Publications (24)57.37 Total impact
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Article: Health care utilisation in patients with non-cardiac chest pain: A longitudinal analysis of chest pain, anxiety and interoceptive fear.
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ABSTRACT: Chest pain can be a frightening experience that leads many to seek medical evaluation. The symptom results in costly health care utilisation. Over half of patients referred for cardiac evaluations of chest pain do not obtain definitive medical explanations for their symptoms; these cases are described as non-cardiac chest pain (NCCP). Some patients with NCCP are not reassured after being informed their chest pain is non-cardiac in origin and seek repeated medical evaluation. Co-morbid anxiety and mood disorders often coexist with NCCP and are associated with health care utilisation. The current study examined chest pain, general anxiety, interoceptive fear and health care utilisation in a sample of 196 chest pain patients near the time of cardiac evaluation (Time 1), and 70 of these patients one year later (Time 2). Results indicate that anxiety and interoceptive fear were significantly associated with health care utilisation at Time 1, and only interoceptive fear (at Time 1) predicted health care utilisation at Time 2. This study develops research in this area by examining the relation of anxiety and health care utilisation longitudinally in patients with NCCP.Psychology & Health 01/2013; · 1.69 Impact Factor -
Article: Does Maintenance CBT Contribute to Long-Term Treatment Response of Panic Disorder With or Without Agoraphobia? A Randomized Controlled Clinical Trial.
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ABSTRACT: Objective: We examined the possibility that maintenance cognitive behavior therapy (M-CBT) may improve the likelihood of sustained improvement and reduced relapse in a multi-site randomized controlled clinical trial of patients who met criteria for panic disorder with or without agoraphobia. Method: Participants were all patients (N = 379) who first began an open trial of acute-phase CBT. Patients completing and responding to acute-phase treatment were randomized to receive either 9 monthly sessions of M-CBT (n = 79) or assessment only (n = 78) and were then followed for an additional 12 months without treatment. Results: M-CBT produced significantly lower relapse rates (5.2%) and reduced work and social impairment compared to the assessment only condition (18.4%) at a 21-month follow-up. Multivariate Cox proportional hazards models showed that residual symptoms of agoraphobia at the end of acute-phase treatment were independently predictive of time to relapse during 21-month follow-up (hazards ratio = 1.15, p < .01). Conclusions: M-CBT aimed at reinforcing acute treatment gains to prevent relapse and offset disorder recurrence may improve long-term outcome for panic disorder with and without agoraphobia. (PsycINFO Database Record (c) 2012 APA, all rights reserved).Journal of Consulting and Clinical Psychology 11/2012; · 4.85 Impact Factor -
Article: The impact of perceived stress and perceived control on anxiety and mood disorders in noncardiac chest pain.
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ABSTRACT: Chest pain without detectable heart disease, noncardiac chest pain (NCCP), is linked with anxiety and depression. Theory posits stress and perceived control may relate to NCCP. We hypothesized stress would have direct and mediated effects via perceived control on anxiety and mood disorders in NCCP. Patients (N = 113) completed questionnaires and a structured diagnostic interview. Stress and perceived control were associated with anxiety and mood disorder severity. Perceived control fully mediated the relation between stress and mood disorder severity but not anxiety disorder severity. Results are partially supportive of anxiety-based theories of NCCP.Journal of Health Psychology 02/2012; 17(8):1183-92. · 1.22 Impact Factor -
Article: Augmenting antidepressant medication with modular CBT for geriatric generalized anxiety disorder: a pilot study.
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ABSTRACT: Generalized anxiety disorder (GAD) is a prevalent psychiatric condition in older adults with deleterious effects on health and cognition. Although selective serotonin reuptake inhibitor (SSRI) medications have some efficacy as acute treatments for geriatric GAD, incomplete response is the most common outcome of monotherapy. We therefore developed a novel sequential treatment strategy, using personalized, modular cognitive-behavioral therapy (mCBT) to augment SSRI medication. In an open label pilot study (N = 10), subjects received a sequenced trial of 12 weeks of escitalopram followed by 16 weeks of escitalopram augmented with mCBT. We also examined the maintenance effects of mCBT over a 28-week follow-up period following drug discontinuation and termination of psychotherapy. Results suggest that (1) adding mCBT to escitalopram significantly reduced anxiety symptoms and pathological worry, resulting in full remission for most patients and (2) some patients maintained response after all treatments were withdrawn. Findings suggest that mCBT may be an effective augmentation strategy when added to SSRI medication and provide limited support for the long-term benefit of mCBT after discontinuation of pharmacotherapy.International Journal of Geriatric Psychiatry 08/2011; 26(8):869-75. · 2.42 Impact Factor -
Article: Noncardiac chest pain in children and adolescents: a biopsychosocial conceptualization.
