Comorbid Panic Disorder Research Articles

Clinical correlates of planned, more lethal suicide attempts in major depressive disorder

BackgroundAssessment of suicide plans is standard in acute psychiatric care, but there is a limited evidence base to guide this routine clinical practice. The purpose of this study was to investigate clinical correlates of suicide planning in depressed patients. Methods151 patients with major depressive disorder and a lifetime history of suicide attempt were studied. Subjects received a comprehensive evaluation including structured diagnostic interview for Axis I and II disorders, current symptoms, impulsivity, and systematic assessment of suicide planning prior to the most recent suicide attempt. ResultsSeriousness of suicide attempt planning correlated with lethality of suicidal acts. Comorbid anxiety disorder and anxiety correlated with less suicide planning. Specifically, this negative correlation was with comorbid panic disorder. Planning did not correlate with severity of depression or aggressive/impulsive traits. LimitationsCross-sectional design, retrospective recall of suicide planning data, limited applicability to completed suicide or other psychiatric disorders. ConclusionsIn major depression, comorbid panic disorder appears protective against more carefully planned, higher lethality suicide attempts. Surprisingly, severity of depression and aggressive impulsive traits do not predict planning or lethality of suicide attempts. We have previously reported that anxiety severity protects against the probability of a suicide attempt and now extend that observation to show there is protection against lethality of a suicide attempt. Treatment of anxiety without directly treating major depression may place patients at greater risk of suicidal behavior.

Familiality of major depressive disorder and gender differences in comorbidity

Gender differences exist in the prevalence and psychiatric comorbidity of major depressive disorder (MDD). This study investigates whether familiality of MDD contributes to observed gender differences in comorbidity. Familial (f-MDD) and non-familial (nf-MDD) MDD cases from a population sample were assessed for comorbid dysthymia, anxiety disorders and alcohol-related disorders using the Composite International Diagnostic Interview (CIDI). Logistic regression analyses were performed to examine the effect of f-MDD on gender differences in comorbidity, adjusted for confounders. Women with f-MDD reported significantly more comorbid dysthymia and generalized anxiety disorder (GAD) than their male counterparts; women with nf-MDD reported significantly more comorbid simple phobias and agoraphobia than their male counterparts. Gender differences in comorbid panic disorder and alcohol-related disorders occurred independently of the familial load. Adjustment for age of onset, severity and recurrence of MDD did not change these results. Models to explain comorbidity patterns of MDD differ by gender. Familiality of MDD should be taken into account.

Biological challenge procedures used to study co-occurring nicotine dependence and panic disorder

A wide array of biological challenge procedures – including carbon dioxide inhalation, hyperventilation, and breath holding – have been used to model panic in laboratory settings. Originally used to study developmental processes in panic disorder (PD), these procedures, along with nicotine patch administration and self-administered smoking, have recently been applied to help understand the etiology of co-occurring nicotine dependence and PD. The goals of the present paper are to review studies that have employed biological challenges to study the comorbid condition, identify the advantages and limitations of the various procedures, describe desirable outcome measures for use in biological challenges, and present recommendations for future challenge studies in this field. We argue that biological challenges, though in need of standardization, are useful for studying the development, maintenance, prevention, and treatment of comorbid nicotine dependence and PD.

Different temperament and character dimensions correlate with panic disorder comorbidity in bipolar disorder and unipolar depression

Background This study aimed to investigate temperament and character correlates of panic disorder (PD) comorbidity in euthymic patients with bipolar disorder (BD) or unipolar depression (UD). Methods Temperament and character were assessed using the Temperament and Character Inventory Revised (TCI-R) in 181 patients (70 patients with BD-I, 51 patients with BD-II and 60 with UD) in a euthymic state for at least 2 months. Results PD was diagnosed in 14.3% of BD-I patients, 31.4% of BD-II and 40% of UD. BD patients with PD, when compared with BD patients without PD, had higher scores on harm avoidance (OR = 1.04; 95% CI = 1.02–1.07; p = 0.002). Patients with UD and PD, when compared to patients with UD without PD, had higher scores on social acceptance (OR = 1.27; 95% CI = 1.08–1.49; p = 0.004). Conclusion Different temperament and character dimensions correlated with PD comorbidity in BD and UD patients, suggesting different underlying pathophysiological mechanisms.

