Anxiety sensitivity as a predictor of the development of panic symptoms, panic attacks, and panic disorder: a prospective study

The purpose of the study was to examine how anxiety sensitivity (AS) acts as a dispositional factor in the development of panic symptoms, panic attacks, and panic disorder. Between 1986 and 1988, data were collected from 505 undergraduates at an urban university. At Time 1, measures used were the ASI to assess AS, the trait scale of the State-Trait Anxiety Inventory (STAI-T) to measure trait anxiety, and self-report questionnaires to measure personal and family history of panic and anxiety symptoms. During the Spring of 1999, 178 of these subjects were re-contacted, and information was gathered on subjects' subsequent development of panic symptoms, panic attacks, panic disorder, and trait anxiety (STAI-T). The ASI was the strongest predictor of the development of panic symptoms and panic attacks. After controlling for trait anxiety, the ASI was not predictive of the development of panic disorder.

Delimiting the boundaries of generalized anxiety disorder: differentiating high worriers with and without GAD

Investigations of the boundary between generalized anxiety disorder (GAD) and normal worry have relied primarily on comparisons of GAD-diagnosed individuals with non-anxious controls. One limitation of this approach has been its inability to determine whether characteristics associated with GAD are unique to the disorder or are typical of severe worry more generally. The present studies made this differentiation using a virtually unstudied population: severe worriers failing to meet the diagnostic criteria for GAD. These studies assessed the prevalence of non-GAD high worriers in several college samples and identified features distinguishing them from individuals with GAD. Non-GAD high worriers far outnumbered GAD high worriers and reported many of the same symptoms as their GAD-diagnosed counterparts. However, results revealed several characteristics that consistently distinguished the two groups. Implications for the conceptualization, assessment, and investigation of worry and GAD are discussed.

The incidence and influence of early traumatic life events in patients with panic disorder: a comparison with other psychiatric outpatients

Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and influence of early traumatic life events in outpatients with panic disorder (n = 101), compared to outpatients with other anxiety disorders (n = 58), major depression (n = 19), or chronic schizophrenia (n = 22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no significant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar findings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to influence the severity of the disorder but are unlikely to be a unique risk factor for any one type of disorder.

Anxiety associated with comorbid depression

Historically, the clinical term for mixed depression and anxiety was anxious depression. With the publication of DSM-III-R, 2 categories were established for the purpose of classifying disorders that involve both anxiety and depression, and that classification system is currently used in DSM-IV as well. These more specific diagnostic criteria have given us a much better understanding of the anxiety spectrum, but have created a need for a better understanding of the place of benzodiazepines in clearly defined indications on the anxiety spectrum. In spite of warnings about side effects, misuse, and dependence, benzodiazepines are frequently prescribed as adjunctive therapy to antidepressants for comorbid anxiety and depression. This article presents data on the prevalence, course, and outcome of comorbid anxiety and depression. It also compares efficacy data from trials of benzodiazepines used alone and in combination with antidepressants for the treatment of anxiety disorders comorbid with depression.

The role of extended-release benzodiazepines in the treatment of anxiety: a risk-benefit evaluation with a focus on extended-release alprazolam

Immediate-release (IR) benzodiazepines have a short duration of therapeutic effect and are generally less effective for anxiety than selective serotonin reuptake inhibitors in reducing concomitant depressive symptomatology. Common criticisms of benzodiazepines also include the patient's tendency to develop a tolerance to the anxiolytic effect and a dependence on the drug itself. The newer extended-release (XR) benzodiazepine formulation was designed to increase efficacy, duration of therapeutic effect, tolerance, compliance, and ease of discontinuation. The XR benzodiazepine alprazolam has shown efficacy in panic disorder and generalized anxiety disorder comparable to the older benzodiazepine formulations. Pharmacokinetic data show that the XR formulation has a longer therapeutic effect compared with IR formulations, which reduces the potential for breakthrough anxiety symptoms. Data also indicate that the XR formulation has less abuse liability than the IR formulation. This article reviews the efficacy, safety, and discontinuation data from clinical trials of IR and XR benzodiazepines in the treatment of anxiety disorders and provides guidelines to minimize the risk of withdrawal syndrome during benzodiazepine discontinuation.

