Characteristics of initial fearful spells and their associations with DSM-IV panic attacks and panic disorder in adolescents and young adults from the community

Panic results in unique molecular and network changes in the amygdala that facilitate fear responses

Recurrent panic attacks (PAs) are a common feature of panic disorder (PD) and post-traumatic stress disorder (PTSD). Several distinct brain regions are involved in the regulation of panic responses, such as perifornical hypothalamus (PeF), periaqueductal gray, amygdala and frontal cortex. We have previously shown that inhibition of GABA synthesis in the PeF produces panic-vulnerable rats. Here, we investigate the mechanisms by which a panic-vulnerable state could lead to persistent fear. We first show that optogenetic activation of glutamatergic terminals from the PeF to the basolateral amygdala (BLA) enhanced the acquisition, delayed the extinction and induced the persistence of fear responses 3 weeks later, confirming a functional PeF-amygdala pathway involved in fear learning. Similar to optogenetic activation of PeF, panic-prone rats also exhibited delayed extinction. Next, we demonstrate that panic-prone rats had altered inhibitory and enhanced excitatory synaptic transmission of the principal neurons, and reduced protein levels of metabotropic glutamate type 2 receptor (mGluR2) in the BLA. Application of an mGluR2-positive allosteric modulator (PAM) reduced glutamate neurotransmission in the BLA slices from panic-prone rats. Treating panic-prone rats with mGluR2 PAM blocked sodium lactate (NaLac)-induced panic responses and normalized fear extinction deficits. Finally, in a subset of patients with comorbid PD, treatment with mGluR2 PAM resulted in complete remission of panic symptoms. These data demonstrate that a panic-prone state leads to specific reduction in mGluR2 function within the amygdala network and facilitates fear, and mGluR2 PAMs could be a targeted treatment for panic symptoms in PD and PTSD patients.

Interplay between COMT Val158Met, childhood adversities and sex in predicting panic pathology: Findings from a general population sample

BACKGROUND

The single nucleotide polymorphism rs4680 of the catechol-O-methyltransferase (COMT) gene has been implicated to be involved in the etiopathogenesis of panic. However, it remains unresolved whether rs4680 modifies the risk-association between early life stress and subsequent development of panic pathology.

METHODS

The genotype of rs4680 was determined for n = 2242 adults with European ancestry from the Study of Health in Pomerania (SHIP, a regional longitudinal cohort study from northeastern Germany). Lifetime fearful spells, panic attacks and panic disorder were assessed according to DSM-IV in 2007-2010 (when participants were aged 29-89) using the Munich Composite International Diagnostic Interview (DIA-X/M-CIDI). Childhood adversities were assessed with the Childhood Trauma Questionnaire (CTQ).

RESULTS

Logistic regressions with interaction terms (adjusted for sex and age) revealed that rs4680 interacted with total childhood adversity, emotional abuse and physical abuse in predicting panic disorder: Respective childhood adversities predicted panic disorder in carriers of the Val/Met or Met/Met genotype, but not Val/Val genotype. Moreover, a 3-way interaction was found between rs4680, emotional abuse and sex in predicting panic attacks: Emotional abuse predicted panic attacks among male carriers of the Val/Val genotype and female carriers of the Val/Met or Met/Met genotype, but not among male carriers of the Val/Met or Met/Met genotype or female carriers of the Val/Val genotype.

LIMITATIONS

Genotype data were derived by imputation. Childhood adversities and panic were assessed retrospectively.

CONCLUSIONS

Especially (female) carriers of the Val/Met or Met/Met genotype of rs4680 might profit from targeted early interventions to prevent the onset of panic after childhood adversities.

Assessing the interplay of childhood adversities with more recent stressful life events and conditions in predicting panic pathology among adults from the general population

BACKGROUND

Although research suggests that (a) childhood adversities and more recent stressful life events/conditions are risk factors for panic pathology and that (b) early life stress increases vulnerability to later psychopathology, it remains unclear whether childhood adversities amplify the association between more recent stressful life events/conditions and panic pathology.

METHODS

Data were derived from a general population sample (Study of Health in Pomerania, SHIP). Lifetime panic pathology was assessed with the Munich Composite International Diagnostic Interview (M-CIDI). Childhood adversities (emotional, physical and sexual abuse; emotional and physical neglect) were assessed with the Childhood Trauma Questionnaire (CTQ). More recent separation/loss events and long-lasting stressful conditions were assessed with the Stralsund Life Event List (SEL). Individuals with lifetime panic pathology (fearful spell, panic attack or panic disorder, N = 286) were compared to controls without any psychopathology (N = 286, matched for sex and age).

