Impact of preterm birth on the onset of panic disorder in later life - Results from the Gutenberg Prematurity Study (GPS)

BACKGROUND

The present study aimed to investigate whether prematurity and perinatal stress exert long-term effects on the onset of panic disorder in later life.

METHODS

From 40,189 adults born in Germany between 1969 and 2002, a study cohort (n = 427) stratified by gestational age (GA) (extremely preterm: GA < 29 weeks; very preterm: GA 29-32 weeks; moderately preterm: GA 33-36 weeks; and full-term GA ≥ 37 weeks) was selected (age 28.5 ± 8.7 years). Multivariable logistic regression analyses were conducted to investigate associations between gestational age at birth and panic disorder adjusting for age, gender, socioeconomic status, and perinatal factors.

RESULTS

The prevalence of panic disorder was roughly equal in moderate to very preterm and full-term birth groups at 1.9%-3.8%. However, this rate significantly increased to 14.3% in the extreme preterm category (GA <2 9: 14.3 %, p = 0.002). In multivariable analyses, female gender and GA were independently associated with panic disorder. Adjusting for age, gender and socioeconomic status, panic disorder was associated with lower GA at birth (OR = 1.12 per week (CI95%: 1.01-1.26, p = 0.037). Whereas adjustment for nutrition status or indicators of perinatal stress had no effect, correction for the length of postnatal ICU-stay eliminated the association between preterm birth and later panic disorder.

LIMITATIONS

Limitations include the small number of cases and the reliance on questionnaires to assess mental status.

CONCLUSIONS

Prematurity likely increases the risk of panic disorder later in life, and the subsequent postnatal ICU-stay appears to be of critical importance. However, due to strong collinearity and other associated factors with preterm births, it remains unclear which is the primary determinant.

Generalised anxiety and panic symptoms in the German National Cohort (NAKO)

OBJECTIVES

Anxiety disorders (AD) are common in the general population, leading to high emotional distress and disability. The German National Cohort (NAKO) is a population-based mega-cohort study, examining participants in 16 German regions. The present study includes data of the first 101,667 participants and investigates the frequency and severity of generalised anxiety symptoms and panic attacks (PA).

METHODS

The Generalised Anxiety Disorder Symptoms Scale (GAD-7) and the first part of the Patient Health Questionnaire Panic Disorder (PHQ-PD) were filled out by NAKO participants (93,002). We examined the correlation of GAD-7 and PHQ-PD with demographic variables, stress (PHQ-Stress), depression (PHQ-9) and childhood trauma (CTS).

RESULTS

The total proportion of prior lifetime diagnoses of AD in the NAKO cohort reached 7.8%. Panic attacks were reported by 6.0% and possible/probable current GAD symptoms in 5.2% of the examined participants. Higher anxiety severity was associated with female sex, lower education level, German as a foreign language and younger age as well as high perceived stress and depression.

CONCLUSIONS

Clinically relevant GAD symptoms as well as panic attacks are frequent in the NAKO and are associated with sociodemographic factors, and high anxiety symptoms are accompanied by pronounced stress and depression levels.

The multi-generational familial aggregation of interstitial cystitis, other chronic nociplastic pain disorders, depression, and panic disorder

BACKGROUND

Interstitial cystitis/painful bladder syndrome (IC) is a chronic pelvic pain condition which has high comorbidity with other nociplastic, or unexplained, pain disorders [e.g. fibromyalgia (FM), irritable bowel syndrome (IBS), and myalgic encephalomyelitis/chronic fatigue (ME/CFS)] and some psychiatric conditions [major depressive disorder (MDD) and panic disorder (PD)]. Here we investigated the shared familiality of IC and these other nociplastic and psychiatric conditions.

METHODS

Subjects were identified in the Utah Population Database, which links genealogy data back to the 1800s to medical record diagnosis billing code data back to 1995. We computed the relative risk of each of these disorders among first (FDR), second (SDR), and third-degree relatives (TDR) of six proband groups: IC, FM, IBS, ME/CFS, PD, and MDD. Given the known familial aggregation of each of these disorders, we conducted our analyses to test for heritable interrelationships using proband subgroups whose members did not have the diagnosis assessed in their relatives.

RESULTS

We observed strong evidence for heritable interrelationships among all six disorders. Most analyses indicated significantly increased risk for each of the six disorders in FDR, SDR, and TDR of all or most proband groups. Out of 30 possible bidirectional disorder interrelationships, 26 were significant among FDR, 23 were significant among SDR, and 7 were significant among TDR. Clustering was observed in both close and distant relatives.

CONCLUSIONS

Our results support a common, heritable component to IC and other nociplastic and psychiatric conditions.

The relationship of separation anxiety with the age of onset of panic disorder

AIM

This study aimed to investigate whether separation anxiety (SA) constitutes a dimension related to age at onset of panic disorder (PD), in homogeneous subgroups of outpatients with PD, based on their age of onset and symptom severity.

METHODS

A sample of 232 outpatients with PD was assessed with the Panic Disorder Severity Scale (PDSS) and the Sheehan Disability Scale (SDS) for functional impairments. Separation anxiety was evaluated using structured interviews and questionnaires. We applied a K-Means Cluster Analysis based on the standardized "PD age of onset" and "the PDSS total score" to identify distinct but homogeneous groups.

RESULTS

We identified three groups of patients: group 1 ("PD early onset/severe", N = 97, 42%, onset 23.2 ± 6.7 years), group 2 ("PD early onset/not severe", N = 76, 33%, onset 23.4 ± 6.0 years) and group 3 ("PD adult onset/not severe", N = 59, 25%, onset 42.8 ± 7.0 years). Patients with early onset/severe PD had significantly higher scores on all SA measures than PD late-onset/not severe. Regression analyses showed that SA scores, but not PDSS scores, were predictive of impairment in SDS work/school, social life, and family functioning domains.

CONCLUSIONS

Our data indicate a significant relationship between SA and PD with an earlier age of onset and an impact on individual functioning. This may have important implications for implementing preventive interventions targeting early risk factors for the subsequent onset of PD.

The influence of parental rearing style on the incidence of panic disorder, major depressive disorder and the comorbidity among Chinese college students

BACKGROUND

Panic disorder (PD), major depressive disorder (MDD), and the comorbidity (PD&MDD) in college students have caused a heavy disease burden for individuals and families. However, little was known for the comorbidity, especially the impact of parental rearing style on the incidence of the PD&MDD comorbidity.

METHODS

A cohort study was conducted among 6652 Chinese college students. Composite International Diagnostic Interview (CIDI-3.0) was used for disease diagnosis. The parental rearing styles were measured by the Egna Minnen Beträffande Uppfostran (EMBU) scale and factor analysis was used to reduce the dimension of the EMBU scale. Multinomial logistic regression models were used to determine the relationships between parenting styles and disease incidence. SPSS version 26.0 was used for all statistical analyses.

RESULTS

The 1-year incidence of PD, MDD, and PD&MDD comorbidity was 0.27 %, 2.04 %, and 0.21 %, respectively. Emotional warmth mode (OR = 0.753, 95%CI: 0.631-0.899, P < 0.01) were only negatively correlated with major depressive disorder. However, punishment denial mode (OR = 1.857, 95%CI: 1.316-2.620, P < 0.01) and over-participation mode (OR = 1.862, 95%CI: 1.176-2.949, P < 0.01) were positively correlated with the comorbidity of panic disorder and major depressive disorder.

LIMITATIONS

The limited follow-up period was only 1 year in this study which had impacted the collection of new onset cases.

CONCLUSIONS

Parental rearing style has a long-term influence on the psychiatric status of college students. Parenting style interventions working as the second level of mental disorder prevention will play an important role in MDD, PD and comorbidity prevention.

Discovering Digital Biomarkers of Panic Attack Risk in Consumer Wearables Data

Panic attacks are an impairing mental health problem that impacts more than one out of every 10 adults in the United States (US). Clinical guidelines suggest panic attacks occur without warning and their unexpected nature worsens their impact on quality of life. Individuals who experience panic attacks would benefit from advance warning of when an attack is likely to occur so that appropriate steps could be taken to manage or prevent it. Our recent work suggests that an individual's likelihood of experiencing a panic attack can be predicted by self-reported mood and community-level Twitter-derived mood the previous day. Prior work also suggests that physiological markers may indicate a pending panic attack. However, the ability of objective physiological, behavioral, and environmental measures collected via consumer wearable sensors (referred to as digital biomarkers) to predict next-day panic attacks has not yet been explored. To address this question, we consider data from 38 individuals who regularly experienced panic attacks recruited from across the US. Participants responded to daily questions about their panic attacks for 28 days and provided access to data from their Apple Watches. Mixed Regressions, with an autoregressive covariance structure were used to estimate the prevalence of a next-day panic attack Results indicate that digital biomarkers of ambient noise (louder) and resting heart rate (higher) are indicative of experiencing a panic attack the next day. These preliminary results suggest, for the first time, that panic attacks may be predictable from digital biomarkers, opening the door to improvements in how panic attacks are managed and to the development of new preventative interventions.Clinical Relevance- Objective data from consumer wearables may predict when an individual is at high risk for experiencing a next-day panic attack. This information could guide treatment decisions, help individuals manage their panic, and inform the development of new preventative interventions.

