Comorbidity and course of psychiatric disorders in a community sample of former prisoners of war

OBJECTIVE: The authors assessed DSM-III-R disorders among American former prisoners of war. Comorbidity, time of onset, and the relationship of trauma severity to complicated versus uncomplicated posttraumatic stress disorder (PTSD) were examined. METHOD: A community sample (N=262) of men exposed to combat and imprisonment was assessed by clinicians using the Structured Clinical Interview for DSM-III-R. RESULTS: The rates of comorbidity among the men with PTSD were lower than rates from community samples assessed by lay interviewers. Over one-third of the cases of lifetime PTSD were uncomplicated by another axis I disorder; over one-half of the cases of current PTSD were uncomplicated. PTSD almost always emerged soon after exposure to trauma. Lifetime PTSD was associated with increased risk of lifetime panic disorder, major depression, alcohol abuse/dependence, and social phobia. Current PTSD was associated with increased risk of current panic disorder, dysthymia, social phobia, major depression, and generalized anxiety disorder. Relative to PTSD, the onset of the comorbid disorders was as follows: major depression, predominantly secondary; alcohol abuse/dependence and agoraphobia, predominantly concurrent (same year); social phobia, equal proportions primary and concurrent; and panic disorder, equal proportions concurrent and secondary. Trauma exposure was comparable in the subjects with complicated and uncomplicated PTSD. CONCLUSIONS: The types of comorbid diagnoses and their patterns of onset were comparable to the diagnoses and patterns observed in other community samples. The findings support the validity of the PTSD construct; PTSD can be distinguished from comorbid disorders. Uncomplicated PTSD may be more common than previous studies suggest, particularly in clinician-assessed subjects exposed to severe trauma.     

Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder

Previous research has found high rates of psychiatric disorders among veterans with war zone-related posttraumatic stress disorder (PTSD). However, many studies in this area are methodologically limited in ways that preclude unambiguous interpretation of their results. The purpose of this study was to address some of these limitations to clarify the relationship between war zone-related PTSD and other disorders. Participants were 311 male Vietnam theater veterans assessed at the National Center for PTSD at the Boston Veterans Affairs Medical Center. The Clinician-Administered PTSD Scale and the Structured Clinical Interview for DSM-III-R were used to derive current and lifetime diagnoses of PTSD, other axis I disorders (mood, anxiety, substance use, psychotic, and somatoform disorders), and two axis II disorders (borderline and antisocial personality disorders only). Participants also completed several self-report measures of PTSD and general psychopathology. Relative to veterans without PTSD, veterans with PTSD had significantly higher rates of current major depression, bipolar disorder, panic disorder, and social phobia, as well as significantly higher rates of lifetime major depression, panic disorder, social phobia, and obsessive-compulsive disorder. In addition, veterans with PTSD scored significantly higher on all self-report measures of PTSD and general psychopathology. These results provide further evidence that PTSD is associated with high rates of additional psychiatric disorders, particularly mood disorders and other anxiety disorders. The implications of these findings and suggestions about the direction of future research in this area are discussed.     

Prevalence of comorbid anxiety disorders in primary care outpatients

OBJECTIVE: To estimate the extent to which anxiety disorders (eg, panic disorder, phobia, and generalized anxiety disorder [GAD]) co-occur in patients with major medical and psychiatric conditions. DESIGN: Observational study. SETTING: Offices of primary care providers in three US cities, with mental health specialty providers included for comparative purposes. PATIENTS: Adult patients (N = 2494) with hypertension, diabetes, heart disease (congestive heart failure or myocardial infarction), current depressive disorder, or subthreshold depression. MEASURES: Current (past 12 months) and lifetime panic disorder, phobia, GAD, perceived need for help for emotional or family problems, and unmet need (ie, failure to get help that was needed). METHODS: Comparisons of the prevalence of anxiety comorbidity in medically ill nondepressed patients of primary care providers and in depressed patients of both primary care and mental health specialty providers. RESULTS: Among primary care patients, those with chronic medical illnesses or subthreshold depression had low rates of lifetime (1.5% to 3.5%) and current (1.0% to 1.7%) panic disorder, but those with current depressive disorder had much higher rates (10.9% lifetime and 9.4% current panic disorder). Concurrent phobia and GAD were more common (10.4% to 12.4% current GAD), especially among depressed patients (25% to 54% current GAD). Depending on the type of medical illness or depression, 14% to 66% of primary care patients had at least one concurrent anxiety disorder. Patient-perceived unmet need for care for personal or emotional problems was high among all primary care patients (54.6% to 72.9%). CONCLUSION: Primary care clinicians should be aware of the possible coexistence of anxiety disorders (especially GAD) among their patients with chronic medical conditions, but especially among those with current depressive disorder.     

