Psychosocial rehabilitation: issues and answers for psychiatry.

The American Association of Community Psychiatrists has composed a set of principles to guide psychiatry's relationship with psychosocial rehabilitation. They consist of five basic precepts offering the profession an orientation to rehabilitation, accompanied by seven issues that discuss aspects of how psychiatry must finally adopt psychosocial rehabilitation as a model of practice with people who have severe psychiatric disorders. The authors advance the argument that a confluence of developments, both within and beyond psychiatry, has now created an opportunity for psychiatry to build a mutually productive relationship with rehabilitation.

Weight gain from novel antipsychotic drugs: need for action.

Obesity is common in schizophrenia, and people with schizophrenia appear to be at increased risk for certain obesity-related conditions, such as type 2 diabetes and cardiovascular disease. Antipsychotic drugs, used chronically to control symptoms of schizophrenia, are associated with often-substantial weight gain, a side effect that is a special concern with the latest generation of highly effective "novel" agents. That the most effective (e.g., novel) antipsychotic medications lead to substantial weight gain presents the field with a critical public health problem. Although preliminary data have been reported regarding the beneficial use of behavior therapy programs for short-term weight control in patients with schizophrenia, the available data are quite limited, and there are no data regarding the long-term beneficial effects of these programs in this population. The obesity field recently has developed programs emphasizing "lifestyle changes" (e.g., diet, exercise, and problem-solving skills) to successfully manage weight in patients without schizophrenia. Such programs can be adapted for patients with schizophrenia through the use of highly structured and operationalized modules emphasizing medication compliance, social skills development, and participation in outpatient programs. Moreover, these programs can potentially be combined with the use of adjunctive pharmacotherapy to maximize and maintain weight loss. The field must solve the paradox that some of our most effective medications for schizophrenia produce substantial weight gain and its associated troubling health risks.

Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia, 1991-1996.

OBJECTIVE: Pharmacologic prescriptions for anxiety disorders have changed significantly in the last decade. This article investigates whether psychosocial treatments, as reported by 362 subjects in the Harvard/Brown Anxiety Disorders Research Program from 1991 to 1996, changed as well. METHOD: Subjects were interviewed in 1991 and 1995-1996 to determine which psychosocial treatments (behavioral, cognitive, dynamic, or relaxation or meditation) they had received. RESULTS: The percentage of subjects who received each type of psychosocial treatment either declined or remained the same from 1991 to 1995-1996. Dynamic psychotherapy remained the most frequently used method of these four. The percentage of subjects receiving any such method declined. CONCLUSIONS: Behavioral and cognitive treatment, two empirically validated forms of psychotherapy, were less frequently used than dynamic psychotherapy, which lacks such validation. All use of verbal treatment methods declined from 1991 to 1995-1996.

Comparing primary and secondary generalized anxiety disorder in a long-term naturalistic study of anxiety disorders.

This study explores the potential differences in comorbidity and course between primary generalized anxiety disorder (GAD), which develops before other anxiety disorders, and secondary GAD. As part of the Harvard/Brown Anxiety Research Project (HARP), a naturalistic, long-term, longitudinal study of 711 subjects from a variety of clinic settings with DSM III-R defined anxiety disorders, 210 subjects with GAD were identified. Of these, 78 (37%) had primary GAD, and 84 (40%) had secondary GAD; of the remainder, 28 (13%) had no other anxiety disorder and 20 (10%) developed GAD within a month of another anxiety disorder and were excluded from the analysis. All subjects were comorbid for at least one other anxiety disorder. Primary GAD subjects were more likely to be in episode at intake (90% vs. 77%, P = .04) and less likely than secondary GAD subjects to have current or past agoraphobia without panic disorder (3% vs. 11%, P = .04), social phobia (19% v. 52%, P = .001), simple phobia (14% v. 30%, P = .02), or post traumatic stress disorder (5% vs. 20%, P = .01). Subjects with primary GAD were also less likely to have current or past alcohol use disorders (17% vs. 37%, P = .004) or major depressive disorder (60% vs. 76%, P = .03). There were no significant differences in either treatment approaches or remission rates for primary compared to secondary GAD. Whether GAD first occurs before or after another anxiety disorder, it is similar in terms of prevalence, treatment, and course. The only significant differences between primary and secondary GAD lie in the rates of comorbidity of both other anxiety disorders and non-anxiety disorders, including major depression and substance abuse. These results support the concept of GAD as a valid, separate and distinct entity, whether it occurs primarily or secondarily.

