Asthma and panic attacks Impact of cognitive-behavioral treatment on quality of life in panic disorder patients. An open study of the effectiveness of Internet treatment for panic disorder delivered in a psychiatric setting Clomipramine and fluoxetine effects in the treatment of panic disorder. Suicidal ideation and suicide attempts in panic disorder and attacks. Central Cholecystokinin Activity in Irritable Bowel Syndrome, Panic Disorder, and Healthy Controls Relationship of past depressive episodes to symptom severity and treatment response in panic disorder with agoraphobia. Rate of improvement during and across three treatments for panic disorder with or without agoraphobia: cognitive behavioral therapy, selective serotonin reuptake inhibitor or both combined. A comparison of citalopram and paroxetine in the treatment of panic disorder: a randomized, single-blind study. Anxiety and Depression in an Outpatient Clinic in Lesotho, Africa The attributable burden of panic disorder in the impairment of quality of life in a national survey in Italy The 35% CO2 challenge test in patients with social phobia A 15-year follow-up study of patients with panic disorder. Panic attacks in the community. Social morbidity and health care utilization. MAOA and mechanisms of panic disorder revisited: from bench to molecular psychotherapy The effects of an Internet based self-help course for reducing panic symptoms - Don't Panic Online: study protocol for a randomised controlled trial Prevalence and Characteristics of Multiple Psychiatric Disorders in Cardiac Rehabilitation Patients A three-year follow-up study of patients with the respiratory subtype of panic disorder after treatment with clonazepam Comparison of the treatment with paroxetine and reboxetine in panic disorder: a randomized, single-blind study. Olanzapine Augmentation in Treatment-Resistant Panic Disorder: A 12-Week, Fixed-Dose, Open-Label Trial Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial. Internet-based self-help treatment for panic disorder: a randomized controlled trial comparing mandatory versus optional complementary psychological support Acute exercise reduces the effects of a 35% CO2 challenge in patients with panic disorder. Stepped care versus face-to-face cognitive behavior therapy for panic disorder and social anxiety disorder: Predictors and moderators of outcome. Effects of the GABA-reuptake inhibitor tiagabine on panic and anxiety in patients with panic disorder. A comparison of bibliotherapy and group therapy in the treatment of panic disorder. A striking pattern of cortisol non-responsiveness to psychosocial stress in patients with panic disorder with concurrent normal cortisol awakening responses Antipanic Drug Modulation Of 35% CO2 Hyperreactivity and Short-Term Treatment Outcome Response of patients with panic disorder and symptoms of hypomania to cognitive behavior therapy for panic. Two-year prospective naturalistic study of remission from major depressive disorder as a function of personality disorder comorbidity. Mortality of anxiety syndromes in a normal population. The Lundby Study. A Naturalistic Long-Term Comparison Study of Selective Serotonin Reuptake Inhibitors in the Treatment of Panic Disorder
Panic disorder ( PD ) and asthma share many common characteristics and have been found in epidemiological studies to be significantly comorbid . To investigate possible reasons for this overlapping , the authors evaluated 51 patients with asthma , assessing the prevalence of PD and sporadic panic attacks , the temporal relationship between these two disorders , and the familial risk for PD in the families of asthmatics . The results showed significantly higher prevalences of PD , sporadic panic attacks , and social phobia in asthmatics than those reported for the general population . In 9 ( 90 % ) of the asthmatics with PD , asthma appeared first . Finally , the morbidity risk for PD in families of asthmatics with PD ( 13.5 % ) was significantly higher than in families of asthmatics without evidence of panic ( 2 % ) . Our results suggest that the high prevalence of PD in asthmatics might be related to a facilitating effect of asthma on the development of PD in subjects with familial predisposition to PD Panic disorder ( PD ) is associated with significant social and health consequences . The present study examined the impact of treatment on PD patients '  quality of life . Patients ( N = 156 ) meeting DSM-III-R ( Diagnostic and Statistical Manual of Mental Disorders [ 3rd ed . , rev . ] ; American Psychiatric Association , 1987 ) criteria for PD with agoraphobia were r and omly assigned to group cognitive-behavioral treatment ( CBT ) or a delayed-treatment control . An assessment battery measuring the major clinical features of PD as well as quality of life was administered at baseline ( Week 0 ) , post-treatment ( Week 9 ) and 6-month follow-up ( Week 35 ) . Consistent with previous studies , PD patients displayed significant impairment in quality of life at intake . Compared with delayed-treatment control participants , CBT-treated participants showed significant reductions in impairment that were maintained at follow-up . Consistent with prediction , anxiety and phobic avoidance were significantly associated with quality of life , whereas frequency of panic attacks was not Panic disorder with or without agoraphobia ( PD/A ) is common and can be treated effectively with selective serotonin reuptake inhibitor ( SSRI ) medication or cognitive – behaviour therapy ( CBT ) . However , the lack of access to CBT services has motivated the development of self-help approaches requiring less therapist contact . A novel treatment modality in this field , showing efficacy in several r and omized trials but until now not evaluated within the context of regular psychiatric care , is Internet-based treatment . The aim of the present study was to evaluate the effectiveness of Internet-based CBT  for patients in a psychiatric setting . Twenty consecutively referred patients with PD were included in the study . A structured clinical interview with a psychiatrist was conducted for inclusion , as well as at post-treatment and at the 6-month follow-up . The treatment consisted of a 10-week CBT-based self-help programme , including minimal therapist support by e-mail . At post-treatment , 94 % of patients no longer met DSM-IV criteria for PD ( 82 % at 6-month follow-up ) . The within-group effect sizes ( for the main outcome PDSS ; Panic Disorder Severity Scale ) were Cohen 's d=2.5 ( pre- to post-treatment ) and 2.8 ( pre-treatment