Quality of life and functional impairment in obsessive-compulsive disorder: a comparison of patients with and without comorbidity, patients in remission, and healthy controls

Background: Several studies have demonstrated that obsessive–compulsive disorder (OCD) is associated with interference in quality of life (QOL) and functional impairment. However, these studies did not compare individuals in remission to individuals who continue to have the disorder, predominantly used comparisons with norms and not with a matched normal sample, and did not always consider the impact of comorbidity. Methods: We administered multiple measures that assess QOL and functional impairment to 66 OCD patients who had previously consented for a clinical trial and to 36 age and sex matched individuals who denied any psychiatric history. Results: Results confirm that OCD was associated with significantly lower QOL and functional impairment compared to healthy controls (HCs) in areas of work, social life, and family life. Individuals with OCD and other comorbid psychiatric diagnoses showed the poorest QOL and functioning, with comorbid depression accounting for much of the variance. The levels of QOL and functioning in individuals in remission tended to lie in between HCs and individuals with current OCD: their QOL or functioning did not differ significantly from HCs nor did they consistently differ significantly from those who had current OCD. Conclusion: These results suggest that individuals who are in remission have improved levels of QOL and functioning, whereas individuals with OCD are significantly impaired, and individuals with OCD and comorbid disorders are the most impaired. Treatment strategies should be focused on achieving remission of all symptoms to have the greatest impact on functioning and QOL. Depression and Anxiety, 2009. Published 2008 Wiley‐Liss, Inc.     

Quality of life impairment in generalized anxiety disorder, social phobia, and panic disorder

Interest in the assessment of quality of life in the anxiety disorders is growing. The present study examined quality of life impairments in individuals with generalized anxiety disorder (GAD), social phobia, and panic disorder. Results showed that individuals with these disorders reported less satisfaction with their quality of life than non-anxious adults in the community. However, the degree of quality of life impairment is similar across these three disorders. Additionally, comorbid depression, but not anxiety, was found to negatively impact quality of life in these individuals. Finally, diagnostic symptom severity was not found to influence quality of life, indicating that subjective measures of quality of life offer unique information on the effects of anxiety disorders.     

Minor stressors and generalized anxiety disorder among low-income patients attending primary care clinics.

The total number of minor life events and subjective ratings of distress associated with these events were assessed for individuals with generalized anxiety disorder (GAD) and for nonanxious controls. Participants consisted of 256 randomly selected, low-income patients from primary care medical clinics. Diagnoses were obtained using the Diagnostic Interview Schedule for the DSM-IV (DIS-IV). An analysis of variance revealed that GAD individuals reported significantly more minor life events than did nonanxious controls (F = 50.97, p < .001). An analysis of covariance indicated that persons with GAD perceived their minor stressors as significantly more stressful than did nonanxious controls, even after the total number of events was controlled (F = 42.07, p < .001). These findings are consistent with cognitive theories of GAD and current revisions to the definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Implications for theory and research on GAD are discussed.     

An Investigation of Gelotophobia in Individuals with a Diagnosis of High-Functioning Autism Spectrum Disorder

Samson et al. (Journal of Autism and Developmental Disorders 41:475–483, 2011) conducted the first empirical investigation examining the fear of being laughed at (gelotophobia) and its prevalence in individuals with high-functioning autism spectrum disorder (hfASD). The present research examined gelotophobia in relation to social functioning, perceived social support, life satisfaction and quality of life (QoL) in individuals with hfASD, including past experiences of bullying and the presence of comorbid psychopathology. Participants were 103 adults with a clinical diagnosis of hfASD and 137 typically developing controls. Individuals with hfASD presented with higher rates of gelotophobia symptomatology in comparison to controls (87.4 vs. 22.6% respectively). It was also found that social functioning, past experiences of bullying, anxiety and life satisfaction were predictors of gelotophobia amongst individuals with hfASD.     

Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population

While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD–BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD–BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.     

