Panic disorder
and coping
Panic disorder—recurrent, unexpected panic attacks—is more common among women than
men.
The disorder typically strikes younger people, with an average age of onset of 25.
Several negative behaviours are associated with panic disorder, including withdrawing from
people, smoking more than usual, drinking to cope with stress, or using illicit drugs.
Pamela L. Ramage-Morin
Abstract
Objectives
This article presents prevalence estimates of panic disorder in
the household population aged 15 or older. Associations
All people experience various levels of anxiety as
they go through life. Usually an individual’s anxiety
between panic disorder and measures of physical and mental
health, work status and coping behaviour are examined.
level shifts almost imperceptibly as he or she
Data source
Data are from the 2002 Canadian Community Health Survey:
copes with a potentially difficult, fearful, or even dangerous
Mental Health and Well-being.
Analytical techniques
situation.1 Anxiety is a typical and normal
2002 prevalence rates are presented for people with a history
of panic disorder. Characteristics associated with current and
past panic disorder are examined. Multiple logistic regression
reaction to stress, and a certain amount of it may often be
models are used to examine work status and coping behaviour,
and chronic physical and other mental health problems.
appropriate. Anxiety may be considered normal, but panic
Main results
In 2002, an estimated 1.5% of the population had current panic
attacks—discrete periods of intense fear that occur in the
disorder, and 2.1%, a past history. Average age of onset was
25. People with panic disorder (current and past) were less
likely to work and more likely to be permanently unable to work,
absence of any real danger—are not. Panic attacks are
compared with those who had never had the condition.
Negative coping behaviours, including alcohol or drug use and
accompanied by symptoms such as chest pain, sweating,
smoking, were more common among those with panic disorder.
Key words
trembling, shortness of breath and palpitations. During attacks
age of onset, agoraphobia, comorbidity, coping behaviour,
health status indicators, mental health, prevalence, panic
people may feel that they are choking, losing control or “going
attacks
crazy.” They may express a fear of dying and feel the urge to
Author
Pamela L. Ramage-Morin (613-951-1760; Pamela.Ramage-
escape. The attacks occur suddenly, usually peak within 10
Morin@statcan.ca) is with the Health Statistics Division at
Statistics Canada, K1A 0T6.
minutes and may occur at night, waking the individual from
sleep.2
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Panic disorder and coping
Methods
Data source
Analytical techniques
The data used for this analysis are from the 2002 Canadian
Prevalence rates of panic disorder according to selected socio-
Community Health Survey (CCHS) cycle 1.2: Mental Health and
demographic variables were calculated. Comparisons were made
Well-being, which began in May 2002 and was conducted over eight
between these characteristics, within the current and past panic
months. Residents of institutions, Indian reserves and certain remote
disorder groups. Age of onset and the means were estimated by
areas, the three territories, as well as full-time members of the
examining cumulative incidence by age.
Canadian Armed Forces, were excluded.
Prevalence rates and logistic regression models were used to
The CCHS 1.2 sample was selected using the area frame designed
compare people with panic disorder with the rest of the population
for the Canadian Labour Force Survey. A multi-stage stratified cluster
in relation to physical and mental health, work status, and coping
design was used to sample dwellings within this area frame. One
behaviour. Four mutually exclusive and exhaustive groups were
person aged 15 or older was randomly selected from the sampled
created: those with current panic disorder (met the criteria for panic
households. Individual respondents were selected to over-represent
disorder in the 12 months before the CCHS interview); those with a
young people (15 to 24) and seniors (65 or older), thus ensuring
past history (panic disorder in the past, but not in the last 12 months);
adequate sample sizes for these age groups. More detailed
those who did not meet the criteria for panic disorder (reference
descriptions of the design, sample and interview procedures can
group); and those whose panic disorder status was “unknown.” The
be found in other reports and on Statistics Canada’s Web site.3,4
final group was retained for analysis because of its appreciable size
All interviews were conducted using a computer-assisted
(see Limitations), but the results are not shown. When examining
application. Most (86%) were conducted in person; the remainder,
gender differences for lifetime agoraphobia, as well as certain coping
by telephone. Selected respondents were required to provide their
behaviours (use of alcohol and withdrawing), only respondents with
own information as proxy responses were not accepted. The
panic disorder (current and past) were selected for analysis.
