Course and outcome in panic disorder: a review of recent follow-up studies

Comparative efficacy and acceptability of antidepressants and benzodiazepines for the treatment of panic disorder: A systematic review and network meta-analysis

OBJECTIVE

This systematic review aims to assess the efficacy and acceptability of the different types of antidepressants and benzodiazepines for the treatment of panic disorder (PD) in adult patients.

METHODS

PubMed, Web of Science, EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) published between 1995 and 2020 on the use of antidepressants and benzodiazepines for the treatment of PD. A systematic review and network meta-analysis were performed.

RESULTS

42 RCTs were included in the network meta-analysis, with a comparison of 11 interventions.Escitalopram (odds ratios OR 1.52, 95 % credible interval CI 1.09-2.10), venlafaxine (OR 1.33, 95 % CI 1.16-1.51) and benzodiazepines (OR 1.50, 95 % CI 1.29-1.75) had greater efficacy and acceptability than the placebo. Imipramine(OR 1.43, 95 % CI 1.15-1.79) was also demonstrated to be efficacious and tolerated but the results were restricted to small sample size. Moreover, paroxetine, sertraline, fluoxetine, citalopram and clomipramine (OR 1.37, 1.36, 1.45, 1.33 and 1.36, respectively) were more efficacious, although the acceptability of paroxetine and sertraline were significantly less tolerated than benzodiazepines. Notably, the efficacy of reboxetine and fluvoxamine were merely as equal as that of the placebo.

OUTCOMES

This is the first systematic review of antidepressants and benzodiazepines for the treatment of PD to use a network analysis. Escitalopram and venlafaxine as well as benzodiazepines may be effective choices as treatments for PD with relatively good acceptability, which still needs to be confirmed byhigh-quality RCTs.

Functional Impairment in Patients with Panic Disorder

OBJECTIVE

Anxiety and depression and sociodemographic factors such as age, gender, education level, income, and marital status among people with panic disorder (PD) are associated with functional impairment in the areas of work, social, and family. Although both PD-specific scales such as the Panic Disorder Severity Scale (PDSS) and Anxiety Sensitivity Inventory-Revised (ASI-R) and early trauma have been investigated, their relationship with functional impairment in PD patients has not been clarified.

METHODS

This study included 267 PD patients. The PDSS, Beck Depression Inventory (BDI), ASI-R, and Early Trauma Inventory were used. Pearson's correlation and multiple linear regression analyses were performed. The Sheehan Disability Scale (SDS) was administered to assess the functional impairment level in PD patients.

RESULTS

Our findings showed that high levels of PDSS, BDI, and ASI-R were significantly correlated with the functional impairment among PD patients. Multiple regression analyses showed that PDSS, BDI, and ASI-R can predict the functional impairment levels, and PDSS and ASI-R were significantly associated with lost and underproductive days in PD patients.

CONCLUSION

Panic-specific symptoms, depression, and AS are associated with functional impairment level in PD patients. Elevated symptom severity can play a role by affecting productivity and daily responsibilities in PD patients.

Initial white matter connectivity differences between remitters and non-remitters of patients with panic disorder after 6 months of pharmacotherapy

Panic disorder (PD) is a harmful mental condition that causes relapsed and persistent impairment. In the treatment of PD, the prognosis for PD should be considered. However, the relationship between pharmacotherapy and biomarkers, for predicting a better response through neuroimaging, is a little known. The purpose of the present study was to examine whether there would be the initial white matter (WM) regions associated with the remission in 6 months. A total of 104 patients with PD were investigated in the study. After six months, there were 17 remission patients with PD and 81 non-remission patients. The Panic Disorder Severity Scale, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Inventory-Revised, Beck Anxiety Inventory, and Beck Depression Inventory were assessed for all patients at baseline. We compared the diffusion indices between remission and non-remission group at 6 months using Tract-Based Spatial Statistics. The results showed that the fractional anisotropy (FA) values were significantly higher in the non-remitter group compared with those in the remitter group in the WM regions, such as the posterior corona radiata and superior longitudinal fasciculus, at the 6 month evaluation. The logistic regression analysis with clinical symptom severity and FA values of the WM regions as covariates showed that FA values in those regions and the Beck Depression Inventory-II predicted poor remission. This study suggests that posterior corona radiata and superior longitudinal fasciculus are related to potential predictive factors of 6-month remission in patients with PD. WM regions associated with the long-term remission should be verified with further investigations.

A 15-year follow-up study of patients with panic disorder

Background

Panic disorder (PD) is generally regarded as a chronic condition with considerable variation in severity of symptoms.

Aims

To describe the long-term outcome of naturalistically treated PD.

Methods

Fifty-five outpatients with PD, who participated in a placebo-controlled drug trial of the efficacy of alprazolam and imipramine 15 years ago were reassessed with the same instruments used in the original study.

Results

Complete recovery (no panic attacks and no longer on medication during the last 10 years) was seen in 18% of patients, and an additional 13% recovered but were still on medication. Fifty-one percent experienced recurrent anxiety attacks whereas 18% still met diagnostic criteria for PD. The incidence of agoraphobia decreased from 69% to 20%. Patients with agoraphobia at admission tended to have a poorer long-term outcome according to daily functioning compared with patients without agoraphobia at admission, although both groups reported improved daily functioning at follow-up. Maintenance medication was common. No benzodiazepine abuse was reported.

