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Alcoholism in 274 patients with panic disorder in Spain, one of the main producers of wine worldwide

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Alcoholism in 274 patients with panic disorder in Spain, one of the main producers of wine worldwide
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  Journal of Affective Disorders 75 (2003) 237–245www.elsevier.com/locate/jad Research report Alcoholism in 274 patients with panic disorder in Spain, one of themain producers of wine worldwide a, b c b c *´ ´ ´M. Marquez , J. Seguı , J. Canet , L. Garcıa , M. Ortiz a ´  Hospital Parc Taulı ,  Psychiatric Unit  ,  Sabadell ,  Barcelona ,  Spain b Section of Psychiatry ,  La Alianza General Hospital ,  c  /  Viladomat  288,  Barcelona 08021,  Spain c PSINEP ,  Corcega 357   Entlo .2,  Barcelona 08037,  Spain Received 16 May 2000; received in revised form 23 January 2002; accepted 24 January 2002 Abstract  Background  : Though panic disorder (PD) and alcoholism have been found in epidemiologic studies to often co-occur, theinfluence of cultural factors on the order of onset of the disorders has not been frequently addressed.  Methods : A sample of 274 patients with PD was assessed and compared according to the presence of alcohol use disorder (AUD) (alcohol abuse ordependence), employing several clinical scales.  Results : A total of 26 subjects were diagnosed from AUD. In 73.1% of patients, onset of alcohol use was previous to PD onset. PD subjects with AUD were found to have an earlier age at PDonset. They were more likely to be males, to have a family history of alcoholism, to abuse other drugs and to experience amore severe PD (more attacks in the last month, higher scores in anticipatory anxiety).  Conclusions : Patients with PD andalcoholism may represent a distinct clinical subgroup. Our finding of an uncommon order of onset for both disorders mayreflect cultural influences.  Clinical implications : (i)The study of panic disorder patients with comorbid alcoholism may helpto better characterize this subgroup of patients. (ii) Patterns of alcohol use and the order of onset of both disorders may beinfluenced by cultural factors, with important practical implications. (iii) Patients with panic disorder and alcoholism mayrepresent a distinct clinical subgroup, with an earlier age at panic disorder onset and greater clinical severity of anxiety.  Limitations : (i) Our results refer to a clinical sample, which may not be representative of the general population. (ii)Alcoholic patients with a history of other drug abuse or dependence were not excluded. (iii) Owing to the small sample size,patients with alcohol dependence and with alcohol abuse were not separated. ©  2002 Published by Elsevier B.V. Keywords :   Alcohol use disorder; Drug abuse; Panic disorder 1. Introduction high comorbidity rates between alcoholism and panicdisorder (PD) (Regier et al., 1990; Kessler et al.,Epidemiologic studies have consistently found 1997). By contrast, as has been suggested by Schuc-kit and Hesselbrock (1994), data from clinicalstudies are more conflicting. Some of them reveal * Corresponding author.´  E  - mail address :   maju@incia.es (M. Marquez).  alcoholism rates in PD similar to those in general 0165-0327/02/$ – see front matter  ©  2002 Published by Elsevier B.V.doi:10.1016/S0165-0327(02)00054-X  ´  238  M  .  Marquez et al .  /   Journal of Affective Disorders 75 (2003) 237–245  population (between 14 and 16%) (Winokur and 2.2.  