Thirty-month naturalistic follow-up study of early-onset dysthymic disorder: course, diagnostic stability, and prediction of outcome.

Dysthymic disorder (DD) is defined and distinguished from major depressive disorder (MDD) largely on the basis of its course. Surprisingly, however, there have been few prospective, longitudinal studies of the naturalistic course of DD. This article reports the major findings from a prospective, longitudinal 30-month follow-up study of 86 outpatients with early-onset DD (EOD) and 39 outpatients with episodic MDD. Follow-up assessments included the Longitudinal Interval Follow-Up Evaluation and Hamilton Rating Scale for Depression. Compared with patients with episodic MDD, patients with EOD exhibited less improvement from the baseline evaluation and were more symptomatic at follow-up. Only 39% of patients with EOD recovered from DD during the follow-up period. The diagnosis of DD was fairly stable, with 52% of the EOD group meeting full criteria for DD at follow-up. These data provide prospective confirmation of the chronic course of DD.

Understanding the comorbidity between early-onset dysthymia and cluster B personality disorders: a family study.

OBJECTIVE: A number of studies have documented significant comorbidity between dysthymia and axis II personality disorders, particularly those grouped in cluster B. However, the nature of this comorbidity is poorly understood. The purpose of this investigation was to use the family study method to test five competing models of the comorbidity between early-onset dysthymia and cluster B personality disorders. METHOD: Proband groups consisted of subjects with early-onset dysthymia and a co-occurring cluster B personality disorder (N = 28), subjects with early-onset dysthymia without a cluster B personality disorder (N = 69), and a comparison group of subjects who had never been psychiatrically ill (N = 45). The groups were compared on rates of dysthymia with a cluster B personality disorder, dysthymia without a cluster B personality disorder, and cluster B personality disorders without dysthymia in their first-degree relatives (N = 675). RESULTS: The relatives of both subgroups of dysthymic probands exhibited higher rates of dysthymia with a cluster B personality disorder, dysthymia without a cluster B personality disorder, and cluster B personality disorders without dysthymia than the relatives of the never ill probands. In addition, the relatives of probands with comorbid dysthymia exhibited higher rates of cluster B personality disorders without dysthymia than the relatives of probands with noncomorbid dysthymia. CONCLUSIONS: This pattern of results is consistent with the notion that dysthymia and cluster B personality disorders co-occur because of shared etiological factors. This was the only one of five models of the comorbidity between dysthymia and cluster B personality disorders that was supported by the family data.

Family study of early-onset dysthymia. Mood and personality disorders in relatives of outpatients with dysthymia and episodic major depression and normal controls.

BACKGROUND: The nosological status of dysthymia has generated considerable controversy. The major issues include whether dysthymia should be classified as a form of mood or personality disorder and, if dysthymia is classified as a mood disorder, whether it is sufficiently distinct from major depression to warrant a separate category. METHODS: We conducted a family study of 97 outpatients with early-onset dysthymia, 45 outpatients with episodic major depression, and 45 normal controls, and their 882 first-degree relatives. Axis I and II disorders were assessed in relatives using direct and informant interviews and all available medical records. RESULTS: The rate of major depression in the relatives of early-onset dysthymic probands was significantly greater than in the relatives of normal controls and non-significantly greater than in the relatives of episodic major depressive probands. The rate of dysthymia was significantly greater in the relatives of dysthymic probands than in relatives of both major depressive probands and normal controls. Rates of most personality disorders were increased in the relatives of the dysthymic and major depressive probands compared with relatives of normal controls. In addition, the relatives of dysthymic probands had significantly higher rates of any personality disorder and any cluster B disorder than those of episodic major depressive probands, although these differences disappeared after controlling for Axis II comorbidity in the probands. Finally, dysthymic probands with and without a lifetime history of major depression did not differ on rates of psychiatric disorders in relatives. CONCLUSIONS: There is a strong familial relationship between dysthymia and major depression. However, dysthymia is also somewhat distinct in that it aggregates specifically in the families of patients with dysthymia. Finally, dysthymia and episodic major depression both appear to have a familial association with the personality disorders, although the link appears to be somewhat stronger for dysthymia.

Atypical anxiety disorder: a descriptive study.

This retrospective study examined 75 outpatients who received an atypical anxiety disorder diagnosis in a 30-month period. Patients who were later rediagnosed tended to have multiple anxiety diagnoses. "Atypical," in this sense, meant that insufficient information was available to arrive at specific anxiety diagnoses. A subgroup that continued to be diagnosed as atypical throughout their treatment tended to have multiple subsyndromal complaints, unusual symptoms, or both. This subgroup raises questions regarding the cutoff criteria for the anxiety disorders in DSM-III and DSM-III-R and suggests a possible new diagnostic subtype for future investigation.

