„Comorbidity“ among mental disorders is commonly observed in both clinical and epidemiological samples. The robustness of this observation is rarely questioned; however, what is at issue is its meaning. Is comorbidity „noise“ – nuisance covariance that researchers should eliminate by seeking „pure“ cases for their studies – or a „signal“ – an indication that current diagnostic systems are lacking in parsimony and are not „carving nature at its joints?“ (Krueger, p. 921). With these words, Krueger started a discussion on the structure of mental disorders, which suggested that a 3-factor model of common mental disorders existed in the community. These common factors were labeled „anxious-misery,“ „fear“ (constituting facets of a higher-order internalizing factor), and „externalizing.“ Along with similar evidence from personality research and psychometric explorations and selective evidence from genetic and psychopharmacologic studies, Krueger suggested that this model might not only be phenotypically relevant, but might actually improve our understanding of core processes underlying psychopathology. Since then, this suggestion has become an influential, yet also controversial topic in the scientific community, and has received attention particularly in the context of the current revision process of the Manual of Mental Disorders (Fifth Edition) (DSM-V) and the International Classification of Diseases, 11th Revision (ICD-11). Focusing on anxiety disorders, this article critically discusses the methods and findings of this work, calls into question the model’s developmental stability and utility for clinical use and clinical research, and challenges the wide-ranging implications that have been linked to the findings of this type of exploration. This critical appraisal is intended to flag several significant concerns about the method. In particular, the concerns center around the tendency to attach wide-ranging implications (eg, in terms of clinical research, clinical practice, public health, diagnostic nomenclature) to the undoubtedly interesting statistical explorations.

Background: Maternal perinatal mental health has been shown to be associated with adverse consequences for the mother and the child. However, studies considering the effect of DSM-IV anxiety disorders beyond maternal self-perceived distress during pregnancy and its timing are lacking. Aims: To examine the role of maternal anxiety disorders with an onset before birth and self-perceived distress during pregnancy for unfavourable maternal, obstetric, neonatal and childhood outcomes. Study design: DSM-IV mental disorders and self-perceived distress of 992 mothers as well as obstetric, neonatal and childhood outcomes of their offspring were assessed in a cohort sampled from the community using the Munich-Composite International Diagnostic Interview. Logistic regression analyses revealed associations (odds ratios) between maternal anxiety disorders and self-perceived distress during pregnancy with maternal depression after birth and a range of obstetric, neonatal and childhood psychopathological outcomes. Results: Lifetime maternal anxiety disorders were related to offspring anxiety disorders, but not to offspring externalizing disorders. Analyses focussing on maternal DSM-IV anxiety disorders before birth yielded associations with incident depression after birth. In addition, self-perceived distress during pregnancy was associated with maternal depression after birth, preterm delivery, caesarean section, separation anxiety disorder, ADHD, and conduct disorder in offspring. Conclusion: Findings confirm the transmission of anxiety disorders from mother to offspring. Apart from maternal anxiety, self-perceived distress during pregnancy also emerged as a putative risk factor for adverse outcomes. The finding that maternal anxiety disorders before birth yielded less consistent associations, suggests that self-perceived distress during pregnancy might be seen as a putative moderator/mediator in the familial transmission of anxiety.

Social phobia is a common disorder associated with significant psychosocial impairment, representing a substantial public health problem largely determined by the high prevalence, and the lifelong chronicity. Social phobia starts in early childhood or adolescence and is often comorbid with depression, other anxiety disorders, alcohol and substance abuse or eating disorders. This cascade of comorbidity, usually secondary to social phobia, increases the disability associated with the condition. The possibility that social phobia may be a trigger for later developing comorbid disorders directs attention to the need for early effective treatment as a preventive measure. The most recent drug class to be investigated for the psychopharmacological treatment of social phobia is the SSRI group for which there is growing support. The other drug classes that have been evaluated are monoamine oxidase inhibitors (MAOIs), benzodiazepines, and beta-blockers. The SSRIs represent a new and attractive therapeutic choice for patients with generalized social phobia. Recently the first, large scale, placebo-controlled study to assess the efficacy of drug treatment in generalized social phobia has been completed with paroxetine. Paroxetine was more effective in reducing the symptoms than placebo and was well tolerated. Many now regard SSRIs as the drugs of choice in social phobia because of their effectiveness and because they avoid the problems of treatment with benzodiazepines or classical MAOIs.

