Reduced Sensitivity to Non-Fear-Related Stimulus Changes in Panic Disorder.

Panic disorder (PD) is associated with increased body vigilance and reduced cognitive resources directed at non-fear-related stimuli, particularly in the absence of stimulus-rich environments. To date, only few studies have investigated whether this deficit in PD is reflected in reduced mismatch negativity (MMN), an event-related potential indexing preattentive sensitivity to unexpected stimulus changes. We tested 35 patients affected by PD and 42 matched healthy controls in an oddball paradigm, using frequency and duration deviant stimuli to measure auditory MMN. PD patients displayed reduced duration MMN amplitudes in comparison to healthy controls. No group differences were detected for duration MMN latency, as well as frequency MMN indices. Results support the notion of reduced processing of non-fear-related stimuli in PD patients, particularly with regard to the preattentive processing of sound duration deviants. Additionally, our findings are in line with clinical studies reporting divergent deficits in preattentive processing of frequency and duration deviants.

Clinical and neurobiological effects of aerobic exercise in dental phobia: A randomized controlled trial.

BACKGROUND: Physical activity has shown to be effective in anxiety disorders. For specific phobia, no studies are available that systematically examined the effects of an aerobic exercise intervention on phobic fear within a randomized-controlled design. Therefore, we investigated the acute effect of a standardized aerobic training on clinical symptoms of dental phobia as well as on stress-related neurobiological markers. METHODS: Within a crossover design, 30 patients with dental phobia (mean age: 34.1 years; mean score of the Dental Anxiety Scale: 18.8) underwent two minor dental interventions separated by 7 days. Dental treatment was performed after 30 min of physical activity at either 20% VO2 max (control) or 70% VO2 max (intervention), respectively. To control for habituation, patients were randomly assigned to one of the two conditions prior to the first intervention. Moreover, saliva samples were collected at five times in order to determine changes in salivary cortisol (sC) and alpha-amylase (sAA) due to treatment. RESULTS: In comparison to baseline, aerobic exercise within 70% VO2 max significantly reduced clinical anxiety and sC concentrations before, during, and after the dental treatment. In contrast, the control condition led to decreased sAA levels at different time points of measurement. Habituation occurred at the second study day, independent of the order. CONCLUSIONS: Our study provides evidence for an effect of moderate-intense exercise on clinical symptoms and sC in patients with dental phobia. Therefore, acute aerobic exercise might be a simple and low-cost intervention to reduce disorder-specific phobic fear.

Aerobic exercise training facilitates the effectiveness of cognitive behavioral therapy in panic disorder.

BACKGROUND: Physical activity has been discussed as a therapeutic alternative or add-on for the treatment of anxiety disorders. We studied whether aerobic exercise compared to physical activity with low impact can improve the effect of cognitive behavioral therapy (CBT) in patients with panic disorder (PD) with/without agoraphobia. METHODS: Forty-seven patients received group CBT treatment over 1 month, which was augmented with an 8-week protocol of either aerobic exercise (three times/week, 30 min, 70% VO(2) max; n = 24) or a training program including exercises with very low intensity (n = 23) in a randomized controlled double-blind design. The primary outcome measure was the total score on the Hamilton Anxiety Scale (Ham-A). A 2 × 3 analysis of covariance (ANCOVA) with baseline value as a covariate was conducted for data analysis. RESULTS: Time × group interaction for the Ham-A revealed a significant effect (P = .047, η(2) p = .072), which represented the significant group difference at a 7-month follow-up. For the other clinical outcome measures no statistical significance emerged, although improvement was more sustained in the exercise group. CONCLUSIONS: For patients with PD, regular aerobic exercise adds an additional benefit to CBT. This supports previous results and provides evidence about the intensity of exercise that needs to be performed.

[Managment of the suicidal patient in the out-patient practice]. / Umgang mit dem suizidalen Patienten in der ambulanten Praxis.

Appropriate handling of suicidal tendencies is for certain one of the most important duties within ambulant treatment. As various examples show, occurrence of a suicidal tendency can be chronical as well as acute. Well-known risk factors including current psychopathology and psychodynamics help to identify and assess a suicidal tendency and to take necessary therapeutic options. Some of these can be applied in general, others have to be tailored specifically with respect to the mental disorder in question. Suicide often occurs in an interpersonal context. This fact underlines on one hand the importance and the therapeutic potential of the relationship between the patient and the therapist, on the other hand it results in many cases in a highly stressful situation for the therapist. Significant attention has to be paid to counter transference and its control. Development of an emergency plan and challenges of a "non-suicidal-contract" are discussed. We recommend an agreement with the patient to contact the therapist in case of not feeling able to control his/her own actions. This agreement includes our guarantee of permanent reachability.

