A focal brain abnormality in panic disorder, a severe form of anxiety

Panic disorder is characterized by recurrent anxiety attacks in the absence of a frightening stimulus. It is a common disorder, affecting 2-5% of the general population and 10-14% of patients seen in cardiology practice. Infusion of sodium (DL)lactate precipitates an anxiety attack in most persons with this disorder but rarely does so in normal controls, suggesting a neurobiological basis for the problem. Despite this observation, the pathophysiology of panic disorder remains unknown. We have now used positron emission tomography to measure cerebral blood flow (CBF) in patients with panic disorder in the absence of a panic attack. Analysis of CBF in regions thought to mediate symptoms of panic, anxiety and vigilance reveals a significant (P less than 0.005) abnormal asymmetry of CBF (left less than right) located in a region of the parahippocampal gyrus. This asymmetry was present in seven patients with panic disorder and a positive response to lactate infusion but was absent in six normal controls and in three patients with panic disorder associated with a negative response to lactate. We believe this to be the first study to identify a discrete brain abnormality in patients with this severe form of anxiety.

Response to hyperventilation in a group of patients with panic disorder

Twelve patients with DSM-III diagnoses of panic disorder and four normal volunteers were studied during hyperventilation of room air and increased ventilation stimulated by 5% CO2. Patients also underwent sodium lactate infusion. Eight of the patients had a panic attack during sodium lactate infusion, seven during CO2 inhalation, and three during room-air hyperventilation. Since CO2 increases the firing of the locus ceruleus, and since sodium lactate infusion is known to increase cerebral CO2, these findings are consistent with other evidence implicating the locus ceruleus in panic anxiety.

Hearing difficulty and its psychological implications for the elderly

A random sample of patients aged 70 and over from a general practice were interviewed in their own homes. Information was sought on their hearing difficulty and mental state: standardised measures of anxiety, depression, and memory loss were used. Of the 657 subjects interviewed, 33% reported having difficulty hearing normal conversations and 6% reported experiencing "much difficulty." Hearing difficulty was associated with both depression and anxiety, but the associations weakened when adjustment was made for physical disability. The association with memory loss disappeared when adjusted for physical disability. There was a close relationship both with age and physical disability.

Alcoholism, anxiety disorders, and agoraphobia

A group of 48 inpatient alcoholics were studied using the Schedule for Affective Disorders and Schizophrenia--Life-time Version (SADS-L) and the Brief Standard Self-rating for Phobic Patients. Approximately one-quarter of the patients were diagnosed as suffering from agoraphobia and social and mixed phobias. Approximately 44% were diagnosed as suffering from anxiety disorders and 46% had suffered from an episode of major depression. Data from the self-rating questionnaire were consistent with the diagnostic data. The alcoholics with phobias had experienced more severe dysphoric feelings than nonphobic alcoholics with other psychiatric disorders.

Hypoglycemia and panic attacks

Many patients with panic disorder believe hypoglycemia causes their symptoms. Of 10 patients with panic disorder given sodium lactate to induce panic, none had evidence of low blood sugar levels when they began to experience anxiety symptoms.

Psychopathological effects of solitary confinement

Psychopathological reactions to solitary confinement were extensively described by nineteenth-century German clinicians. In the United States there have been several legal challenges to the use of solitary confinement, based on allegations that it may have serious psychiatric consequences. The recent medical literature on this subject has been scarce. The author describes psychiatric symptoms that appeared in 14 inmates exposed to periods of increased social isolation and sensory restriction in solitary confinement and asserts that these symptoms form a major, clinically distinguishable psychiatric syndrome.