responding sample comprised 36,894 persons aged 15 or older,
Odds ratios were estimated using multiple logistic regression
and the response rate was 77%.
analysis. Two sets of models were used. In model 1, the following
For the CCHS, panic disorder was measured using the World
control variables were introduced: sex, age, marital status, and
Mental Health version of the Composite International Diagnostic
education or household income. These variables were retained for
Interview (WMH-CIDI), an instrument created to assess mental
model 2, in addition to chronic physical conditions and other mental
disorders based on the Diagnostic and Statistical Manual of Mental
disorders: agoraphobia, social anxiety disorder, major depressive
Disorders, Fourth Edition, Text Revision (DSM-IV®-TR).2 The CIDI
episode, and post-traumatic stress disorder (in past 12 months only).
was designed to measure prevalence of mental disorders at the
A comparison of results between models—differences in the odds
community level, and it can be administered by lay interviewers.
ratios—permits an assessment of the contribution of panic disorder
The questions and algorithms used to measure panic attacks and
on two selected outcomes: work status and coping.
panic disorder in the CCHS are presented in the Annex. The CCHS
The analysis was based on a weighted sample representing the
1.2 questionnaire is available on Statistics Canada’s Web site
total population aged 15 or older in the 10 provinces in 2002.
@ www.statcan.ca.4
Variance for prevalence rate estimates, differences between rates,
and odds ratios was calculated using the bootstrap technique in
order to account for the survey design effect.3,9-11
Panic disorder, which is characterized by recurrent,
1.2, conducted among the household population in
unexpected panic attacks, can be chronic and
2002 (see Methods, Definitions and Limitations).
disabling .2,5,6 It most commonly begins in adolescence
Prevalence rates are presented for respondents who
or early adulthood,7 prime years for completing
had panic disorder in the year before the survey
education, entering the job market and forming
interview (current), who did not currently have the
relationships. The stress and disruption that may result
disorder, but had a history (past), and those who had
from panic disorder can have long-lasting personal,
both (lifetime) (see Annex). The analysis presents
social and economic consequences.6-8
selected characteristics of individuals with current or
This article focuses on panic disorder and is based
past panic disorder, comparing them with people who
on recent data from the Canadian Community Health
had never had the disorder. The article then examines
Survey: Mental Health and Well-being (CCHS) cycle
the occurrence of other mental and physical health
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Panic disorder and coping
problems in people with panic disorder, and assesses
Panic disorder more common among
the independent contribution of panic disorder to work
women
status and coping behaviours.
According to the CCHS, 3.7% of the Canadian
People with panic disorder may have other
population aged 15 or older have suffered from panic
conditions such as agoraphobia, depression, social
disorder—recurrent, unexpected panic attacks—at
anxiety disorder, and obsessive compulsive
some point during their lives. This rate is higher than
disorder.8,12-16 In this study, agoraphobia is included
expected based on other international community
as a comorbid condition because the relatively small
surveys.7,17 Because the CCHS did not apply the
number of cases identified in the CCHS prevented
exclusion criteria outlined in the Diagnostic and
the more usual comparison of panic disorder with
Statistical Manual of Mental Disorders, Fourth Edition,
agoraphobia, panic disorder without agoraphobia, and
Text Revision (DSM-IV®-TR)2 (see Limitations), the
agoraphobia without a history of panic disorder.
rates may be inflated. In 2002, the lifetime prevalence
Panic attacks
of panic disorder was higher for women (4.6%) than
men (2.8%) (Table 2), a finding consistent with other
Panic attacks are discrete periods of intense fear that
studies.6,7,18,19 In the CCHS, the female-to-male ratio
occur in the absence of any real danger (see
was 1.7. An estimated 1.5% of Canadians had panic
Definitions and Annex). According to the 2002 CCHS,
disorder in 2002 (current); another 2.1% had a past
over 5 million people in Canada, or 21% of the
history of the disorder.
population aged 15 or older, had had a panic attack at
some point during their lives (data not shown). Almost
Table 2
2 million, or 8%, reported having had an attack in the
Prevalence of panic disorder, by selected socio-demographic
year before their survey interview (Table 1). Women
characteristics, household population aged 15 or older,
were more likely than men to be affected (10% versus
Canada excluding territories, 2002
6%). Panic attacks were more common at younger
Current
Past
ages; for example, 12% of 15- to 24-year-olds had
(past 12 (excluding
Lifetime
months)
current)
had a panic attack in the past 12 months, compared
with 4% of people aged 55 or older.
