Panic Disorder

Question 1

Median age of onset for panic disorder

Answer 1

20-24 years of age

Question 2

What percentage of those with panic disorder develop agoraphobia?

Answer 2

~33%

Question 3

Diagnostic criteria for panic disorder

Answer 3

• Recurrent unexplained panic attacks
• At least one panic attack followed by >1 month of concern about having additional attacks, worry about the consequences of the attacks, or maladaptive change in behavior related to the attacks
• Attacks are not caused by physiologic effects of a substance, medication, or medical condition

Question 4

Typical onset and duration of a panic attack

Answer 4

May or may not be provoked by exercise or an emotional or fearful event

Progresses to a peak within 10 minutes of rapidly intensifying symptoms

Lasts up to 20-30 minutes

Question 5

A patient can have a variety of associated symptoms with a panic attack, but they have to have either __ or __ for it to be a panic attack

Answer 5

A patient can have a variety of associated symptoms with a panic attack, but they have to have either intense fear or intense discomfort for it to be a panic attack

Question 6

Main ddx for panic disorder

Answer 6

• Heart attack
• Arryhthmia
• Paroxysmal vertigo
• Endocrine disorder (especially hyperthyroid, adrenal insufficiency, pheochromocytoma)
• Intoxication
• Medication side effect

Question 7

If someone has a panic attack, do they automatically have panic disorder?

Answer 7

No!

Panic attacks can be seen in other disorders, such as PTSD or specific phobia

So, possible triggers must be carefully elicited.

Question 8

In panic disorder, the direction of fear is. . .

Answer 8

. . . fear of having an attack

Not fear of something that can trigger an attack, such as agoraphobia

However, someone with panic disorder may secondarily develop agoraphobia.

Question 9

First-line treatment of panic disorder

Answer 9

• SSRIs
• SNRIs
• TCAs (considered, often 2nd line due to side effect profile)
• Benzos OR hydroxyzine: Note, benzos or hydroxyzine are often used as a bridging therapy while the above medications take effect and are then discontinued.

OR

• CBT – CBT is as effective as a medication for this condition, and CBT + medication has enhanced efficacy.

Question 10

Role of benzodiazepines in therapy of panic disorder

Answer 10

1. As a rescue medication when a patient presents in a known panic attack
2. As a bridging therapy to SSRI, SNRI, or TCA therapy

Question 11

Treating resistant panic disorder

Answer 11

• CBT + medication
• Addition of atypical antipsychotic onto SSRI or SNRI therapy

Question 12

Beta blockers in panic disorder

Answer 12

May be used episodically in low doses to treat the symptoms of an acute panic attack

Question 13

Panic attacks in the setting of public speaking (“stage fright”) represent. . .

Answer 13

. . . social anxiety disorder

Not panic disorder or specific phobia

Question 14

___ is commonly comorbid with panic disorder and agoraphobia

Answer 14

Major depressive disorder is commonly comorbid with panic disorder and agoraphobia

Question 15

Diagnostic criteria for “anxiety disorder due to another medical condition”

Answer 15

Anxiety or panic attacks are the predominant symptom

History, PE, and/or labs strongly suggest that the symptoms are a direct physiologic consequence of a medical condition.

Syptoms do not occur only during delirium.

Question 16

Treatment of anxiety disorder due to another medical condition

Answer 16

Obviously, the primary focus is the underlying medical condition

However, this may not totally alleviate anxiety symptoms. If this is the case, this may be treated much like GAD. SSRI therapy with benzodiazepine bridge and otherwise sparing use of benzodiazepines is appropriate if symptoms persist. Psychotherapy may also aid in relief of symptoms.

Question 17

Any patient with diabetes mellitus (type I, II, or rarer type) that presents to the ED with diaphoresis and tremulousness should have STAT ___, irrespsective of other details

Answer 17

Any patient with diabetes mellitus (type I, II, or rarer type) that presents to the ED with diaphoresis and tremulousness should have STAT blood glucose, irrespsective of other details

Although TBH, they should probably have this STAT anyway irrespective of symptoms given their diagnosis

Question 18

Someone who has panic attacks whenever they get too far from their home and therefore gets everything delivered and tries never to leave the home except with assistance has. . .

Answer 18

. . . agoraphobia and NOT NECESSARILY panic disorder

Remember, for it to be true panic disorder the events need to happen kind of out of the blue. If the panic attacks happen because of straying from the home, then they are induced by agoraphobia and therefore agoraphobia ALONE is the appropriate diagnosis (not panic disorder + agoraphobia).