Panic attacks and alcohol withdrawal: can subjects differentiate the symptoms?

Combined fluoxetine and disulfiram treatment of alcoholism with comorbid affective disorders. A naturalistic outcome study, including quality of life measurements

This uncontrolled study presents 188 patients primarily diagnosed as addictive alcoholics and fulfilling the DSM III diagnostic criteria for panic disorder or major depression, 104 and 84 patients, respectively. The study focused on clinical outcome of pharmacological intervention with combined fluoxetine and disulfiram treatment. The patients were followed for (up to) 40 months. A good clinical outcome for both groups was found in 70%. In a subgroup of 37 patients ‘quality of life’ was assessed using quality of life scales. An appropriate correlation emerged between clinical judgement of outcome and the patients’ self-rating. Although the study was limited by being uncontrolled, the results have shown, that specific treatment in a group of alcoholics with comorbid psychopathology within the anxiety and depression spectrum is possible even after many years of addictive alcohol abuse. The necessity for proper psychiatric assessment is stressed.

Treating anxiety complicated by substance misuse

The relationship between anxiety disorders and substance misuse is intimate. Here we concentrate on alcohol, although for completeness we also briefly mention other substances taken for anxiety relief or that cause anxiety.

White matter microstructural changes are associated with alcohol use in patients with panic disorder

BACKGROUND

A close relationship between panic disorder (PD) and alcohol use disorder (AUD) has been suggested. We aimed to investigate alterations in white matter (WM) volume or integrity in patients with PD comorbid with AUD.

METHODS

Forty-nine patients with PD, free of comorbid AUD (PD-AUD), and 20 patients with PD comorbid with AUD (PD+AUD) were investigated. All subjects were assessed using the Panic Disorder Severity Scale, Anxiety Sensitivity Inventory-Revised (ASI-R), Beck Depression Inventory, and CAGE questionnaire. Voxel-based morphometry and tract-based spatial statistics were used for imaging analysis.

RESULTS

Increased fractional anisotropy (FA), as well as decreased mean diffusivity and radial diffusivity were observed in multiple WM tracts, including the body and splenium of the corpus callosum and the retrolenticular part of the internal capsule, in the PD+AUD group compared to the PD-AUD group. CAGE scores in the PD+AUD group and ASI-R scores in the PD-AUD group were significantly correlated with FA values for the corpus callosum. No WM volume differences were found.

LIMITATIONS

The present study should be considered preliminary due to relatively small sample size.

CONCLUSIONS

Our findings revealed microstructural changes in multiple WM tracts, including the corpus callosum and internal capsule, suggesting they could be significant neural correlates of AUD in patients with PD.

Resting state synchrony in anxiety-related circuits of abstinent alcohol-dependent patients

BACKGROUND

Anxiety has been linked to initiation, maintenance and relapse of alcohol dependence. Neurobiological models of anxiety have proposed important roles for amygdala-insula and amygdala-medial prefrontal cortex interactions in the generation and regulation of anxiety states, respectively.

OBJECTIVES

This study tested the hypotheses that abstinent alcohol-dependent patients would show a disruption of synchrony in these circuits as measured by resting state functional MRI.

METHODS

The study examined recently abstinent (n = 13), longer-term abstinent (n = 16) alcohol-dependent patients and healthy controls (n = 22). Resting-state synchrony (RSS) was examined in specific circuits, where degree of synchrony has been found to correlate with state anxiety levels in previous studies.

RESULTS

Alcohol-dependent patients showed significantly elevated scores on anxiety and depression inventories compared with controls. No significant group differences in synchrony were observed between right amygdala and right ventromedial prefrontal cortex (vmPFC), between left amygdala and left vmPFC, or, after correction for multiple comparisons, right amygdala and dorsomedial prefrontal cortex (dmPFC). However, significantly decreased positive synchrony was found between left basolateral amygdala and left anterior insula, in patients relative to controls.

