Frequency of isolated panic attacks and panic disorder in patients with the mitral valve prolapse syndrome

Cardiac and Non-Cardiac Chest Wall Pain

The various causes of anterior chest wall pain are reviewed with particular reference to the clinical manifestations of coronary artery disease (CAD), costochondritis and the myofascial pain syndrome.

Attention is drawn to the manner in which myofascial pain syndrome in the anterior chest wall may arise as a result of primary trauma or anxiety-induced activation of myofascial trigger point (MTrP) nociceptors and also as a result of the secondary activation of MTrPs situated in a zone of cardiac pain referral, and how myofascial pain syndrome may develop in patients with mitral valve prolapse.

It is explained that, because of an appreciable incidence of concomitant costochondritis and CAD pain and of MTrP and CAD pain, and because dry needling in both myofascial pain syndrome and costochondritis may relieve underlying CAD pain, it is not infrequently necessary in cases of anterior chest wall pain to carry out a detailed cardiological assessment including electrocardiographic exercise testing and radionuclide cineangiography.

Imaging of Mitral Valve Prolapse: What Can We Learn from Imaging about the Mechanism of the Disease?

Mitral valve prolapse (MVP) is the most common mitral valve disorder affecting 2%-3% of the general population. Two histological forms for the disease exist: Myxomatous degeneration and fibroelastic disease. Pathological evidence suggests the disease is not confined solely to the valve tissue, and accumulation of proteoglycans and fibrotic tissue can be seen in the adjacent myocardium of MVP patients. MVP is diagnosed by demonstrating valve tissue passing the annular line into the left atrium during systole. In this review we will discuss the advantages and limitations of various imaging modalities in their MVP diagnosis ability as well as the potential for demonstrating extra associated valvular pathologies.

Are there anxious genes?

Anxiety comprises many clinical descriptions and phenotypes. A genetic predisposition to anxiety is undoubted; however, the nature and extent of that contribution is still unclear. Methods for the genetic analysis of such complex disorders is briefly reviewed, followed by a discussion of the comorbidity of anxiety with other psychiatric disorders and their possible common genetic etiology. Extensive genetic studies of the serotonin (5-hydroxytryptamine, 5-HT) transporter (5-HTT) gene have revealed how variation in gene expression can be correlated with anxiety phenotypes. Complete genome-wide linkage scans for panic disorder (PD) susceptibility genes have suggested a locus on chromosome arm 7p, and association studies have highlighted many candidate genes. A highly significant association between phobias, panic disorder, and a duplication at chromosomal region 15q24-26 is one of the most exciting findings to date. Emerging molecular genetic technologies and the use of increasingly sophisticated animal models of anxiety provide great promise for the future of the field.

Does the association between mitral valve prolapse and panic disorder really exist?

OBJECTIVE

Although the possible relationship between panic disorder and mitral valve prolapse (MVP) attracted considerable research interest in the 1980s and 1990s, the reported prevalence of MVP in these patients has been inconsistent and widely variable. Clinical and epidemiologic studies have produced controversial data on possible association or definite causal relationship between these 2 entities. The primary objective of the present review was to summarize the current state of knowledge on the association between panic disorder and MVP, including the influence of diagnostic criteria for MVP on the controversial results.

DATA SOURCES

We searched MEDLINE, LILACS, and EMBASE databases using the keywords panic and mitral. Inclusion criteria were articles concerning the reciprocal association of MVP and panic disorder, published from the earliest dates available through December 2006.

STUDY SELECTION

All relevant articles published in English, Spanish, or Portuguese and reporting original data related to the association of MVP and panic disorder were included. Forty articles fulfilling the criteria for inclusion in this review were identified.

DATA SYNTHESIS

Even though the reported prevalence of MVP in panic disorder varied from 0% to 57%, a significant association between the 2 disorders was documented in 17 of the 40 studies. Such inconsistent results were due to sampling biases in case or control groups, widely different diagnostic criteria for MVP, and lack of reliability of MVP diagnosis. None of the reviewed studies used the current state-of-the-art diagnostic criteria for MVP to evaluate the volunteers. Apparently, the more elaborate the study methodology, the lower the chance to observe a significant relationship between these 2 conditions.

CONCLUSIONS

Published results are insufficient to definitely establish or to exclude an association between MVP and panic disorder. If any relationship does actually exist, it could be said to be infrequent and mainly occur in subjects with minor variants of MVP. To clarify this intriguing issue, future studies should mainly focus on the observed methodological biases and particularly should use the current criteria for MVP as the standard for evaluation.

Joint hypermobility and anxiety: the state of the art

Joint hypermobility (JH) is considered a common benign, hereditary, overlap, connective tissue disorder with a prevalence in the general population of about 10% in European populations and 25% in other ethnic groups. JH shows an association with mitral valve prolapse and fibromyalgia. However, the most significant and important association between joint hypermobility syndrome (JHS) and any other disorder from a clinical point of view is with panic disorder. This article summarizes all published studies on JHS and anxiety, analyzing the main results and limitations. An overview of the etiologic explanation of the association between JH and anxiety, with special focus on genetic findings, is also included. The most relevant conclusions are the following: JHS is more prevalent in individuals with panic disorder/agoraphobia, and patients with JHS present with greater prevalence of panic disorder/agoraphobia. In addition, there is an association between JHS severity and severity of anxiety, and mitral valve prolapse plays a secondary role in the association between JHS and anxiety. New fields of research based on these data are suggested.

Bayesian analysis of a previously published genome screen for panic disorder reveals new and compelling evidence for linkage to chromosome 7

This article presents a Bayesian re-analysis of a linkage study of panic disorder Crowe et al. [2001: Am J Med Genet (Neuropsychiatr Genet) 105:105-109]. In the initial analysis Crowe et al. failed to find compelling evidence for linkage based on either LOD scores or NPL scores anywhere in the genome. The maximum LOD score was 2.23 on chromosome 7 at marker D7S2846 (57.79 cM according to Marshfield). Over the past several years we have been developing a Bayesian alternative approach to linkage analysis, based on direct measurement of the posterior probability of linkage (PPL), and have shown elsewhere that this approach has several advantages over the available alternatives for mapping complex-disease genes Vieland [1998: Am J Med Genet 63:947-954]; Wang et al. [1999: Genet Epidemiol 17(Suppl 1):S749-S754]; Wang et al. [2000: Ann Hum Genet 64:533-553]; and Vieland et al. [2001: Hum Hered 51:199-208]. One limitation of this approach in previous applications has been that it required the investigator to specify a fixed genetic model for the trait. We employ a new implementation of the PPL that treats the unknown trait model as a vector of nuisance parameters, which is integrated out of the PPL equation. When we apply this new model-integrated version of the PPL to the data of Crowe et al. [2001: Am J Med Genet (Neuropsychiatr Genet) 105:105-109] we obtain much clearer evidence than previously reported for a locus on chromosome 7, with an 80% probability of linkage to marker D7S521. A second location is also identified on chromosome 16 near marker D16S749 (PPL = 24%). The results for the remainder of the genome are consistently low. The two loci identified here are also supported by independent evidence from other studies.

Psychiatric symptoms and Marfan: part of the syndrome or incidental to it?

The authors report the case of a patient who consulted primarily for depression and anxiety and was secondly diagnosed with Marfan syndrome. The question of whether psychiatric symptoms are part of the Marfan syndrome or merely incidental to it is raised.