Phobic disorders and anxiety states: how do they differ?

A review of the clinical literature to date has shown that the nature of the relationship between phobic disorders and anxiety states is still unclear. As a wide range of symptoms are shared by patients with all DSM-III anxiety disorder diagnoses, at this stage there is still a need to investigate the latent dimensions which distinguish the anxiety disorder subtypes. In the present study 176 patients with the DSM-III diagnoses of agoraphobia with panic attacks, social phobia, panic disorder and generalized anxiety disorder completed the Fear Survey Schedule, Fear Questionnaire, Hostility and Direction of Hostility Questionnaire, Maudsley Personality Inventory, and the Hamilton Anxiety and Depression Scales. Group membership was significantly predicted by a discriminant analysis which yielded a Fear Questionnaire agoraphobia function and a social phobia function. The results from discriminant analysis suggests that agoraphobia and anxiety states may be closely related. Classification errors were also determined, providing further evidence with which to refute the claim that agoraphobia has "all or none" characteristics.     

Health anxiety and fear of fear in panic disorder and agoraphobia vs. social phobia: a prospective longitudinal study

Background: This study is aimed to evaluate the role of two vulnerability factors, health anxiety and fear of fear, in the prediction of the onset of panic disorder/agoraphobia (PDA) relative to a comparison anxiety disorder. Methods: Young women, aged between 18 and 24 years, were investigated at baseline and, 17 months later, using the Anxiety Disorders Interview Schedule‐Lifetime and measures of health anxiety and fear of bodily sensations (subscale disease phobia of the Whiteley Index, and total score of the Body Sensations Questionnaire). First, 22 women with current PDA were compared to 81 women with current social phobia and 1,283 controls. Second, 24 women with an incidence of PDA were compared to 60 women with an incidence of social phobia and 1,036 controls. Results: Multiple logistic regression analyses adjusted for history of physical diseases, somatic symptoms, and other psychological disorders revealed that (a) fear of bodily sensations was elevated for women with PDA vs. controls as well as women with social phobia, and (b) health anxiety (and history of physical diseases) was elevated in women who developed PDA vs. controls and vs. women who developed social phobia. Conclusions: These results suggest that health anxiety, as well as history of physical diseases, may be specific vulnerability factors for the onset of PDA relative to social phobia. Whereas fear of bodily sensations was not found to be a risk factor for the onset of panic disorder/agoraphobia, it was a specific marker of existing PDA relative to social phobia. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Anxiety disorders and substance use disorders: different associations by anxiety disorder

Anxiety disorders (ADs) and substance use disorders (SUDs) often occur together, but the strength of this association and their apparent order of onset differ across studies. The goals of this study were to examine: (1) which ADs were associated with which SUDs, and (2) among people who experienced both an AD and a SUD, which disorder had an earlier onset. Lifetime diagnoses from the National Comorbidity Survey-Replication (n=9282) were used. Social phobia, generalized anxiety disorder, panic disorder, and agoraphobia were positively associated with all SUDs. Among people with both an AD and a SUD, the order of onset differed by anxiety type: social phobia nearly always had an onset prior to any SUD; panic disorder and agoraphobia tended to occur prior to some SUDs; and generalized anxiety disorder tended to occur after the onset of at least one SUD. Therefore, all ADs are positively associated with SUDs, but ADs differ in the timing of their onset relative to comorbid SUDs.     

Clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders - results from a European multicenter study

