Generalized anxiety disorder in patients with major depression: is DSM-IV's hierarchy correct?

OBJECTIVE: DSM-III imposed a hierarchical relationship in the diagnosis of anxiety disorders in depressed patients, stipulating that anxiety disorders could not be diagnosed if their occurrence was limited to the course of a mood disorder. In the subsequent versions of the DSM this hierarchy was eliminated for all anxiety disorders except generalized anxiety disorder. The authors examined the validity of this remaining hierarchical relationship between mood and anxiety disorders. METHOD: Psychiatric outpatients with major depressive disorder (N=332) were evaluated with a semistructured diagnostic interview and completed paper-and-pencil questionnaires on presentation for treatment. To study the validity of the DSM-IV hierarchical relationship between generalized anxiety disorder and mood disorders, the authors made a diagnosis of modified generalized anxiety disorder for patients with major depressive disorder who met all the criteria for generalized anxiety disorder except for the exclusion criterion. The analyses compared the characteristics of three nonoverlapping groups of patients with DSM-IV major depressive disorder: 1) those with coexisting DSM-IV generalized anxiety disorder, 2) those with coexisting modified generalized anxiety disorder, and 3) those with neither DSM-IV nor modified generalized anxiety disorder. RESULTS: Compared to the depressed patients without generalized anxiety disorder, the depressed patients with DSM-IV and modified generalized anxiety disorder had higher levels of suicidal ideation; poorer social functioning; a greater frequency of other anxiety disorders, eating disorders, and somatoform disorders; higher scores on most subscales of a multidimensional self-report measure of DSM-IV axis I disorders; a greater level of pathological worry; and a higher morbid risk for generalized anxiety disorder in first-degree family members. The two generalized anxiety disorder groups did not differ from each other. CONCLUSIONS: The findings question the validity of the DSM-IV hierarchical relationship between major depressive disorder and generalized anxiety disorder and suggest that the exclusion criterion should be eliminated.     

Diagnosing major depressive disorder: II: is there justification for compound symptom criteria?

The DSM-IV symptom inclusion criteria for the diagnosis of major depressive disorder (MDD) are constructed in three ways: single symptom criteria, compound criteria encompassing opposite variants of the same disturbance, and compound criteria encompassing related problems. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the following three hypotheses: (1) the components of compound-opposite criteria rarely occur simultaneously, (2) the components of the compound-related criteria frequently occur simultaneously, and (3) the components of the compound-related criteria more frequently co-occur than other pairs of the MDD criteria. We also examined how many patients would be rediagnosed if the compound criteria were split into separate items. One thousand eight hundred psychiatric outpatients were evaluated with a semistructured diagnostic interview. We inquired about all of the DSM-IV diagnostic criteria for MDD for all patients. As hypothesized, the symptoms of the compound-opposite criteria usually did not co-occur, whereas the symptoms of the compound-related criteria frequently were present simultaneously. However, the results also indicated that other pairs of symptoms were as likely to co-occur, and were as strongly associated with each other, as the symptoms of the compound-related criteria. Thus, the findings provide mixed support for the assumptions hypothesized to underlie the composition of the DSM-IV criteria for MDD. When the compound criteria were subdivided and the diagnostic threshold for MDD was kept constant, only a small percentage of patients was reclassified from a noncase to a case. The implications of these results for constructing diagnostic criteria, and for developing measures to assess the severity of depression, are discussed.     

What is an anxiety disorder?

Initiated as part of the ongoing deliberation about the nosological structure of DSM, this review aims to evaluate whether the anxiety disorders share features of responding that define them and make them distinct from depressive disorders, and/or that differentiate fear disorders from anxious‐misery disorders. The review covers symptom self‐report as well as on‐line indices of behavioral, physiological, cognitive, and neural responding in the presence of aversive stimuli. The data indicate that the anxiety disorders share self‐reported symptoms of anxiety and fear; heightened anxiety and fear responding to cues that signal threat, cues that signal no threat, cues that formerly signaled threat, and contexts associated with threat; elevated stress reactivity to aversive stimuli; attentional biases to threat‐relevant stimuli and threat‐based appraisals of ambiguous stimuli; and elevated amygdala responses to threat‐relevant stimuli. Some differences exist among anxiety disorders, and between anxiety disorders and depressive disorders. However, the differences are not fully consistent with proposed subdivisions of fear disorders vs. anxious misery disorders, and comparative data in large part are lacking. Given the high rates of co‐morbidity, advances in our understanding of the features of responding that are shared across vs. unique to anxiety and depressive disorders will require dimensional approaches. In summary, the extant data help to define the features of responding that are shared across anxiety disorders, but are insufficient to justify revisions to the DSM nosology at this time. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Worry and anxiety: is there a causal relationship?

