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The hippocampus plays an important role in psychopathology and treatment outcome. While posterior hippocampus (PH) may be crucial for the learning process that exposure-based treatments require, affect-focused treatments might preferentially engage anterior hippocampus (AH). Previous studies have distinguished the different functions of these hippocampal sub-regions in memory, learning, and emotional processes, but not in treatment outcome. Examining two independent clinical trials, we hypothesized that anterior hippocampal volume would predict outcome of affect-focused treatment outcome [Interpersonal Psychotherapy (IPT); Panic-Focused Psychodynamic Psychotherapy (PFPP)], whereas posterior hippocampal volume would predict exposure-based treatment outcome [Prolonged Exposure (PE); Cognitive Behavioral Therapy (CBT); Applied Relaxation Training (ART)].
Thirty-five patients with posttraumatic stress disorder (PTSD) and 24 with panic disorder (PD) underwent structural magnetic resonance imaging (MRI) before randomization to affect-focused (IPT for PTSD; PFPP for PD) or exposure-based treatments (PE for PTSD; CBT or ART for PD). AH and PH volume were regressed with clinical outcome changes.
Baseline whole hippocampal volume did not predict post-treatment clinical severity scores in any treatment. For affect-focused treatments, but not exposure-based treatments, anterior hippocampal volume predicted clinical improvement. Smaller AH correlated with greater affect-focused treatment improvement. Posterior hippocampal volume did not predict treatment outcome.
This is the first study to explore associations between hippocampal volume sub-regions and treatment outcome in PTSD and PD. Convergent results suggest that affect-focused treatment may influence the clinical outcome through the ‘limbic’ AH, whereas exposure-based treatments do not. These preliminary, theory-congruent, therapeutic findings require replication in a larger clinical trial.
Randomized control trials (RCTs) comparing attention control training (ACT) and attention bias modification (ABM) in posttraumatic stress disorder (PTSD) have shown mixed results. The current RCT extends the extant literature by comparing the efficacy of ACT and a novel bias-contingent-ABM (BC-ABM), in which direction of training is contingent upon the direction of pre-treatment attention bias (AB), in a sample of civilian patients with PTSD.
Fifty treatment-seeking civilian patients with PTSD were randomly assigned to either ACT or BC-ABM. Clinician and self-report measures of PTSD and depression, as well as AB and attention bias variability (ABV), were acquired pre- and post-treatment.
ACT yielded greater reductions in PTSD and depressive symptoms on both clinician-rated and self-reported measures compared with BC-ABM. The BC-ABM condition successfully shifted ABs in the intended training direction. In the ACT group, there was no significant change in ABV or AB from pre- to post-treatment.
The current RCT extends previous results in being the first to apply ABM that is contingent upon AB at pre-treatment. This personalized BC-ABM approach is associated with significant reductions in symptoms. However, ACT produces even greater reductions, thereby emerging as a promising treatment for PTSD.
This chapter describes the clinical relevance of idioms of distress for the generation and treatment of anxiety disorders, focusing mainly on those related to panic disorder and post-traumatic stress disorder (PTSD) in Southeast Asian and Latino populations. It reviews idioms of distress that are cultural illness syndromes. Certain idioms of distress may indicate impairment in psychosocial functioning, including work and social functioning, as well as general well-being, as assessed by quality-of-life and disability measures. The chapter also presents a model of how anxiety disorders and idioms of distress mutually reinforce each other, forming interacting escalating loops that link expectation, attention, catastrophic cognitions, and activation of the autonomic nervous system. Awareness of the relationship between cultural syndromes and anxiety disorders can enhance clinicians' ability to engage patients about a variety of therapeutic approaches and to tailor evidence-based treatments to patients' cultural understandings and experiences.
Anxiety disorders are amongst the most common of all mental health problems. Research in this field has exploded over recent years, yielding a wealth of new information in domains ranging from neurobiology to cultural anthropology to evidence-based treatment of specific disorders. This book offers a variety of perspectives on new developments and important controversies relevant to the theory, research, and clinical treatment of this class of disorders. Clinicians will find reviews of state-of-the-art treatments for panic disorder, social anxiety disorder, phobias, obsessive-compulsive disorder, generalized anxiety disorder, and post-traumatic stress disorder, as well as controversies over diagnostic and treatment issues. Researchers will find in-depth consideration of important selected topics, including genetics, neuroimaging, animal models, contemporary psychoanalytic theory, and the impact of stressors. This book illustrates the enormous advances that have occurred in anxiety research and describes the evolving multi-disciplinary efforts that will shape the future of the field.
Social phobia turned out to be a severe clinical problem for patients whose fear of evaluation and scrutiny by others interfered with social functioning as well as performance. The study comparing phenelzine, atenolol, and placebo in social anxiety disorder became a model to be followed by subsequent trials. Social anxiety disorder appears to be a highly prevalent condition. While the most recent epidemiologic survey, the NESARC, has found a lifetime prevalence of 5% as opposed to the 13% found in the original National Comorbidity Survey (NCS) study, it would still appear that social anxiety disorder is one of the more common psychiatric conditions. Future studies should go a long way toward clarifying the pathophysiology of social anxiety disorder, which in turn should facilitate diagnosis as well as treatment. Positron emission tomography (PET) scans of patients giving speeches are beginning to delineate the brain circuits relevant to social phobic symptomatology.
This chapter discusses the evidence for the role of genetic factors in the etiology of anxiety disorders, and summarizes the genetic study designs used in research on anxiety disorders. Molecular genetic study designs used to investigate the genetics of anxiety disorders include linkage analysis and candidate gene association studies. Twin studies support a heritability estimate between 30% and 40%. More recently, regulators of G-protein signaling have been investigated regarding anxiety-related phenotypes including panic disorder. Family studies suggest that risk of social anxiety disorder (SAD) to first-degree relatives of SAD probands ranges from 16% to 26%. Investigations of panic disorder, specific phobias, SAD, and obsessive-compulsive disorder (OCD) have produced some evidence of linkage to specific regions. Two exciting yet mostly unexplored areas in anxiety disorder research are gene-environment interaction and epigenetic studies. Epigenetic research examines the dynamic heritable changes in the function of a gene.
This chapter describes the research pertaining to the association between attachment relationships and vulnerability to anxiety disorders. It focuses on recent research that suggests possible pathways from attachment to anxiety disorders in the areas of emotional regulation, anxiety sensitivity, and cognitive style. Recently, attachment researchers have begun to conceptualize the working model in a way more consistent with what is known about brain functions and with the fact that the quality of relationships often varies over time. Researchers have studied the relationship between adult attachment style and psychological functioning. Much research has identified a correlation between insecure attachment and anxiety sensitivity. Childhood separation anxiety disorder (C-SepAD) is the most common childhood anxiety disorder. Researchers have studied attachment style among people with post-traumatic stress disorder (PTSD). More research is needed, however, to elucidate specific relationships between attachment and other DSM-IV anxiety disorders.