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Papp LA, Imre S, Bálint I, Lungu AI, Mărcutiu PE, Papp J, Ion V. Is it Time to Migrate to Liquid Chromatography Automated Platforms in the Clinical Laboratory? A Brief Point of View. J Chromatogr Sci 2024; 62:191-200. [PMID: 36715315 DOI: 10.1093/chromsci/bmad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/28/2022] [Indexed: 01/31/2023]
Abstract
Liquid chromatography coupled to mass spectrometry already started to surpass the major drawbacks in terms of sensitivity, specificity and cross-reactivity that some analytical methods used in the clinical laboratory exhibit. This hyphenated technique is already preferred for specific applications while finding its own place in the clinical laboratory setting. However, large-scale usage, high-throughput analysis and lack of automation emerge as shortcomings that liquid chromatography coupled to mass spectrometry still has to overrun in order to be used on a larger scale in the clinical laboratory. The aim of this review article is to point out the present-day position of the liquid chromatography coupled to mass spectrometry technique while trying to understand how this analytical method relates to the basic working framework of the clinical laboratory. This paper offers insights about the main regulation and traceability criteria that this coupling method has to align and comply to, automation and standardization issues and finally the critical steps in sample preparation workflows all related to the high-throughput analysis framework. Further steps are to be made toward automation, speed and easy-to-use concept; however, the current technological and quality premises are favorable for chromatographic coupled to mass spectral methods.
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Affiliation(s)
- Lajos-Attila Papp
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Public Health Department Mures, Gheorghe Marinescu street 40, 540136 Targu Mures, Romania
| | - Silvia Imre
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
| | - István Bálint
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Public Health Department Mures, Gheorghe Marinescu street 40, 540136 Targu Mures, Romania
| | - Andreea-Ioana Lungu
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Public Health Department Mures, Gheorghe Marinescu street 40, 540136 Targu Mures, Romania
| | - Petra-Edina Mărcutiu
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Public Health Department Mures, Gheorghe Marinescu street 40, 540136 Targu Mures, Romania
| | - Júlia Papp
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Public Health Department Mures, Gheorghe Marinescu street 40, 540136 Targu Mures, Romania
| | - Valentin Ion
- Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
- Center for Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology from Targu Mures, Gheorghe Marinescu street 38, 540142 Targu Mures, Romania
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Papp LA, Hancu G, Szabó ZI. Simultaneous determination of enantiomeric and organic impurities of vildagliptin on a cellulose tris(3-chloro-4-methylphenylcarbamate) column under revered-phase conditions. J Pharm Biomed Anal 2023; 234:115495. [PMID: 37343452 DOI: 10.1016/j.jpba.2023.115495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/27/2023] [Accepted: 05/28/2023] [Indexed: 06/23/2023]
Abstract
A new, reversed-phase HPLC (RP-HPLC) method was developed for the simultaneous determination of the dipeptidyl-peptidase-IV-inhibitor antidiabetic drug vildagliptin (VIL) enantiomeric impurity and four other achiral related impurities. An initial screening was performed on five polysaccharide-type chiral stationary phases (Lux Amylose-1, Lux Amylose-2, Lux-Cellulose-1, Lux-Cellulose-2, Lux-Cellulose-3) in polar organic mode with methanol, ethanol, 2-propanol, or acetonitrile containing 0,1% diethylamine as mobile phase to identify the best conditions for the separation of VIL enantiomers. Lux-Cellulose-2 column was found to provide the best chiral resolution for VIL enantiomers. Further experiments were conducted using different aqueous-organic mobile phases to achieve the simultaneous chiral-achiral separation of the selected compounds. Experimental design-based optimization was performed by using a face-centered central composite design. The optimal separation conditions (Lux Cellulose-2 stationary phase, 45 °C, mobile phase consisting of methanol/water/diethylamine 80:20:0.2 (v/v/v), and 0.45 mL/min flow rate) provided baseline separation for all 6 compounds. The optimized method was validated according to the ICH guideline and proved to be reliable, specific, linear, precise, and accurate for the determination of at least 0.1% for all impurities in VIL samples. The validated method was applied for determinations from a commercially available drug formulation and proved to be suitable for routine quality control of both enantiomeric and organic impurities of VIL.
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Affiliation(s)
- Lajos-Attila Papp
- Department of Pharmaceutical and Therapeutic Chemistry, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, 540142 Târgu Mureș, Romania
| | - Gabriel Hancu
- Department of Pharmaceutical and Therapeutic Chemistry, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, 540142 Târgu Mureș, Romania.
| | - Zoltán-István Szabó
- Department of Drugs Industry and Pharmaceutical Management, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, 540142 Târgu Mureș, Romania
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Orlandini S, Hancu G, Szabó ZI, Modroiu A, Papp LA, Gotti R, Furlanetto S. New Trends in the Quality Control of Enantiomeric Drugs: Quality by Design-Compliant Development of Chiral Capillary Electrophoresis Methods. Molecules 2022; 27:molecules27207058. [PMID: 36296650 PMCID: PMC9607418 DOI: 10.3390/molecules27207058] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/14/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Capillary electrophoresis (CE) is a potent method for analyzing chiral substances and is commonly used in the enantioseparation and chiral purity control of pharmaceuticals from different matrices. The adoption of Quality by Design (QbD) concepts in analytical method development, optimization and validation is a widespread trend observed in various analytical approaches including chiral CE. The application of Analytical QbD (AQbD) leads to the development of analytical methods based on sound science combined with risk management, and to a well understood process clarifying the influence of method parameters on the analytical output. The Design of Experiments (DoE) method employing chemometric tools is an essential part of QbD-based method development, allowing for the simultaneous evaluation of experimental parameters as well as their interaction. In 2022 the International Council for Harmonization (ICH) released two draft guidelines (ICH Q14 and ICH Q2(R2)) that are intended to encourage more robust analytical procedures. The ICH Q14 guideline intends to harmonize the scientific approaches for analytical procedures’ development, while the Q2(R2) document covers the validation principles for the use of analytical procedures including the recent applications that require multivariate statistical analyses. The aim of this review is to provide an overview of the new prospects for chiral CE method development applied for the enantiomeric purity control of pharmaceuticals using AQbD principles. The review also provides an overview of recent research (2012–2022) on the applicability of CE methods in chiral drug impurity profiling.
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Affiliation(s)
- Serena Orlandini
- Department of Chemistry “U. Schiff”, University of Florence, 50019 Florence, Italy
| | - Gabriel Hancu
- Department of Pharmaceutical and Therapeutic Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, 540139 Târgu Mureș, Romania
- Correspondence:
| | - Zoltán-István Szabó
- Department of Pharmaceutical Industry and Management, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, 540139 Târgu Mureș, Romania
| | - Adriana Modroiu
- Department of Pharmaceutical and Therapeutic Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, 540139 Târgu Mureș, Romania
| | - Lajos-Attila Papp
- Department of Pharmaceutical and Therapeutic Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, 540139 Târgu Mureș, Romania
| | - Roberto Gotti
- Department of Pharmacy and Biotechnology, University of Bologna, 40126 Bologna, Italy
| | - Sandra Furlanetto
- Department of Chemistry “U. Schiff”, University of Florence, 50019 Florence, Italy
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Klelemen H, Hancu G, Kacsó E, Papp LA. Photosensitivity Reactions Induced by Photochemical Degradation of Drugs. Adv Pharm Bull 2021; 12:77-85. [PMID: 35517884 PMCID: PMC9012926 DOI: 10.34172/apb.2022.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 04/18/2021] [Accepted: 05/28/2021] [Indexed: 11/14/2022] Open
Abstract
Photochemical degradation of drugs can lead to degradation products with potential toxic or allergizing effects for the human body. A significant amount of work has been carried out over the past few decades to clarify the molecular mechanism of photosensitizing processes observed after the administration of certain drugs and exposure to light. There is a close relation between the photosensitizer effect of a drug and its chemical structure. Compounds possessing certain moieties and functional groups in their molecular structure, like aromatic chromophore systems or photo-dissociable bonds that can form free radicals, and consequently are susceptible to have light-induced adverse effects. Photoionization, photodissociation, photoaddition and photoisomerization are the main chemical processes, which can occur during the photochemical decomposition of a pharmaceutical compound. The current study is a short review describing photochemical degradation of certain pharmaceuticals, presenting specific examples from various pharmaceutical classes for the different types of decomposition mechanisms. In vivo methods and clinical tests available for the investigation of photosensitizing reactions are also discussed.