Psychiatric comorbidity in Greek patients with generalized anxiety disorder

From a total sample of 1,448 psychiatric outpatients, 81 (5.6%) received a diagnosis of generalized anxiety disorder (GAD) according to DSM-III-R criteria. Fifty-three (65%) of them had another Axis I diagnosis, while this percentage increased to 78% (63/81) when lifetime psychiatric diagnoses were recorded. The most frequent comorbid diagnoses were panic disorder, dysthymia, major depression and social phobia. Forty-three (53%) of the GAD patients met the criteria for personality disorder. They manifested obsessive-compulsive, avoidant personality and personalities of cluster C in general significantly more frequently than the rest of the total sample. The presence of a personality disorder was related to a significantly higher score on almost all the Minnesota Multiphasic Personality Inventory clinical and research scales, to a worse level of functioning and to an earlier age of onset of GAD. The results of the present study (1) support previous findings of high rates of comorbidity of clinical syndromes in GAD, (2) indicate that GAD co-occurs frequently with cluster C personality disorders, mainly avoidant and obsessive-compulsive, and (3) that the presence of a concomitant personality disorder is related to severer psychopathology and to a worse level of functioning. Copyright Copyright 1999 S. Karger AG, Basel     

Mood regulation and quality of life in social anxiety disorder: an examination of generalized expectancies for negative mood regulation

The present study examined negative mood regulation expectancies, anxiety symptom severity, and quality of life in a sample of 167 patients with social anxiety disorder (SAD) and 165 healthy controls with no DSM-IV Axis I disorders. Participants completed the Generalized Expectancies for Negative Mood Regulation Scale (NMR), the Beck Anxiety Inventory, and the Quality of Life Enjoyment and Satisfaction Questionnaire. SAD symptom severity was assessed using the Liebowitz Social Anxiety Scale. Individuals with SAD scored significantly lower than controls on the NMR. Among SAD participants, NMR scores were negatively correlated with anxiety symptoms and SAD severity, and positively correlated with quality of life. NMR expectancies positively predicted quality of life even after controlling for demographic variables, comorbid diagnoses, anxiety symptoms, and SAD severity. Individuals with SAD may be less likely to engage in emotion regulating strategies due to negative beliefs regarding their effectiveness, thereby contributing to poorer quality of life.     

Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample

Generalized anxiety disorder (GAD) and substance use disorders (SUDs) are highly comorbid, and GAD-SUD comorbidity is associated with a host of poor psychosocial outcomes, including higher rates of hospitalization, disability, functional impairment, and inferior GAD and SUD treatment outcomes. Despite the noted severity of this group and clinical implications, current research is limited in a few distinct ways; studies have rarely utilized a longitudinal design and non-treatment seeking individuals to examine how GAD comorbidity impacts SUD outcomes over time. The current study utilized a nationally representative sample of individuals in the U.S. assessed in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) at Wave 1 (2001-2002) and Wave 2 (2004-2005), comparing individuals who met criteria for both DSM-IV past year GAD and SUD (n = 286) and those who met criteria for past year SUD only without GAD (n = 5730) at Wave 1. Results indicated that GAD-SUD individuals were significantly more severe than the SUD only group across almost all outcomes assessed (with the exception of alcohol frequency); individuals with GAD-SUD had a more severe psychiatric history, worse health-related quality of life at both waves, greater incidence of new Axis I disorders, higher rates of treatment seeking, and greater self-reported drug use at the follow up. The current study is the first to compare individuals with SUD with and without comorbid GAD over time using a nationally representative sample. Findings further support the clinical severity of this group and suggest the need for GAD-SUD treatment options.     

Generalized anxiety disorder within the course of major depressive disorder: examining the utility of the DSM‐IV hierarchy rule

Background: The current Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR) specifies that generalized anxiety disorder (GAD) should not be diagnosed if it occurs exclusively during an episode of a major depressive disorder (MDD) or another mood disorder. This hierarchy rule was intended to promote diagnostic parsimony, but may result in the loss of important clinical information. The goal of this study was to compare individuals with MDD, comorbid MDD and GAD, and GAD within the course of MDD at intake and 12‐month follow‐up on self‐report measures, clinician ratings, and rates of comorbidity. Methods: Participants were divided into three diagnostic groups: MDD without GAD (n=124), comorbid MDD and GAD (n=59), and GAD within the course of MDD (n=166). All the participants completed a semi‐structured clinical interview and self‐report measures assessing psychopathology, temperament, and functional impairment. A subset of the total sample completed a follow‐up assessment of 12 months postintake. Results: Individuals with comorbid MDD and GAD and GAD within the course of MDD reported more psychopathology, negative affect, and functional impairment at intake than individuals with MDD only. The presence of GAD at intake, however, did not differentially predict symptom severity, functional impairment, or the presence of comorbidity at 12‐month follow‐up. Conclusions: Cross‐sectional findings indicate that individuals with GAD within the course of MDD experience levels of psychopathology, functional impairment, and comorbidity similar to those found in individuals with comorbid GAD and MDD. Preliminary longitudinal findings, however, suggest that the presence of GAD in patients with MDD does not have prognostic significance. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Posttraumatic stress disorder and alcohol dependence: Individual and combined associations with social network problems

