The prediction of nonresponse to pharmacotherapy in panic disorder: a review

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.

Latency to selective serotonin reuptake inhibitor vs benzodiazepine treatment in patients with panic disorder: a naturalistic study

BACKGROUND

Panic disorder (PD) is a prevalent and impairing anxiety disorder with previous reports suggesting that the longer the condition remains untreated, the greater the likelihood of nonresponse. However, patients with PD may wait for years before receiving a guideline-recommended pharmacological treatment. The widespread prescription of benzodiazepines (BDZ) for managing anxiety symptoms and disorders might delay the administration of pharmacotherapy according to guidelines (eg, selective serotonin reuptake inhibitors, SSRIs). The present study aimed to determine the mean duration of untreated illness (DUI) in a sample of PD patients, to quantify and compare DUI-SSRI to DUI-BDZ, and to compare findings with those from previous investigations.

METHODS

Three hundred and fourteen patients with a Diagnostic and Statistical Manual of Mental Disorders, fifth edition diagnosis of PD were recruited from an Italian outpatient psychotherapy unit, and epidemiological and clinical variables were retrieved from medical records. Descriptive statistical analyses were undertaken for sociodemographic and clinical variables, Wilcoxon matched-pair signed rank test was applied to compare the distribution of DUI-SSRI vs DUI-BDZ, and Welch's t test was performed to compare findings with those from previous studies.

RESULTS

The mean DUI-SSRI of the total sample was 64.25 ± 112.74 months, while the mean DUI-BDZ was significantly shorter (35.09 ± 78.62 months; P < 0.0001). A significantly longer DUI-SSRI, compared to findings from previous studies, was also observed.

CONCLUSIONS

The present results confirm a substantial delay in implementing adequate pharmacological treatments in patients with PD, and highlight the discrepancy between recommendations from international treatment guidelines and common clinical practice in relation to BDZ prescription.

Systematic review and meta-analysis of the placebo effect in panic disorder: Implications for research and clinical practice

OBJECTIVE

This review aimed to measure the degree of placebo response in panic disorder.

DATA SOURCES

We searched major databases up to 31 January 2021, for randomized pharmacotherapy trials published in English.

STUDY SELECTION

A total of 43 studies met inclusion criteria to be in the analysis (with 174 separate outcome measurements).

DATA EXTRACTION

Changes in outcome measures from baseline in the placebo group were used to estimate modified Cohen's d effect size.

RESULTS

A total of 43 trials (2392 subjects, 174 outcomes using 27 rating scales) were included in the meta-analysis. Overall placebo effect size was 0.57 (95% confidence interval = [0.50, 0.64]), heterogeneity (I²: 96.3%). Higher placebo effect size was observed among clinician-rated scales compared to patient reports (0.75 vs 0.35) and among general symptom and anxiety scales compared to panic symptoms and depression scales (0.92 and 0.64 vs 0.56 and 0.54, respectively). There was an upward trend in effect size over the publication period (r = 0.02, p = 0.002) that was only significant among clinician-rated scales (r = 0.02, p = 0.011). There was no significant publication bias, Egger's test (p = 0.08).

CONCLUSION

We observed a substantial placebo effect size in panic disorder. This effect was more prominent for some aspects of panic disorder psychopathology than for others and was correlated with the source of the assessment and publication year. This finding has implications both for research design, to address the heterogeneity and diversity in placebo responses, and for clinical practice to ensure optimal quality of care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO, CRD42019125979.

Pathological Worry is Related to Poor Long-Term Pharmacological Treatment Response in Patients With Panic Disorder

OBJECTIVE

Several predictors of unfavorable pharmacological treatment response (PTR) in panic disorder (PD) patients have been suggested, such as the duration of the illness, presence of agoraphobia, depression, being a woman, and early trauma. This study aimed to examine whether pathological worry is associated with PTR in PD patients.

METHODS

This study included 335 PD patients and 418 healthy controls (HCs). The Penn State Worry Questionnaire (PSWQ), the Early Trauma Inventory Self Report-Short Form (ETISR-SF), Beck Depression Inventory (BDI), Panic Disorder Severity Scale (PDSS), and Anxiety Sensitivity Inventory-Revised (ASI-R) were administered. We measured the PTR at 8 weeks and 6 months. Student t-test, chisquare tests, Pearson's correlation analyses, and binary logistic regression model were used.

RESULTS

Our results showed that the total scores of the PSWQ correlated with the ETISR-SF, BDI, and ASI-R were significantly higher in patients with PD compared with HCs. The PSWQ and BDI could predict unfavorable PTR at 6 months in PD patients.

CONCLUSION

This is the first study to demonstrate that pathological worry may contribute to poor long-term PTR in PD patients. Therefore, our research suggests that clinicians must be aware of worry to optimize PTR for PD patients.

Early Trauma Is Associated with Poor Pharmacological Treatment Response in Patients with Panic Disorder

OBJECTIVE

Pharmacotherapy is established as an effective method for reducing symptoms of panic disorder (PD). However, about 20-40% of PD patients are treatment-resistant. Predictors of pharmacotherapy outcomes for PD patients are needed.

METHODS

This study included 152 PD patients to measure the clinical severities of PD symptoms and used the Early Trauma Inventory (ETI) to measure early trauma. Treatment response was defined as a 40% reduction in the total Panic Disorder Severity Scale score from baseline. We measured the treatment responses at 8 weeks and 6 months. Binary logistic regression was used to predict treatment response after controlling for confounding variables.

RESULTS

Early sexual trauma alone was associated with poor treatment response at 8 weeks. However, at 6 months, the total ETI score was associated with an unfavorable treatment response.

CONCLUSION

Therefore, our study suggests that clinicians need to be aware of a history of early trauma to optimize treatment outcomes for PD patients.

Anticonvulsant and antipsychotic medications in the pharmacotherapy of panic disorder: a structured review

BACKGROUND

As the remission rate of panic disorder (PD) achieved with conventional pharmacotherapy ranges between 20% and 50%, alternative psychopharmacological strategies are needed. We aimed to firstly review data regarding use of antipsychotic and non-benzodiazepine anticonvulsant medication in PD patients with or without comorbidities; secondly, to review data concerning reduction of panic symptoms during treatment of another psychiatric disorder with the same medications; and thirdly, to examine reports of anticonvulsant- or antipsychotic-induced new-onset panic symptomatology.

METHODS

We performed a PubMed search (last day: 28 April 2020) of English-language studies only, combining psychopathological terms (e.g. 'panic disorder') and terms referring either to categories of psychotropic medications (e.g. 'anticonvulsants') or to specific drugs (e.g. 'carbamazepine'). All duplications were eliminated. All studies included in the review met certain inclusion/exclusion criteria. The level of evidence for the efficacy of each drug was defined according to widely accepted criteria.

