Assessment of the relationship between thyroid function and panic disorder: A mendelian randomization study

Assessment of the relationship between thyroid function and panic disorder: A mendelian randomization study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of the relationship between thyroid function and panic disorder: A mendelian randomization study Sijie Yu, Chongkai Shen, Junpeng Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3577312/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Multiple observational studies have indicated a correlation between thyroid function and the risk of panic disorder (PD). Nevertheless, the causality surrounding this association remains unclear. Our objective was to evaluate the causality between thyroid function and the risk of PD by employing Mendelian randomization (MR). Methods We employed publicly available genome-wide association studies (GWAS) to select single nucleotide polymorphisms (SNPs) that are associated with various aspects of thyroid function (hyperthyroidism, hypothyroidism, FT4, TSH, TPOAb, and thyroid nodules). The statistical data on panic disorder were obtained from the FinnGen consortium. To assess causality, we utilized the inverse variance weighted (IVW) method, MR-Egger method and weighted median (WM) method for the MR estimates. Sensitivity analyses were conducted using Cochran’s Q test, MR-Egger intercept, MR-Pleiotropy Residual Sum and Outlier method, leave-one-out analysis, and funnel plot. Results The genetically predicted presence of hyperthyroidism showed an inverse association with PD as evident from the IVW OR of 0.93 (95% CI: 0.87–0.98; P = 0.01).However, our findings did not indicate any causal effects of variation in FT4 (OR: 0.78, 95%CI: 0.78–1.27; P = 1)、TSH (OR: 1.03, 95%CI: 0.83–1.28; P = 0.77)、TPOAb (OR: 0.9, 95%CI: 0.47–1.72; P = 0.75)、hypothyroidism (OR: 0.57, 95%CI: 0.01–50.54; P = 0.81) and thyroid nodules (OR: 1.02, 95%CI: 0.91–1.14; P = 0.76) on PD risk. Conclusions In summary, Our findings indicated a significant inverse correlation between hyperthyroidism and PD risk, with no discernible causal impacts of alterations in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on PD risk. It may suggest that most thyroid function may not be the etiological factor of PD, further studies are needed to verify our results in the real world. panic disorder thyroid function thyroid hormone hyperthyroidism Mendelian randomization study Figures Figure 1 Figure 2 Introduction Panic disorder (PD), a prevalent and severe psychological ailment within the anxiety continuum, is distinguished by frequent and unforeseeable episodes of panic, accompanied by a variety of physiological manifestations. It often results in substantial impairment, particularly when accompanied by agoraphobia, and is associated with notable functional morbidity and diminished quality of life. Diagnosis based on International Classification of Diseases 10 (ICD-10) necessitates recurrent panic attacks, accompanied by either apprehension regarding future episodes or the emergence of phobic avoidance. Panic attacks are abrupt and sometimes unforeseen episodes of intense anxiety, often accompanied by physical manifestations such as cardiovascular, otoneurological, gastrointestinal, or autonomic symptoms [ 1 ]. A comprehensive meta-analysis revealed that the most common age of onset is during late adolescence or early adulthood [ 2 ]. The National Comorbidity Survey Replication (NCS-R) provides prevalence estimates of 2.7% within a 12-month period and 4.7% over the course of a lifetime [ 3 , 4 ]. Research has shown that risk factors for anxiety disorders include alcohol use, smoking, avoidance behaviors, marijuana use, occupational factors, and negative evaluations of stressful life events. Protective factors that produce some support include physical activity, sports participation, social support, and coping skills. The most researched risk or protective factor was cigarette smoking, which was found to increase the risk of PD development in many prospective studies [ 5 ], while much less is known about the role of thyroid function. At present, the etiology of PD remains unclear, among which the hypothalamic-pituitary-thyroid (HPT) axis is an etiological factor. A large amount of studies have shown that the endocrine system responds to various stressors. Many researchers have explored changes in HPT axis hormones in stress responses [ 6 ]. The regulation of thyroid function is a multifaceted process that encompasses not only the thyroid gland, but also the pituitary gland, hypothalamus, and feedback mechanisms. The hypothalamus releases thyrotropin releasing hormone (TRH) acts on the pituitary, rereleasing thyroid stimulating hormone (TSH) acts on the thyroid, which releases free thyroid hormone (FT4). Studies of panic disorder have found evidence of a dulled response of thyroid stimulating hormone (TSH) to thyroid stimulating hormone (TRH) stimulation [ 7 , 8 ]. Thyroid hormones are essential for neurocognitive development and function, so the link between thyroid dysfunction and panic disorder has been studied over the past few decades [ 6 , 9 ]. Indeed, both TSH and FT4 have been associated with PD in an observational study [ 6 ]. Some researches found initial support for an increased prevalence of thyroid disorders in patients with PD [ 10 , 11 ]. Because of the high incidence of PD patients, a better understanding of its underlying mechanisms made essential to further improve its prevention and treatment. Thyroid dysfunction can cause symptoms similar to those seen in people with anxiety disorders, especially panic disorder. Some of the physical symptoms of hyperthyroidism, such as palpitations, shortness of breath, and increased sweating, overlap with what people with panic disorder experience during panic attacks. A link has been suggested between thyroid disease and panic attacks and phobias [ 12 ]. However, the extent to which PD patients suffer from thyroid dysfunction remains unclear. Learning more about such dysfunction first means obtaining an estimate of whether a person with PD has (subclinical) thyroid disease. Besides, this means studying subtle changes in individual thyroid function parameters, namely TSH, FT3, and FT4. Doing so may shed light on the complex relationship between PD and thyroid function and help determine whether the aforementioned panic symptoms may also occur as an epiphenomenon of subclinical thyroid dysfunction. Since observational studies are sometimes vulnerable to selection bias, residual confounding, and reverse causality, it is unclear if the reported relationships are causal [ 13 , 14 ]. Overall, the previous studies point to a connection between thyroid function and panic disorder, but it's important to clarify whether this connection is causative or not. In recent years, with the increasing popularity of genome-wide association studies (GWAS) databases, Mendelian randomization (MR) has attracted a lot of attention. MR can avoid some types of confounding by using genetic variants, which are fixed at conception, to support causal inferences about the effects of changeable risk factors [ 15 ]. MR can also yield insights into causality in situations where randomized controlled trials (RCTs) are impractical or insufficient [ 16 ], its level of research evidence lies at the junction of RCTs and observational studies [ 15 ], as it has the ability to emulate RCTs, and offers a reliable statistical