Early life events and panic disorder: course of illness and comorbidity.

1. Some reports have suggested that there may be a link between the experience of traumatic life events in childhood and adolescence and the development of panic disorder in adults. In addition early loss event also seems increase depressive risk by a factor about two to three. 2. The authors wondered whether panic patients who experienced a traumatic life event would have a higher prevalence of subsequent major depressive episode than panic patients without history of depression. 3. One hundred fifty seven patients with panic disorder according DSM III-R criteria are included in this study. Fifty three (33.7%) had experienced a major loss or separation before the age of 15 years. 4. The panic group with early life events showed a significantly higher life time prevalence of major depression than the panic group who did not experience early life events.

Major depression in panic disorder: role of recent life events.

The authors assessed life events during the year before the onset of panic disorder in 57 panic patients with a lifetime history of major depression. Compared with a group of 43 panic patients without major depression, the group with depression had experienced more severe events. The clinical and theoretical implications of these results are discussed in the context of current concepts regarding the role of recent life events in comorbidity of panic disorder and major depression.

Prevalence of hepatitis B virus, delta agent and human immunodeficiency virus infections in drug addicts.

Infections with the hepatitis B (HBV) and delta (HDV) viruses and with the human immunodeficiency virus (HIV) are very common among intravenous drug addicts. The serum of 80 percent of drug addicts contains one of the HBV markers, and 15 percent of them carry an anti-D antibody. Infections with the hepatitis A and non A-non B viruses are also very common among drug abusers. Some of them may harbour several of these pathogens. This can explain the frequency of liver disease (biological anomalies and histological lesions) observed in drug addicts, as does alcohol consumption associated with drug abuse. Fifty to 60 per cent of intravenous drug addicts are seropositive for HIV. This prevalence varies across studies and countries. The high prevalence of infection by HIV in drug addicts may be explained by the use of a shared syringe. This prevalence exposes drug addicts to an increase in AIDS cases in the near future. The high prevalence of infections by HBV, HDV and HIV in drug addicts represents a risk factor for the spread of HBV, HDV and HIV infections among the general population. Preventing the rapid spread of these viruses among drug addicts is of utmost importance for the future.

Effects of beta-blocking drugs in alcohol withdrawal: a double-blind comparative study with propranolol and diazepam.

Alcohol withdrawal is associated with a decrease in gamma-aminobutyric acid neurotransmission. This explains the efficacy of benzodiazepines. However, an increase in adrenergic activity may also play a part in alcohol withdrawal symptoms, suggesting a potential efficacy of beta-blocking drugs. A double-blind comparative study of propranolol and diazepam was carried out in 28 patients suffering from moderate uncomplicated alcohol withdrawal. Patients were treated for 15 days with either 75 mg of propranolol or 30 mg of diazepam. The results show that both drugs at the dosages used are equipotent in reducing physical withdrawal symptoms and anxiety symptoms. This suggests that most likely the central as well as the peripheral effects determine the clinical usefulness of propranolol in the management of alcohol withdrawal. However, propranolol is ineffective in preventing major motor seizures, suggesting that different neurobiological mechanisms underlie the alcohol withdrawal symptoms.

Platelet serotonin levels in alcoholic patients: changes related to physiological and pathological factors.

This study investigated platelet serotonin (5-hydroxytryptamine; 5-HT) levels and the effects of different physiological and pathological factors in 108 alcoholic patients (alcohol abuse, n = 49; alcohol dependence, n = 59) and 32 healthy control subjects. Platelet 5-HT levels were determined by a fluorescent-ortho-phthalaldehyde assay. In patients, platelet 5-HT levels during withdrawal from alcohol and after 2 weeks of abstinence were significantly lower than in control subjects. Among patients, this decrease was enhanced both in alcohol-dependent patients and in patients who were depressed during the withdrawal phase, whereas lifetime impulse control disorders (mostly found in alcohol abusers) were associated with comparatively high platelet 5-HT levels (i.e., close to control subjects' values). These results, which reflect the likely biphasic effect of alcohol ingestion upon 5-HT functioning, are consistent with the dimensional 5-HT hypothesis in psychiatric disorders.