This naturalistic European multicenter study aimed to elucidate the association between major depressive disorder (MDD) and comorbid anxiety disorders. Demographic and clinical information of 1346 MDD patients were compared between those with and without concurrent anxiety disorders. The association between explanatory variables and the presence of comorbid anxiety disorders was examined using binary logistic regression analyses. 286 (21.2%) of the participants exhibited comorbid anxiety disorders, 10.8% generalized anxiety disorder (GAD), 8.3% panic disorder, 8.1% agoraphobia, and 3.3% social phobia. MDD patients with comorbid anxiety disorders were characterized by younger age (social phobia), outpatient status (agoraphobia), suicide risk (any anxiety disorder, panic disorder, agoraphobia, social phobia), higher depressive symptom severity (GAD), polypsychopharmacy (panic disorder, agoraphobia), and a higher proportion receiving augmentation treatment with benzodiazepines (any anxiety disorder, GAD, panic disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder). The results in terms of treatment response were conflicting (better response for panic disorder and poorer for GAD). The logistic regression analyses revealed younger age (any anxiety disorder, social phobia), outpatient status (agoraphobia), suicide risk (agoraphobia), severe depressive symptoms (any anxiety disorder, GAD, social phobia), poorer treatment response (GAD), and increased administration of benzodiazepines (any anxiety disorder, agoraphobia, social phobia) and pregabalin (any anxiety disorder, GAD, panic disorder) to be associated with comorbid anxiety disorders. Our findings suggest that the various anxiety disorders subtypes display divergent clinical characteristics and are associated with different variables. Especially comorbid GAD appears to be characterized by high symptom severity and poor treatment response.     

Experience sampling and ecological momentary assessment for studying the daily lives of patients with anxiety disorders: A systematic review

Anxiety disorders are highly prevalent. Symptoms may occur unpredictably (e.g., panic attacks) or predictably in specific situations (e.g., social phobia). Consequently, it may be difficult to assess anxiety and related constructs realistically in the laboratory or by traditional retrospective questionnaires. Experience sampling methods (ESM) and ecological momentary assessment (EMA) can deepen the understanding of the course of anxiety disorders by frequently assessing symptoms and other variables in the natural environment. We review 34 ESM/EMA studies on adult panic disorder, generalized anxiety disorder, social phobia, post-traumatic stress disorder, and obsessive–compulsive disorder, as well as anxiety disorders in youth. Benefits of ESM/EMA for the study of anxiety disorders include generating insight into the temporal variability of symptoms and into the associations among daily affect, behaviors, and situational cues. Further, ESM/EMA has been successfully combined with ambulatory assessment of physiological variables and with treatment evaluations. We provide suggestions for future research, as well as for clinical applications.     

Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year longitudinal study

OBJECTIVE: To examine whether separation anxiety disorder (SAD) in childhood is a risk factor for panic disorder and agoraphobia in adulthood. METHOD: Patients (n = 85) who had completed treatment for SAD, generalized anxiety disorder, and/or social phobia 7.42 years earlier (on average) were reassessed using structured diagnostic interviews. RESULTS: Subjects with a childhood diagnosis of SAD did not display a greater risk for developing panic disorder and agoraphobia in young adulthood than those with other childhood anxiety diagnoses. Subjects with a childhood diagnosis of SAD did not more frequently meet full diagnostic criteria for panic disorder and agoraphobia, generalized anxiety disorder, social phobia, or major depressive disorder in adulthood than subjects with childhood diagnoses of generalized anxiety disorder or social phobia, but were more likely to meet criteria for other anxiety disorders (i.e., specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, and acute stress disorder). CONCLUSIONS: These results argue against the hypothesis that childhood SAD is a specific risk factor for adult panic disorder and agoraphobia.     

Anxiety disorders and onset of cardiovascular disease: The differential impact of panic,phobias and worry

Anxiety has been linked to onset of cardiovascular disease. This study examines the differential impact of types of anxiety (panic, phobia and worry) on 3-year onset of non-fatal cardiovascular disease (CVD). By investigating anxiety disorders as opposed to anxiety symptoms and by using a reliable diagnostic instrument to assess anxiety, limitations of previous studies are considered.5149 persons at risk for CVD were interviewed using the Composite International Diagnostic Interview. The panic-type included panic disorder and panic attacks; the phobic-type included agoraphobia and social phobia, and the worry-type included generalized anxiety disorder. CVD was self-reported and required treatment or monitoring by a doctor. Analyses were adjusted for sociodemographics, behavioral variables, and comorbid somatic and psychiatric disorders. During follow-up, 62 persons (1.2%) developed CVD. Baseline generalized anxiety disorder was strongly associated with onset of CVD (adjusted OR: 3.39). Further research should replicate findings and focus on biological underpinnings of this association.     

