Anxiety disorders in women.

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.     

Neuropsychological functions in anxiety disorders in population-based samples: evidence of episodic memory dysfunction

Most of the available evidence on neuropsychological functioning in anxiety disorders is based on clinical samples, investigating persons affected by obsessive-compulsive disorder. Knowledge is sparse regarding cognitive functions in other types of anxiety disorders. The aim of this study was to examine whether persons diagnosed with an anxiety disorder show neuropsychological impairments relative to healthy controls in tasks tapping episodic memory, verbal fluency, psychomotor speed, and executive functioning. Population-based samples comprising individuals affected by panic disorder with and without agoraphobia or agoraphobia (n=33), social phobia (n=32), generalised anxiety disorder (n=7), obsessive-compulsive disorder (n=16), and specific phobia (n=24) were compared with healthy controls (n=175) in test performance. Overall, the total anxiety disorder group exhibited significant impairments in episodic memory and executive functioning. Separate analyses on the respective anxiety subgroup indicated that panic disorder with and without agoraphobia, and obsessive-compulsive disorder were related to impairments in both episodic memory and executive functioning. In addition, social phobia was associated with episodic memory dysfunction. Verbal fluency and psychomotor speed were not affected by anxiety. Specific phobia and generalised anxiety disorder did not affect neuropsychological functioning.     

Behavioral psychotherapy for anxiety disorders

Behavioral psychotherapy is probably the treatment of choice for most phobic and obsessive-compulsive disorders and plays a lesser role in the management of panic disorder without agoraphobia, generalized anxiety disorder, and posttraumatic stress disorder. This article discusses treatment goals and strategies for each disorder.     

Management of anxiety in late life

Epidemiologic data are used as a framework to discuss the pharmacologic and cognitive-behavioral management of anxiety disorders in late life. Generalized anxiety disorder (GAD) and phobias account for most cases of anxiety in late life. The high level of comorbidity between GAD and major depression, and the observation that the anxiety usually arises secondarily to the depression, suggests that antidepressant medication should be the primary pharmacologic treatment for many older people with GAD. Most individuals with late-onset agoraphobia do not have a history of panic attacks and the illness often starts after a traumatic event. Exposure therapy is the treatment of choice for agoraphobia without panic. It is uncommon for obsessive-compulsive disorder (OCD) and panic disorder to start for the first time in old age, but these disorders can persist from younger years into late life. Case reports and uncontrolled case series suggest that elderly people with OCD or panic disorder can benefit from pharmacologic and cognitive-behavioral treatments that are known to be effective in younger patients. However, it is not known whether the rate of response among elderly patients is adversely affected by the chronicity of these disorders. The prevalence and incidence of post-traumatic stress disorder in late life are not known. Uncontrolled data support the use of selective serotonin reuptake inhibitors in war veterans with chronic symptoms of post-traumatic stress disorder; other treatments for this condition await evaluation in the elderly.     

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.     

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.     

Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions

The objective of this study was to determine the prevalence and co-occurrence of DSM-IV personality disorders (PDs) among individuals with current DSM-IV mood and anxiety disorders in the US population and among individuals who sought treatment for such mood or anxiety disorders. Face-to-face interviews were conducted with 43,093 individuals, 18 years and older, in the National Institute on alcohol abuse and alcoholism's 2001-2002 National epidemiologic survey on alcohol and related conditions (NESARC). Odds ratios (ORs) were calculated to determine the prevalence and associations between current DSM-IV axis I and axis II disorders. Associations between mood, anxiety and PDs were all positive and statistically significant. Avoidant and dependent PDs were more strongly related to mood and anxiety disorders than other PDs. Associations between obsessive-compulsive PD and mood and anxiety disorders were significant, but much weaker. Paranoid and schizoid PDs were most strongly related to dysthymia, mania, panic disorder with agoraphobia, social phobia and generalized anxiety disorder, while histrionic and antisocial PDs were most strongly related to mania and panic disorder with agoraphobia. Results of this study highlight the need for further research on overlapping symptomatology, factors giving rise to the associations and the treatment implications of these disorders when comorbid.     

