Panic disorder in cardiac outpatients

OBJECTIVE: Continuing the long history of interest in the relation of anxiety disorders to cardiovascular function and symptoms, this study investigated the level of anxiety and prevalence of panic disorder in cardiac patients and the possible associations between specific abnormal ECG results and a diagnosis of panic disorder. METHOD: Consecutive patients referred for ambulatory ECG recordings were assessed with the seven anxiety items of the Hospital Anxiety and Depression Scale. Then, 50 patients with scores higher than 8 (the anxious group) were interviewed with the Schedule for Affective Disorders and Schizophrenia--Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA). RESULTS: Of the 50 anxious patients (26 male and 24 female) interviewed with the SADS-LA, 62% (N = 31) met the DSM-III-R criteria for panic disorder. Patients with panic disorder had a higher mean maximal heart rate and a shorter P-R interval than patients without panic disorder. Unlike the patients without panic disorder, the patients with panic disorder showed no correlation between maximal heart rate and minimal P-R interval. CONCLUSIONS: The rate of panic disorder was high in the patients referred for ECG. Moreover, the prevalence of panic disorder was similar in the patients with and without ECG abnormalities, indicating that in anxious patients the presence of panic disorder does not rule out organic cardiac disease. On the other hand, the higher maximal heart rate and shorter P-R interval of the panic patients may be attributable to hypersensitivity of beta-adrenergic receptors in panic disorder.     

Zollinger-Ellison syndrome. Improved treatment options for this complex disorder

Zollinger-Ellison syndrome is a rare disorder characterized by severe peptic ulcer disease, gastric acid hypersecretion, and non-beta islet cell tumors of the pancreas. Most gastrinomas are found within an anatomic area known as the gastrinoma triangle. However, they commonly occur in extrapancreatic sites in multiple endocrine neoplasia type 1 syndrome. In patients in whom Zollinger-Ellison syndrome is suspected, laboratory evidence of hypergastrinemia and hyperacidity establishes the diagnosis. Until the advent of proton pump inhibitors, total gastrectomy was the treatment of choice. Therapy with these agents (eg, omeprazole, lansoprazole) can prevent ulcer disease. However, surgical removal of gastrinomas offers a chance for cure and can improve longevity by preventing the malignant spread of the tumors.     

Panic and panic disorder in the United States

OBJECTIVES: Shift work and rapid travel across several time zones leads to desynchronization of internal circadian rhythms from the external environment and from each other with consequent problems of behaviour, physiology and performance. Field studies of travellers and shift workers are expensive and difficult to control. This investigation concerns the simulation of such rhythm disturbance in a laboratory environment. The main objectives are to assess the ability of controlled exposure to moderately bright light and darkness/sleep to delay circadian rhythms in volunteers without environmental isolation and, secondly, to evaluate the use of different indices of melatonin (MT) secretion together with self-rated alertness as marker rhythms. PATIENTS: Six normal volunteers aged 22-26 years (mean +/- SD 24.3 +/- 1.4). DESIGN: Subjects were exposed to the following periods of moderately bright light (1200 lux) on three consecutive days in early December 1991: Day (D)1: 2000-0200 h, D2: 2200-0400 h and D3: 2400-0600 h. Each period was followed by 8 hours of darkness (< 1 lux). Hourly blood, sequential 4-hourly urine (8-hourly when asleep) and hourly saliva (except when asleep) samples were taken throughout a 24-hour period on D0 (baseline), D4 (1 day post-light treatment) and D7 (4 days post-light treatment). During waking hours, subjective alertness was rated every 2 hours on a visual analogue scale. MEASUREMENTS: MT was measured in plasma and saliva, and its metabolite, 6-sulphatoxymelatonin (aMT6s), was measured in urine. MT, aMT6s and alertness scores were analysed by ANOVA and a cosinor analysis program. RESULTS: A delay shift was present in the aMT6s, plasma MT and salivary MT rhythms (degree of shift: 2.67 +/- 0.3 h (P < 0.001, n = 5); 2.35 +/- 0.29 h (P < 0.001, n = 6); and 1.97 +/- 0.32 h (P < 0.01, n = 6), mean +/- SEM, respectively) 1 day post-light treatment compared to baseline. Adaptation to the initial phase position was apparent by the 4th post-treatment day. Significant correlations were obtained between plasma MT onset (degree of shift: 3.12 +/- 0.74 h (P < 0.001, n = 6, mean +/- SEM)) and the acrophases (calculated peak times) of plasma MT (P < 0.001), salivary MT (P < 0.05) and urinary aMT6s (P < 0.01). A significant phase delay in the alertness rhythm was also evident 1 day post-treatment (3.08 +/- 0.67 h (P < 0.01, n = 6, mean +/- SEM)) with adaptation by the 2nd post-treatment day. CONCLUSIONS: This study suggests that these methods of determining MT secretion are comparable and give reliable assessments of the MT circadian phase position even after a phase-shift. Significant phase-shifts of similar magnitude can be induced in both MT and alertness rhythms using moderate intensity bright light at night.     

