Panikstörung und Agoraphobie sind häufig auftretende Angststörungen, die mit einer hohen individuellen aber auch gesellschaftlichen Belastung einhergehen. Es existieren sehr erfolgreiche, aber auch aufwändige Behandlungsmethoden. Trotz einer hohen Erfolgsquote dieser Behandlungen kommt es immer wieder zu einer nicht ausreichenden Verbesserung der Beschwerden oder auch Therapieabbrüchen. Zu möglichen Einflussfaktoren auf den Therapieerfolg, -misserfolg oder Abbrüche wurde bereits mit widersprüchlichen Ergebnissen geforscht. Es erscheint sinnvoll, diese Faktoren zu kennen, um Fehlindikationen in ein aufwändiges Therapieverfahren zu vermeiden und den Leidensdruck der Patient:innen gegebenenfalls mit einem anderen Verfahren schneller zu lindern. Die vorliegende Arbeit untersucht, ob solche Prädiktoren für den Nicht-Erfolg im Kontext eines naturalistischen Behandlungssettings in der Angst-Tagesklinik an der Klinik und Poliklinik für Psychotherapie und Psychosomatik des Universitätsklinikums Carl Gustav Carus identifiziert werden können. Dazu wurde der Therapieeffekt anhand 214 Patient:innen geprüft. Weiterhin wurden sie hinsichtlich demografischer, sozialmedizinischer und störungsspezifischer Kennwerte am Anfang und am Ende der Behandlung untersucht und am Grad der Veränderung angstspezifischer Kennwerte in Responder und Non-Responder unterteilt. Anschließend wurden über logistische Regressionen Faktoren für die Non-Response identifiziert. Es stellte sich heraus, dass die Behandlung einen mittleren bis großen Effekt auf verschiedene Störungsmaße aufwies, jedoch ca. 57,5% der Patient:innen keine oder eine im klinischen Sinne unzureichende Verbesserung erlebt hatten. Dabei zeigte sich, dass sich die Betrachtung des Familienstands, des Ausmaßes der Angst vor körperlichen Krisen und die Mobilitätsvermeidung ohne Begleitperson gemeinsam am besten eignen, um eine mögliche Non-Response vorherzusagen. Das errechnete Modell fällte dabei auf Basis der Aufnahmedaten in 62,8% der Fälle die korrekte Entscheidung zur Zuordnung in die Gruppen der Responder und Non-Responder. Somit ist das Modell leider nicht ausreichend, um zweifelsfrei im Vorfeld einer Behandlung individuell zu entscheiden, ob die angebotene Expositionsbehandlung zielführend ist oder nicht. Das Modell gibt allerdings wichtige Hinweise auf mögliche Einflussfaktoren auf die Eignung zur Behandlung, auch wenn weitere, nicht untersuchte oder nicht messbare Faktoren bedeutsam sein könnten. / Panic disorder and agoraphobia are common anxiety disorders that are associated with a high individual burden, but also social burden. There are very successful, but also costly treatment methods. Despite a high success rate of these treatments, there sometimes is an insufficient reduction of symptoms or even therapy discontinuation in individual patients. Research has already been done on possible factors influencing the success, failure or discontinuation of therapy, with contradictory results. It makes sense to know these factors in order to avoid wrong indications for a complex therapy procedure and to alleviate the patients' suffering more quickly with another procedure. This study investigates whether such predictors of non-response can be identified in the context of a naturalistic treatment setting in the Angst-Tagesklinik at the Klinik und Poliklinik für Psychotherapie und Psychosomatik of the University Hospital Carl Gustav Carus Dresden. For this purpose, the therapy’s effect was tested on 214 patients. Furthermore, they were examined with regard to demographic, socio-medical and disorder-specific parameters at the beginning and end of treatment and divided into responders and non-responders according to the degree of change in anxiety-specific parameters. Subsequently, logistic regressions were used to identify factors for non-response. It was found that the treatment had a medium to large effect on various disorder specific measures, but that about 57.5% of the patients had experienced no improvement or insufficient improvement in the clinical sense. It was found that looking at marital status, level of fear of physical crises and mobility avoidance without a companion were best suited to predict a possible non-response to the treatment. Based on the patients’ admission data, the calculated predictor model made the correct decision to assign the patient to the responder and non-responder groups in 62,8% of the cases. In conclusion, the model is not sufficient to predict, whether the exposure treatment will be successful or not. However, the model provides important indications of possible factors influencing the suitability for treatment, even though other factors that have not been investigated or that are not measurable could be significant.

