The diagnosis and treatment of generalized anxiety disorder

Neurochemical and genetic factors in panic disorder: a systematic review

This systematic review addresses the complex nature of Panic Disorder (PD), characterized by recurrent episodes of acute fear, with a focus on updating and consolidating knowledge regarding neurochemical, genetic, and epigenetic factors associated with PD. Utilizing the PRISMA methodology, 33 original peer-reviewed studies were identified, comprising 6 studies related to human neurochemicals, 10 related to human genetic or epigenetic alterations, and 17 animal studies. The review reveals patterns of altered expression in various biological systems, including neurotransmission, the Hypothalamic-Pituitary-Adrenal (HPA) axis, neuroplasticity, and genetic and epigenetic factors leading to neuroanatomical modifications. Noteworthy findings include lower receptor binding of GABAA and serotonin neurotransmitters in the amygdala. The involvement of orexin (ORX) neurons in the dorsomedial/perifornical region in triggering panic reactions is highlighted, with systemic ORX-1 receptor antagonists blocking panic responses. Elevated Interleukin 6 and leptin levels in PD patients suggest potential connections between stress-induced inflammatory changes and PD. Brain-derived neurotrophic factor (BDNF) and tyrosine receptor kinase B (TrkB) signaling are implicated in panic-like responses, particularly in the dorsal periaqueductal gray (dPAG), where BDNF's panicolytic-like effects operate through GABAA-dependent mechanisms. GABAergic neurons' inhibitory influence on dorsomedial and posterior hypothalamus nuclei is identified, potentially reducing the excitability of neurons involved in panic-like responses. The dorsomedial hypothalamus (DMH) is highlighted as a specific hypothalamic nucleus relevant to the genesis and maintenance of panic disorder. Altered brain lactate and glutamate concentrations, along with identified genetic polymorphisms linked to PD, further contribute to the intricate neurochemical landscape associated with the disorder. The review underscores the potential impact of neurochemical, genetic, and epigenetic factors on the development and expression of PD. The comprehensive insights provided by this systematic review contribute to advancing our understanding of the multifaceted nature of Panic Disorder and pave the way for targeted therapeutic strategies.

EFFECTS OF DEPRESSION, ANXIETY, OR LOW SELF-ESTEEM UPON GLYCEMIC VARIABILITY, IN DIABETIC PREGNANT VERSUS NON-PREGNANT PATIENTS

Objective

We analyzed the correlation between glycemic variability and psychological problems such as depression, anxiety disorder, and low self-esteem in pregnant and non-pregnant (excluding gestational diabetes) patients with diabetes. Besides its originality, this study might contribute to better / earlier diagnosis of these psychological conditions, with a special interest in pregnant diabetic women. Better management and cost reduction of care could be a consequence.

Methods

We compared diabetic pregnant and non-pregnant women from the perspective of the glycemic variability (for a period of 15 days prior inclusion in the study) and their results on the standardized questionnaires: Beck depression inventory, Hamilton anxiety scale - HRSA, Rosenberg self-esteem test.

Results and Conclusions

A statistically significant correlation was identified in both groups between the glycemic oscillation and depression, anxiety, and low self-esteem. Diabetic pregnant women had a higher statistical significance for the correlation between the glycemic oscillation and depression, as well as between the glycemic oscillation and anxiety than non-pregnant diabetic patients. The present data justify further research. Our results could be developed into a preliminary intervention protocol, using the daily glycemic values measurements, collected by patients.

[Treatment of diseases with consequences of traumatic brain injury]

Traumatic brain injury (TBI) is one of the leading causes of neurological morbidity, disability and mortality in all age groups of the population. As a result of the general increase in the number of cases of brain injuries, there is a significant increase in the consequences of TBI, the dominant part of which is asthenic, vegetative, cognitive, emotional and liquorodynamic disorders. Therapeutic measures in the long-term period of TBI should be carried out intensively as in the first 12 months. after TBI, and in the future, considering the ongoing processes of morphofunctional maturation of the CNS and high brain plasticity, especially in childhood. Syndromic treatment should be differentiated and pathogenetically substantiated. The article covers in detail the modern methods of drug therapy in patients with remote residual effects of brain injury. The high efficiency of the use of the neuroprotective drug Cortexin in the correction of the consequences of TBI was shown.

