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.     

Emotionally triggered asthma: a review of research literature and some hypotheses for self-regulation therapies

Asthma is a common disease whose morbidity and mortality are rapidly increasing. Panic disorder is common in asthma. Panic, other negative emotions, and a passive coping orientation may affect asthma by producing hyperventilation, increased general autonomic lability, a specific pattern of autonomic arousal that may cause bronchoconstriction, and/or detrimental effects on health care behaviors. Generalized panic is a risk factor for increased asthma morbidity. A repressive coping style also appears to be a risk factor for asthma morbidity because it is accompanied by an impaired ability to perceive symptoms, a necessary prerequisite for taking appropriate remediation. Several self-regulation strategies are hypothesized to be useful adjuncts to asthma treatment. Preliminary research has been done on relaxation therapy, EMG biofeedback, biofeedback for improved sensitivity in perceiving respiratory sensations, and biofeedback training for increasing respiratory sinus arrhythmia. It is hypothesized that finger temperature biofeedback also may be a promising treatment method, and that relaxation-oriented methods will have their greatest effect among asthmatics who experience panic symptoms, while improved perceptual sensitivity will be helpful both for patients who panic and those with repressive coping styles.     

Psychophysiological, somatic, and affective changes across the menstrual cycle in women with panic disorder.

This study explored menstrual symptoms, somatic focus, negative affect, and psychophysiological responding across the menstrual cycle in women with panic disorder and controls. Women with and without panic disorder completed a psychophysiological task and self-report measures of menstrual symptoms, somatic focus, and negative affect on 4 occasions across 2 menstrual cycles (twice during intermenstrual and premenstrual phases). Women in the panic disorder group exhibited greater skin conductance magnitude and more frequent skin conductance responses to anxiety-provoking stimuli during the premenstrual phase than did controls. Compared to controls, women with panic disorder endorsed more severe menstrual symptoms relating to bodily sensations, anxiety sensitivity, state and trait anxiety, fear of body sensations, and illness-related concerns. The applicability of anxiety sensitivity to understanding the relation of menstrual reactivity and panic disorder is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictability, controllability, and fear of symptoms of anxiety in epinephrine-induced panic

BACKGROUND: Psychological manipulations (supplied information, safety cues) may influence panic rates during pharmacologic challenge tests in subjects with panic disorder (PD). Psychological panic models assume that fear of stress-related bodily sensations is central to the etiology of PD. METHODS: Prior to infusion of epinephrine, 50 subjects with PD were randomly assigned to one out of four experimental conditions: with or without extensive information and with or without external control, according to a 2 x 2 design. The panic rate was hypothesized to be lower in subgroups possessing extensive information and/or control. Fear of bodily sensations was used as a predictor. RESULTS: Thirty-four out of 50 patients (68%) panicked during the infusion. Subjects who received extensive information were marginally less likely to panic, but manipulation of control did not influence panic rates. Panickers did not differ from nonpanickers in measures of fear of fear. Anxiety sensitivity best predicted baseline anxiety and cognitive symptom scores, but was not associated with other outcome measures in panickers. Only baseline partial pressure of CO2 discriminated between panickers and nonpanickers. CONCLUSIONS: Manipulating external safety cues appears to be of limited value in modulating responses to epinephrine challenge. Together with our finding that fear of anxiety symptoms does not predict panic rates, these data argue against "fear of fear" as a key mechanism in epinephrine-induced panic.     

Automatic Negative Evaluation of Suffocation Sensations in Individuals With Suffocation Fear.

The current study tested whether "suffocation sensations" (respiratory loads) are automatically evaluated in a negative way by people fearing these sensations. It was found that, after having been primed with a slight respiratory load, participants with high suffocation fear (n = 15) reacted more quickly to suffocation words and more slowly to positive words than participants with low suffocation fear (n = 21). However, the effect was present only in participants who had noticed the primes. The findings are relevant to the cognitive model of panic disorder because automatic negative appraisal of sensations may play a role in initiating a panic attack. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anxiety sensitivity and depression: How are they related?

Anxiety sensitivity is the fear of anxiety-related bodily sensations, which arises from beliefs that the sensations have harmful somatic, psychological, or social consequences. Elevated anxiety sensitivity, as assessed by the Anxiety Sensitivity Index (ASI), is associated with panic disorder. The present study investigated the relationship between anxiety sensitivity and depression. Participants were people with panic disorder (n?=?52 ), major depression (n?=?46), or both (n?=?37 ). Mean ASI scores of each group were elevated, compared to published norms. Principal components analysis revealed 3 factors of anxiety sensitivity: (a) fear of publicly observable symptoms, (b) fear of loss of cognitive control, and (c) fear of bodily sensations. Factors 1 and 3 were correlated with anxiety-related measures but not with depression-related measures. Conversely, factor 2 was correlated with depression related measures but not with anxiety-related measures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Body vigilance in panic disorder: Evaluating attention to bodily perturbations.

