Anxiety and Mood Vol 13, No 1 ORIGINAL ARTICLE 공황장애환자에서범불안장애공존유무에따른임상적특징비교 차의과학대학교분당차병원정신건강의학교실 오종수. 정슬아

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1 Anxiety and Mood Vol 13, No 1 ORIGINAL ARTICLE 공황장애환자에서범불안장애공존유무에따른임상적특징비교 차의과학대학교분당차병원정신건강의학교실 오종수. 정슬아. 최태규 A Comparison of the Clinical Characteristics of Panic Disorder with and without Generalized Anxiety Disorder Jongsoo Oh, MD, Sra Jung, MD and Tai-Kiu Choi, MD, PhD Department of Psychiatry, CHA Bundang Medical Center, CHA University, Seongnam, Korea ABSTRACT Objective : This study aimed to investigate differences in demographic, clinical characteristics, and quality of life between panic-disorder patients with generalized anxiety disorder (PD+GAD) and without generalized anxiety disorder (PD-GAD). Methods : We examined data from 218 patients diagnosed with PD+GAD (150 patients) and PD-GAD (68patients). The following instruments were applied: Stress coping strategies, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Panic Disorder Severity Scale (PDSS), Anxiety Sensitivity Index- Revised (ASI-R), Albany Panic and Phobia Questionnaire (APPQ), NEO-neuroticism(NEO-N), Short Form health survey-36 (SF-36). Results : Compared to the PD-GAD group, the PD+GAD group had higher scores in emotion-focused coping strategies and clinical severity, such as BDI, BAI, PDSS, ASI, APPQ, and neuroticism. The PD+ GAD group showed lower scores in most scales in SF-36 status than PD-GAD group. Conclusions : This study shows that PD+GAD patients are different from PD-GAD patients in coping strategies, clinical severity and quality of life. It emphasizes the need of personalized therapy in clinical approach among patients with PD+GAD. (Anxiety and Mood 2017;13(1):10-16) KEY WORDS : Panic disorder Generalized anxiety disorder Stress coping strategies Clinical characteristics Quality of life. 서 론 공황장애는공황발작의반복과지속적으로다시공황발작 이올것에대한걱정을주요증상으로하는질환이다. 공황 장애는만성적인경과로진행되는특징뿐만아니라사회적기 능및건강에있어서도악영향을미친다고알려져있다. 1 공황장애는단독으로진단되는경우보다다른정신과적 동반질환을동반하는경우가더많으며 2 범불안장애가주요 한정신과적동반질환이다. Brown 등 3 의연구에따르면공황 Received : November 21, 2016 / Revised : April 7, 2017 Accepted : April 18, 2017 Address for correspondence Tai-Kiu Choi, M.D., Ph.D., Department of Psychiatry, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang, Seongnam 13496, Korea Tel : , Fax : ctk7089@hanmail.net 장애에서범불안장애유병률은 16% 으로주요우울장애다음으로유병률이높은것으로나타났으며 Staecevic 등 4 의연구에서도공황장애에서범불안장애높은비율로공존비율이높았다. 범불안장애는여러사건과행동에대해지나치고조절할수없는걱정을주요증상으로하는질환으로흔히신체적증상을동반한다. 5 범불안장애는평생유병률이 5% 에달하는흔한질환 5 이며신체적인증상으로나타나는경우가많아증상과구분하기힘들어진단이어렵다. 6 공황장애가다른불안장애를공존하게되는이유를여러측면에서추측해볼수있다. 우선공황장애의여러임상양상들이다른불안장애의진단기준을충족시키기에공황장애진단만으로도다른불안장애와공존가능성이높아진다. 7,8 유전적인측면에서는불안에기여하고불안장애취약성과관련된 불안유전자 (Anxiety genes) 에대해연구되고있다. 9 그 10 Anxiety and Mood Volume 13, No 1 April, 2017

2 오종수등 중 5-HTTLPR(serotonin-transporter-linked polymorphic region) 과같은세로토닌관련유전자는공황장애에영향을미칠뿐만아니라 10 범불안장애와도관련이있다. 11 또한모노아민산화효소 A 관련유전자가불안장애중에서도공황발작에관련된영역과범불안장애와관련이있다고알려져있다. 12 기존연구에따르면공황장애에대해 2년간추적관찰을한결과정신과적공존질환이있는경우, 정신과적공존질환이없는경우보다더심한공항장애증상과사회적기능저하를보였다. 13 또한정신과적동반질환숫자가많을수록증상의심각도와기능적저하의정도가더높은것으로나타났다. 14 그러므로공황장애에있어서정신과적동반질환의심각성에대해고려해야한다. 하지만공황장애에서공존질환에대한연구는질환비특이적이거나우울증에대한연구가대다수이다. 15 공황장애에있어범불안장애역시중요한정신과적동반질환이므로이에대한연구가필요하다. 따라서, 본연구에서는공황장애에서범불안장애가동반된군 (PD+GAD) 과동반되지않은군 (PD- GAD) 을구분하고이들간의사회인구학적및임상적특징을비교해보고자한다. 대상및방법 연구대상본연구는횡단적연구로 2013년 7월부터 2016 년 8월까지분당차병원정신건강의학과외래에방문하여공황장애로진단받고연구에동의한 18세이상 70세이하의모든환자를대상으로조사하였다. 정신건강의학과전문의의구조화된임상면담도구 (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorder, fourth edition, SCID DSM-IV) 16 에의해공황장애와범불안장애를진단하였다. 이와같은기준에부합하는총 379명의환자중조현병, 조울증, 물질관련장애, 지적장애, 그리고현재혹은과거에심각한내과적, 신경과적질환의병력이있는경우는연구대상에서제외하였으며설문을완전하게작성하지않은참여자를제외한후 218명의환자군을대상으로분석하였다. 이중범불안장애를동반한공황장애환자군은 150명이었으며범불안장애를동반하지않은공황장애환자군은 68명이었다. 모든연구의과정은분당차병원연구윤리심의위원회 (Institutional Review Board) 의승인을받았으며, 모든대상자들로부터연구참여에대한동의서를받았다. 평가사회인구학적특성으로는나이, 결혼유무, 수입, 교육수준 등을비교하였고, 임상적척도에대해서는스트레스대처전략 (Stress coping strategies), 벡우울척도 (Beck Depression Inventory, 이하 BDI), 벡불안척도 (Beck Anxiety Inventory, 이하 BAI) 공황장애심각도척도 (Panic Disorder Severity Scale, 이하 PDSS), 불안민감도척도 (Anxiety Sensitivity Index-Revised, 이하 ASI-R), 알바니공황공포질문지 (Albany Panic and Phobia Questionnaire, 이하 APPQ), NEO 성격차원검사 -신경증 (NEO-neuroticism, 이하 NEO-N), Short Form health survey-36( 이하 SF-36) 을평가도구로사용하였다. 모든참여자들은 Generalized Anxiety Disorder 7-item scale( 이하 GAD-7) 을수행하였다. GAD-7 은범불안장애를선별하고그심각도를평가하기위한도구로총 7문항으로구성되어있다. 17 각문항은최근 2주간경험한증상에대해 0~3 점까지선택하여답하도록되어있으며질문지끝부분에이로인해발생한문제가얼마나일상생활에불편함을주었는지를선택할수있도록되어있다. 한국판 GAD-7에서내적일치도는 이었고, 민감도와특이도는각각 0.89, 0.82로외국연구와동일한수준에서보고되었다. 18 Folkman과 Lazarus 등이개발한스트레스대처전략설문지는스트레스대처방식을크게문제중심과감정중심대처전략으로분류하였고, 총 62문항에대하여각 1~4점까지표시하도록하였다. 19 하위항목으로직면 (confrontation), 거리감두기 (distancing), 자기조절 (self-control), 사회적도움요청 (seeking social support), 책임수용 (accepting responsibility), 도피-회피 (escape-avoidance), 계획된문제해결 (planned problem solving) 그리고긍정적재해석 (positive reappraisal) 과같이총 8가지로구성되어있다. 20 BDI는 Beck 등에의해개발된우울증상의심각도를평가하기위한자가보고형설문지이다. 21개의문항으로 0~3점까지의척도로측정되어총점을기준으로평가한다. 21 한국판 BDI-II 에서내적일치도는 0.84로보고되었다. 22 BAI는 Beck 등에의해개발된불안증상의심각도를평가하기위한자가보고형설문지이다. 21개의문항으로 0~3점까지척도로측정되어총점을기준으로평가한다. 23 PDSS는공황발작과관련된증상의경험빈도및예기불안, 회피등의관련증상의심각도측정을위해, 0~4점에해당하는척도를가진 7가지의문항으로구성되어있다. 24 한국형 PDSS 검사의내적일치도는 0.88로보고되었다. 25 ASI-R 은불안관련감각에대한민감도를측정하였다. ASI-R 은 36개의문항으로구성되어있으며, 4개의부척도인호흡기계증상에대한두려움 (Fear of respiratory symptoms), 공적상황에서관찰되는불안반응 (Publicly observable anxiety reactions), 심혈관계증상에대한두려움 (Fear Anxiety and Mood Volume 13, No 1 April,

