The epidemiology and cross-national presentation of obsessive-compulsive disorder.

One of the challenges facing modern psychiatry is to determine to what extent the diagnostic categories clinicians have represent valid constructs. Epidemiologic studies are helpful in this regard when their findings are consistent across various cultural or geographic settings or with those of clinical studies. The cross-national epidemiologic data on OCD reviewed in this article are remarkable for their consistency in rates, age at onset, and comorbidity across diverse countries, a fact which lends additional support to the validity of the diagnosis of OCD. The variability in symptom presentation across national sites suggests that cultural factors may affect the symptom expression; however, why the rates of OCD and other psychiatric disorders are so much lower in Taiwan than in other sites, including another Asian site, is unclear. Epidemiologic studies of adolescents and of adults have shown similar prevalence of OCD and substantial comorbidity with major depression and other anxiety disorders. Studies of adolescent populations indicate that OCD symptoms are fairly common among adolescents but not necessarily predictive of developing the full disorder within 1 year of follow-up. Family studies have suggested an association between OCD and TS and other CMT disorders. Clinical studies have suggested an association between Sydenham's chorea and OCD. These various studies provide a growing body of knowledge regarding the nature of OCD. Together with evidence of the substantial demand on mental health services by those afflicted with OCD, the epidemiologic data make a compelling case for additional efforts to improve the understanding and treatment of this troubling disorder.

Familial aggregation of delusional depression: re-examination in a recent family study.

BACKGROUND: Delusional (D-MDD) and nondelusional depression (ND-MDD) differ in clinical presentation, biological abnormalities, course of illness, and treatment response. Family data, however, have been less consistent regarding differential risk both for any major depression (MDD) and specifically D-MDD in relatives of D-MDD probands. In an earlier family study, we observed a 1.5-fold increase in rates of any MDD, specificity of transmission of D-MDD, and increased rates of bipolar disorders in relatives of D-MDD compared to relatives of ND-MDD probands. In a new family study, we attempted to replicate these findings. METHOD: A family study of 361 directly interviewed adult first-degree relatives (FDRs) of 163 probands (118 with MDD and 45 screened normal controls) was used to examine familial aggregation of any MDD, D-MDD, and bipolarity by proband delusional status. RESULTS: Compared to FDRs of ND-MDD probands, FDRs of D-MDD probands were at modestly increased risk for any MDD. These results were unaffected by adjustment for proband ascertainment source, comorbidity, or whether probands had chronologically primary MDD. There was a trend toward increased rates of broadly defined bipolarity (bipolar I, bipolar II, or cyclothymia) in FDRs of D-MDD compared to FDRs of ND-MDD probands. CONCLUSION: Results from the present study were broadly consistent with those from our previous work. While other lines of evidence for D-MDD as a distinct subtype are more compelling than family data, it would be of methodologic interest to identify sources of inconsistency across studies in findings concerning the familial aggregation of delusional depression.

Familial aggregation and phenomenology of 'early'-onset (at or before age 20 years) panic disorder.

BACKGROUND: While early age at onset has been associated with increased familial risk, increased clinical severity, and distinctive patterns of comorbidity in a range of psychiatric disorders, it has received limited attention in panic disorder, both in family studies and with respect to clinical presentation. METHODS: A family study of 838 adult first-degree relatives of 152 probands in 3 diagnostic groups (panic disorder with or without major depression, subdivided by age at onset at or before 20 and after 20 years, and screened normal controls) was used to examine familial aggregation of panic disorder by proband age at panic disorder onset. Phenomenology of panic disorder in ill probands and their affected adult first-degree relatives was investigated as a function of proband panic disorder onset at or before 20 vs after 20 years of age. RESULTS: Compared with adult first-degree relatives of normal controls, the risks of panic disorder in adult first-degree relatives of probands with panic disorder onset at or before 20 and after 20 years of age were increased 17-fold and 6-fold, respectively. These findings were not explained by the numerous potential confounding factors that we tested. Age at panic disorder onset did not appear to be specifically transmitted within families. The clinical presentation of panic disorder differed little in either probands or affected relatives by proband age at onset. CONCLUSION: The strikingly elevated risk of panic disorder in relatives of probands with panic disorder onset at or before 20 years of age suggests that age at onset may be useful in differentiating familial subtypes of panic disorder and that genetic studies of panic disorder should consider age at onset.