Effect of breathing exercises on respiratory indices and anxiety level in individuals with generalized anxiety disorder: a randomized double-blind clinical trial

[Purpose] The purpose of this study was to assess the efficacy of breathing exercises alongside traditional therapy on respiratory indexes and the level of anxiety of generalized anxiety disorder patients. [Participants and Methods] Forty-one patients were assigned a study group undergoing medication and routine counselling plus breathing exercises (EXS), and a control group received medication and routine counselling only (Non-EXS). Every two weeks, patients are called (weeks 2, 4, 6, and 8) to monitor their schedule adherence. [Results] This study’s results showed FEV1/FVC ratio significantly increased in the EXS group in the second study follow-up period after two months. Anxiety, FVC, FEV1, Etco2, respiration, and pulse rate over time have tended towards desirable results in the exercise group than control groups, especially after two months, but significant differences not seen. [Conclusion] This study’s findings indicated that breathing exercises could improve generalized anxiety disorder’s pharmacotherapy and psychotherapy. Our data bring up this hypothesis that longer follow up, increasing breathing period, and more exercising is associated with higher outcome.

The Effect of Group-Based Emotional Schema Therapy on Anxiety Sensitivity and Anxiety Severity in Outpatient Females with Generalized Anxiety Disorder

"Purpose: The aim of the present study was to examine the effectiveness of Group-Based Emotional Schema Therapy (GBEST) on anxiety sensitivity and anxiety severity decrease in females with Generalized Anxiety Disorder (GAD). Methods: This was a double-blind randomized experimental study that was carried out with three pretest, posttest, and follow-up stages within an experimental group and the control group. The participants were 50 outpatient females with GAD that they recruited by a random sampling method in each group. The Anxiety Sensitivity Index (ASI) and the Generalized Anxiety Disorder 7-Item Scale (GAD-7) were used in this study. The experimental group was imposed on the GBEST in 10 sessions which were held weekly for 90 minutes; finally, the post-test was applied to both experimental and control groups and three months later, they were followed up. Results: Findings showed that the experimental group had a significant decrease in anxiety sensitivity and anxiety severity compared with the control group during the post-test and the follow-up stages. Conclusions: The GBEST is recommended for the treatment of anxiety sensitivity and anxiety severity in females with GAD."

Influence of Simvastatin as Augmentative Therapy in the Treatment of Generalized Anxiety Disorder: A Pilot Randomized, Placebo-Controlled Study

BACKGROUND

Preliminary evidence is promising regarding the anxiolytic effects of statins in animal models of anxiety. Hence, this study aimed to evaluate the efficacy of simvastatin augmentation versus placebo in the treatment of patients with generalized anxiety disorder (GAD) with residual symptoms despite treatment with selective serotonin reuptake inhibitors (SSRIs).

METHODS

A double-blind, 8-week controlled trial was conducted from August 2018 to December 2019 in an outpatient psychiatry clinic in Hamadan, Iran. A total of 138 patients with a diagnosis of GAD were assessed for eligibility. Of them, 84 patients who met the study criteria were randomly assigned either to the adjuvant simvastatin (20 mg/day) or to the placebo group. Standard medication consisting of SSRIs was consistent 2 months prior to and during the study. The severity of anxiety symptoms for each patient was assessed based on the Hamilton Anxiety Rating Scale (HAM-A) score at baseline, week 4, and week 8 after treatment. Additionally, blood lipid values were assessed at baseline and on completion of the study.

RESULTS

Thirty-three out of 42 patients in the intervention group and 35 out of 42 patients in the control group completed the 8 weeks of the study period. Compared to the placebo group, in the simvastatin group cholesterol, triglycerides, and low-density lipoprotein significantly decreased, and high-density lipoprotein significantly increased over time. General linear model analysis demonstrated that although over time a higher decrease in mean HAM-A scores was observed in the intervention group compared to the control group, this difference was not statistically significant (p = 0.11). In addition, at the end of the study, the number of responders and remitters was comparable in the two groups.