approach utilizing instrumental variables (IVs) to elucidate the causal relationship between exposure and disease [ 17 ]. Therefore, in our current investigation, we executed a two-sample MR analysis using the GWAS database to scrutinize the genetic causality interlinking thyroid functionality and panic disorder. The thyroid function we studied included hyperthyroidism, hypothyroidism, FT4, TSH, thyroid peroxidase antibody (TPOAb), and thyroid nodules. Materials and Methods Two-sample Mendelian Randomization We conducted two-sample MR analyses using the data from the most recent GWAS on thyroid function as exposures, and PD as summary-level statistics. There was no necessity for further ethical consent as this involved a reevaluation of preexisting summary-level data. The MR analysis was conducted utilizing Two-sample MR (version 0.5.5) and R (version 4.2.1). The MR analysis hinges on three fundamental assumptions: 1) The chosen IVs must have a significant correlation with the exposure (thyroid function) [ 18 ]. We employ the F-statistic to evaluate the potency of each genetic tool. The subsequent formula calculates the F-statistic: F = beta 2 /se 2 (beta for the exposure association (beta); variance (se)) [ 19 ]. If the F-statistic exceeds 10, the IV possesses a robust capacity to forecast PD. 2) The chosen IVs cannot influence the outcome (panic disorder) via alternative routes, only through the specified exposure [ 20 ]. 3) Confounding elements are not linked to the selected IVs. The schematic representation of the research design is depicted in Fig. 1 . GWAS data We procured single nucleotide polymorphisms (SNPs) from the GWAS database, serving as genetic IVs [ 18 ]. Associations between diverse thyroid characteristics and instrument exposure among individuals of European descent. The significant SNPs associated with FT4、 TSH、TPOAb、hypothyroidism、hyperthyroidism (P < 5×10 − 8 ) and thyroid nodules (P < 5×10 − 6 ) were procured from the correspondingly latest and most extensive GWAS database (Table 1 ). We utilized PhenoScannerV2 ( www.phenoscanner.medschl.cam.ac.uk ) to delve deeper into the potential correlation of IVs with PD risk confounders [ 21 ]. To circumvent any potential skewness instigated by intense linkage disequilibrium (LD), we opted for SNPs with an LDr 2 less than 0.001. Summary data from GWAS for FT4 and TSH were procured from a research study involving 26,089 and 27,916 participants respectively [ 22 ]. TPOAb [ 23 ] was from GWAS data that the participants was 18297. We procured summary-level GWAS data associated with hyperthyroidism from the FinnGen consortium, comprising 962 instances and 172,976 control subjects. Summary statistics for hypothyroidism from UK biobank comprising 463,010 participants (9674 cases and 453,336 controls). The GWAS data pertaining to thyroid nodule were obtained from a comprehensive meta-analysis, encompassing a total of 1121 cases juxtaposed with 187,684 control subjects [ 24 ]. The GWAS data pertinent to the outcome (PD) was culled from the FinnGen consortium, encompassing 2376 cases and 198,110 controls of European lineage. A comprehensive detailing of the GWAS summary data in our investigation is provided Table 1 . Table 1 Details of the GWAS included in the Mendelian randomization. Trait DOI Year Population Cases Controls Samplesize hyperthyroidism www.finngen.fi/en 2021 European 962 172976 173938 hypothyroidism www.nealelab.is/uk-biobank 2018 European 9674 453336 463010 FT4 10.1038/s41467-018-06356-1 2018 European NA NA 26089 TSH 10.1038/s41467-018-06356-1 2018 European NA NA 27916 thyroid nodule 10.1186/s13044-021-00094-1 2021 European 1121 187684 188805 TPOAB 10.1371/journal.pgen.1004123 2014 European NA NA 18297 FT4, thyroid hormone; TSH, thyroid stimulating hormone; TPOAb, thyroid peroxidase antibody; NA, Not Applicable. Statistical analysis Estimations of thyroid function's influence on PD risk via Mendelian randomization were computed utilizing the inverse variance weighting (IVW) approach, weighted median (WM) technique and the MR-Egger methodology. The IVW method, which used a meta-analysis method to integrate the Wald ratio of each SNPs, was the main MR analysis in our work. It was based on the assumption that IVs can only affect outcomes through a specific exposure. When horizontal pleiotropy was not present, the IVW method could produce unbiased causal estimates [ 25 ]. Consequently, the IVW method offered the most accurate evaluation [ 26 ]. To examine the bias caused by inefficient IV and horizontal pleiotropy effects, the complement of analysis was subjected to the WM method and the MR-Egger method [ 27 ]. Due to the impact of outlying genetic variations, the estimations of the MR-Egger technique were likely erroneous [ 28 ]. It was conducted to test whether there was evidence of the intercept parameter being different from zero. The WM method's accuracy was lower and its bias was quite moderate, especially for the proportion of IVs with horizontal pleiotropy below 50% [ 29 ]. The IV estimates of each SNP should be distributed symmetrically close to the point estimation in the absence of directional pleiotropy, demonstrating that there was no systematic bias in the data. The necessity of a comprehensive sensitivity analysis to scrutinize potential heterogeneity and horizontal pleiotropy was underscored, encompassing methods such as IVW, MR-Egger regression, weighted median, funnel plots, and leave-one-out analysis, in which a single variant was excluded at each step. To evaluate the variability of impact sizes for certain genetic IVs, the Cochran's Q test was used. To measure vertical pleiotropy, the intercept from MR-Egger regression was used [ 30 ]. We employed MR-PRESSO to evaluate the horizontal pleiotropy within the constructed MR model, eliminating any outlier prior to recalculating the causal influence if directional pleiotropy was identified with a p-value less than 0.05. A leave-one-out analysis was carried out to examine how the findings would change if one of the chosen SNPs were not included [ 31 ]. Results In the GWAS, we pinpointed 31 SNPs for FT4 within the reference range, 61 SNP for TSH, 36 SNPs for hypothyroidism, 7 SNPs for hyperthyroidism, 9 SNPs for TPOAb concentration and 7 SNPs for thyroid nodules. Each of these exhibited an F-statistic exceeding 80, thereby suggesting the absence of weak instrumental bias. Detailed information regarding specific SNP, inclusive of the effect alleles, other alleles, effect allele frequency, beta (β), standard error, P-value, and F-statistic, can be found in Table S1 . The outcomes of MR analyses exploring the correlations between genetically predicted thyroid function levels and PD risk are presented in Table S2 and summarized in Fig. 2 . Hyperthyroidism The genetic predisposition towards hyperthyroidism was found to have a negative correlation with PD, as indicated by an IVW OR of 0.93 (95% CI: 0.87–0.98; P = 0.01). It was similar to WM (OR = 0.91, 95% CI: 0.84–0.99, P = 0.02) (Fig. 2 , Fig. S1 A ). This MR analysis did not reveal any substantial heterogeneity (Cochran’s Q P = 0.49) or horizontal pleiotropy (P = 0.79) ( Tables S3 and S4 ). The robustness of the results was confirmed by sequentially removing SNPs and reanalyzing with the remaining ones, thereby demonstrating that the positive outcomes are not influenced by a single SNP ( Fig. S1 C ). Hypothyroidism We found no indications of a plausible causal link between hypothyroidism and the