Age of onset of phobic disorders: a reevaluation

Cognitive–Behavioural Treatment of Internalising Disorders in Youth

Cognitive-behavioural (CB) therapy for internalising disorders in youth is discussed from both a procedural and empirical standpoint. A theoretical overview of CB treatment is provided, and the unique difficulties faced in the identification and treatment of internalising disorders are considered. With reference to specific internalising disorders (i.e., anxiety and depression), the present paper considers the differential application of CB strategies and the efficacy of treatment procedures. Issues relevant to CB treatment, including (a) flexibility in application, (b) developmental considerations, (c) treatment methodology, and (d) transportability, are discussed.

Anxiety and related outcomes in young adults 7 to 19 years after receiving treatment for child anxiety

OBJECTIVE

This study evaluated follow-up outcomes associated with cognitive behavioral therapy (CBT) for childhood anxiety by comparing successfully and unsuccessfully treated participants 6.72 to 19.17 years after treatment.

METHOD

Participants were a sample of 66 youths (ages 7-14 years at time of treatment, ages 18-32 years at present follow-up) who had been diagnosed with an anxiety disorder and randomized to treatment in a randomized clinical trial on average 16.24 (SD = 3.56, range = 6.72-19.17) years prior. The present follow-up included self-report measures and a diagnostic interview to assess anxiety, depression, and substance misuse.

RESULTS

Compared with those who responded successfully to CBT for an anxiety disorder in childhood, those who were less responsive had higher rates of panic disorder, alcohol dependence, and drug abuse in adulthood. Relative to a normative comparison group, those who were less responsive to CBT in childhood had higher rates of several anxiety disorders and substance misuse problems in adulthood. Participants remained at particularly increased risk, relative to the normative group, for generalized anxiety disorder and nicotine dependence regardless of initial treatment outcome.

CONCLUSIONS

The present study is the first to assess the long-term follow-up effects of CBT treatment for an anxiety disorder in youth on anxiety, depression, and substance abuse through the period of young adulthood when these disorders are often seen. Results support the presence of important long-term benefits of successful early CBT for anxiety.

Homotypic versus heterotypic continuity of anxiety symptoms in young adolescents: evidence for distinctions between DSM-IV subtypes

Objective: to investigate homotypic and heterotypic longitudinal patterns of symptoms of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia (SoPh), panic disorder (PD), and obsessive compulsive disorder (OCD) in young adolescents from the Dutch general population.

Method: 2,067 individuals (51.4% girls) from a Dutch community sample, who were assessed for the first time when they were aged 10 to 12 years, were followed up across a period of two years. At both assessments, anxiety symptoms were assessed with the RCADS, a self-report questionnaire.

Results: Regression analyses indicated that homotypic continuity was relatively high for SAD, GAD, and SoPh symptoms, and for PD in girls.

Conclusions: In many studies, anxiety disorders are treated as one group of disorders, and some widely used assessment instruments, such as the Child Behavior Checklist, do not even contain scales that tap different anxiety dimensions. In the present study, evidence for homotypic continuity was found, especially for symptoms of separation, social, and generalized anxiety, and for symptoms of panic disorder in girls, underscoring the usefulness of making distinctions between different anxiety constructs.

Onset of spontaneous panic attacks: a prospective study of risk factors

OBJECTIVE

Earlier analyses have shown that, among currently well individuals with no history of panic attacks, a family history of panic disorder is associated with a greater likelihood of panic symptoms after exposure to 35% CO2 and of ventilatory-response abnormalities during inhalation of 5% CO2. An association of those features with a subsequent onset of panic attacks would compose additional evidence that they are trait markers for panic disorder.

METHODS

Subjects who were free of current Axis I disorders other than simple or social phobia and who had a first-degree relative with panic disorder (high risk) and subjects who had no first-degree relatives with panic disorder or major depressive disorder (low-risk) underwent two challenge procedures. The first measured anxiety responses to a single breath of 35% CO2, and the second measured ventilatory responses to a 3-minute exposure to 5% CO2. After a mean interval of 4 years, 66 high-risk (48 female; mean age = 23.0 years) and 24 low-risk subjects (15 female; mean age = 23.1 years) were questioned by telephone about the occurrence of any spontaneous panic attack in the interval.

