Early Trauma Is Associated With Suicidal Ideation in Patients With Panic Disorder.

ABSTRACT: There are several predictors of suicidality in patients with panic disorder (PD). Being a woman, younger age, low education level, unmarried status, and symptom severity have been suggested. This study aimed to examine whether early trauma is associated with suicidal ideation in patients with PD. Our study included 267 patients with PD and 105 controls. Data on sociodemographic variables and data from the Early Trauma Inventory Self Report-Short Form, Beck Depression Inventory, Panic Disorder Severity Scale, Anxiety Sensitivity Inventory-Revised, Coping Scales, and Scale for Suicide Ideation were collected, and correlation and regression analyses were performed. This study suggests that clinicians should consider early trauma when assessing suicidal ideation in patients with PD. Clinicians could consider alternative treatments, such as trauma-focused cognitive-behavioral therapy, eye movement desensitization, reprocessing approaches, and classical pharmacological and psychological treatments for patients with PD who have a history of early trauma and are expected to be at high risk for suicide.

Identification and medical utilization of newly diagnosed panic disorder: A Nationwide case-control study.

OBJECTIVE: Ascertaining comorbid illnesses and patterns of medical utilization early in the course of psychiatric illness can help identify patients with panic disorder. We investigated how such cases were diagnosed and the comorbidities associated with newly diagnosed panic disorder in a nationwide database. METHODS: We enrolled a large representative cohort of the general population in Taiwan (N = 1000,000) and selected 9759 cases of panic disorder from January 1, 2000 to December 31, 2013. The distribution of the departments in which the cases were identified and the medical utilization 12 months before diagnosis were analyzed. Based on a nested case-control study, four controls were randomly selected for each case and matched for sex, age, and incidence year. Conditional logistic regression was used to explore the factors associated with newly-diagnosed panic disorder such as demographic factors, concomitant medications, and physical and psychiatric comorbidities. RESULTS: Most (58.5%) cases of panic disorder were diagnosed in the psychiatry department, whereas only 3.7% were identified in the emergency department. Before diagnosis, the patients frequently visited the departments of internal medicine, family practice, and Chinese herbal medicine. A multivariate analysis revealed a higher number of physical and psychiatric comorbidities before diagnosis in the cases compared with the controls, especially depressive disorder and other anxiety disorders. CONCLUSIONS: Individuals with certain comorbidities and patterns of medical utilization are more likely to be diagnosed with panic disorder. We suggest providing more training to general practitioners and emergency physicians for the early diagnosis of panic disorder.

Allergic rhinitis increases the risk of incident panic disorder among young individuals: A nationwide population-based cohort study in Taiwan.

BACKGROUND: Studies have reported an association between allergy and panic disorder. However, few studies have explored the relationship between allergic rhinitis and panic disorder. Previous studies were limited by cross-sectional study designs, self-reported symptoms, absence of matched controls, and lack of consideration of the influence of steroid and comorbidities. This study aimed to explore the longitudinal association between allergic rhinitis and panic disorder in a large population-based cohort of young people. METHODS: In this study, 79,917 new cases of allergic rhinitis between 1998 and 2012 in individuals younger than 20 years were identified from Taiwan's National Health Insurance Research Database. One control (nonallergic rhinitis) per case (allergic rhinitis) was randomly selected from the remaining sample, matching for age, sex, residence, and insurance premium. Both groups were followed until the end of 2013 for incidence of panic disorder. Cox regression analysis was performed, adjusting for sex, age, residence, insurance premium, systemic steroids, asthma, atopic dermatitis, allergic conjunctivitis, attention deficit hyperactivity disorder, depression, and Charlson index. RESULTS: Allergic rhinitis was associated with a 2-fold increase in risk for panic disorder after adjustment for other variables. Additional independent risk factor of panic disorders were female sex, older age group, and depression. LIMITATIONS: Lifestyle, substance use, smoking by the patient or family members, and psychosocial stressors were not evaluated. CONCLUSIONS: Allergic rhinitis was associated with increased risk of panic disorder. Assessment and intervention of allergy rhinitis among young people with panic disorder are critical.

Non-cardiac chest pain: a 2018 update.

