[Panic attacks and anxiety depression. Clinical, biological and therapeutic update]

The breaking-up of anxiety neurosis and the particularization of panic attacks according to the DSM III square with the recent data of clinical, biological and therapeutic research. The alterations of anguish nosography go with a renewed outbreak of studies of clinical and biological ties between anxiety and anxious depressions. A review of the main recent work and their bibliography is displayed as their therapeutical involvement.

Autonomic characteristics of agoraphobia with panic attacks

We compared electrodermal and heart rate measures of autonomic activation between patients meeting DSM-III criteria for agoraphobia with panic attacks and controls in terms of tonic level, reactivity to various types of stimuli, recovery, habituation, and spontaneous variability. The most striking differences between groups in the laboratory were higher tonic levels of skin conductance and heart rate among patients. Patients' heart rates were also tonically elevated in a test situation outside the laboratory. Certain measures of habituation and spontaneous variability also differed between groups, but there were only weak and inconsistent differences in reactivity to, or recovery from, stimuli with diverse qualities of novelty, startlingness, intensity, or phobicity. The elevated activation levels may be signs of a chronic state or may be phobic responses to the testing situations. A minority of patients failed to show these elevated levels.

Interface of panic and depression: clinical and sleep EEG correlates

Four groups of subjects were compared with respect to their clinical and demographic status and electroencephalographic (EEG) characteristics, namely: primary major depressive disorder (PRI MDD); panic disorder (Panic); "Mixed" group comprising patients meeting full syndromal criteria for MDD and panic occurring concomitantly; and normal controls. The "Mixed" (MDD + Panic) patients were characterized by earlier age of onset of psychiatric illness, longer duration of current episode, greater intensity of symptoms, higher impairment of functioning, increased miscellaneous psychopathology, and greater objective stress and anger. With respect to sleep EEG variables, PRI MDD patients were clearly different from the other three groups. The sleep profile of the "Mixed" group occupies an intermediate position between the "pure" Panic and MDD groups. Classification of the "Mixed" patients based on the discriminant function coefficients of the Schedule for Affective Disorders and Schizophrenia and sleep analysis of the "pure" groups (PRI MDD and Panic) reveals that some patients are classified as true PRI MDD while others are classified as falling somewhere along the PRI-MDD/Panic spectrum. The separation of the PRI MDD from Panic and Normals, however, is clear, suggesting that sleep can be successfully used as a physiological marker in the separation of these conditions.

Cholinergic mechanisms in affective disorders. Future directions for investigation

Advances in clinical and basic research methodology combined with clearly articulated concepts create new opportunities for researching the roles of cholinergic mechanisms in the pathophysiology of affective disorders. Areas for study include: roles of cholinergic mechanisms in mediating effects of stress and cholinergic mechanisms linking the pathophysiologies of affective and panic disorders, use of pharmacologic agents to produce cholinergic system supersensitivity in modeling biologic aspects of affective illness, use of multigenerational intrapedigree studies of cholinergic markers associated with affective disease, research into the neurobiology of lithium and ECT as they pertain to muscarinic cholinergic mechanisms, study of the interrelationship of sodium, calcium and lithium ion metabolism and their relationship to cholinergic-monoaminergic interaction, the development of brain imaging strategies and techniques, e.g., positron emission tomography (PET), to measure changes in cholinergic receptor density and affinity as a function of clinical state, identification and validation of a peripheral model of the central muscarinic receptor, study of the pharmacology of abusable substances and its relationship to mechanisms regulating mood, affect, psychomotor function and other variables related to the affective disorders, and development of in vitro and in vivo models useful in studying the physiology and biochemistry of the interaction of cholinergic and monoaminergic neurons. These models may allow us to bridge the traditional cholinergic and monoamine hypotheses of affective disorders.

Panic attacks: new approaches to an old problem

Anxiety attacks were included in the first descriptions of the syndrome of anxiety neurosis. Recently it has been suggested that such attacks (now usually called panic attacks) characterize a distinct form of anxiety disorder--panic disorder. It has also been proposed that panic attacks result from a biochemical disorder and require pharmacological treatment. Some of the evidence for these ideas is presented, and two other explanations for panic attacks are reviewed: that they are caused by hyperventilation, and that they result from a cognitive disorder. It is concluded that although it is not possible on the present evidence to choose between the three theories, there is strong indirect support for the cognitive theory and good reason to investigate cognitive factors more thoroughly. Future work on biochemical causes of, and pharmacological treatments for panic attacks should take account of such factors.

