Indications for Psychiatric Consultation or Referral

Although most patients with panic disorder can be successfully treated in primary care, some cases would benefit from psychiatric consultation or referral:

• In patients with panic disorder who present with one or more somatic complaints, such as chest pain or irritable bowel syndrome, and tend to deny or minimize stressful life events and anxiety, diagnosis can be difficult. A psychiatric consultation may help confirm the diagnosis of panic disorder as well as elucidate family relationships, alcohol and drug history, affective illness, or somatoform disorders that are part of the patient's problem (Katon 1986).
  
  
• Many patients with panic disorder can have their panic attacks treated psychopharmacologically within the primary care system. A small subgroup of patients have treatment-resistant panic attacks or are hypersensitive to the side effects of psychopharmacologic agents. They may benefit from psychiatric consultation and/or referral.
  
  
• Patients with panic disorder frequently also suffer from major depression as well as demoralization about the overwhelming nature of their anxiety attacks. It is not unusual to see patients with either panic disorder alone or panic disorder and major depression who have serious suicidal ideation and a suicide plan. Coryell and colleagues' (1982) 20-year followup study of patients with panic disorder suggested that these patients are more apt to die from suicide than are controls. Psychiatric consultation and/or referral should usually be sought in this subgroup of patients.
  
  
• Some patients with panic disorder have serious medical illness such as heart disease, diabetes, or chronic obstructive lung disease that may complicate psychopharmacologic treatment of panic attacks. Also, the medications the patient needs to take for the chronic medical condition may interact with the therapeutic medications used for panic disorder. A psychiatric consultation or referral is often helpful to determine the safest possible psychopharmacologic treatment to prescribe.
  
  
• Patients with panic disorder who have a strong family history of alcoholism, affective disorders, or suicide or a personal history of alcoholism, substance abuse/dependence, erratic behavior or personality disorder, or psychotic illness would benefit from psychiatric consultation and/or referral.
  
  
• In panic disorder complicated by agoraphobia, psychopharmacologic amelioration of panic disorder and supportive therapy aimed at pushing the patient to confront formerly phobic situations usually gradually decrease avoidance behavior and phobic patterns. In recalcitrant patients who are too fearful to reenter phobic situations despite effective pharmacologic blockade of acute panic attacks, referral to a behaviorally oriented psychotherapist is often quite helpful.