%
%
%
Total
3.7
1.5
2.1
Men†
2.8
1.0
1.7
Women
4.6*
2.0*
2.5*
Age group
Table 1
15-24
2.9
1.8*
1.1*E1
Prevalence of panic attack in past 12 months, by age group
25-34
3.9*
1.8*
2.1
and sex, household population aged 15 or older, Canada
35-44
4.5*
2.0*
2.4*
excluding territories, 2002
45-54
5.1*
1.5*
3.5*
55 or older†
2.5
0.8
1.6
Both sexes
Men
Women
Marital status‡
Married/Common-law†
3.9
1.4
2.5
%
%
%
Widowed
6.4E2
F
F
Divorced/Separated
7.2*
3.2*
3.6*
Total
8.0
6.0
9.9‡
Never married
4.8
2.3*
2.4
Age group
Education‡
15-24
11.8*
7.4*
16.4*
Less than secondary education
5.1
1.9
3.0
25-34
10.3*
7.2*
13.3*
Secondary graduation
4.9
2.3*
2.5
35-44
8.6*
6.8*
10.4*
Some postsecondary/Postsecondary
45-54
7.6*
5.8*
9.2*
graduation†
4.0
1.5
2.5
55 or older†
4.2
3.9
4.4
Household income
Data source: 2002 Canadian Community Health Survey: Mental Health and
Low/Lower-middle
5.7*
3.1*
2.3
Well-being
Middle
3.5
1.8
1.7*
† Reference category
Upper-middle/High†
3.7
1.3
2.3
* Significantly different from estimate for reference category (p < 0.05)
Data source: 2002 Canadian Community Health Survey: Mental Health and
‡ Significantly different from estimate for men (p < 0.05)
Well-being
Note: A “missing” category for household income was included, but prevalence
is not shown.
† Reference category
‡ For people aged 25 to 64
* Significantly different from estimate for reference category (p < 0.05)
E1 Coefficient of variation between 16.6% and 25.0%
E2 Coefficient of variation between 25.1% and 33.3%
F Coefficient of variation greater than 33.3%
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Panic disorder and coping
Definitions
To be classified as having panic disorder, Canadian Community
The presence of at least one chronic condition was determined by
Health Survey (CCHS) cycle 1.2: Mental Health and Well-being
asking respondents if they had “any long-term health conditions
respondents must have first met the diagnostic criteria for panic
that are expected to last or have already lasted six months or more
attacks. See the Annex for the full definitions, questions and
and that have been diagnosed by a health professional.” The
algorithms used in the CCHS.
interviewer then read a checklist of conditions. The 18 self-reported
There are three types of panic attacks. Unexpected attacks—
conditions considered in this analysis were: asthma, fibromyalgia,
characteristic of panic disorder—seem to occur “out of the blue”;
arthritis/rheumatism, back problems excluding fibromyalgia and
that is, they do not appear to be related to a particular event or set
arthritis, high blood pressure, migraine, diabetes, epilepsy, heart
of circumstances. Situationally bound attacks are predictable, in
disease, cancer, stomach or intestinal ulcers, effects of a stroke,
that they happen when the person is in a certain situation (public
bowel disorder/Crohn’s disease or colitis, thyroid condition, chronic
speaking, for example) or is anticipating that situation. Situationally
fatigue syndrome, multiple chemical sensitivities, chronic bronchitis,
predisposed panic attacks are similar, except they do not always
and emphysema or chronic obstructive pulmonary disease.
occur in the given set of circumstances, or if they do, it is not
Respondents who met the 12-month criteria for agoraphobia, social
immediately after the exposure.2
anxiety disorder or major depressive episode or who said they
Age of onset for panic disorder was defined as the age of the
suffered from post-traumatic stress disorder were considered to have
respondent when the first panic attack occurred.
a concurrent mental health disorder. (See the Annex for detailed
Respondents were placed into the following age groups for this
descriptions of social anxiety disorder and major depressive
analysis: 15 to 24, 25 to 34, 35 to 44, 45 to 54, 55 or older. Some
disorder.)
analyses were restricted to certain groups (25 to 64 for marital status
Respondents who met the lifetime criteria for agoraphobia, social
and education, for example). Age was entered into logistic regression
anxiety disorder or major depressive episode, but who had not had
models as a continuous variable.