RESULTS

Conditional logistic regressions revealed that childhood adversities as well as more recent separation/loss events and long-lasting stressful conditions were associated with panic pathology (OR 1.1-2.5). Moreover, more recent separation/loss events - but not long-lasting stressful conditions - interacted statistically with each of the examined childhood adversities except for sexual abuse in predicting panic pathology (OR 1.1-1.3). That is, separation/loss events were associated more strongly with panic pathology among individuals with higher childhood adversities.

LIMITATIONS

Data were assessed retrospectively and might be subject to recall biases.

CONCLUSIONS

Findings suggest that early childhood adversities amplify the risk of developing panic pathology after experiencing separation or loss events.

Risk factors for fearful spells, panic attacks and panic disorder in a community cohort of adolescents and young adults

BACKGROUND

Panic attacks (PA) and panic disorder (PD) as well as fearful spells only (FS-only, attacks of anxiety not meeting full criteria for PA or PD) increase the risk for various mental disorders. It is unclear so far whether FS-only, PA and PD share the same etiologies and risk factors.

METHODS

A representative community sample of adolescents and young adults (n=3021, aged 14-24 at baseline) was prospectively followed up over up to 10 years. Panic pathology and putative risk factors were assessed using the DSM-IV/M-CIDI and its embedded assessment modules and questionnaires.

RESULTS

In Cox regressions stratified by sex and age, female sex, parental anxiety and depression, behavioral inhibition, harm avoidance, lower coping-efficacy and parental rejection predicted the onset of FS-only, PA and PD (Hazard Ratios 1.2-3.0). Associations with other risk factors partially differed for FS-only, PA and PD and tended to be stronger for PA and PD than for FS-only.

LIMITATIONS

No strictly prospective analytical approach was used. Time intervals between some risk factors and their retrospective assessment were relatively long.

CONCLUSIONS

Findings suggest that FS-only, PA and PD are etiologically similar and represent qualitatively equal, albeit differently severe forms of panic pathology that lie on different points of the same fear-panic dimension.

The 'Early Developmental Stages of Psychopathology (EDSP) study': a 20-year review of methods and findings

PURPOSE

The "Early Developmental Stages of Psychopathology (EDSP)" study is a prospective-longitudinal study program in a community sample (Munich, Germany) of adolescents and young adults. The program was launched in 1994 to study the prevalence and incidence of psychopathological syndromes and mental disorders, to describe the natural course and to identify vulnerability and risk factors for onset and progression as well as psychosocial consequences. This paper reviews methods and core outcomes of this study program.

METHODS

The EDSP is based on an age-stratified random community sample of originally N = 3021 subjects aged 14-24 years at baseline, followed up over 10 years with up to 3 follow-up waves. The program includes a family genetic supplement and nested cohorts with lab assessments including blood samples for genetic analyses. Psychopathology was assessed with the DSM-IV/M-CIDI; embedded dimensional scales and instruments assessed vulnerability and risk factors.

RESULTS

Beyond the provision of age-specific prevalence and incidence rates for a wide range of mental disorders, analyses of their patterns of onset, course and interrelationships, the program identified common and diagnosis-specific distal and proximal vulnerability and risk factors including critical interactions.

CONCLUSIONS

The EDSP study advanced our knowledge on the developmental pathways and trajectories, symptom progression and unfolding of disorder comorbidity, highlighting the dynamic nature of many disorders and their determinants. The results have been instrumental for defining more appropriate diagnostic thresholds, led to the derivation of symptom progression models and were helpful to identify promising targets for prevention and intervention.

Panic attacks in minority Americans: the effects of alcohol abuse, tobacco smoking, and discrimination

BACKGROUND

Lifetime prevalence of panic attacks is estimated at 22.7%, and research on the correlates and causes of depression, anxiety, and other mental illnesses have yielded mixed results in minority groups. Therefore, the purpose of this study is to evaluate the relationship between panic attacks, minority status, and nativity by focusing on the effects of health lifestyle behaviors and discrimination.

METHODS

Multivariate analysis was performed using logistic regression, which was used to estimate the probability of meeting the criteria for panic attacks (n=17,249).

RESULTS

Demographic and socioeconomic variables had significant associations; females had over 2.4 times higher odds than males of meeting the criteria for panic attacks. The more frequently respondents were treated as dishonest, less smart, with disrespect, threatened, or called names, the more likely they met the criteria for panic attacks. Additionally, smoking and alcohol abuse were significant predictors of panic attacks. Those who abused alcohol have over 2 times the odds of having panic attacks. Similarly, smokers had 52% higher odds of panic attacks than non-smokers.

LIMITATIONS

The primary limitation of this project was the lack of a true acculturation measure with a secondary limitation being the inability to determine respondents׳ legal status.

