Risk factors for the onset of panic disorder and other panic attacks in a prospective, population-based study

Heterotypic and homotypic continuity in psychopathology: a narrative review

Psychopathology is a process: it unfolds over time and involves several different factors. To extend our knowledge of such process, it is vital to understand the trajectories that lead to developing and maintaining a specific disorder. The construct of continuity appears very useful to this aim. It refers to the consistency, similarity, and predictability of behaviors or internal states across different developmental phases. This paper aims to present a narrative review of the literature on homotypic and heterotypic continuity of psychopathology across the lifespan. A detailed search of the published literature was conducted using the PsycINFO Record and Medline (PubMed) databases. Articles were included in the review based on the following criteria: (1) publication dates ranging from January 1970 to October 2022; and (2) articles being written in the English language. To ensure a thorough investigation, multiple combinations of keywords such as "continuity," "psychopathology," "infancy," "childhood," "adolescence," "adulthood," "homotypic," and "heterotypic" were used. Articles were excluded if exclusively focused on epidemiologic data and if not specifically addressing the topic of psychopathology continuity. The literature yielded a total of 36 longitudinal studies and an additional 190 articles, spanning the research published between 1970 and 2022. Studies on continuity focus on the etiology of different forms of mental disorders and may represent a fundamental resource from both a theoretical and clinical perspective. Enhancing our understanding of the different trajectories beneath psychopathology may allow clinicians to implement more effective strategies, focusing both on prevention and intervention. Since literature highlights the importance of early detection of clinical signs of psychopathology, future research should focus more on infancy and pre-scholar age.

Social Anxiety Disorder: Associated Conditions and Therapeutic Approaches

Social anxiety disorder (SAD) is a highly distressing chronic psychiatric disorder characterized by persistent fear of social situations in anticipation of being judged negatively by others. As shyness mimics some of the symptoms of SAD, people suffering from this debilitating disease are often underdiagnosed. It can have a devastating impact on all areas of life including academic performance, social growth, relationship status, and work performance. In recent years, research on anxiety and related disorders has proliferated due to the increased use of cognitive-behavioral models. The understanding of SAD has evolved greatly from distinguishing it from shyness to implementing modalities to comprehend the sophisticated underlying mechanism of disease prevalence and progression as well as methods to treat it. This review summarizes the concept of SAD, its epidemiology, symptoms, and diagnostic tools. Frequent comorbidities including other psychiatric disorders are also discussed. Additionally, we examine the latest evidence related to treatment options including psychotherapy and pharmacotherapy as well as recommendations for managing SAD.

Emergency department visits for panic attacks and ambient temperature: A time-stratified case-crossover analysis

BACKGROUND

Panic disorder is a common anxiety disorder affecting up to 5% of the population. Although its pathogenesis is unclear, evidence about its association with ambient temperature is limited. We aimed to investigate the association between short-term exposure to increased ambient temperature and exacerbation of panic attacks requiring emergency department visits.

METHODS

From the national emergency database of South Korea, we identified 1,926 patients who presented with panic attacks at the emergency department in Seoul from 2008 to 2014. Using a time-stratified case-crossover design and conditional logistic regression analysis, we compared ambient temperature levels on emergency department visits and correspondingly matched-control days.

RESULTS

Increased ambient temperature levels were significantly associated with panic attacks. The risk of a panic attack increased by 2.2% (95% confidence interval, 0.7-3.8%) per every 1°C increase in temperature. This association was significant after adjusting for air pollutants.

CONCLUSIONS

Our results provide new evidence that short-term exposure to increased ambient temperature may increase the risk of exacerbation of panic attacks. These findings may provide a basis for further research to establish the association between panic attacks and ambient temperature, thus establishing preventive measures for panic attacks.

