Patient outcomes in schizophrenia I: correlates with sociodemographic variables, psychopathology, and side effects.

OBJECTIVE: The present cross-sectional study examined the relationships of psychopathology, side effects, and sociodemographic factors with treatment outcomes in terms of patients' quality of life (QOL), functioning, and needs for care. METHOD: Sixty outpatients with chronic schizophrenia who had been treated with either clozapine or olanzapine for at least 6 months were investigated. RESULTS: Most psychopathological symptoms as well as psychic side effects, weight gain, and female sex were associated with lower QOL, while cognitive symptoms correlated with better QOL. Female sex, cognitive symptoms, and parkinsonism negatively influenced occupational functioning, and negative symptoms determined a lesser likelihood of living independently. Age, education, depression/anxiety, negative symptoms, and psychic side effects were predictors of patients' needs for care. CONCLUSION: Our results highlight the complex nature of patient outcomes in schizophrenia. They reemphasize the need of targeting effectiveness, i.e. both symptomatic improvement as well as drug safety, in such patients.     

Effect of comorbid anxiety, depressive, and personality disorders on treatment outcome of somatoform disorders.

Comorbid mental disorders of DSM-IV axis I and axis II have repeatedly been found to be a negative predictor for the treatment of axis I disorders, although recent contrary findings exist. Little is known about the effect of comorbidity on the therapy outcome of somatoform disorders. We compared three types of comorbidity, (1) personality disorders (PDs), (2) major depression (MDD) and anxiety (ANX) disorders, and (3) PDS and MDD and ANX, with regard to their relevance for the treatment outcome of somatoform disorders. One hundred twenty-six inpatients were assessed at least 4 weeks before admission to treatment, upon admission, and again at discharge. Somatoform, hypochondriacal, and depressive symptomatology, dysfunctional cognitions about body and health, dysfunctional social relationships, and other clinical characteristics were measured. Diagnostic assessments were based on the DSM-IV. Our findings suggest that none of the three types of comorbidity influence the therapy outcome of somatoform disorders or have a modifying effect on the level of psychopathology.     

Views of practicing psychiatrists on the treatment of anxiety and somatoform disorders

Psychiatrists in Australia were asked to recommend treatments for several anxiety and somatoform disorders. In previous surveys they had agreed about the preferred treatments for schizophrenia and major affective disorder but not about treatments for "neurotic depression" or agoraphobia. In the present survey, no treatment was regarded as critical by a majority of psychiatrists for any of the five anxiety and somatoform disorders studied. The authors conclude that because neurotic disorders form an important part of the workload of psychiatrists, consensus procedures should be used to develop guidelines for treatment until the research literature can provide more adequate guidance.     

Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition

Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).     

DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics.

This study investigated the characteristics of each of the specific DSM-III-R (American Psychiatric Association, 1987) anxiety disorders in a clinic sample of 188 anxiety disordered children. Characteristics examined included sociodemographic variables (age-at-intake, gender, and race of the child, and family marital and socioeconomic status) and clinical variables (disorder age-at-onset and severity, and history of additional disorders). Findings are discussed in light of the contemporary literature on childhood anxiety disorders.     

Predominance of anger in depressive disorders compared with anxiety disorders and somatoform disorders

OBJECTIVE: The object of this study was to make a comparison regarding various dimensions of anger between depressive disorder and anxiety disorder or somatoform disorder. METHOD: The subjects included 73 patients with depressive disorders, 67 patients with anxiety disorders, 47 patients with somatoform disorders, and 215 healthy controls (diagnoses made according to DSM-IV criteria). Anger measures--the Anger Expression Scale, the hostility subscale of the Symptom Checklist-90-Revised (SCL-90-R), and the anger and aggression subscales of the Stress Response Inventory--were used to assess the anger levels. The severity of depression, anxiety, phobia, and somatization was assessed using the SCL-90-R. RESULTS: The depressive disorder group showed significantly higher levels of anger on the Stress Response Inventory than the anxiety disorder, somatoform disorder, and control groups (p < .05). The depressive disorder group scored significantly higher on the anger-out and anger-total subscales of the Anger Expression Scale than the somatoform disorder group (p < .05). On the SCL-90-R hostility subscale, the depressive disorder group also scored significantly higher than the anxiety disorder group (p < .05). Within the depressive disorder group, the severity of depression was significantly positively correlated with the anger-out score (r = 0.49, p < .001), whereas, in the somatoform and anxiety disorder groups, the severity of depression was significantly positively correlated with the anger-in score (somatoform disorder: r = 0.51, p < .001; anxiety disorder: r = 0.57, p < .001). CONCLUSION: These results suggest that depressive disorder patients are more likely to have anger than anxiety disorder or somatoform disorder patients and that depressive disorder may be more relevant to anger expression than somatoform disorder.     

