Response of patients with panic disorder and symptoms of hypomania to cognitive behavior therapy for panic

Objectives:  The purpose of this cohort study was to determine in patients with Panic Disorder (PD): (1) the prevalence of subsyndromal symptoms of hypomania, and (2) whether subsyndromal hypomania symptoms affect the outcome of cognitive behavior therapy (CBT) for panic.
Methods:  Using the Diagnostic Interview Schedule, and DSM-III-R criteria we identified 18 individuals with a history of symptoms of hypomania among 56 patients with PD. Patients were treated in an open CBT group program. They were assessed before treatment and 6 and 12 months later. We used the Brief Symptom Inventory (BSI), the Perceived Stress Scale (PSS), the Pearlin-Schooler Mastery Scale (PMS), and the Social Adjustment Scale (SAS) at all assessments.
Results:  The total group significantly improved on all measures. The Clinically Significant Change was 71.4% and the Reliable Change Index 48.2%. Between 6 and 12 months, there was a trend for the hypomania symptom subgroup (PH) to continue to improve on the BSI Depression Scale, the Perceived Stress Scale, the Pearlin–Schooler Mastery Scale, and the Social Adjustment Scale but to lose gains on the BSI Phobic Anxiety and Somatization subscales compared with the group without symptoms of hypomania (PNH).
Conclusions:  Thirty-two percent of patients with PD had symptoms of hypomania. With CBT for panic, patients with PD and symptoms of hypomania improve as much as those without hypomania symptoms. The presence or absence of symptoms of hypomania might help explain the inconsistent effects of depression and personality disorders on the treatment of PD.     

Self-rated importance of religion predicts one-year outcome of patients with panic disorder

Cognitive-behavioral therapy and medication are efficacious treatments for panic disorder, but individual attributes such as coping and motivation are important determinants of treatment response. A sample of 56 patients with panic disorder, treated with group cognitive-behavioral therapy, were reassessed 6 months and 12 months after initial assessment. We studied the effect of self-rated importance of religion, perceived stress, self-esteem, mastery, and interpersonal alienation on outcome as measured by the General Severity Index of the Brief Symptom Inventory (BSI.GSI). Importance of religion was a predictor of BSI.GSI symptom improvement at 1 year. Over time, improvement was seen for the religion is very important subgroup in the BSI.GSI and Perceived Stress Scales. This study suggests that one mechanism by which high importance of religion reduces psychiatric symptoms is through reducing perceived stress.     

Relationships between depressive symptoms and panic disorder symptoms during guided internet-delivered cognitive behavior therapy for panic disorder

Abstract

Aims: The current study explore the relationship between the trajectories of primary panic disorder symptoms and secondary depressive symptoms during guided internet-delivered cognitive behaviour therapy for panic disorder.

Materials and methods: The patients (N=143) were recruited from an ongoing effectiveness study in secondary mental health outpatient services in Norway. Weekly self-reported primary panic disorder symptoms and secondary depressive symptoms were analysed.

Results: primary panic disorder symptoms and secondary depressive symptoms improved significantly during the course of treatment, and at six months follow-up. Parallel process latent growth curve modelling showed that the trajectory of depressive symptoms and trajectory of panic disorder symptoms were significantly related. A supplementary analysis with cross-lagged panel modelling showed that (1) pre-treatment depressive symptoms predicted a positive effect of panic disorder symptoms early in treatment; (2) high early treatment panic disorder symptoms predicted low depressive symptoms at post-treatment.

Conclusions: Guided ICBT for panic disorder is effective for both primary panic disorder symptoms and secondary depressive symptoms. Patients with high pre-treatment secondary depressive symptoms may constitute a vulnerable subgroup. A high level of panic disorder symptoms early in treatment seems beneficiary for depressive symptoms outcome. A time-dependent model may be necessary to describe the relationship between PAD symptoms and depressive symptoms during the course of treatment.     

A preliminary investigation of the effects of cognitive behavioral therapy for panic disorder on gastrointestinal distress in patients with comorbid panic disorder and irritable bowel syndrome

Background: High comorbidity between panic disorder with/without agoraphobia (PD/A) and irritable bowel syndrome (IBS) has been identified in the literature. These findings have resulted in the recent development of neurobiological models to explain their overlapping symptoms and related origins. This study was a preliminary investigation of the influence of cognitive behavioral therapy (CBT) for PD/A on PD/A patients with and without comorbid IBS. Methods: All patients completed a thorough intake assessment, brief waitlist period, and a 12‐week CBT group for PD/A. Results: The results demonstrated significant reductions in the symptoms of anxiety, depression, and overall impairment in both patient groups (ts>2.3; Ps<.05). In addition, PD/A patients with comorbid IBS also experienced reductions in the disability and distress associated with their gastrointestinal symptoms of IBS (ts>1.9; Ps<.07). Conclusions: Although additional research still is needed, these preliminary findings suggest that CBT for PD/A can be used to simultaneously treat comorbid symptoms of PD/A and IBS. Implications for the neurobiological models for these comorbid conditions were discussed. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.     

