Is the course of panic disorder the same in women and men?

[Exposure therapy for panic disorder and agoraphobia in the context of existing antidepressive medication]

BACKGROUND

Cognitive behavioral therapy (CBT) and pharmacotherapy with antidepressants are both a highly effective treatment for agoraphobia and/or panic disorder; however, a combination of CBT and antidepressants is under debate due to potentially unfavorable interference effects. The associations of existing antidepressant medication with panic and agoraphobia symptom burden and their change in the context of a structured 5‑week day hospital and exposure-focused treatment in a naturalistic setting were investigated.

METHODS

Out of a total of n = 488 patients medication use during treatment was retrospectively determined for n = 380: n = 100 (26.3%) were taking antidepressants of different drug classes. Calculations were performed using multiple linear regression analysis, t‑tests, response analyses, and χ2-tests.

RESULTS

Patients with existing antidepressant medication more often met the criteria for comorbid depressive disorder (p < 0.001). The measure of symptom change and treatment response rates did not differ between patients with and without antidepressants with respect to anxiety symptoms.

DISCUSSION

In the context studied, patients with and without existing antidepressant medication benefited equally from CBT with respect to anxiety symptoms.

Premature death and causes of death among patients with panic disorder and comorbid psychiatric disorders: A nationwide cohort study

OBJECTIVES

Panic disorder (PD) is associated with high psychiatric and physical comorbidity, but the cause of mortality has not been well studied. This study investigated mortality rates and causes of death in an Asian cohort with PD.

METHODS

We enrolled a nationwide retrospective cohort of 298,466 persons diagnosed with PD from January 1, 2001, to December 31, 2016. Each cohort member was matched with a comparison one randomly selected from the general population with the same sex, age at entry, and birth year. The data of both the PD cohort and the comparison group were linked with the national mortality database to obtain each individual's mortality status. We used mortality rate ratios (MRRs) to compare mortality risks between the patients with PD and the general population. Stratified analysis of mortality risks was performed based on sex and psychiatric comorbidities.

RESULTS

PD was associated with a slightly increased mortality risk (MRR, 1.14 [99% CI, 1.11-1.17]). The risk of unnatural death (MRR, 2.83 [99% CI, 2.59-3.10]) was significantly higher among the individuals with PD than among the general population, whereas the risk of overall natural death across all categories was not (MRR, 1.01 [99% CI, 0.98-1.04]). The mortality risk was the highest for suicide (MRR, 4.94 [99% CI, 4.32-5.72]) and was higher in women (MRR, 6.37 [99% CI, 5.25-7.96]) than in men (MRR, 3.77 [99% CI, 3.14-4.64]). Comorbid substance use disorders increased the risk of mortality from natural (MRR, 3.23 [99% CI, 2.59-4.14]) and unnatural (MRR, 9.45 [99% CI, 6.29-17.85]) causes.

CONCLUSION

PD was associated with increased all-cause mortality, especially suicide. Substance use further increased mortality risk in persons with PD. Targeted treatment for substance use and suicide prevention are essential among persons with PD.

Individuals' conceptions of COVID-19 pandemic through metaphor analysis

The main purpose of the current study is to investigate the perceptions of individuals' living in Turkey during the COVID-19 pandemic through metaphor analysis. The current study employed the descriptive phenomenological design, one of the qualitative research methods. A total of 210 individuals living in Turkey (114 females (68.6%) and 66 males (31.4%)) participated in the current study through an online questionnaire on a voluntary basis. As the data collection tool, the online questionnaire form developed by the researchers was used. The collected data were analyzed within the framework of five-stage metaphor analysis. As a result of the analysis, a total of seven metaphor categories called being restricted, restlessness, uncertainty/obscurity, deadly/dangerous, struggling, faith/destiny, and supernatural were obtained. These categories were subsumed under three themes called "anxiety/concern, risk, and faith".

Psychosocial and biological risk factors of anxiety disorders in adolescents: a TRAILS report

Anxiety disorders are a common problem in adolescent mental health. Previous studies have investigated only a limited number of risk factors for the development of anxiety disorders concurrently. By investigating multiple factors simultaneously, a more complete understanding of the etiology of anxiety disorders can be reached. Therefore, we assessed preadolescent socio-demographic, familial, psychosocial, and biological factors and their association with the onset of anxiety disorders in adolescence. This study was conducted among 1584 Dutch participants of the TRacking Adolescents' Individual Lives Survey (TRAILS). Potential risk factors were assessed at baseline (age 10-12), and included socio-demographic (sex, socioeconomic status), familial (parental anxiety and depression), psychosocial (childhood adversity, temperament), and biological (body mass index, heart rate, blood pressure, cortisol) variables. Anxiety disorders were assessed at about age 19 years through the Composite International Diagnostic Interview (CIDI). Univariate and multivariate logistic regression analyses were performed with onset of anxiety disorder as a dependent variable and the above-mentioned putative risk factors as predictors. Of the total sample, 25.7% had a lifetime diagnosis of anxiety disorder at age 19 years. Anxiety disorders were twice as prevalent in girls as in boys. Multivariate logistic regression analysis showed that being female (OR = 2.38, p < .01), parental depression and anxiety (OR = 1.34, p = .04), temperamental frustration (OR = 1.31, p = .02) and low effortful control (OR = 0.76, p = .01) independently predicted anxiety disorders. We found no associations between biological factors and anxiety disorder. After exclusion of adolescents with an onset of anxiety disorder before age 12 years, being female was the only significant predictor of anxiety disorder. Being female was the strongest predictor for the onset of anxiety disorder. Psychological and parental psychopathology factors increased the risk of diagnosis of anxiety, but to a lesser extent. Biological factors (heart rate, blood pressure, cortisol, and BMI), at least as measured in the present study, are unlikely to be useful tools for anxiety prevention and intervention strategies.

Gender differences in avoidance and repetitive negative thinking following symptom provocation in men and women with spider phobia

OBJECTIVES

Women's greater prevalence of anxiety disorders compared to men is widely assumed to be partly due to gender differences in cognitive and behavioural factors that perpetuate anxiety, such as repetitive negative thinking (RNT) and avoidance. However, past studies assessing this assumption have not controlled for gender differences in baseline symptom severity, the type of stressful life experiences against which RNT and avoidance are measured, or emotional reactivity to these experiences.

DESIGN

Using a two-group design, the present study controlled for these confounds by comparing avoidance and RNT in relation to a controlled symptom provocation task in spider phobic men and women with equivalent spider fear severity on the Fear of Spiders Questionnaire.

METHODS

Participants engaged in a behavioural approach test (BAT) involving a live spider, during which they were assessed for avoidance (physical proximity to the spider) and subjective distress. Two weeks later, participants reported on their levels of negative affect and RNT experienced during the preceding weeks in relation to the BAT.

RESULTS

Women exhibited greater avoidance and reported greater RNT than men, despite reporting comparable distress and negative affect. Gender remained a significant predictor of avoidance when accounting for distress and also remained a significant predictor of RNT when accounting for depressive symptoms and negative affect.

CONCLUSIONS

These results provide in vivo evidence that heightened avoidance and RNT may perpetuate anxiety symptoms in women independently of gender differences in symptom severity, daily experiences, or emotional reactivity.

