Comparing panic disorder uncomplicated and panic disorder with agoraphobia in cardiology patients with atypical or nonanginal chest pain

Thirty-eight cardiology patients with either atypical or nonanginal chest pain and current panic disorder were divided into two groups, those with agoraphobia (N = 8) and those without agoraphobia (N = 30). The agoraphobia group reported marginally longer duration of panic disorder (17.0 ± 21.1 years vs. 3.0 ± 3.2 years) and significantly more panic symptoms (10.6 ± 3 vs. 7.3 ± 2.2) during the last major attack. The agoraphobia group also scored significantly higher on measures of anxiety, depression, phobic avoidance, somatization, interpersonal sensitivity, and psychoticism and also scored higher on three of three global measures of distress. This agoraphobia group differed from previously reported agoraphobics with panic attacks in that they all had current panic disorder, while previously reported groups were categorized according to DSM-III, which required only a history of panic attacks. These findings suggest that patients who have current panic disorder and agoraphobia are more symptomatic. Of interest is the low proportion of agoraphobics compared to nonagoraphobics found in this panic disorder population.     

The epidemiology of panic symptomatology and agoraphobic avoidance

In a random community survey of 1,498 urban adults age 18 to 64 years who were interviewed using the Diagnostic Interview Schedule (DIS), the lifetime prevalence of panic disorder was 2.2% +/- 0.4%. This was higher in women (3.4% +/- 0.7%) than in men (0.9% +/- 0.6%), and in those under the age of 45 years. Lifetime prevalence for panic attacks was 7.8% +/- 0.7%. Panic attacks and panic disorder had a similar distribution by age and sex, with higher rates in women than men, and also in the under 45 age groups. The panic symptomatology reported by those subjects with panic attacks was similar to that described by subjects meeting full criteria for panic disorder. The lifetime prevalence of phobic disorders was 10.7% +/- 0.9% and was more common in women (14.6% +/- 1.3%) than in men (6.8% +/- 1.3%). The lifetime prevalence of agoraphobia was 3.8% +/- 0.5%. The occurrence of panic attacks and phobic disorders were frequently related, and in agoraphobic subjects those with more severe agoraphobic avoidance reported more panic symptoms. Indeed, among agoraphobic subjects with at least moderate agoraphobic avoidance, nearly all had either panic attacks or major depression. Subjects with panic attacks and moderate agoraphobic avoidance compared with patients with panic attacks alone, especially when panic symptoms appear before the age of 15, are more likely to have grown up in a family where there was parental conflict, are more likely to have left school at a younger age and without school exams, and are likely to have had more symptoms of a childhood conduct disorder.     

Thyroid disorders in female psychiatric patients with panic disorder or agoraphobia

The authors interviewed 144 consecutive female psychiatric patients and found that those with a lifetime history of either panic disorder or agoraphobia with panic attacks (panic/agoraphobia) were more likely than other patients to report a history of hyperthyroidism or goiter in themselves and in their first-degree relatives. A personal history of hyperthyroidism or goiter was found almost exclusively in the subgroup of patients with panic/agoraphobia who also had a lifetime history of major depression.     

Panic disorder and major depression. A tale of two syndromes

Considerable research has been conducted to clarify relationships between panic disorder and major depression. From a number of perspectives, it now appears that panic disorder and major depression are not identical illnesses. While many patients with panic disorder are likely to experience an episode of major depression at some point during their lives, the timing of this occurrence is highly variable. While depression may be an expected and understandable result of having to live with chronic anxiety and phobic avoidance, the available evidence suggests that such a hypothesis is not particularly tenable. Depression can occur in individuals with or without severe agoraphobia and in individuals ill with panic for greater or lesser periods of time. Comorbidity in panic, particularly for social phobic or obsessive-compulsive symptomatology, does serve as a risk factor for the lifetime occurrence of depression and may denote a more severe illness. Biologic markers (Table 4), while of limited diagnostic utility in clinical practice, may reveal important pathophysiologic similarities and differences between panic disorder and major depression. Current evidence points to many areas of biologic overlap, with some important areas of independence (Fig. 7A). Although not extensively discussed in this chapter, several clinical parameters paint an analogous picture (Fig. 7B). There is a need for future studies of biologic markers in individuals over time, in various phases of illness. Furthermore, the study of multiple biologic markers in the same individuals would be a worthwhile pursuit, perhaps leading toward the delineation of underlying pathophysiologic mechanisms. In summary, then, we favor a conceptualization of panic disorder and major depression as nonidentical disorders with many shared characteristics. Future studies as suggested above, particularly when coupled with the power of genetic studies not described in this chapter, may eventually lead to a clearer demarcation of the boundaries between these two intriguing psychiatric syndromes.     

