Psychobiological Aspects of Panic Disorder

Anxiety is a useful warning sign that helps an individual face potential or real danger. At appropriate levels, it serves as a warning for the presence of internal or external threats, causing a person to be alert and prepare to deal appropriately with such situations. Moreover, moderate levels of anxiety can lead to improved performance in several activities. However, anxiety becomes pathological when its duration is excessively long or its intensity is extremely high and leads to significant suffering and distress. In such cases, anxiety is appropriately described as part of a pathological response, characterizing an anxiety disorder. The historical concept of a unitary anxiety disorder has been replaced by a heterogeneous group of psychopathologies with different etiologies. Panic disorder is a complex anxiety disorder that involves both recurrent, unexpected panic attacks, and persistent concern about having additional attacks. The present chapter reviews current psychobiological perspectives in the etiology and treatment of panic disorder. The first section describes the current classification of this anxiety disorder. We then explore possible neural circuitry associated with panic disorder. Finally, the chapter addresses current treatment approaches, considering the efficacy of different forms of psychotherapy and pharmacological treatments

The relationship between obesity and quality of life in Brazilian adults

The incidence of obesity has reached epidemic proportions, affecting 30% of the adult population globally. During the last decade, the rising rates of obesity in developing countries has been particularly striking. One potential consequence of obesity is a decline in quality of life. Thus, the objective of the present study was to investigate the possible relationship between obesity, defined by body mass index (BMI), and quality of life, evaluated using the short version of the World Health Organization Quality of Life (WHOQOL) scale in a Brazilian population. The sample consisted of 30 men and 30 women, divided into three groups according to BMI: normal weight, obese, and morbidly obese. All of the subjects responded to the WHOQOL inventories. The results indicated that the groups with lower BMIs had better quality of life than the groups with higher BMIs. Being overweight interfered with quality of life equally in both sexes, with no difference found between men and women. The results indicate the necessity of multidisciplinary care of obese individuals

Self-awareness in dementia: a taxonomy of processes, overview of findings, and integrative framework

Purpose of Review: Self-awareness, the capacity of becoming the object of one’s own awareness, has been a frontier of knowledge, but only recently scientific approaches to the theme have advanced. Self-awareness has important clinical implications, and a finer understanding of this concept may improve the clinical management of people with dementia. The current article aims to explore self-awareness, from a neurobiological perspective, in dementia. Recent Findings: A taxonomy of self-awareness processes is presented, discussing how these can be structured across different levels of cognitive complexity. Findings on self-awareness in dementia are reviewed, indicating the relative preservation of capacities such as body ownership and agency, despite impairments in higher-level cognitive processes, such as autobiographical memory and emotional regulation. Summary: An integrative framework, based on predictive coding and compensatory abilities linked to the resilience of self-awareness in dementia, is discussed, highlighting possible avenues for future research into the topic

Metacognitive Improvements Following Cognitive Stimulation Therapy for People with Dementia: Evidence from a Pilot Randomized Controlled Trial

OBJECTIVES: Impaired self-awareness is a common feature of dementia, with considerable clinical impact. Some therapeutic strategies such as cognitive stimulation and psychotherapy have been suggested to mitigate loss of awareness. Nevertheless, evidence of intervention improving awareness of deficits is scarce. The present study aims to explore the impact of a Brazilian adapted version of Cognitive Stimulation Therapy (CST-Brasil), an evidence-based psychosocial intervention for people with dementia (PwD), on the level of awareness, reporting here a secondary outcome of a pilot randomized controlled trial. METHODS: 47 people with mild to moderate dementia attending an out-patient unit were randomly allocated to CST (n = 23) or treatment as usual (TAU) (n = 24) across 7 weeks, in a pilot randomized controlled trial. Awareness was measured before and after the intervention. RESULTS: Results indicated that people in both groups increased in overall awareness of the disease, but only those receiving CST exhibited improvements of awareness of cognitive ability. CONCLUSIONS: These findings suggest that CST may also improve metacognitive abilities in PwD, which could potentially be applied to other settings with beneficial effects. CLINICAL IMPLICATIONS: Considering the negative impacts of anosognosia, CST-led improvements in awareness have the potential to benefit PwD and their caregivers

Predictors of functional impairment and awareness in people with dementia, mild cognitive impairment and healthy older adults from a middle-income country

ObjectiveTo investigate the demographic, clinical and cognitive correlates of functional capacity and its awareness in people with dementia (PwD; n = 104), mild cognitive impairment (PwMCI; n = 45) and controls (healthy older adults; n = 94) in a sample from a middle-income country.MethodsDementia and MCI were diagnosed, respectively, with DSM-IV and Petersen criteria. Performance in activities of daily living (ADL) at three different levels [basic (The Katz Index of Independence), instrumental (Lawton instrumental ADL scale) and advanced (Reuben’s advanced ADL scale)], measured through self- and informant-report, as well as awareness (discrepancy between self- and informant-report), were compared between groups. Stepwise regression models explored predictors of ADL and their awareness.ResultsPwD showed impairment in all ADL levels, particularly when measured through informant-report. No differences were seen between controls and PwMCI regardless of measurement type. PwD differed in awareness of instrumental and basic, but not of advanced ADL, compared to controls. Age, gender, education and fluency were the most consistent predictors for ADL. Diagnosis was a significant predictor only for instrumental ADL. Awareness of basic ADL was predicted by memory, and awareness of instrumental ADL was predicted by general cognitive status, educational level, and diagnosis.ConclusionResults reinforce the presence of lack of awareness of ADL in PwD. Use of informant-reports and cognitive testing for fluency are suggested for the clinical assessment of ADL performance. Finally, assessment of instrumental ADL may be crucial for diagnostic purposes