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Affiliation(s)
- Hajnal Klelemen
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Târgu Mureș, Romania
| | - Gabriel Hancu
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Târgu Mureș, Romania
| | - Edina Kacsó
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Târgu Mureș, Romania
| | - Lajos-Attila Papp
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Medicine, Pharmacy, Science and Technology “George Emil Palade” of Târgu Mureș, Târgu Mureș, Romania
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Martinez JM, Kent JM, Coplan JD, Browne ST, Papp LA, Sullivan GM, Kleber M, Perepletchikova F, Fyer AJ, Klein DF, Gorman JM. Respiratory variability in panic disorder. Depress Anxiety 2002; 14:232-7. [PMID: 11754131 DOI: 10.1002/da.1072] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Disordered breathing may play an important role in the pathophysiology of panic disorder. Several studies have now indicated that panic disorder patients have greater respiratory variability than normal controls. In this study, we examine baseline respiratory measures in four diagnostic groups to determine whether greater respiratory variability is specific to panic disorder and whether effective anti-panic treatment alters respiratory variability. Patients with panic disorder, major depression, or premenstrual dysphoric disorder, and normal control subjects underwent two respiratory exposures (5% and 7% CO(2) inhalation), while in a canopy system. Panic disorder patients returned after 12 weeks of either anti-panic medication or cognitive behavioral therapy, and were retested. Normal control subjects were also retested after a period of 12 weeks. Panic disorder patients had significantly greater respiratory variability at baseline than normal control subjects and patients with major depression. The premenstrual dysphoric patients also had greater variability than the normal control group. Panic disorder patients who panicked to 7% CO(2) inhalation had significantly greater baseline variability than panic disorder patients who did not panic. Anti-panic treatment did not significantly alter baseline respiratory variability. Our data suggest that increased respiratory variability may be an important trait feature for some panic disorder patients and may make them more vulnerable to CO(2)-induced panic.
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Affiliation(s)
- J M Martinez
- Department of Psychiatry, Columbia University, New York, New York 10032, USA.
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Goetz RR, Klein DF, Papp LA, Martinez JM, Gorman JM. Acute panic inventory symptoms during CO(2) inhalation and room-air hyperventilation among panic disorder patients and normal controls. Depress Anxiety 2002; 14:123-36. [PMID: 11668665 DOI: 10.1002/da.1054] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
There is scant literature on anxiety symptoms induced during respiratory challenges developed to induce panic symptoms and attacks. Here we report on the prevalence of Acute Panic Inventory (API) symptoms during three consecutive respiratory challenges to patients with panic disorder (PD) and normal controls (NC). The challenges performed using a closed canopy system included voluntary room air hyperventilation (RAH), inhalation of 5% CO(2), and 7% CO(2)-enriched air. The PD patients were 41 men and 53 women whose mean age was 33.4 (SD = 8.55). The normal comparison group consisted of 35 men and 27 women with a mean age of 31.3 (SD = 9.21). The diagnosis of panic disorder was made using the Structured Clinical Interview for DSM-III-R. All potential normal controls underwent structured clinical interview using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA), and must have been free of a lifetime history of anxiety disorders, affective disorders, substance use disorders, and schizophrenia. All participants also had a complete medical evaluation and were in good health. The experiment consisted of seven experimental epochs: three baseline/recovery periods each followed by a respiratory challenge, and then a final recovery epoch. The API was administered at the end of each epoch. Clinical staff trained and experienced in rating panic attacks rated participants' response during each challenge as panic or no panic. Three groups were defined for analysis: PD patients who panicked, PD patients who did not panic, and NC who did not panic. Staff ratings indicated that the 7% CO(2) challenge was the most panicogenic, followed by the 5% CO(2), and the RAH challenges. Conventional statistics (analysis of variance and partial correlations) indicated that many baseline symptoms as well as symptom increments differed across groups, and were associated with the outcome of panic/no panic during each challenge. However, logistic regression analysis indicated that only a few symptoms independently predicted the panic/no panic outcome because many symptoms were redundant. The symptom cluster of fear in general, dizziness, difficulties with concentrating, and doing one's job predicted panic to RAH. The cluster of fear in general, confusion, dyspnea, and twitching/trembling predicted the response to 5% CO(2). Finally, fear in general, confusion, twitching/ trembling and dizziness predicted the response to 7% CO(2). While univariate analyses indicated that many symptoms distinguished between panic and no panic outcome, logistic regression revealed that group differences were subsumed under a few prominent symptoms, namely, fear in general, confusion, dizziness, twitching/trembling, and dyspnea. The results are discussed in the context of patient (having a diagnosis of PD) and panic effects (rated as panicking to a challenge).
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Affiliation(s)
- R R Goetz
- Department of Clinical Psychobiology, New York State Psychiatric Institute, New York, New York 10032, USA
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Abstract
Patients with depression almost always suffer from comorbid anxiety or anxiety disorder. It is commonly stated that comorbid depression and anxiety has a worse prognosis, even with adequate therapy, than depression alone. An accumulation of data now make clear that the antidepressants venlafaxine and venlafaxine XR are effective in reducing anxiety in patients with depression. Several of the studies supporting this are reviewed here. Venlafaxine and venlafaxine XR have also been shown to be effective in treating anxiety disorders and venlafaxine XR is presently the only antidepressant approved by the FDA for the specific treatment of generalized anxiety disorder. The effectiveness of venlafaxine in treating anxiety associated with depression and anxiety disorders supports theories implicating abnormal noradrenergic activity as a component of pathological anxiety.
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Affiliation(s)
- J M Gorman
- Department of Psychiatry, Columbia University, New York, New York 10032, USA
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Gorman JM, Kent J, Martinez J, Browne S, Coplan J, Papp LA. Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: evidence for a central fear mechanism. Arch Gen Psychiatry 2001; 58:125-31. [PMID: 11177114 DOI: 10.1001/archpsyc.58.2.125] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Inhalation of carbon dioxide (CO(2)) has been shown to produce more anxiety in patients with panic disorder (PD) than in healthy comparison subjects or patients with most other psychiatric illnesses tested, although premenstrual dysphoric disorder (PMDD) may be an exception. Several reasons have been proposed to explain CO(2) breathing effects in PD. We examined differences in respiratory response to CO(2) breathing in 4 groups to address these issues. METHODS Patients with PD (n = 52), healthy controls (n = 32), patients with PMDD (n = 10), and patients with major depression without panic (n = 21) were asked to breathe 5% and 7% CO(2). Continuous measures of respiratory physiological indices were made. RESULTS Carbon dioxide breathing produced the expected increases in all 4 respiratory variables measured. More patients with PD and PMDD had panic attacks than did controls or patients with major depression. Subjects who experienced panic during 5% or 7% CO(2) inhalation had the most extreme increases regardless of diagnostic group. Among patients with PD, baseline end-tidal carbon dioxide levels were significantly lower in those who subsequently had a panic attack during 5% CO(2) breathing than those who did not. CONCLUSIONS Although CO(2) breathing causes a higher rate of panic attacks in patients with PD than other groups (except PMDD), the physiological features of a panic attack appear similar across groups. Once a panic attack is triggered, minute ventilation and respiratory rate increase regardless of whether the subject carries a PD diagnosis. These findings are compatible with preclinical fear conditioning models of anxiogenesis.
