Panic attacks and psychopathology among youth

Exposure to mass disaster and probable panic disorder among children in New York City

While both direct and indirect exposure to mass trauma are increasing in the United States, relatively little is known about the potential link between mass trauma and risk of panic disorder early in life. It is also unclear whether history of prior individual trauma increases risk of panic disorder even further among those with exposure to mass trauma. The current study investigated the association between exposure to a mass trauma event (the World Trade Center (WTC) attack) and risk of panic disorder among children, how panic disorder varies by exposure severity and sociodemographic characteristics, and whether there is an interaction between individual and mass trauma exposure in the risk of panic disorder. Data were from an epidemiologic study of probable mental disorders among New York City schoolchildren exposed to the WTC terrorist attack. Severe (adjusted odds ratio [AOR] = 2.0 (1.1, 3.7)) exposure to the WTC disaster was associated with increased odds of probable panic disorder, relative to mild exposure. The prevalence of panic disorder increased with higher level of WTC exposure among all sociodemographic strata. Prior individual trauma exposure was associated with increased odds of panic disorder (AOR = 2.4 (1.6, 3.5)), but there was no evidence of interaction between prior individual trauma exposure and exposure to the WTC disaster. Preventive measures to address the widespread nature of mass disaster exposure at increasingly earlier ages and via media could mitigate the potential impact on mental health.

Disorder-specific internet-based cognitive-behavioral therapy in treating panic disorder, comorbid symptoms and improving quality of life: A meta-analytic evaluation of randomized controlled trials

Compared to conventional face-to-face psychological treatments, internet-based cognitive-behavioral therapy (iCBT) presents an innovative alternative that has been found to be effective in the treatment of anxiety disorders. The current study provides a meta-analysis investigating the efficacy of disorder-specific guided self-help (Gsh) iCBT compared to various active and inactive control conditions, with focus on adult panic disorder sufferers with or without agoraphobia (PD/A). Systematic literature search yielded 13 randomized controlled trials (RCTs) (N = 1214) that met the eligibility criteria for this study. We found no statistically significant differences between Gsh iCBT and various active CBT interventions in reducing PD/A symptoms at both post-test (g = 0.015, k = 10) and follow-up (g = 0.113, k = 6) levels. Also, comorbid anxiety and depression were reduced equivalently at post-test (g = 0.004, k = 6) and follow-up (g = 0.004, k = 6). Quality of life was equally improved at post-test (g = -0.100, k = 5) and follow-up (g = 0.074, k = 2). When compared to inactive controls, we found large effect sizes in PD/A (g = -0.892, k = 9) and comorbid anxiety and depression (g = -0.723, k = 9) symptoms, and moderate change in quality of life (g = -0.484, k = 3) at post-test. There was no difference between Guided self-help iCBT and Self-help iCBT in PD/A (g = -0.025, k = 3) and comorbid anxiety and depression (g = -0.025, k = 3) at post-test. Baseline severity, country of original research and adherence to the treatment in form of initial uptake were identified as statistically significant moderators of the iCBT treatment.

Serum biomarkers predictive of depressive episodes in panic disorder

Panic disorder with or without comorbid agoraphobia (PD/PDA) has been linked to an increased risk to develop subsequent depressive episodes, yet the underlying pathophysiology of these disorders remains poorly understood. We aimed to identify a biomarker panel predictive for the development of a depressive disorder (major depressive disorder and/or dysthymia) within a 2-year-follow-up period. Blood serum concentrations of 165 analytes were evaluated in 120 PD/PDA patients without depressive disorder baseline diagnosis (6-month-recency) in the Netherlands Study of Depression and Anxiety (NESDA). We assessed the predictive performance of serum biomarkers, clinical, and self-report variables using receiver operating characteristics curves (ROC) and the area under the ROC curve (AUC). False-discovery-rate corrected logistic regression model selection of serum analytes and covariates identified an optimal predictive panel comprised of tetranectin and creatine kinase MB along with patient gender and scores from the Inventory of Depressive Symptomatology (IDS) rating scale. Combined, an AUC of 0.87 was reached for identifying the PD/PDA patients who developed a depressive disorder within 2 years (n = 44). The addition of biomarkers represented a significant (p = 0.010) improvement over using gender and IDS alone as predictors (AUC = 0.78). For the first time, we report on a combination of biological serum markers, clinical variables and self-report inventories that can detect PD/PDA patients at increased risk of developing subsequent depressive disorders with good predictive performance in a naturalistic cohort design. After an independent validation our proposed biomarkers could prove useful in the detection of at-risk PD/PDA patients, allowing for early therapeutic interventions and improving clinical outcome.

A comparison of the nature and correlates of panic attacks in the context of Panic Disorder and Social Anxiety Disorder

Panic attacks occurring outside of Panic Disorder are not well-understood despite their inclusion as a diagnostic specifier in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5). This study compares panic attacks in the context of Panic Disorder compared to social anxiety in terms of their symptom frequency, severity, and clinical correlates.

