Personalized virtual reality exposure for panic disorder and agoraphobia: A preliminary neurophysiological study

BACKGROUND

Personalization is considered an important principle in virtual reality (VR) exposure therapy. We aimed to identify whether personalized VR exposure could provoke increased anxiety in patients with panic disorder and agoraphobia as it is considered the first step in successful treatment for anxiety.

METHODS

We performed a double-arm, one-day preliminary study among 28 patients with panic disorder and agoraphobia. Three sessions of VR exposure, including a theater, train, and elevator scenario, were conducted in two groups. In the personalized group (n = 14), the brightness and crowd density were customized based on a pre-assessment. In the control group (n = 14), these conditions were fully randomized. Self-reported anxiety, heart rate, skin conductance, and electroencephalography were measured before, during, and after the VR sessions.

RESULTS

In the later VR sessions, higher self-reported anxiety levels measured by the Visual Analogue Scale were observed in the personalized exposure group. Increased heart rates during and after the VR sessions were observed in the personalized group. The changes in skin conductance peaks were not significantly different between the groups, but the increase in skin conductance was associated with the participants' perception of presence. The electroencephalogram showed widespread increases in alpha waves in the frontal and temporal areas of the brain in the personalized group than in the control group.

CONCLUSION

Personalized VR exposure elicits stronger anxiogenic effects in patients with panic disorder and agoraphobia as suggested by self-report and neurophysiological data. Personalization of VR exposure has the potential for effective behavioral therapy.

Agoraphobia and panic attacks complicated by primary aldosteronism improved by treatment with eplerenone: a case report

BACKGROUND

Primary aldosteronism (PA) is an adrenal gland disease, that induces increased secretion of the mineralocorticoid, aldosterone, resulting in symptoms such as hypertension. This study reports a patient with agoraphobia and panic attacks, associated with PA. This patient's psychiatric symptoms improved after treatment with eplerenone, a mineralocorticoid receptor antagonist.

CASE PRESENTATION

The patient was a 40-year-old female with agoraphobia, which refers to the irrational fear of situations that may cause anxiety, and panic attacks characterized by profuse sweating, palpitations, and generalized weakness. She was diagnosed with hypertension from PA. Subsequently, she received treatment with eplerenone, which improved her agoraphobia and panic attacks.

CONCLUSIONS

There have been no previous reports on PA associated with agoraphobia and panic attacks that improved with pharmacotherapy. Patients with agoraphobia and panic attacks should be evaluated for PA. In patients with PA, pharmacotherapy with eplerenone should be considered.

Gender differences in anxiety and depressive symptomatology determined by network analysis in panic disorder

BACKGROUND

It has been suggested that gender differences in anxiety and depressive symptoms characterize panic disorder (PD) in terms of vulnerability to stressful life events, anxiety, depressive symptom patterns, and brain structure. However, few studies have investigated the gender differences in PD using a network approach.

METHODS

This study included 619 participants with PD (313 men). The Panic Disorder Severity Scale, Albany Panic and Phobia Questionnaire, and Beck Depression Inventory-II were used to evaluate symptomatology. To investigate the PD-related white matter (WM) neural correlates, tract-based spatial statistics were used. The PD-related clinical scales and WM neural correlates were included in the network analysis to identify associations between variables. To evaluate network differences between genders, network comparison tests were conducted.

RESULTS

Our findings revealed that agoraphobia in men was the strongest central symptom. In addition, loss of pleasure, and not anxiety or panic symptoms, was the strongest central symptom in women with PD. The network comparison test revealed that the bridge strength score was higher in agoraphobia and tiredness in men and in self-criticalness in women. Furthermore, in the network that includes neural correlates of WM, the bridge strength score was higher in the cingulate gyrus WM in men and the cingulum hippocampus in women.

LIMITATIONS

Since this is a cross-sectional network study of PD patients, the causal relationship between interactions in this network analysis for both genders may not be accurately determined.

CONCLUSION

Network structures of anxiety and depressive symptomatology and related WM neural correlates can differ according to gender in PD patients.

Afraid to go out: Poor quality of life with phobic anxiety in a large cross-sectional adult epilepsy center sample

PURPOSE

People with epilepsy (PWE) have unmet healthcare needs, especially in the context of mental health. Although the current literature has established increased incidence of anxiety and depression in PWE and their contribution to poor quality of life, little is known regarding the presence and impact of specific phobia and agoraphobia. Our aim was to assess factors associated with high phobic/agoraphobic symptoms in a large, single tertiary epilepsy center sample, and to assess their impact on quality of life.

METHODS

In a diverse sample of 420 adults with epilepsy, cross-sectional association of demographic, epilepsy and cognitive factors with high phobic symptoms were assessed using multiple logistic regression. Symptoms were measured with the SCL-90R validated self-report subscale (T-score ≥ 60 considered high phobic symptom group). Multiple logistic regression modeling was used to assess for independent association of demographic and clinical variables with presence of high phobic symptoms, and multiple linear regression modeling was used to evaluate for independent cross-sectional associations with epilepsy-specific quality of life (QOLIE-89).

RESULTS

Lower education (adjusted OR 3.38), non-White race/ethnicity (adjusted OR 2.34), and generalized anxiety symptoms (adjusted OR 1.91) were independently associated with high phobic/agoraphobic symptoms, all p < 0.005. Phobic/agoraphobic symptoms were independently associated with poor quality of life as were depression symptoms, older age, and non-White race/ethnicity. Generalized anxiety did not demonstrate a significant independent association with quality of life in the multivariable model.

CONCLUSION

In this study sample, phobic/agoraphobic symptoms were independently associated with poor quality of life. Clinicians should consider using more global symptom screening instruments with particular attention to susceptible populations, as these impactful symptoms may be overlooked using generalized-anxiety focused screening paradigms.

Agoraphobic avoidance in patients with psychosis: Severity and response to automated VR therapy in a secondary analysis of a randomised controlled clinical trial

BACKGROUND

The social withdrawal of many patients with psychosis can be conceptualised as agoraphobic avoidance due to a range of long-standing fears. We hypothesised that greater severity of agoraphobic avoidance is associated with higher levels of psychiatric symptoms and lower levels of quality of life. We also hypothesised that patients with severe agoraphobic avoidance would experience a range of benefits from an automated virtual reality (VR) therapy that allows them to practise everyday anxiety-provoking situations in simulated environments.

METHODS

345 patients with psychosis in a randomised controlled trial were categorised into average, moderate, high, and severe avoidance groups using the Oxford Agoraphobic Avoidance Scale. Associations of agoraphobia severity with symptom and functioning variables, and response over six months to brief automated VR therapy (gameChange), were tested.

RESULTS

Greater severity of agoraphobic avoidance was associated with higher levels of persecutory ideation, auditory hallucinations, depression, hopelessness, and threat cognitions, and lower levels of meaningful activity, quality of life, and perceptions of recovery. Patients with severe agoraphobia showed the greatest benefits with gameChange VR therapy, with significant improvements at end of treatment in agoraphobic avoidance, agoraphobic distress, ideas of reference, persecutory ideation, paranoia worries, recovering quality of life, and perceived recovery, but no significant improvements in depression, suicidal ideation, or health-related quality of life.

CONCLUSIONS

Patients with psychosis with severe agoraphobic avoidance, such as being unable to leave the home, have high clinical need. Automated VR therapy can deliver clinical improvement in agoraphobia for these patients, leading to a number of wider benefits.

Valproate Adjuvant Cognitive Behavioral Therapy in Panic Disorder Patients With Comorbid Bipolar Disorder: Case Series and Review of the Literature

Anxiety disorders are the most common comorbid psychiatric disorders in patients with bipolar disorder. Managing anxiety symptoms in comorbid conditions is challenging and has received little research interest. The findings from preclinical research on fear conditioning, an animal model of anxiety disorder, have suggested that memory reconsolidation updating (exposure-based therapy) combined with valproate might facilitate the amelioration of fear memories. Here, three cases of successful amelioration of agoraphobia and panic symptoms through valproate adjuvant therapy for cognitive behavioral therapy in patients who failed to respond to two to three consecutive standard pharmacotherapy trials over several years are described. To the best of the author's knowledge, this is the first attempt to combine CBT with valproate in patients with panic disorder, agoraphobia, and comorbid bipolar disorder. Additionally, the background preclinical research on this combination therapy based on the reconsolidation-updating mechanism, the inhibition of histone deacetylase 2, and critical period reopening, off-label use of valproate in panic disorder, plasticity-augmented psychotherapy, and how to combine valproate with CBT is discussed.

