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.     

Prodromal symptoms in panic disorder with agoraphobia

Of 20 patients suffering from panic disorder with agoraphobia, 18 reported experiencing agoraphobic avoidance, generalized anxiety, and/or hypochondriacal fears and beliefs before the first panic attack. The prevalence of these symptoms in the patients was significantly higher than the prevalence in 20 healthy control subjects. The results indicate that phobic avoidance in panic disorder with agoraphobia may not be secondary to the panic attacks, a finding that runs counter to the current DSM-III-R classification of anxiety disorders.     

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.     

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.     

Three cases of panic disorder with agoraphobia in children

The authors report three cases of panic disorder with agoraphobia in children, with characteristic panic attacks, separation anxiety, and fear and avoidance of crowds and public places. The panic and agoraphobic symptoms responded to medications effective with agoraphobic adults, i.e., imipramine and alprazolam.     

The latent structure of anxiety symptoms in anxiety disorders.

OBJECTIVE: Research in the psychopathology of panic and anxiety disorders, particularly agoraphobia, suggests that fear of fear may be the basis of these conditions. However, there is little empirical research on the definition and validity of the concept of fear of fear in a clinical study group. The authors' aims are 1) to determine empirically if particular associations between symptoms and beliefs exist in a group of patients with anxiety disorders and what underlying dimensions of perceived threat they represent and 2) to assess the relative importance of these associations in agoraphobia with panic attacks, panic disorder, social phobia, and generalized anxiety disorder. METHOD: In an anxiety disorders treatment unit, 390 outpatients with anxiety disorders diagnosed according to DSM-III criteria completed the Anxiety Symptoms and Beliefs Scale. RESULTS: A principal components analysis of the patients' ratings on the Anxiety Symptoms and Beliefs Scale produced a four-factor solution in which specific sets of anxiety symptoms loaded with specific beliefs. These four factors were interpreted as respiratory symptoms, vestibular symptoms, autonomic arousal, and psychological threat. Respiratory and vestibular symptoms were more associated with panic disorder diagnoses than with social phobia and generalized anxiety disorder diagnoses. CONCLUSIONS: These findings support a conception of fear of fear in anxiety disorders as fearful beliefs concerning the experience of anxiety symptoms. Associations between symptoms and fear of fear are present across anxiety disorders but are most pronounced in agoraphobia with panic attacks.     

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.     

Assessing the clinical utility of agoraphobia in the context of panic disorder

In the DSM-IV, a panic disorder (PD) diagnosis includes specification of agoraphobia, which is primarily an index of situational avoidance due to fear of panic. No other anxiety diagnosis requires specification of level of avoidance. This raises the question as to whether agoraphobia provides unique information beyond the core features of PD (i.e., panic attacks and panic-related worry). The incremental validity of agoraphobia, defined using DSM-IV specifiers versus level of situational avoidance, was examined in relation to the expression and treatment of PD (N=146). Analyses indicate that agoraphobia status adds uniquely to the prediction of PD symptoms, impairment, and response to treatment. However, level of situational avoidance, defined either as a continuous or dichotomous variable, appears to have greater utility compared to the DSM-IV method of classifying agoraphobia. In summary, the agoraphobia specifier seems to have clinical utility but this could be improved by focusing on a dimensional assessment of situational avoidance.     

Clinical and psychosocial outcome of patients affected by panic disorder with or without agoraphobia: results from a naturalistic follow-up study.