RESULTS

In treatment-resistant PD, beneficial effects have been reported after treatment (mostly augmentation therapy) with a range of anticonvulsant (carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbamazepine, valproate, vigabatrin, tiagabine) and antipsychotic (aripiprazole, olanzapine, risperidone, sulpiride) medications: overall, most medications appear generally well tolerated. Additionally, bipolar patients receiving valproate or quetiapine-XR (but not risperidone or ziprasidone) demonstrated reductions of comorbid panic-related symptoms. There are case reports of new-onset panic symptoms associated with clozapine, haloperidol, olanzapine and topiramate, in patients with conditions other than PD. The small-to-modest sample size, the lack of control groups and the open-label and short-term nature of most of the reviewed studies hinder definitive conclusions regarding either the short-term and long-term efficacy of antipsychotic and anticonvulsant medications or their potential long-term side effects.

CONCLUSION

Some atypical antipsychotic and anticonvulsant medications may have a role in the treatment of some PD patients, mostly when more conventional approaches have not been successful, but the quality of supporting evidence is limited.

Personality characteristics of research volunteers

We evaluated Big Five personality factor differences between research volunteers and nonvolunteers. In the first study, 158 military officers were asked to participate in a mail survey. The personality scores of the officers were available from an archival data set. In our second study, adult siblings from large families were invited to participate in extensive clinical epidemiological evaluations. The personality scores of volunteers (N = 55) and nonvolunteers from the same families (N = 29) were estimated from sibling ratings made by those who participated in the study. In both studies, respondents, compared to nonrespondents, were found to be significantly lower in Neuroticism and higher in Conscientiousness. The second study further indicated respondents as being higher in Extraversion and Agreeableness. Copyright © 2007 John Wiley & Sons, Ltd.

The Impact of Personality Pathology on Treatment Outcome in Late-life Panic Disorder

BACKGROUND

Comorbid personality disorders are assumed to negatively interfere with the treatment outcome of affective disorders. Data on late-life panic disorder remain unknown. We examined the association of personality pathology and treatment outcome related to age and treatment modality.

METHODS

An observational study on the effectiveness of cognitive-behavioral therapy (CBT) for panic disorder with agoraphobia among patients 18 to 74 years of age and randomized controlled comparison of paroxetine and CBT in older patients (60 y of age or older) were performed. The diagnosis of panic disorder was confirmed by the Anxiety Disorder Interview Schedule-Revised (ADIS-IV) and personality features were assessed with the Personality Diagnostic Questionnaire. The impact of personality features on either agoraphobic cognitions (Agoraphobic Cognitions Questionnaire) or avoidance behavior (Mobility Inventory Avoidance Scale) was examined by multiple linear regression analyses adjusted for sex, level of education, duration of illness, comorbid psychopathology, and baseline severity. The interaction between personality and age was examined among those treated with CBT (n=90); the interaction between personality and treatment modality was examined among the older subgroup (n=34).

RESULTS

Cluster B personality pathology (evaluated on the basis of either Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria depending on the date of assessment) was negatively associated with outcomes of CBT in both younger and older adults with panic disorder and agoraphobia. Older adults with a higher number of features of any personality pathology or cluster A pathology had worse treatment outcomes when treated with paroxetine compared with CBT.

CONCLUSIONS

Cluster B pathology had a detrimental effect on CBT treatment outcome for panic disorder in both age groups. In late-life panic disorder with comorbid personality pathology, CBT may be preferred over treatment with paroxetine.

Trauma and defense style as response predictors of pharmacological treatment in panic patients

Background

As panic disorder (PD) has a chronic course, it is important to identify predictors that might be related to non-remission. The aim of this study is to verify whether history of trauma and defense style are predictors to pharmacological treatment response in PD patients.

Method

The sample was composed by 47 PD patients according to DSM-IV who were treated with sertraline for 16 weeks. Evaluations were assessed by the C.G.I. (Clinical Global Impression), the Hamilton-Anxiety Scale, the Hamilton-Depression Scale, the Panic Inventory and the DSQ-40 (Defense Style Questionnaire) at baseline and after treatment.

Results

Full remission was observed in 61.7% of the sample. The predictors significantly associated with non-remission were: severity of PD (p = 0.012), age of onset (p = 0.02) and immature defenses (p = 0.032). In addition, the history of trauma was associated with early onset of PD (p = 0.043).

Conclusion

Panic patients had as predictors of worse response to pharmacological treatment the early onset and the severity of PD symptoms as well as the use of immature defenses at baseline. This finding corroborates the relevance of the evaluation of factors that might affect the response so as to enable the development of appropriate treatment for each patient.

Biological and Clinical Markers in Panic Disorder

OBJECTIVE

Classifying mental disorders on the basis of objective makers might clarify their aetiology, help in making the diagnosis, identify "at risk" individuals, determine the severity of mental illness, and predict the course of the disorder. This study aims to review biological and clinical markers of panic disorder (PD).

METHODS

A computerized search was carried out in PubMed and Science Direct using the key words: "marker/biomarker/clinical marker/neurobiology/staging" combined using Boolean AND operator with "panic." In addition, the reference lists from existing reviews and from the articles retrieved were inspected. Only English language papers published in peer-reviewed journals were included.

RESULTS

Structural changes in the amygdala, hippocampus, cerebral blood level in the left occipital cortex, serotonin 5-TH and noradrenergic systems activation, aberrant respiratory regulation, hearth rate variability, blood cells and peripheral blood stem cells, hypothalamic-pituitary-adrenal axis dysregulation were identified as potential candidate biomarkers of PD. Staging was identified as clinical marker of PD. According to the staging model, PD is described as follows: prodromal phase (stage 1); acute phase (stage 2); panic attacks (stage 3); chronic phase (stage 4).

CONCLUSION

The clinical utility, sensitivity, specificity, and the predictive value of biomarkers for PD is still questionable. The staging model of PD might be a valid susceptibility, diagnostic, prognostic, and predictive marker of PD. A possible longitudinal model of biological and clinical markers of PD is proposed.

Predictors of Pharmacotherapy Response in Generalized Anxiety Disorder: A Systematic Review

BACKGROUND

Pharmacotherapy for generalized anxiety disorder (GAD) may be effective in reducing symptoms in the majority of patients. The study of moderators and predictors of treatment response may help clinicians both to select appropriate interventions to maximize the probability of response and to inform the general prognosis.

METHODS

A systematic literature search of electronic databases, selected authors, and reference lists was used to identify articles that reported trials of drug monotherapy in GAD. Data on predictors and moderators were extracted. Quality of evidence was determined by the presence of a priori hypotheses, number of variables investigated, adequate quality of the measurement, and use of interaction-effects testing.

RESULTS

From the 98 articles meeting inclusion criteria, 24 reported a total of 22 factors associated with treatment response. The reported results were heterogeneous, ranging over sociodemographic, clinical, comorbidity, genetic, and functional-imaging studies. Major depressive symptoms were found to moderate treatment outcome in favor of antidepressants versus benzodiazepines. Neuroticism, previous treatment, genetic polymorphisms (including serotonin receptor gene 2A), and functional activation of the anterior cingulate cortex and amygdala were identified as potential predictors of treatment response.

