Current concepts in psychiatry. Panic attacks and phobias

Biological and cognitive theories explaining panic disorder: A narrative review

The current narrative review summarizes and examines several theories of panic disorder (PD) including biological theories, encompassing neurochemical factors, metabolic and genetic theories, respiratory and hyperventilation theories and cognitive theory. Biological theories have informed the development of psychopharmacological treatments; however, they may be limited in their utility given the efficacy of psychological treatments. In particular, behavioral and, more recently, cognitive models have garnered support due to the efficacy of cognitive-behavior therapy (CBT) in treating PD. The role of combination treatments has been found to be superior in the treatment of PD in particular cases, lending support for the need for an integrated approach and model for PD given that the etiology of PD is complex and multifactorial.

What can be learnt from the natural history of anxiety disorders?

Background

There is insufficient knowledge of the long-term course of panic disorder (PD).

Aim

To determine the long-term course and prognostic variables in patients diagnosed with PD.

Methods

Patients who were diagnosed of anxiety states between 1950 and 1961, were examined using a structured clinical interview (SCID-DSM-III-R) between 1984 and 1988 (n = 144). A re-examination was performed in the period 1997–2001 (N = 125). Mean length of follow-up from onset was 47 years.

Results

PD tends to be chronic. Among those who recovered, 93% had done so already by the 1980s. Lack of regular treatment compliance, progression to agoraphobia and number of episodes of panic disorder were associated with worse outcome. Agoraphobia without panic attacks and somatization symptoms were the most prevalent clinical status at follow-up.

Conclusion

After several decades, participants improve with regard to number of panic attacks, though most continue to have residual symptoms.

Treatment of Self-Mutilation with Olanzapine

Background:

Self-mutilation or dermatitis artefacta is a facet of a much broader spectrum of factitial disease. Three nonpsychotic patients with self-mutilation are presented in this article who were successfully treated with low dose olanzapine when all other modalities of therapy had failed, including trials with numerous antidepressants and antipsychotics.

Objective:

The patients were simultaneously evaluated and treated by a dermatologist and a psychiatrist who run the psychodermatology or consultation-liaison clinic based at McMaster University. After dermatologic conditions had been excluded as a cause of the clinical findings, olanzapine was prescribed on a trial basis due to its low risk of parkinsonian side-effects and its antihistaminic properties.

Conclusions:

The excellent clinical response of the patients can be attributed to the low side-effect profile of the drug but also to the anti-impulsive effect which stems not only from antihistaminic properties but also from its anti-dopamine and serotonin-blocking action.

Medically unexplained symptoms

In summary, caring for patients with MUS is challenging for health care providers. Even defining somatization syndromes is complex and controversial, reflecting the medical community’s limited understanding of the pathophysiology for this group of disorders. Although risk factors for MUS have been described and are well understood, little is known about how MUS can be prevented. Uncertainty in medicine, as in any human enterprise, is a given, but the difficulties in identification and treatment of patients with MUS highlight the limitations in understanding the intersection between physical and mental health. Patients come to their physician looking for clarity, understanding, and relief of debilitating symptoms. The understanding of MUS will evolve, and perhaps an organic cause not yet understood or described may emerge to lend clarity and therapeutic opportunities to some patients with somatic disorders. In the meantime, the most powerful tools available are the ability to communicate the limits of current understanding, acknowledge the difficulties faced by patients with this disorder, and reinforce the willingness and desire of clinicians to partner with patients as the focus shifts from diagnosis to symptom management. Thus, the physician-patient relationship, still in its rightful place at the heart of the practice of medicine, lies at the center of effective treatment of patients with MUS.

Anxiety and cardiovascular symptoms: the modulating role of insomnia

BACKGROUND

Anxiety and insomnia are associated with cardiovascular (CV) symptoms. We assessed whether the relation between anxiety and CV symptoms is modulated by insomnia.

METHODS

Independently living women (n = 1,440; mean age = 59.36 +/- 6.53 years) were recruited by cluster sampling technique. We obtained data on demographic characteristics, health beliefs, access to health care, CV symptoms, sleep, stress and anxiety levels.

RESULTS

Overall, 56% of the sample reported insomnia; 46% reported CV symptoms, and 54% were highly anxious. There was a greater likelihood for highly anxious women and those experiencing insomnia to report CV symptoms (r(s) = 0.31* and r(s) = 0.32*, respectively). In logistic regression analysis, the adjusted odds ratios for reporting CV symptoms were 1.39 for patients with insomnia and 2.79 for those with anxiety. With control for insomnia, we observed a 3-fold reduction in the magnitude of the association between anxiety and CV symptoms (r(p) = 0.09*). Stepwise adjustments for sociodemographic factors, CV risk markers, and factors anchoring health beliefs and access to health care showed lesser impact on the relationships. With simultaneous control for those covariates, the correlation was r(p) = 0.13*; * p < 0.01.

CONCLUSION

The association of CV symptoms with anxiety is partly accounted for by insomnia.

Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder

OBJECTIVE

Attachment theory suggests that anxious attachment styles are associated with risk to psychiatric disorder, especially anxiety disorders. Separation anxiety would appear to be a core form of anxiety that is associated with anxious attachment. Nevertheless, as yet no research has examined the relationship of attachment styles to adult separation anxiety disorder, a condition that has only recently been fully recognized.

