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

Pituitary-adrenal axis hormones in early-onset versus late-onset panic disorder

OBJECTIVE

It has been hypothesised that early-onset panic disorder (PD) may constitute a biologically distinct subtype of PD, but the few relevant data are inconclusive. We systematically explored for potential psychopathological and hormonal differences between early-onset (age at onset ≤ 27 years) versus late-onset PD, in consecutively-referred, medication-free, acutely-ill PD outpatients, moreover without comorbid mental disorders except agoraphobia (N = 54; age = 32.3 ± 7.5 years; early-onset = 27; females = 38).

METHODS

Hormones assessed (plasma levels) included adrenocorticotropic hormone (ACTH), cortisol and dehydroepiandrosterone sulphate (DHEAS). Psychopathological measures included panic attacks' number during last three weeks, the Agoraphobic Cognitions and the Body Sensations Questionnaires and the Hamilton Anxiety Rating Scale.

RESULTS

Early-onset PD patients - compared to their late-onset counterparts - had longer duration of the disease. The two onset-groups demonstrated similar panic and anxiety symptoms and similar ratios of smokers/never-smokers. However, early-onset patients demonstrated significantly greater ACTH and DHEAS levels and higher (marginally significant) cortisol levels than the late-onset patients. Moreover, in the early-onset patients only, significant positive correlations emerged between ACTH levels and the severity of both panic and anxiety symptomatology.

CONCLUSIONS

These findings suggest that the two onset-groups demonstrate significant differences in the hypothalamic-pituitary-adrenal axis functioning, at least when acutely-ill.Key pointsEarly-onset panic disorder (EOPD) may differ biologically from late-onset PD (LOPD).EOPD was correlated with greater adrenocorticotropic hormone (ACTH) plasma levels.EOPD was correlated with greater dehydroepiandrosterone sulphate plasma levels.In EOPD only, ACTH levels were positively correlated with panic and anxiety symptoms.

The natural course of anxiety symptoms in early adolescence: factors related to persistence

BACKGROUND AND OBJECTIVES

Anxiety disorders are the most common mental health problems during childhood and adolescence. This study examined the course of anxiety symptoms in early adolescents from the general population over three phases.

DESIGN

Prospective cohort study.

METHODS

Two hundred and forty-two participants (mean-age of 13.52) from a baseline sample of 1514 (mean-age of 10.23) were followed up three times. Of the 1514 children, those with emotional risk and controls without risk constituted the second-phase sample (n = 562; mean-age of 11.25). The Screen for Child Anxiety Related Emotional Disorders-SCARED was administered in all three phases.

RESULTS

Fifty-six percent and 32% of respondents showed total scores above the SCARED cutoff point at one and three years follow-up, respectively. Eight percent showed fluctuating symptoms. Fifty-five percent of respondents showed high scores for any subtype of anxiety over three years. Social phobia and generalized anxiety symptoms were the most prevalent and persistent. Participants with persistent separation anxiety showed the highest co-occurrence with symptoms of other psychopathological disorders. Participants with persistent anxiety showed lower academic performance. Being male was a protective factor against persistence.

CONCLUSIONS

The data support anxiety maintenance during early adolescence. Early adolescence is a critical period which may involve other serious academic, social, and family problems.

A cluster analysis of early onset in common anxiety disorders

Early onset is regarded as an important characteristic of anxiety disorders, associated with higher severity. However, previous findings diverge, as definitions of early onset vary and are often unsubstantiated. We objectively defined early onset in social phobia, panic disorder, agoraphobia, and generalised anxiety disorder, using cluster analysis with data gathered in the general population. Resulting cut-off ages for early onset were ≤22 (social phobia), ≤31 (panic disorder), ≤21 (agoraphobia), and ≤27 (generalised anxiety disorder). Comparison of psychiatric comorbidity and general wellbeing between subjects with early and late onset in the general population and an outpatient cohort, demonstrated that among outpatients anxiety comorbidity was more common in early onset agoraphobia, but also that anxiety- as well as mood comorbidity were more common in late onset social phobia. A major limitation was the retrospective assessment of onset. Our results encourage future studies into correlates of early onset of psychiatric disorders.

College Students: Mental Health Problems and Treatment Considerations

Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms. Given the uniqueness of college students, there is a need to outline critical issues to consider when working with this population. In this commentary, first, the prevalence of psychiatric and substance use problems in college students and the significance of assessing age of onset of current psychopathology are described. Then, the concerning persistent nature of mental health problems among college students and its implications are summarized. Finally, important aspects of treatment to consider when treating college students with mental health problems are outlined, such as the importance of including parents in the treatment, communicating with other providers, and employing of technology to increase adherence. It is concluded that, by becoming familiar with the unique problems characteristic of the developmental stage and environment college students are in, practitioners will be able to better serve them.

