Childhood environment of women having panic disorder with agoraphobia

Are there associations between early emotional trauma and anxiety disorders? Evidence from a systematic literature review and meta-analysis

BACKGROUND

Previous studies indicate a possible association between early emotional trauma (EET) and the development of anxiety disorders (ADs) in adult life. However, no previous studies have compiled the findings of such studies and analyzed their statistical significance. Therefore, the objective of this study was to conduct a systematic literature review and meta-analysis to determine possible associations between EET and three ADs (panic, generalized anxiety, and social anxiety disorders).

METHODS

A systematic search was conducted in PubMed, PsycInfo, and Scielo with no publication date limitations. A total of 2127 studies were found, 32 studies of which were selected for the systematic review and 13 studies of which were selected for the meta-analysis.

RESULTS

High prevalence rates of different EETs were observed among the individuals with ADs (median: 18%-45%). The results of the meta-analysis indicated that individuals with EETs were 1.9- to 3.6-fold more likely to develop ADs compared with a control group of healthy individuals. Emotional traumas were the main risk factor for social anxiety disorder. However, no specific associations were found for the other ADs.

CONCLUSIONS

EET is a risk factor for ADs, underscoring the importance of preventive measures to combat the development of these disorders. Moreover, the identification of EETs among patients with ADs is essential for implementing remedial measures to minimize the impact and damage arising from this association by decreasing the risk and severity of symptoms and to improve the response rate to treatment of ADs.

Life events in panic disorder-an update on "candidate stressors"

Studies on gene-environment interactions in mental disorders are characterized by powerful genetic techniques and well defined "candidate genes," whereas a definition of "candidate stressors," in most cases assessed in the form of life events (LEs), is inconsistent or not even provided. This review addresses this problem, with particular attention to the clinical phenotype of panic disorder (PD), by providing an overview and critical discussion for which life events are known to contribute to the etiology of the disease and how they may be conceptualized. There is converging evidence for a significant impact of cumulative as well as specific life events, such as threat, interpersonal and health-related events in adulthood, and abuse or loss/separation experiences in childhood, respectively, on the pathogenesis of panic disorder with some overlapping effect across the anxiety disorder spectrum as well as on comorbid major depression. Besides genetic vulnerability factors, personality and behavioral characteristics, such as anxiety sensitivity, neuroticism, and cognitive appraisal might moderate the influence of LEs on the development of panic disorder. The present state of knowledge regarding the specification and conceptualization of LEs in PD within a more complex multifactorial model, involving mediating and moderating factors in between genes and the clinical phenotype, is hoped to aid in informing future gene-environment interaction studies in panic disorder.

Agoraphobia: a review of the diagnostic classificatory position and criteria

The status of agoraphobia (AG) as an independent diagnostic category is reviewed and preliminary options and recommendations for the fifth edition of The Diagnostic and Statistical Manual (DSM-V) are presented. The review concentrates on epidemiology, psychopathology, neurobiology, vulnerability and risk factors, clinical course and outcome, and correlates and consequences of AG since 1990. Differences and similarities across conventions and criteria of DSM and ICD-10 are considered. Three core questions are addressed. First, what is the evidence for AG as a diagnosis independent of panic disorder? Second, should AG be conceptualized as a subordinate form of panic disorder (PD) as currently stipulated in DSM-IV-TR? Third, is there evidence for modifying or changing the current diagnostic criteria? We come to the conclusion that AG should be conceptualized as an independent disorder with more specific criteria rather than a subordinate, residual form of PD as currently stipulated in DSM-IV-TR. Among other issues, this conclusion was based on psychometric evaluations of the construct, epidemiological investigations which show that AG can exist independently of panic disorder, and the impact of agoraphobic avoidance upon clinical course and outcome. However, evidence from basic and clinic validation studies remains incomplete and partly contradictory. The apparent advantages of a more straightforward, simpler classification without implicit hierarchies and insufficiently supported differential diagnostic considerations, plus the option for improved further research, led to favoring the separate diagnostic criteria for AG as a diagnosis independent of panic disorder.