RESULTS

Sixteen (23.9%) of the high-risk and one (4.2%) of low-risk subjects had experienced at least one spontaneous panic attack; Cox regression analyses revealed a significant relationship between abnormal ventilatory responses to 5% CO2 and the later onset of panic attacks. Subjective responses to 35% CO2 were not predictive. Neuroticism scores were not associated with abnormal ventilatory responses to CO2 but were also predictive of later panic attacks.

CONCLUSIONS

High neuroticism scores and abnormal ventilatory responses to 5% CO2 appear to be additive trait markers for panic disorder.

Specific phobia

This article describes specific phobia of childhood and its clinical presentation, discusses issues related to the differential diagnosis of specific phobia, considers the issue of comorbidity among phobic and anxiety disorders and developmental trends in the manifestation of fears, summarizes the epidemiology, causes, and course of specific phobia, and presents assessment and treatment issues. Finally, a case study is offered that serves to illuminate the major topics outlined in the article.

Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up

Research suggests that the sequelae of childhood anxiety disorders, if left untreated, can include chronic anxiety, depression, and substance abuse. The current study evaluated the maintenance of outcomes of children who received a 16-week cognitive-behavioral treatment for primary anxiety disorders (generalized, separation, and social anxiety disorders) an average of 7.4 years earlier. The 86 participants (ages 15 to 22 years; 91% of the original sample) and their parents completed diagnostic interviews and self- and parent-report measures. According to the diagnostic interviews, a meaningful percentage of participants maintained significant improvements in anxiety at long-term follow-up. With regard to sequelae, positive responders to anxiety treatment, as compared with less positive responders, had a reduced amount of substance use involvement and related problems at long-term follow-up. The findings are discussed with regard to child anxiety and some of its sequelae.

Prevalence of psychopathology in preschool-age children

PROBLEM

Little is known about psychopathology in preschool-age children.

METHODS

A review of representative studies of psychiatric disorders in preschoolers.

FINDINGS

Sample sizes ranged from 104 to 3,860 subjects, ages 1 to 9 years. Prevalence rates of psychiatric disorders varied from 0.1% to 26.4%; high rates of co-morbidity were reported.

CONCLUSIONS

Studies addressing psychiatric disorders in preschoolers are extremely limited. Future research is needed to improve the diagnosis, treatment, and outcomes in preschool-age children.

Patterns of axis II comorbidity in early-onset versus late-onset panic disorder in Japan

Early onset of psychiatric disorders has been reported to be associated with increased familial risk or more severe clinical symptoms. In this study, we specifically examine the association between clinical severity and early versus late onset in panic disorder. We hypothesize the existence of differences in rates of axis II disorders in these two groups that will relate to clinical severity. Subjects were a consecutive clinical case series of 105 panic disorder patients (age, 18.3 to 70.9 years). Thirty-one panic disorder patients were classified as early onset (age of onset < or = 25 years) and 74 as late onset (age of onset >25). We compared symptomatology and rates of comorbid axis II disorders (diagnosed by structured clinical interview) between the early- and the late-onset groups. We found a statistically significant increase in the number of suicide attempts and likelihood of comorbid axis II disorders in the early-onset group compared to the late-onset group. In logistic regression analyses, cluster B personality disorders (PDs), especially borderline and histrionic, were statistically significantly associated with the presence of suicide attempts. The following limitations are present: first, we have not taken into consideration comorbidity of other axis I disorders, especially major depression. Second, there is imprecision associated with efforts to date the onset of panic disorder retrospectively. We conclude that comorbid axis II disorders are more likely to occur in early-onset panic disorder patients. Cluster B PDs, especially borderline or histrionic, may be associated with a high frequency of suicide attempts in this group. In clinical practice, efforts to aggressively detect and treat axis II disorders in early-onset panic disorder patients are warranted.

Differential clinical features of early-onset panic disorder

BACKGROUND

Although panic disorder (PD) begins typically in adulthood, an earlier onset is not uncommon. Recent studies on early-onset PD indicate that this subgroup of patients may display distinct clinical characteristics.

OBJECTIVE

To compare a subgroup of early-onset PD patients with the rest of the sample.