Clinical experience with substance P receptor (NK1) antagonists in depression

Substance P (SP) belongs to the neurokinin (NK) family of neuropeptides and exerts its biological effects via interaction with the NK1 receptor. The SP-NK1 receptor system is one of the best-characterized neurotransmitter pathways in both the central and peripheral nervous systems. It has been postulated that this pathway may have important roles in a variety of centrally regulated pathophysiologic conditions, including depression. In animal models, central injection of SP was associated with a series of anxiety-like behaviors, and this response could be abolished by pretreatment with SP (NK1) receptor antagonists (SPAs). On the basis of these and other encouraging preclinical results, several clinical trials have examined the potential of SPAs in the treatment of depression. In phase 2 trials, therapy with the SPAs aprepitant (MK-0869) and compound A resulted in improvements in depression and anxiety symptoms that were quantitatively comparable with those seen with selective serotonin reuptake inhibitors (SSRIs) and significantly greater than those seen with placebo. These positive results have established a proof of concept that the inhibition of the SP-NK1 receptor pathway may be a potentially useful novel treatment option for management of patients with depression. The apparent lack of benefit with SPAs versus placebo in subsequent dose-finding studies with aprepitant and compound A is not surprising, considering the fact that the outcomes with an active control (SSRI) in these trials were also similar to those observed with placebo. Future trials with SPAs will focus on the identification of appropriate patients and drug regimens and will also define the role of these agents in the treatment of depression.

A follow-up study of DSM-III-R generalized anxiety disorder with syndromal and subsyndromal major depression

OBJECTIVE

The authors examined the long-term outcome of generalized anxiety disorder with depressive symptoms utilizing both categorical and dimensional analyses.

METHOD

Thirty-nine out-patients with a DSM-III-R diagnosis of generalized anxiety disorder (GAD) with depressive symptoms, both with (n=23) and without (n=16) syndromal major depression (MD) participated in an 11-week clinical trial. Approximately 18 months after initial screening, these individuals were once again evaluated using a structured diagnostic interview and a battery of rating scales.

RESULTS

Three distinct groups were discernible at follow-up. Twenty-three (60%) of the patients remained syndromal for GAD; 10 patients (43%) were in partial remission from GAD; six (15%) were asymptomatic. Of the 23 patients who were syndromal for MD at baseline, 13 (56%) remained syndromal for MD at follow-up. All of the patients who were syndromal for MD at follow-up remained syndromal for GAD as well.

CONCLUSIONS

Outcomes in this study were quite divergent, though they support the concept of GAD as a chronic illness in most patients, with or without MD. The presence or absence of MD versus subsyndromal depression at baseline appeared to have relatively little impact upon the outcome. Patients with subsyndromal anxiety and depressive symptoms may be at special risk for syndromal disorders over time.

Psychiatric adjustment in chronic fatigue syndrome of childhood and in juvenile idiopathic arthritis

BACKGROUND

High rates of psychopathology and of personality problems have been reported in children and adolescents with chronic fatigue syndrome (CFS). It is not clear whether this is consequent on the experience of chronic physical ill health. We compare psychiatric adjustment in children with CFS and in children suffering from another chronic physical disorder (juvenile idiopathic arthritis or JIA).

METHOD

Our sample consisted of 28 children with CFS and 30 with JIA attending tertiary paediatric centres (age range, 11 to 18 years, mean 15, S.D. 2.3). In order to assess psychiatric status and functioning, we used the K-SADS psychiatric interviews, CGAS and Harter Self-Esteem Questionnaire with child subjects; behavioural questionnaires (CBCL) and child personality assessment interviews (PAS) with parent informants.

RESULTS

Psychiatric disorders in the year prior to interview had been present significantly more commonly in the CFS group (72% v. 34% in JIA) and were more impairing to them (CGAS scores of 45 v. 77). Most common diagnoses in both groups were depressive and anxiety disorders. Personality problems were also significantly more frequent in CFS subjects (48% disorder and 26% difficulty v. 11% and 11% in JIA). There were few differences between the two groups in self-esteem.

CONCLUSIONS

Psychopathology and personality problems are common in children and adolescents with severe forms of CFS and cannot be explained strictly through the experience of chronic physical illness.

Prevalence of generalized anxiety at eight weeks postpartum

OBJECTIVE

This study investigated the prevalence and nature of generalized anxiety symptoms in women who were eight weeks postpartum.