Non-cardiac chest pain (NCCP) is defined as recurring, angina-like, chest pain of non-cardiac origin. Studies have estimated that gastroesophageal reflux disease (GERD) is the most common contributing factor for NCCP. In patients with non-GERD related NCCP, esophageal motility disorders, and functional chest pain of presumed esophageal origin are the main underlying mechanisms for symptoms. Epidemiologic studies show a high prevalence of panic disorder, anxiety and major depression in NCCP patients. The diagnostic esophageal workup starts only after that cardiac and pulmonary diseases have been ruled out. NCCP patients with typical reflux symptoms are more likely to have GERD-related NCCP than those without typical reflux symptoms. High-dose proton pump inhibitor trial (PPI test) can be used to confirm the diagnosis of GERD-related NCCP. Negative upper endoscopy is quite common. For patients unresponsive to antireflux treatment and with negative endoscopy, impedance-pH monitoring should be done. Treatment of patients with non-GERD-related NCCP has focused on esophageal (hypercontractile or spastic) motility disorders and esophageal visceral hypersensitivity. In the first case, several trials using calcium channel blockers, nitrates, anticholinergics, or botulinum toxin injection and recent trials with endoscopic myotomy have been conducted. In case of visceral hypersensitivity, studies found that the amelioration, when compared to placebo, was significant with venlafaxine, sertraline, and imipramine. In this context, also cognitive behavioral therapy has been proposed.

Cultural aspects of anxiety disorders in India.

Cultural factors have influenced the presentation, diagnoses, and treatment of anxiety disorders in India for several centuries. This review covers the antecedents, prevalence, phenomenology, and treatment modalities of anxiety disorders in the Indian cultural context. It covers the history of the depiction of anxiety in India and the concept of culture in the classification of anxiety disorders, and examines the cultural factors influencing anxiety disorders in India. We review the prevalence and phenomenology of various disorders, such as generalized anxiety disorder, panic disorder, social anxiety, and phobic disorder, as well as culture-specific syndromes such as dhat and koro in India. Finally, the review examines the wide range of therapeutic modalities practiced in India, such as faith healing, psychotherapy, ayurveda, psychopharmacology, Unani medicine, homeopathy, yoga, meditation, and mindfulness. We conclude by emphasizing the significance of cultural factors in making relevant diagnoses and offering effective and holistic treatments to individuals with anxiety disorders.

Por varios siglos, Ios factores culturales han influenciado la presentación, diagnóstico y tratamiento de Ios trastornos de ansiedad. Esta revisión abarca Ios antecedentes, prevalencia, fenomenología y modalidades terapéuticas de Ios trastornos de ansiedad en el contexto cultural de India. También incluye la historia de la descripción de la ansiedad en India y el concepto de cultura en la clasificación de Ios trastornos de ansiedad, como asimismo examina Ios factores culturales que influyen en Ios trastornos de ansiedad en India. Se revisa la prevalencia y la fenomenología de varios trastornos, como el trastorno de ansiedad generalizada, el trastorno de pánico, la ansiedad social y el trastorno fóbico, como también síndromes culturales específicos en India como el dhat y el koro. Por ultimo, el artículo revisa el amplio rango de modalidades terapéuticas practicadas en India, como la curación por la fe, la psicoterapia, el ayurveda y la psicofarmacología. Se concluye enfatizando en el significado de Ios factores culturales que son relevantes para realizar diagnósticos y ofrecer tratamientos efectivos y holísticos para individuos con trastornos de ansiedad.

Depuis plusieurs siècles, des facteurs culturels influent sur la présentation, le diagnostic et le traitement des troubles anxieux en Inde. Cet article parcourt les antécédents, la prévalence, la phénoménologie et les modalités de traitement des troubles anxieux dans le contexte culturel indien. Il traite de l'histoire de la représentation de l'anxiété en Inde et du concept de culture dans la classification des troubles anxieux et analyse les facteurs culturels influant sur les troubles anxieux en Inde. Nous examinons la prévalence et la phénoménologie des différents troubles, comme les troubles anxieux généralisés, le trouble panique, l'anxiété sociale et les troubles phobiques, ainsi que les syndromes culturels spécifiques comme le syndrome du Dhat et du koro en Inde. Enfin, l'article analyse la large gamme de modalités thérapeutiques pratiquées en Inde, comme la guérison par la foi, la psychothérapie, l'ayurvéda, la psychopharmacologie, la médecine Unani, l'homéopathie, le yoga, la méditation et la pleine conscience. Nous concluons en soulignant l'importance des facteurs culturels dans l'établissement de diagnostics pertinents et en proposant des traitements efficaces et holistiques aux individus ayant des troubles anxieux.