to follow-up ) , respectively . The proportion of responders on the PDSS was 75 % at post-treatment and 70 % at 6-month follow-up . The results supports earlier efficacy data on Internet-based CBT for PD and indicates that it is effective also within a regular psychiatric setting . However , a larger r and omized controlled trial should be conducted , directly comparing Internet-based CBT with traditionally administered CBT within such a setting Panic disorder ( PD ) is an acute psychobiologic reaction manifested by intense anxiety and panic attacks , that occur unpredictably with subjective sense of intense apprehension or terror , accompanied by temporary loss of the ability to plan , think , or reason and the intense desire to escape or flee the situation . Panic attacks may last from a few seconds to an hour or longer . Symptoms typically include , among others , palpitations , tachycardia , hypertension , chest pain , dyspnoea , and fear of loosing control or going crazy and vague feeling of imminent doom or death . Since pharmacotherapy of PD includes the administration of selective serotonin reuptake inhibitors and tricyclic antidepressants , the objective of this study was to perform a pilot double blind clinical trial design ed to compare the effects of two studied drugs in the treatment of PD . A total number of 40 patients with a history of panic disorder were r and omly assigned into two groups of 20 patients each . Hamilton anxiety rating scale and St and ard Psychiatric Interview were methods for PD assessment . One group was treated with clomipramine hydrochloride ( ANAFRANIL ) 75 mg/day and the other with fluoxetine ( OXETIN ) 60 mg/day . Both drugs were administrated by mouth ( PO ) two times-a-day in equally divided doses for 6 weeks . Both studied agents produced similar antipanic effectiveness . Favourable response was achieved in 95 % of patients treated with fluoxetine and 90 % of patients treated with clomipramine . The onset of antipanic effects was quicker in all clomipramine treated patients , while fluoxetine produced more-favourable response in male patients . The duration of treatment with both antidepressants studied should be at least 10 weeks , instead of 6 weeks Panic disorder , which is found in about 1.5 percent of the population at some time in their lives , includes recurrent episodes of sudden , unpredictable , intense fear accompanied by symptoms such as palpitations , chest pain , and faintness . Panic attacks , which do not meet these diagnostic criteria fully , are two to three times more prevalent . Since panic symptoms can mimic those of other medical disorders , patients with these symptoms use medical services frequently . To determine the risk of suicidal ideation and suicide attempts in panic disorder and attacks , we studied a r and om sample of 18,011 adults drawn from five U.S. communities . Subjects who had panic disorder , as compared with other psychiatric disorders , had more suicidal ideation and suicide attempts , with an adjusted odds ratio for suicide attempts of 2.62 ( 95 percent confidence interval , 1.83 to 3.74 ) . The odds ratio was 17.99 ( 95 percent confidence interval , 12.18 to 26.58 ) when the group with panic disorder was compared with subjects who had no psychiatric disorder . Twenty percent of the subjects with panic disorder and 12 percent of those with panic attacks had made suicide attempts . These results could not be explained by the coexistence of major depression or of alcohol or drug abuse . We conclude that panic disorder and attacks are associated with an increased risk of suicidal ideation and suicide attempts . Physicians working in general medical setting s and emergency departments should be alert to this problem Objective : Irritable bowel syndrome ( IBS ) and panic disorder ( PD ) coexist with a high frequency . However , the nature of this relationship remains obscure . We have proposed that PD and IBS may share a common dysfunction of the central cholecystokinin ( CCK ) system . To test this hypothesis , we assessed whether the enhanced panicogenic response to CCK-tetrapeptide ( CCK-4 ) observed in PD is also present in IBS . Methods : Eight psychiatrically healthy IBS patients , 8 PD patients with no history of IBS , and 12 normal controls received a bolus injection of CCK-4 and placebo on two separate days in a double-blind , r and omized fashion . Results : Consistent with previous findings , panicogenic sensitivity to  CCK-4  was enhanced in PD patients relative to controls . In contrast , IBS patients exhibited a response that was comparable to controls . Interestingly , CCK-4-induced nausea and abdominal distress were decreased in IBS patients relative to the other groups . No diagnostic difference was noted for cardiovascular response to CCK-4 . Conclusion : These data indicate that IBS patients with no lifetime psychiatric history do not share the CCK-2 receptor dysfunction implicated in the pathophysiology of PD and that this dysfunction may not be a common mechanism for both CNS and enteric nervous system disorders . Nevertheless , the results suggest that a dysfunction of the CCK system may be involved in the pathophysiology of some enteric symptoms associated with IBS . IBS = irritable bowel syndrome ; PD = panic disorder ; CCK = cholecystokinin ; NTS = nucleus tractus solitarius ; CBF = cerebral blood flow ; NC = normal controls ; PSS = Panic Symptom Scale ; CCK-4 = cholecystokinin-tetrapeptide ; VAS = visual analog scale BACKGROUND Many investigators have reported that panic disorder ( PD ) patients with comorbid major depression ( MD ) have more severe symptoms and a poorer response to treatment than patients with PD alone . It is not known if this is due to a distinct and more serious underlying disorder in these patients or simply a result of the simultaneous presence of the two disorders . METHOD Nondepressed patients presenting for treatment of panic disorder with agoraphobia ( PDA ) were studied before treatment ( N = 180 ) and after 4 weeks of treatment with adinazolam sustained release ( N = 89 ) or placebo ( N = 91 ) . Twenty-nine percent ( N = 53 ) of the patients had a past history of MD .  