Overlap of symptom domains of separation anxiety disorder in adulthood with panic disorder–agoraphobia

There is a need to explain the high level of comorbidity between separation anxiety disorder (SAD) in adulthood and panic disorder with agoraphobia (Pd-Ag). One possibility is that inadequate specification of symptom domains and/or diagnostic questions accounts for some of the comorbidity. The present anxiety clinic study examined responses of adult patients (n = 646) with SAD and/or Pd-Ag on eight symptom domains based on a previous factor analysis of a commonly used separation anxiety measure, the ASA-27, as well as on the Anxiety Sensitivity Index. We also examined questionnaire items that did not load on the factor structure. All separation anxiety domains distinguished strongly between SAD and Pd-Ag. Comparisons across three groups (SAD alone, Pd-Ag alone and comorbid SAD/Pd-Ag) revealed that two symptom domains (anxiety about embarking on trips, and sleep disturbances) showed some overlap between Pd-Ag and SAD. Two of the items of the ASA-27 that did not load with other items in the factor analysis also showed overlap with Pd-Ag, with both referring to anxieties about leaving home. Patients with SAD (with or without Pd-Ag) returned higher scores on anxiety sensitivity than those with Pd-Ag alone. The findings support the distinctiveness of the construct of SAD and the capacity of the ASA-27 to discriminate between that disorder and Pd-Ag. SAD appears to be a more severe form of anxiety than Pd-Ag. There may be a need to refine items to include the reasons for avoiding leaving home, reluctance to sleep alone and to embark on trips, to ensure accurate discrimination between Pd-Ag and SAD in adulthood.     

Cognitive–behavioural group treatment of panic disorder and agoraphobia in a psychiatric setting: A naturalistic study of effectiveness

The purpose of the present study was to investigate the effectiveness of cognitive–behavioural group treatment of panic disorder and agoraphobia in a clinical setting. Fifty-three patients were offered treatment and assessed before, after and at follow-up 1½–2?years after treatment. The study included an informal waiting-list control group of 40 patients. The investigation group achieved better outcome on most analyses with 47.2% found to be panic-free after treatment compared with 12.5% in the control group. Treatment gains were durable with 66.7% without panic attacks at follow-up. Most patients, however, still had major psychological problems after treatment. The outcomes of cognitive–behavioural group treatment of panic disorder in this study were modest compared with most controlled studies, possibly due to an unselected patient group with a high degree of agoraphobia.     

Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT?

This study compared Panic Online (PO), an internet-based CBT intervention, to best-practice face-to-face CBT for people with panic disorder with or without agoraphobia. Eighty-six people with a primary diagnosis of panic disorder were recruited from Victoria, Australia. Participants were randomly assigned to either PO (n=46) or best practice face-to-face CBT (n=40). Effects of the internet-based CBT program were found to be comparable to those of face-to-face CBT. Both interventions produced significant reductions in panic disorder and agoraphobia clinician severity ratings, self reported panic disorder severity and panic attack frequency, measures of depression, anxiety, stress and panic related cognitions, and displayed improvements in quality of life. Participants rated both treatment conditions as equally credible and satisfying. Participants in the face-to-face CBT treatment group cited higher enjoyment with communicating with their therapist. Consistent with this, therapists' ratings for compliance to treatment and understanding of the CBT material was higher in the face-to-face CBT treatment group. PO required significantly less therapist time than the face-to-face CBT condition.     

Are eight-year olds already suffering from panic disorder? Investigation of prevalence with focus on panic disorder and agoraphobia

A representative sample of 826 eight-year-old second-graders in Dresden was examined in a two-stage procedure to ascertain the 6-month prevalence of DSM-IV anxiety disorders. Particular care was taken to assess panic disorder. The eight-year-olds had already been interviewed personally in a screening session and in 230 children an individual diagnostic examination with a structured diagnostic interview was carried out. The total prevalence of anxiety disorder was 9.5%. No case of either panic disorder or agoraphobia was found. For the diagnosis of agoraphobia the DSM-IV diagnostic criterion was lacking in which situations typical to agoraphobia are feared or avoided because escape would be difficult or it would be difficult to reach help. Eight-year-olds do not forge this cognitive link. In agoraphobic situations 2.5% of the children (almost exclusively, girls) suffer from a specific phobia. The prevalence of anxiety disorders is markedly higher among girls than in boys.     