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Affiliation(s)
- J M Gorman
- Department of Psychiatry, Columbia University, 1051 Riverside Dr, Unit 32, New York, NY 10032, USA
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Kent JM, Papp LA, Martinez JM, Browne ST, Coplan JD, Klein DF, Gorman JM. Specificity of panic response to CO(2) inhalation in panic disorder: a comparison with major depression and premenstrual dysphoric disorder. Am J Psychiatry 2001; 158:58-67. [PMID: 11136634 DOI: 10.1176/appi.ajp.158.1.58] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The behavioral response to CO(2) inhalation has been used to differentiate panic disorder patients from normal subjects and other clinical populations. This study extended examination of the diagnostic specificity of CO(2)-induced anxiety by testing panic disorder patients and clinical populations with reported low and high sensitivity to CO(2) inhalation (patients with major depression and patients with premenstrual dysphoric disorder, respectively). METHOD The behavioral responses to inhalation of 5% and 7% CO(2), administered by means of a respiratory canopy, were studied in 50 patients with panic disorder, 21 with major depression, and 10 with premenstrual dysphoric disorder and in 34 normal comparison subjects. Occurrence of panic attacks was judged with DSM-IV criteria by a blind rater. Subjects were rated on three behavioral scales at baseline and after each CO(2) inhalation. RESULTS Panic disorder patients had a higher rate of CO(2)-induced panic attacks than depressed patients and normal subjects, whose panic rates were not distinguishable. The panic rate for patients with premenstrual dysphoric disorder was similar to that for panic disorder patients and higher than that for normal subjects. Subjects with CO(2)-induced panic attacks had similarly high ratings on the behavioral scales, regardless of diagnosis, including the small number of panicking normal subjects. Seven percent CO(2) was a more robust panicogen than 5%, and response to 7% CO(2 )better distinguished panic disorder patients from normal subjects than response to 5% CO(2). CONCLUSIONS Patients with panic disorder and patients with premenstrual dysphoric disorder are highly susceptible to CO(2)-induced panic attacks, and depressed patients appear to be insensitive to CO(2) inhalation. The symptoms of CO(2)-induced panic attacks have a similar intensity regardless of the subject's diagnosis.
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Affiliation(s)
- J M Kent
- Biological Studies Unit, New York State Psychiatric Institute, New York, NY 10032, USA.
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Abstract
There is a substantial body of literature demonstrating that stimulation of respiration (hyperventilation) is a common event in panic disorder patients during panic attack episodes. Further, a number of abnormalities in respiration, such as enhanced CO2 sensitivity, have been detected in panic patients. This led some to posit that there is a fundamental abnormality in the physiological mechanisms that control breathing in panic disorder and that this abnormality is central to illness etiology. More recently, however, evidence has accumulated suggesting that respiratory physiology is normal in panic patients and that their tendency to hyperventilate and to react with panic to respiratory stimulants like CO2 represents the triggering of a hypersensitive fear network. The fear network anatomy is taken from preclinical studies that have identified the brain pathways that subserve the acquisition and maintenance of conditioned fear. Included are the amygdala and its brain stem projections, the hippocampus, and the medial prefrontal cortex. Although attempts to image this system in patients during panic attacks have been difficult, the theory that the fear network is operative and hyperactive in panic patients explains why both medication and psychosocial therapies are clearly effective. Studies of respiration in panic disorder are an excellent example of the way in which peripheral markers have guided researchers in developing a more complete picture of the neural events that occur in psychopathological states.
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Affiliation(s)
- S Sinha
- Department of Psychiatry, Columbia University, 722 West 168th Street, New York, NY 10032, USA
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Pine DS, Klein RG, Coplan JD, Papp LA, Hoven CW, Martinez J, Kovalenko P, Mandell DJ, Moreau D, Klein DF, Gorman JM. Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group. Arch Gen Psychiatry 2000; 57:960-7. [PMID: 11015814 DOI: 10.1001/archpsyc.57.10.960] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND To examine the relationship between respiratory regulation and childhood anxiety disorders, this study considered the relationship between anxiety disorders and symptoms during carbon dioxide (CO(2)) exposure, CO(2) sensitivity in specific childhood anxiety disorders, and the relationship between symptomatic and physiological responses to CO(2). METHODS Following procedures established in adults, 104 children (aged 9-17 years), including 25 from a previous study, underwent 5% CO(2) inhalation. The sample included 57 probands with an anxiety disorder (social phobia, generalized anxiety disorder, separation anxiety disorder, and panic disorder) and 47 nonill comparison subjects. Symptoms of anxiety were assessed before, during, and after CO(2) inhalation. RESULTS All children tolerated the procedure well, experiencing transient or no increases in anxiety symptoms. Children with an anxiety disorder, particularly separation anxiety disorder, exhibited greater changes in somatic symptoms during inhalation of CO(2)-enriched air, relative to the comparison group. During CO(2) inhalation, symptom ratings were positively correlated with respiratory rate increases, as well as with levels of tidal volume, minute ventilation, end-tidal CO(2), and irregularity in respiratory rate during room-air breathing. CONCLUSIONS Childhood anxiety disorders, particularly separation anxiety disorder, are associated with CO(2) hypersensitivity, as defined by symptom reports. Carbon dioxide hypersensitivity is associated with physiological changes similar to those found in panic disorder. These and other data suggest that certain childhood anxiety disorders may share pathophysiological features with adult panic disorder.
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Affiliation(s)
- D S Pine
- New York State Psychiatric Institute, Box 74, 1051 Riverside Dr, New York, NY 10032, USA.
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Abstract
Fifteen patients with panic disorder participated in a 12-week treatment trial with open-label nefazodone. Nefazodone was well-tolerated with minimal side effects; none of the patients reported sexual dysfunction, and only one patient experienced weight gain. Although the response rate was lower than that found with most other antipanic medications, given its favorable side effect profile, nefazodone may be a good alternative for patients apprehensive about potential adverse drug reactions.
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Affiliation(s)
- L A Papp
- Department of Clinical Psychobiology, New York State Psychiatric Institute, New York 10032,USA.
