Suicide attempts in patients with panic disorder.

In a clinical sample of 100 outpatients with panic disorder, 42% had a history of suicide attempt. Female sex and being single, divorced, or widowed were associated with an increased risk of suicide attempt. Thirty-one (73.8%) of the suicide attempts occurred after the first panic attack and 27 (64.3%) after the onset of panic disorder. Eighty-eight of these patients met DSM-III-R criteria for at least one other diagnosis in addition to panic disorder. Moreover, 52% had a history of major depressive episode and 31% had a lifetime diagnosis of alcohol and/or other substance abuse. Compared with those who did not attempt suicide, those who attempted suicide were significantly more likely to have suffered from major depressive episode and alcohol or other substance abuse in their lifetime. Among the 35 patients with no comorbidity with either major depression or addictive behaviors, 17.1% had a history of suicide attempt. All had suffered from depressive symptoms and/or a personality disorder. The same association was found in four of 19 patients suffering from panic disorder only with or without agoraphobia.

Panic disorder in cardiac outpatients.

OBJECTIVE: Continuing the long history of interest in the relation of anxiety disorders to cardiovascular function and symptoms, this study investigated the level of anxiety and prevalence of panic disorder in cardiac patients and the possible associations between specific abnormal ECG results and a diagnosis of panic disorder. METHOD: Consecutive patients referred for ambulatory ECG recordings were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale. Then, 50 patients with scores higher than 8 (the anxious group) were interviewed with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA). RESULTS: Of the 50 anxious patients (26 male and 24 female) interviewed with the SADS-LA, 62% (N = 31) met the DSM-III-R criteria for panic disorder. Patients with panic disorder had a higher mean maximal heart rate and a shorter P-R interval than patients without panic disorder. Unlike the patients without panic disorder, the patients with panic disorder showed no correlation between maximal heart rate and minimal P-R interval. CONCLUSIONS: The rate of panic disorder was high in the patients referred for ECG. Moreover, the prevalence of panic disorder was similar in the patients with and without ECG abnormalities, indicating that in anxious patients the presence of panic disorder does not rule out organic cardiac disease. On the other hand, the higher maximal heart rate and shorter P-R interval of the panic patients may be attributable to hypersensitivity of beta-adrenergic receptors in panic disorder.

Cost of anxiety disorders: impact of comorbidity.

The aim of this study was to assess the relative impact of co-mobidity and of symptom severity on the costs of caring for patients with generalized anxiety disorders (GAD). One thousand and forty-two patients with GAD according to DSM III-R were observed by psychiatrists using a cross-sectional methodology. Demographic, clinical, therapeutic as well as health care utilization data were collected at a single point in time. Patients were stratified according to prevalence of co-morbidity. An economic analysis was performed based on a societal perspective. Hospitalizations and losses of productivity were the two major components of costs both in patients with and without co-morbidity. On the other hand costs of pharmaceuticals remain a marginal component of costs associated with GAD in the two groups. Controlling for confounding variables, the prevalence of health care utilisation was found to be significantly higher in patients with co-morbidity for hospitalization, laboratory tests, medications and absenteeism from work. Most of cost components were found to be significantly higher in patients with co-morbidity. The relative risk of health care utilization was higher in patients with co-morbidity, past history of anxiety, high level of anxiety as well as in older patients. Overall our findings suggest that both co-morbidity and symptom severity play a role in cost generation in GAD patients.

[Treatment of depression: methods and stages]. / Traitement du déprimé: moyens et étapes.