Agoraphobia with panic attacks. Development, diagnostic stability, and course of illness

A structured psychiatric interview was used to examine the symptom history of 55 patients meeting DSM-III criteria for agoraphobia with panic attacks and five patients meeting DSM-III criteria for panic disorder. Anticipatory anxiety and generalized anxiety occurred in over 80% of the patients, and these anxiety states together with panic attacks and phobic avoidances had courses that were chronic and unremitting. Major depression occurred in 70% of the patients and had an episodic course that differentiated it from the anxiety states. Other frequently reported disorders were childhood separation disorder (18%), alcoholism (17%), and obsessive compulsive disorder (17%). An initial nonspontaneous first panic attack and separation anxiety was associated with earlier onset and longer duration of agoraphobia and panic disorder. An inaccurate cognitive appraisal of the initial panic attack frequently led to the rapid development of subsequent agoraphobia. Caffeine consumption exacerbated anxiety in 54% of the patients and triggered panic attacks in 17%. Fifty-one percent of female agoraphobics experienced premenstrual exacerbation of anxiety symptoms.     

Reliability of the telephone interview in diagnosing anxiety disorders

The reliability of psychiatric diagnosis using the Schedule of Affective Disorders and Schizophrenia-Lifetime Version in personal and telephone interviews with 39 subjects was assessed using a 12- to 19-month test-retest design. Interrater reliability was high (kappa, .69 to .84) for the diagnosis of panic disorder, agoraphobia with panic attacks, probable panic disorder, major depression, and alcohol abuse. We conclude that it is possible to reliably make these lifetime diagnoses in a family study using the telephone interview.     

A cluster analysis of early onset in common anxiety disorders

Early onset is regarded as an important characteristic of anxiety disorders, associated with higher severity. However, previous findings diverge, as definitions of early onset vary and are often unsubstantiated. We objectively defined early onset in social phobia, panic disorder, agoraphobia, and generalised anxiety disorder, using cluster analysis with data gathered in the general population. Resulting cut-off ages for early onset were ≤22 (social phobia), ≤31 (panic disorder), ≤21 (agoraphobia), and ≤27 (generalised anxiety disorder). Comparison of psychiatric comorbidity and general wellbeing between subjects with early and late onset in the general population and an outpatient cohort, demonstrated that among outpatients anxiety comorbidity was more common in early onset agoraphobia, but also that anxiety- as well as mood comorbidity were more common in late onset social phobia. A major limitation was the retrospective assessment of onset. Our results encourage future studies into correlates of early onset of psychiatric disorders.     

Panic disorder without fear in patients with angiographically normal coronary arteries

By DSM-III-R criteria, patients may be diagnosed as having panic disorder without reporting the experience of intense fear. However, if such patients do not report subjective fear, they may be less likely to receive a panic diagnosis. The authors studied 32 subjects with angiographically normal coronary arteries who fit panic disorder criteria. A total of 13 (41%) reported no fear during their last major attack. These subjects were contrasted with those who did report fear. Few differences were found in group demographic data or responses to self-report questionnaires. We conclude that there appear to be few differences between the nonfear panic disorder subjects and those who do report fear. This conclusion awaits further support using challenge tests, medication trials, biological indices, alexithymia inventories, and family studies. The recognition of the existence of this subtype is likely to increase the number of patients receiving the panic disorder diagnosis in cardiology settings, in psychiatric settings, and in research projects using structured clinical interviews.     

