Anxiety Disorders: Starcevic V

Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Anonymous00037, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J. · Department of Psychiatry and Psychotherapy, University of Gottingen, Gottingen, Germany. · World J Biol Psychiatry. · Pubmed #18949648 No free full text.

Abstract: In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.

Starcevic V. · University of Sydney, Discipline of Psychological Medicine Head, Academic Department of Psychological Medicine, Nepean Hospital, PO Box 63, Penrith NSW 2751, Australia. · Expert Rev Neurother. · Pubmed #18671666 No free full text.

Abstract: Panic disorder is a commonly encountered condition in general medical practice and in various medical settings. It is important for all medical practitioners to be able to recognize this disorder, provide patients with basic information and medical advice, and depending on the specific circumstances, to refer patients for appropriate treatment by primary care physicians, psychiatrists and/or clinical psychologists. This article reviews the developments in the treatment of panic disorder, focusing on the major treatment modalities of pharmacotherapy and cognitive-behavior therapy, as well as their combinations. In addition to providing information on current treatments for panic disorder and the main underlying treatment issues, the article identifies areas where improvements need to be made and areas where much research has been conducted in recent years. These include simplified modes of delivery of cognitive-behavior therapy, optimal ways of combining medications with cognitive-behavior therapy, and minimizing the risk of recurrence after the cessation of treatment.

Starcevic V, Brakoulias V. · University of Sydney, Discipline of Psychological Medicine, NSW, Australia. · Aust N Z J Psychiatry. · Pubmed #18622773 No free full text.

Abstract: Several symptom subtypes of obsessive-compulsive disorder (OCD) have been identified on the basis of the predominant obsessions and compulsions. The objectives of the present article were to review the literature on the relationship between OCD symptom subtypes and treatment response and to suggest strategies that might assist with the choice of treatment and improve treatment outcome in patients with various subtypes. An extensive literature search was performed, relevant studies were identified, and their results reported. Overt compulsions were generally associated with a relatively good response to the behaviour therapy technique of exposure and response prevention (ERP) and with poorer response to serotonin re-uptake inhibitors (SRIs). Washing/cleaning and checking compulsions tend to respond well to ERP, whereas the majority of studies show that washing/cleaning compulsions are associated with a poorer response to SRIs. Most studies suggest that patients with the symmetry, ordering and arranging subtype do not fare worse with ERP and SRIs than patients with other symptom subtypes. Some studies suggested that obsessions might respond to SRIs somewhat better than to ERP. In the majority of the studies, hoarding and the subtype characterized by sexual or religious obsessions and absence of overt compulsions ('pure obsessions') have been associated with poor response to ERP and SRIs. It was concluded that treatment strategies cannot be precisely tailored to OCD symptom subtypes. Many other factors influence the outcome of treatment and need to be considered along with the symptom subtypes when making decisions about treatment. While ERP and SRIs remain the mainstay of treatment regardless of the symptom subtype, the addition of cognitive therapy techniques and/or antipsychotic medications may enhance treatment response in the presence of certain features discussed in the article.

Starcevic V. · Discipline of Psychological Medicine, University of Sydney, Sydney, NSW, Australia. · Australas Psychiatry. · Pubmed #17464626 No free full text.

Abstract: OBJECTIVE: The aim of this study was to conceptualize dysphoria in a way that is clearer, better delineated and more clinically useful, after reviewing its meanings in a variety of psychopathological contexts and the consequent conceptual confusion. CONCLUSIONS: The current semantic status of dysphoria is most unsatisfactory. Its definitions are usually too broad or too simplistic and, therefore, not clinically useful. There is no agreement on what the term means. In this article, dysphoria is conceptualized primarily as a complex emotional state, consisting of intense unhappiness/discontent and irritability. In addition, dysphoria is often, though not invariably, accompanied by certain cognitive and behavioural features. This article reviews relationships between dysphoria and related emotional states and various psychiatric disorders, and proposes differentiations that have implications for clinical practice. The role of dysphoria in mixed states within bipolar disorder is particularly in need of further study.

Starcevic V, Berle D. · University of Sydney and Nepean Hospital, Penrith, New South Wales, Australia. · Depress Anxiety. · Pubmed #16402368 No free full text.

