Agoraphobic behavior and panic attack: a study of male twins

We used data from 3372 pairs of male twins from the Vietnam Era Twin Registry to examine comorbidity and familial influences on the frequently observed association between agoraphobic behavior and panic. Due to low prevalence of DSM-III-R-defined panic disorder, we also examined subjects who had experienced at least one panic attack during their lives. Agoraphobic behavior among individuals with a history of panic attacks showed familial aggregation (odds ratio = 5.7; P = .018 ). Probands with panic attacks and agoraphobic behavior and their co-twins had higher risk of major depression than probands without agoraphobic avoidance and their co-twins (P = .01). Groups did not differ for alcohol dependence or antisocial personality. Agoraphobic behavior associated with panic attack is familial and associated with comorbid major depression. Agoraphobia following panic attack does not seem to reflect severity as agoraphobic behavior in the proband was unrelated to risk of panic attacks in the co-twin.     

Relationship of cognitions to fear of somatic symptoms: a test of the cognitive theory of panic

The relationship between fear of physical anxiety symptoms and cognitive misinterpretation of those symptoms, as measured by responses to the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire, respectively, was examined for two samples of outpatients with panic disorder. Factor analytic and correlational analyses demonstrated that the patients' self-rated fear of specific physical and psychological symptoms was related to the frequency of specific logically related catastrophic thoughts (e.g., fears of heart palpitations or chest pressure with thoughts of a heart attack). This specific relationship between the somatic sensations and the catastrophic thoughts experienced by agoraphobic individuals provides further support for the cognitive theory of panic disorder. When the responses to the two questionnaires were factor-analyzed together, four factors were identified: symptoms and thoughts relevant to cardiovascular, neurological, gastrointestinal, and behavioral control systems, respectively. These findings suggest that the nature of panic-related fears varies across patients, and that the use of specific treatment interventions designed to modify the specific variations in their expression may be advisable.     

Assessment of self-statements in agoraphobic situations construction and psychometric evaluation of the Agoraphobic Self-Statements Questionnaire (ASQ).

The study describes the development and psychometric evaluation of a self-report questionnaire for use in both treatment-outcome research and process studies: the Agoraphobic Self-Statements Questionnaire (ASQ). The ASQ comprises two subscales: a positive self-statements subscale and a negative self-statements subscale. Confirmatory factor analysis showed that, with the exception of one item, the proposed bidimensional structure of the ASQ reappeared in a second agoraphobic patient sample. Internal consistency of both subscales was satisfactory. Both subscales appeared to be sensitive to change in treatment and discriminated between agoraphobic patients and normal controls. Construct validity of the negative subscale was satisfactory, whilst additional validation of the positive subscale is required. Findings also revealed that positive thinking may serve as a coping device and that the occurrence of negative self-statements might be considered a sine qua non for the occurrence of positive self-statements. It is concluded that the ASQ can contribute to the understanding of cognitive processes during treatment of agoraphobia.     

Anxiety sensitivity in agoraphobics

This study further validated the "Reiss-Epstein-Gursky Anxiety Sensitivity Index" (ASI) as a measure of the fear of anxiety. Agoraphobics scored high on the ASI before, but not after, behavioral treatment. Residual anxiety sensitivity, however, did not predict resurgence of agoraphobic avoidance at six months follow-up. Indeed, anxiety sensitivity continued to decline during the follow-up period. Multiple regression analyses indicated that the ASI predicted the number of fears in agoraphobics beyond that predicted by the level of general anxiety. This finding supports the hypothesis that high anxiety sensitivity enhances fear acquisition; it also suggests that the ASI measures a construct different from that measured by general anxiety scales. Empirical similarities and differences were found between the ASI and two other "fear of fear" measures: the Agoraphobic Cognitions Questionnaire and the Body Sensations Questionnaire.     

Psychological features of subjects with idiopathic environmental intolerance

OBJECTIVES: Idiopathic environmental intolerance (IEI) is associated with unexplained symptoms attributed to non-noxious levels of environmental substances. Clinically, some of the symptoms of IEI overlap with those of panic disorder (PD). We have recently reported a link between IEI and panic responses to a single inhalation of 35% carbon dioxide (CO(2)), a reliable panic induction challenge. This study assessed depression, stress, anxiety, and agoraphobic symptoms among IEI subjects from our previous study versus healthy controls. METHODS: Thirty-six IEI and 37 control subjects with no preexisting psychiatric history were compared on self-report psychological questionnaires. RESULTS: IEI subjects scored significantly higher than controls on the Agoraphobic Cognitions Questionnaire (ACQ), Depression Anxiety Stress Scales (DASS), and Mobility Inventory for Agoraphobia (MI) (Student's t, P<.05). CONCLUSIONS: IEI subjects represent a group with morbidity significantly higher than a control population but less than what would be expected for a clinical psychiatric population.     

