Comprehensive Psychiatry (Official Journal of the American Psychopathological
JULY/AUGUST
VOL. 32, NO. 4
Examination
Association)
of Comorbid Anxiety Inpatients
1991
in Psychiatric
Michael Garvey, Russell Noyes, Jr., Dorothy Anderson, and Brian Cook Seventy-three percent of 90 psychiatric inpatients had a coexisting anxiety disorder. There were few differences between patients with or without coexisting anxiety on more than 100 clinical and demographic variables that were tested. Patients who had an anxiety syndrome before the onset of their major psychiatric disorder also showed few differences when compared with patients whose anxiety started coincident to or after another DSM-III axis I disorder. The concept of primary/secondary anxiety disorder cross-section of psychiatric inpatients. Copyright 0 199 1 by W. B. Saunders Company
may
not be useful when
applied
to a
D
URING THE PAST DECADE, there has been an increased awareness that comorbid psychiatric disorders may exert significant influence on what is presumed to be the major or underlying psychiatric disorder. For example, some studies have shown that comorbid anxiety symptoms in major depression are associated with a poorer prognosis.‘-4 Similarly, panic disorder patients with secondary or comorbid depression have a poorer prognosis1,5W7 and more severe symptoms.x~y Anxiety symptoms are ubiquitous in psychiatric disorders. The frequency of comorbid anxiety disorders in a general population of psychiatric patients is unknown. Furthermore, there is little information about whether a mixed diagnostic group of patients with coexisting anxiety disorders would differ from those who did not have coexisting anxiety, as is the case for major depression.‘-4 The study described herein examines these issues. A related, but yet different, issue from that of comorbid diagnoses, is whether the distinction of primary versus secondary disorder, which is based on the chronological onset of the involved illnesses, could have clinical relevance for anxiety disorders. The primary/ secondary dichotomization of major depression appears to be a valid and useful concept.1° This study examines whether there are clinical or demographic differences between patients with primary versus secondary anxiety.
From the Depafiment of Psychiatry, University of Iowa College of Medicine, Iowa City, IA; and the Veterans Administration Medical Center, Iowa City, IA. Address reprint requests to Michael Garvey, M.D., Department of Psychiatry, VA Medical Center, Iowa City, IA 52246. Copyright 0 1991 by W.3. Saunders Company OOlO-440X/91/3204-0007$03.OOiO Comprehensive
Psychiatv,
Vol. 32, No. 4 (July/August),
1991: pp 277-282
277
278
GARVEY ET AL
METHOD Consecutive patients admitted to the University of Iowa Psychiatric Hospital during a 2-month period were invited to participate in a study about psychiatric diagnoses. A semistructured interview formulated by one of the authors (R.N.) was administered to all consenting patients. The interviews were conducted within 1 week of admission unless the patient was unable to cooperate, in which case the interview was conducted at a later time. Information was collected from the patient, medical records, and a significant other, when available. The interview included questions about demographics, current and past anxiety, and longitudinal psychiatric history. Patients with comorbid anxiety were asked about alcohol or drug use, premorbid as well as morbid personality traits, family history, and social, marital, and work adjustments. Detailed information was gathered about the temporal relationship between the comorbid diagnoses, illness precipitants, and treatments. Current DSM-III diagnoses were made for all study patients. The DSM-III hierarchical schema was suspended in making certain anxiety disorder diagnoses. For example, a patient given a diagnosis of schizophrenia could also be diagnosed as generalized anxiety disorder (GAD) if the DSM-III criteria for the GAD were met, except for the criterion that excludes the diagnosis of GAD if it was secondary or due to another diagnosis such as schizophrenia or major depression. Some patients met criteria for more than one comorbid anxiety disorder; however, only the predominant comorbid diagnosis was listed. For the purposes of this report, the major psychiatric disorder was defined as the DSM-III disorder that was predominant and led to the current hospitalization. The major diagnoses were grouped together into categories. They included affective (mood) disorders, substance dependence disorders, schizophrenia, organic mental disorders, anxiety disorders, eating disorders, adjustment disorders, personality disorders, and miscellaneous. Comparisons of clinical and demographic variables were made between patients with and without a comorbid anxiety disorder. Patients were also divided into three groups based on whether their comorbid anxiety disorder began before, coincident, or after their major psychiatric disorder. Comparisons of study variables were made between these patients groups. Continuous variables were analyzed with the Student’s t test or an analysis of variance (ANOVA) if normally distributed, otherwise, a nonparametric test was used. Categorical variables were analyzed with a chi-square statistic. If any cell size was less than 5, a Fisher’s exact test was used.
