Biobehavioral approach to distinguishing panic symptoms from medical illness.

Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.

Respiratory symptom perception during exercise in patients with heart failure with preserved ejection fraction.

We investigated whether central or peripheral limitations to oxygen uptake elicit different respiratory sensations and whether dyspnea on exertion (DOE) provokes unpleasantness and negative emotions in patients with heart failure with preserved ejection fraction (HFpEF). 48 patients were categorized based on their cardiac output (Q̇c)/oxygen uptake (V̇O2) slope and stroke volume (SV) reserve during an incremental cycling test. 15 were classified as centrally limited and 33 were classified as peripherally limited. Ratings of perceived breathlessness (RPB) and unpleasantness (RPU) were assessed (Borg 0-10 scale) during a 20 W cycling test. 15 respiratory sensations statements (1-10 scale) and 5 negative emotions statements (1-10) were subsequently rated. RPB (Central: 3.5±2.0 vs. Peripheral: 3.4±2.0, p=0.86), respiratory sensations, or negative emotions were not different between groups (p>0.05). RPB correlated (p<0.05) with RPU (r=0.925), "anxious" (r=0.610), and "afraid" (r=0.383). While DOE provokes elevated levels of negative emotions, DOE and respiratory sensations seem more related to a common mechanism rather than central and/or peripheral limitations in HFpEF.

fMRI BOLD responses to film stimuli and their association with exhaled nitric oxide in asthma and health.

Little is known about central nervous system (CNS) responses to emotional stimuli in asthma. Nitric oxide in exhaled breath (FENO) is elevated in asthma due to allergic immune processes, but endogenous nitric oxide is also known to modulate CNS activity. We measured fMRI blood oxygen-dependent (BOLD) brain activation to negative (blood-injection-injury themes) and neutral films in 31 participants (15 with asthma). Regions-of-interest analysis was performed on key areas relevant to central adaptive control, threat processing, or salience networks, with dorsolateral prefrontal cortex (PFC), anterior insula, dorsal anterior cingulate cortex (dACC), amygdala, ventral striatum, ventral tegmentum, and periaqueductal gray, as well as top-down modulation of emotion, with ventrolateral and ventromedial PFC. Both groups showed less BOLD deactivation from fixation cross-baseline in the left anterior insula and bilateral ventromedial PFC for negative than neutral films, and for an additional number of areas, including the fusiform gyrus, for film versus recovery phases. Less deactivation during films followed by less recovery from deactivation was found in asthma compared to healthy controls. Changes in PCO2 did not explain these findings. FENO was positively related to BOLD activation in general, but more pronounced in healthy controls and more likely in neutral film processing. Thus, asthma is associated with altered processing of film stimuli across brain regions not limited to central adaptive control, threat processing, or salience networks. Higher levels of NO appear to facilitate CNS activity, but only in healthy controls, possibly due to allergy's masking effects on FENO.

Putting back respiration into respiratory sinus arrhythmia or high-frequency heart rate variability: Implications for interpretation, respiratory rhythmicity, and health.

Research on respiratory sinus arrhythmia, or high-frequency heart rate variability (its frequency-domain equivalent), has been popular in psychology and the behavioral sciences for some time. It is typically interpreted as an indicator of cardiac vagal activity. However, as research has shown for decades, the respiratory pattern can influence the amplitude of these noninvasive measures substantially, without necessarily reflecting changes in tonic cardiac vagal activity. Although changes in respiration are systematically associated with experiential and behavioral states, this potential confound in the interpretation of RSA, or HF-HRV, is rarely considered. Interpretations of within-individual changes in these parameters are therefore only conclusive if undertaken relative to the breathing pattern. The interpretation of absolute levels of these parameters between individuals is additionally burdened with the problem of residual inspiratory cardiac vagal activity in humans. Furthermore, multiple demographic, anthropometric, life-style, health, and medication variables can act as relevant third variables that might explain associations of RSA or HF-HRV with experiential and behavioral variables. Because vagal activity measured by these parameters only represents the portion of cardiac vagal outflow that is modulated by the respiratory rhythm, alternative interpretations beyond cardiac vagal activity should be considered. Accumulating research shows that activity of multiple populations of neurons in the brain and the periphery, and with that organ activity and function, are modulated rhythmically by respiratory activity. Thus, observable health benefits ascribed to the cardiac vagal system through RSA or HF-HRV may actually reflect beneficial effects of respiratory modulation. Respiratory rhythmicity may ultimately provide the mechanism that integrates central, autonomic, and visceral activities.

