Perceived health status and perceived diabetes control: psychological indicators and accuracy

OBJECTIVE: The aim of this study is to assess the association of psychological, as well as physical and sociodemographic, indicators with patients' ratings of personal health status and diabetes control and to investigate the association of mental health and depression with errors in the perception of diabetes control. METHOD: A sociodemographically diverse sample of 623 diabetes patients was recruited from the general medicine clinics of a county health care system and a Veterans Affairs health care system. We examined three types of determinants of patients' health perceptions: physical health indicators (symptoms, comorbid diagnoses, and glycosylated hemoglobin or HbA1c levels), psychological health indicators (general mental health and diabetes-related worry), and sociodemographic factors (age, race, gender, income, and education). RESULTS: After controlling for patient' sociodemographic characteristics, perceived general health was associated with patients' symptom burden and emotional distress (but not with patients' HbA1c levels). Perceived diabetes control additionally was associated with HbA1c and diabetes-related worries. Further analyses showed that both mental health and diagnosed depression were associated with errors in personal appraisals of diabetes control, with depressed patients more often inaccurately assessing their glycemic control as poor (false-positive error) and nondepressed patients more often missing poor HbA1c levels (false-negative error). CONCLUSIONS: Findings indicate that patients use a comprehensive model for assessing their general health and that depression may lead to more accurate assessments of poor glucose control.     

Sex differences,responses sets and response biases in fear assessment

Sex differences and response bias in assessment of fears were investigated in two studies. Both used a fear survey schedule, with the first employing normal instructions plus instructional sets of “best impression” (“create the most favorable impression you can”) and “worst impression” (simulate psychiatric illness) with 60 female and 60 male college students in a 2 x 3 design. Both generalized and extreme (phobic) fear scores were obtained. Both fear scores showed significant increases in the “sick” simulation. These results were compared to fear ratings by (“real”) psychiatric patients. The students “sick” simulation bore little resemblance to the fears of the patients; the greatest similarity was found between students' normal fears and the patients' fears! The second study examined opposite-sex simulations in 2 x 2 design with 46 female and 46 male college students. Females had significantly greater generalized and extreme fear scores. The males' simulations most closely reflected this reality. Multidimensional scaling of the results from both experiments, as well as other available data, was reported. It was concluded that the aproach used here to investigate sex effects on the perception of fears might well be extended to other situations, e.g. marriage.     

Quality of life measurements in patients with Parkinson's disease: A community-based study

The objective of this paper is to evaluate the health-related quality of life in a community-based population of patients with Parkinson's disease (PD). The PD population consisted of 233 patients and was derived from a wider prevalence study in the county of Rogaland, Norway. The quality of life was measured by the Nottingham Health Profile (NHP) and four general health and well-being questions. The results were compared with quality of life measurements in 100 patients with diabetes mellitus (DM) and 100 healthy elderly people. The control groups had the same age and sex distribution as the patients with PD. This study showed that PD has a substantial impact on the health-related quality of life. Patients with PD had higher distress scores in all measured dimensions of the NHP than the two control groups. The negative impact of PD was highest for physical mobility, emotional reactions, social isolation and energy. Correlation analysis of the quality of life showed that age, duration of levodopa therapy, higher levodopa doses, depression, cognitive impairment and more advanced disease correlated with higher distress scores in patients with PD. The results of this study showed that PD had a broad impact on well-being, more so than DM. The distress related to the severity of the disease, as well as to depressive symptoms and cognitive impairment. An important finding was the underestimated distress related to lack of energy.     

Fear of cognitive dyscontrol in relation to depression symptoms: comparisons between original and alternative measures of anxiety sensitivity

Previous research has found that a facet of anxiety sensitivity (AS), referred to as fear of cognitive dyscontrol or fear of mental incapacitation, is associated with severity of depressed mood. Other research has extended the “fear of fear” concept to include fear of losing control over emotion in general (including depression). Because anxiety and depression share the common feature of general distress (Clark & Watson, 1991. Journal of Abnormal Psychology, 93, 19–30), the present study took a conservative approach and statistically controlled for the effect of trait anxiety and negative affectivity before contributions of AS to depression were examined. In a large college student sample (N=348), facets of the original and alternative measures of AS were evaluated in attempts to predict severity of depression symptoms. Fear of cognitive dyscontrol facets from both measures of AS were significant predictors in the regression analyses. A new set of items reflective of control over emotions was also significant and both cognitive and emotional control added to the prediction of depression symptoms in a complementary fashion. Implications of these findings for identifying a proposed “depression sensitivity” are discussed.     

