Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study

Helpful and hindering factors for remission in dysthymia and panic disorder at 9-year follow-up: a mixed methods study

BACKGROUND

A better understanding is needed of factors behind the long-term outcome of dysthymic and panic disorders. Combining patients' perceptions of factors that help and hind remission with objective assessments of outcome may give greater insight into mechanisms for maintaining recovery.

METHODS

Twenty-three dysthymic and 15 panic disorder patients participated in a 9-year follow-up investigation of a naturalistic study with psychotherapy and antidepressants. Degree of remission was determined by reassessments with SCID-I & II interviews, self-reported symptoms and life-charting (aided by case records). Qualitative content analysis of in-depth interviews with all 38 patients was done to examine the phenomenon of enduring remission by exploring: 1) perceived helpful and hindering factors, 2) factors common to and specific for the diagnostic groups, 3) convergence between patients' subjective views on remission with objective diagnostic assessments.

RESULTS

About 50% of the patients were in full or partial remission. Subjective and objective views on degree of remission generally converged, and remission was perceived as receiving 'Tools to handle life'. Common helpful factors were self-understanding, enhanced flexibility of thinking, and antidepressant medication, as well as confidence in the therapist and social support. The perceived main obstacle was difficulty in negotiating treatments. Remitted had overcome the obstacles, whereas many non-remitted had problems expressing their needs. Patients with dysthymia and panic disorder described specific helpful relationships with the therapist: 'As a parent' versus 'As a coach', and specific central areas for change: self-acceptance and resolution of relational problems versus awareness and handling of feelings.

CONCLUSION

A general model for recovery from dysthymic and panic disorders is proposed, involving: 1) understanding self and illness mechanisms, 2) enhanced flexibility of thinking, and 3) change from avoidance coping to approach coping; and recognising that a vehicle for this change is a helpful relationship to the health care provider. The perceived needs of specific treatment ingredients suggest that it is essential to differentiate between early-onset dysthymia and secondary depressions. The perceived access problems will be further investigated.

Alexithymia and cognitive dysfunctions in patients with panic disorder

BACKGROUND

In patients with panic disorder (PD), the difficulty to identify and manage emotional experience might contribute to the enduring vulnerability to panic attacks. Such a difficulty might reflect a dysfunction of fronto-temporo-limbic circuits. The present study was designed to test the hypothesis that drug-free patients with PD, as compared with healthy subjects (HS), show a higher prevalence of alexithymia, greater difficulty in emotional stimuli processing and poorer performance on neuropsychological tests exploring the activity of fronto-temporo-limbic circuits.

METHODS

Alexithymia, general cognitive abilities, focused and sustained attention, working memory, secondary memory, incidental learning, susceptibility to interference from both cognitive and emotional stimuli, and ability to recognize facial emotional expressions were assessed in 32 drug-free patients with PD and 32 HS.

RESULTS

Alexithymia was more frequent in patients with PD than in HS. Patients with PD, as compared to HS, had lower verbal cognitive abilities and more difficulty to inhibit interference from nonverbal stimuli and from panic-related words; they performed better than HS on the test assessing spatial incidental learning. Anxiety, panic symptomatology and verbal cognitive abilities (VIQ) were associated with alexithymia.

CONCLUSIONS

Findings are compatible with a dysfunction of frontolimbic circuits, in particular orbitofrontal and cingulate cortices. A reduction in verbal cognitive abilities was also observed, which might suggest reduced abstraction and symbolization in these patients.

Social anxiety disorder above and below the diagnostic threshold: prevalence, comorbidity and impairment in the general population

BACKGROUND

There is a lack of data systematically describing subthreshold expressions of social anxiety disorder (SAD) with regard to prevalence, comorbidity, and impairment.

METHODS

This analysis was based on data from the German Health Survey (GHS) and its Mental Health Supplement (GHS-MHS). Social anxiety disorder and its syndromes as well as other mental disorders were assessed with a standardized diagnostic interview (M-CIDI) in 4,174 adults.

RESULTS

The 12-month prevalence rate for threshold SAD was 2.0%, subthreshold and symptomatic social anxiety (one DSM-IV criterion missing/two or more criteria missing) was found in 3.0 and 7.5% of the participants, respectively. As expected, threshold SAD was characterized by an elevated risk for comorbid disorders and associated with impairment in diverse areas of life. However, this was also true for the two subthreshold expressions of social anxiety, which were also significantly associated with higher comorbidity and greater impairment compared to the control group.

CONCLUSIONS

Our results suggest that social anxiety below the diagnostic threshold is clearly associated with adverse outcomes. Prospective designs should examine the exact temporal and possible causal pathways of this burden in order to inform prevention and early intervention programs.

Nine-year follow-up of panic disorder in chest pain patients: clinical course and predictors of outcome

OBJECTIVE

The aim was to investigate the association between panic disorder (PD) and long-term outcomes in terms of psychiatric morbidity, psychological distress and health-related quality of life (HRQOL), and to identify predictors of poor outcome for PD in chest pain patients.

METHOD

Nine-year follow-up study of chest pain patients (n=199) referred to cardiology outpatient investigation. Assessments included Structured Clinical Interview for DSM-IV, Symptom Checklist-90-R (SCL-90-R), Illness Attitude Scale, Agoraphobia Cognitions Questionnaire, the Mobility Inventory for Agoraphobia, Personality Diagnostic Questionnaire and the Medical Outcome Study Short Form-36. At baseline, 76 patients suffered from PD.