Conclusion

PD has a favourable outcome in a substantial proportion of patients. However, the illness is chronic and needs treatment. The short-term treatment given in the drug trial had no influence on the long-term outcome.

What can be learnt from the natural history of anxiety disorders?

Background

There is insufficient knowledge of the long-term course of panic disorder (PD).

Aim

To determine the long-term course and prognostic variables in patients diagnosed with PD.

Methods

Patients who were diagnosed of anxiety states between 1950 and 1961, were examined using a structured clinical interview (SCID-DSM-III-R) between 1984 and 1988 (n = 144). A re-examination was performed in the period 1997–2001 (N = 125). Mean length of follow-up from onset was 47 years.

Results

PD tends to be chronic. Among those who recovered, 93% had done so already by the 1980s. Lack of regular treatment compliance, progression to agoraphobia and number of episodes of panic disorder were associated with worse outcome. Agoraphobia without panic attacks and somatization symptoms were the most prevalent clinical status at follow-up.

Conclusion

After several decades, participants improve with regard to number of panic attacks, though most continue to have residual symptoms.

Panic patients in the non-panic state: physiological and cognitive dysfunction

Panic attacks and the antipanic effect of antidepressants are claimed to distinguish panic disorder (PD) from generalised anxiety disorder. However, most studies showing neurochemical disturbances in PD overlook the non-panic state. We compared panic patients in the non-panic state with controls on biochemical, psychological and physiological measures. There were no differences on the neuroendocrine tests. Self-ratings of bodily and psychological symptoms of anxiety were significantly higher in patients and they scored worse on word recall. Patients had significantly more skin conductance fluctuations and slow wave activity in the electroencephalogram, a sign of hyperventilation which may have implications for brain activity. Discrepancies between patients' self-ratings and objective measures of pulse rate and psychomotor performance indicated that panic patients have distorted perceptions of both physical and mental functioning. Hyperventilation and cognitive distortions in the non-panic state may facilitate panic attacks and are part of the pathophysiology of PD.

Personality disorders and the persistence of anxiety disorders in a nationally representative sample

BACKGROUND

Among individuals with anxiety disorders, comorbid personality disorders (PDs) increase cross-sectional symptom severity and decrease functioning. Little is known, however, about how PDs influence the course of anxiety disorders over time. The purpose of this study was to examine the effect of PDs on the persistence of four anxiety disorders in a nationally representative sample in the United States.

METHODS

Two waves of data were collected on 34,653 participants, 3 years apart. At both waves, participants were evaluated for generalized anxiety disorder (GAD), social and specific phobias, and panic disorder. Predictors of persistence included all DSM-IV PDs. Control variables included demographics, comorbid PDs, age at onset of the anxiety disorder, number of prior episodes, duration of the current episode, treatment history, and cardinal symptoms of exclusionary diagnoses for each anxiety disorder.

RESULTS

Any PD, two or more PDs, borderline PD, schizotypal PD, mean number of PD criteria met, and mean number of PDs diagnosed predicted the persistence of all four anxiety disorders. Narcissistic PD predicted persistence of GAD and panic disorder. Schizoid and avoidant PDs also predicted persistence of GAD. Finally, avoidant PD predicted persistence of social phobia. Particular patterns of cross-cluster PD comorbidity were strong predictors of the persistence of individual anxiety disorders as well.

CONCLUSIONS

In this national sample, a variety of PDs robustly predicted the persistence of anxiety disorders over 3 years, consistent with the results of recent prospective clinical studies. Personality psychopathology should be assessed and addressed in treatment for all patients with anxiety disorders.

Psychopharmacology of anxiety disorders

Exposure of the general population to a 1:4 lifetime risk of disabling anxiety has inspired generations of fundamental and clinical psychopharmacologists, from the era of the earliest benzodiazepines (BZ) to that of the selective serotonin reuptake inhibitors (SSRIs) and related compounds, eg, the serotonin and norepinephrine reuptake inhibitors (SNRIs). This comprehensive practical review summarizes current therapeutic research across the spectrum of individual disorders: generalized anxiety disorder (GAD), panic disorder (PD) and agoraphobia (social anxiety disorder), compulsive disorder (OCD), phobic disorder (including social phobia), and posttraumatic stress disorder (PTSD). Specific diagnosis is a precondition to successful therapy: despite substantial overlap, each disorder responds preferentially to specific pharmacotherapy. Comorbidity with depression is common; hence the success of the SSRIs, which were originally designed to treat depression. Assessment (multidomain measures versus individual end points) remains problematic, as-frequently-do efficacy and tolerability The ideal anxiolytic remains the Holy Grail of worldwide psychopharmacologic research.

The development of agoraphobia is associated with the symptoms and location of a patient's first panic attack

Background

The place where a patient experiences his/her first panic attack (FPA) may be related to their agoraphobia later in life. However, no investigations have been done into the clinical features according to the place where the FPA was experienced. In particular, there is an absence of detailed research examining patients who experienced their FPA at home. In this study, patients were classified by the location of their FPA and the differences in their clinical features were explored (e.g., symptoms of FPA, frequency of agoraphobia, and severity of FPA).

Methods

The subjects comprised 830 panic disorder patients who were classified into 5 groups based on the place of their FPA (home, school/office, driving a car, in a public transportation vehicle, outside of home), The clinical features of these patients were investigated. Additionally, for panic disorder patients with agoraphobia at their initial clinic visit, the clinical features of patients who experienced their FPA at home were compared to those who experienced their attack elsewhere.