Symptom severity and treatment outcome were compared in patients with primary , secondary , single , recurrent , or no past MD . RESULTS There were no consistent differences in symptom severity or treatment outcome in patients with a past history of primary , secondary , or single episode MD compared with patients with no history of MD . However , a small number of patients with history of recurrent MD exhibited consistently greater symptom severity and poorer response to treatment than patients with no history of MD . CONCLUSION The greater severity and worse outcome of comorbid PD and MD observed in earlier studies are more likely due to the simultaneous presence of the two disorders than to a more serious and enduring underlying disorder . However , our results suggest that recurrent MD may indicate a more serious condition in patients with PDA . This possibility warrants further study BACKGROUND Existing literature on panic disorder ( PD ) yields no data regarding the differential rates of improvement during Cognitive Behavioral Therapy ( CBT ) , Selective Serotonin Reuptake Inhibitor ( SSRI ) or both combined ( CBT+SSRI ) . METHOD Patients were r and omized to CBT , SSRI or CBT+SSRI which each lasted one year including three months of medication taper . Participating patients kept record of the frequency of panic attacks throughout the full year of treatment . Rate of improvement on panic frequency and the relationship between rate of improvement and baseline agoraphobia ( AG ) were examined . RESULTS A significant decline in frequency of panic attacks was observed for each treatment modality . SSRI and CBT+SSRI were associated with a significant faster rate of improvement as compared to CBT . Gains were maintained after tapering medication . For patients with moderate or severe AG , CBT+SSRI was associated with a more rapid improvement on panic frequency as compared to patients receiving either mono-treatment . LIMITATIONS Frequency of panic attacks was not assessed beyond the full year of treatment . Second , only one process variable was used . CONCLUSIONS Patients with PD respond well to each treatment as indicated by a significant decline in panic attacks .  CBT is associated with a slower rate of improvement as compared to SSRI and CBT+SSRI . Discontinuation of SSRI treatment does not result in a revival of frequency of panic attacks . Our data suggest that for patients without or with only mild AG , SSRI-only will suffice . For patients with moderate or severe AG , the combined CBT+SSRI treatment is recommended BACKGROUND Serotonin Selective Re-uptake Inhibitors ( SSRIs ) are the drugs of choice for treating panic disorder ( PD ) . In vitro studies have shown different pharmacodynamic profiles for SSRIs , but their clinical relevance is still unknown . Paroxetine , the SSRI with the strongest serotonergic effect , also shows significant cholinergic and noradrenergic activities . In this class of drugs , citalopram is the most selective for serotonin . We compared these two drugs and their effectiveness and tolerability in a sample of patients with PD in a two-month treatment course . METHOD Fifty-eight patients with PD were r and omly assigned to either the paroxetine or the citalopram treatment group in a single-blind , r and omized design . Each patient was assessed at days 0 , 7 and 60 by the Panic Associated Symptoms Scale ( PASS ) , the Sheehan Disability Scale ( SDS ) and the Fear Question naire ( FQ ) . Primary outcome measures were the percentage of patients free of panic attacks , anticipatory anxiety and phobic avoidance in the last week of the trial and the percentage of good responders , as defined by a reduction of at least 50 % from baseline of both PASS and SDS global scores at day 60 . RESULTS At day 60 , 86 % of patients receiving citalopram and 84 % of those receiving paroxetine responded well to treatment . No significant differences between the two drugs were found . Both were well tolerated , although sexual side effects and weight gain were frequent . Anticipatory anxiety decreased significantly after the first week of treatment , and no initial worsening in the panic attacks was observed . CONCLUSION Paroxetine and citalopram show similar anti-panic properties and a good tolerability profile . Our results support evidence that the serotonergic system plays a significant role in the anti-panic properties of these two SSRIs Objective : Past studies of psychiatric disorders in primary care in developing countries have utilized measures to determine conspicuous psychiatric morbidity ( CPM ) rather than diagnoses . Our goal was to determine the prevalence of DSM-III major depression ( DEP ) , panic disorder ( PD ) , and generalized anxiety disorder ( GAD ) in an outpatient clinic in Lesotho , Africa . Methods : As part of a larger community study , we utilized a translated version of the N.I.M.H. Diagnostic Interview Schedule to determine the prevalence of DEP , PD , and GAD in 126 r and omly selected out patients ( response rate = 77 % ) attending a general hospital clinic . We compared these data to information about demographics and symptom presentation . Results : We found twenty-nine ( 23 % ) patients with DEP , thirty ( 24 % ) with PD , and thirty-six ( 29 % ) with GAD . Forty-six ( 36 % ) had either DEP or PD , with thirteen ( 45 % ) having concurrent illness . Patients with DEP and /or PD presented with a significantly higher number of physical symptoms , and a higher percentage of symptoms that were pain or autonomic nervous system related than patients with no disorder ever . Conclusion : There is significant psychiatric morbidity of common diagnoses in outpatient clinic in Lesotho , and patients present primarily with somatic symptoms , as in developed countries . There is a need for better elucidation of cross-cultural phenomenology , medical co-morbidity as a con-founder , and help-seeking and treatment patterns in the developing world Introduction / Objective : The aim was to measure the lifetime prevalence of panic disorder ( PD ) in an Italian community sample , and to estimate the burden attributable to PD in compromising the quality of life ( QoL ) of people diagnosed with it . Methods : Community survey was conducted on a sample of 4,999 r and omly selected adult subjects . Instruments used were  semi-structured clinical interview Advanced Neuropsychiatric Tools and Assessment Schedule ( ANTAS ) , administered by clinicians and allowing diagnosis according to Diagnostic and Statistical Manual of Mental Disorder ( 4th ed . ; DSM-IV ) ; Short Form Health Survey ( SF-12 ) . Results : The lifetime prevalence of PD was 3.6 % ( 4.4 % in females , 2.5 % in males ; p = .002 ) . People with PD had a lower SF-12 score than the st and ardized community sample ( 35.5 ± 6.5 vs. 38.4 ± 5.9 ; p < .0001 ) with a mean difference ( attributable burden ) of 2.9 ± 0.7 , that is , lower than PD with agoraphobia ( AP ; 4.2 ± 2.4 ) . Wilson Disease ( WD ) , Multiple Sclerosis , Major Depressive Disorder and Eating Disorders ( ED ) show a higher attributable burden in impaired QoL than PD , while the attributable burden of PD with AP is not lower than in ED and WD . Conclusions : The burden attributable to the impairment of QoL following a lifetime diagnosis of PD was found to be not so great compared to the impairment caused by Major Depressive Disorder ( MDD ) or neurological conditions . The comorbidity of PD with AP worsens QoL significantly Panic disorder ( PD ) and social phobia ( SP ) share many clinical , demographic and biological characteristics . To investigate the relationships between the two disorders , the responses to inhalation of a 35 % carbon-dioxide ( CO2 ) and 65 % oxygen ( O2 ) gas mixture were assessed . Sixteen patients with PD , 16 patients with SP , 13 patients with both SP and PD , seven patients with SP who experienced sporadic unexpected panic attacks and 16 healthy control subjects inhaled one vital capacity of 35 % CO2 or compressed air . A double-blind , r and omized , crossover design was used . PD patients and SP patients showed similar anxiogenic reactions to 35 % CO2 , both stronger than seen in control subjects . Patients with both disorders and SP patients with sporadic unexpected panic attacks reacted similarly to subjects with PD or SP alone . These results suggest that PD and SP share a common hypersensitivity to CO2 and thus might belong to the same spectrum of vulnerability BACKGROUND Panic disorder ( PD ) is generally regarded as a chronic condition with considerable variation in severity of symptoms . AIMS To describe the long-term outcome of naturalistically treated PD . METHODS Fifty-five out patients with PD , who participated in a placebo-controlled drug trial of the efficacy of alprazolam and imipramine 15 years ago were reassessed with the same instruments used in the original study . RESULTS Complete recovery ( no panic attacks and no longer on medication during the last 10 years ) was seen in 18 % of patients , and an additional 13 % recovered but were still on medication . Fifty-one percent experienced recurrent anxiety attacks whereas 18 % still met diagnostic criteria for PD . The incidence of agoraphobia decreased from 69 % to 20 % . Patients with agoraphobia at admission tended to have a poorer long-term outcome according to daily functioning compared with patients without agoraphobia at admission , although both groups reported improved daily functioning at follow-up . Maintenance medication was common . No benzodiazepine abuse was reported . CONCLUSION PD has a favourable outcome in a substantial proportion of patients . However , the illness is chronic and needs treatment . The short-term treatment given in the drug trial had no influence on the long-term outcome This article focuses on social morbidity and health care utilization in persons with panic attacks not meeting full diagnostic criteria for panic disorder . The findings are based on data from a r and om sample of over 18,000 adults drawn from five US communities . Panic attacks not meeting full criteria for panic disorder have a relatively high lifetime prevalence ( 3.6 % of the adult population ) . Persons with panic attacks had impairment in perceived physical and emotional health , and in occupational and financial functioning , increased use of health care facilities , emergency departments , and psychoactive drugs . Persons with panic attacks were intermediate in severity between those with panic disorder and those with other psychiatric disorders . The findings could not be explained by comorbidity with other psychiatric disorders . We conclude that panic attacks have clinical significance and are associated with substantial morbidity Panic disorder with agoraphobia ( PD/AG ) is a prevalent mental disorder featuring a substantial complex genetic component . At present , only a few established risk genes exist . Among these , the gene encoding monoamine oxidase A ( MAOA ) is noteworthy given that genetic variation has been demonstrated to influence gene expression and monoamine levels . Long alleles of the MAOA-uVNTR promoter polymorphism are associated with PD/AG and correspond with increased enzyme activity . Here , we have thus investigated the impact of MAOA-uVNTR on therapy response , behavioral avoidance and brain activity in fear conditioning in a large controlled and r and omized multicenter study on cognitive behavioral therapy ( CBT ) in PD/AG . The study consisted of 369 PD/AG patients , and genetic information was available for 283 patients . Carriers of the risk allele had significantly worse outcome as measured by the Hamilton Anxiety scale ( 46 % responders vs 67 % , P=0.017 ) . This was accompanied by elevated heart rate and increased fear during an anxiety-provoking situation , that is , the behavioral avoidance task . All but one panic attack that happened during this task occurred in risk allele carriers and , furthermore , risk allele carriers did not habituate to the situation during repetitive exposure . Finally , functional neuroimaging during a classical fear conditioning paradigm evidence d that the protective allele is associated with increased activation of the anterior cingulate cortex upon presentation of the CS+ during acquisition of fear . Further differentiation between high- and low-risk subjects after treatment was observed in the inferior parietal lobes , suggesting differential brain activation patterns upon CBT . Taken together , we established that a genetic risk factor for PD/AG is associated with worse response to CBT and identify potential underlying neural mechanisms . These findings might govern how psychotherapy can include genetic information to tailor individualized treatment approaches Background Internet based self-help for panic disorder ( PD ) has proven to be effective . However , studies so far have focussed on treating a full-blown disorder . Panic symptoms that do not meet DSM-IV criteria are more prevalent than the full-blown disorder and patients with sub- clinical panic symptoms are at risk of developing PD . This study is a r and omised controlled trial aim ed to evaluate an Internet based self-help intervention for sub- clinical and mild PD compared to a waiting list control group . Methods Participants with mild or sub- clinical PD ( N = 128 ) will be recruited in the general population .  