RESULTS

Of 184 eligible patients, 150 participated in the follow-up study. Panic disorder at baseline was associated with a higher prevalence of comorbid Axis I disorders, psychological distress and poorer HRQOL at follow-up compared with patients without PD. Of the participants with PD at baseline (n=55), 14 suffered from persistent PD at follow-up. Patients with persistent PD had particularly poor outcomes regarding comorbid Axis I disorders, suicidal ideation (21%) and HRQOL. A mean baseline SCL-90-R somatization score above 1.4 predicted a 5-fold increased risk of persistent PD.

CONCLUSION

Chest pain patients with PD have a negative long-term outcome and those who score high on somatization require special attention because of particularly poor outcomes.

A multivariate genetic analysis of specific phobia, separation anxiety and social phobia in early childhood

BACKGROUND

Comorbidity amongst anxiety disorders is very common in children as in adults and leads to considerable distress and impairment, yet is poorly understood. Multivariate genetic analyses can shed light on the origins of this comorbidity by revealing whether genetic or environmental risks for one disorder also influence another. We examined the genetic and environmental influences on the comorbidity between three common childhood anxiety disorders: Specific Phobia, Separation Anxiety and Social Phobia.

METHODS

Using a two-phase design 4,662 twin-pairs were screened in the first phase and 854 pairs were assessed in the second phase by maternal-informant diagnostic interview using DSM-IV criteria.

RESULTS

Multivariate genetic analysis revealed significant shared environmental over-lap between Specific Phobia and Separation Anxiety and significant familial and non-shared environmental over-lap between Specific Phobia and Social Phobia.

CONCLUSIONS

Familial influences, especially shared environment, are central to the comorbidity between Specific Phobia and both Separation Anxiety and Social Phobia.

Definitions of the term 'recovered' in schizophrenia and other disorders

BACKGROUND

The use of the term 'recovered' in outcome studies of schizophrenia has for a long time been problematic because of the many different definitions in use. In the present study different definitions of recovered in schizophrenia are reviewed and compared with similar definitions in other fields of medicine.

SAMPLING AND METHODS

A literature search was done for criteria-based definitions of recovered as used in follow-up studies of patients with schizophrenia during the last 50 years and the current use of the term in other fields of medicine.

RESULTS

In medicine, only the field of psychiatry defines the term recovered to be synonymous with no or minimal signs of illness. Other fields only apply the term when studying the outcome of a specific function. In psychiatry, only the field of schizophrenia includes both symptoms and functioning in the definition. All but 1 of the 18 definitions found in use in the field of schizophrenia required minimal or no symptoms, while all differed in defining functional recovery. Recovered was seldom defined as following from a state of remission, and studies varied in requiring a stable phase.

CONCLUSION

When using the term in the field of schizophrenia, a distinction should be made between symptomatic and functional recovery in order to place it in line with other fields of medicine. To avoid confusing the process of recovery from the state of being recovered, the term recovered should be reserved for use in outcome studies, following from a time in remission. We suggest 2 years.

The Netherlands Study of Depression and Anxiety (NESDA): rationale, objectives and methods

The Netherlands Study of Depression and Anxiety (NESDA) is a multi-site naturalistic cohort study to: (1) describe the long-term course and consequences of depressive and anxiety disorders, and (2) to integrate biological and psychosocial research paradigms within an epidemiological approach in order to examine (interaction between) predictors of the long-term course and consequences. Its design is an eight-year longitudinal cohort study among 2981 participants aged 18 through 65 years. The sample consists of 1701 persons with a current (six-month recency) diagnosis of depression and/or anxiety disorder, 907 persons with life-time diagnoses or at risk because of a family history or subthreshold depressive or anxiety symptoms, and 373 healthy controls. Recruitment took place in the general population, in general practices (through a three-stage screening procedure), and in mental health organizations in order to recruit persons reflecting various settings and developmental stages of psychopathology. During a four-hour baseline assessment including written questionnaires, interviews, a medical examination, a cognitive computer task and collection of blood and saliva samples, extensive information was gathered about key (mental) health outcomes and demographic, psychosocial, clinical, biological and genetic determinants. Detailed assessments will be repeated after one, two, four and eight years of follow-up. The findings of NESDA are expected to provide more detailed insight into (predictors of) the long-term course of depressive and anxiety disorders in adults. Besides its scientific relevance, this may contribute to more effective prevention and treatment of depressive and anxiety disorders.

Long-term efficacy of pregabalin in generalized anxiety disorder

A multicenter, randomized, placebo-controlled, double-blind study was conducted to evaluate the efficacy of pregabalin in preventing relapse of generalized anxiety disorder (GAD) after response to short-term treatment. Outpatients (n=624) with GAD for > or =1 year received open-label pregabalin (450 mg/day) for 8 weeks and, if a clinical response was observed, were randomized to receive either pregabalin (450 mg/day; n=168) or placebo (n=170) for 24 weeks. The primary efficacy parameter was time to relapse. Among responders to open-label acute treatment with pregabalin, time to relapse of GAD was significantly longer for patients treated with pregabalin compared with placebo (P<0.0001). Fifty per cent of the placebo group had relapsed by day 23, and at study endpoint, 65% had relapsed. In the pregabalin group, only 42% had relapsed by study end. Total attrition during double-blind treatment was somewhat higher on pregabalin compared with placebo (21.4 vs. 15.3%); attrition owing to adverse events (AEs) was also somewhat higher on pregabalin (6.0 vs. 2.4%). AEs were relatively low in the double-blind phase; only three AEs occurred with an incidence of more than 5% on pregabalin and placebo, respectively: infection (14.9 vs. 11.2%), headache (10.1 vs. 11.2%), and somnolence (6.0 vs. 0%). No safety concerns were identified with long-term treatment. The study indicates that pregabalin is an effective treatment for the prevention of relapse in patients with GAD.

