Continuous monitoring of panic

Data on naturally occurring panic attacks were gathered through continuous self-monitoring for 94 patients suffering from panic disorder with agoraphobia. A total of 1276 panic attacks were collected. In this article various aspects of panic attacks, including severity, duration and time of onset and situations in which panic occurs are addressed. In addition, the symptoms of panic were investigated, examining the (in)variability of attacks within each patient and the patterning of symptoms in the entire group of patients. The most important findings were as follows: attacks occurred predominantly in nonphobic situations; nocturnal panic attacks were generally more severe than attacks during the day; symptom patterns across various attacks, stemming from the same patient, were rather variable; and finally, a substantial number of the attacks (40%) did not meet the DSM-III-R criteria for number of symptoms.     

The phenomenology of the first panic attack in clinical and community-based samples

The purpose of the study was to contrast first panic attacks (PAs) of patients with panic disorder (PD) with vs. without agoraphobia and to explore differences between first PAs leading to the development of PD and those that remain isolated. Data were drawn from a community survey (N = 2259 including 88 isolated PAs and 75 PD cases). An additional sample of 234 PD patients was recruited in a clinical setting. A standardized interview assessed the symptoms of the first PA, context of its occurrence and subsequent coping attempts. Persons who developed PD reported more severe first PAs, more medical service utilization and exposure-limiting coping attempts than those with isolated PAs. The context of the first PA did not differ between PD and isolated PAs. PD with agoraphobia was specifically associated with greater symptom severity and occurrence of first attacks in public. Future research should validate these findings using a longitudinal approach.     

The symptom structure of panic disorder: a trial using factor and cluster analysis

Using cluster analysis of 207 patients with panic disorder (PD), we investigated the relationships between several panic symptoms at the time of panic attacks, which included anticipatory anxiety, agoraphobia, and 13 clinical symptoms based on the Diagnostic and Statistics Manual-III-Revised. Cluster analysis revealed three panic symptom clusters: cluster A (dyspnea, choking, sweating, nausea, flushes/chills); cluster B (dizziness, palpitations, trembling or shaking, depersonalization, agoraphobia, and anticipatory anxiety); and cluster C (fear of dying, fear of going crazy, paresthesias, and chest pain or discomfort). Generally, cluster A was comprised exclusively of physiological symptoms, among which respiratory symptoms were prominent, cluster B included both panic and non-panic symptoms such as agoraphobia and anticipatory anxiety, and cluster C was comprised chiefly of fear symptoms.     

Semiology and subtyping of panic disorders

To date, the quantitative psychopathology of panic disorder (PD) has been less well studied than that of other psychiatric conditions such as schizophrenia or major depression. The aim of the present study was to assess the frequency and factorial grouping of symptoms in a naturalistic sample of PD patients. A total of 274 consecutive cases of PD who contacted an out-patient clinic in Barcelona, Spain were assessed by two experienced interviewers. The assessment instruments included the Structured Clinical Interview for DSM-III-R Upjohn version (SCID-UP-R) and an inventory of panic attack symptoms based on DSM-III-R. Of the patients who presented at the unit during the assessment period, 8.5% presented with PD. Palpitations, shortness of breath, fear of dying and dizziness were the most frequent and intense symptoms reported by the PD patients. Principal-component analysis revealed four factors which accounted for 57% of the variance, including‘cardiorespiratory’(26.1%) and‘vestibular’(15.1%) factors, and two additional factors with mixed symptoms. The frequency of presentation of symptoms was similar to that reported in other studies. However, some discrepancies were observed that may be attributed to transcultural differences as well as to terminological problems and the range of symptoms assessed. These factors may also explain some of the differences found in factor analysis groupings in previous studies. Our findings support the symptom subtyping of PD.     

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.     

Acute panic inventory symptoms during CO(2) inhalation and room-air hyperventilation among panic disorder patients and normal controls.

