Community correlates of outcomes in subjects with panic attacks.

The purpose of this study was to document the association between community factors and mental health outcomes in subjects with panic attacks. Randomly selected adults from 18 census tracts were screened for the presence of panic attacks. A structured interview was used to assess health care utilization, psychiatric morbidity, quality of life, and sense of control over panic. Community measures were obtained from census data. Regression analyses found that each community measure was associated with at least one outcome even when adjusted for individual socioeconomic status and barriers to access. Research concerning mental health outcomes in subjects with panic attacks should include community-level data.

Symptom severity and perceptions in subjects with panic attacks.

OBJECTIVES: To (1) identify aspects that defined the self-perceived worst panic attack, (2) determine how subjects with panic attacks perceive symptoms compared with control subjects, and (3) determine the role of symptom perceptions in seeking care for the worst panic attack. DESIGN: Cross-sectional survey. SETTING: Community-based. PATIENTS OR OTHER PARTICIPANTS: Ninety-seven subjects with panic attacks as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (with or without panic disorder), and 97 demographically matched controls. INTERVENTION: None. MAIN OUTCOME MEASURES: Subjects and controls completed the Symptom Perception Scales, and subjects with panic attacks completed the Acute Panic Inventory and a questionnaire concerning care-seeking behavior for their self-perceived worst attack. RESULTS: Compared with controls, subjects with panic attacks perceived many symptoms as more embarrassing but differed little in their perceptions of need for treatment, threat to life, and disruption of functioning. Particular symptoms (ie, dyspnea, fear, dizziness, and faintness) tended to differ in most perceptions. However, symptom perceptions did not play a significant role in care-seeking behavior for the worst attack. CONCLUSIONS: Subjects with panic attacks perceive symptoms as more embarrassing than controls, and have different perceptions about particular symptoms. Cognitive approaches addressing negative patient perceptions may reduce anxiety, inappropriate use of health care services, and adverse outcomes. Arch Fam Med. 2000;9:1028-1035

Effect of attendance at an annual primary care research methods conference on research productivity and development.

BACKGROUND AND OBJECTIVES: This study determined whether attendance at a research methods conference is associated with an increase in research productivity in conference participants and identified predictors in participants of postconference productivity measures. METHODS: We mailed survey instruments to 423 participants who attended the Primary Care Research Methods and Statistics Conference between 1986 and 1995 to document their professional characteristics, conference attendance, and preconference and postconference research productivity. In addition, respondents were asked to send us their curriculum vitae (CV) and the CV of a colleague with a similar interest in research who had never attended the conference. RESULTS: A total of 294 participants completed the survey, and 40 of these sent the CV of a colleague. Preconference and postconference changes in research publications and presentations were significant, especially in novice researchers. Regression analyses found that the number of conferences attended predicted postconference publications, presentations, and current research activity. Compared to colleagues who never attended the conference, postconference total publications and presentations were higher in conference participants. CONCLUSIONS: Attendance at a research skills conference was associated with increased postconference research productivity, compared with preconference productivity and that of matched controls.

Predictors of the development of phobic avoidance.

BACKGROUND: Panic disorder and agoraphobia are closely linked. There are indications that uncontrolled panic attacks often lead to the rapid development of phobic avoidance, but our ability to predict which individuals with panic will develop avoidance has been limited. The purpose of this study was to identify independent predictors of the development of phobic avoidance and the time course of that development. METHOD: We conducted a secondary analysis of survey data from the community-based Panic Attack Care-Seeking Threshold Study. The presence of panic attacks was confirmed in 97 randomly selected adults from randomly selected households screened using the Structured Clinical Interview of DSM-III-R (SCID). The presence of limited and extensive phobic avoidance was measured using the SCID, while rapidity of development (lag time) was measured as the difference between onset of panic and onset of avoidance. Predictors considered included panic characteristics, psychiatric comorbidity, cognitive appraisal, family characteristics, illness attitudes, symptom perceptions, and coping style. RESULTS: Thirty-six subjects (37%) had at least mild phobic avoidance, with 81% (N = 29) of those developing the avoidance less than 1 year after the onset of panic attacks. The development of phobic avoidance was associated with the presence of panic disorder (beta = 1.36), the number of comorbid psychiatric disorders (beta = 0.69), and the number of family members and/or friends available to discuss health concerns (beta = 0.87). Further progression to agoraphobia was predicted by the presence of depersonalization during panic attacks (beta = 0.50). Rapid onset of avoidance (panic avoidance lag time < 1 year) was predicted by the perception that depersonalization is a life-threatening symptom (beta = 1.56). CONCLUSION: The development of phobic avoidance is closely linked to panic attacks and often develops soon after panic onset. Full-blown panic disorder and psychiatric comorbidity are important in this development. Depersonalization is also key to the development of avoidance and the rapidity of the development.

Diagnosis and management of acute pancreatitis.

Acute pancreatitis usually occurs as a result of alcohol abuse or bile duct obstruction. A careful review of the patient's history and appropriate laboratory studies can help the physician identify the etiology of the condition and guide management. Serum amylase and lipase levels are still used to confirm the diagnosis of acute pancreatitis. Although not routinely available, the serum trypsin level is the most accurate laboratory indicator for pancreatitis. Ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography are additional modalities that can help the family physician choose the best treatment approach. Prompt identification of patients who need intensive care referral or subspecialty consultation is crucial. The APACHE II and the multiple organ system failure scales provide prognostic information at the time of admission and may be repeated daily to monitor disease progression. Therapies such as nasogastric suctioning, anticholinergics and histamine H2-receptor blockers have not been shown to decrease symptoms or hospital stays in patients with acute pancreatitis. Systemic antibiotics have been found to improve outcome in patients with severe disease. With supportive care, most patients have a good clinical outcome.

