Does ‘fear of dying’ indicate a more severe presentation of panic disorder?

Research suggests a relationship between the presence of fearful cognitions and panic disorder (PD) severity. With little existing evidence addressing the clinical significance of individual panic-cognitions, the current study examined presentation and impairment differences among 331 outpatients with PD according to whether they experience “fear of dying” (FOD) during panic attacks. Patients reporting FOD (n = 153) were compared to patients denying FOD (n = 178) on variables indicating PD severity (e.g., number of symptoms) and psychiatric impairment (e.g., hospitalizations). PD patients with FOD reported a greater number of panic symptoms, agoraphobia diagnoses, and were more likely to be seeking treatment primarily for PD. We found no clinical impairment or comorbidity differences between groups. Results suggest that panic attacks with FOD are related to a more acute presentation of PD. Such results substantiate past research connecting cognitive distress and PD severity and further suggest that FOD may be particularly relevant to this relationship.     

Pre-treatment peripheral biomarkers associated with treatment response in panic symptoms in patients with major depressive disorder and panic disorder: A 12-week follow-up study

ObjectivePeripheral biomarkers have been studied to predict treatment response of panic symptoms. We hypothesized that depressive disorder (MDD) vs. panic disorder (PD) would exhibit different peripheral biomarkers, and their correlation with severity of panic attacks (PA) would also differ.MethodsForty-one MDD patients, 52 PD patients, and 59 healthy controls were followed for 12 weeks. We measured peripheral biomarkers along with the Panic Disorder Severity Scale (PDSS) at each visit—pre-treatment, 2, 4, 8, and 12 weeks on a regular schedule. Peripheral biomarkers including serum cytokines, plasma and serum brain-derived neurotrophic factor (BDNF), leptin, adiponectin, and C-reactive protein (CRP) were quantified using enzyme-linked immunosorbent assay (ELISA).ResultsPatients with MDD and PD demonstrated significantly higher levels of pre-treatment IL-6 compared to controls, but no differences were seen in plasma and serum BDNF, leptin, adiponectin, and CRP. Pre-treatment leptin showed a significant clinical correlation with reduction of panic symptoms in MDD patients at visit 5 (p = 0.011), whereas pre-treatment IL-6 showed a negative correlation with panic symptom reduction in PD patients (p = 0.022). An improvement in three panic-related items was observed to be positively correlated with pre-treatment leptin in MDD patients: distress during PA, anticipatory anxiety, and occupational interference.ConclusionHigher pre-treatment leptin was associated with better response to treatment regarding panic symptoms in patients with MDD, while higher IL-6 was associated with worse response regarding panic symptoms in PD patients. Different predictive peripheral biomarkers observed in MDD and PD suggest the need for establishing individualized predictive biomarkers, even in cases of similar symptoms observed in different disorders.     

Sub-threshold panic attacks and agoraphobic avoidance increase comorbidity of mental disorders: Results from an adult general population sample

Full-blown panic attacks are frequently associated with other mental disorders. Most comorbidity analyses did not discriminate between isolated panic attacks vs. panic attacks that occurred in the context of a panic disorder and rarely evaluated the impact of comorbid agoraphobia. Moreover, there are no larger scale epidemiological studies regarding the influence of sub-threshold panic attacks. 4075 German-speaking respondents aged 18–64 were interviewed using the fully structured Munich Composite International Diagnostic Interview. Limited symptom attacks, isolated panic attacks, and panic disorder were associated with other lifetime DSM-IV disorders with monotonically increasing odds and increasing tendency for multiple comorbidities across the three groups. The presence of agoraphobia was associated with more frequent comorbidity in all panic subgroups and also in persons who never experienced panic attacks. The present study suggests that populations with isolated or limited symptom should be carefully attended to in clinical practice, especially if agoraphobia is present.     

