Medical illness and response to treatment in primary care panic disorder

OBJECTIVE: Although studies have suggested that comorbid medical illness can affect the outcome of patients with depression, little is known about whether medical illness comorbidity affects treatment outcome in patients with anxiety. METHOD: Primary care patients with panic disorder (n=232), participating in a randomized collaborative care intervention of CBT and pharmacology, were divided into those above (n=125) and below (n=107) the median for burden of chronic medical illness and assessed at 3, 6, 9 and 12 months. RESULTS: Subjects with a greater burden of medical illness were more psychiatrically ill at baseline, with greater anxiety symptom severity, greater disability and more psychiatric comorbidity. The intervention produced significant and similar increases in amount of evidence-based care, and reductions in clinical symptoms and disability that were comparable in the more and less medically ill groups. CONCLUSIONS: The comparable response of individuals with more severe medical illness suggests that CBT and pharmacotherapy for panic disorder work equally well regardless of medical illness comorbidity. However, the more severe psychiatric illness both at baseline and follow-up in these same individuals suggest that treatment programs may need to be extended in time to optimize treatment outcome.     

Antidepressant treatment outcomes of psychogenic movement disorder

BACKGROUND: Psychogenic movement disorder (PMD) is a subtype of conversion disorder. We describe the outcomes of a series of PMD patients following antidepressant treatment. METHOD: Twenty-three outpatients with chronic PMD, diagnosed using Fahn and Williams' criteria, underwent psychiatric assessment. The patients were referred for assessment and management from January 2003 to July 2004. Fifteen agreed to be treated with antidepressants. Patients received citalopram or paroxetine; those who did not respond after 4 weeks of taking an optimal dose were switched to venlafaxine. Concurrently, 3 had supportive psychotherapy, and 1 had family intervention. Assessments included the DSM-IV-based Mini-International Neuropsychiatric Interview and scales measuring depression, anxiety, and motor and global severity. RESULTS: Eighteen patients (78%) had at least 1 Axis I diagnosis in addition to the somatoform diagnosis, and 3 (13%) had somatization disorder. Five (22%) had previous psychiatric contact. Nine (39%) had previously been treated with antidepressants, but only 4 (17%) had adequate trials. No significant differences existed in patient characteristics between treated and untreated groups. Among treated patients, Montgomery-Asberg Depression Rating Scale scores improved from baseline (p < .01). Two treated subgroups were identified: 10 patients (67%) had primary conversion disorder, of whom 8 had marked motor and global improvements with 7 complete remissions, and 5 (33%) had primary hypochondriasis, somatization disorder, or probable factitious disorder/malingering, of whom none improved. All of the patients with primary conversion disorder had a current or previous depressive or anxiety disorder compared with 40% (N = 2) of the patients with additional somatoform diagnoses. DISCUSSION: Our preliminary findings suggest that chronic PMD with primary conversion symptoms and with recent or current depression or anxiety may respond to antidepressants. Further well-designed studies, now under way, are required to confirm these findings.     

Factitious disorder and factitious disorder by proxy

Similar to the adult patient, a child or adolescent may actively feign or produce artificial symptoms (synonymous: Munchausen syndrome). The more frequent case is that the child suffers from being an object of symptom fabrication induced by a close person caring for the child, regularly the mother (Munchausen syndrome by proxy). This review focuses on psychopathological aspects of the clinically more relevant factitious disorder by proxy. Typical behaviour and personality characteristics are presented that can be taken as clinical warning signs. Doctor-mother-interaction is affectively challenging due to conflicting tasks imposed on the physician. Complementary to pediatric exclusion of genuine disease, psychopathological assessment is required to exclude other sources of deviant illness behaviour. Factious disorder shares particular features (active violation of the child, false report of history, aggravated symptom presentation and increased doctor-hopping, difficulties in conforming maternal report in biomedical data) with other psychopathological entities (child abuse, simulation, dissociative disorders, somatoform disorders including hypochondria, variants of maternal overprotection and infantilization, psychosis or delusion in the mother). Criteria for differentiation are presented. Three concepts on the psychopathological etiology of factitious disorder by proxy are relevant: In some cases, it may be conceived as secondary manifestation of a primary psychopathological entity or personality disorder. Learning theory emphasises operant rewards received from vicarious sick role. Attachment theory provides possible explanations concerning the traumatic impact on the child, early sources of psychopathology in the fabricating mother and risks for intergenerational transmission of factitious disorders.     