METHOD

The Attachment Style Questionnaire was used to examine attachment styles among 83 consecutive anxiety clinic patients diagnosed with panic disorder with agoraphobia and those re-assigned from that category to adult separation anxiety disorder.

RESULTS

Dimensional associations showed strong correlations with scales measuring anxious attachment and separation anxiety. Patients assigned to the separation anxiety group scored significantly higher than those in the panic disorder group on the scales of Need for Approval and Preoccupation with Relationships.

CONCLUSIONS

The findings finally dispel the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder. Possible implications for treatment are considered.

EFFECTS OF MATERNAL DEPRESSION AND PANIC DISORDER ON MOTHER-INFANT INTERACTIVE BEHAVIOR IN THE FACE-TO-FACE STILL-FACE PARADIGM

The present study evaluated the interactive behavior of three groups of mothers and their 3-month-old infants in the Face-to-Face Still-Face paradigm. The mothers had either a clinical diagnosis of major depressive disorder (MDD, n = 33) with no comorbidity, a clinical diagnosis of panic disorder (PD, n = 13) with no comorbidity, or no clinical diagnosis (n = 48). The sample was selected to be at otherwise low social and medical risk, and all mothers with PD or MDD were in treatment. The findings indicated that (a) infants of mothers with PD or MDD displayed the traditional still-face and reunion effects described in previous research with nonclinical samples; (b) the 3-month-old infants in this study showed similar, but not identical, gender effects to those described for older infants; and (c) there were no patterns of maternal or infant interactive behavior that were unique to the PD, MDD, or control groups. These results are discussed in light of mothers' risk status, receipt of treatment, severity of illness, and comorbidity of PD and MDD.

Medical utilization across the anxiety disorders

Individuals with panic disorder often seek medical care for their symptoms prior to receiving effective treatment. However, little is known about how often, and in what settings, patients with other anxiety disorders present for medical treatment. In the present study, utilization of general and specialty medical services was coded via electronic chart review for 171 consecutive outpatients referred to an anxiety disorders clinic. Results indicated that panic disorder patients accrued the most medical visits overall, as well as the most frequent visits to cardiology, family medicine, and emergency medicine. Few differences in medical utilization were evident among patients with generalized anxiety disorder, obsessive-compulsive disorder, social phobia, and specific phobias. Patients with anxiety disorders appear to be frequent utilizers of medical services prior to receiving effective treatment. Our findings highlight the need for improved recognition and treatment of anxiety disorders, particularly panic disorder, in a number of medical settings.

Anxiety symptoms in patients with hypertension: a community-based study

OBJECTIVES

To investigate incidence and severity of anxiety symptoms in patients with hypertension.

METHODS

A cross-sectional survey in 891 (432 females) hypertensive patients was conducted in a regional community. All patients were interviewed and detailed physical examination was performed. Zung self-rating anxiety scale (SAS) was used to evaluate the severity of anxiety symptoms.

RESULTS

Anxiety was diagnosed on clinical grounds in 103 patients (11.6%) who also had a raw SAS score of more than 40. In all subjects surveyed, the average SAS score in females was higher than males (32.9+/- 7.1 vs 31.2+/-6.4, p < 0.001). The average SAS score was also higher in patients with hypertension of more than 3 years (32.4+/-7.0 vs 31.2+/-6.1, p = 0.01), in patients with severe hypertension (39.8+/-6.9 vs 29.6 4+/-4.5, p < 0.001), and in patients with a history of hospitalization for cardiovascular disorders (35.7+/-7.7 vs 31.7+/-6.6, p < 0.001). Multivariate regression analysis showed that female gender, duration of hypertension, and hospitalization history were independent predictors of anxiety symptoms (p < 0.05).

CONCLUSIONS

Almost 12% of hypertensive patients have anxiety symptoms. Female gender, the duration of hypertension, and the history of hospitalization are associated with the occurrence and severity of anxiety symptoms in patients with hypertension.

A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder

BACKGROUND

Panic disorder is a prevalent, often disabling condition among patients in the primary care setting. Although numerous studies have assessed the effectiveness of treatments for depression in primary care, few such studies have been conducted for panic disorder.

OBJECTIVE

To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting.

DESIGN

Randomized, controlled study comparing intervention to treatment as usual.

SETTING

Six primary care clinics associated with 3 university medical schools, serving an ethnically and socioeconomically diverse patient population.

PARTICIPANTS

Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder. Comorbid mental and physical disorders were permitted, provided these did not contraindicate the treatment to be provided and were not acutely life threatening.

INTERVENTION

Patients were randomized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions (across 12 weeks) of cognitive-behavioral therapy (CBT) modified for the primary care setting, with up to 6 follow-up telephone contacts during the next 9 months, and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist. Behavioral health specialists, the majority inexperienced in CBT for panic disorder, were trained to deliver the CBT and coordinated overall care, including pharmacotherapy.

