MEDLINE Abstracts: Panic Disorder Review
What's new concerning the issues and treatment of panic disorder? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Psychiatry & Mental Health.
Sheehan DV
J Clin Psychiatry 1999;60 Suppl 18:16-21
Panic disorder is a prevalent psychiatric condition that often is chronic and rarely resolves without medical intervention. Many patients with panic disorder initially present with a variety of somatic symptoms, including chest pain, nausea, or dizziness, and patients frequently seek care in ambulatory care settings. Although panic disorder is classified as a single entity, it can have many dimensions and may be associated with significant morbidity. During the past 2 decades, there have been significant advances in the treatment of panic disorder, and a range of therapeutic choices is now available. Four classes of medications, including the selective serotonin reuptake inhibitors (SSRIs), high-potency benzodiazepines, tricyclic antidepressants, and monoamine oxidase inhibitors, may be considered for the management of patients with panic disorder. Emerging clinical data favor the SSRIs as first-line treatment for patients with panic disorder, and paroxetine and sertraline have been approved by the U.S. Food and Drug Administration for use in panic disorder. This article reviews the efficacy and safety of these treatments, as well as their relative merits and disadvantages, and assists the practicing clinician in choosing among the various pharmacotherapies to tailor therapy to each patient's individual needs.
Candilis PJ; McLean RY; Otto MW; Manfro GG; Worthington JJ 3rd; Penava SJ; Marzol PC; Pollack MH
J Nerv Ment Dis 1999 Jul;187(7):429-34
In this study we assessed the quality of life of patients with panic disorder, with particular attention to the influence of anxiety and depression comorbidity on quality of life. Findings were compared with established general population norms as well as norms for patients with chronic medical conditions and major depression. The Medical Outcomes Study Short-Form Health Survey (SF-36) was administered to panic disorder patients entering clinical trials or treatment in an outpatient anxiety disorders program. Subjects were 73 consecutive patients with a primary diagnosis of panic disorder without current substance abuse or contributory medical illness. Their quality of life scores were compared with population mean estimates using single-sample t-tests, and the influence of comorbidity was examined with between-group comparisons. All SF-36 mental and physical health subscale scores were worse in patients with panic disorder than in the general population. This was true regardless of the presence of comorbid anxiety or mood disorders, although the presence of the comorbid conditions worsened select areas of functioning according to subscale analyses. SF-36 scores in panic patients were at approximately the same level as patients with major depression and tended to be worse in specific areas than patients with select medical conditions. This study provides evidence of the pervasive negative effects of panic disorder on both mental and physical health.
Friedman S
J Anxiety Disord 1999 Sep;13(5):447-461
Recent findings by Weissman, Klerman, Markowitz, and Ouellette (1989) that subjects with panic disorder, with and without comorbid conditions, may be at increased risk for suicide attempts have been controversial. In an attempt to further investigate this finding, we utilized the original National Institute of Mental Health Epidemiological Catchment Area (ECA) suicide questions in an outpatient psychiatric clinic. We examined patients with panic disorder (n = 101). other anxiety disorders (n = 47), schizophrenia (n = 22). and major depression (n = 19). No significant differences were found among all four groups on any of the ECA suicide ideation questions. Only two (2%) of the panic disorder patients and none of the other groups made a suicide attempt in the past year. While 17% of patients with panic disorder and 9% of patients with other anxiety disorders reported having made a suicide attempt at some other time in their life, the schizophrenic (33%) and depressed groups (40%) reported significantly greater histories of suicide attempts. In a forward stepwise regression analysis for panic disorder patients, a history of substance abuse and comorbid depression predicted suicidality. The actual clinical risk for suicide attempts in panic disorder patients appears to occur when they suffer with comorbid diagnoses. These results highlight the need to aggressively treat panic disorder patients so they do not suffer the all-too-common sequelae of depression and substance abuse.
Woodman CL; Noyes R Jr; Black DW; Schlosser S; Yagla SJ
J Nerv Ment Dis 1999 Jan;187(1):3-9
To examine the course and outcome of subjects with generalized anxiety disorder (GAD) and panic disorder, we compared 64 patients with GAD and 68 patients with panic disorder who had participated in drug treatment studies and were interviewed an average of 5 years earlier. At baseline GAD subjects were significantly older, had an earlier onset, and longer duration of illness than panic subjects. GAD subjects also had less severe symptoms. At follow-up, diagnostic stability was observed for both GAD and panic disorder. Significantly fewer GAD subjects achieved full remission at follow-up (18% vs. 45%, p < .01). Subjects with GAD were significantly less anxious at baseline than the panic disorder comparison group, but at follow-up there were few significant differences between groups on most severity of illness variables. This change was due in great part to improvement in the panic disorder group with a concomitant lack of change in the GAD group.
Blier P; de Montigny C
Neuropsychopharmacology 1999 Aug;21(2 Suppl):91S-98S
The therapeutic effectiveness of antidepressant drugs in major depression was discovered by pure serendipity. It took over 20 years before the neurobiological modifications that could mediate the antidepressive response were put into evidence. Indeed, whereas the immediate biochemical effects of these drugs had been well documented, their antidepressant action generally does not become apparent before 2 to 3 weeks of treatment. The different classes of antidepressant treatments were subsequently shown to enhance serotonin neurotransmission albeit via different pre- and postsynaptic mechanisms. Clinical trials based on this hypothesis led to the development of treatment strategies producing greater efficacy and more rapid onset of antidepressant action; that, is lithium addition and pindolol combination, respectively. It is expected that the better understanding recently obtained of the mechanism of action of certain antidepressant drugs in obsessive-compulsive and panic disorders will also lead to more effective treatment strategies for those disorders.
Wade AG
Int Clin Psychopharmacol 1999 May;14 Suppl 2:S13-7
Panic disorder is a serious and common illness affecting 1% of the population at any one time. Comorbidity with depression may be as high as 40%. The illness has been recognized as a separate entity since the 1960s and treatment with tricyclics being used since that time. Tricyclics, monoamine oxidase inhibitors, benzodiazepines, beta-blockers and anticonvulsants have all been used with varying degrees of success. Until recently, tricyclics and benzodiazepines were the treatments of choice but selective serotonin reuptake inhibitors (SSRIs) have recently been studied intensively and, based on studies of citalopram and paroxetine, must now be considered first line therapy. Both SSRIs and tricyclics suffer from a long latency period, possibly as long as 12 weeks before maximal benefit is obtained, which is in contrast to the benzodiazepines that produce almost instant symptom relief. The dependency potential of the benzodiazepines, however, limits their usefulness. Paroxetine and citalopram have good efficacy data over both the short and long term and are effective at standard dosages, the most effective for citalopram being 20-30 mg. Both drugs performed better than the comparator tricyclic antidepressant (chlomipramine) and must now be considered current drugs of choice. Despite the superior efficacy of these drugs, however, many patients are poorly controlled and investigation of combination therapies for resistant panic disorder is needed.
Busch FN
J Psychother Pract Res 1999;8(3):234-242
The authors elaborate psychodynamic factors that are relevant to the treatment of panic disorder. They outline psychoanalytic concepts that were employed to develop a psychodynamic approach to panic disorder, including the idea of unconscious mental life and the existence of defense mechanisms, compromise formations, the pleasure principle, and the transference. The authors then describe a panic-focused psychodynamic treatment based on a psychodynamic formulation of panic. Clinical techniques used in this approach, such as working with transference and working through, are described. Finally, a case vignette is employed to illustrate the relevance of these factors to panic disorder and the use of this treatment.(The Journal of Psychotherapy Practice and Research 1999; 8:234-242).
Goisman RM; Warshaw MG; Keller MB
Am J Psychiatry 1999 Nov;156(11):1819-21
Objective: Pharmacologic prescriptions for anxiety disorders have changed significantly in the last decade. This article investigates whether psychosocial treatments, as reported by 362 subjects in the Harvard/Brown Anxiety Disorders Research Program from 1991 to 1996, changed as well.
Method: Subjects were interviewed in 1991 and 1995-1996 to determine which psychosocial treatments (behavioral, cognitive, dynamic, or relaxation or meditation) they had received.
Results: The percentage of subjects who received each type of psychosocial treatment either declined or remained the same from 1991 to 1995-1996. Dynamic psychotherapy remained the most frequently used method of these four. The percentage of subjects receiving any such method declined.
Conclusions: Behavioral and cognitive treatment, two empirically validated forms of psychotherapy, were less frequently used than dynamic psychotherapy, which lacks such validation. All use of verbal treatment methods declined from 1991 to 1995-1996.
Dyckman JM; Rosenbaum RL; Hartmeyer RJ; Walter LJ
Psychosomatics 1999 Sep-Oct;40(5):422-7
For patients initially seen in the emergency department (ED) for panic attack, this study evaluated the effect of two brief psychological interventions in the ED on later utilization of emergency, psychiatric, and nonpsychiatric medical department services. Each of the two intervention groups received usual ED care, a brochure on panic disorder, and a referral to treatment at the psychiatry department; one of the two groups also received 20-30 minutes of contact with a representative from the psychiatry department. Both intervention groups were compared with a historical control group. The contact condition reduced ED use after the initial visit to the ED, although all three groups had more visits to the psychiatry department and to all nonpsychiatric departments. This decrease was statistically significant (P = 0.0017) when compared with the brochure condition but not when compared with the historical control group (P = 0.0672). The decrease seen in ED use is an important therapeutic and economic finding.
Otto MW; Pollack MH; Penava SJ; Zucker BG
Behav Res Ther 1999 Aug;37(8):763-70
The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.
