Relationship between substance abuse and panic attacks.

This study was done to determine the strength of association between substance abuse and panic states, including subsyndromal panic, its temporal relationship, and self-medication for panic using abusable substances. A community-based sample was screened for panic using DSM-III-R criteria. Panic and matched control groups participated in a structured interview concerning the presence of substance abuse, use of substances to treat panic symptoms, and the age-of-onset of panic and substance abuse. Of 97 individuals with panic, 39% had abused at least one substance. None of the panic disorder-subsyndromal panic differences reached significance. Only 10% of subjects reported using alcohol and 6% reported ever using illicit drugs to treat their panic. The majority (63%) of those abusing alcohol reported that alcohol use began prior to onset of panic, and the majority (59%) of those abusing illicit drugs reported that drug use began first. This study documents the panic-substance abuse relationship even in those with subsyndromal panic. Substance abuse began prior to onset of panic and substances were used to self-medicate for panic attacks by only a few subjects.

Associations with subsyndromal panic and the validity of DSM-IV criteria.

The purpose of this study was to compare subsyndromal panic--infrequent panic (IP) and limited symptom attacks (LSA)--with panic disorder (PD) in psychiatric comorbidity, quality of life (QOL), and health care utilization and to assess validity of DSM-III-R criteria for panic disorder. Randomly selected adults were screened for the presence of PD, IP, and LSA by using the Structured Clinical Interview of the DSM-IIIR. Subjects with panic symptoms and matched controls completed a structured interview concerning comorbidity, QOL, and utilization. Although PD and IP subjects reported more psychiatric comorbidity than did LSA subjects, LSA subjects had more comorbid conditions than did controls. Differences in utilization were limited to PD subjects. Although subsyndromal panic was associated with poor QOL, panic-related work disability was primarily seen in PD subjects. Regression analyses demonstrated little difference between LSA and IP subjects, but interaction analysis supported the distinction between LSA and full-blown panic attacks. Compared with controls, LSA and IP subjects had more psychiatric comorbidity. PD subjects also had poorer QOL and more utilization. Interaction analysis supports DSM-IV criteria for panic disorder.

Panic disorder in Hispanic patients.

BACKGROUND AND OBJECTIVES: This study determined the proportion of community-dwelling Hispanics who present for medical care for their panic attacks and identified factors associated with seeking care. We also compared characteristics of Hispanic subjects with those of non-Hispanic white panic sufferers. METHODS: In this community-based study, subjects with panic attacks completed a structured interview concerning health care utilization, panic characteristics, coexisting psychiatric problems, and illness attitudes. Hispanics were self-identified and completed the Cuellar acculturation scale for Mexican-Americans. RESULTS: Twenty-nine (53.7%) of 54 Hispanic subjects had sought medical care for their panic attacks. Care seeking in non-Hispanic whites was not dependent on these factors. CONCLUSIONS: Half of the Hispanics with panic attacks seek no medical care for their attacks. Predictors of seeking care among Hispanics in San Antonio included coping style, symptom perceptions, and access to transportation.

Comorbid psychiatric disorders in subjects with panic attacks.

Several psychiatric disorders are associated with panic disorder (PD), although the nature of their relationships is unknown. The purpose of this study was to a) document comorbid associations with both PD and infrequent panic (IP), and b) investigate the nature of the relationships among these disorders. This community-based study included 97 adults who met DSM-III-R criteria for panic attacks compared with 97 matched controls. Psychiatric comorbidity was assessed using the SCID and SCL-90. Subjects with either PD or IP had higher rates of psychiatric comorbidity than controls. PD differed from IP only in its higher rate of phobic avoidance. Factor analysis found three factors: PD with phobic avoidance; substance abuse; major depression with obsessive compulsive disorder, social and simple phobias. Only phobic avoidance began secondary to panic onset. In conclusion, this study supports the PD-agoraphobia DSM-IV grouping while lending support to the common diathesis hypothesis for anxiety and affective disorders.

Family characteristics of subjects with panic attacks.

