Low-dose neuroleptic regimens in the treatment of borderline patients.

The use of pharmacologic agents in treating patients described as borderline generally has been accorded an insignificant, or at best, minor, role. We discuss this observation and review the literature that has dealt with this aspect of treatment. Diagnostic criteria are presented that appear to define a specific population of borderline patients who have been observed to be responsive to low doses of neuroleptic drugs. Five case histories of patients with conditions diagnosed and treated in this manner are presented, followed by a discussion of the implications of this approach in terms of clarifying the nosologic issues that have arisen around the "borderline" concept.

Atypical or nonanginal chest pain. Panic disorder or coronary artery disease?

Of 195 patients with atypical or nonanginal chest pain presenting in a cardiology clinic, 104 consented to be evaluated for anxiety disorders using a structured psychiatric interview. Thirty patients had histories of coronary artery disease (CAD). Fifty-nine patients in the sample (16 of those with CAD and 43 of those without CAD) fit diagnostic criteria for panic disorder (PD). Those without CAD and with PD were primarily women (mean age, 43 years) with predominantly nonanginal chest pain. Those patients with both CAD and PD were primarily men (mean age, 54 years) with predominantly atypical angina. Since PD has been shown to be readily responsive to pharmacologic intervention, this diagnosis should be considered in patients with atypical or nonanginal chest pain.

The movement toward integrating the psychotherapies: an overview.

There is a growing tendency among psychotherapists to ignore the ideological barriers dividing schools of psychotherapy and to define what is common among them and what is useful in each of them. After a brief introduction the authors provide a short glossary of terms often associated with psychotherapy integration. They then characterize integrative-eclectic therapists, describe the forces fostering their emergence, and outline recurrent themes of the movement and points of contention within it. The authors hope to encourage clinical thinking about the less ideological approaches to psychotherapy and to advance the integrative movement, which is likely to influence psychotherapeutic practice for decades to come.

The relation between alcohol problems and the anxiety disorders.

The idea that people suffering from anxiety have a proclivity to consume alcohol to relieve their symptoms is supported by reports showing high comorbidity rates of alcohol and anxiety problems. The authors reviewed relevant epidemiologic surveys, family studies, and field studies and conclude that the relationship between alcohol problems and anxiety appears to be variable among the anxiety disorders. In agoraphobia and social phobia, alcohol problems appear more likely to follow from attempts at self-medication of anxiety symptoms, but panic disorder and generalized anxiety disorder may be more likely to follow from pathological alcohol consumption. Simple phobia does not appear to be related to alcohol problems in any meaningful way.

Nonfearful panic disorder in neurology patients validated by lactate challenge.

OBJECTIVE: Nonfearful panic disorder meets the DSM-III-R criteria for panic disorder but is not associated with subjective fear and anxiety. The authors determined its prevalence in a group of neurology patients and assessed its diagnostic validity as a panic disorder subtype by evaluating the response of the patients with nonfearful panic disorder to sodium lactate and antipanic pharmacotherapy. METHOD: The subjects were all neurology patients referred over 1 year to a university hospital's psychiatric consultation service because of negative medical workups for their symptoms (N = 48). Patients who met the DSM-III-R criteria for panic disorder but did not report subjective anxiety or fear during panic episodes were diagnosed as having nonfearful panic disorder. Afterward, each of those patients received a sodium lactate infusion and, 5 hours later, a sodium chloride infusion. They were then treated with antipanic medication and followed for at least 6 months. RESULTS: Of the 48 neurology patients referred for psychiatric evaluation, 11 (23%) met the criteria for panic disorder, and all 11 met the criteria for nonfearful panic disorder. All 11 responded positively to lactate but not to placebo, and they each experienced an at least 75% reduction in symptoms during the 6-month follow-up period. Detailed case reports of three of these patients are presented. CONCLUSIONS: These findings support the construct and predictive diagnostic validity of nonfearful panic disorder as a subtype of panic disorder and suggest that a lack of attention to this group leads to both the underestimation of the prevalence of panic disorder and to the withholding of potentially successful treatments for this group.