Body vigilance, consciously attending to internal cues, is a normal adaptive process. The present report investigated whether body vigilance is exaggerated among those with panic disorder, a condition characterized by intense fear and worry regarding bodily sensations. The Body Vigilance Scale is validated in nonclinical and anxiety disorder patients. Study 1 suggests that body vigilance is normally distributed in a nonclinical sample (n?=?472) but vigilance is related to a history of spontaneous panic attacks, anxiety symptomatology, and anxiety sensitivity. Study 2 suggests that body vigilance is elevated in panic disorder patients (n?=?48) relative to social phobia patients (n?=?18) and nonclinical controls (n?=?71). During cognitive-behavioral treatment, panic disorder patients show substantial reductions in body vigilance associated with reductions in anxiety symptomatology. Anxiety sensitivity was found to be related to body vigilance and to predict changes in body vigilance during treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

étude exploratoire des attitudes envers l'activité physique chez les sujets souffrant d'un trouble panique.

The aim of this study was to assess the attitude of panic disorder patients with and without agoraphobia (PD/A) concerning physical activities. Self-report instruments were used to compare 141 PD/A subjects (68 being in remission of their symptoms) to 172 control subjects. Results indicated that PD/A subjects are more prone to apprehend physical sensations related to the practise of physical activities, more specifically tachycardia, vertigo and hot flushes. They also tend to fear that those symptoms could generate negative consequences. In comparison with control subjects, PD/A subjects find the practise of aerobic physical activities harder and less pleasurable. PD/A subjects considered in remission could present a cognitive style likely to maintain a vulnerability to recurrence of symptoms. Clinical implications are discussed and future directions are delineated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical features in panic disorder with agoraphobia: a comparison of men and women

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.     

A 1-year prospective study of panic attacks: Clinical course and factors associated with maintenance.

A prospective naturalistic l-year follow-up study of 39 patients with current panic disorder, 17 remitted panic patients, 46 infrequent panickers, 22 patients with simple phobias, and 45 controls assessed clinical course and variables related to the maintenance of panic attacks. Nearly all panic disorder patients (92%) continued to experience panic attacks, and 41% of the initially remitted patients relapsed. No significant effects of treatments delivered in the community were found. Infrequent panickers tended to be more likely to develop panic disorder (15%) than controls (2%). Maintenance/relapse was most consistently linked with good heartbeat perception, anxiety sensitivity, and avoidance in the different subsamples. Patients with simple phobias or normal controls who experienced their first panic attack during follow-up had shown higher anxiety sensitivity at initial assessment than nonpanickers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral group therapy for panic disorder in the general clinical setting: a naturalistic study with 1-year follow-up

BACKGROUND: Cognitive-behavioral therapy (CBT) is well documented in the treatment of panic disorder. As most investigators have studied selected patients without comorbid disorders, it is less clear how well the treatment will perform in the usual clinical setting for patients with comorbid disorders and with physicians who do not have training in CBT. During the last 6 years, we have offered CBT in outpatient groups for patients with panic disorder and agoraphobia. The purpose of this prospective study was to assess the outcome of group treatment and compare the results with those of studies that used individual treatment. We wanted to identify variables that might predict outcome at follow-up and to assess the number and characteristics of dropouts. METHOD: Eighty-three consecutive patients with DSM-III-R panic disorder (56 women and 27 men; mean age = 34.5 years) were studied. Mean duration of panic disorder was 7.5 years. There was a high degree of comorbid major depression, social phobia, and psychoactive substance abuse/dependence. Treatment consisted of 4-hour group sessions conducted once a week for 11 weeks. More than half of the patients used antidepressant drugs. Degree of phobic avoidance, bodily sensations, anxiety cognitions, and depression were assessed at pretreatment, baseline, and end of treatment and at follow-up after 3 and 12 months. RESULTS: There was a large decrease in scores from start to end on all assessments. Sixty-three (89%) of 73 completers responded (> or = 50% reduction in Phobic Avoidance Rating Scale scores). Gains were maintained and even improved upon at follow-up. The results are comparable with studies that used individual therapy. A high depression score at the end of treatment predicted poor outcome at 1-year follow-up. Twelve (14%) of 83 did not complete the program. The presence of severe personality disorders and ongoing alcohol or substance abuse or dependence was associated with poor outcome and high dropout rate. CONCLUSION: CBT appears to be effective in the usual clinical setting, even in the hands of therapists without formal competence. Group therapy is a feasible arrangement, and the results from group treatment are comparable to those of individual approaches. Precise diagnosis and treatment of comorbid depression are of utmost importance. Patients with additional substance abuse or dependence, as well as severe personality disorders, may find this treatment modality less helpful.     

Drugs and toxins associated with myopathies

BACKGROUND: The sympathetic nervous system has long been believed to be involved in the pathogenesis of panic disorder, but studies to date, most using peripheral venous catecholamine measurements, have yielded conflicting and equivocal results. We tested sympathetic nervous function in patients with panic disorder by using more sensitive methods. METHODS: Sympathetic nervous and adrenal medullary function was measured by using direct nerve recording (clinical microneurography) and whole-body and cardiac catecholamine kinetics in 13 patients with panic disorder as defined by the DSM-IV, and 14 healthy control subjects. Measurements were made at rest, during laboratory stress (forced mental arithmetic), and, for 4 patients, during panic attacks occurring spontaneously in the laboratory setting. RESULTS: Muscle sympathetic activity, arterial plasma concentration of norepinephrine, and the total and cardiac norepinephrine spillover rates to plasma were similar in patients and control subjects at rest, as was whole-body epinephrine secretion. Epinephrine spillover from the heart was elevated in patients with panic disorder (P=.01). Responses to laboratory mental stress were almost identical in patient and control groups. During panic attacks, there were marked increases in epinephrine secretion and large increases in the sympathetic activity in muscle in 2 patients but smaller changes in the total norepinephrine spillover to plasma. CONCLUSIONS: Whole-body and regional sympathetic nervous activity are not elevated at rest in patients with panic disorder. Epinephrine is released from the heart at rest in patients with panic disorder, possibly due to loading of cardiac neuronal stores by uptake from plasma during surges of epinephrine secretion in panic attacks. Contrary to popular belief, the sympathetic nervous system is not globally activated during panic attacks.     

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.     

The effect of exercise training on the severity and duration of a viral upper respiratory illness

OBJECTIVE: The purpose of this study was to assess whether joint hypermobility syndrome is more frequent in patients with panic disorder, agoraphobia, or both than in control subjects and, if so, to determine whether mitral valve prolapse modifies or accounts in part for the association. METHOD: A case-control study was conducted in a general teaching hospital outpatient clinic. Subjects were 99 patients, newly diagnosed and untreated, with panic disorder, agoraphobia, or both and two groups of age- and sex-matched control subjects: 99 psychiatric patients and 64 medical patients who had never suffered from any anxiety disorder. Measures consisted of the Structured Clinical Interview for DSM-III-R, Beighton's criteria for joint hypermobility syndrome, and two-dimensional and M-mode echocardiogram. The presence of mitral valve prolapse and joint hypermobility syndrome was explored by raters who were blind to subjects' psychiatric status. RESULTS: Joint hypermobility syndrome was found in 67.7% of patients with anxiety disorder but in only 10.1% of psychiatric and 12.5% of medical control subjects. On the basis of statistical analysis, patients with anxiety disorder were over 16 times more likely than control subjects to have joint laxity. These findings were not altered after the presence of mitral valve prolapse was taken into account. Of the patients with anxiety disorder, those who had joint hypermobility syndrome were younger and more often women and had an earlier onset of the disorder than those without joint hypermobility syndrome. CONCLUSIONS: Joint laxity is highly prevalent in patients with panic disorder, agoraphobia, or both and may reflect a constitutional disposition to suffer from anxiety. Mitral valve prolapse plays a secondary role in the association between joint hypermobility and anxiety.     

Diagnostic comorbidity in panic disorder: effect on treatment outcome and course of comorbid diagnoses following treatment

The impact and course of additional diagnoses was examined in 126 patients undergoing cognitive-behavioral treatment for panic disorder. With the Anxiety Disorders Interview Schedule--Revised, a high comorbidity rate (51%) was observed at pretreatment. Pretreatment comorbidity was not predictive of premature termination, nor did it have a substantial impact on short-term treatment outcome. However, patients with comorbidity at posttreatment were more likely to have sought additional treatment over the follow-up interval. Although a significant and dramatic decline in the overall comorbidity rate was found at posttreatment (17%), at 24-month follow-up this rate had increased to a level (30.2%) that was no longer significantly different from pretreatment. This was despite the fact that patients maintained or improved on treatment gains for panic disorder over this interval. The implications of these findings for the treatment, conceptualization, and classification of emotional disorders are discussed.     

