Effects of antidepressant on FKBP51 mRNA expression and neuroendocrine hormones in patients with panic disorder.

OBJECTIVE: The purpose of this study was to investigate the effects of escitalopram on the peripheral expression of hypothalamic-pituitary-adrenal (HPA) axis-related genes (FKBP51, HSP90, NR3C1 and POMC) and HPA-axis hormones in patients with panic disorder (PD). METHODS: Seventy-seven patients with PD were treated with escitalopram for 12 weeks. All participants were assessed for the severity of panic symptoms using the Panic Disorder Severity Scale (PDSS). The expression of HPA-axis genes was measured using real-time quantitative fluorescent PCR, and ACTH and cortisol levels were measured using chemiluminescence at baseline and after 12 weeks of treatment. RESULTS: At baseline, patients with PD had elevated levels of ACTH and cortisol, and FKBP51 expression in comparison to healthy controls (all p < 0.01). Correlation analysis revealed that FKBP51 expression levels were significantly positively related to cortisol levels and the severity of PD (all p < 0.01). Furthermore, baseline ACTH and cortisol levels, and FKBP51 expression levels were significantly reduced after 12 weeks of treatment, and the change in the PDSS score from baseline to post-treatment was significantly and positively related to the change in cortisol (p < 0.01). CONCLUSIONS: The results suggest that PD may be associated with elevated levels of ACTH and cortisol, and FKBP51 expression, and that all three biomarkers are substantially decreased in patients who have received escitalopram treatment.

Discrimination between healthy participants and people with panic disorder based on polygenic scores for psychiatric disorders and for intermediate phenotypes using machine learning.

OBJECTIVE: Panic disorder is a modestly heritable condition. Currently, diagnosis is based only on clinical symptoms; identifying objective biomarkers and a more reliable diagnostic procedure is desirable. We investigated whether people with panic disorder can be reliably diagnosed utilizing combinations of multiple polygenic scores for psychiatric disorders and their intermediate phenotypes, compared with single polygenic score approaches, by applying specific machine learning techniques. METHODS: Polygenic scores for 48 psychiatric disorders and intermediate phenotypes based on large-scale genome-wide association studies (n = 7556-1,131,881) were calculated for people with panic disorder (n = 718) and healthy controls (n = 1717). Discrimination between people with panic disorder and healthy controls was based on the 48 polygenic scores using five methods for classification: logistic regression, neural networks, quadratic discriminant analysis, random forests and a support vector machine. Differences in discrimination accuracy (area under the curve) due to an increased number of polygenic score combinations and differences in the accuracy across five classifiers were investigated. RESULTS: All five classifiers performed relatively well for distinguishing people with panic disorder from healthy controls by increasing the number of polygenic scores. Of the 48 polygenic scores, the polygenic score for anxiety UK Biobank was the most useful for discrimination by the classifiers. In combinations of two or three polygenic scores, the polygenic score for anxiety UK Biobank was included as one of polygenic scores in all classifiers. When all 48 polygenic scores were used in combination, the greatest areas under the curve significantly differed among the five classifiers. Support vector machine and logistic regression had higher accuracy than quadratic discriminant analysis and random forests. For each classifier, the greatest area under the curve was 0.600 ± 0.030 for logistic regression (polygenic score combinations N = 14), 0.591 ± 0.039 for neural networks (N = 9), 0.603 ± 0.033 for quadratic discriminant analysis (N = 10), 0.572 ± 0.039 for random forests (N = 25) and 0.617 ± 0.041 for support vector machine (N = 11). The greatest areas under the curve at the best polygenic score combination significantly differed among the five classifiers. Random forests had the lowest accuracy among classifiers. Support vector machine had higher accuracy than neural networks. CONCLUSIONS: These findings suggest that increasing the number of polygenic score combinations up to approximately 10 effectively improved the discrimination accuracy and that support vector machine exhibited greater accuracy among classifiers. However, the discrimination accuracy for panic disorder, when based solely on polygenic score combinations, was found to be modest.

