Early separation anxiety and adult agoraphobia

[Separation anxiety disorder in adults - a new diagnostic category]

Anxiety separation disorder (SAD) became the subject of increased attention of researchers in recent decades. DSM-5 and project of ICD-11 allow us to treat this disorder as an independent nosological unit without attachment to age. The review provides information on the prevalence, clinical manifestations and diagnosis of SAD in adults, summarizes information on the etiopathogenesis, relations to other psychiatric disorders, and highlights the lack of modern therapeutic approaches to SAD. The purpose of this review is to raise the level of knowledge about SAD and its new positioning in classification systems.

Separation anxiety disorder in adult patients with obsessive-compulsive disorder: prevalence and clinical correlates

OBJECTIVE

Individuals with obsessive-compulsive disorder (OCD) and separation anxiety disorder (SAD) tend to present higher morbidity than do those with OCD alone. However, the relationship between OCD and SAD has yet to be fully explored.

METHOD

This was a cross-sectional study using multiple logistic regression to identify differences between OCD patients with SAD (OCD+SAD, n=260) and without SAD (OCD, n=695), in terms of clinical and socio-demographic variables. Data were extracted from those collected between 2005 and 2009 via the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders project.

RESULTS

SAD was currently present in only 42 (4.4%) of the patients, although 260 (27.2%) had a lifetime diagnosis of the disorder. In comparison with the OCD group patients, patients with SAD+OCD showed higher chance to present sensory phenomena, to undergo psychotherapy, and to have more psychiatric comorbidities, mainly bulimia.

CONCLUSION

In patients with primary OCD, comorbid SAD might be related to greater personal dysfunction and a poorer response to treatment, since sensory phenomena may be a confounding aspect on diagnosis and therapeutics. Patients with OCD+SAD might be more prone to developing specific psychiatric comorbidities, especially bulimia. Our results suggest that SAD symptom assessment should be included in the management and prognostic evaluation of OCD, although the psychobiological role that such symptoms play in OCD merits further investigation.

Childhood stressful events, HPA axis and anxiety disorders

Anxiety disorders are among the most common of all mental disorders and their pathogenesis is a major topic in psychiatry, both for prevention and treatment. Early stressful life events and alterations of hypothalamic pituitary adrenal (HPA) axis function seem to have a significant role in the onset of anxiety. Existing data appear to support the mediating effect of the HPA axis between childhood traumata and posttraumatic stress disorder. Findings on the HPA axis activity at baseline and after stimuli in panic disordered patients are inconclusive, even if stressful life events may have a triggering function in the development of this disorder. Data on the relationship between stress, HPA axis functioning and obsessive-compulsive disorder (OCD) are scarce and discordant, but an increased activity of the HPA axis is reported in OCD patients. Moreover, normal basal cortisol levels and hyper-responsiveness of the adrenal cortex during a psychosocial stressor are observed in social phobics. Finally, abnormal HPA axis activity has also been observed in generalized anxiety disordered patients. While several hypothesis have attempted to explain these findings over time, currently the most widely accepted theory is that early stressful life events may provoke alterations of the stress response and thus of the HPA axis, that can endure during adulthood, predisposing individuals to develop psychopathology. All theories are reviewed and the authors conclude that childhood life events and HPA abnormalities may be specifically and transnosographically related to all anxiety disorders, as well as, more broadly, to all psychiatric disorders.

Early predictors of separation anxiety disorder: early stranger anxiety, parental pathology and prenatal factors

OBJECTIVE

The present study seeks to extend research on the etiology of separation anxiety disorder (SAD) in a German-speaking sample by examining differences between children with SAD and healthy comparisons, using a retrospective-reporting paradigm.

METHOD

The sample included 106 children with SAD and 44 healthy children between the ages of 4 and 14 years. Parents completed questionnaires and structured clinical interviews to assess parental pathology, pregnancy variables and strong early stranger anxiety.

RESULTS

Children with SAD were more likely than healthy children to have had a phase of stronger stranger anxiety in infancy. Further, early stranger anxiety remained a significant predictor of SAD after controlling for maternal depression. Meaningful effects were not found for the influence of parental age at birth or other pregnancy factors.

CONCLUSION

This study provides beginning evidence of the potential predictive value of strong stranger anxiety in distinguishing children with SAD from those with no disorder, above and beyond the influence of parental pathology.

