Protocol for a multi-site randomized controlled trial of a stepped-care intervention for emergency department patients with panic-related anxiety.

BACKGROUND: Approximately 40% of Emergency Department (ED) patients with chest pain meet diagnostic criteria for panic-related anxiety, but only 1-2% are correctly diagnosed and appropriately managed in the ED. A stepped-care model, which focuses on providing evidence-based interventions in a resource-efficient manner, is the state-of-the art for treating panic disorder patients in medical settings such as primary care. Stepped-care has yet to be tested in the ED setting, which is the first point of contact with the healthcare system for most patients with panic symptoms. METHODS: This multi-site randomized controlled trial (RCT) aims to evaluate the clinical, patient-centred, and economic effectiveness of a stepped-care intervention in a sample of 212 patients with panic-related anxiety presenting to the ED of Singapore's largest public healthcare group. Participants will be randomly assigned to either: 1) an enhanced care arm consisting of a stepped-care intervention for panic-related anxiety; or 2) a control arm consisting of screening for panic attacks and panic disorder. Screening will be followed by baseline assessments and blocked randomization in a 1:1 ratio. Masked follow-up assessments will be conducted at 1, 3, 6, and 12 months. Clinical outcomes will be panic symptom severity and rates of panic disorder. Patient-centred outcomes will be health-related quality of life, daily functioning, psychiatric comorbidity, and health services utilization. Economic effectiveness outcomes will be the incremental cost-effectiveness ratio of the stepped-care intervention relative to screening alone. DISCUSSION: This trial will examine the impact of early intervention for patients with panic-related anxiety in the ED setting. The results will be used to propose a clinically-meaningful and cost-effective model of care for ED patients with panic-related anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT03632356. Retrospectively registered 15 August 2018.

Identifying children with anxiety disorders using brief versions of the Spence Children's Anxiety Scale for children, parents, and teachers.

Anxiety disorders are among the most prevalent mental health disorders experienced by children and are associated with significant negative outcomes. Only a minority of affected children, however, access professional help, and a failure to identify children with anxiety disorders presents a key barrier to treatment access. Existing child anxiety questionnaire measures are long and time consuming to complete, limiting their potential for widespread use as identification tools in community settings. We developed a brief questionnaire for parents, children, and teachers using items from the Spence Children's Anxiety Scale (SCAS) and evaluated the new measure's psychometric properties, capacity to discriminate between a community (n = 361) and clinic-referred sample (n = 338) of children aged 7-11, and identified optimal cut-off scores for accurate identification of preadolescent children experiencing clinically significant levels of anxiety. The findings provided support for the reliability and validity of 8-item versions of the SCAS, with the brief questionnaire scores displaying comparable internal consistency, agreement among reporters, and convergent/divergent validity to the full-length SCAS scores. The brief SCAS scores also discriminated between the community and clinic-referred samples and identified children in the clinic-referred sample with a moderate-to-good level of accuracy and acceptable sensitivity and specificity. Combining reporters improved sensitivity, but at the expense of specificity, and findings suggested parent report should be prioritized. This new brief questionnaire has potential for use in community settings as a tool to improve identification of children who are experiencing clinically significant levels of anxiety and warrant further assessment and potential support. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

"Psychiatric assessment of deaf and mute patients - A case series".

Deafness is negatively associated with higher distress, depression, somatization, and loneliness in patients of all age groups. The psychiatric presentation of patient also varies. Due to lack of proper communication, clinical approach often becomes quite difficult. We will be discussing various psychiatric presentations in 3 different deaf mute patients. We will also be highlighting the different clinical approach applied to all the patients. This case series might help in giving an insight into the psychiatric symptoms of deaf mute patients which might pave way for new diagnostic guidelines for future research and in clinical practice.

The health preoccupation diagnostic interview: inter-rater reliability of a structured interview for diagnostic assessment of DSM-5 somatic symptom disorder and illness anxiety disorder.

