Triggering the false suffocation alarm in panic disorder patients by using a voluntary breath-holding procedure

The authors compared the maximal duration of voluntary breath-holding in patients with panic disorder (N = 23), patients with generalized social phobia (N = 10), and healthy subjects (N = 26). Patients with panic disorder had significantly shorter breath-holding durations than either comparison group. Groups did not otherwise differ in physiologic response to the breath-holding. Implications for a false suffocation alarm in panic disorder are discussed.     

Behavioral, neurochemical, anatomical and electrophysiological correlates of panic disorder: multiple transmitter interaction and neuropeptide colocalization

Neurochemical accounts of panic disorder focus on peripheral indices of central transmitter activity, hormonal correlates and therapeutic efficacy. Anxiogenic agents augment norepinephrine activity, some anxiolytics increase serotonin neurotransmission while benzodiazepines and antidepressants influence catecholamine, indoleamine and gamma-aminobutyric acid turnover in infrahuman subjects. Reliable correlates of central transmitter activity in panic disorder are not in evidence. While animal models of anxiety may not mirror the symptom profile of panic, neurobiological accounts of panic disorder fail to consider extensive central colocalization of neurotransmitter and putative neurotransmitters. In effect, transmitter release in major ascending and descending transmitter systems is modulated by variable neuropeptide interfacing. The behavioral concomitants of psychological disturbance likely follow from variable neurochemical release induced by stimuli as well as conditioning and sensitization. The functional role of receptor sites associated with multiple neurochemical systems may vary and the sensitivity and/or density of receptor sites may be modified. Accordingly, the behavioral and neurochemical concomitants of acute and chronic pathology may be fundamentally different from one another. The present review argues that the symptoms of panic disorder and the etiology of the illness must be evaluated against a background of genetic, organismic and experiential factors. Such variables presumably underlie the diverse behavioral symptoms associated with panic disorder and variations in the therapeutic efficacy of pharmacological treatment.     

Evidence for the synthesis and secretion of a CBG-like serpin by human cumulus oophorus and fallopian tubes

BACKGROUND: The goal of the present study was to validate the French version of the Agoraphobic Cognitions Questionnaire (ACQ). METHODS: Subjects consisted of 115 patients with panic disorder and agoraphobia, 54 obsessive-compulsive patients and 72 normal controls. Patients were referred for outpatient treatment. They filled in the questionnaire before and after entering treatment. The control group consisted of people taken from the general population. It was matched with the clinical groups on age, sex and education. RESULTS: The ACQ appears to have a constant factor structure across US, Dutch and French samples. Results support the validity of the total score of the ACQ. Patients with panic disorder and agoraphobia scored significantly higher than obsessive-compulsive patients and control subjects. On the ACQ physical concerns subscale agoraphobic patients were significantly different from obsessive-compulsive patients and control subjects. On the social/behavioural subscale agoraphobic patients and obsessive-compulsive patients were significantly different from control subjects. The French translation of the ACQ was found to be stable over an interval of 15 days in the control group. The Cronbach coefficients of both subscales were also satisfactory. These results support the stability and the internal consistency of the questionnaire. In addition, the French translation of the ACQ was sensitive to changes with cognitive-behavioural therapy. CONCLUSIONS: These results support the findings of Chambless and Gracely [Cogn Ther Res 1989;13:9-20]. The ACQ physical concerns subscale is a specific feature for the anxiety status experienced by patients with panic disorder and agoraphobia. The ACQ social/behavioural subscale seems to be a more general feature of anxious patients.     

Disgust implicated in obsessive-compulsive disorder

Psychiatric classificatory systems consider obsessions and compulsions as forms of anxiety disorder. However, the neurology of diseases associated with obsessive-compulsive symptoms suggests the involvement of fronto-striatal regions likely to be involved in the mediation of the emotion of disgust, suggesting that dysfunctions of disgust should be considered alongside anxiety in the pathogenesis of obsessive-compulsive behaviours. We therefore tested recognition of facial expressions of basic emotions (including disgust) by groups of participants with obsessive-compulsive disorder (OCD) and with Gilles de la Tourette's syndrome (GTS) with an without co-present obsessive-compulsive behaviours (GTS with OCB; GTS without OCB). A group of people suffering from panic disorder and generalized anxiety were also included in the study. Both groups with obsessive-compulsive symptoms (OCD; GTS with OCB) showed impaired recognition of facial expressions of disgust. Such problems were not evident in participants with panic disorder and generalized anxiety, or for participants with GTS without obsessions or compulsions, indicating that the deficit is closely related to the presence of obsessive-compulsive symptoms. Participants with OCD were able to assign words to emotion categories without difficulty, showing that their problem with disgust is linked to a failure to recognize this emotion in others and not a comprehension or response criterion effect. Impaired recognition of disgust is consistent with the neurology of OCD and with the idea that abnormal experience of disgust may be involved in the genesis of obsessions and compulsions.     

