Further Exploration of Treatment Response in Latinos with Comorbid Asthma and Panic Disorder: A Brief Report of HRV and ETCO2 as Potential Mediators of Treatment Response

Heart rate variability (HRV) and end tidal CO2 (ETCO2) in relation to treatment response have not been studied in Latino populations or in comorbid asthma and panic disorder (PD). An extension of previously published research, the current study explored psychophysiological variables as possible mediators of treatment response. Latino treatment completers (N = 32) in the Bronx with asthma-PD received either Cognitive-Behavioral Psychophysiological Therapy (CBPT) or Music Relaxation Therapy (MRT). CBPT included HRV-biofeedback (HRVB); in-the-moment heart rate data to help an individual learn to influence his/her own heart rate. The sample was primarily female (93.8%) and Puerto Rican (81.25%). Treatment groups did not differ on demographics, except for less education in CBPT. The Panic Disorder Severity Scale (PDSS) and Asthma Control Questionnaire (ACQ) assessed changes in symptoms. HRV and ETCO2 were measured at four of eight therapy sessions. Baseline ETCO2 and changes in HRV from first to last of psychophysiology sessions were investigated as mediators of change on ACQ and PDSS. Mixed model analyses indicated in the CPBT group, changes in both asthma control and PD severity were not mediated by changes in HRV. In the CBPT and MRT groups combined, changes in PD severity were not mediated by baseline ETCO2. These findings may be due to the brevity of HRVB in CBPT, multiple treatment components, ETCO2 not directly targeted, and/or unique physiological pathways in Latinos with asthma-PD.

[Workplace-related anxiety, workplace phobia and disorders of participation]

Work is an important domain of life. It is therefore clear that problems at the workplace and mental disorders will have negative interactions. Job-related anxieties are of special importance as any workplace causes or intensifies anxiety by its very nature. A common final pathway of mental disorders in general and workplace-related anxieties in particular is workplace phobia. Similarly to agoraphobia, it is characterised by panic when approaching or even thinking of the stimulus, in this case the workplace. Workplace phobia has serious negative consequences for the further course of illness. It impairs the ability to work, and can lead to sick leave and early retirement. It requires special therapeutic interventions. This paper describes workplace-related anxieties and workplace phobia and gives a conceptual framework for their understanding.

A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care

BACKGROUND

Treated anxiety increased in the UK by over 30% since 1994. Medication and psychological treatment is most common, but outcomes are sometimes poor, with high relapse rates. Lifestyle has a potential role in treatment, but is not considered in clinical guidelines. Panic disorder is potentially influenced by lifestyle factors.

METHODS

16 week unblinded pragmatic randomised controlled trial in 15 East of England primary care practices (2 Primary Care Trusts). Participants met DSM-IV criteria for panic disorder with/without agoraphobia. Follow-up at 20 weeks and 10 months. Control arm, unrestricted routine GP care. Trial Arm, Occupational therapy-led lifestyle treatment comprising: lifestyle review of fluid intake, diet pattern, exercise, caffeine, alcohol and nicotine; negotiation of positive lifestyle changes; monitoring and review of impact of changes.

PRIMARY OUTCOME MEASURE

Beck Anxiety Inventory.

DATA ANALYSIS

Intention-to-treat analysis provided between-group comparisons using analysis of co-variance. Bonferroni method to adjust p-values.

RESULTS

From 199 referrals, 36 GP care and 31 lifestyle arm patients completed to final follow-up. Significantly lower lifestyle arm BAI scores at 20 weeks (p<0.001), non-significant (p=0.167) at 10 months after Bonferroni correction. 63.6% lifestyle arm, and 40% GP arm patients (p=0.045) panic-free at 20 weeks; 67.7% and 48.5% (p=0.123) respectively at 10 months.

LIMITATIONS

Final study size/power calls for caution in interpreting findings.

CONCLUSIONS

A lifestyle approach may provide a clinically effective intervention at least as effective as routine GP care, with significant improvements in anxiety compared with routine GP care at the end of treatment. Further study is required before suggesting practice changes.

[Rehabilitative elements for the treatment of patients with mental disorders: are they considered in the development of guidelines?]