Panic disorder (PD) and claustrophobia are commonly co-occurring anxiety disorders associated with high distress and impairment. Interoceptive exposure (IE; exposure focused on anxiety about somatic sensations) is a well-established component of treatments for PD, but little is known about the specificity of its effects or individual response patterns resulting from this intervention. This study investigated the utility of IE in the treatment of PD with claustrophobia, examining its mechanisms in isolation and in combination with more traditional exposure to phobic situations (situational exposure). Ten adults with PD and claustrophobia (aged 23-74, 30% female) were treated with a flexible single-case experimental approach. Participants received up to 6 sessions of IE exercises (e.g., running in place to build tolerance to racing heart). Nonresponders received up to 6 additional sessions of IE combined with situational exposure entailing entering a closet to induce claustrophobia. Hypotheses included: 1) Reductions in somatic anxiety coinciding with the introduction of IE; 2) Reductions in agoraphobic symptoms coinciding with the introduction of situational exposure for initial nonresponders; 3) Habituation to both interventions whereby distress and participants’ expectancy of the most feared outcome (e.g., fainting) would decrease, and fear tolerance would increase, with improvements maintained at retest. Four participants experienced a clinically significant reduction in somatic anxiety coinciding with IE as predicted; three other participants improved following the addition of situational exposure. One aspect of agoraphobic anxiety – willingness to enter enclosed spaces – generally improved only after combined exposure, as predicted. Both IE and combined exposure elicited habituation whereby distress and expectancies of feared outcomes decreased and fear tolerance increased, supporting hypotheses. All improvements were maintained at retest. Ideographic analysis suggested that IE can rapidly change beliefs about somatic sensations and lead to distress habituation, but has variable immediate effects on overall somatic anxiety and does not reliably reduce related symptom sets (e.g., agoraphobia). IE appeared more helpful to participants who were fearful of the physical consequences of somatic sensations (e.g., heart attack) vs. other consequences (e.g., embarrassment). The observed variability in response to IE and combined exposure suggests a need for individualized implementation of treatments in PD with claustrophobia.

Introduction: Obesity is one of the most important medical problems in the U.S. and is considered to be an epidemic with over 30% of the population being obese. Obesity is associated with increased risk of hypertension, diabetes, cardiovascular diseases, certain cancers and a shorter life expectancy. Recent studies have shown that higher BMI levels are also significantly associated with several lifetime mental disorders such as major depressive disorder, anxiety disorders as well as panic attacks and panic disorders. Purpose: The purpose of this study was to quantify the extent to which higher BMI increased the likelihood of Depression, Anxiety Disorder and Panic Disorder and to observe if co-morbid illnesses such as Hypertension and Diabetes affect this association. Methods: A cross-sectional secondary data analysis was conducted using the 2008 National Health Interview Survey. There were 20,593 adult respondents (over 18 years of age) who were included in the study. Logistic regression models were weighted to account for the complex weighting scheme. Main Determinant measures: Based on their BMI, the participants were classified into 5 groups: Underweight (BMI <18.50), Normal Weight (BMI 18.50 – 24.99), Overweight (BMI 25.00 – 29.99), Obese (BMI 30.00-39.99) and Morbidly Obese (BMI > 40.00). Main Outcome Measures: Presence or absence of Depression, Anxiety Disorder or Panic Disorder based on self-report. Results: People who were obese or morbidly obese had higher odds of suffering from depression, anxiety disorder and panic disorder compared to people who were normal weight. Obese individuals were 35% as likely to suffer from depression, 22% as likely to suffer from anxiety disorder and 36% as likely to suffer from panic disorder relative to normal weight persons. Morbidly obese people were 85% as likely to suffer from depression, 27% as likely to suffer from anxiety disorder and 34% as likely to suffer from panic disorder. No interactions were observed based on the presence of hypertension or diabetes. Conclusion: Obesity is associated with an increased prevalence of depression, anxiety disorder and panic disorder. With obesity rates steadily increasing, understanding the impact of obesity on the occurrence of mental disorders is important.

L'objectif du travail était l'étude des effets ventilatoires et cardiovasculaires de l'hyperventilation volontaire (HV) ainsi que psychophysiologiques chez les sujets sains et les patients souffrant de trouble panique. Nous avons mené deux études : la première sur des sujets sains sur lesquels le débit ventilatoire, les mouvements du thorax et de l'abdomen, le pourcentage de CO2 dans l'air expiré (FETCO2), l'électrocardiogramme (ECG) ont été enregistre au cours de deux tests d'hyperventilation : l'un à la fréquence de repos (THV) et l'autre à la fréquence de 20 cycles par minute (THV20). La deuxième étude a porté sur un groupe de sujets sains (groupe contrôle) et un groupe de patients souffrant du trouble panique (TP) sur lesquels le débit ventilatoire et l'ECG ont été enregistrés et les niveaux d'anxiété (Spielbergher), de dépression (Beck), du stress (Holmes), des symptômes de troubles fonctionnels (Profil Végétatif) et