Panic disorder — acceptance of the diagnostic entity and treatment modalities preferred by German health professionals

298

Eur Psychiarty 1996; 11:298-305 0 Elsevier, Paris

Original

article

Panic disorder - acceptance of the diagnostic entity and treatment modalities preferred by German health professionals B Bandelow,

M Rathemeyer,

(Received

11 July

K Sievert,

1995; accepted

12 March

G Hajak, E Riither

1996)

Summary - A survey

of the pharmacological and psychological treatment of panic disorder and agoraphobia (PDA) was conducted among 103 physicians, psychologists and psychotherapists. It revealed that the treatments for PDA preferred by the majority of the respondents are inconsistent with the recommendations given in the international literature. Non-psychiatric physicians most frequently proposed herbal preparations as a possible treatment (46% of non-psychiatric physicians), followed by homoeopathic formulations (32%). Tricyclic antidepressants which are recommended as first-line treatment in panic disorder by the literature are preferred by 74% of the psychiatrists, but only by 24% of the non-psychiatric physicians. Benzodiazepines are prescribed by twice as many psychiatrists (45%) as non-psychiatric physicians (22%). Beta blockers and neuroleptics which are not recommended as first-line treatment in panic disorder are used quite often (psychiatrists: 15%; non-psychiatric physicians: 26%). Selective serotonin reuptake inhibitors are prescribed by 24% of the psychiatrists, but by only 3% of the non-psychiatric physicians. Among psychological therapies, psychoanalysis was proposed as first-line treatment by 44% of all professionals applying psychological therapies, while cognitive/behaviour therapy was preferred by only 28%, though proof of efficacy exists only for cognitivelbehaviour therapy. In general, psychologists prefer behaviourally-orientated therapy, while physicians mostly propose psychodynamic therapy. One reason for the fact that the results of controlled studies have little influence on professionals treating PDA patients might be that 40% of the respondents do not accept the new classification of the anxiety disorders as introduced in 1980 by the DSM-III.

panic disorder / agoraphobia

I drug treatment / psychological treatment

INTRODUCTION Panic disorder with or without agoraphobia (PDA) is one of the most frequent psychiatric disorders (Regier et al, 1988). PDA can be treated either with drugs or psychological therapies or both (Ballenger, 1994; Barlow, 1994; Clark, 1994). Thus these patients consult psychiatrists, psychologists or psychotherapists. Moreover, panic disorder is also treated by general practitioners, internists and other non-psychiatric physicians, as patients often seek organic treatment for their condition (Katon et al, 1992) and sometimes refuse to see a psychiatrist. In a retrospective study (Bandelow et al, 1995), patients with PDA were questioned about the psychopharmacological, psychological and ‘alternative’ treatments they had received in the course of

their illness. The results showed an underutilisation of available effective treatments for panic disorder (eg, tricyclic antidepressants or cognitive/behaviour therapy) and the overutilisation of treatments without proven efficacy (eg, herbal preparations or autogenic training). The survey revealed that patients were most satisfied with precisely those treatment methods which had proven effective in controlled studies. Underutilisation of effective therapies was also shown in other surveys among PDA patients (Breier et al, 1986; Aronson and Logue, 1988; Taylor et al, 1989; Swinson et al, 1992; Goisman et al, 1994). In order to elucidate the reasonsfor this situation unsatisfactory for the affected patients, a second survey was initiated among persons involved in the treatment of PDA. Additionally, these persons were asked for an opinion regarding the DSM class-

Treatment

and definition

ification of anxiety disorders. This classification system categorises disorders strictly by symptoms and omits terms like ‘neurosis’ that presuppose that the aetiology of the anxiety disorder is wellestablished (eg, psychic trauma in childhood). Thus, the DSM system was criticized because it questions the psychodynamic explanation model for anxiety disorders. METHODS In this survey performed in 1993 and 1994 practising physicians, psychologists and psychotherapists who treat PDA patients in the town of Giittingen, Germany, were approached: general practitioners, internists and other non-psychiatric physicians, psychiatrists/neurologists. psychologists as well as psychotherapists who are neither physicians nor psychologists. Giittingen, a town with a population of 125,000, has a high concentration of physicians, psychologists and psychotherapists due to the presence of a large university. An attempt was made to reach all health professionals working in Giittingen who might treat PDA patients via lists compiled by the Medical Board and General Health Insurance Authorities. All major psychological treatment modalities (such as psychoanalysis, client-centred psychotherapy or cognitivelbehaviour therapy) are available and are taught by university instructors. The respondents were sent a questionnaire that presented a symptom description of panic disorder and agoraphobia taken from the DSM-III-R (American Psychiatric Association, 1987) and the ICD-IO (International Classification of Diseases, 1991). It was stated that the described disorder was called panic disorder with/without agoraphobia according to DSM-III-R criteria. Respondents were asked if they had encountered such patients in their office. Only one respondent answered that he had never treated PDA patients, and was therefore excluded from the study. Furthermore, respondents were requested to specify the quality and duration of their education in medicine, psychology. psychiatry and psychological treatments. They were asked a series of questions concerning the use of the DSM classification to characterise such PDA patients; and also their preferred pharmacological or psychological therapy. Of the 450 persons to whom the questionnaire was mailed. 104 returned the questionnaire. Of these replies. 103 were evaluable. The response rates did not differ significantly among the different health professionals.

Respondents

of PDA

physicians nor psychologists, but practised as psychotherapists. Of the 79 physicians, 20 (26%) were physicians without any speciality (mostly general practionet-s), 51 (65%) were specialists (eg, in internal medicine and other fields) and eight (IO’%) were being trained as specialists. Among the 5 I specialists (and trainees), the specialities were: general medicine 12, internal medicine four. neurology one, psychiatry ten, neurology and psychiatry combined 28, other six. Of the 38 psychiatrists, eight were trainees in psychiatry as a speciality. Fifty-four percent of the physicians had received a special education in psychological therapy which is available to all physicians in Germany without necessarily being a psychiatrist. On average, all respondents had seen 16.25 PDA patients in the previous year (range: IO- 100. SD: 43.4). Psychiatrists cited an average of 17.9 (range: 5-100; SD: 28.1) PDA patients per year. Respondents stated having had an average of I I .3 years’ professional experience (range: O-39; SD: 8.4).

RESULTS Acceptance of the concept of ‘panic disorder’ In table I, the respondents‘ statements about their knowledge regarding the term ‘panic disorder’ are given. Nine respondents stated they had never heard of the term ‘panic disorder’ in connection with the syndrome described in the questionnaire. Sixty-seven percent of the questioned persons stated that they had a good or very good knowledge of the diagnostic entity ‘panic disorder’. The term ‘panic disorder’ was not widely acknowledged among respondents. Forty-one (40%) of the respondents would not agree to using the term ‘panic disorder’ for the described syndrome (4 I % of the psychiatrists, 23% of the psychologists). The rejection of the term ‘panic disorder’ was particularly high (73%) in 22 respondents with psychoanalytical training compared to 17% of the 22 respondents with behaviourally-orientated training. The statement that “panic disorder is a new-fangled term without practical significance” was accepted by 13% of all respondents. When respondents were asked which alternative term they would use instead, most prefered terms like ‘anxiety neurosis’, ‘phobia’ or ‘heart neurosis’ (table II). To test whether respondents were familiar with

DSM/ICD classifications, the term ‘generalised anxiety’ was offered among a list of possible alternative

Of the 103 respondents questioned, 78 (76%) were physicians, 22 (217~) were psychologists, one subject was both physician and psychologist and two were neither

299

terms

for panic

disorder.

who only had a superficial DSM/ICD

classification

Even

respondents

knowledge of the

of anxiety

disorders

should know that ‘panic disorder’ and ‘generalised

300

B Bandelow

Table 1. Have you ever heard of the term ‘panic disorder”?

9

0

0

16 9 2x 39

II s 30 54

0 s 36 60

NO

Yes. Yes. Yes. Yes.

a little by chance well informed detailed knowledge

Table II. Terms preferred

by 31 respondents

Respondents were asked whether they thought that the DSM/ICD classification of anxiety disorders by symptomatology made sense. Fifty-eight percent considered this as advantageous, while 37% said it was better to classify anxiety disorders by aetiology (no answer: 5%). Preferred treatments Drugs and herbal preparations Most physicians preferred tricyclic antidepressants in panic disorder treatment (table III). Second in line, herbal preparations were prescribed. The prescribing pattern of psychiatrists and nonpsychiatric physicians differed considerably: 74% of the psychiatrists used tricyclic antidepressants, whereas only 24% of the nonpsychiatric physicians prefered these drugs. Herbal preparations and homoeopathic formulations were most popular among non-psychiatric physicians. Psychiatrists used more benzodiazepines than other physicians. Selective serotonin reuptake inhibitors, proposed by 24% of the psychiatrists, were very rarely prescribed by nonpsychiatric physicians (3%). Psychologists are not able to make prescriptions, and therefore have not been considered.

not using the term

‘pamc disorder’.

Anxiety neuro& Phobia Heart neurosis Hyperventllatlon syndrome Paroxysmal anxiety Nervous exhaustion

anxiety’ are clearly distinguished and should not be used as synonyms. Twenty-nine of the respondents proposed ‘generalised anxiety disorder’ as a synonym for panic disorder. Among the 69 respondents who had stated they were well informed about panic disorder, 29% wrongly proposed ‘generalised anxiety disorder’ as a synonym for panic disorder. Even of the persons indicating they had a very good knowledge of the disorder, 25% suggestedthe use of ‘generalised anxiety disorder’ as a synonym.

Table III. Percentage Drug

of different

groups

ywup

of physicians

All p/~~.~ic~ron

inhibitors

Psychological therapies In table IV it can be seen that respondents utilise many different psychological therapies for PDA patients. As many psychotherapists are educated in more than one treatment modality and sometimes apply these methods simultaneously, the percentages do not add up to 100. When the respondents were asked which of the methods that they do not apply they would consider as effective in panic disorder, a wide

who propose

% Trlcychc antidepressants Herbal preparations Benzodiazepines Neuroleptics Beta blockers Homoeopathic formulations Serotonin reuptake inhibitors Irreversible monoamine oxidase Others

et al

different \

drug groups

(more

than one choice

Norm-ps~r.hicrt,-ic, ph~.&icrns ‘7r

(n = 7Y)

Cn = 11)

38 30 33 24 20 IX I3 x I

23 16 32 20 I5 32 3 0 3

possible). Psychiarrisfs

(n =“,8) 74 29 45 29 26 3 24 16 3

Treatment Table

IV. Application

of psychological

therapies

and opinion

and definition

about other therapies

Psychoanalytic (psychodynamic) therapie\ Short psychoanalytical therapy Psychoanalysis Individual psychotherapy (Adlerian) ‘Catathymic image perception’ Behavioural orientated therapies Cognitive behaviour therapy Systematic desensitisation Coping strategies Exposure (flooding) Biofeedback Humanistic psychotherapies Client-centred psychotherapy (Rogerian) Dance and art therapy Music therapy Hypnosis Techniques applied by the patient Autogenic training Progressive relaxation

range of different methods were thought to be useful (table IV). Respondents using psychological therapies were then asked which method they would use first in treating panic disorder patients (table V). Psychodynamic therapy was the preferred treatment (44%). Client-centred psychotherapy (Rogerian) and cognitive/behaviour therapy were both proposed by 28% of the respondents applying psychological therapies. Psychologists clearly preferred cognitive/behaviour therapy over the other two major therapy schools (no differentiation was made between cognitive therapy and traditional behaviour therapy, because a complex mixture of the two is usually used in clinical practice). Among physicians. psychoanalysis was clearly preferred. When asked about proof of efficacy, 43% of the professionals utilising psychodynamic therapy as a first-line treatment for PDA patients were convinc-

Table

V. Respondent\

practising

Psychoanalysis Client-centred therapy (Rogerian) Cognitive/behaviour therapy

psychological

therapies

44 28 28

: treatment

301

of PDA (more

than one choice

possible).

35 37 3 13

2s I7 13 17

3.3 28 ?Y 26 I1

2’) 17 I7 19 24

47 5 4 I3

I7 16 35 20

33 37

37 16

ed that this method had been proven effective in controlled studies, whereas 89% of the behaviourally-orientated respondents considered that cognitive/behaviour therapy had been shown to be effective.

Comparison of pharmacological and psychological treatment modalities When asked about their opinion on the combined use of psychological therapies and drugs, 10% of the respondents considered that only psychological methods and no drugs should be used to treat PDA, whereas 1% thought that only drugs and no psychological methods should be used. Twentyeight of the respondents were of the opinion that a combination of drug and psychological treatments was a logical approach. Only 6% of the 103 respondents held the opinion that a combination of

modality

proposed

51 3.5 1

as first-line

therapy

51 33 6

9 9 64

302 Table

B Bandelow VI. PDA treatments

with proven

efficacy.

