This document discusses panic disorders and their treatment. It defines panic disorder as recurrent, unpredictable panic attacks involving physical symptoms like palpitations, sweating, and fear of losing control. Panic disorder often co-exists with agoraphobia, an anxiety disorder characterized by a marked fear of public places. The document outlines biological, psychological, and cognitive behavioral theories for the causes of panic disorders. Treatment involves both pharmacological options like SSRIs and benzodiazepines as well as non-pharmacological cognitive and exposure therapies.

1. PANIC DISORDERS
DR. MOHAMMED FEROS
2ND YEAR POST GRADUATE
GENERAL MEDICINE

2. Neurotic , Stress related &
Somatoform disorders
1. Phobic anxiety disorder
2. Other anxiety disorder
3. Obsessive compulsive disorder

3. Phobic disorder
• “ Irrational fear of a specific object, situation or activity,
often leading to persistent avoidance of the feared object,
situation or activity.”
1. Agoraphobia
2. Social phobia
3. Specific (Simple) phobia

4. ANXIETY
• “ A diffuse unpleasant vague sense of apprehension often
accompanied by autonomic symptoms usually caused by
anticipation of danger”
• Anxiety is a response to a threat that is unknown,
internal, vague or conflictual.
• Fear is response to a known, external , definite or non
conflictual threat.
• Cognitive behavioural view: anxiety is a conditioned
response.

5. 1. Trait anxiety
2. State anxiety
• Trait: Habitual tendency to be anxious in general and is
exemplified by “ I often feel anxious”
• State: Anxiety felt at present, and is exemplified by “ I
feel anxious now”
• Persons with trait anxiety often have episodes of state
anxiety.

6. Aetiology
1. Psychodynamic theory
2. Behavioural Theory
3. Cognitive behavioural theory
4. Biological theory

7. Psychodynamic theory
• Signal anxiety – internal psychological equilibrium
• Signal anxiety  Defensive action
• In anxiety repression fails to function adequately but
secondary mechanisms are not activated, hence anxiety
comes to forefront unopposed.
Repression
(primary)
Secondary defense
mechanism
(conversion, isolation)

8. • Developmentally primitive anxiety is manifested as
somatic symptomatology while developmentally advanced
anxiety is signal anxiety.
• According to this theory panic anxiety – closely related to
separation anxiety of childhood

9. Behavioural theory
• According to this theory : Anxiety – unconditioned
inherent response of the organism to painful or
dangerous stimuli.

10. Cognitive behavioural theory(CBT)
• According to CBT:
• In anxiety disorders there is evidence of selective
information processing (with more attention paid to
threat related information )
• Cognitive distortions
• Negative automatic thoughts
• Perception of decreased control over both internal and
external stimuli.

11. Biological theory
• Genetic evidence: 15- 20% 1st degree relative.
• Concordance rate in monozygotic twins of patients with
panic disorders is as high as 80%.
• Chemically induced anxiety states:
• Infusion of chemicals( Na lactate, isoproterenol, caffeine)
• Inhalation of 5% CO2 can produce panic episodes in
predisposed individuals.

12. • GABA- BZD receptors:
• 2 types: Type I – GABA and chloride independent
• Type II - GABA and chloride dependent
• BZD facilitates GABA transmission causing generalised
effect on CNS – relieves anxiety
• BZD antagonist(flumazenil) and inverse agonist (beta
carbolines) cause anxiety – supports this hypothesis

13. BZD
administered
Binds with BZD
receptor I GABA
complex
Facilitates
GABA release
1. Anxiety
2. Muscle
relaxation
3. Anticonvulsant
action

14. • Organic anxiety disorder:
• Presence of anxiety secondary to various medical
disorders – hyperthyroidism, pheochromocytoma, CAD

15. Symptoms
Physical Symptoms Psychological Symptoms
A. Motoric Symptoms: tremors,
restlessness, muscle twitches
A. Cognitive Symptoms: poor
concentration, distractibility
B. Perceptual Symptoms:
derealisation, depersonalisation
B. Autonomic and Visceral symptoms:
Palpitations, tachycardia, sweating,
flushing, hyperventilation, diarrhoea
C. Affective Symptoms: diffuse,
unpleasant, and vague sense of
apprehension.
D. Other symptoms: insomnia,
increased sensitivity to noise.

16. Generalised
Anxiety
Disorder
Panic Disorder
Anxiety
disorder

17. Panic disorder
• “ Presence of recurrent and unpredictable panic attacks,
which are distinct episodes of intense fear and discomfort
associated with variety of physical symptoms including
• Palpitations or rapid heart rate,
• Breathlessness
• Feeling unsteady, dizzy, light-headed or faint
• Trembling or shaking
• Sweating

18. •Having a hot flush or chills
• Chest pain or discomfort
• Numbness or tingling sensations
• Feeling as if you or surroundings are unreal
• Nausea or burning stomach
• Choking
• Fear of dying
• Fear of losing control or going crazy
• At least 4 panic attacks over 4 weeks for diagnosis.

19. • Onset usually in early third decade with often c/c course
• Sudden onset developing within 10 min, resolving within
1 hour.
• Frequency and severity of panic attacks vary ranging
from once a week to clusters separated by months of well-
being.
• D/D: Cardio respiratory disorders, Pheochromocytoma,
Hypoglycemia.
• Life time prevalence: 1.5-2% with 3-4% sub syndromal
panic symptoms
• Panic disorders and Agoraphobia often co exist

20. Agoraphobia
• Marked and consistently manifest fear of crowds, public
places, travelling alone, travelling away from home
• Avoidance of these phobic situation is important
symptom.
• Symptoms of anxiety in the feared situation including
autonomic arousal, difficulty in breathing, choking,
abdominal discomfort, dizziness, fear of losing
control/dying.

21. Treatment
• Non pharmacological management
1. Cognitive therapy
2. Relaxation training, biofeedback
3. Respiratory training, breathing exercises
4. Exposure therapy

22. • Pharmacological management
1. SSRI
2. BZD
3. SNRI

23. • SSRI benefit majority of panic disorders and do not have
adverse effects of TCA.
• Drugs should be started 1/3 rd of their usual
antidepressant dose.
• MAOIs effective in patients with atypical depression –
(hypersomnia and weight gain)
• Because of anticipatory anxiety and need for immediate
relief of panic symptoms BZD are useful early in course of
treatment.

24. Thank you