Atypical Anxiety Disorder: A Descriptive

Study

Thomas A. Aronson This retrospective study examined 75 outpatients who received an atypical anxiety disorder diagnosis in a 30-month period. Patients who were later rediagnosed tended to have multiple anxiety diagnoses. “Atypical, ” in this sense, meant that insufficient information was available to arrive at specific anxiety diagnoses. A subgroup that continued to be diagnosed as atypical throughout their treatment tended to have multiple subsyndromal complaints, unusual symptoms, or both. This subgroup raises questions regarding the cutoff criteria for the anxiety disorders in DSM-III and DSM-III-R and suggests a possible new diagnostic subtype for future investigation. 0 1990 by W. B. Saunders Company.

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TYPICAL ANXIETY DISORDER, CREATED BY DSM-III’s subdivision of the DSM-II neuroses, is a residual diagnostic category. It refers to disorders with prominent anxiety or phobic avoidance that are not classifiable as a specific anxiety disorder. In DSM-II, neuroses refers to disorders in which the “chief characteristic” is anxiety, whether “felt and expressed directly [or unconsciously] by conversion, displacement and various other psychological mechanisms.“’ In DSM-III, on the other hand, the disorders in which anxiety is experienced directly are grouped together in the class of anxiety disorders. The other neuroses are distributed among other classes (e.g., somatoform disorders) descriptively defined by shared symptoms and explicit diagnostic criteria. Whereas the concept of atypical depression has led to a growing empirical literature regarding a putative distinct phenomenology and treatment response,274 there are no published studies of atypical anxiety disorder, according to a 1988 Medline computerized literature search. It remains a wastebasket diagnosis with no specific diagnostic criteria. Yet it is an important area for research for nosological reasons: It may contain other distinct diagnostic entities as yet unclassified, and it may help clarify the boundaries of currently defined syndromes by examining cases that present atypically or fall short of meeting the diagnostic cutoffs. With these questions in mind, we conducted a chart review study of all outpatients at a University Hospital who received an atypical anxiety disorder diagnosis in a 30-month period. The phenomenology, naturalistic clinical course, and treatment response were examined. Tentative diagnostic clustering of these cases is suggested in this report. METHODS Charts were identified by a computerized system that records the principal diagnosis for each outpatient visit at University Hospital at Stony Brook. The chart review comprised patients seen in the adult outpatient psychiatric department between January 1985 and June 1988 who received a diagnosis of atypical anxiety disorder (code 300.00). After weeding out miscoded charts, 75 patients of approximately 1,250 new patients seen during this time were identified with this diagnosis. From the Department of Psychiatry and Behavioral Science. Health Sciences Center, State University of New York at Stony Brook. Address reprint requests to Thomas A. Aronson, M.D., Department of Psychiatry and Behavioral Sciences, Health Sciences Center, T-IO, State University of New York at Stony Brook, Stony Brook, NY 11794-8101. o 1990 by W.B. Saunders Company. 0010-440X/90/31 OZ-0006$03.00/O 152

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Chart reviews assessed the following variables: sex, marital status, current age, age of onset of symptoms, duration of treatment in the OPD, global outcome according to the Clinical Global Impressions (CGI) Scale (scored 1 through 7, from very much improved to very much worse), descriptive symptoms, and longitudinal course. Initially, we attempted to develop a symptom checklist, but quickly realized that this was difficult because of the atypicality of symptoms. Symptoms and their longitudinal course were thus recorded in descriptive detail according to general categories, e.g., paniclike, obsessional, social phobic. Consequently, there is a heavy reliance on case descriptions in the Results section. These cases are described in the context of different symptomatic clusters chosen for heuristic reasons. The chart review did not use any exclusionary criteria. Forty-two (56%) of the patients were later rediagnosed in the charts as having other axis I diagnoses. Thirty-three (44%) remained diagnosed as atypical throughout their outpatient course of treatment. Chart diagnoses reflect best-estimate consensus diagnoses by psychiatric resident and attending teams according to DSM-III criteria. For the sake of clarity, the atypical Anxiety label is used instead of DSM-III-R’s “Anxiety Disorder, Not Other Specified,” and results are presented in terms of DSM-III criteria. The revisions of DSM-III-R are considered in the Discussion section.

