Non-fearful panic disorder: a variant of panic in medical patients?

Is it possible to have panic attacks without fear? Beitman et al. reported that 32%-41% of panic disorder (PD) patients seeking treatment for chest pain have non-fearful panic disorder (NFPD). To replicate and extend this work on NFPD, the authors compared NFPD patients (N = 48), PD patients (N = 60), and No-PD patients (N = 333) at the time of an emergency department visit and follow-up approximately 2 years later. The authors compared comorbid Axis I diagnoses, panic attack symptoms, and scores on self-report measures. A significantly greater proportion of PD patients had comorbid generalized anxiety disorder and agoraphobia than NFPD patients. NFPD patients had self-report scores that were between no-PD and PD patients or similar to no-PD patients, with the exception of the Beck Depression Inventory. At follow-up, NFPD patients, like PD patients, were still symptomatic and had either not improved or had worsened according to scores on all self-report measures. NFPD should be recognized as a variant of PD, both because of its high prevalence in medical settings and its poor prognosis.

Is panic disorder associated with coronary artery disease? A critical review of the literature.

OBJECTIVE: To critically review existing literature examining the relationship between panic disorder (PD) and coronary artery disease (CAD). We specifically sought answers to the following questions: (1) What is the prevalence of PD in CAD patients? (2) What is the directionality of the relationship between PD and CAD? (3) What mechanisms may mediate the link between PD and CAD? METHODS: Medline and Psychlit searches were conducted using the following search titles: "panic disorder and coronary artery disease", "panic disorder and coronary heart disease", and "panic disorder and cardiovascular disease" for the years 1980-1998. The above search was also repeated replacing "panic disorder" with "panic attacks" for the same period. RESULTS: The prevalence of PD in both cardiology out-patients and patients with documented CAD ranges from 10% to 50%. The association between PD and CAD appeared strongest in patients with atypical chest pain or symptoms that could not be fully explained by coronary status. There is some evidence linking phobic anxiety but not PD per se to CAD risk, but little evidence linking CAD to PD risk. Studies of the mechanisms linking PD to CAD are still in their infancy, but there is preliminary evidence linking PD to reduced heart rate variability (HRV) and myocardial ischemia, two pathophysiological mechanisms related to CAD. CONCLUSION: PD is prevalent in CAD patients, but it is unclear the extent to which PD confers risk for and/or exacerbates CAD. Prospective research is needed to more firmly establish PD as a distinct risk factor for the development and progression of CAD. However, because many of the symptoms of PD mimic those of CAD, differentiating these disorders and learning how they may influence each other is imperative for clinical practice.

Clonazepam treatment of panic disorder in patients with recurrent chest pain and normal coronary arteries.

OBJECTIVE: To examine the efficacy of clonazepam in chest pain patients with panic disorder and normal coronary arteries. METHOD: We conducted a placebo controlled, double blind, flexible dose (1-4 mg/d), six-week trial of clonazepam. All subjects (N = 27) had current panic disorder and a negative coronary angiogram or thallium exercise tolerance test within the previous year. RESULTS: Analyses show modest improvements in the clonazepam and placebo groups over the first four weeks in both primary outcome measures. Eight of twelve (67%) clonazepam treated patients responded with reduction of panic attacks by week four to zero per week or half of initial frequency, while seven of fifteen (47%) placebo treated patients responded (not significant). When response was measured by 50 percent reduction in Hamilton Anxiety total score, however, seven of twelve (58%) clonazepam treated patients responded, while two of fifteen (14%) placebo treated patients responded, (p = .038) by Fisher's exact test. Within-subject improvements over the first four weeks were not significantly greater for the clonazepam group than for the placebo group on either outcome measure. CONCLUSIONS: These results show a generally good outcome in chest pain patients with panic disorder, and they provide suggestive evidence for the efficacy of clonazepam compared to placebo. This study points to the need for larger, well-funded treatment studies of chest pain patients with panic disorder.

A new psychotherapy training program : description and preliminary results.

Psychotherapy training programs require a uniform introduction to psychotherapy that presents the basic, generic concepts common to the major schools in a time-efficient manner. The program described in this article fits these criteria. The program has been initiated at seven residency training programs in the United States. The authors describe the six modules comprising the program-verbal response modes and intentions, working alliance, inducing patterns, change, resistance, and transference and countertransference. The authors also report preliminary results of the program evaluation (N = 15) from the University of Missouri-Columbia. By using a well-researched measure of trainee self-confidence as psychotherapist (The Counselor Self-Estimate Inventory), the authors report a statistically significant increase in trainee self-confidence beginning and maintained after Module 4. The authors conclude that this training shows promise as a standard introduction to psychotherapy for psychiatric residents.

