Catherine Mancini

The impact of anxiety disorders on educational achievement

Anxiety disorders typically have an age of onset in childhood and adolescence, resulting in significant disability in social and occupational functioning. Epidemiological evidence suggests that persons with psychiatric disorders and perhaps especially social phobia are at increased risk for premature withdrawal from school [Am. J. Psychiatry 157 (2000) 1606]. In order to further determine the impact of anxiety disorders on school functioning and/or premature withdrawal from school, 201 patients meeting DSM-IV criteria for a primary anxiety disorder completed a school leaving questionnaire as well as self-report measures of anxiety, depression, and social adjustment. About 49% (n = 98) reported leaving school prematurely and 24% of those indicated that anxiety was the primary reason for this decision. Patients who had left school prematurely were significantly more likely to have a lifetime diagnosis of generalized social phobia, a past history of alcohol abuse/dependence and a greater number of lifetime diagnoses than those who completed their desired level of education. This study suggests that anxiety disorders, and perhaps especially generalized social phobia, are associated with premature withdrawal from school. Further studies are required to determine methods for early identification and treatment of anxiety disorders in school aged children to enable these students to reach their full potential.

Post-traumatic stress disorder in Canada.

Post‐traumatic stress disorder (PTSD) has become a global health issue, with prevalence rates ranging from 1.3% to 37.4%. As there is little current data on PTSD in Canada, an epidemiological study was conducted examining PTSD and related comorbid conditions. Modified versions of the Composite International Diagnostic Interview (CIDI) PTSD module, the depression, alcohol and substance abuse sections of the Mini International Neuropsychiatric Interview (MINI), as well as portions of the Childhood Trauma Questionnaire (CTQ) were combined, and administered via telephone interview in English or French. Random digit dialing was used to obtain a nationally representative sample of 2991, aged 18 years and above from across Canada. The prevalence rate of lifetime PTSD in Canada was estimated to be 9.2%, with a rate of current (1‐month) PTSD of 2.4%. Traumatic exposure to at least one event sufficient to cause PTSD was reported by 76.1% of respondents. The most common forms of trauma resulting in PTSD included unexpected death of a loved one, sexual assault, and seeing someone badly injured or killed. In respondents meeting criteria for PTSD, the symptoms were chronic in nature, and associated with significant impairment and high rates of comorbidity. PTSD is a common psychiatric disorder in Canada. The results are surprising, given the comparably low rates of violent crime, a small military and few natural disasters. Potential implications of these findings are discussed.

Relationship of childhood sexual and physical abuse to anxiety disorders

This study reports on the relationship of childhood sexual and physical abuse in adult outpatients of an anxiety disorders clinic. A total of 205 consecutive patients admitted to two anxiety disorders clinics in Hamilton, Ontario, Canada, were given the Child Maltreatment History-Self-Report to elicit a history of childhood sexual or physical abuse. Childhood sexual abuse was reported by 23.4% and childhood physical abuse by 44.9%. Patients with a history of childhood sexual or physical abuse had significantly higher Beck depression scores and concurrent major depression, as well as more significant impairment in social functioning. They also demonstrated significantly higher state and trait anxiety scores. The occurrence of sexual or physical abuse was not associated with the presence of any particular primary anxiety disorder diagnosis. However, childhood sexual and/or physical abuse may affect the severity of the anxiety disorder as well as the presence of concurrent major depression.

A High-Risk Pilot Study of the Children of Adults with Social Phobia

OBJECTIVE Children of patients with social phobia were studied to estimate their rates of psychiatric disorder. METHOD Twenty-six social-phobic outpatients who had at least one child between the ages of 4 and 18 years participated in the study. Information was collected from parents on all 47 children and from the children between 12 and 18 years of age. Diagnoses in the children were made based on DSM-III-R and were done by a best-estimate method, using parent and child reports from a modified Anxiety Disorders Interview Schedule for Children, the Survey Diagnostic Instrument, the Current Self-Report Childhood Inhibition Scale, and the Alcohol Dependence Survey. RESULTS Of the 47 children, 49% had at least one lifetime anxiety disorder diagnosis. The most common diagnoses were overanxious disorder (30%), social phobia (23%), and separation anxiety disorder (19%). Sixty-five percent had more than one anxiety disorder diagnosis. Lifetime major depression was found, in 8.5% of the children. Parents whose children met criteria for an anxiety disorder had a greater mean number of comorbid diagnoses than did the parents of unaffected children. CONCLUSION This pilot study suggests that children of social-phobic parents may have increased rates of psychiatric disorder. Further studies incorporating a control group are needed.

Sertraline in social phobia

Twenty-two patients meeting a primary DSM-III-R diagnosis of Social Phobia, entered a 12 week open trial of sertraline. Twenty patients completed at least 8 weeks of treatment. Sixteen patients (80%) were considered responders and 4 (20%) were considered non-responders. All measures of social anxiety and avoidance, depression and social functioning showed a statistically significant change from baseline to end point.

