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Original Investigation |

Prevalence and Correlates of Panic Attacks in Postmenopausal Women:  Results From an Ancillary Study to the Women's Health Initiative FREE

Jordan W. Smoller, MD, ScD; Mark H. Pollack, MD; Sylvia Wassertheil-Smoller, PhD; Bruce Barton, PhD; Susan L. Hendrix, DO; Rebecca D. Jackson, MD; Tammy Dicken, LPN; Albert Oberman, MD, MPH; David S. Sheps, MD, MSPH
[+] Author Affiliations

From the Department of Psychiatry, Massachusetts General Hospital, Boston (Drs Smoller and Pollack); the Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, NY (Dr Wassertheil-Smoller); the Maryland Medical Research Institute, Baltimore (Dr Barton); the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Mich (Dr Hendrix); the Department of Internal Medicine, Ohio State University, Columbus (Dr Jackson); the Division of Cardiovascular Medicine, Veterans Affairs Medical Center, University of Florida School of Medicine, Gainesville (Ms Dicken and Dr Sheps); and the Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham School of Medicine (Dr Oberman). The authors have no relevant financial interest in this article.


Arch Intern Med. 2003;163(17):2041-2050. doi:10.1001/archinte.163.17.2041.
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Background  Panic attacks are known to be more common in women than in men, but the prevalence and correlates of panic in the postmenopausal period have not been well defined.

Methods  Cross-sectional survey of 3369 community-dwelling postmenopausal women enrolled between December 1, 1997, and November 30, 2000, in the Myocardial Ischemia and Migraine Study, a 10-center ancillary study of the 40-center Women's Health Initiative. Participants, aged 50 to 79 years and predominantly white (73%), completed questionnaires about the occurrence of panic attacks in the previous 6 months and about migraine headaches and underwent 24-hour ambulatory electrocardiographic monitoring. The 6-month prevalences of full-blown and limited-symptom panic attacks were calculated, and their associations with other sociodemographic and clinical variables were examined in multivariate analyses.

Results  One of the panic attack types was reported by 17.9% (95% confidence interval, 16.6%-19.2%) of women (full-blown attacks, 9.8%; limited-symptom attacks, 8.1%). Adjusting for age and race or ethnicity, full-blown panic attacks were more common in women with a history of migraine, emphysema, cardiovascular disease, chest pain during ambulatory electrocardiography, and symptoms of depression. Full-blown panic attacks were associated in a dose-response manner with negative life events during the past year. Panic attacks were associated with functional impairment even after adjusting for comorbid medical conditions and depression. There was no significant association with self-reported use of hormone replacement therapy.

Conclusions  Panic attacks may be relatively common among postmenopausal women and seem to be associated with stressful life events, medical comorbidity, and functional impairment.

PREVIOUS RESEARCH has established that panic attacks and panic disorder are more common in women than in men,1 but relatively little is known about the frequency of panic after menopause. The most recent large-scale epidemiologic survey of psychiatric disorders in the United States, the National Comorbidity Survey (NCS),2 did not include individuals older than 54 years. The earlier Epidemiologic Catchment Area (ECA) study3 included older adults and found the lowest prevalence of panic attacks and panic disorder in those 65 years and older. In an analysis of 3 ECA sites, the 6-month prevalence of simple panic attacks ranged from 0% to 3.7%,4 and the lifetime prevalence of panic disorder in women 65 years and older across 5 ECA sites was only 0.67%.5 During perimenopause, a period of change in reproductive hormone levels, somatic symptoms (eg, vasomotor symptoms and sleep disturbance) and psychological symptoms (eg, dysphoria, anxiety, and irritability) are relatively common.6 Although some studies have reported a perimenopausal increase in depression (for reviews see Pearlstein et al7 and Burt et al8), the prevalence of anxiety and panic during this period has received less attention. In a Scottish population-based survey6 of 8000 women aged 45 to 54 years, 23% of respondents who had experienced natural menopause reported that anxiety had been a problem for them during the past 6 months. However, 2 prospective studies9,10 in which women were assessed before and after the onset of menopause found no significant increase in anxiety symptoms. Panic attacks are a distinctive form of anxiety, and, to our knowledge, their prevalence specifically among postmenopausal women has not been documented.

We surveyed a subset of women participating in the largest-ever study of postmenopausal women in the United States, the Women's Health Initiative (WHI).11 More than 3000 women participating in the Myocardial Ischemia and Migraine Study (MIMS), an ancillary study of the WHI, were surveyed about the occurrence of panic attacks in the previous 6 months. This article describes the prevalence and correlates of panic attacks in these women. Further analyses of the relationship between panic and cardiovascular and other health measures will be described in future articles.

PARTICIPANTS

Participants in the MIMS were drawn from among the 93 676 postmenopausal women aged 50 to 79 years enrolled in the observational study (OS) of the WHI.11 The WHI is a 40-center study of the major health problems affecting older women. The study has 2 components: a set of randomized controlled clinical trials and a parallel, long-term OS. The clinical trials will evaluate the effect of a low-fat dietary pattern, the effects of hormone replacement therapy, and the effect of calcium and vitamin D supplementation on the various outcomes of breast and colorectal cancer, coronary heart disease, and osteoporotic fractures. Women were enrolled in the concurrent long-term OS to delineate new risk factors and biological markers for disease in women. The MIMS is a 10-center ancillary study of the WHI to investigate the relationship among 3 putative risk factors for cardiovascular disease in a subsample of WHI-OS participants: migraine headaches, panic attacks, and daily life ischemia as measured by 24-hour ambulatory electrocardiography (AECG).

Women were recruited into the MIMS at their baseline or first follow-up visit for the WHI-OS. All women in the OS who agreed to 24-hour AECG and who completed the additional questionnaires were eligible. After a complete description of the study, written informed consent was obtained. There were 3372 women enrolled in the MIMS who completed the migraine questionnaire and had WHI baseline data, of whom 3132 had AECGs that were read at the ECG center; 3369 women completed the panic questionnaire. These data were collected between December 1, 1997, and November 30, 2000.

PROCEDURE

Participants were asked to complete an Anxiety Questionnaire, which begins with 2 screening questions adapted from those used in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), panic disorder field trial12,13 referring to the past 6 months. The first question asks whether the participant has experienced a sudden attack of feeling frightened, anxious, or extremely uncomfortable; the second asks whether she has experienced a sudden episode of rapid or irregular heartbeats. If the answer to either of these questions is "yes," the participant is asked which panic attack symptoms occurred during the most recent bad episode. Owing to a clerical error, the panic symptom of sweating was inadvertently omitted from this symptom list (see the "Definition of Variables" subsection), so that the panic symptom checklist included 12 rather than 13 panic attack symptoms.

Participants were also asked to complete a 13-item Migraine Status Questionnaire that asked about the history and features of headaches lasting more than 4 hours, history of physician-diagnosed migraine headache, and family history of migraine.

