Dizziness- and Palpitations-predominant Orthostatic Panic: Physiology,Flashbacks, and Catastrophic Cognitions

In an orthostatic challenge, Cambodian patients with orthostatic panic in the last month (OP patients) sometimes panicked during orthostatic challenge, whereas those without orthostatic panic in the last month (NOP patients) did not. Also, OP patients with primarily dizziness during orthostatic challenge panic (OP_OCP-D) had a less vigorous physiological response than two other groups: (a) OP patients with primarily palpitations during orthostatic challenge panic (OP_OCP-P) and (b) NOP patients who had no symptoms during orthostatic challenge (NOP_NOCP-NS). Among the patients experiencing orthostatic challenge–induced panic (i.e., the OP_OCP-D and OP_OCP-P patients), there were prominent orthostatic challenge–induced flashbacks and catastrophic cognitions, and the severity of orthostatic challenge–induced flashbacks and catastrophic cognitions correlated with the severity of orthostatic panic in the previous month and with the severity of orthostatic challenge–induced panic.     

The panic attack-posttraumatic stress disorder model: applicability to orthostatic panic among Cambodian refugees

This article examines the ability of the panic attack-posttraumatic stress disorder (PTSD) model to predict how panic attacks are generated and how panic attacks worsen PTSD. The article does so by determining the validity of the panic attack-PTSD model in respect to one type of panic attack among traumatized Cambodian refugees: orthostatic panic (OP) attacks (i.e. panic attacks generated by moving from lying or sitting to standing). Among Cambodian refugees attending a psychiatric clinic, the authors conducted two studies to explore the validity of the panic attack-PTSD model as applied to OP patients (i.e. patients with at least one episode of OP in the previous month). In Study 1, the panic attack-PTSD model accurately indicated how OP is seemingly generated: among OP patients (N = 58), orthostasis-associated flashbacks and catastrophic cognitions predicted OP severity beyond a measure of anxious-depressive distress (Symptom Checklist-90-R subscales), and OP severity significantly mediated the effect of anxious-depressive distress on Clinician-Administered PTSD Scale severity. In Study 2, as predicted by the panic attack-PTSD model, OP had a mediational role in respect to the effect of treatment on PTSD severity: among Cambodian refugees with PTSD and comorbid OP who participated in a cognitive behavioural therapy study (N = 56), improvement in PTSD severity was partially mediated by improvement in OP severity.     

Anger-associated panic attacks in Cambodian refugees with PTSD; a multiple baseline examination of clinical data

Despite the increasing recognition of the importance of anger as a key aspect of post-traumatic stress disorder (PTSD), the presence of anger-induced panic attacks has been understudied in traumatized groups. The present investigation determines the prevalence of anger-associated panic attacks among Cambodian refugees suffering from PTSD. Specific characteristics of these episodes that were examined included frequency, symptoms, and cognitions (in particular, fear of death from bodily dysfunction). In a survey of 100 Khmer patients suffering PTSD, 58% reported anger-associated panic attacks in the last month. These attacks occurred at a mean rate of 6.2 attacks a month and were characterized by extreme arousal and in 81% of these cases, fears of death due to bodily dysfunction during the anger-induced panic. Mechanisms for this high rate of fear of death during anger arousal are discussed with a focus on culture-specific catastrophic cognitions.     

Anxiety sensitivity in traumatized Cambodian refugees: a discriminant function and factor analytic investigation

We examined the psychometric properties and factor structure of a Cambodian translation of the Anxiety Sensitivity Index (ASI) and an Augmented ASI (the ASI supplemented with a 9-item addendum that assesses additional Cambodian concerns about anxiety-related sensations). Both the ASI and the Augmented ASI distinguished among three diagnostic groups: highest score, PTSD with panic disorder (PP group); next, panic disorder without PTSD (P group); and then, other disorders than PTSD or panic disorder (O group). In the discriminant function analysis using the Augmented ASI, the best classificatory predictor (PP vs. P vs. O) was an Addendum item (“It scares me when I stand up and feel dizzy”). The principal component analysis (oblimin rotation) of the ASI yielded a 3-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Social Concerns) and of the Augmented ASI, a 4-factor solution (I, Weak Heart Concerns; II, Control Concerns; III, Wind Attack Concerns; IV, Social Concerns). The item clustering within the factor solution of both the ASI and Augmented ASI illustrates the role of cultural syndromes in generating fear of mental and bodily events.     

