Cortisol response under low intensity exercise during cognitive-behavioral therapy is associated with therapy outcome in Panic Disorder – an exploratory study

Investigating the salivary cortisol and heart rate response in patients with Panic Disorder and healthy controls and associate the physiologic stress responses with psychopathology, before and after cognitive-behavioral therapy

Rates and predictors of mental health care utilisation in patients following a prolonged stay on intensive care unit: a prospective cohort study

Objectives An acute critical illness and secondary complications may necessitate a prolonged treatment on an intensive care unit (ICU). As long-term consequences, ICU survivors may suffer from both physical and psychological sequelae. To improve the aftercare of these patients, the present study aimed to assess the use of mental healthcare and associated factors following prolonged ICU stay.Methods N=197 patients with a primary diagnosis of critical illness polyneuropathy/myopathy were enrolled within 4 weeks (T1) and interviewed three (T2) and six (T3) months following the transfer from acute-care to postacute ICU. Symptoms and a current diagnosis of major depression/post-traumatic stress disorder (PTSD) were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. The potential need for mental healthcare, its current and past use and reasons for non-use were raised.Results Full syndromal and subsyndromal major depression/PTSD were diagnosed in 8.3%/15.6% at T2, 12.2%/23.5% at T3. About 29% of the patients reported mental healthcare utilisation. Considering somatic complaints, more important was a common reason for the non-use of mental healthcare. Female gender, previous mental healthcare, number of sepsis episodes and pension receipt increased the chance for mental healthcare utilisation, a pre-existing mental disorder decreased it.Conclusion Every fourth patient surviving prolonged ICU treatement makes use of mental healthcare . Particularly male patients with pre-existing mental disorders should be targeted preventively, receiving specific psychoeducation about psychological long-term sequelae and mental healthcare options post-ICU.Trial registration numberDRKS00003386

Cortisol response under low intensity exercise during cognitive-behavioral therapy is associated with therapeutic outcome in panic disorder: An exploratory study

Objectives: Patients with Panic Disorder (PD) show an abnormal stress-induced functioning of the Hypothalamic-Pituitary-adrenal (HPA)-axis. Different protocols for stress induction are of rather low relevance for the psychotherapeutic treatment. In practice, interoceptive exposure is often realized as Low Intensity Exercise (LIE), as compared to an incremental cycle exercise test to exhaustion. Currently, it is not known, whether LIE displays an effective interoceptive stressor 1.) leading to a significant anxiety induction; 2.) a comparable HPA- and Sympathetic-Adreno-Medullar (SAM)-axis response in both patients and healthy controls; 3.) stress responses under LIE are associated with treatment outcomes. Patients and methods: N = 20 patients with PD and n = 20 healthy controls were exposed to ten minutes of LIE on an exercise bike. LIE was applied as part of the interoceptive exposure, during an intensive Cognitive-Behavioral Therapy (CBT) in a day clinic. Heart rate was monitored and salivary cortisol samples collected. Before and after the LIE, state anxiety/ arousal were assessed. In order to evaluate psychopathology, the Panic and Agoraphobia Scale, Mobility Inventory, Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire were applied, before (T1) and after five weeks (T2) of an intensive CBT. Results: LIE led to a significant and similar heart rate increase in both groups. Cortisol decreased over time in both groups, especially in male patients. A higher psychopathology before, and after CBT, was associated with a significantly lower cortisol response under LIE. Conclusions: In the present study, LIE led to a divergent stress response: while there was a significant heart rate increase, cortisol decreased over time, particularly in male patients. A lower reactivity of the HPA-axis seems to be associated with a lower treatment outcome, which may affect extinction based learning. The findings suggest, that interoceptive stimuli should be designed carefully in order to be potent stressors

Impact of post-traumatic stress symptoms on the health-related quality of life in a cohort study with chronically critically ill patients and their partners: age matters