Changes in positive and negative affect in psychotherapy for depression and anxiety.

OBJECTIVE: Positive and negative affect play critical roles in depression and anxiety treatment, but the dynamic processes of how affect changes over treatment in relation to changes in symptoms is unclear. The study goal was to examine relationships among changes in positive and negative affect with changes in depression and anxiety symptoms. METHOD: This secondary analysis used a combined sample (N = 196) of two trials (Craske et al., 2019, 2023) comparing positive affect treatment (PAT) to negative affect treatment. Longitudinal cross-lag panel models explored whether changes in positive and negative affect (Positive and Negative Affect Schedule; Watson et al., 1988) predicted subsequent changes in depression and anxiety symptoms (Depression Anxiety Stress Scales; Lovibond & Lovibond, 1995), whether symptoms predicted subsequent changes in affect, and whether treatment condition moderated these relationships. RESULTS: Increases in positive affect predicted subsequent decreases in depression and anxiety symptoms, regardless of treatment condition. Symptoms did not reciprocally predict changes in positive affect. For individuals in PAT, decreases in negative affect predicted subsequent decreases in symptoms. Moreover, decreases in symptoms predicted subsequent decreases in negative affect, regardless of treatment condition. CONCLUSIONS: Results did not support a reciprocal relationship between positive affect and symptoms of depression and anxiety since positive affect predicted depression and anxiety symptoms but not vice versa. Results supported a reciprocal relationship between negative affect and symptoms of depression and anxiety since negative affect predicted depression and anxiety symptoms in PAT, and depression and anxiety symptoms predicted negative affect in both treatment conditions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Psychological distress and symptom-related burnout in asthma during the COVID-19 pandemic.

People with asthma may be particularly vulnerable to pandemic-related psychological distress, and research is needed to understand the impact of the coronavirus disease 19 (COVID-19) pandemic on their health and well-being. We sought to study the well-being of people with asthma relative to non-asthmatic controls during the COVID-19 pandemic. We also investigated asthma symptoms and COVID-19-related anxiety as potential mediators of distress. Participants completed self-report measures of psychological functioning, including anxiety, depression, stress, and burnout. Controlling for potential confounds, multiple-regression analyses examined differences in psychological health between people with and without asthma. Mediator analyses investigated the role of asthma symptoms and COVID-19-related anxiety in this relationship. 234 adults (111 with asthma, 123 without) participated in an online survey from July to November 2020. During this time, people with asthma reported higher levels of anxiety, perceived stress, and burnout symptoms compared to controls. Elevations in burnout symptoms were found beyond general anxiety and depression (sr2 = .03, p < .001). Reported symptoms typical in both asthma and COVID-19 partially mediated this relationship (Pm = .42, p < .05). People with asthma reported unique psychological challenges during the COVID-19 pandemic including elevated burnout symptoms. Experience of asthma symptoms played a key role in vulnerability to emotional exhaustion. Clinical implications include increased attention to asthma symptom burden within the context of heightened environmental stress and restricted healthcare access.

Biofeedback Training to Increase P co2 in Asthma With Elevated Anxiety: A One-Stop Treatment of Both Conditions?

OBJECTIVE: Anxiety is highly prevalent in individuals with asthma. Asthma symptoms and medication can exacerbate anxiety, and vice versa. Unfortunately, treatments of comorbid anxiety and asthma are largely lacking. A problematic feature common to both conditions is hyperventilation. It adversely affects lung function and symptoms in asthma and anxiety. We examined whether a treatment to reduce hyperventilation, shown to improve asthma symptoms, also improves anxiety in asthma patients with high anxiety. METHOD: One hundred twenty English- or Spanish-speaking adult patients with asthma were randomly assigned to either Capnometry-Assisted Respiratory Training (CART) to raise P co2 or feedback to slow respiratory rate (SLOW). Although anxiety was not an inclusion criterion, 21.7% met clinically relevant anxiety levels on the Hospital Anxiety and Depression Scale (HADS). Anxiety (HADS-A) and depression (HADS-D) scales, anxiety sensitivity (Anxiety Sensitivity Index [ASI]), and negative affect (Negative Affect Scale of the Positive Affect Negative Affect Schedule) were assessed at baseline, posttreatment, 1-month follow-up, and 6-month follow-up. RESULTS: In this secondary analysis, asthma patients with high baseline anxiety showed greater reductions in ASI and PANAS-N in CART than in SLOW ( p values ≤ .005, Cohen d values ≥ 0.58). Furthermore, at 6-month follow-up, these patients also had lower ASI, PANAS-N, and HADS-D in CART than in SLOW ( p values ≤ .012, Cohen d values ≥ 0.54). Patients with low baseline anxiety did not have differential outcomes in CART than in SLOW. CONCLUSIONS: For asthma patients with high anxiety, our brief training designed to raise P co2 resulted in significant and sustained reductions in anxiety sensitivity and negative affect compared with slow-breathing training. The findings lend support for P co2 as a potential physiological target for anxiety reduction in asthma. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00975273 .