METHOD

A community-based sample of 68 postpartum women completed an interview assessing generalized anxiety disorder and depression and a self-report measure of worry associated with concerns relevant to postpartum women.

RESULTS

Three women (4.4%) met DSM-IV criteria for generalized anxiety disorder, and an additional 19 women (27.9%) endorsed subsyndromal difficulties with generalized anxiety. Approximately one third of these women endorsed symptoms of depression. In contrast, only two woman met criteria for major depressive disorder.

CONCLUSION

Postpartum generalized anxiety has a higher prevalence than postpartum depression.

Outpatient psychotherapy for mothers--a new treatment

The perinatal period and new motherhood entail a multitude of physiologic and psychosocial changes and are also associated with an increased risk of mental illness. Nevertheless, many mothers with an acute postpartum mental illness reject hospitalization to avoid being separated from their children even when treatment is urgently needed. A new psychotherapeutic outpatient treatment program adapted to the special needs of mothers and offering a substitute to inpatient treatment is presented. Empirical results indicate that this treatment is an effective alternative to hospitalization.

Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a difficult condition to treat, and existing studies show considerable variability in outcome. Investigations of factors that influence outcome have the potential to inform alternate treatment approaches to maximize benefits gained from interventions for the disorder. Because PTSD is commonly associated with comorbidity, it is important to investigate the influence of comorbidity on symptom change after treatment. This article examines pretreatment and 9-month follow-up data for 134 Australian Vietnam veterans who attended a treatment program for combat-related PTSD. A series of analyses were conducted to investigate the influence of the comorbid factors of anxiety, depression, anger, and alcohol use on PTSD symptom change after treatment. Analyses identified anger, alcohol, and depression as significant predictors of symptom change over time, independent of the effect of initial PTSD severity. Further analyses indicated that anger at intake was the most potent predictor of symptom change. Further investigations of anger as an influence on symptom change after treatment of combat-related PTSD is recommended.

Structure of the Anxiety Sensitivity Index psychometrics and factor structure in a community sample

Converging evidence suggests that anxiety sensitivity (i.e., threatening beliefs regarding autonomic arousal) is a risk factor for anxiety pathology. Specification of premorbid risk factors requires exclusion of individuals with a history of spontaneous panic to ensure that anxiety sensitivity is not merely a consequence or concomitant of the experience of panic. However, the psychometrics and dimensional nature of anxiety sensitivity in such a sample is undetermined. The present study evaluated the factor structure of the Anxiety Sensitivity Index (ASI), a measure of anxiety sensitivity, in a community sample (N = 233) with no history of psychiatric illness or spontaneous panic. Exploratory factor analyses (EFA) suggested a two- or three-factor solution (1, Fear of Mental Catastrophe; II, Fear of Cardiopulmonary Sensations; III, Fear of Vasovagal Sensations). Confirmatory factor analyses (CFA) comparing alternative models indicated that a hierarchical two-factor solution (I, Fear of Mental Catastrophe; II, Fear of Cardiopulmonary Sensations) best accounted for the data. This model generalized well to a nonclinical college sample (N = 809).

Measurement issues in postpartum depression part 1: anxiety as a feature of postpartum depression

We investigated the contribution of anxiety symptoms to scores on the Edinburgh Postnatal Depression Scale (EPDS) between 36 weeks gestation and 16 weeks postpartum in 150 women. The 3-item anxiety subscale of the EPDS accounted for 47% of the total score in late pregnancy, and 38% of the total score in the postpartum period. Two categories of anxiety were common in the perinatal period: subsyndromal, situational anxiety (in particular during the last weeks of pregnancy); and clinically significant comorbid anxiety, which was experienced by nearly 50% of clinically depressed pregnant and postpartum women. The close relationship between anxiety and depression raises questions about whether symptoms of anxiety might be more common in the perinatal period than in other depressions. A strong role for anxiety symptoms in postpartum depression, and implications for its etiology and treatment, are discussed.

