Antecedents to panic disorder in nonreferred adults

OBJECTIVE: Previous work has shown that childhood anxiety disorders are unique antecedents for panic disorder. The current study examined both childhood and adult comorbid disorders as potential antecedent disorders to panic disorder in a large sample of nonreferred adults. METHODS: Subjects were 1018 adults with (N = 58) and without (N = 960) panic disorder who were derived from a sample originally ascertained through family studies of probands with and without attention-deficit/hyperactivity disorder (ADHD); data were obtained from 1988 to 1996. Classification and regression trees (CART) analysis was used to examine anxiety and nonanxiety disorders antecedent to panic disorder. RESULTS: CART analysis showed that separation anxiety disorder, social phobia, and simple phobia were unique predictors of subsequent panic disorder. CONCLUSION: These results support and expand previously reported findings in referred samples documenting that comorbid anxiety disorders are unique antecedent risk factors for panic disorder.     

Separation anxiety and panic disorder in clinically referred youth

This study examined whether youngsters with separation anxiety disorder (SAD) and panic disorder (PD) had experienced more separation-related events than youngsters with SAD (without comorbid PD). We also examined whether age of onset of SAD and comorbidity with other psychological disorders was related to the occurrence of PD. We compared youngsters who were diagnosed with SAD and PD (N=31) with youngsters who were diagnosed with SAD without comorbid PD (N=63) for the number of separation-related events, severity of psychopathology, and parent and child CBCL ratings, age of onset of SAD, and the number of comorbid diagnoses. The findings indicate that youngsters with SAD and PD had a later age of onset of SAD and more extensive psychopathology and functional impairment than youngsters with SAD (without comorbid PD). Contrary to hypothesis, there were no differences between the groups in the occurrence or number of separation-related events.     

Childhood trauma and dissociative symptoms in panic disorder

OBJECTIVE: Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. The authors hypothesized that among individuals with a primary diagnosis of panic disorder, those experiencing depersonalization/derealization during panic attacks would be more likely to have a history of childhood trauma. METHOD: Rates of traumatic events were compared between panic disorder patients with (N=34) and without (N=40) prominent depersonalization/derealization during panic attacks. Symptom severity in the two groups was also examined. RESULTS: Contrary to the authors' hypothesis, no evidence was found that depersonalization/derealization during panic attacks was associated with childhood trauma. Minimal differences in severity of illness were found between patients with dissociative symptoms and those without such symptoms. CONCLUSIONS: This finding is consistent with a multifactorial model of dissociation. Factors other than childhood trauma and general psychopathology may underlie vulnerability to dissociative symptoms in panic disorder.     

Childhood antecedents of exposure to traumatic events and posttraumatic stress disorder

OBJECTIVE: The authors prospectively examined childhood antecedents of exposure to traumatic events to estimate the risk of posttraumatic stress disorder (PTSD) among those exposed to trauma. METHOD: Two consecutive cohorts of children entering first grade of a public school system in a large mid-Atlantic city in the mid-1980s were followed into young adulthood (mean age=21). Exposure to traumatic events and PTSD were assessed in 75% of the original cohort (N=1,698). Childhood assessments, conducted upon entry into the first grade, included standardized measures of reading readiness, teacher ratings of behavioral problems, and child self-reports about depression and anxiety. Family characteristics were assessed by parental report. RESULTS: Young adults who had been rated by their first grade teacher as having aggressive/disruptive behavior problems were more likely to experience traumatic assaultive violence events (e.g., being mugged/threatened with a weapon, badly beaten-up) (relative risk=2.6) but not PTSD following trauma exposure. Youths with high levels of self-rated depressive and anxious feelings in first grade were more likely to experience PTSD once exposed to trauma (relative risk=1.5). Youths who scored in the highest quartile on a reading test in the first grade were at lower risk for exposure to assaultive violence traumas. CONCLUSIONS: Childhood behavioral and depressive/anxious problems may influence the risk for PTSD directly by increasing the vulnerability to the PTSD effects of trauma exposure, and indirectly by increasing the likelihood of exposure to assaultive violence.     

