Classification and epidemiology of social phobia

The individualization of social phobia among other phobic disorders is very recent, although previous clinical descriptions can be found in the literature. The new classifications (DSM-III, DSM-IV and ICD-10) have provided operationalized criteria for this disorder, which have allowed researchers to conduct epidemiological studies. However, some diagnostic issues are not completely solved, namely, those with other boundary disorders. Cross-cultural prevalence and risk factors of social phobia are reviewed. Results of a French community study have found a lifetime prevalence rate of 2.1% in males and 5.4% in females. Comorbidity of social phobia with other anxiety disorders and major depression was high. Suicidal tendencies, family history and health services utilization were analyzed according to the lifetime comorbidity pattern of social phobia and depression.

[Comorbidity of anxiety and depression: epidemiologic perspectives]

The validity of diagnosis in psychiatry remains controversial. The new international classifications of mental disorders and the use of diagnostic criteria have allowed a marked improvement in the diagnostic process but the validity of the clinical entities is far from being strongly established. Epidemiological approach is a way among others which can offer new insights to that problem. During the recent decade, several community surveys have been conducted using quite similar methods and designs, referring to the same classification systems and using structured diagnostic interviews. A systematic collection of clinical signs and symptoms has found that, in the community, as well as in clinical setting, anxiety and affective disorders are frequently comorbid in the same subject. The concept of comorbidity has different meanings in a clinical or epidemiological sense. Results from several community surveys underline the importance of this phenomenon in various countries whatever the specific prevalence of anxiety and affective disorders could be. The most recent large study, the National Comorbidity Survey, has been undergone partly to address many questions concerning the comorbidity patterns between affective, anxiety and substance use disorders, their risk factors and influence on morbidity and health seeking process. Comorbidity is high between major depression and all different anxiety disorders, and to a much larger extent with generalized anxiety disorder. The distinction between pur and comorbid disorders on one hand, primary and secondary disorders according to the sequence of age of onset in comorbid disorders on the other hand has been also underlined recently. Comorbidity between anxiety and affective disorders strongly argue for investigating the genetics as well as the psychosocial factors involved in this phenomenon. Within this methodological perspective, these studies may offer new answers to major problems encountered in clinical and psychopathological research and, by the way, improve current therapeutic strategies.

[Evaluation of the psychometric properties of the French version of the Tridimensional Personality Questionnaire (TPQ)]

The Tridimensional Personality Questionnaire (TPQ) is a 100-item true-false self-questionnaire proposed by R. Cloninger and based on a three independent dimensions model of personality. These three dimensions, each with four sub-scales, are Novelty Seeking (NS), Harm Avoidance (HA) and Reward Dependence (RD). Recently, several groups have used the TPQ to study clinical samples, and other have reported normative data in the general population but, up to date, no result has been published on the French TPQ version. The aims of this study were therefore to assess the psychometric properties of this questionnaire and also to research an eventual relationship between dimensions of personality and anxiety and depression mood, measured by mood and anxiety scales in out-patients. A population of 165 subjects was included in this study and assessed with the TPQ. In this sample, 119 patients completed also the Hospital Anxiety and Depression (HAD) scale. The factor analysis with a Varimax rotation suggests three possible solutions with 3, 4 or 5 factors for the TPQ. These all three analysis indicate that the dimensions NS and HA load consistently unto the first two factors, and seem therefore two robust and independent dimensions. Contrastly, the RD dimension seems definitely heterogeneous, even if the RD2 sub-scale (persistence) is treated separately from the other as proposed by Cloninger. Analysis of correlations between TPQ dimensions and HAD sub-score show that only the HA dimension is related to anxiety sub-score (r = 0.34), depression subscore (r = 0.52) and total HAD score (r = 0.47).(ABSTRACT TRUNCATED AT 250 WORDS)

[What should be the duration of a treatment with antidepressive agents?]

The main clinical factors involved in deciding the length of an antidepressant treatment are briefly reviewed in the framework of current classifications of affective disorders. History of previous episodes and the polarity of depressive illness have a major role in such a process. Current definitions of remission, relapse and recurrence are given. In the context of a single depressive episode, treatment must be continued for at least 4 months after the start of clinical improvement in order to prevent a relapse. In case of recurrent depressive episode, the indications of a long-term treatment must be discussed. Some issues unsettled as to the adequate dosage of such a treatment, as well as to the length of treatment in other types of depressive states.