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.

Hintergrund: Angststörungen gehören zu den häufigsten psychischen Störungen im Jugend- und Erwachsenenalter. Ein Großteil der Betroffenen bleibt meist unbehandelt. Informationen über die Behandlungswahrscheinlichkeit bei Jugendlichen und jungen Erwachsenen in Abhängigkeit von der Störungs- und Behandlungsart, Lebensalter, Geschlecht und Komorbidität liegen bisher nicht vor. Methode: In einer repräsentativen Stichprobe 14- bis 34-Jähriger aus dem Großraum München (Early Developmental Stages of Psychopathology Studie, N = 3021) werden die Prävalenz und Lebenszeitinzidenz von Angststörungen sowie ihre Behandlungsraten mittels M-CIDI erfasst und differenziert für Lebensalter, Komorbidität und Geschlecht präsentiert. Ergebnisse: 30% der Befragten berichteten mindestens eine Angststörung in ihrem Leben. Fast die Hälfte der Betroffenen (43%) suchte irgendeine Behandlung, ein Drittel (28%) suchte einen Psychotherapeuten auf. Für die meisten Angststörungen lagen hohe Quoten psychotherapeutischer Behandlungen vor (Range: 50–61%). Jugendliche berichteten seltener als Erwachsene irgendeine Behandlung, eine psychotherapeutische Behandlung, die Konsultation eines Psychiaters oder Hausarztes. Frauen nahmen häufiger eine Psychotherapie in Anspruch als Männer. Das Vorliegen einer komorbiden Angst- oder depressiven Störung erhöhte die Behandlungswahrscheinlichkeit. Diskussion: Verglichen mit europäischen Studien berichtete die Stichprobe relativ häufig eine Behandlung, auch eine psychotherapeutische. Dies kann eine Folge des großen Behandlungsangebotes in München sein. Dennoch bleibt der Großteil der jungen Betroffenen unbehandelt. Zur Prävention langfristiger Beeinträchtigungen sowie sekundärer psychischer Störungen sollte das Versorgungssystem verstärkt auf diese Bevölkerungsgruppe ausgerichtet werden. / Background: Anxiety disorders are among the most frequent mental disorders in adolescence and adulthood. Most of the affected individuals do not receive treatment. Information about treatment use among adolescents and young adults, differentiated for the kind of treatment and anxiety disorder, age, gender and co-morbidity, is still missing. Methods: In a representative sample of 14–34 year-old adolescents and young adults of the Munich area (Early Developmental Stages of Psychopathology study, N = 3,021) prevalence and lifetime incidence of anxiety disorders and treatment use are assessed using the M-CIDI and will be presented for age, co-morbidity and gender. Results: 30% of all participants reported at least one lifetime diagnosis of an anxiety disorder. Almost half of those affected (43%) received some kind of treatment; one third (28%) received psychotherapy. Psychotherapy use was frequent in most anxiety disorders (range: 50–61%). Older individuals more frequently reported any treatment, psychotherapy, consultations with psychiatrists or general practitioners. Women used psychotherapy more often than men. Co-morbid anxiety or depressive disorders increased the probability of treatment use. Discussion: As compared to European estimations, we found relatively high rates of treatment use. This may be due to the many treatment possibilities in the Munich area. Nevertheless, most young people affected do not receive treatment. Considering the long-term effects of anxiety disorders and in order to prevent secondary disorders, efforts should be increased to reach these young individuals.