des symptômes produits par l'hyperventilation ont été évalués. Les variables ventilatoires classiques ont été calculées cycle par cycle. La forme des cycles ventilatoires a été étudiée en calculant les asters (représentation vectorielle des quatre premières harmoniques d'une décomposition en série de Fourier de chaque cycle respiratoire) ainsi que les triads (complexe trivarié: volume courant Vt, temps d'inspiration Ti et d'expiration Te). Les asters et triads ont été comparés dans les différentes conditions en utilisant un test statistique multi-varié (test de similarité). Les composantes du spectre de la période cardiaque, les périodes cardiaques moyennes et les coefficients de variation de la période cardiaque ont été calculés à partir des intervalles RR de l'ECG. Les résultats du test de similarité montrent que la forme du cycle ventilatoire de repos est modifiée au cours de l'hyperventilation volontaire, mais que la forme cycle à l'HV est conservée à un an d'intervalle et aussi pour les périodes d'HV des deux tests THV et TVH20. L'hyperventilation volontaire modifie significativement les caractéristiques de la ventilation (variables et forme du cycle). Cependant, au cours de l'hyperventilation volontaire ces caractéristiques sont conservées à un an d'intervalle et il semble que la personnalité ventilatoire de repos ne se conserve pas au cours de l'HV, mais l'on retrouve une personnalité « différente » au cours de l'HV. Les variables ventilatoires et leurs coefficients de variation sont modifiés pendant toutes les périodes des deux tests d'hyperventilation. Les variables ventilatoires du groupe contrôle ne sont significativement différentes du groupe TP qu'au cours des trois premières minutes de récupération. La variabilité cardiaque est significativement modifiée au cours des périodes des tests d'hyperventilation volontaire. La variabilité cardiaque est significativement plus faible chez les patients TP que chez les sujets sains et l'analyse des composantes spectrales de la période cardiaque permet de déduire que les patients semblent présenter au repos et pendant l'HV, une activité cardio-vagale plus faible et une activité sympathique plus élevée que les sujets sains. Les patients TP ont des niveaux plus élevés d'anxiété et de dépression que les sujets du groupe contrôle. Au cours des trois première minutes de récupération après l'hyperventilation volontaire à la fréquence de repos, la ventilation est plus élevée chez les sujets présentant une anxiété élevée que chez ceux présentant une anxiété normale à moyenne. Le nombre de symptômes fonctionnels et produits par l'hyperventilation volontaire est aussi plus élevé chez les sujets présentant une anxiété élevée. / The aim of this research was the evaluation of the ventilatory and cardiovascular effects the voluntary hyperventilation (HV) and psychophysiological peculiarities in healthy subjects and patients with panic disorder. We performed two studies: we recorded the airflow, thoracic and abdominal movements, percent of the CO2 in expired air (FETCO2), electrocardiogram (ECG) in a group of healthy subjects during the two voluntary hyperventilation tests: at rest frequency (THV) and at 20 breaths per minute (THV20). The second study was performed on the healthy subjects (control group) and panic disorder patients (TP): airflow and ECG were recorded and the levels of anxiety (Spielbergher), depression (Beck), stress (Holmes), functional symptoms (Vegetative Profile) and symptoms generated by voluntary hyperventilation were evaluated. The classical respiratory variables were calculated cycle by cycle. The shape of ventylatory cycles were studied by calculation of asters (vectorial representation of the first four harmonics obtained by Fourier transformation of each respiratory cycle) and triads (trivariate complex tidal volume - Vt, inspiratory - Ti and expiratory - Te times). The asters and triads were compared in different conditions using statistical multivariate test (similarity test). The components of heart periods spectre, mean cardiac periods and their variation coefficients were determined from the RR intervals of ECG. The results of the similarity test show the change of respiratory cycle shape during voluntary hyperventilation compared with rest, but the shape of the cycle during HV is conserved during one year interval and between periods of HV of two tests THV and THV20. Voluntary hyperventilation changes significantly ventilatory characteristics (variables and shape of cycle). However, these characteristics are conserved during voluntary hyperventilation after one year interval and the rest ventilatory personality is not conserved during HV, but the different personality appears during HV. Ventilator variables and their variation coefficients are modified during all periods of the two hyperventilation tests. The ventilatory variables of the control group compared with TP group differ only during first three minutes of recovery. Heart rate variability is significantly modified during all periods of hyperventilation test. Heart rate variability is significantly diminished in TP patients compared with healthy subjects and the analysis of spectral components of cardiac period allows affirming a weaker cardio-vagal activity and higher sympathetic activity compared with the healthy subjects. The TP patients compared with control group have higher levels of anxiety and depression. The ventilation during three minutes of recovery after voluntary hyperventilation at rest frequency is higher in subjects with high anxiety level compared with subjects with normal and mean level of anxiety. The number of functional symptoms and symptoms caused by voluntary hyperventilation is also higher in subjects with high anxiety.

