Panic disorder with and without agoraphobia: comorbidity within a half-year of the onset of panic disorder

A causal relationship between panic disorder and risk of alzheimer disease: a two-sample mendelian randomization analysis

BACKGROUND

Observational studies have suggested a link between panic disorder (PD) and Alzheimer disease (AD). This study aimed to identify the underlying association of PD with the risk of AD using Mendelian randomization.

METHODS

Genetic instrumental variables (IVs) were retrieved in the genome-wide association study between PD and AD. Then, five different models, namely inverse variance weighting (IVW), weighted median, weighted mode, MR-Egger and MR-robust adjusted profile scores (MR-RAPS), were used for MR Analysis. Finally, the heterogeneity and pleiotropy of identified IVs were verified by multiple sensitivity tests.

RESULTS

The Cochran's Q test based on MR Egger and IVW showed that no evidence of heterogeneity was found in the effects of instrumental variables, so a fixed-effect model was used. IVW analysis (OR 1.000479, 95% CI [1.000147056, 1.000811539], p = 0.005) indicated that PD was associated with an increased risk of AD, and a causal association existed between them. Meanwhile, weighted median (OR 1.000513373, 95% CI [1.000052145, 1.000974814], p = 0.029) and MR-RAPS (OR 1.000510118, 95% CI [1.000148046, 1.00087232], p = 0.006) also showed the similar findings. In addition, extensive sensitivity analyses confirmed the robustness and accuracy of these results.

CONCLUSION

This investigation provides evidence of a potential causal relationship between PD and the increased risk of AD. Based on our MR results, when diagnosing and treating patients with PD, clinicians should pay more attention to their AD-related symptoms to choose therapeutic measures or minimize comorbidities. Furthermore, the development of drugs that improve both PD and AD may better treat patients with these comorbidities.

Anxiety onset in adolescents: a machine-learning prediction

Recent longitudinal studies in youth have reported MRI correlates of prospective anxiety symptoms during adolescence, a vulnerable period for the onset of anxiety disorders. However, their predictive value has not been established. Individual prediction through machine-learning algorithms might help bridge the gap to clinical relevance. A voting classifier with Random Forest, Support Vector Machine and Logistic Regression algorithms was used to evaluate the predictive pertinence of gray matter volumes of interest and psychometric scores in the detection of prospective clinical anxiety. Participants with clinical anxiety at age 18-23 (N = 156) were investigated at age 14 along with healthy controls (N = 424). Shapley values were extracted for in-depth interpretation of feature importance. Prospective prediction of pooled anxiety disorders relied mostly on psychometric features and achieved moderate performance (area under the receiver operating curve = 0.68), while generalized anxiety disorder (GAD) prediction achieved similar performance. MRI regional volumes did not improve the prediction performance of prospective pooled anxiety disorders with respect to psychometric features alone, but they improved the prediction performance of GAD, with the caudate and pallidum volumes being among the most contributing features. To conclude, in non-anxious 14 year old adolescents, future clinical anxiety onset 4-8 years later could be individually predicted. Psychometric features such as neuroticism, hopelessness and emotional symptoms were the main contributors to pooled anxiety disorders prediction. Neuroanatomical data, such as caudate and pallidum volume, proved valuable for GAD and should be included in prospective clinical anxiety prediction in adolescents.

Comparative efficacy and acceptability of antidepressants and benzodiazepines for the treatment of panic disorder: A systematic review and network meta-analysis

OBJECTIVE

This systematic review aims to assess the efficacy and acceptability of the different types of antidepressants and benzodiazepines for the treatment of panic disorder (PD) in adult patients.

METHODS

PubMed, Web of Science, EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) published between 1995 and 2020 on the use of antidepressants and benzodiazepines for the treatment of PD. A systematic review and network meta-analysis were performed.

RESULTS

42 RCTs were included in the network meta-analysis, with a comparison of 11 interventions.Escitalopram (odds ratios OR 1.52, 95 % credible interval CI 1.09-2.10), venlafaxine (OR 1.33, 95 % CI 1.16-1.51) and benzodiazepines (OR 1.50, 95 % CI 1.29-1.75) had greater efficacy and acceptability than the placebo. Imipramine(OR 1.43, 95 % CI 1.15-1.79) was also demonstrated to be efficacious and tolerated but the results were restricted to small sample size. Moreover, paroxetine, sertraline, fluoxetine, citalopram and clomipramine (OR 1.37, 1.36, 1.45, 1.33 and 1.36, respectively) were more efficacious, although the acceptability of paroxetine and sertraline were significantly less tolerated than benzodiazepines. Notably, the efficacy of reboxetine and fluvoxamine were merely as equal as that of the placebo.

OUTCOMES

This is the first systematic review of antidepressants and benzodiazepines for the treatment of PD to use a network analysis. Escitalopram and venlafaxine as well as benzodiazepines may be effective choices as treatments for PD with relatively good acceptability, which still needs to be confirmed byhigh-quality RCTs.

