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Der Schmerz 36(1), 19-29 (2022). doi:10.1007/s00482-021-00596-9, Published by Springer, Berlin ; Heidelberg

Wie lässt sich die Wirksamkeit der Kognitiven Verhaltenstherapie (KVT) für Angststörungen noch weiter steigern? Dieser Frage ist die Wissenschaft in letzter Zeit verstärkt nachgegangen. Neben pharmakologischen und psychotherapeutischen Augmentationsstrategien scheint auch der Einsatz von körperlicher Aktivität eine vielversprechende Herangehensweise bei der Behandlung von Angst zu sein. Zahlreiche empirische Studien bestätigen, dass körperliche Aktivität Angst reduzieren sowie den Prozess der Angstextinktion unterstützen kann. Das Ziel dieser randomisierten kontrollierten Multicenter-Studie war es, zu untersuchen, ob körperliche Aktivität vor in-vivo Exposition die Wirksamkeit einer KVT bei Panikstörung mit Agoraphobie verbessern kann. Alle Proband*innen erhielten eine manualisierte KVT mit fünf Expositionssitzungen. Unmittelbar vor jeder Exposition wurde ein 30-minütiges Laufbandtraining absolviert. Die Experimentalgruppe betätigte sich bei moderater Intensität (entsprechend 70 % der maximalen Sauerstoffaufnahme), während die Kontrollgruppe bei niedriger Intensität (30 % der maximalen Sauerstoffaufnahme) körperlich aktiv war. Die Assessments fanden vor (Baseline) und nach (Post) der Behandlung sowie sechs Monate nach Behandlungsende (Follow-up) statt. Als primäre Endpunkte wurden die Hamilton-Angst-Skala (Ham-A) sowie das Mobilitätsinventar eingesetzt. Als sekundäre Endpunkte dienten die Panik- und Agoraphobie-Skala, Fragebögen zu angstbezogenen Kognitionen und körperbezogenen Ängsten sowie der EuroQol zur Erfassung der gesundheitsbezogenen Lebensqualität. An drei Studienstandorten wurden insgesamt 77 Proband*innen mit einer Panikstörung mit Agoraphobie in die Studie aufgenommen und auf die beiden Bedingungen randomisiert. Über beide Bedingungen hinweg zeigen sich von Baseline zu Post signifikante Verbesserungen in allen eingesetzten Messinstrumenten. Varianzanalysen mit Messwiederholung erbringen jedoch keine signifikanten Interaktionseffekte zwischen Bedingung und Zeit. Nichtsdestotrotz deutet ein Trend in Richtung eines signifikanten Interaktionseffekts für die Ham-A auf eine größere Symptomverbesserung in der Experimentalgruppe hin (f[1, 74] = 4.15, p = .045, α = .025). Diese Überlegenheit der Experimentalgruppe ist zum Follow-up Zeitpunkt nicht mehr zu beobachten, da die Kontrollgruppe von Post zu Follow-up eine signifikante Ham-A-Verbesserung erreicht und somit aufholt. Folglich beenden beide Bedingungen die Studienteilnahme mit vergleichbaren Ergebnissen. Diese Befunde deuten darauf hin, dass körperliche Aktivität vor Expositionssitzungen die Wirksamkeit der KVT beschleunigen kann. Ein solcher Effekt würde bedeuten, dass die Betroffenen das zu erwartende Therapieergebnis in kürzerer Zeit erreichen, was klinisch u.a. eine schnellere Reduktion des Leidensdrucks sowie eine frühzeitigere Wiederherstellung der Mobilität bedeuten und damit auch eine ökonomische Entlastung darstellen würde. Zu den Stärken dieser Studie zählen u.a. der Einsatz einer Kontrollgruppe, die größtmögliche Vergleichbarkeit der Bedingungen, die relativ große Stichprobe, die Randomisierung mit Verblindung, die standardisierte Diagnosestellung sowie die Intention-to-treat-Analyse. Nichtsdestotrotz sollten für die Interpretation der Ergebnisse einige Einschränkungen berücksichtigt werden wie die hohe Dropout-Rate sowie die relativ kleine Anzahl an Trainingseinheiten., Lately, increasing the effectiveness of the cognitive-behavioral therapy (CBT) for anxiety disorders has become a focus of scientific research. Next to pharmacological and psychotherapeutic augmentation physical activity appears to be promising. As shown in numerous empirical findings the effects of physical activity are to reduce anxiety and to improve the process of fear extinction. The aim of this randomized controlled multicenter trial was to examine whether physical activity prior to in-vivo exposure can improve the outcome of a CBT for patients with panic disorder with agoraphobia (PD/AG). All participants received an evidence-based manualized CBT including five exposure sessions. Prior to each exposure a 30-minute treadmill task was accomplished. The experimental condition completed this task at moderate intensity (70 % of the individual maximal oxygen uptake [VO2max]) while the control condition was active at low intensity (30 % VO2max). Assessments took place before (baseline), after (post) and six months after the treatment (follow-up). The Hamilton-Anxiety-Scale (Ham-A) and the Mobility-Inventory served as primary outcome measures. As secondary outcome measures the Panic- and Agoraphobia-Scale, Agoraphobic-Cognitions-Questionnaire, Body-Sensations-Questionnaire and the EuroQol for assessing the health-related quality of life were used. At three study centers 77 patients with PD/AG were included in this trial and randomized to one of the two conditions. Beyond the two conditions significant improvements in all measurements are evident from baseline to post. Repeated-measures analyses of variance find no significant interaction effects between condition and time. However, a trend towards a significant interaction effect in the Ham-A points to a bigger symptom reduction in the experimental group (f[1, 74] = 4.15, p = .045, α = .025). At follow-up this superiority disappears since the control group improves significantly from post to follow-up and catches up. As a result, both conditions complete this trial with a similar outcome. These findings indicate that exercise prior to exposure sessions speeds up the effect of a CBT. The expected therapeutic success would be reached earlier resulting in a faster reduction of psychological strain and an earlier restoration of mobility which would be an economic relief as well. Strengths of this study are the application of a control group, the maximum comparability of the two conditions, the relatively large sample, the randomization with blinding, the standardized diagnostics as well as the intention-to-treat-analysis. Nonetheless, for interpreting the results some limitations should be taken into account, for example the high dropout rate and the relatively small number of exercise sessions.

