Hypertension and Panic Attacks
abstract & commentary
Source: Davies SJ, et al. Association of panic disorder and panic attacks with hypertension. Am J Med 1999;107: 310-316.
To further characterize the potential association between panic disorder and hypertension, Davies and colleagues studied hypertensive family practice (HFP) patients, normotensive family practice (NFP) clinic patients, and hypertensive hospital-based clinic (HHC) patients. HFP patients were randomly sampled, with hypertension identified by a computerized problem list, antihypertensive treatment, or chart documentation of a recent blood pressure measurement of 160/90 or greater. In the same clinic, NFP patients were matched for age and gender. Finally, hypertensive patients from another clinic (HHC) were matched with the HFP patients by age and gender, excluding those (82) who were participating in a medication trial for panic disorder. All three groups were mailed a cover letter, a questionnaire based on DSM-III-R for panic attacks and panic disorder, a Hospital Anxiety and Depression Scale, and supplementary questions on medications and age at diagnosis of hypertension. Those not responding within two months were sent another questionnaire; they were deemed nonresponders if they had not replied within six weeks.
Of the 1053 questionnaires sent, 916 (88%) were returned; 25 were excluded because of uninterpretable responses or having been miscategorized (e.g., hypertensive instead of normotensive). HFP and HHC patients had a significantly greater prevalence of lifetime and current panic attacks than the NFP patients; only HFP had a significantly greater prevalence of panic disorder diagnosis (see Table). Anxiety scores were significantly higher in the HPC and the HHC groups compared to the NFP group; only HHC patients had significantly higher depressive scores compared to NFP patients. As for the effect of gender, both men and women with hypertension had elevated rates of panic attacks. Prevalence of panic symptoms was not related to age. Hypertensive patients who had experienced panic attacks (n = 197) were asked their ages at the time of the first panic attack and at diagnosis of hypertension. Hypertension preceded panic attacks in 48%, panic attacks preceded hypertension in 27%, and the timing coincided for 25%. There were no differences in antihypertensive use in those with and without panic symptoms.
| Table-Prevalence of Lifetime and Current Panic Attacks and the Diagnosis of Panic Disorder | |||
| Issue | HFP | NFP | HHC |
| Lifetime prevalence of panic attacks | 35%* | 22% | 39%* |
| Prevalence of current panic attacks | 17%* | 11% | 19%* |
| Diagnosis of panic disorder | 13%* | 8% | 10% |
| *Signifies P < 0.05 compared to NFP patients. | |||
Davies et al considered several possible reasons why panic symptoms and hypertension may be associated. First, panic symptoms could increase the chance of hypertension being diagnosed through greater medical contact. Second, antihypertensive medication may be initiated due to elevations in blood pressure associated with panic attacks and/or hyperventilation rather than hypertension. Finally, hypertension and panic attacks might be linked by a shared etiology (e.g., pheochromocytoma).
Comment by Donald m. Hilty, MD
The apparent association of panic disorder and hypertension is noteworthy. However, this study does not allow an examination of a causal or non-causal relationship; it looks at the prevalence of panic attacks and panic disorder in patients with and without hypertension. In addition, there are several important methodological limitations to this study. Self-administered questionnaires are practical but less valid than clinical diagnoses. The study did not control for comorbid medical conditions that may influence the prevalence of panic attacks (e.g., smoking, depression, lung disease—see Hilty DM. Are smoking and panic attacks related? Psychiatr Med Prim Care 2000;1:92-93.) By increasing the risk for cardiac disease, hypertension might indirectly increase the risk for panic attacks (cardiac disease was not assessed as a confounding variable). Similarly, norepinephrine may be involved in both panic attacks and hypertension. Finally, 82 patients in the HHC group were excluded because they participated in a prior panic study—this in all likelihood artificially lowered the prevalence rates for panic attacks and panic disorder in that group.
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