Lifetime prevalence of panic states.

OBJECTIVE: Little is known about the prevalence of panic symptoms that do not meet criteria for panic disorder. This study was conducted to determine the prevalence of panic disorder, panic attacks, and limited-symptom attacks in the general population. METHOD: The authors identified a community-based sample of 1,683 randomly selected adults in 18 census tracts in San Antonio, Tex.; 1,306 of these subjects agreed to be interviewed with the Structured Clinical Interview for DSM-III. Subjects were classified as having panic disorder if they met DSM-III-R criteria, as having panic attacks if they had attacks of four or more panic symptoms but did not have panic disorder, and as having limited-symptom attacks if they had attacks of fewer than four symptoms but no full-blown panic attacks. RESULTS: The crude lifetime prevalence rates were 3.8% for panic disorder, 5.6% for panic attacks, and 2.2% for limited symptom attacks. Women had higher rates of panic disorder and panic attacks than men, but the difference between men and women was not statistically significant for limited-symptom attacks. No statistically significant differences in rates between Hispanic and either non-Hispanic white or black subjects were found. Non-Hispanic white subjects had higher rates of limited-symptom attacks than black subjects. CONCLUSIONS: The prevalence of limited-symptom attacks in this community-based study was 2.2%; black subjects had lower rates than non-Hispanic white subjects. Panic attacks appear to be at least as common as DSM-III-R panic disorder and, like panic disorder, are more common among women.

Quality of life and panic-related work disability in subjects with infrequent panic and panic disorder.

BACKGROUND: Panic disorder is associated with poor quality-of-life (QOL). However, little is known regarding the impact of panic disorder or infrequent panic on work-related disability. The purpose of this study was (1) to document QOL and panic-related work disability in subjects with panic disorder or infrequent panic, (2) to identify independent predictors of QOL and disability, and (3) to compare outcomes in subjects with panic disorder versus infrequent panic. METHOD: This cross-sectional community survey included 97 subjects with panic and matched controls. Subjects were screened for panic disorder or infrequent panic using the Structured Clinical Interview for DSM-III-R. The QOL questionnaire addressed life satisfaction as well as panic-related work disability. A structured interview assessed possible predictors of impaired QOL including comorbidity, illness attitudes and behaviors, coping style, family measures, and symptom perceptions. RESULTS: QOL was significantly (p < or = .001) poorer in subjects with panic than in controls. Comorbid depression, social support, worry, and severity of chest pain predicted QOL. Although subjects with infrequent panic reported a lower QOL than controls, subjects with panic disorder had more panic-related disability and poorer QOL than those with infrequent panic. Predictors of work disability included panic frequency, illness attitudes, family dissatisfaction, and gender. CONCLUSION: Although both infrequent panic and panic disorder impact QOL and disability, panic disorder has a greater effect. Using predictors, patient education, provision of support, and focused therapy could potentially improve QOL and disability.

Family practice, internal medicine, and pediatrics as partners in the education of generalists.

The generalist of the future will play an integral role in the health care delivery system, yet the three recognized generalist specialties have developed and functioned along largely separate tracks. No matter what form of generalism evolves, family practice, internal medicine, and pediatrics must begin to cooperate and collaborate in developing new graduate medical education programs that are sufficiently flexible to meet whatever emerges in the future. They must devote their energies to working together, rather than competing; to emphasizing those parts of their programs that have similarities; and to sharing their knowledge, skills, attitudes, and perspectives about the care of patients. They must develop training experiences in which residents will obtain maximum contact with a wide variety of problems and patients in many different settings; a substantial portion of such training should be generic and virtually interchangeable among the three specialties. As the health care system evolves, so should these disciplines; they must begin to "train physicians to provide continuing, comprehensive and coordinated medical care to a population undifferentiated by gender, disease or organ system," as urged by the American Boards of Family Practice and Internal Medicine.

Use of health care services by persons with panic symptoms.

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.

Relationship between substance abuse and panic attacks.

This study was done to determine the strength of association between substance abuse and panic states, including subsyndromal panic, its temporal relationship, and self-medication for panic using abusable substances. A community-based sample was screened for panic using DSM-III-R criteria. Panic and matched control groups participated in a structured interview concerning the presence of substance abuse, use of substances to treat panic symptoms, and the age-of-onset of panic and substance abuse. Of 97 individuals with panic, 39% had abused at least one substance. None of the panic disorder-subsyndromal panic differences reached significance. Only 10% of subjects reported using alcohol and 6% reported ever using illicit drugs to treat their panic. The majority (63%) of those abusing alcohol reported that alcohol use began prior to onset of panic, and the majority (59%) of those abusing illicit drugs reported that drug use began first. This study documents the panic-substance abuse relationship even in those with subsyndromal panic. Substance abuse began prior to onset of panic and substances were used to self-medicate for panic attacks by only a few subjects.

Panic disorder in Hispanic patients.