METHOD

Participants (n=404) were interviewed using the Anxiety Disorders Interview Schedule (ADIS-IV-L; Brown et al., 1994), from which we analyzed interviewer ratings of panic attacks and panic attack symptoms, as well as other demographic and clinical characteristics.

RESULTS

Panic attacks in the context of Panic Disorder were characterized by a greater number and severity of symptoms compared to panic attacks in the context of Social Anxiety Disorder, and were associated with a history of traumatization, inpatient psychiatric treatment, and benzodiazepine use. Social anxiety panic attacks were associated with reduced physical health concerns. Cognitive panic attack symptoms were more prevalent in Panic Disorder and were associated with a variety of poor clinical correlates.

CONCLUSIONS

Panic attacks in the context of Panic Disorder are more severe than those in social anxiety, and this may be driven by cognitive disturbances during those attacks.

A laboratory-based test of the relation between adolescent alcohol use and panic-relevant responding

A burgeoning literature supports a link between alcohol use and panic-spectrum problems (e.g., panic attacks, disorder) among adolescents, but the direction of influence has yet to be properly examined. From a theoretical perspective, panic-spectrum problems may increase risk for problematic drinking via affect regulation efforts (e.g., self-medication), and problematic consumption also may increase or initiate panic-relevant responding (e.g., learning or kindling models). The objective of the current investigation was to examine the role of prior alcohol use in predicting panic-relevant responding, as well as panic symptom history in predicting the desire to consume alcohol, in the context of either a voluntary hyperventilation or a low-arousal task. Participants were community-recruited adolescents aged 12-17 years (n = 92, Mage = 15.42, SD = 1.51; 39.1% girls). Results indicated that prior alcohol use predicted panic-relevant responding among those undergoing the hyperventilation task (but not the low-arousal task), and that this finding was robust to the inclusion of theoretically relevant covariates (i.e., age, sex, negative affectivity). However, panic symptom history did not predict the desire to consume alcohol as a function of either the hyperventilation or low-arousal condition. This work sheds further light on the nature of the relation between panic-spectrum problems and problematic alcohol use in adolescence. Specifically, the current findings suggest that frequent alcohol use may increase panic vulnerability among adolescents, whereas acute panic symptoms may not elicit the immediate (self-reported) desire to drink.

Frontal cortex absolute beta power measurement in Panic Disorder with Agoraphobia patients

Panic disorder patients are hypervigilant to danger cues and highly sensitive to unpredictable aversive events, what leads to anticipatory anxiety, that is one key component of the disorder maintenance. Prefrontal cortex seems to be involved in these processes and beta band activity may be related to the involvement of top-down processing, whose function is supposed to be disrupted in pathological anxiety. The objective of this study was to measure frontal absolute beta-power (ABP) with qEEG in panic disorder and agoraphobia (PDA) patients compared to healthy controls.

METHODS

qEEG data were acquired while participants (24 PDA patients and 21 controls) watched a computer simulation (CS), consisting of moments classified as "high anxiety" (HAM) and "low anxiety" (LAM). qEEG data were also acquired during two rest conditions, before and after the computer simulation display. The statistical analysis was performed by means of a repeated measure analysis of variance (two-way ANOVA) and ABP was the dependent variable of interest. The main hypothesis was that a higher ABP in PDA patients would be found related to controls. Moreover, in HAM the ABP would be different than in LAM.

RESULTS

the main finding was an interaction between the moment and group for the electrodes F7, F8, Fp1 and Fp2. We observed a higher ABP in PDA patients when compared to controls while watching the CS. The higher beta-power in the frontal cortex for the PDA group may reflect a state of high excitability, together with anticipatory anxiety and maintenance of hypervigilant cognitive state.

CONCLUSIONS

our results suggest a possible deficiency in top-down processing reflected by a higher ABP in the PDA group while watching the CS and they highlight the recruitment of prefrontal regions during the exposure to anxiogenic stimuli.

LIMITATIONS

the small sample, the wide age range of participants and the use of psychotropic medications by most of the PDA patients.

Panic symptoms and elevated suicidal ideation and behaviors among trauma exposed individuals: Moderating effects of post-traumatic stress disorder

Panic attacks (PAs) are highly prevalent among trauma exposed individuals and have been associated with a number of adverse outcomes. Despite high suicide rates among trauma exposed individuals, research to date has not examined the potential relation between panic symptoms and suicidal ideation and behaviors among this high risk population. The current study tested the association of panic with suicidal ideation and behaviors among a large sample of trauma exposed smokers. Community participants (N=421) who reported a lifetime history of trauma exposure were assessed concurrently for current panic, suicidal ideation and behaviors, and psychiatric diagnoses. Those who met criteria for a current panic disorder diagnosis were removed from analyses to allow for the assessment of non-PD related panic in line with the recent addition of the PA specifier applicable to all DSM-5 disorders. Findings indicated that panic symptoms were significantly associated with suicidal ideation and behaviors beyond the effects of depression and number of trauma types experienced. Further, post-traumatic stress disorder (PTSD) diagnostic status significantly moderated this relationship, indicating that the relationship between panic and suicidal ideation and behaviors is potentiated among individuals with a current PTSD diagnosis. This investigation suggests that panic symptoms may be a valuable clinical target for the assessment and treatment of suicidal ideation and behaviors among trauma exposed individuals.

