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IntroductionDepersonalization during panic attacks may be a feature of a subgroup of Panic disorder. Several studies suggest that such subgroup corresponds to a more clinically severe form of Panic Disorder, with earlier onset and a higher rate of comorbidity with other psychiatric disorders, such as obsessive-compulsive disorder and generalized anxiety disorder. It is also hypothesized that depersonalization during panic attacks may lead Panic disorder to evolve into Agoraphobia.ObjectivesTo present the case report of a patient with severe Agoraphobia, whose only symptom of Panic disorder was depersonalization.MethodsDescription of a case report.ResultsWe describe the case of a 20-year-old woman who developed Agoraphobia after a single panic attack, during a physical education class, at the age of 13, with depersonalization symptoms only. After the attack, the patient stopped playing sports and engaging in any kind of activity in the absence of a trusted person. At the age of 20, the patient will only travel alone in the immediacies of her home, sometimes missing classes, because she cannot get a ride from trusted acquaintances. She justifies such avoidances with her fear of feeling depersonalized again. Over the course of her illness, she denied having experienced any other symptoms of a panic attack. She was treated with Paroxetine 40mg daily and cognitive behavioral therapy, having improved.ConclusionsWe believe this case provides good insight into depersonalization in panic attacks, supporting the view that Panic disorder with depersonalization may be a distinct and more severe subgroup of Panic Disorder.

PurposePsychometric properties and clinical sensitivity of brief self-rated dimensional scales to supplement categorical diagnoses of anxiety disorders in the DSM-5 were recently demonstrated in a German treatment seeking sample of adults. The present study aims to demonstrate sensitivity of these scales to clinical severity levels.MethodsThe dimensional scales were administered to 102 adults at a university outpatient clinic for psychotherapy. Diagnostic status was assessed using the Munich-Composite International Diagnostic Interview. To establish a wide range of clinical severity, we considered subthreshold (n= 83) and threshold anxiety disorders (n= 49, including Social Phobia, Specific Phobia, Agoraphobia, Panic Disorder, and Generalized Anxiety Disorder).ResultsIndividuals with either subthreshold or threshold anxiety disorder scored higher on all dimensional scales relative to individuals without anxiety. In addition, individuals with a threshold anxiety disorder scored higher on the dimensional scales than individuals with a subthreshold anxiety disorder (except for specific phobia). Disorder-related impairment ratings, global functioning assessments and number of panic attacks were associated with higher scores on dimensional scales. Findings were largely unaffected by the number of anxiety disorders and comorbid depressive disorders.ConclusionThe self-rated dimensional anxiety scales demonstrated sensitivity to clinical severity, and a cut-off based on additional assessment of impairment and distress may assist in the discrimination between subthreshold and threshold anxiety disorders. Findings suggest further research in various populations to test the utility of the scales for use in DSM-5.

Background and aimTo document long-term prevalence trends and changes in Post-Traumatic Stress Disorder (PTSD), Current Major Depression (MD), Agoraphobia, Generalized Anxiety Disorder (GAD), and Panic Disorder, in two groups of people with different levels of exposure to a massive terrorist attack.MethodsCohort study. Two random samples of people exposed to a terrorist attack, the injured (n = 127) and community residents (n = 485) were followed and assessed, 2 and 18 months after the event.ResultsAmong the injured, 2 and 18 months after the attack, the prevalences were respectively, PTSD: 44.1% and 34%, MD: 31.5% and 23.7%, Agoraphobia: 23.8% and 20.7%, GAD: 13.4% and 12.4% and Panic Disorder: 9.4% and 11.3%. The corresponding figures among residents were PTSD: 12.3% and 3.5%, MD: 8.5% and 5.4%, Agoraphobia: 10.5% and 8.7%, GAD: 8.6%, and 8.2% and Panic Disorder 2.1% and 2.7%.ConclusionsTwo months after the event, the prevalence of mental disorders among both injured and residents was higher than expected levels at baseline conditions. Eighteen months after the event, psychopathological conditions did not change significantly among the injured but returned to the expected baseline rates among community residents.

ObjectiveThe epidemiology of panic disorder has not been investigated in the past in the UK using a nationally representative sample of the population. The aim of the present paper was to examine the epidemiology, comorbidity and functional impairment of subthreshold panic and panic disorder with or without agoraphobia.MethodWe used data from the 2000 Office for National Statistics Psychiatric Morbidity survey (N = 8580). Panic disorder and agoraphobia were assessed with the Revised Clinical Interview Schedule (CIS-R).ResultThe prevalence of panic disorder with or without agoraphobia was 1.70% (95% confidence interval: 1.41–2.03%). Subthreshold panic was more common. Economic inactivity was consistently associated with all syndromes. The comorbidity pattern of the panic syndromes and the associated functional impairment show that panic-related conditions are important public health problems, even in subthreshold status.ConclusionsThe findings show that efforts to reduce the disability associated with psychiatric disorders should include detection and management of panic disorder.

