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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.

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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
Mental Health and Primary Care

Primary

Care

Mental

Health

primary care and mental health
Primary Care and Mental Health

Mental

Health

Primary

Care

epidemiologic catchment area study
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
70,000,000 people in the US have a Diagnosable Mental/Addictive Disorder

Reiger et al. 1993

40 000 000 people in the us receive services for mental addictive disorders
40,000,000 people in the US receive services for Mental/Addictive Disorders

Reiger et al. 1993

sectors where mental health services are provided
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)
de facto mental health system regier 1978
“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
psychiatric disorders in the primary care setting
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 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
Panic Attack: 4 or more

Fear of Dying Fear of Losing Control

Sweating Derealization

Trembling Nausea

SOB Choking feeling

Parathesias Hot flashes

Chest Pain

agoraphobia criteria
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
Panic Attacks: Comorbidity
  • Substance Abuse
  • Major Depression
  • Post Traumatic Stress Disorder
  • Obsessive Compulsive Disorder
  • Generalized Anxiety Disorder
  • Personality Disorder
panic depression comorbidity
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
Medical Presentations
  • Cardiac Panic
  • Pulmonary Panic
  • GI Panic
  • “Vertigo” Panic
  • Panic exacerbating pre-existing disease
cardiac panic
“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
“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
“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
“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
“Personalities”
  • Alexithymia
  • Somatothymia
  • Diminished ego strength
  • Medicalized distress
  • Resists diagnosis
  • Personality Disorder
panic personality comorbidity
Panic-Personality Comorbidity
  • 40-50% with PD have a Personality Disorder
  • Most likely Cluster C (anxious type):
    • Avoidant
    • Obsessive-compulsive
    • Dependent
treatment
Treatment
  • Psychotherapy-Cognitive Behavioral Therapy
  • SSRI
  • TCAD
  • Benzodiazepines
  • MAOI
  • Combinations
  • Other
management issues
Management Issues
  • Overstimulation
  • Jitteriness
  • Dependence
  • Drug-Drug Interactions
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