Similarities and differences between aggressive and delinquent children and adolescents in a national sample

OBJECTIVE: To examine differences in the correlates, comorbidity and use of services between aggressive and delinquent children and adolescents. METHOD: An Australian representative sample (n = 4083) of parents of children and adolescents were administered a psychiatric diagnostic interview, the Child Behaviour Checklist, and other instruments to measure service use. The characteristics of children with high scores (top 5%) in the aggressive and delinquent syndromes or both were then examined. RESULTS: The proportion of aggressive children decreased with increasing age while that of delinquents increased. The aggressive group was specifically associated with the impulsive-hyperactive subtype of attention deficit hyperactivity disorder (ADHD) (OR = 12.63; 95% CI = 5.97-26.74). Comorbidity between ADHD, aggression and delinquency was less frequent among adolescents than in children, with the exception of the inattentive subtype in which comorbidity was higher. Both aggressive and delinquent groups had a considerable overlap with conduct disorder. Aggressive and delinquent youths used services more often, but parents perceived aggressive children as more in need of help than delinquent ones. Living in a sole parent family was specifically associated with the delinquent group (OR = 3.34; 95% CI = 2.25-4.96). CONCLUSIONS: The results suggest that these empirically derived syndromes while sharing many features also differ in important ways, highlighting the need for further convergence between categorical and dimensional classifications. Their differential association with the subtypes of ADHD requires further examination and may help to understand the relationship between ADHD and conduct problems. The importance of aggressive behaviour in children should not be underestimated since it is associated with significant psychopathology, parental distress and use of services.     

MMPI subgroups and affective disorder in chronic pain patients

Patients with chronic pain syndromes are commonly depressed. Chronic pain populations also contain distinct subgroups of personality profiles as defined by the MMPI. To assess the relevance of personality subtype to affective disorder we determined the relationship of psychiatric diagnoses defined by Research Diagnostic Criteria (RDC) to MMPI subgroups in a sample of hospitalized patients with predominantly chronic low back pain. RDC psychiatric diagnoses for the sample were major depression (44.2%), minor depression (19.2%), other psychiatric disorder (13.5%), and no mental disorder (21.6%). Patients satisfying RDC criteria for major depression were significantly associated with discrete MMPI personality subtypes. No other psychiatric diagnoses were significantly associated with distinct personality subgroups. No relationship was observed between personality profile and presence of demonstrable organic etiology for pain. These findings indicate that behavioral and pharmacological interventions directed at depression as well as pain are important in the treatment of chronic pain populations, especially in selected subgroups.     

Psychiatric comorbidity among patients with gender identity disorder

Aims: Psychiatric comorbidity and mental instability seem to be important unfavorable prognostic factors for long‐term psychosocial adjustment in gender identity disorder (GID). However, psychiatric comorbidity in patients with GID has rarely been assessed. In this study, we investigated the psychiatric comorbidity and life events of patients with GID in Japan. Methods: A total of 603 consecutive patients were evaluated independently by at least two senior psychiatrists at the GID clinic using clinical information and results of examinations. Results: Using DSM‐IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female‐to‐male (FTM) type, and 230 (39.7%) were the male‐to‐female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579). Conclusions: Comparison with previous reports on the psychiatric comorbidity among GID patients revealed that the majority of GID patients had no psychiatric comorbidity. GID is a diagnostic entity in its own right, not necessarily associated with severe comorbid psychological findings.     

