Idell Goldenberg

A comparison of symptom determinants of patient and clinician global ratings in patients with panic disorder and depression.

The Clinical Global Impression (CGI) is a standard assessment tool that generally shows good sensitivity to change in psychopharmacology trials. However, systematic assessment has not been conducted to determine how rating decisions are made. In this article, we examine the relationship between syndromal symptomatology and the CGI severity and improvement ratings in a study of 116 patients who met DSM-III-R criteria for both Panic Disorder and Depression. Anticipatory anxiety and depression ratings were significantly associated with each CGI item. Frequency of panic attacks was consistently related to the clinicians rating of severity but was only sporadically related to the clinician and patient improvement ratings. These findings are fairly consistent during the course of treatment. Our empirical examination of symptom determinants of the CGI demonstrates that it appears to be used systematically, yet global ratings are not merely a composite of symptomatology. Its widespread application in clinical trials is well justified.

A prospective follow-along study of the course of social phobia

The goals of this study were to delineate the courses of social phobia and to determine whether the course of generalized and specific social phobia differed. In the Harvard/Brown Longitudinal Study of Anxiety Research Project, 66 specific and 74 generalized social phobic subjects were identified for whom adequate course data were available. These subjects had been followed prospectively with a standardized follow-along measure of psychopathology. The probability of remission was calculated for each individual group and both groups combined. Demographics were the same for both groups except that the specific social phobia group had a marginally higher mean score on the Global Assessment Scale. Complete remission for the combined group was not different from that for either subgroup and was 0.11 at 65 weeks. Social phobia appears to be a disorder with considerable long-term morbidity. Surprisingly, both subtypes took a comparably long time to remit and were similar in their high level of psychosocial dysfunction.

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.

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 those 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. Depression and Anxiety 7:105–112, 1998.

Comparing primary and secondary generalized anxiety disorder in a long-term naturalistic study of anxiety disorders.

This study explores the potential differences in comorbidity and course between primary generalized anxiety disorder (GAD), which develops before other anxiety disorders, and secondary GAD. As part of the Harvard/Brown Anxiety Research Project (HARP), a naturalistic, long‐term, longitudinal study of 711 subjects from a variety of clinic settings with DSM III‐R defined anxiety disorders, 210 subjects with GAD were identified. Of these, 78 (37%) had primary GAD, and 84 (40%) had secondary GAD; of the remainder, 28 (13%) had no other anxiety disorder and 20 (10%) developed GAD within a month of another anxiety disorder and were excluded from the analysis. All subjects were comorbid for at least one other anxiety disorder. Primary GAD subjects were more likely to be in episode at intake (90% vs. 77%, P=.04) and less likely than secondary GAD subjects to have current or past agoraphobia without panic disorder (3% vs. 11%, P=.04), social phobia (19% v. 52%, P=.001), simple phobia (14% v. 30%, P=.02), or post traumatic stress disorder (5% vs. 20%, P=.01). Subjects with primary GAD were also less likely to have current or past alcohol use disorders (17% vs. 37%, P=.004) or major depressive disorder (60% vs. 76%, P=.03). There were no significant differences in either treatment approaches or remission rates for primary compared to secondary GAD. Whether GAD first occurs before or after another anxiety disorder, it is similar in terms of prevalence, treatment, and course. The only significant differences between primary and secondary GAD lie in the rates of comorbidity of both other anxiety disorders and non‐anxiety disorders, including major depression and substance abuse. These results support the concept of GAD as a valid, separate and distinct entity, whether it occurs primarily or secondarily. Depression and Anxiety 10:1–7, 1999.

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 studys 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.

A prospective, follow-along study of the course of social phobia: II. Testing for basic predictors of course.

This study examined the 65-week outcome of a group of subjects with social phobia to determine predictors of course. Social phobic patients in the Harvard/Brown Anxiety Disorders Research Project study were followed for 65 weeks using the Longitudinal Interval Follow-Up Evaluation-UpJohn scale. The following variables did not predict outcome over the course of the study: sex, age of onset, duration of illness, lifetime history of various anxiety disorders, current comorbidity of anxiety or depressive disorders, Global Assessment Scale score, or measures of role functioning. We find that in a social phobic population with a mean duration of illness of 18 years, none of the tested variables examined predicted 65- week outcome.

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 that 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. Depression and Anxiety 5:12–20, 1997.

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. Depression and Anxiety 4:209–216, 1996/1997.© 1997 Wiley‐Liss, Inc.