Panic disorder with smothering symptoms: evidence for increased risk in first-degree relatives.

Klein's (1993: Arch Gen Psychiatry 50:306-317) "false suffocation alarm" theory of spontaneous panic attacks posits that central receptors compare CO2, O2, and lactate levels and trigger panic when an impending "false" state of suffocation is detected. Several investigators have found abnormalities of respiratory physiology in subjects with panic disorder. Twin and family studies have suggested that both panic disorder and tidal volume response to CO2 are inherited. We hypothesized that, if smothering symptoms are a marker for a hypersensitive suffocation detector and if this hypersensitivity is familial, then relatives of panic subjects with smothering symptoms would have higher rates of panic with smothering than relatives of panic subjects without smothering. We conducted a family study involving 104 panic disorder probands and 247 of their interviewed first-degree relatives. Probands and their relatives were interviewed using the Schedule for Affective Disorders and Schizophrenia--Lifetime Version for Anxiety Disorders to determine their panic disorder and smothering symptom status. Relatives of panic probands with smothering symptoms had an almost threefold higher risk for panic and an almost sixfold higher risk for panic with smothering symptoms when compared with relatives of panic probands without smothering. We conclude that panic disorder with smothering symptoms may be a subtype of panic disorder associated with increased familial risk and may be a group of interest to genetic investigators. These findings provide the first empiric evidence from a family study in support of Klein's false suffocation alarm theory of spontaneous panics.

Illicit-drug injection among psychiatric patients without a primary substance use disorder.

OBJECTIVE: To increase understanding of HIV infection risk among patients with severe mental illness, the study sought to identify predictors of injection drug use among patients who did not have a primary substance use disorder. METHODS: A total of 192 patients recruited from inpatient and outpatient public psychiatric facilities were interviewed by trained mental health professionals using the Structured Clinical Interview for DSM-III-R (SCID), the Positive and Negative Syndrome Scale, and the Parenteral Drug Use High-Risk Questionnaire. RESULTS: Sixty percent of the sample met SCID criteria for lifetime substance abuse or dependence. Although only two patients reported drug injection in the past six months, 38 (20 percent) had injected drugs since 1978, the year that HIV began to spread in the U.S. A lifetime diagnosis of opioid abuse or dependence was a strong predictor of drug injection, but only 11 of the 38 patients with a recent history of injection drug use had either of these diagnoses. The likelihood of injecting drugs was four times greater among patients with a history of intranasal substance use compared with those without such use, three and a half times greater among African-American patients than among non-African-Americans, and five times greater among patients aged 36 or older compared with younger patients. CONCLUSIONS: In assessing HIV risk among patients with severe mental illness, it may be more important to identify the route of drug administration than the specific substances used because of the strong association between intranasal drug use and history of injection.

Comparison of RDC, DSM-III, DSM-III-R diagnostic criteria for generalized anxiety disorder.

