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Case of a Bus Driver Who Suffered from Panic Disorder in the Course of Treatment for Depression

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The comorbidity of psychiatric disorders with chronic health conditions has emerged as a topic of considerable clinical and political interest, in part owing to the evidence that anxiety disorders are associated with depression. Nevertheless, the implications for health-related quality of life that result from anxiety disorders, which are comorbid to chronic medical or psychiatric illness, are not well understood, especially in primary care samples1). There are few clinical studies of depression and panic disorder comorbidity in occupational health. From the epidemiological point of view, major depressive disorder and generalized anxiety disorder frequently co-occur with panic disorder, with estimates ranging 20% to 50% for each disorder2). In this report, we discuss the association between depression, panic disorder and hypertension in a bus driver.
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J Occup Health 1999; 41: 267–270
Case Study
disorder, psychosomatic therapy (medication, autogenic
training and counseling) was tried for the complaint.
Case of a Bus Driver Who Suffered from
Past history: He had been suffering from hypertension
since his thirties and had taken ? blocker (atenorol, 25
Panic Disorder in the Course of Treatment
1
mg a day); since the age of 47 he had been taking
for Depression
psychosomatic therapy for depression.
Family History: His 42-year-old wife had suffered
Eiichi UCHIDA1, Fumika OKAJIMA2, Hirono ISHIKAWA3, Chihiro
from autonomic imbalance for 15 yr, and recovered 4 yr
SASAKI4, Taisaku KATSURA1 and Tetsuro OKINO5
ago. His 10-year-old son and 18-year-old daughter were
healthy.
1Department of Psychosomatic Internal Medicine, LCC Medi-
Physical examination and Clinical data: Height 170
cal Institute on Stress, 2Department of Nutrition, Kagawa Nu-
cm, Weight 65 kg. Clinical laboratory findings (blood,
trition University, 3Department of Health Sociology, Graduate
urine, biochemical data) in the patient were within the
School of Health Science and Nursing, University of Tokyo,
normal range. Nutritional condition was good. Blood
4Department of Psychology, Ochanomizu University and
pressure 125/80 mmHg, pulse pate 64/min, regular.
5Mitsubishi Material Co.
Electrocardiogram: no specific finding.
Birth and occupation: He, the youngest of three
Key words: Depression, Panic disorder, Hypertension,
brothers, born in Chiba prefecture, was apt to behave
Stress, Psychosomatic therapy, Bus driver, Comorbidity
like a spoiled child and to depend on others. After
graduating from high school, he got a job in a railway
The comorbidity of psychiatric disorders with chronic
company and became a bus driver. His personality was
health conditions has emerged as a topic of considerable
happy-go-lucky, but he became punctual in his work.
clinical and political interest, in part owing to the evidence
Recently, he began to feel stress after hard and long
that anxiety disorders are associated with depression.
driving hours related to restructuring of the company.
Nevertheless, the implications for health-related quality
His wife had suffered from autonomic imbalance, but
of life that result from anxiety disorders, which are
recovered and had taken care of him. His blood pressure
comorbid to chronic medical or psychiatric illness, are
had been unstable. He has continued to be treated for
not well understood, especially in primary care samples1).
depression for 5 yr. He had taken medication, and got
There are few clinical studies of depression and panic
along without trouble in driving.
disorder comorbidity in occupational health. From the
Mental test: The Score of Self-rating Depression Scale
epidemiological point of view, major depressive disorder
(SDS); 57 points (>50) implied depression2). Manifest
and generalized anxiety disorder frequently co-occur with
Anxiety Scale (MAS); 28 points (>26) revealed high
panic disorder, with estimates ranging 20% to 50% for
anxiety. The Cornell Medical Index (CMI) Score showed
each disorder2). In this report, we discuss the association
a IV area (Fukumachi Method) which meant a nervous
between depression, panic disorder and hypertension in
personality. Self Grow-up Egogram (SGE); Critical
a bus driver.
Parent (CP) showing a personality critical of others: 12/
Case Report
20 points, Nurturing Parent (NP) revealing kindness and
helpfulness: 12/20 points, Adult (A) indicating mature
A 49-year-old male bus driver, who had been working
decision: 10/20 points, Free Child (FC) representing
in a railway company for 21 years, visited our clinic to
cheerfulness and positiveness: 9/20 points, and Adapted
receive psychosomatic therapy. He complained suddenly
Child (AC) manifesting being cooperative with others:
of acute palpitations, vertigo, breathlessness, dizziness,
16/20 points (highest score). Therefore he seems to have
anxiety, phobia, restlessness, numbness of left hand,
high adaptability, and may even overadapt himself to the
nausea and headache. Before onset of the symptoms, he
surroundings.
