This dissertation is divided into three parts. The first part aimed to investigate the cannabidiol anxiolytic effect in treatment-naïve individuals with social anxiety disorder through simulation of public speaking. Twenty-four never-treated social anxiety disorder subjects were allocated to receive 0 or 600 mg cannabidiol (CBD; n=12) in a double-blind randomized design. The same number of controls performed the simulation of a public speaking test without receiving any medication. Pretreatment with CBD significantly reduced anxiety, cognitive impairment, and discomfort in speech performance and significantly decreased alertness in their anticipatory speech. The placebo group displayed higher anxiety, cognitive impairment, discomfort, and alertness when compared with controls as assessed with the Visual Analogue Mood Scale (VAMS). The SSPS-N scores showed significant increases during testing of the placebo group that was almost abolished in the cannabidiol group. No significant differences were observed between the cannabidiol and control groups in SSPS-N scores or in cognitive impairment, discomfort, and alertness factors of the VAMS. The second part evaluated healthy subjects\' x y during a public speaking test following a high rimonabant oral dose, to understand better the possible pharmacological approaches for anxiety disorder treatment. Twenty four participants were randomly allocated to receive 0 or 90 mg rimonabant (n=12) in a double-blind design. No significant adverse effects were reported in either group. Participants who received rimonabant showed increased anxiety levels compared to placebo during anticipatory speech and performance measurements. Rimonabant treatment did not affect sedation, cognitive impairment, discomfort, blood pressure, heart rate, self-statements during public speaking, or bodily symptoms scales. Increased anxiety may reflect lower endocannabinoid activity in CB1 receptors and CB1 p \' possible role in modulation of anxiety and anxiety disorders. The third part aimed to monitor cannabinoid blood concentrations during sustained abstinence from chronic daily cannabis smoking. Thirty male chronic daily cannabis smokers resided on a secure clinical research unit for up to 33 days, with blood collected once daily. ?9-tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), and 11-nor-9-carboxy-THC (THCCOOH) whole blood concentrations were quantified by two-dimensional gas chromatography-mass spectrometry. Twenty-seven of 30 participants were THC-positive on admission, with a median (range) concentration 1.4 ng/mL (0.3-6.3). THC decreased gradually with only 1 of 11 participants negative at 26 days; 2 of 5 participants remained THC-positive (0.3 ng/mL) for 30 days. 5.0% f p p h TH >=1 0 g/ L f 12 y M 11-OH-THC w 1 1 g/ L w h >=1 0 g/ L 24h THCCOOH detection rates were 96.7 on admission, decreasing slowly to 95.7 and 85.7% on days 8 and 22, respectively; four of 5 participants remained THCCOOH positive (0.6-2.7 ng/mL) after 30 days and one remained positive on discharge at 33 days. THC was quantified in some participants for 30 days, albeit in low concentrations, due to the large cannabinoid body burden from extended exposure / Esta tese é dividida em três partes. A primeira parte consiste em investigar o efeito ansiolítico do canabidiol na ansiedade social através do teste de simulação de falar em público. Vinte e quatro sujeitos com ansiedade social, nunca tratados, receberam placebo ou canabidiol (CBD) 600 mg (n=12) em um estudo randomizado e duplo-cego. O mesmo número de indivíduos saudáveis realizaram o teste de simulação de falar em público sem receber medicação. A administração do CBD reduziu significativamente a ansiedade, sedação física e outros sentimentos e atitudes durante a fase de estresse, e diminui o nível de alerta na fase pré-estresse. O grupo placebo apresentou níveis elevado de ansiedade, sedação física, outros sentimentos e atitudes, e alerta comparado com o grupo controle. A pontuação do SSPS-N evidenciou aumento significativo durante o teste no grupo placebo, enquanto que o CBD reduziu estes níveis. Não houve diferenças significativas entre os grupos CBD e controle na SSPS-N e nos fatores sedação física, outros sentimentos e atitudes e alerta, da Visual Analogue Mood Scale (VAMS). A segunda parte do estudo avaliou a ansiedade em indivíduos