MAIN OUTCOMES MEASURES

Proportion of subjects remitted (no panic attacks in the past month, minimal anticipatory anxiety, and agoraphobia subscale score <10 on Fear Questionnaire) and responding (Anxiety Sensitivity Index score <20) and change over time in World Health Organization Disability Scale and short form 12 scores.

RESULTS

The combined cognitive-behavioral and pharmacotherapeutic intervention resulted in sustained and gradually increasing improvement relative to treatment as usual, with significantly higher rates at all points of both the proportion of subjects remitted (3 months, 20% vs 12%; 12 months, 29% vs 16%) and responding (3 months, 46% vs 27%; 12 months, 63% vs 38%) and significantly greater improvements in World Health Organization Disability Scale (all points) and short form 12 mental health functioning (3 and 6 months) scores. These effects were obtained in spite of similar rates of delivery of guideline-concordant pharmacotherapy to the 2 groups.

CONCLUSION

Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naive, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder.

Prospective study of phobic anxiety and risk of Parkinson's disease

Anxiety disorders are common in Parkinson's disease (PD). However, the risk of PD among people with anxiety has not been examined in a prospective cohort study. We examined this relation prospectively within the Health Professionals Follow-Up Study, a cohort of US male health professionals. In 1988, anxiety was assessed using the Crown-Crisp phobic anxiety index in 35,815 men without PD, stroke, or cancer at baseline. There were 189 incident cases of PD during 12 years of follow-up. After adjusting for age, smoking, and caffeine intake, the relative risk of PD among men with the highest level of anxiety (Crown-Crisp index scores of 4 and above) was 1.5 (95% CI = 1.0-2.1; P-trend = 0.01) compared to men with the lowest level of anxiety. This positive association persisted after excluding cases of PD with onset in the first 2 years of follow-up. Use of anxiolytic medication was also associated with an elevated risk of PD (RR= 1.6; 95% CI = 0.9-3.1), but adjusting for this potential confounder did not materially affect the association between anxiety and risk of PD. Our results suggest that anxiety is a risk factor for PD. Whether this association is causal or the result of shared underlying biology remains a question.

The panic-agoraphobic spectrum: development, description, and clinical significance

The results of the authors' research efforts to date support the idea that the panic-agoraphobic spectrum is a robust and culturally transferable construct with important clinical implications for patients with mood and anxiety disorders. In particular, their findings suggest the need for alternate treatment strategies to treat mood patients with comorbid panic features [50,52]. They maintain that the spectrum approach could add to the knowledge of course and outcome of mood and anxiety disorders and inform treatment decisions. The spectrum concept has other potential implications. For the purposes of neurobiologic research, reliable identification of phenotypes that map [Figure 3: see text] onto specific brain processes in crucial. The definition of the diathesis phenotype is also important if we are to elucidate the cause and pathophysiology of mental disorders at a molecular level. A panic-agoraphobic spectrum assessment incorporate temperamental features and trait-like manifestations into a comprehensive symptom assessment to provide a detailed picture of the clinical features of PD. Such an approach holds some promise for progress in studies of neurobiologic basis of panic and may be useful in further efforts to overcome the nagging problem of the ambiguous boundaries of DSM diagnostic categories [53].

Heart rate variability in depressive and anxiety disorders

Loss of normal autonomic nervous system control of heart rate and rhythm is an important risk factor for adverse cardiovascular events. After myocardial infarction, reduction in beat-to-beat heart rate variability, a measure of cardiac autonomic innervation by the brain, is a strong predictor of death. With loss of vagal innervation, as is noted in patients with severe neuropathy and in heart transplant recipients, there is loss of heart rate variability. It is speculated that decreased parasympathetic innervation exposes the heart to unopposed stimulation by sympathetic nerves. Individuals with high hostility scores and patients with anxiety or depressive disorders have low heart rate variability and may be at increased risk for cardiovascular death associated with coronary heart disease and arrhythmias. After myocardial infarction, depressed patients exhibit higher mortality rates compared with nondepressed patients. Men with "phobic anxiety," a construct that appears to overlap substantially with panic disorder, also have higher rates of sudden cardiac death and coronary artery disease than control populations. The reduction in autonomic nervous system control to the heart may be one link between psychopathology and heart disease. Although tricyclic antidepressants reduce heart rate variability, at least one study has suggested that, in patients with panic disorder, treatment with the selective serotonin reuptake inhibitor paroxetine normalizes heart rate variability. Hence there is potential for the treatment of psychiatric disorders to affect positively the development and course of cardiovascular disease.

Recognition and acute management of patients with panic attacks in the emergency department

Patients with panic attacks commonly present to emergency departments. If the disorder is identified early, intervention can be begun, even during the evaluation phase. Effective therapies significantly improve these patients' health and quality of life.

Parental representations associated with adult separation anxiety and panic disorder--agoraphobia

OBJECTIVE

Early bonding abnormalities have been associated with a range of anxiety and depressive disorders in adulthood, but no specific parental patterns have emerged for particular disorders. The present study investigated the possibility that parental overprotectiveness may be linked to a risk of separation anxiety (SA) in adulthood.

METHOD

Two samples were recruited: volunteers (n = 34) whose major anxieties focused on separation concerns, and adult anxiety clinic patients (n = 37) who were diagnosed with panic disorder. Parental characteristics and early SA were assessed by dichotomising the combined sample first according to adult SA categorisation and then by panic disorder status.