QT wave dispersion in patients with panic disorder

Objective QT dispersion (QTd), defined as the maximal inter-lead difference in QT intervals on 12 leads of the surface electrocardiogram (ECG), reflects the regional heterogeneity of ventricular repolarization and has been suggested as an important marker for risk of arrhythmia in addition to the QT interval. Some investigators proposed that it might be a predisposing factor for arrhythmic events and sudden death. Thus, we aimed to investigate whether QTd differs in patients with panic disorder from that in healthy controls. Methods In 40 panic disorder patients and 40 healthy controls, Qmax, Qmin, and QTd values were measured. In addition, the Hamilton depression rating scale and the panic agoraphobia scale were scored for both patients and healthy volunteers. Results Qmax and Qmin values in the panic disorder patients were significantly higher than those in healthy controls. The mean corrected QTd was significantly greater in the patients than in the controls. One-way analysis of covariance (ANCOVA; using left atrial size, age and heart rate as covariates) also corrected the significant difference. In addition, ANCOVA revealed a significant main effect for the diagnosis, indicating a significantly higher QTd for patients compared with controls. Conclusion QTd might be associated with panic disorder. Future studies in larger samples evaluating the effects of treatment are required.     

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.     

Effectiveness of mindfulness‐based cognitive therapy as an adjuvant to pharmacotherapy in patients with panic disorder or generalized anxiety disorder

Background: Mindfulness‐based cognitive therapy (MBCT) has been widely used to treat patients with depressive disorder to prevent relapse. The objective of this study was to examine the effectiveness of newly developed MBCT program as an adjuvant to pharmacotherapy in the treatment of patients with panic disorder or generalized anxiety disorder. Methods: Forty‐six patients with panic disorder or generalized anxiety disorder were assigned to either MBCT or an anxiety disorder education (ADE) program for a period of 8 weeks. The Hamilton Anxiety Rating Scale (HAM‐A), Hamilton Depression Rating Scale (HAM‐D), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Symptom Checklist‐90‐Revised (SCL‐90‐R) were used to assess the patients at 0 week and after the two programs had been running for 2, 4, and 8 weeks. Results: The MBCT group demonstrated significantly more improvement than the ADE group according to all anxiety (HAM‐A, p<0.01; BAI, p<0.01; anxiety subscale of SCL‐90‐R, p=0.01) and depression (HAM‐D, p<0.01; BDI, p<0.01; depression subscale of SCL‐90‐R, p<0.01) scale scores. The obsessive‐compulsive and phobic subscales of the SCL‐90‐R also showed significantly more improvement in the MBCT group. However, no significant improvement was observed in the MBCT group versus the ADE group in terms of the somatization, interpersonal sensitivity, paranoid ideation, or psychoticism subscale scores of the SCL‐90‐R. Conclusions: MBCT may be effective at relieving anxiety and depressive symptoms in patients with panic disorder or generalized anxiety disorder. However, well‐designed, randomized controlled trials are needed. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up

Two years after completion of a controlled outcome study of treatments for panic disorder with agoraphobia, patients were revisited and interviewed about their complaints. In the initial study, four treatments had been compared: (i) fluvoxamine combined with exposure; (ii) placebo medication plus exposure; (iii) psychological panic management plus exposure; and (iv) exposure alone. Comparison of the results at post-test had revealed superior efficacy of fluvoxamine combined with exposure over the other three treatments in reducing agoraphobic avoidance. The current naturalistic follow-up study investigated the long-term efficacy of the treatments with regard to abatement of complaints and reduced demand for further treatment. In addition, we examined whether patients were able to taper off the study medication without a recurrence of complaints. In total, 71 of the 76 patients of the original trial (93%) were interviewed. Comparison of the mean level of psychopathology at follow-up revealed no difference between the original treatment groups. The effect in the fluvoxamine plus exposure group was maintained, but was no longer superior, due to further improvements in the other treatment groups. Most patients received additional treatment during the follow-up period, usually because the 12 treatment sessions in the controlled study had yielded insufficient improvement. There was a trend for patients who received the fluvoxamine plus exposure treatment to require less aftercare than those who received the other treatments. Finally, almost 50% of the patients who had received medication in the original trial were able to taper off the use of fluvoxamine without a recurrence of complaints.     

