Social fears and social phobia in a community sample of adolescents and young adults: prevalence, risk factors and co-morbidity

BACKGROUND: The paper describes prevalence, impairments, patterns of co-morbidity and other correlates of DSM-IV social phobia in adolescents and young adults, separating generalized and non-generalized social phobics. METHODS: Data are derived from the baseline investigation of the Early Developmental Stages of Psychopathology Study (EDSP), a prospective longitudinal community study of 3021 subjects, aged 14-24. Diagnoses were based on the DSM-IV algorithms of an expanded version of the Composite International Diagnostic Interview. RESULTS: Lifetime prevalence of DSM-IV/CIDI social phobia was 9.5% in females and 4.9% in males, with about one-third being classified as generalized social phobics. Twelve-month prevalence was only slightly lower, indicating considerable persistence. Respondents with generalized social phobia reported an earlier age of onset, higher symptom persistence, more co-morbidity, more severe impairments, higher treatment rates and indicated more frequently a parental history of mental disorders than respondents with non-generalized social phobia. CONCLUSIONS: History of DSM-IV social phobia was found to be quite prevalent in 14-24 year-olds. The generalized subtype of social phobia was found to have different correlates and to be considerably more persistent, impairing and co-morbid than non-generalized social phobia. Although generalized social phobics are more likely than non-generalized social phobics to receive mental health treatments, the treatment rate in this sample was low despite the fact that mental health services are free in Germany.     

Fear induced complexity loss in the electrocardiogram of flight phobics: a multiscale entropy analysis

In this study we explored the changes in the variability and complexity of the electrocardiogram (ECG) of flight phobics (N=61) and a matched non-phobic control group (N=58) when they performed a paced breathing task and were exposed to flight related stimuli. Lower complexity/entropy values were expected in phobics as compared to controls. The phobic system complexity as well as the heart rate variability (HRV) were expected to be reduced by the exposure to fearful stimuli. The multiscale entropy (MSE) analysis revealed lower entropy values in phobics during paced breathing and exposure, and a complexity loss was observed in phobics during exposure to threatening situations. The expected HRV decreases were not found in this study. The discussion is focused on the distinction between variability and complexity measures of the cardiac output, and on the usefulness of the MSE analysis in the field of anxiety disorders.     

Fear induced complexity loss in the electrocardiogram of flight phobics: A multiscale entropy analysis

In this study we explored the changes in the variability and complexity of the electrocardiogram (ECG) of flight phobics (N = 61) and a matched non-phobic control group (N = 58) when they performed a paced breathing task and were exposed to flight related stimuli. Lower complexity/entropy values were expected in phobics as compared to controls. The phobic system complexity as well as the heart rate variability (HRV) were expected to be reduced by the exposure to fearful stimuli. The multiscale entropy (MSE) analysis revealed lower entropy values in phobics during paced breathing and exposure, and a complexity loss was observed in phobics during exposure to threatening situations. The expected HRV decreases were not found in this study. The discussion is focused on the distinction between variability and complexity measures of the cardiac output, and on the usefulness of the MSE analysis in the field of anxiety disorders.     

Emotional sensitization highlights the attentional bias in blood-injection-injury phobics: an ERP study

The presence of an attentional bias towards disorder-related stimuli has not been consistently demonstrated in blood phobics. The present study was aimed at investigating whether or not an attentional bias, as measured by event-related potentials (ERPs), could be highlighted in blood phobics by inducing cognitive-emotional sensitization through the repetitive presentation of different disorder-related pictures. The mean amplitudes of the N100, P200, P300 and late positive potentials to picture onset were assessed along with subjective ratings of valence and arousal in 13 blood phobics and 12 healthy controls. Blood phobics, but not controls, showed a linear increase of subjective arousal over time, suggesting that cognitive-emotional sensitization did occur. The analysis of cortical responses showed larger N100 and smaller late positive potentials in phobics than in controls in response to mutilations. These findings suggest that cognitive-emotional sensitization induced an attentional bias in blood phobics during picture viewing, involving early selective encoding and late cognitive avoidance of disorder-related stimuli depicting mutilations.     

Blood phobia and spider phobia: two specific phobias with different autonomic cardiac modulations

Cardiac reactions to two fear-related and one control film were compared in individuals high in spider or blood/injury fear. Twelve subjects in each phobic group were selected on the basis of their scores in the Spider or Mutilation Questionnaires and a semi-structured interview. Cardiac responses and self-reported affective ratings to the films were investigated. Sympathetic and parasympathetic cardiac influences were indexed by T-wave amplitude and respiratory sinus arrhythmia measured during film viewing. Basal parasympathetic cardiac control was also assessed during a paced breathing task. Results indicate differential autonomic modulation of cardiac responses for blood and spider phobics. Although each group reacted with marked cardiac activation to its feared stimulus, a sympathetic increase followed by withdrawal over time was found in blood phobics. Greater vagal tone at rest was present in blood phobics compared with spider phobics.     