French adaptation and validation of the Panic Disorder Severity Scale-self-report

BACKGROUND

The aims of this study were to conduct a cross-cultural validation of the Panic Disorder Severity Scale - Self-Report (PDSS-SR) and to examine psychometric properties of the French-Canadian version.

METHODS

A sample of 256 adults were included in the validation study based on data from the baseline interview of a clinical trial on transdiagnostic cognitive-behavioral therapy for mixed anxiety disorders. Participants completed the Anxiety and Related Disorders Interview Schedule (ADIS-5), and self-report instruments including the PDSS-SR, Beck Anxiety Inventory (BAI), Mobility Inventory for Agoraphobia (MIA), Sheehan Disability Scale (SDS), Patient Health Questionnaire (PHQ-9), Social Phobia Inventory (SPIN), Insomnia Severity Index (ISI) and Penn State Worry Questionnaire (PSWQ). The cross-cultural adaptation in French of the PDSS-SR included a rigorous back-translation process, with an expert committee review. Sensitivity to change was also examined with a subgroup of patients (n = 72) enrolled in the trial.

RESULTS

The French version of the PDSS-SR demonstrated good psychometric properties. The exploratory factor analysis supported a one factor structure with an eigenvalue > 1 that explained 64.9% of the total variability. The confirmatory factor analysis (CFA) corroborated a one-factor model with a good model fit. Internal consistency analysis showed a .91 Cronbach's alpha. The convergent validity was adequate with the ADIS-5 clinical severity ratings for panic disorder (r = .56) and agoraphobia (r = .39), as well as for self-report instruments [BAI (r = .63), MIA (accompanied: r = .50; alone: r = .47) and SDS (r = .37)]. With respect to discriminant validity, lower correlations were found with the SPIN (r = .17), PSWQ (r = .11), ISI (r = .19) and PHQ-9 (r = .28). The optimal threshold for probable diagnosis was 9 for the PDSS-SR and 4 for the very brief 2-item version. The French version showed good sensitivity to change.

CONCLUSIONS

The French version of the PDSS-SR has psychometric properties consistent with the original version and constitutes a valid brief scale to assess the severity of panic disorder and change in severity over time, both in research and clinical practice.

Global prevalence of anxiety and PTSD in immigrants: a systematic review and meta-analysis

BACKGROUND

A systematic and meta-analysis of the prevalence of anxiety and posttraumatic stress disorder (PTSD) in immigrants was conducted.

METHODS

Based on the keywords, scientific databases were systematically searched to identify articles. The search included the three databases PubMed, Google Scholar and Research Gate until June 2020. The analysis was performed to assess the prevalence of anxiety and PTSD; subgroups were examined based on anxiety disorders.

RESULTS

The prevalence of agoraphobia, PTSD, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), social phobia and specific phobia were 4, 25, 9, 4, 3, 5 and 8%, respectively.

CONCLUSIONS

Considering the findings of the present study regarding the significant prevalence of anxiety and PTSD in the immigrant population, it is necessary to pay special attention to the mental health of this population.

Self-guided digital treatment with virtual reality for panic disorder and agoraphobia: a study protocol for a randomized controlled trial

Background

Cognitive behavioral therapy is the first-line treatment for patients with panic disorder (PD) and agoraphobia (AG). Yet, many patients remain untreated due to limited treatment resources. Digital self-guided short-term treatment applications may help to overcome this issue. While some therapeutic applications are already supported by health insurance companies, data on their efficacy is limited. The current study investigates the effect of self-guided digital treatment comprising psychoeducation and virtual reality exposure therapy (VRET).

Methods

Thirty patients diagnosed with PD, AG, or panic disorder with agoraphobia (PDA) will be randomly assigned to either the experimental group (EG) or the control group (CG). Participants of both groups will undergo baseline diagnostics in the first two sessions. The subsequent treatment for the EG consists of a self-guided 6-week phase of application-based psychoeducation, one therapy session preparing for the VRET, and 4 weeks of application-based self-guided VRET. To control for the potential effects of the therapy session with the therapist, the CG will receive relaxation and stress-reduction training instead. All patients will then undergo a closing session which terminates with the post-assessment (~ 10 weeks after baseline assessment) and a follow-up assessment 6 weeks following the closing session. Symptom severity (primary outcome) will be assessed at baseline, interim, post-treatment, and follow-up. Additionally, remission status (secondary outcome) will be obtained at follow-up. Both measures will be compared between the groups.

Discussion

The current study aims at providing insights into the efficacy of short-term treatment applications including psychoeducation and self-guided VRET. If successful, this approach might be a feasible and promising way to ease the burden of PD, AG, and PDA on the public health system and contribute to a faster access to treatment.

Trial registration

ISRCTN ISRCTN10661970. Prospectively registered on 17 January 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06366-x.

Psychosocial treatment for panic disorder: An umbrella review of systematic reviews and meta-analyses

BACKGROUND

Panic disorder is a common and disabling psychiatric condition marked by sudden onset of physiological sensations that are appraised as dangerous. A number of studies and reviews have examined the efficacy of psychosocial treatments for PD; however, there is a lack of overarching reports that discuss the strength of evidence for the different psychosocial treatments for PD. This umbrella review provides an overview of systematic reviews and meta-analyses on psychosocial treatments for PD.

METHODS

A systematic search and review of the literature was conducted according to PRISMA guidelines.

RESULTS

A total of 38 reviews (31 meta-analyses and 7 systematic reviews) were included in the umbrella review. Most of the 38 reviews were focused on the use of CBT, both in-person and internet-based, to treat PD among adults, generally finding it to be an efficacious treatment compared to control conditions. A limited number of the 38 reviews included other age ranges or examined other forms of psychosocial treatments. The methodological quality of most included reviews was rated as critically low according to the AMSTAR-2 rating system.

CONCLUSIONS

Future reviews should focus on improving their methodological quality. Although the included reviews supported CBT as an efficacious treatment for reducing panic symptoms among adults, future research could focus on how CBT compares to other psychosocial treatments and the efficacy of CBT for PD among other populations (e.g., children and adolescents) and among diverse cultural groups.

Association of Serotonin Transporter Gene (5-HTTLPR/rs25531) Polymorphism with Comorbidities of Panic Disorder

INTRODUCTION

Panic disorder (PD) has many comorbidities such as depression, bipolar disorder (BPD), and agoraphobia (AG). PD is a moderately heritable anxiety disorder whose pathogenesis is not well understood. Recently, a tri-allelic serotonin transporter (5-HTTLPR/rs25531) polymorphism was reported to be more sensitive to personality traits compared to the bi-allelic 5-HTTLPR polymorphism. We hypothesized that the 5-HTTLPR/rs25531 polymorphism may lead to a pathological anxious state depending on the presence or absence of a comorbidity in PD.

METHODS

In this study, we investigated the relationship between comorbidities in PD and tri-allelic 5-HTTLPR polymorphisms. A total of 515 patients with PD (148 males, 367 females) were genotyped, and the Revised NEO Personality Inventory as well as anxiety-related psychological tests were administered. Depression, BPD, and AG were diagnosed as comorbidities.

RESULTS

For the tri-allele 5-HTTLPR genotype, a significant interaction effect was found between openness to experience and comorbid depression. Examination of the interaction between AG and the tri-allelic 5-HTTLPR genotype revealed that L' allele carriers are associated with higher trait anxiety than the S'S' genotype group in PD without AG.

CONCLUSION

Some anxiety and personality traits can be characterized by the tri-allelic gene effect of 5-HTTLPR. These results suggest that tri-allelic 5-HTTLPR genotypes have genetic effects on the presence of comorbidities of PD.

The Burden of Agoraphobia in Worsening Quality of Life in a Community Survey in Italy

OBJECTIVE

Current nosology redefined agoraphobia as an autonomous diagnosis distinct from panic disorder. We investigated the lifetime prevalence of agoraphobia, its association with other mental disorders, and its impact on the health-related quality of life (HR-QoL).

METHODS

Community survey in 2,338 randomly selected adult subjects. Participants were interviewed with the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS), administered by clinicians. The diagnoses were based on the ICD-10 criteria. The Short-Form Health Survey (SF-12) was used to quantify HR-QoL.

RESULTS

In the sample, 35 subjects met the criteria for agoraphobia (1.5%), with greater prevalence among women (2.0%) than men (0.9%): odds ratio (OR) 2.23; 95% CI: 1.0-5-2. Agoraphobia was more often seen among those with (n=26; 1.1%) than without (n=9; 0.4%) panic disorder: OR=8.3; 2.9-24.4. Co-morbidity with other mental disorders was substantial. The mean score of SF-12 in people with agoraphobia was 35.2±7.8, with similar levels of HR-QoL in people with (35.3±7.9) or without (34.8±7.3) panic disorder: ANOVA: F(1;33)=0.0; p=1.00.