Management of treatment-resistant panic disorder

Panic disorder (PD) is a severe, chronic disorder characterized by one or more unexpected panic attacks followed by worry about additional attacks and/or the implications of the attacks. If attacks are sufficiently severe or frequent, they can promote marked, sometimes debilitating behavioral changes. Many panic disorder sufferers appear to be incompletely responsive to treatment and are subject to relapse after remission. In this article, we highlight the current understanding of the pathophysiology of PD using a "fear circuit" model. Using this model as a reference point, we review the evidence base supporting existing and emerging treatments and suggest strategies for optimizing initial treatment response. Finally, a differential diagnostic approach for clinical evaluation of unsatisfactory response to treatment in PD is presented.

Psychiatric epidemiology: challenges and opportunities

This paper discusses challenges and prospects for increasing the clinical relevance of psychiatric epidemiological research. The discussion begins with a review of the structural determinants of the fact that current psychiatric epidemiological research has less clinical relevance than epidemiological research in other areas of medicine. The discussion then turns to ways in which the focus of psychiatric epidemiological research might be changed to increase its clinical relevance. A review is then presented of recent innovations in community psychiatric epidemiological research that were designed to increase clinical relevance. An argument is then made that the full clinical value of psychiatric epidemiology will only be realized when community epidemiology becomes better integrated with clinical epidemiology and the latter takes on a more prominent role than it currently has in psychiatric research. Existing initiatives to realize an integration of community psychiatric epidemiology with clinical epidemiology are then reviewed. Finally, an agenda is proposed for an expansion of clinical psychiatric epidemiology to include a focus on both naturalistic and quasi-experimental studies of illness course and treatment response in diverse clinical samples.

Atomoxetine treatment for pediatric patients with attention-deficit/hyperactivity disorder with comorbid anxiety disorder

OBJECTIVE

Research suggests 25% to 35% of children with attention-deficit/hyperactivity disorder (ADHD) have comorbid anxiety disorders. This double-blind study compared atomoxetine with placebo for treating pediatric ADHD with comorbid anxiety, as measured by the ADHD Rating Scale-IV-Parent Version: Investigator Administered and Scored (ADHDRS-IV-PI) and the Pediatric Anxiety Rating Scale (PARS).

METHOD

Patients (ages 8-17 years) meeting DSM-IV criteria for ADHD and generalized anxiety disorder, separation anxiety disorder, and/or social phobia were randomized to 12 weeks of atomoxetine (n = 87) or placebo (n = 89). ADHDRS-IV-PI and PARS total scores were analyzed using analysis of covariance last observation carried forward and repeated-measures analyses.

RESULTS

Sixty-six patients in each group completed the study. Mean ADHDRS-IV-PI total score improved significantly for atomoxetine (n = 55; -10.5, SD 10.6) relative to placebo (n = 58; -1.4, SD 8.3; p < .001). Mean PARS total score also improved significantly for atomoxetine (n = 55; -5.5, SD 4.8) relative to placebo (n = 58; -3.2, SD 5.0; p = .011).

CONCLUSIONS

Atomoxetine was efficacious in reducing ADHD symptoms in patients who have ADHD with comorbid anxiety and was well tolerated. There was also a significant reduction in independently assessed anxiety symptoms using both clinician-rated and self-rated measures, which merits further investigation. Results support consideration of atomoxetine for the treatment of ADHD in youths who have ADHD with comorbid anxiety disorder.

CLINICAL TRIAL REGISTRATION INFORMATION

The LYBP study, on which this article is based, was not registered at clinicaltrials.gov because the last patient visit occurred before July 1, 2005. Results, however, are publicly posted at lillytrials.com and clinicalstudyresults.org. The unique study ID at both sites is 6477a.

Treatment of social phobia through pure self-help and therapist-augmented self-help

BACKGROUND

Self-help for social phobia has not received controlled empirical evaluation.

AIMS

To evaluate the efficacy of pure self-help through written materials for severe social phobia and self-help augmented by five group sessions with a therapist. These conditions were compared with a waiting-list control and standard, therapist-led group therapy.

METHOD

Participants with severe generalised social phobia (n=224) were randomised to one of four conditions. Assessment included diagnoses, symptoms and life interference at pretreatment, 12 weeks and at 24 weeks.

RESULTS

A larger percentage of patients no longer had a diagnosis of social phobia at post-intervention in the pure self-help group than in the waiting-list group, although this percentage decreased slightly over the next 3 months. Symptoms of social anxiety and life interference did not differ significantly between these groups. Augmented self-help was better than waiting list on all measures and did not differ significantly from group treatment.

CONCLUSIONS

Self-help augmented by therapist assistance shows promise as a less resource-intensive method for the management of social phobia. Pure self-help shows limited efficacy for this disorder.

Temperament and character dimensions in patients with social phobia: patterns of change following treatments?

The aim of this study was to examine Temperament and Character Inventory (TCI) profiles in patients with social phobia (DSM-IV) and to outline patterns of change following intensive group cognitive therapy (IGCT), individual cognitive therapy (ICT) and treatment as usual (TAU). One hundred patients recruited by advertisements in local papers were randomized to IGCT, ICT and TAU. Patients (n=59) who completed diagnostic evaluation and TCI assessments at baseline and 1-year follow-up were examined in this study. Patients differed from healthy controls in novelty seeking (NS), harm avoidance (HA), self-directedness (SD), cooperativeness (C), and self-transcendence (ST). Treatments overall were associated with decrease in HA, while increase in SD was observed after psychotherapy only. Reduced social anxiety was correlated with decrease in HA and increase in SD. High HA at baseline was related to poor treatment outcome in all treatments. To conclude, patients with social phobia show a temperamental vulnerability for developing anxiety and character traits associated with personality disorders. Successful treatment is related to decrease in HA and increase in SD. High HA at baseline may suggest a need for extensive treatment in order to achieve remission.