Panic and epilepsy in adults: A systematic review

The purpose of the current paper was to review the empirical literature on the cooccurrence of panic and epilepsy, in order to determine whether there is an increased risk of panic attacks and panic disorder among adults with epilepsy and an increased risk of epilepsy among adults with panic disorder. Given the overlap between panic and ictal fear, a preliminary aim of the current review was to critically evaluate the methodology used to differentiate between diagnoses of panic disorder and epilepsy in existing research. A literature search was conducted in relevant electronic databases, and articles that directly focused on panic and epilepsy among adults were selected for the current review (n = 17). Overall, results suggest that rates of epilepsy are elevated among individuals with panic disorder and that panic attacks are elevated among individuals with epilepsy, but rates of panic disorder among people with epilepsy are inconsistent. However, most studies did not use sufficiently rigorous methods to differentiate between panic disorder and epilepsy. Therefore, a critical next step in this area of research is to develop a standard procedure for differentiating ictal fear from panic attacks and panic disorder.

Risk factors for the onset of panic and generalised anxiety disorders in the general adult population: a systematic review of cohort studies

BACKGROUND

We aimed to assess available evidence on risk factors associated with the onset of panic disorder (PD) and/or generalised anxiety disorder (GAD) in cohort studies in the general adult population.

METHODS

Systematic review using MEDLINE, PsycINFO and Embase. Search terms included panic disorder, generalised anxiety disorder, cohort studies and risk factors.

RESULTS

We finally selected 21 studies, involving 163,366 persons with a median follow-up of 5 years. 1) Sociodemographic factors: PD was associated with age, female gender, and few economic resources. GAD was associated with age, non-Hispanics and Blacks, being divorced or widowed, and few economic resources. 2) Psychosocial factors: PD was associated with smoking and alcohol problems. GAD was associated with stressful life events in childhood and adulthood, and personality. 3) Physical and mental health factors: PD was associated with the number of physical diseases suffered and the joint hypermobility syndrome. PD was also associated with a parental history of mental disorders, as well as with other anxiety disorders and other mental health problems in the person affected. GAD was associated with a parental history of mental disorders, as well as with other anxiety disorders and other mental health problems in the person affected, plus already having received psychiatric care.

LIMITATIONS

Few studies examined the same risk factors.

CONCLUSIONS

Sociodemographic, psychosocial and mental-physical health risk factors were determinant for the onset of PD and GAD in the general adult population. These findings could be useful for developing preventive interventions in PD and GAD.

Characteristics of initial fearful spells and their associations with DSM-IV panic attacks and panic disorder in adolescents and young adults from the community

BACKGROUND

Few studies examined characteristics of initial fearful spells (FS) or panic attacks (PA) and their relation to DSM-IV PA and panic disorder (PD).

METHODS

A community sample of adolescents and young adults (N=3021) was followed up in 4 waves (T0-T3) over up to 10 years. FS, PA, and PD were assessed at each wave using the DSM-IV/M-CIDI. Characteristics of the initial FS/PA including perceived reasons/triggers, appraisal, duration, and behavioral/emotional consequences of the initial FS/PA were retrospectively assessed at T1 and T2 in those reporting the experience of lifetime FS or PA at these waves (N=363). Multinomial logistic regressions adjusted for sex and age were used to reveal associations of initial FS/PA characteristics (aggregated data from T1 and T2) with PA only (N=88) and PD (N=62; lifetime incidences cumulated across assessment waves) (reference group: No PA/PD).

RESULTS

Alcohol consumption, drugs/medication, and physical illness as perceived reasons for the initial FS/PA were associated with PA-only (OR 2.46-5.44), while feelings of depression, feelings of anxiety, and having always been anxious/nervous as perceived reasons for the initial FS/PA, appraising the initial FS/PA as terrible and long-term irritating/burdensome, subsequent feelings of depression, subsequent avoidance, and subsequent consumption of medication, alcohol, or drugs were associated with PD (OR 2.64-4.15). A longer duration until "feeling okay again" was associated with both PA-only (OR=1.29 per category) and PD (OR=1.63).

LIMITATIONS

Initial FS/PA characteristics were necessarily assessed retrospectively by self-report only. Thus, our data might be subject to recall/evaluation biases. Aggregated data were used and strictly prospective-longitudinal studies are necessary that replicate our findings.

CONCLUSION

Assessing initial FS/PA characteristics might be useful to identify individuals at increased risk for more severe panic pathology.

