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Friday, November 16, 2012

Garments -- How to calculate the CM (Cost of Making) of a Garments?



Please consider the below points first:

Monthly Total Expenditure of the Factory (MTE): Suppose – BDT. 5,000,000.00
This expenditure is included of the below items:
a)      Factory Rent,
b)      Commercial Cost,
c)       Electricity Bill,
d)      Water Bill,
e)      Transportation cost,
f)       Worker and Staff wages (8 hours/day – WHD),
g)      Miscellaneous cost, etc.

* Qty of Running Machine of the factory of the following month (which total expenditure need to be considered here) – (NRM). Suppose – 100 machines.
* Number of machine to complete the layout for the relevant item (NML). Suppose – 25 machines.
* Hourly Production Target/Capacity of the relevant item (PCH), excluding alter & reject. Suppose – 200 pcs.
* Total working day of the relevant month (TWD). Suppose – 26 days.
* If the CM needs to be converted in US$ , then conversion rate (CR) would be 1 US$ = BDT. 75.00

The Formula of Cost of Making:

CM = [{(MTE / TWD) / (NRM / NML)} / (PCH x WHD)] x 12 / CR)}

The Calculation will be as below:
CM = [{(5,000,000.00 / 26) / (100 / 25)} / (200 x 8)] x 12 / 75
CM = US$ 4.81 / Dz

MTE
(in BDT.)
TWD
(Days)
NRM
(unit)
NML
(unit)
PCH
(pcs)
WHD
(hours)
Dozen
(pcs)
CR
(BDT.)
CM/Dz
(in US$)
5,000,000.00
26
100
25
200
8
12
75
$4.81

But after starting the new salary scale in Bangladesh, the CM might be calculated by considering the overhead sewing machine cost as below:

* For a Non-compliance Factory:
To be considered the overhead sewing machine cost (OSMC) @BDT. 1,400 to 1,600.00 per day.

* For a Compliance Factory:
To be considered the overhead sewing machine cost (OSMC) @BDT. 2,000 to 2,400.00 per day.

So, if any factory produces any item 200 x 8 = 1,600 pcs per day by using 25 machines, then the CM will be as below:

For a Non-compliance Factory:
  CM = {(OSMC x 25 / 1,600) x 12} / 75
  CM = {(1,600 x 25 / 1,600) x 12} / 75 = US$ 4.00/Dz
     
        * For a Compliance Factory:
  CM = {(OSMC x 25 / 1,600) x 12} / 75
  CM = {(2,400 x 25 / 1,600) x 12} / 75 = US$ 6.00/Dz


Monday, September 17, 2012

Al-Bador of 1971: A Portrait of Ugly Beasts


Victims of Al-Badors: 1971

Al-Bador means a gang of fierce beasts, more than hyenas! Al-Bador means a gang of blood suckers, just like brutal Satan! Al-Bador means a gang of rapists, who did it in the name of Islam. They were the self declared, so-called 'Protectors' of ISLAM and PAKISTAN. They were the bastards of Pakistan Army (who used the name of "ISLAM" to cover their dirty works) and controlled by them to kill Bengali innocent civilians, intellectuals, scientists, professionals, politicians and to rape the Bengali women during their (Pakistanis) dirty war in 1971 (from 25 March – 16 December).
A portrait of a Hyena: General Yahia Khan

Al-Bador means a gang of fanatics, who were the enemies of humanity and civilizations! Al-Bador means a gang of barbarians, fascists, hypocrites - who had no proper education, were blind to Political Islam.

WHO WERE THE AL-BADORS?

All members of ISLAMIC CHHATRO SANGHO, the student wing of Jamat-E-Islami of Pakistan. Each and everybody converted themselves as Al-Bador from May 1971. They took oath to sacrifice their lives to protect PAKISTAN from the hands of freedom-fighters (in their language, miscreants, Indian Agents, etc.).

WHO CREATED AL-BADORS?


Creator of Al-Bador: Rao Forman Ali

Head of Eastern Command: General Niazi

Governor of East Pakistan: General Tikka Khan


Pakistan Army / ISI created and controlled this gang of bandits to get help from their ugly and brutal activities. During their dirty war in 1971, Pakistan Army kept engaged them to fulfill their target to find out and kill their opponents mercilessly. During their ethnic cleansing in East Pakistan, Al-Badors rendered their all out supports to Pakistan Army by killing civilians, intellectuals, scientists, professionals, politicians and supporters of Awami League. They usually picked up the Bengali girls and women and handed over them to Pakistan Army or they themselves raped them by declaring them as “Gonimoter Mal” (Booty). Not only that many of those victims (raped women) were killed brutally too by those ugly beasts (Al-Bador, Al-Shams, Paki-Army, Razakar) during March-December, 1971 period.

WHO WERE THE LEADERS OF AL-BADOR?

Gang Leader (Head of Colllaborators, 1971): Gulam Azom

Head of Al-Bador (Pakistan): Motiur Rahman Nizami
Head of Al-Bador (East Pakistan): Ali Ahsan Muhammad Mujahid


Moulana Motiur Rahman Nizamee was the head of Al-Bador of Pakistan. Ali Ahsan Mohammad Mujahid was his deputy, head of Al-Bador of East Pakistan. Their spiritual and top line head was Professor Golam Azom, the master mind decision maker and controller of those beasts in East Pakistan (Bangladesh).

WHAT WERE THEIR STRATEGIES AND COURSES OF ACTIONS?

As they were controlled by the Pakistan Army, they always started their actions according to the game plans of those hyenas (Pakistan Army). They hid their identities from the civilians, they spread out themselves in the society and searched their targeted people who were the supporters of the freedom fighters, as well as the supporters of Awami Leagues, picked them up from their houses, from their offices and either handed over them to Pakistan Army or they themselves killed them brutally after torturing mercilessly.

To perform their duty perfectly, they prepared lists first of their targeted peoples and after getting final signals from their controlling unit of Pakistan Army, they started their nasty jobs to slaughter those civilians. After long time (40 years) of the independence of Bangladesh, the recent research works of Dr. Muntasir Mamun (which was published in the Daily Janakantha, from 28 August to 11 September, 2012) revealed that scenario widely, though still it is a very small part of their actual activities.

WHO SUPPORTED THEIR UGLY WORKS?


All anti-liberation forces (Jamat-e-Islam, Muslim League, etc.) in East Pakistan supported their ugly and nasty activities during the dirty war of Pakistan in 1971.

In abroad, most of the Muslim Countries in Middle East, like Saudi Arabia, UAE, Katar, Yemen, etc. did not criticize their dirty activities during the war in 1971! Even they permitted it as a part of their duty to protect “ISLAM” in Pakistan!  So, all the dirty works of those hyenas (brutal Pakistan Army and their ugly collaborators) became acceptable to them in the name to protect “ISLAM”!

By this, those brutes killed around 3.00 million civilians of East Pakistan and raped around 200,000 – 400,000 women during their (Pakistanis) ugly war (Operation Search Light) in just nine months’ period (from March 25 to December 16, 1971). Not only that those brutes torched the villages after villages, towns after towns to uproot the Bengali Nationalism from East Pakistan. For this reason, around 10.00 million people had to force to take refuge in the neighboring country, India.

Victims of the Dirty War of Pakistan, 1971.


During the last phase of their dirty war in 1971, it was widely publicized that CIA (USA) and ISI (Pakistan) jointly planned to slaughter the leading intellectuals, scientists, professionals, politicians of East Pakistan and Al-Bador, Al-Shams (another killing squad of Jamat-e-Islami) implemented this dirty plan in East Pakistan. Pakistan’s intention was to paralyze the prospective country (Bangladesh) without those leading persons, who could guide the future Bangladesh. CIA had another plan to resist Bangladesh that it would not be able to adopt socialism/communism in their state political system. Because, most of the intellectuals (who were slaughtered) were progressive minded, in their beliefs and activities.

Leading War-Criminals
Still now, some Middle Eastern countries (like Saudi Arabia, UAE, Turkey, etc.) are supporting those Al-Badors and war criminals by spending money, political supports to save them from the running War Crimes’ Trials in Bangladesh. The latest visit of Khaleda Zia in Saudi Arabia was the part of this master plan and the Chief of Saudi Intelligence (GID - General Intelligence Department), Prince  Mukhrin has urged Khaleda Zia to promote strong political agitations to save war-criminals in Bangladesh (Saudi Connection of Khaleda Zia, by Abdul Gaffar Chowdhury, the Daily Jankantha, 12/09/2012).

Sunday, April 29, 2012

Panic Disorders among the Patients Attending Cardiology Emergency Department





Dr. S. Abdullah Al-Farooq
MBBS.
FCPS Part- II (Psychiatry ) examinee






National Institute of Mental Health
Dhaka, Bangladesh
2006


Panic Disorders Among the Patients Attending Cardiology Emergency Department






This dissertation is submitted in partial fulfillment of the requirement for the FCPS Part-II (Psychiatry) examination of Bangladesh College of Physician and Surgeons.






Dr. S. Abdullah Al-Farooq
MBBS.
FCPS Part-II (Psychiatry ) examinee






National Institute of Mental Health
Dhaka, Bangladesh
2006



I am pleased to certify that Dr. S. Abdullah Al-Farooq, a FCPS Part-11 (Psychiatry) examinee completed his dissertation titled, “Panic Disorders Among the Patients Attending Cardiology Emergency Department” under my supervision. He has worked very hard to complete this study which is based on real primary data.  I am highly satisfied with his work.


(Professor Dr. Abul Hasnat Mohammad Firoz)
MBBS, FCPS (Psy), MRCP, FRCP
Director cum Professor,
Head of the Department, Adult Psychiatry,
National Institute of Mental Health and Research (NIMH),
Sher-e- Bangla Nagar,
Dhaka,
Bangladesh.

Declaration

I humbly declare that this dissertation is based on the work carried by me. No part of it had been presented previously for any higher degree. The research was carried out in National Institute of Mental Health, Dhaka under the guidance of Professor (Dr.) Abul Hasnat Mohammed Firoz, Director and Professor, National Institute of Mental Health (NIMH), Dhaka.
(Dr. S. Abdullah Al-Farooq)
National Institute of Mental Health (NIMH),
Dhaka. Bangladesh

Contents



Abstract                                                                       6                                                                

Chapter 1: introduction

      

1.1              Introduction                                                                                        8
1.2              General Objective                                                                               10
1.3              Specific Objectives                                                                             10
1.4              Rationale of the study                                                                          11
                                                           
Chapter 2: Review of Literature     
                                               
2.1.      Prevalence and diagnostic confusion                                                  13
2.2       Impact                                                                                              15                   
2.3       Socio demographic correlates                                                            15                   
2.4       Presenting symptoms                                                                          16
2.5       Care seeking                                                                                      18

Chapter 3: Methodology

3.1                   Study design                                                                          19
3.2                   Study site                                                                               19
3.3                   The sample                                                                             20
3.4                    Study period                                                                          21
3.5                   Data collection                                                                        21
3.6                   Data analysis                                                                           22
3.7                   Ethical issues                                                                           22
3.8                   Operational definitions                                                             23
3.9                   Limitation of the study                                                             27

Chapter 4: Results

4.1                   Characteristics of the study respondents                                29

4.2                   Panic disorders and socio-demographic characteristics          33

4.3                   Panic disorders and symptom characteristics                         38
4.4                   Care seeking behavior of panic disorders                              46
4.5                   Impact of panic disorders                                                     49

Chapter 5: Discussion                                                                                   51

Chapter 6: Recommendation                                              55

Chapter 7: Conclusion                                                         56

Acknowledgements                                                                                      57     
                                               
References                                                                          59

Appendices                                                                          61                 


Abstract

Panic disorder is an emerging issue among patients attending the cardiac emergency. Around 20% of patients attending cardiac emergency is found to have panic disorders which includes a half who do not have any cardiac diseases. Panic disorder exerts detrimental impact on the well being of the individual patient and his / her functioning as a member of the family and society. It also poses an economic threat to national health services and may be labeled as ‘high health care utilizers’. There is a dearth of information regarding the magnitude and pattern, socio-demographic characteristics and the impact, and presenting symptoms and care seeking behavior. These all have paramount implication on planning and sustaining effective health care services. 