Panic disorder history in the families of patients with angiographically normal coronary arteries.

OBJECTIVE: The authors evaluated the diagnostic validity of an interview-based panic disorder diagnosis in cardiology chest pain patients with angiographically normal coronary arteries. METHOD: Patient probands with normal coronary arteries (N = 65) were first contracted immediately after their normal angiogram and were given a structured diagnostic interview. On the basis of the results of the interview, probands were grouped as having panic disorder (N = 19), panic attacks that did not meet frequency criteria for panic disorder (N = 17), or no panic (N = 29). At a later time, patient probands were recontacted and given a structured family history interview that inquired about psychopathology in their first-degree biological relatives (N = 544). RESULTS: As predicted, panic disorder was significantly more prevalent among the first-degree relatives of probands with normal coronary arteries diagnosed with panic disorder or panic attacks than among the family members of probands with normal coronary arteries without panic (17.4% versus 15.7% versus 4.0%). Family members of probands with panic attacks were significantly more likely to be diagnosed with major depression than were the family members of probands with no panic; however, differences did not reach significance for family members of the panic disorder proband group. Groups did not differ significantly in familial alcoholism. CONCLUSIONS: These data support the construct validity of an interview-based panic disorder diagnosis among patients with chest pain and normal coronary arteries and suggest that these patients could benefit from treatment for panic disorder.

Panic disorder in patients with angiographically normal coronary arteries.

Several lines of investigation strongly support the notion that panic disorder afflicts at least one third of patients with angiographically normal coronary arteries and unexplained chest pain. Panic disorder is a common problem, affecting 1-2% of the U.S. population. Current research suggests an etiology that is both psychophysiologic and cognitive. The locus ceruleus and cortico-releasing factor are implicated in the biological circuit associated with panic attacks, while psychological research indicates that catastrophic thinking, phobic responses to somatic sensations, and repressed anger, grief, and traumatic events play a part in triggering attacks. Treatment consists of pharmacologic interventions, including antidepressants and benzodiazepines, as well as psychotherapeutic work focusing on catastrophic thinking and repressed anger, grief responses, and other traumatic experiences.

Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition.

PURPOSE: To establish the prevalence of panic disorder in emergency department (ED) chest pain patients; compare psychological distress and recent suicidal ideation in panic and non-panic disorder patients; assess psychiatric and cardiac comorbidity; and examine physician recognition of this disorder. DESIGN: Cross-sectional survey (for psychiatric data). Prospective evaluation of patient discharge diagnoses and physician recognition of panic disorder. SETTING: The ambulatory ED of a major teaching hospital specializing in cardiac care located in Montreal, Canada. SUBJECTS: Four hundred and forty-one consenting, consecutive patients consulting the ED with a chief complaint of chest pain. PRIMARY OUTCOME MEASURE: Psychiatric diagnoses (AXIS I). Psychological and pain test scores, discharge diagnoses, and cardiac history. RESULTS: Approximately 25% (108/441) of chest pain patients met DSM-III-R criteria for panic disorder. Panic disorder patients displayed significantly higher panic-agoraphobia, anxiety, depression, and pain scores than non-panic disorder patients (P < 0.01). Twenty-five percent of panic disorder patients had thoughts of killing themselves in the week preceding their ED visit compared with 5% of the patients without this disorder (P = 0.0001) even when controlling for co-existing major depression. Fifty-seven percent (62/108) panic disorder patients also met criteria for one or more current AXIS I disorder. Although 44% (47/108) of the panic disorder patients had a prior documented history of coronary artery disease (CAD), 80% had atypical or nonanginal chest pain and 75% were discharged with a "noncardiac pain" diagnosis. Ninety-eight percent of the panic patients were not recognized by attending ED cardiologists. CONCLUSIONS: Panic disorder is a significantly distressful condition highly prevalent in ED chest pain patients that is rarely recognized by physicians. Nonrecognition may lead to mismanagement of a significant group of distressed patients with or without coronary artery disease.

Chest pain: relationship of psychiatric illness to coronary arteriographic results.