Examining determinants of early and late age at onset in panic disorder: an admixture analysis

Past research demonstrated that age at onset might account for different clinical and etiological characteristics in panic disorder (PD). However, prior research relied on arbitrary choices of age cut-offs. Using a data-driven validated method, this study aimed to examine differences between early and late onset PD in various determinants. Admixture analysis was used to determine the best fitting model of age at onset distribution in PD. Data was collected from 511 individuals (ages 18-65) with PD diagnoses, who participated in the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV comorbidities and various measures of childhood adversities, suicidal behavior, anxiety and depressive symptoms were assessed. The best fitting cut-off score between early and late age at onset groups was 27 years (early age at onset ≤ 27 years). Univariate tests showed that participants with early onset PD were younger and more likely to be female. Early onset PD was associated with agoraphobia, higher frequency of childhood trauma and life events, and higher rates of suicide attempts as compared to late onset PD. Multivariate logistic regression analysis demonstrated that only current age, childhood trauma and agoraphobia remained significantly associated with early onset PD. Findings suggest that 27 years marks two onset groups in PD, which are slightly distinct. Early onset PD is independently associated with exposure to childhood trauma and increased avoidance. This highlights the importance of subtyping age of onset in PD. Clinical implications are further discussed.

Age at onset and clinical correlates in body dysmorphic disorder

OBJECTIVE

Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.

METHODS

Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.

RESULTS

BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.

CONCLUSIONS

BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research

BACKGROUND

A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.

METHODS

A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.

RESULTS

The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.

LIMITATIONS

Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.

CONCLUSIONS

The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.

Age of onset, clinical characteristics, and 15-year course of anxiety disorders in a prospective, longitudinal, observational study

BACKGROUND

Age of onset is rarely studied in the anxiety disorders literature. The current study examined age of onset as it relates to clinical characteristics and course of anxiety disorders using a prospective, longitudinal, observational design.

METHODS

Fifteen-year follow-up data were examined for participants with panic disorder with (PDA) or without (PD) agoraphobia, social phobia (SP), and/or generalized anxiety disorder (GAD) at baseline. Logistic regression analyses were conducted to determine whether age of onset was associated with demographic or clinical variables at baseline. Cox regression analyses were conducted to examine longitudinal course (time to recurrence and recovery, respectively) for each diagnostic group.

RESULTS

At baseline, PD participants with early onset (i.e., < age 20) were more likely to have comorbid MDD, GAD, and SP relative to late-onset participants (≥ age 20). For PDA, early-onset participants were less likely to be married, and more likely to have both GAD and SP at baseline. With respect to longitudinal course, earlier onset was associated with an increased likelihood of recurrence in participants with PDA. No other models reached significance.

LIMITATIONS

The sample sizes for some disorders were comparatively small in relation to PDA, and all participants were treatment-seeking, which may limit generalizability.

CONCLUSIONS

For some anxiety disorders, earlier age of onset appears to be associated with greater severity and worse course, as evidenced by increased risk of recurrence over 15years of follow-up. Early interventions focused on children and adolescents may alleviate some of the public health burden associated with anxiety disorders.

Relationship between Personality and Insomnia in Panic Disorder Patients

OBJECTIVE

Panic disorder (PD) is frequently comorbid with insomnia, which could exacerbate panic symptoms and contribute to PD relapse. Research has suggested that characteristics are implicated in both PD and insomnia. However, there are no reports examining whether temperament and character affect insomnia in PD. Thus, we examined the relationship between insomnia and personality characteristics in PD patients.

METHODS

Participants were 101 patients, recruited from 6 university hospitals in Korea, who met the DSM-IV-TR criteria for PD. We assessed sleep outcomes using the sleep items of 17-item Hamilton Depression Rating Scale (HAMD-17)(item 4=onset latency, item 5=middle awakening, and item 6=early awakening) and used the Cloninger's Temperament and Character Inventory-Revised-Short to assess personality characteristics. To examine the relationship between personality and insomnia, we used analysis of variance with age, sex, and severity of depression (total HAMD scores minus sum of the three sleep items) as the covariates.

RESULTS

There were no statistical differences (p>0.1) in demographic and clinical data between patients with and without insomnia. Initial insomnia (delayed sleep onset) correlated to a high score on the temperamental dimension of novelty seeking 3 (NS3)(F(1,96)=6.93, p=0.03). There were no statistical differences (p>0.1) in NS3 between patients with and without middle or terminal insomnia.