A cross sectional descriptive study was carried out among the patients attending an emergency unit of a cardiac hospital. A total of 444 patients aged 18 years or above were assessed for psychiatric diseases including panic disorders applying Structured Clinical Interview for DSM-IV Axis – I Disorders (SCID-clinical version), socio-demographic correlates, presenting features, impact on the individuals and care seeking behaviour.

More than a half (52.3%) of the patients who were interviewed had at least one psychiatric disease, which included 13.5% having panic disorders. None but one panic disorder patient had any organic cardiac disease. Young age (t= -12.11, p<. 001) and female gender (c12 =17.12, p= <0.001) are significantly associated with panic disorders. Around 70% of panic disorder patients were females compared to 41% of non-panic disorders. The mean age of panic disorder patients was 32.43 (SD=7.41) years and for non-panic 47.23 (SD=14.86) years. Housewives appeared more vulnerable and accounted for exactly half of all panic disorder patients.

Significantly, more patients with panic disorders …

Geographic accessibility, perception about the nature of illness and under diagnosis at primary care level shaped up the care seeking and resulted in repeated care seeking (68.3%) but less admission (13%). None of panic patients consulted a psychiatrist although 90% had visited a general practitioner. 

An overwhelming majority of patients having panic disorders (83.3%) rated their health as bad and said it was exerting detrimental effect on their working ability (82.8% in panic disorders) as well as on their sleeping habits (69% in panic group).

The problem of panic disorders underscore the need for developing special training programme for general practitioners in order to reduce the rate of  underdiagnosis and hospital centered awareness raising programme for patients attending the cardiac emergency.  Proper referral from cardiac emergency to psychiatric services is also important.

Chapter – 1

Introduction
Panic disorder is a growing concern at primary care level and studies showed a median prevalence figure of 4% among total attendees.  However, among certain patient group the prevalence figures were found even much higher. Around 28% to 40% of those with gastrointestinal presentations and around 20% to 50% with cardiac symptoms had panic disorders (1). Because there is a lack of information on this matter in our context, finding out more about this subject would prove to be helpful for patient referral and management in planning health facility services.

Panic disorder is also very common among patients attending cardiac emergency units. Around one in every five cardiac patient attending emergency departments may have panic disorder which includes a half of those who do not have any findings for cardiac disease (2). Although it is assumed that the scenario would be the same in Bangladesh, we do not have any local data on this issue. Exploring this association would help in formulating possible prevention strategies for cardiac morbidity as well.

Panic disorder often coexists with cardiac diseases. Around a half of those with panic disorders who have attended cardiology unit also had findings for cardiac diseases . Panic disorder when coexists with a cardiac disease can have ‘serious consequences’ as panic disorder has often been linked to the risk factors for cardiac diseases such as hyperlipidaemia and hypertension, which ‘may be caused by increased catecholamines’(3).  Diagnosing the cardiac disorder may miss panic diagnosis or vice versa. Moreover, failure to diagnose panic disorder in cardiac emergency often results in increased medical costs as well as detrimental cardiac events.

Around six out of each 10 who were sent for ECG had panic disorders . The increase in heart rate in panic attacks may result in an acute myocardial infarction in someone with underlying cardiac pathology, which may cause sudden death or fatal cardiovascular diseases (3). There is a dearth of information on the magnitudes of cardiac patients with a diagnosis of panic disorders in our setting. We need to know how many of our patients in cardiac emergency have both cardiac and panic disorders, which would help in increasing awareness among cardiologists, psychiatrists, as well as the policy makers. That may in turn help in reducing the potential consequences of undetected comorbidity of cardiac and panic disorders.

Panic disorder has detrimental impact on the well-being of the patients and often hinders their functioning as a member of the family and society. Their impairment is often worse than those with cardiac diseases (3). Exploring the impact would enable us to understand the magnitude and pattern of problems that is imposed due to the disease.  The scenario of the impact in our settings will help us in planning and organizing services in order to ameliorate the suffering of the patients.

Panic disorders often involve unnecessary cost not only for the  patient and his or her family but also on cardiology units.  They are branded as ‘high health care utilizers’ (1). Assessing their magnitude would help in restructuring the services.

Care seeking behaviour of panic disorder patients is also important. How they perceive their illnesses and what they do when they feel ill is an important issue worth exploring. This may help in planning awareness programme among the general population as well as among health professionals. 

Certain demographic characteristics such as younger age, female sex and certain presenting features such as chest pain are found to be associated with panic disorders (3). Exploring the characteristics would help in developing an index of suspicion for panic disorder among patients attending cardiac units, which may help in reducing unnecessary investigations and thus the burden on cardiology units as well as on health budget.

Panic disorder remains under diagnosed in primary care settings. Consequently these patients put unnecessary strain on cardiology units. Looking at the symptom profiles, type of symptoms, their frequency and pattern of presentation would allow us to develop an algorithmic screening tool, which may be helpful in reducing under diagnosis by medical providers.  If diagnosed early they can be referred to psychiatrists for better management, as panic disorder is a category of psychiatric problems

General objective:

To delineate a profile of panic disorders among the patient attending cardiology emergency departments in a hospital in Dhaka city.

Specific objectives:
·         To find out the proportion of functional conditions among patients with cardiac symptoms 
·         To determine the proportion of panic attacks among cardiac emergency patients 
·         To find out the prevalence of panic disorders among the cardiac emergency patients without any organic cardiac disease
·         To study the  association of different socio-demographic variables  with patients of panic disorders
·         To examine the difference in presenting panic symptoms in panic and non-panic patients attending the cardiac emergency department
·         To compare the impact of panic disorders with those of non panic cardiac emergency problem.
·         To explore the care seeking behavior of patients with panic disorders 

Rationale of the study:
Panic disorder patients frequently present to cardiac emergency with the perception that they are having heart ailment and some time even with organic cardiac diseases. Since information about panic disorder such as its magnitude among the patients attending cardiology emergency department is largely inadequate, documenting the proportion of panic disorder among the various categories of patients attending the cardiology emergency would be helpful in understanding the disease burden and planning effective health services.
An exploration of associated socio-demographic characteristics would be helpful in identifying vulnerable groups and developing a more focused programme aimed at the group. The programme may focus on raising awareness at individual and family level and would help  in reducing the problem before it adds to the load in the cardiac emergency.
A study of presenting feature would allow programme planners in understanding the nature of presentation, which would be helpful in planning orientation programme for general practitioners, who largely fail to diagnose beforehand. If general practitioners are aware of the magnitude and presenting feature in the context of our community, it is more likely that the cases can be properly referred and managed.
Unearthing the care seeking behaviors, which may include perception of their illnesses and what they do when they become ill, are crucial for policy planners for restructuring research activity, developing health care services and formulating training programmes for care providers at various levels. 
An understanding of the impact of panic disorder on an individual and his family would help the planners and policymaker to justify resource allocation by highlighting economic implication.
To summarise, understanding the magnitude, socio-demographic characteristics, presenting features, care seeking behaviour and its impact would help in raising awareness at individual, family and policy level. This would in turn assist in planning and implementing effective services and reducing the suffering of the affected.

Chapter –2

Review of Literature
This section will focus on literature relevant to the study objectives and mostly discusses epidemiological issues such as prevalence and socio-demographic correlates documented by others. It also attempts to make an analytical review of symptoms, presentations, diagnostic confusion and tends to create a context of the study.
2.1 Prevalence and diagnostic confusion

Panic Disorders are one of those psychiatric disorders that have appeared as an issue of ‘much debate and controversy in recent years’ and generated much interest as 20% of people with panic disorder may attempt suicide in their lifetime (4).

Like many other psychiatric disorders, the prevalence figures for panic disorders vary across studies and across time due to use of different diagnostic criteria, different definition and time frame, and different group of population studied. Two schools of diagnostic approaches such as DSM–IV–TR and ICD-10 require different criteria for the diagnosis of panic disorders.
 The criteria in DSM – IV – TR defines panic disorders as presence of panic attacks with at least four of the 13 symptoms and followed by at least a month long period of concern about having another panic attack or about the implication of the attack or a significant change in behavior. DSM – IV – TR does not mention specifically what the minimum number of panic attacks would be or a time frame but require at least one attack. The attack is generally unexpected. However, it also includes the attack which is expected or ‘situationally predisposed’ in the absence of any precipitating cause or other psychiatric diagnosis (5,6,7).

On the other hand, in ICD-10, the central feature of panic disorder is recurrent attack of severe anxieties (panic) which are not restricted to any particular situation or a set of circumstances, and are therefore unpredictable. Patients with a panic attack often experience a crescendo of fear and autonomic symptoms which result in an exit, usually hurried from wherever they are in. For a definite diagnosis of panic disorder severe attack of autonomic anxiety should occur in following situation: (i) at least once a week, (ii) in circumstances where there is no objective danger, (iii) the attacks must not be confined to known or predictable situations and (iv) between attacks there should be comparative freedom from anxiety symptoms (8). Moreover, in ICD – 10, agoraphobia is a distinct disorder that may or may not follow the onset of panic attacks and the diagnosis of panic disorder with agoraphobia is given only if a primary diagnosis of agoraphobia has been excluded (9).

As mentioned earlier, the differences in prevalence figures varied across the studies for timeframe considered in the studies. One-month prevalence is less than lifetime prevalence while community based studies documented low prevalence compared to hospital or practice based prevalence.

The Epidemiological Catchments Area (ECA) study with DSM-III criteria documented lifetime general population prevalence for panic disorder approximately 1.7% and the National Co morbidity Survey (NCS) estimated 3.5%. The 1 month prevalence of panic disorder was 0.5% in the ECA study and 1.5% in the NCS study (9). The crude lifetime prevalence rates were 3.8% for panic disorder (10). The estimated prevalence in cardiac out patients was 9.2% (4). In medical setting the life time prevalence was 27.6% while one-month prevalence was 18.6% using DSM-III-R criteria. In one study among cardiac outpatients using DSM-IV criteria, it was found that 12.5% ware suffering from panic disorders (4). To summarise, whatever may be the prevalence figure in our setting it should be necessarily found out in order to determine the disease load. This information is crucial for planning health care programmes.
2.2 Impact

Panic disorders affect the well being of the individual and the family. It is very incapacitating and the disability caused by it is very persistent. It has been found that one year after cathetersation 41% still suffer from chest pain, 63% continue to seek help from ‘nonpsychiatrist physician’. The impact is worse for those whose condition become chronic. A follow up study documented that 74% after 11 years were still experiencing chest pain. This means a comprehensive intervention at various levels such as community level, primary care physicians and at the level of specialists including cardiologist is very important to abate the impact.