Current somatoform disorders in Norway: prevalence,risk factors and comorbidity with anxiety,depression and musculoskeletal disorders

BACKGROUND: The future existence of somatoform disorders (SDs) has recently been debated. The objectives of this study were to investigate the prevalence of current SDs (defined as the presence of multisomatoform disorder [MSD] or somatoform disorders not otherwise specified [SDnos], without psychosocial impairment) and severe current SDs (MSD or SDnos with psychosocial impairment) in Norway. Differences in markers of severe current SDs, anxiety/depression and self-reported musculoskeletal disorders were explored. In addition, psychological distress and utilization of healthcare in subclasses (defined according to comorbidity with anxiety, depression and musculoskeletal disorders) of severe current SDs were examined. METHODS: We interviewed 1,247 respondents using the Composite International Diagnostic Interview (CIDI) in the Oslo-Lofoten general population survey in 2000-2001. Six-month prevalence rates (%) and 95% confidence intervals (CIs) for current SDs were investigated by gender and age. Risk factors of disorders, psychological distress, healthcare utilization and use of medication were explored using logistic regression analyses. RESULTS: The overall prevalence rate for severe current SDs was 10.2%. When psychosocial impairment was excluded as a criterion, the rate increased to 24.6%. Anxiety was strongly correlated with severe current SDs. Comorbidity of severe current SDs with anxiety/depression was 45%, and with musculoskeletal disorders, 43%. Analysis of healthcare utilization and use of medication showed that the presence of a comorbid psychiatric condition was more important than the presence of somatoform disorders alone. CONCLUSION: Somatoform symptoms alone (with no psychiatric comorbidity) should not be considered a psychiatric disorder.     

Commonalities and differences between the diagnostic groups: Current somatoform disorders, anxiety and/or depression, and musculoskeletal disorders

Objective

To identify the similarities and differences of risk factors and correlates of different groups of people fulfilling criteria for specified diagnostic groups according to current somatoform disorder (SDs) criteria, presence of anxiety and/or depression, and self-reported musculoskeletal disorders.

Methods

Participants of the Oslo-Lofoten general population cross-sectional study in 2000-2001 interviewed with the Composite International Diagnostic Interview (CIDI) somatoform section were examined by comparing similarities and differences in 8 groups identified by cross-tabulation of current SDs, anxiety and/or depression, and musculoskeletal disorders. The current SDs group was computed from the CIDI somatoform section raw data, anxiety and/or depression from the CIDI diagnostic algorithms and musculoskeletal disorders by questionnaire and self evaluation.

Results

In the 2001 sample of 1668 (875 women and 793 men) participants, the following eight disorder groups were identified: (i) current SDs, n=49 (75.5% women) (ii) musculoskeletal (functional somatic disorders), n=327; (53.5% women) (iii) anxiety and/or depression, n=148 (73.6% women); (iv) current SDs with anxiety and/or depression, n=38 (73.7% women); (v) current SDs with musculoskeletal, n=44 (72.7% women); (vi) current SDs with anxiety and/or depression and musculoskeletal, n=34 (76.5% women); (vii) musculoskeletal with anxiety and/or depression, n=101 (66.3% women); and (viii) no disorders, n=927 (43.3% women). Commonalities and differences between current SDs, anxiety and/or depression, and musculoskeletal disorders are apparent. Impairment of outcomes and risk factor load is high in current SDs with anxiety and/or depression and musculoskeletal.

Conclusion

The data in this article could help toward the needed DSM-V and ICD-11 diagnostic revision of the SDs category.     

The relation between anger management style, mood and somatic symptoms in anxiety disorders and somatoform disorders

The objective of this study was to examine the relationship between anger management style, depression, anxiety and somatic symptoms in anxiety disorder and somatoform disorder patients. The subjects comprised 71 patients with anxiety disorders and 47 with somatoform disorders. The level of anger expression or anger suppression was assessed by the Anger Expression Scale, the severity of anxiety and depression by the Symptom Checklist-90-Revised (SCL-90-R) anxiety and depression subscales, and the severity of somatic symptoms by the Somatization Rating Scale and the SCL-90-R somatization subscale. The results of path analyses showed that anger suppression had only an indirect effect on somatic symptoms through depression and anxiety in each of the disorders. In addition, only anxiety had a direct effect on somatic symptoms in anxiety disorder patients, whereas both anxiety and depression had direct effects on somatic symptoms in somatoform disorder patients. However, the anxiety disorder group showed a significant negative correlation between anger expression and anger suppression in the path from anger-out to anger-in to depression to anxiety to somatic symptoms, unlike the somatoform disorder group. The results suggest that anger suppression, but not anger expression, is associated with mood, i.e. depression and anxiety, and somatic symptoms characterize anxiety disorder and somatoform disorder patients. Anxiety is likely to be an important source of somatic symptoms in anxiety disorders, whereas both anxiety and depression are likely to be important sources of somatic symptoms in somatoform disorders. In addition, anger suppression preceded by inhibited anger expression is associated with anxiety and somatic symptoms in anxiety disorders.     