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial.

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.

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.

Risk factors in the origin of congenital left-ventricular outflow-tract obstruction defects of the heart: a population-based case-control study.

The aim of our project was to study possible etiological factors in the origin of congenital heart defects (CHDs) because in the majority of patients the underlying causes are unclear. Cases with different CHD entities as homogeneously as possible were planned for evaluation in the population-based large data set of the Hungarian Case Control Surveillance of Congenital Abnormalities. Dead or surgically corrected 302 live-born cases with different types of left-ventricular outflow tract obstructive defects (LVOT, i.e., valvular aortic stenosis 76, hypoplastic left heart syndrome 76, coarctation of the aorta 113, and other congenital anomalies of aorta 32) were compared with 469 matched controls, 38,151 controls without any defects, and 20,750 malformed controls with other isolated defects. Medically recorded pregnancy complications and chronic diseases were evaluated based on prenatal maternity logbooks, whereas acute diseases, drug treatments, and folic acid/multivitamin supplementation were analyzed both on the basis of retrospective maternal information and medical records. The results of the study showed the role of maternal diabetes in the origin of LVOT in general, while panic disorder was associated with a higher risk of hypoplastic left heart syndrome and ampicillin treatment with a higher risk of coarctation of the aorta (COA). High doses of folic acid had a protective effect regarding the manifestation of LVOT, particularly COA. In conclusion, only a minor portion of causes was shown in our study; thus, further studies are needed to understand better the underlying causal factors in the origin of LVOT.

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.

[Prevalence of psychiatric disorders in French general practice using the patient health questionnaire: comparison with GP case-recognition and psychotropic medication prescription]. / Prévalence des troubles psychiatriques en médecine générale selon le patient health questionnaire: adéquation avec la détection par le médecin et le traitement prescrit.

INTRODUCTION: Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. OBJECTIVES: To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. METHODS: GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. RESULTS: The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. CONCLUSION: This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.

Increased risk of acute myocardial infarction for patients with panic disorder: a nationwide population-based study.

OBJECTIVE: To examine prospectively the relationship between a diagnosis of panic disorder and the risk of acute myocardial infarction within 1 year of follow-up. Panic disorder is associated prospectively with coronary artery disease, but the risk of acute myocardial infarction associated with panic disorder has not been specifically investigated. METHOD: This nationwide population-based study used data from the Taiwan National Health Insurance Research Database covering the years 2000 to 2005. A total of 9641 patients diagnosed with panic disorder in 2004 were included, together with 28,923 matched nonpanic disorder enrollees as a comparison cohort. Cox proportional hazard regressions were conducted to compute hazard ratios, after adjustment for comorbid medical disorders and sociodemographic characteristics. RESULTS: Results indicated that 4.77% of patients with panic disorder (approximately one in 21) experienced an acute myocardial infarction episode within a year, compared with 2.73% of patients in the comparison cohort. The adjusted hazard of acute myocardial infarction was significantly higher (1.75 times, 95% Confidence Interval = 1.55-1.97) for patients with panic disorder, relative to the comparison cohort. The association persisted in further analyses stratified by hypertension, coronary heart diseases, and age. CONCLUSION: Panic disorder was identified as an independent risk factor for subsequent acute myocardial infarction. Comprehensive multidisciplinary approaches are needed to optimize primary and secondary prevention of acute myocardial infarction among patients with panic disorder.

Anxiety disorders in pregnancy.

