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.     

Clinical differentiation between major depression only, major depression with panic disorder and panic disorder only. Childhood, personality and personality disorder

A consecutive sample of 298 nonpsychotic psychiatric outpatients was classified according to DSM-III and divided into 4 diagnostic groups: pure major depression, mixed major depression/panic disorder, pure panic disorder and a remaining group of other disorders. The patients' report of childhood relationship to parents and siblings, family atmosphere, their own personality characteristics as children and precipitating events were compared in the various groups. In addition, differences in personality and frequencies of personality disorders were investigated by means of various instruments. Our results show that the type of relationship to parents in childhood differed in the various groups. The mother seems to be the most crucial person for the development of depression, the father for the development of panic disorder. Patients with major depression are more obsessive and patients with panic disorder more infantile and avoidant with less control of their personality. Finally, patients with mixed conditions are more in accordance with the DSM-III anxious personality disorder cluster.     

Relationships among psychosocial functioning, diagnostic comorbidity, and the recurrence of generalized anxiety disorder, panic disorder, and major depression

The present study examined the relationships among impaired psychosocial functioning, comorbidity, and the cumulative probability of future recurrence of anxiety disorders and major depression in recovered patients. Participants were part of the Harvard/Brown Anxiety Disorders Research Program (HARP), a naturalistic, prospective, longitudinal study of anxiety disorders in psychiatric outpatients. Using proportional hazards regressions, worsening psychosocial impairment in general and in specific areas was significantly associated with an increased risk of panic disorder, generalized anxiety disorder, and major depression recurring, even after controlling for diagnostic comorbidity. These results are consistent with and extend similar findings for patients with major depression [Leon, A., Solomon, D. A., Mueller, T. I., Endicott, J., Posternak, M., Judd, L. L., et al. (1999). The range of Impaired Functioning Tool (LIFE-RIFT): a brief measure of functional impairment. Psychological Medicine, 29, 869-878; Leon, A., Solomon, D. A., Mueller, T. I., Endicott, J., Posternak, M., Judd, L. L., et al. (2000). A brief assessment of psychosocial functioning of subjects with bipolar I disorder: The LIFE-RIFT. The Journal of Nervous and Mental Disease, 188, 805-812], and suggest that increased psychosocial impairment may be a risk factor for relapse.     

Moderating effects of major depression on patterns of comorbidity in patients with panic disorder

Given the high rate of co-occurring major depression in patients with panic disorder, it is unclear whether patterns of comorbidity in individuals with panic disorder reported in the literature are associated with panic disorder or with the presence of major depression. Subjects were 231 adult subjects with panic disorder and major depression (n=102), panic disorder without comorbid major depression (n=29), major depression without comorbid panic disorder (n=39), and neither panic disorder nor major depression (n=61). Subjects were comprehensively assessed with structured diagnostic interviews that examined psychopathology across the life cycle. Panic disorder, independently of comorbidity with major depression, was significantly associated with comorbid separation anxiety disorder, simple phobia, obsessive-compulsive disorder, generalized anxiety disorder, and agoraphobia. Major depression, independently of comorbidity with panic disorder, was significantly associated with comorbidity with psychoactive substance use disorders and childhood disruptive behavior disorders. Overanxious disorder was associated with both panic disorder and major depression. Major depression has important moderating effects on patterns of comorbidity of panic disorder in referred adults.     

Patterns of comorbidity in panic disorder and major depression: findings from a nonreferred sample

Previous findings in referred adult samples document major depression as having important moderating effects on the patterns of comorbidity for panic disorder and major depression. This study evaluated whether these patterns of comorbidity are moderated by referral bias. Panic disorder (PD) and major depression (MD) were used to predict the risk for comorbid psychiatric disorders and functional outcomes using data from a large sample of adults who had not been ascertained on the basis of clinical referral (N=1,031). Participants were comprehensively assessed with structured diagnostic interview methodology to evaluate childhood and adult comorbid psychiatric disorders. PD increased the risk for anxiety disorders, independently of MD. MD increased the risk for mania, antisocial personality disorder, psychoactive substance use disorder, disruptive behavior disorders, overanxious disorder, social phobia, and generalized anxiety disorder, independently of PD. These results extend to nonreferred samples' previously reported findings documenting that MD has important moderating effects on patterns of comorbidity for PD and indicate that patterns of comorbidity for PD are not due to referral bias.     

Residual symptoms and comorbidity in panic disorder.