Practice-based buprenorphine maintenance treatment (BMT): how do French healthcare providers manage the opiate-addicted patients?

UNLABELLED: France was the first country to promote the extensive use of buprenorphine for the treatment of drug-addicted subjects through the primary care system. To assess both professional commitment and patients' characteristics, all the physicians and pharmacists of a French area having prescribed/dispensed buprenorphine from 2/12/96 (the official release date) to 1/31/98 were identified from data files of the Health Insurance and then interviewed. During the first 61 weeks of buprenorphine maintenance treatment (BMT), 27.5% of physicians and 51.2% of pharmacists of that area were involved; 142 patient records were documented. Features of the clinical routines spontaneously implemented for practice-based BMT were: a high level of on-site supervised dispensation by the pharmacist (71% at treatment induction and 23% thereafter); the absence of objective measurement of illicit drug use; and a low buprenorphine dosage. These features are consistent with the lack of physicians' experience and training, and also the relatively good status of the population treated (no HIV-positives, heroin use duration averaging 4.2 +/- 3.1 years, and 81.7% with stable accommodations). Despite liberal regulations guiding BMT, a negligible proportion of cases had a "nomadic" attitude (multiple buprenorphine prescribers/deliverers). The treatment outcomes (no deaths, three drug overdoses, improvement in occupational status) are encouraging. CONCLUSION: Practice-based BMT appears to be a safe and acceptable response to moderate heroin addiction, but further training of the professionals involved and longitudinal investigations of individual outcomes are needed.

[Prevalence of hepatitis C, B and D markers and histopathological aspects in a group of intravenous drug addicts]. / Prévalence des marqueurs des hépatites C, B et D et aspects histopathologiques dans un groupe de toxicomanes intraveineux.

OBJECTIVES: The aim of this study was to assess the prevalence of infection by HCV, HBV, HDV and HIV and their biological and histopathological patterns in 104 intravenous drug users. METHODS AND RESULTS: Seventy-five patients (72%) had anti-HCV antibodies. Transmission was rapid because 33% of those who had been drug users for 6 months or less had anti-HCV antibodies. The contamination rate was very high because 90% of those who had been drug users for 2 years or less had anti-HCV antibodies. Thirty-four (33%) had an HBV marker, and 6 were HBs Ag carriers. None of the patients had anti-HDV antibodies. Only one patient had anti-HIV antibodies. Twenty-five anti-HCV antibody positive drug users underwent liver biopsy. Seven (28%) had normal ALAT levels and 18 (72%) had permanently or intermittently elevated ALAT levels. The mean histological activity on the Knodell index was 4.1 (range: 1-8). CONCLUSIONS: This study indicates that contamination by HCV is almost inevitable after 2 years of intravenous drug use. The low prevalence of HBV, HDV, and HIV infection might be explained by a low endemic state of these viruses in our area.

[Psychopathological disorders and coronary diseases]. / Troubles psychopathologiques et coronaropathies.

The role of psychological factors in the genesis of coronary diseases has been considered for a long time. Friedman took it upon himself to describe a personality profile (pattern A) constituting a risk factor for coronary heart disease of which, however, the practical interest seems limited. The association of psychopathological conditions and coronary heart disease has on the other hand not been extensively studied. Recent epidemiological data show that anxiety and depressive states represent a high comorbidity with coronary heart diseases. Panic attacks remain underestimated; they seem to participate in a complex physiopathological mechanism along with ischemic coronary heart diseases. Recent studies have shown that the existence of a depressive illness during coronary heart disease and particularly in the time period following a myocardial infarction, constitutes an independent risk factor, thus increasing the mortality rate. The evolution of coronary heart disease seems greatly influenced by the existence of anxious or depressive states, the diagnosis and the treatment of these states represent a major interest towards a better management of coronary patients.

[Is DSM IV of value in training of psychiatrists?]. / Le DSM IV est-il utile à la formation des psychiatres?