Munchausen's syndrome: a reconceptualization of the disorder

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) delineates three categories of factitious disorders: chronic with physical symptoms (Munchausen's syndrome); factitious disorder with psychological symptoms; and other factitious disorders with physical symptoms. Munchausen's syndrome served as the prototype for all factitious disorders at the time DSM-III was drafted, partly due to the disproportionate attention given to this variant of the disorder. Clinical experience suggests that existing categories do not adequately provide for commonly seen forms of factitious illness. It is now recognized that factitious disorder is the result of a complex interaction of personality factors and psychosocial stressors that often present with both medical and psychiatric symptomatology. Proposed changes in the revised edition of the diagnostic manual DSM-III-R include separate categories of factitious disorder with psychological, physical, and both psychological and physical symptoms. A case report of a patient for whom extensive records and thorough psychological assessment were available is exemplary of a more common course of the disorder (both psychological and physical symptoms) that by current classification would be considered "atypical." A reconceptualization of the disorder that gives emphasis to course and clinical features is suggested.     

Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder

OBJECTIVE: To obtain a comprehensive view of differences in current comorbidity between bipolar I and II disorders (BD) and (unipolar) major depressive disorder (MDD), and Axis I and II comorbidity in BD in secondary-care psychiatric settings. METHOD: The psychiatric comorbidity of 90 bipolar I and 101 bipolar II patients from the Jorvi Bipolar Study and 269 MDD patients from the Vantaa Depression Study were compared. We used DSM-IV criteria assessed by semistructured interviews. Patients were inpatients and outpatients from secondary-care psychiatric units. Comparable information was collected on clinical history, index episode, symptom status, and patient characteristics. RESULTS: Bipolar disorder and MDD differed in prevalences of current comorbid disorders, MDD patients having significantly more Axis I comorbidity (69.1% vs. 57.1%), specifically anxiety disorders (56.5% vs. 44.5%) and cluster A (19.0% vs. 9.9%) and C (31.6% vs. 23.0%) personality disorders. In contrast, BD had more single cluster B personality disorders (30.9% vs. 24.6%). Bipolar I and bipolar II were similar in current overall comorbidity, but the prevalence of comorbidity was strongly associated with the current illness phase. CONCLUSIONS: Major depressive disorder and BD have somewhat different patterns in the prevalences of comorbid disorders at the time of an illness episode, with differences particularly in the prevalences of anxiety and personality disorders. Current illness phase explains differences in psychiatric comorbidity of BD patients better than type of disorder.     

Factitious disorder in a manic patient: case report and treatment considerations

A case of factitious disorder with physical symptoms is described in a patient with manic-depressive illness. The coexistence of factitious disorder and bipolar disorder has not been previously reported. Clinicians should search for an underlying affective disorder in patients who fabricate signs and symptoms of physical illness, since mania may simulate or contribute to the production of factitious behavior.     

Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder

OBJECTIVE: The aim of this study was to evaluate dissociative disorder and overall psychiatric comorbidity in patients with conversion disorder. METHOD: Thirty-eight consecutive patients previously diagnosed with conversion disorder were evaluated in two follow-up interviews. The Structured Clinical Interview for DSM-III-R, the Dissociation Questionnaire, the Somatoform Dissociation Questionnaire, and the Childhood Trauma Questionnaire were administered during the first follow-up interview. The Structured Clinical Interview for DSM-IV Dissociative Disorders was conducted in a separate evaluation. RESULTS: At least one psychiatric diagnosis was found in 89.5% of the patients during the follow-up evaluation. Undifferentiated somatoform disorder, generalized anxiety disorder, dysthymic disorder, simple phobia, obsessive-compulsive disorder, major depression, and dissociative disorder not otherwise specified were the most prevalent psychiatric disorders. A dissociative disorder was seen in 47.4% of the patients. These patients had dysthymic disorder, major depression, somatization disorder, and borderline personality disorder more frequently than the remaining subjects. They also reported childhood emotional and sexual abuse, physical neglect, self-mutilative behavior, and suicide attempts more frequently. CONCLUSIONS: Comorbid dissociative disorder should alert clinicians for a more chronic and severe psychopathology among patients with conversion disorder.     