A comparison of DSM-III personality disorders in panic/agoraphobia and obsessive-compulsive disorder

One hundred eighty-seven patients meeting DSM-III criteria for panic disorder (161 with agoraphobia) and 51 patients meeting DSM-III criteria for obsessive-compulsive disorder (OCD) were assessed with the Personality Diagnostic Questionnaire (PDQ), a self-rating scale designed to assess axis II personality disorders and traits. The results showed that the personality profiles were similar between the two diagnostic groups and that the major personality characteristics identified in panic/agoraphobic patients, e.g., avoidant, dependent, histrionic, and borderline, were more pronounced in patients with OCD. These findings support our earlier suggestion of a nonspecific link between panic disorder/agoraphobia and personality disorder (PD)/traits.     

DSM-III-R Axis I and II disorders in agoraphobic patients with and without panic disorder

Patients attending an inpatient phobia treatment program were diagnosed for DSM-III-R Axis I and II disorders, using the Structured Clinical Interview for DSM-III-R Disorders, and completed a set of self-report instruments. They were divided into 3 groups: (a) those who met the criteria for panic disorder with agoraphobia (n= 57), (b) those who met the criteria for agoraphobia without a history of panic disorder (n= 21), and (c) those who met criteria for other anxiety disorders, but not for panic/agoraphobia (n= 14). On Axis I, more of the panic with agoraphobia than of the agoraphobia without panic patients had obsessive-compulsive disorder. On Axis II, no significant differences between the agoraphobic patients with and without panic occurred. However, the number of hysterical traits was related to the presence of panic disorder among the agoraphobic patients. Avoidant and dependent traits were related to symptom severity.     

Personality disorder comorbidity in panic disorder patients with or without current major depression

To investigate the relationship between current or past major depressive disorder (MDD) on comorbid personality disorders in patients with panic disorder, we compared the comorbidity of personality disorders using the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II) in 34 panic disorder patients with current MDD (current-MD group), 21 with a history of MDD but not current MDD (past-MD group), and 32 without lifetime MDD comorbidity (non-MD group). With regard to personality disorders, patients in the current-MD group met criteria for at least one personality disorder significantly more often than patients in the past-MD group or the non-MD group (82.4% vs. 52.4% and 56.3%, respectively). The current-MD group showed statistically significantly more borderline, dependent, and obsessive-compulsive personality disorders than the past-MD group or non-MD group. With stepwise regression analyses, number of MDD episodes emerged as an indicator of the comorbidity of cluster C personality disorder and any personality disorders. Future studies should determine whether aggressive treatment of comorbid personality disorders improves the outcome (e.g., lowers the likelihood of comorbid MDD) of patients with panic disorder.     

Temperament and personality features in panic disorder with or without comorbid mood disorders

Personality and temperament features, assessed with the Structured Interview for DSM-III-R Personality Disorders — Revised (SIDP-R) and the Tridimensional Personality Questionnaire (TPQ), respectively, were evaluated in 62 patients affected by panic disorder with (PD+MD) (n= 22) or without comorbid mood disorder (PD) (n=40). A significant difference in the prevalence of personality disorders (PD+MD, 86% vs. PD, 62%; P <0.05), particularly dependent (PD+DM, 50% vs. PD, 17%; P < 0.01) and borderline (PD+DM, 9% vs. PD, 0%; P=0.05) personality disorders, was observed between the groups. Moreover, patients in the PD+MD group had higher scores for harm avoidance (PD+MD, 22.2±5.6 vs. PD, 26.9±5.1; P < 0.05) than patients in the PD group. The harm avoidance score in PD patients was significantly related to personality disorder and not to MD, suggesting that harm avoidance is not associated with greater severity of the illness. Our data confirm the hypothesis that subjects with higher harm avoidance scores have a greater probability of being affected by cluster C personality disorders and comorbid mood and anxiety disorders.     

Childhood trauma and personality disorder: positive correlation with adult CSF corticotropin-releasing factor concentrations

OBJECTIVE: To test the hypothesis that early life trauma results in adult stress hormone alterations in individuals with personality disorders, the authors examined the relationship between history of childhood adversity and lumbar CSF corticotropin-releasing factor (CRF). METHOD: Participants were 20 otherwise healthy men who met DSM-IV criteria for personality disorders. CSF CRF was obtained by lumbar puncture, and childhood adversity was measured by the Childhood Trauma Questionnaire. Correlations were obtained between CSF CRF and the total score on the Childhood Trauma Questionnaire as well as scores on its four subscales. RESULTS: CSF CRF concentrations were positively correlated with the total score on the Childhood Trauma Questionnaire. Analysis of the subscales revealed that CSF CRF was correlated with emotional neglect. Correlations between CSF CRF level and physical and emotional abuse and with physical neglect were not statistically significant. CONCLUSIONS: Consistent with the hypothesis that the severity of early life stress is correlated with stress hormone abnormalities in adulthood, Childhood Trauma Questionnaire total scores and emotional neglect scores were significantly correlated with CSF CRF levels in individuals with personality disorders.     