People with either posttraumatic stress disorder (PTSD) or alcohol dependence (AD) are apt to report problems in their social networks, including low perceived support and elevated conflict. However, little research has examined social networks among people with comorbid PTSD/AD despite evidence suggesting these two conditions commonly co-occur and are linked to particularly severe problems. To test the hypothesis that people with comorbid PTSD/AD experience particularly elevated social network problems, individuals with lifetime diagnoses of PTSD, AD, comorbid PTSD/AD, or no lifetime history of Axis I psychopathology in the National Comorbidity Survey-Replication were compared on four dimensions of social networks: (1) Closeness, (2) Conflict, (3) Family Support, and (4) Apprehension. Persons with PTSD, AD, or comorbid PTSD/AD endorsed more problems with the Conflict, Family Support, and Apprehension factors compared to people with no history of Axis I psychopathology. Moreover, individuals with comorbid PTSD/AD endorsed greater Apprehension and significantly less Family Support compared to the other three groups. Results suggest people with comorbid PTSD/AD experience increased problems with their family as well as greater concerns about enlisting social support than even people with PTSD or AD alone. Treatments for people suffering from comorbid PTSD/AD should consider assessing for and possibly targeting family support and apprehension about being close to others.     

Quality of life in geriatric generalized anxiety disorder: a preliminary investigation

OBJECTIVE: To examine the impact of late-life generalized anxiety disorder (GAD) on health-related quality of life. METHOD: We compared quality of life in 75 treatment-seeking older adults with GAD, 39 of whom had psychiatric comorbidity, with 32 older adults without psychiatric illness. We examined predictors of quality of life in these samples. We also compared data from the GAD patients to published norms from a large national sample of older adults with chronic medical conditions or major depression. RESULTS: Older GAD patients reported worse health-related quality of life across most domains than asymptomatic older individuals. There were no differences in quality of life between GAD patients with and without psychiatric comorbidity, and comorbidity did not predict quality of life in multivariate regression analyses. Presence of GAD or symptoms of anxiety or depression were significantly related to impairment in every domain of quality of life. Comparisons with national norms suggest that older GAD patients report overall worse quality of life than individuals with recent acute myocardial infarction or type II diabetes, and are comparable in quality of life to individuals with major depression. CONCLUSION: Results suggest that late-life GAD is associated with substantial impairment in quality of life, and these findings cannot be explained by psychiatric comorbidity.     

Quality of life in older adults with generalized anxiety disorder

Improving the quality of life is an important goal in the treatment of psychiatric disorders. The current study described subjective quality of life, or life satisfaction, in a sample of older adults with generalized anxiety disorder (GAD). Patients with GAD were compared to other anxious and nonpsychiatric samples on measures of life satisfaction. Older adults with GAD reported lower quality of life than did nonpsychiatric samples; levels of life satisfaction were comparable between older adults with GAD and younger adults with social phobia. Predictors of quality of life for the GAD sample were examined. Severity of depression predicted decreased life satisfaction as measured by both the Quality of Life Inventory (QOLI) and the Life Satisfaction Index (LSI-Z). Severity of anxiety predicted poorer quality of life as measured by the QOLI, and optimism predicted better life satisfaction as measured by the LSI-Z. The findings suggest that quality of life is diminished in older adults with GAD, and that additional factors also affect quality of life for these patients.     

Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity

Objectives

To compare quality of life (QoL) in mental health outpatients to non-clinical norms, and examine the associations between QoL and principal diagnosis, number of comorbid Axis I diagnoses, and type of comorbidity.