Buspirone augmentation of selective serotonin reuptake inhibitors (SSRIs) in social phobia

We evaluated the efficacy of buspirone, in the augmentation of social phobic symptom response to the selective serotonin reuptake inhibitors (SSRIs). Ten patients meeting DSM-III-R criteria for generalized social phobia were studied. Patients obtaining only a partial response to an adequate trial of an SSRI, received buspirone in addition to the SSRI for 8 weeks in an open trial. Seven patients (70%) were considered responders (moderate or marked improvement) and 3 (30%) were considered nonresponders (minimal improvement or no change). This study provides clinical evidence suggesting that buspirone augmentation may be a useful clinical strategy in social phobic patients who show a partial response to an SSRI.

Antiepileptic drugs in the treatment of anxiety disorders: role in therapy.

Pharmacotherapy for anxiety disorders is an active area of research. A variety of drug groups have been shown to be effective in treating many of the anxiety disorders, with selective serotonin reuptake inhibitors (SSRIs) being considered first-line agents for virtually all anxiety disorders. There is a clinical need for alternative drug treatments, as many patients do not achieve a complete response and experience significant adverse effects. The successful use of antiepileptic drugs in mood disorders has led clinicians and researchers to investigate their potential efficacy in other psychiatric disorders, particularly in anxiety disorders.There have been a number of investigations conducted in the form of case reports, case series and open-label trials, suggesting the potential usefulness of antiepileptic drug treatment in a variety of anxiety disorders. More reliable evidence for the use of antiepileptic drugs in anxiety disorders can be gleaned from recent placebo-controlled trials. Thus far, the strongest placebo-controlled evidence has demonstrated the efficacy of pregabalin in treating social phobia and generalised anxiety disorder, while smaller or less robust controlled trials have suggested the potential efficacy of gabapentin in social phobia, lamotrigine in post-traumatic stress disorder, and valproic acid in panic disorder.Antiepileptic drugs may have a place in the treatment of anxiety disorders; however, further investigation is warranted to determine in what circumstances they should be used as monotherapy or as augmenting agents in individuals who are partially or non-responsive to conventional therapy.

Individuals with social phobia are biased to become aware of negative faces

To evaluate whether individuals with social phobia are biased to become aware of negative faces participants searched visual displays containing varying number of neutral face distractors for the location of positive and negative faces. Individuals with social phobia had shallower search slopes for locating negative compared to positive faces, suggesting that they are biased to become aware of negative faces more readily than they become aware of positive faces. A similar bias was found for individuals with panic disorder; but no such bias was found either for individuals with obsessive-compulsive disorder or for control participants. The findings illustrate the importance of considering the characteristics of participants in the study of human attention.

A randomized, double-blind, placebo-controlled trial of olanzapine in the treatment of trichotillomania.

BACKGROUND Trichotillomania has been considered as part of the obsessive-compulsive disorder spectrum; however, trichotillomania treatment with obsessive-compulsive disorder medications has largely been unsuccessful. OBJECTIVE To determine whether a dopaminergic treatment as used in tics and Tourettes syndrome would be effective in trichotillomania. METHOD Twenty-five participants with DSM-IV trichotillomania participated in a 12-week, randomized, double-blind, placebo-controlled trial of flexible-dose olanzapine for trichotillomania. Recruitment occurred between August 2001 and December 2005, and follow-up was completed in February 2006. The primary outcome measure was the Clinical Global Impressions-Improvement (CGI-I) scale, and secondary measures of efficacy included the Yale-Brown Obsessive Compulsive Scale for Trichotillomania (TTM-YBOCS) and the Clinical Global Impressions-Severity of Illness (CGI-S) scale. RESULTS Eleven of 13 participants (85%) in the olanzapine group and 2 of 12 (17%) in the placebo group were considered responders according to the CGI-I (P = .001). There was a significant change from baseline to end point in the TTM-YBOCS (P < .01) and the CGI-S (P < .001). The mean ± SD dose of olanzapine at end point was 10.8 ± 5.7 mg/d. Twenty-one of 25 patients (84%) reported at least 1 adverse event, but no adverse events resulted in early withdrawal from the study. CONCLUSION Olanzapine seems to be a safe and effective treatment for primary DSM-IV trichotillomania. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182507.

The potential role of haloperidol in the treatment of trichotillomania

BACKGROUND Trichotillomania is categorized as an impulse control disorder in DSM-IV and is considered by some to be closely related to Obsessive Compulsive Disorder (OCD). We review the clinical phenomenology and pharmacological response of trichotillomania, and suggest that it may be more related to Tourette Syndrome than to OCD. Serotonin reuptake inhibitors (SRIs) are typically employed in the treatment of OCD, while neuroleptic medications such as haloperidol are typically used in the treatment of Tourette Syndrome. Evidence for the efficacy of treatment of trichotillomania with drugs typically used for OCD is equivocal. METHOD Nine patients with trichotillomania were treated with haloperidol. Six patients unresponsive to SSRI medication had haloperidol added to their treatment. Three patients received only haloperidol. Response to treatment was assessed using descriptions of hair pulling, quantity of hair pulled, and severity of depilation at hair pulling sites. RESULTS Eight of nine patients responded to haloperidol treatment, with seven experiencing complete or near complete cessation of hair pulling. LIMITATIONS Inferences from the results of this study are limited by the lack of a control group, the small sample size, and the use of unstandardized ratings as measures of symptom severity. CONCLUSIONS Results suggest that the addition of haloperidol to SSRIs or haloperidol alone may be effective in the treatment of trichotillomania. Results also encourage speculation about the relation between OCD, Tourette Syndrome, and trichotillomania.