CONCLUSIONS

Correlates of poor emotion regulation predicted poor treatment response, but subclinical depression was the only variable capable of informing treatment selection in this review. Future research should focus on further exploring the value of depression as a moderator and on a narrower list of potential genetic, brain-imaging, and temperament predictors of response to pharmacotherapy in GAD.

Neurobiological and clinical effects of fNIRS-controlled rTMS in patients with panic disorder/agoraphobia during cognitive-behavioural therapy

BACKGROUND

A relevant proportion of patients with panic disorder (PD) does not improve even though they receive state of the art treatment for anxiety disorders such as cognitive-behavioural therapy (CBT). At the same time, it is known, that from a neurobiological point of view, PD patients are often characterised by prefrontal hypoactivation. Intermittent Theta Burst Stimulation (iTBS) is a non-invasive type of neurostimulation which can modulate cortical activity and thus has the potential to normalise prefrontal hypoactivity found in PD. We therefore aimed at investigating the effects of iTBS as an innovative add-on to CBT in the treatment for PD.

METHODS

In this double-blind, bicentric study, 44 PD patients, randomised to sham or verum stimulation, received 15 sessions of iTBS over the left prefrontal cortex (PFC) in addition to 9 weeks of group CBT. Cortical activity during a cognitive as well as an emotional (Emotional Stroop) paradigm was assessed both at baseline and post-iTBS treatment using functional near-infrared spectroscopy (fNIRS) and compared to healthy controls.

RESULTS

In this manuscript we only report the results of the emotional paradigm; for the results of the cognitive paradigm please refer to Deppermann et al. (2014). During the Emotional Stroop test, PD patients showed significantly reduced activation to panic-related compared to neutral stimuli for the left PFC at baseline. Bilateral prefrontal activation for panic-related stimuli significantly increased after verum iTBS only. Clinical ratings significantly improved during CBT and remained stable at follow-up. However, no clinical differences between the verum- and sham-stimulated group were identified, except for a more stable reduction of agoraphobic avoidance during follow-up in the verum iTBS group.

LIMITATIONS

Limitations include insufficient blinding, the missing control for possible state-dependent iTBS effects, and the timing of iTBS application during CBT.

CONCLUSION

Prefrontal hypoactivity in PD patients was normalised by add-on iTBS. Clinical improvement of anxiety symptoms was not affected by iTBS.

What predicts a positive response to acupuncture? A secondary analysis of three randomised controlled trials of insomnia

OBJECTIVE

Few studies have investigated the predictors of the specific and non-specific effects of acupuncture. The aim of this secondary analysis was to determine patient characteristics that may predict a better treatment response to acupuncture for insomnia.

METHODS

We pooled the data of three randomised, double-blind, placebo-controlled trials of acupuncture for insomnia to examine sociodemographic variables, clinical characteristics, baseline sleep-wake variables, and treatment expectancy in relation to acupuncture response. Subjects with an improvement in insomnia severity index (ISI) scores of ≥8 points from baseline to 1 week post-treatment were classified as responders. Factors were compared between responders and non-responders, and also by univariate and multivariate logistic regression analysis.

RESULTS

A total of 116 subjects who received traditional needle acupuncture were included, of which 37 (31.9%) were classified as responders. Acupuncture responders had a higher educational level (p<0.01) and higher baseline ISI score (p<0.05), compared to non-responders. In the multivariate logistic regression analysis, only the number of years spent in full-time education remained significant as a predictor of treatment response (OR 1.21, 95% CI 1.06 to 1.38, p<0.01).

CONCLUSIONS

Consistent with previous studies, our data suggest that the response to acupuncture is difficult to predict. Although the predictive power of educational level is weak overall, our findings provide potentially valuable information that could be built upon in further research (including a larger sample size), and may help to inform patient selection for the treatment of chronic insomnia with acupuncture in the future.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: #NCT00839592; Results, #NCT00838994; Results, and #NCT01707706; Results.

Epilepsy spectrum disorders: A concept in need of validation or refutation

Episodic psychiatric symptoms are not uncommon and range from panic attacks to repeated violent acts. Some evidence has accumulated over the years that at least in a subset of patients exhibiting these symptoms there may be evidence for the presence of focal cortical/subcortical hyperexcitability. In these cases the condition could be conceptualized as an epilepsy spectrum disorder (ESD) with significant treatment implications. There is currently no clear demarcation of this category of symptoms, their prevalence, an understanding of how these symptoms occur, what is appropriate work up and possible treatments. In this article, we propose that milder degrees of increased neural excitability (i.e., a subthreshold excitation insufficient to cause seizures) may nonetheless be capable of causing observable phenotypic changes. The observable phenotypic changes depend on the degree of hyperexcitability and the location of the hyperexcitable neural tissue. The location of the abnormal neural tissue may dictate the initial manifestation of an attack resulting from activation of the hyperexcitable tissue, but the anatomical connectivity of the abnormal region will dictate the breadth of manifestations. We provide some evidence, derived mainly from either electroencephalography studies of these populations or clinical reports of response to anti-epilepsy treatment, for the assumption and propose methods to test the advanced hypothesis.

Anticonvulsant medications for panic disorder: a review and synthesis of the evidence

OBJECTIVES

Currently, there are no guidelines for when to use an antiepileptic drug (AED) in nonepileptic panic disorder (PD) patients. We conducted this review to ascertain what guidance available literature can provide as to when to consider AEDs for PD patients.

METHODS

The primary data sources were PubMed and Google-Scholars. Search was limited to "English" and "Humans". Only papers addressing use of nonbenzodiazepine AEDs in PD were included. Data regarding study subjects, the AED utilized, and clinical responses were collected. EEG data were used to classify reports of patients with abnormal versus those with normal and/or no EEG work-up.

RESULTS

Ten reports were identified for use of AEDs in PD patients with abnormal EEGs with a total of 20 patients (17 responders). None of the 10 reports were controlled studies. Eighteen reports were identified for use of AEDs in panic patients with either normal EEGs or unselected groups (no EEG work-up). Out of the 18 reports, three were controlled studies. Included in the 18 studies were 253 patients (137 responders).

CONCLUSIONS

We preliminary concluded that EEG work-up could be useful in guiding the treatment in PD as an abnormal EEG may be indicative of a higher likelihood of a positive response to an AED.

Decreased gray matter volume of the medial orbitofrontal cortex in panic disorder with agoraphobia: a preliminary study

BACKGROUND

Patients with panic disorder with agoraphobia (PDA) have clinical symptoms such as the fear of being outside or of open spaces from which escape would be difficult. Although recent neurobiological studies have suggested that fear conditioning and extinction are associated with PDA, no study has examined the possible structural abnormalities in patients with PDA.