METHOD

A consecutive series of 442 patients with PD were included. Family histories were investigated, and clinical assessment employed the following instruments: Hamilton's scales, Global Functioning Scale, Marks-Mathews' Fears and Phobia Scale, and Panic-Associated Symptom Scale. The age threshold for 'early-onset' was considered at 18 years.

RESULTS

A total of 45 patients (10.2%) exhibited early-onset PD, with a mean age at onset of 14.6. They were younger and had a longer duration of illness than later-onset patients. No differences were found in severity of panic symptoms, anxiety or depressive symptoms, and social functioning. They had more comorbidity with simple phobia, social phobia, and substance dependence. Rates of PD among first-degree relatives were higher in the early-onset group.

CONCLUSION

Early-onset PD patients displayed a greater familial loading, but clinical severity of their panic-agoraphobia symptoms was not higher. Comorbidity was greater with phobic and substance-related disorders.

Possible association of a cholecystokinin promotor polymorphism (CCK-36CT) with panic disorder

We searched for mutations in the CCK gene in panic disorder with single-strand conformational polymorphism (SSCP) analysis of the three exons and promotor region of the gene. We found a C-->T transition at position -36 (CCK(-36C-->T)) in a GC box, a binding site for transcription factor Sp1, in the promotor region. The allele frequency was 0.168 (95% CI, 0.116-0.221) in 98 persons with panic disorder and 0.083 (95% CI, 0.059-0.107) in 247 geographically matched, unscreened controls. A transmission disequilibrium test based on panic disorder as the affected phenotype was nonsignificant (chi2 = 0.93), but when panic disorder or attacks were considered as affected, statistically significant transmission disequilibrium was detected (chi2 = 4.00, P < 0.05). Linkage analysis was uninformative. In exploratory analyses to search for clinical correlations, the "T" allele was found in 59% of 22 persons with panic attacks but not panic disorder, compared with 31% of those who met the criteria for panic disorder. An association between the CCK polymorphism and panic disorder cannot be considered established due to the inconsistencies in the results noted above, but if the provisional association can be replicated, the findings are consistent with CCK(-36C-->T) being a disease-susceptibility allele that alone is neither necessary nor sufficient to cause panic disorder but that increases vulnerability by acting epistatically.

Life events in childhood, adolescence and adulthood and the relationship to panic disorder

The aim of this study was to explore the association between stressful life events (SLE) and the development of panic disorder (PD) in an Israeli sample. A total of 44 PD patients and a matched control group were studied with regard to SLE over the life cycle (in childhood, adolescence, adulthood and the year preceding the outbreak of the disorder). The major findings were as follows. (i) With regard to the total number of life events experienced in childhood and adolescence, the PD group had experienced significantly more life events than the control group. (ii) No differences were detected in the total amount of SLE between the PD group and the control group with regard to adulthood and the year preceding the outbreak of the disorder, although the PD group had more life events relating to loss in adulthood, whereas in the year before the outbreak of PD life events relating to 'love and family', negative and loss events were more prevalent. These results expand previous findings by demonstrating that SLE in childhood and adolescence may contribute to the development of PD in adulthood.

Panic disorder: diagnosis and treatment in emergency medicine

Panic disorder is a newly recognized psychiatric illness involving unexpected, unprovoked attacks of anxiety. Patients with panic disorder commonly seek treatment in the ED. It is important for the emergency physician to properly recognize and categorize this disorder to initiate appropriate treatment. Illness description and treatment guidelines of this disorder are discussed in this article.

Hypersensitivity to carbon dioxide as a disease-specific trait marker

There is now substantial evidence that an abnormal threshold for suffocation alarm underlies panic disorder. Because this disorder is highly familial, evidence of an abnormal suffocation threshold may be apparent in high-risk individuals before they develop clinical illness. To explore this possibility, we used a single inhalation of 35% CO2 vs. air to evaluate 11 subjects who had at least one first-degree relative with DSM-III-R panic disorder, 13 who had at least two relatives treated for mania or for depression (HR-AD), and 15 low-risk controls who had no family history of panic disorder, affective disorder, or alcoholism (LR-C). All were aged 18-34 and had no history of panics or of any Research Diagnostic Criteria disorder. Five (45.5%) of the subjects at high risk for panic disorder, but none of the LR-C subjects (p = .007), nor any of the HR-AD subjects (p = .011), developed a panic attack following inhalation of the CO2 mixture.