Dt7Ag.S

Psychological

Benzodiazepines Tricyclic antidepressants Irreversible monoamine oxidase inhibitors Selective serotonin reuptake inhibitors

Exposure Cognitive

therrpes

therapy therapy

drugs and psychological therapies was ineffective, and only 4% of respondents thought the combination to be obsolete. Five percent of the physicians compared to 32% of the psychologists considered that drugs were ineffective in PDA. On the other hand, 4% of the physicians and none of the psychologists thought that psychological therapies were ineffective. DISCUSSION Efficacy

of PDA treatments

The treatment modalities for panic disorder and agoraphobia (PDA) preferred by professionals have to be judged in the light of existing studies that have shown the efficacy of certain pharmacological and psychological treatments. Because a high placebo response rate can be expected in panic disorder (Rosenberg et al, 1991), only the results of the studies involving a drug placebo, a ‘psychological placebo’ or a ‘waiting list’ condition as a control should be considered when judging the efficacy of a treatment (see table VI for overview). Among the drugs proven to be effective against PDA in many controlled studies are benzodiazepines such as alprazolam (Ballenger et al, 1988), tricyclic antidepressants like imipramine (CNCPS. 1992) and clomipramine (Johnston et al, 1988>, the irreversible MAO-inhibitor phenelzine (Sheehan et al, 1980), and selective serotonin reuptake inhibitors like fluvoxamine (Black et al, 1993). For other drug groups, proof of efficacy is less consistent. In Europe, neuroleptics like sulpiride or fluspirilene are widely used in the treatment of anxiety disorders. Efficacy of neuroleptics in anxiety neuroses has been shown in many older studies in the 1970s and 1980s (eg. Laakmann et al, 1988), but no studies have used patient samples comparable with the DSM definition of PDA. Neuroleptics were not considered as possible treatment for PDA by a National Institute of Health consensus conference

et al

( 1991). Treatment with beta blockers such as propranolol has led to conflicting results (Munjack et al, 1989; Ravaris et al, 1991). For herbal preparations (Piper methysticum or Hypericum perforuturn) or homoeopathic formulations, no controlled studies pertinent to anxiety disorders have been published. Among psychological treatments, cognitive/behaviour therapies have consistently shown efficacy in PDA (Barlow, 1994; Clark, 1994). Within the group of behaviourally-orientated therapies, techniques that use in vivo exposure to feared situations have shown the best results in patients with agoraphobia (Marks, 1987). Exposure therapy has its limitations, because many patients have panic disorder without agoraphobia and many agoraphobics do not only experience their panic attacks in feared situations, but have unexpected panic attacks as well. To target panic attacks directly, cognitive treatment methods have been developed and proven effective (Clark, 1994). These methods aim at changing the patients’ misinterpretations of benign bodily sensations. Other behavioural methods like systematic desensitization (Wolpe, 1958) or progressive relaxation (Jacobson, 1938) were found to be less effective than exposure (Marks, 1987; Marks et al, 1983, 1993). Investigations on the efficacy of psychological anxiety treatments other than cognitive/behaviour therapy are rarely found. The efficacy of psychodynamic therapy in panic disorder has been regarded as unproven by a consensus conference of the National Institute of Health (1991). The only study investigating psychodynamic treatment of panic disorder compared a combination of psychodynamic therapy and exposure with pure psychodynamic therapy. The combination was found to be superior (Hoffart and Martinsen, 1990). Client-centred psychotherapy (Rogers, 195 l), individual therapy (Adler, 1933), ‘catathymic image perception’ (Leuner, 1981), dance, music or art therapy (Bolay, 1983; Duggan, 1983; Levick, 1983), hypnosis, autogenic training (Schultz, 1987), and biofeedback (Hatch and Saito, 1990) have never been investigated in controlled studies with DSM-defined PDA patients. To be complete, anxiety studies performed before the DSM-III era ( 1980) should also be considered. However, a comprehensive meta-analysis of various psychological therapies by Grawe et al (1994) revealed that for anxiety patients. proof of efficacy for longterm psychoanalytical therapy, ‘catathymic image perception’, individual therapy, dance or art therapy, autogenic training, and biofeedback are

