Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders.

OBJECTIVE: To evaluate the frequency and clinical correlates of adult separation anxiety disorder in a large cohort of patients with mood and anxiety disorders. METHOD: Overall, 508 outpatients with anxiety and mood disorders were assessed by the structured clinical interview for diagnostic and statistical manual (IV edition) axis I disorders for principal diagnosis and comorbidity and by other appropriate instruments for separation anxiety into adulthood or childhood. RESULTS: Overall, 105 subjects (20.7%) were assessed as having adult separation anxiety disorder without a history of childhood separation anxiety and 110 (21.7%) had adult separation anxiety disorder with a history of childhood separation anxiety. Adult separation anxiety was associated with severe role impairment in work and social relationships after controlling for potential confounding effect of anxiety comorbidity. CONCLUSION: Adult separation anxiety disorder is likely to be much more common in adults than previously recognized. Research is needed to better understand the relationships of this condition with other co-occurring affective disorders.

Case study: ego-dystonic anger attacks in mothers of young children.

Parental anger can have detrimental effects on children and can contribute to physical abuse. Ego-dystonic anger attacks are an underrecognized psychiatric symptom that occurs in associated with depression, with other psychiatric disorders, and in the absence of comorbid disorders. They are characterized by overwhelming anger and autonomic arousal occurring upon provocation viewed as trivial by the individual, and they respond well to treatment with serotonergic antidepressants. Consequently, they represent a readily treatable problem. Four cases of anger attacks in mothers of young children are described to illustrate the importance of recognizing and treating anger attacks.

The bipolar spectrum: a clinical reality in search of diagnostic criteria and an assessment methodology.

Failure to recognize subthreshold expressions of mania contributes to the frequent under-diagnosis of bipolar disorder. There are several reasons for the lower rate of recognition of subthreshold manic symptoms, when compared to the analogous pure depressive ones. These include the lack of subjective suffering, enhanced productivity, ego-syntonicity, and diurnal and seasonal rhythmicity associated with many of the manic and hypomanic symptoms, and the psychiatrists' tendency to subsume persistent or even alternating symptoms among personality disorders. Furthermore, the central diagnostic importance placed on alterations in mood distracts clinicians from paying attention to other more subtle but clinically meaningful symptoms, such as changes in energy, neurovegetative symptoms and distorted cognitions. Although officially accepted in both ICD-10 and DSM-IV, we believe bipolar II disorder is underdiagnosed because of inattention to symptoms of hypomania. Moreover, by requiring the presence of both full-blown hypomanic and major depressive episodes, current nosology fails to include symptoms or signs which are mild and do not meet threshold criteria. There is already agreement in the field that such symptoms are important for depression. We now propose that attention should also be devoted to mild symptomatic manifestations of a manic diathesis, even if such manifestations may sometimes enhance quality of life. The term 'spectrum' is used to refer to the broad range of such manifestations of a disorder from core symptoms to temperamental traits. Spectrum manifestations may be present during, between, or even in the absence of, an episode of full-blown disorder. We have developed a structured clinical interview to assess the mood spectrum (SCI-MOODS) to evaluate the whole range of depressive and manic symptoms. This instrument is currently undergoing psychometric testing procedures. Similar to the SCID interview, the SCI-MOODS interview provides a separate rating for each of the major DSM-IV symptoms, but the latter also identifies and rates subthreshold and atypical manifestations. This paper presents the concept of a subthreshold bipolar disorder and discusses the potential epidemiological, diagnostic and therapeutic relevance of such a spectrum conditions. We also describe the SCI-MOODS interview used reliably to identify the occurrence of a bipolar spectrum condition. Obviously a great deal of systematic research needs to be conducted to ascertain the reliability and validity of subthreshold bipolarity as summarized in this paper and embodied in our instrument.

Influence of depression on the treatment of panic disorder with imipramine, alprazolam and placebo.

