Anxiety comorbidities

Tollefson GD, Montague-Clouse J, Tollefson SL Treatment of comorbid generalized anxiety in a recently detoxified alcohol population with a selective serotonergic drug (buspirone). J Clin Psychopharmacol 12 19-26, 1992... 

The anxiety disorders are a case in point. They comprise a range of conditions contiguous with the affective disorders and the stress responses (Table 4.1). Much overlap and comorbidity exist. Furthermore, definitions and diagnostic criteria have changed substantially over the years. For example, generalized anxiety disorder is a rare condition in its pure form, but a common condition if comorbid phobic and depressive disorders are accepted. 

Another study used data from the National Comorbidity Study (Greenberg et al, 1999). The annual economic burden of anxiety disorders was estimated at US 42.3 billion in 1990 terms. This represents an annual cost... 

Out-patient treatment is substantially cheaper than in-patient management and is generally as effective (Lowman, 1991). A French study on patients with generalized anxiety disorder estimated costs per patient over 3 months to he US 423 for hospitalization, 335 for out-patient services and 43 for medications (Souetre et al, 1994). Comorbid conditions (mostly alcoholism and depression) doubled these direct health-care costs. Over three-quarters of all patients were taking anxiolytic medication. 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

Lecrubier Y (1998). Comorbidity in social anxiety disorder impact on disease burden and management. / Clin Psychiatry 5 (suppl. 17), 33-7. 

Souetre E, Lozet H, Cimarosti I, et al (1994). Cost of anxiety disorders impact of comorbidity. / Psychosom Res3% (suppl. 1), 151-60. 

MDD is quite common lifetime and 12-month prevalence estimates are 16.2% and 6.6%, respectively. Thus, approximately 35 million United States adults will experience MDD in their lifetime.2 Females are approximately twice as likely as males to experience MDD.2 Although MDD may begin at any age, the average age at onset is the mid-20s.3 Interestingly, MDD appears to occur earlier in life in people born in more recent decades.2 Most patients with MDD also suffer from comorbid psychiatric disorders, especially anxiety disorders and substance-use disorders.2... 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Bipolar I disorder affects men and women equally bipolar II seems to be more common in women. Rapid cycling and mixed mania occur more often in women. Individuals with bipolar disorder commonly have another psychiatric disease with 78% to 85% reporting another Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis during their lifetime. The most common comorbid conditions include anxiety, substance abuse, and eating disorders.2... 

Selective serotonin reuptake inhibitors (SSRIs) are considered the drugs of choice based on their tolerability and efficacy for social anxiety disorder as well as comorbid disorders. 

With a lifetime prevalence of 28.8%, anxiety disorders collectively represent the most prevalent Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR)2 class of disorders, with specific phobia (12.5%) and social anxiety disorder (12.1%) being the most common.3 Recent reports from the National Comorbidity Survey Revised (NCS-R) estimate the lifetime and 1-year prevalence of generalized anxiety disorder (GAD) for those 18 years of age and older to be 5.7% and 3.1%, respectively.3,4 Rates for panic disorder (PD) are slightly lower, with an estimated 12-month prevalence of 2.7% and lifetime prevalence of 4.7%. 

O The goals of therapy for GAD are to acutely reduce the severity and duration of anxiety symptoms and restore overall functioning. The long-term goal in GAD is to achieve and maintain remission. With a positive response to treatment, patients with GAD and comorbid depression should have minimal depressive symptoms. 

The main objectives of treatment are to reduce the severity and frequency of panic attacks, reduce anticipatory anxiety and agoraphobic behavior, and minimize symptoms of depression or other comorbid disorders.48 The long-term goal is to achieve and sustain remission. 

ADHD is rarely encountered without comorbid conditions and often is underdiagnosed. Between 40% and 75% of patients with ADHD will have one or more comorbidities (e.g., learning disabilities, oppositional defiant conduct, anxiety, or depressive disorders).10 It is important to identify other coexisting conditions in patients with ADHD to assist in initial and ongoing selection of treatment. 

The tricyclic antidepressants (TCAs), such as imipramine, can alleviate symptoms of ADHD. Like bupropion, TCAs likely will improve symptoms associated with comorbid anxiety and depression. The mechanism of action of TCAs is in blocking norepinephrine transporters, thus increasing norepinephrine concentrations in the synapse the increase in norepinephrine is believed to alleviate the symptoms of ADHD. TCAs have been demonstrated to be an effective non-stimulant option for ADHD but less effective than stimulants. However, their use in ADHD has declined owing to case reports of sudden death and anticholinergic side effects6,13 (Table 39-3). Further, TCAs may lower seizure threshold and increase the risk of car-diotoxicity, (e.g., arrythmias). Patients starting on TCAs should have a baseline and routine electrocardiograms. 

Schneier, F. R., Blanco, C., Campeas, R., Lewis-Fernandez, R. el al. (2003). Citalopram treatment of social anxiety disorder with comorbid major depression. Depress. Anxiety, 17, 191-6. 

It is considered a second-line agent for GAD because of inconsistent reports of efficacy, delayed onset of effect, and lack of efficacy for comorbid depressive and anxiety disorders (e.g., panic disorder or SAD). It is the agent of choice in patients who fail other anxiolytic therapies or in patients with a history of alcohol or substance abuse. It is not useful for situations requiring rapid antianxiety effects or as-needed therapy. 

Patients with mixed states often have comorbid alcohol and substance abuse, severe anxiety symptoms, a higher suicide rate, and a poorer prognosis. 

After the acute psychotic episode has resolved, the patient typically has residual features (e.g., anxiety, suspiciousness, lack of volition, lack of motivation, poor insight, impaired judgment, social withdrawal, difficulty in learning from experience, and poor self-care skills). Patients often have comorbid substance abuse and are nonadherent with medications. 

In this chapter we reviewed taxometric studies in domains of psychopathology that only recently attracted the attention of taxometricians eating disorders, depression, anxiety, personality disorder, and issues surrounding comorbidity. In all these areas the findings are mixed, and it is impossible to offer a verdict about the taxonic status of any of these forms of psychopathol-... 

Mineka, S., Watson, D., Clark, L. A. (1998). Comorbidity of anxiety and unipolar mood disorders. Annual Review of Psychology, 49,377-412. 

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