Cotinine enhances the extinction of contextual fear memory and reduces anxiety after fear conditioning

Posttraumatic stress disorder (PTSD) is an anxiety disorder triggered by traumatic events. Symptoms include anxiety, depression and deficits in fear memory extinction (FE). PTSD patients show a higher prevalence of cigarette smoking than the general population. The present study investigated the effects of cotinine, a tobacco-derived compound, over anxiety and contextual fear memory after fear conditioning (FC) in mice, a model for inducing PTSD-like symptoms. Two-month-old C57BL/6J mice were separated into three experimental groups. These groups were used to investigate the effect of pretreatment with cotinine on contextual fear memory and posttreatment on extinction and stability or retrievability of the fear memory. Also, changes induced by cotinine on the expression of extracellular signal-regulated kinase (ERK)1/2 were assessed after extinction in the hippocampus. An increase in anxiety and corticosterone levels were found after fear conditioning. Cotinine did not affect corticosterone levels but enhanced the extinction of contextual fear, decreased anxiety and the stability and/or retrievability of contextual fear memory. Cotinine-treated mice showed higher levels of the active forms of ERK1/2 than vehicle-treated mice after FC. This evidence suggests that cotinine is a potential new pharmacological treatment to reduce symptoms in individuals with PTSD.     

A twin study of the genetics of fear conditioning

BACKGROUND: Fear conditioning is a traditional model for the acquisition of fears and phobias. Studies of the genetic architecture of fear conditioning may inform gene-finding strategies for anxiety disorders. The objective of this study was to determine the genetic and environmental sources of individual differences in fear conditioning by means of a twin sample. METHODS: Classic fear conditioning data were experimentally obtained from 173 same-sex twin pairs (90 monozygotic and 83 dizygotic). Sequences of evolutionary fear-relevant (snakes and spiders) and fear-irrelevant (circles and triangles) pictorial stimuli served as conditioned stimuli paired with a mild electric shock serving as the unconditioned stimulus. The outcome measure was the electrodermal skin conductance response. We applied structural equation modeling methods to the 3 conditioning phases of habituation, acquisition, and extinction to determine the extent to which genetic and environmental factors underlie individual variation in associative and nonassociative learning. RESULTS: All components of the fear conditioning process in humans demonstrated moderate heritability, in the range of 35% to 45%. Best-fitting multivariate models suggest that 2 sets of genes may underlie the trait of fear conditioning: one that most strongly affects nonassociative processes of habituation that also is shared with acquisition and extinction, and a second that appears related to associative fear conditioning processes. In addition, these data provide tentative evidence of differences in heritability based on the fear relevance of the stimuli. CONCLUSION: Genes represent a significant source of individual variation in the habituation, acquisition, and extinction of fears, and genetic effects specific to fear conditioning are involved.     

An experimental demonstration that fear, but not disgust, is associated with return of fear in phobias

It has been suggested that disgust, rather than anxiety, may be important in some phobias. Correlational studies have been ambiguous, indicating either that disgust increases phobic anxiety or that phobic anxiety potentiates disgust. In the experimental study reported here, disgust and phobic anxiety were manipulated in the context of habituation to phobic stimuli. Spider fearful participants were randomly allocated to conditions in which neutral, disgusting, and phobic anxiety provoking stimuli were introduced into a video-based spider phobic habituation sequence. Exposure to the phobic stimulus resulted in a return of self-reported fear and disgust levels. However, exposure to disgusting stimulus increased disgust levels, but not anxiety levels. Results are most consistent with the hypothesis that fear enhances the disgust response in phobias, but that disgust alone does not enhance the fear response. Previously observed links between disgust and spider phobia may be a consequence of fear enhancing disgust.     

Learning and unlearning fear: A clinical and evolutionary perspective

Many fears, phobias and rituals seem to arise from prepared phylogenetic mechanisms which favor old over new evolutionary dangers and affect the rules of aversive learning which govern the acquisition of fear. Recent developments in several forms of aversive learning (sensitization, conditioning, extinction, observational learning) can improve them as paradigms of the acquisition, spread and maintenance of normal and clinical fears. The most reliable treatment for phobias and rituals is exposure, whose effects closely parallel the habituation of normal defensive responses and the extinction of conditioned fear and avoidance in animals. Habituation during exposure is usually slow and step by step, and generalizes little, but once attained tends to endure. Conditioned fear extinction and fear habituation have similar courses and may depend on similar neural processes. To be reduced, avoidance has to be prevented or the safety intervals that it heralds must be given up. Some phobias may result less from enhanced acquisition than from insufficient exposure to attain habituation. Finally, the review discusses the limits of habituation and the instability of fear extinction in relation to the long-term efficacy of exposure therapy.     