Individualization: the categorical imperative of behavior therapy practice

The fact that unadaptive neurotic anxiety response habits are learned makes it necessary for the stimulus antecedents to be accurately defined in every case in order to plan effective treatment. This requirement has been frequently neglected in recent years that have witnessed a growing tendency to apply common treatments to cases with common labels, e.g. agoraphobia. This paper argues for the desirability of accurate individual diagnosis, and illustrates its benefits in unique cases and also in respect of three common syndromes--agoraphobia, panic attacks and depression.

Skin conductance feedback and panic attacks

A method is described for using skin conductance response (SCR) biofeedback to help patients control their panic attacks. The SCR signal is presented as a symptom analogue, and patients practice provoking and subduing the signal, using a combination of cognitive strategies and physiological relaxation.

Platelet serotonin uptake in panic disorder

Platelet serotonin uptake was measured in 45 patients (12 males, 33 females) with panic attacks and 21 controls (9 males, 12 females). Higher Vmax values were obtained in the patient group than in the controls (100.2 +/- 11.5 vs. 34.9 +/- 3.8 pmol/10(8) platelets/min; P less than 0.0005) while the affinity constant Km was not significantly different (2.28 +/- 0.3 vs. 1.71 +/- 0.18 microM). A value of Vmax in excess of 60 pmol/10(8) platelets/min was observed in 60% of patients and in only 5% of controls. The results point to a specific abnormality of platelet serotonin uptake in patients with panic attacks.

Immunological response to stress in agoraphobia and panic attacks

The authors studied in vitro immune function as measured by lymphocytic proliferative response to mitogen stimulation in 36 patients with agoraphobia and panic attacks who were participating in a double-blind placebo-controlled psychopharmacological study of anxiety disorder. No significant difference in immune status was observed between panic patients and healthy controls.

[Spasmophilia or panic attack?]

For many years, the symptoms grouped under the label "spasmophilia" have been differently evaluated in France by psychiatrists, who ascribe them to hysteria or anxiety, and by endocrinologists and general practitioners for whom they are all due to neuromuscular hyperexcitability, the cause of which must be sought in the biochemistry of calcium. Recent studies on anxiety should reduce the gap between these discordant views. The concept of anxiety itself has changed owing to the discriminant effects of psychotropic drugs and to a classification based on precise diagnostic criteria without theoretical presuppositions. Since anxiety can be biochemically induced, the hypotheses put forward by "spasmophilologists", such as disorders of calcium metabolism or hyperventilation, can now be tested in the laboratory.

Pathophysiology of panic: a review of pharmacologic provocative tests and naturalistic monitoring data

Panic is a psychologic symptom with prominent physiologic manifestations. Pathophysiologic theories need to explain both the central emotional state and peripheral symptoms. This paper reviews current findings and hypotheses from studies using two strategies for understanding panic. First, recent results from provocative tests using sodium lactate, caffeine, CO2, yohimbine, and isoproterenol suggest panic patients have a special sensitivity to these substances. Underlying mechanisms may be related to abnormal functioning of the central noradrenergic (locus ceruleus) system. However, cognitive and behavioral aspects of pharmacologic provocative testing need further study. Second, naturalistic studies support findings of peripheral physiologic activation during panic, but do not show evidence for sustained hyperactivity throughout the day. Studies of phobic patients demonstrate the potential for imagined fear to provoke physiologic changes, again underlining the need to pay attention to psychologic aspects of panic.