likelihood of PD (OR = 0.57, 95%CI = 0.01–50.54, P = 0.81). Analyses of sensitivity employing the MR Egger and WM techniques yielded both negative results (Fig. 2 , Fig. S2 A ). Based on the Egger intercept and Cochran’s Q test, no evidence of directional pleiotropy (p = 0.4) and heterogeneity (p = 0.24) were found ( Tables S3 and S4 ). The leave-one-out analysis indicated the robustness of the results ( Fig. S2 C ) and the funnel plot showed it was symmetric ( Fig. S2 B ). FT4 The association between FT4 and PD was not discovered through the IVW method (OR = 1, 95%CI = 0.78–1.27, P = 1), MR-Egger (OR = 0.63, 95%CI = 0.37–1.07, P = 1) and WM (OR = 0.85, 95%CI = 0.62–1.18, P = 0.34) (Fig. 2 , Fig.S3A ). The outcomes of Cochran’s Q test, MR Egger regression, MR-PRESSO and the leave-one-out test indicated that the MR estimates were fairly robust ( Tables S3 and S4, Fig. S3C ). TSH Heterogeneity (p = 0.01) was found in TSH and PD ( Tables S3 ). Therefore, we used random effect model for this two-sample MR analysis. There was no statistically significant between TSH and PD (OR = 1.03, 95%CI = 0.83–1.28, P = 0.77) (Fig. 2 , Fig.S4A ). There was no existence of pleiotropy (p = 0.19) as shown in Tables S4 , and the exclusion of potentially pleiotropic variants identified using the MR-PRESSO method did not alter the outcomes. The robustness of the MR estimates was further confirmed by the leave-one-out test ( Fig. S4C ). Thyroid nodules, TPOAb We did not find a genetic association between thyroid nodules, TPOAb with PD, respectively (Fig. 2 , Fig. S5-6A) . Regarding thyroid nodules, the sensitivity analysis and heterogeneity test failed to reveal any potential horizontal pleiotropy or significant heterogeneity ( Tables S3 and S4 ). The leave-one-out test affirmed the stability of the MR estimate upon the removal of individual SNP ( Fig. S5-6C ). Lastly, the funnel plots on thyroid function and PD are presented in Fig. S1 -6B. Discussion This represents the inaugural study employing the MR methodology to scrutinize the causal correlation between thyroid function and PD. Given the accessible vast GWAS datasets pertaining to thyroid function and PD, the current time is indeed opportune for conducting MR analyses on these parameters. Our findings did not corroborate any causal impact of variation in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on the susceptibility to PD. On the contrary, we discerned significant inverse relationship between hyperthyroidism and the risk of PD. The underlying mechanism of the causal relationship between hyperthyroidism and reduced risk of PD is still unclear. Thyroxine, a hormone that individually respond to risk, so that hyperthyroidism may be associated with a higher risk response in individuals. This may mean that the individual does not make an excessively reaction about the dangerous environment, thereby alleviating the panic attack. In addition, previous studies have shown that thyroid hormone receptors are widely distributed in high concentrations in the cerebral cortex, hippocampus and other brain regions [ 32 ]. we discerned significant inverse relationship between hyperthyroidism and the risk of PD. Thyroid hormone is involved in neuron migration, differentiation and synaptic formation [ 33 ]. Therefore, it is necessary to further study the role of hyperthyroidism in the pathogenesis of PD. In an observational study [ 6 ], significant correlations between the thyroid hormone levels and clinical features were observed in PD patients, as well as a positive correlation between TSH levels and the severity of PD. However, other studies have reported an inverse correlation between TSH response and anxiety severity in the same patient population [ 8 ], but no evidence of a causal effect of TSH levels on PD risk was found in our study. Despite higher SNP-heritability estimates for thyroid function (TSH, FT4), there were no significant genetic correlations with PD in our study. Therefore, the negative results of our study suggest that thyroid function changes either do not affect PD risk at all. This may suggest that the genetically determined relationship between thyroid function and PD is not mediated through thyroid hormones directly, but using pathways that underpin disease pathogenesis, such as (general) autoimmunity [ 34 ]. Besides, it's worth noting that most of the current researches about thyroid function and PD are observational. Evidence from observational studies should be interpreted with caution as it cannot reveal causality and effect and completely exclude the influence of confounding factors. In another study, the authors tested the thyroid function of 165 patients diagnosed with PD and found that these subjects reported a higher prevalence of thyroid disease compared to the prevalence of thyroid disease in the general population; however, less than 1% of the subjects currently had thyroid dysfunction. The intensity of panic attacks or phobias did not correspond with thyroid function indicators [ 12 ]. Studies have shown that patients with PD have changes in peripheral hypothalamic– pituitary– adrenal (HPA) axis markers, which may indicate abnormal functioning of the central corticotropin-releasing hormone system [ 35 ]. In a sample of mostly women hospitalized with panic disorder, abnormal expression of N-methyl- D-aspartate receptors (NMDARs) is closely related to anxiety disorder with thyroid lesions, NMDAR subunits may have various activities and exert diverse effects in thyroid nodules, and the NR2A subunit may be an important regulator in anxiety disorder with thyroid nodules [ 36 ]. It's crucial to acknowledge that the bulk of existing research is observational. Findings from such studies ought to be treated with skepticism as they neither establish causality nor entirely eliminate the potential impact of extraneous variables. Therefore, we do MR analysis to exclude the interference of confounding factors, in order to study the causal relationship between the thyroid function and PD. Our research has several strengths. Primarily, the MR design's primary benefit is its ability to significantly mitigate the impact of confounding factors and reverse causality. Furthermore, to guarantee the independence of IVs, we conducted a comprehensive screening of single nucleotide polymorphisms utilizing Plink clumping. Finally, the included genetic instruments were fairly powerful because the F-statistics of the included SNPs were all over 10. There are still some limitations in our study. First of all, our exposure and outcome were both selected from the FinnGen consortium without the original study, so the sample overlap rate could not be calculated. Therefore, it is probable to have sample size overlap. Additionally, our study may be subject to racial bias as all chosen GWAS database populations were of European ancestry, necessitating further exploration to determine if this causal relationship still remains in other demographics. Furthermore, due to the unavailability of comprehensive demographic and clinical data on participants were not available, we were unable to conduct any subgroup analysis. Lastly, despite utilizing the largest GWAS database, the sample size of this study is comparatively modest when juxtaposed with population-based observational studies. Conclusion In summary, Our findings indicated a significant inverse correlation between hyperthyroidism and PD risk ,with no discernible causal impacts of alterations