Co-occurrence of Axis I and Axis II disorders in female and male patients with panic disorder with agoraphobia.

OBJECTIVE: The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA. METHODS: The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders. RESULTS: Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women. CONCLUSIONS: The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.

Addictive potential of novel treatments for refractory depression and anxiety.

Treatment-resistant mood disorders and anxiety disorders require intensive treatment, but treatment options should balance benefits and adverse effects or other potential detrimental effects on patients, including the risk of developing prescription medication addiction. Some of the newer treatment modalities for mood and anxiety disorders may have similar properties to benzodiazepines. The goal of this review was to identify the potential for developing dependence on the novel treatment approaches to treatment-resistant depression and refractory anxiety disorders. PubMed, MEDLINE, PsycINFO, Ovid, Cochrane Library, and Google Scholar were searched. Ketamine is effective in improving symptoms of major depressive disorder, but with no sustained benefits. Long-term use of oral or intranasal ketamine formulations may be associated with the risk of developing dependence. Augmentation of stimulant medication is usually effective for residual symptoms of depression, but the effects are usually short lasting and there is a potential for abuse. Synthetic cannabinoids and medicinal cannabis are increasingly being prescribed for a number of medical conditions, including anxiety disorders, without enough evidence about their efficacy and with the risk of patients developing dependence. In summary, benzodiazepines, ketamine, stimulant medications, and cannabinoids have some common characteristics, including short-lasting benefits and the risk of developing prescription medication addiction with longer use. All of these treatments may raise ethical dilemmas about the appropriateness of prescribing these medications in the long run for patients with depression and anxiety disorders.

Mixed symptoms in major depressive and bipolar disorders: A systematic review.

BACKGROUND: The DSM-5 mixed features specifier for mood disorders encourages renewed interest in mixed states and led us to pool research findings regarding prevalence of mixed features in episodes of major depressive (MDD) and bipolar disorders (BD). METHODS: We systematically searched to July 2017 for reports on mixed symptoms in depressive episodes of MDD and in depression and mania or hypomania in types I and II BD. For primary mood-states and diagnostic groups we compared rates of the presence of mixed symptoms: as defined by DSM-5 (≥3 features opposite to the dominant mood-polarity but not overlapping those of the primary disorder) or as having any ≥3 features of opposite polarity. RESULTS: We identified 17 reports, from 13 world regions involving 19,198 participants meeting standard diagnostic criteria for an index major depressive or [hypo]manic episode. Prevalence of cases with ≥3 features of opposite polarity averaged 27.8% [CI: 27.2-28.5] overall, and differed significantly between BD and MDD disorders, ranking: BD-depressed (35.2% [33.8-36.5]) = BD-[hypo]manic (35.1% [32.9-37.3]) > MDD-depressed (23.8% [23.0-24.5]). LIMITATIONS: Available findings were limited to mood disorders with mixed features by particular criteria, with few comparisons to other criteria or to their prognostic or therapeutic implications. CONCLUSIONS: Prevalence of ≥3 features of opposite polarity ranked: depressive = [hypo]manic episodes of BD > depression in MDD.

Current status of electroconvulsive therapy for mood disorders: a clinical review.

Electroconvulsive therapy (ECT) is an effective treatment for mood disorders and a viable treatment option especially when urgency of clinical situation requires a prompt treatment response. After acute series of ECT, the ECT long-term treatment may be considered, although this practice may vary significantly between countries or even within the same country, because there is no universal consensus about its indications, duration and frequency of administration. Continuation or maintenance ECT is common in routine clinical practice and clinicians should be aware of the risks of using ECT long term. Neuropsychological assessment should be an essential part of a good clinical practice in ECT services. Cognitive side effects of ECT are sometimes underestimated and may last much longer after completed treatment than it is usually expected. These cognitive impairments associated with ECT may cause significant functional difficulties and prevent patients to return to work. Cognitive assessment during ECT treatment is usually not comprehensive enough and is limited to bedside assessment. A more proactive approach to careful neuropsychological assessment and consideration of combined maintenance medication treatment after ECT are essential.