Eye movement impairment and schizotypal psychopathology

OBJECTIVE: Eye movement dysfunction in relation to a smooth pursuit task has been documented in schizophrenic patients and in patients with the related personality disorder, schizotypal personality disorder. To investigate which quantitative measures are associated with the eye movement dysfunction and whether the dysfunction is more related to the psychotic-like or the deficit-like symptoms of schizotypal personality disorder, ratings of eye movements in several groups of subjects were compared. METHOD: The study groups consisted of 26 patients with schizotypal personality disorder, 42 patients with other personality disorders (22 who also had two or more schizotypal personality traits and 20 who had fewer than two), and 37 normal comparison subjects. Smooth pursuit eye tracking of sinusoidal and constant velocity targets was recorded by an infrared eye tracking system. Two raters evaluated pursuit gain and large and small saccades in the direction of the target and in the direction opposite to that of the target (quantitative ratings) and constant velocity (qualitative rating). RESULTS: Patients with schizotypal personality disorder and patients with other personality disorders and two or more schizotypal traits, but not those with fewer than two schizotypal traits, had significantly poorer qualitative ratings of tracking than the normal comparison subjects. Neither gain nor any of the saccadic measures significantly differed between groups. The number of large saccades in the direction of the target was the only quantitative variable that predicted low qualitative ratings. Qualitatively poor tracking was associated with the deficit-like, but not the psychotic-like, symptoms of schizotypal personality disorder. CONCLUSIONS: Patients with schizotypal personality disorder demonstrate qualitatively poorer tracking than comparison groups, and the impaired tracking is associated with deficit-like symptoms.     

Can patients with obsessive-compulsive disorder discriminate between percepts and mental images? A signal detection analysis.

Signal detection analysis was used to test three hypotheses for repetitive thoughts and behaviors characteristic of obsessive-compulsive disorder (OCD). Patients might have (a) low sensitivity for the difference between having seen something or having imagined seeing it, (b) a high criterion for this discrimination, or (c) difficulty associating context with information in memory. Subjects judged viewed words or imagined words and later indicated which were actually seen. Patients with OCD discriminated seen from imaged words significantly better than normal control subjects, as evidenced by higher d′ scores on a recognition memory task. Groups did not differ in response criterion, β, used to decide whether words had been seen or imaged. Implications for the study of OCD from an information-processing perspective are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cerebral structural abnormalities in obsessive-compulsive disorder. A quantitative morphometric magnetic resonance imaging study

BACKGROUND: A previous pilot study of only posterior brain regions found lower white-matter volume in patients with obsessive-compulsive disorder than in normal control subjects. We used new cohorts of patients and matched normal control subjects to study whole-brain volume differences between these groups with magnetic resonance imaging-based morphometry. METHODS: Ten female patients with obsessive-compulsive disorder and 10 female control subjects, matched for handedness, age, weight, education, and verbal IQ, underwent magnetic resonance imaging with a 3-dimensional volumetric protocol. Scans were blindly normalized and segmented by means of well-characterized semiautomated intensity contour mapping and differential intensity contour algorithms. Brain structures investigated included the cerebral hemispheres, cerebral cortex, diencephalon, caudate, putamen, globus pallidus, hippocampus amygdala, third and fourth ventricles, corpus callosum, operculum, cerebellum, and brain stem. Anterior to posterior neocortical regions, including precallosum, anterior pericallosum, posterior pericallosum, and retrocallosum, with adjacent white matter were also measured. Volumes found different between groups were correlated with Yale-Brown Obsessive Compulsive Scale score and Rey-Osterieth Complex Figure Test measures. RESULTS: Confirming results of our earlier pilot study and expanding the findings to the whole brain, patients with obsessive-compulsive disorder had significantly less total white matter but, in addition, significantly greater total cortex and opercular volumes. Severity of obsessive-compulsive disorder and nonverbal immediate memory correlated with opercular volume. CONCLUSIONS: Replication of volumetric white-matter differences suggests a widely distributed structural brain abnormality in obsessive-compulsive disorder. Whereas determining the etiogenesis may require research at a microscopic level, understanding its functional significance can be further explored via functional neuroimaging and neuropsychological studies.     