Abstract Background Survivors of an acute critical illness with continuing organ dysfunction and uncontrolled inflammatory responses are prone to become chronically critically ill. As mental sequelae, a post-traumatic stress disorder and an associated decrease in the health-related quality of life (QoL) may occur, not only in the patients but also in their partners. Currently, research on long-term mental distress in chronically critically ill patient-partner dyads, using appropriate dyadic analysis strategies (patients and partners being measured and linked on the same variables) and controlling for contextual factors, is lacking. Methods The present study investigates the interdependence of post-traumatic stress symptoms (PTSS) and the health-related QoL in n = 70 dyads of chronically critically ill patients and their partners, using the Actor-Partner-Interdependence Model (APIM) under consideration of contextual factors (age, gender, length of partnership). The Post-traumatic Stress Scale (PTSS-10) and Euro-Quality of Life (EQ-5D-3L) were applied in both the patients and their partners, within up to 6 months after the transfer from acute care ICU to post-acute ICU. Results Clinically relevant post-traumatic stress symptoms were reported by 17.1% of the patients and 18.6% of the partners. Both the chronically critically ill patients and their partners with more severe post-traumatic stress symptoms also showed a decreased health-related QoL. The latter was more pronounced in male partners compared to female partners or female patients. In younger partners (≤ 57 years), higher values of post-traumatic stress symptoms were associated with a decreased QoL in the patients. Conclusions Mental health screening and psychotherapeutic treatment options should be offered to both the chronically critically ill patients and their partners. Future research is required to address the special needs of younger patient-partner dyads, following protracted ICU treatment. Trial registration German Clinical Trials Register No. DRKS00003386. Registered 13 November 201

Predictors of Major Depressive Disorder following Intensive Care of Chronically Critically Ill Patients

Objective. Major depressive disorder (MDD) is a common condition following treatment in the Intensive Care Unit (ICU). Long-term data on MDD in chronically critically ill (CCI) patients are scarce. Hence, the primary aim of the present study was to investigate the frequency and predictors of MDD after intensive care of CCI patients. Materials and Methods. In a prospective cohort study, patients with long-term mechanical ventilation requirements () were assessed with respect to a diagnosis of MDD, using the Structured Clinical Interview for DSM-IV, three and six months after the transfer from acute ICU to post-acute ICU. Sociodemographic, psychological, and clinical risk factors with values ≤ 0.1 were identified in a univariate logistic regression analysis and entered in a multivariable logistic regression model. A mediator analysis was run using the bootstrapping method, testing the mediating effect of perceived helplessness during the ICU stay, between the recalled traumatic experience from the ICU and a post-ICU MDD. Results. 17.6% () of the patients showed a full- or subsyndromal MDD. Perceived helplessness, recalled experiences of a traumatic event from the ICU, symptoms of acute stress disorder, and the diagnosis of posttraumatic stress disorder (PTSD) after ICU could be identified as significant predictors of MDD. In a mediator analysis, perceived helplessness could be proved as a mediator. Conclusions. Every fifth CCI patient suffers from MDD up to six months after being discharged from ICU. Particularly, perceived helplessness during the ICU stay seems to mainly affect the long-term evolvement of MDD. CCI patients with symptoms of acute stress disorder/PTSD should also be screened for MDD

Correction: Altered Olfactory Processing of Stress-Related Body Odors and Artificial Odors in Patients with Panic Disorder.

Background: Patients with Panic Disorder (PD) direct their attention towards potential threat, followed by panic attacks, and increased sweat production. Onés own anxiety sweat odor influences the attentional focus, and discrimination of threat or non-threat. Since olfactory projection areas overlap with neuronal areas of a panic-specific fear network, the present study investigated the neuronal processing of odors in general and of stress-related sweat odors in particular in patients with PD. Methods: A sample of 13 patients with PD with/ without agoraphobia and 13 age- and gender-matched healthy controls underwent an fMRI investigation during olfactory stimulation with their stress-related sweat odors (TSST, ergometry) as well as artificial odors (peach, artificial sweat) as non-fearful non-body odors. Principal Findings: The two groups did not differ with respect to their olfactory identification ability. Independent of the kind of odor, the patients with PD showed activations in fronto-cortical areas in contrast to the healthy controls who showed activations in olfaction-related areas such as the amygdalae and the hippocampus. For artificial odors, the patients with PD showed a decreased neuronal activation of the thalamus, the posterior cingulate cortex and the anterior cingulate cortex. Under the presentation of sweat odor caused by ergometric exercise, the patients with PD showed an increased activation in the superior temporal gyrus, the supramarginal gyrus, and the cingulate cortex which was positively correlated with the severity of the psychopathology. For the sweat odor from the anxiety condition, the patients with PD showed an increased activation in the gyrus frontalis inferior, which was positively correlated with the severity of the psychopathology. Conclusions: The results suggest altered neuronal processing of olfactory stimuli in PD. Both artificial odors and stress-related body odors activate specific parts of a fear-network which is associated with an increased severity of the psychopathology