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ABSTRACT: Pediatric NCCP may be characterized by recurrent pain accompanied by emotional distress and functional impairment. This paper reviews and critiques literature on pediatric noncardiac chest pain (NCCP) and introduces a theoretical conceptualization to guide future study of NCCP in children and adolescents. A developmentally informed biopsychosocial conceptualization of NCCP etiology is proposed based on a synthesis of empirical evidence and clinical observations of pediatric NCCP within the context of relevant findings from the broader pediatric pain and anxiety literature. Multiple factors from biological, psychological, social, familial, and developmental domains are potentially relevant to the etiology of this ailment. This article concludes with directions for future research and clinical implications.Child Psychiatry and Human Development 06/2011; 43(1):1-26. · 1.93 Impact Factor -
Article: Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain.
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ABSTRACT: The aim of this study was to examine independent and combined influences of alexithymia and anxiety sensitivity on chest pain and life interference in patients with non-cardiac chest pain (NCCP). Theories of NCCP posit a central role for emotion in the experience of chest pain, however, studies have not examined how alexithymia characterized by a difficulty identifying or verbalizing emotions, may influence this relationship. This study examined 231 patients (56% females, M age=50 years) with chest pain seeking cardiac evaluation, who showed no abnormalities during exercise tolerance testing. Forty percent (40%) scored at or above the moderate range of alexithymia. Whereas health care utilization was associated with elevated alexithymia among men, health care utilization was associated with elevated anxiety sensitivity among women. Hierarchical regression analyses revealed that alexithymia and anxiety sensitivity were both uniquely and independently associated with pain severity and life interference due to pain. Alexithymia-pain links were stronger for men compared to women. Secondary analyses conducted with a subsample suggest that alexithymia may be increasingly stable over time (i.e., 18-month follow-up). Findings are largely congruent with theoretical models of NCCP showing that personality and emotional factors are important in this medically unexplained syndrome.Journal of behavior therapy and experimental psychiatry 04/2011; 42(4):432-9. · 2.48 Impact Factor -
Article: Assessment and treatment of psychological factors in pediatric chest pain.
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ABSTRACT: Chest pain is regularly encountered in pediatric medical settings and may be associated with many organic diagnoses that vary widely in morbidity and mortality. Patients with chest pain with and without organic disease may also suffer from comorbid, exacerbating, or causal psychopathology. This article provides practical general guidelines for psychological diagnosis and alleviation of emotional and behavioral difficulties. Specific medical conditions that may benefit from psychological consultation are highlighted. Pediatric chest pain, including an analysis of medically unexplained chest pain, is examined from a psychological perspective that includes a critical review of relevant literature and suggestions for the clinical management of this condition.Pediatric Clinics of North America 12/2010; 57(6):1235-60. · 2.24 Impact Factor -
Article: Attrition in a multicenter clinical trial for panic disorder.
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ABSTRACT: This study examined attrition in a multisite clinical trial for panic disorder. Of 379 eligible patients, 19 refused treatment (5% Refusal Rate), 104 discontinued treatment prematurely (19% Dropout Rate) or were withdrawn by the investigators (8% Withdrawal Rate), and 256 completed the treatment (68% Completion Rate). Logistic regression was used to examine 5 domains theorized to be related to attrition (e.g., diagnostic severity, treatment factors). Few variables were associated with increased odds of attrition at padj < 0.004. Younger age was the only independent predictor of attrition in the demographic factor model. Diagnostic severity and comorbidity, panic disorder symptom severity, treatment factors, and therapist factors were unrelated to study attrition. Patient dropout was highest after treatment sessions that targeted interoceptive and situational exposure exercises. Findings suggest that attrition may not strongly threaten the validity of results from treatment outcome studies.The Journal of nervous and mental disease 09/2010; 198(9):665-71. · 1.77 Impact Factor -
Article: Cognitive-Behavior Therapy (CBT) for Panic Disorder: Relationship of Anxiety and Depression Comorbidity with Treatment Outcome.
