Panic Disorder: Diagnosis and Treatment in Primary Care
Am Fam Physician. 1998 May 15;57(10):2328-2334.
Anxiety disorders affect millions of persons in the United States and are among the most common psychiatric disorders. Everyone experiences anxiety at one time or another, especially in situations such as meeting someone new, giving a speech or taking a test. Some individuals, however, have severe disabling panic attacks that significantly interfere with school, work, relationships and overall health status.
Panic disorder, a common, chronic anxiety disorder manifested by recurrent unexpected panic attacks, is potentially debilitating. The intense fear and physical symptoms that accompany panic episodes may lead to repeated visits to the emergency department or the family physician's office because of the fear of having a heart attack or stroke, or the fear of dying.
Individuals who have panic disorder live with a persistent concern about having another attack. This concern is called “anticipatory anxiety.” Agoraphobia (phobic avoidance) may also develop. As discussed by Saeed and Bruce in this issue of American Family Physician, agoraphobia usually accompanies panic disorder in clinical populations.1 Those who are employed may avoid going to work for fear of having a panic attack, and students may not attend classes. The ability to recognize anticipatory anxiety and phobic symptoms can be extremely helpful to the family physician in the evaluation of panic disorder.
Panic disorder may mimic or coexist with other medical problems such as asthma. By definition, however, panic attacks in panic disorder are not caused by the direct physiologic effects of a substance or a general medical condition.2
Panic disorder occurs in approximately 3.5 percent of the population.3 Typical age at onset is in young adulthood, and it occurs twice as frequently in females as it does in males. Estimates of the incidence of panic disorder in primary care settings range between 4 and 10 percent.4
The classic presentation of panic disorder may be easily recognized, but it is not uncommon for panic disorder to present atypically and thus go unrecognized. It is important for the family physician to recognize limited-symptom attacks (one or two symptoms), nocturnal panic and non-fearful panic. Non-fearful attacks, consisting primarily of somatic symptoms, may be confused with other medical conditions such as cardiovascular, pulmonary, gastrointestinal and neurologic conditions.4,5 If no adequate medical explanation can be found in patients with episodes of physical symptoms, panic disorder should be considered even without associated fear and anxiety.4
Factors contributing to the cause of panic disorder include serotonin and norepinephrine dysregulation, respiratory control dysfunction and hormonal dysregulation.4,6 Stress, sudden loss of social supports, separation anxiety and childhood psychologic trauma have been associated with panic disorder.6 A comprehensive family, personal and social history is invaluable in the evaluation of panic disorder.
Persons with panic disorder often have comorbid psychiatric disorders. Depressions develops in at least 30 to 50 percent of patients with panic disorder.6 The Epidemiological Catchment Area Survey found that 20 percent of patients with panic disorder made at least one suicide attempt.6
Panic disorder may cause impaired quality of life and increased utilization of health care resources. Patients ultimately diagnosed with panic disorder often have been seen by many primary care practitioners and consultants, and often have undergone costly diagnostic tests. Patients with panic disorder are more likely than others to seek general medical care, visit the emergency department and take prescription tranquilizers.7
A careful history and brief physical examination with a few screening tests are important in the evaluation of panic disorder. Medical diagnoses such as thyroid dysfunction, mitral valve prolapse and asthma must be considered. The physician should inquire about caffeine, alcohol and over-the-counter cold medication use that may cause or aggravate particular symptoms. A concern is the potential for substance abuse in a patient who tries to self-medicate to relieve the intense, uncomfortable anxiety symptoms.
The treatment of panic disorder includes medications (antidepressants and benzodiazepine anxiolytics) and cognitive-behavioral therapy. In patients with panic disorder, it is wise to start antidepressants at low doses and carefully titrate upward to minimize the risk of activating symptoms. Saeed and Bruce give very practical recommendations for starting and titrating antidepressants in patients with panic disorder. The doses of antidepressants required in the treatment of panic disorder may ultimately be similar to those used in the treatment of depression. Benzodiazepines are especially useful for the highly distressing anticipatory anxiety4—however, they are not useful for treating comorbid depression. Cognitive-behavioral approaches include supportive measures, education (e.g., brochures), breathing retraining and helping the patient restructure distorted thinking patterns. A trusting relationship with the family physician is vital. An integrated treatment approach is recommended by the Anxiety Disorders Association of America.8
Individuals with panic disorder may require repeated reassurance and explanation about the disorder, especially regarding the physical symptoms. Frequent contact with the physician, either by telephone or in the office, is helpful, particularly during the initial treatment phase. Several medication adjustments are not uncommon.
Panic disorder is a legitimate disorder that may present with medically unexplainable symptoms that may go unrecognized for a long time. Early recognition allows for effective treatment by the family physician, with mental health consultation as necessary. The improvement in the patient's quality of life and the satisfaction of both the patient and the physician is most rewarding.
1. Saeed SA, Bruce TJ. Panic disorder: evidence-based treatment options. Am Fam Physician. 1998;57:2405–20.
2. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, D.C., American Psychiatric Association, 1994:393–405.
3. Hirschfield RM. Panic disorder: diagnosis, epidemiology, and clinical course. J Clin Psychiatry. 1996;57(Suppl 10):3–8.
4. Elliot R. Panic disorder in primary care. Primary Psychiatry. 1995;2:52–9.
5. Roy-Bryne P, Cowley D. Assessment and treatment of panic disorder. In: Dunner DL, ed. Current psychiatric therapy. 2d ed. Philadelphia: Saunders, 1997:309–16.
6. Gorman J. Recent developments in understanding panic disorder leading to improved treatment strategies. Primary Psychiatry. 1996;3:31–8.
7. Rosenbaum JF. Panic disorder in the emergency department. Emerg Med. 1996;28:54–69.
8. Ballenger J, Pollack M, Ross J. Practical approaches to the treatment of panic disorder. J Clin Psychiatry. 1996;57:45–52.
Copyright © 1998 by the American Academy of Family Physicians.
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