Panic disorder respiratory subtype: psychopathology and challenge tests - an update

Panic disorder (PD) pathophysiology is very heterogeneous, and the discrimination of distinct subtypes could be very useful. A subtype based on respiratory symptoms is known to constitute a specific subgroup. However, evidence to support the respiratory subtype (RS) as a distinct subgroup of PD with a well-defined phenotype remains controversial. Studies have focused on characterization of the RS based on symptoms and response to CO2. In this line, we described clinical and biological aspects focused on symptomatology and CO2 challenge tests in PD RS. The main symptoms that characterize RS are dyspnea (shortness of breath) and a choking sensation. Moreover, patients with the RS tended to be more responsive to CO2 challenge tests, which triggered more panic attacks in this subgroup. Future studies should focus on discriminating respiratory-related clusters and exploring psychophysiological and neuroimaging outcomes in order to provide robust evidence to confirm RS as a distinct subtype of PD.

Anxiety Disorders - Assessment and Management in General Practice

@#The objective of this article is to provide an update on the diagnosis, assessment, and management of anxiety disorders in adults. This article covers the following disorders: panic disorder, panic attacks, specific phobia, social anxiety disorder and generalized anxiety disorder. Selective mutism and separation anxiety disorder, being childhood anxiety disorders, will not be covered. Obsessive compulsive disorder and post-traumatic stress disorder, which are not categorized as anxiety disorders in DSM-5, will not be covered. Anxiety and related disorders are common mental health disorders but are under-diagnosed and undertreated. Most cases of anxiety disorders present first to the primary care physician and can be managed in primary care.It is important to take a detailed history of the patient’s symptoms and their severity and duration, enquire about psychosocial stressors, as well as symptoms that may be suggestive of a medical condition and also to assess suicidality. A combined approach of psycho-education, relaxation training, and medications give the best results. SSRIs are first line pharmacologic treatment for most anxiety disorders. There is a need to stress that benzodiazepines have no role in the long-term treatment of anxiety disorders. They should not be given for more than 2 to 4 weeks. Treatment for generalized anxiety disorder should be for at least 32 weeks as high relapse rates are reported after discontinuing medications.

Critical neuropsychobiological analysis of panic attack- and anticipatory anxiety-like behaviors in rodents confronted with snakes in polygonal arenas and complex labyrinths: a comparison to the elevated plus- and T-maze behavioral tests

Objective: To compare prey and snake paradigms performed in complex environments to the elevated plus-maze (EPM) and T-maze (ETM) tests for the study of panic attack- and anticipatory anxiety-like behaviors in rodents. Methods: PubMed was reviewed in search of articles focusing on the plus maze test, EPM, and ETM, as well as on defensive behaviors displayed by threatened rodents. In addition, the authors’ research with polygonal arenas and complex labyrinth (designed by the first author for confrontation between snakes and small rodents) was examined. Results: The EPM and ETM tests evoke anxiety/fear-related defensive responses that are pharmacologically validated, whereas the confrontation between rodents and snakes in polygonal arenas with or without shelters or in the complex labyrinth offers ethological conditions for studying more complex defensive behaviors and the effects of anxiolytic and panicolytic drugs. Prey vs. predator paradigms also allow discrimination between non-oriented and oriented escape behavior. Conclusions: Both EPM and ETM simple labyrinths are excellent apparatuses for the study of anxiety- and instinctive fear-related responses, respectively. The confrontation between rodents and snakes in polygonal arenas, however, offers a more ethological environment for addressing both unconditioned and conditioned fear-induced behaviors and the effects of anxiolytic and panicolytic drugs.

Características básicas do transtorno do pânico / Basic features of panic disorder

O objetivo é caracterizar o Transtorno do Pânico (TP) com ênfase em seu diagnóstico e tratamento. O TP é um dos transtornos de ansiedade, caracterizado por ataques de pânico recorrentes acompanhados por uma persistente preocupação com ataques adicionais e alterações mal adaptativas do comportamento (Associação Americana de Psiquiatria - DSM-V). Sua etiologia ainda não é conhecida, mas deve envolver uma interação de fatores genéticos, de desenvolvimento e ambientais que resultam em altera- ções no funcionamento de algumas áreas cerebrais. O tratamento farmacológico de primeira escolha é com o uso de antidepressivos inibidores seletivos da recaptação de serotonina, os quais apresentam uma latência de 20 a 30 dias para o início do efeito. (AU)

The aim of this paper is to characterize the Panic Disorder (PD) with an emphasis on diagnosis and treatment. PD is one of the anxiety disorders, characterized by recurrent panic attacks accompanied by a persistent preoccupation with additional attacks and maladaptive behavioral changes (American Psychiatric Association ­ DSM-V). Its etiology is not known, but should involve an interaction of genetic, developmental and environmental factors that result in changes in the functioning of some brain areas. The pharmacological treatment of choice is with the use of selective serotonin reuptake inhibitors, which has a latency of 20 for 30 days for the beginning of the therapeutic effect. (AU)