CONCLUSION

One out of seventy people may suffer from agoraphobia in their lifetime. The attributable burden in terms of HR-QoL is substantial and comparable to the one observed for chronic mental disorders such as major depression, post-traumatic stress disorder, or obsessive-compulsive disorder.

Internet-delivered exposure therapy versus internet-delivered cognitive behavioral therapy for panic disorder: A pilot randomized controlled trial

AIM

To compare the efficacy and acceptability of internet-delivered exposure therapy for panic disorder, to multi-component internet-delivered cognitive behavioral therapy (iCBT) that included controlled breathing, cognitive restructuring and exposure.

METHODS

Participants with panic disorder, with or without agoraphobia, were randomized to internet-delivered exposure therapy (n = 35) or iCBT (n = 34). Both programs were clinician guided, with six lessons delivered over eight weeks. Outcomes included panic disorder and agoraphobia symptom severity, as well as depression symptom severity, functional impairment and days out of role.

RESULTS

Participants in both conditions displayed a large reduction in panic disorder symptom severity (ds >1.30) from pre- to post-treatment. Participants in both conditions displayed medium to large reduction in agoraphobia and depression symptom severity, functional impairment and days out of role. Effects were maintained at three- and six-month follow-up. There was no significant difference between the interventions in clinical outcomes, adherence or treatment satisfaction.

CONCLUSIONS

Internet-delivered exposure therapy appeared to be as acceptable and efficacious as more established iCBT, despite including less strategies. However, a fully powered replication is now needed to compare the two approaches.

Blood endocannabinoid levels in patients with panic disorder

BACKGROUND

The development and maintenance of anxiety disorders is not fully understood. There is consensus in the literature that in addition to genetic factors, social, psychological and neurobiological factors are of crucial importance. The present exploratory study investigates the influence of the endocannabinoids (EC) and related N-acylethanolamines (NA) on the maintenance of panic disorder (PD).

METHODS

A total of n = 36 PD and n = 26 healthy controls (HC) were included in the study. Baseline characteristics showed no differences between the two groups. The participants were exposed to the Trier Social Stress Test (TSST) for reliable laboratory stress induction. Blood samples were taken during the TSST by an intravenous catheter to examine the endocannabinoid (EC) stress response. Repeated measures ANOVA was conducted to test for main effects of time and group as well as the respective interaction.

RESULTS

Participants with PD consistently had significantly higher EC and NA blood levels than HC. The consistently high EC and NA levels barely showed any reactivity as indicated by a lack of statistical variance. In line with these findings no reaction to the psychosocial stressor TSST could be detected.

CONCLUSION

Our main results show significant differences in EC concentrations between participants with PD and HC. These findings suggest that an imbalance in the ECS contributes to the maintenance of PD. Increased endocannabinoid levels may have important implications for organic diseases such as cardiovascular disorders. The limitations of the study as well as implications for further investigations are discussed.

Are Internet- and mobile-based interventions effective in adults with diagnosed panic disorder and/or agoraphobia? A systematic review and meta-analysis

BACKGROUND

There is no meta-analysis that specifically evaluates the effectiveness of Internet- and mobile-based interventions (IMIs) in adults with diagnosed panic disorder and/or agoraphobia (PD/A) so far. The current meta-analysis aims to fill this gap (PROSPERO CRD 42016034016).

METHODS

Systematic literature searches in six databases for randomised and controlled clinical trials investigating IMIs in adults, who met diagnostic criteria for PD/A. Study selection and data extraction were conducted independently by two reviewers. Random-effects meta-analyses, pre-planned subgroup and sensitivity analyses were conducted when appropriate. Primary outcomes were PD and A symptom severity. In addition, adherence, response, remission, quality of life, anxiety and depression symptom severity were examined.

RESULTS

A total of 16 trials (1015 patients), with 21 comparisons (9 IMI vs. waitlist; 7 IMI vs. IMI; 5 IMI vs. active treatment condition), were included. IMIs revealed beneficial effects on panic (Hedges' g range -2.61 to -0.25) and agoraphobia symptom severity when compared to waitlist (pooled g = -1.15, [95%-CI = -1.56; -0.74]). Studies comparing IMIs to active controls (i.e., face-to-face CBT and applied relaxation) did not find significant differences for reductions in panic (g = -0.02, [95%-CI = -0.25; 0.21]) and agoraphobia symptom severity (g = -0.10, [95%-CI = -0.39; 0.19]). Furthermore, IMIs were superior to waitlist controls regarding anxiety and depression symptom severity and quality of life.

LIMITATIONS

Tests for publication bias were not feasible due to the limited number of trials per comparison, and the risk of bias assessment indicated some methodological shortcomings.

CONCLUSIONS

Findings from this meta-analytic review provide support for the effectiveness of IMIs in patients with verified PD/A. However, before IMIs can be included in treatment guidelines for PD/A, future high quality research is needed that substantiates and extends the evidence base, especially in regard to intervention safety.

Influence of Comorbid Psychiatric Disorders on the Risk of Development of Alcohol Dependence by Genetic Variations of ALDH2 and ADH1B

BACKGROUND

Inactive aldehyde dehydrogenase-2 (ALDH2) is a well-known deterrent to the development of alcohol use disorder (AUD), and however, some individuals with inactive ALDH2 do go on to develop AUD. These alcoholics are likely to have strong risk factors for the development of this disorder. Using a model of alcoholics with inactive ALDH2 (the AIA model), we investigated the unique characteristics of alcoholics with inactive ALDH2 in an attempt to identify the risk factors for AUD. In this study, we focused on comorbid psychiatric and personality disorders as potential risk factors for AUD.

METHODS

The subjects were 103 male alcoholics with inactive ALDH2 (AIAs), 87 age- and ADH1B genotype-matched alcoholics with active ALDH2 (AAAs) and 200 age-matched healthy men. The alcoholics were divided into 4 subgroups according to their ALDH2 and ADH1B genotypes (inactive ALDH2 vs. active ALDH2, usual ADH1B vs. superactive ADH1B). To assess the participants' comorbid psychiatric disorders, we conducted semi-structured interviews using the Japanese translation of SSAGA version 2. We compared the prevalence of comorbid psychiatric and personality disorders among groups with different combinations of the ALDH2 and ADH1B genotypes.

RESULTS

The prevalence of attention-deficit/hyperactivity disorder (ADHD) was significantly higher in the AIAs with usual ADH1B than in the other 3 subgroups of alcoholics. In contrast, the prevalence rates of agoraphobia and panic disorder were significantly lower in the AIAs with superactive ADH1B than in the other 3 subgroups of alcoholics.

CONCLUSIONS

This study suggested that (i) ADHD is a risk factor for AUD, consistent with previous reports; (ii) agoraphobia and panic disorder may have deterrent effects against the development of AUD in individuals with inactive ALDH2, probably attributable to the similarity between the symptoms of agoraphobia and panic disorder and the adverse reactions to consumption of alcohol in subjects with inactive ALDH2.

Cognitive behavioral group therapy for panic disorder in a general clinical setting: a prospective cohort study with 12 to 31-years follow-up

BACKGROUND

The long-term prognosis after cognitive behavioral therapy (CBT) in outpatient groups for panic disorder and agoraphobia is not well known. The purpose of this study was to assess long-term outcomes in terms of psychological health, health-related quality of life (HRQoL), quality of life (QoL) and treatment satisfaction after CBT for panic disorder and agoraphobia.

METHODS

The sample consisted of 68 patients (61% response rate), who were assessed at pretreatment; at the start and end of treatment; and after 3 months, after 1 year, and over the long term (M = 24 years; SD = 5.3; range: 12 to 31 years). The main outcome was the total score on the Phobic Avoidance Rating Scale (PARS-total). At long-term follow-up, HRQoL was measured with the RAND-12 questionnaire, and QoL was measured with two questions from the "Study on European Union Statistics on Income and Living Conditions". Patient experiences and treatment satisfaction were assessed by the Generic Short Patient Experiences Questionnaire. A marginal longitudinal model was applied to study the main outcome.

RESULTS

The effect size of the long-term change (mean change/ pooled SD) in the PARS-total score was (- 1.6, p < 0.001) and was stable over time. A PARS-total score reduction of 50% was found in 98% of patients at the long-term follow-up. The patients' HRQoL and QoL were similar to the expected scores for the general Norwegian population. Of the patients, 95% reported high to very high satisfaction with the CBT, and 93% reported large treatment benefits.

CONCLUSIONS

To the best of our knowledge, this study has the longest follow-up after group CBT for panic disorder and agoraphobia, showing a good prognosis in ≥93% of the participating patients.