Psychiatric manifestations in moyamoya disease: more than a puff of smoke? a systematic review and a case-reports meta-analysis.

Introduction: Moyamoya disease (MMD) is a life-threatening condition characterized by stenosis of intracranial arteries. Despite the frequency and the impact of psychiatric symptoms on the long-term prognosis and quality of life of MMD patients, no systematic review on this topic exists. Methods: This systematic review and meta-analysis included 41 studies (29 being case reports), from PubMed, Scopus, Embase until 27/3/2023, on MMD patients exhibiting psychiatric symptoms. Results: Despite a fair average quality of the articles, quantitative synthesis through logistic regression was possible only for case reports, due to heterogeneity between the other studies. Psychosis, the most frequent psychiatric symptom reported in case reports, was more frequent in MMD patients with left hemisphere involvement. Neurological symptoms occurrence increased the odds of MMD diagnosis preceding psychiatric symptoms. Psychiatric symptoms are highly prevalent in MMD patients and are relatively often the only presenting symptoms. Discussion: We discuss the diagnostic, therapeutic, and prognostic implications of recognizing and characterizing specific psychiatric symptoms in MMD, outlining preliminary guidelines for targeted pharmacological and psychotherapeutic interventions. Lastly, we outline future research and clinical perspectives, striving to enhance the oft-overlooked psychiatric care for MMD patients and to ameliorate their long-term outcome. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023406303.

The Effectiveness of a Digital App for Reduction of Clinical Symptoms in Individuals With Panic Disorder: Randomized Controlled Trial.

BACKGROUND: Panic disorder is a common and important disease in clinical practice that decreases individual productivity and increases health care use. Treatments comprise medication and cognitive behavioral therapy. However, adverse medication effects and poor treatment compliance mean new therapeutic models are needed. OBJECTIVE: We hypothesized that digital therapy for panic disorder may improve panic disorder symptoms and that treatment response would be associated with brain activity changes assessed with functional near-infrared spectroscopy (fNIRS). METHODS: Individuals (n=50) with a history of panic attacks were recruited. Symptoms were assessed before and after the use of an app for panic disorder, which in this study was a smartphone-based app for treating the clinical symptoms of panic disorder, panic symptoms, depressive symptoms, and anxiety. The hemodynamics in the frontal cortex during the resting state were measured via fNIRS. The app had 4 parts: diary, education, quest, and serious games. The study trial was approved by the institutional review board of Chung-Ang University Hospital (1041078-202112-HR-349-01) and written informed consent was obtained from all participants. RESULTS: The number of participants with improved panic symptoms in the app use group (20/25, 80%) was greater than that in the control group (6/21, 29%; χ21=12.3; P=.005). During treatment, the improvement in the Panic Disorder Severity Scale (PDSS) score in the app use group was greater than that in the control group (F1,44=7.03; P=.01). In the app use group, the total PDSS score declined by 42.5% (mean score 14.3, SD 6.5 at baseline and mean score 7.2, SD 3.6 after the intervention), whereas the PDSS score declined by 14.6% in the control group (mean score 12.4, SD 5.2 at baseline and mean score 9.8, SD 7.9 after the intervention). There were no significant differences in accumulated oxygenated hemoglobin (accHbO2) at baseline between the app use and control groups. During treatment, the reduction in accHbO2 in the right ventrolateral prefrontal cortex (VLPFC; F1,44=8.22; P=.006) and the right orbitofrontal cortex (OFC; F1,44=8.88; P=.005) was greater in the app use than the control group. CONCLUSIONS: Apps for panic disorder should effectively reduce symptoms and VLPFC and OFC brain activity in patients with panic disorder. The improvement of panic disorder symptoms was positively correlated with decreased VLPFC and OFC brain activity in the resting state. TRIAL REGISTRATION: Clinical Research Information Service KCT0007280; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=21448.

Temperament Clusters in Patients With Panic Disorder in Relation to Character Maturity.