Results

In comparison of the FPAs of the 5 groups, significant differences were seen among the 7 descriptors (sex ratio, drinking status, smoking status, severity of the panic attack, depression score, ratio of agoraphobia, and degree of avoidance behavior) and 4 symptoms (sweating, chest pain, feeling dizzy, and fear of dying). The driving and public transportation group patients showed a higher incidence of co-morbid agoraphobia than did the other groups. Additionally, for panic disorder patients with co-morbid agoraphobia, the at-home group had a higher frequency of fear of dying compared to the patients in the outside-of-home group and felt more severe distress elicited by their FPA.

Conclusion

The results of this study suggest that the clinical features of panic disorder patients vary according to the place of their FPA. The at-home group patients experienced "fear of dying" more frequently and felt more distress during their FPA than did the subjects in the other groups. These results indicate that patients experiencing their FPA at home should be treated with a focus on the fear and distress elicited by the attack.

The association of personality disorders with the prospective 7-year course of anxiety disorders

BACKGROUND

This study prospectively examined the natural clinical course of six anxiety disorders over 7 years of follow-up in individuals with personality disorders (PDs) and/or major depressive disorder. Rates of remission, relapse, new episode onset and chronicity of anxiety disorders were examined for specific associations with PDs.

METHOD

Participants were 499 patients with anxiety disorders in the Collaborative Longitudinal Personality Disorders Study, who were assessed with structured interviews for psychiatric disorders at yearly intervals throughout 7 years of follow-up. These data were used to determine probabilities of changes in disorder status for social phobia (SP), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder and panic disorder with agoraphobia.

RESULTS

Estimated remission rates for anxiety disorders in this study group ranged from 73% to 94%. For those patients who remitted from an anxiety disorder, relapse rates ranged from 34% to 67%. Rates for new episode onsets of anxiety disorders ranged from 3% to 17%. Specific PDs demonstrated associations with remission, relapse, new episode onsets and chronicity of anxiety disorders. Associations were identified between schizotypal PD with course of SP, PTSD and GAD; avoidant PD with course of SP and OCD; obsessive-compulsive PD with course of GAD, OCD, and agoraphobia; and borderline PD with course of OCD, GAD and panic with agoraphobia.

CONCLUSIONS

Findings suggest that specific PD diagnoses have negative prognostic significance for the course of anxiety disorders underscoring the importance of assessing and considering PD diagnoses in patients with anxiety disorders.

The 2-year prognosis of panic episodes in the general population

BACKGROUND

Panic disorder (PD) is generally considered to be a chronic or intermittent disorder. This view may be biased because of a lack of general population studies investigating panic from the onset of an episode onwards. Data regarding the course of subthreshold panic disorder (sub-PD) and predictors of its course are lacking.

METHOD

Using data from a large community-based survey, the Netherlands Mental Health and Incidence Study (NEMESIS), that retrospectively assessed the 2-year course of panic with a Life Chart Interview (LCI), this study investigated remission, chronicity and recurrence in subjects with new episodes of PD or sub-PD. Predictor variables of remission consisted of sociodemographics, psychobiological, environmental, psychiatric and panic-related factors.

RESULTS

In PD, remission of panic attacks occurred in 64.5% of subjects, mean time to remission was 5.7 months, and the remission rate was 5.8/100 person-months. In 43.3% of subjects panic was still present after 1 year. Recurrence of panic attacks occurred in 21.4% of those with PD who had achieved remission and for whom sufficient follow-up time was available. In general, the course of sub-PD was more favourable. Predictors of remission were female gender, the absence of ongoing difficulties, subthreshold panic and a low initial frequency of attacks.

CONCLUSIONS

These results suggest that the course of panic is diverse in the general population, thereby underlining the need for accurate predictors. This requires further research including biological data and additional psychological data. In addition, given the large proportion with a relapse, relapse prevention should be part of any treatment programme.

Alexithymia and cognitive dysfunctions in patients with panic disorder

BACKGROUND

In patients with panic disorder (PD), the difficulty to identify and manage emotional experience might contribute to the enduring vulnerability to panic attacks. Such a difficulty might reflect a dysfunction of fronto-temporo-limbic circuits. The present study was designed to test the hypothesis that drug-free patients with PD, as compared with healthy subjects (HS), show a higher prevalence of alexithymia, greater difficulty in emotional stimuli processing and poorer performance on neuropsychological tests exploring the activity of fronto-temporo-limbic circuits.

METHODS

Alexithymia, general cognitive abilities, focused and sustained attention, working memory, secondary memory, incidental learning, susceptibility to interference from both cognitive and emotional stimuli, and ability to recognize facial emotional expressions were assessed in 32 drug-free patients with PD and 32 HS.

RESULTS

Alexithymia was more frequent in patients with PD than in HS. Patients with PD, as compared to HS, had lower verbal cognitive abilities and more difficulty to inhibit interference from nonverbal stimuli and from panic-related words; they performed better than HS on the test assessing spatial incidental learning. Anxiety, panic symptomatology and verbal cognitive abilities (VIQ) were associated with alexithymia.

CONCLUSIONS

Findings are compatible with a dysfunction of frontolimbic circuits, in particular orbitofrontal and cingulate cortices. A reduction in verbal cognitive abilities was also observed, which might suggest reduced abstraction and symbolization in these patients.