Abstract: Cognitive models of anxiety disorders propose that certain cognitive constructs, that is, underlying beliefs and cognitive processes, may be specific for particular disorders. In this article, we review the specificity of four representative cognitive constructs-anxiety sensitivity, pathological worry, intolerance of uncertainty, and thought-action fusion-for particular disorders. Conceptual overlap, inconsistent definitions, and insufficient consideration of the components of these constructs are limitations of the existing literature. We suggest that the constructs are unlikely to be pathognomonic for any given disorder or to occur in isolation. Rather, the association of each cognitive construct is evident, to varying degrees, with different disorders. Relative to other disorders, anxiety sensitivity is to a certain extent specific for panic disorder, as are pathological worry for generalized anxiety disorder, intolerance of uncertainty for generalized anxiety disorder and obsessive-compulsive disorder, and thought-action fusion for obsessive-compulsive disorder. We discuss the implications of these findings for diagnostic systems and treatment, and suggest areas for further research.

Berle D, Starcevic V. · Nepean Anxiety Disorders Clinic, Department of Psychological Medicine, Nepean Hospital, P.O. Box 63, Penrith, NSW 2751, Australia. · Clin Psychol Rev. · Pubmed #15792850 No free full text.

Abstract: Thought-action fusion (TAF) is the tendency for individuals to assume that certain thoughts either imply the immorality of their character or increase the likelihood of catastrophic events. The burgeoning literature on TAF is reviewed. It is not clear whether TAF refers to a specific appraisal style, a more enduring belief, or a combination of both. Inconsistent definitions of magical thinking have hindered better understanding of the relationship between TAF and magical thinking. Much work remains to be done to improve assessment and measurement of TAF. TAF is associated with tendencies towards obsessive-compulsive disorder (OCD) and may contribute to its symptoms. However, the literature investigating TAF and other variables implicated in OCD remains inconclusive. It is suggested that TAF is not specific to OCD, but also prevalent in other anxiety disorders. TAF appears to be moderately related to depressive symptoms and a similar bias may contribute to preoccupations in eating disorders. TAF is also associated with the presence of psychological disorders in children and adolescents. Educational and cognitive therapy approaches to reduce TAF and consequent symptoms are discussed, and suggestions for further research made.

Starcevic V. · University of Belgrade School of Medicine, Yugoslavia. · Gen Hosp Psychiatry. · Pubmed #10514948 No free full text.

Abstract: The purpose of this study was to examine several conceptual and cross-cultural issues in neurasthenia, particularly in terms of their relationship to chronic fatigue syndrome. A review of this relationship led to the conclusion that these conditions are much more alike in Western countries than in countries such as China, where neurasthenia could almost be regarded as a "culture-bound syndrome." This may be a consequence of factors such as the heterogeneous nature of neurasthenia and different diagnostic practices in different countries, despite the ICD-10 definition of neurasthenia, intended for worldwide use. Likewise, there is no consensus on what the "core" characteristics of neurasthenia are, because its clinical presentation and key features in different countries are very different. Despite the finding of relatively low comorbidity rates between neurasthenia and other mental disorders, clinical experience suggests that features of neurasthenia frequently overlap with those of depression, chronic anxiety, and somatoform disorders. There is no convincing evidence that in cases of overlap or comorbidity, other diagnoses should automatically have "primacy" over neurasthenia nor should the diagnosis of neurasthenia thereby be excluded. Although some aspects of its validity have improved recently, especially its descriptive validity, the overall validity of the diagnosis of neurasthenia is still not satisfactory. Suggestions for further research, aimed at improving the diagnostic validity of neurasthenia, are offered in this paper.

Lamplugh C, Berle D, Milicevic D, Starcevic V. · Nepean Anxiety Disorders Clinic, Sydney West Area Health Service, Penrith, NSW, Australia. · Clin Psychol Psychother. · Pubmed #19115462 No free full text.

Abstract: This pilot study reports the outcome of cognitive behaviour therapy for panic disorder augmented by panic surfing. This treatment approach encourages acceptance of feelings rather than control of symptoms and anxiety, at the same time also targeting catastrophic misinterpretations, bodily vigilance and safety-seeking behaviours. Eighteen participants completed a brief group treatment for panic disorder incorporating psychoeducation, panic surfing, interoceptive exposure, graded exposure and cognitive restructuring. Significant improvements occurred over the course of this treatment and were maintained at a 1-month follow-up. Results suggest that cognitive behaviour therapy augmented by panic surfing may be effective in the treatment of panic disorder, but there is a need for controlled studies and investigation of the relative contribution of its various components.

