A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

Guillaume Foldes-Busque, Isabelle Denis, Julien Poitras, Richard P Fleet, Patrick Archambault, Clermont E Dionne, Guillaume Foldes-Busque, Isabelle Denis, Julien Poitras, Richard P Fleet, Patrick Archambault, Clermont E Dionne

Abstract

Introduction: Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain.

Methods and analysis: The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument.

Ethics and dissemination: This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

Keywords: Emergency medicine; Non-cardiac chest pain; Panic attacks; Panic disorder; Unexplained chest pain.

Figures

Figure 1
Figure 1
The Panic Screening Score (PSS) questionnaire.

References

    1. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Adv Data 2004;340:1–34
    1. Christenson J, Innes G, Mcknight D, et al. Safety and efficiency of emergency department assessment of chest discomfort. CMAJ 2004;170:1803–7
    1. Foldes-Busque G, Marchand A, Chauny JM, et al. Unexplained chest pain in the ED: could it be panic? Am J Emerg Med 2011;29:743–51
    1. Karlson BW, Herlitz J, Pettersin P. Patients admitted to the emergency room with symptoms indicative of acute myocardial infarction. J Intern Med 1991;230:251–8
    1. Kontos MC, Jesse RL. Evaluation of the emergency department chest pain patient. Am J Cardiol 2000;85:32B–9B
    1. Srinivasan K, Joseph W. A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine. Gen Hosp Psychiatry 2004;26:470–4
    1. Karlson BW, Wiklund I, Bengston A, et al. Prognosis, severity of symptoms, and aspects of well-being among patients in whom myocardial infarction was ruled out. Clin Cardiol 1994;17:427–31
    1. Papanicolaou MN, Califf RM, Hlatky MA, et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986;58:1181–7
    1. Eslick GD, Talley NJ. Natural history and predictors of outcome for non-cardiac chest pain: a prospective 4-year cohort study. Neurogastroenterol Motil 2008;20:989–97
    1. Rolls M, Kollind M, Theorel T. Five-year follow-up of young adults visiting an emergency unit because of atypical chest pain. J Intern Med 1992;231:59–65
    1. Dumville J, MacPherson H, Griffith K, et al. Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic. Fam Pract 2007;24:152–7
    1. Herlitz J, Karlson BW, Wiklund I, et al. Prognosis and gender differences in chest pain patients discharged from an ED. Am J Emerg Med 1995;13:127–32
    1. Lichtlen PR, Bargheer F, Wenzlaff P. Long-term prognosis of patients with angina like chest pain and normal coronary angiographic findings. J Am Coll Cardiol 1995;25:1013–18
    1. Eslick GD, Talley NJ. Non-cardiac chest pain: predictors of health care seeking, the types of health care professional consulted, work absenteeism and interruption of daily activities. Aliment Pharmacol Ther 2004;20:909–15
    1. Dammen T, Ekeberg A, Arnesen H, et al. Health-related quality of life in non-cardiac chest pain patients with and without panic disorder. Int J Psychiatry Med 2008;38:271–86
    1. Jerlock M, Kjellgren KI, Gaston-Johanson F, et al. Psychosocial profile in men and women with unexplained chest pain. J Intern Med 2008;264:265–74
    1. Jerlock M, Gaston-Johanson F, Danielson E. Living with unexplained chest pain. J Clin Nurs 2005;14:956–64
    1. Fagring AJ, Kjellgren KI, Rosengren A, et al. Depression, anxiety, stress, social interaction and health-related quality of life in men and women with unexplained chest pain. BMC Public Health 2008;8:165.
    1. Wong WM, Lam KF, Cheng C, et al. Population based study of noncardiac chest pain in southern Chinese: prevalence, psychosocial factors and health care utilization. World J Gastroenterol 2004;10:707–12
    1. Fagring A, Gaston-Johanson F, Kjellgren K, et al. Unexplained chest pain in relation to psychosocial factors and health-related quality of life in men and women. Eur J Cardiovasc Nurs 2007;6:329–36
    1. Rolls M, Kollind M, Theorel T. Five years follow-up of young adults visiting an emergency unit because of atypical chest pain. J Intern Med 1992;231:59–65
    1. Potts SG, Bass CM. Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study. Q J Med 1993;86:583–93