Somatic symptom disorder (SSD) and illness anxiety disorder (IAD) are two new diagnoses introduced in the DSM-5. There is a need for reliable instruments to facilitate the assessment of these disorders. We therefore developed a structured diagnostic interview, the Health Preoccupation Diagnostic Interview (HPDI), which we hypothesized would reliably differentiate between SSD, IAD, and no diagnosis. Persons with clinically significant health anxiety (n = 52) and healthy controls (n = 52) were interviewed using the HPDI. Diagnoses were then compared with those made by an independent assessor, who listened to audio recordings of the interviews. Ratings generally indicated moderate to almost perfect inter-rater agreement, as illustrated by an overall Cohen's κ of .85. Disagreements primarily concerned (a) the severity of somatic symptoms, (b) the differential diagnosis of panic disorder, and (c) SSD specifiers. We conclude that the HPDI can be used to reliably diagnose DSM-5 SSD and IAD.

Prognostic subgroups for remission and response in the Coordinated Anxiety Learning and Management (CALM) trial.

OBJECTIVE: Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data are available to inform clinicians of likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders. METHOD: We conducted an exploratory moderator analysis from the Coordinated Anxiety Learning and Management (CALM) trial. In the CALM trial, 1,004 adults who met DSM-IV criteria for generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, and/or posttraumatic stress disorder (PTSD) were randomized to usual care (UC) or a collaborative care intervention (ITV) of cognitive-behavioral therapy and/or pharmacotherapy between June 2006 and April 2008. Logistic regression was used to examine baseline characteristics associated with remission and response overall and by treatment condition. Receiver operating curve (ROC) analyses identified subgroups associated with similar likelihood of response and remission of global anxiety symptoms. Remission was defined as score < 6 on the 12-item Brief Symptom Inventory (BSI-12) anxiety and somatization subscales. Response was defined as at least 50% reduction on BSI-12, or meeting remission criteria. RESULTS: Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (P < .001), low socioeconomic status (perceived [P < .001] and actual [P < .05]), and limited social support (P < .001). Patient characteristics associated with particular benefit from ITV were being female (P < .05), increased depression (P < .01)/GAD severity (P < .05), and low socioeconomic status (P < .05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood. CONCLUSIONS: Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00347269.

Assessment and screening of panic disorder in cancer patients: performance of the PHQ-PD.

OBJECTIVE: This study's objective was to promote the transcultural adaptation of the Patient Health Questionnaire-Panic Disorder Module (PHQ-PD) for Brazilian Portuguese and to evaluate the discriminative validity of this scale in detecting PD among cancer patients. METHODS: Adult cancer outpatients (n=400) from a specialized cancer hospital (61.50% female; 68.40% married; 56% incomplete elementary education or elementary school as the highest educational level) were assessed with the Structured Clinical Interview for DSM-IV and PHQ-PD. Using receiver operating characteristic (ROC) analyses, we determined the sensitivity and specificity values for the original PD algorithm and the PD screening. RESULTS: The prevalence of PD in cancer patients (8.75%) was higher than the prevalence of PD for the general population. The original PD algorithm demonstrated an accuracy of 0.66, sensitivity of 0.31 and specificity of 0.94. The PD screening question in the PHQ-PD had a sensitivity of 0.66 and a specificity of 0.75 (accuracy=0.80). CONCLUSION: PD screening questions in the PHQ-PD may be useful for identifying cancer patients with PD because of the high prevalence of PD in this population and because the questionnaire's sensitivity is greater than that of the original PD algorithm. Nevertheless, researchers and clinical practitioners should consider the original PD algorithm (five items) in the PHQ-PD when they investigate PD in patients because of the algorithm's high specificity. Individuals who are found to be positive for PD on screening should be referred for assessment and a thorough psychiatric interview that focuses on the differential diagnosis of an anxiety disorder relating to cancer.

Experience sampling and ecological momentary assessment for studying the daily lives of patients with anxiety disorders: a systematic review.