The carbon dioxide challenge test in panic disorder: a systematic review of preclinical and clinical research

This systematic review assesses the current state of clinical and preclinical research on panic disorder (PD) in which the carbon dioxide (CO2) challenge was used as a trigger for panic attacks (PAs). A total of 95 articles published from 1984 to 2012 were selected for inclusion. Some hypotheses for PD evolved greatly due to the reproducibility of PAs in a controlled environment using the safe and noninvasive CO2 test. The 35% CO2 protocol was the method chosen by the majority of studies. Results of the test report specific sensitivity to hypercapnia in PD patients of the respiratory PD subtype. The CO2 challenge helped assess the antipanic effects of medication and non-pharmaceutical approaches such as physical exercise and cognitive behavioral therapy. The test was also used in studies about the genetic component of PD, in which twins and relatives of PD patients were analyzed.

Defense mechanisms in cardiovascular disease patients with and without panic disorder / Mecanismos de defensa en pacientes cardiópatas con y sin crisis de angustia

Introduction Throughout the investigation of psychosocial factors in cardiovascular diseases, type A personality, anger, hostility, anxiety, and depression have been proved to participate in this kind of sufferings. Cardiac patients exposed more frequently to life stressing events than patients who do not suffer a cardiac disease might lack adaptive coping defense mechanisms to protect them or use maladaptive defense mechanisms that facilitate the pathogenic effects of anxiety. Few studies have been done in Mexico related to psychological defense mechanisms; none of them was related to medically ill patients. In the present study, the use of defense mechanisms by cardiac patients with panic disorder (panic attack) was compared to the use of defense mechanisms by patients that present similar cardiovascular pathologies but without mental disorders. Material and method The present investigation was made as a comparative and explanatory study with a nonexperimental design. The sample was constituted by two groups: one of 33 cardiac patients diagnosed with panic attack and another group, used as control, of 30 cardiac outpatients without psychiatric disorder; all attended the Instituto Nacional de Cardiología Ignacio Chávez (Mexico City). The 63 cardiac patients were evaluated using the Structured Interview for the Diagnosis of Axis I, Hamilton's Anxiety Scale, Hopkins's 90 Symptom Checklist and the Defensive Styles Questionnaire, self-report instrument whose reliability and validity has been established for Mexican patients with panic disorder. The statistical analysis was made through chi-square test, Student's t test, Pearson correlation and a gradual multiple regression analysis. Results Within the group of cardiac patients with panic attack, 72.73% were female patients and 27.27% male, with an average age of 38.52 ± 14.18 years and 5.73 ± 2.75 years of schooling. The group of cardiac patients used as control was formed by 30 subjects also in its majority female (56.7%), with an age of 45.27 ± 14.51 years and an average of 5.67 ± 3.31 years of schooling. The patients of the group with panic disorder had higher levels of anxiety and used more maladaptive defense mechanisms, such as social isolation and inhibition, tended to use more somatization and less the adaptive defenses (suppression, work orientation, sublimation, affiliation and humor), in comparison to the group without mental disorder. The criteria for panic disorder (DSM-IV) correlated directly with somatization; the ones from major depression correlated directly with regression and inversely with humor and socioeconomical level; the score in Hamilton's Anxiety Scale with maladaptive defenses as social isolation, acting out and somatization; the SCL-90 with the maladaptive defenses acting out, projection and regression. The multiple regression analysis determined that regression and somatization contributed to the panic disorder symptomatology, and leads to major depressive disorder; projection, somatization and social isolation to anxiety's intensity and reaction formation, humor, regression, fantasy, inhibition, projective identification, passive aggression and omnipotence in general to the psychiatric symptoms. Discussion The greater use of maladaptive defenses by the cardiac patients group with panic disorder allows to conclude that low level defenses are related to the symptoms of this mental disorder. This group showed relation between levels of anxiety, psychological discomfort and the use of maladaptive defenses such as social isolation, inhibition and somatization, tending to isolate themselves and presenting in a corporal or <> form, through somatization, many physical symptoms. The observation of the use by cardiac patients without mental disorder of suppression, work orientation, sublimation, affiliation and humor, all of them adaptive defenses, reinforces this conclusion.

