Experiential,autonomic, and respiratory correlates of CO2 reactivity in individuals with high and low anxiety sensitivity

Psychometric studies indicate that anxiety sensitivity (AS) is a risk factor for anxiety disorders such as panic disorder (PD). To better understand the psychophysiological basis of AS and its relation to clinical anxiety, we examined whether high-AS individuals show similarly elevated reactivity to inhalations of carbon dioxide (CO₂) as previously reported for PD and social phobia in this task. Healthy individuals with high and low AS were exposed to eight standardized inhalations of 20% CO₂-enriched air, preceded and followed by inhalations of room air. Anxiety and dyspnea, in addition to autonomic and respiratory responses were measured every 15 s. Throughout the task, high AS participants showed a respiratory pattern of faster, shallower breathing and reduced inhalation of CO₂ indicative of anticipatory or contextual anxiety. In addition, they showed elevated dyspnea responses to the second set of air inhalations accompanied by elevated heart rate, which could be due to sensitization or conditioning. Respiratory abnormalities seem to be common to high AS individuals and PD patients when considering previous findings with this task. Similarly, sensitization or conditioning of anxious and dyspneic symptoms might be common to high AS and clinical anxiety. Respiratory conditionability deserves greater attention in anxiety disorder research.     

Psychophysiological assessment of stress reactivity and recovery in anxiety disorders

The present study aimed to examine changes in psychophysiological arousal from baseline to a stressor phase (reactivity) and from the stressor phase to a second resting phase (recovery) in patients with anxiety disorders. Fifty adult patients with DSM-5 anxiety disorders (panic disorder, generalized anxiety disorder, or social anxiety disorder) and 28 healthy control (HC) participants underwent psychophysiological monitoring including electrocardiogram, respiration rate, electrodermal activity, gastrocnemius electromyograph, and end-tidal CO₂ for a 3-min resting phase, a 6-min mild stressor phase, and a 3-min recovery phase. Anxious patients then went on to receive naturalistic cognitive-behavioral therapy (CBT) in a specialty outpatient clinic. Results for the reactivity phase indicated that compared to HCs, patients with social anxiety disorder exhibited heightened psychophysiological reactivity while patients with panic disorder and generalized anxiety disorder exhibited attenuated reactivity. Results for physiological recovery (return to baseline after the stressor was withdrawn) were mixed, but provided some support for slower autonomic recovery in patients with generalized anxiety disorder and panic disorder compared to HCs. Participants with all anxiety disorders exhibited diminished change in high frequency heart rate variability compared to HCs. Generally, psychophysiological reactivity and recovery were not associated with CBT outcome, though exploratory analyses indicated that greater respiration rate reactivity and stronger respiration rate recovery were associated with better CBT outcomes in patients with panic disorder.     

Cognitive behavioral group therapy for anxiety: recent developments

Anxiety disorders occur frequently, and can have a negative impact on the quality of people''s lives. They often begin at an early age and can have some serious consequences. This article is an overview of the recent studies concerning group cognitive-behavioral interventions for anxiety disorders. In the last few years, anxiety disorder prevention for children and adolescents has become an important focus of research work. Group prevention programs are based on standard cognitive behavioral therapy (CBT) strategies and are aimed at preventing anxiety disorders as early as possible. Numerous cognitive behavioral group therapies for children as well as adults have been well studied. There are many CBT protocols that have been developed for treating specific anxiety disorders. Now, specialized CBT programs are available for individuals who suffer from different anxiety disorders, enabling them to be treated together in groups.     

Cognitive Behavioral Therapy for Anxiety Disorders: Outcomes From a Multi-State,Multi-Site Primary Care Practice

BackgroundAnxiety disorders are among the most common mental health conditions. Individuals with anxiety typically seek services in primary, rather than specialty, care. While there is significant evidence supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for anxiety disorders, there have been no naturalistic studies reporting anxiety-specific treatment outcomes in primary care.MethodsParticipants (N = 1,589) were recruited from a multi-state, multi-site primary care practice, with 491 participants endorsing moderate to severe anxiety at baseline and engaging in at least one CBT session. Data was drawn from a psychotherapy tracking database.ResultsAmong participants with moderate to severe anxiety who engaged in CBT, a significant decrease in anxiety and depression symptoms was observed over the course of psychotherapy (p < .001, d = 0.57-0.95). Rates of reliable change, response, and remission varied across diagnostic categories. The use of CBT interventions also varied across diagnoses in line with evidence-based treatment recommendations.DiscussionShort-term CBT delivered in primary care is associated with significant improvements in anxiety and depression symptoms among participants with anxiety disorders. These findings support the use of a population-based approach to anxiety disorders treatment and suggest that evidence-based CBT can be implemented in the real-world setting.     

Do emotion regulation,attentional control,and attachment style predict response to cognitive behavioral therapy for anxiety disorders? – an investigation in clinical settings

Abstract

Objective: Approximately, 50% of all individuals with anxiety disorders do not benefit from the “gold standard” treatment, namely cognitive behavioral therapy (CBT). Reliable predictors of treatment effect are lacking. The primary aim of this study was to investigate the predictive value of emotion regulation, attentional control, and attachment style for group-based CBT outcomes in routine clinical settings. Method: A total of 76 patients with anxiety disorders received manual-based group CBT at psychiatric outpatient clinics. Emotion regulation, attachment style, and attentional control were assessed with self-report measures and with an experimental computer-based attentional control task at baseline. The severity of anxiety was assessed at intake, post-treatment, and at a 6-month follow-up. Results: Attentional control, emotion regulation, and attachment avoidance did not predict treatment outcomes. Higher attachment anxiety at baseline was significantly related to poorer outcome. Conclusion: In routine clinical settings, high attachment anxiety may predict poorer outcomes for group-based CBT.     

Acute panicogenic, anxiogenic and dissociative effects of carbon dioxide inhalation in patients with post-traumatic stress disorder (PTSD)

Background

Increased anxiety and panic to inhalation of carbon dioxide (CO₂) has been described in patients with anxiety disorders, especially panic disorder, compared to healthy subjects. Post-traumatic stress disorder (PTSD) has been hypothesised to resemble panic disorder and is currently classified as an anxiety disorder in DSM-IV. However, there are only very few data available about the sensitivity of patients with PTSD to CO₂.

Methods

In 10 patients with PTSD, 10 sex- and age-matched healthy subjects and 8 patients with panic disorder we assessed anxiety, panic, dissociative and PTSD symptoms before and after a single vital capacity inhalation of 35% CO₂.

Results

Patients with PTSD showed an increased anxiety, panic and dissociative reaction to the inhalation of 35% CO₂ compared to healthy participants. PTSD subjects’ responses were indistinguishable from those of panic patients. Additionally, PTSD-typical symptoms like post-traumatic flashbacks were provoked in patients with PTSD after the inhalation of CO₂.

Conclusions

In our sample, PTSD was associated with an increased CO₂ reactivity, pointing to an increased susceptibility of PTSD patients to CO₂ challenge.     

Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence

A large amount of research has accumulated on the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for anxiety disorders including posttraumatic stress disorder, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, social anxiety disorder, and specific phobia. The purpose of the current article is to provide an overview of two of the most commonly used CBT methods used to treat anxiety disorders (exposure and cognitive therapy) and to summarize and discuss the current empirical research regarding the usefulness of these techniques for each anxiety disorder. Additionally, we discuss the difficulties that arise when comparing active CBT treatments, and we suggest directions for future research. Overall, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but dismantling studies are needed to determine which specific treatment components lead to beneficial outcomes and which patients are most likely to benefit from these treatment components.     

Cognitive behavioral therapy in anxiety disorders: current state of the evidence

A plethora of studies have examined the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for adult anxiety disorders. In recent years, several meta-analyses have been conducted to quantitatively review the evidence of CBT for anxiety disorders, each using different inclusion criteria for studies, such as use of control conditions or type of study environment. This review aims to summarize and to discuss the current state of the evidence regarding CBT treatment for panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Overall, CBT demonstrates both efficacy in randomized controlled trials and effectiveness in naturalistic settings in the treatment of adult anxiety disorders. However, due to methodological issues, the magnitude of effect is currently difficult to estimate. In conclusion, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but more high-quality studies are needed to better estimate the magnitude of the effect.     

Pre-treatment child and family characteristics as predictors of outcome in cognitive behavioural therapy for youth anxiety disorders

Abstract

Background: Cognitive behavioural therapy (CBT) has been found to be effective for children and adolescents (6–18 years) with anxiety disorders, but the non-response rate is high—a fact that may argue for the importance of studies on pre-treatment characteristics of children and their families that predict treatment outcome. Aims: To provide a systematic review of clinical and demographic pre-treatment child and family predictors of treatment outcome in CBT for anxiety disorders in youth. Method: A systematic literature search was conducted based on electronic databases (PsycINFO, Embase and PubMed), and retrieved studies were analysed according to the box-score method of counting significant findings. Results: 24 studies with a sample size ≥ 60 were located. Most studies dealt with the following predictors: child age, gender, comorbidity, symptom severity and parental psychopathology. There was some evidence that a higher degree of pre-treatment symptomatic severity and non-anxiety comorbidity predicted higher end-state severity, but not a lesser degree of improvement. There was some but inconsistent support for a negative influence of parental psychopathology. Conclusion: Studies on pre-treatment child and family predictors of outcome in CBT for youth anxiety disorders have until now resulted in few findings of clinical or theoretical significance.     