OBJECTIVE: This study explored whether temperament profiles are associated with psychological functioning and whether character maturity affects this association in patients with panic disorders (PD). METHODS: A total of 270 patients with PD were enrolled in this study. Measurements included the Temperament and Character Inventory-revised-short (TCI-RS), a self-report version of the Panic Disorder Severity Scale (PDSS-SR), Beck Depression Inventory-II (BDI-II), and Spielberger State-Trait Anxiety Inventory (STAI). Cluster analysis was used to define the patients' temperament profiles, and the differences in discrete variables among temperament clusters were calculated using a one-way analysis of variance. An analysis of covariance was conducted to control for the impact of character maturity on psychological functioning among clusters. RESULTS: We identified four temperament clusters of patients with PD. Significant differences in the PDSS-SR, BDI-II, STAI-state, and STAI-trait scores among the four clusters were detected [F(3, 262)=9.16, p<0.001; F(3, 266)=33.78, p<0.001; F(3, 266)=19.12, p<0.001; F(3, 266)=39.46, p<0.001]. However, after controlling for the effect of character maturity, the effect of cluster type was either eliminated or reduced ([STAI-state] cluster type: F(3, 262)=0.94, p>0.05; SD+CO: F(1, 262)=65.95, p<0.001, ηp2 =0.20). CONCLUSION: This study enabled a more comprehensive and integrated understanding of patients by exploring the configuration of all temperament dimensions together rather than each temperament separately. Furthermore, we revealed that depending on the degree of character maturity, the psychological functioning might differ even within the same temperament cluster. These results imply that character maturity can complement inherently vulnerable temperament expression.

Leptin, Nesfatin-1, Orexin-A, and Total Ghrelin Levels in Drug-Naive Panic Disorder.

OBJECTIVE: This study aimed to examine the changes in serum nesfatin-1, leptin, orexin-A, and total ghrelin levels of patients diagnosed with drug-naive panic disorder (PD) before and after six weeks of the treatment and to compare the findings with the healthy subjects. METHODS: The neuropeptides were measured in venous blood samples taken from 32 patients and 32 healthy subjects. The blood samples of the patients who used paroxetine 20 mg/day plus alprazolam 0.5 mg/day were retaken again after six weeks. Measurements were performed with the Enzyme-Linked Immunosorbent Assay (ELISA) method. RESULTS: Serum nesfatin-1, leptin, orexin-A and total ghrelin levels of the patient group were found to be significantly lower than the control group (p<0.001, p<0.001, p<0.001, and p<0.001, respectively). When the serum nesfatin-1, leptin, orexin-A and total ghrelin levels of the patient group were compared before and after treatment, significant differences were found in terms of orexin-A and total ghrelin levels (p=0.046, p<0.001, respectively). However, no significant differences were found in terms of nesfatin-1and leptin levels (p=0.205, p=0.988, respectively). CONCLUSION: This study reports that PD, like other anxiety disorders, may affect serum nesfatin-1, leptin, orexin-A, and total ghrelin levels, and there may be a relationship between PD treatment and the levels of these neuropeptides. The variability of this relationship among the neuropeptides examined indicates that various factors other than treatment play a role in this process.

A causal relationship between panic disorder and risk of alzheimer disease: a two-sample mendelian randomization analysis.