Anxiety disorders are highly prevalent. Symptoms may occur unpredictably (e.g., panic attacks) or predictably in specific situations (e.g., social phobia). Consequently, it may be difficult to assess anxiety and related constructs realistically in the laboratory or by traditional retrospective questionnaires. Experience sampling methods (ESM) and ecological momentary assessment (EMA) can deepen the understanding of the course of anxiety disorders by frequently assessing symptoms and other variables in the natural environment. We review 34 ESM/EMA studies on adult panic disorder, generalized anxiety disorder, social phobia, post-traumatic stress disorder, and obsessive-compulsive disorder, as well as anxiety disorders in youth. Benefits of ESM/EMA for the study of anxiety disorders include generating insight into the temporal variability of symptoms and into the associations among daily affect, behaviors, and situational cues. Further, ESM/EMA has been successfully combined with ambulatory assessment of physiological variables and with treatment evaluations. We provide suggestions for future research, as well as for clinical applications.

Efficacy of a hybrid online training for panic symptoms and agoraphobia: study protocol for a randomized controlled trial.

BACKGROUND: Recently, internet-based interventions have been proposed as effective treatments for people with panic disorder (PD). However, little is known about the clinical effects of integrating mobile technology into these interventions. Because users carry their smartphones with them throughout the day, we hypothesize that this technology can be used to significantly support individuals with monitoring and overcoming their PD symptoms. The aim of the present study is to evaluate the efficacy and cost-effectiveness of a newly developed hybrid intervention that combines internet/PC with smartphone delivery to treat the symptoms of PD. The intervention is based on cognitive behavioral therapy and consists of six modules over a total of six weeks. METHODS/DESIGN: A two-arm randomized controlled trial (RCT) will be conducted to evaluate the effects of a hybrid online training module for PD. Based on a power calculation (d =0.60; 1-ß of 80%; α =0.05), 90 participants with mild to moderate panic symptoms with or without agoraphobia (as assessed by the Panic and Agoraphobia Scale) will be recruited from the general population and randomly assigned to either the intervention group or a six-month waitlist control group. The primary outcome measure will be the severity of panic symptoms. Secondary outcomes will include depression, quality of life, and an observer-based rating of panic severity. Furthermore, data regarding acceptance and the usability of the smartphone app will be assessed. Assessments will take place at baseline as well as eight weeks, three months, and six months after randomization. Moreover, a cost-effectiveness analysis will be performed from a societal perspective. Data will be analyzed on an intention-to-treat basis and per protocol. DISCUSSION: To our knowledge, this RCT is one of the first to examine the efficacy of a hybrid online training for adult PD. This study seeks to contribute to the emerging field of hybrid online training. If the intervention is efficacious, then research on this hybrid online training should be extended. The cost-effectiveness analysis will also indicate whether online training is an economical tool for treating PD among adults. TRIAL REGISTRATION: German Clinical Trial Register: DRKS00005223 (registered on 15 August 2013).

Evaluation of a practice team-supported exposure training for patients with panic disorder with or without agoraphobia in primary care - study protocol of a cluster randomised controlled superiority trial.

