بروز و نفوذ وقایع زندگی زودرس پس از سانحه در بیماران مبتلا به اختلال پانیک: مقایسه با دیگر بیماران سرپایی روانپزشکی

Early traumatic life events, including childhood physical and sexual abuse, has been associated with increased risk for panic disorder in adulthood. We examined the incidence and influence of early traumatic life events in outpatients with panic disorder (n=101), compared to outpatients with other anxiety disorders (n=58), major depression (n=19), or chronic schizophrenia (n=22). Data were obtained by means of Structured Clinical Interviews and self-report questionnaires. The incidence of childhood physical abuse ranged from 16 to 40% and for childhood sexual abuse from 13 to 43% with no significant differences among the four diagnostic groups. Across all outpatient groups a history of childhood physical or sexual abuse was positively correlated to clinical severity. Patients with panic disorder who reported childhood physical abuse were more likely to be diagnosed with comorbid depression, to have more comorbid Axis I disorders, to score higher on symptom checklists as well as reporting a greater history of suicide attempts in the past year (5% vs. 0%); or lifetime (36% vs. 15%). Similar findings were noted, but not as robustly, for patients with panic disorder who reported childhood sexual abuse. There is a high rate of adverse early childhood events across diagnostic groups in psychiatric outpatients and these events are likely to influence the severity of the disorder but are unlikely to be a unique risk factor for any one type of disorder.

A number of studies have suggested that psychiatric morbidity in adulthood is associated with a variety of developmental traumas such as sexual and physical abuse. In particular, childhood abuse has been found to be a possible risk factor for anxiety disorders such as panic disorder (PD), in both epidemiological (Brown & Harris, 1993a; Brown, Harris, & Eales, 1993b; Burnam et al., 1988; Kessler, Davis, & Kendler, 1997) and clinical studies (Brier, Charney, & Heninger, 1986; Faravelli, Webb, Ambonetti, Fonnesu, & Sessarego, 1985; Mancini, Van Ameringen, & Macmillan, 1995; Raskin et al., 1989 and Stein et al., 1996). In addition, a history of developmental traumas, such as early losses and separations, childhood illnesses, and chaotic family environments have also been implicated as possible factors affecting the course and treatment response of patients with PD (Alnaes & Torgersen, 1988; Brier et al., 1986; David, Giron, & Mellman, 1995; Fierman et al., 1993; Gerlsma, Emmelkamp, & Arrindell, 1990; Laraia, Stuart, Frye, Lydiard, & Ballenger, 1994; Mancini et al., 1995 and Noyes et al., 1993; Servant & Parquet, 1994; Wade, Monroe, & Michelson, 1993). The purpose of the present study was to examine the incidence and possible influence of early traumatic life events in patients with PD. Previous studies have been hampered by a number of methodological limitations; among them are insufficient psychiatric comparison groups or the lack of standardized questions regarding traumatic events. The present study benefited from the use of standardized structured interviews, self-report questionnaires, and use of comparison groups which covered a wide range of outpatient diagnostic groups. Studies that have looked at the frequency of childhood sexual and physical abuse in patients with panic disorder have found rates ranging from 13 to 54% (Mancini et al., 1995 and Stein et al., 1996). Similarly the range reported for childhood sexual or physical abuse is quite high in patients with other anxiety disorders such as generalized anxiety disorder (GAD) with a reported incidence of childhood sexual abuse range from 7 to 35%, and for physical abuse 5–45% (Mancini et al., 1995 and Stein et al., 1996). At the same time studies have found that the rate of childhood sexual or physical abuse is elevated for affective disorders (35% for sexual or physical abuse) and schizophrenia (sexual abuse as high as 60% and physical abuse 44–60%) (Bryer, Nelson, Miller, & Krol, 1987; Davres-Bornoz, Lemperiere, Degiovanni, & Gaillard, 1995; Friedman & Harrison, 1984; Giese, Thomas, Dubovsky, & Hilty, 1998; Jacobson & Herald, 1990; Jacobson & Richardson, 1987; Mullen, Martin, Anderson, Romans, & Herbison, 1993; Read, 1997; Sansomnet-Hayden, Haley, Marriage, & Fine, 1987; Surrey, Swett, Michaels, & Levin, 1990; Swett, Surrey, & Cohen, 1990). In psychiatric inpatient settings, reviews of the literature have found that incidence of childhood physical and/or sexual abuse in patients, of mixed diagnostic groups, ranges from 51 to 64% for women and from 24 to 39% for males (Jacobson & Richardson, 1987; Sansomnet-Hayden et al., 1987). In comparison, the range for severe childhood physical abuse in several community samples is 8–10% (Burnam et al., 1988), though one study (Straus & Gelles, 1986) reported a 62% rate for physical abuse. Childhood sexual abuse rates