The epidemiology of panic attacks and panic disorder. Results of three community surveys

The authors report findings pertaining to panic disorder from the first three sites of the National Institute of Mental Health Epidemiologic Catchment Area Program. Probability samples of about 3,000 persons aged 18 years or older were interviewed in the New Haven, Connecticut area, eastern Baltimore City, Maryland, and the greater St. Louis, Missouri area in 1980-1982. Information on panic attacks and panic disorder was obtained using the Diagnostic Interview Schedule. The prevalence rate of panic attacks in the prior six months was found to be about 3% at each of the sites, while the prevalence of panic disorder varied from 0.6 to 1.0%. Age at onset was found to peak at 15-19 years. Simple panic attacks, severe and recurrent panic attacks, and panic disorder were found to be characterized by similar symptom profiles and age at onset distributions, and to have similar distributions by demographic factors.     

The prevalence of panic attacks in the United States: 1980 to 1995

OBJECTIVE: The purpose of this study was to determine the difference in the prevalence of panic attacks among adults in the US population between 1980 and 1995. METHODS: Data were drawn from the Epidemiologic Catchment Area Program study (1980) and the Midlife Development in the United States Survey (1996), which are epidemiologic survey studies with samples representative of the US adult population. A chi-square test was used to determine the difference between the prevalence of panic attack in 1980 and 1995. RESULTS: There was a statistically significant increase in the prevalence of panic attacks among adults 25 to 74 years of age from 1980 to 1995 in the United States (12.7% versus 5.3%; chi(2)=135.2, df=1, P<.0001). CONCLUSIONS: These data suggest that there may have been an increase in the prevalence of panic attacks among adults 25 to 74 years of age in the general US population over the past two decades.     

Epidemiologic evidence on cocaine use and panic attacks

Experienced drug takers and clinicians report that cocaine causes panic attacks. This claim is supported by laboratory evidence on the pharmacologic activity of the drug. In this paper, the authors have used an epidemiologic strategy to examine the suspected cocaine-panic association, with interview data from 5,896 adult household residents sampled in the early 1980s and followed prospectively for a collaborative multisite study of mental disorders in five US metropolitan areas: New Haven, Connecticut; Baltimore, Maryland; St. Louis, Missouri; Durham, North Carolina; and Los Angeles, California. The risk of panic attacks was observed to be greater for identified cocaine users in this sample, as compared with subjects who did not use cocaine during the follow-up interval. The cocaine-panic association remained strong after statistical adjustment for preexisting psychiatric conditions, use of alcohol and marijuana, and suspected sociodemographic risk factors for panic attacks. The risk was greatest among cocaine users who reported no marijuana use during the follow-up interval (estimated relative risk = 13.0, 95% confidence interval: 2.24-75.8). The study also identified other determinants for panic attack, including sex, marital status, employment status, job prestige, major depression, and heavy drinking.     

Risk factors for the onset of panic disorder and other panic attacks in a prospective, population-based study

A total of 383 cases of incident panic attack were identified among 12,823 participants in the Epidemiologic Catchment Area Program over various 12-month periods in 1980-1983. These cases not phobia-stimulated were compared with 766 controls. Risk factors were examined for the onset of panic attacks, with attacks categorized as panic disorder, severe and unexplained panic attacks, or other panic attacks. Risk factors were also examined for the onset of attacks in which cardiovascular symptoms were experienced and those in which psychologic symptoms were experienced. Females were at greater risk than males for each category of attacks (relative odds ranged from 1.36 to 2.25). Persons aged 65 years or older were at lower risk than younger persons (relative odds, compared with 30- to 44-year-olds, ranged from 0.26 to 0.71). A history of cardiac symptoms, shortness of breath, depression or a major grief episode, drug abuse or dependence, alcohol abuse or dependence, and seizures were each strongly associated with panic attacks. A history of cardiac symptoms was more strongly associated with attacks in which cardiovascular symptoms were experienced than with attacks in which psychologic symptoms were experienced (relative odds, 8.36 vs. 2.23). A history of seizures was more strongly associated with attacks with psychologic symptoms than with attacks with cardiovascular symptoms (relative odds, 5.21 vs. 1.58).     