Intensive one-week internet-delivered cognitive behavioral therapy for panic disorder and agoraphobia: A pilot study

This is the first pilot study to explore the feasibility, acceptability and preliminary efficacy of intensive cognitive behavioral therapy (CBT) for panic disorder and/or agoraphobia delivered via the internet. Ten participants who met DSM-5 criteria for panic disorder and/or agoraphobia (6 males; mean age = 43.40, SD = 15.25) completed The Intensive Panic Program: a six-lesson exposure-based CBT program, delivered online over seven days. Clinician support was provided via phone and email. All 10 participants completed the program (100% adherence) and high levels of satisfaction were reported. We found large and significant reductions in panic symptom severity at post-treatment (d = 1.40), which were maintained at two-month follow-up. We also found large reductions in agoraphobic avoidance (d = 0.92) and functional impairment (d = 1.04) at follow-up, and days out of role were halved. On average, 132 min (SD = 42, range: 47-183) of clinician time was spent per participant during the treatment week. The results provide promising preliminary evidence for the feasibility and acceptability of internet-delivered intensive CBT for panic disorder and/or agoraphobia. A larger, randomized control trial is now needed to evaluate the efficacy of this program compared to a control group and to explore long-term outcomes. Clinical trial registration number ACTRN12618001501235.

Panic attack provocation in panic disorder patients with a computer simulation

BACKGROUND

Computer simulations (CS) and virtual reality exposure are promising techniques for research and treatment of panic disorder with agoraphobia (PDA). The objective of this study was to ascertain whether a given CS was a stimulus capable of producing panic attacks (PAs), anxiety and psychophysiological changes in patients with PDA.

METHODS

Thirty PDA patients and 30 healthy subjects were recruited for this study. Subjects were exposed to a 3-min CS of a situation relevant to agoraphobic patients. Anxiety, panic symptoms, PAs, heart rate, skin conductance and respiration were recorded before, during and after the CS exposure.

RESULTS

The CS effectively induced anxiety, hyperventilation and electrodermal responses in PDA patients but not in healthy subjects. Forty percent of PDA patients had a PA while none of the control subjects had a PA. A subgroup of patients who were less sensitive to the CS than the other subgroup of PDA patients and did not present full-blown PAs still had more panic symptoms, higher anxiety levels and more respiratory irregularities than the controls.

LIMITATIONS

Low immersion and low sense of presence, lack of interaction with the environment.

CONCLUSIONS

Exposure to the CS produced effects similar to in vivo exposure, respiratory and caffeine challenges. Subsequent studies should: make direct comparisons between CS and other challenges for PDA; investigate if CS can be a tool for predicting effects of medication; determine the potential of CS as a desensitization technique for situational PAs.

Hypovitaminosis D is associated with negative symptoms, suicide risk, agoraphobia, impaired functional remission, and antidepressant consumption in schizophrenia

Hypovitaminosis D has been associated with, respectively, major depressive disorder, schizophrenia (SZ), and cognitive disorders in the general population, and with positive and negative symptoms and metabolic syndrome in schizophrenia. The objective was to determine the prevalence of hypovitaminosis D and associated factors in a non-selected multicentric sample of SZ subjects in day hospital. Hypovitaminosis D was defined by blood vitamin D level < 25 nM. Depressive symptoms were assessed by the Calgary Depression Rating Scale Score and Positive and Negative Syndrome Scale Score. Anxiety disorders and suicide risk were evaluated by the Structured Clinical Interview for Mental Disorders. Functioning was evaluated with the Functional Remission of General Schizophrenia Scale. Hypovitaminosis D has been found in 27.5% of the subjects. In multivariate analysis, hypovitaminosis D has been significantly associated with, respectively, higher suicide risk (aOR = 2.67 [1.31-5.46], p = 0.01), agoraphobia (aOR = 3.37 [1.66-6.85], p < 0.0001), antidepressant consumption (aOR = 2.52 [1.37-4.64], p < 0.001), negative symptoms (aOR = 1.04 [1.01-1.07], p = 0.04), decreased functioning (aOR = 0.97[0.95-0.99], p = 0.01), and increased leucocytosis (aOR = 1.17 [1.04-1.32], p = 0.01) independently of age and gender. No association with alcohol use disorder, metabolic syndrome, peripheral inflammation, insulin resistance, or thyroid disturbances has been found (all p > 0.05). Despite some slight abnormalities, no major cognitive impairment has been associated with hypovitaminosis D in the present sample (all p > 0.05 except for WAIS similarities score). Hypovitaminosis D is frequent and associated with suicide risk, agoraphobia and antidepressant consumption in schizophrenia, and more slightly with negative symptoms. Patients with agoraphobia, suicide risk and antidepressant consumption may, therefore, benefit in priority from vitamin D supplementation, given the benefit/risk profile of vitamin D. Further studies should evaluate the impact of vitamin D supplementation on clinical outcomes of SZ subjects.

A mobile application for panic disorder and agoraphobia: Insights from a multi-methods feasibility study

BACKGROUND

Panic disorder with and without agoraphobia (PD) is a common psychological disorder. Internet-based interventions have the potential to offer highly scalable low-threshold evidence-based care to people suffering from PD. GET.ON Panic is a newly developed internet-based intervention addressing symptoms of PD. In order to transfer the training into the daily life of the individuals, we integrated mobile components in the training and created a so-called hybrid online training. The development and beta-testing of such a training requires a novel interdisciplinary approach between IT specialists and psychologists. From this point of view, we would like to share our experiences in this exploratory paper.

METHODS

This initial feasibility study (N = 10) offers, on the one hand, a brief overview of the interdisciplinary development phase of the mobile application and on the other hand, provides first insights into the usage, usability and acceptance of this mobile application using qualitative interview data as well quantitative measures of 8 completing participants. For these reasons, we used a pre-posttest design without a control group. Furthermore, we present initial clinical outcomes of the intervention on e.g. panic symptom severity, depressive symptoms as well additional anxiety measures. Finally, we end with implications for further research in the relatively new field of mobile mental health.

RESULTS

Overall, usability, user satisfaction, motivational value and technology acceptance of the app were perceived as high. The usage of app components was diverse: The use of interoceptive exposure exercises and daily summaries on anxiety and mood was highest while using in-vivo exposure exercises and monitoring panic symptoms was perceived as difficult. Furthermore, participants showed after the training less clinical symptoms as at baseline-assessment.

DISCUSSION

The current feasibility study contributes to an in-depth understanding of the potential of mobile technology in e-mental health. Overall, the GET.ON Panic app appears to be an acceptable and motivational part of a CBT-based hybrid online training for PD that has the potential to promote training success. After some suggested adjustments have been made, the efficacy should be investigated in a randomized controlled trial.

Association of NPSR1 gene variation and neural activity in patients with panic disorder and agoraphobia and healthy controls

•

Higher amygdala activation in T risk allele carriers during the perception of agoraphobia-specific stimuli

•

Amygdala activation correlated negatively trendwise with the trait neuroticism in healthy controls carrying A/A genotype

•

A diagnosis x genotype interaction as a trend in the inferior orbitofrontal cortex during the perception of agoraphobia-specific stimuli

Introduction

The neurobiological mechanisms behind panic disorder with agoraphobia (PD/AG) are not completely explored. The functional A/T single nucleotide polymorphism (SNP) rs324981 in the neuropeptide S receptor gene (NPSR1) has repeatedly been associated with panic disorder and might partly drive function respectively dysfunction of the neural “fear network”. We aimed to investigate whether the NPSR1 T risk allele was associated with malfunctioning in a fronto-limbic network during the anticipation and perception of agoraphobia-specific stimuli.

Method

121 patients with PD/AG and 77 healthy controls (HC) underwent functional magnetic resonance imaging (fMRI) using the disorder specific “Westphal-Paradigm”. It consists of neutral and agoraphobia-specific pictures, half of the pictures were cued to induce anticipatory anxiety.

Results

Risk allele carriers showed significantly higher amygdala activation during the perception of agoraphobia-specific stimuli than A/A homozygotes. A linear group x genotype interaction during the perception of agoraphobia-specific stimuli showed a strong trend towards significance. Patients with the one or two T alleles displayed the highest and HC with the A/A genotype the lowest activation in the inferior orbitofrontal cortex (iOFC).

Discussion

The study demonstrates an association of the NPSR1rs324981 genotype and the perception of agoraphobia-specific stimuli. These results support the assumption of a fronto-limbic dysfunction as an intermediate phenotype of PD/AG.

Cognitive behavioral therapy for postpartum panic disorder: a case series

Background

Clinical anxiety is common during the perinatal period, and anxiety symptoms often persist after childbirth. Ten to 30 % of perinatal women are diagnosed with panic disorder (PD)—far more than the 1.5–3% rate among the general population. Although cognitive behavioral therapy (CBT) has been determined to be an effective treatment for PD, few studies have been conducted on CBT effectiveness in treating postpartum PD and, to the best of the knowledge of the present authors, no research has been conducted on postpartum PD among Japanese women. In this manuscript, we report on our administration of CBT to three postpartum patients with PD, detailing the improvement in their symptoms.

Case presentation

All patients in this study were married, in their thirties, and diagnosed using the Mini-International Neuropsychiatric Interview as having PD with agoraphobia. The Panic Disorder Severity Scale (PDSS) was used to evaluate patients’ panic symptoms and their severity. All patients received a total of 16 weekly 50-min sessions of CBT, and all completed the treatment. All patients were exceedingly preoccupied with the perception that a “mother must protect her child,” which reinforced the fear that “the continuation of their perinatal symptoms would prevent them from rearing their children”. After treatment, all participants’ panic symptoms were found to have decreased according to the PDSS, and two no longer met clinical criteria: Chihiro’s score changed from 13 to 3, Beth’s PDSS score at baseline from 22 to 6, and Tammy’s score changed from 7 to 1.

Conclusions

CBT provides a therapeutic effect and is a feasible method for treating postpartum PD. It is important that therapists prescribe tasks that patients can perform collaboratively with their children.

Electronic supplementary material

The online version of this article (10.1186/s40359-019-0330-z) contains supplementary material, which is available to authorized users.

Efficacy of repetitive transcranial magnetic stimulation in the treatment of depression with comorbid anxiety disorders

BACKGROUND

The presence of comorbid anxiety is generally associated with poorer treatment outcomes in people with depression. Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective for treatment resistant depression, but there has been little research examining rTMS in depressed patients with comorbid anxiety disorders. This study aimed to investigate the efficacy of rTMS in patients with treatment resistant Major Depressive Disorder (MDD) and comorbid anxiety disorders.

METHODS

This study included 248 patients with treatment resistant MDD who were treated with rTMS. Of these, 172 patients had one or more comorbid anxiety disorders, so their outcomes were compared with patients who did not have comorbid anxiety.

RESULTS

Patients both with and without comorbid anxiety disorders showed improvement in depression ratings after rTMS treatment, with no significant difference in remission rates between groups. In those with comorbid anxiety disorders, 23.3% met criteria for remission and 39.5% met response criteria. For each anxiety disorder diagnosis, there was a significant reduction in HAM-A, HAM-D21, MADRS and ZUNG scores (p = <0.001 for all).

LIMITATIONS

This was not a sham-controlled study, so placebo response rates are not known. Patients were referred by private psychiatrists so are not representative of all patients with depression.

CONCLUSION

Our study indicates that rTMS is an effective treatment for Major Depressive Disorder in people who have comorbid anxiety disorders.

Heart rate variability in patients with agoraphobia with or without panic disorder remains stable during CBT but increases following in-vivo exposure

Patients with anxiety disorders have a lower heart rate variability (HRV) than healthy controls. Low HRV is associated with cardiovascular disease and dysfunction of the autonomic nervous system (ANS). The aim of the present study was to investigate if HRV in patients with agoraphobia with or without panic disorder can be influenced by cognitive behavioral therapy (CBT). 73 patients with agoraphobia with or without panic disorder were included in the study. Heart rate (HR) and HRV were recorded at rest before and after CBT and during in-vivo exposure. No changes in HR and HRV were observed throughout therapy. During in-vivo exposure HRV increased significantly and HR exhibited a tendency to decrease. Despite clinical improvement of anxiety symptoms, ANS activity at rest did not seem to be influenced by CBT. However, during in-vivo exposure, HRV changed significantly, indicating a higher parasympathetic activity at the end of exposure.

The allocation of resources in the care for patients with panic disorder in Germany: an excess cost analysis informing policy and science

Background

Panic disorder is a mental disorder of high prevalence, which frequently co-occurs with agoraphobia. There is a lack of studies measuring excess costs of panic disorder patients with and without agoraphobia. We compared costs of panic disorder patients with or without agoraphobia with costs of the anxiety-free population in Germany.

Methods

Primary data from a cluster-randomized trial of adults suffering from panic disorder (n = 419) and from a representative survey of the German general population (N = 5005) were collected between 2012 and 2014. Missing data from the cluster-randomized trial were first imputed by multiple imputation using chained equations and subsequently balanced with the data from the survey by Entropy Balancing. The societal perspective was chosen. Excess costs were calculated by generalized linear models and two-part-models.

Results

Entropy Balancing led to an exact match between the groups. We found 6-month total excess costs of 3220€ (95% CI 1917€–4522€) for panic disorder patients without agoraphobia and of 3943€ (95% CI 2950€–4936€) for patient with agoraphobia. Panic disorder patients with or without agoraphobia had significantly higher costs for psychotherapy, general practitioners, general hospital stays and informal care Indirect costs accounted for approximately 60% of the total excess costs.

Conclusions

Panic disorder with or without agoraphobia is associated with significant excess costs. Agoraphobia changes the pattern of resource utilization. Especially indirect costs are relevant. Agoraphobia influences resource utilization in the inpatient sector.

Trial registration ISRCTN64669297

Associations of plasma testosterone with clinical manifestations in acute panic disorder

The probable implication of testosterone in the neurobiology of anxiety disorders, and particularly panic disorder (PD), is poorly studied. We explored for potential differences concerning testosterone (T) plasma levels and the ratio testosterone/cortisol (T/C) between medication-free, consecutively-referred patients with acute exacerbation of PD comorbid with agoraphobia (PDA) (N = 40; females = 24; age = 31.4 ± 7.1 years) and healthy controls (N = 80; females = 48; matched for age). Moreover, we investigated for potential associations of T levels and T/C ratio with the severity of acute PDA psychopathology in the patients of the sample. Psychometric measures included panic attacks' number during last three weeks (PA-21days), the Agoraphobic Cognitions Questionnaire (ACQ) and the Hamilton Anxiety Rating Scale (HARS). Male patients -but not female ones- demonstrated significantly lower T levels compared to controls. Moreover, in male patients, a significant inverse association emerged between T/C ratio and PA-21days, so that lower T/C ratio is associated with significantly more panic attacks. On the contrary, female patients demonstrated significant positive associations: (a) between T levels and PDA-related pathological cognitions (ACQ); (b) between the T/C ratio and both PA-21days and anxiety symptoms' severity (HARS). The results of the study suggest that testosterone is significantly associated to the severity of clinical manifestations of acute panic disorder, although in a different fashion concerning the two genders.

Effects of Cognitive Behavioral Therapy on Neural Processing of Agoraphobia-Specific Stimuli in Panic Disorder and Agoraphobia

BACKGROUND

Patients suffering from panic disorder and agoraphobia are significantly impaired in daily life due to anxiety about getting into a situation due to apprehension about experiencing a panic attack, especially if escape may be difficult. Dysfunctional beliefs and behavior can be changed with cognitive behavioral therapy; however, the neurobiological effects of such an intervention on the anticipation and observation of agoraphobia-specific stimuli are unknown.

METHODS

We compared changes in neural activation by measuring the blood oxygen level-dependent signal of 51 patients and 51 healthy controls between scans before and those after treatment (group by time interaction) during anticipation and observation of agoraphobia-specific compared to neutral pictures using 3-T fMRI.

RESULTS

A significant group by time interaction was observed in the ventral striatum during anticipation and in the right amygdala during observation of agoraphobia-specific pictures; the patients displayed a decrease in ventral striatal activation during anticipation from pre- to posttreatment scans, which correlated with clinical improvement measured with the Mobility Inventory. During observation, the patients displayed decreased activation in the amygdala. These activational changes were not observed in the matched healthy controls.

CONCLUSIONS

For the first time, neural effects of cognitive behavioral therapy were shown in patients suffering from panic disorder and agoraphobia using disorder-specific stimuli. The decrease in activation in the ventral striatum indicates that cognitive behavioral therapy modifies anticipatory anxiety and may ameliorate abnormally heightened salience attribution to expected threatening stimuli. The decreased amygdala activation in response to agoraphobia-specific stimuli indicates that cognitive behavioral therapy can alter the basal processing of agoraphobia-specific stimuli in a core region of the fear network.

A queer case of Parry-Romberg syndrome with coexisting psychiatric ailment

Progressive facial hemiatrophy or Parry-Romberg syndrome is a rare disorder of unknown etiology which is characterized by atrophy of the one side of the face and various neurological complications. Clinical overlap is sometimes seen with linear scleroderma or en coup de sabre. We present such a case that manifested clinically with partial epilepsy and novel psychiatric complaints of agoraphobia.