Episodic hypertension secondary to panic disorder

Episodic elevation of blood pressure was evaluated in two middle-aged men by assessing home, clinic, and 24-hour ambulatory values following exclusion of secondary forms of hypertension. Both individuals had normotensive home and clinic readings. The 24-hour blood pressure was 125/85 +/- 12/9 mm Hg in patient 1 and 119/84 +/- 13/13 mm Hg in patient 2; however, both patients experienced large, sustained rises in blood pressure associated with panic attacks that were not abolished with prophylactic benzodiazepine therapy. Episodic blood pressure elevations were not associated with concomitant increases in heart rate. Patient 1 underwent extensive psychological investigation that diagnosed a panic disorder, and he underwent therapy that reduced the frequency and intensity of his panic-related hypertensive episodes. Because patient 2 demonstrated hypertensive readings at work, he was given a beta-blocking agent that ultimately controlled his blood pressure during episodes of anxiety and panic. These findings suggest that patients with panic attacks may present with episodic hypertension and that ambulatory blood pressure monitoring is useful in the diagnosis of this disorder and in assessment of treatment outcome.

Mindlessness and brainlessness in psychiatry

The theme of this address—that brain and mind are as warp and woof in the fabric of psychiatry—may seem so much a truism as to be a banal choice. I think not. Despite the lip service paid to brain-mind integration, its implications are daily contravened in both theory and practice. At least, this is so in the country where I reside. If the problem is more extreme in the States, as most everything seems to be, recall the words Sir Aubrey Lewis (1953) wrote in commenting on Anglo-American contrasts, some 30 years ago: “the chief differences between your psychiatric scene and ours are differences only of quantity and tempo.” Think of me, then, as an anthropologist describing an exotic foreign culture and reporting on the strange customs of the natives, in hope of shedding light on your own.

Respiratory control in the treatment of panic attacks: replication and extension with concurrent measurement of behaviour and pCO2

A case series is reported in which nine patients who experienced phobic and/or nonphobic panic attacks were given a cognitive-behavioural treatment based on the supposition that catastrophic interpretations of sensations produced by hyperventilation played an important role in their attacks. Large and rapid reductions in panic attack frequency and questionnaire report of fear were observed. Patients' resting pCO2 was significantly lower than controls and rose to normal levels during treatment.

Postpanic anxiety disorder: diagnosis and treatment

Patients with a postpanic anxiety disorder (PPAD) have panic attacks less frequently than patients with a panic disorder. A PPAD must be suspected when a physician notes the following: persistent somatic complaints despite repeatedly normal results of physical examinations and laboratory tests, reluctance to engage in certain activities or avoidance of activities because the patient fears the precipitation of panic or aggravation of symptoms, and history of one or more panic attacks. Three different groups of medication are effective in the treatment of PPAD: alprazolam (a triazolobenzodiazepine), imipramine (a tricyclic antidepressant), and phenelzine (a monoamine oxidase inhibitor). Relaxation training, desensitization, and family conferences assist in lowering anxiety and in improving the prognosis. An early diagnosis of PPAD reduces the patient's discomfort and morbidity and lowers the cost of medical care.

Simultaneous panic and depressive disorders: clinical and sleep EEG correlates

Panic and depressive symptoms occur simultaneously in many depressed patients. To study the frequency of this association and to determine whether patients with simultaneous panic and major depression differed from those with only major depressive disorder (MDD) in clinical features and in sleep electroencephalographic (EEG) variables, we evaluated a total sample of 336 patients with MDD. Fifty-eight (17%) had both panic and MDD; 50 had complete data and were matched for age and severity of illness with other patients having only MDD. Patients with simultaneous panic and depression had significantly higher ratings for psychic and somatic anxiety, and rapid eye movement (REM) latencies approximating normal values. Patients with only MDD (without panic disorder) rated significantly higher in guilt feelings and had shorter REM latencies. Our results suggest that the simultaneous occurrence of panic and depression is relatively frequent, is accompanied by differences in sleep EEG variables, and may have implications for treatment.

Agoraphobia: a superstitious conditioning perspective

The disabling escape and avoidance behaviors of agoraphobics are known to be psychological sequelae to the onset of apparently spontaneous attacks of severe anxiety. Evidence is cited in favor of the view that such spontaneous panic attacks have a biological etiology and that the avoidance rituals and escape behavior of the agoraphobic may be accounted for in terms of superstitious conditioning. Although panic attacks subside within a few minutes, in most cases, regardless of the activities of the individual, ongoing operant behavior such as flight may be adventitiously reinforced by the removal of severe anxiety. Only a few such episodes may be required to establish superstitious avoidance. This analysis is supported by extensive clinical research indicating that an effective technique in alleviating agoraphobic behavior consists of exposing the patient for prolonged periods of time to anxiety-evoking situations while he refrains from all escape and avoidance behavior. This appears to weaken the apparent established contingency relationships between panic relief, and phobic escape and avoidance, and extinguishes such superstitious behavior.

