Miriam A. Schiele

Objectives: Anxiety disorders involve abnormal fear learning and exaggerated generalization, proposed as potential risk factors. However, it is unclear whether these processes reflect stable vulnerability markers or symptoms of psychopathology, as most research relies on cross‐sectional correlations and few longitudinal studies assess their predictive role in anxiety. Furthermore, little is known about the test‐retest reliability of fear learning paradigms, despite their suggested function as trait‐like markers for anxiety. Methods: This longitudinal study reassesses initially healthy adults after 3–12 years, and children first examined at ages 8–12, then 12–16, and now at 16–22. Participants repeat the “screaming lady” paradigm, including fear acquisition and generalization. We integrate fear learning, psychometrics, HPA‐axis activity, and (epi)genetics to assess the stability of fear generalization, its predictive value for later anxiety, and the link of fear learning to the HPA system. Conclusion: Our findings will clarify the long‐term stability of fear learning paradigms and evaluate their value as markers of anxiety risk. In addition, a random forest model will explore multiple risk factors and their interaction in anxiety symptomatology. This may improve understanding of anxiety disorders and support early detection and prevention. Trial Registration: Retrospectively registered on AsPredicted.org (#238,927)

Stress plays a significant role in the development of mental and somatic disorders by dysregulating the hypothalamic-pituitary-adrenal (HPA) axis. Epigenetic mechanisms, particularly DNA methylation (DNAm), are assumed to mediate this relationship, with increasing evidence linking stress experience to DNAm changes, though the longitudinal effects of acute stress remain unclear. Here, 122 healthy individuals underwent the Maastricht Acute Stress Test (MAST). Salivary samples for cortisol measurements were taken at seven time points from before to 45 min after stress induction, and blood was drawn for DNAm analyses before and 45 min after. Cortisol reactivity was predicted by baseline DNAm using robust linear models, and a mixed linear model was performed to investigate DNAm changes over time. Downstream analyses included identifying differentially methylated regions (DMRs) and overrepresented Gene Ontology (GO) Terms. A total of 120 CpG sites and four DMRs were associated with cortisol reactivity, with chromatin modifiers among the top findings. Longitudinal epigenome-wide changes were observed at 32 CpG sites and four DMRs. Overrepresented GO terms were related to learning, cognition, and synaptic processes. Two thyroid-related genes, TTR and TSHR , were observed among the top hits. These findings highlight the association between acute stress and DNAm, suggesting DNAm levels to be related to cortisol reactivity and acute stress to influence DNA methylation patterns dynamically. Key genes involved in thyroid function and transcriptional regulation were implicated in the stress response. Further research with larger samples and multi-omics approaches is needed to confirm these findings, assess their long-term stability, and explore their functional relevance.

Mental disorders arise through the interaction of genetic predisposition and environmental influences such as stress. Epigenetic processes, like DNA methylation, could represent a mechanism mediating this interplay in the pathogenesis and maintenance of stress-related mental disorders. Changes in methylation of the serotonin transporter gene (SLC6A4, 5-HTT) are associated with both stress and mental disorders. The present study for the first time longitudinally examines the relationship between the acute stress response and SLC6A4 methylation. For this purpose, 122 healthy adults participated in a standardized acute stress induction paradigm (Maastricht Acute Stress Test; MAST). The stress response was assessed via salivary cortisol collected at seven time points before and after stress induction. SLC6A4 promoter methylation was determined using pyrosequencing of bisulfite-converted DNA from peripheral blood before and 45 min after stress induction. A relative increase in SLC6A4 methylation from before to after the stress test was associated with increased salivary cortisol stress reactivity. Increased SLC6A4 methylation has previously been reported as a potential pathogenetic marker for stress-related mental disorders such as depression and posttraumatic stress disorder (PTSD), and to predict clinical response to both pharmacotherapy and psychotherapy. The present results therefore suggest that acute stress induction may serve as a model paradigm for investigating the potential pathogenetic and treatment mechanisms of stress-related mental disorders.