Recovery from social phobia in the community and its predictors: data from a longitudinal epidemiological study

The present longitudinal study aimed to determine rate of natural recovery from DSM-IV social phobia in the community and to examine predictors of recovery. Data were derived from the Dresden Predictor Study of a representative sample of 1396 young German women. The participants completed a diagnostic interview and self-report questionnaires at two survey points approximately 1.5 years apart. Of the 91 women with social phobia at baseline 64% were at least partially recovered and 36% showed full recovery from social phobia at follow-up, defined as absence of any of the DSM-IV criteria of social phobia. Predictors of recovery from social phobia were: being employed, no lifetime depression, fewer than three lifetime psychiatric disorders, less psychopathology, less anxiety sensitivity, fewer daily hassles, and better mental health. These results show that rates of recovery from social phobia are relatively high in community and that less stress and internal psychological problems play an important role in recovery from social phobia.

Facilitating a benign interpretation bias in a high socially anxious population

Previous research has shown that high socially anxious individuals lack the benign interpretation bias present in people without social anxiety. The tendency of high socially anxious people to generate more negative interpretations may lead to anticipated anxiety about future social situations. If so, developing a more benign interpretation bias could lead to a reduction in this anxiety. The current study showed that a benign interpretation bias could be facilitated (or 'trained') in a high socially anxious population. Participants in the benign training groups had repeated practice in accessing benign (positive or non-negative) interpretations of potentially threatening social scenarios. Participants in the control condition were presented with the same social scenarios but without their outcomes being specified. In a later recognition task, participants who received benign interpretation training generated more benign, and less negative, interpretations of new ambiguous social situations compared to the control group. Participants who received benign training also predicted that they would be significantly less anxious in a future social situation than those in the control group. Possible implications of the findings for therapeutic interventions in social phobia are discussed.

[What our patients want and need to know about generalized anxiety disorder]

Persons with generalized anxiety disorder often do not seek treatment, and if they do, it is more often for the somatic symptoms (muscle tension, insomnia) or for a secondary depression than because of the cardinal feature of generalized anxiety disorder: worry. The worry aspect becomes apparent when the patient is proposed to try anxiolytic medication. The physician will then need to be prepared to answer many questions regarding the potential hazards and benefits of such medication. These patients tend to have a sceptical attitude, having informed themselves on websites that display claims that are based on anything from evidence-based scientific guidelines to distorted, erroneous and unfounded allegations. Which are the frequent questions that worried patients pose to the physician before accepting anxiolytic pharmacotherapy? Having seen anxious patients in my practice during 25 years, and having conducted several clinical trials of anxiolytics I have put together evidence-based answers in plain language to these questions in this paper.

Caffeine and 35% carbon dioxide challenge tests in panic disorder

Our aim was to compare the demographic and clinical features of panic disorder (PD) patients with agoraphobia-DSM-IV-who had a panic attack after both an oral caffeine and the 35% carbon dioxide (CO2) challenge tests (responsive group) and compare them with PD patients who did not have a panic attack after both tests (non-responsive group). We examined 83 PD patients submitted to a 35% CO2 test and to an oral caffeine (480 mg) intake within 1 week interval. A panic attack was induced in 51 (61.4%) patients during the CO2 test (chi2=31.67, df=1, p<0.001) and in 38 (45.8%) patients during the caffeine test (chi2=18.28, df=1, p=0.023). All patients who had a panic attack during the caffeine test also had a panic attack during the CO2 test (n=38)-responsive group. The responsive had more (chi2=24.55, df=1, p=0.008) respiratory PD subtype, disorder started earlier (Mann-Whitney, p<0.001) had a higher familial prevalence of PD (chi2=20.34, df=1, p=0.019), less previous alcohol abuse (chi2=23.42, df=1, p<0.001), and had more previous depressive episodes (chi2=27.35, df=1, p<0.001). Our data suggest that there is an association between respiratory PD subtype and hyperreactivity to challenge tests: CO2 and oral caffeine.

Generalized anxiety disorder: a 40-year follow-up study

OBJECTIVE

There is insufficient knowledge of the long-term course of generalized anxiety disorder (GAD). We studied the course of this disorder in patients who were followed up for 40 years.

METHOD

Patients admitted with the diagnosis of anxiety states ('anxious thymopathy' ) to the Lopez Ibor Neuropsychiatric Research Institute between 1950 and 1961 were examined between 1984 and 1988 (n = 65). The retrospective diagnosis of GAD was made according to DSM-III-R criteria during 1984-1988 (first examination). A re-examination was performed by the same psychiatrist in the period 1997-2001 (n = 59; second examination).

RESULTS

At first and second examinations 20% and 17% of subjects were diagnosed as GAD. Improvement was observed in 83%. GAD tended to disappear around age 50, but was replaced by somatization disorders. Lack of regular treatment compliance, female sex, and onset of GAD before age 25 were variables associated with a worse outcome. Undifferentiated somatization disorder was the most prevalent clinical status at follow-up.

CONCLUSION

After several decades, participants improve with regard to GAD, although most continue to present somatizations.

Impact of parental history of substance use disorders on the clinical course of anxiety disorders

Background

Among the psychological difficulties seen in children of parents with substance use problems, the anxiety disorders are among the most chronic conditions. Although children of alcoholic parents often struggle with the effects of parental substance use problems long into adulthood, empirical investigations of the influence of parental substance use disorders on the course of anxiety disorders in adult offspring are rare. The purpose of this study was to examine prospectively the relationship between parental substance use disorders and the course of anxiety disorders in adulthood over the course of 12 years.

