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.     

Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features

OBJECTIVE: The authors investigated frequencies and clinical correlates of multiple associations of panic disorder, obsessive-compulsive disorder (OCD), and social phobia in patients with severe mood disorders. METHOD: Subjects were 77 consecutively hospitalized adults with psychotic symptoms and with a diagnosis of bipolar I disorder, major depression, or schizoaffective disorder, bipolar type. Principal diagnosis and comorbidity were assessed by the Structured Clinical Interview for DSM-III-R-Patient Version. RESULTS: Of the entire cohort, 33.8% had a single anxiety disorder and 14.3% had two or three comorbid diagnoses. Patients with multiple comorbidity had significantly higher scores on the Brief Psychiatric Rating Scale and SCL-90 and abused stimulants more frequently than did those without anxiety disorders. CONCLUSIONS: Multiple associations of panic disorder, OCD, and social phobia are not rare among patients with affective psychoses and are likely to be associated with more severe psychopathology than is found in patients without anxiety disorders.     

History of childhood abuse in panic disorder,social phobia,and generalized anxiety disorder

The authors examined the prevalence of self-reported childhood physical or sexual abuse in a sample of adult patients presenting for treatment of panic disorder, social phobia, or generalized anxiety disorder. Regardless of the presence of comorbid anxiety disorders or comorbid depression, patients with panic disorder had significantly higher rates of past childhood physical or sexual abuse than patients with social phobia. Patients with generalized anxiety disorder had intermediate rates of past physical or sexual abuse that were not significantly different from the other two diagnostic groups. Anxiety disorder patients with a history of childhood abuse were also more likely to have comorbid major depression than those without. These findings are discussed in terms of biological and behavioral factors that may influence the development of anxiety disorders after the experience of a traumatic event.     

Situational panic attacks: impact on distress and impairment among patients with social phobia

To investigate the impact of situational panic attacks in social phobia, this study examined symptoms of social anxiety and avoidance, dysfunction, and associated psychopathology among individuals with social phobia who experience situational panic attacks, individuals meeting criteria for both social phobia and panic disorder, and individuals with social phobia but no report of panic attacks. One hundred thirty-three persons with a principal diagnosis of social phobia were evaluated. Fifty-seven individuals, who experienced panic attacks exclusively in the context of feared social situations, were compared to 15 individuals with social phobia who also experienced spontaneous panic attacks and met criteria for panic disorder and 61 social phobics who did not experience panic attacks. Compared to social phobics without panic, social phobics with situational panic attacks demonstrated greater fear and avoidance of social situations and higher ratings of somatic anxiety, were more distressed and impaired by their social phobias, and reported higher levels of anxiety sensitivity and hopelessness than social phobics without panic. Additionally, social phobia patients with situational panic but without panic disorder reported greater hopelessness than participants with comorbid panic disorder. In regression analyses, situational panic attacks accounted for significant unique variance beyond that contributed by the presence of comorbid panic disorder. Situational panic attacks are common in social phobia. They are associated with significant and unique disturbances compared either to the absence of panic attacks or to panic attacks in the context of comorbid panic disorder and deserve attention in both research and treatment of social phobia.     

An examination of syndromal validity and diagnostic subtypes in social phobia and panic disorder.

BACKGROUND: We investigated whether patients with DSM-III-R panic disorder and patients with social phobia could be distinguished on the basis of selected demographic variables and by several commonly used anxiety and phobia rating scales. METHOD: Sixty-six patients with social phobia and 60 patients with panic disorder (42 with and 18 without agoraphobia) were studied. Subjects completed a battery of self-report measures that assessed phobic fears, avoidance, and related problems. RESULTS: Social phobic patients showed an earlier age at onset than the panic disorder group, and there was a trend for more social phobics to have never married. Social phobics reported significantly greater levels of social phobic avoidance and distress, fear of negative evaluation, and avoidance of social situations than the panic disorder patients who reported more overall anxiety and rated themselves as significantly more avoidant of situations involving exposure to public places and to blood or injury. Discriminant function analyses showed that social phobic and panic disorder patients can be reliably discriminated on these scales. CONCLUSION: The results of this study lend further support for the validity of the DSM-III-R nosologic distinctions between social phobia and panic disorder. Furthermore, generalized social phobia appears to be remarkably different from discrete social phobia on these measures. This study provides less support for considering panic disorder with agoraphobia to be distinct from panic disorder without agoraphobia.     