There is now growing realization that many women suffer from new onset or worsening of anxiety disorders during pregnancy. Studies of anxiety symptoms in pregnancy show that a significant portion of women are affected. Anxiety symptoms in pregnancy have been associated with adverse fetal and infant outcomes. Furthermore, having an anxiety disorder during pregnancy is one of the strongest risk factors for postnatal depression. Although the literature on treating anxiety disorders in pregnancy per se is sparse, response to standard treatment is good. The risk of teratogenicity with pharmacotherapy must be considered, but it can be minimized by judicious tapering and cessation of medication during high-risk periods.

Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder.

BACKGROUND: Given growing evidence that respiratory dysregulation is a central feature of panic disorder (PD) interventions for panic that specifically target respiratory functions could prove clinically useful and scientifically informative. We tested the effectiveness of a new, brief, capnometry-assisted breathing therapy (BRT) on clinical and respiratory measures in PD. METHODS: Thirty-seven participants with PD with or without agoraphobia were randomly assigned to BRT or to a delayed-treatment control group. Clinical status, respiration rate, and end-tidal pCO(2) were assessed at baseline, post-treatment, 2-month and 12-month follow-up. Respiratory measures were also assessed during homework exercises using a portable capnometer as a feedback device. RESULTS: Significant improvements (in PD severity, agoraphobic avoidance, anxiety sensitivity, disability, and respiratory measures) were seen in treated, but not untreated patients, with moderate to large effect sizes. Improvements were maintained at follow-up. Treatment compliance was high for session attendance and homework exercises; dropouts were few. CONCLUSIONS: The data provide preliminary evidence that raising end-tidal pCO(2) by means of capnometry feedback is therapeutically beneficial for panic patients. Replication and extension will be needed to verify this new treatment's efficacy and determine its mechanisms.

Do comorbid personality disorders moderate panic-focused psychotherapy? An exploratory examination of the American Psychiatric Association practice guideline.

OBJECTIVE: The American Psychiatric Association (APA) practice guideline for panic disorder recommends psychodynamic psychotherapy for panic disorder patients with comorbid personality disorders. No data underlie this recommendation. This exploratory study assessed the moderating effect of personality disorder on psychodynamic and non-psychodynamic psychotherapy outcome. METHOD: Forty-nine subjects with primary DSM-IV panic disorder were randomly assigned to 12 weeks of twice-weekly Panic-Focused Psychodynamic Psychotherapy or Applied Relaxation Training. The primary outcome measure was the Panic Disorder Severity Scale; the moderating effect of Axis II psychopathology on the Sheehan Disability Scale was also tested. The trial was conducted between February 2000 and January 2005. RESULTS: Twenty-four subjects (49%) met DSM-IV criteria for a Structured Clinical Interview for DSM-IV Axis II Disorders-diagnosed personality disorder, of whom 19 (79%) had a cluster C diagnosis. Presence of a cluster C diagnosis moderated treatment outcome. Such subjects experienced greater improvements in Panic-Focused Psychodynamic Psychotherapy than subjects without cluster C comorbidity. CONCLUSIONS: Despite its small sample size, this exploratory analysis provides initial preliminary evidence corroborating the APA practice guideline recommendation. Future panic disorder clinical trials should explore Axis II moderator effects. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT00128388.

Neural correlates of trauma script-imagery in posttraumatic stress disorder with and without comorbid major depression: a functional MRI investigation.

The goal of this study was to compare neural activation patterns in patients with PTSD with and without current comorbid major depression. Traumatized subjects with PTSD (n=11), PTSD+major depression (MDD, n=15), and subjects (n=16) who met criterion A for PTSD but never developed the disorder were studied using the script-driven symptom-provocation paradigm adapted to functional magnetic resonance imaging (fMRI) at a 4-Tesla field strength. Both the PTSD+MDD and PTSD-MDD groups revealed decreased brain activation in the anterior cingulate gyrus (BA 24) and the right ventrolateral prefrontal cortex (BA 47). After covariation for differences in PTSD severity between these groups, the left insula (BA 13) remained more significantly activated in the PTSD-MDD group than in the PTSD+MDD group. In contrast, the PTSD+MDD group showed greater activation than the PTSD-MDD group in the bilateral anterior cingulate gyrus (BA 24) and posterior cingulate cortices (BA 23, 31). These results suggest different patterns of brain activation related to comorbid major depression occurring in the context of PTSD.