RESULTS

Subjects assigned to the adult SA category reported high levels of juvenile SA and exposure to maternal overprotectiveness, whereas patients diagnosed with panic disorder reported few differences in their bonding histories compared to residual anxious patients.

CONCLUSIONS

The findings of this study suggest that early SA and parental overprotectiveness may not be associated with panic disorder per se, but rather with persisting SA symptoms in adulthood. The overlapping samples and retrospectivity of some measures are important limitations of the study.

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.

Chronic recurrent stress due to panic disorder does not precipitate Graves' disease

A role of psychic stress in precipitating hyperthyroid Graves' disease has been suggested, but the evidence in support of this pathogenetic mechanism is conflicting. In this study we investigated the possible occurrence of Graves' disease in patients with panic disorder, a psychiatric condition characterized by recurrent endogenous stress. The study group included 87 consecutive patients suffering from panic disorder since 1 to 30 years: 17 males (mean age 31.3, range 26-43 years) and 70 females (mean age 37.6, range 15-73 years). Two hundred and sixty-two normal subjects with no present or past history of psychiatric disorder served as controls. Patients were submitted to a full evaluation of the thyroid that included physical examination, assays for free thyroid hormones, TSH, thyroglobulin (TgAb), thyroperoxidase (TPOAb) and TSH receptor (TRAb) antibodies, and thyroid echography. The prevalence of circulating TgAb and/or TPOAb in patients with panic disorder did not differ from that in the control group. Twelve patients with panic disorder (13.7%) had circulating TgAb and/or TPOAb, but none had TRAb. Three out of 12 patients with thyroid antibodies, indicating a genetic susceptibility to autoimmune thyroid disease, had a family history of clinical thyroid autoimmunity, and 4 of them had a hypoechogenic pattern of the thyroid at ultrasound suggesting autoimmune thyroiditis. None of the patients with panic disorder had a previous history of hyperthyroidism. On examination, clinical hyperthyroidism or endocrine ophthalmopathy were not found in any of them. A small goiter was appreciated by palpation in 16 patients (18.3%). Free thyroid hormones and TSH were within the normal range in all patients but one: a 55-year old lady with normal serum free thyroid hormones and undetectable TSH. During an 18-month follow-up she did not develop hyperthyroidism and her TSH spontaneously returned in the normal range. Considering the individual duration of panic disorder, evidence for previous or present Graves' hyperthyroidism was not found for a total of 478 patient-years of exposure to recurrent endogenous stress in the whole study group, and for a total of 39 patient-years in patients with a genetic susceptibility to autoimmune thyroid disease. In conclusion, we found that recurrent endogenous stress did not precipitate Graves' hyperthyroidism in a series of 87 patients with panic disorder, encompassing a total of 478 patient-years of exposure to stress. Failure to activate the hypothalamic-pituitary-adrenal axis by endogenous stress due to panic disorder as opposed to exogenous stress due to life-events might explain why panic disorder does not precipitate Graves' hyperthyroidism.

Toward a definition of generalized anxiety disorder as an anxious temperament type

Generalized anxiety disorder (GAD) is defined as an uncontrollable disposition to worry about one's welfare and that of one's immediate kin. Associated manifestations include arousal, vigilance, tension, irritability, unrestful sleep and gastrointestinal distress. There is growing evidence for the lifelong nature of this condition among many of its sufferers. This and other evidence reviewed in the present paper provide further support for the thesis that the chronic disposition to worry should probably be classified under constitutional or trait anxiety. GAD is best considered an exaggeration of a normal personality disposition that can be named 'Generalized anxious temperament' (GAT). Despite some overlap with anxious-phobic, inhibited and avoidant-sensitive temperaments, GAT seems to have a distinct profile with altruistic overtones; on the other hand, GAT is less easily distinguished from harm-avoidant and obsessive traits. That worrying would increase upon relaxation is not a paradox at all, and is understandable in an ethological perspective as subserving the defensive function of being vigilant of ever present yet uncertain external dangers--to oneself and one's kin--in day-to-day living. GAT can thus be considered as 'altruistic anxiety', subserving hypothetically the survival of one's extended phenotype in a 'kin selection' paradigm. Only when extreme does worrying manifest in a clinical context, impairing one's interpersonal life and functioning at work, and increasing use of general health care resources. Furthermore, generalized anxiety appears to predispose to and is often associated with depression, and a spectrum of phobic disorders, as well as alcohol and sedative use. These considerations place GAD (and the putative GAT) in the limelight and underscore the need for more research into its fundamental characteristics. Towards this aim, a self-rated GAT measure under development in our center is provided in an appendix to this paper.

