Original Paper Psychopathology 2015;48:137–144 DOI: 10.1159/000368904
Received: December 12, 2013 Accepted after revision: September 23, 2014 Published online: March 31, 2015
Clinical Symptoms Associated with Suicidality in Patients with Panic Disorder Se-Won Lim Eun-Mi Ko Dong-Won Shin Young-Chul Shin Kang-Seob Oh Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Abstract Background: Patients with panic disorder have higher rates of suicide than the general population. Among panic disorder subjects, early onset, female gender, alcohol abuse, and mood disorder increase the risk of suicidality. However, less is known about the unique relationships between discrete DSM-IV panic symptoms and higher suicidality. Therefore, in the current study we examined the panic symptom profile that is associated with higher suicidality in a sample of outpatients with panic disorder. Methods: This cross-sectional study included 427 patients diagnosed with current panic disorder on the basis of the DSM-IV-TR. In order to assess the contribution of the clinical variables, a univariate logistic regression was carried out examining the relationships between the demographic variables, suicidality from the suicide module of the Korean version of the MINI International Neuropsychiatric Interview Plus, and DSM-IV panic symptoms. Additionally, a multivariate logistic regression was performed to identify specific panic symptoms that were significant risk factors for suicidality among patients with current panic disorder. Results: We found that 74 (17.33%) panic disorder patients experienced high suicidality. Univariate analyses showed that high suicidality was significantly associated with a younger age (OR = 13.66; 95% CI 2.68– 69.70), comorbid depressive disorders (OR = 4.57; 95% CI 2.57–8.11), and the following panic symptoms: palpitations
© 2015 S. Karger AG, Basel 0254–4962/15/0483–0137$39.50/0 E-Mail [email protected] www.karger.com/psp
(OR = 2.20; 95% CI 0.90–5.35), trembling (OR = 0.61; 95% CI 0.362–1.18), nausea or abdominal distress (OR = 1.77; 95% CI 0.96–3.27), fear of losing control or going crazy (OR = 2.18; 95% CI 1.12–4.23), and paresthesia (OR = 1.57; 95% CI 0.83– 2.98). Multivariate logistic regression analyses demonstrated that specific panic symptoms, such as palpitations (adjusted OR = 2.69; 95% CI 1.08–6.73) and fear of losing control or going crazy (adjusted OR = 2.28; 95% CI 1.21–4.31), were related to suicidality after controlling for confounding factors. Conclusion: Some panic symptoms (e.g. palpitations and fear of losing control or going crazy) are associated with a risk of suicidality among patients with panic disorder. A priori identification of high-risk suicidal subjects could lead to effective treatment strategies for panic disorder. © 2015 S. Karger AG, Basel
Introduction
Panic disorder (PD) is a common disorder in the general population that reduces the quality of life and increases disability and the risk of suicide [1]. Studies have shown that the rate of suicide attempts among patients with PD varies considerably, ranging from low rates of 0.7 [2] and 2% [3] to a high rate of 42% [4]. Such inconsistencies may be due to differences in methodology, including whether the effects of comorbid disorders are controlled
Se-Won Lim and Eun-Mi Ko contributed equally to this work.