Nine-year follow-up of panic disorder in chest pain patients: clinical course and predictors of outcome

OBJECTIVE

The aim was to investigate the association between panic disorder (PD) and long-term outcomes in terms of psychiatric morbidity, psychological distress and health-related quality of life (HRQOL), and to identify predictors of poor outcome for PD in chest pain patients.

METHOD

Nine-year follow-up study of chest pain patients (n=199) referred to cardiology outpatient investigation. Assessments included Structured Clinical Interview for DSM-IV, Symptom Checklist-90-R (SCL-90-R), Illness Attitude Scale, Agoraphobia Cognitions Questionnaire, the Mobility Inventory for Agoraphobia, Personality Diagnostic Questionnaire and the Medical Outcome Study Short Form-36. At baseline, 76 patients suffered from PD.

RESULTS

Of 184 eligible patients, 150 participated in the follow-up study. Panic disorder at baseline was associated with a higher prevalence of comorbid Axis I disorders, psychological distress and poorer HRQOL at follow-up compared with patients without PD. Of the participants with PD at baseline (n=55), 14 suffered from persistent PD at follow-up. Patients with persistent PD had particularly poor outcomes regarding comorbid Axis I disorders, suicidal ideation (21%) and HRQOL. A mean baseline SCL-90-R somatization score above 1.4 predicted a 5-fold increased risk of persistent PD.

CONCLUSION

Chest pain patients with PD have a negative long-term outcome and those who score high on somatization require special attention because of particularly poor outcomes.

Characteristics and course of panic disorder and panic disorder with agoraphobia in primary care patients

OBJECTIVE

To examine the course of panic disorder (PD) and panic disorder with agoraphobia (PDA) in 235 primary care patients during a 3-year period.

METHOD

Patients were recruited from primary care waiting rooms and diagnosed using the Structured Clinical Interview for DSM-IV. They were reassessed at 6 months, 1 year, and annually thereafter for diagnosis, treatment, and other clinical and demographic variables. Recruitment occurred between July 1997 and May 2001.

RESULTS

At intake, 85 patients were diagnosed with PD and 150 were diagnosed with PDA. Patients with PD were significantly more likely to achieve recovery (probability estimate, 0.75) from their disorder than patients with PDA (0.22) at the end of 3-year follow-up (p < .0001). There was no difference in recurrence rates between the 2 disorders. Women were more likely to recover from PD (p = .001). At intake, comorbid generalized anxiety disorder (p = .004), higher Global Assessment of Functioning score (p = .0003), and older age at panic onset (p = .05) were related to recovery from PDA, and comorbid major depressive disorder (p = .05) and psychosocial treatment (p = .002) predicted remaining in an episode of PDA. The relationship between psychosocial treatment and poor recovery must be interpreted with caution and is most likely due to the treatment bias effect.

CONCLUSION

Primary care patients with PDA have a chronic course of illness, whereas those with PD have a more relapsing course. Given the significant burden of PD and PDA in primary care, attention to factors relevant to the course of these disorders is important for recognition and for continued improvement of treatment interventions in this setting.

Panic disorder

Panic disorder is a common mental disorder that affects up to 5% of the population at some point in life. It is often disabling, especially when complicated by agoraphobia, and is associated with substantial functional morbidity and reduced quality of life. The disorder is also costly for individuals and society, as shown by increased use of health care, absenteeism, and reduced workplace productivity. Some physical illnesses (eg, asthma) commonly occur with panic disorder, and certain lifestyle factors (eg, smoking) increase the risk for the disorder, but causal pathways are still unclear. Genetic and early experiential susceptibility factors also exist, but their exact nature and pathophysiological mechanisms remain unknown. Despite an imprecise, although increased, understanding of cause, strong evidence supports the use of several effective treatments (eg, pharmacological, cognitive-behavioural). The adaptation and dissemination of these treatments to the frontlines of medical-care delivery should be urgent goals for the public-health community.

Cognitive-behavioral treatment combined with asthma education for adults with asthma and coexisting panic disorder

This study tested the efficacy of a nurse-administered 8-week group treatment program for adults with asthma suffering from coexisting panic disorder. The program consisted of cognitive behavioral treatment (CBT) for panic disorder combined with asthma education (AE). Forty-eight women with a confirmed diagnosis of asthma and panic disorder were randomly allocated to a treatment condition (n=25) and a wait-list control condition (n=23). Twenty-five participants--15 in the treatment group and 10 in the wait-list control group--completed treatment. Repeated measures ANOVA procedures were used to compare the groups on panic and asthma outcomes at posttreatment and 6-month follow-up. The results demonstrate that the CBT-AE program is capable of producing substantial and durable antipanic and antianxiety treatment effects and led to substantial but nonsustained improvement in morning peak-flow expiratory rate and asthma-related quality of life. Implications of these findings for this clinical population are addressed.

Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: a 12-year prospective study

OBJECTIVE

The authors sought to observe the long-term clinical course of anxiety disorders over 12 years and to examine the influence of comorbid psychiatric disorders on recovery from or recurrence of panic disorder, generalized anxiety disorder, and social phobia.

METHOD

Data were drawn from the Harvard/Brown Anxiety Disorders Research Program, a prospective, naturalistic, longitudinal, multicenter study of adults with a current or past history of anxiety disorders. Probabilities of recovery and recurrence were calculated by using standard survival analysis methods. Proportional hazards regression analyses with time-varying covariates were conducted to determine risk ratios for possible comorbid psychiatric predictors of recovery and recurrence.

