Stress hormone response to the DEX-CRH test and its relation to psychotherapy outcome in panic disorder patients with and without agoraphobia

Neurochemical and genetic factors in panic disorder: a systematic review

This systematic review addresses the complex nature of Panic Disorder (PD), characterized by recurrent episodes of acute fear, with a focus on updating and consolidating knowledge regarding neurochemical, genetic, and epigenetic factors associated with PD. Utilizing the PRISMA methodology, 33 original peer-reviewed studies were identified, comprising 6 studies related to human neurochemicals, 10 related to human genetic or epigenetic alterations, and 17 animal studies. The review reveals patterns of altered expression in various biological systems, including neurotransmission, the Hypothalamic-Pituitary-Adrenal (HPA) axis, neuroplasticity, and genetic and epigenetic factors leading to neuroanatomical modifications. Noteworthy findings include lower receptor binding of GABAA and serotonin neurotransmitters in the amygdala. The involvement of orexin (ORX) neurons in the dorsomedial/perifornical region in triggering panic reactions is highlighted, with systemic ORX-1 receptor antagonists blocking panic responses. Elevated Interleukin 6 and leptin levels in PD patients suggest potential connections between stress-induced inflammatory changes and PD. Brain-derived neurotrophic factor (BDNF) and tyrosine receptor kinase B (TrkB) signaling are implicated in panic-like responses, particularly in the dorsal periaqueductal gray (dPAG), where BDNF's panicolytic-like effects operate through GABAA-dependent mechanisms. GABAergic neurons' inhibitory influence on dorsomedial and posterior hypothalamus nuclei is identified, potentially reducing the excitability of neurons involved in panic-like responses. The dorsomedial hypothalamus (DMH) is highlighted as a specific hypothalamic nucleus relevant to the genesis and maintenance of panic disorder. Altered brain lactate and glutamate concentrations, along with identified genetic polymorphisms linked to PD, further contribute to the intricate neurochemical landscape associated with the disorder. The review underscores the potential impact of neurochemical, genetic, and epigenetic factors on the development and expression of PD. The comprehensive insights provided by this systematic review contribute to advancing our understanding of the multifaceted nature of Panic Disorder and pave the way for targeted therapeutic strategies.

The predictive value of cortisol in psychodynamic psychotherapy for social anxiety disorder: Extended results of the SOPHONET-Study

Psychotherapy is an effective treatment for anxiety disorders (AD), yet a vast majority of patients do not respond to therapy, necessitating the identification of predictors to enhance outcomes. Several studies have explored the relationship between stress response and treatment outcome, as a potential treatment mechanism. However, the latter remains under-researched in patients with social anxiety disorder (SAD). We studied N = 29 patients undergoing psychodynamic psychotherapy (PDT) within the SOPHONET-Study. Stress reactivity (i.e., area under the curve with respect to the increase; AUCi) was induced by a standardized psychosocial stressor (Trier Social Stress Test; TSST) and assessed by means of adrenocorticotropic hormone (ACTH), blood and salivary cortisol samples before (t1) treatment. Samples of these biomarkers were taken -1 min prior stress exposure and six more blood samples were collected post-TSST ( + 1, + 10, + 20, + 30, + 45, + 60 min.). The participants were diagnosed with SAD based on the Structured Clinical Interview for DSM-IV (SCID) and completed the Liebowitz Social Anxiety Scale as well as the Beck Depression Inventory before (t1) and after psychotherapy (t2). Pre-treatment stress reactivity significantly predicted changes in depression (salivary p < 0.001 and blood cortisol p = 0.001), as well as in avoidance behavior (blood cortisol p = 0.001). None of the biomarkers revealed significant results in fear or in the total LSAS-scores, except for ACTH with a trend finding (p = 0.06). Regarding therapy success, symptoms of social anxiety (p = 0.005) and depression (p < 0.001) were significantly reduced from pre (t1) to post-treatment (t2). Our study showed that stress reactivity pre-treatment may serve as a predictor of psychotherapy outcome. In this regard, alterations in stress response relate to changes in symptoms of social anxiety and depression after PDT. This implies that patients with chronic stress might benefit from a targeted interventions during psychotherapy, especially to manage fear in social contexts.