Symptom Presentation and Symptom Meaning Among Traumatized Cambodian Refugees: Relevance to a Somatically Focused Cognitive-Behavior Therapy

Among psychologically distressed Cambodian refugees, somatic complaints are particularly prominent. Cambodians interpret anxiety-related somatic sensations in terms of “Wind” (khyâl), an ethnophysiology that gives rise to multiple catastrophic interpretations; and they have prominent trauma-memory associations to anxiety-related somatic symptoms. In this article, we detail some of the common sensation-related dysphoric networks of Cambodian refugees, focusing on catastrophic cognitions and trauma associations. We argue that delineating symptom-related dysphoric networks is crucial to successfully adapt cognitive-behavioral interventions to treat panic disorder and posttraumatic stress disorder among Cambodian refugees, and that such an approach may be useful for the culturally sensitive adaptation of cognitive-behavior therapy for other traumatized non-Western groups.     

The psychophysiology of combat-induced post-traumatic stress disorder in Vietnam veterans

The psychophysiological responses of heart rate (HR), systolic and diastolic blood pressure, skin conductance level and forehead electromyogram were compared during: rest, mental arithmetic and combat sounds of gradually increasing intensity for five groups of Ss: Vietnam veterans with post-traumatic stress disorder (PTSD); Vietnam veterans without PTSD but with comparable levels of combat experience; Vietnam veterans with other psychiatric disorders; Vietnam-era veterans; and nonveteran phobics. HR response to low-intensity combat sounds provided good discrimination between veterans with PTSD and the other groups and seems to resemble a conditioned emotional response.     

Mental and physical stress as moderators of the postural response in insulin-dependent diabetic patients

Two simple stressors, mental arithmetic and isometric handgrip, were studied as moderators of the physiological response to standing in insulin-dependent diabetic patients and in healthy controls. Continuous (beat-to-beat) measures were taken of heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and skin conductance (SC) during postural change under baseline and stressor conditions. Diabetic patients without symptoms of neuropathy and healthy controls showed generally similar responses to postural change and to the stressor conditions. SBP and DBP were more responsive to the mental and physical stressors than were HR or SC, especially after standing. Two diabetic patients with postural hypotension showed significant increases in overall BP levels and less of a fall in BP during postural change under the stressor conditions, despite minimal HR or SC responses. Results indicate that these strategies are effective in increasing BP during postural change in both diabetic and nondiabetic individuals and may be useful in the management of orthostatic hypotension.     

Intrusive images in PTSD and in traumatised and non-traumatised depressed patients: a cross-sectional clinical study

Although intrusive images are a hallmark of post-traumatic stress disorder (PTSD) and also occur in depression, little is known about the differences and similarities of such images in these conditions. Our study focuses on the qualities and triggers of intrusive images and responses to them in three groups--patients with PTSD, and depressed patients with and without trauma (n=65)-to highlight the diagnostic specificity of intrusive images for PTSD and depression. We distinguished intrusive images from verbal intrusive cognitions such as rumination and intrusive (brief) lexical thoughts. Consistent with the literature, the intrusive images of PTSD patients had a more "here-and-now quality" and were perceived more visually compared to those of both depressed groups. The groups showed a good deal of similarity concerning other image qualities. Most importantly, the intrusive images in PTSD and depressed patients with and without trauma were perceived as similarly distressing. Rumination and intrusive (brief) lexical thoughts were two of the five most named triggers of intrusive images. Limitations, such as the lack of a control group, and the clinical implications of these results are discussed, demonstrating the need to help non-PTSD patients with and without trauma to deal with intrusive images.     