OBJECTIVE

In the context of the current discussion of integrating rehabilitative elements into the (acute) treatment of patients with mental disorders, it is investigated what rehabilitative elements actually are and whether these elements are considered in existing guidelines.

METHODS/RESULTS

An expert-based consensus, especially results of expert ratings using a 46-item questionnaire (Delphi Technique; n = 16), shows that it is possible to specify rehabilitative elements, although there are still aspects which need further clarification. Analyses of current guidelines (using published guidelines for panic disorders) demonstrate that rehabilitative elements which are rated as important by the experts are only marginally mentioned in guidelines up to now.

CONCLUSIONS

A considerable need for research exists for a further specification of rehabilitative elements and for the development of evidence based recommendations in the form of guidelines.

The long-term course of panic disorder--an 11 year follow-up

BACKGROUND

The purpose of this study was to assess the naturalistic long-term course of panic disorder over a period of 11 years.

METHOD

Thirty DSM-III-R panic disorder patients, who had suffered from panic disorder for 6 years on average and who had taken part in an 8-week multicenter drug trial, were included in the intent-to-follow-up group to be reinterviewed 11 years after the end of the trial. At baseline and at follow-up the same instruments were used to assess frequency of panic attacks, level of phobic avoidance, and disabilities. Treatments received during the follow-up period and attempted suicides were assessed with a structured interview. Periods of well-being during the follow-up period were elicited retrospectively with a specifically designed longitudinal chart.

RESULTS

Twenty-four patients could actually be reinterviewed after 11.3 years. While at baseline all patients had suffered from panic attacks and had been severely disabled on a number of measures, 66.7% had no panic attack during the year before follow-up. During the month before follow-up 87.5% had no panic attack, and 54% showed no or only mild phobic avoidance. In the areas of work and family life 90% showed no or only mild disabilities, whereas in the area of social life this percentage was lower (67%). Thirty-three percent of the patients were completely remitted according to a composite remission criterion.

CONCLUSIONS

Panic disorder is not a uniformly chronic and progressing disorder. Over a period of 11 years there is a good chance of recovery from panic attacks and disabilities, and full remission is also possible.

Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care

OBJECTIVE

Recent policy has focused on documenting and reducing ethnic disparities in availability and quality of health care. The authors examined differences by ethnic status in unmet need for alcoholism, drug abuse, and mental health treatment.

METHOD

Data were from a follow-up survey of adult respondents to a 1996-1997 national survey. Non-Hispanic whites, African Americans, and Hispanics were compared in access to alcoholism and drug abuse treatment and mental health care (primary or specialty), unmet need for care, satisfaction with care, and use of active treatment for alcoholism, drug abuse, and mental health problems in the prior 12 months.

RESULTS

A total of 31.9% of whites, 28.1% of African Americans, and 30.1% of Hispanics had some alcoholism, drug abuse, and mental health care, mostly in primary care. Among those with perceived need, compared to whites, African Americans were more likely to have no access to alcoholism, drug abuse, or mental health care (25.4% versus 12.5%), and Hispanics were more likely to have less care than needed or delayed care (22.7% versus 10.7%). Among those with need, whites were more likely than Hispanics or African Americans to be receiving active alcoholism, drug abuse, or mental health treatment (37.6% versus 22.4%-25.0%).

CONCLUSIONS

The authors document greater unmet need for alcoholism and drug abuse treatment and mental health care among African American and Hispanics relative to whites. New policies are needed to improve access to and quality of alcoholism, drug abuse, and mental health treatment across diverse populations.

Impact of panic attacks on rehabilitation and quality of life among persons with severe psychotic disorders

OBJECTIVE

The study evaluated data from a sample of persons with severe psychotic disorders to determine whether those with and without comorbid panic attacks differed in rates of comorbidity of other psychiatric disorders, in quality of life, and in rehabilitation outcomes.

METHODS

A total of 120 individuals with psychotic disorders were assessed with the Center for Epidemiologic Studies-Depression scale, the Structured Clinical Interview for DSM-III-R, the General Health Questionnaire, the Global Assessment of Functioning scale, and several quality-of-life measures at baseline and four and a half months after they had participated in a social rehabilitation program. Multivariate analyses of variance and Pearson's chi square tests were used to compare baseline and follow-up scores between individuals who did and did not have panic attacks.

