J Occup Health 1999; 41: 267Ð270

Case Study disorder, psychosomatic therapy (medication, autogenic training and counseling) was tried for the complaint. Case of a Bus Driver Who Suffered from Past history: He had been suffering from hypertension β since his thirties and had taken 1 blocker (atenorol, 25 Panic Disorder in the Course of Treatment mg a day); since the age of 47 he had been taking for Depression psychosomatic therapy for depression. Family History: His 42-year-old wife had suffered Eiichi UCHIDA1, Fumika OKAJIMA2, Hirono ISHIKAWA3, Chihiro from autonomic imbalance for 15 yr, and recovered 4 yr SASAKI4, Taisaku KATSURA1 and Tetsuro OKINO5 ago. His 10-year-old son and 18-year-old daughter were healthy. 1Department of Psychosomatic Internal Medicine, LCC Medi- Physical examination and Clinical data: Height 170 cal Institute on Stress, 2Department of Nutrition, Kagawa Nu- cm, Weight 65 kg. Clinical laboratory findings (blood, trition University, 3Department of Health Sociology, Graduate urine, biochemical data) in the patient were within the School of Health Science and Nursing, University of Tokyo, normal range. Nutritional condition was good. Blood 4Department of Psychology, Ochanomizu University and pressure 125/80 mmHg, pulse pate 64/min, regular. 5Mitsubishi Material Co. Electrocardiogram: no specific finding. Birth and occupation: He, the youngest of three Key words: Depression, Panic disorder, Hypertension, brothers, born in Chiba prefecture, was apt to behave Stress, Psychosomatic therapy, Bus driver, Comorbidity like a spoiled child and to depend on others. After graduating from high school, he got a job in a railway The comorbidity of psychiatric disorders with chronic company and became a bus driver. His personality was health conditions has emerged as a topic of considerable happy-go-lucky, but he became punctual in his work. clinical and political interest, in part owing to the evidence Recently, he began to feel stress after hard and long that anxiety disorders are associated with depression. driving hours related to restructuring of the company. Nevertheless, the implications for health-related quality His wife had suffered from autonomic imbalance, but of life that result from anxiety disorders, which are recovered and had taken care of him. His blood pressure comorbid to chronic medical or psychiatric illness, are had been unstable. He has continued to be treated for not well understood, especially in primary care samples1). depression for 5 yr. He had taken medication, and got There are few clinical studies of depression and panic along without trouble in driving. disorder comorbidity in occupational health. From the Mental test: The Score of Self-rating Depression Scale epidemiological point of view, major depressive disorder (SDS); 57 points (>50) implied depression2). Manifest and generalized anxiety disorder frequently co-occur with Anxiety Scale (MAS); 28 points (>26) revealed high panic disorder, with estimates ranging 20% to 50% for anxiety. The Cornell Medical Index (CMI) Score showed each disorder2). In this report, we discuss the association a IV area (Fukumachi Method) which meant a nervous between depression, panic disorder and hypertension in personality. Self Grow-up Egogram (SGE); Critical a bus driver. Parent (CP) showing a personality critical of others: 12/ Case Report 20 points, Nurturing Parent (NP) revealing kindness and helpfulness: 12/20 points, Adult (A) indicating mature A 49-year-old male bus driver, who had been working decision: 10/20 points, Free Child (FC) representing in a railway company for 21 years, visited our clinic to cheerfulness and positiveness: 9/20 points, and Adapted receive psychosomatic therapy. He complained suddenly Child (AC) manifesting being cooperative with others: of acute palpitations, vertigo, breathlessness, dizziness, 16/20 points (highest score). Therefore he seems to have anxiety, phobia, restlessness, numbness of left hand, high adaptability, and may even overadapt himself to the nausea and headache. Before onset of the symptoms, he surroundings. had been treated for depression and hypertension, Personality: He is a serious type of man and cannot complaining of depression, loss of volition, stiffness refuse other’s requests. In fact, he is emotionally unstable, (especially in his shoulders), sleep disturbance, general but forced to adapt himself to surroundings. In addition, fatigue, asthenopia, nephelopia and loss of appetite. In he tended to require himself to be perfect and punctual the course of his treatment, he felt that the present because of his job (bus driver). complaints were different from previous ones, and wanted Clinical course: Figure 1 and Fig. 2 show his clinical another course of treatment. On a diagnosis of panic course and treatment. Around October, 1996, he was Received Jan 5, 1999; Accepted June 8, 1999 treated for depressive mood, loss of volition and appetite, Correspondence to: E. Uchida, Otsuka á Eiichi Clinic, Kinseido- sleep disturbance, shoulder stiffness, nephelopia, building 401, Minami-otsuka 3Ð46Ð10, Toshima-ku, Tokyo 170- asthenopia and general fatigue. After work, he felt fatigue 0005, Japan and had unstable blood pressure, so he had been careful 268 J Occup Health, Vol. 41, 1999

