1. Chapter 13 PANIC DISORDER

2. Panic Disorder An acute intense attack of anxiety accompanied by feelings of impending doom is known as panic disorder. The anxiety is characterized by discrete periods of intense fear that can vary from several attacks during one day to only a few attacks during a year. Patients with panic disorder presents with a number of co-morbid conditions, most commonly agoraphobia, which refers to a fear of or anxiety regarding places from which escape might be difficult

3. Panic attacks A panic attack is a sudden period of intense fear or apprehension that may last from minutes to hours. Panic attacks can occur in mental disorders other than panic disorder, particularly in specific phobia, social phobia, and PTSD. Unexpected panic attacks occur at any time and are not associated with any identifiable situational stimulus, but panic attacks need not be unexpected. Attacks in patients with social and specific phobias are usually expected or cued to a recognized or specific stimulus.

4. Diadnostic Criteria for panic disorder according to DSM-IV A. Both (1) and (2) 1.Recurrent unexpected panic attacks : a discrete period of intense fear or discomfort, in which ≥4 of the following symptoms develop abruptly and reach a peak withwin 10 minutes # palpitations, pounding heart, or accelerated heart rate # sweating # trembling or shaking # sensations of shortness of breath or smothering # feeling of choking # chest pain or discomfort # nausea or abdominal distress # feeling dizzy, unsteady, lightheaded or faint # derealization (feelings of unreality) or depersonalization (being detached from oneself) # fear of losing control or going crazy. # fear of dying paresthesias (numbness or tingling sensations), chills, or hot flushes

5. 2. At least one of the attacks has been followed by 1 month (or more) of ≥1 of the following # persistent concern about having additional attacks # worry about the implications of the attack or its consequences (e.g. losing control, Having a heart attack, “going crazy”.) # a significant change in behaviour related to the attacks B. Absence of agoraphobia. C. The panic attacks are not due to the direct physiological effects of a substance or GMC. D. The panic attacks are not better accounted for by another mental disorder, such as social phobia, specific phobia, Obsessive- compulsive disorder, post traumatic stress disorder, separation anxiety disorder.

6. Epidemiology # prevalence: 1.5-5% (one of the top five most common reasons to see a family doctor); M:F = 1:2.3 # onset: average late 20s, familial pattern. Treatment 1.psychological: # supportive psychotherapy, relaxation techniques (visualization, box breathing), CBT (correct distorted thinking, desensitization,/exposure therapy) 2. biological # SSRIs: fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline # SNRI: venlafaxine With SSRI/SNRIs start with low doses titrate up slowly and aim for higher doses than used for depression. # to prevent non-compliance due to physical side effects, explain symptoms to expect prior to initiation of therapy # other anti depressents (TCAs, mirtazapine, MAOIs) consider avoiding bupropion due to stimulating effects

7. # benzodiazepines (short term, low dose, regular schedule, long half life) Prognosis 6-10 yrs post treatment: 30% well, 40-50% improved, 20-30% no change or worse. Clinical course: chronic, but episodic with psychosocial stressors. Panic disorder with agoraphobia 1.Agoraphobia # anxiety about being in places or situations from which escape might be difficult (or embarrassing) or where help may not be available in the event of having an unexpected panic attack # fears commonly involve situations such as being out alone, being in a crowd, standing in a line or travelling on a bus. 2. Situations are avoided, endured with anxiety or panic, or require companion 3. treatment: as per panic disorder

8. The End