Recognition of panic disorder ULLA LEPOLA

Lepola U. Recognition of panic disorder. Nord Psykiatr Tidsskr 1989;43:511-513. Oslo. ISSN 0029-1455.

Panic disorder has been a relatively unknown concept in Finland until recent years. This study presents the ability of patients to recognize a panic disorder themselves on the basis of information given. All of the 22 patients suspected of having a panic disorder came for consultation during 1 month in the autumn of 1987. Twenty patients met the DSM 111 cri- teria for panic disorder. They were treated with imipramine and alprazolam with good re- suits. The illness should be recognized and treated at an early stage before it becomes com- plex and working capacity is impaired. 0 Diagnosis, Panic disorder.

Ulla Lepola, M.D., Vaajasalo Hospital, SF-71130 Kortejoki, Finland; Accepted: 1 1.04.1989.

Introduction Until recently panic disorder was a relatively un- known concept in Finland. After the adoption of the DSM I11 classification 8 years ago this syn- drome became known to Finnish psychiatrists (1). According to the new Finnish classification of diseases (adopted in 1987), based on DSM III- R, panic disorder is an independet diagnosis (2). The differential diagnosis of panic disorder has proved difficult. Early diagnosis and treatment, however, is essential to prevent the condition from becoming chronic and complicated.

Panic disorder is a relatively common illness that disrupts everyday life. The prevalence of anxiety disorders is estimated to be 2 . 0 4 4 % and of panic disorder 0.4-3.1% (3). The syn- drome is commoner among women than men, and symptoms often appear already in adoles- cence or early adulthood.

The aim of the present study was to determine the ability of patients to recognize the condition themselves on the basis of information given.

Patients and methods The study included all patients who sought help for anxiety by coming to the outpatient clinic of Vaajasalo Hospital during 1 month in the autumn of 1987. The patients themselves sus- pected that they had a panic disorder after read- ing a newspaper article on the condition.

A total of 22 patients came for consultation, 16 of whom were women and 6 men. They un- derwent an interview (SCID-UP) (4). The de- gree of anxiety was assessed by the Hamilton Rating Scale for Anxiety (HAM-A) (5). In addi- tion to background data for sex, age, marital sta- tus, social status, and capacity to work, the pa- tients were asked about the duration of the pres- ent condition, at what age it had started, and how it had been previously treated. Any precipi- tating life events were registered. Panic disorder was evaluated in accordance with DSM 111 cri- teria. Any avoidance behaviour associated with the condition was assessed, together with the number of the panic attacks during the past week.

The patients meeting the criteria for panic dis- order were included in the actual study group. Excluded were patients who had social phobia, simple phobia, obsessive compulsive disorder, melancholia, mania, hypomania, cyclothymic disorder, or psychotic symptoms.

Results Twenty patients met the DSM 111 criteria for panic disorder. One patient had less than three attacks per 3 weeks, and in one patient the pri- mary illness was melancholia. These two patients were excluded from the study. Of those in- cluded, three were aged 20-29 years, six were aged 30-39, and 11 were over 40. Thirteen of the

Nor

d J

Psyc

hiat

ry D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y Fr

eie

Uni

vers

itaet

Ber

lin o

n 11

/12/

14Fo

r pe

rson

al u

se o

nly.

512 Ulla Lepola NORD PSYKIATR TIDSSKR 4316 (1989)

patients were married. The patients belonged equally to all social classes. Five patients were not able to work because of the panic disorder.

The primary symptoms were anxiety attacks. The patients had not previously consulted the present psychiatrist, but 11 had received psychi- atric treatment, 8 on an outpatient basis and 3 both on an outpatient basis and in a psychiatric ward.

In two patients the symptoms had lasted for less than 6 months, in two from 6 months to 2 years, and in 16 for over 2 years. In most of these last patients symptoms had persisted for more than 10 years. A precipitating life event was present in 15 patients, being a sudden event in 8 and a long-term stress factor in 7 patients. One patient had undergone two operations for removal of a malignant tumour, but these had not provoked panic symptoms. The rest were physicauy well. One patient habitually consumed excessive amounts of alcohol.

At entry to the study all patients were consid- erably anxious. All patients had a HAM-A score of more than 22 points; four had a score of more than 30. The median was 25.4. The inclusion in the study was not dependent on the HAM-A points. Sixteen patients had received psycho- tropic medication either temporarily or regular- ly. Twelve patients had used benzodiazepines, antidepressants, or neuroleptics. Four patients had used analgesics and/or beta-blockers tempo- rarily. None of the patients had found relief in any of the previous treatments.