Is atopy in early childhood a risk factor for ADHD and ASD? A longitudinal study

Objective

Previous studies have found a temporal concordance in the increased prevalence of atopic diathesis/atopic diseases, attention-deficit hyperactivity disorder (ADHD), and autistic spectrum disorder (ASD) worldwide. But, the temporal association among these 3 distinct diseases is unknown.

Method

14,812 atopic subjects diagnosed with any atopic disease (asthma, atopic dermatitis, allergic rhinitis, or allergic conjunctivitis) before the age of 3 (atopic cohort) and 6944 non-atopic subjects with no lifetime atopic disease (non-atopic cohort), born between 1997 and 2000, were enrolled and followed to December 31, 2010 to identify the development of ADHD and ASD.

Results

The presence of any atopic disease in early childhood increased the risk of developing ADHD (hazard ratio [HR]: 1.97) and ASD (HR: 3.40) in later life. Greater numbers of atopic comorbidities (4 comorbidities: ADHD: HR: 2.53; ASD: HR: 4.29) were significantly related to a greater risk of developing ADHD and ASD.

Discussion

Atopic diathesis in early childhood elevated the risk of developing ADHD and ASD in later life, with the dose-dependent relationship of more atopic comorbidities with a greater likelihood of ADHD and ASD.     

Is panic disorder a distinct diagnostic entity? A critical review of the borders of a syndrome

The evidence supporting the existence of panic disorder as a distinct clinical entity is critically examined, as are the current criteria for panic disorder in DSM-III. It is argued that the current definition of a panic attack is imprecise and that the borders and overlap of panic disorder with other psychiatric disorders raise broader questions as to what is meant by a distinct psychiatric disorder. DSM-III "panic disorder" defines an ideal type that may be more relevant for research purposes than clinical. In defining fairly homogeneous "pure" cases, it overlooks the prevalence and importance of atypical "mixed" and subsyndromal cases.     

Is there a complex relation between social anxiety disorder,childhood traumatic experiences and dissociation?

Background: A possible relationship has been suggested between social anxiety and dissociation. Traumatic experiences, especially childhood abuse, play an important role in the aetiology of dissociation.

Aim: This study assesses childhood trauma history, dissociative symptoms, and dissociative disorder comorbidity in patients with social anxiety disorder (SAD).

Method: The 94 psychotropic drug-naive patients participating in the study had to meet DSM-IV criteria for SAD. Participants were assessed using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), the Dissociation Questionnaire (DIS-Q), the Liebowitz Social Anxiety Scale (LSAS), and the Childhood Trauma Questionnaire (CTQ). Patients were divided into two groups using the DIS-Q, and the two groups were compared.

Results: The evaluation found evidence of at least one dissociative disorder in 31.91% of participating patients. The most prevalent disorders were dissociative disorder not otherwise specified (DDNOS), dissociative amnesia, and depersonalization disorders. Average scores on LSAS and fear and avoidance sub-scale averages were significantly higher among the high DIS-Q group (p?p?Conclusions: It is concluded that, on detecting SAD symptoms during hospitalization, the clinician should not neglect underlying dissociative processes and traumatic experiences among these patients.     

Discriminating between generalized anxiety disorder and anxiety disorder not otherwise specified in a Hispanic population: Is it only a matter of worry?