Comparing emergency department and psychiatric setting patients with panic disorder.

In a recent study, the authors reported that 25% (108/441) of consecutive emergency department (ED) chest pain patients had panic disorder (PD). As part of this study, the authors sought to answer the question: How do ED patients with PD compare with patients with PD who seek treatment in a psychiatric setting? PD patients from an ED (n = 108) and psychiatric clinic (n = 137) were compared with respect to comorbid Axis I diagnoses, self-report scores, and recent suicidal ideation. The group of psychiatric patients was younger (36.5 vs. 52.3 years) (P < 0.0001) and consisted of proportionally more women (63% vs. 39%) (P = 0.0001) than the ED patients. The psychiatric patients had significantly higher rates of comorbid agoraphobia (100% vs. 15%) (P < 0.0001), social phobia (23% vs. 3%) (P = 0.0001), specific phobia (12.3% vs. 4.6%) (P = 0.03), and posttraumatic stress disorder (16.9% vs. 5.6%) (P = 0.006), compared with the ED patients, and displayed significantly higher scores on all of the self-report panic measures. However, the patients in both groups had similar rates of comorbid generalized anxiety disorder (41.2% vs. 33.3%) (P = 0.17), major depression (8.8% vs. 11.1%) (P = 0.54), and obsessive-compulsive disorder (1.5% vs. 2.8%) (P = 0.7). Both groups also did not differ on the Beck Depression Inventory and in their rate of report of recent suicidal ideation (32% vs. 25%) (P = 0.23). Both psychiatric and ED patients with PD appear to be highly distressed patients who require treatment. Early intervention for ED patients may prevent both chronic patient distress and development of the significant phobic avoidance observed in psychiatric patients.

Panic disorder: a different perspective.

Panic disorder is a chronic and debilitating illness. In this article, we present an algorithm of the diagnosis and treatment of the illness. We place much importance upon the patient variables associated with the treatment decisions. We emphasize strong patient involvement in treatment as a way to become panic free and improve level of functioning. Panic disorder is defined in DSM-IV1 as "The presence of recurrent panic attacks followed by at least one month of persistent concern about having another panic attack, worry about the possible implications or consequences of the panic attack, or a significant behavioral change related to the attacks." A panic attack is defined as "a discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes." 1) Palpitations, pounding heart or accelerated heart rate; 2) sweating; 3) trembling or shaking; 4) sensations of shortness of breath or smothering; 5) feeling of choking; 6) chest pain or discomfort; 7) nausea or abdominal distress; 8) feeling dizzy, unsteady, light-headed or faint; 9) derealization or depersonalization; 10) fear of losing control or going crazy; 11) fear of dying; 12) paresthesias; 13) chills or hot flashes. The following hypotheses have been used to conceptualize panic disorder from a psychiatrist's perspective.

Cardiovascular death from panic disorder and panic-like anxiety: a critical review of the literature.

Several symptoms of panic disorder mimic those of cardiovascular diseases and patients with this disorder frequently consult physicians with the fear of dying from a heart attack. The salient question is: Can the patient with panic disorder die from the cardiovascular consequences of his/her panic attacks? We critically review the six studies that have examined the association between panic disorder (or panic-like anxiety) and cardiovascular mortality or complications associated with the cardiovascular system. We then briefly review the evidence by which mechanisms panic may be linked to cardiovascular mortality and conclude with proposed guidelines for patient management.

Panic disorder in coronary artery disease patients with noncardiac chest pain.

In this study we address the following questions: (1) What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)? (2) How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress? Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales. Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample. A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD. Thirty-four percent (25 of 74) of CAD patients met criteria for PD. Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD. However, they did not differ from non-CAD patients with PD. PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.

Suicidal ideation in emergency department chest pain patients: panic disorder a risk factor.

