Sympathetic reactivity in agoraphobic patients with and without personality disorders

Salivary alpha-amylase and cortisol responsiveness to stress in first episode, drug-naïve patients with panic disorder

Reported findings on reactivity to stress of the sympathetic-adreno-medullar (SAM) and hypothalamic-pituitary-adrenal (HPA) systems in panic disorder (PD) are very variable. This inconsistency may be explained by differences in treatment exposure, illness duration and emotion regulation strategies. The present study examined the reactivity to mental stress of the SAM and HPA axes in a sample of first episode, drug naïve patients with PD which avoids confounds of medications exposure and illness chronicity. Activation of the SAM axis was evaluated by dosage of salivary alpha-amylase (sAA) and heart rate. Activation of the HPA axis was tested by dosage of salivary cortisol. Psychological assessments were done by the Self-Rating Depression Scale, the Self-Rating Anxiety Scale, the State-Trait Anxiety Inventory, the Cope Orientation to Problems Experienced (COPE) Inventory and the 16 Personality Factor Questionnaire (16PF). Patients showed reduced sAA stress reactivity, higher baseline cortisol levels and a more rapid decrease in stress cortisol levels as compared with controls. A significant correlation was found between active coping strategies and cortisol levels (response to stress). The findings suggest that blunted SAM stress reactivity and a rapid decrease in stress cortisol levels reflect traits that may enhance vulnerability to psychopathology in patients with PD.

Anxiety is Not Manifested by Elevated Heart Rate and Blood Pressure in Acutely Ill Cardiac Patients

BACKGROUND

Accurate assessment of anxiety in cardiac patients is important because anxiety is associated with adverse outcomes. Clinicians often use heart rate and blood pressure as indicators of anxiety; however, little is known about whether these measures accurately reflect anxiety in acutely ill patients.

AIMS

The purpose of this study was to determine whether heart rate and blood pressure were related to level of anxiety in patients with chronic advanced heart failure (HF), patients with acute myocardial infarction (AMI), and healthy individuals.

METHODS AND RESULTS

In this descriptive, correlational study, anxiety, heart rate, and blood pressure were measured at the same time in three groups of individuals: (1) 54 patients hospitalized for AMI; (2) 32 patients with chronic advanced HF; and (3) 31 healthy individuals. State anxiety was measured using the anxiety subscale of the Brief Symptom Inventory. Heart rate and blood pressure data were collected immediately prior to the anxiety assessment. Data were collected in the outpatient setting for patients with HF and healthy individuals. For patients with AMI, data were collected a mean of 48+/-33 h after admission. There were no correlations between anxiety and heart rate or diastolic blood pressure. Higher anxiety was associated with lower systolic blood pressure in patients with AMI (r=-0.23, P<0.05) and in healthy individuals (r=-0.27, P<0.05).

CONCLUSION

Elevated heart rate and blood pressure do not accurately reflect level of anxiety as reported by patients with HF or AMI and healthy individuals, and thus cannot be used to assess anxiety in acutely ill patients. Clinicians who use changes in heart rate or blood pressure as indicators of anxiety may fail to recognize and treat anxiety, placing their patients at high risk for both immediate and long-term complications.

Salivary alpha-amylase response following repeated psychosocial stress in patients with panic disorder

BACKGROUND

This study examined autonomic responses (salivary alpha-amylase, sAA; heart rate, HR) to repeated psychosocial stress as a candidate mechanism linking autonomic hyper-arousal and sensitization to the occurrence of panic disorder (PD).

METHODS

Thirty-three patients with PD and 34 healthy controls were exposed to the Trier Social Stress Test (TSST) twice on consecutive days.

RESULTS

sAA changes were comparable between PD and controls on both testing days with overall decreasing sAA responses (delta) on day two. In contrast, HR delta increased on day two in both groups. This sensitization was driven by female controls while male PD showed most pronounced HR changes to the first TSST.