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Coplan JD, Tamir H, Calaprice D, DeJesus M, de la Nuez M, Pine D, Papp LA, Klein DF, Gorman JM. Plasma anti-serotonin and serotonin anti-idiotypic antibodies are elevated in panic disorder. Neuropsychopharmacology 1999; 20:386-91. [PMID: 10088140 DOI: 10.1016/s0893-133x(98)00130-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The psychoneuroimmunology of panic disorder is relatively unexplored. Alterations within brain stress systems that secondarily influence the immune system have been documented. A recent report indicated elevations of serotonin (5-HT) and ganglioside antibodies in patients with primary fibromyalgia, a condition with documented associations with panic disorder. In line with our interest in dysregulated 5-HT systems in panic disorder (PD), we wished to assess if antibodies directed at the 5-HT system were elevated in patients with PD in comparison to healthy volunteers. Sixty-three patients with panic disorder and 26 healthy volunteers were diagnosed by the SCID. Employing ELISA, we measured anti-5-HT and 5-HT anti-idiotypic antibodies (which are directed at 5-HT receptors). To include all subjects in one experiment, three different batches were run during the ELISA. Plasma serotonin anti-idiotypic antibodies: there was a significant group effect [patients > controls (p = .007)] and batch effect but no interaction. The mean effect size for the three batches was .76. Following Z-score transformation of each separate batch and then combining all scores, patients demonstrated significantly elevated levels of plasma serotonin anti-idiotypic antibodies. Neither sex nor age as covariates affected the significance of the results. There was a strong correlation between anti-serotonin antibody and serotonin anti-idiotypic antibody measures. Plasma anti-serotonin antibodies: there was a significant diagnosis effect [patients > controls (p = .037)]. Mean effect size for the three batches was .52. Upon Z-score transformation, there was a diagnosis effect with antibody elevations in patients. Covaried for sex and age, the result falls below significance to trend levels. The data raise the possibility that psychoimmune dysfunction, specifically related to the 5-HT system, may be present in PD. Potential interruption of 5-HT neurotransmission through autoimmune mechanisms may be of pathophysiologic significance in certain patients with panic disorder. It remains to be demonstrated if the peripheral autoimmunity is representative of CNS 5-HT neuronal alterations. Replication appears warranted.
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Affiliation(s)
- J D Coplan
- College of Physicians and Surgeons of Columbia University, New York State Psychiatric Institute, New York, NY, USA
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Grilo CM, Money R, Barlow DH, Goddard AW, Gorman JM, Hofmann SG, Papp LA, Shear MK, Woods SW. Pretreatment patient factors predicting attrition from a multicenter randomized controlled treatment study for panic disorder. Compr Psychiatry 1998; 39:323-32. [PMID: 9829138 DOI: 10.1016/s0010-440x(98)90043-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
This study examined pretreatment factors associated with attrition from a clinical trial for panic disorder. The study group consisted of 162 patients who began 11-visit treatments. Six domains (demography, panic disorder severity, psychiatric comorbidity, illness/treatment attributions, coping styles, and personality styles) with 52 variables were used to predict attrition. One hundred twenty-two patients completed and 40 dropped out from treatment. Final multivariate regression analyses showed that the following two variables were independently associated with attrition: lower household income and negative treatment attitudes; attributing the panic disorder to life stressors and greater age were independently associated with attrition at the trend level. Preliminary analyses suggested, in addition, associations between attrition and lower education, shorter length of prior treatment, higher anxiety sensitivity, lower agoraphobic avoidance, and a coping style of seeking social support that were not confirmed by best predictor analysis. Psychiatric comorbidity and personality styles were unrelated to attrition. The implications of these findings for future research and clinical practice are discussed.
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Affiliation(s)
- C M Grilo
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA
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Papp LA, Sinha SS, Martinez JM, Coplan JD, Amchin J, Gorman JM. Low-dose venlafaxine treatment in panic disorder. Psychopharmacol Bull 1998; 34:207-9. [PMID: 9641002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venlafaxine, a structurally novel antidepressant that combines mechanisms of action of both the cyclic antidepressants and SSRIs, may be effective in the treatment of panic disorder. Thirteen patients with DSM-IV panic disorder with or without agoraphobia participated in an open-label, fixed-flexible dose treatment study with venlafaxine. All patients who completed the 10-week trial exhibited statistically significant decreases in scores on anxiety symptoms as well as complete cessation of panic attacks at an effective mean daily dose of 47 mg per day. Venlafaxine was well tolerated in all completers. Venlafaxine may be an effective antipanic agent, even at lower than typical antidepressant dosages.
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Affiliation(s)
- L A Papp
- Biological Studies Unit, New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University, NY, USA
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Bouwer C, Stein DJ, Papp LA, Martinez JM, Klein DF. Breath of panic. Harv Ment Health Lett 1998; 14:6-7. [PMID: 9552797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Pine DS, Coplan JD, Papp LA, Klein RG, Martinez JM, Kovalenko P, Tancer N, Moreau D, Dummit ES, Shaffer D, Klein DF, Gorman JM. Ventilatory physiology of children and adolescents with anxiety disorders. Arch Gen Psychiatry 1998; 55:123-9. [PMID: 9477925 DOI: 10.1001/archpsyc.55.2.123] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abnormalities in ventilatory physiology have been noted in adults with panic disorder. We tested the hypothesis that abnormalities in ventilatory physiology differentiate children and adolescents with anxiety disorders from psychiatrically healthy children. METHODS Ventilatory physiology was monitored with a canopy apparatus during room-air breathing and 15 minutes of carbon dioxide exposure in 33 children and adolescents comprising 18 probands with an anxiety disorder and 15 psychiatrically healthy children. RESULTS During room-air breathing, probands had significantly larger minute ventilation, larger tidal volumes, and more variable breathing patterns than healthy comparisons, but the groups did not differ in end-tidal carbon dioxide or respiratory rate. During carbon dioxide challenge, probands exhibited larger minute ventilation and respiratory rate responses relative to comparisons. CONCLUSION These findings on the association between ventilatory physiology and anxiety disorders in children and adolescents are consistent with results from studies of adults with panic disorder.
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Affiliation(s)
- D S Pine
- New York State Psychiatric Institute, USA
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18
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Coplan JD, Goetz R, Klein DF, Papp LA, Fyer AJ, Liebowitz MR, Davies SO, Gorman JM. Plasma cortisol concentrations preceding lactate-induced panic. Psychological, biochemical, and physiological correlates. Arch Gen Psychiatry 1998; 55:130-6. [PMID: 9477926 DOI: 10.1001/archpsyc.55.2.130] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND We evaluated the role of plasma cortisol levels in determining sodium lactate-induced panic by reporting psychological, physiological, and biochemical data collected from an extended sample of 214 subjects during the "placebo" infusion (isotonic saline solution) immediately preceding the lactate infusion procedure. METHODS One hundred seventy patients with panic disorder, 101 (59%) of whom were assessed to have panicked (P group), and 69 (41%) who were assessed not to have panicked (NP group) with lactate infusion; and 44 normal healthy volunteer controls (1 of whom panicked with lactate infusion) were studied. RESULTS Before the lactate infusion, the P group exhibited hypothalamic-pituitary-adrenal (HPA) axis activation (high plasma cortisol levels) and evidence of hyperventilation (low PCO2 levels) in comparison with NP and control groups. Self-reported fear, dyspnea, and diastolic blood pressure were highest in the P group, intermediate in the NP group, and lowest in the control group. Within the P group, baseline fear scores correlated inversely with PCO2 levels and positively with cortisol levels while PCO2 levels correlated negatively with cortisol levels. Significant predictors of lactate-induced panic were prelactate infusion fear and the interaction of high cortisol levels and low PCO2 levels. CONCLUSION Combined data suggest that synchronized elevations of HPA axis activity, self-reported fear, and hyperventilation during the period before lactate infusion predisposes to lactate-induced panic.