The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic

BACKGROUND

Adult separation anxiety disorder (ASAD) has been identified recently, but there is a paucity of data about its prevalence and associated characteristics amongst anxiety patients. This study assessed the prevalence and risk factor profile associated with ASAD in an anxiety clinic.

METHODS

Clinical psychologists assigned 520 consecutive patients to DSM-IV adult anxiety subcategories using the SCID. We also measured demographic factors and reports of early separation anxiety (the Separation Anxiety Symptom Inventory and a retrospective diagnosis of childhood separation anxiety disorder). Other self-report measures included the Adult Separation Anxiety Symptom Questionnaire (ASA-27), the Depression, Anxiety, Stress Scales (DASS-21), personality traits measured by the NEO PI-R and the Work and Social Adjustment Scale. These measures were included in three models examining for overall differences and then by gender: Model 1 compared the conventional SCID anxiety subtypes (excluding PTSD and OCD because of insufficient numbers); Model 2 divided the sample into those with and without ASAD; Model 3 compared those with ASAD with the individual anxiety subtypes in the residual group.

RESULTS

Patients with ASAD had elevated early separation anxiety scores but this association was unique in females only. Except for social phobia in relation to some comparisons, those with ASAD recorded more severe symptoms of depression, anxiety and stress, higher neuroticism scores, and greater levels of disability.

CONCLUSIONS

Patients with ASAD attending an anxiety clinic are highly symptomatic and disabled. The findings have implications for the classification, clinical identification and treatment of adult anxiety disorders.

Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder

OBJECTIVE

Attachment theory suggests that anxious attachment styles are associated with risk to psychiatric disorder, especially anxiety disorders. Separation anxiety would appear to be a core form of anxiety that is associated with anxious attachment. Nevertheless, as yet no research has examined the relationship of attachment styles to adult separation anxiety disorder, a condition that has only recently been fully recognized.

METHOD

The Attachment Style Questionnaire was used to examine attachment styles among 83 consecutive anxiety clinic patients diagnosed with panic disorder with agoraphobia and those re-assigned from that category to adult separation anxiety disorder.

RESULTS

Dimensional associations showed strong correlations with scales measuring anxious attachment and separation anxiety. Patients assigned to the separation anxiety group scored significantly higher than those in the panic disorder group on the scales of Need for Approval and Preoccupation with Relationships.

CONCLUSIONS

The findings finally dispel the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder. Possible implications for treatment are considered.

Does Repression Exist? Memory, Pathogenic, Unconscious and Clinical Evidence

The current dispute regarding the existence of repression has mainly focused on whether people remember or forget trauma. Repression, however, is a multidimensional construct, which, in addition to the memory aspect, consists of pathogenic effects on adjustment and the unconscious. Accordingly, in order to arrive at a more accurate decision regarding the existence of repression, studies relevant to all three areas are reviewed. Moreover, since psychoanalysis regards repression as a key factor in accounting for the development and treatment of neurotic disorders, relevant research from these two domains are also taken into account. This comprehensive evaluation reveals little empirical justification for maintaining the psychoanalytic concept of repression.

Childhood separation anxiety and the risk of subsequent psychopathology: Results from a community study

OBJECTIVE

To examine the association between separation anxiety disorder (SAD) and mental disorders in a community sample and to evaluate whether separation anxiety is specifically related to panic disorder with and without agoraphobia.

METHOD

The data come from a 4-year, prospective longitudinal study of a representative cohort of adolescents and young adults aged 14-24 years at baseline in Munich, Germany. The present analyses are based on a subsample of the younger cohort that completed baseline and two follow-up investigations (n = 1,090). DSM-IV diagnoses were made using the Munich Composite International Diagnostic Interview. Cox regressions with time-dependent covariates were used to examine whether prior SAD is associated with an increased risk for subsequent mental disorders.