Predictors of the development of phobic avoidance

BACKGROUND: Panic disorder and agoraphobia are closely linked. There are indications that uncontrolled panic attacks often lead to the rapid development of phobic avoidance, but our ability to predict which individuals with panic will develop avoidance has been limited. The purpose of this study was to identify independent predictors of the development of phobic avoidance and the time course of that development. METHOD: We conducted a secondary analysis of survey data from the community-based Panic Attack Care-Seeking Threshold Study. The presence of panic attacks was confirmed in 97 randomly selected adults from randomly selected households screened using the Structured Clinical Interview of DSM-III-R (SCID). The presence of limited and extensive phobic avoidance was measured using the SCID, while rapidity of development (lag time) was measured as the difference between onset of panic and onset of avoidance. Predictors considered included panic characteristics, psychiatric comorbidity, cognitive appraisal, family characteristics, illness attitudes, symptom perceptions, and coping style. RESULTS: Thirty-six subjects (37%) had at least mild phobic avoidance, with 81% (N = 29) of those developing the avoidance less than 1 year after the onset of panic attacks. The development of phobic avoidance was associated with the presence of panic disorder (beta = 1.36), the number of comorbid psychiatric disorders (beta = 0.69), and the number of family members and/or friends available to discuss health concerns (beta = 0.87). Further progression to agoraphobia was predicted by the presence of depersonalization during panic attacks (beta = 0.50). Rapid onset of avoidance (panic avoidance lag time < 1 year) was predicted by the perception that depersonalization is a life-threatening symptom (beta = 1.56). CONCLUSION: The development of phobic avoidance is closely linked to panic attacks and often develops soon after panic onset. Full-blown panic disorder and psychiatric comorbidity are important in this development. Depersonalization is also key to the development of avoidance and the rapidity of the development.     

Panic attacks. A review of treatments and pathogenesis

In the psychiatric literature, panic attacks have been considered as part of the clinical manifestations of anxiety neurosis, agoraphobia, functional cardiovascular disturbances, and the phobic depersonalization syndrome. Even though recurrent spontaneous panic attacks are described in these entities, the importance ascribed to them has been minor one. Therefore, panic attacks are poorly understood from a psycho-physio pathological point of view. In the past years, new trends in the nosology of psychiatric disorders have grouped the recurrent spontaneous panic attacks under the heading "panic disorder and agoraphobia with panic attacks." In this view, we present the results of the controlled pharmacological trials on patients complaining of panic attacks. Some relationships between panic attacks, panic disorder, and agoraphobia are discussed.     

Pharmacogenomics and therapeutic prospects in dementia

OBJECTIVE: To describe the prevalence and correlates of post-traumatic stress disorder (PTSD), depressive and anxiety disorders, or any other mental disorder among adult victims treated in a hospital at different points in time after the 11 March 2004 terrorist attacks in Madrid. DESIGN, SETTING, AND PARTICIPANTS: A random sample of 56 individuals injured in the attacks was interviewed in person at one, six, and twelve months after the attacks. MAIN OUTCOME MEASURES: Current DSM-IV mental disorders: depressive disorders and anxiety disorders (PTSD, generalised anxiety, agoraphobia, social phobia, and panic disorder) were assessed with the Spanish version of the MINI (Mini International Neuropsychiatric Interview), a structured, lay-administered psychiatric interview. RESULTS: PTSD was the most prevalent psychiatric disorder (35.7% at month 1, 34.1% at month 6, and 28.6% at month 12), followed by major depression (28.6%, 22.7%, and 28.6%, respectively). Others relevant conditions were suicide risk, generalised anxiety disorder (GAD), agoraphobia, and panic disorder. No significant differences in the prevalence of the disorders were found between the different assessment times. Patients with a psychiatric history prior to 11 March had a higher prevalence of PTSD, major depression, GAD, and panic disorder at month 1. Females had higher prevalence of PTSD, agoraphobia, and panic disorder at month 1. The only predictive factor for PTSD at month 12 was PTSD at month 6 (OR = 14.007). The only predictive factor for major depression at month 12 was major depression at month 6 (OR = 15.847). CONCLUSION: The prevalence of PTSD and major depression was high and remained stable between month 1, month 6, and month 12. The only predictive factor for PTSD at month 12 was PTSD at month 6.     