Procedure Holemon, 1963; Woodruff et al., 1972; Thyrer et al.,1987), and between 7 and 17% in agoraphobic Clinical assessment was conducted by two ex-patients (Amies et al., 1983; Breier et al., 1986; Bibb perienced interviewers, a psychiatrist (J.S.) or aand Chambless, 1986), whereas other studies find clinical psychologist (J.C.), following DSM-III-R´higher rates ranging from 20.7 to 28% (Seguı et al., criteria (American Psychiatric Association, 1987).1995; Chignon and Lepine, 1993; Otto et al., 1992; The Structured Clinical Interview for DSM-III-RReich and Chaudry, 1987). Socio-cultural aspects of UpjohnVersion rev (SCID-UP-R) was used for axis Ithe order of onset of alcoholism with respect to PD diagnoses (Spitzer and Williams, 1988). Patientshave not attracted much attention, despite the fact were interviewed and assessed at their initial pre-that alcohol consumption is influenced by cultural sentation of PD or at recurrence of panic attacks afterdeterminants. Indeed, patterns of alcohol use in non-symptomatic periods. At presentation, all pa-Spain (Alvira, 1986) and other Mediterranean coun- tients were suffering from panic attacks. They weretries have been noted to differ from those in Anglo- referred by other medical specialists or from theSaxon countries. hospital’s emergency room, with a total of 90.7% of subjects having a previous medical consultation.Most of them were not under specific treatment fortheir PD and 67.6% had received benzodiacepines as 2. Methods  initial medication. A total of 40.7% of patients hadmade a psychiatric consultation at any time. Presence 2.1.  Subjects  of comorbid psychiatric disorders was also studied,following DSM-III-R criteria. Owing to the reducedThe sample consisted of 274 patients over 16 number of patients within some diagnosticyears old, both men and women, suffering from PD. categories, diagnostic groupings were made forAll subjects were outpatients from the Department of eating disorders (which included anorexia andPsychiatry at Sagrat Cor Hospital (La Alianza) and bulimia nervosa). For the same reason, diagnoses of were consecutively selected as they were referred schizophrenia (one case), bipolar disorder (fourfrom either the emergency rooms or other medical cases) and somatization disorder were also notdepartments. This centre is part of the area’s most included as comorbid disorders. Diagnostic reliabili-important health maintenance organization. The ty was checked by two independent evaluators in astudy lasted 4 years, beginning with the creation of group of 30 patients, obtaining a kappa coefficient of this unit (1 March 1991–28 February 1995). Of the 0.8 for axis I diagnoses.3206 patients examined during the assessment The Family History Research Diagnostic Criteriaperiod, a total of 274 (8.5%) presented with PD. Of (FH-RDC) interview (Endicott et al., 1975), in itsthis sample, 76.4% were women. Age at the first Spanish version (Humbert, 1989), was used to assessinterview was 44.1 years (range: 61.5). Single people the patients’ family history. Patients or their first-represented 20.8% of the group, while 69.0% were degree relatives were the source of information formarried, 3.3% were separated or divorced and 6.9% psychiatric family histories. As the FH-RDC inter-were widowed. Average age at PD onset was 35.9 view does not include anxiety disorders, an openyears and duration of PD was 8.2 years. Subjects question on PD family history was added. To assesswere excluded from the study if PD was clearly the severity of PD, clinical evaluation at the first visitsecondary to some other medical condition, or included the administration of the Hamilton’s depres-associated with organic brain disorders, in accord- sion and anxiety scales (HDRS and HARS) (Hamil-ance with DSM-III-R criteria. In patients over 60, a ton, 1959, 1960), the Global Assessment of Func-definite diagnosis was delayed until any other medi- tioning Scale (GAF) (American Psychiatric Associa-cal causes could be ruled out. Thyroid tests were tion, 1987), the Marks and Mathews’ Fears andconducted for all patients, as well as EKG, chest Phobia Scale (Marks and Mathews, 1979) and theX-ray and a neurological exam. Panic-Associated Symptom Scale (PASS) (Argyle et  ´   M  .  