in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on PD risk. It may suggest that most thyroid function may not be the etiological factor of PD, further studies are needed to verify our results in the real world. In the future, studies should explore the related mechanism of hyperthyroidism leading to reduced incidence of panic disorder, and more RCTS are needed to investigate whether thyroid hormone can treat panic disorder. Declarations Competing interests The authors declare no competing interests. Ethics approval and consent to participate Not applicable. Ethical approval and informed consent for studies included in the analyses were provided in the original publications. Each study was approved by the appropriate institutional review board/ethics committee. Consent for publication Not applicable. Data Availability The datasets generated and analysed during the current study are available in the IEU open gwas project [https://gwas.mrcieu.ac.uk/] and its additional file. Funding This work was supported by the Medical Science and Technology Project of Zhejiang Province (2022KY613). Author contributions Sijie Yu: Conceptualization, Methodology, Software, Data curation, Writing- Original draft preparation. Chongkai Shen: Visualization, Investigation. Junpeng Zhu: Supervision, Software, Project administration, Validation, Writing- Reviewing and Editing. Acknowledgements We gratefully acknowledge all the studies and databases that made GWAS summary data available. 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Wang, S., et al., Role of N-methyl-d-aspartate receptors in anxiety disorder with thyroid lesions. Journal of psychosomatic research, 2022. 161 : p. 110998. Additional Declarations No competing interests reported. Supplementary Files supplementfigures.docx supplementtables.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3577312","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":247115836,"identity":"8b809eb5-d2ae-4d4e-99ae-8ea6df514dbc","order_by":0,"name":"Sijie Yu","email":"","orcid":"","institution":"Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sijie","middleName":"","lastName":"Yu","suffix":""},{"id":247115839,"identity":"a4f030f0-370e-4668-bb03-0e2bd611a17a","order_by":1,"name":"Chongkai Shen","email":"","orcid":"","institution":"The First People's Hospital of Xiaoshan District, Hangzhou","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chongkai","middleName":"","lastName":"Shen","suffix":""},{"id":247115841,"identity":"b853d48c-3907-4b43-9ae0-326a3478165b","order_by":2,"name":"Junpeng Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDACCQYGAwiL+QDDAwPStLAlMCQQqwUKeAwYEojRIT+7x6CYd8cdOXP+NR8/JBQcTtzOwPzw0Q08WhjnnDEw5j3zzNhyxtvNEgkGhxN3NrAZG+fg0cIskQPU0nY4ccONsxvAWjYc4GGTxqeFDaqlfsONM49/EKWFB6olweB8DxtxtkhIpBUYzm17ZrjhBpuZRYJBuvGGwwT8Ij8jeZvB27Y78gbnDz++8eGPteyG480PH+PTAvIOMP4OAO1LAHGagSGCXzkIMD8Aa+E/AOLUEVY/CkbBKBgFIw4AAGs9UjXAGg1tAAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Junpeng","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2023-11-08 04:29:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3577312/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3577312/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46239939,"identity":"945de424-3f24-46fb-9c1c-75c3dc103273","added_by":"auto","created_at":"2023-11-10 17:48:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236316,"visible":true,"origin":"","legend":"\u003cp\u003eAn overview of the study design. SNP, single nucleotide polymorphisms.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3577312/v1/0ebbbf4fc2596500d9bc874f.png"},{"id":46240376,"identity":"daa6fe62-99ed-46b0-bc8e-8119ee001705","added_by":"auto","created_at":"2023-11-10 17:56:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":943877,"visible":true,"origin":"","legend":"\u003cp\u003eCausal effects of variation in thyroid function and panic disorder risk. (OR: odds ratio; CI: confidence interval)\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3577312/v1/2131b26e74807dc699e066a4.png"},{"id":56869559,"identity":"b4658810-62ca-41ae-aa85-09cf2523e520","added_by":"auto","created_at":"2024-05-21 13:23:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1507431,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3577312/v1/42110992-80e0-4ec9-b87a-7560916a6097.pdf"},{"id":46239940,"identity":"eb3e34e5-4666-408a-8088-7768bd326e87","added_by":"auto","created_at":"2023-11-10 17:48:22","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":478653,"visible":true,"origin":"","legend":"","description":"","filename":"supplementfigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-3577312/v1/20323273b072355fc284654e.docx"},{"id":46239942,"identity":"b29865a0-c447-4824-8563-041bc6e377b2","added_by":"auto","created_at":"2023-11-10 17:48:23","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":164175,"visible":true,"origin":"","legend":"","description":"","filename":"supplementtables.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3577312/v1/6cbed44a24c2fdf9c8c75bc3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of the relationship between thyroid function and panic disorder: A mendelian randomization study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePanic disorder (PD), a prevalent and severe psychological ailment within the anxiety continuum, is distinguished by frequent and unforeseeable episodes of panic, accompanied by a variety of physiological manifestations. It often results in substantial impairment, particularly when accompanied by agoraphobia, and is associated with notable functional morbidity and diminished quality of life. Diagnosis based on International Classification of Diseases 10 (ICD-10) necessitates recurrent panic attacks, accompanied by either apprehension regarding future episodes or the emergence of phobic avoidance. Panic attacks are abrupt and sometimes unforeseen episodes of intense anxiety, often accompanied by physical manifestations such as cardiovascular, otoneurological, gastrointestinal, or autonomic symptoms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A comprehensive meta-analysis revealed that the most common age of onset is during late adolescence or early adulthood [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The National Comorbidity Survey Replication (NCS-R) provides prevalence estimates of 2.7% within a 12-month period and 4.7% over the course of a lifetime [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch has shown that risk factors for anxiety disorders include alcohol use, smoking, avoidance behaviors, marijuana use, occupational factors, and negative evaluations of stressful life events. Protective factors that produce some support include physical activity, sports participation, social support, and coping skills. The most researched risk or protective factor was cigarette smoking, which was found to increase the risk of PD development in many prospective studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while much less is known about the role of thyroid function.