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.     

Childhood separation anxiety and panic disorder: a comparative study

1. The relationship between childhood separation anxiety and panic disorder in adults is analyzed using data from a multicenter trial in 107 patients. 2. The patients included in this study presented anxiety disorder with or without agoraphobia, diagnosed according to DSM-III criteria. 3. The percentage of patients with antecedents of separation anxiety was 17.8% in patients without agoraphobia and 21.7% in patients with agoraphobia. These rates are significantly higher than those encountered in a group of normal controls (4%). 4. The existence of separation anxiety in childhood does not seem to significantly modify the clinical manifestations or severity of panic disorder in the adult.     

Childhood antecedents of avoidant personality disorder: a retrospective study

OBJECTIVE: To explore potential risk factors and early manifestations of avoidant personality disorder (AVPD) by examining retrospective reports of social functioning and adverse childhood experiences. METHOD: Early social functioning and pathological childhood experiences were assessed using the Childhood Experiences Questionnaire-Revised. The responses of 146 adults diagnosed with primary AVPD were compared with a group of 371 patients with other personality disorders as a primary diagnosis and a group of 83 patients with current major depression disorder and no personality disorders, using chi2 analyses. Diagnoses were based on semistructured interviews by trained reliable clinicians. RESULTS: Adults with AVPD reported poorer child and adolescent athletic performance, less involvement in hobbies during adolescence, and less adolescent popularity than the depressed comparison group and the other personality disorder group. Reported rates of physical and emotional abuse were higher than the depressed group, but this result was influenced by comorbid diagnoses. CONCLUSIONS: These results suggest that early manifestations of AVPD are present in childhood but that various forms of abuse are not specific to the disorder.     

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.     

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.     

Attention deficit/hyperactivity disorder and working memory in clinically referred adults

A current theory of attention deficit/hyperactivity disorder (ADHD) implicates a dysfunction in working memory as a significant factor in ADHD. The Working Memory Indexes of the Wechsler Adult Intelligence Scale--Third Edition (WAIS-III; The Psychological Corporation, 1997a) and the Wechsler Memory Scale--Third Edition (WMS-III; The Psychological Corp -oration, 1997b) were used to evaluate this theory. Seventy adults clinically diagnosed with ADHD (mean age = 25) and who were previously administered the WAIS-III and WMS-III were reviewed to determine the association between working memory and ADHD symptomology. The respondent was asked to estimate the frequency of occurrence of ADHD symptoms by completing the Brown ADD Scales (Brown, 1996). Results indicated no significant relationship between working memory and self-reported symptoms, although the Working Memory Indexes of the WAIS-III and the WMS-III were significantly correlated. Implications for current ADHD theory and suggestions for future research were discussed.     

Dsm-iv panic attacks and panic disorder in a community sample of adolescents and young adults: how specific are panic attacks?

The study investigates the lifetime and 12-month prevalence, symptoms, age of onset and comorbidity patterns of DSM-IV panic attacks and panic disorder in a community sample of 3021 adolescents and young adults aged 14–24 years. Findings are based on DSM-IV symptoms and diagnoses assessed by interviews using a computerised, extended version of the Munich Composite International Diagnostic Interview (M-CIDI). Lifetime prevalence of DSM-IV panic disorder among 14–24 year-olds was 1.6% (0.8% with and 0.8% without agoraphobia). Panic symptoms were found to be quite frequent (13.1%) in the community, with lifetime prevalence of DSM-IV panic attack at 4.3% (12-month prevalence, 2.7%), with first onset rarely before puberty. Women were considerably more likely to have panic disorder and to have an earlier age of onset than males. Occurrence of DSM-IV panic attacks was strongly related to the subsequent development of various forms of mental disorders—not only panic disorder and agoraphobia. The conditional probability in those with panic attacks to develop other forms of mental disorders was 63% in males and 40% in females. Particularly late onset panic attacks (after the age of 18 years) are associated strongly with the development of multimorbidity of mental disorders. This suggests that panic attacks are generally highly indicative for more severe psychopathology and not only for panic disorder and agoraphobia.     

