Panic attacks in patients with chronic schizophrenia: a complication of long-term neuroleptic treatment

Plasma catecholamine levels before and after paroxetine treatment in patients with panic disorder

Catecholamines such as norepinephrine, epinephrine, and dopamine are closely related to the autonomic nervous system, suggesting that panic disorder may involve elevated catecholamine levels. This study investigated basal and posttreatment catecholamine levels in patients with panic disorder. A total of 29 patients with panic disorder and 23 healthy controls participated in the study. Panic disorder patients received paroxetine treatment for 12 weeks after clinical tests and examination had been conducted. We investigated the difference in basal levels of catecholamine and measured the changes in catecholamine levels before and after drug treatment in panic disorder patients. The basal plasma epinephrine (48.87±6.18 pg/ml) and dopamine (34.87±3.57 pg/ml) levels of panic disorder patients were significantly higher than those (34.79±4.72 pg/ml and 20.40±3.53 pg/ml) of the control group. However, basal plasma norepinephrine levels did not show statistically significant differences between patients and controls. After drug therapy, plasma catecholamine levels were nonsignificantly decreased and norepinephrine levels showed a tendency toward a decrease that did not reach significance. In conclusion, this study suggests the possibility of a baseline increase of plasma catecholamine levels and activation of sympathetic nervous systems in patients with panic disorder which may normalize after treatment with paroxetine.

Schizophrenia comorbid with panic disorder: evidence for distinct cognitive profiles

Patients with comorbid schizophrenia and panic symptoms share a distinct clinical presentation and biological characteristics, prompting some to propose panic psychosis as a separate subtype of schizophrenia. Less is known about these patients' neuropsychological profiles, knowledge of which may facilitate target-specific treatments and research into the etiopathophysiology for such cases. A total of 255 schizophrenia patients with panic disorder (n=39), non-panic anxiety disorder (n=51), or no anxiety disorder (n=165) were assessed with the Wechsler Adult Intelligence Scale-Revised, the Wisconsin Card Sorting Test, the Trail Making Test, the Controlled Oral Word Association Test, the Animal Naming subtest of the Boston Diagnostic Aphasia Examination, and the Wechsler Memory Scale-Revised. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale. Patients with panic disorder demonstrated a higher verbal IQ and better problem solving, set switching, delayed recall, attention, and verbal fluency as compared to schizophrenia patients without comorbid anxiety. The schizophrenia-panic group reported a higher level of dysthymia on stable medication. Our findings suggest that patients with schizophrenia and comorbid panic disorder exhibit distinct cognitive functioning when compared to other schizophrenia patients. These data offer further support for a definable panic-psychosis subtype and suggest new etiological pathways for future research.

Effects of tapering of long-term benzodiazepines on cognitive function in patients with schizophrenia receiving a second-generation antipsychotic

BACKGROUND

The high use of long-term benzodiazepines (BZDs) with second-generation antipsychotics (SGAs) has been identified as an important issue in the treatment of schizophrenia in Japan. The aim of this study was to evaluate the effects of gradual reduction or discontinuation of daytime BZD use on cognitive function and quality of life (QOL) in patients with chronic schizophrenia receiving an SGA.

METHODS

Thirty schizophrenic patients who had received an SGA with concomitant BZDs for at least 3 months were enrolled. Before and 4 weeks after tapering of daytime BZDs, the Brief Assessment of Cognition in Schizophrenia Japanese-language version (BACS-J) and the Schizophrenia Quality of Life Scale Japanese-language version (SQLS-J) were administered. Clinical evaluation also included the Positive and Negative Syndrome Scale (PANSS). To compare for practice effects on the BACS-J, 10 patients with chronic schizophrenia were assessed without tapering BZDs.

RESULTS

BZDs were reduced or discontinued safely in most patients, and no emergent withdrawal symptoms were observed. Significant improvements were shown in verbal memory, working memory, and composite score, as measured by the BACS-J without practice effects. In addition, the motivation/energy score on the SQLS-J, the negative symptoms and total scores on the PANSS significantly improved after tapering BZDs.

CONCLUSION

Reduction or discontinuation of long-term daytime use of BZDs may be warranted in patients with schizophrenia treated with SGAs, as it may improve cognitive function, subjective QOL, and psychiatric symptoms with no significant adverse effects.