The role of treatment delivery factors in exposure-based cognitive behavioral therapy for panic disorder with agoraphobia

Treatment delivery factors (i.e., therapist adherence, therapist competence, and therapeutic alliance) are considered to be important for cognitive behavioral therapy (CBT) for panic disorder and agoraphobia (PD/AG). In the current study, four independent raters conducted process evaluations based on 168 two-hour videotapes of 84 patients with PD/AG treated with exposure-based CBT. Two raters evaluated patients’ interpersonal behavior in Session 1. Two raters evaluated treatment delivery factors in Session 6, in which therapists provided the rationale for conducting exposure exercises. At the 6-month follow-up, therapists’ adherence (r = 0.54) and therapeutic alliance (r = 0.31) were significant predictors of changes in agoraphobic avoidance behavior; therapist competence was not associated with treatment outcomes. Patients’ interpersonal behavior in Session 1 was a significant predictor of the therapeutic alliance in Session 6 (r = 0.17). The findings demonstrate that treatment delivery factors, particularly therapist adherence, are relevant to the long-term success of CBT for PD/AG.     

A discussion of various aspects of panic disorder depending on presence or absence of agoraphobia

ObjectiveThe quality of life of individuals with panic disorder and agoraphobia can be improved by the alleviation of agoraphobia. In other words, examining panic disorder in terms of whether agoraphobia is present is crucial. The current study examined panic disorder from this perspective.MethodsSubjects were 253 patients who met the diagnostic criteria for panic disorder (lifetime) according to the Mini International Neuropsychiatric Interview (MINI). Of those patients, 179 had agoraphobia and 74 did not. Statistical analysis was used to examine gender differences in the presence (or absence) of agoraphobia, comorbidities, and the effects of the presence of agoraphobia (severity, assessment of depression, assessment of anxiety, and personality) in these patients.ResultsResults indicated gender differences in the presence (or absence) of agoraphobia. Compared to patients without agoraphobia, significantly more patients with agoraphobia were female (p < .001), and had a higher prevalence of comorbidities. Patients with agoraphobia had a higher suicide risk (p < .05), more hypomanic episodes (current) (p < .05), and more frequent episodes of social phobia (p < .05). In addition, patients with agoraphobia had more severe panic disorder and a higher level of neuroticism, sensitivity to anxiety, and trait anxiety [PDSS-J, P&A, NEO-N: p < .01, ASI, STAI (Trait Anxiety): p < .05].ConclusionsThe current findings suggest that when treating a panic disorder, diagnosing the presence of agoraphobia is extremely important.     

“But it might be a heart attack”: Intolerance of uncertainty and panic disorder symptoms

Panic disorder models describe interactions between feared anxiety-related physical sensations (i.e., anxiety sensitivity; AS) and catastrophic interpretations therein. Intolerance of uncertainty (IU) has been implicated as necessary for catastrophic interpretations in community samples. The current study examined relationships between IU, AS, and panic disorder symptoms in a clinical sample. Participants had a principal diagnosis of panic disorder, with or without agoraphobia (n = 132; 66% women). IU was expected to account for significant variance in panic symptoms controlling for AS. AS was expected to mediate the relationship between IU and panic symptoms, whereas IU was expected to moderate the relationship between AS and panic symptoms. Hierarchical linear regressions indicated that IU accounted for significant unique variance in panic symptoms relative to AS, with comparable part correlations. Mediation and moderation models were also tested and suggested direct and indirect effects of IU on panic symptoms through AS; however, an interaction effect was not supported. The current cross-sectional evidence supports a role for IU in panic symptoms, independent of AS.     

A taxometric investigation of agoraphobia in a clinical and a community sample

The nosological status of agoraphobia is controversial. Agoraphobia may be a distinct diagnostic entity or a marker of avoidance severity. The current study examines the latent structure of agoraphobia through the use of taxometric analysis. The latent structure of agoraphobia was examined in two independent samples, one comprising outpatients presenting for treatment for panic disorder (PD) with or without agoraphobia (n = 365), and the other comprising community volunteers to a national mental health survey who experienced fear or avoidance of at least one prototypic agoraphobic situation (n = 640). Two taxometric procedures were carried out – maximum eigenvalue (MAXEIG) and mean above minus below a cut (MAMBAC) – using indicators derived from questionnaire measures of, and structured diagnostic interviews for, agoraphobia. Results show consistent evidence of dimensional latent structure in both samples. It is concluded that scores on measures of agoraphobia best represent an agoraphobic severity dimension.     