Restless Legs Syndrome is Associated with DSM-IV Major Depressive Disorder and Panic Disorder in the Community

The authors examined the association between restless legs syndrome (RLS) and DSM-IV major depressive disorder and panic disorder based on Wave III and IV of the Baltimore ECA follow-up study. Of 1071 participants, 1024 completed the RLS Questionnaire and Diagnostic Interview Schedule. Adjusted odds ratio for diagnosis of major depressive disorder (4.7, 95% confidence interval [1.6, 14.5]) and panic disorder (12.9 [3.6, 46.0]) and comorbidity of major depressive disorder and panic disorder (9.7 [1.4, 69.0]) in the past 12 months suggested a strong association between restless legs syndrome and major depressive disorder and/or panic disorder.

Treating comorbid panic disorder in veterans with posttraumatic stress disorder.

This study compares the effectiveness of panic control treatment (PCT) with that of a psychoeducational supportive treatment (PE-SUP) in treating panic disorder among a veteran sample with a primary diagnosis of chronic posttraumatic stress disorder (PTSD). Thirty-five patients randomized to receive 10 individual sessions of either PCT or PE-SUP underwent assessments at pretreatment, at 1-week posttreatment, and at a 3-month follow-up. Intent-to-treat analyses of covariance showed that PCT participants significantly improved on panic severity at posttreatment and panic fear at the 3-month follow-up. The PCT group also showed significant reductions in anxiety sensitivity at posttreatment and follow-up compared with that of the PE-SUP group. A significantly higher proportion of persons (63%) in the PCT group was panic free by the follow-up period compared with that of the PE-SUP group (19%). Patient self-report and clinician ratings showed no changes in general anxiety, depression, and PTSD symptoms in either group. These findings indicated that PCT was superior to an active control therapy in reducing the frequency, severity, and distress associated with panic disorder and suggested that brief cognitive-behavioral therapy for panic is effective for persons with chronic PTSD.

Joint Hypermobility in Schizophrenia: A Potential Marker for Co-Morbid Anxiety

Introduction: The objective is to evaluate the presence and clinical relevance of the Joint Hypermobility Syn- drome (JHS) among patients with schizophrenia. Methods: One hundred and twenty four outpatients with DSM-IV diagnosis of schizophrenia were assessed by means of the following: Hospital del Mar criteria for joint Hypermobility (JHdMar), Positive and Negative Syndrome Scale (PANSS), Fear Survey Schedule (FSS) and Social Adjustment Scale (SAS). Results: JHS correlated positively with FSS (rho= 0.36p<0.0001) and negatively with age (rho=-0.34; p=0.0001). When taken as a dichotomic variable, PANSS-P (positive subscale) scores were significantly higher in the group with JHS as well (Z=2.0; p=0.045). Subjects with co-morbid panic disorder scored significantly higher in the JHdMar. JHdMar scores were linked by stepwise multiple regression to panic disorder, positive symptoms, and age(-). Conclusion: Joint hypermobility is significantly related to panic anxiety, positive symptoms and age in patients with schizophrenia. It is a probable clinical biological marker of interest.

Sympathetic activity in major depressive disorder: identifying those at increased cardiac risk?

Evidence exists linking major depressive disorder (MDD) with clinical cardiovascular events. The importance of the sympathetic nervous system in the generation of cardiac risk in other contexts is established. To examine the importance of the sympathetic nervous system in the generation of cardiac risk in patients with major depressive disorder (MDD). Studies were performed in 39 patients meeting the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria for MDD and in 76 healthy subjects. Treatment for patients consisted of selective serotonin reuptake inhibition (SSRI) for 12 weeks. Whole body and cardiac sympathetic activity were examined using noradrenaline isotope dilution methodology and sympathetic nerve recording techniques. Measurement of the extraction of infused tritiated noradrenaline by the heart, and estimation of cardiac dihydroxyphenylglycol production provided direct quantification of neuronal noradrenaline reuptake. Sympathetic activity, particularly in the heart and for the whole body, in patients with MDD followed a bimodal distribution. Elevated values were observed in patients with co-morbid panic disorder (P = 0.006). Consistent with a defect in noradrenaline reuptake, the cardiac extraction of tritiated noradrenaline (0.80 +/- 0.01 versus 0.56 +/- 0.04%, P < 0.001) and cardiac dihydroxyphenylglycol overflow (109 +/- 8 versus 73 +/- 11, P = 0.01) were reduced in patients with MDD. SSRI therapy abolished the excessive sympathetic activation, with whole body noradrenaline spillover falling from 518 +/- 83 to 290 +/- 41 ng/min (P = 0.008). We have identified a subset of patients with MDD in whom sympathetic nervous activity is extraordinarily high, including in the sympathetic outflow to the heart. Treatment with an SSRI may reduce sympathetic activity in a manner likely to reduce cardiac risk.

P.3.a.022 Anxiety disorders comorbidity in patients with psychoses in remission phase after hospitalization

Eighty-seven patients with current episode of depression were assessed by the SCID-P and subdivided in bipolar depressives (N=24), unipolar depressives (n=38) and dysthymics (n=25). Anxiety disorders comorbidity in these three groups was investigated by means of the SCID-P. Panic disorder comorbidity was found in 36.8% of bipolar depressives, 31.4% of unipolar depressives and 13% of dysthymics. Prevalence of obsessive–compulsive disorder was 21.1% in bipolars, 14.3% in unipolars and 8.7% in dysthymics. Generalized anxiety disorder resulted in being much more associated with dysthymia (65.2%) than with bipolar (31.6%) or unipolar depression (37.1%). Social phobia comorbidity was exhibited mainly by unipolars (11.4%), while no cases were detected in the bipolar group. Odds ratios revealed that generalized anxiety disorder is significantly more likely to co-occur with dysthymia. Panic disorder showed a higher trend to be associated with bipolar and unipolar depression. Social phobia was more frequent among unipolar depression.

Retrospective Reports of Parenting in Depressed Adults With and Without Comorbid Panic Disorder and Social Anxiety Disorder

Previous research has examined the role of parenting in the development of depression and anxiety disorders using retrospective reports of parenting behaviors. However, most studies have not considered comorbidity; the few that have did not differentially examine individual anxiety disorders and yielded inconsistent results. The present study compared retrospective parenting reports given by depressed individuals with no comorbid anxiety disorder, comorbid panic disorder, and comorbid social anxiety disorder. Results indicated that depressed men with panic disorder reported significantly greater maternal and nonsignificantly greater paternal protectiveness than depressed men without panic disorder but not than depressed women with and without panic disorder. No differences were found for the retrospective parenting reports given by depressed participants with or without social anxiety disorder. This work highlights the importance of examining specific anxiety disorders rather than grouping all depressed patients with any anxiety disorder together, as well as examining males and females separately when investigating the influence of parental behavior.

Efficacy of Cognitive-Behavioral Therapy for Comorbid Panic Disorder With Agoraphobia and Generalized Anxiety Disorder

The goal of this study was to evaluate the efficacy of cognitive-behavioral therapy for comorbid panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) by combining treatment strategies for both disorders. A single-case, multiple-baseline design across participants was used. Three participants with primary PDA and secondary GAD took part in the study. The efficacy of the treatment was assessed by means of a structured interview, self-administered questionnaires, and daily self-monitoring measures. After treatment, 2 of the 3 participants achieved high end-state functioning and maintained this level of functioning at 3-, 6-, and 12-month follow-ups. The third participant also improved but only reached high end-state functioning at 6-month follow-up. It therefore appears that the combined treatment is relatively effective for PDA-GAD comorbidity. Possible avenues for improving the treatment are suggested.

Social phobia with sudden onset—Post-panic social phobia?

Overlap between social phobia (SP) and panic disorder (PD) has been observed in epidemiological, family, and challenge studies. One possible explanation is that some cases of SP develop as a consequence of a panic attack in a social situation. By definition, these cases of SP have sudden onset. It is hypothesized that patients with SP with sudden onset are more similar to patients with comorbid SP and PD than to patients with SP without sudden onset regarding age of onset, extraversion, and prevalence of anxiety symptoms. One hundred and eighty-two patients with a lifetime diagnosis of PD and/or SP were recruited as part of an etiological study. Patients with SP with sudden onset did, as hypothesized, differ from patients with SP without sudden onset with regard to age of onset and extraversion, but not with regard to symptoms. They did not differ markedly from patients with comorbid SP and PD. The concept of post-panic SP is discussed.