Five patients had developed panic disorder be- fore 20 years of age, eight at 20-30 years, and seven at over 30 years. In 11 cases panic disorder was associated with phobic behaviour; 3 patients had only mild symptoms limiting their daily liv- ing, but 6 patients had severe phobic avoidance. In one case the limiting phobic symptoms had begun before the age of 20, in three cases at 20- 30 years, and in five at over 30 years.

Seven patients had had one panic attack dur- ing the previous week, nine had had 2-10 at- tacks, and four patients more than 10 attacks.

Four patients had severe concomitant depres- sion, and one patient had had severe depression previously.

After diagnostic investigation the drug treat- ment was started in 19 patients. Four of the pa- tients were treated with imipramine (up to 150 mglday), and 15 patients were treated with al-

prazolam (up to 6 mg/day). The follow-up period was from 6 months to 1 year; the patients were re-investigated by the same psychiatrist. In the imipramine group all patients were symptom- free after 6 months; in the alprazolam group 10 patients benefited significantly from the treat- ment, and 5 to some extent. One patient with al- cohol problems did not receive any medication.

The patients did not have any other treatment except education about panic disorder.

Discussion In this study, which is a part of a panic disorder program in Vaajasalo Hospital, it was demon- strated that patients can recognize panic disorder if information is given. Most of these patients had had symptoms for years, were moderately anxious, and had limitations in their daily living. Panic disorder should be recognized and treated at an early stage before the illness becomes com- plex and working capacity is impaired. Patients often develop prodromal fear of the attacks and phobic avoidance restricting their lives, and in such cases panic disorder can be described as ex- tensive. Many patients develop concomitant symptoms of severe depression (6). Alcohol abuse is a relatively common consequence in these patients (7).

Until 1987 the correct diagnosis of panic dis- order was difficult, especially for general practi- tioners who had no access to clear diagnostic cri- teria. The new classification of disease makes it easier to diagnose panic disorder, and proper relevant information also helps patients to recog- nize their illness and seek early help.

Effective psychopharmacologic agents include tricyclic antidepressants (notably imipramine and chlomipramine), monoamine oxidase inhibi- tors (phenelzine), and high-potency benzodiaze- pines (alprazolam, clonazepam) (8). Most pri- mary care patients with panic disorder can be ef- fectively and safely treated with tricyclic antide- pressants and/or alprazolam. In addition, patient education and supportive or cognitive psycho- therapy are needed to decrease symptoms such as depression and phobic behaviour.

References 1. American Psychiatric Association. Diagnostic and

statistical manual of mental disorders. 3rd ed. Washington DC, 1980.

Nor

d J

Psyc

hiat

ry D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y Fr

eie

Uni

vers

itaet

Ber

lin o

n 11

/12/

14Fo

r pe

rson

al u

se o

nly.

NORD PSYKIATR TIDSSKR 4316 (1989) Recognition of panic disorders 513

2. Laakintohallitus. Tautiluokitus 1987, osa 1, syste- maattinen osa. Valtion painatuskeskus, Helsinki 1986.

3. Marks I, Lader M. Anxiety states (anxiety neuro- sis). A review. J Nerv Ment Dis 1973;156:>18.

4. Spitzer RL, Williams JBW. Structural clinical inter- view for DSM I11 - Upjohn version.

5. Hamilton MA. The assessment of anxiety states by rating. Br J Med Psycho1 1959;32:5@-5.

6. Lesser IM, Rubin RT. Diagnostic considerations in panic disorder. J CIin Psychiatry 1986;47 (suppl 6): 4-10.

7. Strain JJ, Liebowitz MR, Klein DF. Anxiety and panic attacks in the medically ill. Psychiatr Clin North Am 1982;4:33>50.

8. Katon W. Panic disorder: epidemiology, diagnosis, and treatment in primary care. 1 Clin Psychiatry 1986;47 (SUPPI 10):21-7.

Ulla Lepola, M.D., Specialist in Psychiatry, Medical Director, Vaajasalo Hospital, SF-71130 Kortejoki.

Nor

d J

Psyc

hiat

ry D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y Fr

eie

Uni

vers

itaet

Ber

lin o

n 11

/12/

14Fo

r pe

rson

al u

se o

nly.