CRITICAL REVIEW OF AVAILABLE TREATMENT OPTIONS FOR TREATMENT REFRACTORY DEPRESSION AND ANXIETY - CLINICAL AND ETHICAL DILEMMAS.

Treatment-resistant mood and anxiety disorders require an intensive therapeutic approach, and it should balance benefits and adverse effects or other potential detrimental effects of medications. The goal of treatment is to provide consistent and lasting improvement in symptoms of depression and anxiety. Beozodiazepines are effective for anxiety symptoms, but with no sustained treatment effects. Other medication treatment options for anxiety disorders are outlined. Ketamine is usually very effective in treating maior depressive disorder but without sustained benefits. Loog-term use may pose a signiticant risk of developing tolerance and dependence. Stimulant medication augmentation for treatment-resistant depression is effective for residual symptoms of depression, but effects are usually short-lasting and it sounds mor as an artificial way of improving energy, alertness and cognitive functioning. Synthetic cannabinoids and medical marijuana are increasingly prescribed for various medical conditions. but more recently also for patients with mood and anxiety disorders. All of these treatments may raise ethical dilemmas about appropriateness of prescribing these medications and a number of questions regarding the optimal treatment for patients with treatment-resistant depression and treatment refractory anxiety disorders.

Treatment of panic disorder with agoraphobia in an anxiety disorders clinic: factors influencing psychiatrists' treatment choices.

The main objective of this report was to identify patient characteristics that led psychiatrists in an academic anxiety disorders clinic to make a decision about intensive treatment of patients with panic disorder with agoraphobia (PDA) with cognitive-behavioral therapy (CBT) alone, CBT plus a high-potency benzodiazepine (CBT+BZ) or CBT combined with BZ and an antidepressant, fluoxetine (CBT+BZ+AD). On the basis of their clinical judgment and collaborative negotiation with the patient, psychiatrists chose one of the three treatment modalities for 102 PDA outpatients. Two stepwise logistic regressions were performed to explore pre-treatment patient characteristics the psychiatrists may have considered in choosing among these treatments. One regression examined the decision to add BZ to CBT, while the other examined the decision to add AD to CBT+BZ. Psychiatrists generally used combination treatments in patients with more severe PDA. CBT alone was a more likely choice for dominant anxiety-related cognitive phenomena. Patients with prominent panic attacks and somatic symptoms were more likely to be treated with CBT+BZ, while those who also had significant depressive symptoms and higher disability levels were more likely to receive CBT+BZ+AD. Patients in all three treatment groups showed significant reduction in symptoms during intensive treatment and reached similar end states. In a clinic setting where CBT is accepted as the basic treatment for PDA, psychiatrists added BZ to control prominent panic symptoms and added AD to elevate depressed mood and help cope with marked disability. These choices appear rational and resulted in substantial clinical improvement at the end of intensive treatment in the clinic.

[Chlorpromazine-induced status epilepticus: a case report].

INTRODUCTION: It is largely known that some antipsychotic agents could have proconvulsive and proepileptogenic effects in some patients and could induce EEG abnormalities as well. However, the association of status epilepticus with certain antipsychotic drugs has been very rarely reported. CASE REPORT: A case of an 18-year-old adolescent girl, with chlorpromazine therapy started for anxiety-phobic disorder was reported. Her personal history disclosed delayed psychomotor development. Shortly after the introduction of the neuroleptic chlorpromazine therapy in minimal daily dose (37.5 mg), she developed myoclonic status epilepticus, confirmed by the EEG records. Frequent, symmetrical bilateral myoclonic jerks and altered behavior were associated with bilateral epileptiform discharges of polyspikes and spike-wave complexes. This epileptic event lasted 3.5 hours and it was stopped by the parenteral administration ofvalproate and lorazepam; she was EEG monitored until stable remission. Status epilepticus as initial epileptic event induced by neuroleptic agent was not previously reported in our national literature. CONCLUSION: Introduction of chlorpromazine to a patient without history of seizures is associated with the evolution of an epileptic activity, including the occurrence of status epilepticus. Clinical evaluation of the risk factors possibly related to chlorpromazine-induced seizure is recommended in individual patients before administering this drug.

