander E, Montgomery SA, Nutt DJ, Okasha A, Pollack MH, Stein DJ, Swinson RP, Anonymous00175. · Department of Psychiatry, Harvard University School of Medicine, Boston, Massachusetts, USA. · CNS Spectr. · Pubmed #14767398 No free full text.

Abstract: What are the current recommendations for the long-term treatment of generalized anxiety disorder (GAD)? GAD is a common disorder with a lifetime prevalence of 4% to 7% in the general population. GAD is characterized by excessive, uncontrollable worry or anxiety about a number of events or activities that the individual experiences on more days than not over a 6-month period. Onset of GAD symptoms usually occurs during an individual's early twenties; however, high rates of GAD have also been seen in children and adolescents. The clinical course of GAD is often chronic, with 40% of patients reporting illness lasting >5 years. GAD is associated with pronounced functional impairment, resulting in decreased vocational function and reduced quality of life. Patients with GAD tend to be high users of outpatient medical care, which contributes significantly to healthcare costs. Currently, benzodiazepines and buspirone are prescribed frequently to treat GAD. Although both show efficacy in acute treatment trials, few long-term studies have been performed. Benzodiazepines are not recommended for long-term treatment of GAD, due to associated development of tolerance, psychomotor impairment, cognitive and memory changes, physical dependence, and a withdrawal reaction on discontinuation. The antidepressant venlafaxine extended-release (XR) has received approval for the treatment of GAD in the United States and many other countries. Venlafaxine XR has demonstrated efficacy over placebo in two randomized treatment trials of 6 months' duration as well as in other acute trials. Paroxetine is the first of the selective serotonin reuptake inhibitors (SSRIs) to receive US approval for the treatment of GAD. Paroxetine demonstrated superiority to placebo in short-term trials, and investigations into the use of other SSRIs are ongoing. This suggests that other SSRIs, and serotonin and noradrenaline reuptake inhibitors, are likely to be effective in the treatment of GAD. Of the psychological therapies, cognitive-behavioral therapy (CBT) shows the greatest benefit in treating GAD patients. Treatment gains after a 12-week course of CBT may be maintained for up to 1 year. Currently, no guidelines exist for the long-term treatment of GAD.

Nandi A, Beard JR, Galea S. · Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, USA. · BMC Psychiatry. · Pubmed #19486530 links to  free full text

Abstract: BACKGROUND: Clinical evidence has long suggested there may be heterogeneity in the patterns and predictors of common mood and anxiety disorders; however, epidemiologic studies have generally treated these outcomes as homogenous entities. The objective of this study was to systematically review the epidemiologic evidence for potential patterns of heterogeneity of common mood and anxiety disorders over the lifecourse in the general population. METHODS: We reviewed epidemiologic studies examining heterogeneity in either the nature of symptoms experienced ("symptom syndromes") or in patterns of symptoms over time ("symptom trajectories"). To be included, studies of syndromes were required to identify distinct symptom subtypes, and studies of trajectories were required to identify distinct longitudinal patterns of symptoms in at least three waves of follow-up. Studies based on clinical or patient populations were excluded. RESULTS: While research in this field is in its infancy, we found growing evidence that, not only can mood and anxiety disorders be differentiated by symptom syndromes and trajectories, but that the factors associated with these disorders may vary between these subtypes. Whether this reflects a causal pathway, where genetic or environmental factors influence the nature of the symptom or trajectory subtype experienced by an individual, or whether individuals with different subtypes differed in their susceptibility to different environmental factors, could not be determined. Few studies addressed issues of comorbidity or transitions in symptoms between common disorders. CONCLUSION: Understanding the diversity of these conditions may help us identify preventable factors that are only associated with some subtypes of these common disorders.

Gunderson JG. · McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA. · Am J Psychiatry. · Pubmed #19411380 No free full text.

