The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis

BACKGROUND: A self-rated measure of health anxiety should be sensitive across the full range of intensity (from mild concern to frank hypochondriasis) and should differentiate people suffering from health anxiety from those who have actual physical illness but who are not excessively concerned about their health. It should also encompass the full range of clinical symptoms characteristic of clinical hypochondriasis. The development and validation of such a scale is described. METHOD: Three studies were conducted. First, the questionnaire was validated by comparing the responses of patients suffering from hypochondriasis with those suffering from hypochondriasis and panic disorder, panic disorder, social phobia and non-patient controls. Secondly, a state version of the questionnaire was administered to patients undergoing cognitive-behavioural treatment or wait-list in order to examine the measure's sensitivity to change. In the third study, a shortened version was developed and validated in similar types of sample, and in a range of samples of people seeking medical help for physical illness. RESULTS: The scale was found to be reliable and to have a high internal consistency. Hypochondriacal patients scored significantly higher than anxiety disorder patients, including both social phobic patients and panic disorder patients as well as normal controls. In the second study, a 'state' version of the scale was found to be sensitive to treatment effects, and to correlate very highly with a clinician rating based on an interview of present clinical state. A development and refinement of the scale (intended to reflect more fully the range of symptoms of and reactions to hypochondriasis) was found to be reliable and valid. A very short (14 item) version of the scale was found to have comparable properties to the full length scale. CONCLUSIONS: The HAI is a reliable and valid measure of health anxiety. It is likely to be useful as a brief screening instrument, as there is a short form which correlates highly with the longer version.     

Computerized,interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice

BACKGROUND: Cognitive-behavioural therapy (CBT) brings about significant clinical improvement in anxiety and depression, but therapists are in short supply. We report the first phase of a randomized controlled trial of an interactive multimedia program of cognitive-behavioural techniques, Beating the Blues (BtB), in the treatment of patients in general practice with anxiety, depression or mixed anxiety/depression. METHOD: One hundred and sixty-seven adults suffering from anxiety and/or depression and not receiving any form of psychological treatment or counselling were randomly allocated to receive, with or without medication, BtB or treatment as usual (TAU). Measures were taken on five occasions: prior to treatment, 2 months later, and at 1, 3 and 6 months follow-up using the Beck Depression Inventory, Beck Anxiety Inventory and Work and Social Adjustment Scale. RESULTS: Patients who received BtB showed significantly greater improvement in depression and anxiety compared to TAU by the end of treatment (2 months) and to 6 months follow-up. Symptom reduction was paralleled by improvement in work and social adjustment. There were no interactions of BtB with concomitant pharmacotherapy or duration of illness, but evidence, on the Beck Anxiety Inventory only, of interaction with primary care practice. Importantly, there was no interaction between the effects of BtB and baseline severity of depression, from which we conclude that the effects of the computer program are independent of starting level of depression. CONCLUSIONS: These results demonstrate that computerized interactive multimedia cognitive-behavioural techniques under minimal clinical supervision can bring about improvements in depression and anxiety, as well as in work and social adjustment, with and without pharmacotherapy and in patients with pre-treatment illness of durations greater or less than 6 months. Thus, our results indicate that wider dissemination of cognitive-behavioural techniques is possible for patients suffering from anxiety and/or depression.     

Effects of mailed preoperative instructions on learning and anxiety

This study sought to contrast mailing a booklet to accomplish preoperative instruction with teaching performed by nurses after hospital admission. Sixty-six patients were studied in a 700-bed medical center and were assigned to three teaching groups and a control group which did not receive teaching. The researcher compared the four groups preoperatively after admission to determine the patients' knowledge and ability to perform surgical exercises, as well as their anxiety levels.

Findings were that patients who received a booklet by mail preadmission learned surgical exercises equally well compared to patients taught postadmission, and mastered significantly more exercise behaviors than those receiving no instruction. No statistical difference in anxiety level was found among groups. One may infer that mailing preadmission material should be considered as an effective teaching mode and alternative to postadmission instruction.     