Distinguishing generalized anxiety disorder, panic disorder, and mixed anxiety states in older treatment-seeking adults

Eighty treatment-seeking adults age 60 or over with panic disorder, generalized anxiety disorder, and mixed anxiety states (generalized anxiety with panic attacks, panic disorder with secondary generalized anxiety) completed a clinical assessment and battery of self report measures. Several hypotheses were tested from the domains of distinguishing symptoms, associated features, and rates of comorbidity with other disorders. Greater between- than within-group variance was found on a subset of measures suggesting that the distinction between GAD and PD is generally valid in the older adult population. Higher scores on measures of sympathetic arousal, agoraphobic avoidance, and rates of comorbid somatization disorder and alcohol dependence distinguished those with PD from those with GAD. Higher scores on measures of depression and hostility, but not trait anxiety or worry, distinguished the GAD group. Results indicate that distinguishing features of GAD and PD in older treatment-seeking adults may be fewer and slightly different from those of younger adults.     

Retrospective reports of parenting in depressed adults with and without comorbid panic disorder and social anxiety disorder

Previous research has examined the role of parenting in the development of depression and anxiety disorders using retrospective reports of parenting behaviors. However, most studies have not considered comorbidity; the few that have did not differentially examine individual anxiety disorders and yielded inconsistent results. The present study compared retrospective parenting reports given by depressed individuals with no comorbid anxiety disorder, comorbid panic disorder, and comorbid social anxiety disorder. Results indicated that depressed men with panic disorder reported significantly greater maternal and nonsignificantly greater paternal protectiveness than depressed men without panic disorder but not than depressed women with and without panic disorder. No differences were found for the retrospective parenting reports given by depressed participants with or without social anxiety disorder. This work highlights the importance of examining specific anxiety disorders rather than grouping all depressed patients with any anxiety disorder together, as well as examining males and females separately when investigating the influence of parental behavior.     

Thyroid hormones in panic disorder, panic disorder with agoraphobia, and generalized anxiety disorder

Fifty-two patients with generalized anxiety disorder who had symptoms persisting for at least 6 months, 41 patients suffering from either panic disorder (32 patients) or panic disorder with agoraphobia (9 patients), and 14 control subjects were screened for thyroid disease. Total serum thyroxine (TT4), serum-free thyroxine index (FT4I), and triiodothyronine resin uptake (T3RU), were examined for the entire sample, using a one-way analysis of variance (ANOVA). No significant differences were found in TT4 (p = .24), FT4I (p = .24), and T3RU (p = .19). Thyroid-stimulating hormone (TSH) was examined in a subsample of 10 patients with generalized anxiety disorder, 11 with panic disorder or panic disorder with agoraphobia, and 10 controls. One-way ANOVA again showed no significant differences, although there was a trend (p = .07). This is the first report that compares generalized anxiety disorder patients, panic disorder patients, and patients with panic disorder and agoraphobia with controls on measures of thyroid function. It is also the first to report normal values in the thyroid indices of generalized anxiety disorder patients.     

Instrument to assess depersonalization-derealization in panic disorder

There is a long history of scholarly interest on depersonalization-derealization (DD) and its role in clinical anxiety, but there is a paucity of appropriate assessment instruments available. Our objective was to develop and evaluate a self-report measure of DD for use with clinically anxious patients. Panic disorder patients (n=169) were surveyed about DD experiences and provided data on a new item pool for psychometric development. DD episodes were common and a 28-item Depersonalization-Derealization Inventory was found to possess good reliability and validity. DD appears to be prevalent and clinically relevant in panic disorder. Continued study of DD is warranted and may be facilitated by the availability of a suitable instrument with promising psychometric properties. A 12-item version of the instrument may be appropriate as a brief screen.     

Hypersensitivity to carbon dioxide in panic disorder

Seven male panic patients did not panic but were significantly more sensitive to steady-state carbon dioxide inhalation than five male normal control subjects. The male patients' hypersensitivity to carbon dioxide was unrelated to current state of anxiety or acute panic.