The sleep of non-depressed patients with panic disorder: a comparison with normal controls

Arriaga F, Paiva T, Matos-Pires A, Cavaglia F, Lara E, Bastos L. The sleep of non-depressed patients with panic disorder: a comparison with normal controls. Acta Psychiatr Scand 1996: 93: 191–194. © Munksgaard 1996. All-night sleep EEG recordings were performed in non-depressed patients with panic disorder, agoraphobia, and a group of age- and sex-matched normal controls. Patients were selected according to DSM-IV and all subjects were studied under drug-free conditions. In addition to sleep continuity disturbances, patients with panic disorder have a reduced percentage of slow wave sleep, mainly due to diminished amounts of stage 4. REM sleep characteristics are identical in the two groups. When depressive co-morbidity and non-specific causes of insomnia are excluded, the sleep EEG of panic patients seems to be characterized by modest changes in sleep continuity and sleep architecture. These findings favour the existence of a neurophysiological frontier between anxiety disorders and depressive illness.     

Panic disorder versus panic disorder with major depression: Defining and understanding differences in psychiatric morbidity

The present study examined the impact of comorbid major depressive disorder (MDD) on psychiatric morbidity, panic symptomatology and frequency of other comorbid psychiatric conditions in subjects with panic disorder (PD). Four hundred thirty-seven patients with PD were evaluated at intake as part of a multicenter longitudinal study of anxiety disorders; 113 of these patients were also in an episode of MDD. Patients were diagnosed by DSM-III-R criteria utilizing structured clinical interviews. The 113 PD/MDD patients were compared with the 324 remaining PD subjects regarding panic symptoms at intake, sociodemographic, quality of life and psychiatric morbidity variables. Differences in frequency of other comorbid Axis I psychiatric disorders were assessed at intake; personality disorders were evaluated twelve months after intake. The results revealed that PD/MDD patients exhibit increased morbidity and decreased psychosocial functioning as compared to PD patients. Personality disorders were more prevalent in the PD/MDD group at six month follow-up assessment; the PD/MDD group also had an increased frequency of posttraumatic stress disorder (PTSD) and more comorbid Axis I anxiety disorders as compared to the PD group. The total number and frequency of panic symptoms was highly consistent between the two patient groups. Depression and Anxiety 5:12–20, 1997. © 1997 Wiley-Liss, Inc.     

A randomized study of massed three‐week cognitive behavioural therapy schedule for panic disorder

Objective: To compare the efficacy of massed vs. spaced group cognitive behavioural therapy (CBT) for patients with panic disorder with or without agoraphobia (PD). Method: Thirty‐nine PD patients were randomly assigned to massed group CBT (daily 4‐h sessions in week 1, two 2‐h sessions in week 2 and one 2‐h session in week 3) or traditional spaced weekly group CBT (13 consecutive, weekly 2‐h sessions). The content and number of hours in the two treatment schedules were identical. Outcome was assessed after treatment, and at 3, 6 and 18 months of follow‐up. Results: Both treatment groups achieved significant improvement on all measures with large pre‐ to post‐treatment and pre‐treatment to follow‐up effect sizes. No between‐group differences were registered. Adherence and patient satisfaction did not differ between groups. Conclusion: The massed, 3‐week group CBT schedule proved to be effective and feasible for PD patients with outcomes comparable with that of standard, spaced group CBT.     

The fear circuitry in panic disorder and its modulation by cognitive-behaviour therapy interventions

Panic disorder (PD) is a multidimensional anxiety disorder that involves the activation of a complex brain fear-network. The goals of this systematic review are to pinpoint some working functions of the most important neuroanatomical structures of fear and panic neurocircuitry and to raise hypotheses about how cognitive-behaviour therapy (CBT) may work on modulating the neurocircuitry of fear. The bibliographical search was carried out using mainly the PubMed database. Fifty-six articles were selected. A number of studies regarding several brain sites that participate in fear and anxiety circuitry were found and each region was described with its functionalities within the circuitry. Among the structures chosen were: the amygdala, the hippocampus and the prefrontal cortex, which play a special role. Study hypotheses showed that CBT may operate upstream from the amygdala and exert inhibitory effects on a variety of learned responses. It may work by strengthening the medial prefrontal cortex ability to inhibit firing of amygdala neurons, under the modulation of the hippocampus. Only two studies examined the modulation of fear neurocircuitry with CBT in PD. The results indicate that CBT has the potential to modify the dysfunctional neural circuitry associated with PD, but there is insufficient evidence to support the preliminary hypothesis.     

Factors associated with the development of panic attack and panic disorder: survey in the Japanese population

Environmental factors, in addition to genetic factors, may be related to the development of panic attack (PA) and panic disorder (PD). Previous studies suggested that there may be seasonal variation in the onset of PA/PD and possibly a higher prevalence of PA/PD in colder areas. Also observed were lactate-induced PA and elevated serum cholesterol in PD patients. These suggest that living environment and lifestyle, such as weather conditions, preference of food and physical exercise, might play a role in the occurrence of PA and PD. The present study explored the association of such candidate factors with the development of PA and PD in 4000 Japanese subjects, using a questionnaire. The subjects were recruited from the general population of Japan, using stratified random sampling. Logistic regression with stepwise selection of variables was employed for statistical analysis. Variables including "dislike of physical exercise", mostly in female subjects, and "living in areas with longer winter", in male subjects, were suggested for associations with PA and PD among the candidate factors. The result is preliminary but indicates that lifestyle such as like/dislike of physical exercise and environmental factors including weather conditions could play a partial role in the development of PA and PD. Further investigations are required before firm conclusions can be reached.     