Relationship between panic attacks and health locus of control

BACKGROUND. Health locus of control has significant implications for treatment response, compliance, patient education, and health maintenance. Because of the association between locus of control and anxiety, this study was conducted to determine the health locus of control (HLOC) in patients with panic attacks, changes in HLOC through treatment of panic attacks, and the relationship between HLOC and phobic avoidance. METHODS. The HLOC and panic screening questionnaires were administered to 50 patients complaining of a panic-related symptom or condition known to be associated with panic, and to 119 randomly selected patients. Nineteen patients with panic attacks were later reevaluated to determine if there had been a change in locus of control. RESULTS. Stepwise multiple regression demonstrated that panic attacks, educational level, and being divorced significantly predicted HLOC (F = 5.66, P less than or equal to .0001). An analysis of covariance (ANCOVA) showed that resolution of panic attacks was associated with a greater decrease in the HLOC score (F = 4.68, P less than or equal to .05). Phobic avoidance was also associated with greater levels of externality (r = .48, P less than or equal to .05) and correlated with HLOC in response to treatment. CONCLUSIONS. This study suggests there is a significant relationship between HLOC and panic attacks, and between HLOC and phobic avoidance. Panic resolution is associated with a decrease in externality. Measurement of HLOC may be helpful in assessing the treatment response of patients who have panic attacks.     

Symptom severity and perceptions in subjects with panic attacks

OBJECTIVES: To (1) identify aspects that defined the self-perceived worst panic attack, (2) determine how subjects with panic attacks perceive symptoms compared with control subjects, and (3) determine the role of symptom perceptions in seeking care for the worst panic attack. DESIGN: Cross-sectional survey. SETTING: Community-based. PATIENTS OR OTHER PARTICIPANTS: Ninety-seven subjects with panic attacks as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (with or without panic disorder), and 97 demographically matched controls. INTERVENTION: None. MAIN OUTCOME MEASURES: Subjects and controls completed the Symptom Perception Scales, and subjects with panic attacks completed the Acute Panic Inventory and a questionnaire concerning care-seeking behavior for their self-perceived worst attack. RESULTS: Compared with controls, subjects with panic attacks perceived many symptoms as more embarrassing but differed little in their perceptions of need for treatment, threat to life, and disruption of functioning. Particular symptoms (ie, dyspnea, fear, dizziness, and faintness) tended to differ in most perceptions. However, symptom perceptions did not play a significant role in care-seeking behavior for the worst attack. CONCLUSIONS: Subjects with panic attacks perceive symptoms as more embarrassing than controls, and have different perceptions about particular symptoms. Cognitive approaches addressing negative patient perceptions may reduce anxiety, inappropriate use of health care services, and adverse outcomes. Arch Fam Med. 2000;9:1028-1035     

Panic plaques: panic disorder & coronary artery disease in patients with chest pain

BACKGROUND: The purpose of this systematic review was to identify characteristics of the chest pain associated with the presence of panic disorder, to determine the strength of the association between panic disorder and coronary artery disease (CAD), and to determine the association between panic disorder and known cardiovascular risk factors. METHODS: Potential studies were identified via computerized search using MEDLINE and PSYCINFO databases, and review of bibliographies. MeSH headings used included "panic disorder" with "chest pain," "panic disorder" with "coronary disease or cardiovascular disorders or heart disorders," and "panic disorder" with "cholesterol or essential hypertension or tobacco smoking." Studies had to base their diagnosis of panic disorder on criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and objective criteria of CAD and risk factors had to be used. Only case-control and cohort studies were included. RESULTS: The relative risk of panic disorder in patients with nonanginal chest pain is 2.03 [confidence interval (CI), 1.41 to 2.92]. Concerning the relationship between panic disorder and CAD, studies conducted in emergency departments found a relative risk of 1.25 (CI, 0.87 to 1.80). However, there is an inverse relationship between the prevalence of CAD in the study and the prevalence of panic disorder among the patients with CAD (r = -.469, P =.086). Panic disorder has also been linked to cardiac risk factors. CONCLUSIONS: Panic disorder and CAD are correlated in noncardiology settings, and recurrent panic attacks may actually cause CAD. Recognition of either condition should lead the family physician to consider the other, resulting in increased vigilance and possible screening.     

