Epidemiology Of Panic Disorder

Phenomenology and Epidemiology of Panic Disorder

William R. Yates, M.D.

Evolution of Diagnostic Criteria ■ ■ ■ ■ ■ ■

1968 1972 1980 1987 1994 2011

DSM-II Anxiety Neurosis Feighner Criteria Panic Disorder DSM-III Panic Disorder (3 in 3 w) DSM-IIIR-Frequency modified DSM-IV Panic attack description DSM-V

ECS vs NCS Prevalence Studies ■ ■

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Five sites Diagnostic Interview Schedule DSM-III 1980-1984 Probability sample Lifetime and six month prevalence

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National sample – 48 states

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Composite Intnl Diagnostic Interview DSM-IIIR/DSM-IV 1990-92 & 2001-3 Age 18 to 54 12 month prev

Rates of Recent Anxiety Disorder ■

ECA rank order – – – – – – –

Any anxiety Simple phobia Generalized anxiety Agoraphobia Social phobia OCD Panic disorder

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NCS rank order – – – – – –

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Any anxiety Simple phobia Social phobia Generalized anxiety Agoraphobia Panic disorder

Did not estimate rates of OCD*

Epidemiology ■

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Lifetime prevalence 2%, 12 month prevalence about 1% Onset in 20s 33-50% have agoraphobia Lifetime prevalence of depression estimated at 50-60% Depression precedes 33% Panic precedes/co-occurs in 67%

Noyes/Crowe Panic D/O Validity ■ ■

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Clinical description Exclusion of other disorders-generalized anxiety, hypochondriasis Follow-up studies-prognosis/outcome Family studies-breeding true (Crowe 83) Biological markers-fMRI, genotype

Recent Prevalence Rates 20 18 16 14 12 10 8 6 4 2 0

ECA NCS NCS-Rep

Any Anx

Sim Soc GAD Agora Panic OCD Phob Phob

Risk Factors for Anxiety Disorder ■ ■ ■ ■

Female Gender Low educational attainment Low income Northeast United States

Female:Male Ratio NCS 2.5 2 1.5 Female:Male

1 0.5 0

Panic Agora

Sim Phob

GAD

Any Anx

Soc Phob

Female:Male Gender NCS-R 1.6 1.4 1.2 Anxiety Mood Impulse Sub Ab Any

1 0.8 0.6 0.4 0.2 0

Odds

Divorced/Separated (% Married) 45 40 35 30 25 20 15 10 5 0

Percent

No Schiz ManicPanic GAD Psych Phobia Cog Imp

Any Anxiety Disorder & Income 1.6 1.4 1.2 1 0.8

East

0.6 0.4 0.2 0

>70 K

35-69K

20-34K

<20 K

Anxiety Disorder & Education 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0

Anxiety Mood

>16

13-15

12

0-11

Any Anxiety D/O Severity-NCS-R 45 40 35 30 Serious Moderate Mild

25 20 15 10 5 0

Degree

Geographic Overrepresentation ■

Northeast – Anxiety disorder – Substance abuse

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West – Any substance abuse – Antisocial personality disorder – 3 or more psychiatric disorders

Geography & Anxiety Disorder 1.4 1.2 1 0.8 Ratio

0.6 0.4 0.2 0

Midwest

Northeast

West

South

Cultural Issues in Panic Disorder 3.5 3 2.5 2 1.5 1 0.5 0

Prevalence

US (ECA) Canada Puerto Rico France West Germany Italy Lebanon Taiwan Korea New Zealand US (NCS)

Panic Disorder-Natural History ■ ■ ■

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Attacks often unexpected at first Then can become situation related Common with agoraphobia-avoid buses, subways, bridges, tunnels, crowded malls, travel away from home (situations where escape is hard) Variable in frequency and intensity – Limited symptom attacks can occur

Noyes Outcome/Environment ■ ■

Outcome study 69 patient Poor outcome associated with: – Parental separation by death/divorce – Low social class – Unmarried marital status

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Outcome related to social environment-illness development and course

