Joseph W. Lamberti

Panic disorder in patients with chest pain and angiographically normal coronary arteries

Although patients with angiographically normal or near normal coronary arteries are at low risk for cardiac disease, several follow-up studies have shown that many continue to report recurrent chest pain associated with social and work dysfunction. Three diagnostic entities have been proposed to explain the morbidity of this group: microvascular angina, esophageal motility disorders and panic disorder. The purpose of this study was to test the hypothesis that panic disorder is found frequently in patients with chest pain who have normal epicardial vessels. Ninety-four subjects with angiographically normal coronary arteries were interviewed according to a structured psychiatric protocol within 24 hours of their catheterizations. Thirty-two (34%) fit Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria for current panic disorder. Because panic disorder can be effectively treated, physicians should consider this diagnosis in this group of patients. Current research findings suggest that panic disorder, microvascular angina and esophageal disorders may each form the basis for chest pain in approximately 25% of these patients. Miscellaneous problems account for the other 25%.

Non-fearful panic disorder: panic attacks without fear.

Abstract Twelve of 38 cardiology patients with chest pain and current panic disorder reported that during their last major panic attack they did not experience intense fear, nor did they experience fear of dying, fear of loss of control or fear of going crazy. Using the DSM-III(R) criteria, they were diagnosed as non-fearful panic disorder (NFPD), and contrasted with the other 26 S s on several descriptive and self-report measures. The NFPD group reported significantly fewer phobias but was no different on reports of depression and several panic attack variables. The NFPD group scored lower on only three of 18 self-report scales. These results suggest that the DSM-III(R) defined NFPD S s resemble those who report the subjective experience of anxiety during their attacks.

Panic disorder without fear in patients with angiographically normal coronary arteries.

By DSM-III-R criteria, patients may be diagnosed as having panic disorder without reporting the experience of intense fear. However, if such patients do not report subjective fear, they may be less likely to receive a panic diagnosis. The authors studied 32 subjects with angiographically normal coronary arteries who fit panic disorder criteria. A total of 13 (41%) reported no fear during their last major attack. These subjects were contrasted with those who did report fear. Pew differences were found in group demographic data or responses to self-report questionnaires. We conclude that there appear to be few differences between the nonfear panic disorder subjects and those who do report fear. This conclusion awaits further support using challenge tests, medication trials, biological indices, alexithymia inventories, and family studies. The recognition of the existence of this subtype is likely to increase the number of patients receiving the panic disorder diagnosis in cardiology settings, in psychiatric settings, and in research projects using structured clinical interviews.

Major depression in cardiology chest pain patients without coronary artery disease and with panic disorder

104 patients in a cardiology clinic with atypical or non-anginal chest pain were studied through a structured clinical interview. 43 without coronary artery disease fit diagnostic criteria for panic disorder. 19 (44%) of this group reported a lifetime prevalence of major depression, nine (21%) current and ten (23%) past only. Nine reported that their major depressive episodes had preceded the onset of their panic disorder. On many self-report questionnaire scales the group with a lifetime history of major depression (n = 19) differed significantly from the group with no lifetime history of major depression (n = 24). These differences, however, could be attributed primarily to the group with current major depression. There appears to be a subgroup of panic disorder patients who have current major depression who are more symptomatic than those with panic disorder and past major depression and panic disorder alone. These findings also suggest that the association between panic disorder and depression may remain high outside of psychiatric settings.

Situational factors and behavioral self‐predictions in the identification of clients at high risk to drop out of psychotherapy

Two hundred and eight adults who requested outpatient treatment at a community mental health center were asked to complete brief questionnaires immediately prior to and after their first therapy session. Questionnaires contained items that pertained to self-predicted length of stay in psychotherapy, situational barriers to regular attendance, and past behavior in similar situations (e.g., appointment-keeping with other health care professionals). Therapists also were asked to make predictions with regard to client length of stay. Questionnaire data were analyzed via a series of double cross-validated multiple regression and discriminant function equations, and results indicated that client and therapist predictions of length of stay in therapy were the most stable and consistent correlates of attendance behavior.

Panic disorder in patients with angiographically normal coronary arteries: A pilot study

Although persons with angiographically normal arteries have low cardiac morbidity and mortality, continuing chest pain with resulting social and vocational morbidity may occur. Using the hypothesis that the chest pain was related to panic attacks, the authors studied 33 cardiac catheterization patients through a structured interview based on DSM-III and through self-reports of anxiety and depression. One third of this group proved to fit the criteria for panic disorder. These findings suggest that patients with chest pain who are being evaluated by cardiologists and primary care physicians should also be considered for panic disorder.

Model of family grief assessment and treatment

Abstract Two major models for family therapy are the structural model of Minuchin and family systems model of Bowen. Both are commonly used in assessing and treating dysfunctional families. This paper utilizes the structural and family system models as a basis for evaluation and treatment of grieving families. Using the structural model, families can be assessed in terms of how the family has attempted to fill a role left empty by loss. The clinician can evaluate whether the “new” subsystem structure [s] are appropriate, resulting in family satisfaction, or inappropriate and requiring intervention. The family systems approach is integrated with the structural model, demonstrating techniques to assess changes in family relationships due to the reductions in available dyads and triads, and lowered levels of functional differentiation resulting from the death crisis. Interventions to increase levels of differentiation and avoid fusion and cutoff are suggested.

Major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder.

Patients with panic disorder and/or agoraphobia appearing in psychiatric settings report rates for lifetime major depression between 24% and 91 %. Between 40% and 90% of patients with panic disorder in psychiatric populations report concomitant agoraphobia. A recent study of panic disorder subjects appearing in an outpatient cardiology clinic confirmed the strong link between panic and depression but found only a weak association between panic disorder and agoraphobia. In order to test the reliability of these outpatient cardiology findings, the authors studied major depression and agoraphobia in patients with angiographically normal coronary arteries and panic disorder. Twelve of the 32 (37.5%) panic disorder subjects reported a lifetime history of major depression (nine current, three past only). Only two of the 32 (six percent) reported any phobic avoidance. This study confirms the previous findings which suggest that major depression is common in cardiology populations with panic disorder and that phobic avoidance is uncommon in this group.

Panic Disorder: A Frequent Occurrence in Patients with Chest Pain and Normal Coronary Arteries:

From 10% to 20% of patients undergoing coronary arteriography for chest pain are subsequently found to have normal coronary arteries. We investigated the prevalence of panic disorder in these patients in a two-stage study. Our results indicate that approximately one third of patients with chest pain and angiographically normal coronary arteries have panic disorder. Proper diagnosis and treatment of these patients with panic disorder may be expected to substantially reduce their psychosocial morbidity.