METHODS

This preliminary study compares the gray matter volume among patients with PDA, those with panic disorder without agoraphobia (PDW), and healthy controls (HC) using high-resolution 3.0 T magnetic resonance imaging (MRI) with voxel-based morphometry (VBM).

RESULTS

Compared with HC, patients with PDA showed decreased gray matter volume in their left medial orbitofrontal gyrus. However, differences were not found in the gray matter volumes of patients with PDW and whole panic disorder compared with HC.

CONCLUSIONS

These findings suggest that the phobic avoidance found in patients with PDA arise from abnormalities in the medial orbitofrontal cortex, which plays an important role in fear extinction. Future studies should investigate the neuroanatomical substrates of PDA and distinguish them from those of PDW.

Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research

BACKGROUND

A comprehensive meta-analysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders (AD) has not previously been published.

METHODS

A literature search identified 125 empirical papers from the period 1980-2010 on patients with panic disorders, social phobia, generalised anxiety, obsessive-compulsive (OCD) and post-traumatic stress disorder (PTSD). Several moderators were coded.

RESULTS

The rate of any comorbid PD was high across all ADs, ranging from .35 for PTSD to .52 for OCD. Cluster C PDs occurred more than twice as often as cluster A or B PDs. Within cluster C the avoidant PD occurred most frequently, followed by the obsessive-compulsive and the dependent PD. PTSD showed the most heterogeneous clinical picture and social phobia was highly comorbid with avoidant PD. A range of moderators were examined, but most were non-significant or of small effects, except an early age of onset, which in social phobia increased the risk of an avoidant PD considerably. Gender or duration of an AD was not related to variation in PD comorbidity.

LIMITATIONS

Blind rating of diagnoses was recorded from the papers as an indication of diagnostic validity. However, as too few studies reported it the validity of the comorbid estimates of PD was less strong.

CONCLUSIONS

The findings provided support to several of the proposed changes in the forthcoming DSM-5. Further comorbidity studies are needed in view of the substantial changes in how PDs will be diagnosed in the DSM-5.

Psychological characteristics of early remitters in patients with panic disorder

We aimed to examine whether anxiety sensitivity and agoraphobic fear could affect the time taken to remission after 24 weeks of open-label escitalopram treatment of patients with panic disorder (PD). We recruited 158 patients, and 101 patients completed the study. Clinical severity and psychological characteristics were assessed at baseline and 4, 12, and 24 weeks after the treatment, using the Clinical Global Impression-Severity (CGI-S), the Hamilton Rating Scales for Anxiety and Depression, the Anxiety Sensitivity Index-Revised (ASI-R), the Albany Panic and Phobia Questionnaire (APPQ), and the Panic Disorder Severity Scale (PDSS). Remission was defined as the absence of full panic attacks and PDSS scores of 7 or less. Completing patients were stratified according to the time taken to remit: early (n=20) and late (n=58) remission and non-remission groups (n=23). There were no significant differences among the three groups at baseline on the CGI-S and the PDSS mean scores. However, early remitters had significantly lower scores than late remitters and non-remitters on the ASI-R and APPQ. In conclusion, anxiety sensitivity and agoraphobic fear can affect the time to remission after pharmacotherapy, and clinicians should consider the psychological characteristics of PD patients in order to achieve an optimal response to pharmacotherapy.

The anxiety spectrum and the reflex physiology of defense: from circumscribed fear to broad distress

Guided by the diagnostic nosology, anxiety patients are expected to show defensive hyperarousal during affective challenge, irrespective of the principal phenotype. In the current study, patients representing the whole spectrum of anxiety disorders (i.e., specific phobia, social phobia, panic disorder with or without agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder(PTSD)), and healthy community control participants, completed an imagery-based fear elicitation paradigm paralleling conventional intervention techniques. Participants imagined threatening and neutral narratives as physiological responses were recorded. Clear evidence emerged for exaggerated reactivity to clinically relevant imagery--most pronounced in startle reflex responding. However, defensive propensity varied across principal anxiety disorders. Disorders characterized by focal fear and impairment (e.g., specific phobia) showed robust fear potentiation. Conversely, for disorders of long-enduring, pervasive apprehension and avoidance with broad anxiety and depression comorbidity (e.g., PTSD secondary to cumulative trauma, GAD), startle responses were paradoxically diminished to all aversive contents. Patients whose expressed symptom profiles were intermediate between focal fearfulness and broad anxious-misery in both severity and chronicity exhibited a still heightened but more generalized physiological propensity to respond defensively. Importantly, this defensive physiological gradient--the inverse of self-reported distress--was evident not only between but also within disorders. These results highlight that fear circuitry could be dysregulated in chronic, pervasive anxiety, and preliminary functional neuroimaging findings suggest that deficient amygdala recruitment could underlie attenuated reflex responding. In summary, adaptive defensive engagement during imagery may be compromised by long-term dysphoria and stress-a phenomenon with implications for prognosis and treatment planning.

Predictors of outcome of pharmacological and psychological treatment of late-life panic disorder with agoraphobia

OBJECTIVE

This study aims to evaluate the differential predictive values of age, age of onset and duration of illness on paroxetine and cognitive-behavioural therapy (CBT) outcome in late-life panic disorder with agoraphobia.

METHOD

Patients 60 years and older with a confirmed diagnosis of panic disorder with agoraphobia (n = 49) were randomly assigned to paroxetine (40 mg/day) treatment, individual CBT or a waiting-list control condition. Multiple regression analyses were conducted per treatment arm with post-treatment avoidance behaviour and agoraphobic cognitions as the dependent variables.

RESULTS

Higher age at onset and shorter duration of illness were predictors of superior outcomes following CBT, although these variables did not influence the treatment effects of paroxetine.

CONCLUSIONS

In late-life agoraphobic panic disorder, chronological age has no impact on treatment modality outcome. In older patients with a late disease onset or shorter duration of illness, CBT is to be preferred over paroxetine, whereas paroxetine might be the treatment of choice for older people with an early onset and short duration of illness.

Aversive imagery in panic disorder: agoraphobia severity, comorbidity, and defensive physiology

BACKGROUND

Panic is characterized as a disorder of interoceptive physiologic hyperarousal, secondary to persistent anticipation of panic attacks. The novel aim of this research was to investigate whether severity of agoraphobia within panic disorder covaries with the intensity of physiological reactions to imagery of panic attacks and other aversive scenarios.

METHODS

A community sample of principal panic disorder (n = 112; 41 without agoraphobia, 71 with agoraphobia) and control (n = 76) participants imagined threatening and neutral events while acoustic startle probes were presented and the eye-blink response (orbicularis oculi) recorded. Changes in heart rate, skin conductance level, and facial expressivity were also measured.

RESULTS

Overall, panic disorder patients exceeded control participants in startle reflex and heart rate during imagery of standard panic attack scenarios, concordant with more extreme ratings of aversion and emotional arousal. Accounting for the presence of agoraphobia revealed that both panic disorder with and without situational apprehension showed the pronounced heart rate increases during standard panic attack imagery observed for the sample as a whole. In contrast, startle potentiation to aversive imagery was more robust in those without versus with agoraphobia. Reflex diminution was most dramatic in those with the most pervasive agoraphobia, coincident with the most extreme levels of comorbid broad negative affectivity, disorder chronicity, and functional impairment.

CONCLUSIONS

Principal panic disorder may represent initial, heightened interoceptive fearfulness and concomitant defensive hyperactivity, which through progressive generalization of anticipatory anxiety ultimately transitions to a disorder of pervasive agoraphobic apprehension and avoidance, broad dysphoria, and compromised mobilization for defensive action.

Defense style in panic disorder before and after pharmacological treatment

Whether or not the use of maladaptive defense style is a trait, as opposed to a state dependent phenomenon, in panic disorder (PD) is a topic still very much up for debate. The aim of the study was to verify whether PD patients, both before and after treatment, used different defense style than the control group. Sixty-one PD patients (recruited from an original sample of 90 patients) and 64 healthy controls were evaluated against the Structured Clinical Interview for DSM-IV disorders, the Symptoms Check List-90, the Hamilton Rating Scales for Anxiety and for Depression and finally the Defense Style Questionnaire-40 (DSQ). The patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission. The DSQ was re-administered to the patients at the end of the study. Before treatment, PD patients used more neurotic and immature forms of defense than controls. After treatment, those in remission used the same defense styles as the control group, whereas non-remitters still used more immature defenses. However, all the aforementioned difference disappeared, after excluding the effect of symptom severity. Our data supports the hypothesis that the use of maladaptive defenses might be the consequence of PD: when subjects fall ill, their capacity to use mature adaptive defenses may diminish, but when they recover their defensive style returns to a greater maturity. The present results are however limited by the dropout rate (one third of patients did not complete the study) and the use of just one questionnaire to evaluate the complexity of defense styles.

The effects of comorbid personality disorders on cognitive behavioral treatment for panic disorder

The present study investigated the influence of personality pathology assessed both dimensionally and categorically on acute clinical response to group cognitive-behavioral treatment in a large sample of panic disorder patients (N = 173) meeting DSMIII-R criteria for panic disorder with or without agoraphobia. Nearly one-third of the sample met for one or more personality disorders, with the majority meeting for a Cluster C diagnosis. Patients with one or more comorbid personality disorders displayed higher baseline and higher post treatment scores across multiple indices of panic disorder severity compared to those without personality disorders. After controlling for panic disorder severity at baseline, the presence of both Cluster C and Cluster A Pers-Ds predicted a poorer outcome, whereas when assessed dimensionally, only Cluster C symptoms predicted a poorer treatment response. However, the influence of personality pathology was modest relative to that of baseline panic disorder severity.

Anxiety symptomatology: the association with distress tolerance and anxiety sensitivity

Research focused on psychological risk factors for anxiety psychopathology has led to better conceptualization of these conditions as well as pointed toward preventative interventions. Anxiety sensitivity (AS) has been well-established as an anxiety risk factor, while distress tolerance (DT) is a related construct that has received little empirical exploration within the anxiety psychopathology literature. The current investigation sought to extend the existing literature by examining both DT and the relationship between DT and AS across a number of anxiety symptom dimensions, including panic, generalized anxiety, social anxiety, and obsessive-compulsive anxiety. Participants (N=418) completed a number of measures that assessed DT, AS, anxiety symptomatology, and negative affect. Findings indicated that DT was uniquely associated with panic, obsessive compulsive, general worry, and social anxiety symptoms, but that DT and AS were not synergistically associated with each of these symptom dimensions. These findings indicate that an inability to tolerate emotional distress is associated with an increased vulnerability to experience certain anxiety symptoms.

Changes in Cerebral Cortex and Limbic Brain Functions after Short-Term Paroxetine Treatment in Panic Disorder: An [F]FDG-PET Pilot Study

OBJECTIVE

Panic disorder (PD) is a common and often chronic psychiatric illness, and serotonin-specific reuptake inhibitors (SSRIs) are the drugs of choice for the treatment of PD. Previous studies suggested the cerebral cortex and limbic brain structures played a major role in the development of PD, but the therapeutic effect of SSRIs on specific brain structures remains unclear in PD. We examined the changes in PD patients' glucose metabolism using the [(18)F] Fluorodeoxy-glucose-positron emission tomography (FDG-PET) before and after 12 weeks of paroxetine treatment.

METHODS

We assessed the brain glucose metabolism of 5 PD patients, using the [(18)F]FDG-PET, and treated them with paroxetine (12.5-37.5 mg/day) for 12 weeks. Then, we compared before and after treatment PET images of the patients, using voxel-based statistical analysis and a post hoc regions of interest analysis. Furthermore, we measured the patients' clinical variables, including information from the Panic Disorder Severity Scale (PDSS), Clinical Global Impression for Severity (CGI-S), and Hamilton Anxiety Rating Scale (HAMA).

RESULTS

After 12 weeks of paroxetine treatment, the patients showed significant clinical improvement in terms of PDSS, CGI-S and HAMA scores (12.8±1.8 vs. 3.8±2.3, 4.6±0.5 vs. 2.0±1.4, and 15.2±4.0 vs. 5.0±1.2, respectively; all p values<0.05). After treatment, patients' glucose metabolism increased significantly in global brain areas: the right precentral gyrus, right middle frontal gyrus, right amygdala, right caudate body, right putamen, left middle frontal gyrus, left precentral gyrus, left insula, left parahippocampal gyrus, and left inferior frontal gyrus (All areas were significant at uncorrected p<0.001 and cluster level corrected p<0.05).

CONCLUSION

In these PD patients, cerebral cortex and limbic brain functions changed after short-term treatment with paroxetine. The therapeutic action of paroxetine may be related to altered glucose metabolism at both the cerebral cortex and limbic brain areas.

Lamotrigine administration in panic disorder with agoraphobia

Several anticonvulsants, although as yet not lamotrigine (LTG), have been found useful in the treatment of panic disorder with (PDA) or without agoraphobia. We administered LTG (200 mg/d) to 4 outpatients with PDA, as an augmentation therapy (3 patients with chronic and severe agoraphobia) or monotherapy (1 drug-naive patient with first-onset PDA) in a 14-week trial. The patient under LTG monotherapy improved significantly, whereas PDA symptoms in 2 of the other patients improved to some extent.