Positive affect treatment targets reward sensitivity: A randomized controlled trial.

OBJECTIVE: Determine whether a novel psychosocial treatment for positive affect improves clinical status and reward sensitivity more than a form of cognitive behavioral therapy that targets negative affect and whether improvements in reward sensitivity correlate with improvements in clinical status. METHOD: In this assessor-blinded, parallel-group, multisite, two-arm randomized controlled clinical superiority trial, 85 treatment-seeking adults with severely low positive affect, moderate-to-severe depression or anxiety, and functional impairment received 15 weekly individual therapy sessions of positive affect treatment (PAT) or negative affect treatment (NAT). Clinical status measures were self-reported positive affect, interviewer-rated anhedonia, and self-reported depression and anxiety. Target measures were eleven physiological, behavioral, cognitive, and self-report measures of reward anticipation-motivation, response to reward attainment, and reward learning. All analyses were intent-to-treat. RESULTS: Compared to NAT, individuals receiving PAT achieved superior improvements in the multivariate clinical status measures at posttreatment, b = .37, 95% CI [.15, .59], t(109) = 3.34, p = .001, q = .004, d = .64. Compared to NAT, individuals receiving PAT also achieved higher multivariate reward anticipation-motivation, b = .21, 95% CI [.05, .37], t(268) = 2.61, p = .010, q = .020, d = .32, and higher multivariate response to reward attainment, b = .24, 95% CI [.02, .45], t(266) = 2.17, p = .031, q = .041, d = .25, at posttreatment. Measures of reward learning did not differ between the two groups. Improvements in reward anticipation-motivation and in response to reward attainment correlated with improvements in the clinical status measures. CONCLUSIONS: Targeting positive affect results in superior improvements in clinical status and reward sensitivity than targeting negative affect. This is the first demonstration of differential target engagement across two psychological interventions for anxious or depressed individuals with low positive affect. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Asthma, the central nervous system, and neurocognition: Current findings, potential mechanisms, and treatment implications.

Accumulating behavioral evidence suggests that asthma is associated with cognitive deficits. A number of studies have identified potential biological contributions to cognition in asthma; however, mechanistic pathways of central nervous system (CNS) involvement in asthma are yet to be established. We therefore conducted a literature review to identify studies examining potential CNS contributions to cognition in asthma. In this review, we discuss our general understanding of the CNS in asthma in the context of cognitive performance and outline a working model of mechanistic pathways linking the proposed neural influences of asthma pathology with cognition. To this extent, we incorporate neural, behavioral, psychological, social and environmental factors. Finally, we underscore the clinical significance of the CNS and neurocognitive sequelae in asthma, highlighting potential opportunities for routine monitoring, therapeutic intervention, and recommend key areas for future research.

Respiratory psychophysiology and COVID-19: A research agenda.

After multiple waves of the COVID-19 pandemic, it has become clear that the impact of SARS-CoV-2 will carry on for years to come. Acutely infected patients show a broad range of disease severity, depending on virus variant, vaccination status, age and the presence of underlying medical and physical conditions, including obesity. Additionally, a large number of patients who have been infected with the virus present with post-COVID syndrome. In September 2020, the International Society for the Advancement of Respiratory Psychophysiology organized a virtual interest meeting on 'Respiratory research in the age of COVID-19', which aimed to discuss how research in respiratory psychophysiology could contribute to a better understanding of psychophysiological interactions in COVID-19. In the resulting current paper, we propose an interdisciplinary research agenda discussing selected research questions on acute and long-term neurobiological, physiological and psychological outcomes and mechanisms related to respiration and the airways in COVID-19, as well as research questions on comorbidity and potential treatment options, such as physical rehabilitation.

An Examination of the RDoC Negative Valence Systems Domain Constructs and the Self-Reports Unit of Analysis.