A systematic review on the therapeutic effectiveness of non-invasive brain stimulation for the treatment of anxiety disorders

The interest in the use of non-invasive brain stimulation for enhancing neural functions and reducing symptoms in anxiety disorders is growing. Based on the DSM-V classification for anxiety disorders, we examined all available research using repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) for the treatment of specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. A systematic literature search conducted in PubMed and Google Scholar databases provided 26 results: 12 sham-controlled studies and 15 not sham-controlled studies. With regard to the latter sub-group of studies, 9 were case reports, and 6 open label studies. Overall, our work provides preliminary evidence that both, excitatory stimulation of the left prefrontal cortex and inhibitory stimulation of the right prefrontal cortex can reduce symptom severity in anxiety disorders. The current results are discussed in the light of a model for the treatment for anxiety disorders via non-invasive brain stimulation, which is based on up-/downregulation mechanisms and might serve as guide for future systematic investigations in the field.

Learn to forget: Does post-exposure administration of d-cycloserine enhance fear extinction in agoraphobia?

The use of d-cycloserine (DCS) to augment exposure based therapy for anxiety disorders has shown mixed, although overall positive effects. Aim of the present study was to examine post-exposure administration of DCS in patients with agoraphobia with or without panic disorder. 73 patients with agoraphobia (with or without panic disorder) were treated with 12 sessions of cognitive behavioral therapy (CBT) including 3 exposures. Following successful exposure patients were given double blind either placebo or 50 mg of DCS. Primary outcome criterion was change in the Panic and Agoraphobia Scale (PAS) between CBT session t1, t4 (+∼2 months), t10 (+∼3 months) und t11 (+∼4 months). During the course of CBT the patients' symptomatology decreased significantly as measured by primary and secondary outcome criteria, however, without an additional benefit for DCS treated patients. Exploratory sub-group analyses for severely ill patients and patients with high anxiety and strong habituation during exposure showed that DCS administration was associated with increased improvement during the 1-month follow-up period (t10 - t11) with medium to large effect sizes (range in effect size η²_p from .06 to .25). Our study results are consistent with recent research on DCS, indicating a beneficial augmentative effect for sub-groups of anxiety patients. The lack of an overall DCS effect for the whole patient sample might be explained by a dual mechanism in fear conditioning and extinction with different cognitive processes being involved during exposure depending on the degree of anxiety experienced by the patient.

Suicidal ideation in primary care patients suffering from panic disorder with or without agoraphobia

BACKGROUND

Suicidal ideation is common in patients suffering from panic disorder. The present study investigated rates of suicidal ideation and risk factors for suicidal ideation in a sample of primary care patients suffering from panic disorder with or without agoraphobia.

METHODS

A total of N = 296 patients [n = 215 (72.6%) women; age: M = 43.99, SD = 13.44] were investigated. Anxiety severity, anxiety symptoms, avoidance behavior, comorbid depression diagnosis, severity of depression, age, sex, employment status, living situation and frequency of visits at the general practitioner were considered as risk factors of suicidal ideation.

RESULTS

Suicidal ideation was experienced by 25% of the respondents. In a logistic regression analysis, depression diagnosis and depression severity emerged as significant risk factors for suicidal ideation. Anxiety measures were not associated with suicidal ideation.

CONCLUSION

Suicidal ideation is common in primary care patients suffering from panic disorder with or without agoraphobia. Individuals with greater burden of mental illness in terms of mood disorder comorbidity and depressive symptomatology are especially likely to suffer from suicidal ideation.

Early scars are forever: Childhood abuse in patients with adult-onset PTSD is associated with increased prevalence and severity of psychiatric comorbidity

Childhood abuse and PTSD are independently associated with severe psychiatric comorbidity. We hypothesized that among patients with adult-onset PTSD, a history of child abuse was associated with increased prevalence and severity of comorbid mental disorders. Participants were 109 adult treatment-seeking patients, 23.9% of whom had a history of childhood sexual, physical or emotional abuse. The socio-demographic characteristics and comorbidity profile of PTSD patients with and without history of child abuse were compared using the two-tailed t-test and the chi-square test. PTSD patients with a history of child abuse had significantly higher average PCL-C hyperarousal [21.8 (SD = 3.6) vs 19.8 (SD = 3.5)] and BDI [35.7 (SD = 9.2) vs 29.1 (SD = 13.9)] scores, a significantly increased average number of lifetime [4.85 (SD = 1.43) vs 3.93 (SD = 1.33)] and current [4.46 (SD = 1.24) vs 3.75 (SD = 1.32)] comorbid disorders, and a greater prevalence of lifetime (73.1% vs 44.6%) and current (79.2% vs 46.7%) panic disorder/agoraphobia and of psychotic symptoms (73.1% vs 30.1%). All effect sizes were in the medium to large range. Adult-onset PTSD patients with a history of child abuse may represent a subgroup with a more severe form of the disorder that is associated with a more serious clinical course, treatment resistance and poorer outcome.

Patients' characteristics and their influence on course of fear during agoraphobic symptom provocation: may SS(N)RI treatment compensate unfavorable individual preconditions?

BACKGROUND

Patients' characteristics and antidepressants are discussed to be relevant in the context of phobic exposure.

AIMS

To identify patients characteristics associated with a differential course of fear during disorder-specific symptom provocation as well as to elucidate the effect of selective serotonin-(noradrenalin-) reuptake inhibitors [SS(N)RI] on development of fear in the context of re-exposure to the phobic stimuli.

METHODS

Twenty-eight clinically well-characterized patients with panic disorder and agoraphobia (PD/AG) were classified into subjects who show a reduction of fear ('Fear-') during a symptom provocation via a picture-based paradigm (T1) and those who did not ('Fear+'). Subsequently, SS(N)RI treatment was administered to all patients and subjects were re-exposed to the feared stimuli after 8 weeks of treatment (T2). Moreover, brain activity within the 'fear network' was measured via functional magnetic resonance imaging (fMRI) at T1 and T2.

RESULTS

Fear - were significantly younger and demonstrated increased exposure-related fear as well as stronger activity in several fear-related brain areas than Fear+. We found significant improvements in all clinical parameters after pharmacological intervention for the whole sample (T1-T2; all measures p < .02). However, reduction of fear as well as activation in (para)limbic structures during symptom provocation were now attenuated in Fear - but increased in Fear+.

CONCLUSIONS

Advanced age may predict a therapeutically unfavorable course of fear during agoraphobic symptom provocation. Since we found no negative impact of medication on fear development at all, there was some evidence that SS(N)RI treatment might improve the individual ability to get involved with the agoraphobic stimuli while conducting disorder-specific exposure.

Anxiety disorders and figural fluency: A measure of executive function

BACKGROUND

Anxiety possibly interferes with executive functioning, although most studies rely on anxiety symptoms or lack control for comorbid depression. The objective of the present study is to examine the association between executive functioning and (individual) anxiety disorders with ak,ld without controlling for depression.

METHOD

Generalized anxiety disorder (GAD), panic disorder with and without agoraphobia, agoraphobia, social phobia, as well as depressive disorder according to DSM-IV criteria were assessed with the Mini International Neuropsychiatric Interview in 82,360 community-dwelling people participating in the Lifelines cohort. Figural fluency as a measure of executive functioning was assessed with the Ruff Figural Fluency Test (RFTT). Linear regression analyses with the RFFT score as the dependent variable and psychiatric diagnosis as independent variables (dummies) were performed, adjusted for potential confounders. Multivariate results are presented with and without adjustment for depression.

RESULTS

Presence of any anxiety disorder was associated with worse performance on the RFFT (B = - 0.78, SE = 0.32, p = .015), independent of depression. No dose-response relationship with the number of anxiety disorders was found. Only agoraphobia and generalized anxiety disorder were significantly associated with the RFFT score in the multivariate models. Agoraphobia remained significant when further adjusted for depressive disorder (B = - 1.14, SE = 0.41, p < .01), while GAD did not (B = 0.013, SE = 0.431, p = .975).

LIMITATIONS

Executive function was tested by only one measure, namely figural fluency.

CONCLUSION

Agoraphobia is associated with worse executive functioning. Treatment of agoraphobia could be influenced by the executive dysfunction which clinicians should be aware of when regular treatment fails.

[The role of childhood stress in symptoms of social phobia and agoraphobia in adulthood]

The role of childhood stress in symptoms of social phobia and agoraphobia in adulthood Objectives: Anxiety disorders are among themost prevalent mental disorders inmodern times. Childhood stress constitutes a risk factor for their occurrence in adulthood.