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.

Situational panic attacks in social anxiety disorder

BACKGROUND

Panic attacks (PAs) are common in many psychiatric disorders other than panic disorder, especially social anxiety disorder (SAD). PAs have been associated with increased severity, comorbidity, and impairment in many disorders; therefore, PAs can now be used as a descriptive specifier across all DSM-5 disorders. However, the clinical implications of PAs in SAD remain unclear.

METHODS

The aim of the present investigation was to examine demographic and clinical characteristics associated with SAD-related situational panic attacks in a large, representative epidemiological sample of individuals with SAD (N=1138). We compared individuals with SAD who did and did not endorse situational PAs in terms of demographic factors, fear/avoidance of social situations, distress, impairment, and diagnostic comorbidity.

RESULTS

Being male, black, Asian, or over 65 years old was associated with a decreased likelihood of experiencing situational PAs, whereas being unemployed was associated with an increased likelihood. Individuals with situational PAs also exhibited greater fear and avoidance of social situations, impairment, coping-oriented substance use, treatment utilization, and concurrent and longitudinal psychiatric comorbidity.

LIMITATIONS

Consistent with most epidemiologic studies, the information collected relied on self-report, and not all participants were available for both waves of assessment.

CONCLUSIONS

The present findings suggest that SAD-related situational PAs are associated with more severe and complex presentations of SAD. Implications for the assessment and treatment of SAD, as well as for the use of PAs as a descriptive specifier for SAD, are discussed.

Panic attacks and hoarding disorder: an initial investigation

Panic attacks (PAs) defined as a discrete period of intense fear or discomfort, occur in the context of numerous anxiety and mood related disorders. Research has suggested that PAs serve as a significant indicator and prognostic factor for overall symptom severity, course, and comorbidity within various conditions. Consequently, a PA specifier is now applicable to all DSM-5 disorders. Despite these clinical and nosological implications, no research to date has examined associations between PAs and hoarding disorder. The current investigation evaluated relationships between PA endorsement and hoarding severity within a sample of 32 patients with hoarding disorder. Findings suggested a high rate of panic history among those with hoarding disorder (56%). Hoarders with co-occurring PAs, compared to those without PAs, evidenced significantly higher symptom severity. Moreover, PAs continued to significantly predict hoarding severity even after controlling for relevant covariates. When examining the specific relationships among PAs and hoarding symptoms (i.e., acquiring, difficulty discarding, and clutter), the endorsement of PAs was associated with increased acquiring and difficulty discarding symptoms. These findings add considerably to a growing body of literature on hoarding disorder. Implications for the assessment and treatment of PAs that co-occur with hoarding disorder are discussed.

Comorbidity of anxiety and depression in children and adolescents: 20 years after

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

Experiencing core symptoms of anxiety and unipolar mood disorders in late adolescence predicts disorder onset in early adulthood

BACKGROUND

Identification of youth at risk for anxiety and unipolar mood disorders (UMDs) can improve public health by targeting those who may warrant early or preventive intervention. This study examined whether endorsing core features of anxiety and UMDs predicted onset of later anxiety and UMDs across the next 7-9 years, and whether having subthreshold or subclinical manifestations of these disorders similarly predicted onset.

METHODS

Data from this study come from the Youth Emotion Project (YEP), a two-site investigation of common and specific risk factors for emotional disorders. Endorsement of core features of a disorder and subclinical or subthreshold anxiety and UMD diagnoses were determined using data from the Structured Clinical Interview for DSM-IV (SCID) at the baseline assessment. Participants completed annual SCIDs over the course of the next 7-9 years (depending on cohort).

RESULTS

Endorsement of panic attacks, obsessions and/or compulsions, and depression and/or anhedonia predicted onset of panic disorder, obsessive compulsive disorder, and major depressive disorder, respectively. When including all anxiety disorders in a model, only the presence of panic attacks uniquely predicted anxiety disorder onset. The presence of subclinical or subthreshold panic disorder, obsessive compulsive disorder, and social phobia at baseline predicted the full onset of these disorders over the follow-up period.

CONCLUSIONS

Experiencing some symptoms of anxiety and UMDs in the absence of meeting diagnostic criteria is indicative of risk for later onsets of clinically significant DSM manifestations of these disorders. These individuals should be identified and targeted for prevention programs.

