1. 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

2. Mental Health and Primary Care Mental Health Primary Care

3. Primary Care and Mental Health Primary Care Mental Health

4. 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

5. 70,000,000 people in the US have a Diagnosable Mental/Addictive Disorder Reiger et al. 1993

6. 40,000,000 people in the US receive services for Mental/Addictive Disorders Reiger et al. 1993

7. 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)

8. Percentage of Patients per Sector

9. “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

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

11. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders Psychotic Disorders Substance Abuse Other

12. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Substance Abuse Other

13. Organizing Principles DSM-IV Affective Disorders Major Depression, Bipolar Disorder, Dysthymia Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Other

14. Organizing Principles DSM-IV Affective 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

15. Organizing Principles DSM-IV Affective 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

16. 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

18. 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

19. Panic Attack: 4 or more Fear of DyingFear of Losing Control SweatingDerealization TremblingNausea SOBChoking feeling ParathesiasHot flashes Chest Pain

20. 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

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

22. 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

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

24. “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

25. “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)

26. “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%

27. “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

28. “Personalities” Alexithymia Somatothymia Diminished ego strength Medicalized distress Resists diagnosis Personality Disorder

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

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

31. Management Issues Overstimulation Jitteriness Dependence Drug-Drug Interactions