RESULTS

Eighteen (15 percent) of the participants who had severe psychotic disorders also had panic attacks. Participants with this type of comorbidity had significantly higher rates of major depressive disorder, specific phobia, sedative abuse, polysubstance abuse, other substance abuse, and anorexia nervosa than participants who did not have panic attacks. Participants who had panic attacks also had poorer rehabilitative outcomes and poorer quality of life at baseline and at follow-up than participants who did not have panic attacks.

CONCLUSIONS

These data are the first to show that comorbid panic attacks are associated with poorer rehabilitative outcomes and poorer quality of life among individuals with severe psychotic disorders than among those who have psychotic disorders without panic attacks. Panic attacks may be a valuable prognostic indicator among persons with psychotic disorders and may have implications for treatment and rehabilitation.

Panic disorder in a Spanish sample of 89 patients with pure alcohol dependence

High rates of anxiety disorders, including panic disorder (PD), have been found in patients suffering from alcohol dependence (AD). It has been suggested that alcoholic subjects with PD represent a more severe subgroup of patients. Eighty-nine patients with 'pure' AD (without abuse of other drugs) were examined and compared for the presence of PD. Several clinical scales were administered to assess symptomatology and severity. Twenty-three patients (25.8%) met the criteria for PD. The mean age at onset for alcohol use was 18.7 versus 28.5 years for PD onset. Our finding of an earlier onset for alcoholism than for PD in a sample of Spanish patients illustrates the potential importance of transcultural factors. These patients were more likely to be women and to have first-degree relatives with PD. Overall, alcoholic patients with comorbid PD showed greater clinical severity. They were found to have more comorbidity with axis I disorders (major depression and dysthymia), greater clinical severity, and a history of more suicide attempts.

An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women

OBJECTIVE

Social phobia is a chronic disorder with a higher prevalence among women than men. Data from an eight-year longitudinal study were analyzed to investigate the course of social phobia and to explore potential sex differences in the course and characteristics of the illness.

METHODS

Data were analyzed from the Harvard/Brown Anxiety Research Program, a naturalistic, observational study begun in 1989 in which patients with social phobia are assessed every six to 12 months. Treatment was observed but not prescribed by the program personnel. Data on comorbidity, remission, and health-related quality of life were collected for 176 patients with social phobia.

RESULTS

Only 38 percent of women and 32 percent of men experienced a complete remission during the eight-year study period, a difference that was not significant. A larger proportion of women than men had the generalized form of social phobia, although the difference was not significant. Women were more likely to have concurrent agoraphobia, and men had a higher rate of comorbid substance use disorders. Social phobia had a more chronic course among women who had low Global Assessment of Functioning scores and a history of suicide attempts at baseline than among men who had these characteristics. Health-related quality of life was similar for both men and women, except that women were slightly but significantly more impaired in household functioning.

CONCLUSIONS

The chronicity of social phobia was striking for both men and women. Although remission rates did not differ significantly between men and women, clinicians should be alert to the fact that women with poor baseline functioning and a history of suicide attempts have the greatest chronicity of illness.

Behavior therapy for vestibular rehabilitation

Patients with panic disorder and patients with vestibular disorders often share symptomatology, such as dizziness, spatial disorientation, and anxiety in particular environments. Because of the similar clinical presentations, it is not always apparent whether these symptoms are due primarily to a vestibular disorder or to panic disorder. Depending on where and how these patients enter the medical system, their symptoms may be remedied by treatment from behavioral therapists or physical therapists trained in vestibular rehabilitation. Although vestibular rehabilitation developed independently of behavioral treatment for anxiety disorders, there are remarkable similarities in treatment conceptualization and implementation. For example, both use exposure procedures designed to produce habituation of dizziness and disorientation, as well as enhancing functional compensation. Furthermore, there appears to be a subset of individuals with panic disorder who also have vestibular pathology and thus, may benefit from both interventions. In this paper, similarities and differences in the clinical presentation, treatment goals, and specific interventions for patients with panic disorder or vestibular pathology is examined, and future implications are discussed.

