psychiatry in internal medicine

1. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
INTRODUCTION
● common problems
● DSM-5, agoraphobia is diagnosed independently of panic disorder
● Panic attacks
○ present with spontaneous, discrete episodes of intense fear
○ begin abruptly
○ last for several minutes to an hour
● Panic disorder
○ patients experience recurrent panic attacks
○ > 1 month
○ worry about future attacks/consequences
○ significant maladaptive change in behavior related to the attacks, such as
avoidance of the precipitating circumstances.
EPIDEMIOLOGY
● Prevalence 2-4%
● age of onset = 24 years
● F>M
● Associated Comorbidities
○ Psychiatric
■ major depression
■ social anxiety disorder
■ generalized anxiety disorder
■ PTSD
○ Medical
■ Asthma
■ CAD
■ Hypertension
■ PUD
■ Interstitial cystitis
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

2. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
■ Migraine headaches
○
PATHOGENESIS
● Stress-diathesis model
○ the combination of an underlying predisposition interacting with or triggered by
life stress
● Risk factors
○ genetic factors
○ childhood adversity
■ H/O physical or sexual abuse increases the risk
○ personality traits
■ anxiety sensitivity
■ Neuroticism
■ Anxious temperaments
Neurobiology
● Proposed neural circuitry closely linked with basic animal models of fear development
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

3. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
CLINICAL MANIFESTATIONS
● Panic attack
○ discrete episodes of intense fear
■ Spontaneous
■ begin abruptly
■ last for several minutes to an hour
● In panic disorder
○ experience recurrent panic attacks
○ some of which are not triggered or expected
○ >1m
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

4. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
○ significant maladaptive change in behavior related to the attacks, such as
avoidance of the precipitating circumstances or of situations where they would be
unable to escape or obtain help were they to panic
○ present with autonomic symptoms of a panic attack such as chest pain or
shortness of breath.
Agoraphobia
● anxiety about and avoidance of situations where help may not be available or where it
may be difficult to leave the situation in the event of developing panic-like symptoms
APPROACH
● History
● psychiatric examination
● neurologic examination
● Routine Ix
○ CBC
○ LFT
○ KFT
○ TFT
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

5. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
○ ECG
DIAGNOSIS
DSM-5 diagnostic criteria
Panic attack
● An abrupt surge of intense fear + >=4 /13 symptoms occur
○ Palpitations
○ Sweating
○ Trembling
○ SOB
○ Choking
○ Chest pain or discomfort
○ Nausea
○ Feeling dizzy, unsteady, light-headed, or faint
○ Chills or heat sensations
○ Paresthesias
○ Derealization (feelings of unreality) or depersonalization (being detached from
oneself)
○ Fear of losing control or "going crazy"
○ Fear of dying
Panic disorder
● Recurrent unexpected panic attacks
● >1m
● Persistent concern or worry about additional panic attacks or their consequences
● Significant maladaptive change in behavior ( such as avoidance of exercise or unfamiliar
situations)
● Not a/w substance abuse or another medical condition
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

6. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
Differential diagnosis
● Somatic symptom disorder
● Illness anxiety disorder
● Substance abuse
○ Cocaine
○ Amphetamines
○ Caffeine
○ Alcohol
● Angina
● Arrhythmias
● Asthma/COPD
● Pulmonary embolus
● Hyperthyroidism
● Pheochromocytoma
Rx
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

7. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

8. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
MEDICATIONS
● SSRI
● SNRI
● TCA
● MAOI
● SSRI
○ S​tarted at low doses
■ Paroxetine 10 mg
■ Citalopram 10 mg
○ Side effect
■ GI S/E
■ Headaches
■ sexual dysfunction
● SNRI
○ Venlafaxine
■ Reduces attack frequency, anticipatory anxiety, and phobic avoidance
■ Started at 37.5 mg OD
■ Side effects
● Nausea
● dry mouth
● Constipation
● Anorexia
● TCA
○ Imipramine or clomipramine can be started at 10 mg/day
○ Substantial side effect burden
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

9. “I was thinking about how people seem to read the bible a lot more as they get older,
and then it dawned on me—they’re cramming for their final exam.”
― George Carlin
Benzodiazepines
● alprazolam
● Clonazepam
● Lorazepam
● diazepam
● Disadvantage
○ Risk of abuse and addiction
● Clonazepam preferred
○ Longer acting
○ Less abuse potential
○ Less withdrawal symptoms on discontinuation
● S​tarting dose of clonazepam is typically 0.5 mg/day
● Side effects
○ Sedation
○ Fatigue
○ psychomotor impairment
○ reduced memory and concentration
○ Risk of addiction
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava