Course Of Panic Disorder Research Articles

Comorbidity of anxiety disorders and hypochondriasis considering different diagnostic systems

The influence of different hierarchical guidelines in various classification systems on the diagnosis of anxiety disorders and hypochondriasis was investigated. Using a semistructured polydiagnostic interview (including DSM-111, DSM-III-R, and the 1987 draft version of ICD-10), lifetime diagnoses were determined in 82 outpatients with a DSM-III-R anxiety disorder. In all diagnostic systems, half of our patients exhibited the descriptive features of hypochondriasis. As demonstrated, the formulation of restrictive hierarchical rules—as in DSM-III—contributes to the concept of “primary” hypochondriasis, while secondary hypochondriasis remains underdiagnosed. Concordance rates for hypochondriasis were high between DSM-111-R and ICD-10, but not with DSM-III. Although hypochondriasis showed a strong association with the clinical course of panic disorder (PD), it could not be explained as a consequence of greater illness severity of PD with agoraphobia (AP). Our data underline the conceptualization of hypochondriasis as a phenomenologically homogeneous diagnostic category that may be differentiated from comorbid psychiatric conditions.

Cognitive-Behavior Therapy and the Longitudinal Course of Panic Disorder

This article examines the nature and course of panic disorder as understood from a cognitive-behavioral perspective. A model of the causes and maintenance of panic disorder is presented, and is followed by a discussion of the elements and efficacy of cognitive-behavioral treatment. Treatment effects and factors associated with relapse are considered within the context of evidence for a differential course of panic disorder for patients treated with cognitive-behavioral therapy relative to those treated with pharmacotherapy. Issues of combined treatment, maintenance of treatment gains, and preventive interventions are discussed.

Panic Disorder in Pregnancy

Background: Some reports have suggested that panic disorder may go into remission during pregnancy. The universality of this finding, however, is questionable. In this retrospective survey, we examined the influence of pregnancy on the course of panic disorder in 46 women who developed panic disorder either before, during, or between pregnancies. Method: A questionnaire inquired about the clinical course of panic disorder before, during, and after each pregnancy. Additional questions were asked about symptom change following breastfeeding and about caffeine use during pregnancy. The questionnaire was mailed to 138 women with a DSM-III-R diagnosis of panic disorder who had been assessed in our Anxiety Disorders Clinic. Results: Response rate to the questionnaire was 70%. Forty-six women reported a total of 67 pregnancies occurring after the development of panic disorder. Of these pregnancies, 43% were associated with improvement in panic symptoms, 33% with worsening, and 23% with no change. Furthermore, women were unlikely to experience the same outcome (i.e., worsening, improvement, or no change) in subsequent pregnancies. In contrast, the majority (63%) of pregnancies were associated with exacerbation of symptoms in the postpartum period. No association with weaning or caffeine use was detected. Conclusion: Our findings suggest that pregnancy may have a highly variable influence on the course of panic disorder. In contrast, postpartum worsening of panic may be a more consistent phenomenon. Implications for pregnancy counseling and management are discussed

L'impact des relations interpersonnelles et familiales sur les personnes souffrant d'agoraphobie: L'état de la question.