There is scant literature on anxiety symptoms induced during respiratory challenges developed to induce panic symptoms and attacks. Here we report on the prevalence of Acute Panic Inventory (API) symptoms during three consecutive respiratory challenges to patients with panic disorder (PD) and normal controls (NC). The challenges performed using a closed canopy system included voluntary room air hyperventilation (RAH), inhalation of 5% CO(2), and 7% CO(2)-enriched air. The PD patients were 41 men and 53 women whose mean age was 33.4 (SD = 8.55). The normal comparison group consisted of 35 men and 27 women with a mean age of 31.3 (SD = 9.21). The diagnosis of panic disorder was made using the Structured Clinical Interview for DSM-III-R. All potential normal controls underwent structured clinical interview using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA), and must have been free of a lifetime history of anxiety disorders, affective disorders, substance use disorders, and schizophrenia. All participants also had a complete medical evaluation and were in good health. The experiment consisted of seven experimental epochs: three baseline/recovery periods each followed by a respiratory challenge, and then a final recovery epoch. The API was administered at the end of each epoch. Clinical staff trained and experienced in rating panic attacks rated participants' response during each challenge as panic or no panic. Three groups were defined for analysis: PD patients who panicked, PD patients who did not panic, and NC who did not panic. Staff ratings indicated that the 7% CO(2) challenge was the most panicogenic, followed by the 5% CO(2), and the RAH challenges. Conventional statistics (analysis of variance and partial correlations) indicated that many baseline symptoms as well as symptom increments differed across groups, and were associated with the outcome of panic/no panic during each challenge. However, logistic regression analysis indicated that only a few symptoms independently predicted the panic/no panic outcome because many symptoms were redundant. The symptom cluster of fear in general, dizziness, difficulties with concentrating, and doing one's job predicted panic to RAH. The cluster of fear in general, confusion, dyspnea, and twitching/trembling predicted the response to 5% CO(2). Finally, fear in general, confusion, twitching/ trembling and dizziness predicted the response to 7% CO(2). While univariate analyses indicated that many symptoms distinguished between panic and no panic outcome, logistic regression revealed that group differences were subsumed under a few prominent symptoms, namely, fear in general, confusion, dizziness, twitching/trembling, and dyspnea. The results are discussed in the context of patient (having a diagnosis of PD) and panic effects (rated as panicking to a challenge).     

Associations with subsyndromal panic and the validity of DSM-IV criteria

The purpose of this study was to compare subsyndromal panic—infrequent panic (IP) and limited symptom attacks (LSA)—with panic disorder (PD) in psychiatric comorbidity, quality of life (QOL), and health care utilization and to assess validity of DSM-III-R criteria for panic disorder. Randomly selected adults were screened for the presence of PD, IP, and LSA by using the Structured Clinical Interview of the DSM-IIIR. Subjects with panic symptoms and matched controls completed a structured interview concerning comorbidity, QOL, and utilization. Although PD and IP subjects reported more psychiatric comorbidity than did LSA subjects, LSA subjects had more comorbid conditions than did controls. Differences in utilization were limited to PD subjects. Although subsyndromal panic was associated with poor QOL, panic-related work disability was primarily seen in PD subjects. Regression analyses demonstrated little difference between LSA and IP subjects, but interaction analysis supported the distinction between LSA and full-blown panic attacks. Compared with controls, LSA and IP subjects had more psychiatric comorbidity. PD subjects also had poorer QOL and more utilization. Interaction analysis supports DSM-IV criteria for panic disorder. Depression and Anxiety 8:33–38, 1998. © 1998 Wiley-Liss, Inc.     

The relationship between cognitions and panic attack intensity

OBJECTIVE: To investigate the relationship between panic attack intensity, catastrophic belief and cognitions. METHOD: Data from 540 panic diaries were collected from 42 patients with panic disorder with agoraphobia. RESULTS: When we controlled for individual variation, effects of treatment and number of symptoms, catastrophic belief contributed significantly to more intense panic attacks (r2 change = 0.10, P<0.0001). There were no significant differences in panic attack intensity between primary and secondary cognitions. CONCLUSION: Our results indicate that catastrophic belief is a reliable predictor of panic attack intensity.     