Major depressive disorder, panic disorder, and post-traumatic stress disorder in Korean subway drivers

Purpose

The purposes of this study are to investigate the prevalence of major depressive disorder, panic disorder, and post-traumatic stress disorder (PTSD) in Korean subway drivers, and find the association between these disorders and the drivers’ person-under-train (PUT) experiences.

Methods

A total of 826 subway drivers who participated in a cross-sectional work and health survey were included for this study. The Korean version of the Composite International Diagnostic Interview 2.1 was applied to assess major depressive disorder, panic disorder, and PTSD. The date of PUT, whether victim died, and how many PUTs the drivers experienced were asked using a structured questionnaire.

Results

The standardized prevalence ratios (SPRs) for lifetime prevalence of panic disorder and PTSD in subway drivers were 13.3 (95 % confidence interval [CI] 6.6–22.4) and 2.1 (95 % CI 1.1–3.4), respectively. In lifetime prevalence, after adjusting for age, education, income, and working career, the drivers who experienced PUT had significantly higher risks for panic disorder (odds ratio [OR] = 4.2, 95 % CI 1.2–16.6) and PTSD (OR = 4.4, 95 % CI 1.3–16.4). In 1-year prevalence, the drivers who experienced PUT had a significantly higher risk for PTSD (OR = 11.7, 95 % CI 1.9–225.8). There was no significant value of SPR and OR in major depressive disorder.

Conclusions

This study suggests that Korean subway drivers are at higher risk for panic disorder and PTSD compared to the general population, and PUT experience is associated with panic disorder and PTSD. Drivers who have experienced PUT should be treated quickly, sympathetically, and sensitively by a psychological professional and their colleagues, so they can return to work soon.     

'Hyperventilation syndrome': often an easy to treat panic disorder

Three patients, 2 men aged 35 and 26 years and 1 woman aged 41 years, had acutely occurring attacks, accompanied by diverse somatic complaints, and were diagnosed with hyperventilation syndrome. They recovered only when the complaints were recognised and treated as a panic disorder. Hyperventilation and the decrease of CO2 in the blood do not explain the symptoms and complaints in patients with panic disorder, a psychiatric disorder with a good prognosis. Treatment consists of cognitive behavioural therapy or a selective serotonin re-uptake inhibitor in the case of panic disorder and of a combination of those two treatments in the case of panic disorder with agoraphobia. Breathing exercises can form part of the behavioural therapy but not because the disorder is due to faulty breathing habits.     

A family study of panic disorder

Panic disorder, as defined by the DSM III diagnostic criteria, was diagnosed in 117 probands for whom age of onset ranged from 10 to 59 years, with a mean of 26.6 years. Diagnosis of parents and siblings was based on interviews with the probands, and only those with “definite” panic disorder by the FISC criteria were considered to be affected. The pattern of concordances for panic across different groups of relatives was estimated concurrently by a log-linear model for binary pedigree data, assuming different values for the cumulative risk. When an adjustment for age was made, based on the age of onset of probands, there was no significant difference between parent-offspring concordance and sibling concordance. There was a negative, but not significant, concordance between spouse pairs. Assuming the lifetime cumulative risk was 1.9% for males and 4.7% for females, values considered appropriate for this population, our model predicted that the presence of an affected parent or sibling incurs an approximately five times increase in the risk of developing panic disorder. Our model assumes in effect that this risk is multiplied for each further affected relative. Although the common concordance across relationship groups is consistent with a genetic hypothesis, it can also be explained by common family environmental factors. There is a need for further pedigree studies, using twins and relatives, for example, and reliable information on the cumulative risk.     

The sequence of panic symptoms

Although much research has focused on the pathophysiology of panic attacks, little work has been done to describe the phenomenon itself. Twenty-one patients with panic attacks were asked to sequence the panic-related symptoms during an attack in an attempt to clarify the phenomenon. Overall, panic symptoms could be grouped into three categories: early symptoms--consisting of dyspnea, palpitations, chest discomfort, and hot flashes; intermediate symptoms--including shaking, choking, feelings of unreality, sweats, faintness, and dizziness; late symptoms-consisting of fear and paresthesias. Based on symptom clustering and temporal relationships, this study describes the panic phenomenon.     

