Obsessive-compulsive symptoms in panic disorder

Previous reports have noted an increased prevalence of obsessive-compulsive symptoms in patients with panic disorder. The authors found a prevalence of obsessive-compulsive symptoms in 19 (27%) of 70 patients with panic disorder. Compared to a subgroup of 25 patients with classic features of panic disorder and no obsessive-compulsive symptoms, the subgroup with obsessive-compulsive symptoms had an earlier onset of illness, were more likely to have personal and family histories of major depression and substance abuse, and showed a poorer outcome after treatment.     

Panic disorder in schizophrenia.

OBJECTIVE: To determine the frequency of panic attacks and panic disorder in patients with chronic schizophrenia or schizoaffective disorder. METHOD: Fifty-three male outpatients meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for chronic schizophrenia or schizoaffective disorder were administered sections of the Structured Clinical Interview for DSM-IV (SCID). If panic attacks were reported, patients were queried about treatment and about onset relative to psychotic symptoms. RESULTS: Forty-nine patients were sufficiently organized to participate in the evaluation. Twenty-one (43%) experienced panic attacks, and 16 (33%) had current or past panic disorder. Eight (50%) of the 16 with panic disorder had been treated for panic. Substance dependence was not associated with having panic attacks or current or past panic disorder. Patients with paranoid schizophrenia were more likely than patients with schizoaffective or undifferentiated schizophrenia to have experienced panic attacks (57% versus 20%, chi 2 = 6.0, P < 0.02) or panic disorder (47% versus 10%, chi 2 = 6.9, P < 0.01). CONCLUSION: Panic attacks and panic disorder are common in men with schizophrenia or schizoaffective disorder. Panic disorder may be an overlooked comorbid diagnosis in patients with schizophrenia.     

Obsessive-compulsive and panic symptoms in patients with first-admission psychosis

OBJECTIVE: The occurrence, persistence and specificity of the association between comorbid obsessive-compulsive and panic symptoms and three psychotic disorders--schizophrenia/schizoaffective disorder, bipolar disorder with psychosis, and major depression with psychosis--were examined in a first-admission, epidemiologically defined group of patients with psychotic symptoms. METHOD: The Structured Clinical Interview for DSM-III-R obsessive-compulsive and panic modules were administered at baseline and 24-month follow-up to patients with schizophrenia/schizoaffective disorder (N=225), bipolar disorder with psychosis (N=138), and major depression with psychosis (N=87) participating in the Suffolk County (N.Y.) Mental Health Project. The rates of subsyndromal symptoms and disorder criteria met were compared across the three psychosis groups. Recognition and treatment of anxiety symptoms at initial discharge and impact of the baseline presence of anxiety symptoms on 24-month clinical status were also examined. RESULTS: Obsessive-compulsive and panic symptoms were present at baseline in 10%-20% of all three groups. There was no specific association between obsessive-compulsive symptoms and any specific psychosis diagnosis; however, women with major depression with psychosis had a significantly higher rate of panic symptoms than the other two groups, and schizophrenia/schizoaffective disorder patients with baseline panic symptoms were significantly more likely to exhibit positive symptoms of psychosis after 24 months. CONCLUSIONS: The authors found no specific association between obsessive-compulsive symptoms and diagnosis early in the illness course, but the finding of an association between panic symptoms and psychotic depression among female patients and between baseline panic and positive psychotic symptoms in schizophrenia/schizoaffective disorder patients at 24 months suggests the need for further study.     

Effects of citalopram treatment on behavioural, cardiovascular and neuroendocrine response to cholecystokinin tetrapeptide challenge in patients with panic disorder.

Eight patients with panic disorder were administered 20 micrograms of cholecystokinin tetrapeptide (CCK-4) before and after 8 weeks of treatment with the selective serotonin reuptake inhibitor (SSRI) citalopram. All patients responded to treatment by showing a significant general improvement and reaching a panic-free state for 2 weeks. At the rechallenge with CCK-4, patients displayed a marked reduction in the intensity and number of panic symptoms. The frequency of panic attacks induced with CCK-4 decreased by 50% after treatment. Citalopram treatment had no substantial effect on cardiovascular (heart rate and blood pressure) or hormonal (cortisol, prolactin and growth hormone) responses to CCK-4. Patients who still had panic attacks after treatment demonstrated a blunted growth hormone response to CCK-4 that was not seen in those who did not have panic attacks. This study suggests that treatment with an SSRI can reduce an enhanced sensitivity to CCK-4 without modifying cardiovascular and neuroendocrine responses to CCK-4 in patients with panic disorder.     