Methods

Data on 618 subjects were derived from the Harvard/Brown Anxiety Research Project (HARP), a longitudinal naturalistic investigation of the clinical course of multiple anxiety disorders. Kaplan-Meier survival estimates were used to calculate probabilities of time to anxiety disorder remission and relapse. Proportional hazards regressions were conducted to determine whether the likelihood of remission and relapse for specific anxiety disorders was lower for those who had a history of parental substance use disorders than for individuals without this parental history.

Results

Adults with a history of parental substance use disorders were significantly more likely to be divorced and to have a high school level of education. History of parental substance use disorder was a significant predictor of relapse of social phobia and panic disorders.

Conclusion

These findings provide compelling evidence that adult children of parents with substance use disorders are more likely to have relapses of social phobia and panic disorders. Clinicians who treat adults with anxiety disorders should assess parental substance use disorders and dependence histories. Such information may facilitate treatment planning with regards to their patients' level of vulnerability to perceive scrutiny by others in social situations, and ability to maintain a long-term panic-free state.

Relapse and Relapse Prevention

Most psychological disorders and problem behaviors are characterized by very high rates of postremittance relapse. Thus, advances in the long-term efficacy of psychological interventions require understanding the causes and processes of relapse, with the ultimate goal of developing strategies that reduce the probability of relapse. Existing psychological theory and interventions relevant to relapse and relapse prevention (RP) are reviewed, with a focus on addictive behaviors. The past two decades have produced increased attention toward the relapse problem and important advances in the conceptualization of relapse (i.e., as a process rather than a discrete event). Further progress will require the translation of basic theory into applied theory, the development of integrative theories of relapse, and the design and testing of theory-based, multimodal RP interventions.

Intensive group cognitive treatment and individual cognitive therapy vs. treatment as usual in social phobia: a randomized controlled trial

To compare the effects of an intensive group cognitive treatment (IGCT) to individual cognitive therapy (ICT) and treatment as usual (TAU) in social phobia (DSM-IV).

METHOD

Hundred patients were randomized to: IGCT involving 16 group sessions spread over three weeks; ICT involving 16 shorter weekly sessions in 4 months and; TAU involving an indicated selective serotonin reuptake inhibitor (SSRI) with therapy sessions as required for 1 year. The main outcome measure was a Social Phobia Composite that combined several standardized self-report measures. Diagnostic assessment was repeated at 1-year follow-up.

RESULTS

Significant improvements were observed with all treatments. ICT was superior to IGCT and TAU, which did not differ in overall effectiveness.

CONCLUSION

The study confirms and extends previously reported findings that ICT is more effective than group cognitive treatment and treatment with SSRIs. IGCT lasts only 3 weeks, and is as effective as more protracted TAU.

Homotypic versus heterotypic continuity of anxiety symptoms in young adolescents: evidence for distinctions between DSM-IV subtypes

Objective: to investigate homotypic and heterotypic longitudinal patterns of symptoms of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia (SoPh), panic disorder (PD), and obsessive compulsive disorder (OCD) in young adolescents from the Dutch general population.

Method: 2,067 individuals (51.4% girls) from a Dutch community sample, who were assessed for the first time when they were aged 10 to 12 years, were followed up across a period of two years. At both assessments, anxiety symptoms were assessed with the RCADS, a self-report questionnaire.

Results: Regression analyses indicated that homotypic continuity was relatively high for SAD, GAD, and SoPh symptoms, and for PD in girls.

Conclusions: In many studies, anxiety disorders are treated as one group of disorders, and some widely used assessment instruments, such as the Child Behavior Checklist, do not even contain scales that tap different anxiety dimensions. In the present study, evidence for homotypic continuity was found, especially for symptoms of separation, social, and generalized anxiety, and for symptoms of panic disorder in girls, underscoring the usefulness of making distinctions between different anxiety constructs.

Escitalopram for comorbid depression and anxiety in elderly patients: A 12-week, open-label, flexible-dose, pilot trial

BACKGROUND

Comorbid depression and anxiety may result in greater symptom severity and poorer treatment response than either condition alone. Selective serotonin reuptake inhibitors have been found to be effective in treating both depression and anxiety; however, pharmacodynamic and pharmacokinetic changes associated with aging warrant special attention in medication trials in older patients.

OBJECTIVE

The objective of this study was to assess the efficacy and tolerability of short-term (12-week) administration of escitalopram oxalate 10 to 20 mg/d for moderate to marked comorbid depression and anxiety in elderly patients.

METHODS

This open-label, flexible-dose (10-20 mg/d), pilot trial was conducted at the Psychiatry Service, Veterans Affairs Medical Center, Cincinnati, Ohio. Outpatients aged > or =65 years were included if they met the criteria for comorbid major depressive disorder (MDD) and generalized anxiety disorder (GAD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, for > or =4 weeks and had a baseline Montgomery-Asberg Depression Rating Scale (MADRS) score of >22 and a Hamilton Rating Scale for Anxiety (HAM-A) score of > or =18. All patients received escitalopram 10 to 20 mg/d. The primary efficacy variables were the mean changes from baseline in total MADRS and HAM-A scores at 12 weeks (last observation carried forward). The secondary efficacy end point was the change from baseline in Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) 8 subscale scores. Adverse events were assessed at each visit (treatment weeks 1, 2, 3, 4, 6, 8, 10, and 12) with the use of open-ended questioning.