RESULTS

Participants meeting DSM-IV criteria for SAD were at an increased risk of developing subsequent panic disorder with agoraphobia (PDAG) (HR = 18.1, 95% CI = 5.6-58.7), specific phobia (HR = 2.7, 95% CI = 1.001-7.6), generalized anxiety disorder (HR = 9.4, 95% CI = 1.8-48.7), obsessive-compulsive disorder (HR = 10.7, 95% CI = 1.7-66.1), bipolar disorder (HR = 7.7, 95% CI = 2.8-20.8), pain disorder (HR = 3.5, 95% CI = 1.3-9.1), and alcohol dependence (HR = 4.7, 95% CI = 1.7-12.4). Increased hazard rates for PDAG (HR = 4.2, 95% CI = 1.4-12.1), bipolar disorder type II (HR = 8.1, 95% CI = 2.3-27.4), pain disorder (HR = 1.9, 95% CI = 1.01-3.5), and alcohol dependence (HR = 2.1, 95% CI = 1.1-4.) were also found for subjects fulfilling subthreshold SAD.

CONCLUSIONS

Although revealing a strong association between SAD and PDAG, our results argue against a specific SAD-PDAG relationship. PDAG was neither a specific outcome nor a complete mediator variable of SAD.

Relationship between separation anxiety disorder, parental panic disorder, and atopic disorders in children: a controlled high-risk study

OBJECTIVE

To test the hypotheses that rates of atopic disorders are elevated in offspring of parents with panic disorder (PD) and in children with separation anxiety disorder (SAD).

METHOD

Rates of atopic disorders were assessed in 343 offspring (aged 6-17 years) of parents with PD, nonpanic psychiatric disorders, and no psychiatric disorder. Lifetime history of atopic disorders was determined by parental responses to a clinician-administered questionnaire assessing medical treatment for asthma and allergies. Logistic regression analyses assessed the association between atopic disorders and parental PD, and between atopic disorders and probable or definite childhood SAD. Analyses controlled for age, sex, socioeconomic status, and treatment for other medical illnesses.

RESULTS

Increased rates of atopic disorders were found in offspring of parents with PD (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.27-5.16, p = .009) and in children with SAD (OR = 2.71, 95% Cl = 1.22-6.03, p = .015). Associations remained significant when both parental PD and SAD were included in the model, suggesting that each contributed independently to increased rates of atopy. The interaction of parental PD and child SAD was not significant.

CONCLUSIONS

Atopic disorders in children are associated with parental PD and with childhood SAD. Results do not appear to support that having both childhood SAD and a parent with PD confers increased risk for atopic disorders above and beyond either condition alone.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with panic disorder

Traumatic life events during childhood and parental attitudes are discussed as possible etiological factors for panic disorder (PD). Patients with PD (n = 115) and subjects without a history of psychiatric disorders (n = 124) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders, and birth risk factors. The frequency of reports of some traumatic childhood experiences was significantly different between patients and controls, including death of father, separation from parents, childhood illness, parents' alcohol abuse, violence in the family, sexual abuse, and other factors. On a 0 to 9 "severe trauma scale" patients had significantly more severe traumatic events (mean score, 1.31; SD 1.21) than control subjects (0.52; SD 0.80; P <.0001). Only 31.3% of the panic patients, but 62.9% of the controls, did not report any severe traumatic events at all (P <.0001). Compared to controls, patients described the attitude of their parents as more restricting and providing less loving care and attention. Patients reported significantly higher rates of psychiatric disorders in their families in general, in particular PD and generalized anxiety disorder. Birth risk factors did not differ significantly. In a logistic regression model, the following possible etiological factors showed a significant influence: family history of anxiety disorders, severe traumatic events during childhood, and unfavorable parental attitudes. The present data support the hypothesis that the etiology of PD is multifactorial and that traumatic life events may be a contributing factor. Owing to the retrospective nature of the data, the results have to be interpreted with caution.

Anxiety and depressive disorders in fathers and mothers of anxious school-refusing children

OBJECTIVE

To examine anxiety and depressive disorders in the mothers and fathers of children with anxious school refusal and to test for the existence of differences in familial aggregation between children suffering from school refusal related to separation anxiety disorder and those suffering from phobic disorder-based school refusal.

METHOD

Using a blind standardized diagnostic evaluation (Schedule for Affective Disorders and Schizophrenia-Lifetime version, modified for the study of anxiety disorders; Diagnostic Interview for Genetic Studies; and Schedule for Affective Disorders and Schizophrenia for School-Age Children), the authors compared parental lifetime psychiatric illness for the 2 groups of anxious school refusers.