Clark DM; Salkovskis PM; Hackmann A; Wells A; Ludgate J; Gelder M
J Consult Clin Psychol 1999 Aug;67(4):583-9
Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.
Loerch B; Graf-Morgenstern M; Hautzinger M; Schlegel S; Hain C; Sandmann J; Benkert O
Br J Psychiatry 1999 Mar;174:205-12
Background: In the treatment of panic disorder with agoraphobia, the efficacy of pharmacological, psychological and combined treatments has been established. Unanswered questions concern the relative efficacy of such treatments. AIMS: To demonstrate that moclobemide and cognitive-behavioural therapy (CBT) are effective singly and more effective in combination.
Method: Fifty-five patients were randomly assigned to an eight-week treatment of: moclobemide plus CBT; moclobemide plus clinical management ('psychological placebo'); placebo plus CBT; or placebo plus clinical management.
Results: Comparisons between treatments revealed strong effects for CBT. Moclobemide with clinical management was not superior to placebo. The combination of moclobemide with CBT did not yield significantly better short-term results than CBI with placebo. The CBT results remained stable during a six-month follow-up, although a substantial proportion of patients treated with placebo plus CBT needed additional treatment.
Conclusions: CBT was highly effective in the treatment of panic disorder with agoraphobia and reduced agoraphobia to levels that were comparable to those of non-clinical controls.
Gelder MG
J Clin Psychopharmacol 1998 Dec;18(6 Suppl 2):2S-5S
Cognitive behavior therapy (CBT) has been combined with pharmacotherapy in the treatment of panic disorder in three ways: (1) to treat agoraphobic symptoms in the condition of panic with agoraphobia; (2) to reduce withdrawal effects during drug taper; and (3) to treat panic attacks. Exposure treatment and pharmacotherapy have a modest additive effect, although more patients drop out of exposure therapy combined with imipramine treatment compared with exposure therapy alone. CBT reduces symptoms of withdrawal from alprazolam and other benzodiazepines and improves the outcome of drug treatment. At present, sufficient data are not available to determine whether the effects of CBT combined with drug therapy are additive in treating panic disorder. The results of a large trial are awaited. Current CBT consists of 12 sessions and is not widely offered to patients because of cost considerations. Efforts are being made to decrease the number of sessions necessary by improving cognitive techniques. One of these models is the subject of an ongoing trial. Finally, efforts to educate and counsel patients in the clinical setting regarding the psychopathology of panic attacks may improve the outcome of pharmacotherapy.
Breslau N
Arch Gen Psychiatry 1999 Dec;56(12):1141-1147
Background: Epidemiologic studies have reported a lifetime association between smoking and panic disorder. In this study, we examine potential explanations for this association.
Methods: Analysis was conducted on data from 2 epidemiologic studies, the Epidemiologic Study of Young Adults in southeast Michigan (N = 1007) and the National Comorbidity Survey Tobacco Supplement (n = 4411). Cox proportional hazards models with time-dependent covariates were used to estimate the risk for onset of panic attacks associated with prior smoking and vice versa, controlling for history of major depression. The role of lung disease in the smoking-panic attacks association was explored.
Results: Daily smoking signaled an increased risk for first occurrence of panic attack and disorder; the risk was higher in active than past smokers. No significant risk was detected for onset of daily smoking in persons with prior panic attacks or disorder. Exploratory analyses suggest that lung disease might be one of the mechanisms linking smoking to panic attacks.
Conclusions: The evidence that the association between smoking and panic disorder might result primarily from an influence in one direction (i.e., from prior smoking to first panic attack) and the possibility of a higher risk in active than past smokers suggest a causal hypothesis for the smoking-panic attacks relationship.
Lautenbacher S
Psychosom Med 1999 Nov;61(6):822-827
Objective: There is evidence that depression and panic disorder are both associated with an increased frequency of clinical pain complaints. A change in pain sensitivity is alleged to be involved in this phenomenon. However, few studies have assessed clinical pain complaints and pain sensitivity in the same group of patients.
Methods: Thirteen patients with a major depressive disorder, 13 patients with a panic disorder (diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition), and 13 healthy control subjects were investigated. None of the subjects were taking medications. Body maps were used to measure the number of painful sites as well as the intensity and unpleasantness of pain complaints in the previous 6 months. Furthermore, pain thresholds for pressure, cold, and heat were assessed at the forearm or hand.
Results: Patients with depression and panic disorder had significantly more frequent, more intense, and more unpleasant pain complaints than healthy control subjects. Despite this similarity, patients with depression had significantly higher pain thresholds than patients with panic disorder in two (pressure and cold) of three stimulus modalities and significantly higher pressure pain thresholds than the healthy control subjects. There were no differences between the pain thresholds of patients with panic disorder and healthy control subjects. The correlations between clinical pain measures and pain thresholds were generally weak.
Conclusions: These findings suggest that the clinical pain complaints of patients with depression and panic disorder cannot simply be explained by changes in pain sensitivity.
Davies SJ; Ghahramani P; Jackson PR; Noble TW; Hardy PG; Hippisley-Cox J; Yeo WW; Ramsay LE
Am J Med 1999 Oct;107(4):310-6
Purpose: Previous studies of the association between hypertension and panic disorder were uncontrolled or involved small numbers of patients.
Patients and Methods: We compared the prevalence of panic disorder and panic attacks in 351 patients with documented hypertension who were randomly selected from all hypertensive patients registered in one primary care practice with age- and gender-matched normotensive patients from the same practice and with hypertensive patients attending a hospital clinic. All three groups completed questionnaires for panic disorder based on standard criteria, as well as the Hospital Anxiety and Depression scale.
Results: The prevalence of current (previous 6 months) panic attacks was significantly greater in primary care patients with hypertension (17%, P <0.05) and hospital-based hypertensive patients (19%, P <0.01) than in normotensive patients (11%). Similar results were seen for lifetime panic attacks (35% versus 39% versus 22%; both P for comparisons with normotensive patients <0.001). The prevalence of panic disorder was significantly greater in primary care patients with hypertension (13%) than normotensive patients (8%, P <0.05). Anxiety scores were significantly higher in both hypertensive groups than in normotensive patients. Depression scores were significantly higher in hospital-based hypertensive patients than in the other two groups. The reported diagnosis of hypertension antedated the onset of panic attacks in a large majority of patients (P <0.01).
Conclusions: Physicians caring for patients with hypertension should be aware of the significantly greater prevalence of panic attacks in these patients.
Marazziti D; Toni C; Pedri S; Bonuccelli U; Pavese N; Lucetti C; Nuti A; Muratorio A; Cassano GB
Int Clin Psychopharmacol 1999 Jul;14(4):247-51
We investigated the prevalence of headache in a group of patients attending a psychiatric clinic because suffering from panic disorder, according to DSM-IV criteria. The psychopathological assessment was performed with the 'Panic Disorder/Agoraphobia Questionnaire' and the presence of headache was evaluated according to the criteria of the International Headache Society. The results showed that two-thirds of patients met the criteria for a diagnosis of headache, with migraine without aura being the most frequent form, followed by tension headache, while two patients only were affected by migraine with aura. When we compared panic patients with and without headache, those with headache had a longer duration of panic disorder, a higher number of attacks and a heavier family loading for panic disorder and headache. This suggests that the comorbidity of headache with panic disorder renders this condition more severe and possibly responsive to different treatments compared to panic disorder alone.
Roy-Byrne PP; Stein MB; Russo J; Mercier E; Thomas R; McQuaid J; Katon WJ; Craske MG; Bystritsky A; Sherbourne CD
J Clin Psychiatry 1999 Jul;60(7):492-9; quiz 500
Background: Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome.
Method: Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications.
Results: Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p < .01), more utilization of emergency room and medical provider visits (p < .01), and more mental health visits (p < .05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy.
Conclusion: These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.
Stein MB; Roy-Byrne PP; McQuaid JR; Laffaye C; Russo J; McCahill ME; Katon W; Craske M; Bystritsky A; Sherbourne CD
Psychosom Med 1999 May-Jun;61(3):359-64
Objective: The purpose of this study was to determine the utility of a brief screening tool for panic disorder in the primary care setting.
Methods: A total of 1476 primary care outpatients in three primary care medical clinics on the West Coast of the United States were studied. Patients completed a brief self-report measure, the five-item Autonomic Nervous System Questionnaire (ANS), while in the waiting room. The presence of DSM-IV panic disorder was subsequently determined in groups of "screen-positive" and "screen-negative" subjects using the Composite International Diagnostic Interview. A subset of patients (N = 511) also completed the 21-item Beck Anxiety Inventory. Indices of diagnostic utility were calculated using receiving operating characteristic analyses to guide the selection of optimal cutoff levels.
Results: The two-question version of the ANS had excellent sensitivity (range = 0.94-1.00 across the three clinic sites) and negative predictive value (0.94-1.00) but low specificity (0.25-0.59) and positive predictive value (range 0.18-0.40). The three- and five-question versions of the ANS had only modestly improved specificity, and this was achieved at the cost of reduced sensitivity and increased respondent burden to complete the questionnaire. The 21-item Beck Anxiety Inventory had maximal clinical utility at a cutoff level of > or =20, but sensitivity was lower than desirable for a screening instrument (0.67).
Conclusions: The two-question version of the ANS shows promise as a screening instrument for panic disorder in the primary care setting.