PRACTITIONER POINTS

Following symptom provocation, men and women with spider phobia differ in cognitive and behavioural coping responses. Women exhibit greater avoidance and repetitive negative thinking than men, and these differences are not attributable to gender differences in symptom severity or emotional reactivity. These findings provide novel evidence for gender differences in maintaining factors that perpetuate anxiety disorders whilst accounting for confounding factors present in prior research.

Gender differences in anxiety: The mediating role of sensitivity to unpredictable threat

Anxiety disorders and symptoms disproportionately impact women relative to men, but it is unclear what mechanism(s) contribute to this phenomenon. The present study examined sensitivity to unpredictable threat as a potential mechanism of gender differences in panic symptoms. The sample included 67 participants (35 women) who completed the no, predictable, and unpredictable threat (NPU-threat) startle paradigm with electric shocks as the aversive stimulus. Participants also completed the self-report Inventory of Depression and Anxiety Symptoms to assess current panic and depression symptoms. Results indicated that women, relative to men, reported greater panic symptoms and demonstrated increased startle potentiation in anticipation of predictable and unpredictable threat. Furthermore, across all participants increased startle potentiation in anticipation of unpredictable (but not predictable) threat was associated with greater panic symptoms, but there was no relationship with depression symptoms. Finally, the gender difference in panic symptoms was mediated by startle potentiation in anticipation of unpredictable (but not predictable) threat. The present study suggests that a heightened sensitivity to unpredictable threat might be a mechanism that contributes to increased anxiety in women.

Panic disorder during pregnancy and postpartum period

Background

– Earlier studies on the influence of pregnancy and postpartum period on the course of panic disorder have been inconsistent. The present study aims to quantify panic manifestations in these periods in large sample of women.

Method

– Panic manifestations, including exacerbations and new manifestations of panic disorder, were assessed retrospectively in a sample of 128 women with panic disorder with or without agoraphobia, 93 of whom had had 195 pregnancies.

Results

– Panic manifestations were fewer during pregnancy and more frequent in the postpartum period when compared with the control period. Women who had never been pregnant had significantly more panic manifestations than women with prior pregnancies. Breastfeeding and miscarriages did not have a significant effect. Women with postpartum panic reported more psychosocial stress events during this period.

Conclusions

– Possible reasons for postpartum panic and the protective effects of pregnancy are discussed, including psychosocial or hormonal factors and other neurobiological changes. Postpartum panic coincides with a sudden drop of hormones after delivery.

Gender-related distribution of personality disorders in a sample of patients with panic disorder

Objective

We examined gender differences in the frequency of DSM-IV personality disorder diagnoses in a sample of patients with a diagnosis of panic disorder (PD).

Method

One hundred and eighty-four outpatients with a principal diagnosis of PD (DSM-IV) were enrolled. All patients were evaluated with a semi-structured interview to collect demographic and clinical data and to generate Axis I and Axis II diagnoses in accordance with DSM-IV criteria.

Results

Males were significantly more likely than females to meet diagnoses for schizoid and borderline personality disorder. Compared to males, females predominated in histrionic and cluster C diagnoses, particularly dependent personality disorder diagnoses. A significant interaction was found between female sex and agoraphobia on personality disorder (PD) distribution.

Conclusions

Male PD patients seem to be characterized by more severe personality disorders, while female PD patients, particularly with co-morbid agoraphobia, have higher co-morbidity rates with personality disorders belonging to the ‘anxious-fearful cluster’.

Sex differences in incidence and psychiatric comorbidity for alcohol dependence in patients with panic disorder

BACKGROUND

Sex differences in the development of alcohol dependence (AD) among patients with panic disorder (PD) remain unexplored. The study investigated sex as an effect modifier in the incidence of AD among patients with PD.

METHOD

We included 9480 patients with PD from the Taiwan National Health Insurance Research Database. A total of 169 patients (89 men and 80 women) developed incident AD during the follow-up period. Standardized incidence ratios (SIRs) were used to represent the relative risks of incident AD compared with the general population. Based on a nested case-control study design, 10 controls were selected for each case. Medical utilization and psychiatric comorbidity before diagnosing AD were analyzed using conditional logistic regression.

RESULTS

The SIR of incident AD was 3.36 for men and 6.29 for women. Women with PD and incident AD had more visits to the outpatient department than the controls did, whereas men exhibited no significant differences. Women with incident AD were more likely to comorbid with depressive disorder (adjusted risk ratio [aRR] = 2.94), personality disorder (aRR = 5.03), and sleep disorder (aRR = 1.72), whereas men with incident AD were more likely to comorbid with sleep disorder (aRR = 1.85) and other substance use disorders (aRR = 3.08).

CONCLUSION

Patients with PD have an additional risk of developing AD compared with the general population, and that risk is higher in women. Women and men exhibited dissimilar patterns of medical utilization and psychiatric comorbidity before developing AD. Sex differences should be taken into consideration when establishing preventive measures.

Sex differences in breathing

Breathing is a vital behavior that ensures both the adequate supply of oxygen and the elimination of CO₂, and it is influenced by many factors. Despite that most of the studies in respiratory physiology rely heavily on male subjects, there is much evidence to suggest that sex is an important factor in the respiratory control system, including the susceptibility for some diseases. These different respiratory responses in males and females may be related to the actions of sex hormones, especially in adulthood. These hormones affect neuromodulatory systems that influence the central medullary rhythm/pontine pattern generator and integrator, sensory inputs to the integrator and motor output to the respiratory muscles. In this article, we will first review the sex dependence on the prevalence of some respiratory-related diseases. Then, we will discuss the role of sex and gonadal hormones in respiratory control under resting conditions and during respiratory challenges, such as hypoxia and hypercapnia, and whether hormonal fluctuations during the estrous/menstrual cycle affect breathing control. We will then discuss the role of the locus coeruleus, a sexually dimorphic CO₂/pH-chemosensitive nucleus, on breathing regulation in males and females. Next, we will highlight the studies that exist regarding sex differences in respiratory control during development. Finally, the few existing studies regarding the influence of sex on breathing control in non-mammalian vertebrates will be discussed.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder

Objective:

To provide practical clinical guidance for the treatment of adults with panic disorder, social anxiety disorder and generalised anxiety disorder in Australia and New Zealand.

Method:

Relevant systematic reviews and meta-analyses of clinical trials were identified by searching PsycINFO, Medline, Embase and Cochrane databases. Additional relevant studies were identified from reference lists of identified articles, grey literature and literature known to the working group. Evidence-based and consensus-based recommendations were formulated by synthesising the evidence from efficacy studies, considering effectiveness in routine practice, accessibility and availability of treatment options in Australia and New Zealand, fidelity, acceptability to patients, safety and costs. The draft guidelines were reviewed by expert and clinical advisors, key stakeholders, professional bodies, and specialist groups with interest and expertise in anxiety disorders.

Results:

The guidelines recommend a pragmatic approach beginning with psychoeducation and advice on lifestyle factors, followed by initial treatment selected in collaboration with the patient from evidence-based options, taking into account symptom severity, patient preference, accessibility and cost. Recommended initial treatment options for all three anxiety disorders are cognitive–behavioural therapy (face-to-face or delivered by computer, tablet or smartphone application), pharmacotherapy (a selective serotonin reuptake inhibitor or serotonin and noradrenaline reuptake inhibitor together with advice about graded exposure to anxiety triggers), or the combination of cognitive–behavioural therapy and pharmacotherapy.