Alpha absolute power measurement in panic disorder with agoraphobia patients

BACKGROUND

Panic attacks are thought to be a result from a dysfunctional coordination of cortical and brainstem sensory information leading to heightened amygdala activity with subsequent neuroendocrine, autonomic and behavioral activation. Prefrontal areas may be responsible for inhibitory top-down control processes and alpha synchronization seems to reflect this modulation. The objective of this study was to measure frontal absolute alpha-power with qEEG in 24 subjects with panic disorder and agoraphobia (PDA) compared to 21 healthy controls.

METHODS

qEEG data were acquired while participants watched a computer simulation, consisting of moments classified as "high anxiety"(HAM) and "low anxiety" (LAM). qEEG data were also acquired during two rest conditions, before and after the computer simulation display.

RESULTS

We observed a higher absolute alpha-power in controls when compared to the PDA patients while watching the computer simulation. The main finding was an interaction between the moment and group factors on frontal cortex. Our findings suggest that the decreased alpha-power in the frontal cortex for the PDA group may reflect a state of high excitability.

CONCLUSIONS

Our results suggest a possible deficiency in top-down control processes of anxiety reflected by a low absolute alpha-power in the PDA group while watching the computer simulation and they highlight that prefrontal regions and frontal region nearby the temporal area are recruited during the exposure to anxiogenic stimuli.

Cued panic attacks in body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) is a common and often severe disorder. Clinical observations suggest that panic attacks triggered by BDD symptoms may be common. However, to our knowledge, no study has examined such panic attacks in BDD. We investigated the prevalence, clinical features, and correlates of BDD- triggered panic attacks in individuals with this disorder.

METHODS

Panic attacks and other variables were assessed using reliable and valid measures in 76 individuals with lifetime DSM-IV BDD.

RESULTS

28.9% (95% CI, 18.5%-39.4%) of participants reported lifetime panic attacks triggered by BDD symptoms. The most common triggers of such attacks were feeling that others were looking at or scrutinizing the perceived appearance defects (61.9%), looking in the mirror at perceived defects (38.1%), and being in bright light where perceived defects would be more visible (23.8%). The most common panic attack symptoms were palpitations (86.4%), sweating (66.7%), shortness of breath (63.6%), trembling or shaking (63.6%), and fear of losing control or going crazy (63.6%). Compared to participants without such panic attacks, those with BDD-triggered panic attacks had more severe lifetime BDD, social anxiety, and depressive symptoms, as well as poorer functioning and quality of life on a number of measures. They were also less likely to be employed and more likely to have been psychiatrically hospitalized and to have had suicidal ideation due to BDD.

CONCLUSIONS

Panic attacks triggered by BDD-related situations appear com- mon in individuals with this disorder. BDD-triggered panic attacks were associated with greater symptom severity and morbidity.

Panic attacks in generalized anxiety disorder

Panic attacks have been reported by patients with generalized anxiety disorder (GAD) in response to catastrophic worry. This has not been characterized in the literature. We examined the prevalence of GAD panic attacks in an anxiety disorders clinic sample. Charts of 254 patients with DSM-IV GAD were retrospectively evaluated. The presence and type of panic attacks were examined as well as correlates including comorbidity, baseline symptom severity, demographic variables, and family history. Twenty-one percent had GAD panic attacks, 21.7% had situationally predisposed attacks, 15.6% had situationally bound attacks, and 39.4% had unexpected panic attacks. The individuals who had GAD panic attacks had higher scores on the Anxiety Sensitivity Index compared with those who also had other types of panic attacks. One in five patients with GAD reported GAD panic attacks; however, these individuals did not differ significantly on the correlates that were evaluated. These findings require replication and further evaluation.

Childhood internalizing and externalizing problems predict the onset of clinical panic attacks over adolescence: the TRAILS study

BACKGROUND

Panic attacks are a source of individual suffering and are an independent risk factor for later psychopathology. However, much less is known about risk factors for the development of panic attacks, particularly during adolescence when the incidence of panic attacks increases dramatically. We examined whether internalizing and externalizing problems in childhood predict the onset of panic attacks in adolescence.

METHOD

This study is part of the TRacking Adolescents' Individual Lives Survey (TRAILS), a Dutch longitudinal population cohort study (N = 1,584). Internalizing and Externalizing Problems were collected using the Youth Self-Report (YSR) and the parent-report Child Behavior Checklist (CBCL) at baseline (age 10-12). At age 18-20, DSM-IV defined panic attacks since baseline were assessed with the Composite International Diagnostic Interview (CIDI). We investigated whether early adolescent Internalizing and Externalizing Problems predicted panic attacks between ages 10-20 years, using survival analysis in univariate and multivariate models.

RESULTS

There were N = 314 (19.8%) cases who experienced at least one DSM-IV defined panic attack during adolescence and N = 18 (1.2%) who developed panic disorder during adolescence. In univariate analyses, CBCL Total Problems, Internalizing Problems and three of the eight syndrome scales predicted panic attack onset, while on the YSR all broad-band problem scales and each narrow-band syndrome scale predicted panic attack onset. In multivariate analyses, CBCL Social Problems (HR 1.19, p<.05), and YSR Thought Problems (HR 1.15, p<.05) and Social Problems (HR 1.26, p<.01) predicted panic attack onset.