[Panic disorder in patients consulting a cardiologist]

The relationship of anxiety with cardiovascular function and symptoms has been of long historic interest, culminating in the recent emphasis given to the modulation of cardiovascular response in panic patients. Cognitive approaches postulate an interaction of physiological and psychological factors in the maintenance of panic disorder. Pharmacological approaches postulate a dysfunction of central alpha-adrenoceptors in panic and also in some cardio-vascular diseases. Ambulatory heart rate recordings confirm the presence of major cardiovascular changes during panic attacks in several studies. We have carried out a study in an unselected population being explored in an outpatient cardiology unit with 24 hours ambulatory heart rate recordings. Hundred and ninety-seven consecutive referrals for an ambulatory heart rate examination were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale (HAD-A). Fifty patients (26 males and 24 females), with an higher score than 8, were interviewed with the SADS-La. Sixty-two per cent of them fit DSM III-R criteria for panic disorder. Among these 50 interviewed patients, 19 (11 males and 8 females) were referred for organic heart disease and 31 (15 males and 16 females) were investigated only for functional symptomatology. The proportion of panickers was similar in patients referred either for functional or organic heart disease (63.2 vs 61.3; chi 2 = .02; p = .89). Nineteen patients (11 males and 8 females) had pathological ECG ambulatory recording results and 31 patients (15 males and 16 females) were classified as Holter (-). The proportion of panickers was found similar in these two subgroups of patients (63.2 vs 61.3; chi 2 = .02; p = .89).(ABSTRACT TRUNCATED AT 250 WORDS)

[Panic disorder and alcoholism: effects of comorbidity]

Both epidemiological and clinical studies have demonstrated a high prevalence of panic disorder among alcoholic patients. In contrast, little attention has been given to studying alcohol abuse and/or dependence in patients suffering from panic disorder. One hundred and fifty-five consecutive referrals for treatment for panic disorder were interviewed using a modified version of the Schedule for Affective Disorders and Schizophrenia--Lifetime Version, modified for the study of anxiety disorders. Thirty-two patients (20.7%) had a lifetime history of alcohol abuse and/or dependence. Although the lifetime comorbidity rate of either agoraphobia and/or social phobia seems without any influence on the risk of alcohol-related disorder, alcoholic patients suffering from panic disorder appear to be more likely to have a history of depression and other addictive disorders. The majority of patients with primary alcoholism were male, and those who became alcoholics after they developed panic disorder were more likely to be female. The comparison between patients with primary and secondary alcoholism did not indicate any difference in the comorbidity rate with other psychiatric disorders nor the severity of panic disorder.

[Validation of a French version of the General Health Questionnaire (GHQ-28) in a diabetic population]

The contrast between the great importance of psychiatric disorders and the fact that they are often not identified as thus in medical and surgical units has been emphasized during the last ten years. The prevalence of depression disorders in an hospitalised population of medical patients is generally estimated between 15% and 30%. It is admitted that one third to two third of theses cases are not diagnosed by non psychiatrist physicians. It is the reason why self questionnaires have been finalized in order to detect psychiatric troubles in medical populations. The General Health Questionnaire (GHQ), constructed by Goldberg, is surely the most internationality used, but no validation study has yet been undertaken in France. This study means the validation of a french version of GHQ-28 items, set on 46 diabetics (type 1 and type 2) selected in a week hospital. This validation is based on the comparison of the two principal scoring methods: "GHQ" (0,0,1,1); "CGHQ" (0,1,1,1 for negative items) and the determination of the best cut-off score in this specific population. The referring DSM III-R diagnoses were assessed by the Composite International Diagnostic Interview (CIDI; Robins et al., 1988), which is a highly structured psychiatric interview developed by the World Health Organisation. Sixteen patients out of the 46 diabetics showed criterions of depressive and/or anxious disorders, 6 of them presenting both. The analysis of the answers to the questionnaires was based upon the technic of the Relative Operating Characteristic (ROC) curves which takes all the sensitivity-specificity couples bound to each of the possible threshold-score into account.(ABSTRACT TRUNCATED AT 250 WORDS)

Self-reported psychotropic drug use and associated factors in a French community sample

Drug use was examined in a French general population adult sample from a household survey conducted in 1987-8 in a newly built town near Paris. Psychotropic drug use was measured by the percentage of subjects reporting their use during the past week. It was prominently represented by benzodiazepines (90% of psychotropic users), differed strongly between genders (4.6% in men, 10.2% in women) and age groups (higher after 40 years). A lifetime history of major depressive episode (MDE) or of anxiety disorders was associated with a higher proportion of psychotropic drug use. Psychotropic drug use also went with a current well-being questionnaire score. Using a logistic analysis, the following set of variables held for women: well-being score, history of both MDE and anxiety disorder, age, and marital status. Making allowance for the cross-sectional nature of this retrospective survey, these finding confirmed the relatively high level of benzodiazepine drug use in an urban French community sample and emphasized its association with mental health status.

[What is a predictive factor?]

