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Panic Disorder Patients, the Emergency Department, and Noncardiac Chest Pain

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Panic Disorder Patients, the Emergency Department, and Noncardiac Chest Pain

 

March 8, 2010


Geneviève Belleville, PhD
Professor, School of Psychology, Université du Québec à Montréal

Guillaume Foldes-Busque, MPs
Research Associate, Centre Hospitalier Affilié Universitaire Hôtel-Dieu de Lévis

André Marchand, PhD
Professor, Department of Psychology, Université du Québec à Montréal


First published in Psychiatry Weekly, Volume 5, Issue 5, on March 8, 2010

 

Introduction

Chest pain is one of the 13 symptoms that may occur during a panic attack, and it is the symptom most likely to prompt consultation at an emergency department (ED).1 Reports show that 17% to 32% of patients who consult an ED with chest pain have panic disorder,2-4 but panic disorder still remains virtually unidentified in the ED.2

These relatively low detection rates raise important questions regarding the clinical profile of panic disorder patients consulting in the ED. These patients may present a different profile compared to panic disorder patients encountered in psychiatric settings. Exploratory data have suggested that panic disorder patients from the ED are older, are more likely to be male, have less severe panic symptoms, and have lower rates of agoraphobia than their psychiatric counterparts.5 Reports of clinical experiences also suggested that it is likely for people with panic disorder to initially present to their general practitioner or hospital ED with a focus on somatic symptoms and concerns.6

Another concern is the proportion of patients in the ED that appear to have a subtype of panic disorder, referred to as non-fearful panic disorder (NFPD), which is characterized by no report of either fear of dying or fear of going crazy or losing control during panic attacks.7 One report8 found that 44% of panic disorder patients seeking treatment for chest pain could be categorized as having NFPD.

Method

Belleville and colleagues compared panic disorder patients from the ED to those in psychiatric settings on measures of panic symptoms, psychiatric comorbidity, and psychological correlates of panic disorder.

Inclusion criteria for the ED sample (n=84) were: ≥18 years of age, French or English speaking, and consulted the ED for chest pain non-associated with chest trauma. Patients presenting results outside the normal ranges on the electrocardiogram or blood tests, suggesting coronary artery disease; or presenting a clear medical cause for the chest pain (eg, pulmonary embolism), were excluded from study. Patients were assessed with self-report questionnaires and a clinical diagnostic interview conducted by a research assistant while they were in medical observation or waiting for tests results.

The psychiatric settings sample (n=126) were recruited through advertisements and medical referrals and received treatment delivered in a specialized anxiety clinic. Inclusion criteria were: 18–65 years of age; diagnosis of panic disorder with agoraphobia, based on DSM-IV criteria, for at least 1 year; onset of panic disorder prior to 40 years of age; and had not participated in cognitive-behavioral therapy for panic disorder within the last year. Patients were assessed using a clinical interview, and self-report questionnaires were completed before receiving treatment.

Results

The ED sample was nearly equally composed of men and women (47.6% women), while the psychiatric settings sample had a greater proportion of women (77.0%).

Eleven out of 13 DSM-IV panic disorder symptoms were more frequently reported by psychiatric settings patients than by ED patients. Cramér’s V values ranged from .14 (fear of dying) to .50 (fear of losing control or going crazy), indicating effect sizes of moderate to large magnitude for most differences. Only paresthesia was evenly encountered in both groups. Although participants from the ED sample consulted for chest pain, they may have reported not having it during panic attacks; thus, most (83.1%), but not every, panic disorder patients from the ED reported chest pain. On average, psychiatric settings patients reported three more symptoms during panic attacks than ED patients (9.21 vs. 6.61).

Agoraphobia was encountered in 32.1% of ED patients (Table). The high prevalence of agoraphobia in the psychiatric settings sample (100%) only reflected the selection criteria used to recruit this sample. The proportion of NFPD patients in the ED sample (32.1%) was almost three times that observed in the psychiatric settings sample (11.9%).

table

Discussion

One implication of these findings is that, as a result of their less severe symptoms, infrequent manifestations of agoraphobia, less reported overall impairment, and a less “psychiatric” presentation, patients with panic disorder in the ED may not be adequately screened and offered appropriate therapeutic options. Failure to recognize panic among chest pain patients is associated with serious consequences in terms of phobic avoidance, quality of life, and healthcare utilization.9-11

Conclusion

These findings join earlier reports demonstrating that panic disorder encountered in the ED presents different clinical characteristics than panic disorder seen in psychiatric settings. There is a need for valid and “user-friendly” instruments to help ED physicians and nurses, who are not extensively familiar with psychiatric nosologies and subtle diagnostic particularities, to rapidly and efficiently identify panic disorder.


Disclosures: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.

 

References

1. Katerndahl DA. Factors associated with persons with panic attacks seeking medical care. Fam Med. 1990;22(6):462-466.

2. Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. 1996;101(4):371-380.

3. Srinivasan K, Joseph W. A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine. Gen Hosp Psychiatry. 2004;26(6):470-474.

4. Wulsin L, Liu T, Storrow A, Evans S, Dewan N, Hamilton C. A randomized, controlled trial of panic disorder treatment initiation in an emergency department chest pain center. Ann Emerg Med. 2002;39(2):139-143.

5. Fleet RP, Marchand A, Dupuis G, Kaczorowski J, Beitman BD. Comparing emergency department and psychiatric setting patients with panic disorder. Psychosomatics. 1998;39(6):512-518.

6. Austin D, Blashki G, Barton D, Klein B. Managing panic disorder in general practice. Aust Fam Physician. 2005;34(7):563-571.

7. Beitman BD, Basha I, Flaker G, DeRosear L, Mukerji V, Lamberti J. Non-fearful panic disorder: panic attacks without fear. Behav Res Ther. 1987;25(6):487-492.

8. Fleet RP, Martel JP, Lavoie KL, Dupuis G, Beitman BD. Non-fearful panic disorder: a variant of panic in medical patients? Psychosomatics. 2000;41(4):311-320.

9. Katerndahl DA. Panic plaques: panic disorder & coronary artery disease in patients with chest pain. J Am Board Fam Pract. 2004;17(2):114-126.

10. Roy-Byrne PP, Stein MB, Russo J, et al. Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. J Clin Psychiatry. 1999;60(7):492-500.

11. Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder. Arch Gen Psychiatry. 1989;46(11):984-992.