Panic attack symptom dimensions and their relationship to illness characteristics in panic disorder

Subtyping panic disorder by predominant symptom constellations, such as cognitive or respiratory, has been done for some time, but criteria have varied considerably between studies. We sought to identify statistically symptom dimensions from intensity ratings of 13 DSM-IV panic symptoms in 343 panic patients interviewed with the Anxiety Disorders Interview Schedule for DSM-IV Lifetime Version. We then explored the relation of symptom dimensions to selected illness characteristics. Ratings were submitted to exploratory maximum likelihood factor analysis with a Promax rotation. A three-factor solution was found to account best for the variance. Symptoms loading highest on the first factor were palpitations, shortness of breath, choking, chest pain, and numbness, which define a cardio-respiratory type (with fear of dying). Symptoms loading highest on the second factor were sweating, trembling, nausea, chills/hot flashes, and dizziness, which defines a mixed somatic subtype. Symptoms loading highest on the third factor were feeling of unreality, fear of going crazy, and fear of losing control, which defines a cognitive subtype. Subscales based on these factors showed moderate intercorrelations. In a series of hierarchical multiple regression analyses, the cardio-respiratory subscale was a strong predictor of panic severity, frequency of panic attacks, and agoraphobic avoidance, while the cognitive subscale mostly predicted worry due to panic. In addition, patients with comorbid asthma had higher scores on the cardio-respiratory subscale. We conclude that partly independent panic symptom dimensions can be identified that have different implications for severity and control of panic disorder.     

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.     

The effect of panic attack on mitral valve prolapse

It has been reported that panic attacks might cause mitral valve prolapse (MVP) via haemodynamic or indirect effects. Such prolapse can be classified as being physiological (benign course) or pathological (poor course). It is therefore important to consider whether panic attacks, as a risk factor for MVP, are associated with its physiological or pathological type. Our study sample consisted of two groups of patients with panic disorder (PD), one having onset within 1 year (n=24) and the other with a history of more than 10 years (n=21). Demographic data, symptom presentations, auscultatory and echocardiographic findings of both groups were compared, but no significant difference was found except with regard to anticipatory anxiety. It is concluded that panic attack exerts no significant effect on mitral valve prolapse.     

Nocturnal panic and recent life events

Recent research has hypothesized an association between traumatic events and nocturnal panic (NP). The purpose of this study was to investigate whether the onset of nocturnal panic attacks is associated with a higher frequency of and/or greater severity of stressful or traumatic life events than that of patients with panic disorders (PDs) who experience daytime panic attacks (DPs) while awake. A secondary aim was to investigate whether NP is associated with specific life events at the onset of the disorder. Our sample comprised 129 subjects with PD (DSM-IV). We investigated the number and types of stressful life events that occurred in the year prior to PD onset using a semistructured interview. Of the sample, 28.7% had recurrent nocturnal panic attacks (NP group). Subjects with and without recurrent NP did not differ on any sociodemographic or clinical characteristic. Neither the number nor type of life event distinguished those with or without NP. The subgroup of patients with PD with recurrent NP appears to represent a variant of PD with a possible increased vulnerability to conditions of diminished arousal as a trigger of panic attacks. However, the hypothesis that this vulnerability might be determined by life events that occur in the period preceding PD onset was not supported by the findings of this study.     

Impact of panic attacks on quality of life among patients with schizophrenia

Objective

Schizophrenia patients had decreased levels of quality of life compared to normal population. The aim of this study was to investigate the impact of panic attacks on quality of life in patients with schizophrenia.

Methods

Eighty-eight patients with schizophrenia and 85 healthy subjects were included in the study.World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) was given to patients and healthy subjects to assess quality of life. Panic module of Structured Clinical Interview for DSM-IV (SCID) was administered to patients for diagnosis of panic attacks and panic disorder. Positive and Negative Syndrome Scale (PANSS) for symptom severity and Calgary Depression Scale (CDS) for depressive symptoms were administered to the patients.

Results

Patients with schizophrenia demonstrated significantly lower scores compared to healthy controls in all domains of WHOQOL-Bref. Twenty-five patients (28.4%) with schizophrenia had panic attacks (PA) and 10 patients (11.4%) met criteria for panic disorder (PD). Schizophrenia patients with PA had significantly lower scores on psychological domain of WHOQOL-Bref compared to the patients without PA. Schizophrenic patients with panic attacks had higher CDS scores than patients without PA.In the multivariate regression analyses the variance in psychological domain of WHOQOL-Bref was explained by depression rather than panic attack.