Stereotaxy during intravenous anesthesia with propofol

BACKGROUND: Abnormally high levels of saccadic distractibility have been demonstrated to occur in patients with schizophrenia. Converging evidence implicates frontal cortical dysfunction as a mechanism; however, much of the neuropharmacology of saccadic distractibility has not yet been established. METHODS: We measured antisaccade, no-saccade, and visually guided saccade components in healthy subjects following single doses of lorazepam 2 mg, chlorpromazine 50-100 mg, and placebo. Visual analogue rating scales (VARS) provided a subjective measure of sedation. RESULTS: Lorazepam, but not chlorpromazine, was shown to cause an increase in saccadic distractibility in both the antisaccade and no-saccade tasks. Peak visually guided saccade velocity was decreased by lorazepam and chlorpromazine in a dose-dependent manner, with corresponding changes seen in VARS. Lorazepam, unexpectedly, did not affect peak antisaccade velocity. The background level of antisaccade directional errors was 6.43%, which is relatively low compared to control groups in patient studies. CONCLUSIONS: These results support the view that abnormal saccadic distractibility in patients with schizophrenia is not due to an acute effect of antipsychotic medication. The use of benzodiazepines and the level of task practice are highlighted as possible confounding variables in patient studies. The implications of these results for the current neuropathological theories of abnormal saccadic distractibility are discussed.     

Panic disorder in cardiac outpatients

OBJECTIVE: Continuing the long history of interest in the relation of anxiety disorders to cardiovascular function and symptoms, this study investigated the level of anxiety and prevalence of panic disorder in cardiac patients and the possible associations between specific abnormal ECG results and a diagnosis of panic disorder. METHOD: Consecutive patients referred for ambulatory ECG recordings were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale. Then, 50 patients with scores higher than 8 (the anxious group) were interviewed with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA). RESULTS: Of the 50 anxious patients (26 male and 24 female) interviewed with the SADS-LA, 62% (N = 31) met the DSM-III-R criteria for panic disorder. Patients with panic disorder had a higher mean maximal heart rate and a shorter P-R interval than patients without panic disorder. Unlike the patients without panic disorder, the patients with panic disorder showed no correlation between maximal heart rate and minimal P-R interval. CONCLUSIONS: The rate of panic disorder was high in the patients referred for ECG. Moreover, the prevalence of panic disorder was similar in the patients with and without ECG abnormalities, indicating that in anxious patients the presence of panic disorder does not rule out organic cardiac disease. On the other hand, the higher maximal heart rate and shorter P-R interval of the panic patients may be attributable to hypersensitivity of beta-adrenergic receptors in panic disorder.     

Clinical features distinguishing patients with Tourette's syndrome and obsessive-compulsive disorder from patients with obsessive-compulsive disorder without tics

OBJECTIVE: It is not clear whether obsessive-compulsive disorder (OCD) in the context of Tourette's syndrome (TS) is the same as that disorder found in patients with OCD alone. This study evaluated the severity and characteristics of the obsessive-compulsive symptoms in adult patients with OCD and TS compared to adult patients with OCD alone. METHOD: Thirteen subjects with both DSM-III-R TS and OCD and 13 subjects with OCD alone were recruited. Obsessive-compulsive severity was determined by using the Yale-Brown Obsessive Compulsive Scale. The Tourette Syndrome Association Unified Tic Rating Scale was administered to determine tic severity, and the adult version of the Attention Deficit and Hyperactivity Checklist was used to detect a history of childhood attention-deficit hyperactivity disorder (ADHD). RESULTS: Subjects with OCD alone had very few obsessions and compulsions that were not also experienced by subjects with both TS and OCD. In contrast, subjects with TS and OCD were significantly more likely to report obsessions involving nonviolent images, excessive concern with appearance, and need for symmetry. Touching, blinking or staring, and counting compulsions were also significantly more common in this group. Eight subjects with OCD and TS had a childhood history of ADHD, compared to none of the pure OCD subjects. CONCLUSION: There are subtle but definite differences in symptomatology of subjects with pure OCD compared to those with OCD and TS consistent with putative differences in pathophysiology between the 2 groups, i.e., abnormalities in the serotonergic system in OCD patients and serotonergic and dopaminergic abnormalities in those with OCD and TS. These observations may be consistent with genetic heterogeneity within both OCD and TS.     

