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ANALYSIS OF PSYCHIATRIC HEREDITYIN PATIENTS WITH AGORAPHOBIA AND PANIC DISORDER

Danka Nestorovic1

Milan Latas1,2

1 School of Medicine, University of Belgrade, Belgrade, Serbia

2 Clinic for Psychiatry, Clinical Centre of Serbia, Belgrade, Serbia

Summary

Introduction: The previous studies reporthigh prevalence of psychiatric disordersamong family members of patients withagoraphobia and panic disorder. In ourcountry there have been no studies thatexamine psychiatric heredity in patientswith agoraphobia and panic disorder.

Objective: The objective of the rese-arch is to investigate the presence of here-dity in patients with agoraphobia and pa-nic disorder, and to compare the clinicaland demographic characteristics of pati-ents with agoraphobia and panic disorderwith and without psychiatric heredity.

Method: The sample included 40 pati-ents with panic disorder and agorapho-bia. Data were obtained from the questi-onnaire for the assessment of panic disor-der NIMH-PQ, which included questionsabout the occurrence of psychiatric disor-ders in families of the patients, as well as44 questions about the severity and frequ-ency of panic disorder symptoms.

Results: The results indicate that themajority of patients (62.5 %) have the po-sitive psychiatric heredity. The most fre-quent were depression and alcoholism.The results, also, showed that there are nosignificant differences in the characteri-stics of the main symptoms of panic disor-der of patients with and without psychia-tric heredity.

Conclusion: The results of the studyindicate high prevalence of psychiatric he-redity in patients with panic disorder andagoraphobia but more studies are neededto conclude that there is a direct link bet-ween family history of psychiatric disor-ders and occurrence of panic disorder andagoraphobia.

Key words: panic disorder, agorapho-bia, depression, alcoholism, heredity

INTRODUCTION

Panic disorder is a syndrome charac-terized by frequent, unexpected panicattacks, intense concern about panic at-tacks and their potential consequences.The prevalence of panic disorder in theworld is 3 – 4 % [1]. It is believed thatin the development of a panic disordernumerous factors are include, so we cansay that the etiology is multifactorial.Agoraphobia is a fear of public places,open spaces, and the fear of leaving thehouse alone. The prevalence of agorap-hobia is 3 % - 8 %, it is more commonin women. Agoraphobia and panic di-sorder are most often encountered as asingle entity and so that they are recog-nized in the International Classificationof Diseases under the code number fordiagnosis F40.01 [2].

Clinical studies have proven that inthe etiology of panic disorder traumaticevents in childhood, congenital factors,family attitudes, and family history ofpsychiatric illness all have a role, amongother things. Results of a survey that de-alt with predisposing factors in the onsetof panic disorder indicate that the majo-rity of patients with panic disorder haveexperienced some of the examined pre-disposing events for a period of one yearprior to the first panic attack, most com-monly a case of death was stated [3]. Ina study conducted by Bandelov and as-sociates, patients with panic disorder re-ported significantly greater presence ofpsychiatric disorders in the family, espe-cially panic disorder and generalized an-xiety disorder, as compared to the con-trol group [4]. Epidemiological studiesconfirmed that the occurrence of certainpsychiatric diseases has a partial geneticinfluence. French scientists have shown

that people with a family history of pa-nic disorder are more likely to sufferfrom the same [5]. Panic disorder, gene-ral anxiety, phobias and obsessive-com-pulsive disorder have a family tendency[6]. Other studies have shown that therisk of panic disorder in the families ofthe patients with panic disorder is hig-her in first-degree relatives, while withthe second degree relatives the risk dec-reases [7]. These findings imposed a qu-estion, whether other psychiatric illnes-ses in the family history may influencethe occurrence of panic disorder.

According to our information, nostudies that would address the psychia-tric heredity and panic disorder andagoraphobia were conducted in Serbia.Such a study could indicate some etiolo-gical factors that influence the occurren-ce of panic disorder.

Objectives and research hypotheses

The first objective of the research isto investigate the existence of psychia-tric heredity (depression, alcoholism,psychosis, schizophrenia, obsessive-compulsive disorder, panic disorder,agoraphobia, and other forms of phobi-as) in patients with panic disorder andagoraphobia.