these conditions in the year before the survey were coded as having
Marital status at the time of the interview was used: married/
other past mental disorders. Post-traumatic stress disorder was
common-law; widowed; divorced or separated; and never married.
not included in this definition because it was evaluated only as a
Education was grouped as follows: less than secondary
current chronic condition.
graduation, secondary graduation, some postsecondary, and
To establish work status, respondents were asked if they had
postsecondary graduation.
worked at a job or business in the past 12 months. Those who
Household income was based on the number of people in the
indicated “no” were coded “1” for this dichotomous variable.
household and total household income from all sources in the 12
Responses of “yes” were coded “0.”
months before the 2002 interview.
The CCHS also asked about working in the last week: “Last week,
Household
People in
Total household
did you work at a job or a business?”. A dichotomous variable was
income group
household
income
created; those who reported they were permanently unable to work
Low
1 to 4
Less than $10,000
were coded “1.” Those who responded “yes” or “no” to this question
5 or more
Less than $15,000
were coded “0.”
Lower-middle
1 or 2
$10,000 to $14,999
Based on residential postal code and 1996 Census geography,
3 or 4
$10,000 to $19,999
respondents were categorized as living in an urban or rural area.
5 or more
$15,000 to $29,999
Middle
1 or 2
$15,000 to $29,999
3 or 4
$20,000 to $39,999
5 or more
$30,000 to $59,999
Upper-middle
1 or 2
$30,000 to $59,999
3 or 4
$40,000 to $79,999
5 or more
$60,000 to $79,999
High
1 or 2
$60,000 or more
3 or more
$80,000 or more
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Panic disorder and coping
Mid-twenties onset
People in lower household income groups were
As seen in other studies,2,7,14 panic disorder first
more likely to have current panic disorder than were
appears most often in the younger age groups. The
those at higher income levels. It is possible that lower
CCHS results show that people younger than 55 were
income is indicative of other stressful circumstances
more likely to have current panic disorder than those
that contribute to the illness, or that the disorder itself
aged 55 or older (Table 2). The average age of onset
leads to reduced income when people with panic
for lifetime panic disorder was 25; for 75% of those
disorder are unable to work. Although it has been
with the disorder, it had begun by age 33 (Chart 1).
suggested that panic disorder is most prevalent in
urban areas,7 this was not the case in the CCHS.
Chart 1
Other physical and mental illnesses
Cumulative incidence of panic disorder, by age of onset,
Among those with current panic disorder, three-
household population aged 15 or older with lifetime history
quarters (76%) reported at least one diagnosed
of panic disorder, Canada excluding territories, 2002
chronic condition (Chart 2). Among people with past
Cumulative %
panic disorder, the proportion with at least one such
100
illness was slightly lower (68%), yet it exceeded the
figure for those who had never had panic disorder
80
(54%).
25th
The presence of other mental disorders is fairly
percentile
common among people who have experienced panic
60
disorder.13,22-24 Almost half of those with current panic
75th
percentile
disorder (48%) had also had agoraphobia, social
40
anxiety disorder, post-traumatic stress disorder, or a
Average
20
Chart 2
0
Percentage of people with chronic condition(s) and other
0
5
10
15
20
25
30
35
40
45
50
55 60+
mental health disorders, by history of panic disorder,
Age of onset
household population aged 15 or older, Canada excluding
Data source: 2002 Canadian Community Health Survey: Mental Health and
territories, 2002
Well-being
%
Panic disorder
80
Marital status, education and income
*
Current (past 12 months)
Past (excluding current)
*
In 2002, panic disorder (current and past) was more
Never
common among individuals who were separated or
60
divorced than among those who were married
†
*
(Table 2), a finding consistent with other research.7
The higher prevalence among this group may reflect
40
an association between stressful life events and the
development of panic disorder.20 For example, a
†
20
*
review that focussed specifically on panic disorder with
agoraphobia concluded that major life events—
including marital and interpersonal problems—tend to
0
occur in the period preceding the disorder.21
At least one
Current mental
Past mental
§
Lower education and income levels were also
chronic physical condition‡
health disorder
health disorder‡‡
associated with the presence of panic disorder. The
Physical/Mental health
prevalence of current panic disorder was higher among
individuals whose education had ended with
Data source: 2002 Canadian Community Health Survey: Mental Health and
secondary graduation, compared with those who had
Well-being
† Significantly different from estimate for “never” and “past” (p < 0.05)
postsecondary education. People with less than
‡ See Definitions for list of 18 self-reported diagnosed chronic conditions
secondary graduation were no more likely to have
§ Agoraphobia, social anxiety disorder, post-traumatic stress disorder, major
current or past panic disorder than those with
depressive episode
‡‡ Agoraphobia, social anxiety disorder, major depressive episode
postsecondary graduation, in contrast to previous
* Significantly higher than estimate for “never” (p < 0.05)
research.7
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Panic disorder and coping
major depressive episode in the preceding 12 months.
