Life events in childhood, adolescence and adulthood and the relationship to panic disorder

Peripheral Endocannabinoid Components and Lipid Plasma Levels in Patients with Resistant Migraine and Co-Morbid Personality and Psychological Disorders: A Cross-Sectional Study

Resistant migraine characterizes those patients who have failed at least three classes of migraine prophylaxis. These difficult-to-treat patients are likely to be characterized by a high prevalence of psychological disturbances. A dysfunction of the endocannabinoid system (ECS), including alteration in the levels of endocannabinoid congeners, may underlie several psychiatric disorders and the pathogenesis of migraines. Here we explored whether the peripheral gene expression of major components of the ECS and the plasma levels of endocannabinoids and related lipids are associated with psychological disorders in resistant migraine. Fifty-one patients (age = 46.0 ± 11.7) with resistant migraine received a comprehensive psychological evaluation according to the DSM-5 criteria. Among the patients, 61% had personality disorders (PD) and 61% had mood disorders (MD). Several associations were found between these psychological disorders and peripheral ECS alterations. Lower plasma levels of palmitoiletanolamide (PEA) were found in the PD group compared with the non-PD group. The MD group was characterized by lower mRNA levels of diacylglycerol lipase α (DAGLα) and CB2 (cannabinoid-2) receptor. The results suggest the existence of peripheral dysfunction in some components of the ECS and an alteration in plasma levels of PEA in patients with resistant migraine and mood or personality disorders.

Psychological predictors of negative treatment outcome with Erenumab in chronic migraine: data from an open label long-term prospective study

Background

Monoclonal antibodies (mABs) targeting the calcitonin gene-related peptide (CGRP) pathway represent the first disease-specific preventive migraine therapy. Growing evidence suggests that they are effective in the preventive treatment of difficult-to-treat patients. In this study, we evaluated the psychological predictors of the outcome of treatment with the anti-CGRP monoclonal antibody erenumab in patients with chronic migraine (CM).

Methods

Seventy-five patients with CM who had already failed at least 3 preventive therapies received erenumab every 28 days for a period of 12 months. Before the first administration, patients received a full psychological evaluation using The Structured Clinical Interview for DSM-5 Clinician Version (SCID-5-CV) to assess personality disturbances (primary outcome), mood and anxiety disorders, and as well specific questionnaires to evaluate alexithymia traits, childhood traumas, and current stressors (secondary outcomes).

Results

After 12 months of treatment, 53 patients reported a reduction of at least 50% in headache days/per month (Responders), whereas 22 did not (Non Responders). When compared to Responders, Non Responders were characterized by a higher prevalence of personality disorders belonging to Cluster C (avoidant, dependent, and obsessive-compulsive) (77% vs 37%, p = .001). Non Responders were also characterized by a higher prevalence of anxiety disorders (90% vs 60%, p = 0.007), showed more alexithymic traits (51.7 ± 13.7 vs 42.9 ± 14.3, p = 0.017), and reported a higher number of 'at least serious' current stressors (3.2 ± 4.0 vs 0.8 ± 1.4, p < .0001) than Responders. At the multivariate analysis, higher prevalence of Cluster C personality disorders (OR 3.697; p = 0.05) and higher number of ‘at least serious’ life events (OR 1.382; p = 0.017) arose as prognostic factors of erenumab failure.

Conclusions

Erenumab confirmed its effectiveness in a population of difficult-to-treat migraine. The presence of “anxious-fearful” personality together with current stressors and anxiety represent negative predictors of treatment outcome.

Trial registration

The study protocol was registered at clinicaltrials.gov (NCT04361721).