\u003c/p\u003e \u003cp\u003eAt present, the etiology of PD remains unclear, among which the hypothalamic-pituitary-thyroid (HPT) axis is an etiological factor. A large amount of studies have shown that the endocrine system responds to various stressors. Many researchers have explored changes in HPT axis hormones in stress responses [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The regulation of thyroid function is a multifaceted process that encompasses not only the thyroid gland, but also the pituitary gland, hypothalamus, and feedback mechanisms. The hypothalamus releases thyrotropin releasing hormone (TRH) acts on the pituitary, rereleasing thyroid stimulating hormone (TSH) acts on the thyroid, which releases free thyroid hormone (FT4). Studies of panic disorder have found evidence of a dulled response of thyroid stimulating hormone (TSH) to thyroid stimulating hormone (TRH) stimulation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thyroid hormones are essential for neurocognitive development and function, so the link between thyroid dysfunction and panic disorder has been studied over the past few decades [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Indeed, both TSH and FT4 have been associated with PD in an observational study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Some researches found initial support for an increased prevalence of thyroid disorders in patients with PD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Because of the high incidence of PD patients, a better understanding of its underlying mechanisms made essential to further improve its prevention and treatment.\u003c/p\u003e \u003cp\u003eThyroid dysfunction can cause symptoms similar to those seen in people with anxiety disorders, especially panic disorder. Some of the physical symptoms of hyperthyroidism, such as palpitations, shortness of breath, and increased sweating, overlap with what people with panic disorder experience during panic attacks. A link has been suggested between thyroid disease and panic attacks and phobias [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the extent to which PD patients suffer from thyroid dysfunction remains unclear. Learning more about such dysfunction first means obtaining an estimate of whether a person with PD has (subclinical) thyroid disease. Besides, this means studying subtle changes in individual thyroid function parameters, namely TSH, FT3, and FT4. Doing so may shed light on the complex relationship between PD and thyroid function and help determine whether the aforementioned panic symptoms may also occur as an epiphenomenon of subclinical thyroid dysfunction. Since observational studies are sometimes vulnerable to selection bias, residual confounding, and reverse causality, it is unclear if the reported relationships are causal [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the previous studies point to a connection between thyroid function and panic disorder, but it's important to clarify whether this connection is causative or not. In recent years, with the increasing popularity of genome-wide association studies (GWAS) databases, Mendelian randomization (MR) has attracted a lot of attention. MR can avoid some types of confounding by using genetic variants, which are fixed at conception, to support causal inferences about the effects of changeable risk factors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. MR can also yield insights into causality in situations where randomized controlled trials (RCTs) are impractical or insufficient [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], its level of research evidence lies at the junction of RCTs and observational studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], as it has the ability to emulate RCTs, and offers a reliable statistical approach utilizing instrumental variables (IVs) to elucidate the causal relationship between exposure and disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, in our current investigation, we executed a two-sample MR analysis using the GWAS database to scrutinize the genetic causality interlinking thyroid functionality and panic disorder. The thyroid function we studied included hyperthyroidism, hypothyroidism, FT4, TSH, thyroid peroxidase antibody (TPOAb), and thyroid nodules.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTwo-sample Mendelian Randomization\u003c/h2\u003e \u003cp\u003eWe conducted two-sample MR analyses using the data from the most recent GWAS on thyroid function as exposures, and PD as summary-level statistics. There was no necessity for further ethical consent as this involved a reevaluation of preexisting summary-level data. The MR analysis was conducted utilizing Two-sample MR (version 0.5.5) and R (version 4.2.1).\u003c/p\u003e \u003cp\u003eThe MR analysis hinges on three fundamental assumptions: 1) The chosen IVs must have a significant correlation with the exposure (thyroid function) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. We employ the F-statistic to evaluate the potency of each genetic tool. The subsequent formula calculates the F-statistic: F\u0026thinsp;=\u0026thinsp;beta\u003csup\u003e2\u003c/sup\u003e/se\u003csup\u003e2\u003c/sup\u003e (beta for the exposure association (beta); variance (se)) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. If the F-statistic exceeds 10, the IV possesses a robust capacity to forecast PD. 2) The chosen IVs cannot influence the outcome (panic disorder) via alternative routes, only through the specified exposure [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. 3) Confounding elements are not linked to the selected IVs. The schematic representation of the research design is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eGWAS data\u003c/h3\u003e\n\u003cp\u003eWe procured single nucleotide polymorphisms (SNPs) from the GWAS database, serving as genetic IVs [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Associations between diverse thyroid characteristics and instrument exposure among individuals of European descent. The significant SNPs associated with FT4、 TSH、TPOAb、hypothyroidism、hyperthyroidism (P\u0026thinsp;\u0026lt;\u0026thinsp;5\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;8\u003c/sup\u003e) and thyroid nodules (P\u0026thinsp;\u0026lt;\u0026thinsp;5\u0026times;10\u003csup\u003e\u0026minus;\u0026thinsp;6\u003c/sup\u003e) were procured from the correspondingly latest and most extensive GWAS database (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). We utilized PhenoScannerV2 (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.phenoscanner.medschl.cam.ac.uk\u003c/span\u003e\u003c/span\u003e) to delve deeper into the potential correlation of IVs with PD risk confounders [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. To circumvent any potential skewness instigated by intense linkage disequilibrium (LD), we opted for SNPs with an LDr\u003csup\u003e2\u003c/sup\u003e less than 0.001.\u003c/p\u003e\n\u003cp\u003eSummary data from GWAS for FT4 and TSH were procured from a research study involving 26,089 and 27,916 participants respectively [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. TPOAb [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] was from GWAS data that the participants was 18297. We procured summary-level GWAS data associated with hyperthyroidism from the FinnGen consortium, comprising 962 instances and 172,976 control subjects. Summary statistics for hypothyroidism from UK biobank comprising 463,010 participants (9674 cases and 453,336 controls). The GWAS data pertaining to thyroid nodule were obtained from a comprehensive meta-analysis, encompassing a total of 1121 cases juxtaposed with 187,684 control subjects [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The GWAS data pertinent to the outcome (PD) was culled from the FinnGen consortium, encompassing 2376 cases and 198,110 controls of European lineage. A comprehensive detailing of the GWAS summary data in our investigation is provided Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDetails of the GWAS included in the Mendelian randomization.