AbstractMany authors have suggested that interpersonal relationships play an important role in the development, the maintenance and the behavioural treatment of agoraphobia. The literature is reviewed to study the impact of interpersonal relationship on agoraphobia, specially familial variables, agoraphobic's social characteristics, and marital relationship. On the basis of the available data and critical review of the literature, we conclude that interpersonal relationships plays some role in the agoraphobic pathology, mainly for the onset of agoraphobia and the presence of social anxiety. However, it would seem that its importance is less than what has been suggested in the literature.ReferencesAronson, T.A., & Logue, C.M. (1987). On the longitudinal course of panic disorder: Developmental history and predictors of phobic complications. Comprehensive Psychiatry, 28, 345-355.Arrindell, W.A., & Emmelkamp, P.M.G. (1986). Marital adjustment, intimacy and needs in female agoraphobics and their partners: A control study. British Journal of Psychiatry, 149, 592-602.Arrindell, W.A., Emmelkamp, P.M.G., Monsma, A., & Brilman, E. (1983). The role of perceived parental practices in the aetiology of phobic disorders: A controlled study. British Journal of Psychiatry, 143, 183-187.Arrindell, W.A., Emmelkamp, P.M.G., & Sanderman, R. (1986). Marital quality and general life adjustment in relation to treatment outcome in agoraphobia. Advances in Behavior Research and Therapy, 139-135.Barlow, D.H. (1988). Anxiety and its disorders. New York: The Guilford Press.Bland, K., & Hallam, R.S. (1981). Relationship between response to graded exposure and marital satisfaction in agoraphobics. Behaviour Research and Therapy, 19, 335-338.Bouchard, S., & Gauthier, J. (1992). Les modeles etiologiques du trouble panique. Sciences et Comportement, 22, 93-120.Bowlby, J. (1973). Attachment and loss: (vol 2). Separation: Anxiety and anger. New York: Basic Books.Breier, A., Charney, D.S., & Heninger, G.R. (1986). Agoraphobia with panic attacks. Archives of General Psychiatry, 43, 1029-1036.Brodbeck, C., & Michelson, L. (1987). Problem-solving skills and attributional styles of agoraphobia. Cognitive Therapy and Research, 11(5), 593-610.Brown, G.W., Bifulco, A., & Harris, T.O. (1987). Life events, vulnerability and onset of depression: Some refinements.British Journal of Psychiatry, 150, 30-42.Buglass, D., Clarke, J., Henderson, A.S., Kreitman, N., & Presley, A.S. (1977). A study of agoraphobic house-wives. Psychological Medicine, 7, 73-86.Cerny, J.A., Barlow, D.H., Craske, M.G., & Himadi, W.G. (1987). Couples treatment of agoraphobia: A two year follow-up. Behavior Therapy, 18, 401-415.Chambless, D.L., Hunter, K., & Jackson, A. (1982). Social anxiety and assertiveness in normal and phobic populations. Behaviour Research and Therapy, 20, 403-404.Chambless, D.L., Rennenberg, B., Goldstein, A., & Gracely, E. (1992). MCMI-diagnosed personality disorders among agoraphobic outpatients: Prevalence and relationship to severity and treatment outcome. Journal of Anxiety Disorders, 6, 193-213.Cobbs, J.P., Mathews, A.M., Childs-Clarke, A., & Blowers, C.M. (1984). The spouse as co-therapist in the treatment of agoraphobia. British Journal of Psychiatry, 144, 282-287.de Ruiter, C., & Garsen, B. (1989). Social anxiety and fear of bodily sensations in panic disorder and agoraphobia: A matched comparison. Journal of Psychopathology and Behavioral Assessment, 11(2), 175-184.de Ruiter, C., & van Ijzendoorn, M.H. (1992). Agoraphobia and anxious-ambivalent attachment: An integrative review. Journal of Anxiety Disorders, 6, 365-381.Doctor, R.M. (1982). Major results of a large scale pretreatment survey of agoraphobics. Dans R. …

Alcohol Dependence May Be the Missing Link Between Posttraumatic Stress Disorder and Panic-Reply

In reply We appreciate Dr Wiseman's effort to highlight the possible neurobiological significance of substance abuse for patients with PTSD and panic disorder. Similar to the clinical reports on patients with panic disorder that she cited, we and others previously described cases in which acute alcohol or opiate withdrawal exacerbated PTSD symptoms in dually diagnosed patients. 1,2 The hypothesis that activation of noradrenergic systems might increase panic or PTSD symptoms was studied in a series of investigations using the α 2 -adrenergic antagonist, yohimbine. We found that this drug elicited panic attacks in some patients with panic disorder and PTSD, but not in healthy subjects or patients with other major psychiatric disorders including generalized anxiety disorder, major depression, and schizophrenia. 3,4 While it is likely that the cycle of alcohol consumption and withdrawal affects the course of panic disorder and PTSD, there is little evidence to support the hypothesis that subacute alcohol

Quality of life and psychiatric morbidity in panic disorder and generalized anxiety disorder

This report examines the impact of panic disorder and/or generalized anxiety disorder on quality of life and the implications of these findings on nosological categories. A total of 357 subjects with a current episode of panic disorder and/or generalized anxiety disorder were diagnosed according to DSM-III-R criteria, using structured clinical interviews, as part of a prospective, naturalistic, longitudinal, multicenter study of a clinical population with anxiety disorders. There was a high degree of coexistence of anxiety disorders and major depressive disorder. Subjects with generalized anxiety disorder almost universally had other disorders, were the most likely to have at least one other anxiety disorder or major depressive disorder at intake, had the earliest age at onset, and had the worst emotional health rating. Subjects with panic disorder without agoraphobia had the most likelihood of a history of alcohol abuse. Nine percent of the subjects had a history of suicide attempts or gestures. The subjects showed significant impairment in quality of life. The highly frequent coexistence of other anxiety disorders with generalized anxiety disorder and the overall lack of differences on many quality of life measures raise questions of nosology, particularly for generalized anxiety disorder.

