Psychiatrist in Dubai

Panic
disorder
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Contents
• Definition 3
• Some features of PD 4
• Risk factors 5
• Difference between panic attack or panic disorder
6
• Pathological physiology 7
• Classification 9
• Cause 10
• PD in school time 15
• Outcomes 16
• DSM criteria 17
• When to hospitalize a PD patient 19
• Disease which mmic PD 20
• Sucide rate 21
• Ttreatment 22
• Store products which interfere with the treatment
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• Relapse 36
• Prognosis 37
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Defination
It is a recurrent and unexpected anxiety attack of panic, which
are more often called as panic attach. In a month or more of
one with feature such as following:
a) Persisting fear of having another attach
b) Worry about the implications and consequence of the attack.
c) Significant changes of behavior after the attacks
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Some features of PD
• Panic attacks can occur at any time, even during sleep.
• An attack usually peaks within 10 minutes, but some
symptoms may last much longer.
• Panic disorder affects about 6 million American adults.
• Panic disorder is twice as common in women as men.
• Panic attacks often begin in late adolescence or early
adulthood,
• Not everyone who experiences panic attacks will develop
panic disorder. Many people have just one attack and never
have another.
• The tendency to develop panic attacks appears to be inherited.
• Panic disorder is often accompanied by other serious problems,
such as depression, drug abuse, or alcoholism. 4
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Risk factors
• Adolecence or early adulthood
• Major life transitions perceived as stressful
• Graduating from college, getting married, having a first child
• Genetics
• If a family member has panic disorder, you have an increased
risk
• Especially during a time in your life that is particularly
stressful.
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Differences between Panic attack
and Panic Disorder
• Anyone can suffer of a Panic attack that is an
extreme anxiety reaction that result when a real
threat suddenly emerges (E.g.: when they are afraid
of somebody in their house stealing)
• The experience of “Panic Disorder,” however, is
different
• Panic attacks are periodic, short bouts of panic that occur
suddenly, reach a peak, and pass
• Sufferers often fear they will die, go crazy, or lose control
• Attacks happen unexpectedly in the absence of a real threat
• Sufferers also experience dysfunctional changes in thinking
and behavior as a result of the attacks 6
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Pathophysiology
While the various symptoms of a panic attack may cause the person to feel that
their body is failing, it is in fact protecting itself from harm. The various
symptoms of a panic attack can be understood as follows. First, there is
frequently (but not always) the sudden onset of fear with little provoking
stimulus. This leads to a release of nonadrenaline which brings about the so-
called fight-or-flight response, wherein the person's body prepares for strenuous
physical activity. This leads to a tachycardia, hyperventilation which may be
perceived with dyspnea and sweating (which increases grip and aids heat loss).
Because strenuous activity rarely ensues, the hyperventilation leads to a drop
in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in
blood pH (respiratory alkalosis or hypocapnia), which in turn can lead to many
other symptoms, such as tingling or
numbness, dizziness, burning and lightheadedness. Moreover, the release
of adrenaline during a panic attack causes vasoconstriction resulting in slightly
less blood flow to the head which causes dizziness and lightheadedness. A panic
attack can cause blood sugar to be drawn away from the brain and towards the
major muscles. It is also possible for the person experiencing such an attack to
feel as though they are unable to catch their breath, and they begin to take
deeper breaths, which also acts to decrease carbon dioxide levels in the blood.
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• It is also unclear why some people have such abnormalities in
norepinephrine activity
• Inherited biological predisposition is one possibility
• Prevalence should be (and is) greater among close relatives
• Among monozygotic (MZ, or identical) twins = 24%
• Among dizygotic (DZ, or fraternal) twins = 11%
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Classification
Two diagnoses:
• panic disorder with agoraphobia
• panic disorder without agoraphobia (twice more
common)
• ~3% of U.S. population affected in a given year
• ~5% of U.S. population affected at some point in their
lives
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What does cause Panic Disorders
There are 3 perspective which can lead to the pathological
abnormality of Noradrenalin activity:
1) Biological perspective
2) Pharmacological
3) Chronic illness (Comorbid disorders in PD accounts more
than 90%)
4) cognitive
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Biological perspective
• Vulnerability to panic disorder tends to run in families. E.g.:Twin studies: Higher
concordance rates among identical twins.
• Among monozygotic (MZ, or identical) twins = 24%
• Among dizygotic (DZ, or fraternal) twins = 11%
• Possible imbalance of neurotransmitters involved in arousal
Serotonin & Norepinephrine. (Smokers have a fourfold risk of a 1st-time panic attack.
Why?)
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Pharmacological Triggers
Certain chemical substances, mainly stimulants but also certain
depressants, can either contribute pharmacologically to a
constellation of provocations, and thus trigger a panic attack
or even a panic disorder, or directly induce one. This includes
caffeine, amphetamine, alcohol and many more. Some
sufferers of panic attacks also report phobias of specific drugs
or chemicals, that thus have a merely psychosomatic effect,
thereby functioning as drug triggers by nonpharmacological
means.