Methods

Consecutively referred and assessed patients (n = 2024) formed the study sample pool. Of these, 1486 individuals who had completed a QoL instrument at intake and had a principal diagnosis amenable to comparison by group analysis were included in the study. Principal diagnoses were unipolar mood disorder (n = 687), eating disorder (n = 226), bipolar disorder (n = 165), social anxiety disorder (n = 165), generalized anxiety disorder (n = 125), and panic disorder (n = 118). QoL for psychiatric groups was compared to non-clinical norms using a valid and reliable measure.

Results

QoL was significantly impaired in all psychiatric groups compared to nonclinical norms. There was a significant interaction between principal diagnosis and number of comorbid Axis I disorders, controlling for age, sex, marital status, employment, and years of school. The addition of one comorbidity significantly attenuated QoL in social anxiety disorder, panic disorder, and bipolar disorder. For all other conditions, a significant loss in QoL occurred with two or more comorbidities. Axis I depressive and anxiety comorbidity significantly attenuated QoL across all diagnostic groups.

Conclusions

QoL is significantly impaired in psychiatric outpatients and diagnostic groups vary in the extent to which they experience additional QoL burden with increasing comorbidities.     

Depressed Suicide Attempters with Posttraumatic Stress Disorder

Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters.     

Chronic depression and comorbid personality disorders: response to sertraline versus imipramine

BACKGROUND: Chronic subtypes of depression appear to be associated with high rates of Axis II personality disorder comorbidity. Few studies, though, have systematically examined the clinical correlates of Axis II personality disorder comorbidity or its effect on treatment response or time to response. METHOD: 635 patients diagnosed with DSM-III-R chronic major depression or "double depression" (dysthymia with concurrent major depression) were randomized to 12 weeks of double-blind treatment with either sertraline or imipramine between February 1993 and December 1994. Axis II diagnoses were made using the personality disorders version of the DSM-III-R Structured Clinical Interview. The effect of study treatment was measured utilizing the Hamilton Rating Scale for Depression and the Clinical Global Impressions scale. RESULTS: Forty-six percent of patients met criteria for at least 1 comorbid Axis II personality disorder, with cluster C diagnoses being the most frequent at 39%; 21% met criteria for at least 2 Axis II personality disorders. A cluster C diagnosis was associated with significantly higher rates of early-onset depression (before age 21; 47% vs. 32% for no cluster C; p =.005) and comorbid anxiety disorder (34% vs. 18% for no cluster C; p <.001). Overall, the presence of Axis II personality disorder comorbidity had minimal-to-no effect on the ability to achieve either an antidepressant response or remission and had inconsistent effects on time to response. The presence of Axis II personality disorder comorbidity did not appear to reduce functional and quality-of-life improvements among patients responding to acute treatment with sertraline or imipramine. CONCLUSION: In this treatment sample, rates of Axis II personality disorder comorbidity were substantial in patients suffering from chronic forms of depression. Axis II personality disorder comorbidity did not appear to diminish symptomatic response to acute treatment or associated improvement in functioning and quality of life.     

Differences in clinical presentation between depressed outpatients wanting versus not wanting treatment for comorbid social anxiety disorder

Patients with comorbid major depressive disorder (MDD) and social anxiety disorder (SAD) demonstrate greater severity of symptoms and functional impairment compared with patients with either disorder alone. However, no known studies have examined what differentiates patients who do and do not want treatment for comorbid SAD in addition to MDD. The aim of the current study was to examine clinical characteristics (e.g., variables related to depression and social anxiety severity) of patients who did versus did not desire treatment for comorbid SAD. Results showed that patients who desired treatment for comorbid SAD reported a greater number of social fears and poorer work and current social functioning compared with patients who did not desire treatment for SAD. Work functioning and number of social fears remained significant after controlling for depression and overall illness severity. Results suggest that future treatments adapted for comorbid MDD and SAD perhaps should target work functioning and a broad range of social fears.     

DSM-IV personality disorders in the National Comorbidity Survey Replication.