According to recent epidemiological studies, the lifetime prevalence of major depression ranges between 10 and 20%. However, informations concerning the course of depressive illness remain limited. It appears that only about one-quarter, or even less, of all depressives are affected once in their lifetime. Today, it could be assumed that 75-80% of depressive cases are recurrent. Many antidepressive treatments are available today, including first generation and second-generation antidepressants, psychotherapies, and sismotherapies. While antidepressants are similar in terms of drug or efficacy, onset of action, and latency to treatment response, their potential side effect and toxicity profiles are quite different. These factors must be weighed before treatment of depression is begun in an effort to prescribe the compound that is most beneficial i.e., clinically effective while exhibiting the fewest negative aspects. Determination of patients with an "at-risk" profile for drug side effects is best done by a careful analysis of their medical history, comorbidity with other axis I and axis II disorders and concomitant drug therapies. In fact, it appears that depressive patients with coexisting anxiety are often prone to side effects either with tricyclic compounds and SSRI's. In these patients these medications should therefore be introduced at a low dose and slowly increased. Otherwise, because of the frequent comorbidity of depression and alcoholic disorders, the clinician should make very effort to obtain a detailed history of the patient's substance use. If the patient is found to have a substance use disorder, a program to secure abstinence should be regarded as a priority in the treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Panic disorder and alcoholism]. / Trouble panique et conduites d'alcoolisation.

Relationships between alcoholism and anxiety disorder are well known by clinicians. Studies have recently shown that the prevalence of alcohol abuse or dependence is very high in patients with panic disorder with or without agoraphobia (Thyer et al., 1986; Bibb and Chambless, 1986). The aims of this study were to determine the prevalence and comorbidity of alcohol abuse and dependence in a population of panic outpatients who were consecutive referrals for treatment of panic disorder (PD) in an anxiety clinic. Patients were interviewed with the Schedule for Affective Disorders and Schizophrenia-Lifetime Version Modified for the study of anxiety disorders (SADS-LA) which is a standardized and semi-structured interview allowing to make diagnoses according to RDC, DSM III and DSM III-R criteria. One hundred and three panic patients (39 males and 64 females) were included in the study. Their mean age was 38.5 years (SD: 11.6). In this sample, 24.3% met the DSM III-R criteria for alcohol abuse and 8.7% those for alcohol dependence. Among these patients, 26.2%, abused of benzodiazepines and 16.5% of them of other substances. We found a high comorbidity rate. In fact, 6.8% of the patients met diagnostic criteria for PD alone, 31.0% for one more diagnosis, 29.1% for two more and 33.0% for three or more besides PD. In this study, we found an association between alcohol abuse and the presence of a lifetime diagnosis of major depressive episode and/or other addictive behaviors. Otherwise, alcohol abuse did not occur more often in patients suffering from panic disorder associated with agoraphobia and/or social phobia.

[Effect of antidepressant treatment on sense of dyscontrol: preliminary studies]. / Sensibilité du dyscontrôle aux effets des traitements antidépresseurs: données préliminaires.

Cumulative data in the field of phenomenology, neurobiology and psychopharmacology indicate "discontrol" as a dimension probably linked to serotonin central activity and frequently observed in major depression and other related disorders. A new questionnaire for evaluating this dimension is proposed: Behavioral Discontrol Scale (BDS). The BDS was constructed in 1990 and validated through multiple clinical studies: the first validation study included 166 patients (subdivided in 4 subgroups, anxious, depressed, alcohol abusers and bulimics fulfilling DSM III-R criteria) and 35 controls. The second validation study concerned a large clinical population suffering from major depression according tho DSM III-R criteria (n = 1360 patients). The episodes classified as psychogenic or neurotic and characterised as "agitated, anxious, impulsive and/or suicidal"' showed the highest scores on discontrol (p < 0.001). Following these initial studies, the present study was conducted to evaluate prospectively the sensitivity of BDS to change under different antidepressant treatments (serotonergic versus other agents). Preliminary data were obtained within a group of 62 outpatients suffering from major depression (DSM III-R criteria), treated naturalisticly and followed on a 4 weeks period. Results showed that discontrol is sensitive to change, especially in the fluoxetine group (decrease at day 28 by 35% vs 23% and 24% in other groups, p = 0.17). Changes of discontrol scores was shown to be related to benzodiazepine (BZD) combination to antidepressant treatment. In fact, in the group "with BZD" (n = 42), the magnitude of BDS score variation was less important than in the group "without BZD" (n = 19): respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Panic disorder in patients consulting a cardiologist]. / Etude du trouble panique chez des patients consultant en cardiologie.

