Generalized Anxiety Disorder: Revisited.

Generalized Anxiety Disorder (GAD) from an official recognition as a residual category in DSM-III has come a long way to be appreciated as a common underlying anxiety pathway in the literature. Despite still being defined as extreme anxiety and worry upon performance and about one's health, GAD seems to be a general umbrella of anxiety, covering even social anxiety and panic disorder (PD) and even when not treated and chronic, leading to major depressive disorder (MDD). Along the line of some other similar studies and contentions, in the present study we sought to validate the hypothesis of GAD encompassing social anxiety as well as performance anxiety and its extension to PD and MDD. We also examined the onset of each diagnostic category of GAD, PD and MDD and their developmental course in our clinical sample. 113 patients with Generalized Anxiety Disorder (GAD) out of 295 referrals to our mood and anxiety clinic during the three months of May-July 2019, were identified and included in this research. We expanded the definition of GAD as per our clinical observation to include any situations triggering the anxiety including any performance and social situations and did not exclude if the anxiety led to panic attacks. The results of our study showed that an encompassing GAD (including performance and social anxiety) has an early onset, recognized partially in childhood, but mostly during adolescence. An untreated GAD was complicated with panic disorder and episodes of major depression, each with an onset later in life. GAD in our study was also found to be familial and genetic, while its post-morbid depression seemed to be more a reaction to a long-standing untreated anxiety. The findings of our study if replicated has research implication of better understanding the developmental course of mood disorders and hold the promise of more targeted treatments of anxiety, panic and depression in clinical practice.

Psychometric analysis of the Swedish panic disorder severity scale and its self-report version.

BACKGROUND: Panic disorder, with or without agoraphobia (PDA or PD, respectively), is a major public health problem. After having established a PD diagnosis based on the DSM or the ICD systems, the Panic Disorder Severity Scale (PDSS) is the most widely used interview-based instrument for assessing disorder severity. There is also a self-report version of the instrument (PDSS-SR); both exist in a Swedish translation but their psychometric properties remain untested. METHODS: We studied 221 patients with PD/PDA recruited to a randomized controlled preference trial of cognitive-behavioral and brief panic-focused psychodynamic psychotherapy. In addition to PDSS and PDSS-SR the participants completed self-reports including the Clinical Outcome in Routine Evaluation - Outcome Measure, Montgomery Åsberg Depression Rating Scale, Sheehan Disability Scale, Bodily Sensations Questionnaire and the Mobility Inventory for Agoraphobia. RESULTS: PDSS and PDSS-SR possessed excellent psychometric properties (internal consistency, test-retest reliability) and convergent validity. A single factor structure for both versions was not confirmed. In terms of clinical utility, the PDSS had very high inter-rater reliability and correspondence with PD assessed via structured diagnostic interview. Both versions were sensitive to the effects of PD-focused treatment, although subjects scored systematically lower on the self-report version. CONCLUSIONS: The study confirmed the reliability and validity of the Swedish versions of PDSS and PDSS-SR. Both versions were highly sensitive to the effects of two PD-focused treatments and can be used both in clinical and research settings. However, further investigation of the factor structures of both the PDSS and PDSS-SR is warranted. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01606592.

IDENTIFYING PANIC DISORDER SUBTYPES USING FACTOR MIXTURE MODELING.