RESULTS
Ninety-five patients were interviewed. The mean age (*SD) for the study sample was 32 f 14 years. Sixty-nine percent of the sample were women. The major psychiatric disorder that led the patient’s hospitalization as well as the comorbid anxiety diagnoses are listed in Table 1. The “other” category (N = 7) listed in Table 1 was comprised of somatiform disorder (N = 3), conduct disorder (N = 3), and factitious disorder (N = 1). Sixty-six of the 90 patients (73%) whose
Table 1. Primary Diagnoses and Comorbid Anxiety Diagnoses
Primary Diagnoses
N
Affective disorders Schizophrenia Organic disorders Personality disorders Other disorders Eating disorder Anxiety disorders Adjustment disorders Substance dependence
35 18 9 7 7 6 5 4 4
Comorbid Panic Disorder (%I
Comorbid GAD w-1
43 17 22 14 28 33 -
34 22 22 71 43 33 50 75
25 0
Comorbid “Other” Anxiety Disorders W)
No Comorbidity Anxiety (%I
11 5 0 0 14 17
11 56 56 14 14 17 -
0 0
25 25
COMORBID
ANXIETY
279
DISORDER
major diagnosis was not an anxiety disorder were given a comorbid anxiety disorder diagnosis. The specific comorbid anxiety diagnoses given to these 66 patients were GAD (33) panic disorder (PD) (17), agoraphobia with panic attacks (nine), atypical anxiety disorder (five), social phobia (one), and obsessivecompulsive disorder (one). The nine patients who were diagnosed as agoraphobia with panic attacks would be diagnosed as PD with agoraphobia using DSM-III-R criteria. Combining these nine patients with the 17 patients with PD results in a PD group of 26. PD and GAD accounted for nearly 90% of patients given a comorbid anxiety diagnoses. Table 1 shows a breakdown of the major diagnoses by comorbid anxiety disorder diagnoses. The percentage of patients with comorbid anxiety ranged from a low of 44% in schizophrenia and organic disorders to a high of 89% in mood disorders. A comparison of patients with comorbid anxiety disorders (N = 66) and those without (N = 24) produced few differences (Table 2), except for the presence of certain kinds of symptoms. As expected, patients with comorbid anxiety disorders had significantly more of the 35 symptoms of anxiety that were examined. Some other psychiatric symptoms that were also more common in patients with comorbid anxiety disorders included depersonalization (P < .003), derealization (P < .004), obsessions (P < .02), and conversion symptoms (P < .06). Social phobias and simple phobias were slightly more common in comorbid anxiety patients, but not significantly so. Only two diagnostic categories (affective disorders, N = 35; and schizophrenia, N = 18) had enough patients to evaluate the effect of comorbid anxiety on specific diagnostic groups. Of the 35 affectively disordered patients, 27 had major depression. All but one of these 27 patients had a comorbid anxiety disorder, making comparisons within this category meaningless. There were eight schizophrenic patients with and 10 without a comorbid anxiety disorder. Schizophrenics with comorbid anxiety had a shorter current episode duration (median months, 2 v 25; P < .05, Mann-Whitney U test) and a greater frequency of patients with a remitting course of illness (50% v 0%; P < .05). Their mean (*SD) age of illness onset was 25 2 11 versus 21 ? 7 years for those with no comorbid anxiety (not significant) and those with comorbid
Table 2. Comparison
Variable Women Age (mean 2 SD) Age of onset of major illness Duration of current episode of major illness (median mo) Course of major illness Remitting Chronic fluctuating symptoms Chronic No. of major illness episodes (mean +- SD) Family history of PD Family history of GAD *Mann-Whitney
U test.