Severity of panic and anxiety symptoms are the primary outcome measures . Secondary outcomes include depressive symptoms , quality of life , loss of production and health care consumption . Assessment s will take place on the Internet at baseline and three months after baseline . Discussion Results will indicate the effectiveness of  Internet based self-help  for sub- clinical and mild PD . Strengths of this design are the external validity and the fact that it is almost completely conducted online . Trial registration Netherl and s Trial Register ( NTR ) : NTR1639 The Netherl and s Trial Register is part of the Dutch Cochrane Centre PURPOSE Anxiety and depressive disorders have been established as independent risk factors for the development of and recovery from coronary heart disease ( CHD ) . However , few studies have reported on the prevalence and personal characteristics of comorbid psychiatric disorders ( PD ) among cardiac population s. This project examined the prevalence of comorbid depressive and anxiety disorders among men and women with CHD commencing cardiac rehabilitation ( CR )  and the demographic , medical , and psychosocial characteristics among those meeting multiple PD criteria . METHODS Participants were 143 CHD patients ( M age , 61 years ; SD , 11.2 ; 70 % men , 91 % Caucasian , 64 % married ) entering CR who were evaluated via a semistructured , psychiatric interview to assess both current and lifetime prevalence rates of PD . Demographic , medical , and psychosocial variables were also assessed . RESULTS Approximately 45 % met criteria for at least 1 anxiety disorder , and 20 % met criteria for either major depressive disorder or dysthymic disorder either at the time of evaluation or in their lifetime . Across all participants , 26 % met criteria for ≥2 PD . Of those with a depressive disorder , 76 % also met criteria for at least 1 anxiety disorder . Participants with comorbid PD were of younger age and female and reported less education ( P < .01 ) . Comorbidity was also associated with self-reported overall diminished physical , emotional , and social quality of life , depression , and anxiety . CONCLUSION Comorbid PD are highly prevalent in the CR setting and are associated with specific demographic characteristics and reduced quality of life . These data offer additional support that routine screening for PD is warranted in outpatient cardiac setting The demographic , clinical and therapeutic features of the respiratory subtype of panic disorder ( PD ) versus the non-respiratory subtype were studied in a prospect i ve design . Sixty-seven PD out patients ( DSM-IV ) , who had previously been categorized into respiratory ( n=35 ) and non-respiratory ( n=32 ) subgroups , were openly treated with clonazepam for a 3-year period . The principal measure of efficacy was the number of panic attacks , obtained from the Sheehan Panic and Anticipatory Anxiety Scale . In the first 8 weeks of treatment ( acute phase ) , the respiratory subtype group had a significantly faster response to clonazepam . During the follow-up ( weeks 12 - 156 ) , the two subgroups did not differ significantly in the number of panic attacks experienced from baseline to end point . Patients in the respiratory subtype were characterized by a later onset of disorder and a family history of PD . Patients in the non-respiratory subgroup had a significantly higher number of past depressive episodes than those in the respiratory subgroup . The respiratory subgroup had a faster response after 8 weeks of treatment and an equivalent response in the 3-year follow-up period . Clonazepam had a sustained therapeutic effect over the entire treatment period INTRODUCTION Serotonergic agents have greater effectiveness than noradrenergic ones in the treatment of Panic Disorder ( PD ) . However preliminary studies suggested that reboxetine might be effective in the treatment of PD . We compared the effectiveness and tolerability of reboxetine and paroxetine in the treatment of PD . METHODS Sixty-eight patients with PD were assigned to treatment groups in a single-blind , r and omized design . Each patient was assessed at day 0 and 90 by the Panic Associated Symptoms Scale ( PASS ) , the Sheehan Disability Scale ( SDS ) and the Fear Question naire ( FQ ) . Side effects were also recorded . RESULTS Reduction of PASS scores was significantly greater in the paroxetine group than in the reboxetine one . Vice versa we did not find any significant differences for other outcome measures . Sexual dysfunction and weight gain were significantly less frequent in the reboxetine group . CONCLUSIONS The results showed a greater effect of paroxetine on panic attacks than reboxetine , while no differences for anticipatory anxiety and avoidance were found , suggesting a different role of noradrenaline and serotonin in the treatment of PD The purpose of our study was to evaluate the efficacy and tolerability of low-dose olanzapine augmentation in selective serotonin reuptake inhibitor (SSRI)-resistant panic disorder ( PD ) with or without agoraphobia . In this 12-week , open-label study , 31 adult out patients with treatment-resistant PD who had previously failed to respond to SSRI treatment were treated with fixed dose of olanzapine ( 5 mg/d ) in addition to SSRI .  Efficacy was assessed using the Panic Attack and Anticipatory Anxiety Scale ( PAAAS ) , the Agoraphobic Cognitions Question naire ( ACQ ) , the Hamilton Rating Scale for Anxiety ( HAM-A ) , the Hamilton Rating Scale for Depression ( HAM-D ) , the Global Assessment of Functioning Scale ( GAF ) , and the Clinical Global Impression of Improvement ( CGI-I ) . Twenty-six patients completed the trial period with a dropout rate of 16.1 % . At week 12 , 21 patients were responders ( 81.8 % ) , and an overall improvement on all rating scales was observed in all patients both with or without agoraphobia . Fifteen patients ( 57.7 % ) achieved remission . Olanzapine was well tolerated and the most frequent adverse effects were mild-to-moderate weight gain and drowsiness . No extrapyramidal symptoms were reported . Olanzapine appears to be effective as augmentation strategy in the treatment of SSRI-resistant PD , but study limitations must be considered and placebo-controlled studies are needed Confusion between panic and asthma symptoms can result in serious self-management errors . A cognitive behavior psychophysiological therapy ( CBPT ) intervention was culturally adapted for Latinos consisting of CBT for panic disorder ( PD ) , asthma education , differentiation between panic and asthma symptoms , and heart rate variability biofeedback . An RCT compared CBPT to music and relaxation therapy ( MRT ) , which included listening to relaxing music and paced breathing at resting respiration rates . Fifty-three Latino ( primarily Puerto Rican ) adults with asthma and PD were r and omly assigned to CBPT or MRT for 8 weekly sessions . Both groups showed improvements in PD severity , asthma control , and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up . CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids . Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT , although earlier levels of these mediators did not predict subsequent improvements . Attrition was high ( 40 % ) in both groups , albeit comparable to CBT studies targeting anxiety in Latinos . Additional strategies are needed to improve retention in this high-risk population . Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD , and CBPT may offer additional benefits for improving medication adherence Abstract Panic disorder ( PD ) is one of the most common psychiatric disorders . Web-based self-help treatments for PD have had promising results . These online treatments seem to have larger effect sizes ( ESs ) when professional support is added . However , the amount of support or how it should be administered is not yet clear . The aim of this trial was to study two ways of administering psychological support provided by phone as a part of Internet-based self-help treatment for PD based on cognitive behavioral therapy .  Seventy-seven participants diagnosed with PD were r and omly assigned to one of three experimental conditions : a waiting list control group ; a treatment group with non-scheduled psychological support ; or a treatment group with scheduled psychological support .  PD symptoms of participants who received treatment improved significantly compared to the control group ( mean ES d = 1.18 , p < .05 ) . In addition , there were statistically and clinical ly significant differences between treatment groups ( Mean difference = −3.20 , p = .005 , 95 % CI [ −5.62 , −.79 ] ) . The scheduled group showed a larger ES , a lower dropout rate , and better adherence to treatment than the non-scheduled group .  Scheduled support  seems to be indicated for patients who seek Web-based treatment for PD , and their symptoms of panic , anxiety , and depression improve at post-treatment and six-month follow-up . In contrast , when support depends on patient dem and , they receive less support and so , the therapeutic effect is poorer BACKGROUND Chronic exercise has been shown to have therapeutic effects in panic disorder ( PD ) . The mechanism of these effects is unknown . Acute exercise reduces the effect of a panic challenge in healthy volunteers . Such an effect has not yet been demonstrated in PD patients . The present study aim ed at exploring the antipanic effects of acute exercise on a 35 % CO2 panic provocation in treatment-naïve PD patients to further eluci date the mechanisms of the beneficial effects of exercise on panic . METHODS Eighteen PD patients performed either moderate/hard exercise or very-light exercise before a 35 % CO2 challenge in a r and omized , between-group design . The reactivity to CO2 was assessed with the Visual Analogue Anxiety Scale and the DSM-IV Panic Symptom List . RESULTS Panic reactions to CO2 were smaller in patients that performed moderate/hard exercise in contrast to those that performed very-light exercise . Increments in both measurements and panic rates were consistently reduced by intense exercise . LIMITATIONS Since this study focuses on the acute effects of exercise on CO2 sensitivity in patients with PD , the results of repetitive exercise sessions on the rate of spontaneous panic attacks and overall symptoms are warranted . The small sample size and other limitations are addressed . CONCLUSIONS Exercise reduced the panicogenic effects of a CO2 challenge . In addition to its therapeutic potential , exercise may also be useful as a laboratory maneuver with heuristic value in experimental research into the mechanisms of antipanic treatment OBJECTIVE To investigate predictors and moderators of treatment outcome by comparing immediate face-to-face cognitive behavioral therapy ( FtF-CBT ) to a Stepped Care treatment model comprising three steps : Psychoeducation , Internet-delivered CBT , and FtF-CBT for panic disorder ( PD ) and social anxiety disorder ( SAD ) . METHOD Patients ( N = 173 ) were recruited from nine public mental health out-patient clinics and r and omized to immediate FtF-CBT or Stepped Care treatment .  Characteristics related to social functioning , impairment from the anxiety disorder , and comorbidity was investigated as predictors and moderators by treatment format and diagnosis in multiple regression analyses . RESULTS Lower social functioning , higher impairment from the anxiety disorder , and a comorbid cluster C personality disorder were associated with significantly less improvement , particularly among patients with PD . Furthermore , having a comorbid anxiety disorder was associated with a better treatment outcome among patients with PD but not patients with SAD . Patients with a comorbid depression had similar outcomes from the different treatments , but patients without comorbid depression had better outcomes from immediate FtF-CBT compared to guided self-help . CONCLUSIONS In general , the same patient characteristics appear to be associated with the treatment outcome for CBT provided in low- and high-intensity formats when treated in public mental health care clinics . The findings suggest that patients with lower social functioning and higher impairment from their anxiety disorder benefit less from these treatments and may require more adapted and extensive treatment . CLINICAL TRIALS.GOV : Identifier : NCT00619138 INTRODUCTION There is evidence that a decreased GABAergic tone plays a role in the pathophysiology of panic disorder ( PD ) . Selective GABAergic treatment has been suggested as a new therapeutic strategy in PD . In this pilot- study anxiolytic effects of the GABA reuptake inhibitor tiagabine ( TGB ) were investigated in PD . METHODS A total of 19 patients were treated with TGB ( n=10 ) or placebo ( n=9 ) for 4 weeks . PAS , HAM-A , and CGI ratings were administered every week . To further assess specific antipanic activity , panic challenges with CCK-4 were carried out in single subjects . RESULTS Although there was a significant reduction of clinical rating scores over time , no differences were detected between the groups . However , during challenge experiments TGB treated subjects showed decreased sensitivity to CCK-4 . DISCUSSION Whereas tiagabine did not show beneficial effects on clinical