health problems were also considered, these
This is significantly more than the 20% of people with
relationships held.
past panic disorder. Both groups were more likely to
By contrast, there was no difference in work status—
have had one of these mental illnesses in the past
not working in the past year or being permanently
year than the rest of the population (7%).
unable to work—between those with a history of panic
Although many people with current panic disorder
disorder and those who had never had the disorder.
did not have another mental disorder in the year before
In other words, the work status of people who
the survey interview, they may have had one or more
experience remission for a year or more and those
in the past: 22% had a history of agoraphobia, social
with no history of panic disorder appears to be similar.
anxiety disorder, or a major depressive episode (see
Limitations). Among people with a history of panic
Negative ways of coping
disorder, 46% had an accompanying history of at least
The frequent use of negative coping behaviour has
one of these other mental disorders.
been documented for people suffering from panic
disorder: avoidance, self-blame and wishful thinking
Less likely to work
(as opposed to a problem-solving approach), for
People aged 25 to 64 who had panic disorder in the
example.25-27 Analysis of results from the 2002 CCHS
12 months before the CCHS interview were less likely
also indicated that people with current or past panic
to have worked at a job or business during that time
disorder had odds that were around two to three times
(72%) than those who had panic disorder in the past
higher than those with no history of the disorder to
(82%) or who had never had the condition (84%) (data
withdraw from people, to blame themselves, and to
not shown). Individuals with current panic disorder
wish problems away (Table 4). They were also less
were also more likely to be permanently unable to
likely to look on the “bright side” of things (see Coping
work: 11% compared with 2% for those with past panic
behaviours).
disorder or who never had the condition. When socio-
The odds of drinking to cope with stress, and of
demographic factors were taken into account,
smoking more than usual, were approximately twice
individuals with current panic disorder had higher odds
as high for those with current and past panic disorder
of being permanently unable to work than those who
in comparison with people who had never had the
had never had the disorder (Table 3, Appendix Tables
condition. According to the CCHS (data not shown),
A and B). And even when other physical and mental
18% of people with panic disorder said they coped
Table 3
Adjusted odds ratios relating panic disorder to work status, without and with controlling for physical and other mental health
problems, household population aged 25 to 64, Canada excluding territories, 2002
Model 1
Model 2
Controlling for
Controlling for
socio-demographic factors
socio-demographic
and physical and other
factors†
mental health problems‡
95%
95%
Odds
confidence
Odds
confidence
Work status
Panic disorder
ratio
interval
ratio
interval
Did not work at job or
Current (past 12 months)
2.0*
1.5, 2.7
1.6*
1.1, 2.2
business in past 12 months
Past (excluding current)
0.9
0.7, 1.2
0.9
0.7, 1.1
Never§
1.0
…
1.0
…
Permanently unable to work
Current (past 12 months)
6.4*
3.9,10.5
3.2*
1.8, 5.8
Past (excluding current)
1.1
0.7, 1.7
0.9
0.5, 1.4
Never§
1.0
…
1.0
…
Date source: 2002 Canadian Community Health Survey: Mental Health and Well-being
Note: Summarizes results of 4 separate regression models; complete results can be found in Appendix Tables A and B.