saudáveis que receberam alta dose oral de rimonabanto e submetidos ao teste de simulação de falar em público, para melhor entendimento do possível mecanismo farmacológico para tratamento de transtornos de ansiedade. Vinte e quatro sujeitos saudáveis receberam placebo ou rimonabanto 90 mg (n=12) em um randomizado e duplo-cego. Não foi observado efeitos adversos significativo em ambos grupos. O grupo rimonabanto apresentou maiores níveis de ansiedade na fase pré-estresse e durante o estresse. Não houve diferença significativa quanto aos demais fatores avaliados entre os grupos. O aumento na ansiedade após administração do rimonabanto pode-se ao fato de haver diminuição no sistema endocanabinóide nos receptores CB1 e a possível modulação na ansiedade clínica e patológica. A terceira parte objetivou quantificar canabinóides no sangue total em usuários crônicos de cannabis durante abstinência supervisionada. Trinta usuários crônicos de cannabis, do sexo masculino, permaneceram no centro de pesquisa por até 33 dias, com coleta de sangue uma vez ao dia. ?9-tetrahidrocanabinol (THC), 11-hidróxi-THC (11-OH-THC) e 11-nor-9-carbóxi-THC (THCCOOH) foram quantificados no sangue por meio da cromatografia gasosa-espectrometria de massa bidimensional. Vinte e sete de 30 usuários foram positivos para THC no ingresso do estudo, com concentração mediana (variação) de 1.4 ng/mL (0.3-6.3). Níveis de THC diminuíram gradativamente com somente 1 de 11 participantes negativo no dia 26; 2 de 5 indivíduos permaneceram positivos para THC (0.3 g/ L p 30 5 0% j TH >=1 0 g/ L p 12 ç mediana de 11-OH-TH f 1 1 g/ L g >=1 0 g/ L pó 24h. A taxa de detecção de THCCOOH foi 96.7% no ingresso, diminuindo gradativamente para 95.7 e 85.7% nos dias 8 e 22, respectivamente; 4 de 5 sujeitos permaneceram positivo para THCCOOH (0.6-2.7 ng/mL) após 30 dias e um permaneceu positivo no 33º dia. Foi detectado THC em alguns indivíduos por 30 dias, porém em baixas concentrações, devido a extensa eliminação do canabinóide em decorrência da exposição crônica

Submitted by Rosangela Silva (rosangela.silva3@unioeste.br) on 2018-05-15T18:52:22Z No. of bitstreams: 2 Camila Borges Villas Boas.pdf: 1194832 bytes, checksum: 0d293fa14c23d9d546fc5cd44cffa2b6 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) / Made available in DSpace on 2018-05-15T18:52:22Z (GMT). No. of bitstreams: 2 Camila Borges Villas Boas.pdf: 1194832 bytes, checksum: 0d293fa14c23d9d546fc5cd44cffa2b6 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-03-06 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Attention Deficit Hyperactivity Disorder (ADHD) is defined as a persistent condition of inattention and/or hyperactivity/impulsivity which promotes interference in the development of the subject. It is estimated that between 65 and 89% of adult ADHD patients suffer from one or more life-long psychiatric disorders. This high percentage of comorbidities is also similar in the child population, where ADHD may be associated with other disorders in 60-100% of cases. One of the often associated disorders is anxiety, which reaches rates close to 25% in many samples of patients with ADHD. Therapies considered first-line for the treatment of ADHD and for Anxiety Disorder (ANX) alone are relatively well established through use of stimulants and cognitive-behavioral therapy, respectively. However, evidence for the most appropriate treatment when both disorders are present is quite controversial. Objectives: Perform systematic review about pharmacological options used to treat ADHD associated with ANX in order to generate evidence about the most effective, safe and tolerable therapeutic option. Methods: Systematic review was performed following the methodological standards recommended by Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) in the PubMed, Scopus and Directory of Open Access Journals databases in August 2016 and by manual search. Randomized, double-blind, parallel-design trials evaluating efficacy, safety and/or tolerability outcomes were considered. The methodological quality and risk of bias of included studies were assessed using the Jadad Scale and the Cochrane Collaboration tool. Relevant data from all included studies were collected using a previously developed form. At this stage, pertinent information from each study, according to the objective of the