Michael T. Suelzer

Generalized anxiety disorder vs. panic disorder. Distinguishing characteristics and patterns of comorbidity.

In order to examine the validity of the distinction between generalized anxiety disorder (GAD) and panic disorder (PD) we compared 41 subjects with GAD and 71 subjects with PD. The GAD subjects had never had panic attacks. In contrast to the symptom profile in PD subjects suggestive of autonomic hyperactivity, GAD subjects had a symptom pattern indicative of central nervous system hyperarousal. Also, subjects with GAD had an earlier, more gradual onset of illness. In terms of coexisting syndromes, GAD subjects more often had simple phobias, whereas PD subjects more commonly reported depersonalization and agoraphobia. GAD subjects more frequently had first-degree relatives with GAD, whereas PD subjects more frequently had relatives with PD. A variety of measures indicated that our GAD subjects had a milder illness than those with PD. Also, fewer GAD subjects gave histories of major depression than did PD subjects. Among GAD subjects, coexisting major depression was associated with simple phobia and thyroid disorders and among PD subjects, comorbid depression was associated with social phobia and hypertension. Our findings indicate that the separation of GAD from PD is a valid one. They also indicate that, within disorders, unique patterns of comorbidity may exist that are important both clinically and theoretically.

Psychiatric comorbidity among patients with hypochondriasis

The purpose of this study was to determine the nature and extent of comorbidity among patients with DSM-III-R hypochondriasis and to examine the relationships between this disorder and coexisting psychiatric illness. For this purpose, patients seen in a general medicine clinic were screened using measures of hypochondriacal attitudes and somatic symptoms. Those scoring above an established cutoff were given a structured diagnostic interview. In this manner, 50 patients who met DSM-III-R criteria for hypochondriasis and 50 age- and sex-matched controls were identified. The presence of other psychiatric disorders (current and past) was determined by means of the same diagnostic interview. More hypochondriacal subjects (62.0%) had lifetime comorbidity than did controls (30.0%). Major depression, the most frequent comorbid disturbance, was usually current and most often had an onset after that of hypochondriasis. Panic disorder with agoraphobia, the most frequent anxiety disorder, was also current but often began before or at the same time as hypochondriasis. Few subjects met criteria for somatization disorder but a third qualified for a subsyndromal form of this disorder. The data show that, in medical outpatients with hypochondriasis, mood and anxiety disorders frequently coexist. This comorbidity is subject to varying interpretations including overlap of symptom criteria, treatment-seeking bias, and the possibility that hypochondriasis predisposes to or causes the comorbid disorder, as seems likely in the case of depression. In some instances hypochondriasis may be an associated feature of another illness.

One-Year Follow-up of Medical Outpatients With Hypochondriasis

To examine the diagnostic stability and outcome of hypochondriasis, the authors followed 50 patients with this disorder and 50 age- and sex-matched control subjects after 1 year. After 1 year, two-thirds of the subjects continued to meet criteria for hypochondriasis, and the remaining third had persisting hypochondriacal symptoms. The hypochondriacal subjects were improved on most measures but still differed from the control subjects with regard to attitudes, perceptions, and behaviors that had distinguished them initially. More severe symptoms, longer duration of illness, and coexisting psychiatric illness were predictive of a worse outcome. The data indicate that the diagnosis of hypochondriasis is stable over time, and that, although symptoms wax and wane, characteristic features persist. The findings underscore the importance of diagnosing and treating hypochondriasis in medical outpatients.

Distress Associated with Cancer as Measured by the illness Distress Scale

Over 400 cancer patients were given the Illness Distress Scale (IDS), a brief measure of the physical and emotional distress related to serious illness. Physical manifestations of the disease proved to be the source of greatest discomfort among these patients. Greater distress was reported by younger patients and by those who were unmarried. Also, patients with more advanced disease scored higher on the scale. The IDS appeared to measure four dimensions of distress related to the experience of illness, including loss of meaning, physical disease, medical treatment and social isolation. Scores on the instrument correlated highly with a measure of depression, the Beck Depression Inventory. The IDS appears to be a reliable and valid measure of distress associated with serious illness.

