Salvatore Mannuzza

Adolescent and Adult Outcomes in Attention-Deficit/Hyperactivity Disorder

Follow-up studies of childhood disorders are valuable for multiple reasons. Knowledge of which symptoms are likely to persist and what secondary complications are likely to develop is important to families of affected children, as well as to the design of long-term interventions. Knowledge of the course and outcome of a disorder also contributes to the assessment of diagnostic validity. Furthermore, longitudinal studies can be used to identify early predictors of later functioning. The fate of children with Attention-Deficit/ Hyperactivity Disorder (ADHD)* is especially important because the disorder is one of the most prevalent (see Chapter 2, this volume), and is associated with impairment in multiple functional domains in childhood (Arnold & Jensen, 1995; Barkley, 1996).

Delineating the boundaries of social phobia: Its relationship to panic disorder and agoraphobia

Abstract The present article was prompted by the differential diagnostic ambiguities surrounding the social phobic syndrome. The following questions were addressed: (a) Is social phobia a distinct clinical syndrome, differing from panic disorder and agoraphobia on a number of variables? (b) What is the relationship between social phobia, panic disorder, and agoraphobia regarding co-occurrence of syndromes? (c) What are the principal differential diagnostic features which define the boundaries of the syndrome? A literature review suggested that social phobia is a distinct entity which differs from panic/agoraphobia regarding prevalence, sex ratio, age of onset, familial psychiatric history, response to provocative tests, and pharmacotherapy. Several studies have shown substantial comorbidity between the syndromes. Critical features for formulating a differential diagnosis include distinguishing type and pattern of panic attacks and determining what the patient fears. Symptoms must be evaluated within the context of the individuals disturbance, which requires an informed, precise, and thorough assessment.

Panic disorder and social phobia: Effects of comorbidity on familial transmission

The aim of this study was to examine effects of comorbidity of panic disorder and social phobia on familial transmission of each of these disorders. Rates of panic disorder and social phobia were compared in directly interviewed relatives of four proband groups: (1) panic disorder, (2) social phobia, (3) panic disorder and social phobia, and (4) never ill controls. Anxiety disorder probands had no additional lifetime anxiety disorder comorbidity. The familial pattern of the comorbid (panic disorder and social phobia) probands resembled that of the panic disorder group: an increased rate of panic disorder but not social phobia as compared to relatives of controls. Relatives of social phobia probands had an increased rate of social phobia but not panic disorder. These data indicate that social phobia in individuals who subsequently develop panic disorder: (1) differs with respect to familial transmission from social phobia which occurs without lifetime anxiety comorbidity; and (2) may be nonfamilial and/or causally related to panic disorder. Additional studies in larger epidemiologic samples are required to assess generalizability of these findings.

Adolescent depression: controlled desipramine treatment and atypical features.

The study was designed to test the efficacy of desipramine in adolescents with major depression (MDD). In addition, we assessed the presence of atypical features of MDD, consisting of mood reactivity and two of four associated features (rejection sensitivity, hyperphagia, hypersomnia, and leaden paralysis). Patients were randomized to desipramine (DMI) or placebo for 6 weeks, provided they failed to improve (e.g., meeting MDD criteria and a Hamilton Depression Scale score ≥18) after 2 weeks on single blind placebo. Of 94 adolescents (ages 13–18) who were diagnosed as having MDD, 64 entered the study and 62 received placebo for 2 weeks. Of these, 45 were randomized to DMI or placebo. Completer analyses did not reveal significant improvement for the active treatment compared to the placebo. A large proportion of adolescents responded to placebo (50%), suggesting the need for very large samples to detect differential treatment efficacy, should it exist. A relatively high rate of atypical depression was observed (47% in the 64 patients entered). In view of the demonstrated specificity of monoamine oxidase inhibitor efficacy in adults with atypical features of MDD, this clinical subtype may have relevance to future investigation of therapeutic interventions in adolescent MDD. Depression and Anxiety 7:15–31, 1998.

Panic disorder and suicide attempts

Abstract This study investigated predictive risk of suicide attempts in individuals with panic disorder. Subjects were 546 relatives of anxiety clinic patients and 301 acquaintances of those relatives. Compared to subjects with no mental disorder, subjects with panic disorder (PD) were ten times more likely to attempt suicide (11% vs. 1%, p p

A direct interview family study of obsessive-compulsive disorder. I.

BACKGROUNDnThis and the companion paper present two sequential family studies of obsessive-compulsive disorder (OCD) conducted by the same research group, but with different sampling and best-estimate procedures. In addition to providing further data on familial transmission of OCD, we used comparison of disparate findings (moderate, specific familial aggregation in this first study versus a stronger effect for other anxiety disorders than for OCD alone in the second) to examine possible effects of proband characteristics and informant data on outcome.nnnMETHODnIn this initial study we interviewed 179 first-degree relatives of 72 OCD probands and 112 relatives of 32 never mentally ill (NMI) controls. Informant data were obtained on an additional 126 relatives (total combined samples of 263 and 154 respectively). Analyses used best-estimate diagnoses made by consensus of two blinded senior clinicians who reviewed all diagnostic materials including proband informant data about relatives.nnnRESULTSnSignificantly higher risk for OCD but not other anxiety disorders was found in relatives of OCD probands compared to relatives of controls in both the directly interviewed and combined samples. There was no relationship between proband age at onset of OCD and strength of familial aggregation.nnnCONCLUSIONSnThese data indicate moderate familial aggregation of OCD, but do not support increased transmission by early onset probands, or a familial relationship between OCD and other anxiety disorders with the possible exception of generalized anxiety disorder.