BACKGROUND AND OBJECTIVES: This study identified associations between panic states and family 1) structure, 2) functioning, and 3) stress/support. METHODS: Ninety-seven adults with panic disorder or infrequent panic attacks, based on the structured Clinical Interview of the Diagnostic and Statistical Manual, Third Edition, Revised, were matched to 97 subjects without panic symptoms based on age, gender, and race/ethnicity. All subjects completed a structured interview concerning health care use by family members and family characteristics. Family functioning was assessed using the Family Adaptability and Cohesion Evaluation Scales, and family stress/support were assessed using the Duke Social Support and Stress Scales. RESULTS: Although groups did not differ in either perceived or ideal family cohesion or adaptability, the panic group perceived their families as more dysfunctional and reported higher levels of family stress and total stress but lower levels of support, including family support, nonfamily support, and total support. CONCLUSIONS: Subjects with panic symptoms have families with high levels of dysfunction and stress but low levels of support. Increased family dysfunction may be due to comorbid substance abuse.

Oral contraceptives and venous thromboembolism: a case-control study designed to minimize detection bias.

BACKGROUND: Previous epidemiologic studies of venous thromboembolism and oral contraceptive use are susceptible to bias in the detection of venous thromboembolic events. This case-control study uses a unique design to minimize the influence of detection bias. METHODS: Nonpredisposed women younger than the age of 40 years who underwent pulmonary angiography, lower extremity venography, or lower extremity duplex Doppler sonography at a large urban hospital were classified into a case group or control group based on results of their diagnostic studies. Medical records were reviewed for a history of current oral contraceptive use. RESULTS: Fifty-seven women met the study criteria during the 11-year study period. Seven of 9 women in the case group and 17 of 48 women in the control group were currently using oral contraceptives (odds ratio 6.38; 95 percent confidence limits 1.19, 34.2). CONCLUSIONS: The association previously noted between venous thromboembolism and oral contraceptive use is not due to bias in the detection of venous thromboembolic events.

PIP: Both case-control and cohort studies have consistently documented an association between oral contraceptive (OC) use and venous thromboembolism risk. However, since OC users undergo closer medical surveillance than non-users, these studies are susceptible to detection bias. To overcome this potential source of bias, the present study used a new case-control study design in which 234 women under 40 years of age with suspected deep vein thrombosis or pulmonary embolism recruited from University Hospital in San Antonio, Texas, during 1983-94 underwent contrast venography, pulmonary angiography, or duplex Doppler ultrasound examination. 127 of these women were subsequently excluded from the study because of predispositions to venous thromboembolism. The 9 women whose test results were positive comprised the case group, while the 48 with negative findings served as controls. 7 of the 9 cases and 17 of the 48 controls were current OC users (odds ratio, 6.38; 95% confidence interval, 1.19-34.2). Although documentation of the OC brands women were using was sparse, 12 of the 13 women for whom these data were available were using OCs containing 35 mcg or less of estrogen. The findings of this analysis indicate that the documented association between OC use and venous thromboembolism is not a result of detection bias. The use of women undergoing diagnostic procedures to form both the case and control groups should be replicated in larger populations and diverse settings. The study design could be further strengthened by collecting data on OC use prospectively and uniformly, before women undergo diagnostic procedures.

Use of health care services by persons with panic symptoms.

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.

Quality of life and panic-related work disability in subjects with infrequent panic and panic disorder.

BACKGROUND: Panic disorder is associated with poor quality-of-life (QOL). However, little is known regarding the impact of panic disorder or infrequent panic on work-related disability. The purpose of this study was (1) to document QOL and panic-related work disability in subjects with panic disorder or infrequent panic, (2) to identify independent predictors of QOL and disability, and (3) to compare outcomes in subjects with panic disorder versus infrequent panic. METHOD: This cross-sectional community survey included 97 subjects with panic and matched controls. Subjects were screened for panic disorder or infrequent panic using the Structured Clinical Interview for DSM-III-R. The QOL questionnaire addressed life satisfaction as well as panic-related work disability. A structured interview assessed possible predictors of impaired QOL including comorbidity, illness attitudes and behaviors, coping style, family measures, and symptom perceptions. RESULTS: QOL was significantly (p < or = .001) poorer in subjects with panic than in controls. Comorbid depression, social support, worry, and severity of chest pain predicted QOL. Although subjects with infrequent panic reported a lower QOL than controls, subjects with panic disorder had more panic-related disability and poorer QOL than those with infrequent panic. Predictors of work disability included panic frequency, illness attitudes, family dissatisfaction, and gender. CONCLUSION: Although both infrequent panic and panic disorder impact QOL and disability, panic disorder has a greater effect. Using predictors, patient education, provision of support, and focused therapy could potentially improve QOL and disability.

