Panic Disorders In Primary Care

PANIC DISORDERS IN PRIMARY CARE ROBERT K. SCHNEIDER, MD Assistant Professor Departments of Psychiatry and Internal Medicine Medical College of Virginia Campus of the Virginia Commonwealth University

Mental Health and Primary Care Primary Care Mental Health

Primary Care and Mental Health Mental Health Primary Care

Epidemiologic Catchment Area Study • Five specific geographic areas • Adults aged 18 years and older • Structured interviews initially, at 6 and 12 months • Defined areas of mental health services

70,000,000 people in the US have a Diagnosable Mental/Addictive Disorder No Mental/ Addictive Disorder 72%

Mental/ Addictive Disorder 28%

Reiger et al. 1993

40,000,000 people in the US receive services for Mental/Addictive Disorders

Treatment 15%

No Treatment 85%

Reiger et al. 1993

Sectors Where Mental Health Services are Provided • Specialty Mental /Addictive Sector – Inpatient and Outpatient Psychiatric/Addictive

• General Medical Sector – Nursing Home and Hospitals – Outpatient (Primary Care Setting)

• Other – Human Service Professionals (Clergy, Counselors) – Voluntary support Network (Family, Friends, AA)

Percentage of Patients per Sector PATIENTS SECTOR 21.5%

Not in Treatment

15.0%

Specialty Mental Health, Inpatient and Outpatient Overlap

6.0%

54.1% 3.4%

General Medical Sector Outpatient, Primary Care General Medical Sector, Inpatient, including Nursing Homes

“de facto mental health system” Regier,1978 • 54% of people with mental illness who seek treatment are exclusively seen in the “general medical sector” • 25% of patients in primary care setting have a diagnosable mental illness

Organizing Principles DSM-IV Affective Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other

Organizing Principles DSM-IV Affective Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other

Major Depression, Bipolar Disorder, Dysthymia

Organizing Principles DSM-IV Affective Disorders

Major Depression, Bipolar Disorder, Dysthymia

Anxiety Disorders

GAD, Panic Disorder, PTSD, OCD, Phobias

Psychotic Disorders Substance Abuse Other

Organizing Principles DSM-IV Affective Disorders

Major Depression, Bipolar Disorder, Dysthymia

Anxiety Disorders

GAD, Panic Disorder, PTSD, OCD, Phobias

Psychotic Disorders Substance Abuse Other

Schizophrenia, Schizoaffective

Organizing Principles DSM-IV Affective Disorders

Major Depression, Bipolar Disorder, Dysthymia

Anxiety Disorders

GAD, Panic Disorder, PTSD, OCD, Phobias

Psychotic Disorders Substance Abuse Other

Schizophrenia, Schizoaffective Alcohol, Cocaine, Nicotine, Other

Organizing Principles DSM-IV Affective Disorders

Major Depression, Bipolar Disorder, Dysthymia

Anxiety Disorders

GAD, Panic Disorder, PTSD, OCD, Phobias

Psychotic Disorders Substance Abuse Other

Schizophrenia, Schizoaffective Alcohol, Cocaine, Nicotine, Other Psychiatric Aspects of Medical Disease: Stroke, Dementia, HIV, CAD Other Psych: Personality Disorders, Eating Disorders, Somatization

Psychiatric Disorders in the Primary Care Setting • Any Diagnosis 30-50% • Major Depression 7-19% • Substance Abuse/Dependence 3-7% • Any Anxiety Disorder 10-25% • Panic Disorder 1-6% JAMA Dec. 14,1994

Panic Attacks: General • Panic Disorder 1.5-4.0% General Population • “Panic Attacks” (no disorder) 15% • 2-3x Females: Males • Develops in Young Adulthood and Adolescence

Panic Attack: 4 or more Fear of Dying Sweating Trembling SOB Parathesias Chest Pain

Fear of Losing Control Derealization Nausea Choking feeling Hot flashes

Agoraphobia: Criteria Anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having a panic attack

Panic Attacks: Comorbidity • Substance Abuse • Major Depression • Post Traumatic Stress Disorder • Obsessive Compulsive Disorder • Generalized Anxiety Disorder • Personality Disorder

Panic-Depression Comorbidity • • • •

30-40% MDD have recurrent panic attacks 10-20% MDD have panic disorder 50-55% PD (or panic attacks) have MDD Patients with MDD and PD – Earlier onset MDD – More severe MDD

Medical Presentations • Cardiac Panic • Pulmonary Panic • GI Panic • “Vertigo” Panic • Panic exacerbating pre-existing disease

“Cardiac” Panic • Chest pain, tachycardia and palpations most common panic symptoms • Chest pain with negative angiography – 43-61% have PD – 80% have PD, MDD or Both – 50% with dysfunction years after study

• 9.2% of cardiology practice had PD – 40-60% had ischemic heart disease

“Pulmonary” Panic • 32% of asthmatic patients have panic attacks during an asthma attack • Of patients referred for PFTs – 41% had panic attacks – 17% had panic disorder – (24%)-67% of patients with COPD had panic disorder

• No PD – – Subjective improvement in dyspenia with sertraline (only 7 in case series)

“GI” Panic • 6-25%Unexplained GI symptoms in general pop • Significant concurrence between IBS and PD • Lifetime prevalence of PD – In IBD: ~3% – In IBS: 28%

“Vertigo” Panic • Dizziness second most common symptom in PD • 50-85% of PD patients report dizziness • Some studies find a high rate of vestibular dysfunction in patients with PD – (especially if agoraphobia is present)

• Headache third most common PD symptom – 12-15% of headache patients have PD

“Personalities” • • • • • •

Alexithymia Somatothymia Diminished ego strength Medicalized distress Resists diagnosis Personality Disorder

Panic-Personality Comorbidity • 40-50% with PD have a Personality Disorder • Most likely Cluster C (anxious type): – Avoidant – Obsessive-compulsive – Dependent

Treatment • Psychotherapy-Cognitive Behavioral Therapy • SSRI • TCAD • Benzodiazepines • MAOI • Combinations • Other

Management Issues • Overstimulation • Jitteriness • Dependence • Drug-Drug Interactions