CONCLUSION

Risk indicators of panic attack include the wide range of internalizing and externalizing problems. Yet, when adjusted for co-occurring problem behaviors, Social Problems were the most consistent risk factor for panic attack onsets in adolescence.

Alcohol use history and panic-relevant responding among adolescents: a test using a voluntary hyperventilation challenge

Given the onset of alcohol use, neurological sensitivity, and enhanced panic-relevant vulnerability, adolescence is a key period in which to study the documented linkage between alcohol and panic-related problems. The current study was designed to build upon and uniquely extend extant work via (a) utilization of well-established experimental psychopathology techniques and (b) evaluation of unique associations between alcohol use and panic symptoms after controlling for theoretically relevant behavioral, environmental, and individual difference variables (i.e., age, gender, negative affectivity, anxiety sensitivity, child and parent tobacco use, and parental panic disorder). Participants were 111 community-recruited adolescents ages 12-17 years (M = 15.76 years; n = 50 girls). Youth completed a battery of well-established questionnaires and a voluntary hyperventilation challenge, and parents present at the laboratory completed a structured clinical interview. Adolescent alcohol use was categorized as Non-Users, Experimenters, or Users. Panic symptoms were indexed via retrospective self-report and adolescents' response to a biological challenge procedure (i.e., voluntary hyperventilation). After controlling for theoretically relevant covariates, Users evidenced elevated panic-relevant symptoms and responding compared with Non-Users; Experimenters did not differ from Non-Users. Findings suggest alcohol use history is uniquely associated with panic symptomatology among youth, including "real-time" reactivity elicited by a laboratory challenge. Although there is significant work yet to be done, these data advance extant work and lay the groundwork for the types of sophisticated designs that will be needed to answer the most pressing and complex questions regarding the link between alcohol use and panic symptoms among adolescents.

An examination of the relation between traumatic event exposure and panic-relevant biological challenge responding among adolescents

The current study uniquely extended research that has linked traumatic event exposure to panic-spectrum problems among adolescents. It was hypothesized that among 127 adolescents (age range: 10 to 17 years; M = 14.63, SD = 2.24), those who endorsed a history of traumatic event exposure would evidence significantly greater anxious and fearful reactivity to a well-established 3-min voluntary hyperventilation procedure compared to nonexposed individuals. Results were consistent with hypotheses, suggesting traumatic event exposure is associated with anxious and fearful reactivity to abrupt increases in bodily arousal among adolescents. Moreover, consistent with hypotheses, anxiety sensitivity significantly mediated the relations between traumatic event exposure and both self-reported panic symptoms and panic symptoms elicited by the challenge. Future prospective research is now needed to better understand temporal relations between traumatic event exposure and indices of panic and related vulnerability.

Panic attacks as a risk for later psychopathology: results from a nationally representative survey

BACKGROUND

There is a growing body of literature suggesting that panic attacks without panic disorder are associated with increases in a wide range of psychopathology and impairment. However, the majority of the literature to date has been cross-sectional. Some longitudinal research supports the view that panic attacks are a nonspecific risk factor for future psychopathology. Using a large nationally representative longitudinal survey of adults, we sought to determine whether panic attacks predict new onset Axis I disorders.

METHODS

The Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version was used to make diagnoses of psychiatric disorders in the National Epidemiologic Survey on Alcohol and Related Conditions Waves 1 and 2 (n = 34,653, aged 18 and older, response rate = 70.2%). Incident psychiatric disorders at Wave 2 were compared between people with and without panic attacks at Wave 1.

RESULTS

Panic attacks at Wave 1 were significantly associated with increased incidents of generalized anxiety disorder, panic disorder, social phobia, major depression, dysthymia, mania and hypomania, any anxiety disorder, and any mood disorder even after adjusting for sociodemographic variables, Wave 1 Axis I disorders, and Axis II disorders (OR's ranging from 1.62 to 2.77).

CONCLUSIONS

The presence of panic attacks may be an important indicator of overall psychological distress and the risk of more severe psychopathology in the future.

Cognitive-behavioral treatment of panic disorder in adolescence

This investigation represents the first randomized controlled trial to evaluate the feasibility and efficacy of Panic Control Treatment for Adolescents (PCT-A). Thirteen adolescents, ages 14 to 17, were randomized to 11 weekly sessions of PCT-A treatment, whereas 13 were randomized to a self-monitoring control group. Results indicate that adolescents receiving immediate PCT-A showed a significant reduction in clinician-rated severity of panic disorder and in self-reported anxiety, anxiety sensitivity, and depression, in comparison to control group participants. These treatment gains were maintained at 3- and 6-month follow-up. Clinical severity of panic continued to improve from posttreatment to 3-month follow-up and then remained stable at 6-month follow-up. In light of study limitations, these findings suggest that cognitive-behavioral treatment for panic disorder in adolescence is a feasible and potentially efficacious intervention for this debilitating condition in youth.

Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders

OBJECTIVE

To evaluate the frequency and clinical correlates of adult separation anxiety disorder in a large cohort of patients with mood and anxiety disorders.

METHOD

Overall, 508 outpatients with anxiety and mood disorders were assessed by the structured clinical interview for diagnostic and statistical manual (IV edition) axis I disorders for principal diagnosis and comorbidity and by other appropriate instruments for separation anxiety into adulthood or childhood.

RESULTS

Overall, 105 subjects (20.7%) were assessed as having adult separation anxiety disorder without a history of childhood separation anxiety and 110 (21.7%) had adult separation anxiety disorder with a history of childhood separation anxiety. Adult separation anxiety was associated with severe role impairment in work and social relationships after controlling for potential confounding effect of anxiety comorbidity.

CONCLUSION

Adult separation anxiety disorder is likely to be much more common in adults than previously recognized. Research is needed to better understand the relationships of this condition with other co-occurring affective disorders.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V

This review covers the literature since the publication of DSM-IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

Specific phobia: a review of DSM-IV specific phobia and preliminary recommendations for DSM-V

The present review was conducted in order to evaluate the current diagnostic criteria for specific phobia (SP) in light of the empirical evidence gathered since DSM-IV and to propose changes to DSM-V where change is clearly and reliably indicated by the evidence. In response to questions put forth by the DSM-V Anxiety, OC Spectrum, Posttraumatic, and Dissociative Disorder Work Group, four primary areas were determined for this review: the accuracy and utility of the current SP type classification system, the validity of test anxiety as a type of SP, the boundary between agoraphobia and SP, and the reliability and utility of the diagnostic criteria for SP. Developmental issues are addressed within each area. Literature reviews examining academic findings published between 1994 and 2009 were carried out and the results are included herein. The review presents a number of options and preliminary recommendations to be considered for DSM-V. All of these recommendations should be considered tentative as they await the field trials and expert consensus necessary prior to their inclusion in the DSM-V. The present review also reveals a great need for future research in the area of SP and directions for such research is provided.

Gibt es die Panikstörung im Kindes- und Jugendalter?

Seit dem DSM-IV gelten für das Kindes- und Jugendalter weitestgehend die gleichen diagnostischen Kriterien für Angststörungen wie für Erwachsene. Das Vorkommen der Panikstörung im Kindesalter ist jedoch umstritten. Im vorliegenden Beitrag werden epidemiologische, klinisch-psychologische sowie experimentelle Untersuchungen zur Panikstörung im Kindesalter kritisch diskutiert. Die untersuchten Studien zeigen, dass bereits präpubertäre Kinder Panikattacken erleben, die phänomenologisch vergleichbar mit denen des Erwachsenenalters sind. Diagnostisch sind diese Panikattacken jedoch nicht unter das Label der Panikstörung einzuordnen, da die für die Diagnose der Panikstörung erforderlichen katastrophisierenden Bewertungen der Attacken fehlen. Panikattacken in Kindheit und Jugend stellen dabei unspezifische Marker einer erhöhten Vulnerabilität für folgende psychopathologische Auffälligkeiten dar.

Panic attacks and their relation to psychological and physical functioning in Canadians: results from a nationally representative sample

OBJECTIVE

US-based studies have suggested that panic attacks (PA) are common and associated with an increased prevalence of mental disorders and poorer quality of life, and may be a marker of severe psychopathology. Using a population-based survey with a greater sample size than has been previously used, we sought to determine the prevalence rates and correlates of PAs among Canadians aged 15 years and older.

METHOD

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classification was used to determine the past-year prevalence of PAs in the Canadian Community Health Survey: Mental Health and Well-Being (n = 36,984, aged 15 and older, response rate = 77%). Psychological and physical function variables were compared among people with PAs, with panic disorder (PD), and without PAs.

RESULTS

The prevalence of past-year PAs was 6.4%. Compared to people without PAs, those with PAs had poorer overall functioning for disability, mental disorders, suicidal ideation, psychological distress, restriction of activity, chronic physical conditions, psychological well-being, and self-rated physical and mental health. PD was associated with poorer overall functioning than PAs for numerous variables; however, there were no significant differences between these 2 panic groups for several other variables.

CONCLUSIONS

Though associated with less severe impairment than PD in some domains, PAs are associated with mental health problems and reduced overall psychological and physical functioning and may be an indicator of more severe psychopathology.

Metabotropic glutamate receptor modulation, translational methods, and biomarkers: relationships with anxiety

RATIONALE

The increasing awareness of the need to align clinical and preclinical research to facilitate rapid development of new drug therapies is reflected in the recent introduction of the term "translational medicine". This review examines the implications of translational medicine for psychiatric disorders, focusing on metabotropic glutamate (mGlu) receptor biology in anxiety disorders and on anxiety-related biomarkers.

