PANIC DISORDERS IN PRIMARY CARE

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PANIC DISORDERS IN PRIMARY CARE

• ROBERT K. SCHNEIDER, MD
• Assistant Professor
• Departments of Psychiatry and Internal Medicine
• Medical College of Virginia Campus
• of the Virginia Commonwealth University

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Mental Health and Primary Care
Primary Care
Mental Health
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Primary Care and Mental Health
Mental Health
Primary Care
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Epidemiologic Catchment Area Study

• Five specific geographic areas
• Adults aged 18 years and older
• Structured interviews initially, at 6 and 12
  months
• Defined areas of mental health services

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70,000,000 people in the US have a Diagnosable
Mental/Addictive Disorder
Reiger et al. 1993
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40,000,000 people in the US receive services for
Mental/Addictive Disorders
Reiger et al. 1993
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Sectors Where Mental Health Services are Provided

• Specialty Mental /Addictive Sector
• Inpatient and Outpatient Psychiatric/Addictive
• General Medical Sector
• Nursing Home and Hospitals
• Outpatient (Primary Care Setting)
• Other
• Human Service Professionals (Clergy, Counselors)
• Voluntary support Network (Family, Friends, AA)

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Percentage of Patients per Sector
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de facto mental health system Regier,1978

• 54 of people with mental illness who seek
  treatment are exclusively seen in the general
  medical sector
• 25 of patients in primary care setting have a
  diagnosable mental illness

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Organizing Principles DSM-IV
Affective Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder, Dysthymia
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder, Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder, Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse
Other
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Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder, Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse Alcohol, Cocaine, Nicotine, Other
Other
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Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder, Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse Alcohol, Cocaine, Nicotine, Other
Other Psychiatric Aspects of Medical Disease Stroke, Dementia, HIV, CAD Other Psych Personality Disorders, Eating Disorders, Somatization
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Psychiatric Disorders in the Primary Care Setting

• Any Diagnosis 30-50
• Major Depression 7-19
• Substance Abuse/Dependence 3-7
• Any Anxiety Disorder 10-25
• Panic Disorder 1-6
• JAMA Dec. 14,1994

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Panic Attacks General

• Panic Disorder 1.5-4.0 General Population
• Panic Attacks (no disorder) 15
• 2-3x Females Males
• Develops in Young Adulthood and Adolescence

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Panic Attack 4 or more

• Fear of Dying Fear of Losing Control
• Sweating Derealization
• Trembling Nausea
• SOB Choking feeling
• Parathesias Hot flashes
• Chest Pain

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Agoraphobia Criteria

• Anxiety about being in places or situations from
  which escape might be difficult or in which help
  may not be available in the event of having a
  panic attack

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Panic Attacks Comorbidity

• Substance Abuse
• Major Depression
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Generalized Anxiety Disorder
• Personality Disorder

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Panic-Depression Comorbidity

• 30-40 MDD have recurrent panic attacks
• 10-20 MDD have panic disorder
• 50-55 PD (or panic attacks) have MDD
• Patients with MDD and PD
• Earlier onset MDD
• More severe MDD

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Medical Presentations

• Cardiac Panic
• Pulmonary Panic
• GI Panic
• Vertigo Panic
• Panic exacerbating pre-existing disease

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Cardiac Panic

• Chest pain, tachycardia and palpations most
  common panic symptoms
• Chest pain with negative angiography
• 43-61 have PD
• 80 have PD, MDD or Both
• 50 with dysfunction years after study
• 9.2 of cardiology practice had PD
• 40-60 had ischemic heart disease

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Pulmonary Panic

• 32 of asthmatic patients have panic attacks
  during an asthma attack
• Of patients referred for PFTs
• 41 had panic attacks
• 17 had panic disorder
• (24)-67 of patients with COPD had panic
  disorder
• No PD
• Subjective improvement in dyspenia with
  sertraline (only 7 in case series)

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GI Panic

• 6-25Unexplained GI symptoms in general pop
• Significant concurrence between IBS and PD
• Lifetime prevalence of PD
• In IBD 3
• In IBS 28

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Vertigo Panic

• Dizziness second most common symptom in PD
• 50-85 of PD patients report dizziness
• Some studies find a high rate of vestibular
  dysfunction in patients with PD
• (especially if agoraphobia is present)
• Headache third most common PD symptom
• 12-15 of headache patients have PD

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Personalities

• Alexithymia
• Somatothymia
• Diminished ego strength
• Medicalized distress
• Resists diagnosis
• Personality Disorder

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Panic-Personality Comorbidity

• 40-50 with PD have a Personality Disorder
• Most likely Cluster C (anxious type)
• Avoidant
• Obsessive-compulsive
• Dependent

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Treatment

• Psychotherapy-Cognitive Behavioral Therapy
• SSRI
• TCAD
• Benzodiazepines
• MAOI
• Combinations
• Other

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Management Issues

• Overstimulation
• Jitteriness
• Dependence
• Drug-Drug Interactions