Dina R. Hirshfeld

Behavioral Inhibition in Childhood: A Risk Factor for Anxiety Disorders

&NA; 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 epidemlologically 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.

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

Abstract 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 (≥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.

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.

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.

Further Evidence of an Association between Behavioral Inhibition and Anxiety Disorders: Results from a Family Study of Children from a Nonclinical 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.

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.