How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association

OBJECTIVE

The presence of anxiety disorders (AD) in schizophrenia (SZ) is attracting increasing interest. However, published studies have yielded very broad variations in prevalence rates across studies. The current meta-analysis sought to (1) investigate the prevalence of co-occurring AD in SZ by reporting pooled prevalence rates and (2) identify potential sources of variations in reported rates that could guide our efforts to identify and treat these co-occurring disorders in patients with SZ.

METHODS

We performed a systematic search of studies reporting prevalence of AD in SZ and related psychotic disorders. Mean prevalence rates and 95% confidence intervals (CIs) were first computed for each disorder. We then examined the impact of potential moderators related to patient sampling or to AD assessment methods on these rates.

RESULTS

Fifty-two eligible studies were identified. Pooled prevalence rates and CIs were 12.1% (7.0%-17.1%) for obsessive-compulsive disorders, 14.9% (8.1%-21.8%) for social phobia, 10.9% (2.9%-18.8%) for generalized AD, 9.8% (4.3%-15.4%) for panic disorders, and 12.4% (4.0%-20.8%) for post-traumatic stress disorders. For all disorders, we found significant heterogeneity in rates across studies. This heterogeneity could at least partially be explained by the effect of moderator variables related to patient characteristics or assessment methods.

CONCLUSIONS

AD are highly prevalent in SZ, but important variations in rates are observed between studies. This meta-analysis highlights several factors that affect risk for, or detection of AD in SZ, and could, thus, have an important impact on treatment and outcome of SZ patients.

Impact of panic attacks on quality of life among patients with schizophrenia

OBJECTIVE

Schizophrenia patients had decreased levels of quality of life compared to normal population. The aim of this study was to investigate the impact of panic attacks on quality of life in patients with schizophrenia.

METHODS

Eighty-eight patients with schizophrenia and 85 healthy subjects were included in the study. World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) was given to patients and healthy subjects to assess quality of life. Panic module of Structured Clinical Interview for DSM-IV (SCID) was administered to patients for diagnosis of panic attacks and panic disorder. Positive and Negative Syndrome Scale (PANSS) for symptom severity and Calgary Depression Scale (CDS) for depressive symptoms were administered to the patients.

RESULTS

Patients with schizophrenia demonstrated significantly lower scores compared to healthy controls in all domains of WHOQOL-Bref. Twenty-five patients (28.4%) with schizophrenia had panic attacks (PA) and 10 patients (11.4%) met criteria for panic disorder (PD). Schizophrenia patients with PA had significantly lower scores on psychological domain of WHOQOL-Bref compared to the patients without PA. Schizophrenic patients with panic attacks had higher CDS scores than patients without PA. In the multivariate regression analyses the variance in psychological domain of WHOQOL-Bref was explained by depression rather than panic attack.

CONCLUSION

In patients with schizophrenia comorbid panic attacks may have a negative impact on quality of life, which is associated with depression significantly. Panic attacks and depressive symptomatology must be examined comprehensively in order to improve quality of life in patients with schizophrenia.

Psychiatric comorbidities and schizophrenia

Psychiatric comorbidities are common among patients with schizophrenia. Substance abuse comorbidity predominates. Anxiety and depressive symptoms are also very common throughout the course of illness, with an estimated prevalence of 15% for panic disorder, 29% for posttraumatic stress disorder, and 23% for obsessive-compulsive disorder. It is estimated that comorbid depression occurs in 50% of patients, and perhaps (conservatively) 47% of patients also have a lifetime diagnosis of comorbid substance abuse. This article chronicles these associations, examining whether these comorbidities are "more than chance" and might represent (distinct) phenotypes of schizophrenia. Among the anxiety disorders, the evidence at present is most abundant for an association with obsessive-compulsive disorder. Additional studies in newly diagnosed antipsychotic-naive patients and their first-degree relatives and searches for genetic and environmental risk factors are needed to replicate preliminary findings and further investigate these associations.

Panic symptoms in schizophrenia: comorbidity and clinical correlates

The aim of the present study was to investigate the prevalence of panic attack (PA) and panic disorder (PD) in patients with schizophrenia and detect the clinical features. Forty-nine patients with schizophrenia were included in the study. Positive and Negative Syndrome Scale (PANSS), Hamilton Depression Rating Scale (HDRS), Clinical Global Impression (CGI), Extrapyramidal Symptom Rating Scale (ESRS) and Bandelow Panic and Agoraphobia Rating Scale were administered. Fifteen patients were found to have PA and seven patients had PD. Patients with panic symptoms had higher scores of PANSS, HDRS, CGI and ESRS. Comorbid panic symptoms in schizophrenia may be related to positive symptoms, extrapyramidal side-effects and depression.

