Diagnosis and management of generalized anxiety disorder and panic disorder in adults.

Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States, and they can negatively impact a patient's quality of life and disrupt important activities of daily living. Evidence suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes. Diagnosing GAD and PD requires a broad differential and caution to identify confounding variables and comorbid conditions. Screening and monitoring tools can be used to help make the diagnosis and monitor response to therapy. The GAD-7 and the Severity Measure for Panic Disorder are free diagnostic tools. Successful outcomes may require a combination of treatment modalities tailored to the individual patient. Treatment often includes medications such as selective serotonin reuptake inhibitors and/or psychotherapy, both of which are highly effective. Among psychotherapeutic treatments, cognitive behavior therapy has been studied widely and has an extensive evidence base. Benzodiazepines are effective in reducing anxiety symptoms, but their use is limited by risk of abuse and adverse effect profiles. Physical activity can reduce symptoms of GAD and PD. A number of complementary and alternative treatments are often used; however, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syndrome when used in combination with antidepressants. Medication should be continued for 12 months before tapering to prevent relapse.

Efficacy, tolerability, and safety of hypnosis in adult irritable bowel syndrome: systematic review and meta-analysis.

OBJECTIVE: To assess the efficacy, tolerability, and safety of hypnosis in adult irritable bowel syndrome by a meta-analysis of randomized controlled trials. METHODS: Studies were identified by a literature search of the databases Allied and Complementary Medicine Database, Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, PubMed, PsycINFO, and Scopus (from inception to June 30, 2013). Primary outcomes were adequate symptom relief, global gastrointestinal score, and safety. Summary relative risks (RRs) with number needed to treat (NNT) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were calculated using random-effects models. RESULTS: Eight randomized controlled trials with a total of 464 patients and a median of 8.5 (7-12) hypnosis sessions over a median of 12 (5-12) weeks were included into the analysis. At the end of therapy, hypnosis was superior to control conditions in producing adequate symptom relief (RR, 1.69 [95% CI = 1.14-2.51]; NNT, 5 [3-10]) and in reducing global gastrointestinal score (SMD, 0.32 [95% CI = -0.56 to -0.08]). At long-term follow-up, hypnosis was superior to controls in adequate symptom relief (RR, 2.17 [95% CI = 1.22-3.87]; NNT, 3 [2-10]), but not in reducing global gastrointestinal score (SMD, -0.57 [-1.40 to 0.26]). One (0.4%) of 238 patients in the hypnosis group dropped out due to an adverse event (panic attack). CONCLUSION: This meta-analysis demonstrated that hypnosis was safe and provided long-term adequate symptom relief in 54% of patients with irritable bowel syndrome refractory to conventional therapy.

Vitamin D and common mental disorders in mid-life: cross-sectional and prospective findings.

BACKGROUND & AIMS: The relationship between vitamin D and common mental disorders (CMDs) remains unclear. We aimed to determine if behaviours affecting vitamin D concentrations differ between individuals with or without CMDs and evaluate, cross-sectionally and prospectively, the extent to which the association between 25(OH)D and CMDs are explained by these behaviours. METHODS: Data are from the 1958 British birth cohort (n = 7401). Behaviours were ascertained by questionnaire at age 45 years. CMDs (depression, anxiety, panic, phobia) were assessed using the Clinical Interview Schedule-Revised at 45 years and depression using Mental Health Inventory-5 at 50 years. RESULTS: Participants with CMDs at 45 years differed from others on some but not all vitamin D related behaviours. There were inverse, cross-sectional associations at 45 years of 25(OH)D with depression and panic, which persisted after adjustment for vitamin D related behaviours (OR = 0.57, 95% CI: 0.40,0.81 and OR = 0.33, 95% CI: 0.40,0.81, respectively). Association between 25(OH)D and subsequent (50 years) risk of depression was non-linear (p = 0.01), with lower risk for participants with 25(OH)D between 50 and 85 nmol/l compared with those with lower or higher concentrations. CONCLUSION: This study provides support for an association of low 25(OH)D concentrations with current and subsequent risk of depression in mid-adulthood.

Challenges in management of complex panic disorder in a palliative care setting.