Major depressive disorder and axis I diagnostic comorbidity

BACKGROUND: Recognition of comorbid conditions in patients presenting for the treatment of depression is clinically important because the presence of other disorders can influence treatment planning. In the present study, we examined the frequency of diagnostic comorbidity in psychiatric outpatients presenting for treatment of nonbipolar major depressive disorder (MDD) and patients' desire for treatment for the comorbid disorders. METHOD: Four hundred seventy-nine psychiatric outpatients with DSM-IV nonbipolar MDD were evaluated with a modified version of the Structured Clinical Interview for DSM-IV. RESULTS: Excluding nicotine dependence, at the time of the evaluation 64.1% (N = 307) of the patients met criteria for at least 1 of the 23 specific Axis I disorders, and more than one third (36.7%, N = 176) had 2 or more disorders. Anxiety disorders, as a group, were the most frequent current comorbid disorders (56.8%), and social phobia was the most frequent individual disorder. Including subthreshold conditions, the percentage of patients with at least 1 disorder increased to 73.5%. When the scope of assessment was expanded to include nicotine dependence, nicotine dependence was the most frequent lifetime individual disorder (38.2%) and the second most frequent current disorder (27.3%). There was considerable variability among the disorders regarding desire for treatment of the comorbid condition. CONCLUSION: The majority of nonbipolar depressed patients have a current comorbid disorder, especially an anxiety disorder, although the actual rate of comorbidity depends on the breadth of the assessment.     

Insomnia, quality of life and psychopathological features

Most of the studies about chronic insomnia focused only on specific features, providing in this way a partial outlook of the problem. The aim of this study was to examine a sample of chronic insomniacs from different points of view, by estimating the prevalence of stress, psychopathological symptoms, psychiatric disorders, changes in quality of life and illness behaviour. Forty-three patients (54.4%) experienced some psychosocial stressors in the last 6 months preceding the enrollment in the study. More than 55% of insomniacs reported symptoms of psychopathology. One or more than one psychiatric disorder was diagnosed in 61.5% of insomniacs. Life events could play a role in facilitating the transformation of a psychopathological symptom in a psychiatric disorder, since patients with a psychiatric diagnosis showed a higher percent of stress. The more noticeable disability in the group of insomniacs with psychiatric disorders and the absence of a corresponding worsening in illness behaviour suggests that insomniacs feelings about their health status are so negative to be not fatherly worsen by comorbidity in spite of a worsen disability. The evaluation of insomniacs should be as much detailed as possible, without neglecting tests for the evaluation of disability and illness behaviour, which are important not only for a correct diagnosis but also for monitoring the effects of therapies.     

Depression and somatic diseases. On one retrospective study of 210 patients with major depression hospitalized in a psychiatric hospital

Associations between depression and somatic disorders are common and little studied. We present the results of a retrospective study including 210 psychiatric inpatients, suffering from a major depressive episodes (MDE-DSM III-R criteria). The purpose of this study was: first, to access the prevalence of comorbid MDEs with somatic illness, second to describe the clinical, therapeutic and evolutionary characteristics of MDEs secondary to a physical trouble, comparatively with primary depressions and depressions secondary to another psychiatric disorder. A somatic comorbidity was found in 55% of patients (n = 116), the physical illness being, in 6% of cases, causal regarding MDEs. MDEs with a somatic comorbidity (n = 55) are significantly different from primary MDEs (n = 36) and MDEs secondary to another psychiatric disorder (n = 58), regarding an older age at hospitalization and at first affective episode. Moreover, they are different from MDEs secondary to another psychiatric disorder through fewer past suicide attempts, more episodes with melancholic or psychotic characteristics and a lower frequency of tricyclic antidepressant use. Despite methodologically limited, these results confirm the frequency of physical comorbidity in depressed patients hospitalized in general hospitals, especially in elderly subjects. They also reflect the heterogeneity of the group of secondary depressions, MDEs associated with a somatic illness being closer to MDEs secondary to another psychiatric disorder than to primary MDEs.     