Made available in DSpace on 2016-04-04T18:27:27Z (GMT). No. of bitstreams: 1 Graziela Siebert.pdf: 1011844 bytes, checksum: 8cc453da65d734b48b6fc0795fde9f8d (MD5) Previous issue date: 2006-02-01 / Universidade Estadual Paulista J?lio de Mesquita Filho / Panic Disorder is one of the most frequent and incapability problems among anxiety disturbing, representing one of major reasons people look for health support in Brazil and in world. The Behavior Analyses Therapy constitutes a treatment propose with very satisfactory results, focusing on the relation between clients felt and described symptoms and the operation contingencies, of which his/her behavior means the functions. The fully removal of symptoms (private events described by client) may occur since contingencies changing. The goal of this present work is to verify the changing occurrence from a verbal report of a client (25 years old) diagnosed with Panic Disorder by a psychiatrist. The changes occurred were verbalizations on auto-analyses and symptom descriptions for observation report and description of the relation among behavior/symptoms/environment, creating an initial strategy for psychotherapy treatment of such disorder. First eleven psychotherapy sessions were recorded and transcribed, and verbalizations were divided into categories by three independent judges - categories of client verbalization: Symptom, Environment, Behavior, Symptom/ Environment, Others; and functional categories of therapist verbalizations: Information, Investigation, Feedback, Advice/Rule, Interpretations, Others. Results have demonstrated as an answer for therapy intervention an important decrease on client verbalization frequency concerning category of symptom and an increase on category concerning symptom/environment. Those results contribute with clinical practice based on Radical Behaviorism philosophy, by demonstrating, in a natural clinical situation, that client behavior statement is selected (by therapist), as any other behavior, following the behavior concept as a result of environmental concern. / O Transtorno do P?nico ? um dos mais freq?entes e incapacitantes problemas dentre os transtornos ansiosos, representando um dos motivos de maior procura dos servi?os de sa?de no Brasil e no mundo. A Terapia Anal?tico-Comportamental constitui uma proposta com resultados bastante satisfat?rios para seu tratamento, e seu enfoque ? o esclarecimento da rela??o entre os sintomas sentidos e descritos pelo cliente e as conting?ncias em opera??o, das quais seus comportamentos s?o fun??o. A completa remo??o dos sintomas (eventos privados descritos pelo cliente) poder? ocorrer em conjunto com a altera??o das conting?ncias. O objetivo do presente trabalho foi verificar a ocorr?ncia da mudan?a do relato verbal de uma cliente (25 anos) diagnosticada com Transtorno do P?nico por um psiquiatra. A mudan?a ocorrida foi de verbaliza??es sobre auto-observa??o e descri??o de sintomas para o relato de observa??o e descri??o da rela??o comportamento / sintoma / ambiente, compondo uma estrat?gia inicial para o tratamento psicoterap?utico deste transtorno. Foram gravadas e transcritas as onze primeiras sess?es de psicoterapia, e as verbaliza??es categorizadas por tr?s juizes independentes - categorias para verbaliza??es da cliente: Sintoma, Ambiente, Comportamento, Sintoma / Ambiente, Outras; e categorias funcionais para verbaliza??es do terapeuta: Informa??o, Investiga??o, Feedback, Conselhos / Regras, Interpreta??es, Outras. Os resultados demonstraram uma diminui??o acentuada na freq??ncia de verbaliza??es da cliente referentes ? categoria sintoma e um aumento na freq??ncia da categoria rela??o sintoma / ambiente, como produto da interven??o terap?utica desenvolvida. Estes resultados contribuem com a pr?tica cl?nica baseada na filosofia do Behaviorismo Radical, por demonstrar, em uma situa??o cl?nica natural , que o comportamento da cliente de relatar ? selecionado (no caso, pelo terapeuta), como qualquer outro comportamento, seguindo uma concep??o de comportamento como produto de rela??es ambientais.

Introdução: O transtorno de ansiedade social (TAS) é uma condição que pode ser muito incapacitante, com considerável sofrimento subjetivo, alta prevalência de comorbidades psiquiátricas e impacto negativo no funcionamento psicossocial. Entretanto, existem poucos dados na literatura sobre a possível extensão deste comprometimento nos indivíduos com sinais e sintomas subclínicos do TAS. Além disso, a discussão sobre a associação entre o prolapso de valva mitral (PVM) e os transtornos de ansiedade, particularmente com o transtorno de pânico e o TAS, existe já há cerca de três décadas, mas os resultados publicados não são suficientes para definitivamente estabelecer ou excluir a associação entre essas condições, com prevalências variando de 0 a 57%. Método: O delineamento metodológico envolveu duas etapas. Na primeira, as comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial foram avaliados em 355 estudantes universitários que haviam sido diagnosticados previamente como TAS (n=141), TAS subclínico (n=92) ou controles (n=122). Na segunda etapa, um total de 232 voluntários diagnosticados como transtorno de pânico (n=41), TAS (n=89) ou controles (n=102) foram avaliados em ecocardiografia quanto ao PVM. Os exames foram realizados por dois cardiologistas que estavam cegos em relação ao diagnóstico psiquiátrico dos participantes. Foram obtidas medidas utilizando os critérios atuais e antigos para o diagnóstico de PVM, para permitir a comparação e generalização dos resultados. Resultados: A taxa de comorbidade com outros transtornos psiquiátricos foi de 71,6% no grupo TAS e de 50% nos sujeitos com TAS subclínico, ambos significativamente maiores que os controles (28,7%). A presença de comorbidades foi progressivamente maior de acordo com o subtipo e a gravidade do TAS. Quanto ao funcionamento psicossocial o grupo TAS apresentou maior comprometimento que os outros dois grupos em todos os domínios avaliados, e os sujeitos com TAS subclínico apresentaram valores intermediários. Na segunda etapa, os resultados demonstraram que não há diferenças estatísticas entre os grupos quanto à prevalência de PVM, seja pelos critérios ecocardiográficos atuais para o