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder.

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.

Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database.

OBJECTIVE: The association between panic disorder (PD) and coronary heart disease (CHD) was examined in a large national managed care database. METHODS: The Integrated Health Care Information Services managed care database is a fully de-identified, Health Insurance Portability and Accountability Act-compliant database and includes complete medical history for more than 17 million managed care lives; data from more than 30 United States health plans covering 7 census regions and from patient demographics, including morbidity, age, and gender. A cohort study was designed with a total of 39,920 PD patients and an equal number of patients without PD. The Cox proportional hazards regression models were used to assess the risk of CHD adjusted for age at entry into the cohort, tobacco use, obesity, depression, and use of medications including angiotensin converting enzyme inhibitors, beta blockers, and statins. RESULTS: Patients with PD were observed to have nearly a 2-fold increased risk for CHD (HR = 1.87, 95% CI = 1.80-1.91) after adjusting for these factors. There was some evidence of a possible trend toward increased risk in a subgroup of patients diagnosed with depression. After controlling for the aforementioned covariates and comparing these patients with those who did not have a diagnosis of depression, it was noted that patients with a comorbid diagnosis of depression were almost 3 times more likely to develop CHD (HR = 2.60, 95% CI = 2.30-3.01). CONCLUSIONS: The risk of CHD associated with a diagnosis of PD suggests the need for cardiologists and internists to monitor panic disorder to ensure a reduction in the risk of CHD.

Managing panic disorder in general practice.

BACKGROUND: Panic disorder (PD) is common in the community and contributes to significant distress and decreased quality of life for people who suffer from it. Most people with PD will present in the first instance to their general practitioner or hospital emergency department for assistance, often with a focus on somatic symptoms and concerns. OBJECTIVE: This article aims to assist the GP to manage this group of patients by providing an outline of aetiology, approaches to assessment, and common management strategies. DISCUSSION Although GPs have an important role to play in ruling out any causal organic basis for panic symptoms, the diagnosis of PD can usually be made as a positive diagnosis on the basis of careful history taking. Thorough and empathic education is a vital step in management. The prognosis for PD can be improved by lifestyle changes, specific psychological techniques, and the judicious use of pharmacotherapy.

Covariation bias and its physiological correlates in panic disorder patients.

A covariation bias, i.e., the overestimation of random contingencies between fear-relevant stimuli and aversive consequences, seems to characterize anxiety disorders. Panic patients (n=30) and healthy controls (n=25) were exposed to panic-relevant, neutral, and phobia-relevant but panic-irrelevant picture stimuli, followed randomly be aversive consequences (acoustic startle stimuli). While covariation estimates reflected objective contingencies in both groups, only panic patients revealed a more negative Contingent Negative Variation (CNV) to panic-relevant than to phobia-relevant and neutral pictures. For startle reflex, only main effects of picture category were found, indicating that valence effects of picture stimuli were not specifically distorted in panic patients. CNV presumably reflects a biased processing of disorder-relevant stimuli by panic patients, perhaps with the expectation that aversive consequences will follow these stimuli.

Dissociation, childhood trauma, and ataque de nervios among Puerto Rican psychiatric outpatients.

OBJECTIVE: This study examined the relationships of dissociation and childhood trauma with ataque de nervios. METHOD: Forty Puerto Rican psychiatric outpatients were evaluated for frequency of ataque de nervios, dissociative symptoms, exposure to trauma, and mood and anxiety psychopathology. Blind conditions were maintained across assessments. Data for 29 female patients were analyzed. RESULTS: Among these 29 patients, clinician-rated dissociative symptoms increased with frequency of ataque de nervios. Dissociative Experiences Scale scores and diagnoses of panic disorder and dissociative disorders were also associated with ataque frequency, before corrections were made for multiple comparisons. The rate of childhood trauma was uniformly high among the patients and showed no relationship to dissociative symptoms and disorder or number of ataques. CONCLUSIONS: Frequent ataques de nervios may, in part, be a marker for psychiatric disorders characterized by dissociative symptoms. Childhood trauma per se did not account for ataque status in this group of female outpatients.