Behavioral inhibition in children of parents with panic disorder and agoraphobia. A controlled study.

To investigate the role of "behavioral inhibition to the unfamiliar" as an early temperamental characteristic of children at risk for adult panic disorder and agoraphobia (PDAG), we compared children of parents with PDAG with those from psychiatric comparison groups. Fifty-six children aged 2 to 7 years, matched for age, socioeconomic status, ethnic background, and ordinal position, were blindly evaluated at the Harvard Infant Study laboratory, Cambridge, Mass. The rates of behavioral inhibition in children of probands with PDAG, with or without comorbid major depressive disorder (MDD), were significantly higher than for our comparison group without PDAG. Further, the data suggest a progression of increasing rates of inhibition from the comparison group without MDD (15.4%), to MDD (50.0%), and to comorbid PDAG and MDD (70%) and PDAG (84.6%). In contrast, the rate of behavioral inhibition in children of probands with MDD did not meaningfully differ from the comparison group without MDD. Behavioral inhibition to the unfamiliar, as defined and measured in the previous work of the Harvard Infant Study program, is highly prevalent in the offspring of adults in treatment for PDAG. These children appear to be at risk for distress and disability in childhood and also perhaps for development of psychiatric disorder in later childhood and aulthood.

Psychiatric correlates of behavioral inhibition in young children of parents with and without psychiatric disorders.

Behavioral inhibition is a laboratory-based temperamental category by the tendency to constrict behavior in unfamiliar situations and assumed to reflect low thresholds of limbic arousal. We previously found behavioral inhibition prevalent in the offspring of parents with panic disorder and agoraphobia. In this report, we examined the psychiatric correlates of behavioral inhibition by evaluating the sample of offspring of parents with panic disorder and agoraphobia, previously dichotomized as inhibited and not inhibited, and an existing epidemiologically derived sample of children, followed by Kagan and colleagues and originally identified at 21 months of age as inhibited or uninhibited. A third group of healthy children was added for comparison. Our findings indicate that inhibited children had increased risk for multiple anxiety, overanxious, and phobic disorders. It is suggested that behavioral inhibition may be associated with risk for anxiety disorders in children.

Comorbidity of parental anxiety disorders as risk for childhood-onset anxiety in inhibited children.

OBJECTIVE: Previous work suggested that children of parents with panic disorder and agoraphobia were likely to be classified as behaviorally inhibited and that behaviorally inhibited children were likely to develop anxiety disorders. However, the factors determining which inhibited children were at risk for childhood onset of anxiety disorders remained unknown. The authors of this study hypothesized that greater anxiety loading in parents would increase the risk for anxiety disorders in children with behavioral inhibition. METHOD: Using DSM-III structured interviews, the authors examined patterns of aggregation of anxiety disorders in parents of two existing cohorts of children, one cross-sectional and clinically derived (31 children, 60 parents) and the other epidemiologically derived and longitudinal (40 children, 75 parents). Within each cohort, parents were stratified into three groups based on the presence (behavioral inhibition and anxiety) or absence (behavioral inhibition only, no behavioral inhibition and no anxiety) of behavioral inhibition and two or more anxiety disorders in their child. RESULTS: Parents of children with behavioral inhibition and anxiety, from both the clinical and nonclinical cohorts, had significantly higher rates of two or more anxiety disorders than did parents of children with behavioral inhibition only and parents of children with no behavioral inhibition and no anxiety. CONCLUSIONS: These results indicate that the presence of parental loading for anxiety disorders may help to identify the subgroup of inhibited children at very high risk for developing childhood-onset anxiety disorders.

The etiology of social phobia.