† Sex, age, marital status and education
‡At least one of 18 self-reported diagnosed chronic conditions (see Definitions); agoraphobia, social anxiety disorder, major depressive episode, and post-traumatic
stress disorder (past year only)
§ Reference category
* Significantly different from estimate for reference category (p < 0.05)
… Not applicable
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Panic disorder and coping
Table 4
Adjusted odds ratios relating panic disorder to selected behaviours, without and with controlling for physical and other mental
health problems, household population aged 15 or older, Canada excluding territories, 2002
Model 1
Model 2
Controlling for
Controlling for
socio-demographic factors
socio-demographic
and physical and other
factors†
mental health problems‡
95%
95%
Odds
confidence
Odds
confidence
Behaviour
Panic disorder
ratio
interval
ratio
interval
Withdrawing from people
Current (past 12 months)
3.0*
2.2, 3.9
1.8*
1.4, 2.5
Past (excluding current)
2.1*
1.7, 2.7
1.6*
1.2, 2.0
Never§
1.0
…
1.0
…
Drinking alcohol to cope
Current (past 12 months)
1.8*
1.4, 2.4
1.2
0.9, 1.6
Past (excluding current)
1.9*
1.4, 2.6
1.4*
1.0, 2.0
Never§
1.0
...
1.0
...
Smoking more than usual
Current (past 12 months)
2.6*
1.8, 3.7
1.7*
1.2, 2.5
Past (excluding current)
2.2*
1.6, 3.1
1.7*
1.2, 2.5
Never§
1.0
...
1.0
...
Blaming oneself
Current (past 12 months)
2.6*
2.0, 3.4
1.7*
1.3, 2.2
Past (excluding current)
2.3*
1.8, 3.1
1.7*
1.3, 2.3
Never§
1.0
...
1.0
...
Wishing problem would go away
Current (past 12 months)
2.8*
1.9, 4.0
1.9*
1.3, 2.8
Past (excluding current)
2.0*
1.2, 3.2
1.6
1.0, 2.6
Never§
1.0
...
1.0
...
Praying/Seeking spiritual help
Current (past 12 months)
1.3*
1.1, 1.7
1.2
0.9, 1.5
Past (excluding current)
1.5*
1.2, 1.9
1.3*
1.0, 1.7
Never§
1.0
...
1.0
...
Looking on the bright side
Current (past 12 months)
0.4*
0.3, 0.5
0.7*
0.5, 0.9
Past (excluding current)
0.8
0.5, 1.1
1.0
0.7, 1.5
Never§
1.0
...
1.0
...
Lifetime illicit drug use excluding
Current (past 12 months)
2.1*
1.7, 2.8
1.5*
1.1, 2.0
one-time cannabis use
Past (excluding current)
2.5*
1.9, 3.2
1.9*
1.4, 2.4
Never§
1.0
...
1.0
...
Date source: 2002 Canadian Community Health Survey: Mental Health and Well-being
Note: Summarizes results for 16 separate regression models; complete results available on request.
† Sex, age, marital status and household income
‡At least one of 18 self-reported diagnosed chronic conditions (see Definitions); agoraphobia, social anxiety disorder, major depressive episode, and post-traumatic
stress disorder (past year only)
§ Reference category
* Significantly different from estimate for reference category (p < 0.05)
… Not applicable
with stress by consuming alcohol, significantly more
Some studies have reported gender differences
than among people who had never had the condition
among people with panic disorder in relation to
(11%). Of those with either current or past panic
agoraphobia and agoraphobic avoidance.5,28,29 But
disorder, men were more likely to handle their stress
other research has found no such differences,30
by drinking (24%) than were women (14%). Even
consistent with analysis of CCHS data for these
when socio-economic factors, as well as other mental
behaviours by sex. Among men and women with panic
and physical conditions were taken into account, men
disorder, there were no significant differences for
had higher odds of drinking as a way of coping. Similar
coping with stress by withdrawing or in the presence
differences in alcohol use rates have been noted in
of lifetime agoraphobia (data not shown).
other studies.5,28,29
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Panic disorder and coping
Coping behaviours
Seeking help
It has been reported that a high proportion of people
In the 2002 Canadian Community Health Survey (CCHS), all
with panic disorder use medical services,18,20,32-34 a
respondents were asked about coping with stress. Withdrawing
finding supported by results from the CCHS. All CCHS
indicates respondents who “often” or “sometimes” coped by
respondents were asked if they had ever seen or
talked on the telephone to a professional about their
avoiding being with people, sleeping more than usual, or by “rarely”
emotions, mental health or use of alcohol or drugs.