diagnóstico de PVM (visão longitudinal paraesternal: pânico=2,4%, TAS=4,5%, controles=1,0%) ou pelos critérios antigos (visão apical de 4-câmaras: pânico=2,4%, TAS=4,5%, controles=10,8%; modo-M: pânico=2,4%, TAS=6,7%, controles=4,9%). Também não houve diferenças significativas em relação a outras características morfológicas, como presença de regurgitação mitral, espessamento valvar ou presença de alongamento de cordoalhas. Conclusões: A prevalência de comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial aumentam progressivamente ao longo do espectro de ansiedade social. O fato de o TAS subclínico apresentar considerável incapacidade e sofrimento em comparação com sujeitos controles justifica uma revisão na validade desses critérios diagnósticos. Por outro lado, não houve associação entre o transtorno de pânico ou o TAS com o PVM em nossos resultados, independente dos critérios diagnósticos utilizados, com prevalências compatíveis com a esperada na população geral. Dessa forma, é preciso desmistificar a relação entre essa alteração cardíaca e o transtorno de pânico e o TAS, pelas repercussões que pode ter para o paciente e em seu tratamento psiquiátrico. / Background: Social anxiety disorder (SAD) is a highly disabling condition that causes considerable subjective suffering. It has a high prevalence rate of psychiatric comorbidities and a negative impact on psychosocial functioning. However, few data are available in the literature about the possible extent of this impairment in individuals with subthreshold signs and symptoms of SAD. In addition, the discussion about the association between mitral valve prolapse (MVP) and anxiety disorders, especially panic disorder and SAD, has been going on for over three decades, but the published results are insufficient to establish or to exclude an association between these conditions, with reported prevalence rates ranging from 0% to 57%. Method: The methodological design involved two stages. In the first, psychiatric comorbidities and psychosocial functioning impairment were evaluated in 355 college students diagnosed with SAD (n=141), subthreshold SAD (n=92) or as healthy controls (n=122) in a previous study. In the second stage, a total of 232 volunteers previously diagnosed with panic disorder (n=41), SAD (n=89) or as healthy controls (n=102) underwent echocardiographic evaluation for MVP. The exams were performed by two cardiologists who were blind to the psychiatric diagnosis of the participants. Measurements based on current and earlier MVP diagnostic criteria were taken in order to permit the comparison and generalization of the results. Results: The rate of comorbidity with other psychiatric disorders was 71.6% in the SAD group and 50% in subjects with subthreshold SAD, both significantly greater than controls (28.7%). The presence of comorbidities increased progressively according to SAD subtype and severity. Concerning psychosocial functioning, the SAD group had greater impairment than the other two groups in all domains evaluated, and subjects with subthreshold SAD presented intermediate values. In the second stage, the results demonstrated that there were no statistically significant differences among the groups in terms of MVP prevalence, whether using current diagnostic criteria (long-axis view: panic=2.4%, SAD=4.5%, control=1.0%) or earlier criteria (apical four-chamber view: panic=2.4%, SAD=4.5%, control=10.8%; M-mode: panic=2.4%, SAD=6.7%, control=4.9%). Also, there were no significant differences regarding other morphological characteristics, such as presence of mitral regurgitation, mean valve thickness or elongation of chordae. Conclusions: The rates of psychiatric comorbidities and the psychosocial functioning impairment increase progressively along the spectrum of social anxiety. The fact that subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of current diagnostic criteria. On the other hand, in this investigation no association between panic disorder or SAD and MVP was documented, regardless of the diagnostic criteria used, with prevalence rates similar to those reported for the general population. Thus, it seems necessary to demystify the relationship between this cardiac alteration and panic disorder and SAD in order to avoid unwanted influences for the patient and his psychiatric treatment.

Introdução: O transtorno de ansiedade social (TAS) é uma condição que pode ser muito incapacitante, com considerável sofrimento subjetivo, alta prevalência de comorbidades psiquiátricas e impacto negativo no funcionamento psicossocial. Entretanto, existem poucos dados na literatura sobre a possível extensão deste comprometimento nos indivíduos com sinais e sintomas subclínicos do TAS. Além disso, a discussão sobre a associação entre o prolapso de valva mitral (PVM) e os transtornos de ansiedade, particularmente com o transtorno de pânico e o TAS, existe já há cerca de três décadas, mas os resultados publicados não são suficientes para definitivamente estabelecer ou excluir a associação entre essas condições, com prevalências variando de 0 a 57%. Método: O delineamento metodológico envolveu duas etapas. Na primeira, as comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial foram avaliados em 355 estudantes universitários que haviam sido diagnosticados previamente como TAS (n=141), TAS subclínico (n=92) ou controles (n=122). Na segunda etapa, um total de 232 voluntários diagnosticados como transtorno de pânico (n=41), TAS (n=89) ou controles (n=102) foram avaliados em ecocardiografia quanto ao PVM. Os exames foram realizados por dois cardiologistas que estavam cegos em relação ao diagnóstico psiquiátrico dos participantes. Foram obtidas medidas utilizando os critérios atuais e antigos para o diagnóstico de PVM, para permitir a comparação e generalização dos resultados. Resultados: A taxa de comorbidade com outros transtornos psiquiátricos foi de 71,6% no grupo TAS e de 50% nos sujeitos com TAS subclínico, ambos significativamente maiores que os controles (28,7%). A presença de comorbidades foi progressivamente maior de acordo com o subtipo e a gravidade do TAS. Quanto ao funcionamento psicossocial o grupo TAS apresentou maior comprometimento que os outros dois grupos em todos os domínios avaliados, e