Psychotic reactivity in borderline personality disorder

Glaser J‐P, Van Os J, Thewissen V, Myin‐Germeys I. Psychotic reactivity in borderline personality disorder. Objective: To investigate the stress relatedness and paranoia specificity of psychosis in borderline personality disorder (BPD). Method: Fifty‐six borderline patients, 38 patients with cluster C personality disorder, 81 patients with psychotic disorder and 49 healthy controls were studied with the experience sampling method (a structured diary technique) to assess: i) appraised subjective stress and ii) intensity of psychotic experiences. Results: All patient groups experienced significantly more increases in psychotic experiences in relation to daily life stress than healthy controls, borderline patients displaying the strongest reactivity. Borderline patients, moreover, reported significantly more hallucinatory reactivity than healthy controls and subjects with cluster C personality disorder. Paranoid reactivity to daily life stress did not differ between the patient groups. Conclusion: These results are the first to ecologically validate stress‐related psychosis in BPD. However, psychotic reactivity was not limited to expression of paranoia but involved a broader range of psychotic experiences including hallucinations.     

Onset of panic disorder with agoraphobia. Toward an integrated model

Of 57 patients with panic disorder with agoraphobia, more had their first panic in late spring and summer than in fall and winter, and in warm weather than in cold weather. In the month before the first panic 52% of the patients had prodromal depression or anxiety. Agoraphobic avoidance preceded the first panic in 23%, began within days after the first panic in 32% (without prodromal anxiety or depression in only 20%), and after more than one panic (1 week to 11 years later) in 41%. The site of the first panic was from the agoraphobic cluster (public places) in 81%, at work or school in 11%, and inside the home in 8%. Thirty-eight percent of patients were with a familiar adult at the time. Many features of the syndrome can be explained by an integrated model with several interacting factors contributing in varying degrees to the different routes by which it develops. To the learning and biological factors already suggested we add an evolutionary factor to explain why most first panics occur outside the home and mainly in public places. Certain extraterritorial cues constituting an agoraphobic cluster seem to be prepotent and prepared triggers or modifiers of fear during stress.     

Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity

OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community. METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study. RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD. CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.     

The prediction of nonresponse to pharmacotherapy in panic disorder: a review.

Several effective pharmacotherapeutic treatments exist for panic disorder; however, not all patients respond to treatment: between 20% to 40% are non‐responders. Recent studies have reported several predictors of nonresponse to pharmacotherapy. In this review two questions are addressed: is there consensus with respect to predictors of nonresponse and are there any differences between short‐term and long‐term predictors? In this review both short‐term and long‐term outcome studies are discussed. Studies were included if at least DSM‐III criteria were used and baseline variables were investigated as possible predictor of response, or nonresponse, to pharmacotherapy. Of each clinical predictor, tallies were made of the particular predictors employed and of those predictors that predicted nonresponse. It appears that a long duration of illness and severe agoraphobic avoidance are robust predictors of nonresponse, particularly in long‐term studies. Personality disorders, or even personality traits, are possibly the most robust predictors of nonresponse. Several factors appear to be robust predictors of nonresponse: factors that are present before treatment and exert their influence on short‐term and long‐term treatment outcome. Prospective studies are needed to further investigate these factors and to test whether it is viable to intervene in an attempt to increase treatment response. Depression and Anxiety 14:112–122, 2001. © 2001 Wiley‐Liss, Inc.     

Vestibular migraine patients are more anxious than migraine patients without vestibular symptoms

The link between vertigo and anxiety is well known. The aim of this study is to compare anxiety disorders in 3 groups: patients with vestibular migraine (VM), patients with migraine but without vertigo (MO) and healthy controls (HC).We performed cross-sectional analysis of following tests: (a) Hamilton Anxiety Rating Scale (HAMA); (b) State-Trait Anxiety Inventory (STAI-X1 and STAI-X2); (c) Beck Depression Inventory (BDI); (d) Panic–Agoraphobic Scale and (e) Penn State Worry Questionnaire (PSWQ). ANOVA, Kruskal–Wallis and Chi-square tests were used for comparisons and least significant difference was used for further post-hoc analysis. There were 35 definite VM patients, 31 MO patients and 32 volunteer HC. There were no significant differences between three groups in age, total years of education or duration of headaches in VM and MO patients. On the other hand, vertigo severity  was moderately and positively correlated with headache severity and with headache duration. There were significant differences in scores of HARS, BDI, PSWQ, and various PAS-R sub-scales between the three groups. Our study shows that VM patients are significantly more anxious and agoraphobic than MO patients and HC, displaying higher sensitivity to separation and being more prone to seeking medical reassurance.     