Human beings are by nature social animals, but for some, social scrutiny is a source of extreme anguish. Those with social phobia, for example, suffer excessive and often disabling concern about potential and real social-evaluative threat. As new and effective therapies for this condition are pursued, there is a simultaneous movement to extend the understanding of this disorder's etiology. In psychiatry, as in the rest of medicine, this development of new treatments often occurs in parallel with increasing sophistication about causes of illness. Advances in one area typically inform and predictably lead to advances in the other. Social phobia is recognized as a relatively common and significantly impairing anxiety disorder. As with other psychiatric disorders, emerging models of the etiology of social phobia are derived from converging evidence of interacting biological and environmental contributions. Current theories regarding the evolution of social phobia will be addressed, including biological preparedness to fear scrutiny by others, genetically transmitted predisposition to fear acquisition, nongenetic familial and environmental factors, as well as other possible causes and antecedents. Additionally, we describe recent work on behavioral inhibition in infancy as an identifiable early marker of proneness to the development of anxiety disorders, including social phobia.

Behavioral inhibition in children: a possible precursor to panic disorder or social phobia.

A biological-environmental interaction currently provides the best explanation of an anxiety disorder's evolution. In this sense, anxiety disorders are like other medical disorders for which a person may have a predisposition. Our knowledge of the evolution of anxiety disorders would be enhanced by the ability to identify those persons predisposed to anxiety and to identify such "proneness" before an anxiety disorder emerges in adulthood. We discuss the developmental aspects of panic disorder and social phobia, in particular findings suggesting that behavioral inhibition in children may be a precursor to phobic disorders in adults. Only longitudinal studies will resolve whether childhood response patterns are specifically linked to the risk of developing anxiety disorders or other psychopathology across the life cycle. In the interim, we suggest some guidelines for parents and clinicians to meet the unique needs of the inhibited child.

Further evidence of an association between behavioral inhibition and anxiety disorders: results from a family study of children from a non-clinical sample.

Behavioral inhibition to the unfamiliar, identifiable in early childhood and reflecting the tendency to exhibit withdrawal and excessive autonomic arousal to challenge or novelty, has been found to be prevalent in young offspring of parents with panic disorder and agoraphobia and associated with risk for anxiety disorders in these children. Using family study methodology, we now examine psychopathology in first degree relatives of children from a non-clinical longitudinal cohort identified at 21 months of age as inhibited (N = 22) or uninhibited (N = 19) and followed through the age of seven years for a study of preservation of temperamental characteristics in normal children. These assessments were compared with evaluations of the first degree relatives of 20 normal comparison children. Psychiatric assessments of parents (N = 110) and siblings (N = 72) were based on structured interviews conducted blindly to the temperamental classification of the index child. Parents of inhibited children, compared with parents of uninhibited and normal controls, had significantly higher risks for multiple (greater than or equal to 2) anxiety disorders, continuing anxiety disorders (both a childhood and adulthood anxiety disorder in the same parent), social phobia, and childhood avoidant and overanxious disorders. These findings provide additional support for the hypothesis linking behavioral inhibition with risk for anxiety disorder.

Expressed emotion toward children with behavioral inhibition: associations with maternal anxiety disorder.

OBJECTIVE: To examine the role of maternal psychopathology in influencing "expressed emotion" (EE) directed toward children with behavioral inhibition (BI) or psychiatric disorders. METHOD: Maternal EE was assessed via Five-Minute-Speech-Sample in two samples of children previously evaluated for child and maternal lifetime prevalence of DSM-III disorders and assessed via laboratory observations for BI. The authors previously reported that maternal EE was associated with BI and with the number of child behavior and mood disorders in these samples. The at-risk sample (N = 30) consisted of mothers with panic disorder and psychiatric controls and their 4-through 10-year-old children. The Kagan sample (N = 41) consisted of children selected at age 21 months as BI or uninhibited and followed through age 11. RESULTS: Interaction effects were found: in mothers with anxiety disorders, but not those without, maternal criticism (a component of EE) was significantly associated with child BI, independently of the child's number of disorders. Similarly, in mothers with anxiety disorders only, maternal criticism was significantly associated with a high number of child disorders. CONCLUSIONS: The relationships between mothers who have anxiety disorders and their children who have BI or psychiatric disorders may be marked by criticism or dissatisfaction. If confirmed, these findings offer opportunities for appropriate interventions.