Examining a dimensional representation of depression and anxiety disorders' comorbidity in psychiatric outpatients with item response modeling.

The current study replicated, in a sample of 2,300 outpatients seeking psychiatric treatment, a previous study (R. F. Krueger & M. S. Finger, 2001) that implemented an item response theory approach for modeling the comorbidity of common mood and anxiety disorders as indicators along the continuum of a shared latent factor (internalizing). The 5 disorders examined were major depressive disorder, social phobia, panic disorder/agoraphobia, specific phobia, and generalized anxiety disorder. The findings were consistent with the prior research. First, a confirmatory factor analysis yielded sufficient evidence for a nonspecific factor underlying the 5 diagnostic indicators. Second, a 2-parameter logistic item response model showed that the diagnoses were represented in the upper half of the internalizing continuum, and each was a strongly discriminating indicator of the factor. Third, the internalizing factor was significantly associated with 3 indexes of social burden: poorer social functioning, time missed from work, and lifetime hospitalizations. Rather than the categorical system of presumably discrete disorders presented in DSM-IV, these 5 mood and anxiety disorders may be alternatively viewed as higher end indicators of a common factor associated with social cost. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rethinking the mood and anxiety disorders: A quantitative hierarchical model for DSM-V.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." There are now sufficient data to eliminate this rational system and replace it with an empirically based structure that reflects the actual similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching class of emotional disorders, which can be decomposed into 3 subclasses: the bipolar disorders (bipolar I, bipolar II, cyclothymia), the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), and the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia). The optimal placement of other syndromes (e.g., obsessive-compulsive disorder) needs to be clarified in future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical characteristics of patients with concurrent major depressive disorder and panic disorder

OBJECTIVE: This study was designed to test the hypothesis that patients with both major depressive disorder and panic disorder exhibit more clinical symptoms and have a more protracted course of illness than patients with major depressive disorder only. METHOD: The authors compared standardized clinical evaluations (from Schedule for Affective Disorders and Schizophrenia interviews) of 119 patients with major depressive disorder only and 57 patients with major depressive disorder and concurrent panic disorder. Clinical and demographic variables were included. RESULTS: The patients with both disorders reported symptoms of major depressive disorder earlier in life and also required treatment and hospital admission earlier in life. Many clinical features during the index episode were significantly more severe in the patients with both disorders. A logistic regression identified a "panic index" consisting of the symptoms of somatic anxiety, phobia, indecisiveness, and feelings of inadequacy. Scores on this index allowed proper classification of patients to either of the two diagnostic groups with high reliability. CONCLUSIONS: In major depressive disorder, the presence of panic disorder is suggestive of a more severe and precocious form of illness.     

Comorbid anxiety disorders and treatment of depression in people with multiple sclerosis.

Objective: Anxiety is highly comorbid with depression, but little is known about the impact of anxiety disorders on the effectiveness of empirically supported psychotherapies for depression. We examined such outcomes for people with Multiple Sclerosis (MS) and depression, with versus without comorbid anxiety disorders. Design: Participants with MS (N = 102) received 16 weeks of telephone-administered psychotherapy for depression and were followed for one year post-treatment. Results: Participants with comorbid anxiety disorders improved to a similar degree during treatment as those without anxiety disorders. Outcomes during follow-up were mixed, and thus we divided the anxiety diagnoses into distress and fear disorders. The distress disorder (GAD) was associated with elevated anxiety symptoms during and after treatment. In contrast, fear disorders (i.e., panic disorder, agoraphobia, social phobia, specific phobia) were linked to depression, specifically during follow-up, across 3 different measures. Conclusions: People with GAD receiving treatment for depression may benefit from additional services targeting anxiety more specifically, while those with comorbid fear disorders may benefit from services targeting maintenance of gains after treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting prospective episodes of depression in patients with panic disorder: A longitudinal study.

This study used a naturalistic, longitudinal study to examine predictors of the emergence of major depression among 90 nondepressed patients with panic disorder who were followed for a 2-yr period. 24% of the sample experienced a major depressive episode during the study period. Adequacy and type of medication treatment were not associated with decreased risk. Past history of major depression was associated with a greater risk for a prospective episode. The degree of assertiveness, presence of comorbid generalized anxiety disorder, and severity of agoraphobia were each significant predictors of the occurrence of depression when considered alone and when the influence of past history of depression was statistically controlled. The implications of these findings for the clinical management of patients with panic disorder are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I psychopathology in individuals with traumatic brain injury

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.     

Recent developments in the psychopharmacology of anxiety disorders.