Effect of a selective serotonin uptake inhibitor in agoraphobia with panic attacks. A double-blind comparison of zimeldine, imipramine and placebo

A double-blind clinical trial of zimeldine, a potent inhibitor of central serotonin reuptake, versus imipramine and placebo was carried out on 44 patients suffering from agoraphobia with panic attacks. Zimeldine was a superior treatment on all rating scales other than a global rating scale which did not reach statistically significant superiority. Imipramine was not shown to be superior to placebo. The implications of these results for further research on the underlying pathophysiology of agoraphobia with panic attacks are discussed.

Effects of lactate-induced panic attacks on brain stem auditory evoked potentials

As the clinical symptomatology of panic attacks may be conceivably related to abnormal brain stem activity, the present study examined the effect of lactate-precipitated panic on brain stem auditory evoked potentials (BSAEPs). The subjects were 27 patients who met DSM-III criteria for panic disorder (Pd), agoraphobia with panic attacks (AgPa) or agoraphobia (Ag). Following drug washout, patients were tested in two separate sessions, in a double-blind randomised controlled design in which each session involved two sequentially ordered BSAEP collection periods - a baseline period with no infusion followed by an intravenous infusion of 5% dextrose in water or 1.0 M sodium lactate (5 ml/kg in 5% dextrose/water) over a 20-min period. Of the 27 patients, 17 were clear responders, reporting panic attacks and self-report changes under lactate similar to those occurring during spontaneous panic. Of the remaining 10 patients, 6 were pseudo-responders, reporting panic symptoms under both dextrose and lactate, and 4 were non-responders. In the clear responders, lactate did not alter electrical events of the BSAEP, but further analysis within the clear responders, comparing AgPa patients with Pd patients, yielded a significant effect with lactate resulting in a prolonged III-V inter-peak interval in the AgPa group. It is suggested that the increased III-V interval in the AgPa group may be reflective of hyperactivity of brain stem noradrenergic nuclei.

[Panic attacks in adolescents]

Anxiety has been the object of many therapeutic attempts, often in the absence of well-founded indications and often yielding inconclusive results. We obtained good results in two adolescents for whom we used a new classification system based upon the differential action of psychotropic drugs on anxiety. More specifically, this approach singled out the panic disorder by demonstrating that patients with this disorder react specifically to antidepressant drugs. More extensive studies are clearly needed to confirm that these results, well established for adult patients, also apply to an adolescent population.

The biological basis of anxiety. An overview

The DSM-III divides anxiety disorders into two broad categories, Phobic Disorders and Anxiety States. Anxiety states characterised by panic attacks have been separated from generalised anxiety disorders. While this classification may not be generally accepted it is of heuristic value. Delineation of panic disorder as a distinct diagnostic entity has led to renewed efforts to identify a biological cause for the sudden severe somatic and psychological symptoms experienced by these patients. A review of evidence for the involvement of the major neurotransmitter systems is presented. Systematic investigations in DSM-III defined groups of patients are only beginning to be reported. It is difficult as yet to draw any definite conclusions, but some tentative evidence for abnormalities of the noradrenergic system and the GABA-benzodiazepine chloride ionophore receptor complex are emerging. The reliable induction of panic attacks by chemical agents provides the promise of a greater understanding of the possible biological mechanisms involved in this anxiety disorder.

Platelet monoamine oxidase activity in patients with panic disorder

Preliminary reports have indicated that platelet monoamine oxidase (MAO) activity is elevated in patients with anxiety disorder. We compared MAO activity in 20 drug-free patients with panic disorder with 20 age- and sex-matched normal controls. MAO activity in patients was significantly higher than in normals. MAO activity was not correlated with age or plasma catecholamine levels. The authors speculate about the possible significance of elevated MAO activity in patients with panic disorder.