Finally, participants were fitted with an AECG Holter monitor, which they wore for 24 hours, including during usual daily activities. Participants were instructed to press the event marker on the AECG recorder if they experienced chest pain while wearing the Holter monitor. At the end of the 24-hour recording period, participants completed a questionnaire asking about any episodes of chest pain, headaches lasting 4 or more hours, medications, and ratings on their peak and average levels of physical activity and mental stress during the recording period. The AECG recordings were made using a Zymed 2010/2010 plus series Holter analysis system, which uses the digitrak Holter monitor (Zymed, Camarillo, Calif) and were transmitted over telephone lines to the AECG Core Laboratory at the University of Florida, Gainesville.

In addition to the data described previously, sociodemographic and clinical covariates obtained as part of the WHI-OS were examined in the MIMS women. Clinical variables included history of comorbid medical conditions and medical treatments, a measure of current depression,14 quality of life as measured by the Rand 36-Item Health Survey,15 and self-reported history of smoking, alcohol and coffee intake, and hormone use.

The measure of depression14 was an 8-item screening instrument that incorporates 6 items from the Center for Epidemiological Studies Depression Scale16 and 2 items from the Diagnostic Interview Schedule.17 A logistic regression prediction equation was used to assign a scale score based on a weighted combination of item responses. A cutoff score of 0.06 has demonstrated good sensitivity and specificity for detecting depressive disorder in the past month in primary care and mental health user populations14 and was therefore used to define positive depression screen findings in our sample.

DEFINITION OF VARIABLES

Two types of panic episodes were defined on the basis of responses to the anxiety questionnaire. Full-blown panic was defined as reporting an attack of sudden fear, anxiety, or extreme discomfort during the past 6 months accompanied by 4 or more panic attack symptoms from the 12-symptom checklist. Limited-symptom panic was defined as full-blown panic except that fewer than 4 panic symptoms were endorsed. A third response category, "indeterminate panic," comprised women who endorsed only the second screening question (a sudden episode of rapid or irregular heartbeats in the past 6 months but not an attack of fear, anxiety, or extreme discomfort) accompanied by 4 or more panic symptoms. This second screening question had been included in the DSM-IV field trial of panic disorder based on previous evidence that it might detect individuals with true panic attacks or panic disorder who do not endorse the traditional screening question about anxiety attacks.18 Thus, the group that endorsed only this autonomic symptom screen along with 4 or more panic symptoms likely included a mixture of women with and without true panic attacks, and we considered their status indeterminate with respect to panic. Any panic was defined as a 6-month history of either full-blown or limited-symptom episodes of panic. The no panic group, used as a comparison group in logistic regression analyses, consisted of women who were not classified as having either of the 2 types of panic defined in the previous sentences and who were not in the indeterminate category. As noted in the "Procedure" subsection, the symptom of sweating was inadvertently omitted from the panic symptom checklist. We therefore calculated panic attack prevalence in 2 ways: (1) "conservative" prevalence was the proportion of women who met the respective panic attack type criteria using the 12-symptom checklist (without sweating), and (2) "upper-bound" prevalence was the prevalence of the respective panic attack types assuming that all women would have endorsed sweating as a symptom of their panic episodes. Multivariate analyses were performed using only the conservative definitions of panic attacks.

Migraine variables were defined using modified International Headache Society criteria.19 Migraine with aura was defined as headaches lasting more than 4 hours, with pain mostly on one side of the head or a headache that was throbbing, pulsating, or pounding, and accompanied by nausea or vomiting or being bothered by bright lights and having such headaches for more than 1 year or having 5 or more in 1 year and having spots, jagged lines, or "heat waves" in either or both eyes before the headache. Migraine with no aura was defined similarly except for the last item, that is, no spots before headache were reported.

We hypothesized that panic attacks would be associated with several medical comorbidities that have been linked to panic in studies of other age groups and populations: obstructive pulmonary disease,20 cardiovascular disease (and related symptoms and risk factors),21 thyroid disease,22 and migraine headache.23 Self-report of physician-diagnosed conditions (in answer to the question, "Has a doctor ever told you that you had [condition]?") was used to assess a history of emphysema, asthma, cardiovascular disease, angina, hypertension, diabetes mellitus, and thyroid problems (including overactive and underactive thyroid). Body mass index was measured at the first clinic visit, and migraine headaches and chest pain during AECG monitoring were assessed as described in the "Procedure" subsection.

Because panic attacks and panic disorder have previously been associated with functional limitations and impairments in quality of life,24 we examined whether panic attacks were associated with impaired social and role functioning in this sample of postmenopausal women. Impairment in social functioning was assessed by 2 questions from the RAND 36-Item Health Survey15 asking to what extent and how much of the time physical health or emotional problems interfered with usual social activities with family, neighbors, friends, or groups in the past 4 weeks. Role limitations due to emotional problems were assessed with the question, "In the past 4 weeks, as a result of any emotional problems (feeling depressed or anxious), have any of the following occurred: (1) you cut down on the amount of time you spent on work or other activities, (2) you accomplished less than you would have liked, or (3) you did work or other things less carefully than usual?" These variables were dichotomized to indicate no role limitations or any role limitations.

Life events were assessed by 12 items asking about the death or serious illness of a spouse, partner, family member, friend, or pet; divorce or a friend's or family member's divorce; problems with money; major conflicts with children or grandchildren; accidents, muggings, disasters, and unwanted sexual experiences; job loss or a close friend's or family member's job loss or retirement; and physical or verbal abuse by a close friend or family member. The scale is based on that used in the Alameda County Study,25 which was later modified and used in the β-Blocker Heart Attack Trial in patients after myocardial infarction26 and modified by the WHI to add items on domestic violence. The score used for analysis was the sum of the life events.

DATA ANALYSIS

Prevalence estimates (and their 95% confidence intervals [CIs]) of any, full-blown, or limited-symptom panic were determined for the overall sample of 3369 women and by age and race or ethnicity. Multivariate logistic regression was used to compute odds ratios (ORs) adjusted for age and race or ethnicity. Odds ratios were computed by comparing each panic group with the reference group of women who reported no panic, that is, excluding those with full-blown, limited-symptom, or indeterminate panic, except as otherwise noted.

BASELINE CHARACTERISTICS

Table 1 gives the sociodemographic composition of the MIMS sample and of the entire OS cohort for comparison. Approximately two thirds of the sample was 60 years or older. The women were predominantly white (73%) and relatively well educated (46% had a college degree or higher). Nevertheless, 32% of the sample had low-middle incomes (<$35 000 annual household income) and 12% had incomes of less than $20 000. The MIMS sample is enriched for Asians and Pacific Islanders (16.1%) compared with the WHI-OS population (2.9%) because 1 of the 10 clinics participating in the MIMS was in Honolulu, Hawaii, where 69% of the overall OS population is Asians and Pacific Islanders. In other respects, the MIMS sample is similar to the full OS cohort of 93 676 women. The OS cohort is somewhat healthier than a probability sample of US women aged 50 to 79 years in the NHANES III (third National Health and Nutrition Examination Survey) cohort.27 In that cohort, 10.0% of participants reported receiving treatment for diabetes mellitus with insulin or pills, 5.6% reported they had been told by a physician that they had a previous myocardial infarction, and 4.6% were told that they had a previous stroke (compared with our OS cohort, for which the values are 4.2%, 2.5%, and 1.5%, respectively).