Effects of the cholecystokinin agonist pentagastrin in patients with generalized anxiety disorder

OBJECTIVE: The anxiogenic and panicogenic effects of peripheral administration of the cholecystokinin-B receptor agonist pentagastrin and placebo were evaluated in patients with generalized anxiety disorder and normal comparison subjects. METHODS: Seven patients with generalized anxiety disorder and seven age- and sex-matched normal subjects received an intravenous bolus of placebo and pentagastrin. RESULTS: Panic attacks occurred in five patients with generalized anxiety disorder (71%) and in one normal subject (14%). Patients with generalized anxiety disorder were more likely to report more nonpanic anxiety than were normal subjects. CONCLUSIONS: Patients with generalized anxiety disorder appear to exhibit greater subjective sensitivity to pentagastrin than do normal subjects.     

Antidepressants as first-line agents in the current pharmacotherapy of anxiety disorders.

Over the last decade, there has been a shift in the order of medications considered as first-line treatments for anxiety disorders. This transition was largely initiated by the introduction and consolidation of the selective serotonin reuptake inhibitors (SSRIs)—fluoxetine, paroxetine, sertraline, fluvoxamine, and citalopram—in the treatment of depression, and by the subsequent extension of these agents beyond depression to various anxiety disorders, such as obsessive-compulsive disorder and panic disorder. This article reviews important clinical considerations for prescribing SSRIs for the treatment of panic disorder, obsessive-compulsive disorder, social phobia, posttraumatic stress disorder, and generalized anxiety disorder. The SSRIs and newer atypical antidepressants have established equal or superior efficacy and a more favorable side effect profile when compared to their predecessors. However, the newer agents are not without side effects, such as nausea, diarrhea, insomnia, headaches, sexual dysfunction, sedation, and weight gain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical characteristics of patients with concurrent major depressive disorder and panic disorder

OBJECTIVE: This study was designed to test the hypothesis that patients with both major depressive disorder and panic disorder exhibit more clinical symptoms and have a more protracted course of illness than patients with major depressive disorder only. METHOD: The authors compared standardized clinical evaluations (from Schedule for Affective Disorders and Schizophrenia interviews) of 119 patients with major depressive disorder only and 57 patients with major depressive disorder and concurrent panic disorder. Clinical and demographic variables were included. RESULTS: The patients with both disorders reported symptoms of major depressive disorder earlier in life and also required treatment and hospital admission earlier in life. Many clinical features during the index episode were significantly more severe in the patients with both disorders. A logistic regression identified a "panic index" consisting of the symptoms of somatic anxiety, phobia, indecisiveness, and feelings of inadequacy. Scores on this index allowed proper classification of patients to either of the two diagnostic groups with high reliability. CONCLUSIONS: In major depressive disorder, the presence of panic disorder is suggestive of a more severe and precocious form of illness.     

How good are patients with panic disorder at perceiving their heartbeats?

Palpitations are among the most common symptoms of panic attacks. The present review addresses the question of whether systematic differences in heartbeat perception exist between patients with panic disorder and control subjects. Paradigms involving the comparison of heartbeat sensations with external signals such as discrimination task have failed to find group differences. Recent improvements in methodology may give clearer results in future studies. The majority of studies using the mental tracking paradigm have shown that panic disorder patients show a better heartbeat perception than controls. Discrepant results are probably related to different instructions and differences in sample characteristics such as the inclusion of patients on medication affecting the cardiovascular system. More accurate heartbeat perception, may, however, be restricted to those patients who show agoraphobic avoidance behavior. It is also conceivable that group differences in the mental tracking paradigm are due to attentional biases or a tendency to interpret weak sensations as heartbeats rather than differences in perceptual sensitivity. More ambulatory studies are needed to test whether the results can be generalized to the patients' natural environment. So far ambulatory studies have established superior heartbeat perception only in the subgroup of panic disorder patients with cardiac neurosis. A 1-year prospective study showed that heartbeat perception as assessed with the mental tracking paradigm predicted maintenance of panic attacks. This supports the clinical significance of the findings. Increased cardiac awareness may increase the probability of anxiety-inducing bodily sensations triggering the vicious cycle of panic. Laboratory and ambulatory monitoring studies showed that panic disorder patients respond with anxiety when they think that their heart rate has accelerated. Increased cardiac awareness may also contribute to the maintenance of the disorder by motivating the patients to avoid situations in which these sensations occur.     

