Disorder-specific emotional imagery for differential and quantitative assessment of agoraphobia.

Visual emotional stimulation is supposed to elicit psycho-vegetative reactions, which are similar to as the ones elicited by exposure to actual experience. Visual stimulation paradigms have been widely used in studies on agoraphobia with and without panic disorder. However, the applied imagery has hardly ever been disorder- and subject- specific. 51 patients with an ICD-10 and DSM-IV diagnosis of agoraphobia with or without panic disorder (PDA) and matching healthy controls have been examined. Subjects were confronted with 146 picture showing characteristic agoraphobic situations (high places, narrow places, crowds, public transport facilities, or wide places) or pictures associated with acute physical emergency (panic) situations, which had been pre-selected by anxiety experts. Participants were asked to rate emotional arousal induced by the respective images on the Self- Assessment Manikin scale (SAM). Data on PDA severity (PAS) depressive symptoms (MADRS) and sociodemographic data were recorded. Saliva cortisol levels were measured before and after exposure in a second test applying the individually mostly feared stimuli combined with emotionally neutral pictures for every single patient. 117 of the PDA-specific images were rated significantly more fear-eliciting by patients than by healthy individuals. Sub-categorization into agoraphobia clusters showed differential effects of clusters with regard to gender distribution, severity of PDA and cortisol secretion during exposure. In this study disorder specific and individual characteristics of agoraphobia were assessed for use in future trials applying emotional imagery. It could be used for the differential assessment of PDA and associated neurobiological and psychological phenomena and in neuroimaging paradigms.

Global panic reaction II - a 7-step repetitive vicious circle.

The GPR-II model describes a "7-step" panic model. In this model, the single panic patient is not only affected as single member. The pressure weighing on him is not only exerted by external factors but also by group members of his network. Therefore, he has to cope with his individual problems and with the expectations of all members. The "therapeutic" model of instant sedation used (rescue screens) and long-lasting steps (behavioural therapy in group models) are not appropriate to treat the patients successfully.

Power law relationships between health care utilization and symptom assessment among people with panic attacks.

RATIONALE: Although people with panic attacks are high utilizers of health care, the role of symptom assessment in care-seeking is unclear. Previous studies suggest that symptom perceptions are linearly related to utilization but panic appraisal is not. The purpose of this study was to determine whether the relationships between symptom assessment and utilization are non-linear, displaying power law distributions. METHODS: This community-based study of 97 subjects with panic attacks assessed utilization of family doctor offices, total ambulatory utilization, and hospitalizations as well as symptom perceptions and panic appraisals. Matrices of symptom assessment versus utilization were created, and log-log plots were constructed. To minimize the risk of overestimation of power law distributions, linear, quadratic and cubic regression models were computed. RESULTS: None of the utilization versus symptom perceptions displayed power law distributions. However, all three measures of utilization showed power law relationships with panic appraisals, but in unique patterns. CONCLUSIONS: Although power law relationships were not found between symptom perceptions and utilization, unique patterns of power laws were identified between panic appraisals and all three measures of utilization.

Partial seizures due to sclerosis of the right amygdala presenting as panic disorder. On the importance of psychopathological assessment in differential diagnosis.

The differential diagnosis between panic disorder and focal epilepsy may sometimes pose a serious challenge. We report the case of a 32-year-old woman who complained of paroxysmal episodes of acute anxiety that evaded diagnosis for 8 years. Standard EEGs and brain CT scan showed no clear pathologic findings. Antidepressants, support psychotherapy and several courses of antiepileptic drugs were not beneficial. She was referred to our centre for a comprehensive diagnostic assessment. Clinical and standardized personality assessment did not reveal the personality organization typically associated with proneness to develop phobic anxiety disorders. Also, agoraphobic avoidance was absent, and the patient's main worries during the episodes involved negative social judgments rather than health. A brain MRI revealed a slightly increased signal at FLAIR images in the right amygdala. Video-EEG monitoring was decisive in establishing the diagnosis of drug-resistant right mesial temporal lobe epilepsy. Anteromesial temporal lobectomy was offered and successfully performed. Pathological examination of removed brain tissue revealed amygdalar sclerosis and mild hippocampal neuronal loss. At a 6-month follow-up visit, the paroxysmal episodes had completely disappeared. Depression, anxiety and quality of life were markedly improved. This case suggests that focal epilepsy should be considered in patients with paroxysmal episodes of anxiety, especially if dissociative symptoms and atypical clinical features for panic disorder are present, and if there is no satisfactory response to adequate trials of medication and psychotherapy within one year. A careful psychopathological analysis rather than a descriptive enumeration of symptoms is needed to bring these features to light. In such cases, even if routine EEGs or MRI are inconclusive and there is no response to antiepileptic drugs, it would be advisable to perform video-EEG monitoring to rule out partial seizures.