Why Is Panic Disorder Less Frequent in Late life?

Epidemiological studies have found that few cases of panic disorder arise for the first time after the age of 40 years, and there is a steady decline in the prevalence of existing cases in the latter half of life. The authors review these epidemiological findings and explore various hypotheses that might explain the decreased frequency of panic disorder in old age. There is no available evidence to suggest that methodological factors have led to an underestimation of the prevalence of this disorder in older rather than younger age groups. However, there is evidence that disorder-associated mortality and age-related changes in brain neurochemistry may contribute to the decreased frequency of this illness in later life. A cohort effect also should be considered, although currently there are no data available to support or refute this idea.

Epidemiology of panic disorder: progress and unresolved issues

Recent epidemiological studies have consistently shown that panic disorder, according to DSM-III, occurs in adults with a lifetime prevalence of about 2% and a 6-month prevalence of about 1.2%. Panic attacks are relatively common, with a lifetime rate of about 9%. Being female and divorced and separated is associated with higher prevalence of panic disorder. The hazard rates for panic disorder were highest between the ages of 25 and 34 years for females and between the ages of 30 and 44 years for males. Panic disorder frequently co-occurs with other anxiety disorders as well as with a wide range of mental disorders such as depression and substance use disorder. Based on few epidemiological studies, panic disorder has been found to have a chronic course with rare complete remission. Subjects with panic disorder were at an increased risk of social impairment, not getting along with their partners, as well as being financially dependent, and were likely to report fair or poor global physical health, and emotional health. Cases with panic disorder had the most severe psychosocial impairment and the worst outcome as compared to other anxiety disorders. Moreover, they are high users of all types of medical services, including mental health and general medical providers. Although recent epidemiological data, with its improved methodology, have considerably increased our knowledge concerning panic attack, panic disorder and agoraphobia, there are still major questions concerning the etiology, natural history, prevention, or control of panic disorder that need to be answered. Furthermore, since panic disorder has been considered as developing in stages, our current epidemiological knowledge cannot tell us in sufficient detail about the specific role of suggested risk factors in the development of panic disorder through its various stages.

Panic disorder: a biological perspective

Panic disorder (PD) was first delineated as a separate diagnostic entity 25 years ago. It is a prevalent disorder that responds well to pharmacological interventions, most notably to antidepressants and benzodiazepines. PD and other psychiatric disorders, such as generalized anxiety disorder and major depression, overlap clinically, but it is unresolved whether they also overlap biologically. Finally, the pathogenesis of PD is still unclear. Theories linking panic to increased sensitivity to CO2 or serotonin are preliminary, while alpha 2-adrenergic dysregulation in panic is still unproven. However, the development of new, selective, receptor agonists and antagonists in combination with imaging techniques may produce some of the answers to the questions raised since.

Biological correlates of panic disorder with agoraphobia: practice perspectives for nurses

The literature on panic disorder is summarized with regard to epidemiological, environmental, cultural, psychological, family, and genetic factors. Laboratory provocation of anxiety is reviewed with emphasis on the noradrenergic model of panic from a biological perspective. Positron emission tomography results involving brain asymmetries in lactate-sensitive panic patients are discussed, as are the psychopharmacological agents currently effective in the treatment of panic disorder. It is suggested that psychiatric nurses base their clinical practice on a holistic understanding of treatment implications as they relate to an individual's broader functioning. Areas for future nursing research are also identified.

Phobic disorders in the elderly

Sixty confirmed cases of phobic disorder identified in an urban elderly community sample were compared with 60 controls matched pairwise for age and sex. Cases reported higher rates of specific and non-specific neurotic symptoms, and all were assigned to a diagnostic CATEGO class, compared with seven of the controls. A past history of chronic psychiatric disorder other than phobia was commoner in the cases. Most cases had more than one fear; agoraphobic main fears were predominantly of late onset and associated with moderate to severe social impairment, whereas specific main fears were associated with early onset and minimal social impairment. The onset of agoraphobic fears in old age was attributed by most cases to an episode of physical illness or other traumatic event. Increased rates of palpitations, dyspnoea, giddiness and tinnitus not attributable to anxiety were identified in the cases. Cases did not differ from the controls in socio-economic status, or in the number or quality of current intimate confiding relationships, but they reported higher rates than controls of parental loss before the age of 18 years. Cases reported higher rates of contact with general practitioners, but only one was in contact with psychiatric services at the time of interview. Cases also reported receiving more help in personal care from family members.

