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Javelot H, Weiner L, Hingray C, Freire RC, Nardi AE. COVID-19 and its psychological consequences: Beware of the respiratory subtype of panic disorder. Respir Physiol Neurobiol 2020; 282:103530. [PMID: 32818605 PMCID: PMC7431396 DOI: 10.1016/j.resp.2020.103530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/30/2022]
Abstract
COVID-19 could increase the rates of the respiratory subtype of panic disorder.
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Affiliation(s)
- Hervé Javelot
- Établissement Public De Santé Alsace Nord, Brumath, France, Laboratoire De Toxicologie Et Pharmacologie Neuro Cardiovasculaire, Université De Strasbourg, Strasbourg, France.
| | - Luisa Weiner
- Clinique De Psychiatrie, CHU De Strasbourg, France, Laboratoire De Psychologie Des Cognitions, Université De Strasbourg, Strasbourg, France
| | - Coraline Hingray
- Pôle Hospitalo-Universitaire De Psychiatrie d'Adultes Du Grand Nancy, Centre Psychothérapique De Nancy, Laxou, France, CHU De Nancy, Département De Neurologie, Nancy, France
| | - Rafael C Freire
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio De Janeiro, Rio De Janeiro, Brazil
| | - Antonio E Nardi
- Department of Psychiatry and Centre for Neuroscience Studies, Queen's University, Kingston, Canada
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2
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Javelot H, Weiner L. [Panic and pandemic: Review of the literature on the links between panic disorder and the SARS-CoV-2 epidemic]. Encephale 2020; 46:S93-S98. [PMID: 32507556 PMCID: PMC7241353 DOI: 10.1016/j.encep.2020.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/17/2020] [Indexed: 12/15/2022]
Abstract
L’état de panique associé à la pandémie liée au SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) incite à s’interroger sur les troubles anxieux que cette situation pourrait générer ou aggraver. Si la littérature a déjà fourni des projections généralistes en la matière, les données concrètes concernent à ce stage davantage le trouble de stress post-traumatique et le trouble obsessionnel compulsif, tandis que quelques évaluations s’intéressent au cadre nosographie du trouble anxieux généralisé. Le trouble panique ne se voit que peu ou pas cité et l’évocation de la « panique », au sens social, la supplante largement. Bien que d’une légitimité clinique encore débattue, le trouble panique qualifié de « respiratoire » pourrait se voir augmenter en nombre et/ou être intensifié chez les patients qui en présentent déjà. D’éventuelles situations co-morbides entre un tel trouble et la COVID-19 (coronavirus disease 2019) doivent inciter à certaines précautions en matière de prescriptions médicamenteuses, notamment en lien avec les traitements ou situations, sources d’hypokaliémie : (i) le salbutamol, source potentielle de surconsommation, notamment chez les patients anxieux ; (ii) l’infection par le SARS-CoV-2 et plus encore en cas de diarrhées et/ou vomissements. L’hypokaliémie est associée à un risque accru de torsade de pointe, il convient donc également d’être prudent en matière de prescription de psychotropes à risque : comme avec le citalopram et l’escitalopram, des antidépresseurs indiqués dans le trouble panique ou encore l’hydroxyzine, à visée anxiolytique. Ces données sont de nature à resituer l’importance de la prise en considération du trouble panique dans le cadre de la pandémie en cours.
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Affiliation(s)
- H Javelot
- Établissement Public de Santé Alsace Nord (EPSAN), Brumath, France; Laboratoire de toxicologie et pharmacologie neurocardiovasculaire, université de Strasbourg, Strasbourg, France.