Table Graphic Jump LocationTable 1. Sociodemographic Characteristics of Women in the MIMS Sample and of the Full Cohort of the WHI-OS
PREVALENCE OF PANIC ATTACKS

Of the 3369 women who completed the panic questionnaire, 17.9% (95% CI, 16.6%-19.2%) reported experiencing 1 of 2 panic attack types in the past 6 months. Full-blown panic attacks were reported by 9.8% (95% CI, 8.8%-10.8%) of participants, whereas limited-symptom attacks were reported by 8.1% (95% CI, 7.2%-9.0%). The upper-bound prevalence values (assuming all women who endorsed the panic attack stem question would have also endorsed sweating had it been included) were 19.6% (95% CI, 18.3%-20.9%) for any panic, 13.0% (95% CI, 11.9%-14.2%) for full-blown attacks, and 6.6% (95% CI, 5.7%-7.4%) for limited-symptom attacks. All subsequent analyses use the conservative definition of panic attacks in which it is assumed that none of the women would have endorsed sweating as a panic symptom. The prevalence of full-blown panic attacks was highest in the youngest age group (aged 50-59 years) (Table 2).

Table Graphic Jump LocationTable 2. Six-Month Prevalence of Panic Attacks, by Age and Race or Ethnicity
SOCIODEMOGRAPHIC ASSOCIATIONS WITH PANIC ATTACKS

Table 3 gives the association between panic attack subtypes and sociodemographic and lifestyle characteristics. Compared with women in the 50- to 59-year-old group, adjusting for race or ethnicity, older women were significantly less likely to report full-blown panic attacks but not limited-symptom panic attacks. White, black, or Hispanic race or ethnicity was not significantly associated with panic attacks after adjustment for age, but Asians and Pacific Islanders were significantly less likely to report full-blown or limited-symptom panic attacks than were white women. There were only 11 women who self-reported being American Indian or Alaskan native. Consequently, their data were combined with those of women whose race or ethnicity was unspecified to use the full data set in stable multivariate models, but results for this combined group itself are not meaningful and are omitted from Table 3. Lower-income women (annual income <$20 000) were 2.7 times more likely to report full-blown panic attacks, after adjustment for race or ethnicity and age, than those with higher incomes. There was no significant relationship between marital status and 6-month prevalence of panic attacks and no consistent relationship with education level.

Table Graphic Jump LocationTable 3. Sociodemographic and Lifestyle Variables Associated With Panic Attacks
ASSOCIATION WITH HABITS, LIFESTYLE VARIABLES, AND USE OF HORMONE REPLACEMENT THERAPY

Current smoking, after adjustment for age and race or ethnicity, was associated with full-blown panic (OR, 2.00; 95% CI, 1.30-3.06), whereas alcohol and coffee intake were not (Table 3). Consistent with the idea that adverse life events may trigger panic attacks, the number of life events during the past year was strongly associated with 6-month prevalence of panic attacks. Full-blown and limited-symptom panic attacks were highly and significantly related to the number of negative life events during the past year, with those having 5 or more such events being 6.9 times more likely to report full-blown panic attacks (95% CI, 4.05-11.65) and 3.1 times more likely to report limited-symptom attacks (95% CI, 1.61-6.02).

Finally, we also examined whether the prevalence of panic attacks is associated with hormone replacement therapy in postmenopausal women. Adjusting for age and race or ethnicity, we found no significant relationship between self-reported past or current hormone replacement therapy and panic attacks.

COMORBIDITY

We examined whether comorbid medical conditions were associated with risk of panic attacks in these women (Table 4). Consistent with previous evidence28 that pulmonary disease may be a risk factor for the development of panic disorder, we found that panic attacks were more likely to be reported by women with a history of emphysema (OR, 4.13; 95% CI, 2.65-6.43). Women with a history of asthma were also more likely to report limited-symptom and full-blown panic attacks. We also found an association between full-blown panic and a history of cardiovascular disease (OR, 2.92; 95% CI, 2.24-3.80), angina (OR, 4.13; 95% CI, 2.68-6.38), and reported chest pain during 24-hour AECG monitoring (OR, 2.55; 95% CI, 1.87-3.48). Of the 3 cardiovascular risk factors examined, body mass index was also associated with full-blown panic (OR, 1.03 per unit increase in body mass index; 95% CI, 1.01-1.05), whereas hypertension and diabetes mellitus were not. Full-blown panic attacks were associated with a history of thyroid problems (OR, 1.47; 95% CI, 1.14-1.89), including a self-reported history of underactive thyroid problems (OR, 1.51; 95% CI, 1.12-2.04) and overactive thyroid (OR, 1.80; 95% CI, 1.02-3.17).

Table Graphic Jump LocationTable 4. Association of Panic Attacks With Comorbid Conditions

The strongest association with panic attacks was observed for a history of migraine with aura. Women who reported such a history were more than 6 times more likely to report full-blown panic than were women without headaches (OR, 6.44; 95% CI, 4.68-8.85). Migraine without aura was also associated with full-blown panic, although less strongly (OR, 2.83; 95% CI, 2.00-4.00). Finally, current depression, as defined by the depression screening instrument, was significantly associated with full-blown panic attacks (OR, 5.32; 95% CI, 4.01-7.05) but not with limited-symptom panic. Thirty-one percent of women with full-blown panic had accompanying symptoms of depression compared with 10% of those with limited-symptom panic and 7.3% of those with no panic (P<.001 for both).

ASSOCIATION OF PANIC ATTACKS WITH SOCIAL IMPAIRMENT AND ROLE LIMITATIONS

Table 5 indicates that women who reported full-blown panic attacks in the previous 6 months were more likely to report impairment in social functioning in the past 4 weeks (OR, 2.51; 95% CI, 1.86-3.39) and role limitations due to emotional problems (OR, 1.84; 95% CI, 1.35-2.50), after controlling for age and race or ethnicity and other variables that were univariately associated with panic attacks and each of these 2 quality-of-life outcomes. Limited-symptom panic attacks also seemed to be associated with impaired social functioning (OR, 1.42; 95% CI, 1.04-1.94) and role limitations (OR, 1.56; 95% CI, 1.12-2.17), although to a lesser degree than full-blown panic attacks.

Table Graphic Jump LocationTable 5. Association of Panic Attacks With Functional Impairment

To our knowledge, this study is the largest survey of the prevalence and correlates of panic attacks in postmenopausal women.