The aim of this study was to examine the relationship between worry and anxiety and depression. Path analysis was used to estimate a nonrecursive model which describes the reciprocal causal relation between worry and anxiety. The final model fits the data well and leads to the conclusion that the association between these two constructs is not bidirectional. Indeed, we observed a significant positive effect of worry on anxiety, but no effect in the opposite direction. This result provides a supporting argument for researchers wishing to distinguish these two constructs. Moreover, depression is not directly affected by worry, but is indirectly affected through anxiety.     

Antithrombin replacement in neonates: is there any indication?

INTRODUCTION: Activation of the coagulation system and severe acquired antithrombin (AT) deficiency are common and prognostically important findings in sick and preterm neonates. It has been hypothesised that treatment of the acquired AT deficiency with AT concentrate may improve the outcome of conditions such as the neonatal respiratory distress syndrome (RDS), intracranial hemorrhage (ICH) and sepsis. MATERIALS AND METHODS: We performed a systematic review of randomised controlled trials (RCTs) of AT replacement therapy in newborn infants. RESULTS: Two full-length trial reports were found. Both were placebo-controlled. The first RCT examined the effects of AT therapy in 122 preterm infants with RDS. Administration of AT prolonged rather than shortened the duration of mechanical ventilation and oxygen therapy. The second RCT determined whether AT replacement decreased the incidence of ICH in 60 preterm infants who were born before 30 weeks of gestation. No beneficial effect on ICH was found. CONCLUSIONS: Preterm infants with RDS do not benefit from therapy with AT concentrate and may be harmed. There is also little evidence that the administration of AT reduces the risk of ICH. The role of AT replacement during neonatal sepsis remains uncertain.     

Obsessive-compulsive disorder and serotonin: is there a connection?

Reports of the antiobsessional efficacy of clomipramine have led to a "serotonin hypothesis" of obsessive-compulsive disorder (OCD). To test this hypothesis, 16 outpatients with DSM-III OCD were studied using several measures of serotonergic function. Platelet 3H-imipramine binding and serotonin uptake were not significantly different between the OCD patients and a normal, age-matched control group. The level of the metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid (CSF) was significantly higher in a small cohort of obsessionals compared with healthy volunteers, possibly reflecting increased brain serotonin turnover. In a direct test of the role of serotonin uptake in clomipramine's antiobsessional effects, the serotonin uptake inhibitor zimelidine was compared with the noradrenergic uptake inhibitor desipramine in a double-blind, controlled study. Zimelidine reduced CSF 5-HIAA, but was clinically ineffective in this group. Desipramine had weak but significant clinical effects. Nonresponders to zimelidine or desipramine improved significantly during a subsequent double blind trial of clomipramine. These findings demonstrate that pharmacological blockade of serotonin reuptake alone is not sufficient for an antiobsessional response.     

GAD is good? Generalized anxiety disorder predicts a superior five-year outcome following an acute coronary syndrome

While differing anxiety disorders have been reported to have quite variable impact on outcome following an acute coronary syndrome (ACS), a recent study quantified generalized anxiety disorder (GAD) as having a distinctly negative impact. We examined anxiety disorder status at baseline for any differential five-year impact on cardiac outcome following initial hospitalization for an ACS in 489 subjects. Of those initially assessed, 89% were examined at a five-year review. There were non-significant trends for all non-GAD anxiety disorders to be associated with a worse cardiac outcome. Meeting GAD criteria (both at baseline assessment and over the subjects' lifetime) was associated with a superior five-year cardiac outcome, particularly in the sub-set of those experiencing GAD as their only anxiety disorder, and after controlling for depression and medical comorbidities. As our results are at distinct variance with two previous studies specifically examining the impact of GAD on outcome in cardiac patients, we consider methodological and other explanations. We conclude that, if our findings are valid, then they may more reflect GAD patients having a ‘constructive worrying’ capacity and therefore being more likely to seek help in response to less severe somatic symptoms and to also be more adherent with cardiac rehabilitation programs.     

Generalized anxiety disorder – a risk factor for depression?

