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Have you ever felt anxious? How do you usually react when you are afraid of something? Anxiety is a normal feeling that everyone gets from time to time. Since it is an unpleasant feeling, people often try to avoid situations that make them feel that way. For example, skipping school because you have to give a presentation in front of the whole class. Some people can feel too much anxiety. Anxiety makes them nauseous, and they might start to stutter. In our work, we would like to discuss “avoidance of learned fear”. In this article, we will explore anxious feelings and whether people tend to avoid things they are anxious about.

Objective: To examine attachment insecurity and low social support as potential mediators of the association between childhood maltreatment (CM) types and depression severity in patients with a lifetime history of major depressive disorders (MDD). Method: Participants with an acute or remitted MDD (N = 580) completed questionnaires about CM (Childhood Trauma Questionnaire), attachment (Relationship Scales Questionnaire), social support (Social Support Questionnaire), and depression severity (Beck Depression Inventory). Mediation and path models with CM types as independent variables, attachment avoidance and anxiety as mediators and depression severity as dependent variable were calculated. In addition, a sequential mediation model with attachment insecurity and social support as mediators of the association between CM and depression was tested. Results: Attachment avoidance and anxiety partially mediated the effect of CM on depression. In the path model including the different CM types, there were significant indirect effects of emotional abuse on depression via attachment anxiety and of emotional neglect on depression via attachment avoidance. Results also supported the hypothesized sequential mediation via attachment insecurity and social support. Limitations: A cross-sectional design with a retrospective self-report measure of CM was used and the developmental timing of exposure to CM was not considered. Conclusion: Our findings suggest that the effect of emotional abuse and emotional neglect on depression is partially mediated by attachment avoidance and anxiety. Further, the results support the hypothesis of a sequential mediation via attachment insecurity and social support. Accordingly, attachment insecurity is discussed as a target of psychotherapy for patients with MDD and CM.

Background A habitual avoidance component may enforce the persistence of maladaptive avoidance behavior in anxiety disorders. Whether habitual avoidance is acquired more strongly in anxiety disorders is unclear. Methods Individuals with current social anxiety disorder, panic disorder and/or agoraphobia (n = 62) and healthy individuals (n = 62) completed a devaluation paradigm with extensive avoidance training, followed by the devaluation of the aversive outcome. In the subsequent test phase, habitual response tendencies were inferred from compatibility effects. Neutral control trials were added to assess general approach learning in the absence of previous extensive avoidance training. Results The compatibility effects indicating habitual control did not differ between patients with anxiety disorders and healthy controls. Patients showed lower overall approach accuracy, but this effect was unrelated to the compatibility effects. Conclusions In this study, anxiety disorders were characterized by reduced approach but not stronger habitual avoidance. These results do not indicate a direct association between anxiety disorders and the acquisition of pervasive habitual avoidance in this devaluation paradigm.

Background: There is a lack of knowledge regarding the relationship between dimensional psychopathological syndromes and neurocognitive functions, particularly across the major psychiatric disorders (i.e., Major Depressive Disorder (MDD), Bipolar Disorder (BD), and Schizophrenia (SZ)). Method: SANS, SAPS, HAMA, HAM-D, and YMRS were assessed in 1064 patients meeting DSM-IV-TR criteria for MDD, BD, SZ or schizoaffective disorder (SZA). In addition, a comprehensive neuropsychological test battery was administered. Psychopathological syndromes derived from factor analysis and present state of illness were used to explore psychopathology-cognition relationships. Correlational analyses were corrected for age, sex, verbal IQ, years of education, and DSM-IV-TR diagnosis. Age of onset and total duration of hospitalizations as proxies for illness severity were tested as moderators on the cognition - psychopathology relationship. Results: The negative syndrome, positive formal thought disorder as well as the paranoid-hallucinatory syndrome exhibited associations with neuro-cognition in an illness state-dependent manner, while the psychopathological factors depression and increased appetite only showed weak associations. Illness severity showed moderating effects on the neurocognitive-psychopathology relationship only for the negative syndrome and positive formal thought disorder. Limitations: No healthy control subjects were entered into the analyses because of lack of variance in psychopathological symptoms, which prevents from drawing conclusions regarding the relative level of potential cognitive impairments. Conclusions: This study suggests the relationship of neuro-cognition and psychopathology to be highly state of illness-dependent across affective and psychotic disorders. Results hint at the moderating effects of illness severity on psychopathological factors that might be more treatment resistant.

Background: In treatment-resistant major depressive disorder (MDD), electroconvulsive therapy (ECT) is a treatment with high efficacy. While knowledge regarding changes in brain structure following ECT is growing, the effects of ECT on brain function during emotional processing are largely unknown. Objective: We investigated the effects of ECT on the activity of the anterior cingulate cortex (ACC) and amygdala during negative emotional stimuli processing and its association with clinical response. Methods: In this non-randomized longitudinal study, patients with MDD (n = 37) were assessed before and after treatment with ECT. Healthy controls (n = 37) were matched regarding age and gender. Functional magnetic resonance imaging (fMRI) was obtained twice, at baseline and after six weeks using a supraliminal face-matching paradigm. In order to evaluate effects of clinical response, additional post-hoc analyses were performed comparing responders to non-responders. Results: After ECT, patients with MDD showed a statistically significant increase in ACC activity during processing of negative emotional stimuli (pFWE = .039). This effect was driven by responders (pFWE = .023), while non-responders showed no increase. Responders also had lower pre-treatment ACC activity compared to non-responders (pFWE = .025). No significant effects in the amygdala could be observed. Conclusions: ECT leads to brain functional changes in the ACC, a relevant region for emotional regulation during processing of negative stimuli. Furthermore, baseline ACC activity might serve as a biomarker for treatment response. Findings are in accordance with recent studies highlighting properties of pre-treatment ACC to be associated with general antidepressive treatment response.

Major depressive disorder (MDD) is associated to affected brain wiring. Little is known whether these changes are stable over time and hence might represent a biological predisposition, or whether these are state markers of current disease severity and recovery after a depressive episode. Human white matter network (“connectome”) analysis via network science is a suitable tool to investigate the association between affected brain connectivity and MDD. This study examines structural connectome topology in 464 MDD patients (mean age: 36.6 years) and 432 healthy controls (35.6 years). MDD patients were stratified categorially by current disease status (acute vs. partial remission vs. full remission) based on DSM-IV criteria. Current symptom severity was assessed continuously via the Hamilton Depression Rating Scale (HAMD). Connectome matrices were created via a combination of T1-weighted magnetic resonance imaging (MRI) and tractography methods based on diffusion-weighted imaging. Global tract-based metrics were not found to show significant differences between disease status groups, suggesting conserved global brain connectivity in MDD. In contrast, reduced global fractional anisotropy (FA) was observed specifically in acute depressed patients compared to fully remitted patients and healthy controls. Within the MDD patients, FA in a subnetwork including frontal, temporal, insular, and parietal nodes was negatively associated with HAMD, an effect remaining when correcting for lifetime disease severity. Therefore, our findings provide new evidence of MDD to be associated with structural, yet dynamic, state-dependent connectome alterations, which covary with current disease severity and remission status after a depressive episode.

Background: Blended cognitive behavioral therapy (bCBT) — the combination of cognitive behavioral therapy and digital mental health applications — has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed. Objective: This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety. Methods: This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app. Results: The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=−0.70 to −0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=−0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=−0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=−0.49; P<.001) but not in the anxiety group (Cohen d=−0.06; P=.72). Patients’ mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups. Conclusions: This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults.