Brief Communication
Serum Cholesterol Level Comparison: Control Subjects, Anxiety
Disorder Patients, and Obsessive–Compulsive Disorder Patients
Helmut Peter, MD1,
Iver Hand, MD2,
Fritz Hohagen, MD3,
Anne Koenig, MD4,
Olaf Mindermann, MD5,
Frank Oeder, MD6,
Markus Wittich, MD7
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Objective: To determine whether panic disorder is
associated with elevated serum cholesterol levels. Serum cholesterol
levels of panic disorder patients are reported to be elevated.
This could explain the higher-than-expected cardiovascular
mortality in this population. Some evidence exists wherein
cholesterol levels are also increased in patients with general
anxiety disorder and phobias. To date, there are only 2 reports
on cholesterol levels of obsessive–compulsive disorder
(OCD) patients, giving controversial results.
Method: We compared serum cholesterol levels of anxiety
disorder patients, OCD patients, and normal control subjects
with each other (n = 60 in each group). Serum cholesterol
was measured in each subject before treatment. Subjects of
the 3 groups were matched by age and sex.
Results: Patients with anxiety disorders and OCD had
elevated cholesterol levels, compared with normal control
subjects. Cholesterol levels in OCD patients were comparable
with those in patients with phobia.
Conclusions: Our data support the assumption that
elevation in cholesterol level is not a specific feature of
panic disorder (as most assumed), but more generally associated
with anxiety disorders. Increased cholesterol levels in patients
with anxiety disorders and OCD may be of clinical relevance.
(Can J Psychiatry 2002; 47:557–561)
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Author Affiliations
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Clinical Implications
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Cholesterol levels need to be checked regularly
in patients with anxiety disorders and obsessive–compulsive
disorder (OCD).
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A high percentage of anxiety disorder and OCD patients
need specific interventions to decrease cholesterol
levels.
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Elevated cholesterol levels could at least partly
explain the increased cardiovascular morbidity in
panic disorder patients.
Limitations
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Anxiety disorder patients are diagnostically heterogeneous.
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Dietary and physical exercise habits were not controlled.
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Control subjects were recruited partly from the
social surrounding of the authors.
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Key Words: cholesterol levels, anxiety disorders,
panic disorder, agoraphobia, obsessive–compulsive disorder
Résumé
: Comparaison des taux de cholestérol sérique
: sujets témoins et patients souffrant de trouble anxieux
et de trouble obsessionnel-compulsif
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Panic disorder seems to be associated with elevated serum cholesterol
levels (1–3), but the clinical significance of these findings
is still not evident (4). Since prospective epidemiologic studies
(5,6) leave no doubt about the importance of cholesterol in the
development of cardiovascular diseases, elevated cholesterol levels
in panic disorder could contribute to the increase in cardiovascular
morbidity and mortality found in these patients (7–11). Recently,
Peter and others reported clinically relevant cholesterol elevations
in patients with panic disorder and phobia (4). First, patients
also had elevated low-density lipoprotein (LDL) values and elevated
cholesterol–high-density lipoprotein (HDL) ratios. Both variables
were not assessed in earlier external studies. Variables are considered
more specifically correlated with risk of coronary disease. Second,
following the guidelines of the Expert Panel of the American National
Cholesterol Education Program (12), patients showed a borderline
high or high cholesterol range almost 3 times as frequently as control
subjects and a borderline high or high LDL range 2.5 times as frequently
as control subjects.
Several reports suggest that cholesterol elevation is not so much
a specific pattern of panic disorders (most reports up to now) but
may be associated generally with anxiety disorders. In fact, 2 studies
found a cholesterol elevation in patients with general anxiety disorder
(GAD) (13). Another study showed increased lipoproteins in a mixed
population of patients with panic disorder and phobia (4). This
raises the question whether the same holds true for obsessive–compulsive
disorder (OCD), which, according to DSM-IV (14), is classified as
anxiety disorder. So far, there are 2 studies on cholesterol in
OCD patients, with controversial results. Freedman and others (2)
found normal cholesterol levels, and Peter and others (15) reported
increased cholesterol values in OCD patients, compared with control
subjects.