Panic disorder, comorbidity, and suicide attempts

In a previous report, we demonstrated a strong association between panic disorder and suicide attempts based on data from the Epidemiologic Catchment Area study (a probability sample of more than 18,000 adults living in five US communities). In these analyses, although we controlled statistically for comorbidity of panic disorder with other psychiatric disorders, we did not directly estimate the risk of suicide attempts in persons with uncomplicated panic disorder (ie, without any other Axis I disorders) compared with those with comorbid conditions. Persons with uncomplicated panic disorder represent fewer than a third of persons with panic disorder. However, the lifetime rates of suicide attempts in persons with uncomplicated panic disorder (7%) were consistently higher than for persons with no psychiatric disorder (1%). Similar findings on the rate of suicide attempts in persons with uncomplicated major depression (7.9%) emerged. We conclude that suicide attempts are associated with panic disorder in its uncomplicated or its comorbid form and that the risks are comparable with those of major depression, comorbid and uncomplicated. These epidemiologic findings are discussed within a clinical perspective to explain why these associations may not appear obvious in clinical practice.     

Secondary depression in panic disorder and agoraphobia. I. Frequency, severity, and response to treatment

Depressive symptomatology in 481 subjects with panic disorder and phobic avoidance was studied as part of an investigation of the efficacy of alprazolam in panic disorder. Subjects who had a major depressive episode (MDE) before the onset of their panic disorder were not included in the trial. With this exclusion criterion, 31% of subjects had a secondary MDE occurring after the onset of the panic disorder. The occurrence of secondary MDE was related to the length of time subjects were ill with panic disorder. Compared with the subjects without depression, those subjects with current MDE had higher scores on measures of anxiety and depression but not on the number of panic attacks per week. The presence of depression and the degree of phobic avoidance contributed independently to measures of the severity of the panic illness. Alprazolam was effective in reducing panic and depressive symptomatology in both depressed and nondepressed subjects with panic disorder. The presence of an MDE was not predictive of the outcome of treatment for the panic and phobic symptoms. Subjects with or without depression responded similarly to alprazolam.     

Psychiatric disorders in asthmatic outpatients

It has been reported that the lifetime prevalence of panic disorder in patients with pulmonary disease is higher than epidemiologic estimates of population prevalence. We evaluated the frequency of anxiety disorders in 86 subjects from the Outpatient Asthma Clinic. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview 4.4 Version (MINI). Forty-five asthmatic patients (52.3%) reported at least one current anxiety disorder. The frequency of panic disorder with or without agoraphobia was 13.9% (n=12) and that of agoraphobia without panic disorder was 26.8% (n=23). Social anxiety and generalized anxiety disorders occurred in 9.3% (n=8) and 24.4% (n=21) of the sample, respectively. Twenty-nine patients (33.7%) reported a major depressive episode. The psychiatric morbidity of the sample was 61.6% (n=53). Our results tend to support the high morbidity of anxiety disorders, particularly panic/agoraphobic spectrum disorders, in asthmatic outpatients.     

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.     

Lifetime and 12-month prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition disorders among older African Americans: findings from the National Survey of American Life.

OBJECTIVE: The purpose of this study was to estimate lifetime and 12-month prevalence of 13 psychiatric disorders for older African Americans. METHODS: Data are from the older African American subsample of the National Survey of American Life. Selected measures of lifetime and 12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric disorders were examined (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder, posttraumatic stress disorder (PTSD), major depressive disorder, dysthymia, bipolar I and II disorders, alcohol abuse/dependence, and drug abuse/dependence). RESULTS: Twenty-three percent of older African Americans reported at least one lifetime disorder and 8.54% reported at least one 12-month disorder. Alcohol abuse, PTSD, and major depression were the most prevalent lifetime disorders. The most prevalent 12-month disorders were PTSD, major depression, and social phobia. Age, sex, education, and region were significantly associated with the odds of having a lifetime disorder. CONCLUSION: This is the first study of prevalence rates of serious mental disorders for older African Americans based on a national sample. Demographic correlates of the prevalence of disorders are discussed with an emphasis on age and regional differences.     