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Affiliation(s)
- J D Coplan
- Department of Psychiatry, College of Physicians & Surgeons of Columbia University, New York State Psychiatric Institute, New York, USA
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Hofmann SG, Barlow DH, Papp LA, Detweiler MF, Ray SE, Shear MK, Woods SW, Gorman JM. Pretreatment attrition in a comparative treatment outcome study on panic disorder. Am J Psychiatry 1998; 155:43-7. [PMID: 9433337 DOI: 10.1176/ajp.155.1.43] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Whereas the fact of attrition during the course of treatment is well documented, little is known about the factors that affect sample selection before the beginning of a study ("pretreatment attrition"). The present study reports on the degree and sources of pretreatment attrition at two sites of a multicenter study on panic disorder that compared treatment outcomes for imipramine and cognitive behavior therapy. METHOD Data were collected at two clinical research sites, one with a pharmacological treatment orientation (N = 420) and one with a psychosocial treatment orientation (N = 208). RESULTS The main source of pretreatment attrition was participant refusal. At both research sites, eligible patients most often refused participation because they were either unwilling to start treatment with imipramine (30.6% and 47.4%, respectively) or discontinue their current medication (22.6% and 35.1%, respectively). CONCLUSIONS Results from comparative treatment outcome studies are limited not only to people who meet the study criteria but also to those who are willing to begin a medication treatment and discontinue their current medication.
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Affiliation(s)
- S G Hofmann
- Phobia Clinic, Hillside Hospital, Long Island Jewish Medical Center, Glen Oaks, N.Y., USA
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Abstract
This study compares the hemodynamic response to panic disorder subjects with that of normal controls during respiratory challenges. Panic patients meeting DSM-IIIR criteria for panic disorder and normal controls were challenged with room air hyperventilation, 5% CO2 breathing, and 7% CO2 breathing. Measurements of pulse and blood pressure were taken at resting baseline and before and at the end of each respiratory challenge. Panic attack to each challenge was determined by using raters blinded to subject diagnosis and each subject's self-rating of panic. Significantly larger systolic and diastolic blood pressure increases were found in patients who panicked with room air hyperventilation than nonpanicking patients or normal controls. No significant blood pressure differences were found with 7% or 5% CO2 challenges, but higher pulse rates were found in the patient group. It may be possible that panic with room air hyperventilation causes a significant increase in systolic and diastolic blood pressure, or that a subgroup of panic disorder patients has a hyperactive vascular response to hypocapnia. These patients panic with room air hyperventilation and develop greater vasoconstriction and/or increased blood pressure response.
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Affiliation(s)
- J M Martinez
- Biological Studies Unit, New York State Psychiatric Institute, Columbia University, New York 10032, USA
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21
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Abstract
BACKGROUND Disordered breathing among patients with panic disorder, including hyperventilation during attacks and increased anxiogenic response to carbon dioxide (CO2) inhalation, is well established. We wished to assess whether there is a change in the physiological response to CO2 after patients have undergone antipanic therapy with either tricyclic antidepressants or cognitive behavioral therapy (CBT). METHODS Twenty-nine patients with panic disorder underwent baseline CO2 sensitivity testing using the traditional Read rebreathing method and then received either antidepressant treatment (n = 21) or CBT (n = 8). After completing treatment, CO2 testing was repeated. A comparison sample of 14 normal volunteers also had two CO2 sensitivity tests, separated by an average of 21.6 (SD = 8.8) weeks. RESULTS Using a liberal standard, in which all CO2 sensitivity tests whose correlations between minute ventilation and end-tidal CO2 were at least .75 were used, patients, but not controls, demonstrated a significant reduction in CO2 sensitivity between the first and second test. Using a more conservative .90 correlation standard reduced the sample size available and resulted in trend reduction in patients but no significant change in controls. There was a suggestion that the change was most pronounced in treatment responders, although the number of patient nonresponders is extremely small in this sample. CONCLUSIONS These data indicate that treatment reduces CO2 sensitivity in patients with panic disorder. We speculate that manipulation of the serotonergic and noradrenergic neurotransmission systems, both known to play a role in the control of respiration, may have a specific effect in reducing respiratory hyperactivity in panic disorder.
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Affiliation(s)
- J M Gorman
- Biological Studies Unit, New York State Psychiatric Institute, New York, USA
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Abstract
OBJECTIVE To address the lack of a simple and standardized instrument to assess overall panic disorder severity, the authors developed a scale for the measurement of panic disorder severity. METHOD Ten independent evaluators used the seven-item Panic Disorder Severity Scale to assess 186 patients with principal DSM-III-R diagnoses of panic disorder (with no or mild agoraphobia) who were participating in the Multicenter Collaborative Treatment Study of Panic Disorder. In addition, 89 of these patients were reevaluated with the same scale after short-term treatment. A subset of 24 patients underwent two independent assessments to establish interrater reliability. Internal consistency, convergent and discriminant validity, and sensitivity to change were also determined. RESULTS The Panic Disorder Severity Scale was associated with excellent interrater reliability, moderate internal consistency, and favorable levels of validity and sensitivity to change. Individual items showed good convergent and discriminant validity. Analysis suggested a two-factor model fit the data best. CONCLUSIONS The Panic Disorder Severity Scale is a simple, efficient way for clinicians to rate severity in patients with established diagnoses of panic disorder. However, further research with more diverse groups of panic disorder patients and with a broader range of convergent and discriminant validity measures is needed.
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Affiliation(s)
- M K Shear
- Department of Psychiatry, University of Pittsburgh, PA, USA.
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Papp LA, Martinez JM, Klein DF, Coplan JD, Norman RG, Cole R, de Jesus MJ, Ross D, Goetz R, Gorman JM. Respiratory psychophysiology of panic disorder: three respiratory challenges in 98 subjects. Am J Psychiatry 1997; 154:1557-65. [PMID: 9356564 DOI: 10.1176/ajp.154.11.1557] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Respiratory abnormalities may play a central role in the pathophysiology of panic disorder. The current study was undertaken to examine the respiratory response in the largest series of subjects to date during three respiratory challenges that used improved methodology. METHOD Fifty-nine patients with DSM-III-R panic disorder and 39 normal volunteers were challenged with 5% and 7% CO2 inhalation and room air hyperventilation separated by room air breathing with continuous spirometry. RESULTS Patients with panic disorder were more sensitive to the anxiogenic effects of CO2 than were normal subjects, and CO2 was a more potent stimulus to panic than hyperventilation. Patients increased their respiratory rate more quickly during CO2 inhalation than did comparison subjects, and this increase preceded the panic attacks. Patients who panicked in response to 5% CO2 demonstrated continued rise in end-tidal CO2, while the end-tidal CO2 of the comparison groups stabilized. Low end-tidal CO2 and high variance in minute ventilation at baseline predicted panic attacks during CO2 inhalation. Following CO2 or hyperventilation challenges, respiratory rate dropped sharply, while tidal volume remained elevated longer in patients than in comparison subjects. CONCLUSIONS The findings confirm the greater behavioral and physiological sensitivity of patients with panic disorder to CO2 inhalation and identify a series of respiratory abnormalities. Panic attacks in panic disorder may be explained by inefficient compensatory mechanisms, primarily of respiratory rate.
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Affiliation(s)
- L A Papp
- Biological Studies Unit, New York State Psychiatric Institute, College of Physicians and Surgeons, Columbia University, NY, USA
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Papp LA, Schneier FR, Fyer AJ, Leibowitz MR, Gorman JM, Coplan JD, Campeas R, Fallon BA, Klein DF. Clomipramine treatment of panic disorder: pros and cons. J Clin Psychiatry 1997; 58:423-5. [PMID: 9375591 DOI: 10.4088/jcp.v58n1002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Controlled trials suggest that clomipramine may be a highly effective antipanic drug. Lowering the starting dose may alleviate troublesome initial side effects and increase acceptability and compliance. METHOD Fifty-eight patients with DSM-III-R panic disorder with or without agoraphobia underwent 13 weeks of clomipramine treatment. Starting at 10 mg/day, the dose was gradually increased to a mean dose of 97 mg/day. RESULTS While completers showed highly significant improvement, the benefits were severely limited by a high dropout rate due to adverse reactions occurring mostly during the first 2 weeks of treatment. CONCLUSION Given the alternatives, clomipramine should not be used as a first-line antipanic medication.
