SCI-PAS: structured clinical interview-panic agoraphobic spectrum

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Panic agoraphobic spectrum

BIOL. PSYCHIATRY 1997;42:15-2975

46. Panic agoraphobic spectrum

146-1 I articulate Co-morbidity, co-occurrence. or confusion: Can we a more coherent model for describing the complexity of psychiatric symptomatology? E. Frank, G.B. cassano, S. Michelin, M.K. Shear, E. Coli, J. Maser,

M. Mauri. University of Pittsburgh School of Medicine, Department of Psychiatry. Pittsburgh, USA, University of Piss. Institute of Psychiatry. Piss, Italy Various schemes have been proposed for the understanding and diagnostic description of patients who show evidence of more than one psychiatric disorder. None of these has been fully satisfactory and some appear to have led to more confusion than clarity. Grounded in many years of clinical experience with mood and anxiety disorders, clinical researchers working In the Institute of Psychiatry at the University of Plsa began to evolve a systematic approach to the assessment and treatment of patients based upon what they have called the Spectrum Model. Now, together with a group of U.S. consultants. they have elaborated this model, one that they believe fills the pronounced gap between clinical reality and the options provided by the official categorical nomenclatures of the DSM and ICD. The Spectrum Model and its associated assessment methods seek to capture the continuum between the core symptoms of each disorder and the associated aura of prodromal, atypical and subclin• Ical psychopathology. Along this continuum they include: 1) core atypical and subclinical symptoms of the primary Axis I disorder; 2) signs, iso• lated symptoms. symptom clusters and behavioral patterns related to the core symptoms that may either be prodromal, represent pre-cursors of a not-yet-fully-expressed condition or sequelae of a previously experienced full-fledged disorder; and 3) temperamental or personality traits. To further clarify how different symptoms (isolated or clustered) and psychopathological dimensions are related, they use the metaphor of a beam of white light, representing a DSM IV diathesis. When refracted by a prism, one can see a spectrum of component colors (symptoms. traits. signs. etc) that are clinically relevant. The metaphor emphasizes that such variable manifestations are derived from a common source. Acoording to the Spectrum Model. patients presenting an episode of depression with no other current Axis I diagnosis might differ greatly from one another depending upon whether they: a) showed no evidence of any spectrum condition other than mood, b) showed evidence of considerable panic spectrum symptomatology or c) showed evidence of considerable eating disorder spectrum symptomatology. Each of these possibilities would suggest a somewhat different approach to the treatment of the major depression and to the assessment of the extent to which that treatment had been successful, not only In bringing about a remission of the major depression but In alleviating the full range of distressing symptoms from which the patient suffers. We believe that the Spectrum approach has numerous clinical and didactic advantages including enhancing the patienfs sense of being understood by the clinician, Improved specificity of treatment selection and monitoring of treatment outcome, more sophisticated subtyplng of patients for clinical research and, finally, providing a superior method for teaching trainees the subtleties of psychiatric diagnosis.

146-21 questionnaire Panic-agoraphobic spectrum: From the Idea to the G.B. cassano, S. Michelini, M.K. Shear. E. Coli, J.D. Maser, E. Frank. Institute of Psychiatry. University of Piss. Italy ObJective.: Psychiatric classification, In spite of major advances In the past two decades, Is still a topic of considerable discussion and debate. The debate Involves categorical versus dimensional approaches, cut-off numbers of symptoms to define a case. the degree of Impairment. objective diagnostic criteria versus more theoretically based criteria, episodic versus tralto/ike symptoms, and the role of atypical and subclinical symptoms. All of these Issues have been raised for the anXiety disorders and depression (Klein, 1981, Roth. 1996). We present here a relatively novel and testable approach to the diagnosis and classification of psychiatric disorders called the Spectrum Model (cassano at ai, In press). The goal of this research