Long-term effectiveness and prediction of treatment outcome in cognitive behavioral therapy and sertraline for late-life anxiety disorders

BACKGROUND

Although anxiety disorders are prevalent in older adults, randomized controlled trials of treatment effectiveness for late-life anxiety are scarce and have focused primarily on the effectiveness of psychotherapeutic interventions. However, recent findings suggest that in some cases, pharmacological treatment may be more beneficial for late-life anxiety disorders. As yet, there have been no systematic studies investigating prognostic factors for the outcome of cognitive behavioral therapy (CBT) and pharmacotherapy for late-life anxiety. The objective of the present study was to study long-term treatment outcomes and to explore differential predictors for both short-term and long-term treatment outcomes of sertraline and CBT for late-life anxiety disorders.

METHODS

Participants of a randomized controlled trial (RCT) comparing sertraline and CBT for the treatment of late-life anxiety were contacted one year after completing their treatment, so that predictors for both short-term and long-term treatment outcome could be established.

RESULTS

Sertraline showed a greater reduction of symptoms than CBT on anxiety (Hamilton Anxiety Rating Scale; HARS) and worry (Worry Domain Questionnaire) ratings at one-year follow-up. The strongest predictor for short-term CBT outcome was poor perceived health, explaining 40% of the variance in post-treatment residual gain scores on the HARS. The strongest predictor for long-term CBT outcome was neuroticism, explaining 20% of the variance in residual gain scores at one-year follow-up. Analyses revealed no significant predictors for treatment outcome in sertraline participants.

CONCLUSIONS

Our study suggests that long-term use of sertraline might be more beneficial for late-life anxiety than a 15-week CBT program. Poor perceived health and neuroticism are predictive of less improvement after CBT in anxious older adults. Implications of these findings are discussed.

Predictors of clinical improvement in a randomized effectiveness trial for primary care patients with panic disorder

This study's aim was to prospectively examine and identify a model of demographic, clinical, and attitudinal variables that impact improvement among patients with panic disorder. Subjects were 232 primary care patients meeting criteria for DSM-IV panic disorder. Eligible patients were randomly assigned to a collaborative care intervention or to treatment as usual. Assessments occurred at 3-month intervals during the course of 1 year. In final multivariate logistic regression models, patients with higher anxiety sensitivity and higher neuroticism scores at baseline were less likely to show clinical improvement (using a criterion of 20 or less on the Anxiety Sensitivity Index) at 3 months. Those who were non-white, had higher anxiety sensitivity, and higher overall phobic avoidance at baseline were less likely to show clinical improvement at 12 months. A greater understanding of these predictors may help clinicians identify who is at greatest risk for persistent panic-related symptoms and to plan the intensity of interventions accordingly.

Empirically supported treatments for panic disorder

This article provides an empirical review of the elements and efficacy of both pharmacologic and psychosocial treatments for panic disorder. Both monotherapies and combination treatment strategies are considered. The available evidence suggests that both cognitive behavioral therapy (CBT) and pharmacotherapy (prominently, selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors) are effective first-line agents and that CBT offers particular cost efficacy relative to both pharmacotherapy alone and combined pharmacotherapy and CBT. Predictors of non-response and mechanisms of action are considered, as are novel treatment strategies, including the use of memory enhancers to improve CBT outcome.

Caffeine challenge in patients with panic disorder: baseline differences between those who panic and those who do not

A proportion of patients with panic disorder (PD) display an increased sensitivity to the anxiogenic/panicogenic properties of caffeine. The aim of this study is to identify probable baseline differences between PD patients who panic and those who do not, after caffeine administration. In a randomized, double-blind, cross-over experiment performed in two occasions 3-7 days apart, 200 and 400 mg of caffeine, respectively, were administered in a coffee form to 23 patients with PD with or without Agoraphobia. Evaluations included the State-Trait Anxiety Inventory, the DSM-IV 'panic attack' symptoms (visual analogue scale form), the Symptom Checklist-90-Revised (SCL-90-R), as well as breath-holding (BH) duration, heartbeat perception accuracy and heart rate. Only those patients who did not present a panic attack after both challenges ('no panic group', N=14, 66.7%), and those who presented a panic attack after at least one challenge ('panic group', n=7, 33.3%) were included in the analysis. The panickers, compared to the non-panickers, presented at baseline: significantly higher total score of the SCL-90-R; significantly higher scores on all the SCL-90-R clusters of symptoms, except that of 'paranoid ideation'; significantly lower BH duration. The present preliminary findings indicate that PD patients who panic after a 200 mg or a 400 mg caffeine challenge, compared to the PD patients who do not panic after both of these challenges, may present at baseline significantly higher non-specific general psychopathology--as reflected in the SCL-90-R--and significantly shorter BH duration.

Common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders

The aim of this study is to summarize available knowledge about common genetic, clinical, demographic and psychosocial predictors of response to pharmacotherapy in mood and anxiety disorders. A literature search was carried out by using MEDLINE and references of selected articles. The search included articles published up to March 2008. The main genetic finding concerns the serotonin transporter gene promoter polymorphisms, the long variant of which seems to be related to a positive response to therapy in mood disorders and could also have a role in the treatment of anxiety disorders. Among other predictors, the main factors common to both classes of disorder are comorbid axis II disorders and early onset of illness, which are related to a worse response to therapy and concomitant good physical conditions, absence of earlier treatments, early administration and response to therapies, and higher self- directedness, which is related to a better outcome. Many common predictors have been identified and these seem to be related to features covering the totality of patients that go beyond specific characteristics of single disorders. Possible limitations and suggestions for future research based on a more integrated vision of human complexity are discussed.

Assessing the clinical utility of agoraphobia in the context of panic disorder

In the DSM-IV, a panic disorder (PD) diagnosis includes specification of agoraphobia, which is primarily an index of situational avoidance due to fear of panic. No other anxiety diagnosis requires specification of level of avoidance. This raises the question as to whether agoraphobia provides unique information beyond the core features of PD (i.e., panic attacks and panic-related worry). The incremental validity of agoraphobia, defined using DSM-IV specifiers versus level of situational avoidance, was examined in relation to the expression and treatment of PD (N=146). Analyses indicate that agoraphobia status adds uniquely to the prediction of PD symptoms, impairment, and response to treatment. However, level of situational avoidance, defined either as a continuous or dichotomous variable, appears to have greater utility compared to the DSM-IV method of classifying agoraphobia. In summary, the agoraphobia specifier seems to have clinical utility but this could be improved by focusing on a dimensional assessment of situational avoidance.

Effect of pharmacological treatment on temperament and character in panic disorder

Temperament and character were evaluated in patients with panic disorder (PD) before and after 1 year of pharmacological therapy to verify whether personality characteristics change after treatment. Therefore, 65 PD patients and 71 healthy subjects participated in the study. All subjects were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram. The TCI was re-administered to the patients at the end of the study. At the end of the study, complete remission was achieved by 31 patients (R), whereas symptoms did not disappear in the remaining 34 patients (NR). Before treatment, NR patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C) than healthy controls. Only HA levels were higher than normal in R, although they were significantly lower in R than in NR patients. These differences persisted after treatment. However, in NR patients the levels of SD and C worsened, whereas the difference between R patients and controls in HA levels (higher in R patients than in controls) disappeared after controlling the effect of residual phobic anxiety (higher than normal in R patients). Our data suggest that the high levels of HA found after remission may depend on the subsyndromal residual phobic symptoms, observed in R patients. Moreover, the persistence of anxious symptoms may have worsened the low levels of SD and C observed before treatment in patients who did not achieve remission.