or “never” talking to others. Respondents were also asked how
About 70% of those with panic disorder (current or
often they used/did each of the following when dealing with stress:
past) had consulted a medical professional
• try to feel better by drinking alcohol
(psychiatrist, family doctor, other medical doctor, or
• try to feel better by smoking more cigarettes than usual
psychologist) about these concerns, compared with
• blame yourself
18% of people who had never had panic disorder
• wish the situation would go away or somehow be finished
(Table 5). Almost half (48%) of the people who
• pray or seek spiritual help
currently had panic disorder had had a consultation in
• try to look on the bright side of things
the past year. Even after demographic and other
Responses were grouped as often/sometimes versus rarely/never.
mental and physical health characteristics were taken
Lifetime illicit drug use, excluding one-time cannabis use, was
into account, people with panic disorder had almost
derived from a series of questions asking respondents if they had
six times the odds of having consulted a medical
professional about their mental health compared with
ever used or tried:
people without the disorder (Appendix Table C).
• marijuana, cannabis or hashish
CCHS respondents who had experienced two or
• cocaine or crack
more unexpected panic attacks were specifically asked
• speed (amphetamines)
if they had consulted a medical doctor or other
• ecstasy (MDMA) or other similar drugs
professional about their attacks (data not shown). The
• hallucinogens, PCP or LSD (acid)
term “professional” was used more broadly in this
• heroin
question to include social workers, counsellors,
• steroids, such as testosterone, dianabol or growth
spiritual advisors, homeopaths, acupuncturists and
hormones, to increase your performance in a sport or activity
self-help groups. About 73% of people with panic
or to change your physical appearance
disorder (past or current) reported such a consultation.
• [sniffing] glue, gasoline or other solvents
Women were significantly more likely than men to have
sought help: 77% compared with 65%.
Illicit drug use
Table 5
Percentage of people who consulted a medical professional
Other research has concluded that substance use,
about emotions, mental health, or use of alcohol or drugs, by
including cannabis, is associated with panic
panic disorder status, household population aged 15 or older,
disorder,13,31 a finding consistent with results from the
Canada excluding territories, 2002
CCHS: 62% of people with current panic disorder and
60% of those with a history had used illicit drugs at
Panic disorder
%
some point (data not shown). By contrast, 41% of
Ever seen or talked to
Current (past 12 months)
71.8*
people with no history of the disorder had tried illicit
medical professional
Past (excluding current)
69.7*
drugs (see Definitions). When those who reported
Never†
18.1
trying cannabis only once were excluded, the rates of
Seen or talked to
Current (past 12 months)
48.4‡
lifetime illicit drug use fell to 52% for those with current
medical professional in
Past (excluding current)
20.9*
panic disorder, 51% for those with past panic disorder,
past 12 months
Never†
6.1
and 33% for everyone else. Regardless of the
Date source: 2002 Canadian Community Health Survey: Mental Health and
direction of the relationship, which cannot be
Well-being
Note: Medical professional includes psychiatrist, family doctor or general
established with the CCHS cross-sectional data, it is
practitioner, other medical doctor such as cardiologist, gynaecologist or
clear that people with panic disorder were more likely
urologist, and psychologist.
to have used illicit drugs than were those who had
† Reference category
* Significantly different from estimate for reference category (p < 0.05)
never had the disorder.
‡ Significantly different from estimate for reference category and past panic
disorder (p < 0.05)
… Not applicable
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Panic disorder and coping
Those who had sought help for their attacks were
The high proportion of people with panic disorder
asked if they had ever received helpful or effective
who seek medical help is not surprising given the
treatment. Seven out of ten answered positively.
physical symptoms that may accompany attacks
However, this means that, overall, just half of the
(shortness of breath, chest pain or palpitations, for
people with current or past panic disorder received
example).38 Previous research has determined that
effective help. Some lack of satisfaction may result if
those with panic disorder are likely to seek treatment
the panic attacks remain undiagnosed or are
in the year of onset.39 The CCHS asked respondents
misdiagnosed. Other studies have concluded that
how old they were at the time of their first panic attack
many people with panic disorder seek help at
and their age when they first consulted a professional
emergency departments where their disorder remains
about the attacks. For most of them (68%), the
unrecognized or misdiagnosed.33-37
difference was one year or less, although some waited
Limitations
Studies of panic disorder often compare three mutually exclusive
symptom “Feeling dizzy, faint, unsteady or light-headed.” To reduce
groups: people with panic disorder, those with agoraphobia, and
respondent burden, respondents were “skipped out” of the module
people who have both. This was not possible using data from the
once they met the criteria with 4 positive responses. However, due
Canadian Community Health Survey (CCHS), given the small
to a programming error in the computer-assisted interviewing
sample size for each category. The high proportion of “unknown”
application, respondents were skipped out even if their 4 responses
cases in the panic disorder module contributed to the small sample.
included the 2 questions that contributed to a single symptom. These
A total of 1,397 people met the criteria for lifetime panic disorder,
respondents then failed to meet the criteria requiring 4 symptoms.