Most patients who present to the emergency department (ED) for chest pain do not have a cardiac disorder. Approximately 30% of noncardiac chest pain patients suffer from panic disorder (PD), a disabling, treatable, yet rarely detected psychiatric condition. Although still controversial, PD may be a risk factor for suicidal ideation and attempts. The prevalence of recent suicidal ideation (ie, past week) was studied in 441 consecutive ED chest pain patients who underwent a structured psychiatric interview. To examine the controversial link between panic and suicidal behavior, logistic regression analyses were conducted in which current psychiatric diagnoses (Axis I) as well as pertinent medical and demographic information were assessed as risk factors for suicidal ideation. Participants were interviewed with the Anxiety Disorders Interview Schedule-Revised to establish psychiatric diagnoses. Recent suicidal ideation (ie, past week) was assessed with question 9 of the Beck Depression Inventory. Ten percent of patients had recent suicidal ideation. Sixty percent of patients with suicidal thoughts met criteria for PD. In the patients with PD, suicidal ideation could not be explained by the presence of comorbid psychiatric or medical conditions or medication. In the total sample, only diagnoses of PD (odds ratio [OR] = 4.3; 95%, confidence interval [CI], 2.09-8.82; P = .0001) and dysthymia (OR = 9.98; 95% CI, 4.00-24.8; P = .00001) were significant and independent risk factors for suicidal ideation. PD, the most common psychiatric condition in ED chest pain patients, may be an independent risk factor for suicidal ideation, further supporting the need for recognition and treatment of these patients.

Application of the Stages of Change Scale in a clinical drug trial.

The Stages of Change Scale (SOC: McConnaughy, Prochaska, & Velicer, 1983) was used to predict outcome among 131 outpatients with generalized anxiety disorder who were enrolled in a clinical drug trial. As predicted, subjects high on Precontemplation did not experience as much relief from anxiety as subjects low on Precontemplation, whereas subjects high on Contemplation or Action experienced more decrease in anxiety during the trial than subjects low on these stages. Contrary to our hypothesis, only Contemplation was related to illness severity changes, and scores on the Maintenance scale were not related to outcome. Of the four stage scores, only Maintenance was related to premature termination of treatment. There were no differences between drug (adinazolam) and placebo groups and only Action scores interacted with drug/placebo assignment in this study. Results suggest that the SOC may be useful in identifying individuals who are most likely to experience decreased anxiety while enrolled in a clinical drug trial.

Detecting panic disorder in emergency department chest pain patients: a validated model to improve recognition.

OBJECTIVE: To develop and validate a detection model to improve the probability of recognizing panic disorder in patients consulting the emergency department for chest pain. METHODS: Through logistic regression analysis, demographic, self-report psychological, and pain variables were explored as factors predictive of the presence of panic disorder in 180 consecutive patients consulting an emergency department with a chief complaint of chest pain. The detection model was then prospectively validated on a sample of 212 patients recruited following the same procedure. RESULTS: Panic-agoraphobia (Agoraphobia Cognitions Questionnaire, Mobility Inventory for Agoraphobia), chest pain quality (Short Form McGill Pain Questionnaire), pain loci, and gender variables were the best predictors of the presence of panic disorder. These variables correctly classified 84% of chest pain subjects in panic and non-panic disorder categories. Model properties: sensitivity 59%; specificity 93%; positive predictive power 75%; negative predictive power 87% at a panic disorder sample prevalence of 26%. The model correctly classified 73% of subjects in the validation phase. CONCLUSION: The scales in this model take approximately ten minutes to complete and score. It may improve upon current physician recognition of panic disorder in patients consulting for chest pain.

Unexplained chest pain: when is it panic disorder?

Noncardiac chest pain is a common costly phenomenon in the cardiology setting. Recent research suggests that panic disorder, a highly distressful yet treatable anxiety disorder, occurs in a significant proportion of noncardiac chest pain patients. This article reviews research on the prevalence of panic disorder in patients seen in cardiology settings for unexplained chest pain. Financial, psychosocial, and historical aspects of noncardiac chest pain are described. Panic disorder and the potential consequences of its nonrecognition by physicians are examined. Current psychological and pharmacologic treatments are reviewed. Recommendations on the management of panic patients in the cardiology setting are provided.

Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition.

PURPOSE: To establish the prevalence of panic disorder in emergency department (ED) chest pain patients; compare psychological distress and recent suicidal ideation in panic and non-panic disorder patients; assess psychiatric and cardiac comorbidity; and examine physician recognition of this disorder. DESIGN: Cross-sectional survey (for psychiatric data). Prospective evaluation of patient discharge diagnoses and physician recognition of panic disorder. SETTING: The ambulatory ED of a major teaching hospital specializing in cardiac care located in Montreal, Canada. SUBJECTS: Four hundred and forty-one consenting, consecutive patients consulting the ED with a chief complaint of chest pain. PRIMARY OUTCOME MEASURE: Psychiatric diagnoses (AXIS I). Psychological and pain test scores, discharge diagnoses, and cardiac history. RESULTS: Approximately 25% (108/441) of chest pain patients met DSM-III-R criteria for panic disorder. Panic disorder patients displayed significantly higher panic-agoraphobia, anxiety, depression, and pain scores than non-panic disorder patients (P < 0.01). Twenty-five percent of panic disorder patients had thoughts of killing themselves in the week preceding their ED visit compared with 5% of the patients without this disorder (P = 0.0001) even when controlling for co-existing major depression. Fifty-seven percent (62/108) panic disorder patients also met criteria for one or more current AXIS I disorder. Although 44% (47/108) of the panic disorder patients had a prior documented history of coronary artery disease (CAD), 80% had atypical or nonanginal chest pain and 75% were discharged with a "noncardiac pain" diagnosis. Ninety-eight percent of the panic patients were not recognized by attending ED cardiologists. CONCLUSIONS: Panic disorder is a significantly distressful condition highly prevalent in ED chest pain patients that is rarely recognized by physicians. Nonrecognition may lead to mismanagement of a significant group of distressed patients with or without coronary artery disease.