The relationship of anxiety with cardiovascular function and symptoms has been of long historic interest, culminating in the recent emphasis given to the modulation of cardiovascular response in panic patients. Cognitive approaches postulate an interaction of physiological and psychological factors in the maintenance of panic disorder. Pharmacological approaches postulate a dysfunction of central alpha-adrenoceptors in panic and also in some cardio-vascular diseases. Ambulatory heart rate recordings confirm the presence of major cardiovascular changes during panic attacks in several studies. We have carried out a study in an unselected population being explored in an outpatient cardiology unit with 24 hours ambulatory heart rate recordings. Hundred and ninety-seven consecutive referrals for an ambulatory heart rate examination were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale (HAD-A). Fifty patients (26 males and 24 females), with an higher score than 8, were interviewed with the SADS-La. Sixty-two per cent of them fit DSM III-R criteria for panic disorder. Among these 50 interviewed patients, 19 (11 males and 8 females) were referred for organic heart disease and 31 (15 males and 16 females) were investigated only for functional symptomatology. The proportion of panickers was similar in patients referred either for functional or organic heart disease (63.2 vs 61.3; chi 2 = .02; p = .89). Nineteen patients (11 males and 8 females) had pathological ECG ambulatory recording results and 31 patients (15 males and 16 females) were classified as Holter (-). The proportion of panickers was found similar in these two subgroups of patients (63.2 vs 61.3; chi 2 = .02; p = .89).(ABSTRACT TRUNCATED AT 250 WORDS)

[The use of therapeutic isolation and confinement in psychiatry. A prospective study]. / Utilisation de l'isolement thérapeutique et des contentions en psychiatrie. Enquête prospective.

Despite recent developments in psychopharmacology and a better understanding of agitation patterns in psychiatric patients, the use of seclusion and restraint procedures remains a matter of daily practice. Little or no time is spent on its teaching in a formal way. There is almost no literature on these issues, and it has grown only since legal procedures initiated by patients, which forced practitioners to spend some time analysing these methods. Facing this problem, we realized a prospective study at the CHS de la Savoie, in Chambéry, so as to clarify the current modes of these procedures. This study was led among 460 secluded patients, during one year. 11 data were studied, such as the duration of the seclusion, the reason and the medical history, the desire of the patient to be liberated ... The review or awareness of certain variables may give clinicians a better perspective on the use of procedures which, unfortunately, continue to be the cause of deaths in psychiatric practice.

[Behavior dyscontrol scale: validation and initial results]. / Echelle de dyscontrôle comportemental. Validation et résultats préliminaires.

The numerous recent trials devoted to disruptive behavior disorders indicate the renewed interest of clinicians for these so-called dimensions and call for revision of the instruments with which they are evaluated. The present paper provides a brief review of the currently used scales for rating impulsivity. A new scale for evaluating the behavioural dyscontrol is proposed. The items of this scale are selected a priori according to clinical experience with patients suffering from lack of behavioural control. The Behaviour Dyscontrol Scale (BDS) includes, in the initial version, 4 parts. The first part concerns the generalized lack of control (G-BDS). This is a questionnaire of 24 items. The second part is constituted by a questionnaire which lists a number of specific behaviours where impulsivity has a central role (S-BDS). Part III is constituted with 4 Visual Analogue Scales for evaluating handicap linked to dyscontrol. Part IV is constituted by 3 Visual Analogue Scales concerning the physician global impression about the lack of general control in cognitions, emotions and behaviours. For validation, 166 patients (111 females and 55 males), either hospitalized or ambulatory, and 35 controls (16 females and 19 males) were included in this study. Mean age of patients was 38.5 (SD = 10.5) years. The patients population is subdivided in 4 subgroups, anxious, depressed, abusers and bulimics according to DSM III-R criteria. Patients and controls global scores were significantly different at the G-BDS (p less than 10(-4)) and not at S-BDS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Attempted suicide and alcohol dependence: results of an epidemiologic survey]. / Tentative de suicide et dépendance alcoolique: résultats d'une enquête épidémiologique.