Age at onset, precipitating events, sex distribution, and co-occurrence of anxiety disorders.

178 outpatients were administered to a structured interview evaluating diagnostic, illness history, and sociodemographic data of DSM-III-R anxiety disorders. Patients with panic disorder with agoraphobia were a more severely ill subgroup than patients with panic disorder without agoraphobia. Simple and social phobia had the earliest age at onset, panic disorder the latest age at onset. Conjugal stress was the most frequent event preceding the onset of the anxiety disorders. Female patients showed more severe impairment suffering more frequently from concomitant phobic avoidance, generalized anxiety, and depression compared to male patients.     

Major depression in patients with social phobia

The authors examined the longitudinal course of affective illness retrospectively in 63 patients with social phobia and 54 patients with panic disorder. Significantly fewer (35%) of the patients with social phobia than patients with panic disorder (63%) had experienced at least one major depressive episode. Patients with generalized social phobia and patients with specific social phobia had comparable past rates of major depression (37% and 30%, respectively). The clinical and theoretical implications of these findings are discussed within the context of current concepts regarding the development of depressive symptoms in patients with anxiety disorders.     

Anxiety disorders in major depression

The prevalence and clinical impact of anxiety disorder comorbidity in major depression were studied in 255 depressed adult outpatients consecutively enrolled in our Depression Research Program. Comorbid anxiety disorder diagnoses were present in 50.6% of these patients and included social phobia (27.0%), simple phobia (16.9%), panic disorder (14.5%), generalized anxiety disorder ([GAD] 10.6%), obsessive-compulsive disorder ([OCD] 6.3%), and agoraphobia (5.5%). While both social phobia and generalized anxiety preceded the first episode of major depression in 65% and 63% of cases, respectively, panic disorder (21.6%) and agoraphobia (14.3%) were much less likely to precede the first episode of major depression than to emerge subsequently. Although comorbid groups were not distinguished by depression, anxiety, hostility, or somatic symptom scores at the time of study presentation, patients with comorbid anxiety disorders tended to be younger during the index episode and to have an earlier onset of the major depressive disorder (MDD) than patients with major depression alone. Our results support the distinction between anxiety symptoms secondary to depression and anxiety disorders comorbid with major depression, and provide further evidence for different temporal relationships with major depression among the several comorbid anxiety disorders.     

Comorbidity in generalized anxiety disorder: prevalence and course after cognitive-behavioural therapy]

OBJECTIVE: To evaluate the prevalence and course of Axis I concurrent disorders in a population of patients who underwent cognitive-behavioural therapy (CBT) to treat their generalized anxiety disorder (GAD). METHOD: This study is a secondary analysis combining patients from 3 treatment studies done at Université Laval. A total of 90 patients with a DSM-IV consistent GAD diagnosis received from 12 to 16 CBT sessions to treat GAD. Symptomatology was assessed at pretest, posttest, and 6 months after treatment, with the Anxiety Disorders Interview Schedule, a structured diagnostic interview. RESULTS: Seventy-three per cent of patients had both GAD and a concurrent diagnosis. The most common diagnoses were simple phobia, social phobia, panic disorder, and major depression. CBT applied to GAD decreases the number of concurrent diagnoses. A panic disorder or a greater number of concurrent diagnoses at pretest is associated with a less efficient treatment at follow-up 6 months later. CONCLUSION: Patients with GAD have a high comorbidity rate with other Axis I disorders, but these significantly decrease after a short CBT aimed at GAD. Implications for GAD treatment and mechanisms that might explain these findings are discussed.     

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.     