Positive affect regulation in anxiety disorders

Although individual differences exist in how people respond to positive affect (PA), little research addresses PA regulation in people with anxiety disorders. The goal of this study was to provide information about responses to PA in people with symptoms of social phobia, generalized anxiety disorder, panic disorder, agoraphobia, and obsessive-compulsive disorder. The tendency to dampen PA and the ability to savor PA were examined in an undergraduate sample. Analyses examined the unique links between these reactions and symptoms of anxiety disorders, controlling for a history of depression. Given the high comorbidity of depression and anxiety, exploratory analyses further controlled for generalized anxiety disorder. Results demonstrated that one or both measures of affect regulation made a unique and substantial contribution to predicting each anxiety disorder except agoraphobia, above and beyond prediction afforded by symptoms of depression and generalized anxiety disorder. Clinical implications and areas for future research are discussed.     

Antidepressants in the treatment of agoraphobia and obsessive-compulsive disorder

Agoraphobia and obsessive-compulsive disorder share many similarities, not the least of which is their response to behavioral and pharmacological treatments. The mechanism of action of antidepressants in these complex anxiety disorders is not known. The question as to whether they possess antiphobic/antiobsessional properties, independent of their antidepressant effect, is controversial and unlikely to be solved on symptomatic grounds alone. A fruitful approach is indicated by recent biochemical findings that link their obsessional effect to the serotonergic neurotransmitter system. The use of agents with more specific biochemical action should permit a more accurate differentiation of antiphobic/antiobsessional and antidepressant effects. Furthermore, the exploration of the role of neurotransmitter systems in agoraphobia and obsessive-compulsive disorder might further elucidate the relationship between depressive disorders and anxiety disorders.     

The relationship of hypochondriasis to anxiety disorders

There is evidence from the literature of phenomenological overlap between hypochondriasis and several anxiety disorders, including specific phobia, panic disorder with agoraphobia, generalized anxiety disorder, and obsessive-compulsive disorder. Even though the boundaries of these disorders are specifically addressed in the DSM-IV criteria, there is evidence of anxiety and phobic symptoms among hypochondriacal patients and hypochondriacal concerns among patients with these various anxiety disorders. Beyond that there appears to be considerable shared comorbidity. However, the data remain limited and few direct comparisons have been made between hypochondriacal and anxious patients belonging to particular diagnostic categories. Subtypes of hypochondriasis may exist. In fact, the clearest link would seem to be between the illness phobia subtype and other phobic disorders, although this subgroup has had little study. Thus, hypochondriasis is distinct from the anxiety disorders but, because of phenomenological similarities and extensive comorbidity, consideration should be given to classifying it among them.     

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.     

Personality disorders evident by early adulthood and risk for anxiety disorders during middle adulthood

Data from the Children in the Community Study, a prospective longitudinal investigation, were used to investigate the association of personality disorder (PD) traits, evident by early adulthood, with risk for development of anxiety disorders by middle adulthood. Individuals without a history of anxiety disorders who met diagnostic criteria for >or=1 PD by early adulthood were at markedly elevated risk for agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder by middle adulthood. Antisocial, avoidant, borderline, dependent, depressive, histrionic, obsessive-compulsive, passive-aggressive, and schizotypal PD traits, evident by early adulthood, were associated with elevated risk for >or=1 anxiety disorder during middle adulthood. These associations remained significant after a history of anxiety disorder and co-occurring Axis I psychiatric disorder was controlled statistically. Findings of this study suggest that some types of PD traits that become evident by early adulthood may contribute to increased risk for the development of anxiety disorders by middle adulthood.     