RESULTS Most (N = 42; 56%) of the 75 patients who initially received an atypical anxiety disorder diagnosis were subsequently rediagnosed. Fourteen received other single anxiety or affective diagnoses, such as organic anxiety disorder (N = 1), major depressive disorder (N = 2) or adjustment disorder (N = 3). However, most of the rediagnosed patients (N = 28) received multiple diagnoses: 12 dual diagnoses (e.g., panic disorder-generalized anxiety disorder), 9 triple, 6 quadruple, 1 quintuple. Many (N = 16) represented panic disorder plus other diagnoses. Most of these multiply diagnosed patients improved only mildly to moderately with treatment (mean CGI = 2.4). Many (12 of 28) dropped out of treatment prematurely. Ten patients who received both anxiety and depressive diagnoses were similarly relatively treatment refractory (mean CGI = 2.6). Overall, these patients were not unusual in their presentation; rather, a more extensive evaluation was required to arrive at a diagnosis for them. In this sense, atypical anxiety disorder meant that insufficient information had been collected at the initial intake; i.e., it reflected diagnostic uncertainty and the need for more data. Thirty-three of the 75 patients (44%) defied simple classification and continued to be diagnosed as atypical anxiety disorders throughout their course of treatment. Roughly half (17 of 33; 5 1.5%) were female. Their average current age was 34.2 f 8.3 years (range, 18 to 63 years). The average duration of symptoms was 3.2 + 3.1 years (range, 1 week to 25 years). They were followed for an average of 13.2 k 4.0 months (range, 3 months to 6 years) in the outpatient clinic and were rated at termination (or currently if still in treatment) as very much improved (N = 15), much improved (N = 6), mildly improved (N = 5), or unchanged (N = 7). The majority of the 33 patients (N = 28, 85%) also received personality disorder diagnoses, most often histrionic, borderline, or mixed. The following summary tentatively clusters these 33 atypical cases for heuristic descriptive purposes. Illustrative case histories are also presented. Panic Disorder Spectrum

The most common atypical presentation was with paniclike attacks that failed to meet DSM-III criteria (N = 16). Eight patients’ attacks were too infrequent. Two patients experienced drug-precipitated panic attacks that were short-lived and left

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each with residual persistent anxiety. One experienced only three attacks in her life, each precipitated by marijuana,. yet more than 2 years later she still feared panicking again: “going crazy and winding up like my manic-depressive sister.” Another experienced four attacks in 2 months, precipitated by amantadine, and then developed feelings for the next 6 months of an “annoying edginess like too much caffeine” lasting 5 to 6 hours daily without physical symptoms, fears of another attack, or improvement with biofeedback, relaxation training, or supportive psychotherapy. This latter patient was typical of several others (N = 5) who reported previous unequivocal panic disorder that had abated, leaving them with residual symptoms of nervousness, easy startle, tension, palpitations, and trembling, but without typical fears of dying, going crazy, losing control, or anticipatory anxiety about possible panic attacks. Characteristically, they complained about not knowing why they felt nervous and felt frustrated or angry that their “body was overreacting.” They denied excessive worry focused on specific situational problems; rather, their anxiety had more of a free-floating, noncognitively meditated quality. One patient with a somewhat different presentation described a residual psychogenic (somatoform) pain disorder, with “constant pain and tightness of my body . . . like a rubber band ready to be released.” Another complained of 2 years of residual symptoms of a constant feeling of numbness, lightheadedness, and depersonalization, with minimal anxiety. Three patients described, for lack of a better term, an adjustment disorder with panic attacks. They experienced panics only during interpersonal crisis or times of extreme stress. One young woman described “waves of panic” that met DSM-III criteria after a coronary care unit hospitalization for a ventricular arrhythmia that proved benign. Attacks abated with supportive therapy, and she has been symptomfree for 1 year of follow-up. Another developed panic attacks, crying, labile mood (without vegetative features), and hypochondriacal worrying about recurrent blood clots after hospitalization for pulmonary emboli. She also improved with supportive therapy. Several of these panic spectrum patients reported unusual presentations of their panic attacks. One developed panic during a traumatic computed tomography scan for hyperprolactinemia after the technicians repeatedly unsuccessfully tried to start an intravenous line and taped her chin back to hyperextend her neck. Three patients presented with globus hystericus, and one had atypical chest pain as the prominent symptom of paniclike attacks. Another described new onset vasovagal attacks of near-syncopy at age 58. Another had seasonal panics from January through March without concomitant affective symptoms. Occasionally, the report of panic was suspect (e.g., never lasting more than 15 seconds or lasting all day long), or clouded by histrionic style of reporting or by drug and alcohol dependence and withdrawal. In general, most patients improved very much (mean CGI = 1.3) with treatment. Supportive psychotherapy was sufficient for the adjustment type of patients. The other patients did well with desipramine, alprazolam, clonazepam, phenelzine, and other typical antipanic medications. Obsessive-Compulsive Spectrum