Marquez et al .  /   Journal of Affective Disorders 75 (2003) 237–245   239 al., 1991). This latter questionnaire comprises five test for categorical ones (with Yates’ correction orsubscales that assess: situational panic attacks, un- Fisher’s exact test when necessary) were used andexpected panic attacks, limited panic attacks, an- differences were considered significant with  P , ticipatory anxiety and phobias. 0.05. Data analyses were performed by using theIn addition, we used a 14-item Inventory of Panic SPSS software package (Norusis, 1990).Attack Symptoms (ISAP) based on DSM-III-Rsymptoms. This self-administered inventory rates ona 4-point Likert scale to assess the severity of  3. Results symptoms (0 5 non-existent; 1 5 mild; 2 5 ´moderate; 3 5 severe) (ISAP) (Seguı et al., 1999a).A total of 26 subjects from the sample of 274Patients over 60 years of age (or under 60 wheneverpatients with PD (9.4%) were diagnosed as sufferingcognitive deterioration was suspected) completed asfrom AUD: 12 patients (4.3%) met criteria forwell the Spanish version (Lobo et al., 1979) of thealcohol abuse and 14 (5.1%) for alcohol dependence.Mini-Mental Status Examination (Folstein et al.,1975).The research protocol was approved by the 3.1.  Onset of panic disorder in relation to onset of  Alianza Hospital’s Ethics Committee. Written con-  alcohol use disorder  sent to participate into the study was obtained fromthe subjects after they were thoroughly informed Among the 26 subjects with AUD and PD, meanabout the research’s characteristics. age at onset of alcohol use was 20.5 (S.D.: 8.5)Owing to the small number of patients in each years, vs. 28.5 (S.D.: 9.8) years for PD ( t  : 4.7, df: 25,group of alcohol abuse and alcohol dependence, both  P , 0.001). In 73.1% of patients, onset of alcoholwere included in the same group under the diagnosis use was previous to that of panic (see Fig. 1).of Alcohol Use Disorder (AUD). Patients with PD A total of 3.8% of the sample began their alcoholwere divided in two groups according to the presence use before age 10, 23.1% began between 10 and 15of alcoholism (or AUD): alcohol/PD patients and years of age, 34.6% between 16 and 19, 27.0%non-alcohol/PD patients. between 20 and 30, 7.7% between 30 and 40 and 2 Student’s  t  -test for continuous variables and  x   - 3.8% after age 40. Fig. 1.  ´  240  M  .  Marquez et al .  /   Journal of Affective Disorders 75 (2003) 237–245  Duration of illness was longer for alcohol use frequent in the alcohol group. As regards use of (17.1 years; S.D.: 9.5) than for PD (8.8 years; S.D.: other drugs in the last 6 months, alcohol/PD patients7.8) ( t  : 2.3, df: 25,  P , 0.05). had more often used nicotine, caffeine, cocaine andcannabis. Differences between both groups weresignificant for all drugs, especially for cannabis. 3.2.  Clinical differences between panic disorder   Alcoholic patients were more likely to have con- subgroups according to presence of alcohol use  sulted other psychiatrists, but not other kinds of  disorder   physicians or emergency rooms, nor to have receivedother previous pharmacological treatments withIn the PD group with AUD, males tended to be benzodiazepines or antidepressants. No differencesmore prevalent. Alcoholic patients were younger and were found with respect to previous suicide attemptshad a higher educational level (Table 1). (Table 1).As for family history (Table 1), the two subgroups Age at PD onset was lower in the alcohol/PDdid not differ in history of PD or depressive disorder, group than in the non-alcohol/PD group. Patients inbut did differ in history of