Showing papers by "Michelle G. Craske published in 1999"

Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment.

Abstract: Background: Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome. Method: Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications. Results: Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p <.01), more utilization of emergency room and medical provider visits (p <.01), and more mental health visits (p <.05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy. Conclusion: These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.

Alteration of memory in the reduction of children's distress during repeated aversive medical procedures.

Abstract: The present study sought to reduce children's distress during aversive medical procedures using a brief, cost-effective intervention aimed at reframing memory. Fifty children diagnosed with leukemia (25 treatment, 25 attention control, aged 3-18) were observed as they underwent 3 consecutive lumbar punctures (LPs; baseline, postintervention, and follow-up). Self-report, physiological, and observable distress measures were collected before and after each LP. At posttreatment, children in the intervention group showed reductions in anticipatory physiological and self-report ratings relative to the control group. At follow-up, these effects generalized to reductions in procedural distress. These results suggest that (a) a simple memory-based intervention is efficacious at reducing children's distress and (b) benefits from this intervention are maintained over 1 week even without continued intervention.

Development of a brief diagnostic screen for panic disorder in primary care.

Abstract: Objective The purpose of this study was to determine the utility of a brief screening tool for panic disorder in the primary care setting. Methods A total of 1476 primary care outpatients in three primary care medical clinics on the West Coast of the United States were studied. Patients completed a brief self-report measure, the five-item Autonomic Nervous System Questionnaire (ANS), while in the waiting room. The presence of DSM-IV panic disorder was subsequently determined in groups of "screen-positive" and "screen-negative" subjects using the Composite International Diagnostic Interview. A subset of patients (N = 511) also completed the 21-item Beck Anxiety Inventory. Indices of diagnostic utility were calculated using receiving operating characteristic analyses to guide the selection of optimal cutoff levels. Results The two-question version of the ANS had excellent sensitivity (range = 0.94-1.00 across the three clinic sites) and negative predictive value (0.94-1.00) but low specificity (0.25-0.59) and positive predictive value (range 0.18-0.40). The three- and five-question versions of the ANS had only modestly improved specificity, and this was achieved at the cost of reduced sensitivity and increased respondent burden to complete the questionnaire. The 21-item Beck Anxiety Inventory had maximal clinical utility at a cutoff level of > or =20, but sensitivity was lower than desirable for a screening instrument (0.67). Conclusions The two-question version of the ANS shows promise as a screening instrument for panic disorder in the primary care setting.

Self-monitoring with panic and anxiety disorders.

Abstract: Self-monitoring has become a popular assessment tool in treatment outcome research and descriptive psychopathology for panic and anxiety disorders. Commonly used formats of self-monitoring for each anxiety disorder are described. Self-monitoring is compared with self-report estimation. On the one hand, self-monitoring may be influenced by reactivity, as well as by attentional and judgmental biases that underlie fear and anxiety. On the other hand, self-monitoring may minimize certain influences that tarnish estimation, such as response demand biases, memory deficits, inflation of aversive experiences, and availability heuristics. Issues for statistical analysis of self-monitored data for panic and the anxiety disorders are outlined. Finally, directions for future research and clinical use of self-monitoring are discussed.

Worry affects the immune response to phobic fear.

Abstract: Worry, the cognitive enumeration and anticipation of potential future negative events, is associated with autonomic dysregulation, which may in turn have implications for the immune system. People endorsing high (n = 7) and normal levels of trait worry (n = 8) were briefly exposed to a phobic stimulus and the autonomic and immune responses and recovery were assessed. A time-matched control group (n = 6) was not exposed to any stimulus. Both worry groups showed increased heart rate and skin conductance in response to phobic fear. However, only the normal worry group showed a concomitant increase in natural killer cells in peripheral blood. Patterns of change during the follow-up period suggested that phobic fear had disrupted a normal circadian increase in natural killer cells. Adrenergic and hypothalamus-pituitary-adrenal mechanisms may be responsible for the differences between high and normal worry groups in their natural killer cell response to and recovery from phobic fear.

Implications of a New Theory of Disuse for the Treatment of Emotional Disorders

Abstract: In this review, we conceptualize exposure-based treatment as a learning experience. With this approach, optimizing treatment is a matter of optimizing memory for new learning. Given that perspective, we discuss the implications of a "new theory of disuse," proposed by Bjork and Bjork (1992) to capture the storage and retrieval dynamics that characterize human memory. The theory distinguishes between the storage strength and retrieval strength of learned representations and provides a framework from which we derive a number of manipulations that have the potential to improve the long-term effectiveness of Cognitive behavioral therapy. Implications for treatment of specific fears are described in detail, with additional discussion regarding treatment for other emotional disorders.

Anxiety: at the intersection of genes and experience

Abstract: Human anxiety disorders arise from a combination of genetic vulnerability and traumatic experience. Mice with a GABAA receptor mutation may provide a model for these disorders.

Nocturnal panic and trauma.

Abstract: We examined the recollection of traumas in panic disorder patients with and without history of nocturnal panic attacks. From a sample of 154 patients seeking treatment for panic disorder, almost 85% of those with nocturnal panic reported a history of traumatic events in comparison to only 28% without nocturnal panic. Fear of loss of vigilance is considered as a potential mediator of the relationship between nocturnal panic and traumatic events.