The diagnosis of generalized anxiety disorder (GAD) has been controversial since its inception. It remains unclear whether more stringent diagnostic criteria, such as in DSM-III-R, have improved the validity of GAD. Family studies suggest that GAD aggregates at least weakly in families of probands with GAD, and support the separation of panic disorder (PD) and GAD. Therefore, we can use a family study design to examine the validity of GAD. Independent familial transmission of GAD supports the validity of GAD. We report here the risk of GAD according to RDC, DSM-III, and DSM-III-R criteria in the first-degree relatives of probands from four diagnostic groups: panic disorder, panic disorder with major depression, early-onset major depression (MDD), and normal controls. We did not find an elevated risk of DSM-III or DSM-III-R GAD in the relatives of any of the ill proband groups compared to the relatives of the never mentally ill when controlling for proband comorbidity for GAD. In contrast, RDC GAD aggregates in the first-degree relatives of probands from both of the PD proband groups (with and without MDD) compared to relatives of the normal control group. The inclusion of cases of subsyndromal panic attacks that did not meet the strict RDC for panic disorder as meeting the less restrictive RDC for GAD may partially account for the familial aggregation of RDC panic disorder and RDC GAD. RDC GAD seems to identify one or more syndrome(s) that may be on the familial spectrum of panic disorder. This syndrome may represent a mild or early variant of panic disorder. We also found a trend for RDC and DSM-III GAD to aggregate in the first-degree relatives of the MDD proband group compared to the relatives of the never mentally ill controls. These data suggest that GAD demonstrates more independent familial transmission from PD and MDD when defined by DSM-III-R criteria than when defined by RDC or DSM-III, and thus support the validity of DSM-III-R GAD.

Is the comorbidity between social phobia and panic disorder due to familial cotransmission or other factors?

BACKGROUND: We previously reported significantly elevated rates of social phobia in relatives of probands with panic disorder compared with relatives of other proband groups. This study further investigates the relationship between social phobia and panic disorder. METHOD: This sample is from a family study that included 193 probands from four mutually exclusive groups (patients with panic disorder, patients with panic disorder and major depression, patients with early-onset major depression, and normal controls) and 1047 of their adult first-degree relatives. Best-estimate diagnoses were completed using DSM-III-R criteria. RESULTS: Social phobia and agoraphobia aggregate in the families of probands with panic disorder without major depression. Social phobia frequently co-occurs with panic disorder in relatives, but the risk for comorbidity does not vary across proband groups. CONCLUSIONS: The familial aggregation of social phobia with panic disorder may be explained by the aggregation of panic disorder in relatives of probands with panic disorder combined with the tendency for panic disorder to occur comorbidly with social phobia in individuals.

Psychiatric disorders in relatives of probands with panic disorder and/or major depression.

BACKGROUND: Panic disorder and major depression (MDD) are both highly familial disorders that co-occur in individuals but do not cosegregate in families. Evidence concerning their familial aggregation with other psychiatric disorders, including phobias, substance abuse, and antisocial personality, has been contradictory. In part, the contradictory findings may be due to failure to account for the effects of proband comorbidity on risks in relatives. METHODS: A family study of 1047 adult first-degree relatives of 193 probands in four diagnostic groups (panic disorder without MDD, panic disorder plus MDD, early-onset MDD, and screened normal controls) was used to determine the range of psychiatric disorders associated with panic disorder and MDD and the effects of proband comorbidity on the rates of disorders in relatives. RESULTS: Compared to relatives of normal controls, relatives of probands with panic disorder or panic disorder and MDD showed significantly increased risks of panic disorder, but relatives of probands with early-onset MDD did not. After proband comorbidity was controlled for, relatives of probands with panic disorder were also at a significantly increased risk for social phobia but not for any other psychiatric disorders. Relatives of probands with early-onset MDD were at significantly increased risk for MDD, dysthymia, abuse of or dependence on alcohol and other drugs, and antisocial personality disorders but not for any other psychiatric disorders. CONCLUSIONS: We conclude that panic disorder is a specific familial entity that is not associated with a broad range of other anxiety or other psychiatric disorders, with the possible exception of social phobia. Dysthymia, substance abuse, and antisocial personality appear to be on the spectrum of early-onset MDD.

Sexual activity and risk of HIV infection among patients with schizophrenia.