CONCLUSIONS

Overall, a general autonomic hyper-arousal in PD could not be confirmed. In contrast, sAA responses slightly habituated to repeated stress. Whether sAA findings mirror assumed habituation effects of repeated stress exposure on normalizing autonomic reactivity remains to be investigated in longitudinal studies.

Physiological reactivity to phobic stimuli in people with fear of flying

OBJECTIVE

The nature of the relationship between physiological and subjective responses in phobic subjects remains unclear. Phobics have been thought to be characterized by a heightened physiological response (physiological perspective) or by a heightened perception of a normal physiological response (psychological perspective).

METHOD

In this study, we examined subjective measures of anxiety, heart rate (HR), and cardiac autonomic responses to flight-related stimuli in 127 people who applied for fear-of-flying therapy at a specialized treatment center and in 36 controls without aviophobia.

RESULTS

In keeping with the psychological perspective, we found a large increase in subjective distress (eta(2)=.43) during exposure to flight-related stimuli in the phobics and no change in subjective distress in the controls, whereas the physiological responses of both groups were indiscriminate. However, in keeping with the physiological perspective, we found that, within the group of phobics, increases in subjective fear during exposure were moderately strong coupled to HR (r =.208, P=.022) and cardiac vagal (r =.199, P=.028) reactivity. In contrast to predictions by the psychological perspective, anxiety sensitivity did not modulate this coupling.

CONCLUSION

We conclude that subjective fear responses and autonomic responses are only loosely coupled during mildly threatening exposure to flight-related stimuli. More ecologically valid exposure to phobic stimuli may be needed to test the predictions from the physiological and psychological perspectives.

Using a 0-10 Scale for Assessment of Anxiety in Patients With Acute Myocardial Infarction

Patients with acute myocardial infarction (AMI) often experience anxiety, an emotion that predicts adverse physiologic outcomes. The purpose of this study was to determine whether a single-item anxiety assessment instrument, the Anxiety Level Index (ALI), is a valid alternative to the State Anxiety Index (SAI) or the anxiety subscale of the Brief Symptom Inventory (BSI) for assessing state anxiety for patients with AMI. In this prospective multicenter study, 243 inpatients with AMI rated their anxiety using the SAI, the anxiety subscale of the BSI, and the ALI. Anxiety Level Index scores were compared to SAI and BSI anxiety subscale scores. There were moderate, positive correlations between the SAI and the ALI (rs = 0.52, P < .001), and between the ALI and the anxiety subscale of the BSI (rs = 0.45, P < .001). Although ALI scores were moderately and significantly correlated with scores on the SAI and the BSI anxiety subscales, the results of the Bland-Altman method indicate a lack of construct validity of the single-item measure. The quest continues to construct a simple self-report measure of anxiety that is appropriate for critically ill patients with AMI.

Basal norepinephrine in depersonalization disorder

In contrast to the noradrenergic dysregulation described in PTSD, little is known regarding noradrenergic function in dissociative disorders. The purpose of this preliminary study was to investigate basal norepinephrine in depersonalization disorder (DPD). Nine subjects with DSM-IV DPD, without lifetime PTSD, were compared to nine healthy comparison (HC) subjects. Norepinephrine was measured via 24-h urine collection and three serial plasma determinations. Groups did not differ significantly in plasma norepinephrine levels. Compared to the HC group, the DPD group demonstrated significantly higher urinary norepinephrine, only prior to covarying for anxiety. The DPD group also demonstrated a highly significant inverse correlation between urinary norepinephrine and depersonalization severity (r=-0.88). Norepinephrine and cortisol levels (reported in a prior study) were not intercorrelated. We concluded that although dissociation accompanied by anxiety was associated with heightened noradrenergic tone, there was a marked basal norepinephrine decline with increasing severity of dissociation. The findings are in concordance with the few reports on autonomic blunting in dissociation and merit further investigation.