The impact is potentially lethal if panic disorders are associated with coronary artery diseases. Repeated attack of panic disorders may lead to repeated surge of adrenaline and noradrenaline and may damage electrical stability. This in turn may make the heart more vulnerable to fatal arrhythmias (10).  An integrated management that is a combination of psychotherapy and pharmacotherpy advised by both cardiologists and psychiatrist are essential to avert the situation

2.3 Socio-demographic correlates
Socio-demographic correlates are important for identifying the high-risk group. Young age and female gender have been identified as common risk factor for panic disorders (4,10). Panic disorder most commonly starts at young age with the mean age of about 25 years but no age is immune and the female to male ratio is approximately three to one in-patients with agoraphobia and two to one without agoraphobia (9).

Among occupational categories, house wives seem the most vulnerable single group (11).

Presence of stress factors is also important correlates of panic disorders. The onset of panic disorder although reported to occur spontaneously, but most individuals with panic disorders were able to identify a life-stressor occurring within the year prior to the onset of panic, which may be associated with its onset (9).

In order to develop a strategy that suits these people with high risk of panic disorders, we need to know the scenario and to explore the situation in our setting to formulate a community based awareness. This would help us to launch an effective programme.

2.4 Historical background
Psychologists, neurlogists and psychiatrists took years together to reach a consensus about the presenting features and diagnosis. Since palpitation is usually one of the most common symptoms presenting in medical setting, patients often become confused to select where to go (4). This confusing feature may have its roots in the concept of irritable heart syndrome, which the physician Jacob Mendes DaCosta (1833-1900) noted in soldiers in American civil war. Da Costa`s syndrome included many psychological and somatic symptoms that have since been included among the diagnostic criteria for panic disorder (6). At that time, cases we might now call panic disorder without agoraphobia were recognized, but were regarded as a cardiac and not an anxiety disorder. Hecker (1893) observed that half his neurasthenic patients suffered from anxiety attacks describing palpitations, rapid breathing, dizziness, sweating, and frequency of micturition. He also pointed out that such patients often complain of physical symptoms not anxiety (12). In the past, these symptoms have been variously referred to as irritable heart, neurorocirculatory asthenia, disorderly action of the heart, and effort syndrome (5). In 1895, Sigmund Freud introduced the concept of anxiety neurosis, consisting of acute and chronic psychological and somatic symptoms. Freud’s acute anxiety neurosis was similar to panic disorder as defined in DSM IV – TR (6).

The early terms assumed that patients were correct in fearing a disorder of cardiac function. Wood (1941) showed convincingly that the condition was a form of anxiety disorder. From then until 1980 patients with panic attacks were classified as having either generalized or phobic anxiety disorder.

In 1980, DSM-III introduced the new diagnostic category the panic disorder (5). DSM-III and subsequent DSM III–R divided the category of anxiety neurosis into panic disorder and generalized anxiety disorder (GAD) (13). DSM III included patients whose panic attacks occurred with or without generalized anxiety, but excluded those panic attacks that appeared in the course of agoraphobia. In DSM IV all patients with frequent panic attacks are classified as having panic disorder whether or not having agoraphobia. The category of panic disorder that did not appear in ICD – 9 were included in ICD – 10 (5).

Most of the symptoms of a panic attack are physical rather than emotional; this may contribute to the frequent presentation of patients with panic disorder in general medical setting and increased rates of use of medical services among affected patients. The sudden onset of panic attacks and their episodic nature distinguish them from the more diffuse symptoms characterizing anticipatory or generalized anxiety.
This notion of panic disorders as medical diseases is very popular in community setting.

2.5 Care seeking

Most patients with panic disorder never seek appropriate treatment (14). As they perceive their illness as ‘serious physical disorder’, they try general medicine for years together and spend enormous amounts of wealth (10). As panic symptoms overlap some serious medical conditions and cardiac diseases, panic disorder patients often undergo expensive investigations. It has been found that 39% of panic disorder patients in cardiology unit have undergone such investigations.

The dramatic nature of the onset and the battery of symptoms of panic disorders also play a role in sustaining the belief of physical ill health and the patient remains unconvinced of the findings of the investigations even after cardiac catheterisation (10). They stick to either general medicine or cardiology without resorting to psychiatry or psychology. Consequently, the number of panic disorder patients increases as time passes by and they place huge burden on medicine and cardiology units.

The situation is worsened by under diagnosis and poor referral. Panic disorder remains largely undiagnosed at primary care level and it has been found that none was diagnosed as having panic disorders (14). Among those who attend cardiac emergency around 98% were found to be ‘missed’ by attending cardiologists and appropriate referral to psychiatric services was not done (10).

The end result is that patients try one doctor after another.  It was found in one study that 70% of panic disorder patients sought help from more than 10 physicians (4).
Chapter-3

Methodology
This section describes the methodological aspects of the study, which included study design, place of study, study population, sample and sampling techniques, data collection and analysis. The section is concluded with a subsection on limitation of the study.
3.1 Study design
The present study was aimed at describing a profile of panic disorders among the patient attending cardiology emergency department. A cross sectional study was thought to be an appropriate design to achieve the objective. Accordingly a cross sectional descriptive study design was followed. Prior to the commencement of the study , consent was taken from the appropriate authority. Necessary discussions were held with the director and guide, other teachers of the institute and consultant cardiologists of NHFRI about the aim and design of the study. Every patient attending the cardiology emergency department  was examined and diagnosed by cardiologists  whether they are having any cardiac or any other physical illness or not. Before psychiatric  assessment  the consent of the patient was taken and assured that confidentiality would be maintained. The interview was conducted in single stage. Socio demographic information was collected and mental state was examined. Lastly each patient was interviewed structured clinical interview for DSM-IV axis-I disorder.

3.2 Study site
The study was carried out in the cardiology emergency department of National Heart Foundation Hospital & Research Institute (NHF&RI). This hospital was chosen because a good number of patients from different parts of the country attend the institution, which has good reputation for cardiac treatment. Moreover, being managed privately this hospital has a good laboratory back up which was hoped to enrich study results. However, no assistance was taken from the laboratory. Finally, the researcher is familiar with the physicians working in the institutions, which is very much necessary to collect quality data from patients with cardiac emergency complaints.

3.3 The Sample
It was found that around 20% of cardiac emergency patients have panic disorder (2) and based on this figure the sample size was calculated with the formulae given below:
n=
Where, p (Observed proportion of panic disorder among cardiac patients) =20%
q=1-p=80%
d= p-p1(expected proportion of panic disorder among cardiac patients)=2.5%[1]
n= sample size
Z= 1.96 (value of standard normal variant at 95% level of confidence)

The calculated sample size (n) = 983.45
Since the researcher has only one month for data collection and it was expected to have a total 600 (N) patients in one month, the finite population correction gave a corrected sample size:
nc (corrected sample size)        =                       =          373
The corrected sample size was more than 60% of total assumed population that is 600. It was predicted that it would not be possible to stay in the emergency room for 24 hours and interview all the patients. The researcher decided to include all patients who would attend the cardiac units during the study period and available for the study.

Finally, a total of 740 patients who attended the emergency during the study period were included in the analysis. However, it was not possible to assess all 740 for psychiatric disorders as the researcher could not stay at the hospital round the clock for 24 hours a day for a month and there was none who could do the same when he had to take rest. Thus a total of 444 were assessed which amounted to 60% of total number.

3.4 Study period
The study was carried out during August-September 2005. The researcher himself collected data from 28 August to 27 September 2005.

3.5 Data collection
A structured questionnaire incorporating the variables of interest such as socio-demographic characteristics, presenting symptoms and referral information was developed. A checklist for panic symptoms was incorporated in the questionnaire. The researchers developed Bengali version of Structured Clinical Interview for DSM-IV Axis – I Disorders (SCID-clinical version) and was used as a tool for psychiatric assessment (15,7). These instruments were pre-tested and finalized after incorporating necessary changes.
After obtaining consent, relevant socio-demographic information was collected from the patients whenever possible, if not from the attendants along with the presenting complaints. As it was not possible to interview all the patients by the lone investigator, some of the information was collected from hospital records. The researcher worked from around 08:30 in the morning and continued till around 10:30 at night. After initial management and when condition of the patient becames stable, questions related to SCID items were asked to the patients to reach a psychiatric diagnosis. In the cases, where there were no organic cardiac diseases, psychiatric assessments were carried out immediately after cardiac diagnoses were excluded. After reaching a psychiatric diagnosis, information on clinical and laboratory investigations were obtained from records, from attending physicians or through physical examination when necessary. Information on cardiac diagnosis was crosschecked with consultant cardiologists.

After collecting data, the researcher tried to check all information for completeness and consistency. However after collecting data from morning till around 10:30 p.m., some data remained missing on various occasions. Moreover, there were patients who had come in the middle of the night or even later on or who had left the hospital or were referred to another hospital,. These were who could not be interviewed. Patients who were admitted or kept in the observation room were interviewed the next morning. 

3.6 Data analysis
Data were coded and entered into (SPSS) computer programme (16). Mean and 95% confidence interval were calculated for describing normally distributed quantitative data such as age, monthly expenditure, duration of illness, and other quantitative findings. When data distribution was not normal median was used to describe the data. For qualitative data such as presence of panic disorder and its symptoms, cardiac disease and its presenting features, proportion with 95% confidence interval were calculated.  Relevant statistical tests including t test, X 2 and if necessary other parametric and non-parametric tests were also applied to see association or differences.  Odds ratio with 95 % confidence interval were calculated to estimate the strength of association or risk. 

3.7 Ethical issues
The study respondents and key relatives were clearly informed about the objectives, scope and limitation of the study. Written or verbal consent were obtained from the subjects or from the relatives if the subject was unable to give reliable information. Confidentiality of the subjects about personal information was strictly maintained. The researcher advised psychiatric cases to attend psychiatry outpatient department for treatment. Respondents had every right to refuse the interview and the liberty to withdraw from the study anytime. No environmental hazard was caused and no animal was used for the study.

3.8 Operational definition


Cardiac diseases:
Organic cardiovascular diseases include ischaemic heart disease, heart failure, heart block, cadiac arrythmias, hypertension, cerebrovascular diseases, coronary artery block, valvular diseases, septal defects, infective endocarditis, pericardial effusion, congenital heart diseases, and drug induced bradycardia.

Non cardiac physical illnesses:
Conditions considered as non-cardiac physical illness were diabetes and other endocrine conditions, bronchial asthma, peptic ulcer diseases, musculoskeletal pain, respiratory infection, traumatic chest pain, fracture, dengue fever, migraine, vertigo, cervical spondylosis, acute abdomen, tension headache, septicaemia, cholelithiasis, gastroenteritis, renal failure, retention of urine and where cardiac pathology could not be established.

Cardiac and physical illness:

It included respondents who have both cardiac and non cardiac diagnosis as a combination of the above two categories of illness.

Functional:

This category includes those categories, which do not have any organic disease as evident by clinical examination and electrocardiogram.

Panic attack:
Period of intense fear, apprehension, or discomfort that develops suddenly and reaches a peak of intensity within ten minutes of the initiation of symptom (9).                                    If any one fulfilled the criteria of panic attack according to DSM-IV TR, he/she was diagnosed to have panic attack (7). Please see appendix-1 for details of the DSM-IV TR criteria.