OBJECTIVE: This study sought to determine the frequency and types of sexual behavior among patients with schizophrenia and to assess the behavior with respect to risk of HIV infection. METHOD: Ninety-five inpatients and outpatients with a research diagnosis of schizophrenia underwent a series of face-to-face interviews to determine their sexual activity and correlate it with demographic characteristics, psychopathology, and medication side effects. RESULTS: Forty-four percent of the patients had been sexually active in the preceding 6 months, and 62% of these had had multiple partners. Sexual activity was associated with greater general psychopathology. Having multiple sexual partners was associated with younger age, a lower level of functioning, the presence of delusions, and more positive symptoms. Of the sexually active patients, 12% reported at least one partner who was HIV positive or injected drugs, or both, and 50% had exchanged sex for money or goods. Ten percent of the patients had engaged in homosexual activity in the preceding 6 months and 22% during their lifetime; the frequency was similar among men and women. Consistent condom use was uncommon. CONCLUSIONS: A substantial proportion of schizophrenic patients had recent histories of sexual abstinence, but an almost equal number were sexually active. Sexual activity was usually accompanied by behavior related to HIV risk. Sexual activity and having multiple partners were associated with certain measures of more severe illness. Younger patients were more likely to have multiple partners but were also more likely to use condoms. There is a need for aggressive prevention strategies with this population.

The familial aggregation of panic disorder by source of proband ascertainment.

Estimates of familial aggregation of psychiatric disorder obtained from relatives of probands ascertained in treatment settings may differ from estimates obtained from relatives of probands ascertained from the general population. In this paper we investigate this hypothesis for panic disorder, by comparing the degree of familial aggregation of panic disorder in relatives of probands with panic disorder ascertained from either a specialty anxiety clinic, a specialty depression clinic or a population survey, respectively. Results for panic disorder do not suggest that familial rates are associated with source of proband ascertainment. Results show that the rates of panic disorder in relatives were similar by proband source. This suggests that familial rates of panic disorder are not associated with proband ascertainment and that selecting probands from treatment clinics rather than from the general population does not necessarily lead to greater estimates of familial aggregation of panic disorder. Further research is needed to determine if this finding can be generalized to other psychiatric disorders.

HIV-1 infection at two public psychiatric hospitals in New York City.

Seroprevalence for HIV-1 was anonymously evaluated between November 1989 and July 1991 among severely mentally ill patients at two public psychiatric hospitals in New York City. The study population consisted of new admissions and long-stay patients aged 18-59. Of 1116 eligible patients, usable samples were obtained from routine blood drawings on 971 (87%). Seroprevalence was comparable among men (5.2%) and women (5.3%). Age did not predict seropositivity. Men with a recorded history of homosexual behaviour or injection drug use were, respectively, 1.8 and 2.0 times more likely to be seropositive than men without these histories. Women with a recorded history of injection drug use were 4.0 times more likely to be seropositive than women without such a history. Ethnicity was not predictive for men, but Black women were 2.4 times more likely to be HIV-1 positive than non-Black women. Severely mentally ill inpatients had a substantial rate of HIV-1 seropositivity, indicating a need for additional testing, education and counselling efforts for this population.

What are the public health implications of subclinical depressive symptoms?

Longitudinal data from a community study of 9900 adults in the United States show that persons with depressive symptoms, as compared to those without such symptoms, were 4.4 times more likely to develop a first onset major depression over one year. The attributable risk, a measure which reflects both the relative risk associated with depressive symptoms (4.4) and the prevalence of exposure to that risk (24%) and is a useful measure for documenting burden of a risk to the community, indicated that more than 50% of first onset major depressions are associated with prior depressive symptoms. Since depressive symptoms have a high prevalence in the community, but are often unrecognized and untreated in clinical practice, we conclude that their identification and the development of effective treatments could have public health implications for the prevention of associated social morbidity, service utilization and major depression.

Agoraphobia without panic: clinical reappraisal of an epidemiologic finding.