BACKGROUND: Observational studies have suggested a link between panic disorder (PD) and Alzheimer disease (AD). This study aimed to identify the underlying association of PD with the risk of AD using Mendelian randomization. METHODS: Genetic instrumental variables (IVs) were retrieved in the genome-wide association study between PD and AD. Then, five different models, namely inverse variance weighting (IVW), weighted median, weighted mode, MR-Egger and MR-robust adjusted profile scores (MR-RAPS), were used for MR Analysis. Finally, the heterogeneity and pleiotropy of identified IVs were verified by multiple sensitivity tests. RESULTS: The Cochran's Q test based on MR Egger and IVW showed that no evidence of heterogeneity was found in the effects of instrumental variables, so a fixed-effect model was used. IVW analysis (OR 1.000479, 95% CI [1.000147056, 1.000811539], p = 0.005) indicated that PD was associated with an increased risk of AD, and a causal association existed between them. Meanwhile, weighted median (OR 1.000513373, 95% CI [1.000052145, 1.000974814], p = 0.029) and MR-RAPS (OR 1.000510118, 95% CI [1.000148046, 1.00087232], p = 0.006) also showed the similar findings. In addition, extensive sensitivity analyses confirmed the robustness and accuracy of these results. CONCLUSION: This investigation provides evidence of a potential causal relationship between PD and the increased risk of AD. Based on our MR results, when diagnosing and treating patients with PD, clinicians should pay more attention to their AD-related symptoms to choose therapeutic measures or minimize comorbidities. Furthermore, the development of drugs that improve both PD and AD may better treat patients with these comorbidities.

Effect of Integrated Yoga as an Adjuvant to Standard Care for Panic Disorder: A Randomized Control Trial Study.

BACKGROUND: Individuals wrestling with panic disorder (PD) know all too well its debilitating impact. Sudden, intense fear episodes disrupt lives and erode well-being. Fortunately, integrating complementary therapies like yoga with standard treatment offers a glimmer of hope for improved outcomes. Yoga's unique blend of physical postures (asanas), breathing exercises (pranayama), and meditative practices holds promise for mitigating anxiety and fostering a sense of inner peace, potentially making it a valuable tool in the fight against panic disorder. METHODS AND MATERIALS: This study investigated the effect of yoga as an adjuvant to standard care for panic disorder. Sixty-four panic disorder patients of both genders previously diagnosed with panic disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria were randomly assigned to the yoga group (n = 32) and the control group. The yoga group participated in integrated yoga sessions lasting 60 minutes, five days a week, for 12 weeks. Both groups received standard care. Pre- and post-intervention data were collected for HAM-A and WHOQOL-BREF. RESULTS: The yoga group exhibited a significant reduction in HAM-A scores (Pre: 49.13 ± 4.55, Post: 13.53 ± 5.54, p < 0.001) with a substantial effect size of 7.02. Quality of life significantly improved across all domains (physical, psychological, social, and environmental) in the yoga group (p < 0.001), demonstrating effect sizes ranging from 4.11 to 4.57. Control group participants also experienced improvements, though less pronounced. Between-group comparisons revealed significant differences in anxiety reduction (p = 0.042) and quality of life enhancement (p < 0.001), favouring the yoga group. CONCLUSION: The results suggest that yoga can be a valuable complementary or alternative approach to traditional treatments for anxiety disorders.

Impaired implicit emotion regulation in patients with panic disorder: An event-related potential study on affect labeling.

BACKGROUND: Panic disorder (PD) involves emotion dysregulation, but its underlying mechanisms remain poorly understood. Previous research suggests that implicit emotion regulation may play a central role in PD-related emotion dysregulation and symptom maintenance. However, there is a lack of studies exploring the neural mechanisms of implicit emotion regulation in PD using neurophysiological indicators. AIM: To study the neural mechanisms of implicit emotion regulation in PD with event-related potentials (ERP). METHODS: A total of 25 PD patients and 20 healthy controls (HC) underwent clinical eva-luations. The study utilized a case-control design with random sampling, selecting participants for the case group from March to December 2018. Participants performed an affect labeling task, using affect labeling as the experimental condition and gender labeling as the control condition. ERP and behavioral data were recorded to compare the late positive potential (LPP) within and between the groups. RESULTS: Both PD and HC groups showed longer reaction times and decreased accuracy under the affect labeling. In the HC group, late LPP amplitudes exhibited a dynamic pattern of initial increase followed by decrease. Importantly, a significant group × condition interaction effect was observed. Simple effect analysis revealed a reduction in the differences of late LPP amplitudes between the affect labeling and gender labeling conditions in the PD group compared to the HC group. Furthermore, among PD patients under the affect labeling, the late LPP was negatively correlated with disease severity, symptom frequency, and intensity. CONCLUSION: PD patients demonstrate abnormalities in implicit emotion regulation, hampering their ability to mobilize cognitive resources for downregulating negative emotions. The late LPP amplitude in response to affect labeling may serve as a potentially valuable clinical indicator of PD severity.