Integrating pharmacotherapy and psychotherapy: an emerging field of study.

The mind-brain barrier is being challenged by clinicians using both medications and psychotherapy for the major psychiatric disorders. In this paper, six categories of study are outlined: 1) Diagnosis specific questions, 2) psychotherapy during randomized controlled mediation trials, 3) psychotherapeutic aspects of pharmacotherapy, 4) pharmaco-therapist and the non-medical psychotherapist, 5) meaning of medications during psychotherapy, and 6) neurology of psychotherapy. Three of these are elaborated upon: 1) diagnostic questions as they relate to panic disorder, 2) pharmacotherapy during the stages of psychotherapy, and 3) the neurology of psychotherapy.

Integrating pharmacotherapy and psychotherapy: an emerging field of study.

The mind-brain barrier is being challenged by clinicians using both medications and psychotherapy for the major psychiatric disorders. In this article, six categories of study are outlined: (1) diagnosis-specific questions, (2) psychotherapeutic aspects of randomized controlled medication trials, (3) psychotherapeutic aspects of pharmacotherapy, (4) the pharmacotherapist and the nonmedical psychotherapist triangle, (5) the meaning of medications during the stages of psychotherapy, and (6) a neurology of psychotherapy. Three categories are elaborated upon: (1) diagnosis-specific questions as they relate to disorder, (2) the meaning of medications during the stages of psychotherapy, and (3) neurology of psychotherapy.

Panic disorder, chest pain and coronary artery disease: literature review.

OBJECTIVE: To examine the association among panic disorder, atypical chest pain and coronary artery disease (CAD). This article's purpose is to inform cardiologists of the prevalence of psychiatric disorders, primarily panic disorder, among patients consulting for chest pain. Panic disorder is described. Treatment modalities are summarized, and social, financial and medical consequences of nondetection are underlined. DATA SOURCES: PSYCHLIT and MEDLINE searches under panic disorder and chest pain-related headings were conducted. DATA EXTRACTION: The search covered January 1973 to June 1993. Thirty-eight articles were studied. DATA SYNTHESIS: Panic disorder is present in 30% or more of chest pain patients with no or minimal CAD and may coexist with CAD. Panic disorder may often be unrecognized by physicians. Left untreated, risk for disease progression may be augmented, and social vocational disability as well as medical costs may increase. CONCLUSION: Physicians should attend to the panic symptomatology and, when in doubt, refer possible panic patients with or without CAD to a mental health professional for assessment and treatment. Future panic prevalence studies in cardiology patients should be prospective, attempt to increase sample size and use randomized protocols where experimenters are blind to chest pain and medical diagnoses. Studies should also focus on CAD patients with atypical chest pain refractory to optimal cardiac therapy.

Adinazolam sustained-release treatment of panic disorder: a double-blind study.

Two hundred six outpatients with panic disorder and agoraphobia were randomly assigned to receive 4 weeks of treatment with placebo or sustained-release adinazolam under double-blind conditions. Eighty-eight percent of patients receiving drug and 85% of patients receiving placebo remained in the study at week 4. This report describes the "intent-to-treat" analysis of 202 patients who made at least one follow-up visit after randomization at baseline. On the basis of the Clinical Global Impressions-Improvement Scale, 69.7% of the adinazolam-treated patients were much or very much improved compared with 39.6% of the placebo-treated patients at week 4 or end-point (p = 0.0001). At week 4, panic attacks were completely blocked in 57.1% of adinazolam-treated patients and in 39.2% of the placebo-treated patients (p = 0.009). Adinazolam sustained-release treatment was statistically more effective than placebo treatment on measures of global improvement, number of panic attacks, SCL-90 phobia severity, main phobia severity, and anticipatory and general anxiety. No drug-placebo differences were found for overall self-rated phobia severity, unexpected or situational panic attacks, or for work, family, or social disability.