BACKGROUND: The clinical presentation of panic disorder (PD) is known to be highly heterogeneous, complicating research on its etiology, neurobiological pathways, and treatment. None of the attempts to identify PD subtypes have been independently reproduced, rendering the current literature inconclusive. METHODS: Using a data-driven, case-centered approach (factor mixture modeling) on a broad range of anxiety symptoms assessed with the Beck anxiety inventory, the present study identifies PD disorder subtypes in a large (n = 658), well-documented mixed-population sample from the Netherlands Study of Depression and Anxiety (NESDA), with subtypes being validated and detailed using a variety of clinical characteristics. RESULTS: A three-class, one-factor model proved superior to all other possible models (Bayesian information criterion = 13,200; Lo-Mendel-Rubin = 0.0295; bootstrapped likelihood ratio test ≤ 0.0001), with the first class, a cognitive-autonomic subtype, accounting for 29.8%, the second class, the autonomic subtype, for 29.9%, and a third class, the aspecific subtype, for 40.3% of the population. The cognitive-autonomic and autonomic subtypes showed significant differences compared to the aspecific subtype (e.g., comorbidity and suicide attempts) but on severity differed between themselves only. CONCLUSION: Three qualitatively different PD subtypes were identified: a severe cognitive-autonomic subtype, a moderate autonomic subtype, and a mild aspecific subtype. Qualitative and quantitative differences were related to severity and clinical properties such as comorbidity, suicide attempts, sleep, and sense of mastery.

Panic disorder and agoraphobia: an overview and commentary on DSM-5 changes.

The recently published DSM-5 contains a number of changes pertinent to panic disorder and agoraphobia. These changes include separation of panic disorder and agoraphobia into separate diagnoses, the addition of criteria and guidelines for distinguishing agoraphobia from specific phobia, the addition of a 6-month duration requirement for agoraphobia, the addition of panic attacks as a specifier to any DSM-5 diagnosis, changes to descriptors of panic attack types, as well as various changes to the descriptive text. It is crucial that clinicians and researchers working with individuals presenting with panic attacks and panic-like symptoms understand these changes. The purpose of the current paper is to provide a summary of the main changes, to critique the changes in the context of available empirical evidence, and to highlight clinical implications and potential impact on mental health service utilization. Several of the changes have the potential to improve access to evidence-based treatment; yet, although certain changes appear justified in that they were based on converging evidence from different empirical sources, other changes appear questionable, at least based on the information presented in the DSM-5 text and related publications. Ongoing research of DSM-5 panic disorder and agoraphobia as well as application of the new diagnostic criteria in clinical contexts is needed to further inform the strengths and limitations of DSM-5 conceptualizations of panic disorder and agoraphobia.

Is post-event processing a social anxiety specific or transdiagnostic cognitive process in the anxiety spectrum?

BACKGROUND: Research on post-event processing (PEP), where individuals conduct a post-mortem evaluation of a social situation, has focused primarily on its relationship with social anxiety. AIMS: The current study examined: 1) levels of PEP for a standardized event in different anxiety disorders; 2) the relationship between peak anxiety levels during this event and subsequent PEP; and 3) the relationship between PEP and disorder-specific symptom severity. METHOD: Participants with primary DSM-IV diagnoses of social anxiety disorder (SAD), obsessive compulsive disorder (OCD), panic disorder with/without agoraphobia (PD/A), or generalized anxiety disorder (GAD) completed diagnosis specific symptom measures before attending group cognitive behavioural therapy (CBT) specific to their diagnosis. Participants rated their peak anxiety level during the first group therapy session, and one week later rated PEP in the context of CBT. RESULTS: The results indicated that all anxiety disorder groups showed heightened and equivalent PEP ratings. Peak state anxiety during the first CBT session predicted subsequent level of PEP, irrespective of diagnostic group. PEP ratings were found to be associated with disorder-specific symptom severity in SAD, GAD, and PD/A, but not in OCD. CONCLUSIONS: PEP may be a transdiagnostic process with relevance to a broad range of anxiety disorders, not just SAD.

A latent class approach to the external validation of respiratory and non-respiratory panic subtypes.

BACKGROUND: The phenotypic variance observed in panic disorder (PD) appears to be best captured by a respiratory and non-respiratory panic subtype. We compared respiratory and non-respiratory panic subtypes across a series of external validators (temporal stability, psychiatric co-morbidity, treatment response) to determine whether subtypes are best conceptualized as differing: (1) only on their symptom profiles with no other differences between them; (2) on a quantitative (i.e. severity) dimension only; or (3) qualitatively from one another. METHOD: Data from a large epidemiological survey (National Epidemiologic Survey on Alcohol and Related Conditions) and a clinical trial (Cross-National Collaborative Panic Study) were used. All analytic comparisons were examined within a latent class framework. RESULTS: High temporal stability of panic subtypes was observed, particularly among females. Respiratory panic was associated with greater odds of lifetime major depression and a range of anxiety disorders as well as increased treatment utilization, but no demographic differences. Treatment outcome data did not suggest that the two PD subtypes were associated with differential response to either imipramine or alprazolam. CONCLUSIONS: These data suggest that respiratory and non-respiratory panic represent valid subtypes along the PD continuum, with the respiratory variant representing a more severe form of the disorder.