Associations between expressed emotion and child behavioral inhibition and psychopathology: a pilot study.

OBJECTIVE: To examine the relationship between behavioral inhibition and child psychopathology and measures of family adversity indexed through "expressed emotion." METHOD: Maternal expressed emotion was assessed via Five-Minute-Speech-Sample in two samples of children evaluated for prevalence of DSM-III disorders and assessed via laboratory observations for behavioral inhibition. The at-risk sample (N = 30) consisted of 4- to 10-year-old children of mothers with and without panic disorder (psychiatric controls). The Kagan sample (N = 41) consisted of children selected at age 21 months as behaviorally inhibited or uninhibited and followed through age 11. RESULTS: In the at-risk sample, child behavioral inhibition was associated with high/borderline maternal criticism, independent of other measures of child psychopathology. In both samples combined, high/borderline maternal criticism was associated with child externalizing symptoms and with the number of child mood and behavior disorders. Emotional overinvolvement was significantly associated with child separation anxiety disorder in the at-risk sample. CONCLUSIONS: Results suggest that child behavioral inhibition may be associated with maternal criticism/dissatisfaction and confirm other reports of associations between criticism and child behavior and mood disorders and between emotional overinvolvement and child separation anxiety.

Stable behavioral inhibition and its association with anxiety disorder.

"Behavioral inhibition to the unfamiliar" is a temperamental construct reflecting the tendency to be shy, timid, and constrained in novel situations. Previous work has suggested that it may be associated with anxiety disorders in children. Psychopathology was assessed in children from a nonclinical sample originally identified as behaviorally inhibited or uninhibited at 21 months and followed through 7 1/2 years. Children who remained inhibited at 4, 5 1/2 and 7 1/2 years (Stable Inhibited) had higher rates of anxiety disorders than children who were not consistently inhibited. Their parents had higher rates of multiple childhood anxiety disorders and of continuing anxiety disorder. These results suggest that the association between behavioral inhibition and anxiety disorder is accounted for by children who have stable behavioral inhibition.

A 3-year follow-up of children with and without behavioral inhibition.

OBJECTIVE: Previous work suggested that children of parents with panic disorder and agoraphobia were likely to be classified as behaviorally inhibited and that behaviorally inhibited children were likely to develop anxiety disorders. Although these findings suggested that "behavioral inhibition to the unfamiliar" may be associated with risk for anxiety disorders in children, longitudinal data were needed to confirm the initial impressions. METHOD: Using DSM-III structured interviews, the authors examined psychiatric disorders at 3-year follow-up in children of two independently ascertained, previously described, and preexisting samples of children. One sample was cross sectional and clinically derived (Massachusetts General Hospital at-risk sample), and the other was epidemiologically derived and longitudinal (Kagan et al. Longitudinal Cohort). RESULTS: Analyses of follow-up findings revealed significant differences between inhibited and not inhibited children in the rates of multiple > or = 4 psychiatric disorders, multiple > or = 2 anxiety disorders, avoidant disorder, separation anxiety disorder, and agoraphobia. Among inhibited children, the rates of anxiety disorders increased markedly from baseline to follow-up assessments, attaining statistical significance for multiple > or = 2 anxiety disorders and avoidant disorder. Our findings also show there were significant differences between inhibited and not inhibited children in the emergence of multiple > or = 2 anxiety disorders, avoidant disorder, and separation anxiety disorder in children who did not have these diagnoses at baseline. CONCLUSIONS: These findings indicate that inhibited children are at high risk for developing childhood-onset anxiety disorders and provide additional support for the hypothesis that behavioral inhibition is a predictor of later anxiety disorder.

Five-factor personality traits in patients with seasonal depression: treatment effects and comparisons with bipolar patients.