Depression, pain, and somatoform disorders

PURPOSE OF REVIEW: The frequent co-occurrence of depression and somatic symptoms poses a continuing challenge to clinicians, researchers and experts involved in drawing up classifications. In this review we present recently published literature on aspects of epidemiology, classification and treatment in this important overlap area. RECENT FINDINGS: From the multitude of papers published annually on the co-occurrence of different pain conditions and depression, temporomandibular dysfunction stands out this year by sheer quantity; it can be seen as a model case of the necessity for differentiated high-quality assessments on the biological as well as the psychosocial level. There is a general move to separate utility of diagnostic classifications from their validity, and this strengthens classificatory approaches that help to view the regular overlap of depression, pain and other somatic symptoms as the rule rather than the exception. The incorporation of cognitive variables like causal attributions should help to distinguish clinically relevant subtypes among overlap cases. The classificatory future of the category of 'somatoform disorders' is somewhat in doubt, but reforms seem to be more productive than abolishment. Psychopharmacology provides rather intense recent coverage of the overlap field, with newer dual serotonergic-noradrenergic reuptake inhibitors offering some promise. SUMMARY: Treating the overlap of depression, pain and other somatic symptoms as the rule rather than the exception is necessary for adequate aetiological research as well as for diagnosis and treatment, with one-dimensional classificatory and treatment approaches almost certainly being insufficient.     

Substance P: A neuropeptide involved in the psychopathology of anxiety disorders

Substance P (SP) is the most widely distributed neuropeptide in central nervous system (CNS) where it participates in numerous physiological and pathophysiological processes including stress and anxiety related behaviors. In line with this notion, brain areas that are thought to be involved in anxiety regulation contains SP and its specific NK1 receptors. SP concentration in different brain regions alters with the exposure of stressful stimulus and affected NK1 receptor binding is observed. SP is released in response to a stressor, which produces anxiogenic effects via activation of hypothalamic-pituitary-adrenal (HPA) axis, resulting in the liberation of cortisol. Moreover, SP is also involved in the activation of the sympathetic nervous system via stimulation of locus coeruleus (LC). This sympathetic surge initiates cortisol discharge by activation of HPA axis, representing the indirect anxiogenic effect of SP. Besides the aforementioned regions, SP also has an impact on other brain regions known to be involved in stress and anxiety mechanisms, including amygdala, lateral septum (LS), periaqueductal gray (PAG), ventromedial nucleus of the hypothalamus (VMH), and bed nucleus of stria terminalis (BNST). Thus, SP acts as an important neuromodulator in various brain regions in stress and anxiety response. Consistent with the above statement, SP makes a robust link in the psychopathology of anxiety disorders. As SP concentration is found elevated in stressed conditions, several studies have reported that the pharmacological antagonism or genetic depletion of NK-1 receptors results in the anxiolytic response making them a suitable therapeutic target for the treatment of stress and anxiety related disorders.     

文拉法辛与舍曲林治疗躯体形式障碍门诊病例对照研究

目的 评价文拉法辛与舍曲林对躯体化障碍和未分化躯体形式障碍的临床疗效和安全性. 方法文拉法辛组26例,剂量范围75～225mg/d;舍曲林组26例,剂量范围50～100mg/d,两组均以汉密尔顿焦虑量表(HAMA)、临床大体印象量表(CGI)、副反应量表(TESS)评定观察12周. 结果 47例完成研究(文拉法辛组22例,舍曲林组25例).研究终点,文拉法辛组和舍曲林组的HAMA-躯体性焦虑因子分均明显下降,文拉法辛组HAMA-躯体性焦虑因子分减分值平均为1.9±2.1,舍曲林组为3.2±2.5,差异无统计学意义(t=-1.961,P＞0.05).文拉法辛组临床总有效率为59.1%,舍曲林组为60.0%,差异无统计学意义(χ2=0.004,P＞0.05).文拉法辛组不良反应发生率为40.0%,舍曲林组为28.0%,差异无统计学意义(χ2=0.869, P＞0.05). 结论文拉法辛与舍曲林治疗躯体化障碍和未分化躯体形式障碍疗效相当,且均较为安全.     

Comparing primary and secondary generalized anxiety disorder in a long-term naturalistic study of anxiety disorders.

