Diazepam versus alprazolam for the treatment of panic disorder.

BACKGROUND: Alprazolam has proven efficacy as a treatment for panic disorder, but the place of other benzodiazepines is less well established. METHOD: To compare the efficacy and tolerability of diazepam and alprazolam for the disorder, a placebo-controlled, double-blind trial was undertaken in two sites. Two hundred forty-one subjects with panic disorder or agoraphobia with panic attacks were randomly assigned to flexible doses of diazepam, alprazolam, or placebo for 8 weeks. RESULTS: At the end of the trial, over 60% of subjects taking either diazepam or alprazolam were at least moderately improved compared with less than 30% of those taking placebo. On all measures of efficacy, subjects taking diazepam and alprazolam showed an equally favorable response. Despite some sedation early in the trial, both drugs were tolerated well. More severely ill subjects responded less well to either benzodiazepine. CONCLUSION: The results indicate that diazepam is an effective alternative to alprazolam for the treatment of panic disorder.

Avoidant personality traits distinguish social phobic and panic disorder subjects.

The purpose of this study was to show that, as a group, patients with social phobia and panic disorder differ with respect to personality traits, further validating the distinction between these anxiety disorders. To show this, we compared the response of 46 subjects with social phobia with the response of 72 subjects with panic disorder with or without agoraphobia on the Personality Diagnostic Questionnaire. The subjects, who were recruited for treatment studies, completed this personality questionnaire after they had been off psychotropic medication for at least 1 week. Responses to the Personality Diagnostic Questionnaire showed that the social phobics had more severe personality pathology. These subjects had higher anxious and schizoid cluster scores and differed from panic subjects in having more avoidant personality traits. Panic subjects had more dependent traits. The results indicate that social phobic and panic disorder patients are distinguishable on the basis of personality characteristics. They also show that the generalized situational subtype of social phobia is closely associated with avoidant personality disorder and that these may be differing categorizations of a single disturbance.

Effect of personality disorders on the treatment outcome of axis I conditions: an update.

The authors review recent studies that assess the impact of personality pathology on the treatment outcomes of axis I disorders. Studies reported include both structured treatment trials and surveys of the outcome of naturalistic treatment. Personality diagnosis in each of the studies reviewed was established by a structured diagnostic instrument. In some of the studies examined, personality traits, not categorical personality diagnoses, are reported in relation to treatment outcome. The authors describe 17 studies published within the past 3 years, and discuss them in relation to a previous review that covered 21 earlier studies. Consistent with previous investigations, recent studies continue to describe an adverse impact of personality pathology on the treatment outcome of a wide range of axis I disorders. The authors examine new studies that describe the effect of specific aspects of personality dysfunction on outcome measures of axis I disorders. New developments in this area include the predictive importance of both personality traits and disorders as well as possible specificity of traits in predicting outcome in some circumstances.

Epidemiology of mental disorders and psychosocial problems: personality disorders / Epidemiology of mental disorders and psychosocial problems: personality disorders

Despite the high prevalence of personality disorders and their significant effect on human functioning, it is only recently that they have been investigated to any extend. This book reviews recent studies on the epidemiology of personality disorders in the general population, among users of primary health care facilities and among psychiatric patients, drawing attention to the comorbidity of these disorders. The main issues related to the classification of personality disorders and their assessment are discussed, using criteria from the International Statistical Classification of Diseases and Related Health Problems, Tenth revision (ICD-10) and the revised third edition of the Diagnostic and Statisticl Manual of Mental Disorders (DSM-III-R), and recommendations made for future studies. Annexed to the book are the ICD-10 clinical descriptions and diagnostic guidelines, and the ICD-10 diagnostic criteria for research for this group of disorders

Personality disorders / G. de Girolamo, J. H. Reich / Troubles de la personnalité / Trastornos de la personalidad