CONCLUSION

Both early and longer-term abstinent alcohol-dependent patients showed increased anxiety levels relative to controls and altered resting state synchrony in circuits previously linked to state anxiety. Notably, the significant group differences in synchrony were in the opposite direction to our predictions based on the literature. These results may point to a lack of generalizability of models derived from young healthy homogeneous samples.

Alcohol and anxiety: subtle and obvious attributes of abuse in adults with social anxiety disorder and panic disorder

Previous research has found a relation between social anxiety disorder and alcoholism but recent work found no differences in drinking levels among socially anxious individuals, dysthymics, and normal controls. Using a more sophisticated measure of substance abuse may further explicate the relation between social anxiety and drinking. We examined aspects of substance abuse in treatment-seeking individuals with social anxiety disorder or panic disorder (psychiatric control group) as well as nondisordered individuals (normal control group). We used the Substance Abuse Subtle Screening Inventory-3 because it includes both face valid and subtle items to control for social desirability. Contrary to the hypotheses, there were few obvious or subtle aspects of substance abuse significantly greater for individuals with social anxiety disorder than those with panic disorder or normal controls. Implications for understanding the social anxiety-alcohol relationship, assessment of substance abuse in socially anxious populations, and the construct of social anxiety-are discussed.

Repeated withdrawal from ethanol impairs acquisition but not expression of conditioned fear

Repeated withdrawal from ethanol impairs acquisition of conditioned fear [Stephens, D.N., Brown, G., Duka, T. & Ripley, T.L. (2001) Eur. J. Neurosci., 14, 2023-2031]. This study further examined the effect of repeated withdrawal from ethanol on the expression and acquisition of fear conditioning. Following training, presentation of a cue associated with footshock (CS+) resulted in a suppression of operant responding for food reinforcement. In different groups, shock thresholds were manipulated to give weak or severe behavioural suppression. Rats were subsequently chronically treated with ethanol-containing liquid diet either continuously (single withdrawal) or with three withdrawal periods (repeated withdrawal). Ethanol treatment and withdrawal had no effect on conditioned suppression of responding tested 2 weeks after the final withdrawal, at either shock intensity. Nevertheless, extinction of conditioned fear was impaired in the repeated withdrawal group exposed to the higher shock intensity. In the high intensity group, the stimulus-shock association was then reversed, so that the previously neutral conditioned stimulus (CS-) became the CS+. Acquisition of suppression to the new CS+ was significantly less in the animals previously given repeated experience of withdrawal, confirming our previous finding. Thus, repeated withdrawal from ethanol lead to disruption in the acquisition of fear conditioning but had no effect on retrieval of an association formed prior to the ethanol-withdrawal experiences.

Impaired fear conditioning but enhanced seizure sensitivity in rats given repeated experience of withdrawal from alcohol

Repeated experience of withdrawal from chronic alcohol treatment increases sensitivity to seizures. It has been argued by analogy that negative affective consequences of withdrawal also sensitize, but repeated experience of withdrawal from another sedative-hypnotic drug, diazepam, results in amelioration of withdrawal anxiety and aversiveness. We tested whether giving rats repeated experience of withdrawal from alcohol altered their ability to acquire a conditioned emotional response (CER). Male Hooded Lister rats were fed a nutritionally complete liquid diet as their only food source. Different groups received control diet, or diet containing 7% ethanol. Rats receiving ethanol diet were fed for either 24 days (Single withdrawal, SWD), or 30 days, with two periods of 3 days, starting at day 11, and 21, in which they received control diet (Repeated withdrawal, RWD). All rats were fed lab chow at the end of their liquid diet feeding period. Starting 12 days after the final withdrawal, groups of Control, SWD and RWD rats were given pentylenetetrazole (PTZ; 30 mg/kg, i.p.) three times a week, and scored for seizures. The occurrence of two successive Stage 5 seizures was taken as the criterion for full PTZ kindling. Other groups of control, SWD and RWD rats were trained to operate levers to obtain food, and were then exposed, in a fully counterbalanced design, to light and tone stimuli which predicted unavoidable footshock (CS+), or which had no consequences (CS-). Rats consumed approximately 17.5 g/kg/day of ethanol, resulting in blood alcohol levels of approximately 100 mg/dL. Repeated administration of PTZ resulted in increasing seizure scores. RWD rats achieved kindling criterion faster than either Control or SWD rats. No differences were seen in the groups in flinch threshold to footshock (0.3 mA). At a shock intensity of 0.35 mA, Control, but not RWD or SWD rats showed significant suppression to the CS+ CS- presentation did not affect response rates. The three groups differed in their response to pairing the CS+ with increasing shock levels, the Controls remaining more sensitive to the CS+. SWD rats showed significant suppression of lever pressing during CS+ presentations only at 0.45 and 0.5 mA, and RWD rats only at 0.5 mA. Giving rats repeated experience of withdrawal from chronic ethanol results in increased sensitivity to PTZ kindling, but reduces their ability to acquire a CER. Withdrawal kindling of sensitivity to anxiogenic events does not seem to occur under circumstances which give rise to kindling of seizure sensitivity.