Mouse model of panic disorder: Vulnerability to early environmental instability is strain-dependent

Early life experiences and genetic background shape phenotypic variation. Several mouse models based on early treatments have evaluated short- and long-term phenotypic alterations and explored their molecular mechanisms. The instability of maternal cues was used to model human separation anxiety in outbred mice, one of the etiopathogenetic factors that predict panic disorder (PD). Application of the repeated cross-fostering (RCF) protocol to inbred strains (C57 and DBA) allowed us to measure differential responses to the same experimental manipulation. Ultrasounds emitted during isolation indicated that after RCF, pups from both strains lose their ability to be comforted by nest cues, but the frequency modulation of separation calls increased in RCF-C57 and decreased in RCF-DBA mice. No strain-specific difference in olfactory ability explained these responses in RCF-exposed mice. Rather, disruption of the infant-mother bond may differentially affect separation calls in the two strains. Moreover, the RCF-associated increased respiratory response to hypercapnia-an endophenotype of human PD documented among mice outbred strains-was replicated in the C57 strain only. We suggest that RCF-induced instability of the early environment affects emotionality and respiratory physiology differentially, depending on pups' genetic background. These strain-specific responses provide a lead to understand differential vulnerability to emotional disorders.

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.

Early sexual trauma is related with the tapetum in patients with panic disorder

BACKGROUND

Early trauma exposure is suggested to confer a greater risk for the development of panic disorder (PD) by altering neurodevelopmental processes. A body of studies have shown that white matter microstructures, particularly in the fronto-limbic and callosal regions, could be affected by a history of early trauma in patients with PD. The tapetum, the extended posterior part of the corpus callosum connecting the bilateral temporal lobes, has not yet been studied regarding its relationship with early trauma, especially sexual one.

METHODS

Seventy participants with PD, sixty age- and sex-matched healthy controls were enrolled. The Early Trauma Inventory Self Report-Short Form (ETISR-SF), Neuroticism Scale, and Panic Disorder Severity Scale (PDSS) were administered. Voxel-wise statistical analysis of diffusion tensor imaging data was performed within the bilateral tapetum regions using Tract-Based Spatial Statistics (TBSS).

RESULTS

In participants with PD, higher levels of sexual trauma were significantly associated with the increased fractional anisotropies (FAs) in a cluster of the right tapetum. Exploratory correlation analysis revealed that FAs in this cluster were significantly correlated with higher neuroticism and poorer treatment response after one year of pharmacotherapy. No significant correlation was found between FAs of the right tapetum cluster and the PDSS scores.

LIMITATIONS

The possibility of retrospective recall bias for early trauma cannot be completely ruled out.

CONCLUSIONS

The findings of this study suggest that the right tapetum may serve as a potential neural marker of early sexual trauma in patients with PD and contribute to personal vulnerability and poorer treatment outcome after pharmacotherapy.

Amiloride modulation of carbon dioxide hypersensitivity and thermal nociceptive hypersensitivity induced by interference with early maternal environment

BACKGROUND

Early life adversities are risk factors for anxiety disorders and for pain syndromes, which are, in turn, highly comorbid with anxiety disorders. Repeated cross-fostering mouse pups to adoptive lactating females induces epigenetic modification and heightened mRNA-expression of the acid-sensing-ion-channel-1 gene, altered nociception, and hypersensitivity to 6% carbon dioxide air mixtures, a trait marker of specific human anxiety disorders such as, most clearly and prominently, panic disorder.

AIMS

We hypothesized that the acid-sensing ion channel inhibitor amiloride can modulate repeated cross-fostering animals' exaggerated responses to carbon dioxide and nociceptive thermal stimulation.

METHODS

Respiratory carbon dioxide sensitivity was assessed by plethysmography during 6% carbon dioxide air mixture challenges, and nociception was assessed by latency of paw withdrawal to thermal stimulation, in repeated cross-fostering and control animals. To circumvent the blood-brain barrier, prior to testing, amiloride was nebulized in a plethysmograph. Data were analyzed by general linear models.

RESULTS

Analyses of tidal volume responses to 6% carbon dioxide of animals pre-treated with nebulized amiloride/saline in a randomized crossover design showed significant modulatory effect of amiloride, and amiloride×repeated cross-fostering interaction. In contrast, repeated cross-fostering animals' responses to 6% carbon dioxide after intraperitoneal amiloride, saline, or no treatment, were no different. Analyses of responses to thermal stimuli showed a significant modulatory effect of nebulized amiloride, and repeated cross-fostering×amiloride interaction.