RESULTS

Twenty patients were enrolled (mean [SD] age, 73.0 [4.8] years; 6 [30%] women; race: 17 [85%] white, 2 [10%] black, and 1 [5%] "other"). Seventeen (85%) of 20 patients completed the study; 3 (15%) withdrew: 1 (5%) due to lack of efficacy and 2 (10%) due to adverse events (dizziness and somnolence [1 (5%) patient each]). Statistically significant improvements from baseline to end point were found with escitalopram treatment (MADRS: t19 = 7.38, P < 0.001, effect size = 2.93; HAM-A: t19 = 4.19, P < 0.001, effect size = 1.83). Significant changes from baseline in scores on 4 (Social Functioning, Role Functioning-Emotional, Mental Health, and Energy/Fatigue) of the 8 subscales of the SF-36 were also found (all, P < 0.01).

CONCLUSION

In this small study in elderly patients with comorbid MDD and GAD, treatment with escitalopram 10 to 20 mg/d for 12 weeks was associated with significant improvements in symptoms of depression and anxiety.

Comorbid anxiety and depression: illumination of a controversy

Depression and anxiety frequently coexist in the same individual, either concurrently or at different times, and numerous studies show that the presence of an anxiety disorder is the single strongest risk factor for development of depression. When the two coexist simultaneously, either as diagnosed disorders or subsyndromal states, they may be viewed as mixed anxiety-depression or as comorbid syndromes, i.e. separate disorders occurring concurrently. Controversy continues over the nature of the relationship between depression and anxiety, some believing they are distinct, separate entities while others - now the majority - view them as overlapping syndromes that present at different points on a phenomenological and/or chronological continuum, and share a common neurobiology, the degree of overlap depending on whether each is described at the level of symptoms, syndrome or diagnosis. Community data likely underestimate true prevalence, since affected individuals frequently present in primary care with somatic, rather than psychological, complaints. Irrespective of the nature of the relationship, patients with both disorders experience significant vocational and interpersonal impairment, and more frequent recurrence, with greater likelihood of suicide, than individuals with single disorders. Various classes of antidepressant drugs offer symptom relief for these patients, the most selective of th SSRIs holding the greatest promise for sustained clinical improvement. Yet, the crucial parameter of successful pharmacotherapy seems to be the length of treatment, ensuring enhancement of the compromised neuroprotective and neuroplastic mechanisms. Further clarification of the relationship is a prerequisite for offering effective treatment to the many patients who experience lifetime depression and anxiety.

Characteristics and course of panic disorder and panic disorder with agoraphobia in primary care patients

OBJECTIVE

To examine the course of panic disorder (PD) and panic disorder with agoraphobia (PDA) in 235 primary care patients during a 3-year period.

METHOD

Patients were recruited from primary care waiting rooms and diagnosed using the Structured Clinical Interview for DSM-IV. They were reassessed at 6 months, 1 year, and annually thereafter for diagnosis, treatment, and other clinical and demographic variables. Recruitment occurred between July 1997 and May 2001.

RESULTS

At intake, 85 patients were diagnosed with PD and 150 were diagnosed with PDA. Patients with PD were significantly more likely to achieve recovery (probability estimate, 0.75) from their disorder than patients with PDA (0.22) at the end of 3-year follow-up (p < .0001). There was no difference in recurrence rates between the 2 disorders. Women were more likely to recover from PD (p = .001). At intake, comorbid generalized anxiety disorder (p = .004), higher Global Assessment of Functioning score (p = .0003), and older age at panic onset (p = .05) were related to recovery from PDA, and comorbid major depressive disorder (p = .05) and psychosocial treatment (p = .002) predicted remaining in an episode of PDA. The relationship between psychosocial treatment and poor recovery must be interpreted with caution and is most likely due to the treatment bias effect.

CONCLUSION

Primary care patients with PDA have a chronic course of illness, whereas those with PD have a more relapsing course. Given the significant burden of PD and PDA in primary care, attention to factors relevant to the course of these disorders is important for recognition and for continued improvement of treatment interventions in this setting.

Generalised anxiety disorder

Generalised anxiety disorder is a persistent and common disorder, in which the patient has unfocused worry and anxiety that is not connected to recent stressful events, although it can be aggravated by certain situations. This disorder is twice as common in women than it is in men. Generalised anxiety disorder is characterised by feelings of threat, restlessness, irritability, sleep disturbance, and tension, and symptoms such as palpitations, dry mouth, and sweating. These symptoms are recognised as part of the anxiety syndrome rather than independent complaints. The symptoms overlap greatly with those of other common mental disorders and we could regard the disorder as part of a spectrum of mood and related disorders rather than an independent disorder. Generalised anxiety disorder has a relapsing course, and intervention rarely results in complete resolution of symptoms, but in the short term and medium term, effective treatments include psychological therapies, such as cognitive behavioural therapy; self-help approaches based on cognitive behavioural therapy principles; and pharmacological treatments, mainly selective serotonin reuptake inhibitors.

35% Carbon dioxide and breath-holding challenge tests in panic disorder: a comparison with spontaneous panic attacks

Respiration and its control mechanisms may represent an important system involved in abnormal anxiety. Our aim was to compare the demographic and clinical features of patients with panic disorder (PD) with agoraphobia (DSM-IV) who had a panic attack after both the 35% carbon dioxide (CO(2)) test and the breath-holding test (CPA group), and compare them with PD patients who did not have a panic attack after both tests (NPA group). We examined 76 patients with PD who were administered a 35% CO(2)test and a breath-holding test within a 1-week interval. Anxiety scales were applied before and after each test. A panic attack was induced in 50 (65.8%) patients during the CO(2)test (chi(2) = 28.44, df = 1, P<.001) and in 40 (52.6%) patients during the breath-holding test (chi(2) = 15.35, df = 1, P = .036). All patients who had a panic attack during the breath-holding test also had a panic attack during the CO(2)test (n = 40; CPA group). Twenty-six (34.2%) patients with PD did not have a panic attack after both respiratory tests (NPA group). The CPA group had more (chi(2) = 21.67, df = 1, P = .011) respiratory PD subtype. In the CPA group, the disorder started earlier (Mann-Whitney, P<.001), had a higher familial prevalence of PD (chi(2) = 18.34, df = 1, P = .028), and had more previous depressive episodes (chi(2) = 23.59, df = 1, P<.001). Our data suggest that there is an association between respiratory PD subtype and the response to respiratory challenge tests: CO(2)and breath-holding. The CPA may be confirmed as a subgroup of respiratory PD subtype.