Kang-Seob Oh, MD Department of Psychiatry, Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine 108, Pyung-dong, Jongno-Ku, Seoul 110-746 (Republic of Korea) E-Mail ks2485 @ empal.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/19/2015 8:56:11 AM
Key Words Panic disorder · Suicidality · Risk factor · Panic symptom
138
Psychopathology 2015;48:137–144 DOI: 10.1159/000368904
panic symptoms associated with suicidality. Four categories of clinical variables were considered: demographic characteristics (e.g. age and sex), comorbidity [e.g. depressive disorder, alcohol use disorders, social phobia, generalized anxiety disorder (GAD), and other anxiety disorders], and DSM-IV-TR panic symptoms (e.g. palpitations, sweating, trembling, the sensation of shortness of breath or smothering, the feeling of choking, chest pain, nausea or abdominal distress, feeling dizzy or faint, derealization or depersonalization, fear of losing control or going crazy, fear of dying, paresthesia, and chills or hot flushes). Upon examining prior research findings [2, 8, 13–15] and clinical experience, we initially expected PD patients with suicidality to have a younger age and significantly higher comorbidity rates, which are known to be associated with an increased risk of suicidality. We also sought to determine whether any specific symptoms of PD were significantly associated with suicidality after adjusting for other clinical risk variables, such as depressive disorder. Multivariate models were used for the evaluation of unique clinical variables of suicidality in order to determine distinct characteristics of patients with PD at a high risk for suicidality. Methods Sample The subjects in this cross-sectional study were 582 outpatients diagnosed with current PD according to DSM-IV-TR criteria. The outpatients were recruited from the Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Republic of Korea. A structured interview based on the DSM-IV along with the Korean version of the MINI International Neuropsychiatric Interview Plus (MINI-Plus) was administered to determine current axis I psychiatric diagnoses. Given the low prevalence of these anxiety diagnoses (i.e. specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, acute stress disorder, and anxiety disorder not otherwise specified), we did not consider these individually in our analyses but classified them as ‘other anxiety disorders’. Psychiatric evaluations also included demographic characteristics and the psychiatric history. The study design, protocol, and consent procedures were reviewed and approved by the Institutional Review Board of Kangbuk Samsung Hospital and are in accordance with the Declaration of Helsinki of 1975. Measures Suicide Questionnaire Suicidality was evaluated using the suicide module of the Korean version of the MINI-Plus. The suicidality section inquires about several components of suicidality using the following questions: over the last month: (1) Have you wished you were dead? (score: 1 point); (2) Have you wanted to harm yourself? (2 points); (3) Have you thought of committing suicide? (6 points); (4) Have you planned how to commit suicide? (10 points); (5) Have you attempted suicide in the past month? (10 points), and (6) Have you ever attempted suicide? (4 points). Total scores on the MINI suicidality
Lim/Ko/Shin/Shin/Oh
Downloaded by: University of Tokyo 157.82.153.40 - 5/19/2015 8:56:11 AM
for, and which methods of statistical control (i.e. controlling for confounding factors) are used. In fact, Hornig and McNally [5] found that of the 50 subjects in an epidemiologic catchment area that they studied, who fulfilled the criteria for a lifetime diagnosis of PD and attempted suicide, 40% also met the criteria for schizophrenia, 46% met the criteria for alcohol dependence/abuse, 32% met the criteria for major depression, and 21% met the criteria for bipolar disorder. Most panic patients develop coexisting conditions that are associated with an increased risk of suicide [6, 7]. However, it has been demonstrated that the presence of PD may increase the suicide risk in individuals with PD but without comorbid disorders [1, 8, 9]. In a large community survey, Weissman et al. [8] first reported a significant association between panic attacks, PD, and a lifetime prevalence of suicidal ideation and attempts. Controlling separately for the effects of major depression, alcohol, drug abuse, and agoraphobia, the associations between panic attacks, PD, and suicidal ideation and suicide attempts remained significant. These results suggest that specific panic factors may also contribute to suicidality in patients with PD. However, previous studies have typically examined suicidality in PD in relation to comorbidities or demographic variables. PD is characterized by recurrent panic attacks that consist of sudden episodes of intense fear or discomfort. These panic attacks are associated with several cognitive and somatic symptoms [10]. However, little is known about which symptoms among the discrete DSM-IV panic symptoms in PD are associated with suicidality. Moreover, there are conflicting reports about the relationship between specific panic symptoms and suicidality. For example, a study by Schmidt et al. [11] suggested that high scores on certain configurations of panic symptoms may play a significant role in the prediction of the suicide risk. They found that, in a sample of patients with PD, the suicide risk was predicted by high levels of: (1) overall anxiety symptoms, (2) anticipatory anxiety, (3) avoidance of bodily sensations, (4) attentional vigilance toward bodily perturbations, and (5) phrenophobia. In another study, Yaseen et al. [12] revealed a positive association between suicide risk and fear of dying among patients with panic attacks. These discrepancies may be explained by methodological differences, such as the type and severity of comorbidity and the extent to which it was assessed and described. These studies raise important questions about the potential relationship of panic symptoms with suicidality in patients with PD. The purpose of this study was to compare patients with PD with and without suicidality in order to determine the specific