Diminished medial prefrontal cortex activity in blood-injection-injury phobia

We examined the effects of symptom induction on neural activation in blood-injection-injury (BII) phobia. Nine phobic and 10 non-phobic subjects participated in an fMRI study in which they were presented with disorder-relevant, generally disgust-inducing, generally fear-evoking and neutral pictures. We observed diminished medial prefrontal cortex (MPFC) activity in patients compared to controls for phobia-relevant and disgust-inducing pictures. The MPFC has been shown to be critically involved in the automatic and effortful cognitive regulation of emotions. Therefore, the results might reflect reduced cognitive control of emotions in BII phobics during the experience of phobic symptoms as well as during states of disgust. The latter response component might be a result of the elevated disgust sensitivity of BII phobics.     

Vagally mediated heart rate variability and heart rate entropy as predictors of treatment outcome in flight phobia

In the present study a computer-assisted exposure-based treatment was applied to 54 flight phobics and the predictive role of vagally mediated heart rate (HR) variability (high frequency, 0.15-0.4 Hz band power) and heart rate entropy (HR time series sample entropy) on treatment outcome was investigated. Both physiological measures were taken under controlled breathing at 0.2 Hz and during exposure to a fearful sequence of audiovisual stimuli. Hierarchical regression analyses were conducted to assess the predictive power of these variables in these conditions on treatment self-report measures at the end of treatment and at 6 months follow-up, as well as on the behavioral treatment outcome (i.e. flying at the end of treatment). Regression models predicting significant amounts of outcome variance could be built only when HR entropy was added to the HR variability measure in a second step of the regression analyses. HR variability alone was not found to be a good predictor of neither self-reported nor behavioral treatment outcomes.     

Taking the laboratory to the skies: Ambulatory assessment of self-report, autonomic, and respiratory responses in flying phobia

We evaluated the feasibility of recording multiple physiological anxiety measures during a flight and how well they could distinguish flight phobics from controls. Benefits of baseline adjustment and transformation for all variables and adjustment of heart rate by ventilation to give additional heart rate were calculated. Effect size, one measure of the power to discriminate groups, was between 1.1 and 1.7 for heart rate measures. Although respiratory rate and minute ventilation, indicators of hyperventilation, did not differ between groups, phobics paused more during inspiration than did controls. Phobics also showed more skin conductance fluctuations and less respiratory sinus arrhythmia. Self-reported anxiety was a more powerful discriminator than physiological measures, a result that may be partially explained by how phobics were selected. These results indicate that monitoring of multiple physiological systems outside the laboratory is practical and informative. Physiological measures of psychological importance can be quantified accurately in a noisy, changing, unsupervised ambulatory setting.     

Vagally mediated heart rate variability and heart rate entropy as predictors of treatment outcome in flight phobia

In the present study a computer-assisted exposure-based treatment was applied to 54 flight phobics and the predictive role of vagally mediated heart rate (HR) variability (high frequency, 0.15–0.4 Hz band power) and heart rate entropy (HR time series sample entropy) on treatment outcome was investigated. Both physiological measures were taken under controlled breathing at 0.2 Hz and during exposure to a fearful sequence of audiovisual stimuli. Hierarchical regression analyses were conducted to assess the predictive power of these variables in these conditions on treatment self-report measures at the end of treatment and at 6 months follow-up, as well as on the behavioral treatment outcome (i.e. flying at the end of treatment). Regression models predicting significant amounts of outcome variance could be built only when HR entropy was added to the HR variability measure in a second step of the regression analyses. HR variability alone was not found to be a good predictor of neither self-reported nor behavioral treatment outcomes.     

Psychophysiology of spider phobia in 8- to 12-year-old girls

The present investigation focused on late event-related potentials (ERPs) and facial electromyographic (EMG) activity in response to symptom provocation in 8- to 12-year-old spider phobic girls and compared results to those in non-fearful controls. Fourteen patients and 14 controls were presented with phobia-relevant, generally fear-inducing, disgust-inducing and affectively neutral pictures in an EEG/EMG session. ERPs were extracted in the time-windows 340-500 ms (P300) and 550-770 ms (late positive potential, LPP). Relative to controls, phobics showed enhanced amplitudes of P300 and LPP in response to spider pictures. This result is interpreted to reflect motivated attention to emotionally salient stimuli. Moreover, phobics showed enhanced average facial EMG activity of the levator labii and the corrugator supercilii in response to spider pictures, reflecting the negative valence and disgust relevance of spiders. Additionally, spider phobic girls relative to controls showed higher overall disgust proneness and heightened average facial EMG activity in both muscle regions in response to disgust stimuli, possibly revealing a disgust-based origin of spider phobia in children. These aspects should be considered in psychotherapeutic treatment of childhood spider phobia.     