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Affiliation(s)
- L A Papp
- New York State Psychiatric Institute, NY 10032, USA
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Coplan JD, Papp LA, Pine D, Martinez J, Cooper T, Rosenblum LA, Klein DF, Gorman JM. Clinical improvement with fluoxetine therapy and noradrenergic function in patients with panic disorder. Arch Gen Psychiatry 1997; 54:643-8. [PMID: 9236548 DOI: 10.1001/archpsyc.1997.01830190069007] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Central noradrenergic (NA) dysregulation has provided a major theoretical framework for understanding the pathogenesis of panic disorder (PD). Using clonidine, an alpha 2-adrenergic receptor agonist, as a probe of NA function, we investigated the hypothesis that the antipanic efficacy of the selective serotonin reuptake inhibitors may be associated with normalization of a putatively dysregulated NA system. METHODS We report further analyses on data from 17 subjects with PD and 16 healthy volunteers who underwent measurement of the plasma NA metabolite 3-methoxy-4-hydroxyphenylglycol (MHPG) immediately before and after oral clonidine administration. Thirteen patients with PD were rechallenged after 12 weeks during open fluoxetine hydrochloride treatment using the same clonidine paradigm; 13 healthy volunteers were rechallenged at 12 weeks, not having received treatment between challenges. RESULTS Patients with PD, compared with healthy volunteers, have markedly elevated plasma MHPG volatility during the first clonidine challenge. Volatility describes the magnitude of within-subject plasma MHPG oscillatory activity as assessed by the root of the mean square successive difference. A greater degree of clinical global improvement was predicted by a greater magnitude of basal MHPG reduction with fluoxetine treatment. Antipanic response to fluoxetine was accompanied by a significant decrease of MHPG volatility to volunteer levels. Volunteer MHPG volatility remained unchanged from the first to second clonidine challenge. CONCLUSIONS Further evidence is provided for the hypothesis of NA dysregulation in PD as reflected by elevations of within-subjects plasma MHPG volatility during clonidine challenge. Effective selective serotonin reuptake inhibitor-antipanic treatment in this clinical sample was paralleled by normalization of dysregulated NA function.
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Affiliation(s)
- J D Coplan
- College of Physicians and Surgeons of Columbia University, New York State Psychiatric Institute, NY, USA
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Coplan JD, Pine DS, Papp LA, Gorman JM. A view on noradrenergic, hypothalamic-pituitary-adrenal axis and extrahypothalamic corticotrophin-releasing factor function in anxiety and affective disorders: the reduced growth hormone response to clonidine. Psychopharmacol Bull 1997; 33:193-204. [PMID: 9230631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- J D Coplan
- New York State Psychiatric Institute, New York, USA
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Abstract
On the basis of preclinical studies, we hypothesized that deficient serotonin neurotransmission may be associated with the respiratory hyperactivity and carbon dioxide sensitivity seen in panic disorder. We used the tryptophan depletion method to investigate the effects of transient reductions in serotonin on respiration in five patients with panic disorder and seven normal control subjects. During room air breathing, the patients showed significantly increased ventilation when tryptophan-depleted, while the normal subjects showed no significant changes in respiration. These preliminary data suggest that serotonergic manipulation may affect ventilatory indices, with panic disorder patients being particularly sensitive to the effect of tryptophan depletion.
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Affiliation(s)
- J M Kent
- Biological Studies Unit, New York State Psychiatric Center, New York, NY, USA
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Martinez JM, Papp LA, Coplan JD, Anderson DE, Mueller CM, Klein DF, Gorman JM. Ambulatory monitoring of respiration in anxiety. Anxiety 1996; 2:296-302. [PMID: 9160637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
An ambulatory monitor, body suit, and calibration procedure were developed to compare the respiration of seven patients with panic disorder and twelve normal volunteers. Subjects wore a body suit with Respitrace bands, connected to a portable respiratory monitor for a period of 24 hours. Breath by breath values for respiratory rate and tidal volume were computed every two minutes. There was a significant difference between patients and controls in their patterns of minute ventilation during sleep. Tidal volume, rather that respiratory rate increases characterized the periods of anxiety and limited symptom attacks.
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Affiliation(s)
- J M Martinez
- Biological Studies Unit, New York State Psychiatric Institute, NY 10032, USA
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Abstract
In an attempt to reproduce the findings of Rapee et al (1986) that instructional set could alter the anxiogenic effects of carbon dioxide inhalation, 45 patients with panic disorder received two sets of instructions and then underwent a series of respiratory challenges (room air hyperventilation, 5% and 7% CO2 inhalation). The instructions failed to alter the anxiogenic response to any of the interventions.
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Affiliation(s)
- L A Papp
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, N.Y. 10032, USA
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Papp LA, Weiss JR, Greenberg HE, Rifkin A, Scharf SM, Gorman JM, Klein DF. Sertraline for chronic obstructive pulmonary disease and comorbid anxiety and mood disorders. Am J Psychiatry 1995; 152:1531. [PMID: 7573598 DOI: 10.1176/ajp.152.10.1531a] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
In order to compare the ventilatory response of panic patients and normal controls, 21 panic disorder patients with agoraphobia and 21 normal controls underwent the Read rebreathing test. Panic patients panicked significantly more during the test, responded with more respiratory rate and less tidal volume, but showed no hypersensitivity to inhaled carbon dioxide compared to normal controls.
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Affiliation(s)
- L A Papp
- Biological Studies Unit, New York State Psychiatric Institute, NY 10032, USA
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Carter CS, Fawcett J, Hertzman M, Papp LA, Jones W, Patterson WM, Swinson RP, Weise CC, Maddock RJ, Denahan AQ. Adinazolam-SR in panic disorder with agoraphobia: relationship of daily dose to efficacy. J Clin Psychiatry 1995; 56:202-10. [PMID: 7737960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND We report the results from a multicenter, double-blind, randomized, fixed-dose study designed to evaluate the relationship between daily dose and efficacy of adinazolam-SR in patients with panic disorder with agoraphobia. METHOD Patients (N = 315) were randomized to one of four treatment groups (placebo, N = 83; 30-mg group, N = 79; 60-mg group, N = 81; and 90-mg group, N = 72) and then treated twice daily for 4 weeks. All treatment groups were comparable demographically. Primary efficacy measures included total number of panic attacks, global improvement score using the Clinical Global Impressions (CGI) scale, phobic anxiety dimension of the Symptom Checklist-90 phobic cluster, overall phobia state using the Phobia Scale, and severity of illness on the CGI. RESULTS The 60- and 90-mg/day adinazolam-SR treatment groups showed superior results when compared with the placebo group at Week 4 while the 30-mg group did not. Treatment with adinazolam-SR was well tolerated, with sedation the only treatment-emergent symptom that occurred more frequently in patients treated with adinazolam-SR than placebo. CONCLUSION These results suggest that adinazolam-SR at doses of 60-mg/day or greater administered twice daily is a safe and effective treatment in selected patients with panic disorder with agoraphobia.
