Panic Disorder
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Introduction
Panic disorder is a discrete period of intense fear or discomfort that comes on unexpectedly and recurrently. It is commonly associated with a number of physical symptoms.
Its peak onset is from 15-19 years, with a prevalence 3.5%.
Health care providers will often see patients after the first panic attack, or in the early stages when avoidance or anticipatory anxiety have not yet begun. It is important to be able to recognize this and address the condition before worsening condition occurs.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Pathophysiology
Signs and Symptoms
- history
- physical exam
History
recurrent unexpected panic attacks
at least four of the following symptoms
- tachycardia/palpitations
- tembling/shaking
- choking
- nausea
- sweating
- shortness of breath/hyperventilation
- chest pain/discomfort
- dizzy
- fear of losing control or going crazy
- paresthesias
- chills/hot flushes
there is persistent worry that things could happen again
abruptly and peak within 10 minutes
phobic avoidance of situations that could trigger an attack
changes in behaviour such as frequent health/medical visits
can be with or without agoraphobia
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
Differential Diagnosis
Treatments
Treatment depends on stage of the disorder and it's severity.
Psychotherapy
If a strong pattern to panic attacks has not yet developed, therapy should includes education about anxiety, supportive psychotherapy to deal with life stressors, and instruction in relaxation techniques.
If attacks have become more frequent, with avoidance, cognitive behavioural therapy (CBT) can be very helpful. CBT focuses on recognizing the link among situation, negative thoughts and emotions, and avoidant behaviour.. This understanding helps reframe negative thinking and behaviours. Once attacks are lessened, the triggering situation should be re-entered.
Medications
There are many classes of medication that have been shown to be helpful for panic disorder:
- SSRIs
- SNRIs
- TCAs
- benzodiazepines: immediately during an episode or before a stressful situation
- monoamine oxidase inhibitors
While symptoms often stabilize within a few months, treatment should be continued for a year or more before being reassessed and tapered downwards. Other medical and psychiatric conditions should be treated during this time, and psychosocial stressors should be addressed (relationships, work, etc) to reduce the risk of relapse.
A slow taper should be used, with antidepressants decreasing over 4-8 weeks and BZPs decreased lover a longer term. If symptoms recur, the taper should be slowed or stopped. Some patients require long-term treatment with antidepressants.
However, when considering medication, combination therapy alone may actually worsen long-term outcomes, compared with CBT (Foa et al, 2002).
Consequences and Course
Resources and References
Topic Development
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