Illness appraisals and self-esteem as correlates of anxiety and affective comorbid disorders in schizophrenia

Comorbidity of anxiety and affective disorders in people with a diagnosis of schizophrenia is common. This study investigated the hypothesis that greater negative beliefs about illness and lower self-esteem will be significantly associated with the presence of anxiety or affective comorbidity in a sample of persons (n = 138) diagnosed with schizophrenia. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the Positive and Negative Syndrome Scale; the Global Assessment of Functioning Scale; the Personal Beliefs about Illness Questionnaire; and the Rosenberg Self-Esteem Scale were all completed for each participant. Of the total sample, 62 (44.9%) had a comorbid anxiety or affective disorder. Logistic regression revealed that those with a comorbid anxiety or affective disorder had significantly lower levels of functioning (Global Assessment of Functioning), more negative appraisals of entrapment in psychosis (Personal Beliefs about Illness Questionnaire), and lower levels of self-esteem (Rosenberg Self-Esteem Scale). Although further research is required, the strong association between personal beliefs about self and illness and comorbidity suggests that negative beliefs about psychotic experiences and self-esteem may be linked to the development and maintenance of anxiety and affective comorbid conditions among people with a diagnosis of schizophrenia or the like.

Panic attacks after treatment with zuclopenthixol decanoate

The association between neuroleptics and anxiety is unclear: neuroleptics have been used to treat anxiety though may also themselves be anxiogenic. We present the case of a man who developed new onset panic attacks after treatment with zuclopenthixol decanoate, a commonly administered depot antipsychotic. We review the literature on the association between antipsychotics and anxiety and present possible pathophysiological mechanisms.

Psychiatric symptoms associated with oculogyric crisis: a review of literature for the characterization of antipsychotic-induced episodes

Antipsychotics have been found to induce recurrent psychotic episodes lasting minutes to hours, mostly accompanied by oculogyric crisis (OGC). To characterize this side effect, antipsychotic-induced and postencephalitic OGCs that were reported in the literature were compared to find out common characteristics of OGCs and their associated symptoms. Both postencephalitic and antipsychotic-induced OGCs were found to occur late in the day and at regular intervals, and were associated with autonomic symptoms such as profuse sweating, facial flushing, transitory hypertension and difficulty in micturition. They were often associated also with transient psychiatric episodes: visual hallucinations and illusions, auditory hallucinations, delusions, catatonic phenomena, obsessive thoughts and panic attacks. These (OGC) characteristics will be useful in recognizing antipsychotic-induced psychiatric episodes. The associated psychiatric episodes were noted to recur occasionally also without OGC in a few postencephalic cases, and during gradual dose reduction or after a switch to a novel or low-potency antipsychotic in drug-induced cases. These findings suggest that episodes with the OGC characteristics but without OGC per se, may be less severe reactions to antipsychotic medication than those with OGC, and may represent manifestations of subclinical OGC.

Anxiety disorders in schizophrenia

Data regarding the co-occurrence of anxiety symptoms or syndromes in schizophrenia is scant. Hierarchical assumptions embedded in diagnostic systems and methodologic difficulties hamper the development of studies on accessory symptomatology outside of the core positive-negative-disorganized symptoms. Recent studies have repeatedly challenged these assumptions by presenting data on comorbid disorders in schizophrenia. We review the current knowledge about anxiety comorbidity in schizophrenia, and its relative prevalence, relevance, and treatment. A computerized search of the literature published from 1966 to July 2003 was conducted on Medline using the word "schizophrenia" and the words from the names of each anxiety disorder listed in DSM-IV, one at a time. Only studies including exclusively the diagnosis of schizophrenia were included. Only 15 studies were dedicated to the subject of anxiety comorbidity prevalence in schizophrenia. The most studied comorbidities were obsessive-compulsive disorder (OCD) and panic disorder, and most reports suggested them to be highly prevalent in schizophrenia. Posttraumatic stress disorder (PTSD) was the least studied (N = 2). Except for two pharmacologic studies in OCD, there were no double-blind randomized controlled trials regarding the treatment of anxiety in schizophrenia. Most case reports and open label trials tried conventional treatment for anxiety disorders with some degree of success. The literature indicates that anxiety comorbidities are prevalent in schizophrenia and conventional treatment for anxiety can help alleviate the symptoms in those patients. However, the body of data provided by research so far is still far from allowing evidence-based conclusions. Large studies with operationalized criteria, as well as comprehensive assessments of treatment response and outcome are needed to clarify the relationship between anxiety disorders and schizophrenia.