Simple phobia as a comorbid anxiety disorder.

This study sought to describe clinical and demographic characteristics differentiating patients with DSM-III-R simple phobias comorbid with one or more of five DSM-III-R index anxiety disorders as compared with those with the index diagnoses alone. From 711 subjects participating in a multicenter, longitudinal, naturalistic study of anxiety disorders, 115 subjects with comorbid simple phobias were compared with 596 subjects without simple phobias in terms of demographic data, comorbidity with other disorders, somatic and psychosocial treatment received, and quality of life. In addition, episode characteristics, types of simple phobias found, and course of illness were specified. Subjects with simple phobias had more additional comorbid anxiety disorders by history than did those without. Mean length of intake episode was 22.43 years and severity was typically moderate. Fears of heights and animals were the most commonly represented simple phobias. Subjects with uncomplicated panic disorder were less likely to have comorbid simple phobias than were subjects with other index diagnoses, and subjects with simple phobia were more likely to have comorbid posttraumatic stress disorder than were these without simple phobia. Subjects with and without simple phobias did not differ by somatic or psychosocial treatment received or in terms of quality of life. Simple phobia appeared in this study to be a chronic illness of moderate severity for which behavioral treatment methods of recognized efficacy were not being frequently utilized. Uncomplicated panic disorder may reflect some type of resistance to phobia development.

The psychosocial treatments interview for anxiety disorders. A method for assessing psychotherapeutic procedures in anxiety disorders.

The authors report on development, reliability, and findings of the Psychosocial Treatments Interview (PTI) to assess treatments reported by patients in a naturalistic study of the longitudinal course of anxiety disorders. The PTI ascertains frequency of different types of psychosocial treatments, based on patients' reports. The PTI showed good internal consistency and very good interrater reliability. At first 6-month follow-up, the most common modalities were supportive, medication discussion, and dynamic intervention. Combinations were common. Delivery of treatments differed by site. Overall, the PTI fills a methodological need for the assessment of the treatments reported by patients in naturalistic follow-up studies.

Panic disorder versus panic disorder with major depression; defining and understanding differences in psychiatric morbidity.

The present study examined the impact of comorbid major depressive disorder (MDD) on psychiatric morbidity, panic symptomatology and frequency of other comorbid psychiatric conditions in subjects with panic disorder (PD). Four hundred thirty-seven patients with PD were evaluated at intake as part of a multicenter longitudinal study of anxiety disorders; 113 of these patients were also in an episode of MDD. Patients were diagnosed by DSM-III-R criteria utilizing structured clinical interviews. The 113 PD/MDD patients were compared with the 324 remaining PD subjects regarding panic symptoms at intake, sociodemographic, quality of life and psychiatric morbidity variables. Differences in frequency of other comorbid Axis I psychiatric disorders were assessed at intake; personality disorders were evaluated twelve months after intake. The results revealed the PD/MDD patients exhibit increased morbidity and decreased psychosocial functioning as compared to PD patients. Personality disorders were more prevalent in the PD/MDD group at six month follow-up assessment; the PD/MDD group also had an increased frequency of posttraumatic stress disorder (PTSD) and more comorbid Axis I anxiety disorders as compared to the PD group. The total number and frequency of panic symptoms was highly consistent between the two patient groups.

The infrequency of "pure culture" diagnoses among the anxiety disorders.

