Panic disorder

Comorbidity

Psychiatric disorders associated with panic disorder (PD) are simple phobia (intense irrational fear of a situation or object that is not dangerous, e.g. a picture of a snake, claustrophobia) and social phobia (fear of embarrassing oneself in public, or even being watched by others). With simple phobia, the panic occurs immediately before or on exposure to a fearful situation while with social phobia the panic attacks occur only when the patient feels they are the focus of others' attention, such as while eating, walking or speaking in front of people.

Other disorders that should be considered as differential diagnoses for PD include claustrophobia, severe depression, dissociative disorders, generalised anxiety without panic attacks, alcohol or drug abuse, including stimulant abuse (caffeine, cocaine, amphetamines) and withdrawal and seizures.

The frequent co-existence of major depression and panic is an especially serious problem and occurs in 50-65% of patients with PD (Starcevic et al., 1993). These comorbid conditions are more difficult to recognise and diagnose and they are also more difficult to treat successfully than an uncomplicated panic disorder. The presence of comorbid depression results in greater disease severity, increased risk of suicide and a worse prognosis (DeVane, 1997).

The other psychiatric comorbid conditions include the presence of other anxiety disorders such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), social anxiety disorder (SAD), and other psychiatric disorders such as bipolar mood disorder, dissociative disorders, eating disorders or complex personality disorders. A number of these disorders may require further treatment.

Another comorbid condition is the abuse of alcohol and other drugs. The high rates of substance abuse are usually associated with attempts at self-medication to dull the experience of the panic attacks or the anticipatory anxiety. However, prolonged use of alcohol, marijuana, cocaine and other illicit drugs may induce or even worsen episodes of panic. The treatment of panic patients with depressive and alcohol problems usually requires long-term treatment.

Medical disorders that occur more commonly in patients with panic disorder include angina, irritable bowel syndrome, asthma and migraine . These may affect treatment planning and often need to be treated concurrently with the PD as these conditions may affect the safety or efficacy of psychopharmacological treatments for PD, as with specific cardiovascular, pulmonary, gastrointestinal or endocrine disorders, pregnancy or lactation. Certain conditions with prominent anxiety symptoms, such as thyroid disease, polycythaemia, lupus and pulmonary insufficiency may exaggerate the anxiety symptoms, while conditions requiring treatment with medications such as vasoconstrictors, bronchodilators or steroids may cause or exacerbate anxiety.