Panic Disorder

Question 1

Define panic disorder

Answer 1

Recurrent unexpected attacks of severe anxiety (panic) that are not restricted to particular stimuli or situations

Discrete episodes of intense fear or apprehension accompanied by the rapid concurrent onset of several characteristic symptoms
Persistent concern about the recurrence or significance of panic attacks, or behaviours intended to avoid their recurrence, that results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning

Question 2

What is the aetiology/risk factors for panic disorder

Answer 2

Genetics
Childhood adversity or life events
Dysregulation of serotonin, noradrenaline, GABA
Classical conditioning
Negative reinforcement
Cognitive theories
Attachment theory

Question 3

What is the epidemiology of panic disorders

Answer 3

25-44 y/o
Prevalence decreases with age
F>M

Question 4

What are the symptoms of panic disorder

Answer 4

Panic Attacks:
Sudden unexpected onset, lasts <30 minutes
Intense fear and discomfort
Recurrent, several within a month
Absence of multi-themed worry
Fear of dying → provokes further panic

Physical symptoms:
Chest pain
Nausea
Dizziness/light-headedness
Palpitations
SOB
Sweating
Shaking/trembling
Hot or cold flushes
Tingling of hands, feet or around the mouth

In between episodes, relatively fine with minimal anxiety , but avoids situations they feel will trigger an attack

Question 5

What are the differentials for panic disorder

Answer 5

generalised anxiety disorder
Agoraphobia
Depression
Alcohol withdrawal
Hyperthyroidism
CVD e.g. arrhythmia, atrial fibrillation
Phaeochromocytoma

Question 6

What investigations should be done for panic disorder

Answer 6

Clinical diagnosis (Should rule out organic pathology)
- GAD-7
- HADS (Hospital Anxiety and Depression Scale)
- Social and occupational assessments for effect on QoL

Bedside: ECG, urine drug screen, urine VMAs
Bloods: TFTs, LFTS, blood glucose, 5-HIAA

Question 7

What is the management for first presentation panic disorder

Answer 7

1. Education, reassurance, self help e.g. relaxation techniques, breathing exercises, symptom diary
2. Psychosocial intervention
   - Psycho: low intensity (6wks), individual non-facilitated/facilitated self-help, psychoeducational groups
   - Social: exercise, rely on friends, befriending programme

Question 8

What is the management for moderate-severe panic disorder

Answer 8

Bio
First line: SSRIs
Second: TCAs e.g. clomipramine

Psycho
CBT

If unsuccessful after two interventions: refer to CMHT

Question 9

What is the CMHT/secondary care management for panic disorder

Answer 9

Bio
Full exploration of pharmacotherapy

Psycho
CBT or Home-based CBT

Social
Exercise
Encourage relying on natural supports- friends, family, faith groups
Support groups: Anxiety UK, Mind, No Panic
Befriending or rehabilitation programme
Support to carers

Question 10

What is the prognosis for panic disorder

Answer 10

Good, 65% achieve complete remission
10-20% continue to have significant symptoms
Relapse rates are higher amongst women than men