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Personality Of Panic Disorder Alcohol Abusers

Originally Published in The Journal of Nervous and Mental Disease Vol. 175 No. 4 1987


By: James H. Reich, MD, MPH, and Dewat Chadury, MD
Tel: 415-673-2950
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Seventeen (28%) of 61 panic disorder patients in a drug treatment study were retrospectively found to have a history of alcoholism (none had abused alcohol in the past year), More men than women had a history of alcohol abuse (p < .03). Alcohol patients were less independent and less able to recognize appropriate social cues on personality testing. There was significant improvement in general anxiety for the drug treatment and nonalcoholic placebo group but not for the alcohol placebo group. This indicates a superior response to supportive therapy for general anxiety in the placebo group without an alcohol abuse history compared with the placebo group with an alcohol abuse history.

There has been little scientific investigation of the relationship between anxiety disorders and alcohol abuse and none examining differences in personality factors between those anxiety disorder patients with and without a history of alcohol abuse. There is evidence, however, for an overlap of alcohol abuse and anxiety disorders. Winokur and Holemon (1963), using criteria similar to that of DSM-III panic disorder, found that five (16% ) of 31 patients showed signs of excessive drinking at the time of the interview. Four of these five had anxiety disorders before excessive alcohol intake. Woodruff et al. (1972) found that nine (15% ) of 61 anxiety disorder patients in a psychiatric clinic had secondary alcoholism. Mullaney and Trippett (1979) reported that one third of their alcohol abuse population had clinically disabling agoraphobia or social phobia. Hesselbrock et al. (1985) found a lifetime history of phobia in 27% and panic disorder in 10% of a hospitalized alcoholic population. In his sample, alcohol abuse occurred subsequent to panic disorder in 63% of the men and 50% of the women. Smail et al. (1984) found that over half of their alcoholic inpatients had agoraphobia, social phobia, or both when last drinking. They found a relationship between severity of alcohol dependence and severity of phobic symptoms in male patients but not in female patients. There is also evidence of an association of the two disorders in family studies. Munjack and Moss (1981) found a difference in family history of alcoholism between agoraphobic and social phobic probands when compared with the miscellaneous specific phobia group. Crowe et al. (1980) reported an increase in alcohol abuse or dependence among relatives of anxiety neurotics but not in control subjects.

In sum, there is evidence for a subgroup of anxiety patients who are also alcohol abusers. This group of anxiety patients may have an increased genetic predisposition toward alcoholism. We hypothesized that this alcoholic subgroup would be less socially skillful and independent than a nonalcoholic group. This study examined how a history of alcohol abuse related to standardized personality measures and affected outcome in one treatment study.

Methods

Subjects and Treatment Schedule

Of the original 61 patients, information was available for the present study of 56. Of this group, 26 (46%) were men; the average age was 35.8 (±8.5) years. All were white. A review of charts and telephone screening sheets identified 17 with a past history of alcohol abuse; these 17 did not differ significantly from the rest of the group in mean age. There was a significant difference in the percentage of men, however. The alcohol group comprised 11 men (65%) and the nonalcoholic group, 16 men (25%) (p < .03).

Subjects from this study were drawn from a doubleblind treatment study on the effects of alprazolam on panic disorders. There were 61 subjects in this original study. Subjects were recruited by newspaper advertisements and were given the Structured Clinical Interview for Diagnosis (SCID) (Spitzer and Williams, 1982) to assure that they met revised DSM-III criteria for panic disorder or agoraphobia. Patients who had active drug or alcohol abuse within the past year were excluded from the study, as were patients with a diagnosis of schizophrenia or obsessive-compulsive disorder, a history of mania, or depression predating or predominating panic attacks. All those who qualified and were willing to participate were enrolled in the study. This was approximately 90% of those qualifying to enter. Those accepted were randomly assigned to either placebo or alprazolam treatment. Half of the subjects in the study received placebo and the other half, alprazolam (mean dose, 5.6 mg daily). Patients were not permitted to take other antianxiety medications (benzodiazepines, monoamine oxidase inhibitors, beta-blockers, or tricyclic antidepressants) during the course of the study. Dosage of alprazolam was adjusted during the study between 1 and 10 mg a day, adjusted to the point at which there was maximal reduction of panic symptoms and minimal side effects.

The 60 patients were studied weekly for the first 4 weeks and then every other week for the next 4 weeks. In follow-up visits, the patient would describe his or her difficulties with panic disorder to a research assistant and a physician. Quite often these descriptions included personal details or life problems. During these visits patients were taught more about their disorder, medication was adjusted, and patients were actively encouraged to enter phobic situations. Visits lasted from 30 minutes to one hour. No formal psychotherapy was given during visits.