This paper examines the functions of stories in an online peer-to-peer advice forum on pregnancy and parenting, particularly drawing attention to how parents as advice-givers use stories in health-related discussions. The analysis shows that stories are multi-functional, serving to establish rapport with advice-seekers, give and support advice, express and substantiate agreement or disagreement. The results add to the current scholarship by showing that response stories can be used to give etiological (causal) assessments of others’ health issues, thus delivering a diagnostic opinion.

Einleitung: Die Kognitive Verhaltenstherapie (KVT) und die medikamentöse Therapie mit Selektiven Serotonin oder Serotonin-Noradrenalin Wiederaufnahme- Hemmern (SSRI/SSNRI) haben sich als effektive Strategien zur Behandlung der Panikstörung mit Agoraphobie (PD/AG) erwiesen. Dennoch sind die behandlungsspezifischen Effekte auf die kritischen Symptome dieser Störung und deren neurofunktionellen Korrelate noch weitestgehend unbekannt. Methoden: Im Rahmen eines komparativen Designs erhielten Patienten mit PD/AG entweder eine von zwei KVT-Varianten (therapeutenbegleitete (n=29) oder unbegleitete (n=22) Expositionsbehandlung), eine Pharmakotherapie (SSRI/SSNRI; n=28) oder eine Warte-Kontroll-Bedingung (WL; n=15), um die therapiespezifischen Effekte auf störungsübergreifende Angst- und Depressionssymptome (Hamilton Angst Skala HAM-A und Beck Depressionsinventar BDI), störungsspezifische Symptome (Mobilitätsinventar MI, Panik- und Agoraphobie-Skala Subskala Panikattacken PAS-Panik, Angstsensitivitätsindex ASI, Einschätzung agoraphobischer Stimuli) und die neuronalen Grundlagen während der Symptomprovokation (Westphal- Paradigma) im funktionellen Magnetresonanztomographen (fMRT) zu untersuchen. Die Gruppenvergleiche bezüglich neuronaler Aktivierungsmuster schlossen auch gesunde Kontrollprobanden ein (n=29). Ergebnisse: Beide Behandlungsstrategien führten zu einer signifikant stärkeren Abnahme von Panikattacken, Depressionssymptomen und allgemeiner Ängstlichkeit als die WL-Bedingung. Die KVT-Gruppen, insbesondere die therapeutenbegleitete Subgruppe, zeigten eine signifikant stärkere Reduktion von Vermeidungsverhalten, Angst vor phobischen Situationen und Angstsymptomen sowie von bilateraler Amygdala-Aktivität bei der Verarbeitung Agoraphobie-relevanter Bilder verglichen mit der SSRI/SSNRI und der WL Gruppe. Diskussion: In dieser Studie konnte gezeigt werden, dass therapeutenbegleitete KVT zu ausgeprägteren Kurzzeiteffekten auf die Agoraphobie-spezifische Psychopathologie führt und untermauert die Annahme von der zentralen Rolle der Amygdala in einem komplexen Angstverarbeitungssystem sowie ihrer Beteiligung an der Behandlungssensitivität des Angstnetzwerkes., Introduction: Cognitive behavioural therapy (CBT) and pharmacological treatment with selective serotonin or serotonin-noradrenalin reuptake inhibitors (SSRI/SSNRI) are regarded as efficacious treatments for panic disorder with agoraphobia (PD/AG). However, little is known about treatment- specific effects on symptoms and neurofunctional correlates. Experimental procedures: We used a comparative design with PD/AG patients receiving either two types of CBT (therapist-guided (n=29) or non-guided exposure (n=22)) or pharmacological treatment (SSRI/SSNRI; n=28) as well as a wait-list control group (WL; n=15) to investigate differential treatment effects in general aspects of fear and depression (Hamilton Anxiety Rating Scale HAM-A and Beck Depression Inventory BDI), disorder-specific symptoms (Mobility Inventory MI, Panic and Agoraphobia Scale subscale panic attacks PAS-panic, Anxiety Sensitivity Index ASI, rating of agoraphobic stimuli) and neurofunctional substrates during symptom provocation (Westphal-Paradigm) using functional magnetic resonance imaging (fMRI). Comparisons of neural activation patterns also included healthy controls (n=29). Results: Both treatments led to a significantly greater reduction in panic attacks, depression and general anxiety than the WL group. The CBT groups, in particular, the therapist-guided arm, had a significantly greater decrease in avoidance, fear of phobic situations and anxiety symptoms and reduction in bilateral amygdala activation while the processing of agoraphobia-related pictures compared to the SSRI/SSNRI and WL groups. Discussion: This study demonstrates that therapist- guided CBT leads to a more pronounced short-term impact on agoraphobic psychopathology and supports the assumption of the amygdala as a central structure in a complex fear processing system as well as the amygdala's involvement in the fear system's sensitivity to treatment.