had been treated for depression and hypertension,
Personality: He is a serious type of man and cannot
complaining of depression, loss of volition, stiffness
refuse other’s requests. In fact, he is emotionally unstable,
(especially in his shoulders), sleep disturbance, general
but forced to adapt himself to surroundings. In addition,
fatigue, asthenopia, nephelopia and loss of appetite. In
he tended to require himself to be perfect and punctual
the course of his treatment, he felt that the present
because of his job (bus driver).
complaints were different from previous ones, and wanted
Clinical course: Figure 1 and Fig. 2 show his clinical
another course of treatment. On a diagnosis of panic
course and treatment. Around October, 1996, he was
treated for depressive mood, loss of volition and appetite,
Received Jan 5, 1999; Accepted June 8, 1999
sleep disturbance, shoulder stiffness, nephelopia,
Correspondence to: E. Uchida, Otsuka · Eiichi Clinic, Kinseido-
building 401, Minami-otsuka 3–46–10, Toshima-ku, Tokyo 170-

asthenopia and general fatigue. After work, he felt fatigue
0005, Japan
and had unstable blood pressure, so he had been careful

268
J Occup Health, Vol. 41, 1999
Fig. 1. Clinical course and treatment of a case of depression, a
bus driver aged 49 years.
Treatments in Figure 1 are as follows;
Fig. 2. Clinical course and treatment of the case in Fig. 1 from
Treatment (1): clomipramine (75 mg, 3x), amitryptyline
the onset of panic disorder in July, 1997.
(150 mg, 3x), bromazepam (15 mg, 3x),
Treatments in Fig. 2 are as follows;
piperiden (3 mg, 3x), triazolam (0.25
mg, 1x v.d.S), estazolam (2 mg, 1x
Treatment (5): alprazolam (2.4 mg, 3x)
v.d.S), chlorphenesin carbamate (750
Treatment (6): alpraxolam (6.4 mg, 3x), imipramine
mg, 3x), atenorol (50 mg, 2x)
(50 mg, 1x), oxprenolol (60 mg, 3x)
Treatment (2): amitryptyline (50 mg, 1x v.d.S),
Treatment (7): alpraxolam (3.2 mg, 3x), imipramine
bromazepam (15 mg, 3x), piperiden (3
(50 mg, 1x), oxprenolol (120 mg, 3x)
mg, 3x), atenorol (50 mg, 2x)
Treatment (8): alpraxolam (3.2 mg, 3x), imipramine
Treatment (3): amitriptyline (50 mg, 2x), bromazepam
(150 mg, 1x), oxprenolol (120 mg, 3x)
(5 mg, 1x)
Treatment (9): alpraxolam (1.2 mg, 4x), imipramine
Treatment (4): amitriptyline (30 mg, 1x v.d.S),
(100 mg, 4x), oxprenolol (80 mg, 4x)
bromazepam (5 mg, 1x v.d.S),
Treatment (10): alpraxolam (0.8 mg, 4x), imipramine
methylphenidate (30 mg, 2x)
(40 mg, 4x), oxprenolol (80 mg, 4x)
of his work condition. With the medication in Fig. 1-
headache had continued. When he had frequent fits, he
(1)–(4), his condition was becoming stable, and the
took alprazolam 1.6 mg and oxprenolol 40 mg. In August,
quantity of medicine was gradually decreased, but since
1997, he often had headaches, acute palpitation,
the middle of July, 1997, his present complaints have
restlessness, dizziness and nausea. In the same month,
been different from previous ones. He often felt anxiety,
we decreased the dose of drugs as shown in Fig. 2-(6).
phobia, sudden acute palpitations, restlessness, numbness
His blood pressure changed little. In September his
of the left hand, nausea and headache. On the other hand,
condition was still bad, so he required one or two weeks
loss of appetite, sleep disturbance, general fatigue,
off from the company with a medical certificate. On 4
asthenopia had been gradually disappearing. In July, 1997
Sep. he had an electrocardiogram, but there was no
he therefore asked for another treatment; medication was
specific finding. His physical symptoms continued.
changed on the diagnosis of panic disorder (from DSM-
Because he had frequent acute palpitation, we changed
IV)3). At the time, medication for his depression had
his prescription as in Fig. 2-(7). In October, his
continued as in Fig. 1-(4). For his severe complications
prescription was changed again as in Fig. 2-(8), because
caused by anxiety and phobia of panic disorder, he took
his phobia had not disappeared. In November physical
20–30 min of counseling and autogenic training at every
symptoms decreased, so we made the prescription as in
visit and brought his mental pattern causing the symptoms
Fig. 2-(9). In January, 1998 since his condition had been
to his awareness. Medication for depression had been
stable, we changed the prescription as in Fig. 2-(10).