Assessment and treatment of nocturnal panic attacks.

Nocturnal panic (NP), waking from sleep in a state of panic, is a common occurrence among patients with panic disorder, with 44-71% reporting at least one such attack. NP is a non-REM event that is distinct from sleep terrors, sleep apnea, nightmares or dream-induced arousals. This review outlines recent advances in the characterization of NP, as well as current approaches to the assessment and treatment of NP. In contrast to earlier work, more recent studies suggest that patients with NP do not differ from patients without NP on sleep architecture, sleep physiology, self-reported sleep quality and severity of panic disorder. However, more precise measurement of physiological precipitants and features is warranted. Assessment of NP focuses on ruling out other explanations for NP, with differential diagnosis based on interviews, sleep polysomnography and ambulatory recording of sleep. Psychological treatment (cognitive-behavioral therapy) targets misappraisals of anxiety sensations, hyperventilatory response, and conditioned reactions to internal, physical cues. Recent evidence supports the efficacy of this approach, however, controlled studies on pharmacological agents in the treatment of NP are lacking. Research is needed to examine the effects of combined cognitive-behavioral therapy and medications, compared to medication alone in the treatment of NP.

Psychophysiologic assessment of mental imagery of stressful events in Israeli civilian posttraumatic stress disorder patients.

This study explored the physiological responses of posttraumatic stress disorder (PTSD) patients to reminders of a stressful event that had preceded the onset of their illness and was not related to its cause: the SCUD missile alarms of the Gulf War. A mental-imagery technique used in previous studies of PTSD was used. Three 30-second audiotapes were presented to each subject, including (1) the Gulf War's missile alarm, (2) a radio announcement of a terrorist attack, and (3) a standardized relaxing scene. Subjects were instructed to imagine each event as vividly as possible while heart rate (HR), skin conductance (SC), and left lateral frontalis electromyogram (EMG) responses were measured. The responses of 12 outpatients with PTSD were compared with those of panic disorder patients (n = 11), survivors of traumatic events who had not developed PTSD (n = 9), and mentally healthy subjects with no lifetime history of major trauma (n = 19). Multivariate analysis of variance (MANOVA) for the three physiological measures showed a significant group difference during imagery of the Gulf War alarm, with PTSD subjects showing higher SC and EMG responses than the others. The differences remained significant when age, level of distress during the war, and concurrent anxiety were controlled for. There were no group differences in responses to the other stimuli. We conclude that, PTSD patients may either acquire and maintain prolonged conditioned responses to various stressors during their life span or become sensitized to reminders of past traumata following the onset of their illness. Heightened conditionability may be expressed before the trauma in subjects who are liable to develop PTSD.

Psychophysiological assessment of respiratory function in panic disorder: evidence for a hyperventilation subtype.

OBJECTIVE: Previous research has found differences in respiratory function between panic disorder and other anxiety disorder populations. These differences have been explained as reflecting either a) a specific feature of panic disorder, b) merely a sign of increased general arousal, or c) a result of population sampling error. The current study addressed the question of such differences by using improved methodology over previous research. A preliminary evaluation of respiratory symptoms during panic attacks was undertaken as a means of identifying a respiratory-sensitive subtype of the panic patient. METHOD: Seventeen panic disorder patients (PD), 18 patients with generalized anxiety disorder (GAD), and 20 normal control (NC) subjects were administered a psychophysiological evaluation composed of baseline, stressor, and recovery phases. Panic patients were measured for the severity of respiratory symptoms during panic attacks. End-tidal CO2 (EtCO2) and respiration rate were measured throughout the psychophysiological evaluation. RESULTS: PDs demonstrated significantly lower baseline EtCO2 levels than the GADs and NCs, in spite of being equivalent to GADs on baseline anxiety levels. Moreover, panic patients reporting a high level of respiratory symptoms during panic attacks seemed to account for the bulk of observed differences. CONCLUSIONS: These findings lend support to a group of studies showing differences in respiratory function between panic disorder and other anxiety disorder populations. In addition, this study provides preliminary support for the presence of a distinct "hyperventilation subtype" of panic disorder. The implications of these findings for future research and treatment are discussed.