study, was extracted and analyzed. Results: A total of 1590 articles were found from databases searched, 218 were evaluated in full text for eligibility and finally 5 studies met all inclusion criteria and were included in the systematic review. Two of the included studies used atomoxetine compared to placebo, in which one population was composed of adult patients and the other was pediatric. Desipramine was also one of the medications used, which was studied to treat children from 6 to 17 years old. The others two studies included methylphenidate as pharmacological treatment for pediatric patients, but in one of them fluvoxamine was combined with methylphenidate. Regarding the methodological quality, studies obtained scores of 3, 4 and 5 on the Jadad scale, being considered of moderate to high quality, respectively. The bias risk analysis found that 60% of the articles were supported by the pharmaceutical industry and therefore classified as having a high bias risk in the "Other bias" domain. All studies in the domains "Blinding of participants and professionals" and "Blinding of outcome assessors" presented low risk of bias. Regarding the domain "Incomplete outcomes", 80% obtained low and 20% high risk of bias. The "Random Sequence Generation", "Allocation Concealment" and "Selective outcome reporting" obtained the following proportions of low vs uncertain risk of bias: 60% vs 40%, 20% vs 80% and 60% vs 40%. Due to the high heterogeneity of eligible studies, it was not possible to combine the results for generation of meta-analyzes. This was mainly due to the diversity of drugs studied and the disparity between the outcomes measures employed. Conclusion: Although few studies have been found, the results obtained through this systematic review point to a more expressive benefit of atomoxetine in the treatment of ADHD with ANX, because it was studied in a wider age group and the studies evaluated atomoxetine through more specific scales for both disorders. It is not possible to say that atomoxetine is superior to the other pharmacological options and only larger clinical trials and with sufficiently fed populations will be able to answer this question. / O Transtorno do Déficit de Atenção com Hiperatividade (TDAH) é definido como um quadro persistente de desatenção e/ou hiperatividade/impulsividade que promove interferências no desenvolvimento do indivíduo. Estima-se que entre 65 a 89% dos pacientes adultos com TDAH sofram um ou mais transtornos psiquiátricos ao longo da vida. Esta alta porcentagem de comorbidades também é semelhante na população infantil, onde o TDAH pode estar associado com outros distúrbios em 60-100% dos casos. Um dos transtornos frequentemente associados é a ansiedade, a qual atinge taxas próximas a 25% em muitas amostras de pacientes com TDAH. As terapias consideradas de primeira linha para o tratamento do TDAH e para o Transtorno de ansiedade (TA) de forma isolada estão relativamente bem estabelecidas, por meio da utilização de estimulantes e terapia cognitivo-comportamental, respectivamente. Porém, as evidências sobre o tratamento mais apropriado para quando ambos os transtornos estão presentes são bastante controversas. Objetivos: Realizar revisão sistemática de literatura sobre as opções farmacológicas utilizadas no tratamento do TDAH associado ao TA com o intuito de gerar evidências sobre a opção terapêutica mais eficaz, segura e tolerável. Metodologia: A revisão sistemática foi realizada seguindo padrões metodológicos recomendados pelo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) nas bases de dados PubMed, Scopus e Directory of Open Access Journals em agosto de 2016 e por busca manual. Ensaios clínicos randomizados, duplo-cego com design paralelo que avaliavam desfechos de eficácia, segurança e/ou tolerabilidade foram considerados. A qualidade metodológica e o risco de viés dos estudos incluídos foram avaliados por meio da Escala de Jadad e pela ferramenta da Colaboração Cochrane. Dados relevantes de todos os estudos incluídos foram coletados utilizando formulário previamente elaborado. Nesta etapa, as informações pertinentes de cada estudo, segundo o objetivo do trabalho, foram extraídas e analisadas. Resultados: Um total de 1590 artigos foi encontrado nas bases de dados pesquisadas, 218 foram avaliados em texto completo para elegibilidade e, por