Panic disorders:
Panic attacks occur unexpectedly not in response to a known phobic stimulus, and when more than four attacks have occurred in four weeks or one attack has been followed by four weeks of persistent fear of another attack (5). If any one fulfilled the following criteria of panic disorders with or without agoraphobia according to DSM-IV TR, he / she was diagnosed as having panic disorders. (Please see appendix-1.B for details of the DSM-IV TR criteria).

Other psychiatric diagnosis:
If any one fulfilled the criteria of any other psychiatric disorders according to DSM-IV TR, he/she was diagnosed as having other psychiatric disorders.

Non-panic disorders:
It included all other patients who attended the cardiac emergency but did not fulfill the criteria for panic disorder with or without agoraphobia. This group included organic cardiac diseases, non-cardiac diseases, and functional patients other than panic disorders.

Occupational category:
Patients were asked about their occupation and were then grouped under the following 9 categories:
1.      Day laborers, rickshaw pullers, farmers
2.      Housewives
3.      Professionals, doctors, engineers, managers
4.      Businessmen or businesswomen
5.      Unemployed
6.      Students
7.      Technical personnel 
8.      Retired persons
9.      Others
·         Govt. or non-govt. employees
·         Armed force personnel
·         Public representatives
·         Social workers
·         Farm house workers
·         Teachers

3.9 Limitation of the study

The study has several limitations, which should be kept in mind during interpreting the results.

Firstly, the study was carried out only in one hospital, which is not a public hospital and is being operated by a foundation. Although, 10% of the beds are for the poor it may be assumed that the patients who attend the hospital are not representative of all socio-economic strata of the society, so are the results of the study.  However, this is a welfare hospital with good reputation for the treatment of heart diseases. People from all walks of life try to get service from this hospital. Therefore, the results would give an idea about the patients with perceived heart diseases largely. 

Secondly, as mentioned before, it was not possible to interview all the patients who attended the hospital with cardiac problem for a number of reasons. Thus the results is not reflective of all patients who attended the hospital and should be interpreted with due caution. However, as the researcher interviewed 60% of all patients and important socio-demographic characteristics such as number of children, marital status and gender did not differ significantly between those who were interviewed and who were not, the results would be reflective of all who attended the emergency.

Thirdly, psychiatric assessments were done on the basis of a single interview and may be subjected to some error. Moreover, in emergency situation people might not be cooperative enough to reach a valid diagnosis as expected. However, as the researcher used a valid instrument like SCID, the diagnoses can be relied on.

Finally, diagnoses were based on mostly clinical symptoms and very few laboratory supports were available, which might yield in information bias.

Chapter-4


Results


The results of the study are presented in the section under four broad subsections. The first subsection describes socio-demographic characteristics of patients who were interviewed. It would be helpful to understand the role of different variables such as age, educational status in terms of completed years of schooling, duration of illness, gender, marital status, type of treatment undertaken and influence of different types of family. It also includes patients’ diagnoses made by cardiologists and the psychiatrist. The second section depicts the types of patients attending the emergency departments of study hospital, and panic disorders across different socio-demographic characteristics. The third section shows the difference in various symptoms among panic and non-panic patients and the impact of panic disorders. The fourth section displays the health care seeking of panic disorders and non-panic patients attending the emergency department. A total of 444 patients were interviewed and 13.5% had panic disorder. Female and young age group were significantly associated with panic disorder.

4.1 Characteristics of the study respondents


As mentioned earlier, a total of 444 out of 740 cases could be assessed for psychiatric ailments using SCID. Table –4.1.1 illustrates that mean age (t=5.14, df =738, p=<0. 001) and mean completed years in school (t=2.74, df =690, p=0.006) of the interviewed group was significantly lower than those of non interviewed group.
While mean number children (t= -0.91, df =599, p=0.364), mean months before the respondents were completely disease free (t= -0.5, df =220, p=0.615), gender (c12=2.68, p= 0.059) and marital status (c22=5.53, p= 0.063) did not differed significantly across the groups.
Table-4.1.3 Socio-demographic characteristics of the patients
      attending cardiac emergency
Socio-demographic characteristics
Patients assessed for psychiatric disease
(n=444)
Patients not assessed for psychiatric disease (n=296)
Age (Mean)
45.23 (SD=14.97)
51.13 (SD=15.76)
Number of children (Mean)
 03.22  (SD=1.94)
03.09(SD=1.70)
Completed years in schools (Mean)
10.68   (SD=4.51)
12.24   (SD=10.39)
How many days before were you completely okay? (Mean)
726.70
(SD=1162.56)
791.32
(SD=1410.12)

Gender

   Male
   Female

243     (54.7%)
201     (45.3%)

180  (60.6%)
116  (39.4%)

Marital status (n=732)

   Married
   Unmarried            Widow/widower

398     (89.6%)
42       (9.5%)
04        (0.9%)

270   (93.8%)
14     (4.9%)
04        (1.4%)
Undertake treatment in previous month (n=600)
Yes
No

177     (39.9%)
267     (60.1%)

46     (29.5%)
106   (67.9%)

Living (n=645)

Alone
Nuclear family
Extended family

16    ( 3.6%)
337  (76.2%)
89    (20.1)

01       (0.5%)
157   (77.3%)
42     (20.7%)
Note: Total count may be different in some rows as information is missing for some respondents. Percentages are column percents and may not add to hundred due to rounding                      
                                   
Majority lives in nuclear family and sought no treatment in previous month. This indicates social transition in urban area and emergency nature of illness. Below are the socio-demographic characteristics of both groups.

Around one in four (23.5%) who attended the emergency had no clinically evident organic disease and diagnosed as “functional” by attending cardiologists. As depicted in the Table-4.1.2, around 60% (443 out of 740) had some cardiac problem while another fifteen percent have non-cardiac medical illnesses. The reason why so many non cardiac patients attending cardiac emergency is perhaps poor awareness about cardiac symptoms.

Table-4.1.2 Diagnoses by attending cardiologists                                               
Provisional diagnosis categories
Frequency
percentage
Organic cardiovascular diseases
380
51.4
Non cardiac physical illness
107
14.5
cardiac and non-cardiac disease
63
08.5
Functional
174
23.5
Brought dead
16
02.2
Total
740
100.1
Note- Percentages are column percents and may not add to hundred due to rounding       

As stated earlier, a total of 444 patients could be assessed for psychiatric disorders. The remaining 296 could not be assessed for the following reasons:
    • Investigator was absent
    • Non communicable patient
    • Brought dead
    • Severe physical impairment
    • CCU patient
    • Rush in the emergency
    • Cardiologist asked not to interview
    • Referred to other institutions
    • Acute condition

More than a half (52.3%) of the patients who were interviewed had at least one psychiatric diagnosis (Table-4.1.3). This included around 10% who presented with symptoms of panic attack only while another 4% panic attack had additional psychiatric diagnoses. Around 12% had panic disorders while another 1% panic disorders and additional psychiatric diagnosis. Around a quarter had symptoms of other psychiatric disorders.

Table-4.1.1 Psychiatric diagnosis of patients attending cardiac emergency
Psychiatric diagnoses
Count
Percentages

Panic attack

43
9.7%
Panic attack with other psychiatric diagnoses
17       
3.8%
Panic disorders
55
12.4%
Panic disorder with other psychiatric disease
05
01.1%
Other psychiatric diagnosis
112
25.2%
No psychiatric diseases
212
47.7%
Total
444
99.9%
Note- Percentages are column percents and may not add to hundred due to rounding.      

The following psychiatric disorders were included in other psychiatric diagnosis category:

·         Major Depressive Disorder                                                                  1

·         Agoraphobia Without History Of Panic Disorder                 
·         Specific Phobia                                                                      
·         Social Phobia                                                                         
·         Obsessive Compulsive Disorder                                            
·         Post Traumatic Stress Disorder                                              
·         Acute Stress Disorder                                                            
·         Generalized Anxiety Disorder                                               
·         Anxiety Disorder NOS                                                          
·         Conversion Disorder                                                              
·         Hypochondriasis                                                                    
·         Somatization Disorder                                                           
·         Somatoform Disorder NOS                                                   
·         Major Depressive Episode                                                     
·         SRD               

As mentioned before, a total of 444 patients were assessed by the researcher and psychiatric diagnoses were compared with their medical diagnosis. Table-4.1.4  shows, none among those who had any organic cardiac disease was having panic disorders. However, around a quarter of them had other psychiatric disorders, which included 2% with panic attack. While around 2% who had additional physical illness and 5% of those who did not have any cardiac pathology but medical disease had panic disorders. However, around 40% of those diagnosed as ‘Functional’ had panic disorders. To summarise, more than a half of the patients attending cardiac emergency had some psychiatric disorders, which included more than a quarter (27%) with either panic attacks (13.5%) or panic disorders.

 Table-4.1.4 Psychiatric diagnoses across different diagnoses by cardiologists (n=444)                 
Provisional diagnosis categories
Panic attack
(%)
Panic disorders
(%)
Other psychiatric disorders (%)
No psychiatric diagnosis
(%)
Organic cardiovascular diseases
04 (2.1)
00
42 (22.5)
141(75.4)
Non cardiac physical illness
09 (13.8)
03 (4.6)
14(21.5)
39(60)
Cardiac and non-cardiac disease
00
01(2.1)
14(29.8)
32(68.1)
Functional
47 (32.4)
56 (38.6)
42(29)
00
Total
60 (13.5)
60 (13.5)
112 (25.2)
212 (47.7)
Note- Figure in the parentheses are row percentages and may not add to hundred due to rounding

4.2    Panic disorders and socio-demographic characteristics


Mean age of patients, educational qualification measured as completed years of schooling, and number of children were compared. As shown in the Table- 4.2.1, the mean age was significantly (t= -12.11, p= <. 001) lower among the panic disorder patients than non-panic patients (32.43 years, SD=7.41 vs. 47.23 years SD=14.86) so was the mean number of children  (1.79, SD=1.20 vs. 3.43, SD=1.95) (t=-8.44, p <. 001). Although mean completed year of schooling is higher among the panic disorders than non-panic disorders but the difference is not significant.

Table- 4.2.1, Comparison means of age, number of children and completed years of schooling across panic disorders and non-panic disorders
Variables
Panic disorders (n=60)
No panic disorders
(n=384)
t test (p value)
Age (Mean)
32.43 (SD=7.41)
47.23 (SD=14.86)

Number of children (Mean)
1.79 (SD=1.20)
3.43 (SD=1.95)
-8.44   (<.001)
Completed years in the school  (Mean)
11.55 (SD=4.06)
10.54 (SD=4.56)
1.62    (.106)
Note: The number of panic disorders and non panic disorders are 53 and 353 respectively in the analysis of mean number of children

Age distribution is significantly different amongst panic and non-panic patients (c52=67.52, p= <0.001). As expected majority panic disorder patients ware comparatively younger with 65% aged 18-34 years while only 19.5% of non-panic patients ware in this age group (Table-4.2.2). A further third of panic patients were between 35-49 and only one was above 49 years of age. On the other hand around a half (46.3%) of the patients with no panic disorders ware aged above 49 years.

Table-4.2.2 Age distribution of the patients
Age groups
Panic Disorder
Non panic disorders
18-34
39     (65.0%)
75         (19.5%)
35-49
20     (33.3%)
131       (34.1%)
50-64
01        (1.7%)
118       (30.7%)
65-79
00
51         (13.3%)
80-95
00
09           (2.3%)
Total
60      (100.0%)
384        (100.0%)
                                   
                     Note: Figures in the parentheses are column percentages
As expected, significantly more females than males attended the cardiology emergency with panic disorders. As shown in Table – 4.2.3, around 70% of panic patients were females compared to 41% of others (c12 =17.12, p= <0.001).

Table-4.2.3 Gender distribution of panic and non panic disorders
Gender of the respondent
Panic disorders
No panic disorders
Total
Male
18        (30.0% )                       
225      (58.6%)
243   (54.7%)
Female
42        (70.0% )                       
159       (41.4%)
201   (45.3%)
Total   
60        (100.0%)

384       (100.0%)
444   (100.0%)
Figures in the parentheses are column percentages

Marital status was not significantly associated with panic disorders (c22 =0.995, p= <0.601). Almost similar percentages of patients with both panic disorders (88.3 %) and non panic disorders (89.8%) ware married while none of the panic disorders was widow or widower. Table-4.2.4 shows the distribution of marital status in detail.

Table-4.2.4 Marital status of patients with panic and non panic disorders
Marital status of the respondent
Patients with panic disorders
Patients with no panic disorders
Total
Married
53        (88.3% )                       
345     (89.8%)
398   (89.6 %)
Not married
07        (11.7% )                       
35        (9.1%)
42   (9.5%)
Widow/widower

00
04        (1.0%)
04      (0.9%)
Total   
60        (100%)

384       (99.9%)
444   (100%)
Note: Figures in the parentheses are column percentages and may not add to hundred for rounding.

Exactly a half of the panic disorders patients were housewife. It is interesting to note that there was none in retired categories. As illustrated in the Table-4.2.5, the proportions of panic disorders compared to non-panics are lower in business category but the proportions are higher in all other categories.

Table-4.2.5 Occupation of patients with panic disorders and non panic disorders
Occupation of the respondent
Panic disorders
No panic disorders
Total
Day labourer
01        (1.7%)            
04         (1.0%)
05         (1.1%)
House wife                 
30        (50.0%)                        
134      (34.9%)
164    (36.9%)
Professionals              
10        (16.7%)
56        (14.6%)
66      (14.9%)
Business                                 
06          (10.0%)                       
74         (19.3%)
80       (18.0%)
Unemployed                          
01          (1.7% )
02        (0.5%)
03        (0.7%)
Student
04           (6.7%            )          
21         (5.5%)
25       (5.6%)
Retired
00
51        (13.3%)           
51      (11.5%)
Technician      
05          (8.3%)                       
31         (8.1%)
36      (8.1%)
Others                        
03          (5.0%)                       
11          (2.9%)
14       (3.2%)
Total   
60        (100%)

384       (100%)
444     (100%)
Note: Figures in the parentheses are column percentages and add to hundred after rounding.

Smoking status is quite different in panic disorders than non-panic disorders.  As illustrated in the Table-4.2.6, around 82% of the panic disorder patients ware non-smokers and for non-panic disorders the figure was 63.5%. On the other hand, the smoker and ex-smokers ware almost double among non-panic patients than panic patients, 35.2% vs. 18.3%.

 

Table-4.2.6 Smoking status of patients with panic disorders and non panic disorders
Do you smoke?
Panic disorders
No panic disorders
Yes
9          (15.0% )                       
91          (23.7%)
No
49        (81.7%)                       
244        (63.5%)
Occasionally   

0
5            (1.3%)
Previous smoker

2           (3.3%)
44          (11.5%)
Total   
60        (100%)

384        (100%)
Note: Figures in the parentheses are column percentages.


When asked whether there was any issue they think was related to their present illness, a number of responses were elicited. More than three quarters patients with panic disorders could identify at least one category of problem such as familial, social or economic while a little more than a half of the non-panic patients have attributed their diseases to any of such problems. The panic patients ware more likely than non-panic patients to report any of the problems mentioned above. However, a little less than a quarter panic patients did not attribute their illness to the antecedent factors while the corresponding figure for non panic disorders was around 43%. As shown in Table-4.2.7, more than 50% patients with panic disorders had blamed familial problem which might have some relation with panic diseases. However, around a third of patients with non-panic disorders who ware also critical about the relationship between panic disorder and no panic disorder.  However, 8.5 % of the panic patients blamed social problem as antecedents. Presently, around 5.8 % of non-panic patients attributed their illness to social events. Around a quarter of both panic and non-panic groups held economic problems accountable for their diseases. Please note multiple responses were allowed which meant patient could attribute their illnesses to more than one category of problems.

Table-4.2.7 Nature of problems perceived as related to diseases
Have you faced any problem before, you think, is related to this episode?
Patients with panic disorders
Patients with no panic disorders
None
14        (23.7%)                       
160    (42.7%)
Familial
30        (50.8%)                       
127      (33.9%)
Social 

05          (8.5%)
22        (5.9%)
Economic

15       (25.4%)
89        (23.7%)
Total   
59        (100%)

375      (100%)
Note: Multiple response allowed, total number of the cells might exceed column total and 100% respectively. Figures in the parentheses are column percentages information was missing in 10 cases and they were not included in the analysis.


 4.3  Panic disorders and symptom characteristics

A total of thirteen symptoms were compared between panic and non-panic patients. The mean number of total ‘yes’ answers were also compared. More patients with panic disorders than non panic had symptoms such as trembling, sweating, vertigo or dizziness, depersonalisation or derealisation, feeling of choking, discomfort or pain in the chest, feeling of tingling and numbness in the limbs, feeling of losing control or going crazy, fear of dying, feeling hot flashes or chill, nausea or abdominal discomfort, palpitation or shortness of breath. Incase of all symptoms but one, these differences ware statistically significant. Details are given below.

Trembling was significantly associated with panic disorders (c12 =65 .88, p= <0.001). Three out of every four panic patients have had experienced trembling while only a little less than a quarter non-panic patients had trembling (Table-4.3.1)

Table-4.3.1 Trembling in panic and non panic disorders
Have you had trembling?
Panic disorders
No panic disorders
Total
Yes
45        (75.0%)                       
89  (23.2%)
134 (30.2%)
No
15        (25.0% )                       
294 (76.8%)
309 (69.8%)
Total   
60        (100%)

383       (100%)
444   (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.

Sweating was significantly associated with panic disorders (c12 =40.89, p= <0.001). As depicted in the Table-4.3.2, more than three-quarter of panic disorder patients had excessive sweating compared to a little more than a third of non-panic disorders, who had excessive sweating.               

Table-4.3.2 Sweating in panic and non panic disorders
Have you had a lot of sweating?
Panic disorders
No panic disorders
Total
Yes
47        (78.3%)                       
133  (34.7%)
180 (40.6%)
No
13        (21.7% )                       
250 (65.3%)
263 (59.4%)
Total   
60        (100%)

383       (100%)
443   (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.
                                                                                   
Vertigo or dizziness is significantly more common in the patients with panic disorders (c12 =11.61, p= <0.01). As illustrated in the Table-4.3.3, more than a half of patients with panic disorders had either vertigo or dizziness while around 30% of the non-panic group had those symptoms.

Table-4.3.3 vertigo or dizziness in panic and non panic disorders 
Have you had vertigo or dizziness?
Panic disorders
No panic disorders
Total
Yes
31        (51.7%)                       
113     (29.5%)
144    (32.5%)
No
29        (48.3% )                       
270     (70.5%)
299    (67.5%)
Total   
60        (100%)

383       (100%)
443     (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.
                                               

Although very few had either depersonalisation or derealisation, yet either of those symptoms was significantly more common in the patients with panic disorders  (c12 =11.61, p= <0.01) than in non panic disorders. As illustrated in the Table-4.3.4, more than 8% of patients with panic disorders had either depersonalization or derealisation while around 1% of the non-panic group had such symptoms.

Table-4.3.4 Depersonalization or derealisation in panic and non panic disorders 
Have you notice noticed any change in your feeling or in your surrounding environment?
Panic disorders
No panic disorders
Total
Yes
5 (8.3%)                     
5 (1.3%)
10 (2.3%)
No
55        (91.7%)                       
378 (98.7%)
433 (97.7%)
Total   
60        (100%)

383       (100%)
443   (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.


As many as 85% panic disorders patients, as illustrated in the Table-4.3.5, had felt choking during an attack and this was significantly more in this group (c12 =47.88, p= <0.001).

Table-4.3.5 Feeling choking in panic and non panic disorders 
Have you had feeling of choking?
Panic disorders
No panic disorders
Total
Yes
51         (85.0%)                       
143      (37.3%)
194 (43.8%)
No
9          (15.0%)                       
240       (62.7%)
249 (56.2%)
Total   
60        (100%)

383       (100%)
443   (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.

Discomfort or pain in the chest was the most common symptom both in panic and non panic disorders. As described in the Table-4.3.6, although it is more common in panic disorders compared to non-panic disorders (90% vs. 85.6%) but the difference was not statistically significant (c12 =.831, p= 0.362)
Table-4.3.6 Chest pain in panic and non panic disorders 
Have you had pain or discomfort in chest?
Panic disorders
No panic disorders
Total
Yes
54         (90.0 %)                       
328      (85.6%)
382   (86.2%)
No
6          (10.0%)                       
 55       (14.4%)
61     (13.8% %)
Total   
60        (100%)

383       (100%)
443   (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.

Feeling of tingling or numbness is one of important symptoms of panic disorders. Around 87% panic disorders had these symptoms (Table-4.3.7). Significantly, more panic disorders have feeling of tingling and numbness in the limb compared to the non panic disorders (c12 =55.12, p= <0.001).
                                                                                                     

Table-4.3.7 Feeling of tingling or numbness in panic and non panic disorders 
Have you had feeling of tingling or numbness?
Panic disorders
No panic disorders
Total
Yes
52        (86.7%)                       
137     (35.7%)
189   (42.6%)
No
8          (13.3%)                       
247      (64.3%)
255   (57.4%)
Total   
60        (100%)

383       (100%)
443   (100%)
Note: Figures in the parentheses are column percentages.

Symptom such as feeling of loosing control or going crazy are significantly higher among the patients with panic disorders (c12 =89.02, p= <0.001). More than two-thirds (68.3%) of panic patients had a feeling of loosing control or going crazy while around one in seven (14.4%) patients of non panic disorders had the same (Table-4.3.8).     

Table-4.3.8 Feeling of loosing control or going crazy in panic and non panic disorders 
Have you had feeling of loosing control or going crazy?
Panic disorders
No panic disorders
Total
Yes
41        (68.3%)                       
55         (14.4%)
96     (21.7%)
No
19        (31.7%)                       
328      (85.6%)
347   (78.3%)
Total   
60        (100%)

383       (100%)
443    (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.

When asked whether they have had any fear of dying, a little than two third of panic disorder patients answered affirmatively while only a little less than 10% non panic patients did so (Table-4.3.9). The difference was also statistically significant (c12 =106.58, p= <0.001).

Table-4.3.9 Fear of dying in panic and non panic disorders 
Have you had fear of dying?
Panic disorders
No panic disorders
Total
Yes
38        (63.3%)                       
37         (9.6%)
75     (16.9%)
No
19        (31.7%)                       
328       (85.6%)
347   (78.3%)
Total   
60        (100%)

383       (100%)
443    (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.