RESULTS

Survival analyses revealed an overall chronic course for the majority of the anxiety disorders. Social phobia had the smallest probability of recovery after 12 years of follow-up. Moreover, patients who had prospectively observed recovery from their intake anxiety disorder had a high probability of recurrence over the follow-up period. The overall clinical course was worsened by several comorbid psychiatric conditions, including major depression and alcohol and other substance use disorders, and by comorbidity of generalized anxiety disorder and panic disorder with agoraphobia.

CONCLUSIONS

These data depict the anxiety disorders as insidious, with a chronic clinical course, low rates of recovery, and relatively high probabilities of recurrence. The presence of particular comorbid psychiatric disorders significantly lowered the likelihood of recovery from anxiety disorders and increased the likelihood of their recurrence. The findings add to the understanding of the nosology and treatment of these disorders.

The association between panic disorder and the L/L genotype of catechol-O-methyltransferase

To clarify the role of catechol-O-methyltransferase (COMT) polymorphism in panic disorder (PD), we investigated a large group of Korean PD patients (N = 178) and controls (N = 182) using a case-control study. We also assessed the response to paroxetine treatment and other clinical variables in the PD patients. The increase in the COMT(L) allele was not statistically significant in PD (p = 0.104). However, compared with the sum of the other genotypes, the frequency of the L/L genotype was significantly higher in PD (p = 0.042). The odd ratios (ORs) also indicated a significant effect of the homozygosity for the COMT(L) allele on an increased risk for PD (OR=2.38; 95% CI 1.03-5.51). In addition, patients with L/L genotype had higher trait-anxiety levels (p = 0.030) and poorer treatment response to paroxetine than those with other genotypes (p = 0.002). Our results suggest that the COMT L/L genotype is associated with PD and the genetic variant of the COMT enzyme may be related to the clinical severity and treatment response to paroxetine in PD.

Panic disorder

BACKGROUND

This article reviews the clinical features, epidemiology, pathophysiology, dental findings, and dental and medical management of the care of patients with panic disorder, or PD.

TYPES OF STUDIES REVIEWED

The authors conducted a MEDLINE search for the period 1998 through 2003, using the key term "panic disorder" to define the pathophysiology of the disorder, its epidemiology and dental implications. The articles they selected for further review included those published in peer-reviewed journals.

RESULTS

PD is a common and debilitating psychiatric disease in which a person experiences sudden and unpredictable panic attacks, or PAs, with symptoms of overwhelming anxiety, chest pain, palpitations and shortness of breath. Persistent concern about having another attack and worry that it may indicate a heart attack or "going crazy" impairs the person's social, family and working lives. Frequently accompanying the disorder is agoraphobia, depression and mitral valve prolapse, or MVP.

CLINICAL IMPLICATIONS

In patients with PD, the prevalence of dental disease may be extensive because of the xerostomic effects of psychiatric medications used to treat it. Dental treatment consists of preventive dental education and prescribing saliva substitutes and anticaries agents. Precautions must be taken when prescribing or administering analgesics, antibiotics or sedative agents that may have an adverse interaction with the psychiatric medications. Because there is a connection between PAs and MVP, the dentist needs to consult with the patient's physician to determine the presence of MVP and whether there is associated mitral valve regurgitation. Patients with MVP and accompanying mitral valve regurgitation require prophylactic antibiotics when undergoing dental procedures known to cause a bacteremia and heightened risk of endocarditis.

The long-term course of panic disorder--an 11 year follow-up

BACKGROUND

The purpose of this study was to assess the naturalistic long-term course of panic disorder over a period of 11 years.

METHOD

Thirty DSM-III-R panic disorder patients, who had suffered from panic disorder for 6 years on average and who had taken part in an 8-week multicenter drug trial, were included in the intent-to-follow-up group to be reinterviewed 11 years after the end of the trial. At baseline and at follow-up the same instruments were used to assess frequency of panic attacks, level of phobic avoidance, and disabilities. Treatments received during the follow-up period and attempted suicides were assessed with a structured interview. Periods of well-being during the follow-up period were elicited retrospectively with a specifically designed longitudinal chart.

RESULTS

Twenty-four patients could actually be reinterviewed after 11.3 years. While at baseline all patients had suffered from panic attacks and had been severely disabled on a number of measures, 66.7% had no panic attack during the year before follow-up. During the month before follow-up 87.5% had no panic attack, and 54% showed no or only mild phobic avoidance. In the areas of work and family life 90% showed no or only mild disabilities, whereas in the area of social life this percentage was lower (67%). Thirty-three percent of the patients were completely remitted according to a composite remission criterion.

CONCLUSIONS

Panic disorder is not a uniformly chronic and progressing disorder. Over a period of 11 years there is a good chance of recovery from panic attacks and disabilities, and full remission is also possible.

Heart rate variability as predictor of nonresponse to mirtazapine in panic disorder: a preliminary study

Using spectral analysis of heart rate, several studies have shown that panic disorder patients are characterized by a reduced heart rate variability (HRV), indicative of abnormalities in autonomous nervous system (ANS) function. We recently reported that patients with panic disorder, who did not respond to pharmacotherapy, were characterized at baseline by a higher heart rate. In this study, ANS functioning is investigated as a possible predictor of nonresponse to pharmacotherapy. Twenty-eight medication-free panic disorder patients entered a 12-week open-label treatment study with mirtazapine. Five-minute HRV recordings were obtained before treatment and were analysed using spectral analysis. The data of 17 patients could be used. The total spectrum and low frequency power of responders to mirtazapine were significantly higher than those of nonresponders. Our findings suggest that nonresponders to short-term mirtazapine treatment are characterized at baseline by a lowered output of the ANS. The results are preliminary in view of the small sample studied.

