Aline Sardinha

A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine.

Abstract This long-term extension of an 8-week randomized, naturalistic study in patients with panic disorder with or without agoraphobia compared the efficacy and safety of clonazepam (n = 47) and paroxetine (n = 37) over a 3-year total treatment duration. Target doses for all patients were 2 mg/d clonazepam and 40 mg/d paroxetine (both taken at bedtime). This study reports data from the long-term period (34 months), following the initial 8-week treatment phase. Thus, total treatment duration was 36 months. Patients with a good primary outcome during acute treatment continued monotherapy with clonazepam or paroxetine, but patients with partial primary treatment success were switched to the combination therapy. At initiation of the long-term study, the mean doses of clonazepam and paroxetine were 1.9 (SD, 0.30) and 38.4 (SD, 3.74) mg/d, respectively. These doses were maintained until month 36 (clonazepam 1.9 [SD, 0.29] mg/d and paroxetine 38.2 [SD, 3.87] mg/d). Long-term treatment with clonazepam led to a small but significantly better Clinical Global Impression (CGI)–Improvement rating than treatment with paroxetine (mean difference: CGI-Severity scale −3.48 vs −3.24, respectively, P = 0.02; CGI-Improvement scale 1.06 vs 1.11, respectively, P = 0.04). Both treatments similarly reduced the number of panic attacks and severity of anxiety. Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001). The efficacy of clonazepam and paroxetine for the treatment of panic disorder was maintained over the long-term course. There was a significant advantage with clonazepam over paroxetine with respect to the frequency and nature of adverse events.

Tapering clonazepam in patients with panic disorder after at least 3 years of treatment.

High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic disorder (PD) because of their rapid onset of action and good tolerability. However, there is concern about their potential to cause withdrawal symptoms. We aimed to develop a protocol for safely tapering off clonazepam in patients with PD who had been receiving treatment for at least 3 years. A specific scale for judging withdrawal was also developed, the Composite Benzodiazepine Discontinuation Symptom Scale. We selected 73 patients with PD who had been asymptomatic for at least 1 year and who wished to discontinue the medication. The trial consisted of a 4-month period of tapering and an 8-month follow-up period. The dosage of clonazepam was decreased by 0.5 mg per 2-week period until 1 mg per day was reached, followed by a decrease of 0.25 mg per week. The mean dosage at the start of tapering was 2.7 ± 1.2 mg/d. In total, 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol, and 19 (26.0%) of the patients needed another 3 months to be free of medication. Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches. The improvement in PD and general well-being was maintained during both the taper and follow-up phases. Clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. We recommend reducing the dosage of clonazepam after intermediate-term use by 0.25 mg/wk.

Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy.

Psychological factors such as stress and depression have already been established as primary and secondary cardiovascular risk factors. More recently, the role of anxiety in increasing cardiac risk has also been studied. The underlying mechanisms of increased cardiac risk in panic disorder patients seem to reflect the direct and indirect effects of autonomic dysfunction, as well as behavioral risk factors associated with an unhealthy lifestyle. Implications of the comorbidity between panic and cardiovascular disease include higher morbidity, functional deficits, increased cardiovascular risk, and poor adherence to cardiac rehabilitation or exercise programs. This article probes the most recent evidence on the association between coronary artery disease, anxiety and panic disorder, and discusses the potential role of incorporating regular physical exercise and cognitive behavioral therapy in the treatment of this condition.

Tradução e adaptação transcultural da versão brasileira do Questionário de Ansiedade Cardíaca

INTRODUCTION: There has been a growing interest in the cross-cultural application of psychological questionnaires to assess anxiety. The translation and cross-cultural adaptation of the original instrument is the first step in validating an instrument in a new population that will permit comparisons between different populations. The goals of this study were to translate the Cardiac Anxiety Questionnaire, assess its semantic equivalence, and perform a preliminary test with participants from the Brazilian population that were drawn from different educational backgrounds. METHOD: The cross-cultural adaptation process consisted of two translations and back translations performed by two independent evaluators; a critical evaluation of the two versions, and the development of a synthesized version. We also examined comments provided by participants on the preliminary version of the questionnaire and used them for the development of the final version. RESULTS: We report the results of the four stages for each item of the instrument. Participants with tertiary education had no difficulties comprehending the translated items of the questionnaire, only pointing item 5 as ambiguous. Participants from the lower educational level reported comprehension problems regarding items 2, 4, 6, 7, 10, 11 and 14. Some small changes were made in our first version to enhance comprehensibility. CONCLUSION: The use of two versions of translations, a critical examination of the two versions, and suggestions made by participants resulted in a final Brazilian version with a satisfactory degree of semantic accuracy and semantic equivalence with the original version.