General relations among drug use, alcohol use, and major indexes of psychopathology

Relations among measures of trait anxiety, depression, panic, somatization, alcohol use, drug use, and treatment for depression were investigated because, typically, studies (a) addressed relations among subsets of only 2 or 3 of the measures and (b) dealt almost exclusively with narrow samples of the population representing extremes on 1 or 2 of the measures. In this study, relations among all 7 measures were assessed with participants representing a wide range of scores on all the measures. The 369 participants (155 men, 214 women) were sampled from the general population. Three replications of the same study consistently yielded hypothesized positive intercorrelations among all 7 scales. Factor 1 (Anxiety-Depression) included Trait Anxiety, Depression, and Panic scales. Factor 2 (Substance Abuse) included Drug Use, Alcohol Use, Treatment for Depression, and Somatization scales. Factor 2 highlighted self-medication as a defining characteristic of somatizers and corroborated findings showing that substance abuse is often a precursor to treatment for depression-like symptoms that can be ameliorated with abstinence. Factors 1 and 2 were significantly intercorrelated (r = .41, df = 367, p < .05), showing a 17% shared variance in two common groupings of psychological dysfunction (anxiety-depression, substance abuse) in the general population. Thus, depending on socioeconomic and demographic variables, a third common form of dysfunction in the general population is represented by a combination of anxiety-depression plus substance abuse.

Effect of alcoholism on the incidence of lactate-induced panic attacks

BACKGROUND

Chronic alcohol use is associated with higher than expected rates of panic disorder.

METHODS

To study the relationship between alcoholism and panic disorder, we administered the panicogenic agent, sodium lactate, to 26 alcoholics with either panic disorder or frequent panic attacks (ALCPAN), 20 nonalcoholics with panic disorder (PAN), 14 alcoholics without a history of panic attacks, and 14 healthy volunteers.

RESULTS

PAN were significantly more likely to have a lactate-induced panic attack (65%) than ALCPAN (23%). ALCPAN who had the onset of panic attacks prior to alcoholism also had a reduced frequency of lactate-induced panic attacks (26.7%) compared to PAN.

CONCLUSIONS

There is a reduced incidence of lactate-induced panic attacks in ALCPAN. This reduction does not appear to be explained by the relative onset of panic attacks to alcoholism. The role of excessive alcohol consumption in the decreased frequency of lactate-induced panic attacks seen in ALCPAN needs further study.