Medical utilisation and costs in panic disorder: a comparison with social phobia

There is considerable evidence that people with panic disorder utilise the physical health care system more frequently than people in the general community and so incur for themselves, and impose on the public health care system, considerably greater costs. Although this is probably because of specific characteristics to do with panic disorder, it may also be a function of having any anxiety disorder where panic is prominent. This study represents one of the few comparisons of medical utilisation and costs incurred by people with panic disorder to those incurred by people with another anxiety disorder, in this case, social phobia. Before treatment, 41 people with panic disorder, 15 with social phobia and 43 nonanxious controls were interviewed about their use of the medical care system over the previous 12 months. As expected, people with panic disorder had significantly higher utilisation rates than either the nonanxious controls or the socially phobic subjects, and incurred substantially higher costs. Adequate screening for panic disorder at the primary medical care level together with appropriate treatment referral therefore have the potential to substantially reduce the personal and community costs incurred by people with panic disorder.

Mechanism of triazolo-benzodiazepine and benzodiazepine action in anxiety and depression: behavioral studies with concomitant in vivo CA1 hippocampal norepinephrine and serotonin release detection in the behaving animal

1. Real time, in vivo microvoltammetric studies were performed, using miniature carbon-based sensors, to concurrently detect norepinephrine (NE) release and serotonin (5-HT) release, in 2 separate electrochemical signals, within CA1 region of hippocampus in the freely moving and behaving, male, Sprague Dawley laboratory rat. 2. Concurrently, four parameters of open-field behavior, i.e. Ambulations, Rearing, Fine Movements and Central Ambulatory behavior (a measure of anxiety reduction behavior), were assayed by infrared photobeam detection. 3. Time course studies showed that the mechanism of action of the triazolobenzodiazepine (TBZD), adinazolam, (Deracyn) is dramatically different from that of the classical benzodiazepine (BZD), diazepam (Valium, i.e., adinazolam increased, whereas diazepam decreased, 5-HT release within CA1 region of hippocampus in the freely moving and behaving rat. 4. Adinazolam initially increased NE release and then decreased NE release in CA1 region of hippocampus in the freely moving and behaving rat whereas diazepam only decreased the electrochemical signal for NE; the decrease in NE produced by adinazolam was greater than the decrease in NE release produced by diazepam. 5. The Behavioral Activity Patterns, derived from same animal controls, simultaneously with detection of in vivo microvoltammetric signals for NE release and 5-HT release, showed that the BZD, diazepam, exhibited more potent sedative properties than did the TBZD adinazolam. 6. Hippocampal 5-HT and NE release effects of the TBZD, adinazolam, concomitant with behavioral effects lends explanation to the dual anxiolytic/antidepressant properties of the TBZDs.

Panic disorder: diagnosis and treatment in emergency medicine

Panic disorder is a newly recognized psychiatric illness involving unexpected, unprovoked attacks of anxiety. Patients with panic disorder commonly seek treatment in the ED. It is important for the emergency physician to properly recognize and categorize this disorder to initiate appropriate treatment. Illness description and treatment guidelines of this disorder are discussed in this article.

Is early separation anxiety a risk factor for adult panic disorder?: a critical review

Heightened levels of early separation anxiety (SA) have long been linked to the risk of adult panic disorder (PD), suggesting that the two types of anxiety arise from a common diathesis--a proposition that has considerably influenced the classification of the anxiety disorders. However, the SA-PD link remains contentious, with some recent studies failing to confirm that putative association. All published research studies investigating the relationship of early SA to PD and/or other anxiety disorders were reviewed. Taken as a whole, the evidence provides support for the SA-PD hypothesis, although the specificity of that relationship needs further clarification. Problems of sample selection, retrospective measurement of early SA and comorbid diagnoses limit the certainty with which inferences can be drawn from existing data. Nevertheless, a recent community-based study provides additional support for the SA-PD hypothesis. Possible developmental pathways linking SA to PD are considered. One possibility that has not received adequate research attention is that early SA disorder (SAD) may persist into adulthood, rendering the sufferer vulnerable to panic and other anxiety symptoms when confronted with salient life stressors. We conclude that it is premature to reject the SA hypothesis of PD. Only well-designed longitudinal studies can map the complex developmental pathways linking early and later manifestations of morbid anxiety.

Panic attacks as ictal manifestations of parietal lobe seizures

Although most panic attacks appear to be primary psychiatric disturbances, some evidence suggests a biologic basis for panic disorder, possibly associated with temporal lobe dysfunction. Fear is a common affective change associated with some complex partial seizures (CPS) originating from the right temporal lobe. We describe a previously unreported association between panic attacks and seizures originating from the parietal lobe in 2 patients with right parietal lobe tumors. Intracranial monitoring documented correlations between the symptoms of fear and restricted regional parietal cortical discharges. Surgical resections of the lesions (one total, one subtotal) resulted in complete recovery or improvement.

Prospective study of phobic anxiety and risk of coronary heart disease in men

BACKGROUND

To examine prospectively the association between self-reported symptoms of phobic anxiety and subsequent risk of coronary heart disease, a 2-year follow-up study was conducted of a cohort of 33,999 US male health professionals, aged 42 to 77 years in 1988, who were free of diagnosed cardiovascular disease at baseline. Levels of phobic anxiety were assessed using the Crown-Crisp index, a short, diagnostic self-rating scale used for common phobias. Main outcomes were incidents of coronary heart disease consisting of nonfatal myocardial infarction (MI) and fatal coronary heart disease (CHD).