OBJECTIVES

This review aims to (1) examine recent progress in translational medicine, emphasizing the role that translational research has played in understanding of the potential of mGlu receptor agonists and antagonists as anxiolytics, (2) identify lacunas where animal and human research have yet to be connected, and (3) suggest areas where translational research can be further developed.

RESULTS

Current data show that animal and human mGlu(5) binding can be directly compared in experiments using the PET ligand (11)C-ABP688. Testing of the mGlu(2/3) receptor agonist LY354740 in the fear-potentiated startle paradigm allows direct functional comparisons between animals and humans. LY354740 has been tested in panic models, but in different models in rats and humans, hindering efforts at translation. Other potentially translatable methods, such as stress-induced hyperthermia and HPA-axis measures, either have been underexploited or are associated with technical difficulties. New techniques such as quantitative trait loci (QTL) analysis may be useful for generating novel biomarkers of anxiety.

CONCLUSIONS

Translational medicine approaches can be valuable to the development of anxiolytics, but the amount of cross-fertilization between clinical and pre-clinical departments will need to be expanded to realize the full potential of these approaches.

Pharmacological management of panic disorder

Panic disorder (PD) is a disabling condition which appears in late adolescence or early adulthood and affects more frequently women than men. PD is frequently characterized by recurrences and sometimes by a chronic course and, therefore, most patients require long-term treatments to achieve remission, to prevent relapse and to reduce the risks associated with comorbidity. Pharmacotherapy is one of the most effective treatments of PD. In this paper, the pharmacological management of PD is reviewed. Many questions about this effective treatment need to be answered by the clinician and discussed with the patients to improve her/his collaboration to the treatment plan: which is the drug of choice; when does the drug become active; which is the effective dose; how to manage the side effects; how to manage nonresponse; and how long does the treatment last. Moreover, the clinical use of medication in women during pregnancy and breastfeeding or in children and adolescents was reviewed and its risk-benefit balance discussed.

Attention bias in children of patients with panic disorder

Cognitive models of panic disorder have emphasized the role of cognitive distortions in the maintenance of this disorder. Several studies have produced results consistent with this hypothesis, but it is still unclear whether cognitive biases precede anxiety disorders or whether they are a consequence of the disorder. In the present study, we compared children of individuals with panic disorder, children of individuals with animal phobia, and children of normal controls with respect to attentional bias with an emotional Stroop task, which included three types of words: panic-relevant, animal phobia-relevant, and neutral words. Our results revealed that children of panic patients did not show an attentional bias for panic-relevant stimuli. Results will be discussed in the context of theoretical models explaining the etiological factor of cognitive biases for the development of anxiety disorders.

Developmental course(s) of lifetime cigarette use and panic attack comorbidity: an equifinal phenomenon?

The present investigation examined the developmental course(s) of lifetime cigarette use and panic attack comorbidity. Participants included 4,409 adults, ages 15 to 54 years of age (M(Age) = 33.1, SD = 10.7, N (females) = 2,221) from the National Comorbidity Survey (NCS). The primary objective of the present investigation was to better understand the developmental course(s) of lifetime cigarette use and panic attacks. A second objective of the investigation was to evaluate the developmental features of smoking-panic comorbidity in relation to other comorbid psychiatric and substance outcomes. Results demonstrated two distinct and novel operative developmental patterns of smoking-panic attack co-occurrence. The theoretical and clinical implications of delineating course-related factors underlying smoking-panic attack comorbidity are discussed.

Risk-factor research and prevention programs for anxiety disorders: A translational research framework

The aim of the present essay is to discuss the interconnection between risk-factor research and prevention program development for panic-spectrum psychopathology. We argue that prevention of panic-spectrum psychopathology specifically, and anxiety disorders more generally, is likely to be best advanced through active, systematic translation of basic, risk-factor research. After operationalizing key terminology, we present some exemplar risk-factor candidates for panic-spectrum psychopathology, summarize research related to their role as risk-factors for panic problems, and link this discussion to risk-factor nomenclature. We then present a translational framework for extrapolating extant knowledge on these and other potential risk-factors for panic-spectrum psychopathology with respect to the development of preventative interventions. The proposed translational framework is intended to describe a forward-feeding process by which risk-factor research could be used by clinical researchers to inform prevention programs; and reciprocally, how such prevention knowledge could be most effectively utilized to drive new, clinically focused risk-factor research.

Panic attacks, panic disorder, and agoraphobia: associations with substance use, abuse, and dependence

Anxiety and substance use disorders frequently co-occur. Despite the clinical importance of this co-occurrence, theory and research addressing the relations between anxiety-substance use disorder comorbidity remain limited. The present commentary is intended to briefly review and summarize key aspects of this literature, with a specific focus on panic-spectrum psychopathology (panic attacks, panic disorder, and agoraphobia) and its associations with tobacco, alcohol, and marijuana use, abuse, and dependence. A heuristic theoretical model for better understanding the panic-substance use relations also is offered. Extant data suggest clinically meaningful bidirectional associations are evident between panic problems and premorbid risk factors for such problems and various forms of tobacco, alcohol, and marijuana use. Key clinical implications and future directions are outlined based upon the review.