Abstract: OBJECTIVE: The purpose of this article is to describe the development of the borderline personality disorder diagnosis, highlighting both the obstacles encountered and the associated achievements. METHOD: On the basis of a review of the literature, the author provides a chronological account of the borderline construct in psychiatry, summarizing progress in decade-long intervals. RESULTS: Borderline personality disorder has moved from being a psychoanalytic colloquialism for untreatable neurotics to becoming a valid diagnosis with significant heritability and with specific and effective psychotherapeutic treatments. Nonetheless, patients with this disorder pose a major public health problem while they themselves remain highly stigmatized and largely neglected. CONCLUSIONS: Despite remarkable changes in our knowledge about borderline personality disorder, increased awareness involving much more education and research is still needed. Psychiatric institutions, professional organizations, public policies, and reimbursement agencies need to prioritize this need.

Kubzansky LD, Koenen KC. · Department of Soci ety, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA. · Cleve Clin J Med. · Pubmed #19376986 links to  free full text

Abstract: It has long been hypothesized that posttraumatic stress disorder (PTSD) increases coronary heart disease (CHD) risk; however, empirical evidence is limited. In the first prospective study to date, individuals with higher PTSD symptom levels had a significantly increased risk for CHD, after controlling for known coronary risk factors. PTSD indicates a chronic stress reaction and is hypothesized to influence CHD either by causing biological alterations that lead to cardiovascular damage, or by leading to adverse health behaviors that increase CHD risk. A key issue is whether PTSD contributes to the development of CHD, if PTSD and CHD share common pathways, or if CHD causes PTSD. Research combined across different disciplines suggests that prolonged or chronic stress does influence the development of CHD. A better understanding of the relationship will increase prevention and intervention efforts. Cardiologists may be most effective when they can recognize and manage emotional distress in practice.

Pollack MH. · Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA. · J Clin Psychiatry. · Pubmed #19371505 No free full text.

Abstract: Generalized anxiety disorder (GAD) has a lifetime prevalence in the US population of about 5.7%. Typically, GAD begins in early adulthood and tends to have a chronic and persistent course. The disorder frequently presents comorbidly with other conditions, and about 90% of patients with GAD have at least 1 comorbid lifetime psychiatric disorder. Patients with GAD tend to be high users of medical services; the disorder is associated with significant physical as well as psychological symptomatology and impacts health, family relationships, and employment. Pharmacologic and psychosocial treatments are available for GAD. Different side effect profiles, speed of onset of action, and discontinuation requirements of individual drugs need to be taken into account when selecting treatment. Treatment selection should include consideration of comorbidity, psychological function, social impairment, and refractoriness, as well as the need for ongoing intervention for many individuals. Innovative treatments, including anticonvulsants, atypical antipsychotics, and others, as well as treatment targeting concomitant insomnia, may help improve outcomes for affected individuals.

Simon NM. · Massachusetts General Hospital, Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Simches 2200, 185 Cambridge St, Boston, MA 02114, USA. · J Clin Psychiatry. · Pubmed #19371501 No free full text.

Abstract: Generalized anxiety disorder (GAD) has a high rate of comorbidity with other psychiatric disorders, including major depressive disorder (MDD), bipolar disorder, other anxiety disorders, and substance use disorders. The similarities between GAD and MDD have led some to suggest that GAD should be reclassified as a mood disorder. The concurrence of GAD with another disorder heightens a patient's risk for impairment, disability, and suicidality. Clinical trials for GAD and disorders that are most likely to occur with GAD have generally not taken comorbidity into account, and there is a paucity of data guiding how comorbidity should inform treatment selection. Research into the biology and psychopathology underlying the high rate of comorbidity of GAD and into efficacious interventions for GAD with comorbidity is needed.

Joshi G, Wilens T. · Pervasive Developmental Disorders Program, Clinical and Research Programs in Pediatric Psychopharmacology, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street, Boston, MA 02114, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #19264265 No free full text.

