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Panic Disorder |
Overcoming Anxiety (Home) > Panic Disorder > Short and Long-term Outcomes Short and Long Term OutcomesAfter DSM-III reclassification of anxiety disorders, several reports focused on the long-term outcome of panic disorder. Retrospective descriptions by individuals seen in clinical settings suggest that the usual course of the illness is generally chronic, with waxing and waning. Some individuals may have episodic outbreaks with years of remission in between, and others may have continuous severe symptomatology. Specific follow-up studies confirm the general chronicity of PD, although with a variety of possible outcomes. Although the earliest studies, which included relatively brief follow-up periods, showed a relatively good prognosis, with recovery rates ranging from 25% to 72% after 1 or 2 years, further studies reported less favourable outcomes . After five years of prospective follow-up, only 10–12% of patients fully recovered (i.e. no symptoms and no treatment). Moreover, higher risks of suicide, major depressive episodes, cardiovascular diseases, as well as an increased general morbidity and mortality, have been reported in these patients However, since PD is frequently comorbid with other axis I and II disorders, the long-term consequences could be attributed to the comorbid condition rather than to PD itself. Recent studies seem to confirm this position: the worst consequences in terms of fatality, morbidity, and substance abuse seem to be related to the associated conditions Noyes et al. found that patients with extensive phobic avoidance or agoraphobia have a more severe form of PD, with a longer duration of illness, more severe symptoms and greater social maladjustment than subjects with limited or no phobic avoidance. Breier et al., Lesser et al. and Noyes et al. found that subjects with panic disorder with secondary depression (current or past) were part of a more severely ill group: they had been ill longer and had more severe anxiety symptoms, more frequent panic attacks and more extensive phobic avoidance, and they more frequently had personality disorders. There is some evidence that concomitant personality disorders influence the outcome of patients with PD: the presence of a personality disturbance predicts in fact a less favourable treatment response. When PD is the primary psychopathological condition, the rate of recovery is relatively low (12%) and that PD tends to be chronic disturbance; the long-term outcome shows a wide variability, with the intermediate outcome of neither ill nor well being the most common. Among the predictors taken into consideration, only duration of the disorder before treatment showed a close relationship to outcome: patients with a shorter duration of illness more frequently experienced a complete recovery or remission and reported fewer relapses. In this sample, the number of suicides is small. Using data from the ECA study, Markowitz et al. reported that PD (with or without agoraphobia) was associated with a greater risk of poor physical and emotional health, alcohol and other drug abuse, suicide attempts, poorer marital functioning, and greater financial dependence. The risk for PD was even greater than for major depression for many measures, including alcohol abuse and financial dependence. ECA suicide rates for the separate diagnoses of panic disorder or major depression alone were similar and were higher than rates for the general population. Patients with PD had levels of mental health and role functioning that were substantially lower than those of patients with other major chronic medical illnesses. PD is associated with poor quality of life: comorbid depression, social support, worry and severity of chest pain predicted quality of life. Although subjects with infrequent panic attacks reported a lower quality of life than controls, subjects with PD had more panic-related disability and poorer quality of life than those with infrequent panic attacks. Predictors of work disability included panic frequency, illness attitudes and family dissatisfaction. Coryell (1988) reviewed earlier studies from 1936 to 1986 and concluded that patients with anxiety states appeared as likely as patients with primary depression to commit suicide. Weissman et al. (1989) found a very high rate of suicide attempt and suicidal ideation in subjects suffering from PD even when controlling for lifetime major depressive episode and alcoholism. Le´pine et al. (1993) found that 42% of outpatients with PD had attempted suicide at some time during their lives. In patients with PD, they found demographic determinants for suicide attempts to be similar to those of other clinical populations, such as depressed patients: the suicide attempts occur most frequently in single, divorced, or widowed women. In this study the authors found a significantly longer duration of panic disorder at the time at referral in suicide attempters. Otherwise, severity of the worst episode of PD did not differ between suicide attempters and non-attempters. They found that suicide attempt in patients with PD were often associated with a lifetime diagnosis of major depressive episode and alcohol and/or other substance abuse. Warshaw et al. (1995) found that suicidal behaviour in subjects with PD seems to be better related to factors not inherent in the PD; presence of depression, post-traumatic stress disorder, eating disorders, substance abuse/dependency or personality disorders (in particular, borderline and antisocial personality disorders) and factors related to quality of life (in fact, being married or having a child, working full-time all seemed to be protective factors).
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