Beta-blockers in anxiety disorders

Studies evaluating the antianxiety and antipanic properties of beta-blockers do not support their routine use in treating either generalized anxiety disorder or panic disorder. The use of propranolol for anxiety disorders accompanied by physical symptoms, especially cardiovascular complaints, may be effective in some patients when combined with benzodiazepines or perhaps in some non-responders to conventional treatment. Better designed studies are needed to evaluate the exact role of beta-blocking agents in treating anxiety. The efficacy of propranolol in patients with panic disorder has not been widely researched, but preliminary results have not been encouraging. Propranolol may provide symptomatic relief in some patients with residual somatic complaints (i.e., palpitations and tachycardia), when combined with the patient's ongoing drug regimen. Because beta-blockers may induce depression, they should be used cautiously--if at all--in panic patients with concurrent depressive illness.     

A review on cognitive impairments in depressive and anxiety disorders with a focus on young adults

BACKGROUND: There is growing evidence for cognitive dysfunction in depressive and anxiety disorders. Nevertheless, the neuropsychological profile of young adult patients has not received much systematic investigation. The following paper reviews the existing literature on cognitive impairments in depressive and anxiety disorders particularly among young adults. Additionally, the focus of young adult age group and the effect of confounding variables on study results are discussed. METHODS: Electronic database searches were conducted to identify research articles focusing on cognitive impairments in depressive or anxiety disorders among young adults published in English during years 1990-2006. RESULTS: Cognitive impairments are common in young adults with major depression and anxiety disorders, although their nature remains partly unclear. Accordingly, executive dysfunction is evident in major depression, but other more specific deficits appear to depend essentially on disorder characteristics. The profile of cognitive dysfunction seems to depend on anxiety disorder subtype, but at least obsessive-compulsive disorder is associated with deficits in executive functioning and visual memory. The conflicting results may be explained by heterogeneity within study participants, such as illness status, comorbid mental disorders, and medication, and other methodological issues, including inadequate matching of study groups and varying testing procedures. LIMITATIONS: The study is a comprehensive review, but not a formal meta-analysis, due to methodological heterogeneity. CONCLUSIONS: Cognitive impairments are common in major depression and anxiety disorders. However, more research is needed to confirm and widen these findings, and to expand the knowledge into clinical practice. Controlling of confounding variables in future studies is highly recommended.     

Psychiatric screening in general practice: comparison of the general health questionnaire and the hospital anxiety depression scale

The prevalence of psychiatric disorder in 100 patients attending their general practitioner was found to be 33% based on the criteria of the DSM-3 diagnostic system. Using the DSM-3 diagnosis as a yardstick, the performance of the hospital anxiety depression scale was compared with that of the general health questionnaire. Relative operating coefficient analysis showed good discrimination between `cases' and `non-cases' for both questionnaires, and the optimum threshold score was found to be eight for the hospital anxiety depression scale and five for the general health questionnaire. Using these threshold scores the positive predictive value was 81% for the hospital anxiety depression scale and 77% for the general health questionnaire. The hospital anxiety depression scale appeared more sensitive than the general health questionnaire (90% versus 77%) and simpler to complete. In addition, it does not require a different threshold score for each population studied. The use of screening questionnaires in general practice is discussed.     

The Nottingham Study of Neurotic Disorder: predictors of 12-year outcome of dysthymic, panic and generalized anxiety disorder