A controlled trial of cognitive behavioral treatment of panic in alcoholic inpatients with comorbid panic disorder

Patients entering a 4-week inpatient alcoholism treatment program were screened for anxiety symptoms. Those with panic disorder with or without agoraphobia were randomly assigned to two groups. The treatment group received 12 hours of cognitive-behavioral treatment (CBT) for panic disorder in addition to the regular alcoholism treatment program: the control group received the regular program. Dropouts from the treatment group were also followed. Problem drinking and anxiety symptoms were measured at the start of the study, and at 3, 6, and 12 months posttreatment. Abstinence from drinking, and anxiety and mood symptoms improved after treatment in all of the groups; there were few differences in outcome between the groups. We concluded that this particular intervention had not been more effective than the regular alcohol treatment program in reducing problem drinking in those with panic disorder.

[Styles of interpersonal conflict in patients with panic disorder, alcoholism, rheumatoid arthritis and healthy controls: a cluster analysis study]

OBJECTIVE

Conflict and conflict resolution in intimate relationships are not only among the most important factors influencing relationship satisfaction but are also seen in association with clinical symptoms. Styles of conflict will be assessed in patients suffering from panic disorder with and without agoraphobia, in alcoholics and in patients suffering from rheumatoid arthritis.

METHODS

176 patients and healthy controls filled out the Styles of Conflict Inventory and questionnaires concerning severity of clinical symptoms.

RESULTS

A cluster analysis revealed 5 types of conflict management. Healthy controls showed predominantely assertive and constructive styles, patients with panic disorder showed high levels of cognitive and/or behavioral aggression. Alcoholics showed high levels of repressed aggression, and patients with rheumatoid arthritis often did not exhibit any aggression during conflict.

CONCLUSIONS

5 Clusters of conflict pattern have been identified by cluster analysis. Each patient group showed considerable different patterns of conflict management.

Do specific anxiety disorders show specific drug problems?

OBJECTIVE

Comorbidity between anxiety and substance use disorders was examined. The hypothesis was tested that social phobics may report greater problem alcohol use (if alcohol is used to manage social anxiety) while problem use of sedative-hypnotics may be greater in people with panic (who may be over-prescribed anxiolytics because they repeatedly seek medical assistance).

METHOD

Self-reported lifetime rates of drug and alcohol problems were assessed with the computerised Diagnostic Interview Schedule-Revised. Subjects were 146 consecutive patients treated for panic disorder (with and without agoraphobia) and social phobia at the Clinical Research Unit for Anxiety Disorders.

RESULTS

High prevalences of alcohol problems (three times that expected) and problem use of sedative hypnotics (eight times that expected) were found in all diagnoses. Social phobics exhibited comparatively high rates of problem alcohol use, but no diagnostic specific differences in problem sedative-hypnotic use were found.

CONCLUSION

Routine screening for drug and alcohol problems is necessary for patients with anxiety disorders.

Alcohol and depression in panic disorder

Panic disorder (PD) is a common psychiatric illness, which has many complications such as major depression, increased suicide risk, agoraphobic avoidance behaviour, alcohol abuse and dependence. A number of studies have now documented increased rates of anxiety disorders among alcoholics and of alcoholism among patients presenting with anxiety disorders. In general, it appears that PD is more prevalent in alcoholics than would be expected on the basis of general population rates. Alcohol withdrawal is clearly associated with severe anxiety symptoms. It is suggested that repeated withdrawal episodes may trigger panic through a kindling process by causing subconvulsive stimuli with increasing amounts of electrical excitability or even spontaneous seizures. Serotonergic medications are effective in treating PD and depression. They also diminish interest in drinking in ethanol-dependent patients. Serotonergic agents can also affect conditioning and learning as well as behavioral control and self-administration. The treatment of panic patients with depressive and alcohol problems usually requires long-term treatment.

Social adjustment in panic-agoraphobic patients reconsidered

Forty-eight depressed panic-agoraphobic patients--clinically matched for severity of depression with 35 primary chronic depressives--had significantly better adjustment in most areas of social functioning, especially those related to interpersonal contact, work, leisure activities, and sexual life. Even when depressed, panic-agoraphobic patients appear to possess sufficient interpersonal skills--that is, by learning on significant others--to engage in a range of social activities, both at home and beyond. These data, which are open to different interpretations, nonetheless suggest that anxiety and mood disorders differently affect certain key areas of social adjustment.

