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-p
1(expected proportion of panic disorder among cardiac
patients)=2.5%
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:
n
c (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.
References
1. Roy-Byrne PP, Wagner AW, Schraufnagel TJ. Understanding and treating panic disorder in the primary care setting.
J Clin Psychistry. 2005; 66 (Suppl.)4:16-22.
3. Katerndahl D. Panic and plaques: Panic disorder and coronary artery disease in patients
with chest pain. Br J Psychiatry 1989; 154: 28-31.
4. Moris A., Baker B., Devins G
M., Shapiro CM. Prevalence of Panic Disorder in Cardiac Outpatients. Can J Psychiatry 1997; 42: 185-190.
5. Glender M, Myor R, Cowen P. Shorter Oxford Text Book Of Psychiatry,
fourth edition, Oxford. Oxford. University Presss.2001. 237-241.
6.Murry R, Hill P, McGuffin P.
Essentials of Postgraduate Psychiatry, third edition,. Cambridge. Cambridge
University Press UK 1997. 168-71
7.American Psychiatric
Association Diagnostic and Stastical Manual fourth edition. Text Revision
Washington DC, American Psychiatric Association 2000.
8.World
Health Organization: The ICD-10 Classification of Mental and Behavioural
Disorders, Geneva, Switzerland, World Health Organization:1987.
9. Stein DJ, Hollander E. Text
Book of Anxiety Disorders, American Psychiatric Publishing., Washington DC 2002. 237-254.
10.
Lynch P, Galbraith KM. Panic in the Emergency Room, Review Paper, Can J
Psychiatry 2003; 48 (6): 361-366
11. Katerndahl DA, Realini JP,
Ljfe time prevalence of panic attack. Am J Psychiatry1993; 150: 246-49.
12. Gelder MG. The Classification
of Anxiety Disorders. Br J Psychiatry 1989; 154: 28-31.
13. Hollander E, Simeon D.
Concise Guide to Anxiety Disorder, American Psychiatric Publishing Inc.,
Washington DC -2003,21-26.
14. Horwath E, Johnson J, Hornig
CD. Epidemiology of panic disorder in African-Americans. Am J Psychiatry 1993;
150 (3): 465-469.
15. First MB, Spitzer RL, Gibbon
M, William JBW. Structured Clinical Interview for DSM-IV Axis I Disorders- Clinical Version (SCID-CV). Biometric
Research Department, Department of Psychiatry, Columbia University, New
York, American Psychiatric Press, Washington DC, 1997.
16. The SPSS 8.0 for window. Statistical Product and Service Solutions
Inc. Chicago 1997.
17. Neki JS. Psychiatry in South-East Asia. Br J Psych 1973; 123: 257-69.
18. Patel V, Gwanzura F, Simunyu
E, Lloyd K, Mann A. The phenomenology and explanatory models of common mental
disorders: a study in primary care in Harare, Zimbabwe. Psychological Med 1995; 25: 1191-1199.
19. Chignon JM, Lepine JP, Ades
J. Panic Disorder in Cardiac Outpatients. Am J Psychiatry 1993; 150 (5):
780-785
20. Katon W, Panic disorder and
somatization, Am J Med 1994; 77: 101-106.
21.Roy-Bryne PP, Stein MB, Russo
J, et. al. Panic disorder in primary care setting: Co morbidity, Disability,
Service utilization and Treatment. J Clinl Psychiatry 1999; 60 (7):
492-99.
22.Katerndahl DA, Realini JP.
Ljfe time prevalence of panic attack. Am J Psychiatry 1993; 150: 246-49.
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|