Acquiring the skill to be a psychiatrist requires learning in three fields: academic, clinical and research. Academic training includes various kinds of objectives which are analysed and to which the DSM IV provides only an imperfect response. Clinical training which shapes clinical practice, requires the organization of knowledge: the DSM IV, in so far as it analyses and classifies data is a useful tool, but the utility is limited since the DSM IV is inherently biased towards a psychiatric view of illness. The utility of the DSM IV is analysed for research training, particularly with the triple goal of preparing for the manipulation of knowledge, for practical care, and for the transmission of knowledge.

[Life events and anxiety]. / Evénements de vie et anxiété.

During the last few decades many studies have examined the role of life events in psychiatric disorders. Majority of investigators have mainly focused on depression. Recently the specific etiological role of life events in anxiety have been reexamined. Two possible causal relationships have been hypothesized: loss or separation during childhood can serve as a predisposing factor for adult psychologic conditions and life events occurring in the months before the onset of anxiety disorder, can serve as a precipitating factor. However the main methodologic issue in life events research involves the distorting effect of time recall when life events are elicited retrospectively. Epidemiological and clinical data are consistent with the view that panic disorder is significantly and strongly associated with both parental death and separation in childhood. The relationship between recent life events and anxiety disorders remain unclear. Studies that compare recent life events of anxiety disorder subjects and controls have equivocal results. Different variables (number of events, type, impact) may play a role in anxiety. Recent data have also suggested that early and recent life events specially loss and separation may be a risk factor for secondary depression in anxiety. However, life events do not operate independently of other predispositional variables such as genetic, neurologic and cognitive factors. Further studies using a prospective design may be useful to clarify the relation between life events and anxiety.

[Diagnosis and management of panic disorder in psychiatry (PANDA Study)]. / Etude sur le diagnostic et la prise en charge du trouble panique en psychiatrie (étude PANDA).

Panic disorder is a genuine public health problem given by their frequency and the various and repeated consultations that they involve. PD is underdiagnosed in primary care and in medical specialist. A public campaign might lead to improved diagnosis and better treatment of panic disorder, with a beneficial effect on medico-economic indicators. Intervention by the psychiatrist is of key importance, although it has not been evaluated to any great extend. The objective of the PANDA study was to look at the prevalence and diagnostic of panic disorder, the conditions of access to and use of care, as well as the method of treatment. Four hundred and twenty three psychiatrists participated in the study and 8,137 patients seen consecutively were included. The prevalence of actual panic disorder evaluated using the Mini International Neuropsychiatric Interview (MINI) systematic is 9%. In two third of cases coexisted agoraphobia and in one third a depression. Eighty six percent of patients with actual panic disorder were treated by the psychiatrists. The diagnosis and suitable treatment of panic disorder would appear to be a significant objective in term of public health, leading to a reduction in medical and social cost of this disorder.

[Separation anxiety. Theoretical considerations]. / L'angoisse de séparation. Au fil des théories.

The interest in separation anxiety is nowadays increasing: this disorder appearing during childhood may predispose to the occurrence of anxiety disorders (such as panic disorder and agoraphobia) and major depression into adulthood. Psychoanalytic theories differ on the nature of separation anxiety and its place in child development. For some authors, separation anxiety must be understood as resulting from the unconscious internal conflicts inherent in the individuation process and gradual attainment of autonomy. From this point of view, the fear of loss of mother by separation is not regarded as resulting from a real danger. However, Freud considers the primary experience of separation from protecting mother as the prototype situation of anxiety and compares the situations generating fear to separation experiences. For him, anxiety originates from two factors: the physiological fact is initiated at the time of birth but the primary traumatic situation is the separation from mother. This point of view may be compared with behavioral theories. Behavioral theories suggest that separation anxiety may be conditioned or learned from innate fears. In Freud's theory, the primary situation of anxiety resulting from the separation from mother plays a role comparable to innate fears. Grappling with the problem of separation anxiety, Bowlby emphasizes then the importance of the child's attachment to one person (mother or primary caregiver) and the fact that this attachment is instinctive. This point of view, based on the watch of infants, is akin to ethological theories on behaviour of non human primates. Bowlby especially shows that the reactions of infant separated from mother evolve on three stages: the phase of protestation which may constitute the prototype of adulthood anxiety, the phase of desperation which may be the prototype of depression, and the phase of detachment. He emphasizes so the role of early separations in the development of vulnerability to depression. For Bowlby, these reactions are not acquired but genetically programmed and biologically determined.(ABSTRACT TRUNCATED AT 250 WORDS)