OBJECTIVE: In the United States, the consensus among clinicians and researchers, reflected in DSM-III-R, is that agoraphobia is a conditioned response to panic attacks and almost never occurs without panic attacks. The predominant view in the United Kingdom is that agoraphobia frequently occurs in the absence of panic. While clinicians report that they rarely see patients with agoraphobia who have no history of panic disorder, community studies report that agoraphobia without panic disorder is common. For example, the Epidemiologic Catchment Area (ECA) study found that 68% of 961 persons with agoraphobia had no history of panic attacks or disorder. METHOD: To understand this discrepancy, 22 subjects who had been diagnosed as having agoraphobia without panic disorder or panic attacks in the ECA study were blindly reinterviewed 7-8 years later with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders; data from these interviews were blindly reviewed by a research psychiatrist who was not involved in the original data collection or the reinterview process. RESULTS: On reappraisal, 19 of the 22 subjects had simple phobias or fears but not agoraphobia. One subject had probable agoraphobia without panic attacks, one had definite panic disorder with agoraphobia, and one had probable agoraphobia with limited symptom attacks. CONCLUSIONS: Epidemiologic studies that used the Diagnostic Interview Schedule and lay interviewers, such as the ECA study, may have over-estimated the prevalence of agoraphobia without panic. Agoraphobia without panic attacks occurs but is uncommon, and the diagnostic boundary between agoraphobia and simple phobia is unclear.

The relationship between panic disorder and major depression. A new family study.

OBJECTIVE: The comorbidity between panic disorder and major depression (MDD) in individuals has been amply documented. However, data from family studies to determine whether panic disorder and MDD aggregate separately or together in families have been inconclusive, in part because of the absence of studies with the full range of proband groups. This report presents results from a family study with the necessary mutually exclusive groups: panic disorder without MDD, panic disorder with MDD, MDD without panic disorder, and normal controls. METHODS: Diagnostic information was obtained from 193 probands and 1047 of their adult relatives with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version for Anxiety Disorders by direct interview, and/or from multiple informants, without knowledge of proband diagnoses. Best-estimate diagnoses were based on all available information by clinicians independently of data collection and without knowledge of probands' and other relatives' status. RESULTS: Findings indicated the specific and independent transmission of panic disorder and MDD, the separation of panic disorder from MDD, and the nonfamilial nature of late-onset MDD. The pattern of results was unaffected by the use of different diagnostic criteria, number of informants, interview status of relatives, presence of substance abuse or agoraphobia or the sequence of MDD and panic disorder in probands, or whether probands were selected from treatment clinics or community sample. CONCLUSIONS: We conclude that panic disorder and MDD are separate disorders with substantial co-occurrence in individuals, and that panic comorbid with MDD is not a single, distinct disorder. Finally, we illustrate an approach to examining comorbidity in family data through analysis of mutually exclusive, parallel diagnoses in probands and relatives.

Asceticism: creative spiritual practice or pathological pursuit?

Asceticism in a religious context refers to a voluntary and sustained practice of self-denial in which immediate or sensual gratifications are renounced in order to attain a higher spiritual state (Kaelber 1987). Virtually all of the major world religions have within them a way in which the individual, through ascetic practices, can strive to achieve a more thorough absorption in the sacred. Although many psychiatrists might consider any ascetic or religious practice to be pathological, others take a more neutral view by emphasizing that religious or mystical practice can also be adaptive and creative (Group for the Advancement of Psychiatry 1976).

Epidemiology of panic disorder in African-Americans.