North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: two-year follow-up and economic evaluation

BACKGROUND: There is good evidence now that cognitive behaviour therapy (CBT) is effective in the treatment of people suffering from schizophrenia. There is also some evidence that the benefits of CBT persist after the end of treatment and that the direct costs of providing CBT as an adjunct to standard care are no higher than the direct costs of standard care alone. The aims of the present study were to discover if the benefits of CBT for acute schizophrenia which were found 1 year after index admission persist for another year, and to evaluate the comparative costs of providing CBT. METHOD: Consecutive admissions meeting criteria were recruited. After screening, 43 were assigned at random to a treatment-as-usual (TAU) control group and 47 were assigned to TAU plus CBT. Patients (73% of original) were rated on symptoms and social functioning 2 years after index admission. An evaluation of the direct costs of services was also completed. RESULTS: The CBT group had maintained its advantage over the TAU group on negative symptoms and social functioning but had lost the advantage it previously enjoyed in positive symptoms. The difference between groups in total direct costs over the 2 years was not statistically significant despite the cost of providing CBT. CONCLUSIONS: Some of the benefits of CBT for patients suffering acute psychotic episodes persist for 2 years. After the end of regular treatment, CBT should probably be targeted on the appearance of early signs of relapse to forestall the re-emergence of positive symptoms.     

Behavioural and drug treatments of phobic and obsessive-compulsive disorders

The two most-used treatments for phobic and obsessive-compulsive disorders are exposure and drugs. In exposure therapy, the patient is persuaded to re-enter the phobia- or ritual-evoking situation and to stay there despite the ensuing panic until it starts to subside, which may take 1 h or more. The patient does this repeatedly and systematically, noting outcome in an exposure-homework diary which the clinician reviews. Controlled studies show that such self-exposure treatment (requiring little time from the clinician) has lasting value. Only a minority of cases need additional therapist-aided exposure. Antidepressants are useful adjuvants to exposure in dysphoric phobics and ritualisers. No antidepressant is clearly superior to any other. Relapse on stopping medication is a problem. Neither beta-blockers nor benzodiazepines are yet of proven lasting value for these syndromes. It is too easy to forget that drugs have unpleasant side-effects which are not seen with exposure therapy.     

The health economics of allergen immunotherapy

In contrast to symptomatic drug treatment, which only temporarily relieves allergy symptoms, allergen-specific immunotherapy (SIT) has the potential to alter the course of allergic disease, thereby reducing the need for long-term treatment, the progression of allergic rhinitis (AR) to asthma, and the development of new allergies. The clinical benefits of SIT have been shown to persist for an additional 3 to 12 years after discontinuation of a 2.5- to 5.0-year treatment. It therefore stands to reason that the clinical benefits of SIT also extend to economic benefits. A growing number of studies have evaluated the economic benefits of SIT in patients with AR and/or asthma. The authors critically examine each of these studies published from 1995 to present.     

Cardiovascular dynamics in blood phobia: evidence for a key role of sympathetic activity in vulnerability to syncope

This study was aimed at clarifying the mechanism predisposing people with blood phobia to syncope by investigating the complete hemodynamic response pattern and the underlying autonomic control. Blood phobics and controls were shown 3 film-clips: phobia-related, phobia-unrelated, and neutral. Hemodynamic responses were recorded using impedance cardiography and Finapres. Preejection period and respiratory sinus arrhythmia were employed as indices of cardiac sympathetic and parasympathetic activity. Self-ratings of emotion were also collected. Blood phobics displayed global heart rate and cardiac output increases to the phobic film, mediated by augmented cardiac sympathetic activity. Systolic blood pressure and total peripheral resistance markedly declined, with no evidence of diphasic reaction or parasympathetic activation. An impaired vasomotor response under sympathetic control might be the key mechanism underlying the phobic dysfunctional response.     