The prediction of nonresponse to pharmacotherapy in panic disorder: a review

Several effective pharmacotherapeutic treatments exist for panic disorder; however, not all patients respond to treatment: between 20% to 40% are non-responders. Recent studies have reported several predictors of nonresponse to pharmacotherapy. In this review two questions are addressed: is there consensus with respect to predictors of nonresponse and are there any differences between short-term and long-term predictors? In this review both short-term and long-term outcome studies are discussed. Studies were included if at least DSM-III criteria were used and baseline variables were investigated as possible predictor of response, or nonresponse, to pharmacotherapy. Of each clinical predictor, tallies were made of the particular predictors employed and of those predictors that predicted nonresponse. It appears that a long duration of illness and severe agoraphobic avoidance are robust predictors of nonresponse, particularly in long-term studies. Personality disorders, or even personality traits, are possibly the most robust predictors of nonresponse. Several factors appear to be robust predictors of nonresponse: factors that are present before treatment and exert their influence on short-term and long-term treatment outcome. Prospective studies are needed to further investigate these factors and to test whether it is viable to intervene in an attempt to increase treatment response.

Anxiety Disorders in Neurologic Illness

Anxiety disorders frequently occur in individuals with neurologic illness. Anxiety may be a symptom of or a reaction to the neurologic disorder, a medication side effect, or a comorbid condition. The most common anxiety disorders seen in neurologic patients are panic disorder, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder (OCD). Very often, these conditions go unrecognized (and therefore untreated) or are attributed to being a normal response to having a neurologic illness. However, if they are not treated, anxiety disorders can significantly increase morbidity and mortality in neurologic patients. Selective serotonin reuptake inhibitors (SSRIs) should be considered the first-line of pharmacologic treatment, because they offer a broad spectrum of efficacy in the anxiety disorders, are generally well tolerated, and are effective in treating comorbid depression. Benzodiazepines, although most effective for acute anxiety, are now considered adjunctive or second-line treatments. Cognitive behavioral therapy and other behavioral treatments are effective in the treatment of anxiety disorders. They should be considered primary treatments for patients who cannot tolerate or prefer not to take medications.

A dose-finding and discontinuation study of clomipramine in panic disorder

Eighty-one panic disorder patients with or without agoraphobia were treated with flexible doses of clomipramine under single-blind conditions. Fifty-seven (70.3%) reached operational criteria for full remission in 16.2 +/- 6.5 weeks, with a mean dose of 89.1 +/- 8.2 mg/day. Fifty-four (81%) of them received a continuous post-remission maintenance treatment at full doses of clomipramine for 4-6 months. No patient relapsed during the clomipramine maintenance phase. Their medication was then tappered and discontinued with placebo substitution under double-blind conditions. Fifty-one (63%) patients were followed-up until relapse or recurrence for up to 3 years, with periodic assessments. Three different outcome groups were identified: the first (n = 19, 19; 37.2%) experienced an early/immediate relapse (5.2 +/- 4.9 weeks after drug discontinuation); the second group (n = 22, 22; 43.1%) experienced recurrence after 42.9 +/- 35 weeks following discontinuation; and the third group (n = 10, 10; 19.6%) remained assymptomatic and functionally well throughout the follow-up. Predictors of early relapse were: (1) higher baseline score in the Beck Depression Inventory; (2) higher global score on the phobic avoidance scale after the full remission criteria; and (3) the need for higher clomipramine doses to reach full remission. The need for long-term or intermittent maintenance for most patients is emphasized.

Comorbidity in generalized anxiety disorder

GAD has rates of comorbidity that equal or exceed those of other anxiety disorders, and it is one of the most common comorbid conditions with other disorders. Depressive disorders, especially MDD, and other anxiety disorders, especially panic disorder, most commonly co-occur. The pattern of comorbidity is consistent in community and clinical populations and in children and elderly people. Comorbidity is associated with greater impairment, more treatment seeking, and worse outcome among persons with GAD compared with pure GAD. Likewise, patients with panic disorder and MDD who have coexisting GAD tend to have more severe symptoms and less favorable outcome. The relationship between GAD and MDD seems especially close, and data from twin studies suggest that these conditions share a genetic diathesis. Patients with GAD and coexisting conditions respond less well to psychological and pharmacologic treatment, but, for those who do respond, treatment for the primary disorder often also produces improvement in comorbid conditions. Thus, research continues to show that GAD is important as a primary and a comorbid disturbance.

Panic: course, complications and treatment of panic disorder

Panic disorder is a chronic condition typically associated with significant distress and disability. In addition to the acute distress associated with the panic attack itself, the disorder often leads to distressing anticipatory anxiety and phobic avoidance. Affected individuals experience significant impairment in social and vocational functioning, high utilization of medical resources, constriction of function, premature mortality and diminution in overall quality of life. Panic disorder is frequently comorbid with other conditions, particularly depression, as well as alcohol and other substance abuse, and other anxiety disorders including social phobia, generalized anxiety disorder, obsessive-compulsive disorder and post-traumatic stress disorder. A number of pharmacological agents and cognitive-behavioural treatments have been shown to be effective in the treatment of panic disorder, with the selective serotonin reuptake inhibitors (SSRIs) becoming first-line pharmacotherapy for this condition. Among these, the SSRI sertraline appears effective not only in improving symptoms of panic, but also in reducing anticipatory anxiety and improving multiple aspects of quality of life. For patients who remain partly or fully symptomatic despite adequate first-line treatment, a variety of strategies are emerging for the management of refractory conditions. We provide an overview of the prevalence, presentation and associated complications of panic disorder, review the therapeutic options and discuss the management of refractory patients.