PREVALENCE OF PANIC ATTACKS

In this sample of 3369 women, 9.8% reported a full-blown panic attack within the past 6 months. Limited-symptom panic attacks, which have been reported to confer a similar risk of phobic and functional complications,29,30 were reported by an additional 8.1% of participants. This prevalence is higher than that reported in other population-based samples that have included women in a similar age range. For example, an analysis4 from 3 ECA sites found the unadjusted 6-month prevalence of simple panic attacks to range from 0% to 3.7% among women older than 65 years and from 4.5% to 7.9% among those aged 45 to 64 years. In fact, the 6-month prevalence of panic attacks in the present study was comparable to the overall lifetime prevalence (9.7%) reported in the ECA study.5 The more recent NCS included only individuals aged 15 to 54 years and estimated the lifetime prevalence of panic attacks to be 7.3%.1 The discrepancy in prevalence estimates in our study compared with the ECA and NCS studies may be due in part to differences in methods of assessment. The ECA and NCS studies used structured diagnostic interviews, in contrast to the self-report questionnaire used in the present study. It may be that women are less likely to report panic symptoms in a face-to-face interview than on a questionnaire. In addition, the definition of a full-blown panic attack used in this study is somewhat broader than that used in the ECA and NCS studies. The stem question in the Diagnostic Interview Schedule used in the ECA study was, "Have you ever had a spell or attack when all of a sudden you felt frightened, anxious, or very uneasy in a situation when most people wouldn't be afraid?" Individuals diagnosed as having "simple panic attacks" were those who responded positively to this stem question and endorsed at least 4 of 12 symptoms of panic. The italicized phrase in the stem question implies that the panic episode is spontaneous. The panic attacks reported by women in the present study did not include the italicized phrase and thus may have captured "situationally bound" panic attacks (eg, in the presence of a phobic stimulus). The NCS study used a modified version of the Composite International Diagnostic Interview2 and defined panic attacks as unexplained fearful spells (which corresponded to the ECA concept of simple panic attacks) but also required a crescendo quality to the panic symptoms (ie, they are limited to only a few minutes).1 The lifetime prevalence of intense fearful spells (sudden unexplained fear without the crescendo feature) was 11.3% in the NCS.1 In the present study, we based our panic screen on screening questions used in the DSM-IV field trial13 supplemented by the checklist of panic attack symptoms corresponding to those used to define panic attacks in the DSM-IV.31 In the field trial, 72% of individuals who screened positive met DSM-III-R or DSM-IV criteria for panic disorder on structured clinical interview, whereas 28% were "infrequent panickers" who did not meet disorder criteria.13 Panic disorder and infrequent panic were associated with excess functional disability in that study.12 Thus, our panic screen seems likely to have identified women with functionally significant panic symptoms.

Our results might also differ from those of previous epidemiologic studies because the WHI-OS, from which the MIMS sample was derived, is somewhat healthier than the probability sample of the US population as determined in NHANES III.27 To the extent that comorbid medical conditions are associated with panic attacks, this difference might be expected to result in an underestimate of panic attack prevalence. Thus, we believe that the rates we observed may be a conservative estimate of panic in postmenopausal women.

Our data suggest that the occurrence of panic attacks in older women is relatively common, consistent with findings from previous smaller studies of panic in later life. In a study of 70 older adults (mean age >80 years, 83% women) from retirement communities, Deer and Calamari32 reported a 1-year prevalence of 27% for panic attacks, although no cases of panic disorder were observed. In that study, anxiety sensitivity (a fear of somatic anxiety-related symptoms) was a predictor of panic symptoms. Among women with high anxiety sensitivity, somatic symptoms associated with perimenopause or menopause and medical illness in the elderly may potentiate panic attacks. Other predisposing features of the postmenopausal period may include stressful life transitions (eg, retirement and widowhood), and, consistent with this, we observed a dose-response relationship between the number of negative life events in the preceding year and the 6-month prevalence of panic attacks.

Because the present data are cross-sectional, we do not know whether the onset of panic attacks in the women we studied was premenopausal or postmenopausal. The age of onset for panic attacks and panic disorder is typically in the second or third decade of life,4,33 although there may be a bimodal distribution with a later peak between ages 45 and 54 years.1 However, a 13- to 15-year follow-up of 1920 participants in the Baltimore ECA study34 found no new cases of panic disorder among those older than 65 years. In a clinical sample, more than half of the elderly individuals with panic attacks and panic disorder reported symptom onset after age 60 years.35 Compared with earlier-onset cases, late onset of panic attacks and panic disorder (after age 50-60 years) has been associated with lesser severity,36 less use of mental health services,37 and lower levels of psychiatric comorbidity37 but higher levels of medical comorbidity.35

We found that panic attack prevalence was highest in the youngest age group of these postmenopausal women. This is consistent with data from the ECA study,5 which found the lowest prevalence of panic disorder in individuals older than 65 years. In our sample, the highest prevalence was observed in women aged 50 to 59 years, the group likely to be closest to perimenopause, a time when hormonal changes, psychological distress, and somatic symptoms may be greatest.7 If panic, like depression, is associated with increased mortality rates in older adults, the age-dependent decline in panic prevalence might also be attributable in part to decreased survival, although longitudinal studies are required to evaluate this hypothesis. Consistent with the ECA and NCS studies,1,5 we found little evidence for an effect of race or ethnicity on panic attack prevalence but, as in the NCS, a higher prevalence of attacks in women in the lowest income group. The relationship between education level and panic attack prevalence was nonlinear, with the highest risk in those who had not completed high school.

RELATIONSHIP TO COMORBID DISORDERS

There has been considerable interest in the association between panic attacks and medical comorbidities, particularly pulmonary and cardiovascular disease. Previous studies have documented an excess risk of panic disorder in patients with obstructive airways disease (including asthma and emphysema),38 and there is evidence that pulmonary disease may be a risk factor for the development of panic disorder.28 Consistent with this literature, we found that women with a reported history of asthma or emphysema were more likely to report panic attacks. In the absence of data on the age of onset of panic and pulmonary disease in these women, we cannot address whether there is a temporal or causal relationship between the two.

An excess risk of panic disorder among patients with coronary heart disease has also been reported previously.21 In our sample, a history of cardiovascular disease was associated with a nearly 3-fold increased likelihood of panic attacks in the past 6 months. An association of similar magnitude was seen between chest pain during AECG monitoring and panic attacks. Because cardiopulmonary symptoms are central features of panic attacks, it is possible that panic attacks reported by women with a history of cardiac or pulmonary disease were actually symptoms of their underlying medical illness. However, results of previous studies,3943 most of which have examined men, have suggested that anxiety is a risk factor for subsequent fatal or nonfatal coronary heart disease. The present study is the first, to our knowledge, to document an association between panic and cardiovascular disease specifically in postmenopausal women. The mechanisms behind this relationship are the subject of ongoing investigation. In patients with a history of coronary artery disease, mental stress–induced myocardial ischemia has been shown to be a predictor of fatal and nonfatal cardiac events.44 In addition, numerous studies4548 have documented evidence of altered cardiac autonomic balance (decreased vagal tone or increased sympathetic heart rate control) in individuals with panic or phobic anxiety, suggesting a possible explanation for an elevated risk of sudden death.

The strongest relationship between panic attacks and comorbid medical conditions was observed for migraine headaches with aura. Women who reported such headaches were 6.4 times more likely to report full-blown panic attacks than were women without headaches. Several studies have previously documented excess comorbidity between panic disorder and migraine and other chronic daily headache syndromes,23,4951 and some have suggested shared genetic or environmental causes.23,49,52 Consistent with previous research,49 migraine with aura was somewhat more strongly associated with panic attacks than was migraine without aura. Previous studies have addressed the etiologic relationship between panic and migraine. Longitudinal data from community samples have documented that panic and other anxiety disorders may either precede the onset of migraine23,49,51 or follow it.48 In a recent analysis of a population-based sample of 1287 persons aged 25 to 55 years, Breslau and colleagues23 found that migraine headaches were a risk factor for and a sequela of panic disorder. This bidirectional relationship is consistent with the hypothesis that genetic or environmental effects on the 2 conditions are overlapping. Thus far, however, family study data49 have not supported the hypothesis that migraine and anxiety/affective disorders represent alternate expressions of a common genetic diathesis. Migraine and panic disorder have been associated with dysregulation of serotonergic neurotransmitter systems,53,54 suggesting a possible neurobiological connection between them. Although the cross-sectional nature of the present data does not allow us to evaluate whether the observed association between migraine and panic represents a causal relationship, this study is the first to extend the reported connection between migraine and panic to a large sample of postmenopausal women.

