Life Events and Panic Disorder /Agoraphobia

Ghada N. Lteif and Mat ig R. Mavissakal ian

A patient-rated checklist adapted from the Psychiatric Epidemiology Research Interview was used to assess frequency and desirability of life events in the 12 months preceding an index evaluation of a large sample of patients with a DSM-III diagnosis of panic disorder or agoraphobia with panic, on average 12 years after onset of illness. A total of 1,360 events were reported; 25% were considered most undesir- able, whereas 22% were estimated to be most desir- able. Negative life events were predominantly health- related issues and interpersonal conflicts. Making new friends, having significant success at work, and taking up a new activity were examples of positive events.

Correlations of life events with clinical and demo- graphic variables and with symptom rating scales were also analyzed. Negative life events were associ- ated with greater psychopathology and neuroticism scores. Positive life events were associated with greater extraversion scores, more years of education, better employment status, and less functional impair- ment due to symptoms. This exploratory study does not allow interpretation from an etiologic perspective. It begins to shed light on the possible role of life events in the course of the disorder. Copyright © 1995 by W.B. Saunders Company

A NUMBER OF STUDIES have examined the relationship of life events and anxiety

disorders in general and panic disorder and agoraphobia in particular. 1-12 Most of these studies have focused on life events preceding onset of the disorder, often in an attempt to establish a precipitating or etiologic role in the genesis of panic disorder and agoraphobia. 1-9 Some investigators a,2,8 have found that com- pared with control groups, panic disorder and agoraphobia patients report an excess number of life events preceding the onset of their disorder. Rapee et al. 9 suggested that the adver- sity and negative impact of life events is more relevant than the mere occurrence and number of these events.

Few studies have examined life events at an index point during the illness. Pollard et al., 8 using a within- and between-subject control period, found that major life events were re- ported in greater numbers during the time close to a panic onset. Wade et al. t° found that 43% of the patients continued to evidence life stress of marked or moderate severity throughout the follow-up period. Chronicity rather than speci- ficity of life events was a better predictor of treatment outcome. In our earlier study n of a group of chronic agoraphobic and panic disor-

From the Department of Psychiatry, Ohio State University College of Medicine, Columbus, OH.

Supported in part by Grant No. MH42730 from the National Institute of Mental Health.

Address reprint requests to Matig R. Mavissakalian, M.D., 1670 Upham Dr, Columbus, 0H43210.

Copyright © 1995 by W..B. Saunders Company 0010-440X/95/3602-0003503.00/0

der patients with a mean illness duration of 12 years, we reported that greater personality dys- function was correlated with greater overall stress in the year preceding index evaluation. Interestingly, personality variables did not corre- late significantly with the number and severity of life events.

The first aim of the present report was to provide detailed characteristics of life events in the year prior to evaluation of 187 patients with panic disorder and agoraphobia with panic from the aforementioned study, n The second aim was to explore the relationship between life events and symptom severity, clinical variables, and demographic characteristics of the sample. To our knowledge, no previous study has pro- vided detailed analysis of the frequency, type, and valency of life events or examined the above-mentioned correlations in the course of panic disorder and agoraphobia.

METHOD

Subjects Demographic, clinical, and personality characteristics of

the sample have been described elsewhere. Briefly, the subjects were 187 consecutive referrals who met DSM-III criteria for either panic disorder or agoraphobia with panic (161 patients, 86%) using the Anxiety Disorder Interview Schedule. 13 The patients had been referred to our specialty clinic for evaluation for a double-blind imipramine proto- col. Demographically, the sample was 75% female, 73% married, and 59% employed, with an average age of 38.3 years (range, 18 to 64) and an average duration of agorapho- bia or panic disorder of 12.1 years (range, 0.2 to 50). Ten patients had incomplete life events data; hence, the present analysis was conducted on 177 patients.