in community samples are also reported to be lower than that of psychiatric patients with a range for men from 1 to 16% and for women from 15 to 27%. In summary, a consistent finding in the literature appears to be that childhood physical or sexual abuse is more common in clinical populations than in non-clinical groups. Within anxiety disorders several studies have found that occurrence of sexual and physical abuse was not associated with any particular anxiety disorder (Mancini et al., 1995). However, subjects with an anxiety disorder who reported childhood abuse scored significantly higher on measures of trait and state anxiety (Mancini et al., 1995), exhibited increased social fears and avoidance (Stein et al., 1996), higher depressive symptoms (Mancini et al., 1995), were more likely to be diagnosed with post-traumatic stress disorder (PTSD) (Fierman et al., 1993), were more likely to be diagnosed with Axis II disorders (Moisan & Engels, 1995), reported a greater number of previous episodes of major depression, and were less likely to remit from these depressive episodes (Zlotnick, Warshaw, Shea, & Keller, 1997). Incidence of other kinds of developmental trauma, when compared to normal subjects, has been reported to be greatly elevated in patients with panic disorder. Developmental trauma has been defined as either childhood separations from early caretakers, “grossly disturbed childhood environments” (Raskin et al., 1989), parental alcohol abuse, parental divorce (Moisan & Engels, 1995), and major losses or separations before age 15 (David et al., 1995 and Faravelli et al., 1985; Servant & Parquet, 1994). This relationship of the role of childhood adversity in anxiety disorders is illustrated in a study by Brown and Harris (1993a), in which they administered a survey to an inner city population consisting of 404 working class and single mothers. They found that subjects diagnosed with PD, when compared to community members without psychiatric disorders, were 8.7 times more likely to report a history of any childhood adversity (defined as either physical abuse, sexual abuse, or parental indifference). Subjects diagnosed with agoraphobia, Social Phobia or GAD were 3.7 times more likely to report a history of any childhood adversity than the control groups. The above studies suggest that developmental traumas (such as early separations or losses), childhood sexual and physical abuse, and life stressors (such as chronic poverty and chaotic family environments) may be associated with the later development of anxiety disorders, and in particular PD. However, given the lack of appropriate comparison groups, such as patients from different psychiatric diagnostic categories (i.e., non-anxiety related disorders), these traumatic events may actually be markers for severity of psychopathology and/or comorbidity rather than a risk factor for any particular anxiety disorder. For example, Van der Molen, Van der Hout, Van Dieren, & Griez (1989) found that although a higher incidence of childhood separations and separation anxiety was reported by patients with PD, this finding did not appear to be uniquely related to the diagnosis of PD. Rather, their data suggested that such a history was associated with severity of psychopathology, since their comparison groups of “mixed neurotics” showed similar prevalence rates and treatment outcome. Another example of how childhood sexual abuse may be a risk factor for a variety of psychiatric conditions is a study by Fergusson, Horwood, and Lynskey (1996), who followed a birth cohort of over 1000 children. At age 18, they obtained retrospective reports of childhood sexual abuse prior to age 16 and concurrently measured psychiatric symptoms. Individuals who reported childhood sexual abuse were diagnosed with higher rates of major depression, anxiety disorders, conduct disorders, substance use disorders, and suicidal behavior. Those reporting more severe sexual abuse, such as attempted or completed intercourse, had higher rates of these disorders. These results persisted even when adjusted for prospectively measured possibly confounding childhood family and related factors. Increased risk ranged from 3.0 to 8.7 with the highest risk demonstrated for conduct disorder and lowest for anxiety disorders. We, therefore, decided to study four groups of patients (panic disorder, “other anxiety disorder,” depression and schizophrenia), who presented to an inner-city outpatient psychiatric clinic. Through use of structured diagnostic and assessment interviews we obtained data on the incidence of a host of early life traumas, including self-report of childhood physical and sexual abuse. At the same time, we assessed a variety of symptoms and their intensity. In particular, for patients with PD we were interested in examining the association of early negative life events on severity of the anxiety disorder as measured by psychometric and clinical ratings.