BACKGROUND: Panic disorder and agoraphobia are debilitating and frequently comorbid anxiety disorders. A large number of patients with these conditions are treated by general practitioners in primary care. Cognitive behavioural exposure exercises have been shown to be effective in reducing anxiety symptoms. Practice team-based case management can improve clinical outcomes for patients with chronic diseases in primary care. The present study compares a practice team-supported, self-managed exposure programme for patients with panic disorder with or without agoraphobia in small general practices to usual care in terms of clinical efficacy and cost-effectiveness. METHODS/DESIGN: This is a cluster randomised controlled superiority trial with a two-arm parallel group design. General practices represent the units of randomisation. General practitioners recruit adult patients with panic disorder with or without agoraphobia according to the International Classification of Diseases, version 10 (ICD-10). In the intervention group, patients receive cognitive behaviour therapy-oriented psychoeducation and instructions to self-managed exposure exercises in four manual-based appointments with the general practitioner. A trained health care assistant from the practice team delivers case management and is continuously monitoring symptoms and treatment progress in ten protocol-based telephone contacts with patients. In the control group, patients receive usual care from general practitioners. Outcomes are measured at baseline (T0), at follow-up after six months (T1), and at follow-up after twelve months (T2). The primary outcome is clinical severity of anxiety of patients as measured by the Beck Anxiety Inventory (BAI). To detect a standardised effect size of 0.35 at T1, 222 patients from 37 general practices are included in each group. Secondary outcomes include anxiety-related clinical parameters and health-economic costs. TRIAL REGISTRATION: Current Controlled Trials [http://ISCRTN64669297].

Perceived social support mediates anxiety and depressive symptom changes following primary care intervention.

BACKGROUND: The current study tested whether perceived social support serves as a mediator of anxiety and depressive symptom change following evidence-based anxiety treatment in the primary care setting. Gender, age, and race were tested as moderators. METHODS: Data were obtained from 1004 adult patients (age M = 43, SD = 13; 71% female; 56% White, 20% Hispanic, 12% Black) who participated in a randomized effectiveness trial (coordinated anxiety learning and management [CALM] study) comparing evidence-based intervention (cognitive-behavioral therapy and/or psychopharmacology) to usual care in the primary care setting. Patients were assessed with a battery of questionnaires at baseline, as well as at 6, 12, and 18 months following baseline. Measures utilized in the mediation analyses included the Abbreviated Medical Outcomes (MOS) Social Support Survey, the Brief Symptom Index (BSI)-Somatic and Anxiety subscales, and the Patient Health Questionnaire (PHQ-9). RESULTS: There was a mediating effect over time of perceived social support on symptom change following treatment, with stronger effects for 18-month depression than anxiety. None of the mediating pathways were moderated by gender, age, or race. CONCLUSIONS: Perceived social support may be central to anxiety and depressive symptom changes over time with evidence-based intervention in the primary care setting. These findings possibly have important implications for development of anxiety interventions.

Agoraphobia: an outreach treatment programme.

BACKGROUND: Agoraphobia is disabling and clients find it hard to access effective treatment. AIMS: This paper describes the development of an inexpensive service, delivered by trained volunteers in or near the client's own home. METHOD: We describe the development of the service, including selection, training and supervision. Outcomes were evaluated over 5 years, and compared with those available from the local psychology service. RESULTS: Effect sizes on all measures were high. Benchmarking indicated that results on comparable measures were not significantly different from the local psychology service. As in many previous studies drop-out rate was fairly high. CONCLUSIONS: This model worked well, and was inexpensive and effective. Further research on long term outcome and methods of enhancing engagement is needed.

Childhood sexual abuse and psychiatric disorders in middle-aged and older adults: evidence from the 2007 Adult Psychiatric Morbidity Survey.