Starcevic V, Latas M, Kolar D, Vucinic-Latas D, Bogojevic G, Milovanovic S. · Discipline of Psychological Medicine, University of Sydney, Sydney/Penrith, NSW 2751, Australia; Department of Psychological Medicine, Nepean Hospital, Sydney/Penrith, NSW 2751, Australia. · Compr Psychiatry. · Pubmed #18970901 No free full text.

Abstract: OBJECTIVE: The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA. METHODS: The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders. RESULTS: Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women. CONCLUSIONS: The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.

Starcevic V. · Discipline of Psychological Medicine, University of Sydney, Sydney, NSW, Australia. · Australas Psychiatry. · Pubmed #18608149 No free full text.

Abstract: OBJECTIVE: The aim of this article was to critically examine options for the future classification of the current Diagnostic and Statistical Manual (DSM) group of anxiety disorders. CONCLUSIONS: There is a strong trend towards the narrowing of the current DSM group of anxiety disorders and to the adopting of a different name for it. A future conceptualization of the conditions currently classified as anxiety disorders will be useful to the extent that it espouses a longitudinal diagnostic approach and acknowledges a lack of clear boundaries between anxiety and related disorders.

Berle D, Starcevic V, Hannan A, Milicevic D, Lamplugh C, Fenech P. · Nepean Anxiety Disorders Clinic, Sydney West Area Health Service, Nepean Hospital, P.O. Box 63, Penrith, NSW 2751, Australia. · Behav Res Ther. · Pubmed #18191103 No free full text.

Abstract: There remains a lack of consensus regarding the possibility that especially high levels of panic-related cognitions characterise panic disorder with agoraphobia. We administered the Anxiety Sensitivity Index, the Agoraphobic Cognitions Questionnaire and the Anxious Thoughts and Tendencies Scale as well as measures of agoraphobic avoidance to patients diagnosed with panic disorder with agoraphobia (n=75) and without agoraphobia (n=26). Patients with panic disorder with agoraphobia did not score significantly higher on any of the cognitive variables than did panic disorder patients without agoraphobia. However, most of the cognitive variables showed small to moderate-strength correlations with self-report measures of agoraphobic avoidance. Our findings suggest that anxiety sensitivity, catastrophising of the consequences of panic and a general anxiety-prone cognitive style, although to some extent associated with agoraphobic avoidance, do not discriminate panic disorder with agoraphobia from panic disorder without agoraphobia.

Berle D, Starcevic V. · Nepean Anxiety Disorders Clinic, Sydney West Area Health Service, Penrith, NSW, Australia. · Int J Methods Psychiatr Res. · Pubmed #18188836 No free full text.

Abstract: A recent survey of the British Medical Journal (BMJ) and Nature revealed that inconsistencies in reported statistics were common. We sought to replicate that survey in the psychiatry literature. We checked the consistency of reported t-test, F-test and chi(2)-test values with their corresponding p-values in the 2005 issues of the Australian and New Zealand Journal of Psychiatry (ANZJP) and compared this with the issues of the ANZJP from 2000, and with a similar journal, Acta Psychiatrica Scandinavica (APS). A reported p-value was 'inconsistent' if it differed (at its reported number of decimal places) from our calculated p-values (using three different software packages), which we based on the reported test statistic and degrees of freedom. Of the 546 results that we checked, 78 (14.3%) of the p-values were inconsistent with the corresponding degrees of freedom and test statistic. Similar rates of inconsistency were found in APS and ANZJP, and when comparing the ANZJP between 2000 and 2005. The percentages of articles with at least one inconsistency were 8.5% for ANZJP 2005, 9.9% for ANZJP 2000 and 12.1% for APS. We conclude that inconsistencies in p-values are common and may reflect errors of analysis and rounding, typographic errors or typesetting errors. Suggestions for reducing the occurrence of such inconsistencies are provided.

Uhlenhuth EH, Starcevic V, Qualls C, Antal EJ, Matuzas W, Javaid JI, Barnhill J. · Department of Psychiatry, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA. <> · Depress Anxiety. · Pubmed #17960759 No free full text.

