panic disorders in primary care robert k. schneider, md assistant professor departments of...
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PANIC DISORDERS IN PRIMARY CARE
ROBERT K. SCHNEIDER, MD
Assistant ProfessorDepartments of Psychiatry and Internal Medicine
Medical College of Virginia Campus of the Virginia Commonwealth University
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Mental Health and Primary Care
MentalHealth
PrimaryCare
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Primary Care and Mental Health
PrimaryCare
MentalHealth
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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
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70,000,000 people in the US have a Diagnosable Mental/Addictive Disorder
Mental/ Addictive Disorder
28%
No Mental/Addictive Disorder
72%
Reiger et al. 1993
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40,000,000 people in the US receive services for Mental/Addictive Disorders
Reiger et al. 1993
No Treatment
85%
Treatment15%
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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)
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Percentage of Patients per Sector
PATIENTS SECTOR 21.5% Not in Treatment
15.0% Specialty Mental Health, Inpatient and Outpatient
6.0% Overlap
54.1% General Medical Sector Outpatient, Primary Care
3.4% General Medical Sector, Inpatient, including Nursing Homes
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“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
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Organizing Principles DSM-IVAffective Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias
Psychotic Disorders
Substance Abuse
Other
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Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse
Other
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Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse Alcohol, Cocaine, Nicotine, Other
Other
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Organizing Principles DSM-IVAffective Disorders Major Depression, Bipolar Disorder,
Dysthymia
Anxiety Disorders GAD, Panic Disorder, PTSD,
OCD, Phobias
Psychotic Disorders Schizophrenia, Schizoaffective
Substance Abuse Alcohol, Cocaine, Nicotine, Other
Other Psychiatric Aspects of Medical Disease:
Stroke, Dementia, HIV, CAD
Other Psych:
Personality Disorders, Eating Disorders, Somatization
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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
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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
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Panic Attack: 4 or more
Fear of Dying Fear of Losing Control
Sweating Derealization
Trembling Nausea
SOB Choking feeling
Parathesias Hot flashes
Chest Pain
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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
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Panic Attacks: Comorbidity
• Substance Abuse
• Major Depression
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Generalized Anxiety Disorder
• Personality Disorder
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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
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Medical Presentations
• Cardiac Panic
• Pulmonary Panic
• GI Panic
• “Vertigo” Panic
• Panic exacerbating pre-existing disease
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“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
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“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)
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“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%
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“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
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“Personalities”
• Alexithymia
• Somatothymia
• Diminished ego strength
• Medicalized distress
• Resists diagnosis
• Personality Disorder
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Panic-Personality Comorbidity
• 40-50% with PD have a Personality Disorder
• Most likely Cluster C (anxious type):– Avoidant– Obsessive-compulsive– Dependent
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Treatment
• Psychotherapy-Cognitive Behavioral Therapy
• SSRI
• TCAD
• Benzodiazepines
• MAOI
• Combinations
• Other
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Management Issues
• Overstimulation
• Jitteriness
• Dependence
• Drug-Drug Interactions