Association between panic disorder and childhood adversities: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) increase the risk of mental health difficulties in general, but the link to panic disorder (PD) has received comparatively little attention. There are no data for the magnitudes between ACEs and PD. This systematic review and meta-analysis estimated the overall, as well as the subgroups, odds ratio of having PD in adults who report ACEs, compared to adults who do not.

METHODS

The study was pre-registered on PROSPERO [CRD42018111506] and the database was searched in June 2021. In order to overcome the violation of independent assumptions due to multiple estimations from the same samples, we utilized a robust variance estimation model that supports meta-analysis for clustered estimations. Accordingly, an advanced method relaxing the distributional and asymptotic assumptions was used to assess publication bias and sensitivity.

RESULTS

The literature search and screening returned 34 final studies, comprising 192,182 participants. Ninety-six estimations of 20 types of ACEs were extracted. Pooled ORs are: overall 2.2, CI (1.82-2.58), sexual abuse 1.92, CI (1.37-2.46), physical abuse 1.71, CI (1.37-2.05), emotional abuse 1.61, CI (0.868-2.35), emotional neglect 1.53, CI (0.756-2.31), parental alcoholism 1.83, CI (1.24-2.43), and parental separation/loss 1.82, CI (1.14-2.50). No between-group difference was identified by either sociolegal classification (abuse, neglect, household dysfunction) or threat-deprivation dimensions (high on threat, high on deprivation and mixed).

CONCLUSIONS

There are links of mild to medium strength between overall ACEs and PD as well as individual ACEs. The homogeneous effect sizes across ACEs either suggest the effects of ACEs on PD are comparable, or raised the question whether the categorical or dimensional approaches to classifying ACEs are the definitive ways to conceptualize the impact of ACEs on later mental health.

The Oxford Agoraphobic Avoidance Scale

BACKGROUND

Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms.

METHOD

The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test-retest reliability was assessed with 264 participants.

RESULTS

An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24-5.43; distress: a = 1.60-5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test-retest reliability, and validity.

CONCLUSIONS

The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.

Suicidality in patients with primary diagnosis of panic disorder: A single-rate meta-analysis and systematic review

BACKGROUND

This study investigated the lifetime suicide attempt and ideation rates among patients with panic disorder (PD).

METHODS

Online databases regarding lifetime suicide attempt and ideation rates in patients with PD were searched up to May 2021.

RESULTS

The suicide attempt and ideation rates were 0.17 (95% CI: 0.16, 0.18) and 0.23 (95% CI: 0.22, 0.25). The suicide attempt rates among female and male patients were 0.17 (95% CI: 0.14, 0.20) and 0.15 (95% CI: 0.12, 0.19). When PD was comorbid with anxiety, depression, substance abuse, and personality disorders, the suicide attempt rates increased to 0.23 (95% CI: 0.20, 0.26), 0.23 (95% CI: 0.18, 0.27), 0.25 (95% CI: 0.20, 0.31), and 0.25 (95% CI: 0.23, 0.28), respectively.

LIMITATIONS

The suicide attempt and ideation by age, suicide ideation by sex, and suicide ideation by comorbidity with other mental disorders were passed in our meta-analysis as sample size was small. Stratification analysis on ethnicity, marital status, education levels, resident location, and severity of PD should be considered in the future.

CONCLUSION

The lifetime suicide ideation and attempt rates in patients with PD were higher than general populations but lower than patients with bipolar or depression. The lifetime suicide attempt rate in female patients was slightly higher than male patients. When PD was comorbid with one other mental illness, the lifetime suicide attempt rate increased by about 50%.

Early Trauma Is Associated With Suicidal Ideation in Patients With Panic Disorder

ABSTRACT

There are several predictors of suicidality in patients with panic disorder (PD). Being a woman, younger age, low education level, unmarried status, and symptom severity have been suggested. This study aimed to examine whether early trauma is associated with suicidal ideation in patients with PD. Our study included 267 patients with PD and 105 controls. Data on sociodemographic variables and data from the Early Trauma Inventory Self Report-Short Form, Beck Depression Inventory, Panic Disorder Severity Scale, Anxiety Sensitivity Inventory-Revised, Coping Scales, and Scale for Suicide Ideation were collected, and correlation and regression analyses were performed. This study suggests that clinicians should consider early trauma when assessing suicidal ideation in patients with PD. Clinicians could consider alternative treatments, such as trauma-focused cognitive-behavioral therapy, eye movement desensitization, reprocessing approaches, and classical pharmacological and psychological treatments for patients with PD who have a history of early trauma and are expected to be at high risk for suicide.

Classifying patients with depressive and anxiety disorders according to symptom network structures: A Gaussian graphical mixture model-based clustering

Patients with mental disorders often suffer from comorbidity. Transdiagnostic understandings of mental disorders are expected to provide more accurate and detailed descriptions of psychopathology and be helpful in developing efficient treatments. Although conventional clustering techniques, such as latent profile analysis, are useful for the taxonomy of psychopathology, they provide little implications for targeting specific symptoms in each cluster. To overcome these limitations, we introduced Gaussian graphical mixture model (GGMM)-based clustering, a method developed in mathematical statistics to integrate clustering and network statistical approaches. To illustrate the technical details and clinical utility of the analysis, we applied GGMM-based clustering to a Japanese sample of 1,521 patients (Mage = 42.42 years), who had diagnostic labels of major depressive disorder (MDD; n = 406), panic disorder (PD; n = 198), social anxiety disorder (SAD; n = 116), obsessive-compulsive disorder (OCD; n = 66), comorbid MDD and any anxiety disorder (n = 636), or comorbid anxiety disorders (n = 99). As a result, we identified the following four transdiagnostic clusters characterized by i) strong OCD and PD symptoms, and moderate MDD and SAD symptoms; ii) moderate MDD, PD, and SAD symptoms, and weak OCD symptoms; iii) weak symptoms of all four disorders; and iv) strong symptoms of all four disorders. Simultaneously, a covariance symptom network within each cluster was visualized. The discussion highlighted that the GGMM-based clusters help us generate clinical hypotheses for transdiagnostic clusters by enabling further investigations of each symptom network, such as the calculation of centrality indexes.

Optimal well-being in the aftermath of anxiety disorders: A 10-year longitudinal investigation

BACKGROUND

Although preliminary research has explored the possibility of optimal well-being after depression, it is unclear how rates compare to anxiety. Using Generalized Anxiety Disorder (GAD) and Panic Disorder (PD) as exemplars of anxiety, we tested the rates of optimal well-being one decade after being diagnosed with an anxiety disorder. Based on reward deficits in depression, we pre-registered our primary hypothesis that optimal well-being would be more prevalent after anxiety than depression as well as tested two exploratory hypotheses.

METHOD

We used data from the Midlife in the United States (MIDUS) study, which contains a nationally representative sample across two waves, 10 years apart. To reach optimal well-being, participants needed to have no symptoms of GAD, PD, or major depressive disorder (MDD) at the 10 year follow-up and exceed cut-offs across nine dimensions of well-being.

RESULTS

The results failed to support our primary hypothesis. Follow-up optimal well-being rates were highest for adults previously diagnosed with MDD (8.7%), then PD (6.1%), and finally GAD (0%). Exploratory analyses revealed optimal well-being was approximately twice as prevalent in people without anxiety or depression at baseline and provided partial support for baseline well-being predicting optimal well-being after anxiety. Results were largely replicated across different classifications of optimal well-being.

LIMITATIONS

Findings are limited by the somewhat unique measurement of anxiety in the MIDUS sample as well as the relatively high rate of missing data.

CONCLUSIONS

We discuss possible explanations for less prevalent optimal well-being after anxiety vs. depression and the long-term positivity deficits from GAD.

Understanding importance of clinical biomarkers for diagnosis of anxiety disorders using machine learning models

Anxiety disorders are a group of mental illnesses that cause constant and overwhelming feelings of anxiety and fear. Excessive anxiety can make an individual avoid work, school, family get-togethers, and other social situations that in turn might amplify these symptoms. According to the World Health Organization (WHO), one in thirteen persons globally suffers from anxiety. It is high time to understand the roles of various clinical biomarker measures that can diagnose the types of anxiety disorders. In this study, we apply machine learning (ML) techniques to understand the importance of a set of biomarkers with four types of anxiety disorders—Generalized Anxiety Disorder (GAD), Agoraphobia (AP), Social Anxiety Disorder (SAD) and Panic Disorder (PD). We used several machine learning models and extracted the variable importance contributing to a type of anxiety disorder. The study uses a sample of 11,081 Dutch citizens’ data collected by the Lifelines, Netherlands. The results show that there are significant and low correlations among GAD, AP, PD and SAD and we extracted the variable importance hierarchy of biomarkers with respect to each type of anxiety disorder which will be helpful in designing the experimental setup for clinical trials related to influence of biomarkers on type of anxiety disorder.