Our study also documented the well-established association between depression and panic attacks.55,56 Women who screened positive on the depression screening instrument were 5 times more likely to report full-blown panic attacks in the past 6 months than were those who did not, although this relationship did not exist for limited-symptom panic. The screening instrument is not intended to establish a clinical diagnosis of major depression. In a recent study57 of a sample of WHI participants, the positive predictive value of the screen was relatively low for a diagnosis of current major depression or dysthymia when measured against a structured clinical interview. Thus, the association we observed may apply to depressive symptoms rather than clinically diagnosable major depression.

FUNCTIONAL SIGNIFICANCE OF PANIC

The significance of panic attacks in these postmenopausal women is underscored by the finding that full-blown panic attacks are strongly associated with limitations in social and emotional functioning (Table 5), even after controlling for psychiatric (depression) and medical comorbidities. Our results accord with previous research12 documenting that even infrequent panic attacks are associated with substantial comorbidity and disability. In a study of primary care patients, Katon and colleagues12 found that patients who had at least 1 panic attack within the past 6 months resembled those with DSM-III-R panic disorder in having greater psychiatric comorbidity and functional disability compared with control patients without panic.

The limitations of this study should be considered in interpreting these results. First, as noted in the "Procedure" subsection, the panic checklist we used did not include the symptom of sweating. This omission might be expected to result in a conservative estimate of panic attack prevalence among women who most recently reached menopause because "night sweats" is a common perimenopausal and postmenopausal symptom.6,9 We evaluated this by calculating an upper-bound estimate, assuming that all women who endorsed the panic attack stem question would have also endorsed sweating. The prevalence of panic attacks using this assumption was slightly higher for any panic attack (19.6% vs 17.9% without this assumption) and full-blown panic attacks (13.0% vs 9.8%). The prevalence of limited-symptom attacks was correspondingly lower (4.9% vs 8.1%) because some proportion of women who endorsed only 3 panic symptoms would now reach full-blown panic attack criteria with the fourth symptom of sweating. Second, the data are based on a cross-sectional, self-report measure of panic attack symptoms. It is possible that the prevalence estimates would differ if a diagnostic interview were used to assess panic attacks. Third, there may be substantial heterogeneity in the frequency and severity of panic among women who reported attacks. Our prevalence estimate of full-blown panic attacks would include women who experienced a single threshold attack and women with recurrent, severe panic attacks occurring as part of panic disorder. Screening positive for panic episodes within the past 6 months is likely to be a sensitive, although not a specific, indicator of underlying panic disorder.58 The differential diagnosis of panic attacks includes not only panic disorder but also other psychiatric and medical disorders and panic in response to medication or illicit substance use. Because panic attacks can occur in these contexts and sporadically, the prevalence of panic attacks is necessarily greater than that of panic disorder. On the other hand, individuals with infrequent panic attacks have been reported12,29,30 to be similar to those with frequent, recurrent attacks or panic disorder in terms of clinical profiles and levels of disability. Fourth, the temporal relationship between the onset of panic attacks and some of the comorbid conditions examined is unknown, making it difficult to determine the causal directionality (if any) between panic and these variables. Finally, because this study was intended to be descriptive and to highlight areas deserving further study, our statistical tests were not corrected for multiple comparisons, raising the possibility of type I error in some findings.

In summary, we found that the 6-month prevalence of panic attacks in a large sample of postmenopausal women was substantial (9.8% for full-blown attacks and 17.9% for full-blown or limited-symptom attacks). The higher prevalence of attacks in this study compared with previous large epidemiologic surveys may be due in part to differences in methods of assessment and differences in the target populations. Panic attacks were associated with younger age, lower income, recent negative life events, a history of medical comorbidity (especially cardiopulmonary disease, thyroid problems, and migraine headache), and depression as well as self-reported limitations in social functioning. Future studies of this sample will further characterize the association of panic attacks with cardiac and other health outcomes. Given previous research12 suggesting that the occurrence of panic attacks within the past 6 months can be an indicator of significant psychiatric comorbidity and functional disability, primary care clinicians treating postmenopausal women may wish to screen for such attacks using the questionnaire applied in this study or even briefer available instruments (eg, the 2-item Autonomic Nervous System Questionnaire developed by Stein and colleagues58). However, panic attacks include a cluster of symptoms that can be associated with a variety of physical and mental disorders so that their diagnostic and treatment implications depend on a more thorough evaluation of a given patient. Further research is needed to clarify the frequency and severity of panic symptoms in postmenopausal women and their impact on quality of life.

Corresponding author and reprints: Jordan W. Smoller, MD, ScD, Department of Psychiatry, Massachusetts General Hospital, 15 Parkman St, WAC-812, Boston, MA 02114 (e-mail: jsmoller@hms.harvard.edu).

Accepted for publication November 21, 2002.

The MIMS study was supported by Glaxo Wellcome (now GlaxoSmithKline), ResearchTriangle Park, NC, and the Women's Health Initiative was supported by the National Heart, Lung, and Blood Institute, Bethesda, Md.

We thank Victor Kamensky, MS, for programming the statistical analyses.

University of Florida at Gainesville: David S. Sheps, MD, MSPH, principal investigator. University of Hawaii at Manoa, Honolulu: David Curb, MD. University of Nevada, Reno: Sandra Daugherty, MD, PhD (deceased). St John's Hospital and Medical Center, Detroit, Mich: Julius Gardin, MD. Wayne State University, Detroit: Susan L. Hendrix, DO. George Washington University Medical Center, Washington, DC: Judith Hsia, MD. Ohio State University Medical Center, Columbus: Rebecca D. Jackson, MD. University of Alabama at Birmingham: Albert Oberman, MD, MPH. University of North Carolina, Chapel Hill: Carla A. Sueta, MD, PhD. University of Iowa College of Medicine, Iowa City: James Torner, MD. Albert Einstein College of Medicine: Sylvia Wassertheil-Smoller, PhD.

Women's Health Initiative Investigators

Program Office

National Heart, Lung, and Blood Institute: Jacques E. Rossouw, Linda Pottern, Shari Ludlam, Joan McGowan, Nancy Morris.

Clinical Coordinating Centers

Fred Hutchinson Cancer Research Center, Seattle, Wash: Ross Prentice, Garnet Anderson, Andrea LaCroix, Ruth Patterson, Anne McTiernan. Bowman Gray School of Medicine, Winston-Salem, NC: Sally Shumaker, Pentti Rautaharju. Medical Research Labs, Highland Heights, Ky: Evan Stein. University of California at San Francisco: Steven Cummings. University of Minnesota, Minneapolis: John Himes. University of Washington, Seattle: Susan Heckbert.