Der Langzeitverlauf und die Häufigkeit sogenannter spontaner Remissionen wurde anhand von 77 Fallen mit einer Lifetime-Diagnose einer Angststörung untersucht. Die 77 Angstfälle wurden als Teil der Münchner Follow-up-Studie im Rahmen einer allgemeinen Bevölkerungsuntersuchung im Jahre 1974 identifiziert und wurden über einen Zeitraum von sieben Jahren (bis 1981) weiter untersucht. Die Diagnosen wurden einerseits durch ein standardisiertes diagnostisches Instrument (den DIS), andererseits über eine klinisch-psychiatrische Nachuntersuchung (1981) abgesichert. In Ergänzung hierzu wurde der Verlauf der psychopathologischen Symptome sowie die psychologische und psychosoziale Integration der Versuchspersonen beurteilt. Ergebnisse: Die Lebenszeit-Prävalenz, irgendeine Anststörung zu entwickeln, betrug 13,9%. Einfache und soziale Phobien wiesen eine Prävalenz von 8,0%, Agoraphobie von 5,7%, Zwangsstörungen von 2,0% und Panikstörungen von 2,4% auf. Die Inzidenz, d.h. das Auftreten neuer Fälle im Zeitraum zwischen der Erst- und Zweituntersuchung war niedrig, mit Ausnahme für Panikstörungen (1,2%, bei einer Gesamtprävalenz von 2,4%) und Agoraphobie (1,3% bei einer Gesamtprävalenz von 5,7%). Die Komorbidität war sowohl innerhalb der Angststörungen wie auch bezüglich anderer psychischer Störungen erhöht. 62% hatten mehr als eine Angstdiagnose, Major Depression und Abhängigkeit von Alkohol oder Medikamenten waren die häufigsten komorbiden Störungen, die in der überwiegenden Mehrzahl deutlich nach dem Beginn der Angststörung auftraten. Spontanremissionen wurden auf drei unterschiedlichen Ebenen definiert, von denen ein Kombinationsmaβ als Hauptergebnis interpretiert wurde. Danach war die symptomatische Remission in alien Angstgruppen niedrig, während die psychosoziale Remissionsrate ein günstigeres Bild mit Remissionsraten zwischen 28,6% für Panikstörung und 53,1% für einfache und soziale Phobien ergab. Das kombinierte spontane Remissionsmaβ ergab für keine der Zwangsstörungen, nur 14,3% der Panikstörungen, 19,2% der Agoraphobien und 18,8% der einfachen und sozialen Phobie eine voile Remission. Die Ergebnisse unterstreichen, daβ Angststörungen zumeist in der Kindheit oder frühen Adoleszenz beginnen und dazu neigen, chronisch über den Groβteil des Lebens zu persistieren und nur selten zu remittieren.

Objectives: For characterizing the association between parenting and offspring social phobia (SP), contrasting maternal vs. paternal contributions, putative predictors of unfavorable parenting behaviors and its specificity for SP are warranted to delineate targeted prevention and intervention strategies. Methods: A population-based sample of 1053 adolescents was followed-up using the M-CIDI. Parenting was assessed via questionnaire in offspring passing the high risk period for SP-onset. Natal complications and childhood serious health problems as assessed by maternal reports were hypothesized to relate to unfavorable parenting. Results: The pattern of maternal overprotection, paternal rejection and lower emotional warmth was associated with SP, but not with other offspring anxiety disorders. Natal complications were related to overprotection and lower emotional warmth; trend-level associations emerged for serious health problems and unfavorable parenting. Conclusions: Paternal behavior appears particularly relevant for SP. The pattern of maternal overprotection, paternal rejection and lower emotional warmth was observed in SP only, suggesting that its detailed assessment provides a promising opportunity for targeted prevention and intervention in SP.

