Panic Disorder Prepared by Stephanie Gilbert Summary

Panic Disorder Prepared by Stephanie Gilbert Summary The Diagnostic and Statistical Manual of Mental Disorders, IV, classifies the most prominent feature of Panic Disorder as being the sudden repetition of Panic Attacks in addition to a follow-up period of a minimum of 30 days worrying about future occurrences. These attacks cannot be substance induced or occur as the direct result of another psychiatric diagnosis. This disorder is often associated or diagnosed with or without Agoraphobia (DSM-IV, 1996). The one-year prevalence rate of Panic Disorder is approximately 1.6% (U.S. Department of Health and Human Services, 1999). The mean age at first onset of Panic Disorder is usually in early to middle adulthood, rates are higher in female than male subjects, and is associated with an increased risk of agoraphobia and major depression (Weissman et al., 1997). The search engines utilized provided a total of approximately two hundred (206) studies that provided the basis for the original data base for Panic Disorder. This first data base was trimmed according to the basic requirements for inclusion to leave (164) studies for further study beyond the abstracts. Similar to previous disorders, most studies were rejected due to sampling techniques that did not lead to random, population based cohorts. Many originated from clinic samples, the sample size was too small to provide the generalizable results required, or the risk factors were not considered malleable. The final database included five prospective studies that were population based. The studies included in this report for Panic Disorder are as follows: the Epidemiologic Catchment Area (ECA) by Eaton et al. (1998), Early Developmental Stages of Psychopathology study (EDSP) by Wittchen et al. (2000), Children in the Community Study by Johnson et al. (2000), Breslau et al. (1992), the Epidemiologic Catchment Area Follow-up Study by Bienvenu et al. (2001). All studies were population based and prospective with the exception of one ambispective study. The risk factors for each are unique with exception of gender reported in two studies. The ECA study was an original three year prospective study that sampled East Baltimore households using the DIS and SCAN to assess the current rates and risk factors of all major mental disorders. The risk factor of interest for Panic Disorder reported in this paper was being female younger than 30 years of age, odds ratio = 2.08 (1.64-2.52). (The confidence interval was calculated by the author using statistics provided within the paper). The EDSP study was conducted in Munich, Germany and utilized government registries from 1994 to sample the population randomly. The CIDI was self administered to adolescents and young adults of ages 14 to 24 at baseline. Odds ratios were reported at the significant level of p-value = 0.05, but exact confidence intervals and p-values were not provided. All results provided were also adjusted for the presence of Major Depressive Disorder. Females, poor educational attainment, and parental alcohol abuse

are among the more prominent risk factors noted for the presence of Panic Disorder with each presenting an odds ratio of approximately 2.0 to 2.7. The Children in the Community Study was administered to a sample from upstate New York that had a mean age of 14 years at baseline. This study was drawn from a larger sample that was selected by residence. The DISC was self administered to these young adults that were predominantly Caucasian and Catholic. Cigarette smoking was found to be a statistically significant risk factor for Panic Disorder ( OR = 15.58; 2.31, 105.14) with adjustments presented in the evidence table. The Breslau et al. prospective study utilized the DIS and DSM III-R criteria to assess the presence of Panic Disorder and its risk factors. The sample was 21-30 years of age using a large HMO from Southeast Michigan for random selection with a 14 month follow-up. The primary risk factor of interest was the presence of migraine headaches both independently and then stratified by gender. The odds of having Panic Disorder with migraines as a risk factor is odds ratio = 9.5 (1.3, 69.6) with adjustments detailed within the evidence table. Females with migraine headaches are also more likely to have Panic Disorder versus those without migraines [OR = 6.2 (2.6, 14.5)] than males with migraine headaches versus without [OR = 5.5 (1.1, 30.0)]. The ECA Follow-up study uses a subset of the original cohort for an additional 3 year follow-up period using the SCAN with DSM III-R diagnostic criteria. As in the previous report, being female is a significant risk factor for Panic Disorder (OR = 5.66; 1.56, 20.6). The literature review for Panic Disorder has shown a greater emphasis on population based, prospective studies than for other anxiety diagnoses. Given the different risk factors that were significantly associated with the presence of PD, repetitive studies to strengthen these results would only further the scientific community to better diagnose, treat, and possibly prevent its prevalence based on known risk factors.