Abstract: The growing literature shows the pervasiveness and importance of comorbidity in youth with bipolar disorder (BPD). For instance, up to 90% of youth with BPD have been described to manifest comorbidity with attention-deficit hyperactivity disorder. Multiple anxiety, substance use, and disruptive behavior disorders are the other most commonly reported comorbidities with BPD. Moreover, important recent data highlight the importance of obsessive-compulsive and pervasive developmental illness in the context of BPD. Data suggest that not only special developmental relationships are operant in the context of comorbidity but also that the presence of comorbid disorders with BPD results in a more severe clinical condition. Moreover, the presence of comorbidity has therapeutic implications for the treatment response for both BPD and the associated comorbid disorder. Future longitudinal studies to address the relationship and the impact of comorbid disorders on course and therapeutic response over time are required in youth with BPD.

Kessler RC, Keane TM, Ursano RJ, Mokdad A, Zaslavsky AM. · Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. · Int J Methods Psychiatr Res. · Pubmed #19035440 No free full text.

Abstract: Although needs assessment surveys are carried out after many large natural and man-made disasters, synthesis of findings across these surveys and disaster situations about patterns and correlates of need is hampered by inconsistencies in study designs and measures. Recognizing this problem, the US Substance Abuse and Mental Health Services Administration (SAMHSA) assembled a task force in 2004 to develop a model study design and interview schedule for use in post-disaster needs assessment surveys. The US National Institute of Mental Health subsequently approved a plan to establish a center to implement post-disaster mental health needs assessment surveys in the future using an integrated series of measures and designs of the sort proposed by the SAMHSA task force. A wide range of measurement, design, and analysis issues will arise in developing this center. Given that the least widely discussed of these issues concerns study design, the current report focuses on the most important sampling and design issues proposed for this center based on our experiences with the SAMHSA task force, subsequent Katrina surveys, and earlier work in other disaster situations.

Chosak A, Marques L, Greenberg JL, Jenike E, Dougherty DD, Wilhelm S. · OCD & Related Disorders Program, Simches Research Building, Massachusetts General Hospital, 185 Cambridge Street, Boston MA 02114, USA. · Expert Rev Neurother. · Pubmed #18671665 No free full text.

Abstract: Obsessive-compulsive disorder and body dysmorphic disorder have many similarities in clinical presentation. Obsessive-compulsive disorder has historically been considered an anxiety disorder, whereas body dysmorphic disorder has been grouped among the somatoform disorders. Researchers in these areas are currently debating whether the similarities warrant the inclusion of body dysmorphic disorder within a proposed category of obsessive-compulsive spectrum disorders. This article describes the association between obsessive-compulsive disorder and body dysmorphic disorder as evidenced by the emerging literature, and presents theoretical and clinical implications of this association.

Lu W, Dean-Clower E, Doherty-Gilman A, Rosenthal DS. · Harvard Medical School, Boston, MA, USA. · Hematol Oncol Clin North Am. · Pubmed #18638692 links to  free full text

Abstract: Clinical research on acupuncture in cancer care is a new and challenging field in oncology. The results of clinical research will continue to provide clinically relevant answers for patients and oncologists. The evidence currently available has suggested that acupuncture is a safe and effective therapy to manage cancer and treatment related symptoms, while giving patients the ability to actively participate in their own care plan. The article explains the potential benefits of acupuncture and describes the difficulties in studying its effectiveness.

