Panic disorders in primary care
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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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Assistant Professor

Departments of Psychiatry and Internal Medicine

Medical College of Virginia Campus

of the Virginia Commonwealth University

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Mental Health and Primary Care





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Primary Care and Mental Health





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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

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

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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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“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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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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  • 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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  • Psychotherapy-Cognitive Behavioral Therapy

  • SSRI

  • TCAD

  • Benzodiazepines

  • MAOI

  • Combinations

  • Other

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Management Issues

  • Overstimulation

  • Jitteriness

  • Dependence

  • Drug-Drug Interactions