[page 14 of handout]

Kushner, M.G. and Beitman, B.D. (1990) Panic attacks without fear: an overview. Behaviour Research and Therapy, 28, 469-479.

  • ‘Non-fearful panic disorder’ (NFPD) is a condition that meets DSM-III-R criteria for panic disorder

  • but lacks a report of subjective fear or anxiety. ..

  • The authors describe a wide range of overlapping phenomena includes ‘somatically expressed panic’, ‘non-cognitive panic’... and ‘masked anxiety’.

  • The review shows that such conditions account for from 20% to 40% of the panic disorder found in various medical populations and that this group resembles conventional panic disorder in statistical comparisons of age, gender and other demographic variables.

  • NFPD patients have attacks of intense ‘discomfort’ without ‘fear’.

  • They have the same sort of physical symptoms as conventional panic disorder patients (e.g. heart pounding, chest pain, faintness, trembling) but little anticipatory anxiety or subjective fears such as fear of dying or losing control.

  • E.g. the authors analysed data for 49 cardiology patients who cardiologists identified as having no evidence of coronary artery disease. They had less inter-attack anxiety than panic patients and were less likely to be rated as agoraphobic.

  • There are many case histories of people which negative physical tests, who deny psychological problems but whose physical symptoms can be relieved by anti-depressant or anti-anxiety drugs.

  • e.g. a surgeon who had lost a patient and his partner a few months before he started having attacks (fainting) before difficult operations, but denied needing psychiatric help.

  • Conclusion. Cognitions are not an invariable factor in panic attacks, and the ‘3-systems’ or ‘triple-response’ view of anxiety is consistent with the syndrome.
A more recent report on the high percentage (25-43%) of patients undergoing cardiac investigations who turn out to have no evidence of coronary disease is Carmin et al. (2003).

See also Fleet et al (1998) below — it is more typical to find cases where cognitions are a part of panic disorder   [not included in paper handout]

In the case below it seems likely that being diagnosed as having coronary artery disease predisposes patients to having panic attacks involving fear of heart attacks.

Fleet, RP, Dupuis, G, Marchand, A, Kaczorowski, J, Burelle, D, Arsenault, A, Beitman, BD (1998) Panic disorder in coronary artery disease patients with noncardiac chest pain. Journal of Psychosomatic Research, Vol.44, No.1, Pp.81-90.

  • What percentage of coronary artery disease (CAD) patients that present with chest pain, but whose symptoms cannot be fully explained by their cardiac status, suffer from panic disorder (PD)?

  • How do patients with both CAD and PD compare to patients without CAD and to patients without either PD or CAD in terms of psychological distress?

  • Four hundred forty-one consecutive walk-in emergency department patients with chest pain underwent a structured psychiatric interview (ADIS-R) and completed psychological scales.

  • Fifty-seven percent (250 of 441) of these patients were diagnosed as having noncardiac chest pain and constituted this study's sample,

  • A total of 30% (74 of 250) of noncardiac chest pain patients had a documented history of CAD.

  • Thirty-four percent (25 of 74) of CAD patients met criteria for PD.

  • Patients with both PD and CAD displayed significantly more psychological distress than CAD patients without PD and patients with neither CAD nor PD.

  • However, they did not differ from non-CAD patients with PD.

  • PD is highly prevalent in patients with CAD that are discharged with noncardiac diagnoses. The psychological distress in these patients appears to be related to the panic syndrome and not to the presence of the cardiac condition.