of Patients With and Without Comorbid Anxiety No Anxiety Disorder (N = 24)
Comorbid Anxiety Disorder (N = 66)
P
JULY/AUGUST
VOL. 32, NO. 4
Examination
Association)
of Comorbid Anxiety Inpatients
1991
in Psychiatric
Michael Garvey, Russell Noyes, Jr., Dorothy Anderson, and Brian Cook Seventy-three percent of 90 psychiatric inpatients had a coexisting anxiety disorder. There were few differences between patients with or without coexisting anxiety on more than 100 clinical and demographic variables that were tested. Patients who had an anxiety syndrome before the onset of their major psychiatric disorder also showed few differences when compared with patients whose anxiety started coincident to or after another DSM-III axis I disorder. The concept of primary/secondary anxiety disorder cross-section of psychiatric inpatients. Copyright 0 199 1 by W. B. Saunders Company
may
not be useful when
applied
to a
D
URING THE PAST DECADE, there has been an increased awareness that comorbid psychiatric disorders may exert significant influence on what is presumed to be the major or underlying psychiatric disorder. For example, some studies have shown that comorbid anxiety symptoms in major depression are associated with a poorer prognosis.‘-4 Similarly, panic disorder patients with secondary or comorbid depression have a poorer prognosis1,5W7 and more severe symptoms.x~y Anxiety symptoms are ubiquitous in psychiatric disorders. The frequency of comorbid anxiety disorders in a general population of psychiatric patients is unknown. Furthermore, there is little information about whether a mixed diagnostic group of patients with coexisting anxiety disorders would differ from those who did not have coexisting anxiety, as is the case for major depression.‘-4 The study described herein examines these issues. A related, but yet different, issue from that of comorbid diagnoses, is whether the distinction of primary versus secondary disorder, which is based on the chronological onset of the involved illnesses, could have clinical relevance for anxiety disorders. The primary/ secondary dichotomization of major depression appears to be a valid and useful concept.1° This study examines whether there are clinical or demographic differences between patients with primary versus secondary anxiety.
From the Depafiment of Psychiatry, University of Iowa College of Medicine, Iowa City, IA; and the Veterans Administration Medical Center, Iowa City, IA. Address reprint requests to Michael Garvey, M.D., Department of Psychiatry, VA Medical Center, Iowa City, IA 52246. Copyright 0 1991 by W.3. Saunders Company OOlO-440X/91/3204-0007$03.OOiO Comprehensive
Psychiatv,
Vol. 32, No. 4 (July/August),
1991: pp 277-282
277
278
GARVEY ET AL
METHOD Consecutive patients admitted to the University of Iowa Psychiatric Hospital during a 2-month period were invited to participate in a study about psychiatric diagnoses. A semistructured interview formulated by one of the authors (R.N.) was administered to all consenting patients. The interviews were conducted within 1 week of admission unless the patient was unable to cooperate, in which case the interview was conducted at a later time. Information was collected from the patient, medical records, and a significant other, when available. The interview included questions about demographics, current and past anxiety, and longitudinal psychiatric history. Patients with comorbid anxiety were asked about alcohol or drug use, premorbid as well as morbid personality traits, family history, and social, marital, and work adjustments. Detailed information was gathered about the temporal relationship between the comorbid diagnoses, illness precipitants, and treatments. Current DSM-III diagnoses were made for all study patients. The DSM-III hierarchical schema was suspended in making certain anxiety disorder diagnoses. For example, a patient given a diagnosis of schizophrenia could also be diagnosed as generalized anxiety disorder (GAD) if the DSM-III criteria for the GAD were met, except for the criterion that excludes the diagnosis of GAD if it was secondary or due to another diagnosis such as schizophrenia or major depression. Some patients met criteria for more than one comorbid anxiety disorder; however, only the predominant comorbid diagnosis was listed. For the purposes of this report, the major psychiatric disorder was defined as the DSM-III disorder that was predominant and led to the current hospitalization. The major diagnoses were grouped together into categories. They included affective (mood) disorders, substance dependence disorders, schizophrenia, organic mental disorders, anxiety disorders, eating disorders, adjustment disorders, personality disorders, and miscellaneous. Comparisons of clinical and demographic variables were made between patients with and without a comorbid anxiety disorder. Patients were also divided into three groups based on whether their comorbid anxiety disorder began before, coincident, or after their major psychiatric disorder. Comparisons of study variables were made between these patients groups. Continuous variables were analyzed with the Student’s t test or an analysis of variance (ANOVA) if normally distributed, otherwise, a nonparametric test was used. Categorical variables were analyzed with a chi-square statistic. If any cell size was less than 5, a Fisher’s exact test was used.