[Treatment resistance in anxiety disorders-Definition and treatment options]. / Therapieresistenz bei Angsterkrankungen ­ Definition und Behandlungsoptionen.

Treatment resistance in anxiety disorders represents a clinical challenge, contributes to the chronicity of the diseases as well as sequential comorbidities, and is associated with a significant individual and socioeconomic burden. This narrative review presents the operational definition of treatment resistance in anxiety disorders according to international consensus criteria (< 50% reduction in the Hamilton Anxiety Scale, HAM­A, score or < 50% reduction in the Beck Anxiety Inventory, BAI, score or a clinical global impression-improvement, CGI­I, score > 2). At least two unsuccessful guideline-based treatment attempts with pharmacological monotherapy or at least one unsuccessful treatment attempt with adequately delivered cognitive behavioral therapy are required. Pharmacotherapeutically, after excluding pseudo-resistance, switching the medication within one class or to another class and augmentation strategies with other antidepressants (mirtazapine, agomelatine), antipsychotics (quetiapine) or anticonvulsants (valproate) are recommended. Psychotherapeutically, third-wave therapies, psychodynamic therapy, systemic therapy and physical exercise can be considered for therapy resistance. In cases of no response to psychotherapy or pharmacotherapy, the respective other form of therapy or a combination of both should be offered. Compounds targeting the glutamatergic and endocannabinoid systems as well as neuropeptides are being tested as potential innovative pharmaceuticals for treatment-resistant anxiety disorders. There is an urgent need for further research to identify predictive markers and mechanisms as well as to develop innovative pharmacological and psychotherapeutic interventions for treatment-resistant anxiety disorders.

Unraveling the Complexity: Exploring the Intersection of Panic Disorder, Dissociation, and Complex Post-Traumatic Stress Disorder.

BACKGROUND: Patients with panic disorder (PD) may experience increased vulnerability to dissociative and anxious phenomena in the presence of repeated traumatic events, and these may be risk factors for the development of complex post-traumatic stress disorder (cPTSD). The present study aims to find out whether the presence of cPTSD exacerbates anxiety symptoms in patients suffering from panic disorder and whether this is specifically associated with the occurrence of dissociative symptoms. METHODS: One-hundred-and-seventy-three patients diagnosed with PD were recruited and divided into two groups based on the presence (or absence) of cPTSD using the International Trauma Questionnaire (ITQ) scale. Dissociative and anxious symptoms were assessed using the Cambridge Depersonalization Scale (CDS) and Hamilton Anxiety Scale (HAM-A), respectively. RESULTS: Significant differences in re-experienced PTSD (p < 0.001), PTSD avoidance (p < 0.001), PTSD hyperarousal (p < 0.001), and DSO dysregulation (p < 0.001) were found between the cPTSD-positive and cPTSD-negative groups. A statistically significant association between the presence of cPTSD and total scores on the HAM-A (p < 0.001) and CDS (p < 0.001) scales was found using regression analysis. CONCLUSIONS: This study highlights the potential link between dissociative symptoms and a more severe clinical course of anxiety-related conditions in patients with PD. Early intervention programs and prevention strategies are needed.

Exploring Brainstem Structural Abnormalities: Potential Biomarkers for Panic Disorder.