Personality features of patients with mixed and pure manic episodes

OBJECTIVE: To test the hypothesis that patients with a mixed manic episode show different personality features than patients with a pure manic episode. METHOD: Sixteen patients with a mixed manic episode (broad criteria) and 26 patients with a pure manic episode were assessed with diagnostic interviews (SCID I/II) as well as instruments for depression, mania and personality. RESULTS: Even after controlling for age as well as depression and mania score at assessment, no differences between the two groups emerged concerning either personality features as assessed with the NEO-five-factor inventory (NEO-FFI) or personality disorders. CONCLUSION: We found no difference between patients with mixed mania and patients with pure mania concerning their personality features. Possible reasons for this are being discussed.     

Normalization of personality characteristics in patients with incapacitating anxiety disorders after capsulotomy

The personality characteristics of 24 consecutive patients undergoing psycho-surgery for incapacitating anxiety disorders were assessed prospectively using a self-report personality inventory. The main findings were: absence of negative personality changes after surgery, significant postoperative changes towards normalization on the majority of the scales, and significant symptomatic relief in 80% of the cases. The changes on scales reflecting anxiety proneness were conspicuous in patients suffering from "pure" anxiety disorders, as compared with those suffering from obsessive-compulsive disorder (OCD). In OCD patients, correlations were obtained between changes in brain metabolism studied with positron emission tomography and changes in personality scores. It is concluded that negative personality changes are not likely to occur after capsulotomy.     

Predictors of trait aggression in bipolar disorder

OBJECTIVES: Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. METHODS: Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). RESULTS: In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). CONCLUSIONS: Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.     

Persistent social dysfunction in anxious and depressed patients with personality disorder

OBJECTIVE: To determine the long-term social function of psychiatric patients with anxiety and depressive disorders and to relate this to personality status and other factors. METHOD: A cohort of 210 patients (mean age 35 years) with dysthymic disorder, generalized anxiety disorder or panic disorder diagnosed using a structured interview (SCID) were assessed at baseline for personality status using the Personality Assessment Schedule (PAS) and ratings of anxiety and depression. Exactly 12 years later social function was assessed using the Social Functioning Questionnaire (SFQ) and personality reassessed with the PAS by a rater blind to initial personality status. Individual social function items were examined in those with and without personality disorders. RESULTS: Social function was significantly better in those with little or no baseline personality disturbance (P < 0.001) and the domains of close relationships, stress in completing tasks, use of spare time and family relationships showed the largest personality differences. A multiple linear regression model showed that self-rated depression scores, single marital status and personality status were the main baseline variables predicting social function at 12 years. CONCLUSION: Although personality characteristics may change over time social dysfunction persists and persistent social dysfunction in mental state disorders may be a strong indicator of personality disturbance rather than an indicator of treatment resistance.     

Validation of the self-report questionnaire DIP-Q in diagnosing DSM-IV personality disorders: a comparison of three psychiatric samples

The DSM-IV section of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q) was used to screen for personality disorders in 448 subjects from three clinical samples (general and forensic psychiatric patients and candidates for psychotherapy) and a sample of 139 healthy volunteers. Differences between the samples with regard to patterns of personality pathology in relation to concurrent Axis I disorders and sociodemographic variables were analysed. The prevalence of personality disorders according to DIP-Q was 14% among the healthy volunteers, compared to 59% in the general psychiatric sample, 68% in the forensic psychiatric sample and up to 90% among psychotherapy candidates. Moreover, from a dimensional perspective (i.e. the number of fulfilled Axis II criteria), all clinical groups differed significantly from the control group in all specified personality dimensions and clusters. Dimensional DIP-Q cluster scores also discriminated significantly between the three clinical samples. Unexpectedly, the odds ratio for an Axis II disorder was nearly five times higher among psychotherapy applicants than among general psychiatric patients, independent of concomitant Axis II disorders, gender or age. The strongest association between DIP-Q score and Axis I disorders was found for depressive disorders, which more than doubled the odds ratio for a personality disorder diagnosis. This association could result from high true comorbidity, but could also be due to the fact that a concomitant depressive state can increase self-reported personality difficulties. The high prevalence among psychotherapy candidates may to some extent reflect help-seeking exaggeration of problems. These are aspects to consider when using the DIP-Q, which overall appears to discriminate well between different samples.