The epidemiology of anxiety disorders: a review

Epidemiological studies show that anxiety disorders are highly prevalent and an important cause of functional impairment; they constitute the most frequent menial disorders in the community. Phobias are the most common with the highest rates for simple phobia and agoraphobia. Panic disorder (PD) and obsessive-compulsive disorder (OCD) are less frequent (2% lifetime prevalence), and there are discordant results for social phobia (SP) (2%-16%) and generalized anxiety disorder (GAD) (3%-30%). These studies underline the importance of an accurate definition of disorders using unambiguous diagnostic and assessment criteria. The boundaries between anxiety disorders are often ill defined and cases may vary widely according to the definition applied. Simple phobia, agoraphobia, and GAD are more common in vmrnen, while there is no gender différence for SP, PD, and OCD, Anxiety disorders are more common in separated, divorced, and widowed subjects; their prevalence is highest in subjects aged 25 to 44 years and lowest in subjects aged >65 years. The age of onset of the different types of anxiety disorders varies widely: phobic disorders begin early in life, whereas PD occurs in young adulthood. Clinical - rather than epidemiological - studies have examined risk factors such as life events, childhood experiences, and familial factors. Anxiety disorders have a chronic and persistent course, and are frequently comorbid with other anxiety disorders, depressive disorders, and substance abuse. Anxiety disorders most frequently precede depressive disorders or substance abuse, Comorbid diagnoses may influence risk factors like functional impairment and quality of life. It remains unclear whether certain anxiety disorders (eg, PD) are risk factors for suicide. The comorbidity of anxiety disorders has important implications for assessment and treatment and the risk factors should be explored. The etiology, natural history, and outcome of these disorders need to be further addressed in epidemiological studies.

Agoraphobia: a review of the diagnostic classificatory position and criteria

The status of agoraphobia (AG) as an independent diagnostic category is reviewed and preliminary options and recommendations for the fifth edition of The Diagnostic and Statistical Manual (DSM-V) are presented. The review concentrates on epidemiology, psychopathology, neurobiology, vulnerability and risk factors, clinical course and outcome, and correlates and consequences of AG since 1990. Differences and similarities across conventions and criteria of DSM and ICD-10 are considered. Three core questions are addressed. First, what is the evidence for AG as a diagnosis independent of panic disorder? Second, should AG be conceptualized as a subordinate form of panic disorder (PD) as currently stipulated in DSM-IV-TR? Third, is there evidence for modifying or changing the current diagnostic criteria? We come to the conclusion that AG should be conceptualized as an independent disorder with more specific criteria rather than a subordinate, residual form of PD as currently stipulated in DSM-IV-TR. Among other issues, this conclusion was based on psychometric evaluations of the construct, epidemiological investigations which show that AG can exist independently of panic disorder, and the impact of agoraphobic avoidance upon clinical course and outcome. However, evidence from basic and clinic validation studies remains incomplete and partly contradictory. The apparent advantages of a more straightforward, simpler classification without implicit hierarchies and insufficiently supported differential diagnostic considerations, plus the option for improved further research, led to favoring the separate diagnostic criteria for AG as a diagnosis independent of panic disorder.

Anxiety disorders in older adults: a comprehensive review

This review aims to address issues unique to older adults with anxiety disorders in order to inform potential changes in the DSM-V. Prevalence and symptom expression of anxiety disorders in late life, as well as risk factors, comorbidity, cognitive decline, age of onset, and treatment efficacy for older adults are reviewed. Overall, the current literature suggests: (a) anxiety disorders are common among older age individuals, but less common than in younger adults; (b) overlap exists between anxiety symptoms of younger and older adults, although there are some differences as well as limitations to the assessment of symptoms among older adults; (c) anxiety disorders are highly comorbid with depression in older adults; (d) anxiety disorders are highly comorbid with a number of medical illnesses; (e) associations between cognitive decline and anxiety have been observed; (f) late age of onset is infrequent; and (g) both pharmacotherapy and CBT have demonstrated efficacy for older adults with anxiety. The implications of these findings are discussed and recommendations for the DSM-V are provided, including extending the text section on age-specific features of anxiety disorders in late life and providing information about the complexities of diagnosing anxiety disorders in older adults.