| | - L Weiner
- Clinique de psychiatrie, CHU de Strasbourg, Strasbourg, France; Laboratoire de psychologie des cognitions, université de Strasbourg, Strasbourg, France
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Okuro RT, Freire RC, Zin WA, Quagliato LA, Nardi AE. Panic disorder respiratory subtype: psychopathology and challenge tests - an update. ACTA ACUST UNITED AC 2020; 42:420-430. [PMID: 32074230 PMCID: PMC7430397 DOI: 10.1590/1516-4446-2019-0717] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/01/2019] [Indexed: 02/06/2023]
Abstract
Panic disorder (PD) pathophysiology is very heterogeneous, and the discrimination of distinct subtypes could be very useful. A subtype based on respiratory symptoms is known to constitute a specific subgroup. However, evidence to support the respiratory subtype (RS) as a distinct subgroup of PD with a well-defined phenotype remains controversial. Studies have focused on characterization of the RS based on symptoms and response to CO2. In this line, we described clinical and biological aspects focused on symptomatology and CO2 challenge tests in PD RS. The main symptoms that characterize RS are dyspnea (shortness of breath) and a choking sensation. Moreover, patients with the RS tended to be more responsive to CO2 challenge tests, which triggered more panic attacks in this subgroup. Future studies should focus on discriminating respiratory-related clusters and exploring psychophysiological and neuroimaging outcomes in order to provide robust evidence to confirm RS as a distinct subtype of PD.
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Affiliation(s)
- Renata T Okuro
- Laboratório Pânico e Respiração, Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Rafael C Freire
- Laboratório Pânico e Respiração, Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Walter A Zin
- Instituto de Biofísica Carlos Chagas Filho, UFRJ, Rio de Janeiro, RJ, Brazil
| | - Laiana A Quagliato
- Laboratório Pânico e Respiração, Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Antonio E Nardi
- Laboratório Pânico e Respiração, Instituto de Psiquiatria (IPUB), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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Leibold NK, Schruers KR. Assessing Panic: Bridging the Gap Between Fundamental Mechanisms and Daily Life Experience. Front Neurosci 2018; 12:785. [PMID: 30459546 PMCID: PMC6232935 DOI: 10.3389/fnins.2018.00785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/10/2018] [Indexed: 12/16/2022] Open
Abstract
Panic disorder (PD) is one of the most common psychiatric disorders. Recurrent, unexpected panic attacks (PAs) are the primary symptom and strongly impact patients’ quality of life. Clinical manifestations are very heterogeneous between patients, emphasizing the need for a dimensional classification integrating various aspects of neurobiological and psychological circuits in line with the Research Domain Criteria (RDoC) proposed by the US National Institute of Mental Health. To go beyond data that can be collected in the daily clinical situation, experimental panic provocation is widely used, which has led to important insights into involved brain regions and systems. Genetic variants can determine the sensitivity to experimental models such as carbon dioxide (CO2) exposure and can increase the risk to develop PD. Recent developments now allow to better assess the dynamic course of PAs outside the laboratory in patients’ natural environment. This can provide novel insights into the underlying mechanisms and the influence of environmental factors that can alter gene regulation by changing DNA methylation. In this mini review, we discuss assessment of PAs in the clinic, in the laboratory using CO2 exposure, genetic associations, and the benefits of real-life assessment and epigenetic research.