OBJECTIVE: This study aimed (1) to assess the relationship of childhood sexual abuse and revictimization with 6 common mental disorders, alcohol and drug dependence, posttraumatic stress disorder, eating disorders, and suicidal behavior; (2) to test whether gender moderates the relationship between childhood sexual abuse and psychiatric comorbidity; and (3) to assess the association of childhood sexual abuse with health care service use among middle-aged and older adults. METHOD: The author conducted secondary analyses of data from a population-based, nationally representative sample of 3,493 community-dwelling adults aged 50 years and above who were interviewed in England in 2006 and 2007 as part of the 2007 Adult Psychiatric Morbidity Survey. The survey assessed childhood sexual abuse (sexual touching and sexual intercourse), sexual abuse revictimization (experiencing both childhood and adult sexual abuse), demographics, health care service use, 6 common mental disorders according to ICD-10 diagnostic criteria (depressive episode, mixed anxiety and depression, generalized anxiety disorder, panic disorder, phobia, and obsessive-compulsive disorder), eating disorders, posttraumatic stress disorder, alcohol and drug dependence, and suicidal behavior. RESULTS: After weighting, the prevalence of childhood sexual abuse was 8.0%, and the prevalence of revictimization was 1.9%. Multivariate analyses revealed that childhood sexual abuse was significantly associated with mixed anxiety and depression (adjusted odds ratio [AOR] = 1.69; 95% CI, 1.09-2.63), generalized anxiety disorder (AOR = 1.78; 95% CI, 1.01-3.11), eating disorders (AOR = 2.04; 95% CI, 1.12-3.75), posttraumatic stress disorder (AOR = 2.45; 95% CI, 1.20-4.99), and suicidal ideation (AOR = 2.32; 95% CI, 1.27-4.27). Revictimization was significantly related to mixed anxiety and depression (AOR = 3.21; 95% CI, 1.63-6.32), generalized anxiety disorder (AOR = 2.60; 95% CI, 1.07-6.35), phobia (AOR = 4.07; 95% CI, 1.23-13.46), posttraumatic stress disorder (AOR = 8.88; 95% CI, 3.68-21.40), and suicidal ideation (AOR = 3.03; 95% CI, 1.08-8.51). Gender did not moderate the association of childhood sexual abuse or revictimization with psychiatric disorders. Finally, both childhood sexual abuse (AOR = 3.73; 95% CI, 2.03-6.86) and revictimization (AOR = 7.54; 95% CI, 3.09-17.42) were significantly associated with psychiatric hospitalization. CONCLUSIONS: The prevalence of childhood sexual abuse in this sample was comparable to the prevalence rates identified in previous studies. The associations of childhood sexual abuse and revictimization with a wide range of psychiatric disorders raises further questions about the underlying mechanisms in the elderly. This study also supports the notion that childhood sexual abuse and revictimization are associated with a higher rate of utilization of mental health services.

[Anxiety and anxiety disorders--differential diagnosis, etiology and medico-legal assessment]. / Angst und Angststörungen-- Differenzialdiagnose, Ursachen und Empfehlungen für die Begutachtung (I).

Psychiatric disorders including anxiety disorders, are becoming more and more important in medico-legal assessment. Anxiety disorders are frequent in the general population. However, they may not be reliably diagnosed even by psychiatric experts because the disorders' symptoms may fail to manifest themselves during the examination. Functional impairments related to anxiety disorders are similarly problematic to assess. Finally, given the existence of effective therapies, it is hard to explain why patients with anxiety disorders have to be assessed at all. This report discusses the various and quite heterogeneous concepts associated with the word "anxiety". Anxiety disorder as a disease is differentiated from anxiety as a physiological emotion. Evidence concerning the etiology of anxiety disorders is compiled and strategies for medico-legal assessment, including the efficacy of therapies, are presented.

Disorder-specific emotional imagery for differential and quantitative assessment of agoraphobia.

Visual emotional stimulation is supposed to elicit psycho-vegetative reactions, which are similar to as the ones elicited by exposure to actual experience. Visual stimulation paradigms have been widely used in studies on agoraphobia with and without panic disorder. However, the applied imagery has hardly ever been disorder- and subject- specific. 51 patients with an ICD-10 and DSM-IV diagnosis of agoraphobia with or without panic disorder (PDA) and matching healthy controls have been examined. Subjects were confronted with 146 picture showing characteristic agoraphobic situations (high places, narrow places, crowds, public transport facilities, or wide places) or pictures associated with acute physical emergency (panic) situations, which had been pre-selected by anxiety experts. Participants were asked to rate emotional arousal induced by the respective images on the Self- Assessment Manikin scale (SAM). Data on PDA severity (PAS) depressive symptoms (MADRS) and sociodemographic data were recorded. Saliva cortisol levels were measured before and after exposure in a second test applying the individually mostly feared stimuli combined with emotionally neutral pictures for every single patient. 117 of the PDA-specific images were rated significantly more fear-eliciting by patients than by healthy individuals. Sub-categorization into agoraphobia clusters showed differential effects of clusters with regard to gender distribution, severity of PDA and cortisol secretion during exposure. In this study disorder specific and individual characteristics of agoraphobia were assessed for use in future trials applying emotional imagery. It could be used for the differential assessment of PDA and associated neurobiological and psychological phenomena and in neuroimaging paradigms.