Time to response in panic disorder in a naturalistic setting: combination therapy with alprazolam orally disintegrating tablets and serotonin reuptake inhibitors compared to serotonin reuptake inhibitors alone

OBJECTIVE

This study evaluated time to response in the treatment of panic disorder with a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) combined with alprazolam orally disintegrating tablets (ODT), or SSRI/SNRI alone.

DESIGN

Subjects were randomized to eight weeks open-label treatment with alprazolam ODT (4 weeks treatment followed by 3-4 week taper) combined with an SSRI or SNRI, or treatment with SSRI/SNRI alone.

SETTING

The study was conducted under naturalistic conditions at 62 primary care and 34 psychiatric practices.

PARTICIPANTS

Male or female subjects ≥18 years of age diagnosed with panic disorder, with or without agoraphobia.

MEASUREMENTS

The primary efficacy measure was time to response, defined as ≥50-percent decrease from baseline Hamilton Rating Scale for Anxiety (HAM-A) total score. Secondary measures included change from baseline in HAM-A scores and the Clinical Global Impression of Improvement (CGI-I) and Patient Global Impression (PGI) scales.

RESULTS

The intent-to-treat (ITT) population comprised 245 subjects. There was no statistical difference between treatment groups in time to response in the ITT population; however, a prospectively defined per protocol analysis revealed a statistically significant earlier onset of effect in subjects receiving SSRI/SNRI plus alprazolam ODT (P<0.05). Mean change from baseline in HAM-A total score and clinician and patient measures of global improvement also showed statistically significant early advantages for combination therapy compared with SSRI/SNRI monotherapy.

CONCLUSION

Combined treatment of panic disorder with alprazolam ODT and an SSRI/SNRI may be associated with more rapid improvement in anxiety symptoms compared with an SSRI/SNRI alone.

Pregabalin for the treatment of generalised anxiety disorder

Pregabalin is a new anxiolytic that has been recently licensed for the treatment of generalised anxiety disorder (GAD) in Europe. Short-term efficacy is based on six positive placebo-controlled studies, all of which showed a significant early separation from placebo in all of the doses used (150-600 mg) at the first week, and the efficacy at the end of the treatment was comparable with the comparators used in four of these studies. Pregabalin was effective in more or less severe GAD, on psychic and somatic symptoms of GAD, and in treating the subsyndromal depressive symptoms of GAD. Efficacy in the elderly was shown in a separate placebo-controlled study. The effect on cognitive function was minimal and notably less than that observed with benzodiazepines. The discontinuation symptoms following abrupt treatment cessation were similar to the rates with serotonin-noradrenaline re-uptake inhibitors and lower than with benzodiazepines with no signals of tolerance or dependence.

Panic disorder

Panic disorder is a common mental disorder that affects up to 5% of the population at some point in life. It is often disabling, especially when complicated by agoraphobia, and is associated with substantial functional morbidity and reduced quality of life. The disorder is also costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. Some physical illnesses (eg, asthma) commonly occur with panic disorder, and certain lifestyle factors (eg, smoking) increase the risk for the disorder, but causal pathways are still unclear. Genetic and early experiential susceptibility factors also exist, but their exact nature and pathophysiological mechanisms remain unknown. Despite an imprecise, although increased, understanding of cause, strong evidence supports the use of several effective treatments (eg, pharmacological, cognitive-behavioural). The adaptation and dissemination of these treatments to the frontlines of medical-care delivery should be urgent goals for the public-health community.

Azapirones for generalized anxiety disorder

BACKGROUND

Azapirones are a group of drugs that work at the 5-HT1A receptor and are used to treat patients suffering from generalized anxiety disorder (GAD). However, several studies have shown conflicting results. Whether azapirones are useful as first line treatment in general anxiety disorders still needs to be answered.

OBJECTIVES

To assess the efficacy and the acceptability of azapirones for the treatment of GAD.

SEARCH STRATEGY

Initially the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR) and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched, incorporating results of group searches of MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005), CINAHL (1982 to June 2005), PsycLIT (1974 to June 2005), PSYNDEX (1977 to June 2005), and LILACS (1982 to June 2005). Subsequently the revised Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 21-10-2005. Reference lists of relevant papers and major text books of anxiety disorder were examined. Authors, other experts in the field and pharmaceutical companies were contacted for knowledge of suitable trials, published or unpublished. Specialist journals concerning azapirones were handsearched.

SELECTION CRITERIA

Randomized controlled trials of azapirones, including buspirone versus placebo and/or other medication and/or psychological treatment, were included. Participants were males and females of all ages with a diagnosis of generalized anxiety disorder.

DATA COLLECTION AND ANALYSIS

Data were extracted from the original reports independently by CC, MA and MT. The main outcomes studied were related to the objectives stated above. Data were analysed for generalized anxiety disorder versus placebo, versus other medication and versus psychological treatment separately. Data were analysed using Review Manager Version 4.2.7.

MAIN RESULTS

Thirty six trials were included in the review, reporting on 5908 participants randomly allocated to azapirones and/or placebo, benzodiazepines, antidepressants, psychotherapy or kava kava. Azapirones, including buspirone, were superior to placebo in treating GAD. The calculated number needed to treat for azapirones using the Clinical Global Impression scale was 4.4 (95% confidence interval (CI) 2.16 to 15.4). Azapirones may be less effective than benzodiazepines and we were unable to conclude if azapirones were superior to antidepressants, kava kava or psychotherapy. Azapirones appeared to be well tolerated. Fewer participants stopped taking benzodiazepines compared to azapirones. The length of studies ranged from four to nine weeks, with one study lasting 14 weeks.