CONCLUSIONS

Single-dose nebulized amiloride decreased repeated cross-fostering animals' carbon dioxide sensitivity and nociception indices to levels that were no different from those of control animals. Inasmuch as these results pertain to human anxiety and/or pain hypersensitivity, our findings provide a rationale for studying inhaled amiloride in some anxiety disorders and/or pain syndromes.

Cognitive Behavioral Therapy vs. Eye Movement Desensitization and Reprocessing for Treating Panic Disorder: A Randomized Controlled Trial

Objective: Cognitive Behavioral Therapy (CBT) is an effective intervention for patients with panic disorder (PD). From a theoretical perspective, Eye Movement Desensitization and Reprocessing (EMDR) therapy could also be useful in the treatment of PD because: (1) panic attacks can be experienced as life threatening; (2) panic memories specific to PD resemble traumatic memories as seen in posttraumatic stress disorder (PTSD); and (3) PD often develops following a distressing life event. The primary objective of this Randomized Controlled Trial (RCT), was to compare EMDR therapy with CBT for PD and determine whether EMDR is not worse than CBT in reducing panic symptoms and improving Quality Of Life (QOL). Methods: Two-arm (CBT and EMDR) parallel RCT in patients with PD (N = 84). Patients were measured at baseline (T1), directly after the last therapy session (T2), and 3 months after ending therapy (T3). Non-inferiority testing (linear mixed model with intention-to-treat analysis) was applied. Patients were randomly assigned to 13 weekly 60-min sessions of CBT (N = 42) or EMDR therapy (N = 42). Standard protocols were used. The primary outcome measure was severity of PD at T3, as measured with the Agoraphobic Cognitions Questionnaire (ACQ), the Body Sensations Questionnaire (BSQ), and the Mobility Inventory (MI). The secondary outcome measure was QOL, as measured with the World Health Organization Quality of Life short version (WHOQOL-Bref), at T3. Results: The severity of PD variables ACQ and BSQ showed non-inferiority of EMDR to CBT, while MI was inconclusive (adjusted analyses). Overall QOL and general health, Psychological health, Social relationships, and Environment showed non-inferiority of EMDR to CBT, while Physical health was inconclusive. Conclusion: EMDR therapy proved to be as effective as CBT for treating PD patients. Trial Registration: Dutch Trial Register, Nr. 3134 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3134.

Impact of childhood trauma on course of panic disorder: contribution of clinical and personality characteristics

OBJECTIVE

To investigate the impact of childhood trauma on the clinical course of panic disorder and possible contributing factors.

METHOD

Longitudinal data of 539 participants with a current panic disorder were collected from the Netherlands Study of Depression and Anxiety (NESDA). Childhood trauma was assessed with a structured interview and clinical course after 2 years with a DSM-IV-based diagnostic interview and the Life Chart Interview.

RESULTS

At baseline, 54.5% reported childhood trauma, but this was not predictive of persistence of panic disorder. Emotional neglect and psychological abuse were associated with higher occurrence of anxiety disorders other than panic disorder (social phobia) and with higher chronicity of general anxiety symptoms (anxiety attacks or episodes and avoidance). Baseline clinical features (duration and severity of anxiety and depressive symptoms) and personality traits (neuroticism and extraversion) accounted for roughly 30-60% of the total effect of childhood trauma on chronicity of anxiety symptoms and on occurrence of other anxiety disorders.

CONCLUSION

After two years, childhood trauma is associated with chronicity of anxiety symptoms and occurrence of social phobia, rather than persistence of panic disorder. These relationships are partially accounted for by duration and severity of anxiety and depressive symptoms, and neuroticism and extraversion.