Child versus family cognitive-behavioral therapy in clinically anxious youth: an efficacy and partial effectiveness study

ObjectiveThe efficacy and partial effectiveness of child-focused versus family-focused cognitive-behavioral therapy (CBT) for clinically anxious youths was evaluated, in particular in relation to parental anxiety disorders and child's age.MethodClinically referred children with anxiety disorders (N = 128) and their parents were randomly assigned to child or family CBT and evaluated at pretreatment, posttreatment, and 3-month follow-up. Twenty-five families were measured before and after a 2- to 3-month waitlist period.ResultsNone of the waitlisted children recovered from their anxiety disorders. In contrast, 41% of the treated children no longer met criteria for any anxiety disorder after CBT, and 52% demonstrated continued improvement at the 3-month follow-up. Significantly more children were free of anxiety disorders (53%) in the child CBT condition compared with family CBT condition (28%) at posttreatment, whereas at 3-month follow-up, the superior effect of child CBT was no longer significant. Similar results were obtained from the questionnaire measures. Both child and family CBT were less effective if parents had an anxiety disorder themselves. On some of the measures, child CBT was superior if parents had anxiety disorders themselves, whereas family CBT was superior if parents had no anxiety disorders. Finally, younger children had better outcomes than older children, regardless of the treatment condition.ConclusionsOverall, child CBT seems slightly more beneficial than family CBT. Because this study was conducted in a clinical setting with clinically referred children, results indicate partial effectiveness for child CBT.     

Three-year outcomes of adults with anxiety and related disorders following cognitive-behavioral therapy in a non-research clinical setting

Anxiety and related disorders are highly prevalent and costly to society. Fortunately, a large number of randomized controlled trials have demonstrated the efficacy of cognitive behavioral therapy (CBT) in the treatment of anxiety and related disorders. A smaller number of effectiveness studies have also demonstrated that similar outcomes to randomized controlled trials can be obtained in “real-world” settings. There is minimal research, however, into long-term outcomes in effectiveness research. This study describes the outcomes of 98 individuals with anxiety and related disorders treated in an outpatient, fee-for-service setting using a case formulation CBT approach. Participants were followed up each year after their discharge, for a period of 3 years. The results indicate that patients maintained their treatment gains, with large effect sizes obtained from pre-treatment to each follow-up time point (d = 1.11–1.60). The results provide preliminary evidence to suggest that individuals treated with CBT in “real-world” settings maintain their treatment gains in the long-term.     

School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups

ObjectiveTo follow 61 participants (7–11 years old) from a study that compared three school-based interventions for anxious children: group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training, and no-treatment control to determine whether posttreatment benefits are sustained longitudinally.MethodParent, child, and clinician report measures of child anxiety were completed at 3,6, and 12 months posttreatment. Semistructured diagnostic interviews were administered at 6- and 12-month follow-ups. For initial analyses, the group CBT and group CBT plus parent training conditions were collapsed into one group and compared to control. When significant results were found, each active treatment group was compared to control.ResultsAcross several measures, the collapsed CBT group sustained significant improvement in anxiety severity and impairment across a 12-month period compared to control. There were no significant differences between the three groups on remission of baseline anxiety disorders or incidence of new anxiety disorders during the follow-up. Several parent-report measures at 3 and 6 months posttreatment suggested that group CBT for children plus parent training provided additional benefit over the group CBT for children when each was compared to the control group.ConclusionsSchool-based CBT appears effective in decreasing anxiety symptoms up to 12 months posttreatment for anxious children. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(9): 1039–1047.     