Ambulatory monitoring of panic disorder

Twelve patients with panic disorder and 11 control subjects received 24-hour ambulatory monitoring of heart rate, finger temperature, ambient temperature, and self-rated anxiety. No differences were found between groups in tonic levels of any measure or in their patterns of variation throughout the day. However, substantial heart rate increases and finger temperature changes did occur in panic attacks but not during control periods having equally high anxiety ratings. These measures may be useful in the diagnosis of panic disorder and in the assessment of treatment outcome.

A case of panic disorder treated with breathing retraining

In view of the marked prevalence of panic attacks in psychiatric populations, it is surprising that little interest has been devoted to their behavioral management. It has been suggested that hyperventilation may be important in the onset and/or maintenance of panic attacks and hence some form of respiratory control may be of value in their treatment. A method of breathing retraining is presented and applied to a subject suffering panic disorder (DSM-III). The results indicate that breathing retraining can reduce the frequency and intensity of panic attacks. A number of suggestions are made regarding the nature of panic attacks including the possible role of aberrant cognitions and the unique nature of panic attacks compared to other forms of anxiety.

Normalization of venous pH, pCO2, and bicarbonate levels after blockade of panic attacks

Recent evidence suggests that hyperventilation may be associated with spontaneous panic attacks in patients with panic disorder. This is reflected in abnormal patterns of blood gas and blood pH levels in these patients. In this study, absolute levels and variances of pH, pCO2, and bicarbonate were compared between controlled patients before and after successful pharmacological treatment. The results indicate that successful treatment of panic disorder results in a normalization of pH, pCO2, and bicarbonate levels.

Normal pain sensitivity in patients with panic disorder

The pain sensitivity of 18 patients with panic disorder and age- and sex-matched controls was assessed by signal detection analysis. The authors failed to demonstrate any difference in pain sensitivity between the two groups. The relationship between state anxiety, as assessed by the Spielberger scale, and pain in panic patients tended to be in the opposite direction from that in normals.

Urinary catecholamines and mitral valve prolapse in panic-anxiety patients

Free norepinephrine and epinephrine were measured in two consecutive 12-hour urine collections gathered during normal activity and sleep from 23 panic-anxiety patients and 9 normal subjects. Mitral value prolapse (MVP) was found in 7 of 20 patients who had echocardiograms. Mean nighttime norepinephrine and epinephrine excretion in panic-anxiety patients without MVP was significantly higher than that of control subjects, and was significantly higher than that of anxiety patients with MVP. In the daytime, all groups had higher catecholamine (CA) levels, but the differences between the groups were less pronounced. Medication significantly relieved symptoms and was associated with decreased CA levels. Elevated basal CA levels may characterize the subgroup of panic-anxiety patients who do not have MVP.

Sodium lactate infusion, panic attacks, and ionized calcium

The ability of sodium lactate to precipitate panic attacks in vulnerable individuals has been repeatedly demonstrated, although its mechanism of action is unknown. Pitts and McClure hypothesized that the panicogenic effect of sodium lactate was due to its induction of a peripheral hypocalcemia via the complexing of infused lactate ions with extracellular ionized calcium. In the current study, serial ionized calcium measurements during lactate infusion are assessed for 22 panic patients who panicked during infusion, 11 panic patients who did not panic during the procedure, and 6 normal controls. Intravenous sodium lactate infusion was found to be associated with a significant decrease in ionized calcium in all groups. No specific association was found between the rate or magnitude of decrease in ionized calcium and the occurrence of a panic attack during the infusion.

The sleep of patients with panic disorder: a preliminary report

Electroencephalographic sleep recordings were compared in patients with panic disorder and normal controls. Correlation coefficients of standard sleep parameters versus ratings of anxiety, depression, and panic attack frequency were calculated in the panic-anxious patients. Overall findings are discussed in the context of previous sleep studies in patients with depressive, anxiety, and obsessive-compulsive disorders.

