Correlation of severity of panic disorder and neuroanatomical changes on magnetic resonance imaging

Thirty consecutive lactate-sensitive panic disorder patients were studied with magnetic resonance imaging (MRI) to investigate the relationship between temporal lobe abnormalities and panic disorder. Neuroanatomical abnormalities, most involving the right temporal lobe, were found in 43% of patients, compared with 10% of the control subjects. Patients with temporal lobe abnormalities were significantly younger at the onset of panic disorder and had more panic attacks compared with patients with normal MRI scans (p less than .05). These results suggest that panic disorder could be secondary to temporal lobe dysfunctions and that panic disorder patients with abnormal MRIs could have a worse prognosis than those with normal MRIs and would require long-term pharmacological treatment.

Obsessive disorder with self-mutilation: a subgroup responsive to pharmacotherapy

Obsessive-compulsive disorder (OCD) can be considered a complex entity with possibly different subgroups responsive to specific treatment. This article presents two cases of OCD with self-mutilation, successfully treated with serotonergic antidepressants. The authors discuss a sub-group of OCD patients whose rituals present as self-destructive behavior and are responsive to pharmacotherapy.

[Neurobiology in panic states]

Research in panic disorder (PD) has highlighted a low biological threshold (lactate infusion). Also, several studies have shown neurophysiological changes with PD patients: increased brain perfusion (Stewart), parahypocampal hyper-perfusion (Reiman) and we reported an increased incidence of epileptiform abnormalities. In order to assess neuroanatomical changes we carried out a study with magnetic resonance imaging (MRI) of P.D. as compared to controls. A prospective study with MRI was done with 13 P.D. patients and 10 controls. The inclusion criteria were outpatients with P.D. according to DSM-III criteria. All subjects (patients and controls) were right handed and between 18 and 40 years of age. Usual exclusion criteria were used. A Signa MR machine of 1.5 telsa (General Electric) was used and images in T1, T2 mode were generated. We found a higher percentage of brain atrophy in patients with PD (64%) than with controls (20%) and the differences reached significance (p-.04-Fisher ex. test). Right temporal lobe horn atrophy was the most common finding in P.D. patients. There were no difference between patients and controls for age, sex and weight. We have found anatomical changes in young P.D. patients. Whether this atrophy found with MRI and physiological changes previously reported are related should assessed further. However, our findings support biological factors in the etiology of PD and stimulates the development of better pharmacological treatments.

Comparison of withdrawal of buspirone and diazepam: a placebo controlled study

In a 8-week double-blind placebo controlled study, 48 outpatients with generalized anxiety disorder were randomized to diazepam, buspirone, a non-benzodiazepine anxiolytic, or placebo. During the treatment phase of 4 weeks duration diazepam was found to be significantly better than placebo and buspirone. Following abrupt withdrawal by placebo substitution the diazepam group showed a gradual relapse maximal after two weeks while the buspirone and the placebo groups did not differ. There were more cases of rebound anxiety with diazepam as compared to buspirone or placebo. In addition, there were three early terminations related to rebound anxiety in the diazepam group while there were none in the placebo and buspirone groups. There were significantly more new symptoms in the diazepam group than in the placebo or buspirone group.

Bromazepam and lorazepam in generalized anxiety: a placebo-controlled study with measurement of drug plasma concentrations

Sixty outpatients with a diagnosis of generalized anxiety were randomly assigned to 4 weeks of treatment with bromazepam, lorazepam or placebo, following a 1-week placebo washout period. There was no significant difference in the anxiolytic effects of bromazepam and lorazepam, both of which were superior to placebo. However, lorazepam-treated patients tended to have a more depressed mood than those treated with bromazepam. Drug-treated patients had consistently less cognitive impairment than those treated with placebo, the difference being statistically significant (P less than .05) in the case of bromazepam. The most frequent side-effects reported with each drug were drowsiness, which tended to subside with time, and depression, which tended to emerge toward the end of the 4-week period. There was a positive correlation (r = 0.64) between age and bromazepam plasma concentration per unit dose, adjusted for weight, and a negative correlation (r = -0.50) between weight and lorazepam plasma concentration per unit dose, adjusted for age.