Four patients’ infrequent paniclike attacks were organized around obsessional themes involving an interoceptive phobia of vomiting or choking. Two cases are described in detail.

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Case 1. The patient was a 26-year-old married woman whose symptoms began 6 years earlier when she bit into a Chicken McNugget and found a bone. According to her husband, she developed a sensation of choking which developed into palpitations, shortness of breath, dizziness, sweating, shaking, and a trancelike state. A phobia developed, first concerning all poultry, then all meat and fish that contain bones, then small objects such as paperclips on which she potentially could choke. Not only external phobic cues, but also family arguments could precipitate the choking and histrionic panic episodes. She constantly obsessed about the fear of choking and dying, and organized her life around it; e.g., poultry, meat, fish and small objects like paperclips were not allowed in their home. Two separate contacts with the outpatient department were never followed up. Case 2. The patient was a 20-year-old single woman student. She dated her “phobia of vomiting” from age 7. Whenever anyone in the house had an illness, she automatically began to fear that she would vomit and lose control. This typically progressed to flushing, hypersalivating, tachycardia, insomnia, crying, and praying. She gradually developed an increasing number of situations that she avoided because she might become nervous, then nauseous, and then vomit: bars, rowdy crowds at sporting events, hospitals, driving home alone at night. She could not remember any time in her life when she actually vomited, but the possibility of vomiting was always in the back of her mind. These cases could be conceptualized as obsessional phobias. The fears were experienced as intrusive, but not as senseless, and had a ruminative quality. They did not give rise to compulsive rituals, but rather to phobic avoidance. Two of the four patients terminated treatment prematurely, one after several unsuccessful pharmacotherapeutic trials. Two others markedly improved with supportiveexpressive psychotherapy. Somatoform Spectrum Six patients presented with a mixture of prominent generalized anxiety, varying degrees of hypochondriasis, and multiple somatic complaints that failed to achieve DSM-III criteria for a specific anxiety or somatoform disorder. Shifting physical complaints, transient conversion reactions, and fluctuating levels of anxiety and dysphoria typified the course of these patients. Symptoms were often described in dramatic and unusual ways, e.g., “a tearing sensation in my chest . . . a headache like my head is being pushed in and torn off. . . . I feel the adrenalin pouring out all day.” Three patients responded poorly to trials of anxiolytics and antidepressants; initial improvement was followed by development of new symptoms. The other three patients much improved with phenelzine, alprazolam plus propranolol, and supportive psychotherapy, respectively. Case 3. The patient was a 35-year-old married man with a 7-year history of palpitations and blushing of his hands and face during stressful situations when he felt angry, frustrated, powerless, or all three. The symptoms began during periods of marital discord and tended to recur during confrontations with his business partner or ex-wife. He complained of fatigue but denied other depressive symptoms. Multiple medical workups showed no physiological basis to his complaints. Palpitations and blushing occurred situationally, never spontaneously, and did not lead to development of phobic avoidance. During the episodes, which lasted minutes to hours, he felt unclear, irritable, excessively worried and anxious, and embarrassed

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by the blushing. He improved greatly with 11 months of supportive-expressive psychotherapy that focused on issues of unassertiveness and excessive guilt. Personality Disorders With Pleomorphic Symptomatic Presentation

