Panic disorder has been generally found to have a chronic, recurring course (Pollack and Otto, 1997; Pollack and Marzol, 2000; Faravelli et al., 1995). There is often a persistence of subthreshold symptoms even in the absence of a DSM IV-TR diagnos-able disorder. In a naturalistic, 5-year study following 99 patients with panic disorder without any psychiatric comorbidity (Faravelli et al., 1995), even transitory full remission was achieved by only 37.5 percent of patients, while full remission, sustained at 5 years only, occurred for 12 percent. Seventy-three percent of patients in this study experienced some improvement, but only 41 percent of those were still well at 5-year follow-up. On the other hand, many treatment outcome studies, particularly of cognitive-behavioral therapy, cite high rates of remission (Craske et al., 1991; Clark et al., 1994; Fava et al., 1995). It was the varying definitions of "remission" of panic disorder, ranging from a narrower view in which elimination of panic attacks signified remission, to a wider definition of panic disorder that included anxiety sensitivity, hypochondriacal and phobic concerns, and impairments in quality of life, that ultimately led to the National Institute of Mental Health (NIMH) Consensus Conference on Panic Disorder (Shear and Maser, 1994), in which the range of illness necessary to be monitored by panic disorder outcome studies was defined.
In addition to a spectrum of anxiety symptoms, patients with panic disorder have a high rate of comorbid psychiatric disorders, many of which have been shown to negatively influence outcome, including degree of impairment and suicidality (RoyByrne et al., 2000). Comorbid depression has been cited as increasing the likelihood of a chronic, disabling illness (Roy-Byrne et al., 2000; Hollifield et al., 1997). There is some data indicating that preexisting panic disorder increases the subsequent risk for the development of major depression in both men and women, and that controlling for prior anxiety disorders accounts for 50 percent of the observed twofold increased incidence of major depression in women over men (Breslau et al., 1995). The effect of comorbid personality disorders on the course of panic disorder has yet to be adequately studied.
Panic patients experience tremendous distress and have been shown to have a high level of functional impairment as a result of this (Roy-Byrne et al., 2000). They report poor physical health, poor emotional health, a higher incidence of alcohol and drug abuse than normals, and a higher incidence of attempted suicide (Rosenbaum, 1997). Medical costs are high for patients with panic disorder, with half of all primary care visits being precipitated by physical sensations associated with panic disorder, such as dizziness, heart palpitations, chest pain, dyspnea, and abdominal pain, as demonstrated by both epidemiological and retrospective studies (Katon, 1996). Patients with panic disorder account for 20 to 29 percent of all emergency room visits (Swenson et al., 1992; Weissman et al., 1989) and are 12.6 times more likely to visit emergency rooms than the general population (Markowitz et al., 1989).
Additionally, panic disorder has been found to co-occur with a variety of medical conditions, including mitral valve prolapse, cardiomyopathy, hypertension, irritable bowel syndrome, chronic obstructive pulmonary disease, and migraines (Zauber and Katon, 1996). Coryell et al. (1982) found that the death rate in patients with panic disorder exceeded that of the general population. In their study, 20 percent of deaths in 113 former psychiatric inpatients with panic disorder followed up 35 years later were the result of suicide. Also in this study, men with panic disorder were found to have twice the risk of death due to cardiovascular disease than men in the general population.
The high morbidity level in patients with panic disorder points to the importance of developing appropriate, broad-based treatments. As noted in the panic spectrum section, even lower levels of persistent symptoms can cause significant functional impairment and poor prognosis. Thus, strategies for treatment of panic disorder should aim for remission rather than simply symptom reduction.
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