The epidemiology of anxiety disorders: a review

Epidemiological studies show that anxiety disorders are highly prevalent and an important cause of functional impairment; they constitute the most frequent menial disorders in the community. Phobias are the most common with the highest rates for simple phobia and agoraphobia. Panic disorder (PD) and obsessive-compulsive disorder (OCD) are less frequent (2% lifetime prevalence), and there are discordant results for social phobia (SP) (2%-16%) and generalized anxiety disorder (GAD) (3%-30%). These studies underline the importance of an accurate definition of disorders using unambiguous diagnostic and assessment criteria. The boundaries between anxiety disorders are often ill defined and cases may vary widely according to the definition applied. Simple phobia, agoraphobia, and GAD are more common in vmrnen, while there is no gender différence for SP, PD, and OCD, Anxiety disorders are more common in separated, divorced, and widowed subjects; their prevalence is highest in subjects aged 25 to 44 years and lowest in subjects aged >65 years. The age of onset of the different types of anxiety disorders varies widely: phobic disorders begin early in life, whereas PD occurs in young adulthood. Clinical - rather than epidemiological - studies have examined risk factors such as life events, childhood experiences, and familial factors. Anxiety disorders have a chronic and persistent course, and are frequently comorbid with other anxiety disorders, depressive disorders, and substance abuse. Anxiety disorders most frequently precede depressive disorders or substance abuse, Comorbid diagnoses may influence risk factors like functional impairment and quality of life. It remains unclear whether certain anxiety disorders (eg, PD) are risk factors for suicide. The comorbidity of anxiety disorders has important implications for assessment and treatment and the risk factors should be explored. The etiology, natural history, and outcome of these disorders need to be further addressed in epidemiological studies.     

A cognitive-behavioral group for patients with various anxiety disorders

OBJECTIVE: Cognitive-behavioral therapy (CBT) protocols for each of the anxiety disorders are robust and effective but are best suited for specialty clinics. This study assessed a format more suitable for general clinics: a single protocol based on standard CBT techniques designed to treat patients who have different anxiety disorders in the same group. METHODS: Potential participants in Vancouver, British Columbia, were administered a structured clinical interview to identify those with major anxiety disorders: panic disorder, with or without agoraphobia; obsessive-compulsive disorder; social phobia; generalized anxiety disorder; specific phobia; and posttraumatic stress disorder. Forty-three percent of participants had more than one current anxiety diagnosis. Those with active substance abuse or dependence or with psychosis were excluded. A total of 152 patients were randomly assigned to immediate treatment in the 11-week CBT group or to a wait-list control group. The Beck Anxiety Inventory (BAI) was administered at baseline, at the end of treatment or of the waiting period, and six months later. RESULTS: Reductions in BAI scores for participants in the immediate-treatment groups were greater than those for the control group participants. Patients with panic disorder in particular appeared to benefit. Outcomes for the immediate-treatment group were superior in terms of clinically significant changes, defined as a 20% or 40% improvement. Reductions in BAI scores continued to be present six months later. The improvements correspond to a medium effect size (Cohen's d=.50). CONCLUSIONS: A group CBT protocol for mixed anxiety disorders may make effective treatment more widely available.     

Anxiety and depressive disorders and the five-factor model of personality: a higher- and lower-order personality trait investigation in a community sample

We describe in detail normal personality traits in persons with psychiatrist-ascertained anxiety and depressive disorders in a general population sample. We investigated Revised NEO Personality Inventory traits in 731 community subjects examined by psychiatrists with the Schedules for Clinical Assessment in Neuropsychiatry. All of the lifetime disorders of interest (simple phobia, social phobia, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), generalized anxiety disorder, major depressive disorder (MDD), and dysthymia) were associated with high neuroticism. Social phobia, agoraphobia, and dysthymia were associated with low extraversion, and OCD was associated with high openness to experience. In addition, lower-order facets of extraversion (E), openness (O), agreeableness (A), and conscientiousness (C) were associated with certain disorders (specifically, low assertiveness (E) and high openness to feelings (O) with MDD, low trust (A) with social phobia and agoraphobia, low self-discipline (C) with several of the disorders, and low competence and achievement striving (C) with social phobia). Neuroticism in particular was related to acuity of disorder. Longitudinal study is necessary to differentiate state versus pathoplastic effects.     

Absence of placebo response in obsessive-compulsive disorder

Analyses in 30 patients with a diagnosis of obsessive-compulsive disorder given single-blind placebo over a 2-week period and of 12 of these patients who continued treatment on double-blind placebo for an additional 10 weeks revealed virtual absence of improvement on both clinician and self-rating scales of obsessions, compulsions, phobias, depression, and anxiety. This result would imply that the contribution of the placebo effect to the pharmacotherapy of patients with obsessive-compulsive disorder is negligible although considerable effort and work is still required to reliably identify one of four panic disorder with agoraphobia patients who respond to placebo. The placebo response thus presents a clear distinction between these two phenomenologically complex anxiety disorders.     