Abstract: This study investigated an anxiety-prone cognitive style (measured by the Anxious Thoughts and Tendencies Questionnaire, AT&T) as a predictor of the acute response to increasing alprazolam plasma levels in panic disorder. Panic disorder patients (n=26) were treated with escalating doses of alprazolam for 4 weeks, then a fixed dose of 1 mg four times a day for 4 weeks. At 0, 1, 2, 3, 4, 6, and 8 weeks, trough alprazolam plasma levels; clinical, self-report, and performance measures; and vital signs were assessed. Panic attack data were from daily diaries. The repeated response measures were analyzed in relation to alprazolam plasma levels using SAS GENMOD, with patients classified as high or low on the baseline AT&T. Panic attacks, anticipatory anxiety, fear, avoidance, overall agoraphobia, the Hamilton Anxiety Rating Scale, and clinicians' global ratings improved with increasing alprazolam plasma levels. Hopkins Symptom Checklist-90 Anger-Hostility; Profile of Mood States Vigor, Confusion, and Friendliness; and speed and accuracy of performance worsened. Patients with high AT&T scores were worse throughout the study on situational panics, fear, avoidance, overall agoraphobia, the Hamilton Anxiety Rating Scale, the Hamilton Rating Scale for Depression, and Clinical Global Improvement; most Hopkins Symptom Checklist-90 clusters; Profile of Mood States Anxiety, Depression, and Confusion; and Continuous Performance Task omissions. We conclude that in panic disorder: (1) alprazolam has a broad spectrum of clinical activity related to plasma levels in individual patients; (2) sedation, disinhibition, and performance deficits may persist for at least a month after dose escalation ends; (3) marked anxiety-prone cognitions predict more symptoms throughout treatment, but do not modify the response to alprazolam and therefore should not influence the choice of alprazolam as treatment.

Starcevic V, Berle D, Milicevic D, Hannan A, Lamplugh C, Eslick GD. · University of Sydney, Discipline of Psychological Medicine, Nepean Hospital, Sydney/Penrith, NSW, Australia. · J Anxiety Disord. · Pubmed #17270391 No free full text.

Abstract: The Penn State Worry Questionnaire (PSWQ) was administered to 123 outpatients with principal diagnoses of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder with agoraphobia, and panic disorder without agoraphobia (PD) to examine the specificity of pathological worry for GAD. The mean PSWQ scores in patients with GAD and SAD were significantly higher than the mean PSWQ scores in patients with PD, while not differing significantly in the subgroups without any co-occurring depressive or anxiety disorders. Patients with any co-occurring depressive or anxiety disorder scored significantly higher on the PSWQ. In a logistic regression analysis, high PSWQ scores independently predicted only GAD and SAD diagnoses. The study suggests that pathological worry is specific not only for GAD, and indicates that a significant relationship exists between pathological worry, GAD and SAD, and that depressive and anxiety disorders co-occurrence increases levels of pathological worry in patients with anxiety disorders.

Starcevic V, Latas M, Kolar D, Berle D. · University of Sydney, Discipline of Psychological Medicine, and Nepean Hospital, Penrith, New South Wales, Australia. · Depress Anxiety. · Pubmed #17131303 No free full text.

Abstract: Our aim in this study was to compare panic-related catastrophic appraisals between women and men with panic disorder with agoraphobia (PDA). One hundred two outpatients with PDA (75 women and 27 men) participated. Two instruments for the assessment of catastrophic appraisals, Agoraphobic Cognitions Questionnaire and Panic Appraisal Inventory, were administered before and after cognitive-behavioral therapy (CBT) that also included pharmacotherapy in three-fourths of the patients. Female and male patients did not differ significantly in terms of their tendency to anticipate catastrophic consequences of panic, before or after CBT-based treatment. For both females and males, the tendency to make catastrophic appraisals decreased significantly with treatment. We conclude that among patients with PDA there are no gender differences in catastrophic appraisals of panic sensations and symptoms. The apparently higher risk of panic recurrence in women does not seem to be related to their panic-related catastrophic appraisals. These findings also support a notion that there is no gender difference in response to CBT-based treatment of PDA.

Starcevic V. · University of Sydney and Nepean Hospital, Sydney, NSW, Australia. · Evid Based Ment Health. · Pubmed #17065312 No free full text.

This publication has no abstract.