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTrait\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDOI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYear\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePopulation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCases\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControls\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSamplesize\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehyperthyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.finngen.fi/en\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e962\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e172976\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e173938\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ehypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.nealelab.is/uk-biobank\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9674\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e453336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e463010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41467-018-06356-1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTSH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41467-018-06356-1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27916\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ethyroid nodule\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13044-021-00094-1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e187684\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e188805\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTPOAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pgen.1004123\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEuropean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eFT4, thyroid hormone; TSH, thyroid stimulating hormone; TPOAb, thyroid peroxidase antibody; NA, Not Applicable.\u003c/p\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eEstimations of thyroid function\u0026apos;s influence on PD risk via Mendelian randomization were computed utilizing the inverse variance weighting (IVW) approach, weighted median (WM) technique and the MR-Egger methodology. The IVW method, which used a meta-analysis method to integrate the Wald ratio of each SNPs, was the main MR analysis in our work. It was based on the assumption that IVs can only affect outcomes through a specific exposure. When horizontal pleiotropy was not present, the IVW method could produce unbiased causal estimates [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. Consequently, the IVW method offered the most accurate evaluation [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. To examine the bias caused by inefficient IV and horizontal pleiotropy effects, the complement of analysis was subjected to the WM method and the MR-Egger method [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. Due to the impact of outlying genetic variations, the estimations of the MR-Egger technique were likely erroneous [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. It was conducted to test whether there was evidence of the intercept parameter being different from zero. The WM method\u0026apos;s accuracy was lower and its bias was quite moderate, especially for the proportion of IVs with horizontal pleiotropy below 50% [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. The IV estimates of each SNP should be distributed symmetrically close to the point estimation in the absence of directional pleiotropy, demonstrating that there was no systematic bias in the data.\u003c/p\u003e\n \u003cp\u003eThe necessity of a comprehensive sensitivity analysis to scrutinize potential heterogeneity and horizontal pleiotropy was underscored, encompassing methods such as IVW, MR-Egger regression, weighted median, funnel plots, and leave-one-out analysis, in which a single variant was excluded at each step. To evaluate the variability of impact sizes for certain genetic IVs, the Cochran\u0026apos;s Q test was used. To measure vertical pleiotropy, the intercept from MR-Egger regression was used [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. We employed MR-PRESSO to evaluate the horizontal pleiotropy within the constructed MR model, eliminating any outlier prior to recalculating the causal influence if directional pleiotropy was identified with a p-value less than 0.05. A leave-one-out analysis was carried out to examine how the findings would change if one of the chosen SNPs were not included [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the GWAS, we pinpointed 31 SNPs for FT4 within the reference range, 61 SNP for TSH, 36 SNPs for hypothyroidism, 7 SNPs for hyperthyroidism, 9 SNPs for TPOAb concentration and 7 SNPs for thyroid nodules. Each of these exhibited an F-statistic exceeding 80, thereby suggesting the absence of weak instrumental bias. Detailed information regarding specific SNP, inclusive of the effect alleles, other alleles, effect allele frequency, beta (β), standard error, P-value, and F-statistic, can be found in \u003cb\u003eTable \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e. The outcomes of MR analyses exploring the correlations between genetically predicted thyroid function levels and PD risk are presented in \u003cb\u003eTable \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e\u003c/b\u003e and summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eHyperthyroidism\u003c/h2\u003e \u003cp\u003eThe genetic predisposition towards hyperthyroidism was found to have a negative correlation with PD, as indicated by an IVW OR of 0.93 (95% CI: 0.87\u0026ndash;0.98; P\u0026thinsp;=\u0026thinsp;0.01). It was similar to WM (OR\u0026thinsp;=\u0026thinsp;0.91, 95% CI: 0.84\u0026ndash;0.99, P\u0026thinsp;=\u0026thinsp;0.02) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eFig. \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003eA\u003c/b\u003e). This MR analysis did not reveal any substantial heterogeneity (Cochran\u0026rsquo;s Q P\u0026thinsp;=\u0026thinsp;0.49) or horizontal pleiotropy (P\u0026thinsp;=\u0026thinsp;0.79) (\u003cb\u003eTables S3 and S4\u003c/b\u003e). The robustness of the results was confirmed by sequentially removing SNPs and reanalyzing with the remaining ones, thereby demonstrating that the positive outcomes are not influenced by a single SNP ( \u003cb\u003eFig.\u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003eC\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHypothyroidism\u003c/h2\u003e \u003cp\u003eWe found no indications of a plausible causal link between hypothyroidism and the likelihood of PD (OR\u0026thinsp;=\u0026thinsp;0.57, 95%CI\u0026thinsp;=\u0026thinsp;0.01\u0026ndash;50.54, P\u0026thinsp;=\u0026thinsp;0.81). Analyses of sensitivity employing the MR Egger and WM techniques yielded both negative results (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eFig.