A comparison of persons with early-versus late-onset panic attacks.

BACKGROUND: Although some evidence suggests a bimodal age at onset of panic attacks, the literature comparing subjects with early versus late onset is limited. Previous work suggests that people with late-onset panic attacks may have fewer panic symptoms and exhibit less avoidance. This study sought to compare late-onset panic attacks and early-onset panic attacks with regard to (I) comorbidity, (2) health care utilization, and (3) illness behaviors and coping. METHOD: This community-based study involved interviewing randomly selected adults for the presence of DSM-III-R panic attacks. If panic attacks were confirmed, subjects were asked questions concerning panic characteristics, psychiatric comorbidity, symptom perceptions, illness attitudes, coping, and family characteristics. Subjects reporting early-onset panic (panic onset < 50 years of age) were compared with those reporting late onset (onset > or = 50 years of age). Significant univariate analyses were controlled for differences in age, panic duration, and socioeconomic status by using analysis of covariance and logistic regression. RESULTS: Subjects with late-onset panic attacks (N = 9) utilized the mental health sector less, but were more likely to present to family physicians for their worst panic. Patients with late-onset panic felt that choking and numbness more strongly disrupted function, but felt less strongly that either depersonalization or sweating disrupted function. Subjects with late-onset had fewer comorbid conditions and lower Symptom Checklist-90 scores. Late-onset subjects also had less hypochondriasis and thanatophobia while coping less through avoidance or wishful thinking. CONCLUSION: Late-onset panic attacks are associated with less mental health utilization, lower levels of comorbidity, less hypochondriasis, and a greater number of positive coping behaviors.

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.

Illness attitudes and coping process in subjects with panic attacks.

Personality disorders may affect comorbidity and health care utilization in subjects with panic attacks. The purpose of this study was to identify differences in illness attitudes and behaviors, and in coping strategies in community-based subjects with panic attacks compared with controls. A community-based sample of 97 subjects meeting DSM-III-R criteria and matched controls completed the Illness Behavior Questionnaire, the Illness Attitude Scale, and the Ways of Coping Checklist. The panic group reported less healthy attitudes and behaviors. Although there were no panic-control differences in use of positive coping strategies, the panic group reported more use of negative coping strategies. The differences in illness attitudes and behaviors, and in coping strategies, may explain comorbidity and care-seeking behavior in subjects with panic attacks.

Progression of limited symptom attacks.

To study the progression of limited symptom attacks (LSAs) to panic attacks, we screened a community sample for LSAs using the Structured Clinical Interview of the DSM-IIIR initially and one year thereafter. Of 21 subjects with LSAs initially, 4 (19%) reported progression of their LSAs to panic attacks after one year.

Variability in meta-analytic results concerning the value of cholesterol reduction in coronary heart disease: a meta-meta-analysis.

Despite official support for the efficacy of cholesterol reduction, considerable controversy exists, and meta-analyses of this topic have produced conflicting results. The authors assessed the variability of meta-analyses, evaluating the cardiovascular value of cholesterol reduction while attempting to explain the variability. Metaanalyses were identified by electronic search and citation tracking. Included were those conducted prior to 1995 that dealt with cholesterol reduction and total mortality, cardiovascular mortality, or nonfatal cardiovascular disease. In addition to extracting odds ratios for total mortality, cardiovascular mortality, and nonfatal cardiovascular disease, the authors encoded methodological variables, publication variables, and data concerning investigators' backgrounds. Twenty-three meta-analyses were reviewed, and 15 concluded that cholesterol reduction was beneficial. Summary odds ratios for total mortality were heterogeneous, generally failing to support the value of cholesterol reduction. Odds ratios depended on inclusion criteria and investigator variables. Odds ratios for cardiovascular mortality and for nonfatal cardiovascular disease were more homogeneous and supported the value of cholesterol reduction. Methodologically better meta-analyses tended to report more beneficial odds ratios. Although "supportiveness" of the value of cholesterol reduction was associated with inclusion/exclusion criteria and publication variables, the primary outcome variable related to supportiveness was the statistical significance of the odds ratios for cardiovascular mortality.

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.

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.

Prevalence and recognition of panic states in STARNET patients presenting with chest pain.

BACKGROUND: The purpose of this study was to document the prevalence of panic states in patients presenting with chest pain in primary care settings, to determine the recognition rate of panic states by family physicians, and to assess the impact of lack of recognition on interventions and costs. METHODS: Patients from the South Texas Ambulatory Research Network (STARNET) presenting with a new complaint of chest pain were asked to participate in the study. Before seeing their physician, subjects completed the panic disorder section of the Structured Clinical Interview (SCID) of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. The SCID was used to assign diagnoses of panic disorder, infrequent panic, or limited symptom attacks. Health care outcomes included medications prescribed, tests ordered, follow-up and referrals, costs, and physician diagnosis. RESULTS: Although approximately one half of the 51 patients in this study met criteria for either panic disorder or infrequent panic, few were recognized by physicians as having a panic state (kappa = -.003). Patients with panic disorder were more likely to receive follow-up or referral (P = .042), incurring higher follow-up costs (P = .080). Patients with infrequent panic received more testing (P = .008), with higher costs for testing (P = .001) and higher overall costs (P = .067). Panic-diagnosis associations were found between psychotropic (P = .001) and total (P = .070) medications as well as follow-up and referral costs (P = .009). CONCLUSIONS: Although common, panic states are rarely recognized in patients presenting with complaints of chest pain. The presence of panic leads to more testing, follow-up, and referral with subsequent higher costs. Failure to diagnose panic results in increased prescribing of medications, higher costs, and inappropriate pharmacotherapy.