BACKGROUND: Controlled prospective studies of the simultaneous long-term outcome of several mental disorders are rare. This study sought to determine if there were important differences between the outcome of anxiety and depressive disorders after 12 years and to examine their main predictors. METHOD: A cohort of 210 people seen in general practice psychiatric clinics with a DSM-III diagnosis of generalized anxiety disorder (71), panic disorder (74), or dysthymic disorder (65), including combined anxiety-depressive disorder (cothymia) (67) was followed up after 12 years. Interview assessments of symptoms, social functioning and outcome were made, the latter using a new scale, the Neurotic Disorder Outcome Scale. Seventeen baseline predictors were also examined. RESULTS: Data were obtained from 201 (96 %) patients, 17 of whom had died. Only 73 (36 %) had no DSM diagnosis at the time of follow-up. Using univariate and stepwise multiple linear regression those with cothymia, personality disorder, recurrent episodes and greater baseline self-rated anxiety and depression ratings had a worse outcome than others; initial diagnosis did not contribute significantly to outcome and instability of diagnosis over time was much more common than consistency. CONCLUSION: Only two out of five people with the common neurotic disorders have a good outcome despite alleged advances in treatment. Those with greater mood symptoms and pre-morbid personality disorder have the least favourable outcome. It is suggested that greater attention be paid to the concurrent treatment of personality disorder and environmental factors rather than symptoms as these may be the real cause of apparent treatment resistance.     

Suicide risk in patients with anxiety disorders: a meta-analysis of the FDA database

BACKGROUND: Previous reports of suicide risk in patients with anxiety disorders have been inconsistent. METHODS: Using the FDA database, we assessed suicide and suicide attempt risk among patients, participating in recent clinical trials evaluating new anti-anxiety medications, with diagnosis of panic disorder (PD), social anxiety disorder or social phobia (SP), generalized anxiety disorder (GAD), post traumatic stress disorder (PTSD), and obsessive compulsive disorder (OCD). RESULTS: Overall, among 20076 participating anxious patients, 12 committed suicide and 28 attempted suicide. The annual suicide risk rate was 193/100000 patients and annual suicide attempt risk was 1350/100000 patients. LIMITATIONS: Clinical trial data have limited applicability to clinical practice. Participants in clinical trials are a highly selected, nonrepresentative sample of the clinical population. A number of patients never complete clinical trials and thus data are based on a limited sub-sample. These trials were not primarily designed to assess suicide risk. CONCLUSIONS: Suicide risk in patients with anxiety disorders is higher than previously thought. Patients with anxiety disorders warrant explicit evaluation for suicide risk.     

The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues

BACKGROUND: Although symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder, the pathophysiologic, theoretical, and clinical significance of their co-occurrence has not been well studied. METHODS: The epidemiological and clinical studies that have assessed the overlap of bipolar and anxiety disorders are reviewed, with focus on panic disorder and obsessive-compulsive disorder (OCD), and to a lesser extent, social phobia and post-traumatic stress disorder. Potential neural mechanism and treatment response data are also reviewed. RESULTS: A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder. Psychobiological mechanisms that may account for these high comorbidity rates likely involve a complicated interplay among various neurotransmitter systems, particularly norepinephrine, dopamine, gamma-aminobutyric acid (GABA), and serotonin. The second-messenger system constituent, inositol, may also be involved. Little controlled data are available regarding the treatment of bipolar disorder complicated by an anxiety disorder. However, adequate mood stabilization should be achieved before antidepressants are used to treat residual anxiety symptoms so as to minimize antidepressant-induced mania or cycling. Moreover, preliminary data suggesting that certain antimanic agents may have anxiolytic properties (e.g. valproate and possibly antipsychotics), and that some anxiolytics may not induce mania (e.g. gabapentin and benzodiazepines other than alprazolam) indicate that these agents may be particularly useful for anxious bipolar patients. CONCLUSIONS: Comorbid anxiety symptoms and disorders must be considered when diagnosing and treating patients with bipolar disorder. Conversely, patients presenting with anxiety disorders must be assessed for comorbid mood disorders, including bipolar disorder. Pathophysiological, theoretical, and clinical implications of the overlap of bipolar and anxiety disorders are discussed.     