This study explores the potential differences in comorbidity and course between primary generalized anxiety disorder (GAD), which develops before other anxiety disorders, and secondary GAD. As part of the Harvard/Brown Anxiety Research Project (HARP), a naturalistic, long-term, longitudinal study of 711 subjects from a variety of clinic settings with DSM III-R defined anxiety disorders, 210 subjects with GAD were identified. Of these, 78 (37%) had primary GAD, and 84 (40%) had secondary GAD; of the remainder, 28 (13%) had no other anxiety disorder and 20 (10%) developed GAD within a month of another anxiety disorder and were excluded from the analysis. All subjects were comorbid for at least one other anxiety disorder. Primary GAD subjects were more likely to be in episode at intake (90% vs. 77%, P = .04) and less likely than secondary GAD subjects to have current or past agoraphobia without panic disorder (3% vs. 11%, P = .04), social phobia (19% v. 52%, P = .001), simple phobia (14% v. 30%, P = .02), or post traumatic stress disorder (5% vs. 20%, P = .01). Subjects with primary GAD were also less likely to have current or past alcohol use disorders (17% vs. 37%, P = .004) or major depressive disorder (60% vs. 76%, P = .03). There were no significant differences in either treatment approaches or remission rates for primary compared to secondary GAD. Whether GAD first occurs before or after another anxiety disorder, it is similar in terms of prevalence, treatment, and course. The only significant differences between primary and secondary GAD lie in the rates of comorbidity of both other anxiety disorders and non-anxiety disorders, including major depression and substance abuse. These results support the concept of GAD as a valid, separate and distinct entity, whether it occurs primarily or secondarily.     

Evaluation and treatment of anxiety disorders in the general pediatric population: a clinician's guide

This article provides an overview of research on the recognition, assessment, and treatment of children and adolescents who have anxiety disorders and emphasizes practical issues facing clinicians. Discussion includes an overview of the prevalence and consequences of anxiety and reviews assessment tools, maintenance factors, and evidence-based approaches to treatment. Topics also include developmental considerations, approaches to informant discrepancy, predictors of treatment outcome, and recent innovative approaches to treatment that may potentially improve dissemination to the general pediatric population.     

Differentiating DSM-IV anxiety and depressive disorders in the general population: comorbidity and treatment consequences.

OBJECTIVE: To attempt, for the first time, to apply a positive and differential diagnosis process in the general population during interviews using DSM-IV classification to ascertain the profile and occurrence of concomitant mental disorders. METHOD: A representative sample of 1832 individuals aged 15 years or older living in the metropolitan area of Toronto were interviewed by means of telephone interviews. The participation rate was 72.8%. RESULTS: Overall, 13.2% (n = 242) of the sample had either a mood disorder (n = 127; 6.9%) or an anxiety disorder (n = 170; 9.3%) at the time of their interview. The prevalence was higher among women (16.5%) than among men (9.7%), with an odds ratio of 1.8. The comorbidity of mood and anxiety disorders was found in 3% (n = 55) of the sample. Less than one-third of respondents with a mood and/or anxiety disorder were being treated by a physician for a mental disorder. However, these individuals were greater consumers of health care services. Most of them consulted a physician an average of 5 times in the past year. Individuals on medication diagnosed with a mood and an anxiety disorder consulted a physician an average of 12 times in the past year. Only 13% of them were treated with antidepressants and under 9% with anxiolytics. CONCLUSIONS: More than 70% of subjects with a mood disorder also complained of insomnia. With the differential process, 12% of the subjects manifesting a full-fledged anxiety disorder were diagnosed with only a mood disorder because the anxiety occurred only in the course of the mood disorder. About two-thirds of the subjects diagnosed in this study were undiagnosed and untreated by their physician.     

Alexithymia and anxiety sensitivity in Turkish depressive,anxiety and somatoform disorder outpatients

Objective. To assess the relations between anxiety sensitivity, and dimensions of alexithymia in somatoform, anxiety and depressive disorder patients. Methods. The sample consisted of 124 patients with the diagnosis of depressive, anxiety, or somatoform spectrum disorders (DSM-IV). Toronto Alexithymia Scale (TAS-20), 16-item Anxiety Sensitivity Index (ASI), Hamilton Depression (HDRS), and Anxiety (HAS) scales were used. Results. The total sample (n=124) was divided into three diagnostic categories. There was one Depression Group (n=69). Due to small sample sizes, diagnoses in anxiety and somatoform spectrum disorders were combined in two relatively larger Anxiety (n=42) and Somatoform Groups (n=13) for statistical purposes. No statistically significant difference was found in the TAS-20 total or subscale scores between the three diagnostic groups. In all three diagnostic groups, there was a strong and significant positive correlation between ASI and TAS-20 total scores. In all three groups, there was a significant positive correlation between TAS-20 Factor 1 and ASI. In the Depression and Somatoform Groups, ASI scores were found to be significantly positively correlated with scores on TAS-20 Factor 2. Conclusion. This study reveals that alexithymia does not differentiate depressive, anxiety, or somatoform disorders, yet suggests a functional relation with anxiety sensitivity on a subscale basis.