Panic Disorder
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Missing from Katon's review of panic disorder (June 1 issue)1 is the frequent correlation of symptoms with acute respiratory alkalosis resulting from hyperventilation. Table 1 of the article, showing criteria for the diagnosis of panic disorder, lists 13 symptoms, all of them common in the hyperventilation syndrome.2 Many patients with this syndrome are referred for a cardiac or neurologic workup before the correct diagnosis is made. Good symptomatic relief may be obtained with the use of a simple three-step approach. First, provide an elementary explanation of the carbon dioxide depletion consequent to overbreathing and the symptoms that may result. Second, have the patient reproduce the symptoms by voluntary hyperventilation for 1 to 2 minutes. Third, have the patient repeat the hyperventilation by rebreathing into a paper bag to prevent loss of carbon dioxide and inducing the symptoms induced in step two.
In his summary and recommendations, Katon suggests cognitive behavioral or pharmacologic therapy as initial treatment. However, reassurance regarding the absence of cardiac and neurologic disease, education in control of breathing, and use of the three-step approach outlined above are frequently curative and should be tried first.
Irwin Hoffman, M.D.
Lovelace Medical Center
Albuquerque, NM 87108
irw.hoffman@stvin.org
References
Katon WJ. Panic disorder. N Engl J Med 2006;354:2360-2367.
Tavel ME. Hyperventilation syndrome -- hiding behind pseudonyms? Chest 1990;97:1285-1287.
The author replies: Most researchers now view the hyperventilation syndrome as subsumed under the diagnosis of panic disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.1 Low values for the partial pressure of carbon dioxide in arterial blood (PaCO2) are found during most naturally occurring panic attacks. Voluntary hyperventilation is also associated with higher levels of anxiety and lower PCO2 values in patients with panic, as compared with control subjects. In addition, as compared with controls, patients with panic disorder have a slower recovery from voluntary hyperventilation1,2 and are more likely to have dysregulated breathing patterns (e.g., frequent sighing or disorganized breathing patterns) and to have their panic attacks provoked by voluntarily holding their breath.1,2,3
On the one hand, a recent review of breathing training alone in patients with panic disorder gave a mixed picture of therapeutic efficacy.1 On the other hand, as noted in my review article, among patients with panic disorder, cognitive behavioral therapy has been found to be as effective as medication.4 Cognitive theory of panic disorder posits that minor somatic symptoms such as breathlessness are misinterpreted and lead to catastrophic thoughts (I am having a stroke), increasing the panic.4 Cognitive behavioral therapy may combine the use of voluntary hyperventilation to reproduce symptoms in patients with panic disorder who already have frightening respiratory symptoms with targeting maladaptive thoughts as well as teaching patients how to slow and regularize their breathing patterns.
Wayne J. Katon, M.D.
University of Washington
Seattle, WA 98195-6560
wkaton@u.washington.edu
References
Meuret AE, Ritz T, Wilhelm FH, Roth WT. Voluntary hyperventilation in the treatment of panic disorder -- functions of hyperventilation, their implications for breathing training, and recommendations for standardization. Clin Psychol Rev 2005;25:285-306.
Friedman SD, Mathis CM, Hayes C, Renshaw P, Dager SR. Brain pH response to hyperventilation in panic disorder: preliminary evidence for altered acid-base regulation. Am J Psychiatry 2006;163:710-715.
Maddock RJ, Carter CS, Gietzen DW. Elevated serum lactate associated with panic attacks induced by hyperventilation. Psychiatry Res 1991;38:301-311.
Mitte K. A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Disord 2005;88:27-45.
In his summary and recommendations, Katon suggests cognitive behavioral or pharmacologic therapy as initial treatment. However, reassurance regarding the absence of cardiac and neurologic disease, education in control of breathing, and use of the three-step approach outlined above are frequently curative and should be tried first.
Irwin Hoffman, M.D.
Lovelace Medical Center
Albuquerque, NM 87108
irw.hoffman@stvin.org
References
Katon WJ. Panic disorder. N Engl J Med 2006;354:2360-2367.
Tavel ME. Hyperventilation syndrome -- hiding behind pseudonyms? Chest 1990;97:1285-1287.
The author replies: Most researchers now view the hyperventilation syndrome as subsumed under the diagnosis of panic disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.1 Low values for the partial pressure of carbon dioxide in arterial blood (PaCO2) are found during most naturally occurring panic attacks. Voluntary hyperventilation is also associated with higher levels of anxiety and lower PCO2 values in patients with panic, as compared with control subjects. In addition, as compared with controls, patients with panic disorder have a slower recovery from voluntary hyperventilation1,2 and are more likely to have dysregulated breathing patterns (e.g., frequent sighing or disorganized breathing patterns) and to have their panic attacks provoked by voluntarily holding their breath.1,2,3
On the one hand, a recent review of breathing training alone in patients with panic disorder gave a mixed picture of therapeutic efficacy.1 On the other hand, as noted in my review article, among patients with panic disorder, cognitive behavioral therapy has been found to be as effective as medication.4 Cognitive theory of panic disorder posits that minor somatic symptoms such as breathlessness are misinterpreted and lead to catastrophic thoughts (I am having a stroke), increasing the panic.4 Cognitive behavioral therapy may combine the use of voluntary hyperventilation to reproduce symptoms in patients with panic disorder who already have frightening respiratory symptoms with targeting maladaptive thoughts as well as teaching patients how to slow and regularize their breathing patterns.
Wayne J. Katon, M.D.
University of Washington
Seattle, WA 98195-6560
wkaton@u.washington.edu
References
Meuret AE, Ritz T, Wilhelm FH, Roth WT. Voluntary hyperventilation in the treatment of panic disorder -- functions of hyperventilation, their implications for breathing training, and recommendations for standardization. Clin Psychol Rev 2005;25:285-306.
Friedman SD, Mathis CM, Hayes C, Renshaw P, Dager SR. Brain pH response to hyperventilation in panic disorder: preliminary evidence for altered acid-base regulation. Am J Psychiatry 2006;163:710-715.
Maddock RJ, Carter CS, Gietzen DW. Elevated serum lactate associated with panic attacks induced by hyperventilation. Psychiatry Res 1991;38:301-311.
Mitte K. A meta-analysis of the efficacy of psycho- and pharmacotherapy in panic disorder with and without agoraphobia. J Affect Disord 2005;88:27-45.