Social phobia: biological aspects and pharmacotherapy

Anxiety and depressive disorders in an adult insulin-dependent diabetic mellitus (IDDM) population: relationships with glycaemic control and somatic complications

The frequency of anxiety and depressive disorders was examined in 69 insulin-dependent diabetic mellitus (IDDM) outpatients and in two control group. Based on self-report measures, these disorders were similar in IDDM sample and in the control groups. In diabetic outpatients, according to DSM-III-R criteria, there was a high lifetime prevalence of not otherwise specified anxiety and depressive disorders (44% and 41.5%), of simple phobia (26.8%), social phobia (24.6%), and agoraphobia — with and without panic disorder (14.6%). Current social phobia, dysthymia and not otherwise specified depressive disorders were associated with impaired glycaemic control. Glycosylated haemoglobin was associated with compliance but psychiatric disorders were not, except for social phobia which was significantly associated with more frequent consultations and a bad compliance for dietary regimen (more snacking). Somatic complications were not associated with anxious and depressive disorders (current or lifetime) or compliance and were best explained by the duration of the illness and impaired glycaemic control.

Endophenotypes in the personality disorders

The identification of endophenotypes in the personality disorders may provide a basis for the identification of underlying genotypes that influence the traits and dimensions of the personality disorders, as well as susceptibility to major psychiatric illnesses. Clinical dimensions of personality disorders that lend themselves to the study of corresponding endophenotypes include affective instability impulsiwity aggression, emotional information processing, cognitive disorganization, social deficits, and psychosis. For example, the propensity to aggression can be evaluated by psychometric measures, interview, laboratory paradigms, neurochemical imaging, and pharmacological studies. These suggest that aggression is a measurable trait that may be related to reduced serotonergic activity. Hyperresponsiveness of amygdala and other limbic structures may be related to affective instability, while structural and functional brain alterations underlie the cognitive disorganization in psychoticlike symptoms of schizotypal personality disorder. Thus, an endophenotypic approach not only provides clues to underlying candidate genes contributing to these behavioral dimensions, but may also point the way to a better understanding of pathophysiological mechanisms.

Social anxiety and premorbid personality disorders in paranoid schizophrenic patients treated with clozapine

The concept of anxiety as a distinct comorbid disorder in schizophrenia has recently been rediscovered after having been neglected for a long period of time due to both theoretical and clinical approaches adopted from the appearance of the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1950. This rediscovery was accentuated by the fact that the concept of comorbidity in various psychiatric disorders has recently won widespread favor within the scientific community, and that the use of atypical neuroleptic medication to treat patients with schizophrenia has been reported to lead to the emergence of anxiety symptoms. Of the atypical neuroleptic medications used to treat schizophrenia, clozapine has most frequently been reported to induce anxiety symptoms. In this paper, 12 cases of patients with paranoid schizophrenia who developed social phobia during clozapine treatment are reported, and their response to fluoxetine augmentation is assessed. Premorbid personality disorders were also investigated; patients were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (DSM-III-R=Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). In addition, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Liebowitz Social Anxiety Scale (LSAS), the Frankfurt Beschwerde Fragebogen (Frankfurt Questionnaire of Complaints), and the Brief Psychiatric Rating Scale were used to rate clinical symptomatology. All patients were reevaluated after 12 weeks of cotreatment with clozapine and fluoxetine. In 8 (66.6%) of the 12 cases, symptoms responded (>/=35% LSAS score reduction) to an adjunctive regimen of fluoxetine. Furthermore, in 7 (58.3%) of the 12 cases, an anxious personality disorder (avoidant=33.3%; dependent=25%) was identified, but no significant differences in the prevalence of comorbid personality disorders emerged in comparison with a group of 16 patients with paranoid schizophrenia treated with clozapine who did not show symptoms of social phobia. The clinical relevance of the assessment and treatment of anxiety disorders is discussed in light of a clinical therapeutic approach that overcomes the implicit hierarchy of classification. Considering that the onset of anxiety-spectrum disorders (such as social phobia) can occur during the remission of psychotic symptoms in clozapine-treated patients with schizophrenia, a comprehensive approach to pharmacological therapy for patients with schizophrenia (or, at least for those treated with clozapine) should be adopted.

International study of expert judgement on therapeutic use of benzodiazepines and other psychotherapeutic medications: II. Pharmacotherapy of anxiety disorders

OBJECTIVE

To assemble expert clinical experience and judgement in the treatment of anxiety and related disorders in a systematic, quantitative manner.

METHODS

A panel of internationally recognized Experts in treating anxiety and depression was constituted by multistage peer nomination. 90% completed a questionnaire. This report focuses on case vignettes of 7 anxiety disorders followed by questions about relevant therapeutic options.

RESULTS

Panelists usually recommended both psychological and pharmacological interventions. Most favored antidepressants, usually tricyclic, for agoraphobia, panic and OCD; beta-blockers for specific social phobia; and benzodiazepines for GAD and adjustment disorder. Some Experts favored polypharmacy, usually an antidepressant and a benzodiazepine. The majority usually advocated pharmacotherapy for 6 months or more. They recommended the same duration of treatment with benzodiazepines and other medications, except for GAD.

CONCLUSIONS

The responses of the Expert Panel imply that; (1) most anxiety disorders are serious and merit vigorous, prolonged pharmacotherapy; and (2) antidepressants and benzodiazepines are effective and safe for long-term treatment of these conditions. This outcome contrasts with the widespread apprehension about long-term pharmacotherapy, especially with benzodiazepines, and some regulatory views.

Risk factors for the incidence of social phobia as determined by the Diagnostic Interview Schedule in a population-based study

The Diagnostic Interview Schedule was used to identify 89 incident social phobia cases in wave 2 household subjects from 9437 at risk persons age 18 or older as part of the Epidemiologic Catchment Area study. Crude annual incidence of Diagnostic Interview Schedule/DSM-III social phobia was estimated at 9 per 1000 population per year. Onset of social phobia was associated with low education, never having been married and female gender. First onsets occurred throughout the life course of this adult sample. Nervousness, headache, panic spells, palpitations, other phobias, binge pattern of alcohol consumption, dysthymia and schizophrenic symptoms were also predictive of social phobia onset. There was no difference in predictive factors when "primary" social phobia (without premorbid panic) was analyzed separately.