Bipolar II and unipolar comorbidity in 153 outpatients with social phobia

Previous studies on social phobia (SP) have focused largely on comorbidity between SP and major depression. Less attention has been devoted to the comorbidity between SP and bipolar disorder. In this retrospective study, we investigated family history, lifetime comorbidity, and demographic and clinical characteristics among 153 outpatients who met DSM-III-R diagnostic criteria for SP. Information regarding axis I diagnoses was obtained using the Structured Clinical Interview for DSM III-R (SCID-UP-R). Social phobic symptoms and the severity of the illness were assessed by the Liebowitz Social Anxiety Scale (LSAS) and the Liebowitz Social Phobic Disorders Rating Scale, Severity (LSPDRS). Patients completed the Hopkins Symptom Checklist (HSCL 90). Fourteen patients (9.1%) satisfied DSM-III-R criteria for lifetime bipolar disorder not otherwise specified (NOS) (bipolar II), while 71 (46.4%) had unipolar major depression and 68 (44.4%) had no lifetime history of major mood disorders. Comorbid panic disorder/agoraphobia (PDA), obsessive-compulsive disorder (OCD), and alcohol abuse were reported more frequently in the bipolar group than in the other two subgroups. Unipolar patients showed higher rates of comordid PDA and OCD compared with SP patients without mood disorders. Severity and generalization of the SP symptoms, prevalent interactional anxiety, multiple comorbidity, and alcohol abuse appeared to be the most relevant consequences of SP-bipolar coexistence. In a significant minority of cases, protracted social anxiety may hypothetically have represented, along with inhibited depression, the dimensional opposite of gregarious hypomania.     

Alcohol dependence in panic disorder patients.

The present study examined the prevalence of alcohol dependence among panic disorder patients. Twenty-four of 100 patients had a history of alcohol dependence according to DSM-III-R criteria; only one patient met criteria for current alcohol dependence. The lifetime prevalence obtained for this clinic sample exceeded that for the general population, and appeared to be due primarily to higher than expected rates among women. A childhood history of anxiety disorders and co-morbid diagnoses of social phobia and major depression were each associated with relatively higher rates of alcohol dependence. The clinical implications of these findings are discussed.     

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.     

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.     

Psychopathology in the offspring of parents with bipolar disorder: a controlled study.

BACKGROUND: To examine the risk for psychopathology in offspring at risk for bipolar disorder and the course of psychiatric disorders in these youth. METHODS: Using structured diagnostic interviews (Structured Clinical Interview for DSM-IV [SCID] and Kiddie Schedule for Affective Disorders and Schizophrenia [K-SADS]), psychiatric diagnoses of 117 nonreferred offspring of parents with diagnosed bipolar disorder were compared with those of 171 age- and gender-matched offspring of parents without bipolar disorder or major depression. RESULTS: Compared with offspring of parents without mood disorders, high-risk youth had elevated rates of major depression and bipolar disorder, anxiety, and disruptive behavior disorders. High-risk offspring also had significantly more impaired Global Assessment of Functioning (GAF) scores, higher rates of psychiatric treatment, and higher rates of placement in special education classes. Disruptive behavior disorders, separation anxiety disorder, generalized anxiety disorder (GAD), social phobia, and depression tended to have their onset in early or middle childhood, whereas bipolar disorder, obsessive-compulsive disorder (OCD), panic disorder, and substance use disorder had onset most frequently in adolescence. CONCLUSIONS: These findings support the hypothesis that offspring of parents with bipolar disorder are at significantly increased risk for developing a wide range of severe psychiatric disorders and accompanying dysfunction. Early disruptive behavior and anxiety disorders, as well as early-onset depression, may be useful markers of risk for subsequent bipolar disorder in high-risk samples.     

Generalized anxiety disorder vs. panic disorder. Distinguishing characteristics and patterns of comorbidity.