Barsky AJ; Delamater BA; Orav JE
Psychosomatics 1999 Jan-Feb;40(1):50-6
The goal of the study was to examine the functional status and medical care of general medical outpatients with panic disorder. One hundred patients completed self-report questionnaires and a diagnostic interview for panic disorder. They were compared with a random sample of patients without panic disorder. Medical morbidity was assessed from the medical record, and the patients' clinic physicians completed a questionnaire about them. The prevalence of current (1 month) panic disorder was 6.7%-8.3%. The panic disorder patients had fewer serious medical diagnoses, but more medical utilization and more role impairment than the comparison group. The clinic physicians rated the panic patients as more anxious, more depressed, more hypochondriacal, and more difficult to care for. Sixty-one percent of the panic disorder patients recalled receiving an anxiety disorder diagnosis. These findings add to a growing body of evidence that panic disorder imposes a significant burden on those with this illness and that it is a seriously underdiagnosed condition in primary care practice.
Carr RE
J Asthma 1999;36(2):143-52
The presence of asthma is a risk factor for the development of panic disorder. The co-occurrence of panic disorder and asthma is greater than would be expected based on their individual prevalence rates. This may be due in part to the important role of respiratory factors in panic disorder. Panic and anxiety can directly exacerbate asthma symptoms through hyperventilation, and are associated with patients' overuse of as-needed asthma medications, with more frequent hospital admissions and longer hospital stays, and with more frequent steroid treatment, all of which are independent of degree of objective pulmonary impairment. This paper reviews the literature on the relationship between panic and anxiety on the one hand, and the experience and management of asthma on the other.
Akiyoshi J
Nihon Shinkei Seishin Yakurigaku Zasshi 1999 Jul;19(3):93-99
A study on the biology of 'panic disorder,' which I have classified under the category of 'anxiety disorder,' made progress recently. In a genetic study, the hereditary of panic disorder was checked by a 'linkage and twins' study, and the anticipation of panic disorder was recognized as being the same as that which is also found in the psychiatric conditions known as schizophrenia and manic depression. A panic disorder patient regards the anxious sign of a model as ruinous, and this weakness in recognition has been duly noted. Therefore, I studied a patient showing a continuance state of 'hyper-sensitivity,' and compared this to a patient showing a 'sleep disorder.' Noradrenaline plays an important role in anxiety as suppression of the locus ceruleus (LN), the major NE-containing nucleus of the noradrenaline nervous system, brings on a calming effect. Yohimbine, however, which is an alpha 2 antagonist, is found to induce panic attacks. The fact that selective serotonin reuptake inhibitor (SSRI) suppresses panic attacks suggests that serotonin is connected with panic disorders. It is also thought that the 'raphe nucleus' is the site of origin of the serotonin nervous system, which participates in the control of anxiety. This suggests the participation of a gamma-aminobutyric acid (GABA) nervous system in which the administration of benzodiazepine at a high potency would be an effective agent against panic disorder. Cholecystokinin (CCK) is also suggested to have a connection with panic disorder as CCK-4 causes panic attacks. There has been no CCK antagonist found effective for an object- or time-oriented panic disorder at the present. It is thought that corticotropin-releasing factor (CRF) is released during a panic attack. The development of a new CRF receptor antagonist is needed. In addition to the studies on the neurotransmitters of the traditional type, such as noradrenaline, serotonin and GABA, studies on the neuropeptides, such as CCK and CRF have become important for future consideration. Understanding this, image studies such as MRI, SPECT, fMRI and PET have become highly desirable.
Fyer AJ; Weissman MM
Am J Med Genet 1999 Apr 16;88(2):173-81
This paper describes the clinical methodology and currently collected pedigrees from an ongoing genetic study of panic disorder. The main objectives are to (1) document the clinical aspects of the study for current [Knowles et al., 1998: Am. J. Med. Genet. (Neuropsychiatr. Genet.) 81:138-147] and future reports of genetic analysis; (2) assist other investigators working on the genetic aspects of panic disorder who wish to compare results; and (3) illustrate the numerous judgment calls required in such studies that may lead to methodological variability and could account for differences in findings between studies. We also describe initial strategies to identify more genetically homogeneous panic disorder subtypes. Families were recruited through letters to magazines, word of mouth referral, and screening in anxiety disorder clinics and were asked to participate if at initial diagnostic screening they appeared to have at least three members (in two generations) affected with panic disorder. Diagnostic evaluations included a lifetime clinician-administered semistructured psychiatric interview, family history assessment, and pertinent medical records. Diagnoses for linkage analysis are derived from a best-estimate procedure that includes independent review of all materials by two senior investigators. All clinical evaluations were done blind to genotypes. Fifty-five pedigrees including 679 individuals have been collected to date. DNA is available from 500 family members of whom almost half (48%) are definitely or probably affected with panic disorder. Most (93%) of these subjects were directly interviewed, and the clinical data include not only lifetime psychiatric and medical diagnoses and but also detailed narrative histories describing sequence and context of symptoms. Family sizes range from 4-36 individuals (mean = 12.3) and the number of affected individuals per family from 2-12.
[Epidemiologie genetique et psychiatrie (I): Portees et limites des etudes de concentration familiale. Exemple du trouble panique.]
Gorwood P; Feingold J; Ades J
Encephale 1999 Jan-Feb;25(1):21-9
Genetics epidemiology shed new light on multifactorial disorders for which genes are partly involved, for example on numerous psychiatric diseases. Nevertheless, each epidemiological technic has it's caracteristics and limitations. This review discuss the impact of aggregation studies, on the bases of an example, namely all aggregation studies on panic disorder. We detected through Medline thirteen studies, comparing 3,700 relatives of 780 probands affected with panic disorder, with 3,400 relatives of 720 unaffected controls. It is computed that relatives of patients with panic disorder have an increased risk (10.7%) for panic disorder than relatives of controls (1.4%), relatives from affected probands having a high relative risk (6.8) for panic disorder according to the meta-analysis. On the basis of these 13 aggregation studies, there is an important attribuable risk (78.3%) of "having a familial history of panic disorder" in the risk for panic disorder. Furthermore, the estimated heritability is 73% (73% of the total variance would be explained by additive genetic effects), if Reich's conditions are fulfilled for a valid estimation of the heritability on the basis of aggregation families. These studies can also be used to highlight the variability of expression according to gender, to show the relevance of quantitative approaches (versus the qualitative approach which is nearly systematically used), to underline the informations raised by experimental technics (such as panic disorder induced by lactate), and to raise the potential existence of phenocopies. Lastly, aggregation studies on panic disorder can help to understand the high comorbidity of this disorder, with other anxiety disorders and mood disorder.
Sullivan GM
Biol Psychiatry 1999 Nov 01;46(9):1205-1218
Over the past three decades of psychiatric research, abnormalities in the noradrenergic system have been identified in particular anxiety disorders such as panic disorder. Simultaneously, neuroscience research on fear pathways and the stress response have delineated central functions for the noradrenergic system. This review focuses on the noradrenergic system in anxiety spectrum disorders such as panic disorder, generalized anxiety disorder, and phobias for the purpose of elucidating current conceptualizations of the pathophysiologies. Neuroanatomic pathways that are theoretically relevant in anxiogenesis are discussed and the implications for treatment reviewed.
Coplan JD; Lydiard RB
Biol Psychiatry 1998 Dec 15;44(12):1264-76
This paper reviews the pathophysiology of panic disorder (PD), within the context of newly described "fear circuitries," which have been well characterized in preclinical models. Substantial advances in the neurosciences have made it possible for clinical neuroscientists to refine our understanding of the pathophysiology of PD and the mechanisms of currently effective treatment. These advances have in turn helped generate testable hypotheses for future neurobiological and psychopharmacologic research. Perturbation of mutual modulation ("cross talk") between key brain transmitter systems (serotonin, norepinephrine, gamma-aminobutyric acid, corticotropin-releasing factor, and others) may underlie the pathogenesis of panic-anxiety. Restoration of normal homeostasis may be an important therapeutic component of antipanic therapy and may provide information about underlying neurocircuits. Neuroimaging, an important new tool, has already begun to bridge the gap between the preclinical and clinical neurosciences through confirmation of hypothesized dysfunction of the complex human prefrontal cortex and its subcortical components. In higher species, such as humans, dysfunction of cortical inhibition or excessive cortical activation of caudal limbic structures is postulated to lead to activation of the phylogenetically conserved amygdalofugal pathways. Consistent with probable subtypes of PD, overlapping theoretical models of panic neurocircuitries are proposed, including ventilatory dysregulation, which is coupled with neurovascular instability in a critical area of the panic neurocircuitry--the amygdalohippocampus. Neuroimaging appears a critical tool in guiding further elaboration of the interaction of cortical and subcortical components of the panic neurocircuitry, whereas challenge studies appear crucial in gathering further information regarding brain stem dysfunction.
Smith LC; Friedman S; Nevid J
J Nerv Ment Dis 1999 Sep;187(9):549-60
Much attention has been paid to the study of panic disorder symptomatology among primarily European American populations. However, such research has not adequately generalized to include minority groups. The present study examined phenomenological differences between African American and European American patients with panic disorder with or without agoraphobia. African American (N = 48) and European American (N = 33) patients with panic disorder were assessed by structured interview and self-report questionnaires upon presentation to an anxiety disorders clinic for treatment. African Americans evidenced a higher rate of comorbid posttraumatic stress disorder (16% vs. 0%). European Americans reported having their initial panic attack at an earlier age than African Americans (21 vs. 29). In terms of discrete panic attack symptoms, African Americans reported more intense levels of numbing/tingling in extremities (4.3 vs. 2.5) as well as greater fear of dying (6.3 vs. 4) or going crazy (4.6 vs. 3) than European Americans. African Americans evidenced less satisfaction with social support (2.7 vs. 3.2), especially financial support (2.3 vs. 3.2), than European Americans. African Americans employed coping strategies such as counting one's blessings (1.9 vs. 1.4) and religiosity (1.9 vs. 1.2) more often than European Americans but evidenced less self blame (1.7 vs. 2). This study extends previous findings by showing that African Americans have a later age of onset as well as different coping strategies than European American patients with panic disorder.