Introduction: Treatment resistance in anxiety disorders (TR-ADs) constitutes a major clinical challenge conferring a considerable burden regarding quality of life and societal health costs. Methods: This systematic review provides an overview of pharmacological, psychotherapeutic, and neurostimulatory treatment options in adults with treatment-resistant generalized anxiety disorder (TR-GAD), panic disorder (TR-PD)/agoraphobia, and social anxiety disorder (TR-SAD). Results: A total of 26 randomized controlled trials (RCTs) and 36 open label studies were identified, with, however, mostly small sample sizes and several methodological limitations. According to RCTs, selective serotonin reuptake inhibitors (SSRIs) or clomipramine are effective in TR-PD after failure to respond to cognitive behavioral therapy (CBT). In pharmacological TR-SAD, switching from one SSRI to another or to venlafaxine was found helpful in open label trials. RCTs further suggest augmentation with quetiapine, risperidone, olanzapine, or pregabalin in TR-GAD, pindolol in TR-PD, and clonazepam in TR-SAD. Open label studies in TR-AD provide preliminary evidence for ketamine or augmentation with nefazodone, reboxetine, buspirone, aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone, divalproex sodium, levetiracetam, zonisamide, flumazenil, pregabalin, cannabidiol, and acamprosate. For pharmacological TR, CBT was effective in several RCTs. Following nonresponse to CBT, first evidence suggests effectiveness of Acceptance and Commitment Therapy and Mindfulness-Based Cognitive Therapy. Only inconclusive support was identified for repetitive transcranial magnetic stimulation in TR-AD. Conclusion: In summary, this integrative review may provide an evidence base for expert recommendations, inform clinical guidelines, and inspire further research into innovative, personalized treatment of TR-AD increasing response rates and lowering the considerable individual and public health burden of anxiety disorders.

Despite extensive research on DNA methylation (DNAm) signatures associated with alcohol use disorder (AUD), findings are often inconsistent and not replicated. We conducted a large-scale meta-analysis of epigenome-wide association studies (EWAS) to identify reliable, reproducible epigenetic markers of AUD. Seven cohorts, comprising 3,775 individuals (1,325 with AUD), contributed to this meta-analysis within the framework of the Psychiatric Genomics Consortium Substance Use Disorders Epigenetics Working Group. Downstream analyses included the identification of differentially methylated regions, overrepresentation analyses, and the construction of a methylation risk score (MRS). We identified 118 significant CpG sites associated with AUD, with the strongest association found at cg24889777 ( p =5.12×10 ^-17 ) in the long non-coding RNA LOC100505942. CpG sites were enriched for pathways related to GTPase signaling and transmembrane transporter activity, as well as EWAS signals of alcohol consumption. The MRS explained 10.44% of variance in heavy drinking in an independent cohort (N=2,534, AUC=0.657). This large-scale meta-analysis offers key insights into the epigenetic mechanisms of AUD and lays the groundwork for future research on methylation risk scores for the diagnosis, prognosis, and treatment in AUD.

Background: Separation anxiety disorder (SEPAD) is characterized by pronounced fear or anxiety concerning separation from attachment figures. Despite its high lifetime prevalence, adult SEPAD often remains undetected due to a lack of diagnostic tools in multiple languages. The Adult Separation Anxiety Questionnaire (ASA-27) is a key instrument for assessing symptoms of SEPAD in adults. However, no validated German version is available. Objectives: This study addressed the translation and validation of the ASA-27 in a German-speaking population to introduce the first German questionnaire assessing SEPAD. Materials and methods: A consecutive forward and backward translation was conducted. Reliability and validity of the German ASA-27 against several established anxiety-related psychometric scores were assessed in a large sample of 1520 healthy participants. Results: Results revealed robust internal consistency (Cronbach’s α = 0.87) and a factor structure explaining 49.7% of variations in answers. Concurrent validity was confirmed through significant correlations with established anxiety measures. Younger age and female sex were positively correlated with ASA-27 scores. Conclusion: The German ASA-27 constitutes a promising diagnostic tool for adult SEPAD with sound psychometric properties and a coherent factor structure, offering a structured and reliable assessment of SEPAD and its dimensional evaluation in German-speaking populations.