Treatment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with cognitive-behavior therapy vs sertraline alone

Cambodian refugees with posttraumatic stress disorder (PTSD) represent a cohort in severe need of treatment, but little information is available to guide treatment choices. We selected a sample of pharmacotherapy-refractory individuals to test the efficacy of combination treatment with sertraline and cognitive-behavior therapy (CBT) for treating PTSD. Participants in this pilot study were ten Khmer-speaking women who had been at a mean age of 22-26 years during the Pol Pot period (1975-1979). These patients were randomly assigned to either sertraline alone or combined treatment. We found that combined treatment offered additional benefit in the range of medium to large effect sizes for PTSD and associated symptoms. Our findings indicate that substantial gains can be achieved by adding CBT to pharmacotherapy for PTSD, and that a program of CBT emphasizing information, exposure, and cognitive-restructuring can be successfully modified for Khmer-speaking refugees.     

Agoraphobic avoidance and panic frequency as predictors of laboratory induced panic reactions

This study examined the importance of agoraphobic avoidance and frequency of panic as predictors of psychological and physiological responses of panic sufferers to a laboratory based provocation procedure. Psychophysiologic comparisons were made between 22 panic disorder patients and 15 controls, at baseline and across three periods of carbon dioxide gas inhalations (1, 3, 5%; balance oxygen). Subjective measures of anxiety, frightening cognitions and body sensations were obtained across the phases. Physiological measures of minute ventilation, breathing rate, tidal volume, end tidal CO₂ and heart rate were also obtained. Between group comparisons revealed significant differences between the groups on the subjective measures with no significant differences occurring on the physiological measures. Within group analyses revealed that pre-session questionnaire measures of agoraphobia avoidance and panic frequency predicted the degree of anxiety, frightening sensations and cognitions during baseline and 5% CO₂ inhalation. The results indicated that both self-reported agoraphobic avoidance and panic frequency are strong clinical predictors of psychological reactions of panic sufferers during laboratory provocation.     

The catastrophic misinterpretation of physiological distress.

Cognitive theories of panic disorder suggest that the catastrophic misinterpretation of bodily sensations is the trigger for a panic attack. A challenge to cognitive theories is the suggestion that dyspnea (shortness of breath) is central to the development of panic and that negative cognitions are by-products of panic. To examine these seemingly contradictory theoretical perspectives, the present study investigated panic symptomatology in a sample of patients with chronic shortness of breath (i.e. pulmonary patients). Past studies have shown an increased prevalence of panic in pulmonary patients, a finding that may be useful in elucidating panic etiology. The current sample of pulmonary patients (N = 28) confirmed previous reports of high prevalence rates of panic in this population. Based on self-report of panic symptomatology, a total of nine patients (32%) met DSM-IV criteria that were consistent with panic disorder. Multivariate comparison of participants with and without panic symptomatology revealed that panickers had significantly higher levels of anxiety, depression and agoraphobic cognitions. However, these groups showed no significant differences on physiological measures of pulmonary functioning. The authors conclude that dyspnea alone is inadequate in predicting panic development. High levels of panic symptomatology in pulmonary samples may reflect increased opportunities for these patients to misinterpret bodily sensations and, in particular, their pulmonary symptoms.     

Responsivity to stress in chronic posttraumatic stress disorder due to childhood sexual abuse

The purpose of this study was to investigate psychological, cardiovascular, and neuroendocrine reactivity to standardized stress tests (orthostatic challenge, Stroop Color Word Test) in drug-free adult women with chronic PTSD due to repetitive childhood sexual abuse. At baseline, the 11 patients showed significantly higher mean scores on the Symptom Check List-90 and the Profile of Mood States than 13 healthy female controls, whereas baseline cardiovascular or hormonal parameters showed no differences between the groups. Also, no significant differences were found between the two groups in cardiovascular and hormonal responsivity to the stress tests. Thus, in the presence of robust psychological differences, the patients with chronic PTSD due to childhood sexual abuse did not show alterations in baseline values of neurobiological parameters, nor did they react differently to a physical and mental stress test when compared to healthy controls.     