Sociodemographic and psychopathologic predictors of first incidence of DSM-IV substance use, mood and anxiety disorders: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions

The objective of this study was to present nationally representative findings on sociodemographic and psychopathologic predictors of first incidence of Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) substance, mood and anxiety disorders using the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. One-year incidence rates of DSM-IV substance, mood and anxiety disorders were highest for alcohol abuse (1.02), alcohol dependence (1.70), major depressive disorder (MDD; 1.51) and generalized anxiety disorder (GAD; 1.12). Incidence rates were significantly greater (P<0.01) among men for substance use disorders and greater among women for mood and anxiety disorders except bipolar disorders and social phobia. Age was inversely related to all disorders. Black individuals were at decreased risk of incident alcohol abuse and Hispanic individuals were at decreased risk of GAD. Anxiety disorders at baseline more often predicted incidence of other anxiety disorders than mood disorders. Reciprocal temporal relationships were found between alcohol abuse and dependence, MDD and GAD, and GAD and panic disorder. Borderline and schizotypal personality disorders predicted most incident disorders. Incidence rates of substance, mood and anxiety disorders were comparable to or greater than rates of lung cancer, stroke and cardiovascular disease. The greater incidence of all disorders in the youngest cohort underscores the need for increased vigilance in identifying and treating these disorders among young adults. Strong common factors and unique factors appear to underlie associations between alcohol abuse and dependence, MDD and GAD, and GAD and panic disorder. The major results of this study are discussed with regard to prevention and treatment implications.

Anxiety and mood disorder in young males with mitral valve prolapse

Objective

This study explored the prevalence of panic disorder and other psychiatric disorders in young Han Chinese males with mitral valve prolapse (MVP). With the factors of age, sex, and ethnicity controlled, the specific role of MVP in panic disorder was analyzed.

Methods

Subjects with chest pain aged between 18 and 25 years were assessed with the echocardiograph for MVP and the Chinese version of the Mini-International Neuropsychiatric Interview for panic disorder (n = 39).

Results

Of the 39 participants, 35.9% met the diagnosis of anxiety disorder, 46.2% met at least one criterion of anxiety disorder, and 23.1% met the diagnostic criteria of major depressive disorder. There was no statistically significant difference in the prevalence of panic disorder between one of the (8.3%) MVP patients, and two (7.4%) control participants.

Conclusions

There is a high prevalence of psychiatric disorder, including anxiety disorder and major depressive disorder, in those who report pain symptoms, so that diagnosis and treatment of these patients is of great importance. In addition, individuals with MVP did not have an increased risk for panic disorder. Whether MVP may be a modifier or mediating factor for panic disorder needs to be further assessed in a larger scale study.

Prevalence and incidence studies of anxiety disorders: a systematic review of the literature

OBJECTIVE

To present the results of a systematic review of literature published between 1980 and 2004 reporting findings of the prevalence and incidence of anxiety disorders in the general population.

METHOD

A literature search of epidemiologic studies of anxiety disorders was conducted, using Medline and HealthSTAR databases, canvassing English-language publications. Eligible publications were restricted to studies that examined age ranges covering the adult population. A set of predetermined inclusion and exclusion criteria were used to identify relevant studies. Prevalence and incidence data were extracted and analyzed for heterogeneity.

RESULTS

A total of 41 prevalence and 5 incidence studies met eligibility criteria. We found heterogeneity across 1-year and lifetime prevalence rates of all anxiety disorder categories. Pooled 1-year and lifetime prevalence rates for total anxiety disorders were 10.6% and 16.6%. Pooled rates for individual disorders varied widely. Women had generally higher prevalence rates across all anxiety disorder categories, compared with men, but the magnitude of this difference varied.

CONCLUSION

The international prevalence of anxiety disorders varies greatly between published epidemiologic reports. The variability associated with all anxiety disorders is considerably smaller than the variability associated with individual disorders. Women report higher rates of anxiety disorders than men. Several factors were found to be associated with heterogeneity among rates, including diagnostic criteria, diagnostic instrument, sample size, country studied, and response rate.