BACKGROUND: Increasingly, the Five Factor Model (FFM) of personality is being used to assess personality characteristics of patients with Axis I disorders. Recent study indicates that patients with the seasonal subtype of major depression (SAD) may differ meaningfully from other depressed patients. In the present study, we further examined this finding, with attention to the stability of personality characteristics across treatment. METHODS: We used the NEO-FFM to assess the personality characteristics of two samples of depressed outpatients: patients with SAD and patients with bipolar disorder. Assessment was repeated in the SAD patients after light therapy. RESULTS: Consistent with previous research, we found elevated scores on the Openness domain in the SAD patients. SAD patients also scored significantly lower on Neuroticism and significantly higher on the Conscientiousness and Extroversion domains than patients with bipolar disorder. Scores on the Openness domain remained elevated after treatment of SAD; this occurred in the context of significant decreases in Neuroticism and increases in Extroversion scores. LIMITATIONS: These results were obtained in a relatively small-sample study. Although our sample of bipolar patients were taking mood stabilizers, it is unlikely that medication effects could explain our results. CONCLUSIONS: Our findings are consistent with those reported by Bagby et al. (Major depression and the five-factor model of personality. J. Pers. Disord. 1995;9:224-234) and suggests that Neuroticism and Extroversion are the FFM domains most responsive to treatment for depression. Our results also suggest that elevations on the Openness domain do not change with treatment and may be an enduring characteristic of patients with SAD.

A high risk study of young children of parents with panic disorder and agoraphobia with and without comorbid major depression.

Using family study methodology and psychiatric assessments by blind raters, this study tested hypotheses about patterns of familial association between anxiety and depressive disorders among high risk children of clinically referred parents. The study design contrasted five groups of children defined by the presence or absence in a parent of (1) panic disorder and agoraphobia (PDAG) without comorbid major depressive disorder (MDD) (n = 14); (2) comorbid PDAG plus MDD (PDAG + MDD) (n = 25); (3) MDD without comorbid PDAG (n = 12); (4) other psychiatric disorders (n = 23); and (5) normal comparisons (n = 47). While the PDAG and PDAG + MDD groups had similarly elevated rates of anxiety disorders and MDD, offspring of MDD parents had an elevated rate of MDD but not of anxiety disorders. Among children of parents with PDAG + MDD, the presence of an anxiety disorder did not significantly increase the risk for MDD in the same child. Thus, anxiety and MDD did not cosegregate among children of PDAG parents. These findings indicate that parental PDAG, either alone or comorbidly with MDD, increases the risk for both anxiety and depressive disorders in offspring. In the absence of PDAG, however, parental MDD does not appear to place children at risk for anxiety disorders. These findings are most consistent with the hypothesis that PDAG and PDAG + MDD share common familial etiologic factors while MDD alone is an independent disorder. More studies are needed to confirm these preliminary findings as well as to identify mediating factors that influence the transition from childhood to adult anxiety disorders.

Behavioral inhibition in childhood: a risk factor for anxiety disorders.

Childhood antecedents of anxiety disorders in adulthood remain poorly understood. We have, therefore, examined from longitudinal and familial perspectives the relationship between behavioral inhibition in children and anxiety disorders. We review a series of studies describing the association between behavioral inhibition and anxiety disorders in two independently ascertained and previously described samples of children. One sample was cross-sectional and clinically derived (Massachusetts General Hospital at-risk sample), and the other was epidemiologically derived and longitudinal (Kagan et al. longitudinal cohort). Our studies have found that (1) children of parents with panic disorder with agoraphobia, either alone or comorbid with major depressive disorder, are at increased risk for behavioral inhibition; (2) children identified as having behavioral inhibition have high rates of childhood-onset anxiety disorders themselves; (3) behavioral inhibition is associated with familial risk for anxiety disorders; (4) children with behavioral inhibition and anxiety disorders have greater familial loading of anxiety disorders; (5) children who remain inhibited over time are at highest risk for anxiety disorders in themselves and their families; and (6) these differences between inhibited children and not-inhibited controls become more robust at 3-year follow-up. Our research strongly indicates that behavioral inhibition is an identifiable early childhood predictor of later anxiety disorders.