Anxiety disorders and schizophrenia

Anxiety symptoms and disorders have long been described in schizophrenia. This article reviews the epidemiology, phenomenology, and neurobiologic underpinnings of comorbid anxiety symptoms and disorders in schizophrenia. Recent literature was obtained by Medline searches using key words relating to schizophrenia and anxiety symptoms or disorders. There is some evidence that anxiety may be a core symptom dimension in schizophrenia, although further work is required. There is evidence that comorbid obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and social anxiety disorder are all more common than expected by chance in schizophrenia, although additional work is needed to determine the mechanisms that underlie these associations and their clinical implications. In the interim, however, the data emphasize the importance of assessing and treating comorbid anxiety symptoms and disorders in schizophrenia.

Correlation of panic attacks and hostility in chronic schizophrenia

The aim of this study was to investigate the relationship between panic attacks and hostility in patients with chronic schizophrenia. Thirty-two patients with a minimum 2-year history of treatment for schizophrenia were interviewed. The patients took mood stablizers lithium, carbamazepine and valproate adjunctively for hostility and anger attacks. Panic attacks were defined by Structure Clinical Interview of DSM-IV. Severity of psychopathology was assessed by the Hamilton Depression Rating Scale (HDRS) and Brief Psychiatric Rating Scale (BPRS). Functional level was assessed by the Global Assessment of Functioning Scale (GAF). Eight (25%) patients met the diagnostic criteria for panic attacks (DSM-IV) with affective symptoms including hostility and sudden spells of anger. Their HDRS scores were significantly higher (P < 0.01), and GAF scores were significantly lower (P < 0.05) than those of patients without panic attacks. Patients with panic attacks displayed significantly higher hostility in the score of the BPRS (P = 0.01). Those who received higher doses of neuroleptics were more likely to be considered hostile. Multivariate analysis revealed that panic attacks were correlated with more severe depression, greater hostility and lower GAF scores. The results suggest that increased hostility and anger spells may be symptoms of panic attacks, which are overlooked by psychiatrists.

Social anxiety and premorbid personality disorders in paranoid schizophrenic patients treated with clozapine

The concept of anxiety as a distinct comorbid disorder in schizophrenia has recently been rediscovered after having been neglected for a long period of time due to both theoretical and clinical approaches adopted from the appearance of the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1950. This rediscovery was accentuated by the fact that the concept of comorbidity in various psychiatric disorders has recently won widespread favor within the scientific community, and that the use of atypical neuroleptic medication to treat patients with schizophrenia has been reported to lead to the emergence of anxiety symptoms. Of the atypical neuroleptic medications used to treat schizophrenia, clozapine has most frequently been reported to induce anxiety symptoms. In this paper, 12 cases of patients with paranoid schizophrenia who developed social phobia during clozapine treatment are reported, and their response to fluoxetine augmentation is assessed. Premorbid personality disorders were also investigated; patients were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (DSM-III-R=Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). In addition, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Liebowitz Social Anxiety Scale (LSAS), the Frankfurt Beschwerde Fragebogen (Frankfurt Questionnaire of Complaints), and the Brief Psychiatric Rating Scale were used to rate clinical symptomatology. All patients were reevaluated after 12 weeks of cotreatment with clozapine and fluoxetine. In 8 (66.6%) of the 12 cases, symptoms responded (>/=35% LSAS score reduction) to an adjunctive regimen of fluoxetine. Furthermore, in 7 (58.3%) of the 12 cases, an anxious personality disorder (avoidant=33.3%; dependent=25%) was identified, but no significant differences in the prevalence of comorbid personality disorders emerged in comparison with a group of 16 patients with paranoid schizophrenia treated with clozapine who did not show symptoms of social phobia. The clinical relevance of the assessment and treatment of anxiety disorders is discussed in light of a clinical therapeutic approach that overcomes the implicit hierarchy of classification. Considering that the onset of anxiety-spectrum disorders (such as social phobia) can occur during the remission of psychotic symptoms in clozapine-treated patients with schizophrenia, a comprehensive approach to pharmacological therapy for patients with schizophrenia (or, at least for those treated with clozapine) should be adopted.