The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication

CONTEXT: Only limited information exists about the epidemiology of DSM-IV panic attacks (PAs) and panic disorder (PD). OBJECTIVE: To present nationally representative data about the epidemiology of PAs and PD with or without agoraphobia (AG) on the basis of the US National Comorbidity Survey Replication findings. DESIGN AND SETTING: Nationally representative face-to-face household survey conducted using the fully structured World Health Organization Composite International Diagnostic Interview. PARTICIPANTS: English-speaking respondents (N=9282) 18 years or older. MAIN OUTCOME MEASURES: Respondents who met DSM-IV lifetime criteria for PAs and PD with and without AG. RESULTS: Lifetime prevalence estimates are 22.7% for isolated panic without AG (PA only), 0.8% for PA with AG without PD (PA-AG), 3.7% for PD without AG (PD only), and 1.1% for PD with AG (PD-AG). Persistence, lifetime number of attacks, and number of years with attacks increase monotonically across these 4 subgroups. All 4 subgroups are significantly comorbid with other lifetime DSM-IV disorders, with the highest odds for PD-AG and the lowest for PA only. Scores on the Panic Disorder Severity Scale are also highest for PD-AG (86.3% moderate or severe) and lowest for PA only (6.7% moderate or severe). Agoraphobia is associated with substantial severity, impairment, and comorbidity. Lifetime treatment is high (from 96.1% for PD-AG to 61.1% for PA only), but 12-month treatment meeting published treatment guidelines is low (from 54.9% for PD-AG to 18.2% for PA only). CONCLUSION: Although the major societal burden of panic is caused by PD and PA-AG, isolated PAs also have high prevalence and meaningful role impairment.     

Coping behavior in patients with panic disorder

The purpose of the present paper was to investigate the role of coping behavior in patients with panic disorder (PD). This was done by evaluating three items of coping behavior (seeking of social support, wishful thinking and avoidance) in the Ways of Coping Checklist. The subjects consisted of 30 patients with PD (26 with agoraphobia). Coping behavior and the severity of PD was investigated at baseline and at 24 months (the final outcome). At baseline there were no gender differences in coping behavior. The severity of panic attacks significantly correlated with that of agoraphobia. The baseline severity of PD (panic attacks and agoraphobia) did not correlate with coping behavior. At the outcome assessment there was no significant correlation between the severity of panic attack and coping behavior. The severity of agoraphobia at final outcome and the coping behavior (seeking of social support) at baseline were significantly correlated. In the group that had remission in agoraphobia (the good outcome group), the severity of agoraphobia at baseline was significantly lower and the seeking of social support coping behavior was significantly higher than that of the poor outcome group. No significant difference in panic attack severity was noted between the good and poor outcome groups. Discriminant analysis revealed that seeking of social support coping behavior was a significant discriminant factor of agoraphobia. Although these are preliminary data, special coping behavior might be related to improvement of agoraphobia in patients with PD.     

How specific are inhibitory deficits to obsessive-compulsive disorder? A neurophysiological comparison with panic disorder

ObjectiveImpaired inhibition may perpetuate repetitive symptoms in obsessive-compulsive disorder (OCD), however OCD-specific deficits have yet to be established. We investigated neural correlates of inhibition in OCD vs. healthy and anxious controls.MethodsERPs and reaction times (RTs) were compared between participants with OCD (n = 20), panic disorder (PD; n = 20) and healthy controls (HCs; n = 20) during an adapted Go/NoGo task, which manipulated inhibitory difficulty.ResultsA classic P3 NoGo anteriorisation effect occurred across groups. Both clinical groups showed RT impairment, and similar topographical anomalies of several (P2, N2 and P3) ERP components. Notably, both clinical groups lacked the strong frontally maximal N2 component topography seen in the HCs, across stimuli. Additionally, with increasing inhibitory difficulty, N2 latency increased in HCs but not in the clinical groups.ConclusionsUnexpectedly, ERP and behavioural anomalies during inhibition in OCD were not qualitatively different to those in PD, but were generally more severe. Common general and inhibitory deficits may underlie intrusive mental phenomena in both conditions.SignificanceThis first ERP response inhibition study in OCD to include anxious controls disconfirmed hypotheses regarding OCD-specific inhibitory deficits, indicating the importance of comparing OCD to other conditions, to evaluate neurobiological models.     