Conclusion:

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder provide up-to-date guidance and advice on the management of these disorders for use by health professionals in Australia and New Zealand.

Gender Differences of Stressful Life Events, Coping Style, Symptom Severity, and Health-Related Quality of Life in Patients With Panic Disorder

Although affective disorders have been known to have sex differences in the associated clinical characteristics and quality of life (QOL), sex differences among patients with panic disorder (PD) have remained relatively unexplored in Korea. We examined the sex differences in different types of stressful life events (SLEs), coping styles, symptom severity, and health-related QOL (HRQOL) in patients with PD. Data from 291 female and 254 male participants diagnosed with PD were analyzed using a structured clinical interview following the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria. Females with PD reported more SLEs including separation issues, physical illness or disability, and pregnancy-related problems than males. They also reported lower levels of confrontation and help-seeking coping strategies and higher levels of agoraphobia in symptom severity than males. The HRQOL of females with PD was significantly lower than male in physical functioning of HRQOL. This study suggests that the patient's sex is relevant to the assessment and treatment of PD.

Development and validation of a risk-prediction algorithm for the recurrence of panic disorder

BACKGROUND

To develop and validate a risk prediction algorithm for the recurrence of panic disorder.

METHODS

Three-year longitudinal data were taken from the National Epidemiologic Survey on Alcohol and Related Conditions (2001/2002-2004/2005). One thousand six hundred and eighty one participants with a lifetime panic disorder and who had not had panic attacks for at least 2 months at baseline were included. The development cohort included 949 participants; 732 from different census regions were in the validation cohort. Recurrence of panic disorder over the follow-up period was assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule, based on the DSM-IV criteria. Logistic regression was used for deriving the algorithm. Discrimination and calibration were assessed in the development and the validation cohorts.

RESULTS

The developed algorithm consisted of 11 predictors: age, sex, panic disorder in the past 12 months, nicotine dependence, rapid heartbeat/tachycardia, taking medication for panic attacks, feelings of choking and persistent worry about having another panic attack, two personality traits, and childhood trauma. The algorithm had good discriminative power (C statistic = 0.7863, 95% CI: 0.7487, 0.8240). The C statistic was 0.7283 (95% CI: 0.6889, 0.7764) in the external validation data set.

CONCLUSIONS

The developed risk algorithm for predicting the recurrence of panic disorder has good discrimination and excellent calibration. Data related to the predictors can be easily attainable in routine clinical practice. It can be used by clinicians to calculate the probability of recurrence of panic disorder in the next 3 years for individual patients, communicate with patients regarding personal risks, and thus improve personalized treatment approaches.

Gender-specific abnormalities in the serotonin transporter system in panic disorder

The central serotonergic system has been implicated in the pathophysiology of panic disorder (PD) by evidence of abnormally elevated serotonin-turnover, reduced pre- and post-synaptic 5-HT(1A)-receptor sensitivity and binding and clinical improvement during administration of agents that enhance serotonergic transmission. Polymorphisms in genes that putatively influence serotonergic neurotransmission increase the vulnerability for developing PD specifically in males. We tested the hypotheses that serotonin transporter (5-HTT) binding is elevated in PD subjects vs. healthy controls in regions where in vivo evidence exists for both elevated 5-HTT and 5-HT(1A) receptor levels in PD and investigated whether the extent of this difference depends upon gender. Volunteers were out-patients with current PD (n=24) and healthy controls (n=24). The non-displaceable component of 5-HTT binding-potential (BP(ND)) was measured using positron emission tomography and the 5-HTT selective radioligand, [(11)C]DASB. PD severity was assessed using the PD Severity Scale. The 5-HTT-BP(ND) was increased in males with PD relative to male controls in the anterior cingulate cortex (F=8.96, p(FDR)=0.01) and midbrain (F=5.09, p(FDR)=0.03). In contrast, BP(ND) did not differ between females with PD and female controls in any region examined. The finding that 5-HTT-binding is elevated in males but not in females with PD converges with other evidence suggesting that dysfunction within the central serotonergic system exists in PD, and also indicates that such abnormalities are influenced by gender. These findings conceivably may reflect a sexual dimorphism that underlies the greater efficacy of serotonin reuptake inhibitor treatment in females vs. males with PD.

Genetic polymorphism of angiotensin I-converting enzyme (ACE), but not angiotensin II type I receptor (ATr1), has a gender-specific role in panic disorder

AIMS

Angiotensins were shown to have some role in the development of panic disorder (PD). In this study, we aimed to determine the frequency of polymorphisms in two angiotensin-related genes, angiotensin I-converting enzyme (ACE) and angiotensin II type I receptor (ATr1), in a sample of Turkish patients with PD and to evaluate their association with PD development.

METHODS

Polymerase chain reaction and restriction fragment length polymorphism was used to analyze ATr1 A1166C polymorphism, and only polymerase chain reaction was used to analyze functional ACE insertion/deletion polymorphism in 123 patients with PD and in 169 similarly aged disease-free controls.

RESULTS

 There was no significant difference in the genotype distribution between PD patients and controls for each polymorphism (P>0.05). Allele frequency of ACE insertion/deletion was borderline statistically significant between the groups (P=0.055; odds ratio: 1.39; 95% confidence interval: 0.99-1.95), and allele frequency of ATr1 A1166C was not significantly different between the groups (P=0.32; odds ratio: 0.81; 95% confidence interval: 0.53-1.22).

CONCLUSION

This study suggests that polymorphisms of ACE I/D and ATr1 A1166C are not associated with risk of PD in Turkish patients. However, in ACE insertion/deletion polymorphism, the insertion allele was found to be more frequent in the male subgroup of patients (χ²=4.61, P=0.032) than in controls, suggesting a potential male-specific role of the less active ACE insertion allele in the pathogenesis of PD.

Sex differences in panic-relevant responding to a 10% carbon dioxide-enriched air biological challenge

The current study examined sex differences in psychological (i.e., self-reported anxiety, panic symptoms, and avoidance) and physiological (i.e., heart rate and skin conductance level) response to, and recovery from, a laboratory biological challenge. Participants were a community-recruited sample of 128 adults (63.3% women; M(age)=23.2 years, SD=8.9) who underwent a 4-min 10% CO(2)-enriched air biological challenge. As predicted, women reported more severe physical panic symptoms and avoidance (i.e., less willingness to participate in another challenge) and demonstrated increased heart rate as compared to men above and beyond the variance accounted for by other theoretically relevant variables (recent panic attack history, neuroticism, and anxiety sensitivity). Additionally, women demonstrated a faster rate of recovery with respect to heart rate compared to men. These results are in line with literature documenting sex-specific differences in panic psychopathology, and results are discussed in the context of possible mechanisms underlying sex differences in panic vulnerability.

Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness

Women have consistently higher prevalence rates of anxiety disorders, but less is known about how gender affects age of onset, chronicity, comorbidity, and burden of illness. Gender differences in DSM-IV anxiety disorders were examined in a large sample of adults (N=20,013) in the United States using data from the Collaborative Psychiatric Epidemiology Studies (CPES). The lifetime and 12-month male:female prevalence ratios of any anxiety disorder were 1:1.7 and 1:1.79, respectively. Women had higher rates of lifetime diagnosis for each of the anxiety disorders examined, except for social anxiety disorder which showed no gender difference in prevalence. No gender differences were observed in the age of onset and chronicity of the illness. However, women with a lifetime diagnosis of an anxiety disorder were more likely than men to also be diagnosed with another anxiety disorder, bulimia nervosa, and major depressive disorder. Furthermore, anxiety disorders were associated with a greater illness burden in women than in men, particularly among European American women and to some extend also among Hispanic women. These results suggest that anxiety disorders are not only more prevalent but also more disabling in women than in men.