Pharmacological management of panic disorder

Panic disorder (PD) is a disabling condition which appears in late adolescence or early adulthood and affects more frequently women than men. PD is frequently characterized by recurrences and sometimes by a chronic course and, therefore, most patients require long-term treatments to achieve remission, to prevent relapse and to reduce the risks associated with comorbidity. Pharmacotherapy is one of the most effective treatments of PD. In this paper, the pharmacological management of PD is reviewed. Many questions about this effective treatment need to be answered by the clinician and discussed with the patients to improve her/his collaboration to the treatment plan: which is the drug of choice; when does the drug become active; which is the effective dose; how to manage the side effects; how to manage nonresponse; and how long does the treatment last. Moreover, the clinical use of medication in women during pregnancy and breastfeeding or in children and adolescents was reviewed and its risk-benefit balance discussed.

Self-rated importance of religion predicts one-year outcome of patients with panic disorder

Cognitive-behavioral therapy and medication are efficacious treatments for panic disorder, but individual attributes such as coping and motivation are important determinants of treatment response. A sample of 56 patients with panic disorder, treated with group cognitive-behavioral therapy, were reassessed 6 months and 12 months after initial assessment. We studied the effect of self-rated importance of religion, perceived stress, self-esteem, mastery, and interpersonal alienation on outcome as measured by the General Severity Index of the Brief Symptom Inventory (BSI.GSI). Importance of religion was a predictor of BSI.GSI symptom improvement at 1 year. Over time, improvement was seen for the religion is very important subgroup in the BSI.GSI and Perceived Stress Scales. This study suggests that one mechanism by which high importance of religion reduces psychiatric symptoms is through reducing perceived stress.

Anxiety disorders: treatable regardless of the severity of comorbid alcohol dependence

AIMS

Clinical and epidemiological research has shown that comorbidity is the rule rather than exception in the case of psychiatric disorders. Cognitive behavioral therapy (CBT) has been clearly demonstrated to be effective in treating anxiety and avoidance symptoms in patient samples of social phobia and agoraphobia without comorbid alcohol use disorders. It has recently been shown that treatment of comorbid anxiety disorders in alcohol-dependent patients can also be very successful. The purpose of the present study was to find predictors of treatment success for comorbid anxiety disorders in alcohol-dependent patients.

METHODS

The study was conducted in a sample of 34 completers with a double diagnosis of alcohol dependence and agoraphobia or social phobia who received CBT for their comorbid anxiety disorder in a 32-week randomized controlled trial comparing alcohol and CBT anxiety disorder treatment with alcohol treatment alone. In the current report, treatment success was defined as a clinically significant change (recovery) on the anxiety discomfort scale.

RESULTS

The severity of comorbid alcohol dependence did not influence the beneficial effect of CBT on the anxiety disorder. Psychological distress (SCL-90), neuroticism (NEO N), conscientiousness (NEO C), gender, employment and age of onset of alcohol dependence showed some predictive value.

CONCLUSIONS

Alcohol-dependent males with a comorbid anxiety disorder seem to benefit most from CBT if their alcohol dependence started after age 25, if they are employed and if their general psychopathology is less severe. The most important conclusion, however, is that even severely alcohol-dependent patients with an anxiety disorder can benefit from psychotherapy for their anxiety disorder.

Personality disorders and response to medication treatment in panic disorder: a 1-year naturalistic study

OBJECTIVE

In this naturalistic and prospective study, personality was assessed in patients with panic disorder (PD), in order to evaluate whether personality features negatively influence the outcome of pharmacological treatment.

METHOD

Before drug treatment, PD was diagnosed with the Structured Clinical Interview for DSM-IV disorders and personality was assessed with the Structured Interview for DSM-IV Personality Disorders. Moreover, all patients were evaluated with the SCL-90, the Ham-A and Ham-D. Then, patients were randomly treated with paroxetine (33.5+/-13.3 mg/day) or citalopram (34.7+/-15.2 mg/day) and were followed at monthly intervals for 1 year. Absence of full and limited-symptom attacks, anticipatory anxiety, phobic avoidance and depression for 3 months was used to establish remission. The effect of personality traits on each symptom domain was evaluated.

RESULTS

Seventy-one patients completed the study. Remission rate was 76% for panic attacks and 46% for complete remission. When the effects of age, gender, age of onset and duration of PD, baseline SCL-90 phobic anxiety, Ham-A and Ham-D scores, Axis I comorbidity and the SIDP traits on remission were analyzed in a logistic regression, only borderline traits negatively influenced remission of panic attacks (OR=0.69; 95% CI=0.49-0.96; p=0.03), whereas the number of traits of each personality Cluster and the total number of SIDP traits did not affect the outcome of treatment.

CONCLUSIONS

This study suggests that in PD patients, borderline features may negatively influence the response to monotherapy with SSRI drugs; therefore, other treatment strategies (i.e., combination of SSRI with psychotherapy) are needed to obtain remission in these patients.

The effect of temperament and character on response to selective serotonin reuptake inhibitors in panic disorder

OBJECTIVE

In this prospective study, temperament and character were evaluated in patients with panic disorder (PD), before 1 year of medication therapy, to verify whether these factors influenced the outcome of treatment.

METHOD

Seventy-one PD patients were evaluated with the SCID-IV, the Temperament and Character Inventory (TCI), the SCL-90, the Ham-A and the Ham-D. Patients were treated with pharmacotherapy and were evaluated monthly over 1 year.

RESULTS

Before treatment, non-remitted patients showed higher levels of harm avoidance (HA) and lower levels of persistence (P), self-directedness (SD) and cooperativeness (C), whereas remitted patients showed only higher levels of HA. After controlling the effect of the confounding variables, the likelihood to achieve remission was positively related to SD score (OR = 1.12; P = 0.002), particularly 'self-acceptance' SD dimension (OR = 1.30; P = 0.02).

CONCLUSIONS

Our data suggest that in PD: i) the evaluation of personality, using the Cloninger's model, confirms the presence of personality pathology as one predictor of non-response to treatment; ii) in patients with low SD a combination of medication and cognitive-behaviour therapy should be the most effective treatment.

