Brief
Treatment
of Emergency Room With Panic Attacks
Richard P. Swinson, M.D., Christos Brian J. Cox, M.A., and Klaus
Patients
Soulios, Kuch,
M.D.,
M.D.
Objective: Most research on treatment for panic disorder has involved chronic forms of the illness. To determine the efficacy of early intervention, the authors examined the effects of treatment for patients with panic attacks who were seen in the emergency room, which is the first point of contact with the health delivery system for many persons with panic attacks. Method: The subjects were 33 patients with panic attacks seen in two emergency rooms. The presence of panic attacks was confirmed with a modified version of the Structured Clinical Interview for DSM-III-R; approximately 40% ofthe patients met the DSM-III-R criteria for panic disorder with agoraphobia. The patients were randomly assigned to groups receiving reassurance
(N=1
6) or exposure
instruction
(N=1
7). Scores
on the Fear
Questionnaire
agora-
phobia subscale, Mobility Inventory, and Beck Depression Inventory and the frequency of panic attacks were determined at baseline, 3 months, and 6 months. Results: The subjects who received exposure instruction significantly improved over the 6-month period on depression, avoidance, and panic frequency. The reassurance subjects did not improve on any measure and eventually reported more agoraphobic avoidance. Conclusions: These results suggest that early intervention with exposure instruction may reduce the long-term consequences of panic attacks. The exposure instruction was of value even though the subjects had relatively low levels ofavoidance at the outset ofthe study. (Am J Psychiatry 1992; 149:944-946)
P
anic
disorder
is common
in the
general
population
(1), and individuals with panic attacks are frequent users of health services (2). Although much has been written about pharmacological and behavioral treatments for panic-related disorders (3, 4), and there is evidence of a decline in the utilization of health care services by successfully treated agoraphobic patients (5), most of the available literature relates to the treatment of relatively chronic forms of panic disorder. For examplc, the average length of illness of patients studied in phase I of the Cross-National Collaborative Panic Study (6) was 8 years. Because the emergency room is the first point of contact with the health delivery system for many persons with panic attacks, we examined the effects of Received Jan. 25, 1991; revisions received July 24 and Nov. 4, 1991; accepted Dec. 5, 1991. From the Anxiety Disorders Clinic, Clarke Institute of Psychiatry; the Department of Psychiatry, Faculty of Medicine, University of loronto; and the Department of Psychiatry, the Toronto Hospital. Address reprint requests to Dr. Swinson, Anxiety Disorders Clinic, Clarke Institute of Psychiatry, 250 College St., Toronto, ON MST 1R8, Canada. Supported by a grant from the Canadian Psychiatric Research Foundation to Dr. Soulios and a studentship from the Medical Research Council of Canada to Mr. Cox. The authors thank Drs. B. Rowat and H. Ovens for their help. Copyright © 1992 American Psychiatric Association.
944
treatment tacks
for emergency
to determine
the
room efficacy
patients of early
with
panic
at-
intervention.
METHOD
Subjects Forty patients (23 men, 17 women) in the emergency rooms of two large Toronto hospitals volunteered to undergo the initial assessment interview. Of these 40 patients, 33 (20 men, 13 women) agreed to random assignment
to treatment
and
to follow-up.
The
age
range
of these subjects was 19-58 years (mean=31.S years), and there were no significant differences in demographic variables between the two treatment groups. The Ontario Health Insurance Plan provides no-cost medical
services,
including
emergency
room
residents of Ontario, so access to emergency ing medical care is affected little by financial
visits,
to all
and ongostatus.
Procedure Physicians
aware
working
of the nature
in the
of panic
emergency
disorder
AmJPsychiatry
room
and
were
its somatic
149:7,July
1992
SWINSON,
TABLE
1. Effect of
Exposure Instruction
or Reassu rance on Symptoms
, Variable lest scores Beck Depression Baseline Midpoint
Endpoint
agoraphobia
Emerge ncy Room Patients With Panic AttaCkS
of
Exposure Instruction
Reassurance
(N=17)
(N=16)
ANOVA
F (df=1,
31)
p
Mean
SD
Mean
SD
8.82 4.06
7.94 3.77
4.06
4.10
9.75 8.88 9.56
6.66 5.41 5.27
0.13 8.89 11.30
n.s. 0.006 0.002
1.56 1.31
0.73 0.50
1.50 1.62
0.78 0.82
0.05 1.77
n.s.
1.30
0.51
1.61
0.83
1.72
4.35 2.65 2.53
6.34 4.17 4.16
4.13 5.40 5.47
5.72 6.48 6.37
0.01 2.09 2.44a
n.s. n.s.
in previous
2.53 0.88 0.76
3.34 1.36 1.52
2.50 2.31 3.38
3.52 4.41 5.71
0.00 1.63 3.30
n.s n.s. 0.08
n.s. n.s.
n.s.
week
30.
presentation because of ongoing research on hyperventilation in the emergency room. Panic patients were seen by the attending emergency room physician, who excluded the presence of actual physical disease. These patients were then informed of the study by emergency room staff and, if they consented, were contacted within 24 hours by one of us (C.S.). The patients were seen before they left the emergency room on were interviewed within 2 days of their initial emergency room contacts. At the first
interview the patient was assessed with a version of the Structured Clinical Interview for DSM-ffl-R (7) to confirm the presence of panic attacks and rule out other psychiatric disorders. Approximately 40% of the patients met the DSM-III-R criteria for panic disorder with agoraphobia. In almost all cases the patients were just beginning to experience panic attacks and did not have long histories of panic. All subjects were informed of the voluntary nature of the study
modified
and signed consent
statements.
