Panic Disorder

How do panic attacks present clinically?

At least 4 of the following symptoms of sympathetic system overdrive - sense of impending doom or dread (hallmark). 1) Dizziness 2) Trembling 3) Choking feeling 4) Paresthesias 5) Sweating 6)Shortness of breath 7) Chest pain/discomfort 8) Chills or hot flashes 9) Fear of losing control 10) Fear of dying 11) Palpitations, increased heart rate 12) Nausea or abdominal distress 13) Depersonalization (being detached from oneself) or derealization (feelings of unreality)

What is the role of cognitive behavioral therapy (CBT) in the management of panic disorder?

Adjunctive treatment that focuses on thinking and behavior (e.g. relaxation, desensitization, examining behavior consequences, etc.). Psychotherapy may be used in mild cases as initial therapy. Pharmacotherapy + CBT most effective.

What is the epidemiology of panic disorder?

Average age of onset in early - mid 20's. Greater risk if first degree relative is affected. >60% may also have major depression. More common in females.

How are acute panic attacks managed?

Benzodiazepines (e.g. alprazolam, clonazepam). Watch for dependence or abuse.

How are acute panic attacks managed?

Benzodiazepines first-line medical management (e.g. alprazolam, lorazepam, diazepam, etc.). Watch for dependence or abuse. With a panic attack (even in patients with panic disorder), one must rule out potentially life-threatening conditions (e.g. heart attack, thyrotoxicosis, etc.). Panic attacks are a feature of many different anxiety disorders but is not a disorder in and of itself.

What is the etiology of panic disorder?

Genetic factors: greater risk of panic disorder if first-degree relative affected. Psychosocial factors: increased incidence of stressors (especially loss) prior to onset of disorder; history of childhood physical or sexual abuse.

What is the course and prognosis of panic disorder?

Panic disorder has a chronic course with waxing and waning symptoms. Relapses are common with discontinuation of medical therapy. Only a minority of patients has full remission of symptoms. Up to 65% of patients with panic disorder have major depression. Other comorbid syndromes include other anxiety disorders (especially agoraphobia), bipolar disorder, and alcohol use disorder.

What is panic disorder?

Panic disorder is characterized by spontaneous, recurrent panic attacks. These attacks occur suddenly, "out of the blue." Patients may also experience panic attacks with a clear trigger. The frequency of attacks ranges from multiple times per day to a few monthly. Patients develop debilitating anticipatory anxiety about having future attacks--"fear of the fear." This can lead to avoidance behaviors and become so severe as to leave patients homebound (i.e. agoraphobia).

What are the diagnostic criteria for panic disorder?

Recurrent, unexpected panic attacks (at least 2 attacks) may or may not be related to a trigger. At least one of the following must occur for at least 1 month: 1) Panic attacks often followed by persistent concern about future attacks. 2) Persistent worry about the implication of the attacks (e.g. losing control). 3) Significant maladaptive behavior related to the attacks. Symptoms are not due to substance use, medical condition (e.g. thyroid, hypoglycemia, cardiac) or other mental disorder. Agoraphobia: anxiety about being in places or situations from which escape may be difficult (e.g. open spaces, enclosed spaces, crowds, public transportation, or outside of the home alone). Agoraphobia now seen as a separate entity from panic disorders and can occur with other psychiatric disorders.

What is the long-term management for panic disorder?

SSRIs first-line medical treatment (e.g. sertraline, citalopram, fluoxetine). May initiate therapy with SSRIs + benzodiazepines, then taper and discontinue the benzodiazepine. SNRIs also used (e.g. venlafaxine). TCAs option if SSRIs are ineffective.

What are panic attacks?

Sudden, abrupt, discrete episodes of intense fear or discomfort that usually peaks within 10 minutes and rarely last more than 1 hour (most end in 20-30 minutes). Patients may feel anxious for hours after the attack.