RESULTS

Relationships between specific anxiety disorders in children and their parents revealed increased prevalence of simple phobia and simple and/or social phobia among the fathers and mothers of phobic school refusers, and increased prevalence of panic disorder and panic disorder and/or agoraphobia among the fathers and mothers of school refusers with separation anxiety disorder. Simple and/or social phobia in the father, simple phobia in the mother, and age of the father were associated with the group of phobic school refusers.

CONCLUSIONS

The data show the high prevalence of both anxiety and depressive disorders in fathers and mothers of anxious school refusers. Significant differences were observed in familial aggregation considering the subgroups of anxious school-refusing children.

Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. American Academy of Child and Adolescent Psychiatry

Anxiety disorders comprise one of the most prevalent categories of psychopathology in children and adolescents. These revised practice parameters highlight the DSM-IV changes for anxiety disorders and review the literature related to the assessment and treatment of anxiety disorders in children and adolescents. Up-to-date information on longitudinal outcome data, assessment of anxiety, parent-child interventions, and use of selective serotonin reuptake inhibitors has been added to the previous parameters, published in September 1993. Recommendations for evaluation and multimodal approaches to treatment are presented.

Is early separation anxiety a risk factor for adult panic disorder?: a critical review

Heightened levels of early separation anxiety (SA) have long been linked to the risk of adult panic disorder (PD), suggesting that the two types of anxiety arise from a common diathesis--a proposition that has considerably influenced the classification of the anxiety disorders. However, the SA-PD link remains contentious, with some recent studies failing to confirm that putative association. All published research studies investigating the relationship of early SA to PD and/or other anxiety disorders were reviewed. Taken as a whole, the evidence provides support for the SA-PD hypothesis, although the specificity of that relationship needs further clarification. Problems of sample selection, retrospective measurement of early SA and comorbid diagnoses limit the certainty with which inferences can be drawn from existing data. Nevertheless, a recent community-based study provides additional support for the SA-PD hypothesis. Possible developmental pathways linking SA to PD are considered. One possibility that has not received adequate research attention is that early SA disorder (SAD) may persist into adulthood, rendering the sufferer vulnerable to panic and other anxiety symptoms when confronted with salient life stressors. We conclude that it is premature to reject the SA hypothesis of PD. Only well-designed longitudinal studies can map the complex developmental pathways linking early and later manifestations of morbid anxiety.

Genetic factors in early separation anxiety: implications for the genesis of adult anxiety disorders

An important contemporary conceptualization of anxiety has suggested that heightened early separation anxiety is specifically associated with the risk of adult panic disorder, with hereditary factors underlying that cluster of anxiety disorders. Yet there is a dearth of studies examining whether early separation anxiety is inherited. The present twin study, based on a retrospective approach, revealed a substantial genetic contribution to separation anxiety in females but not in males, with unique environmental influences being important in both gender groups. Although speculative, an evolutionary explanation is offered to account for the apparent gender difference in the inheritance of early separation anxiety. It is hypothesized that, in some women, phylogenetic vestiges of separation anxiety may conflict with their need to compete in an individualistic manner in the modern workplace. Whether such an attachment-autonomy conflict accounts for the increased rate of panic disorder and agoraphobia in women is worthy of further study.

Understanding separation anxiety disorder

BACKGROUND

When children are acutely ill and life is threatened, separation anxiety can develop in parents and children. Separation anxiety has been studied through two traditions--as a normative phenomenon and as a disorder.

SOURCE

A comprehensive review of the literature.

OBJECTIVE

To analyze and evaluate the literature to derive clinical and research implications.

CONCLUSIONS

Support was found for the development of interventions beyond the developmental stage of early childhood. The need for a family approach was evident.

Is early separation anxiety a specific precursor of panic disorder-agoraphobia? A community study

The present study aimed to examine memories of early separation anxiety symptoms in a community sample of women at heightened risk to neurotic disorder. The chief finding was that subjects with a lifetime history of panic disorder-agoraphobia (PD-Ag) returned statistically higher scores on a retrospective measure of early separation anxiety compared to subjects with either generalized anxiety or other phobic disorders, a result which was not accounted for by differences in neuroticism or General Health Questionnaire scores. Although limited by its retrospective design and the problem of co-morbidity in subclassifying the anxiety disorders, the present study does provide added support for the hypothesis--endorsed by DSM-III-R--that there is a developmental link between early separation anxiety and panic disorder.