NMDA receptors and fear extinction: implications for cognitive behavioral therapy

Based primarily on studies that employ Pavlovian fear conditioning, extinction of conditioned fear has been found to be mediated by N-methyi-D-aspartate (NMDA) receptors in the amygdala and medial prefrontal cortex. This led to the discovery that an NMDA partial agonist, D-cycloserine, could facilitate fear extinction when given systemically or locally into the amygdala. Because many forms of cognitive behavioral therapy depend on fear extinction, this led to the successful use of D-cycloserine as an adjunct to psychotherapy in patients with so-called simple phobias (fear of heights), social phobia, obsessive-compulsive behavior, and panic disorder. Data in support of these conclusions are reviewed, along with some of the possible limitations of D-cycloserine as an adjunct to psychotherapy.     

Depression,Anxiety, Anger,and Somatic Symptoms in Patients with Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a relatively common and impairing disorder. However, little is known about non-BDD symptoms and well-being in patients with this disorder. Seventy-five outpatients with DSM-IV BDD completed the Symptom Questionnaire, a validated self-report measure with four scales: depression, anxiety, somatic/somatization, and anger-hostility. Scores were compared to published norms for normal subjects and psychiatric outpatients. Participants in an open-label fluvoxamine trial completed the Symptom Questionnaire at baseline and endpoint. Compared to normal controls, BDD subjects had markedly elevated scores on all four scales, indicating severe distress and psychopathology. Compared to psychiatric patients, BDD subjects had higher scores on the depression, anxiety, and anger/hostility scales but not on the somatic/somatization scale. Scores on all scales significantly decreased with fluvoxamine. In conclusion, patients with BDD have markedly high levels of distress, are highly symptomatic, and have poor well-being in the domains of depression, anxiety, somatic symptoms, and anger-hostility. All of these symptoms significantly improved with fluvoxamine.     

Coping as an index of illness behavior in panic disorder

Illness behavior in panic disorder was examined by comparing the coping strategies of female primary care patients (34 with panic disorder, 30 with simple panic, and 78 without panic.) Relationships of coping and distress were also examined within each group. The groups differed significantly on the Ways of Coping Checklist, anxiety (SCL-90 and Zung scales), depression (SCL-90 and Beck scales), and number of phobias. The panic disorder group used proportionately less problem-focused and more wishful thinking than the other groups. Within the panic disorder group, anxiety and depression were correlated negatively with problem-focused coping and positively with wishful thinking, and number of phobias was correlated negatively with the seeking of social support and positively with wishful thinking. Most importantly, when an attempt was made to statistically separate panic patients with multiple phobias from those without multiple phobias, coping was a better marker than was distress. These results emphasize the importance of cognitions in illness behavior and anxiety disorder.     

Sleep in children with type 1 diabetes and their parents in the T1D Exchange

ObjectivesSleep has physiological and behavioral impacts on diabetes outcomes, yet little is known about the impact of sleep disturbances in children with type 1 diabetes. The current study sought to characterize sleep in children with type 1 diabetes and in their parents and to examine the associations between child sleep, glycemic control and adherence, parent sleep and well-being, parental fear of hypoglycemia, and nocturnal caregiving behavior.MethodsSurveys were emailed to parents of 2- to 12-year-old participants in the Type 1 Diabetes (T1D) Exchange clinic registry. Clinical data were obtained from the registry for the 515 respondents.ResultsIn our sample, 67% of children met criteria for poor sleep quality. Child sleep quality was related to glycemic control (HbA1c of 7.9% [63 mmol/mol] in children with poor sleep quality vs 7.6% [60 mmol/mol] in children with non-poor sleep quality; P < 0.001) but not mean frequency of blood glucose monitoring (BGM) (7.6 times/day vs 7.4 in poor/non-poor quality; P = 0.56). Associations were similar for sleep duration. Children with poor sleep quality were more likely to experience severe hypoglycemia (4% in children with poor sleep quality vs 1% in children with non-poor sleep quality; P = 0.05) and more likely to experience DKA (7% vs 4%, respectively; P < 0.001). Poorer child sleep quality was associated with poorer parental sleep quality, parental well-being, and fear of hypoglycemia (P < 0.001 for all). Child sleep was not related to the use of diabetes-related technology (CGM, insulin pump).ConclusionsSleep may be a modifiable factor to improve glycemic control and reduce parental distress.     

