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Gender effects and alcohol use in panic disorder with agoraphobia
B&u. Rcs. Thu. Vol. 31. No. 4. pp. 4lWl6, Printed in Great Britain. All rights reserved
1993 Copyright
ooos-7967193 56.00 + 0.00 Q 1993 Pergamon Press Ltd
Gender effects and alcohol use in panic disorder with agoraphobia BRIAN J. COX,‘~*RICHARD P. SWINSON, I.’ IAN D. SHIJLMAN.’ KLAUS KucH’-’ and JAAK T. REICHMAN’ ‘Anxiety Dirorders Clinic, Clarke Institute of Psychiatry, 250 College St, Toronto, Ontario, Canada. M.5T lR8; zDepartment of Psychology. York University, Toronto, Cana&; and, ‘Department of Psychiatry, University of Toronto, Toronto, Can& (Received
14 May 1992)
Snnnnary-Previous studies have found some significant, but weak, gender dilTerenas in panic and agoraphobia with females generally being more symptomatic. The present study sought to expand this line of research by examining alcohol use and self-medication in relation to gender differences and measures of psychopathology. Seventy-four male and 162 female patients with panic disorder with agoraphobia were compared. There were some significant, but relatively small. gender differences with females reporting higher levels of phobic avoidance. Males reported significantly more weekly alcohol intake and also perceived alcohol to be a more effective strategy in coping with anxiety. Alcohol-related factors were significantly correlated with several measures of psychopathology for males but this was less evident in females. The correlations were not large but the results do suggest that a subset of males consume moderate to large amounts of alcohol, believe self-medication to be an effective anti-anxiety strategy, and yet report higher levels of psychopathology such as social fears.
INTRODUCTION There are few published studies that have directly investigated gender differences in agoraphobia (Chambless & Mason, 1986; Hafner. 1981: Mavissakalian. 1985: Qei. Wanstall & Evans. 1990). This nealcct is all the more sururisina Riven the number of studies that have been published over the past decade on panic and agiraphobia. As Qci et a/.~(l99~)correctly point out, there appears to be an assumption that gender differences are minimal in this area and are thus not explored in most studies. Data from the few studies available suggest that there are some statistically significant, albeit weak, differences between males and females, and these findings warrant further investigation. Further, there are several clinically meaningful variables such as alcohol use which have not been addressed in these studies. Hafner (1981) published the first systematic study that directly investigated gender differences in agoraphobia. Only 20 male and 20 female subjects were used in the analysis but they were matched for age and marital status. The study did not employ DSM-III (APA, 1980) diagnostic criteria and the prevalence of panic attacks was not reported. Very few gender differences emerged. Males were found to score significantly higher on some items reflecting fears of somatic symptoms. These few significant dilferences were not large and may have been the result of Type 1 error, however. as there were 55 comparisons made on the Fear Survey Schedule (FSS; Wolpc % Lang, 1964) using only 40 Ss. Similar results on the FSS were obtained in a sample of 104 females and 37 males with various anxiety disorders (fhyer. Tomlin, Curtis, Cameron & Nesse, 1985). Mavissakalian (1985) compared 10 males and 52 females with a DSM-III diagnosis of agoraphobia with panic on several self-report measures of personality and psychopathology. There were no significant differences on any of the personality dimensions. The only main finding was that males had significantly higher agoraphobia scores from the Fear Questionnaire (FQ; Marks & Mathews, 1979) following exposure therapy, compared to females. There are only two studies that have used a large sample of Ss with DSM-III agoraphobia with panic attacks. Chambless and Mason (1986) found few gender dilferenccs on a number of measures of personality and psychopathology. Females were more symptomatic on some measures but the effects were small. Both male and female agoraphobics scored lower on a measure of masculinity compared to a normative sample and masculinity scores were negatively correlated with some measures of psychopathology. Qei et al. (1990) compared 68 males and 204 females diagnosed with DSM-III agoraphobia with panic attacks on xveral measures of psychopathology and personality. Unlike findings from most previous studies. females scored significantly higher on the FSS total score compared to males and also had significantly higher levels of clinician-rated anxious and depressed mood. Males and females did not differ significantly in age of onset, panic symptomatology or agoraphobic avoidance. Most of the differences between males and females were not large and the authors concluded that there were no real gender differences. A similar pattern of results has been observed in community-based studies of panic and agoraphobia (Bourdon ef al.. 1988; Macaulay and Kleinknecht. 1989; Norton. Dorward & Cox. 1986). Females have been found to report higher severity ratings of some panic and agoraphobic symptoms compared to males. In general, however, the differences have been few and small. One potentially important set of variables that has not been fully explored in relation to gender differences concerns that of alcohol use and self-medication in panic disorder with agoraphobia. There has been recent interest in examining the effects of alcohol on anxiety and the comorbidity of the two conditions (for reviews set Cox. Norton, Swinson & Endler, 1990; Kushner. Sher & Bcitman, 1990; Linnoila, 1989; Weissman. 1988). The data suggest that alcohol and anxiety problems frequently co-exist and the majority of alcoholic patients with panic and agoraphobia believe self-medication to be effective, despite evidence that they frequently have a more serious clinical condition compared to patients with only one of the conditions (Cox et al., 1990). The vast majority of alcoholic Ss studied have been males, however, and gender differences *Address
for correspondence. 413
414
CASE HlSTORIES AhW SHORER COhiWt,‘NICAllONS
have not been adequately examined. Haflam (1978) originaily h~o~hesiz~ that elf-m~i~tion via alcohol may be the male agoraphobic’s version of the staying-at-home strategy used by females. If this is true, there should be a different pattern of alcohol use and self-medication in males and females. The purpose of the present study was therefore to investigate gender differences in a relatively large sample of PDA patients. This study sought to replicate previous fmdings and investigate new variables related to alcohol.