Mental health problems and post-migration stress among multi-traumatized refugees attending outpatient clinics upon resettlement to Norway

Refugees have often been exposed to multiple traumas making them prone to mental health problems later. The aim of this study is to describe the prevalence and symptom load of psychiatric disorders in refugees admitted to psychiatric outpatient clinics and to investigate the relationship between multiple exposure to traumatic events, the severity of traumatic symptoms and post-migration stressors. A clinical sample of 61 refugee outpatients from psychiatric clinics in Southern Norway was cross-sectionally examined using three structured clinical interviews (SCID-PTSD, SIDES and MINI) and self-report psychometric instruments (HSCL-25, IES-R). Post-traumatic Stress Disorder (PTSD) was diagnosed in 82% of the patients, while Disorders of Extreme Stress Not Otherwise Specified (DESNOS) was present in 16% of them. Comorbidity was considerable; 64% of the patients had both PTSD and major depression disorder (MDD) and 80% of those who had PTSD had three or more additional diagnoses. Multi-traumatized refugees in outpatient clinics have high prevalence of PTSD, DESNOS, comorbid depression and anxiety disorders. A more severe symptomatology was found in patients diagnosed with both PTSD and DESNOS, than in those diagnosed with only PTSD. Higher rates of unemployment, weak social network and weak social integration were also prevalent in these outpatients, and related to increased psychiatric comorbidity and severity of symptoms. Further research may clarify the existence of a cumulative relationship between pre-resettlement traumas and post-resettlement stressors in the mental health of refugees, which in turn may help to improve therapeutic interventions.     

Overgeneral memory extends to pictorial retrieval cues and correlates with cognitive features in posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) show overgeneral memory (OGM) when retrieving autobiographical memories to word cues. We investigated whether OGM extends to picture cues and whether it is related to PTSD symptoms and cognitions. Trauma survivors with (n = 29) and without (n = 26) PTSD completed the standard Autobiographical Memory Test (AMT) and a novel picture version. Compared to the no-PTSD group, the PTSD group showed OGM in both test versions. Pictures facilitated specific memory retrieval, but this effect was no longer significant when verbal intelligence or depressive symptoms were controlled. OGM correlated with PTSD symptoms and perceived self-change; with intrusive memories, their perceived "nowness," responses to intrusions (thought suppression, rumination, dissociation), and negative interpretations of symptoms.     

Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder

Although peritraumatic dissociation predicts subsequent posttraumatic stress disorder (PTSD), little is understood about the mechanism of this relationship. This study examines the role of panic during trauma in the relationship between peritraumatic dissociation and subsequent PTSD. Randomized eligible admissions to 4 major trauma hospitals across Australia (n = 244) were assessed during hospital admission and within one month of trauma exposure for panic, peritraumatic dissociation and PTSD symptoms, and subsequently re-assessed for PTSD three months after the initial assessment (n = 208). Twenty (9.6%) patients met criteria for PTSD at 3-months post injury. Structural equation modeling supported the proposition that peritraumatic derealization (a subset of dissociation) mediated the effect of panic reactions during trauma and subsequent PTSD symptoms. The mediation model indicated that panic reactions are linked to severity of subsequent PTSD via derealization, indicating a significant indirect relationship. Whereas peritraumatic derealization is associated with chronic PTSD symptoms, this relationship is influenced by initial acute panic responses.     

Exploring negative emotion in women experiencing intimate partner violence: shame, guilt, and PTSD

This study explored the association of shame and guilt with PTSD among women who had experienced intimate partner violence (IPV). Sixty-three women were assessed by a research clinic serving the mental health needs of women IPV survivors. Results indicated that shame, guilt-related distress, and guilt-related cognitions showed significant associations with PTSD but global guilt did not. When shame and guilt were examined in the context of specific forms of psychological abuse, moderation analyses indicated that high levels of both emotional/verbal abuse and dominance/isolation interacted with high levels of shame in their association with PTSD. Neither guilt-related distress nor guilt-related cognitions were moderated by specific forms of psychological abuse in their association with PTSD. These data support the conceptualization of shame, guilt distress, and guilt cognitions as relevant features of PTSD. Results are discussed in light of proposed changes to diagnostic criteria for PTSD.     