Neural biases to covert and overt signals of fear: dissociation by trait anxiety and depression

Although biases toward signals of fear may be an evolutionary adaptation necessary for survival, heightened biases may be maladaptive and associated with anxiety or depression. In this study, event-related potentials (ERPs) were used to examine the time course of neural responses to facial fear stimuli (versus neutral) presented overtly (for 500 msec with conscious attention) and covertly (for 10 msec with immediate masking to preclude conscious awareness) in 257 nonclinical subjects. We also examined the impact of trait anxiety and depression, assessed using psychometric ratings, on the time course of ERPs. In the total subject group, controlled biases to overtly processed fear were reflected in an enhancement of ERPs associated with structural encoding (120-220 msec) and sustained evaluation persisting from 250 msec and beyond, following a temporo-occipital to frontal topography. By contrast, covert fear processing elicited automatic biases, reflected in an enhancement of ERPs prior to structural encoding (80-180 msec) and again in the period associated with automatic orienting and emotion encoding (230-330 msec), which followed the reverse frontal to temporo-occipital topography. Higher levels of trait anxiety (in the clinical range) were distinguished by a heightened bias to covert fear (speeding of early ERPs), compared to higher depression which was associated with an opposing bias to overt fear (slowing of later ERPs). Anxiety also heightened early responses to covert fear, and depression to overt fear, with subsequent deficits in emotion encoding in each case. These findings are consistent with neural biases to signals of fear which operate automatically and during controlled processing, feasibly supported by parallel networks. Heightened automatic biases in anxiety may contribute to a cycle of hypervigilance and anxious thoughts, whereas depression may represent a "burnt out" emotional state in which evaluation of fear stimuli is prolonged only when conscious attention is allocated.     

Normalization of enhanced fear recognition by acute SSRI treatment in subjects with a previous history of depression

OBJECTIVE: The present study aimed to 1) assess facial expression recognition in subjects with a previous history of major depressive disorder relative to subjects with no history of depression and 2) characterize the effects of acute citalopram infusion on recognition performance for both groups. METHOD: Unmedicated euthymic women with a history of major depression and matched comparison subjects with no history of depression were given a facial expression recognition task following intravenous infusion of saline or citalopram (10 mg) in a double-blind, between-group design. RESULTS: Following saline infusion, subjects with a previous history of depression showed a selectively greater recognition of fear relative to the subjects with no history of depression. The abnormal fear processing observed in the subjects with a previous history of depression was normalized following citalopram infusion, an effect that was opposite to that seen with the subjects with no history of depression. CONCLUSIONS: These results suggest that increased recognition of fear is a trait vulnerability marker for depression and that this is normalized following a single dose of citalopram.     

Analysis of behavioral constraints and the neuroanatomy of fear to the predator odor trimethylthiazoline: a model for animal phobias

Specific phobias, including animal phobias, are the most common anxiety disorders, and have a strong innate and genetic component. Research on the neurobiology and environmental constraints of innate fear of predators in rodents may be useful in elucidating mechanisms of animal phobias in humans. The present article reviews research on innate fear in rats to trimethylthiazoline (TMT), an odor originally isolated from fox feces. TMT induces unconditioned freezing and other defensive responses that are regulated by the dose of TMT and the shape of the testing environment. Contextual conditioning induced by TMT occurs, but is constrained by the environment. Lesion studies indicate the amygdala circuitry subserving fear conditioning is not necessary for unconditioned fear to TMT. Additionally, a medial hypothalamic defensive circuit also appears not necessary for unconditioned freezing to TMT, whereas circuits that include the medial nucleus of the amygdala and the bed nucleus of the stria terminalis are essential. The importance of these findings of innate predator odor fear in rodents to animal phobias in humans is discussed.     

The relationship between agoraphobia, social phobia and blood-injury phobia in phobic and anxious-depressed patients

This paper reports the results of principal components and stepwise discriminant analyses of anxiety, depression and fear scores for 74 phobic and anxious-depressed psychiatric patients. Factor analysis indicated a coherent agoraphobia factor, with less coherent blood-injury and social phobia factors. Discriminant analysis showed a high degree of correct classification of diagnosed agoraphobic, blood-injury and social phobic patients particularly for agoraphobia. A frequency distribution of the phobia scores indicated an all or nothing quality to agoraphobic fears. The results indicate that agoraphobia is a fairly coherent syndrome, but that more work is needed on the concepts and measurement of blood-injury and social phobias.     