Die vorliegende Arbeit beschäftigt sich mit der Diagnostik unerwünschter Gedanken sowie der Spezifität von Gedankenunterdrückung bei phobischen Patienten. Zwei Fragebogenverfahren zum Thema Sorgen sowie ein Instrument zur Erfassung von Strategien im Umgang mit intrusiven Gedanken wurden bezüglich der Gütekriterien der deutschen Übersetzung in einer klinischen Stichprobe evaluiert. Dabei handelt es sich um den Worry Domains Questionnaire (WDQ), der Sorgeninhalte erhebt, den Penn State Worry Questionnaire (PSWQ), der die Intensität von Sorgen erfasst, und den Thought Control Questionnaire (TCQ) zur Erfassung der Gedankenkontrollstrategien. Die Verfahren wurden bei 440 Psychotherapie-Patienten zu drei Meßzeitpunkten eingesetzt. Hinsichtlich der inneren Konsistenz und der Retest-Reliabilität ergeben sich für alle Instrumente zufriedenstellende bis gute Kennwerte. Die Validität ist nur für den PSWQ als gut zu bezeichnen. Beim WDQ zeigen sich Probleme hinsichtlich der Trennung von Sorgen und sozialer Ängstlichkeit, während der TCQ wohl eher Aspekte allgemeiner Psychopathologie als spezifische Strategien erfasst. Eine zweite Studie befasste sich mit intentionaler Gedankenunterdrückung. Die paradoxen Effekte dieser Bemühungen wurden wiederholt mit psychischen Störungen, vor allem mit Angststörungen, in Verbindung gebracht. Dabei ist ein wichtiges Thema, ob die Gedankenkontrollfähigkeit nur für störungsspezifische Inhalte oder generell beeinträchtigt ist. Die vorliegende Studie verglich Patienten mit Agoraphobie und Patienten mit Sozialphobie mit einer gesunden Kontrollgruppe. Alle Personen mussten Gedanken an ein neutrales Kontrollthema sowie zwei störungsspezifische Themen unterdrücken. Es zeigte sich ein störungsspezifischer Effekt bei den Agoraphobikern. Sozialphobiker scheinen hingegen ein generelles Defizit ihrer mentalen Kontrolle aufzuweisen. Zusätzlich erwies sich soziale Ängstlickeit innerhalb einer Reihe psychopathologischer Variablen als stärkster Prädikator für Schwierigkeiten bei der Gedankenunterdrückung. Ingesamt weisen einige Ergebnisse dieser Arbeit darauf hin, dass Gedankenunterdrückung ein wichtiges Merkmal der Sozialphobie sein könnte. / The work conducted aimed at evaluating instruments investigating unwanted thoughts as well as determining the specifity of thought suppression in phobia. German translations of two questionnaires measuring worry as well as an instrument, measuring strategies used in dealing with unwanted thoughts, were evaluated in a clinical sample. We used the Worry Domains Questionnaire (WDQ), measuring contents of worry, the Penn State Worry Questionnaire (PSWQ), measuring the intensity of worry, and the Thought Control Questionnaire (TCQ), investigating strategies in thought control. The instruments were administered at three points in a sample of 440 patients receiving psychological treatment. Concerning internal consistency and retest-reliability all questionnaires showed acceptable to good results. Validity is only good concerning PSWQ. WDQ has problems in differentiating worry and social anxiety, where as TCQ seems to measure general psychopathology more than specific strategies. The second study investigated intended thought suppression. Its paradoxical effects have been linked to psychological disorders, namely anxiety disorders. One important issue is if thought suppression is impaired only for thoughts related to the disorder or if the ability for mental control is generally impaired in anxiety patients. This study compared groups of agoraphobics and social phobics with healthy controls. All subjects had to suppress a neutral topic and two topics related to the central fear of the two disorders. We found a rather specific deficit in thought suppression for the agoraphobics. Social phobics seem to be characterized by a general impairment of mental control. In addition, among several psychopathological variables, social anxiety proved to be the strongest predictor for problems with thought suppression. Taken together, there are several indicators that thought suppression may be an important feature of social phobia.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Os transtornos de ansiedade (TAs) estão entre os principais problemas que acometem crianças e adolescentes, podendo atingir uma prevalência de até 24,9% ao longo da vida. A eficácia do tratamento de TAs na infância e na adolescência tem sido demonstrada em estudos de curto prazo de terapia cognitivo-comportamental (TCC), mas ainda são poucos os estudos que avaliam a eficácia da terapia de longo prazo. Portanto, a presente pesquisa tem por objetivo realizar uma revisão sistemática de estudos de seguimento sobre TCC com crianças e adolescentes com TAs (artigo 1) e verificar a resposta a longo prazo da terapia cognitivocomportamental em grupo (TCCG) em relação à intensidade dos sintomas de ansiedade e depressão e à qualidade