Alcohol, medication or drug withdrawal — Various substances
both prescribed and unprescribed can cause panic attacks to
develop as part of their withdrawal syndrome or rebound
effect. Alcohol withdrawal and benzodiazepine withdrawal are 12
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Chronic illness
• Chronic/serious illness — Cardiac conditions that can cause sudden
death such as long QT syndrome; catecholaminergic polymorphic
ventricular tachycardia or Wolff-Parkinson-White syndrome can also
result in panic attacks. This is particularly difficult to manage as
the anxiety relates to events that may occur such as cardiac arrest,
or if an implantable cardioverter-defibrillator is in situ, the possibility
of having a shock delivered. It can be difficult for someone with a
cardiac condition to distinguish between symptoms of cardiac
dysfunction and symptoms of anxiety. In CPVT the anxiety itself can
and does trigger arrythmia. Current management of panic attacks
secondary to cardiac conditions appears to rely heavily
on benzodiazepines, selective serotonin reuptake
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Cognitive
1. Major life transitions (post graduation, losing
job, after marriage)
2. Stimulus generalization
• 1st attack occurs in one location
• Fear another attack in similar locations
3. Being helplessness increases fear
4. Maintained by negative reinforcement
5. Excessive focus on potential threats (Cognitive)
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PD in school life
• There are many student that appears with PD in the school life
time, why does it happen?
I. Test/performance anxiety
II. Poor academic performance
III. Avoidance of school entirely
What can we do to help?
• Talk with them about possible triggers.
• Stand near them in stressful situations (e.g. speeches)
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outcomes
• People who have full-blown, repeated panic attacks can become
very disabled by their condition and should seek treatment before
they start to avoid places or situations where panic attacks have
occurred.
• For example, if a panic attack happened in an elevator, someone
with panic disorder may develop a fear of elevators that could affect
the choice of a job or an apartment, and restrict where that person
can seek medical attention or enjoy entertainment.
• Some people's lives become so restricted that they avoid normal
activities, such as grocery shopping or driving.
• About one-third become housebound or are able to confront a
feared situation only when accompanied by a spouse or other
trusted person.When the condition progresses this far, it is called
agoraphobia, or fear of open spaces.
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DSM Criteria for PD diagnosis
DSM (Diagnostic and Statistical Manual of Mental Disorders)
expects at least 4 of 13 symptoms in stating the patient has
had a “panic attack.” List as many of the 13.
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At least 4 of following develop suddenly and peak in 10 minutes:
1.palpitations or increased pulse
2. sweating
3. trembling or shaking
4. sensation of shortness of breadth
5. feeling of choking
6. chest discomfort
7. nausea or stomach distress
8. dizzy, unsteady, lightheaded, or faint
9. derealization/depersonalization
10. fear of losing control or going “crazy”
11. fear of dying
12. paresthesias
13. chills or hot flashes
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When to hospitalize a patient with
PD?
Only hospitalize if there is another psychiatric disorder present that
so justifies.
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Disease which mimic PD
i. Hyperthyroidism
ii. Hypothyroidism
iii. Temporal-lobe epilepsy
iv. Asthma
v. Cardiac arrhythmias
vi. Pheochromocytoma
vii. Too much coffee and other stimulants
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Suicide rate
Guideline says 1/5, but article implies that is so because many
have comorbid with depression. Still, it would seem that
“1/5” would be correct answer.
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Treatment goals
1. Decrease frequency of attacks
2. Decrease intensity of attacks
3. Decrease anticipatory anxiety
4. Decrease phobic avoidance
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• All patients with PD should be monitored by a psychiatrist,
psychologist or a mental healthy care, it is shown that a psychiatric
care is the most effective and low costs because of addition of
pharmacological therapy, decreasing emergency department intake
and costs and nonpsychiatric outpatient care
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Cognitive behavioral therapy(CBT)
CBT with or without pharmacotherapy, is the treatment of choice for panic disorder, and
it should be considered for all patients.CBT has higher efficacy and lower cost,
dropout rates, and relapse rates than do pharmacologic treatments.
In 12 to 16 sessions, usually weekly, the focus is on recreating the feared symptoms and
then modifying the patient’s response.
• The trigger in an individual case could be something like
• A thought
• A situation
• Something subtle like a slight change in heartbeat.
• Therapy Goals
• Understanding that the panic attack is separate and independent of the trigger
• Awareness of the trigger(s) so it begins to lose some of its power to induce an
attack.
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Behavioral therapy
Behavioral therapy involves sequentially greater exposure of the patient to anxiety-
provoking stimuli; over time, the patient becomes desensitized to the
experience. Relaxation techniques also help to control patients' levels of anxiety.
• Respiratory training can help patients to control hyperventilation during panic
attacks and to control anxiety with controlled breathing. Capnometry feedback-
assisted breathing training can be used to prevent hypocapnia and stabilize the
respiratory rate.
The trigger could be:
• Intentional hyperventilation – creates lightheadedness, derealization, blurred
vision, dizziness
• Spinning in a chair – creates dizziness, disorientation
• Straw breathing – creates dyspnea, airway constriction
• Breath holding – creates sensation of being out of breath
• Running in place – creates increased heart rate, respiration, perspiration
• Body tensing – creates feelings of being tense and vigilant
Therapy goals: it help the patient to come through an attack by controlling the
symptoms.