    1. Fagring AJ, Gaston-Johansson F, Danielson E. Description of unexplained chest pain and its influence on daily life in men and women. Eur J Cardiovasc Nurs 2005;4:337–44
    1. Coley KC, Saul MI, Seybert AL. Economic burden of not recognizing panic disorder in the emergency department. J Emerg Med 2009;36:3–7
    1. Carter C, Maddock R, Zoglio M, et al. Panic disorder and chest pain: a study of cardiac stress scintigraphy patients. Am J Cardiol 1994;74:296–8
    1. Abbass A, Campbell S, Magee K, et al. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study. CJEM 2009;11:529–34
    1. Katerndahl DA. Factors associated with persons with panic attacks seeking medical care. Fam Med 1990;22:462–6
    1. Kahn S. The challenge of evaluating the patient with chest pain. Arch Pathol Lab Med 2000;124:1418–19
    1. Eslick GD, Coulshed DS, Talley NJ. The burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther 2002;16: 1217–23
    1. Bringager CB, Arnesen H, Friis S, et al. A long term follow-up study of chest pain patients: effect of panic disorder on mortality, morbidity and quality of life. Cardiology 2008;110: 8–14
    1. Dammen T, Bringager CB, Arnesen H, et al. A 1-year follow-up study of chest-pain patients with and without panic disorder. Gen Hosp Psychiatry 2006;28:516–24
    1. Fleet RP, Lavoie KL, Martel JP, et al. Two-year follow-up status of emergency department patients with chest pain: was it panic disorder? CJEM 2003;5:247–54
    1. Fleet RP, Dupuis G, Kaczorowski J, et al. Suicidal ideation in emergency department chest pain patients: panic disorder a risk factor. Am J Emerg Med 1997;15:345–9
    1. Fleet RP, Dupuis G, Marchand A, et al. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med 1996;101:371–80
    1. Yingling KW, Wulsin LR, Arnold LM, et al. Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain. J Gen Intern Med 1993;8:231–5
    1. Foldes-Busque G, Fleet R, Poitras J, et al. Suicidality and panic in emergency department patients with unexplained chest pain. Gen Hosp Psychiatry 2012;34:178–84
    1. Worthington JJ, Pollack MH, Otto MW, et al. Panic disorder in emergency ward patients with chest pain. J Nerv Ment Dis 1997;185:274–6
    1. Wulsin L, Liu T, Storrow A, et al. A randomized controlled trial of panic disorder treatment initiation in an emergency department chest pain center. Ann Emerg Med 2002;39:139–43
    1. Wulsin LR, Hillard JR, Geier P, et al. Screening emergency room patients with atypical chest pain for depression and panic disorder. Int J Psychiatry Med 1988;18:315–23
    1. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Text Revised Washington, DC: American Psychiatric Association, 2000
    1. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 5th edn. DSM-5. Washington, DC: American Psychiatric Association, 2013
    1. Kessler RC, Chiu WT, Jin R, et al. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006;63:415–24
    1. Ramage-Morin PL. Trouble panique et comportements d'adaptation. Suppl Rapp Santé 2004;15:37–72
    1. Baillie AJ, Rapee RM. Panic attacks as risk markers for mental disorders. Soc Psychiatry Psychiatr Epidemiol 2005;40:240–4
    1. Batelaan N, De Graaf R, Van Balkom A, et al. Thresholds for health and thresholds for illness: panic disorder versus subthreshold panic disorder. Psychol Med 2007;37:247–56
    1. Batelaan N, Smit F, de Graaf R, et al. Economic costs of full-blown and subthreshold panic disorder. J Affect Disord 2007;104: 127–36
    1. Kinley DJ, Cox BJ, Clara I, et al. Panic attacks and their relation to psychological and physical functioning in Canadians: results from a nationally representative sample. Can J Psychiatry 2009;54:113–22
    1. Rubens M. Chronic anxiety: aspects of diagnosis and treatment. Can J CME 1997;9:147–67
    1. Stephenson DT. Medically unexplained physical symptoms in emergency medicine. Emerg Med J 2006;23:595–600
    1. Epstein NL. Chest pain and panic disorder in the ED? CJEM 2003;5:308.
    1. Pollard CA, Lewis LM. Managing panic attacks in emergency patients. J Emerg Med 1989;7:547–52
    1. Lee J, Dade LA. The buck stops where? What is the role of the emergency physician in managing panic disorder in chest pain patients? CJEM 2003;5:237–8
