Evidence for a general neurotic syndrome. Page 1 of 17http://spider.apa.org/ftdocs/ccp/1995/june/ccp633408.html 10/2/2000Diagnostic Comorbidity in Panic Disorder: Effect on Treatment Outcome and Course of Comorbid Diagnoses Following Treatment Timothy A. BrownCenter for Stress and Anxiety Disorders University at Albany, State University of New York Martin M. AntonyCenter for Stress and Anxiety Disorders University at Albany, State University of New York David H. BarlowCenter for Stress and Anxiety Disorders University at Albany, State University of New York ABSTRACTThe impact and course of additional diagnoses was examined in 126 patients undergoing cognitive—behavioral treatment for panic disorder. With the Anxiety Disorders Interview Schedule–Revised, a high comorbidity rate (51%) was observed at pretreatment. Pretreatment comorbidity was not predictive of premature termination, nor did it have a substantial impact on short-term treatment outcome. However, patients with comorbidity at posttreatment were more likely to have sought additional treatment over the follow-up interval. Although a significant and dramatic decline in the overall comorbidity rate was found at posttreatment (17%), at 24-month follow-up this rate had increased to a level (30.2%) that was no longer significantly different from pretreatment. This was despite the fact that patients maintained or improved on treatment gains for panic disorder over this interval. The implications of these findings for the treatment, conceptualization, and classification of emotional disorders are discussed. Portions of this article were presented in November 1992 at the 26th annual meeting of the Association for Advancement of Behavior Therapy, Boston, Massachusetts. Correspondence may be addressed to Timothy A. Brown, Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety Disorders, State University of New York at Albany, 1535 Western Avenue, Albany, New York, 12203. Received: May 23, 1994 Revised: September 12, 1994 Accepted: September 27, 1994 Studies published within the past 5 years indicate that the majority of patients presenting with an anxiety disorder (as diagnosed by the Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.; DSM—III—R; American Psychiatric Association, 1987 ]) have at least one additional disorder ( Brown & Barlow, 1992 ; de Ruiter, Rijken, Garssen, van Schaik, & Kraaimaat, 1989 ; Sanderson, Di Nardo, Rapee, & Barlow, 1990 ; cf. Maser & Cloninger, 1990 ). The high degree of comorbidity observed among anxiety disorders is partly attributable to the expansion of the DSM classification system over the past several decades. Whereas only three anxiety disorders existed in the second edition of the DSM ( DSM—II; American Psychiatric Association, 1968 ), there are 12 Journal of Consulting and Clinical Psychology © 1995 by the American Psychological Association June 1995 Vol. 63, No. 3, 408-418 For personal use only--not for distribution.Evidence for a general neurotic syndrome. Page 2 of 17http://spider.apa.org/ftdocs/ccp/1995/june/ccp633408.html 10/2/2000diagnostic categories for adults in the fourth edition of the DSM ( DSM—IV; American PsychiatricAssociation, 1994 ). Citing the high rates of comorbidity among the anxiety and mood disorders as one piece of supporting evidence, many researchers have raised the possibility that current classification systems such as the DSM and the International Classification of Diseases are erroneously distinguishing phenomena on the basis of differing manifestations of common pathophysiology (e.g., Andrews, in press ; Andrews, Stewart, Morris-Yates, Holt, & Henderson,1990 ; Hudson & Pope, 1990 ; Tyrer, 1989 ). Thus, whereas the rise in the number of diagnostic categories within these systems might imply greater precision in the organization and understanding of psychopathology, high rates of comorbidity may be indicative of nosologies that are artificially differentiating symptomatology that would be more parsimoniously merged. This issue was quite salient throughout the process of developing DSM—IV particularly for certain diagnoses such as generalized anxiety disorder (GAD; cf. Brown, Barlow, & Liebowitz, 1994 ). Although controversy remains regarding how classification should be approached, most researchers concede that these nosologies should be regarded more for their heuristic value rather than as a "final word" on the nature of mental disorders (cf. Brown, in press ; Maser, Kaelber, & Weise, 1991 ). An important indicator of the usefulness of a classification system is the extent to which it guides the selection of the optimal treatment ( Tyrer, 1989 ). In recent years, substantial advances have been achieved in the development and evaluation of successful psychosocial treatments for every anxiety disorder specified by the DSM—III—R (cf. Barlow, 1994 ; Brown, Hertz, & Barlow, 1992 ). These treatments typically contain therapeutic procedures that have been designed to address the specific features of the disorder ( Barlow, 1989 ). For example, an intervention of choice for blood—injection phobia includes applied muscle tension, a therapeutic component that is not found in treatments for other anxiety disorders, or other types of specific phobias ( Öst & Sterner, 1987 ). Treatments for panic disorder involve eliciting specific somatic sensations while attending to relevant cognitions ( Craske & Barlow, 1993 ). Nevertheless, cognitive—behavioral treatments for anxiety disorders possess many overlapping elements such as therapeutic exposure and the restructuring of cognitions pertaining to the overestimation of threat risk and catastrophic perceptions of the impact of feared events. These overlapping treatment components address features that are common to all anxiety disorders. Despite the significant strides taken in the documentation of effective treatments for anxiety disorders, relatively little research has been conducted on the role of comorbidity in treatment outcome. This lack of research can be attributed to such factors as (a) the infancy of many treatments for anxiety disorders, (b) failure to assess comorbid diagnoses, (c) use of comorbid diagnoses as study exclusion criteria, and (d) use of small sample sizes that prevent the examination of the impact of specific patterns of comorbidity ( Brown & Barlow, 1992 ). One important issue is whether the presence of certain comorbid diagnoses affects short-
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