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ABSTRACT: Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.Journal of Psychopathology and Behavioral Assessment 06/2010; 32(2):185-192. · 1.55 Impact Factor -
Article: Anxiety and hypervigilance to cardiopulmonary sensations in non-cardiac chest pain patients with and without psychiatric disorders.
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ABSTRACT: We investigated body vigilance, cardiac anxiety, and the mediating role of interoceptive fear on pain in patients with non-cardiac chest pain (NCCP; a syndrome of chest pain in the absence of identifiable organic etiology). Patients were more attentive to cardiac-congruent sensations than cardiac-incongruent sensations (e.g., gastrointestinal, cognitive dyscontrol; p's < .001). Patients with a DSM-IV Axis I anxiety or mood disorder were more body vigilant compared to patients who did not have a disorder (p's < .05). Patients with anxiety disorders were particularly vigilant to and fearful of cardiac sensations relative to patients without anxiety disorders. Latent variable path models examined the extent that interoceptive fear mediated the association between body vigilance and cardiac anxiety on chest pain. Within each model, diagnostic status, body vigilance, and cardiac anxiety were exogenous and predicted interoceptive fear that in turn predicted pain. Separate models examined body vigilance and cardiac anxiety, and both models fit the data well. Findings showed partial mediation for the body vigilance factor, and full mediation for the cardiac anxiety factor. Interoceptive fear played a mediating role in both models. The syndrome of NCCP may persist partly due to conscious hypervigilance to and fear of cardiac-congruent body sensations, particularly among anxious patients.Behaviour research and therapy 05/2010; 48(5):394-401. · 3.00 Impact Factor -
Article: Assessment and treatment of psychological causes of chest pain.
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ABSTRACT: Chest pain prompts an estimated 4.6 million people in the United States to seek emergency medical care each year. Chest pain is common in patients with coronary artery disease (CAD). Chest pain is also common in patients without CAD or other cardiac causes for their chest pain, sometimes called non-cardiac chest pain. Psychological assessment and treatment may clinically aid patients with chest pain in ways that may influence disease onset, maintenance, and progression and may improve quality of life. This article highlights factors important for psychological assessment and treatment of patients with chest pain.The Medical clinics of North America 03/2010; 94(2):291-318. · 2.18 Impact Factor -
Article: Risk factors for isolated sleep paralysis in an African American sample: a preliminary study.
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ABSTRACT: Isolated sleep paralysis (ISP) is a temporary period of involuntary immobility that can occur at sleep onset or offset. It has previously been reported in association with both panic disorder (PD) and posttraumatic stress disorder (PTSD). The current study examined the association between ISP and several possible risk factors--anxiety sensitivity, trauma exposure, life stress, and paranormal beliefs--in a sample of African American participants with and without a history of ISP. Significant between-group differences were found for PD and PTSD diagnoses, anxiety sensitivity, life stress, and certain aspects of paranormal belief, with the ISP group being higher on all of these indices. No differences were found with regard to trauma exposure. Hierarchical regression analyses indicated that PD, anxiety sensitivity, and life stress each contributed unique variance to ISP cognitive symptoms, whereas PTSD and paranormal beliefs did not. These results provide preliminary support for an association between ISP and anxiety sensitivity and corroborate previous reports of ISP's association with PD and life stress. The current trauma/PTSD findings are mixed, however, and warrant future research.Behavior therapy 01/2009; 39(4):386-97. · 2.85 Impact Factor -
Article: Relapse following combined treatment discontinuation in a placebo-controlled trial for panic disorder.
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ABSTRACT: A recent double-blind, placebo-controlled trial (Barlow et al., 2000 JAMA. 283:2529-2536) examined separate and synergistic effects of psychological and pharmacological treatments for panic disorder. One finding warranting further investigation involved relatively high relapse rates of participants who received cognitive-behavioral therapy (CBT) + imipramine when compared with those receiving CBT + placebo. In this article, we investigate why CBT was less effective in protecting against relapse for individuals in the active drug condition. We hypothesized that participants correctly deduced treatment assignments and, for those taking imipramine, this was associated with the belief that they were no longer taking active drug after discontinuation, accounting for increased relapse rates. Contrary to hypothesis, there were no group differences in frequencies of guessing drug or placebo, nor were specific beliefs about taking drug or placebo differentially associated with relapse. Other possible reasons for differential relapse rates and treatment implications are discussed.The Journal of nervous and mental disease 08/2008; 196(7):548-55. · 1.77 Impact Factor -
Article: Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization.