Asthma and panic in young adults: a 20-year prospective community study

RATIONALE

Psychologic factors are increasingly recognized to influence the onset and course of asthma. Previous cross-sectional community-based studies have provided evidence for a relatively specific association between asthma and panic.

OBJECTIVES

To examine concurrent and longitudinal associations between asthma and panic in young adults.

MEASUREMENTS AND MAIN RESULTS

Prospective community-based cohort study of young adults (n = 591) followed between ages 19 and 40. Information was derived from six subsequent semistructured diagnostic interviews conducted by professionals. Cross-sectionally (over the whole study period), asthma was more strongly associated with panic disorder (odds ratio [OR] = 4.0; 95% confidence interval [CI], 1.7, 9.3) than with any panic, which included panic disorder and panic attacks (OR = 2.1; 95% CI, 1.1, 4.5). Longitudinally, after adjusting for potentially confounding variables, active asthma predicted subsequent panic disorder (OR = 4.5; 95% CI, 1.1, 20.1), and the presence of panic disorder predicted subsequent asthma activity (OR = 6.3; 95% CI, 2.8, 14.0). Asthma predicted any panic (OR = 2.7; 95% CI, 1.1, 7.1), whereas any panic did not predict subsequent asthma activity. Associations were stronger in smokers than in nonsmokers, and stronger in women than in men. Smoking, early-childhood anxiety, and a family history of allergy were important confounders of the asthma-panic association.

CONCLUSIONS

This is the first long-term follow-up study on asthma and panic. It showed dose-response-type relationships between panic and asthma, and bidirectional longitudinal associations between the two conditions. It provided evidence for familial factors and smoking as possible shared etiologic explanations.

Panic attacks and psychopathology among youth

OBJECTIVE

To determine the association between panic attacks and mental disorders among youth in the community.

METHOD

Data were drawn from the Methods for the Epidemiology of Child and Adolescent Mental Disorders study (n = 1285), a community-based sample of youth aged 9-17. Multiple logistic regression analyses were used to determine the association between panic attacks and the range of mental disorders, diagnosed with the Diagnostic Interview Schedule for Children 2.3.

RESULTS

Panic attacks were prevalent among 3.3% of the sample. Panic attacks were associated with an increased likelihood of any anxiety disorders [OR = 4.6 (2.5, 8.5)] and any affective disorder [OR = 5.8 (2.8, 11.7)], as well as social phobia [OR = 2.3 (1.0, 5.4)], specific phobia [OR = 3.4 (1.1, 10.1)], agoraphobia [OR = 2.9 (1.1, 7.6)], generalized anxiety disorder [OR = 4.8 (1.9, 12.1)], separation anxiety disorder [OR = 3.1 (1.3, 7.7)], major depression [OR = 3.6 (1.6, 8.3)], dysthymia [OR = 6.7 (2.9, 15.5)], and hypomania [OR = 26.1 (5.5, 124.1)].

CONCLUSION

These data are consistent with, and extend, previous clinical findings by showing that panic attacks are associated with increased likelihood of a range of affective and anxiety disorders, but not substance use disorders, among youth in the community. The use of longitudinal study designs in future investigations may be useful in increasing our understanding of the mechanisms underlying these associations.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Diagnosis and Management of Panic Disorder in Older Patients