Hertzberg T; Wahlbeck K
J Psychosom Obstet Gynaecol 1999 Jun;20(2):59-64
There is little known about the effect of pregnancy and the puerperium on the risk for, and course of anxiety disorders. Initial case reports concerning the relationship between panic disorder (PD) and pregnancy/puerperium suggested that pregnancy protected against PD, while the postpartum period seemed to increase the risk for onset or exacerbation of PD. Later studies have offered a more mixed picture. A computerized search identified eight relevant studies in this area. All were non-controlled and all but one retrospective. Out of the total 215 pregnancies that were described in these studies, 89 (41%) were associated with improvement of PD symptoms during the pregnancy, while 38% of the described pregnancies exhibited onset or exacerbation of PD in the postpartum period. No definite conclusions regarding the effect of pregnancy and puerperium on PD can be drawn from these reviewed studies.
Yonkers KA; Zlotnick C; Allsworth J; Warshaw M; Shea T; Keller MB
Am J Psychiatry 1998 May;155(5):596-602
Objective: Panic disorder with or without agoraphobia has a chronic relapsing course. Factors associated with poor outcome include early onset of illness and phobic avoidance. Several, but not all, authors have found a worse clinical course for women. Using observational, longitudinal data from the Harvard/Brown Anxiety Disorders Research Program, the authors analyzed remission and symptom recurrence rates in panic patients with respect to sex.
Method: Male and female patients (N=412) in an episode of panic with or without agoraphobia were assessed by structured interview and prospectively followed for up to 5 years. Data on remission, symptom recurrence, and comorbid psychiatric conditions for each sex were compared.
Results: There were no significant differences between men and women in panic symptoms or level of severity at baseline. Women were more likely to have panic with agoraphobia (85% versus 75%), while men were more likely to have uncomplicated panic (25% versus 15%). The rates of remission for panic with or without agoraphobia at 5 years were equivalent in men and women (39%). Of the subjects who achieved remission, 25% of the women and 15% of the men reexperienced symptoms by 6 months. Recurrence of panic symptoms continued to be higher in women (82%) than men (51%) during the follow-up period and was not influenced by concurrent agoraphobia.
Conclusions: This study extends previous findings by showing that not only are women more likely to have panic with concurrent agoraphobia, but they are more likely than men to suffer a recurrence of panic symptoms after remission of panic.
Turgeon L; Marchand A; Dupuis G
J Anxiety Disord 1998 Nov-Dec;12(6):539-53
This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.
Starcevic V; Djordjevic A; Latas M; Bogojevic G
Depress Anxiety 1998;8(1):8-13
We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall "profile" of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings.
Sansone RA; Sansone LA; Righter EL
J Womens Health 1998 Oct;7(8):983-9
Panic disorder, an intense exacerbation of anxiety accompanied by a variety of physical symptoms, is twice as common among women as among men. Onset is bimodal (teens/20 s and mid-30 s/40 s), 50% of cases are accompanied by agoraphobia, and the etiology is probably multifactorial. Treatment in the primary care setting includes pharmacologic (selective serotonin reuptake inhibitors) and cognitive-behavioral intervention. Medication is initiated at low doses, and the drug-evaluation trial is of 6 weeks duration. Psychiatric referral is helpful in nonresponders and in those with comorbid psychiatric conditions. Outcome varies, with most patients experiencing relief with treatment. For some people, however, the disorder is chronic, with ongoing exacerbations and remissions.
Fleet RP; Marchand A; Dupuis G; Kaczorowski J; Beitman BD
Psychosomatics 1998 Nov-Dec;39(6):512-8
In a recent study, the authors reported that 25% (108/441) of consecutive emergency department (ED) chest pain patients had panic disorder (PD). As part of this study, the authors sought to answer the question: How do ED patients with PD compare with patients with PD who seek treatment in a psychiatric setting? PD patients from an ED (n = 108) and psychiatric clinic (n = 137) were compared with respect to comorbid Axis I diagnoses, self-report scores, and recent suicidal ideation. The group of psychiatric patients was younger (36.5 vs. 52.3 years) (P < 0.0001) and consisted of proportionally more women (63% vs. 39%) (P = 0.0001) than the ED patients. The psychiatric patients had significantly higher rates of comorbid agoraphobia (100% vs. 15%) (P < 0.0001), social phobia (23% vs. 3%) (P = 0.0001), specific phobia (12.3% vs. 4.6%) (P = 0.03), and posttraumatic stress disorder (16.9% vs. 5.6%) (P = 0.006), compared with the ED patients, and displayed significantly higher scores on all of the self-report panic measures. However, the patients in both groups had similar rates of comorbid generalized anxiety disorder (41.2% vs. 33.3%) (P = 0.17), major depression (8.8% vs. 11.1%) (P = 0.54), and obsessive-compulsive disorder (1.5% vs. 2.8%) (P = 0.7). Both groups also did not differ on the Beck Depression Inventory and in their rate of report of recent suicidal ideation (32% vs. 25%) (P = 0.23). Both psychiatric and ED patients with PD appear to be highly distressed patients who require treatment. Early intervention for ED patients may prevent both chronic patient distress and development of the significant phobic avoidance observed in psychiatric patients.
Altshuler LL; Hendrick V; Cohen LS
J Clin Psychiatry 1998;59 Suppl 2:29-33
Because the onset of mood and anxiety disorders often occurs during the childbearing years, many women may be taking psychotropic medications for these disorders when they conceive. These medications easily diffuse across the placenta, and their impact on the fetus is of concern. But discontinuation may lead to relapse, in which case psychiatric symptoms may affect the fetus. Thoughtful treatment planning presents a dilemma to the clinician. Limited data suggest heightened vulnerability to relapse of mood and anxiety disorders in women during the postpartum period. Pregnancy appears to exacerbate symptoms of obsessive-compulsive disorder, while panic disorder patients may remain well after discontinuing medication. Future studies should address the prevalence and relapse rates of mood and anxiety disorders, particularly after medication discontinuation, among pregnant women.
Pilowsky DJ; Wu LT; Anthony JC
Am J Psychiatry 1999 Oct;156(10):1545-9
Objective: The aim of this study was to investigate the association of panic attacks and suicide attempts in a community-based sample of 13-14-year-old adolescents.
Method: The data are from a survey of 1,580 students in an urban public school system located in the mid-Atlantic region of the United States. Logistic regression methods were used to estimate associations between panic attacks and suicidal ideation and suicide attempts.
Results: Controlling for demographic factors, major depression, the use of alcohol, and the use of illicit drugs, the authors found that adolescents with panic attacks were three times more likely to have expressed suicidal ideation and approximately two times more likely to have made suicide attempts than were adolescents without panic attacks.
Conclusions: This new epidemiologic research adds to the evidence of an association between panic attacks and suicide attempts during the middle years of adolescence.
Renaud J; Birmaher B; Wassick SC; Bridge J
J Child Adolesc Psychopharmacol 1999;9(2):73-83
This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.
Essau CA; Conradt J; Petermann F
Depress Anxiety 1999;9(1):19-26
Masi G; Favilla L; Romano R
Panminerva Med 1999 Jun;41(2):153-6
Panic disorder (PD) is a well-known and frequently described psychiatric disorder in adults, that can cause clinically significant distress and impairment of social and occupational functioning. It is characterized by a discrete period of intense fear and discomfort, that develops abruptly and reaches a peak in 10 minutes or less, with other somatic and cognitive symptoms. PD in prepubertal children and early adolescents in rarely reported, but 18% of adult patients with PD indicate onset of PA before 10 years of age. Probably many of the prepubertal cases are being misdiagnosed, and/or they can have a different clinical expression from adults. The lack of identification of these affected subjects can have serious consequences on social and academic development. The aim of this paper is to review clinical literature describing PD in children and adolescents. Prevalence, specificity of clinical features, comorbidity, instruments for diagnosis are described. Directions in pharmacological, psychotherapeutic and educational management of PD in children and adolescents are suggested.
What's new concerning the issues and treatment of panic disorder? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Psychiatry & Mental Health.
Sheehan DV
J Clin Psychiatry 1999;60 Suppl 18:16-21
Panic disorder is a prevalent psychiatric condition that often is chronic and rarely resolves without medical intervention. Many patients with panic disorder initially present with a variety of somatic symptoms, including chest pain, nausea, or dizziness, and patients frequently seek care in ambulatory care settings. Although panic disorder is classified as a single entity, it can have many dimensions and may be associated with significant morbidity. During the past 2 decades, there have been significant advances in the treatment of panic disorder, and a range of therapeutic choices is now available. Four classes of medications, including the selective serotonin reuptake inhibitors (SSRIs), high-potency benzodiazepines, tricyclic antidepressants, and monoamine oxidase inhibitors, may be considered for the management of patients with panic disorder. Emerging clinical data favor the SSRIs as first-line treatment for patients with panic disorder, and paroxetine and sertraline have been approved by the U.S. Food and Drug Administration for use in panic disorder. This article reviews the efficacy and safety of these treatments, as well as their relative merits and disadvantages, and assists the practicing clinician in choosing among the various pharmacotherapies to tailor therapy to each patient's individual needs.