3 범불안장애동반공황장애환자의임상특징 of cardiovascular symptoms), 인지통제장애에대한두려움 (Fear of cognitive dyscontrol) 으로이루어져있다. 26 한국형 ASI-R 의내적일치도는 0.93으로보고되었다. 27 APPQ 또한공황관련증상의정도를측정하기위한것이나, 조금더구체적인문항 27가지로구성되어있으며, 상황형광장공포증 (Situational agoraphobia), 사회공포증 (Social phobia), 자극감응회피 (Interoceptive avoidance) 의하위척도로구성되어있다. 28 한국형 APPQ의내적일치도는 0.95로보고되었다. 29 NEO-N 를이용하여하위항목인신경증척도와외향성척도를측정하였다. 30 이환자들의삶의질평가를위해서 SF-36 을사용하였다. 31 이는신체적기능 (physical functioning), 신체적건강문제에의한역할제한 (role limitations due to physical health), 정서적문제에의한역할제한 (role limitations due to emotional problems), 에너지 / 피로 (energy/fatigue), 감정적웰빙 (emotional well being), 사회적기능 (social functioning), 신체적통증 (bodily pain), 전반적건강상태 (general health) 의삶의질관련항목척도로구성되어있다. 통계분석본연구에서는범불안장애가동반군과비동반군사이에사회인구학적특성에대해서는 independent t test 및 χ 2 test (chi-square, 카이제곱 ) 로비교하였으며여러임상변인들의 차이에대해서는 independent t test로비교하였다. 모든분석에서통계적유의수준은 0.05 미만으로하였다. 통계프로그램은 Statistical Package for the Social Sciences 21.0(SPSS Inc., Chicago, Illinois, USA) 을이용하였다. 결과 범불안장애가동반에따른사회인구학적특성범불안장애동반유무에따라나이, 성별, 결혼, 종교, 소득등사회인구통계학특성전반적분야에서통계적으로유의한차이는없었다 (Table 1). 범불안장애가동반에따른스트레스대처전략차이두환자군사이에스트레스대처전략에있어서 문제초점 대처의경우에는두군간에유의한차이가없었으나 감정초점 대처의경우에는범불안장애동반군에서통계적으로유의하게높았다 (17.60±6.39 vs ±5.91, p<0.001). 세부항목의경우 직면 (confrontation) (8.92±3.86 vs. 7.44±4.09, p=0.015), 거리두기 (Distancing) (5.87±2.77 vs. 4.45±2.68, p=0.001), 탈출-회피 (Escape-avoidance) (9.57±3.57 vs ±4.49, p=0.034), 긍정재평가 (Positive reappraisal) (12.58± 4.14 vs. 9.98±4.81, p<0.001) 에있어서범불안장애가동반 Table 1. Sociodemographic between PD-GAD patients and PD+GAD patients PD-GAD (n=68) PD+GAD (n=150) t, χ 2 p Age (years) (mean±sd) 41.63± ± Sex-male (n, %) 28 (41.18) 74 (49.33) Married (n, %) 45 (66.18) 95 (63.33) Education (mean±sd) 14.47± ± Religion (n, %) 40 (58.82) 83 (55.33) Income (1,000,000 won, KRW) (mean±sd) 02.78± ± * : p<0.05. PD+GAD : Panic Disorder with Generalized Anxiety Disorder, PD-GAD : Panic Disorder without Generalized Anxiety Disorder, SD : standard deviation, KRW : Korean Won Table 2. Coping strategies difference between PD-GAD patients and PD+GAD patients Coping strategies PD-GAD (n=68) PD+GAD (n=150) t p Problem-focused 36.83± ± Emotion-focused 