fim, cinco estudos preencheram todos os critérios de inclusão e foram incluídos na revisão sistemática. Dois dos estudos incluídos utilizaram a atomoxetina comparada ao placebo, sendo que em um deles a população era composta por pacientes adultos e no outro pediátrica. A desipramina foi também um dos medicamentos utilizados, a qual foi estudada para tratar crianças de 6 a 17 anos. Os outros dois trabalhos incluídos utilizaram o metilfenidato como tratamento farmacológico de pacientes pediátricos, porém, em um deles, a fluvoxamina foi combinada ao metilfenidato. Em relação à qualidade metodológica, os estudos obtiveram pontuações de 3, 4 e 5 na escala de Jadad, sendo considerados de qualidade moderada a elevada, respectivamente. A análise do risco de viés verificou que 60% dos artigos receberam suporte da indústria farmacêutica e, por isso, foram classificados com um alto risco de viés no domínio “Outros vieses”. Todos os estudos nos domínios “Cegamento dos participantes e profissionais” e “Cegamento dos avaliadores do desfecho” apresentaram baixo risco de viés. Em relação ao domínio “Desfechos incompletos”,80% obtiveram baixo e 20% alto risco de viés. A “Geração da sequência aleatória”, “Ocultação da alocação” e “Relato de desfecho seletivo” obtiveram as seguintes proporções de baixo vs incerto risco de viés: 60% vs 40%, 20% vs 80% e 60% vs 40%. Devido à alta heterogeneidade dos estudos elegíveis, não foi possível combinar os resultados para geração de meta-análises. Isso ocorreu principalmente pela diversidade de medicamentos estudados e pela disparidade entre as medidas de desfecho empregadas. Conclusões: Embora poucos estudos tenham sido encontrados, os resultados obtidos por meio desta revisão sistemática apontam para um benefício mais expressivo da atomoxetina no tratamento do TDAH com TA, tanto por ter sido estudada em faixa etária mais abrangente bem como por escalas mais específicas de avaliação para ambos os transtornos terem sido utilizadas. Não é possível afirmar que a atomoxetina é superior às demais opções farmacológicas e apenas ensaios clínicos maiores poderão responder a esta questão.

Diferentes ensaios clínicos randomizados demonstram que a Terapia Cognitivo-Comportamental (TCC) é muito efetiva no tratamento do Transtorno de Ansiedade Social (TAS). Entretanto, uma quantidade significativa de pacientes não apresentam melhora após a finalização da intervenção com TCC. Tal dado indica a necessidade de desenvolver novas estratégias de tratamento para o TAS. A Terapia Cognitiva Processual (TCP) é uma nova abordagem dentro do campo da TCC que tem como principal objetivo auxiliar os pacientes a identificar e modificar suas crenças centrais disfuncionais, sendo o Processo uma das principais técnicas utilizadas. Algumas pesquisas têm demonstrado a efetividade do Processo no tratamento do TAS e de outros transtornos psiquiátricos. Entretanto, novas pesquisas são necessárias para avaliação não somente de tal técnica, mas de todo o protocolo de intervenção da TCP. Esta pesquisa objetivou avaliar se participantes que receberam uma intervenção individual em TCP apresentam diferenças em relação a sintomas de ansiedade social, medo da avaliação negativa, esquiva e desconforto social, ansiedade, depressão, sofrimento psíquico, distorções cognitivas e viés atencional. Este é um ensaio clínico randomizado que comparou um grupo que recebeu intervenção em TCP e um grupo lista de espera no tratamento do TAS. O estudo apresenta três grupos de pesquisa: o TCP (n =18), o lista de espera (n =21) e o saudável (n =19). Um pesquisador independente ao estudo realizou a distribuição aleatória dos participantes com TAS entre os grupos TCP e lista de espera. Foram realizadas avaliações no pré e pós-teste através de diferentes escalas de auto-relato e do teste de Stroop emocional. Adicionalmente, o grupo TCP respondeu tais escalas a cada quatro sessões. O tratamento foi realizado em 16 sessões com duração de 1h30min cada utilizando a TCP no formato individual. Houve uma redução significativa nos sintomas de ansiedade social, ansiedade, depressão, esquiva e desconforto social, e sofrimento psíquico no grupo TCP ao longo do tratamento (p < 0,05). Tais reduções foram associadas a tamanhos de efeito grandes. Não foram observadas mudanças em nenhum dos instrumentos utilizados no grupo lista de espera (p > 