Stress Triggers Slow, Steady Rise in Panic Symptoms

Deborah Brauser

June 23, 2011

June 23, 2011 — Instead of an immediate, acute reaction, stressful life events (SLEs) in patients with panic disorder (PD) can cause a gradual, but steady, increase in panic symptoms over time, new research suggests.

Investigators at Brown University note they expected to find that panic symptoms would spike immediately after a stressful event and then taper off, but this was not the case.

In analysis of more than 400 patients with PD and panic disorder with agoraphobia (PDA) from the Harvard/Brown Anxiety Research Program (HARP) study, panic symptoms worsened progressively over 3 months after participants experienced specific SLEs, including serious family discord or being fired.

Dr. Ethan Moitra

"We actually looked at a number of different categories of SLEs, ranging from those that happen less frequently, such as criminal or legal stressors like getting arrested, to those that are more common, such as arguments or death of a family member," lead study author Ethan Moitra, PhD, from the Department of Psychiatry and Human Behavior at the Alpert Medical School of Brown University, Providence, Rhode Island, told Medscape Medical News.

"And we found that there really wasn't an immediate impact for any of these events, which was definitely surprising. However, we did find that certain types of events really have this gradual, residual effect on how the participants' panic symptoms changed," said Dr. Moitra.

He added that panic attacks are currently defined as a physiologic, stressful response from the body that seems to come out of the blue.

"What this study tells clinicians is that they need to be aware that, although people may have an immediate reaction, be vigilant in keeping track of how patients are doing over the next few months after the event, and perhaps even longer," said Dr. Moitra.

"In other words: watch out! After these bad things happen and the dust settles, don't assume the person is going to be okay and back to what their baseline was. They're actually at risk for getting even worse."

The study was published online June 11 in the Journal of Affective Disorders.

Long-Term Impact

It is estimated that PD and PDA will affect 3.7% and 1.1% of the population over a lifetime.

"Extant research shows a relationship between SLEs and the onset of panic attacks in adults who ultimately develop PD/PDA," write the investigators. "However, limited attention has been paid to how SLEs might affect the severity of panic symptoms in individuals."

HARP is a long-term, observational study of 711 patients older than 18 years with a current or past history of anxiety disorders enrolled at 11 hospitals in Massachusetts and Rhode Island.

"During that study, we were following the occurrence of [SLEs], and we became interested in how that may potentially impact a person's mental health. We knew from previous research that these events are important, but we wanted to take it a step further and get a better sense of how they affect the course of the disorder," said Dr. Moitra.

For this analysis, the investigators evaluated HARP data for 418 adults with PD/PDA (67.7% female; 98.1% white; mean age, 40.3 years).

Data were assessed 12 weeks before the occurrence of SLEs (to evaluate the effects of anticipating a scheduled SLE, such as a divorce) and up to 12 weeks afterwards.

The psychiatric status rating from the Longitudinal Interval Follow-up Evaluation was used to assess severity of panic symptoms.

The Short Life Events and Difficulties Scale interview was used to collect information about stressful experiences in 9 domains: school, work, love, health, crime/legal, family/friends/household, residence, death, and childbirth. Events judged to be positive, such as changing a job for a better one, were not included.

Stay Vigilant

Results showed no significant change in panic symptom severity in the 12 weeks before the SLE occurred or in the week in which it occurred.

However, the study showed that panic symptoms steadily worsened in the 12 weeks following a stressful family/friends/household or work-related event (P = .001 and P = .015, respectively).

Common family/friend/household SLEs included stopping seeing a close family member or having a serious argument with a loved one. Serious work-related SLEs, in addition to being laid off, included changing jobs for a worse one and being demoted.

Panic symptoms did not significantly worsen after 12 weeks for participants experiencing SLEs in other categories evaluated.

"I would recommend that physicians stay vigilant in the short term after an event but also watch out in the long term because patients will be at risk much further out than what is intuitively expected," said Dr. Moitra.

The investigators add that studying SLEs may have important clinical implications.

"The design of interventions...and coping processes in adults begins with a basic knowledge of their differential response to stressors. Clinicians may then tailor risk assessments and treatments based on the individual's vulnerability to the pernicious effects of SLEs," they write.

Dr. Moitra reported his team has just completed a new study, currently under review, that evaluates how SLEs affect those with general anxiety disorder and how those events can put people at risk for relapse.

Pluses and Minuses

Dr. Stefan G. Hofmann

"This was an interesting study. It's not a tsunami that is screaming over the scientific field, but it is reasonable with pluses along with several weaknesses," Stefan G. Hofmann, PhD, professor of psychology at Boston University in Massachusetts and director of the university's Psychotherapy and Emotion Research Laboratory, told Medscape Medical News.

"The pluses include that it is a longitudinal study that is based on a large number of subjects that test an important theoretical model. It examined to what extent [SLEs] contribute to the symptomatology of this disorder," said Dr. Hofmann, who was not involved with this research.

In 2001, he was lead author of a study ( Depress Anxiety . 2001;13:101-102) that compared potentially traumatizing events in PD and other anxiety disorders. They found no significant differences in the number or type of events between the disorders.

Concerns with this study noted by Dr. Hofmann included that PD and PDA were added together in the study population; the investigators only examined 12 weeks prior and after an SLE, "which is sort of arbitrary" and "we really can't make a generalization as to how specific this is to panic disorder because they only examined panic disorder. So the specificity isn't there."

He added that the definition of trauma used was also "a bit problematic."

However, Dr. Hofmann said that the finding that panic symptoms increase steadily not acutely after an SLE makes the study a valuable contribution to the literature.

"It showed that there is a delayed effect to stressful events. And clinicians need to be aware that a stressor that just happened may not have an immediate impact. Also, if a person's symptomatology is worsening, it's worth examining what happened not just recently but also months ago," he concluded.

The HARP study is funded by a grant from the National Institute of Mental Health (NIMH). The study authors report several disclosures; a full list is included in the original article. Dr. Hofmann reported no direct conflicts with this analysis but reported having received previous funding from the NIMH.

J Affect Disord. Published online June 11, 2011. Abstract

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