Four other patients presented with severe personality disorders and a mixture of subsyndromal anxiety symptoms. These patients typically had stress and anxiety intolerance and often a histrionic style. Their symptoms were multiple, shifting, inconstant, and exquisitely reactive to interpersonal events. Case 4. A 34-year-old woman with a borderline personality disorder, alcohol dependence, and two previous psychiatric hospitalizations complained of chronic anxiety and multiple somatic symptoms only when involved in interpersonal relationships. She felt calm and asymptomatic when alone. She showed minimal improvement despite trials of 5 neuroleptics, 2 tricyclic antidepressants, 1 monoamine oxidase inhibitor, 2 benzodiazepines, buspirone, and supportive psychotherapy. Case 5. A 32-year-old female borderline, hysteroid dysphoric, initially presented with conversion reactions (e.g., atasia abasia). These spontaneously resolved, followed by fluctuating situational paniclike attacks and fluctuating symptoms of a major depression that correlated with her boyfriend’s repeated physical abuse, desertion of her, or both. She also chronically complained of diverse somatic symptoms, generalized anxiety, and maladjustment reactions to multiple psychosocial stressors. She improved markedly on phenelzine. Polyneurotic Syndrome

Three nonborderline patients had such a mixture of somatic, obsessional, generalized anxiety, and phobic symptoms that it was difficult to determine which symptom was most dominant or else the symptomatic picture frequently shifted over time. As opposed to the previously described patients who had a subsyndromal mixture of symptoms, these patients met criteria for various DSM-III syndromes, but at different times, and showed little diagnostic stability. Case 6. A 42-year-old male school principal complained of the recent onset of “wooziness” and fears of fainting during public speaking since papilledema was discovered in one eye. He worried excessively about having a brain tumor. When this symptom subsided after he received low-dose alprazolam, he began to focus increasingly on feelings of “giddiness” and perceptual distortions while walking down a hall, numb and tight feelings in his calf muscles, and sensations that the ground was uneven when he walked outside. He described a past history of anticipatory anxiety and near-panic when driving over bridges. The patient also had a severely perfectionistic, workaholic, tightly wound style. He improved greatly on alprazolam and supportive-expressive therapy that focused on his obsessivecompulsive personality style. DISCUSSION

This study is best viewed as a preliminary, hypothesis-generating study limited by several methodological shortcomings. Patients were not systematically diagnosed with structured interviews. Treatment was naturalistic and uncontrolled. Charts were not reviewed blindly. There are no comparisons to other control groups. The

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reader may also dispute the diagnostic formulation of several of these cases; however, they appear to us to “fall through the cracks” of the DSM-III syndromal classification of major axis I disorders. The results suggest that the term atypical anxiety disorder is often used, as is atypical psychosis, when there is insufficient information to make a specific axis I diagnosis. Roughly half (56%) of the 75 patients were subsequently rediagnosed. Most of these rediagnosed patients received multiple axis I diagnoses and most were relatively treatment refractory. Nevertheless, 33 patients remained atypical and difficult to diagnose on longitudinal follow-up. This study suggests that many of them could be subsumed under less restrictively defined diagnostic categories (the panic disorder spectrum, somatoform spectrum) as well as under new putative diagnostic subtypes that call for further investigation to clarify their phenomenology, epidemiology, treatment response and, if possible, etiology. The most common atypical presentation was paniclike symptoms. Many reports have described atypical presentations of panic and agoraphobia. Several recent reports have associated attacks of prominent irritability, derealization, and autonomic symptoms with electroencephalographic abnormalities, partial complex seizures, and poor response to antidepressant medication.*v3 Others have described an association with atypical chest pain without arteriographic evidence of coronary artery disorder and suggested that panic disorder can sometimes present without the “panic”.4*5 Jacob6 catalogued several “pseudoagoraphobic” syndromes distinguished from classical panic-agoraphobia: the “supermarket syndrome,” or intolerance to looking up and down shelf aisles’; “motorist vestibular disorientation syndrome,” or intolerance to driving over the crests of hills and on open featureless roads’; and “space phobia,” or fear of falling owing to paucity of visual cues for orientation in space.’ Other investigators have implicitly or explicitly questioned the cutoff criteria for the number of symptom and attacks in DSM-III and DSM-III-R. Individuals with infrequent or limited symptom attacks do not appear to differ from panic disorder patients in symptomatic presentation,” demographic characteristics,” depression and anxiety scores, history of major depression,‘2*‘3 response to sodium lactate,i4 or prevalence of mitral valve prolapse.” Studies have shown an increased prevalence of subpanic symptoms in the families of probands with panic disorder or agoraphobia.r6 The New Haven Epidemiological Catchment Area (ECA) findings also showed that 67 of 144 subjects with “agoraphobia without panic disorder” actually had subsyndromal panic symptoms and that such subjects outnumbered patients with “agoraphobia with panic disorder.“” Our patients with limited symptom attacks (predominant vasovagal symptoms, globus hystericus, or chest pain) and infrequent panic attacks responded well to antipanic medications. These data suggest that rather than a clear demarcation between patients with infrequent or limited symptoms and those with classical panic disorder, there is a spectrum of severity. The DSM-III cutoff criteria are not empirically well founded and appear to be too restrictively defined, leading to an artificial creation of atypical patients. Panic disorder is best heuristically viewed as a spectrum, similar to schizophrenia and bipolar disorder. Further research is needed to define more appropriate clinical cutoff criteria. Although DSM-III-R extends the boundaries of panic disorder to include infrequent attacks “followed by a period of at least one month of persistent fear of

