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A relation between anxiety disorders and serum cholesterol level has been noted in contemporary psychiatric literature since 1989 (1). Panic disorder patients have significantly higher serum cholesterol levels, compared with age- and sex-matched normal control subjects (2,3). It can be speculated that lipoprotein lipase is induced by increased noradrenalin activity in panic disorder (2). This leads to a suggestion that the elevated cholesterol level is associated with increased autonomic arousal in panic disorder patients. An elevated serum cholesterol level was also found in posttraumatic stress disorder (PTSD) patients. Recently, Kagan and others reported elevated lipid levels in Vietnam veterans with chronic PTSD (4). Consequently, it has been hypothesized that increased catecholamine level or increased noradrenalin activity is related to lipoprotein lipase activity in PTSD patients as well as in panic disorder patients. Recent studies also report an association between increased cholesterol level and generalized anxiety disorder and phobias (5–7). There are 3 studies of serum cholesterol level in patients with obsessive–compulsive disorder (OCD). Freedman and others found normal cholesterol levels in OCD (8), whereas Peter and others (9) and Peter and others (10) reported increased cholesterol values in OCD patients, compared with control subjects. In our opinion, this issue needs further investigation. Panic attacks are also relatively frequent in OCD patients. Thus there is a need to clarify whether a high serum cholesterol level is associated with panic anxiety or whether serum lipid concentrations are consistently high regardless of the occurrence of panic attacks. In this study, we tested whether panic symptoms affect serum lipid concentrations in OCD patients. MethodsWe included 33 OCD patients and 33 healthy subjects in this study. OCD patients were recruited from consecutively presenting outpatients who sought psychiatric care at the Psychiatric Outpatient Clinic of the Yuzuncu Yil University Hospital in Van, Turkey. The patient and control groups were matched for sex and age. For each group, there were 18 men and 15 women. In each group, the subjects ranged in age from 18 to 57 years (mean 29.3, SD 9.5 years). The OCD patient group was divided into 2 subgroups: OCD patients with and without panic attacks. We used the Structured Clinical Interview for DSM-IV Axis I Disorders–ClinicianVersion (SCID-CV) (11) to establish OCD diagnosis and the presence of panic attacks without panic disorder. OCD patients with panic attacks were eligible for inclusion when their panic attacks were associated with obsessions and (or) compulsions. In other words, these subjects did not meet DSM-IV Criterion D for panic disorder. All participants had good physical health, as determined by physical and laboratory examination, and no history of psychotic disorders or current substance abuse. No OCD patients were treated with antidepressants or benzodiazepines during the study. We allowed a washout period of at least 2 weeks for psychotropic drugs before blood was collected. The control subjects were also drug-free during the study. We obtained the subjects’ written informed consent to participate in this study after the procedure(s) had been fully explained. All were requested to avoid medication affecting lipid levels (for example beta blockers, diuretics, androgens, estrogens, disulfiram, corticosteroids, levodopa, and aminosalycylic acid) for at least 2 weeks. All subjects abstained from a cholesterol-lowering diet. Blood samples were drawn after a night of fasting. Venipuncture was done in a sitting position with a tourniquet. Blood was then centrifuged at 1000 g for 1 minute in a refrigerated centrifuge, and the serum samples were separated from the cells. We determined total cholesterol, triglyceride, and high-density lipoprotein (HDL) levels in the serum, using commercially available kits (Roche Diagnostic GmbH, Mannheim, Germany) on a Hitachi 747 autoanalyzer (Hitachi Ltd, Tokyo, Japan). An enzymatic colorimetric method was used to determine total cholesterol and triglyceride. We used the direct HDL cholesterol method to measure HDL. Low-density lipoprotein (LDL) was calculated according to the Friedewald formula (12). We used the statistical Package for the Social Sciences (SPSS) for Windows version 9.01 (13) to perform analyses. Group data were analyzed using Student’s t test and one-way analysis of variance (ANOVA). We used the post hoc Bonferroni test to carry out post hoc comparisons of patient and normal subject means. ResultsThere was a significant difference between OCD patients and normal control subjects in serum HDL, very-low-density lipoprotein (VLDL), and tryglyceride levels. HDL level was lower in OCD patients than in normal control subjects (mean 39.3, SD 8.8 vs mean 48.2, SD 12.2; t = 2.84, P = 0.006). Conversely, VLDL and tryglyceride levels were higher (mean 29.4, SD 19.7 vs mean 26.2, SD 7.1; t = 2.04, P = 0.047 and mean 154.6, SD 87.1 vs mean 130.1 SD 36.2; t = 2.38, P = 0.043, respectively). Total cholesterol level did not differ between the groups (mean 164.4 SD 37.6 vs mean 173.6 SD 15.5; t = 1.02, P = 0.31). As a second step, we classified OCD patients into 2 subgroups: those who had panic attacks (at least 4 monthly) and those who never had panic attacks during their illness. Table 1 shows serum tryglyceride, total cholesterol, HDL, LDL, and VLDL levels across the groups. When we compared OCD patients with and without panic attacks and normal control subjects, we found a significant difference across the groups in HDL, VLDL, and tryglyceride levels. Post hoc comparison with the Bonferroni test revealed that significant differences in HDL, VLDL, and tryglyceride levels exist only between OCD patients with panic attacks and normal control subjects. Interestingly, OCD patients without panic attacks did not differ from normal control subjects.
