Sharon O. Davies

Screening for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale.

OBJECTIVE We sought to determine optimal cutoff values for the Liebowitz Social Anxiety Scale (LSAS) total and subscale scores for the diagnosis of social anxiety disorder (SAD) and designation of the generalized subtype of SAD. METHOD Three hundred and sixty-four patients from a multi-site sample who met criteria for SAD according to structured diagnostic interview, 262 of whom met criteria for the generalized subtype, and 34 control participants free of current Axis I disorders participated in this study. All participants were given the Liebowitz Social Anxiety Scale by an independent assessor. RESULTS Receiver Operating Characteristics analysis revealed that the LSAS performed well in identifying individuals who met criteria for SAD and for the generalized subtype of SAD. Cutoffs of 30 for SAD and 60 for its generalized subtype on the LSAS total score represented the best balance of specificity and sensitivity. CONCLUSIONS These findings provide support for the use of the Liebowitz Social Anxiety Scale for the identification of individuals with SAD and its generalized subtype in clinical settings. Identification of patients with SAD should increase the percentage of these patients who receive appropriate treatment for this impairing disorder.

An open trial of fluoxetine in the treatment of panic attacks

Fluoxetine is a new antidepressant with pharmacologic effects apparently limited to blockade of neuronal serotonin reuptake. We entered 20 patients who met DSM-III criteria for either panic disorder or agoraphobia with panic attacks into an open, uncontrolled pilot study of fluoxetine. Four responded to placebo in the week before fluoxetine administration and were dropped from the study. Of the remaining 16 patients, nine were nonresponders and seven were responders, with complete cessation of their panic attacks. Eight of the nine nonresponders were unable to tolerate the side effects of fluoxetine. In contrast, all of the responders (and one nonresponder) experienced minimal side effects. Fluoxetine may be effective in the treatment of panic attacks, perhaps implicating the serotonergic system in the pathophysiology of panic disorder. Future studies should use very low doses of fluoxetine to initiate treatment. (J Clin Psychopharmacol 1987;7:329–332)

Cognitive‐behavioral group therapy versus phenelzine in social phobia: Long term outcome

To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitive‐behavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment‐free follow‐up phases. Experimental design: Responders to an acute trial contrasting PZ and CBGT entered a six‐month maintenance phase. Patients who continued to respond through the maintenance phase entered a six‐month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study. Principal observations: PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment‐free follow‐up. There was a greater relapse among patients with generalized social phobia with phenelzine. Conclusions: PZ and cognitive‐behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment‐free follow‐up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long‐term efficacy of combined PZ and CBGT. Depression and Anxiety 10:89–98, 1999.

Fluoxetine in children and adolescents with OCD: a placebo-controlled trial.

OBJECTIVE To examine the safety and efficacy of fluoxetine in child and adolescent obsessive-compulsive disorder (OCD). METHOD Between 1991 and 1998, 43 patients were randomly assigned to fluoxetine or placebo for 8 weeks. Dosing was fixed for the first 6 weeks (up to 60 mg/day) and then could be increased to 80 mg/day. Responders entered an 8-week maintenance phase. The primary outcome measures were the Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) and the Clinical Global Impression-Improvement (CGI-I) scale. Analyses were done on the intent-to-treat sample. RESULTS Fluoxetine patients (n = 21) had significantly lower CY-BOCS scores than placebo patients (n = 22) after 16 (but not 8) weeks. Fluoxetine responders (n = 11) had significantly lower CY-BOCS scores than placebo responders (n = 7) after an additional 8 weeks of treatment. After 16 weeks, 57% of fluoxetine (versus 27% of placebo) patients were much or very much improved on the CGI-I scale (p <.05). No patient terminated the study because of adverse medication effects. CONCLUSION Fluoxetine was well tolerated and effective for the treatment of child and adolescent OCD, but fluoxetines full effect took more than 8 weeks to develop.

Fluoxetine in panic disorder

Twenty-five patients with a primary DSM-III-R diagnosis of panic disorder with or without agoraphobia were treated openly with the serotonin uptake inhibitor fluoxetine for up to 12 months. For most patients, treatment was initiated at 5 mg/day to minimize adverse effects previously reported with initiation at higher doses. Nineteen (76%) experienced moderate to marked improvement in panic attacks. Four (16%) were unable to tolerate fluoxetine due to adverse effects. Initiating treatment of panic disorder with low doses of fluoxetine may increase its acceptability and permit more patients to benefit from fluoxetine.

Imipramine in the treatment of social phobia

We report the results of an 8-week open trial of imipramine in 15 patients with social phobia. Nine patients completed the trial; six dropped out early because of adverse effects. The mean reduction in the Liebowitz Social Anxiety Scale was 15% and 18% for the intent-to-treat and completer groups, respectively; the overall response rate (based on the Clinical Global Impression Scale of 1 or 2, very much or much improved) was 20% (3/15) and 22% (2/9), respectively. The results from this open trial do not support the efficacy of imipramine as a treatment for social phobia.

Fluoxetine treatment of obsessive-compulsive disorder: an open clinical trial

The selective serotonin reuptake blocker fluoxetine was administered to 49 patients with obsessive-compulsive disorder in a 12-week open clinical trial. A minimum adequate trial of at least 8 weeks of treatment was completed by 39 patients. Response rates were 62% (24/39) of adequately treated patients and 49% (24/49) of the whole sample. These uncontrolled findings suggest that fluoxetine is of significant benefit for a substantial proportion of obsessive-compulsive disorder patients. However, controlled trials comparing fluoxetine with placebo and other active agents are needed to confirm this, as are studies aimed to delineate fluoxetines full dose range, optimal length of treatment and relapse rate following discontinuation.

Anxiety and depression : discrete diagnostic entities ?

&NA; Some forms of anxiety and affective disorder, such as panic disorder and major depression, appear distinct, while other forms, such as generalized anxiety disorder and chronic depression or dysthymia, may lie on a continuum and blend with each other. However, even panic disorder and major depression have many common features. Moreover, for reasons not yet clear, they occur together frequently, and their combined occurrence in the same patient has been associated with greater severity and chronicity, decreased treatment responsiveness, and, possibly, increased familial prevalence of anxiety and/or depression. Finally, studies of primary care patients suggest the frequent occurrence of a mixed anxiety‐depressive disorder that may often be subsyndromal by DSM‐III‐R criteria but is nevertheless associated with prominent distress and/or impairment.

Ataque de nervios and history of childhood trauma

Objective: Ataque de nervios is a common, self-labeled Hispanic folk diagnosis. It typically describes episodic, dramatic outbursts of negative emotion in response to a stressor, sometimes involving destructive behavior. Dissociation and affective dysregulation during such episodes suggested a link to childhood trauma. We therefore assessed psychiatric diagnoses, history of ataque, and childhood trauma in treatment-seeking Hispanic outpatients (N = 70). Significantly more subjects with an anxiety or affective disorder plus ataque reported a history of physical abuse, sexual abuse, and/or or a substance-abusing caretaker than those with psychiatric disorder but no ataque. In some Hispanic individuals, ataque may represent a culturally sanctioned expression of extreme affect dysregulation associated with childhood trauma. Patients with ataque de nervios should receive a thorough traumatic history assessment.

Lateralized auditory processing in depression: Dichotic click detection

The intensity needed to detect dichotic click stimuli was measured in 14 bipolar depressed patients, 19 unipolar depressed patients, and 15 normal controls. The results replicated, in unmedicated bipolar depressed patients, an earlier finding of reversed lateral asymmetry in medicated affective psychotic patients. Two new findings concern the relation of lateral asymmetry patterns to diagnostic subtypes of the Research Diagnostic Criteria and symptom ratings on the Schedule for Affective Disorders and Schizophrenia. First, patients with bipolar disorders (history of mania or hypomania) were more likely than patients with unipolar disorders to display reversed lateral asymmetry. Second, greater severity of depressive or endogenous symptoms was associated with less lateral asymmetry.