Re-examining the differential familial liability of agoraphobia and panic disorder.

BACKGROUND: Controversy surrounds the question of whether agoraphobia (AG) exists as an independent diagnostic entity apart from panic. In favor of this position, AG without panic disorder (PD) in parents was found being unrelated to offsprings' risk for AG or PD, albeit it may enhance the familial transmission of PD (Nocon et al., Depress Anxiety 2008;25:422-434). However, a recent behavioral genetic analysis (Mosing et al., Depress Anxiety 2009;26:1004-1011) found an increased risk for both PD and AG in siblings of those with AG without PD, casting doubt on whether AG exists independently of PD. Convincing evidence for either position notably requires considering also other anxiety disorders to establish the position of AG relative to the panic/anxiety spectrum. METHODS: Familial transmission of panic attacks (PAs), PD, and AG was examined in a 10-year prospective-longitudinal community study of 3,021 adolescents and young adults including completed direct and indirect information on parental psychopathology. Standardized diagnostic assessments using the Munich-Composite International Diagnostic Interview allowed generating exclusive diagnostic groups independent from diagnostic hierarchy rules. RESULTS: Parental PD without AG was associated with an increased risk for PA and PD+AG, but not for PD without AG or AG without PD in offspring. Parental AG without PD was unrelated to the offsprings' risk for PA, exclusive PD or AG, or PD+AG. Findings were largely unaffected by adjustment for other offspring or parental anxiety disorders. CONCLUSIONS: Findings provide further evidence for the independence of AG apart from the PD spectrum.

Panic disorder and its subtypes: a comprehensive analysis of panic symptom heterogeneity using epidemiological and treatment seeking samples.

BACKGROUND: Panic disorder (PD) is a heterogeneous syndrome that can present with a variety of symptom profiles that potentially reflect distinct etiologic pathways. The present study represents the most comprehensive examination of phenotypic variance in PD with and without agoraphobia for the purpose of identifying clinically relevant and etiologically meaningful subtypes. METHOD: Latent class (LC) and factor mixture analysis were used to examine panic symptom data ascertained from three national epidemiologic surveys [Epidemiological Catchment Area (ECA), National Comorbidity Study (NCS), National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Wave 1], a twin study [Virginia Adult Twin Study of Psychiatric and Substance Use Disorders (VATSPSUD)] and a clinical trial (Cross-National Collaborative Panic Study [CNCPS]). RESULTS: Factor mixture models (versus LC) generally provided better fit to panic symptom data and suggested two panic classes for the ECA, VATSPSUD and CNCPS, with one class typified by prominent respiratory symptoms. The NCS yielded two classes, but suggested both qualitative and quantitative differences. The more contemporary NESARC sample supported a two and three class model, with the three class model suggesting two variants of respiratory panic. The NESARC's three class model continued to provide the best fit when the model was restricted to a more severe form of PD/panic disorder with agoraphobia. CONCLUSIONS: Results from epidemiologic and clinical samples suggest two panic subtypes, with one subtype characterized by a respiratory component and a second class typified by general somatic symptoms. Results are discussed in light of their relevance to the etiopathogenesis of PD.

Panic disorder: a review of DSM-IV panic disorder and proposals for DSM-V.