Panic disorder: epidemiology in primary care

One hundred ninety-five patients in a primary care practice were screened with the National Institute of Mental Health Diagnostic Interview Schedule, a structured psychiatric interview, so that the epidemiology of panic disorder could be studied. Thirteen percent of the patients met criteria described in the Diagnostic and Statistical Manual of Mental Disorders, ed 3 (DSM-III) for panic disorder (6.7 percent if the DSM-III exclusionary criteria are used). An additional 8.7 percent of patients, labeled in the study as having simple panic, had four or more autonomic symptoms of panic disorder but did not meet DSM-III criteria (three panic attacks in a three-week period). Compared with controls, patients with panic disorder or simple panic had a significantly higher lifetime risk of major depression, multiple phobias, and avoidance behavior and higher scores on their psychological distress scales. Patients with panic disorder and simple panic often misinterpreted their symptoms as being due to a physical illness and had significantly higher scores on the somatization scale of the SCL-90 and on a medical review of symptoms than did the controls with no panic disorder. It is important to diagnose panic disorder accurately because double-blind placebo-controlled studies have demonstrated the efficacy of psychopharmacologic treatments, including tricyclic antidepressants (notably imipramine and desipramine), the high-potency benzodiazepine (alprazolam) and monoamine oxidase inhibitors (phenelzine). Primary care physicians, by screening patients with complaints of tension and anxiety, as well as multiple unexplained somatic complaints for panic disorder, may be able to reduce somatic preoccupation and disease phobia by instituting effective therapy.     

Characteristics of patients with panic disorder attended in primary care during the COVID-19 pandemic: A cross-sectional multicenter study

ObjectiveTo assess the prevalence of panic disorder during the second and third waves of the COVID-19 pandemic.DesignCross-sectional multicenter study.SettingPrimary care.ParticipantsParticipating primary care physicians selected patients visiting their primary care centers for any reason over a 16-month period.Main outcome measureDiagnosis of panic disorder was established using The Primary Care Evaluation of Mental Disorders (PRIME-MD) instrument.ResultsOf a total of 678 patients who met the inclusion criteria, 36 presented with panic disorder, with a prevalence of 5.3% (95% confidence interval 3.6–7.0). A total of 63.9% of cases occurred in women. The mean age was 46.7 ± 17.1 years. Socioeconomic difficulties, such as very low monthly income rate, unemployment, and financial constraints to make housing payments and to make ends meet were more frequent in patients with panic disorders as compared to patients without panic disorder. A high level of stress (Holmes–Rahe scale > 300), concomitant chronic fatigue syndrome and irritable bowel disease, and having financial difficulties in the past 6 months were associated with factors of panic disorder.DiscussionThis study characterizes patients with panic disorder diagnosed with a validated instrument during the COVID-19 pandemic and identified risk factors for this disease.ConclusionsIn non-selected consecutive primary care attendees in real-world conditions during the COVID-19 pandemic, the prevalence of panic disorder was 5.3%, being more frequent in women. There is a need to enhance primary care resources for mental health care during the duration of the pandemic and beyond.     

Pharmacotherapeutic treatment of panic disorder in patients presenting with chest pain

While psychiatric populations with panic disorder have been shown to be responsive to several classes of psychoactive medications, there is little evidence that medical patients with panic disorder respond to similar interventions. In this non-blind, eight-week trial of alprazolam in patients presenting with chest pain and found to have panic disorder, 15 of 20 met the single criterion for improvement: a 50 percent or greater reduction in panic frequency. Several other measures were also significantly positive for those who completed the study. Furthermore, these patients reported a marginally significant drop in episodes of chest pain or discomfort. A double-blind, placebo-controlled trial is now required to test the validity of these findings.     

Eating disorders and panic: Four cases of pathological coping

Four cases demonstrate the intensification of distress when coping triggers panic and pathological eating. In all four cases, eating-disordered patients attempt to alleviate panic with food, and instead exacerbate both the panic and eating disorder symptomatology. Implications for the assessment and treatment of persons diagnosed with panic disorder and an eating disorder are presented. © 1997 John Wiley & Sons, Inc. Int J Eat Disord 22: 219– 22, 1997.     