0,05). Houve ainda uma significativa redução no medo da avaliação negativa após a utilização do Processo no grupo tratado, além de uma redução em distorções cognitivas (p < 0,05). Não foram observadas diferenças no pré e pós-teste em relação ao viés atencional nos três grupos da pesquisa (p > 0,05). Este estudo sugere que a TCP pode ser uma nova abordagem clínica efetiva no tratamento do TAS associado à diferentes comorbidades, haja vista que houve uma redução em sintomas de ansiedade social e sintomas comórbidos / Different randomized clinical trials show that Cognitive Behavioral Therapy (CBT) is highly effective in the treatment of Social Anxiety Disorder (SAD). However, a large number of patients do not show improvement after receiving CBT. This indicates that it is important to develop new treatments for SAD. Trial-Based Cognitive Therapy (TBCT) is a new approach within the field of CBT area. It aims to help patients to identify and to modify their dysfunctional core beliefs. One of the main TBCT techniques proposed by TBCT is the Trial. Some research studies have demonstrated the effectiveness of Trial in the treatment of SAD, and other disorders. However, further investigation is needed to firmly establish the efficacy not just for the Trial technique, but also the TBCT approach as a treatment for SAD and other disorders. This research aims to evaluate wheter SAD participants receiving TBCT individual-sessions differ from a SAD waiting list group condition regarding symptoms of social anxiety, fear of negative evaluation, social avoidance and distress, anxiety, depression, mental suffering, and attentional bias. This is a randomized clinical trial comparing TBCT and a Waitlist control condition for the treatment of SAD. The study has three groups: TBCT (n =18), Wailist (n =21), and healthy group (n =19). An independent researcher to study distributed randomly the participants with SAD between TBCT or Waitlist condition. Assessments were made at pre and post-test using several self-report scales, and the emotional Stroop test in the three groups. Additionaly, the TBCT group answered these scales each four sessions. The treatment was delivered in sixteen 1.5 hour sessions using the individual TBCT format. There were reductions in social anxiety, anxiety, depression, social avoidance and distress, and mental suffering symptoms at TBCT group (p < 0.05), but not in the Waitlist group (p > 0.05). Those reductions were associated with a large effect size. There was a significant reduction at fear of negative evaluation after Trial use, and reductions at cognitive distortions throughout the treatment as well (p < 0.05). There were no differences among the three groups regarding attentional bias at pre-test nor at post-test (p > 0.05). This study suggests that TBCT may be a new effective clinical approach to treat SAD associated with high rates of comorbidity, as there were significant reductions in the comorbid symptoms

Predicting who will benefit from what in the treatment of psychiatric disorders is incremental to future development of psychological treatments. In the current study functional magnetic resonance imaging (fMRI) data from participants with social anxiety disorder (SAD) was used to elucidate whether neural responses to negative evaluation could predict treatment response in SAD. Nine weeks prior to Internet- delivered Cognitive Behaviour Therapy (ICBT) onset, participants viewed negative social stimuli directed either at themselves or an significant other during fMRI scanning. Regression analyses including the differential activations for other-referential criticism in contrast to self-referential criticism in the posterior mid cingulate cortex (pMCC) and the lingual gyrus (LG) predicted 34% of treatment change as measured by residual gain scores on the Liebowitz Social Anxiety Scale Self-Report (LSAS-SR) in our sample. The final regression model, combining these measures with behavioural measures, which by themselves explained 27% of the variance, resulted in a model explaining 50% of the variance regarding treatment response. This lends additional support to the notion that further elucidating the neurobiological underpinnings of core processes in SAD, as well as the neural correlates of treatment response to CBT, would be of great value in predicting treatment outcome.