Instruments

At baseline (i.e., after 1 week off of all antianxiety medication) subjects were given the Guilford-Zimmerman Temperament Survey (Guilford et al., 1976), Interpersonal Dependency Inventory (IDI) (Hirschfeld et al , 1977), Hamilton Anxiety Scale, Sheehan Patient-Rated Anxiety Scale, Physician Global Improvement Scale, and the patient-rated Clinical Global Improvement Scale. The Guilford-Zimmerman is a self-report, extensively validated, measure of normal personality traits with good reliability and validity. It has been used in both normal and psychiatric populations. The IDI is a standardized measure of dependency. It is also a self-report instrument. It has three subscales that have been validated on one population and cross-validated on a second. These two personality measures were selected for ease of administration and for their combined coverage of a large number of personality traits. Both the Hamilton and the Sheehan Scales are measures of state anxiety.

Analysis

At baseline the group with a history of alcohol abuse was compared with the nonalcohol abuse group on personality measures, current age, marital status, age of onset, age of first psychiatric treatment, average ounces of alcoholic beverages consumed the day before the onset of the study, number of major and minor panic attacks at baseline week, age of onset of panic symptoms, whether panic disorder caused occupational difficulties, associated psychiatric diagnoses of agoraphobia and depression, anxiety, and global improvement scales.

Personality measures were performed at baseline when anxiety was high and could possibly affect measures. As a check on this, personality measures that were significantly different between groups were checked by referring to specific analyses in a previous paper (Reich et al., 1986) to determine whether they were affected by anxiety. For those measures not previously reported, an analysis identical to that of Reich et al. was performed to determine whether they were affected by state anxiety.

To determine response to treatment the population was divided into four groups. These were: those who received active medication and had no history of alcohol abuse, those who received active medication and who had a history of alcohol abuse, those who received placebo and had a history of alcohol abuse, and those who received placebo and had no history of alcohol abuse. Using a 2 X 2 design, medication/placebo group by history of alcohol abuse, each subject was assigned to one of the four groups. The change for each group from week 1 to week 6 was determined using their Hamilton and Sheehan scores on anxiety and their global improvement scores. Comparison was by twoway analysis of variance.

Week 6 instead of week 8 was chosen for analysis for two reasons. First, there were a greater number of subjects with Hamilton scores at week 6 than 8. Six patients who dropped out were contacted for Hamiltons at week 6 (three from the placebo, no alcohol group and one from each remaining group) to give an N of 56 for Hamilton analyses. Second, there were no significant differences between groups in mean number of visits at week 6, whereas there were at week 8.

Of the 61 subjects completing at least 3 weeks, 11 had dropped out by week 6, eight from the placebo, no alcohol group, and one from each other group. In order to determine whether sicker placebo patients were dropping out, the eight dropouts in the placebo, no alcohol group were compared with non-dropouts in the same group on the Hamilton and Sheehan anxiety scales at week 3.

Results

On the baseline personality tests there were two significant differences. The autonomy scale of the IDI was 24.38 (5.44) for the alcoholic and 29.49 (7.43) for the nonalcoholic group (p < .02). The Guilford-Zimmerman Carelessness scale was 2.41 (2.83) for the alcoholic group and 4.75 (3.07) for the nonalcoholic group (p < .01). A lower IDI autonomy score indicates less independence, whereas a lower Guilford-Zimmerman Carelessness score means less awareness of appropriate social cues. The autonomy scale in previous research was not found to be affected by anxiety (Reich et al., 1986). A replication of that analysis for the Carelessness scale demonstrated that it, too, was not significantly affected by anxiety.

Baseline consumption of mean ounces of alcoholic beverages the day before study entry was higher for the alcoholic than nonalcoholic group, but the difference was not significant. There were no baseline differences in current age, marital status, age of onset, age of first psychiatric treatment, number of major or minor panic attacks, occupational difficulties, associated depression or agoraphobia, and Hamilton or Sheehan anxiety scores...

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James H. Reich, MD, MPH, is a board-certified Forensic Psychiatrist with extensive civil psychiatry experience who has done hundreds of evaluations. His services are available for civil and some criminal law cases. Clients are assured of his personal dedication to each case. He does high quality research, expert evaluations, writes a solid report, and will testify well. Dr. Reich has been deposed over 50 times..

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