A comparison of hormone therapy,coping skills training,and relaxation for the relief of premenstrual syndrome

Approximately 10% of women are severely affected by premenstrual syndrome (PMS) during their reproductive years. Several biological theories of causation have been proposed and each has provoked treatment attempts through medication to little sustained effect. As many of the reported complaints are psychological, a new treatment approach was considered using cognitive-behavioral therapy. A preliminary study which combined cognitive-behavioral therapy with drug treatment produced considerable symptom reduction. The present study examined the efficacy of cognitive-behavioral therapy alone in direct comparison with hormone treatment. Relaxation instructions were provided to a control group. Initial rapid responses to drug treatment and relaxation diminishes after 2 months, together with marked attrition in the control group. Significant positive benefits from cognitive-behavioral therapy were achieved after the first treatment month that continued throughout and were maintained at follow-up 3 months later. Implications for future management are discussed.     

Enzyme replacement therapy for mucopolysaccharidosis VI from 8 weeks of age–a sibling control study

McGill JJ, Inwood AC, Coman DJ, Lipke ML, de Lore D, Swiedler SJ, Hopwood JJ. Enzyme replacement therapy for mucopolysaccharidosis VI from 8 weeks of age–a sibling control study Mucopolysaccharidosis type VI (MPS VI) is a progressive, multisystem disorder caused by a deficiency of the lysosomal enzyme N‐acetylgalactosamine‐4‐sulphatase (ASB). Enzyme replacement therapy (ERT) has been shown to clinically benefit affected individuals greater than 6 years of age. This case control study of affected siblings assessed the safety, efficacy and benefits of ERT in children less than 5 years of age. Siblings, aged 8 weeks and 3.6 years, were treated weekly with 1 mg/kg recombinant human N‐acetylgalactosamine‐4‐sulphatase (rhASB) with an end‐point of 3.6 years. Clinical and biochemical parameters were monitored to assess the benefits of ERT. The treatment was well tolerated by both siblings. In the younger sibling, ERT was associated with the absence of the development of scoliosis and preserved joint movement, cardiac valves and facial morphology. The older sibling had a marked improvement in joint mobility and cardiac valve pathology and scoliosis slowed or stabilized. Corneal clouding and progressive skeletal changes were observed despite treatment. This study demonstrated a clear benefit of early initiation of ERT to slow or prevent the development of significant pathological changes of MPS VI. These results indicate that the earlier ERT is started, the greater the response.     

Scared to lose control? General and health locus of control in females with a phobia of vomiting

The term emetophobia (i.e., a fear of vomiting) exists as rather an elusive predicament, often eluding conventional treatment. The present study involved 149 participants, consisting of 51 emetophobics, 48 phobic controls (i.e. those who suffered from a different phobia), and 50 nonphobic controls. Participants were administered the Rotter (1966) Locus of Control Scale and the Health Locus of Control Scale by B.S. Wallston, Wallston, Kaplan, and Maides (1976). Significant differences were found among the three groups; specifically, that emetophobics had a significantly higher internal Locus of Control Scale score with regard to both general and health-related issues than did the two control groups. It is suggested that vomiting phobics may have a fear of losing control, and that their vomiting phobia is reflective of this alternative, underlying problem. More research is required to explore the association between emetophobia and issues surrounding control; however, the current study suggests that it may be helpful for therapists to consider this aspect when treating a patient with vomiting phobia.     

Lack of startle blink potentiation to mutilation pictures irrespective of fearfulness

Previous research has shown that in healthy individuals blood-related stimuli elicit a distinctive autonomic response pattern and heightened processing as compared with other unpleasant and arousing visual stimuli. In addition, growing evidence suggests that information processing of disorder-related stimuli is also different in blood phobia as compared with other specific phobias. In the present study, the magnitude of the startle eyeblink reflex elicited during the viewing of mutilation, human attack, erotica and neutral pictures was recorded in 22 blood phobics and 25 healthy controls. Startle eyeblink responses were measured at 300, 1500, 3500 and 4500-ms time intervals after picture onset in order to assess the attentional/affective modulation and its temporal course. Reliable startle inhibition to erotic pictures and startle potentiation to human attack scenes were found relative to neutral pictures. However, while both groups rated mutilations as the most unpleasant and arousing content, no blink facilitation relative to neutral contents was found at either early or late probe times. Crucially, such effect occurred independently of fear levels, as no difference between phobics and controls was found in the size of the startle blinks elicited throughout the viewing of blood pictures.     

Major depression and the use of electroconvulsive therapy (ECT) in lung transplant recipients

The purpose of this study is to describe the potential risks and benefits of electroconvulsive therapy (ECT) for treatment of depression in lung transplant recipients. The authors performed a record review of depressed patients who underwent lung transplantation at Johns Hopkins Hospital and evaluated their treatment, including ECT. In 9 years, 131 lung transplants were performed, and four patients had been diagnosed with major depression. Of those, two were candidates for ECT, and one received it. This patient's depression did abate with ECT. ECT, an effective treatment for depression, remains a treatment method of choice for depression in the posttransplant population.