Tradução e adaptação transcultural do Questionário de Atividade Física Habitual

CONTEXTO: Atualmente ha na literatura um crescente interesse na interface entre exercicio fisico e transtornos psiquiatricos. Apesar disso, ainda ha uma deficiencia de instrumentos de autorrelato para medir os niveis de atividade fisica dos pacientes. OBJETIVO: A traducao, a afericao da equivalencia semântica e uma aplicacao piloto (n = 30), sem pretensao psicometrica, do Questionario de Atividade Fisica Habitual, visando sua utilizacao na populacao brasileira de diferentes niveis de escolaridade. METODOS: O processo envolveu duas traducoes e retrotraducoes realizadas por avaliadores independentes, avaliacao das versoes seguida da elaboracao de uma versao sintese e pre-teste comentado. RESULTADOS: A maioria dos participantes (91%) nao apresentou dificuldades de compreensao com o questionario. Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Mais estudos sao necessarios para determinar a adequacao para populacoes de baixa escolaridade. Os autores recomendam que sujeitos menos instruidos sejam supervisionados ao preencher o questionario. CONCLUSOES: A utilizacao de duas versoes de traducao e retrotraducao, a discussao sobre a versao sintese e a interlocucao com a populacao-alvo proporcionam maior seguranca ao processo de equivalencia semântica.

As relações entre a satisfação conjugal e as habilidades sociais percebidas no cônjuge

This study investigated the association between the social skills perceived by the spouse and marital satisfaction. Fifty couples (n=100), aged from 29 to 69 and with relationship lasting from seven to 38 years, were asked to fill in the Marital Satisfaction Scale, the Marital Social Skills Inventory and the Marital Empathy Questionnaire. Multiple regression analysis revealed that spouses empathy was strongly correlated with marital satisfaction, followed by the expression of feelings and defense of own rights. The number of offspring was inversely correlated with satisfaction, and women were perceived by their partners as more empathic. The presence of social skills, particularly empathy, seems to be facilitators of marital satisfaction. Interventions directed to the development of social skills may be useful in the treatment of distressed couples.

Dismorfia muscular: análise comparativa entre um critério antropométrico e um instrumento psicológico

Psychiatric disorders related to body image distortions are highly associated with physical and psychological distress and significant social and ocupacional disfunction. Also, they are caracterized for inducing behaviors that can be harmful for the patients health. Muscle Dysmorfia (MD) is a subtype of Body Dysmorfic Disorder, marked by specific and recurrent worring about muscle appearance and hipertrophy. This disorder is significantly more prevalent in men and, despite the actual level of muscle hipertrophy, the subjects seek increasing their body mass by excessive weight lifting, engaging in hiperproteic diets and using anabolic substances. The present study aimed to evaluate the construct validity of an antropometric criteria (The B/P index - the ratio between the perimeter of the contracted arm and the perimeter of the leg), previously proposed, as an antropometric indicator to suspect of MD in weight lifters. A sample (n = 100) of male body builders, between 18 and 35 years old, were measured and responded the Muscle Appearance Satisfaction Scale (MASS). Their cineantropometric measures were also compared to the ones from another sample (n = 313), with similar demografic caracteristics, evaluated to start an exercise program. Data analysis sugest that a subjetc with B/P > 1 have a higher probability of presenting a score that would indicate MD in the MASS. This results indicate that the B/P index can be used as a valid antropometric criteria to help exercise professionals suspect of MD in individuals with B/P > 1 and reffer them to especialized professionals for diagnose and treatment.Psychiatric disorders related to body image distortions are highly associated with physical and psychological distress and significant social and ocupacional disfunction. Also, they are caracterized for inducing behaviors that can be harmful for the patients health. Muscle Dysmorfia (MD) is a subtype of Body Dysmorfic Disorder, marked by specific and recurrent worring about muscle appearance and hipertrophy. This disorder is significantly more prevalent in men and, despite the actual level of muscle hipertrophy, the subjects seek increasing their body mass by excessive weight lifting, engaging in hiperproteic diets and using anabolic substances. The present study aimed to evaluate the construct validity of an antropometric criteria (The B/P index - the ratio between the perimeter of the contracted arm and the perimeter of the leg), previously proposed, as an antropometric indicator to suspect of MD in weight lifters. A sample (n = 100) of male body builders, between 18 and 35 years old, were measured and responded the Muscle Appearance Satisfaction Scale (MASS). Their cineantropometric measures were also compared to the ones from another sample (n = 313), with similar demografic caracteristics, evaluated to start an exercise program. Data analysis sugest that a subjetc with B/P > 1 have a higher probability of presenting a score that would indicate MD in the MASS. This results indicate that the B/P index can be used as a valid antropometric criteria to help exercise professionals suspect of MD in individuals with B/P > 1 and reffer them to especialized professionals for diagnose and treatment.

Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications

Multiplas anormalidades respiratorias podem ser encontradas em pacientes com transtornos de ansiedade, particularmente no transtorno de pânico (TP). Individuos com TP experimentam ataques de pânico inesperados, caracterizados por ansiedade, medo e diversos sintomas autonomicos e respiratorios. A estimulacao respiratoria e um fenomeno comum durante os ataques de pânico. A anormalidade respiratoria mais citada em pacientes com TP e a sensibilidade aumentada para o CO2, que originou a hipotese de uma disfuncao fundamental nos mecanismos fisiologicos de controle da respiracao no TP. Ha evidencias de que pacientes com TP com sintomas respiratorios predominantes sao mais sensiveis a testes respiratorios do que aqueles sem a manifestacao de tais sintomas, representando um subtipo distinto. Pacientes com TP tendem a hiperventilar e a reagir com pânico como resposta a estimulantes respiratorios como o CO2, gerando uma ativacao de um circuito de medo hipersensivel. Apesar de a fisiologia respiratoria desses pacientes permanecer normal, algumas evidencias recentes apontam a presenca de disfuncoes subclinicas na respiracao e em outras funcoes relacionadas a homeostase corporal. O circuito do medo, composto pelo hipocampo, cortex pre-frontal medial, amigdala e projecoes do tronco cerebral, pode estar hipersensivel em pacientes com TP. Essa teoria pode explicar porque os medicamentos e a terapia cognitivocomportamental sao claramente eficazes. Nosso objetivo foi revisar a relacao entre respiracao e TP, especialmente o subtipo respiratorio de TP e a sindrome da hiperventilacao, focalizando os testes respiratorios, bem como as hipoteses mecanisticas e as implicacoes farmacologicas dessa relacao.Multiple respiratory abnormalities can be found in anxiety disorders, especially in panic disorder (PD). Individuals with PD experience unexpected panic attacks, characterized by anxiety and fear, resulting in a number of autonomic and respiratory symptoms. Respiratory stimulation is a common event during panic attacks. The respiratory abnormality most often reported in PD patients is increased CO2 sensitivity, which has given rise to the hypothesis of fundamental abnormalities in the physiological mechanisms that control breathing in PD. There is evidence that PD patients with dominant respiratory symptoms are more sensitive to respiratory tests than are those who do not manifest such symptoms, and that the former group constitutes a distinct subtype. Patients with PD tend to hyperventilate and to panic in response to respiratory stimulants such as CO2, triggering the activation of a hypersensitive fear network. Although respiratory physiology seems to remain normal in these subjects, recent evidence supports the idea that they present subclinical abnormalities in respiration and in other functions related to body homeostasis. The fear network, composed of the hippocampus, the medial prefrontal cortex, the amygdala and its brain stem projections, might be oversensitive in PD patients. This theory might explain why medication and cognitive-behavioral therapy are both clearly effective. Our aim was to review the relationship between respiration and PD, addressing the respiratory subtype of PD and the hyperventilation syndrome, with a focus on respiratory challenge tests, as well as on the current mechanistic concepts and the pharmacological implications of this relationship.

Cognitive–behavioral therapy for bipolar disorder

Bipolar disorder is one of the most serious and prevalent psychiatric disorders. The aim of the present article is to review the efficiency of cognitive–behavioral therapy (CBT) for bipolar patients. Some studies show consistent evidence that cognitive therapy, concomitant to psycho-education and pharmacological treatment, offers efficacy in different phases of the disease. In most of the studies, patients undergoing CBT showed improvements in quality of life, with a reduction in both frequency and duration of mood episodes, as well as higher degrees of compliance and fewer hospitalizations. More studies are required to prove the effectiveness of CBT for bipolar disorder in the context of standardizing diagnostic criteria and measuring instruments to evaluate the disorder’s different phases and severity.

Psychiatric disorders and cardiac anxiety in exercising and sedentary coronary artery disease patients: a case-control study

Regular physical exercise has been shown to favorably influence mood and anxiety; however, there are few studies regarding psychiatric aspects of physically active patients with coronary artery disease (CAD). The objective of the present study was to compare the prevalence of psychiatric disorders and cardiac anxiety in sedentary and exercising CAD patients. A total sample of 119 CAD patients (74 men) were enrolled in a case-control study. The subjects were interviewed to identify psychiatric disorders and responded to the Cardiac Anxiety Questionnaire. In the exercise group (N = 60), there was a lower prevalence (45 vs 81%; P < 0.001) of at least one psychiatric diagnosis, as well as multiple comorbidities, when compared to the sedentary group (N = 59). Considering the Cardiac Anxiety Questionnaire, sedentary patients presented higher scores compared to exercisers (mean ± SEM = 55.8 ± 1.9 vs 37.3 ± 1.6; P < 0.001). In a regression model, to be attending a medically supervised exercise program presented a relevant potential for a 35% reduction in cardiac anxiety. CAD patients regularly attending an exercise program presented less current psychiatric diagnoses and multiple mental-related comorbidities and lower scores of cardiac anxiety. These salutary mental effects add to the already known health benefits of exercise for CAD patients.