This review covers the literature since the publication of DSM-IV on the diagnostic criteria for panic attacks (PAs) and panic disorder (PD). Specific recommendations are made based on the evidence available. In particular, slight changes are proposed for the wording of the diagnostic criteria for PAs to ease the differentiation between panic and surrounding anxiety; simplification and clarification of the operationalization of types of PAs (expected vs. unexpected) is proposed; and consideration is given to the value of PAs as a specifier for all DSM diagnoses and to the cultural validity of certain symptom profiles. In addition, slight changes are proposed for the wording of the diagnostic criteria to increase clarity and parsimony of the criteria. Finally, based on the available evidence, no changes are proposed with regard to the developmental expression of PAs or PD. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

Posterior orbitofrontal sulcogyral pattern associated with orbitofrontal cortex volume reduction and anxiety trait in panic disorder.

AIMS: The posterior region of the orbitofrontal cortex (OFC), which forms its sulcogyral pattern during neurodevelopment, receives multisensory inputs. The purpose of the present study was to assess the relationship between posterior OFC sulcogyral pattern and OFC volume difference in patients with panic disorder. METHODS: The anatomical pattern of the posterior orbital sulcus (POS) was classified into three subtypes (absent POS, single POS, double POS) using 3-D high-spatial resolution magnetic resonance images obtained from 28 patients with panic disorder and 28 age- and gender-matched healthy controls. Optimized voxel-based morphometry (VBM) was performed to assess OFC volume differences between the two groups by subtype. Categorical regression analysis was applied to examine the association of POS subtypes with State-Trait Anxiety Inventory and Revised Neuroticism-Extraversion-Openness Personality Inventory scores. RESULTS: No significant difference was found in POS subtype distribution between control subjects and patients with panic disorder. VBM, however, indicated volume reduction in the right posterior-medial OFC region in panic disorder patients with absent POS and single POS. Single POS was positively associated with Trait-Anxiety (beta = 0.446, F = 6.409, P = 0.020), and absent POS was negatively associated with Trait-Anxiety (beta = -0.394, F = 5.341, P = 0.032) and Neuroticism trait (beta = -0.492, F = 6.989, P = 0.017). CONCLUSIONS: POS subtypes may be relevant to volume reduction in OFC and the anxiety trait in patients with panic disorder. These findings suggest that volume reduction in OFC in panic disorder may be associated with neurodevelopment.

[Rethink the panic disorder]. / Repenser le trouble panique.

INTRODUCTION: We propose some reflexions on the validity of the conceptualization of panic disorder, its nosographical place, and its clinical homogeneity, through the study of the frequency of some of its psychiatric comorbidities. BACKGROUND: To define a panic attack, DSM IV requires a number of symptoms which vary from four to 13. However, some patients suffer from panic attacks with less than four symptoms (paucisymptomatic attacks) and which fill the other criteria of panic disorder. These patients would have a biological vulnerability, familial antecedents, and a treatment response which are similar to those that fill the criteria of the panic attack according to the DSM. Some authors differentiate the panic disorder in several sub-groups, such as the panic disorder with cardiorespiratory symptoms, or vestibular symptoms, or cognitive symptoms. This division of the panic disorder in several sub-groups would have an interest in the knowledge of the etiopathogeny, the attacks' frequency, the disorder severity and the treatment response. Panic disorder with prevalent somatic expression includes crises without cognitive symptoms. This sub-type can be common in the medical context, especially in cardiology, but it is often ignored, at the price of loss of socio-professional adaptability, and a medical overconsumption. DISCUSSION AND ARGUMENTS: The relationship between panic disorder and agoraphobia appears to be the subject of controversies. According to the behavioral theory, phobic disorder is the primum movens of the sequence of appearance of the disorders. American psychiatry considers agoraphobia as a secondary response to the panic disorder, and pleads for a central role of panic attacks as an etiopathogenic factor in the development of agoraphobia. The distinction between panic disorder and generalized anxiety disorder can be difficult. This is due to the existence of paucisymptomatic panic attacks. Their paroxystic nature is difficult to distinguish from the fluctuations of the generalized anxiety disorder. This frequent comorbidity could be also due to the community of certain symptoms of each disorder. These observations increase the validity of the anxiety generalized disorder as an autonomous morbid entity, rather than corresponding to a residual syndrome of the panic disorder, and could be an argument of an implicit return to the Freudian concept of the anxiety neurosis. The frequent comorbidity of panic disorder and personality disorders suggests the existence of a link. The pathological personality can be a factor of vulnerability in the panic disorder, as it can be a consequence of the panic disorder through the personality changing related on the evolution of the disorder and its complications. The relationship between panic disorder and depression has been interpreted in various ways, with mainly three assumptions: the unit position, which considers anxiety and depression as concerning a common diathesis; the dualistic position, which suggests that anxiety and depression are heterogeneous diagnostic categories and the anxio-depressive position that considers anxiety and depression combined as a syndrome differing from the pure anxiety and pure depression. The genetic studies, as well as the family studies, clearly show that the two entities are undissociated. Likewise, the therapeutic action of serotoninergic antidepressants in the two types of disorders reinforces the idea of a common biological vulnerability between anxiety and depression. Several studies have shown a significant association between panic disorder and suicide. However, the suicidal conducts are multiple and proceed by complex interactions between factors of features and states. Accordingly, panic disorder can be considered as a factor of state associated with the suicidal risk.