    1. Larkin GL, Beautrais AL, Spirito A, et al. Mental health and emergency medicine: a research agenda. Acad Emerg Med 2009;16:1110–19
    1. Gates TJ. Screening for cancer: evaluating the evidence. Am Fam Physician 2001;63:513–22
    1. Stiell I, Wells G. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47
    1. American Psychiatric Association Practice guideline for the treatment of patients with panic disorder. 2nd edn Washington, DC: American Psychiatric Association, 2009:90.
    1. Foldes-Busque G, Marchand A, Landry P. [Early detection and treatment of panic disorder with or without agoraphobia: update]. Can Fam Physician 2007;53:1686–93
    1. National Collaborating Centre for Mental Health and National Collaborating Centre for Primary Care Generalised Anxiety disorder and panic disorder (with or without agoraphobia) in adults. Management in primary, secondary and community care. London, UK: National Institute for Health and Clinical Expertise, 2011
    1. Starcevic V. Anxiety disorder in adults: a clinical guide. New York, NY: Oxford University Press, 2005
    1. Marchand A, Boivin I. Le trouble panique. In: Ladouceur R, Marchand A, Boisvert JM. eds. Les troubles anxieux: approche cognitive et comportementale. Montréal, QC: Gaétan Morin, 1999:59–94
    1. Swinson RP, Soulios C, Cox BJ, et al. Brief treatment of emergency room patients with panic attacks. Am J Psychiatry 1992;149:944–6
    1. Pelland ME, Marchand A, Lessard MJ, et al. Efficacy of 2 interventions for panic disorder in patients presenting to the ED with chest pain. Am J Emerg Med 2011;29:1051–61
    1. Lessard MJ, Marchand A, Pelland MÈ, et al. Comparing two brief psychological interventions to usual care in panic disorder patients presenting to the emergency department with chest pain. Behav Cogn Psychother 2012;40:129–47
    1. Roy-Byrne PP, Stein MB, Russo J, et al. Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment. J Clin Psychiatry 1999;60:492–9
    1. Swinson RP, Kuch K. Clinical-features of panic and related disorders. In: Ballenger JC.ed. Clinical aspects of panic disorder. New York, NY: Wiley-Liss, 1990:13–30
    1. Reich J, Warshaw M, Peterson LG, et al. Comorbidity of panic and major depressive disorder. J Psychiatr Res 1993;27:23–33
    1. Kessler RC, Ustün TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004;13:93–121
    1. Beitman BD, Kushner MG, Basha I, et al. Follow-up status of patients with angiographically normal coronary arteries and panic disorder. JAMA 1991;265:1545–9
    1. Brown TA, Barlow DH. Comorbidity among anxiety disorders: implications for treatment and DSM-IV. J Consult Clin Psychol 1992;60:835–44
    1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51:8–19
    1. Schmidt NB. Panic disorder: cognitive behavioral and pharmacological treatment strategies. J Clin Psychol Med Settings 1999;6:89–111
    1. Johnson MR, Gold PB, Siemon L, et al. Panic disorder in primary care: patients’ attributions of illness causes and willingness to accept psychiatric treatment. Int J Psychiatry Med 2000;30:367–84
    1. Foldes-Busque G, Fleet RP, Poitras J, et al. Preliminary investigation of the Panic Screening Score for emergency department patients with unexplained chest pain. Acad Emerg Med 2011;18:322–5
    1. Fleet RP, Dupuis G, Marchand A, et al. Detecting panic disorder in emergency department chest pain patients: a validated model to improve recognition. Ann Behav Med 1997;19:124–31
    1. Foldes-Busque G, Hamel S, Castonguay J, et al. Prospective validation of the Panic Screening Score for emergency department patients with unexplained chest pain: a preliminary investigation. Psychosom Med 2013;75:A142
    1. Jaffery Z, Hudson MP, Jacobsen G, et al. Modified thrombolysis in myocardial infarction (TIMI) risk score to risk stratify patients in the emergency department with possible acute coronary syndrome. J Thromb Thrombolysis 2007;24:137–44
    1. Hess EP, Perry JJ, Calder LA, et al. Prospective validation of a modified thrombolysis in myocardial infarction risk score in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med 2010;17:368–75
    1. Chase M, Robey JL, Zogby KE, et al. Prospective validation of the thrombolysis in myocardial infarction risk core in the emergency department chest pain population. Ann Emerg Med 2006;48:252–9
