Panic disorder, phobias, and generalized anxiety disorder

The use of virtual reality in acrophobia research and treatment

Acrophobia, or fear of heights, is a widespread and debilitating anxiety disorder affecting perhaps 1 in 20 adults. Virtual reality (VR) technology has been used in the psychological treatment of acrophobia since 1995, and has come to dominate the treatment of numerous anxiety disorders. It is now known that virtual reality exposure therapy (VRET) regimens are highly effective for acrophobia treatment. This paper reviews current theoretical understanding of acrophobia as well as the evolution of its common treatments from the traditional exposure therapies to the most recent virtually guided ones. In particular, the review focuses on recent innovations in the use of VR technology and discusses the benefits it may offer for examining the underlying causes of the disorder, allowing for the systematic assessment of interrelated factors such as the visual, vestibular and postural control systems.

[Influence of morbidity and the use of health resources in patients who require care for generalised anxiety disorder in the primary health care setting]

OBJECTIVE

To evaluate the co-morbidity, health care use, economical impact, and availability of effective treatments used in generalised anxiety disorder (GAD) patients in a primary care setting (PCS).

METHOD

A retrospective multicentre population-based study.

SETTING

Five primary care clinics managed by Badalona Serveis Assistencials S.A., Barcelona, Spain.

PARTICIPANTS

Outpatient records of patients over 18 years managed at 5 PCSs during 2006. Patients with and without GAD were compared. In GAD patients, 4 groups were established for comparison, according to pharmacological prescription.

MEASUREMENTS

Main outcomes measures were general, reason/co-morbidity, health care use and primary care cost (visits, diagnostic/therapeutic tests, and drugs). We counted work absenteeism as an indirect cost. Pharmacological prescription was studied according to evidence-based recommendations and Spanish health-approved indications. The statistical analysis included a multivariate model: logistic regression, analysis of covariance (ANCOVA), P< .05. RESULTS. Of the 65 767 patients included, 4.6% (95% confidence interval [CI], 3.9-5.3) had GAD. Patients with/without GAD, the average episode/year was 6.1 versus 4.7 and attendance/year 10.0 versus 7.6; P< .001. GAD was associated with women (odds ratio [OR], 1.8), dyslipidemia (OR, 1.2), smoking (OR, 1.4), depression (OR, 1.2), and cerebrovascular accident (OR, 1.6) (P< .02). The mean direct cost/year adjusted by age, gender and morbidity load was euro686 versus euro557 (P< .001). GAD was associated with higher directs costs. The recommended treatment was followed in 40.1% of total patients (95% CI, 38.4-41.8).

CONCLUSIONS

Patients with GAD have greater co-morbidity and higher direct costs in PCS. Means designed to improve the recognition and treatment of these patients should be established in the PCS.

High-frequency stimulation of the dorsolateral periaqueductal gray and ventromedial hypothalamus fails to inhibit panic-like behaviour

Electrical stimulation of the dorsolateral periaqueductal gray (dlPAG) and one of its target structures, the ventromedial hypothalamus (VMH), produces a typical behaviour in rats consisting of vigorous running and jumping which is known as "escape behaviour". Escape behaviour in rodents closely mimics panic attacks in humans. Since electrical stimulation at higher frequencies generally inhibits the stimulated region, we tested in this study the hypothesis that deep brain stimulation (DBS) of the dlPAG and VMH at higher frequencies (> 100 Hz) would not induce escape behaviour. More specifically, we evaluated whether experimental DBS could be used to inhibit panic-like behaviour. Rats underwent implantation of DBS-electrodes at the level of the dlPAG and VMH and the effects of various stimulation parameters were assessed. In addition, we studied the neural activation pattern resulting from DBS of the dlPAG and VMH using c-Fos immunohistochemistry. We found that stimulation amplitude is the most important stimulation parameter in the induction of escape behaviour. Remarkably, stimulation frequency (1-300 Hz) had no effect on stimulation-induced escape behaviour and therefore it was not possible to prevent the induction of escape behaviour with higher frequencies. The neuronal activation pattern resulting from dlPAG and VMH DBS was similar. These findings suggest that DBS of the dlPAG and VMH induces panic-related behaviours even at higher frequencies.