BackgroundData about quality of life (QoL) are important to estimate the impact of diseases on functioning and well-being. The present study was designed to assess the association of different aspects of panic disorder (PD) with QoL and to examine the relationship between QoL and symptomatic outcome following brief cognitive-behavioral group therapy (CBGT).MethodsThe sample consisted of 55 consecutively recruited outpatients suffering from PD who underwent CBGT. QoL was assessed by the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at baseline, post-treatment and six months follow-up. SF-36 baseline scores were compared with normative data obtained from a large German population sample.ResultsAgoraphobia, disability, and worries about health were significantly associated with decreased QoL, whereas frequency, severity and duration of panic attacks were not. Treatment responders showed significantly better QoL than non-responders. PD symptom reduction following CBGT was associated with considerable improvement in emotional and physical aspects of QoL. However, the vitality subscale of the SF-36 remained largely unchanged over time.ConclusionsOur results are encouraging for cognitive-behavior therapists who treat patients suffering from PD in groups, since decrease of PD symptoms appears to be associated with considerable improvements in QoL. Nevertheless, additional interventions designed to target specific aspects of QoL, in particular vitality, may be useful to enhance patients’ well-being.

BackgroundThere is insufficient knowledge of the long-term course of panic disorder (PD).AimTo determine the long-term course and prognostic variables in patients diagnosed with PD.MethodsPatients who were diagnosed of anxiety states between 1950 and 1961, were examined using a structured clinical interview (SCID-DSM-III-R) between 1984 and 1988 (n = 144). A re-examination was performed in the period 1997–2001 (N = 125). Mean length of follow-up from onset was 47 years.ResultsPD tends to be chronic. Among those who recovered, 93% had done so already by the 1980s. Lack of regular treatment compliance, progression to agoraphobia and number of episodes of panic disorder were associated with worse outcome. Agoraphobia without panic attacks and somatization symptoms were the most prevalent clinical status at follow-up.ConclusionAfter several decades, participants improve with regard to number of panic attacks, though most continue to have residual symptoms.

IntroductionThe relationship between traumatic brain injury and neuropsychiatric conditions has a strong clinical link. Despite significant clinical presentations, there has been a limited focus on quantifying the association between traumatic brain injury and psychiatric disorders.ObjectivesTo conduct a systematic review to determine the prevalence and incidence of neuropsychiatric conditions in patients with traumatic brain injury.AimsTo determine the association between traumatic brain injury and psychiatric illness.MethodsA systematic search was made of Medline, PsycINFO, EMBASE and article bibliographies. Search terms for rates of psychosis, mood disorders, anxiety conditions, organic personality disorder, neuropsychiatric disorders, neuro-behavioural disorders, aggression, dementia and frontal lobe disorder were utilised. We followed MOOSE criteria and did not apply temporal limits.ResultsThere were 845 relevant searches in total. After exclusion of duplicates, case reports, case series reports, letters, reviews, commentaries, systematic reviews, and editorials there were 143 relevant abstracts identified. This was further reduced to a review of 48 full text papers. We identified prevalence rates of depression between 6.9–62.5%, mania of 9–12.5%, PTSD 1.9–50%, aggression 28.4–57%, anxiety disorders 6–63% (including GAD 8–9%, agoraphobia 2–6%, panic disorder 9%, social phobia 1%) insomnia 11–29%, personality change of 33.3%, dementia 8.16% and substance use 3–8%.ConclusionsWe have identified significant rates of neuropsychiatric morbidity in patients with traumatic brain injury. We have particularly identified limited research studies into psychosis, mania, dementia and personality disorders in this patient group. The review further emphasises the importance of identifying neuropsychiatric comorbidities in post-traumatic brain injury and the importance of addressing these comorbidities.Disclosure of interestThe authors have not supplied their declaration of competing interest.