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Affiliation(s)
- C S Carter
- Western Psychiatric Institute and Clinic, Pittsburgh, PA, USA
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Coplan JD, Papp LA, Martinez J, Pine D, Rosenblum LA, Cooper T, Liebowitz MR, Gorman JM. Persistence of blunted human growth hormone response to clonidine in fluoxetine-treated patients with panic disorder. Am J Psychiatry 1995; 152:619-22. [PMID: 7694915 DOI: 10.1176/ajp.152.4.619] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The authors determined the effects of antipanic treatment with fluoxetine on human growth hormone (GH) response to the alpha 2 agonist clonidine. METHOD Seventeen patients with panic disorder and 15 healthy volunteers were challenged with clonidine. Thirteen of the patients and 12 of the volunteers were given a second challenge with clonidine 12 weeks later. The patients received open fluoxetine and the healthy subjects received no treatment between challenges. Subjects with high baseline human GH levels (greater than 2 ng/ml) at the first and second challenges were excluded from further analysis. RESULTS The patients with panic disorder (N = 13 for the first challenge and N = 9 for the second) had significantly lower human GH responses to clonidine than the healthy subjects (N = 14 during the first challenge and N = 9 for the second) during both challenges, despite clinical improvement in eight of the nine patients at the time of the second challenge. CONCLUSIONS Blunted secretion of human GH in response to clonidine in patients with panic disorder persists despite clinical recovery.
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Affiliation(s)
- J D Coplan
- College of Physicians and Surgeons of Columbia University, New York, NY 10032
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Gorman JM, Papp LA, Coplan JD, Martinez JM, Lennon S, Goetz RR, Ross D, Klein DF. Anxiogenic effects of CO2 and hyperventilation in patients with panic disorder. Am J Psychiatry 1994; 151:547-53. [PMID: 8147452 DOI: 10.1176/ajp.151.4.547] [Citation(s) in RCA: 146] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Previous studies have indicated that patients with panic disorder are more likely than normal subjects to have acute panic attacks during inhalation of CO2, but methodological objections have been raised. In this study the authors attempted to address three of these methodological problems by ensuring that raters who assessed whether panic attacks occurred were blind to subjects' diagnoses, by randomizing the order of administration of 5% CO2 and hyperventilation, and by challenging a greater number of subjects with 7% CO2. METHOD Patients with panic disorder and normal subjects underwent 20-minute inhalations of 5% CO2 and 7% CO2 and 15 minutes of room-air hyperventilation. Ratings of panic/no panic during each condition were made separately by an assessor blind to diagnosis and by the subject. Scores on four panic rating scales were also recorded before and after each intervention. RESULTS Room-air hyperventilation caused panic attacks in a small number of patients; the difference in panic rate between patients and comparison subjects was statistically significant by the subjects' but not by the raters' assessment. Panic rates during 5% CO2 and 7% CO2 were significantly greater among the patients by both assessments; the panic rate was greatest during 7% CO2. Order of administration did not significantly affect panic rates for hyperventilation and 5% CO2. CONCLUSIONS Panic patients were clearly more sensitive to the anxiogenic effects of CO2 than comparison subjects, and CO2 was a more potent anxiogenic stimulus than room-air hyperventilation. Seven percent CO2 discriminated best between patients and comparison subjects and should be the focus of further research.
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Affiliation(s)
- J M Gorman
- Biological Studies Unit, New York State Psychiatric Institute, New York
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Tiffon L, Coplan JD, Papp LA, Gorman JM. Augmentation strategies with tricyclic or fluoxetine treatment in seven partially responsive panic disorder patients. J Clin Psychiatry 1994; 55:66-9. [PMID: 8077156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although panic disorder is generally responsive to single antidepressant pharmacotherapy, a substantial percentage of patients fail either to respond adequately or to maintain a therapeutic response. METHOD The authors report on seven consecutive openly treated patients with panic disorder who showed inadequate antipanic responses to treatment regimens including either a tricyclic (TCA) or fluoxetine. Those patients taking a TCA had fluoxetine added and those patients taking fluoxetine had a TCA added. RESULTS All seven patients showed an improvement in antipanic response to the combination treatment. CONCLUSION The current case series is the first, to our knowledge, to suggest that the combination of a TCA and fluoxetine may provide a viable pharmacotherapeutic option for panic disorder patients who have failed to respond to an adequate trial of either a TCA or fluoxetine. Appropriate controlled studies are recommended.
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Affiliation(s)
- L Tiffon
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, NY
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Abstract
OBJECTIVE Patients with panic disorder are behaviorally hypersensitive to CO2 inhalation and may also be biologically hypersensitive. A report by Mathew et al. showed, however, that administration of the carbonic anhydrase inhibitor acetazolamide, which is believed to increase brain CO2 level, did not cause panic in panic disorder patients. The authors of the present study noted that respiratory frequency did not increase in the earlier experiment and wondered whether respiratory stimulation occurred during acetazolamide administration, as would be expected if CO2 level increases significantly. METHOD Ten patients with panic disorder and six normal control subjects received injections of acetazolamide, 1 g i.v., as per the Mathew et al. protocol, during breath by breath measurement of both tidal volume and frequency of respiration. RESULTS Three patients had panic attacks, one before receiving acetazolamide, one during the injection, and one 2 minutes after injection. Only the last of these attacks appeared possibly attributable to acetazolamide. None of the control subjects panicked. Neither patients nor control subjects exhibited meaningful change in tidal volume, respiratory frequency, or minute ventilation, and both groups experienced a trend toward significant decrease in overall levels of anxiety and dyspnea after acetazolamide injection. CONCLUSIONS The authors replicated the earlier finding that acetazolamide is not panicogenic in patients with panic disorder but also showed that at the dose given, there is no meaningful effect on ventilation. If acetazolamide does affect CO2 levels it does so in a way that does not stimulate ventilation. Therefore, the acetazolamide injection results of Mathew et al. and of the present study do not challenge hypotheses linking panic attacks to hypersensitive respiratory control mechanisms.
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Affiliation(s)
- J M Gorman
- Biological Studies Unit, New York State Psychiatric Institute
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Abstract
OBJECTIVE The purpose of this article is to offer a comprehensive, data-based explanation of the relationship between hyperventilation and panic disorder linking CO2 hypersensitivity, cognitive/behavioral factors, and the respiratory effects of antipanic pharmacologic and psychological treatments. METHOD The authors conducted a computerized search of MEDLINE for relevant articles. RESULTS Some panic patients have a chronic, subtle respiratory disturbance. Acute hyperventilation is neither necessary nor sufficient for panic to occur. Respiratory abnormalities in panic patients may adaptively aim at coping with a hypersensitive CO2 chemoreceptor system. Pharmacologic panicogens also stimulate the respiratory system, causing hyperventilation. Triggering this hypersensitive respiratory control mechanism may incite panic. Antipanic medications may reset the receptor threshold. Misattribution and catastrophic interpretation of somatic symptoms or the sense of loss of control may contribute to panic symptoms. Behavioral interventions such as desensitization or breathing retraining may block the full-blown attack. Cognitive strategies through cognitive control of respiration may supplement and accentuate these interventions. CONCLUSIONS Panic disorder may be due to an inherently unstable autonomic nervous system, coupled with cognitive distress.