Brave men and timid women? A review of the gender differences in fear and anxiety

Substantial evidence indicates that women report greater fear and are more likely to develop anxiety disorders than men. Women's greater vulnerability for anxiety disorders can be partly understood by examining gender differences in the etiological factors known to contribute to anxiety. This review examines evidence for gender differences across a broad range of relevant factors, including biological influences, temperamental factors, stress and trauma, cognitive factors, and environmental factors. Gender differences are observed with increasing consistency as the scope of analysis broadens to molar levels of functioning. Socialization processes cultivate and promote processes related to anxiety, and moderate gender differences across levels of analysis.

Anxiety in middle adulthood: effects of age and time on the 14-year course of panic disorder, social phobia and generalized anxiety disorder

BACKGROUND

Much about the long-term course of anxiety disorders is unknown. The present study utilizes a naturalistic, longitudinal, short-interval follow-up design to elucidate the course of anxiety disorders over 14 years in a largely middle-aged adult sample recruited from out-patient psychiatry and primary care facilities.

METHOD

The sample consisted of 453 participants with a diagnosis of panic disorder (PD), social phobia (SP) and/or generalized anxiety disorder (GAD). Anxiety symptom ratings were tracked using weekly psychiatric status ratings (PSRs). Controlling for demographic and clinical variables, the course of PD, GAD and SP were examined using longitudinal growth models, with the most severe PSR at each follow-up point as the main outcome variable.

RESULTS

PSRs significantly decreased in severity over time in each of the three disorders. In the interaction effects models, age x time had a significant effect on course for PD and GAD, but not for SP, in that older age was associated with lower PSRs over time.

CONCLUSIONS

The present findings suggest that the severity of anxiety disorders declines over time, although this decline is modest and depends on the specific disorder being assessed. Older individuals with PD and GAD have a better prognosis than their younger counterparts, as their course is characterized by a steeper decline in severity. The present findings provide important information about the course of anxiety disorders in mid-life.

Co-occurrence of Axis I and Axis II disorders in female and male patients with panic disorder with agoraphobia

OBJECTIVE

The aim of this study is to compare female and male patients with panic disorder with agoraphobia (PDA) for the co-occurring Axis I and Axis II (personality) disorders, to better understand sex differences in PDA.

METHODS

The Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) Axis I Disorders, Clinician Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders were administered to 157 consecutive outpatients (112 females and 45 males) with principal diagnosis of PDA, who sought treatment at the 2 anxiety disorders clinics. Women and men with PDA were then compared with regard to the type and frequency of the co-occurring Axis I and Axis II disorders.

RESULTS

Women with PDA had a statistically greater tendency to receive co-occurring Axis I diagnoses and a greater number of Axis I diagnoses than men. Such a difference was not found for personality disorders. However, no sex difference was found for the mean number of co-occurring Axis I and Axis II diagnoses per patient. There were significantly more women with at least one co-occurring anxiety disorder. Women had a significantly higher frequency of specific phobia, whereas men were diagnosed with hypochondriasis and past alcohol abuse or dependence significantly more often. With regard to Axis II disorders, the only significant sex difference pertained to the higher frequency of dependent personality disorder among women.

CONCLUSIONS

The results of this study suggest that there are more similarities than differences between sexes in the co-occurring Axis I and Axis II disorders. Still, the relatively specific relationships between PDA and excessive alcohol use in men and between PDA and dependent personality traits and personality disorder in women seem important and have implications for clinical practice and treatment.

Panic, suffocation false alarms, separation anxiety and endogenous opioids

This review paper presents an amplification of the suffocation false alarm theory (SFA) of spontaneous panic [Klein DF (1993). False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry; 50:306-17.]. SFA postulates the existence of an evolved physiologic suffocation alarm system that monitors information about potential suffocation. Panic attacks maladaptively occur when the alarm is erroneously triggered. That panic is distinct from Cannon's emergency fear response and Selye's General Alarm Syndrome is shown by the prominence of intense air hunger during these attacks. Further, panic sufferers have chronic sighing abnormalities outside of the acute attack. Another basic physiologic distinction between fear and panic is the counter-intuitive lack of hypothalamic-pituitary-adrenal (HPA) activation in panic. Understanding panic as provoked by indicators of potential suffocation, such as fluctuations in pCO(2) and brain lactate, as well as environmental circumstances fits the observed respiratory abnormalities. However, that sudden loss, bereavement and childhood separation anxiety are also antecedents of "spontaneous" panic requires an integrative explanation. Because of the opioid system's central regulatory role in both disordered breathing and separation distress, we detail the role of opioidergic dysfunction in decreasing the suffocation alarm threshold. We present results from our laboratory where the naloxone-lactate challenge in normals produces supportive evidence for the endorphinergic defect hypothesis in the form of a distress episode of specific tidal volume hyperventilation paralleling challenge-produced and clinical panic.

Are there gender differences in catastrophic appraisals in panic disorder with agoraphobia?

Our aim in this study was to compare panic-related catastrophic appraisals between women and men with panic disorder with agoraphobia (PDA). One hundred two outpatients with PDA (75 women and 27 men) participated. Two instruments for the assessment of catastrophic appraisals, Agoraphobic Cognitions Questionnaire and Panic Appraisal Inventory, were administered before and after cognitive-behavioral therapy (CBT) that also included pharmacotherapy in three-fourths of the patients. Female and male patients did not differ significantly in terms of their tendency to anticipate catastrophic consequences of panic, before or after CBT-based treatment. For both females and males, the tendency to make catastrophic appraisals decreased significantly with treatment. We conclude that among patients with PDA there are no gender differences in catastrophic appraisals of panic sensations and symptoms. The apparently higher risk of panic recurrence in women does not seem to be related to their panic-related catastrophic appraisals. These findings also support a notion that there is no gender difference in response to CBT-based treatment of PDA.

Gender-specific association of a functional coding polymorphism in the Neuropeptide S receptor gene with panic disorder but not with schizophrenia or attention-deficit/hyperactivity disorder

Panic disorder is a common anxiety disorder characterized by sudden and recurrent panic attacks. Previous studies have indicated significant genetic contributions and a susceptibility locus for panic disorder has been mapped to human chromosome 7p 15. The receptor for Neuropeptide S (NPS) is located in the same genomic region while NPS is known to produce arousal and anxiolytic-like effects in rodents. Here we report that a coding polymorphism in the Neuropeptide S receptor (NPSR) is associated with panic disorder in male patients of Japanese ancestry. The polymorphism (Asn(107)Ile) results in a gain-of-function of the receptor protein by increasing the agonist sensitivity about tenfold. The allele representing the less active isoform (NPSR Asn(107)) was found under-represented in male panic disorder patients, indicating a potential protective function of the protein. Two unrelated groups of patients diagnosed with schizophrenia or attention-deficit/hyperactivity disorder (ADHD) showed no association of particular NPSR alleles with the disorders. These results provide evidence for a gender-specific effect of NPSR in the pathogenesis of panic disorder.