Anxiety disorders of childhood and adolescence: a critical review

The 1980s were a decade of advancement in the knowledge of anxiety disorders in children and adolescents; this sets the stage for research achievements in the 1990s. This review examines the anxiety disorders of childhood and adolescence (separation anxiety disorder, overanxious disorder, and avoidant disorder), including prevalence rates, demographic profiles, comparisons of clinical presentations in different developmental age groups, and comorbidity patterns. Fears and simple phobias, obsessive-compulsive disorder, post-traumatic stress disorder, and panic disorder in children and adolescents are also evaluated. The controversy of whether panic attacks occur in prepubertal children is addressed. A brief review of behavioral and pharmacological treatment studies is included. Future directions for research are suggested.

Phobia: prevalence and risk factors

This article is the presentation of the main phobia data from the Epidemiologic Catchment Area (ECA) program, with a sample size of n = 18.571. Work on this article was initiated in 1981 at the beginning of the ECA study, but publication has been delayed a decade. Phobias are determined from information from the Diagnostic Interview Schedule (DIS), classified according to DSM III. Phobias are found to be the most common psychiatric disorder in the community, more common than major depression or alcohol abuse or dependence in the month prior to interview. The one month prevalence is between 4.0 and 11.1%, with the estimated prevalence in the United States being 6.2%. There were nine community surveys of the prevalence of phobia that pre-dated the ECA studies, which found a wide range of prevalence rates from 1.2% to 26.1%. By far the strongest risk factor associated with phobias is the presence of another psychiatric disorder. Prevalence rates of simple phobia and agoraphobia are found in the ECA studies to be significantly higher in women; social phobia, which is less prevalent, has no significant sex difference. The prevalence rates are higher in younger age groups, and in those with low socioeconomic status (SES). The onset of phobias occurs primarily in the childhood or teenage years, and they tend to be chronic conditions. Less than a quarter of phobics receive treatment.

Panic disorder on a child psychiatric consultation service

In a review of all cases seen from 1984 to 1988 by the psychiatric consultation-liaison service of a tertiary referral pediatric hospital, four cases of definite panic disorder meeting DSM-III-R criteria were identified. Three of these children were referred to the consultation service after intensive investigation of physical complaints had failed to yield a diagnosis. These cases of panic disorder differed from those previously reported in child psychiatric populations by their relative absence of psychiatric comorbidity. This suggests that uncomplicated panic disorder may present with primarily somatic symptoms in pediatric subspecialty clinics, while panic disorder, complicated by behavioral or emotional disturbance, is more likely to present directly to child psychiatric services. Children presenting with somatic symptoms are at risk for receiving nonproductive investigations while having delayed diagnosis and treatment of the panic disorder.

Neuroticism and age of onset for agoraphobia with panic attacks

The study of the age of onset of psychiatric conditions can provide some clues to the aetiology of these disorders. A number of studies have examined the age of onset in agoraphobia but results have varied. This may be associated with small sample sizes or differences in populations. There has been very little work examining the factors determining age of onset. The present study examines age of onset in relation to sex and personality. Results indicate no sex differences in age of onset, but an association with age and high levels of neuroticism.

Panic disorder in children and adolescents

Panic disorder is a common and well-known psychiatric disorder which commonly has its onset during adolescence. However, the disorder has only recently been described in children and adolescents. The clinical literature describing panic disorder in children and adolescents is reviewed, and six cases are presented. Future directions for research are suggested.