BACKGROUND: Anxiety disorders are known to commonly coexist in individuals, both with other anxiety disorders and with mental disorders from other groupings, such as affective disorders. We questioned how frequently anxiety disorders actually occur in isolation, as "pure cultures." METHOD: We examined diagnostic patterns among the 711 subjects entered into a large, multicenter study of anxiety disorders, the Harvard/ Brown Anxiety Disorders Research Program (HARP), which focused on panic, agoraphobia, generalized anxiety disorder, and social phobias as "index disorders" required for intake. RESULTS: We used various definitions for "pure culture." By all definitions, subjects with "pure culture" represented a minority, especially in cases of generalized anxiety disorder and social phobia, where comorbidity was virtually ubiquitous. "Pure culture" status was associated with later onset of illness and less chronicity. CONCLUSION: Future studies of anxiety disorder should aim to document the extensive comorbidity, rather than eliminate it by restrictive diagnostic exclusion criteria, lest they yield atypical or even misrepresented groups of patients. Clinicians should not stop at identifying only the "main" diagnosis but look for other, comorbid diagnoses that are often present.

Prevalence of somatoform disorders in a large sample of patients with anxiety disorders.

The authors investigated the prevalence and characteristics of somatoform (SOM) disorders among 654 subjects with anxiety disorders who were part of the larger Harvard/Brown Anxiety Disorders Research Project. Thirty-six (5.5%) of the subjects had past or current SOM disorders. The subjects with SOM disorders were significantly more likely to have histories of posttraumatic stress disorder (22% vs. 8%, P = 0.01). The subjects with generalized anxiety disorder had significantly higher rates of SOM disorder (9.2% vs. 4.0%, P = 0.01). These results add support to the observation that SOM disorders are frequently comorbid with anxiety and depressive disorders.

Profile of a large sample of patients with social phobia: comparison between generalized and specific social phobia.

This study examines a large cohort of subjects with social phobia, as part of a larger naturalistic and longitudinal study of 711 subjects with anxiety disorders. We focused on 176 subjects who were in an episode of social phobia at intake. We were particularly interested in evaluating the diagnostic distinction between generalized and specific social phobia. We compared these two groups along demographic characteristics, comorbidities, psychosocial functioning (health, role functioning, social functioning, and emotional functioning) and global assessment scores. We found that generalized social phobics tended to have an earlier age of onset as compared to the specific group; however, this is not a statistically significant difference at this level of analysis. The two groups did not differ for the current comorbidities examined. We observed no differences in the treatment received by the two types of social phobia subjects, and the two groups functioned equally well in terms of health and fulfilling social roles. In addition, we examined adverse childhood events (i.e., death of a parent, childhood abuse) and found no evidence for any differential impact these events might have on the type of social phobia. Although we did observe significantly greater fear of public speaking among the specific compared to the generalized group, which may indicate a qualitative difference between the subtypes, our results suggest that for most parameters, generalized and specific social phobia represent a continuum of similar and overlapping entities.

DSM-IV and the disappearance of agoraphobia without a history of panic disorder: new data on a controversial diagnosis.

OBJECTIVE: This analysis describes subjects who met rigorous criteria for DSM-III-R agoraphobia without a history of panic disorder and makes inferences from these data regarding relationships among agoraphobia without a history of panic disorder, panic disorder, and panic disorder with agoraphobia. METHOD: Twenty-six subjects (seven men and 19 women) with agoraphobia without a history of panic disorder were identified from among 711 subjects recruited for a multicenter, longitudinal anxiety disorder study. Narrative transcripts prepared by raters from study evaluations were coded for limited symptom attacks, situational panic, catastrophic cognitions, and possible precipitants and stressors, course, and somatic and psychosocial treatments received. RESULTS: Sixty-five percent of the subjects reported experiences consistent with situational panic attacks, and 57% had definite or probable limited symptom attacks; these attacks usually preceded or appeared at the same time as avoidance behavior. Eighty-one percent had catastrophic cognitions associated with agoraphobia. Twenty-six percent reported a likely precipitating factor for symptom onset, and 30% reported a definite or probable major life stressor within 6 months before symptom onset. Cognitive-behavioral treatments were relatively infrequently used. Course was relatively unchanged across the follow-up period. CONCLUSIONS: These data support a view of agoraphobia without a history of panic disorder on a continuum with uncomplicated panic disorder and with panic disorder and agoraphobia, rather than as a separate diagnosis.