OBJECTIVE: A clinical and psychosocial follow-up study of a cohort of 85 patients affected by panic disorder (PD) with or without agoraphobia was performed an average of 40 months after initial observation and following a mean duration of illness of 8 years. METHODS: Eighty-five out of 130 patients affected by PDs with or without agoraphobia according to DSM-III R criteria, examined between 1990 and 1995 at an outpatient clinic were re-examined in 1997/1998 using the same standardized clinical evaluation performed on admission. Patients also underwent a structured diagnostic interview (Mini International Neuropsychiatric Interview, MINI) and psychosocial evaluation (Scale of Sheehan's Disability Scale, DISS, Baker and Intagliata's Satisfaction with Life Domains Scale, SLDS). RESULTS: At follow-up, the percentage of patients who had either improved or were in remission was considerably higher among those initially diagnosed as PD with respect to those diagnosed as panic disorder with agoraphobia (PDA): Thirty-eight percent of PD and 20.6% of PDA patients were in clinical remission. Mild panic symptoms and phobic avoidance were found in the majority of patients who were still symptomatic (respectively 71% and 57%). Approximately 60% of patients reported a significant difficulty in performing daily activities and 40% expressed dissatisfaction in at least 50% of life domains considered. Seventy-two percent of subjects examined were still undergoing pharmacological treatment at the time of follow-up. CONCLUSIONS: The findings of the study are suggestive of a chronic illness with a significant impact on everyday quality of life of patients.     

Infrequent and limited-symptom panic attacks

Due to their prevalence and relationship to agoraphobia, panic attacks are receiving considerable attention. The DSM-III requires that they include at least four associated symptoms and occur at least weekly for a diagnosis of panic disorder. This study of panic symptoms and frequency in 68 panic sufferers addresses the validity of these DSM-III requirements in terms of symptom patterns and phobic avoidance. Using chi-square, Fisher, and t-test analyses, this study found no clinical distinction between frequent (occurring at least weekly) and infrequent panic attacks. When comparing limited-symptom attacks (associated with less than four symptoms) with full-blown panic attacks, as expected, symptom frequencies were greater (p less than .05) in full-blown attacks, with the exceptions of feelings of unreality and fear of dying, going crazy, or losing control. Phobic avoidance did not differ between limited-symptom and full-blown attacks. This study not only demonstrates the arbitrary nature of the DSM-III requirements for a diagnosis of panic disorder but recognizes the importance of limited-symptom attacks to the development of agoraphobia.     

Social phobic symptoms in patients with panic disorder: practical and theoretical implications

Of 35 patients with DSM-III-R diagnoses of panic disorder, 16 also received diagnoses of social phobia, and 15 of these 16 reported past episodes of major depression. Only nine of the 19 panic patients without social phobia had histories of depression. The panic patients with histories of depression had significantly higher self-ratings of social anxiety and avoidance, but not agoraphobic fear and avoidance, than those without histories of depression. Panic disorder and social phobia may coexist in many cases, and the presence of social phobia may be associated with a higher morbid risk for major depression in this population.     

DSM-III-R Axis I and II disorders in agoraphobic patients with and without panic disorder

Patients attending an inpatient phobia treatment program were diagnosed for DSM-III-R Axis I and II disorders, using the Structured Clinical Interview for DSM-III-R Disorders, and completed a set of self-report instruments. They were divided into 3 groups: (a) those who met the criteria for panic disorder with agoraphobia (n= 57), (b) those who met the criteria for agoraphobia without a history of panic disorder (n= 21), and (c) those who met criteria for other anxiety disorders, but not for panic/agoraphobia (n= 14). On Axis I, more of the panic with agoraphobia than of the agoraphobia without panic patients had obsessive-compulsive disorder. On Axis II, no significant differences between the agoraphobic patients with and without panic occurred. However, the number of hysterical traits was related to the presence of panic disorder among the agoraphobic patients. Avoidant and dependent traits were related to symptom severity.     

Brief treatment of emergency room patients with panic attacks.

OBJECTIVE: Most research on treatment for panic disorder has involved chronic forms of the illness. To determine the efficacy of early intervention, the authors examined the effects of treatment for patients with panic attacks who were seen in the emergency room, which is the first point of contact with the health delivery system for many persons with panic attacks. METHOD: The subjects were 33 patients with panic attacks seen in two emergency rooms. The presence of panic attacks was confirmed with a modified version of the Structured Clinical Interview for DSM-III-R; approximately 40% of the patients met the DSM-III-R criteria for panic disorder with agoraphobia. The patients were randomly assigned to groups receiving reassurance (N = 16) or exposure instruction (N = 17). Scores on the Fear Questionnaire agoraphobia subscale, Mobility Inventory, and Beck Depression Inventory and the frequency of panic attacks were determined at baseline, 3 months, and 6 months. RESULTS: The subjects who received exposure instruction significantly improved over the 6-month period on depression, avoidance, and panic frequency. The reassurance subjects did not improve on any measure and eventually reported more agoraphobic avoidance. CONCLUSIONS: These results suggest that early intervention with exposure instruction may reduce the long-term consequences of panic attacks. The exposure instruction was of value even though the subjects had relatively low levels of avoidance at the outset of the study.     

