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The widespread occurrence of psychiatric comorbidity among patients with generalized anxiety disorder (GAD) has been well documented. However, there is a paucity of studies examining the impact comorbid disorders have on the clinical course of GAD. In this study, 179 patients with GAD at intake, 12 patients with a past history of GAD, and 109 patients who subsequently onset a first episode of GAD during the course of follow-up were followed for 8 years in this naturalistic, prospective study of anxiety disorders. Results indicate that comorbid anxiety, mood, and substance use disorders are very common with GAD and increased during follow-up. For example, 39% of participants with GAD also had a comorbid diagnosis of major depressive disorder at intake and increased to 65% at 4 years and 74% at the 8-year follow-up. Inspection of "pure" cases of GAD indicated that out of 20 patients with GAD alone at intake, all but 1 went on to develop some comorbidity. Results also indicate that being in episode of comorbid MDD or panic disorder with agoraphobia decreased the probability that a subject would remit from their GAD. The findings highlight the need for such long-term, prospective research since results show that patients with GAD at intake had increasing risk for developing other mental disorders during subsequent follow-ups. Additionally, results of such high comorbidity and the impact of these comorbid disorders on the clinical course of GAD should have a notable impact on research into the treatment of GAD.

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While symptom status and social functioning have been observed to be correlated in many cross-sectional studies, little is known about the time course of change in functioning after a change in diagnostic status. Using data from a large longitudinal study of anxiety disorders, we present analyses of the time course of seven domains of social functioning up to 18 months before and after remission from panic disorder with or without agoraphobia. The effect of remission from panic disorder varies by domain. Four domains show a change in outcome, usually positive, after remission. The presence of major depressive disorder (MDD) affects the course of functioning for two domains. Generalized anxiety disorder (GAD) was observed to have effects on five of seven domains. For some domains there is improvement at approximately the same time as change in diagnostic status, although progressive change was seen in others. The amount of improvement was modest on average, indicating that other factors beyond panic symptoms may limit post-remission improvement in social functioning.

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OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.

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The Longitudinal Interval Follow-up Evaluation (LIFE), has been shown to be a valid and reliable instrument for characterizing the week-by-week course of anxiety disorders examined retrospectively over the period of 1 year. Due to the chronic nature of these disorders, there is a need for reliable, valid instruments for measuring course over periods of several years if we are to learn more about the natural history of these disorders. This paper describes a rater-monitoring program designed to ensure long-term inter-rater reliability and prevent "rater drift". In this program, clinical interviewers score taped interviews and are required to maintain a median intra-class correlation coefficient (ICC) of at least 0.80 with the other raters. Raters also assess tapes from previous years, to ensure that they are using the same diagnostic criteria as earlier generations of interviewers. A reliability study was conducted to compare psychiatric status ratings (PSRs) collected using biweekly telephone interviews with the semi-annual interviews. The ICCs for panic, agoraphobia, social phobia, and generalized anxiety disorder were very good to excellent. Another reliability study examined the PSRs of subjects who had been previously lost to follow-up. ICCs for panic, agoraphobia, generalized anxiety disorder and depression were good to excellent. These results show that the LIFE, when used in conjunction with an intensive training and rater monitoring system, is a reliable instrument for use in longitudinal studies of the course of anxiety disorders.

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Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.

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OBJECTIVE: Social phobia is a chronic disorder with a higher prevalence among women than men. Data from an eight-year longitudinal study were analyzed to investigate the course of social phobia and to explore potential sex differences in the course and characteristics of the illness. METHODS: Data were analyzed from the Harvard/Brown Anxiety Research Program, a naturalistic, observational study begun in 1989 in which patients with social phobia are assessed every six to 12 months. Treatment was observed but not prescribed by the program personnel. Data on comorbidity, remission, and health-related quality of life were collected for 176 patients with social phobia. RESULTS: Only 38 percent of women and 32 percent of men experienced a complete remission during the eight-year study period, a difference that was not significant. A larger proportion of women than men had the generalized form of social phobia, although the difference was not significant. Women were more likely to have concurrent agoraphobia, and men had a higher rate of comorbid substance use disorders. Social phobia had a more chronic course among women who had low Global Assessment of Functioning scores and a history of suicide attempts at baseline than among men who had these characteristics. Health-related quality of life was similar for both men and women, except that women were slightly but significantly more impaired in household functioning. CONCLUSIONS: The chronicity of social phobia was striking for both men and women. Although remission rates did not differ significantly between men and women, clinicians should be alert to the fact that women with poor baseline functioning and a history of suicide attempts have the greatest chronicity of illness.