This paper presents findings from a multisite study of 126 subjects meeting DSM-III-R criteria for Panic Disorder who also met criteria for a concurrent Major Depressive Episode, Dysthymia, or Depressive Disorder NOS. The study's primary aim was to discern the influence of varying degrees of depression on the comparative efficacy of alprazolam, imipramine and placebo on anxiety outcomes. A placebo-controlled, double-blind, parallel random assignment design was utilized over a total of 16 weeks. There was no medication effect on panic outcomes. At endpoint, percent of anticipatory anxiety (i.e., time spent worrying about having an anxiety attack) was significantly lower in the patients taking active medications vs. placebo. Phobic measures were significantly improved by alprazolam, vs. both imipramine and placebo early in the study; however, by week 8 both active medications were equally superior to placebo in the reduction of phobic symptoms. In addition, both active medications were significantly more effective than placebo in reducing depression. The same efficacy pattern (i.e., active medications superior to placebo) was observed on measures of general functioning. Importantly, there were no significant interactions observed between medication and presence of major depression on the depression measures, indicating that both alprazolam and imipramine were equally efficacious in treating the depression in patients with panic disorder and major depression. Since the patients enrolled in this study suffered from major depressive disorder in the mild to moderate severity range, these results may not be transferrable to patients with panic disorder and severe major depression.

Anxiety disorders in late life: an evolving picture.

Although anxiety disorders are the most prevalent group of disorders in the United States, little is known about the efficacy of treatments for these disorders in elderly patients. Anxiety disorders, especially generalized anxiety disorder and phobias, are highly prevalent in older people. Anxiety symptoms and disorders are associated with increased mortality and disability in older people. Risk factors for anxiety disorders include chronic medical illness, disability, low education, low social network, and poor social support. The newer antidepressant medications, in particular the selective serotonin reuptake inhibitors and venlafaxine-extended relief, are recommended as first-line pharmacotherapy of these disorders in elderly. Cognitive-behavioral therapy is recommended as first-line psychotherapy for these disorders. However, these recommendations are based on extrapolation of data from younger adults or retrospective analysis of datasets, the results need to be confirmed with controlled studies in an elderly age group.

Field trial of a diagnostic axis for defense mechanisms for DSM-IV.

Following critiques that the DSM multiaxial system lacks psychodynamic information useful for treatment, an axis for defense mechanisms was developed for DSM-IV, including up to 7 individual defenses from a glossary of 27, and 3 predominant defense levels from a list of 7. We tested the feasibility, reliability, and discriminability of the proposed axis. Clinician and psychiatric resident volunteers were trained at two U.S. and one Norwegian sites. After conducting initial interviews on 107 patients, they rated the DSM-III-R and defense axes, as did a second blind rater. Median kappa reliabilities were .42 (individual defenses), and .47 (defense levels). A summary measure, Overall Defensive Functioning (ODF), had similar reliability to current GAF (IR .68 vs. .62), similar 1-month stability (.75 vs. .78), but greater 6-month stability (.51 vs. .17). Independent of Axis III, ODF had small to moderate associations with other Axes and symptoms. Our findings indicate that the defense axis is a feasible, acceptably reliable, and nonredundant addition to DSM-IV, which may prove useful for planning and conducting treatment.

Anger attacks and treatment nonadherence in a perinatal psychiatry clinic.

Anger attacks are common in depressive disorders. High levels of anger have been associated with treatment nonadherence in medical and psychiatric patients. In this study we examined the relationship between anger attacks and treatment nonadherence in a perinatal psychiatry clinic that treats pregnant and postpartum women. Treatment adherence was examined by chart review. Patients with anger attacks at initial assessment were more likely to drop out of treatment than were patients without anger attacks at initial assessment (11/34 vs. 2/21; one-tailed Fisher's exact test p < .05). Treatment nonadherence among pregnant and postpartum women with anger attacks may be an important problem because of its impact on treatment outcome and because anger in depressed mothers is frequently directed at their children.