11.40± ± *0.000* Confrontation 7.44± ± *0.015* Distancing 4.45± ± *0.001* Self-control 6.00± ± Seeking social support 6.70± ± Accepting responsibility 4.14± ± Escape-avoidance 8.20± ± *0.034* Planned problem solving 5.13± ± Positive reappraisal 9.98± ± *0.000* * : p<0.05. PD+GAD : Panic Disorder with Generalized Anxiety Disorder, PD-GAD : Panic Disorder without Generalized Anxiety Disorder, SD : standard deviation 12 Anxiety and Mood Volume 13, No 1 April, 2017

4 오종수등 군에서유의하게높았다 (Table 2). 고 찰 범불안장애가동반에따른공황장애심각도차이범불안장애동반군에서비동반군에비해 BDI(17.85± 9.21 vs. 8.27±5.22, p<0.001), BAI(28.26±11.11 vs ± 7.56, p<0.001) 및 PDSS(12.21±6.30 vs. 7.27±5.00, p<0.001) 점수가유의하게높았다. ASI(57.85±6.28 vs ±19.95, p< 0.001) 및 APPQ(64.95±42.21 vs ±25.77, p<0.001) 총점및모든하위척도에서범불안장애동반군이유의하게높았다. NEO-N 신경증성향 (8.76±2.66 vs. 5.92±2.86, p< 0.001) 은범불안장애동반군에서유의하게높았으며외향성성향 (4.84±3.54 vs. 6.78±3.26, p<0.001) 은유의하게낮았다 (Table 3). 범불안장애가동반에따른삶의질척도차이범불안장애동반군에서 SF-36 으로측정한삶의척도에서신체적기능 (71.03±20.06 vs ±15.94, p=0.007), 신체적문제에의한역할제한 (20.10±32.81 vs ±41.70 p= 0.001), 정서적문제에의한역할 (18.44±33.43 vs ±5.44, p<0.001) 제한, 감정적웰빙 (50.11±7.39 vs ±6.41, p= 0.007), 신체적통증 (45.05±29.39 vs ±29.25 p<0.001), 전반적인건강상태 (38.53±18.45 vs ±14.75 p<0.001) 는범불안장애동반군에서유의하게낮았으며, 에너지 / 피로 (51.36 ±11.66 vs ±10.69 p<0.001) 는범불안장애동반군에서유의하게높았다 (Table 4). 본연구에서는범불안장애를동반한공황장애환자군과 범불안장애를동반하지않은공황장애군의사회인구학및 임상적특징을비교하였다. 본연구는집단의크기가크고다 양한평가도구로분석하였으며질환특이적으로범불안장애 공존에따른임상적특징을살펴보았다는특징이있다. 범불안장애를동반된공황장애환자군이스트레스대처 전략으로감정중심대처전략을더사용하며, 우울, 불안및 불안민감도, 공황장애증상관련척도, 신경증정도가유의 미하게높았으며외향성정도는더낮았다. 또한범불안장애를 Table 4. SF-36 status difference between PD-GAD patients and PD+GAD patients SF-36 survey PD-GAD (n=68) PD+GAD (n=150) t, χ 2 p SF_PF 78.77± ± * SF_RP 38.85± ± * SF_RE 48.48± ± * SF_EF 44.62± ± * SF_EW 52.85± ± * SF_SF 63.26± ± * SF_BP 64.89± ± * SF_GH 50.00± ± * * : p<0.05. PD+GAD : Panic Disorder with Generalized Anxiety Disorder, PD-GAD : Panic Disorder without Generalized Anxiety Disorder, SD : Standard Deviation, SF-36 : Short Form health survey (PF : Physical Functioning, RP : Role-Physical, RE : Role- Emotional, EF : Energy/Fatigue, EW : Emotional well-being, SF : Social Functioning, BP : Bodily Pain, GH : General Health) Table 3. Clinical characteristics difference between PD-GAD patients and PD+GAD patients PD-GAD (n=68) PD+GAD (n=150) t p BDI (mean±sd) 8.27± ± * BAI (mean±sd) 10.92± ± * PDSS (mean±sd) 7.27± ± * ASI-Resp (mean±sd) 12.29± ± * ASI-Public (mean±sd) 6.62± ± * ASI-Cardi (mean±sd) 8.08± ± * ASI-Cogn (mean±sd) 1.88± ± * ASI (mean±sd) 28.57± ± * APQQ (mean±sd) 32.03± ± * APQQ-Agora (mean±sd) 12.16± ± * APQQ-Social (mean±sd) 9.14± ± * APQQ-Introsp (mean±sd) 11.44± ± * Neuroticism (mean±sd) 5.92± ± * Extraversion (mean±sd) 6.78± ± * * : p<0.05. PD+GAD : Panic Disorder with Generalized Anxiety Disorder, PD-GAD : Panic Disorder without Generalized Anxiety Disorder, SD : Standard Deviation, BDI : Beck Depression Inventory, PDSS : Panic Disorder Severity Scale, ASI : Anxiety Sensitivity Index (Resp : Fear of respiratory symptoms, Public : Publicly observable anxiety reactions, Cardi : Fear of cardiovascular symptoms ; Cogn : Fear of cognitive dyscontrol), APPQ : Albany Panic and Phobia Questionnaire (Agora : Situational agoraphobia, Social : Social phobia, Introsp : Interoceptive avoidance) Anxiety and Mood Volume 13, No 1 April,

5 범불안장애동반공황장애환자의임상특징 동반한군에서에너지 / 피로를제외한전반적인신체적, 정신적건강과관련삶의질이낮았다. 범불안장애동반군에서높게나타난감정중심대처전략은문제중심대처전략과는다르게상황자체를해결하기보단스트레스상황의부정적이고고통스러운감정의수준을낮추려는특징을가진다. 19 이러한대처전략은갑작스러운죽음과도같은스스로통제불가능한문제상황에서사용하는방식 32 이며스트레스요인에대한우울감과적대감을낮추는데도움이된다. 32 범불안장애가동반된환자의경우사소한문제나어려움등을예측할수없거나통제할수없다고생각하게만드는인지의왜곡및상위인지 (meta-cognition) 33 가있다. 그결과환자는불확실에대한두려움을견뎌내지못하고결국걱정을통제불가능한영역으로인지할수있다. 따라서범불안장애가동반된공황장애환자는스트레스요인이발생했을때상황을해결하기보다는우선감정을완화하기위해감정중심대처전략을사용하여예측불가능한사건에대한적대감을낮추려노력할것이라생각된다. 한편, 기존연구에따르면공황장애에있어공존질환이있을경우마음챙김인지치료와같은인지치료의효과가공황장애단독으로있는경우보다덜효과적이라보고하였다. 34 이번연구에적용하자면범불안장애가동반된공황장애환자는대처전략을감정적으로사용하기에 인지치료 적접근이범불안장애가동반되지않은공황장애환자에비해치료의반응이양호하지않을것이라추정된다. 하지만상위인지의인지왜곡을교정을하는접근을통해범불안장애가동반된공황장애를인지치료하고자한다면인지치료에도효과를거둘수있을것이라생각된다. 범불안장애가동반된공황장애환자에서경우우울점수가높은것으로나타났다. 피로와불면등의범불안장애에서보일수있는주요증상들이주요우울장애의우울삽화에서도나타나서두질환에서의증상이겹쳐구분하기쉽지않다. 또한범불안장애가기저에있는상황에서는환경적변화에따른우울삽화가오기쉬워서흔히 불안우울증 (anxious depression) 이라불리는진단이흔하게나타난다. 35 본연구에서범불안장애가동반된공황장애환자군에서우울점수가높은것으로나타난것은범불안장애가우울장애와구분되기어렵고쉽게동반된다는점과연관이될수있다. 불안민감도척도도범불안장애가동반된공황장애에서더높은점수로측정되었다. 불안민감도는불안과관련된감각에대한두려움으로신체적, 사회적, 인지적측면의다측면으로바라볼수있다. 공황장애환자의경우신체적측면의불안민감도가두드러지게높은반면에범불안장애의경우에는인지적측면의불안민감도가높다. 36 범불안장애가동반된공황장 애의환자의경우공황장애만있는환자에비해신체적측면의불안민감도뿐만아니라인지적측면의불안민감도도높아져서 ASI-R 총점이더높게나온것으로예상할수있다. 불안점수와공황장애증상관련척도도범불안장애가동반된공황장애환자군에서더높게나타났다. Apfeldorf 등 14 의연구에따르면공황장애환자에서공존질환이있을경우불안에관련된증상의심각도가더높다고보고한바가있다. Scheibe 등 13 도공존질환이있는공황장애환자가더심한증상을가지고있다고보고하였다. 그러므로본연구는과거의연구와일치한다고볼수있다. 한편, 범불안장애가동반된환자군이공황장애자체의심각도가범불안장애가동반되지않은공황장애환자군에비해서높은것이라추정할수있다. 기존연구에따르면 PDSS 점수와여타우울, 불안에관련된증상척도가양의상관관계를보임이알려져있다. 37 그러므로범불안장애가동반된환자군에서더욱공황장애증상이심하기에앞에서살펴보았듯이우울이나불안증상이높게나타난것이라추정할수있다. 본연구에서는범불안장애가동반된공황장애의환자가신경증점수가더높게나타났다. 신경증은부정적감정상태를지속하는경향성을의미하는성격요인이며높은신경증을보이는사람일수록불안, 두려움등의감정으로부터고통받는것으로알려져있다. 38 또한높은신경증은정신질환의발병의강력한예측인자이다. 