Alcoholism and phobic anxiety--a clinical-demographic comparison

The prevalence of anxious and phobic symptoms in 97 alcohol-dependent and alcohol abuse patients, and that of alcohol abuse and dependence in 90 patients with panic/agoraphobia (PAG), were respectively determined in out-patients attending alcoholism and anxiety clinics in a university psychiatric hospital. The clinical and socio-demographic data of both the phobics and non-phobics of the alcoholic sample, and the alcohol dependents and non-dependent of the PAG sample, were compared. Panic attacks and phobias were associated with increased severity and worse prognosis for alcoholism. The infrequent instances of alcohol use to cope with anxiety in the PAG sample were associated with symptoms of social phobia. Alcohol abuse and dependence were more frequent in PAG men who used alcohol to cope with anxiety. Finally, the frequency and intensity of the panic and phobic symptoms of the alcoholic and PAG samples were contrasted. The alcoholism clinic patients with anxiety had less frequent and milder panic attacks. The predominant diagnosis of this group was agoraphobia, which was infrequent in the anxiety disorders clinic.

The association of alcoholism and anxiety

The relationship between alcoholism and anxiety disorders is complex and has been the subject of much investigation. While data from community samples as well as samples of treatment-seeking populations indicate that these disorders co-occur far more commonly than would be expected by chance, the nature of the relationship is unclear. It is clear from both prevalence as well as order of onset data that various anxiety disorders have differing associations with alcohol problems. There is much overlap in symptomatology of panic disorder, generalized anxiety disorder, and alcohol withdrawal. This observation has led to speculation about common neurochemical perturbations and a kindling phenomenon as a possible connection between these disorders. Cognitive theories have been used to connect alcohol abuse and phobic disorders. Treatment of patients with co-morbid anxiety and alcoholism is discussed.

Alcoholic hangover and performance: a review

The study of alcoholic hangover is reviewed, with particular concern given to its effects upon skills performance. Different models of hangover, and the evidence gathered in their support, are surveyed. Several factors appear to contribute to hangover, and individuals may be differentially susceptible to these influences. The severity of hangover is affected by dose, coproducts of manufacture, and a number of psychological variables. Hangover is differentiated from post-intoxication effects on performance, and the results of a variety of studies on these effects are considered. Post-intoxication effects have been found in a variety of tasks, but no tasks have been consistently affected in a number of studies. This may reflect the fact that few studies have used the same tasks to assess performance. Proposed mechanisms of post-intoxication effects are considered, and the most consistent symptom accompanying impaired performance is found to be fatigue. This notion finds some support in electroencephalographic data collected during the period following intoxication.

Alcohol abuse, substance abuse, and panic disorder

The purpose of this article is to review the literature concerning the interaction of alcohol and/or substance abuse with panic disorder, the comorbidity of these disorders, possible causal relationships, biologic relationships, and the recognition and treatment of dually disordered patients. A number of studies suggest significant comorbidity between panic disorder and alcoholism or abuse of drugs, especially cocaine and sedatives. Panic may lead to drinking or sedative use and also result from prolonged use or withdrawal of alcohol or other drugs. Possible biologic relationships involve the gamma-aminobutyric acid (GABA)-benzodiazepine receptor complex and the central noradrenergic system. Although treatment of panic in substance abusers has not been studied specifically, guidelines for recognition and management of these patients, including use of antipanic medication, are discussed.

Alcohol dependence in panic disorder patients

The present study examined the prevalence of alcohol dependence among panic disorder patients. Twenty-four of 100 patients had a history of alcohol dependence according to DSM-III-R criteria; only one patient met criteria for current alcohol dependence. The lifetime prevalence obtained for this clinic sample exceeded that for the general population, and appeared to be due primarily to higher than expected rates among women. A childhood history of anxiety disorders and co-morbid diagnoses of social phobia and major depression were each associated with relatively higher rates of alcohol dependence. The clinical implications of these findings are discussed.

Effects of age and alcoholism on the prevalence of panic disorder

Findings are reported evaluating the effects of aging and alcoholism histories on the 6-month prevalence rates of panic disorder. The data were collected in 5 communities as part of the Epidemiologic Catchment Area (ECA) study: New Haven, CT; Baltimore, MD; St. Louis, MO; Durham, NC; and Los Angeles, CA. Reanalysis of ECA data provided additional support for a decline in the prevalence of panic disorder among elderly people. In addition, the presence of a history of alcohol abuse or dependence was associated with significantly elevated panic disorder rates in younger individuals, but an earlier decline in panic disorder prevalence with age, regardless of gender. These findings offer preliminary support for neurodevelopmental hypotheses for the onset and outgrowing of panic disorder. They also highlight the impact of alcoholism on the course of panic disorder.

