Panic patients are suddenly hit with a barrage of physical symptoms, “Out of the Blue”.
When dizziness, heart pounding, shortness of breath, weakness, numbness in the hands and feet, and hot cold spells strike without apparent cause, panic sufferers frequently seek medical evaluations (emergency rooms, family doctors) to determine the cause. Ballenger (1987) states that 90% of panic sufferers believe they have a physical disorder.
Panic Patients Desperately Need to Know “Why Am I Feeling This Way?”
When patients present in medical settings with an array of somatic complaints, a thorough medical investigation is undertaken. The panic-struck individual waits apprehensively, convinced they will receive a serious medical diagnosis. When the Doctor informs the patient there is no medical cause for these intense bodily sensations, (“Everything is fine”), the provider feels he is bringing “good news” to the patient.
Physician Reassurance Backfires!
Good news from the doctor’s perspective is bad news for the patient. The panic sufferer is extremely disappointed. The doctor did not answer the whyPanic question: “Why am I feeling this way?
No cause for such severe complaints of chest pain and shortness of breath does not make any sense to the patient. Consistent with my own observations, Pollard and Lewis (1989) report that doctor reassurance for panic symptoms can “actually exacerbate rather than alleviate anxiety. In essence, lack of information, or misinformation, may perpetuate the catastrophic attributions involving impending death or mental instability that are central to this disorder.”
The Doctor Missed Something
Physician reassurance is viewed by the patient as a minimization of their complaints. Because of the intensity of symptoms, the patient has already concluded something is seriously wrong. Panic patients are seeking a diagnosis and an accurate explanation for the WhyPanic Question. “We can’t find any cause” does not fit with the patient experience. The patient feels that the doctor may have overlooked a serious medical cause. No cause for severe physical complaints creates more patient ambiguity and uncertainty.
The patient begins to worry more about what COULD be causing them to feel this way and may look for a more thorough doctor and investigation to finally pin down the answer the WhyPanic Question. A case of doctor doubt can develop, and the patient catches “online disease” and the “read and catch syndrome.” You look up your symptoms online and discover possible related symptoms and diseases and think you could have all of them. Increased worry that panic symptoms represent some life-threatening illness can produce additional anxiety symptoms and amplify existing ones. In extreme cases, patients begin to worry that they might have some rare undetected disease that will be discovered upon autopsy!
High Prevalence of Undetected Panic Disorder in Medical Settings
Panic disorder patients congregate in general medical practices, searching for the WhyPanic answer.
A growing body of evidence shows very low detection rates for panic disorder in the medical setting. No cause or “? etiology” is a common diagnostic conclusion for panic symptoms in the emergency room, primary care and cardiology practices. Doctors often feel they have completed the evaluation when they ruled out medical causes for somatic complaints. Rushed for time and with limited training, all too often they stop short of considering the diagnosis of panic disorder. The patient, convinced that the doctor missed something can go from doctor to doctor, doctor shopping until they arrive at an accurate diagnosis.
The continued search for the answer to WhyPanic creates very high medical utilization patterns for panic disorder. Sheehan (1982) reports that 70% of panic disorder patients had consulted at least 10 doctors without receiving a correct diagnosis. Anthony and Swinson (2000) report that compared to the general population, panic disorder patients “visit physicians seven times more often and missed twice as many work days.”
Patient Perceptions of the Doctor’s Diagnosis for Panic Disorder
Watkins and his associates (1996) asked a selected sample of panic patients who underwent a medical evaluation for panic symptoms “What diagnosis did you receive?” A sample response was “I was perfectly healthy. It was nothing to worry about. Quit being such a worrier.”
Then, the researchers asked the panic patients “Describe how you felt about hearing the diagnosis.” A sample response was “Scared and confused because I wasn’t 100% convinced I knew what triggered it and I didn’t want it to happen again.”
Early Diagnosis Brief Intervention in the Medical Setting and the Medical Cost Offset Effect
Undiagnosed panic disorder in medical settings leads to high medical utilization, patient dissatisfaction, doctor frustration, increased emotional distress, prolonged suffering, occupational impairment, social isolation and ultimately, patient despair. Anthony and Swinson (2000) reported that, during the year following a diagnosis of panic disorder, the frequency of visits to medical doctors decreased from a mean of 5.13 to .25 per person. Hospital emergency room visits decreased from 1.23 per person to 0.11 per person.
Integration of Early Diagnosis and Brief CBT for panic disorder into medical settings could prevent the progression of panic disorder, shorten treatment length, rapidly diminish patient suffering, prevent escalating redundant medical utilization and yield substantial cost savings.