Modeling the development of panic disorder with interoceptive conditioning

Impact of childhood trauma on the abnormal functional connectivity of brain regions in the fear network model of panic disorder

BACKGROUND

People who have suffered childhood trauma may be more susceptible to panic disorder (PD). Existing evidence indicates that childhood trauma can significantly impact brain function. Meanwhile, the brain regions involved in the fear network model (FNM) of PD highly overlap with the brain regions affected by childhood trauma. However, it remains unclear whether functional connections between brain regions associated with the FNM in patients with PD are affected by childhood trauma. This study aimed to investigate the effects of childhood trauma on the functional connectivity (FC) of brain regions associated with the FNM in patients with PD.

METHOD

This study recruited 62 patients with PD, including 21 with a high level of childhood trauma (PD_HCT), 41 with a low level of childhood trauma (PD_LCT), and 40 healthy controls (HCs). The patients underwent magnetic resonance imaging resting-state scanning. The amygdala, anterior cingulate, thalamus, and hippocampus were chosen as regions of interest (ROIs) to examine group differences in ROIs and whole-brain resting-state FC (rsFC).

RESULTS

Compared with PD_HCT patients, PD_LCT patients exhibited significantly increased rsFC in the right thalamus, right temporo-occipital middle temporal gyrus, left thalamus, and right temporo-occipital middle temporal gyrus. Compared with HCs, PD_LCT patients had increased rsFC between the right thalamus and the right temporo-occipital middle temporal gyrus.

CONCLUSION

Patients with PD who had suffered high and low levels of childhood trauma were found to exhibit different pathological rsFC alterations in the FNM, suggesting that childhood trauma may be an important risk factor for the development of PD symptoms.

Balance Rehabilitation with Peripheral Visual Stimulation in Patients with Panic Disorder and Agoraphobia: An Open-Pilot Intervention Study

Given the involvement of balance system abnormalities in the pathophysiology of panic disorder and agoraphobia (PD-AG), we evaluated initial evidence for feasibility, acceptability, and potential clinical usefulness of 10 sessions of balance rehabilitation with peripheral visual stimulation (BR-PVS) in an open-pilot 5-week intervention study including six outpatients with PD-AG who presented residual agoraphobia after selective serotonin reuptake inhibitor (SSRI) treatment and cognitive-behavioral therapy, dizziness in daily life, and peripheral visual hypersensitivity measured by posturography. Before and after BR-PVS, patients underwent posturography, otovestibular examination (no patients presented peripheral vestibular abnormalities), and panic-agoraphobic symptom and dizziness evaluation with psychometric tools. After BR-PVS, four patients achieved postural control normalization measured by posturography, and one patient exhibited a favorable trend of improvement. Overall, panic-agoraphobic symptoms and dizziness decreased, even though to a lesser extent in one patient who had not completed the rehabilitation sessions. The study presented reasonable levels of feasibility and acceptability. These findings suggest that balance evaluation should be considered in patients with PD-AGO presenting residual agoraphobia and that BR-PVS might be an adjunctive therapeutic option worth being tested in larger randomized controlled studies.

Diminished body trust uniquely predicts suicidal ideation and nonsuicidal self-injury among people with recent self-injurious thoughts and behaviors

INTRODUCTION

Self-injurious thoughts and behaviors (SITBs) are difficult to predict, and novel risk factors must be identified. While diminished interoception is associated with SITBs cross-sectionally, the current study assesses whether multiple measures of interoception predict future SITBs.

METHODS

Adults (N = 43) with recent SITBs completed assessments of interoception during a baseline visit. Participants then completed biweekly assessments for 6 months in which they reported the presence and severity/frequency of suicidal ideation and nonsuicidal self-injury (NSSI).

RESULTS

Multilevel models were performed, where baseline interoceptive measures predicted presence and severity/frequency of suicidal ideation and NSSI at follow-up. The Multidimensional Assessment of Interoceptive Awareness (MAIA) Trusting subscale was the only significant predictor of the presence/severity of suicidal ideation. The MAIA Trusting, Emotional Awareness, and Body Listening subscales significantly predicted the presence of NSSI. The MAIA Emotional Awareness subscale and the Body Perception Questionnaire significantly predicted NSSI frequency.

DISCUSSION

Diminished body trust predicted both suicidal ideation and NSSI, indicating a potential shared risk pathway. However, two interoception measures (Body Listening subscale and Body Perception Questionnaire) were associated with NSSI only, indicating potentially unique risk pathways. Given the differential associations between interoception measures and SITBs, results highlight the importance of clearly defining how interoception is measured.

Are Patients at Risk for Developing Panic Disorder After an Emergency Department Visit With Noncardiac Chest Pain?

BACKGROUND

Panic disorder (PD) is common in emergency department (ED) patients with noncardiac chest pain (NCCP). The literature suggests that initially PD-free patients may be at increased risk of developing PD in the months or years following an ED visit.

OBJECTIVES

This study aims to determine the incidence of PD in the 2 years following an ED visit with NCCP and to identify predictors of incident PD.

