Frequency and severity of the symptoms of irritable bowel syndrome across the anxiety disorders and depression

High rates of irritable bowel syndrome (IBS) symptoms have been reported in individuals diagnosed with anxiety and depressive disorders. However, most studies have investigated these relations in a single disorder, rather than a heterogeneous group of patients, thereby not allowing for comparisons across anxiety disorders and depression, or for considering the effects of comorbidity. Thus, the present study investigated the symptoms of IBS in a diverse group of patients (N=357) by administering questionnaires and a diagnostic interview. A high frequency of IBS symptoms was found in patients with panic disorder, generalized anxiety disorder, and major depressive disorder. However, the frequency of IBS symptoms in patients with social anxiety disorder, specific phobia, and obsessive-compulsive disorder was comparable to rates found in community samples. In addition, anxiety sensitivity and illness attitudes and intrusiveness were predictive of elevated IBS symptomatology. Together, these findings emphasize the role physiological symptoms of anxiety and worry in the co-occurrence of the anxiety disorders and IBS.     

Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder

BACKGROUND: High rates of comorbid anxiety disorders have been described in individuals with bipolar disorder. Although it is well recognized that anxiety disorders often co-occur with bipolar disorder, few studies have examined the impact of more than 1 anxiety disorder on long-term outcome in patients with bipolar disorder. METHOD: The rates of DSM-IV generalized anxiety disorder, panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder were determined using structured clinical interviews in 138 patients with bipolar disorder who presented consecutively between 1994 and 1999. Patients were then followed for up to 3 years with longitudinal clinical surveillance. The impact of 1 or more comorbid anxiety disorders on mood symptoms and general function was evaluated. RESULTS: In our sample, 55.8% of the patients had at least 1 comorbid anxiety disorder, and 31.8% had 2 or more anxiety disorder diagnoses. The most common anxiety disorder was generalized anxiety disorder, followed by panic disorder. The presence of an anxiety disorder led to significantly (p <.05) worse outcome on global as well as specific illness measures, including illness severity, proportion of patients characterized as euthymic, and proportion of the year spent ill. Number of anxiety disorders was less important than type, with generalized anxiety disorder and social phobia having the most negative impact on outcome. CONCLUSION: Our data suggested that multiple anxiety disorder comorbidities were not infrequent in bipolar disorder and that generalized anxiety disorder and social phobia were more likely to be associated with poor outcome. We discuss some potential mechanisms and implications in our findings.     

Major depression in patients with social phobia

The authors examined the longitudinal course of affective illness retrospectively in 63 patients with social phobia and 54 patients with panic disorder. Significantly fewer (35%) of the patients with social phobia than patients with panic disorder (63%) had experienced at least one major depressive episode. Patients with generalized social phobia and patients with specific social phobia had comparable past rates of major depression (37% and 30%, respectively). The clinical and theoretical implications of these findings are discussed within the context of current concepts regarding the development of depressive symptoms in patients with anxiety disorders.     

Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000

OBJECTIVE: There is little information about obsessive-compulsive disorder in large representative community samples. The authors aimed to establish obsessive-compulsive disorder prevalence and its clinical typology among adults in private households in Great Britain and to obtain generalizable estimates of impairment and help-seeking. METHOD: Data from the British National Psychiatric Morbidity Survey of 2000, comprising 8,580 individuals, were analyzed using appropriate measurements. The study compared individuals with obsessive-compulsive disorder, individuals with other neurotic disorders, and a non-neurotic comparison group. ICD-10 diagnoses were derived from the Clinical Interview Schedule-Revised. RESULTS: The authors identified 114 individuals (74 women, 40 men) with obsessive-compulsive disorder, with a weighted 1-month prevalence of 1.1%. Most individuals (55%) in the obsessive-compulsive group had obsessions only. Comorbidity occurred in 62% of these individuals, which was significantly greater than the group with other neuroses (10%). Co-occurring neuroses were depressive episode (37%), generalized anxiety disorder (31%), agoraphobia or panic disorder (22%), social phobia (17%), and specific phobia (15%). Alcohol dependence was present in 20% of participants, mainly men, and drug dependence was present in 13%. Obsessive-compulsive disorder, compared with other neurotic disorders, was associated with more marked social and occupational impairment. One-quarter of obsessive-compulsive disorder participants had previously attempted suicide. Individuals with pure and comorbid obsessive-compulsive disorder did not differ according to most indices of impairment, including suicidal behavior, but pure individuals were significantly less likely to have sought help (14% versus 56%). CONCLUSIONS: A rare yet severe mental disorder, obsessive-compulsive disorder is an atypical neurosis, of which the public health significance has been underestimated. Unmet need among individuals with pure obsessive-compulsive disorder is a cause for concern, requiring further investigation of barriers to care and interventions to encourage help-seeking.     