effective since 15, July, 1997; medication for panic disorder
was added to the previous treatment as in Fig. 2-(5). We
Discussion
decided to decrease medicines for depression and observe
The results of the present study support the diagnosis
his condition. His agoraphobia was not reduced, and
of comorbidity among depression, panic disorder and
besides headache continued, and he felt pain in the whole
hypertension; headache may commonly imply the three
neck, but made an effort to go to job. His anxiety was
diseases. The patient had been working as a bus driver
reduced, but acute palpitations, shoulder stiffness and
for 21 yr. Before he visited our clinic in October, 1996

Eiichi UCHIDA, et al.: Comorbidity between depression and panic disorder in a bus driver
269
he had been suffering from hypertension since his thirties
gradually, taking 6 to 12 months. And the work schedule
and had been treated for depression for 5 yr. His primary
should be adjusted appropriately with agreement of
complaints were general fatigue, headache and so on. In
superiors under the direction of an occupational physician.
July, 1997 his complaints changed, and he was now
The recent study, carried out in a neurology headache
diagnosed as having panic disorder.
clinic, showed that the major associations of headache
From the viewpoint of occupational health, the authors
were with current anxiety disorder, especially panic and
pointed out the following problems:
related conditions5). Moreover, another recent study
(1) When the patient drives a bus, the symptoms
observed no differences in the prevalence of panic,
which make driving impossible, such as sudden
anxiety and depression between patients with resistant
palpitation, anxiety and phobia, shivering, chest pain,
hypertension and non-resistant controls. On the other
nausea and dizziness, may cause traffic accidents leading
hand, the prevalence of panic disorder and panic attacks
to damage; it is too late to avoid damage when the panic
were remarkably high in both groups patients attending
disorder has already occurred. As in this case, panic
a hospital hypertension clinic6). The characteristics of
disorder seems to appear comorbid with other symptoms.
the patient resembled those in the report.
The partial symptoms of panic attack should also be
From the psychological point of view, he was a serious
checked at screening for hypertension and depression to
type of man and overadapted himself to the surroundings;
detect attacks in the earlier stages.
the Self Grow-up Egogram score showed his high
(2) It is to be expected that driving, which requires
adaptability. In addition, he tended to require himself to
continuing tension without talking, causes great stress in
be perfect because his job required punctuality. The stress
such workers as bus drivers. Depression, due to
caused by high adaptability and punctuality may be
hypertension and cumulative fatigue in concentrating on
related to depression, panic disorder and hypertension.
driving for hours, is supposed to be not as difficult to
Other research reports indicated that primary care
detect in regular medical examinations and mental tests,
clinicians should be aware of the possible coexistence of
but the symptoms of panic disorder are rarely checked in
anxiety disorders (especially generalized anxiety disorder
the field of occupational health. Panic attack is not
[GAD]) in their patients with chronic medical conditions
difficult to detect in a brief medical interview; it should
(hypertension), but especially in those with current
be looked for in regular medical examinations.
depressive disorder. Among primary care patients, those
D e p r e s s i o n a n d h y p e r t e n s i o n n e e d l o n g - t e r m
with chronic medical illness or subthreshold depression
pharmachotherapy. The symptoms depend on the case,
had low rates of lifetime and current panic disorder, but
and the patient often recovers after getting worse and
those with current depressive disorder had much higher
better several times. Frequent health checks are needed
rates. Concurrent phobia and GAD were more common,
if he is to continue to work as a bus driver. When a
especially in depressed patients. Depending on the type
driver feels a panic symptom such as palpitation, a self-
of medical illness or depression, 14% to 66% of primary
reported health check is essential before driving.
care patients had at least one concurrent anxiety disorder7).
(3) When taking a long time off from work, the decline
Another study repeated that anxiety disorders co-
in physical strength and driving technique may become
occurring with another disease (medical illness or
serious; it is considered to be necessary for the treatment
depression) increase the need for counseling and the use
of depression and panic disorder to let the patient go back
of psychotropic medication in the general medical sector8).
to daily work gradually, taking 6 to 12 months. The work
This research showed the importance of primary care
schedule should therefore be adjusted appropriately with
including occupational health; it seems necessary to
agreement of superiors under the direction of an
conduct advanced research on the comorbidity of the
occupational physician.
diseases (disorders), treatment and the occupational care
Balls S.G. et al. reported that the majority of patients
(employment and support) of these patients. And more
with panic disorder complained of at two or more
study should be directed at increasing cooperation
depressive symptoms. These symptoms met the DSM-
between occupational health (primary care) and
III-R definitional criteria for significance; subdiagnostic
psychosomatic internal medicine (psychiatrics)
levels of clinically significant depressive and generalized
concerning depression, panic disorder and hypertension.
anxiety symptoms in patients with panic disorder4). Past
References
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depression as the most common psychiatric disorder,
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270
J Occup Health, Vol. 41, 1999
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