118 Comprehensive Psychiatry, Vol. 36, No. 2 (March/April), 1995: pp 118-122

LIFE EVENTS AND PANIC DISORDER/AGORAPHOBIA 119

Assessments

Methods of assessment have been previously described. 11 Briefly, a patient-rated checklist of 104 items adapted from the Psychiatric Epidemiology Research Interview 14 was used to assess life events for the 12 months preceding the interview. Patients were instructed to rate each reported event for desirability on a scale ranging from -3 to +3, with -3 being most undesirable and +3 being most desirable. The severity of each patient's condition was assessed using the Global Assessment of Severity Scale, a five-point clini- cally rated scale of global severity. Clinical measures of agoraphobic fears included the agoraphobic subscale of the Fear Questionnaire 15 and a more individualized clinical measure of phobia and avoidance consisting of the mean rating of the patient's five most-feared situations. Panic attacks were assessed with self- and clinician-rated question- naires adapted from DSM-III criteria for panic disorder. Additional instruments included the Zung Anxiety Rating Scale, 16 the Hamilton Anxiety Scale, 17 the Beck Depression Inventoryfl 8 the Hamilton Rating Scale for Depression, 19 and the Hopkins Symptom Checklist. 2°

RESULTS

A total of 1,360 events were endorsed by this group of patients. All patients reported at least one positive and one negative event, with a mean number of events of 7.8 (range, 1 to 31) and a mean rating of all events of 0.1. The mean number of positive events was 3.6 (range, 1 to 12), with a mean rating of 2.3. The mean number of negative events was 4.1 (range, 1 to 16), with a mean rating of -2 .3 . Twenty-five percent of the total number of events were considered most undesirable ( - 3 ) , whereas 22% were considered most desirable (+3).

Table 1 lists details of the frequency and rating of 28 life events reported by at least 10% of the patients. As can be seen, a serious illness or accident involving a family member or close friend, personal physical illness, serious family arguments, worsening of the relationship with a spouse, trouble with a boss, and worsening conditions at work were prominent negative life events. Making new friends, having significant success at work, changing jobs for a bet ter one, and remodeling one 's home were among events judged to be very desirable. It is interesting that events considered overwhelmingly positive were judged to be undesirable by some. Thus, we note that 7% of those moving to a bet ter residence, 8% of those taking a vacation, 10% of those changing jobs for a bet ter one, and 12% of those remodeling their home viewed these events as undesirable.

Table 2 lists results of Pearson's r correlations between life events and demographic and clini- cal characteristics, and with symptom rating scales. Pearson's test of significance in the case of the two categorical variables gender and marital status is equivalent to the two-sample t test for the equality of the means for the two groups. The correlation coefficients were gener- ally found to be low. As shown, the number and degree of undesirability of negative life events were significantly correlated with greater symp- tom severity and neuroticism. These associa- tions were strongest for depression scales, less so for panic and anxiety scales, and not signifi- cant for phobic scales. The number of positive life events was significantly correlated with greater extraversion scores, more years of edu- cation, bet ter employment status, and less func- tional impairment due to symptoms. Age and marital status did not correlate significantly with life events. Female gender was associated with a smaller number but higher rating of life events.

DISCUSSION

This is an exploratory study of life events and their relationship with demographic and clinical characteristics in a large sample of panic disor- der and agoraphobia with panic patients, on average 12 years after onset of illness. The cross-sectional, descriptive, and correlational design of the study does not allow interpreta- tion from an etiologic or cause-and-effect per- spective, although the findings begin to shed light on the possible role of life events in the course of the disorder, an important but under- studied topic.

It is interesting in this respect that the pre- dominant categories of negative life events, e.g., interpersonal conflicts and physical illness, found in the present study were similar to events described prior to illness onset in the available literature. 1,3,6,7,8,1° Because events preceding on- set of the disorder are generally assigned a causative/precipitating role, it is plausible to suggest that the same types of events would have a role in maintaining or exacerbating the disorder. This would be consistent with a recent study showing that agoraphobic patients who continued to experience adverse life events after behavioral t reatment had a poorer out-

20 LTEIF AND MAVtSSAKALIAN

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LIFE EVENTS AND PANIC DISORDER/AGORAPHOBIA

Table 2. Correlation Between Life Events and Clinical Demographic, and Psychopathologic Variables

