Panic disorder: the role of the balance system

doi:10.1016/S0022-3956(01)00031-0

Journal of Psychiatric Research

Volume 35, Issue 5, September–October 2001, Pages 279-286

https://doi.org/10.1016/S0022-3956(01)00031-0 Get rights and content

Abstract

Experimental evidences suggest that Panic Disorder (PD) is characterized by abnormalities in respiratory and vestibular functions. We studied balance system function in patients with PD and its relationships with CO₂ reactivity and clinical characteristics. Nineteen patients with PD with/without agoraphobia underwent static posturography and the 35% CO₂ challenge. The severity of clinical symptomatology was measured by standardized psychometric scales. Patients were free of psychotropic medications during the 2 weeks before the study. Different investigators blind to each other carried out the CO₂ challenge, static posturography and clinical assessment. Nineteen age and sex-matched healthy controls underwent static posturography. Body sway velocity and length were significantly higher in panic patients than in controls and patients showed high percentages of abnormal scores. Patients with two or more abnormal scores on static posturography were significantly more agoraphobic than those with less than two. Abnormal posturography scores under the eyes-opened was related to high anticipatory anxiety, whereas those under eyes-closed was related to phobic avoidance. Symptomatological reactivity to CO₂ was significantly correlated to abnormal functions of the balance system in the eyes-closed condition. Our findings suggest that (1) many patients with PD (5–42%) have abnormalities in their balance system function compared with healthy controls (0–5%), (2) symptomatological reactivity to CO₂ and balance system function in patients with PD are correlated only in the eyes-closed condition and (3) there is a significant link between agoraphobic avoidance and subclinical abnormal function of the balance system network.

Introduction

Significant relationships between balance function disorders and panic disorder (PD) has been repeatedly reported (27, 28, 29, 48, 12, 14, 25, 50, 52, 53, 16, 19, 2). The studies into these relationships have focused on two main areas: vestibular abnormalities in patients with PD, and anxiety symptoms or disorders among patients with abnormalities in the vestibular system. Jacob and co-workers (26, 28) reported vestibular abnormalities in patients with PD who complained of dizziness. This finding has been replicated in patients with PD non-specifically selected for the presence of dizziness (48, 25, 32), where the abnormalities were not the expression of a full-blown vestibular disorder. Similarly, patients with vestibular disorders have psychiatric syndromes with a particular reference to PD and agoraphobia (Hallam and Stephens, 1985).

Yardley and co-workers (1995) reported an association between vestibular abnormalities and phobic avoidance. Jacob and co-workers (1996) showed that patients with PD and agoraphobia had more vestibular abnormalities than patients with PD but without agoraphobia, patients with depressive disorders or with anxiety disorders other than panic or healthy controls. We (Allevi et al., 1997) found a significant relationship between the presence of dizziness during panic attacks and agoraphobia. It seems that in some patients phobic avoidance might not be a mere consequence of panic attacks but rather the result of a more complex interaction.

Abnormalities in the respiratory function may play a central role in the pathogenetic mechanisms underlying PD and has been mainly associated with panic attacks (34, 8). Some observations have indicated that the vestibular and the respiratory systems may work in complex interrelationships with one another. Dizziness is one of the main symptoms induced by CO₂ inhalations (Perna et al., 1994a) and by hyperventilation (Fried and Grimaldi, 1993).

Balance and respiratory systems seem to influence two different aspects of panic disorder, respectively agoraphobia and panic attacks. Control centers of both, however, are located nearby in the brainstem with significant reciprocal influences and there is evidence of vestibular-respiratory functional interconnections (Furman et al., 1998). We hypothesize that balance function might play a role in the development of agoraphobia and that respiratory reactivity might influence this process. To test this hypothesis we evaluated the balance system function by posturography and respiratory reactivity by CO₂ inhalation test in a sample of patients with PD.

Section snippets

Subjects

Nineteen patients with PD with/without agoraphobia were included in the study [13 women and six men, mean age 27.1±9.1 years (17–46 years), age at onset: 20.1±4.8]. The patients were consecutively recruited over 8 months at the outpatient facilities of the Anxiety Disorders Clinical and Research Unit at San Raffaele Hospital in Milan. Eighteen patients (95%) admitted to the study had a lifetime history of agoraphobia. Since no normative data for the Italian general population on static

Results

The clinical characteristics of the sample and CO₂ reactivity are listed in Table 1. The scores on the psychometric scales and CO₂ reactivity tests equaled those of other patient populations with PD but were higher than those of healthy controls (42, 43, 44). The DHI scale score was higher than those of the general population (Guidetti, 1989) and similar to those of patients with peripheral vestibular system disorders (Mann et al., 1996).

MANOVA showed significant differences in static

Discussion

We have studied the balance system function in relation to respiratory abnormal reactivity in patients with PD. The results should be considered preliminary for two reasons. The sample size could create type II errors and the absence of comparison groups with other psychiatric disorders precludes discussion on the specificity of our findings. Moreover, static posturography measures postural sway, a valid indicator of the balance system function. However, this technique is relatively unspecific

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Panic disorder: the role of the balance system

Abstract

Introduction

Section snippets

Subjects

Results

Discussion

Journal of Psychosomatic Research

Journal of Anxiety Disorders

Journal of Psychiatry Research

Brain Research

Psychiatry Research

Trends in Neurological Sciences

Journal of Psychosomatic Research

Psychiatric Clinic of North America

Journal of Anxiety Disorder

Journal of Anxiety Disorder

Neuroscience Letters

Behavior Research and Therapy

Progress in Neurobiology

Psychiatry Research

Neuroscience Letters

Behavior Research and Therapy

Biological Psychology

Brain Research

Otolaryngology, Head and Neck Surgery

Computerized posturography, a development of the measuring system

Acta Otolaryngology (Stockh)

Dizziness, panic attacks and agoraphobia

European Neuropsychopharmacology

The Panic-Associated Symptoms Scale: measuring the severity of PD

Acta Psychiatrica Scandinavica

Vestibular nucleus projections to the parabrachial nucleus in rabbits: implications for vestibular influences on the autonomic nervous system

Experimental Brain Research

The panic respiration connection

Specification for building a vertical force platform designed for clinical stabilometry

Medicine and Biology Engineer Computing

Visual vertigo syndrome: clinical and posturography findings

Journal of Neurology and Neurosurgery

Panic in otolaryngology patients presenting with dizziness or hearing loss

American Journal of Psychiatry