Cognitive behavioral therapy in anxiety disorders: current state of the evidence

A plethora of studies have examined the efficacy and effectiveness of cognitive-behavioral therapy (CBT) for adult anxiety disorders. In recent years, several meta-analyses have been conducted to quantitatively review the evidence of CBT for anxiety disorders, each using different inclusion criteria for studies, such as use of control conditions or type of study environment. This review aims to summarize and to discuss the current state of the evidence regarding CBT treatment for panic disorder, generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Overall, CBT demonstrates both efficacy in randomized controlled trials and effectiveness in naturalistic settings in the treatment of adult anxiety disorders. However, due to methodological issues, the magnitude of effect is currently difficult to estimate. In conclusion, CBT appears to be both efficacious and effective in the treatment of anxiety disorders, but more high-quality studies are needed to better estimate the magnitude of the effect.     

Distress tolerance in OCD and anxiety disorders,and its relationship with anxiety sensitivity and intolerance of uncertainty

There is a growing interest in the role of distress tolerance (i.e., the capacity to withstand negative emotions) in the onset and maintenance of anxiety. However, both empirical and theoretical knowledge regarding the role of distress tolerance in the anxiety disorders is relatively under examined. Accumulating evidence supports the relationship between difficulties tolerating distress and anxiety in nonclinical populations; however, very few studies have investigated distress tolerance in participants with diagnosed anxiety disorders. Individuals with social anxiety disorder (SAD), generalized anxiety disorder (GAD), panic disorder with and without agoraphobia (PD/A) and obsessive-compulsive disorder (OCD) completed measures of distress tolerance (DT), conceptually related measures (i.e., anxiety sensitivity (AS), intolerance of uncertainty (IU)), and anxiety symptom severity. Results showed that DT was negatively associated with AS and IU. DT was correlated with GAD, SAD and OCD symptoms, but not PD/A symptoms, in individuals with those respective anxiety disorders. DT was no longer a significant predictor of OCD or anxiety disorder symptom severity when AS and IU were also taken into account. There were no between group differences on DT across OCD and the anxiety disorder groups. Implications for the role of distress tolerance in anxiety pathology are discussed.     

The identification of OCD-related subgroups based on comorbidity.

BACKGROUND: Individuals with obsessive-compulsive disorder (OCD) frequently have other psychiatric disorders. This study employed latent class analysis (LCA) to explore whether there are underlying clinical constructs that distinguish "OCD-related" subgroups. METHODS: The study included 450 subjects, case and control probands and their first-degree relatives, and LCA was used to derive empirically based subgroups of 10 disorders: OCD, obsessive-compulsive personality disorder (OCPD), recurrent major depressive disorder (RMDD), separation anxiety disorder, panic disorder or agoraphobia (PD/AG), tic disorders (TD), generalized anxiety disorder (GAD), somatoform disorders (hypochondriasis or body dysmorphic disorder), pathologic skin picking or nail biting (PSP/NB), and eating disorders (EDs). The derived classes were compared on several clinical variables. RESULTS: The best fitting model is a four-class structure: minimal disorder, predominant RMDD and GAD, "highly comorbid," and PD/AG and TD. The nature and number of disorders represented suggests that the first classes are distributed ordinarily on a dimension of severity, and the fourth class is qualitatively distinct. Support for this structure is based on the number of disorders, age at onset of OCD, neuroticism, and extraversion. CONCLUSIONS: In this OCD enriched sample, LCA identified four classes of disorder. These classes appear to conform to two subgroups that may prove useful in investigating the etiology of OCD.     

Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow-up study

Our objective was to determine whether the presence of an anxiety disorder was a risk factor for future suicide attempts. Data were drawn from the 13-year follow-up Baltimore Epidemiological Catchment Area survey (n=1,920). Multiple logistic regression analysis was used to determine the association between baseline anxiety disorders (social phobia, simple phobia, obsessive-compulsive disorder, panic attacks, or agoraphobia) and subsequent onset suicide attempts. The presence of one or more anxiety disorders at baseline was significantly associated with subsequent onset suicide attempts (adjusted odds ratio 2.20, 95% confidence interval 1.04-4.64) after controlling for sociodemographic variables and all baseline mental disorders assessed in the survey. These findings suggest that anxiety disorders are independent risk factors for suicide attempts, and underscore the importance of anxiety disorders as a serious public health problem.