Family practice, internal medicine, and pediatrics as partners in the education of generalists.

The generalist of the future will play an integral role in the health care delivery system, yet the three recognized generalist specialties have developed and functioned along largely separate tracks. No matter what form of generalism evolves, family practice, internal medicine, and pediatrics must begin to cooperate and collaborate in developing new graduate medical education programs that are sufficiently flexible to meet whatever emerges in the future. They must devote their energies to working together, rather than competing; to emphasizing those parts of their programs that have similarities; and to sharing their knowledge, skills, attitudes, and perspectives about the care of patients. They must develop training experiences in which residents will obtain maximum contact with a wide variety of problems and patients in many different settings; a substantial portion of such training should be generic and virtually interchangeable among the three specialties. As the health care system evolves, so should these disciplines; they must begin to "train physicians to provide continuing, comprehensive and coordinated medical care to a population undifferentiated by gender, disease or organ system," as urged by the American Boards of Family Practice and Internal Medicine.

Where do panic attack sufferers seek care?

BACKGROUND: Although 40% of people with panic attacks never seek care for their attacks, those who do may use medical settings or mental health settings, or both. The purpose of this study was to examine where people seek care for their panic attacks within and outside the health care system, and to determine what variables predict the choice of a given site. METHODS: The Panic Attack Care-Seeking Threshold (PACT) study is a community-based survey of 97 subjects meeting the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for panic attacks. A structured interview was used to collect information about panic attacks, family characteristics, psychiatric comorbidity, health care access and utilization, illness attitudes and behaviors, quality of life, and symptom perceptions. RESULTS: Forty-nine percent of the subjects seeking care for panic attacks presented to medical settings, whereas 26% of subjects used mental health settings. The family physician's office was the most frequent site of presentation (35%), followed by a hospital emergency department (32%). Only 13% of subjects sought care from a site outside the health care system. Variables predicting presentation to specific health care sites varied. Subject demographics, panic characteristics, and symptom perceptions were generally significant factors in care-seeking. Illness behaviors, readiness for sick role, health locus of control, and family measures failed to predict the seeking of care specific to any particular site. CONCLUSIONS: When subjects with panic attacks seek care, they most commonly present to a general or family physician's office or a hospital emergency department.

Computerized student testing as a learning tool in a family practice clerkship.

BACKGROUND: The purpose of this paper is to describe and evaluate a computerized multiple choice testing system developed to teach family medicine core content in a junior clerkship. METHODS: Students were tested in a minimum of 10 content areas based upon a pretest, and answered sets of 10 randomly generated questions in each area. Students received immediate feedback on scores and correct answers. RESULTS: A total of 192 students took 10,184 computerized tests. Mean student scores rose significantly with successive tests. Scores on the written final clerkship examination correlated with computerized testing scores. Students accepted the computerized testing system well. CONCLUSIONS: The computerized testing system led to immediate learning, but its effects on long-term learning were less clear.

Factors affecting the threshold for seeking care: the Panic Attack Care-Seeking Threshold (PACT) Study.

BACKGROUND: This study was conducted to explore the phenomenon of seeking medical care for panic attacks and to identify factors associated with seeking care. METHODS: A community sample of adults was screened using the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Subjects who had experienced panic attacks participated in a structured interview concerning their health care access and utilization, panic characteristics, comorbidity, illness attitudes and perceptions, and family characteristics. RESULTS: Forty-one percent of the subjects had not sought medical care for their panic attacks. Having to get someone to drive (RR [relative risk] = 1.8; P = 0.0026), inability to work because of panic (RR = 1.6; P = 0.0054), and a high treatment experience score on the Illness Attitude Scales (RR = 1.5; P = 0.034) independently predicted seeking care. Seeking support was also significantly associated with seeking care (t = -4.05; P = 0.0001). Care seekers tended to have more severe symptoms, stronger symptom perceptions, and more bodily preoccupation and to abuse drugs more frequently. Seeking care was not influenced by sex, race or ethnicity, stress, psychiatric comorbidity, family function, social support, or access to health care. CONCLUSIONS: Nearly one-half of persons with panic attacks do not seek care for their attacks. Those who seek care differ from those who do not in ways that have important implications for the understanding of this illness.