Panic disorder occurs less frequently in the elderly than in younger adults and rarely starts for the first time in old age. Panic attacks that begin in late life should prompt the clinician to conduct a careful search for a depressive disorder, physical illness or drugs that could be contributing to their presence. When panic attacks do occur in the elderly, the symptoms are qualitatively similar to those experienced by younger people. The elderly, however, may have fewer and less severe symptoms and exhibit less avoidant behaviour. As panic disorder is typically a chronic or recurrent condition, its management requires a long-term approach. With the exception of one descriptive pilot study, there have been no randomised controlled trials of the treatment of panic disorder in later life. Therefore, recommendations regarding the management of this disorder in the elderly must be extrapolated from research pertaining to younger patients. Selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, benzodiazepines and cognitive behavioural therapy are efficacious treatments for panic disorder. There are no consistent differences in efficacy between classes of medications or between pharmacotherapy and cognitive behavioural therapy. Furthermore, there are no reliable predictors of response to one type of treatment compared with another. Treatment selection, therefore, depends on an individual assessment of the risks and benefits of each type of treatment (taking into account comorbid psychiatric and physical conditions), patient preference, cost and the availability of therapists skilled in cognitive behavioural techniques. As a general rule, antidepressant medication is preferable to a benzodiazepine as a first-line treatment for panic disorder in the elderly, especially given the high level of comorbidity between panic disorder and depressive disorders. Of the antidepressants, an SSRI is recommended as the initial choice of treatment in older patients. Anxious patients frequently misattribute somatic symptoms of anxiety to adverse effects of medication. Adherence with treatment, therefore, can be enhanced by starting antidepressant medication at a low dosage so as to avoid initial exacerbation of anxiety (but then gradually increasing the dosage to the therapeutic range), frequent follow-up during the first few weeks of treatment, discussion about potential adverse effects and addressing any other concerns the patient may have about taking medication. Given the delayed onset of action of antidepressant medication, the short-term use of adjunctive lorazepam in the first few weeks of treatment may be helpful in selected patients.

Understanding the association between socioeconomic status and physical health: do negative emotions play a role?

In this article, the authors evaluate the possible roles of negative emotions and cognitions in the association between socioeconomic status (SES) and physical health, focusing on the outcomes of cardiovascular diseases and all-cause mortality. After reviewing the limited direct evidence, the authors examine indirect evidence showing that (a) SES relates to the targeted health outcomes, (b) SES relates to negative emotions and cognitions, and (c) negative emotions and cognitions relate to the targeted health outcomes. The authors present a general framework for understanding the roles of cognitive-emotional factors, suggesting that low-SES environments are stressful and reduce individuals' reserve capacity to manage stress, thereby increasing vulnerability to negative emotions and cognitions. The article concludes with suggestions for future research to better evaluate the proposed model.

Likelihood formulation of parent-of-origin effects on segregation analysis, including ascertainment

We developed a likelihood-based method for testing for parent-of-origin effect in complex diseases. The likelihood formulations model parent-of-origin effect and allow for incorporation of ascertainment, as well as differential male and female ascertainment probabilities. The results based on simulated data indicated that the estimates of parental effect (either maternal or paternal) were biased when ascertainment was ignored or when the wrong ascertainment model was used. The exception was single ascertainment, in which we proved that ignoring ascertainment does not bias the estimation of parental effect, in a simple parent-of-origin model. These results underscore the importance of considering ascertainment models when testing for parent-of-origin effect in complex diseases.

Association between allergy and anxiety disorders in youth

OBJECTIVE

Studies have documented associations between anxiety disorders and allergy in adults, but these associations have not been studied extensively in children. The objective of this study is to examine the associations between allergy and six anxiety disorders (AD) in youth.

METHOD

This is a data analysis of two epidemiologic-services studies: (i) alternative service use patterns of youth with serious emotional disturbance (n = 936), and (ii) methods for the epidemiology of child and adolescent mental disorders (n = 1285). Child psychiatric diagnoses were measured by the diagnostic interview schedule for children. Allergy was assessed by the service utilization and risk factors interview.

RESULTS

Among ADs, the strongest association found was between allergy and panic disorder (adjusted odds ratio 5.0; p < or = 0.001). Associations of allergy and the other ADs do not seem to be clinically significant.

CONCLUSIONS

Findings suggest that in some patients panic disorder may be associated with hypersensitivity of immune system. Panic disorder should be considered in anxious children reporting allergy when no organic cause of allergy is found, and likewise allergy should considered in children with panic disorder.

Predictors of panic attacks in adolescents

OBJECTIVE

To identify risk factors for onset of panic attacks in adolescents, a prospective cohort design was used to evaluate the following risk factors: negative affectivity, female sex, anxiety sensitivity, and childhood separation anxiety disorder. These risk factors were also evaluated for predicting onset of major depression to test their specificity.

