Diagnosis, Assessment and Management of Panic Disorder in Patients Presenting with Pain Symptoms
Dr. Saji Joseph MD, DNB Dr. A. Krishnadas MD
Asst. Professor, Psychiatry Consultant Physician
Co-operative Medical College Good Shiphered Hospital
Cochin, Kerala Wayanad, Kerala
ABSTRACT : We have evaluated 115 patients with pain symptoms to find out the rate and clinical profile of panic disorder (PD) as per the DCR criteria of ICD -10. Forty three percentage had PD and non cardiac chest pain was the most common presenting symptom. Female to male ratio was 5:1. Onset of PD was in 3rd decade in both sexes. Agoraphobia was the most common co morbidity. Low dosage response to combination of TCA and BNZ were observed and 56% were in remission when followed up for a period of 6 months to 1 year. These findings were compared with the existing literature. This study points out the high rate of PD in patients with pain symptoms and also emphasis the need of a high rates of physician recognition of this common and costly phenomenon in medicine.
KEY WORDS : Panic disorder, pain symptoms, non cardiac chest pain, physician recognition
INTRODUCTION : Most of the patients with Panic Disorder (PD) do not initially present to Psychiatrist, but to other health care professionals like, cardiologists, emergency room Physicians or general practitioners due to divers symptomatology (Marshall, 1997). Studies have reported that one fifth of the PD patients presented with five or more medically unexplained symptoms, which includes pain symptoms, especially non cardiac chest pain (Simon and Von Korft, 1991).
Prevalence of PD, in patients with non cardiac chest pain ranges from 25 to 57% (Katon et al. 1988; Beitman et al, 1987; Fleet et al, 1996). Data from India also shows that 30% of the out patients and 50% of the inpatients with non cardiac chest pain had PD (Alexander, 1996, unpublished data)
Many of these non cardiac chest pain patients undergo expensive and extensive cardiologic investigations, shows the low rates of physician recognition of PD (Fleet et al 1996). Due to the poor recognition and explanation, these patients may suffer a chronic course and there by significant psychosocial disability (Beitman et al 1991).
Data regarding prevalence of PD in other pain symptoms are largely unknown. So this study was an attempt to find out the rate of PD and to evaluate its assessment and management in patients presenting with pain symptoms.
MATERIAL AND METHOD : This study was conducted in a general hospital at Wayanad. All the patients (N=15) with pain symptoms referred to psychiatry OPD during the period of October 2000 to October 2001 were included in the study. These patients were initially seen and evaluated by the physician (AKD) and those who doesn't have any organic basis after a thorough clinical examination and investigation (ECG, X-ray Chest, routine blood examination and thyroid function test in relevant patients) were referred to the psychiatry OPD.
Patients were evaluated by the psychiatrist (SJ) in terms of physical examination and a detailed psychiatric interview. Diagnosis was arrived as per the DCR guidelines of ICD-10. These patients were followed up for a period of 6 months to 1 year.
RESULTS : Out of 115 patients 50 (43%) received a diagnosis of PD. Forty two (84%) were female and 8 (16%) males. Majority of the patients were married (90%) and 10% were unmarried. Mean age at onset of PD was 35 years (35.82 +_ 15.16). Average duration of pain symptoms was 1.5 years. non cardiac chest pain (82%) was the most frequently encountered presenting symptom and abdominal pain, headache (32% and 30% respectively) were the next common. (see table 1 and II). Somatoform disorder was the second common diagnosis (25%) and the rest includes desociative disorder (11%) anxiety disorders (10%) and depressive disorder (4%).