Cardiovascular reactivity to psychological stress in aerobically trained versus untrained mild hypertensives and normotensives

Cardiovascular reactivity to video game and mental arithmetic stressors was compared among three groups of men: aerobically trained mild hypertensives, untrained mild hypertensives, and a comparison group of untrained normotensives. Relative to the untrained hypertensives, the trained hypertensives reacted to the video game with marginally smaller systolic blood pressure and diastolic blood pressure, but there were no significant differences between these groups in reactivity during the mental arithmetic task. Comparisons between each hypertensive group and the normotensive group showed that blood pressure (BP) reactivity of normotensives during the video game was generally similar to that of trained hypertensives but smaller than that of untrained hypertensives. These results indicate that aerobic training, which has been found to reduce resting BP in mild hypertensives, may also exert a favorable impact in reducing cardiovascular reactivity of hypertensives during some stressful situations.     

Hemodynamic responses to active and passive coping tasks and the prediction of future blood pressure in Thai participants: A preliminary prospective cohort study

Cardiovascular responses to mental stress tests have been related to future blood pressure (BP) levels. However, most studies have been completed in North America and Europe; only one study has been conducted in Asia. Therefore, the study explored whether cardiovascular responses to mental stress predict future resting BP in Thailand. Hemodynamic measures were obtained from 101 healthy adults before, during and after mental arithmetic, a speech task, and a cold pressor task. A follow‐up assessment of resting BP was undertaken 1 year later. Results showed that Thais responded to standardized mental stress tasks with large and significant cardiovascular reactivity. Regression analyses indicated that, after adjustment for baseline BP and traditional risk factors, heightened systolic blood pressure (SBP) responses to mental arithmetic were associated with increased future SBP (ΔR² = .045). These findings suggest that BP reactivity predicts future BP and may play a role in the development of hypertension. In addition, Thais displayed large cardiovascular responses to standardized mental stress tasks, of a similar magnitude to previous studies of North Americans and Europeans.     

Emotional-processing in posttraumatic stress disorder II: startle reflex modulation during picture processing

This study examined the impact of a trauma-related stressor on subsequent emotional behavior in veterans with (n = 35) and without (n = 24) posttraumatic stress disorder (PTSD). Self-report and physiological responses, including acoustic startle, were recorded during viewing of emotionally evocative photographs at baseline and following exposure to trauma-related and non-trauma-related stressors. The 2 groups exhibited equivalent patterns of emotional response across self-report and physiological measures at baseline. In contrast, following the trauma challenge, participants with PTSD showed a pattern of startle modulation suggestive of greater defensive reactivity and reduced visual perceptual engagement. These findings, along with augmented corrugator EMG reactivity during the same interval, suggest that trauma-related reexperiencing primes subsequent negative emotional responding in individuals with PTSD.     

Cognitions in generalized anxiety disorder and panic disorder patients. A prospective approach.

Self-observations of cognitions during episodes of anxiety were examined in 38 patients with generalized anxiety disorder and 36 patients with panic disorder. Two independent observers who where blind to the diagnoses categorised the cognitions. The inter-rater reliability was high (mean kappa 0.82). The GAD-patients had significantly more cognitions in the following categories: interpersonal confrontation, competence, acceptance, concern about others and worry over minor matters, while the PD-patients had significantly more cognitions in the physical catastrophe category. Furthermore, GAD-patients with a comorbidity of social phobia reported more cognitions regarding social embarrassment than did GAD-patients with other or no (axis-I) comorbidity. The results of this study support the cognitive theory regarding the cognitive specificity of anxiety disorders. The implications of these results are discussed, along with the issues of reliability and validity of the instrument used.