In order to examine the validity of the distinction between generalized anxiety disorder (GAD) and panic disorder (PD) we compared 41 subjects with GAD and 71 subjects with PD. The GAD subjects had never had panic attacks. In contrast to the symptom profile in PD subjects suggestive of autonomic hyperactivity, GAD subjects had a symptom pattern indicative of central nervous system hyperarousal. Also, subjects with GAD had an earlier, more gradual onset of illness. In terms of coexisting syndromes, GAD subjects more often had simple phobias, whereas PD subjects more commonly reported depersonalization and agoraphobia. GAD subjects more frequently had first-degree relatives with GAD, whereas PD subjects more frequently had relatives with PD. A variety of measures indicated that our GAD subjects had a milder illness than those with PD. Also, fewer GAD subjects gave histories of major depression than did PD subjects. Among GAD subjects, coexisting major depression was associated with simple phobia and thyroid disorders and among PD subjects, comorbid depression was associated with social phobia and hypertension. Our findings indicate that the separation of GAD from PD is a valid one. They also indicate that, within disorders, unique patterns of comorbidity may exist that are important both clinically and theoretically.     

Patterns of psychopathology and dysfunction in high-risk children of parents with panic disorder and major depression

OBJECTIVE: The purpose of the study was to evaluate 1) whether an underlying familial predisposition is shared by all anxiety disorders or whether specific risks are associated with specific disorders, and 2) whether panic disorder and major depression have a familial link. METHOD: The study compared four groups of children: 1) offspring of parents with panic disorder and comorbid major depression (N=179), 2) offspring of parents with panic disorder without comorbid major depression (N=29), 3) offspring of parents with major depression without comorbid panic disorder (N=59), and 4) offspring of parents with neither panic disorder nor major depression (N=113). RESULTS: Parental panic disorder, regardless of comorbidity with major depression, was associated with an increased risk for panic disorder and agoraphobia in offspring. Parental major depression, regardless of comorbidity with panic disorder, was associated with increased risks for social phobia, major depression, disruptive behavior disorders, and poorer social functioning in offspring. Both parental panic disorder and parental major depression, individually or comorbidly, were associated with increased risk for separation anxiety disorder and multiple (two or more) anxiety disorders in offspring. CONCLUSIONS: These findings confirm and extend previous results documenting significant associations between the presence of panic disorder and major depression in parents and patterns of psychopathology and dysfunction in their offspring.     

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.     

Further evidence of association between behavioral inhibition and social anxiety in children

OBJECTIVE: The authors sought to examine psychopathological correlates of behavioral inhibition in young offspring of parents with panic disorder and/or major depression. METHOD: Behavioral inhibition, determined by using standard laboratory observations, was assessed in four groups of children (age 2-6 years): 129 children of parents with both panic disorder and major depression, 22 children of parents with panic disorder alone, 49 children of parents with major depression alone, and 84 comparison children of parents with neither panic disorder nor major depression. Psychopathology in children > or =5 years was compared between children with behavioral inhibition (N=64) and without (N=152). RESULTS: Social anxiety disorder (social phobia or avoidant disorder) was significantly more likely to be found in the children with behavioral inhibition (17%) than in those without (5%). Noninhibited children were significantly more likely than inhibited children to have disruptive behavior disorders (20% versus 6%, respectively) and had higher scores on the attention problems scale of the Child Behavior Checklist (mean=52.1 versus 50.8). CONCLUSIONS: This study adds to the growing literature suggesting an association between behavioral inhibition and social anxiety disorder and an inverse relationship between inhibition and disruptive behavior disorders.     

Hyperventilation in panic disorder and social phobia

The aim of our study was to observe the induction of panic attacks by hyperventilation in a group of panic disorder and social phobia patients (DSM-IV). We randomly selected 26 panic disorder patients, 22 social phobics and 25 normal volunteers. They were drug-free for 1 week. Hyperventilation (30 breaths/min) was induced for 3 min. Anxiety scales were taken before and after the test. 61.5% (n = 16) of panic disorder patients, 22.7% (n = 5) of social phobics and 4.0% (n = 1) of control subjects had a panic attack after hyperventilating (p < 0.01, panic disorder vs. control; p < 0.05, panic disorder vs. social phobia; p = n.s., social phobia vs. control). Both anxiety disorder groups were more sensitive to hyperventilation than normal volunteers. The induction of panic attacks by voluntary hyperventilation may be an easy and useful test for validating the diagnosis in some specific panic disorder patients.