[Panic disorder and alcoholism: effects of comorbidity]

Both epidemiological and clinical studies have demonstrated a high prevalence of panic disorder among alcoholic patients. In contrast, little attention has been given to studying alcohol abuse and/or dependence in patients suffering from panic disorder. One hundred and fifty-five consecutive referrals for treatment for panic disorder were interviewed using a modified version of the Schedule for Affective Disorders and Schizophrenia--Lifetime Version, modified for the study of anxiety disorders. Thirty-two patients (20.7%) had a lifetime history of alcohol abuse and/or dependence. Although the lifetime comorbidity rate of either agoraphobia and/or social phobia seems without any influence on the risk of alcohol-related disorder, alcoholic patients suffering from panic disorder appear to be more likely to have a history of depression and other addictive disorders. The majority of patients with primary alcoholism were male, and those who became alcoholics after they developed panic disorder were more likely to be female. The comparison between patients with primary and secondary alcoholism did not indicate any difference in the comorbidity rate with other psychiatric disorders nor the severity of panic disorder.

Suicide, chemical abuse, and panic attacks: a preliminary report

Seventy-two chemical abuse patients who either met DSM-III-R criteria for panic disorder (PD), experienced infrequent panic attacks (IP), or did not experience panic attacks in the past year (NP) were compared on several dimensions. PD subjects were more likely to be female and to have attempted suicide. Patients who had attempted suicide, when compared to non-suicide attempters, were more likely to be classified as having PD, and be non-married. IP and NP groups did not differ on any of the relevant variables. The similarities of these findings to those obtained with PD and chemical abuse patients are discussed.

Medication use and the assessment of agoraphobic avoidance

Many anxiety disorder patients who present for behaviour therapy are already taking anxiolytic medications. The present study added a new subscale to the Mobility Inventory labelled 'Without Medication' to assess possible reliance on medication for coping with phobic situations. 121 Patients with panic-related disorders were administered the scale. The results supported the reliability and validity of the existing Mobility Inventory subscales in general and of the new subscale in particular. It appears to reliably assess a clinically important domain that is not measured in traditional self-report measures of phobic avoidance.

Management of early postdischarge adjustment reactions following psychiatric hospitalization

Psychiatric patients frequently experience serious symptoms and demonstrate disturbed behaviors in the very early postdischarge period. Based on 25 years of clinical experience, the author reviews symptoms and behaviors that can occur and notes that they should most often be viewed as adjustment reactions rather than as exacerbations of the primary illness. A team approach to management of early postdischarge reactions that uses a psychiatrist and psychiatric nurse is effective. Interventions include forewarning inpatients that problems may occur and helping them identify potential problems. Social skills training, learning therapies, and family counseling help patients prepare to cope. Accompanying patients home on passes during hospitalization is helpful, as is inviting them to visit the hospital during their first days at home. Scheduling initial office visits within three days of discharge is another way of easing a difficult transition.

Adult children of alcoholics in treatment programs for anxiety disorders and substance abuse

Studies of the first-degree relatives of patients with alcoholism and anxiety disorders have identified a significant overlap of these disorders. Forty percent of the patients in an outpatient anxiety disorder program were adult children of alcoholics (ACOA), a proportion similar to that found in the substance abuse program. The ACOAs in both programs were younger, had higher co-dependency scores and were younger when they had their first psychiatric contact than the controls. The adult children of alcoholics who had anxiety disorders were more likely to be female and their alcoholic parents were less likely to have had psychiatric antecedents to alcoholism. Aside from substance abuse, similarities in sociodemographic variables and the impact of the parents' alcoholism were noted, reinforcing the hypothesis that vulnerabilities to anxiety disorders and alcoholism overlap.

Relapse among alcoholics with phobic and panic symptoms

A group of 35 alcoholics who indicated they had symptoms of phobia, panic, or both (the anxiety problem group) were compared to their matched controls who did not indicate having anxiety problems. Comparisons of relapse rates, reasons for relapse, and rates of emotional problems at six months posttreatment were made. Results showed that although relapse rates were similar between the two groups, significantly more anxious subjects reported relapsing to cope with depression and experiencing problems with nervousness, tension, and anger posttreatment. Implications for treatment and the need for further research are discussed.