EMDR in the Treatment of Panic Disorder With Agoraphobia: A Case Description

The results of preliminary research investigating the application of eye movement desensitization and reprocessing (EMDR) treatment in panic disorder and panic disorder with agoraphobia suggests that reprocessing of past traumas produces significant reduction of anxiety and consequently, remission from panic attacks and avoidance behavior. This article describes the case study of a 30-year-old working professional where EMDR treatment, used to target early childhood traumas, led to reduction in symptoms of panic disorder with agoraphobia. Panic attacks diminished after 17 sessions of EMDR treatment, which followed Leeds’s treatment model. Treatment gains were maintained 5 years after termination. The study shows the value of solid preparation work, and of addressing the current triggers and recent events, before targeting historical traumas. EMDR worked as a first-line treatment to resolving the roots of the panic attacks, suggesting that the resolution of traumatic childhood memories can make a significant difference to current symptoms of panic disorder with agoraphobia.

Serotonergic genes (5-HTT and HTR1A) and separation life events: gene-by-environment interaction for panic disorder

BACKGROUND

The polymorphisms of serotonergic genes (5-HTTLPR and HTR1A rs6295) and separation life events have been studied to find an association with panic disorder, respectively. However, there are no studies that have yet evaluated the interaction effect between serotonergic genes and separation life events for panic disorder.

METHODS

For this study, 194 panic disorder patients and 172 healthy controls were included for genotyping and environmental factor analysis. Separation life events were assessed using the Stressful Life Events Scale and clinical interviews. To evaluate the potential endophenotypes of panic disorder, the Anxiety Sensitivity Index-revised (ASI-R), harm avoidance in the Temperament and Character Inventory (HA), and neuroticism in the Eysenck Personality Questionnaire (neuroticism) scales were administered.

RESULTS

For 5-HTTLPR and HTR1A rs6295, there was no significant main effect of each genotype on panic disorder alone. However, the number of separation life events and their interaction with 5-HTTLPR showed a statistically significant effect on panic disorder. In addition, the interaction between 5-HTTLPR and the number of separation life events significantly affected the HA for potential endophenotypes.

CONCLUSION

This study could suggest the effect of the interaction between 5-HTTLPR and separation life events on panic disorder and its potential endophenotype.

Examining determinants of early and late age at onset in panic disorder: an admixture analysis

Past research demonstrated that age at onset might account for different clinical and etiological characteristics in panic disorder (PD). However, prior research relied on arbitrary choices of age cut-offs. Using a data-driven validated method, this study aimed to examine differences between early and late onset PD in various determinants. Admixture analysis was used to determine the best fitting model of age at onset distribution in PD. Data was collected from 511 individuals (ages 18-65) with PD diagnoses, who participated in the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV comorbidities and various measures of childhood adversities, suicidal behavior, anxiety and depressive symptoms were assessed. The best fitting cut-off score between early and late age at onset groups was 27 years (early age at onset ≤ 27 years). Univariate tests showed that participants with early onset PD were younger and more likely to be female. Early onset PD was associated with agoraphobia, higher frequency of childhood trauma and life events, and higher rates of suicide attempts as compared to late onset PD. Multivariate logistic regression analysis demonstrated that only current age, childhood trauma and agoraphobia remained significantly associated with early onset PD. Findings suggest that 27 years marks two onset groups in PD, which are slightly distinct. Early onset PD is independently associated with exposure to childhood trauma and increased avoidance. This highlights the importance of subtyping age of onset in PD. Clinical implications are further discussed.

Associations between parenting behavior and anxiety in a rodent model and a clinical sample: relationship to peripheral BDNF levels