Another aim of the research was tocompare the clinical and demographiccharacteristics of patients with panic di-sorder and agoraphobia with psychia-tric heredity (depression, alcoholism,obsessive-compulsive disorder, psycho-sis, schizophrenia, panic attacks) andwithout psychiatric heredity.

The first hypothesis is that there is ahigh prevalence of psychiatric heredityin the families of the patients with panicdisorder and agoraphobia.

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Another hypothesis is that the pati-ents with psychiatric heredity have mo-re severe and earlier onset disordersthan patients without psychiatric here-dity.

MATERIALS AND METHODS

The survey was conducted at theDay Hospital of the Clinic for Psychia-try, Clinical Centre of Serbia in Belgra-de. The study comprised 40 patientswith panic disorder and agoraphobia asan underlying disorder.

Examination of patients with psychi-atric illnesses in their families is donethrough the use of the National Institu-te of Mental Health Panic Questionnai-re (NIMH PQ), which serves as a clini-cal and research method for testing theclinical characteristics of patients withpanic disorder or those in whom there isa suspicion of panic disorder [8]. Pati-ents independently answer questionsabout the characteristics of panic disor-der and psychiatric disorders that appe-ar in their family.

The questionnaire consisted of 9psychiatric disorders: depression,psychosis, schizophrenia, panic disor-der, a severe form of fear, agoraphobia,and other types of phobias, obsessive-compulsive disorder and alcoholism.The tenth question is about the existen-ce of other psychiatric illnesses that arenot listed. Patients were asked to circlewhether the disease occurred among:mother, father, sister, brother, child,grandfather/grandmother, aunt, uncle,cousin or other relative.

The questionnaire includes questionsabout the characteristics of the symp-toms, the patients provided data on theintensity and frequency of individual

symptoms that occur during a panic at-tack according to the Likert scale (ran-ging from 0 to 3). The questionnaire in-cluded 44 questions such as: palpitati-ons, irregular heartbeat, numbness ofthe mouth, numbness in the hands or fe-et, chest pain, and more. In addition, pa-tients had the task to evaluate the cur-rent state of health, ranging from 1 to 5,and to state the age at the time of thefirst occurrence of a panic attack.

In the statistical analysis of materialsstandard descriptive and analytical stati-stical methods were used. Data are pre-sented through the mean value of thestandard deviation and relative frequen-cies. A statistical analysis was perfor-med using Student’s t test.

RESULTS

Demographics

Respondents had an average age of32.33 ± 8.23 ??years, ranging from 20 -51 years. Among them 15 (37.5 %) we-re men and 25 (62.5 %) were women.Of the 40 patients that participated inthe study 19 (47.5 %) were married.Asked whether closely tied to a parent27 (67.5 %) of the respondents gave apositive answer. Of these 22 are closelytied to the mother and 5 to the father.The average grade of the health condi-tion of the patients was 3.87 ± 1.02 inthe range of 1 to 5.

Psychiatric heredity

In a sample of 25 subjects (62.5 %)stated that at least one of the primarymembers of the family had a psychiatricdisorder. Table 1 shows the distributionof the frequency of psychiatric disorders

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that have appeared in heredity. Amongthe family members depression and al-coholism usually emerged. This is follo-wed by a severe form of fear and muchless frequently psychosis, some form ofphobia and obsessive-compulsive disor-der. Although the research concerns pa-nic disorder and agoraphobia, it is inte-resting that panic disorder in hereditywas mentioned by 5 patients and ago-raphobia only by 4 respondents. Notone respondent stated schizophrenia inheredity. Two patients have stated thatin their families existed other psychiatricdisorders, however they did not namethem (in Table 1).

If we look at the group of subjectswith psychiatric heredity we can get tothe conclusion whether the patients had

one, two or more persons in heredity.The results we obtained showed thatthere were 11 (27.5 %) patients with aheredity disease. Seven of them (17.5%) said that family members had 2members with a psychiatric disorder,three (7.5 %) that their family had 3members, a total of 4, 5 or 6 membersper family, were stated by only four (10%) patients.

Most commonly a family memberthat was listed as the person who had apsychiatric disorder was the mother(42.5 %), followed by father (30 %),grandfather/grandmother (27.5 %),aunt (20 %), uncle (father’s brother) (15 %), cousin (7.5%), sister (10%),brother (2.5%), uncle (mother’s brot-her) (2.5%).