Comorbidity in hoarding disorder

Background: Hoarding Disorder (HD) is currently under consideration for inclusion as a distinct disorder in DSM‐5 (1). Few studies have examined comorbidity patterns in people who hoard, and the ones that have suffer from serious methodological shortcomings including drawing from populations already diagnosed with obsessive compulsive disorder (OCD), using outdated definitions of hoarding, and relying on inadequate assessments of hoarding. The present study is the first large‐scale study of comorbidity in a sample of people meeting recently proposed criteria for hoarding disorder (1) and relying on validated assessment procedures. Methods: We compared psychiatric comorbidity in a large HD sample (n = 217) to 96 participants meeting criteria for OCD without HD. Results: High comorbidity rates were observed for major depressive disorder (MDD) as well as acquisition‐related impulse control disorders (compulsive buying, kleptomania, and acquiring free things). Fewer than 20% of HD participants met criteria for OCD, and the rate of OCD in HD was higher for men than women. Rates of MDD and acquisition‐related impulse control disorders were higher among HD than OCD participants. No specific anxiety disorder was more frequent in HD, but social phobia was more frequent among men with HD than among men with OCD. Inattentive ADHD was diagnosed in 28% of HD participants and was significantly more frequent than among OCD participants (3%). Conclusions: These findings form important base rates for developing research and treatments for hoarding disorder. Depression and Anxiety, 2011. © 2011 Wiley‐Liss, Inc.     

Substance use disorder comorbidity among inpatient youths with psychiatric disorder

OBJECTIVE: Substance abuse/dependence has been reported to show significant association with psychopathology, and is likely to influence the course and outcome of psychiatric illness. The aim of this study was to determine the rate of substance use disorders (other than alcohol) comorbidity among inpatient adolescents with severe Axis 1 psychiatric disorder. METHOD: A retrospective analysis of systematically collected data was carried out. The subjects were 16-18-year-old youths, admitted to an inpatient unit for severe psychiatric disorder. The data collection process utilized the DSM-IV criteria for diagnostic categorization of psychiatric disorder and substance use disorder. Demographic data, and data on suicide attempts were also collected. RESULTS: Over a period of one year (March 2001-March 2002), 62 patients were admitted to the Christchurch Youth Inpatient Unit; 40 (64.5%) had a comorbid Substance Abuse Disorder (SAD) according to DSM-IV criteria and none had a Substance Dependence Disorder. The vast majority involved cannabis and stimulants. Sixty per cent of those with mood disorder, 63% of those with anxiety disorder and 80% of those with schizophrenia spectrum disorder had a comorbid SAD. Internalizing problems, especially mood disorders, pre-dominated among those with SAD reflecting the Unit's admission criteria. There were no differences in attempted suicide rates between those with SAD and those without SAD, but those with SAD were more likely to have unstable accommodation/living arrangements than those without SAD. CONCLUSIONS: Our findings confirm previous reports suggestive of high rates of SAD comorbidity among youth with severe psychiatric illness. There are clinical and process implications for these findings particularly identification of substance use disorders and their treatment as well as resource availability and staff training.     