Atypical depression, somatic depression and anxious depression in women: are they gender-preferred phenotypes?

BACKGROUND

Both depression and anxiety disorders affect women at rates significantly greater than men. Women also have a documented higher frequency of comorbid depression and anxiety disorders, and a three-fold higher prevalence of atypical depression.

HYPOTHESES

These gender differences are mainly due to specific depressive phenotypes including anxious depression and atypical depression. The prevalence of comorbid anxiety and depression strongly suggests overlap of pathophysiological mechanisms-which in women are also affected by fluctuations in gonadal hormones. Similar efficacy of serotonergic antidepressants as treatment for anxiety disorders as well as depressions further underscores the blurred boundaries between these two descriptive entities.

CONCLUSIONS

Symptoms of depression and anxiety may be a departure point for differential diagnosis in which dimensionally-based phenotypes substantiated by pathobiology would replace current descriptive entities. It is suggested that at least some biologically-based dysphorias may be specific to women, ensuing from the combination of specific vulnerabilities, and complex interactions between brain mechanisms and gonadal hormones.

Characteristics and course of panic disorder and panic disorder with agoraphobia in primary care patients

OBJECTIVE

To examine the course of panic disorder (PD) and panic disorder with agoraphobia (PDA) in 235 primary care patients during a 3-year period.

METHOD

Patients were recruited from primary care waiting rooms and diagnosed using the Structured Clinical Interview for DSM-IV. They were reassessed at 6 months, 1 year, and annually thereafter for diagnosis, treatment, and other clinical and demographic variables. Recruitment occurred between July 1997 and May 2001.

RESULTS

At intake, 85 patients were diagnosed with PD and 150 were diagnosed with PDA. Patients with PD were significantly more likely to achieve recovery (probability estimate, 0.75) from their disorder than patients with PDA (0.22) at the end of 3-year follow-up (p < .0001). There was no difference in recurrence rates between the 2 disorders. Women were more likely to recover from PD (p = .001). At intake, comorbid generalized anxiety disorder (p = .004), higher Global Assessment of Functioning score (p = .0003), and older age at panic onset (p = .05) were related to recovery from PDA, and comorbid major depressive disorder (p = .05) and psychosocial treatment (p = .002) predicted remaining in an episode of PDA. The relationship between psychosocial treatment and poor recovery must be interpreted with caution and is most likely due to the treatment bias effect.

CONCLUSION

Primary care patients with PDA have a chronic course of illness, whereas those with PD have a more relapsing course. Given the significant burden of PD and PDA in primary care, attention to factors relevant to the course of these disorders is important for recognition and for continued improvement of treatment interventions in this setting.

Psychometric characteristics of the Mobility Inventory in a longitudinal study of anxiety disorders: replicating and exploring a three component solution

Psychometric characteristics of the Mobility Inventory (MI) were examined in 216 outpatients diagnosed with panic disorder with agoraphobia participating in a longitudinal study of anxiety disorders. An exploratory principal components analysis replicated a three-component solution for the MI reported in prior studies, with components corresponding to avoidance of public spaces, avoidance of enclosed spaces, and avoidance of open spaces. Correlational analyses suggested that the components tap unique but related areas of avoidance that were remarkably stable across periods of 1, 3, and 5 years between administrations. Implications of these results for future studies of agoraphobia are discussed.

Personality traits in early phases of panic disorder: implications on the presence of agoraphobia, clinical severity and short-term outcome

OBJECTIVE

To explore the relations between personality traits using the Big Five model and presence of agoraphobia, clinical severity and short-term outcome in an unbiased clinical sample of never-treated panic disorder patients.

METHOD

Panic disorder (PD) patients (n = 103) in the first stages of their illness were evaluated using the Neuroticism-Extraversion-Openness Five Factor Inventory of Personality (NEO-FFI) and were compared with a sample of healthy subjects. Severity was assessed by the Panic Disorder Severity Scale and the Clinical Global Impression Scales. Patients were evaluated after 8 weeks of naturalistic pharmacologic treatment with Selective Serotonin Reuptake Inhibitors.

RESULTS

Panic disorder patients show more neuroticism than healthy subjects. Patients suffering from agoraphobia are more introverted than controls. Extraversion, in addition to gender and distress, during panic attacks allows to correctly classifying 72% of the cases of agoraphobia.

CONCLUSION

Low scores in extraversion contribute to explain the presence of agoraphobia in panic disorder. Personality traits are neither related to clinical severity nor to short-term response to pharmacological treatment.

Sex differences in clinical presentation and response in panic disorder: pooled data from sertraline treatment studies

OBJECTIVE

Gender differences in clinical presentation and response to sertraline treatment were examined for patients diagnosed with DSM-III-R panic disorder with or without agoraphobia.

METHOD

Data was pooled from 4 double-blind, placebo-controlled outpatient studies (males, N = 335; females, N = 338). Two were 12-week fixed-dose studies (sertraline 50 mg vs. 100 mg vs. 200 mg) and 2 were 10-week flexible-dose studies (sertraline 50-200 mg). Primary outcome measures consisted of the Clinical Global Impression-Improvement scale (CGI-I) and change in panic attack frequency.

RESULTS

The clinical presentation of panic disorder was similar except that men reported an earlier age of onset, shorter duration of illness, and significantly more frequent history of alcohol and/or substance dependence/abuse. Sertraline was significantly more effective than placebo in both women and men on the 2 primary outcome measures. When between-sex efficacy was compared, women achieved significantly greater improvement than men on panic frequency and CGI-I, but had equivalent improvement on all other measures. There was no significant between-sex difference in study completion rates, or in adverse event profiles.

CONCLUSIONS

There was a modest but consistent trend for women to show superior efficacy at the end of acute sertraline treatment. This gender effect only occasionally achieved significance, and must be confirmed by future treatment research.

Recurrence of Panic Disorder During Pregnancy

OBJECTIVES

The aim of this naturalistic follow-up study was to examine the effect of pregnancy as a predicting factor of relapse in patients with panic disorder (PD).

METHODS

Eighty-five female patients with PD (between the ages of 20 and 35 years) were included in this study. They were divided into 2 groups based on whether the onset of PD had been during pregnancy (PD-pregnancy [PD-P]) or whether the onset of PD had been while not pregnant (PD-nonpregnant [PD-NP]). Patients were treated with paroxetine up to 40 mg/day for 12 months, and the full responders were tapered off their medication and were monitored for an additional 6 years. Treatment response was assessed using the Panic Self-Questionnaire (PSQ) with full response being defined as "0" panic attacks. Assessments using the PSQ were made at baseline and every 4 weeks for the first twelve months. During the 6-year drug-free follow-up period, patients were assessed using the PSQ every 3 months. Relapse was defined as the occurrence of a panic attack in any phase of the study. The effect of group membership (PD-P vs. PD-NP) and new pregnancies as risk factors for relapse were explored.

RESULTS

Sixty-eight patients completed the 6-year follow-up, and each of the study groups (PD-P and PD-NP) was composed of 34 patients. Twenty-six of 34 (76.6%) patients in the PD-P group had another pregnancy, and 15/26 (57%) in this group experienced a relapse during the subsequent pregnancy. Three of 8 (37%) PD-P patients experienced a relapse without pregnancy. Among the second group (PD-NP), 18/34 (52.9%) became pregnant and 8/18 (44.4%) experienced a relapse at the time of pregnancy, whereas 4/16 (25%) experienced a relapse while not pregnant. Patients who relapsed during pregnancy had a more severe relapse (as defined by the severity of the PSQ score) compared with nonpregnant relapsers.

CONCLUSIONS

Our naturalistic follow-up study demonstrated that pregnancy might confer an increased risk of relapse in PD. Moreover, when compared with patients who develop PD while not pregnant (PD-NP), patients who develop PD during pregnancy (PD-P) appear to have a higher risk of relapse at the time of a subsequent pregnancy (P < 0.001).

Psychopathology of panic attacks in panic disorder

PURPOSE

This study examined the relationships among certain subtypes of panic attacks (full vs. limited symptom; spontaneous vs. situational) and between these subtypes, panic disorder subtypes, and other characteristics of panic disorder, especially agoraphobia.

METHOD

Data were drawn from a large (n = 1,168) treatment study of panic disorder in which panic attacks were carefully subtyped and counted using a diary. Relationships between variables at baseline were examined primarily using non-parametric methods, and the course of improvement for panic subtypes among completers was plotted.

RESULTS

The median number of spontaneous panic attacks per week at baseline was similar among patients with panic disorder without agoraphobia (PD), limited phobic avoidance (PDL), and agoraphobia (PDA). The median number of situational attacks and the median agoraphobia ratings rose progressively across diagnostic subtypes. Anticipatory anxiety, HAM-A, HAM-D, and disability scores were higher in PDA than in PD. Full and limited symptom panic attacks were positively correlated. The proportion of total attacks that were limited rose during the first two weeks of treatment, suggesting conversion of full to limited symptom attacks before complete disappearance. Spontaneous and situational attacks were correlated minimally or not at all. Agoraphobia ratings were more positively correlated with situational than with spontaneous panic attacks. Few of the correlations among measures at baseline were high.

CONCLUSIONS

Full and limited symptom panic attacks differ primarily in severity. Spontaneous and situational attacks are relatively independent, and situational attacks are more closely related to agoraphobia. These findings are consistent with previous work suggesting that spontaneous attacks reflect a biological component, whereas situational attacks reflect a cognitive component in the psychopathology-- and possibly the pathogenesis-- of panic disorder. This provides a rationale for the use of combined pharmacotherapy and psychotherapy in the treatment of panic disorder. Future investigations of panic disorder should carefully separate panic attack subtypes.

The cost of treating anxiety: the medical and demographic correlates that impact total medical costs

The purpose of this retrospective, multivariate analysis is to examine how medical conditions and demographic characteristics affect the costs of treating individuals diagnosed with anxiety. Data from MarketScan Databases [The MEDSTAT Group, 2000] were used to identify individuals with new episodes of anxiety. Multivariate analysis was used, with the dependent variable being the log of total medical costs. This analysis controlled for demographic characteristics, medical comorbidities, anxiety diagnosis, and prior resource utilization. A smearing estimate is used to calculate the total medical costs for patients with any anxiety disorder. The mean estimated total medical cost for individuals diagnosed with any anxiety disorder was $6,475. The multivariate model indicates that controlling for demographics and other disease states, generalized anxiety disorder (GAD), panic disorders, and posttraumatic stress disorder (PTSD) are associated with a $2,138, $1,603, and $3,940 increase, respectively, in the total medical cost (P < .0001). The incremental impact of depression, other anxiety disorders, and prior mental health diagnoses on the total medical costs were $1,945, $1,900, and $1,515, respectively (P < .0001). Individuals with the highest costs, and therefore the greatest need for intervention, are anxious patients with depression, individuals diagnosed with PTSD or GAD, and individuals diagnosed with both anxiety and a comorbid medical condition such as an acute myocardial infarction or diabetes.

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

The present study was performed to compare the clinical features of patients with panic disorder with and without agoraphobia. The subjects were 233 outpatients with panic disorder (99 males and 134 females) diagnosed according to DSM-IV criteria. Sixty-three patients met the criteria for panic disorder without agoraphobia, and 170 met the criteria for panic disorder with agoraphobia. Patients with agoraphobia showed a significantly longer duration of panic disorder and higher prevalence of generalized anxiety disorder. However, there were no significant differences in prevalence of major depressive episodes, in current severity of panic attacks, or in gender ratio between the two groups. The second aim of the present study was to investigate the effects of onset age and sex differences on the development of agoraphobia within a half-year. The subjects were divided into two groups according to their self-report: patients who did or did not develop agoraphobia within 24 weeks of onset of panic disorder. A total of 40.6% of the patients developed agoraphobia within 24 weeks of the onset of panic disorder, and onset age and sex differences had no robust effect on the development of agoraphobia within 24 weeks.

Anxiety disorders in women: does gender matter to treatment?

Women have a substantially higher risk of developing lifetime anxiety disorders compared with men. In addition, research evidence has generally observed an increased symptom severity, chronic course, and functional impairment in women with anxiety disorders in comparison to men. However, the reasons for the increased risk in developing an anxiety disorder in women are still unknown and have yet to be adequately investigated. Evidence from various studies has suggested that genetic factors and female reproductive hormones may play important roles in the expression of these gender differences. The significant differences in onset and course of illness observed in men and women diagnosed with anxiety disorders warrants investigations into the need of differential treatment; however, evidence of gender differences in treatment response to different anxiety disorders are varying and remain largely inconclusive. This article reviews the prevalence, epidemiology, and phenomenology of the major anxiety disorders in women, as well as the implications of such differences for treatment.

A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia

The efficacy of (cognitive) behavioural ((C)BT) and pharmacological therapy was investigated using meta-analytic techniques. After a comprehensive review of the literature, the results of 124 studies were included. (C)BT was more effective than a no-treatment control and a placebo control. No difference of efficacy was found when using cognitive elements compared to not using them for anxiety; for associated depressive symptoms, additional cognitive elements seems superior. Pharmacotherapy was more effective than a placebo control; there was no superiority of any drug class. Sample size was related to effect size in pharmacotherapy and publication bias was found. (C)BT was at least as effective as pharmacotherapy and depending on type of analysis even significantly more effective. There were no significant differences between (C)BT alone and a combination approach but characteristics of studies have to be considered.

Gender differences in anxiety-related traits in patients with panic disorder

This study examined gender differences in anxiety-related personality traits in patients with panic disorder with or without agoraphobia (PD+/-AG). Outpatients (101 total) with SCID confirmed PD+/-AG completed the Anxiety Sensitivity Index (ASI), the Trait form of the State-Trait Anxiety Inventory (STAI-T), the NEO Personality Inventory Revised (NEO PI-R), and the Retrospective Self-Report of Inhibition (RSRI) as part of their assessment. Significant gender differences were not detected for the total ASI scores. Females scored significantly higher than males on the Physical Concerns subscale of the ASI, whereas males scored significantly higher than women on the Social Concerns subscale. Women scored higher than men on the Extraversion scale of the NEO PI-R as well as on certain subscales of this domain. Although a significant gender difference was not detected on the Neuroticism subscale, men scored higher on the angry hostility and depression facets of this trait. Significant gender differences were not found for the STAI-T or the RSRI. These findings suggest that gender differences exist among patients with PD+/-AG in the feared consequences of anxiety symptoms as well as in the personality characteristics of extraversion.

Gender differences in clinical presentation and response to sertraline treatment of generalized anxiety disorder

OBJECTIVE

To evaluate gender differences in the clinical presentation of generalized anxiety disorder (GAD) and response to sertraline treatment.

METHODS

Adult outpatients who met DSM-IV criteria for GAD with a minimum Hamilton rating scale for anxiety (HAM-A) total score>or=18 were randomized to 12 weeks of double-blind treatment with flexible doses (50-150 mg) of sertraline (n=182; female, 59%) or placebo (n=188; female, 51%).

RESULTS

Clinical presentation of GAD was very similar in men and women in terms of the severity of the HAM-A psychic factor, severity of concomitant depression symptoms, duration of GAD, quality of life and impairment in physical health. Women had an earlier age of onset and higher HAM-A somatic factor scores compared with men. For both men and women, treatment with sertraline resulted in greater change from baseline to endpoint on the HAM-A compared with placebo (adjusted change+/-SE: men:-12.1+/-0.9 vs -8.8+/-0.9; women: -11.4+/-0.8 vs -7.1+/-0.9, p<0.001); the interaction between gender and treatment group was not significant, nor was there a significant difference between the average change from baseline for men compared with women. Similarly, responder rates based upon clinical global impression-improvement (CGI-I) scores at endpoint showed no significant interaction between gender and treatment, nor was there a significant difference in the response rates by gender; however, the response rate of sertraline compared with placebo was significantly different (p<0.0001) (men: 64% vs 40%; women: 62% vs 34%). Similar findings were evident at week 4 assessment and for completers (week 12). Overall, sertraline was well tolerated by both men and women.

DISCUSSION

Women and men with GAD showed similar clinical presentations, with the exception that women had an earlier age of onset and reported more somatic anxiety symptoms. Sertraline was an effective and well tolerated treatment for GAD in both men and women.

Panic disorder in menopause: a case control study

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

New trends in the treatment of anxiety disorders

Anxiety disorders are among the most prevalent psychiatric disorders in the general population, found nearly twice as often in women, and estimated to affect 26.9 million individuals in the United States alone. Anxiety disorders are associated with considerable chronicity, morbidity, and disability. Treatment of anxiety disorders includes pharmacologic and nonpharmacologic approaches. The first-line pharmacologic treatments currently include the use of serotonin reuptake inhibitors and selective serotonin reuptake inhibitors. However, despite the general success of the available treatments, no single anxiolytic appears to be effective for all patients suffering from anxiety. Low recovery rates have been reported in all anxiety disorders, underscoring the need for optimizing treatment for these disabling disorders. In recent years, there is increasing interest in the use of atypical neuroleptics in the treatment of anxiety disorders patients. This article discusses the emerging data on the use of these agents in the treatment of anxiety with a focus on treatment-refractory patients and on the implications for the treatment of women suffering from anxiety disorders.

Panic disorder

BACKGROUND

This article reviews the clinical features, epidemiology, pathophysiology, dental findings, and dental and medical management of the care of patients with panic disorder, or PD.

TYPES OF STUDIES REVIEWED

The authors conducted a MEDLINE search for the period 1998 through 2003, using the key term "panic disorder" to define the pathophysiology of the disorder, its epidemiology and dental implications. The articles they selected for further review included those published in peer-reviewed journals.

RESULTS

PD is a common and debilitating psychiatric disease in which a person experiences sudden and unpredictable panic attacks, or PAs, with symptoms of overwhelming anxiety, chest pain, palpitations and shortness of breath. Persistent concern about having another attack and worry that it may indicate a heart attack or "going crazy" impairs the person's social, family and working lives. Frequently accompanying the disorder is agoraphobia, depression and mitral valve prolapse, or MVP.

CLINICAL IMPLICATIONS

In patients with PD, the prevalence of dental disease may be extensive because of the xerostomic effects of psychiatric medications used to treat it. Dental treatment consists of preventive dental education and prescribing saliva substitutes and anticaries agents. Precautions must be taken when prescribing or administering analgesics, antibiotics or sedative agents that may have an adverse interaction with the psychiatric medications. Because there is a connection between PAs and MVP, the dentist needs to consult with the patient's physician to determine the presence of MVP and whether there is associated mitral valve regurgitation. Patients with MVP and accompanying mitral valve regurgitation require prophylactic antibiotics when undergoing dental procedures known to cause a bacteremia and heightened risk of endocarditis.

Angiotensin-related genes in patients with panic disorder

Enhanced respiratory variability and decreased heart rate variability have repeatedly been observed in patients with panic disorder. Prompted by the notion that angiotensin may be involved in the control of respiration, heart rate variability, and anxiety-like behavior, we investigated the putative association between polymorphisms in three angiotensin-related genes and panic disorder-angiotensinogen (AGT), angiotensin converting enzyme (ACE), and angiotensin II (ANG II) receptor type 1 (ATr1) in 72 patients with panic disorder and 504 controls. Allele and genotype distribution of the ATr1 A1166C allele and the AGT M235T did not differ between patients and controls. With respect to the ACE I/D polymorphism, the I allele was found to be more frequent in male (chi(2) = 8.042, df = 1, P = 0.005), but not female, panic disorder patients than in controls. The results of this investigation provide preliminary evidence for the suggestion that angiotensin-related genes may be associated with panic disorder in men.

Australian and New Zealand clinical practice guidelines for the treatment of panic disorder and agoraphobia

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority.

METHOD

For these guidelines, the CPG team reviewed the treatment outcome literature, consulted with practitioners and patients and conducted a meta-analysis of recent outcome research.

TREATMENT RECOMMENDATIONS

Education for the patient and significant others covering: (i) the nature and course of panic disorder and agoraphobia; (ii) an explanation of the psychopathology of anxiety, panic and agoraphobia; (iii) rationale for the treatment, likelihood of a positive response, and expected time frame. Cognitive behaviour therapy (CBT) is more effective and more cost-effective than medication. Tricyclic antidepressants (TCAs) and serotonin selective reuptake inhibitors are equal in efficacy and both are to be preferred to benzodiazepines. Treatment choice depends on the skill of the clinician and the patient's circumstances. Drug treatment should be complemented by behaviour therapy. If the response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used. A second opinion can be useful. The presence of severe agoraphobia is a negative prognostic indicator, whereas comorbid depression, if properly treated, has no consistent effect on outcome.