Exercise and physical activity in mental disorders.

Exercise (EX) and physical activity (PA) have been shown to prevent or delay the onset of several mental disorders and to have therapeutic effects in different groups of psychiatric disorders. This review focuses on studies investigating EX as therapeutic intervention in anxiety disorders, affective disorders, eating disorders, schizophrenia, and substance use disorders. Despite EX being discussed as a potential therapy for several decades, adequately powered randomized, controlled trials are sparse in most disorder groups. Nevertheless, evidence points toward disorder-specific benefits that can be induced by EX/PA. Mechanisms of the therapeutic effects of EX/PA are summarized, including metabolic and physiological as well as psychological aspects. Finally, implications for research and therapeutic practice are illustrated.

Fronto-lateral alpha power asymmetry in panic disorder.

Resting state alpha power asymmetry in frontal and temporal regions has been reported in various clinical populations, possibly indicating deficits in prefrontal control. In panic disorder (PD), results regarding alpha asymmetric activity to date have been mixed. This study compared 55 PD patients and 42 healthy controls (HC) with regards to resting state alpha power asymmetry. Our results show more right-than-left fronto-lateral alpha power in PD, whereas at other sites and in HC no significant differences were detected. These results support the notion of altered neurobiological processes in PD that possibly represent a vulnerability to the experience of panic attacks. Further studies are needed to clarify potential causal implications of this finding in the genesis of PD, as well as to specify the functional significance of fronto-lateral alpha power asymmetry in PD.

P50, N100, and P200 Sensory Gating in Panic Disorder.

Panic disorder (PD) has been linked to abnormalities in information processing. However, only little evidence has been published for sensory gating in PD. Sensory gating describes the brain's ability to exclude stimuli of low relevance from higher level information processing, thereby sustaining efficient cognitive processing. Deficits in sensory gating have been associated with various psychiatric conditions, most prominently schizophrenia. In this case-control event-related potential study, we tested 32 patients with PD and 39 healthy controls in a double click paradigm. Both groups were compared with regard to pre-attentive (P50), early-attentive (N100), and late-attentive (P200) sensory gating indices. Contrary to a hypothesized deficit, PD patients and healthy controls showed no differences in P50, N100 and P200 values. These results suggest that sensory gating seems to be functional across the pre-attentive, early-attentive, and late-attentive time span in this clinical population. Given this consistency across auditory sensory gating indices, further research aiming to clarify information processing deficits in PD should focus on other neurophysiological markers to investigate information processing deficits in PD (eg, P300, error-related negativity or mismatch negativity).

The fear of being laughed at as additional diagnostic criterion in social anxiety disorder and avoidant personality disorder?

Social anxiety disorder (SAD) is the most common anxiety disorder and has considerable negative impact on social functioning, quality of life, and career progression of those affected. Gelotophobia (the fear of being laughed at) shares many similarities and has therefore been proposed as a subtype of SAD. This hypothesis has, however, never been tested in a clinical sample. Thus, the relationship between gelotophobia, SAD and avoidant personality disorder (APD) was investigated by examining a sample of 133 participants (64 psychiatric patients and 69 healthy controls matched for age and sex) using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and an established rating instrument for gelotophobia (GELOPH<15>). As expected, gelotophobia scores and the number of gelotophobic individuals were significantly higher among patients with SAD (n = 22) and APD (n = 12) compared to healthy controls and other psychiatric patients. Furthermore, gelotophobia scores were highest in patients suffering from both SAD and APD. In fact, all patients suffering from both disorders were also suffering from gelotophobia. As explained in the discussion, the observed data did not suggest that gelotophobia is a subtype of SAD. The findings rather imply that the fear of being laughed at is a symptom characteristic for both SAD and APD. Based on that, gelotophobia may prove to be a valuable additional diagnostic criterion for SAD and APD and the present results also contribute to the ongoing debate on the relationship between SAD and APD.

Who is stressed? A pilot study of salivary cortisol and alpha-amylase concentrations in agoraphobic patients and their novice therapists undergoing in vivo exposure.