CONCLUSION

The present study suggests that higher NS3 is related to the development of initial insomnia in PD and that temperament and character should be considered when assessing sleep problems in PD patients.

Depersonalization and individualism: the effect of culture on symptom profiles in panic disorder

It has been proposed that highly individualistic cultures confer vulnerability to depersonalization. To test this idea, we carried out a comprehensive systematic review of published empirical studies on panic disorder, which reported the frequency of depersonalization/derealization during panic attacks. It was predicted that the frequency of depersonalization would be higher in Western cultures and that a significant correlation would be found between the frequency of depersonalization and individualism scores of the participant countries. As predicted, the frequency of depersonalization during panic was significantly lower in nonwestern countries. There was also a significant correlation between frequency of depersonalization and Individualism (rho = 0.68, p < 0.0001), and between fears of losing control (rho = 0.57, p = 0.005) and individualism. These findings are interpreted in light of recent studies suggesting that individualistic cultures are characterized by hypersensitivity to threat and by an external locus of control. Two features may be relevant in the genesis of depersonalization.

Panic disorder in the elderly

Despite being the most common group of mental disorders in later life, anxiety disorders in the elderly have historically been a neglected area of research. While clinically important, there have been few studies of anxiety disorders specifically in older persons. However, in recent years, there has been increasing interest and a growing base of studies addressing the epidemiology, comorbidity and treatment of late-life anxiety. The literature on panic disorder in the elderly is illustrative of this trend. Although clinicians who treat panic disorder in the elderly have been left to extrapolate from data derived from younger individuals with panic disorder, the last decade has witnessed the first trials of psychotherapeutic and pharmacological treatments performed exclusively in older patients. Although much work remains to be done in terms of testing both psychosocial and medication treatment strategies in rigorously designed studies, preliminary evidence suggests that both psychotherapeutic and pharmacological treatment can be effective for panic disorder in the elderly.

Axis I and II comorbidities in subjects with and without nocturnal panic

Our purpose in this study was to compare the prevalence and pattern of Axis I and II comorbidities between patients with and without nocturnal panic (NP) attacks. One hundred and sixteen subjects with panic disorder (PD; according to DSM-IV criteria) were included: We assessed Axis I and II comorbidities using the Structured Clinical Interview for DSM-IV Axis I and II disorders, respectively. Of the sample, 27.6% of subjects had recurrent nocturnal panic attacks (NP group). Subjects with NP did not differ from those without in any sociodemographic or clinical characteristics. In the sample (94 subjects), 81% had at least one lifetime comorbid Axis I disorder, without significant differences between subjects with and without nocturnal panic even when considering comorbidity rates for single disorders; a trend toward significance was found for anorexia nervosa and somatization disorder, which both were more frequent among subjects with NP. Concerning Axis II disorders, 49.1% of the sample (57 subjects) met the criteria for at least one personality disorder, without significant differences between patients with and without NP. No significant differences were detected in comorbidity rates for any single Axis II personality disorder. Personality might play a relevant role in influencing treatment approaches to PD, but it does not appear to be a differential focus of concern in patients with compared to those without NP.

Antisocial personality disorder with childhood- vs. adolescence-onset conduct disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions

This study, based on a nationally representative, epidemiologic sample (N = 43,093, response rate 81%), compared sociodemographic and family history correlates, antisocial personality disorder (ASPD) symptom patterns, and Axis I and Axis II comorbidity, among adults with DSM-IV ASPD who reported onset of conduct disorder (CD) in childhood (<age 10) versus adolescence (> or =age 10). Prevalence of each ASPD diagnostic criterion and comorbid lifetime disorder was estimated. Logistic regression was used to examine associations of childhood-onset CD with ASPD symptom patterns and comorbid disorders. Among the 1422 respondents with ASPD, 447 reported childhood-onset CD. Childhood-onset respondents were more likely than adolescence-onset respondents to endorse CD criteria involving aggression against persons, animals, and property before age 15, and to endorse more childhood criteria and lifetime violent behaviors. Childhood-onset respondents displayed significantly elevated odds of lifetime social phobia, generalized anxiety disorder, drug dependence, and paranoid, schizoid, and avoidant personality disorders, but significantly decreased odds for lifetime tobacco dependence. Childhood-onset CD appears to identify a more polysymptomatic and violent form of ASPD, associated with greater lifetime comorbidity for selected Axis I and Axis II disorders, in nonclinical populations.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

Personality and anxiety disorders

Personality traits and most anxiety disorders are strongly related. In this article, we review existing evidence for ways in which personality traits may relate to anxiety disorders: 1) as predisposing factors, 2) as consequences, 3) as results of common etiologies, and 4) as pathoplastic factors. Based on current information, we conclude the following: 1) Personality traits such as high neuroticism, low extraversion, and personality disorder traits (particularly those from Cluster C) are at least markers of risk for certain anxiety disorders; 2) Remission from panic disorder is generally associated with partial "normalization" of personality traits; 3) Anxiety disorders in early life may influence personality development; 4) Anxiety disorders and personality traits are usefully thought of as spectra of common genetic etiologies; and 5) Extremes of personality traits indicate greater dysfunction in patients with anxiety disorders.