CO2 has no therapeutic effect on early microvasospasm after experimental subarachnoid hemorrhage

In addition to delayed vasospasm also early brain injury, which occurs during the first few days after subarachnoid hemorrhage (SAH) when large cerebral arteries are still fully functional, plays an important role for the outcome after SAH. In the current study, we investigated the hypothesis that carbon dioxide (CO₂), a strong cerebral vasodilator, has a therapeutic potential against early posthemorrhagic microvasospasm. C57BL/6 mice (n=36) and Sprague-Dawley rats (n=23) were subjected to sham surgery or SAH by filament perforation. The pial microcirculation in the mice was visualized 3 and 24 hours after SAH using intravital fluorescence microscopy. Partial pressure of CO₂ (PaCO₂) was modulated by hyper- or hypoventilation or by inhalation of 10% CO₂. In rats, CO₂-mediated changes in cerebral blood flow (CBF) were measured at the same time points using laser Doppler fluxmetry. Increased PaCO₂ caused vasodilatation in sham-operated animals. Following SAH, however, cerebral arterioles were nonreactive to CO₂. This lack of microvascular CO₂ reactivity was accompanied by a complete loss of CO₂-induced hyperemia. Our data show that CO₂ is not able to dilate spastic microvessels and to increase CBF early after SAH. Future therapeutic approaches will therefore need to address mechanisms beyond CO₂.     

Global cerebral oxidative metabolism during hypercapnia and hypocapnia in humans: implications for BOLD fMRI

The effect of carbon dioxide (CO₂) on cerebral metabolism is of tremendous interest to functional imaging. In particular, mild-to-moderate hypercapnia is routinely used in calibrated blood oxygen-level dependent (BOLD)-functional magnetic resonance imaging (fMRI)-based quantification of cerebral oxidative metabolism changes (ΔCMRO₂), and relies on the assumption of a stable CMRO₂ during CO₂ challenges. However, this assumption has been challenged by certain animal studies, necessitating its verification in humans and under conditions customary to fMRI. We report, for the first time, on global ΔCMRO₂ measurements made noninvasively in humans during graded hypercapnia and hypocapnia. We used computerized end-tidal CO₂ modulation to minimize undesired concurrent changes in oxygen pressure, and our findings suggest that no significant change in global CMRO₂ is expected at the levels of end-tidal CO₂ changes customary to calibrated BOLD.     

Predictors of Treatment Effectiveness for Youth with ASD and Comorbid Anxiety Disorders: It all Depends on the Family?

The study aimed to explore predictors of treatment effectiveness in a sample of 79 children with ASD who received cognitive behavioral therapy (CBT) for their anxiety disorders. Severity of anxiety disorders and anxiety symptoms were used to measure treatment effectiveness and was assessed pre-treatment, post-treatment, 3 months-, 1 and 2 years after CBT. Child characteristics and maternal anxiety did not predict treatment effect. Children with anxious fathers and children in ‘un-involved’ families had less anxiety symptoms at pre-treatment and displayed a less steep decline. Children from ‘authoritarian’ families showed higher pre-treatment anxiety levels but responded quite well to treatment. Findings stress the importance of parent (father) and family factors in the treatment of anxiety disorders in youth with ASD.     

Temperament and parenting predicting anxiety change in cognitive behavioral therapy: The role of mothers,fathers, and children

ObjectiveA considerable amount of children with anxiety disorders do not benefit sufficiently from cognitive behavioral treatment. The present study examines the predictive role of child temperament, parent temperament and parenting style in the context of treatment outcome.MethodParticipants were 145 children and adolescents (ages 8–18) with DSM-IV-TR anxiety disorders who received a 12-session CBT program and were assessed at pretreatment, posttreatment and three months follow-up. Multiple-regression analyses were used to evaluate the following pretreatment and posttreatment variables as potential predictors of treatment response at follow-up: baseline level of anxiety symptoms, child reported maternal and paternal rearing style (emotional warmth, rejection, and overprotection), parent reported child temperament traits (negative affect, effortful control, and extraversion), and mothers’ and fathers’ self-report temperament traits.ResultsMore maternal negative affect and less emotional warmth as perceived by the child before treatment were related to less favorable treatment outcome (accounting for 29% of the variance in anxiety at follow-up). Furthermore, maternal negative affect and children's extraversion measured after treatment also predicted anxiety at follow-up (together accounting for 19% of the variance). Paternal temperament and parenting style were unrelated to treatment outcome, as were children's pretreatment temperament traits.ConclusionThe results suggest that tailoring intervention to include strategies to reduce maternal negative affect and promote an emotional warm rearing style may improve treatment outcome.     