Panic disorder (PD), characterized by recurrent and intense panic attacks, presents a complex interplay between psychological and neurobiological factors. Although the amygdala and hippocampus have been studied extensively in the context of PD, the brainstem's involvement remains relatively underexplored. This study aims to address this gap by examining structural abnormalities within specific brainstem regions, including the medulla, pons, and midbrain. The study sample population comprised twenty-one adult patients diagnosed with PD and an age-gender-education-matched control group. Utilizing rigorous inclusion and exclusion criteria, confounding factors related to comorbid psychiatric conditions and brain structure abnormalities were minimized. Our findings revealed a significant reduction in medulla volume among PD patients, a finding that persisted even after correcting for individual differences in total intracranial volume. The medulla's role in cardiovascular regulation and autonomic function, coupled with its involvement in fear responses, underscores its potential significance in the pathophysiology of PD. This study elucidates the medulla's structural abnormalities as a potential biomarker for PD. Understanding the role of the brainstem in PD could pave the way for more targeted and effective interventions for this condition.

Terapia Cognitivo Conductual presencial y remota para adultos con pánico en Servicios de Emergencias: tres estudios de caso / Face-to-face and remote Cognitive Behavioral Therapy for adults with panic in Emergency Services: study of three cases

Most patients with panic attacks or panic disorder who seek emergency department care go unnoticed and do not receive appropriate treatment. Although first-line psychological treatments exist for these patients, they may be insensitive and inaccessible to their characteristics. The aim of this study was to describe three different brief protocols based on Cognitive Behavioral Therapy that were adapted for face-to-face or videoconferencing application for patients with panic attacks or panic disorder seeking care in emergency department. Three cases of adult patients, two diagnosed with panic disorder and one with panic attacks, are presented to show the implementation and outcomes of the protocols on diagnostic severity, anxiety sensitivity, quality of life, health services utilization, and patient satisfaction with the protocols. As well as the use of a panic screening diagram designed for the initial evaluation of these patients. After one to seven sessions, a decrease in panic disorder severity or frequency of panic attacks, and anxiety sensitivity was observed. Quality of life improved, patients stopped using emergency department and showed satisfaction with the intervention they received. Brief interventions based on Cognitive Behavioral Therapy, both face-to-face and remote, can be implemented in emergency department to overcome some barriers to mental health access and fit the diverse care possibilities of panic patients. (AU)

Feasibility of Guided Internet-Based Cognitive Behavioral Therapy for Panic Disorder and Social Anxiety Disorder in Japan: Pilot Single-Arm Trial.

BACKGROUND: Cognitive behavioral therapy (CBT) is effective in treating anxiety disorders. Accessibility to CBT has been limited in Japan due to the shortage of therapists. While an open-source e-learning system can be used to create a simple internet-based cognitive behavioral therapy (ICBT) program, the safety and outpatient acceptance of this treatment approach have not been explored in Japan. OBJECTIVE: The aim of this study was to investigate whether outpatients with anxiety disorders could accept and successfully complete the ICBT program with guidance by CBT therapists when implementing therapeutic modules and CBT tasks. Due to being in the initial phase of a novel treatment in Japan, this study was intended for verification with a small sample size. METHODS: In total, 6 adults, including 4 male participants and 2 female participants, were enrolled in a single-arm trial. The intervention involved guided ICBT comprising 12 sessions, including CBT text, comprehension confirmation tests, and explanatory videos about cognitive behavioral models, accessible through a website. The therapist guided the participants in accessing the ICBT program and answering their questions using a chat tool. The primary outcome was anxiety severity assessed using the State-Trait Anxiety Inventory-Trait. Secondary outcomes included the Panic Disorder Severity Scale, Liebowitz Social Anxiety Scale (LSAS), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Working Alliance Inventory-Short Form (WAI-SF). Statistical analyses were performed using paired 2-tailed t tests to assess the changes in clinical symptoms. The total WAI-SF score at the final session was used to evaluate the therapeutic alliance. For statistical analyses, mean changes for total State-Trait Anxiety Inventory-Trait, BAI, Panic Disorder Severity Scale, LSAS, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scores were analyzed using the paired 2-tailed t test. The 2-sided significance level for hypothesis testing was set at 5%, and 2-sided 95% CIs were calculated. RESULTS: Most participants diligently engaged with the ICBT program. No adverse events were reported. The mean total scores for the primary outcome decreased by 11.0 (SD 9.6) points (95% CI -22.2 to 0.20; Hedges g=0.95), but it was not statistically significant. The mean total scores for the secondary outcomes that assess clinical symptoms decreased, with a significant reduction observed in the BAI of 15.7 (SD 12.1) points (95% CI -28.4 to -3.0; P=.03; Hedges g=1.24). The mean total scores for PDSS and LSAS decreased significantly, by 12.0 (SD 4.24) points (95% CI -50.1 to 26.1; P=.16; Hedges g=1.79) and 32.4 (SD 11.1) points (95% CI -59.7 to -4.3; P=.04; Hedges g=1.38), respectively. Of the participants, 67% (n=4) showed treatment response, and 50% (n=3) achieved remission after the intervention. The therapeutic alliance, measured using the WAI-SF, was moderate. CONCLUSIONS: Guided ICBT may be feasible for the treatment of outpatients with panic disorder and social anxiety disorder in Japan. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry UMIN0000038118; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043439.