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ABSTRACT: The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed.Journal of Consulting and Clinical Psychology 07/2008; 76(3):422-30. · 4.85 Impact Factor -
Article: Predictors and time course of response among panic disorder patients treated with cognitive-behavioral therapy.
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ABSTRACT: Cognitive-behavioral therapy (CBT) is well documented as an efficacious treatment for panic disorder. We provided open CBT treatment to patients who subsequently participated in a maintenance treatment study. This article reports on predictors and trajectory of response in 381 participants who completed treatment at 4 sites. Participants who met criteria for panic disorder with or without agoraphobia (N = 381) completed assessment and entered treatment. Of these, 256 completed 11 sessions of CBT delivered by trained and supervised research therapists. Raters trained to reliability obtained demographic data and administered structured diagnostic interviews and the Hamilton Rating Scales for Depression and Anxiety and the Panic Disorder Severity Scale (PDSS) measures at baseline and posttreatment. We obtained self-report (SR) measures of anxiety sensitivity and adult separation anxiety at baseline and posttreatment and PDSS-SR ratings weekly. The study was conducted between November 1999 and July 2002. Treatment response rate was 65.6% for completers and 44.1% for the intent-to-treat sample. Greater severity of panic disorder and lower levels of adult separation anxiety predicted response. Beginning at week 4, responders showed greater mean decreases in PDSS scores than non-responders and maintained the advantage throughout the treatment. By week 6, 76% of responders, compared to 36% of nonresponders, recorded PDSS scores at least 40% below baseline on 2 consecutive weeks (odds ratio = 5.42, 95% CI = 3.10 to 9.48). These results suggest that CBT is just as effective for more severe panic disorder patients as it is for those with less severe panic disorder, regardless of other comorbid disorders, including agoraphobia. However, patients experiencing adult separation anxiety disorder are less likely to respond. Our results further inform clinicians that many people who will respond to 11 weeks of treatment will have done so by the middle of the treatment.The Journal of Clinical Psychiatry 04/2008; 69(3):418-24. · 5.80 Impact Factor -
Article: Panic attack symptom dimensions and their relationship to illness characteristics in panic disorder.
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ABSTRACT: Subtyping panic disorder by predominant symptom constellations, such as cognitive or respiratory, has been done for some time, but criteria have varied considerably between studies. We sought to identify statistically symptom dimensions from intensity ratings of 13 DSM-IV panic symptoms in 343 panic patients interviewed with the Anxiety Disorders Interview Schedule for DSM-IV Lifetime Version. We then explored the relation of symptom dimensions to selected illness characteristics. Ratings were submitted to exploratory maximum likelihood factor analysis with a Promax rotation. A three-factor solution was found to account best for the variance. Symptoms loading highest on the first factor were palpitations, shortness of breath, choking, chest pain, and numbness, which define a cardio-respiratory type (with fear of dying). Symptoms loading highest on the second factor were sweating, trembling, nausea, chills/hot flashes, and dizziness, which defines a mixed somatic subtype. Symptoms loading highest on the third factor were feeling of unreality, fear of going crazy, and fear of losing control, which defines a cognitive subtype. Subscales based on these factors showed moderate intercorrelations. In a series of hierarchical multiple regression analyses, the cardio-respiratory subscale was a strong predictor of panic severity, frequency of panic attacks, and agoraphobic avoidance, while the cognitive subscale mostly predicted worry due to panic. In addition, patients with comorbid asthma had higher scores on the cardio-respiratory subscale. We conclude that partly independent panic symptom dimensions can be identified that have different implications for severity and control of panic disorder.Journal of Psychiatric Research 10/2006; 40(6):520-7. · 4.66 Impact Factor -
Article: Anxiety and psychosocial stress as predictors of headache and abdominal pain in urban early adolescents.