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having another attack,” several of our panic spectrum patients developed persistent generalized anxiety, depersonalization, psychogenic pain, or exaggerated anxiety responses to situational events without anticipatory anxiety of having another panic attack. Residual generalized anxiety, depersonalization, and somatic symptoms, not fear of panic attacks, were the primary problems of these patients. They described an endogenous quality of something being “reset inside.” Characteristically, they were unresponsive to previous supportive, dynamic and behavioral therapies but did well with typical antipanic medication. They appeared to have a unique residual type of generalized anxiety, depersonalization, somatoform disorder, or combinations thereof, secondary to their panic disorder. Katon et al.‘* similarly reported higher levels of anxiety, phobic anxiety, and depression scores on SCL-90s in panic disorder patients after attacks had abated compared with controls. They suggest the term “panic disorder-residual phase,” which appears to be an apt description of this segment of the panic disorder spectrum. The DSM-III-R inclusion of anticipatory anxiety broadens the definition of panic disorder but raises other problematic issues. A hysterical patient with three episodes of marijuana-induced panic attacks continued to worry about subsequent attacks and going crazy for the next 2 years. Is this a panic disorder? Three other patients described infrequent, situational panic attacks, often followed by anticipatory anxiety of subsequent attacks, that occurred only in the context of severe stress. These “adjustment disorders with panic attacks,” for lack of a better term, appear to be common; e.g., the report of Norton et a1.12of a prevalence of panic attacks in 30% of a student population. Whether such disorders should be considered part of a broad definition of panic disorder or as a separate entity is unclear, however. Further research is obviously needed to clarify if and where a dividing line should lie between panic disorder, infrequent or subpanic disorder, and adjustment disorder with panic attacks. Previous reports have described an increased prevalence of obsessive-compulsive symptoms in patients with panic disorder. I9 Four patients described above were of vomiting or choking that led to multiple obsessed with interoceptive fears 20*21 phobic avoidances and panic attacks apparently provoked as a conditioned response to peripheral bodily sensations. Panic is here understood as a psychological reaction to an internal phobic stimulus. Although the four patients did not view their obsessional ruminations as “senseless” (DSM-III-R, p 247), their central fears of vomiting or choking could be viewed in the obsessive compulsive disorder (OCD) spectrum. DSM-III-R restrictively defines OCD, omitting other atypical though common presentations, such as ego-syntonic obsessions, obsessional phobias, bowel obsessions, and obsessions with psychotic features.22-24 Further phenomenological studies of clinical and epidemiological samples are needed to broaden and make more clinically relevant the definition of OCD. DSM-III-R’s reclassification of the somatoform disorders includes undifferentiated somatoform disorder and somatoform disorder, not otherwise specified (NOS), an unfortunately ponderous choice of terms. These subsyndromal variants of somatization disorder appear to be more common than the parent syndrome.25 The new categories would probably subsume the six patients described above as somatoform spectrum disorders, (including case 3, which DSM-II would have diagnosed as a psychophysiological disorder). Quite commonly, patients present as