39 이는범불안장애를동반한공황장애환자에서부정적인감정이지속적으로나타나는성격적특징이있으며정신질환발병위험이높은군임을추정할수있다. 마지막으로, 범불안장애가동반된군에서전반적으로신체적, 정신적삶의질만족도에있어서는더낮았다. 이는동반질환이있을경우삶의질이낮다는기존의연구와부합하다. 14 Olff 등 40 은삶의질에있어서스트레스에대해대처방식의중요성을강조하였다. 스트레스가주어졌을때거기에 도전할것인가위협할것인가 (challenge vs threat) 에대해평가를거치게된다. 그평가를바탕으로감정적, 행동적반응및신경내분비학적반응이나타나게되며결과적으로정신적, 신체적삶의질에영향을미치게된다. 이가운데감정적, 행동적반응에영향을미치는것이감정중심적대처전략이며대처전략의변화는정신적, 신체적삶의질에영향을주게된다 (Figure 1). 본연구에따르면범불안장애가동반된공황장애환자군이감정중심적대처전략을유의미하게높게사용하고 감정적행동적반응 을수치화한 증상심각도 에있어서우울과불안등이더욱높으며삶의질에있어서는낮았다. 범불안장애동반한공황장애환자들은스트레스가주어졌을때미래에대한비특이적인불안으로인해 도전 을선택하기보 14 Anxiety and Mood Volume 13, No 1 April, 2017

6 오종수등 측면에차이가있음이나타났다. 임상적상황에서공황장애 감정중심적대처전략 감정적, 행동적반응 스트레스요인평가 내분비적반응 환자의범불안장애동반이과소평가되는경우가많다. 본연구결과에따르면범불안장애가동반하는경우감정중심적대처를하게되며우울과불안에관련된임상적심각도가높게나타나고삶의질도낮다. 그러므로임상진료에서공황장애환자를만났을때범불안장애를비롯한다양한공존질환의공존여부를고려하고이에따라개개인에대한맞춤형치료계획을세우는것이필요하다. 중심단어 : 공황장애 범불안장애 스트레스대처전략 임상적 정신신체적삶의길 특징 삶의질. Figure 1. Stress-coping model. 단 위협 을선택함으로인해감정적, 행동적반응이더욱심한불안과우울로이어질것이다. 또한상황자체를해결하려는문제중심대처전략이아닌감정중심적대처전략을사용하기에스트레스를 해결할수없는영역 이라판단하기에감정적, 행동적반응이부정적으로진행되어 우울, 불안 등의증상의심각도가더높게나타날것이다. 그결과범불안장애를동반한공황환자군에서삶의질이저하된다고설명할수있다. 한편, 본연구에서는범불안장애가동반된군에서에너지 / 피로측면에서삶의질이더높게나타났다. 이는공황장애에서범불안장애가동반된경우범불안장애의특징인 쉽게피곤해짐 은덜나타나며오히려 근육의긴장 과관련이있는 신체적통증, 신체적건강문제에의한역할제한 등이범불안장애에동반시더드러난다고추정할수있다. 본연구의제한점은다음과같다. 첫째, 대부분의환자들이병원내원시초기진단하에조사한내용을분석하였지만치료초기당시포함된약물치료등이영향을미쳤을수있다. 둘째, 정신건강의학과전문의 2인의진단과평가가시행되었으나자가보고식검사및대상자의회고식기억에의한평가가포함되어있어주관적인영향이일부포함되었을수있다. 셋째, 본연구는한대학병원에서이루어진연구이기에특정지역에서국한된환자를대상으로한연구이고범불안장애가동반되지않은공황장애환자군이 68명으로집단의크기가비교적적으므로이결과를일반화하기는곤란하다. 마지막으로, 본연구는공황장애로진단받은 379명을대상으로연구하였으나제외준거에따라환자를제외하여최종 218 명의환자를대상으로하였기에선택편향의가능성이존재한다. 결론 이번연구는공황장애에범불안장애가동반할경우여러 REFERENCES 1. Wittchen HU, Essau CA. Epidemiology of panic disorder: progress and unresolved issues. Journal of Psychiatric Research 1993;27: Roy-Byrne PP, Stein MB, Russo J, Mercier E, Thomas R, McQuaid J, et al. Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. The Journal of Clinical Psychiatry 1999;60: Brown TA, Antony MM, Barlow DH. Diagnostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnoses following treatment. Journal of Consulting and Clinical Psychology 1995;63: Staecevic V, Uhlenhuth E, Kellner R, Pathak D. Patterns of comorbidity in panic disorder and agoraphobia. Psychiatry Research 1992; 42: Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Archives of General Psychiatry 1994;51: Fogel BS, Greenberg DB. Psychiatric care of the medical patient: Oxford University Press; Brown TA, Barlow DH. Comorbidity among anxiety disorders: Implications for treatment and DSM-IV. Journal of Consulting and