Everyday clinical and therapeutic practice relies on signs, variables or factors allowing to adjust strategies influencing the short and if possible long term evolution of mental disorders. The possible prediction of the future course of illness by such variables is debated. Actually in the present literature a confusion appears between several terms. Stricto sensu the predictive value of a test or of a diagnostic procedure supposes the assessment of a discriminative sensibility and specificity relative to a well established fact: the illness. The importance of some clinical and biological factors may be gauged by such means. More frequently risk factors are proposed. A risk factor represents a particular characteristic or condition associated to an increased probability of a specific disorder being present or developing ulteriorly. However, such factors are not necessarily causal factors. The search of prognostic factors also constitutes an important step in our understanding of pathological processes as well as of evolution.

The reliability of the SADS-LA in a family study setting

The joint-rater and test-retest reliability study of two translated versions of the SADS-LA (Schedule for Affective Disorders and Schizophrenia--Lifetime version--modified for the study of anxiety disorders), one in French and the other in German, have been tested in family study settings, in a sample of patients and first-degree relatives. The test-retest reliability study demonstrated that identification of major affective disorders and schizophrenia was performed with sufficient reliability; however, diagnoses of subtypes of major disorders (e.g. bipolar II disorder) and identification of minor disorders was less reliable. The implications of these findings in phenotype identification during family studies in psychiatry are discussed.

Subtyping familial schizophrenia: reliability, concordance, and stability

This report examines the reliability, concordance, and long-term stability of the subtypes of schizophrenia defined by four major diagnostic systems (DSM-III, DSM-III-R, ICD-10, and Tsuang-Winokur criteria) and rated both for the first hospitalization and for a best estimate diagnosis reflecting lifetime evolution of symptomatology. Schizophrenics studied belonged to two samples of multiply affected families, namely a sample selected in France and a sample of non-metropolitan French identified in the island of La Réunion. ICD-10 and DSM-III-R show opposite stringency regarding subtyping of schizophrenia, with DSM-III-R having a narrow and ICD-10 a broader definition of specific subtypes. Long-term stability of each subtype was fairly good, stability being the highest for hebephrenics and only intermediate for paranoid and undifferentiated subtypes. Comparison of two different cultural and geographical regions reveals an overall similarity of subtype frequencies in familial schizophrenia. The implications of the results for the choice of diagnostic procedures in family studies of schizophrenia are discussed.

Therapeutic target for cognition enhancers: diagnosis and clinical phenomenology

Uncertainty concerning therapeutic targets has probably retarded the development of cognition-enhancing drugs. While enhancement of normal cognitive function may be a legitimate goal it is unlikely that drugs developed without a clear clinical indication will ever be approved by regulatory authorities. Normal aging as a target would also appear to be excluded. The main debate is whether drugs should be developed for specific disease states (e.g., Alzheimer's), particular syndromes (e.g., AAMI) or for treating symptoms (e.g., memory deficits). Although targeting disease states appears the least problematic, it would be difficult to include many potentially treatable patients in such studies. In this respect, the status of AAMI is still the subject of much debate. In any case, it is important that trial populations be as homogeneous as possible, with clear diagnostic criteria (e.g., defined memory impairment, Hachinski score, CT scans) and that patients be moderately to severely affected.

[Is anxiety hereditary?]

Familial aggregation of anxiety disorders has repeatedly been reported: the estimated risk among the first degree relatives is of 15% to 18% compared to 3% in control groups. The most recent studies are focused on more homogeneous clinical subgroups. Thus, among agoraphobics first degree relatives, the risk is elevated not only for agoraphobia but also for panic attacks and other phobias. In families of panic attacks, the risk of panic attacks in the first degree relatives is specifically elevated. Thanks to the extremely fast development of genetic linkage and molecular genetics, progress is expected in the field of genetics and psychiatry. Linkage methods applied to anxiety disorders are discussed.

Simple laboratory test of neuroendocrine disturbance in depression: 11 p.m. saliva cortisol

Saliva cortisol was measured at 11 p.m. in a sample of 74 psychiatric inpatients composed of 24 primary endogenous depressives, 40 secondary depressives and 20 nondepressives (DSM III and Saint-Louis criteria). Primary depressives had significantly higher 11 p.m. saliva cortisol levels than nondepressives (p less than 0.02) and secondary depressives (p less than 0.05). In contrast, there were no significant differences between secondary depressive and nondepressive saliva cortisol levels. A saliva cortisol cutoff limit of 3.45 nmol/l identified primary depressives with a sensitivity of 62.5% and with a specificity of 75% in the depressive group, and 90% in the nondepressive group. The measurement of saliva cortisol at 11 p.m. could be used alone as a reliable and practical index of hypothalamic-pituitary-adrenal axis activity in depression, especially in outpatients.