Panic disorder in children and adolescents: new developments, new directions

Reviewed panic attacks and panic disorders in children and adolescents critically and highlighted new developments. It is concluded that panic attacks and panic disorder are common in adolescence and that they are responsive to cognitive-behavioral treatment regimens. It is also concluded that although panic attacks and panic disorder are less common in children, they are nonetheless present. It is important to note, however, that their expression in childhood may vary from the clinical features seen in adolescence and adulthood. Specifically, it is suggested that most panic attacks in childhood are associated with particular events and are not unexpected or "out of the blue." Moreover, noncatastrophic interpretations of the symptoms of panic prevail. A developmental model for the onset, course, and correlates of panic in children is put forth.     

Panic disorder. Recent concepts of etiology and diagnosis

In the light of recent research, panic disorder, for many years considered to have biological etiology, seems to be psychologically conditioned. The psychological part of etiology consists of distorted cognitive interpretation of somatic and emotional symptoms, which lead to the phenomenon of "fear of fear". "Fear of fear" reinforces vulnerability to experience subsequent attacks and intensity of their symptoms. The research work described in the article changed the diagnostic attitude towards panic disorder, both in DSM IV (APA 1994) and ICD-10 (WHO 1994). That change urges to search for new models of psychotherapy, specific to panic disorder.     

Cholelithiasis: current treatment options

Up to 20 percent of the U.S. population may have cholelithiasis, but most of these persons remain asymptomatic. If symptoms or complications develop, several potential management strategies may be used. Open and laparoscopic cholecystectomy are definitive surgical treatments. Nondefinitive methods, such as lithotripsy, indirect dissolution, direct dissolution, sphincterotomy and drainage, have lower success rates but may be indicated in specific cases. Although laparoscopic cholecystectomy is a relatively new technique, its morbidity and mortality rates are comparable to those of open cholecystectomy, and it tends to be less expensive than other surgical methods. For these reasons, laparoscopic cholecystectomy is rapidly becoming the surgical method of choice in the treatment of cholelithiasis.     

Panic disorder. The pattern of somatic contacts in patients

The epidemiology, phenomenology and treatment of panic disorder have been thoroughly studied in recent years. The symptomatology of panic attacks may mimic cardiopulmonary, neurological and gastrointestinal disease. Forty Danish panic patients with panic disorder of ten years' duration had had contact with several medical specialists, hospital emergency and outpatient services. Thus, 28% had visited neurologists, 8% cardiologists and 20% an emergency service. One third had been admitted to hospital departments. Almost all patients had consulted psychiatrists or psychologists. Ninety had been treated with a benzodiazepine, 35% with tricyclic antidepressants and 57% with neuroleptics. To prevent costly medical testings and delay in accurate diagnosis in psychiatric and somatic settings, the phenomenology of panic disorders should be recognized by all medical specialists and general practitioners.     

Vaginal thrush: diagnosis and treatment options

With computer woes marching into the front office and onto the front page these days, it's time to bone up. This guide to books, Web sites, and other executive resources will get you started.     

Current treatment options in psoriasis

Physicians often do not appreciate the impact of the disease. A variety of topical and systemic treatments are available that--either alone or in rotation--may ameliorate psoriatic manifestations and attendant disability.     