WorkshopAge of onset of mental disorders: etiopathogenetic and treatment implications.BackgroundAge of onset (AOO) of anxiety disorders could serve as a vital statistic in the formulation of mental health policy. Previous reviews have reported on the AOO of anxiety disorders in the general population. However, these review studies did not systematically estimate the AOO of different anxiety disorder subtypes, and did not examine factors that might have influenced reported AOO.ObjectiveThe aims of the present study were (1) to estimate the AOO for all anxiety disorders and for specific subtypes, (2) to examine gender differences in AOO of anxiety disorders, and (3) to examine the influence of study characteristics on reported AOO.MethodSeven electronic databases were searched with keywords representing anxiety disorder subtypes, AOO and study design. The inclusion criteria were studies using a general population sample that provided data on AOO for all anxiety disorders, or specific anxiety disorders, according to DSM-III-R, DSM-IV or ICD-10 criteria. Meta-analysis was used to estimate AOO and gender differences, while meta-regression was used to examine the influence of study characteristics.ResultsA total of 1028 titles were examined, which yielded 24 studies meeting the inclusion criteria. Meta-analysis found an average AOO of all anxiety disorders of 21.3 years (95% CI: 17.46 to 25.07). Separation anxiety disorder, specific phobia and social phobia had their mean onset before the age of 15 years, whereas AOO of agoraphobia, obsessive compulsive disorder, post-traumatic stress disorder, panic disorder and generalized anxiety disorder began on average between 21.1 and 34.9 years. Anxiety disorder is more common in women, but meta-analysis revealed no difference in AOO between genders. Prospective study design and higher developmental level of the study country were associated with earlier AOO.ConclusionResults from this meta-analysis indicate that anxiety disorder subtypes differ in mean AOO, with onsets ranging from early adolescence to young adulthood. These findings suggest that prevention strategies of anxiety disorders should be directed towards the factors associated with the development of subtypes of anxiety disorder in the age groups with the greatest vulnerability for developing those disorders.Disclosure of interestThe authors have not supplied their declaration of competing interest.

BackgroundPanic disorder (PD) is generally regarded as a chronic condition with considerable variation in severity of symptoms.AimsTo describe the long-term outcome of naturalistically treated PD.MethodsFifty-five outpatients 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.ResultsComplete 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.ConclusionPD 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.

IntroductionThe roots of social phobia, lay in the social nature of human beings who fulfil their basic needs in social relations. By the definition, it is the fear of witnessing the negative judgement and the criticism of other people, which is so intense that, is followed by reactions of avoidance of phobic situations and doings, followed by intense vegetative symptoms.AimIntroduce social phobia as an important social and medical problem with common co-morbidity and exceptional risk of suicide. At the same time it gives special accent to the diagnostic procedures and differential diagnosis.MethodAnalysis of the information from literature and practice and coming to conclusions with the inductive method.ResultsSocial phobia is a chronicle illness, equally present in both sexes. The central position is taken by all-the-time present intense irrational fear. Alcoholism, misuse of sedatives, depression, and panic with agoraphobia, OCD are common followers of social phobia. Differential diagnosis witch eliminates panic with agoraphobia, or just the lack of social skills allows the right therapeutic approach.ConclusionSocial phobia, alone or combined with other disorders, has a huge medical and social value. Coming back to regular life tracks depends on the right diagnosis and the right time to go into the healing process.Disclosure of interestThe authors have not supplied their declaration of competing interest.

ObjectiveGoal of the study was to analyze the impact of dissociation on the treatment of the patients with anxiety/neurotic spectrum and depressive disorders, and with or without personality disorders.MethodsThe sample consisted of inpatients who met the ICD-10 criteria for the Depressive disorder, Panic disorder, GAD, Mixed anxiety-depressive disorder, Agoraphobia, Social phobia, OCD, PTSD, Adjustment disorders, dissociative/conversion disorders, Somatoform disorder or other anxiety/neurotic spectrum disorder. The participants completed Beck Depression Inventory, Beck Anxiety Inventory, subjective version of clinical global impression-severity, Sheehan Patient-Related Anxiety Scale, and Dissociative Experience Scale, at the start and the end of the therapeutic program.ResultsThe total of 840 patients with anxiety or depressive spectrum disorders, who were resistant to pharmacological treatment in outpatients basis and were referred for hospitalization for the six-week complex therapeutic program, were enrolled in this study. Six hundred and six of them were statistically analyzed. The patients’ mean ratings on all measurements were significantly reduced during the treatment. The patients without comorbid personality disorder improved significantly more than patients with comorbid personality disorder in the reduction of depressive symptoms. However, there were no significant differences in change of anxiety levels and severity of the disorder between the patients with and without personality disorders. The higher degree of dissociation at the beginning of the treatment predicted minor improvement. The higher therapeutic change was connected to the greater reduction of the dissociation level.ConclusionsDissociation presents an important factor influencing treatment effectiveness in the treatment-resistant patients with anxiety/depression with or without personality disorders.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionUsing self-report assessment methods, the present study examined affective factors that influenced the gender specific use of a survey-based orientation strategy and landmark-based route-finding strategy in an unfamiliar environment. First, we analyzed the role of early navigation experiences and the influence of early parental attachment (emotional warmth, overprotection and rejection) on way finding strategy. Second, the study analyzed the intercorrelations between way finding strategies and fear-related avoidance behavior and anxiousness.MethodsThree hundred and sixteen male and female students were recruited in a study to analyze the relationships between navigation strategies, fears, early parental childrearing behavior and navigation experiences. We proposed that use of navigation strategy depends on not only the physical features of the current environment and the participants’ gender, but also fears of closed and opened spaces and types of perceived parental childrearing behavior.ResultsWe found that when exploring strange places, females used a route-finding strategy in contrast to males who used an orientation strategy for exploring a strange environment. Fear enhanced the preference for a route-finding strategy in both females and males. A route-finding strategy was associated with agoraphobic scores in females and with social fears in males. Perceived rejection from father and emotional warmth from mother together induces usage of route-finding navigation strategy.ConclusionThe family background influence on the capability to have personal experiences in unfamiliar environment and to cope with fears and behavioral avoidance in strange opened and closed places.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionEpilepsy is a chronic disease defined as a brain disorder, characterized by a predisposition to present seizures, generating cognitive, psychological, and social consequences.ObjectiveTo determine the prevalence of psychiatric comorbid disorders in patients with epilepsy (PWEs) and its associated factors.MethodsWe conducted a cross-sectional study involving 30 PWEs who were treated in the neurology department of Habib Bourguiba Hospital in Sfax, Tunisia. We used the Mini International Neuropsychiatric Interview for the diagnosis of Axis I psychiatric disorders.ResultsThe half of patients had psychiatric comorbidities: 4 had major depressive disorder (MDD), 2 had MDD with generalized anxiety disorder, 4 had MDD with social phobia, 1 had bipolar disorder type I, 1 had panic disorder, 1 had agoraphobia and 2 had generalized anxiety disorder.Twenty-five PWEs had seizure-onset below 30 years old and among them, 40% had psychiatric comorbidities. Among patients who had seizure-onset above 30 years old, none had psychiatric comorbidities. Psychiatric comorbidities were found in 71.5% of patients with seizure frequency >2 per year. Psychiatric comorbidities were more common in patients with generalized seizures compared to whom with partial seizures (53% versus 45%). It was also more common in patients treated with polytherapy compared to whom with monotherapy (64% versus 37.5%).ConclusionThe prevalence of psychiatric comorbidities is relatively high among PWEs. The most frequent diagnoses found were mood and anxiety disorders. It is very important to identify them and treat them to enhance seizure control.Disclosure of interestThe authors have not supplied their declaration of competing interest.