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Affiliation(s)
- Nicole K Leibold
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, European Graduate School of Neuroscience, Maastricht University, Maastricht, Netherlands
| | - Koen R Schruers
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, European Graduate School of Neuroscience, Maastricht University, Maastricht, Netherlands.,Faculty of Psychology, Center for Experimental and Learning Psychology, University of Leuven, Leuven, Belgium
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Feldker K, Heitmann CY, Neumeister P, Brinkmann L, Bruchmann M, Zwitserlood P, Straube T. Cardiorespiratory concerns shape brain responses during automatic panic-related scene processing in patients with panic disorder. J Psychiatry Neurosci 2018; 43. [PMID: 29252163 PMCID: PMC5747532 DOI: 10.1503/jpn.160226] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Increased automatic processing of threat-related stimuli has been proposed as a key element in panic disorder. Little is known about the neural basis of automatic processing, in particular to task-irrelevant, panic-related, ecologically valid stimuli, or about the association between brain activation and symptomatology in patients with panic disorder. METHODS The present event-related functional MRI (fMRI) study compared brain responses to task-irrelevant, panic-related and neutral visual stimuli in medication-free patients with panic disorder and healthy controls. Panic-related and neutral scenes were presented while participants performed a spatially nonoverlapping bar orientation task. Correlation analyses investigated the association between brain responses and panic-related aspects of symptomatology, measured using the Anxiety Sensitivity Index (ASI). RESULTS We included 26 patients with panic disorder and 26 heatlhy controls in our analysis. Compared with controls, patients with panic disorder showed elevated activation in the amygdala, brainstem, thalamus, insula, anterior cingulate cortex and midcingulate cortex in response to panic-related versus neutral task-irrelevant stimuli. Furthermore, fear of cardiovascular symptoms (a subcomponent of the ASI) was associated with insula activation, whereas fear of respiratory symptoms was associated with brainstem hyperactivation in patients with panic disorder. LIMITATIONS The additional implementation of measures of autonomic activation, such as pupil diameter, heart rate, or electrodermal activity, would have been informative during the fMRI scan as well as during the rating procedure. CONCLUSION Results reveal a neural network involved in the processing of panic-related distractor stimuli in patients with panic disorder and suggest an automatic weighting of panic-related information depending on the magnitude of cardiovascular and respiratory symptoms. Insula and brainstem activations show function-related associations with specific components of panic symptomatology.
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Affiliation(s)
- Katharina Feldker
- Correspondence to: K. Feldker, Institute of Medical Psychology and Systems Neuroscience, Von-Esmarch-Straße 52, D-48149 Muenster, Germany;
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Ramos PS, Sardinha A, Nardi AE, de Araújo CGS. Cardiorespiratory optimal point: a submaximal exercise variable to assess panic disorder patients. PLoS One 2014; 9:e104932. [PMID: 25157496 PMCID: PMC4144853 DOI: 10.1371/journal.pone.0104932] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 07/15/2014] [Indexed: 11/20/2022] Open
Abstract
Panic disorder (PD) patients often report respiratory symptoms and tend to perform poorly during maximal cardiopulmonary exercise testing (CPX), at least partially, due to phobic anxiety. Thus, we hypothesized that a submaximal exercise variable, minimum VE/VO2 - hereafter named cardiorespiratory optimal point (COP) -, may be useful in their clinical assessment. Data from 2,338 subjects were retrospectively analyzed and 52 (2.2%) patients diagnosed with PD (PDG) (70% women; aged 48±13 years). PD patients were compared with a healthy control group (CG) precisely matched to number of cases, age and gender profiles. PDG was further divided into two subgroups, based on having achieved a maximal or a submaximal CPX (unwilling to continue until exhaustion). We compared COP, VO2 max, maximum heart rate (HR max) between PDG and CG, and also COP between maximal and submaximal PD subgroups. COP was similar between PDG and CG (21.9±0.5 vs. 23.4±0.6; p = 0.07), as well as, for PD subgroups of maximal and submaximal CPX (22.0±0.5 vs. 21.6±1.3; p = 0.746). Additionally, PD patients completing a maximal CPX obtained VO2 max (mL x kg-1 x min-1) (32.9±1.57 vs 29.6±1.48; p = 0.145) and HR max (bpm) similar to controls (173±2.0 vs 168±2.7; p = 0.178). No adverse complications occurred during CPX. Although clinically safe, it is sometimes difficult to obtain a true maximal CPX in PD patients. Normalcy of cardiorespiratory interaction at submaximal effort as assessed by COP may contribute to reassure both patients and physicians that there is no physiological substrate for exercise-related respiratory symptoms often reported by PD patients.
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Affiliation(s)
- Plínio Santos Ramos
- Exercise Medicine Clinic – CLINIMEX, Rio de Janeiro, Rio de Janeiro, Brazil
- Maternity Hospital Therezinha de Jesus, Faculty of Medical and Health Sciences – SUPREMA, Juiz de Fora, Minas Gerais, Brazil
| | - Aline Sardinha
- Panic and Respiration Laboratory, Institute of Psychiatry, Federal University of Rio de Janeiro, National Institute for Translational Medicine (INCT-TM/CNPq), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Egidio Nardi
- Panic and Respiration Laboratory, Institute of Psychiatry, Federal University of Rio de Janeiro, National Institute for Translational Medicine (INCT-TM/CNPq), Rio de Janeiro, Rio de Janeiro, Brazil
| | - Claudio Gil Soares de Araújo
- Exercise Medicine Clinic – CLINIMEX, Rio de Janeiro, Rio de Janeiro, Brazil
- Heart Institute Edson Saad, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Preter M, Klein DF. Lifelong opioidergic vulnerability through early life separation: a recent extension of the false suffocation alarm theory of panic disorder. Neurosci Biobehav Rev 2014; 46 Pt 3:345-51. [PMID: 24726574 DOI: 10.1016/j.neubiorev.2014.03.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 03/03/2014] [Accepted: 03/14/2014] [Indexed: 12/11/2022]
Abstract
The present paper is the edited version of our presentations at the "First World Symposium On Translational Models Of Panic Disorder", in Vitoria, E.S., Brazil, on November 16-18, 2012. We also review relevant work that appeared after the conference. Suffocation-False Alarm Theory (Klein, 1993) 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. The expanded Suffocation-False Alarm Theory (Preter and Klein, 2008) hypothesizes that endogenous opioidergic dysregulation may underlie the respiratory pathophysiology and suffocation sensitivity in panic disorder. Opioidergic dysregulation increases sensitivity to CO2, separation distress and panic attacks. That sudden loss, bereavement and childhood separation anxiety are also antecedents of "spontaneous" panic requires an integrative explanation. Our work unveiling the lifelong endogenous opioid system impairing effects of childhood parental loss (CPL) and parental separation in non-ill, normal adults opens a new experimental, investigatory area.
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Affiliation(s)
- Maurice Preter
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - Donald F Klein
- Phyllis Green and Randolph Cowen Institute for Pediatric Neuroscience, Department of Child and Adolescent Psychiatry, New York University Langone Medical Center, 550 1st Ave, New York, NY 10016, USA.
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Lehrer P, Buckman JF, Mun EY, Vaschillo EG, Vaschillo B, Udo T, Ray S, Nguyen T, Bates ME. Negative mood and alcohol problems are related to respiratory dynamics in young adults. Appl Psychophysiol Biofeedback 2013; 38:273-83. [PMID: 23975541 PMCID: PMC3854952 DOI: 10.1007/s10484-013-9230-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This study examined the relationship of negative affect and alcohol use behaviors to baseline respiration and respiratory response to emotional challenge in young adults (N = 138, 48 % women). Thoracic-to-abdominal ratio, respiratory frequency and variability, and minute volume ventilation were measured during a low-demand baseline task, and emotional challenge (viewing emotionally-valenced, emotionally-neutral, and alcohol-related pictures). Negative mood and alcohol problems principal components were generated from self-report measures of negative affect and mood, alcohol use, and use-related problems. The negative mood component was positively related to a thoracic bias when measured throughout the study (including baseline and picture exposure). There was generally greater respiratory activity in response to the picture cues, although not specifically in response to the content (emotional or alcohol-related) of the picture cues. The alcohol problems component was positively associated with respiratory reactivity to picture cues, when baseline breathing patterns were controlled. Self-report arousal data indicated that higher levels of negative mood, but not alcohol problems, were associated with greater arousal ratings overall. However, those with alcohol problems reported greater arousal to alcohol cues, compared to emotionally neutral cues. These results are consistent with theories relating negative affect and mood to breathing patterns as well as the relationship between alcohol problems and negative emotions, suggesting that the use of respiratory interventions may hold promise for treating problems involving negative affect and mood, as well as drinking problems.
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Affiliation(s)
- Paul Lehrer
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, 671 Hoes Lane, Piscataway, NJ, 08854, USA,
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