Daily life situations and anxiety in panic disorder and agoraphobia

Naturally occuring daily life situations and anxiety experiences were studied in panic-disordered patients with different levels of agoraphobic fear. Time-sampled self-reports of mental state, social context, and setting, obtained with the Experience Sampling Method (ESM), have been compared for panic patients with high scores on the agoraphobia scale of the Fear Questionnaire (n = 19), panic patients with low to medium agoraphobia scores (n = 23), and a normal reference group (n = 20). Panic patients with high agoraphobia scores reported more anxiety than panic patients with limited agoraphobic fear. In general, agoraphobic subjects, as defined by the Fear Questionnaire, demonstrated higher frequencies of being at home and with the family. Panic patients with limited agoraphobic fear reported being alone more often when anxious, while patients with extensive agoraphobia were more often in the company of family members during moments of high anxiety. Individual variations in time-sampled anxiety ratings and time allocation data found in this study challenge the validity of retrospective reports about anxiety and avoidance. These results suggest that further research into anxiety disorders should link experimental and natural environment methods.     

International reliability of a diagnostic intake procedure for panic disorder.

Test-retest diagnostic reliability interviews using the Upjohn version of the Structured Clinical Interview for DSM-III (SCID) were conducted with 72 patients at 13 international sites of the Cross-National Collaborative Panic Study. Agreement on the diagnosis of panic disorder was very good. For the subtypes (uncomplicated, with limited phobic avoidance, and agoraphobia), agreement was fair to good.     

Clinical Characteristics of the Respiratory Subtype in Panic Disorder Patients

Objective

Panic disorder has been suggested to be divided into the respiratory and non-respiratory subtypes in terms of its clinical presentations. The present study aimed to investigate whether there are any differences in treatment response and clinical characteristics between the respiratory and non-respiratory subtypes of panic disorder patients.

Methods

Among the 48 patients those who completed the study, 25 panic disorder patients were classified as the respiratory subtype, whereas 23 panic disorder patients were classified as the non-respiratory subtype. All patients were treated with escitalopram or paroxetine for 12 weeks. We measured clinical and psychological characteristics before and after pharmacotherapy using the Panic Disorder Severity Scale (PDSS), Albany Panic and Phobic Questionnaire (APPQ), Anxiety Sensitivity Index-Revised (ASI-R), State-Trait Anxiety Inventory (STAI-T, STAI-S), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HAM-D).

Results

The prevalence of the agoraphobia was significantly higher in the respiratory group than the non-respiratory group although there were no differences in gender and medication between the two groups. The respiratory group showed higher scores on the fear of respiratory symptoms of the ASI-R. In addition, after pharmacotherapy, the respiratory group showed more improvement in panic symptoms than the non-respiratory group.

Conclusion

Panic disorder patients with the respiratory subtype showed more severe clinical presentations, but a greater treatment response to SSRIs than those with non-respiratory subtype. Thus, classification of panic disorder patients as respiratory and non-respiratory subtypes may be useful to predict clinical course and treatment response to SSRIs.     

Association Study between 5-HT1A Receptor Gene C(-1019)G Polymorphism and Panic Disorder in a Korean Population

Objective

Serotonergic dysfunction is quite evident in panic disorder. We investigated whether the C(-1019)G polymorphism of 5-HT1A receptor gene may play a role in the pathogenesis of panic disorder in a Korean population.