\u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003eA\u003c/b\u003e). Based on the Egger intercept and Cochran\u0026rsquo;s Q test, no evidence of directional pleiotropy (p\u0026thinsp;=\u0026thinsp;0.4) and heterogeneity (p\u0026thinsp;=\u0026thinsp;0.24) were found (\u003cb\u003eTables S3 and S4\u003c/b\u003e ). The leave-one-out analysis indicated the robustness of the results (\u003cb\u003eFig. \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003eC\u003c/b\u003e) and the funnel plot showed it was symmetric (\u003cb\u003eFig. \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003eB\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eFT4\u003c/h2\u003e \u003cp\u003eThe association between FT4 and PD was not discovered through the IVW method (OR\u0026thinsp;=\u0026thinsp;1, 95%CI\u0026thinsp;=\u0026thinsp;0.78\u0026ndash;1.27, P\u0026thinsp;=\u0026thinsp;1), MR-Egger (OR\u0026thinsp;=\u0026thinsp;0.63, 95%CI\u0026thinsp;=\u0026thinsp;0.37\u0026ndash;1.07, P\u0026thinsp;=\u0026thinsp;1) and WM (OR\u0026thinsp;=\u0026thinsp;0.85, 95%CI\u0026thinsp;=\u0026thinsp;0.62\u0026ndash;1.18, P\u0026thinsp;=\u0026thinsp;0.34) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eFig.S3A\u003c/b\u003e). The outcomes of Cochran\u0026rsquo;s Q test, MR Egger regression, MR-PRESSO and the leave-one-out test indicated that the MR estimates were fairly robust (\u003cb\u003eTables S3 and S4, Fig. S3C\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTSH\u003c/h2\u003e \u003cp\u003eHeterogeneity (p\u0026thinsp;=\u0026thinsp;0.01) was found in TSH and PD (\u003cb\u003eTables S3\u003c/b\u003e). Therefore, we used random effect model for this two-sample MR analysis. There was no statistically significant between TSH and PD (OR\u0026thinsp;=\u0026thinsp;1.03, 95%CI\u0026thinsp;=\u0026thinsp;0.83\u0026ndash;1.28, P\u0026thinsp;=\u0026thinsp;0.77) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eFig.S4A\u003c/b\u003e). There was no existence of pleiotropy (p\u0026thinsp;=\u0026thinsp;0.19) as shown in \u003cb\u003eTables S4\u003c/b\u003e, and the exclusion of potentially pleiotropic variants identified using the MR-PRESSO method did not alter the outcomes. The robustness of the MR estimates was further confirmed by the leave-one-out test (\u003cb\u003eFig. S4C\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThyroid nodules, TPOAb\u003c/h2\u003e \u003cp\u003eWe did not find a genetic association between thyroid nodules, TPOAb with PD, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cb\u003eFig. S5-6A)\u003c/b\u003e. Regarding thyroid nodules, the sensitivity analysis and heterogeneity test failed to reveal any potential horizontal pleiotropy or significant heterogeneity (\u003cb\u003eTables S3 and S4\u003c/b\u003e). The leave-one-out test affirmed the stability of the MR estimate upon the removal of individual SNP (\u003cb\u003eFig. S5-6C\u003c/b\u003e). Lastly, the funnel plots on thyroid function and PD are presented in \u003cb\u003eFig. \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e-6B.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis represents the inaugural study employing the MR methodology to scrutinize the causal correlation between thyroid function and PD. Given the accessible vast GWAS datasets pertaining to thyroid function and PD, the current time is indeed opportune for conducting MR analyses on these parameters. Our findings did not corroborate any causal impact of variation in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on the susceptibility to PD. On the contrary, we discerned significant inverse relationship between hyperthyroidism and the risk of PD.\u003c/p\u003e \u003cp\u003eThe underlying mechanism of the causal relationship between hyperthyroidism and reduced risk of PD is still unclear. Thyroxine, a hormone that individually respond to risk, so that hyperthyroidism may be associated with a higher risk response in individuals. This may mean that the individual does not make an excessively reaction about the dangerous environment, thereby alleviating the panic attack. In addition, previous studies have shown that thyroid hormone receptors are widely distributed in high concentrations in the cerebral cortex, hippocampus and other brain regions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. we discerned significant inverse relationship between hyperthyroidism and the risk of PD. Thyroid hormone is involved in neuron migration, differentiation and synaptic formation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Therefore, it is necessary to further study the role of hyperthyroidism in the pathogenesis of PD.\u003c/p\u003e \u003cp\u003eIn an observational study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], significant correlations between the thyroid hormone levels and clinical features were observed in PD patients, as well as a positive correlation between TSH levels and the severity of PD. However, other studies have reported an inverse correlation between TSH response and anxiety severity in the same patient population [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], but no evidence of a causal effect of TSH levels on PD risk was found in our study. Despite higher SNP-heritability estimates for thyroid function (TSH, FT4), there were no significant genetic correlations with PD in our study. Therefore, the negative results of our study suggest that thyroid function changes either do not affect PD risk at all. This may suggest that the genetically determined relationship between thyroid function and PD is not mediated through thyroid hormones directly, but using pathways that underpin disease pathogenesis, such as (general) autoimmunity [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Besides, it's worth noting that most of the current researches about thyroid function and PD are observational. Evidence from observational studies should be interpreted with caution as it cannot reveal causality and effect and completely exclude the influence of confounding factors.\u003c/p\u003e \u003cp\u003eIn another study, the authors tested the thyroid function of 165 patients diagnosed with PD and found that these subjects reported a higher prevalence of thyroid disease compared to the prevalence of thyroid disease in the general population; however, less than 1% of the subjects currently had thyroid dysfunction. The intensity of panic attacks or phobias did not correspond with thyroid function indicators [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies have shown that patients with PD have changes in peripheral hypothalamic\u0026ndash; pituitary\u0026ndash; adrenal (HPA) axis markers, which may indicate abnormal functioning of the central corticotropin-releasing hormone system [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In a sample of mostly women hospitalized with panic disorder, abnormal expression of N-methyl- D-aspartate receptors (NMDARs) is closely related to anxiety disorder with thyroid lesions, NMDAR subunits may have various activities and exert diverse effects in thyroid nodules, and the NR2A subunit may be an important regulator in anxiety disorder with thyroid nodules [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt's crucial to acknowledge that the bulk of existing research is observational. Findings from such studies ought to be treated with skepticism as they neither establish causality nor entirely eliminate the potential impact of extraneous variables. Therefore, we do MR analysis to exclude the interference of confounding factors, in order to study the causal relationship between the thyroid function and PD. Our research has several strengths. Primarily, the MR design's primary benefit is its ability to significantly mitigate the impact of confounding factors and reverse causality. Furthermore, to guarantee the independence of IVs, we conducted a comprehensive screening of single nucleotide polymorphisms utilizing Plink clumping. Finally, the included genetic instruments were fairly powerful because the F-statistics of the included SNPs were all over 10.