Betancourt TS, Khan KT. · Harvard School of Public Health, Cambridge, MA 02115, USA. · Int Rev Psychiatry. · Pubmed #18569183 links to  free full text

Abstract: This paper examines the concept of resilience in the context of children affected by armed conflict. Resilience has been frequently viewed as a unique quality of certain 'invulnerable' children. In contrast, this paper argues that a number of protective processes contribute to resilient mental health outcomes in children when considered through the lens of the child's social ecology. While available research has made important contributions to understanding risk factors for negative mental health consequences of war-related violence and loss, the focus on trauma alone has resulted in inadequate attention to factors associated with resilient mental health outcomes. This paper presents key studies in the literature that address the interplay between risk and protective processes in the mental health of war-affected children from an ecological, developmental perspective. It suggests that further research on war-affected children should pay particular attention to coping and meaning making at the individual level; the role of attachment relationships, caregiver health, resources and connection in the family, and social support available in peer and extended social networks. Cultural and community influences such as attitudes towards mental health and healing as well as the meaning given to the experience of war itself are also important aspects of the larger social ecology.

Salvatore P, Bhuvaneswar C, Ebert D, Maggini C, Baldessarini RJ. · Department of Psychiatry, Harvard Medical School, Massachusetts, USA. · Harv Rev Psychiatry. · Pubmed #18569038 No free full text.

Abstract: Emil Kraepelin proposed to separate psychiatric disorders with psychotic features into two major categories, dementia praecox (later schizophrenia) and manic-depressive insanity (later bipolar disorder and major depression). Over the past century, there have been many efforts to categorize conditions that do not fit readily in either group. These conditions include many cases of acute psychotic illnesses of limited duration, with recovery between recurrences. For some of these conditions, Karl Kleist proposed the term cycloid psychosis: acute features were psychotic, as in schizophrenia, but the course was episodic, as in manic-depression. His concept was later elaborated by Karl Leonhard and Carlo Perris, and validated by modern studies. Leonhard described three overlapping cycloid subtypes (anxiety-beatific, excited-inhibited confusional, and hyperkinetic-akinetic motility dysfunction forms); Perris proposed a more unitary syndrome with operational diagnostic criteria; and recent investigators have considered relatively affective versus thought-disordered subtypes. The cycloid concept is not explicitly included in standard international diagnostic schemes, but both DSM-IV and ICD-10 have broad categories for acute, recurrent psychotic disorders, whose validity remains insecure. We present two cases of probable cycloid psychosis, review the history of the concept, and propose that it be reconsidered as a clinically useful category whose validity and utility for prognosis and treatment can be further tested.

McNally RJ. · Department of Psychology, Harvard University, Cambridge, MA 02138, USA. · Cogn Behav Ther. · Pubmed #18470743 No free full text.

Abstract: The articles in this special series reflect productive cross-fertilization between the fields of panic disorder and posttraumatic stress disorder. The purpose of this commentary is to elucidate the implications of this research for the broader themes of culture, risk factors, and treatment.

Smoller JW, Gardner-Schuster E, Covino J. · Harvard Medical School, Psychiatric Genetics Program in Mood and Anxiety Disorders, Massachusetts General Hospital, Boston, MA, USA. · Am J Med Genet C Semin Med Genet. · Pubmed #18412108 No free full text.

Abstract: Panic disorder and phobic anxiety disorders are common disorders that are often chronic and disabling. Genetic epidemiologic studies have documented that these disorders are familial and moderately heritable. Linkage studies have implicated several chromosomal regions that may harbor susceptibility genes; however, candidate gene association studies have not established a role for any specific loci to date. Increasing evidence from family and genetic studies suggests that genes underlying these disorders overlap and transcend diagnostic boundaries. Heritable forms of anxious temperament, anxiety-related personality traits and neuroimaging assays of fear circuitry may represent intermediate phenotypes that predispose to panic and phobic disorders. The identification of specific susceptibility variants will likely require much larger sample sizes and the integration of insights from genetic analyses of animal models and intermediate phenotypes.

Pauls DL. · Harvard Medical School, Psychiatric and Neurodevelopmental Genetics Unit in Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA. · Am J Med Genet C Semin Med Genet. · Pubmed #18412099 No free full text.