Candilis PJ; McLean RY; Otto MW; Manfro GG; Worthington JJ 3rd; Penava SJ; Marzol PC; Pollack MH
J Nerv Ment Dis 1999 Jul;187(7):429-34
In this study we assessed the quality of life of patients with panic disorder, with particular attention to the influence of anxiety and depression comorbidity on quality of life. Findings were compared with established general population norms as well as norms for patients with chronic medical conditions and major depression. The Medical Outcomes Study Short-Form Health Survey (SF-36) was administered to panic disorder patients entering clinical trials or treatment in an outpatient anxiety disorders program. Subjects were 73 consecutive patients with a primary diagnosis of panic disorder without current substance abuse or contributory medical illness. Their quality of life scores were compared with population mean estimates using single-sample t-tests, and the influence of comorbidity was examined with between-group comparisons. All SF-36 mental and physical health subscale scores were worse in patients with panic disorder than in the general population. This was true regardless of the presence of comorbid anxiety or mood disorders, although the presence of the comorbid conditions worsened select areas of functioning according to subscale analyses. SF-36 scores in panic patients were at approximately the same level as patients with major depression and tended to be worse in specific areas than patients with select medical conditions. This study provides evidence of the pervasive negative effects of panic disorder on both mental and physical health.
Friedman S
J Anxiety Disord 1999 Sep;13(5):447-461
Recent findings by Weissman, Klerman, Markowitz, and Ouellette (1989) that subjects with panic disorder, with and without comorbid conditions, may be at increased risk for suicide attempts have been controversial. In an attempt to further investigate this finding, we utilized the original National Institute of Mental Health Epidemiological Catchment Area (ECA) suicide questions in an outpatient psychiatric clinic. We examined patients with panic disorder (n = 101). other anxiety disorders (n = 47), schizophrenia (n = 22). and major depression (n = 19). No significant differences were found among all four groups on any of the ECA suicide ideation questions. Only two (2%) of the panic disorder patients and none of the other groups made a suicide attempt in the past year. While 17% of patients with panic disorder and 9% of patients with other anxiety disorders reported having made a suicide attempt at some other time in their life, the schizophrenic (33%) and depressed groups (40%) reported significantly greater histories of suicide attempts. In a forward stepwise regression analysis for panic disorder patients, a history of substance abuse and comorbid depression predicted suicidality. The actual clinical risk for suicide attempts in panic disorder patients appears to occur when they suffer with comorbid diagnoses. These results highlight the need to aggressively treat panic disorder patients so they do not suffer the all-too-common sequelae of depression and substance abuse.
Woodman CL; Noyes R Jr; Black DW; Schlosser S; Yagla SJ
J Nerv Ment Dis 1999 Jan;187(1):3-9
To examine the course and outcome of subjects with generalized anxiety disorder (GAD) and panic disorder, we compared 64 patients with GAD and 68 patients with panic disorder who had participated in drug treatment studies and were interviewed an average of 5 years earlier. At baseline GAD subjects were significantly older, had an earlier onset, and longer duration of illness than panic subjects. GAD subjects also had less severe symptoms. At follow-up, diagnostic stability was observed for both GAD and panic disorder. Significantly fewer GAD subjects achieved full remission at follow-up (18% vs. 45%, p < .01). Subjects with GAD were significantly less anxious at baseline than the panic disorder comparison group, but at follow-up there were few significant differences between groups on most severity of illness variables. This change was due in great part to improvement in the panic disorder group with a concomitant lack of change in the GAD group.
Blier P; de Montigny C
Neuropsychopharmacology 1999 Aug;21(2 Suppl):91S-98S
The therapeutic effectiveness of antidepressant drugs in major depression was discovered by pure serendipity. It took over 20 years before the neurobiological modifications that could mediate the antidepressive response were put into evidence. Indeed, whereas the immediate biochemical effects of these drugs had been well documented, their antidepressant action generally does not become apparent before 2 to 3 weeks of treatment. The different classes of antidepressant treatments were subsequently shown to enhance serotonin neurotransmission albeit via different pre- and postsynaptic mechanisms. Clinical trials based on this hypothesis led to the development of treatment strategies producing greater efficacy and more rapid onset of antidepressant action; that, is lithium addition and pindolol combination, respectively. It is expected that the better understanding recently obtained of the mechanism of action of certain antidepressant drugs in obsessive-compulsive and panic disorders will also lead to more effective treatment strategies for those disorders.
Wade AG
Int Clin Psychopharmacol 1999 May;14 Suppl 2:S13-7
Panic disorder is a serious and common illness affecting 1% of the population at any one time. Comorbidity with depression may be as high as 40%. The illness has been recognized as a separate entity since the 1960s and treatment with tricyclics being used since that time. Tricyclics, monoamine oxidase inhibitors, benzodiazepines, beta-blockers and anticonvulsants have all been used with varying degrees of success. Until recently, tricyclics and benzodiazepines were the treatments of choice but selective serotonin reuptake inhibitors (SSRIs) have recently been studied intensively and, based on studies of citalopram and paroxetine, must now be considered first line therapy. Both SSRIs and tricyclics suffer from a long latency period, possibly as long as 12 weeks before maximal benefit is obtained, which is in contrast to the benzodiazepines that produce almost instant symptom relief. The dependency potential of the benzodiazepines, however, limits their usefulness. Paroxetine and citalopram have good efficacy data over both the short and long term and are effective at standard dosages, the most effective for citalopram being 20-30 mg. Both drugs performed better than the comparator tricyclic antidepressant (chlomipramine) and must now be considered current drugs of choice. Despite the superior efficacy of these drugs, however, many patients are poorly controlled and investigation of combination therapies for resistant panic disorder is needed.
Busch FN
J Psychother Pract Res 1999;8(3):234-242
The authors elaborate psychodynamic factors that are relevant to the treatment of panic disorder. They outline psychoanalytic concepts that were employed to develop a psychodynamic approach to panic disorder, including the idea of unconscious mental life and the existence of defense mechanisms, compromise formations, the pleasure principle, and the transference. The authors then describe a panic-focused psychodynamic treatment based on a psychodynamic formulation of panic. Clinical techniques used in this approach, such as working with transference and working through, are described. Finally, a case vignette is employed to illustrate the relevance of these factors to panic disorder and the use of this treatment.(The Journal of Psychotherapy Practice and Research 1999; 8:234-242).
Goisman RM; Warshaw MG; Keller MB
Am J Psychiatry 1999 Nov;156(11):1819-21
Objective: Pharmacologic prescriptions for anxiety disorders have changed significantly in the last decade. This article investigates whether psychosocial treatments, as reported by 362 subjects in the Harvard/Brown Anxiety Disorders Research Program from 1991 to 1996, changed as well.
Method: Subjects were interviewed in 1991 and 1995-1996 to determine which psychosocial treatments (behavioral, cognitive, dynamic, or relaxation or meditation) they had received.
Results: The percentage of subjects who received each type of psychosocial treatment either declined or remained the same from 1991 to 1995-1996. Dynamic psychotherapy remained the most frequently used method of these four. The percentage of subjects receiving any such method declined.
Conclusions: Behavioral and cognitive treatment, two empirically validated forms of psychotherapy, were less frequently used than dynamic psychotherapy, which lacks such validation. All use of verbal treatment methods declined from 1991 to 1995-1996.
Dyckman JM; Rosenbaum RL; Hartmeyer RJ; Walter LJ
Psychosomatics 1999 Sep-Oct;40(5):422-7
For patients initially seen in the emergency department (ED) for panic attack, this study evaluated the effect of two brief psychological interventions in the ED on later utilization of emergency, psychiatric, and nonpsychiatric medical department services. Each of the two intervention groups received usual ED care, a brochure on panic disorder, and a referral to treatment at the psychiatry department; one of the two groups also received 20-30 minutes of contact with a representative from the psychiatry department. Both intervention groups were compared with a historical control group. The contact condition reduced ED use after the initial visit to the ED, although all three groups had more visits to the psychiatry department and to all nonpsychiatric departments. This decrease was statistically significant (P = 0.0017) when compared with the brochure condition but not when compared with the historical control group (P = 0.0672). The decrease seen in ED use is an important therapeutic and economic finding.
Otto MW; Pollack MH; Penava SJ; Zucker BG
Behav Res Ther 1999 Aug;37(8):763-70
The last decade has brought exciting advances to the treatment of panic disorder and agoraphobia, and a variety of cognitive-behavioral and pharmacologic treatment strategies offer clear benefit to patients. Nonetheless, treatment nonresponse continues to be a chronic problem, and additional strategies are needed to aid patients who do not respond fully to initial interventions. In the present study, we use 'services' research to document the clinical response of pharmacotherapy nonresponders to a standard program of brief, group cognitive-behavioral therapy. Patients responded well, regardless of whether they had received a full, adequate trial of pharmacotherapy. In addition to its application as an initial treatment for panic disorder, routine application of cognitive-behavioral therapy in pharmacologic treatment algorithms is encouraged, with attention to referral of pharmacotherapy nonresponders to cognitive-behavioral therapy.
Clark DM; Salkovskis PM; Hackmann A; Wells A; Ludgate J; Gelder M
J Consult Clin Psychol 1999 Aug;67(4):583-9
Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.
Loerch B; Graf-Morgenstern M; Hautzinger M; Schlegel S; Hain C; Sandmann J; Benkert O
Br J Psychiatry 1999 Mar;174:205-12
Background: In the treatment of panic disorder with agoraphobia, the efficacy of pharmacological, psychological and combined treatments has been established. Unanswered questions concern the relative efficacy of such treatments. AIMS: To demonstrate that moclobemide and cognitive-behavioural therapy (CBT) are effective singly and more effective in combination.