Childhood and Adult Sexual Abuse

Questions concerning sexual abuse before and after the age of 16 years were included in a general population survey of a representative sample of 1052 UK women and 975 UK men. In relation to women 12.5% reported experiencing some form of sexual abuse before the age of 16 years. The corresponding figures for men in this category were 11.7%. After the age of 16 the figure for women remained at this level. However the proportion of men reporting these traumatic experiences dropped to 3.2%. Sexual abuse both pre and post age 16 was associated with 'addictive' or 'problem' behaviours such as those associated with eating too much (for women), sexual activity and Internet use (for men).

Separation anxiety disorder in childhood as a risk factor for future mental illness

OBJECTIVE

To ascertain the extent to which childhood separation anxiety disorder (SAD) confers risk for the development of psychopathology during young adulthood (ages 19-30).

METHOD

A subset of the participants of the Oregon Adolescent Depression Project (n = 816) was used. Subjects provided retrospective reports of lifetime mental illness (including SAD) and concurrent reports of current mental illness at age 16 and were then followed prospectively until age 30. Diagnostic assessments were conducted twice during adolescence and again at ages 24 and 30. Based on diagnosis during childhood/adolescence, the subjects were partitioned into four orthogonal groups: SAD (n = 42), other anxiety disorders (n = 88), a heterogeneous psychiatric disorders control group (n = 389), and a not mentally ill control group (n = 297). Adjusting for demographic variables that were significantly associated with group status and for comorbid disorders prior to age 19, the results were analyzed with hierarchical multiple logistic regression.

RESULTS

SAD was a strong (78.6%) risk factor for the development of mental disorders during young adulthood. The major vulnerabilities were for panic disorder and depression.

CONCLUSIONS

Because SAD creates a major vulnerability for mental disorders during young adulthood, clinicians should be sensitive to the presence of SAD, and children and adolescents with SAD should be treated. Future research should evaluate whether successful treatment of SAD and/or the provision of a preventive intervention during childhood/adolescence reduce the risk for future psychopathology.

Does Repression Exist? Memory, Pathogenic, Unconscious and Clinical Evidence

The current dispute regarding the existence of repression has mainly focused on whether people remember or forget trauma. Repression, however, is a multidimensional construct, which, in addition to the memory aspect, consists of pathogenic effects on adjustment and the unconscious. Accordingly, in order to arrive at a more accurate decision regarding the existence of repression, studies relevant to all three areas are reviewed. Moreover, since psychoanalysis regards repression as a key factor in accounting for the development and treatment of neurotic disorders, relevant research from these two domains are also taken into account. This comprehensive evaluation reveals little empirical justification for maintaining the psychoanalytic concept of repression.

Parental control in the etiology of anxiety

Anxiety disorders are among the most prevalent forms of adult and childhood psychiatric disorders, and they are highly familial. However, the mechanisms of transmission remain unclear. One familial characteristic that may promote the development of anxiety is the construct of parental control. This paper provides a conceptual overview of the construct of control in the parenting and anxiety literatures, reviews existing literature on control in anxious families, and reviews current conceptual models of and developmental approaches to anxiety. Based on the current empirical literature, an elaborated model that takes child developmental level into consideration is proposed in order to provide a better understanding of the role of parental control in the development of anxiety.

The development and maintenance of anxiety symptoms from infancy through adolescence in a longitudinal sample

This study examined the etiology and course of anxiety symptoms from infancy through adolescence in a longitudinal high-risk community sample. One hundred fifty-five subjects were assessed using a variety of observational, projective, and objective measures. Results of path analyses revealed the following: (a) anxiety symptoms showed moderate stability during childhood and adolescence; (b) heightened neonatal biobehavioral reactivity and poor regulation predicted emotion regulation difficulties in preschool, which predicted anxiety symptoms in childhood; (c) developmental incompetence in childhood predicted anxiety symptoms in preadolescence, and anxiety symptoms in preadolescence predicted incompetence in adolescence; (d) insecure attachment relationships in infancy predicted negative peer relationship representations in preadolescence, and these representations predicted anxiety symptoms in adolescence; (e) compared to males, females showed similar rates of anxiety symptoms in childhood but greater and more stable rates in adolescence; however, males and females showed similar patterns of association between risk factors and anxiety symptoms across childhood and adolescence; and (f) the model tested was specific in predicting anxiety symptoms and not psychopathology in general. The results support a developmental model of the etiology and maintenance of anxiety symptoms in childhood and highlight factors to consider in efforts to prevent and treat childhood anxiety.