Panic Symptoms The panic module of the MINI-Plus was used as a measure of specific panic symptoms. Participants were asked about 13 panic symptoms experienced during panic attacks that were based on DSM-IV-TR criteria as specified in Introduction. All questions were dichotomous, i.e. yes/no. Statistical Analysis Statistical analyses were performed using SPSS for Windows version 18.0 (SPSS Inc., Chicago, Ill., USA). To assess risk factors for suicidality, univariate logistic regression analyses were performed using PD group (with or without suicidality) as the dependent variable and panic symptoms as the independent variable. Demographic variables (e.g. sex and age) and comorbid clinical variables (depressive disorder, alcohol use disorders, social phobia, and GAD and other anxiety disorders) were also included in the model. All candidate predictor variables that achieved significance (p < 0.20) in the univariate analysis were entered into the multivariate analysis [20]. The multivariate logistic regression analysis was then used to evaluate the independence of the relationship between the specific panic symptoms and suicidality by controlling for demographic characteristics and comorbid disorders, which are well-known risk factors of suicide [3, 13, 21, 22]. p < 0.05 was considered statistically significant.
Results
Sample Characteristics and Comorbidity A total of 582 subjects met the diagnostic criteria for PD. We had to exclude 155 cases because the MINI-Plus suicide scale had not been administered at baseline. Patients with PD were divided into 2 groups: those with suicidality (total score ≥10) and those without suicidality (total score
Received: December 12, 2013 Accepted after revision: September 23, 2014 Published online: March 31, 2015
Clinical Symptoms Associated with Suicidality in Patients with Panic Disorder Se-Won Lim Eun-Mi Ko Dong-Won Shin Young-Chul Shin Kang-Seob Oh Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
Abstract Background: Patients with panic disorder have higher rates of suicide than the general population. Among panic disorder subjects, early onset, female gender, alcohol abuse, and mood disorder increase the risk of suicidality. However, less is known about the unique relationships between discrete DSM-IV panic symptoms and higher suicidality. Therefore, in the current study we examined the panic symptom profile that is associated with higher suicidality in a sample of outpatients with panic disorder. Methods: This cross-sectional study included 427 patients diagnosed with current panic disorder on the basis of the DSM-IV-TR. In order to assess the contribution of the clinical variables, a univariate logistic regression was carried out examining the relationships between the demographic variables, suicidality from the suicide module of the Korean version of the MINI International Neuropsychiatric Interview Plus, and DSM-IV panic symptoms. Additionally, a multivariate logistic regression was performed to identify specific panic symptoms that were significant risk factors for suicidality among patients with current panic disorder. Results: We found that 74 (17.33%) panic disorder patients experienced high suicidality. Univariate analyses showed that high suicidality was significantly associated with a younger age (OR = 13.66; 95% CI 2.68– 69.70), comorbid depressive disorders (OR = 4.57; 95% CI 2.57–8.11), and the following panic symptoms: palpitations
© 2015 S. Karger AG, Basel 0254–4962/15/0483–0137$39.50/0 E-Mail [email protected] www.karger.com/psp
(OR = 2.20; 95% CI 0.90–5.35), trembling (OR = 0.61; 95% CI 0.362–1.18), nausea or abdominal distress (OR = 1.77; 95% CI 0.96–3.27), fear of losing control or going crazy (OR = 2.18; 95% CI 1.12–4.23), and paresthesia (OR = 1.57; 95% CI 0.83– 2.98). Multivariate logistic regression analyses demonstrated that specific panic symptoms, such as palpitations (adjusted OR = 2.69; 95% CI 1.08–6.73) and fear of losing control or going crazy (adjusted OR = 2.28; 95% CI 1.21–4.31), were related to suicidality after controlling for confounding factors. Conclusion: Some panic symptoms (e.g. palpitations and fear of losing control or going crazy) are associated with a risk of suicidality among patients with panic disorder. A priori identification of high-risk suicidal subjects could lead to effective treatment strategies for panic disorder. © 2015 S. Karger AG, Basel
Introduction
Panic disorder (PD) is a common disorder in the general population that reduces the quality of life and increases disability and the risk of suicide [1]. Studies have shown that the rate of suicide attempts among patients with PD varies considerably, ranging from low rates of 0.7 [2] and 2% [3] to a high rate of 42% [4]. Such inconsistencies may be due to differences in methodology, including whether the effects of comorbid disorders are controlled
Se-Won Lim and Eun-Mi Ko contributed equally to this work.