Introducción Gracias a la investigación de los factores psicosociales de las enfermedades cardiovasculares, se ha demostrado la participación de la conducta tipo A, enojo, hostilidad, aislamiento social, estrés, ansiedad y depresión en este tipo de padecimientos. La depresión asociada con frecuencia al infarto agudo del miocardio incrementa el riesgo de morir; los niveles altos de angustia se asocian al aumento en el riesgo de enfermedad coronaria y muerte súbita. Los pacientes cardiópatas expuestos a sucesos estresantes de la vida con más frecuencia que los pacientes que no padecen cardiopatía pueden carecer de mecanismos de defensa y afrontamiento adaptativos que los protejan o bien usan mecanismos de defensa desadaptativos que facilitan los efectos patogénicos de la ansiedad. En México se han realizado pocos estudios respecto a los mecanismos psicológicos de defensa y no hay estudios acerca del tema en pacientes médicamente enfermos. Conocer la forma en que el sujeto afronta su enfermedad permitiría una intervención psicoterapéutica oportuna en los pacientes médicos con el objetivo de mejorar su adaptación psicosocial y quizás su supervivencia. Por lo anterior, el objetivo del presente estudio es comparar el uso de los mecanismos de defensa de los pacientes cardiópatas con trastorno de angustia (crisis de angustia) con el de pacientes con patología cardiovascular similar pero sin trastornos mentales. Material y método Se realizó un estudio de tipo comparativo y explicativo con un diseño no experimental. La muestra estuvo constituida por dos grupos, uno de 33 pacientes cardiópatas diagnosticados con crisis de angustia y otro grupo, utilizado como control, de 30 sujetos cardiópatas sin trastorno psiquiátrico; todos acudían a Consulta Externa del Instituto Nacional de Cardiología Ignacio Chávez. Los 63 pacientes cardiópatas fueron evaluados utilizando la Entrevista Estructurada para el Diagnóstico del Eje I, la Escala de Ansiedad de Hamilton, la Lista de 90 Síntomas de Hopkins y el Cuestionario de Estilos Defensivos, instrumento autoaplicable que evalúa mecanismos de defensa adaptativos y desadaptativos del que se ha establecido su confiabilidad y validez en pacientes mexicanos con trastorno de angustia. El análisis estadístico se realizó a través de la chi cuadrada, t de Student, correlación de Pearson y un análisis de regresión múltiple gradual. Resultados Dentro del grupo de cardiopatías con crisis de angustia, 72.73% eran pacientes femeninos y 27.27% masculinos, con edad promedio de 38.52 ± 14.18 años y 5.73 ± 2.75 años de escolaridad. El grupo de pacientes cardiópatas, que se utilizó como control, estuvo constituido por 30 sujetos, también en su mayoría femeninos (56.7%), de 45.27 ± 14.51 años de edad con promedio de 5.67 ± 3.31 años de escolaridad. Los pacientes del grupo con trastorno de angustia tuvieron niveles más altos de ansiedad y utilizaron más mecanismos de defensa desadaptativos como aislamiento social e inhibición, tendieron a usar la somatización y utilizaron menos defensas adaptativas (supresión, orientación al trabajo, sublimación, afiliación y humor), en comparación con el grupo sin trastorno mental. Los criterios del trastorno de angustia (DSM-IV) se correlacionaron con la somatización; los de la depresión mayor, directamente con la regresión e inversamente con el humor y con el nivel socioeconómico; la puntuación de la Escala de Ansiedad de Hamilton, con defensas desadaptativas como aislamiento social, exoactuación y somatización; el SCL-90, con las defensas desadaptativas exoactuación, proyección y regresión. El análisis de regresión múltiple determinó que la regresión y la somatización contribuyeron a la sintomatología del trastorno de angustia, el consumo en el trastorno depresivo, la proyección, somatización y aislamiento social en la intensidad de la angustia y la formación reactiva, humor, regresión, fantasía, inhibición, identificación proyectiva, pasivo-agresividad y omnipotencia en la sintomatología psiquiátrica general. Discusión El mayor uso de defensas desadaptativas por parte del grupo de pacientes cardiópatas con trastorno de angustia permite concluir que las defensas de bajo nivel se relacionan con los síntomas de este trastorno mental. Este grupo mostró relación entre los niveles de ansiedad y malestar psicológico y la utilización de defensas desadaptativas como el aislamiento social, inhibición y somatización. Asimismo, tendió a aislarse y a manifestar en forma corporal o <>, a través de la somatización, muchos síntomas físicos. La observación de que los pacientes cardiópatas sin trastorno mental utilizaron la supresión, orientación al trabajo, sublimación, afiliación y humor, todas ellas defensas adaptativas, refuerza esta conclusión.

Some notes on a historical perspective of panic disorder

This article aims to describe important points in the history of panic disorder concept, as well as to highlight the importance of its diagnosis for clinical and research developments. Panic disorder has been described in several literary reports and folklore. One of the oldest examples lies in Greek mythology - the god Pan, responsable for the term panic. The first half of the 19th century witnessed the culmination of medical approach. During the second half of the 19th century came the psychological approach of anxiety. The 20th century associated panic disorder to hereditary, organic and psychological factors, dividing anxiety into simple and phobic anxious states. Therapeutic development was also observed in psychopharmacological and psychotherapeutic fields. Official classification began to include panic disorder as a category since the third edition of the American Classification Manual (1980). Some biological theories dealing with etiology were widely discussed during the last decades of the 20th century. They were based on laboratory studies of physiological, cognitive and biochemical tests, as the false suffocation alarm theory and the fear network. Such theories were important in creating new diagnostic paradigms to modern psychiatry. That suggests the need to consider a wide range of historical variables to understand how particular features for panic disorder diagnosis have been developed and how treatment has emerged.