RESULTS
Ninety-five patients were interviewed. The mean age (*SD) for the study sample was 32 f 14 years. Sixty-nine percent of the sample were women. The major psychiatric disorder that led the patient’s hospitalization as well as the comorbid anxiety diagnoses are listed in Table 1. The “other” category (N = 7) listed in Table 1 was comprised of somatiform disorder (N = 3), conduct disorder (N = 3), and factitious disorder (N = 1). Sixty-six of the 90 patients (73%) whose
Table 1. Primary Diagnoses and Comorbid Anxiety Diagnoses
Primary Diagnoses
N
Affective disorders Schizophrenia Organic disorders Personality disorders Other disorders Eating disorder Anxiety disorders Adjustment disorders Substance dependence
35 18 9 7 7 6 5 4 4
Comorbid Panic Disorder (%I
Comorbid GAD w-1
43 17 22 14 28 33 -
34 22 22 71 43 33 50 75
25 0
Comorbid “Other” Anxiety Disorders W)
No Comorbidity Anxiety (%I
11 5 0 0 14 17
11 56 56 14 14 17 -
0 0
25 25
COMORBID
ANXIETY
279
DISORDER
major diagnosis was not an anxiety disorder were given a comorbid anxiety disorder diagnosis. The specific comorbid anxiety diagnoses given to these 66 patients were GAD (33) panic disorder (PD) (17), agoraphobia with panic attacks (nine), atypical anxiety disorder (five), social phobia (one), and obsessivecompulsive disorder (one). The nine patients who were diagnosed as agoraphobia with panic attacks would be diagnosed as PD with agoraphobia using DSM-III-R criteria. Combining these nine patients with the 17 patients with PD results in a PD group of 26. PD and GAD accounted for nearly 90% of patients given a comorbid anxiety diagnoses. Table 1 shows a breakdown of the major diagnoses by comorbid anxiety disorder diagnoses. The percentage of patients with comorbid anxiety ranged from a low of 44% in schizophrenia and organic disorders to a high of 89% in mood disorders. A comparison of patients with comorbid anxiety disorders (N = 66) and those without (N = 24) produced few differences (Table 2), except for the presence of certain kinds of symptoms. As expected, patients with comorbid anxiety disorders had significantly more of the 35 symptoms of anxiety that were examined. Some other psychiatric symptoms that were also more common in patients with comorbid anxiety disorders included depersonalization (P < .003), derealization (P < .004), obsessions (P < .02), and conversion symptoms (P < .06). Social phobias and simple phobias were slightly more common in comorbid anxiety patients, but not significantly so. Only two diagnostic categories (affective disorders, N = 35; and schizophrenia, N = 18) had enough patients to evaluate the effect of comorbid anxiety on specific diagnostic groups. Of the 35 affectively disordered patients, 27 had major depression. All but one of these 27 patients had a comorbid anxiety disorder, making comparisons within this category meaningless. There were eight schizophrenic patients with and 10 without a comorbid anxiety disorder. Schizophrenics with comorbid anxiety had a shorter current episode duration (median months, 2 v 25; P < .05, Mann-Whitney U test) and a greater frequency of patients with a remitting course of illness (50% v 0%; P < .05). Their mean (*SD) age of illness onset was 25 2 11 versus 21 ? 7 years for those with no comorbid anxiety (not significant) and those with comorbid
Table 2. Comparison
Variable Women Age (mean 2 SD) Age of onset of major illness Duration of current episode of major illness (median mo) Course of major illness Remitting Chronic fluctuating symptoms Chronic No. of major illness episodes (mean +- SD) Family history of PD Family history of GAD *Mann-Whitney
U test.
of Patients With and Without Comorbid Anxiety No Anxiety Disorder (N = 24)
Comorbid Anxiety Disorder (N = 66)
P
