Estrogen-induced panic attacks

Estrogens, age, and, neonatal stress: panic disorders and novel views on the contribution of non-medullary structures to respiratory control and CO2 responses

CO₂ is a fundamental component of living matter. This chemical signal requires close monitoring to ensure proper match between metabolic production and elimination by lung ventilation. Besides ventilatory adjustments, CO₂ can also trigger innate behavioral and physiological responses associated with fear and escape but the changes in brain CO₂/pH required to induce ventilatory adjustments are generally lower than those evoking fear and escape. However, for patients suffering from panic disorder (PD), the thresholds for CO₂-evoked hyperventilation, fear and escape are reduced and the magnitude of those reactions are excessive. To explain these clinical observations, Klein proposed the false suffocation alarm hypothesis which states that many spontaneous panics occur when the brain's suffocation monitor erroneously signals a lack of useful air, thereby maladaptively triggering an evolved suffocation alarm system. After 30 years of basic and clinical research, it is now well established that anomalies in respiratory control (including the CO₂ sensing system) are key to PD. Here, we explore how a stress-related affective disorder such as PD can disrupt respiratory control. We discuss rodent models of PD as the concepts emerging from this research has influenced our comprehension of the CO₂ chemosensitivity network, especially structure that are not located in the medulla, and how factors such as stress and biological sex modulate its functionality. Thus, elucidating why hormonal fluctuations can lead to excessive responsiveness to CO₂ offers a unique opportunity to gain insights into the neuroendocrine mechanisms regulating this key aspect of respiratory control and the pathophysiology of respiratory manifestations of PD.

Role of progesterone and other neuroactive steroids in anxiety disorders

It remains unexplained why a greater prevalence of anxiety disorders exists in women than in men, and how female hormone-related events (i.e., menstrual cycle and postpartum) can influence the course of anxiety disorders. It would appear logical that female hormones and their derivatives play a major role in these observations. The abundance of preclinical data demonstrating a role for sex hormones and their derivatives in anxiety-like behavior is in contrast to the relative paucity of experimental clinical data on the role of female hormones and neuroactive steroids in anxiety disorders. There is a dramatic potential for therapeutic anxiolytic activity of pharmacological compounds derived from powerful anxiolytic agents, such as the progesterone derivative, allopregnanolone. As a result, there is currently tremendous interest from the pharmaceutical industry in developing and testing such agents in anxiety disorders.

Psychiatric aspects of infertility and infertility treatments

Infertility counseling, whether provided by a psychiatrist or another health care professional, involves the treatment and care of patients, not simply when they are undergoing fertility treatment but also with their long-term emotional well-being, and that of their children and the reproductive helpers who may assist them in achieving biologic or reproductive parenthood. They can educate patients about the side effects of infertility treatment medications and the impact of hormone shifts on psychologic well-being. They are also helpful with differential diagnoses among grief, depressions, and stress; in assessing psychologic preparedness; and in determining the acceptability and suitability of gamete donation, a gestational carrier, or surrogacy as a family-building alternative for individuals, couples, and reproductive collaborators.

Antipanic efficacy of paroxetine and polymorphism within the promoter of the serotonin transporter gene

Serotonin selective reuptake inhibitors (SSRIs) are the drugs of choice in the treatment of panic disorder (PD). The serotonin transporter (5-HTT) is a prime target for SSRIs. A functional polymorphism within the promoter region of the 5-HTT gene, leading to different transcriptional efficiency, was repeatedly reported to influence the response to SSRIs in mood disorders while the response of patients with OCD seems unrelated. We tested the hypothesis that allelic variation of the 5-HTT promoter could be related to the antipanic response to paroxetine. In total, 92 patients with PD completed a treatment with a variable dose of paroxetine for 12 weeks. The severity of panic-phobic symptomatology was measured before the beginning of the treatment and after 12 weeks. Allelic variation in each subject was determined using a PCR-based method. Both homozygotes for the long variant (l/l) of the 5-HTT promoter and heterozygotes (l/s) showed a better response to paroxetine than homozygotes for the short variant (s/s) (chi(2)=6.9, p<0.03). This result emerged in the whole sample, but was related only to female patients (chi(2)=7.6, p<0.02). The presence of the long allelic variant was associated with a better response of panic attacks while was not significantly associated with the response of anticipatory anxiety or phobic avoidance. In conclusion, paroxetine efficacy in PD seems to be related to allelic variation within the promoter of the 5-HTT gene in female subjects. This gender effect might be related to the genomic effects of sex hormones. Understanding the interaction between gender and genes coding for structures target of psychotropic drugs could help to individualize the pharmacological treatment of PD.

Panic disorder in menopause: a case control study

OBJECTIVE

The course of panic disorder (PD) is often influenced by the different phases of the female reproductive cycle. The aim of this study is to assess PD in the climacteric stage and single out possible correlations between symptoms of PD and clinical and demographic variables in order to identify possible risk factors.

METHOD

Forty-five women between 40 and 60 years of age was assessed through the SCL-90, the SCID, a "Climacteric Symptoms Questionnaire" (CSQ) devised to evaluate psychological symptoms typically associated with menopause, the Kupperman Index for the analysis of climacteric symptoms, and plasma level of allopregnanolone (ALLO).

RESULTS

PD results in eight patients (18%). This group does not differ from the controls as far as socio-demographic data is concerned, but exhibits significantly higher values in the Kupperman Index, the SCL-90 total, and the CSQ. The plasma levels of ALLO correlate significantly inversely with the total of CSQ and, in any case, negatively with the other variables analysed.

CONCLUSIONS

PD may arise and worsen with menopause, in correlation with greater severity of the climacteric syndrome in its physical and psychological symptoms.

Neurosteroid secretion in panic disorder

Evidence that neurosteroids have anxiolytic effects in animal models of anxiety has suggested that alterations of neurosteroid secretion might be implicated in the pathogenetic mechanisms of anxiety disorders in humans. In 25 female patients with panic disorder (PD) and 11 healthy female controls, we measured plasma concentrations of progesterone (PROG), pregnenolone (PREG), allopregnanolone (3alpha,5alpha-tetrahydroprogesterone=3alpha,5alpha-THPROG), dehydroepiandrosterone (DHEA) and tetrahydrodeoxycorticosterone (3alpha,5alpha-THDOC) during a drug-free month and during the following month of paroxetine therapy. The neurosteroids were measured during the early follicular phase, the mid-luteal phase and the premenstrual phase of both months (days 7, 22 and 27 from the beginning of the cycle). Significantly higher levels in patients than controls were found in PROG during the mid-luteal phase of both months, PREG in the premenstrual phase in the drug-free month, 3alpha,5alpha-THPROG during the follicular phase of the drug-free month and during the premenstrual phase of the therapy month, and 3alpha,5alpha-THDOC during the premenstrual phases of both months. DHEA levels did not differ in patients and controls. These results suggest that neurosteroids in PD are hypersecreted, possibly as an attempt to counteract the anxiogenic underlying hyperactivity of the hypothalamo-pituitary-adrenal axis and to improve a reduced GABA(A) receptor sensitivity.

Effect of ethinyl estradiol on the panic response to the panicogenic agent pentagastrin

BACKGROUND

Panic disorder (PD) symptomatology has been reported to be altered by hormonal events or treatments which affect estrogen levels. Coryell et al. [Arch. Gen. Psychiatry, 39 (1982) 701-703; Am. J. Psychiatry, 143 (1986) 508-510] have suggested that the increased cardiovascular risk associated with PD is significantly greater in males, alluding to a potential cardioprotective effect of female hormones in the context of panic attacks. In the present study, we were, therefore, interested in elucidating the role of estrogen in modulating the behavioural and cardiovascular responses induced by the panicogenic agent pentagastrin, a cholecystokinin-B (CCK(B)) receptor agonist.

METHODS

A double-blind cross-over placebo-controlled design with randomization of the order of a 3-day pretreatment of ethinyl estradiol (EE) (50 microg/day) or placebo was used to assess the effect of a 30-microg i.v. bolus injection of pentagastrin on panic symptom intensity and on increases in heart rate (DeltaHR), systolic (DeltaSBP) and diastolic (DeltaDBP) blood pressure following each pretreatment. Subjects were 9 male healthy controls and 11 male PD patients.

RESULTS

EE pretreatment did not significantly reduce the pentagastrin-induced panic symptom scale (PSS) scores and had no effect on DeltaDBP or DeltaSBP. EE did, however, attenuate the pentagastrin-induced increase in HR in both PD patients and healthy controls.

LIMITATIONS

Only male subjects were included in the present study; however, we are currently investigating the influence of female gonadal hormones on the panic response to pentagastrin in female PD patients and healthy controls.

CONCLUSION

Our results suggest that estrogens may display cardioprotective effects in the context of panic attacks.

Menstrual cycle-related sensitivity to 35% CO2 in panic patients

In a double blind, random, cross-over design, 10 patients and seven controls inhaled one vital capacity of 35% CO2-65% O2 during their early-follicular and midluteal phases. Anxiety after CO2 intake was significantly stronger in the early-follicular phase than in the midluteal phase for patients. Controls had no anxiety reactions.