METHOD Subjects
The sample consisted of 236 outpatients with a DSM-III-R (APA, 1987) diagnosis of panic disorder with agoraphobia. There were 74 males (mean age = 35.50, SD = 10.48) and 162 females (mean age = 34.39, SD = 10.62). The two groups did not significantly differ in age. Materials
and procedures
AI1 patients had presented to an anxiety disorders clinic and had provided written consent to use the ~ychomet~c information they provided for research purposes. All patients completed a questionnaire fo assess alcohol use and coping efficacy. These questions were introduced in our intake questionnaire in 1987. Patients are asked to indicate the amount of alcohol they consumed per week and the efficacy of ‘having an alcoholic drink’ and ‘taking medication’ for coping with anxiety where I = not at all and 5 = completely. Alcohol consumption was converted to ounces where 1 ounce 5 one beer or one glass of wine. Patients were also asked to estimate the age of their first severe anxiety attack and how successful they though they would be at controlling their next panic attack when? 0 = not at all and 10 = completely. All patients were asked to complete the Fear Questionnaire (FQ; Marks & Mathews, 1979) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961). In recent years two more self-report measures have been added to our database. Consequently, 75% of !he patients were also asked to complete the slate form of the State-Trait Anxiety Inventory (STAI-S; Spielberger. Gorsuch & Lushene, 1970) and approx. 50% were asked to complete the Anxiety Sensitivity index (ASI; Peterson & Reiss, 1987). Patients were diagnosed by either a psychiatrist, psychology intern or psychiatric resident using DSM-III-R criteria. Approximately 90% of the diagnoses were made by experienced psychiatrists. Approximately 25% of the interviews were conducted using the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams & Gibbon, 1988); the remainder were I hr interviews based on the SCID. Of the 146 females and 72 mates on whom medication information was available, 78% of the males and 71% of the females were taking anti-anxiety medication (mostly ~nzodiazepines) at the time of assessment, a difference that was not significant. Patients were excluded if they had a diagnosis of aicahol dependence, but this comorbidity was very rare (< IO%). RFSULTS Gender effects
Table I presents the results of comparisons between males and females on the main variables of interest. There were several significant differences on the psychometric measures, with females reporting higher levels than mules, but in general the direrences were not large (t-values ~4.0). Compared to females, males reported a significantly higher intake of alcohol per week and also rated self-medication with alcohol to be more effective. Tables 2 and 3 present the pattern of correlations between self-reports of psychopathology and alcohol-related variables separately for males and females. There appears to be a different pattern of correlations for the two sexes. For males, several measures of psychopathology such as social fears and anxiety sensitivity were significantly and positively correlated with alcohol intake and perceived efficacy of self-medication. This pattern did not emerge in females, and in fact the opposite appeared true. State anxiety was signjficantly and negatively correlated with alcohol intake. Although there were several significant correlations in both the male and female samples, most of them were not large.
Table 1. Comparisons between male and female PDA patients Malts Variable Ounces of akohol/wk Efficacy rating for alcohol Efficacy rating for medication
Fcmalcs M
SD
r-value
P-WlW
162
3.77
8.43
3.02
0.003*
1.44
162
I .65
1.1 I
3.73
0.001’
n
M
SD
n
74
12.43
23.97
74
2.35
69
3.09
1.15
147
3.12
I .36
0.15
NS
Age of panic attack onsc~
74
25.39
13.84
162
29.02
19.41
1.64
NS
Ability to control next attack FQ-Agor FQ-SK FQ-Bl BDf STAI-S ASI
72 74 74 74 71 37 41
3.33 13.38 II.Jf 9.97 16.58 52.02 36.66
2.08 9.59 8.03 7.97 10.23 14.03 13.46
IS4 159 IS9 IS9 151 124 78
3.1 I 17.40 15.49 12.95 19.03 51.40 37.09
I.81 10.64 8.53 8.80 10.19 12.93 II.38
0.82 2.77 3.47 2.47 I .67 0.29 0.18
NS 0.006 0.001* 0.02 0.10 NS NS
FQ = Fear Questionnaire (Agoraphobia. Social Phobia. Blood and Injury Phobia): BDI = Beck Depression Inventory: STAI-S = State-Trait Anxiety Inventory-State form; ASI = Anxiety Sensitwity Index. ‘Considered significant with Bonferroni-ty~ correction for multiple comparisons.
CASE HISTORIES AND
Table
2. Correlations
between
Alcohol use Alcohol
-
use (ounccs/wk)
Perceived
ctiicacy
of alcohol
SHORTER
alcohol
variables
and self-report
measures
FQ-~
FQ-BI
ASI
0.10
0.25’
0.19
0.36’
0.02
0.22
(n = 74)
(n =41)
(n = 71)
(‘1 = 57)
‘“o;2:“)
(n = 74)
(II = 74)
(n = 74)
0.36”
(n = 74)
415
FQ-Ag
0.45..
use
COMMUNlCATlONS
0.03 (n =4l)
in males
BDI
0.39.
0.12
(n = 41)
(n =7l)
STAN
0.03 (n = 57)
lP < 0.05. l*P < 0.01.
Eficts
of alcohol use and self-medication
in males
Because alcohol frequency and perceived efficacy appeared to have differential effects in males and females, high vs low alcohol use and efficacy were examined further in each gender. To compare high and low alcohol use in males, the sample was divided using a median split procedure (median ounces per week = 4.0). The high alcohol use group (n = 36, mean ounces per week = 24.83, SD = 29.82) and low alcohol use groups (n = 38, mean ounces per week = 0.68, SD = 1.21) did not significantly differ on the age of the first panic attack, social fears, depressed or anxious mood, anxiety sensitivity or the perceived ability to control the next panic attack. The high alcohol use group rated alcohol to be a more efficacious coping strategy (M = 3.14, SD = 1.33) compared to the low alcohol use group (M = 1.61, SD = 1.10). a difference that was significant, r(72) = 5.40, P < 0.001. The two groups did not significantly differ in their efficacy ratings for taking medication. Finally, the high alcohol use group reported a higher level of agoraphobic fears on the FQ (M = 15.61, SD = 9.83) compared to the low alcohol use group (M = 11.26, SD = 8.97). a difference that was significant, f(72) = 1.99. P = 0.05. To compare high and low levels of perceived efficacy of alcohol in males, the Ss were divided into two groups based on their alcohol efficacy ratings on the S-point scale. The low efficacy group was defined as the 33 Ss who indicated I (not at all) and the high efficacy group consisted of the 20 Ss who responded with 4 (a lot) or 5 (completely). The two groups did not significantly differ on the reported age of the first panic attack, agoraphobic fears, depressed or anxious mood, or on the perceived ability to control the next panic attack. The high efficacy group reported a higher weekly alcohol intake (M = 28.95 ounces, SD = 37.85) compared to the low efficacy group (M = 2.36 ounces, SD = 4.26). a difference that was significant, r(SI) = 3.13. P < 0.006. The high ellicacy group reported a higher level of social fears on the FQ (M = 14.95, SD = 8.17) compared to the low enicacy group (M = 9.00. SD = 7.31). a difference that was significant, r(5I) = 2.75, P < 0.01. The high efficacy group also rcportcd a significantly higher level of anxiety sensitivity (M = 43.14, SD = I I .84) compared to the low eflicacy group (M = 29.69, SD = 13.99). a dilTcrencc that was signilicant. r(28) = 2.82, P < 0.01. Finally, the high alcohol efficacy group rcportcd a higher ellicacy level for taking medication (M = 3.71. SD = 0.69) compared to the low efficacy group (M = 2.81. SD = 1.26). a difference that was significant, f(47) = 3.22, P <0.003.
Because of the low r;lte of weekly alcohol use in females the median value was 0. Therefore, a median split procedure on alcohol USCcould not be performed. The same procedure for selecting high vs low perceived efficacy of alcohol used in the male sample was performed in the fcmalc sample. The I8 high efficacy and 109 low efficacy groups did not significantly differ on agoraphobic fears, depressed or anxious mood, anxiety sensitivity or the perceived ability to control the next panic attack. The high eficacy group reported a higher weekly alcohol intake (M = 12.50 ounces, SD = 17.00) compared IO the low efficacy group (M = 1.75, SD = 5.30). a difference that was significant. r(l25) = 2.66, P c 0.02. The high efficacy group also reported a higher level of social fears from the FQ (M = 20.06, SD = 9.45) compared to the low cllicacy group (M = 14.55, SD = 7.96). a ditference that was significant, f(l23) = 2.64, P < 0.01. Finally, the high efficacy group reported an earlier age of panic onset (M = 20.06. SD = 6.08) compared IO the low efficacy group (M = 29.35, SD = 19.20), a difference that was significant, f(l25) = 3.99. P < 0.001. DISCUSSION
Male and female PDA patients significantly differed in only two areas in this study: phobic avoidance and alcohol use and efficacy. The two groups did not difier on age of panic onset, perceived controllability and depressed or anxious mood. The finding that females reported higher levels of various fears is consistent with the results of some previous studies (e.g. Oei ef ul., 1990) although these differences were not large and do not explain a great deal of variance. The results from the present study suggest that there are also several diferences between males and females on alcohol-related factors. Males were found to report more alcohol use and to view alcohol use as an effective strategy for coping with anxiety problems compared to females, although gender effects explain little of the variance in alcohol consumption scores. In males alcohol use and the perceived efficacy of alcohol were found to be significantly correlated with social fears and anxiety sensitivity. The results suggest that there may be two patterns of self-medication in male patients: coping with feared social situations and dampening feared physical symptoms. Ironically. those male patients who had the highest elficacy ratings for alcohol did not have higher ratings on the perceived ability to control their next panic attack compared to malts with
Table
3. Correlations
bcrwcen
Alcohol Alcohol
-
use (ounccsjwk)
Perceived
efficacy
of alcohol
ux
9-p
< 0.01
alcohol
variables
and self-report
FQ-Ag
FQ-Sot
FQ-BI
0.00
-0.04
-0.07
measures ASI -0.21
in fcmalcs BDI - 0.02
STAI-S -0.21
(“;;z”)
(n ==I,‘~)
(n =&9)
(n =7X) 0.00
(n = 151) 0.07
(n = 124) -0.02
(n=I59)
(n=l59)
(n=l59)
(n=78)
(n=ISI)
(n=l24)
0.44.’ (n=l62)
lP < 0.05.