[The dexamethasone suppression test in depression. Critical review]. / Le test à la dexaméthasone dans la dépression. Revue critique.

Within the investigation of the neuroendocrinology of depression, the HPA axis exploration brings the most definite results. Biological measurements indicate an hyperactivity of this system in the endogenous depressions. The dexamethasone cortisol suppression test has been described by Liddle and Nugent and has been used by Carroll since 1970. A standardisation of the protocol is required; thus, within the endogenous deficiencies, either lack of cortisol suppression or cortisol suppression with an early escape are noticed. The various and hazardous reasons that make the results vary are discussed. The dexamethasone suppression test is a practical and useful tool for the diagnosis of endogenous depression (sensitivity above 65%, specificity and diagnostical value near 95%); for treatment management; and prognostic evaluation. From a theoretical aspect, the dexamethasone test enables us to delineate the nosology of the depressive disorder and to detect in childhood depression the same neuro-endocrinological features as noticed in adulthood depression. Physiopathological hypotheses within the norepinephrinergic and serotoninergic depression theories are detailed.

[Obsessive-compulsive symptoms associated with panic disorder. Predictive factor of a good therapeutic response to fluvoxamine]. / Symptômes obsessionnels-compulsifs associés au trouble panique. Facteur prédictif d'une bonne réponse thérapeutique à la fluvoxamine.

In a sample of 35 patients with a diagnosis of panic disorder or agoraphobia with panic attacks according DSM III criteria, the authors found 8 patients (23%) with obsessive compulsive symptoms. This subgroup and 7 patients without obsessive compulsive symptoms were treated with fluvoxamine, a selective serotonin uptake inhibitor in an 8 weeks open study (2 weeks wash out, 6 weeks treatment). At the end of the study, a dramatic reduction of anxiety was found in different rating scales. Ten patients improved and no panic attack was noted: 7 in the group with obsessive compulsive symptoms (N = 8) and 3 in the group without obsessive compulsive symptoms (N = 7). Interest of fluvoxamine in panic patients with obsessive compulsive symptoms who do not respond to common antipanic medication is suggested. Controlled studies are necessary to confirm these first results.

[Monoamine oxidase inhibitor in the treatment of attention deficit disorder of residual type. Apropos of a case]. / Inhibiteur de la monoamine oxydase dans le traitement du trouble déficitaire de l'attention--type résiduel. A propos d'une observation.

Attention deficit disorder is common in children and it may continue during adolescence and adulthood. Some psychotropic drugs can improve the social, school and professional adaptation. A 16 year old girl suffering from an attention deficit disorder of the residual type according to the DSM III criteria was treated by toloxatone, a new monoamine oxidase inhibitor. According to clinical improvement observed with this drug, it may be considered as a new symptomatic treatment of this disorder.

[Value of systematic toxicological analysis in the management of drug addicts]. / Intérêt de l'analyse toxicologique systématique dans la prise en charge des toxicomanes.

This study was carried out between March and December 1985, on 50 drug addicts, including 45 heroin users, hospitalized for detoxication. We compared the clinical informations obtained at the time of admission with the toxicological informations obtained from blood and urinary samples. If the drugs said to have been used over the last 48 hours are always found, in 52% of these cases some other drugs are found too. The reasons of this difference between clinical and toxicological informations are analysed as well as their consequences on diagnosis and treatment. This data finally shows the importance of systematic toxicological analysis in the treatment of drug addicts as well as in the epidemiological studies.

[The CRF test in psychiatry. Preliminary studies]. / Le test au CRF en psychiatrie. Etudes préliminaires.