Independence of mitral valve prolapse and neurosis

An association has been claimed between mitral valve prolapse and the neuroses, especially the anxiety states, panic disorders, and agoraphobia. In this study 103 patients with echocardiographically confirmed mitral valve prolapse were tested with the Eysenck Personality Inventory for neuroticism and with the General Health Questionnaire for the presence of neurotic symptoms. The scores for neuroticism and neurotic symptoms were not significantly different from those of patients with other cardiac diseases or from those of patients presenting in primary care. In addition 50 patients with agoraphobia were screened by echocardiography for mitral valve prolapse, but no cases were detected. It appears that some of the earlier evidence for an association between mitral valve prolapse and neurosis may have been based on groups which were incorrectly diagnosed. It is concluded that mitral valve prolapse and neurosis are independent conditions.

The aetiological importance of stressful life events

Despite a large research effort, there is still some doubt whether life events can increase the rate of psychiatric morbidity. It is argued that this doubt arises from a confusion between measures of goodness of fit and measures of causal importance. The distinction between these types of measures is discussed. Epidemiological studies of life events and psychiatric cases are reviewed. It is argued that, in general, 32 per cent of psychiatric cases can be attributed to stressful life events. Within female samples, approximately 41 per cent of psychiatric cases can be attributed to life events. It is suggested that the effect of specific types of events on specific psychiatric disorders may be of even greater importance.

[Physiopathologic changes and morbidity in divers in saturation. Epidemiologic evaluation of 9 years' activities (1973-1982)]

An epidemiological study was made of 315 man-saturations over a period of 4508 days worked in saturation. The results were compared with those from 541 drillers working on a high-isolation site for periods of 30 days per shift making a total of 16,230 working days. Saturation was asymptomatic in 15,9%. The average length of conditions not interfering with diving or work was 3 days in the sample and 4 days in the controls. There were only two instances of type I decompression sickness in the divers (0,6%). These were both resolved without complications. Two subjects had to give up for health reasons (one case of parotitis and one anxiety-depression syndrome). It is felt that saturation is a very safe procedure as far as immediate pathological consequences are concerned, and that its minor pathological forms are of a significantly different type from those of the control series, especially with regard to ORL forms, upper airway conditions, sleep disturbances, and sensations of malaise and poor adaptation.

Anxiety states: relationship to atmospheric cations and serotonin

Five cases are described that offer evidence for the existence of the "serotonin irritation syndrome," an anxiety state associated with high cation environments, elevated serum serotonin, and decreased urinary 5-hydroxyindoleacetic acid. The therapeutic response and reduction in serum serotonin after treatment with methysergide and/or removal from the high-cation environment support a serotonergic basis of the anxiety.

Undiagnosed myasthenia gravis in emergency psychiatric referrals

The diagnosis of myasthenia gravis is difficult to make in the emergency department. Reported are two cases in which myasthenia was not suspected and the patients were referred to the emergency psychiatrist. In both cases, when appropriate medical treatment was instituted, the psychological symptoms disappeared.

[Anxiety-generating stress]

After a definition of the condition and a discussion of its physiopathological significance, the need to examine the patient as a whole and provide total therapy is emphasised with reference to both the literature and personal cases. It is concluded: 1) that the mesodiencephalic structures, especially the hypothalamus, are of primary importance in human physiological and pathological processes. The hypothalamus is the real brain of the viscera, the functional bridge between the hypophysis, the limbic structures and the upper cortical centres; 2) that doctors should consider the role of the hypothalamus in the diagnosis and therapy of the total person: a) in evaluating the patient's real emotional and psychological situation; b) in realising that the simple administration of a drug to cure the organic symptom really means only partial treatment of the patient himself.

Organic anxiety syndrome

DSM-III defines and offers diagnostic criteria for organic affective, organic delusional, and organic personality syndromes but provides no organic personality syndromes but provides no organic equivalent for anxiety disorders. Nevertheless, symptoms of anxiety characterize such conditions as hyperthyroidism and pheochromocytoma. The authors define and formulate diagnostic criteria for an organic anxiety syndrome and discuss the theoretical and therapeutic implications.

