Panic disorder: from psychopathology to treatment Disturbo di panico: dalla psicopatologia alla terapia 1. Functional psychopathology 1.1 Clinical complexity and simplicity in panic disorder

Summary Key words Panic disorder • Panic attacks • Drug treatment • SSRI • Psychopathology • CBT Correspondence Giampaolo Perna, Department of Clinical Neurosciences, Suore Ospedaliere -Villa San Benedetto Menni, Albese con Cassano (CO), Italy • E-mail: pernagp@tin.it Functional psychopathology Clinical complexity and simplicity in panic disorder Panic disorder (PD) affect approximately 3-4% of general population, mostly women with an age of onset around 20-25 years 1 and it is associated with a significant worsening quality of life 2 3 . In addition, PD is associated with an high use of health care services 4 and a low productivity due to an increased disability 5 and many days off of work 3 . The choice of an appropriated treatment involves a correct diagnostic process. The identification of nuclear psychopathological phenomena, as the central organizing clinical elements, and the secondary psychopathological events becomes a key factor of the diagnostic process. Diagnostic and Statistic Manual of Mental Disorder (DSM) IV revision 6 can provide some general guidelines for the diagnostic process, but is still insufficient for a therapeutic program when the aim is a full recovery of a normal life. The clinical picture of PD includes a constellation of mental phenomena that influence negatively patient's quality of life and his functioning: panic attacks, agoraphobia, anticipatory anxiety, depression, anxiolytics and alcohol abuse and hypochondria. When we organise the described complexity of the clinical picture into the so called "panic march" Clinical organizing principles beyond DSM The central therapeutic action should be focused on the complete prevention of panic attacks' recurrence. The phenomenology of panic attacks is far from being simple to describe as it is generally supposed. If the unexpected appearance of a strong distress, more physical than men- 83 Panic disorder: from psychopathology to treatment their soften expressions and the ability to distinguish them from acute anxiety phenomena or fear are crucial for a correct comprehension of PD and evaluation of the efficacy of the therapeutic intervention Other studies suggest the validity of new pharmacological treatments for the potentiation of behavioural systematic desensitization 11 . Agoraphobia is a complex phenomenon, which most of the time is a defensive response to panic attacks, so we need to keep in mind that the first intervention must be addressed to the blockade of the recurrence of panic attacks. When we talk about agoraphobia we can't forget protective behaviours, such as dependence from a phobic partner, that persist until panic attacks are gone. In order to complete clinical picture of PD it is important to underline the presence of hypochondria, especially when a obsessive compulsive spectrum is present in the tal, without an organic and demonstrable pathology, set down for a panic attack. This phenomenon could be very heterogeneous in the presentation, severity and features. Panic attacks are characterized by its unexpected presentation (PA unexpected) or at least not completely predictable (PA predisposed) while both the intensity, and the number of symptoms are not central in their clinical definition. Panic attacks are the expression of the basic pathological mechanism activity underlying PD. Beyond classical panic attacks, there are two other phenomenology events, harder to recognize, that are still the expression of the basic pathological mechanism: we can call them "abortion" of panic attack or "panic attack shadow". The first one indicates the sensation of an imminent appearance of a panic attack with no clinical manifestation, the second one, even finer, is the expression of the instability of the homeostatic system supposed to be the biological roots underlying the vulnerability to panic attacks and that manifest itself with abnormal somatic sensations, sub continuous, mainly involving cardiac, respiratory and postural systems that maintain a state of somatic alarm. It is not easy to distinguish if this last phenomenon is the expression of heightened attention to the soma due to the activation of the emotional memory of the attacks, or if it is the expression of activation of somatic alarm system still dysfunctional. Finally it is very important to distinguish panic attacks from acute anticipatory anxiety (situational panic attacks); the latter is a secondary response to unexpected panic and they should not be considered the main target of drug treatment. The identification of panic attacks and while there could be some differences in their half life, side effects profile and interaction with other drugs. Some experimental data, however, have shown that one month treatment with fluvoxamine have led to worse results in patients with a respiratory subtype panic compared to paroxetine, sertraline, imipramine and clomipramine Selective serotonin and noradrenaline reuptake inhibitors Venlafaxine extended release is the only drug of this category that has been recommended for PD since to date there are no systematic data available supporting the use of other SNRI. Venlafaxine showed anti panic properties both in placebo-controlled randomized studies and comparative studies with paroxetine 22 23 and was able to decrease CO2 hyperreactivity in patients with PD 24 . Venlafaxine is usually well tolerated with an efficacy and a side effects profile comparable to those of SSRI, even if a small group of individuals could develop arterial hypertension, an effect dose dependent and related to the immediate release formulation. Tricyclic antidepressants Clinical studies supported the efficacy of clomipramine in PD, comparable to SSRI's on