Depression, anxiety, and relevant cognitions in persons with mental retardation

We assessed depression, anxiety, and relevant cognitions in persons with mental retardation by administering modified versions of the Reynolds Child Depression Scale, the Beck Anxiety Inventory, the Automatic Thoughts Questionnaire, and the Cognitions Checklist to 46 persons with borderline to moderate mental retardation. Consistent with research with other groups, self-reports of depression and anxiety were highly correlated (r = .74) in these individuals, and cognitions were strong predictors of negative affect. Subscales measuring cognitions related to depression and anxiety were also highly related, limiting the "cognitive-specificity" hypothesis. Hierarchical multiple regression analyses offered mixed support for cognitive-specificity. We discuss the implications of these findings for the cognitive and affective assessment of persons with intellectual limitations.

The relation between eating disorders and components of perfectionism

OBJECTIVE

The authors' goal was to explore the relation between perfectionism and psychopathology, including eating disorders.

METHOD

Using logistic regression, the authors calculated odds ratios for the associations between perfectionism subscale scores and psychiatric disorders in 1,010 female twins who completed the Multidimensional Perfectionism Scale and participated in diagnostic interviews.

RESULTS

Elevated concern over mistakes was associated with anorexia and bulimia nervosa but not with other psychiatric disorders. Doubts about actions was associated with eating and anxiety disorders. Multivariable models confirmed that higher scores on the subscales for concern over mistakes and doubts about actions were most strongly associated with eating disorders.

CONCLUSIONS

The aspect of perfectionism captured by scores on a subscale measuring concern over mistakes may be particularly associated with eating disorders and not generically predictive of psychopathology.

The Mathematics Anxiety Rating Scale, a brief version: psychometric data

As a measure of mathematics anxiety, the Mathematics Anxiety Rating Scale (MARS) has been a major scale used for research and clinical studies since 1972. Despite the usefulness of the original scale, researchers have sought a shorter version of the scale partly to reduce the administration time of the original 98-item scale. This study created a shorter version of the MARS and provides reliability and validity information for the new version. The Cronbach alpha of .96 indicated high internal consistency, while the test-retest reliability for the MARS 30-item was .90 (p<.001). The validity data confirm that the MARS 30-item test is comparable to the original MARS 98-item scale.

Influence of test anxiety on measurement of intelligence

In this study a measurement model for a test anxiety questionnaire was investigated in a sample of 207 Dutch students in the first grade of junior secondary vocational education. The results of a confirmatory factor analysis showed that a model for test anxiety with three factors for worry, emotionality, and lack of self-confidence is associated with a significantly better fit than a model comprised of only the first two factors. The relations of the three test anxiety factors to scores on intelligence tests for measuring verbal ability, reasoning, and spatial ability were examined. The results indicated that test anxiety appears to be transitory: the negative relation between test anxiety and test performance promptly fades away. Finally, we examined whether a distinction can be made between highly test anxious students with low performance due to worrisome thoughts (interference hypothesis) or low ability (deficit hypothesis). Results do not support the deficit hypothesis because the scores of all highly test anxious students increased in a less stressful situation.

Lifetime history of depression and carotid atherosclerosis in middle-aged women

BACKGROUND

Depression is associated with clinical coronary events, but the association between history of major depression and subclinical cardiovascular disease in women is not yet known. We determined the association between lifetime history of major depression and subclinical carotid atherosclerosis in middle-aged women.

METHODS

Participants included 336 healthy middle-aged women (one third African American) from 1 of the 7 sites of the Study of Women's Health Around the Nation, a prospective study of the perimenopausal transition. Psychiatric diagnoses were assessed using the Structured Clinical Interview for the DSM-IV Axis I Disorders-Non-Patient Edition. Two measures of subclinical carotid atherosclerosis were assessed using B-mode ultrasonography: plaque and intima-media thickness.

RESULTS

Lifetime history of major depression was associated with plaque, and substance abuse was related to intima-media thickness. Lifetime history of an anxiety disorder was not associated with either measure. After controlling for standard cardiovascular risk factors, only the association between major depression and plaque was maintained. The risk of plaque was 2-fold in women with a lifetime history of recurrent major depressive episodes relative to women with no history of depression (odds ratio = 2.30; 95% confidence interval, 1.10-4.82). Lifetime history of a single major depressive episode was not associated with plaque.

CONCLUSIONS

Recurrent major depressive episodes may be a risk factor for subclinical atherosclerosis. Prevention of recurrent episodes may also prevent further progression of atherosclerosis.