CONCLUSIONS

The results from this clinical study did not support the potential efficacy of adjunctive simvastatin in the treatment of patients with GAD. Thus, large-scale and long-term clinical trials are required to more accurately assess the potential efficacy of statins in the treatment of patients with anxiety disorders.

A Three-Arm Randomized Clinical Trial Comparing the Efficacy of a Mindfulness-Based Intervention with an Active Comparison Group and Fluoxetine Treatment for Adults with Generalized Anxiety Disorder

INTRODUCTION

Mindfulness-based interventions have been studied as an alternative treatment for anxiety disorders, but there are only a few studies comparing these with established treatments.

OBJECTIVE

To evaluate the efficacy of a Body in Mind Training (BMT) program for adults with generalized anxiety disorder (GAD), an active comparison protocol called Quality of Life and Psychoeducation (QoL), and treatment with fluoxetine (FLX).

METHODS

This study comprises a 3-arm parallel-group, randomized clinical trial (ClinicalTrials.gov ID: NCT03072264). Adults with a primary diagnosis of GAD and no current treatment were recruited from the community and randomized in a ratio 1:1:1. The primary outcomes were assessed by means of the Hamilton Anxiety Rating Scale (HAM-A) and the Penn State Worry Questionnaire (PSWQ) at week 8. Data were analyzed using a superiority analysis (BMT vs. QoL) and a noninferiority analysis (BMT vs. FLX).

RESULTS

A total of 249 participants were included and 223 were analyzed (76 BMT, 79 FLX, and 68 QoL). All groups improved after intervention. However, BMT was not superior to QoL at week 8 (mean difference = -1.36; p = 0.47), nor was it noninferior to FLX as assessed with theHAM-A (mean difference = 3.5; 95% CI -0.06 to 7.06; noninferiority margin = -2.43; p = 0.054). QoL (mean difference = 3.54; p = 0.04) and FLX (mean difference = -7.72; 95% CI -10.89 to -4.56; noninferiority margin = -2.09; p < 0.001) were superior to BMT in reducing PSWQ score.

CONCLUSION

Our data suggest that BMT, in its current format, cannot be considered an effective mindfulness protocol to improve GAD.

THE RELATIONSHIP BETWEEN DEPRESSION, ANXIETY DISORDER AND LOW SELF-ESTEEM IN REGARD TO GLYCEMIC VARIABILITY IN DIABETIC PATIENTS

OBJECTIVE

We analyzed the possible correlation between glycemic variability and psychological disorders such as depression, anxiety disorder, and low self-esteem, in diabetic patients. These correlations are relevant, as they consume a large number of resources. Their better understanding can increase the effectiveness of incident reduction techniques and could provide better management and cost reduction of care.

METHODS

We compared the relationships between the glycemic variability (for a period of 10 days prior to completing the depression questionnaire) and the results of two standardized questionnaires: Hamilton anxiety scale - HRSA (group 1: 500 patients), Rosenberg self-esteem test (group 2: 490 patients) and Beck depression inventory (both groups).

RESULTS

A statistically significant correlation was identified between the glycemic oscillation and depression as well as both anxiety and low self-esteem. The present data justify further research. Our results could be developed into a preliminary intervention protocol, using the daily glycemic values measurements, collected by patients. In conclusion, psychometric tests could be an important instrument in the management of diabetic patients.

Efficacy and Safety of Escitalopram Oral Drops to Treat Major Depressive Disorder and Generalized Anxiety Disorder in Adolescent, Adult and Geriatric Patients: A Prospective Multicenter Observational Study in Pakistan

Background 

Escitalopram is widely used for the management of the major depressive disorder and generalized anxiety disorder, but there is no to very limited data available regarding efficacy and safety in Pakistani patients. This study was conducted to evaluate the efficacy and safety of escitalopram oral drops to manage the major depressive disorder and generalized anxiety disorder in a local cluster within Pakistan.

Methods

This prospective multicenter observational study was conducted in the department of psychiatry from August 2018 - August 2019. Eighty-five patients meeting the selection criteria were included in the study. Adolescent, adult, and geriatric patients of either gender with generalized anxiety disorder having Hamilton Anxiety Rating Scale (HAM-A) rate ≥ 10 and major depressive disorder having Montgomery-Asberg Depression Rating Scale (MADRS) rate ≥ 7 or patients with co-morbid generalized anxiety disorder (GAD), major depressive disorder (MDD) were selected for the study. We are reporting patients’ improvement from baseline, response rate, and remission rate. Data analysis is performed by using SPSS version 21 (IBM Inc, Armonk, USA).

Results

Among enrolled patients, 42 were adolescents, 22 were adults, and 21 were geriatric. The mean age of an adolescent, adult, and geriatric patients was 14.92 ± 2.04, 44.54 ± 12.08, and 64.61 ± 3.16 years, respectively. Among enrolled patients, the mean change in a total score of HAM-A for anxiety and MADRS for depression were -10.04 ± 4.32 and -17.67 ± 14.42, respectively. At the end of the study, the remission rate and response rate for depression were 82 % and 75%, respectively. Similarly, the remission rate and the response for anxiety were 76% and 81%, respectively. Mean HAM-A and MADRS scores were significantly improved for adolescent, adult, and geriatric patients. Adverse events were reported in eight (9.41%) patients with six having gastrointestinal (GI) disturbance and two having to worsen anxiety. All reported adverse events were of mild severity. 

Conclusion 

Escitalopram oral drops are found effective and tolerable in reducing both anxiety and depression over the duration of study in all age groups, including adolescents, adults, and geriatrics.

Efficacy of venlafaxine extended release in major depressive disorder patients: effect of baseline anxiety symptom severity

Effects of baseline anxiety on the efficacy of venlafaxine extended release versus placebo were examined in a post hoc pooled subgroup analysis of 1573 patients enrolled in eight short-term studies of major depressive disorder. Anxiety subgroups were defined based on baseline 17-item Hamilton Rating Scale for Depression Item 10 score <3 (low) versus ≥3 (high). Change from baseline to final visit in Montgomery-Åsberg Depression Rating Scale total score and Montgomery-Åsberg Depression Rating Scale response and remission rates were analyzed. Change from baseline in Montgomery-Åsberg Depression Rating Scale total score and response and remission rates was significantly greater for venlafaxine extended release versus placebo in both low and high anxiety subgroups (all P < 0.0001). A statistically significant baseline anxiety by treatment interaction was observed for Montgomery-Åsberg Depression Rating Scale total score only (P = 0.0152). The adjusted mean change from baseline in Montgomery-Åsberg Depression Rating Scale total score was significantly greater in the high anxiety subgroup versus low anxiety subgroup for patients treated with venlafaxine extended release (-6.27 versus -3.89; P = 0.0440) but not placebo. These results support the efficacy of venlafaxine extended release for major depressive disorder treatment in patients with anxiety symptoms.

Audio Recording for Independent Confirmation of Clinical Assessments in Generalized Anxiety Disorder

Objective: The assessment of patients with generalized anxiety disorder (GAD) to deteremine whether a medication intervention is necessary is not always clear and might benefit from a second opinion. However, second opinions are time consuming, expensive, and not practical in most settings. We obtained independent, second opinion reviews of the primary clinician's assessment via audio-digital recording. Design: An audio-digital recording of key site-based assessments was used to generate site-independent "dual" reviews of the clinical presentation, symptom severity, and medication requirements of patients with GAD as part of the screening procedures for a clinical trial (ClinicalTrials.gov: NCT02310568). Results: Site-independent reviewers affirmed the diagnosis, symptom severity metrics, and treatment requirements of 90 moderately ill patients with GAD. The patients endorsed excessive worry that was hard to control and essentially all six of the associated DSM-IV-TR anxiety symptoms. The Hamilton Rating Scale for Anxiety scores revealed moderately severe anxiety with a high Pearson's correlation (r=0.852) between site-based and independent raters and minimal scoring discordance on each scale item. Based upon their independent reviews, these "second" opinions confirmed that these GAD patients warranted a new medication intervention. Thirty patients (33.3%) reported a previous history of a major depressive episode (MDE) and had significantly more depressive symptoms than patients without a history of MDE. Conclusion: The audio-digital recording method provides a useful second opinion that can affirm the need for a different treatment intervention in these anxious patients. A second live assessment would have required additional clinic time and added patient burden. The audio-digital recording method is less burdensome than live second opinion assessments and might have utility in both research and clinical practice settings.

Generalized Anxiety Disorder and Hypoglycemia Symptoms Improved with Diet Modification

Observational evidence suggests that a relationship may exist between high glycemic index diets and the development of anxiety and depression symptoms; however, as no interventional studies assessing this relationship in a psychiatric population have been completed, the possibility of a causal link is unclear. AB is a 15-year-old female who presented with concerns of generalized anxiety disorder and hypoglycemia symptoms. Her diet consisted primarily of refined carbohydrates. The addition of protein, fat, and fiber to her diet resulted in a substantial decrease in anxiety symptoms as well as a decrease in the frequency and severity of hypoglycemia symptoms. A brief return to her previous diet caused a return of her anxiety symptoms, followed by improvement when she restarted the prescribed diet. This case strengthens the hypothesis that dietary glycemic index may play a role in the pathogenesis or progression of mental illnesses such as generalized anxiety disorder and subsequently that dietary modification as a therapeutic intervention in the treatment of mental illness warrants further study.

Buspirone for management of dyspnea in cancer patients receiving chemotherapy: a randomized placebo-controlled URCC CCOP study

PURPOSE

Cancer-related dyspnea is a common, distressing, and difficult-to-manage symptom in cancer patients, resulting in diminished quality of life and poor prognosis. Buspirone, a non-benzodiazepine anxiolytic which does not suppress respiration and has proven efficacy in the treatment of generalized anxiety disorder, has been suggested to relieve the sensation of dyspnea in patients with COPD. The main objective of our study was to evaluate whether buspirone alleviates dyspnea in cancer patients.

METHODS

We report on a randomized, placebo-controlled trial of 432 patients (mean age 64, female 51%, lung cancer 62%) from 16 participating Community Clinical Oncology Program (CCOP) sites with grade 2 or higher dyspnea, as assessed by the Modified Medical Research Council Dyspnea Scale. Dyspnea was assessed by the Oxygen Cost Diagram (OCD; higher scores are better) and anxiety by the state subscale of the State-Trait Anxiety Inventory (STAI-S; lower scores are better) at baseline and after the 4-week intervention (post-intervention).

RESULTS

Mean scores from baseline to post-intervention for buspirone were OCD 8.7 to 9.0 and STAI-S 40.5 to 40.1 and for placebo were OCD 8.4 to 9.3 and STAI-S 40.9 to 38.6 with raw improvements over time on both measures being greater in the placebo group. Analysis of covariance (ANCOVA) controlling for baseline scores showed no statistically significant difference between groups for OCD (P = 0.052) or STAI-S (P = 0.062).

CONCLUSION

Buspirone did not result in significant improvement in dyspnea or anxiety in cancer patients. Thus, buspirone should not be recommended as a pharmacological option for dyspnea in cancer patients.

Mice deficient in phosphodiesterase-4A display anxiogenic-like behavior

RATIONALE

Phosphodiesterases (PDEs) are a super family of enzymes responsible for the halting of intracellular cyclic nucleotide signaling and may represent novel therapeutic targets for treatment of cognitive disorders. PDE4 is of considerable interest to cognitive research because it is highly expressed in the brain, particularly in the cognition-related brain regions. Recently, the functional role of PDE4B and PDE4D, two of the four PDE4 subtypes (PDE4A, B, C, and D), in behavior has begun to be identified; however, the role of PDE4A in the regulation of behavior is still unknown.