Investigating the Interplay Between Mental Health Conditions and Social Connectedness on Suicide Risk: Findings from a Clinical Sample of Adolescents.

This study examined whether school and community connectedness buffer the relationships between mental health conditions and suicide risk in a clinical sample of adolescents with histories of substance use disorders. Data from 294 adolescents were examined, with approximately 58% reporting lifetime suicidal ideation and/or prior attempts. Multinomial logistic regression was used to examine main and interaction effects on a three-category measure of suicide risk. Depression severity and panic disorder were associated with elevated suicidal ideation risk, whereas disordered eating was associated with elevated risk of attempts. Higher school-based positive peer interactions, school safety, and neighborhood social connection levels were associated with reduced suicide attempt risk. Moderation analyses revealed that high neighborhood social connection levels may partially mitigate the elevated likelihood of attempting suicide associated with disordered eating. Findings suggest clinical populations of adolescents may benefit from approaches aiming to promote social connectedness, further supporting a comprehensive approach to suicide prevention.

Panic disorder in epilepsy.

A 51-year-old woman showed structural epilepsy following an atypical, nontraumatic intracranial hemorrhage in the right frontal area. Despite successful seizure control with lamotrigine, she developed severe morning anxiety and panic attacks, leading to agoraphobia, social withdrawal, and psychogenic nonepileptic seizures. Neuropsychiatric and psychological assessments confirmed an anxiety disorder with no significant symptoms of depression. The patient received various psychopharmacological treatments with limited success. This case report illustrates that managing panic disorder in patients with structural epilepsy requires a comprehensive treatment approach that includes pharmacotherapy and psychotherapy. Differential diagnosis and accurate treatment are crucial because of the symptom overlap between panic attacks and peri-ictal fear. Screenings instruments such as the Panic and Agoraphobia Scale (PAS) can aid in assessing anxiety-related symptoms. First-line pharmacotherapy with selective serotonin reuptake inhibitors, especially sertraline, or venlafaxine can effectively reduce panic attacks and can be recommended in patients with epilepsy. Psychotherapy, particularly cognitive-behavioral therapy, is the treatment of choice. Referral to a psychiatrist is indicated when symptoms are severe or refractory to treatment.

Which clinical factors delay proper treatment in panic disorder? A cross-sectional multicentric study.

AIM: The aim of the present study was to identify clinical and socio-demographic factors associated with duration of untreated illness (DUI) in patients affected by panic disorder (PD). METHODS: Data were collected from patients' medical records (N = 157) of two mental health services respectively located in Milan and in Monza (Italy). Correlation analyses and analysis of variance (ANOVAs) were run to analyse the relation between DUI and quantitative/qualitative variables respectively. Statistically significant variables in uni- variate analyses were then inserted in a linear multivariable regression model (backward procedure). RESULTS: Mean DUI was 27.33 (±50.56) months. Patients with an earlier age at onset (r = -0.270; p < .01), a longer duration of illness (r = 0.483; p < .01) and who received a lifetime psychotherapy (F = 6.86; p = .01) had a longer DUI. The final global model showed that a longer DUI was associated with pre-onset poly-substance misuse (p = .05) and a longer duration of illness (p < .01). CONCLUSION: The results of our study showed that a longer DUI was predicted by clinical factors such as the presence of a pre-onset poly-substance use disorder and that delayed proper treatment can lead to a chronicization of PD, as indicated by a longer duration of illness. Further studies are needed to in-depth investigate the role of DUI in influencing the course and outcome of anxiety disorders, including PD.