Preliminary evidence for the utility of carbamazepine in alprazolam withdrawal

Alprazolam treatment is effective for panic disorder, but its major disadvantages include possible dependence and withdrawal symptoms upon discontinuation. The authors report three cases in which carbamazepine, a clinically effective anticonvulsant without abuse potential, successfully attenuated alprazolam withdrawal symptoms.     

Gabapentin treatment in a female patient with panic disorder and adverse effects under carbamazepine during benzodiazepine withdrawal

Despite their addictive potential, benzodiazepines belong to the most often prescribed drugs. We report on a patient with alprazolam dependence, who initially was treated with carbamazepine because of severe withdrawal symptoms. Due to liver enzyme elevation related to carbamazepine, we had to stop this treatment and instead of that started gabapentin treatment. Under this new therapy, the patient showed a dramatic relief of withdrawal symptoms and of the panic attacks recurring during withdrawal. Hence, due to their effectiveness and tolerability, newer anticonvulsants could be considered as medication for benzodiazepine withdrawal and as an alternative for benzodiazepine treatment in panic disorders.     

An open pilot study of interpersonal psychotherapy for panic disorder (IPT-PD)

Interpersonal psychotherapy (IPT) is a time-limited psychotherapy initially developed to treat depression. It has yet to be studied systematically for treatment of panic disorder. We modified IPT for the treatment of panic disorder and tested this treatment in an open clinical trial with 12 patients seeking treatment of DSM-IV panic disorder. Patients were assessed before during and after treatment. At completion of treatment, nine patients (75%) were independently categorized as responders (i.e., rated as much improved or very much improved on the Clinical Global Impression-Change Scale). Substantial improvement was found for panic symptoms, associated anxiety and depressive symptoms, and physical and emotional well-being. Degree of change in this sample approximated that obtained in studies using established treatments such as cognitive behavioral therapy. Results, though preliminary, suggest that IPT may have efficacy as a primary treatment of panic disorder. Further study is warranted.     

Hypochondriacal concerns in panic disorder and major depressive disorder: a comparison

OBJECTIVE: To gain perspective on the relationship between hypochondriasis and panic disorder, we compared the occurrence of hypochondriasis in patients with panic disorder (N= 59) and major depressive disorder (N= 27). METHODS: Patients who participated in separate drug treatment trials were assessed at baseline and eight weeks using the Whiteley Index of Hypochondriasis. RESULTS: At baseline, the Whiteley Index score was greater for patients with panic disorder than for those with major depressive disorder. At eight weeks, a statistically significant reduction in the mean hypochondriasis score was observed in panic patients who had improved but not in major depressive patients who had improved. Modest correlations were observed between hypochondriasis and symptoms of panic and major depressive disorder, but in depressed patients, hypochondriasis was positively correlated with anxiety symptoms as well. CONCLUSION: A unique relationship appears to exist between hypochondriasis and panic disorder. The nature of this relationship and its implications for classification are discussed.     

Can panic disorder present as irritable bowel syndrome?

Five patients who had been diagnosed with panic disorder and irritable bowel syndrome are described. Both panic and gastrointestinal symptoms responded dramatically and rapidly to pharmacologic treatment of panic symptoms in all five patients. The frequent overlap of gastrointestinal symptoms and psychiatric (particularly anxiety) disorders suggests that some patients with functional gastrointestinal complaints may have a primary anxiety disorder.     

Infrequent occurrence of EEG abnormalities in panic disorder

EEG abnormalities have been frequently reported in patients with panic disorder, although controlled studies are lacking. The authors examined the EEGs of 35 consecutively evaluated, medication-free patients with panic disorder and found that only five (14%) had nonspecific abnormal EEGs and none displayed EEG evidence supportive of an ictal process. The presence or absence of EEG abnormalities was not significantly associated with the presence or absence of psychosensory symptoms. Although it is not likely that panic disorder is an epileptiform disorder, temporal lobe and limbic structures probably play a major role in the pathophysiology of panic.     