Method: Fifty-five patients were randomly assigned to an eight-week treatment of: moclobemide plus CBT; moclobemide plus clinical management ('psychological placebo'); placebo plus CBT; or placebo plus clinical management.
Results: Comparisons between treatments revealed strong effects for CBT. Moclobemide with clinical management was not superior to placebo. The combination of moclobemide with CBT did not yield significantly better short-term results than CBI with placebo. The CBT results remained stable during a six-month follow-up, although a substantial proportion of patients treated with placebo plus CBT needed additional treatment.
Conclusions: CBT was highly effective in the treatment of panic disorder with agoraphobia and reduced agoraphobia to levels that were comparable to those of non-clinical controls.
Gelder MG
J Clin Psychopharmacol 1998 Dec;18(6 Suppl 2):2S-5S
Cognitive behavior therapy (CBT) has been combined with pharmacotherapy in the treatment of panic disorder in three ways: (1) to treat agoraphobic symptoms in the condition of panic with agoraphobia; (2) to reduce withdrawal effects during drug taper; and (3) to treat panic attacks. Exposure treatment and pharmacotherapy have a modest additive effect, although more patients drop out of exposure therapy combined with imipramine treatment compared with exposure therapy alone. CBT reduces symptoms of withdrawal from alprazolam and other benzodiazepines and improves the outcome of drug treatment. At present, sufficient data are not available to determine whether the effects of CBT combined with drug therapy are additive in treating panic disorder. The results of a large trial are awaited. Current CBT consists of 12 sessions and is not widely offered to patients because of cost considerations. Efforts are being made to decrease the number of sessions necessary by improving cognitive techniques. One of these models is the subject of an ongoing trial. Finally, efforts to educate and counsel patients in the clinical setting regarding the psychopathology of panic attacks may improve the outcome of pharmacotherapy.
Breslau N
Arch Gen Psychiatry 1999 Dec;56(12):1141-1147
Background: Epidemiologic studies have reported a lifetime association between smoking and panic disorder. In this study, we examine potential explanations for this association.
Methods: Analysis was conducted on data from 2 epidemiologic studies, the Epidemiologic Study of Young Adults in southeast Michigan (N = 1007) and the National Comorbidity Survey Tobacco Supplement (n = 4411). Cox proportional hazards models with time-dependent covariates were used to estimate the risk for onset of panic attacks associated with prior smoking and vice versa, controlling for history of major depression. The role of lung disease in the smoking-panic attacks association was explored.
Results: Daily smoking signaled an increased risk for first occurrence of panic attack and disorder; the risk was higher in active than past smokers. No significant risk was detected for onset of daily smoking in persons with prior panic attacks or disorder. Exploratory analyses suggest that lung disease might be one of the mechanisms linking smoking to panic attacks.
Conclusions: The evidence that the association between smoking and panic disorder might result primarily from an influence in one direction (i.e., from prior smoking to first panic attack) and the possibility of a higher risk in active than past smokers suggest a causal hypothesis for the smoking-panic attacks relationship.
Lautenbacher S
Psychosom Med 1999 Nov;61(6):822-827
Objective: There is evidence that depression and panic disorder are both associated with an increased frequency of clinical pain complaints. A change in pain sensitivity is alleged to be involved in this phenomenon. However, few studies have assessed clinical pain complaints and pain sensitivity in the same group of patients.
Methods: Thirteen patients with a major depressive disorder, 13 patients with a panic disorder (diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition), and 13 healthy control subjects were investigated. None of the subjects were taking medications. Body maps were used to measure the number of painful sites as well as the intensity and unpleasantness of pain complaints in the previous 6 months. Furthermore, pain thresholds for pressure, cold, and heat were assessed at the forearm or hand.
Results: Patients with depression and panic disorder had significantly more frequent, more intense, and more unpleasant pain complaints than healthy control subjects. Despite this similarity, patients with depression had significantly higher pain thresholds than patients with panic disorder in two (pressure and cold) of three stimulus modalities and significantly higher pressure pain thresholds than the healthy control subjects. There were no differences between the pain thresholds of patients with panic disorder and healthy control subjects. The correlations between clinical pain measures and pain thresholds were generally weak.
Conclusions: These findings suggest that the clinical pain complaints of patients with depression and panic disorder cannot simply be explained by changes in pain sensitivity.
Davies SJ; Ghahramani P; Jackson PR; Noble TW; Hardy PG; Hippisley-Cox J; Yeo WW; Ramsay LE
Am J Med 1999 Oct;107(4):310-6
Purpose: Previous studies of the association between hypertension and panic disorder were uncontrolled or involved small numbers of patients.
Patients and Methods: We compared the prevalence of panic disorder and panic attacks in 351 patients with documented hypertension who were randomly selected from all hypertensive patients registered in one primary care practice with age- and gender-matched normotensive patients from the same practice and with hypertensive patients attending a hospital clinic. All three groups completed questionnaires for panic disorder based on standard criteria, as well as the Hospital Anxiety and Depression scale.
Results: The prevalence of current (previous 6 months) panic attacks was significantly greater in primary care patients with hypertension (17%, P <0.05) and hospital-based hypertensive patients (19%, P <0.01) than in normotensive patients (11%). Similar results were seen for lifetime panic attacks (35% versus 39% versus 22%; both P for comparisons with normotensive patients <0.001). The prevalence of panic disorder was significantly greater in primary care patients with hypertension (13%) than normotensive patients (8%, P <0.05). Anxiety scores were significantly higher in both hypertensive groups than in normotensive patients. Depression scores were significantly higher in hospital-based hypertensive patients than in the other two groups. The reported diagnosis of hypertension antedated the onset of panic attacks in a large majority of patients (P <0.01).
Conclusions: Physicians caring for patients with hypertension should be aware of the significantly greater prevalence of panic attacks in these patients.
Marazziti D; Toni C; Pedri S; Bonuccelli U; Pavese N; Lucetti C; Nuti A; Muratorio A; Cassano GB
Int Clin Psychopharmacol 1999 Jul;14(4):247-51
We investigated the prevalence of headache in a group of patients attending a psychiatric clinic because suffering from panic disorder, according to DSM-IV criteria. The psychopathological assessment was performed with the 'Panic Disorder/Agoraphobia Questionnaire' and the presence of headache was evaluated according to the criteria of the International Headache Society. The results showed that two-thirds of patients met the criteria for a diagnosis of headache, with migraine without aura being the most frequent form, followed by tension headache, while two patients only were affected by migraine with aura. When we compared panic patients with and without headache, those with headache had a longer duration of panic disorder, a higher number of attacks and a heavier family loading for panic disorder and headache. This suggests that the comorbidity of headache with panic disorder renders this condition more severe and possibly responsive to different treatments compared to panic disorder alone.
Roy-Byrne PP; Stein MB; Russo J; Mercier E; Thomas R; McQuaid J; Katon WJ; Craske MG; Bystritsky A; Sherbourne CD
J Clin Psychiatry 1999 Jul;60(7):492-9; quiz 500
Background: Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome.
Method: Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications.
Results: Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p < .01), more utilization of emergency room and medical provider visits (p < .01), and more mental health visits (p < .05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy.
Conclusion: These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.
Stein MB; Roy-Byrne PP; McQuaid JR; Laffaye C; Russo J; McCahill ME; Katon W; Craske M; Bystritsky A; Sherbourne CD
Psychosom Med 1999 May-Jun;61(3):359-64
Objective: The purpose of this study was to determine the utility of a brief screening tool for panic disorder in the primary care setting.
Methods: A total of 1476 primary care outpatients in three primary care medical clinics on the West Coast of the United States were studied. Patients completed a brief self-report measure, the five-item Autonomic Nervous System Questionnaire (ANS), while in the waiting room. The presence of DSM-IV panic disorder was subsequently determined in groups of "screen-positive" and "screen-negative" subjects using the Composite International Diagnostic Interview. A subset of patients (N = 511) also completed the 21-item Beck Anxiety Inventory. Indices of diagnostic utility were calculated using receiving operating characteristic analyses to guide the selection of optimal cutoff levels.
Results: The two-question version of the ANS had excellent sensitivity (range = 0.94-1.00 across the three clinic sites) and negative predictive value (0.94-1.00) but low specificity (0.25-0.59) and positive predictive value (range 0.18-0.40). The three- and five-question versions of the ANS had only modestly improved specificity, and this was achieved at the cost of reduced sensitivity and increased respondent burden to complete the questionnaire. The 21-item Beck Anxiety Inventory had maximal clinical utility at a cutoff level of > or =20, but sensitivity was lower than desirable for a screening instrument (0.67).
Conclusions: The two-question version of the ANS shows promise as a screening instrument for panic disorder in the primary care setting.
Barsky AJ; Delamater BA; Orav JE
Psychosomatics 1999 Jan-Feb;40(1):50-6
The goal of the study was to examine the functional status and medical care of general medical outpatients with panic disorder. One hundred patients completed self-report questionnaires and a diagnostic interview for panic disorder. They were compared with a random sample of patients without panic disorder. Medical morbidity was assessed from the medical record, and the patients' clinic physicians completed a questionnaire about them. The prevalence of current (1 month) panic disorder was 6.7%-8.3%. The panic disorder patients had fewer serious medical diagnoses, but more medical utilization and more role impairment than the comparison group. The clinic physicians rated the panic patients as more anxious, more depressed, more hypochondriacal, and more difficult to care for. Sixty-one percent of the panic disorder patients recalled receiving an anxiety disorder diagnosis. These findings add to a growing body of evidence that panic disorder imposes a significant burden on those with this illness and that it is a seriously underdiagnosed condition in primary care practice.