Pindolol augmentation in patients with treatment-resistant panic disorder: A double-blind, placebo-controlled trial

The objective of this study was to determine the efficacy of pindolol as an augmentor of fluoxetine in treatment-resistant panic disorder (PD). Twenty-five outpatients having PD with or without agoraphobia were included. These patients had not responded to two different trials with antidepressants and an 8-week trial of fluoxetine 20 mg/day. Treatment-resistant PD was defined as a less than 20% reduction in score on the Panic Self-Questionnaire (number of attacks per week) (PSQ) and the Clinical Anxiety Scale With Panic Attacks (CAS+PA). These patients continued to receive fluoxetine 20 mg/day and were randomly assigned to additionally receive either pindolol (2.5 mg three times daily) or placebo for the following 4 weeks. Evaluations were performed weekly using the Hamilton Rating Scale for Anxiety, the Hamilton Rating Scale for Depression (HAM-D), the CAS+PA, the NIMH Anxiety Scale, the PSQ, and the Clinical Global Impression Scale. The data were analyzed using a repeated-measures analysis of variance (ANOVA) and a t-test for independent samples. Patients treated with the combination of pindolol and fluoxetine (N = 13) demonstrated a significant improvement over the patients treated with fluoxetine and placebo on all rating scales, with the exception of HAM-D. The statistical differences were shown using the repeated-measures ANOVA (baseline, week 2, week 4) and also with t-tests from the second week of the trial. These preliminary results demonstrate that pindolol has an augmenting effect on fluoxetine in patients with treatment-resistant PD.

Panic, hyperventilation and perpetuation of anxiety

1. Studies on the pathogenesis of panic disorder (PD) have concentrated on panic attacks. However, PD runs a chronic or episodic course and panic patients remain clinically unwell between attacks. Panic patients chronically hyperventilate, but the implications of this are unclear. 2. Provocation of panic experimentally has indicated that several biological mechanisms may be involved in the onset of panic symptoms. Evidence from provocation studies using lactate, but particularly carbon dioxide (CO2) mixtures, suggests that panic patients may have hypersensitive CO2 chemoreceptors. Klein proposed that PD may be due to a dysfunctional brain's suffocation alarm and that panic patients hyperventilate to keep pCO2 low. 3. Studies of panic patients in the non-panic state have shown EEG abnormalities in this patient group, as well as abnormalities in cerebral blood flow and cerebral glucose metabolism. These abnormalities can be interpreted as signs of cerebral hypoxia that may have resulted from hyperventilation. 4. Cerebral hypoxia is probably involved in the causation of symptoms of anxiety in sufferers of chronic obstructive pulmonary diseases. By chronically hyperventilating, panic patients may likewise be at risk of exposure to prolonged periods of cerebral hypoxia which, in turn, may contribute to the chronicity of their panic and anxiety symptoms. 5. Chronic hyperventilation may engender a self-perpetuating mechanism within the pathophysiology of PD, a hypothesis which warrants further studies of panic patients in the non-panic state.

Natural animal models of human psychiatric conditions: assessment of mechanism and validity

1. The classic animal models for human psychiatric conditions involves rodents. As prey species, their normal behaviors of avoidance would be considered pathological in humans and dogs. Hence, such models may not be homologous for similar behaviors found in psychiatric pathology in humans. 2. Dogs exhibit pathological behavioral conditions that may be equivalent to certain human psychiatric conditions. These canine conditions appear spontaneously or endogenously in the absence of genetic or neurochemcial manipulation, and as such, may be homologous to the human condition. 3. If canine conditions approach homology with human conditions they should have excellent face, predictive, and construct validity. 4. The canine conditions of separation anxiety, obsessive-compulsive disorder, cognitive dysfunction, dominance aggression, and panic disorder have good to excellent validity at all explored levels for human generalized anxiety disorder, obsessive-compulsive disorder, Alzheimer's disease, impulse control disorders, and panic disorder. 5. Natural canine models can aid our understanding of human psychiatric conditions.

Long-term treatment of panic disorder with agoraphobia in private practice

The author followed 67 patients with panic disorder with agoraphobia (PDA) for a minimum of 5 years in a private practice setting. They were treated with a combination of pharmacotherapy (antidepressants or benzodiazepines) and cognitive-behavioral psychotherapy. The author examines outcomes for three groups: A) 11 male patients, 10 of whom had comorbid conditions; B) 21 female patients with comorbid conditions; and C) 35 female patients without comorbid conditions. Symptom severity was assessed using the Panic Disorder Severity Scale (PDSS). Patients in all groups showed marked improvement in all the domains measured by the PDSS, with the greatest improvement in PDSS scores occurring during the first year in all three groups. Patients in groups A and B tended to plateau after 5 years of treatment and show no additional improvement thereafter, whereas patients in group C (women with "pure PDA") continued to improve, although at a gradually slower rate. However, after an average of 11 years of treatment, the majority of patients remained symptomatic. The presence of comorbid alcohol abuse or depression was associated with poorer outcomes. The results in this effectiveness study are generally not as good as the outcomes of published PDA follow-up efficacy studies, but appear to be superior to outcomes in cohorts of chronically anxious patients treated decades ago.