Fig. 1. Clinical course and treatment of a case of depression, a bus driver aged 49 years. Treatments in Figure 1 are as follows; Fig. 2. Clinical course and treatment of the case in Fig. 1 from Treatment (1): clomipramine (75 mg, 3x), amitryptyline the onset of panic disorder in July, 1997. (150 mg, 3x), bromazepam (15 mg, 3x), Treatments in Fig. 2 are as follows; piperiden (3 mg, 3x), triazolam (0.25 mg, 1x v.d.S), estazolam (2 mg, 1x Treatment (5): alprazolam (2.4 mg, 3x) v.d.S), chlorphenesin carbamate (750 Treatment (6): alpraxolam (6.4 mg, 3x), imipramine mg, 3x), atenorol (50 mg, 2x) (50 mg, 1x), oxprenolol (60 mg, 3x) Treatment (2): amitryptyline (50 mg, 1x v.d.S), Treatment (7): alpraxolam (3.2 mg, 3x), imipramine bromazepam (15 mg, 3x), piperiden (3 (50 mg, 1x), oxprenolol (120 mg, 3x) mg, 3x), atenorol (50 mg, 2x) Treatment (8): alpraxolam (3.2 mg, 3x), imipramine Treatment (3): amitriptyline (50 mg, 2x), bromazepam (150 mg, 1x), oxprenolol (120 mg, 3x) (5 mg, 1x) Treatment (9): alpraxolam (1.2 mg, 4x), imipramine Treatment (4): amitriptyline (30 mg, 1x v.d.S), (100 mg, 4x), oxprenolol (80 mg, 4x) bromazepam (5 mg, 1x v.d.S), Treatment (10): alpraxolam (0.8 mg, 4x), imipramine methylphenidate (30 mg, 2x) (40 mg, 4x), oxprenolol (80 mg, 4x)

of his work condition. With the medication in Fig. 1- headache had continued. When he had frequent fits, he (1)Ð(4), his condition was becoming stable, and the took alprazolam 1.6 mg and oxprenolol 40 mg. In August, quantity of medicine was gradually decreased, but since 1997, he often had headaches, acute palpitation, the middle of July, 1997, his present complaints have restlessness, dizziness and nausea. In the same month, been different from previous ones. He often felt anxiety, we decreased the dose of drugs as shown in Fig. 2-(6). phobia, sudden acute palpitations, restlessness, numbness His blood pressure changed little. In September his of the left hand, nausea and headache. On the other hand, condition was still bad, so he required one or two weeks loss of appetite, sleep disturbance, general fatigue, off from the company with a medical certificate. On 4 asthenopia had been gradually disappearing. In July, 1997 Sep. he had an electrocardiogram, but there was no he therefore asked for another treatment; medication was specific finding. His physical symptoms continued. changed on the diagnosis of panic disorder (from DSM- Because he had frequent acute palpitation, we changed IV)3). At the time, medication for his depression had his prescription as in Fig. 2-(7). In October, his continued as in Fig. 1-(4). For his severe complications prescription was changed again as in Fig. 2-(8), because caused by anxiety and phobia of panic disorder, he took his phobia had not disappeared. In November physical 20Ð30 min of counseling and autogenic training at every symptoms decreased, so we made the prescription as in visit and brought his mental pattern causing the symptoms Fig. 2-(9). In January, 1998 since his condition had been to his awareness. Medication for depression had been stable, we changed the prescription as in Fig. 2-(10). effective since 15, July, 1997; medication for panic disorder was added to the previous treatment as in Fig. 2-(5). We Discussion decided to decrease medicines for depression and observe The results of the present study support the diagnosis his condition. His agoraphobia was not reduced, and of comorbidity among depression, panic disorder and besides headache continued, and he felt pain in the whole hypertension; headache may commonly imply the three neck, but made an effort to go to job. His anxiety was diseases. The patient had been working as a bus driver reduced, but acute palpitations, shoulder stiffness and for 21 yr. Before he visited our clinic in October, 1996 Eiichi UCHIDA, et al.: Comorbidity between depression and panic disorder in a bus driver 269 he had been suffering from hypertension since his thirties gradually, taking 6 to 12 months. And the work schedule and had been treated for depression for 5 yr. His primary should be adjusted appropriately with agreement of complaints were general fatigue, headache and so on. In superiors under the direction of an occupational physician. July, 1997 his complaints changed, and he was now The recent study, carried out in a neurology headache diagnosed as having panic disorder. clinic, showed that the major associations of headache From the viewpoint of occupational health, the authors were with current anxiety disorder, especially panic and pointed out the following problems: related conditions5). Moreover, another recent study (1) When the patient drives a bus, the symptoms observed no differences in the prevalence of panic, which make driving impossible, such as sudden anxiety and depression between patients with resistant palpitation, anxiety and phobia, shivering, chest pain, hypertension and non-resistant controls. On the other nausea and dizziness, may cause traffic accidents leading hand, the prevalence of panic disorder and panic attacks to damage; it is too late to avoid damage when the panic were remarkably high in both groups patients attending disorder has already occurred. As in this case, panic a hospital hypertension clinic6). The characteristics of disorder seems to appear comorbid with other symptoms. the patient resembled those in the report. The partial symptoms of panic attack should also be From the psychological point of view, he was a serious checked at screening for hypertension and depression to type of man and overadapted himself to the surroundings; detect attacks in the earlier stages. the Self Grow-up Egogram score showed his high (2) It is to be expected that driving, which requires adaptability. In addition, he tended to require himself to continuing tension without talking, causes great stress in be perfect because his job required punctuality. The stress such workers as bus drivers. Depression, due to caused by high adaptability and punctuality may be hypertension and cumulative fatigue in concentrating on related to depression, panic disorder and hypertension. driving for hours, is supposed to be not as difficult to Other research reports indicated that primary care detect in regular medical examinations and mental tests, clinicians should be aware of the possible coexistence of but the symptoms of panic disorder are rarely checked in anxiety disorders (especially generalized anxiety disorder the field of occupational health. Panic attack is not [GAD]) in their patients with chronic medical conditions difficult to detect in a brief medical interview; it should (hypertension), but especially in those with current be looked for in regular medical examinations. depressive disorder. Among primary care patients, those Depression and hypertension need long-term with chronic medical illness or subthreshold depression pharmachotherapy. The symptoms depend on the case, had low rates of lifetime and current panic disorder, but and the patient often recovers after getting worse and those with current depressive disorder had much higher better several times. Frequent health checks are needed rates. Concurrent phobia and GAD were more common, if he is to continue to work as a bus driver. When a especially in depressed patients. Depending on the type driver feels a panic symptom such as palpitation, a self- of medical illness or depression, 14% to 66% of primary reported health check is essential before driving. care patients had at least one concurrent anxiety disorder7). (3) When taking a long time off from work, the decline Another study repeated that anxiety disorders co- in physical strength and driving technique may become occurring with another disease (medical illness or serious; it is considered to be necessary for the treatment depression) increase the need for counseling and the use of depression and panic disorder to let the patient go back of psychotropic medication in the general medical sector8). to daily work gradually, taking 6 to 12 months. The work This research showed the importance of primary care schedule should therefore be adjusted appropriately with including occupational health; it seems necessary to agreement of superiors under the direction of an conduct advanced research on the comorbidity of the occupational physician. diseases (disorders), treatment and the occupational care Balls S.G. et al. reported that the majority of patients (employment and support) of these patients. And more with panic disorder complained of at two or more study should be directed at increasing cooperation depressive symptoms. These symptoms met the DSM- between occupational health (primary care) and III-R definitional criteria for significance; subdiagnostic psychosomatic internal medicine (psychiatrics) levels of clinically significant depressive and generalized concerning depression, panic disorder and hypertension. anxiety symptoms in patients with panic disorder4). Past References epidemiological and clinical research has identified depression as the most common psychiatric disorder, 1) Sherbourne C.D, Wells K.B, Meredith L.S, Jackson associated with headache. When taking a long time off C.A, Camp P. Comorbid anxiety disorders and the from work, the decline in physical strength and driving functioning and well-being of chronically ill patients of general medical providers. Arch Gem Psychiatry technique may become serious. Therefore, it is 1996; 53: 889Ð895. considered to be necessary for the treatment of depression 2) American Psychiatric Association. Quick reference to and panic disorder to let the patient go back to daily work 270 J Occup Health, Vol. 41, 1999

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