In cognitive behavioural therapy of phobic anxiety, in vivo exposure is considered as an effective treatment strategy. Apparently, it involves the experience of stress and anxiety in patients. Given the therapist's role during exposure sessions, it is conceivable that the performance is also accompanied with the experience of stress in therapists, especially when unversed in conducting psychotherapy. Studies confirmed that cognitive behavioural therapists tend to avoid therapist-guided in vivo exposure. The objective of this study was the simultaneous investigation of therapist's and patient's stress response during in vivo exposure. Therefore, 23 agoraphobic patients and their 23 treating therapists in training provided five saliva samples during an in vivo exposure and five samples during an ordinary therapy session. Before and during exposure session, subjective evaluations of stress and anxiety were assessed. Results suggested that therapists reported similar levels of perceived stress as patients before exposure. Both groups displayed significantly elevated salivary cortisol (sC) levels during exposure compared to the control session and a trend for alterations in salivary alpha-amylase (sAA) activity was found. Therapists reached peak concentrations of sC before start of the intervention followed by a decline during exposure, while patients displayed peak levels of cortisol secretion after 60 min of exposure. In vivo exposure seems to be a demanding intervention not only for the patient, but also for therapists in training. However, it was also demonstrated that physiological and subjective stress rather decrease during the intervention and that both groups rated exposure to be substantially successful. Based on the presented results, another potential factor contributing to the under-usage of exposure treatment is conceivable and needs to be addressed in future research.

Effect of combined cognitive-behavioural therapy and endurance training on cortisol and salivary alpha-amylase in panic disorder.

Current data point to an alteration of both the hypothalamo-pituitary-adrenal (HPA)-system and the peripheral transmission of catecholamines in anxiety disorders. There is also some evidence for the effect of several components of cognitive-behavioural interventions such as coping and control and for an effect of exercise training on the neuroendocrine stress response in healthy subjects as well as patients suffering from distinct (mental) disorders. This double-blind, controlled study investigated the effect of cognitive-behavioural therapy (CBT) in combination with either high-level endurance training or low-level exercise on salivary cortisol (sC) and on levels of salivary alpha-amylase (sAA) in patients suffering from panic disorder (PD) with and without agoraphobia. In comparison to the low-level exercise condition, there were significantly lower sC-levels in the experimental group performing high-level endurance training at a 7-month follow-up. In contrast, there were no group differences in sAA levels during the study period. In this trial, we found evidence for a decelerated effect of endurance-training on HPA-system's functioning in PD. Further studies addressing the alteration of sAA levels in this population might investigate physical exercise different in intensity and duration.

Exercise and physical activity in mental disorders: clinical and experimental evidence.

Several epidemiological studies have shown that exercise (EX) and physical activity (PA) can prevent or delay the onset of different mental disorders, and have therapeutic benefits when used as sole or adjunct treatment in mental disorders. This review summarizes studies that used EX interventions in patients with anxiety, affective, eating, and substance use disorders, as well as schizophrenia and dementia/mild cognitive impairment. Despite several decades of clinical evidence with EX interventions, controlled studies are sparse in most disorder groups. Preliminary evidence suggests that PA/EX can induce improvements in physical, subjective and disorder-specific clinical outcomes. Potential mechanisms of action are discussed, as well as implications for psychiatric research and practice.

Distinct panicogenic activity of sodium lactate and cholecystokinin tetrapeptide in patients with panic disorder.

BACKGROUND: The validity of experimentally induced panic attacks as a model to study the pathophysiology of panic disorder has been questioned. Unspecific, unpleasant and aversive effects as well as specific patterns of psychovegetative symptoms pointing to different subtypes of panic disorder patients have been observed. These findings raise the question of challenge paradigms as a valuable tool to identify different vulnerabilities in patients with panic disorder. METHODS: We compared the two most widely studied panicogenic drugs sodium lactate and cholecystokinine tetrapeptide (CCK-4) with placebo in 25 patients with panic disorder and matched healthy control subjects. Psychophysiological changes were measured using the Acute Panic Inventory (API) and visual analogue scales for anxiety and arousal. RESULTS: In patients with panic disorder 18 out of 25 experienced a sodium lactate- or a CCK-4 induced panic attack. Lactate or CCK-4 induced symptoms and induced panic attacks were only correlated in healthy controls, but not in patients with panic disorder. CONCLUSION: The mechanisms of lactate and CCK-4 induced panic attacks are distinct in panic disorder patients but not in healthy controls. Different neurobiological vulnerabilities may be uncovered by different challenges.