Panic disorder and somatization. Review of 55 cases

A retrospective study of 55 patients with panic disorder referred for psychiatric consultation by primary care physicians is presented. Eighty-nine percent of the patients initially presented with one or two somatic complaints, and misdiagnosis often continued for months or years. The three most common presentations were cardiac symptoms (chest pain, tachycardia, irregular heart beat), gastrointestinal symptoms (especially epigastric distress), and neurologic symptoms (headache, dizziness/vertigo, syncope, or paresthesias). Eighty-one percent of patients had a presenting pain complaint. Hypertension and peptic ulcer were the most common medical diagnoses, and depression and alcoholism the most frequently associated psychiatric diagnoses.

Some biochemical correlates of panic attacks with agoraphobia and their response to a new treatment

Thirty-two patients with chronic debilitating agoraphobia and panic attacks participated in a comparative study of the triazolobenzodiazepine alprazolam and the anti-inflammatory agent ibuprofen. After a 2-week placebo washout period, patients were randomly assigned to 8 weeks of treatment with alprazolam (2 to 6 mg/day) or ibuprofen (0.8 to 2.4 g/day). Medication was identically packaged and patients were blind to the treatment condition, but investigators were aware of which medication was dispensed. Alprazolam recipients (mean daily dose: 5.4 mg) improved markedly with respect to physician and patient global rating of disease severity, frequency and severity of panic attacks, and phobic anxiety target symptoms on the 90-Item Hopkins Symptom Check List. Ibuprofen recipients (mean daily dose: 2.13 g) experienced significantly less clinical improvement than patients on alprazolam. After 8 weeks of treatment, ibuprofen patients were crossed over to alprazolam, while the original alprazolam group continued on that drug. The daily dosage ceiling was increased to 10 mg. In the ensuing 4 weeks (mean daily alprazolam dose: 6.3 mg), all patients achieved comparably marked clinical improvement relative to baseline. Pretreatment plasma concentrations of platelet factor 4 and beta-thromboglobulin--two measures of platelet turnover and release--were significantly elevated in patients relative to normal controls. The elevated platelet factor 4 and beta-thromboglobulin normalized during treatment with both drugs. Alprazolam appears to produce rapid and specific clinical improvement in patients with severe agoraphobia and panic attacks and deserves further evaluation under double-blind conditions.

A comparison of lactate and isoproterenol anxiety states

Both sodium lactate and isoproterenol can produce anxiety symptoms in patients with panic attacks. We administered both substances intravenously under placebo-controlled, double-blind conditions to patients with panic attacks and normal control subjects. We measured changes in anxiety levels using the Hamilton Anxiety Scale, State-Trait Anxiety Inventory, and a Panic Severity Scale. Measurements of respiratory rate and blood pH, pO2, pCO2, HCO3, and base excess were used to determine the relationship of hyperventilation to the symptoms induced by the infusions. Heart rate, epinephrine and norepinephrine levels were measured to determine whether there are changes related to palpitations and chest pain. Finger temperature and galvanic skin response were monitored to see whether any changes correlate with subject reports of hot or cold flashes and sweating. In this presentation, we will describe the clinical and biochemical changes that occur during panic attacks.

Psychophysiological factors in panic disorder

Panic disorder patients were compared with normal subjects during intravenous infusion of sodium lactate, isoproterenol, and placebo. Panic attacks meeting the criteria of the Diagnostic and Statistical Manual, vol. 3 [American Psychiatric Association, 1980] occurred during all three conditions in patients and during the lactate and isoproterenol infusions in normals. Patients had significantly higher average levels of skin conductance, heart rate and state anxiety, and significantly lower finger temperatures compared to normal subjects. However, no measure reliably differentiated panic attacks from nonattack periods. It is concluded that the peripheral physiologic responses investigated are neither necessary nor sufficient for the occurrence of panic attacks. It is possible that reports of these attacks represent phobic responses to intense anxiety.

Effect of acute beta-adrenergic blockade on lactate-induced panic

Many clinical and theoretic attempts have been made to link anxiety disorders and the beta-adrenergic nervous system. Six patients with panic disorder, who had panic attacks produced by sodium lactate infusions, were given repeated lactate infusions that were immediately preceded by intravenous administration of propranolol hydrochloride. In all cases, propranolol pretreatment infusion failed to prevent panic attacks, anxiety, tachycardia, and increased systolic BP during the lactate infusion.