Personality disorders in patients with panic disorder: Association with childhood anxiety disorders, early trauma, comorbidity, and chronicity

The rates of comorbid personality disorders in patients with panic disorder are reported to be elevated, have an adverse impact on the response to treatment, and increase the likelihood of relapse on treatment discontinuation. We examined the rates of personality disorders in panic disorder patients in a longitudinal, naturalistic study of panic disorder. Of 100 panic disorder patients studied, 42 met criteria for at least one personality disorder as determined by the Personality Disorder Questionnaire-Revised (PDQ-R). The presence of a personality disorder as determined by the PDQ-R was associated with a past history of childhood anxiety disorders, comorbidity with other anxiety disorders and depression, and a chronic, unremitting course of panic disorder in adulthood. The presence of a personality disorder in these patients was not significantly associated with a history of physical or sexual abuse in childhood. Our findings support the notion that an anxiety diathesis, demonstrated by significant difficulties with anxiety in childhood, influences the development of apparent personality dysfunction in panic patients. In other cases, personality pathology may reflect the presence of comorbid anxiety disorders or depression. The association of personality disorder in panic patients with a more unremitting course of illness underscores the importance of axis II pathology in understanding the longitudinal course of panic disorder.

Effects of age and alcoholism on the prevalence of panic disorder.

Findings are reported evaluating the effects of aging and alcoholism histories on the 6-month prevalence rates of panic disorder. The data were collected in 5 communities as part of the Epidemiologic Catchment Area (ECA) study: New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; and Los Angeles, CA. Reanalysis of ECA data provided additional support for a decline in the prevalence of panic disorder among elderly people. In addition, the presence of a history of alcohol abuse or dependence was associated with significantly elevated panic disorder rates in younger individuals, but an earlier decline in panic disorder prevalence with age, regardless of gender. These findings offer preliminary support for neurodevelopmental hypotheses for the onset and outgrowing of panic disorder. They also highlight the impact of alcoholism on the course of panic disorder.

A comparison of phobic subtypes within panic disorder

Panic disordered patients with agoraphobia ( n=81), with limited phobic avoidance ( n=44), and uncomplicated (i.e., with no avoidance: n=19) were compared by demographic characteristics, panic and near-panic attack symptoms, behavioral response to panic attacks, course of panic disorder, and comorbidity. Mean vectors of the three groups differed significantly from chance ( p<.01), and a discriminant function analysis with jackknife correctly classified 52.0% of patients. Although most of the individual variables did not differ significantly between groups, a cluster of symptoms associated with alterations in consciousness, including dizziness/unsteadiness, faintness/fear of passing out, and derealization during panic attacks were most often reported by agoraphobics. Agoraphobics were also significantly more likely to report help-seeking behavior in response to panic attacks and to report at least moderate anticipatory anxiety than were patients with limited or no avoidance. The results support the utility of categorizing extent of avoidance among patients with panic disorder. They suggest a relationship between agoraphobic avoidance and certain features of panic attacks and patients' responses to panic attacks.

Outcome of Panic Disorder

Eighty-nine subjects with panic disorder, who had been naturalistically treated, and 46 nonanxious controls were followed up after 3 years. Although they remained symptomatic, most subjects with panic disorder reported relatively little distress or social maladjustment. The course of panic disorder was characterized by fluctuating anxiety and depressive symptoms. Panic subtypes (uncomplicated, limited phobic avoidance, and extensive phobic avoidance) and Axis I and II comorbidity (major depression and personality disorders) were highly predictive of symptoms and social adjustment after 3 years. Abnormal personality was, in fact, the strongest predictor of social maladjustment in both subjects with panic disorder and controls. The results showed that while panic disorder has a favorable outcome, the illness is a chronic one that may require continuing treatment. They also show that subtypes and comorbid disturbances are important predictors of outcome.

The nature of depression presenting concomitantly with panic disorder

Our data, along with the literature review we have undertaken, suggest that depression seen in the course of panic disorder most commonly represents symptomatic elaboration or complication of panic disorder. Less often it represents an associated independent entity or, more hypothetically, an alternative clinical expression of a shared underlying diathesis for both conditions. Future prospective research efforts, especially along familial-genetic lines, are needed to clarify the precise nature of the cross-sectional and longitudinal overlap of anxiety and depressive states.

Panic disorder during pregnancy

Panic disorder is common in women during the childbearing years. The few and conflicting reports regarding the course of panic disorder during pregnancy underscore the need for prospective studies in this area. This paper reviews possible ways in which pregnancy-induced physiological and psychological changes, life stress, and increases in hormones, especially progesterone, may affect anxiety and panic symptoms. The management of panic disorder and the use of antipanic medication during pregnancy are discussed.

The Course of Panic Attacks and Agoraphobia

<h3>To the Editor.—</h3> Breier et al,¹in the November 1986 issue of theARCHIVES, reported retrospective data on the course of panic disorder and agoraphobia. A major finding was the chronicity of anticipatory anxiety, generalized anxiety, agoraphobia, and frequent panic attacks. The problem with these findings is that the sample may be biased for chronicity: 28 of the 60 patients had a history of anxiety disorders longer than ten years. It may be that these patients came to the research treatment program because their conditions were refractory to treatment received in a primary care setting. Patients with a more favorable course that remits during treatment often never see a psychiatrist. Previous follow-up studies²of anxiety disorders are similarly biased; the retrospective method may increase this bias. The hypothesis of chronicity in anxiety disorders therefore needs support from prospective studies in population samples. We had the opportunity to perform

The Course of Panic Attacks and Agoraphobia-Reply

To the Editor.— In their letter, Maier and Buller report that significant reductions in levels of anxiety occur among patients with panic disorder one year after entering treatment. Based on these data, they conclude that the course of panic disorder is less severe than reported in our study 1 and by other investigators. 2-4 Several points warrant further discussion. First, we reported that although our patient group had nonremitting, chronic courses before admission to our clinic, most patients subsequently made an excellent recovery from their panic and agoraphobic symptoms after combined behavioral therapy and imipramine hydrochloride or alprazolam treatment. 1 Moreover, in a recent prospective 2.5-year outcome study of patients from our study, Nagy et al 5 reported that the significant reductions in anxiety symptoms derived from our treatment program persisted throughout the follow-up period. These data indicate that agoraphobia, with panic attacks, is very responsive to appropriate treatment. However, when panic disorder is

Agoraphobia with panic attacks: 1-Year prospective follow-up

The present report represents an attempt to investigate, using a naturalistic approach, the clinical course of panic disorder over one year of nonprefixed therapy. Fifty-three patients were followed up; outcome, relapses, symptom pattern, social adaptation and predictors to long-term prognosis were investigated. Improvement from panic is more rapid, whereas there is a certain delay in recovery from agoraphobia and interepisodic anxiety. After a year, all symptoms show a consistent and comparable degree of improvement. Five of the 13 cases who attained full recovery and 7 of the 16 cases who satisfied the criteria of improvement, relapsed into a new episode. The variables investigated which gave the greatest contribution to the variance of the outcome were initial agoraphobia, scales Pd and Hy from the Minnesota Multiphasic Personality Inventory (MMPI), extraversion from Maudsley Personality Inventory, and educational level.

Effect of pregnancy on panic attacks.

Three women with panic disorder showed marked improvement in their panic symptoms during pregnancy. Such effects might be due to pregnancy's blunting of the sympathoadrenal response to simple physiologic stimuli, effects on barbiturate receptors, or improvement in psychological functioning.

On the longitudinal course of panic disorder: developmental history and predictors of phobic complications

The longitudinal course and childhood histories of 46 patients with panic disorder or agoraphobia were systematically assessed. DSM-III-R criteria were employed in assessing predictors of phobic complications. It was found that the female sex and any childhood anxiety or depressive disorder were associated with the development of phobic avoidances. Overanxious disorder was reported twice as often as separation anxiety disorder. Most patients could identify a clear-cut precipitant of their disorder, and most developed phobic complications after their first panic attacks. Unemployment, high interpersonal sensitivity, and secondary depression were associated with premature termination.

Panic disorder: Residual symptoms after the acute attacks abate

Patients with a past history of panic disorder who were no longer suffering from acute anxiety attacks were compared to patients who had never experienced anxiety attacks. Patients with past panic attacks had significantly higher anxiety and depression scores on psychological tests, as well as significantly more social phobias and avoidance behavior, than the controls who had never suffered anxiety attacks. Like patients with dysthymic disorder with episodes of superimposed major depression, there appears to be a subgroup of patients who recover from panic disorder, but are left with significant residual symptoms of anxiety, depression, and phobias. More research needs to be focused on the longitudinal course of panic disorder in order to enhance understanding of the relationship among the anxiety disorders (generalized anxiety, social phobia, agoraphobic, and panic disorder) as well as major affective disorder.

Longitudinal course of panic disorder: Clinical and biological considerations

Uhde, Thomas W., Jean-Philippe Boulenger, Peter P. Roy-Byrne, Macilla F. Geraci, Bernard J. Vittone, and Robert M. Post: Longitudinal course of panic disorder: clinical and biological considerations. Prog. Neuro-Psychopharmacol. & Biol. Psychiat. 1985, 9 (1); 39–51. 1. 1. The longitudinal course of panic disorder and its associated symptoms were investigated in thirty-eight patients. 2. 2. The temporal relationships among panic attacks, generalized anxiety, agoraphobia and depression are described. 3. 3. Similar and different biological alterations in the tricyclic-responsive disorders of primary depression and panic disorder are reviewed and discussed.