Specificity of substance use in anxiety-disordered subjects.

The current research (1) examines empirical evidence to substantiate the relationship between substance choice and chronology of onset of anxiety and substance use disorders, and (2) provides information on the specificity of substance choice among anxiety disorders. A study group of 181 subjects in the Harvard Anxiety Research Project (HARP) who had a history of substance use disorder were the focus of this examination. Subjects whose anxiety disorder had an onset before their substance use disorder (primary anxiety) were compared with those whose substance use preceded onset of an anxiety disorder (secondary anxiety) for differences in distribution of subjects among categories of substance of abuse. Primary and secondary anxiety groups do not have different ages of onset for substance use disorder, nor was there greater likelihood for choosing alcohol for any of the anxiety disorders. However, there is a decreased risk of alcohol use in the small group of generalized anxiety subjects and an increased risk of opioid use in the small group of posttraumatic stress disorder subjects. There was no indirect support for the self-medication hypothesis. Neither age of onset data, specific substance association, nor proximal diagnosis association support a simple interaction. The strongest finding supported an "avoidance" of CNS stimulants.

Comorbidity of anxiety disorders in a multicenter anxiety study.

From 11 sites in New England and Missouri, 711 patients with > or = one of five index anxiety disorders were recruited onto a longitudinal study in which they were interviewed every 6 months regarding symptoms, course, and treatments received. Of the five disorders studied, panic disorder without agoraphobia was the disorder most often found as a sole diagnosis and generalized anxiety disorder (GAD) was least often found alone, both as lifetime diagnoses or when restricted to cases active at intake. Panic disorder with agoraphobia and agoraphobia without history of panic disorder (AWOPD) had three specific diagnoses with which they were frequently comorbid: social phobia, simple phobia, and GAD. AWOPD, social phobia, and GAD were frequently found in the presence of each other. It is possible that the experience of anxiety due to any syndromal cause may decrease the threshold for an individual to experience other anxiety symptoms or disorders. Clinicians should be aware of these patterns of comorbidity in order to formulate accurate differential diagnoses and prescribe treatments in a rational manner.

Comparison of personality disorders in different anxiety disorder diagnoses: panic, agoraphobia, generalized anxiety, and social phobia.

Recently there has been increasing interest in the relationship of the personality and the anxiety disorders. This paper presents comorbidity findings between DSM-III-R personality pathology and several DSM-III-R anxiety disorders and makes direct comparisons between anxiety groups. This is the most extensive comparison of this kind reported thus far. This report is on the first 475 anxiety patients who were recruited from multiple sites to take part in a naturalistic study of anxiety. All had a DSM-III-R diagnosis of panic, agoraphobia, social phobia, or generalized anxiety disorder (GAD). Previous studies which found a high comorbidity between the anxiety and the personality pathology were confirmed, with a significantly higher prevalence of personality pathology occurring with social phobia and GAD. Among our patients, all of whom had anxiety disorders, the presence of comorbid major depression is associated with an increase in the levels of comorbid personality pathology--as previously described in the literature. The relationship between low social functioning and the presence of personality pathology was confirmed, however, the relationship appears to be specific to certain areas of functioning, a new finding. There is a clinically important relationship between Personality Diagnostic Questionnaire--Revised personality pathology and the anxiety disorders characterized by different prevalences of personality disorders in different anxiety disorders and specific areas of social dysfunction.

Panic, agoraphobia, and panic disorder with agoraphobia. Data from a multicenter anxiety disorders study.

