Simple phobia as a comorbid anxiety disorder.

This study sought to describe clinical and demographic characteristics differentiating patients with DSM-III-R simple phobias comorbid with one or more of five DSM-III-R index anxiety disorders as compared with those with the index diagnoses alone. From 711 subjects participating in a multicenter, longitudinal, naturalistic study of anxiety disorders, 115 subjects with comorbid simple phobias were compared with 596 subjects without simple phobias in terms of demographic data, comorbidity with other disorders, somatic and psychosocial treatment received, and quality of life. In addition, episode characteristics, types of simple phobias found, and course of illness were specified. Subjects with simple phobias had more additional comorbid anxiety disorders by history than did those without. Mean length of intake episode was 22.43 years and severity was typically moderate. Fears of heights and animals were the most commonly represented simple phobias. Subjects with uncomplicated panic disorder were less likely to have comorbid simple phobias than were subjects with other index diagnoses, and subjects with simple phobia were more likely to have comorbid posttraumatic stress disorder than were these without simple phobia. Subjects with and without simple phobias did not differ by somatic or psychosocial treatment received or in terms of quality of life. Simple phobia appeared in this study to be a chronic illness of moderate severity for which behavioral treatment methods of recognized efficacy were not being frequently utilized. Uncomplicated panic disorder may reflect some type of resistance to phobia development.

Changes in regional cerebral blood flow following light treatment for seasonal affective disorder: responders versus nonresponders.

BACKGROUND: Several brain imaging studies of antidepressant pharmacologic treatment utilizing single photon emission computed tomography (SPECT) have reported a normalization of deficits in cerebral blood flow (CBF) associated with recovery; other studies report no change, or a reduction in CBF following successful treatment. There have been no published SPECT studies of seasonal affective disorder (SAD) assessing response to light treatment in relation to changes in regional CBF (rCBF). In this study, we sought to test the hypothesis that increases in rCBF would be observed in SAD patients who responded to light treatment. METHODS: Ten depressed patients with SAD underwent functional brain imaging studies with 99mTc-hexamethylpropyleneamine oxime SPECT before and after light treatment. RESULTS: Relative increases in rCBF were observed in all brain regions compared to cerebellum in treatment responders, whereas nonresponders showed no change or decreases in rCBF relative to cerebellum. Significant differences in mean percentage change in rCBF between responders (n = 5) and nonresponders (n = 5) were detected in frontal and cingulate cortex, and thalamus. CONCLUSIONS: These findings provide preliminary support for the hypothesis that an increase in rCBF is associated with recovery from depression in SAD.

Panic disorder versus panic disorder with major depression; defining and understanding differences in psychiatric morbidity.

The present study examined the impact of comorbid major depressive disorder (MDD) on psychiatric morbidity, panic symptomatology and frequency of other comorbid psychiatric conditions in subjects with panic disorder (PD). Four hundred thirty-seven patients with PD were evaluated at intake as part of a multicenter longitudinal study of anxiety disorders; 113 of these patients were also in an episode of MDD. Patients were diagnosed by DSM-III-R criteria utilizing structured clinical interviews. The 113 PD/MDD patients were compared with the 324 remaining PD subjects regarding panic symptoms at intake, sociodemographic, quality of life and psychiatric morbidity variables. Differences in frequency of other comorbid Axis I psychiatric disorders were assessed at intake; personality disorders were evaluated twelve months after intake. The results revealed the PD/MDD patients exhibit increased morbidity and decreased psychosocial functioning as compared to PD patients. Personality disorders were more prevalent in the PD/MDD group at six month follow-up assessment; the PD/MDD group also had an increased frequency of posttraumatic stress disorder (PTSD) and more comorbid Axis I anxiety disorders as compared to the PD group. The total number and frequency of panic symptoms was highly consistent between the two patient groups.

Regional cerebral blood flow changes after light therapy in seasonal affective disorder.