This is a complex case of post-traumatic stress disorder (PTSD) with comorbid panic disorder occurring in a woman in her mid-60s, with a family history of neurotic illness. PTSD arose in the context of treatment for terminal lung cancer. This patient who had been close to her father watched him die of cancer, when he was about her age. Her diagnosis and treatment prompted traumatic recollections of her father's illness and death that resulted in her voluntary withdrawal from cancer treatment. The goals of treatment were to promptly reduce anxiety, minimise use of sedating pharmacotherapy, promote lucidity and prolong anxiety-free state thereby allowing time for important family interactions. Prompt, sustained relief of severe anxiety was necessary to achieve comfort at the end of life. Skilled additions of psychological therapies (eye movement desensitisation reprocessing, clinical hypnosis and breathing exercises) with combined pharmacotherapy (mirtazepine and quetiapine) led to control of anxiety and reduction of post-traumatic stress.

Effects of reversible inactivation of the dorsomedial hypothalamus on panic- and anxiety-related responses in rats

The medial hypothalamus is part of a neurobiological substrate controlling defensive behavior. It has been shown that a hypothalamic nucleus, the dorsomedial hypothalamus (DMH), is involved in the regulation of escape, a defensive behavior related to panic attacks. The role played by the DMH in the organization of conditioned fear responses, however, is less clear. In the present study, we investigated the effects of reversible inactivation of the DMH with the GABA A agonist muscimol on inhibitory avoidance acquisition and escape expression by male Wistar rats (approximately 280 g in weight) tested in the elevated T-maze (ETM). In the ETM, inhibitory avoidance, a conditioned defensive response, has been associated with generalized anxiety disorder. Results showed that intra-DMH administration of the GABA A receptor agonist muscimol inhibited escape performance, suggesting an antipanic-like effect (P < 0.05), without changing inhibitory avoidance acquisition. Although a higher dose of muscimol (1.0 nmol/0.2 µL; N = 7) also altered locomotor activity in an open field when compared to control animals (0.2 µL saline; N = 13) (P < 0.05), the lower dose (0.5 nmol/0.2 µL; N = 12) of muscimol did not cause any motor impairment. These data corroborate previous evidence suggesting that the DMH is specifically involved in the modulation of escape. Dysfunction of this regulatory mechanism may be relevant in the genesis/maintenance of panic disorder.

Effects of reversible inactivation of the dorsomedial hypothalamus on panic- and anxiety-related responses in rats.

The medial hypothalamus is part of a neurobiological substrate controlling defensive behavior. It has been shown that a hypothalamic nucleus, the dorsomedial hypothalamus (DMH), is involved in the regulation of escape, a defensive behavior related to panic attacks. The role played by the DMH in the organization of conditioned fear responses, however, is less clear. In the present study, we investigated the effects of reversible inactivation of the DMH with the GABA A agonist muscimol on inhibitory avoidance acquisition and escape expression by male Wistar rats (approximately 280 g in weight) tested in the elevated T-maze (ETM). In the ETM, inhibitory avoidance, a conditioned defensive response, has been associated with generalized anxiety disorder. Results showed that intra-DMH administration of the GABA A receptor agonist muscimol inhibited escape performance, suggesting an antipanic-like effect (P < 0.05), without changing inhibitory avoidance acquisition. Although a higher dose of muscimol (1.0 nmol/0.2 µL; N = 7) also altered locomotor activity in an open field when compared to control animals (0.2 µL saline; N = 13) (P < 0.05), the lower dose (0.5 nmol/0.2 µL; N = 12) of muscimol did not cause any motor impairment. These data corroborate previous evidence suggesting that the DMH is specifically involved in the modulation of escape. Dysfunction of this regulatory mechanism may be relevant in the genesis/maintenance of panic disorder.

Terapia cognitivo-comportamental no transtorno de pânico / Cognitive-behavioral therapy in panic disorder

OBJETIVO: O transtorno de pânico é uma condição crônica e recorrente que prejudica a qualidade de vida e o funcionamento psicossocial dos portadores. Embora os medicamentos sejam efetivos na redução dos ataques de pânico, muitos pacientes não respondem adequadamente a essas intervenções. A terapia cognitivo-comportamental fornece um método alternativo eficaz para tratar transtorno de pânico e evitação agorafóbica. O objetivo do estudo é o de descrever o uso de técnicas cognitivo-comportamentais no tratamento do transtorno de pânico. MÉTODO: Revisão narrativa a partir dos bancos de dados do Medline, SciELO e PsycInfo e de livros-texto especializados. RESULTADOS: Foram descritos os fundamentos da terapia cognitivo-comportamental no tratamento do transtorno pânico e revisadas as evidências de eficácia em curto e longo prazos. O uso de medicação concomitante a terapia cognitivo-comportamental foi também discutido. CONCLUSÕES: A terapia cognitivo-comportamental individual ou em grupo é eficaz para pacientes com transtorno de pânico, seja como tratamento de primeira linha ou como um próximo passo para pacientes com resposta parcial a outros tratamentos.