PurposeSince clinical practice suggests that panic disorder may not be a homogeneous condition, a study was carried out to test the possible existence of different groups or subgroups of panic patients.Subjects and methodsThirty-two panic patients (DSM-III-R) underwent lactate challenge in our laboratory and were assessed for heart rate, blood pressure, sweating and Acute Panic Inventory.ResultsDuring the lactate challenge, patients complaining mainly of ‘cardiorespiratory’ symptoms (N = 12) showed tachycardia and localized sweating. Conversely, patients complaining mainly of ‘pseudoneurological’ symptoms (N = 16) showed bradycardia and generalized sweating. In both groups, Acute Panic Inventory scores were significantly higher during than before the panic attack, but the distribution of the scores was markedly different.Discussion and ConclusionThe results suggest that panic disorder may be a heterogeneous condition. Implications of these results to other phobic disorders, to Klein’s false suffocation alarm theory and to the ‘extended amygdala model’ are discussed.

SummaryThe frequency of anxiety and depressive disorders was examined in 69 insulin-dependent diabetic mellitus (IDDM) outpatients and in two control group. Based on self-report measures, these disorders were similar in IDDM sample and in the control groups. In diabetic outpatients, according to DSM-III-R criteria, there was a high lifetime prevalence of not otherwise specified anxiety and depressive disorders (44% and 41.5%), of simple phobia (26.8%), social phobia (24.6%), and agoraphobia — with and without panic disorder (14.6%). Current social phobia, dysthymia and not otherwise specified depressive disorders were associated with impaired glycaemic control. Glycosylated haemoglobin was associated with compliance but psychiatric disorders were not, except for social phobia which was significantly associated with more frequent consultations and a bad compliance for dietary regimen (more snacking). Somatic complications were not associated with anxious and depressive disorders (current or lifetime) or compliance and were best explained by the duration of the illness and impaired glycaemic control.

SummaryPanic disorder is widespread in Australia, often in combination with other psychiatric conditions such as agoraphobia or major depression. Pharmacotherapy for panic disorder in Australia commenced with benzodiazepines, and later progressed to tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). More recently, treatment has moved towards use of the selective serotonin reuptake inhibitors (SSRIs), which are effective and better tolerated. Paroxetine is the first drug of this class to receive approval for treatment of panic disorder in Australia.