METHODS

In a sample of 1000 Polish and German probands recruited via the internet, we studied the associations of nine childhood stress factors (physical abuse, periodic harsh physical punishment, threat of physical violence, sexual abuse, neglect, long-term absence of a parent, violence between parents, arguments between parents and financial hardship) with later agoraphobic and sociophobic symptoms.

RESULTS

Especially neglect showed a strong association to both forms of phobic symptoms. Threat of physical violence aswell as periodic harsh physical punishment and threat of physical violence also showed an association to both forms of phobic symptoms.

CONCLUSIONS

The study revealed plausible associations for both forms of anxiety and various childhood adversities, though the amounts of explained variances were generally small.

Running for extinction? Aerobic exercise as an augmentation of exposure therapy in panic disorder with agoraphobia

Exposure-based Cognitive Behavioral Therapy (eb-CBT) represents the most evidence-based psychotherapeutic approach in anxiety disorders. However, its efficacy may be limited by a delay in onset of action and a substantial number of patients does not respond sufficiently to treatment. In this context, aerobic exercise was found to be effective in reducing clinical anxiety as well as to improve (elements of) disorder-specific CBT in some mental disorders. We therefore investigated the effect of aerobic exercise supplementary to an eb-CBT in panic disorder and agoraphobia (PD/AG). 77 patients with PD/AG performed a 30 min treadmill task with moderate or low intensity (70% or 30% of the maximal oxygen uptake [VO_2max]) prior to five exposure sessions within a standardized seven-week CBT. At baseline, after completing the treatment period (post) and six month after post (follow-up), several measures of (un)specific psychopathology (Hamilton Anxiety Rating Scale [Ham-A], Mobility Inventory [MI], Panic and Agoraphobia Scale [PAS], Agoraphobic Cognitions Questionnaire [ACQ], Body Sensations Questionnaire [BSQ]) were established to assess for clinical changes. All patients experienced a significant improvement of symptoms from baseline to post (for all measures p < .001) but repeated-measures analyses of variance found a trend towards a significant time × group interaction in the Ham-A in favor for the moderate intense exercise group (f[1, 74] = 4.15, p = .045, α=.025). This trend, however, disappeared at follow-up since the low-intense exercise group further improved significantly in Ham-A after post. Our findings therefore might point to an accelerating effect of moderate-intense exercise within an exposure-based CBT for AG/PD.

Bowel and Bladder Anxiety: An Obsession or a Variant of Agoraphobia?

It has long been debated whether bowel and bladder anxiety are a part of obsessive compulsive spectrum disorder or a variant of agoraphobia with no consensus view yet. Tricyclic antidepressants are reportedly efficacious in such cases and lead to complete resolution of symptoms. Here, we report a 36-year-old male having urges to visit toilet when in public places or where toilets are not easily available and a resulting avoidance of such spaces fearing an episode of incontinence. Symptoms originated 16 years ago when he was in university which compelled him to drop out. We treated him with paroxetine and relaxation therapy to which he responded satisfactorily.

Face Perception in Social Anxiety: Visuocortical Dynamics Reveal Propensities for Hypervigilance or Avoidance

BACKGROUND

Theories of aberrant attentional processing in social anxiety, and anxiety disorders more broadly, have postulated an initial hypervigilance or facilitation to clinically relevant threats and consequent defensive avoidance. However, existing objective measurements utilized to explore this phenomenon lack the resolution to elucidate attentional dynamics, particularly covert influences.

METHODS

We utilized a continuous measure of visuocortical engagement, the steady-state visual evoked potential in response to naturalistic angry, fearful, happy, and neutral facial expressions. Participants were treatment-seeking patients with principal diagnoses of social anxiety circumscribed to performance situations (n = 21) or generalized across interaction contexts (n = 42), treatment-seeking patients with panic disorder with agoraphobia (n = 25), and 17 healthy participants.

RESULTS

At the principal disorder level, only circumscribed social anxiety patients showed sustained visuocortical facilitation to aversive facial expressions. Control participants as well as patients with panic disorder with agoraphobia and generalized social anxiety showed no bias. More finely stratifying the sample according to clinical judgment of social anxiety severity and interference revealed a linear increase in visuocortical bias to aversive expressions for all but the most severely impaired patients. This group showed an opposing sustained attentional disengagement.

CONCLUSIONS

Rather than shifts between covert vigilance and avoidance of aversive facial expressions, social anxiety appears to confer a sustained bias for one or the other. While vigilant attention reliably increases with social anxiety severity for the majority of patients, the most impaired patients show an opposing avoidance. These distinct patterns of attentional allocation could provide a powerful means of personalizing neuroscience-based interventions to modify attention bias and related impairment.

An open-label, flexible dose adaptive study evaluating the efficacy of vortioxetine in subjects with panic disorder

BACKGROUND

Despite the current treatments available for panic disorder (PD), as many as one-third of patients have persistent and treatment-resistant panic attacks. Vortioxetine is an approved medicine for major depressive disorder and has been shown to have anxiolytic properties. The purpose of this study was to evaluate its efficacy and safety in an adult population with a diagnosis of PD.

METHODS

The study design was open label with flexible dose strategies (5, 10, or 20 mg) with a treatment period of 10 weeks. 27 male and female subjects aged between 18 and 60 years, who met DSM-IV criteria for PD with or without agoraphobia, or who had a Panic Disorder Severity Scale (PDSS) score > 8 at baseline were enrolled. Statistical significance was established by the Student's T test.

RESULTS

A statistically significant decrease in the occurrence of panic attacks was measured with the PDSS with vortioxetine. In addition, a moderate improvement in the quality of life and no significant side effects were observed using the Quality-of-Life Scale and Monitoring of Side Effects Scale, respectively.

CONCLUSIONS

These results provide some support for the use of vortioxetine in the management of panic disorder.Trial registration ClinicalTrials.gov ID#: NCT02395510. Registered March 23, 2015, https://clinicaltrials.gov/ct2/show/NCT02395510.

Fear of Fear and Broad Dimensions of Psychopathology over the Course of Cognitive Behavioural Therapy for Panic Disorder with Agoraphobia in Japan

OBJECTIVE

To examine the relationship of fear of fear and broad dimensions of psychopathology in panic disorder with agoraphobia over the course of cognitive behavioural therapy in Japan.

METHODS

A total of 177 Japanese patients with panic disorder with agoraphobia were treated with group cognitive behavioural therapy between 2001 and 2015. We examined associations between the change scores in Agoraphobic Cognitions Questionnaire or Body Sensations Questionnaire and the changes in subscales of Symptom Checklist-90 Revised during cognitive behavioural therapy controlling the change in panic disorder severity using multiple regression analysis.

RESULTS

Reduction in Agoraphobic Cognitions Questionnaire score was related to a decrease in all Symptom Checklist-90 Revised (SCL-90-R) subscale scores. Reduction in Body Sensations Questionnaire score was associated with a decrease in anxiety. Reduction in Panic Disorder Severity Scale score was not related to any SCL-90-R subscale changes.

CONCLUSIONS

Changes in fear of fear, especially maladaptive cognitions, may predict broad dimensions of psychopathology reductions in patients of panic disorder with agoraphobia over the course of cognitive behavioural therapy. For the sake of improving a broader range of psychiatric symptoms in patients of panic disorder with agoraphobia, more attention to maladaptive cognition changes during cognitive behavioural therapy is warranted.

Psychoticism in patients with panic disorder with or without comorbid agoraphobia

OBJECTIVE

A few case-reports have previously described transient psychotic-like symptoms in non-psychotic patients with panic disorder (PD). We aimed to systematically explore whether PD patients without any current or past psychosis can be differentiated according to the severity of 'psychoticism' as a dimension, comprising clinical features such as psychotic-like experiences, increased social alienation, hostility and suspiciousness.

METHODS

Sample included 35 (female = 26) medication-free, non-psychotic patients consecutively referred from our Department's Outpatient Clinic for acute symptoms of DSM-5 PD with (PDA; N = 29) or without concurrent agoraphobia. Psychometric measures included the Symptom Checklist-90-Revised (SCL-90-R), Agoraphobic Cognitions Questionnaire (ACQ), Body Sensations Questionnaire (BSQ), and panic attacks during last 21 days PA-21d.

RESULTS

Multiple regression analysis (forward stepwise) revealed that, among all SCL-90-R subscales, the psychoticism-subscale was most significantly associated with panic-related beliefs included in the ACQ, while significant associations emerged between the paranoid ideation-subscale and the ACQ and BSQ measures. Moreover, significant correlations emerged between the SCL-90-R psychoticism-subscale and all three measures of PD symptoms (ACQ, BSQ, PA-21d) and between the SCL-90-R paranoid ideation-subscale and both the ACQ and BSQ.