Clinical implications of agoraphobia in patients with panic disorder

Agoraphobia is frequently accompanied by panic disorder and causes considerable suffering. The aim of this study was to compare clinical features and treatment courses between patients with and without agoraphobia in panic disorder.In this retrospective study, 87 patients with panic disorder were divided into two groups depending on the presence of agoraphobia: patients with agoraphobia (PDA, n = 41) and patients without agoraphobia (PD, n = 46). Agoraphobia subscale score of the Albany Panic and Phobia Questionnaire was used to identify correlations between agoraphobia and panic and affective symptoms.The PDA group showed more severe panic and affective symptoms than the PD group. Patients with PDA were more likely to be younger at the age of onset, take benzodiazepines for longer durations, and be treated with antipsychotics augmentation. Agoraphobia subscale was associated with panic symptoms, depression, anxiety, and the duration of benzodiazepines use.The findings suggest that patients with PDA experienced more severe panic symptoms, more profound psychiatric comorbidity, and worse illness progression than those with PD.

Brain activation during disorder-related script-driven imagery in panic disorder: a pilot study

Despite considerable effort, the neural correlates of altered threat-related processing in panic disorder (PD) remain inconclusive. Mental imagery of disorder-specific situations proved to be a powerful tool to investigate dysfunctional threat processing in anxiety disorders. The current functional magnetic resonance imaging (fMRI) study aimed at investigating brain activation in PD patients during disorder-related script-driven imagery. Seventeen PD patients and seventeen healthy controls (HC) were exposed to newly developed disorder-related and neutral narrative scripts while brain activation was measured with fMRI. Participants were encouraged to imagine the narrative scripts as vividly as possible and they rated their script-induced emotional states after the scanning session. PD patients rated disorder-related scripts as more arousing, unpleasant and anxiety-inducing as compared to HC. Patients relative to HC showed elevated activity in the right amygdala and the brainstem as well as decreased activity in the rostral anterior cingulate cortex, and the medial and lateral prefrontal cortex to disorder-related vs. neutral scripts. The results suggest altered amygdala/ brainstem and prefrontal cortex engagement and point towards the recruitment of brain networks with opposed activation patterns in PD patients during script-driven imagery.

Two-year course of anxiety disorders: different across disorders or dimensions?

OBJECTIVE

This study compares diagnostic and symptom course trajectories across different anxiety disorders, and examines the role of anxiety arousal vs. avoidance behaviour symptoms in course prediction.

METHOD

Data were from 834 subjects with a current anxiety disorder from the Netherlands Study of Depression and Anxiety (NESDA) who were re-interviewed after 2 years. DSM-IV-based diagnostic interviews and Life Chart Interviews (LCI) were used to assess the diagnostic and symptom course trajectory over 2 years. Anxiety arousal and avoidance behaviour symptoms were measured with LCI, Beck Anxiety Inventory and Fear Questionnaire.

RESULTS

Prognosis varied across disorders, with favourable remittance rates of 72.5% for panic disorder without agoraphobia and 69.7% for generalized anxiety disorder; gradually declining to 53.5% for social phobia and 52.7% for panic disorder with agoraphobia. Only 42.9% of those with multiple anxiety disorder remitted, and this group showed a more chronic course than pure anxiety disorders. Both baseline duration and severity were course predictors. Avoidance behaviour symptoms predicted the outcome better than anxiety arousal symptoms.

CONCLUSIONS

These data suggest that the specific anxiety disorders such as recognized by DSM-IV are useful in predicting the outcome and that this may be determined largely by the relative severity of avoidance behaviour that patients have developed.

Decreased gray matter volume of the medial orbitofrontal cortex in panic disorder with agoraphobia: a preliminary study

BACKGROUND

Patients with panic disorder with agoraphobia (PDA) have clinical symptoms such as the fear of being outside or of open spaces from which escape would be difficult. Although recent neurobiological studies have suggested that fear conditioning and extinction are associated with PDA, no study has examined the possible structural abnormalities in patients with PDA.

METHODS

This preliminary study compares the gray matter volume among patients with PDA, those with panic disorder without agoraphobia (PDW), and healthy controls (HC) using high-resolution 3.0 T magnetic resonance imaging (MRI) with voxel-based morphometry (VBM).

RESULTS

Compared with HC, patients with PDA showed decreased gray matter volume in their left medial orbitofrontal gyrus. However, differences were not found in the gray matter volumes of patients with PDW and whole panic disorder compared with HC.

CONCLUSIONS

These findings suggest that the phobic avoidance found in patients with PDA arise from abnormalities in the medial orbitofrontal cortex, which plays an important role in fear extinction. Future studies should investigate the neuroanatomical substrates of PDA and distinguish them from those of PDW.