Kang-Seob Oh, MD Department of Psychiatry, Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine 108, Pyung-dong, Jongno-Ku, Seoul 110-746 (Republic of Korea) E-Mail ks2485 @ empal.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/19/2015 8:56:11 AM
Key Words Panic disorder · Suicidality · Risk factor · Panic symptom
138
Psychopathology 2015;48:137–144 DOI: 10.1159/000368904
panic symptoms associated with suicidality. Four categories of clinical variables were considered: demographic characteristics (e.g. age and sex), comorbidity [e.g. depressive disorder, alcohol use disorders, social phobia, generalized anxiety disorder (GAD), and other anxiety disorders], and DSM-IV-TR panic symptoms (e.g. palpitations, sweating, trembling, the sensation of shortness of breath or smothering, the feeling of choking, chest pain, nausea or abdominal distress, feeling dizzy or faint, derealization or depersonalization, fear of losing control or going crazy, fear of dying, paresthesia, and chills or hot flushes). Upon examining prior research findings [2, 8, 13–15] and clinical experience, we initially expected PD patients with suicidality to have a younger age and significantly higher comorbidity rates, which are known to be associated with an increased risk of suicidality. We also sought to determine whether any specific symptoms of PD were significantly associated with suicidality after adjusting for other clinical risk variables, such as depressive disorder. Multivariate models were used for the evaluation of unique clinical variables of suicidality in order to determine distinct characteristics of patients with PD at a high risk for suicidality. Methods Sample The subjects in this cross-sectional study were 582 outpatients diagnosed with current PD according to DSM-IV-TR criteria. The outpatients were recruited from the Department of Psychiatry, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Republic of Korea. A structured interview based on the DSM-IV along with the Korean version of the MINI International Neuropsychiatric Interview Plus (MINI-Plus) was administered to determine current axis I psychiatric diagnoses. Given the low prevalence of these anxiety diagnoses (i.e. specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, acute stress disorder, and anxiety disorder not otherwise specified), we did not consider these individually in our analyses but classified them as ‘other anxiety disorders’. Psychiatric evaluations also included demographic characteristics and the psychiatric history. The study design, protocol, and consent procedures were reviewed and approved by the Institutional Review Board of Kangbuk Samsung Hospital and are in accordance with the Declaration of Helsinki of 1975. Measures Suicide Questionnaire Suicidality was evaluated using the suicide module of the Korean version of the MINI-Plus. The suicidality section inquires about several components of suicidality using the following questions: over the last month: (1) Have you wished you were dead? (score: 1 point); (2) Have you wanted to harm yourself? (2 points); (3) Have you thought of committing suicide? (6 points); (4) Have you planned how to commit suicide? (10 points); (5) Have you attempted suicide in the past month? (10 points), and (6) Have you ever attempted suicide? (4 points). Total scores on the MINI suicidality
Lim/Ko/Shin/Shin/Oh
Downloaded by: University of Tokyo 157.82.153.40 - 5/19/2015 8:56:11 AM