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ABSTRACT: To examine the relations among anxiety, psychosocial stress, and headache and abdominal pain complaints within the context of the Biobehavioral Model of Pediatric Pain. Adolescents from urban schools serving a predominantly African-American population completed measures of pain, anxiety, witnessing violence, problem situations, and victimization at the end of the seventh grade (N = 502) and 6 months later (longitudinal N = 289). A high prevalence of weekly headaches (40%) and abdominal pain (36%) was reported. Anxiety partially mediated relations between psychosocial stress and pain at Time 1, particularly for problem situations. Longitudinal models showed that adolescents reporting higher levels of pain at Time 1 reported greater increases in victimization and anxiety at Time 2. Changes in pain were positively correlated with changes in anxiety and stress variables. Implications for understanding the causes and correlates of headache and abdominal pain in normal children are discussed.Journal of Pediatric Psychology 08/2006; 31(6):582-96. · 2.91 Impact Factor -
Article: Avoidance behavior in panic disorder: the moderating influence of perceived control.
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ABSTRACT: The relations among anxiety sensitivity, perceived control, and agoraphobia were examined in 239 patients diagnosed with panic disorder (PD). Most patients exhibited agoraphobia accompanying their PD (98% situational avoidance; 90% experiential avoidance; and 80% endorsed interoceptive fear and avoidance). Anxiety sensitivity and perceived emotional control were associated with agoraphobia, and perceived threat control was found to moderate the relationship between anxiety sensitivity and agoraphobia. Lower levels of perceived control were associated with a stronger relationship between anxiety sensitivity and agoraphobia. Results were consistent for self-reported and clinician-rated agoraphobia. Implications for the role of perceived control in agoraphobia development and treatment are discussed.Behaviour Research and Therapy 02/2006; 44(1):147-57. · 3.30 Impact Factor -
Article: Impact of a Brief Intervention on Patient Anxiety Prior to Day Surgery
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ABSTRACT: Patients anticipating surgical procedures experience significant anxiety, resulting in adverse outcomes and increased expenditures. Research has investigated the impact of anxiety-reducing interventions, frequently the provision of surgical information, with inconsistent results. The present study (N = 98) examined preference for information, or monitor-blunter coping style, and the impact of a pre-surgical phone call from an anesthesiologist on anxiety in which treatment group participants (n = 51) dictated the amount of information received. Monitors were hypothesized to desire more information than blunters, and changes in anxiety for monitors/blunters were hypothesized to be moderated by length of call. Monitors and blunters demonstrated equal call durations and anxiety levels remained equivalent across groups. Findings and implications for future research are discussed.Journal of Clinical Psychology in Medical Settings 05/2005; 12(2):99-110. · 1.49 Impact Factor -
Article: A psychometric reanalysis of the Albany Panic and Phobia Questionnaire.
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ABSTRACT: The psychometric properties of the 27-item Albany Panic and Phobia Questionnaire (APPQ) were evaluated in 1930 outpatients with DSM-IV anxiety and mood disorders. Although prior findings of a 3-factor latent structure were upheld in several replications (Social Phobia, Agoraphobia, Interoceptive), three items failed to load on their predicted factor (Interoceptive). Multiple-groups CFAs indicated that the measurement properties of the APPQ were invariant in male and female patients, with the exception of an intercept of one item from the Agoraphobia scale which evidenced bias against females. The three APPQ dimensions were consistently associated with high levels of scale reliability and factor determinacy. Strong evidence of concurrent validity of the Social Phobia and Agoraphobia factors was obtained in relation to interview and questionnaire measures. Although the Interoceptive factor was more strongly related to criterion measures of anxiety sensitivity and fear of panic than Social Phobia, the Agoraphobia factor had the strongest relationships with these validity indices. The results are discussed in regard to psychometric implications for the APPQ and conceptual issues pertaining to the discriminant validity of fear of agoraphobic situations and fear of sensation-producing activities.Behaviour Research and Therapy 04/2005; 43(3):337-55. · 3.30 Impact Factor
Top co-authors
Top Journals
Institutions
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2006–2013
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University of Missouri - St. Louis
- Department of Psychology
Saint Louis, MI, USA
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2004–2009
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Boston University
- Center for Anxiety and Related Disorders
Boston, MA, USA
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2008
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Brown University
Providence, RI, USA
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1998
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Virginia Commonwealth University
Richmond, VA, USA
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