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Affiliation(s)
- L A Papp
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY
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Papp LA, Klein DF, Martinez J, Schneier F, Cole R, Liebowitz MR, Hollander E, Fyer AJ, Jordan F, Gorman JM. Diagnostic and substance specificity of carbon-dioxide-induced panic. Am J Psychiatry 1993; 150:250-7. [PMID: 8123056 DOI: 10.1176/ajp.150.2.250] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The authors assessed the substance and diagnostic specificity of carbon-dioxide-induced panic since, in addition to the specific biochemical effects of inhaled carbon dioxide (CO2), simple physiologic distress is also frequently implicated as a panicogenic factor during respiratory challenge studies with CO2 in patients with anxiety disorders. METHOD Eighteen patients with panic disorder, 20 with social phobia, and 23 psychiatrically normal subjects inhaled a mixture of 35% CO2 and 65% O2 for 30 seconds through a face mask. They also breathed for 30 seconds through a valve reducing the diameter of the airway. A double-blind, counterbalanced, randomized design was used. RESULTS In spite of important similarities between the two interventions, including the induction of equal amounts of subjective respiratory distress, carbon dioxide inhalation was significantly more potent than increased airway resistance in provoking panic in the anxiety disorder patients. The patients with panic disorder were significantly more sensitive to CO2 than were the patients with social phobia or the normal subjects. CONCLUSIONS Carbon dioxide inhalation appears to have a specific panicogenic effect in panic patients that goes beyond simple breathlessness.
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Affiliation(s)
- L A Papp
- Biological Studies Unit, New York State Psychiatric Institute, NY 10032
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39
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Abstract
Twenty panic disorder patients with mitral valve prolapse showed amelioration of prolapse on repeat echocardiogram after treatment for panic disorder. This effect was significant when compared to repeat echocardiograms in eight psychiatrically normal control subjects with mitral valve prolapse.
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Affiliation(s)
- J D Coplan
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York
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40
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Abstract
Sixteen panic patients and fifteen normal controls performed submaximal exercise testing on a bicycle ergometer. Only one patient subject panicked. Biochemical, physiological, and psychological data showed similar exercise tolerance in both patients and controls. Exercise-induced distress and lactate increment do not appear to cause panic attacks.
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Affiliation(s)
- J M Stein
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, N.Y
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41
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Welkowitz LA, Papp LA, Cloitre M, Liebowitz MR, Martin LY, Gorman JM. Cognitive-behavior therapy for panic disorder delivered by psychopharmacologically oriented clinicians. J Nerv Ment Dis 1991; 179:473-7. [PMID: 1856709 DOI: 10.1097/00005053-199108000-00004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A cognitive-behavioral treatment program for panic disorder was delivered by staff members of a psychiatric center that traditionally utilizes pharmacological methods. Psychiatrists, a nurse practitioner, and psychologists not previously exposed to behavioral techniques were trained by a behavioral psychologist to utilize a treatment program consisting of breathing control, cognitive restructuring, and exposure to panic-eliciting somatic cues. Of the 24 patients treated as part of this training in panic control therapy, 14 were panic-free after treatment and three additional patients showed moderate improvement and decreased frequency of panic. A case example is presented to demonstrate the application of behavioral techniques to individual patients. Discussion is focused on issues surrounding training in behavioral methods and problems in exporting behavioral technology to centers that emphasize psychopharmacological approaches to treatment.
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Affiliation(s)
- L A Welkowitz
- Department of Psychiatry, Columbia University, College of Physicians and Surgeons, New York, New York
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42
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Fallon BA, Liebowitz MR, Hollander E, Schneier FR, Campeas RB, Fairbanks J, Papp LA, Hatterer JA, Sandberg D. The pharmacotherapy of moral or religious scrupulosity. J Clin Psychiatry 1990; 51:517-21. [PMID: 2258366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Moral or religious scrupulosity is a disabling condition which is sometimes seen in patients with obsessive compulsive disorder (OCD). The authors described 10 patients with moral or religious scrupulosity who were treated with fluoxetine or clomipramine. Seven of the 10 patients completed open treatment of at least 8 weeks without requiring adjunctive medication; 5 of those 7 patients were rated as much improved. Among the 3 patients who required adjunctive medication, 1 was rated as much improved. Of the 4 nonresponders at 3 months, 2 responded after longer treatment trials. These results suggest that extreme moral or religious concerns and behaviors might be a form of OCD and that the scrupulosity can be effectively treated with serotonin reuptake blockers.
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Abstract
Many investigators have shown that panic disorder patients and possibly social phobics are hypersensitive to the anxiogenic effects of inhaled carbon dioxide (CO2). In this study we administered double-breath inhalation of 35% CO2 and 65% oxygen (O2) to panic disorder patients, social phobics, and normal controls. At baseline, panic disorder patients were characterized by higher pulse, anxiety score, and evidence of hyperventilation. Panic patients and social phobics panicked more often to 35% CO2 than to room air; normal controls did not have a higher rate of panic to CO2 than to room air. However, we did not find significant group differences in anxiety level, physiological measures, or biochemical measures in response to CO2 breathing compared with room air breathing. These results confirm earlier reports of baseline hyperventilation in panic disorder patients. However, 35% CO2 may be too high a dose to differentiate respiratory responses of patients compared with normals.
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Affiliation(s)
- J M Gorman
- Biological Studies Unit, New York State Psychiatric Institute, NY
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Klein DF, Papp LA, Gorman JM. Acetazolamide as a control for CO2-induced panic. Am J Psychiatry 1990; 147:677-8. [PMID: 2109541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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47
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Abstract
Four men with paruresis received trials of atenolol or phenelzine or both. Atenolol was effective in one patient. Three patients had a poor response to phenelzine, and they all experienced troublesome side effects.
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48
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Gorman JM, Papp LA. Chronic anxiety: deciding the length of treatment. J Clin Psychiatry 1990; 51 Suppl:11-5. [PMID: 1967247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Anxiety disorders are chronic illnesses requiring long-term treatment. Relapse is typical and should not be considered treatment failure. Although the general guiding principle of pharmacotherapy for anxiety disorders--the lowest effective dose for the shortest possible time--remains, this rule should not interfere with the judicious use of medications as long as the benefits justify it. Although most antianxiety drugs are safe and have no long-term side effects, periodic drug discontinuation should be attempted. Establishing a secure and specific diagnosis and ruling out concomitant psychiatric and medical illnesses will augment the success of pharmacotherapy. The efficacy of nonpharmacologic treatments alone is, with very few exceptions, unsubstantiated at present; however, nonpharmacologic techniques may well supplement medication trials. Based on these principles and on the available data, specific recommendations are given for treating patients with generalized anxiety disorder, panic disorder, social phobia, and obsessive compulsive disorder.
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Affiliation(s)
- J M Gorman
- Department of Clinical Psychobiology, New York State Psychiatric Institute, New York
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49
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Abstract
Ehlers et al. (1986b) and Margraf et al. (1986) suggested that panic disorder patients indiscriminately endorse somatic complaints and that their responses to lactate infusion are nonspecific. Their Symptom Questionnaire was composed of anxiety/panic/lactate infusion relevant symptoms, while the Somatic Control Scale was composed of "irrelevant" symptoms. In an attempt to address and in part replicate the above findings among panic disorder patients, we adopted the SCS of Margraf et al. (1986) for use with our Acute Panic Inventory, an instrument similar to their Symptom Questionnaire. Contrary to their reports, we did not find a tendency for panic patients to indiscriminately endorse somatic complaints. Only Acute Panic Inventory scores differed significantly across assessment points.
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Affiliation(s)
- R R Goetz
- Biological Studies Unit, College of Physicians and Surgeons of Columbia University, NY
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50
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Abstract
Seven male panic patients did not panic but were significantly more sensitive to steady-state carbon dioxide inhalation than five male normal control subjects. The male patients' hypersensitivity to carbon dioxide was unrelated to current state of anxiety or acute panic.
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Affiliation(s)
- L A Papp
- Biological Studies Unit, New York State Psychiatric Institute, NY 10032
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