symptoms in PD compared to placebo , results of challenge experiments suggest effects of TGB on sensitivity to experimentally induced panic This study investigated 2 methods of disseminating a cognitive-behavioral intervention for panic disorder ( PD ) . Thirty-six Ss who met diagnostic criteria for PD according to the Anxiety Disorders Interview Schedule-Revised were r and omly assigned to 1 of 3 conditions : bibliotherapy ( BT ) , group therapy ( GT ) , or a waiting-list control ( WL ) condition . Interventions lasted 8 weeks and were followed by a posttest , along with 3- and 6-month follow-up assessment s. Results indicated that both the BT and GT treatments were more effective than the WL condition in reducing frequency of panic attacks , severity of physical panic symptoms , catastrophic cognitions , agoraphobic avoidance , and depression and that the BT and GT treatments were more effective in increasing self-efficacy . Both interventions maintained their effects throughout the follow-up periods and produced clinical ly significant levels of change among the majority of treated Ss BACKGROUND Subtle and inconsistent differences in hypothalamic-pituitary-adrenal ( HPA ) axis activity have been reported for patients with panic disorder . While these patients show little or no alterations in basal ACTH and cortisol levels , it has been hypothesized that HPA hyperresponsivity was a trait in panic patients when exposed to novel and uncontrollable stimulation . METHODS Thirty-four patients ( 23 females , mean age 35 yrs ) diagnosed with panic disorder were compared to 34 healthy controls matched for age , gender , smoking status , and use of oral contraceptives . Both groups were exposed twice to a potent laboratory stress protocol , the Trier Social Stress Test ( TSST ) on consecutive days .  Free salivary cortisol levels and heart rate responses were repeatedly measured before and following the TSST . In addition , the cortisol awakening response ( CAR ) was assessed to further investigate HPA reactivity in PD patients . RESULTS While the TSST induced similar heart rate stress responses in both groups , cortisol responses were clearly absent in the panic patients with normal responses in the controls ( F(1.96 , 66)=20.16 ; p<0.001 ) . No differences in basal cortisol levels were observed in the extended baseline period . The same cortisol stress non-response patterns were observed when patients with/without comorbid depression , or with/without psychotropic medication were compared . In contrast to their non-response to the psychosocial stressor , panic patients showed a significant CAR . CONCLUSION These findings provide strong evidence to suggest that PD patients present with a striking lack of cortisol responsivity to acute uncontrollable psychosocial stress under laboratory conditions . This unresponsiveness of the HPA axis appears to be rather specific , since a normal CAR in the morning could be documented in these patients . Thus , the present results do not support the hypothesis that PD patients show a trait HPA hyperresponsiveness to novel and uncontrollable stimulation . In contrast , the data provide support for a hyporesponsive HPA axis under emotional stress in PD patients Carbon dioxide ( CO2 ) inhalation induces acute anxiety and panic attacks in patients with Panic Disorder ( PD ) . Anti-panic drugs decrease CO2 reactivity after the first days of treatment ; however , the clinical meaning of this finding has not yet been established . This study investigated the effects of treatment with tricyclic antidepressants and selective serotonin re-uptake inhibitors ( SSRIs ) on CO2 reactivity and compared the relationships between 35 % CO2 hyperreactivity modulation and short-term clinical outcome .  One hundred twenty-three patients with PD with or without agoraphobia who were hyperreactive to CO2 were r and omly assigned to treatment groups with imipramine , clomipramine , paroxetine , sertraline , or fluvoxamine . A double-blind , r and omized design was applied . Each patient received the 35 % CO2 challenge on days 0 , 7 , and 30 . The severity of clinical symptomatology was measured on days 0 and 30 . Decreased hyperreactivity to 35 % CO2 in all five treatment groups was already evident after the first week . The decrease in CO2 reactivity at the end of treatment was proportional to the degree of clinical improvement . Multiple regression analyses showed that the decrease in CO2 reactivity after the first week was a significant predictor for good clinical outcome after one month . The results of this study confirm evidence that psychoactive drugs effective in the treatment of PD decrease CO2 hyperreactivity . They also suggest that precocious modulation of CO2 reactivity might fairly reliably predict short-term clinical outcome in patients with “ respiratory ” PD OBJECTIVES The purpose of this cohort study was to determine in patients with Panic Disorder ( PD ) : ( 1 ) . the prevalence of subsyndromal symptoms of hypomania , and ( 2 ) . whether subsyndromal hypomania symptoms affect the outcome of cognitive behavior therapy ( CBT ) for panic . METHODS Using the Diagnostic Interview Schedule , and DSM-III-R criteria we identified 18 individuals with a history of symptoms of hypomania among 56 patients with PD . Patients were treated in an open CBT group program . They were assessed before treatment and 6 and 12 months later . We used the  Brief Symptom Inventory ( BSI ) , the Perceived Stress Scale ( PSS ) , the Pearlin-Schooler Mastery Scale ( PMS ) , and the Social Adjustment Scale ( SAS )  at all assessment s. RESULTS The total group significantly improved on all measures . The Clinical ly Significant Change was 71.4 % and the Reliable Change Index 48.2 % . Between 6 and 12 months , there was a trend for the hypomania symptom subgroup ( PH ) to continue to improve on the BSI Depression Scale , the Perceived Stress Scale , the Pearlin-Schooler Mastery Scale , and the Social Adjustment Scale but to lose gains on the BSI Phobic Anxiety and Somatization subscales compared with the group without symptoms of hypomania ( PNH ) . CONCLUSIONS Thirty-two percent of patients with PD had symptoms of hypomania . With CBT for panic , patients with PD and symptoms of hypomania improve as much as those without hypomania symptoms . The presence or absence of symptoms of hypomania might help explain the inconsistent effects of depression and personality disorders on the treatment of PD In this study , the authors examined prospect ively the 24-month natural course of remission from major depressive disorder ( MDD ) as a function of personality disorder ( PD ) comorbidity . In 302 participants ( 196 women , 106 men ) , psychiatric and PDs were assessed  at baseline with diagnostic interviews , and the course of MDD was assessed with the Longitudinal Interval Follow-Up Evaluation at 6- , 12- , and 24-month follow-ups .  