Clinical and cognitive insight in panic disorder: phenomenology and treatment effects in internet cognitive behavior therapy.

Clinical observations suggest that individuals with panic disorder (PD) vary in their beliefs about the causes of their panic attacks. Some attribute these attacks to psychological factors, while others to physiological or medical factors. These beliefs also extend to whether individuals perceive panic attacks as dangerous. In other areas of psychiatric nosology, these phenomena are commonly called clinical insight (recognition of disorder and the need for treatment) and cognitive insight (the ability to reflect on one's beliefs). Despite its importance, limited research exists on insight in PD and its relation to symptoms and treatment outcomes. This study examines clinical and cognitive insight in 83 patients with PD who received internet-based cognitive behavioral therapy, investigating their relationship with symptoms, treatment outcomes, and changes in insight. We assessed patients using interview and self-report measures of insight and symptoms. Clinical and cognitive insight were correlated and both constructs improved significantly during treatment. Good clinical insight pretreatment was positively correlated with more severe pretreatment symptoms. Pretreatment clinical and cognitive insight were not correlated with symptom change or attrition. Greater change in clinical and cognitive insight was related to greater change in symptoms. The findings highlight the significance of clinical and cognitive insight in PD, and the importance of distinguishing between them. This suggests the need to develop interventions according to patients' level of insight, particularly focusing on those lacking insight. Further research is essential to advance our understanding of the relationship between insight and the phenomenology and treatment of PD.

COVID-19 anxiety and its relation to anxiety-related disorder symptoms and mechanisms.

The COVID-19 pandemic had a significant impact on the mental health of individuals, particularly in the area of anxiety-related disorders. Anxiety regarding COVID-19 has been associated with health anxiety, panic disorder, and obsessive-compulsive disorder symptoms. Additionally, COVID-19 anxiety has been associated with anxiety sensitivity, disgust, maladaptive metacognitions, and intolerance of uncertainty. While researchers have established that anxiety disorders and anxiety-related mechanisms were associated with COVID-19 anxiety, which specific anxiety-related symptoms and mechanisms are primarily associated with COVID-19 anxiety needs to be more extensively explored. The current study sought to further this area by examining which particular anxiety-related disorder symptoms and mechanisms were uniquely associated with COVID-19 anxiety. A non-clinical sample of 593 Canadian undergraduate participants (Mage = 21.13 years; 67.7 % female) completed this cross-sectional study between September 2020 and February 2021. Participants completed online questionaries assessing anxiety-related disorder symptoms and mechanisms in addition to multiple scales of COVID-19 anxiety. When examining symptoms, health anxiety (prs = 0.17-0.29) and obsessive-compulsive disorder (prs = 0.16-0.35) symptoms had the strongest unique associations with COVID-19 anxiety. Among the anxiety-related mechanisms, disgust sensitivity (prs = 0.14-0.16) and health anxiety-specific intolerance of uncertainty (prs = 0.12-0.30) had the strongest unique associations with COVID-19 anxiety. Individuals experiencing these disorders and anxiety-related mechanisms may be at a heightened vulnerability to experiencing heightened anxiety during future pandemics. Mental health professionals should discuss COVID-19 anxiety with individuals experiencing health anxiety or obsessive-compulsive disorder symptoms. Lastly, the study highlights the significance of considering a variety of specific anxiety-related disorder symptoms and mechanisms when working to understand pandemic anxiety.