METHODS AND RESULTS

One hundred sixty-eight incident cases of CHD occurred during 2 years of follow-up (128 cases of nonfatal MI and 40 cases of fatal CHD). The age-adjusted relative risk of fatal CHD among men with highest levels of phobic anxiety (scoring 4 or higher on the Crown-Crisp index) was 3.01 (95% confidence interval, 1.31 to 6.90) compared with men with the lowest levels of anxiety (scoring 0 or 1 on the phobia index). Risk of fatal CHD increased with levels of phobic anxiety (P trend = .002). When fatal CHD was further categorized into sudden and nonsudden coronary death, the excess risk was confined to sudden death (relative risk among men scoring 3 or higher on the phobia index was 6.08; 95% confidence interval, 2.35 to 15.73). No association was found between phobic anxiety and risk of nonfatal MI. These findings remained essentially unchanged after adjusting for a broad range of cardiovascular risk factors.

CONCLUSIONS

The specificity, strength, and dose-response gradient of the association, together with the consistency and biological plausibility of the experimental and epidemiologic evidence, support a strong causal association between phobic anxiety and fatal CHD.

Reported early separation anxiety symptoms in patients with panic and generalised anxiety disorders

Attachment theory has proposed that early separation anxiety is a risk factor for adult anxiety disorder, with the recent focus being particularly on panic disorder. The results of empirical studies examining this link are, however, contradictory, possibly because of inconsistencies across studies in measuring memories of early separation anxiety. In the present study, a psychometrically sound measure, the Separation Anxiety Symptom Inventory (SASI) was used to compare memories of such early symptoms in panic disorder (including those with mild phobic-avoidance), generalised anxiety disorder and control subjects. Anxiety patients as a group returned higher SASI scores (p < 0.001) with a non-significant trend for panic disorder patients to score higher than those with generalised anxiety. These results suggest that early separation anxiety may be a harbinger of adult anxiety and that risk of panic disorder may be higher in the most severely affected youngsters. As a risk factor, early separation anxiety does not however appear to be uniquely related to adult panic disorder.

Perinatally protein-deprived rats and reactivity to anxiolytic drugs in the plus-maze test: an animal model for screening antipanic agents?

Adult rats submitted to a protein deprivation schedule at perinatal age (from 14th day of fetal life until 50 days of age) and then recovered on balanced chow (D rats) were assayed in the elevated plus-maze test for anticonflict effects of diazepam and drugs with therapeutic efficacy in panic disorders as compared with controls (C rats). Diazepam and alprazolam showed a similar anticonflict effect in D rats than in C rats. In contrast, buspirone, which was ineffective in C rats at a wide dosage range, showed a significant anticonflict effect on D rats at 0.3 mg/kg. Neither propranolol, desipramine, nor phenelzine treatment (10 mg/kg/day during 3-7 days) induced anticonflict effect in C rats. Conversely, these treatments fostered a significant and selective anxiolytic effect on D rats. Such results underscore long-lasting alterations caused by early undernutrition, namely, changes in reactivity to the drugs assayed. In addition, perinatally deprived rats may represent a useful animal model for studying potential antipanic agents.

Family transitions and developmental processes in panic-disordered patients

Although there is increasing evidence for a familial role in panic disorder, little research exists on the family interaction patterns and relational stressors that may contribute to this disorder. Using DSM-III-R criteria, 52 families were classified into Panic Disorder, Major Depressive Disorder, and Nonclinical Control groups. A semi-structured interview and self-report measures were then used to examine family processes. MANOVA results were highly significant, suggesting that, compared to depressed and nonclinical control families, panic-disordered families had unresolved life-cycle issues, were enmeshed, used triangulation, and failed to resolve conflicts. These findings suggest that dysfunctional family processes may be involved in the expression and maintenance of panic disorder.

Somatic symptoms and panic attacks: a retrospective study of learning experiences

Individuals with panic attacks evaluate physical anxiety symptoms as dangerous and tend to respond to them with fear. In a retrospective questionnaire study, we explored childhood and adolescent learning experiences with respect to somatic symptoms of panickers. Compared to normal controls (N = 61), patients with panic disorder (N = 121), infrequent panickers (N = 86) and patients with other anxiety disorders (N = 38) reported more frequent instances prior to age 18 when they had experienced symptoms like dizziness, shortness of breath, palpitations or nausea, accompanied by special attention from their parents and instructions to restrain from strenuous or social activities. The differences were due to higher symptom frequencies in the anxiety groups. All anxiety groups reported more frequent uncontrolled behavior of their parents than controls. Patients with panic disorder and infrequent panickers reported that their parents had suffered more frequently from physical symptoms typical of anxiety than patients with other anxiety disorders or normal controls. Panickers, but not patients with other anxiety disorders, had observed sick-role behavior related to panic symptoms in their parents more often than controls. Panic attack Ss reported a higher number of household members suffering from chronic illnesses than controls and patients with other anxiety disorders. No group differences were found in the reported behavior of parents when Ss had colds. Overall, the results point to the role of severe illnesses and physical symptoms typical of anxiety in significant others in the history of Ss with panic attacks. These experiences during childhood and adolescence may contribute to their belief that physical symptoms are dangerous. In contrast, there was no specificity for panic with respect to the Ss' own physical symptoms or cold-related symptoms.