Deciding who gets treatment for depression and anxiety: a study of consecutive GP attenders

BACKGROUND: Most research has focused on recognition by GPs of the common mental disorders: depression and anxiety. However, less is known about the factors that determine whether patients with those disorders that are recognised receive any active treatment. AIM: To investigate factors associated with receiving active treatment among consecutive attenders identified by GPs as having a common mental disorder. SETTING: Data were collected as part of a cluster randomised controlled trial in 30 general practices in the south of Bristol, UK, on the impact of mental health guidelines in primary care. METHOD: We studied 439 consecutive general practice attenders aged 16-64 years who were given a diagnosis of depression, anxiety, or chronic mixed anxiety and depression by their GP. The main outcome measure was the provision of any active treatment, whether pharmacological or psychological, for these disorders. Patient, GP, and practice level data, including sociodemographic, clinical, and administrative data were explored as predictors in a logistic regression model. Huber White variance estimates were used to account for hierarchical clustering. RESULTS: Of those patients identified as having a common mental disorder by the GP, 54% were offered active treatment. Higher symptom score, as measured by the General Health Questionnaire (GHQ) (odds ratio [OR] = 1.09; 95% confidence interval [CI] = 1.06 to 1.13; P<0.001) and being male (OR = 1.54; 95% CI = 1.13 to 2.09; P = 0.006), were both associated with an increased likelihood of being offered active treatment. Patients with anxiety (OR = 0.24; 95% = CI 0.14 to 0.41; P<0.001), or chronic mixed anxiety/depression (OR = 0.41; 95% CI = 0.23 to 0.73; P = 0.003) were less likely to be offered active treatment than those considered to have depression. CONCLUSION: When deciding to offer active treatment for common mental disorders, GPs appear to be influenced by the severity of symptoms rather than their 'understandability' in relation to recent life stresses or the social context of distress. Further research is needed to investigate why men are more likely and those with an anxiety disorder less likely, to be offered active treatment.     

Treatment of child anxiety: an exploratory study of the role of maternal anxiety and behaviours in treatment outcome

Anxiety disorders are common among parents of anxious children and have been found to impede child treatment outcomes, yet it is unclear whether it is parental anxiety that needs to be targeted in therapy or associated parental behaviours. Twenty‐two children (6–12 years) with a current anxiety disorder and their mothers received cognitive–behavioural treatment (CBT) for child anxiety. In addition, of the 12 mothers who met criteria for a current anxiety disorder, 6 received CBT for their own disorder. Assessments were made of the mother–child interaction. The main findings were: (1) children did less well from treatment where their mothers had a current anxiety disorder; (2) treatment of maternal anxiety disorder did not improve child treatment outcome; and (3) maternal overinvolvement and expression of fear was associated with child treatment outcome. The results suggest that in the context of maternal anxiety disorder, child treatment outcome may be improved by specifically targeting parenting behaviours. Copyright © 2008 John Wiley & Sons, Ltd.     

A qualitative study of patients'' views on anxiety and depression.

BACKGROUND: In the management of patients with anxiety and depression in general practice, the emphasis has been on improving detection and appropriate use of drug therapies by health professionals. Patients' own perceptions of their problems and what services they would prefer have not often been sought. AIM: To explore patient perspectives in relation to their healthcare needs in anxiety and depression. DESIGN OF STUDY: Semi-structured individual and focus group interviews. SETTING: A total of 27 patients from an urban four-partner group general practice who were identified as having anxiety and depression by a practice population questionnaire survey. METHOD: All interviews were transcribed and the major themes were summarised using grounded theory analysis. RESULTS: Patients seek many different ways of coping with their problems but view their general practice as a focal point for help. Their experiences are dominated by the struggle to control unwelcome and intrusive thoughts and to live in a hostile and threatening world. They also have distinct preferences regarding their health needs and there is universal scepticism about drug therapies. CONCLUSION: Patients describe personal and professional barriers to seeking help and have particular views on the treatment options. This perspective contrasts with the current professional emphasis on detection and drug use. This view is therefore central to informing the debate on management of neurotic disorders in primary care and on improving the care of these patients.     

