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Prodromal symptoms in panic disorders
11.11.1989, Amer J Med 146: 1084 (& M. Mäntysaari)
(ei kuvausta)

Prodromal symptoms in panic disorders

SIR: Dr. Fava and his colleagues reported in their article that 18 of their 20 patients suffering from panic disorder with agoraphobia experienced agoraphobic avoidance, generalized anxiety, and/or hypochondriacal fears before the first panic attack. This observation is not in accordance with the current view that the first panic attack is "a hit from the clear sky." The finding of Dr. Fava and co-workers is very important because it shows that panic disorder cannot be categorically differentiated from syndromes in which the symptoms are like those in panic disorder but the beginning is not abrupt. If this conclusion is not neglected, we have to consider a anew the relationship between the symptoms and anxiety in panic disorder. Which comes first? This question was a subject of argument in the cardiologic literature on neurocirculatory asthenia (Da Costa's syndrome) from World War 1 to the early 1960s, and it has remained unsolved (1-4).

Neurocirculatory asthenia is a syndrome of symptoms occurring in the cardiovascular systems of patients without signs of organic disease. Anxiety and agoraphobia were also described in these patients (2), but they received less attention in cardiologic publications. The patients were divided into acute and chronic cases. The patients with the chronic form of neurocirculatory asthenia had suffered from the symptoms since childhood. The acute cases were characterized by two facts. First, the abrupt beginning of the symptoms was preceded by some kind of stressful life event, and, second, the prognosis of the acute patients was clearly better than that of the chronic patients. It has been hypothesized that the main difference between the acute and chronic patients is in their stress tolerance: for chronic neurocirculatory asthenia patients, everyday life is too stressful.

The similarity between panic disorder and the acute form of neurocirculatory asthenia is striking. lf it can be shown that panic disorder patients with prodromal symptoms have a poorer prognosis than panic disorder patients without these symptoms, and if stressful life events can be found to precede the abrupt beginning of panic disorder, then one can suspect that a more or less chronic form of panic disorder can he distinguished. We think the recent observations of Dr. Fava and associates support our suspicion. lf it can he accepted that panic disorder and neurocirculatory asthenia basically represent the same pathology, then the investigation of panic disorder needs reconsideration, because the psychic disorder and the effects of environmental stress need to he combined to explain the etiology of panic disorder.

1. Oppenheimer BS, Rothschild MA: The psychoneurotic factor in the irritable heart of soldiers. JAMA 1918; 70:1919-1922
2. Friedman M: Functional Cardiovascular Disease. Baltimore, Williams & Wilkins, 1947
3. Cohen ME, White PD, Johnson RE: Neurocirculatory asthenia, anxiety neurosis or effort syndrome. Arch Intern Med 1948; 81:260-281
4. Levander-Lindgren M: Scudies in neurocirculacory asthenia (Da Costa's syndrome), IV: course during common treatment and physical training and relations between symptoms and signs. Acta Med Scand 1964; 175:791-799

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