Benzodiazepine treatment of panic and agoraphobic symptoms: use, dependence, toxicity, abuse

Benzodiazepines are widely prescribed drugs. Most patients are prescribed benzodiazepines for short periods of time for anxiolytic or hypnotic purposes. However, some benzodiazepines are also used for extended periods at high doses to treat panic and agoraphobic disorders. When chronically prescribed benzodiazepines are discontinued, a predictable pattern of discontinuance symptoms may develop, indicating physiological dependence. Benzodiazepines also produce a variety of side effects including sedation, reduced coordination, and impaired cognition, which are primarily related to dose and duration of treatment. Benzodiazepines are commonly used by polysubstance abusers but their abuse as recreational drugs when taken alone is rare, and high-dose treatment for panic and agoraphobic symptoms does not lead to abuse. Prescribing guidelines are offered.

Drug treatment of panic disorder. Reply to comment by Marks and associates

The February 1992 issue of the British Journal of Psychiatry contained the summary report from the Second Phase of the Cross-National Collaborative Panic Study (CNCPS) on a clinical treatment trial of panic disorder. This manuscript was submitted in 1988 and took four years of response to critiques and revisions to generate a manuscript that was acceptable to the Editor of the British Journal of Psychiatry. In the same issue, Marks et al (1992) provided a ‘Comment’ which was critical of the study, calling it an “elephantine labour” which “resulted in the delivery of a mouse” and was highly critical of the statistical analyses and interpretation. Moreover, their ‘Comment’ was a springboard for discussing general issues in the treatment of panic disorder and the relative value of pharmacological versus psychological treatments. In our opinion, the Marks et al ‘Comment’ is inaccurate and misleading. At many points, they make reference to topics being missing that are actually addressed to our manuscript and they presented a statistical summary in Table 1 (p. 203) of our data which was inaccurate. In this Comment, we address each item criticised.

Experimental stimulation by burst-firing weak magnetic fields over the right temporal lobe may facilitate apprehension in women

Intermittent bursts of weak magnetic fields whose patterns simulate normal amygdaloidal-hippocampal activity were generated by computer over the right or left temporal regions of men and women during partial sensory deprivation. As predicted, women but not men reported greater apprehension during right-hemispheric but not left-hemispheric stimulation. Intrusions of right-hemispheric processes have been hypothesized to affect self-esteem adversely. These results also support the role of the right parahippocampal region in the production of panic attacks.

Drug treatment of panic disorder. Comparative efficacy of alprazolam, imipramine, and placebo. Cross-National Collaborative Panic Study, Second Phase Investigators

The Cross-National Collaborative Panic Study, Phase Two, compared alprazolam with imipramine and with placebo in a sample of 1168 randomly assigned subjects. The study, conducted at 12 centres, assessed clinical change over eight weeks of double-blind drug treatment. Improvement occurred with alprazolam by week 1 and 2, and with imipramine by week 4. By the end of week 8, however, the effects of the two active drugs were similar to each other, and both were superior to placebo for most outcome measures.

Parental representations of patients with panic disorder and generalised anxiety disorder

Previous studies using the Parental Bonding Instrument have shown a general trend for neurotic subjects to score their parents as less caring and more protective. Such a finding was broadly replicated in a study of 80 clinically anxious subjects and age- and sex-matched controls. Although direct comparisons of PBI scores failed to reveal clear-cut differences between generalised anxiety (GA) and panic disorder (PD) subgroups, logistic regression analyses revealed higher odds ratios for parental assignment to aberrant categories in the GA group, with PD patients reporting a more limited pattern of overprotective parenting only. Our findings suggest that adverse parental behaviour may be relevant to the pathogenesis of GA, while parental 'affectionate constraint' may be a parental response to early manifestations of PD.

Anxiety, depression, and substance use disorders: diagnosis, treatment, and prescribing practices

Attending physicians routinely encounter patients with signs and symptoms of anxiety and mood disorders as well as psychoactive substance use and psychoactive substance-induced organic mental disorders. These symptoms may represent either primary disorders or pathology that is secondary to other disorders. This article describes some of the relationships between substance use disorders and symptoms of anxiety and depressive disorders. In addition, some patients with these disorders may have a concurrent substance use disorder or be at high risk for developing one. Routine treatment of anxiety disorders with psychoactive drugs can be successful in many patients but may lead to iatrogenic dependence in high-risk patients. Prescribing for high-risk patients should include a stepwise treatment protocol having three progressive levels: (1) conservative, nonpharmacological approaches; (2) nonpsychoactive pharmacotherapy, including the use of anxioselective agents, such as buspirone; and (3) psychoactive pharmacotherapy, such as the use of benzodiazepines. Proper prescribing practices for high-risk patients are described in terms of diagnosis, dosage, duration, discontinuation, dependence, and documentation.