Changes in the prevalence of mood and anxiety disorders among male and female current smokers in the United States: 1990–2001

PurposeThe present study investigated whether the prevalence of mood and anxiety disorders has increased over time among current smokers and whether these trends differ by gender and in comparison with nonsmokers.MethodsData were drawn from the National Comorbidity Survey (1990) and the National Comorbidity Survey-Replication (2001), representative samples of the US adult population. Binomial regression analyses were used to determine differences between mood and anxiety disorders among current smokers in 1990 and 2001 and whether these differed by gender and in comparison with those who were former or never current smokers.ResultsAny anxiety disorder, panic attacks, panic disorder, social anxiety disorder and dysthymia were all significantly more common among current smokers in 2001 compared with 1990 and except for social anxiety disorder these increases were significantly greater than any trend found in non-smokers. Increases in panic attacks, social anxiety disorder, and dysthymia were more pronounced in female than in male smokers. Major depressive disorder and generalized anxiety disorder were not found to increase over time among smokers.ConclusionsThe prevalence of several anxiety disorders and dysthymia among current smokers appears to have increased from 1990 to 2001. Future studies are needed to determine whether these trends have continued. If so, interventions aimed at moving the prevalence lower may have limited success if treatment of mental health problems such as anxiety disorders and certain mood disorders are not considered in the development and dissemination of tobacco control programs.     

Gulf War veterans with anxiety: prevalence, comorbidity, and risk factors

BACKGROUND: Veterans of the first Gulf War have higher rates of medical and psychiatric symptoms than nondeployed military personnel. METHODS: To assess the prevalence of and risk factors for current anxiety disorders in Gulf War veterans, we administered a structured telephone interview to a population-based sample of 4886 military personnel from Iowa at enlistment. Participants were randomly drawn from Gulf War regular military, Gulf War National Guard/ Reserve, non-Gulf War regular military, and non-Gulf War National Guard/Reserve. Medical and psychiatric conditions were assessed through standardized interviews and questionnaires in 3695 subjects (76% participation). Risk factors were assessed using multivariate logistic regression models. RESULTS: Veterans of the first Gulf War reported a markedly higher prevalence of current anxiety disorders than nondeployed military personnel (5.9% vs. 2.8%; odds ratio = 2.1; 95% confidence interval = 1.3-3.1), and their anxiety disorders are associated with co-occurring psychiatric disorders. Posttraumatic stress disorder, panic disorder, and generalized anxiety disorder were each present at rates nearly twice expected. In our multivariate model, predeployment psychiatric treatment and predeployment diagnoses (posttraumatic stress disorder, depression, or anxiety) were independently associated with current anxiety disorder. Participation in Gulf War combat was independently associated with current posttraumatic stress disorder, panic disorder, and generalized anxiety disorder. CONCLUSIONS: Current anxiety disorders are relatively frequent in a military population and are more common among Gulf War veterans than nondeployed military personnel. Predeployment psychiatric difficulties are robustly associated with the development of anxiety. Healthcare providers and policymakers need to consider panic disorder and generalized anxiety disorder, in addition to posttraumatic stress disorder, to ensure their proper assessment, treatment, and prevention in veteran populations.     

Sexual Dysfunction: A Neglected Complication of Panic Disorder and Social Phobia

Little is known about sexual dysfunctions comorbid with anxiety disorder. The aim of this study is to evaluate retrospectively the sexual function of social phobic patients in comparison with a panic disorder sample. Using a semistructured interview (SCID-I), 30 patients with social phobia and 28 patients with panic disorder were examined. The DSM-IV criteria were employed to diagnose sexual dysfunctions in this sample; however, the C criterion, which states that the sexual dysfunction cannot be related to other Axis I disorders, was excluded. Panic disorder patients reported a significantly greater proportion of sexual disorders compared with social phobics: 75% (21/28) vs. 33.3% (10/30) (p = .0034). Sexual aversion disorder was the most common sexual dysfunction in both male (35.7%; 5/14) and female (50%; 7/14) panic disorder patients, and premature ejaculation was the most common sexual dysfunction in male social phobic patients: 47.4% (9/19). These results suggest that sexual dysfunctions are frequent and neglected complications of social phobia and panic disorder.