Panic disorder in the general medical setting.
Zaubler TS. Katon W.
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA.
There is a high prevalence of panic disorder in medical patients, as well as an association between panic disorder and high rates of utilization of medical services and excessive medical costs incurred from extensive medical workups. The association between panic disorder and specific cardiac, gastrointestinal, respiratory, and neurologic symptoms and disorders are described, and psychophysiological models attempting to account for the medical comorbidity associated with panic disorder are addressed. Finally, clinical trials investigating pharmacological and psychological interventions to treat the somatic symptoms with which patients with panic disorder often present are reviewed and critiqued, and productive avenues for further research on panic disorder in medical patients are recommended.
Panic disorder associated with gastrointestinal disease: review and hypotheses.
Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada.
An association between panic disorder and functional gastrointestinal disease has emerged since the introduction of reliable diagnostic criteria, first for psychiatric disorders and more recently for functional gastrointestinal disorders. At the same time, a more rigorous review of methodology of older reports linking structural gastrointestinal diseases such as peptic ulcer and inflammatory bowel disease to psychiatric illness has cast doubt on the validity of their association. In this review original articles reporting an association between panic disorder and globus, functional chest pain of presumed esophageal origin, functional dyspepsia, and irritable bowel syndrome are critically reviewed and it is concluded that panic disorder is overrepresented in noncardiac chest pain and irritable bowel syndrome. Original reports of the prevalence of panic disorder in structural gastrointestinal disease are reviewed and it is concluded that they do not support an association with panic. Hypotheses explaining the statistical link of panic disorder and functional gastrointestinal disease are discussed.
The value of screening for psychiatric disorders prior to upper endoscopy.
O'Malley PG. Wong PW. Kroenke K. Roy MJ. Wong RK.
Department of Medicine, Walter Reed Army Medical Center, Washington, DC, USA. firstname.lastname@example.org
Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.
The relationship between daily stress and symptoms of irritable bowel: a time-series approach.
Dancey CP. Taghavi M. Fox RJ.
Psychology Department, University of East London, UK. C.P.Dancey@uel.ac.uk
Irritable bowel syndrome (IBS), a chronic disorder that includes symptoms such as abdominal pain and altered bowel habits, affects up to 22% of people in Western populations. The causes of IBS are not well understood, but are believed to be multifactorial. Although stress is widely believed to be implicated, empirical evidence in support of this is lacking, perhaps because a typical between-participants analysis ignores individual differences and therefore may obscure any link. The present study used a within-person, lagged time-series approach to investigate the links between everyday stress and symptomatology in 31 IBS sufferers. Both everyday stress and symptomatology exhibited serial dependence for a statistically significant proportion of sufferers. Multiple regression analysis carried out on same-day and lagged relationships up to and including 4 days found that, for over half the participants, everyday stress and symptoms were related. The best regression model was one in which symptoms were a function of hassles and symptoms on the previous 2 days, and hassles on the same day, fitting the data for 67% of participants. This prospective study confirms other studies that have suggested stress is a significant factor in IBS, and concludes that stress management programs may be both useful and cost-effective in the treatment of IBS.
Psychological distress in patients with chronic, nonalcoholic, uncomplicated liver disease.
Davis H. De-Nour AK. Shouval D. Melmed RN.
Talbieh Mental Health Centre, Jerusalem, Israel.
To study whether the presence of significant disease in a major organ, possibly with minimal or no clinical symptoms, would be associated with psychological disturbance, 80 subjects suffering from chronic hepatitis or cirrhosis, of nonalcoholic etiology were interviewed. Of these, 64 had either minimal or no physical symptoms. Patients completed the Brief Symptom Inventory (BSI) and the Impact of Event Scale (IES), questionnaires, which measure symptoms of psychological distress. It was found that 50% of the liver subjects were defined as cases by the BSI criteria including 15% who were defined as severe cases. There were no gender differences. Forty-five percent of asymptomatic liver subjects were defined as cases. Psychological distress was significantly pronounced in subjects with less than 12 years of education. This study points to a significant incidence of psychological distress, even in clinically asymptomatic subjects, suffering from chronic, nonalcoholic, uncomplicated liver disease.