Relations between anxiety sensitivity and panic symptoms in nonreferred children and adolescents

Anxiety sensitivity (AS), the fear of anxiety-related sensations, has been posited to be a cognitive risk factor for the development of anxiety disorders but has been understudied in youth. The purpose of the present investigations was to evaluate relations between AS and panic symptoms in nonreferred children and adolescents. In Study 1, (N = 113, mean age, 13.98). scores on the Childhood Anxiety Sensitivity Index (CASI) predicted the experience of uncued panic attacks after controlling for general anxiety and depression, although the total variance accounted for was small. In Study 2 (N = 52; mean age, 9.48), the Panic/ Agoraphobia subscale of the Spence Children's Anxiety Scale was used as the criterion variable. CASI score again predicted panic symptoms after controlling for trait anxiety and depression. Identification of a risk factor for panic attacks and panic disorder in youth will have important implications for etiologic theory, intervention, and prevention.     

Les traitements médicamenteux des troubles anxieux

Anxiety disorders are the most common of all the mental health disorders. Considered in the category of the most common anxiety disorders are: generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia and obsessive compulsive disorder. Depending upon the severity of the anxiety, medication is used in combination with cognitive-behavioral psychotherapy interventions. Medication should be prescribed if the anxiety symptoms are serious and interfering with normal daily functioning. Clinicians should be especially watchful of the individual becoming psychologically or physiologically addicted to certain antianxiety medications, such as benzodiazepines. When medication is needed, the most commonly-prescribed class of drugs for acute anxious disorders (i.e. panic attacks) are the benzodiazepines and the SSRI antidepressants are useful for the long-term maintenance treatment. Self-help methods for the treatment of these disorders are often overlooked by the medical profession because very few professionals are involved in them.     

Anxiety disorders in 318 bipolar patients: prevalence and impact on illness severity and response to mood stabilizer

OBJECTIVE: The aim of this study was to assess the frequency and impact of anxiety disorders on illness severity and response to mood stabilizers in bipolar disorders. METHOD: 318 bipolar patients consecutively admitted to the psychiatric wards of 2 centers as inpatients were recruited. Patients were interviewed with a French version of the Diagnostic Interview for Genetic Studies providing DSM-IV Axis I diagnoses and demographic and historical illness characteristics. Logistic and linear regressions to adjust for age and sex were performed. RESULTS: In a population with mostly bipolar type I patients (75%), 24% had at least 1 lifetime anxiety disorder (47% of these patients had more than 1 such disorder), 16% of patients had panic disorder (with and without agoraphobia, and panic attacks), 11% had phobia (agoraphobia without panic disorder, social phobia, and other specific phobias), and 3% had obsessive-compulsive disorder. Comorbidity with anxiety disorders was not correlated with severity of bipolar illness as assessed by the number of hospitalizations, psychotic characteristics, misuse of alcohol and drugs, and suicide attempts (violent and nonviolent). Bipolar patients with an early onset of illness had more comorbidity with panic disorder (p <.05). Anxiety disorders were detected more frequently in bipolar II patients than in other patients, but this difference was not significant (p =.09). Bipolar patients with anxiety responded less well to anticonvulsant drugs than did bipolar subjects without anxiety disorder (p <.05), whereas the efficacy of lithium was similar in the 2 groups. There was also a strong correlation between comorbid anxiety disorders and depressive temperament in bipolar patients (p =.004). CONCLUSION: Patients with bipolar disorders often have comorbid anxiety disorders, particularly patients with depressive temperament, and the level of comorbidity seems to decrease the response to anticonvulsant drugs.     

The epidemiology of anxiety

In a literature review the best estimates for prevalence of anxiety disorders were determined to be 3% for panic, 6% for agoraphobia, 3% for generalized anxiety, 2.5% for simple phobia, and 1.5% for social phobia. Anxiety disorders tended to have a 2:1 female preponderance. Age of onset was 17 years for social and simple phobia, 22 years for generalized anxiety, and 26 years for panic and agoraphobia. Simple phobia was found to respond best to behavioral treatment and to have a good prognosis. Panic and agoraphobia were found to be familial, to have a chronic course, and to respond best to a combination of pharmacological and behavioral treatment.     