project Is to develop and test assessment Instruments that can be used 10 study the Spectrum Model, Its relationship to current diagnostic categorical classification and its usefulness in facilitating more focused consideration or treatment choices and a more complete evaluation of the patienfs quality or life. Specifically, the project Involves the development, psychometric testing, and validation of questionnaires conceived as complementary to categorical nosologies. At present, the panic-agoraphobic spectrum questionnaire Is the most fully developed. Preliminary results suggest the panie-agoraphobic spectrum Instrument we have designed is effective In capturing clinically relevant phenomena. Based on analyses of the data derived from a pilot study, the questionnaire has been further refined In a stnK:turecl Interview (Structured Interview for Panic-Agoraphobic Spectrum-SCI-PAS) and Is currently being tested in a large multi-center study. Method: Following the initial work of cassano. the authors began WOl1t on the empirical validation of the Spectrum Model. This work c:ommeneed with the development of a structured Interview to assess Panio-Agoraphobic Spectrum. The domains at panic-agoraphoblc spectrum evolved from clinical experience in Pisa and they Include typical and atypical panic sY"l?~ anxious expectation. phobic and avoidant features, reassurance orienta!JOr\ and sensitivity to substances, to general stress, and to separation. These domains, as wellss which symptoms that constitute them. must be subjected to formal and rigorous testing to confirm their validity. Conclusions: The Spectrum model of panic and agoraphobia Is a flexible and comprehensive means of describing this clinical complex. The prtlpo$ed model, complementary to the categorical approach. presumably expr&sses a unitary pathophysiology. Its usefulness is discussed in terms of its vaJue for the patient-therapist communication, outcome measures, identification of subtle personality traits, and sUbtyping of patients for research and treatment. References [1] Casino GB, Michelini S, Shear MK, Coil E, Maser JD, Frank E (1997.111 pt'MS): The Panic-Agoraphobic Spectrum: A Descriptive Approach 10 1I1e Assessment and T _ menl 01 Subtle Symptomatology. Am J Psychiatry. [2] K1e/n OF: Anxiety reconceplualized. In Klein OF. Rabkin JG (ads): Anxiety: , . . , . . S8II1Ch and Changing Concepts. New York, Raven Press, 1981. pp: 235-265. [3J Roth M (1996): The panic-agoraphobicsyndrome: a paradigm 011l1e anxiety group of disorder and lis impllcatJons lor psychlalr1c practice and 1heoIy. Am J Psychl&lIy 153 (7); 111-124. Festschrift Supplement.

146-31 SCI·PAS: structured clinical Interview-panic agoraphobic spectrum M. MaUri, E. Frank. G.B. Cassano, S. Michelini, L Dell'Ossa, M.K. Shear. E. Coli, J.D. Maser. University of Piss, Institute of Psychiatry. Piss, Italy , The Spectrum Model makes man~est and gives clinical weight to low severity and isolated symptoms co-occurrlng with a DSM diSorder. In order to accomplish the sssessment of spectrum phenomena in a systematic manner, we are developing specific semistructured clinical instruments. This presentation describes In detail, the Semistructured Clinical Interview tor Panic Agoraphobic Spectrum (SCI-PAS), along with some preliminary data related to reliability and validity. The Instrument Includes nine domains: (a) Typical panic symptoms: This section rates the occurrence of typicaj panic symptoms, which occur alone or In clusters ~imited 8yrTlptom episodes) of fewer symptoms than required for a panic attack. In agree. ment with the observation that limited symptom panic attacks may produce Impairment similar to that of full-blown attacks, we consider isolated panic symptoms, also to be clinically relevant. (b) Atypical panic symptoms: These are symptoms which sometimes ac• company panic but are not listed in DSM IV, such as unstable balance. sudden numbness. sense of disorientation, jelly legs. tiredness. transient loss of sight or hearing, hypersensitivity to noises, light, or heat, 8nci distress In the presence of an indefinite visual perspective such as may occur on a foggy day or opan sea or snowy flat landscapes. (c) Anxious expectation: This domain encompasses two SUbcategories; Il) anticipatory anxiety focused on the occurrence of typical or atypical panic symptoms, b) a persistent general state of alertness, 8SSOcialed with and a sense of Insecurity, Impotence or Impending menace Witf't respect to physical and psychic integrity. (d) Typical agoraphobia: Though agoraphobia and panic disorder are c0n• sidered Independent syndromes in DSM-IV, In clinical practice they are clearly related. (e) Other phobias: this domain encompasses four SUbcategories: SOCial phobias, illness phobia, fear and avoidance of medications, fear and avoidance of bad weather or the anticipation of natural disasters

Social phobia: Facts and controversies

(f) Reassurance orientation: Individuals canying the panic diathesis often rely upon reassurance from others as a means of coping with an overwhelming sense of insecurity and impotence. (g) Substance sensitivity: Sensitivity to chemicals and psychotropic medi• cations is a well described feature 01 panic disorder. (h) General stress sensitivity: the vulnerability of panic patients to stresslul r.le events. Panic symptoms may also occur in reaction to minor stressors ,uch as day-to-