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Previous results also suggest that the onset of panic attacks precedes the onset of other mental disorders in the majority of cases, but further, that earlier onset of panic attacks (<21 years) is associated with even higher risk of comorbid mental disorders, compared with later onset (3, 4, 12, 13, 15, 24).Once primarily considered a subclinical form of panic disorder, or predictor of panic disorder onset, a relationship between panic attacks and increased risk of depressive disorders, bipolar disorder, anxiety disorders, substance use disorders, and psychotic symptoms has been demonstrated in clinical and community-based studies (1–22).While comorbidity associated with mental disorders is overwhelming, especially among those with onsets of depressive and anxiety disorders early in life (3, 4, 24), it is conceivable that the deleterious impact of serious disorders on social and academic functioning might ultimately be reduced with the development of effective intervention and prevention strategies, if identification of specific markers or non-specific causal risk factors were possible (25, 26).
Efforts to identify precursors and prodromal symptoms of severe mental disorders (e.g. schizophrenia, major affective disorders) during childhood have primarily focused on associations between risk for severe psychopathology in adulthood and depressive and psychotic symptoms, disruptive behavior problems, and social and cognitive deficits during childhood (27–33).Yet, numerous studies in youth have shown that panic attacks are not uncommon, identifiable using standard self-report questionnaires, and are strongly associated with a range of mental disorders.
Studies in clinical populations have repeatedly shown linkages between panic attacks and anxiety disorders, depression, and alcohol use disorders. Biederman et al. (22) found high rates of psychotic symptoms and bipolar disorders associated with panic attacks in a clinical sample of youth. Community-based studies have also shown associations between panic attacks and increased odds of panic disorder and other anxiety disorders among young females (13).Specifically, Hayward et al.(13) found high rates of comorbid depressive and anxiety disorders, but not alcohol or substance use disorders among youth with panic attacks.
Taken together, previous data suggest an association between panic attacks and anxiety and depressive disorders in youth. There are several methodological shortcomings, however, that limit the generalizability of these findings. First, no previous study has examined the association between panic attacks and the full range of comorbid psychopathology in youth. Secondly, previous studies that have included assessment of comorbid anxiety and depression have not used standardized assessments (i.e. using DSM criteria), which limit the generalizability of these findings.
The association between panic attacks and increased likelihood of comorbid anxiety disorders is consistent with previous findings from clinical and community-based samples among youth and adults (1– 22, 39, 40).For example, Hayward et al. (12, 13) have noted strong linkages between panic attacks and phobia, panic disorder, and separation anxiety disorder among female high school students in the community, as well as in clinical samples (10, 12, 13, 17, 22).Anxiety disorders are thought to have among the earliest mean onset of any disorders, especially those that are associated with psychiatric comorbidity (4, 39).These findings are therefore not surprising, yet they remain poorly understood in terms of etiologic mechanisms.
These data reflect a strong association between panic attacks and affective disorders, especially major depression and dysthymia. The association between panic attacks and major depression among youth is consistent with previous findings from clinical samples documenting linkages between panic and depression in youth (7–9, 11, 12, 17, 22) and adults (2–6, 39).This association is seemingly inconsistent with the results of one previous study that examined the development of comorbid disorders at 6 months and further after entry into a clinical sample where they were treated for anxiety disorders, and in which over 80% were free of their baseline disorder at follow-up (20).
However, the fact that these youth appear to have been effectively treated for their anxiety disorders may have influenced the lack of development of depression, as previous data suggest that anxiety is a risk factor for depression, and if this is true then the treatment of anxiety should significantly reduce this risk. This comparison then seems relatively consistent with our findings, and also appears to be consistent with previous findings in adult samples showing that treatment of panic attacks is associated with decreased risk of depression (41).
In contrast to previous findings indicating a link between panic attacks and substance use disorders among adults (1, 4, 5), and between panic attacks and substance use disorders in previous studies of youth in clinical settings (9, 10, 12, 17, 22), panic attacks were not independently associated with substance use disorders in the present data. There are several possible reasons for this discrepancy.
First, previous clinical studies among youth with this finding have been performed with slightly older samples (e.g. ages 14, 15 years). Therefore, it is possible that this relationship does not emerge until later in the lifecourse. This may be due to later initiation of substance use because of availability and environmental circumstances. It is also possible that the onset of other factors, which increase the risk of substance use (e.g. exposure to deviant peer groups) is not as prominent in a child’s life until a slightly older age, and this may contribute to the onset of this link. Secondly, this lack of association may also be related to the use of a community vs. clinical sample, as previous studies with this finding among youth have been conducted using selected samples among whom rates of substance use may be higher, compared with the general population. If this finding is replicated, youth who seek treatment for panic attacks or other mental disorders may be at higher risk for several reasons, yet these data suggest that among youth in the community panic attacks are not associated with higher substance use disorders among those under age 17.
The identification of youth who are at risk for severe psychopathology is of public health importance given that mental disorders in youth are associated with increased risk of secondary psychiatric and physical comorbidity throughout the lifecourse, with impairment in social and academic functioning, and with increased risk of suicidal behavior among various age groups (2, 4, 42).If panic attacks are associated with an increased likelihood of a range of mental disorders, as suggested by the present data, then treatment of panic may be one avenue to explore in developing strategies aimed at preventive intervention. As a caveat, longitudinal studies are first needed to determine whether panic attacks are indeed a causal risk factor for comorbid disorders, or whether panic attacks may be a marker for severe psychopathology in some cases. This might suggest that the progressive development of a direct link between panic and depression, which may not emerge until adulthood, might be influenced by these modifiable factors.
Reflection Exercise #6
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