Panic Disorder

Panic d/o is an anxiety d/o

Definition: presence of recurrent and unpredictable panic attacks, which are discrete periods of intense fear or discomfort, in which 4 or more of the following sx develop abruptly and reach a peak within 10 min. They usually resolve within an hour.

4 Panic attacks in 4 weeks or 1 or more panic attacks followed by 4 weeks of continuous anticipatory anxiety.

Pt has fears that center around the possibility of having a recurrent panic attack. Pt. must be proccupied by the fear of having a panic attack.

    1. Palpitations, pounding heart, or accelerated heart rate.

    2. Sweating

    3. Trembling or shaking

    4. Sensations of SOB or smothering

    5. Feeling of choking

    6. Chest pain or discomfort

    7. Nausea of abdominal pain

    8. Feeling dizzy, unsteady, lightheaded, or faint

    9. Derealization (feeling of unreality) or depersonalization (being detached from oneself)

    10. Fear of losing control or going crazy.

    11. Fear of dying

    12. Paresthesias (numbness or tingling sensation)

    13. Chills or hot flushes

    • Onset is usually in late adolescence to early adulthood.

    • Occurs once a week to clusters of attacks separated by months of well being. Episodic.

    • 1st attack occurs usually outside home.

    • Some individuals develop anticipatory anxiety and eventually fear and progressive avoidance of places or situations in which a panic attack might recur. Leading on to Agoraphobia.

Dx is made after med. cond. in diff Dx have been rule out: cardiovascular, respiratory, endocrine, neurologic causes (pheochromocytoma, MVP, PAT, thyrotoxicosis, hypoglycemia, irritable bowel syndrome, asthma, hyperventilation, PE), cocaine, methamphetemine, caffeine, as well as withdrawal from sedatives and alcohol. ECG, echocardiogram, TSH, Sr. Glu, PFT, colonoscopy reqd.

    • Diagnosis of Panic disorder is classified as either with or without agoraphobia.

    • DDx of panic disorder is complicated by comorbidities with other psychiatric conditions like substance abuse, ETOH abuse, major depression.

    • Panic disorder has genetic predisposition.

    • Associated with increased noradrenergic discharge in locus coeruleus, and serotonergic neurons in the dorsal raphe.

Tx: Goal to reduce intensity and frequency of panic attacks.

    • Cognitive-behavior therapy and/or relaxation training and desensitization or flooding.

    • TCA: imipramine and clomipramine low doses

    • SSRI: Fluoxetine (Prozac) 5 - 10 mg), Sertraline (Zoloft) 25 - 50 mg

    • Paroxetine (Paxil) 10 mg.

    • MAOIs (phenelzine): effective in pts with associated atypical depression (hypersomnia and wt. gain).

    • Benzodiazepines: As antidepressants take 2 - 6 weeks to become effective Alprazolam (Xanax) 0.5 mg qid and increasing to 4 mg/d in divided doses, is effective.

    • Psychotherapeutic intervention and psychoeducation aimed at sx control: breathing techniques, etc.

    • Once pts have achieved a satisfactory response, drug Tx should be maintained for 1 to 2 years to prevent relapse.