BackgroundPanic disorder is characterized by the spontaneous and unexpected occurrence ofpanic attacks, the frequency of which can vary from several attacks per day to only afew attacks per year.Panic attacks can occur in other anxiety disorders but occur without discerniblepredictable precipitant in panic disorder.During the episode, patients have the urge to flee or escape and have a sense ofimpending doom (as though they are dying from a heart attack or suffocation).Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue,intrusive thoughts, and ruminations.Panic disorder is usually qualified with the presence or absence of agoraphobia.Agoraphobia is defined as anxiety toward places or situations in which escape maybe difficult or embarrassing.Following exclusion of somatic disease and other psychiatric disorders, confirmationof the diagnosis of panic disorder with a brief mental status screening examinationand initiation of appropriate treatment and referral is time- and cost-effective inpatients with this condition, who have high rates of medical resource use.
Epidemiology Incidence of panic • Lifetime prevalence estimates range from 1.5-disorder in the United 5% for panic disorder and 3-5.6% for panic States attacks. • Panic disorder often coexists with mood disorders, with mood symptoms potentially following the onset of panic attacks. Lifetime prevalence rates of major depression may be as much as 50-60%. • Panic disorder is also associated with a higher risk of sudden death • 30% with chest pain and normal findings on Mortality and angiography. • 5-40% with asthma, 15% with headache, 20% withmorbidity associated epilepsy, and 10% of patients in primary care settings.with panic disorder • The rate of substance abuse (especially stimulants, cocaine, and hallucinogens) in persons with panic disorder is 7-28%, a risk 4-14 times greater than that of the population. In addition, panic disorder is found in 8- 15% of individuals in alcohol treatment programs. • Pregnant mothers with panic disorder during pregnancy are more likely to have preterm labor and infants of smaller birth-weight for gestational age.
Cont’d Race • Data on prevalence in different racial groups are inconsistent. Symptom manifestations may differ, with African Americans more predilection in often presenting with somatic symptoms and more likely seeking help in medical rather than psychiatric settings. panic disorder • One-month prevalence estimates for women are 0.7%, versus 0.3% for men (women are more likely to be affected than men by a Sex predilection 2- to 3-fold factor). • Panic is more common in women who have never been pregnantin panic disorder and during the postpartum period, but it is less common during pregnancy. • Although panic can occur in people at any age, it usually develops between the ages of 18 and 45 years. The average age of onset,Age predilection as with most anxiety disorders, is in the third decade of life. • Patients with late-onset panic disorder have a tendency towardin panic disorder less mental health use, lower comorbidity and hypochondriasis, and better coping behavior
HISTORYPatients with panic disorder have recurring episodesof panic, with the fear of recurrent attack resulting insignificant behavioral changes (eg, avoidingsituations or locations) and worry about theimplications of the attack or its consequences (eg,losing control, going crazy, dying). Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn. DSM-IV criteria include 4 or more attacks in a 4- week period or 1 or more attacks followed by at least 1 month of fear of another.
Etiologyneurochemical dysfunctiongenetic hypothesiscognitive theory
Types of panic attacksUnexpected panic attacks have no known precipitating cue;these attacks often support the diagnosis of panic disorderwithout agoraphobia.Situationally predisposed panic attacks are more likely to occurin relation to a given trigger, but they do not always occur. Thispattern more likely describes panic disorder with agoraphobia.A variant of panic disorder unrelated to fear (nonfearful panicdisorder [NFPD]) is associated with high rates medical resourceuse (32-41% of patients with panic disorder seeking treatmentfor chest pain) and poor prognosis
Panic triggersTriggers of panic can include the following:• Injury (eg, accidents, surgery)• Illness• Interpersonal conflict or loss• Use of cannabis (can be associated with panic attacks, perhaps because of breath-holding)• Use of stimulants, such as caffeine, decongestants, cocaine, and sympathomimetics (eg, amphetamine, MDMA)• Certain settings, such as stores and public transportation (especially in patients with agoraphobia)• Sertraline, which can induce panic in previously asymptomatic patients• The selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, which can induce symptoms similar to those experienced by panic patients
Physical Examination• No signs on physical examination are specific for panic disorder.• Acute state of panic, can physically manifest any anticipated sign of an increased sympathetic state. These nonspecific signs may include hypertension, tachycardia, mild tachypnea, and mild tremors. The attack normally lasts 20-30 minutes from onset, although in rare cases it can go on for more than an hour.• Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in an emergency department.• The patient may have an anxious appearance. Tachycardia and tachypnea are common; blood pressure and temperature may be within the reference range. Cool, clammy skin may be observed.• Hyperventilation may be difficult to detect by observing breathing, because respiratory rate and tidal volume may appear normal.
Mental StatusExamination While the patient may or may not appear anxious at the time of interview, the results on his or her Mini-Mental Status Examination, including: Cognitive performance Memory Proverb interpretation Baseline intellectual functioning
Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition, Text Revision(DSM-IV-TR) Criteria for panic disorder, panic attacks must be associated with More than 1 month of subsequent persistent worry about: • 1. Having another attack • 2. Consequences of the attack, or • 3.Significant behavioral changes related to the attack Panic attacks are a period of intense fear in which 4 of 13 defined symptoms develop abruptly and peak rapidly less than 10 minutes from symptom onset
Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition, Text Revision (DSM-IV-TR)The DSM-IV-TR delineates the following potential symptommanifestations of a panic attack:• Palpitations, pounding heart, or accelerated heart rate• Sweating• Trembling or shaking• Sense of shortness of breath or smothering• Feeling of choking• Chest pain or discomfort• Nausea or abdominal distress• Feeling dizzy, unsteady, lightheaded, or faint• Derealization or depersonalization (feeling detached from oneself)• Fear of losing control or going crazy• Fear of dying• Numbness or tingling sensations• Chills or hot flashes
THERAPYSelective Serotonin Benzodiazepine SerotoninReuptake Inhibitors • By binding to specific Norepinephrine• SSRIs are first-line agents receptor sites, Reuptake Inhibitors for long-term intermediate-acting benzodiazepines appear • Its indicated for panic management of anxiety disorders disorder to potentiate the effects of GABA and facilitate • Venlavaxine• Sertraline, paroxetine, fluvoxetine, citalopram inhibitory GABA neurotransmission and other inhibitory transmitters. • Lorazepam, clonazepam, alprazolam, diazepam
Psycological Theraphy • Inform patients that the causes of panic disorder are likely biological and psychosocial • Advise patients to avoid anxiogenic substances, such as caffeine, energy drinks, and other OTC stimulantsPsychoeducation • educate patients about recognizing trigger stimuli so that they can contribute this to their psychological treatment approach • Family education • cognitive restructuring • relaxation techniques Cognitive- • breathing exercises behavioral • hypnotic suggestiontheraphy (CBT) • interoceptive exposure may prevent recurrence
PrognosisLong-term prognosis is usually good, with almost65% of patients with panic disorder achievingremission, typically within 6 months.The risk of coronary artery disease in patients withpanic disorder is nearly doubled.Appropriate pharmacologic therapy and cognitive-behavioral therapy, individually or in combination,are effective in more than 85% of cases