Feeling of hot flashes or chill ware significantly more common among the panic disorders (c12 =62.07, p= <0.001). Eighty percent of panic disorders patients had feeling of hot flashes or chill in the limbs while around 28% of those who did not have any panic disorders had such feelings (Table-4.3.10).

Table-4.3.10 Feeling of hot flashes or chill 
Have you had Feeling of hot flashes or chill?
Panic disorders
No panic disorders
Total
Yes
48        (80.0%)                       
107        (27.9%)
155     (34.9%)
No
12        (20.0%)                       
277        (72.1%)
289      (65.1%)
Total   
60        (100%)

384       (100%)
444    (100%)
Note: Figures in the parentheses are column percentages.

Nausea or abdominal discomfort significantly common among the panic disorder patients (c12 =6.17, p= <0.05). More than a half of the panic disorder patients had nausea or abdominal discomfort while around a third of non panic disorder patients had such complaints (Table-4.3.11).

Table-4.3.11 Nausea or abdominal discomfort
Have you had nausea or abdominal discomfort?
Panic disorders
No panic disorders
Total
Yes
31        (51.7%)                       
134      (35.0%)
165     (37.2%)
No
29        (48.3%)                       
249      (65.0%)
278     (62.8%)
Total   
60        (100%)

383       (100%)
443    (100%)
Note: Figures in the parentheses are column percentages and information of one participant in non-panic group is missing.


Palpitation although indicates a heart ailment but it was the commonest (96.7%) symptom among the panic disorder patients (Table-4.3.12).  It’s proportion is significantly different from non panic disorders (c12 =88.26, p= <0.001).
Table-4.3.12 Palpitation or trembling in the chest
Have you had palpitation or trembling in the chest?
Panic disorders
No panic disorders
Total
Yes
58        (96.7%)                      
124      (32.5%)
182     (41.2%)
No
2         (3.3%)                                                                                                                                         
258      (67.5%)
260     (58.8%)
Total   
60       (100%)

382       (100%)
442    (100%)
Note: Figures in the parentheses are column percentages and informations of two participants in non-panic group are missing.

Like other symptoms, shortness of breath is significantly higher among the patients with panic disorders (c12 =17.01, p= <0.001). As delineated in the Table-4.3.13, around 72% panic disorder patients had complaints of shortness of breath while only 43% of non panic patients had such symptoms.

Table-4.3.13   Shortness of breath
Have you had shortness of breath ?
Panic disorders
No panic disorders
Total
Yes
43        (71.7%)                      
165      (43.1%)
208    (47.0%)
No
17       (28.3%)                                                                                                                                   
218       (56.9 %)
235    (53.0%)
Total   
60       (100%)

383       (100%)
443    (100%)
Note: Figures in the parentheses are column percentages and information of on participants in non-panic group is missing

As illustrated in the Table-4.3.14, most of the patients with panic disorder (85%) had previous history of same health problem, which indicates the recurrent nature of the disease. It is significantly different from non panic disorder patients where around 57% said they had previously same type of health problems (c12 =16.59, p= <0.001).                   
                   Table-4.3.14 Previous history of same health problem
Previous history of same health problems
Panic disorders

Non panic disorders
Yes
51   (85.0%)
220     (57.4%)
No
09     (15.0%)
163     (42.6%)
Total
60   (100%)
383      (100%)
Note: figures in the parenthesis are column percentages

 Finally, total number of yes answer were compared across two groups. Panic patients were more likely to say higher number of yes to 13 panic symptoms than non-panic patients. The total number of yes in panic group was 544 with a mean of 9.067 and for non-panic group the mean number of yes is 4.089 and total was 1570 for 384 patients (Table-4.3.15).

Table-4.3.15 Total number of people who responds yes or no for 13 panic symptoms
Response categories
Panic disorders

Non panic disorders
Yes
544 (9.067)
1570   (4.089)
No
236 (3.933)
3411    (8.883)
Total
60     (13)
384        (13)
Note: figures in the parenthesis are mean number of responses per person

4. 4 Care seeking behaviour of panic disorder patients

Geographical accessibility, perception about the nature of illness and poor diagnoses at primary care level plays a part in choosing the health care facility for the panic disorder patients.  Near about 80 % of panic disorder patients, as illustrated in the Table- 4.4.1, were from the adjacent areas such as Mirpur and Mohammedpur indicating urgent care seeking nature of the illness. Please note the location of the hospital is almost at the centre of Mirpur. However, a fair proportion 10% also came from other areas of Bangladesh apart from the greater Dhaka City while around 22% of non-panic disorder patients were from those areas of Bangladesh indicating a perceived reputation might have played a role in selecting a particular hospital.
                            
                                   Table-4.4.1 Place of residence of the patients
Place of residence
Patients with panic disorders

Patients with no panic disorders
Mirpur and Mohammedpur
47 (78.3%)
203 (52.9%)
Dhaka city
07    (11.7%)
96   (25%)
Other areas of Bangladesh
06     (10%)
84    (21.9%)
Total
60   (100%)
383   (99.8%)
Note: figures in the parenthesis are column percentages and information was missing in one case of non-panic disorders


When asked what problems have made one come to the hospital to understand how they perceive their illness as perception plays a role in care seeking (17, 18), all panic disorder patients said that they had come here for physical health problems (Table-4.4.2). However, for non-panic patient the scenario was almost same with only one (0.3%) said the reason was psychological.
                     Table-4.4.2 Perceived reason for attending the hospital
Reason for attending the hospital
Patients with panic disorders

Patients with no panic disorders
Physical
 60     (100.0%)
382     (99.5%)
Mental
00
01          (0.3%)
Total
60     (100%)
383     (99.8%)
Note: figures in the parenthesis are column percentages and information is missing for 1 respondents in the panic group.                                                                                                                        
                                                                                                                                   
The misperception persisted even though the trend of seeking traditional help initially appeared extremely low in this particular setting. As illustrated in the Table-4.4.3, almost 90% of panic disorder patients had consulted a general practitioner while none had sought help from traditional healers. This means general practitioner failed to diagnose panic disorders at primary care level.

                             Table-4.4.3 Treatment sought initially for the illnesses 
Who did you consulted with first for this illness?
Patients with panic disorders

Patients with no panic disorders
Medicine shop
0 4        (6.8%)
05         (1.3%)
General practitioner
53      (89.8%)
358      (93.2%)
Traditional healer
00
01           (0.3%)
Specialist
01         (1.7%)
20          (5.2%)
None
01        (1.7%)
00
Total
59      (100%)
384       (100%)
Note: figures in the parenthesis are column percentages and information of one panic patient was not included in the analysis.                     


As mentioned before panic disorder is perceived as medical illness by the patients and remained undiagnosed at primary care level. Perhaps, therefore, although panic disorders is a category of psychiatric disorders, none of the panic disorder patients had consulted a psychiatrist. As shown in Table-4.4.4 one percent non-panic patients, however, had consulted a psychiatrist.
                 
                    Table 4.4.4. Psychiatric consultation the study patients
Have you had consulted a psychiatrist?
Patients with panic disorders

Patients with no panic disorders
Yes
 00
o4     (1.0%)
No
60    (100.0%)
380   (99.0%)
Total
60   (100%)
384   (100%)
Note: figures in the parenthesis are column percentages


Care seeking of panic disorder patients was characterized by repeated seeking of care. More than two-thirds (68.3%) patients with panic disorders had sought treatment in the previous month compared to around a third of those with other type of diseases.  The difference was statistically significant (c12 = 23.45, p= <0.001).                                Table-4.4.5 Treatment sought in the previous month 
Did you take any treatment in the previous month?
Patients with panic disorders

Patients with no panic disorders
Yes
 41     (68.3%)
136     (35.4%)
No
19      (31.7%)
248      (64.6%)
Total
60      (100%)
384       (100%)
Note: figures in the parenthesis are column percentages
   

Patients were asked whether they had been hospitalized for any to assessable ill health. Very few, around 13%, were admitted into any hospital for perceived physical problem while more than a third non-panic patients were admitted into any hospital (Table-4.4.6). This may be due to well differentiation of functional cases at hospitals from truly organic diseases.                     
                      Table-4.4.6 Hospital admission in the study patients
Have you been admitted to hospital for any physical illness?
Patients with panic disorders

Patients with no panic disorders
Yes
0 8     (13.3%)
131     (34.1%)
No
52     (86.7%)
251     (65.4%)
Total
60     (100%)
382     (99.5%)
Note: figures in the parenthesis are column percentages and information is missing for 2 respondents in the panic group.


4.5 Impact of panic disorders


Panic disorders had impact on the well being of self as evident by overwhelming presence of sleep problem, problem in working and lack of energy among the majority of panic patients. As shown in Table-4.5.1, patients with panic disorders had all problems higher in proportion compared to non-panics. The differences were more pronounced in sleep problem and lack of energy.

                    Table-4.5.1 Impact of panic disorders
What has happened to you after you developed this problem?
Patients with panic disorders

Patients with no panic disorders
Problem in sleeping
40     (69.0%)
168      (48.6% )
Problem in eating
28   (48.3%)
137      (39.6%)
Problem in working
48     (82.8%)
282       (81.5%)
lack of energy                                                                               Count
43  (74.1%)
213      (61.6%)
Others
00
03         (0.9%)
Total number of respondents
58     
346    
Note: figures in the parenthesis are column percentages of cases and may not add to hundred as multiple response were allowed.


Participants were asked to assess how their health had been. None of the panic disorder patients had answered affirmatively. This negative perception about self-health was more common among panic patients compared to non-panics. As illustrated in the Table-4.5.2, around 3% patients with non-panic disorders have said that their health had been good. However, an overwhelming majority of panic disorder patients (83.3%) rated their health as bad while around 61% of non-panic rated as such.
                                   
        Table-4.5.2 Self-assessment of health status.
How has your health been?
Panic disorders

Non panic disorders
Good
00
10        (2.6%)
Bad
50   (83.3%)
234      (61.1%)
Average
10     (16.7%)
139       (36.3%)
Total number of respondents
60     (100.0%)
383        (100)
Note: figures in the parenthesis are column percentages of cases and may not add to hundred as multiple response were allowed

Chapter 5


Discussion


This study may be the first one which has attempted to address the issue of panic disorders in a cardiac emergency setting in this country. The researcher could interview a total of 444 out of 740, which amounts to 60% as ‘which one was possible’ basis. However, the main variables such as age, gender, year of schooling, marital status, number of children and previous health status in terms of mean months before the respondents were completely disease free were compared to see the difference. Majorities of these back ground variables such as gender, marital status, previous health status, and mean number children did not differed significantly which means the results would give us largely an idea about the scenario of panic disorders in cardiac emergency settings in our context. However, this methodological weakness of the study should be kept in mind during drawing inference from the study results. 
           
Around one in four, who attended the emergency, had no clinically evident organic disease and another fifteen percent had non-cardiac medical illnesses. Perhaps poor awareness about cardiac symptoms, self-referral and geographic accessibility may have influenced the patient to attend cardiac emergency.

A total of 13.5% patients attending the cardiac emergency had panic disorders. This figure appears to be low compared to the findings of others which ranged from 18-50% (1,2,10,19). This difference could be due to the use of different diagnostic criteria or the study population were outpatients. However, the finding did agree with the finding of some studies, which used almost similar criteria but carried out in cardiac out patients (4).