[Possible subtypes of panic disorder]. / Panik Bozuklugunda Olasi Alt Tipler.

OBJECTIVE: The present study, is aimed to investigate the distributiondispersion of panic attack symptoms, the possible subtypes of panic disorder, and the clinical features related to these subtypes in patients with panic disorder. MATERIAL AND METHODS: The study included 105 patients that presented to the Ondokuz Mayis University Faculty of Medicine Psychiatric Outpatient Clinic and met the DSM-IV-TR diagnostic criteria for panic disorder. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I), Panic Attack Symptom Checklist (PASC), Structured Clinical Interview for DSM-III-R (SCID-II), Beck Anxiety Inventory (BAI), Anxiety Sensitivity Index (ASI), Panic Disorder Severity Scale (PDSS), and Panic and Agoraphobia Scale (PAS) were administered to all the patients. This study examined the correlation between clinical scales and the factors based on factor analysis using PASC. RESULTS: The 3 most frequently observed symptoms during panic attacks were palpitation, sensations of shortness of breath, and sensation of choking, and the 3 most severe were palpitation, chest pain, and sensation of shortness of breath. The 3 most frequently observed non-DSM-IV-TR symptoms were feeling of discomfort, dry mouth, and blurred vision. As a result of our analysis, 3 factors were defined: respiratory-circulatory, cognitive, and autonomic. Panic attack severity, panic attack frequency, and grade of agoraphobia were strong predictors of the respiratory-circulatory subtype; anticipatory anxiety was a strong predictor of the cognitive subtype. Grade of being anxious for health was stronger predictor for respiratory-circulatory subtype, predictor for the "autonomic" subtype, and a reverse predictor for the cognitive subtype. CONCLUSION: It should be considered that the panic attack symptoms in DSM-IV-TR are insufficient to determine the panic disorder subtypes that are based on symptom profiles. The determination of subtypes could contribute in prognosis of disorder and studies about treatment methods.

The structure of lifetime panic-agoraphobic spectrum.

The heterogeneity of the clinical presentation of panic disorder (PD) has prompted researchers to describe different subtypes of PD, on the basis of the observed predominant symptoms constellation. Starting from a dimensional approach to panic disorder, an instrument to assess lifetime panic-agoraphobic spectrum (PAS) available in interview or self-report form (SCI-PAS, PAS-SR) was developed which proved to have sound psychometric properties and the ability to predict delayed response to treatment in patients with mood disorders. However, the structure of the instrument was defined a priori and an examination of its empirical structure is still lacking. Aim of the present report is to analyse the factor structure of the PAS taking advantage of a large database of subjects with panic disorders (N=630) assessed in the framework of different studies. Using a classical exploratory factor analysis based on a tetrachoric correlation matrix and oblique rotation, 10 factors were extracted, accounting overall for 66.3% of the variance of the questionnaire: panic symptoms, agoraphobia, claustrophobia, separation anxiety, fear of losing control, drug sensitivity and phobia, medical reassurance, rescue object, loss sensitivity, reassurance from family members. The first two factors comprise the DSM-IV criteria for panic disorder and agoraphobia. The other factors had received limited empirical support to date. We submit that these symptoms profiles might be clinically relevant for tailoring drug treatments or psychotherapeutic approaches to specific needs. Future perspectives might include the use of these factors to select homogeneous subgroups of patients for brain-imaging studies and to contribute to elucidating the causes and pathophysiology of panic disorder at molecular level.