121

Positive Events Negative Events

No. of Events No. Mean Rating No. Mean Rating

Demographic variables

Age - .09 - .16 .02 .02 .07

Sex - .18" - .09 .20* -.11 .17"

Marital status - .06 - .12 .09 - .02 .03

Employment status .18* .24* - .04 .06 - . 14

Years of education .25" .27* .05 .16 - .04

Clinical variables

Age of onset .08 - .04 .19" .19" .16

Duration of illness - .16 - .12 - .12 - .14 - .08 Eysenck Personality Inventory

Extraversion .16 .20* .11 .09 - .04

Neuroticism .09 .03 -.01 .10 .17" Global Assessment of Severity - .20" - .17" .00 - .15 - .00

Phobic measures

Fear Questionnaire agoraphobia -.11 - .09 - .06 - .08 - .07

Phobic anxiety and avoidance - .12 - .04 -.01 - .15 .02

Anxiety measures

Zung Anxiety Scale .14 .03 .11 .19 .15

Hamilton Anxiety Scale .07 - .09 - .20* .16 .10

Depression measures

Beck Depression Inventory .23* .04 - .08 .30* .23"

Hamilton Depression Scale .19" -.01 -.11 .29* .06

Panic measures Panic attacks clinician-rated .14 .03 - .00 .19* .18*

Panic attacks patient-rated .12 .04 - .07 .15 .10 Hopkins Symptom Checklist

Somatization .16 .03 - .08 .19" .17" Obsessive/compulsive .16 .02 - .17" .22* .27*

Interpersonal sensitivity .13 .05 .00 .13 .21"

Depression .21" .01 - .04 .31" .25*

Anxiety .10 .01 -.01 .14 .13

*Pearson's r correlations significant at P _< .5.

come. 1° It is also consistent with the present finding of a significant correlation between negative life events and greater symptom sever- ity.

Clearly, correlations lend themselves to differ- ent interpretations. In the case of negative life events, for example, it is possible that greater severity of symptoms, and by extension, of dysfunction, leads to experiencing more life events. The finding that positive life events were associated with less functional impairment ten- tatively suggests that they may exert a buffering or protective effect. This view receives support from a recent report that recovery and improve- ment among women with anxiety and depres- sion were associated with a preceding positive event. 21 On the other hand, it would be equally possible to suggest that improved functioning fosters positive life experiences. In this regard, we found that positive life events were signifi-

cantly correlated with greater extraversion, higher education, and better employment. It is possible that these patient-related characteris- tics are critical explanatory variables for experi- encing a greater number of positive life events and for being less functionally impaired by symptoms.

Two additional observations warrant com- ment. The first is the intriguing finding that events overwhelmingly judged to be positive, such as moving to a better residence or taking a vacation, were nevertheless considered negative experiences by some. We may speculate that a subgroup of panic disorder and agoraphobia patients are particularly sensitive to any change in their lives. This underscores the importance of determining the valency in addition to the number and type of life events in clinical and research settings alike. The second observation is related to the association between female

122 LTEIF AND MAVISSAKALIAN

gender and reporting a smaller number and higher rating of life events. Being more affected emotionally by undesirable life events seems not to be unique to agoraphobic women; in fact, previous research 22 has discovered that this observation applies to women in general. This raises the suggestion that women experience life events more intensely than men; this is yet to be determined.

In closing, the findings of this study raise interesting questions regarding the potential role of life events in the course of panic disorder and agoraphobia with panic. It appears that life events in the course of the disorder are similar to those described prior to onset.

Future studies, preferably using interview methods, are needed to replicate the results by independently assessing life events before onset and at specified times during the course of the disorder. Including normal and psychiatric con- trol groups will help determine the specificity of the results for the disorder. As for the sugges- tion that negative and positive life events affect the course of the disorder differently, repeated assessments of life events over a long period encompassing various phases of the disorder such as relapse and remission may go a long way in elucidating the causal relationship between life events and symptom severity and outcome in panic disorder.

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