BACKGROUND: The population prevalence of DSM-IV personality disorders (PDs) remains largely unknown. Data are reported here on the prevalence and correlates of clinician-diagnosed Clusters A, B, and C DSM-IV PDs in the general population of the United States. METHODS: Personality disorder screening questions from the International Personality Disorder Examination (IPDE) were administered in Part II (n = 5692) of the National Comorbidity Survey Replication (NCS-R). A probability sub-sample was then interviewed with the IPDE and used to link screening question responses with IPDE clinical diagnoses. The method of Multiple Imputation (MI) was then implemented to estimate prevalence and correlates of PDs in the full sample. RESULTS: The MI prevalence estimates were 5.7% Cluster A, 1.5% Cluster B, 6.0% Cluster C, and 9.1% any PD. All three PD clusters were significantly comorbid with a wide range of DSM-IV Axis I disorders. Significant associations of PDs with functional impairment were largely accounted for by Axis I comorbidity. CONCLUSIONS: Strong Axis I comorbidity raises questions about the somewhat arbitrary separation of PDs from Axis I disorders in the DSM nomenclature. The impairment findings suggest that the main public health significance of PDs lies in their effects on Axis I disorders rather than in their effects on functioning.     

Utilization of medical services and quality of life among low-income patients with generalized anxiety disorder attending primary care clinics.

OBJECTIVE: Anxiety disorders appear to influence morbidity and medical utilization. However, little is known about the relationship between Generalized Anxiety Disorder, quality of life, and medical utilization, especially among low-income patients. The goals of this investigation were to 1) determine if low-income patients with GAD utilize medical services more than patients with other Axis I diagnoses, or no psychopathology, and 2) compare the health-related quality of life of these three groups. METHOD: Participants were randomly recruited from public primary care clinics and administered intake assessments of demographics, stress, and health-related self-report questionnaires. At the end of the first year a structured psychiatric interview was administered (N = 431). Over the second year, patients (n = 360) were administered a health-related quality of life measure every three months for four assessments. Medical charts were abstracted to collect information about chronic illnesses and visits to outpatient clinics and the emergency department during the two years. RESULTS: Patients were predominantly middle-aged, low-income, uninsured African-American females. In this low-income sample, patients with GAD utilized the emergency department more and reported poorer quality of life than patients with other Axis I disorders and patients without any psychopathology. CONCLUSION: Low-income patients with GAD utilize the emergency department more and report poorer quality of life than patients with other Axis I disorders and patients without any psychopathology. Programs to identify and treat patients with GAD may yield improvements in quality of life, as well as reduce emergency department utilization.     

Quality of life and anxiety and depressive disorder comorbidity

The present investigation evaluated the relations among anxiety and depressive disorder comorbidity and quality of life (QOL) by utilizing self-report measures of life satisfaction and functional disability. Participants were 94 individuals who were presented for treatment at an outpatient anxiety disorders clinic and 26 nonclinical participants. Results indicated that participants diagnosed with anxiety disorders reported lower QOL than did nonclinical participants. Anxiety disorder comorbidity did not additionally impact QOL; however, presence of a depressive disorder comorbid with an anxiety disorder did negatively impact QOL as these individuals reported significantly more functional disability and less life satisfaction than did individuals with anxiety disorders alone or those without a psychiatric diagnosis. These results highlight the negative nature of anxiety disorders and improve clarification on the role of diagnostic comorbidity on QOL among those with an anxiety disorder.     

Social Functioning in Body Dysmorphic Disorder: Assessment Considerations

Individuals with body dysmorphic disorder (BDD) have markedly poor social functioning; however, previous reports may underestimate impairment. Scoring on certain functioning measures such as the Social Adjustment Scale-Self Report (SAS-SR) potentially excludes more severely ill individuals from some domains, thereby possibly underestimating functional impairment. To explore this issue, 73 individuals with BDD who reported having no primary relationship (and were therefore excluded from scoring on the SAS-SR Primary Relationship domain) were compared to 58 individuals with BDD who had a primary relationship. Subjects without a primary relationship had significantly poorer global social adjustment on several measures. They also had poorer scores on the Global Assessment of Functioning Scale and greater severity of BDD and depressive symptoms at a trend level. These findings suggest that the SAS-SR may underestimate social impairment. This underestimation may pertain to other domains of functioning, other disorders, and certain other functioning and quality of life measures.