Before the treatment fear were assessed with
Fear Questionnaire
sessions, phobic the agoraphobia
(8) and the Mobility
avoidance subscale
Inventory
and of the
(9).
Depressed mood was assessed with the Beck Depression Inventory (10), and panic attacks were assessed by a patient-therapist consensual agreement similar to the procedure used in the Cross-National Collaborative Panic Study (6). The patients completed the self-report measures 6 months.
author
and panic diaries One of us (C.S.)
was
to reduce
not
blind
expectation
at baseline, interviewed
to the treatment
3 months, all subjects.
conditions,
and
This and
bias we used only self-report
measures.
After the initial interview each subject was assigned, by predetermined randomization, to a reassurance group (N=16) or an exposure instruction group (N= 17). Each subject was reassured that what he or she had
Am
ET AL.
subscale
Endpoint
adfl,
COX,
Inventory
Mobility Inventory Baseline Midpoint Endpoint Fear Questionnaire, Baseline Midpoint Panic attacks Baseline Midpoint Endpoint
SOUUOS,
J
Psychiatry
149:7,
July
1992
experienced was a panic attack and that there was no physical or psychiatric disorder. The exposure instruction group was given additional information beyond that given to the reassurance group. Each subject who received exposure instruction was told that the most effective way to reduce the fear was to confront the situation in which the attack had occurred. The subject was advised to return to this situation as soon as practicable after the interview and to wait there until the anxiety decreased. All sessions were individual, no treatment goals were set, and there was no ongoing contact with the initial interviewer. Each session lasted approximately 60 minutes. The self-report measures were mailed to the subjects a week before the 3-month and 6-month follow-up visits.
RESULTS
A 2x3 (Treatment by Time) mixed factorial multivariate analysis of variance was conducted for each of the dependent variables with Greenhouse-Geisser cornected degrees of freedom. There were significant Treatment by Time interactions on the agoraphobia subscale of the Fear Questionnaire (F=9.40, df=1, 30, p
Treatment
of Emergency Room With Panic Attacks
Richard P. Swinson, M.D., Christos Brian J. Cox, M.A., and Klaus
Patients
Soulios, Kuch,
M.D.,
M.D.
Objective: Most research on treatment for panic disorder has involved chronic forms of the illness. To determine the efficacy of early intervention, the authors examined the effects of treatment for patients with panic attacks who were seen in the emergency room, which is the first point of contact with the health delivery system for many persons with panic attacks. Method: The subjects were 33 patients with panic attacks seen in two emergency rooms. The presence of panic attacks was confirmed with a modified version of the Structured Clinical Interview for DSM-III-R; approximately 40% ofthe patients met the DSM-III-R criteria for panic disorder with agoraphobia. The patients were randomly assigned to groups receiving reassurance
(N=1
6) or exposure
instruction
(N=1
7). Scores
on the Fear
Questionnaire
agora-
phobia subscale, Mobility Inventory, and Beck Depression Inventory and the frequency of panic attacks were determined at baseline, 3 months, and 6 months. Results: The subjects who received exposure instruction significantly improved over the 6-month period on depression, avoidance, and panic frequency. The reassurance subjects did not improve on any measure and eventually reported more agoraphobic avoidance. Conclusions: These results suggest that early intervention with exposure instruction may reduce the long-term consequences of panic attacks. The exposure instruction was of value even though the subjects had relatively low levels ofavoidance at the outset ofthe study. (Am J Psychiatry 1992; 149:944-946)
P
anic
disorder
is common
in the
general
population
(1), and individuals with panic attacks are frequent users of health services (2). Although much has been written about pharmacological and behavioral treatments for panic-related disorders (3, 4), and there is evidence of a decline in the utilization of health care services by successfully treated agoraphobic patients (5), most of the available literature relates to the treatment of relatively chronic forms of panic disorder. For examplc, the average length of illness of patients studied in phase I of the Cross-National Collaborative Panic Study (6) was 8 years. Because the emergency room is the first point of contact with the health delivery system for many persons with panic attacks, we examined the effects of Received Jan. 25, 1991; revisions received July 24 and Nov. 4, 1991; accepted Dec. 5, 1991. From the Anxiety Disorders Clinic, Clarke Institute of Psychiatry; the Department of Psychiatry, Faculty of Medicine, University of loronto; and the Department of Psychiatry, the Toronto Hospital. Address reprint requests to Dr. Swinson, Anxiety Disorders Clinic, Clarke Institute of Psychiatry, 250 College St., Toronto, ON MST 1R8, Canada. Supported by a grant from the Canadian Psychiatric Research Foundation to Dr. Soulios and a studentship from the Medical Research Council of Canada to Mr. Cox. The authors thank Drs. B. Rowat and H. Ovens for their help. Copyright © 1992 American Psychiatric Association.