Child Panic Revisited

Childhood panic attacks and panic disorder were assessed retrospectively in adult anxiety clinic patients (N = 343) and their adult relatives (N = 560). Only nine (1%) of the 903 subjects were judged to have experienced spontaneous panic attacks before age 13 by clinically trained interviewers. The narrative summaries of these cases were reviewed, and only three of nine provided convincing descriptions of spontaneous panic attacks in childhood. The authors conclude that prepubertal spontaneous panic attacks are rare, and that retrospective assessments of panic phenomena are difficult, even among adequately trained mental health professionals.

Test-Retest Reliability of Maternal Reports of Lifetime Mental Disorders in Their Children

This study examined the test-retest reliability of maternal reports of lifetime psychopathology using DSM-III-R criteria in nonreferred offspring. Sixty-three mothers reported on 79 children, ages 6 to 18 years. Retest intervals were between one and 12 months. The results indicated acceptable reliability for all supraordinate categories (any disorder, any anxiety disorder, any disruptive disorder, externalizing disorders, internalizing disorders) as well as for most individual diagnoses (separation anxiety disorder, simple phobias, oppositional defiant disorder, attention deficit disorder with and without hyperactivity, simple phobias, and adjustment disorder). Maternal reports for any diagnosis were significantly better for intervals under 6 months than for longer retest intervals. Reliability of maternal reports was not significantly affected by childs age or gender. This study supports the expectation that a history of psychiatric disturbance in children can be obtained reliably from mothers.

The DSM-IV panic disorder field trial: panic attack frequency and functional disability.

The goal of the DSM-IV panic disorder field trial was to provide an empirical basis for choosing between alternate proposals (DSM-III-R and proposed DSM-IV) for the diagnostic threshold for panic disorder, in particular the number and frequency of panic attacks required for diagnosis. The two criteria sets were compared with respect to their ability to identify individuals whose panic attacks were associated with distress, impairment, or help-seeking. Subjects were a convenience sample screened in three geographically diverse primary care clinics for presence (past 6 months) or absence (lifetime) of panic attacks. Each underwent a clinician-administered semistructured interview which included assessment of panic frequency, panic-related impairment, psychiatric diagnosis, health services utilization, and medical illness. Self-perceived health-related quality of life was assessed using the Medical Outcome Study SF-36 Health Survey Questionnaire. Although both proposals diagnosed the same proportion of panic-impaired individuals, they were not completely overlapping. Twenty percent of subjects diagnosed by each criteria set were excluded by the other. Subjects who had been excluded by the DSM-III-R but included by the DSM-IV proposal were those with fewer than 4 attacks in 4 weeks who also denied worry about the next attack. Broadening the worry criterion to include concerns about the health implications of attacks enabled diagnosis of this group. Subjects who met DSM-III-R, but not the proposed DSM-IV criteria, had 4 attacks in 4 weeks but denied any panic related worry. Modification of the DSM-IV proposal to include a month of worry or a significant change in behavior related to the attacks allowed inclusion of this group in the diagnostic category. These data suggest that the finalized DSM-IV panic disorder criteria will diagnose a greater proportion of individuals whose panic attacks are associated with impairment without inflating the diagnostic category or significantly reducing specificity.

Obsessive–compulsive disorder and separation anxiety co-morbidity in early onset panic disorder

BACKGROUNDnThis study was undertaken to examine the relationship between anxiety co-morbidity and age of onset of panic disorder.nnnMETHODSnAge of onset of panic disorder and co-morbid anxiety disorders were assessed among 201 panic disorder probands with childhood separation anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, social phobia and specific phobia as part of a clinician-administered lifetime diagnostic interview. A generalized linear model was used to test the association between each anxiety co-morbidity and age of panic disorder onset while simultaneously controlling for the potential confounding effects of sociodemographic characteristics and other psychiatric co-morbidity.nnnRESULTSnEarlier onset of panic disorder was found in patients with co-morbid obsessive-compulsive disorder, obsessive-compulsive symptoms and separation anxiety disorder, but not simple phobia or social phobia. Patients with both childhood separation anxiety disorder and obsessive-compulsive disorder had an even earlier panic onset than those with either childhood separation anxiety disorder or obsessive-compulsive disorder.nnnCONCLUSIONSnThe association between anxiety co-morbidity and earlier onset of panic disorder is specific to obsessive-compulsive disorder and childhood separation anxiety disorder.