One hundred and two Hispanic persons who presented for treatment at a specialized anxiety disorders clinic were evaluated at intake using the Anxiety Disorders Interview Schedule-Revised (ADIS-R; DiNardo and Barlow [1988] Albany: Center for Stress and Anxiety Disorders, State University of New York at Albany). Results indicated that 14% of these patients suffered from anxiety and/or affective disorders that were not adequately captured by our current diagnostic system. Given that the majority of these cases were characterized by predominantly anxious features, further investigation was undertaken to determine the degree of overlap between these patients (anxiety disorder, not otherwise specified; NOS) and those with generalized anxiety disorder (GAD). The two groups differed only with regard to the number of excessive worries they reported and not in terms of somatic symptomatology, psychosocial stressors, or demographic variables. These data suggest that excessive worry may be a discriminating factor between the GAD and NOS groups, providing support for the notion of GAD as a disorder of chromic worry. Future research is needed to tease apart the relative influences of culture and socioeconomic status on our findings. Depression and Anxiety 5:1–6, 1997. © 1997 Wiley-Liss, Inc.     

Does nocturnal panic represent a more severe form of panic disorder?

Nocturnal panic (NP), or waking from sleep in a state of panic, occurs in 18% to 45% of panic disorder patients. This relatively common phenomenon, however, is not well understood. In this study, the authors tested the hypotheses that NP represents a more severe form of panic disorder or is a manifestation of heightened vulnerability to sleep disturbance. Patients with NP ( = 51) were compared with patients with panic disorder without a history of NP ( = 41) on measures of panic disorder severity, comorbidity, interpersonal functioning, and sleep disturbance. There was no evidence for more severe psychopathology and only weak evidence for more sleep disturbance. Instead, patients with NP showed less agoraphobic avoidance, perhaps suggesting that they are less likely to associate panic with situational factors. The authors conclude that NP may be a specific version of panic disorder characterized by fearful associations with sleep and sleeplike states.     

Is there a hypersensitive visual alarm system in panic disorder?

Agoraphobia in panic disorder (PD) has been related to abnormal balance system function. Vision influences balance and behavioural adaptations; peripheral vision influences orienting and fast defensive reactions whereas central vision analyzes details of objects. We have hypothesized that the abnormal balance function in PD could be mainly related to peripheral vision as part of a defensive alarm system in the brain. In 25 patients with PD and agoraphobia and 31 healthy controls we assessed, by posturography, balance system reactivity to video-films projected in peripheral and central visual fields (randomized sequence). Length, velocity and surface of body sway were calculated. Patients increased their body sway during peripheral stimulation, whereas controls did not; the two groups showed a similar increase of body sway during central stimulation. Anxiety levels during peripheral stimulation significantly influenced the postural response in the group of patients. These preliminary results suggest that the higher visual sensitivity to peripheral stimulation in patients with PD and agoraphobia may be linked to a more active “visual alarm system” involving visual, vestibular and limbic areas that might influence the development of agoraphobia in situations where environmental stimuli are uncertain.     

What is the threshold for symptomatic response and remission for major depressive disorder, panic disorder, social anxiety disorder, and generalized anxiety disorder?

OBJECTIVE: Symptom-free remission is a goal for treatment in depression and anxiety disorders, but there is no consensus regarding the threshold for determining remission in individual disorders. We sought to determine these thresholds by comparing, in a post hoc analysis, scores on the Clinical Global Impressions scale (CGI) and disorder-specific symptom severity rating scales from all available studies of the treatment of major depressive disorder, panic disorder, generalized anxiety disorder, and social anxiety disorder with the same medication (escitalopram). We also sought to compare the standardized effect sizes of escitalopram for these 4 psychiatric disorders. DATA SOURCES AND STUDY SELECTION: Raw data from all randomized, double-blind, placebo-controlled, acute treatment studies sponsored by H. Lundbeck A/S (Copenhagen, Denmark) or Forest Laboratories, Inc. (New York, N.Y.), published through March 1, 2004, with patients treated with escitalopram for DSM-IV major depressive disorder (5 studies), panic disorder (1 study), generalized anxiety disorder (4 studies), or social anxiety disorder (2 studies) were compared with regard to the standardized effect sizes of change in CGI score and scores on rating scales that represent the "gold standard" for assessment of these disorders (the Montgomery-Asberg Depression Rating Scale, the Panic and Agoraphobia Scale, the Hamilton Rating Scale for Anxiety, and the Liebowitz Social Anxiety Scale, respectively). DATA SYNTHESIS: In all indications, treatment with escitalopram showed differences from placebo in treatment effect from 0.32 to 0.59 on the CGI-S and CGI-I and standardized effect sizes from 0.32 to 0.50 on the standard rating scales. There were no significant differences among the different disorders. Moderate to high correlations were found between scores on the CGI and the standard scales. The corresponding standard scale scores for CGI-defined "response" and "remission" were determined. CONCLUSION: Comparison of scores on the standard scales and scores on the CGI suggest that the traditional definition of response (i.e., a 50% reduction in a standard scale) may be too conservative.     

Is social anxiety disorder in childhood associated with developmental deficit/delay?

Children with social anxiety disorder (SAD) have been reported to display reduced social skills. Less attention has been paid to whether neurodevelopmental deficits/delays (NDD’s) in language and motor function may contribute to their impaired social skills. The present study aimed to assess the extent of language and motor impairment in children with SAD. A population-based screened sample consisting of 150 children (11–12 years) was assessed with a diagnostic interview (Kiddie-SADS), the Wechsler Abbreviated Scale of Intelligence (WASI) and the Motor Assessment Battery for Children (MABC). Test results were compared across five diagnostic groups: SAD (n = 29); ADHD (n = 23); SAD and ADHD (n = 6); “other disorder” (n = 44) and “no disorder” (n = 48). Delays in language and motor development as reported by mother were also investigated. Verbal IQ and motor skills were reduced and maternally reported delay was more frequent in the SAD group compared to the “other disorder” and “no disorder” group.     

Is a combined therapy more effective than either CBT or SSRI alone? Results of a multicenter trial on panic disorder with or without agoraphobia

Objective: To establish whether the combination of cognitive‐behavioral therapy (CBT) and pharmacotherapy (SSRI) was more effective in treating panic disorder (PD) than either CBT or SSRI alone, and to evaluate any differential effects between the mono‐treatments. Method: Patients with PD (n = 150) with or without agoraphobia received CBT, SSRI or CBT + SSRI. Outcome was assessed after 9 months, before medication taper. Results: CBT + SSRI was clearly superior to CBT in both completer and intent‐to‐treat analysis (ITT). Completer analysis revealed superiority of CBT + SSRI over SSRI on three measures and no differences between CBT and SSRI. ITT analysis revealed superiority of SSRI over CBT on four measures and no differences between CBT + SSRI and SSRI. Conclusion: Both the mono‐treatments (CBT and SSRI) and the combined treatment (CBT + SSRI) proved to be effective treatments for PD. At post‐test, CBT + SSRI was clearly superior to CBT, but differences between CBT + SSRI and SSRI, and between SSRI and CBT, were small.     

Antisocial personality disorder and anxiety disorder: A diagnostic variant?

Antisocial personality disorder (ASPD) with co-morbid anxiety disorder may be a variant of ASPD with different etiology and treatment requirements. We investigated diagnostic co-morbidity, ASPD criteria, and anxiety/affective symptoms of ASPD/anxiety disorder. Weighted analyses were carried out using survey data from a representative British household sample. ASPD/anxiety disorder demonstrated differing patterns of antisocial criteria, co-morbidity with clinical syndromes, psychotic symptoms, and other personality disorders compared to ASPD alone. ASPD criteria demonstrated specific associations with CIS-R scores of anxiety and affective symptoms. Findings suggest ASPD/anxiety disorder is a variant of ASPD, determined by symptoms of anxiety. Although co-morbid anxiety and affective symptoms are the same as in anxiety disorder alone, associations with psychotic symptoms require further investigation.     