Differences in symptom structure between panic attack and limited symptom panic attack: A study using cluster analysis

Abstract We had investigated the clinical characteristics of panic disorder (PD) in a Japanese outpatient population comprised of more than 250 patients diagnosed as having PD during a 13-year study period and observed that some PD patients had both panic attacks (PA) and limited symptom panic attacks (LPA). In the criteria for PD based on the Diagnostic and Statistics Manual of Mental Disorders , third edition-revised ( DSM-III-R ), episodes involving four or more symptoms are classified as PA, while those involving fewer than four symptoms are described as LPA. Therefore, LPA is identified as part of an episode of PA, since the difference between the two episodes is only in the number of symptoms. However, some recent research suggests that there is a distinct subgroup of individuals who suffer LPA. Using cluster analysis, we investigated the differences between PA and LPA groups in terms of the structures of several panic symptoms, which included anticipatory anxiety, agoraphobia and 13 clinical symptoms based on the DSM-III-R at the time of panic attacks, in 247 patients with PD. Cluster analysis revealed clusters of three and four panic symptoms in the PA group and LPA group, respectively, and there were also differences in symptom structure between the two groups. These results suggest that there may be a subgroup of individuals who show LPA among PD patients.     

The role of safety behaviors in exposure-based treatment for panic disorder and agoraphobia: Associations to symptom severity,treatment course,and outcome

The potentially detrimental effects of safety behaviors during exposure therapy are still subject to debate. Empirical findings are inconsistent, and few studies have investigated effects of idiosyncratic safety behavior manifestations during exposure or in everyday life.These limitations might be due to a lack of appropriate measures that address individual safety behaviors. We examined psychometric properties and predictive value of the Texas Safety Maneuver Scale (TSMS), a questionnaire specifically targeting safety behaviors in panic disorder and agoraphobia. Effects of safety behavior use, both during everyday life and during therapy, were examined using data from a multicenter RCT of N = 268 patients that aimed at evaluating efficacy and mechanisms of action of two variants of an exposure-based therapy. The TSMS total score demonstrated good internal consistency (α = 0.89), and it showed significant correlations with selected measures of baseline anxiety and impairment. The proposed factor structure could not be replicated. Frequent safety behavior use at baseline was associated with actual safety behavior during exposure exercises. Pronounced in-situ safety behavior, but not baseline safety behavior was associated to detrimental treatment outcome. The results underline the relevance of a rigorous safety behavior assessment in therapy. The actual relationship between safety behavior use and treatment outcome is yet to determine.     

Panic symptoms and elevated suicidal ideation and behaviors among trauma exposed individuals: Moderating effects of post-traumatic stress disorder

Panic attacks (PAs) are highly prevalent among trauma exposed individuals and have been associated with a number of adverse outcomes. Despite high suicide rates among trauma exposed individuals, research to date has not examined the potential relation between panic symptoms and suicidal ideation and behaviors among this high risk population. The current study tested the association of panic with suicidal ideation and behaviors among a large sample of trauma exposed smokers. Community participants (N = 421) who reported a lifetime history of trauma exposure were assessed concurrently for current panic, suicidal ideation and behaviors, and psychiatric diagnoses. Those who met criteria for a current panic disorder diagnosis were removed from analyses to allow for the assessment of non-PD related panic in line with the recent addition of the PA specifier applicable to all DSM-5 disorders. Findings indicated that panic symptoms were significantly associated with suicidal ideation and behaviors beyond the effects of depression and number of trauma types experienced. Further, post-traumatic stress disorder (PTSD) diagnostic status significantly moderated this relationship, indicating that the relationship between panic and suicidal ideation and behaviors is potentiated among individuals with a current PTSD diagnosis. This investigation suggests that panic symptoms may be a valuable clinical target for the assessment and treatment of suicidal ideation and behaviors among trauma exposed individuals.     

Guided and unguided Acceptance and Commitment Therapy for social anxiety disorder and/or panic disorder provided via the Internet and a smartphone application: A randomized controlled trial

Acceptance and Commitment Therapy (ACT) can be effective in treating anxiety disorders, yet there has been no study on Internet-delivered ACT for social anxiety disorder (SAD) and panic disorder (PD), nor any study investigating whether therapist guidance is superior to unguided self-help when supplemented with a smartphone application. In the current trial, n = 152 participants diagnosed with SAD and/or PD were randomized to therapist-guided or unguided treatment, or a waiting-list control group. Both treatment groups used an Internet-delivered ACT-based treatment program and a smartphone application. Outcome measures were self-rated general and social anxiety and panic symptoms. Treatment groups saw reduced general (d = 0.39) and social anxiety (d = 0.70), but not panic symptoms (d = 0.05) compared to the waiting-list group, yet no differences in outcomes were observed between guided and unguided interventions. We conclude that Internet-delivered ACT is appropriate for treating SAD and potentially PD. Smartphone applications may partially compensate for lack of therapist support.     