Recent longitudinal epidemiological studies suggest that anxiety disorders usually precede the onset of depressive disorders and might be regarded as risk factors for secondary depressive disorders. This paper reviews the available evidence, which suggests that generalized anxiety disorder (GAD) is a temporally primary anxiety disorder, preceding the onset of depression. In retrospective studies, like other anxiety disorders, GAD in adulthood and among adolescents has been reported to precede the onset of depressive disorders in the majority of cases. Prospective longitudinal data suggest that GAD is associated with an increased risk of an earlier first onset of depression. Comparisons with panic disorder reveal that GAD cases predominantly develop depression after 2–4 years, whereas the majority of cases of panic disorder develop depression within a year after onset. These observations suggest differences in the pathogenesis of both conditions, which require further investigation. The comorbidity between GAD and major depression and the fact that temporally primary GAD significantly predicts a subsequent onset of depression raise the question of whether early intervention and treatment of primary GAD would effectively prevent the subsequent first onset of depression. Copyright © 2001 Whurr Publishers Ltd.     

Is obsessive-compulsive disorder an anxiety disorder?

Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder in the DSM-IV-TR [American Psychiatric Association, 2000. Diagnostic and statistical manual of mental disorders, Fourth ed., rev. Washington, DC: Author]; however, the notion of a spectrum of obsessive-compulsive (OC) related disorders that is comprised of such disparate disorders as OCD, body dysmorphic disorder, certain eating disorders, pathological gambling, and autism, is gaining acceptance. The fact that these disorders share obsessive-compulsive features and evidence similarities in patient characteristics, course, comorbidity, neurobiology, and treatment response raises the question of whether OCD is best conceptualized as an anxiety or an OC spectrum disorder. This article reviews evidence from comorbidity and family studies, as well as biological evidence related to neurocircuitry, neurotransmitter function, and pharmacologic treatment response that bear on this question. The implications of removing OCD from the anxiety disorders category and moving it to an OC spectrum disorders category, as is being proposed for the DSM-V, is discussed.     

Slow cortical potential neurofeedback in attention deficit hyperactivity disorder: is there neurophysiological evidence for specific effects?

This study compared changes in quantitative EEG (QEEG) and CNV (contingent negative variation) of children suffering from ADHD treated by SCP (slow cortical potential) neurofeedback (NF) with the effects of group therapy (GT) to separate specific from non-specific neurophysiological effects of NF. Twenty-six children (age: 11.1 ± 1.15 years) diagnosed as having ADHD were assigned to NF (N = 14) or GT (N = 12) training groups. QEEG measures at rest, CNV and behavioral ratings were acquired before and after the trainings and statistically analyzed. For children with ADHD-combined type in the NF group, treatment effects indicated a tendency toward improvement of selected QEEG markers. We could not find the expected improvement of CNV, but CNV reduction was less pronounced in good NF performers. QEEG changes were associated with some behavioral scales. Analyses of subgroups suggested specific influences of SCP training on brain functions. To conclude, SCP neurofeedback improves only selected attentional brain functions as measurable with QEEG at rest or CNV mapping. Effects of neurofeedback including the advantage of NF over GT seem mediated by both specific and non-specific factors. M. Doehnert and D. Brandeis have contributed equally to this paper.     

Antisocial personality disorder and anxiety disorder: A diagnostic variant?

Antisocial personality disorder (ASPD) with co-morbid anxiety disorder may be a variant of ASPD with different etiology and treatment requirements. We investigated diagnostic co-morbidity, ASPD criteria, and anxiety/affective symptoms of ASPD/anxiety disorder. Weighted analyses were carried out using survey data from a representative British household sample. ASPD/anxiety disorder demonstrated differing patterns of antisocial criteria, co-morbidity with clinical syndromes, psychotic symptoms, and other personality disorders compared to ASPD alone. ASPD criteria demonstrated specific associations with CIS-R scores of anxiety and affective symptoms. Findings suggest ASPD/anxiety disorder is a variant of ASPD, determined by symptoms of anxiety. Although co-morbid anxiety and affective symptoms are the same as in anxiety disorder alone, associations with psychotic symptoms require further investigation.     

Left- and right-handed children's drawing performance: is there any difference?

The aim of the present study was to investigate the effect of hand preference on children's drawing development. An equal number of left- and right-handed children (N = 182), aged 7 to 12 years were asked to complete four different drawing tasks. During the drawing process, directionality of horizontal, vertical, and circular strokes as well as sequencing was recorded. Each drawing was scored according to the developmental stage to which is corresponded. It was found that drawing performance improved with age, irrespectively of hand preference and sex. In other words, left- and right-handers' drawing performance across the four tasks was not found to differ significantly. The only consistent difference between the two groups involved was in the production of horizontal lines. The results are discussed in terms of implications for questions about the lack of differences in left- and right-handed children's drawing performance.