Background: The aim of this study was to assess the outcome of the comorbid conditions of panic disorder after 1 year of treatment, emphasizing the detection of residual symptoms and their relationship to other clinical variables. Methods: Subjects (N = 64) were assessed by the Structured Clinical Interview for DSM-III-R and the Eysenck Personality Questionnaire. Comorbidity with other disorders, scores on Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale were assessed at baseline and after 12 months. Criteria for residual anxiety/somatic symptoms were defined. Results: Reduction in generalized anxiety disorder rates accounted for a significant decrease in comorbidity at 1-year follow-up, with regard to baseline assessment. When the more severe symptoms of the disorder had remitted, a third of the patients referred physical symptoms with some concern over a fluctuating state of anxiety. The said symptoms were neither a recurrence of panic disorder nor did they account for other anxiety or somatoform disorders. Lower scores on extraversion predict higher risk of residual symptoms. Discussion: The persistence of residual anxiety/somatic symptoms in a third of the patients who apparently achieved a good response to treatment of panic disorder might characterize a minor form of chronic persistence of this condition. Conclusions: The subgroup of patients with residual symptoms would not be detectable by follow-up studies, which focus on the assessment of relapse of panic disorder by means of strictly defined diagnostic criteria.     

Abnormal visual event-related potentials in obsessive-compulsive disorder without panic disorder or depression comorbidity

Visual event-related potentials and spline map topography during a discriminative response task (DRT) were studied in 8 obsessive-compulsive disorder (OCD) patients without comorbidity for panic disorder or depression and in 12 age-matched controls. In the DRT task (like in a go/no-go task) the subject had to press a button when the target stimuli appeared and had to retain the response when the non-target stimulus appeared (vertical bars were intermixed with an equal probability of horizontals). OC patients had greater N1 latency than controls and their N1 and P3 amplitude was larger for the target stimuli, but not for non-target stimuli. In the normals, non-target stimuli (no-go task) produced a larger activation than target stimuli (go task). In the OCD patients the target stimuli produced the same large activation as the non-target. These findings are consistent with theories that consider OCD to be an attentional disorder deriving from a misallocating of cognitive resources. Moreover, spline map topography confirmed that P3 hyperactivation is localised principally on the frontal lobes.     

Simultaneous major depression and panic disorder: treatment with electroconvulsive therapy.

BACKGROUND: Major depression and panic disorder commonly occur together. Patients with simultaneous depression and panic disorder may have a higher lifetime rate of suicide attempts and an overall worse prognosis than patients with either depression or panic disorder alone. In addition, preliminary work suggests that some of these patients may not respond satisfactorily to antidepressants. In this report, we describe the clinical courses of eight consecutive patients with simultaneous major depression and panic disorder who were referred for ECT at our institution. METHOD: Eight consecutive patients who met DSM-III-R criteria for simultaneous major depression and panic disorder received ECT. All eight patients were evaluated by a structured clinical interview and the patients' major depression and panic disorder were evaluated with a 7-point Clinical Global Impressions severity rating scale. RESULTS: Before ECT was begun, each subject's panic disorder and depression were rated as at least markedly ill. After receiving ECT, all eight showed improvement in their depression. In addition, none of the eight patients reported having a panic attack from the time of their fourth ECT treatment until discharge. CONCLUSION: In this report, eight consecutive patients with simultaneous major depression and panic disorder improved with ECT. Further work is required which examines the potential utility of ECT in treating these patients.     

Divided and selective attention in panic disorder. A comparative study of patients with panic disorder,major depression and healthy controls

OBJECTIVE: While depression is definitely a condition with diminished attentional functioning, there is little evidence as to whether attention is also disturbed in panic disorder. In the present study patients with panic disorder and with depression were compared by means of neuropsychological tests which assess selective and divided attention. METHOD: Twenty-one inpatients with a Panic Disorder, 21 inpatients with a Major Depressive Disorder (DSM-IV diagnoses) and 20 healthy control subjects were investigated drug free. Neuropsychological standard tests were used to measure selective attention (Signal Detection, Wiener-Test-system) and divided attention (Gesichtsfeld-/Neglectprüfung, TAP), which allow the discrimination between left and right visual field stimulus processing. RESULTS: Patients with panic disorder and depression responded significantly slower than healthy control subjects in the test for divided attention, while no differences were found between the two groups of patients. In contrast, there were no differences among the groups of patients and control subjects in regard to reaction time in the test for selective attention. Stimulus presentations in the left and right visual fields did not affect the reaction times differently. CONCLUSIONS: Patients with panic disorder appeared as disturbed in their attentional functioning as patients with depression. Therefore, ignoring attentional deficits in patients with panic disorder is not justified.     

Patterns of comorbidity in panic disorder and agoraphobia.

Diagnoses of comorbid disorders were determined in a sample of 54 patients with panic disorder as defined in DSM-III-R. The sample was divided into the following three groups: (1) uncomplicated panic disorder (PDU); (2) panic disorder with mild agoraphobia (PDM); and (3) panic disorder with moderate to severe agoraphobia (PDA). In comparison with patients with PDU, patients with PDA had higher comorbidity rates in general, received multiple comorbid diagnoses more frequently, had a higher prevalence of major depression, dysthymia, social phobia, generalized anxiety disorder, and obsessive-compulsive disorder, and scored higher on most measures of self-rated psychopathology. These findings support the notion that PDA may be a disorder essentially different from PDU.     

Aging and panic disorder: phenomenology, comorbidity, and risk factors.