There is considerable evidence to indicate that depressive disorders may be associated with changes in regional cerebral blood flow (rCBF), and that successful treatment may reverse these changes. We studied patients with seasonal affective disorder (SAD) using 99Tcm-hexamethylpropylene amine oxime (99TCm-HMPAO) single photon emission tomography (SPET) to examine the effect of light therapy on rCBF. Ten depressed patients (8 females, 2 males) with a mean (+/- S.D.) age of 33.5 +/- 11.3 years underwent 99TCm-HMPAO SPET studies before and after light therapy. The treatment response was evaluated using the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorders Version (SIGH-SAD). A patient was considered responsive to light therapy if the post-treatment SIGH-SAD score was reduced by 60% or more in comparison to the pre-treatment score (responders, n = 5; non-responders, n = 5). Pre- and post-treatment SIGH-SAD scores and SPET data were compared in each patient. An improvement in depressive symptoms after light therapy was associated with an increase in rCBF in the frontal and cingulate regions as well as the thalamus. Such changes were not seen in non-responsive subjects.

Focal cerebral perfusion defects demonstrated by 99mTc-hexamethylpropyleneamine oxime SPECT in elderly depressed patients.

High resolution single photon emission computed tomography (SPECT) was used to evaluate regional cerebral blood flow (rCBF) in 14 acutely depressed elderly patients and 29 normal subjects. SPECT images of the two groups were randomized and blindly read. Foci of decreased radionuclide uptake were assessed by number and location. The total number of rCBF defects per whole brain study was significantly greater in the depressed patients than in the normal subjects. A significantly greater number of rCBF defects was found most strikingly in the lateral frontal and less prominently in the lateral and medial temporal brain regions of the depressed patients.

Single photon emission computed tomography in psychiatry: current perspectives.

Single photon emission computed tomography (SPECT) is a widely available neuroimaging technique for the three-dimensional assessment of regional cerebral blood flow. The clinical utility of SPECT in neuropsychiatry is well established, and research devoted to its use in primary psychiatric disorders has been gaining momentum. In this review recent developments in SPECT neuroimaging are described, including the utility of SPECT in the differential diagnosis of the dementias and other neuropsychiatric conditions; SPECT studies of patients with affective disorders, at baseline and after treatment; and SPECT studies utilizing innovative techniques such as neuroreceptor imaging and activation strategies. Advances in SPECT research methodology and study design that may contribute to clarifying the pathophysiology of psychiatric disorders are examined.

Profile of a large sample of patients with social phobia: comparison between generalized and specific social phobia.

This study examines a large cohort of subjects with social phobia, as part of a larger naturalistic and longitudinal study of 711 subjects with anxiety disorders. We focused on 176 subjects who were in an episode of social phobia at intake. We were particularly interested in evaluating the diagnostic distinction between generalized and specific social phobia. We compared these two groups along demographic characteristics, comorbidities, psychosocial functioning (health, role functioning, social functioning, and emotional functioning) and global assessment scores. We found that generalized social phobics tended to have an earlier age of onset as compared to the specific group; however, this is not a statistically significant difference at this level of analysis. The two groups did not differ for the current comorbidities examined. We observed no differences in the treatment received by the two types of social phobia subjects, and the two groups functioned equally well in terms of health and fulfilling social roles. In addition, we examined adverse childhood events (i.e., death of a parent, childhood abuse) and found no evidence for any differential impact these events might have on the type of social phobia. Although we did observe significantly greater fear of public speaking among the specific compared to the generalized group, which may indicate a qualitative difference between the subtypes, our results suggest that for most parameters, generalized and specific social phobia represent a continuum of similar and overlapping entities.

DSM-IV and the disappearance of agoraphobia without a history of panic disorder: new data on a controversial diagnosis.