Selection Figure for Panic Disorder 206 studies matching the keywords 164 excluded for not meeting criteria 42 studies reviewed for inclusion criteria 37 studies excluded primarily for wrong sampling methods and not being prospective in nature 5 Studies for inclusion

Evidence Table for Panic Disorder

Pub Study Sample Sample Follow-up Outcome Risk Factor OR/RR Estimate Author Date Design Description Size Period Criteria/Measure Measure Risk Factor (95% CI) Adjustment W.W. Eaton, 1998 Prospective, ECA Study, East 1920 3 years DIS, SCAN Self report Female <= 30 yrs age OR = 2.08 et al. population Baltimore (1.64-2.52)a based study household residents H-U Wittchen, 2000 Ambispective, Early Developmental 3021 4-5 years CIDI; DSM-IV Self report Female:Male OR = 2.7 (na) presence of MDD et al. population Stages of Psychopathbased study ology study (EDSP); 14-24 years; Munich, Germany; Early separation OR = 2.3 (na) presence of MDD government registries events used for random sampling Parental Anxiety OR = 2.3 (na) presence of MDD Temperament (BI) OR = 10.0 (na) presence of MDD Johnson, J.G., 2000 Prospective, Children in the 688 3 years DISC Self report Youth Cigarette smoking OR = 15.58 age, sex, difficult et al. population Community Study; (2.31-105.14) childhood temp; based study Baseline mean age, parental ed lvl, 14; NY youth, smoking, psych; White, Catholic adolescent alcohol & drug use & depres. disorders

Risk Factors for Panic Disorder Various Risk Factors Color Category Forest Plot Risk Factors MDD 1 Neuroticism 1 Extraversion 1 Age 1 Female: Male 1 Male, Migraine 2 emale, Migraine 2 Migraine 2 Female <= 30 3 Adol Cig Use 4 Female: Male 5 CI arly Sep Events 5 Parental Anxiety 5 Temperament 5-10 0 10 20 30 UL LL EST Relative Risk / Odds Ratio Bienvenu et al. (1), 2001: Odds Ratio. SCAN, DSM III-R. Breslau et al. (2), 1992: Odds Ratio. DIS, DSM IIIR. Eaton et al. (3) 1998: Odds Ratio. DIS, SCAN. Johnson et al. (4), 2000: Odds Ratio. DISC. Wittchen et al., (5) 2000: Odds Ratio. CIDI, DSM IV. Panic Disorder Bibliography Bienvenu, O.J., Brown, C., Samuels, J.F., Liang, K-L, Costa, P.T., Eaton, W.W., &

Nestadt, G. (2001). Normal personality traits and comorbidity among phobic, panic and major depressive disorders. Psychiatry Research, 102, 73-85. Breslau, N., & Davis, G.C. (1992). Migraine, major depression and panic disorder: a prospective epidemiologic study of young adults. Cephalalgia, 12, 85-90. Eaton, W.W., Anthony, J.C., Romanoski, A., Tien, A., Gallo, J., Cai, G., Neufeld, K., Schlaepfer, T., Laugharne, J., & Chen, L.S. (1998). Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up. British Journal of Psychiatry, 173, 501-507. Johnson, J.G., Cohen, P., Pine, D.S., Klein, D.F., Kasen, S., & Brook, J.S. (2000). Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA, 284(18), 2348-2351. U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Oakley-Browne MA, Rubio- Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. (1997). The cross-national epidemiology of panic disorder. Arch Gen Psychiatry, 54(4):305-9. Wittchen, H-U, Kessler, R.C., Pfister, H., & Lieb, M. (2000). Why do people with anxiety disorders become depressed? A prospective-longitudinal community study. Acta Psychiatr Scand, 102, Suppl 406, 14-23.