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we describe, with a mixture of subsyndromal somatization, hypochondriasis, and generalized anxiety. Further investigation is needed to reassess our heuristic division and cutoff criteria of the somatoform disorders. Research has focused primarily on the classical syndromal rather than the atypical presentations, which may be much more “typical.” Several character disordered patients, mainly borderlines with histrionic features, presented with a shifting panoply of subsyndromal anxiety and depressive symptoms, cutting across multiple axis I disorders. These patients had many anxietyrelated symptoms, which appeared to be related primarily to axis II rather than axis I psychopathology. Kernberg’s original description of borderline personality organization similarly noted a pleomorphic, polyneurotic presentation. With these patients, it was difficult to discern where the character pathology ended and axis I syndrome began. The dividing line between axis I and axis II becomes fuzzy with these patients. These were the atypical patients in the truest sense, as they did not fit into broader diagnostic spectra of other axis I syndromes. Finally, the proposed polyneurotic category addresses the issue of the “lumper” versus “splitter” mentality in nosology. DSM-III and DSM-III-R split: There are now 24 categories of neurosis. Yet whether these disorders are fundamentally distinct from each other, in particular, whether they show stability over time, is still controversial. Although cross-sectional studies suggest distinct differences, many longitudinal studies, as well as the polyneurotic syndromal patients we describe, suggest frequent crossing-over from one disorder to the other.27-29Tyrer3’ has gone so far as to suggest a return to the concept of “The General Neurotic Syndrome” to describe patients who “pass, chameleon-like, through different diagnostic hues depending on the nature of the stresses they encounter” (p. 687). Clearly, studies are needed for better establishment of the diagnostic validity and definition of caseness of the DSM-III-R syndromes. Most of the patients discussed above fit into more broadly defined axis I syndromes. To place the arbitrary DSM-III-R diagnostic cutoffs on a more empirical basis will require future biological, family, and medication response studies that use alternative definitions of syndromes and more heterogeneous populations involving a broader spectrum of diagnostic categories. The traditional research strategy of using narrowly defined diagnostic criteria and homogeneous populations does not address the issue of caseness; rather, it assumes caseness a priori. The question of meaningful diagnostic subtypes of the axis I syndromes, such as cardiac or residual subtypes of panic disorder, can be best answered by traditional studies of criterion validity, such as laboratory, family, treatment, natural history, and descriptive studies. The suggestion of a general neurotic syndrome can be evaluated by longitudinal follow-up studies with serial interviews to chart the course and stability of the various anxiety disorders and their relationships to life events. A similar strategy would help clarify matters regarding the atypical character disorder subgroup, as would the traditional types of studies of criterion validity. Also at issue with the character disorder subgroup is whether the paradigmatic split between axis I and axis II has any useful meaning, i.e., whether an axis I diagnosis should be given at all. A more fundamental issue is the validity of the DSM-III-R assumption that discrete diagnostic entities truly exist. Kendall and Brockington3’ argued that

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broader descriptive and epidemiological studies are needed to demonstrate discreteness: if the term entity is to have any meaning at all in contemporary psychiatry, it should imply the existence of a natural boundary or discontinuity between the condition in question and its neighbors. . . . The most obvious way of doing this is to demonstrate, in a representative and unselected population, that patients exhibiting a mixture of the symptoms of the condition in question and those of neighboring syndromes are relatively uncommon. The mixed forms, the greys, must be shown to be leas common than the pure forms, the blacks and whites, which in mathematical terms involves demonstrating that a distribution of scores on a linear variable, derived from the relevant symptoms, is bimodal with a “point of rarity” in the middle, rather than unimodal.