os sujeitos com TAS subclínico apresentaram valores intermediários. Na segunda etapa, os resultados demonstraram que não há diferenças estatísticas entre os grupos quanto à prevalência de PVM, seja pelos critérios ecocardiográficos atuais para o diagnóstico de PVM (visão longitudinal paraesternal: pânico=2,4%, TAS=4,5%, controles=1,0%) ou pelos critérios antigos (visão apical de 4-câmaras: pânico=2,4%, TAS=4,5%, controles=10,8%; modo-M: pânico=2,4%, TAS=6,7%, controles=4,9%). Também não houve diferenças significativas em relação a outras características morfológicas, como presença de regurgitação mitral, espessamento valvar ou presença de alongamento de cordoalhas. Conclusões: A prevalência de comorbidades psiquiátricas e o comprometimento no funcionamento psicossocial aumentam progressivamente ao longo do espectro de ansiedade social. O fato de o TAS subclínico apresentar considerável incapacidade e sofrimento em comparação com sujeitos controles justifica uma revisão na validade desses critérios diagnósticos. Por outro lado, não houve associação entre o transtorno de pânico ou o TAS com o PVM em nossos resultados, independente dos critérios diagnósticos utilizados, com prevalências compatíveis com a esperada na população geral. Dessa forma, é preciso desmistificar a relação entre essa alteração cardíaca e o transtorno de pânico e o TAS, pelas repercussões que pode ter para o paciente e em seu tratamento psiquiátrico. / Background: Social anxiety disorder (SAD) is a highly disabling condition that causes considerable subjective suffering. It has a high prevalence rate of psychiatric comorbidities and a negative impact on psychosocial functioning. However, few data are available in the literature about the possible extent of this impairment in individuals with subthreshold signs and symptoms of SAD. In addition, the discussion about the association between mitral valve prolapse (MVP) and anxiety disorders, especially panic disorder and SAD, has been going on for over three decades, but the published results are insufficient to establish or to exclude an association between these conditions, with reported prevalence rates ranging from 0% to 57%. Method: The methodological design involved two stages. In the first, psychiatric comorbidities and psychosocial functioning impairment were evaluated in 355 college students diagnosed with SAD (n=141), subthreshold SAD (n=92) or as healthy controls (n=122) in a previous study. In the second stage, a total of 232 volunteers previously diagnosed with panic disorder (n=41), SAD (n=89) or as healthy controls (n=102) underwent echocardiographic evaluation for MVP. The exams were performed by two cardiologists who were blind to the psychiatric diagnosis of the participants. Measurements based on current and earlier MVP diagnostic criteria were taken in order to permit the comparison and generalization of the results. Results: The rate of comorbidity with other psychiatric disorders was 71.6% in the SAD group and 50% in subjects with subthreshold SAD, both significantly greater than controls (28.7%). The presence of comorbidities increased progressively according to SAD subtype and severity. Concerning psychosocial functioning, the SAD group had greater impairment than the other two groups in all domains evaluated, and subjects with subthreshold SAD presented intermediate values. In the second stage, the results demonstrated that there were no statistically significant differences among the groups in terms of MVP prevalence, whether using current diagnostic criteria (long-axis view: panic=2.4%, SAD=4.5%, control=1.0%) or earlier criteria (apical four-chamber view: panic=2.4%, SAD=4.5%, control=10.8%; M-mode: panic=2.4%, SAD=6.7%, control=4.9%). Also, there were no significant differences regarding other morphological characteristics, such as presence of mitral regurgitation, mean valve thickness or elongation of chordae. Conclusions: The rates of psychiatric comorbidities and the psychosocial functioning impairment increase progressively along the spectrum of social anxiety. The fact that subthreshold SAD causes considerable disability and suffering in comparison with control subjects justifies a review of the validity of current diagnostic criteria. On the other hand, in this investigation no association between panic disorder or SAD and MVP was documented, regardless of the diagnostic criteria used, with prevalence rates similar to those reported for the general population. Thus, it seems necessary to demystify the relationship between this cardiac alteration and panic disorder and SAD in order to avoid unwanted influences for the patient and his psychiatric treatment.

A presente pesquisa teve como objetivo caracterizar os elementos de personalidade de pacientes com transtorno de pânico a partir dos dados obtidos pelo Método de Rorschach, segundo o sistema compreensivo. Em linhas gerais, o transtorno de pânico pode ser caracterizado pela vivência recorrente de ataques de pânico, em virtude de crises agudas de ansiedade, onde o indivíduo passa por um mal-estar intenso e uma sensação iminente de perigo e ou morte. Participaram do estudo 60 colaboradores divididos igualmente em quatro grupos: pacientes com pânico do sexo feminino, pacientes com pânico do sexo masculino, não pacientes do sexo feminino e não pacientes do sexo masculino. Os participantes do grupo de não pacientes foram avaliados pelo Questionário de Saúde Geral para verificação de seu estado geral de saúde mental e todos os colaboradores submeteram-se ao Método de Rorschach, conforme as especificações técnicas do sistema compreensivo. As respostas foram codificadas por juízes independentes e os índices obtidos foram submetidos à análise estatística por meio do teste de Kruskal-Wallis e do teste post-hoc de Dunn, comparando-se os quatro grupos. Os resultados com diferença estatisticamente significativa apresentados para os colaboradores com transtorno de pânico foram os seguintes: presença do Índice de Depressão (p = 0,009), indicando depressão e sintomas depressivos ou algum tipo de transtorno afetivo; rebaixamento do Índice Lambda (p = 0,008), demonstrando dificuldade na discriminação entre informações importantes e irrelevantes; predomínio de cor acromática e