Treatment

and definition

weak. Short psychoanalytical treatment and clientcentred psychotherapy were shown to be effective, but less effective than behavioral methods (Grawe et al, 1994). Comparisons psychological

between drug treatment therapies

and

Controlled comparisons of pharmacological with psychological treatments of PDA are rare. Superiority of psychological treatments was found in two studies (Marks et al, 1983, 1993). Superiority of drug treatment was also found in two studies (Klein et al, 1987; Black et al, 1993). No difference between drugs and psychological therapy was found in three studies (Telch et al, 198.5; Mavissakalian and Michelson, 1986a; Klosko et al, 1990). A study by Clark et al (1994) is difficult to interpret because co-medications such as benzodiazepines were allowed in all treatment groups. When pharmacological and psychological treatments are compared, whether a treatment has effects that last beyond the period of treatment itself is also an important consideration. In one follow-up study comparing drugs and exposure therapy (Marks et al, 1993), exposure was more effective after treatment termination than alprazolam. In two studies, no difference between drug and psychological therapy was found on follow-up (Marks et al, 1983; Mavissakalian and Michelson, 1986b). Acceptance entity

of ‘panic

disorder’

as a diagnostic

Forty percent of all respondents did not agree with using the term ‘panic disorder’ (41% of the psychiatrists, 23% of the psychologists), This may partly be due to the fact that in Germany the valid diagnostic system is still the ICD-9 (World Health Organisation, 1978) in which panic disorder had not yet been introduced. Furthermore, the introduction of the new DSM definitions of anxiety disorders has aroused much controversy and scepticism. The former term ‘neurosis’ has been abandoned because it presumes a certain aetiological explanation of the disorder (eg, psychic trauma in childhood). This may be the reason why the term ‘panic disorder’ was rejected in particular by psychoanalytically-orientated respondents (73%). DSM classifications are strictly symptom-orientated. Only 58% of the respondents indicated that classifying anxiety disorders by syndromal appearance and not by aetiology was advantageous. Respondents were explicitly informed that they had to indicate their preferred treatment strategy

303

of PDA

for ‘panic disorder’. An alternative strategy would have been to present a case example and then to ask respondents to indicate how they would treat this case. We refrained from using thjs method, as in a comparable investigation the correct diagnosis ‘panic disorder’ was made by only 2% of the total respondents and by only 12.5% of the psychiatrists (Satoh and Fujii, 1992). Preferred

treatments

Considering the lack of agreement over diagnosis, it is no wonder that the preferred treatment has not been agreed upon by the persons treating PDA patients. The physicians’ prefences differ considerably from the recommendations given in the international literature concerning drug therapy for panic disorder. Herbal preparations and homoepathic formulations have never been proven effective in controlled studies, but seem to be widely used in PDA patients. Other drugs such as neuroleptics and beta blockers, which are not considered as first-line treatments for panic disorder, have often been proposed as possible treatments. Psychiatrists showed a more adequate prescribing profile than non-psychiatric physicians: Tricyclic antidepressants were used three times more frequently by psychiatrists than by non-psychiatric physicians. Benzodiazepines were used second in line by the psychiatrists. Non-psychiatric physicians prefer herbal preparations and homeopathic formulations. The differences in prescribing patterns may partly be due to the fact that non-psychiatric physicians usually treat the less severe cases of panic disorder. On the other hand, it may be assumed that the psychiatrists’ prescribing pattern is determined by a better knowledge of the results of efficacy studies. When examining proposed psychological therapies, underutilisation of effective methods is even more striking. Though sufficient proof of efficacy exists only for cognitive/behaviour therapies, these treatment modalities are proposed less often than psychodynamic therapy. Preference for psychological treatment seems to be influenced less by the literature on treatment efficacy than by guesswork, tradition and ideology. In general, psychologists favour cognitive behaviour therapy and physicians prefer psychodynamic therapy. For instance, ‘music therapy’ is thought to be useful in panic disorder by 25% of the respondents, though only one (positive) efficacy study has ever been performed with music therapy in geriatric patients (Grawe et al, 1994). The representativity of the study may be limited, as only 25% of the persons surveyed responded. It

304

B Bandelow

may be speculated that the questionnaires were mostly completed by those people who were more knowledgable as regards subject matter, and that therefore the results of the survey were biased in this direction. Much effort has been put into controlled studies on the efficacy of panic treatments. For the benefit of the patients concerned, the results of these investigations should be accepted by persons treating PDA patients in order to improve treatment success. Acceptance of the modern DSM/ICD classification of anxiety disorders by health-care professionals treating these patients would constitute a major step in the right direction. ACKNOWLEDGMENT The results published in this paper al thesis of Mrs M RGthemeyer.

are part

of the doctor-

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