Panic Disorder 285
Substance abuse is also common in panic disorder (e.g., Sbrana et al., 2005). Results
of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 43,093
respondents) indicate that panic disorder with agoraphobia and GAD were more likely
associated with a substance use disorder than other mood and anxiety disorders (Grant
et al., 2004). Rates of Axis II personality disorders range from 25 to 75%, with particu-
lar concentration in the Cluster C disorders (Diaferia et al., 1993; Renneberg, Chamb-
less, & Gracely, 1992). Presence of borderline, dependent, schizoid, or schizotypal per-
sonality disorder by age 22 significantly predicted elevated risk for panic disorder by
age 33 (Johnson, Cohen, Kasen, & Brook, 2006). This finding is consistent with the
observed trend for nonpanic conditions to precede the development of panic disorder
when individuals have multiple diagnoses (Katerndahl & Realini, 1997).
Clinician Guideline 8.5
Presence of comorbid conditions, especially major depression, GAD, substance abuse, and
personality disorder, should be determined when conducting a diagnostic evaluation for
panic disorder.Panic and Suicide Attempts
Although findings from the ECA suggested that individuals with panic disorder were
2.5 times more likely to attempt suicide than individuals with other psychiatric con-
ditions (Weissman, Klerman, Markowitz, & Ouellete, 1989), later studies contra-
dicted this finding, showing that suicide attempts are practically nonexistent in panic
disorder (e.g., Beck, Steer, Sanderson, & Skeie, 1991; Swoboda, Amering, Windhaber,
& Katschnig, 2003). More recently Vickers and McNally (2004) reanalyzed the
NCS data set and concluded that any suicide attempts in panic disorder were due to
psychiatric comorbidity and that panic itself did not directly increase risk for suicide
attempts.
Increased Medical Morbidity and Mortality
A number of medical conditions are elevated in panic disorder such as cardiac disease,
hypertension, asthma, ulcers, and migraines (Rogers et al., 1994; Stewart, Linet, &
Celentano, 1989). Panic sufferers are more likely to first seek medical evaluation of
their symptoms than attend a mental health setting (e.g., Katerndahl & Realini, 1995).
A significant number of individuals with cardiac complaints (9–43%) have panic disor-
der (Barsky et al., 1994; Katon et al., 1988; Morris, Baker, Devins, & Shapiro, 1997).
Moreover, higher rates of cardiovascular disease, even fatal ischemic heart attacks, have
been found in men with panic disorder (Coryell, Noyes, & House, 1986; Haines, Ime-
son, & Meade, 1987; Weissman, Markowitz, Ouellette, Greenwald, & Kahn, 1990). In
addition postmenopausal women who experience full-blown panic attacks have a three-
fold increased risk of coronary heart disease or stroke (Smoller et al., 2007). In a recent
cohort study based on analysis of the British General Practice Research Database, men
and women with panic disorder had a significantly higher incidence of coronary heart