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The first year of a twin study undertaken between two occupational therapy programs in Canada and New Zealand is described. The primary aims of the study were to illuminate the lived experiences of students as they learn about cultural difference and had contact with clients of differing cultural backgrounds to themselves during fieldwork placements. While there are similarities between educational programs and the demographic profiles of the two cohorts of students, there are curricular differences primarily based on the described socio-political content of the two countries; Aotearoa/New Zealand as a bicultural society and Canada as multicultural. The paper discusses how these cultural differences interweave with other aspects of the students' educational program, as perceived and experienced by the students. Narrative data was thematically analyzed to reflect the experiences and the attendant thoughts and feelings of the participants.

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The relationship between co-occurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. This article describes findings for 622 participants in the Harvard/Brown Anxiety Research Project, a longitudinal follow-up study of DSM-III-R-defined anxiety disorders. A total of 24% of participants had at least one personality disorder, with avoidant, obsessive compulsive, dependent, and borderline most common. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated. Major depression was associated in particular with dependent, borderline, histrionic, and obsessive compulsive personality disorders and social phobia was associated with avoidant personality disorder. Whereas some of our findings confirm results from earlier studies, others are somewhat inconsistent with previous results and indicate the need for further investigation.

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OBJECTIVE: Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. METHOD: Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. RESULTS: Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. CONCLUSIONS: These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.

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As part of the Metropolis project--a large-scale investigation of immigration and integration, including well-being of immigrants in a number of areas of social life--in this paper we investigate the social determinants of health in Canada's immigrant population using Canada's National Population Health Survey (NPHS). Specifically, we examine differences in health status and health care utilization between immigrants and non-immigrants, immigrants of European and non-European origin, and immigrants of < 10 years and > 10 years' residence in Canada. We also examine social determinants of health care utilization and health status in immigrants and non-immigrants, and evaluate the utility of large-scale, national databases for these purposes. Our conceptual approach draws upon a 'population health' perspective, which suggests that the most important antecedents of human health status are not medical care inputs and health behaviours (smoking, diet, exercise, etc.), but rather social and economic characteristics of individuals and populations. We find no obvious, consistent pattern of association between socio-economic characteristics and immigration characteristics on the one hand, and health status on the other, in the NPHS data. This does not mean that socio-economic factors in Canada are not influential in shaping immigrants' health status. In fact, the results of the logistic regression models calculated for immigrants and non-immigrants on four outcome variables in this study suggest that socio-economic factors are more important for immigrants than non-immigrants, although in ways that defy a simple explanation. The complexity of immigrants' experiences, combined with the inherent limitations of cross-sectional survey data are discussed as major limitations to this kind of research.

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BACKGROUND: Cross-sectional data show that generalised anxiety disorder (GAD) is a chronic condition with episodes lasting much longer than the six-month minimum required by DSM-III-R and DSM-IV. Although GAD is chronic, little is known about factors influencing illness duration. AIMS: To investigate variables that influence the clinical course of GAD. METHOD: A total of 167 patients with GAD participated in the Harvard-Brown Anxiety Research Program. Patients were assessed at intake and re-examined at six- to twelve-month intervals for five years. Kaplan-Meier curves were constructed to assess the likelihood of remission. Regression analysis was used to investigate factors predicting full or partial remission. RESULTS: The rate of remission was 0.38 after five years. Diminished likelihood of remission was associated with low overall life satisfaction, poor spousal or family relationships, a concurrent cluster B or C personality disorder and a low global assessment score. CONCLUSIONS: Full or partial remissions were less likely to occur in patients with poor relationships and personality disorders. These patients should be given more intensive and possibly multi-modal therapy.

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This paper examines employment issues for women diagnosed with multiple sclerosis (MS) and their workplace experiences, focusing analysis on the social and institutional dimensions of the environment. The analysis draws on data from a mixed method study using in-depth interviews and a survey. The findings indicate that although severity of symptoms affect employment status, non-medical factors, including modification of work conditions and understanding employers, and a supportive home environment with the possibility of delegating household tasks, can enhance women's ability to work. The specific focus in the paper on the experiences of women managing their disability in the workplace, from the qualitative phase of the study, acts as an analytic device to illustrate how context influences the way in which such factors play out. In high-lighting the issue of disclosure of diagnosis, and associated identity and income concerns for women, the paper demonstrates the importance of the social and institutional dimensions of environment in shaping occupational performance. The findings suggest that inclusion of environmental analysis in clinical practice broadens the range of intervention strategies to be considered and raises the issue of occupational therapists' role in advocacy.

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Systematic studies of course of illness in obsessive-compulsive disorder (OCD) using standardized diagnostic criteria are relatively rare. In the present study, 100 patients diagnosed with OCD were prospectively followed for up to 5 years. Other comorbid conditions included anxiety disorders (76%), major depressive disorder (33%), and at least one personality disorder (33%), mainly in the anxious cluster. Approximately 20% of patients had full remission and 50% had partial remission during follow-up. Significant predictors of partial remission included being married and having lower global severity scores at intake; the presence of major depression was marginally predictive of poorer course. Adequate serotonergic medication was associated with worse course, but findings are likely spurious. Only marital status and global severity were retained as predictors in a final regression model. Findings are discussed with regard to sample characteristics and similarity to other reports on predictors of course and of treatment outcome.

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The purpose of this study was to examine the relationship of subtypes and particular clinical features of mood disorders to co-occurrence with specific personality disorders. Five hundred and seventy-one subjects recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Percent co-occurrence rates for current and lifetime mood disorders with personality disorders were calculated. Logistic regression analyses examined the effects of clinical characteristics of depressive disorders (e.g., age at onset, recurrence, symptom severity, double depression, and atypical features) on personality disorder co-occurrence. In comparison with other DSM-IV personality disorders, avoidant, borderline, and dependent personality disorders (PDs) were most specifically associated with mood disorders, particularly depressive disorders. Severity and recurrence of major depressive disorder and comorbid dysthymic disorder predicted co-occurrence with borderline and to a lesser extent research criteria depressive personality disorders. The results are consistent with the view that a mood disorder with an insidious onset and recurrence, chronicity, and progression in severity leads to a personality disorder diagnosis in young adults.

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This paper discusses the microgeographies of unemployed women with multiple sclerosis, as they manage the physical, social and economic consequences of their illness. Recent directions in the geography of health and health care draw attention to the relationships between space, place and health experience, and in this paper a focus on the everyday lives of women with Multiple Sclerosis reveals the complex interweaving of space, physical impairment and gender in how they experience place. In-depth interviews were used in the study to investigate how women occupied and used home and neighbourhood space after leaving the paid labour force. The majority of women were found to experience shrinking social and geographical worlds which rendered their lives increasingly hidden from view as patterns of social interaction changed and use of public space diminished. The paper discusses the women's residential and household changes, mediated by marital and socio-economic status, and presents two brief case studies to illustrate the remapping of the meanings of work and place as women renegotiate their lifeworlds. The focus of the study on the spatio-temporal settings of the women's everyday lives revealed an interplay of biomedical discourse, policy structures, sociocultural norms and local sets of social relations that shaped the strategies the women used in reconstructing their lives. The women showed a diversity of responses, but these were all characterized by a restructuring of home and neighbourhood space, a reordering of personal relationships and increasing interpenetration of the public sphere in their private lives. The findings suggest that attention to the body in its geographical as well as social context provides an avenue for investigating the links between subjective experience and the broader social relations and processes which shape the illness experience.

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Recently there has been increasing interest in the relationship of the personality and the anxiety disorders. This paper presents comorbidity findings between DSM-III-R personality pathology and several DSM-III-R anxiety disorders and makes direct comparisons between anxiety groups. This is the most extensive comparison of this kind reported thus far. This report is on the first 475 anxiety patients who were recruited from multiple sites to take part in a naturalistic study of anxiety. All had a DSM-III-R diagnosis of panic, agoraphobia, social phobia, or generalized anxiety disorder (GAD). Previous studies which found a high comorbidity between the anxiety and the personality pathology were confirmed, with a significantly higher prevalence of personality pathology occurring with social phobia and GAD. Among our patients, all of whom had anxiety disorders, the presence of comorbid major depression is associated with an increase in the levels of comorbid personality pathology--as previously described in the literature. The relationship between low social functioning and the presence of personality pathology was confirmed, however, the relationship appears to be specific to certain areas of functioning, a new finding. There is a clinically important relationship between Personality Diagnostic Questionnaire--Revised personality pathology and the anxiety disorders characterized by different prevalences of personality disorders in different anxiety disorders and specific areas of social dysfunction.

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Principles of occupational therapy practice make the profession an important potential partner in health promotion initiatives for immigrant groups. Health promotion embodies the principles of self-definition of health needs by target groups, and working with a community in initiating and supporting programmes. This paper discusses the implications of an exploratory study of the daily activities of immigrant Indo-Canadian mothers for translating health promotion principles into practice. The research process and an analysis of interviews conducted with the women suggest factors to consider in using a health promotion framework with immigrants who have experienced social and economic dislocation through the immigration process. Discussion of household structure, divisions of labour, childcare strategies, and parenting concerns raises issues requiring particular attention in sharing occupational therapy skills and knowledge with ethnocultural communities.

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As occupational therapists increasingly encounter a multicultural clientele, there is growing interest in the influence of a person's culture on his or her interactions with the environment. This paper presents a case study of a Chinese-Canadian immigrant woman with rheumatoid arthritis. The case study illustrates how the subject's family, community networks, and workplace, coupled with the occupational therapy clinical setting, intermingled to shape the daily management of her illness. The case material focuses on the subject's acquisition and use of different types of health care knowledge as she responds to her illness. It shows that the subject's experiences and management decisions about her health are closely linked to the material and social conditions of her life as a working-class immigrant woman. This article suggests that attention needs to be paid to the broader systems of the environment in understanding the responses of immigrant women to occupational therapy, rather than on the cultural distinctiveness of the clients.

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