Fatigue in chronically critically ill patients following intensive care - reliability and validity of the multidimensional fatigue inventory (MFI-20)

Background Fatigue often occurs as long-term complication in chronically critically ill (CCI) patients after prolonged intensive care treatment. The Multidimensional Fatigue Inventory (MFI-20) has been established as valid instrument to measure fatigue in a wide range of medical illnesses. Regarding the measurement of fatigue in CCI patients, the psychometric properties of the MFI-20 have not been investigated so far. Thus, the present study examines reliability and validity of the MFI-20 in CCI patients. Methods A convenience sample of n = 195 patients with Critical Illness Polyneuropathy (CIP) or Myopathy (CIM) were recruited via personal contact within four weeks (t1) following the transfer from acute care ICU to post-acute ICU at a large rehabilitation hospital. N = 113 (median age 61.1 yrs., 72.6% men) patients were again contacted via telephone three (t2) and six (t3) months following the transfer to post-acute ICU. The MFI-20, the Euro-Quality of Life (EQ-5D-3 L) and the Structured Clinical Interview for the Diagnostic and Statistical Manual of mental disorders DSM-IV (SCID-I) were applied within this prospective cohort study. Results The internal consistency Cronbach’s α was adequate for the MFI-total and all but the subscale Reduced Motivation (RM) (range: .50–.91). Item-to-total correlations (range: .22–.80) indicated item redundancy for the subscale RM. Confirmatory Factor analyses (CFAs) revealed poor model fit for the original 5-factor model of the MFI-20 (t2/t3, Confirmatory Fit Index, CFI = .783/ .834; Tucker-Lewis Index, TLI = .751/ .809; Root Mean Square Error of Approximation, RMSEA = .112/ .103). Among the alternative models (1-, 2-, 3-factor models), the data best fit to a 3-factor solution summarizing the highly correlated factors General −/ Physical Fatigue/ Reduced Activity (GF/ PF/ RA) (t2/ t3, CFI = .878/ .896, TLI = .846/ .869, RMSEA = .089/ .085, 90% Confidence Interval .073–.104/ .066–.104). The MFI-total score significantly correlated with the health-related quality of life (range: −.65-(−).66) and the diagnosis of major depression (range: .27–.37). Conclusions In the present sample of CCI patients, a reliable and valid factor structure of the MFI-20 could not be ascertained. Especially the subscale RM should be revised. Since the factors GF, PF and RA cannot be separated from each other and the unclear factorial structure in the present sample of CCI patients, the MFI-20 is not recommended for use in this context

Effects of Mental Stress Induction on Heart Rate Variability in Patients with Panic Disorder

Reduced heart rate variability (HRV) constitutes a widely used marker of cardiac autonomic inflexibility which has been linked to disorders such as panic disorder (PD). To date, the pathophysiological mechanisms whereby panic leads to attenuated HRV are not fully elucidated. We aimed to investigate the hypothesis that PD patients show pathological reactivity both in response to interoceptive and psychosocial stress in comparison to healthy individuals. We performed a controlled study on 38 patients diagnosed with PD [20 males and 18 females aged 35.55 ± 10.12 years, mean ± standard deviation] and 23 age and gender matched healthy control participants. Distress was induced using the Trier Social Stress Test (TSST) and the dexamethasone-corticotropin-releasing-hormone (DEX-CRH) test. We assessed HRV prior to, during, and post-stress induction using the root mean square successive differences (RMSSD) as well as spectral analysis (high frequency; HF and low frequency; LF). Statistical analyses revealed significant main effects of time for mean heart rate (HR), HF, LF (solely DEX-CRH), LFHF-ratio (solely TSST) and the RMSSD. Significant interaction effects were observed with more pronounced increases in mean HR (TSST) and LFHF-ratio (DEX-CRH) in the healthy control participants. No significant main effects of group were observed. Overall, our results indicate "normal" HRV parameters in patients with PD. The HRV of PD patients is no worse than that of healthy control participants since the HRV profiles were similar between the study groups. The current study is one of rather rarely published studies which was unable to show an influence of PD on HRV. Implications for future studies are under discussion