Abstract Generalized anxiety disorder (GAD) is a mental health problem, which is characterized by excessive anxiety and worry, problems that are difficult to control. In the general population, the 12-month prevalence of GAD is 2-3%, with the lifetime prevalence being about 5%. However, GAD is more prevalent among primary care utilizers i.e. approximately 5-8% of them suffer from this disorder. Earlier studies have revealed GAD to be associated with a high utilization of health care resources. There were four goals of the present study; i) to investigate the prevalence of GAD among Finnish health care high utilizers, ii) to examine the association between GAD and utilization of different health care services at the population level, iii) to determine whether there would be any association between frequent utilization of health care services, GAD and somatic symptoms and iv) to compare the costs associated with GAD in secondary care in Finland with those attributable to major depressive disorder (MDD). In addition, the Finnish translation of the 7-item GAD scale (GAD-7) was validated. In a sample (n=150) of health care high utilizers in northern Finland, the prevalence of GAD was found to be 4%; GAD-7 was a valid instrument for detecting GAD in these subjects. In Northern Finland 1966 Birth Cohort, there was a significant association between GAD and health care utilization. Those subjects who screened positive for GAD with GAD-7 made 112% more total health care visits than other individuals. The results were statistically significant when controlled for potential confounders. Both GAD symptoms and physical symptoms were risk factors for frequent attendance of health care services, and the individuals who tested positive for GAD exhibited a higher rate of physical symptoms. Secondary care costs of all patients with a new diagnosis of GAD or MDD were calculated 2 years before and after the diagnosis date using the information from the Finnish Hospital Discharge Registers and National Hospital Benchmarking Database. Patients with a history of earlier depression or anxiety disorder had markedly higher costs compared with patients without psychiatric comorbidities. The highest mean individual costs (€19,538) during the 4-year follow-up were observed among patients with new onset of GAD but with a history of other anxiety disorders or MDD. / Tiivistelmä Yleistynyt ahdistuneisuushäiriö on mielenterveyden häiriö, jolle on ominaista ylenmääräinen ahdistuneisuus ja huolestuneisuus, joita on vaikea kontrolloida. Väestöstä noin 2 % on kärsinyt siitä vuoden aikana ja 5 % elinaikanaan. Perusterveydenhuoltoon hakeutuvilla potilailla sen on todettu olevan muuta väestöä yleisempi n. 5-8 %:n täyttäessä diagnostiset kriteerit. Aiemmat tutkimukset ovat viitanneet yleistyneestä ahdistuneisuushäiriöstä kärsivien käyttävän usein runsaasti terveyspalveluita. Tämän tutkimuksen tarkoituksena oli selvittää yleistyneen ahdistuneisuushäiriön esiintyvyyttä terveyspalveluita paljon käyttävillä suomalaisilla henkilöillä, yleistyneen ahdistuneisuushäiriön yhteyttä erilaisten terveyspalveluiden käyttöön väestötasolla, yleistyneen ahdistuneisuushäiriön ja somaattisten oireiden yhteyttä terveyspalveluiden suurkäyttöön ja yleistyneeseen ahdistuneisuushäiriöön erikoissairaanhoidossa liittyviä kustannuksia vertaillen niitä masennukseen liittyviin kustannuksiin. Samalla validoitiin yleistyneen ahdistuneisuushäiriön seulontaan kehitetyn GAD-7 seulan suomenkielinen käännös. Joukossa pohjoissuomalaisia (n=150) terveyspalveluita paljon käyttäviä henkilöitä 4 %:lla todettiin yleistynyt ahdistuneisuushäiriö. Heillä GAD-7-kysely osoittautui toimivaksi seulontatyökaluksi. Pohjois-Suomen 1966 syntymäkohortissa väestötasolla tutkittaessa todettiin yleistyneeseen ahdistuneisuushäiriöön liittyvän runsasta terveyspalveluiden käyttöä. GAD-7-kyselyssä positiivisen testituloksen saaneilla oli kokonaisuudessaan 112 % enemmän terveyspalveluiden käyttöä. Tulokset olivat tilastollisesti merkitseviä myös huomioitaessa mahdolliset sekoittavat tekijät. Lisäksi sekä yleistynyt ahdistuneisuushäiriö että somaattiset oireet liittyivät terveyspalveluiden