[Effect of somatic factors on the mental state of patients who have had an acute myocardial infarct]

Patients who have survived 3 and more myocardial infarctions (MI) were found to exhibit psychopathologic symptoms twice as frequently as compared to patients with a history of 1-2 MIs. It is the duration (over 5 years) of angina pectoris or arterial hypertension, rather than mere presence of these diseases that appears to be essential for the development of anxiety and depression. Psychopathologic manifestations were about twice as frequent following life-threatening complications (shock, cardiac arrest, repeat MI) during the acute stage of infarction, as compared to uncomplicated clinical course of the disease. Possible causes underlying the established relationship are analysed. The more advantageous approaches to the study of psychosomatic cause--effect relationships in coronary disease are discussed.

[Reversible cerebral ischemia: psychological reactions to the disease]

Two different psychological tests were applied to 40 patients affected by reversible cerebral ischemic attacks in order to evaluate the presence of depression or neurotic symptoms. 40 normal volunteers were used as a control group. While no statistical differences emerged in the mean values of the control tests, significant psychological impairments were observed in the group of patients. Such psychological disturbances were marked in the series with minor neurological deficits. Similar reactions were noted in subjects still employed and in patients submitted to carotid surgery. The authors emphasize the importance of psychological reactions following organic disease for a better therapy in reversible cerebrovascular disorders.

The relation of childhood separation experiences to adult depressive and anxiety states

The relation of childhood separation experiences to adult depression, anxiety and 'general psychological morbidity' was assessed in a random population survey. Four causes of separation were examined in each of three age groups: childhood illness, parental illness, parental marital discord and wartime evacuation. Childhood separations occurring up to five years of age bore no relation to depression, anxiety nor to incidence of morbidity generally. From five to ten years of age, separations caused by parental illness and marital discord were related to morbidity, and in the latter instance were more likely to cause depression than anxiety. From 11 to 15 years, only separations due to parental illness were related to morbidity generally.

[Bromazepam in the treatment of anxiety in nephrology and haemodialysis (author's transl)]

Bromazepam was tested in 15 patients with chronic renal failure undergoing haemodialysis and in 10 patients with normal renal function (controls). The initial dosage (6 mg/day) was modified according to anxiolytic response and sedative effects. Satisfactory results were obtained with 6 mg/day in patients under haemodialysis and in controls with reactional anxiety. Relief from anxiety-induced inhibitions and decrease in somatic disorders were observed. The drug was very well tolerated.

[A clinical trial of bromazepam (author's transl)]

Bromazepam was studied in 32 patients with neurotic anxiety. Daily doses varied between 6 and 12 mg on average. Bromazepam was associated with neuroleptic drugs in 2 cases and with tricyclic antidepressants in 12 cases. Satisfactory results were obtained in 72% of the patients, particularly those with anxiety neurosis and reactional anxiety. The drug was tolerated; transient drowsiness was well noted in 3 cases and some degree of euphoria in 2 cases. Bromazepam appears to be a quick-acting, purely anxiolytic drug, with effects perceptible after 2 or 3 days of the treatment. Its lack of sedative action makes it particularly useful in ambulatory patients.

[Clinical trial of bromazepam in psychiatric hospital practice (author's transl)]

An open trial of bromazepam (Lexomil) was conducted in 35 patients (23 men and 12 women, aged from 18 to 76 years) admitted to a psychiatry unit for various, usually old-standing, conditions associated with major anxiety. The mean effective dosage was 18 mg/day. The effectiveness of the drug administered alone was assessed in 25 patients at the end of the second week of treatment, using the Hamilton and Pull-Guelfi scales. A satisfactory response was obtained in 81% of the cases. Reactional anxiety in alcoholic and neurotic patients was found to constitute the best indication for bromazepam, the value of which during weaning from alcohol in patients admitted with threatening delirium tremens must be stressed. Bromazepam was well tolerated in 83% of the patients; side-effects (daytime somnolence and fatigue) were rare. The drug proved a potent and quick-acting tranquillizer and often resulted in a shorter stay in hospital.