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.     

Comorbid anxiety disorders in depressed elderly patients

OBJECTIVE: Anxiety disorders are common in adults with depressive disorders, but several studies have suggested a relatively low prevalence of anxiety disorders in older individuals with depression. This cross-sectional study measured current and lifetime rates and associated clinical features of anxiety disorders in depressed elderly patients. METHOD: History of anxiety disorders was assessed by using a structured diagnostic instrument in 182 depressed subjects aged 60 and older seen in primary care and psychiatric settings. Associations between comorbid anxiety disorders and baseline characteristics were measured. The modified structured instrument allowed detection of symptoms that met inclusion criteria for generalized anxiety disorder in a depressive episode. RESULTS: Thirty-five percent of older subjects with depressive disorders had at least one lifetime anxiety disorder diagnosis, and 23% had a current diagnosis. The most common current comorbid anxiety disorders were panic disorder (9.3%), specific phobias (8.8%), and social phobia (6.6%). Symptoms that met inclusion criteria for generalized anxiety disorder, measured separately, were present in 27.5% of depressed subjects. Presence of a comorbid anxiety disorder was associated with poorer social function and a higher level of somatic symptoms. Symptoms of generalized anxiety disorder were associated with a higher level of suicidality. CONCLUSIONS: Contrary to previous reports, the present study found a relatively high rate of current and lifetime anxiety disorders in elderly depressed individuals. Comorbid anxiety disorders and symptoms of generalized anxiety disorder were associated with a more severe presentation of depressive illness in elderly subjects.     

Differential response to placebo among patients with social phobia, panic disorder, and obsessive-compulsive disorder

OBJECTIVE: Placebo effects in treatment of three anxiety disorders were compared. METHOD: Treatment response and patients' treatment expectancy were examined by using data from 70 patients with obsessive-compulsive disorder, social phobia, or panic disorder who received placebo in three randomized, controlled trials comparing cognitive behavior therapy, medication, and their combination to placebo. RESULTS: Patients with obsessive-compulsive disorder were less likely to respond to placebo than patients with generalized social phobia or panic disorder. Differential expectancy did not account for these findings. CONCLUSIONS: Further examination of the placebo effect across the anxiety disorders may elucidate maintenance mechanisms of these disorders and have implications for development of more effective treatments.     

What characteristics of primary anxiety disorders predict subsequent major depressive disorder?

OBJECTIVE: The goal of this study was to examine the associations between specific anxiety disorders and the risk of major depressive disorder and to explore the role of various clinical characteristics of anxiety disorders in these relationships using a prospective, longitudinal design. METHOD: The data are from a 4-year prospective, longitudinal community study, which included both baseline and follow-up survey data on 2548 adolescents and young adults aged 14 to 24 years at baseline. DSM-IV diagnoses were made using the Munich-Composite International Diagnostic Interview. RESULTS: The presence at baseline of any anxiety disorder (odds ratio [OR] = 2.2 [95% CI = 1.6 to 3.2]) and each of the anxiety disorders (specific phobia, OR = 1.9 [95% CI = 1.3 to 2.8]; social phobia, OR = 2.9 [95% CI = 1.7 to 4.8]; agoraphobia, OR = 3.1 [95% CI = 1.4 to 6.7]; panic disorder, OR = 3.4 [95% CI = 1.2 to 9.0]; generalized anxiety disorder, OR = 4.5 [95% CI = 1.9 to 10.3]) was associated with a significantly (p <.05) increased risk of first onset of major depressive disorder. These associations remained significant after we adjusted for mental disorders occurring prior to the onset of the anxiety disorder, with the exception of the panic disorder association. The following clinical characteristics of anxiety disorders were associated with a significantly (p <.05) increased risk of developing major depressive disorder: more than 1 anxiety disorder, severe impairment due to the anxiety disorder, and comorbid panic attacks. In the final model, which included all clinical characteristics, severe impairment remained the only clinical characteristic that was an independent predictor of the development of major depressive disorder (OR = 2.2 [95% CI = 1.0 to 4.4]). CONCLUSION: Our findings suggest that anxiety disorders are risk factors for the first onset of major depressive disorder. Although a number of clinical characteristics of anxiety disorders appear to play a role in the association between anxiety disorders and depression, severe impairment is the strongest predictor of major depressive disorder.     

