Panic disorder is characterized by unexpected panic attacks that occur without a discernible trigger. During attacks, patients feel an urge to flee and a sense of impending doom. Panic disorder is diagnosed based on the frequency and severity of panic attacks, as well as worry about future attacks. Treatment involves selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and cognitive-behavioral therapy, which are effective in more than 85% of cases. Long-term prognosis is generally good, with remission occurring within 6 months for 65% of patients.

1. Journal Presentation
PANIC DISORDER

2. Background
Panic disorder is characterized by the spontaneous and unexpected occurrence of
panic attacks, the frequency of which can vary from several attacks per day to only a
few attacks per year.
Panic attacks can occur in other anxiety disorders but occur without discernible
predictable precipitant in panic disorder.
During the episode, patients have the urge to flee or escape and have a sense of
impending 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 may
be difficult or embarrassing.
Following exclusion of somatic disease and other psychiatric disorders, confirmation
of the diagnosis of panic disorder with a brief mental status screening examination
and initiation of appropriate treatment and referral is time- and cost-effective in
patients with this condition, who have high rates of medical resource use.

3. 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% with
morbidity 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.

4. 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 pregnant
in 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 toward
in panic disorder less mental health use, lower comorbidity and hypochondriasis,
and better coping behavior

5. HISTORY
Patients with panic disorder have recurring episodes
of panic, with the fear of recurrent attack resulting in
significant behavioral changes (eg, avoiding
situations or locations) and worry about the
implications 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.

6. Etiology
neurochemical dysfunction
genetic hypothesis
cognitive theory

7. Types of panic attacks
Unexpected panic attacks have no known precipitating cue;
these attacks often support the diagnosis of panic disorder
without agoraphobia.
Situationally predisposed panic attacks are more likely to occur
in relation to a given trigger, but they do not always occur. This
pattern more likely describes panic disorder with agoraphobia.
A variant of panic disorder unrelated to fear (nonfearful panic
disorder [NFPD]) is associated with high rates medical resource
use (32-41% of patients with panic disorder seeking treatment
for chest pain) and poor prognosis

8. Panic triggers
Triggers 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)[5]
• Use of stimulants, such as caffeine, decongestants, cocaine,
and sympathomimetics (eg, amphetamine, MDMA)[6]
• Certain settings, such as stores and public transportation
(especially in patients with agoraphobia)
• Sertraline, which can induce panic in previously
asymptomatic patients[7]
• The selective serotonin reuptake inhibitor (SSRI)
discontinuation syndrome, which can induce symptoms
similar to those experienced by panic patients

9. 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.

10. Mental Status
Examination
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

11. Diagnostic and Statistical Manual of Mental
Disorders, 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

12. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-
TR)
The DSM-IV-TR delineates the following potential symptom
manifestations 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

13. DIAGNOSTIC
History
Clinical manifestasions
Laboratorium
Imaging examinations
• Positron emission tomography (PET)
• Magnetic resonance imaging (MRI)

14. DIFFERENTIAL DIAGNOSIS

15. THERAPY

16. THERAPY
Selective Serotonin Benzodiazepine Serotonin
Reuptake 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

17. 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
stimulants
Psychoeducation • 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 suggestion
theraphy (CBT) • interoceptive exposure may
prevent recurrence

18. 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.
Appropriate pharmacologic therapy and cognitive-
behavioral therapy, individually or in combination,
are effective in more than 85% of cases

19. THANK YOU….