Psychiatric study of patients with severe burn injuries

About two-thirds of a consecutive series of patients severely injured with burns followed up one year after discharge were found to have psychological sequelae. Duration of hospital stay and the presence of certain mental illnesses were related to the incidence and severity of psychological symptoms. This relation did not apply to the site of the burn and the existence of a claim for compensation. The incidence of post-traumatic neurosis in patients with burn injuries could be reduced by identifying and treating, soon after the accident, those who need psychiatric help.

Panic attacks. A review of treatments and pathogenesis

In the psychiatric literature, panic attacks have been considered as part of the clinical manifestations of anxiety neurosis, agoraphobia, functional cardiovascular disturbances, and the phobic depersonalization syndrome. Even though recurrent spontaneous panic attacks are described in these entities, the importance ascribed to them has been minor one. Therefore, panic attacks are poorly understood from a psycho-physio pathological point of view. In the past years, new trends in the nosology of psychiatric disorders have grouped the recurrent spontaneous panic attacks under the heading "panic disorder and agoraphobia with panic attacks." In this view, we present the results of the controlled pharmacological trials on patients complaining of panic attacks. Some relationships between panic attacks, panic disorder, and agoraphobia are discussed.

An independent analysis of the copenhagen sample of the Danish adoption study of schizophrenia. I. The relationship between anxiety disorder and schizophrenia

Familial factors have been shown to be important in the transmission of both anxiety disorder and schizophrenia. The familial relationship between these two disorders, however, has received little attention. This study examines the relationship between anxiety disorder and schizophrenia by a blind independent analysis of the interviews from the Danish Adoption Study of Schizophrenia using DSM-III criteria. The results show neither a genetic nor a familial-environmental link between the two disorders. These results are not consistent with the unitary hypothesis of mental illness. From a genetic and familial-environmental perspective, anxiety disorder and schizophrenia appear to be distinct, unrelated psychiatric illnesses.

The clinical characteristics and treatment of atypical depression

The clinical characteristics, response to pharmacotherapy, and the family history of 15 depressed patients with mixed anxiety and depressive symptomatology are presented. Although these patients manifest the clearcut features of atypical depression, they have several previously unreported features: their primary symptomatology-fatigue, anxiety, and anhedonia-had been present since early adolescence; they responded to tricyclic antidepressant therapy, particularly those agents that increase CNS adrenergic activity; and there was a high loading of psychiatric illness, especially affective disorder and alcoholism, in first degree relatives. A relationship between atypical depression and depressive spectrum disease is hypothesized.

The dichotomy between classical conditioned and cognitively learned anxiety

This paper describes how fears develop on the basis of one or other of two distinct processes--direct autonomic conditioning or the establishment of new cognitive associations to already existing fears. The dichotomy relates both to the appropriate fears of everyday life and to neurotic fears. In the case of the latter, the appropriate treatment procedure should be dictated by the fear basis that behavior analysis reveals. Failure to carry out such analysis is the reason for much confusion and inconclusiveness in therapeutic outcome studies. A retrospective survey of anxiety cases revealed that one-third of their fears were cognitively based and two-thirds due to autonomic conditioning. A study of a clinical population on the basis of a questionnaire designed to separate between cognitively based and conditioned fears has shown the expected bi-modal distribution. These findings undercut the conditioning versus cognition controversy on the causation of neurotic fears.

Hyperventilation syndrome in children and adolescents: long-term follow-up

Records of 34 hyperventilating children aged 18 years or younger seen at the Mayo Clinic over a 25-year period were reviewed. Five different clinical subtypes were identified. Evaluation and treatment varied considerably. At follow-up, 40% were still hyperventilating as adults, and many had signs and symptoms of chronic anxiety. Hyperventilation in childhood can be a signal that the child is experiencing severe anxiety, which may persist into adulthood.