The postural tachycardia syndrome (POTS) is a condition of the autonomic nervous system with symptoms of orthostatic intolerance. In POTS patients, orthostatic stress leads to an overshoot of heart rate increase without a fall in blood pressure. The purpose of this study is to distinguish between anxiety disorders and anxiety as a concomitant phenomenon of orthostatic stress.50 patients fulfilling the diagnostic criteria (orthostatic symptoms, heart rate increase of30 bpm or up to120 bpm by testing with tilt-table) were included. The study design included a thorough medical history as well as standardised questionnaires about anxiety.The average heart rate increase was 36 bpm after ten minutes of standing and 42 bpm after maximal standing time (max. 45 minutes). POTS patients scored significantly higher than a comparison group in a range of anxiety disorders by using anxiety questionnaires like "Beck Angst-Inventar" (BAI) and trait test of "State-Traits-Angstinventar" which include autonomic items. When questionnaires were used that exclude autonomic items (anxiety sensitivity index: ASI; Interaktions-Angst-Fragebogen: IAF) there was no difference.POTS patients do not exhibit signals of anxiety disorders more often than control groups, provided that questionnaires without autonomic items are used.

This example of a fatal diving accident shows how challenging such cases can be in pre-hospital and clinical care. There is no common mechanism in diving fatalities and more than one group of disorders coming along with decompression sickness. Diving medicine is not an element of medical education, which results in insecurity and hampers adequate therapy of diving incidents. This is aggravated by an insufficient availability of hyperbaric chambers in Germany.

Körperliche Aktivität hat positive Auswirkungen auf die Gesundheit des Menschen. Aktive Personen sind motivierter, leistungsfähiger und zeigen ein geringeres Risiko für das Auftreten verschiedener Erkrankungen, wie eines Diabetes Mellitus oder eines arteriellen Hypertonus. Sport leistet nachweislich auch einen positiven Beitrag in der Behandlung psychiatrischer Erkrankungen. Besonders Patienten mit Depressionen profitieren von regelmäßigem Training. In einer Reihe von Studien konnte neben einem antidepressivem auch ein anxiolytischer Effekt von Sport nachgewiesen werden. In der Mehrzahl der vorliegenden Arbeiten wurden gesunde Probanden oder Patienten über einen längeren Zeitraum betreut und in einem regelmäßigen Ausdauertraining angeleitet. Auch eine einmalige körperliche Belastung, die unmittelbar vor dem Auftreten einer Panikattacke erfolgt, scheint einen anxiolytischen Effekt zu haben. Basierend auf kognitiven Erklärungsmodellen zur Entstehung der Panikstörung wird vermutet, dass Sport bei Panikpatienten durch einen Anstieg körperlicher Symptome, wie Schwitzen oder eine beschleunigte Atmung, einen interozeptiven Stimulus darstellt und zum Auftreten von Panikattacken führen kann. Bisher gibt es keine Studie, die den Effekt einer einmaligen körperlichen Belastung unmittelbar vor einer Panikattacke bei Patienten mit Panikstörung und gesunden Probanden gegenüberstellt. Ziel dieser Arbeit war es zum einen den Effekt von Sport unmittelbar vor einer experimentell induzierten Panikattacke bei Patienten und Gesunden miteinander zu vergleichen. Zum anderen sollten mögliche Unterschiede in der Symptomausprägung aufgezeigt werden. In einem Cross-Over-Design wurden zwölf Patienten mit Panikstörung und zwölf vom Alter und Geschlecht identische Probanden untersucht. Um eine systematische und kontrollierte Untersuchung zu gewährleisten, wurden Panikattacken durch die intravenöse Applikation von CCK-4 ausgelöst. CCK-4 induziert in Abhängigkeit von der Dosierung körperliche und psychische Angstsymptome, ist sicher im Gebrauch und einfach anzuwenden. Um die körperliche Betätigung für jeden Teilnehmer entsprechend seines Leistungsniveaus zu dosieren, erfolgte im Vorfeld eine sportmedizinische Voruntersuchung, in der die VO2max jedes Patienten und Probanden ermittelt wurde. In der hier vorliegenden Arbeit konnte gezeigt werden, dass eine 30-minütige Sportphase nicht nur die Häufigkeit der durch CCK-4 ausgelösten Panikattacken, sondern auch die Intensität hervorgerufener Symptome signifikant vermindert. In der Patientengruppe kam es unmittelbar nach körperlicher Betätigung zu einem signifikanten Anstieg somatischer Symptome. In der Kontrollgruppe konnte dieser Effekt nicht beobachtet werden. Es gibt unterschiedliche Ansätze zur Erklärung des anxiolytischen und antipanischen Effekts von Sport. Neben verschiedenen neurobiologischen Prozessen - wie einer Normalisierung der Aktivität unterschiedlicher Serotoninrezeptoren oder dem Einfluss eines veränderten Stresshormonsystems - werden Einflüsse des Atrialen Natriuretischen Peptids diskutiert. Auch kognitive Erklärungsmodelle, systematische Desensibilisierung oder die Reattribuierung als bedrohlich wahrgenommener Körperreaktionen stellen Erklärungsansätze dar. Ob und inwieweit all diese Prozesse ineinandergreifen, ist noch nicht ausreichend geklärt. Es konnte nachgewiesen werden dass auch eine einmalige körperliche Betätigung, die unmittelbar vor dem Auftreten einer Panikattacke erfolgt, einen anxiolytischen Effekt hat und nicht, wie so oft von Patienten befürchtet, dass Entstehen einer Panikattacke fördert. Inwieweit dieses Ergebnis im klinischen Alltag genutzt werden kann und ob Patienten beim Anfluten von Paniksymptomen noch in der Lage sind körperlich aktiv zu werden, bedarf weiterer Untersuchungen. Das vorliegende Ergebnis sollte Patienten mit Panikstörung zumindest die Angst davor nehmen, sich auf eine Behandlung mit Sport einzulassen., Exercise has long been regarded as a healthy behavior with both preventive and therapeutic properties for a variety of physical and mental pathological conditions. Regular physical activity is anxiolytic in healthy subjects and patients with panic disorder. In contrast, acute exercise may induce acute panic attacks or increase subjective anxiety in patients with panic disorder more than in other people. The effects of quiet rest or an aerobic treadmill exercise on cholecystokinin tetrapeptide (CCK-4) induced panic attacks were studied in a crossover design in 12 patients with panic disorder and 12 matched healthy subjects. The effects of CCK-4 were measured with the Acute Panic Inventory (API) score, comparing panic attack frequencies, total score, and subscores for anxiety and somatic symptoms. CCK-4-induced panic attacks were less frequent after prior exercise. In both conditions, CCK-4 administration induced a significant increase in the total API score and the anxiety and somatic symptoms subsores. However, compared to prior rest, exercise resulted in a significantly reduced CCK-4-induced increase of the total API score and the anxiety subscore. In patients with panic disorder exercise increased the total API score and the somatic symptoms subscale but not the anxiety subscore. Patients with panic disorder showed increased somatic but not anxiety symptoms after an acute bout of exercise. Severity of CCK-4-induced panic and anxiety, on the other hand was reduced by exercise. In summary, these findings give further evidence for an acute antipanic activity of exercise and suggest that besides exercise training a single exercise bout may be also used in the treatment of panic disorder.