Uhlenhuth EH, Starcevic V, Qualls C, Antal EJ, Matuzas W, Javaid JI, Barnhill J. · Department of Psychiatry, University of New Mexico, Albuquerque, NM 87131-0001, USA. · J Clin Psychopharmacol. · Pubmed #16974197 No free full text.

Abstract: The objective of this study was to ascertain the relationship of alprazolam plasma levels and an anxiety-prone cognitive style to the characteristics and severity of early withdrawal after abrupt discontinuation of alprazolam in 26 patients with panic disorder. After 8 and 9 weeks of fixed-dose treatment, patients were hospitalized for 24 hours. On 1 admission, ordered at random, treatment was maintained; on the other, placebo was substituted double blind. The Anxious Thoughts and Tendencies questionnaire was administered before treatment. Alprazolam plasma levels were measured 7 times on the day after each admission. Before each blood sampling, the Profile of Mood States and performance tasks were administered, and vital signs were recorded. On the day after abrupt discontinuation of alprazolam, Profile of Mood States anxiety, depression, fatigue, and confusion increased; vigor and elation decreased; speed on the digit symbol substitution task improved; and systolic blood pressure increased substantially over time. High Anxious Thoughts and Tendencies scores were related specifically to more anxiety. Our findings (1) confirm that dysphoric mood, fatigue, low energy, confusion, and elevated systolic blood pressure are part of the early syndrome of withdrawal from alprazolam in patients with panic disorder, notably as the drop in plasma levels approaches 50%; (2) indicate a psychomotor deficit persisting beyond dose stabilization; (3) suggest that an anxiety-prone cognitive style measurable before undertaking treatment may be a risk factor for more severe anxiety upon discontinuation; and (4) provide a rationale for applying cognitive behavior therapy during benzodiazepine taper.

Starcevic V. · Discipline of Psychological Medicine, University of Sydney, Sydney, NSW, Australia. · Australas Psychiatry. · Pubmed #16403134 No free full text.

Abstract: OBJECTIVE: To review various concepts of psychiatric comorbidity, their implications, surrounding controversies and underlying issues. A further aim is to propose an alternative term that might be more clinically useful and meaningful for describing the coexistence of mental disorders. CONCLUSIONS: There is wide dissatisfaction with the concepts of psychiatric comorbidity because of different meanings, speculations on which they are often based and consequent confusion. Although the coexistence of mental disorders should be studied further so that any patterns in the corresponding relationships can be elucidated, there is a need for conceptual clarity and making the concept more meaningful for clinical practice and treatment. With that in mind, this present paper proposes avoidance of the term comorbidity and introduction of the term 'co-occurrence'. The latter is defined in this article, and the distinction made between diagnostic co-occurrence and clinically significant co-occurrence.

Starcevic V. · Discipline of Psychological Medicine, University of Sydney, and Nepean Hospital, Sydney, NSW, Australia. · Australas Psychiatry. · Pubmed #16403133 No free full text.

Abstract: OBJECTIVE: To review the most salient issues in the pharmacotherapy of anxiety disorders. These pertain to means of achieving greater efficacy, accelerating the onset of therapeutic action, improving side-effect profile and tolerability, decreasing the propensity to induce therapeutic dependence and achieving better long-term outcome. CONCLUSIONS: By and large, pharmacological agents with greater efficacy in anxiety disorders have yet to be developed. Several strategies have been used with some success to make medications for anxiety disorders work faster and to lessen their side-effect burden. The field of psychopharmacology has yet to find ways of lessening or eliminating the problem of therapeutic drug dependence and, even more so, of minimizing the risk of relapse following the cessation of medication.

Latas M, Starcevic V, Vucinic D. · Institute of Psychiatry, Clinical Center of Serbia, Pasterova 2, Belgrade 11000, Serbia and Montenegro. · Eur Psychiatry. · Pubmed #15276660 No free full text.

Abstract: OBJECTIVE: The aim of this study was to ascertain predictors of work insufficiency in patients with panic disorder (PD) with agoraphobia (AG). METHOD: Linear regression was used to identify predictors of work insufficiency in a sample of 72 consecutive outpatients with PD with AG. Intensity of work insufficiency was ascertained from modified National Institute of Mental Health Panic Questionnaire (NIMH PQ). That represented dependent variable. Independent variables were demographic data, duration of illness, presence of comorbid current major depression episode, presence of any personality disorder and scores on the Panic and Agoraphobia Scale (PAS) subscales: panic attacks, AG (avoidance behavior), anticipatory anxiety and worries about health. RESULTS: Patients reported severe work insufficiency. The best predict variable for the work insufficiency in patients with PD with AG was high score on the PAS dimension of AG. CONCLUSION: Patients generally reported severe effects of PD with AG on work efficacy and the results suggested that the impaired work efficacy was the most associated with avoidance behavior. These results recommend that the treatment of PD with AG patients should be related to decreasing avoidance behavior in order to establish adequate work performance in patients.

