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.

Este estudo recebeu apoio do Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), processo nº 554411/2005-9. ResumoIntrodução: É crescente a produção científica brasileira na adaptação de instrumentos internacionais para avaliar ansiedade. A tradução e adaptação transcultural de escalas é um primeiro passo na obtenção de instrumentos válidos que permitam a comparação de diferentes populações. O objetivo do presente estudo foi traduzir e avaliar a equivalência semântica do Cardiac Anxiety Questionnaire, realizando um estudo piloto na população brasileira de diferentes níveis de escolaridade. Método: O processo de adaptação transcultural envolveu duas traduções e retrotraduções realizadas por avaliadores independentes, avaliação das versões e elaboração de uma versão síntese. Também examinamos os comentários dos participantes sobre a versão preliminar do questionário, os quais foram usados no desenvolvimento da versão final. Resultados: Para cada item do instrumento, apresentam-se os resultados das quatro etapas. Os participantes com maior grau de escolaridade não apresentaram dificuldades na compreensão do instrumento, tendo apenas apresentado sugestões controversas acerca do item 5. Entretanto, os participantes apenas com escolaridade em nível fundamental relataram dificuldades com os itens 2, 4, 6, 7, 10, 11 e 14. Algumas alterações semânticas foram realizadas com o intuito de facilitar a compreensão do instrumento. Conclusão: A utilização de duas versões de tradução e retrotradução, discussão sobre a versão síntese e a interlocução com a população-alvo proporcionaram maior segurança ao processo de equivalência semântica da versão final brasileira. Descritores: Estudos de validação, astenia neurocirculatória e coronariopatia. AbstractIntroduction: 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...

RESUMO -As relações entre habilidades sociais percebidas pelo cônjuge e satisfação conjugal foram investigadas. Cinquenta casais (n=100), com idades entre 29 a 69 anos e tempo de união entre sete e 38 anos, responderam à Escala de Satisfação Conjugal, ao Inventário de Habilidades Sociais Conjugais e ao Questionário de Empatia Conjugal. A análise de regressão múltipla apontou forte relação entre a empatia do cônjuge e a satisfação conjugal, seguida pela expressão de sentimentos e defesa dos próprios direitos. O número de filhos se correlacionou inversamente com a satisfação e as mulheres foram percebidas como mais empáticas. As habilidades sociais, especialmente a empatia, parecem ser facilitadores da satisfação conjugal. Recomenda-se o desenvolvimento dessas habilidades no tratamento de casais em crise.Palavras-chave: satisfação conjugal; casamento; habilidades sociais; empatia. The Relations between Marital Satisfaction and Social Skills Perceived in the SpouseABSTRACT -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 spouse's 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.

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.

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Panic disorder (PD) patients often report respiratory symptoms and tend to perform poorly during maximal cardiopulmonary exercise testing (CPX), at least partially, due to phobic anxiety. Thus, we hypothesized that a submaximal exercise variable, minimum VE/VO2 - hereafter named cardiorespiratory optimal point (COP) -, may be useful in their clinical assessment. Data from 2,338 subjects were retrospectively analyzed and 52 (2.2%) patients diagnosed with PD (PDG) (70% women; aged 48±13 years). PD patients were compared with a healthy control group (CG) precisely matched to number of cases, age and gender profiles. PDG was further divided into two subgroups, based on having achieved a maximal or a submaximal CPX (unwilling to continue until exhaustion). We compared COP, VO2 max, maximum heart rate (HR max) between PDG and CG, and also COP between maximal and submaximal PD subgroups. COP was similar between PDG and CG (21.9±0.5 vs. 23.4±0.6; p = 0.07), as well as, for PD subgroups of maximal and submaximal CPX (22.0±0.5 vs. 21.6±1.3; p = 0.746). Additionally, PD patients completing a maximal CPX obtained VO2 max (mL.kg−1.min−1) (32.9±1.57 vs 29.6±1.48; p = 0.145) and HR max (bpm) similar to controls (173±2.0 vs 168±2.7; p = 0.178). No adverse complications occurred during CPX. Although clinically safe, it is sometimes difficult to obtain a true maximal CPX in PD patients. Normalcy of cardiorespiratory interaction at submaximal effort as assessed by COP may contribute to reassure both patients and physicians that there is no physiological substrate for exercise-related respiratory symptoms often reported by PD patients.

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 CO 2 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 CO 2 , 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.Keywords: Panic disorder; Anxiety; Respiration; Hyperventilation; Carbon dioxide. ResumoMúltiplas anormalidades respiratórias podem ser encontradas em pacientes com transtornos de ansiedade, particularmente no transtorno de pânico (TP). Indivíduos com TP experimentam ataques de pânico inesperados, caracterizados por ansiedade, medo e diversos sintomas autonômicos e respiratórios. A estimulação respiratória é um fenômeno comum durante os ataques de pânico. A anormalidade respiratória mais citada em pacientes com TP é a sensibilidade aumentada para o CO 2 , que originou a hipótese de uma disfunção fundamental nos mecanismos fisiológicos de controle da respiração no TP. Há evidências de que pacientes com TP com sintomas respiratórios predominantes são mais sensíveis a testes respiratórios do que aqueles sem a manifestação de tais sintomas, representando um subtipo distinto. Pacientes com TP tendem a hiperventilar e a reagir com pânico como resposta a estimulantes respiratórios como o CO 2 , gerando uma ativação de um circuito de medo hipersensível. Apesar de a fisiologia respiratória desses pacientes permanecer normal, algumas evidências recentes apontam a presença de disfunções subclínicas na respiração e em outras funções relacionadas à homeostase corporal. O circuito do medo, composto pelo hipocampo, córtex pré-frontal medial, amígd...