Anxiety disorders are the most prevalent mental disorders in the United States. In the past 3 decades, substantial advances have been made in the ability to identify and treat anxiety disorders including panic disorder (PD), social phobia (SP), obsessive–compulsive disorder (OCD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). It is now known that these common, usually chronic disorders confer significant disability to untreated sufferers. This overview highlights some of the important advances in pharmacological treatment of anxiety disorders. Evidence for efficacy of the various pharmacological agents (including relevant oral dosing and plasma-level data) and of acute and long-term treatment, and the disadvantages of medication treatment are discussed. Finally, some important clinical questions remaining to be addressed by psychopharmacological research are reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia: an update

The literature on social phobia is reviewed in this article. Social phobia has undergone considerable diagnostic evolution to reach its present form in DSM-IV. Its differential diagnosis includes panic disorder with agoraphobia, avoidant personality disorder, depression, and "shyness." Cross-cultural issues are important to consider because the disorder may manifest differently in different cultures and social settings. It is common, with a lifetime prevalence of 13.3% in the United States according to recent epidemiological studies. Underrecognition of social phobia remains an issue of concern. Comorbidity with other psychiatric disorders, including other anxiety disorders, depression, alcohol abuse, and personality disorders, frequently occurs. Current conceptualizations of the etiology of social phobia reflect psychodynamic theories and evidence from family and genetic studies, neurobiological research, and neuroimaging. Drugs such as monoamine oxidase inhibitors, selective serotonin-reuptake inhibitors, benzodiazepines, and beta3-adrenergic blockers have proven to be efficacious, as has cognitive-behavioral treatment, including group approaches.     

Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders

BACKGROUND: The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity. METHOD: Cross-sectional and prospective data on 20,291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period. RESULTS: Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder. CONCLUSIONS: Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.     

The ethical problems of the open label extension study

OBJECTIVE: Comorbidity between anxiety and substance use disorders was examined. The hypothesis was tested that social phobics may report greater problem alcohol use (if alcohol is used to manage social anxiety) while problem use of sedative-hypnotics may be greater in people with panic (who may be over-prescribed anxiolytics because they repeatedly seek medical assistance). METHOD: Self-reported lifetime rates of drug and alcohol problems were assessed with the computerised Diagnostic Interview Schedule-Revised. Subjects were 146 consecutive patients treated for panic disorder (with and without agoraphobia) and social phobia at the Clinical Research Unit for Anxiety Disorders. RESULTS: High prevalences of alcohol problems (three times that expected) and problem use of sedative hypnotics (eight times that expected) were found in all diagnoses. Social phobics exhibited comparatively high rates of problem alcohol use, but no diagnostic specific differences in problem sedative-hypnotic use were found. CONCLUSION: Routine screening for drug and alcohol problems is necessary for patients with anxiety disorders.     

Confirmatory factor analysis of the Fear Questionnaire in panic disorder with agoraphobia.

The Fear Questionnaire responses of 390 patients with panic disorder with agoraphobia were used in a confirmatory factor analysis. The results provide strong support for the 3-factor model of this scale (agoraphobia, social phobia, blood/injury phobia) and the multidimensional model of fears proposed by W. A. Arrindell (1980). The presence of fear clusters other than agoraphobia existing in panic disorder is also discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tumor enucleation as the conservative treatment of choice for renal carcinoma

BACKGROUND: The coexistence of other psychiatric disorders in patients with bulimia nervosa is of major clinical and theoretical interest. We therefore studied a group of consecutively evaluated bulimic patients. METHOD: The Structured Clinical Interview for DSM-III-R (SCID) was administered to a sample of 59 female patients with DSM-III-R-defined bulimia nervosa. RESULTS: The following frequencies of lifetime Axis I comorbid diagnoses were found (in decreasing frequency): any affective disorder (75%), major depressive disorder (63%), any anxiety disorder (36%), any substance abuse disorder (20%), social phobia (17%), generalized anxiety disorder (12%), and panic disorder (10%). In the 44 cases with an affective disorder, 27 (61%) had the onset of affective disorder, 27 (61%) had the onset of their affective disorder prior to the onset of their bulimia, 15 (34%) afterward, and 2 (5%) concurrently. In the 21 cases with any anxiety disorder, 15 (71%) had the onset of their anxiety disorder prior to the onset of their bulimia, 4 (19%) afterward, and 2 (10%) concurrently. CONCLUSION: These data confirm previous reports of a strong association between bulimia nervosa and affective illness, which in most cases precedes the eating disorder. In addition, a high frequency of anxiety disorders, particularly social phobia, is seen in bulimic patients.     