METHOD

The sample consisted of 2,365 high school students assessed over a 4-year period. Assessments included self-report questionnaires and structured clinical interviews. Cox proportional hazards models were used to evaluate risk.

RESULTS

Consistent with previous studies, prior major depression predicted onset of panic attacks and a history of panic attacks predicted onset of major depression. After adjusting for the effects of prior major depression, negative affectivity and anxiety sensitivity, but not female sex or childhood separation anxiety disorder, predicted onset of 4-symptom panic attacks. However, female sex and negative affectivity but not anxiety sensitivity or childhood separation anxiety disorder predicted onset of major depression after adjustment for the effects of prior panic attacks.

CONCLUSION

Negative affectivity appears to be a nonspecific risk factor for panic attacks and major depression, whereas anxiety sensitivity appears to be a specific factor that increases the risk for 4-symptom panic attacks in adolescents.

Types of panic attacks and their association with psychiatric disorder and physical illness

The differentiation of three types of panic attacks is proposed to be significant for understanding the course and etiology of panic and other psychiatric disorders and physical illnesses. The present investigation is based on longitudinal data from the Epidemiologic Catchment Area (ECA) Study of 1980 to 1981 and its 1994 to 1996 follow-up. Multidimensional scaling (MDS) of panic symptoms identified three types of panic which were consistent over time and for which reliable scales were constructed to measure derealization, cardiac panic, and respiratory panic. Unlike panic disorder, none of the three types of panic attacks predicted the incidence of depression. Derealization was associated with a broader variety of psychiatric disorders than the other two types of panic, including simple phobias, but was not associated with physical diseases. Cardiac panic attacks were associated with a history of heart disease and predicted the incidence of agoraphobia but were not comorbid with depression, unlike the other two forms of panic. Respiratory panic attacks were consistently symptomatic of dysthymia and predicted a higher risk of hospitalization for breast cancer and myocardial infarction (MI).

Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up

BACKGROUND

The objective is to estimate parameters of the natural history of panic disorder, including its prodrome, incidence, recovery and recurrence.

METHOD

In 1981 the Baltimore Epidemiologic Catchment Area Study interviewed 3481 individuals probabilistically selected from the household population. During 1993-1996, 1920 of these individuals (73% of survivors) were interviewed again. Baseline and follow-up interviews included the National Institute of Mental Health Diagnostic Interview Schedule. During the follow-up, a subsample was assessed by psychiatrists using the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry (SCAN).

RESULTS

There were 35 new cases of panic disorder in 24,475 person years of exposure, yielding an annual incidence of 1.43 per 1000 per year. Data from the SCAN assessments suggest the incidence estimate is conservative. Incidence is greater in females and declines with age. About one-third of the new cases arise without agoraphobia, but about half have anxiety of some sort present for many years prior to meeting criteria for diagnosis. People with agoraphobia have less intense onsets but slower recoveries than those without agoraphobia.

CONCLUSIONS

Panic is heterogeneous in its pattern of onset and recovery. Some of the heterogeneity is associated with the presence of other anxiety over a long period of the life.

Assessment and phenomenology of nonclinical panic attacks in adolescent girls

Recent reviews of studies concerning panic attacks in adolescents have emphasized research limitations, noting problems of validity, reliability, and lack of normative data. To address some of these limitations we evaluated two methods of panic ascertainment (questionnaire versus interview), reliability of interview-determined panic, and clinical correlates of panic symptoms in a large sample (N = 1013) of early adolescent girls. The 5.4% of the sample who, when interviewed, reported ever experiencing a panic attack scored significantly higher on measures of depression, anxiety sensitivity, and alcohol use, but were not more avoidant than others. Using the interview as the standard, the questionnaire had a specificity of 81% and a sensitivity of 72%. Adolescents do experience panic attacks-whether identified by questionnaire or interview-although for many the attacks may not be salient. Longitudinal studies are required to determine those qualities of nonclinical panic (severity, context, interpretation/attribution), which render some episodes as clinically meaningful.

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.