Treatment of adults with attention-deficit/hyperactivity disorder.

This review focuses on the treatment of attention deficit hyperactivity disorder (ADHD) in adults. It briefly addresses prevalence, diagnostic and differential diagnostic issues specific to adults. Stimulant medication, non-stimulant medication, and psychosocial treatments are thoroughly reviewed. For each class of medication possible mechanism of action, efficacy and side effects are summarized. Special attention is given to the pharmacological treatment for patients with adult ADHD and various comorbidities. In summary, stimulant medications are most effective and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.

Treatment of adults with attention-deficit/hyperactivity disorder.

This review focuses on the treatment of attention deficit hyperactivity disorder (ADHD) in adults. It briefly addresses prevalence, diagnostic and differential diagnostic issues specific to adults. Stimulant medication, non-stimulant medication, and psychosocial treatments are thoroughly reviewed. For each class of medication possible mechanism of action, efficacy and side effects are summarized. Special attention is given to the pharmacological treatment for patients with adult ADHD and various comorbidities. In summary, stimulant medications are most effective and combined medication and psychosocial treatment is the most beneficial treatment option for most adult patients with ADHD.

Current issues and trends in the diagnosis and treatment of adults with ADHD.

Attention-deficit/hyperactivity disorder (ADHD) has been commonly thought of as a childhood disorder that diminished over time. It is one of the most common developmental disorders and it is estimated that ADHD affects 5-10% of children. Two-thirds of children with ADHD will continue to have symptoms of ADHD that persist throughout adolescence. Longitudinal studies have demonstrated that symptoms of ADHD can also remain in adulthood, affecting 4.4% of the adult population. However, diagnosing adults with ADHD can prove difficult because they often find that their symptoms are egosyntonic. In addition, the development of comorbid conditions, such as anxiety, depression, personality disorders or substance abuse, can often overshadow underlying ADHD symptoms. Nonetheless, treatments such as stimulant and nonstimulant medication (e.g., atomoxetine), and cognitive-behavior therapy have been effective in treating adults with ADHD. This article reviews the prevalence of adults with ADHD, followed by a discussion of the neurobiological and genetic underpinnings of the disorder. Issues regarding the diagnosis and treatment of ADHD are also addressed.

Are there gender differences in catastrophic appraisals in panic disorder with agoraphobia?

Our aim in this study was to compare panic-related catastrophic appraisals between women and men with panic disorder with agoraphobia (PDA). One hundred two outpatients with PDA (75 women and 27 men) participated. Two instruments for the assessment of catastrophic appraisals, Agoraphobic Cognitions Questionnaire and Panic Appraisal Inventory, were administered before and after cognitive-behavioral therapy (CBT) that also included pharmacotherapy in three-fourths of the patients. Female and male patients did not differ significantly in terms of their tendency to anticipate catastrophic consequences of panic, before or after CBT-based treatment. For both females and males, the tendency to make catastrophic appraisals decreased significantly with treatment. We conclude that among patients with PDA there are no gender differences in catastrophic appraisals of panic sensations and symptoms. The apparently higher risk of panic recurrence in women does not seem to be related to their panic-related catastrophic appraisals. These findings also support a notion that there is no gender difference in response to CBT-based treatment of PDA.

[Social phobia in developmental period: from theory to therapy].

The contemporary integrative theoretical and therapeutic concepts of social phobia in developmental period have been presented in the study. Besides current neurobiological theories, a very important hypothesis about behavioral inhibition has been represented as a predisposition of social phobia. The cognitive-behavioral theories of social phobia are dominant among psychological theories. The integrative concept of social phobia is the most realistic approach to this disorder and the bridge between biological and psychological theories. The interaction between biological and psychological etiological factors is represented through different therapeutical approaches to social phobia. Therapy of social phobia is integrative and involves different therapeutical modalities in different phases of therapy. In integrative psychotherapy, we use cognitive-behavioral therapy, dynamic oriented supportive psychotherapy, psychodynamic psychotherapy and phenomenological-existential psychotherapy. The cognitive-behavioral therapy yields the best results. The medicaments in use are the following: selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, high-potency benzodiazepines, new antiepileptic drugs and rarely beta-blockers. The combination of integrative psychotherapy and pharmacotherapy is the most optimal therapeutic approach to social phobia. This integrative and to patient adapted treatment will produce the best results in management of children's and adolescent's social phobia.