Increased severity of alcohol withdrawal in in-patient alcoholics with a co-existing anxiety diagnosis

The purpose of this study was to determine whether alcoholics with a co-existing anxiety disorder (dual-diagnosed group) experienced different withdrawal symptomatology from alcoholics without an anxiety disorder (alcohol-only group). Symptoms of alcohol withdrawal were measured on admission to an in-patient treatment program and throughout treatment (days 0, 2, 7, 14 and 21) using the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. The dual-diagnosed group exhibited more severe alcohol withdrawal, as indicated by higher total CIWA-Ar scores, at all time points than the alcohol-only group. The possibility that anxiety disorders and alcohol withdrawal share a common neurochemical basis and that the CIWA-Ar scale may be useful as a screening instrument for anxiety disorders in alcoholics is discussed.

Alcoholism and panic disorder: is the comorbidity more than coincidence?

Studies on alcoholic patients have found a higher than expected prevalence of panic disorder, and suggest a positive correlation between the level of alcohol consumption and severity of anxiety. Conversely, there is an increased prevalence of alcoholism among patients with panic disorder and their blood relatives. A comparison of symptoms, physiological and neurochemical changes known to occur in both alcohol withdrawal and panic disorder reveals a degree of similarity between the 2 conditions. Based on the data, we propose that the chemical and cognitive changes occurring as the result of repeated alcohol withdrawals may kindle and condition coincidence of panic attacks in susceptible individuals. Implications of our postulates for treatment of alcohol withdrawal and panic disorder in alcoholics and for future studies are discussed.

Substance abuse and panic-related anxiety: a critical review

The relationship between substance abuse and panic-related anxiety can be divided into two broad areas: the incidence of anxiety disorders in substance abuse patients and the incidence of substance abuse in patients with panic-related anxiety disorders. Studies indicate that approx. 10-40% of alcoholics have a panic-related anxiety disorder, and about 10-20% of anxiety disorder patients abuse alcohol or other drugs. The majority of patients with both an anxiety and alcohol disorder report that anxiety problems preceded alcohol problems. In some cases substance abuse (e.g. cocaine) triggers the onset of panic attacks. Most patients believe that self-medication is efficacious despite the fact that they appear to have a more serious clinical condition (e.g. higher rates of depression). Directions for future research are outlined, including the proposal for a study to examine the effects of an anxiety intervention procedure for anxious alcoholics to reduce relapse rates.

The pharmacology of human anxiety

The human pharmacology of anxiety disorders, including panic disorder, is detailed. The major theories center around the role of benzodiazepine receptor, noradrenergic and serotonergic dysfunction. The contribution that challenge tests with lactate, hyper- and hypocapnia, beta- and alpha-2-adrenoceptor agonists, peptides, pentylenetetrazol, and caffeine make to our understanding of the biological basis of anxiety and these major theories are described and discussed.

Biogenic amines and their metabolites in body fluids of normal, psychiatric and neurological subjects

The biogenic monoamines and their metabolites have been isolated, identified and quantified in human body fluids over the past forty years using a wide variety of chromatographic separation and detection techniques. This review summarizes the results of those studies on normal, psychiatric and neurological subjects. Tables of normal values and the methods used to obtain them should prove to be useful as a reference source for benchmark amine and metabolite concentrations and for successful analytical procedures for their chromatographic separation, detection and quantification. Summaries of the often contradictory results of the application of these methods to psychiatric and neurological problems are presented and may assist in the assessment of the validity of the results of experiments in this field. Finally, the individual, environmental and the methodological factors affecting the concentrations of the amines and their metabolites are discussed.