Subtypes of panic attacks: a critical review of the empirical literature.

BACKGROUND: Panic disorder is a heterogeneous disorder, comprising a variety of somatic, physiological, and cognitive symptoms during repeated panic attacks. As a result, considerable data have examined whether panic attacks may be classified into distinct diagnostic or functional subtypes. The aim of this study is to evaluate the existing literature regarding the validity of panic attack subtypes. METHODS: This review focuses on data published since 2000, with the publication of DSM-IV-TR, augmented by replicated data published since 1980, with the publication of DSM-III and subsequently DSM-IV. Published reports evaluating empirical evidence for the validity of panic attack subtypes are reviewed. RESULTS: Five sets of panic symptoms (respiratory, nocturnal, nonfearful, cognitive, and vestibular) have been shown to cluster together at varying degrees of consistency. However, none of these potential subtypes have been associated with sufficient and reliable external validation criteria indicative of functional differences. This apparent lack of findings may be related to methodological inconsistencies or limitations across the reviewed studies. CONCLUSIONS: Although at present the data do not warrant the utility of subtyping, further research aimed at patent gaps in the literature, including clearer operationalization of symptom subtypes, greater use of biological challenge paradigms and physiological and other more objective measures of fear and anxiety, and exploration of subtyping based on biological factors such as genetics, may support the future designation of panic attack subtypes and their ultimate clinical utility.

Evidence-based guidelines for interpretation of the Panic Disorder Severity Scale.

BACKGROUND: The Panic Disorder Severity Scale (PDSS) is promising to be a standard global rating scale for panic disorder. In order for a clinical scale to be useful, we need a guideline for interpreting its scores and their changes, and for defining clinical change points such as response and remission. METHODS: We used individual patient data from two large randomized controlled trials of panic disorder (total n=568). Study participants were administered the PDSS and the Clinical Global Impression (CGI)--Severity and --Improvement. We applied equipercentile linking technique to draw correspondences between PDSS and CGI-Severity, numeric changes in PDSS and CGI-Improvement, and percent changes in PDSS and CGI-Improvement. RESULTS: The interpretation of the PDSS total score differed according to the presence or absence of agoraphobia. When the patients were not agoraphobic, score ranges 0-1 corresponded with "Normal," 2-5 with "Borderline," 6-9 with "Slightly ill," 10-13 with "Moderately ill," and 14 and above with "Markedly ill." When the patients were agoraphobic, score ranges 3-7 meant "Borderline ill," 8-10 "Slightly ill," 11-15 "Moderately ill," and 16 and above "Markedly ill." The relationship between PDSS change and CGI-Improvement was more linear when measured as percentile change than as numeric changes, and was indistinguishable for those with or without agoraphobia. The decrease by 75-100% was considered "Very much improved," that by 40-74% "Much improved," and that by 10-39% "Minimally improved." CONCLUSION: We propose that "remission" of panic disorder be defined by PDSS scores of five or less and its "response" by 40% or greater reduction.

Generalized anxiety disorder within the course of major depressive disorder: examining the utility of the DSM-IV hierarchy rule.