On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice

BACKGROUND: Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients. METHOD: 1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder. RESULTS: No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion. CONCLUSION: In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.     

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.     

The Ability of the Symptom Checklist SCL-90 to Differentiate Various Anxiety and Depressive Disorders

We studied the use of the Symptom Checklist-90 (SCL-90) to differentiate between specific anxiety and depressive disorders and/or their symptoms in 280 patients with 6 DSM-III-R diagnoses: major depression (MD), panic disorder (PD), generalized anxiety disorder (GAD), social phobia (SP), obsessive-compulsive disorder (OCD), and mixed anxiety and depression (MAD). Using a comparison group, we found specific patterns for some of the diagnostic categories. Both the MD and MAD subjects had significantly high paranoid ideation, interpersonal sensitivity, hostility, and psychoticism, as well as high depression subscale scores; those with PD and GAD has the highest anxiety and somatization scores; and those with SP or OCD had a mixed pattern. When ranking the severity of psychopathology, the disorders ordered from most to least were MAD, MD, PD, GAD, SP, and OCD. Subsyndromal levels of symptoms frequently were associated with the various conditions. Use of the SCL-90 subscale helps to enlarge our understanding of the various anxiety and depressive disorders.     

Anxiety symptoms distinguishing social phobia from panic and generalized anxiety disorders

Social phobic (N = 14), generalized anxiety disorder (N = 18), and panic disorder patients (N = 48) were compared on four categories of anxiety symptoms: autonomic hyperactivity, muscular tension, vigilance, and apprehensive expectation. Six specific symptoms (palpitations, chest pains, tinnitus, blurred vision, headaches, fear of dying, and dry mouth) distinguished social phobia from panic disorder, while four (headaches, fear of dying, sweating, and dyspnea) distinguished social phobia from generalized anxiety disorder. Most symptom differences were in the autonomic hyperactivity category of symptoms. These findings further confirm the validity of social phobia as a distinct disorder and may help provide specific target symptoms for the treatment of related but different anxiety disorders.     

Rates of isolated sleep paralysis in outpatients with anxiety disorders

Initial research suggests that rates of isolated sleep paralysis (ISP) are elevated in individuals with panic disorder and particularly low in individuals with other anxiety disorders. To further evaluate these findings, we examined rates of ISP in a sample outpatients with primary diagnoses of panic disorder (n=24), social anxiety disorder (n=18), or generalized anxiety disorder (n=18). We obtained an overall rate of ISP of 19.7%; rates for patients with panic disorder (20.8%) fell between those with generalized anxiety disorder (15.8%) and social phobia (22.2%). Analysis of comorbidities failed to provide evidence of link between depressive disorders and ISP, but did indicate a significant association between anxiety comorbidity and higher rates of ISP. Results are discussed relative to other variables predicting variability in the occurrence of ISP.     

Personality disorders and time to remission in generalized anxiety disorder, social phobia, and panic disorder

BACKGROUND: This investigation assessed the effect of personality disorders (PersDs) on time to remission in patients with generalized anxiety disorder, social phobia, or panic disorder. METHODS: Selected Axis I and II predictors of time to remission during 5 years of follow-up were assessed in 514 patients with 1 or more of these anxiety disorders who participated in the Harvard/Brown Anxiety Research Program, a multisite, prospective, longitudinal, naturalistic study. RESULTS: The presence of a PersD predicted a 30% lower likelihood of generalized anxiety disorder remission, a 39% lower likelihood of social phobia remission, and no difference in likelihood of panic disorder remission. More specifically, a lower likelihood of remission from generalized anxiety disorder was predicted by the presence of avoidant PersD (34% lower) and dependent PersD (14% lower). The presence of avoidant PersD predicted a 41% lower likelihood of social phobia remission. The presence of major depressive disorder did not account for these findings. CONCLUSIONS: Our findings provide new data on the pernicious effect of PersDs on the course of generalized anxiety disorder and social phobia but not panic disorder, suggesting that PersDs have a differential effect on the outcome of anxiety disorders.     

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.     

Anxiety and depressive disorders in fathers and mothers of anxious school-refusing children.

