May 2000 • Volume 6 • Number 5
Panic disorder gives fear the upper hand
BY SHARON DICKINSON DENT
Scottsdale, Ariz.
Greg Brotzman, MDJust about everyone has had a panic attack at least once. But if the attacks continue and the fear of an attack is debilitating on its own, the problem becomes more serious, according to Greg Brotzman, M.D., associate professor at the Medical College of Wisconsin's family and community medicine department and a speaker at AAFP's CME course on women's health April 5-8.
Patients don't always present with the classic palpitations and shortness of breath, Brotzman said. "You might do a workup on the gastrointestinal tract, and then the patient starts having coronary artery disease symptoms, so you check that out. Next thing you know, he's having stroke symptoms," he said. "You can end up chasing your tail for some time before you take a step back and see what's going on."
The incidence of panic disorder in the general population is about 4 percent, rising to 15-20 percent for people with an immediate family member suffering from the disorder. Although about 40 percent of people with panic disorder don't seek help, those who do are more likely to visit a primary care office or emergency room than a mental health facility. Brotzman said 35 percent will go to their family physician.
Criteria for diagnosing a panic attack call for the patient to have at least four of the following symptoms: palpitations, pounding heart or accelerated heart rate; sweating; trembling or shaking; sensation of shortness of breath; feeling of choking; chest pain or discomfort; nausea or abdominal stress; feeling dizzy, unsteady, lightheaded or faint; derealization or depersonalization; fear of losing control or going crazy; fear of dying; paresthesias; and chills or hot flashes.
Panic disorder is diagnosed when a patient has recurrent attacks and a one-month history of anticipatory anxiety (fear of having an attack in a place from which the patient can't escape) and/or behavior change related to panic attacks. "This may not be something you can address in one visit," Brotzman said, noting it's essential to take a thorough history to identify other diseases and previous depression, substance abuse or psychiatric disorders.
When coding for panic attacks, specify whether the diagnosis includes agoraphobia and whether it occurs within the context of other anxiety disorders, such as social phobia or post-traumatic stress disorder.
"One thing you've got to keep in mind is that these people are in despair," said Brotzman. "Just having panic attack/panic disorder puts you at a greater risk of suicide, so we have to address that."
Treatment is multifaceted and based on patient education, behavior modification, psychotherapy, support groups and medications. Research shows that the greatest improvement in symptoms occurs with exposure therapy (gradually exposing the patient to the feared situation, if one is identified), especially when used in combination with medication such as serotonin-specific reuptake inhibitors, tricyclic antidepressants or benzodiazepines, Brotzman said.
Patients should be treated for at least 12 months and experience no panic attacks for at least three months before discontinuing medication. Brotzman warned that panic attacks and panic disorder can be chronic, so relapses are common.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
FP Report | Headlines |AAFP Home | Search