Characteristics of panic disorder patients responding to placebo

Forty-one panic disorder patients receiving placebo were investigated in a double-blind comparison of alprazolam, imipramine and placebo in panic disorder. A significantly higher drop-out rate was found in the placebo group than in the active treatment groups, but placebo response was found in 34% of the patients, defined as reduction of panic attacks to zero, and in 23%, defined as a score of greater than or equal to 8 on the Physician Global Improvement Scale (0-10 points). Several predictors of response to placebo were found. The responders had fewer panic attacks than the nonresponders at baseline. They also reported less psychopathology and were less help-seeking than the nonresponders. The implications for psychopathology and possible response to psychotherapy among responders and nonresponders are discussed. It is hypothesized that the responders show more signs of realistic processing of internal and external stimuli and fewer signs of subjective distress than the nonresponders. Responders will therefore probably be more responsive to psychotherapy than nonresponders.

Validation criteria for panic disorder as a nosological entity

Panic disorder (DSM-III, DSM-III-R) has been thoroughly studied in recent years. The main evidence for panic disorder as a nosological entity is reviewed, to delineate some important questions for future research. Validation criteria include epidemiological, phenomenological, genetic, neurobiological, pharmacological and behavioral findings. Biological, behavioral and psychodynamic considerations on etiology, pathogenesis and treatment are presented.

Secondary depression in panic disorder: an indicator of severity with a weak effect on outcome in alprazolam and imipramine treatment

Depressive symptoms are frequent in panic disorder. Among 123 Scandinavian patients participating in a placebo-controlled multicenter study of the efficacy of alprazolam and imipramine treatment in panic disorder, 21% and 23% fulfilled the DSM-III criteria of current and past major depressive episode, respectively, and 17% had dysthymia, even when melancholia and depressive episode with onset prior to the panic symptoms were excluded. According to a subscale of the Hamilton Rating Scale for Depression (HRSD) with higher validity than the full scale, 18% were classified as major depression and 57% as minor depression. A major finding was that patients with affective symptoms had higher scores on many psychopathological measures, including several Symptom Checklist-90 factors. Accordingly, secondary depression was suggested as an indicator of the severity of panic disorder. Depressed and nondepressed patients significantly improved on major outcome measures, but patients with current minor or major depression improved less. Although the sample was too small for detailed analysis of differences in drug efficacy, there was no indication that imipramine was more effective than alprazolam, considering scores on an HRSD subscale.

A trend analysis of changes during treatment of panic disorder with alprazolam and imipramine

A total of 123 Scandinavian patients participated in a cross-national study of panic disorder. Twelve outcome measures, including number of panic attacks and phobias, have been used to describe changes in symptoms during treatment. This article gives a trend analysis of remission for each variable, analysing changes through the total period from baseline to week 8 and also changes in first and second half of this period, separately. Important differences between treatments are demonstrated. Alprazolam had an early effect on variables relating to panic attacks, such as severity of spontaneous attacks and avoidance, whereas imipramine showed a more delayed effect on global measures. Duration of illness, sex and the occurrence of depression in patients' history all affected the sequence of improvement.

Psychofarmakologikum VI

Inleiding In deze rubriek zal worden ingegaan op recente observaties betreffende de psychofarmakologie in de breedst mogelijke zin. Vaak zullen zaken uit de Literatuur worden behandeld. De gekozen onderwerpen dienen altijd klinische relevantie te hebben. Ook zal deze rubriek gaan over gewoontes die in psychofarmakologische behandeling of in onderzoek zijn geslopen die volgens de auteur lang niet altijd logisch zijn. Soms zal deze rubriek een oproep bevatten om te reageren op een bijdrage gepubliceerd in dit of in een ander tijdschrift. Ook zal de lezer worden aangemoedigd hier zijn eigen ervaringen mee te delen. Het is niet de bedoeling in deze rubriek onderzoeken uitvoerig te rapporteren. Daarvoor staan andere pagina's van de Acta Neuropsychiatrica voor u open.

A high risk study of young children of parents with panic disorder and agoraphobia with and without comorbid major depression

Using family study methodology and psychiatric assessments by blind raters, this study tested hypotheses about patterns of familial association between anxiety and depressive disorders among high risk children of clinically referred parents. The study design contrasted five groups of children defined by the presence or absence in a parent of (1) panic disorder and agoraphobia (PDAG) without comorbid major depressive disorder (MDD) (n = 14); (2) comorbid PDAG plus MDD (PDAG + MDD) (n = 25); (3) MDD without comorbid PDAG (n = 12); (4) other psychiatric disorders (n = 23); and (5) normal comparisons (n = 47). While the PDAG and PDAG + MDD groups had similarly elevated rates of anxiety disorders and MDD, offspring of MDD parents had an elevated rate of MDD but not of anxiety disorders. Among children of parents with PDAG + MDD, the presence of an anxiety disorder did not significantly increase the risk for MDD in the same child. Thus, anxiety and MDD did not cosegregate among children of PDAG parents. These findings indicate that parental PDAG, either alone or comorbidly with MDD, increases the risk for both anxiety and depressive disorders in offspring. In the absence of PDAG, however, parental MDD does not appear to place children at risk for anxiety disorders. These findings are most consistent with the hypothesis that PDAG and PDAG + MDD share common familial etiologic factors while MDD alone is an independent disorder. More studies are needed to confirm these preliminary findings as well as to identify mediating factors that influence the transition from childhood to adult anxiety disorders.