주요우울장애를 동반한 공황장애 환자군의 임상적 특징
Clinical Characteristics of Panic Disorder with Comorbid Major Depressive Disorder
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초록
공황장애는 반복적인 공황발작과 예기불안 등을 특징으로하는 질환으로 치료하지 않을 경우 만성화와 재발을 반복하는 병이다.1) 공황장애와 관련한 기질적 특성으로 불안 민감도(anxiety sensitivity)2)는 불안과 관련된 감각에 대한 공포를의미하고, 불확실성에 대한 인내력 부족(intolerance of uncertainty) 3)은 불확실성에 대한 부정적인 믿음과 불확실한 상황이나 사건에 대한 정서적, 인지적, 행동의 부정적 경향성을포함하는 특성을 의미한다. 또한, 특성 불안(trait anxiety)4)은더 다양한 상황에서 자주 불안을 경험하는 개인의 경향성이며, 신경증(neuroticism)5)은 정서적 불안정성, 불안 및 스트레스에 대한 취약성을 포함하는 성격적 특성으로 이런 특질들은공황장애 환자군에서 잘 관찰되는 것으로 알려져 있다.6-9) 공황장애는 우울장애와의 공존율이 높고10) 두 정신장애가공존할 경우 단독으로 존재할 때보다 임상적으로 우울증상과 공황증상의 심각도 및 지속기간을 증가시킨다는 연구 결과가 있다.11) 또한, 자살 시도력이 많고 다른 정신과적 공존질환의 비율이 높아 치료에 잘 반응하지 않아 더 심각한 기능의 손상을 가져온다는 많은 연구 결과가 보고된 바 있다.12) 뿐만 아니라, 두 정신장애가 공존하는 경우 더 많은 초기아동기의 외상경험이 발견된 바 있으며,13) 신체적 학대, 성적학대, 그리고 방임 등이 우울장애 및 공황장애와 연관되어있고 질환의 지속, 악화 및 재발률을 높인다는 보고가 있었다.14) 또한 초기 아동기의 외상경험은 불안 민감도15) 등을 증가시키며 높은 신경증적 기질을 보이는 등 공황장애에서 관찰되는 기질적 특성과 관련성이 있다는 연구 결과가 있다.16)17) 삶의 질은 각 개인의 주관적인 안락감(well-being)과 삶에대한 만족도를 포함하는 광범위한 개념으로18) 우울장애와공황장애의 공존은 공황장애가 단독으로 있을 때와 비교 시기능의 손상과 삶에 대한 만족도를 현저히 떨어트린다는 보고가 꾸준히 있어 왔다.19) 하지만 기존 연구들에서 두 질환이 공존할 경우 관찰되는전반적인 임상적 특성에 대한 연구가 드물며, 적지만 시행된기존 연구는 대상 환자군의 수가 적고 병원 환자들을 대상으로 한 연구가 아니라 역학연구가 많을 뿐 아니라 국외의논문이라는 한계가 있다. 따라서 본 연구는 일 대학병원에내원한 많은 표본 수의 환자 집단을 대상으로 임상현장의 실제를 반영하고, 다음과 같은 가설을 토대로 두 질환이 공존할 때 나타나는 전반적인 특성을 다루고자 한다. 첫째, 주요우울장애가 공존한 공황장애 환자군에서 신경증, 위험회피도, 특성 불안, 불확실성에 대한 인내력 부족, 불안 민감도 등의 기질적 특성이 높은 것으로 발견될 것이다. 둘째, 주요우울장애가 공존한 공황장애 환자군에서 우울과병적 불안 및 공황 관련 증상의 심각도가 높을 것이다. 셋째, 주요우울장애가 공존한 공황장애 환자군에서 초기 아동기의 학대 경험이 많을 것이다. 넷째, 주요우울장애가 공존한공황장애 환자군에서 삶의 질이 낮을 것이다.
Abstract
Objectives : The objective of this study was to investigate the differences in sociodemographic and clinical characteristics, temperaments, and quality of life between panic disorder (PD) patients with and without major depressive disorder (PD+MDD and PD-MDD patients, respectively). Methods : We compared 411 PD-MDD and 219 PD+MDD patients. All patients who were drug-free for at least 1 month were assessed at initial outpatient visits before the administration of medication. The following instruments were used for assessment: the NEO Personality Inventory-Neuroticism (NEO-N) ; the Temperament and Character Inventory-Harm Avoidance (TCI-HA) ; the State-Trait Anxiety Inventory (STAI) ; the Intolerance of Uncertainty Scale-Short (IUS); the Anxiety Sensitivity Index-Revised (ASI-R); the Beck Depression Inventory (BDI) ; the Beck Anxiety Inventory (BAI); the Penn State Worry Questionnaire (PSWQ) ; the Generalized Anxiety Disorder for 7 item (GAD-7) ; the Albany Panic and Phobia Questionnaire (APPQ) ; the Panic Disorder Severity Scale (PDSS) ; the Early Trauma Inventory Self Report-Short Form (ETISR-SF) ; the Scale for Suicidal Ideation (SSI) ; the World Health Organization Quality of Life Scale Abbreviated Version (WHOQOL-BREF) ; the Sheehan Disability Scale (SDS) ; and the Short Form health survey (SF-36). Results : Compared to the PD-MDD patients, the PD+MDD patients were younger and more likely to be unmarried. They showed higher rates of unemployment, lower levels of education and income, younger age of onset, more previous suicide attempts, a greater incidence of agoraphobia, and more previous treatments. The PD+MDD patients showed significantly higher scores on the NEO-N, the TCI-HA, the STAI, the IUS, the ASI-R, the BDI, the BAI, the PSWQ, the GAD-7, the APPQ, the PDSS, the ETISR-SF, and the SSI. In addition, the PD+MDD patients showed significantly lower quality of life than did the PD-MDD patients. In contrast with previous studies, we observed no significant differences between the two groups in terms of gender, duration until treatment, and psychiatric comorbidities. Conclusions : This study showed that the PD+MDD patients have more early trauma experiences, higher levels of anxiety-related temperaments, more severe panic and depressive symptoms, and lower quality of life than the PD-MDD patients.
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