Affective Temperaments, Panic Disorder and Their Bipolar Connections

Background and Objectives: The role of affective temperament in the genesis and outcome of major mood disorders is well studied, but there are only a few reports on the relationship between panic disorder (PD) and affective temperaments. Accordingly, we aimed to study the distribution of affective temperaments (depressive (DE); cyclothymic (CT); irritable (IRR); hyperthymic (HT) and anxious (ANX)) among outpatients with PD. Materials and Methods: Affective temperaments of 118 PD outpatients (80 females and 38 males) with or without agoraphobia but without any other psychiatric disorder at the time of inclusion were evaluated using the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and compared with the affective temperament scores of control subjects. All patients were followed up for at least 1.5 years in order to detect the onset of any major affective disorders, substance use disorders and suicide attempts. Results: Among females, the dominant ANX and DE temperaments were four and three times as common as in a large normative Hungarian sample (for both cases p < 0.01). Among male PD patients, only the dominant DE temperament was slightly overrepresented in a non-significant manner. Females with PD obtained significantly higher scores on ANX, DE and CT subscales of the TEMPS-A, whereas males with PD showed significantly higher scores on ANX, DE and HT temperament subscales compared with the members of a large normative Hungarian sample and also with a gender- and age-matched control group. During the follow-up, newly developed unipolar major depression and bipolar spectrum (bipolar I or II and cyclothymic) disorders appeared in 64% and 22% of subjects, respectively. Conclusions: Our preliminary findings suggest that a specific, ANX-DE-CT affective temperament profile is characteristic primarily for female patients, and an ANX-DE-HT affective temperament profile is characteristic for male patients with PD, respectively. These findings are in line with expectations because PD is an anxiety disorder par excellence on the one hand, whereas, on the other hand, it is quite frequently comorbid with mood (including bipolar) disorders.

The course and clinical correlates of panic disorder during the postpartum period: a naturalistic observational study

OBJECTIVE

To investigate the course of panic disorder and its demographic and clinical correlates during the postpartum period.

METHODS

Data were collected from 38 consecutive postpartum women diagnosed with panic disorder. Psychiatric assessments were carried out on the first day after delivery and at 6-8 weeks postpartum. During the first assessment, the Panic and Agoraphobia Scale (PAS), Hospital Anxiety and Depression Scale (HADS), Coping Orientation to Problems Experienced (COPE), Multidimensional Scale of Perceived Social Support (MSPSS), and Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) were administered to the participants. PAS was also administered at the second assessment.

RESULTS

The mean PAS score reduced significantly from baseline to the second assessment. Logistic regression analysis indicated that a shorter duration of panic disorder independently predicted a ≥ 50-point decrease in the severity of panic symptoms during the postpartum period.

CONCLUSION

These findings suggest that patients with a short duration of illness may experience significant alleviation in the severity of panic symptoms during the postpartum period.

Covid-19-Beyond virology: Potentials for maintaining mental health during lockdown

BACKGROUND

The current study aimed to assess prevalence of mental disorders during Covid-19 pandemic- and respective lockdown in Germany, and potential behaviors/states that can have protective functions on preventing severe mental problems. Assessing prevalence of mental disorders, as well as to find potential protective variables is very important in order to determine people's psychological suffering. It provides the basis for teaching possible coping styles in order to prevent a major breakdown on mental health. Prevalence on mental disorders was expected to increase during the pandemic, especially depression, (general-/and health-) anxiety, panic attacks- and disorder, as well as obsessive-compulsive disorder. Additionally, potentially protective variables, such as resilience and coping, were included.

METHODS

N = 949 subjects completed an online-survey that asked for symptoms regarding depression, (health) anxiety, panic disorder, obsessive-compulsive disorder, and lock-down related behavior-starting 14 days after lockdown in Germany.

RESULTS

Prevalence of mental disorders in the current sample was much higher than usual prevalence of mental disorders, with 50.6% expressing at least one mental disorder. Resilience was associated with lower risks for any mental disorder (OR = 4.23, p < .0001, 95%CI = 3.21-5.57), as well as with any other measured mental illness (all ORs between = 2.82 for obsessive-compulsive disorder and OR = 41.44 for panic disorder, all p < .001). Similar results were obtained regarding coping (focus on positive).

CONCLUSION

Results are highly relevant in order to provide a glance on what substantial influence the current pandemic- and lockdown situation has on mental health across the country, and possibly across the world. Possible ways in order to prevent deterioration and help coping with the current situation are being elaborated and discussed.

Comorbidity of substance misuse with anxiety-related and depressive disorders: a genetically informative population study of 3 million individuals in Sweden

BACKGROUND

Causes of the comorbidity of substance misuse with anxiety-related and depressive disorders (anxiety/depression) remain poorly known. We estimated associations of substance misuse and anxiety/depression in the general population and tested them while accounting for genetic and shared environmental factors.

METHODS

We studied individuals born in Sweden 1968-1997 (n = 2 996 398) with follow-up in nationwide register data for 1997-2013. To account for familial effects, stratified analyses were conducted within siblings and twin pairs. Substance misuse was defined as ICD-10 alcohol or drug use disorder or an alcohol/drug-related criminal conviction. Three dimensions of ICD-10 anxiety and depressive disorders and a substance misuse dimension were identified through exploratory factor analysis.

RESULTS

Substance misuse was associated with a 4.5-fold (95% CI 4.50-4.58) elevated risk of lifetime generalized anxiety/depression, 4.7-fold (95% CI 4.63-4.82) elevated risk of panic disorder and agora/social phobia, and 2.9-fold elevated risk of phobias/OCD (95% CI 2.82-3.02) as compared to those without substance misuse. The associations were attenuated in within-family analyses but we found elevated risks in monozygotic twin pairs discordant for substance misuse as well as significant non-shared environmental correlations. The association between anxiety/depression and substance misuse was mainly driven by generalized anxiety/depression, whereas other anxiety/depression dimensions had minor or no independent associations with substance misuse.

CONCLUSIONS

Substance misuse and anxiety/depression are associated at the population level, and these associations are partially explained by familial liabilities. Our findings indicate a common genetic etiology but are also compatible with a potential partially causal relationship between substance misuse and anxiety/depression.

Panic disorder during pregnancy and postpartum period

Background

– Earlier studies on the influence of pregnancy and postpartum period on the course of panic disorder have been inconsistent. The present study aims to quantify panic manifestations in these periods in large sample of women.

Method

– Panic manifestations, including exacerbations and new manifestations of panic disorder, were assessed retrospectively in a sample of 128 women with panic disorder with or without agoraphobia, 93 of whom had had 195 pregnancies.

Results

– Panic manifestations were fewer during pregnancy and more frequent in the postpartum period when compared with the control period. Women who had never been pregnant had significantly more panic manifestations than women with prior pregnancies. Breastfeeding and miscarriages did not have a significant effect. Women with postpartum panic reported more psychosocial stress events during this period.

Conclusions

– Possible reasons for postpartum panic and the protective effects of pregnancy are discussed, including psychosocial or hormonal factors and other neurobiological changes. Postpartum panic coincides with a sudden drop of hormones after delivery.

Screening social phobia in adolescents from general population: The validity of the Social Phobia Inventory (SPIN) against a clinical interview

Social phobia (SP) has onset during early adolescence, and is associated with significant impairment in social and educational functioning of adolescents. Therefore, valid and easy-to-use tools for screening and identification of SP among adolescent community populations are needed. We investigated both construct and discriminative validity, and screening properties of the 17-item Social Phobia Inventory (SPIN) relative to SP diagnoses based on a semi-structured clinical interview (K-SADS-PL), in a sample of 752 12 to 17-year-old Finnish students from general population. The SPIN demonstrated good properties to differentiate adolescents with SP and those with sub-clinical SP symptoms (SSP), from adolescents without SP. The SPIN also differentiated adolescents with SP from those with depressive and disruptive disorders. In this sample 27% of participants scored above the previously suggested SPIN cut-off (15 points) for adolescent SP. We suggest using a somewhat higher cut-off score, 24 points, when using the SPIN as a screen for SP in general adolescent populations. This cut-off score resulted in a sensitivity of 81.2%, a specificity of 85.1%, a positive predictive value of 26.9%, and a negative predictive value of 98.6% in relation to the SP diagnosis in our sample. To screen for both SP and SSP, 19 points as a cut-off score produced satisfactory diagnostic efficiency statistics. The SPIN appears to have good properties for screening and identification of adolescent SP.