My defi has now saved my life several times in the past. On the other hand it has also often given me a shock in situations which from a medical point of view were not absolutely necessary. In particular it is the coping with this shock which brings me to contradict the standard phrase"Don't be afraid you are protected by the defibrillator!". But I am afraid because my quality of life is substantially impaired not only by the high number of shocks suffered. Each new defi shock triggers in me a series of recurring reaction patterns. There is a tendency to observe by me that with every new shock the restoration of a rudimentary emotional equilibrium always takes longer. However, I want to be able to appear in public again without being accompanied every step of the way by the notion of collapsing in public or to twitch like an electric eel. I can't get used to the idea of an existence as a ticking time bomb.

Fearful patients are in emergency situation often inattentive, unable to concentrate, agitated or even aroused. They show reduced perception and restricted willingness to cooperate. In severe conditions these patients are strongly tending towards more hazardous behavior: refusal of necessary therapy, break out or even high suicidal risk. Within disaster situations (mass accidents, fires) fearful patients with their agitated and persuasive behavior can influence other victims and with that trigger a situation of mass panic that has to be avoided at any cost. Therefore these patients must be swiftly identified and separated from the event. A diligent diagnosis process including physical-neurological examination is necessary. The recommended treatment within the emergency situation consists of a close continuous personal contact through assuring and encouraging conversations. A sense of security should be created by explaining the planned therapeutic interventions in simple, easy-to-follow and understandable words. If this necessary psycho-therapeutic intervention can not be applied a short term psychopharmacological treatment is required preferably with Benzodiazepines. Still a longterm specific therapy is highly advised, since these disturbances, if left untreated, will lead to a chronic manifestation and with that to considerable psychosocial impairments.

Background: Based on the results of research on facial affective behaviour in different psychological disorders, as well as on available findings on the specific behaviour of patients with panic disorder in interaction with their therapists, hypotheses about dyadic facial affective behaviour and its correlation with symptomatic burden of female panic patients are formulated. Sampling and Methods: The facial affective behaviour of 20 patients with panic disorder and their therapists, coded with the Emotional Facial Action Coding System, in the first treatment session is analyzed regarding interactive enmeshment, and for a subgroup of 15 dyads these data are correlated with those on symptomatic burden before treatment. Results: A high degree of interactive enmeshment between patient and therapist correlates positively with the severity of symptomatic burden. All dyadic enmeshment indicators show highly significant positive correlations with body-related symptoms, but not with more general variables like global severity index of the SCL-90R or general anxiety (State Trait Anxiety Inventory). Conclusions: These results are discussed against the background of specific psychodynamics of panic patients and show that, on the one hand, therapists practise an interactive abstinence, but on the other hand, they tend to be pulled into a specific interactive enmeshment by patients with greater symptomatic burden. Limitations of the study arise from the small sample and the lack of a comparison group, therefore the question if the results are disorder specific or more general cannot be answered.

Only recently has functional neuroimaging been used increasingly in the context of psychotherapy research. Based on a literature survey, procedures, methodological underpinnings and paradigms relevant for psychotherapy research are explored regarding functional magnetic resonance imaging (fMRI) and positron emission tomography (PET). Current studies on changes of brain functions and potential mechanisms are presented based on obsessive-compulsive disorders, depression, phobia, panic and borderline personality disorders. Findings and implications are discussed regarding the use of functional neuroimaging in psychotherapy research. Systematic changes of brain activation were demonstrated following successful psychotherapy, partially resembling and partially differing from those induced by psychopharmacological treatments. Thus the traditional split between pharmacological procedures „acting on the brain“ and psychological procedures making the patient „feel better“ has been rendered obsolete. Procedures of functional neuroimaging have been developed to such an extent that they can be used to study issues of great relevance for psychotherapy, e. g. biological underpinnings of psychiatric disorders, plasticity of neural networks, mechanisms of change and prognostic factors of psychotherapy, etc.

OBJECTIVE In the context of the current discussion of integrating rehabilitative elements into the (acute) treatment of patients with mental disorders, it is investigated what rehabilitative elements actually are and whether these elements are considered in existing guidelines. METHODS/RESULTS An expert-based consensus, especially results of expert ratings using a 46-item questionnaire (Delphi Technique; n = 16), shows that it is possible to specify rehabilitative elements, although there are still aspects which need further clarification. Analyses of current guidelines (using published guidelines for panic disorders) demonstrate that rehabilitative elements which are rated as important by the experts are only marginally mentioned in guidelines up to now. CONCLUSIONS A considerable need for research exists for a further specification of rehabilitative elements and for the development of evidence based recommendations in the form of guidelines.