CONCLUSIONS

Key findings were that health lifestyle choices and exposure to discrimination significantly affected the chance of having panic attacks. Nativity was protective; however, its effect was counteracted by exposure to discrimination or engagement in smoking behavior or alcohol abuse. Thus, this study offers insight into contextual factors for clinicians caring for racial and ethnic minorities diagnosed with panic attacks.

Predictors of the course of anxiety disorders in adolescents and young adults

Anxiety disorders belong to the most frequent mental disorders and are often characterized by an early onset and a progressive, persistent/chronic, or recurrent course. Several individual, familial, and environmental risk factors for adverse course characteristics of anxiety disorders (including higher persistence, lower probability of remission, and increased risk of recurrence) have been identified, and previous research suggests that clinical features of anxiety (e.g., higher severity, duration, and avoidance) as well as comorbid other mental disorders are particularly useful for predicting an unfavorable course of anxiety disorders. However, additional studies are needed to identify risk factors for individual course trajectories of anxiety disorders in general as well as specific diagnoses. Doing so is essential in order to more precisely identify individuals with anxiety disorders who are at increased risk for adverse long-term outcomes and might thus particularly profit from targeted early interventions.

Does help-seeking alter the risk for incident psychopathology in adolescents and young adults with and without fearful spells or panic attacks? Findings from a 10-year prospective-longitudinal community study

BACKGROUND

Although fearful spells (FS) and panic attacks (PA) increase the risk for various mental disorders, few studies have examined whether help-seeking in those with FS/PA attenuates the risk for incident psychopathology.

METHODS

A community sample of adolescents and young adults (N=2978, aged 14-24 at baseline) was followed up in up to 3 assessment waves over 10 years. FS, PA, psychopathology, and help-seeking were assessed using the DSM-IV/M-CIDI. Logistic regressions with interaction terms (adjusted for sex and age) were used to test interactions between FS/PA and help-seeking at baseline on predicting incident psychopathology at follow-up. Cases with panic disorder (PD) at baseline were excluded from all analyses.

RESULTS

FS/PA at baseline predicted the onset of any disorder, any anxiety disorder, PD, agoraphobia, generalized anxiety disorder, social phobia, and depression at follow-up (Odds Ratios, OR 1.62-5.80). FS/PA and help-seeking at baseline interacted on predicting incident PD (OR=0.09) and depression (OR=0.22) at follow-up in a way that FS/PA only predicted the respective disorders in individuals not seeking help at baseline. In those with FS/PA, a higher number of panic symptoms interacted with help-seeking on predicting incident PD (OR=0.63) in a way that a higher number of panic symptoms only increased the risk for PD in those without help-seeking at baseline.

LIMITATIONS

Help-seeking at baseline was not restricted to panic-specific interventions, but included treatment due to other psychological problems as well.

CONCLUSIONS

Findings suggest that early help-seeking might modify psychopathology trajectories and prevent incident disorders in high-risk individuals with FS/PA.

Associations of fearful spells and panic attacks with incident anxiety, depressive, and substance use disorders: a 10-year prospective-longitudinal community study of adolescents and young adults

OBJECTIVE

The concept of fearful spells (FS) denotes distressing spells of anxiety that might or might not qualify for criteria of panic attacks (PA). Few studies examined prospective-longitudinal associations of FS not meeting criteria for PA with the subsequent onset of mental disorders to clarify the role of FS as risk markers of psychopathology.

METHOD

A representative community sample of adolescents and young adults (N = 3021, age 14-24 at baseline) was prospectively followed up in up to 3 assessment waves over up to 10 years. FS, PA, anxiety, depressive, and substance use disorders were assessed using the DSM-IV/M-CIDI. Odds Ratios (OR) from logistic regressions were used to examine the predictive value of FS-only (no PA) and PA at baseline for incident disorders at follow-up.

RESULTS

In logistic regressions adjusted for sex and age, FS-only predicted the onset of any subsequent disorder, any anxiety disorder, panic disorder, agoraphobia, GAD, social phobia, any depressive disorder, major depression, and dysthymia (ORs 1.54-4.36); PA predicted the onset of any anxiety disorder, panic disorder, GAD, social phobia, any depressive disorder, major depression, dysthymia, any substance use disorder, alcohol abuse/dependence, and nicotine dependence (ORs 2.08-8.75; reference group: No FS-only and no PA). Associations with psychopathology were slightly smaller for FS-only than for PA, however, differences in associations (PA compared to FS-only) only reached significance for any anxiety disorder (OR = 3.26) and alcohol abuse/dependence (OR = 2.26).

CONCLUSIONS

Findings suggest that compared to PA, FS-only have similar predictive properties regarding subsequent psychopathology and might be useful for an early identification of high-risk individuals.