Carr RE
J Asthma 1999;36(2):143-52
The presence of asthma is a risk factor for the development of panic disorder. The co-occurrence of panic disorder and asthma is greater than would be expected based on their individual prevalence rates. This may be due in part to the important role of respiratory factors in panic disorder. Panic and anxiety can directly exacerbate asthma symptoms through hyperventilation, and are associated with patients' overuse of as-needed asthma medications, with more frequent hospital admissions and longer hospital stays, and with more frequent steroid treatment, all of which are independent of degree of objective pulmonary impairment. This paper reviews the literature on the relationship between panic and anxiety on the one hand, and the experience and management of asthma on the other.
Akiyoshi J
Nihon Shinkei Seishin Yakurigaku Zasshi 1999 Jul;19(3):93-99
A study on the biology of 'panic disorder,' which I have classified under the category of 'anxiety disorder,' made progress recently. In a genetic study, the hereditary of panic disorder was checked by a 'linkage and twins' study, and the anticipation of panic disorder was recognized as being the same as that which is also found in the psychiatric conditions known as schizophrenia and manic depression. A panic disorder patient regards the anxious sign of a model as ruinous, and this weakness in recognition has been duly noted. Therefore, I studied a patient showing a continuance state of 'hyper-sensitivity,' and compared this to a patient showing a 'sleep disorder.' Noradrenaline plays an important role in anxiety as suppression of the locus ceruleus (LN), the major NE-containing nucleus of the noradrenaline nervous system, brings on a calming effect. Yohimbine, however, which is an alpha 2 antagonist, is found to induce panic attacks. The fact that selective serotonin reuptake inhibitor (SSRI) suppresses panic attacks suggests that serotonin is connected with panic disorders. It is also thought that the 'raphe nucleus' is the site of origin of the serotonin nervous system, which participates in the control of anxiety. This suggests the participation of a gamma-aminobutyric acid (GABA) nervous system in which the administration of benzodiazepine at a high potency would be an effective agent against panic disorder. Cholecystokinin (CCK) is also suggested to have a connection with panic disorder as CCK-4 causes panic attacks. There has been no CCK antagonist found effective for an object- or time-oriented panic disorder at the present. It is thought that corticotropin-releasing factor (CRF) is released during a panic attack. The development of a new CRF receptor antagonist is needed. In addition to the studies on the neurotransmitters of the traditional type, such as noradrenaline, serotonin and GABA, studies on the neuropeptides, such as CCK and CRF have become important for future consideration. Understanding this, image studies such as MRI, SPECT, fMRI and PET have become highly desirable.
Fyer AJ; Weissman MM
Am J Med Genet 1999 Apr 16;88(2):173-81
This paper describes the clinical methodology and currently collected pedigrees from an ongoing genetic study of panic disorder. The main objectives are to (1) document the clinical aspects of the study for current [Knowles et al., 1998: Am. J. Med. Genet. (Neuropsychiatr. Genet.) 81:138-147] and future reports of genetic analysis; (2) assist other investigators working on the genetic aspects of panic disorder who wish to compare results; and (3) illustrate the numerous judgment calls required in such studies that may lead to methodological variability and could account for differences in findings between studies. We also describe initial strategies to identify more genetically homogeneous panic disorder subtypes. Families were recruited through letters to magazines, word of mouth referral, and screening in anxiety disorder clinics and were asked to participate if at initial diagnostic screening they appeared to have at least three members (in two generations) affected with panic disorder. Diagnostic evaluations included a lifetime clinician-administered semistructured psychiatric interview, family history assessment, and pertinent medical records. Diagnoses for linkage analysis are derived from a best-estimate procedure that includes independent review of all materials by two senior investigators. All clinical evaluations were done blind to genotypes. Fifty-five pedigrees including 679 individuals have been collected to date. DNA is available from 500 family members of whom almost half (48%) are definitely or probably affected with panic disorder. Most (93%) of these subjects were directly interviewed, and the clinical data include not only lifetime psychiatric and medical diagnoses and but also detailed narrative histories describing sequence and context of symptoms. Family sizes range from 4-36 individuals (mean = 12.3) and the number of affected individuals per family from 2-12.
[Epidemiologie genetique et psychiatrie (I): Portees et limites des etudes de concentration familiale. Exemple du trouble panique.]
Gorwood P; Feingold J; Ades J
Encephale 1999 Jan-Feb;25(1):21-9
Genetics epidemiology shed new light on multifactorial disorders for which genes are partly involved, for example on numerous psychiatric diseases. Nevertheless, each epidemiological technic has it's caracteristics and limitations. This review discuss the impact of aggregation studies, on the bases of an example, namely all aggregation studies on panic disorder. We detected through Medline thirteen studies, comparing 3,700 relatives of 780 probands affected with panic disorder, with 3,400 relatives of 720 unaffected controls. It is computed that relatives of patients with panic disorder have an increased risk (10.7%) for panic disorder than relatives of controls (1.4%), relatives from affected probands having a high relative risk (6.8) for panic disorder according to the meta-analysis. On the basis of these 13 aggregation studies, there is an important attribuable risk (78.3%) of "having a familial history of panic disorder" in the risk for panic disorder. Furthermore, the estimated heritability is 73% (73% of the total variance would be explained by additive genetic effects), if Reich's conditions are fulfilled for a valid estimation of the heritability on the basis of aggregation families. These studies can also be used to highlight the variability of expression according to gender, to show the relevance of quantitative approaches (versus the qualitative approach which is nearly systematically used), to underline the informations raised by experimental technics (such as panic disorder induced by lactate), and to raise the potential existence of phenocopies. Lastly, aggregation studies on panic disorder can help to understand the high comorbidity of this disorder, with other anxiety disorders and mood disorder.
Sullivan GM
Biol Psychiatry 1999 Nov 01;46(9):1205-1218
Over the past three decades of psychiatric research, abnormalities in the noradrenergic system have been identified in particular anxiety disorders such as panic disorder. Simultaneously, neuroscience research on fear pathways and the stress response have delineated central functions for the noradrenergic system. This review focuses on the noradrenergic system in anxiety spectrum disorders such as panic disorder, generalized anxiety disorder, and phobias for the purpose of elucidating current conceptualizations of the pathophysiologies. Neuroanatomic pathways that are theoretically relevant in anxiogenesis are discussed and the implications for treatment reviewed.
Coplan JD; Lydiard RB
Biol Psychiatry 1998 Dec 15;44(12):1264-76
This paper reviews the pathophysiology of panic disorder (PD), within the context of newly described "fear circuitries," which have been well characterized in preclinical models. Substantial advances in the neurosciences have made it possible for clinical neuroscientists to refine our understanding of the pathophysiology of PD and the mechanisms of currently effective treatment. These advances have in turn helped generate testable hypotheses for future neurobiological and psychopharmacologic research. Perturbation of mutual modulation ("cross talk") between key brain transmitter systems (serotonin, norepinephrine, gamma-aminobutyric acid, corticotropin-releasing factor, and others) may underlie the pathogenesis of panic-anxiety. Restoration of normal homeostasis may be an important therapeutic component of antipanic therapy and may provide information about underlying neurocircuits. Neuroimaging, an important new tool, has already begun to bridge the gap between the preclinical and clinical neurosciences through confirmation of hypothesized dysfunction of the complex human prefrontal cortex and its subcortical components. In higher species, such as humans, dysfunction of cortical inhibition or excessive cortical activation of caudal limbic structures is postulated to lead to activation of the phylogenetically conserved amygdalofugal pathways. Consistent with probable subtypes of PD, overlapping theoretical models of panic neurocircuitries are proposed, including ventilatory dysregulation, which is coupled with neurovascular instability in a critical area of the panic neurocircuitry--the amygdalohippocampus. Neuroimaging appears a critical tool in guiding further elaboration of the interaction of cortical and subcortical components of the panic neurocircuitry, whereas challenge studies appear crucial in gathering further information regarding brain stem dysfunction.
Smith LC; Friedman S; Nevid J
J Nerv Ment Dis 1999 Sep;187(9):549-60
Much attention has been paid to the study of panic disorder symptomatology among primarily European American populations. However, such research has not adequately generalized to include minority groups. The present study examined phenomenological differences between African American and European American patients with panic disorder with or without agoraphobia. African American (N = 48) and European American (N = 33) patients with panic disorder were assessed by structured interview and self-report questionnaires upon presentation to an anxiety disorders clinic for treatment. African Americans evidenced a higher rate of comorbid posttraumatic stress disorder (16% vs. 0%). European Americans reported having their initial panic attack at an earlier age than African Americans (21 vs. 29). In terms of discrete panic attack symptoms, African Americans reported more intense levels of numbing/tingling in extremities (4.3 vs. 2.5) as well as greater fear of dying (6.3 vs. 4) or going crazy (4.6 vs. 3) than European Americans. African Americans evidenced less satisfaction with social support (2.7 vs. 3.2), especially financial support (2.3 vs. 3.2), than European Americans. African Americans employed coping strategies such as counting one's blessings (1.9 vs. 1.4) and religiosity (1.9 vs. 1.2) more often than European Americans but evidenced less self blame (1.7 vs. 2). This study extends previous findings by showing that African Americans have a later age of onset as well as different coping strategies than European American patients with panic disorder.