Environmental factors related to the outcome of panic disorder : a seven-year follow-up study

The purpose of this study was to examine factors related to the outcome of naturalisticalry treated panic disorder. In order to achieve this we followed up 69 patients 7 years after they had presented at a psychiatric clinic. At follow-up, the patients were generally doing well despite persisting symptoms. Patients who were more severely ill at the time of initial assessment had a worse outcome. These patients had more severe panic and agoraphobic symptoms, had illnesses of longer duration, and more often had histories of major depression. Among the developmental variables examined, separation from a parent by death or divorce was strongly related to poor outcome. Other factors associated with poor outcome included high interpersonal sensitivity, low social class, and unmarried marital status. The findings show that, for this chronic illness, measures of severity and chronicity predict more severe and persisting symptoms. They also indicate that outcome is importantly related to the social environment in which the illness develops and with which it interacts.

Personality traits associated with panic disorder: Change associated with treatment ☆

Eighty-two subjects with panic disorder completed the Personality Diagnostic Questionnaire (PDQ) before treatment and again after a period of relatively stable improvement 3 years later. At baseline, panic subjects scored higher than normal control subjects, who had been matched for age and sex, on avoidant, dependent, histrionic, and paranoid personality subscales. Improvement in panic symptoms after 3 years was associated with reductions in these same subscale scores. Examination of individual items that distinguished panic from normal subjects showed themes of dependency, lack of self-confidence, emotional instability, and sensitivity to criticism that reflected demoralization in the panic disorder subjects. To a large extent, the findings reveal nonspecific, state-dependent effects of panic and agoraphobic symptoms on the personality functioning and morale of patients with panic disorder.

Respiratory pathophysiologic responses: Comparisons of specific and nonspecific bronchoprovocation in subjects with asthma, rhinitis, and healthy subjects☆

BACKGROUND We studied subjects with atopic asthma, atopic rhinitis, and nonatopic healthy subjects to evaluate responsiveness to bronchoprovocation with both methacholine and allergen. METHODS Subjects with a demonstrable FEV1 PD20 to methacholine or allergen (responders) were further analyzed for putative sensitivity (PD20 FEV1) and reactivity (dose-response slopes) to determine whether any characteristics could distinguish individuals with asthma from other responders. Subjects were recruited without sex restrictions and were between the ages of 18 and 45 years old. They were nonsmokers, had no other medical problems, and were free of upper respiratory infection for at least 6 weeks before challenge. All had a history taken, physical examination, limited laboratory screening, chest radiography, pulmonary function testing, and intradermal skin testing before admission to the study. RESULTS Although the groups were significantly different in both sensitivity and reactivity to methacholine, responses to allergen bronchoprovocation were sufficiently similar between responders with asthma and those with rhinitis to prevent separation on the basis of either sensitivity or reactivity. The fall in FEV1 at the nadir of the late response, which was greater in the asthma group, was significantly correlated with sensitivity and reactivity of the immediate response to allergen but not to methacholine. Regression analysis demonstrated a stronger association between allergen and methacholine responsiveness in subjects with rhinitis than in subjects with asthma. CONCLUSION We concluded that (1) nonspecific bronchial hyperresponsiveness fails to explain why patients with allergic asthma have clinical asthma as a result of allergen exposure and patients with allergic rhinitis do not; (2) hyperresponsiveness to allergen does not simply reflect quantitative or qualitative airway nonspecific hyperresponsiveness; and (3) clinical asthma may involve mechanisms difficult to elucidate by laboratory bronchoprovocation techniques.Abstract Background: We studied subjects with atopic asthma, atopic rhinitis, and nonatopic healthy subjects to evaluate responsiveness to bronchoprovocation with both methacholine and allergen. Methods: Subjects with a demonstrable FEV 1 PD 20 to methacholine or allergen (responders) were further analyzed for putative sensitivity (PD 20 FEV 1 ) and reactivity (dose-response slopes) to determine whether any characteristics could distinguish individuals with asthma from other responders. Subjects were recruited without sex restrictions and were between the ages of 18 and 45 years old. They were nonsmokers, had no other medical problems, and were free of upper respiratory infection for at least 6 weeks before challenge. All had a history taken, physical examination, limited laboratory screening, chest radiography, pulmonary function testing, and intradermal skin testing before admission to the study. Results: Although the groups were significantly different in both sensitivity and reactivity to methacholine, responses to allergen bronchoprovocation were sufficiently similar between responders with asthma and those with rhinitis to prevent separation on the basis of either sensitivity or reactivity. The fall in FEV 1 at the nadir of the late response, which was greater in the asthma group, was significantly correlated with sensitivity and reactivity of the immediate response to allergen but not to methacholine. Regression analysis demonstrated a stronger association between allergen and methacholine responsiveness in subjects with rhinitis than in subjects with asthma. Conclusion: We concluded that (1) nonspecific bronchial hyperresponsiveness fails to explain why patients with allergic asthma have clinical asthma as a result of allergen exposure and patients with allergic rhinitis do not; (2) hyperresponsiveness to allergen does not simply reflect quantitative or qualitative airway nonspecific hyperresponsiveness; and (3) clinical asthma may involve mechanisms difficult to elucidate by laboratory bronchoprovocation techniques.