USC
416
CASE HLSTORl.ES A?JD SHORTER COUUUNICATlONS
low alcohol efficacy ratings. Similarly. continued aicohol use may actually exaarbate the physical symptoms that these patients fear (i.e. anxiety sensitivity). Again it should be noted that some of these significant differences were not large ones and some would not be considered significant with a Bonferroni-type correction. This pattern of results was less evident in females and may be due to the low rates of reported alcohol use. Although females with high alcohol use and efficacy ratings were infrequentiy found. these patients, like their male counterparts, also reported more social fears. In general. the patients in our sample appear to consume more alcohol on average than individuals from the same geographical background. The Addiction Research Foundation of Toronto sponsored a survey (Adlaf and Smart, 1989) of I100 community-dwelling residents in Ontario, On average, males reported drinking 1.90 times per week and females reported drinking 1.08 times per week. Approximately 55% of Ss reported drinking five or more drinks at a single sitting in the past year and only 10% reported this pattern of heavy drinking in the past week. AIthou~ ounces of alcohol per week was not examined in the survey. the statistics available suggesta more conservative pattern of drinking in the general population. The average weekly alcohol consumption in the anxiety disorder sample was 12.4 ounces for males and 3.8 ounces for females using a conservative coding system. Although there was a great range in reported alcohol consumption, it appears that Ss in the anxiety disorder sample, particularly the males, consume more alcohol per week compared to non-anxious individuaIs from the community. Most of the alcohol psychopathology correlations in the male and female samples were not large, however, and the results do await replication. These findings suggest that a subset of male PDA patients may be prone to consume moderate to large amounts of alcohol in the belief that it is an effective coping strategy despite their long-term evidence to the contrary. Finally, these type of male patients also reported higher efficacy ratings for taking medication and may be prone to abuse benzodiazepines. REFERLNCES Adlaf, E. M. & Smart, R. G. (1989). The Ontario Adult Alcohol and Other Drug Use Survey 1977-1989. Toronto, ON: Addiction Research Foundation of Ontario. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd Edn). Washington, DC: American Psychiatric Association. American Psychiatric Association (1987). Diu(mostic and statistical munuuf of mentul disorders (3rd Edn-Revised). Washington. DC: American Psychiatric Association. Beck. A. T., Ward. C. H.. Mcndclson, M., Mock, J. & Erbaugh, J. (1961). An inventory for measuring depression. Arc&es aj ec#cru’ P.r_rc&t,f~. 4f. 56 i -57I. Bourdon, K. H., Boyd, J. Ff.. Rae, D. S., Burns, B. 3.. Thompson, J. W. & Locke, B. Z. (1988). Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 2, 227-241. Chamblcss. D. L. & Mason, J. (1986). Sex, sex-role stereotyping and agoraphobia. Bchaviuur Reseurch und Thcrupy, 24, 23 I -235. COX. B. 1.. Norton. G. R., Swinson, R. P. & Endler, N. S. (1990). Substance abuse and panic-related anxiety: a critical review. Behuviunr Rescwch und Therupy. 28. 385-393. Hafncr, R. J. (1981). Agoraphobia in mtn. Australiun und New Zeulund Jaurnai of Psychiatry, IS, 243-249. Hallam, R. S. (1978). Agoraphobia: a critical review of the concept. Bririslr Journul a/Psychiutry, 133, 314-319. Kushncr, M. G.. Shcr. K. J. & Bcitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. American Jaurnaf of Psychiatry, f47. 685-695. Linnoila. M. I. (1989). Anxiety and alcohol. Journaf of Cfinfcul Psychiatry, fU(SuppL), 26-29. Macaulay, J. L. & Kleinknecht, R. A. (1989). Panic and panic attacks in adolescents. Journ& oJAnriu/y Disurder.~. 3. 221-241. Marks, 1. M. & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Reswrch wd Therapy, I7, 263-267. Maviss~ka~jan, M. (l985}. Male and female agoraphobia: are they different? ~ehuvjaur Reseurch and Therup~y, 23, 469471. Norton, G. R., Donvard. I. & Cox. B. J. (1986). Factors associated with panic attacks in nonclinical subjects, Behuvior Therapy, 17, 239-252. Oei, T. P. S., Wanstall, K. & Evans, L. (1990). Sex difTerences in panic disorder with agoraphobia, Jorrrnol of Anxiety Disorders, 4, 3 17-324. Peterson, R. A. & Reiss, S. (1987). An.rier~ Sensirivity Index munucd. Pales Heights, IL: International Diagnostic Systems. Spielberger. C. D., Gorsuch, R. L. & Lushene, R. E. (1970). Munuaffar rhe State-Truit Anxiety fmentary. Palo Aho. CA: Consulting Psychologists Press. Spifzer, R. L., Williams, J. B. W. & Gibbon, M. (1988). Structured Clinicuf Interview/or DSM-//f-R. Biometrics Research Department, New York State Psychiatric Institute. Thyer, B. A., Tomlin, P.. Curtis, G. C., Cameron, 0. G. & Nesse, R. (1985). Diagnostic and gender dini-rcnces in the expressed fears of anxious patients. Journal of Behuvior Therapy and Experimental Psychiutry. 16, II l-t 15. Weissman, M. (1988). Anxiety and alcoholism. Journul OJ Clinicof Psychiatry, 49(Suppl.), 17-19. Wolpe, J. & Lang. P. J. (1964). A fear survey schedule for use in behavior therapy. Behouiour Reseurch und Therapy. 2, 27-30.