Agoraphobia without panic: clinical reappraisal of an epidemiologic finding

OBJECTIVE: In the United States, the consensus among clinicians and researchers, reflected in DSM-III-R, is that agoraphobia is a conditioned response to panic attacks and almost never occurs without panic attacks. The predominant view in the United Kingdom is that agoraphobia frequently occurs in the absence of panic. While clinicians report that they rarely see patients with agoraphobia who have no history of panic disorder, community studies report that agoraphobia without panic disorder is common. For example, the Epidemiologic Catchment Area (ECA) study found that 68% of 961 persons with agoraphobia had no history of panic attacks or disorder. METHOD: To understand this discrepancy, 22 subjects who had been diagnosed as having agoraphobia without panic disorder or panic attacks in the ECA study were blindly reinterviewed 7-8 years later with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders; data from these interviews were blindly reviewed by a research psychiatrist who was not involved in the original data collection or the reinterview process. RESULTS: On reappraisal, 19 of the 22 subjects had simple phobias or fears but not agoraphobia. One subject had probable agoraphobia without panic attacks, one had definite panic disorder with agoraphobia, and one had probable agoraphobia with limited symptom attacks. CONCLUSIONS: Epidemiologic studies that used the Diagnostic Interview Schedule and lay interviewers, such as the ECA study, may have over-estimated the prevalence of agoraphobia without panic. Agoraphobia without panic attacks occurs but is uncommon, and the diagnostic boundary between agoraphobia and simple phobia is unclear.     

Psychological approaches to panic disorder: A review.

Panic disorder has been the subject of considerable research and controversy. Though biological conceptualizations have been predominant, psychological theorists have recently advanced conditioning, personality, and cognitive hypotheses to explain the etiology of panic disorder. The purpose of this article is to provide an empirical and conceptual analysis of these psychological hypotheses. This review covers variants of the "fear-of-fear" construal of panic disorder (i.e., Pavlovian interoceptive conditioning, catastrophic misinterpretation of bodily sensations, anxiety sensitivity), research on predictability (i.e., expectancies) and controllability, and research on information-processing biases believed to underlie the phenomenology of panic. Suggestions for future research are made. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Atherosclerotic cardiovascular disease, lipemic disorders, hypertension, obesity and diabetes mellitus in the population of a metropolitan area of southeastern Brazil. III--Hypertension

Premature ejaculation is a common sexual disturbance among men. Both open-label and double-blind studies have demonstrated the effectiveness of serotonergic medications for this disorder. These studies support the hypothesis that the serotonergic system has an important role in the modulation of sexual response, especially attainment of orgasm. Serotonergic dysfunction also has been linked to the pathogenesis of panic disorder. Several studies have demonstrated the efficacy of serotonergic drugs in this disorder. The purpose of the present study was to examine the efficacy of fluoxetine, a serotonin selective reuptake inhibitor for the treatment of comorbid premature ejaculation and panic disorder, in 10 men in an open-label design. The patients were given 20 mg of fluoxetine for 8 weeks of the study. Parameters pertaining to sexual function and measures of anxiety were examined. Improvement of premature ejaculation was noted as of week 2 of the study, whereas measures of panic and sexual satisfaction became statistically significant only as of week 4. Further studies with larger samples and longer periods of follow-up are needed in order to determine the usefulness of fluoxetine for the treatment of comorbid premature ejaculation and panic disorder.     

Anxiety sensitivity: theoretical perspectives and recent findings

Anxiety sensitivity (AS) is the fear of anxiety-related sensations, which arises from beliefs that these sensations have harmful somatic, psychological or social consequences. According to Reiss (1991), AS is one of three fundamental fears that amplify or cause many common fears. AS also is thought to play an important role in causing panic attacks. The purpose of the present article is to review recent findings concerning the construct of AS and its place in the nomological network outlined by Reiss. Although the weight of evidence supports a unifactorial model of AS, recent findings suggest AS is multifactorial at the level of first-order factors, and these factors load on a single higher-order factor. People with elevated AS, compared to those with low AS, are more likely to have histories of panic attacks. AS is factorially distinct from other fundamental fears, and is more strongly related to agoraphobia than other common fears. AS can be regarded as a subfactor of trait anxiety, and is more strongly related to agoraphobia than other common fears. AS can be regarded as a subfactor of trait anxiety, although the question arises as to whether AS is a cause of trait anxiety. Important questions for further investigation concern the etiology of AS and whether it can be reduced to still more basic fears.