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Dissociative experiences and health anxiety in panic disorder

Ray, Sujoy; Ray, Rajashree1; Singh, Neha2; Paul, Imon

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doi: 10.4103/psychiatry.IndianJPsychiatry_896_20
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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.[1011] 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.


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.


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.


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[1120] 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.


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


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[718] 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.


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


Conflicts of interest

There are no conflicts of interest.


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Dissociative experiences; health anxiety; panic disorder

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