OBJECTIVE: This analysis describes subjects who met rigorous criteria for DSM-III-R agoraphobia without a history of panic disorder and makes inferences from these data regarding relationships among agoraphobia without a history of panic disorder, panic disorder, and panic disorder with agoraphobia. METHOD: Twenty-six subjects (seven men and 19 women) with agoraphobia without a history of panic disorder were identified from among 711 subjects recruited for a multicenter, longitudinal anxiety disorder study. Narrative transcripts prepared by raters from study evaluations were coded for limited symptom attacks, situational panic, catastrophic cognitions, and possible precipitants and stressors, course, and somatic and psychosocial treatments received. RESULTS: Sixty-five percent of the subjects reported experiences consistent with situational panic attacks, and 57% had definite or probable limited symptom attacks; these attacks usually preceded or appeared at the same time as avoidance behavior. Eighty-one percent had catastrophic cognitions associated with agoraphobia. Twenty-six percent reported a likely precipitating factor for symptom onset, and 30% reported a definite or probable major life stressor within 6 months before symptom onset. Cognitive-behavioral treatments were relatively infrequently used. Course was relatively unchanged across the follow-up period. CONCLUSIONS: These data support a view of agoraphobia without a history of panic disorder on a continuum with uncomplicated panic disorder and with panic disorder and agoraphobia, rather than as a separate diagnosis.

Comorbidity of anxiety disorders in a multicenter anxiety study.

From 11 sites in New England and Missouri, 711 patients with > or = one of five index anxiety disorders were recruited onto a longitudinal study in which they were interviewed every 6 months regarding symptoms, course, and treatments received. Of the five disorders studied, panic disorder without agoraphobia was the disorder most often found as a sole diagnosis and generalized anxiety disorder (GAD) was least often found alone, both as lifetime diagnoses or when restricted to cases active at intake. Panic disorder with agoraphobia and agoraphobia without history of panic disorder (AWOPD) had three specific diagnoses with which they were frequently comorbid: social phobia, simple phobia, and GAD. AWOPD, social phobia, and GAD were frequently found in the presence of each other. It is possible that the experience of anxiety due to any syndromal cause may decrease the threshold for an individual to experience other anxiety symptoms or disorders. Clinicians should be aware of these patterns of comorbidity in order to formulate accurate differential diagnoses and prescribe treatments in a rational manner.

SPECT imaging of the brain: comparison of findings in patients with chronic fatigue syndrome, AIDS dementia complex, and major unipolar depression.

OBJECTIVE: Chronic fatigue syndrome is an illness of unknown origin that begins abruptly with a flulike state and has symptoms suggesting both a chronic viral encephalitis and an affective disorder. We compared single-photon emission computed tomography (SPECT) scans of patients with chronic fatigue syndrome with those of patients with AIDS dementia complex and unipolar depression. SUBJECTS AND METHODS: We used 99mTc-hexamethylpropyleneamine oxime to examine 45 patients with chronic fatigue syndrome, 27 patients with AIDS dementia complex, and 14 patients with major unipolar depression. Scans of 38 healthy persons were used as controls. Comparison of regional defects between groups, as well as midcerebral uptake indexes (an objective measure of global radionuclide uptake), was performed by using analysis of variance with the Student-Newman-Keuls option. Correlation between the number of regional defects and the midcerebral uptake index was determined by using the Spearman rank-correlation test. RESULTS: Patients with AIDS dementia complex had the largest number of defects (9.15 per patient) and healthy patients had the fewest defects (1.66 per patient). Patients with chronic fatigue syndrome and depression had similar numbers of defects per patient (6.53 and 6.43, respectively). In all groups, defects were located predominantly in the frontal and temporal lobes. The midcerebral uptake index was found to be significantly lower (p < .002) in the patients with chronic fatigue syndrome (.667) and patients with AIDS dementia complex (.650) than in patients with major depression (.731) or healthy control subjects (.716). Also, a significant negative correlation was found between the number of defects and midcerebral uptake index in patients with chronic fatigue syndrome and AIDS dementia complex, but not in depressed patients or control subjects. CONCLUSION: These findings are consistent with the hypothesis that chronic fatigue syndrome may be due to a chronic viral encephalitis; clinical similarities between chronic fatigue syndrome and depression may be due to a similar distribution and number of defects in the two disorders.