suurkäyttöön. Sairaaloiden poistoilmoitusrekisteriä ja kansallista sairaaloiden vertailutietokantaa hyödyntäen laskettiin uusien yleistyneen ahdistuneisuushäiriön ja masennuksen diagnoosin saaneiden potilaiden erikoissairaanhoidon kokonaiskustannukset 2 vuotta ennen ja jälkeen diagnoosin. Erityisen suuret kustannukset olivat niillä uuden diagnoosin saaneilla, joilla oli historiassa aiempi masennus tai ahdistuneisuushäiriö. Suurimmat keskimääräiset erikoissairaanhoidon kustannukset (19 538 €) todettiin niillä yliestyneen ahdistuneisuushäiriön diagnoosin saaneilla, joilla aiemmin oli todettu jokin muu ahdistuneisuushäiriö tai masennus.

The purpose of this study was to examine the origins of the Multicultural Relational Model of therapy and demonstrate the application of this model in the clinical setting. Subjects were two ethnic minority children, a Hispanic boy, age nine, and a mixed-race boy, age 10, who was adopted by an African American family.

Social anxiety disorder, also known as social phobia, is one of the most prevalent anxiety disorders, affecting 7-13% of subjects in the community at some time in their lives. Despite being eminently treatable, it remains largely under-recognised and, therefore, undertreated. The disorder is characterized by a fear of scrutiny by others, with sufferers experiencing excessive anxiety in social and performance situations. This excessive anxiety usually leads to avoidance behaviour that can severely affect normal daily living. With onset commonly occurring during childhood or adolescence, social anxiety disorder may disrupt normal patterns of development of social and personal relationships, often having a long-term impact on emotional stability in social or working life. If left untreated, the course of social anxiety disorder is frequently complicated with comorbid conditions, particularly major depression or substance abuse. This review assesses the size of the clinical problem by evaluating current and lifetime prevalence estimates, age of onset, risk factors and evolution of the clinical course; thereby providing the rationale for early recognition and prompt treatment.

Der Beitrag untersucht auf der Grundlage neuer primärärztlicher Befunde die Versorgungsqualität bei der hinsichtlich Chronizität und Arbeitsausfall schwerwiegendsten Angsterkrankung, der Generalisierten Angststörung. Neben einer knappen Einführung in das Störungsbild werden die an über 20 000 Patienten in 558 Hausarztpraxen gewonnenen Kernbefunde der GAD-P-Studie (Generalisierte Angst und Depression in der Primärärztlichen Versorgung) zusammengefasst und Ansatzpunkte zur Verbesserung der Versorgungsqualität dieses selten adäquat behandelten Störungsbildes diskutiert. Insbesondere wird auf die zentrale Bedeutung einer sichereren diagnostischen Erkennung als Voraussetzung für therapeutische Verbesserungen hingewiesen. In Ergänzung zur Verbesserung bestehender Weiterbildungsangebote wird auf Arzt- und Patientenebene der breitere Einsatz bestehender Screeningverfahren, die Nutzung krankheitsspezifischer Patientenratgeber, sowie eine breitere Öffentlichkeitsarbeit zur Information über dieses bislang vernachlässigte, häufig chronisch verlaufende Krankheitsbild empfohlen. / Based on new empirical findings in a large-scale primary care study, the quality of care for the most chronic and debilitating anxiety problem, generalised anxiety disorder, is examined. Following a brief introduction of this disorder, the core findings of the GAD-P study (generalised anxiety and depression in primary care) with more than 20,000 patients of 558 family doctor practices are summarised and measures to improve the quality of care of patients with generalised anxiety disorder, a disorder which is rarely adequately treated, are discussed. This paper particularly emphasises the standard use of time-efficient diagnostic screening instruments, because improved recognition and diagnosis is the prerequisite for appropriate treatment. Further the role of the media to increase awareness of this disorder as well as patient education materials to improve compliance and to enhance treatment outcome effects are highlighted.