METHODS

This study was conducted using a longitudinal, observational design. Five hundred and eighty-five patients with NCCP (without PD) were recruited in two EDs. They underwent an interview and completed a series of questionnaires assessing anxiety disorders, perceived social support, psychological distress, anxiety sensitivity, comorbidities, and stressful life events. PD was assessed 6 months, 1 year, and 2 years after the initial interview.

RESULTS

PD incidence was 11.1% (95% confidence interval: 8.7-13.9) in the two years following the baseline assessment. Anxiety sensitivity (odds ratio = 1.08; 95% confidence interval: 1.04-1.11; P < .001) and stress related to life events (odds ratio = 1.14; 95% confidence interval: 1.06-1.24; P = .001) significantly predicted incident PD.

CONCLUSIONS

Patients with NCCP are at high risk for developing PD in the 2 years following an ED visit with NCCP. Anxiety sensitivity and stress related to life events may be promising clinical targets for preventive interventions.

When gut feelings teach the brain to fear pain: Context-dependent activation of the central fear network in a novel interoceptive conditioning paradigm

The relevance of contextual factors in shaping neural mechanisms underlying visceral pain-related fear learning remains elusive. However, benign interoceptive sensations, which shape patients' clinical reality, may context-dependently become conditioned predictors of impending visceral pain. In a novel context-dependent interoceptive conditioning paradigm, we elucidated the putative role of the central fear network in the acquisition and extinction of pain-related fear induced by interoceptive cues and pain-predictive contexts. In this fMRI study involving rectal distensions as a clinically-relevant model of visceroception, N = 27 healthy men and women underwent differential conditioning. During acquisition training, visceral sensations of low intensity as conditioned stimuli (CS) predicted visceral pain as unconditioned stimulus (US) in one context (Con⁺), or safety from pain in another context (Con^-). During extinction training, interoceptive CS remained unpaired in both contexts, which were operationalized as images of different rooms presented in the MRI scanner. Successful contextual conditioning was supported by increased negative valence of Con⁺ compared to Con^- after acquisition training, which resolved after extinction training. Although interoceptive CS were perceived as comparatively pleasant, they induced significantly greater neural activation of the amygdala, ventromedial PFC, and hippocampus when presented in Con⁺, while contexts alone did not elicit differential responses. During extinction training, a shift from CS to context differentiation was observed, with enhanced responses in the amygdala, ventromedial, and ventrolateral PFC to Con⁺ relative to Con^-, whereas no CS-induced differential activation emerged. Context-dependent interoceptive conditioning can turn benign interoceptive cues into predictors of visceral pain that recruit key regions of the fear network. This first evidence expands knowledge about learning and memory mechanisms underlying interoceptive hypervigilance and maladaptive avoidance behavior, with implications for disorders of the gut-brain axis.

Resting-state causal connectivity of the bed nucleus of the stria terminalis in panic disorder

Panic disorder (PD) is associated with anticipatory anxiety, a sustained threat response that appears to be related to the bed nucleus of the stria terminalis (BNST). Individuals with panic disorder may demonstrate significant differences in causal connectivity of the BNST in comparison to healthy controls. To test this hypothesis, resting-state functional magnetic resonance imaging (fMRI) was used to identify aberrant causal connectivity of the BNST in PD patients. 19 PD patients and 18 healthy controls (HC) matched for gender, age and education were included. Granger causality analysis (GCA) utilizing the BNST as a seed region was used to investigate changes in directional connectivity. Relative to healthy controls, PD patients displayed abnormal directional connectivity of the BNST including enhanced causal connectivity between the left parahippocampal gyrus and left BNST, the right insula and the right BNST, the left BNST and the right dorsolateral prefrontal cortex (dlPFC) and right BNST to the left and right dlPFC. Furthermore, PD patients displayed weakened causal connectivity between the right dlPFC and the left BNST, the left dlPFC and the right BNST, the left BNST and the left dorsomedial prefrontal cortex (dmPFC), right insula, right fusiform, and right BNST to the right insula. The results suggest that PD strongly correlates with increased causal connectivity between emotional processing regions and the BNST and enhanced causal connectivity between the BNST and cognitive control regions.

Interoception and Mental Health: A Roadmap

Interoception refers to the process by which the nervous system senses, interprets, and integrates signals originating from within the body, providing a moment-by-moment mapping of the body's internal landscape across conscious and unconscious levels. Interoceptive signaling has been considered a component process of reflexes, urges, feelings, drives, adaptive responses, and cognitive and emotional experiences, highlighting its contributions to the maintenance of homeostatic functioning, body regulation, and survival. Dysfunction of interoception is increasingly recognized as an important component of different mental health conditions, including anxiety disorders, mood disorders, eating disorders, addictive disorders, and somatic symptom disorders. However, a number of conceptual and methodological challenges have made it difficult for interoceptive constructs to be broadly applied in mental health research and treatment settings. In November 2016, the Laureate Institute for Brain Research organized the first Interoception Summit, a gathering of interoception experts from around the world, with the goal of accelerating progress in understanding the role of interoception in mental health. The discussions at the meeting were organized around four themes: interoceptive assessment, interoceptive integration, interoceptive psychopathology, and the generation of a roadmap that could serve as a guide for future endeavors. This review article presents an overview of the emerging consensus generated by the meeting.