Sensitivity to carbon dioxide in subjects with a single lifetime panic attack: possible clinical "bedside" predictive test for panic disorder after a first attack

There is currently no way of knowing whether a patient who has recently had a single panic attack has incipient panic disorder. Sensitivity to carbon dioxide (CO2) is lower in healthy volunteers than in panic disorder patients. If this is also true of people who experience a single lifetime panic attack, it could be used as a prognostic test. Subjects with a single lifetime panic attack and subjects with panic disorder received an inhalation of 35% CO2. Subjects completed the panic symptoms scale (PSS), and also stated whether they considered that they had experienced an attack. None of 14 subjects with a single lifetime panic attack, compared to 7 of 17 subjects with panic disorder (P=.009), had an attack. The PSS also distinguished between the groups. The 35% CO2 challenge warrants further investigation as a predictive test after a first panic attack.     

Secondary depression in panic disorder and agoraphobia. I. Frequency, severity, and response to treatment

Depressive symptomatology in 481 subjects with panic disorder and phobic avoidance was studied as part of an investigation of the efficacy of alprazolam in panic disorder. Subjects who had a major depressive episode (MDE) before the onset of their panic disorder were not included in the trial. With this exclusion criterion, 31% of subjects had a secondary MDE occurring after the onset of the panic disorder. The occurrence of secondary MDE was related to the length of time subjects were ill with panic disorder. Compared with the subjects without depression, those subjects with current MDE had higher scores on measures of anxiety and depression but not on the number of panic attacks per week. The presence of depression and the degree of phobic avoidance contributed independently to measures of the severity of the panic illness. Alprazolam was effective in reducing panic and depressive symptomatology in both depressed and nondepressed subjects with panic disorder. The presence of an MDE was not predictive of the outcome of treatment for the panic and phobic symptoms. Subjects with or without depression responded similarly to alprazolam.     

Hyperventilation and panic attacks

The symptoms of hyperventilation syndrome and panic disorder are very similar. A questionnaire was used to assess the incidence of panic disorder in 274 patients; 35% of the patients with hyperventilation and only 5% of the non-hyperventilating patients showed panic disorder. The authors conclude that hyperventilation plays an important role in panic disorder and in generalized anxiety disorder.     

Agoraphobia with panic attacks. Development, diagnostic stability, and course of illness

A structured psychiatric interview was used to examine the symptom history of 55 patients meeting DSM-III criteria for agoraphobia with panic attacks and five patients meeting DSM-III criteria for panic disorder. Anticipatory anxiety and generalized anxiety occurred in over 80% of the patients, and these anxiety states together with panic attacks and phobic avoidances had courses that were chronic and unremitting. Major depression occurred in 70% of the patients and had an episodic course that differentiated it from the anxiety states. Other frequently reported disorders were childhood separation disorder (18%), alcoholism (17%), and obsessive compulsive disorder (17%). An initial nonspontaneous first panic attack and separation anxiety was associated with earlier onset and longer duration of agoraphobia and panic disorder. An inaccurate cognitive appraisal of the initial panic attack frequently led to the rapid development of subsequent agoraphobia. Caffeine consumption exacerbated anxiety in 54% of the patients and triggered panic attacks in 17%. Fifty-one percent of female agoraphobics experienced premenstrual exacerbation of anxiety symptoms.     

Depersonalization and personality in panic disorder

Background

Prevalence and clinical correlates of depersonalization symptoms have been associated with panic disorder. Personality traits might increase the likelihood of experiencing depersonalization symptoms or depersonalization disorder in panic patients.

Aims

The objectives of this study are to establish the prevalence of depersonalization symptoms during the panic attack and in depersonalization disorder and to examine the personality factors associated with the presence of depersonalization in patients with panic disorder.

Methods

The sample comprised 104 consecutive adult outpatients with panic disorder, diagnosed according to the Semistructured Clinical Interview for DSM-IV (Axis I/II disorders). Participants were assessed with the Cambridge Depersonalization Scales, the Temperament and Character Inventory, and the Panic and Agoraphobia Scale.

Results

Forty-eight percent of the sample had depersonalization symptoms during the panic attack, whereas 20% of patients had a depersonalization disorder. Women presented more depersonalization disorders than did men (P = .036). Patients with panic disorder with depersonalization disorder had a more severe panic disorder (P = .002). Logistic regression analysis showed that self-transcendence trait (odds ratio, 1.089; 95% confidence interval, 1.021-1.162; P = .010) and severity of panic (odds ratio, 1.056; 95% confidence interval, 1.005-1.110; P = .032) were independently associated with depersonalization disorder.

Conclusions

A high prevalence of depersonalization symptoms and depersonalization disorder was confirmed in patients with panic disorder, supporting a dosage effect model for understanding depersonalization pathology. Self-transcendence trait and severity of panic disorder were reported as risk factors for depersonalization disorder.     