Abstract: Obsessive compulsive disorder (OCD) is a common psychiatric disorder that can have disabling effects on both adults and children. Twin, family, segregation, and linkage studies have demonstrated that OCD is familial, that the familiality is due in part to genetic factors and there are regions of the genome which very likely harbor susceptibility loci for OCD. Over 60 candidate gene studies have been conducted. Most studies have focused on genes in the serotonergic and dopaminergic pathways. Unfortunately, none have achieved genome-wide significance and with the exception of the glutamate transporter gene, none have been reliably replicated. Future research will requite much larger samples and the collaboration of researchers to be able to identify susceptibility loci for OCD.

Kessler RC, Wang PS. · Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA. · Annu Rev Public Health. · Pubmed #18348707 No free full text.

Abstract: Data are reviewed on the descriptive epidemiology of commonly occurring DSM-IV mental disorders in the United States. These disorders are highly prevalent: Roughly half the population meets criteria for one or more such disorders in their lifetimes, and roughly one fourth of the population meets criteria in any given year. Most people with a history of mental disorder had first onsets in childhood or adolescence. Later onsets typically involve comorbid disorders. Some anxiety disorders (phobias, separation anxiety disorder) and impulse-control disorders have the earliest age of onset distributions. Other anxiety disorders (panic disorder, generalized anxiety disorder, post-traumatic stress disorder), mood disorders, and substance disorders typically have later ages of onset. Given that most seriously impairing and persistent adult mental disorders are associated with child-adolescent onsets and high comorbidity, increased efforts are needed to study the public health implications of early detection and treatment of initially mild and currently largely untreated child-adolescent disorders.

Koenen KC, Nugent NR, Amstadter AB. · Department of Society, Human Development, and Health and Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA. · Eur Arch Psychiatry Clin Neurosci. · Pubmed #18297420 No free full text.

Abstract: The purpose of this article is to encourage research investigating the role of measured gene-environment interaction (G x E) in the etiology of posttraumatic stress disorder (PTSD). PTSD is uniquely suited to the study of G x E as the diagnosis requires exposure to a potentially-traumatic life event. PTSD is also moderately heritable; however, the role of genetic factors in PTSD etiology has been largely neglected both by trauma researchers and psychiatric geneticists. First, we summarize evidence for genetic influences on PTSD from family, twin, and molecular genetic studies. Second, we discuss the key challenges in G x E studies of PTSD and offer practical strategies for addressing these challenges and for discovering replicable G x E for PTSD. Finally, we propose some promising new directions for PTSD G x E research. We suggest that G x E research in PTSD is essential to understanding vulnerability and resilience following exposure to a traumatic event.

Licata SC, Rowlett JK. · McLean Hospital/Harvard Medical School, Behavioral Psychopharmacology Research Laboratory, 115 Mill Street, Belmont, MA 02478, United States. · Pharmacol Biochem Behav. · Pubmed #18295321 links to  free full text

Abstract: Over the past several decades, benzodiazepines and the newer non-benzodiazepines have become the anxiolytic/hypnotics of choice over the more readily abused barbiturates. While all drugs from this class act at the GABA(A) receptor, benzodiazepine-type drugs offer the clear advantage of being safer and better tolerated. However, there is still potential for these drugs to be abused, and significant evidence exists to suggest that this is a growing problem. This review examines the behavioral determinants of the abuse and dependence liability of benzodiazepine-type drugs. Moreover, the pharmacological and putative biochemical basis of the abuse-related behavior is discussed.

Koenen KC. · Department of Society, Human Development, and Health and Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA. · J Trauma Stress. · Pubmed #17955543 No free full text.

Abstract: Posttraumatic stress disorder (PTSD) is common and debilitating. Posttraumatic stress disorder is moderately heritable; however, the role of genetic factors in PTSD etiology has been largely neglected by trauma researchers. The goal of this study is to motivate trauma researchers to reflect on the role genetic variation may play in vulnerability and resilience following trauma exposure. Evidence from family, twin, and molecular genetic studies for genetic influences on PTSD is reviewed. Recommendations for future studies are presented with emphasis on study design and assessment issues particular to the field of trauma and PTSD. Clinical implications of PTSD genetic studies are discussed.