Anticipatory anxiety as a function of panic attacks and panic-related self-efficacy: an ambulatory assessment study in panic disorder.

BACKGROUND: Panic attacks and anticipatory anxiety are considered to be inter-correlated, yet distinctive, features of panic disorder, both contributing to its onset and maintenance as well as to the associated impairment. Given the difficulty to yield ecologically valid data on these fluctuating symptoms the natural course of anticipatory anxiety and its correlates have seldom been addressed with adequate methods. AIMS: The current study aimed at further exploring the natural variance of anticipatory anxiety and its interdependence with panic-related variables. In addition, impact of anxiety sensitivity, and perceived ability to cope with panic on the relation between panic attacks and subsequent anxiety was inspected. METHOD: Based on an Ecological Momentary Assessment approach, 21 patients with panic disorder rated study variables continuously over one week; 549 question sets were completed. RESULTS: Anticipatory anxiety followed a diurnal pattern and was associated with situational and internal variables typically linked to panic experiences. Preceding panic attacks intensified anticipatory anxiety and associated negative emotional states; however, perceived ability to cope attenuated these effects. CONCLUSION: Based on natural observation data, results largely support the importance of cognitive appraisals for anticipatory anxiety, and its interplay with panic attacks as it has been suggested by cognitive theory and recent findings in extinction learning research.

The effects of an Internet based self-help course for reducing panic symptoms--Don't Panic Online: study protocol for a randomised controlled trial.

BACKGROUND: Internet based self-help for panic disorder (PD) has proven to be effective. However, studies so far have focussed on treating a full-blown disorder. Panic symptoms that do not meet DSM-IV criteria are more prevalent than the full-blown disorder and patients with sub-clinical panic symptoms are at risk of developing PD. This study is a randomised controlled trial aimed to evaluate an Internet based self-help intervention for sub-clinical and mild PD compared to a waiting list control group. METHODS: Participants with mild or sub-clinical PD (N = 128) will be recruited in the general population. Severity of panic and anxiety symptoms are the primary outcome measures. Secondary outcomes include depressive symptoms, quality of life, loss of production and health care consumption. Assessments will take place on the Internet at baseline and three months after baseline. DISCUSSION: Results will indicate the effectiveness of Internet based self-help for sub-clinical and mild PD. Strengths of this design are the external validity and the fact that it is almost completely conducted online.

Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial.

BACKGROUND: Internet administered cognitive behaviour therapy (CBT) is a promising new way to deliver psychological treatment, but its effectiveness in regular care settings and in relation to more traditional CBT group treatment has not yet been determined. The primary aim of this study was to compare the effectiveness of Internet-and group administered CBT for panic disorder (with or without agoraphobia) in a randomised trial within a regular psychiatric care setting. The second aim of the study was to establish the cost-effectiveness of these interventions. METHODS: Patients referred for treatment by their physician, or self-referred, were telephone-screened by a psychiatric nurse. Patients fulfilling screening criteria underwent an in-person structured clinical interview carried out by a psychiatrist. A total of 113 consecutive patients were then randomly assigned to 10 weeks of either guided Internet delivered CBT (n = 53) or group CBT (n = 60). After treatment, and at a 6-month follow-up, patients were again assessed by the psychiatrist, blind to treatment condition. RESULTS: Immediately after randomization 9 patients dropped out, leaving 104 patients who started treatment. Patients in both treatment conditions showed significant improvement on the main outcome measure, the Panic Disorder Severity Scale (PDSS) after treatment. For the Internet treatment the within-group effect size (pre-post) on the PDSS was Cohen's d = 1.73, and for the group treatment it was d = 1.63. Between group effect sizes were low and treatment effects were maintained at 6-months follow-up. We found no statistically significant differences between the two treatment conditions using a mixed models approach to account for missing data. Group CBT utilised considerably more therapist time than did Internet CBT. Defining effect as proportion of PDSS responders, the cost-effectiveness analysis concerning therapist time showed that Internet treatment had superior cost-effectiveness ratios in relation to group treatment both at post-treatment and follow-up. CONCLUSIONS: This study provides support for the effectiveness of Internet CBT in a psychiatric setting for patients with panic disorder, and suggests that it is equally effective as the more widely used group administered CBT in reducing panic-and agoraphobic symptoms, as well as being more cost effective with respect to therapist time. TRIAL REGISTRATION: ClinicalTrials.gov NCT00845260.