Parental emotional support and subsequent internalizing and externalizing problems among children

This study examined the association between early emotional support provided by parents and child internalizing and externalizing problems, using a nationally representative, longitudinal sample of 1361 children. Parental emotional support was assessed using the Home Observation for the Measurement of the Environment, incorporating both parent report and interviewer observation. We found that, controlling for child externalizing problems at age 6 years, parental emotional support at age 6 years was negatively related to child externalizing problems at age 8 years. A developmental model that assessed the timing of the emergence of this relationship was then analyzed by including parental emotional support at ages 2, 4, and 6 years as predictors of child externalizing problems at age 8 years. The developmental model suggested that less parental emotional support as early as age 2 years is associated with later externalizing problems in children. This study discusses the importance of very early parental emotional support in promoting positive child development.

Early adversity and the prospective prediction of depressive and anxiety disorders in adolescents

The current study was a prospective exploration of the specificity of early childhood adversities as predictors of anxiety and depressive disorders in adolescents. Participants were 816 adolescents (414 males, 402 females) with diagnostic information collected at age 15; information on early adversities had been collected from the mothers during pregnancy, at birth, age 6 months, and age 5 years for a related study. Adolescents with "pure" anxiety disorders were compared with adolescents with "pure" depressive disorders (major depressive disorder, dysthymia), and these groups were compared to never-ill controls. Analyses controlled for gender and maternal depression and anxiety disorders. Results indicated that adolescents with anxiety disorders were more likely than depressed youth to have been exposed to various early stressors, such as maternal prenatal stress, multiple maternal partner changes, and more total adversities, whereas few early childhood variables predicted depressive disorders. Even when current family stressors at age 15 were controlled, early adversity variables again significantly predicted anxiety disorders. Results suggest that anxiety disorders may be more strongly related to early stress exposure, while depressive disorders may be related to more proximal stressors or to early stressors not assessed in the current study.

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.

The panic-agoraphobic spectrum: development, description, and clinical significance

The results of the authors' research efforts to date support the idea that the panic-agoraphobic spectrum is a robust and culturally transferable construct with important clinical implications for patients with mood and anxiety disorders. In particular, their findings suggest the need for alternate treatment strategies to treat mood patients with comorbid panic features [50,52]. They maintain that the spectrum approach could add to the knowledge of course and outcome of mood and anxiety disorders and inform treatment decisions. The spectrum concept has other potential implications. For the purposes of neurobiologic research, reliable identification of phenotypes that map [Figure 3: see text] onto specific brain processes in crucial. The definition of the diathesis phenotype is also important if we are to elucidate the cause and pathophysiology of mental disorders at a molecular level. A panic-agoraphobic spectrum assessment incorporate temperamental features and trait-like manifestations into a comprehensive symptom assessment to provide a detailed picture of the clinical features of PD. Such an approach holds some promise for progress in studies of neurobiologic basis of panic and may be useful in further efforts to overcome the nagging problem of the ambiguous boundaries of DSM diagnostic categories [53].