PREDICTORS OF SERIOUS SUICIDE ATTEMPTS AMONG PATIENTS WITH PANIC DISORDER

Of 74 panic disorder subjects followed up after 7 years, five reported serious suicide attempts and three had completed suicide. Compared with subjects who had not made serious attempts, the serious suicide attempters (including the three suicides) were younger, and fewer of them were married. Also, the serious attempt group had an earlier, more gradual onset of illness. More of the serious attempters had personality disorders and coexisting major depression. At the time of original assessment, the serious attempters had more severe symptoms. These data suggest that among patients with panic disorder, serious suicidal behavior is associated with more severe psychopathology.

Prognostic value of methacholine challenge in patients with respiratory symptoms

BACKGROUND The objective was to study the current clinical status of 78 adults with respiratory symptoms, who were referred 3 to 10 years ago for diagnostic methacholine challenge. We tested the hypothesis that methacholine hyperresponsiveness would be associated on follow-up with increased symptoms of chest tightness, dyspnea, wheezing, cough, and more frequent use of selected treatment modalities. METHODS Current symptoms were evaluated by means of interview questionnaire, and methacholine challenge was repeated during follow-up examination. Comparisons were made between patients who were and those who were not hyperresponsive to methacholine at initial and follow-up challenges by using specific symptoms and calculated symptom and treatment scores. RESULTS We found that subjects who had positive methacholine challenge results on initial challenge (n = 37) were significantly more likely than those with negative results (n = 41) to have nonexertional chest tightness, wheezing, and dyspnea, but not cough. A high proportion of both groups had current symptoms. Two thirds of the patients continued to have positive (n = 25) or negative (n = 27) methacholine challenge results, and one third had a change in status (n = 26). Significant correlations were also found between follow-up methacholine responsiveness and concurrent symptoms, again with the exception of cough. CONCLUSIONS Methacholine challenge warrants cautious interpretation in the individual patient as an aid to diagnosis and prognosis in the evaluation of respiratory symptoms, especially cough.

Alveolar macrophage immunosuppression is maintained in rabbit models of hypersensitivity pneumonitis

In established experimental models of hypersensitivity pneumonitis and, perhaps, in exposed, asymptomatic humans, continued aerosol exposure to protein antigen results in waning disease and a state of desensitization. The mechanisms causing such unresponsiveness are not well understood, but a possibility is enhanced immunosuppression by alveolar macrophages or other bronchoalveolar cells. Similarly, a loss of immunosuppressive function could result in the appearance of alveolitis. We therefore compared the ability of bronchoalveolar lavage (BAL) cells to augment or suppress antigen-specific lymphocyte blastogenesis in rabbit models of acute and chronic hypersensitivity pneumonitis, desensitized animals, and control animals. We found that BAL cells from all treatment groups suppressed antigen-specific lymphocyte blastogenesis at BAL:lymph node cell ratios of 1:1 to 1:8. BAL cells from some animals were suppressive at high BAL concentrations and, at lower concentrations, augmented the blastogenic response. Additional studies revealed no significant differences in the ability of mitomycin C-treated BAL cells to suppress or augment autologous lymphocyte blastogenesis at any ratio tested. Low-density, macrophage-enriched BAL cells obtained by Percoll fractionation maintained suppressive function. Addition of indomethacin to cultures only partially abrogated BAL-mediated suppression of antigen-specific blastogenesis. We conclude that the development of alveolitis in this model cannot be attributed to loss, nor can desensitization be explained by augmentation, of alveolar macrophage immunosuppressive function.