sombreados na Experiência de Base (p = 0,010), caracterizando dor e sofrimento psíquicos em demasia, além de aumento da tensão interna; elevação da Estimulação Sentida (p 0,001), indicando uma vivência de extrema irritação, desconforto e incômodo internos; rebaixamento da Nota D (p 0,001), que revela grande vivência de estresse, associado à falta de recursos internos para enfrentá-lo; elevação das determinantes de sombreado com característica de difusão (p 0,001), que indica extremo desconforto emocional, sofrimento interno e desamparo emocional; elevação de determinantes mistos de cor e sombreado (p = 0,004), que propõe vivências afetivas carregadas de ambivalência e sofrimento e perturbação afetiva; predomínio das respostas empobrecidas de conteúdo humano (p = 0,011), que demonstra dificuldade de adaptação nas relações sociais; rebaixamento das respostas de movimento cooperativo (p = 0,006), revelando dificuldade em estabelecer vínculos positivos e construtivos com outros indivíduos. Em síntese, os aspectos de personalidade observados nos colaboradores com pânico mostram tratar-se de indivíduos que internamente apresentam grande sofrimento psicológico, tensão interna e dificuldades afetivas; não possuem recursos de enfrentamento das situações estressantes e ansiógenas, levando-os a dificuldade de relacionamento adequado. Os quadros de pânico são decorrentes dessa estrutura frágil e comprometida. Embora os dados sejam conclusivos, existe a necessidade de constantes investigações para a melhor compreensão desse quadro psicopatológico que tanto causa sofrimento em seus portadores. / The objective of this research was to characterize the personality elements of patients with panic disorder from data obtained by the Rorschach Method following the comprehensive system. In general terms, the panic disorder can be characterized by the repeated experience of panic attacks due to acute anxiety, in which the individual suddenly develops a severe discomfort or fear of danger and or death. 60 subjects participated in the study, equally divided into four groups: female patients with panic, male patients with panic, female nonpatients and male nonpatients. The nonpatient group was assessed through the General Health Questionnaire for a general mental health assessment, and all subjects were submitted to the Rorschach Method, following the comprehensive system technical specifications. The responses were codified by independent raters and the indices obtained were subjected to statistical analysis using the Kruskal-Wallis test followed by Dunns post-hoc test, comparing the four groups. The results with statistically significant difference presented regarding subjects com panic disorder were the following: presence of Depression Index (p = 0.009), indicating depression and depressive symptoms or some kind of affective disorder; lower Lambda (p = 0.008), showing difficulty to distinguish between important and irrelevant information; prevalence of achromatic and shading colors in the Experience Base (p = 0.010), characterizing overwhelming psychic pain and suffering, in addition to increased inner stress; higher Experienced Stimulation (p 0.001), showing an experience of extreme inner irritation, discomfort and uneasiness; lower D Score (p 0.001), showing great stress experience associated with lack of inner coping resources; increase in the shading with diffusion feature determinants (p 0.001), indicating extreme emotional discomfort, inner suffering and emotional helplessness; increase in mixed color and shading determinants (p = 0.004), suggesting affective experiences full of ambivalence and suffering and affective disturbance; predominance of impoverished human content responses (p = 0.011), showing difficulty in adapting to social relationships; fewer cooperative movement responses (p = 0.006), showing difficulty in establishing positive and constructive bonds with other individuals. In summary, the personality aspects observed in the subjects with panic show they are individuals presenting deep psychological suffering, inner tension and affective difficulties; they lack coping resources to handle stressful and anxious situations, leading them to difficulty in proper interpersonal relationship. The panic disorder results from this fragile and vulnerable structure. Although data is conclusive, permanent investigation is necessary in order to better understand this psychopathologic condition that causes so much pain to those who suffer from it.

A presente pesquisa teve como objetivo caracterizar os elementos de personalidade de pacientes com transtorno de pânico a partir dos dados obtidos pelo Método de Rorschach, segundo o sistema compreensivo. Em linhas gerais, o transtorno de pânico pode ser caracterizado pela vivência recorrente de ataques de pânico, em virtude de crises agudas de ansiedade, onde o indivíduo passa por um mal-estar intenso e uma sensação iminente de perigo e ou morte. Participaram do estudo 60 colaboradores divididos igualmente em quatro grupos: pacientes com pânico do sexo feminino, pacientes com pânico do sexo masculino, não pacientes do sexo feminino e não pacientes do sexo masculino. Os participantes do grupo de não pacientes foram avaliados pelo Questionário de Saúde Geral para verificação de seu estado geral de saúde mental e todos os colaboradores submeteram-se ao Método de Rorschach, conforme as especificações técnicas do sistema compreensivo. As respostas foram codificadas por juízes independentes e os índices obtidos foram submetidos à análise estatística por meio do teste de Kruskal-Wallis e do teste post-hoc de Dunn, comparando-se os quatro grupos. Os resultados com diferença estatisticamente significativa apresentados para os colaboradores com transtorno de pânico foram os seguintes: presença do Índice de Depressão (p = 0,009), indicando depressão e sintomas depressivos ou algum tipo de transtorno afetivo; rebaixamento do Índice Lambda (p = 0,008), demonstrando dificuldade na discriminação entre informações importantes e irrelevantes; predomínio de cor acromática e sombreados na Experiência de Base (p = 0,010), caracterizando dor e sofrimento psíquicos em demasia, além de aumento da tensão interna; elevação da Estimulação Sentida (p 0,001), indicando