286 TREATMENT OF SPECIFIC ANXIETY DISORDERS
disease and those younger than 50 years of age had a higher incidence of myocardial
infarction (Walters, Rait, Petersen, Williams, & Nazareth, 2008). Mitral valve prolapse
(MVP), a malformation of the leaflets of the heart’s mitral valve that causes symptoms
like chest pain, tachycardia, faintness, fatigue, and anxiety (see Taylor, 2000), is twice
as common in individuals with panic disorder as in nonpanic controls (Katerndahl,
1993). However, most individuals are asymptomatic and not at high risk for serious
health consequences (Bouknight & O’Rourke, 2000), so there is no clinical significance
in distinguishing panic patients with or without the condition (Barlow, 20002).
Panic disorder is associated with higher mortality rates possibly due to elevated risk
of cardiovascular and cerebrovascular diseases, especially in men with panic disorder
(Coryell et al., 1986; Weissman et al., 1990). Moreover, panic disorder and respiratory
diseases such as asthma (Carr, Lehrer, Rausch, & Hochron, 1994) and chronic obstruc-
tive pulmonary disease (Karajgi, Rifkin, Doddi, & Kolli, 1990) show a high rate of
incidence, although these diseases usually precede the onset of panic episodes. Panic
disorder is only diagnosed when there is clear evidence that the patient holds exagger-
ated negative beliefs about the dangerousness of unpleasant but harmless sensations like
breathlessness (Carr et al., 1994; Taylor, 2000).
There are a number of medical conditions that can produce physical symptoms
similar to panic disorder. These include certain endocrine disorders (e.g., hypoglycemia,
hyperthyroidism, hyperparathyroidism), cardiovascular disorders (e.g., mitral valve pro-
lapse, cardiac arrhythmias, congestive heart failure, hypertension, myocardial infarc-
tion), respiratory disease, neurological disorders (e.g., epilepsy, vestibular disorders),
and substance use (e.g., drug/alcohol intoxication, or withdrawal) (see Barlow, 2002;
Taylor, 2000, for further discussion). Again, presence of these disorders does not auto-
matically exclude the possibility of diagnosing panic disorder. If panic attacks precede
the disorder, occur outside the context of substance use, or the physical symptoms are
misinterpreted in a catastrophic fashion, than a diagnosis of comorbid panic disorder
should be considered in those with a medical condition (DSM-IV-TR; APA, 2000; Tay-
lor, 2000). Other characteristics such as onset of panic attacks after age 45, presence of
unusual symptoms such as loss of bladder or bowel control, vertigo, loss of conscious-
ness, slurred speech, and the like, and brief attacks that stop abruptly suggest a general
medical condition or substance use may be causing the panic (DSM-IV-TR; APA, 2000;
see Taylor, 2000). It is possible that physiological irregularities and ill health experi-
ences could contribute to a heightened sensitivity to body sensations in panic disorder
(e.g., Hochn-Saric et al., 2004). For example, Craske, Poulton, Tsao, and Plotkin (2001)
found that experience with respiratory ill health or disturbance during childhood and
adolescence predicted the subsequent development of panic disorder with agoraphobia
at 18 or 21 years. Thus medical conditions can play either a contributing cause and/or
effect role in many cases of panic disorder.
Clinician Guideline 8.6
Most individuals with panic disorder have sought medical consultation prior to referral to
mental health services. However, a thorough medical examination should be obtained in
cases where a self- referral was made in order to rule out a co- occurring medical condition
that might mimic or exacerbate panic symptoms.