The HPA axis exploration in the endogenous depressions indicates an hyperactivity of this system. But the reason of this perturbation is not definite. The corticotropin-releasing factor (CRF) test has been described from research work carried out by Vale et al. In the endogenous depressions, this test enables us to specify physiopathological factors of the HPA axis dysfunction. Some research suggest an hypothalamic and limbic CRF hypersecretion in the endogenous depressions. But the results are not consistent principally because of the diversity of technical protocols. So the authors try to take stock of the CRF test specificity. They report the results obtained after 100 micrograms o-CRF intravenous administration in 7 voluntary normal men.

[Schizophrenic psychoses and HLA antigens. Personal data and review of the literature]. / Psychoses schizophréniques et antigènes HLA. Données personnelles et revue de la littérature.

Genetic factors play probably an important part in the development of schizophrenic psychoses. As a consequence the use of a genetic marker as the HLA system appears to be interesting in determining the disease susceptibility gene of these psychoses. Methods and results of an investigation about the frequencies of 33 HLA alleles observed in 51 patients considered as paranoid schizophrenics are presented. The frequency of HLA-A 29 was diminished while the one of HLA-B 15 was increased but the differences were no longer significant when p was corrected. However when all the results published from 1974 to 1980 were pooled in a combined statistical analysis, some associations became significant. It seems that schizophrenia as a whole, once paranoid and hebephrenic sub-types have to be distinguished. It may be concluded from these data that correlations between schizophrenia and HLA antigens which remain doubtful could be explained with a biological genetic heterogeneity of schizophrenic disorders. Review of literature concerning the identification of HLA haplotypes in schizophrenics pedigrees and about the HLA system as a genetic marker for the clinical response to neuroleptics in schizophrenic patients or in vitro, is also discussed.

[Treatment of adjustment disorder with anxiety: efficacy and tolerance of etifoxine in a double-blind controlled study]. / Traitement du trouble de l'adaptation avec anxiété: évaluation de l'efficacité et de la tolérance de l'étifoxine par un essai en double aveugle contre produit de référence.

Adjustment disorder with anxiety is defined as a clinically significant anxiety that occurs within 3 months after the onset of an identifiable psychological stressor. Recent studies indicate that this disorder is not uncommon and must be quickly identified and treated. However, few therapeutic trials have been done in relation with this disorder. According to the criteria set by DSM IV, 170 patients with a primary diagnosis of adjustment disorder with anxiety have been enrolled in a double blind multicenter controlled trial. Patients were treated for 4 weeks with etifoxine (150-200 mg/d), or buspirone (15-20 mg/d). Also both etifoxine and buspirone show clinical efficacy and safety, the two treatments are not equivalent. The global improvement score and the efficacy index are significantly improved in the etifoxine group. These results show the interest of using etifoxine in the treatment of adjustment disorder with anxiety and should be confirmed by further studies.

[Life events and military service]. / Evénements de vie et Service National.

OBJECTIVE: Life events preceding the year of enrollment in the military service were researched in 175 patients invalid out of army because of psychiatric disorders. METHOD: We assessed the diagnostic according to the DSM III-R criteria, using a semi-structured interview. We completed the evaluation with socio-demographic data. The scale for the assessment of life events was the Paykel's scale. RESULTS: 58% of patients fulfilled the diagnostic of adaptation disorders. The anxiety disorders (14.28%) and depressive disorders (9.71%) come after. Compared with an age and socio-demographic data matched conscript group without psychiatric disorders, it seems that the patients experienced twice as much events during the year preceding the enrollment than the control-group (respectively 6.92 and 3.65). In term of quality, the results show more events related to interpersonal conflict (inadaptation in family, affective relation or professional field). Whereas the events related to recent separation, the major events life; decrease, serious illness and the maternal loss were similar in both groups. CONCLUSION: Those data suggest that there is a relationship between excess of life events and personality disorders, which may explain the inadaptation in the military service. Some recent factors of stress could represent a risk of psychiatric disorders occurring during the military service.