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Pharmacological therapy
• Providing a few doses of a benzodiazepine as needed (prn) can
enhance patient confidence and compliance. Total tablet dispensing
should remain limited to ensure that patients understand that they
have a limited supply of the drug and that this medicine represents
a temporary or emergency use option.
• The patient should be made to understand the importance of
longer-term management with SSRI medication and
psychotherapeutic techniques (eg, CBT).
• Avoid the prescription of benzodiazepine in patients with a known
history of substance misuse or alcoholism.
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Follow-up care and referrals
• Initial follow-up care should occur within 2 weeks, because SSRIs can
cause an initial exacerbation of panic symptoms. For this reason,
begin with the lowest dose with the understanding that the dose
must be increased at the initial follow-up visit.
• Assess potential suicide risk at all appointments. Ensure continuing
treatment of any concurrent substance use disorders.
• Follow-up care by a chemical dependence treatment specialist is
recommended when indicated.
• Patients with ventricular dysrhythmias, abnormal findings on ECG,
abnormal findings on cardiac examination, or significant risk factors
for heart disease should be referred to a cardiologist.
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Inpatient care
• Inpatient care is rarely considered for uncomplicated panic disorder.
Patients may get admitted if they display any evidence of dangerous
behavior, safety concerns, report suicidal or homicidal ideation as
may occur in context of acute anxiety, fear of anxiety or its
consequences or with another psychiatric disorder.
• Patients may require hospitalization for intoxication or withdrawal
from sedative/hypnotics such as alcohol or Xanax, which sometimes
get ingested or abused in attempts to medicate or manage the
anxiety. Patients may also get hospitalized if they become so
incapacitated by their anxiety that they are unable to adhere to
outpatient care.
• Inpatient treatment is necessary in patients with suicidal ideation
and plan or with serious alcohol or sedative withdrawal symptoms,
or when the differential includes other medical disorders that
warrant admission (eg, unstable angina, acute myocardial ischemia).
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5 groups of drugs used in the PD
• 1. SSRIs
• 2. SNRIs
• 3. High potency benzodiazepines
• 4. Tricyclics
• 5. MAOIs
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SSRIs
• SSRIs is the fist choice for the treatment of PD.
Flouxetine, Paroxitine, Sertraline or fluvoxamine:
MOA: It is an antagonist at the 5-HT2 receptor and inhibits the
reuptake of 5-HT. It also has a negligible affinity for cholinergic
and histaminergic receptors.
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SNRIs
• Trazodone: it is used in PD with or without agoraphobia.
MOA: It is an antagonist at the 5-HT2 receptor and inhibits the
reuptake of 5-HT. It also has a negligible affinity for cholinergic
and histaminergic receptors.
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Intermediate to strong
Benzodiazepam
• Lorazepam, clonazapam, alprazolam or diazepam. It is not a primary
choice because of the dependence and side effects caused. Useful
in situation as apprehensiveness about taking a airplane flight
MOA: it potentiate GABA by binding to specific GABA receptor.
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Tricyclic antidepressants
• Imipramine, desipramineor clomipramine.
It has a low risk of dependence and no diatary restrictions, but
they are in 35% cases discontinued because of its side effects
such as blurred vision, dry mouth, dizziness, weight gain, GIT
distubences, agitation, headache, insonia and decreased
libido, to avoid side effects abruptly, it must be first
administered in low dose.
MOA: they are Serotonin and Nonadrenaline reuptake
inhibitors.
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Monoamine oxidase inhibitors
• Phenelzine or tranylcypromine, they are effective in patient with PD
or other associated phobia
• MOA: Nonselective monoamine oxidase inhibitor; may inhibit the
enzyme monoamine oxidase, which is responsible for the
breakdown of dopamine, serotonin, epinephrine, and
norepinephrine, in turn causing an increase in endogenous
concentrations of these neurotransmitters.
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Stores products
• Patient can buy some products specially in the
depression or anxiety period that can interfere with the
treatment such as:
• 1. Cigarettes
• 2. Coffee
• 3. sympathomimetics [nasal decongestants]
They should be advised that they can not used this
products while they are in the pharmacological therapy.
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Relapses
• After a successful treatment many patients may fall into a
relapse, specially after a makeable event in patients life as the
loss of a beloved one, discovered of a severe illness and etc.
• We should adopted the prior treatment of CBT and drugs
(SSRIs or SNRIs) and if it does not work, should be maintained
the CBT and change the group of drug (tricyclic)
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Prognosis
• Long-term prognosis is usually good, with almost 65% of
patients with panic disorder achieving remission, typically
within 6 months.
• The risk of coronary artery disease in patients with panic
disorder is nearly doubled. In patients with coronary disease,
panic can induce myocardial ischemia. The risk of sudden
death may also theoretically be increased due to reduced
heart rate variability and increased QT interval variability.
• Appropriate pharmacologic therapy and cognitive-behavioral
therapy, individually or in combination, are effective in more
than 85% of cases.
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