\u003c/p\u003e \u003cp\u003eThere are still some limitations in our study. First of all, our exposure and outcome were both selected from the FinnGen consortium without the original study, so the sample overlap rate could not be calculated. Therefore, it is probable to have sample size overlap. Additionally, our study may be subject to racial bias as all chosen GWAS database populations were of European ancestry, necessitating further exploration to determine if this causal relationship still remains in other demographics. Furthermore, due to the unavailability of comprehensive demographic and clinical data on participants were not available, we were unable to conduct any subgroup analysis. Lastly, despite utilizing the largest GWAS database, the sample size of this study is comparatively modest when juxtaposed with population-based observational studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, Our findings indicated a significant inverse correlation between hyperthyroidism and PD risk ,with no discernible causal impacts of alterations in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on PD risk. It may suggest that most thyroid function may not be the etiological factor of PD, further studies are needed to verify our results in the real world. In the future, studies should explore the related mechanism of hyperthyroidism leading to reduced incidence of panic disorder, and more RCTS are needed to investigate whether thyroid hormone can treat panic disorder.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. Ethical approval and informed consent for studies included in the analyses were provided in the original publications. Each study was approved by the appropriate institutional review board/ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available in the IEU open gwas project [https://gwas.mrcieu.ac.uk/] and its additional file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Medical Science and Technology Project of Zhejiang Province (2022KY613).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSijie Yu: Conceptualization, Methodology, Software, Data curation, Writing- Original draft preparation. Chongkai Shen: Visualization, Investigation. Junpeng Zhu: Supervision, Software, Project administration, Validation, Writing- Reviewing and Editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge all the studies and databases that made GWAS summary data available. We are extremely grateful to Medical Science and Technology Project of Zhejiang Province (2022KY613).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePublisher\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003es Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoy-Byrne, P.P., M.G. Craske, and M.B. 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\u003cstrong\u003e18\u003c/strong\u003e(1): p. 312.\u003c/li\u003e\n\u003cli\u003eWilliams, G.R., \u003cem\u003eNeurodevelopmental and neurophysiological actions of thyroid hormone.\u003c/em\u003e J Neuroendocrinol, 2008. \u003cstrong\u003e20\u003c/strong\u003e(6): p. 784-94.\u003c/li\u003e\n\u003cli\u003eAus\u0026oacute;, E., et al., \u003cem\u003eA moderate and transient deficiency of maternal thyroid function at the beginning of fetal neocorticogenesis alters neuronal migration.\u003c/em\u003e Endocrinology, 2004. \u003cstrong\u003e145\u003c/strong\u003e(9): p. 4037-47.\u003c/li\u003e\n\u003cli\u003eFoldager, L., et al., \u003cem\u003eBipolar and panic disorders may be associated with hereditary defects in the innate immune system.\u003c/em\u003e J Affect Disord, 2014. \u003cstrong\u003e164\u003c/strong\u003e: p. 148-54.\u003c/li\u003e\n\u003cli\u003eFischer, S., \u003cem\u003eThe hypothalamus in anxiety disorders.\u003c/em\u003e Handbook of clinical neurology, 2021. \u003cstrong\u003e180\u003c/strong\u003e: p. 149-160.\u003c/li\u003e\n\u003cli\u003eWang, S., et al., \u003cem\u003eRole of N-methyl-d-aspartate receptors in anxiety disorder with thyroid lesions.\u003c/em\u003e Journal of psychosomatic research, 2022. \u003cstrong\u003e161\u003c/strong\u003e: p. 110998.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"panic disorder, thyroid function, thyroid hormone, hyperthyroidism, Mendelian randomization study","lastPublishedDoi":"10.21203/rs.3.rs-3577312/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3577312/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMultiple observational studies have indicated a correlation between thyroid function and the risk of panic disorder (PD). Nevertheless, the causality surrounding this association remains unclear. Our objective was to evaluate the causality between thyroid function and the risk of PD by employing Mendelian randomization (MR).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe employed publicly available genome-wide association studies (GWAS) to select single nucleotide polymorphisms (SNPs) that are associated with various aspects of thyroid function (hyperthyroidism, hypothyroidism, FT4, TSH, TPOAb, and thyroid nodules). The statistical data on panic disorder were obtained from the FinnGen consortium. To assess causality, we utilized the inverse variance weighted (IVW) method, MR-Egger method and weighted median (WM) method for the MR estimates. Sensitivity analyses were conducted using Cochran\u0026rsquo;s Q test, MR-Egger intercept, MR-Pleiotropy Residual Sum and Outlier method, leave-one-out analysis, and funnel plot.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe genetically predicted presence of hyperthyroidism showed an inverse association with PD as evident from the IVW OR of 0.93 (95% CI: 0.87\u0026ndash;0.98; P\u0026thinsp;=\u0026thinsp;0.01).However, our findings did not indicate any causal effects of variation in FT4 (OR: 0.78, 95%CI: 0.78\u0026ndash;1.27; P\u0026thinsp;=\u0026thinsp;1)、TSH (OR: 1.03, 95%CI: 0.83\u0026ndash;1.28; P\u0026thinsp;=\u0026thinsp;0.77)、TPOAb (OR: 0.9, 95%CI: 0.47\u0026ndash;1.72; P\u0026thinsp;=\u0026thinsp;0.75)、hypothyroidism (OR: 0.57, 95%CI: 0.01\u0026ndash;50.54; P\u0026thinsp;=\u0026thinsp;0.81) and thyroid nodules (OR: 1.02, 95%CI: 0.91\u0026ndash;1.14; P\u0026thinsp;=\u0026thinsp;0.76) on PD risk.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn summary, Our findings indicated a significant inverse correlation between hyperthyroidism and PD risk, with no discernible causal impacts of alterations in FT4、TSH、TPOAb、hypothyroidism and thyroid nodules on PD risk. It may suggest that most thyroid function may not be the etiological factor of PD, further studies are needed to verify our results in the real world.\u003c/p\u003e","manuscriptTitle":"Assessment of the relationship between thyroid function and panic disorder: A mendelian randomization study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-10 17:48:18","doi":"10.21203/rs.3.rs-3577312/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f6aa8a00-1d0f-40f4-805e-b8b2ed96e954","owner":[],"postedDate":"November 10th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-21T13:14:57+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-10 17:48:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3577312","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3577312","identity":"rs-3577312","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}