Adverse early-life environment is associated with anxiety-like behaviors and disorders. Brain-derived neurotrophic factor (BDNF) is sensitive to this environment and could be a marker of underlying brain changes. We aimed at evaluating the development of anxiety-like behaviors in a rat model of early adversity, as well as the possible association with BDNF levels. Similar associations were investigated in a sample of adolescent humans. For the rat study, Wistar rat litters were divided into: early-life stress (ELS, limited access to nesting material) and control groups. Maternal behavior was observed from days 1 to 9 of life and, as adults, rats were subjected to behavioral testing and BDNF measurements in plasma, hippocampus, amygdala and periaqueductal gray. For the human study, 129 adolescents were evaluated for anxiety symptoms and perceived parental care. Serum BDNF levels and the Val66Met polymorphism of the BDNF gene were investigated. We found that ELS dams showed more pure contact, that is, contact with low care and high control, toward pups, and their adult offspring demonstrated higher anxiety-like behaviors and plasma BDNF. Also the pure contact correlated positively with adult peripheral BDNF. Similarly in humans, there was a positive correlation between maternal overprotection and serum BDNF only in Met carriers. We also found negative correlations between maternal warmth and separation anxiety, social phobia and school phobia. Finally, our translational approach revealed that ELS, mediated through variations in maternal care, is associated with anxiety in both rats and humans and increased peripheral BDNF may be marking these phenomena.

Gene-environment interactions in panic disorder and CO₂ sensitivity: Effects of events occurring early in life

Heterogeneous life events (LE) precede the onset of-and potentially increase the susceptibility to-panic disorder (PD). It remains unknown whether LE can act as moderators in the context of gene-by-environment interactions (G×E) that alter the susceptibility to PD and the related trait of CO₂ sensitivity, nor it is known whether such moderation may depend on occurrence of events at different epochs in life. In 712 general population twins we analyzed by Maximum Likelihood analyses of ordinal data whether life (major- and stressful) events moderate the genetic risk for PD and CO₂ sensitivity, as indexed by the 35% CO₂ /65% O₂ challenge. For CO₂ sensitivity, best-fitting models encompassed both additive and interactional effects that increased linearly with the cumulative number and severity (SEV) of events in lifetime. By analyzing the moderation effect of cumulative SEV separately for events that had occurred in adulthood (between age 18 and 37) or during childhood-adolescence (before the 18th birthday), we found evidence of G×E only within the childhood-adolescence window of risk, although twins had rated the childhood-adolescence events as significantly (P = 0.001) less severe than those having occurred during adulthood. For PD, all interactional terms could be dropped without significant worsening of the models' fit. Consistently with a diathesis-stress model, LE appear to act as moderators of the genetic variance for CO₂ sensitivity. Childhood-adolescence appears to constitute a sensitive period to the action of events that concur to alter the susceptibility to this panic-related trait.

Genetics of panic disorder: focus on association studies and therapeutic perspectives

There is evidence for either genetic heterogeneity or complex inheritance with an interaction of environmental factors and multiple single genes in the etiology of panic disorder. Although linkage analyses of panic disorder have implicated several chromosomal regions including 1q, 2q, 4q, 7p, 9q, 12q, 13q, 15q and 22q, they so far have not been able to identify a major gene responsible for panic disorder. Several genes of classical candidate neurotransmitter systems have been reported to be associated with panic disorder. Genetic variation in genes of monoamine oxidase A, catechol-O-methyltransferase, adenosine receptor (ADORA2A) and cholecystokinin B receptor have been inconsistently replicated. There are multiple lines of evidence for highly relevant effects of gender and ethnicity. Future research strategies might focus on broad phenotypes defined by comorbidity or intermediate phenotypes and include the use of animal models for identifying candidate genes, such as the regulator of G-protein signaling (RGS2) gene, genome-wide association studies in large samples, studies of gene-gene and gene-environment interactions and pharmacogenetic studies. The identification of novel pathophysiological pathways may provide the basis for the development of novel therapeutic interventions.