Paroxetine: a review of clinical experience

The selective serotonin reuptake inhibitor paroxetine has been extensively studied and is now an established therapy for the treatment of depressive disorders. Paroxetine has demonstrated efficacy in major depression in both young and elderly patients, with an improved tolerability profile over conventional antidepressants. Paroxetine is effective across a continuum of anxiety and depressive disorders, including severe depression, depression with anxiety, comorbid depression and obsessive-compulsive disorder. The first agent of its class licensed for use in panic disorder, paroxetine has been shown to be effective in reducing the number of panic attacks and preventing relapse. A worldwide clinical database has established that paroxetine has a benign adverse event profile. Paroxetine therefore offers an effective and well tolerated treatment for a broad spectrum of psychiatric disorders.     

The relationship between anxiety disorders and age

OBJECTIVES: To review the major community-based epidemiological studies that have reported data on anxiety disorders in individuals aged 65 and over and to examine age-related changes in their prevalence and incidence. DATA SOURCES AND STUDY SELECTION: All English language entries relating to anxiety in the BIDS, EMBASE, Medline and PsychLit computerized databases, together with a search of relevant citations. DATA SYNTHESIS: The prevalence of phobic disorders in the population aged 65 or over lies between 0.7% and 12% over a 1-6-month period. As the rates for social phobia, 1%, and simple phobia, 4%, are fairly consistent, much of this variation is due to agoraphobia, whose prevalence lies between 1.4% and 7.9%. The prevalence of obsessive-compulsive disorder is 0.1-0.8%, panic disorder 0.1% and generalized anxiety 4%. Women do have a higher prevalence of anxiety disorders than men but this difference diminishes with increasing age, as does the apparent prevalence of all anxiety disorders apart from generalized anxiety, measured without hierarchical rules, which appears to be maintained or increase. The relative importance of various explanations for this apparent reduction is discussed, including the three that are of greatest public health and clinical importance: cohort effects, anxiety-related mortality and comorbidity between anxiety and cognitive impairment. A tri-dimensional approach (psychic, somatic and behavioural) to anxiety measurement is advocated in order to facilitate future studies of age-related changes which may lead to a reappraisal of the status of generalized anxiety as a 'residual category'.     

Cognitive-behavioral group therapy for panic disorder in the general clinical setting: a naturalistic study with 1-year follow-up

BACKGROUND: Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder. As most investigators have studied selected patients without comorbid disorders, it is less clear how well the treatment will perform in the usual clinical setting for patients with comorbid disorders and with physicians who do not have training in CBT. During the last 6 years, we have offered CBT in outpatient groups for patients with panic disorder and agoraphobia. The purpose of this prospective study was to assess the outcome of group treatment and compare the results with those of studies that used individual treatment. We wanted to identify variables that might predict outcome at follow-up and to assess the number and characteristics of dropouts. METHOD: Eighty-three consecutive patients with DSM-III-R panic disorder (56 women and 27 men; mean age = 34.5 years) were studied. Mean duration of panic disorder was 7.5 years. There was a high degree of comorbid major depression, social phobia, and psychoactive substance abuse/dependence. Treatment consisted of 4-hour group sessions conducted once a week for 11 weeks. More than half of the patients used antidepressant drugs. Degree of phobic avoidance, bodily sensations, anxiety cognitions, and depression were assessed at pretreatment, baseline, and end of treatment and at follow-up after 3 and 12 months. RESULTS: There was a large decrease in scores from start to end on all assessments. Sixty-three (89%) of 73 completers responded (> or = 50% reduction in Phobic Avoidance Rating Scale scores). Gains were maintained and even improved upon at follow-up. The results are comparable with studies that used individual therapy. A high depression score at the end of treatment predicted poor outcome at 1-year follow-up. Twelve (14%) of 83 did not complete the program. The presence of severe personality disorders and ongoing alcohol or substance abuse or dependence was associated with poor outcome and high dropout rate. CONCLUSION: CBT appears to be effective in the usual clinical setting, even in the hands of therapists without formal competence. Group therapy is a feasible arrangement, and the results from group treatment are comparable to those of individual approaches. Precise diagnosis and treatment of comorbid depression are of utmost importance. Patients with additional substance abuse or dependence, as well as severe personality disorders, may find this treatment modality less helpful.     

Explicit memory in anxiety disorders.

Two experiments were conducted to study selective memory bias favoring anxiety-relevant materials in patients with anxiety disorders. In the 1st experiment, 32 patients with generalized anxiety disorder (CAD), 30 with social phobia (speaking anxiety), and 31 control participants incidentally learned CAD-relevant words, speech anxiety-relevant words, strongly pleasant words, and words with a neutral valence. Participants did not show any explicit memory bias for threatening materials. Thirty patients suffering from panic disorder (PD) with agoraphobia and 30 controls took part in the 2nd experiment. The design was similar to the 1st experiment. This time a highly specific selective memory bias for threatening words was found. Words describing symptoms of anxiety were better recalled by PD patients. Results are consistent with previous findings but are inexplicable by existing theories. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical features in panic disorder with agoraphobia: a comparison of men and women

This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.