Distinguishing between depression and anxiety: A proposal for an extension of the tripartite model

AimThe aim of the current study was to develop scales that assess symptoms of depression and anxiety and can adequately differentiate between depression and anxiety disorders, and also can distinguish within anxiety disorders. As point of departure, we used the tripartite model of Clark and Watson that discerns three dimensions: negative affect, positive affect and physiological hyperarousal.MethodsAnalyses were performed on the data of 1449 patients, who completed the Mood and Anxiety Symptoms Questionnaire (MASQ) and the Brief Symptom Inventory (BSI). From this, 1434 patients were assessed with a standardized diagnostic interview.ResultsA model with five dimensions was found: depressed mood, lack of positive affect, somatic arousal, phobic fear and hostility. The scales appear capable to differentiate between patients with a mood and with an anxiety disorder. Within the anxiety disorders, somatic arousal was specific for patients with panic disorder. Phobic fear was associated with panic disorder, simple phobia and social anxiety disorder, but not with generalized anxiety disorder.ConclusionsWe present a five-factor model as an extension of the tripartite model. Through the addition of phobic fear, anxiety is better represented than in the tripartite model. The new scales are capable to accurately differentiate between depression and anxiety disorders, as well as between several anxiety disorders.     

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.     

Audiovestibular functioning in patients with panic disorder

OBJECTIVE: The objective of this study was to investigate audiovestibular function in patients with panic disorder and healthy subjects by using vestibular and audiologic tests. METHODS: Thirty-four panic disorder patients and 20 healthy control subjects were assessed by using clinical otoneurological examination, pure tone audiometry, tympanometry, and electronystagmography (ENG). All patients were evaluated with the Panic and Agoraphobia Scale (PAS), the Hamilton Anxiety Rating Scale (HARS), the Hamilton Depression Rating Scale (HDRS), and the State-Trait Anxiety Inventory (STAI). RESULTS: On vestibular testing, abnormal responses were more prevalent in panic disorder patients compared to healthy controls. The presence of agoraphobia in panic disorder patients did not make a significant difference on vestibular test results. The only variable that may be a predictor of vestibular abnormalities in panic disorder patients was found to be dizziness between attacks. CONCLUSION: The results show that dizziness between panic attacks may warrant audiovestibular testing among other medical investigations.     

Hypochondriacal concerns and somatization in panic disorder

To clarify the relationship between panic disorder and the symptoms of hypochondriasis and somatization, we evaluated these symptoms and diagnoses in patients attending an Anxiety Disorders Clinic. Structured clinical interviews, self-report measures, and symptom diaries were used to assess 21 patients with panic disorder, 23 patients with social phobia, and 22 control subjects with no psychiatric disorders. Ten of the patients with panic disorder (48%) also met DSM-IV criteria for hypochondriasis, whereas only one of the patients with social phobia and none of the healthy control subjects met the criteria for this diagnosis. None of the participants met DSM-IV criteria for somatization disorder, even though both anxiety groups reported high levels of somatic symptoms. The panic disorder group reported higher levels of fear about illness and disease conviction and endorsed more somatic symptoms than did the other groups. A higher proportion of panic disorder patients reported previously diagnosed medical conditions (48%) as compared with patients with social phobia (17%) or healthy control subjects (14%). The panic disorder patients with DSM-IV hypochondriasis obtained higher scores on measures of hypochondriacal concerns, somatization, blood–injury phobia, and general anxiety and distress than did the panic disorder patients without hypochondriasis. The results suggest a strong association between panic disorder and hypochondriasis. Depression and Anxiety 6:78–85, 1997. © 1997 Wiley-Liss, Inc.     

Childhood history of anxiety disorders among adults with social phobia: rates, correlates, and comparisons with patients with panic disorder.