Panic disorder and suicidal ideation and behavior: discrepant findings in psychiatric outpatients

OBJECTIVE: Previous investigators found that persons who had ever met criteria for panic disorder or panic attacks reported more lifetime suicide attempts and ideation than persons who had ever met criteria for other psychiatric disorders. To determine whether outpatients with current panic disorders also report such differences, this study examined the suicide attempt rates, levels of suicidal ideation, and levels of hopelessness among four groups of psychiatric outpatients. METHOD: Structured clinical interviews were used to assign diagnoses to 900 consecutive psychiatric outpatients. These patients were administered the Scale for Suicide Ideation and the Beck Hopelessness Scale and were also questioned in detail about previous suicide attempts and past and present suicidal ideation. RESULTS: None (0.0%) of the 73 patients with primary panic disorder without agoraphobia reported having made suicide attempts during their lifetimes. One (1.3%) of the 78 patients who had panic disorder with agoraphobia, 34 (7.0%) of the 485 patients who had mood disorders, and four (1.5%) of the 264 patients who had other psychiatric disorders reported suicide attempts. The mean scores on the Scale for Suicide Ideation and the Beck Hopelessness Scale of the patients with panic disorders and other disorders were significantly lower than the mean scores of the patients with mood disorders. CONCLUSIONS: The rates of suicidal ideation and behavior for psychiatric outpatients who had panic disorders were discrepant with those reported by the earlier group of investigators for a random community sample of persons who reported ever having had panic attacks or met criteria for panic disorders.     

Psychopathological sequelae of the 11 March terrorist attacks in Madrid

Objective To describe the prevalence and correlates of post-traumatic stress disorder (PTSD), depressive and anxiety disorders, or any other mental disorder among adult victims treated in a hospital at different points in time after the 11 March 2004 terrorist attacks in Madrid. Design, Setting, and Participants A random sample of 56 individuals injured in the attacks was interviewed in person at one, six, and twelve months after the attacks. Main Outcome Measures Current DSM-IV mental disorders: depressive disorders and anxiety disorders (PTSD, generalised anxiety, agoraphobia, social phobia, and panic disorder) were assessed with the Spanish version of the MINI (Mini International Neuropsychiatric Interview), a structured, lay-administered psychiatric interview. Results PTSD was the most prevalent psychiatric disorder (35.7% at month 1, 34.1% at month 6, and 28.6% at month 12), followed by major depression (28.6%, 22.7%, and 28.6%, respectively). Others relevant conditions were suicide risk, generalised anxiety disorder (GAD), agoraphobia, and panic disorder. No significant differences in the prevalence of the disorders were found between the different assessment times. Patients with a psychiatric history prior to 11 March had a higher prevalence of PTSD, major depression, GAD, and panic disorder at month 1. Females had higher prevalence of PTSD, agoraphobia, and panic disorder at month 1. The only predictive factor for PTSD at month 12 was PTSD at month 6 (OR = 14.007). The only predictive factor for major depression at month 12 was major depression at month 6 (OR = 15.847). Conclusion The prevalence of PTSD and major depression was high and remained stable between month 1, month 6, and month 12. The only predictive factor for PTSD at month 12 was PTSD at month 6.     

Briquet's syndrome in association with depression and panic: a reconceptualization of Briquet's syndrome

In a sample of 188 consecutive female psychiatric patients, Briquet's syndrome was found to be associated more closely with the aggregation of both major depression and either panic disorder or agoraphobia than with major depression or panic disorder-agoraphobia alone. These results are consistent with the hypothesis of a shared diathesis underlying some cases of major depression, panic disorder, agoraphobia, and Briquet's syndrome. The author proposes that Briquet's syndrome may represent the most extreme expression of a tendency for a number of physical and psychological syndromes to aggregate.     

Depression and anxiety disorders in parents and children. Results from the Yale family study

The children (aged 6 to 17 years) of probands with primary major depression, with and without various anxiety disorders, were compared with the children of a matched normal control group. The results from the study of these young children parallel our previous findings among the adult first-degree relatives of these probands. Depression in the proband increased the risk of depression in the children. Depression plus panic disorder or agoraphobia in the proband conferred an additional risk of depression and of an anxiety disorder in the children. Panic disorder in the parents conferred more than a threefold increased risk of separation anxiety in the children. Other factors that increased the risk to children were degree of familial loading for psychiatric illness, parental assortative mating, and parental recurrent depression. The findings suggest a relationship between depression and some of the anxiety disorders, and between adult panic disorder and agoraphobia and transmission of anxiety disorders to children.