Power law relationships between health care utilization and symptom assessment among people with panic attacks.

RATIONALE: Although people with panic attacks are high utilizers of health care, the role of symptom assessment in care-seeking is unclear. Previous studies suggest that symptom perceptions are linearly related to utilization but panic appraisal is not. The purpose of this study was to determine whether the relationships between symptom assessment and utilization are non-linear, displaying power law distributions. METHODS: This community-based study of 97 subjects with panic attacks assessed utilization of family doctor offices, total ambulatory utilization, and hospitalizations as well as symptom perceptions and panic appraisals. Matrices of symptom assessment versus utilization were created, and log-log plots were constructed. To minimize the risk of overestimation of power law distributions, linear, quadratic and cubic regression models were computed. RESULTS: None of the utilization versus symptom perceptions displayed power law distributions. However, all three measures of utilization showed power law relationships with panic appraisals, but in unique patterns. CONCLUSIONS: Although power law relationships were not found between symptom perceptions and utilization, unique patterns of power laws were identified between panic appraisals and all three measures of utilization.

Mental representations in women with panic disorder: an urban African-American sample.

Psychodynamic theories of panic disorder (PD) suggest an association between PD and impairments in mental representations. This study tested this hypothesis by comparing mental representations of 25 African-American women recruited from an urban primary care clinic with PD with a group of 25 women without PD and matched on race, age, marital status, education, and income. Mental representations were assessed through spontaneous descriptions of mothers and reliably coded with the Qualitative and Structural Dimensions of Object Representations scale (Blatt et al., Unpublished manual, 1992). Results essentially supported the hypotheses for impaired mental representations (lower benevolence, higher ambivalence, and lower conceptual level) for women with PD as compared with women without PD. No differences in mental representations were found between women with PD with major depression and women with only PD. The findings provide preliminary support for a psychodynamic theory of PD in a sample of African-American women.

Characteristics and predictors of social phobia course in a longitudinal study of primary-care patients.

BACKGROUND: Social Phobia (SP) is a prevalent disorder in primary-care settings. To date, few researchers have examined the natural course of SP in primary care. We examined the natural course and predictors of recovery in a large sample of primary-care patients. METHODS: Data are obtained from the Primary Care Anxiety Project, a naturalistic, longitudinal study of anxiety disorders in primary-care patients. This report pertains to 182 patients with SP at intake. We examined intake demographic and clinical variables as predictors of recovery within the 5 years of follow-up. RESULTS: The probability of recovery from SP during the 5-year follow-up period was .40. At intake, a longer duration of SP episode, comorbid Panic Disorder with Agoraphobia, and lower psychosocial functioning predicted lower rates of recovery. CONCLUSIONS: These findings highlight the chronicity of SP, as well as factors that may affect its naturalistic course. It is imperative that primary-care physicians and mental health specialists assess for and treat SP in their practices. Future research is warranted to further examine the effect of medical and psychiatric comorbidity on SP course.