Clinical Centers

Albert Einstein College of Medicine: Sylvia Wassertheil-Smoller. Baylor College of Medicine, Houston, Tex: Jennifer Hays. Brigham and Women's Hospital, Harvard Medical School, Boston: JoAnn Manson. Brown University, Providence, RI: Annlouise R. Assaf. Emory University, Atlanta, Ga: Lawrence Phillips. Fred Hutchinson Cancer Research Center: Shirley Beresford. George Washington University Medical Center: Judith Hsia. Harbor-UCLA Research and Education Institute, Torrance, Calif: Rowan Chlebowski. Kaiser Permanente Center for Health Research, Portland, Ore: Cheryl Ritenbaugh. Kaiser Permanente Division of Research, Oakland, Calif: Bette Caan. Medical College of Wisconsin, Milwaukee: Jane Morley Kotchen. Medstar Research Institute, Washington, DC: Barbara V. Howard. Northwestern University, Chicago/Evanston, Ill: Linda Van Horn. Rush–Presbyterian–St Luke's Medical Center, Chicago: Henry Black. Stanford Center for Research in Disease Prevention, Stanford University, Stanford, Calif: Marcia L. Stefanick. State University of New York at Stony Brook: Dorothy Lane. Ohio State University: Rebecca Jackson. University of Alabama at Birmingham: Cora Beth Lewis. University of Arizona, Tucson/Phoenix: Tamsen Bassford. University at Buffalo, Buffalo, NY: Maurizio Trevisan. University of California at Davis, Sacramento: John Robbins. University of California at Irvine, Orange: Allan Hubbell. University of California at Los Angeles: Howard Judd. University of California at San Diego, LaJolla/Chula Vista: Robert D. Langer. University of Cincinnati, Cincinnati, Ohio: Margery Gass. University of Florida, Gainesville/Jacksonville: Marian Limacher. University of Hawaii, Honolulu: David Curb. University of Iowa, Iowa City/Davenport: Robert Wallace. University of Massachusetts, Worcester: Judith Ockene. University of Medicine and Dentistry of New Jersey, Newark: Norman Lasser. University of Miami, Miami, Fla: Mary Jo O'Sullivan. University of Minnesota: Karen Margolis. University of Nevada: Robert Brunner. University of North Carolina: Gerardo Heiss. University of Pittsburgh, Pittsburgh, Pa: Lewis Kuller. University of Tennessee, Memphis: Karen C. Johnson. The University of Texas Health Science Center, San Antonio: Robert Schenken. University of Wisconsin, Madison: Catherine Allen. Wake Forest University School of Medicine, Winston-Salem: Gregory Burke. Wayne State University School of Medicine/Hutzel Hospital, Detroit: Susan Hendrix.