Seventy-four patients with chest pain and no prior history of organic heart disease were interviewed with a structured psychiatric interview immediately after coronary arteriography. The majority of patients with both negative and positive coronary angiographies had undergone previous exercise tolerance tests, but the patients with angiographic coronary artery disease were significantly more likely to have had positive results on a treadmill test. Patients with chest pain and negative coronary arteriograms were significantly younger; more likely to be female; more apt to have a higher number of autonomic symptoms (tachycardia, dyspnea, dizziness, and paresthesias) associated with chest pain, and more likely to describe atypical chest pain. Patients with chest pain and normal coronary arteriographic results also had significantly higher psychologic scores on indices of anxiety and depression and were significantly more likely to meet criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, for panic disorder (43 percent versus 6.5 percent), major depression (36 percent versus 4 percent), and two or more phobias (36 percent versus 15 percent) than were patients with chest pain and a coronary arteriography study demonstrating coronary artery stenosis.

Panic disorder in patients with chest pain and angiographically normal coronary arteries.

Although patients with angiographically normal or near normal coronary arteries are at low risk for cardiac disease, several follow-up studies have shown that many continue to report recurrent chest pain associated with social and work dysfunction. Three diagnostic entities have been proposed to explain the morbidity of this group: microvascular angina, esophageal motility disorders and panic disorder. The purpose of this study was to test the hypothesis that panic disorder is found frequently in patients with chest pain who have normal epicardial vessels. Ninety-four subjects with angiographically normal coronary arteries were interviewed according to a structured psychiatric protocol within 24 hours of their catheterizations. Thirty-two (34%) fit Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria for current panic disorder. Because panic disorder can be effectively treated, physicians should consider this diagnosis in this group of patients. Current research findings suggest that panic disorder, microvascular angina and esophageal disorders may each form the basis for chest pain in approximately 25% of these patients. Miscellaneous problems account for the other 25%.

The pharmacotherapy-psychotherapy triangle: psychiatrist, nonmedical psychotherapist, and patient.

Members of the Washington State Psychiatric Association (N = 387) were sent a questionnaire asking about their experience with providing adjunctive medicinal treatment to patients in psychotherapy with someone else. Of the 202 respondents, 63% acknowledged such "therapeutic triangles." Younger psychiatrists, psychiatrists working in clinic and/or public settings, and non-psychoanalytic psychiatrists were more likely to participate in such arrangements. It is estimated that between 7200 and 21,000 U.S. psychiatrists participate in such arrangements, with 72,000-210,000 patients seen each month. More extensive study of all aspects of this phenomenon is urged.

Relationship of past depressive episodes to symptom severity and treatment response in panic disorder with agoraphobia.

BACKGROUND: Many investigators have reported that panic disorder (PD) patients with comorbid major depression (MD) have more severe symptoms and a poorer response to treatment than patients with PD alone. It is not known if this is due to a distinct and more serious underlying disorder in these patients or simply a result of the simultaneous presence of the two disorders. METHOD: Nondepressed patients presenting for treatment of panic disorder with agoraphobia (PDA) were studied before treatment (N = 180) and after 4 weeks of treatment with adinazolam sustained release (N = 89) or placebo (N = 91). Twenty-nine percent (N = 53) of the patients had a past history of MD. Symptom severity and treatment outcome were compared in patients with primary, secondary, single, recurrent, or no past MD. RESULTS: There were no consistent differences in symptom severity or treatment outcome in patients with a past history of primary, secondary, or single episode MD compared with patients with no history of MD. However, a small number of patients with history of recurrent MD exhibited consistently greater symptom severity and poorer response to treatment than patients with no history of MD. CONCLUSION: The greater severity and worse outcome of comorbid PD and MD observed in earlier studies are more likely due to the simultaneous presence of the two disorders than to a more serious and enduring underlying disorder. However, our results suggest that recurrent MD may indicate a more serious condition in patients with PDA. This possibility warrants further study.

Panic disorder in cardiology patients: a review of the Missouri Panic/Cardiology Project.