OBJECTIVE: To examine anxiety and depressive disorders in the mothers and fathers of children with anxious school refusal and to test for the existence of differences in familial aggregation between children suffering from school refusal related to separation anxiety disorder and those suffering from phobic disorder-based school refusal. METHOD: Using a blind standardized diagnostic evaluation (Schedule for Affective Disorders and Schizophrenia-Lifetime version, modified for the study of anxiety disorders; Diagnostic Interview for Genetic Studies; and Schedule for Affective Disorders and Schizophrenia for School-Age Children), the authors compared parental lifetime psychiatric illness for the 2 groups of anxious school refusers. RESULTS: Relationships between specific anxiety disorders in children and their parents revealed increased prevalence of simple phobia and simple and/or social phobia among the fathers and mothers of phobic school refusers, and increased prevalence of panic disorder and panic disorder and/or agoraphobia among the fathers and mothers of school refusers with separation anxiety disorder. Simple and/or social phobia in the father, simple phobia in the mother, and age of the father were associated with the group of phobic school refusers. CONCLUSIONS: The data show the high prevalence of both anxiety and depressive disorders in fathers and mothers of anxious school refusers. Significant differences were observed in familial aggregation considering the subgroups of anxious school-refusing children.     

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.     

Efficacy of typical and atypical antipsychotics for primary and comorbid anxiety symptoms or disorders: a review

OBJECTIVE: The efficacy of antipsychotics in the treatment of primary or comorbid anxiety disorders or anxiety symptoms in major depressive disorder or bipolar disorder was reviewed. DATA SOURCES: English-language literature cited in MEDLINE from January 1, 1968, to December 31, 2005, was searched with the keywords anxiety disorder, anxiety symptoms, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, bipolar disorder, major depressive disorder, Hamilton Rating Scale for Anxiety, antipsychotics, typical antipsychotics, atypical antipsychotics, fluphenazine, haloperidol, perphenazine, pimozide, thiothixene, trifluoperazine, loxapine, molindone, chlorpromazine, mesoridazine, thioridazine, fluspirilene, penfluridol, pipothiazine, flupenthixol, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, amisulpride, and clinical trial. Randomized, double-blind, placebo-controlled trials and open-label studies with a minimum of 20 subjects with a DSM-III/IV or ICD-10 diagnosis of anxiety disorder and studies without a DSM-III/IV or ICD-10 diagnosis of anxiety disorder but with Hamilton Rating Scale for Anxiety (HAM-A) scores as an outcome were prioritized. Studies on bipolar disorder or major depressive disorder with the analysis of changes in anxiety symptoms were reviewed. Early studies on neurosis/ anxiety or anxious depression without a HAM-A component were also reviewed. DATA SYNTHESIS: Six trials in primary generalized anxiety disorder (GAD), 15 in refractory obsessive-compulsive disorder (OCD), 8 in posttraumatic stress disorder (PTSD), 6 in neurosis with the HAM-A, 1 in social phobia, and 2 in anxiety symptoms in bipolar depression were identified. Low doses of trifluoperazine were superior to placebo in the treatment of GAD. Most of the less well-designed studies showed that other typical antipsychotics might be superior to placebo or as effective as benzodiazepines in the treatment of GAD and other anxiety conditions. In most studies, risperidone, olanzapine, and quetiapine augmentation to antidepressants was superior to placebo in treating refractory OCD and PTSD. Both olanzapine and quetiapine significantly reduced anxiety compared to placebo in studies of bipolar depression. CONCLUSION: Except for trifluoperazine, there is no large, well-designed study of antipsychotics in the treatment of primary or comorbid anxiety symptoms or disorders. The efficacy of these agents in various anxiety conditions needs to be further investigated with large, well-designed comparison studies.     

Medical utilization across the anxiety disorders

Individuals with panic disorder often seek medical care for their symptoms prior to receiving effective treatment. However, little is known about how often, and in what settings, patients with other anxiety disorders present for medical treatment. In the present study, utilization of general and specialty medical services was coded via electronic chart review for 171 consecutive outpatients referred to an anxiety disorders clinic. Results indicated that panic disorder patients accrued the most medical visits overall, as well as the most frequent visits to cardiology, family medicine, and emergency medicine. Few differences in medical utilization were evident among patients with generalized anxiety disorder, obsessive-compulsive disorder, social phobia, and specific phobias. Patients with anxiety disorders appear to be frequent utilizers of medical services prior to receiving effective treatment. Our findings highlight the need for improved recognition and treatment of anxiety disorders, particularly panic disorder, in a number of medical settings.     

Genetics of pediatric anxiety disorders

This article reviews the familiality, linkage, candidate gene, and genomewide association studies of obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, and other anxiety disorders (ie, generalized anxiety disorder, separation anxiety disorder, social phobia, and specific phobia). Studies involving children and adolescents are highlighted. Clinical and research implications are discussed.