Clinical and research implications of panic-bipolar comorbidity in children and adolescents

A substantial portion of patients with juvenile bipolar disorder (BD) have a comorbid panic disorder (PD). The aim of our study was to analyze the cross-sectional and longitudinal implications of such comorbidity in children and adolescents with BD. The sample comprised 224 referred children and adolescents with BD, 140 males (62.5%) and 84 females (37.5%), mean age 13.8 ± 2.8 years, diagnosed with a clinical interview (K-SADS-PL), and followed up naturalistically for 6 months. Fifty-one BD patients (22.8%) had a lifetime diagnosis of comorbid PD. Subjects with BD + PD and those without BD (BD-noPD) did not differ according to index age, age at onset of BD and bipolar phenotype (episodic vs. continuous course, irritable vs. elated mood). BD + PD was more frequent in females, was less severe at baseline according to the Clinical Global Impression severity score, and was more frequently associated with BD type 2. Moreover, BD + PD presented higher rates of comorbid anxiety disorders (namely separation anxiety disorder) and lower rates of externalizing disorders, namely attention deficit disorder (ADHD) than BD-noPD. However, this different pattern of externalizing comorbidity did not affect severity and improvement. Our findings suggest that PD is frequently comorbid in juvenile BD and can influence severity, pattern of comorbidity and course of BD. The data are compatible with the hypothesis that Panic-BD and ADHD-BD might represent distinct developmental pathways of bipolar disorder. Further research on this question may prove rewarding.

Separation anxiety and panic disorder in clinically referred youth

This study examined whether youngsters with separation anxiety disorder (SAD) and panic disorder (PD) had experienced more separation-related events than youngsters with SAD (without comorbid PD). We also examined whether age of onset of SAD and comorbidity with other psychological disorders was related to the occurrence of PD. We compared youngsters who were diagnosed with SAD and PD ( N = 31) with youngsters who were diagnosed with SAD without comorbid PD ( N = 63) for the number of separation-related events, severity of psychopathology, and parent and child CBCL ratings, age of onset of SAD, and the number of comorbid diagnoses. The findings indicate that youngsters with SAD and PD had a later age of onset of SAD and more extensive psychopathology and functional impairment than youngsters with SAD (without comorbid PD). Contrary to hypothesis, there were no differences between the groups in the occurrence or number of separation-related events.

Panic disorder and suicidality: Is comorbidity with depression the key?

Background The relation between panic disorder and suicidal behavior has been surrounded by perennial controversy. A significant number of reports suggest that PD is associated with suicidal behavior. Alternatively, it has been proposed that comorbid depression may account for the increased suicidality identified in this population. Method A total of n = 474 consecutive psychiatric outpatient subjects were assessed for Axes I and II psychopathology and personality traits, as well as suicidal behavior, using structured interviews. Results Approximately half of the sample ( n = 250) reported suicidal ideation, either lifetime or during the 6 months prior to evaluation. In total, 200 subjects reported a history of suicide attempts. When comorbidity with depressive disorders (DD) was not taken into account, patients with Panic Disorder (PD) did not differ from those with a primary diagnosis of depressive disorder in terms of age, current or lifetime suicide ideation or number of suicide attempts. After separating the group characterized by PD comorbid with DD, PD only subjects had significantly lower number of suicide attempts compared to either DD ( p < 0.01) or comorbid PD–DD ( p < 0.05). Similar levels of SI were noted between PD, DD and PD–DD, both current and lifetime. Suicide attempters with PD, DD or both did not differ in terms of suicide intent or lethality. They were also similar on impulsivity, aggressive behavior and state-trait anxiety measures. Limitations Cross-sectional design, the limited sample size in the PD only group, retrospectively collected data with the possibility of recall bias. Conclusions In this clinical outpatient sample, the association between panic disorder and suicidal behavior was primarily explained by comorbidity with depressive disorders. No differences were observed between different groups for measures of severity of the suicidal behavior. Physicians should be aware of these associations when assessing adults with panic disorder for suicidality.

Panic disorder in later life: results from a national survey of Canadians

At present, our understanding of the risk markers associated with panic disorder among older, community dwelling older adults is limited. To address this gap, we examined the prevalence, risk markers, and comorbidity of panic disorder defined using DSM-IV criteria among older adults. Using data drawn from a large, nationally representative sample of Canadians, we estimated lifetime and 12-month prevalence of panic disorder, and examined demographic predictors and patterns of comorbidity of current panic disorder in adults aged 55 years and older (n = 12,792). The 12-month and lifetime prevalence estimates of panic disorder in this sample were 0.82% and 2.45% respectively, and one-fifth of these cases reported a first onset after the age of 55 years. In multivariate models, the risk of panic disorder decreased with older age and was significantly lower among widowed respondents. Physical limitations in daily activities as well as the presence of other psychiatric disorders (major depression, and social phobia) were also significantly associated with panic disorder in this sample. Consistent with previous research on panic disorder, the prevalence of the disorder decreased with age among older adults. Potential explanations for the age effect and the clinical implications of the mental health comorbidities with panic disorder are discussed.