Eaton  WWKessler  RCWittchen  HUMagee  WJ Panic and panic disorder in the United States. Am J Psychiatry. 1994;151413- 420
PubMed
Kessler  RCMcGonagle  KAZhao  S  et al.  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry. 1994;518- 19
PubMed
Robins  LLock  BRegier  D An overview of psychiatric disorders in America. Robins  LRegier  Deds.Psychiatric Disorders in America. New York, NY Free Press1991;328- 366
Von Korff  MEaton  WKeyl  P The epidemiology of panic attacks and panic disorder. Am J Epidemiol. 1985;122970- 981
PubMed
Eaton  WDryman  AWeissman  M Panic and phobia. Robins  LRegier  Deds.Psychiatric Disorders in America New York, NY Free Press1991;155- 179
Porter  MPenney  GCRussell  DRussell  ETempleton  A A population based survey of women's experience of the menopause. Br J Obstet Gynaecol. 1996;1031025- 1028
PubMed
Pearlstein  TRosen  KStone  AB Mood disorders and menopause. Endocrinol Metab Clin North Am. 1997;26279- 294
PubMed
Burt  VKAltshuler  LLRasgon  N Depressive symptoms in the perimenopause: prevalence, assessment, and guidelines for treatment. Harv Rev Psychiatry. 1998;6121- 132
PubMed
Hunter  MS Psychological and somatic experience of the menopause: a prospective study. Psychosom Med. 1990;52357- 367[published correction appears in Psychosom Med. 1990;52:410].
PubMed
Matthews  KAWing  RRKuller  LH  et al.  Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women. J Consult Clin Psychol. 1990;58345- 351
PubMed
Not Available, Design of the Women's Health Initiative clinical trial and observational study: the Women's Health Initiative Study Group Control Clin Trials. 1998;1961- 109
PubMed
Katon  WHollifield  MChapman  TMannuzza  SBallenger  JFyer  A Infrequent panic attacks: psychiatric comorbidity, personality characteristics and functional disability. J Psychiatr Res. 1995;29121- 131
PubMed
Fyer  AJKaton  WHollifield  M  et al.  The DSM-IV panic disorder field trial: panic attack frequency and functional disability. Anxiety. 1996;2157- 166
PubMed
Burnam  MWells  KLeake  BLandsverk  J Development of a brief screening instrument for detecting depressive disorders. Med Care. 1988;26775- 789
PubMed
Hays  RDSherbourne  CDMazel  RM The RAND 36-Item Health Survey 1.0. Health Econ. 1993;2217- 227
PubMed
Radloff  L The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1385- 401
Robins  LHelzer  JCroughan  JRatcliff  K National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry. 1981;38381- 389
PubMed
Katon  WVitaliano  PPRusso  JJones  MAnderson  K Panic disorder: spectrum of severity and somatization. J Nerv Ment Dis. 1987;17512- 19
PubMed
Not Available, Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain: Headache Classification Committee of the International Headache Society Cephalalgia. 1988;81- 96
PubMed
Smoller  JWSimon  NMPollack  MHKradin  RStern  T Anxiety in patients with pulmonary disease: comorbidity and treatment. Semin Clin Neuropsychiatry. 1999;484- 97
PubMed
Fleet  RLavoie  KBeitman  BD Is panic disorder associated with coronary artery disease? a critical review of the literature. J Psychosom Res. 2000;48347- 356
PubMed
Simon  NMBlacker  DKorbly  NB  et al.  Hypothyroidism and hyperthyroidism in anxiety disorders revisited: new data and literature review. J Affect Disord. 2002;69209- 217
PubMed
Breslau  NSchultz  LRStewart  WFLipton  RWelch  KM Headache types and panic disorder: directionality and specificity. Neurology. 2001;56350- 354
PubMed
Mendlowicz  MVStein  MB Quality of life in individuals with anxiety disorders. Am J Psychiatry. 2000;157669- 682
PubMed
Berkman  LFSyme  SL Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. Am J Epidemiol. 1979;109186- 204
PubMed
Ruberman  WWeinblatt  EGoldberg  JDChaudhary  BS Psychosocial influences on mortality after myocardial infarction. N Engl J Med. 1984;311552- 559
PubMed
US Department of Health and Human Services (DHHS), National Center for Health Statistics. Third National Health and Nutrition Examination Survey, 1988-1994. NHANES III Adult Data File [CD-ROM] Hyattsville, Md Centers for Disease Control and Prevention1997;
Verburg  KGriez  EMeijer  JPols  H Respiratory disorders as a possible predisposing factor for panic disorder. J Affect Disord. 1995;33129- 134
PubMed
Katerndahl  DA Infrequent and limited-symptom panic attacks. J Nerv Ment Dis. 1990;178313- 317
PubMed
Klerman  GLWeissman  MMOuellette  RJohnson  JGreenwald  S Panic attacks in the community: social morbidity and health care utilization. JAMA. 1991;265742- 746
PubMed
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Deer  TMCalamari  JE Panic symptomatology and anxiety sensitivity in older adults. J Behav Ther Exp Psychiatry. 1998;29303- 316
PubMed
Eaton  WW Progress in the epidemiology of anxiety disorders. Epidemiol Rev. 1995;1732- 38
PubMed
Eaton  WWAnthony  JCRomanoski  A  et al.  Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up. Br J Psychiatry. 1998;173501- 507
PubMed
Raj  BACorvea  MHDagon  EM The clinical characteristics of panic disorder in the elderly: a retrospective study. J Clin Psychiatry. 1993;54150- 155
PubMed
Segui  JSalvador-Carulla  LMarquez  MGarcia  LCanet  JOrtiz  M Differential clinical features of late-onset panic disorder. J Affect Disord. 2000;57115- 124
PubMed
Katerndahl  DATalamantes  M A comparison of persons with earlyversus late-onset panic attacks. J Clin Psychiatry. 2000;61422- 427
PubMed
Smoller  JWPollack  MHOtto  MWRosenbaum  JFKradin  R Panic-anxiety, dyspnea and respiratory disease: theoretical and clinical considerations. Am J Respir Crit Care Med. 1996;1546- 17
PubMed
Eaker  EDPinsky  JCastelli  WP Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol. 1992;135854- 864
PubMed
Kawachi  ISparrow  DVokonas  PSWeiss  ST Symptoms of anxiety and risk of coronary heart disease: the Normative Aging Study. Circulation. 1994;902225- 2229
PubMed
Kawachi  IColditz  GAAscherio  A  et al.  Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation. 1994;891992- 1997
PubMed
Kubzansky  LDKawachi  ISpiro 3rd  AWeiss  STVokonas  PSSparrow  D Is worrying bad for your heart? a prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation. 1997;95818- 824
PubMed
Mittleman  MAMaclure  MSherwood  JB  et al.  Triggering of acute myocardial infarction onset by episodes of anger: Determinants of Myocardial Infarction Onset Study Investigators. Circulation. 1995;921720- 1725
PubMed
Jiang  WBabyak  MKrantz  DS  et al.  Mental stress–induced myocardial ischemia and cardiac events. JAMA. 1996;2751651- 1656
PubMed
Yeragani  VKPohl  RBerger  R  et al.  Decreased heart rate variability in panic disorder patients: a study of power-spectral analysis of heart rate. Psychiatry Res. 1993;4689- 103
PubMed
Friedman  BHThayer  JFBorkovec  TDTyrrell  RAJohnson  BHColumbo  R Autonomic characteristics of nonclinical panic and blood phobia. Biol Psychiatry. 1993;34298- 310
PubMed
Kawachi  ISparrow  DVokonas  PSWeiss  ST Decreased heart rate variability in men with phobic anxiety (data from the Normative Aging Study). Am J Cardiol. 1995;75882- 885
PubMed
Piccirillo  GViola  EBucca  C  et al.  QT interval dispersion and autonomic modulation in subjects with anxiety. J Lab Clin Med. 1999;133461- 468
PubMed
Merikangas  KRMerikangas  JRAngst  J Headache syndromes and psychiatric disorders: association and familial transmission. J Psychiatr Res. 1993;27197- 210
PubMed
Juang  KDWang  SJFuh  JLLu  SRSu  TP Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache. 2000;40818- 823
PubMed
Swartz  KLPratt  LAArmenian  HKLee  LCEaton  WW Mental disorders and the incidence of migraine headaches in a community sample: results from the Baltimore Epidemiologic Catchment Area follow-up study. Arch Gen Psychiatry. 2000;57945- 950
PubMed
Peroutka  SPrice  SWilhoit  TJones  K Comorbid migraine with aura, anxiety, and depression is associated with dopamine D2 receptor (DRD2) NcoI alleles. Mol Med. 1998;414- 21
PubMed
Johnson  KWPhebus  LACohen  ML Serotonin in migraine: theories, animal models and emerging therapies. Prog Drug Res. 1998;51219- 244
PubMed
Gorman  JMKent  JMSullivan  GMCoplan  JD Neuroanatomical hypothesis of panic disorder, revised. Am J Psychiatry. 2000;157493- 505
PubMed
Coryell  WEndicott  JAndreasen  N  et al.  Depression and panic attacks: the significance of overlap as reflected in follow-up and family study data. Am J Psychiatry. 1988;145293- 300
PubMed
Kessler  RStang  PWittchen  H-UUstun  TRoy-Byrne  PWalters  E Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry. 1998;55801- 808
PubMed
Tuunainen  ALanger  RDKlauber  MRKripke  DF Short version of the CES-D (Burnam screen) for depression in reference to the structured psychiatric interview. Psychiatry Res. 2001;103261- 270
PubMed
Stein  MBRoy-Byrne  PPMcQuaid  JR  et al.  Development of a brief diagnostic screen for panic disorder in primary care. Psychosom Med. 1999;61359- 364
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Sociodemographic Characteristics of Women in the MIMS Sample and of the Full Cohort of the WHI-OS
Table Graphic Jump LocationTable 2. Six-Month Prevalence of Panic Attacks, by Age and Race or Ethnicity
Table Graphic Jump LocationTable 3. Sociodemographic and Lifestyle Variables Associated With Panic Attacks
Table Graphic Jump LocationTable 4. Association of Panic Attacks With Comorbid Conditions
Table Graphic Jump LocationTable 5. Association of Panic Attacks With Functional Impairment

