What is the best approach to screen for panic disorder?

Screening for Panic Disorder

The most effective approach to screen for panic disorder is to use the Generalized Anxiety Disorder-2 (GAD-2) scale as an initial quick screen, followed by more specific assessment tools like the Panic Disorder Severity Scale (PDSS) for those who screen positive. 1

Initial Screening Process

Step 1: Brief Initial Screening

• Use the GAD-2 scale as a quick first-line screening tool:
  • Takes less than 1 minute to complete
  • Consists of two questions scored from 0-3
  • A score of ≥3 indicates need for further assessment 1

Step 2: Comprehensive Assessment for Positive Screens

For patients with positive GAD-2 screens (score ≥3):

• Administer the full GAD-7 to assess anxiety severity:
  • 0-4: Minimal anxiety
  • 5-9: Mild anxiety
  • 10-14: Moderate anxiety
  • 15-21: Severe anxiety 1
• For suspected panic disorder specifically, use the Panic Disorder Severity Scale (PDSS):
  • 7-item tool with excellent sensitivity and specificity for panic disorder 2

Diagnostic Criteria Assessment

When panic disorder is suspected, assess for these specific DSM-5 criteria:

• Recurrent unexpected panic attacks
• At least one attack followed by ≥1 month of:
  • Persistent concern about additional attacks
  • Worry about implications/consequences of attacks
  • Significant maladaptive behavioral changes related to attacks
• Rule out substance-induced anxiety and medical conditions 3

Risk Factor Identification

Identify pertinent history and specific risk factors:

• Family history of anxiety disorders
• Comorbid psychiatric disorders (especially mood disorders)
• History or presence of substance use/abuse
• Presence of other chronic illnesses 3

Medical Evaluation

Before confirming diagnosis, rule out medical conditions that can mimic panic symptoms:

• Hyperthyroidism
• Hyperparathyroidism
• Cardiac arrhythmias
• Substance use/withdrawal 2

Special Considerations

Women-Specific Screening

• Women have approximately twice the lifetime prevalence of anxiety disorders compared to men (40% vs 20%)
• Screening is particularly important during pregnancy and postpartum periods when anxiety disorders increase in both frequency and impact 3

Adolescents

• Consider using age-appropriate screening tools
• The SCARED (Screen for Child Anxiety Related Emotional Disorders) is validated for adolescents 3

Common Pitfalls to Avoid

1. Misattribution of symptoms: Panic symptoms are frequently misattributed to physical causes, leading to unnecessary medical tests and delayed diagnosis 4, 5

2. Overlooking comorbidities: Panic disorder frequently co-occurs with:

   • Depression (56% of patients with major depression have anxiety disorders)
   • Other anxiety disorders
   • Substance use disorders 3, 6

3. Inadequate follow-up: Only about 20% of affected individuals seek care for anxiety conditions, making follow-up after positive screens crucial 3

4. Delayed diagnosis: Early identification can prevent functional impairment, as panic disorder often leads to anticipatory anxiety and phobic avoidance that significantly impacts quality of life 7

By implementing this structured screening approach in primary care settings, clinicians can effectively identify patients with panic disorder and initiate appropriate treatment, significantly improving outcomes and quality of life.