Biological correlates of lactate sensitivity in panic disorder.

In this pilot study, 9/9 patients with panic disorder experienced a lactate-induced panic attack as compared with 0/9 controls. Baseline measurements were significant for higher anxiety self-ratings, higher heart and respiratory rates, elevated potassium, and lower lymphocyte 3H-dihydroalprenolol (DHA) binding in the patient group. Spielberger State anxiety scores correlated with baseline mean heart rate, and Spielberger Trait anxiety scores with lymphocyte DHA binding. The lactate infusion was not found to differentially affect any physiological or biochemical measures in the two groups, though heart rate surges occurred in most patients. Intravenous propranolol reduced the panic to a negligible degree, whereas intravenous diazepam was quite effective. Neurobiological implications are discussed, and the contradictory biological findings in the lactate literature are reviewed.

A critical review of psychotherapeutic treatments of the borderline personality. Historical trends and future directions.

The borderline personality was originally thought to be on the border of psychosis and treatability. Most psychoanalytic writers of the 1940s-1960s gave these patients subschizophrenic labels and emphasized a supportive, limited treatment approach. They noted that these patients often regressed and became worse with analytic treatment. Nevertheless, in the 1970s a major impetus for a renaissance and revitalization of psychoanalytic thought was a recasting of the theory and therapy of the borderline personality. Renewed optimism and vigor characterized the intensive, exploratory treatment approaches to these writings. The 1980s, however, curiously show a fragmentation of and retrenchment from these views, and a return to many of the treatment recommendations of the earlier authors. The literature on the treatment of the borderline personality is critically examined from a historical perspective in this review. Highlighted, in particular, are the commonalities, trends, empirical studies, and future directions in the treatment literature.

Long-term continuation antidepressant treatment: a comparison study.

This retrospective study examined the clinical characteristics and the course of 26 patients with major affective disorders who repeatedly relapsed during or shortly after antidepressant tapering off at the usual 6-12-month intervals. The patients apparently required long-term antidepressant continuation therapy not preventive therapy, as they were unable to be successfully tapered off antidepressants over a mean of 36.6 months. In contrast with a group of 15 randomly selected patients with a more typical recurrent course of illness and successful tapers after 6-12 months of treatment, the long-term continuation therapy patients were younger, had a longer duration of depression before entering treatment, and were more likely to meet the DSM-III criteria for concomitant dysthymic, panic, or personality disorder or major depression with psychotic features. The findings suggest that secondary Axis I and Axis II diagnoses in antidepressant-responsive depressed patients are associated with the need for long-term continuation treatment.

Treatment-emergent depression with antidepressants in panic disorder.

Two patients with panic disorder received therapeutic doses of antidepressants. They developed endogenomorphic symptoms of major depression according to DSM-III-R criteria despite remission of their panic attacks. Treatment-emergent depression in panic disorder has been previously associated with high potency benzodiazepines. Whether antidepressant medications may unmask a depressive diathesis or are coincidentally associated with depression is discussed in this report.

Differential reactivity to lactate infusions: the relative role of biological, psychological, and conditioning variables.

Nine patients with panic disorder experienced a lactate-induced panic attack, whereas nine controls did not. Higher preinfusion anxiety levels and heart rates were associated with panic disorder, and high baseline anxiety ratings were associated with atypical, severe lactate-induced panic attacks. Nevertheless, it was difficult to reconcile patients' and controls' reactivity to lactate as entirely secondary to baseline differences. Subjects differed qualitatively in the types of specific symptoms experienced and quantitatively in their anxiety and heart rate responses. In most cases, panic began with various central perceptual changes; peripheral cardiovascular and autonomic symptoms followed later. No patient rated a lactate-induced panic attack as identical to a naturally occurring attack. Not only did specific symptoms differ in their severity and order of production, but lactate-induced panic lacked the typical fears of dying, going crazy, or losing control. The results suggest that though environmental effects, expectancy biases, and baseline psychological states play salient roles in modifying the experience of a lactate-induced panic attack, they do not fully account for lactate sensitivity. The relative role that biological, psychological, and conditioning factors play in lactate-induced panic is discussed.

Paranoia and narcissism in psychoanalytic theory. Contributions of self psychology to the theory and therapy of the paranoid disorders.