King F, Steinmann WC. · Department of Continuing Education, Harvard University, Cambridge, MA, and University of Missouri, Columbia, MO 65212, USA. · South Med J. · Pubmed #17943042 No free full text.

Abstract: BACKGROUND: More than one year after Hurricane Katrina, victims exhibit symptoms of a "chronic disease," representing the disruption of psychosocial health. This systematic review assesses the effects of trauma on multiple domains of health following a disaster. METHOD: Authors searched disaster-related literature from 1971 to present, focusing on recent literature involving Hurricane Andrew and outcomes in nonphysical domains of health. Research relied mainly on PubMed, using keywords including "disaster," "hurricane," "psychosocial," "social," and "stress." RESULTS: Disaster victims are at risk for negative psychosocial health. Pre-Katrina, the majority of storm victims already exhibited several risk factors that made them candidates for low levels of health. CONCLUSIONS: Individuals affected by Hurricane Katrina, both those remaining in the Gulf Coast and evacuees, are at significant risk for low levels of psychosocial health. To prevent long-term health deficits in the region, a concerted effort of research and healthcare initiatives is needed as soon as possible.

Miovic M, Block S. · Division of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School Center for Palliative Care, Boston, Massachusetts 02115, USA. · Cancer. · Pubmed #17847017 links to  free full text

Abstract: BACKGROUND: Emotional distress and psychiatric disorders are common among patients with advanced cancer. Oncologists play an important role in screening for these conditions, providing first-line treatment and referring patients for further evaluation and treatment when indicated. METHODS: The literature on psycho-oncology was reviewed, focusing on the epidemiology, assessment, and treatment of psychiatric disorders (adjustment disorders, major depression, anxiety and post-traumatic stress, personality disorders, substance abuse, and major mental disorders such as schizophrenia and bipolar disorder) in patients with advanced cancer. Communication skills and the role of the oncologist in dealing with end-of-life issues were also reviewed. Relevant data were summarized from the most recent systematic reviews, epidemiological studies, and intervention trials. Clinical recommendations are provided. RESULTS: About 50% of patients with advanced cancer meet criteria for a psychiatric disorder, the most common being adjustment disorders (11%-35%) and major depression (5%-26%). Both psychosocial and pharmacological treatments are effective for anxiety and depression, although existing studies have methodological limitations. Collaboration with mental health specialists is recommended for patients with personality disorders, major mental illness, and substance abuse problems. Effective communication involves active listening, exploring emotion and meaning, addressing prognosis, and discussing end-of-life issues when relevant. CONCLUSIONS: Treating psychiatric conditions improves quality of life in patients with advanced cancer. Oncologists play a key role in screening for psychiatric disorders, initiating first-line treatments for depression and anxiety, and communicating with patients and caregivers about prognosis and end-of-life issues.

Schmahmann JD, Weilburg JB, Sherman JC. · Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA. · Cerebellum. · Pubmed #17786822 No free full text.