Assessment instrument for panic disorder that includes fear of sensation-producing activities: the Albany Panic and Phobia Questionnaire

A set of items was developed to assess fear of activities which produce physical sensations (e.g., exercise) based on clinical observations that individuals with panic disorder fear such activities in addition to agoraphobic situations. Factor analysis of a 32-item pool based on responses from 438 subjects confirmed three distinct factors which were labelled: agoraphobia, social phobia, and interoceptive fears. Evidence was obtained to support the internal consistency, test-retest reliability, and construct validity of all three factors. Importantly, the interoceptive factor demonstrated a slightly different pattern of relationships with other constructs to the agoraphobic factor, even though the two were highly related. The present questionnaire will help to expand current assessments of panic disorder for both clinical work and research.     

Oral treatment options for onychomycosis

The author discusses the new oral antifungal agents for the treatment of onychomycosis. The history, mechanisms of action, efficacies, dosing, safety profiles, and costs of itraconazole, terbinafine, and fluconazole are reviewed. The author emphasizes that use of these effective antifungals represents an important paradigm shift for podiatric physicians away from the palliative therapy of nail debridement to a potentially curative treatment.     

Two-level burst fractures: clinical evaluation and treatment options

We have studied the resistance of Toxoplasma gondii-infected mice to subsequent infection with Cryptococcus neoformans. Mice infected with the moderately virulent ME49 strain of T. gondii are resistant to proliferation of yeast cells in their brains after intravenous inoculation of the serotype A C. neoformans strain 184. The resistance serves to limit proliferation of yeast cells that colonize the brain. Maximal levels of resistance correlate not with maximal systemic specific anti-Toxoplasma resistance but rather with high levels of inflammatory response, presumably to parasites released from cysts in the brain. Resistance is localized, as mice infected with ME49 show only limited resistance in their lungs after intratracheal instillation of yeast cells, but there is substantial protection against development of cerebral cryptococcosis.     

Panic disorder and agoraphobia with panic attacks: Covariation along the dimensions of panic and agoraphobic fear.

Tested the validity of the distinction made in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) between the diagnoses of "panic disorder" and "agoraphobia with panic attacks" by examining the pattern of covariation between panic symptoms and agoraphobic fear in a group of individuals presenting with panic attacks as a prominent symptom. Ss were 17 patients (mean age 34.4 yrs) who had been diagnosed as having panic disorder and 56 patients (mean age 36.4 yrs) diagnosed as having agoraphobia with panic attacks, and who had completed at the time of diagnosis both the Fear Survey Schedule and the SCL-90-R. Analyses of the panic-related items and the agoraphobia-related items of these 2 inventories revealed that irrespective of diagnosis, the degree of panic was highly correlated with the degree of agoraphobic fear. Although panic patients tended to experience more severe panic and milder agoraphobic fear than agoraphobics, the groups overlapped with respect to both kinds of symptoms. Findings are discussed in terms of whether panic disorder and agoraphobia should be classified as qualitatively distinct conditions. (10 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacologic treatments effective in both generalized anxiety disorder and major depressive disorder: clinical and theoretical implications

OBJECTIVE: To review the efficacy of anxiolytics (alprazolam and azapirones) in major depressive disorder (MDD) and that of antidepressants in generalized anxiety disorder (GAD), thereby exploring the possible theoretical and clinical implications of this efficacy. METHOD: A Medline literature search was performed for the period January 1980 to September 1997 of randomized, double-blind comparison studies between anxiolytics and antidepressants in the acute treatment of adult patients with either MDD or GAD. RESULTS: Alprazolam, at doses double those generally recommended for anxiety disorders, appears to be as effective as tricyclic antidepressants (TCAs) in the acute treatment of mild to moderate MDD. Alprazolam was also found to have a more rapid onset of action than to TCAs, particularly for the improvement of anxiety, somatization, and insomnia. Two azapirones (buspirone and gepirone) also have demonstrated a modest acute antidepressant effect in preliminary studies, albeit only in a depressed outpatient sample with considerable anxiety at baseline. Finally, various antidepressant drugs (imipramine, trazodone, paroxetine) were shown to have, at the least, comparable efficacy to benzodiazepines (BZDs) in the acute treatment of GAD. CONCLUSIONS: The nonspecificity of treatment response suggests that GAD and MDD are 1) different expressions of a similar disorder with a common neurobiological substrate, 2) discrete diagnostic entities that respond to independent pharmacological effects of the same drugs, or 3) a combination of the two (heterogeneity hypothesis). The most relevant clinical finding is the efficacy of antidepressants in the acute treatment of GAD.