    1. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med 2003;349:2510–18
    1. Stiell IG. Ottawa ankle rules. Can Fam Physician 1996;42:478–80
    1. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005;294:1511–18
    1. Brown TA, Di Nardo PA, Barlow DH. Anxiety Disorders Interview for DSM-IV (ADIS-IV). Oxford University Press, 1994
    1. Boivin I, Marchand A. Évaluation structurée pour les troubles anxieux du DSM-IV. Montréal, QC: Université du Québec à Montréal, 1996
    1. Shear MK, Maser JD. Standardized assessment of panic disorder research. A conference report. Arch Gen Psychiatry 1994;51:346–54
    1. Fraenkel YM, Kindler S, Melmed RN. Differences in cognitions during chest pain of patients with panic disorder and ischemic heart disease. Depress Anxiety 1996–97;4:217–22
    1. First MB, Spitzer RL, Gibbon M, et al. Structured clinical interview for DSM-IV Axis I disorders-patient edition (SCID-I/P, version 2.0). New York, NY: New York State Psychiatric Institute, 1995
    1. Reiss S, Peterson RA, Gursky DM, et al. Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behav Res Ther 1986;24:1–8
    1. Verreault N, Marchand A, Labrecque J, et al. Validation de l'Index de sensibilité à l'anxiété auprès de la population québécoise francophone. Rev Québécoise Psychol 2007;28:253–68
    1. Gauthier J, Bouchard S. Adaptation canadienne-française de la forme révisée de State-Trait Anxiety Inventory de Spielberger. Can J Behav Sci 1993;25:559–78
    1. Spielberger CD. Manual for the state-trait anxiety inventory STAI-form Y. Palo Alto, CA: Consulting Psychologists Press Inc, 1983
    1. Stein MB, Roy-Byrne PP, McQuaid JR, et al. Development of a brief diagnostic screen for panic disorder in primary care. Psychosom Med 1999;61:359–64
    1. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999;282:1737–44
    1. Löwe B, Gräfe K, Zipfel S, et al. Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians’ diagnosis. J Psychosom Res 2003;55:515–19
    1. Hurst MW, Jenkins CD, Rose RM. The assessment of life change stress: a comparative and methodological inquiry. Psychosom Med 1978;40:126–41
    1. Czajkowski SM, Terrin M, Lindquist R, et al. Comparison of preoperative characteristics of men and women undergoing coronary artery bypass grafting (the Post Coronary Artery Bypass Graft [CABG] Biobehavioral Study). Am J Cardiol 1997;79:1017–24
    1. Klauke B, Deckert J, Reif A, et al. Life events in panic disorder—an update on “candidate stressors”. Depress Anxiety 2010;27:716–30
    1. Berhaut JC, Graham ID, Wood TJ, et al. Measuring acceptability of clinical decision rules: validation of the Ottawa acceptability of decision rules instrument (OADRI) in four countries. Med Decis Making 2010;30:398–408
    1. Altman DG, Royston P. What do we mean by validating a prognostic model? Stat Med 2000;19:453–73
    1. Zhang H, Singer B. Recursive partitioning in the health sciences. New York, NY: Springer-Verlag, 1999
    1. Breiman L, Friedman J, Stone CJ, et al. Classification and regression trees. Belmont, CA: Wadsworth International Group, 1984
    1. Skov T, Deddens J, Petersen MR, et al. Prevalence proportion ratios: estimation and hypothesis testing. Int J Epidemiol 1998;27:91–5
    1. Sullivan LM, Massaro JM, D'Agostino RB., Sr Presentation of multivariate data for clinical use: the Framingham Study risk score functions. Stat Med 2004;23:1631–60
    1. Fleiss JL. Statistical methods for rates and proportions. 2nd edn New York, NY: John Wiley & Sons, 1981
    1. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd edion New York, NY: John Wiley & Sons, 2000
    1. Roberge P, Marchand A, Reinharz D, et al. Health care utilization following cognitive-behavioral treatment for panic disorder with agoraphobia. Cogn Behav Ther 2005;34:79–88
    1. Katon W, Russo J, Sherbourne C, et al. Incremental cost-effectiveness of a collaborative care intervention for panic disorder. Psychol Med 2006;36:353–63
    1. Marchand A, Belleville G, Fleet R, et al. Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management. Gen Hosp Psychiatry 2012;34:671–80

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