Panic Disorder-Natural history ■

Disturbance in function – – – –

disturbance in interpersonal function avoidance of work-related triggers hypochondriasis and somatization multiple physician office visits • emergency room • cardiology • neurology/otolaryngology/pulmonology

Mean Age of Onset 35 30

Separation Simple phobia Any anxiety Social phobia OCD Agoraphobia PTSD Panic GAD

25 20 15 10 5 0

Mean Age

Panic attacks in adolescence ■

Presence of panic attacks in adolescence – Increases risk of future anxiety disorder (55% vs 25%) – Increases risk of future mood disorder (43% v 16%) – Increases risk of future substance abuse (60% v 28%)

Panic Disorder Morbidity ■ ■ ■

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Increased emergency room visit Increased physician utilization High rates of sucide attempts and completed suicide Impaired occupational and marital function Increased substance abuse

Onset to Treatment Delay 20 18 16 14 12 10 8 6 4 2 0

ODD BPAD Drug MDD GAD Panic PTSD Social Spec Phob Years

Who Sees Psychiatry-NCSR 30 25 20 15 10 5 0

Percent

No disorder IED Any disorder Spec Phob Any anxiety GAD Social Panic PTSD MDD Dysthymia BPAD Drug Dep

Who Sees General Medical Prov. 45 No Disorder All Subjects Any Disorder IED Any Sub Any Anxiety Any Mood PTSD GAD Panic

40 35 30 25 20 15 10 5 0

Percent

Mental Health Visit Last Year 70 60 50 40 30

Percent

20 10 0 Alc SchizoManic Panic OCD Phobia Abuse Somatiz

Panic and Anxiety Disorders ■

Panic disorder increases the risk of a comorbid anxiety disorder – – – – –

Agoraphobia Social phobia PTSD Specific phobias Obsessive compulsive disorder

Agoraphobia Rates in Panic 60 50

USA (ECA) Canada Puerto Rico France Taiwan Korea New Zealand US (NCS)

40 30 20 10 0

% of Panic

Major Depression Rates in Panic 70 60

USA (ECA) Canada Puerto Rico France Taiwan Korea New Zealand US (NCS)

50 40 30 20 10 0

% of Panic

Panic Disorder & Personality ■

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Panic disorder has high rates of Axis II comorbidity-40-50 % Highest with anxious cluster c – avoidant – obsessive compulsive – dependent

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Some measures of personality psychopathology may remit with panic RX

Noyes Panic Outcome Study ■ ■

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89 subjects with panic disorder Course characterized by fluctuating anxiety and depressive symptoms Comorbidity associated with poor outcome included extensive phobic avoidance, major depression and personality disorder Personality disorder strongest predictor

MDD Rates/No Panic 18 16 14

US (ECA) Canada Puerto Rico France Taiwan Korea New Zealand US (NCS)

12 10 8 6 4 2 0

Prevalence

Odds Ratio Depression/Panic 25 US (ECA) Canada Puerto Rico France Taiwan Korea New Zealand US (NCS)

20 15 10 5 0

OR

Other factors to consider ■

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Suicidality-high rates of suicide attempts in depression associated with panic attacks Cocaine/stimulants/caffeine may precipitate or exacerbate panic disorder Alcohol withdrawal can induce panic attacks

Noyes Panic & Suicide Study ■

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7 year outcome of 74 subjects Serious Suicide Early age onset Personality disorder Comorbid MDD More severe symptoms

7 6 5 4

Suicide Attempt

3 2 1 0

Percent

Anxiety in Major Depression ■ ■

1450 Subjects with MDD from STAR*D Those with high anxiety ratings (46%) were: – – – – –

Older Unemployed Less Educated More severely depressed More likely to have suicidal ideation

Anxiety-Treatment Outcome in MDD 60 50 40 Anxiety Anxiety +

30 20 10 0

Remission

Response

Panic-Vascular/Mortality ■

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Womens Health Initiative 3369 post-menopausal women 5 year followup 10% reported panic attacks

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

HR

CD

+STR Mort