Reported early separation anxiety symptoms in patients with panic and generalised anxiety disorders

Attachment theory has proposed that early separation anxiety is a risk factor for adult anxiety disorder, with the recent focus being particularly on panic disorder. The results of empirical studies examining this link are, however, contradictory, possibly because of inconsistencies across studies in measuring memories of early separation anxiety. In the present study, a psychometrically sound measure, the Separation Anxiety Symptom Inventory (SASI) was used to compare memories of such early symptoms in panic disorder (including those with mild phobic-avoidance), generalised anxiety disorder and control subjects. Anxiety patients as a group returned higher SASI scores (p < 0.001) with a non-significant trend for panic disorder patients to score higher than those with generalised anxiety. These results suggest that early separation anxiety may be a harbinger of adult anxiety and that risk of panic disorder may be higher in the most severely affected youngsters. As a risk factor, early separation anxiety does not however appear to be uniquely related to adult panic disorder.

A 3-year follow-up of children with and without behavioral inhibition

OBJECTIVE

Previous work suggested that children of parents with panic disorder and agoraphobia were likely to be classified as behaviorally inhibited and that behaviorally inhibited children were likely to develop anxiety disorders. Although these findings suggested that "behavioral inhibition to the unfamiliar" may be associated with risk for anxiety disorders in children, longitudinal data were needed to confirm the initial impressions.

METHOD

Using DSM-III structured interviews, the authors examined psychiatric disorders at 3-year follow-up in children of two independently ascertained, previously described, and preexisting samples of children. One sample was cross sectional and clinically derived (Massachusetts General Hospital at-risk sample), and the other was epidemiologically derived and longitudinal (Kagan et al. Longitudinal Cohort).

RESULTS

Analyses of follow-up findings revealed significant differences between inhibited and not inhibited children in the rates of multiple > or = 4 psychiatric disorders, multiple > or = 2 anxiety disorders, avoidant disorder, separation anxiety disorder, and agoraphobia. Among inhibited children, the rates of anxiety disorders increased markedly from baseline to follow-up assessments, attaining statistical significance for multiple > or = 2 anxiety disorders and avoidant disorder. Our findings also show there were significant differences between inhibited and not inhibited children in the emergence of multiple > or = 2 anxiety disorders, avoidant disorder, and separation anxiety disorder in children who did not have these diagnoses at baseline.

CONCLUSIONS

These findings indicate that inhibited children are at high risk for developing childhood-onset anxiety disorders and provide additional support for the hypothesis that behavioral inhibition is a predictor of later anxiety disorder.

DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics

This study investigated the characteristics of each of the specific DSM-III-R (American Psychiatric Association, 1987) anxiety disorders in a clinic sample of 188 anxiety disordered children. Characteristics examined included sociodemographic variables (age-at-intake, gender, and race of the child, and family marital and socioeconomic status) and clinical variables (disorder age-at-onset and severity, and history of additional disorders). Findings are discussed in light of the contemporary literature on childhood anxiety disorders.

Alprazolam, imipramine and placebo treatment of panic disorder: predicting therapeutic response

Factors that predicted the outcome of drug treatment (alprazolam or imipramine) of panic disorder were studied in a sample of 123 Scandinavian patients participating in a multicenter placebo-controlled 8-week trial. The attrition rate was 95% for alprazolam, 73% for imipramine and 46% for placebo. For the intention-to-treat and 3-week-completer samples, drugs and anxiety symptoms at baseline were the best predictors of improvement on the Global Improvement Scale and on symptom scales focusing on panic attacks, phobic behavior and anticipatory anxiety. For completers of the 8-week trial, only baseline scores predicted outcome. Generally, more severe symptoms at baseline predicted a worse outcome. A subsample of patients had a marked placebo response. Avoidance, sex, age, childhood psychopathology and previous treatment experience had no or only a weak impact on the outcome. The relationship between panic disorder and mood disorder is presented elsewhere.

Validation criteria for panic disorder as a nosological entity

Panic disorder (DSM-III, DSM-III-R) has been thoroughly studied in recent years. The main evidence for panic disorder as a nosological entity is reviewed, to delineate some important questions for future research. Validation criteria include epidemiological, phenomenological, genetic, neurobiological, pharmacological and behavioral findings. Biological, behavioral and psychodynamic considerations on etiology, pathogenesis and treatment are presented.

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.

Safety signal withdrawal: a behavioural paradigm sensitive to both "anxiolytic" and "anxiogenic" drugs under identical experimental conditions

A new method involving the blockade of operant behaviour induced by the withdrawal of a conditioned signal for safety without presentation of a punishment signal has been developed for studying drugs with anxiolytic or anxiogenic properties. For this purpose, rats were trained under two alternating components of a multiple schedule of reinforcement FR8 (food)/FR1 (food) + RR 50% (shocks randomly delivered with 50 +/- 15% of the presses). The nonpunished and punished periods were signalled by one cue light above the right lever (safety signal) or the left lever (punishment signal), respectively. On the test session (safety signal withdrawal), the safety signal was turned off at the end of the first nonpunished period, but the punishment signal was not presented (every press was food rewarded and no shocks were delivered). During this period (4 min), rats exhibited a strong blockade of responding that lessened over time. This suppression seemed not to be caused by intervening events such as novelty, temporal conditioning, schedule of food delivery or ambiguity of the signal presented. The behavioural blockade induced by withdrawal of the safety signal was reduced by benzodiazepines: diazepam (0.5-4 mg/kg), chlordiazepoxide (4-8 mg/kg), nitrazepam (0.25-2 mg/kg), alprazolam (0.25-1 mg/kg), and partial agonists at benzodiazepine receptors: bretazenil (0.125-8 mg/kg) and ZK 91296 (32-64 mg/kg). Various 5-HT-related drugs also lessened the behavioural blockade:pCPA (3 x 150 mg/kg) and the 5-HT1A receptor agonists, buspirone (0.25-2 mg/kg), gepirone (0.25-1 mg/kg) but not 8-OH-DPAT. Compounds that may cause anxiety in humans further enhanced the blockade of lever pressing induced by the safety signal withdrawal at doses that did not modify baseline responding: d-amphetamine (0.125-0.5 mg/kg), caffeine (16 mg/kg) and picrotoxin (1 mg/kg). FG 7142 (8 mg/kg) and CGS 8216 (2-8 mg/kg) decreased responding during both components of the session. Therefore, the present paradigm seems sensitive to both "anxiolytic" and "anxiogenic" effects of drugs under identical procedural conditions.

Chronology of panic and avoidance, age of onset in panic disorder, and prediction of treatment response. A report from the Cross-National Collaborative Panic Study

The relevance of the chronology between panic disorder and avoidance behavior and of an early, medium or late onset of panic disorder was tested. Groups from the sample of the cross-national collaborative panic study (CNCPS) were compared for differences in basic characteristics and for the ability to predict treatment response. Patients who developed avoidance behavior before the full syndrome of panic disorder had less often a full agoraphobia but were not different in their response to treatment. Patients with an early onset of panic disorder suffered more often from agoraphobia. The treatment response was similar in the groups with early, medium or late onset of panic disorder. Neither the chronology between panic disorder and avoidance behavior nor the age of onset of panic disorder predicted outcome in short-term treatment with alprazolam or imipramine.

Agoraphobia in phenylketonuria

We describe agoraphobia as a complication of phenylketonuria (PKU) in young adults. The five patients have classic PKU and received phenylalanine-restricted diet only in childhood. Only one has normal intelligence. All but one were also depressed. All were anxious. Three of the five had initiated the phenylalanine-restricted diet after 3 months of age. Two returned to the phenylalanine-restricted diet with dramatic reduction of symptoms. The frequency of manifestations of agoraphobia was also examined in 50 young women with PKU enrolled in a longitudinal study of psychosocial factors in maternal PKU, 47 of their acquaintances and 49 women with diabetes. All were administered a test of agoraphobic-avoidant behaviour. The women with PKU appeared to be more prone to social withdrawal and fear of leaving home. Twenty per cent were within the agoraphobia range of the Mobility Inventory. Those still on diet and those with non-PKU hyperphenylalaninaemia reported less avoidant behaviour than those who had terminated the diet in childhood. These results suggest that young adults with PKU are at risk for agoraphobia but that return to the phenylalanine-restricted diet may be an effective treatment.