Acute treatment response in outpatients with panic disorder: high versus low depressive symptoms.

The authors studied 75 outpatients with DSM-III-R panic disorder who had participated in a clinical trial and had been randomly assigned to receive fluvoxamine, cognitive therapy, or placebo for an 8-week period. They compared a group with high levels of depressive symptoms and a group with low levels of depressive symptoms. At baseline, patients with high levels of depressive symptoms were more likely to have severe phobic avoidance and to have higher scores on measures of anxiety, hyochondriasis, and disability. An important finding was that depressive symptoms improved at a rate which paralleled improvement in panic and anxiety. Likewise, the presence of depressive symptoms did not interfere with treatment response in panic disorder. Clinical implications of the findings are discussed.

Predictors of short-term treatment response in 66 patients with panic disorder.

Short-term treatment response in panic disorder was studies in 66 subjects who had completed 3 weeks of treatment with fluvoxamine (n = 23), cognitive therapy (n = 20), or placebo (n = 23). Clinical and self-rated assessments were gathered at baseline, during, and after treatment. Using multiple logistic regression, treatment with fluvoxamine, a low panic attack severity score, and absence of a comorbid personality disorder were identified as significant predictors of recovery. Personality disorder was an important negative predictor to outcome with cognitive therapy. The results support the efficacy of fluvoxamine, and show that patients with low symptom severity and a normal personality respond well to treatment.

The abrupt discontinuation of fluvoxamine in patients with panic disorder.

BACKGROUND: We evaluated patients abruptly withdrawn from fluvoxamine, a serotonin selective reuptake inhibitor, for evidence of a discontinuation syndrome. METHOD: In an open-label study, 14 subjects were abruptly withdrawn from fluvoxamine after treatment lasting 8 months (7 months for 1 patient). Psychological, somatic, and perceptual symptoms were assessed at Day 5, Day 10, and Day 14 postdiscontinuation. Anxiety and depression were assessed using clinician and self-rated scales. RESULTS: Twelve (86%) of 14 subjects developed new symptoms. The most frequent symptoms reported were dizziness/incoordination, headaches, nausea, and irritability. Symptoms peaked on Day 5 postdiscontinuation. Only 1 subject had a recurrence of panic, but another developed anxiety and depression; both were remedicated. CONCLUSION: Abrupt fluvoxamine discontinuation is associated with a characteristic syndrome in many patients.

A comparison of fluvoxamine, cognitive therapy, and placebo in the treatment of panic disorder.

Seventy-five outpatients with moderate to severe panic disorder were randomly assigned to receive 8 weeks of fluvoxamine, cognitive therapy, or placebo. Fifty-five patients completed the treatment protocol. Fluvoxamine was found to be an effective and well-tolerated treatment for panic using clinician- and patient-rated variables. Subjects receiving cognitive therapy also showed improvement, but this improvement did not significantly differ from the experience of the placebo-treated group for most comparisons. Fluvoxamine was superior to cognitive therapy for many ratings, but cognitive therapy was not superior to fluvoxamine on any rating. Fluvoxamine also produced improvement earlier than cognitive therapy. At the main comparison point (week 4), 57% (13/23) of patients receiving fluvoxamine were rated moderately improved or better vs 40% (8/20) of the group given cognitive therapy and 22% (5/23) of the placebo-treated group. At that point, 43% (10/23) of the fluvoxamine recipients vs 25% (5/20) of cognitive therapy and 4% (1/23) of placebo recipients were free of panic attacks.

A comparison of patients with illness phobia and panic disorder.

Fourteen subjects with illness phobia, a subtype of hypochondriasis, were compared with an equal number of subjects with panic disorder who had been matched for age and sex. The illness phobic subjects differed from panic subjects in not having spontaneous panic attacks or agoraphobic symptoms, the characteristic features of panic disorder. The onset of illness phobia was related to experience with illness in half the subjects. Half of the illness phobic subjects also had family histories of anxiety disorders. The results suggest that illness phobia is distinct from panic disorder and that it is a disorder in which environmental and genetic factors are etiologically important.