AUTHORS' CONCLUSIONS

Azapirones appeared to be useful in the treatment of GAD, particularly for those participants who had not been on a benzodiazepine. Azapirones may not be superior to benzodiazepines and do not appear as acceptable as benzodiazepines. Side effects appeared mild and non serious in the azapirone treated group. Longer term studies are needed to show that azapirones are effective in treating GAD, which is a chronic long-term illness.

Body dysmorphic disorder and social phobia: cross-sectional and prospective data

Much attention has been paid to the relationship between body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD). However, to our knowledge, no published study has focused directly on the relationship between BDD and social phobia (SP). This is striking given similar clinical features of the two disorders, data showing elevated comorbidity between them, and Eastern conceptualizations of BDD as a form of SP. In this study, 39.3% of 178 individuals with current BDD had comorbid lifetime SP, and 34.3% had current SP. SP onset was typically before BDD. Individuals with BDD, with and without lifetime SP, were similar on many general characteristics (e.g., age of BDD onset, gender distribution, BDD severity, overall functional disability). However, subjects with BDD+SP were significantly less likely to be employed, were more likely to report lifetime suicidal ideation, and had poorer global social adjustment on one of two measures. Both BDD and SP were associated with elevated social anxiety; subjects with BDD+SP experienced additional social anxiety that appeared independent of BDD symptoms. Examining 1-year prospective data available for 161 subjects, BDD+SP subjects were somewhat less likely to experience remission (partial or full) of their BDD symptoms over 1-year follow-up, although this difference was not statistically significant (hazard ratio = .64, P = .18). In summary, these findings, including elevated rates of SP in patients with BDD, highlight a need for additional research on the relationship between BDD and SP.

Long-term use of benzodiazepines in participants with comorbid anxiety and alcohol use disorders

BACKGROUND

Although the only widely accepted role for benzodiazepines in alcohol dependence is the treatment of withdrawal syndromes, they are frequently prescribed outside of this clinical setting. There is little empirical evidence to guide the rational use of benzodiazepines in the common clinical situation where anxiety disorders are comorbid with alcohol use disorders (AUD). Since January 1989, the Harvard Anxiety Research Program has naturalistically monitored the prospective clinical course of people with anxiety disorders, some of whom had a history of AUD. Earlier research showed that the use of benzodiazepines was not significantly associated with the presence or absence of a history of an AUD over the first year of follow-up. This report extends that investigation.

METHODS

Using standard parametric analytic methods, patterns of benzodiazepine use (routinely prescribed medication and as-needed [PRN] use) among participants receiving benzodiazepine treatment was prospectively examined over the course of 12 years. Differences in benzodiazepine usage patterns were examined in each year of follow-up between participants who did (n=120) and did not (n=425) have a new episode of AUD. Using proportional hazards regression analysis, benzodiazepine usage levels were examined as predictors of recovery and recurrence of AUD. Additionally, random-effects regression analyses were used to examine the patterns of benzodiazepine use before and after the onset of a prospectively observed episode of AUD.

RESULTS

Benzodiazepine usage levels remained stable for the full sample over the course of the 12 years. Benzodiazepine use did not distinguish participants who had a new AUD from those who did not. Over the 12 years of follow-up, participants who had an AUD used more PRN medication in years five to eight. This difference reached statistical significance but was not clinically significant. Benzodiazepine usage levels did not predict recovery or recurrence in AUD subjects. Neither the total dose nor the PRN usage of benzodiazepines was significantly associated with the onset of AUD, but when combined into a measure of any benzodiazepine use, a relationship between increased use and the onset of AUD emerged.

CONCLUSIONS

For participants in the Harvard Anxiety Research Program with comorbid alcohol dependence and anxiety disorders, there was little association between the use of benzodiazepines and the occurrence of a new AUD. Neither was there a temporal relationship between the use of benzodiazepines and the onset of a new AUD. Whether or not this finding extends to a broader patient population or a group of people who present to addictions treatment awaits further investigation.

Results of a naturalistic longitudinal study of benzodiazepine and SSRI use in the treatment of generalized anxiety disorder and social phobia

The past decade has brought major new developments in the psychopharmacologic management of generalized anxiety disorder and social phobia. We examined medication-prescribing patterns for the treatment of these anxiety disorders for 12 years to assess changes in patients' anti-anxiety psychotropic medication usage during that period of evolving practice guidelines. We examined psychotropic medication use in 305 patients with generalized anxiety disorder and 232 with social phobia enrolled in the Harvard/Brown Anxiety Disorders Research Project (HARP), a prospective, longitudinal study of anxiety disorders. Psychotropic treatment patterns seem to have remained relatively stable over 12 years with benzodiazepines the medications most commonly used for both generalized anxiety disorder and social phobia. Comparatively, selective serotonin reuptake inhibitor (SSRI) and venlafaxine usage as stand-alone medications for these disorders remained low throughout the follow-up period. At the 12-year follow-up, 24% of patients with generalized anxiety disorder and 30% of patients with social phobia were utilizing neither an SSRI/selective norepinephrine reuptake inhibitor (SNRI) nor a benzodiazepine. Treatment recommendations for use of SSRIs and venlafaxine in the management of generalized anxiety disorder and social phobia initially promulgated in 1998 had a modest impact on changes in psychopharmacologic practice 4-5 years later. Difficulties in the implementation of treatment guidelines are discussed.