Background and Objectives: To describe patterns of healthcare utilization among patients with generalized anxiety disorder (GAD) in general practitioner (GP) settings in Germany. Methods: Using a large computerized database with information from GP practices across Germany, we identified all patients, aged > 18 years, with diagnoses of, or prescriptions for, GAD (ICD-10 diagnosis code F41.1) between October 1, 2003 and September 30, 2004 ("GAD patients"). We also constituted an age- and sex-matched comparison group, consisting of randomly selected patients without any GP encounters or prescriptions for anxiety or depression (a common comorbidity in GAD) during the same period. GAD patients were then compared to those in the matched comparison group over the one-year study period. Results: The study sample consisted of 3340 GAD patients and an equal number of matched comparators. Mean age was 53.2 years; 66.3% were women. Over the 12-month study period, GAD patients were more likely than matched comparators to have encounters for various comorbidities, including sleep disorders (odds ratio [OR] = 6.75 [95% CI = 5.31, 8.57]), substance abuse disorders (3.91 [2.89, 5.28]), and digestive system disorders (2.62 [2.36, 2.91]) (all p < 0.01). GAD patients averaged 5.6 more GP encounters (10.5 [SD = 8.8] vs 4.9 [5.7] for comparison group) and 1.4 more specialist referrals (2.3 [2.9] vs 0.9 [1.7]) (both p < 0.01). Only 58.3% of GAD patients received some type of psychotropic medication (i.e., benzodiazepines, antidepressants, and/or sedatives/hypnotics). Conclusions: Patients with GAD in GP practices in Germany have more clinically recognized comorbidities and higher levels of healthcare utilization than patients without anxiety or depression.

Objective: To examine the association between separation anxiety disorder (SAD) and mental disorders in a community sample and to evaluate whether separation anxiety is specifically related to panic disorder with and without agoraphobia. Method: The data come from a 4-year, prospective longitudinal study of a representative cohort of adolescents and young adults aged 14–24 years at baseline in Munich, Germany. The present analyses are based on a subsample of the younger cohort that completed baseline and two follow-up investigations (n = 1,090). DSM-IV diagnoses were made using the Munich Composite International Diagnostic Interview. Cox regressions with time-dependent covariates were used to examine whether prior SAD is associated with an increased risk for subsequent mental disorders. Results: Participants meeting DSM-IV criteria for SAD were at an increased risk of developing subsequent panic disorder with agoraphobia (PDAG) (HR = 18.1, 95% CI = 5.6–58.7), specific phobia (HR = 2.7, 95% CI = 1.001–7.6), generalized anxiety disorder (HR = 9.4, 95% CI = 1.8–48.7), obsessive-compulsive disorder (HR = 10.7, 95% CI = 1.7–66.1), bipolar disorder (HR = 7.7, 95% CI = 2.8–20.8), pain disorder (HR = 3.5, 95% CI = 1.3–9.1), and alcohol dependence (HR = 4.7, 95% CI = 1.7–12.4). Increased hazard rates for PDAG (HR = 4.2, 95% CI = 1.4–12.1), bipolar disorder type II (HR = 8.1, 95% CI = 2.3–27.4), pain disorder (HR = 1.9, 95% CI = 1.01–3.5), and alcohol dependence (HR = 2.1, 95% CI = 1.1–4.) were also found for subjects fulfilling subthreshold SAD. Conclusions: Although revealing a strong association between SAD and PDAG, our results argue against a specific SAD-PDAG relationship. PDAG was neither a specific outcome nor a complete mediator variable of SAD.