OBJECTIVE: Panic disorder is a chronic and recurrent condition that impairs an individual's psychosocial functioning and quality of life. Despite the efficacy of psychopharmacological treatment in reducing panic attacks, many patients fail to respond adequately to these interventions. Cognitive behavioral therapy provides an alternative and efficacious method for treating panic disorder and agoraphobic avoidance. The objective of the study is to describe the use of cognitive behavioral therapy for panic disorder. METHOD: Narrative review of data collected from Medline, SciELO and PsycInfo and specialized textbooks. RESULTS: We describe the cognitive-behavioral model for the treatment of panic disorder, and review both short and long-term efficacy findings. We also discuss the role of combined treatment (cognitive behavioral therapy and psychopharmacology). CONCLUSIONS: Cognitive behavioral therapy, either individual or in group, can be used as first-line therapy for panic disorder. This treatment modality can also be indicated as a next step for patients failing to respond to other treatments.

Utilização de técnicas da terapia cognitivo-comportamental em grupo para pacientes com sintomas residuais do transtorno de pânico: seguimento de 2 anos / Cognitive-behavioral group therapy techniques in panic disorder patients with residual symptoms: 2-year follow-up

Objetivo: Avaliar a utilização das técnicas aprendidas durante a terapia cognitivo-comportamental em grupo (TCCG) para pacientes com transtorno de pânico (TP) que apresentam sintomas residuais em até 2 anos após o término do tratamento. Métodos: Um total de 64 pacientes completou o protocolo de 12 sessões de TCCG, e 62 (97%) foram encontrados para avaliação 2 anos após o término da terapia. As medidas de desfecho foram avaliadas pelos seguintes instrumentos: Impressão Global Clínica (CGI), Inventário de Pânico e Escala Hamilton para Ansiedade. O uso das técnicas foi avaliado através de entrevista semi-estruturada nas avaliações de seguimento, sendo classificadas em: (a) respiração diafragmática; (b) relaxamento muscular; (c) técnica cognitiva; e (d) exposição. Resultados: Considerando os 62 pacientes avaliados no seguimento, 39 (63%) preencheram o critério de remissão (CGI 9 2 e ausência de ataques de pânico) no primeiro ano e 35 (57%) no segundo ano de seguimento. A despeito dos critérios de remissão, um número grande de pacientes (87%) continuava a utilizar as técnicas aprendidas durante a terapia 1 a 2 anos após o término do protocolo. A técnica mais utilizada em ambos os períodos de seguimento foi a respiração diafragmática. Conclusões: Os resultados sugerem que a TCCG é eficaz para pacientes com sintomas residuais de TP. O uso das técnicas aprendidas durante as 12 sessões foi evidenciado em até 2 anos após o término do tratamento, sugerindo benefícios em longo prazo das habilidades desenvolvidas na TCCG.

Objective: To evaluate the techniques learned by patients with panic disorder (PD) and residual symptoms after cognitivebehavioral group therapy (CBGT) up to a 2-year follow-up. Methods: Sixty-four PD patients were treated with a 12-session CBGT and 62 (97%) were followed for 2 years after the end of the treatment. Outcomes were evaluated by Clinical Global Impression (CGI), Panic Inventory, and Hamilton Anxiety Scale. The tools used by patients were assessed through a semi-structured interview and classified as follows: (a) diaphragmatic breathing, (b) muscle relaxation; (c) cognitive technique; and (d) exposure. Results: Of the 62 patients assessed at the follow-up, 39 (63%) met the remission criteria (CGI 9 2 and no panic attacks) in the first year and 35 (57%) in the second year of follow-up. Despite meeting the remission criteria, 87% of patients kept using the tools learned in CBGT up to 2 years after the treatment. Diaphragmatic breathing was the most used technique in both periods. Conclusion: The results of the present study suggest that CBGT is efficacious for patients with residual symptoms of PD. The techniques learned during the 12 therapy sessions are used by the patients up to 2 years after the treatment, suggesting long-term benefits of the skills learned at CBGT protocols.

Psychosocial interventions for panic disorder after coronary artery bypass graft: a case study.