Gender-related distribution of personality disorders in a sample of patients with panic disorder

Objective

We examined gender differences in the frequency of DSM-IV personality disorder diagnoses in a sample of patients with a diagnosis of panic disorder (PD).

Method

One hundred and eighty-four outpatients with a principal diagnosis of PD (DSM-IV) were enrolled. All patients were evaluated with a semi-structured interview to collect demographic and clinical data and to generate Axis I and Axis II diagnoses in accordance with DSM-IV criteria.

Results

Males were significantly more likely than females to meet diagnoses for schizoid and borderline personality disorder. Compared to males, females predominated in histrionic and cluster C diagnoses, particularly dependent personality disorder diagnoses. A significant interaction was found between female sex and agoraphobia on personality disorder (PD) distribution.

Conclusions

Male PD patients seem to be characterized by more severe personality disorders, while female PD patients, particularly with co-morbid agoraphobia, have higher co-morbidity rates with personality disorders belonging to the ‘anxious-fearful cluster’.

Predictors of work disabilities in patients with panic disorder with agoraphobia

Objective

The aim of this study was to ascertain predictors of work insufficiency in patients with panic disorder (PD) with agoraphobia (AG).

Method

Linear regression was used to identify predictors of work insufficiency in a sample of 72 consecutive outpatients with PD with AG. Intensity of work insufficiency was ascertained from modified National Institute of Mental Health Panic Questionnaire (NIMH PQ). That represented dependent variable. Independent variables were demographic data, duration of illness, presence of comorbid current major depression episode, presence of any personality disorder and scores on the Panic and Agoraphobia Scale (PAS) subscales: panic attacks, AG (avoidance behavior), anticipatory anxiety and worries about health.

Results

Patients reported severe work insufficiency. The best predict variable for the work insufficiency in patients with PD with AG was high score on the PAS dimension of AG.

Conclusion

Patients generally reported severe effects of PD with AG on work efficacy and the results suggested that the impaired work efficacy was the most associated with avoidance behavior. These results recommend that the treatment of PD with AG patients should be related to decreasing avoidance behavior in order to establish adequate work performance in patients.

Severity of panic disorder, adverse events in childhood, dissociation, self-stigma and comorbid personality disorders Part 2: Therapeutic effectiveness of a combined cognitive behavioural therapy and pharmacotherapy in treatment-resistant inpatients

OBJECTIVES

A combination of antidepressants with the cognitive-behavioural therapy showed effectiveness in treatment-resistant patients with panic disorder. This prospective study intended to establish how childhood adverse experiences, self-stigma, dissociation, and severity of psychopathology influence the effectiveness of combined cognitive-behavioural therapy and pharmacotherapy in patients with treatment-resistant panic disorder.

METHODS

One hundred and ten patients were included into the study and one hundred five subjects finished the study. After admission, the subjects were assessed during the first two days of hospitalization. Rating scales were administered before the beginning of the cognitive behavioural therapy (measurement-1) and at the end of the treatment which was after six weeks (measurement-2). Patients with panic disorder were treated using a combination of group cognitive-behavioural therapy and antidepressants. The usual antidepressant dosage range was used. Before admission to intensive cognitive behavioural therapy program, the patients were unsuccessfully treated by antidepressants for minimum 3 months, which defined them as pharmacoresistant.

RESULTS

Hospitalized pharmacoresistant patients with panic disorder improved significantly throughout the 6-week intensive CBT program in all measurements that assessed the overall severity of the disorder, the degree of general anxiety and depression and the severity of specific symptoms of panic disorder and agoraphobia. The rate of improvement was negatively related to sexual abuse in childhood, presence of comorbid personality disorder, and positively with the severity of the disorder at the beginning, and the level of self-stigma at the beginning of treatment. Improvement in symptoms correlates significantly with decreasing of dissociation during the treatment.severity of depressive symptoms. The earlier development of the disorder is linked to higher score in childhood adverse events, higher level of dissociation and pathological dissociation, and higher level of self-stigma.

CONCLUSIONS

Our prospective study discovers importance of the role of adverse childhood experiences, self-stigma, dissociation and comorbid personality disorder in effectiveness of combined cognitive-behavioural therapy and pharmacotherapy treatment in patients with treatment-resistant panic disorder.

Severity of panic disorder, adverse events in childhood, dissociation, self-stigma and comorbid personality disorders Part 1: Relationships between clinical, psychosocial and demographic factors in pharmacoresistant panic disorder patients

OBJECTIVES

Little is known about the relation between severity of panic disorder, adverse events in childhood, dissociation, self-stigma and comorbid personality disorders. The aim of this study is to look for the intercorrelations between these factors.

METHOD

The study explores the relation between clinical, demographic and social factors in panic disorder using cross sectional design. The inpatients with pharmacoresistant panic disorder with and without agoraphobia were included in the study. Participants were also assessed for comorbidity with other anxiety or personality disorder. The Clinical Global Impression (CGI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Dissociative Experiences Scale (DES), Internalized Stigma of Mental Illness (ISMI), Childhood Trauma Questionnaire-Short Form (CTQ-SF), Panic Disorder Severity Scale (PDSS) and demographic data were used as measurement tools.

RESULTS

A total of 142 pharmacoresistant patients with panic disorder with or without agoraphobia were admitted for 6-week cognitive behavioral therapy inpatient program in psychotherapeutic department between November 2015 and July 2019. One hundred and five inpatients (33 males and 72 females) with mean age 37.8 + 12.1 years were included in the study. Sixty-nine patients suffer from additional comorbid anxiety disorder and 43 had comorbid personality disorder.

[Epidemiology of anxiéty disorders]

EPIDEMIOLOGY OF ANXIETY DISORDERS - The prevalence of anxiety disorders is higher in high-income countries than in middle- and low-income countries. In France, their lifetime prevalence ranges from 2.1% for panic disorder to 10.7% for specific phobias. They are more frequent among young, female subjects, with low levels of education, unemployed, with low income and not living with a partner. Phobic disorders, separation anxiety and social anxiety have an early onset, most often in childhood; other anxiety disorders have a later and more variable onset age. Apart from separation anxiety, anxiety disorders have a chronic course in more than half of cases and are frequently associated with a substantial functional impairment. The most common comorbid psychiatric disorders are other anxiety disorders, followed by mood disorders, particularly depression, substance use disorders and impulse control disorders. In France, less than a third of people with anxiety disorders receive treatment and less than 15% receive potentially adequate treatment. Of those who perceive a need for care, less than half receive adequate treatment.

Prevalence, onset and course of anxiety disorders during pregnancy: A systematic review and meta analysis

BACKGROUND

Anxiety disorders during pregnancy are associated with various adverse outcomes. Previous reviews of anxiety disorders during pregnancy have methodological limitations and were conducted without a meta-analysis. The present study is a systematic review and meta-analysis of the published research on the prevalence, onset and course of all anxiety disorders during pregnancy plus obsessive-compulsive disorder (OCD) and posttraumatic stress disorder.

METHODS

A comprehensive literature search was performed on a wide range of databases. A random effects model was used for the meta-analysis.

RESULTS

Thirty-six studies were included. Prevalence rates of anxiety disorders during pregnancy varied considerably. The pooled prevalence rate of each disorder during pregnancy was 3%, except for specific phobia, where it was 6%. Between 13% and 39% of pregnant OCD women had the onset of OCD during pregnancy, and this occurred mainly in the 2nd trimester. The onset of panic disorder (PD) was more common in the 1st and 2nd trimesters of pregnancy.

LIMITATIONS

Different designs of the included studies, as well as different assessment tools and assessment times during pregnancy and the paucity of studies of the onset and course, preclude definitive conclusions.

CONCLUSIONS

Anxiety disorders are common during pregnancy. Unlike prevalence rates of other anxiety disorders during pregnancy, prevalence rates of PD and OCD during pregnancy were higher than their lifetime prevalence rates in women in the general population. The onset of OCD during pregnancy is not rare and the course of PD and OCD during pregnancy is highly variable. These findings suggest that pregnancy may be a specific risk factor for the occurrence and/or exacerbation of PD and OCD and underscore the importance of their early diagnosis and management.

Bidirectional Association between First-Episode Panic Disorder and Major Depressive Disorder in a Nationwide General Population Survey in Korea

BACKGROUND

Panic disorder (PD) and major depressive disorder (MDD) can occur concurrently, despite different clinical manifestations. Because MDD and PD patients tend to have more complicated conditions, understanding the co-occurrence and pattern of these conditions is important. Here, we investigated the influence of PD and MDD on each other, with respect to time interval.