CONCLUSIONS

This significant association between levels of psychoticism and severity of panic symptoms may reflect a more severe subtype of PD.

Agoraphobic avoidance predicts emotional distress and increased physical concerns in chronic obstructive pulmonary disease

BACKGROUND

Anxiety and panic attacks are more common in chronic obstructive pulmonary disease (COPD) than in the overall population. Individuals with panic attacks often attempt to avoid situations perceived as at risk of eliciting bodily sensations such as dyspnea, which paradoxically may lead to anxiety-related responsivity. Although there is some evidence that COPD individuals restrict their participation in various life activities because they fear that these may trigger breathlessness, little is known about agoraphobic avoidance and its impact on cognitions and emotional distress in this population. It was thus our aim to investigate the degree of agoraphobic avoidance in COPD individuals, its clinical concomitants and consequences.

METHODS

A total of 48 patients with COPD and 48 matched controlled subjects completed measures of anxiety sensitivity, agoraphobic avoidance, anxiety and depression. Objective COPD severity was measured using forced expiratory volume in the first second.

RESULTS

Patients showed significant impairment in respiratory functioning and psychological distress. Relative to the control, the COPD group exhibited greater depression, anxiety, physical symptom concerns and avoidance (alone and accompanied), irrespective of whether they were panickers or not. Patients with high avoidance showed more intense physical concerns when compared to those with low avoidance. Importantly, the level of avoidance predicted emotional distress and increased physical concerns in COPD.

CONCLUSIONS

Physical concerns scores in COPD patients are partially explained by avoidance in this group. The results of the study provide evidence for the importance of evaluating avoidance in COPD patients and implicate targeting this behavior in therapeutic interventions.

Cortisol as a predictor of psychological therapy response in anxiety disorders-Systematic review and meta-analysis

BACKGROUND

Although psychotherapy generally is effective in anxiety disorders, many patients are treatment-resistant. At the same time, some patients with anxiety disorders show alterations in the hypothalamic-pituitary-adrenal (HPA) axis, one of the major stress-responsive systems. Since raised levels of the end product of the HPA axis, cortisol, adversely affect cognition, we hypothesised that more pronounced alterations in cortisol levels would be associated with a less favourable response to psychotherapy. More specifically, the higher patients' basal levels and the lower their levels during exposure, the less likely we expected them to profit from treatment.

METHODS

We systematically searched the Cochrane Library, EMBASE, MEDLINE, and PsycINFO to review the literature and perform a meta-analysis on the relationship between pre-treatment cortisol and psychotherapy response. Records were included if they studied patients with any anxiety disorder undergoing psychotherapy, with a pre-treatment cortisol and a post-treatment symptom measure. Correlation coefficients were extracted for meta-analyses.

RESULTS

We identified six studies (N=274). No relationship between patients' basal cortisol and post-treatment symptoms was found (p=0.981). The systematic review showed higher cortisol during exposure sessions to predict better outcomes. Meta-analysis did not confirm this (p=0.603).

CONCLUSIONS

Basal cortisol did not seem to predict psychological therapy responses in patients with anxiety disorders. By contrast, the current state of research is equivocal in terms of whether higher cortisol concentrations during exposure sessions are linked with better treatment outcomes, and more research is needed to investigate this.

A randomized controlled trial of a transdiagnostic Internet intervention for individuals with panic and phobias - One size fits all

BACKGROUND AND OBJECTIVES

Many individuals with anxiety disorders do not receive professional treatment. Internet interventions have shown to be effective in the treatment of anxiety. The present randomized controlled trial was designed to examine the effectiveness of a short-term (4-week) Internet intervention in treating panic disorder, agoraphobia, social anxiety disorder, and specific phobias ('ConfID'). We addressed the questions of whether this transdiagnostic program would affect these disorders to varying degrees and whether there would be moderators of effectiveness.

METHODS

Adults who were recruited in online forums for anxiety underwent an online baseline assessment (N = 179) and were randomized either to the intervention group (ConfID) or the control group (care as usual). Online post-assessment took place 4 weeks later. The primary outcome was assessed with the Beck Anxiety Inventory (BAI); the secondary outcomes targeted the disorder-specific symptoms, depression, and somatization.

RESULTS

Participants in the intervention group showed a significantly stronger anxiety reduction compared to participants receiving care as usual (small-to-medium effect size between groups in intention-to-treat analysis). The treatment effect was similar for the different disorders and was moderated by participants' attitudes towards Internet interventions. Secondary outcomes yielded effect sizes in the medium range.

LIMITATIONS

Moderate treatment adherence, lack of measures beyond online self-reports, and unavailability of long-term results.

CONCLUSIONS

The study provides further evidence that transdiagnostic Internet interventions are promising in reducing the existing treatment gap in individuals with panic disorder and phobias. Results extend previous findings by showing that significant effects can also be reached by comprehensive short-term programs and that the effects might be moderated by participants' attitudes towards Internet interventions.

Platzschwindel, agoraphobia and their influence on theories of anxiety at the end of the nineteenth century: theories of the role of biology and 'representations' (Vorstellungen)

During the 1860s, Berlin's exterior physiognomy transformed radically. The city eroded the surrounding rural areas, and the frontiers of the old city centre were abolished. These transformations led to the disappearance of the visible frontiers that once demarcated the limits of the old residential Prussian city. In this context, the description of the clinical picture of agoraphobia by the Berlin psychiatrist Carl Westphal in 1872 marked a turning point, not only in psychiatric theories on anxiety but also in the conceptualization of our experience of space. In this paper, the authors trace the emergence of a new psychology-neurology episteme during the last third of the nineteenth century; and they argue that such an episteme became possible once the relations between anxiety and modern city-scape had been clearly articulated.

A Human Open Field Test Reveals Thigmotaxis Related to Agoraphobic Fear

BACKGROUND

Thigmotaxis refers to a specific behavior of animals (i.e., to stay close to walls when exploring an open space). Such behavior can be assessed with the open field test (OFT), which is a well-established indicator of animal fear. The detection of similar open field behavior in humans may verify the translational validity of this paradigm. Enhanced thigmotaxis related to anxiety may suggest the relevance of such behavior for anxiety disorders, especially agoraphobia.

METHODS

A global positioning system was used to analyze the behavior of 16 patients with agoraphobia and 18 healthy individuals with a risk for agoraphobia (i.e., high anxiety sensitivity) during a human OFT and compare it with appropriate control groups (n = 16 and n = 19). We also tracked 17 patients with agoraphobia and 17 control participants during a city walk that involved walking through an open market square.

RESULTS

Our human OFT triggered thigmotaxis in participants; patients with agoraphobia and participants with high anxiety sensitivity exhibited enhanced thigmotaxis. This behavior was evident in increased movement lengths along the wall of the natural open field and fewer entries into the center of the field despite normal movement speed and length. Furthermore, participants avoided passing through the market square during the city walk, indicating again that thigmotaxis is related to agoraphobia.

CONCLUSIONS

This study is the first to our knowledge to verify the translational validity of the OFT and to reveal that thigmotaxis, an evolutionarily adaptive behavior shown by most species, is related to agoraphobia, a pathologic fear of open spaces, and anxiety sensitivity, a risk factor for agoraphobia.

Taking an RDoC lens to the study of panic disorder: A commentary on Hamm et al. and other thoughts on RDoC

The Research Domain Criteria (RDoC) initiative put forth by the National Institute of Mental Health represents an exciting new framework in which to study psychopathology. The article by Hamm et al. (2016) is an interesting application of an "RDoC lens" toward a program of research on panic disorder. This commentary highlights the many strengths of the Hamm et al. (2016) study-most notably the article's application of a well-studied animal model of anxiety (Fanselow's, , threat imminence model) to humans, utilization of an interesting behavioral paradigm (as an analog for avoidance behaviors in panic disorder), and using RDoC to examine predictors of treatment response. This commentary also discusses several questions about RDoC that arise out of Hamm et al. For example, (a) How should participants be selected for RDoC studies? (b) Are RDoC constructs risk factors (and risk factors for what)? (c) Besides Hamm et al.'s, approach, how else can RDoC be used in treatment studies? In sum, Hamm et al. is a very good example of an RDoC study, and in this early phase of the initiative, more examples for how the approach plays out are needed.

Facing the fear--clinical and neural effects of cognitive behavioural and pharmacotherapy in panic disorder with agoraphobia

INTRODUCTION

Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment-specific effects on symptoms and neurofunctional correlates.

EXPERIMENTAL PROCEDURES

We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29).

RESULTS

Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups.

DISCUSSION

This study demonstrates that therapist-guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment.