Panic Disorder and Perimenopause Presentation

Perimenopause is a time of hormonal fluctuations where some perimenopausal women will experience psychological symptoms during this transition (Carter, 2001; Conboy, O’Connell, & Domar, 2000).  Perimenopause may be connected with a new onset of psychiatric symptoms or exacerbation of pre-existing psychiatric problems in women (Simon, et. al., 1998).  Primary care physicians are usually the first to be made aware of anxiety/panic presentations and to initiate treatment and referral (NIMH, 2002; Carter, 2001; Katerndahl & Dresser, 2000). Panic disorder is difficult to diagnose due to the complexity of somatic symptoms that also bear a close resemblance to the symptoms experienced during perimenopause (Katerndahl & Dresser, 2000; Starr, 1998).  Most often the person with panic disorder will present at the family physician office or the hospital emergency room (Katerndahl & Dresser, 2000; Starr, 1998). 

Additionally, if perimenopausal women are experiencing symptoms that are the same for both perimenopause and panic disorder, and these symptoms meet the severity and duration of symptoms as specified for panic disorder criteria, then the problem of under diagnosing panic disorder will delay onset of treatment.  This is in contradiction to the recommendations, that early intervention is important (APA, 2000).  The transition into menopause might be made with less life disruptions with treatment for panic disorder if an early and accurate diagnosis or referral is made.  Perimenopausal women, as well as family physicians need to be aware of the possibility of co-occurring condition such as panic disorder at this transition. This is significant for perimenopausal women where the possibility of co-occurring panic disorder may exist, especially when early intervention is important if there is to be a promising long-term prognosis.

The results from the Perimenopause – Panic Disorder Questionnaire (PPDQ) found associations that medical treatment is being sought 76% from the primary care physicians (PCP) offices in contrast to mental health offices and emergency departments. 

• Ten out of 50 participants did not seek any type of medical treatment or assistance with the experienced symptoms.
• 44% endorsed having a previous diagnosis of panic disorder.
• 76% met the criteria for a panic disorder diagnosis.
• 1/3 of the participants went undiagnosed with panic disorder during perimenopause.
• Those with a previous diagnosis of panic disorder 35% endorsed that perimenopause exacerbated their pre-existing condition.

The data was collected from an Internet hosted survey (PPDQ), and participants were recruited from various panic/anxiety, and women health web sites.  The PPDQ accepted survey results for 30 days.  Fifty valid (who were not menopausal, and not on hormonal therapy) responses were received out of 85 submitted surveys.

78% of the responses came from the United States, followed by 10% from England, 12% from Canada and 6 people declined to answer question.  Race of the participants classified themselves as Caucasian 68%, British 8%, African American 4%, Hispanic (1%) and Multicultural (1%).  The mean age of participants was 45 with perimenopause onset mean of 41 years old.

Panic Disorder Presentation

Panic disorder diagnosis was based on the DSM IV TR (2001) Criteria in which 44%   endorsed having a previous diagnosis of panic disorder, and 76% met the criteria for a panic disorder diagnosis. Those with a previous diagnosis of panic disorder 35% endorsed that perimenopause exacerbated their pre-existing condition.

The occurrences of panic disorder symptoms were broken down respectively to monthly, daily, weekly, no answer, and not applicable.  The most frequent (90%) panic disorder symptom endorsed was, “Worried about having another panic attack” (n = 45), followed by: avoidance (n=24), nausea or abdominal distress (n = 32), chills or hot flushes (n = 32), increased heart rate (n = 31), feeling dizzy, lightheaded, or faint (n = 31), avoidance behaviors (n = 24), sweating (n = 24), fear of dying (n = 24), sensations of shortness of breath or smothering (n = 23), chest pain or discomfort (n = 23), fear of losing control or going crazy (n = 20), numbness or tingling sensation (n = 14), trembling or shaking (n = 13), feeling of choking (n = 13), and derealization (n = 9).

The intensity of panic disorder symptoms showed that the symptom endorsed with the highest frequency of “severe” was “worry that these symptoms will reoccur”.  A symptom that “mild” was not endorsed included: fear of going crazy, fear of dying, hot flushes, derealization, and faintness.  On the symptom “feeling of choking” no mild to moderate, moderate to severe and severe intensities were endorsed.

Duration of panic disorder symptom constantly endorsed highest in the “over 6 month” duration of time in all symptom questions. Duration length was used as a criterion for panic disorder diagnosis.  Every symptom with “under one month” experienced was not included to met diagnosis criteria.

Perimenopause

Thirty questions addressing perimenopausal symptomology were requested from participants.  The most endorsed five symptoms occurrences respectively were: irritability (90%), fatigue (88%), forgetfulness (82%), anxiety (80%), and difficulty concentrating (78%).

The intensity levels endorsed the highest was: moderate headaches (36%), moderate to severe anxiety (32%), moderate fatigue (30%), and forgetfulness at mild to moderate and moderate levels at 26% each.

The average age for onset for perimenopause was 41 with a SD of 5.8.  There were no significant finding between age of participants and age of perimenopausal symptoms.  There were no significant findings between age of participants, age of panic disorder onset, and age of perimenopausal symptoms.

Treatment Seeking Behavior & Diagnosis Received

Over all treatment-seeking behaviors of perimenopausal women for any service showed that 48.6% did not seek any type of service, 44.6% did seek services, and 6.6% did not respond.  A majority of women who sought treatment for experienced symptoms went to their PCP (38%), with a panic disorder diagnosis received 13%.  “Other” diagnosis received included cardiac related disorders as the highest percentage (14%) in contrast to other disorders.

The top three diagnosis categories participants received from the family physician visits included panic disorder at 26%, perimenopause 12%, and other also at 12%.  Mental health also had panic disorder as its top diagnosis 10%, other 8%, and panic disorder with another diagnosis at 6%. The emergency department visits had cardiac related diagnosis at 14%, endocrine 6%, and cardiac, endocrine, and hemoglobin disorders at 4%.

The medical history question that was filled in by participants included diagnoses of: arthritis, fibromyalgia, vulvadyia, cystic fibrosis, post breast cancer, osteoarthristis, thrombosis, water retention, sleep apnea, and high cholesterol. 

The mental health diagnosis included: post traumatic stress disorder, depression, seasonal affect disorder, and bipolar.

The main finding from the survey is that one third of the women taking this survey met the criteria for panic disorder during perimenopause and did not receive a diagnosis or any sort of treatment for their symptoms.

Pamela Balentine MS, LPC, NCC, RSW, Capella University Health Psychology Doctoral Candidate runuts@chartermi.net

References:

References

American Psychological Association. (2000). Diagnostic and statistical manual of mental Disorders TR (4 eds.). Washington DC: American Psychological Association.

Carter, D. M. (2001). Depression and emotional aspects of the menopause. British Columbia Medical Journal, 43, (8), 463-466.

Conboy, L., O’Connell, E., & Domer, A. (2002). Women at mid-life: Symptoms, attitudes, and choices an Internet based survey. Pending publication in Maturitas.

Katerndahl, D. A., & Dresser, J. G. (2000). Advances in the recognition and treatment of panic disorder: A continuing education monograph. Springfield, N. J. :Scientific Therapetics Information, Inc.

National Institute of Mental Health. (2002). Panic Disorder. Retrieved April 25, 2001 from http://www.nimh.nih.gov/anxiety/pdtr.cfm.

Starr, C. (1998). How well do you manage panic disorder? Patient Care, 32 19-64.