A state-of-the-art review of current knowledge on the epidemiology of personality disorders. In view of the paucity of data on the incidence and prevalence of these disorders, the book also takes a future-oriented approach, concentrating on the types of studies now possible following the recent development of an internationally-agreed nomenclature, a widely tested and accepted diagnostic system, and standardized instruments for assessment. The book is the first in a new WHO series of studies intended to improve understanding of the epidemiology of mental disorders and thus facilitate the identification of risk factors, including social and cultural determinants. The book opens with a review of the evolution of clinical concepts and diagnostic classifications, concentrating on similarities and differences between the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). Further background information is provided through a discussion of several diagnostic categories that have raised important conceptual problems, and a review of the main methods currently available for assessing personality disorders. The chapter also considers questions concerning the concordance between standardized interviews and self-report questionnaires for the diagnosis of these disorders. Findings from epidemiological studies of personality disorders are reviewed in the most extensive chapter, which concentrates on recent prevalence studies conducted in general population samples, in primary health care facilities, and in psychiatric settings. The important issue of comorbidity, among personality disorders as well as with other psychiatric disorders, is also discussed. The book concludes with a series of recommendations for future studies, including the main areas requiring further investigation and key methodological problems that will need to be resolved. Annexed to the book are the ICD-10 clinical descriptions and diagnostic guidelines, and the ICD-10 diagnostic criteria for research for this group of disorders

Personality traits associated with panic disorder: change associated with treatment.

Eighty-two subjects with panic disorder completed the Personality Diagnostic Questionnaire (PDQ) before treatment and again after a period of relatively stable improvement 3 years later. At baseline, panic subjects scored higher than normal control subjects, who had been matched for age and sex, on avoidant, dependent, histrionic, and paranoid personality subscales. Improvement in panic symptoms after 3 years was associated with reductions in these same subscale scores. Examination of individual items that distinguished panic from normal subjects showed themes of dependency, lack of self-confidence, emotional instability, and sensitivity to criticism that reflected demoralization in the panic disorder subjects. To a large extent, the findings reveal nonspecific, state-dependent effects of panic and agoraphobic symptoms on the personality functioning and morale of patients with panic disorder.

Effect of personality disorders on outcome of treatment.

Although many clinicians have long believed that personality pathology may interfere with the effectiveness of treatment of axis I disorders, until recently there were no empirical studies on the subject. This report reviews the recent literature with regard to the following questions: a) Does personality pathology predict negative outcome of treatment for axis I disorders? b) If so, are there specific personality traits or disorders that account for such a negative outcome? The literature review reveals a robust finding that patients with personality pathology have a poorer response to treatment of axis I disorders than those without such pathology. Specific axis I disorders reported on include DSM-III major depression, panic disorder, and obsessive-compulsive disorder. Both inpatients and outpatients have been studied. There is too little literature to determine whether certain pathological personality traits are especially important, but there is enough to provide methodological guidance for future studies. Such studies should use standardized measures of personality and outcome, should match personality and nonpersonality groups on severity of the axis I disorder, and should be certain that axis I diagnoses are not confounded by axis II symptoms.

Comparisons of males and females with DSM-III dependent personality disorder.

To determine whether DSM-III dependent personality disorder (PD) differed in males and females, 30 females and 11 males with this diagnosis were selected from a psychiatric outpatient population. Standardized measures of Axis I, Axis II, and family history were used. There were no differences in age or in the prevalence of Axis I or Axis II disorders in males and females, indicating that females were probably not misdiagnosed as having dependent PD. However, relatives of males had significantly more major depressive disorder and DSM-III anxious personality disorder cluster, while relatives of females had significantly more panic disorder. This may indicate different predisposing factors to dependent PD in males and females.

Effect of DSM-III personality disorders on outcome of tricyclic antidepressant-treated nonpsychotic outpatients with major or minor depressive disorder.

This is the first outcome report of the effect of a personality disorder on nonhospitalized major depressive patients that used a standardized DSM-III measure and did not prescreen to eliminate certain personality disorders. Six-month outcome was compared for nonpsychotic patients with major depression and a DSM-III personality disorder (n = 26) and those who did not have a personality disorder (n = 11). Patients without a personality disorder had significantly better outcome as measured by the Global Assessment Scale and employment status. There was also a trend for less physician utilization in this group.