BACKGROUND: The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) specifies that generalized anxiety disorder (GAD) should not be diagnosed if it occurs exclusively during an episode of a major depressive disorder (MDD) or another mood disorder. This hierarchy rule was intended to promote diagnostic parsimony, but may result in the loss of important clinical information. The goal of this study was to compare individuals with MDD, comorbid MDD and GAD, and GAD within the course of MDD at intake and 12-month follow-up on self-report measures, clinician ratings, and rates of comorbidity. METHODS: Participants were divided into three diagnostic groups: MDD without GAD (n=124), comorbid MDD and GAD (n=59), and GAD within the course of MDD (n=166). All the participants completed a semi-structured clinical interview and self-report measures assessing psychopathology, temperament, and functional impairment. A subset of the total sample completed a follow-up assessment of 12 months postintake. RESULTS: Individuals with comorbid MDD and GAD and GAD within the course of MDD reported more psychopathology, negative affect, and functional impairment at intake than individuals with MDD only. The presence of GAD at intake, however, did not differentially predict symptom severity, functional impairment, or the presence of comorbidity at 12-month follow-up. CONCLUSIONS: Cross-sectional findings indicate that individuals with GAD within the course of MDD experience levels of psychopathology, functional impairment, and comorbidity similar to those found in individuals with comorbid GAD and MDD. Preliminary longitudinal findings, however, suggest that the presence of GAD in patients with MDD does not have prognostic significance.

Cognitive functions and the state of nonspecific brain systems in panic disorders.

A total of 93 patients with panic disorders and 36 healthy control subjects were studied. Clinical-neurological, psychometric, neuropsychological, and neurophysiological (auditory cognitive evoked potentials) investigations were performed. Patients with typical panic disorders were characterized by increased levels of anxiety and depression, along with impairments to cognitive functions in the form of decreases in short-term memory and attention, as compared with healthy subjects. Patients with atypical panic disorders differed from patients with typical panic disorders in having lower levels of anxiety, more severe depression, and more marked cognitive disorders. As compared with healthy subjects, patients with atypical panic disorders showed reductions in the amplitude of the P300 evoked potential wave, while patients with typical panic disorders showed increases. It is suggested that changes in the amplitude parameters of the P300 wave are associated with dysfunction of the limbic-reticular structures of the brain in patients with panic disorders.

Respiratory subtype of panic disorder: Can serum phosphate levels be a possible outcome to group cognitive-behavior therapy?

OBJECTIVE: Panic disorder (PD) respiratory subtype (RS) was described in order to cluster patients according to their symptoms. These patients are characterized by experiencing a relatively high number of noticeable respiratory symptoms during a panic attack (PA) and a higher reactivity to CO2. In this study, we aimed to evaluate the clinical relevance of this diagnostic category, evaluating if there are different responses to cognitive-behavioral therapy in patients with panic disorder RS as compared to those with the non-respiratory subtype (NRS), using serum phosphate as a biological marker. METHODS: Patients were assessed by a clinical interview followed by a structured diagnostic interview (M.I.N.I) and classified as RS or NRS based on symptoms. The severity of PD was evaluated throughout the PDSS, CGI, HAM-A, STAI and the BDI rating scales. All patients underwent 12 structured sessions of group-CBT for PD and had their blood collected at baseline and after treatment to assess phosphate levels. RESULTS: One hundred and thirty-eight patients have been assessed, and 102 were included in this trial. Sixty-nine patients completed the treatment protocol, 42 were classified as RS and 27 as NRS. Both RS and NRS patients improved in all clinical scales (p < 0.001). The mean phosphate levels increased from 2.44 mg/dl ±â€¯0.49 at baseline to 3.38 mg/dl ±â€¯0.52 (p < 0.01) in the RS group as well as from 2.46 mg/dl ±â€¯0.64 at baseline to 3.46 mg/dl ±â€¯0.61 (p < 0.01) in the NSR group. LIMITATIONS: Small sample size and the lack of assessment of other clinical and physiological parameters, such as respiratory variables. CONCLUSION: Our findings suggest that both RS and NRS benefit from group CBT and that there was a change in phosphate levels after effective treatment in both groups. Our data support the idea that there is a reversal of the conditions that promote hypophosphatemia as chronic hyperventilation after CBT treatment, whereas it is in disagreement to the presence of two different PD subtypes based on phosphate levels once their rates did not differ at baseline and had a similar increase after effective treatment.