1993 Copyright
ooos-7967193 56.00 + 0.00 Q 1993 Pergamon Press Ltd
Gender effects and alcohol use in panic disorder with agoraphobia BRIAN J. COX,‘~*RICHARD P. SWINSON, I.’ IAN D. SHIJLMAN.’ KLAUS KucH’-’ and JAAK T. REICHMAN’ ‘Anxiety Dirorders Clinic, Clarke Institute of Psychiatry, 250 College St, Toronto, Ontario, Canada. M.5T lR8; zDepartment of Psychology. York University, Toronto, Cana&; and, ‘Department of Psychiatry, University of Toronto, Toronto, Can& (Received
14 May 1992)
Snnnnary-Previous studies have found some significant, but weak, gender dilTerenas in panic and agoraphobia with females generally being more symptomatic. The present study sought to expand this line of research by examining alcohol use and self-medication in relation to gender differences and measures of psychopathology. Seventy-four male and 162 female patients with panic disorder with agoraphobia were compared. There were some significant, but relatively small. gender differences with females reporting higher levels of phobic avoidance. Males reported significantly more weekly alcohol intake and also perceived alcohol to be a more effective strategy in coping with anxiety. Alcohol-related factors were significantly correlated with several measures of psychopathology for males but this was less evident in females. The correlations were not large but the results do suggest that a subset of males consume moderate to large amounts of alcohol, believe self-medication to be an effective anti-anxiety strategy, and yet report higher levels of psychopathology such as social fears.
INTRODUCTION There are few published studies that have directly investigated gender differences in agoraphobia (Chambless & Mason, 1986; Hafner. 1981: Mavissakalian. 1985: Qei. Wanstall & Evans. 1990). This nealcct is all the more sururisina Riven the number of studies that have been published over the past decade on panic and agiraphobia. As Qci et a/.~(l99~)correctly point out, there appears to be an assumption that gender differences are minimal in this area and are thus not explored in most studies. Data from the few studies available suggest that there are some statistically significant, albeit weak, differences between males and females, and these findings warrant further investigation. Further, there are several clinically meaningful variables such as alcohol use which have not been addressed in these studies. Hafner (1981) published the first systematic study that directly investigated gender differences in agoraphobia. Only 20 male and 20 female subjects were used in the analysis but they were matched for age and marital status. The study did not employ DSM-III (APA, 1980) diagnostic criteria and the prevalence of panic attacks was not reported. Very few gender differences emerged. Males were found to score significantly higher on some items reflecting fears of somatic symptoms. These few significant dilferences were not large and may have been the result of Type 1 error, however. as there were 55 comparisons made on the Fear Survey Schedule (FSS; Wolpc % Lang, 1964) using only 40 Ss. Similar results on the FSS were obtained in a sample of 104 females and 37 males with various anxiety disorders (fhyer. Tomlin, Curtis, Cameron & Nesse, 1985). Mavissakalian (1985) compared 10 males and 52 females with a DSM-III diagnosis of agoraphobia with panic on several self-report measures of personality and psychopathology. There were no significant differences on any of the personality dimensions. The only main finding was that males had significantly higher agoraphobia scores from the Fear Questionnaire (FQ; Marks & Mathews, 1979) following exposure therapy, compared to females. There are only two studies that have used a large sample of Ss with DSM-III agoraphobia with panic attacks. Chambless and Mason (1986) found few gender dilferenccs on a number of measures of personality and psychopathology. Females were more symptomatic on some measures but the effects were small. Both male and female agoraphobics scored lower on a measure of masculinity compared to a normative sample and masculinity scores were negatively correlated with some measures of psychopathology. Qei et al. (1990) compared 68 males and 204 females diagnosed with DSM-III agoraphobia with panic attacks on xveral measures of psychopathology and personality. Unlike findings from most previous studies. females scored significantly higher on the FSS total score compared to males and also had significantly higher levels of clinician-rated anxious and depressed mood. Males and females did not differ significantly in age of onset, panic symptomatology or agoraphobic avoidance. Most of the differences between males and females were not large and the authors concluded that there were no real gender differences. A similar pattern of results has been observed in community-based studies of panic and agoraphobia (Bourdon ef al.. 1988; Macaulay and Kleinknecht. 1989; Norton. Dorward & Cox. 1986). Females have been found to report higher severity ratings of some panic and agoraphobic symptoms compared to males. In general, however, the differences have been few and small. One potentially important set of variables that has not been fully explored in relation to gender differences concerns that of alcohol use and self-medication in panic disorder with agoraphobia. There has been recent interest in examining the effects of alcohol on anxiety and the comorbidity of the two conditions (for reviews set Cox. Norton, Swinson & Endler, 1990; Kushner. Sher & Bcitman, 1990; Linnoila, 1989; Weissman. 1988). The data suggest that alcohol and anxiety problems frequently co-exist and the majority of alcoholic patients with panic and agoraphobia believe self-medication to be effective, despite evidence that they frequently have a more serious clinical condition compared to patients with only one of the conditions (Cox et al., 1990). The vast majority of alcoholic Ss studied have been males, however, and gender differences *Address
for correspondence. 413
414
CASE HlSTORIES AhW SHORER COhiWt,‘NICAllONS
have not been adequately examined. Haflam (1978) originaily h~o~hesiz~ that elf-m~i~tion via alcohol may be the male agoraphobic’s version of the staying-at-home strategy used by females. If this is true, there should be a different pattern of alcohol use and self-medication in males and females. The purpose of the present study was therefore to investigate gender differences in a relatively large sample of PDA patients. This study sought to replicate previous fmdings and investigate new variables related to alcohol.