[Psychological aspects of genital surgery in childhood]. / Psiholoski aspekti decje genitalne hirurgije.

Although the children's urogenital surgery is discipline in expansion which successfully solves even the most complicated anomalies of urogeniral tract, only lately there is enough attention paid on the psychological aspects of these anomalies and surgical operation on genitals. The boys with hypospadias, phimosis and other congenital anomalies represent a risky group for the difficulties in forming the sexual identity and for the appearance of different psychopathology in their childhood and later in life. The surgical operation itself presents a traumatic situation for the child and it may discredit the later psychosexual development of these boys in a great deal. The priority is increasing the sensitivity of children's surgeons for these problems, not only for modernizing the surgical operation, considering the knowledge of normal psychological stages of development, but also for recognizing the psychological phenomena on time and for the consultative joining of the appropriate experts. It is very important to work with these children's parents in view of offering them help for better accepting their child's organic problem, to be less anxious on account of the anomaly and the operation itself and to be more able for better understanding of their child's feelings and his experience. The child's actual psychological condition and his later psychosexual development depend to a great extent on their parent's correct attitude. The caustical survey of the boys with hypospadias illustrates some of the psychological problems which appear with children who had an reparation of hypospadias.

[Specific aspects of psychoses in mentally retarded children and adolescents]. / Specificnosti psihoza mentalno retardirane dece i adolescenata.

Mental retardation is a heterogenous neurodevelopmental disorder characterized by arrested or incomplete psychological development. The first part of the study deals with psychological and biological factors: etiology and pathogenesis of mental retardation and comorbid psychiatric disorders. Their etiopathogenesis is similar as in other neurodevelopmental disorders and it was analyzed in the part dealing with biological specificities of persons with mental retardation. Numerous biopsycho-social factors cause increased vulnerability of the mentally retarded to development of mental disorders. Thus, prevalence of these disorders is higher in mentally retarded persons than in general population. This study also deals with specificities regarding diagnosis of psychotic disorders in mentally retarded persons as well as neurobiologic, epidemiologic, clinical and therapeutic characteristics of schizophrenic psychoses, autism and affective disorders in persons with mental retardation. Special emphasis was given to diagnostics of these disorders in mentally retarded children and adolescents, as well as to problems of differential diagnostics. Apart from other things, we have concluded that specific clinical pictures demand subspeciality approach in the frame of developmental psychiatry.

Panic disorder patients at the time of air strikes.

We assessed the impact of real danger on several aspects of the panic disorder (PD) patients' psychopathology and level of disability. At the time of the NATO air strikes on Belgrade, 84 PD patients who were in partial or complete remission were administered the Panic and Agoraphobia Scale (PAS). All had been treated previously, and the majority (58.3%) were taking antipanic medications. The PAS, which was used as part of the regular follow-up assessment battery for PD patients, measures the overall severity of PD and the severity of key aspects and components of PD. Compared to the PAS assessments made before the onset of air strikes, the PAS assessments made at the time of air strikes showed significant differences in terms of decreased overall severity of PD, fewer health concerns, decrease in the level of disability, and greater intensity and frequency of anticipatory anxiety. Differences on the measures of panic attacks and agoraphobic avoidance were negligible. These results suggest that there is no relationship between panic attacks and real danger and lend support to the notion that panic attacks and fear induced by real danger are different phenomena. Contrary to the expectations of many PD patients, the presence of real danger does not seem to be associated with deterioration in their functioning, and PD patients can be reassured that they are not likely to cope worse under conditions of danger.