Defining a developmental subtype of bipolar disorder in a sample of nonreferred adults by age at onset

OBJECTIVE: To test the hypothesis that the age at onset of bipolar disorder would identify a developmental subtype of bipolar disorder in adults characterized by increased levels of irritability, chronic course, rapid cycling, and comorbidity with attention deficit hyperactivity disorder. METHODS: Forty-four adult subjects diagnosed with bipolar disorder were selected from large family studies of youth with and without attention deficit hyperactivity disorder. These subjects were stratified by the age at onset in childhood (younger than 13 years; n = 8, 18%), adolescence (13-18 years; n = 12, 27%, or adulthood (older than 19 years; n = 24, 55%). All subjects were administered structure diagnostic interviews and a brief cognitive battery. RESULTS: In contrast with adult-onset bipolar disorder, child-onset bipolar disorder was associated with a longer duration of illness, more irritability than euphoria, a mixed presentation, a more chronic or rapid-cycling course, and increased comorbidity with childhood disruptive behavior disorders and anxiety disorders. CONCLUSION: Stratification by age at onset of bipolar disorder identified subgroups of adult subjects with differing clinical correlates. This pattern of correlates is consistent with findings documented in children with pediatric bipolar disorder and supports the hypothesis that child-onset bipolar disorder may represent a developmental subtype of the disorder.     

Temperament and character traits in patients with bipolar disorder and associations with comorbid alcoholism or anxiety disorders

Temperament and character traits may determine differences in clinical presentations and outcome of bipolar disorder. We compared personality traits in bipolar patients and healthy individuals using the Temperament and Character Inventory (TCI) and sought to verify whether comorbidity with alcoholism or anxiety disorders is associated with specific personality traits. Seventy-three DSM-IV bipolar patients were compared to 63 healthy individuals using the TCI. In a second step, the bipolar sample was subgrouped according to the presence of psychiatric comorbidity (alcoholism, n=10; anxiety disorders; n=23; alcoholism plus anxiety disorders, n=21; no comorbidity, n=19). Bipolar patients scored statistically higher than the healthy individuals on novelty seeking, harm avoidance and self-transcendence and lower on self-directedness and cooperativeness. Bipolar patients with only comorbid alcoholism scored statistically lower than bipolar patients without any comorbidity on persistence. Bipolar patients with only comorbid anxiety disorders scored statistically higher on harm avoidance and lower on self-directedness than bipolar patients without any comorbidity. Limitations of this study include the cross-sectional design and the small sample size, specifically in the analysis of the subgroups. However, our results suggest that bipolar patients exhibit a different personality structure than healthy individuals and that presence of psychiatric comorbidity in bipolar disorder is associated with specific personality traits. These findings suggest that personality, at least to some extent, mediates the comorbidity phenomena in bipolar disorder.     

Dissociation (conversion) - malingering - antisocial personality disorder: differential diagnostic reflection on the basis of a case study

In this case report we refer to the big challenge of making a diagnosis in a deliberate malingering in the field of mental disorders. We specifically describe the difficulty regarding the differentiation between a conversion disorder and malingering of a serial delinquent. For such a person avoiding criminal persecution is one of the most frequent reason to deceitfully simulate a mental illness. In this field, symptoms of conversion disorders exceed the average; furthermore, a great number of organic-neurological illnesses may appear to be very similar to a conversion disorder or in many cases a neurological disorder can actually be detected in the course of a somatic examination. A further obstacle for the differential diagnosis can be seen in the difficulty to discern it from factitious disorders. However, it is quite possible to discern the deliberate malingering of a mental disorder from a conversion disorder by means of the diligent diagnosis of a competent and experienced doctor/assessor who specialises.     

Episodic and chronic obsessive-compulsive disorder

Several lines of evidence support the concept of obsessive-compulsive disorder (OCD) as a heterogeneous illness. Using a range of factors such as demographic, psychosocial, and clinical variables, we compared OCD patients with chronic (n = 55) versus episodic (n = 46) courses of illness. Patients were evaluated monthly for 1 year while receiving no treatment. Significant differences in sex ratio, age at onset of the disorder, illness duration, type of symptoms, and familial history were found between the two groups. These findings are consistent with the concept of OCD as a heterogeneous disorder. Patients with an episodic course of the disorder may be a distinct subgroup within the whole group of obsessive-compulsive patients. Depression and Anxiety 6:154–158, 1997. © 1997 Wiley-Liss, Inc.