Life events in panic disorder-an update on "candidate stressors"

Studies on gene-environment interactions in mental disorders are characterized by powerful genetic techniques and well defined "candidate genes," whereas a definition of "candidate stressors," in most cases assessed in the form of life events (LEs), is inconsistent or not even provided. This review addresses this problem, with particular attention to the clinical phenotype of panic disorder (PD), by providing an overview and critical discussion for which life events are known to contribute to the etiology of the disease and how they may be conceptualized. There is converging evidence for a significant impact of cumulative as well as specific life events, such as threat, interpersonal and health-related events in adulthood, and abuse or loss/separation experiences in childhood, respectively, on the pathogenesis of panic disorder with some overlapping effect across the anxiety disorder spectrum as well as on comorbid major depression. Besides genetic vulnerability factors, personality and behavioral characteristics, such as anxiety sensitivity, neuroticism, and cognitive appraisal might moderate the influence of LEs on the development of panic disorder. The present state of knowledge regarding the specification and conceptualization of LEs in PD within a more complex multifactorial model, involving mediating and moderating factors in between genes and the clinical phenotype, is hoped to aid in informing future gene-environment interaction studies in panic disorder.

A comparison of life events in patients with unipolar disorder or bipolar disorder and controls

OBJECTIVE

The present study aimed to explore the association between stressful life events (LEs) and the development of affective psychopathology.

METHOD

Thirty patients with unipolar disorder and 30 patients with bipolar disorder were compared to 60 matched healthy controls in regard to the rate of stressful LEs. Assessment measures included the Beck Depression Inventory, the Adult Life Events Questionnaire, and the Childhood Life Events List.

RESULTS

The entire sample of affective patients had more LEs in general, more negative LEs, and more loss-related LEs in the year preceding their first depressive episode as compared with normal controls. Subjects with unipolar disorder had more positive LEs and more achievement LEs, whereas subjects with bipolar disorder had more uncontrollable LEs in the year preceding the first depressive episode. The relationship between LEs and manic episodes was prominent in the year preceding the first manic episode, with subjects with bipolar disorder reporting more LEs in general and more ambiguous events in that year. Almost no significant differences on LE frequency were observed in the year before the last depressive and manic episodes in the patient groups with unipolar and bipolar disorder. A significant relationship was found between childhood LEs and the development of affective disorders in adulthood, with patients with unipolar disorder exhibiting less positive and achievement LEs.

CONCLUSIONS

In both the unipolar and the bipolar groups, the major impact of LEs on the onset of affective disorders was found in the year before the first depressive or manic episodes. This suggests that the accumulation of stressful LEs at this crucial period contributes to the precipitation of a pathological response mechanism. Once established, this mechanism would be reactivated in the future by even less numerous and less severe stressors, compatible with the kindling hypothesis.

Baseline cortisol measures and developmental pathways of anxiety in early adolescence

OBJECTIVE

This study investigated whether baseline cortisol measures predicted future anxiety, and compared cortisol values of groups with different developmental pathways of anxiety.

METHOD

Cortisol levels were assessed in 1768 individuals (10-12 years). Anxiety levels were assessed at the same age and 2 years later.

RESULTS

Cortisol measures did not predict future anxiety levels. Individuals with persistent anxiety problems did not show higher morning cortisol levels than those with persistently low, decreasing, or increasing anxiety levels. Instead, individuals with persistently high anxiety levels showed significantly lower evening cortisol levels than all other individuals. Further, participants with increasing anxiety levels showed higher morning cortisol levels (area under the curve; AUC) than individuals with persistently low anxiety levels.

CONCLUSION

The extent to which the HPA-axis - by itself - plays a role in the aetiology of anxiety is questionable. Interactions of the HPA-axis with other biological or environmental factors may be more important.

Nocturnal panic and recent life events

Recent research has hypothesized an association between traumatic events and nocturnal panic (NP). The purpose of this study was to investigate whether the onset of nocturnal panic attacks is associated with a higher frequency of and/or greater severity of stressful or traumatic life events than that of patients with panic disorders (PDs) who experience daytime panic attacks (DPs) while awake. A secondary aim was to investigate whether NP is associated with specific life events at the onset of the disorder. Our sample comprised 129 subjects with PD (DSM-IV). We investigated the number and types of stressful life events that occurred in the year prior to PD onset using a semistructured interview. Of the sample, 28.7% had recurrent nocturnal panic attacks (NP group). Subjects with and without recurrent NP did not differ on any sociodemographic or clinical characteristic. Neither the number nor type of life event distinguished those with or without NP. The subgroup of patients with PD with recurrent NP appears to represent a variant of PD with a possible increased vulnerability to conditions of diminished arousal as a trigger of panic attacks. However, the hypothesis that this vulnerability might be determined by life events that occur in the period preceding PD onset was not supported by the findings of this study.