Methods

The 5-HT1A receptor genotype for the single nucleotide polymorphism (SNP) C(-1019)G was analyzed in 94 patients and 111 healthy controls. The severity of the patients'' symptoms was examined using the Spielberger State-Trait Anxiety Inventory (STAI), Panic Disorder Severity Scale (PDSS), Anxiety sensitivity index (ASI), Acute Panic Inventory (API) and Hamilton''s Rating Scale for Anxiety (HAM-A).

Results

The distribution of the genotypes of the C/G polymorphism did not differ significantly from those predicted by Hardy-Weinberg equilibrium in patients as well as the controls. No association between the C(-1019)G polymorphism and panic disorder was detected in either the allele frequency or genotype distribution. There was no significant association with genotype distribution in the panic disorder with agoraphobia. However, there was a significant difference of symptom severity between C/C, C/G, and G/G genotype or between C and G allele in panic disorder patients without agoraphobia. PDSS scores were significantly higher in subjects with the G/G genotype or with G allele in patients without agoraphobia, not in total patients or patients with agoraphobia.

Conclusion

Although there were no significant differences in the genotype and allele distributions, we found a significant association between panic symptom severity and the serotonin 1A receptor gene. This result suggests that the serotonin 1A receptor and serotonin may play a role in the pathogenesis of panic disorder.     

Measurement of lactate-induced panic and anxiety

Acute Panic Inventory (API) scores were obtained from 26 normal controls and 89 patients with either panic disorder or agoraphobia with panic attacks before and during lactate infusions. Retrospective ratings of the patients' usual spontaneous attacks were much higher, by API, than ratings of moments of severe stress by the controls. Point of panic API scores, as well as increments of panic scores over prelactate scores, were higher for patients who experienced lactate panics than for both controls and patients who did not panic.     

Personality traits in early phases of panic disorder: implications on the presence of agoraphobia, clinical severity and short-term outcome

OBJECTIVE: To explore the relations between personality traits using the Big Five model and presence of agoraphobia, clinical severity and short-term outcome in an unbiased clinical sample of never-treated panic disorder patients. METHOD: Panic disorder (PD) patients (n = 103) in the first stages of their illness were evaluated using the Neuroticism-Extraversion-Openness Five Factor Inventory of Personality (NEO-FFI) and were compared with a sample of healthy subjects. Severity was assessed by the Panic Disorder Severity Scale and the Clinical Global Impression Scales. Patients were evaluated after 8 weeks of naturalistic pharmacologic treatment with Selective Serotonin Reuptake Inhibitors. RESULTS: Panic disorder patients show more neuroticism than healthy subjects. Patients suffering from agoraphobia are more introverted than controls. Extraversion, in addition to gender and distress, during panic attacks allows to correctly classifying 72% of the cases of agoraphobia. CONCLUSION: Low scores in extraversion contribute to explain the presence of agoraphobia in panic disorder. Personality traits are neither related to clinical severity nor to short-term response to pharmacological treatment.     

Fluoxetine in panic disorder: pharmacologic and tritiated platelet imipramine and paroxetine binding study.

Serotonergic implication in panic disorder has been demonstrated by the efficacy of serotonin reuptake blockers in treatment. Fluoxetine, a potent 5-HT reuptake blocker, has been suggested to have anti-panic efficacy. This open study examines 30 patients (eight males and 22 females) with an average age of 36.9 years, ranging from 18 to 62, who were treated for eight weeks with fluoxetine (mean dose 20 mg per day). All patients fulfilled DSM-III-R criteria of panic disorder with agoraphobia as determined in a SCID interview schedule. Out of 28 patients who started medication, 64% of the patients completed the clinical trial and 36% of the patients dropped out of treatment because of increased anxiety or a lack of efficacy. Thirty-two percent of the patients had zero panic attacks by week 3. By the end of eight weeks of treatment, 48% of the patients had zero panic attacks. There was a significant reduction in anxiety and phobic avoidance and panic attacks. Tritiated platelet imipramine and paroxetine bindings revealed significantly lower maximal binding for patients with panic disorder in comparison with controls. Paroxetine Bmax showed a trend to increase in the direction of control values by the end of the trial.