References

Eaton  WWKessler  RCWittchen  HUMagee  WJ Panic and panic disorder in the United States. Am J Psychiatry. 1994;151413- 420
PubMed
Kessler  RCMcGonagle  KAZhao  S  et al.  Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry. 1994;518- 19
PubMed
Robins  LLock  BRegier  D An overview of psychiatric disorders in America. Robins  LRegier  Deds.Psychiatric Disorders in America. New York, NY Free Press1991;328- 366
Von Korff  MEaton  WKeyl  P The epidemiology of panic attacks and panic disorder. Am J Epidemiol. 1985;122970- 981
PubMed
Eaton  WDryman  AWeissman  M Panic and phobia. Robins  LRegier  Deds.Psychiatric Disorders in America New York, NY Free Press1991;155- 179
Porter  MPenney  GCRussell  DRussell  ETempleton  A A population based survey of women's experience of the menopause. Br J Obstet Gynaecol. 1996;1031025- 1028
PubMed
Pearlstein  TRosen  KStone  AB Mood disorders and menopause. Endocrinol Metab Clin North Am. 1997;26279- 294
PubMed
Burt  VKAltshuler  LLRasgon  N Depressive symptoms in the perimenopause: prevalence, assessment, and guidelines for treatment. Harv Rev Psychiatry. 1998;6121- 132
PubMed
Hunter  MS Psychological and somatic experience of the menopause: a prospective study. Psychosom Med. 1990;52357- 367[published correction appears in Psychosom Med. 1990;52:410].
PubMed
Matthews  KAWing  RRKuller  LH  et al.  Influences of natural menopause on psychological characteristics and symptoms of middle-aged healthy women. J Consult Clin Psychol. 1990;58345- 351
PubMed
Not Available, Design of the Women's Health Initiative clinical trial and observational study: the Women's Health Initiative Study Group Control Clin Trials. 1998;1961- 109
PubMed
Katon  WHollifield  MChapman  TMannuzza  SBallenger  JFyer  A Infrequent panic attacks: psychiatric comorbidity, personality characteristics and functional disability. J Psychiatr Res. 1995;29121- 131
PubMed
Fyer  AJKaton  WHollifield  M  et al.  The DSM-IV panic disorder field trial: panic attack frequency and functional disability. Anxiety. 1996;2157- 166
PubMed
Burnam  MWells  KLeake  BLandsverk  J Development of a brief screening instrument for detecting depressive disorders. Med Care. 1988;26775- 789
PubMed
Hays  RDSherbourne  CDMazel  RM The RAND 36-Item Health Survey 1.0. Health Econ. 1993;2217- 227
PubMed
Radloff  L The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1385- 401
Robins  LHelzer  JCroughan  JRatcliff  K National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry. 1981;38381- 389
PubMed
Katon  WVitaliano  PPRusso  JJones  MAnderson  K Panic disorder: spectrum of severity and somatization. J Nerv Ment Dis. 1987;17512- 19
PubMed
Not Available, Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain: Headache Classification Committee of the International Headache Society Cephalalgia. 1988;81- 96
PubMed
Smoller  JWSimon  NMPollack  MHKradin  RStern  T Anxiety in patients with pulmonary disease: comorbidity and treatment. Semin Clin Neuropsychiatry. 1999;484- 97
PubMed
Fleet  RLavoie  KBeitman  BD Is panic disorder associated with coronary artery disease? a critical review of the literature. J Psychosom Res. 2000;48347- 356
PubMed
Simon  NMBlacker  DKorbly  NB  et al.  Hypothyroidism and hyperthyroidism in anxiety disorders revisited: new data and literature review. J Affect Disord. 2002;69209- 217
PubMed
Breslau  NSchultz  LRStewart  WFLipton  RWelch  KM Headache types and panic disorder: directionality and specificity. Neurology. 2001;56350- 354
PubMed
Mendlowicz  MVStein  MB Quality of life in individuals with anxiety disorders. Am J Psychiatry. 2000;157669- 682
PubMed
Berkman  LFSyme  SL Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. Am J Epidemiol. 1979;109186- 204
PubMed
Ruberman  WWeinblatt  EGoldberg  JDChaudhary  BS Psychosocial influences on mortality after myocardial infarction. N Engl J Med. 1984;311552- 559
PubMed
US Department of Health and Human Services (DHHS), National Center for Health Statistics. Third National Health and Nutrition Examination Survey, 1988-1994. NHANES III Adult Data File [CD-ROM] Hyattsville, Md Centers for Disease Control and Prevention1997;
Verburg  KGriez  EMeijer  JPols  H Respiratory disorders as a possible predisposing factor for panic disorder. J Affect Disord. 1995;33129- 134
PubMed
Katerndahl  DA Infrequent and limited-symptom panic attacks. J Nerv Ment Dis. 1990;178313- 317
PubMed
Klerman  GLWeissman  MMOuellette  RJohnson  JGreenwald  S Panic attacks in the community: social morbidity and health care utilization. JAMA. 1991;265742- 746
PubMed
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.  Washington, DC American Psychiatric Association1994;
Deer  TMCalamari  JE Panic symptomatology and anxiety sensitivity in older adults. J Behav Ther Exp Psychiatry. 1998;29303- 316
PubMed
Eaton  WW Progress in the epidemiology of anxiety disorders. Epidemiol Rev. 1995;1732- 38
PubMed
Eaton  WWAnthony  JCRomanoski  A  et al.  Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up. Br J Psychiatry. 1998;173501- 507
PubMed
Raj  BACorvea  MHDagon  EM The clinical characteristics of panic disorder in the elderly: a retrospective study. J Clin Psychiatry. 1993;54150- 155
PubMed
Segui  JSalvador-Carulla  LMarquez  MGarcia  LCanet  JOrtiz  M Differential clinical features of late-onset panic disorder. J Affect Disord. 2000;57115- 124
PubMed
Katerndahl  DATalamantes  M A comparison of persons with earlyversus late-onset panic attacks. J Clin Psychiatry. 2000;61422- 427
PubMed
Smoller  JWPollack  MHOtto  MWRosenbaum  JFKradin  R Panic-anxiety, dyspnea and respiratory disease: theoretical and clinical considerations. Am J Respir Crit Care Med. 1996;1546- 17
PubMed
Eaker  EDPinsky  JCastelli  WP Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol. 1992;135854- 864
PubMed
Kawachi  ISparrow  DVokonas  PSWeiss  ST Symptoms of anxiety and risk of coronary heart disease: the Normative Aging Study. Circulation. 1994;902225- 2229
PubMed
Kawachi  IColditz  GAAscherio  A  et al.  Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation. 1994;891992- 1997
PubMed
Kubzansky  LDKawachi  ISpiro 3rd  AWeiss  STVokonas  PSSparrow  D Is worrying bad for your heart? a prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation. 1997;95818- 824
PubMed
Mittleman  MAMaclure  MSherwood  JB  et al.  Triggering of acute myocardial infarction onset by episodes of anger: Determinants of Myocardial Infarction Onset Study Investigators. Circulation. 1995;921720- 1725
PubMed
Jiang  WBabyak  MKrantz  DS  et al.  Mental stress–induced myocardial ischemia and cardiac events. JAMA. 1996;2751651- 1656
PubMed
Yeragani  VKPohl  RBerger  R  et al.  Decreased heart rate variability in panic disorder patients: a study of power-spectral analysis of heart rate. Psychiatry Res. 1993;4689- 103
PubMed
Friedman  BHThayer  JFBorkovec  TDTyrrell  RAJohnson  BHColumbo  R Autonomic characteristics of nonclinical panic and blood phobia. Biol Psychiatry. 1993;34298- 310
PubMed
Kawachi  ISparrow  DVokonas  PSWeiss  ST Decreased heart rate variability in men with phobic anxiety (data from the Normative Aging Study). Am J Cardiol. 1995;75882- 885
PubMed
Piccirillo  GViola  EBucca  C  et al.  QT interval dispersion and autonomic modulation in subjects with anxiety. J Lab Clin Med. 1999;133461- 468
PubMed
Merikangas  KRMerikangas  JRAngst  J Headache syndromes and psychiatric disorders: association and familial transmission. J Psychiatr Res. 1993;27197- 210
PubMed
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