Clinical and subthreshold panic disorder

Background: Panic disorder (PD) is a highly prevalent and disabling condition, and subthreshold cases may be even more prevalent. This study examined psychiatric comorbidities, work functioning, and health‐care utilization of individuals with subthreshold panic. The purpose of this study was to add to the accumulating evidence of significant comorbidity and disability associated with subthreshold PD. Methods: Data are drawn from the Health Care for Communities study, a national household survey of the United States' adult, civilian, noninstitutionalized population (N=9585). Data assessing psychiatric disorders, employment and work productivity, and health‐care utilization were collected. Seven categories of panic and subthreshold panic were created. Results: The prevalence of clinical and subthreshold panic in the general population was 40%. Subthreshold panic was associated with increased odds of several comorbid disorders, including depression, dysthymia, psychosis, generalized anxiety disorder, bipolar disorder, and alcohol and drug use disorders. Subthreshold panic was also associated with greater likelihood of health‐care service utilization but not with the intensity of mental health services. Conclusion: Psychiatric comorbidities and health‐care utilization are common among patients with subthreshold panic. The relationship between varying degrees of panic symptomology and other mental health problems and indices of functioning impairment warrants further investigation. These results inform further research focusing on the course of subthreshold PD and its impact on quality of life. Depression and Anxiety, 2010. © 2009 Wiley‐Liss, Inc.     

Pharmacotherapy of panic disorder

Panic disorder (PD) is a common, persistent and disabling mental disorder. It is often associated with agoraphobia. The present article reviews the current status of pharmacotherapy for PD with or without agoraphobia as well as the current status of treatments combing pharmacotherapy with cognitive behavior therapy (CBT). The review has been written with a focus on randomized controlled trials, meta-analyses, and reviews that have been published over the past few years. Effective pharmacological treatments include tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and various benzodiazepines. Treatment results obtained with CBT compare well with pharmacotherapy, with evidence that CBT is at least as effective as pharmacotherapy. Combining pharmacotherapy with CBT has been found to be superior to antidepressant pharmacotherapy or CBT alone, but only in the acute-phase treatment. Long term studies on treatments combining pharmacotherapy and CBT for PD with or without agoraphobia have found little benefit, however, for combination therapies versus monotherapies. New investigations explore the potential additional value of sequential versus concomitant treatments, of cognitive enhancers and virtual reality exposure therapy, and of education, self management and Internet-based interventions.     

Overcoming resistance to exposure in panic disorder with agoraphobia

The issue of panic disorder resistant to treatment (whether pharmacological or psychological) has attracted little research attention, despite its clinical frequency and importance. The aim of this study was to compare three treatment modalities, namely exposure alone (E), exposure associated with imipramine (EI) and cognitive therapy supplementing exposure (EC), in a sample of 21 patients with DSM-IV panic disorder and agoraphobia, who failed to respond to a first standard course of individual behavioural treatment based on exposure in vivo. Treatments were administered according to a cross-over, controlled design (E-EI-EC, EI-EC-E, EC-E-EI). Twelve of the 21 patients achieved remission (panic-free status) during the trial. In 8 cases this occurred after exposure alone (E) and in two cases each after the other treatments (EI and EC). The results revealed a significant effect of the factor time on a number of variables, and the superiority of exposure alone compared to other treatment modalities with regard to some variables. These findings suggest that long-term behavioural treatment based on exposure may be necessary in some patients, and may induce clinical remission. However, patients who do not respond to exposure show poor tolerance of and compliance with pharmacological treatment, and are unlikely to achieve remission with imipramine or cognitive therapy, even though this may occur in individual cases.     

Decreased R-R variance in panic disorder patients

To investigate autonomic function in panic disorder patients (n = 30), we compared postural changes in heart rate and the R-R interval variance in patients and normal controls (n = 20). There was no significant difference in the immediate changes in heart rate upon standing between the groups. R-R variance was significantly decreased during resting supine condition in patients as indicated by the corrected standard deviation of the R-R intervals. The standing R-R variance was significantly lower than that of normal controls as indicated by the corrected standard deviations, the corrected mean consecutive difference and the corrected standard deviation of the mean consecutive difference of the R-R intervals, suggesting an increase in vagal withdrawal in patients, especially upon standing. If this finding is specific to panic disorder patients, it may be a useful peripheral marker for this condition.