AUD, which was more the alcohol/PD group showed an overall greater Table 1Demographic characteristics and clinical history of PD patients with and without alcoholismDemographic characteristics Sex 2 Women 201 (81.0%) 17 (65.4%)  x   3.55 0.06Men 47 (19.0%) 9 (34.6%)Age 44.8 (15.8) 37.3 (9.8)  t   3.40 0.001School years 8.7 (3.3) 10.19 (4.4)  t   2 2.00 0.046 Family history Schizophrenia 6 (2.0%) 0 (0.0%) 2 Depression 58 (23.4%) 8 (30.8%)  x   1.60 0.21 2 Alcoholism 24 (9.7%) 7 (26.9%)  x   9.50 0.002 2 Panic disorder 58 (29.7%) 9 (34.6%)  x   3.10 0.08 Use of other drugs (  last  6   months  )  2 Nicotine 72 (29.0%) 18 (69.2%)  x   27.40 0.001 2 Caffeine 117 (47.2%) 17 (65.4%)  x   14.50 0.001 2 Cocaine 3 (1.2%) 3 (11.5%)  x   19.30 0.0001Cannabis 2 (0.8%) 2 (7.7%) Fisher 0.009 Previous medical 2 Consultations 228 (91.9%) 22 (84.6%)  x   0.8 0.4 2 Psychiatrist 92 (37.1%) 15 (57.6%)  x   4.2 0.04 2 General practitioner 143 (57.7%) 11 (42.3%)  x   2.3 0.13 2 Emergency room 97 (39.1%) 10 (38.5%)  x   0.004 0.9 Previous treatments 2 BZD 157 (63.3%) 16 (61.5%)  x   0.2 0.86 2 Antidepressants 61 (24.6%) 9 (34.6%)  x   1.24 0.27Hospitalizations 18 (7.3%) 1 (3.8%) Fisher 0.86 2 Suicide attempts 9 (3.6%) 3 (11.5%)  x   (Yates) 2.57 0.17  ´   M  .  Marquez et al .  /   Journal of Affective Disorders 75 (2003) 237–245   241Table 2Clinical characteristics of PD patients with and without alcoholismNo Alcohol Alcohol Significance(248) (26)Statistic Value  P Age at PD onset 36.7 (15.1) 28.5 (9.8)  t   2.7 0.007Duration of PD 8.1 (11.0) 8.8 (7.8)  t   2 0.3 0.7Number of attacks (last month) 11.1 (13.8) 16.1 (21.3)  t   2 3.01 0.003Hamilton Depression Rating Scale (HDRS) 17.6 (7.7) 22.3 (6.4)  t   2 4.75 0.001Hamilton Anxiety Rating Scale (HARS) 23.1 (6.9) 29.8 (5.7)  t   0.56 0.6G.A.F. 56.2 (6.4) 55.4 (7.0)P.A.S.S. 14.4 (5.5) 17.6 (7.5)  t   2 2.6 0.009Situational Panic 2.6 (1.8) 3.3 (2.0)  t   2 1.8 0.06Spontaneous Panic 4.1 (1.2) 4.1 (1.7)  t   2 0.10 0.91Limited Panic 1.2 (1.2) 2.0 (1.4)  t   2 3.3 0.001Anticipatory Anxiety 4.4 (1.8) 5.4 (1.6)  t   2 2.7 0.008Phobias 2.4 (1.7) 2.6 (1.9)  t   2 0.59 0.5Marks–MatthewsSocial 3.7 (8.1) 2.8 (5.8)  t   0.58 0.6Blood 9.8 (8.8) 11.7 (9.4)  t   2 1.04 0.3Agoraphobia 15.1 (13.3) 16.4 (14.7)  t   2 0.5 0.64 severity of their PD (Table 2). They experienced  4. Discussion more attacks in the last month (18.0 vs. 11.4), scoredhigher on the HDRS and especially on the HARS 4.1.  Frequency of alcohol use disorder in panic and had a lower GAS. On the PASS, situational  disorder patients panic and anticipatory anxiety were higher in thissubgroup, and no differences were observed as to In our sample of patients with PD, 9.4% of thefrequency and severity of the panic attacks’ symp- subjects were diagnosed with AUD. Although pre-toms. valence rates of alcoholism are found to be higher inComorbidity rates for other psychiatric disorders community studies, our finding is similar to rateswere similar in both groups (Table 3). Alcoholic from clinical samples where they appear to bepatients showed a trend to report more major depres- similar to those of general population (Cloninger etsion, but differences were not significant. al., 1981; Winokur and Holemon, 1963; Woodruff et Table 3Comorbidity in PD patients with and without alcoholismNo Alcohol Alcohol Significance(248) (26)Statistic Value  P Eating disorders 6 (2.4%) 2 (7.7%) Fisher 0.17 2 Major depression 85 (34.3%) 13 (50.0%)  x   2.50 0.11 2 Dysthymia 32 (12.9%) 4 (15.4%)  x   (Yates) 0.003 0.96OCD 16 (6.5%) 0 (0.0%) Fisher 0.96 2 Simple phobia 77 (31.0%) 10 (38.5%)  x   0.60 0.44Social phobia 32 (12.9%) 2 (7.7%) Fisher 0.34Bipolar disorder 2 (0.8%) 0 (0.0%) Fisher 0.82 2 Agoraphobia 72 (29.6%) 10 (38.5%)  x   0.99 0.32
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