Associations of fearful spells and panic attacks with incident anxiety,depressive, and substance use disorders: A 10-year prospective-longitudinal community study of adolescents and young adults

ObjectiveThe concept of fearful spells (FS) denotes distressing spells of anxiety that might or might not qualify for criteria of panic attacks (PA). Few studies examined prospective-longitudinal associations of FS not meeting criteria for PA with the subsequent onset of mental disorders to clarify the role of FS as risk markers of psychopathology.MethodA representative community sample of adolescents and young adults (N = 3021, age 14–24 at baseline) was prospectively followed up in up to 3 assessment waves over up to 10 years. FS, PA, anxiety, depressive, and substance use disorders were assessed using the DSM-IV/M-CIDI. Odds Ratios (OR) from logistic regressions were used to examine the predictive value of FS-only (no PA) and PA at baseline for incident disorders at follow-up.ResultsIn logistic regressions adjusted for sex and age, FS-only predicted the onset of any subsequent disorder, any anxiety disorder, panic disorder, agoraphobia, GAD, social phobia, any depressive disorder, major depression, and dysthymia (ORs 1.54–4.36); PA predicted the onset of any anxiety disorder, panic disorder, GAD, social phobia, any depressive disorder, major depression, dysthymia, any substance use disorder, alcohol abuse/dependence, and nicotine dependence (ORs 2.08–8.75; reference group: No FS-only and no PA). Associations with psychopathology were slightly smaller for FS-only than for PA, however, differences in associations (PA compared to FS-only) only reached significance for any anxiety disorder (OR = 3.26) and alcohol abuse/dependence (OR = 2.26).ConclusionsFindings suggest that compared to PA, FS-only have similar predictive properties regarding subsequent psychopathology and might be useful for an early identification of high-risk individuals.     

Large and giant pituitary adenoma resection by microscopic trans-sphenoidal surgery: Surgical outcomes and complications in 123 consecutive patients

To evaluate surgical outcomes and complications of patients who underwent microscopic trans-sphenoidal surgery (MTS) for large and giant pituitary adenomas (PAs). A retrospective study of electively operated cases of PA over a six year period was performed. Surgical outcomes and complications of 64 patients with large PAs (≥3 cm) and 59 patients with giant PAs (>4 cm), who underwent MTS at same period, were reviewed. Medical reports of all selected patients were assessed to collect demographic information such as age, sex, clinical symptoms, PA size, the extent of PA extension and resection, outcomes and complications. Patients with large PAs had improvement in visual improvement (78.1%; 50/64), gross total resection (84.4%; 54/64) compared to patients with giant PAs who had improvement in visual (71.2%; 42/59) and gross total resection (74.6%; 44/59). The rate of CSF leakage was 7.8% and 23.7% for large and giant PAs (p = 0.0399). After a mean follow-up period of 40.8 (6−75) months, 10 (15.6%) patients with large PAs experienced tumor recurrence, while 2 giant PA patients (3.4%) experienced tumor recurrence after a mean follow-up period of 40.6 (3−70) months (p = 0.0314). Resection of both large and giant pituitary adenomas by microscopic trans-sphenoidal surgery may be safe and effective surgical technique with low morbidity and mortality.     

Panic-attack-induced transient leukocytosis in a healthy male: a case report

The lifetime prevalence of panic attacks is 28.3% in American adults 18 years and older. The age of onset of panic attack extends throughout adulthood; however, it typically develops in early adulthood, with median age of onset of 22 years [Kessler R.C., Chiu W.T., Jin R., Ruscio A.M., Shear K., Walters E.E. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006 Apr;63(4):415-24.]. As reported in our case, panic attacks could induce transient leukocytosis in healthy adults. If practitioners recognize this association, expensive investigations and extensive hospital stays may be prevented, although prudent practice would likely still require some type of investigations.     