de vida (artigo 2). Para a realização do primeiro artigo (revisão sistemática), foram consultadas as bases de dados Pubmed e Isi Web of Science. Foram considerados como critérios de inclusão: estudos de coorte após TCC para TAs na infância e na adolescência. Foram excluídos os estudos com período de seguimento inferior a um ano. Para a apresentação dos achados dos estudos, foram considerados os resultados significativos (p<0,05). Em relação ao método utilizado na elaboração do segundo artigo (seguimento não controlado), a pesquisa envolveu 20 adolescentes que realizaram 14 sessões de TCCG para TAs e foram reavaliados após 2 anos do término da intervenção. Para avaliar os desfechos, utilizaram-se os instrumentos antes da TCCG, no final (4 meses) e após 2 anos: Autorrelato para Transtornos Relacionados à Ansiedade na Infância (SCARED-C); Inventário de Depressão Infantil (CDI); Impressão Clínica Global (CGI); Escala de Funcionamento Global (CGAS) e Qualidade de Vida de Jovens (YQOL). O estudo foi aprovado pelo Comitê de Ética em Pesquisa do Hospital de Clínicas de Porto Alegra (nº 110181). Os adolescentes e seus responsáveis assinaram o termo de consentimento livre e esclarecido (TCLE). Como resultado da revisão sistemática, obteve-se um total de 10 artigos que preencheram os critérios de inclusão. O período de seguimento variou entre 12 meses a 13 anos e, em geral, os resultados indicaram a manutenção dos ganhos com a TCC de curto prazo. No entanto, os estudos apresentaram limitações, principalmente em relação ao método, como ausência de grupo controle e perdas de seguimento. No estudo de seguimento, um total de 19 (95%) adolescentes com média de idade de 12,3 (DP=1,0) anos foi avaliado. Houve redução significativa (p<0,001) da gravidade dos sintomas (CGI) e melhora do funcionamento global (CGAS) em comparação com a avaliação inicial. A qualidade de vida geral no seguimento melhorou significativamente (p=0,041) em comparação com a avaliação inicial e final da 7 TCCG. Os sintomas específicos de ansiedade e depressão não apresentaram mudanças significativas (p=0,071 e p=0,206, respectivamente). Os resultados do trabalho sugerem a manutenção dos benefícios da TCC de longo prazo e encorajam a sua utilização entre adolescentes com TAs. / Anxiety disorders (ADs) are among the most prevalent conditions affecting children and adolescents with a lifetime prevalence of up to 24.9%. The efficacy of treatment for ADs in childhood and adolescence has been demonstrated in short-term studies of cognitivebehavioral therapy (CBT), but few studies have investigated the long-term effects of this treatment. Therefore, the present study aimed to systematically review follow-up studies of CBT in children and adolescents with ADs (article 1) and explore the long-term effects of group cognitive-behavioral therapy (GCBT) on quality of life and symptoms of anxiety and depression (article 2). The systematic review was based on a search of the PubMed and ISI Web of Science databases. Articles reporting cohort studies of CBT for ADs in childhood and adolescence were included in the review. Studies with follow-up periods of less than one year were excluded. Results were considered significant at p < 0.05. The second article consisted of an uncontrolled follow-up study involving 20 adolescents who underwent 14 sessions of GCBT for ADs and were assessed at three time points (before and after treatment, and two years after the end of treatment) with the following instruments: Screen for Child Anxiety Related Emotional Disorders, child (SCARED-C); Children's Depression Inventory (CDI); Clinical Global Impression (CGI); Children’s Global Assessment Scale (CGAS) and Youth Quality of Life (YQOL). The study was approved by the Hospital de Clínicas de Porto Alegre Research Ethics Committee (protocol number 110181). Participants and guardians provided written informed consent prior to participation. Ten articles were included in the systematic review. Follow-up periods ranged from 12 months to 13 years, with most studies indicating that the effects of short-term CBT remained stable over time. However, the studies presented a series of methodological limitations, such as lack of control groups and follow-up losses. In the present follow-up study, a total of 19 (95%) adolescents with mean age 12.3 (SD=1.0) years were assessed. There were significant reductions (p<0.001) in symptom severity (CGI) and improvements in global functioning (CGAS) over the course of the study. General quality of life improved significantly at follow-up (p=0.041) as compared to assessments immediately before and after GCBT. There were no significant differences in anxiety and depression symptoms (p=0.071 and p=0.206, respectively). Results of the present studies indicate that the benefits of CBT are maintained over time, and that this method is suitable for the treatment of ADs in adolescents.