Currently, data are insufficient with regard to the existence of the DSM-III-R anxiety disorders as discrete, independent entities. Atypical anxiety cases abound. It is not even clear whether the atypical cases are more typical than the pure syndromes. Discrete psychiatric syndromes may be as much a mirage as discrete personality types.32 REFERENCES 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd ed, Washington, DC, American Psychiatric Association Press, 1968 2. Edlund MJ, Swarm AC, Clother J: Patients with panic attacks and abnormal EEG results. Am J Psychiatry 144:508-509,1987 3. Weilburg JB, Bear DM, Sachs G: Three patients with concomitant panic attacks and seizure disorder: Possibleclues to the neurology of anxiety. Am J Psychiatry 144:1053-1056, 1987 4. Beitman BD, Basha I, Flaker G, et al: Major depression in cardiology chest pain patients without coronary artery disease and with panic disorder. J Affect Dis 13:51-59, 1987 5. Katon W, Vitaliano PP, Anderson K, et al: Chest pain: Relationship of psychiatric illness to coronary arteriographic results. Am J Med 84:1-9, 1988 6. Jacob RG: Panic disorder and the vestibular system. Psychiatr Clin North Am 11:361-374, 1988 7. McCabe BF: Diseases of the end organ and vestibular nerve, in Naunton RF (ed): The Vestibular System. New York, Academic Press, 1975 8. Page NGR, Gresty MA: Motorist’s vestibular disorientation syndrome. J Nemo1 Neurosurg Psychiatry 48:729-735,1985 9. Marks I: Space phobia: Syndrome or agoraphobic variant? Br Med J 2:345-347,1976 10. Margraf J, Taylor B, Ehlers A, et al: Panic attacks in the natural environment. J Nerv Ment Dis 175:558-565,1987 11. von Korff M, Eaton W, Key1 P: The epidemiology of panic attacks and panic disorder: Results of three community surveys. Am J Epidemioll22:970-98 1,1985 12. Norton G, Harrison B, Hauch J, et al: Characteristics of people with infrequent panic attacks. J Abnorm Psycho1 94:216-221,1985 13. Katon W, Vitaliano P, Russo J, et al: Panic disorder: Epidemiology in primary care. J Fam Pratt 23:233-240,1986 14. Crowley DS, Dager SR, Foster SI, et al: Clinical characteristics and response to sodium lactate of patients with infrequent panic attacks. Am J Psychiatry 144:795-798, 1987 15. Dager SR, Corneas KA, Dunner DL: Differentiation of anxious patients by two-dimensional echocardiographic evaluation of the mitral valve. Am J Psychiatry 143:533-535,1986 16. Noyes R, Crowe RR, Harris EL, et al: Relationship between panic disorder and agoraphobia: A family study. Arch Gen Psychiatry 43:227-232, 1986 17. Weissman MM, Maikangas KR: The epidemiology of anxiety and panic disorders: An update. J Clin Psychiatry 47:l l-17, 1986 (suppl6) 18. Katon W, Vitaliano PP, Anderson K, et al: Panic disorder: Residual symptoms after the acute attacks abate, Compr Psychiatry 38:151-158, 1987 19. Mellman TA, Uhde TW: Obsessive-compulsive symptoms in panic disorder. Am J Psychiatry 144:1573-1576, 1987

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20. van den Hout MA, van der Molen GM, Griez E, et al: Reduction of CO,-induced anxiety in patients with panic attacks after repeated CO, exposure. Am J Psychiatry 144:788-791,1987 21. Griez EJL, Lou&erg H, van den Hout MA, et al: CO, vulnerability in panic disorder. Psychiatric Res 20:87-95,1987 22. Jenike MA, Vitagliano HL, Rabinowitz J, et al: Bowel obsessions responsive to triyclic antidepressants in four patients. Am J Psychiatry 144:1347-1348,1987 23. Insel TR, Akiskal HS: Obsessive-compulsive disorder with psychotic features: A phenomenological analysis. Am J Psychiatry 143:1527-1533, 1986 24. Rachman S, Hodgson R: Obsessions and Compulsions. Englewood Cliffs, NJ, Prentice-Hall, 1980 25. Escobar JJ, Burman MA, Karna M, et al: Somatization in the community. Arch Gen Psychiatry 44:713-718, 1987 26. Kernberg 0: Borderline personality organization. J Am Psychoanal Assoc 15:641-685, 1967 27. Kendell RE: The stability of psychiatric diagnosis. Br J Psychiatry 124:352-356,1974 28. Roth M, Gurney C, Garside RS, et al: Studies in the classification of affective disorders: The relationship between anxiety states and depressive illness. Br J Psychiatry 121:14X161, 1972 29. Mumby M, Johnson DW: Agoraphobia: The long-term follow-up of behavioural treatment. Br J Psychiatry 137:418-427,198O 30. Tyrer P: Neurosis divisible? Lancet 1:685-688, 1985 3 1. Kendell RE, Brockington IF: The identification of disease entities and the relationship between schizophrenia and affective psychoses. Br J Psychiatry 137:324-33 1, 1980 32. Kendell RE: Clinical validity. Presented at the annual meeting of the American Psychopathological Association, New York, March 1988.

Atypical anxiety disorder: a descriptive study.

This retrospective study examined 75 outpatients who received an atypical anxiety disorder diagnosis in a 30-month period. Patients who were later red...
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