The assessment of panic using self-report: a comprehensive survey of validated instruments.

A repertoire of reliable and valid self-report instruments to assess panic and panic disorder would help both researchers and clinicians. This review presents a description and an analysis of the available instruments. Following a comprehensive search of the literature, 14 instruments with published information on reliability and validity were reviewed. The following information is reported for each instrument: brief description of the instrument and its development, mean and standard deviation for clinical and nonclinical samples, and psychometric properties. Four types of instruments are presented: general assessment and information (n = 2), severity of panic disorder (n = 2), body sensations (n = 2) and cognitive dimensions of panic (n = 8). Overall, it would seem that panic measures have moderate to excellent psychometric qualities. However, the comparison between the instruments is difficult because the amount of empirical support available varies widely from one instrument to the other.

Vagal attenuation in panic disorder: an assessment of parasympathetic nervous system function and subjective reactivity to respiratory manipulations.

We examined the effects of hyperventilation and other manipulations of respiratory pace on parasympathetic nervous system function and subjective reactivity in 15 patients with panic disorder, 15 patients with social phobia, and 15 healthy control subjects. After a 30-minute rest period subjects completed a 2.5-minute trial of each of hypoventilation, normoventilation, and hyperventilation. Trials were separated by a 3 minute inter-trial interval. Incidence of panic attacks, symptom severity, vagal tone, heart rate, end-tidal carbon dioxide level, and respiratory frequency were measured throughout. Resting physiological measures did not differ between groups. Each respiratory manipulation resulted in the expected physiological changes (e.g., hyperventilation attenuated vagal tone), however, groups did not exhibit differential physiological reactivity to the manipulations. There were no panic attacks reported during either the hypoventilation or normoventilation phases; however, two social phobic subjects (13.3%) and two panic disorder patients (13.3%) reported panic attacks during hyperventilation. Although both groups of anxiety patients reported greater severity of hyperventilation-induced symptoms than did control subjects, symptom severity did not correlate significantly with vagal tone or heart rate. These results suggest that parasympathetic function is unlikely to be aberrant in PD patients and that diminished parasympathetic activity is not sufficient for the experience of panic attacks.

Sleep in nondepressed patients with panic disorder: I. Systematic assessment of subjective sleep quality and sleep disturbance.

To systematically assess sleep complaints in panic disorder (PD), the Pittsburgh Sleep Quality Index (PSQI) was administered to 34 untreated patients with DSM-III-R PD and 34 age-matched healthy controls (HC). PD patients reported significantly more impaired sleep than HC as indicated by higher global index scores on the PSQI (6.9 +/- 2.9 versus 3.1 +/- 2.0; p < 0.0001) and on four of seven of its subscales; sleep was worst among those PD patients with a prior history of major depression. Sixty-eight percent of patients with PD reported moderately or severely impaired sleep compared to only 15% of HC (chi 2 = 17.5, p < 0.0005). Twenty-six percent of PD patients--but none of the HC--complained of frequent awakenings in the preceding month because they "could not breathe comfortably" (Fisher's exact test, p < 0.00625). One-month prevalence of sleep panic in the patients was 18%; lifetime prevalence was 68%. Whereas these findings confirm previous reports of frequent sleep complaints in patients with PD, they also raise the possibility that some of the findings might be trait phenomena attributable to a history of mood disorder.

Sleep in nondepressed patients with panic disorder: II. Polysomnographic assessment of sleep architecture and sleep continuity.

This study assessed the EEG sleep of 16 patients with panic disorder who did not currently meet criteria for major depression in comparison to 16 age-comparable healthy controls. Patients with panic disorder had remarkably normal sleep, with only a modest reduction in total sleep time (374 +/- 46 min vs. 399 +/- 36 min) and delta sleep (11.4 +/- 6.2% vs. 16.4 +/- 6.6%) noted. Contrary to expectation, impairment in sleep maintenance and continuity was not found in the patients with panic disorder. We conclude (a) sleep in non-depressed patients with panic disorder is fairly unremarkable, and does not resemble that classically described for depressed patients, and (b) excessive arousability is not a characteristic feature of sleep in panic disorder.