An open clinical trial of fluoxetine in the treatment of obsessive-compulsive disorder

In a 9-week open label study, seven outpatients with obsessive-compulsive disorder were treated with fluoxetine, a selective inhibitor of neuronal reuptake of serotonin. After a 7-day placebo washout period, patients were given a dose of 40 mg/day, which was gradually increased to a maximum of 80 mg/day. A significant improvement was found in the symptomatology of patients as measured on the obsessive-compulsive subscale of the Comprehensive Psychopathological Rating Scale (p less than 0.001) and the Clinical Global Impression of severity of illness (p less than 0.01). These findings support the hypothesis that serotonergic antidepressants may be useful in the treatment of obsessive-compulsive disorder and underline the need to carry out double-blind clinical trials to confirm these results.

Treatment of bulimia with nomifensine

The authors treated 12 consecutive bulimic patients with nomifensine, a novel antidepressant recently approved for American use. Two patients developed fever, necessitating discontinuation of the drug. Of the other 10 patients, nine showed moderate or better improvement, with strikingly few side effects.

Clonazepam in the treatment of patients with recurrent panic attacks

Imipramine, phenelzine, and alprazolam have each been shown to be efficacious in the treatment of panic disorder and in agoraphobia with panic attacks. Clonazepam is a high-potency 1,4-benzodiazepine derivative with an intermediate to long elimination half-life that is used mainly in neurology as an antiepileptic. Eight cases of recurrent panic attacks successfully treated with clonazepam are reported.

Unilateral ECT: advantages and efficacy in the treatment of depression

Electroconvulsive therapy is an efficacious treatment for some acute or drug resistant psychiatric disorders. However, there is some concern with memory impairment and brain damage and in order to decrease these complications, some changes to the technical aspect of electroconvulsive therapy were implemented during the last few decades. One of the major changes is the use of unilateral electrical stimulation on the non-dominant hemisphere which leads to less memory impairment and faster recovery time of cognitive functions. However, for optimal efficacy several variables have to be understood and integrated: electrodes placement, interelectrodes distance, waveform stimuli.

An open clinical trial of clonazepam in the treatment of patients with recurrent panic attacks

Imipramine, phenelzine and alprazolam have each been shown to be efficacious in the treatment of panic disorder and in agoraphobia with panic attacks. Clonazepam, a 1,4 benzodiazepine derivative used mainly in neurology as an anti-epileptic, has specific pharmacodynamic and pharmacokinetic properties which would make it an advantageous antipanic agent. We report 8 cases of recurrent panic attacks which were successfully treated with clonazepam.

Fluoxetine in the treatment of obsessive compulsive disorder

In a 9-week open-label study, 7 outpatients with obsessive compulsive disorder were treated with fluoxetine, a selective inhibitor of neuronal reuptake of serotonin. A significant improvement was found in the symptomatology of patients as measured on the obsessive compulsive subscale of the Comprehensive Psychopathological Rating Scale (p less than 0.001) and the Clinical Global Impression of severity of illness (p less than 0.01). These findings support the hypothesis that serotoninergic antidepressants may be useful in the treatment of obsessive compulsive disorder.

Rebound anxiety in anxious patients after abrupt withdrawal of benzodiazepine treatment

In this double-blind, placebo-controlled study of 4 weeks of benzodiazepine treatment followed by 3 weeks of abrupt or gradual drug withdrawal, 16 patients whose benzodiazepine was withdrawn abruptly were worse (p less than .05) than 13 who had received placebo in terms of change in mean anxiety scores from the pretreatment level. The scores of seven patients (44%) whose benzodiazepine was withdrawn abruptly increased 10% or more on both the Hamilton Rating Scale for Anxiety and the Self Rating Symptom Scale. There were no cases of rebound anxiety in 14 patients whose benzodiazepine was withdrawn gradually; fewer cases of rebound anxiety were seen with a benzodiazepine that had a long half-life.

Panic attacks and panic disorders

The diagnosis and treatment of panic attacks and panic disorders have progressed markedly during the last decade. Unlike phobic disorders, the key feature of panic disorders is the many panic attacks that are mostly spontaneous or not caused by a particular situation. Recent studies linking its pathogenesis with lactate infusion tests are reviewed. For treatment, psychotherapy combined with in vivo exposure and pharmacotherapy is more efficacious than either treatment alone. In most cases, psychological treatment is supportive psychotherapy. The use of imipramine, as reported by Klein et al., is described, and alprazolam is presented as an alternative.