It is interesting to note that none of those with any organic cardiac disease had panic disorders. However, around 2% who had additional physical illness with any cardiac pathology had panic disorders. This figure appeared to be low compared to other studies (10). A larger study based on sound methodology in more hospitals is needed to find out a more valid figure in our setting.

The mean age was lower among the panic disorder patients which agrees with much of literature (14,19,20). However, two studies found a higher mean age than non-panic group (4,21). This could be due to the fact that the later group had more heart disease patients amongst the panic disorder patients. Panic disorder here may be a consequence rather than an antecedent or coincidence. However, it is safe to keep in mind that no age is immune to panic disorders and further study is needed to confirm or refute these results.

Interestingly mean completed year of schooling was higher among the panic disorder patients than non-panic disorder patients, which contradicts earlier findings (14). The difference could be due to the difference in literacy rate in base population. More importantly, this study was done in a welfare hospital which was not universally accessible to all. That means higher number of literate people attended the hospital and contributed to incidence of high years of schooling in the panic group.

Significantly more females than males with panic disorders attended the emergency of cardiac hospital. Around 70% of panic patients were females compared to 41% of others The finding agrees with almost all literature reviewed (4, 14, 22). The prevalence of most psychiatric cases is more among females due to cultural and gender specific vulnerability. However, one study documented higher males among the people suffering from panic disorder that can be explained by selection bias resulted from purposive selection of patients and higher non-response (19).

It is interesting to note that none of the panic disorder patients were widows or widowers. This contradicts earlier finding of others (14, 19). Several explanation can be put forward. Firstly, this study is carried out in a hospital that needs at least some cost, which may not be affordable, by widows and widowers here who are usually poor. Secondly, nuclear families do not have enough social support, as the widow and who are usually old do not have people to take them to the hospital and consequently remain under-represented. Thirdly, it may be true that the prevalence panic of disorders is low in this population than that of others. However, a community based study is recommended to explore the issue.

Exactly a half of the panic disorders patients were housewives. This could be due to the fact that in this context the females usually play the role of housewife and panic disorders are more common in females. That is why their representation was more in panic category. It is also interesting to note that there was none in retired category while business appears to be protective, which again can be explained by gender specific occupational category.

When exploring the role of any stressors preceding the illness, more than three quarters patients with panic disorders could identify at least one category of problem such as familial, social or economic. More than 50% patients with panic disorders attributed their illness to familial problems. The role of stressors has also been mentioned by other studies and can be explained by biochemical know how (20).

A total of thirteen symptoms were compared so the mean number of total ‘yes’ answers. Patients with panic disorders than non panic ware more likely to have symptoms such as trembling, sweating, vertigo or dizziness, depersonalisation or derealisation, feeling of choking, discomfort or pain in the chest, feeling of tingling and numbness in the limbs, feeling of losing control or going crazy, fear of dying, feeling hot flashes or chill, nausea or abdominal discomfort, palpitation or shortness of breath. The symptom characteristics although more or less agrees with other (14). Like others we have also found palpitation as the commonest (96.7%) symptoms among the panic disorders (14).

 Panic disorder patients were more likely to say higher number of yes to 13 panic disorder symptoms than non-panic patients. The mean number of yes in panic group was nine  which was almost same as those of others (14, 21). The finding indicates that the presentation remains same across different population and culture. Further study using both qualitative and quantitative approach is needed to unearth the hidden dynamic of this similarity in presentation.

The exploration of care seeking behaviour from patients with panic disorders revealed a number of findings of significant public health importance. The factors, which in concerted way influenced the care seeking, are geographic accessibility, perception about the nature of illness, poor diagnoses at primary care level and poor advice in the cardiac emergency.

All panic disorder patients said that they had come to cardiac emergency for physical health problems and almost 90% of panic disorder patients had consulted a general practitioner. None of the panic disorder patients had consulted a psychiatrist. This means general practitioners failed to diagnose panic disorders at primary care level. People also fails to perceive their symptoms correctly. The phenomena of poor perception on the part of the patients and poor diagnosis and referral on the part of general practitioners are  almost universal as mentioned by others (4, 10, 20, 21).

Care seeking of panic disorder patients was further characterised by repeated seeking of care. Neither the primary care physician nor the cardiologist could explain the disease characteristics properly.  More than two-third patients with panic disorders had sought treatment in the previous month compared to around a third of those with other type of diseases. Repeated care seeking is highly associated with the panic disorders for reasons mentioned above and it is also confirmed by others (10, 20).

Panic disorders had adverse impact on the well being of self often plagued with sleep problem and problem in working. Their plight further deteriorated by negative evaluation of self-health. Others also found similar negative impact of panic disorders, which resulted in loss of workdays, cut down of normal activities and spending more night in the hospitals (14).


Chapter 6


Recommendation

The following recommendations are made based on the study findings starting from the community through primary care physicians and ending with cardiologist in the emergency room:

1. As most of the panic disorder patients perceived themselves physically ill, community based awareness raising programme focusing on disease burden, presenting symptoms and mental health promotional activities can help in breaking the long held misperception.

2. As panic disorders remained undiagnosed at primary care level, awareness raising cum training programmes should be launched for them. Refresher training on mental health and psychiatry should be carried out regularly. In educational curriculum, the issue should be given more emphasis and extra hours should be allocated for clinical training during internship. A proper referral network should be established

3. A motivational campaign should be developed for cardiologist encouraging them to spend more time explaining the nature and course of the diseases and ensuring proper referral to psychiatric resources. Placement of a psychiatrist in the emergency room and offering brief contact has been found to have ‘lasting therapeutic effect’ and ‘cost savings’ (10).

4. An integrated service jointly operated by mental health professionals and cardiologists should be established so that they can work together to formulate an interventional technique that would address proper referral, effective treatment and prevention of repeated care seeking, waste of resources and suffering of individual and his family.

Chapter 8


Conclusion
Panic disorder is an issue of concern among patients attending the cardiac emergency affecting one in every seven patients. It affects individual well being and productivity, disrupts family dynamics and finance and places an enormous pressure on the health personnels in cardiac emergency rooms. It also hinders national economy by increasing health care cost due to repetitive care seeking.

Young housewives with multiple somatic complaints are at risk of developing panic disorders and attending emergency room. Accessibility, miss conception about the nature of illness and under diagnosis at primary care level resulted in repeated care seeking at medical settings and no consultation with a psychiatrist.

Awareness raising programme at the level of community and general practitioners is of paramount importance. An integrated approach involving general practitioners, cardiologists and psychiatrists is a necessity.  Proper diagnosis at primary care level and proper orientation at cardiac emergency and proper referral to psychiatric resources should be ensured.

Above all a bargaining body should be formed to bargain with planner and policy makers for resource allocation is highly essential to address this crucial issue.

Acknowledgements

I am deeply indebted and highly grateful to my honorable guide and respective teacher Prof. A.H. M. Firoz, Director and Professor National Institute of Mental Health (NIMH), Sher-e- Bangla Nagar Dhaka for selecting and approving the tropic and his valuable advice, and encouragement.

I am very much grateful and highly indebted to my teacher Professor Md. Enayet Karim, Professor of community Psychiatry, NIMH for his advice, constructive criticism, and sympathetic co-operation.

I would like to offer special thanks to Dr. Sohel Reza Chowdury, Assistant Professor,  National Heart Foundation Hospital and Research Institute (NHFHRI) for organising my work there. He was very instrumental in obtaining permission and facilitating data collection. My heartfelt thanks are also due to all the Consultant Cardiologists and Emergency Medical Officers, nurses and staffs of the Emergency Department of NHFHRI for their kind co operation, advice and support during data collection. Truly speaking it would not have been possible for me to prepare this dissertation without their support. I express my heartfelt thanks to Brig. Professor Abdul Malik (Rtd.), Secretary General, National Heart Foundation of Bangladesh for giving me kind permission to work in the Emergency Department of NHFHRI. 

I am grateful to Professor M. A. Sobhan Chairman Department of Psychiatry Bangabandhu Sheikh Mujib Mediacal University (BSMMU) for his valuable suggestion. I am indebted to Prof. Md. Golam Rabbani , Professor and Head of the Department of Child and Adolescent Psychiatry NIMH for his useful comments and suggestion. I wish to pay Dr. Faruq Alam, Associate Professor Child and Adolescent Psychiatry a grateful gratitude for his advice and guidance.

I like to offer my gratitude to Dr. Khashru Pervez Chowdhury Asst. Prof. Department of Forensic Psychiatry NIMH for his active co-operation and continuous support. I would also like to pay my gratitude to Resident Physician, Consultant Psychiatrists, Medical Officers and all the stuffs of the Out Patient Department of NIMH for their active co-operation, advice and support during this work. I express my thanks to Prof. Waziul Alam Chowdhury, Professor and Head of The Department of Organic and Geriatric Psychiatry, Prof. Shah Alam Professor and Head of The Department o f Psychotherapy, Dr. M. A. Hamid, Associate Professor and Head of the Department of Forensic Psychiatry, Dr. M.A. Mohit Kamal, Associate Professor Dept. of Psychotherapy for their valuable suggestions and co operations.

I also remember the support and co operation of Dr. Tazul Islam Associate Prof. Community Psychiatry, Dr. Shahida Chowdhury Asst. Prof. Adult Psychiatry, Dr. Nizamuddin Asst. Prof. Dr. Fahmidur Rahman Asst. Prof. Dr. Algin Sultana Ex-Register, NIMH. Lastly I show respect to all colleagues and other psychiatrists who also encouraged me for this work. 
All credit to Dr. M Manirul Islam whose help and active support made this work possible
My acknowledgement will not be compete if I do not express my sincere thanks and respect to all the patients who have their valuable time even when they were ill and participated in this study.

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Appendices

Appendix-1

1. A.    Panic attack:
DSM-IV TR states a panic attack as a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reached a peak within 10 minutes:

(1)   palpitations, pounding heart, or accelerated heart rate
(2)   sweating
(3)   trembling or shaking
(4)   sensation of shortness of breath or smothering
(5)   feeling of choking
(6)   chest pain or discomfort
(7)   nausea or abdominal discomfort
(8)   feeling dizzy, unsteady, lightheaded, or faint
(9)   derealization (feeling of unreality) or depersonalization (being detached from oneself)
(10)           fear of loosing control or going crazy
(11)           fear of dying
(12)           paresthesias (numbness or tingling sensations)
(13)           chills or hot flashes

1.B.     Panic disorders
It included both categories panic disorders.
DSM-IV TR diagnostic criteria for Panic Disorder Without Agoraphobia

A.    Both (1) and (2) 

(1)   recurrent unexpected Panic Attacks
(2)   at least one of the attacks has been followed by one month (or) more of one (or more) of  the following;

(a)    persistent concern about having additional attacks
(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”
(c)    a significant change in behavior related to the attacks

B.     Absence of Agoraphobia

C.     The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or general medical condition (e.g., hyperthyroidism).


D.     The panic attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive – Compulsive Disorder (e.g., on exposure to a dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).


Panic Disorder With Agoraphobia

A.    Both (1) and (2) 

(3)   recurrent unexpected panic attacks
(4)   at least one of the attacks has been followed by one month (or) more of one (or more) of  the following;

(a)    persistent concern about having additional attacks
(b)   worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”
(c)    a significant change in behavior related to the attacks

B.     The presence of Agoraphobia

C.     The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or general medical condition (e.g., hyperthyroidism).


D.    The panic attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive – Compulsive Disorder (e.g., on exposure to a dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).