DiscussionIn this study, we found that OCD patients had higher LDL, VLDL, and tryglyceride levels, but lower HDL levels, than normal control subjects. These findings replicate Peter and others’ (9) and Peter and others’ (10) reports. It may be suggested that OCD patients are at risk for coronory artery disease. In our second analysis, we found that only OCD patients with panic attacks had higher serum lipid concentrations when compared with normal control subjects. Serum lipid levels of pure OCD patients did not differ from control values. There has been much interest in the clinical and biological overlap of panic disorder and OCD (14). The present study suggests that the presence of panic symptoms is associated with high lipid levels in OCD patients. In a recent study, we suggested that a low serum cholesterol level might serve as a biological marker of major depression in patients with panic disorder (15). Similarly, panic attacks may predict alterations in serum lipid concentration in OCD patients. A limitation of the present study is that we did not assess depressive symptoms and aggressiveness in our patients. Future research should focus on the effect of depressive comorbidity and aggressive behaviours on serum lipid alterations in OCD patients. References1. Agargun MY. Serum cholesterol concentration, depression, and anxiety [editorial]. Acta Psychiatr Scand 2002;105:81–3. 2. Hayward C, Taylor CB, Roth WT, King R, Agras WS. Plasma lipid levels in patients with panic disorder or agoraphobia. Am J Psychiatry 1989;146:917–9. 3. Bajwa WK, Asnis GM, Irfan A, Von Praag HM. High cholesterol levels in patients with panic disorder. Am J Psychiatry 1992;149:376–8. 4. Kagan BL, Leskin G, Haas B, Wilkins J, Foy D. Elevated lipid levels in Vietnam veterans with chronic posttraumatic stress disorder. Biol Psychiatry 1999;45:374–9. 5. Kuczmierczyk AR, Barbee JG, Bologna NA, Townsend MH. Serum cholesterol levels in patients with generalized anxiety disorder (GAD) and with GAD and comorbid major depression. Can J Psychiatry 1996;41:465–8. 6. Peter H, Goebel PN, Müller S, Hand I. Clinically relevant cholesterol elevation in anxiety disorders: a comparison with normal controls. Int J Behav Med 1999;6:30–9. 7. Sevincok L, Buyukozturk A, Dereboy F. Serum lipid concentrations in patients with comorbid generalized anxiety disorder and major depressive disorder. Can J Psychiatry 2001;46:68–71. 8. Freedman DS, Byers T, Barrett DH, Stroup NE, Eaker E, Monroe-Blum H. Plasma lipid levels and psychological characteristics in men. Am J Epidemiol 1995;141:507–17. 9. Peter H, Hand I, Hohagen F, Koenig A, Mindermann O, Oeder F, and others. Serum cholesterol level comparison: control subjects, anxiety disorder patients, and obsessive–compulsive disorder patients. Can J Psychiatry 2002;47:557–61. 10. Peter H, Tabrizian S, Hand I. Serum cholesterol in patients with obsessive–compulsive disorder during treatment with behaviour therapy and SSRI versus placebo. Int J Psychiatry Med 2000;30:27–39. 11. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IVAxis I Disorders-Clinician Version (SCID-CV).Washington (DC): American Psychiatric Press; 1997. 12. Friedewald WT, Levy RI, Fredricskon DS. Estimation of the concentration of the low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499–502. 13. SPSS Inc. SPSS for Windows. Version 9.01. Chicago (IL): SPSS Inc; 1999. 14. Agargun MY, Kara H, Alpkan L, Ucisik M. Obsessive-compulsive symptoms in panic disorder. Eur Psychiatry 1996;11:207–8. 15. Agargun MY, Algün E, Ôekero—lu R, Kara H, Tarakçio—lu M. Low cholesterol level in patients with panic disorder: the association with major depression. J Affect Disord 1998;50:29-32. Author(s)Manuscript received September 2003, revised, and accepted January 2004. 1. Professor of Psychiatry, Yuzuncu Yil University School of Medicine Department of Psychiatry, Van, Turkey. 2. Assistant Professor of Biochemistry, Yuzuncu Yil University School of Medicine Department of Biochemistry, Van, Turkey. 3. Psychiatry Resident, Yuzuncu Yil University School of Medicine Department of Psychiatry, Van, Turkey. 4. Assistant Professor of Psychiatry, Yuzuncu Yil University School of Medicine Department of Psychiatry, Van, Turkey. 5. Professor of Biochemistry, Yuzuncu Yil University School of Medicine Department of Biochemistry, Van, Turkey. Address for correspondence: Dr MY Agargun, Yuzuncu Yil University, School of Medicine, Department of Psychiatry and Neuroscience Research Center Van 65200, Turkey e-mail: myagargun@kure.com.tr
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