Internal and external signal processing in patients with panic disorder: An event-related potential (ERP) study

Self-absorption describes a pathological tendency towards the internal mental world (internalization) that often conflicts with the accurate monitoring of the external world. In performance monitoring, an augmented electrophysiological response evoked by internal signals in patients with anxiety or depressive disorder seems to reflect this tendency. Specifically, the error-related negativity (Ne/ERN), an index of error processing based on internal signals, is larger in patients compared to controls. In the present experiment, we investigated whether the preferential processing of internal signals in patients is linked to diminished and inflexible external signal processing. To this end, the electrophysiological response evoked by external signals was analysed in patients with panic disorder and healthy controls. Participants performed a choice-response task, where informative or uninformative feedback followed each response, and a passive viewing task. As a replication of previous studies, patients presented an augmented Ne/ERN, indexing enhanced processing of internal signals related to errors. Furthermore, the vertex positive potential (VPP) evoked by visual stimuli was larger in patients than in controls, suggesting enhanced attention to external signals. Moreover, patients and controls showed similar sensitivity to the feedback information content, indicating a normal flexibility in the allocation of monitoring resources to external signals depending on how informative these signals are for performance monitoring. These results suggest that the tendency towards internal signals in patients with panic disorder does not hinder the flexible processing of external signals. On the contrary, external signals seem to attract enhanced processing in patients compared to controls.