In a cross-sectional investigation of the properties of DSM-III-R panic disorder (PD), panic disorder with agoraphobia (PDA), and agoraphobia without history of panic disorder (AWOPD), we analyzed demographic, descriptive, comorbidity, treatment, and course data for 562 subjects with PD, PDA, or AWOPD in a multicenter anxiety-disorders study. In general, AWOPD subjects had the worst functioning and PD subjects the best, as measured by length of intake episodes, education attained, likelihood of receiving financial assistance, depressive comorbidity, and likelihood of having experienced 8 weeks symptom-free. Panic disorder with agoraphobia was the most common disorder and emerged as a condition intermediate in severity between the other two. Treatments received varied little by diagnosis. Most subjects received medication, usually benzodiazepines. Psychodynamic psychotherapy was the most frequently received psychosocial treatment; cognitive and behavioral approaches were less common. Subjects classified with AWOPD were the most likely to have received exposure therapies.

Utilization of behavioral methods in a multicenter anxiety disorders study.

BACKGROUND: There are abundant data to justify the use of behavioral methods in treating patients with anxiety disorders. Yet there also is evidence that these methods have been underutilized in treating these patients. In this study we examined a large sample of patients with anxiety disorders to determine the extent to which behavior therapy methods were used in their treatment. METHOD: As part of a multicenter longitudinal study of patients with anxiety disorders in New England, we analyzed data pertinent to the type of treatment received by 231 patients at nine study sites. Study subjects received a battery of interview and self-report instruments administered by trained study interviewers at intake and at 6-month follow-up. A Psychosocial Treatments Interview designed by study personnel and administered by study interviewers at 6 months after intake provided data as to types of psychosocial treatment received by study subjects. RESULTS: Behavioral methods were used less frequently than supportive psychotherapy. medication, or psychodynamic psychotherapy. Among behavioral treatments, relaxation and imaginal exposure were used more frequently than in vivo exposure. Obsessive compulsive disorder and agoraphobia without panic were the diagnoses most likely to be treated behaviorally. Behavioral methods were used more frequently in combination with other modalities than they were alone. CONCLUSION: When compared with previous studies, the frequency of utilization of behavioral methods appears to have increased moderately. But our data are still consistent with a pattern of inappropriately low utilization of these effective treatment methods.

Risk management in the practice of behavior therapy: boundaries and behavior.

Behavior therapy represents a treatment modality widely utilized by clinicians but to date insufficiently examined from the risk-management standpoint. Given that the determination of negligence is dependent on the role of the therapist as proximate cause of the adverse outcome and on the availability of an accepted standard of care from which deviations can be specified, a number of general characteristics of behavior therapy may render its practitioners potentially vulnerable to litigation. These may include its directiveness, its replicability, and its methodologic rigor. Similarly, certain specific behavioral techniques may carry some medicolegal risks, including the use of aversion methods, utilization of family members or other lay cotherapists, response cost, and exposure therapies. In addition, therapeutic boundaries in behavioral treatment may be different from those in psychoanalytic therapy, allowing for therapist practices that might otherwise be considered unusual or in themselves negligent, but the therapist may have a heavier burden of justification in such cases. The authors suggest that recognition of the possibility of adverse results, ongoing and competent informed consent, adequate documentation, willingness to consult, and careful monitoring of treatment outcome may help mitigate the medicolegal risks of these procedures.

AIDS education for patients with chronic mental illness.

Despite the AIDS epidemic's impact, development of prevention and risk-reduction programs has been slow, especially for patients with chronic mental illness. These patients may be at particular risk for HIV transmission and acquisition due to characteristics of their illness. Despite a paucity of such program descriptions in the literature and widespread concern that exposure of such patients to educational material related to sexuality or AIDS would be overstimulating, an effective and safe curriculum to teach risk-reduction can be designed. This paper describes such a program at the Massachusetts Mental Health Center, in Boston.