Update on instruments to measure DSM-III and DSM-III-R personality disorders.

In the last 2 years, researchers have revised personality instruments to encompass the DSM-III-R criteria for personality disorders. More recent, innovative instruments undergoing validity work include a self-report instrument that rederives DSM-III personality categories from dimensional measures, a self-report designed to be used in conjunction with a diagnostic interview, an interview designed to be given by trained lay people, and a family history measure of the DSM-III personality disorder clusters. The modifications of older instruments and those instruments more recently developed are described. Clearly instruments require additional validity testing and better test-retest reliability. Discrepancies between different measurement instruments also need to be addressed.

Familiality of DSM-III dramatic and anxious personality clusters.

This double-blind family study was an investigation of the familiality of DSM-III avoidant, dependent, borderline, anxious cluster, and flamboyant cluster personality disorders (PDs) using a standardized DSM-III axis II measure. With the exception of borderline personality, there are no previous reports in this area. Avoidant, dependent, and anxious cluster PDs showed significant familiality. Borderline showed a trend in the direction of familiality but did not reach significance (p = .07). Relatives of flamboyant cluster PDs demonstrated significant but heterogeneous personality disorder pathology.

A family history method for DSM-III anxiety and personality disorders.

A family history method for DSM-III anxiety and personality disorders (FHPD) was validated by direct interview of 182 relatives. The categories of "any anxiety disorder," "panic disorder," and "any personality disorder" achieved sensitivities and specificities equivalent to currently accepted psychiatric family history methods. The family history results for the DSM-III dramatic and anxious personality disorder clusters showed good specificities, but only fair sensitivities. It is possible these cluster sensitivities could be improved in the future by using less stringent criteria. The FHPD is designed so that it can easily be integrated into the Family History-Research Diagnostic Criteria format and scoring.

DSM-III personality disorders and the outcome of treated panic disorder.

Fifty-two patients with panic disorder who had been receiving active benzodiazepine treatment for 8 weeks were assessed by using the outcome measures of spontaneous and situational panic attacks, scores on the Hamilton scales for anxiety and for depression, and scores on self-rated disability scales. Although spontaneous panic attacks were not affected by the presence of any personality disorder, the remaining outcome measures showed a strong and negative association with DSM-III antisocial, borderline, histrionic, and narcissistic personality disorders. There was also a mild negative association with avoidant personality disorder. A subgroup of patients with both major depression and panic disorder appeared more strongly affected.

Relationship of urinary free cortisol levels in patients with panic disorder to symptoms of depression and agoraphobia.

Sixty-five patients with panic disorder and 37 matched controls collected 24-hour urine specimens for measurement of urinary free cortisol. Although patients with panic disorder had significantly higher urinary free cortisol levels than control subjects, this difference was accounted for by panic disorder patients with concomitant depression, agoraphobia, or both. Urinary free cortisol excretion was not related to the age of onset of panic disorder, the number of spontaneous panic attacks, or the degree of impairment associated with the disorder. They were related, however, to the level of symptoms on both the Hamilton Rating Scale for Depression and the Hamilton Rating Scale for Anxiety in the entire group of panic patients, but this relationship disappeared when those patients with the complications of agoraphobia and depression were excluded. These data suggest that, as with primary depression, depression secondary to panic disorder, as well as to agoraphobia in panic disorder patients, is associated with hyperactivity of the hypothalamic-pituitary-adrenal axis.

Disagreements between court and psychiatrist on competency to stand trial.

To determine the frequency and the nature of disagreements between the court and the forensic psychiatrist regarding a defendant's competence to stand trial, 390 consecutive admissions from the Yale-New Haven Psychiatric Court Clinic were reviewed. Six cases of clear-cut disagreements were found. It appears that when courts rule an individual competent and the psychiatrists rule incompetent, the psychiatrists have tended to overestimate the degree of function necessary to defend the legal charge.