Starcevic V, Linden M, Uhlenhuth EH, Kolar D, Latas M. · Department of Psychological Medicine, Nepean Hospital and University of Sydney, P.O. Box 63, Penrith, NSW 2751, Australia. · Psychiatry Res. · Pubmed #14967551 No free full text.

Abstract: The main objective of this report was to identify patient characteristics that led psychiatrists in an academic anxiety disorders clinic to make a decision about intensive treatment of patients with panic disorder with agoraphobia (PDA) with cognitive-behavioral therapy (CBT) alone, CBT plus a high-potency benzodiazepine (CBT+BZ) or CBT combined with BZ and an antidepressant, fluoxetine (CBT+BZ+AD). On the basis of their clinical judgment and collaborative negotiation with the patient, psychiatrists chose one of the three treatment modalities for 102 PDA outpatients. Two stepwise logistic regressions were performed to explore pre-treatment patient characteristics the psychiatrists may have considered in choosing among these treatments. One regression examined the decision to add BZ to CBT, while the other examined the decision to add AD to CBT+BZ. Psychiatrists generally used combination treatments in patients with more severe PDA. CBT alone was a more likely choice for dominant anxiety-related cognitive phenomena. Patients with prominent panic attacks and somatic symptoms were more likely to be treated with CBT+BZ, while those who also had significant depressive symptoms and higher disability levels were more likely to receive CBT+BZ+AD. Patients in all three treatment groups showed significant reduction in symptoms during intensive treatment and reached similar end states. In a clinic setting where CBT is accepted as the basic treatment for PDA, psychiatrists added BZ to control prominent panic symptoms and added AD to elevate depressed mood and help cope with marked disability. These choices appear rational and resulted in substantial clinical improvement at the end of intensive treatment in the clinic.

Starcevic V, Kolar D, Latas M, Bogojevic G, Kelin K. · Hunter Mental Health Service and University of Newcastle Faculty of Medicine and Health Sciences, Newcastle, NSW, Australia. · Depress Anxiety. · Pubmed #12497646 No free full text.

Abstract: We assessed the impact of real danger on several aspects of the panic disorder (PD) patients' psychopathology and level of disability. At the time of the NATO air strikes on Belgrade, 84 PD patients who were in partial or complete remission were administered the Panic and Agoraphobia Scale (PAS). All had been treated previously, and the majority (58.3%) were taking antipanic medications. The PAS, which was used as part of the regular follow-up assessment battery for PD patients, measures the overall severity of PD and the severity of key aspects and components of PD. Compared to the PAS assessments made before the onset of air strikes, the PAS assessments made at the time of air strikes showed significant differences in terms of decreased overall severity of PD, fewer health concerns, decrease in the level of disability, and greater intensity and frequency of anticipatory anxiety. Differences on the measures of panic attacks and agoraphobic avoidance were negligible. These results suggest that there is no relationship between panic attacks and real danger and lend support to the notion that panic attacks and fear induced by real danger are different phenomena. Contrary to the expectations of many PD patients, the presence of real danger does not seem to be associated with deterioration in their functioning, and PD patients can be reassured that they are not likely to cope worse under conditions of danger.

Uhlenhuth EH, Starcevic V, Warner TD, Matuzas W, McCarty T, Roberts B, Jenkusky S. · Department of Psychiatry, University of New Mexico School of Medicine, 2400 Tucker, N.E., Albuquerque, NM 87131-5326, USA. · J Affect Disord. · Pubmed #12128236 No free full text.

Abstract: OBJECTIVE: This study compared scores on the Anxious Thoughts & Tendencies (AT&T) questionnaire, a putative measure of a general anxiety-prone cognitive style, among patients with panic disorder without agoraphobia (PD, n=62), panic disorder with agoraphobia (PDA, n=29), generalized anxiety disorder (GAD, n=43), limited social phobia (LSP, n=34), generalized social phobia (GSP, n=33), and community residents (n=319). METHOD: Candidates for treatment studies completed a diagnostic interview and the AT&T. AT&T scores were compared among anxious groups using analysis of variance. Then depressed and non-depressed patients were compared. The final analysis compared anxious groups without comorbid depressive or anxiety disorders. RESULTS: AT&T scores were highest in PDA patients, followed by patients with GAD or GSP, then patients with PD or LSP, with community residents lowest. Depressed patients were higher than non-depressed patients. Patients with current or past comorbid depressive disorders did not differ. The ranking of anxious groups on AT&T scores remained unchanged after exclusion of patients with comorbid disorders. Patients with PD or LSP without comorbidity had the same AT&T levels as the community sample. CONCLUSIONS: The AT&T discriminates PDA and GAD from PD per our hypothesis. The low AT&T levels among patients with PD and LSP suggest no association with a general anxiety-prone cognitive style. LSP and GSP may be distinct disorders. The cognitive style assessed by the AT&T is also associated with depression and may be a marker for vulnerability to depression. Definitive conclusions about a pathogenic role for cognitions require their measurement before the onset of the disorder.

Starcevic V, Bogojevic G, Marinkovic J. · Institute of Mental Health, Belgrade, Yugoslavia. · J Pers Disord. · Pubmed #11019744 No free full text.

Abstract: Our objective was to examine whether the SCL-90-R, a widely used self-report measure of distress and psychopathology, could screen for personality disorders in general and for severe personality disturbance (SPD) in particular, at the time when patients seek treatment for a state (mood or anxiety) disorder. The SCL-90-R was administered to 112 consecutive outpatients with various mood and anxiety disorders. The personality severity index (PSI) score, defined as the mean value of the scores on the SCL-90-R subscales of interpersonal sensitivity, hostility, and paranoid ideation, was compared with the current symptom index (CSI) score, defined as the mean value of the scores on the remaining six SCL-90-R subscales. A positive screen was considered if PSI > CSI. SPD was defined as the presence of any DSM-III-R Cluster A and/or Cluster B personality disorder. The accuracy of the screen was verified by means of the Structured Clinical Interview for DSM-III-R Personality Disorders. The sensitivity of the PSI > CSI criterion to screen for SPD was 89.4%, while its sensitivity to screen for any DSM-III-R personality disorder was 72.9%. The SCL-90-R subscales that contributed the most to the screening discriminability of this SCL-90-R-derived screening measure were hostility, paranoid ideation, somatization, and obsessive-compulsive behavior. The SCL-90-R may be used to screen for SPD in routine work with outpatients with mood and anxiety disorders, but the results of the screening need to be verified because of the possibility of false negatives and false positives, although that possibility is apparently low. These findings may have important prognostic and treatment implications.

Latas M, Starcevic V, Trajkovic G, Bogojevic G. · Institute of Psychiatry, Clinical Center of Serbia, Belgrade, Yugoslavia. · Compr Psychiatry. · Pubmed #10646616 No free full text.

Abstract: The aim of this study was to ascertain predictors of comorbid personality disorders in patients with panic disorder with agoraphobia (PDAG). Sixty consecutive outpatients with PDAG were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) for the purpose of diagnosing personality disorders. Logistic regressions were used to identify predictors of any comorbid personality disorder, any DSM-IV cluster A, cluster B, and cluster C personality disorder. Independent variables in these regressions were gender, age, duration of panic disorder (PD), severity of PDAG, and scores on self-report instruments that assess the patient's perception of their parents, childhood separation anxiety, and traumatic experiences. High levels of parental protection on the Parental Bonding Instrument (PBI), indicating a perception of the parents as overprotective and controlling, emerged as the only statistically significant predictor of any comorbid personality disorder. This finding was attributed to the association between parental overprotection and cluster B personality disorders, particularly borderline personality disorder. The duration of PD was a significant predictor of any cluster B and any cluster C personality disorder, suggesting that some of the cluster B and cluster C personality disorders may be a consequence of the long-lasting PDAG. Any cluster B personality disorder was also associated with younger age. In conclusion, despite a generally nonspecific nature of the relationship between parental overprotection in childhood and adult psychopathology, the findings of this study suggest some specificity for the association between parental overprotection in childhood and personality disturbance in PDAG patients, particularly cluster B personality disorders.