The epidemiology of panic symptomatology and agoraphobic avoidance

In a random community survey of 1,498 urban adults age 18 to 64 years who were interviewed using the Diagnostic Interview Schedule (DIS), the lifetime prevalence of panic disorder was 2.2% +/- 0.4%. This was higher in women (3.4% +/- 0.7%) than in men (0.9% +/- 0.6%), and in those under the age of 45 years. Lifetime prevalence for panic attacks was 7.8% +/- 0.7%. Panic attacks and panic disorder had a similar distribution by age and sex, with higher rates in women than men, and also in the under 45 age groups. The panic symptomatology reported by those subjects with panic attacks was similar to that described by subjects meeting full criteria for panic disorder. The lifetime prevalence of phobic disorders was 10.7% +/- 0.9% and was more common in women (14.6% +/- 1.3%) than in men (6.8% +/- 1.3%). The lifetime prevalence of agoraphobia was 3.8% +/- 0.5%. The occurrence of panic attacks and phobic disorders were frequently related, and in agoraphobic subjects those with more severe agoraphobic avoidance reported more panic symptoms. Indeed, among agoraphobic subjects with at least moderate agoraphobic avoidance, nearly all had either panic attacks or major depression. Subjects with panic attacks and moderate agoraphobic avoidance compared with patients with panic attacks alone, especially when panic symptoms appear before the age of 15, are more likely to have grown up in a family where there was parental conflict, are more likely to have left school at a younger age and without school exams, and are likely to have had more symptoms of a childhood conduct disorder.     

Sertraline treatment of panic disorder: results of a long-term study.

OBJECTIVE: To investigate the long-term efficacy, prevention of relapse and safety of sertraline in the treatment of panic disorder. METHOD: This study consisted of 52 weeks of open-label sertraline treatment (n=398) followed by a 28 weeks of a double-blind, placebo-controlled discontinuation trial (n=183). RESULTS: Ninety-three patients were randomized to sertraline and 90 were randomized to placebo. Discontinuation due to insufficient clinical response occurred in 23.6% of placebo-treated patients and 12.0% of sertraline-treated patients (log-rank test, P=0.040). Thirty-three per cent of placebo-treated patients had an exacerbation of panic symptomatology, versus 13% of sertraline-treated patients (log-rank test, P=0.005). Abrupt cessation of sertraline resulted in dizziness (4.3% sertraline vs. 16.9% placebo; P=0.007) and insomnia (4.3% sertraline vs. 15.7% placebo; P=0.013) occurring at significantly higher rates. CONCLUSION: Long-term sertraline treatment was effective in preventing relapse of panic disorder, well tolerated and associated with minimal discontinuation symptoms.     

The prognostic significance of HPA-axis disturbance in panic disorder: a three-year follow-up

Seventy-seven patients with DSM-III panic disorder underwent a baseline dexamethasone suppression test (DST), participated in an 8-week controlled treatment trial, and provided follow-up interviews 2-4 years later. The 20 patients who had exhibited DST nonsuppression at baseline had more symptoms of anxiety, more work and social disability, and a greater likelihood of ongoing major depression than did patients who had had normal DST results. DST nonsuppression in panic disorder apparently indicates a more persistent and chronically disabling condition.     

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.     

Respiratory variability in panic disorder.

Disordered breathing may play an important role in the pathophysiology of panic disorder. Several studies have now indicated that panic disorder patients have greater respiratory variability than normal controls. In this study, we examine baseline respiratory measures in four diagnostic groups to determine whether greater respiratory variability is specific to panic disorder and whether effective anti-panic treatment alters respiratory variability. Patients with panic disorder, major depression, or premenstrual dysphoric disorder, and normal control subjects underwent two respiratory exposures (5% and 7% CO(2) inhalation), while in a canopy system. Panic disorder patients returned after 12 weeks of either anti-panic medication or cognitive behavioral therapy, and were retested. Normal control subjects were also retested after a period of 12 weeks. Panic disorder patients had significantly greater respiratory variability at baseline than normal control subjects and patients with major depression. The premenstrual dysphoric patients also had greater variability than the normal control group. Panic disorder patients who panicked to 7% CO(2) inhalation had significantly greater baseline variability than panic disorder patients who did not panic. Anti-panic treatment did not significantly alter baseline respiratory variability. Our data suggest that increased respiratory variability may be an important trait feature for some panic disorder patients and may make them more vulnerable to CO(2)-induced panic.