Clinical Psychology 1992;60: Goisman RM, Goldenberg I, Vasile RG, Keller MB. Comorbidity of anxiety disorders in a multicenter anxiety study. Comprehensive Psychiatry 1995;36: Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry 2001;158: Maron E, Lang A, Tasa G, Liivlaid L, Toru I, Must A, et al. Associations between serotonin-related gene polymorphisms and panic disorder. International Journal of Neuropsychopharmacology 2005; 8: You J-S, Hu S-Y, Chen B, Zhang H-G. Serotonin transporter and tryptophan hydroxylase gene polymorphisms in Chinese patients with generalized anxiety disorder. Psychiatric Genetics 2005;15: Samochowiec J, Hajduk A, Samochowiec A, Horodnicki J, Stȩpień G, Grzywacz A, et al. Association studies of MAO-A, COMT, and 5-HTT genes polymorphisms in patients with anxiety disorders of the phobic spectrum. Psychiatry Research 2004;128: Scheibe G, Albus M. Predictors and outcome in panic disorder: a 2-year prospective follow-up study. Psychopathology 1997;30: Apfeldorf WJ, Spielman LA, Cloitre M, Heckelman L, Shear MK. Morbidity of comorbid psychiatric diagnoses in the clinical presentation of panic disorder. Depression and Anxiety 2000;12: Gorman JM, Coplan JD. Comorbidity of depression and panic disorder. The Journal of Clinical Psychiatry; First MB, Gibbon M. The Structured Clinical Interview for DSM- Anxiety and Mood Volume 13, No 1 April,

7 범불안장애동반공황장애환자의임상특징 IV Axis I Disorders (SCID-I) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II); Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine 2006;166: Seo J-G, Park S-P. Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine. The Journal of Headache and Pain 2015;16: Lazarus RS, Folkman S. Stress, appraisal, and coping: Springer Publishing Company; Ceslowitz SB. Burnout and coping strategies among hospital staff nurses. Journal of Advanced Nursing 1989;14: Beck AT, Steer RA, Brown GK. Beck depression inventory; Song Y-M, Lee H-K, Kim JW, Lee K. Reliability and validity of the Korean Version of Beck Depression Inventory-II via the internet: Results from a university student sample. Journal of Korean Neuropsychiatric Association 2012;51: Steer RA, Beck AT. Beck Anxiety Inventory; Shear MK, Brown TA, Barlow DH, Money R, Sholomskas DE, Woods SW, et al. Multicenter collaborative panic disorder severity scale. American Journal of Psychiatry 1997;154: Lee EH, Kim JH, Yu BH. Reliability and validity of the self-report version of the Panic Disorder Severity Scale in Korea. Depression and Anxiety 