Gender Differences in Bipolar Disorder Type 1

To explore gender differences in bipolar I disorder, we compared the longitudinal treatment outcome and baseline demographic and clinical characteristics of 27 male and 45 female adult subjects who were treated for an acute affective episode and longitudinally followed for a period of up to 48 weeks. Females were more likely to report a history of suicidal gestures and a comorbid panic disorder; males were more likely to present with a comorbid obsessive-compulsive disorder, and there was a trend for a more frequent history of alcohol or substance abuse. No significant differences were found between the genders for the time to remission from the index episode, number of recurrences, and time spent with any clinical or subclinical mood symptom during the 48 weeks of maintenance treatment. Although differences may exist between bipolar I male and female subjects, prospective course does not seem to reveal differences in a 48-week period, at least when similar treatment strategies are adopted.

Panic disorder and suicide in Mie Prefecture, Japan

The number of suicides in Japan has been increasing.1 It has increased from about 22 000 per year from 1988 to 1997 to over 30 000 per year since 1998, and the need to decrease suicidal numbers is one of the important problems in Japan. In Japan, 34 427 suicides in 2003 was the highest on record. In recent years, many researchers around the world have tried to elucidate almost every aspect of anxiety disorders. Among anxiety disorders, panic disorder is one of the psychiatric disorders that is most frequently diagnosed according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.2 There have been many reports on panic disorder.3–5 However, there are few reports on completed suicide in panic disorder patients. The increase in suicide is one of the crucial problems in the world. In addition, many reports have concluded that psychiatric disorders are the main reason for the increase.6 Therefore, it is important to elucidate the relationship between panic disorder and suicide. In this report, the authors examine the presence of panic disorder in all suicidal cases reported at Mie Prefectural Police Headquarters during the 7-year period from 1996 to 2002. Psychiatric specialists confirmed the diagnoses of psychiatric disorders. Mie Prefecture is located in the center of Japan. The population is approximately 1 800 000, with a population density of approximately 320 per km2. All data were completely anonymous after encoding. During the test period, 1979 male and 969 female suicides were reported to Mie Prefectural Police Headquarters, giving a male/female ratio of approximately 2:1. Among all the victims of completed suicide, nine exhibited panic disorder diagnosed by psychiatric specialists, including three men and six women. The results of Fisher’s exact test among suicides in Mie Prefecture and for completed suicides among individuals with panic disorder of this Prefecture showed a statistically significant difference (P < 0.05). Therefore, medical staff members should especially pay attention to female patients with panic disorder, who have a high risk of completed suicides. Of the nine victims of completed suicide who exhibited panic disorder, six suffered from major depression and panic disorder. There was a high rate of comorbidity of major depression and panic disorder among panic disorder patients in the current results, which are similar to the results of other reports. In the current results, the authors discovered that the risk of completed suicide among individuals with panic disorder is higher in women than men. The authors conclude that medical staff members must pay attention to suicide attempts and completed suicides in panic disorder patients who also exhibit other psychiatric disorders. Special attention should be paid to female patients with major depression and panic disorder. As they provide medical care to such patients, medical professionals should perform not only subjective evaluation but also objective evaluation of psychiatric symptoms as well as of suicidal risk. The current study involves suicides that occurred over a short-term of 7 years, from 1996 to 2002. Therefore, the authors intend to continue this investigation in the future so as to verify their results.

Panic symptoms at the interface of body and mind

Panic disorder is a common illness with significant impact on function and, at times, disabling consequences. Advances over recent years have yielded potential pathophysiologic mechanisms, including neurotransmitter systems and neural substrates. This article provides an overview of various models and hypotheses regarding the etiology of panic disorder. Because its symptoms overlap with the symptoms of various medical disorders, this discussion reviews the comorbidity of panic disorder with medical conditions, especially cardiac and respiratory disorders.

Repetitive transcranial magnetic stimulation (rTMS) in a patient suffering from comorbid depression and panic disorder following a myocardial infarction

Application of repetitive transcranial magnetic stimulation was effective and safe in treating a 55-year-old man with comorbid depression and panic disorder, which occurred 6 months after a myocardial infarction.