In response to shortcomings with the current diagnostic classification system for mental health disorders, such as poor validity and reliability of categorical diagnoses, the National Institute of Mental Health proposed the Research Domain Criteria (RDoC) initiative to move towards a dimensional approach using translational research. The current study examined associations between measures of behaviors, cognitions, and mental health symptoms and how they overlap in the Negative Valence Systems (NVS) domain. Specifically, we examined how the Self-Reports unit of analysis reflects the RDoC NVS constructs of acute threat, potential threat, sustained threat, frustrative nonreward, and loss. The overall goal was to identify additional self-report measures that reflect these constructs. Participants, two student samples and two community samples (total N = 1,509), completed online self-reported measures. Questionnaire total and subscale scores were submitted to a principal-axis factor analysis with Promax rotation separately for each sample. For both student samples and one community sample six-factor solutions emerged reflecting major aspects of the RDoC NVS and positive valence systems, particularly acute threat (i.e., fear/panic), potential threat (i.e., inhibition/worry), sustained threat (i.e., chronic stress), loss (i.e., low well-being), frustrative nonreward (i.e., reactive aggression), and reduced behavioral activation. The second community sample differed in that fear/panic and frustration/anger was combined in a general distress factor. Recommendations for additional NVS self-report markers are discussed.

Social support, exhaled nitric oxide, and upper respiratory symptoms in health and asthma.

Accumulating research identifies a role of psychological process, particularly negative affect, in the expression of airway nitric oxide (NO), yet directional associations tend to vary across methodologies and samples. Recent findings indicate higher social support to be associated with higher airway NO; however, consequences for respiratory infection remain unexplored. NO has a key role in the first line of epithelial defense against pathogens, thus, social support could unfold airway protective effects through enhanced production of NO. We therefore examined the associations among social support, negative affect, airway NO, and cold symptoms in a sample of undergraduate students. In this cross-sectional study, 637 participants completed questionnaires of social support, negative affect, medical history, and current cold symptoms followed by measurements of fractional exhaled NO (FENO) to study airway NO during a semester period of relative low stress. Findings showed that greater social support was associated with higher FENO and fewer cold symptoms, controlling for key covariates. Further analysis suggested an additional indirect effect of social support on FENO through cold symptoms such that higher social support was related to lower cold symptoms, which were related to lower FENO. These results, coupled with longitudinal findings in the previous research, suggest that social support can affect FENO and cold symptoms through a complex pattern of direct and indirect effects. Overall, findings support the role of psychological processes - particularly social support - as relevant to FENO and cold symptoms in young adults.

An apnea-hypothesis of anxiety generation: Novel, respiratory, and falsifiable.

The Apnea-induced Anxiety model of Feinstein et al. continues a line of respiratory theories of panic, extending Klein's false suffocation alarm theory to a broader range of fear and anxiety states. It draws on neurobiological evidence including the underappreciated role of the amygdala in eliciting periods of apnea and CO2 tolerance. Further progress can be expected from empirical testing and integration with neuromodulatory systems that support respiration, activity, fear and anxiety, in particular the orexin system.

Social Contagion of Vasovagal Symptoms in Blood Donors: Interactions With Empathy.

BACKGROUND: Vasovagal reactions (VVRs) are commonly experienced in medical situations such as blood donation. Many believe that psychosocial contagion can contribute to the development of VVRs, but this is largely clinical lore. PURPOSE: The goal of the present investigation was to examine the physiological effects of observing another experience a reaction, focusing on the potential moderating effects of empathy. METHODS: This study was part of a randomized controlled trial of behavioral techniques on the prevention of VVRs in blood donors. The sample was composed of 530 healthy university students. Measures of symptoms were obtained with the Blood Donation Reactions Inventory (BDRI) and through observation. Physiological variables were measured using respiratory capnometry and a digital blood pressure monitor. The Affective and Cognitive Measure of Empathy was administered to 230 participants. RESULTS: Donors who witnessed another experiencing a reaction were more likely to spontaneously report symptoms during the blood draw, to be treated for a reaction, to score higher on the BDRI, and to exhibit smaller compensatory heart rate increases. Donors with higher affective empathy reported more symptoms, exhibited hyperventilation, and were more likely to be treated. Donors with higher cognitive empathy were less likely to require treatment if they witnessed a reaction. CONCLUSION: These results suggest that psychosocial contagion of physical symptoms can occur. The moderating effects of empathy differed depending on the subtype of empathy. Perhaps a better cognitive understanding of how other people are feeling functions as a coping response, whereas feeling sympathetic about others' distress increases one's own.