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
Mental Health and
Primary Care

Primary
Care

Mental
Health
Primary Care and
Mental Health

Mental
Health

Primary
Care
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

70,000,000 people in the US have a
Diagnosable Mental/Addictive Disorder

No Mental/
Addictive
Disorder
72%

Mental/
Addictive
Disorder
28%

Reiger et al. 1993

40,000,000 people in the US receive services
for Mental/Addictive Disorders

Treatment
15%

No
Treatment
85%

Reiger et al. 1993

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)
Percentage of Patients per Sector
PATIENTS SECTOR
21.5% Not in Treatment
15.0% Specialty Mental Health,
Inpatient and Outpatient
6.0% Overlap
54.1% General Medical Sector
Outpatient, Primary Care
3.4% General Medical Sector,
Inpatient, including Nursing Homes
“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
 Organizing Principles DSM-IV
Affective Disorders

Anxiety Disorders

Psychotic Disorders
Substance Abuse
Other
 Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders

Psychotic Disorders
Substance Abuse
Other
 Organizing Principles DSM-IV
Affective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias
Psychotic Disorders
Substance Abuse
Other
 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
 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
 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
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

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
Panic Attack: 4 or more
Fear of Dying Fear of Losing Control
Sweating Derealization
Trembling Nausea
SOB Choking feeling
Parathesias Hot flashes
Chest Pain
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
Panic Attacks: Comorbidity
• Substance Abuse
• Major Depression
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Generalized Anxiety Disorder
• Personality Disorder
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
Medical Presentations
• Cardiac Panic
• Pulmonary Panic
• GI Panic
• “Vertigo” Panic
• Panic exacerbating pre-existing disease
“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
“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)
“GI” Panic
• 6-25%Unexplained GI symptoms in general pop
• Significant concurrence between IBS and PD
• Lifetime prevalence of PD
– In IBD: ~3%
– In IBS: 28%
 “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
“Personalities”
• Alexithymia
• Somatothymia
• Diminished ego strength
• Medicalized distress
• Resists diagnosis
• Personality Disorder
Panic-Personality Comorbidity
• 40-50% with PD have a Personality Disorder
• Most likely Cluster C (anxious type):
– Avoidant
– Obsessive-compulsive
– Dependent
Treatment
• Psychotherapy-Cognitive Behavioral Therapy
• SSRI
• TCAD
• Benzodiazepines
• MAOI
• Combinations
• Other
Management Issues
• Overstimulation
• Jitteriness
• Dependence
• Drug-Drug Interactions