Depersonalization in psychiatric patients: a transcultural study

There is evidence suggesting that the prevalence of depersonalization in psychiatric patients can vary across cultures. To explore the possible influence of culture on the prevalence of depersonalization, we compared psychiatric inpatient samples from the United Kingdom (N = 31), Spain (N = 68), and Colombia (N = 41) on standardized and validated self-rating measures of dissociation and depersonalization: the Cambridge Depersonalization Scale and the Dissociative Experiences Scale (DES). Colombian patients were found to have lower global scores on the Cambridge Depersonalization Scale and the DES and all its subscales, with the exception of DES-Absorption. No differences were found for measures of depression or anxiety. These findings seem to support the view that depersonalization is susceptible to cultural influences. Attention is drawn to the potential relevance of the sociological dimension "individualism-collectivism" on the experience of the self, and it is proposed that cultures characterized by high individualism may confer vulnerability to depersonalization experiences.

Suicide and deliberate self-harm in personality disorders

PURPOSE OF REVIEW

This article reviews literature published over the period January 2004-May 2005 on suicidal behaviour and self-harm in personality disorders.

RECENT FINDINGS

Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviours, and self-mutilation. Negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders. Findings seem to confirm that suicidality and self-injurious behaviour are efficient DSM-IV diagnostic criteria for borderline personality disorder. Out of several psychosocial and pharmacological interventions for treating suicidality in personality disorders, only one randomized, controlled study has recently been published. Medico-legal concerns related to the clinical management of chronically suicidal patients, including hospitalization and alternative treatment approaches, are also discussed.

SUMMARY

Although recent studies have contributed to the theoretical knowledge and clinical practice, there are unsettled questions that should be addressed in the future. More randomized, controlled trials evaluating the efficacy of interventions in suicidal individuals with personality disorders should be conducted. As the majority of studies conducted to date have concentrated on borderline personality disorder and antisocial personality disorder, the prevalence and risk factors for suicidal behaviours and self-mutilation in other personality disorders require further clarification. The introduction of unified nomenclature related to suicidal behaviours and self-mutilation would facilitate comparability of results across studies.

The reliability and validity of the Panic Disorder Self-Report: A new diagnostic screening measure of panic disorder

This study examined the Panic Disorder Self-Report (PDSR), a new self-report diagnostic measure of panic disorder based on the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). PDSR diagnoses were compared with structured interview diagnoses of individuals with generalized anxiety disorder, social phobia, and panic disorder and nonanxious controls. Receiver operating characteristic analyses revealed that the PDSR showed 100% specificity and 89% sensitivity. The PDSR also demonstrated retest reliability, convergent and discriminant validity, and kappa agreement of .93 with a structured interview. Finally, the PDSR demonstrated clinical validity. Students who were identified as having panic disorder using the PDSR did not have significantly different scores on the Panic Disorder Severity Scale--Self-Report form (P. R. Houck, D. A. Speigel, M. K. Shear, & P. Rucci, 2002) than a panic disordered community sample. However, both groups had significantly higher scores than students identified as not meeting criteria for panic disorder.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Panic disorder with and without agoraphobia: comorbidity within a half-year of the onset of panic disorder

The present study was performed to compare the clinical features of patients with panic disorder with and without agoraphobia. The subjects were 233 outpatients with panic disorder (99 males and 134 females) diagnosed according to DSM-IV criteria. Sixty-three patients met the criteria for panic disorder without agoraphobia, and 170 met the criteria for panic disorder with agoraphobia. Patients with agoraphobia showed a significantly longer duration of panic disorder and higher prevalence of generalized anxiety disorder. However, there were no significant differences in prevalence of major depressive episodes, in current severity of panic attacks, or in gender ratio between the two groups. The second aim of the present study was to investigate the effects of onset age and sex differences on the development of agoraphobia within a half-year. The subjects were divided into two groups according to their self-report: patients who did or did not develop agoraphobia within 24 weeks of onset of panic disorder. A total of 40.6% of the patients developed agoraphobia within 24 weeks of the onset of panic disorder, and onset age and sex differences had no robust effect on the development of agoraphobia within 24 weeks.