The impact of comorbid mood and personality disorders in the cognitive-behavioral treatment of panic disorder

The present review examined the effect of comorbid major depressive disorder and personality disorder on the outcome of cognitive-behavioral interventions for panic disorder. Panic disorder patients often present with these comorbid conditions, but for the most part, treatment studies have paid little attention to them. Most studies on the effects of comorbidity on treatment outcome address pharmacological treatment. However, there is a growing literature on the effect of additional disorders on the outcome of cognitive-behavioral interventions for panic disorder. Findings from the studies of comorbidity with depression are equivocal, possibly reflecting inconsistencies in measurement methodology across studies. However, personality psychopathology was found to exert a detrimental effect on the outcome of cognitive-behavioral treatment for panic disorder. Further research is necessary to elucidate the impact of these concurrent conditions on cognitive-behavioral treatment for panic disorder. It is suggested that studies utilizing cognitive-behavioral treatment routinely examine the influence of comorbid conditions on treatment outcome.

Current treatments of the anxiety disorders in adults

The progress in developing effective treatments for the five principal anxiety disorders (ADs) in adults--panic disorder (PD), social phobia (SP), obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD)--has been rapid in the past 15 years. There are now well-controlled clinical trials documenting effective pharmacological and psychological treatments for all of these disorders, although generally the evidence is better developed for some disorders than for others. Both the pharmacological treatments and the effective psychological treatments for each disorder will be briefly reviewed. The available data for combination treatment will be reviewed and comparisons of the two types of treatment will be made. This review will contain at least brief reviews of what the treatments involve and attempt to describe how well they work. Many studies unfortunately report only the percentage of patients who "improve" without quantifying the clinical significance of those responses. Data underlining clinical response in terms of the percentage of patients who have an "excellent," "marked," or "moderate" response, and the percentage of patients with a "clinically significant" response will be reported whenever available. Other clinically relevant issues such as length of treatment-relapse rates upon discontinuation and side effects will be presented. As such, this article should provide a brief but comprehensive review of the treatment of these disorders in adults.

Associations between cortical slow potentials and clinical rating scales in panic disorder: a 1.5-year follow-up study

In a previous study of 15 panic patients, we demonstrated that body-related (somatic) word stimuli elicited an enhanced positive cortical slow wave compared to non-somatic word stimuli. Healthy controls did not show this difference. The present paper reports on psychometric ratings in relation to cortical slow waves in these patients. Patients were clinically reexamined after about 1.5 years. Although no significant correlations between neurophysiology and psychometric measures could be found at the onset of the study, there was a significant correlation between improvement over the follow-up period and neurophysiology. A decline in the Hamilton Anxiety Scale (HAMA), which proved to be the best estimate for improvement, was associated with the relative magnitude of the positive slow wave elicited by somatic stimuli. Our findings support cognitive models of panic disorder, which stress that abnormal processing of bodily symptoms is relevant for the development and/or maintenance of the disorder.

Group cognitive-behavior therapy for patients failing to respond to pharmacotherapy for panic disorder: a clinical case series

The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.

The long-term course of panic disorder and its predictors

Whereas lifetime prevalence rates of panic disorder--as established in epidemiologic surveys--range between 1.6 and 3.5%, 1-month rates usually amount to much less than one half of the lifetime rates. This finding indicates that a substantial proportion of patients who had panic disorder at some stage in their life must have remitted. In contrast to these results, clinicians tend to regard panic disorder as a chronic condition because, as a rule, they see panic patients only several years after onset of the disorder. A number of small, prospective, long-term studies of such clinical populations indicate that after several years, between 17 and 70% of patients still have panic attacks, and between 36 and 82% have phobic avoidance. In the largest and longest follow-up study published to date, 45% of all patients showed an unremitting--although in a certain proportion waxing and waning--course, 24% followed a pattern of remissions and relapses, whereas 31% went back into a stable remission. The evidence of factors predicting the course of panic disorder in clinical populations suggests that long duration and agoraphobia at baseline--not the severity and frequency of panic attacks--are predictors of an unfavorable course. Additional studies are needed to determine whether personality factors, depression, and other variables are also of predictive relevance. Also, factors working during follow-up, such as positive and negative life events, coping behaviors, and treatment, should be considered in future studies.

Treatment goals for panic disorder

In light of the mounting evidence that panic disorder (PD) tends to run a chronic or recurrent course, treatment goals for PD--both specific and general--have been reviewed and a model has been developed to assess the achievement of these goals over the long-term treatment of this disorder. The role of patient education in setting treatment goals has received special attention. The Goal-Oriented Monitoring and Assessment of the Efficacy of Treatment model measures the efficacy of treatment in terms of which treatment goals have been achieved and to what extent. Success of long-term treatment of PD depends on clear formulation of realistic treatment goals; implementation of effective treatment modalities for achieving these goals; maintenance of all treatment gains; prevention of relapses, recurrences, and complications; ensuring decreased vulnerability for PD and its exacerbations; and continuity of care. The Goal-Oriented Monitoring and Assessment of the Efficacy of Treatment model was used to assess the treatment of 118 patients at a day clinic. Patients were followed up for 24 months. Most treatment goals were achieved during the initial intensive, integrative treatment, with treatment gains being successfully maintained during follow-up. The model identified often-neglected patient needs that required particular attention over the course of treatment and during follow-up.