Zur differenzierten Analyse kurz- und langfristiger Folgen sexuellen Missbrauchs mittels intimen Hautkontaktes wurde eine Typologie minderschwerer sexueller Übergriffe herangezogen. Bekannte theoretische Ansätze zur schädigenden Wirkung sexuellen Missbrauchs wurden überprüft und die Frage untersucht, ob sich das Vorkommen peri- und posttraumatischer Reaktionen bei verschiedenen Formen sexueller Interaktion mit Kindern unterscheidet. Mittels einer Clusteranalyse wurde das Vorkommen von Symptomvariablen in 141 Gutachten entnommenen Kinderberichten ausgewertet. Danach wurden Varianzanalysen dieser Symptomcluster für sechs unterschiedliche Missbrauchskonstellationen durchgeführt. Für die Missbrauchskonstellationen zeigten sich verschiedene Symptomprofile. Signifikant unterschiedliche Ausprägungen fanden sich für Paniksymptome, Schamgefühle, Vermeidungsverhalten und durch Angst bedingte physische Reaktionen. Die Folgen auf verschiedene Formen minderschweren sexuellen Kindesmissbrauchs unterscheiden sich und hängen eher von der Situationsdynamik als der Art der Beziehung zwischen Erwachsenem und Kind ab. Schlagwörter: sexueller Missbrauch - Traumatisierung - Kinderpsychologie - psy- chosomatische Symptome A typology of less severe sexual encounters was used to analyze short and long term sequelae of sexual abuse via intimate skin contact. Well known theoretical approaches on the harmful effects of sexual abuse were tested. Do we find different peri- and posttraumatic reactions dependent upon varied forms of sexual interactions with children? A cluster analysis was calculated with symptom variables that were described in 141 child statements taken out of written expert opinions. Afterwards variance analyses of these symptom clusters were conducted in reference to six different abuse constellations. Different symptom profiles were found for these six abuse constellations. Panic symptoms, shame related feelings, avoidant behavior and physical reactions showed significant results. The sequelae to different forms of less severe sexual child abuse differ and depend more upon the situational dynamic than upon the kind of relationship between adult and child. Key words: sexual abuse - traumatization - child psychology - psychosomatic symptoms

Within the range of highly contagious diseases there are well-known diseases, and those caused by newly detected infectious agents (i. e. SARS) or, in the worst case, bioterror agents. Public Health Services as well as clinicians and practitioners will be confronted with a new paradigm of infectious disease control: not only the infectious agent itself, the constitution of the host or the environment will influence the spread of a disease, but also globalization, mobile societies and new communication systems. Thus, the emergence, respectively the re-emergence of such diseases demands new or better skills in management of infectious diseases. Finally, the demonstration of national and federal plans for smallpox control focuses on organisational, logistical and financial problems following the implementation of such plans.

Aktuelle Ergebnisse der Hirnforschung belegen, dass wir möglicherweise mehr als ein System haben, mit dem wir Disstress bewältigen. Das vielleicht archaischste ist das System Erstarrung/Freeze/Dissoziation. Das zweite wäre das System Bindung/ Herde/Unterstützung. Allen N. Schore führt in seinen Arbeiten aus, wie die wesentlichen Regulationsmechanismen des Selbst, der Affekte und der zwischenmenschlichen Beziehungen durch traumatisierende Bindungserfahrungen in der Kindheit (Relational Trauma/Attachement Trauma) dauerhaft geschädigt werden können. Jaak Panksepp hat das Disstress-System Panik/Bindung dem Disstress-System Furcht/Kognition gegenübergestellt. Holzschnitthaft geht es einerseits um das Cluster Panik - PAG - laterales Septum - Gyrus cinguli - Glutamat - Opioide - Bindung - Parasympathikus - trophotroper Zustand - Hypometabolismus - Freeze - Dissoziation, andererseits um das Cluster Furcht - Locus coeruleus - Amygdala - präfrontaler Kortex - Noradrenalin - Cortisol - Feind - Sympathikus - ergotroper Zustand - Hypermetabolismus - Kampf und Flucht - Kognition und Lernen. Eine differenzierte Wahrnehmung dieser beiden Systeme kann therapeutisches Vorgehen präzisieren und bahnen. Schlagwörter: Gehirnentwicklung - Bindungstrauma - Dissoziation - Disstress- System Panik - Disstress-System Furcht Actual results of brain research show that we might have more than one system to cope with disstress. The most archaic one might be the system freeze/dissocation. The second one is the system attachment/relationship/herd/support. Articles by Allan N. Schore show that the central regulation of the self, the affects, and the interpersonal relations are impaired permanently by relational traumata/attachment traumata during early childhood. Jaak Panksepp differentiates the disstress systems panic versus fear. On the one side we find the cluster panic - periaqueductal gray PAG - lateral septum - gyrus cinguli - glutamate - opioids - attachment - parasympathetic autonomic nerve system - trophotorphic state - hypometabolism - freeze reaction - dissociation, on the other side the cluster fear - enemy - sympathetic autonomic nerve system-ergotrophic state - hypermetabolism - fight and flight - cognition and learning. It can be helpful for therapy strategies to differentiate these systems. Keywords: brain research - attachment trauma - dissociation - disstress system panic - disstress system fear

29 of 31 patients with agoraphobia and/or panic-disorder (DSM-III R), treated with an inpatient therapy program with client-centered foundation, could be investigated on a one-year follow up. The investigation was performed by means of the Angst-Katamnese-Fragebogen (AKF), Clinical Global Impressions (CGI), Freiburger Persönlichkeits Inventar (FPI) and Fear Survey Schedule (FSS). On the whole about 2/3 of the patients had a good or very good outcome concerning central anxiety symptoms (panic and agoraphobia). In most of the cases favourable changes of the mental state, interpersonal relationship and personality development were found. The results indicate that an insight orientated and experiential client-centered therapy program helps to reduce anxiety symptoms and to diminish the risk of negative consequences (alcohol and drug abuse).

Beginning with the eighties, a paradigm-change concerning anxiety disorders has taken place in considerable parts of psychiatry. Anxiety disorders are no longer regarded as consequences of conflicts and ineffective defences or as concomitants of other psychiatric disorders but rather as disorders of their own. This resulted in a modified outlook on anxiety disorders focusing on the acute panic attack (Panic disorder) instead of focusing on chronic anxiety (Anxiety neurosis). This paper reviews recent empirical studies concerning classification, pathogenesis, and therapy of anxiety disorders, i.e. after introduction of the concept of Panic disorder. Epidemiological studies could demonstrate that in western countries anxiety disorders account for the most frequent psychiatric disorders with prevalence rates of 2.0% to 4.7%. Panic disorders show prevalence rates of 0.4% to 1.1%. Results of recent follow-up studies indicate a favorable course for outpatients and an unfavorable course for inpatients with anxiety disorders. Family studies reported on positive familial loading for Panic disorder but not for Agoraphobia and Generalized anxiety disorder. A twin study found higher concordance rates for panic attacks and Agoraphobias in monozygotic twins than in dizygotic twins. Pharmacological provocation studies with lactate infusion, CO2-inhalation, and administration of Caffeine, Yohimbine, Isoproterenol showed a higher vulnerability of patients with Panic Disorder as compared to healthy controls. However, all studies display methodological short-comings and could be interpreted differently as to the concept of a biologically determined vulnerability. Provocation studies using inverse Benzodiazepine-agonists dealt only with healthy probands. Whereas life events play a rather unimportant role für the pathogenesis of anxiety disorders, recent studies point to the influence of cognitive processes and personality variables for the pathogenesis of anxiety disorders. Concerning treatment of anxiety disorders and especially of panic disorders, pharmacological studies as well as studies of behavioural therapy indicate very good results for acute treatment and good results for behavioural therapy with respect to one to four year follow-up studies. Recently, combined drug and psychotherapy gains growing interest. Conclusions are drawn with respect to the usefulness of the new classification, i.e. after the introduction of Panic disorder as a diagnostic category, and references are given for further research strategies.

Patients suffering from cardiac phobia or neurocirculatory asthenia (also known as cardiac neurosis or effort syndrome) represent a uniform disease group due to the typicality of the signs and symptoms and of the course of the disease; this group should be distinguished from the broad spectrum of cardiovascular disorders. There is close agreement with panic disorder according to DSM III, one of the reasons being that cardiac phobia was originally the model pattern for defining that disorder. In the present prospective study the significance of psychosocial and clinical factors for the prediction of the further course of the disease was studied in 36 patients with cardiac phobia treated on an inpatient basis for the first time, 29 of whom could be followed up by a checkup 2 1/2 years later. The duration of the disease before treatment, as well as difficulties in various social spheres, especially in partnership problems, were found to be variables exercising a particularly strong influence on the course of illness. The variables concerning the marital status and school education were also found to be statistically relevant predictors. Familial stress and the appeal-for-help behaviour of these patients were also recorded. The results of the study point to the importance of psychosocial factors as major coursemodifying factors and underline the need to pay particular attention to this part of the treatment.

In a crossectional investigation based on a group of 122 patients with panic attacks, compiled from a variety of hospitals and therapy institutions, 97 patients were found to be suffering from panic disorder as a relevant medical problem. The disease, however, is often identified in an unsatisfactory manner. Avoidance behaviour (extensive or limited) associated with a severe form of panic disorder, was evident in more than one-half of the group (60%). In these patients the incidence of panic attacks is higher, anxiety is more marked, and there are more often additional anxiety disorders (generalised anxiety, sociophobia). These results underline the importance of early recognition and specific treatment of panic disorder to prevent development of avoidance behaviour.