We examined the rates and correlates of a childhood history of anxiety disorders in 100 adults with a primary diagnosis of social phobia (social anxiety disorder). Adulthood and childhood disorders were assessed by experienced clinicians with structured clinical interviews. Rates of childhood anxiety disorders were evaluated to diagnostic comorbidity and a comparison group of patients with panic disorder. Onset of social phobia occurred before age 18 in 80% of the sample. Over half of the sample (54%) met criteria for one or more childhood anxiety disorders other than social phobia: 47% for overanxious disorder, 25% for avoidant disorder, 13% for separation anxiety disorder, and 1% for childhood agoraphobia. A history of childhood anxiety was associated with an early age of onset of social phobia, greater severity of fear and avoidance of social situations, greater fears of negative evaluation, and greater anxiety and depression morbidity. Rates of childhood social phobia, overanxious disorder, and avoidant disorder were significantly higher in patients with social phobia relative to our panic-disordered comparison group. We found approximately equal rates of a childhood history of separation anxiety disorder in patients with social phobia and panic disorder, providing further evidence against a unique relationship between separation anxiety disorder and panic disorder.     

Specificity of lactate infusions in social phobia versus panic disorders

Lactate infusions produced panic attacks in one of 15 patients with social phobia, four of nine with agoraphobia, and 10 of 20 with panic disorder in a blind study. The proportion of patients with social phobia who panicked in response to lactate was significantly lower than that of patients with agoraphobia or panic disorder. These findings lend validity to the DSM-III classification of anxiety states. They also suggest that the pathophysiology of social phobia differs from that of disorders characterized by spontaneous panic attacks.     

Symptom profiles of patients with DSM-III anxiety disorders

The authors used symptom profiles, demographic data, and other variables to compare 316 patients representing all specific DSM-III anxiety disorders except posttraumatic stress disorder to each other and to published norms for both an unselected psychiatric outpatient population and normal subjects. The results support the grouping of these disorders, with the possible exception of obsessive-compulsive disorder, into one general diagnostic category of "anxiety disorders." The distinction between the specific diagnoses of simple phobia and social phobia was also supported; however, the differentiation between panic disorder, agoraphobia, and generalized anxiety was only weakly supported.     

Assessing excessive reassurance seeking in the anxiety disorders

Reassurance seeking has long been hypothesized to be a key factor in the maintenance of anxiety within contemporary cognitive-behavioral approaches to the conceptualization and treatment of anxiety disorders. However, empirical studies have lagged due to the absence of a reliable and valid measure of reassurance seeking. The present study sought to develop and examine the psychometric properties of a theoretically derived measure of reassurance seeking in treatment-seeking participants with DSM-IV-TR (American Psychiatric Association, 2000) social phobia (n = 116), generalized anxiety disorder (n = 75), panic disorder with or without agoraphobia (n = 50), and obsessive compulsive disorder (n = 42). Participants (N = 283) completed the Reassurance Seeking Scale (RSS), Depression Anxiety Stress Scale, Beck Anxiety Inventory, and Beck Depression Inventory-II. An exploratory factor analysis resulted in a coherent three factor solution reflecting the need to seek excessive reassurance regarding: (1) uncertainty about decisions, (2) attachment and the security of relationships, and (3) perceived general threat and anxiety. The RSS was found to possess good internal consistency and was moderately correlated with measures of anxiety, stress, and depression. The psychometric properties of the RSS appear promising for the promotion of programmatic research on reassurance seeking and its treatment in the anxiety disorders.     

Childhood and family characteristics in panic and generalized anxiety disorders

The author compared 32 patients who had generalized anxiety disorders with 29 patients who had panic disorder and agoraphobia with panic attacks. He observed that patients with generalized anxiety disorder more often had lost their fathers and/or mothers before the age of 16 years, whereas patients with panic disorder and agoraphobia with panic attacks had more often experienced chronic anxiety in childhood. More parents and siblings of patients with panic disorder had affective disorders and alcohol abuse than did parents and siblings of patients with anxiety disorders.