OBJECTIVES: The relationship between alcoholism and suicidal behaviour has long been recognized. The present study examined the lifetime prevalence of suicide attempts in alcoholic patients and the impact of comorbidity, namely with depressive anxiety disorders and antisocial personnalit disorder in alcoholic patients who attempted suicide. METHODS: In a cross-sectional design including outpatients referring for alcohol dependance according to DSM III-R criteria, we used a specific standardized and structured interview allowing DSM III-R diagnoses. RESULTS: We include 507 patients (343 males of 164 females). The mean age at the intake of the study was 43.2 (SD:9.6) years without difference between males and females. 129 patients (25.4%) had attempted suicide during their lifetime. The proportion of female was found higher than males among suicide attempters (41.9 vs 29.3%; p < or = 0.001). Age of onset of alcoholism was found younger in suicide attempters than non (p < or = 0.01), either in males and females. Moreover, we found that alcoholic suicide attempters more often reported family histories of alcoholism than did nonattempters. As regard lifetime comorbidity, major depression and drugs misuse were found more frequent in alcoholics who attempted suicide (p < or = 0.001). Moreover, we found a higher prevalence for Panic Disorder and Social Phobia in male suicide attempters.

[Alternating addictions: apropos of 3 cases]. / Addictions alternantes: á propos de trois cas.

The concept of addiction is now of interest in psychiatry, but is a great subject of controversies. It is now recognized that as different disorders as alcoholism, drug addiction, bulimia, kleptomania, trichotillomania, pathological gambling are to be considered as addictive states. Other pathological behaviours could be included in the addictive spectrum (i.e. suicidal behaviours, compulsive spending). The comorbidity rates of these disorder are elevated in these populations. For example, high comorbidity rates are found between kleptomania and bulimia or drug addiction and pathological gambling. Polyaddictive states are well established. For some subjects, more than one addiction is present in life-time, but not occurring in the same period. We present three patients in whom different addictive states occurred alternately. All the patients had a history of compulsive spending and kleptomania, two of them had a history of bulimia and sexual compulsion. Some clinical characteristics were common: recurrent mood disorder, depression preceeding the addictive state, no psychoactive substance disorder. In all patients, severity of depressive state decreased when addiction appeared. Depressive symptoms varied inversely to addiction severity. The hypothesis about psychopathological links between kleptomania and bulimia on one hand and mood disorders on the other hand has been known for a long time. Kleptomania as other impulsive disorders is, for some authors, understood in the meaning of a "spectrum affective disorder". For these three patients, an antidepressant effect of the behavioural addictions is suggested. In fact, the addictions appeared alternately. The possibility of common psychopathological and/or biological mechanisms for behavioural addiction is supported by these clinical observations, that could contribute to the addiction concept validity.

[Self-assessment questionnaire of alcoholic craving (ECCA Questionnaire: Behavior and Cognition in Relation to Alcohol: French translation and validation of the Obsessive-Compulsive Drinking Scale]. / Auto-questionnaire d'appétence alcoolique (questionnaire ECCA: échelle de comportement et de cognitions vis-à-vis de l'alcool: traduction française et validation de l'OCDS (obsessive compulsive drinking scale).

Clinical, neurobiological and neuropsychological hypotheses suggest that the dimension of alcohol craving includes the concept of both obsessive thoughts about alcohol use and compulsive behaviors toward drinking. Anton et al. (1995) developed a 14 items self-rating scale, the Obsessive Compulsive Drinking Scale (OCDS) which includes items for assessing three dimensions: global, and the obsessive and the compulsive subdimensions. In this study, we included 156 patients, 105 men and 51 women, who met DSM IV diagnostic criteria for alcohol dependence. The mean age of our population was 39.1 +/- 11.2 years without difference between sexes. We did not found any correlation between the CAGE score and the OCDS total score or the obsessive and compulsive subscores (respectively, r = .15, r = .10 et r = .18). Moreover, we did not found any correlation between OCDS scores and mean daily alcohol consumption (r = .18, r = .16, r = .19). This could indicate that the dimension measured by the scale was somewhat independent of actual drinking. As such, it might act as an independent measure of the "state of illness" for alcohol-dependent patients. The test-retest correlation for the OCDS total score was .95 and the obsessive and compulsive subscales test-retest correlations were .93 and .89 respectively. The internal consistency of the items of the OCDS was high (alpha = .89). Principal component analysis had identified in the french version of the OCDS, three factors accounting for 63.5% of the total variance. These results indicate that the french version of the OCDS seems to validly measure a dimension of alcohol dependence. The ease of administration, reliability, and concurrent validity of the OCDS makes it particularly useful as an outcome measurement tool for various clinical therapeutic protocols in alcoholism.

[Anxiety disorders in private practice psychiatric out-patients: prevalence, comorbidity and burden (DELTA study)]. / Epidémiologie des troubles anxieux en psychiatrie libérale: prévalences, comorbidité et retentissement (étude DELTA).

Few data are currently available on the prevalence and associated characteristics of anxiety disorders in psychiatric out-patients in France, in particular in the private health-care. However, this represents one of the principal systems of care for patients suffering from anxiety disorders, with a possible direct access and several types of treatments available (pharmacotherapy but also different kinds of psychotherapy). The aim of our study was to describe the prevalence of anxiety disorders in a large sample of patients consulting in the private sector, and in addition to study the comorbidity, the severity of the disorders, their consequences on quality of life and health care consumption. The studied patients were included and assessed by 501 psychiatrists from all the country, at the time of a first visit. Inclusions were to be made in a consecutive way, but with the exclusion of psychotic disorders and dementia. A sample of 1 955 patients was obtained, and all subjects had a standardized diagnostic assessment with the Mini International Neuropsychiatric Interview (MINI) and with various dimensional scales of symptomatology severity, quality of life, and health care consumption. On the whole, at least one current anxiety disorder was found in 64.3% of the patients, while 55% had a depressive disorder. Individually, the prevalence rates are 29.4% for generalized anxiety disorder, 25.9% for agoraphobia, 19.2% for panic disorder, 15.3% for social phobia, 11.4% for obsessive-compulsive disorder, and 5.4% for post-traumatic stress disorder (PTSD). A history of suicide attempts was found in 12-20% of patients, and an elevated suicide risk was found for example in 25% of PTSD patients. The scores of the symptomatic scales, adaptation and quality of life measure show a very significant anxious symptomatology, with serious functional consequences. Approximately 75% of patients had another medical consultation during the three previous months, and 9% have been hospitalized. An interruption of work was found in 25% of the patients during the last three months, in average for 35 days. Concerning drug consumption before the visit by anxiety disorders patients, the preponderance of anxiolytic use is notable (85 to 98% according to categories of anxiety disorders) when compared to that of antidepressants (20 to 40%). Moreover, 38.4% of the whole sample took an anxiolytic once a day for at least three months and about 40% of them had dependence symptoms. In conclusion, this study showed the quantitative importance of anxiety disorders among psychiatric out-patients in the private practice sector in France, all the categories of anxiety being represented, and the high level of severity and burden of these disorders. Compared to some data published before, the prevalence rates of these anxiety disorders seem to be increasing.

[Social adjustment and depression: value of the SAS-SR (Social Adjustment Scale Self-Report)]. / Adaptation sociale et dépression: intérêt de l'échelle SAS-SR (Social Adjustment Scale Self-Report).

The Social Adjustment Scale Self-Report (SAS-SR) is a simple and inexpensive method, which allows the routine assessment of the patient's social adjustment, especially in the case of depression. Compared with other scales based on an interview with the patient, the SAS-SR is more sensitive to change in the patient's clinical status. The SAS-SR is a useful method as part of the detection of even mild depressions, regular aftercare evaluation of out-patients or as an outcome measure in longitudinal studies. A French version of the SAS-SR is now available and is currently under evaluation in a large-scale randomized therapeutic trial.

[Cardiovascular pathology and panic disorder]. / Pathologie cardio-vasculaire et trouble panique.

The relationship between anxiety and cardiovascular function and symptoms has long been of interest, culminating in the recent emphasis on the modulation of cardiovascular response in patients with panic disorder. The relationship between panic disorder and mitral valve prolapse remains controversial. Panic disorder appears to be significantly associated with increased incidence of cardiovascular morbidity. The detection and treatment of panic disorder in patients with cardiovascular risk or diseases could have an important impact on prognosis and quality of life of the patients.