Treatment of generalized anxiety disorder in older adults

Older adults with generalized anxiety disorder (GAD; N = 75; M age = 67.1 years) were randomly assigned to cognitive-behavioral therapy (CBT), a discussion group (DG) organized around worry-provoking topics, or a waiting period. Participants in both active conditions improved relative to the waiting list. Although CBT participants improved on more measures than DG participants, the authors found only I significant difference immediately after treatment and no differences at 6-month follow-up. Effect sizes were smaller than in younger samples, but CBT showed large effects and DG showed medium-sized effects Overall, results indicate that brief treatment of late-life GAD is beneficial, but they provide only limited support for the superiority of CBT to a credible comparison intervention.

Cross validation of the Social Anxiety Scale for Adolescents in a high school sample

Social anxiety disorder in adolescents is increasingly recognized as a common condition that may precede onset of other mental health problems. However, few measures are currently available to screen for adolescent social anxiety, and little is known about their psychometric characteristics in school-based samples. To this end, the present study was undertaken as a psychometric cross validation of the Social Anxiety Scale for Adolescents (SAS-A). Exploratory and Confirmatory Factor Analyses (CFA) supported the original 3-factor structure of the SAS-A but retained fewer items than in the original scale. The revised scales demonstrated good internal consistency as well as criterion and concurrent validity. Despite including fewer items, psychometric characteristics of the revised scales were equivalent to or stronger than those reported in previous studies of the measure. As such, the present study provides initial support for the utility of the revised SAS-A as a measure of social anxiety in adolescent school samples.

[Hippotherapy as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy]

Influence and therapeutic efficacy of horseback riding (hippotherapy) as a method for complex rehabilitation of patients with late residual stage of infantile cerebral palsy were studied. Significant increase of a range of active and passive mosements in large joints of lower extremities, higher, indices of hand dynamometry on the left, of vital lung capacity as well as a relief of relief of reactive and personality anxiety and depression, higher motivation for rehabilitation treatment, etc., were registered. Neurophysiological study revealed significant changes of afferentation at stem and thalamus cortical levels and of spectral components of cortical rhythmics. The data obtained allow to consider hippotherapy as an effective method of complex rehabilitation of patients with late residual stage of infantile cerebral palsy. A combination of sensory stimulation and motor rehabilitation components may be a key mechanism of positive effect.

Parsing the comorbidity between bipolar disorder and anxiety disorders: a familial risk analysis

BACKGROUND

A growing literature suggests that anxiety disorders (ANX) co-occur with bipolar disorder (BPD), but the nature of this overlap is unknown. Thus, we investigated the familial association between BPD and ANX among the first-degree relatives of children with BPD with and without comorbid ANX.

METHODS

We compared relatives of four proband groups defined by the presence or absence of BPD and ANX in the proband: (1) BPD + ANX (n = 23 probands, 74 relatives), (2) BPD without ANX (n = 11 probands, 38 relatives), (3) ANX without BPD (n = 48 probands, 167 relatives), and (4) controls without BPD or ANX (n = 118 probands, 385 relatives). All subjects were evaluated with structured diagnostic interviews. Diagnoses of relatives were made blind to the diagnoses of probands.

RESULTS

The results show high rates of both BPD and ANX in relatives of children with BPD + ANX. Moreover, BPD and ANX cosegregated among the relatives of children with BPD + ANX. Although relatives of both ANX proband groups (with and without BPD) had high rates of ANX, and relatives of both BPD proband groups (with and without ANX) had high rates of BPD, the combined condition BPD + ANX was the predominant form of BPD among relatives of probands with BPD + ANX.

CONCLUSIONS

These family-genetic findings suggest that the comorbid condition BPD+ANX may be a distinct clinical entity. More work is needed to evaluate whether the presence of comorbid ANX may be a marker of very early onset BPD.

[Anxiety disorders in children and adolescents. Psychotherapeutic interventions]

Anxiety disorders are among the most prevalent mental health problems in childhood and adolescence. In this article authors share their experience working with anxiety disorders in inpatient department. Fifty four case histories were analyzed. Authors present, which part of psychiatric disorders takes the anxiety disorders and how they distribute according to ICD-10 diagnostic categories. Anxiety disorders' risk factors, main clinical symptoms and psychotherapeutic methods are discussed.