uma vivência de extrema irritação, desconforto e incômodo internos; rebaixamento da Nota D (p 0,001), que revela grande vivência de estresse, associado à falta de recursos internos para enfrentá-lo; elevação das determinantes de sombreado com característica de difusão (p 0,001), que indica extremo desconforto emocional, sofrimento interno e desamparo emocional; elevação de determinantes mistos de cor e sombreado (p = 0,004), que propõe vivências afetivas carregadas de ambivalência e sofrimento e perturbação afetiva; predomínio das respostas empobrecidas de conteúdo humano (p = 0,011), que demonstra dificuldade de adaptação nas relações sociais; rebaixamento das respostas de movimento cooperativo (p = 0,006), revelando dificuldade em estabelecer vínculos positivos e construtivos com outros indivíduos. Em síntese, os aspectos de personalidade observados nos colaboradores com pânico mostram tratar-se de indivíduos que internamente apresentam grande sofrimento psicológico, tensão interna e dificuldades afetivas; não possuem recursos de enfrentamento das situações estressantes e ansiógenas, levando-os a dificuldade de relacionamento adequado. Os quadros de pânico são decorrentes dessa estrutura frágil e comprometida. Embora os dados sejam conclusivos, existe a necessidade de constantes investigações para a melhor compreensão desse quadro psicopatológico que tanto causa sofrimento em seus portadores. / The objective of this research was to characterize the personality elements of patients with panic disorder from data obtained by the Rorschach Method following the comprehensive system. In general terms, the panic disorder can be characterized by the repeated experience of panic attacks due to acute anxiety, in which the individual suddenly develops a severe discomfort or fear of danger and or death. 60 subjects participated in the study, equally divided into four groups: female patients with panic, male patients with panic, female nonpatients and male nonpatients. The nonpatient group was assessed through the General Health Questionnaire for a general mental health assessment, and all subjects were submitted to the Rorschach Method, following the comprehensive system technical specifications. The responses were codified by independent raters and the indices obtained were subjected to statistical analysis using the Kruskal-Wallis test followed by Dunns post-hoc test, comparing the four groups. The results with statistically significant difference presented regarding subjects com panic disorder were the following: presence of Depression Index (p = 0.009), indicating depression and depressive symptoms or some kind of affective disorder; lower Lambda (p = 0.008), showing difficulty to distinguish between important and irrelevant information; prevalence of achromatic and shading colors in the Experience Base (p = 0.010), characterizing overwhelming psychic pain and suffering, in addition to increased inner stress; higher Experienced Stimulation (p 0.001), showing an experience of extreme inner irritation, discomfort and uneasiness; lower D Score (p 0.001), showing great stress experience associated with lack of inner coping resources; increase in the shading with diffusion feature determinants (p 0.001), indicating extreme emotional discomfort, inner suffering and emotional helplessness; increase in mixed color and shading determinants (p = 0.004), suggesting affective experiences full of ambivalence and suffering and affective disturbance; predominance of impoverished human content responses (p = 0.011), showing difficulty in adapting to social relationships; fewer cooperative movement responses (p = 0.006), showing difficulty in establishing positive and constructive bonds with other individuals. In summary, the personality aspects observed in the subjects with panic show they are individuals presenting deep psychological suffering, inner tension and affective difficulties; they lack coping resources to handle stressful and anxious situations, leading them to difficulty in proper interpersonal relationship. The panic disorder results from this fragile and vulnerable structure. Although data is conclusive, permanent investigation is necessary in order to better understand this psychopathologic condition that causes so much pain to those who suffer from it.

<p>As evidenced by several trials, cognitive behavior therapy (CBT) is a highly effective treatment for Panic disorder with or without agoraphobia (PD). However, therapists are short in supply, and patients with agoraphobia may not seek therapy due to fear of leaving their homes or traveling certain distances. A major challenge therefore is to increase the accessibility and affordability of evidence-based psychological treatments.</p><p>This thesis is based on five studies; three treatment studies set up as randomized controlled trails (RCT), one prevalence study, and one study testing the equivalence of an Internet-administered diagnostic assessment tool with a clinician-administered interview.</p><p>Study I showed that the Swedish 12-month PD prevalence is consistent with findings in most other parts of the Western world (2.2%; CI 95% 1.0%-3.4%). There was a significant sex difference, with a greater prevalence for women (3.6%) compared to men (0.7%).</p><p>Study II showed that the validity of the computerized diagnostic interview (CIDI-SF) was generally low. However, the agoraphobia and obsessive-compulsive disorder modules had good specificity and sensitivity, respectively.</p><p>The three RCTs showed, directly or indirectly, that Internet-based self-help is superior to a waiting-list. When 10 individual weekly sessions of CBT for PD was compared with a 10-module self-help program on the Internet, the results suggest that Internet-administered self-help, plus minimal therapist contact via e-mail, is as effective as traditional individual CBT (80% vs. 67% no longer met criteria for panic disorder; composite within-group effect size was Cohen’s <i>d</i>= 0.78 vs. 0.99). One-year follow-up confirmed the results (92% vs. 88% no longer met criteria for panic disorder; <i>d</i>= 0.80 vs. 0.93). The results generally provide evidence to support the continued use and development of Internet-distributed self-help programs.</p>