Childhood adversity is a strong predictor of developing psychopathological conditions. Multiple theories on the mechanisms underlying this association have been suggested which, however, differ in the operationalization of ‘exposure.’ Altered (threat) learning mechanisms represent central mechanisms by which environmental inputs shape emotional and cognitive processes and ultimately behavior. 1402 healthy participants underwent a fear conditioning paradigm (acquisition training, generalization), while acquiring skin conductance responses (SCRs) and ratings (arousal, valence, and contingency). Childhood adversity was operationalized as (1) dichotomization, and following (2) the specificity model, (3) the cumulative risk model, and (4) the dimensional model. Individuals exposed to childhood adversity showed blunted physiological reactivity in SCRs, but not ratings, and reduced CS+/CS- discrimination during both phases, mainly driven by attenuated CS+ responding. The latter was evident across different operationalizations of ‘exposure’ following the different theories. None of the theories tested showed clear explanatory superiority. Notably, a remarkably different pattern of increased responding to the CS- is reported in the literature for anxiety patients, suggesting that individuals exposed to childhood adversity may represent a specific sub-sample. We highlight that theories linking childhood adversity to (vulnerability to) psychopathology need refinement.

Childhood adversity is a strong predictor for developing psychopathological conditions. Exposure to threat-related childhood adversity has been suggested to be specifically linked to altered emotional learning as well as changes in neural circuits involved in emotional responding and fear. Learning mechanisms are particularly interesting as they are central mechanisms through which environmental inputs shape emotional and cognitive processes and ultimately behavior. Multiple theories on the mechanisms underlying this association have been suggested which, however, differ in the operationalization of “exposure”. In the current study, 1,402 physically and mentally healthy participants underwent a differential fear conditioning paradigm including a fear acquisition and generalization phase while skin conductance responses (SCRs) and different subjective ratings were acquired. Childhood adversity was retrospectively assessed through the childhood trauma questionnaire (CTQ) and participants were classified as individuals exposed or unexposed to at least moderate childhood adversity according to established cut-off criteria. In addition, we provide exploratory analyses aiming to translate different (verbal) theories on how exposure to childhood adversity is related to learning from threat into statistical models. During fear acquisition training and generalization, childhood adversity was related to reduced discrimination in SCRs between stimuli signaling danger vs. safety, primarily due to reduced responding to danger cues. During fear generalization, no differences in the degree of generalization were observed between exposed and unexposed individuals but generally blunted SCRs occurred in exposed individuals. No differences between the groups were observed in ratings in any of the experimental phases. The reduced discrimination between signals of danger and safety in SCRs in exposed individuals was evident across different operationalizations of “exposure” which was guided by different (verbal) theories. Of note, none of these tested theories showed clear explanatory superiority. Our results stand in stark contrast to typical patterns observed in patients suffering from anxiety and stress-related disorders (i.e., reduced discrimination between danger and safety cues due to increased responses to safety signals). However, reduced CS discrimination - albeit due to blunted CS+ responses - is also observed in patient or at risk samples reporting childhood adversity, suggesting that this pattern may be specific to individuals with a history of childhood adversity. In addition, we conclude that theories linking childhood adversity to psychopathology need refinement.

Obsessive-compulsive disorder (OCD) affects ∼1% of children and adults and is partly caused by genetic factors. We conducted a genome-wide association study (GWAS) meta-analysis combining 53,660 OCD cases and 2,044,417 controls and identified 30 independent genome-wide significant loci. Gene-based approaches identified 249 potential effector genes for OCD, with 25 of these classified as the most likely causal candidates, including WDR6, DALRD3, CTNND1 and multiple genes in the MHC region. We estimated that ∼11,500 genetic variants explained 90% of OCD genetic heritability. OCD genetic risk was associated with excitatory neurons in the hippocampus and cortex, along with D1- and D2-type dopamine receptor-containing medium spiny neurons. OCD genetic risk was shared with 65 of 112 additional phenotypes, including all of the psychiatric disorders we examined. In particular, OCD shared genetic risk with anxiety, depression, anorexia nervosa, and Tourette syndrome, and was negatively associated with inflammatory bowel diseases, educational attainment, and body mass index.