BACKGROUND AND OBJECTIVES: This study determined the proportion of community-dwelling Hispanics who present for medical care for their panic attacks and identified factors associated with seeking care. We also compared characteristics of Hispanic subjects with those of non-Hispanic white panic sufferers. METHODS: In this community-based study, subjects with panic attacks completed a structured interview concerning health care utilization, panic characteristics, coexisting psychiatric problems, and illness attitudes. Hispanics were self-identified and completed the Cuellar acculturation scale for Mexican-Americans. RESULTS: Twenty-nine (53.7%) of 54 Hispanic subjects had sought medical care for their panic attacks. Care seeking in non-Hispanic whites was not dependent on these factors. CONCLUSIONS: Half of the Hispanics with panic attacks seek no medical care for their attacks. Predictors of seeking care among Hispanics in San Antonio included coping style, symptom perceptions, and access to transportation.

Computerized student testing as a learning tool in a family practice clerkship.

BACKGROUND: The purpose of this paper is to describe and evaluate a computerized multiple choice testing system developed to teach family medicine core content in a junior clerkship. METHODS: Students were tested in a minimum of 10 content areas based upon a pretest, and answered sets of 10 randomly generated questions in each area. Students received immediate feedback on scores and correct answers. RESULTS: A total of 192 students took 10,184 computerized tests. Mean student scores rose significantly with successive tests. Scores on the written final clerkship examination correlated with computerized testing scores. Students accepted the computerized testing system well. CONCLUSIONS: The computerized testing system led to immediate learning, but its effects on long-term learning were less clear.

Family characteristics of subjects with panic attacks.

BACKGROUND AND OBJECTIVES: This study identified associations between panic states and family 1) structure, 2) functioning, and 3) stress/support. METHODS: Ninety-seven adults with panic disorder or infrequent panic attacks, based on the structured Clinical Interview of the Diagnostic and Statistical Manual, Third Edition, Revised, were matched to 97 subjects without panic symptoms based on age, gender, and race/ethnicity. All subjects completed a structured interview concerning health care use by family members and family characteristics. Family functioning was assessed using the Family Adaptability and Cohesion Evaluation Scales, and family stress/support were assessed using the Duke Social Support and Stress Scales. RESULTS: Although groups did not differ in either perceived or ideal family cohesion or adaptability, the panic group perceived their families as more dysfunctional and reported higher levels of family stress and total stress but lower levels of support, including family support, nonfamily support, and total support. CONCLUSIONS: Subjects with panic symptoms have families with high levels of dysfunction and stress but low levels of support. Increased family dysfunction may be due to comorbid substance abuse.

Screening for colorectal cancer. Issues for primary care physicians.

Fecal occult blood testing, proctosigmoidoscopy, and digital rectal examination have been recommended as screening tests for colorectal cancer in asymptomatic people. This article evaluates the advisability of recommendations by applying accepted principles of screening to the case of colorectal cancer.

Where do panic attack sufferers seek care?

BACKGROUND: Although 40% of people with panic attacks never seek care for their attacks, those who do may use medical settings or mental health settings, or both. The purpose of this study was to examine where people seek care for their panic attacks within and outside the health care system, and to determine what variables predict the choice of a given site. METHODS: The Panic Attack Care-Seeking Threshold (PACT) study is a community-based survey of 97 subjects meeting the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) criteria for panic attacks. A structured interview was used to collect information about panic attacks, family characteristics, psychiatric comorbidity, health care access and utilization, illness attitudes and behaviors, quality of life, and symptom perceptions. RESULTS: Forty-nine percent of the subjects seeking care for panic attacks presented to medical settings, whereas 26% of subjects used mental health settings. The family physician's office was the most frequent site of presentation (35%), followed by a hospital emergency department (32%). Only 13% of subjects sought care from a site outside the health care system. Variables predicting presentation to specific health care sites varied. Subject demographics, panic characteristics, and symptom perceptions were generally significant factors in care-seeking. Illness behaviors, readiness for sick role, health locus of control, and family measures failed to predict the seeking of care specific to any particular site. CONCLUSIONS: When subjects with panic attacks seek care, they most commonly present to a general or family physician's office or a hospital emergency department.

Oral contraceptive use and cardiovascular disease: is the relationship real or due to study bias?