A history of anxiety: from Hippocrates to DSM

This article describes the history of the nosology of anxiety disorders. Greek and Latin physicians and philosophers distinguished anxiety from other types of negative affect, and identified it as a medical disorder. Ancient Epicurean and Stoic philosophers suggested techniques to reach an anxiety-free state of mind that are reminiscent of modern cognitive psychology. Between classical antiquity and the late 19^th century there was a long interval during which anxiety was not classified as a separate illness. However, typical cases of anxiety disorders kept being reported, even if under different names. In the 17^th century, Robert Burton described anxiety in The Anatomy of Melancholy. Panic attacks and generalized anxiety disorder may be recognized in the “panophobias” in the nosology published by Boissier de Sauvages in the 18^th century. Also, anxiety symptoms were an important component of new disease constructs, culminating in neurasthenia in the 19^th century. Emil Kraepelin devoted much attention to the possible presence of severe anxiety in manic-depressive illness, thereby anticipating the “anxious distress” specifier of bipolar disorders in DSM-5. A pitfall to consider is that the meaning of common medical terms, such as melancholia, evolves according to places and epochs.     

Group cognitive behavioral treatment in female soldiers diagnosed with binge/purge eating disorders

ABSTRACT

Cognitive behavioral treatment (CBT) is the recommended intervention in bulimia nervosa (BN) and eating disorders not otherwise specified with binge/purge (EDNOS-B/P) symptoms. There are fewer data on its application in a group format. We sought to investigate the effect of group CBT in female soldiers with B/P symptomatology in an open trial design. For this purpose we assessed 64 female soldiers serving in the Israeli Defense Force diagnosed with BN and EDNOS-B/P who participated in a group CBT format of 16 weekly sessions and one follow-up session. In this study, 42 participants (65.6%) completed treatment and 22 participants (34.4%) did not. A total of 39 treatment completers (92.8% of treatment completers) and 19 non-completers (86.4% of treatment non-completers) were assessed around 12 months after treatment. Participants completed at baseline and following treatment questionnaires assessing eating-related symptoms, depression, anxiety, and overall functioning. At follow-up they were assessed for eating-related symptoms. Our findings show only minimal baseline differences between treatment completers and non-completers. Significant improvement from baseline to post-treatment was shown for B/P and restrictive symptoms, depression, anxiety, and overall functioning. At that time, more than a third of treatment completers were abstinent from binging and more than a half from vomiting. The improvement in B/P and restricting symptoms was maintained at 1 year follow-up for treatment completers. At that time around 60% were abstinent from binging and more than 70% from vomiting. Participants not completing treatment were also improved at follow-up but to a lesser extent. The findings of the present study suggest that group CBT may be effective for the treatment of female soldiers with BN and EDNOS-B/P.     

Dysregulation in Youth with Anxiety Disorders: Relationship to Acute and 7- to 19- Year Follow-Up Outcomes of Cognitive-Behavioral Therapy

This study evaluated the impact of dysregulation across cognitive, affective, and behavioral domains on acute and 7- to 19-year follow-up outcomes of cognitive-behavioral therapy (CBT) for anxiety, and explored dysregulation as a predictor of psychopathology and impairment in young adulthood among individuals who received anxiety treatment as youth. Participants (N = 64; 50 % female, 83 % non-Hispanic White) from two randomized clinical trials completed a follow-up assessment 7–19 years later. Latent profile analysis identified dysregulation based on Anxious/Depressed, Attention Problems, and Aggressive Behavior scores on the Child Behavior Checklist. Although pretreatment dysregulation was not related to acute or follow-up outcomes for anxiety diagnoses that were the focus of treatment, dysregulation predicted an array of non-targeted psychopathology at follow-up. Among youth with a principal anxiety disorder, the effects of CBT (Coping Cat) appear to be robust against broad impairments in self-regulation. However, youth with a pretreatment dysregulation profile likely need follow-up to monitor for the emergence of other disorders.     

Anxiety and DSM-5

The DSM-5 process, and the publication of DSM-5 in 2013, have had a considerable impact on the classification of anxiety disorders. Major changes included the reorganization of the chapter structure, individual groupings of disorders within each chapter from a life span viewpoint, and the use of specifiers. The DSM-5 chapter on anxiety disorders does not include obsessive-compulsive disorder or post-traumatic stress disorder. The chapter itself now reflects a developmental approach. The text of each disorder has been enhanced with short sections on development and course, risk and prognostic factors, etc. It is expected that the reformulation of anxiety disorders in DSM-5 will lead to greater precision in a variety of ways, as illustrated in the papers in this issue of Dialogues in Clinical Neuroscience. In summary, these changes in the way we classify anxiety disorders reflect our best view on the clinical empirical data and should prove useful in the assessment of specific anxiety disorders.