The behavior of anxious parents: examining mechanisms of transmission of anxiety from parent to child

Examined the behavior of anxious parents in interactions with their children (ages 6 to 12 years) to test hypotheses about possible psychosocial mechanisms of transmission of anxiety from parent to child. Fifty-one parent-child dyads completed the study. Parents and children were assessed with structured interviews and participated in 2 tasks that were videotaped and coded. Twenty-five dyads had an anxious parent. Primary diagnoses of the anxious group were mostly panic disorder (PD), with or without agoraphobia (AG), social phobia (SP), and generalized anxiety disorder. Anxious participants were excluded if they presented a secondary diagnosis other than another anxiety disorder. Control parents had no present or past diagnosis. Observational data revealed that anxious parents were significantly less productively engaged and more withdrawn and disengaged during the interactions but did not differ from nonanxious parents in terms of overall levels of control. Sequential analyses indicated that there was a trend for both parent group and child sex to effect efforts to control the interaction in response to child expression of negative affect. Implications of these results for a mediational role of parental behavior in the development and maintenance of child anxiety are discussed.

Recollections of parent-child relationships in patients with obsessive-compulsive disorder and panic disorder with agoraphobia

OBJECTIVE

In previous studies, patients with different psychiatric conditions, as compared with matched controls, have reported that their parents were more protective and less caring towards them when they were children. However, studies investigating associations between parental behaviours and anxiety disorders have yielded inconsistent results. The aim of this study was to compare recalled parental behaviours in out-patients with obsessive-compulsive disorder (OCD), in out-patients with panic disorder with agoraphobia (PDA), and in non-anxious controls.

METHOD

The sample included 43 out-patients with OCD, 38 with PDA, and 120 controls. Participants completed the Parental Bonding Instrument and the Egna Minnen Beträffande Uppfostran or Own Memories of Parental Rearing Experiences in Childhood.

RESULTS

No differences were found between the two anxious groups. However, compared with the control group, anxious patients recalled their parents as more protective.

CONCLUSION

Our findings suggest that child rearing practices such as overprotection may be a risk factor in the development of anxiety disorders.

Separation anxiety and actual separation experiences during childhood in patients with panic disorder

OBJECTIVE

The association between separation anxiety in childhood and actual separation experiences during childhood has not yet been investigated in patients with panic disorder.

METHODS

In 115 patients with panic disorder with or without agoraphobia and in 124 control subjects without a history of psychiatric illness, we assessed separation anxiety during childhood, retrospectively, using DSM-IV and ICD-10 criteria and the Separation Anxiety Symptom Inventory (SASI). In addition, actual separation experiences from age 0 to 15 years were assessed, retrospectively.

RESULTS

A total of 22.6% of the patients and 4.8% of the control subjects fulfilled both DSM-IV and ICD-10 criteria for childhood separation anxiety (chi 2 = 11.8; P < 0.0001). Further, 57.4% of the patients and 37.9% of the control subjects reported actual separation experiences during their childhood (chi 2 = 9.09, P < 0.003). Separation anxiety and actual separation experiences, however, were independent of each other.

CONCLUSION

These results suggest that separation anxiety during childhood is not a consequence of actual traumatic separation experiences in panic disorder patients.

Panic disorder and perceived parental rearing behavior investigated by the Japanese version of the EMBU scale

Although recent studies have found dysfunctional parental rearing behaviour is associated with certain aspects of psychopathology of panic disorder (PD), the results are not in complete agreement. By using a translated Japanese version of the EMBU (Egna Minnen Beträffande Uppfostran), we investigated the parental rearing behavior perceived by 103 normal subjects, 71 PD patients with agoraphobia, and 32 PD patients without agoraphobia. The PD patients scored both parents as more rejecting and overprotective than did the controls. However, subgroup analysis showed that the patients with agoraphobia reported significantly more rejection from both parents and less emotional warmth from mothers, while the patients without agoraphobia, by contrast, reported more overprotection from both parents and more favouring subject from fathers than did the controls. Interestingly, these results were consistent with those documented in the Western literature, which reported "affectionless control" as a parenting style in PD, and, furthermore, indicated a cross-cultural similarity of parental rearing factor. In addition, it was suggested that a lack of care might be associated with the development of agoraphobia in Japan.

Is there an adult form of separation anxiety disorder? A brief clinical report

OBJECTIVE

The aim of this clinical report is to investigate whether symptoms of separation anxiety disorder can occur in adulthood.