Psychological functioning in a cohort of gay men at risk for AIDS. A three-year descriptive study

This study describes the mental health of a large cohort of gay men participating in the Chicago Multicenter AIDS Cohort Study/Coping and Change Study. Six biannual questionnaires were self-administered between 1984 and 1988. General mental health was determined by the Hopkins Symptom Checklist (HSCL). An abbreviated version of the Center for Epidemiologic Study Depression Scale (CESD-5) and an adapted Diagnostic Interview Schedule (DIS) question also measured depression. Suicidal ideation was assessed by one question in the HSCL. AIDS-specific distress was determined by three subscales specifically developed for this study. While mean HSCL and CESD-5 scores were stable during the observational period, AIDS-specific distress increased over time. The HSCL scores for the cohort were somewhat elevated above general population norms but considerably below psychiatric outpatient norms. Fewer than 12% of the men reported elevated HSCL or CESD-5 scores three or more times. A self-reported episode of depression of two weeks or more, measured by the DIS screening question, was experienced by 40.1% of the sample. Suicidal ideation was reported on three or more visits by 18.8% of the men. The younger members of this cohort exhibit greater general and AIDS-specific distress. Income was inversely associated with general distress. HIV-seropositive participants had generally higher AIDS-specific distress scores than those who were seronegative, but their scores were equivalent on the HSCL and CESD-5.     

Comorbidity of ictal fear and panic disorder

Purpose. We sought to determine the prevalence of psychiatric conditions, particularly panic disorder, in epilepsy patients with ictal fear.Methods. A consecutive series of 12 patients with ictal fear underwent psychiatric evaluation, via either formal consultation with a psychiatrist or standardized interview using the Mini International Neuropsychiatric Interview; the latter was addended to create an instrument specifically for use in epilepsy patients (MINI-Epi).Results. Four of the twelve patients (33%) with ictal fear had a comorbid diagnosis of panic disorder. One of these developed panic attacks only after epilepsy surgery, and another worsened after surgery, while in the other two panic attacks were not related to any surgical procedure. Two patients had other anxiety disorders. Eight patients (67%) had current or past depression; this did not appear to be related to the presence of panic disorder.Conclusion. A specific comorbidity exists between focal epilepsy with ictal fear and panic disorder. Involvement of the amygdala in both temporal lobe epilepsy and panic disorder may underlie this. The predisposition to panic disorder in these patients may be exacerbated by anterior temporal lobectomy.     

A serial model of the interrelationship between perceived vulnerability to disease,fear of COVID-19, and psychological distress among teachers in South Africa

The current study examined the serial relationship between perceived vulnerability to disease, fear of COVID-19, anxiety, and psychological distress among school teachers. Participants were South African school teachers (n = 355) who completed the Perceived Vulnerability to Disease Questionnaire, Fear of COVID-19 Scale, trait scale of the State-Trait Anxiety Inventory, Beck Hopelessness Scale, and the Centre for Epidemiological Depression Scale. A path analysis confirmed that teachers who appraised themselves as more susceptible to disease, experienced heightened levels of fear of COVID-19, which led to heightened levels of anxiety, depression, and hopelessness. Specifically, germ aversion and perceived infectability were separately associated with heightened fear of COVID-19, which in turn was associated with heightened anxiety. This serial relationship was associated with heightened levels of hopelessness and depression. The current study extends research on the impact of the COVID-19 pandemic among a distinct subgroup of the population.     

Phobias, other psychiatric comorbidities and chronic migraine

BACKGROUND: Comorbidity of chronic migraine (CM) with psychiatric disorders, mostly anxiety and mood disorders, is a well-recognized phenomenon. Phobias are one of the most common anxiety disorders in the general population. Phobias are more common in migraineurs than non-migraineurs. The clinical profile of phobias in CM has never been studied. METHOD: We investigated the psychiatric profile in 56 patients with CM using the SCID I/P interview. RESULTS: Lifetime criteria for at least one mental disorder was found in 87.5% of the sample; 75% met criteria for at least one lifetime anxiety disorder and 60.7% of our sample fulfilled DSM-IV criteria for lifetime phobic avoidant disorders. Mood and anxiety scores were higher in phobic patients than in non-phobic CM controls. Number of phobias correlated with higher levels of anxiety and depression. CONCLUSION: Phobias are common in CM. Its recognition may influence its management. Early treatment may lead to better prognosis.