SummaryPanic disorder is a chronic condition for many patients and can be socially, emotionally and occupationally disabling. Until recently, clomipramine and alprazolam were the only drugs approved for its treatment. While widely used in the US and Europe, both belong to drug classes (tricyclics and benzodiazepines) with well-recognised side effects that can be problematic and thus limit their use. Recently, paroxetine became the first selective serotonin reuptake inhibitor to receive approval and licensing for panic disorder.The short- and long-term efficacy and tolerability of paroxetine in panic disorder has been established in clinical trials of almost 1,000 patients meeting Diagnostic and Statistical Manual (DSM)-IIIR criteria for panic disorder, with or without agoraphobia. In a 12-week double-blind study of 120 panic patients receiving standardised cognitive therapy, paroxetine was significantly more effective than placebo in reducing panic attack frequency. In a 12-week placebo-controlled comparison in 367 panic patients, paroxetine was at least as effective as clomipramine and better tolerated. There was also some evidence that paroxetine had an earlier onset of action than clomipramine.A 9-month extension of the placebo-controlled comparison with clomipramine showed that the efficacy of paroxetine and clomipramine is maintained when treatment is continued into the longer term. In a relapse prevention study, 105 responders to 3 months' treatment with paroxetine or placebo were re-randomised, either to continue existing treatment or to receive placebo for 3 months. Only 5% of patients who continued to take paroxetine experienced a relapse compared with 30% of those who switched to placebo (P = 0.002). Paroxetine was generally well tolerated. In the short-term trials, the frequency of withdrawals due to adverse events (7.3%) was lower than that for placebo (11.4%) or clomipramine (14.9%). In the longer term, the dropout rate due to adverse events increased in the clomipramine group (19.0%) but was unchanged in the paroxetine group (7.4%). Since most patients with panic disorder will require prolonged treatment, the long-term tolerability of paroxetine and its lack of potential for dependence are important advantages that will encourage good compliance with treatment and improve the quality of life of patients.

SummaryPanic has not always been recognised as an exclusively psychiatric condition. Research in this area continued along separate medical and psychological axes until 1980, when the development of Diagnostic and Statistical Manual (DSM)-III criteria established the overall concept of panic disorder. The lifetime prevalence of DSM-III panic disorder and repeated panic attacks, defined as the average of individual estimates from six studies, are 2.7% and 7.1% of the general population, respectively. Females are almost twice as likely as males to suffer panic disorder, and about seven times as likely to suffer repeated panic attacks. Overall, panic disorder or panic attacks occur in up to one in ten of the general population. The prevalence of panic disorder and panic attacks, their associations with other conditions, and their time courses have been investigated in a prospective epidemiological study in Zurich, Switzerland, in which 591 individuals were followed for 15 years. The validity of panic disorder and panic attacks as genuine psychological phenomena are attested to by their positive associations with a family history of panic disorder, elevated risk of suicide, lifetime treatment for psychiatric disorders, and especially treatment with prescribed medication and substantial work and social impairment. Strong comorbidity exists between panic states and other psychiatric conditions, including depression (major depression, bipolar disorder and recurrent brief depression), agoraphobia, social phobia, specific phobia, and obsessive-compulsive disease. A lower degree of comorbidity is seen with alcohol and tobacco dependence. Comorbid conditions usually precede panic, except for alcohol abuse, which is usually secondary to episodes of panic. The prognosis of panic states is often optimistic, and chronic disease is present in less than half of sufferers. Both panic disorder and repeated panic attacks are common, serious and disabling conditions. Effective diagnosis and treatment of repeated panic attacks and panic disorder are of equal importance.

SummaryPanic disorder is a common condition. Epidemiological studies throughout the world consistently indicate that the lifetime prevalence of panic disorder (with or without agoraphobia) is between 1.5% and 3.5%. Panic disorder shows substantial comorbidity with other forms of mental illness. Major depressive disorder occurs in 50 to 65% of individuals with panic disorder and there is considerable cross-sectional and longitudinal comorbidity with recurrent brief depression and dysthymia. Phobic anxiety disorders, most notably social phobia and generalised anxiety disorder, commonly occur with panic disorder, especially in individuals with more severe agoraphobia. Approximately 35 to 50% of individuals with panic disorder in community settings also have agoraphobia. Panic disorder also shows significant comorbidity with physical illness. Compared with individuals without or with some other psychiatric diagnosis, patients with panic disorder have an increased risk of suffering from multiple medically unexplained symptoms and are associated with high use of medical services and increased mortality from both cardiovascular and cerebrovascular disease.