The Role of High-Potency Benzodiazepines in the Treatment of Panic Disorder

Medication plays a central role in the treatment of panic disorder, with the goal of eliminating panic attacks and restoring normal function (i.e., achieving full remission). Four drug classes have similar efficacy (tricyclic antidepressants, selective serotonin reuptake inhibitors [SSRIs], benzodiazepines, and monoamine oxidase inhibitors). Nonetheless, benzodiazepines remain the most prescribed medication for panic disorder in the United States. The high-potency benzodiaze-pines alprazolam (available as immediate- and extended-release tablets) and clonazepam (available as tablets and orally disintegrating wafers) are the only benzodiazepines approved by the U.S. Food and Drug Administration for the treatment of panic disorder. High-potency benzodiaze-pines, with their proven efficacy in panic disorder exerted through control of the central nervous system excitability by a selective and potent enhancement of inhibitory gamma-aminobutyric acid-mediated neurotransmission, are also a safe and well-tolerated option for potentiation of rapid treatment response when initiating treatment with SSRIs. Judicious use of high-potency benzodiazepines followed by a cautious taper and discontinuation may optimize the benefits and minimize any potential risk associated with this class of drugs.

Panic disorder in menopause: a case control study

OBJECTIVE

The course of panic disorder (PD) is often influenced by the different phases of the female reproductive cycle. The aim of this study is to assess PD in the climacteric stage and single out possible correlations between symptoms of PD and clinical and demographic variables in order to identify possible risk factors.

METHOD

Forty-five women between 40 and 60 years of age was assessed through the SCL-90, the SCID, a "Climacteric Symptoms Questionnaire" (CSQ) devised to evaluate psychological symptoms typically associated with menopause, the Kupperman Index for the analysis of climacteric symptoms, and plasma level of allopregnanolone (ALLO).

RESULTS

PD results in eight patients (18%). This group does not differ from the controls as far as socio-demographic data is concerned, but exhibits significantly higher values in the Kupperman Index, the SCL-90 total, and the CSQ. The plasma levels of ALLO correlate significantly inversely with the total of CSQ and, in any case, negatively with the other variables analysed.

CONCLUSIONS

PD may arise and worsen with menopause, in correlation with greater severity of the climacteric syndrome in its physical and psychological symptoms.

Life events and personality factors in children and adolescents with obsessive-compulsive disorder and other anxiety disorders

The association among life events, personality factors, and anxiety disorders in children and adolescents was assessed in 28 children with obsessive-compulsive disorder (OCD), 28 children with other anxiety disorders (AD), and 24 normal controls using the Life Events Checklist (LEC) and the Junior Temperament and Character Inventory (JTCI). No significant differences were found among the groups for demographic and clinical characteristics. Children with OCD had significantly more total life events and more negative life events in the year before onset than normal controls, and they perceived the life events as having more impact. Scores for children with other AD fell between the other two groups for most of the life event parameters. The only specific life event that distinguished children with AD from normal controls was major illness or injury of a relative. High anxiety levels and older age--but not depression level--predicted a greater perceived impact of life events. Children with OCD and other AD both scored higher than normal controls on the harm avoidance parameter of the JTCI. Harm avoidance scores correlated positively and significantly with the reported occurrence of negative life events and their perceived impact. Thus, quantity, quality, and specificity of life events may be associated with AD in young people, especially OCD. This association may be related to the personality characteristic of harm avoidance.