METHODS

Data from three national representative surveys were pooled (total 18,807 respondents), and the age of onset (AOO) of PD and MDD was analyzed. We performed Kaplan-Meier analysis to estimate separate survival functions, using the AOO of MDD and PD as the outcome. To understand the temporal effect of other disorders, we used a Cox proportional hazard model to estimate the hazard ratios for the onset of MDD/PD with other comorbidities as time-dependent covariates.

RESULTS

PD elevated the risk of subsequent MDD by 1.5-fold, whereas MDD elevated the risk of subsequent PD by 3.8-fold. The effect of such an elevation risk was significant for up to 2 years.

CONCLUSION

The results revealed a bidirectional relationship between MDD and PD. Each disease represents a risk of a subsequent occurrence of the other, which lasts for a considerable duration.

Sexual Assault Reporting and Emotional Distress Among College Female-Identified Victims/Survivors

PURPOSE

The current study tests associations between reporting sexual victimization to a healthcare provider, campus authority, police, or social contact, and emotional well-being among college women.

METHODS

Data from 2,162 women who participated in the 2015 College Student Health Survey at 17 colleges in Minnesota was used. Analyses tested associations between reporting sexual assault to formal or informal resources and diagnosis with anxiety, depression, panic attacks, and posttraumatic stress disorder, as well as self-rated health.

RESULTS

Significantly higher rates of all four diagnoses were observed among those who reported to formal resources (e.g., healthcare provider, police) compared with those who reported to informal resources (i.e., friends, family). However, no differences were seen in self-rated physical or mental health.

CONCLUSIONS

Expansion of trauma-informed healthcare services and advocacy efforts is recommended to optimally support students who report sexual assault experiences.

Establishing US norms for the Adult ADHD Self-Report Scale (ASRS-v1.1) and characterising symptom burden among adults with self-reported ADHD

AIMS

To estimate Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist normative total scores among the US adult general population and to evaluate overall attention-deficit hyperactivity disorder (ADHD) symptom burden among US adults with ADHD.

METHODS

Prior 2012 and 2013 US National Health and Wellness Survey respondents were re-contacted. Demographics, comorbidities, and ASRS-v1.1 data were collected. ASRS-v1.1 scores were compared by sex, age, ADHD diagnosis, and ADHD medication use. Group differences were evaluated using chi-square tests and independent samples t-tests for categorical and continuous variables, respectively.

RESULTS

Of 22 397 respondents, 465 self-reported being diagnosed with ADHD by a physician; of these, 174 self-reported using ADHD medication. The mean ASRS-v1.1 total score was 2.0 (SD = 3.2); scores differed by age and sex (all, P < 0.001). ADHD (vs no ADHD) was associated with depression (58.1% vs 18.0%), anxiety (53.1% vs 16.0%), and sleep difficulties (37.0% vs 14.0%) (all, P < 0.001). ADHD medication use (vs no use) was associated with depression (68.4% vs 51.9%), anxiety (67.2% vs 44.7%), panic disorder (25.9% vs 17.2%), and insomnia (27.6% vs 19.6%) (all, P < 0.05). ADHD (vs no ADHD) respondents scored higher on all 18 ASRS-v1.1 items (all, P < 0.05). Medication users (vs non-users) scored higher on six items (all, P < 0.05).

DISCUSSION

Adult ADHD may be undertreated or sub-optimally treated, despite a high symptom burden. Normative data will allow comparisons with individuals' scores to support the assessment of ADHD symptom burden among adults.

CONCLUSION

Findings highlight the importance of assessing ADHD symptom burden, especially among adults presenting with comorbidities.

Epidemiology of panic attacks, panic disorder and the moderating role of age: Results from a population-based study

BACKGROUND

The aim of this study was to investigate the prevalence of panic attacks (PA) and panic disorder (PD) over the lifespan, determine the main correlates and analyze the potential moderating role of age.

METHOD

We analyzed cross-sectional data from a nationally-representative sample of 4,569 non-institutionalized adults. Three panic groups were created according to results in the CIDI interview: non-panic, PA (without PD) and PD. Panic groups were used as outcomes in adjusted multinomial regression models where several correlates were investigated. Interactions between each covariate and age were explored.

RESULTS

The highest prevalence rates of PA (9.5%) and PD (3.3%) were found in people aged 30-39 and 40-49, respectively. Respondents aged 80 + presented the lowest rates. In the adjusted multinomial model, younger ages, having depression, and poorer levels of quality of life were significant correlates for both PA and PD, whereas being female and having 2 or more chronic conditions were only significant for PA (not for PD) and being a frequent drinker (last 12-months) only for PD. Age significantly interacted with frequent alcohol consumption in the last 12-months for PD. The predicted probability of having PD decreased with age for life-abstainer or occasional drinkers, whereas the probability increased with older ages for frequent drinkers.

LIMITATIONS

Low prevalence of PA and PD resulted in large confidence intervals whereas self-reports could be affected by recall bias.

CONCLUSIONS

Overall, our results suggest that the probability of having PA and PD decreases as people age and that the significant risk factors are independent of age. However, older adults with a frequent drink pattern seem to be at higher risk of PD. Future longitudinal studies are needed to determine the trajectories of PD and alcohol consumption over the lifespan.

Body Image Dissatisfaction and Anxiety Trajectories During Adolescence

The primary goal of this study was to examine the associations between baseline body image dissatisfaction (BID) and subsequent anxiety trajectories in a diverse, community sample of adolescent girls and boys. Participants were 581 adolescents (baseline age: M = 16.1, SD = 0.7; 58% female; 65% non-Hispanic White) from U.S. public high schools. Self-report questionnaires were administered during school at 3 annual assessment waves. Latent growth curve modeling examined the association between baseline BID and growth factors of anxiety disorder symptom trajectories. Covariates included baseline gender, age, race/ethnicity, parental education attainment, body mass index standard scores, and depressive symptoms. Higher BID at baseline was significantly associated with higher initial symptoms of generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and significant school avoidance (SSA; ps = .001-.04) but was unrelated to initial separation anxiety disorder (SEP) symptoms (p = .27). Higher baseline BID also was associated with attenuated decreases in SAD symptoms across time (p = .001). Among adolescents with low baseline anxiety symptoms only, higher BID was associated with more attenuated decreases in SAD symptoms (p = .01) and greater increases in PD symptoms (p = .02). BID was unrelated to changes in GAD, SEP, and SSA symptoms (ps = .11-.94). Findings suggest that BID is associated with concurrent symptoms of multiple anxiety disorders and may have a prospective link to SAD and PD symptoms during adolescence. As such, assessing body image issues may be important to assess when identifying adolescents at risk for exacerbated SAD and PD symptoms.

Prevalence and treatment of panic disorder in bipolar disorder: systematic review and meta-analysis

QUESTION

Recent data suggest that anxiety disorders are as often comorbid with bipolar disorder (BD) as with unipolar depression. The literature on panic disorder (PD) comorbid with BD has been systematically reviewed and subject to meta-analysis.

STUDY SELECTION AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were thoroughly followed for literature search, selection and reporting of available evidence. The variance-stabilising Freeman-Tukey double arcsine transformation was used in the meta-analysis of prevalence estimates. Both fixed-effect and random-effects models with inverse variance method were applied to estimate summary effects for all combined studies. Heterogeneity was assessed and measured with Cochran's Q and I2 statistics.

FINDINGS

Overall, 15 studies (n=3391) on cross-sectional prevalence and 25 independent lifetime studies (n=8226) were used to calculate pooled estimates. The overall random-effects point prevalence of PD in patients with BD, after exclusion of one potential outlier study, was 13.0% (95% CI 7.0% to 20.3%), and the overall random-effects lifetime estimate, after exclusion of one potential outlier study, was 15.5% (95% CI 11.6% to 19.9%). There were no differences in rates between BD-I and BD-II. Significant heterogeneity (I2 >95%) was found in both estimates.

CONCLUSIONS

Estimates that can be drawn from published studies indicate that the prevalence of PD in patients with BD is higher than the prevalence in the general population. Comorbid PD is reportedly associated with increased risk of suicidal acts and a more severe course. There is no clear indication on how to treat comorbid PD in BD. Findings from the current meta-analysis confirm the highly prevalent comorbidity of PD with BD, implicating that in patients with BD, PD might run a more chronic course.