34,711 did not, and a further 876 respondents could not be classified.
These people were coded as not having panic attacks or panic
Most of the unknown cases (497) were “lost” in the 16-question/14-
disorder (and were therefore included in the denominator). For the
symptom checklist for panic attacks due to non-response (see
most part, their status as non-cases was confirmed when they failed
Annex). A further 282 cases became “unknown” after a non-
to meet other criteria for the disorder further on in the questionnaire.
response to the question about the number of unexpected attacks a
However, it is possible that a small number of cases were
person had experienced during his or her lifetime. Of the remaining
misclassified, resulting in a possible underestimation of the
unknown cases, 64 were lost due to a non-response to the screening
prevalence of panic disorder.
questions; 33 others were lost due to non-response to other
In the Diagnostic and Statistical Manual of Mental Disorders, Fourth
questions.
Edition,Text Revision,2 people are excluded from a diagnosis of panic
For this study, two separate analyses were undertaken to evaluate
disorder if their panic attacks are due to a general medical condition
the impact of omitting cases with unknown panic disorder status. In
(e.g., hyperthyroidism) or are the physiological consequence of a
these analyses, the unknown cases were retained and were grouped
substance (e.g., caffeine). Based on advice to Statistics Canada
separately in an “unknown” category. Then, in a “worst case
from clinicians, these exclusion criteria were not applied, which may
scenario,” all unknown cases were coded as having current panic
have resulted in an overestimation of prevalence; therefore, the
disorder. Results were compared and for the most part the direction
estimates may be higher than expected.
and significance of relationships remained unaltered. Thus while
It is not uncommon for obsessive-compulsive disorder to occur
the number of unknown cases for panic disorder may lower the
with panic disorder. Because of a translation error between English
prevalence estimates, it should not affect associations between
and French, data for this variable were suppressed; therefore,
variables.
obsessive-compulsive disorder could not be assessed or controlled
To meet the criteria for panic attacks and panic disorder,
for in the multivariate models.
respondents must have reported at least 4 symptoms out of a
CCHS respondents were identified as “having panic disorder”
possible 14. In the CCHS, 16 questions were used to assess the
based solely on their responses to the questionnaire, and the
14 symptoms. The questions, “Did you feel dizzy or faint?” and
presence or absence of the disorder was not clinically confirmed.
“Were you afraid that you may pass out?”, both contributed to the
This may have contributed to higher rates.
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Panic disorder and coping
longer. For 17%, the gap between onset of attacks
medical consultations for their panic attacks, nearly
and professional help was at least 10 years.
the same proportion reported seeking such help.
The findings presented in this article highlight the
Concluding remarks
complex of problems that people with panic disorder
According to the 2002 Canadian Community Health
typically have. For example, they are more likely to
Survey on mental health and well-being, almost
have a chronic physical condition or another mental
1 million Canadians either had panic disorder in the
health disorder. They may also have problems with
year before the survey interview, or they had had the
working, and may even be permanently unable to
condition at some point in their lives. Symptoms
work. After a year or more of remission from panic
usually began appearing in early adulthood—at age
disorder, however, their work status resembled that
25, on average.
of people who had never had the condition.
Health care utilization was fairly common among
Those with current or past panic disorder tended to
people with panic disorder. The physical sensations
cope with stress by withdrawing, blaming themselves,
of panic attacks often lead people to seek medical
or wishing their problems would simply disappear.
treatment, as they may fear a heart attack or other
Negative health behaviours—drinking to cope with
catastrophic illness.31 About 7 in 10 Canadians with
stress, smoking more than usual, and illicit drug use—
panic disorder had consulted a psychiatrist, family or
were also fairly common among people with panic
other doctor, or a psychologist, about their emotions
disorder.
or mental health. And when asked specifically about
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