Adverse life events and coping skills in panic disorder

Research literature and clinical experience shows that panic patients are often able to identify stressors that preceded the onset of their first attacks. In this study we investigated the relation between life events, coping skills, and panic disorder. METHODS: Forty-tree panic patients were compared with 29 control subjects regarding the occurrence and the impact of stressful life events in a 1-year period preceding the onset of panic attacks using the Social Readjustment Rating Scale and London Life Event and Difficulty Schedule. Coping skills were measured using the Ways of Coping Questionnaire. RESULTS: No differences were observed between panic patients and controls regarding the number of reported stressful life events in the previous year. Panic patients compared to controls reported loss of social support as the most meaningful class of events significantly more often. In response to stressful situations, panic patients more often used coping skills judged as ineffective. CONCLUSIONS: The present study suggests that the type of life event and the coping skills used in response to them, more than the occurrence of stressful events itself, may be associated with the onset of panic disorder.

Marital relationship and the treatment of panic disorder with agoraphobia: a critical review

The purpose of this paper is (1) to specify, among studies on the links between marital relationship and cognitive-behavioral treatment of panic disorder with agoraphobia (PDA), the conceptual and methodological limitations that may have produced inconsistent results in this field so far; and (2) to propose avenues of research that will help in remedying current weaknesses and answering important questions in this area. Following definition of PDA and a survey of its socioeconomic consequences, the authors examine results of the various ways research has tried to specify the links between marital relationship and the development, maintenance, and treatment of this disorder: the study of major life events before and after the onset of PDA, interpersonal problems and quality of marital relationship in the presence of PDA, the links between marital relationship and PDA treatment outcome, variability of experimental outcomes according to types of measure used to study these links, the effect of the spouse as co-therapist in PDA treatment, and the impact of a PDA treatment based on marital communication and problem-solving. Research hypotheses and methodological procedures are proposed to improve understanding of PDA and its treatment outcome.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with panic disorder

Traumatic life events during childhood and parental attitudes are discussed as possible etiological factors for panic disorder (PD). Patients with PD (n = 115) and subjects without a history of psychiatric disorders (n = 124) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders, and birth risk factors. The frequency of reports of some traumatic childhood experiences was significantly different between patients and controls, including death of father, separation from parents, childhood illness, parents' alcohol abuse, violence in the family, sexual abuse, and other factors. On a 0 to 9 "severe trauma scale" patients had significantly more severe traumatic events (mean score, 1.31; SD 1.21) than control subjects (0.52; SD 0.80; P <.0001). Only 31.3% of the panic patients, but 62.9% of the controls, did not report any severe traumatic events at all (P <.0001). Compared to controls, patients described the attitude of their parents as more restricting and providing less loving care and attention. Patients reported significantly higher rates of psychiatric disorders in their families in general, in particular PD and generalized anxiety disorder. Birth risk factors did not differ significantly. In a logistic regression model, the following possible etiological factors showed a significant influence: family history of anxiety disorders, severe traumatic events during childhood, and unfavorable parental attitudes. The present data support the hypothesis that the etiology of PD is multifactorial and that traumatic life events may be a contributing factor. Owing to the retrospective nature of the data, the results have to be interpreted with caution.

Gender-related differences in the onset of panic disorder

OBJECTIVE

To investigate gender-related differences in premorbid conditions and in the role of triggering events in the onset of panic disorder (PD).

METHOD

One hundred and eighty-four out-patients with a principal diagnosis of PD (DSM-IV) were evaluated with a semi-structured interview to generate Axis I and Axis II diagnoses according to DSM-IV, to collect family history of psychiatric disorders and life events. The statistical analysis was performed comparing men and women.

RESULTS

Men and women showed similar age at onset of PD. A family history of mood disorders characterized females. Men had higher rates of cyclothymia, body dysmorphic disorder and depersonalization disorder preceding PD, while women had higher rates of bulimia nervosa. Dependent and histrionic PDs were more common among women, while borderline and schizoid PDs were more common among men. Life events showed a significant role in precipitating PD onset in women.

CONCLUSION

Premorbid clinical conditions of PD seem to differentiate between males and females in the role of precipitating events.