Close linkage of esterase-D to unipolar depression and alcoholism is ruled out in eight pedigrees.

Unipolar depression and alcoholism were tested for genetic linkage to esterase-D at 13q14.1. Tight linkage to esterase-D was ruled out for three phenotypes using three models of penetrance: (1) unipolar depression and alcoholism taken together as affected, (2) unipolar depression alone as affected with alcoholism considered unaffected and (3) alcoholism alone as affected with unipolar depression considered unaffected. This study does not support an earlier finding of possible linkage between the esterase-D locus at 13q14.1 and alcoholism.

Imipramine an effective treatment for illness phobia.

Ten subjects with illness phobia were treated with imipramine for 8 weeks. All of the eight subjects who remained on the drug for 4 weeks or more reported at least moderate improvement. Overstimulatory reactions occurred in four subjects causing two to discontinue medication. Imipramine appears to be a potentially useful treatment for this subtype of hypochondriasis.

Organic mood disorder: a valid psychiatry consultation diagnosis?

To determine the validity of the DSM-IIIR category organic mood disorder, we compared 50 psychiatric consultations with this diagnosis to 50 psychiatric consultations diagnosed with major depression in the medically ill. Organic mood disorder patients were more likely to be in the index affective disorder episode and have a negative family history of depression. Despite similar pharmacologic treatment between groups, the organic mood disorder group was less likely to be completely recovered at 4 years follow-up. This study suggests organic mood disorder is a valid diagnosis in the psychiatry consultation service.

Lack of linkage to chromosome 5q11-q13 markers in six schizophrenia pedigrees.

We examined linkage between schizophrenia and five genetic markers on chromosome 5 in six pedigrees. Analyses were run considering the affected phenotype to be schizophrenia, schizophrenia plus a spectrum of related disorders, and these disorders plus any axis I diagnosis. None of the analyses were suggestive of linkage at any of the markers, either considering the pedigrees individually or in the aggregate. In our pedigrees, multipoint linkage analyses excluded much of the region that had supported linkage in an earlier study. These findings are consistent with other attempts to replicate the chromosome 5 linkage finding.

Alcohol use and abuse secondary to anxiety.

The relationship between alcohol use and anxiety is complex. From a clinical standpoint, it is clear that psychiatrists caring for anxious patients must be aware of the possibility of secondary alcohol abuse. For the most part, anxiety disorders are highly treatable conditions, whereas alcoholism is less successfully treated. With this in mind, it is important for the clinician to accurately diagnose anxiety disorders in their patients. Failure to do so may lead a high percentage of patients to the major complication of substance abuse, which itself may be very difficult to treat. Further research to understand the relationship between anxiety and alcohol use is warranted. Future studies should focus on discovering which anxious patients are likely to abuse alcohol. Studies screening patients for the presence of alcoholic traits, such as antisocial behavior or a family history of alcoholism, may help identify anxiety disorder patients who are likely to go on to become alcohol abusers. Researchers interested in the treatment of substance abusers should become acutely interested in the recognition and treatment of anxiety disorder in their patients. Identifying patients with anxiety disorders would be a first step in individualizing treatment for a given alcoholic patient.

Close linkage between panic disorder and alpha-haptoglobin excluded in 10 families.

We previously reported a lod score of 2.3 suggesting linkage between panic disorder and the alpha-haptoglobin locus on chromosome 16q22 in 26 pedigrees. In the present study we tested for linkage between alpha-haptoglobin and panic disorder in 10 new pedigrees and excluded a gene for panic disorder from 6 centimorgans (recombination fraction, 0.06) surrounding the alpha-haptoglobin locus. The data were analyzed under a variety of assumptions about the transmission of panic disorder, and linkage was excluded by all genetic models but one. When lod scores from the present set of 10 pedigrees were pooled with those from the first 26, no evidence of genetic heterogeneity was found, and the maximum lod score was 0.67 at a recombination fraction of 0.17. Taken as a whole, the present findings do not support the presence of a disease gene for panic disorder closely linked to the alpha-haptoglobin locus on chromosome 16q22.

The occurrence of performance anxiety among musicians.

A questionnaire was given to the students and faculty of the University of Iowa School of Music to learn about their experiences with and attitudes about performance anxiety. Forty-nine (16.5%) of the 302 respondents indicated that their musical performance was impaired by anxiety. Over 21% of the respondents indicated that they experienced marked distress while performing and 16.1% indicated that performance anxiety had adversely affected their careers. Women more frequently reported distress and impairment due to performance anxiety than men. Age was not found to affect problems with performance anxiety. Poor concentration, rapid heart rate, tremor, sweating, and dry mouth were the most commonly reported anxious symptoms. Drug and alcohol use among this group of musicians was minimal. The findings suggest that performance anxiety is an important problem that may in some instances warrant medical treatment.

Linkage of c-Harvey-ras-1 and INS DNA markers to unipolar depression and alcoholism is ruled out in 18 families.

Eighteen families informative for c-Harvey-ras-1 and INS DNA markers were tested for linkage to unipolar depression and alcoholism. No evidence of linkage was found between these DNA markers and the disorders observed in the families. This study fails to replicate the Old Order Amish Study and suggests that a significant degree of genetic heterogeneity may be present among psychiatric disorders.

The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy.

The influence of age on the natural history of unipolar depression when treated with electroconvulsive therapy (ECT) was studied using a naturalistic/archival study design. A sample of 125 patients who received no somatic treatment were compared with 128 patients who all received a course of ECT with at least four treatments. Patients were separated according to age at admission. Treated patients, aged 40 or older, who were clearly remitters showed no differences in previous episodes, subsequent episodes, subsequent hospitalizations, or likelihood of experiencing a period of full recovery when compared with a similar group of untreated patients. Hospitalization greater than 1 year and chronicity were significantly more common in the untreated older subjects. Treated patients aged 39 or younger, who also were clearly remitters, showed significant increases in subsequent episodes and subsequent hospitalizations when compared with a group of depressed patients of similar age who received no somatic treatment. Hospitalization greater than 1 year was also more common in the untreated younger patients. ECT clearly reduces the rate of chronicity in older patients but may be associated with an increase in episodes after treatment in the younger population.

Advances in anxiety management.

Recent developments in neurobiology, diagnostic classification, and drug/psychotherapy trials have increased our ability to manage patients with anxiety disorders. These recent developments, along with epidemiologic surveys showing the high frequency of anxiety disorders in the general population as well as in the primary care population, have reemphasized the importance of anxiety disorders in family practice. This review presents treatment recommendations, including dosage, products, guidelines for monitoring, and discontinuation. Advances in the neurobiology of anxiety are also included.

Tolerance to the therapeutic effect of phenelzine in patients with panic disorder.

Tolerance to the therapeutic effects of phenelzine developed in three patients with panic disorder. A central dysfunction of neurotransmitters or a change in receptor function may have been involved.

An archival study of depression before and after age 55.

In this archival study, 58 patients with unipolar depression who were 55 years of age or older were compared to 155 depressed control patients age 54 years or less. The older patients with unipolar depression had a significantly worse outcome, with only 51.7% experiencing a period of full remission during follow-up. Medical disorders were common, and older depressed patients showed a clear excess of cardiovascular disorders. Clinical symptoms did not separate the two groups, with the exception of psychomotor retardation and agitation. Electroconvulsive therapy was associated with less continuous hospitalization and an overall superior outcome.

Comparison of seasonal and nonseasonal affective disorders.

Eighteen patients with seasonal affective disorder were compared to 13 patients with recurrent nonseasonal depressions. Seasonal depressions were associated with hypersomnia and carbohydrate craving, and there was a trend for a younger age at onset of seasonal affective disorder.