A survey of the pharmacological and psychological treatment of panic disorder and agoraphobia (PDA) was conducted among 103 physicians, psychologists and psychotherapists. It revealed that the treatments for PDA preferred by the majority of the respondents are inconsistent with the recommendations given in the international literature. Non-psychiatric physicians most frequently proposed herbal preparations as a possible treatment (46% of non-psychiatric physicians), followed by homoeopathic formulations (32%). Tricyclic antidepressants which are recommended as first-line treatment in panic disorder by the literature are preferred by 74% of the psychiatrists, but only by 24% of the non-psychiatric physicians. Benzodiazepines are prescribed by twice as many psychiatrists (45%) as non-psychiatric physicians (22%). Beta blockers and neuroleptics which are not recommended as first-line treatment in panic disorder are used quite often (psychiatrists: 15%; non-psychiatric physicians: 26%). Selective serotonin reuptake inhibitors are prescribed by 24% of the psychiatrists, but by only 3% of the non-psychiatric physicians. Among psychological therapies, psychoanalysis was proposed as first-line treatment by 44% of all professionals applying psychological therapies, while cognitive/behaviour therapy was preferred by only 28%, though proof of efficacy exists only for cognitive/behaviour therapy. In general, psychologists prefer behaviourally-orientated therapy, while physicians mostly propose psychodynamic therapy. One reason for the fact that the results of controlled studies have little influence on professionals treating PDA patients might be that 40% of the respondents do not accept the new classification of the anxiety disorders as introduced in 1980 by the DSM-III.

IntroductionAcceptance and commitment therapy for the treatment of panic disorder and agoraphobia has been a big boost in last years, and there are preliminary studies about its efficacy. However, most studies have used individual interventions.ObjectivesEvaluate the effect of an acceptance and commitment group therapy in patients with panic disorder and agoraphobia.MethodsThe sample consisted of 24 patients, aged between 18 and 55 years old, who were referred to groups by psychologists and psychiatrists of Mental Health Center. The intervention in each group consisted of 12 treatment sessions of 1 h 30 m duration, weekly. One pretest and posttest evaluation was conducted. The variables studied were: severity of panic disorder (Panic Disorder Severity Scale [PDSS]), fear of physical sensations (Body Sensations Questionnaire [BSQ]), frequency of catastrophic thoughts (Agoraphobic Cognitions Questionnaire [ACQ]) and level of experiential avoidance (Acceptance and Action Questionnaire-II [AAQ-II]).ResultsThe mean scores for all variables studied decreased in the post-evaluation. Means in post-evaluation were significantly lower (t Student, a = 0.10) in three of the four variables studied: severity of the condition (P = 0.001), frequency of catastrophic thoughts (P = 0.038) and level experiential avoidance (P = 0.073). In other words, patients had fewer panic attacks after treatment, and those who had were less intense, they had less catastrophic thoughts about consequences of anxiety, and they were better to accept their feelings and thoughts.ConclusionsAlthough it is necessary to continue the study with a larger sample, these preliminary results support the use of ACT in group format in the treatment of panic disorder and agoraphobia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionIt has been hypothesized that lowered antioxidant capacity, which leads to increased oxidative stress, may be involved in the pathophysiology of major depressive disorder (MDD) and anxiety disorders and might be altered by antidepressant treatment.ObjectivesThis study investigated the association of plasma uric acid, the greatest contributor to blood antioxidant capacity, with MDD, generalized anxiety disorder, social phobia, panic disorder, agoraphobia and antidepressants in a large cohort.MethodsData was derived from the Netherlands Study of Depression and Anxiety including patients with current (n = 1648) or remitted (n = 609) MDD and/or anxiety disorder(s) (of which n = 710 antidepressant users) and 618 controls. Diagnoses were established with the Composite Interview Diagnostic Instrument. Symptom severity was ascertained in all participants with the Inventory of Depressive Symptoms and the Beck Anxiety Inventory. ANCOVA and regression analyses were adjusted for sociodemographic, health and lifestyle variables.ResultsPlasma uric acid was lower in those with current MDD and/or anxiety disorder(s) (adjusted mean 270 μmol/L) compared to those with remitted disorders (280 μmol/L, P < 0.001) or to controls (281 μmol/L, P < 0.001; Cohen's d 0.14). Within patients antidepressants were not associated with uric acid levels. Increasing symptom severity was associated with lower uric acid levels for both depression (β = –0.05, P = 0.001) and anxiety symptoms (β = –0.05, P = 0.004).ConclusionThis large scale study finds that the antioxidant uric acid is lower in current, but not remitted, MDD or anxiety disorders and in persons with higher symptom severity, suggesting disturbances in redox homeostasis play a role in the pathophysiology of depression and anxiety disorders.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionOxidative stress has been implicated in the pathophysiology of depression and anxiety disorders and may be influenced by antidepressant use.ObjectivesThis study investigated the association of oxidative stress, measured by plasma levels of F2-isoprostanes and 8-hydroxy-2′-deoxyguanosine (8-OHdG), reflecting oxidative lipid and DNA damage respectively, with major depressive disorder (MDD), generalized anxiety disorder, social phobia, panic disorder, agoraphobia and antidepressant use in a large cohort.MethodsData was derived from the Netherlands Study of Depression and Anxiety including patients with current (n = 1641) or remitted (n = 610) MDD and/or anxiety disorder(s) (of which n = 709 antidepressant users) and 633 controls. Diagnoses were established with the Composite Interview Diagnostic Instrument. Plasma 8-OHdG and F2-isoprostanes were measured using UHPLC-MS/MS. ANCOVA was performed adjusting for sampling, sociodemographic, health and lifestyle variables.ResultsF2-isoprostanes did not differ between controls and patients, or by antidepressant use. Patients (current or remitted) using antidepressants had lower 8-OHdG (adjusted mean 38.3 pmol/L) compared to patients (current or remitted) without antidepressants (44.7 pmol/L) and controls (44.9 pmol/L, P < 0.001; Cohen's d 0.26). Findings for 8-OHdG were similar over all disorders and all antidepressant types (SSRIs, TCAs, SNRIs; P < 0.001).ConclusionContrary to previous findings this large-scale study did not find increased oxidative stress measured by F2-isoprostanes or 8-OHdG in MDD or anxiety disorders. 8-OHdG levels were lower in antidepressant users, which suggests antidepressants may have antioxidant properties.Disclosure of interestThe authors have not supplied their declaration of competing interest.