Experiences of cognitive stimulation therapy (CST) in Brazil: a qualitative study of people with dementia and their caregivers

Objectives: There is a lack of investment in psychosocial treatments for people with dementia in Brazil. Cognitive Stimulation Therapy (CST) is a group-based intervention that has shown to have benefits on activities of daily living and mood for people with dementia in Brazil. This study aims to explore the experiences and perceived changes following CST groups. Methods: Individual interviews were conducted with the participants of the group (n = 12) and their caregivers (n = 11). Framework analysis was used to inspect the data. Results: Two main themes have emerged: ‘Personal benefits of being part of the group’, containing two subthemes: ‘Benefits for caregivers’ and ‘Benefits for person with dementia’ and ‘Day-to-day changes’, containing seven subthemes; ‘Memory’, Sociability’, ‘Language’, ‘Mood’, ‘Orientation’, ‘Everyday activities’ and ‘Behavioural and psychological symptoms’. Conclusion: Results suggest that CST groups led to perceived personal benefits for the people with dementia and caregivers and that there are perceived changes for the participants of the groups

Understanding Alzheimer's disease as a disorder of consciousness.

People with Alzheimer's disease (AD) demonstrate a range of alterations in consciousness. Changes in awareness of cognitive deficit, self-awareness, and introspection are seen early in AD, and dysfunction of awareness and arousal progresses with increasing disease severity. However, heterogeneity of deficits between individuals and a lack of empirical studies in people with severe dementia highlight the importance of identifying and applying biomarkers of awareness in AD. Impairments of awareness in AD are associated with neuropathology in regions that overlap with proposed neural correlates of consciousness. Recent developments in consciousness science provide theoretical frameworks and experimental approaches to help further understand the conscious experience of people with AD. Recognition of AD as a disorder of consciousness is overdue, and important to both understand the lived experience of people with AD and to improve care

A new approach for developing “implementation plans” for cognitive stimulation therapy (CST) in low and middle-income countries: Results from the CST-International study

Background: Even with a strong evidence base, many healthcare interventions fail to be translated to clinical practice due to the absence of robust implementation strategies. For disorders such as Alzheimer's disease and other dementias, access to evidence-based interventions beyond research settings is of great importance. Cognitive Stimulation Therapy (CST) is a brief, group-based intervention, with consistent evidence of effectiveness. Methods: An implementation focused, three-phase methodology was developed using extensive stakeholder engagement. The methods resulted in a standardized Implementation Plan for the successful translation of CST from research to practice. The methodology was developed using the Consolidated Framework for Implementation Research (CFIR) and refined in three countries that vary in levels of economic development and healthcare systems (Brazil, India and Tanzania. Results: Five Implemention Plans for CST were produced. Each plan contained implementation strategies and action plans devised in conjunction with policy professionals, healthcare professionals, people with dementia and family carers, and an international team of researchers and clinicians. Conclusion: This novel methodology can act as a template for implementation studies in diverse healthcare systems across the world. It is an effective means of devising socio-culturally informed Implementation Plans that account for economic realities, health equity and healthcare access

Mixed methods implementation research of cognitive stimulation therapy (CST) for dementia in low and middle-income countries: study protocol for Brazil, India and Tanzania (CST-International)

INTRODUCTION In low/middle-income countries (LMICs), the prevalence of people diagnosed with dementia is expected to increase substantially and treatment options are limited, with acetylcholinesterase inhibitors not used as frequently as in high-income countries (HICs). Cognitive stimulation therapy (CST) is a group-based, brief, non-pharmacological intervention for people with dementia that significantly improves cognition and quality of life in clinical trials and is cost-effective in HIC. However, its implementation in other countries is less researched. This protocol describes CST-International; an implementation research study of CST. The aim of this research is to develop, test, refine and disseminate implementation strategies for CST for people with mild to moderate dementia in three LMICs: Brazil (upper middle-income), India (lower middle-income) and Tanzania (low-income). METHODS AND ANALYSIS Four overlapping phases: (1) exploration of barriers to implementation in each country using meetings with stakeholders, including clinicians, policymakers, people with dementia and their families; (2) development of implementation plans for each country; (3) evaluation of implementation plans using a study of CST in each country (n=50, total n=150). Outcomes will include adherence, attendance, acceptability and attrition, agreed parameters of success, outcomes (cognition, quality of life, activities of daily living) and cost/affordability; (4) refinement and dissemination of implementation strategies, enabling ongoing pathways to practice which address barriers and facilitators to implementation. ETHICS AND DISSEMINATION Ethical approval has been granted for each country. There are no documented adverse effects associated with CST and data held will be in accordance with relevant legislation. Train the trainer models will be developed to increase CST provision in each country and policymakers/governmental bodies will be continually engaged with to aid successful implementation. Findings will be disseminated at conferences, in peer-reviewed articles and newsletters, in collaboration with Alzheimer's Disease International, and via ongoing engagement with key policymakers