Hertzberg T; Wahlbeck K
J Psychosom Obstet Gynaecol 1999 Jun;20(2):59-64
There is little known about the effect of pregnancy and the puerperium on the risk for, and course of anxiety disorders. Initial case reports concerning the relationship between panic disorder (PD) and pregnancy/puerperium suggested that pregnancy protected against PD, while the postpartum period seemed to increase the risk for onset or exacerbation of PD. Later studies have offered a more mixed picture. A computerized search identified eight relevant studies in this area. All were non-controlled and all but one retrospective. Out of the total 215 pregnancies that were described in these studies, 89 (41%) were associated with improvement of PD symptoms during the pregnancy, while 38% of the described pregnancies exhibited onset or exacerbation of PD in the postpartum period. No definite conclusions regarding the effect of pregnancy and puerperium on PD can be drawn from these reviewed studies.
Yonkers KA; Zlotnick C; Allsworth J; Warshaw M; Shea T; Keller MB
Am J Psychiatry 1998 May;155(5):596-602
Objective: Panic disorder with or without agoraphobia has a chronic relapsing course. Factors associated with poor outcome include early onset of illness and phobic avoidance. Several, but not all, authors have found a worse clinical course for women. Using observational, longitudinal data from the Harvard/Brown Anxiety Disorders Research Program, the authors analyzed remission and symptom recurrence rates in panic patients with respect to sex.
Method: Male and female patients (N=412) in an episode of panic with or without agoraphobia were assessed by structured interview and prospectively followed for up to 5 years. Data on remission, symptom recurrence, and comorbid psychiatric conditions for each sex were compared.
Results: There were no significant differences between men and women in panic symptoms or level of severity at baseline. Women were more likely to have panic with agoraphobia (85% versus 75%), while men were more likely to have uncomplicated panic (25% versus 15%). The rates of remission for panic with or without agoraphobia at 5 years were equivalent in men and women (39%). Of the subjects who achieved remission, 25% of the women and 15% of the men reexperienced symptoms by 6 months. Recurrence of panic symptoms continued to be higher in women (82%) than men (51%) during the follow-up period and was not influenced by concurrent agoraphobia.
Conclusions: This study extends previous findings by showing that not only are women more likely to have panic with concurrent agoraphobia, but they are more likely than men to suffer a recurrence of panic symptoms after remission of panic.
Turgeon L; Marchand A; Dupuis G
J Anxiety Disord 1998 Nov-Dec;12(6):539-53
This study compared 96 women and 58 men suffering from panic disorder with agoraphobia. Participants completed questionnaires assessing various clinical features associated with panic disorder with agoraphobia (PDA), general adjustment, and drug/alcohol use. Results showed that PDA is a more severe condition in women. Women reported more severe agoraphobic avoidance when facing situations or places alone, more catastrophic thoughts, more body sensations, and higher scores on the Fear Survey Schedule. Also, women more often had a comorbid social phobia or posttraumatic stress disorder. The lower agoraphobic avoidance of men was associated with their alcohol use. However, there were no differences between genders in other dimensions, including depression, situational and trait anxiety, stressful life events, social self-esteem, marital adjustment, and drug use.
Starcevic V; Djordjevic A; Latas M; Bogojevic G
Depress Anxiety 1998;8(1):8-13
We compared female and male patients with panic disorder with agoraphobia (PDA) in terms of characteristics of agoraphobia (AG). Ninety-five patients (73 women and 22 men) with the SCID-based diagnosis of PDA were administered the National Institute of Mental Health Panic Questionnaire (NIMH PQ), and women and men were compared on the items of the NIMH PQ that pertain to AG and symptoms of panic attacks. Male and female patients did not differ significantly with respect to demographic characteristics, age of onset of panic disorder and AG, duration of PDA, and severity and frequency of symptoms experienced during panic attacks. Women avoided more situations than did men, but this difference was not statistically significant. Women avoided buses and being in unfamiliar places alone significantly more often. The only situation that was avoided more often by men, although not significantly, was staying at home alone. Women were significantly more likely to stay at home to avoid agoraphobic situations and significantly less likely to go outside of home alone. When going outside, women required a companion significantly more often. There were significantly more married women than married men who required a spouse as a companion, and significantly more women with children than men with children who required a child as a companion. Women thought that AG had affected the overall quality of their lives significantly more adversely. Whereas the overall "profile" of agoraphobic situations does not seem to distinguish between female and male patients with AG, females may be more impaired and appear more dependent than men in terms of requiring companions to move outside of the home. Cultural and psychological factors may be most likely to account for these findings.
Sansone RA; Sansone LA; Righter EL
J Womens Health 1998 Oct;7(8):983-9
Panic disorder, an intense exacerbation of anxiety accompanied by a variety of physical symptoms, is twice as common among women as among men. Onset is bimodal (teens/20 s and mid-30 s/40 s), 50% of cases are accompanied by agoraphobia, and the etiology is probably multifactorial. Treatment in the primary care setting includes pharmacologic (selective serotonin reuptake inhibitors) and cognitive-behavioral intervention. Medication is initiated at low doses, and the drug-evaluation trial is of 6 weeks duration. Psychiatric referral is helpful in nonresponders and in those with comorbid psychiatric conditions. Outcome varies, with most patients experiencing relief with treatment. For some people, however, the disorder is chronic, with ongoing exacerbations and remissions.
Fleet RP; Marchand A; Dupuis G; Kaczorowski J; Beitman BD
Psychosomatics 1998 Nov-Dec;39(6):512-8
In a recent study, the authors reported that 25% (108/441) of consecutive emergency department (ED) chest pain patients had panic disorder (PD). As part of this study, the authors sought to answer the question: How do ED patients with PD compare with patients with PD who seek treatment in a psychiatric setting? PD patients from an ED (n = 108) and psychiatric clinic (n = 137) were compared with respect to comorbid Axis I diagnoses, self-report scores, and recent suicidal ideation. The group of psychiatric patients was younger (36.5 vs. 52.3 years) (P < 0.0001) and consisted of proportionally more women (63% vs. 39%) (P = 0.0001) than the ED patients. The psychiatric patients had significantly higher rates of comorbid agoraphobia (100% vs. 15%) (P < 0.0001), social phobia (23% vs. 3%) (P = 0.0001), specific phobia (12.3% vs. 4.6%) (P = 0.03), and posttraumatic stress disorder (16.9% vs. 5.6%) (P = 0.006), compared with the ED patients, and displayed significantly higher scores on all of the self-report panic measures. However, the patients in both groups had similar rates of comorbid generalized anxiety disorder (41.2% vs. 33.3%) (P = 0.17), major depression (8.8% vs. 11.1%) (P = 0.54), and obsessive-compulsive disorder (1.5% vs. 2.8%) (P = 0.7). Both groups also did not differ on the Beck Depression Inventory and in their rate of report of recent suicidal ideation (32% vs. 25%) (P = 0.23). Both psychiatric and ED patients with PD appear to be highly distressed patients who require treatment. Early intervention for ED patients may prevent both chronic patient distress and development of the significant phobic avoidance observed in psychiatric patients.
Altshuler LL; Hendrick V; Cohen LS
J Clin Psychiatry 1998;59 Suppl 2:29-33
Because the onset of mood and anxiety disorders often occurs during the childbearing years, many women may be taking psychotropic medications for these disorders when they conceive. These medications easily diffuse across the placenta, and their impact on the fetus is of concern. But discontinuation may lead to relapse, in which case psychiatric symptoms may affect the fetus. Thoughtful treatment planning presents a dilemma to the clinician. Limited data suggest heightened vulnerability to relapse of mood and anxiety disorders in women during the postpartum period. Pregnancy appears to exacerbate symptoms of obsessive-compulsive disorder, while panic disorder patients may remain well after discontinuing medication. Future studies should address the prevalence and relapse rates of mood and anxiety disorders, particularly after medication discontinuation, among pregnant women.
Pilowsky DJ; Wu LT; Anthony JC
Am J Psychiatry 1999 Oct;156(10):1545-9
Objective: The aim of this study was to investigate the association of panic attacks and suicide attempts in a community-based sample of 13-14-year-old adolescents.
Method: The data are from a survey of 1,580 students in an urban public school system located in the mid-Atlantic region of the United States. Logistic regression methods were used to estimate associations between panic attacks and suicidal ideation and suicide attempts.
Results: Controlling for demographic factors, major depression, the use of alcohol, and the use of illicit drugs, the authors found that adolescents with panic attacks were three times more likely to have expressed suicidal ideation and approximately two times more likely to have made suicide attempts than were adolescents without panic attacks.
Conclusions: This new epidemiologic research adds to the evidence of an association between panic attacks and suicide attempts during the middle years of adolescence.
Renaud J; Birmaher B; Wassick SC; Bridge J
J Child Adolesc Psychopharmacol 1999;9(2):73-83
This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.
Essau CA; Conradt J; Petermann F
Depress Anxiety 1999;9(1):19-26
Masi G; Favilla L; Romano R
Panminerva Med 1999 Jun;41(2):153-6
Panic disorder (PD) is a well-known and frequently described psychiatric disorder in adults, that can cause clinically significant distress and impairment of social and occupational functioning. It is characterized by a discrete period of intense fear and discomfort, that develops abruptly and reaches a peak in 10 minutes or less, with other somatic and cognitive symptoms. PD in prepubertal children and early adolescents in rarely reported, but 18% of adult patients with PD indicate onset of PA before 10 years of age. Probably many of the prepubertal cases are being misdiagnosed, and/or they can have a different clinical expression from adults. The lack of identification of these affected subjects can have serious consequences on social and academic development. The aim of this paper is to review clinical literature describing PD in children and adolescents. Prevalence, specificity of clinical features, comorbidity, instruments for diagnosis are described. Directions in pharmacological, psychotherapeutic and educational management of PD in children and adolescents are suggested.
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