Abstract: A central aspect of the cerebellar cognitive affective syndrome is the dysregulation of affect that occurs when lesions involve the 'limbic cerebellum' (vermis and fastigial nucleus). In this case series we describe neuropsychiatric disturbances in adults and children with congenital lesions including cerebellar agenesis, dysplasia, and hypoplasia, and acquired conditions including cerebellar stroke, tumor, cerebellitis, trauma, and neurodegenerative disorders. The behaviors that we witnessed and that were described by patients and families included distractibility and hyperactivity, impulsiveness, disinhibition, anxiety, ritualistic and stereotypical behaviors, illogical thought and lack of empathy, as well as aggression and irritability. Ruminative and obsessive behaviors, dysphoria and depression, tactile defensiveness and sensory overload, apathy, childlike behavior, and inability to appreciate social boundaries and assign ulterior motives were also evident. We grouped these disparate neurobehavioral profiles into five major domains, characterized broadly as disorders of attentional control, emotional control, and social skill set as well as autism spectrum disorders, and psychosis spectrum disorders. Drawing on our dysmetria of thought hypothesis, we conceptualized the symptom complexes within each putative domain as reflecting either exaggeration (overshoot, hypermetria) or diminution (hypotonia, or hypometria) of responses to the internal or external environment. Some patients fluctuated between these two states. We consider the implications of these neurobehavioral observations for the care of patients with ataxia, discuss the broader role of the cerebellum in the pathogenesis of these neuropsychiatric symptoms, and revisit the possibility of using cerebellar stimulation to treat psychiatric disorders by enhancing cerebellar modulation of cognition and emotion.

Burstein HJ. · Dana-Farber Cancer Institute, Harvard Medical School, 44 Binney Street, Boston, MA 02115, USA. · Breast. · Pubmed #17719225 No free full text.

Abstract: Symptoms associated with cognitive dysfunction-difficulties with memory, concentration, and language-are frequent among breast cancer survivors after chemotherapy. The true incidence, functional significance, and causes of these symptoms remain unclear. Models of cognitive dysfunction suggest multiple possible contributors including changes in hormonal milieu, direct effects of chemotherapy, medications given as supportive care, psychiatric changes including depression and anxiety, and mediators of inflammation. Novel neuro-cognitive testing and imaging methods are being evaluated in breast cancer survivors to better understand cognitive side-effects of therapy.

Milad MR, Rauch SL. · Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA 02129, USA. · Ann N Y Acad Sci. · Pubmed #17698998 No free full text.

Abstract: Advances in neuroimaging techniques over the past two decades have allowed scientists to investigate the neurocircuitry of anxiety disorders. Such research has implicated the orbitofrontal cortex (OFC). Characterizing the role of OFC in anxiety disorders, however, is principally complicated by two factors-differences in underlying pathophysiology across the anxiety disorders and heterogeneity in function across different OFC sub-territories. Contemporary neurocircuitry models of anxiety disorders have primarily focused on amygdalo-cortical interactions. The amygdala is implicated in generating fear responses, whereas cortical regions, specifically the medial OFC (mOFC) and the ventromedial prefrontal cortex (vmPFC), are implicated in fear extinction. In contrast to mOFC, anterolateral OFC (lOFC) has been associated with negative affects and obsessions and thus dysfunctional lOFC may underlie different aspects of certain anxiety disorders. Herein, we aim to review the above-mentioned theories and provide a heuristic model for conceptualizing the respective roles of mOFC and lOFC in the pathophysiology and treatment of anxiety disorders. We will also review the role of the OFC in fear extinction and the implications of this role to the pathophysiology of anxiety disorders.

Flory N, Salazar GM, Lang EV. · Department of Radiology, Beth Israel Deaconess Medical Center - Harvard Medical School, Boston, Massachusetts 02215, USA. · Int J Clin Exp Hypn. · Pubmed #17558720 No free full text.

Abstract: The use of hypnosis during medical procedures has a long-standing tradition but has been struggling for acceptance into the mainstream. In recent years, several randomized-controlled trials with sufficient participant numbers have demonstrated the efficacy of hypnosis in the perioperative domain. With the advancements of minimally invasive high-tech procedures during which the patient remains conscious, hypnotic adjuncts have found many applications. This article describes the procedural environment as well as pharmacologic and nonpharmacologic interventions to reduce distress. Current research findings, controversies in the literature, and safety considerations are reviewed. Implications for clinical practice and training as well as directions for future research are discussed. Obstacles and possible reasons for the slow acceptance of nonpharmacologic interventions, mind-body therapies, and patient-centered approaches are addressed.