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Table 1: The existence of heredity sample

Tabela 1: Prikaz postojanja herediteta uzorka

Psihijatrijski poreme aj

Psychiatric disorder N (%)

Depresija

Depression 13 32,5 %

Alkoholizam

Alcoholism 12 30 %

Težak oblik straha

Severe form of fear 8 20 %

Pani ni napadi

Panic attack 5 12,5 %

Psihoze

Psychosis 4 10 %

Agorafobija

Agoraphobia 4 10 %

Fobija od drugih stvari, bi a, situacija

Other phobia 4 10 %

Opsesivno-kompulzivni poreme aj

Obsessive-compulsive disorder 2 5 %

Neki drugi mentalni poreme aj

Some other mental disorder 2 5 %

Shizofrenija

Schizophrenia 0 0

Comparison of patients with psychiatric heredity and without

psychiatric heredity

The comparison between the groupof patients with psychiatric heredity andthe group of patients without psychia-tric heredity in relation to age, evalua-ting the health status and age at the timeof the first occurrence of panic attackare shown in Table 2. The results showthat there are no significant differencesin the assessment of the health statusbetween the group of patients withpsychiatric heredity and the group ofpatients without heredity. Significantdifferences do not exist in the age of thepatients at the time of the first occurren-ce of panic attack between the two gro-ups of patients. It should be underlinedthat two patients from the group of pa-tients with psychiatric heredity did notspecify how old they were at the time ofthe first panic attack.

The investigation showed that signi-ficant differences in the characteristicsof the symptoms between the patientswith psychiatric heredity and the pati-ents without heredity, were only presentin a few symptoms of a total of 44symptoms of panic attacks, that were te-sted through the questionnaire. The fre-quency of palpitations in patients withheredity was 2.67 ± 0.49, whereas in pa-tients without heredity 2.20 ± 0.93 (t =2.10, p = 0.04). In addition, the differen-ce between the symptoms was observedin the intensity of the feeling of floating,patients with heredity 0.07 ± 0.26, andpatients without heredity sensed an in-creased feeling 0.60 ± 1.08 (t = -2.36, p= 0.02). The intensity of feeling thatthings are unreal in the patient groupwith psychiatric hereditary was 0.00

(patients had such symptoms during theattack), whereas in patients without he-reditary the intensity was 0.32 ± 0.69 (t= -2.32, p = 0 , 03). Another symptomthat the patients with psychiatric heredi-tary had during the attack is that thethings appeared brighter or darker tothem, where the difference between thetwo groups was observed also in inten-sity. Intensity among the patients witho-ut heredity was 0.36 ± 0.70 (t = -2.57, p= 0.02). The latest symptom was stif-fness, where the differences were obser-ved in both frequency and severity. Theincidence in patients with heredity was0.40 ± 0.63 in patients without heredity1.04 ± 1.21 (t = 2.19, p = 0.03). Thestrength of the first group was 0.20 ±0.41, while in the second group 0.80 ±1.118 (t = 2.42, p = 0.02). All othersymptoms did not differ in frequencyand intensity in the patients with psychi-atric hereditary compared to the pati-ents without heredity.

DISCUSSION

Before you start interpreting the re-sults we must point out the methodolo-gical limitations of the study. The studydid not include a control group of re-spondents (respondents who were notpsychiatric patients or patients with ot-her psychiatric disorders) and on the ba-sis of the results obtained cannot saywhether the results are specific to panicdisorder and agoraphobia. The limita-tion may be that the questionnaire inclu-ded 9 psychiatric disorders.

Results of family studies have esta-blished higher rates of prevalence of pa-nic disorder in first-degree relatives ofpanic patients compared to studies wit-hout a family history of psychiatric di-

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sorders. This in itself does not provethat panic disorder is hereditary, becau-se social learning can be explained bytransfer of behavioral anxiety from pa-rents to children. [4] And other epidemi-ological studies involve a family historyof the disease among the risk factors foranxiety disorders [9]. However, to ourknowledge, the study did not addressthe question of what are the psychiatricdisorders that have an impact in here-dity panic disorder and agoraphobia,and therefore we are not able to compa-re the results of our study with otherstudies.