The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication

CONTEXT

Only limited information exists about the epidemiology of DSM-IV panic attacks (PAs) and panic disorder (PD).

OBJECTIVE

To present nationally representative data about the epidemiology of PAs and PD with or without agoraphobia (AG) on the basis of the US National Comorbidity Survey Replication findings.

DESIGN AND SETTING

Nationally representative face-to-face household survey conducted using the fully structured World Health Organization Composite International Diagnostic Interview.

PARTICIPANTS

English-speaking respondents (N=9282) 18 years or older.

MAIN OUTCOME MEASURES

Respondents who met DSM-IV lifetime criteria for PAs and PD with and without AG.

RESULTS

Lifetime prevalence estimates are 22.7% for isolated panic without AG (PA only), 0.8% for PA with AG without PD (PA-AG), 3.7% for PD without AG (PD only), and 1.1% for PD with AG (PD-AG). Persistence, lifetime number of attacks, and number of years with attacks increase monotonically across these 4 subgroups. All 4 subgroups are significantly comorbid with other lifetime DSM-IV disorders, with the highest odds for PD-AG and the lowest for PA only. Scores on the Panic Disorder Severity Scale are also highest for PD-AG (86.3% moderate or severe) and lowest for PA only (6.7% moderate or severe). Agoraphobia is associated with substantial severity, impairment, and comorbidity. Lifetime treatment is high (from 96.1% for PD-AG to 61.1% for PA only), but 12-month treatment meeting published treatment guidelines is low (from 54.9% for PD-AG to 18.2% for PA only).

CONCLUSION

Although the major societal burden of panic is caused by PD and PA-AG, isolated PAs also have high prevalence and meaningful role impairment.

Pharmacological treatment options for panic disorder in children and adolescents

Although panic disorder usually emerges in early to middle adulthood, adults with panic disorder often retrospectively report that their panic symptoms began in childhood or early adolescence. The majority of these juvenile cases are being misdiagnosed, and/or do not come to clinical attention. Awareness of early-onset panic disorder, as well as a more precise definition of early signs and possible clinical subtypes, can favour timely diagnosis and treatment, reduce clinical impairment and improve the prognosis of these patients. In the context of a multimodal approach, pharmacological treatment can be helpful. This review focuses on the empirical evidence of pharmacotherapy in early-onset panic disorder, including selective serotonin re-uptake inhibitors, benzodiazepines and tricyclics. The data supporting efficacy are still limited, and no controlled studies are available. Practical guidelines for the management of these patients are provided, including treatment of the most frequent psychiatric comorbidities.

Parental predictors of pediatric panic disorder/agoraphobia: a controlled study in high-risk offspring

Our objective was to evaluate parental risk factors for pediatric-onset panic disorder/agoraphobia (PD/AG) in offspring at high risk for PD/AG. Comparisons were made between parents with PD who had a child with PD or AG (N = 27) and parents with PD without children with PD or AG (N = 79). Comparisons were also made between the spouses of these parents with PD. Separation anxiety disorder, social phobia, obsessive-compulsive disorder, and bipolar disorder in the parents with PD and their spouses accounted for the risk for childhood onset PD/AG in the offspring. This risk was particularly high if both parents were affected with social phobia. These findings suggest that psychiatric comorbidity with other anxiety disorders and with bipolar disorder in parents with PD and their spouses confer a particularly high risk in their offspring to develop PD/AG in childhood.

Psychiatric comorbidity in children and adolescents

PURPOSE OF REVIEW

This review critically discusses recent research findings on psychiatry comorbidity in children and adolescent persons.

RECENT FINDINGS

Several epidemiological studies have confirmed previous findings in relation to the high rates of psychiatric comorbidity in children and adolescents. In particular, psychiatric comorbidity has been detected in children with substance abuse, and with conduct and oppositional defiant, anxiety and attention deficit-hyperactivity disorders. These studies have also investigated the impact comorbidity has on symptom presentation, outcome and service utilization. Although the presence of concurrent psychiatric disorders in children and adolescents is well established, there has been limited research on the need for different treatment modalities in children suffering from more than one disorder.

SUMMARY

It is widely accepted that children and adolescents frequently present with more than one psychiatric diagnosis. The substantial variation in psychiatric comorbidity found in the literature may be due to the different methods of data collection as well as to the classification system used. Whether children and adolescents fulfil diagnostic criteria for a mixed condition (International Classification of Diseases-10) or multiple disorders (Diagnostic and Statistical Manual of Mental Disorders-IV), it is important that the concurrent psychopathology be recognized and treated.