Agoraphobia

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic – like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and travelling in a bus, train,  or automobile.

Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations.

B. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic – like symptoms, or require the presence of a companion.

C. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive – Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoidance of leaving home or relatives).

Demographic:

1)    bvg      t     Avcbvi bvg wK?

2)   eqm     t     Avcbvi eqm KZ?

3)   Avcwb wK weevnxZ? nu¨v n‡j
      weevnxZ n‡j t Avcbvi †Q‡j †g‡q Av‡Q wK/bv? hw` _v‡K –

      KZ Rb †Q‡j - 
      KZ Rb †g‡q - 

4)          Avcbvi †Q‡j †g‡q KZ Rb?

5)          Avcwb †Kv_vq _v‡Kb?

6)         Avcwb Kvi mv‡_ _v‡Kb?

7)          Avcwb KZ ermi cov‡jLv K‡i‡Qb?

8)         hw` cov‡jLv m¤ú~Y© K‡i bv _v‡Kb Z‡e KviY wK wQj?

9)          Avcwb eZ©gv‡b wK ai‡Yi KvR K‡ib?

10)
      K) hw` †Kvb KvR bv K‡ib Z‡e K‡ib bv?

      L) Av‡M wK KvR Ki‡Zb?

      M) msmvi wK fv‡e P‡j?

N) Ggb KL‡bv wK n‡q‡Q †h Avcwb A‡bKw`b hver Kv‡R ‡h‡Z
 cv‡ibwb? KLb I †Kb?

O) Ggb KL‡bv wK n‡q‡Q †h Avcwb A‡bKw`b hver cov‡kvbv Ki‡Z cv‡ibwb? KLb I †Kb?

11) MZ gv‡m Avcwb wK †Kvb Kvi‡Y wPwKrmv wb‡q‡Qb?
     
      KLb?

      ‡Kv_vq?

      wK ai‡Yi wPwKrmv wb‡q‡Qb?
12) Avcwb GB nvmcvZv‡j wK mgm¨vi Rb¨ G‡m‡Qb? we¯—vwiZ ejyb (mgm¨v m¤ú‡K© we¯—vwiZ ejyb)| H mgm¨v¸‡jv KLb ïi“ n‡qwQj?

13)  KZw`b Av‡M m¤ú~Y© my&¯’/fvj wQ‡jb?

14)  GB mgm¨vq Gi Av‡MI fy‡MwQ‡jb wK bv?

15)  Avcbv‡K GLv‡b †K wb‡q G‡m‡Q?

16)  GB mgm¨v ïi“i wVK Av‡M Ggb wKQy wK N‡U‡Q? [hvi gv‡b GB mgm¨vi mv‡_ m¤úK© Av‡Q (PvwiwÎK/mvgvwRK/A_©‰bwZK)]

17)  GB mgm¨v ïi“i Av‡M Avcbvi Avi wK wK mgm¨v wQj?

18)  GB mgm¨v¸‡jv †`Lv †`Iqvi ci Avcbvi wK Amyweav nj? (†hgb- Nygv‡Z Amyweav, ˆL‡Z Amyweav, KvR Ki‡Z Amyweav, KvR Kivi kw³ cvB bv, BZ¨vw`)|

19)  GB mgm¨v kyi“ nIqvi ci KLb Avcwb me‡P‡q †ekx Lvivc †eva
      K‡iwQ‡jb?

20)  Avcwb GB mgm¨vi Rb¨ cÖ_g Kvi Kv‡Q wPwKrmvi Rb¨ wM‡qwQ‡jb?

21)  Avcwb GB mgm¨vi Rb¨ wK wK wPwKrmv wb‡qwQ‡jb?

22)  Avcwb GB mgm¨vi Rb¨ wK wK Jla †L‡qwQ‡jb?

23) Avcwb wK a~gcvb K‡ib?

24)  Avcwb wK Ab¨ †Kvb †blvi `ªe¨ e¨envi K‡ib? K) MZ gv‡m wK cwigv‡Y e¨envi K‡i‡Qb?

25)  (c~‡e©i cÖ‡kœi Reve nu¨v n‡j) †bkvi Rb¨ †Kvb wPwKrmv wb‡qwQ‡jb wK bv?

26) KLbI gvbwmK †ivM we‡k‡Ái civgk© wb‡qwQ‡jb wK bv?

27)  (c~‡e©i cÖ‡kœi Reve nu¨v n‡j) †Kb civgk© wb‡qwQ‡jb Ges KZ evi civgk© wb‡qwQ‡jb?

28) Avcwb wK kvixwiK †Kvb †iv‡Mi Rb¨ †Kvb nvmcvZv‡j fwZ© wQ‡jb?

29) (nu¨v n‡j) wK Rb¨?

30) MZ 1 gv‡m Avcbvi wK Ab¨ †Kvb mgm¨v wQj?

31)  Avcbvi gbUv †Kgb Av‡Q?

32) Avcbvi kixiUv †Kgb Av‡Q?

33) Avcwb wK Jla ev wfUvwgb Lvb hv Av‡M Avgv‡K ejv nqwb?

      K)   wK cwigv‡Y Lvb?
      L)   KZevi Lvb?
      M)   ‡h cwigv‡b Lvw”Q‡jb Zv wK evov‡bv n‡q‡Q?

34) Avcwb Aemi mgq wK fv‡e KvUvb ev wK K‡ib?

35) Kvi mv‡_ Avcwb mgq KvUvb?

Major Depressive Episode

A)
1)           MZ GK gv‡m cÖvq cÖwZw`bB Ges w`‡bi †ekxi fvM mgqB Avcbvi gbUv Lvivc ev nZvk _v‡K?

2)          Av‡M †hme Kv‡R Avb›` †c‡Zb MZ 1 gv‡m †m me Kv‡R wK Avi †Kvb Avb›` cv‡”Qb bv?

3)         MZ 15 w`b hver Avcbvi wK IRb K‡g‡Q ev †L‡Z wK B”Qv K‡i bv?

4)          MZ 15 w`b hver Avcbvi Nyg †Kgb n‡”Q?

K)   Nyg Avm‡Z †`ix nq?

L)   cÖvq Nyg †f‡½ hvq?

M)   Lye †fvi iv‡Z Nyg †f‡½ hvq Ges Avi Nygv‡Z cv‡ib bv|

N)   Nyg †ekx n‡”Q?

5)          MZ 15 w`b hver Avcwb wK KvR K‡g© GZUvB Aw¯’i ev axi MwZ m¤úbœ n‡q c‡o‡Qb hv Ab¨‡`i †Pv‡L co‡Q?

6)         MZ 15 w`b hver Avcwb me mgq K¬vš— _v‡Kb?

7)          Avcwb wK wb‡R‡K g~j¨nxb ev Acivax g‡b K‡ib? (hZUzKz Aciva K‡i‡Qb Zvi †P‡qI A‡bK †ekx Acivax g‡b nq wK bv?)

8)         Avcbvi wK †Kvb wel‡q wVKgZ wPš—v Ki‡Z ev wm×vš— wb‡Z Amyweav nq?

9)          Avcbvi g‡bi Ae¯’v wK GZUvB Lvivc †h g‡b nq †eu‡P †_‡K †Kvb jvf †bB; Ggb wK wPš—v Av‡m wb‡R‡K †kl K‡i w`‡Z ev Ab¨‡K AvNvZ Kwi? (AvZ¥nZ¨v Kwi ev Ab¨‡K †kl K‡i w`B)|
B)
10)     c~‡e©i 5 ev Z‡ZvwaK nu¨v n‡j Zvi g‡a¨ cÖ_g 2Uvi †h †Kvb 1wUi cieZx© cÖkœ 2Uv Ki‡Z n‡e|
C)
11)      Dc‡ii mgm¨v ¸‡jvi Rb¨ Avcbvi cÖwZw`‡bi KvR Kg© (†hgb – PvKzix / cov‡kvbv / evmvi KvR / gvb‡li mv‡_ †gjv‡gkv) Kiv KwVb n‡q c‡o‡Q wK?
D)
12)      GB mgm¨v ïi“i Av‡M ev mv‡_ mv‡_ kvixwiK †Kvb Amy¯’Zvq fy‡MwQ‡jb ev †Kvb Jla Lvw”Q‡jb ev †Kvb ai‡Yi ‡bkv K‡iwQ‡jb?
E)
13)     GB mgm¨v¸‡jv wK †Kvb AwZ AvcbR‡bi g„Zz¨i ci ciB ïi“ n‡q‡Q?

14)      A, C, D I E - nu¨v n‡j Major Depressive Episode.

15)     GB mgm¨v¸‡jv Avcbvi †gvU KZ evi n‡q‡Q?

Manic Episode

A)
16)     Avcbvi †Kvb GKUv mgq n‡q‡Q wK †h ¯^vfvwe‡Ki Zzjbvq A‡bK †ekx fvj jvM‡Z, A‡bK †ekx Avb‡›` _vK‡Zb, ev AwZ Drmvnx/D‡ËwRZ A_ev wLUwL‡U †gRv‡R _vK‡Zb?

17)      KZw`b hver G Ae¯’vq wQ‡jb? ev G Ae¯’vi Rb¨ wK nvmcvZv‡j _vK‡Z n‡qwQj? hw` 1 mßvn ev †ekx nq A_ev nvmcvZv‡j fwZ© n‡q _vK‡Z n‡j cieZx© cÖkœ| 1mßv‡ni Kg n‡j  30bs cÖkœ|

18)     Avcbvi wb‡R‡K wK Lye eo I ¶gZvevb ev we‡kl ¶gZvi AwaKvix g‡b nq?

19)     eZ©gv‡b wK Av‡Mi Zzjbvq A‡bK Kg Nygv‡jI nq (3 N›Uv)?

20)     Avcwb wK B`vwbs ¯^vfvwe‡Ki Zzjbvq †ekx K_v e‡jb ev ej‡Z B‡”Q K‡i?

21)      Avcbvi gv_vi wfZ‡i wPš—v fvebv¸‡jv wK Lye ZvovZvwo cwieZ©b nq?

22)     Avcbvi wK †Kvb wel‡q g‡bv‡hvM w`‡Z Amyweav nq A_ev Av‡k cv‡ki mvgvb¨ kãI ev NUbv wK Avcbvi eZ©gvb g‡bv‡hvM‡K Ab¨ w`‡K mwi‡q wb‡q hvq?

23)    Avcwb wK Ggb †Kvb Kv‡R e¨¯— n‡q c‡o‡Qb hv‡Z Avcbvi cwievi cwiRb ev eÜzevÜe wPwš—Z?

24)     Avcwb wK AwZwi³ e¨q Ki‡Qb ev e¨q Ki‡Z fvj jv‡M ev kvixwiK †gjv‡gkv Ki‡Z ev SuywKc~Y© e¨emvq UvKv LvUv‡Z fvj jv‡M?

25)       18 n‡Z  24 ch©š— 3Uv (+) nu¨v A_ev hw` wLUwL‡U †gRvR _v‡K ev 4Uv + n‡j|



[1] Initially a sample size of 547 was determined taking the value of d=1% and the present calculation is a revised one.