OBJECTIVES

The purpose of this study was to characterize the functional role of PDE4A in behavior.

METHODS

The role of PDE4A in behavior was evaluated through a battery of behavioral tests using PDE4A knockout (KO) mice; urine corticosterone levels were also measured.

RESULTS

PDE4A KO mice exhibited improved memory in the step-through-passive-avoidance test. They also displayed anxiogenic-like behavior in elevated-plus maze, holeboard, light-dark transition, and novelty suppressed feeding tests. Consistent with the anxiety profile, PDE4A KO mice had elevated corticosterone levels compared with wild-type controls post-stress. Interestingly, PDE4A KO mice displayed no change in object recognition, Morris water maze, forced swim, tail suspension, and duration of anesthesia induced by co-administration of xylazine and ketamine (suggesting that PDE4A KO may not be emetic).

CONCLUSIONS

These results suggest that PDE4A may be important in the regulation of emotional memory and anxiety-like behavior, but not emesis. PDE4A could possibly represent a novel therapeutic target in the future for anxiety or disorders affecting memory.

A case of anxiety associated with miliary tuberculosis

Miliary tuberculosis (TB) is a serious infection with various presentations that can perplex even the most experienced clinicians. To our knowledge, there is a lack of published reports that link psychiatric symptoms directly with miliary TB (either alone or co-occurring with other medical symptoms). Mental health workers may, therefore, not consider, and consequently miss, this important diagnosis. Here we are reporting a case of cyclical anxiety occurring in a 67-year-old patient. For 3 years prior to admission, the patient failed to respond to multiple courses of different antianxiety medications. The patient required hospital admission as he deteriorated and had a reduced level of consciousness. A chest X-ray revealed bilateral nodules and a magnetic resonance imaging scan showed multiple enhancing tuberculous lesions in the cerebral white matter, brain stem, and cerebellum. A diagnosis of miliary TB was finally made. Several characteristics of this case suggest that the diagnosed anxiety disorder was due to miliary TB. However, we cannot exclude the possibility that generalized anxiety disorder preceded the onset of miliary TB or that both diseases were coincidental. The report serves as a reminder that organic causes for psychiatric symptoms always need to be considered, particularly if they follow an atypical pattern or fail to improve with usual psychiatric medications.

The diagnosis of and treatment recommendations for anxiety disorders

BACKGROUND

Anxiety disorders (panic disorder/agoraphobia, generalized anxiety disorder, social phobia, and specific phobias) are the most common mental illnesses. For example, the 12-month prevalence of panic disorder/agoraphobia is 6%.

METHOD

This guideline is based on controlled trials of psychotherapy and pharmacotherapy, retrieved by a systematic search for original articles that were published up to 1 July 2013. Experts from 20 specialty societies and other organizations evaluated the evidence for each treatment option from all available randomized clinical trials and from a synthesis of the recommendations of already existing international and German guidelines.

RESULTS

403 randomized controlled trials were evaluated. It was concluded that anxiety disorders should be treated with psychotherapy, psychopharmacological drugs, or both. Response rates to initial treatment vary from 45% to 65%. Cognitive behavioral therapy is supported by higher-level evidence than any other psychotherapeutic technique. Psychodynamic therapy is recommended as a second-line treatment. Among anxiolytic drugs, the agents of first choice are selective serotonin reuptake inhibitors and serotoninnorepinephrine reuptake inhibitors. The patient's preference should be considered in the choice of treatment. Drug treatment should be continued for 6 to 12 months after remission. If psychotherapy or drug treatment is not adequately effective, then the treatment should be switched to the other form, or to a combination of both.

CONCLUSION

The large amount of data now available from randomized controlled trials permits the formulation of robust evidence-based recommendations for the treatment of anxiety disorders. Future work should more closely address the necessary duration of psychotherapy and the efficacy of combined psychotherapy and drug treatment.