Panic Disorder

Question 1

What is panic disorder?

Answer 1

Panic disorder is characterised by recurrent, episodic, severe panic attacks, which are unpredictable and not restricted to any particular situation or circumstance.

Question 2

What are the biological causes of panic disorder?

Answer 2

Genetics: along with OCD, it is one of the most heritable anxiety disorders.

Neurochemical: post synaptic hypersensitivity to serotonin and adrenaline.

Sympathetic nervous system (SNS): fear or worry stimulates the SNS→ ↑ cardiac output which can lead to further anxiety.

Question 3

What are the cognitive causes of panic disorder?

Answer 3

Misinterpretation of somatic symptoms (e.g. fear that palpitations will lead to a heart attack).

Question 4

What are the environmental causes of panic disorder?

Answer 4

Presence of life stressors can lead to panic disorder.

Question 5

How common is panic disorder?

Answer 5

Prevalence of 1% in the general population.

Question 6

Are men or women more likely to have panic disorder?

Answer 6

It is 3 times more common in women.

Question 7

What is the age of onset in panic disorder?

Answer 7

Late adolescence.

Question 8

What are the risk factors for panic disorder?

Answer 8

• Family history
• Major life events
• Age (20-30)
• Recent trauma
• Females
• Other mental disorders
• White ethnicity
• Asthma
• Cigarette smoking
• Medication (e.g. benzodiazepine withdrawal)

Question 9

How long to panic symptoms usually last?

Answer 9

Panic symptoms usually peak within 10 minutes and rarely persist beyond an hour.

Question 10

What are the clinical features of panic disorder?

Note: PANICS Disorder

Answer 10

• Palpitations
• Abdominal distress
• Numbness and nausea
• Intense fear of death
• Choking feeling and chest pain
• Sweating, shaking and shortness or breath
• Depersonalisation and derealisation

Question 11

Briefly describe the ICD-10 Classification of panic disorder

Answer 11

Recurrent panic attacks that are not consistently associated with a specific situation or object and often occur spontaneously. The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations.

Characterised by ALL of the following:

1. Discrete episode of intense fear or discomfort;
2. Starts abruptly;
3. Reaches a crescendo within a few minutes and lasts at least some minutes;
4. At least one symptom of autonomic arousal: palpitations, sweating, shaking/ tremor, dry mouth;
5. Other symptoms: worry, tension in muscles, headache, concentration difficulities, energy loss, restlessness, startled easily and sleep disturbance.

Question 12

Briefly describe the MSE for panic disorder

Answer 12

Appearance and behaviour: face looks worried with brow furrowed, restless with tremor, sweaty when you shake their hand, hyperventilating, lip biting, pallor and tense posture.

Speech: trembling and slow rate.

Mood: anxious.

Thought: repetitive worrying thoughts, thoughts may concern personal health, safety of others or excessive worry about everyday events, e.g. relationships, finances.

Perception: no hallucinations.

Cognitiong: may complain of poor memory and reduced attention/concentration.

Insight: may or may not have insight.

Note: the MSE findings will be largely the same in GAD. However, features of appearance and behaviour may be more intense such as hyperventilation and restlessness.

Question 13

What are the investigations for panic disorder?

Answer 13

Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia).

ECG: may show sinus tachycardia.

Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and Depression Scale.

Question 14

Briefly describe the management of panic disorder

Answer 14

SSRIs are first-line but if they are not suitable, or there is no improvement after 12 weeks, then a TCA, e.g. imipramine or clomipramine may be considered. Benzodiazepines should not be prescribed.

CBT is the psychological intervention of choice, focusing on recognition of panic triggers.

Self-help methods include bibliotherapy (giving written information on panic disorder and how to overcome it), support groups and encouraging exercise to promote good health.

NICE offers a stepped care approach.

Question 15

Briefly describe the step care model for the manage of panic disorder (NICE)

Answer 15

Question 16

What differentials should be considered for panic disorder?

Answer 16

Psychiatric: other anxiety disorders (e.g. generalized anxiety disorder, phobic anxiety disorder), dissociative disorder, bipolar affective disorder, depression, schizophrenia, adjustment disorder.

Organic: phaeochromocytoma, hyperthyroidism, hypoglycaemia, carcinoid syndrome, arrhythmias and alcohol/substance withdrawal.

Question 17

Compare and contrast GAD, panic disorders and phobic anxiety

• Age of onset
• When does it occur?
• Associated behaviour
• Cognition
• Associations

Answer 17