Verbal and nonverbal memory processing in patients with obsessive-compulsive disorder: Its relationship to clinical variables.

Memory deficits have been reported in several neuropsychological studies of obsessive-compulsive disorder (OCD). Dysfunction in nonverbal memory has been consistently reported, whereas findings on verbal memory are more heterogeneous. The authors studied 50 patients with OCD who were matched for sex, age, educational level, and hand dominance with 50 healthy controls (HC). Cognitive performance in both groups was assessed on verbal and nonverbal memory tasks, and several clinical variables were also assessed in the patient group. Patients with OCD showed a pattern of cognitive dysfunction with alterations in areas of nonverbal memory (recall and recognition), and verbal memory (learning and recall). Older age at onset of OCD was associated with poorer performance on verbal memory tasks. Low scores on some verbal memory tasks were associated with severity of OCD, and nonverbal memory was influenced by depressive symptoms. The study suggests the existence of dysfunction in the execution of verbal and nonverbal memory tasks in OCD; the influence of clinical variables depends on the specific neuropsychological function. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family characteristics of subjects with panic attacks

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.     

Medical utilisation and costs in panic disorder: a comparison with social phobia

There is considerable evidence that people with panic disorder utilise the physical health care system more frequently than people in the general community and so incur for themselves, and impose on the public health care system, considerably greater costs. Although this is probably because of specific characteristics to do with panic disorder, it may also be a function of having any anxiety disorder where panic is prominent. This study represents one of the few comparisons of medical utilisation and costs incurred by people with panic disorder to those incurred by people with another anxiety disorder, in this case, social phobia. Before treatment, 41 people with panic disorder, 15 with social phobia and 43 nonanxious controls were interviewed about their use of the medical care system over the previous 12 months. As expected, people with panic disorder had significantly higher utilisation rates than either the nonanxious controls or the socially phobic subjects, and incurred substantially higher costs. Adequate screening for panic disorder at the primary medical care level together with appropriate treatment referral therefore have the potential to substantially reduce the personal and community costs incurred by people with panic disorder.     

Frontal CSF enlargement in panic disorder: a qualitative CT-scan study

Brain morphology was assessed qualitatively in CT scans of 21 patients with panic disorder and 21 normal control subjects. Patients showed significant bilateral enlargement of frontal cerebrospinal fluid (CSF) spaces. These findings suggest that alterations in brain morphology are involved in the etiology of panic disorder.     

Extinction of panicogenic effects of a 35% CO? challenge in patients with panic disorder.

Inhalations of high concentrations of carbon dioxide (CO?) reliably produce panic attacks in patients with panic disorder. The present study evaluated whether cognitive–behavioral treatment (CBT) for panic disorder would extinguish CO?-induced panic and whether changes in panic and arousal-related cognitions were associated with the induction of panic. Patients with panic disorder (N?=?54) were assigned to 1 of 3 experimental conditions: CBT with respiratory training (CBT-R), CBT without respiratory training (CBT), or delayed treatment. Participants received 5 repeated vital-capacity inhalations of 35% CO?/65% O? prior to and following either 12 treatment sessions or a 12-week waiting period. During pretreatment assessments, 74% of patients experienced a panic attack during at least 1 inhalation. At posttreatments only 20% of treated participants (CBT-R?=?19%, CBT?=?22%), compared with 64% of untreated participants, panicked. Forty-four percent of treated participants, compared with 0% of untreated participants, reported no anxiety during all posttreatment inhalations. Anxiety sensitivity as well as panic appraisals regarding the likelihood of panic and self-efficacy with coping with panic were significantly related to fearful responding to the CO? challenge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of isoproterenol infusions on heart rate variability in patients with panic disorder

Some evidence suggests that patients with panic disorder have a decreased cardiac vagal and a relatively higher sympathetic activity. In this study, spectral analysis of the time series of heart rate before and after isoproterenol infusions was used to study heart rate variability in six panic disorder patients and 11 normal control subjects. These preliminary data reveal a significant increase of sympathovagal ratios only in the patient group after isoproterenol administration. The findings suggest a relative increase in cardiac sympathetic and a relative decrease in cardiac vagal function in patients with panic disorder during isoproterenol infusions.