Personality and anxiety disorders

Personality traits and most anxiety disorders are strongly related. In this article, we review existing evidence for ways in which personality traits may relate to anxiety disorders: 1) as predisposing factors, 2) as consequences, 3) as results of common etiologies, and 4) as pathoplastic factors. Based on current information, we conclude the following: 1) Personality traits such as high neuroticism, low extraversion, and personality disorder traits (particularly those from Cluster C) are at least markers of risk for certain anxiety disorders; 2) Remission from panic disorder is generally associated with partial "normalization" of personality traits; 3) Anxiety disorders in early life may influence personality development; 4) Anxiety disorders and personality traits are usefully thought of as spectra of common genetic etiologies; and 5) Extremes of personality traits indicate greater dysfunction in patients with anxiety disorders.

The effect of pharmacotherapy on personality disorders in panic disorder: a one year naturalistic study

BACKGROUND

In this prospective study, Personality Disorders (PersD) were evaluated in patients with Panic Disorder (PD), before and after one year of pharmacotherapy to verify whether personality characteristics changed after treatment.

METHOD

Sixty PD patients and 60 sex and age-matched normal controls participated in the study. All subjects were evaluated with the SCID-IV, the Structured Interview for DSM-IV Personality Disorders (SIDP), the SCL-90, the Ham-A and the Ham-D. Patients were treated with paroxetine or citalopram and were evaluated monthly for one year to assess the remission of symptoms. The SIDP was re-administered to the patients at the end of the study.

RESULTS

Before treatment, PD patients showed a higher prevalence (60%) of PersD than normal subjects (8%). After treatment, PersD rate decreased (43%) due to the reduction of the rate of paranoid, avoidant and dependent PersD. When the effect of the treatment on personality traits was evaluated, we found that avoidant traits decreased only in remitted patients, paranoid traits decreased both in remitted and in non-remitted patients, and dependent traits decreased only in patients with major depression comorbidity.

LIMITATIONS

The small sample size and the short length of the follow-up period of our study suggest caution in the generalization of our results.

CONCLUSIONS

In our PD patients, an improvement of symptoms was associated with a reduction of paranoid, avoidant and dependent traits, with a normalization of paranoid traits and a persistence of avoidant and dependent characteristics. Therefore, our data suggest that in PD patients not only paranoid traits but also avoidant and dependent traits show, at least in part, a state phenomenon.

Do Medications Matter in the Context of Cognitive Behavior Therapy for Panic Disorder?

Patients with panic disorder are frequently medicated when they participate in psychotherapy such as cognitive behavioral therapy (CBT). The present study examined the effects of overall medication status, medication type (benzodiazepine versus antidepressant), and medication dose in a large sample of patients with panic disorder (N = 178) participating in CBT. Overall, medications exhibited very little effect on outcome. After controlling for the effects of CBT, however, taking higher doses of antidepressants was associated with poorer end-state functioning. Results are discussed in relation to better understanding the role of combining psychopharmacological and psychosocial treatments for panic disorder.

Predictors of pharmacotherapy response in anxiety disorders

Although treatment with different compounds such as tricyclic antidepressants, selective serotonin reuptake inhibitors, high-potency benzodiazepines, and monoamine oxidase inhibitors has been proven effective in anxiety disorders, 20% to 40% of patients are nonresponders. Given the limited efficacy, the delayed onset of response (it takes several weeks before a clinical effect can be seen for most of these drugs), and the occurrence of side effects associated with pharmacotherapy, predicting response in anxiety disorders would be immensely valuable. This review surveys the literature over the past years on predictors of response to pharmacotherapy in obsessive-compulsive disorder, social anxiety disorder, panic disorder, and posttraumatic stress disorder. Prediction of treatment response may be founded on demographic and clinical variables, neurochemical and electrophysiologic parameters, imaging studies, and genetic markers.

Serum brain-derived neurotrophic factor (BDNF) levels in patients with panic disorder: as a biological predictor of response to group cognitive behavioral therapy

Little is known about biological predictors of treatment response in panic disorder. Our previous studies show that the brain-derived neurotrophic factor (BDNF) may play a role in the pathophysiology of major depressive disorders and eating disorders. Assuming that BDNF may be implicated in the putative common etiologies of depression and anxiety, the authors examined serum BDNF levels of the patients with panic disorder, and its correlation with therapeutic response to group cognitive behavioral therapy (CBT). Group CBT (10 consecutive 1 h weekly sessions) was administered to the patients with panic disorder after consulting the panic outpatient special service. Before treatment, serum concentrations of BDNF and total cholesterol were measured. After treatment, we defined response to therapy as a 40% reduction from baseline on Panic Disorder Severity Scale (PDSS) score as described by [Barlow, D.H., Gorman, J.M., Shear, M.K., Woods, S.W., 2000. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. 283, 2529-2536]. There were 26 good responders and 16 poor responders. 31 age- and sex-matched healthy normal control subjects were also recruited in this study. The serum BDNF levels of the patients with poor response (25.9 ng/ml [S.D. 8.7]) were significantly lower than those of the patients with good response (33.7 ng/ml [S.D. 7.5]). However, there were no significant differences in both groups of the patients, compared to the normal controls (29.1 ng/ml [S.D. 7.1]). No significant differences of other variables including total cholesterol levels before treatment were detected between good responders and poor responders. These results suggested that BDNF might contribute to therapeutic response of panic disorder. A potential link between an increased risk of secondary depression and BDNF remains to be investigated in the future.

Treatment-resistant panic disorder

A substantial number of patients with panic disorder and agoraphobia may remain symptomatic after standard treatment (including selective serotonin reuptake inhibitors, tricyclic antidepressants, benzodiazepines, or irreversible monamine oxidase inhibitors). In this review, recommendations for the treatment of patients with panic disorder and agoraphobia who do not respond to these drugs are provided. Nonresponse to drug treatment could be defined as a failure to achieve a 50% reduction on a standard rating scale after a minimum of 6 weeks of treatment in adequate dose. When initial treatments have failed, the medication should be changed to other standard treatments. In further attempts at treatment, drugs should be used that have shown promising results in preliminary studies, such as venlafaxine. Combination treatments may be used, such as the combination of an selective serotonin reuptake inhibitor and a benzodiazepine. Psychological treatments such as cognitive-behavioral therapy have to be considered in all patients, regardless whether they are nonresponders or not. According to existing studies, a combination of pharmacologic treatment with cognitive-behavioral therapy can be recommended.

Clinicians' predictions of patient response to psychotropic medications

Clinicians prescribe a medication when they assume that there is a reasonable probability of its success. There are many studies on the predictive value of social or clinical information, but these studies do not include the prognosis made by psychiatrists before treatment. These studies indicate that a small to moderate proportion of the total variance of outcome can be predicted from social or clinical information. It is peculiar that there are very few studies on the accuracy of psychiatrists’ “bets” about the effects of psychotropic drugs when they use the clinical characteristics of patients as predictors, considering the practical relevance of predicting the outcome of a psychiatric treatment. The absence of studies on the accuracy of clinicians’ bets or predictions in psychiatry is unfortunate.