Psychotherapies for comorbid anxiety in bipolar spectrum disorders

Background

Comorbid anxiety disorders are highly prevalent in bipolar disorder and have been shown to have serious negative impacts on the course of illness. The pharmacological treatment of anxiety can interact with the bipolar disorder and has not been proven effective. As such, many have recommended the psychological treatment of anxiety. This paper reviews the literature on psychological treatments for anxiety comorbid to bipolar disorder.

Method

The Medline, PsychInfo and Web of Science databases were thoroughly examined for relevant treatment studies.

Results

Despite frequent recommendations in the literature, surprisingly few have studied the psychological treatment of comorbid anxiety in bipolar disorders. Nevertheless, preliminary results suggest that comorbid anxiety disorders can be effectively treated in a bipolar clientele using cognitive-behavioral therapy, mindfulness-based cognitive-behavioral therapy or relaxation training. In contrast, interpersonal, family therapy and psychoeducation alone would not seem to be beneficial treatment alternatives for anxiety. Cognitive-behavioral therapy appears to reduce the symptoms of obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder and general symptoms of anxiety among patients with bipolar disorder. However, the long-term maintenance of anxiety treatment effects may be somewhat reduced and adaptations may be called for to augment and sustain benefits.

Conclusions

There is an urgent need for randomized controlled trials of different forms of psychotherapy for anxiety disorders comorbid to bipolar disorder. Until such trials are available, the most promising approach would appear to be the sequential or modular CBT-based treatment of the anxiety disorder.     

Neurasthenia in the 1980s: chronic mononucleosis, chronic fatigue syndrome, and anxiety and depressive disorders

In the 1980s, patients suffering from unexplained fatigue and what seemed like a prolonged attack of acute mononucleosis were given the diagnosis of chronic mononucleosis or chronic infection with the Epstein-Barr virus. Although the diagnosis has great appeal, the Epstein-Barr virus does not cause the syndrome (CFS) of chronic fatigue, which has been renamed and redefined chronic fatigue syndrome to remove the inference that the virus is its cause. From a historical perspective, both syndromes represent the 1980s equivalent of neurasthenia, a disease of fatigue that influenced the development of psychiatric nosology. Because patients with depression and anxiety also have chronic fatigue and because most patients with CFS have an affective disorder, the assessment of organic causes of this syndrome requires careful psychiatric diagnosis and treatment. Defining chronic fatigue syndrome as a medical disorder may deprive patients of competent treatment of their affective disorder.     

Preliminary investigation of intolerance of uncertainty treatment for anxiety disorders

Intolerance of uncertainty (IU) is the tendency to react negatively to uncertain situations or events, and it has been found to be an important maintaining factor in a number of different anxiety disorders. It is often included as a part of cognitive behavioural interventions for anxiety disorders but its specific contribution to treatment outcome has not been examined. The aim of the present study was to examine the effectiveness of a brief treatment specifically targeting IU in a 25‐year‐old man with comorbid diagnoses of social phobia, panic disorder, generalised anxiety disorder, major depressive disorder and dysthymia. A single case design series was utilised. Six sessions of individual therapy were provided with symptom measures administered weekly throughout the 3‐week baseline, treatment and 1‐month post‐treatment phase. Clinically significant improvement occurred on measures of IU and social anxiety but not on a general measure of anxiety. The clinical implications of this finding and directions for future research are discussed.     

Depression and anxiety associated with secondary amenorrhea

Secondary amenorrhea, when an organic etiology has been ruled out, is a considerable challenge to gynecologists and family physicians. Five of 18 patients suffering from amenorrhea were found to have major depressive disorder and four others generalized anxiety disorder. The dexamethasone suppression test corroborated clinical findings in three of the five depressed patients, but otherwise yielded low specificity. Since antidepressants may potentially reverse amenorrhea when a severe depressive state is present, the findings should alert the physician to include clinical and biologic criteria for depression in the diagnostic work-up for amenorrhea.     