Prevalence and disability of comorbid social phobia and obsessive–compulsive disorder in patients with panic disorder and generalized anxiety disorder

Objective. Generalized anxiety disorder (GAD) and panic disorder (PD) are disabling conditions, often comorbid with other anxiety disorders. The present study was aimed to assess prevalence and related disability of comorbid social phobia (SP) and obsessive–compulsive disorder (OCD) in 115 patients with GAD (57) or PD (58). Methods. Patients were classified as having threshold, subthreshold, or no comorbidity, and related prevalence rates, as well as disability (Sheehan Disability Scale, SDS), were compared across diagnostic subgroups. Results. SP and OCD comorbidities were present in 30.4% of the sample, with subthreshold comorbidities present at twice the rate of threshold ones (22.6% vs. 11.3%). Compared with GAD patients, PD patients showed significantly higher subthreshold and threshold comorbidity rates (27.6% and 13.8% vs. 17.5% and 8.8%, respectively). Comorbid PD patients had higher SDS scores than the comorbid and non-comorbid GAD subjects. The presence of threshold SP comorbidity was associated with the highest SDS scores. Conclusions. SP and OCD comorbidities were found to be prevalent and disabling among GAD and PD patients, with higher subthreshold than threshold rates, and a negative impact on quality of life. Present findings stress the importance of a dimensional approach to anxiety disorders, the presence of threshold and subthreshold comorbidity being the rule rather than the exception.     

Depersonalization disorder and anxiety: a special relationship?

A significant association between anxiety and depersonalization has been found in healthy controls and psychiatric patients irrespective of underlying conditions. Although patients with depersonalization disorder (DPD) often have a history of severe anxiety symptoms, clinical observations suggest that the relation between anxiety and depersonalization is complex and poorly understood. Using relevant rating scales, levels of anxiety and depersonalization were assessed in 291 consecutive DPD cases. 'High' and 'low' depersonalization groups, were compared according to anxiety severity. Correlation and multivariate regression analyses were also used to assessed the contribution of anxiety to the phenomenology and natural course of depersonalization. A low but significant association between depersonalization and anxiety (as measured by Beck's Anxiety Inventory) was only apparent in those patients with low intensity depersonalization, but not in those with severe depersonalization. Levels of anxiety did not seem to make specific contributions to the clinical features of depersonalization itself, although DPD patients with high anxiety seem characterised by additional non-specific perceptual symptoms. The presence of a 'statistical dissociation' between depersonalization and anxiety adds further evidence in favour of depersonalization disorder being an independent condition and suggests that its association with anxiety has been overemphasized.     

Is “shy bladder syndrome” a subtype of social anxiety disorder? A survey of people with paruresis

Paruresis is characterized by the fear of not being able to urinate in public bathrooms and has been classified by some to be a sub-type of social anxiety disorder (social phobia). Despite the existence of a consumer advocacy organization, the "Intentional Paruresis Association (www.paruresis.org)," there is sparse literature on this condition. A survey of people affiliated with the "International Paruresis Association" was undertaken using a self-report questionnaire with items that addressed demographic variables, the phenomenology of paruresis, comorbid disorders, and the impact of symptoms on quality of life. Sixty-three patients (59 M, 4 F) completed the questionnaire. The mean age of the subjects was 38.1+/-12 years, with the mean duration of symptoms being 24.5+/-13 years. Paruresis impacts significantly on sufferers' lives, with approximately one third limiting or avoiding parties, sports events, or dating and just over half of the sample limiting the job they choose to do. Social anxiety disorder (SAD) and depression are the most common comorbid disorders and the most common disorders in family members. Analysis of Liebowitz Social Anxiety Scale (LSAS) scores showed higher performance than social interaction subscale scores across the whole sample (whether suffering from SAD or not.) However, compared to subjects without co-morbid SAD, those with comorbidity had higher total, performance, and social interaction scores. Thus, paruresis can be a chronic and disabling symptom, and there seems to be an association between paruresis and other performance anxieties. Further research to characterize paruresis and to determine effective treatments is needed.