A family study of panic disorder: reanalysis using a regressive logistic model that incorporates a sibship environment

Previous analysis of affection status in parents and siblings of 117 probands with panic disorder by a log-linear model for binary pedigree data found a common concordance across biological first-degree relatives and no spouse association [Hopper JL, Judd FK, Derrick PL, Burrows GD: Genet Epidemiol 4:33-41, 1987]. In this paper the data were reanalyzed using a regressive logistic model that modelled both vertical transmission and a shared sibship environment. Ascertainment correction was made by a) an "ascertainment assumption-free" procedure, following Ewens and Shute [Theor Pop Biol 30:388-412, 1986] and compared with b) complete ascertainment and c) single ascertainment. Under every scheme there was evidence for vertical transmission from parents to offspring. Inclusion of a sibship environment gave an improved fit, suggesting that vertical transmission alone may not be sufficient to explain the familial aggregation observed in these families. The effects of an affected parent, of the postulated environmental factor (present for all siblings if it was present for one sibling), and of the prevalence of the rare environmental factor were estimated and found to be roughly similar under the different schemes. Model predictions of lifetime prevalence were consistent with other population-based studies. Under the same assumption-free method, standard errors approximately doubled and computation time increased compared with the other ascertainment schemes that made specific, although not necessarily correct, assumptions. The regressive logistic model used less computation time and gave greater insight into the pattern of familial aggregation than did the previous modelling.

Simple phobia: evidence for heterogeneity

Although simple phobia is a residual category in DSM-III, clinical experience suggests at least four subtypes of this group. To test the validity of the subtypes, the authors compared patients with one of four simple phobias subtypes (n: animal-insect = 25, blood-injury = 9, situational = 46, choking-vomit = 8). Significant sex differences were observed; all animal and insect phobics and seven of eight choking-vomit phobics were female, while the other two groups showed approximately equal numbers of males and females. Mean age of onset was significantly older for situational phobics than animal-insect or blood-injury phobics; choking-vomit probands were intermediate. Frequency of situational phobias differed significantly among relatives of the four proband groups, with highest frequency being found among situational probands. Thus, these clinical and epidemiological variables support the separation of simple phobia into at least these four diagnostic groups.

Clinical features of carcinoid syndrome and the use of somatostatin analogue in its management

A review is given on the clinical features of carcinoid syndrome including symptomatology, diagnostics, biochemistry and treatment. We have reviewed the literature on current therapy of carcinoid patients with special emphasis on the use of the somatostatin analogue SMS 20-1995. In addition, we present data on the effects of SMS 201-995 on indices of a clinical, biochemical and tumor growth. Diarrhea is abolished or significantly reduced in 75% of patients, flushing improves in 100%, wheezing in 100% with a decrease in airways resistance, and in one patient myopathy has improved. Blood serotonin is notoriously resistant to intervention and urinary 5-HIAA will decrease in 75% of causes but subsequently rebounds in 38%. Tumors, in general, continue to grow, but this may be slowed or in rare cases tumor growth is arrested. In individual instances the tumor may even infarct, leading to spontaneous cure. Tumors secreting PP, ACTH and calcitonin may be particularly resistant to treatment, whereas VIP secreting tumors appear to be sensitive.

Agoraphobia: review and considerations in dental treatment

The nature of agoraphobia as well as problems that may be encountered during dental treatment of the patient with agoraphobia is discussed to aid dentists' recognition and understanding of the syndrome.

Assortative mating and affective disorders: psychopathology in offspring

Familial aggregation has been frequently observed among probands with depression, anxiety disorders, and alcoholism (Gershon et al. 1976; Goodwin et al. 1973; Crowe et al. 1983). Because of the familial nature of these disorders, offspring of such probands have been identified to be at high risk for developing these illnesses themselves (Tarter 1983). Information regarding such risk has come from several sources: retrospective studies of patients with psychiatric disorders; studies of children whose parents are being treated for these disorders; and longitudinal follow-up studies of children with symptoms of the disorder.