Method
Subjects
Anxiety disorder patients either received treatment at our outpatient
behaviour therapy unit or were admitted for inpatient treatment.
They met ICD-10 criteria for anxiety disorders (16): panic disorder
(n = 23), social phobia (n = 14), agoraphobia with
panic disorder (n = 12), specific phobia (n = 5),
agoraphobia without panic disorder (n = 2), adjustment disorder
with predominant anxiety symptoms (n = 2), generalized anxiety
disorder (n = 1), and posttraumatic stress disorder with
predominant anxiety symptoms (n = 1).
OCD patients were treated as inpatients either in the University
Hospital of Hamburg or at Freiburg. All subjects were participants
in a multicentre study comparing the outcome of multimodal behaviour
therapy (MBT) and fluvoxamine vs placebo (17). They all had to meet
DSM-III-R criteria for an OCD (18). Diagnoses were made after a
structured clinical interview for DSM-III-R (SCID) (19). Patients
with a Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 16
or more were included in the study (20).
Control subjects were recruited mainly from
the staff of a large company (n = 35) or from the authors’
social surrounding (n = 25). Control subjects had to be free
of current or past psychiatric illnesses. They volunteered without
any payment. To avoid selection bias, control subjects were unaware
of their cholesterol levels and did not come from the same families.
Anxiety disorder and OCD patients and control subjects were matched
according to sex (30 men and 30 women) and age. Mean age in the
entire population was 35.2 years (SD 10.3, range 18 to 61 years).
Body mass index (BMI) was controlled in all anxiety patients, in
control subjects, and in all except 1 OCD patient (Table
1).
Data from a subsample of the whole population (anxiety disorder:
n = 30; OCD: n = 30) were already published in previous
studies (4,15).
Procedure
We drew all blood samples of anxiety disorder patients, OCD patients,
and control subjects after a night of fasting. We measured cholesterol
by means of enzymatic procedures (cholesterol oxidase/phenylperoxidaseaminophenozonphenol
[CHOD-PAP], Boehringer Mannheim), adapted to the Hitachi Analyzer
747. HDL and LDL cholesterol were measured in anxiety patients and
control subjects only. OCD patients participated in a study design
wherein only cholesterol levels were assessed. HDL was measured
by the same enzymatic procedure and by spectrometric analysis. We
calculated LDL cholesterol according to the method of Friedewald
and colleagues (21).
Results
Cholesterol levels in patients with anxiety disorder or OCD were
significantly higher than were levels in normal control subjects.
Cholesterol levels did not differ between anxiety disorder and OCD
patients (Table 1).
We performed a more detailed comparison of serum lipoproteins between
anxiety patients and control subjects. Compared with normal control
subjects, there was a highly significant increase in LDL, and HDL
was significantly decreased (Table
1).
The Expert Panel of the US National Education
Program guidelines (12) classify total cholesterol levels below
200 mg/dl and LDL values below 130 mg/dl as “desirable”
values. Total cholesterol levels above 199 mg/dl and LDL values
above 129 mg/dl, however, are classified as borderline high or high
cholesterol (³ 240 mg/dl) and borderline high LDL or high LDL
(³ 160 mg/dl), respectively. Of the anxiety disorder patients,
41/60 (68%) had borderline high or high cholesterol, as did 39/60
(65%) OCD patients. Of the control subjects, 18/60 (30%) had these
levels. In addition, 14 anxiety disorder patients (23%) and 18 OCD
patients (30%), compared with 8 control subjects (13%), exceeded
the upper threshold of 240 mg/dl (c2 = 23.7, df 4, P = 0.0001)
(Figure 1).
Of 60 anxiety disorder patients, 34 (56%) and of 60 control subjects
15 (25%) had high or borderline high LDL levels. Similarly, 15 anxiety
disorder patients (25%) and only 6 control subjects (10%) exceeded
the upper threshold of 160 mg/dl (c2 = 13.1, df 2, P = 0.001).
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