METHOD Subjects
The sample consisted of 236 outpatients with a DSM-III-R (APA, 1987) diagnosis of panic disorder with agoraphobia. There were 74 males (mean age = 35.50, SD = 10.48) and 162 females (mean age = 34.39, SD = 10.62). The two groups did not significantly differ in age. Materials
and procedures
AI1 patients had presented to an anxiety disorders clinic and had provided written consent to use the ~ychomet~c information they provided for research purposes. All patients completed a questionnaire fo assess alcohol use and coping efficacy. These questions were introduced in our intake questionnaire in 1987. Patients are asked to indicate the amount of alcohol they consumed per week and the efficacy of ‘having an alcoholic drink’ and ‘taking medication’ for coping with anxiety where I = not at all and 5 = completely. Alcohol consumption was converted to ounces where 1 ounce 5 one beer or one glass of wine. Patients were also asked to estimate the age of their first severe anxiety attack and how successful they though they would be at controlling their next panic attack when? 0 = not at all and 10 = completely. All patients were asked to complete the Fear Questionnaire (FQ; Marks & Mathews, 1979) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961). In recent years two more self-report measures have been added to our database. Consequently, 75% of !he patients were also asked to complete the slate form of the State-Trait Anxiety Inventory (STAI-S; Spielberger. Gorsuch & Lushene, 1970) and approx. 50% were asked to complete the Anxiety Sensitivity index (ASI; Peterson & Reiss, 1987). Patients were diagnosed by either a psychiatrist, psychology intern or psychiatric resident using DSM-III-R criteria. Approximately 90% of the diagnoses were made by experienced psychiatrists. Approximately 25% of the interviews were conducted using the Structured Clinical Interview for DSM-III-R (SCID; Spitzer, Williams & Gibbon, 1988); the remainder were I hr interviews based on the SCID. Of the 146 females and 72 mates on whom medication information was available, 78% of the males and 71% of the females were taking anti-anxiety medication (mostly ~nzodiazepines) at the time of assessment, a difference that was not significant. Patients were excluded if they had a diagnosis of aicahol dependence, but this comorbidity was very rare (< IO%). RFSULTS Gender effects
Table I presents the results of comparisons between males and females on the main variables of interest. There were several significant differences on the psychometric measures, with females reporting higher levels than mules, but in general the direrences were not large (t-values ~4.0). Compared to females, males reported a significantly higher intake of alcohol per week and also rated self-medication with alcohol to be more effective. Tables 2 and 3 present the pattern of correlations between self-reports of psychopathology and alcohol-related variables separately for males and females. There appears to be a different pattern of correlations for the two sexes. For males, several measures of psychopathology such as social fears and anxiety sensitivity were significantly and positively correlated with alcohol intake and perceived efficacy of self-medication. This pattern did not emerge in females, and in fact the opposite appeared true. State anxiety was signjficantly and negatively correlated with alcohol intake. Although there were several significant correlations in both the male and female samples, most of them were not large.
Table 1. Comparisons between male and female PDA patients Malts Variable Ounces of akohol/wk Efficacy rating for alcohol Efficacy rating for medication
Fcmalcs M
SD
r-value
P-WlW
162
3.77
8.43
3.02
0.003*
1.44
162
I .65
1.1 I
3.73
0.001’
n
M
SD
n
74
12.43
23.97
74
2.35
69
3.09
1.15
147
3.12
I .36
0.15
NS
Age of panic attack onsc~
74
25.39
13.84
162
29.02
19.41
1.64
NS
Ability to control next attack FQ-Agor FQ-SK FQ-Bl BDf STAI-S ASI
72 74 74 74 71 37 41
3.33 13.38 II.Jf 9.97 16.58 52.02 36.66
2.08 9.59 8.03 7.97 10.23 14.03 13.46
IS4 159 IS9 IS9 151 124 78
3.1 I 17.40 15.49 12.95 19.03 51.40 37.09
I.81 10.64 8.53 8.80 10.19 12.93 II.38
0.82 2.77 3.47 2.47 I .67 0.29 0.18
NS 0.006 0.001* 0.02 0.10 NS NS
FQ = Fear Questionnaire (Agoraphobia. Social Phobia. Blood and Injury Phobia): BDI = Beck Depression Inventory: STAI-S = State-Trait Anxiety Inventory-State form; ASI = Anxiety Sensitwity Index. ‘Considered significant with Bonferroni-ty~ correction for multiple comparisons.
CASE HISTORIES AND
Table
2. Correlations
between
Alcohol use Alcohol
-
use (ounccs/wk)
Perceived
ctiicacy
of alcohol
SHORTER
alcohol
variables
and self-report
measures
FQ-~
FQ-BI
ASI
0.10
0.25’
0.19
0.36’
0.02
0.22
(n = 74)
(n =41)
(n = 71)
(‘1 = 57)
‘“o;2:“)
(n = 74)
(II = 74)
(n = 74)
0.36”
(n = 74)
415
FQ-Ag
0.45..
use
COMMUNlCATlONS
0.03 (n =4l)
in males
BDI
0.39.
0.12
(n = 41)
(n =7l)
STAN
0.03 (n = 57)
lP < 0.05. l*P < 0.01.
Eficts
of alcohol use and self-medication
in males
Because alcohol frequency and perceived efficacy appeared to have differential effects in males and females, high vs low alcohol use and efficacy were examined further in each gender. To compare high and low alcohol use in males, the sample was divided using a median split procedure (median ounces per week = 4.0). The high alcohol use group (n = 36, mean ounces per week = 24.83, SD = 29.82) and low alcohol use groups (n = 38, mean ounces per week = 0.68, SD = 1.21) did not significantly differ on the age of the first panic attack, social fears, depressed or anxious mood, anxiety sensitivity or the perceived ability to control the next panic attack. The high alcohol use group rated alcohol to be a more efficacious coping strategy (M = 3.14, SD = 1.33) compared to the low alcohol use group (M = 1.61, SD = 1.10). a difference that was significant, r(72) = 5.40, P < 0.001. The two groups did not significantly differ in their efficacy ratings for taking medication. Finally, the high alcohol use group reported a higher level of agoraphobic fears on the FQ (M = 15.61, SD = 9.83) compared to the low alcohol use group (M = 11.26, SD = 8.97). a difference that was significant, f(72) = 1.99. P = 0.05. To compare high and low levels of perceived efficacy of alcohol in males, the Ss were divided into two groups based on their alcohol efficacy ratings on the S-point scale. The low efficacy group was defined as the 33 Ss who indicated I (not at all) and the high efficacy group consisted of the 20 Ss who responded with 4 (a lot) or 5 (completely). The two groups did not significantly differ on the reported age of the first panic attack, agoraphobic fears, depressed or anxious mood, or on the perceived ability to control the next panic attack. The high efficacy group reported a higher weekly alcohol intake (M = 28.95 ounces, SD = 37.85) compared to the low efficacy group (M = 2.36 ounces, SD = 4.26). a difference that was significant, r(SI) = 3.13. P < 0.006. The high ellicacy group reported a higher level of social fears on the FQ (M = 14.95, SD = 8.17) compared to the low enicacy group (M = 9.00. SD = 7.31). a difference that was significant, r(5I) = 2.75, P < 0.01. The high efficacy group also rcportcd a significantly higher level of anxiety sensitivity (M = 43.14, SD = I I .84) compared to the low eflicacy group (M = 29.69, SD = 13.99). a dilTcrencc that was signilicant. r(28) = 2.82, P < 0.01. Finally, the high alcohol efficacy group rcportcd a higher ellicacy level for taking medication (M = 3.71. SD = 0.69) compared to the low efficacy group (M = 2.81. SD = 1.26). a difference that was significant, f(47) = 3.22, P <0.003.
Because of the low r;lte of weekly alcohol use in females the median value was 0. Therefore, a median split procedure on alcohol USCcould not be performed. The same procedure for selecting high vs low perceived efficacy of alcohol used in the male sample was performed in the fcmalc sample. The I8 high efficacy and 109 low efficacy groups did not significantly differ on agoraphobic fears, depressed or anxious mood, anxiety sensitivity or the perceived ability to control the next panic attack. The high eficacy group reported a higher weekly alcohol intake (M = 12.50 ounces, SD = 17.00) compared IO the low efficacy group (M = 1.75, SD = 5.30). a difference that was significant. r(l25) = 2.66, P c 0.02. The high efficacy group also reported a higher level of social fears from the FQ (M = 20.06, SD = 9.45) compared to the low cllicacy group (M = 14.55, SD = 7.96). a ditference that was significant, f(l23) = 2.64, P < 0.01. Finally, the high efficacy group reported an earlier age of panic onset (M = 20.06. SD = 6.08) compared IO the low efficacy group (M = 29.35, SD = 19.20), a difference that was significant, f(l25) = 3.99. P < 0.001. DISCUSSION
Male and female PDA patients significantly differed in only two areas in this study: phobic avoidance and alcohol use and efficacy. The two groups did not difier on age of panic onset, perceived controllability and depressed or anxious mood. The finding that females reported higher levels of various fears is consistent with the results of some previous studies (e.g. Oei ef ul., 1990) although these differences were not large and do not explain a great deal of variance. The results from the present study suggest that there are also several diferences between males and females on alcohol-related factors. Males were found to report more alcohol use and to view alcohol use as an effective strategy for coping with anxiety problems compared to females, although gender effects explain little of the variance in alcohol consumption scores. In males alcohol use and the perceived efficacy of alcohol were found to be significantly correlated with social fears and anxiety sensitivity. The results suggest that there may be two patterns of self-medication in male patients: coping with feared social situations and dampening feared physical symptoms. Ironically. those male patients who had the highest elficacy ratings for alcohol did not have higher ratings on the perceived ability to control their next panic attack compared to malts with
Table
3. Correlations
bcrwcen
Alcohol Alcohol
-
use (ounccsjwk)
Perceived
efficacy
of alcohol
ux
9-p
< 0.01
alcohol
variables
and self-report
FQ-Ag
FQ-Sot
FQ-BI
0.00
-0.04
-0.07
measures ASI -0.21
in fcmalcs BDI - 0.02
STAI-S -0.21
(“;;z”)
(n ==I,‘~)
(n =&9)
(n =7X) 0.00
(n = 151) 0.07
(n = 124) -0.02
(n=I59)
(n=l59)
(n=l59)
(n=78)
(n=ISI)
(n=l24)
0.44.’ (n=l62)
lP < 0.05.
USC
416
CASE HLSTORl.ES A?JD SHORTER COUUUNICATlONS
low alcohol efficacy ratings. Similarly. continued aicohol use may actually exaarbate the physical symptoms that these patients fear (i.e. anxiety sensitivity). Again it should be noted that some of these significant differences were not large ones and some would not be considered significant with a Bonferroni-type correction. This pattern of results was less evident in females and may be due to the low rates of reported alcohol use. Although females with high alcohol use and efficacy ratings were infrequentiy found. these patients, like their male counterparts, also reported more social fears. In general. the patients in our sample appear to consume more alcohol on average than individuals from the same geographical background. The Addiction Research Foundation of Toronto sponsored a survey (Adlaf and Smart, 1989) of I100 community-dwelling residents in Ontario, On average, males reported drinking 1.90 times per week and females reported drinking 1.08 times per week. Approximately 55% of Ss reported drinking five or more drinks at a single sitting in the past year and only 10% reported this pattern of heavy drinking in the past week. AIthou~ ounces of alcohol per week was not examined in the survey. the statistics available suggesta more conservative pattern of drinking in the general population. The average weekly alcohol consumption in the anxiety disorder sample was 12.4 ounces for males and 3.8 ounces for females using a conservative coding system. Although there was a great range in reported alcohol consumption, it appears that Ss in the anxiety disorder sample, particularly the males, consume more alcohol per week compared to non-anxious individuaIs from the community. Most of the alcohol psychopathology correlations in the male and female samples were not large, however, and the results do await replication. These findings suggest that a subset of male PDA patients may be prone to consume moderate to large amounts of alcohol in the belief that it is an effective coping strategy despite their long-term evidence to the contrary. Finally, these type of male patients also reported higher efficacy ratings for taking medication and may be prone to abuse benzodiazepines. REFERLNCES Adlaf, E. M. & Smart, R. G. (1989). The Ontario Adult Alcohol and Other Drug Use Survey 1977-1989. Toronto, ON: Addiction Research Foundation of Ontario. American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd Edn). Washington, DC: American Psychiatric Association. American Psychiatric Association (1987). Diu(mostic and statistical munuuf of mentul disorders (3rd Edn-Revised). Washington. DC: American Psychiatric Association. Beck. A. T., Ward. C. H.. Mcndclson, M., Mock, J. & Erbaugh, J. (1961). An inventory for measuring depression. Arc&es aj ec#cru’ P.r_rc&t,f~. 4f. 56 i -57I. Bourdon, K. H., Boyd, J. Ff.. Rae, D. S., Burns, B. 3.. Thompson, J. W. & Locke, B. Z. (1988). Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 2, 227-241. Chamblcss. D. L. & Mason, J. (1986). Sex, sex-role stereotyping and agoraphobia. Bchaviuur Reseurch und Thcrupy, 24, 23 I -235. COX. B. 1.. Norton. G. R., Swinson, R. P. & Endler, N. S. (1990). Substance abuse and panic-related anxiety: a critical review. Behuviunr Rescwch und Therupy. 28. 385-393. Hafncr, R. J. (1981). Agoraphobia in mtn. Australiun und New Zeulund Jaurnai of Psychiatry, IS, 243-249. Hallam, R. S. (1978). Agoraphobia: a critical review of the concept. Bririslr Journul a/Psychiutry, 133, 314-319. Kushncr, M. G.. Shcr. K. J. & Bcitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. American Jaurnaf of Psychiatry, f47. 685-695. Linnoila. M. I. (1989). Anxiety and alcohol. Journaf of Cfinfcul Psychiatry, fU(SuppL), 26-29. Macaulay, J. L. & Kleinknecht, R. A. (1989). Panic and panic attacks in adolescents. Journ& oJAnriu/y Disurder.~. 3. 221-241. Marks, 1. M. & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Reswrch wd Therapy, I7, 263-267. Maviss~ka~jan, M. (l985}. Male and female agoraphobia: are they different? ~ehuvjaur Reseurch and Therup~y, 23, 469471. Norton, G. R., Donvard. I. & Cox. B. J. (1986). Factors associated with panic attacks in nonclinical subjects, Behuvior Therapy, 17, 239-252. Oei, T. P. S., Wanstall, K. & Evans, L. (1990). Sex difTerences in panic disorder with agoraphobia, Jorrrnol of Anxiety Disorders, 4, 3 17-324. Peterson, R. A. & Reiss, S. (1987). An.rier~ Sensirivity Index munucd. Pales Heights, IL: International Diagnostic Systems. Spielberger. C. D., Gorsuch, R. L. & Lushene, R. E. (1970). Munuaffar rhe State-Truit Anxiety fmentary. Palo Aho. CA: Consulting Psychologists Press. Spifzer, R. L., Williams, J. B. W. & Gibbon, M. (1988). Structured Clinicuf Interview/or DSM-//f-R. Biometrics Research Department, New York State Psychiatric Institute. Thyer, B. A., Tomlin, P.. Curtis, G. C., Cameron, 0. G. & Nesse, R. (1985). Diagnostic and gender dini-rcnces in the expressed fears of anxious patients. Journal of Behuvior Therapy and Experimental Psychiutry. 16, II l-t 15. Weissman, M. (1988). Anxiety and alcoholism. Journul OJ Clinicof Psychiatry, 49(Suppl.), 17-19. Wolpe, J. & Lang. P. J. (1964). A fear survey schedule for use in behavior therapy. Behouiour Reseurch und Therapy. 2, 27-30.