Effect of personality disorders on the treatment outcome of axis I conditions: an update.

The authors review recent studies that assess the impact of personality pathology on the treatment outcomes of axis I disorders. Studies reported include both structured treatment trials and surveys of the outcome of naturalistic treatment. Personality diagnosis in each of the studies reviewed was established by a structured diagnostic instrument. In some of the studies examined, personality traits, not categorical personality diagnoses, are reported in relation to treatment outcome. The authors describe 17 studies published within the past 3 years, and discuss them in relation to a previous review that covered 21 earlier studies. Consistent with previous investigations, recent studies continue to describe an adverse impact of personality pathology on the treatment outcome of a wide range of axis I disorders. The authors examine new studies that describe the effect of specific aspects of personality dysfunction on outcome measures of axis I disorders. New developments in this area include the predictive importance of both personality traits and disorders as well as possible specificity of traits in predicting outcome in some circumstances.

Changes in norepinephrine output following light therapy for fall/winter seasonal depression.

Recurrent fall/winter depressions that remit during spring and summer have been called Seasonal Affective Disorders (SAD) (Wehr and Rosenthal 1989). The pathophysiology of SAD, its relationship to nonseasonal affective disorders, and the mechanism of action of light therapy, which is effective in treating SAD, remain to be elucidated (Depue et al 1989; Jacobsen et al 1987; James et al 1986; Joseph-Vanderpool et al 1991; Skwerer et al 1988, Terman et al 1989). Norepinephrine (NE) may play a role in the mechanisms of action of many antidepressant treatments (Schildkraut 1965) that alter NE metabolism (Schildkraut et al 1964 and 1965) and decrease the urinary output of NE and its metabolites, i.e., "whole-body NE turnover" (WBNET) (Golden et al 1988; Potter et al 1988). The present study explored whether light therapy also reduces the urinary output of NE and its metabolites.

Abnormal flash visual evoked response in melancholia: a replication study.

Grand mean flash visual evoked responses (FVER) were measured in two new groups of depressed patients with melancholia to replicate findings of an abnormal FVER in a previously reported pilot study (Vasile et al 1989). These different, independently collected groups of melancholic patients demonstrated a statistically significant negative deviation of the FVER 224-300 msec poststimulus maximal in the midline centroparietal region when compared with appropriate normative age-matched control groups (n = 56) in each group). We utilized the identical computer-based quantified neurophysiological technique with mapping to analyze the data in all three melancholic patient groups--the pilot group (n = 9) with mean age 73.1 years, an older replication group (n = 14) with mean age 75.5 years, and a younger replication group (n = 15) with mean age 63.8 years. We also studied a group of depressed patients without melancholia (n = 11) with mean age 65.2 years, and found a similar, but less pronounced, alteration of the FVER. Lastly, we studied a group of nondepressed neuropsychiatric patients (n = 10) with mean age 61.9 years and found no abnormality of the FVER. Our data suggest that a gradient of FVER abnormality exists in depressed patients, most prominent, but not limited to elderly melancholic patients.

A biopsychosocial approach to treating patients with affective disorders.

The authors describe the development of an affective disorders consultation service that implemented a biopsychosocial model of subspecialty consultation within a university-affiliated community mental health center. They retrospectively analyzed the first 2 years of consultations, assessing the process of consultation and examining patterns of consultee inquiries and consultation recommendations. Consultants recommended combined psychopharmacologic and psychodynamic therapies for most patients and found psychodynamic psychotherapy strikingly overlooked by consultees, all of whom were psychiatrists or other mental health professionals. This evaluation documents the psychiatric consultees' deemphasis of the biopsychosocial perspective in clinical practice.

HLA in psychiatric and control subjects. A comparative study of HLA antigen frequencies in schizophrenic, schizoaffective and control subjects.

HLA antigens were typed among 24 schizophrenic, 13 schizoaffective and 246 control subjects. Schizoaffective patients showed significantly decreased incidence of A2 compared with schizophrenic patients or controls.