This paper reviews current evidence from several cardiology populations that suggests that panic disorder is prevalent and underdiagnosed. Cardiology patients with atypical angina, and no heart disease have a high likelihood of having panic disorder, as suggested by studies of two separate cardiology populations. That they resemble psychiatric populations with panic is suggested by their positive response to alprazolam. A panic disorder subtype, called non-fear panic disorder also appeared in about one-third of these cardiology panic patients. These patients have most of the panic symptoms but do not report fear during their episodes.

Generalized anxiety disorder patients seek evaluation for cardiological symptoms at the same frequency as patients with panic disorder.

Although panic disorder (PD) and generalized anxiety disorder (GAD) have similar somatic symptoms, panic attacks with chest pain and/or palpitations may seem more likely to be mistaken for heart attacks because of their acute onset. One would therefore expect that PD patients are more likely than GAD patients to seek cardiological consultations. In a survey of 146 PD and 154 GAD patients entering a multi-site drug trial, we found virtually identical rates of such consults. Approximately 50% of each patient group sought medical evaluation for cardiac symptoms. Furthermore, 40% of each group had standard treadmill evaluations and 33% reported having an echocardiogram. This study suggests that future epidemiological studies in cardiology populations should include probes for generalized anxiety disorder.

Mitral valve prolapse, panic disorder, and chest pain.

Mitral valve prolapse is a common cardiac disorder that can readily be diagnosed by characteristic auscultatory and echocardiographic criteria. Although many diseases have been associated with mitral valve prolapse, most affected individuals have the primary form of the disorder. Mitral valve prolapse is an inherited condition commonly associated with myxomatous degeneration of the mitral valve and its support structures. Complications of mitral valve prolapse, including cardiac arrhythmias, sudden death, infective endocarditis, severe mitral regurgitation (with or without chordae tendineae rupture), and cerebral ischemic events, occur infrequently considering the wide prevalence of the disorder. Panic disorder is a specific type of anxiety disorder characterized by at least three panic attacks within a 3-week period or one panic attack followed by fear of subsequent panic attacks for at least 1 month. It too is a common condition with a prevalence and age and gender distribution similar to that of mitral valve prolapse. Panic disorder and mitral valve prolapse share many nonspecific symptoms, including chest pain or discomfort, palpitations, dyspnea, effort intolerance, and pre-syncope. Chest pain is the symptom in both conditions that most commonly brings the patient to medical attention. The clinical description of chest pain in patients with mitral valve prolapse is highly variable, possibly reflecting multiple etiologies. Chest pain in panic disorder is usually characterized as atypical angina pectoris and as such bears resemblance to the chest pain commonly described by patients with mitral valve prolapse. Multiple investigative attempts to elucidate the mechanism of chest pain in both conditions have failed to identify a unifying cause. Review of the literature leaves little doubt that mitral valve prolapse and panic disorder frequently co-occur. Given the similarities in their symptomatology, a high rate of co-occurrence is, in fact, entirely predictable. There is, however, no convincing evidence of a cause-effect relationship between the two disorders, nor has a single pathophysiologic or biochemical mechanism been identified that unites these two common conditions. Until specific biologic markers for these disorders are identified, it may be impossible to do so. The lack of a proven cause-and-effect relationship between mitral valve prolapse and panic disorder and the absence of a unifying mechanism do not diminish the clinical significance of the high rate of co-occurrence between the two conditions. Primary care physicians and cardiologists frequently encounter patients with mitral valve prolapse and nonspecific symptoms with no discernible objective cause who fail to respond to beta-blockade. Panic disorder should be considered as a possible explanation for symptoms in such patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Validating studies for panic disorder in patients with angiographically normal coronary arteries.

This article describes validating studies for diagnosing panic disorder in some patients with angiographically normal coronary arteries (NCA) and chest pain. Psychiatric interviews of 94 such patients showed that 34% met the diagnostic criteria for panic disorder. Further studies showed that NCA patients with panic disorder were more disabled at 3.5-year follow-up, had more relatives with panic disorder, were more likely to suffer from major depression, and were more likely to respond to 35% CO2 challenge with panic symptoms. Because panic disorder is highly disabling but responds well to psychological and pharmacologic treatments, screening NCA patients in the cardiology population for this disorder is recommended.