Conclusion

In patients with schizophrenia comorbid panic attacks may have a negative impact on quality of life, which is associated with depression significantly. Panic attacks and depressive symptomatology must be examined comprehensively in order to improve quality of life in patients with schizophrenia.     

A caffeine challenge test in panic disorder patients, their healthy first-degree relatives, and healthy controls

Our aim was to observe the induction of anxiety symptoms and panic attacks by a caffeine challenge test in panic disorder (PD) patients (DSM-IV) and their healthy first-degree relatives. We randomly selected 25 PD patients, 27 healthy first-degree relatives of probands with PD, and 22 healthy volunteers with no family history of PD. In a randomized double-blind experiment performed over two occasions 7 days apart, 480 mg caffeine and a caffeine-free solution were administered in a coffee form. Using specific panic attack criteria, 52.0% (n=13) PD patients, 40.7% (n=11) first-degree relatives (chi2=1.81, df=1, P=0.179), and none of the control subjects had a panic attack after the test (chi2=51.7, df=2, P<0.001). In this caffeine challenge test, PD patients and their first-degree relatives were more sensitive than healthy volunteers to the panic attack symptoms but less sensitive to headache, increase in blood pressure, and insomnia. Our data suggest that there is an association between panic attacks after the intake of 480 mg of caffeine in PD patients and their first-degree relatives. There is a clear differentiation of PD patients and their first-degree relatives by a caffeine test from the healthy group.     

Towards a ‘map’ of panic: structure of the bodily symptoms

Despite the large amount of research on panic attacks according to DSM criteria, there are some inconsistencies between this and reports from clinical settings. Some naturalistic and non-standard studies are needed. The authors of the present study submitted a list of 24 bodily symptoms to 65 panic patients who had sought medical help. The results of principal-component analysis revealed five factors, four of which represent the forms described in clinical and epidemiological contexts: cephalo-vertiginous, cervico-respiratory, thoraco-cardiac and abdomino-digestive. Each of these factors is differentially related to some specific fearful anticipations, which may organize the symptoms in a body-related topographical way.     

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.     

101例惊恐发作患者诊断归属及发作场所调查

目的:分析101例惊恐发作患者诊断归属及发作场所变化。方法:对101例惊恐发作患者以美国精神障碍诊断与统计手册第4版(DSM-Ⅳ)轴Ⅰ障碍用定式临床检查-临床版(SCID-CV)进行诊断;采用自制问卷调查发作情况。结果:符合DSM-Ⅳ惊恐障碍90例(89.1%),广泛性焦虑障碍6例(5.9%),抑郁障碍3例(2.9%),强迫障碍及精神分裂症各1例。90例惊恐障碍患者中,首次发作场所为家中50例,公共场所31例,途中9例;76.6%患者常在初次发生发作的场所发作,23.4%发作场所没有倾向性,仅1例发作场所固定。11例非惊恐障碍患者首发场所为家中3例,公共场所8例;此后发作场所均不固定。结论:约90%惊恐发作患者诊断为惊恐障碍,首次多发作于家中,并且倾向于在初次发作的场所发作;非惊恐障碍患者发作场所不固定。     

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.     

Depersonalization in panic disorder: a clinical study

Panic disorder (PD) has been hypothesized to be a heterogeneous entity, with distinct clinical subgroups. The presence of depersonalization during panic attacks may distinguish a specific subgroup of PD. We sought to analyze the differential features of a subgroup of PD patients with depersonalization. A total of 274 patients with PD were assessed and divided into 2 groups according to the presence or absence of depersonalization. The Structured Clinical Interview for DSM-III-R (SCID-UP-R) was used to assess PD and comorbid disorders. The clinical scales administered included the Hamilton Anxiety and Depression Rating Scale (HARS and HDRS), the Marks and Mathews Fears and Phobia Scale, Panic-Associated Symptom Scale (PASS), and a panic attack symptoms inventory. A total of 66 patients (24.1%) exhibited depersonalization during the attacks. Patients with depersonalization appeared to be younger and had an earlier age at onset. PD was more severe in the depersonalization group (greater number of attacks, worse level of functioning, and higher scores on most self-rating scales). Also, depersonalization patients showed more comorbidity with specific phobia. Our results support the view that PD with depersonalization may be considered a distinct and more severe subcategory of PD.