Is aversive learning a marker of risk for anxiety disorders in children?

Aversive conditioning and extinction were evaluated in children with anxiety disorders (n=23), at-risk for anxiety disorders (n=15), and controls (n=11). Participants underwent 16 trials of discriminative conditioning of two geometric figures, with (CS+) or without (CS-) an aversive tone (US), followed by 8 extinction trials (4 CS+, 4 CS-), and 8 extinction re-test trials averaging 2 weeks later. Skin conductance responses and verbal ratings of valence and arousal to the CS+/CS- stimuli were measured. Anxiety disordered children showed larger anticipatory and unconditional skin conductance responses across conditioning, and larger orienting and anticipatory skin conductance responses across extinction and extinction re-test, all to the CS+ and CS-, relative to controls. At-risk children showed larger unconditional responses during conditioning, larger orienting responses during the first block of extinction, and larger anticipatory responses during extinction re-test, all to the CS+ and CS-, relative to controls. Also, anxiety disordered children rated the CS+ as more unpleasant than the other groups. Elevated skin conductance responses to signals of threat (CS+) and signals of safety (CS-; CS+ during extinction) are discussed as features of manifestation of and risk for anxiety in children, compared to the specificity of valence judgments to the manifestation of anxiety.

Translational aspects of pharmacological research into anxiety disorders: the stress-induced hyperthermia (SIH) paradigm

In anxiety research, the search for models with sufficient clinical predictive validity to support the translation of animal studies on anxiolytic drugs to clinical research is often challenging. This review describes the stress-induced hyperthermia (SIH) paradigm, a model that studies the activation of the autonomic nervous system in response to stress by measuring body temperature. The reproducible and robust SIH response, combined with ease of testing, make the SIH paradigm very suitable for drug screening. We will review the current knowledge on the neurobiology of the SIH response, discuss the role of GABA(A) and serotonin (5-HT) pharmacology, as well as how the SIH response relates to infectious fever. Furthermore, we will present novel data on the SIH response variance across different mice and their sensitivity to anxiolytic drugs. The SIH response is an autonomic stress response that can be successfully studied at the level of its physiology, pharmacology, neurobiology and genetics and possesses excellent animal-to-human translational properties.

Threat-based cognitive biases in anxious children: comparison with non-anxious children before and after cognitive behavioural treatment

Attention and interpretation biases for threat stimuli were assessed in 19 anxious (ANX) children before and after cognitive behavioural therapy (CBT), and compared with responses from 19 non-anxious (NA) control children collected over the same period. Attentional bias was assessed using a picture version of the visual probe task with threat, neutral and pleasant pictures. Threat interpretation bias was assessed using both a homographs task in which children used homograph words in a sentence and their neutral or threatening meaning was assessed, and a stories task in which children rated their negative emotion, danger judgments, and influencing ability in ambiguous situations. ANX children showed attention biases towards threat on the visual probe task and threat interpretation biases on the stories task but not the homographs task at pre-treatment in comparison with NA children. Following treatment, ANX children's threat interpretation biases as assessed on the stories task reduced significantly to within levels comparable to NA children. However, ANX children continued to show larger attentional biases towards threat than pleasant pictures on the visual probe task at post-treatment, whereas NA children did not show attentional biases. Moreover, a residual threat interpretation style on the stories task at post-treatment was associated with higher anxiety symptoms in both ANX and NA children.

Depressive und Angststörungen bei somatischen Krankheiten

Depressiv-ängstliche Störungen sind bei den unterschiedlichen somatischen Erkrankungen häufig. Sie sind nicht nur als Reaktion auf die Situation der Erkrankung zu verstehen, sondern in ein komplexes Bedingungsgefüge eingebettet. Sie sind besonders häufig bei Erkrankungen, die das Zentralnervensystem oder endokrine Regulationssysteme direkt betreffen. Es besteht ein enger Zusammenhang zur Chronizität, Schwere und Prognose der Erkrankung. Eigenständige Effekte von diversen pharmakologischen Substanzgruppen sind wahrscheinlich.