2009;26:E120-E Deacon BJ, Abramowitz JS, Woods CM, Tolin DF. The Anxiety Sensitivity Index-Revised: psychometric properties and factor structure in two nonclinical samples. Behaviour Research and Therapy 2003;41: Kim JH, Yu BH, Oh KS, Yang JC, Kim Y, Lee SY, et al. A validation study of Korean anxiety sensitivity index-revised (ASI-R). Journal of Korean Neuropsychiatric Association 2004;43: Brown TA, White KS, Barlow DH. A psychometric reanalysis of the Albany Panic and Phobia Questionnaire. Behaviour Research and Therapy 2005;43: Kim JH, Yang JC, Kim JB, Lim KY, Lee SY, Yu BH. A validation study of Korean Albany Panic and Phobia Questionnaire (APPQ). Journal of Korean Neuropsychiatric Association 2004;43: Stough C, Donaldson C, Scarlata B, Ciorciari J. Psychophysiological correlates of the NEO PI-R openness, agreeableness and conscientiousness: preliminary results. International Journal of Psychophysiology 2001;41: Nam B, Lee S. Testing the validity of the Korean SF-36 health survey. J Korean Soc Health Stat 2003;28: Fawzy FI, Kemeny ME, Fawzy NW, Elashoff R, Morton D, Cousins N, et al. A structured psychiatric intervention for cancer patients: II. Changes over time in immunological measures. Archives of General Psychiatry 1990;47: Wells A. Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and Cognitive Psychotherapy 1995;23: Kim B, Cho SJ, Lee KS, Lee J-Y, Choe AY, Lee JE, et al. Factors associated with treatment outcomes in mindfulness-based cognitive therapy for panic disorder. Yonsei Medical Journal 2013;54: Zbozinek TD, Rose RD, Wolitzky-Taylor KB, Sherbourne C, Sullivan G, Stein MB, et al. Diagnostic overlap of generalized anxiety disorder and major depressive disorder in a primary care sample. Depression and Anxiety 2012;29: Deacon B, Abramowitz J. Anxiety sensitivity and its dimensions across the anxiety disorders. Journal of Anxiety Disorders 2006;20: Monkul ES, Tural Ü, Onur E, Fidaner H, Alkın T, Shear MK. Panic Disorder Severity Scale: reliability and validity of the Turkish version. Depression and Anxiety 2004;20: Gunthert KC, Cohen LH, Armeli S. The role of neuroticism in daily stress and coping. Journal of Personality and Social Psychology 1999;77: Flint J. The genetic basis of neuroticism. Neuroscience & Biobehavioral Reviews 2004;28: Olff M. Stress, depression and immunity: the role of defense and coping styles. Psychiatry Research 1999;85: Anxiety and Mood Volume 13, No 1 April, 2017

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar