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 Table of Contents    
BRIEF RESEARCH COMMUNICATION  
Year : 2021  |  Volume : 63  |  Issue : 1  |  Page : 70-73
Dissociative experiences and health anxiety in panic disorder


1 Department of Psychiatry, IQ City Medical College, Durgapur, West Bengal, India
2 Department of Psychiatry, Vivekananda Institute of Medical Sciences, Kolkata, West Bengal, India
3 International Training Fellow, Cumbria, Newcastle, Tyne and Wear NHS Trust, UK, UKs

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Date of Submission23-Jul-2020
Date of Decision09-Aug-2020
Date of Acceptance10-Aug-2020
Date of Web Publication15-Feb-2021
 

   Abstract 


Background: Dissociative experiences and health anxiety are frequently encountered in anxiety disorders and contribute to the burden of illness.
Aim: The aim was to assess and compare dissociative experiences and level of health anxiety in patients with panic disorder and normal individuals.
Materials and Methods: We recruited forty eligible patients with panic disorder and forty healthy volunteers without any psychiatric diagnoses. Health anxiety was evaluated by the Short Health Anxiety Inventory and dissociative symptoms were assessed by the Dissociative Experiences Scale (DES).
Results: Dissociative experiences were more frequently reported by patients with panic disorder compared to normal controls, but overall mean DES scores were lower in both groups compared to previous literature. A high level of health anxiety was also seen in panic disorder compared to normal individuals.
Conclusion: Health anxiety and dissociative experiences, especially depersonalization-derealization, are commonly encountered in panic disorder and should be actively explored to understand how they influence psychopathology and treatment outcome.

Keywords: Dissociative experiences, health anxiety, panic disorder

How to cite this article:
Ray S, Ray R, Singh N, Paul I. Dissociative experiences and health anxiety in panic disorder. Indian J Psychiatry 2021;63:70-3

How to cite this URL:
Ray S, Ray R, Singh N, Paul I. Dissociative experiences and health anxiety in panic disorder. Indian J Psychiatry [serial online] 2021 [cited 2021 Mar 1];63:70-3. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/1/70/309519





   Introduction Top


Panic disorder is a distressing psychiatric condition characterized by cognitive distortions such as misinterpretation of harmless bodily or mental sensations and increased body vigilance.[1] Dissociative experiences (dissociative disorder not otherwise specified, dissociative amnesia, and depersonalization) have been reported in patients with panic disorder.[2] Depersonalization-derealization, which is often present in panic disorder, may be a manifestation of dissociative experiences.[3] Conversely, acute dissociation may be associated with symptoms of panic disorder.[4] One study postulated that panic attacks may serve as traumatic stressors and reported that comorbid posttraumatic stress disorder (PTSD), feeling of “being cut off” from others, and numbness in panic disorder patients highlight the increased vulnerability of panic disorder patients to dissociative experiences due to traumatic stress.[5] However, some earlier studies did not find higher dissociative experiences in panic disorder when compared to normal controls[6] or to other anxiety disorders.[7] Dissociative symptoms in patients with panic disorder negatively impact the treatment outcome and response to medication,[8] but Indian studies on dissociation in panic disorder are scarce.[9]

Health anxiety is characterized by persistent preoccupation about health and well-being in spite of the absence of any organic or medical illness and excessive vigilance to bodily symptoms.[10],[11] Sunderland et al.[12] found that 6% of the population had health anxiety which was associated with more distress, impairment, disability, and higher rate of health service utilization. An Indian study reported the occurrence of health anxiety as 25% and 19% in psychiatry and neurology settings, and in both scenarios, patients with somatoform disorder and multiple diagnoses had high health anxiety.[13] Health anxiety has been identified as a risk factor for the onset of panic disorder.[1] Panic disorder also has higher rates of health anxiety compared to other anxiety disorders.[10]

Previous research on anxiety disorders has demonstrated that both dissociative experiences and health anxiety are often unacknowledged but frequently encountered and they contribute to the burden of illness.

In this background, we planned this study to assess health anxiety and dissociative experiences in panic disorder and to compare these with normal individuals.


   Materials and Methods Top


Aim and objectives

The aim of the study was to assess and compare dissociative experiences and the level of health anxiety in patients with panic disorder and normal individuals.

Methodology

This was a cross-sectional observational study conducted in the Psychiatry Outpatient Department of a Medical College in Eastern India. Purposive sampling was used to recruit forty adult patients with panic disorder diagnosed as per the International Statistical Classification of Diseases and Related Health Problems, 10th Revision[14] 10 criteria by a consultant psychiatrist with more than 10 years of experience in psychiatry. Patients with any psychiatric comorbidity other than depression and anxiety disorders and those with debilitating medical illness were excluded from the study. We also enrolled forty healthy volunteers from among the unrelated attendants of patients attending the psychiatry outpatient department, who were without any psychiatric morbidity, screened by General Health Questionnaire 12[15] and having a score of <5. All the study participants provided written informed consent, and the study was approved by the institutional ethics committee.

Assessment

Sociodemographic data were recorded using a semi-structured sociodemographic datasheet. Anxiety symptoms were evaluated by the Hamilton Anxiety Rating Scale (HAM-A),[16] whereas depression was assessed using the Hamilton Depression Rating Scale (HAM-D)[17] Dissociative symptoms were assessed by the Dissociative Experiences Scale (DES)[18] which is a reliable and valid[19] self-administered 28-item questionnaire. Health anxiety was evaluated using the Short Health Anxiety Inventory (SHAI) which comprises of 18 items, each scored on a scale of 0–3 and summed to obtain the total score. It has good reliability and criterion validity[11],[20] and has been previously used in the Indian setting. Both the DES and SHAI were translated to Bengali by a health-care professional familiar with the terminology of the scales and whose mother tongue was Bengali and then back translated by a bilingual expert (as translator with English as mother tongue was not available) from Humanities stream as per standard procedures. All the participants were evaluated using the above mentioned scales.

Statistical analysis

The Statistical Package for the Social Sciences Windows version 16.0 (SPSS, Inc., Chicago [IL], US) was used for statistical analyses. The study participants were divided into two groups, a panic disorder group and a normal control group. Normal distribution of the demographic and clinical variables was determined by the Shapiro–Wilk W test, with exception of DES, SHAI, HAM-A, and HAM-D. Groups were compared using Pearson's Chi-square test (with Yates continuity correction when required) and Mann–Whitney U-test for categorical and continuous variables, respectively. All tests were two tailed, and significance was set at P value of ≤0.05.


   Results Top


The comparison between panic disorder and normal individuals is detailed in [Table 1]. Patients with panic disorder were of similar age group (30.7 ± 7.9 years) when compared to the normal control group (33.2 ± 8.2) (P = 0.108). Both groups had female preponderance. Six patients in the panic disorder group (15%) had comorbid agoraphobia and one patient had social phobia. Patients with panic disorder had the mean HAM-A score of 19.1 ± 4.7 and the mean HAM-D score was 11.00 ± 4, which expectedly was significantly higher than the mean scores of the control group. The mean SHAI score was significantly higher in panic disorder compared to normal individuals (22.2 ± 8.8 in panic disorder vs. 8.0 ± 3.7 in the normal group, P =< 0.001). The mean DES score was also higher in the panic disorder group (6.6 ± 4.3 in panic disorder vs. 3.9 ± 2.8 in normal individuals, P = 0.019). None of the patients with panic disorder or normal controls had DES score more than 30 which is considered as cutoff score for severe dissociation. No correlation of the DES scores was found with the severity of depressive or anxiety symptoms.
Table 1: Variables with values and comparison between two groups

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   Discussion Top


In our study, panic disorder patients had a female preponderance, a finding which is consistent with previous literature.[21] The mean HAM-D score in this study was 11.00 ± 4 and is explained by the well-established relation of depressive symptoms with panic disorder.[9] The mean DES score of 6.6 ± 4.3 in panic disorder was consistent with some earlier studies[7],[18] but lower than the mean DES score for panic disorder reported in a recent meta-analysis[3] and depersonalization/derealization was commonly encountered. In the study by Ball et al.,[7] low DES values were reported in panic disorder, as well as other anxiety disorders except PTSD, suggesting that dissociation is more related to trauma than anxiety. In another meta-analysis,[19] the mean DES score of 11.6 was reported for healthy individuals and our values were well below this range. In the study by Pastucha et al.,[6] patients with panic disorder had similar DES scores when compared to healthy controls, but they had more frequent severe dissociative states and level of dissociation correlated with severity of anxiety symptoms. In another study,[2] 19% of patients with panic disorder had the comorbid dissociative disorder and patients with a high degree of dissociative symptoms and dissociative disorder comorbidity had more severe panic symptoms. The wide variability in the DES scores in panic disorder can probably be explained by a difference in the conceptualization of dissociation as comprising only of depersonalization-derealization during panic attacks or more broadly as disturbances in integrity of memory, cognition, and awareness. This implies that further research is needed to clarify the relation between dissociation and anxiety disorders and that dissociative experiences should be explored while assessing panic disorder patients as higher rates of dissociative experiences if present, can have an impact on the course, outcome, and response to treatment.[8] This study also found high levels of health anxiety in panic disorder. A previous study reported a mean SHAI score of 19.08 ± 10.32 in panic disorder,[10] and our findings were comparable. A meta-analysis summarized that the pooled mean SHAI across anxiety disorders was 22.94 ± 10.98 and SHAI scores in this study were corroborative. This review also reported the pooled SHAI scores in nonclinical samples as 12.41 ± 6.81 which is slightly higher than our values.[20] This can be explained by the fact that most of the individual studies in nonclinical samples were done on undergraduate students, while our normal individuals comprised a more heterogeneous population representing diverse socioeconomic and cultural backgrounds. High rates of health anxiety cause more impairment, distress, and disability as well as injudicious use of health-care resources if it coexists with any mental disorder, and hence, it also needs to be actively explored.

This study had few limitations. First of all, the small sample size and cross-sectional design of the study made it difficult to determine how the presentation of panic disorder is modified by the dissociative experiences and health anxiety. Second, we used self-report questionnaires to assess health anxiety and dissociation and corroboration with clinician-rated instruments would have yielded better results.


   Conclusion Top


Health anxiety and dissociative experiences, especially depersonalization-derealization, are often commonly encountered in panic disorder and should be routinely explored in regular clinical assessment. Future research utilizing well-validated tools in the Indian setting is needed to understand how they influence psychopathology, treatment outcome, and usage of health resources.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Rudaz M, Craske MG, Becker ES, Ledermann T, Margraf J. Health anxiety and fear of fear in panic disorder and agoraphobia vs. social phobia: A prospective longitudinal study. Depress Anxiety 2010;27:404-11.  Back to cited text no. 1
    
2.
Ural C, Belli H, Akbudak M, Tabo A. Childhood traumatic experiences, dissociative symptoms, and dissociative disorder comorbidity among patients with panic disorder: A preliminary study. J Trauma Dissociation 2015;16:463-75.  Back to cited text no. 2
    
3.
Lyssenko L, Schmahl C, Bockhacker L, Vonderlin R, Bohus M, Kleindienst N. Dissociation in psychiatric disorders: A meta-analysis of studies using the dissociative experiences scale. Am J Psychiatry 2018;175:37-46.  Back to cited text no. 3
    
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Bryant RA, Panasetis P. The role of panic in acute dissociative reactions following trauma. Br J Clin Psychol 2005;44:489-94.  Back to cited text no. 4
    
5.
McNally RJ, Lukach BM. Are panic attacks traumatic stressors? Am J Psychiatry 1992;149:824-6.  Back to cited text no. 5
    
6.
Pastucha P, Prasko J, Grambal A, Latalova K, Sigmundova Z, Sykorova T, et al. Panic disorder and dissociation-Comparison with healthy controls. Neuro Endocrinol Lett 2009;30:774-8.  Back to cited text no. 6
    
7.
Ball S, Robinson A, Shekhar A, Walsh K. Dissociative symptoms in panic disorder. J Nerv Ment Dis 1997;185:755-60.  Back to cited text no. 7
    
8.
Gulsun M, Doruk A, Uzun O, Turkbay T, Ozsahin A. Effect of dissociative experiences on drug treatment of panic disorder. Clin Drug Investig 2007;27:583-90.  Back to cited text no. 8
    
9.
Trivedi JK, Gupta PK. An overview of Indian research in anxiety disorders. Indian J Psychiatry 2010;52:S210-8.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Deacon B, Abramowitz, JS. Is hypochondriasis related to obsessive compulsive-disorder, panic disorder, or both? An empirical evaluation. J Cogn Psychother 2008;22:115-27.  Back to cited text no. 10
    
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Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32:843-53.  Back to cited text no. 11
    
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Sunderland M, Newby JM, Andrews G. Health anxiety in Australia: Prevalence, comorbidity, disability and service use. Br J Psychiatry 2013;202:56-61.  Back to cited text no. 12
    
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Prabha L, Ganjekar S, Gupta V, Desai G, Chaturvedi SK. A comparative study of health anxiety in neurology and psychiatry settings. J Neurosci Rural Pract 2020;11:125-9.  Back to cited text no. 13
    
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World Health Organization.The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization;1992.  Back to cited text no. 14
    
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Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;32:50-5.  Back to cited text no. 16
    
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Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56-62.  Back to cited text no. 17
    
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Carlson EB, Putnam FW. An update on the dissociative experiences scale. Dissociation 1993;6:16-27.  Back to cited text no. 18
    
19.
van IJzendoorn MH, Schuengel C. The measurement of dissociation in normal and clinical populations: Meta-analytic validation of the dissociative experiences scale (DES). Clin Psychol Rev 1996;16:365-82.  Back to cited text no. 19
    
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Alberts NM, Hadjistavropoulos HD, Jones SL, Sharpe D. The short health anxiety inventory: A systematic review and meta-analysis. J Anxiety Disord 2013;27:68-78.  Back to cited text no. 20
    
21.
McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res 2011;45:1027-35.  Back to cited text no. 21
    

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Correspondence Address:
Imon Paul
Department of Psychiatry, IQ City Medical College, IQ City Road, Durgapur - 713 206, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_896_20

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