There is an increasing literature about the implementation of the staging model in many mental disorders. According to this approach, there are four stages of a psychiatric disorder: prodromal stage, acute manifestations, residual phase, chronic. In this study, we empirically investigate whether additional clinical variables such as clinical manifestations and comorbid disorders may be useful to modify the staging model to panic disorder (PD).We distinguished inpatient sample (n = 79) with a diagnosis of “panic disorder” according to the DSM-IV criteria. We propose that the inclusion of prodromal stage of PD does not make clinical sense since the different unspecific neurotic symptoms may proceed to a variety of anxiety and depressive disorders. First stage was characterized by the situationally predisposed panic attacks (PA) with both somatic and cognitive symptoms. Comorbid disorders included somatoform disorders and generalized anxiety disorder (GAD). During second stage individuals experienced agoraphobic avoidance until traveling in public transport. On the other hand, spontaneous PA were accompanied by the only somatic but not cognitive symptoms. The most common patterns of comorbidity were GAD and alcohol misuse. Third stage was associated with the absence or limited symptom attacks and chronic agoraphobia. Major depression and obsessive-compulsive disorder might be an integral part of the clinical manifestations. This study supports that the staging model in PD might be updated by the detailed description of clinical manifestations and comorbid disorders at each stage that may help the practitioners to choose the best strategy for the treatment of a particular patient.Disclosure of interestThe author has not supplied his declaration of competing interest.

SummaryThe Phobic Attitude Scale (PAS) is a new 15-item inventory designed to assess sub-clinical agoraphobic attitudes as well as the severity of pathological avoidance. Its psychometric properties have been examined in three groups of subjects: 41 outpatients suffering from DSM III-R Panic Disorder, with or without agoraphobia, 62 healthy controls and 12 mixed psychiatric patients.The instrument proved to be simple and easy to use. PD patients scored significantly higher than healthy controls, with mixed psychiatric cases showing intermediate values. The Test-Retest procedure gave rise to satisfactory kappa coefficients (0.25 to 1) and the internal consistency was good (Cronbach alpha = 0.86). Factor analysis produced three factors: “crowded and social situations”,“enclosed and open spaces/riding situations” and “simple phobia”.

SummaryThis case note sludy examined the clinical features and outcome of 30 patients with dysmorphophohia (perhaps (he largest series so far) who had behavioural (exposure) therapy. Method: The clinical Features and treatment outcome on standard contemporary measures were reviewed. Results: All palienls had social avoidance and dysmorphophohia, with abnormal beliefs, often of delusional intensity. For up lo 1-12 months follow-up after exposure, most patients improved in avoidance, work and social adjustment, and in beliefs even if these had initially been delusional. Gains were less than after exposure therapy for non-dysmorphophobic problems such as agoraphobia, specific phobia, social phobia and obsessive-compulsive disorder (OCT)). Conclusions: The importance of separating delusional from delusional dysmorphophohia can be questioned. Exposure therapy appeared useful for dysmorphophohia, but this must be confirmed in a controlled trial and in patients who attend dermatology, plastic surgery and general psychiatric clinics.

SummaryThis review studies the epidemiology of anxiety disorders of childhood and adolescence, including prevalence rates, comorbidity patterns, risk factors and course. Comorbidity is very important: most children with anxiety disorders also have one or several other anomalies, usually anxiety or mood disorders. The authors point out the main evidence suggesting that a number of risk factors are associated with childhood anxiety disorders: age, sex, low socioeconomic setting; child's personality, and lastly, familial risk factors which have a very strong influence: children of parents with current or past anxiety disorders are more at risk of having anxiety disorders. Concerning the course of disorders, we have tentatively defined subsets of children or adolescents with anxiety disorders, and tried to clarify the recovery rate of these subsets. Future directions for research are suggested.