Aetiology and mechanisms of anxiety disorders

Theories on the aetiology of pathological anxiety abound. A critical review is given of the most influential approaches (e.g. psychoanalytical, "somatogenic", behavioural, psychophysiological and "biological" theories), with emphasis on panic and agoraphobic disorders. Evidence is presented from epidemiological and genetic research and from observations on the course of illness. A surprisingly constant prevalence of anxiety syndromes, and a familial distribution suggesting a pivotal importance of genetic factors, speak in favour of a biological model. The course of illness, however, points to the importance of environmental influences as triggering factors, and to cognitive and behavioural mechanisms for the perpetuation of the symptoms. Treatment responses hitherto documented support the biological and behavioural concepts, but the cognitive and psychophysiological theories are also supported to some extent. An attempt is made to combine these findings with biochemical and pharmacological findings in an integrated model of panic and agoraphobia. This model takes the form of a vicious circle, and is compatible with biological and neuropharmacological as well as evolutionary and psychological concepts.

Recent developments in the treatment of panic disorder

The focus of this paper is the treatment of panic disorder with alprazolam. Drug treatments alone are sometimes not sufficient by themselves, to adequately control all of the symptoms or components of this disorder. In the typical case we can identify four targets of treatment: The first target is the biological core of the condition, that is characterized by the unexpected, unprovoked attacks of anxiety. This responds best to medication. The second target is the phobic avoidance behaviour. It appears to be a conditioned or learned complication of the biological core, and appears to follow the laws of learning theory. Unlearning treatments, like behaviour therapy (notably in vivo exposure) are usually necessary to make a full impact against the phobic avoidance behaviour. Thirdly, there is no drug that reverses the psycho-social problems these patients have. Not all of them have such problems, but those that do may need psychotherapy to deal with their conflicts and stresses. Finally, the evidence in several chronic studies, suggest that this is a chronic relapsing disorder in the majority of cases. It is not enough to treat these patients acutely. They must be followed chronically and monitored carefully over many years, if they are to be protected against relapse.

Social support and married agoraphobic women

This study was conducted to determine if a relationship exists between social support and agoraphobia. Married agoraphobic women from a support group for phobics were compared with married, non-agoraphobic women from Family Practice clinics, and social support factors were examined. The agoraphobic women were found to perceive their husbands as less supportive. As well, there were important reductions in network size and network support in these agoraphobic women.

A family study of panic disorder

Panic disorder, as defined by the DSM III diagnostic criteria, was diagnosed in 117 probands for whom age of onset ranged from 10 to 59 years, with a mean of 26.6 years. Diagnosis of parents and siblings was based on interviews with the probands, and only those with "definite" panic disorder by the FISC criteria were considered to be affected. The pattern of concordances for panic across different groups of relatives was estimated concurrently by a log-linear model for binary pedigree data, assuming different values for the cumulative risk. When an adjustment for age was made, based on the age of onset of probands, there was no significant difference between parent-offspring concordance and sibling concordance. There was a negative, but not significant, concordance between spouse pairs. Assuming the lifetime cumulative risk was 1.9% for males and 4.7% for females, values considered appropriate for this population, our model predicted that the presence of an affected parent or sibling incurs an approximately five times increase in the risk of developing panic disorder. Our model assumes in effect that this risk is multiplied for each further affected relative. Although the common concordance across relationship groups is consistent with a genetic hypothesis, it can also be explained by common family environmental factors. There is a need for further pedigree studies, using twins and relatives, for example, and reliable information on the cumulative risk.

Differential diagnosis and treatment of panic disorder: a medical model perspective

The authors present a review of existing literature along with new data regarding the phenomenology, differential diagnosis, course and treatment of panic disorder and agoraphobia. Panic attacks are viewed as central to the development of these disorders, and individual cognitive frameworks contribute to the manner in which a patient's symptoms evolve. An apparent though unclear relation to depressive states is described. Substance abuse may also be a consequence of recurrent panic attacks. A scheme towards differential diagnosis of panic disorder from other psychiatric and medical disorders is proposed. Personality characteristics of these patients vary considerably, but certain factors, such as dependency, are common. Family relations are often strained and assume importance in treatment. Data on the longitudinal course of illness is presented implying a relationship of panic disorder to both depression and stressful life events in many patients. Treatments that thus far seem most effective are pharmacological and behavioural approaches. Imipramine, MAO inhibitors, and alprazolam currently appear to be the most useful medications employed, although other agents may at times be useful alternatives. Dietary interventions, family therapy, and group and individual psychotherapy are also reviewed and discussed as adjunctive therapies in the treatment of panic disorder.