It is increasingly recognized that patients with cardiovascular disease may also suffer from concurrent psychological problems. Many patients present to emergency services and cardiologists with a history of panic disorder. Because of the similarity of presenting symptoms, these patients are often undiagnosed and consequently have slower recovery times and are costly to the healthcare system. Panic disorder is a significant public health problem; however, it is a treatable condition. Healthcare providers should be aware of its occurrence in cardiovascular disease. This case study describes the use of psychosocial interventions, such as the cognitive behavior therapy, in the management of panic disorder after coronary artery bypass graft. A 64-year-old man was treated with 9 sessions of cognitive behavior therapy over a 5-month period. Baseline assessment showed significant distress and deficit in functioning. Following intervention, there was marked reduction in objective and subjective measurement of distress and overall improvement in functioning. Healthcare providers, particularly nurses, need to consider the integration of psychosocial interventions into areas of critical care to provide effective and holistic care. Preoperative screening would be helpful as well.

Induced arousal and reexperiencing in acute stress disorder.

This study investigated the relationship of hyperarousal and intrusive symptoms in acute stress disorder (ASD). Civilian trauma survivors with ASD (n = 18) and without ASD (n = 14) completed a hyperventilation provocation test (HVPT) and then completed the Physical Reactions Scale. All participants provided a narrative describing their hyperventilation experience that was audiotaped and independently coded. Individuals with ASD reported greater numbers of intrusive memories and reported greater distress than non-ASD participants. More ASD than non-ASD participants experienced a flashback-type reaction during the hyperventilation. Intrusive symptoms were significantly correlated with elevated arousal following the HVPT. The findings provide evidence that reexperiencing is directly associated with elevated states of arousal.

Successful management of claustrophobia and depression during allogeneic SCT.

As psychological problems are frequent in SCT patients we report on a patient with chronic myeloid leukemia, claustrophobia and depression. The successful allogeneic stem cell transplant of this patient in a reverse isolation setting required intensive interdisciplinary hematological, psychological and psychiatric collaboration. Psychopharmacologically the patient was treated with lorazepam 1 mg at 10 a.m. and 8 p.m. and after crisis on day +6, and 2.5 mg twice daily i.v. until one day before discharge (total 20 doses). Psychological counseling followed a cognitive-behavioural approach including progressive muscle relaxation and cognitive techniques focusing on the actual coping processes.

Panic disorder from a monistic perspective: integrating neurobiological and psychological approaches.

In the literature, psychological and biological theories of panic disorder are often regarded as mutually exclusive. The present article presents an integrative theory that explains how and why cognitive misinterpretations and "false threat alarms" leading to irrational fear and anxiety can arise from a neurobiological dysfunction in the amygdala and ascending transmitter systems. According to this view, physiological symptoms (such as palpitations and respiration manoeuvres) and psychological symptoms of anxiety (perception of threat and anticipation of catastrophe) are elicited simultaneously by a subcortical threat detection mechanism. This perspective might help to integrate conflicting earlier approaches. It is discussed with respect to theoretical, empirical, and clinical implications.

Hyperventilation syndrome: a chimera?

There is now an impressive body of research to suggest that the concept of a discrete hyperventilation syndrome is no longer tenable. The evidence for this has been carefully gathered and the scientific studies have employed innovative methodological techniques and have introduced a key psychological dimension. Both have led to a greater understanding of the respiratory correlates of anxiety, but in the process have revealed the "hyperventilation syndrome" to be a chimera. Furthermore, there is no evidence to support the view that panic attacks and hyperventilation are synonymous: on the contrary, hyperventilation rarely accompanies panic and, when it does, it is more likely to be a consequence than a cause of the panic. Finally, there is no evidence that "breathing therapy" works by normalizing pCO2; its nonspecific effects on anxiety appear to be mediated in part by slowing respiratory rate. Further research in this field might be more profitably focused on the nature of the association between anxiety disorders and organic lung disease, especially asthma.

Seasonality in panic disorder.

Following a clinical observation of increased anxiety symptoms and mood changes during winter in panic disorder patients, the Seasonal Pattern Assessment Questionnaire (SPAQ) was completed by 133 patients. Global Seasonality Scores (GSS), and the prevalence of Seasonal Affective Disorder (SAD), were significantly higher than reported in general population studies. Seasonal changes were also found in anxiety and panic attacks. These findings suggest the possibility of a common aetiology for panic disorder and SAD, that seasonality may be a far more general phenomenon in psychopathology, and that light therapy may be a useful treatment for some panic disorder patients.