CLINICAL PICTURE

Three cases are described to illustrate that adults may experience: wide-ranging separation anxiety symptoms, such as extreme anxiety and fear, when separated from major attachment figures; avoidance of being alone; and fears that harm will befall those close to them. Symptoms of panic appeared to be secondary to separation anxiety, and none of the patients fulfilled criteria for dependent personality disorder.

TREATMENT

Group cognitive behavioural treatment focusing on preventing panic attacks and generalised anxiety did not appear to have an impact on core separation anxiety symptoms.

OUTCOME

Exacerbations of separation anxiety appeared to be closely linked to actual or threatened ruptures to primary bonds.

CONCLUSIONS

Separation anxiety disorder may be a neglected diagnosis in adulthood. Formal nosological systems such as the DSM may need to be revised to incorporate adult manifestations of the disorder.

Relationships between anxiety sensitivity, hyperventilation, and emotional reactivity to displays of facial emotions

Undergraduate women who scored in the top (n = 24) and bottom 15% (n = 24) on the Anxiety Sensitivity Index viewed randomly counterbalanced sets of three neutral and three dysphoric faces after having either hyperventilated or relaxed. Participants rated the amount of change they experienced in Happiness, Sadness, Fear, Anger, Surprise, Disgust, and Contempt after viewing each face. High Anxiety Sensitive (AS) women reported significantly greater changes on six of the seven emotions, even though pretreatment differences in somatically experienced anxiety were covaried out. Significant three-way interactions were found for participants self-rated changes in Fear and Surprise, with tendencies toward significance (p < .10) also emerging for Anger and Disgust. The pattern of interactions was identical for all four variables. Low AS women manifested greater reductions in these four emotions when viewing neutral as opposed to dysphoric faces, regardless of whether they hyperventilated or relaxed. High AS women who relaxed manifested similar discriminative abilities. High AS women who hyperventilated, however, reported no relative changes in emotional arousal to both dysphoric and neutral faces. The blunted discrimination shown by high AS women who hyperventilated suggests that, when these individuals are in a physiologically challenged state, they may be less responsive to "early warning" indicators of social distress displayed by others which may, in turn, cause them to experience subsequent interpersonal difficulties.

Potential role of childrearing practices in the development of anxiety and depression

There is a vast literature describing the importance of childrearing factors in the development of anxiety and depression. Unfortunately, much of this work comes from diverse areas, has variable theoretical bases, and makes use of a variety of methods, each with its own limitations. Thus, conclusions about the state of the research are difficult to draw. This review pulls together literature related to childrearing factors and anxiety and depression from a wide variety of areas. Many of the studies are methodologically limited and results have been variable. Nevertheless, there is surprising consistency that suggests that rejection and control by parents may be positively related to later anxiety and depression. There is also more limited evidence to indicate that rejection may be more strongly associated with depression, whereas control is more specifically associated with anxiety. Limitations of the research are highlighted and specific suggestions for future research directions are discussed.

Is early separation anxiety a risk factor for adult panic disorder?: a critical review

Heightened levels of early separation anxiety (SA) have long been linked to the risk of adult panic disorder (PD), suggesting that the two types of anxiety arise from a common diathesis--a proposition that has considerably influenced the classification of the anxiety disorders. However, the SA-PD link remains contentious, with some recent studies failing to confirm that putative association. All published research studies investigating the relationship of early SA to PD and/or other anxiety disorders were reviewed. Taken as a whole, the evidence provides support for the SA-PD hypothesis, although the specificity of that relationship needs further clarification. Problems of sample selection, retrospective measurement of early SA and comorbid diagnoses limit the certainty with which inferences can be drawn from existing data. Nevertheless, a recent community-based study provides additional support for the SA-PD hypothesis. Possible developmental pathways linking SA to PD are considered. One possibility that has not received adequate research attention is that early SA disorder (SAD) may persist into adulthood, rendering the sufferer vulnerable to panic and other anxiety symptoms when confronted with salient life stressors. We conclude that it is premature to reject the SA hypothesis of PD. Only well-designed longitudinal studies can map the complex developmental pathways linking early and later manifestations of morbid anxiety.