OBJECTIVE: The authors compared young and older adults with panic disorder (PD) to investigate differences in panic-associated phenomenology, psychiatric comorbidity, and risk factors. METHOD: Patients in the older group (age 60 and above) were further subdivided into early- and late-onset groups and compared. Phenomenology (number of panic symptoms, severity of anxiety, physiological symptoms, panic-associated cognitions, and overall severity of PD); comorbidity (depressive and anxiety disorders); and risk factors (family history of anxiety and life stressors) were assessed in 167 outpatients with PD. RESULTS: Older patients reported fewer panic symptoms, less anxiety and arousal, less severe PD, lower levels of depression, and higher levels of functioning. Furthermore, within the older-patient group, late-onset patients were found to report less distress during panic attacks in relation to body sensations and panic-related cognitions and emotions. Multiple-regression analysis of the entire sample showed that chronological age and age at onset of PD distinctly predicted different domains of panic phenomenology. CONCLUSION: PD was consistently less severe in older patients across multiple domains, and a later age at onset was associated with less distress due to body sensations, cognitions, and emotions during panic attacks.     

Coping in panic and major depressive disorder. Relative effects of symptom severity and diagnostic comorbidity.

This study used the Ways of Coping Checklist to examine coping style in patients with panic and major depressive disorders. The relative contribution of distress (symptom severity) and diagnostic comorbidity was determined in three sets of diagnostic subgroups: patients suffering from both panic and major depressive disorders (compared with either disorder alone); panic patients with and without agoraphobia (regardless of concurrent depression); and patients with versus without a concurrent axis II personality disorder. Use of less problem-focused and more emotion-focused coping was strongly correlated with level of distress and was associated with all three examples of diagnostic comorbidity when level of distress was used as a covariate. Regression analyses showed that, except for the presence of a personality disorder, distress was a much stronger predictor of coping than diagnostic subtype.     

Dopaminergic function in panic disorder: comparison with major and minor depression.

Several lines of evidence suggest that dopamine might be involved in anxiety states. In this study, we assessed the growth hormone (GH) response to apomorphine (a dopaminergic agonist) 0.5 mg SC in nine drug-free inpatients meeting Research Diagnostic Criteria (RDC) for panic disorder who were age-matched and gender-matched with nine major depressive, and nine minor depressive inpatients. The three groups differed significantly in their mean GH peak response: 5.29 +/- 2.75 ng/ml in major depressives, 26.27 +/- 12.71 ng/ml in minor depressives, and 37.28 +/- 10.58 ng/ml in panics, with a significantly higher response in panic than in either minor or major depressive patients. These results support dopaminergic overactivity in panic disorder as compared with major and minor depression.     

Clinical and psychobiological characteristics of simultaneous panic disorder and major depression

Simultaneous major depression and panic disorder appears to be a common occurrence in psychiatric patients. Patients with this condition present with more severe symptoms than patients with major depression only, respond less well to conventional antidepressants, and in general exhibit greater psychopathology over the course of their illness. Evidence suggesting a possible "dual diathesis," depression and panic, in these patients is reviewed from epidemiological, clinical, and biological perspectives. The importance of taking into account the combined symptoms in treatment planning and physiopathological studies is discussed.     

Patterns of abnormal processing of emotional information in panic disorder and major depression.

Studies showing interference with color naming threat-related words in patients with anxiety disorders suggest a bias towards processing threatening material in these patients. We assessed the specificity of this finding to anxiety disorders and to threatening stimuli by administering Stroop cards with a variety of types of emotional stimuli to 24 panic disorder patients with no history of major depression, 30 patients with major depression and no history of panic attacks and 25 controls with no history of an axis I disorder. Our findings suggest that the abnormal information processing seen in panic disorder may be characterized by a more general bias towards processing emotional stimuli than previously thought. They also suggest that this more general bias may illustrate differences in information processing in panic disorder and major depression.     

The relationship between anxiety and depression: a clinical comparison of generalized anxiety disorder, dysthymic disorder, panic disorder, and major depressive disorder.

This study examined the relationship between the chronic disorders, generalized anxiety disorder (GAD) and dysthymic disorder (DD), and the more acute disorders, panic disorder (PD) and major depressive disorder (MDD) in 110 psychiatric outpatients with diagnoses of either PD, MDD, GAD, or DD. Pure, mixed, and early-/late-onset forms of the chronic disorders were compared with each other and then with PD and MDD on clinical measures and psychiatric history. Minimal differences were found between pure GAD and mixed GAD or between pure DD and mixed DD. The chronic disorders, DD and GAD, had distinct clinical symptom profiles when compared with each other and appeared more closely related to their parent disorders than to each other. However, despite these similarities, there were significant differences between DD and MDD in contrast to the minimal differences between GAD and PD, providing less support for GAD as a valid diagnostic category separate from PD. Comparisons of early-/late-onset DD and GAD showed more severe symptoms in late-onset DD, in contrast to more severe symptoms in early-onset GAD. These varying patterns of symptom severity may warrant study for further syndromal delineation.