Why Does Psychotherapy Work and for Whom? Hormonal Answers

The questions of for whom and why psychotherapy is effective have been the focus of five decades of research. Most of this knowledge is based on self-report measures. Following the biopsychosocial model of mental disorders, this article explores the potential of hormones in answering these questions. The literature on cortisol, oxytocin, and oestradiol in psychotherapy was systematically searched, focusing on (a) baseline hormonal predictors of who may benefit from psychotherapy and (b) hormonal changes as indicators of therapeutic change. The search was limited to depression and anxiety disorders. In sum, the findings show that, of all three hormones, the role of cortisol is most established and that both cortisol and oxytocin are implicated in psychotherapy, although a causal role is still waiting to be demonstrated. Moreover, there is a differential role of hormones in the psychotherapy of depression versus anxiety. The directions of research mapped in this article may elucidate how psychotherapy can be selected to match patients’ endocrine states and how hormonal levels can be manipulated to improve outcomes.

Stress Hormones as Predictors of Response to Cognitive Behavior Therapy in Panic Disorder

OBJECTIVE

Data regarding the potential association between the outcome of psychotherapy of panic disorder (PD) and biological parameters are few. In 21 (16 females) consecutively referred, medication-free, acutely ill PD outpatients, without comorbidities, except agoraphobia, we systematically explored for potential neuroendocrine and clinical correlates of response to a brief cognitive behavior therapy (CBT).

METHODS

Cortisol and adrenocorticotropic hormone (ACTH) basal plasma levels were measured. Measures of psychopathology: (a) Symptom Checklist-90-Revised (SCL-90-R), (b) Clinical Global Impressions-Improvement (CGI-I) Scale, (c) Agoraphobic Cognitions Questionnaire (ACQ), and (d) Mobility Inventory (MI)-alone subscale.

RESULTS

Nonresponders to CBT (CGI-I >2; N = 6) - as compared to the responders (CGI-I ≤2; N = 15) - demonstrated significantly higher cortisol and ACTH basal plasma concentrations. These differences were much stronger when only female patients (nonresponders = 4; responders = 12) were taken into consideration. Regarding psychopathology, nonresponders to CBT suffered from more severe agoraphobia (MI-alone) at baseline. On the contrary, more intense manifestations of anger (SCL-90-R) at baseline were associated with a better treatment outcome. Response to CBT was associated with significant reductions in all SCL-90-R subscales, more pronounced for "phobic anxiety" and "anxiety" subscales.

CONCLUSIONS

This study suggests that in acutely ill, medication-free PD patients, response to CBT may be associated with certain hormonal and clinical parameters at baseline.

Hormonal responsiveness in the Trier Social Stress Test and the dexamethasone-corticotropin releasing hormone test in healthy individuals

A number of different laboratory procedures investigate the hormonal response in a standardized pharmacological challenge test (dexamethasone-corticotropin releasing hormone; DEX-CRH) or in a psychosocial stress induction on the hypothalamic-pituitary-adrenocortical axis by the Trier Social Stress Test (TSST). However, the magnitude of the response related to the different stressors and the interaction of the responsiveness between the two tests is still unclear. Fifty-two participants underwent both the DEX-CRH test and the TSST on two separate days. The cortisol and the plasma adrenocorticotropic hormone (ACTH) release were assessed before and after the stress tests. For a specification of the cortisol response to both conditions, subgroups of high- and low-cortisol responders to the TSST and the DEX-CRH test were formed. The healthy participants showed a substantial increase in the ACTH and the cortisol concentration after the two tests. This increase was 3 times greater in the TSST than the DEX-CRH test. High responders in both tests demonstrated a higher factor of the cortisol reactivity ratio (TSST/DEX-CRH test). Psychosocial stress as induced by the TSST was associated with a significantly greater increase in cortisol compared to the DEX-CRH test, even though the ACTH response displayed no differences. Our findings indicate an interaction of the hormonal responsiveness between the two tests with regard to the cortisol patterns.

The hypothalamus in anxiety disorders

Of all mental disorders, anxiety disorders are currently the strongest contributors to the global burden of disease, with 7.3% of the general population affected worldwide. The hypothalamus is crucial hub of a network of neural structures modulating fear conditioning and extinction and, as such, highly relevant to the pathophysiology of these conditions. Three hypothalamic systems have emerged as particularly relevant in this context. First, the oxytocin system is highly likely to be involved anxiety disorders and in particular in the cognitive and behavioral deficits pertaining to social anxiety disorder. Second, peripheral markers of the hypothalamic-pituitary-adrenal axis appear altered in patients with panic disorder and generalized anxiety disorder, which may denote aberrant functioning of their central corticotropin-releasing hormone system. Furthermore, cortisol seems to augment the effects of exposure therapy in patients with specific phobia. Third, the integrity of the hypothalamic-pituitary-thyroid axis is likely compromised in panic disorder. Further, cross-disciplinary research efforts are required to shed more light on how, exactly, these hypothalamic systems interact with the neural structures involved in fear conditioning and extinction, which should ultimately open up new avenues for the prevention and treatment of anxiety disorders.