Panic disorder, cardiology patients, and atypical chest pain.

Although patients with angiographically normal coronary arteries have low mortality, several studies have indicated that their social and work morbidity is high. Panic disorder appears to be a major contributor to the continuing chest pain in this population. There are also many chest pain patients appearing in cardiology clinics who also do not have heart disease but who are not given the opportunity to be evaluated for psychiatric disorders. Among those presenting with atypical or nonanginal chest pain, panic disorder represents a likely etiologic consideration. The fact that such patients do exist in cardiology populations is further substantiated by an open-label trial of alprazolam which demonstrated a positive effect in patients selected from those with atypical chest pain and no heart disease found to fit panic disorder criteria. These findings strongly support the increasing affiliation between cardiology and psychiatry and reinforce the belief that many problems of the heart may be problems of the mind/brain.

Major depression in cardiology chest pain patients without coronary artery disease and with panic disorder.

104 patients in a cardiology clinic with atypical or non-anginal chest pain were studied through a structured clinical interview. 43 without coronary artery disease fit diagnostic criteria for panic disorder. 19 (44%) of this group reported a lifetime prevalence of major depression, nine (21%) current and ten (23%) past only. Nine reported that their major depressive episodes had preceded the onset of their panic disorder. On many self-report questionnaire scales the group with a lifetime history of major depression (n = 19) differed significantly from the group with no lifetime history of major depression (n = 24). These differences, however, could be attributed primarily to the group with current major depression. There appears to be a subgroup of panic disorder patients who have current major depression who are more symptomatic than those with panic disorder and past major depression and panic disorder alone. These findings also suggest that the association between panic disorder and depression may remain high outside of psychiatric settings.

Cardiovascular death from panic disorder and panic-like anxiety: a critical review of the literature.

Several symptoms of panic disorder mimic those of cardiovascular diseases and patients with this disorder frequently consult physicians with the fear of dying from a heart attack. The salient question is: Can the patient with panic disorder die from the cardiovascular consequences of his/her panic attacks? We critically review the six studies that have examined the association between panic disorder (or panic-like anxiety) and cardiovascular mortality or complications associated with the cardiovascular system. We then briefly review the evidence by which mechanisms panic may be linked to cardiovascular mortality and conclude with proposed guidelines for patient management.

Is panic disorder associated with coronary artery disease? A critical review of the literature.

OBJECTIVE: To critically review existing literature examining the relationship between panic disorder (PD) and coronary artery disease (CAD). We specifically sought answers to the following questions: (1) What is the prevalence of PD in CAD patients? (2) What is the directionality of the relationship between PD and CAD? (3) What mechanisms may mediate the link between PD and CAD? METHODS: Medline and Psychlit searches were conducted using the following search titles: "panic disorder and coronary artery disease", "panic disorder and coronary heart disease", and "panic disorder and cardiovascular disease" for the years 1980-1998. The above search was also repeated replacing "panic disorder" with "panic attacks" for the same period. RESULTS: The prevalence of PD in both cardiology out-patients and patients with documented CAD ranges from 10% to 50%. The association between PD and CAD appeared strongest in patients with atypical chest pain or symptoms that could not be fully explained by coronary status. There is some evidence linking phobic anxiety but not PD per se to CAD risk, but little evidence linking CAD to PD risk. Studies of the mechanisms linking PD to CAD are still in their infancy, but there is preliminary evidence linking PD to reduced heart rate variability (HRV) and myocardial ischemia, two pathophysiological mechanisms related to CAD. CONCLUSION: PD is prevalent in CAD patients, but it is unclear the extent to which PD confers risk for and/or exacerbates CAD. Prospective research is needed to more firmly establish PD as a distinct risk factor for the development and progression of CAD. However, because many of the symptoms of PD mimic those of CAD, differentiating these disorders and learning how they may influence each other is imperative for clinical practice.