Thirty (60%) had more than 4 Panic attach (PA) in a month and 20 (40%) had 4 PA per week. Most of them had unexpected PA (61%) (see Table III) Agoraphobia (20%) was the most common psychiatric co morbidity and the physical co morbidity was not significant (Table IV)
 Mean dosage of tricyclic (TCA) like amitriptyline, imipramine, clomipramine or nor-triptyline and benzodiazepine (BNZ), (both given in combination) alprazolam were 27 mg. (27 +_ 17.9) and 0.79 mg (0.79 +_ o.37) respectively. When followed up for a period of 6 months to 1 year 28 (56%) were observed to be in remission (85% were on pharmacological treatment), 6 (12%)) had I to 2PA per month, 2 (4%) were unchanged and 14 (28%) did not come for follow up.
DISCUSSION : In the present study all the patients were referred from a medical OP illustrates the route of the PD patients to the Psychiatry care. Non cardiac chest pain (a somatic rather than psychological symptom) was the most common presenting symptom, justifies the high utility of medical OP services by these patients. Analysis of data from the ECA study indicated that patients with PD were 5 to 8 times more likely than non affected individuals to be high users of medical services (Simon and Von Korff, 1991).
Present study also gives a high rate of PD in pain symptoms (43%). Nearly 30% of patients each had abdominal pain, and headache as the presenting symptoms, shows the divers mode of presentation of PD, and also warrants a careful assessment of other pain symptoms in the diagnosis of PD. This is also supported by the relatively low rates of somatoform disorders in the present study.
Female to male ratio is 5:1, when compared to the 3:1 in the existing literature. Age at onset in 3rd decade in both exes, was in agreement with the previous findings (Pollack et al, 1996).
As reported earlier (Weissman et al, 1997), present study also finds agoraphobia as the most common psychiatric co morbidity. Remission rates in the present study was in comparable range with the previous observations (Pollack et al, 1990). Response to low dosage of TCA and BNZ, in this study may nor agree with majority of the western literature, but fewer studies had reported significant response to low dose strategy of both TCA and BNZ in PD (Mavisskalian and Perel, 1989, 1995; Lydiard et al, 1992).
Although the finding of this study is largely in consensus with the existing literature, it points out the high utility of medical OP services and the need of a high rates of Physician recognition of PD in patients with pain symptoms. Simple label of non cardiac chest pain or "functional pain" often insufficient to reassure the patient with PD, but a proper recognition and a prompt referral to psychiatry care is required to relieve the patient. Without a specific explanation or treatment the patient may suffer chronically (Fleet and Beitman, 1999).
The study has few limitations also, as it did not use any structured diagnostic instrument or a detection instrument to improve the physician recognition can be improved by using detection instruments like Agoraphobia Cognition questionnaire or short From MC Gill pain questionnaire. Psychosocial disability is also need to be explored more systematically. In future studies with larger sample size and improved methodology may throw more light in this area
Family to conclude, the recognition and treatment of PD in general medical setting is critical, given the association of the disorder with adverse effects across multiple domains of functioning and the demonstration that early recognition, prompt referral to psychiatry care and appropriate treatment results in symptomatic relief, improvement in role functioning, decreased use if medical resources, and thereby reduction in overall costs.

Table 1 : Mode of Presentation
Chest pain : 82%
Abdominal Pain : 32%
Head Ache : 30%
Burning Sensation : 18%
Autonomic Symptoms : 18%
Unresponsive : 10%

Table II : Symptom Analysis as per the DCR
Chest Pain : 82%
Palpitation : 81%
Feeling unsteady, dizzy, faint : 70%
Dry mouth : 66%
 Fear of Dying : 58%
Sweating : 42%
Trembling/Shaking : 36%
Difficulty in breathing : 36%
Abdominal symptoms : 20%
Hot flushes, cold chills : 6%
Numbness of Tingling : 4%
Table III : Frequency of Panic Attacks (PA)
PD Moderate (4 PA in a month) : 60%
PD Severe (4 PA per week in a month) : 40%
Mean duration of PA (mins) : 27.19 +/- 33.73
Nature of PA
Unexpected : 61%
Situational : 39%
Anticipatory Anxiety : 24%
Table IV : Physical Co morbidity
Bronchial Asthma : 2%
GTCS : 2%
RHD : 2%
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