BACKGROUND: Epidemiologic studies link oral contraceptive use with several cardiovascular events, but the literature is difficult to summarize, and potential biases remain poorly addressed. This study uses meta-analysis to summarize study results and to analyze the influence of study characteristics, including susceptibility to bias, on study outcome. METHODS: Forty-seven case-control and cohort studies of oral contraceptives and four cardiovascular events were coded for relative risk (RR) and study characteristics, including adherence to 14 bias-control standards. Key RRs were pooled to summarize findings for each disease type. Univariate determinants of the magnitude of the relative risks were identified, and partial correlation analysis was performed for each disease type. RESULTS: Relative risks were significantly greater than 1.0 for venous thromboembolism (RR = 2.8, CI = 2.4 to 3.2), stroke (RR = 1.8, CI = 1.6 to 2.0), and myocardial infarction (RR = 1.6, CI = 1.4 to 1.8), but not for death due to any cardiovascular cause (RR = 1.0, CI = 0.8 to 1.3). Study characteristics were diverse, and potential biases were frequently uncontrolled. For three of ten study characteristics identified as independently influencing relative risk, methodologically stronger studies of venous thromboembolism tended to have higher RRs. The RRs for stroke and myocardial infarction were lower in studies that were methodologically stronger with regard to variables identified as important. In studies of cardiovascular death, bias-control standards identified as important were generally well addressed by the studies. CONCLUSIONS: Oral contraceptive use does not appear to increase overall cardiovascular mortality. The associations noted with stroke and myocardial infarction may be due to methodologic flaws in the studies, while the association with venous thromboembolism is more likely to be valid.

PIP: Epidemiologic studies link oral contraceptive (OC) use with several cardiovascular events, but the literature is difficult to summarize, and potential biases remain poorly addressed. This study uses meta-analysis to summarize study results and to analyze the influence of study characteristics, including susceptibility to bias, on study outcome. 47 case-control and cohort studies of OCs and 4 cardiovascular events were coded for relative risk (RR) and study characteristics, including adherence to 14 bias-control standards. Key RRs were pooled to summarize findings for each disease type. Univariate determinants of the magnitude of the RRs were identified, and partial correlation analysis was performed for each disease type. RRs were significantly greater then 1.0 for venous thromboembolism (RR=2.8, confidence interval ,CI]=2.4-3.2), stroke (RR=1.8, CI=16-2.0), and myocardial infarction (RR=1.6, CI=1.4-1.8, but not for death due to any cardiovascular cause (RR=1.0, CI=0.8-1.3). Study characteristics were diverse, and potential biases were frequently uncontrolled. For 3 of 10 study characteristics identified as independently influencing RR, methodologically stronger studies of venous thromboembolism tended to have higher RRs. In studies that were methodologically stronger where variables were identified as important, the RRs for stroke and myocardial infarction were stronger. In studies with cardiovascular death, bias-control standards identified as important were generally handled by the studies. OC use does not appear to increase overall cardiovascular mortality. The associations noted with stroke and myocardial infarction may be due to methodologic flaws within the studies, while the association with venous thromboembolism is more likely to be valid.

Infant circumcision in an outpatient setting.

We conducted a retrospective evaluation of 442 infant circumcisions performed in an ambulatory setting. Procedures done with the Gomco clamp (Gomco Division, Allied Health Care, Buffalo, NY) and the Plastibell device (Hollister, Inc, Libertyville, Ill) were compared with respect to the frequency of complications. The overall complication rate was 6.8%. Bleeding requiring action by a physician occurred in 3.4% of cases and was significantly more common with the Gomco clamp than with the Plastibell device (p less than 0.05). There were no statistically significant differences between the two methods in the rate of infection or other complications. The rate of complications is comparable to previous studies of inpatient circumcision.

Comorbid psychiatric disorders in subjects with panic attacks.

Several psychiatric disorders are associated with panic disorder (PD), although the nature of their relationships is unknown. The purpose of this study was to a) document comorbid associations with both PD and infrequent panic (IP), and b) investigate the nature of the relationships among these disorders. This community-based study included 97 adults who met DSM-III-R criteria for panic attacks compared with 97 matched controls. Psychiatric comorbidity was assessed using the SCID and SCL-90. Subjects with either PD or IP had higher rates of psychiatric comorbidity than controls. PD differed from IP only in its higher rate of phobic avoidance. Factor analysis found three factors: PD with phobic avoidance; substance abuse; major depression with obsessive compulsive disorder, social and simple phobias. Only phobic avoidance began secondary to panic onset. In conclusion, this study supports the PD-agoraphobia DSM-IV grouping while lending support to the common diathesis hypothesis for anxiety and affective disorders.

The evaluation and treatment of urinary incontinence in women: a primary care approach.

BACKGROUND: Urinary incontinence, the involuntary loss of urine severe enough to have adverse social or hygienic consequences, is a major clinical problem and a significant cause of disability and dependency. At least 10 million adults in the US suffer from urinary incontinence, including an estimated 15 to 30 percent of community-dwelling older persons. In spite of its high rate of occurrence, fewer than one-half of women with regular urinary incontinence seek medical help for their problem, either because of embarrassment or the perception that their symptoms are normal. METHODS: MEDLINE files were searched from 1970 to 1990 using the key words "incontinence," "prevalence," and "diagnosis" and for specific nonsurgical treatments. Only articles pertaining to adult women were chosen. RESULTS AND CONCLUSIONS: Urinary incontinence frequently can be diagnosed accurately by family physicians using basic tests in the office. Many women experience improvement of incontinence with properly employed behavioral and pharmacologic therapy. Other women benefit from referral for specialized evaluation and consideration for surgical therapy.