Effects of nasal continuous positive airway pressure on panic disorder comorbid with obstructive sleep apnea syndrome

BackgroundsBoth obstructive sleep apnea syndrome (OSAS) and panic disorder (PD) are common disorders that often coexist. Continuous positive airway pressure (CPAP) has been established as the first-line treatment for OSAS. In this study, we examined the efficacy of CPAP on PD comorbid with OSAS by conducting a randomized crossover study using sham CPAP as control.MethodsPD patients (n = 12) with an apnea hypopnea index (AHI) of 20/h or higher completed the study. At baseline, the subjects were asked to write their own records pertaining to the frequency of attacks and their score on the panic disorder severity scale (PDSS), and then they participated in the randomized crossover trial period, which measured optimal CPAP and sham CPAP set at 4 cmH₂O during nighttime sleep for each 4-week assignment.ResultsThe frequency of panic attacks, total PDSS score, and the frequency of alprazolam use for alleviating the attack symptoms were significantly decreased during the optimal CPAP period than during the baseline period and the sham CPAP period. Among the PDSS subitems, the frequency of attacks, panic distress, work impairment, and social impairment showed significant improvements during the optimal pressure period.ConclusionOur results suggest that OSAS contributes to PD aggravation, and a combination of pharmaceutical treatment for PD and OSAS-specific treatments such as CPAP could be recommended for patients with PD comorbid with OSAS.     

Therapist-assisted Internet-delivered cognitive behavior therapy for depression and anxiety: Translating evidence into clinical practice

This dissemination study examined the effectiveness of therapist-assisted Internet-delivered Cognitive Behavior Therapy (ICBT) when offered in clinical practice. A centralized unit screened and coordinated ICBT delivered by newly trained therapists working in six geographically dispersed clinical settings. Using an open trial design, 221 patients were offered 12 modules of ICBT for symptoms of generalized anxiety (n = 112), depression (n = 83), or panic (n = 26). At baseline, midpoint and post-treatment, patients completed self-report measures. On average, patients completed 8 of 12 modules. Latent growth curve modeling identified significant reductions in depression, anxiety, stress and impairment (d = .65–.78), and improvements in quality of life (d = .48–.66). Improvements in primary symptoms were large (d = .91–1.25). Overall, therapist-assisted ICBT was effective when coordinated across settings in clinical practice, but further attention should be given to strategies to improve completion of treatment modules.     

Endoscopic endonasal approach to pituitary adenomas: Impact on adenohypophyseal function. Study of 231 cases

PurposeTo identify presurgical and surgical factors associated with the development of hypopituitarism and its recovery after endoscopic endonasal transsphenoidal (EET) resection of pituitary adenomas (PAs).MethodsRetrospective study of patients with PAs operated by the same neurosurgeon through an EET approach in two Spanish tertiary hospitals in ten years.Results242 pituitary surgeries performed in 231 patients were analyzed. In the 154 surgeries performed in 146 patients with non-functioning PAs (NFPAs), 46.8% (n = 72) presented presurgical hypopituitarism. After PAs resection, 41 of these (56.9%) normalized pituitary function and 11 of 82 patients with preoperative normal function (13.4%) developed new pituitary deficits. Patients with preoperative visual impairment (OR = 3.9, p = 0.046) and operated in the first four years of the neurosurgeon's learning curve (OR = 5.7, p = 0.016) presented a higher risk of developing postoperative hypopituitarism.Of the 88 surgeries in 85 patients with functioning PAs (FPAs), 23.9% presented presurgical hypopituitarism, and 47.6% of those recovered after surgery. 9% of the cases with preoperative normal function developed new pituitary deficit/s. Diabetic patients presented a higher risk of persistence of hypopituitarism (OR = 10.5, p = 0.024). Patients with presurgical visual impairment (OR = 30.0, p = 0.010) and PAs >3 cm (OR = 14.0, p = 0.027) had higher risk of developing new pituitary deficits.ConclusionApproximately 50% of patients with PAs and preoperative hypopituitarism recover pituitary function after EET surgery. 10% of patients with normal function develop new deficits. Patients with NFPAs with visual involvement and operated in the first four years of neurosurgeon's learning curve, and FPAs patients with presurgical visual impairment and tumor size >3 cm have a higher risk of postoperative hypopituitarism.