The general population prevalence and incidence of late-life agoraphobia was estimated and its clinical characteristics and risk factors described using data from the French ESPRIT study. One thousand nine hundred and sixty-eight persons aged 65 and above were randomly recruited from the electoral rolls of the district of Montpellier. Prevalent and incident agoraphobia diagnosed by a standardized psychiatric examination and validated by a clinical panel was assessed at base-line and over 4-year follow-up. The one-month prevalence of agoraphobia was estimated at 10.4% of whom 10.9% reported having the first-episode at age 65 or over. During the 4-year follow-up 11.2% of participants without agoraphobia at base line were classified as cases giving an incident rate of 32 per 1000 person-years. These 132 incident late-onset cases were associated with higher incident rates of anxiety disorders and suicidal ideation. Only two incident cases had past or concurrent panic attacks, which was not significantly different from non-cases. The principal base-line risk factors for incident cases derived from a multivariate model incorporating all significant risk factors were younger age of onset (OR = 0.94; 95% CI 0.90–0.99, P = 0.02), poorer visuospatial memory performance (OR = 1.60; 95% CI 1.02–2.49, P = 0.04), severe depression (OR = 2.62; 95% CI 1.34–5.10, P = 0.005) and trait anxiety (OR = 1.73; 95% CI 1.03–2.90, P = 0.04). No significant association was found with cardiac pathologies. We conclude that agoraphobia has high prevalence in the elderly and unlike younger cases, late-onset cases are not more common in women, and are not associated with panic attacks, suggesting a late-life subtype. Severe depression, trait anxiety and poor visuospatial memory are the principal risk factors for late-onset agoraphobia.

Introduction Patients with schizophrenia mightexperience panic attacks and meet the criteria for both schizophrenia and panicdisorder. Classification of mental disorders with hierarchical approach givesschizophrenia the first position before the panic disorder. The panic attacksmight not be well recognized and adequately treated. The aim of this study isto determine the prevalence of panic disorder in schizophrenic patients, torecognise the impact of comorbidity on the clinical picture and the course ofthe disease, and to determine the appropriate/possible treatment. Method The articles were identified by the keywords “schizophrenia” and “panic disorder”, or “agoraphobia”, using the Medline and Web of Science search. Additional sources were obtained by studying the references of summaries ofimportant articles. Results The prevalence of comorbid panic disorder inpatients with schizophrenia ranges from 16% to 63%, but the results are notconsistent. Etiopathogentical hypothesis of schizophrenia and panic disorderand also the concept of panic psychosis are discussed. There is a limitedbiological evidence to support those hypotheses. Data suggest that patientswith schizophrenia and panic disorder exhibit higher rates of depression, suicidal ideation and increased extrapyramidal side effects. Panic comorbiditymay worsen severity of positive and negative symptoms of schizophrenia and theoverall quality of life. Conclusion Panic disorder and schizophreniaoften occurs comorbid. It is found most commonly in patients with paranoidsubtype. Comorbid panic disorder may worsen positive symptoms and lead todepressive symptoms. It negatively affects the quality of life and add up tohigher level of suicidality. The pharmacotherapy with atypical antipsychoticsis preferred, or their combination with clonazepam or alprazolam.

Introduction Complications of anxiety disorders can be serious and even life-threatening in some cases. Objective The aim of our study was to identify the complications related to anxiety disorders. Methods This is a cross-sectional study of 40 patients suffering from anxiety disorders and followed to the outpatient psychiatry Hedi Chaker University Hospital in Sfax Tunisia during the month of August 2014. The subjects who participated in the survey responded to an anonymous questionnaire to collect socio-economic and demographic data, the type of anxiety disorders and the presence of psychiatric complications related disorders. Diagnoses of anxiety disorders were selected according to DSM-IV-TR. Results The rate of each anxiety disorder was as follows in our patients: Obsessive Compulsive Disorder (OCD) 31.6%, Generalized Anxiety Disorder (GAD) 15.8%, Panic Disorder(PD) without agoraphobia 21.1%, PD with agoraphobia 5.3%, Post Traumatic Stress Disorder (PTSD) 13.2%, Acute Stress Disorder(ESD) 10.5%, agoraphobia 2.6%. 55.3% of the patients were female. The mean age was 41.55 years, ranging from 18 to 67 years. 71% of patients were young people between 25 years and 45 years. 55.3% of patients lived in urban areas. 63.1% were married. 50% of the patients had, along the evolutionary course of their illness, psychiatric complications including: depression 57.9%, suicide attempts 31.6%, alcohol abuse 10.5%. Conclusion The findings underline the importance of the proper management of any anxiety disorder to reduce its complications and improve the quality of life of these patients.