for, and which methods of statistical control (i.e. controlling for confounding factors) are used. In fact, Hornig and McNally [5] found that of the 50 subjects in an epidemiologic catchment area that they studied, who fulfilled the criteria for a lifetime diagnosis of PD and attempted suicide, 40% also met the criteria for schizophrenia, 46% met the criteria for alcohol dependence/abuse, 32% met the criteria for major depression, and 21% met the criteria for bipolar disorder. Most panic patients develop coexisting conditions that are associated with an increased risk of suicide [6, 7]. However, it has been demonstrated that the presence of PD may increase the suicide risk in individuals with PD but without comorbid disorders [1, 8, 9]. In a large community survey, Weissman et al. [8] first reported a significant association between panic attacks, PD, and a lifetime prevalence of suicidal ideation and attempts. Controlling separately for the effects of major depression, alcohol, drug abuse, and agoraphobia, the associations between panic attacks, PD, and suicidal ideation and suicide attempts remained significant. These results suggest that specific panic factors may also contribute to suicidality in patients with PD. However, previous studies have typically examined suicidality in PD in relation to comorbidities or demographic variables. PD is characterized by recurrent panic attacks that consist of sudden episodes of intense fear or discomfort. These panic attacks are associated with several cognitive and somatic symptoms [10]. However, little is known about which symptoms among the discrete DSM-IV panic symptoms in PD are associated with suicidality. Moreover, there are conflicting reports about the relationship between specific panic symptoms and suicidality. For example, a study by Schmidt et al. [11] suggested that high scores on certain configurations of panic symptoms may play a significant role in the prediction of the suicide risk. They found that, in a sample of patients with PD, the suicide risk was predicted by high levels of: (1) overall anxiety symptoms, (2) anticipatory anxiety, (3) avoidance of bodily sensations, (4) attentional vigilance toward bodily perturbations, and (5) phrenophobia. In another study, Yaseen et al. [12] revealed a positive association between suicide risk and fear of dying among patients with panic attacks. These discrepancies may be explained by methodological differences, such as the type and severity of comorbidity and the extent to which it was assessed and described. These studies raise important questions about the potential relationship of panic symptoms with suicidality in patients with PD. The purpose of this study was to compare patients with PD with and without suicidality in order to determine the specific
Panic Symptoms The panic module of the MINI-Plus was used as a measure of specific panic symptoms. Participants were asked about 13 panic symptoms experienced during panic attacks that were based on DSM-IV-TR criteria as specified in Introduction. All questions were dichotomous, i.e. yes/no. Statistical Analysis Statistical analyses were performed using SPSS for Windows version 18.0 (SPSS Inc., Chicago, Ill., USA). To assess risk factors for suicidality, univariate logistic regression analyses were performed using PD group (with or without suicidality) as the dependent variable and panic symptoms as the independent variable. Demographic variables (e.g. sex and age) and comorbid clinical variables (depressive disorder, alcohol use disorders, social phobia, and GAD and other anxiety disorders) were also included in the model. All candidate predictor variables that achieved significance (p < 0.20) in the univariate analysis were entered into the multivariate analysis [20]. The multivariate logistic regression analysis was then used to evaluate the independence of the relationship between the specific panic symptoms and suicidality by controlling for demographic characteristics and comorbid disorders, which are well-known risk factors of suicide [3, 13, 21, 22]. p < 0.05 was considered statistically significant.
Results
Sample Characteristics and Comorbidity A total of 582 subjects met the diagnostic criteria for PD. We had to exclude 155 cases because the MINI-Plus suicide scale had not been administered at baseline. Patients with PD were divided into 2 groups: those with suicidality (total score ≥10) and those without suicidality (total score