Chronicity, relapse, and illness--course of panic disorder, social phobia, and generalized anxiety disorder: findings in men and women from 8 years of follow-up

Anxiety disorders are chronic illnesses that occur more often in women than men. Previously, we found a significant sex difference in the 5-year clinical course of uncomplicated panic disorder that was attributable to a doubling of the illness relapse rate in women compared to men. However, we have not detected a sex difference in the clinical course of panic with agoraphobia, generalized anxiety disorder (GAD), or social phobia (SP), which are conditions generally thought to be more chronic than uncomplicated panic disorder. Given that a longer follow-up period may be required to detect differences in clinical course for more enduring illnesses, we conducted further analyses on this same cohort after a more protracted interval of observation to determine whether sex differences would emerge or be sustained. Data were analyzed from the Harvard/Brown Anxiety Research Program (HARP), a naturalistic, longitudinal study that repeatedly assessed patients at 6 to 12 month intervals over the course of 8 years. Data regarding remission and relapse status were collected from 558 patients and treatment was observed but not prescribed. Cumulative remission rates were equivalent among men and women with all diagnoses. Patients who experienced remission were more likely to improve during the first 2 years of study. Women with GAD continued remitting late into the observation period and experienced fewer overall remission events by 8 years. However, the difference in course failed to reach statistical significance. Relapse rates for women were comparable to those for men who suffered from panic disorder with agoraphobia, GAD, and SP. Again, initial relapse events were more likely to occur within the first 2 years of observation. However, relapse events for uncomplicated panic in women were less restricted to the first 2 years of observation and by 8 years, the relapse rates for uncomplicated panic was 3-fold higher in women compared with men. Anxiety disorders are chronic in the majority of men and women, although uncomplicated panic is characterized by frequent remission and relapse events. Short interval follow-up shows sex differences in the remission and relapse rates for some but not all anxiety disorders. These findings suggest important differences in the clinical course among the various anxiety disorders and support nosological distinctions among the various types of anxiety. It may be that sex differences in the clinical course of anxiety disorders hold prognostic implications for patients with these illnesses.

Anxiety disorders in women

Women have higher overall prevalence rates for anxiety disorders than men. Women are also much more likely than men to meet lifetime criteria for each of the specific anxiety disorders: generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), simple phobia, panic disorder, and agoraphobia. Considerable evidence suggests that anxiety disorders remain underrecognized and undertreated despite their association with increased morbidity and severe functional impairment. Increasing evidence suggests that the onset, presentation, clinical course, and treatment response of anxiety disorders in women are often distinct from that associated with men. In addition, female reproductive hormone cycle events appear to have a significant influence on anxiety disorder onset, course, and risk of comorbid conditions throughout a woman's life. Further investigations concerning the unique features present in women with anxiety disorders are needed and may represent the best strategy to increase identification and optimize treatment interventions for women afflicted with these long-neglected psychiatric disorders.

Heightened embarrassability discriminates between panic disorder patients with and without agoraphobia

Embarrassability refers to an individual's general susceptibility to becoming embarrassed and is closely linked to another personality characteristic known as fear of negative evaluation. To find out if panic disorder patients with and without agoraphobia differ in terms of embarrassability and fear of negative evaluation 100 patients with a DSM-III-R diagnosis of panic disorder with agoraphobia, 30 patients with a DSM-III-R diagnosis of uncomplicated panic disorder and 80 controls were administered the Embarrassability Scale and the 12-item version of the Fear of Negative Evaluation Scale. Depressive mood in the clinical group was assessed with the help of the Beck Depression Inventory. Comparisons between these three groups, between patients with mild, moderate, and severe phobic avoidance and between male and female subjects were carried out. Patients with agoraphobic avoidance showed significantly higher scores on both scales than patients with uncomplicated panic disorder and controls and women generally showed higher embarrassability scores than men. We conclude that heightened embarrassability is an important characteristic of patients suffering from panic disorder with agoraphobia.

WCA recommendations for the long-term treatment of panic disorder

What are the symptoms of panic disorder and how is the disorder most effectively treated? One of the most commonly encountered anxiety disorders in the primary care setting, panic disorder is a chronic and debilitating illness. The core symptoms are recurrent panic attacks coupled with anticipatory anxiety and phobic avoidance, which together impair the patient's professional, social, and familial functioning. Patients with panic disorder have medically unexplained symptoms that lead to overutilization of healthcare services. Panic disorder is often comorbid with agoraphobia and major depression, and patients may be at increased risk of cardiovascular disease and, possibly, suicide. Research into the optimal treatment of this disorder has been undertaken in the past 2 decades, and numerous randomized, controlled trials have been published. Selective serotonin reuptake inhibitors have emerged as the most favorable treatment, as they have a beneficial side-effect profile, are relatively safe (even if taken in overdose), and do not produce physical dependency. High-potency benzodiazepines, reversible monoamine oxidase inhibitors, and tricyclic antidepressants have also shown antipanic efficacy. In addition, cognitive-behavioral therapy has demonstrated efficacy in the acute and long-term treatment of panic disorder. An integrated treatment approach that combines pharmacotherapy with cognitive-behavioral therapy may provide the best treatment. Long-term efficacy and ease of use are important considerations in treatment selection, as maintenance treatment is recommended for at least 12-24 months, and in some cases, indefinitely.

Association between estrus cycle-related changes in respiration and estrus cycle-related aggression in outbred female Wistar rats

Premenstrual dysphoric disorder is characterized by irritability surfacing during the luteal phase of the menstrual cycle, and disappearing shortly after the onset of menstruation. Although the cardinal symptoms of premenstrual dysphoria are different from those of panic disorder, the two conditions share a number of traits indicating that they both may be associated with abnormalities in the regulation of respiration. Both subjects with panic disorder and subjects with premenstrual dysphoria are hence reported to display enhanced respiratory variability, and to experience anxiety when exposed to CO(2). In the present study, the possible influence of the estrus cycle on respiratory parameters in outbred female rats of the Wistar strain was investigated. Before being tested with respect to respiration, the rats were subdivided into two groups: those displaying estrus cycle-related variation in aggression, as evaluated using the resident intruder paradigm, and those not showing aggression throughout the cycle. Whereas the former group was found to display higher respiratory rate during the diestrus phase than during the proestrus/estrus phase, no cycle-related variation in respiration was observed in animals not showing cycle-related variation in aggression. The results support previous studies indicating that the estrus cycle exerts an influence on respiration, and suggest that rats prone to cycle-related aggression are more sensitive also to the influence of hormonal cyclicity on respiration. The possible bearing of these findings for the aberration in respiration displayed by subjects with premenstrual dysphoria is discussed.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.

Longitudinal outcome with pharmacotherapy in a naturalistic study of panic disorder

BACKGROUND

Current recommendations suggest that pharmacotherapy for patients with panic disorder should be continued for at least 1 year [Am. J. Psychiatry 155 (1998) 1], despite a paucity of data systematically examining outcome for periods greater than 3-6 months. It is critically important to obtain more information on the effectiveness of medications over time for patients who initially responded to pharmacotherapy for panic disorder.

METHODS

Long-term outcome was examined for 78 patients who attained a 2-month period of sustained remission on medication and received maintenance pharmacotherapy for up to 24 months during the Massachusetts General Hospital Longitudinal Study of Panic Disorder, a prospective, naturalistic study. Participants were categorized by their maintenance treatment condition at remission: benzodiazepine alone (N = 45, 58%), antidepressant alone (N = 12, 16%), and combined treatment with a benzodiazepine and an antidepressant (N = 21, 27%).

RESULTS

Approximately half (N = 36, 46%) of the patients who had achieved remission relapsed at some time over the 2-year naturalistic study period, despite continued and adequate pharmacotherapy. There was no difference in timing or frequency of relapse by type of maintenance pharmacotherapy.

LIMITATIONS

Interpretation of the data is limited by the naturalistic nature of the study, and by the relatively low sample size.

CONCLUSIONS

This data suggests that patients with panic disorder have a high rate of relapse even after acute response to pharmacotherapy, despite continued treatment. In addition, the use of combined pharmacotherapy with antidepressants and benzodiazepines does not appear to provide greater protection from relapse than monotherapy.