Many factors go into a choice of a therapeutic focus: the patient's psychopathology; the therapist's training, countertransference reactions, and ideological beliefs; and, importantly, a decision about what seems most amenable to treatment and change. As a theory, self psychology describes one aspect of the paranoid process; as such, it is an incomplete theory that complements rather than invalidates more classical theories. As a technique, however, it suggests a style and focus conducive to working with paranoid patients, one that is markedly supportive, nonconfrontational, yet also interpretive. In this context, it must be remembered how difficult it is to treat paranoid patients psychotherapeutically, much less to keep them in treatment. The strategies discussed above do not wholly replace other dynamic approaches (e.g., counterprojective techniques), nor are they universally applicable. Some patients may be more amenable than others. However, the techniques provide a very supportive framework that may help the therapist to be more available to and in contact with the paranoid patient. More broadly, this paper's application of self psychology to the theory and therapy of the paranoid disorders further illustrates the practical utility of this approach. Attention to the narcissistic developmental line, interpersonal selfobject relationships, intrapsychic conflicts and deficits, and empathic immersion in the patients's world are important adjuncts to the psychotherapy of paranoid patients. Rather than an either/or dichotomy, the principle of overdetermination suggests a both/and relationship between self psychology and traditional theory, such that the self psychological approach complements rather than contradicts the classical psychoanalytic theory. The vicissitudes of the self simply add another perspective or vantage point from which to understand and respond to the patient, one which has perhaps more applicability for preoedipally disordered patients.

Clonazepam treatment of five lithium-refractory patients with bipolar disorder.

The authors describe the first five patients enrolled in an open clinical trial of clonazepam as a maintenance treatment in lithium-refractory bipolar disorder. All patients relapsed quickly after taking clonazepam (one within 2 weeks and four within 10-15 weeks), and the study was prematurely terminated. The results cast doubt over the usefulness of clonazepam as a prophylaxis in lithium-resistant bipolar patients who have histories of psychotic mania or delusional depression.

Failure to detect organic factors in mania.

Forty patients from an outpatient lithium clinic were studied who had a clear history of organic abnormalities which predated their affective symptomatology. In the course of reviewing the clinical histories regarding these patients, it was observed that only 37.5% of the patients had ever received a clinical diagnosis of organic affective syndrome. Variables associated with a failure to consider a diagnosis of organic affective syndrome were investigated.

Cognitive function in manics with associated neurologic factors.

Researchers studying cognition in mania have assumed that mania is a homogeneous entity. Recent preliminary evidence indicates that some manic syndromes may be preceded by medical, pharmacological, and neurologic antecedents. While DSM-III suggests that mild cognitive impairment may be associated with these manic syndromes, studies to date have not documented this assertion. We compared bipolar patients with antecedent neurologic factors (neurologic manics, NM) to bipolar patients without such histories (primary manics, PM) on standard neuropsychological measures and clinical parameters to ascertain whether cognitive testing could be used as an adjunctive diagnostic tool in defining this subgroup of patients. Results indicated that the NM group was more dysfunctional in intellectual functioning and course of psychiatric illness than the PM group.

Phenomenology of panic attacks: a descriptive study of panic disorder patients' self-reports.

The phenomenology of panic disorder and panic attacks was systematically assessed in 46 consecutive patients. The results suggest that DSM-III criteria include several symptoms that are not frequently present during a panic attack and that DSM-III's characterization of a panic attack is imprecise and misleading. Panic attacks were found to vary in intensity, frequency, spontaneity, and associated symptoms. A panic attack typically presents as a unified symptom complex of psychic anxiety and multiple somatic symptoms in multiple body systems. It occurs in a crescendolike pattern, is self-limited, and often leaves the subject weak or shaken. The temporal course as much as the symptomatic presentation defines a panic attack.

Proposed delusional depression subtypes: preliminary evidence from a retrospective study of phenomenology and treatment course.

An analysis of the phenomenology and treatment course of 52 subjects with delusional depression suggests that there may be various subtypes: bipolar, early-onset unipolar and possibly a late-onset unipolar. The bipolar subgroup tended to relapse in different but always psychotic directions, and was resistant to lithium carbonate treatment alone. Treatment refractoriness, delusional depressive recurrences, and a dementia-like presentation were associated with a small late-onset subgroup. A high rate of delusionally depressive relapses also characterized the early-onset unipolar group, however, patients with single episodes were found only in this subgroup.

Mania with associated organic factors.

Thirty-nine patients with bipolar illness preceded by organic factors were compared to age and sex matched bipolar controls. The patients with pre-existing organic factors were older at onset of their bipolar illness, had fewer depressive episodes, less family history of affective disorder, and were symptomatically different in a number of respects. The nosology of such disorders is discussed and the literature reviewed.

A follow-up of two panic disorder-agoraphobic study populations. The role of recruitment biases.

A self-referred and recruited panic disorder-agoraphobic study population are compared in terms of their symptomatic presentation and treatment outcome. The recruited group was found to be more symptomatically severe, more phobic, less character disordered, and more likely to stay in treatment. Implications for the potential methodological biases in recruiting study populations are explored.