944
treatment tacks
for emergency
to determine
the
room efficacy
patients of early
with
panic
at-
intervention.
METHOD
Subjects Forty patients (23 men, 17 women) in the emergency rooms of two large Toronto hospitals volunteered to undergo the initial assessment interview. Of these 40 patients, 33 (20 men, 13 women) agreed to random assignment
to treatment
and
to follow-up.
The
age
range
of these subjects was 19-58 years (mean=31.S years), and there were no significant differences in demographic variables between the two treatment groups. The Ontario Health Insurance Plan provides no-cost medical
services,
including
emergency
room
residents of Ontario, so access to emergency ing medical care is affected little by financial
visits,
to all
and ongostatus.
Procedure Physicians
aware
working
of the nature
in the
of panic
emergency
disorder
AmJPsychiatry
room
and
were
its somatic
149:7,July
1992
SWINSON,
TABLE
1. Effect of
Exposure Instruction
or Reassu rance on Symptoms
, Variable lest scores Beck Depression Baseline Midpoint
Endpoint
agoraphobia
Emerge ncy Room Patients With Panic AttaCkS
of
Exposure Instruction
Reassurance
(N=17)
(N=16)
ANOVA
F (df=1,
31)
p
Mean
SD
Mean
SD
8.82 4.06
7.94 3.77
4.06
4.10
9.75 8.88 9.56
6.66 5.41 5.27
0.13 8.89 11.30
n.s. 0.006 0.002
1.56 1.31
0.73 0.50
1.50 1.62
0.78 0.82
0.05 1.77
n.s.
1.30
0.51
1.61
0.83
1.72
4.35 2.65 2.53
6.34 4.17 4.16
4.13 5.40 5.47
5.72 6.48 6.37
0.01 2.09 2.44a
n.s. n.s.
in previous
2.53 0.88 0.76
3.34 1.36 1.52
2.50 2.31 3.38
3.52 4.41 5.71
0.00 1.63 3.30
n.s n.s. 0.08
n.s. n.s.
n.s.
week
30.
presentation because of ongoing research on hyperventilation in the emergency room. Panic patients were seen by the attending emergency room physician, who excluded the presence of actual physical disease. These patients were then informed of the study by emergency room staff and, if they consented, were contacted within 24 hours by one of us (C.S.). The patients were seen before they left the emergency room on were interviewed within 2 days of their initial emergency room contacts. At the first
interview the patient was assessed with a version of the Structured Clinical Interview for DSM-ffl-R (7) to confirm the presence of panic attacks and rule out other psychiatric disorders. Approximately 40% of the patients met the DSM-III-R criteria for panic disorder with agoraphobia. In almost all cases the patients were just beginning to experience panic attacks and did not have long histories of panic. All subjects were informed of the voluntary nature of the study
modified
and signed consent
statements.
Before the treatment fear were assessed with
Fear Questionnaire
sessions, phobic the agoraphobia
(8) and the Mobility
avoidance subscale
Inventory
and of the
(9).
Depressed mood was assessed with the Beck Depression Inventory (10), and panic attacks were assessed by a patient-therapist consensual agreement similar to the procedure used in the Cross-National Collaborative Panic Study (6). The patients completed the self-report measures 6 months.
author
and panic diaries One of us (C.S.)
was
to reduce
not
blind
expectation
at baseline, interviewed
to the treatment
3 months, all subjects.
conditions,
and
This and
bias we used only self-report
measures.
After the initial interview each subject was assigned, by predetermined randomization, to a reassurance group (N=16) or an exposure instruction group (N= 17). Each subject was reassured that what he or she had
Am
ET AL.
subscale
Endpoint
adfl,
COX,
Inventory
Mobility Inventory Baseline Midpoint Endpoint Fear Questionnaire, Baseline Midpoint Panic attacks Baseline Midpoint Endpoint
SOUUOS,
J
Psychiatry
149:7,
July
1992
experienced was a panic attack and that there was no physical or psychiatric disorder. The exposure instruction group was given additional information beyond that given to the reassurance group. Each subject who received exposure instruction was told that the most effective way to reduce the fear was to confront the situation in which the attack had occurred. The subject was advised to return to this situation as soon as practicable after the interview and to wait there until the anxiety decreased. All sessions were individual, no treatment goals were set, and there was no ongoing contact with the initial interviewer. Each session lasted approximately 60 minutes. The self-report measures were mailed to the subjects a week before the 3-month and 6-month follow-up visits.
RESULTS
A 2x3 (Treatment by Time) mixed factorial multivariate analysis of variance was conducted for each of the dependent variables with Greenhouse-Geisser cornected degrees of freedom. There were significant Treatment by Time interactions on the agoraphobia subscale of the Fear Questionnaire (F=9.40, df=1, 30, p