Assisted bibliotherapy: effective, efficient treatment for moderate anxiety problems.

Specific psychological treatments of proven effectiveness for moderate anxiety disorders are not often easily accessible in general practice. In this study, selected patients were supported in learning skills to manage their symptoms. This approach was efficient, acceptable, and led to clinically significant symptom reduction for a high proportion of patients. This improvement was well sustained at three-month follow-up.     

Ambiguity in the manifestation of adult separation anxiety disorder occurring in complex anxiety presentations: Two clinical case reports

Two case reports are described in which patients presented for the treatment of multiple comorbid anxiety disorders, all of which appeared to derive from prolonged separation anxiety disorder. In particular, these adults had effectively altered their lifestyles to avoid separation, thereby displaying only ambiguous separation anxiety symptoms that initially seemed attributable to their comorbid anxiety disorders. These reports highlight the complex nature of separation anxiety disorder in adulthood, as well as the substantial impairment to the patients' lives that occurred in coping with the disorder. Lastly, difficulties in identifying the disorder in the presence of comorbid anxiety are discussed.     

Clinically relevant cholesterol elevation in anxiety disorders: A comparison with normal controls

Recently, several studies reported elevated cholesterol levels in panic disorder, agoraphobia, and general anxiety disorder, but the clinical relevance is still unsettled. All studies so far have disregarded the possible influence of dietary and physical exercise factors. In this study, 30 patients with different anxiety disorders and 30 normal controls were compared for total cholesterol, low-density lipoprotein (LDL), and cholesterol/high-density lipoprotein (HDL) ratio. Dietary and physical exercise habits were measured by self-rating questionnaires. Patients with anxiety disorders had significantly elevated total cholesterol, LDL, and cholesterol/HDL ratios. Patients showed borderline-high or high cholesterol levels almost 3 times as often as control participants. Anxiety-specific avoidance of physical exercise and special dietary habits of anxiety patients had a significant but minor impact on differences in cholesterol between both groups. Our data support the assumption that serum cholesterol elevations in anxiety disorder patients are within a clinically relevant range.     

Treating anxiety by discontinuing antidepressants: A case series

When a patient has symptoms of anxiety, while taking an antidepressant for depression, is it possible that the antidepressant is part of the problem? Can antidepressants cause anxiety? If this were so, even if relatively rare, it would have widespread implications because of the broad use of antidepressants. However, antidepressants are widely used as a treatment for anxiety. Therefore, unless suggestive evidence were to emerge to implicate them as a potential exacerbating factor, broad use of antidepressants would likely continue for patients whose depression has improved but whose anxiety has not responded, or worsened. In that context we present 12 patients whose anxiety diminished substantially when antidepressants were tapered off, as reflected in Clinical Global Improvement Scale scores assigned by their respective clinicians. Mean duration of antidepressant taper was 17 weeks (range 0–48), as suggested by limited prior evidence supporting very slow taper rates for this purpose. Alternative treatments for depression were often used for these patients as antidepressants were tapered, particularly lithium and lamotrigine, but none of the alternatives used are generally regarded as having anti-anxiety effects. Patients with bipolar disorder diagnoses, including schizoaffective disorder, were specifically excluded. In many of these cases, other medications that might have anti-anxiety effects (including buspirone, quetiapine, olanzapine, gabapentin, and diphenhydramine) were also tapered off. Results suggest that antidepressants may actually cause anxiety in some patients with unipolar depression. Alternatively, lamotrigine or lithium may have more anti-anxiety effects than generally recognized; or these patients may have had subtle bipolar disorder despite the absence of symptoms meeting formal criteria, supporting the “bipolar spectrum” perspective on mood disorder diagnosis. This study is limited by the outcome measure used, which assesses anxiety only indirectly in the context of global improvement. However, in view of the broad implications of the findings, these preliminary observations warrant further consideration. Some patients with anxiety may be treatable not by adding medications, but rather by tapering off existing ones.