Survival analyses revealed an overall 24-month remission rate of 73.5 % for MDD that differed little by gender . Participants with MDD who had certain forms of coexisting PD psychopathology ( schizotypal , borderline , or avoidant ) as their primary PD diagnoses had a significantly longer time to remission from MDD than did patients with MDD without any PD . These PDs emerged as robust predictors of slowed remission from MDD even when controlling for other negative prognostic predictors The mortality of anxiety syndromes  between 1972 and 1992 was investigated in a prospect i ve study of a normal population , the 1947 Lundby cohort . 121 persons with anxiety according to the Lundby definition ( Anx ) , and 74 persons with panic disorder with/without agoraphobia ( PD-Ag ) according to the DSM-III-R , all of them developing their first episode between 1947 and 1972 , were analyzed with regard to general mortality and special cause of death . Sex- and age-specific mortality rates for these groups were calculated and compared with the corresponding rates of the cohort 's 1,877 remaining subjects without first episodes of Anx/PD-Ag . In contrast to the females , the annual rates of general mortality in males with Anx/PD-Ag were 1.9/2.2 times higher in the age group 65 - 84 years , compared with the rates of the non-Anx/PD-Ag groups . They also had an increase in death due to circulatory disorders , most pronounced in males with PD-Ag before the age of 65 . There were no suicides in any of the Anx/PD-Ag groups during the observation period Objectives : Selective serotonin reuptake inhibitors ( SSRIs ) are currently considered as the first drug of choice in the treatment of panic disorder ( PD ) . The aim of this long-term , naturalistic comparison study was to compare 4 SSRIs with respect to tolerability and treatment outcome of PD . Outcome measures included relapse rates and adverse effects . Methods : Two hundred patients with PD were enrolled in our study . All subjects met DSM-IV criteria for PD or PD with agoraphobia ( PDA ) . All patients were assigned to receive SSRI monotherapy for 12 months with either citalopram ( n = 50 ) , fluoxetine ( n = 50 ) , fluvoxamine ( n = 50 ) , or paroxetine ( n = 50 ) in a r and omized , nonblinded fashion . Both the treating psychiatrist and the patients were not blind to the assigned treatment , but the clinician raters were blind to the study medication . The study design allowed for assignment of a particular SSRI as indicated according to the clinical judgment of the study psychiatrists . The Panic Self- Question naire , which is a self-report scale , was administered at baseline and then once per month during the duration of the 12-month study . The visual analog scale and the Clinical Global Impression Scale were administered at baseline and then once per month during the period of the study . Reports of sexual dysfunction were assessed using a nonstructured clinical interview at monthly visits . The body weight of study subjects was measured at baseline , and then at the 12th month visit end point . Results : Of 200 patients who entered the study , 127 patients ( 63.5 % ) completed the full 12-month protocol . Retention rates were highest for paroxetine ( 76 % [ 38/50 ] ) , intermediate for citalopram ( 68 % [ 34/50 ] ) and fluvoxamine ( 60 % [ 30/50 ] ) , and lowest for fluoxetine ( 50 % [ 25/50 ] ) . Patients who completed the 12-month protocol responded favorably to the study treatment . The paroxetine and the citalopram groups had significantly lower rates of panic symptoms as measured at visits on weeks 4 and 8 . At visits on months 3 , 6 , 9 , and 12 , however , there were no statistically significant differences between the 4 groups in relapse rates ( defined as the occurrence of 1 or more panic attacks during the previous week of treatment ) ( F1,127 = 0.17 ; P = 0.13 [ not statistically significant ] ) . At the 12th month end point , patients in all 4 treatment groups had a statistically significant increase in body weight . Body weight among the study population increased by 6.1 + 4.9 kg from a mean weight of 72.4 + 7.3 kg at the onset of treatment . Reports of sexual adverse effects at the 12th month visit were similar in the citalopram , fluoxetine , and paroxetine groups , but the fluvoxamine patient group reported fewer sexual adverse effects at the 12th month visit . Conclusions : Most of our PD patients responded well to 12-month treatment with either citalopram , fluoxetine , fluvoxamine , or paroxetine , and the overall response rate was equal after the first 4 weeks of treatment . Although patients treated with paroxetine had the lowest dropout rates during the initiation phase , they had the highest rate of adverse effects as measured at the 12th month visit . Conversely , patients in the fluvoxamine group had the highest dropout rate ( which was primarily caused by adverse effects in the initiation phase of treatment . ) ; however , patients who were able to tolerate fluvoxamine throughout the full course of the study were observed to have lower rates of sexual dysfunction and weight gain compared with patients treated with the other agents . Overall , when measured at the 12th month visit , monotherapy with paroxetine and citalopram was associated with a higher rate of sexual adverse effects than was treatment with fluoxetine or fluvoxamine . In addition , monotherapy with paroxetine , citalopram , and fluoxetine seemed to cause more weight gain than did treatment with fluvoxamine
These drugs were better tolerated than tricyclics and benzodiazepines as they had a low risk of dependence and overdosing complications .
The serotonergic , noradrenergic and GABAergic pathways play a major role in the fear network and in the physiopathology of PD .
INTRODUCTION Panic disorder ( PD ) is a prevalent psychiatric disorder characterized by unexpected and recurrent panic attacks .
PD patients present significant psychosocial impairment and a high risk of psychiatric comorbidities and suicide .
PD should be treated effectively as soon as the symptoms emerge because the longer these patients remain without treatment , the worse the prognosis will be .
SSRIs and SNRIs are the first-line compounds in the treatment of PD .