Association between sleep disorder and panic disorder in South Korea: Nationwide nested case-control study of data from 2004 to 2013

After 2010, panic disorders became relatively common in South Korea, with many celebrities confessing to the public that they have panic disorder. The annual number of patients with panic disorder and sleep disorder have been gradually increasing. In light of these increases, we analyzed the relationship between sleep disorder and panic disorder. We used national claim data to design a 1:3 nested case-control study. The study included medical claims filed for 29,312 patients during 2004-2013. We performed conditional logistic regression analysis to investigate the relationship between sleep disorder and panic disorder. There were 7436 patients who were diagnosed with panic disorder, and 21,876 patients who were gender- and age-matched as controls. Patients with sleep disorder had higher incidence of panic disorder. In particular, patients with insomnia had the strongest association with panic disorder (adjusted, OR, 1.386; 95% CI, 1.201-1.599; p < 0.05). These associations were stronger in healthy patients and those with worse socioeconomic status. In conclusion, sleep disorder, in particular, insomnia was positively associated with panic disorder. Thus, healthcare professionals and policy makers should effectively control insomnia and consider strategies for early intervention for vulnerable patients with risk of panic disorder.

Drug-induced panic attacks: Analysis of cases registered in the French pharmacovigilance database

BACKGROUND

The potential role of drugs in the onset of panic attacks (PAs) is poorly understood.

AIM

The objective of our study was to characterize drug-induced PAs.

METHOD

We performed an analysis of PAs registered in the French pharmacovigilance database between 01/01/1985 and 05/11/2014.

RESULTS

Among the 163 recorded cases, 136 (83.4%) were directly related to drugs, mainly antidepressants (11.3%, mainly serotonin reuptake inhibitors), mefloquine (7.2%), isotretinoin (5.2%), rimonabant (3.6%) and corticosteroids (4.7%). PAs are labelled in the Summary of Product Characteristics (SmPC) for a minority (8.6%) of these drugs. In 31.4% of these cases, withdrawal of the suspected drug was performed more than a week after the onset of PAs. PAs could also be secondary to another adverse drug reaction (ADR; n = 14, 8.6%), mainly an allergy to antineoplastic or immunomodulating agents. In 13 cases (8.0%), PAs occurred during a drug-withdrawal syndrome, mainly after benzodiazepines or opioids. Most cases (73%) involved patients without any previous psychiatric disorder.

CONCLUSION

This is the first pharmacoepidemiological study about iatrogenic PAs. Beside antidepressants, the most often encountered drugs are not indicated for psychiatric diseases. This study also reveals that iatrogenic PAs mostly occur in patients without any psychiatric medical history and that PAs can be triggered by another ADR. Lastly, the many cases with delayed management underline the need to raise awareness of this relatively unknown ADR among physicians, especially since PAs are generally not labelled in SmPCs of the suspected drugs.

Cultural aspects of anxiety disorders in India

Cultural factors have influenced the presentation, diagnoses, and treatment of anxiety disorders in India for several centuries. This review covers the antecedents, prevalence, phenomenology, and treatment modalities of anxiety disorders in the Indian cultural context. It covers the history of the depiction of anxiety in India and the concept of culture in the classification of anxiety disorders, and examines the cultural factors influencing anxiety disorders in India. We review the prevalence and phenomenology of various disorders, such as generalized anxiety disorder, panic disorder, social anxiety, and phobic disorder, as well as culture-specific syndromes such as dhat and koro in India. Finally, the review examines the wide range of therapeutic modalities practiced in India, such as faith healing, psychotherapy, ayurveda, psychopharmacology, Unani medicine, homeopathy, yoga, meditation, and mindfulness. We conclude by emphasizing the significance of cultural factors in making relevant diagnoses and offering effective and holistic treatments to individuals with anxiety disorders.

Panic attacks and panic disorder in the American Indian community

Panic disorder is a common mental health condition, but little is known about panic disorder in non-Caucasian populations. The purpose of this study is to describe the epidemiology, clinical features, and comorbidities of panic attacks and panic disorder in two large American Indian (AI) tribes (N=3084). A culturally-adapted version of the Composite International Diagnostic Interview assessed panic attacks, panic disorder, and various psychiatric comorbidities. After adjusting for age, gender, and tribe, linear and logistic regression analyses were conducted to compare AIs with panic disorder to those with panic attacks only on clinical characteristics and panic symptoms. Approximately 8.5% (N=234) of American Indians reported a lifetime history of panic attacks. Among individuals with panic attacks, comorbid posttraumatic stress disorder was higher in females (p=0.03) and comorbid alcohol-related disorders were higher in males (p≤0.001). The prevalence and clinical features of panic attacks and panic disorder in American Indians were similar to epidemiologic studies with majority populations. However, in contrast to earlier research, panic symptoms were similar in both males and females, and different patterns of comorbidity emerged. Future research should examine the availability and accessibility of evidence-based panic treatments for this traditionally underserved population.

Reduction in Costs after Treating Comorbid Panic Disorder with Agoraphobia and Generalized Anxiety Disorder

BACKGROUND

Panic disorder with agoraphobia (PDA) and generalized anxiety disorder (GAD) are impairing and costly disorders that are often misdiagnosed and left untreated despite multiple consultations. These disorders frequently co-occur, but little is known about the costs associated with their comorbidity and the impact of cognitive-behavioral therapy (CBT) on cost reduction.

AIMS OF THE STUDY

The first objective of this study was to assess the mental health-related costs associated with the specific concomitance of PDA and GAD. The second aim was to determine whether there is a reduction in direct and indirect mental health-related costs following conventional CBT for the primary disorder only (PDA or GAD) or combined CBT adapted to the comorbidity (PDA and GAD).

METHODS

A total of 123 participants with a double diagnosis of PDA and GAD participated in this study. Direct and indirect mental health-related costs were assessed and calculated from a societal perspective at the pre-test, the post-test, and the three-month, six-month and one-year follow-ups.

RESULTS

At the pre-test, PDA-GAD comorbidity was found to generate a mean total cost of CADUSD 2,000.48 (SD = USD 2,069.62) per participant over a three-month period. The indirect costs were much higher than the direct costs. Both treatment modalities led to significant and similar decreases in all cost categories from the pre-test to the post-test. This reduction was maintained until the one-year follow-up.

DISCUSSION

Methodological choices may have underestimated cost evaluations. Nonetheless, this study supports the cost offset effects of both conventional CBT for primary PDA or GAD and combined CBT for PDA-GAD comorbidity.

IMPLICATIONS FOR HEALTHCARE PROVISION AND USE

Treatment of comorbid and costly disorders with evidence-based treatments such as CBT may lead to considerable economic benefits for society.

IMPLICATIONS FOR HEALTH POLICIES

Considering the limited resources of healthcare systems, it is important to make choices that will lead to better accessibility of quality services. The application of CBT for PDA, GAD or both disorders and training mental health professionals in this therapeutic approach should be encouraged. Additionally, it would be favorable for insurance plans to reimburse employees for expenses associated with psychological treatment for anxiety disorders.

IMPLICATIONS FOR FURTHER RESEARCH

In addition to symptom reduction, it would be of great pertinence to explore which factors can contribute to reducing direct and indirect mental health-related costs.

Emotionally triggered asthma and its relationship to panic disorder, ataques de nervios, and asthma-related death of a loved one in Latino adults

OBJECTIVE

Research has demonstrated high comorbidity between asthma and panic disorder (PD). Less is known about the relationship between asthma and the Latino cultural idiom of distress of ataques de nervios, as well as the role that psychosocial stressors play. The current study tested the hypotheses that Latino asthma patients who experience PD, ataques de nervios, and/or asthma-related death of a loved one endorse greater psychological triggers of asthma, greater perceived impact of asthma triggers, and greater difficulty controlling such triggers than do those without these conditions.

METHODS

Data originated from an interview conducted prior to a randomized controlled trial in which 292 Latino adults with self-reported asthma were recruited from outpatient clinics in the Bronx, NY. The PRIME-MD Patient Health Questionnaire (PHQ) was used to screen for PD symptoms, while the Structured Clinical Interview for DSM-IV (SCID-I) was used to confirm diagnosis of PD. Lifetime history of ataques de nervios and asthma-related death of a loved one were based upon self-report. Asthma triggers were examined using the Asthma Trigger Inventory (ATI).

RESULTS

PD, ataques de nervios, and asthma-related death of a loved one each predicted a higher frequency of psychological asthma triggers, controlling for gender and comorbid medical conditions. Participants with PD also reported greater impact of asthma triggers than those without PD, while no significant differences in perceived control were observed.

CONCLUSION

Providers should screen for PD, ataques de nervios, and asthma-related death of a loved one in Latino asthma patients, given their observed association with emotionally triggered asthma.

Pattern and risk of developing alcohol use disorders, illegal substance use and psychiatric disorders after early onset of alcohol use: Results of the Thai National Mental Health Survey 2013

INTRODUCTION

Although underage drinking is a global concern, little is known about the relationship between age at first drink and development of various psychiatric comorbidities.

METHODS

A secondary data analysis was done among 2928 lifetime drinkers from the Thai National Mental Health Survey 2013. Age at first drink, and onset of related psychiatric outcomes were inquired. Survival analysis using Cox regression was performed to estimate the risk over time for psychiatric problems across age ranges at first drink.

RESULTS

Two-thirds of male and one-third of female drinkers were considered underage at drinking onset. Substance use and abuse developed earlier (<5 years) than alcohol use disorders (AUDs) and other outcomes (mostly >10 years). Those who started drinking before age 15 years were more likely to develop use of cannabis (HR=4.75; 95% CI 2.73, 8.24), club drugs (HR=2.88; 95% CI 1.46, 5.71) and inhalants (HR=6.46; 95% CI% 1.64, 25.37), compared to those who were 20 years or older at drinking onset. Using age as an alternative time-scale, those aged <15years at drinking onset were significantly more likely to experience AUDs, psychotic symptoms, intermittent explosive disorder and panic disorder. However, the early onset drinkers were less likely to develop depression compared to those who started at age 20 years and over.

CONCLUSION

Premature alcohol consumption tends to be a gateway to various serious consequences. Efforts of such drinking age policy and interventions are needed to address vulnerable young populations.

Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates

INTRODUCTION

Complicated grief (CG) has been the subject of increasing attention in the past decades but its relationship with separation anxiety disorder (SEPAD) is still controversial. The aim of the current study was to explore the prevalence and clinical significance of adult SEPAD in a sample of help-seeking individuals with CG.

METHODS

151 adults with CG, enrolled in a randomized controlled trial comparing the effectiveness of (CG) treatment to that of interpersonal therapy, were assessed by means of the Inventory of Complicated Grief (ICG), the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression (HAM-D), the Work and Social Adjustment Scale (WSAS), the Adult Separation Anxiety Questionnaire (ASA-27), the Grief Related Avoidance Questionnaire (GRAQ), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), and the Impact of Events Scale (IES).

RESULTS

104 (68.9%) individuals with CG were considered to have SEPAD (ASA-27 score ≥22). Individuals with SEPAD were more likely to have reported a CG related to the loss of another close relative or friend (than a parent, spouse/partner or a child) (p=.02), as well as greater scores on the ICG (p=<.001), PDEQ (p=.004), GRAQ (p<.001), intrusion (p<.001) and avoidance (p=<.001) IES subscales, HAM-D (p<.001) and WSAS (p=.006). ASA-27 total scores correlated with ICG (p<.0001), PDEQ (p<.001) GRAQ (p<.0001) scores and both the IES intrusion (p<.0001) and IES avoidance (p<.0001) subscale scores. People with SEPAD had higher rates of lifetime post-traumatic stress disorder (PTSD) (p=.04) and panic disorder (PD) (p=.01).

CONCLUSIONS

SEPAD is highly prevalent among patients with CG and is associated with greater symptom severity and impairment and greater comorbidity with PTSD and PD. Further studies will help to confirm and generalize our results and to determine whether adult SEPAD responds to CG treatment and/or moderates CG treatment response.

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.

Developmental risk factors in generalized anxiety disorder and panic disorder

BACKGROUND

There is a lack of clarity regarding specific risk factors discriminating generalized anxiety disorder (GAD) from panic disorder (PD).

GOAL

This study investigated whether GAD and PD could be discriminated through differences in developmental etiological factors including childhood parental loss/separation, psychological disorders, and maternal and paternal attachment.

METHOD

Twenty people with adult generalized anxiety disorder (GAD), 20 with adult panic disorder (PD), 11 with adult comorbid GAD and PD, and 21 adult non-anxious controls completed diagnostic interviews to assess symptoms of mental disorders in adulthood and childhood. Participants also reported on parental attachment, loss and separation.

RESULTS

Childhood diagnoses of GAD and PD differentiated clinical groups from controls as well as from each other, suggesting greater likelihood for homotypic over heterotypic continuity. Compared to controls, specific phobia was associated with all three clinical groups, and childhood depression, social phobia, and PTSD were uniquely associated with adult GAD. Both maternal and paternal attachment also differentiated clinical groups from controls. However, higher levels of subscales reflecting maternal insecure avoidant attachment (e.g., no memory of early childhood experiences and balancing/forgiving current state of mind) emerged as more predictive of GAD relative to PD. There were no group differences in parental loss or separation.

CONCLUSIONS

These results support differentiation of GAD and PD based on developmental risk factors. Recommendations for future research and implications of the findings for understanding the etiology and symptomatology of GAD and PD are discussed.

Implicit and Explicit Self-Esteem in Current, Remitted, Recovered, and Comorbid Depression and Anxiety Disorders: The NESDA Study

Background

Dual processing models of psychopathology emphasize the relevance of differentiating between deliberative self-evaluative processes (explicit self-esteem; ESE) and automatically-elicited affective self-associations (implicit self-esteem; ISE). It has been proposed that both low ESE and ISE would be involved in major depressive disorder (MDD) and anxiety disorders (AD). Further, it has been hypothesized that MDD and AD may result in a low ISE “scar” that may contribute to recurrence after remission. However, the available evidence provides no straightforward support for the relevance of low ISE in MDD/AD, and studies testing the relevance of discrepant SE even showed that especially high ISE combined with low ESE is predictive of the development of internalizing symptoms. However, these earlier findings have been limited by small sample sizes, poorly defined groups in terms of comorbidity and phase of the disorders, and by using inadequate indices of discrepant SE. Therefore, this study tested further the proposed role of ISE and discrepant SE in a large-scale study allowing for stricter differentiation between groups and phase of disorder.

Method

In the context of the Netherlands Study of Depression and Anxiety (NESDA), we selected participants with current MDD (n = 60), AD (n = 111), and comorbid MDD/AD (n = 71), remitted MDD (n = 41), AD (n = 29), and comorbid MDD/AD (n = 14), recovered MDD (n = 136) and AD (n = 98), and never MDD or AD controls (n = 382). The Implicit Association Test was used to index ISE and the Rosenberg Self-Esteem Scale indexed ESE.

Results

Controls reported higher ESE than all other groups, and current comorbid MDD/AD had lower ESE than all other clinical groups. ISE was only lower than controls in current comorbid AD/MDD. Discrepant self-esteem (difference between ISE and ESE) was not associated with disorder status once controlling for ESE.

Limitations

Cross-sectional design limits causal inferences.

Conclusion

Findings suggest a prominent role for ESE in MDD and AD, while in comorbid MDD/AD negative self-evaluations are also present at the implicit level. There was no evidence to support the view that AD and MDD would result in a low ISE “scar”.

Panic attacks and smoking cessation among cancer patients receiving smoking cessation treatment

OBJECTIVE

Little is known about factors associated with smoking cessation in cancer patients. This study examined the impact of panic attacks on smoking abstinence likelihood among cancer patients receiving tobacco cessation treatment.

METHOD

The relationship of panic attacks to 7-day point-prevalence abstinence at mid-treatment, end of treatment, and 6-month post-end of treatment were examined among cancer patients (N=2255 patients; 50.1% female; Mage=54.9, SD=11.0) who received counseling and pharmacotherapy for smoking cessation. Panic attack history indexed by two questions from the Patient Health Questionnaire (PHQ). Point-prevalence abstinence was assessed via the Timeline Follow-Back.

RESULTS

Cancer patients with a history of panic attacks, (n=493, 21.9%) relative to those without, were less likely to be abstinent at mid-treatment (OR=0.79, CI95%=0.64-0.98) and end of treatment (OR=0.72, CI95%=0.58-0.89). After adjusting for significant covariates, panic attack history remained predictive of decreased abstinence likelihood at end of treatment (OR =0.78, CI95%=0.62-0.99).

CONCLUSIONS

Panic attacks may be related to poorer cessation outcome during smoking treatment among cancer patients, and may be usefully assessed and targeted for intervention.

A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia

OBJECTIVE

The quality of life of individuals with panic disorder and agoraphobia can be improved by the alleviation of agoraphobia. In other words, examining panic disorder in terms of whether agoraphobia is present is crucial. The current study examined panic disorder from this perspective.

METHODS

Subjects were 253 patients who met the diagnostic criteria for panic disorder (lifetime) according to the Mini International Neuropsychiatric Interview (MINI). Of those patients, 179 had agoraphobia and 74 did not. Statistical analysis was used to examine gender differences in the presence (or absence) of agoraphobia, comorbidities, and the effects of the presence of agoraphobia (severity, assessment of depression, assessment of anxiety, and personality) in these patients.

RESULTS

Results indicated gender differences in the presence (or absence) of agoraphobia. Compared to patients without agoraphobia, significantly more patients with agoraphobia were female (p<.001), and had a higher prevalence of comorbidities. Patients with agoraphobia had a higher suicide risk (p<.05), more hypomanic episodes (current) (p<.05), and more frequent episodes of social phobia (p<.05). In addition, patients with agoraphobia had more severe panic disorder and a higher level of neuroticism, sensitivity to anxiety, and trait anxiety [PDSS-J, P&A, NEO-N: p<.01, ASI, STAI (Trait Anxiety): p<.05].

CONCLUSIONS

The current findings suggest that when treating a panic disorder, diagnosing the presence of agoraphobia is extremely important.

Multiple Channel Exposure Therapy

A large proportion of patients who present for treatment of posttraumatic stress disorder (PTSD) experience comorbid panic attacks, yet it is unclear to what extent currently available PTSD treatment programs address this problem. Here we describe a newly developed treatment, multiple-channel exposure therapy (M-CET), for comorbid PTSD and panic attacks. The treatment utilizes elements of cognitive processing therapy treatment for PTSD and elements of panic control treatment to target physiological, cognitive, and behavioral symptoms. Preliminary results suggest that M-CET may provide a promising treatment program for a subset of patients with PTSD who experience panic attacks. In addition, guidelines for conducting M-CET with clients who have been exposed to diverse traumatic events are provided.

Is there cardiac risk in panic disorder? An updated systematic review

BACKGROUND

The recognized relationship between panic disorder (PD) and cardiac disorders (CDs) is not unequivocal. We reviewed the association between PD and coronary artery disease (CAD), arrhythmias, cardiomyopathies, and sudden cardiac death.

METHODS

We undertook an updated systematic review, according to PRISMA guidelines. Relevant studies dating from January 1, 2000, to December 31, 2014, were identified using the PubMed database and a review of bibliographies. The psychiatric and cardiac diagnostic methodology used in each study was then to very selective inclusion criteria.

RESULTS

Of 3044 studies, 14 on CAD, 2 on cardiomyopathies, and 1 on arrhythmias were included. Overall, the studies supported a panic-CAD association. Furthermore, in some of the studies finding no association between current full-blown PD and CAD, a broader susceptibility to panic, manifesting as past PD, current agoraphobia, or subthreshold panic symptoms, appeared to be relevant to the development of CAD. Preliminary data indicated associations between panic, arrhythmias, and cardiomyopathies.

LIMITATIONS

The studies were largely cross-sectional and conducted in cardiological settings. Only a few included blind settings. The clinical conditions of patients with CDs and the qualifications of raters of psychiatric diagnoses were highly heterogeneous. CDs other than CAD had been insufficiently investigated.

CONCLUSIONS

Our review supported a relationship between PD and CDs. Given the available findings and the involvement of the cardiorespiratory system in the pathophysiology of PD, an in-depth investigation into the panic-CDs association is highly recommended. This should contribute to improved treatment and prevention of cardiac events and/or mortality, linked to PD.

Disorder-specific versus transdiagnostic and clinician-guided versus self-guided internet-delivered treatment for panic disorder and comorbid disorders: A randomized controlled trial

Transdiagnostic cognitive behaviour therapy (TD-CBT) aims to target the symptoms of multiple disorders whereas disorder-specific CBT (DS-CBT) targets the symptoms of principal disorders. This study compared the relative benefits of internet-delivered TD-CBT and DS-CBT when provided in clinician-guided (CG-CBT) and self-guided (SG-CBT) formats for people with a principal diagnosis of Panic Disorder (PD). Participants (n=145) were randomly allocated to receive TD-CBT or DS-CBT and CG-CBT or SG-CBT. Large reductions in symptoms of PD (Cohen's d ≥ 0.71; avg. reduction ≥ 36%) and moderate-to-large reductions in symptoms of comorbid depression (Cohen's d ≥ 0.71; avg. reduction ≥ 33%), generalised anxiety disorder (Cohen's d ≥ 0.91; avg. reduction ≥ 34%) and social anxiety disorder (Cohen's d ≥ 0.50; avg. reduction ≥ 15%) were found over the 24-month follow-up period. Highlighting their efficacy and acceptability, no marked and consistent differences were observed between TD-CBT and DS-CBT or CG-CBT and DS-CBT.

Contribution of the Mission in Afghanistan to the Burden of Past-Year Mental Disorders in Canadian Armed Forces Personnel, 2013

OBJECTIVE

The purpose of this study was to estimate the contribution of the mission in Afghanistan to the burden of mental health problems in the Canadian Armed Forces (CAF).

METHODS

Data were obtained from the 2013 Canadian Forces Mental Health Survey, which assessed mental disorders using the World Health Organization's Composite International Diagnostic Interview. The sample consisted of 6696 Regular Force (RegF) personnel, 3384 of whom had deployed in support of the mission. We estimated the association of past-year mental health problems with Afghanistan deployment status, adjusting for covariates using logistic regression; population attributable fractions (PAFs) were also calculated.

RESULTS

Indication of a past-year mental disorder was identified in 18.4% (95% confidence interval [CI], 17.0% to 19.7%) of Afghanistan deployers compared with 14.6% (95% CI, 13.3% to 15.8%) in others. Afghanistan-related deployments contributed to the burden of a past-year disorder (PAF = 8.7%; 95% CI, 3.0% to 14.2%), with the highest PAFs being seen for panic disorder (34.7%) and posttraumatic stress disorder (32.1%). The PAFs for individual alcohol use disorders and suicide ideation were not different from zero. Child abuse, however, had a much greater PAF for any past-year disorder (28.7%; 95% CI, 23.4% to 33.7%) than did the Afghanistan mission.

CONCLUSIONS

The mission in Afghanistan contributed significantly to the burden of mental disorders in the CAF RegF in 2013. However, the much stronger contribution of child abuse highlights the need for strong military mental health systems, even in peacetime, and the need to target the full range of determinants of mental health in prevention and control efforts.

Is panic disorder associated with clinical severity of fibromyalgia? A preliminary study in a tertiary-care centre

OBJECTIVES

To investigate the influence of panic disorder (PD) with/without agoraphobia on the clinical severity of fibromyalgia (FM).

METHODS

Eighty-one patients with FM, among those consecutively referring to a tertiary-care setting, were included in this cross-sectional study. Psychiatric diagnoses were made by the structured clinical interview in accordance with the 4th-TR version of the diagnostic and statistical manual of mental disorders. The clinical severity of FM was measured by means of the following self-administered scales: Fibromyalgia Impact Questionnaire (FIQ), Fibromyalgia Assessment Status (FAS), Health Assessment Questionnaire (HAQ).

RESULTS

A final sample of 66 females with FM with or without past PD was included in the analyses. The two groups did not significantly differ in age, years of education, length of illness or medication distribution. We did not find significant differences between the two groups in the FIQ and FAS scale scores, whereas subjects with FM and past PD showed significantly higher HAQ scale scores than those without past PD (p<.001).

CONCLUSIONS

A history of PD in patients with FM increases the severity of functional impairment in performing a wide range of daily-life activities, as measured by the HAQ scale, with no effects on the severity of other clinical dimensions of FM. Potential underlying mechanisms and clinical implications will be discussed.

Psychiatric comorbidity in adolescent electronic and conventional cigarette use

The popularity of electronic (e-) cigarettes has greatly increased recently, particularly in adolescents. However, the extent of psychiatric comorbidity with adolescent e-cigarette use and dual use of conventional (combustible) and e-cigarettes is unknown. This study characterized psychiatric comorbidity in adolescent conventional and e-cigarette use. Ninth grade students attending high schools in Los Angeles, CA (M age = 14) completed self-report measures of conventional/e-cigarette use, emotional disorders, substance use/problems, and transdiagnostic psychiatric phenotypes consistent with the NIMH-Research Domain Criteria Initiative. Outcomes were compared by lifetime use of: (1) neither conventional nor e-cigarettes (non-use; N = 2557, 77.3%); (2) e-cigarettes only (N = 412, 12.4%); (3) conventional cigarettes only (N = 152, 4.6%); and (4) conventional and e-cigarettes (dual use; N = 189, 5.6%). In comparison to adolescents who used conventional cigarettes only, e-cigarette only users reported lower levels of internalizing syndromes (depression, generalized anxiety, panic, social phobia, and obsessive-compulsive disorder) and transdiagnostic phenotypes (i.e., distress intolerance, anxiety sensitivity, rash action during negative affect). Depression, panic disorder, and anhedonia were higher in e-cigarette only vs. non-users. For several externalizing outcomes (mania, rash action during positive affect, alcohol drug use/abuse) and anhedonia, an ordered pattern was observed, whereby comorbidity was lowest in non-users, moderate in single product users (conventional or e-cigarette), and highest in dual users. These findings: (1) raise question of whether emotionally-healthier ('lower-risk') adolescents who are not interested in conventional cigarettes are being attracted to e-cigarettes; (2) indicate that research, intervention, and policy dedicated to adolescent tobacco-psychiatric comorbidity should distinguish conventional cigarette, e-cigarette, and dual use.