OBJECTIVE: The authors investigated the prevalence and clinical characteristics of panic disorder among African-Americans and whites in a community study. METHOD: A total of 4,287 African-American and 12,142 white subjects were interviewed at five sites as part of the Epidemiologic Catchment Area study. Panic disorder and other diagnoses were made using the National Institute of Mental Health Diagnostic Interview Schedule and DSM-III criteria. RESULTS: The lifetime prevalence of panic disorder was 1.2% among African-Americans and 1.4% among whites, a nonsignificant difference. Comparisons between African-Americans and whites on age at onset, years with panic disorder, and suicide attempts revealed no significant differences. Rates of individual panic symptoms in African-American and white subjects with panic disorder were similar, although African-Americans reported a higher mean number of symptoms during their worst episode. Among subjects with comorbid panic disorder, African-Americans and whites had similar rates of major depression, alcohol abuse, drug abuse, obsessive-compulsive disorder, agoraphobia, somatization disorder, and schizophrenia. Patterns of treatment seeking among African-American and white panic subjects were similar, with the exception that African-Americans were significantly less likely to seek help from a mental health professional in private practice. CONCLUSIONS: On the basis of these findings, the authors conclude that panic disorder in the community is similar among African-Americans and whites with respect to lifetime prevalence, age at onset, years of disorder, symptom distribution, suicide attempts, and comorbidity with other psychiatric disorders. Differences in the diagnosis and treatment of panic disorder by race are not due to differences in the prevalence or nature of the disorder.

HIV seroprevalence among homeless patients admitted to a psychiatric inpatient unit.

OBJECTIVE: This study was conducted to determine the seroprevalence of HIV-1 antibodies among hospitalized homeless mentally ill patients. METHOD: From December 1989 through May 1991 the authors collected discard blood samples from patients consecutively admitted to a psychiatric unit designated for the care of severely mentally ill persons removed from the streets of New York City. The blood samples were tested for HIV-1 antibodies, and the results were analyzed for associations with age, gender, ethnicity, male homosexual activity, and use of injected drugs. RESULTS: The HIV seroprevalence was 6.4% (13 of 203 samples). Patients between ages 18 and 39 accounted for 51.2% of the admissions and 84.6% of the 13 positive results, a seroprevalence of 10.6% for this subsample. Patients under age 40 were more than six times as likely to test positive for HIV antibodies as those 40 or over. Ethnicity did not predict seropositivity. Women were as likely as men to be infected. Although clinicians had noted high-risk behavior on the charts for only three (23.1%) of the 13 positive cases, a recorded history of use of injected drugs was associated with a 6.5-fold greater risk of HIV seropositivity. CONCLUSIONS: One in every 16 patients admitted to the special unit was HIV positive. Age under 40 and use of injected drugs were strongly associated with seropositivity. Because information on high-risk behavior was infrequent, the reasons for younger patients' greater risk are unclear. The homeless mentally ill require outreach efforts to reduce the risk of acquiring or transmitting HIV.

Depressive symptoms as relative and attributable risk factors for first-onset major depression.

Using longitudinal data from a community study of 9900 adults drawn from four sites in the United States and interviewed twice, 1 year apart, we investigated the predictors of first-onset major depression. Using odds ratios to estimate relative risk, we found that persons with depressive symptoms, compared with those without such symptoms, were 4.4 times more likely and persons with dysthymia were 5.5 times more likely to develop a first-onset major depression during a 1-year period. The lifetime prevalence rate for depressive symptoms was 24%. The attributable risk is a compound epidemiologic measure that reflects both the relative risk associated with depressive symptoms (4.4) and the prevalence of exposure to that risk (24%). It is a useful measure to document the burden of a risk to the community, and it was determined to be greater than 50%. Thus, more than 50% of cases of first-onset major depression are associated with prior depressive symptoms. The high prevalence of depressive symptoms in the community and their strong association with first-onset major depression make them important from a public health perspective. Because depressive symptoms are often unrecognized and untreated in clinical practice, we conclude that their identification and the development of effective treatments could have implications for the prevention of major depression.

The validity of major depression with atypical features based on a community study.

This article reports on evidence for the validity of major depression (MDD) with atypical features (defined as overeating and oversleeping) as a distinct subtype based on cross-sectional and 1-year prospective data from the Epidemiologic Catchment Area study. MDD with atypical features, when compared to MDD without atypical features, was associated with a younger age of onset, more psychomotor slowing, and more comorbid panic disorder, drug abuse or dependence, and somatization disorder. These differences could not be explained by differences in demographic characteristics or by symptom severity. This study, based on a community sample, found that major depression with atypical features may constitute a distinct subtype.