The definition of a separate nosological entity "panic disorder" in the Diagnostic and Statistical Manual of Mental Disorders, 3rd revision (DSM III) of the American Psychiatric Association triggered a flood of empirical research into this disorder. In this article the literature is surveyed to find out to what extent panic attacks and panic disorder bear specific relationships to measurable variables from the psychosocial and biological spheres. The investigated psychosocial variables are: experiences of separation in childhood; separation anxieties in childhood; sociodemographic correlates as they are known from epidemiological studies; personality factors; life events as possible triggering events of periods with panic attacks; and, finally, socalled "cognitive correlates". The results obtained in this field are just as inhomogeneous as they continue to be in the sphere of biological variables. Of these, the following factors are discussed: genetic factors; neurological and psycho-physiological correlates; the problem of mitral valve prolapse; endocrinal correlates and neurotransmitters. Present findings do not supply conclusive evidence either for or against separation of panic attacks from free-floating anxiety. The relationship between panic attacks and depressive disorders is equally unclear if judged on the basis of the results from empirical research which are far from uniform.

Paroxysmal states of anxiety that cannot be traced back to somatic causes have been called panic attacks since the publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) of the American Psychiatric Association. This term has since been accepted as part of psychiatric everyday language in many countries. The present review discusses initially the diagnostic and differential diagnostic aspects against the background of nosological classifications as practised to date, with particular emphasis on the requirements of the practising psychiatrist. The authors of this review hold the opinion that whereas the phenomenon of panic attack is a valid concept, the conceptualisation of a panic disorder is still largely hypothetical. The often observed "natural history"--after panic attacks, anticipatory anxiety, coupling of attacks to certain situations, avoidance of these situations, as well as agoraphobia, depressivity, self-medication with tranquilisers and alcohol, hypochondriacal fears with increased consultation of doctors, and family conflicts may develop--requires early therapeutic intervention. Hence, the second part of this article presents the pharmacological and psychotherapeutical treatment methods for panic attacks and their complications as developed and successfully tried out during the past few years. The efficacy has been proven of drug therapy on the one hand of prophylactic treatment using tricyclic antidepressives, MAO-inhibitors and alprazolam or clonazepam, and on the other hand also of a non-continuous attack-related treatment strategy. Of the more recent psychotherapeutic methods, relaxation methods and the cognitive treatment of panic attacks are discussed. This direct focus on panic attacks seems to be more promising than the conventional treatment methods centered on secondary symptoms such as anticipatory anxiety or agoraphobia.

The currently available empirical findings lead us to assume that various forms of anxiety disorders--such as generalised anxiety syndrome or panic disorder--are based on different pathophysiological mechanisms with varying involvement of different neurotransmitter systems. We must bear in mind that whereas the disturbance of a transmitter may predominate--such as the disturbance of the noradrenalin system in panic disorder and that of the GABA-ergen system in generalised anxiety--on the other hand the transmitter systems are mutually interlinked, so that an isolated disturbance of a system is very unlikely. However, to the present date it has not been possible to give a definite biochemical characterisation of a certain disease pattern, such as that of panic disorder. Likewise, no unequivocal conclusions can be drawn in respect of cerebral localisation. Nevertheless, results obtained in animal experiments suggest that in panic disorder certain brain areas like e.g. the locus ceruleus may be affected. Future hopes rest in developing more specific drugs that selectively change a transmitter system and on new techniques such as positron emission tomography enabling a better insight into the mode of functioning of the brain. New possibilities seem to be offered also by defining a predisposition via molecular-genetic methods.

On the point of anxiety states, behavioural sciences have only recently been provided with sufficient operational definitions of clinical concepts to enable us to start working on the construction of valid models for the different disorders. Panic attacks are defined as attacks manifested by discrete periods of apprehension or fear, concomitant with at least four marked vegetative sensations, as described in the DSM-III. Several interventions have proved to be able to mimic experimentally such episodes in vulnerable patients, providing the researcher with valuable models for panic research such as the lactate infusion technique, the single CO2 inhalation model and, to a lesser extent, the hyperventilation provocationtest. The study of these models may be a major contribution to a better understanding of panic anxiety, both from a biological and behavioural point of view. Biological observations of those models point to pH changes and ionic shifts as a physiological concomitant in the genesis of experimentally induced panic, and suggests that hypersensitive chemoreceptive structures of the CNS may be implicated. As to the behavioural aspects of the models, there is strong evidence for the ancient phobophobia, or "fear of fear" idea, which may explain the invaldating recurrence of panic attacks.