The results show that a larger num-ber of patients have a positive family he-redity. These data confirm the earlierhypothesis of research, and pointed tothe possible association between psychi-atric heredity and the development ofpanic disorder and agoraphobia. Weconfirmed the results of earlier studiesthat associated psychiatric disorders in

the family with the development of pa-nic disorder. We also supplementedthem, because we obtained results thro-ugh this study that show us whichpsychiatric disorders have a role in here-dity panic disorder and agoraphobia.All of the psychiatric disorders that we-re included in the questionnaire (depres-sion, psychosis, obsessive-compulsivedisorder, a severe form of fear, panic at-tacks, agoraphobia, some other form ofphobias, alcoholism) were found in thefamilies of the subjects except schizop-hrenia, not a single respondent mentio-ned this disorder in the family history.

One of the two disorders that stoodout in heredity is alcoholism. Earlier stu-dies found that alcoholism is a diseasemore common in people who are first-degree relatives of people that had panicdisorder [10]. The conducted study de-monstrated the association of alcoho-lism to heredity and panic disorder. De-pression proved to be a disease com-

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Table 2. Comparasion of patients with and without psychiatric heredity

Tabela 2. Komparacija pacijenata sa psihijatrijskim hereditetom i bez

herediteta

Supskala

Subscale

Pol

Gender

Srednja

vrednost

Mean

SD t p

bez herediteta

without heredity 32,93 7,90

Starost

Age sa hereditetom

with heredity 31,96 8,55

0,36 0,72

bez herediteta

without heredity 3,93 0,96

Ocena zdravstvenog stanja

Assessment of health status sa hereditetom

with heredity 3,84 1,07

0,28 0,78

bez herediteta

without heredity 28,33 7,38

Starost prvog napada

Age of the first attack sa hereditetom

with heredity 26,43 6,97

0,80 0,43

monly tied to heredity which has provenits great connectivity with panic disor-der. Previous studies have noted the roleof depression in the development of pa-nic disorder, but the risk of panic disor-der significantly increased in the pati-ents in whose families depression occur-red in co-morbidity with panic attacks[11]. However, as the sample of thisstudy contains only 40 respondents itdoes not have the statistical power onwhich we could base conclusions aboutthe prevalence and significance ofpsychiatric heredity for the whole popu-lation of patients with panic disorderand agoraphobia. This survey is the firstof its kind in our country, and it pointsto an important phenomenon that sho-uld be further investigated in future re-search on larger samples with the inclu-sion of control groups of subjects (pati-ents with other psychiatric diagnosesand respondents from the general popu-lation).

Studying physical symptoms earlierstudies have found that patients whohad a positive family heredity for pa-nic disorder had significantly greaterfear of bodily excitement and a higherincidence of unexpected panic attacksthan patients who did not have family

heredity for panic disorder [12]. Wedid not come to such conclusions, butthe survey showed that the significantdifferences in the clinical picture of pe-ople with psychiatric heredity and wit-hout heredity exists in only five symp-toms, of which the four symptoms ofgreater intensity/frequency had re-spondents from the group withoutpsychiatric heredity. As of 44 symp-toms studied, we cannot confirm thatmore severe patients have no psychia-tric heredity because differences in theintensity/frequency of symptoms maycontribute to the fact that it is a su-bjective feeling of the patients.

CONCLUSION

Based on these results, it can beconcluded that the majority of the pa-tients with agoraphobia and panic di-sorder have a positive psychiatric here-dity, mostly depression and alcoho-lism. We concluded that the patientswith psychiatric heredity do not exhi-bit a severe clinical picture, nor dothey have a significantly earlier onsetof panic attacks, compared to the pati-ents without psychiatric heredity.

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ISPITIVANJE PSIHIJATRIJSKOG HEREDITETA KOD PACIJENATA SA AGORAFOBIJOM I PANIČNIM POREMEĆAJEM

Danka Nestorović1

Milan Latas1,2

1 Medicinski fakultet, Univerzitetu Beogradu, Beograd, Srbija

2 Klinika za psihijatriju, Klinički centar Srbije, Beograd, Srbija

Kratak sadržaj

Uvod: U našoj zemlji do sada nije bilo is-pitivanja psihijatrijskg herediteta kod pa-cijenata sa agorafobijom i paničnim pore-mećajem.

Cilj: Ciljevi istraživanja su: 1) da se is-pita postojanje psihijatrijskog hereditetakod pacijenata sa agorafobijom i panič-nim poremećajem i 2) da se uporede kli-ničke i demografske karakteristike pacije-nata sa agorafobijom i paničnim poreme-ćajem sa psihijatrijskim hereditetom i pa-cijenata bez herediteta.

Materijal i metode: Uzorak je obuhva-tio 40 pacijenta sa paničnim poremećajemi agorafobijom. Podaci su dobijeni naosnovu Upitnika za procenu paničnog po-remećaja NIMH-PQ koji je obuhvatio pi-tanja o učestalosti pojave 9 psihijatrijskihoboljenja u užoj i široj porodici, kao i 44pitanja o jačini i učestalosti simptoma ko-je su pacijenti ocenili na Likertovoj skaliocenama od 0 do 3.

Rezultati: Rezultati istraživanja uka-zuju da većina pacijenata (62,5%) u užojili široj porodici ima bar jednu osobu sapsihijatrijskim oboljenjem. Među članovi-ma porodice najčešće su se javljali depre-sija i alkoholizam. Ispitivanje nije pokaza-lo značajne razlike u karakteristikamasimptoma pacijenta sa psihijatrijskim he-reditetom u odnosu na pacijente bez here-diteta.

Zaključak: Na osnovu rezultata dola-zimo do zaključka da je psihijatrijski here-ditet učestao kod pacijenata sa paničnimporemećajem i agorafobijom te su potreb-na dalja istraživanja da bi se povezala po-java herditeta i moguće etiologije panič-nog poremećaja i agorafobije.

Ključne reči: Panični poremećaj, ago-rafobija, depresija, alkoholozam, heredi-tet

1. Latas M, Jašović-Gašić M. Neurotični, sastresom povezani i somatoformni pore-mećaji. Anksiozni poremećaji. U: Jašović-Gašić M, Lečić-Toševski D, urednici. Psihi-jatrija- udžbenik za studente medicine.Beograd; 2010.p.155-68.

2. Latas M. Panični poremećaj i agorafobija:terapijski vodič. Beograd; 2010.

3. Latas M, Stojanović M. Predisponirajućifaktori u nastanku paničnog poremećaja.Engrami 2008; 30(1):9-15.

4. Bandelow B, Späth C, Tichauer GA, Bro-ocks A, Hajak G, Rüther E. Early trauma-tic life events, parental attitudes, family hi-story, and birth risk factors in patients withpanic disorder. Compr Psychiatry 2002;43(4):269-78.

5. Gorwood P, Feingold J, Ades J. [Geneticepidemiology and psychiatry (I): scopeand limitations of familial studies. Case ofpanic disorder]. Encephale 1999;25(1):21-9. [Article in French]

6. Hettema JM, Neale MC, Kendler KS. A re-view and meta-analysis of the genetic epi-demiology of anxiety disorders. Am JPsychiatry 2001; 158(10):1568-78.

7. Pauls DL, Noyes R, Crowe RR. The fami-lial prevalence in second-degree relativesof patients with anxiety neurosis (panic di-sorder). J Affect Disord 1979; 1(4):279-85.

8. Scupi BS, Maser JD, Uhde TW. The Nati-onal Institute of Mental Health Panic Que-stionnaire. An instrument for assessing cli-nical characteristics of panic disorder. JNerv Ment Dis 1992; 180(9):566-72.

9. Weissman MM, Merikangas KR. The epi-demiology of anxiety and panic disorders:an update. J Clin Psychiatry 1986; 47Suppl:11-7.

10. Goodwin DR, Lipsitz DJ, Keyes K, GaleaS, Fyer AJ. Family history of alcohol usedisorders among adults with panic disor-der in community. J Psychiatr Res 2011;45:1123-7.

11. Rise B. Goldstein, PhD, MPH; Myrna M.Weissman, PhD; Phillip B. Adams, PhD; etal. Psychiatric disorders in relatives of pro-bands with panic disorder and/or majordepression. Arch Gen Psychiatry 1994;51(5):383-94.

12. Zvolensky MJ1, Raulin ML. Panic-Relatedfears in persons reporting a family historyof panic disorder. Anxiety Stress Coping1999; 12(4):351-62.

Milan LATASKlinika za psihijatriju, Klinicki centar SrbijePasterova 2, 11000 Beograd, SrbijaE-mail: latasm@eunet.rs

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Literatura: