Panic disorder

Question 1

Panic attack specifier - dx

Answer 1

Note: a panic attack is not a mental disorder (no code in DSM). Can occur in context of any anxiety disorder as well as other mental disorders (e.g. depressive disorders, PTSD, substance use disorders).

An abrupt surge of intense fear/discomfort that reaches a peak within minutes, with four or more of the following symptoms:

1. Palpitations, pounding heart or accelerated HR
2. Sweating
3. Trembling or shaking
4. Sensations of SOB or smothering
5. Feelings of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed or faint
9. Chills or heat sensations
10. Paraesthesias (numbness or tingling sensations)
11. Derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
12. Fear of losing control or ‘going crazy’
13. Fear of dying

Question 2

Panic attack - mx (3)

Answer 2

1. Panic attacks may initially suggest an acute medical condition (e.g. heart attack, stroke, hyperthyroidism, respiratory condition such as asthma). First presentation (especially with clear physical element) needs evaluation for significant acute physical illness
2. Treat isolated panic attacks with psychological interventions. Explanation, support, stress management advice + discussion and education for family and close friends
3. Teach the technique of breathing slowly and deeply - raises arterial carbon dioxide concentration and abolishes many acute symptoms

Question 3

Panic disorder - dx

Answer 3

A. Recurrent unexpected panic attacks
B. At least one of the attacks has been followed by 1mo (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, ‘going crazy’)
2. Significant maladaptive change in behaviour related to the attacks (e.g. behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
C. Not due to substance or another medical condition
D. Not better explained by another mental disorder (e.g. social anxiety disorder, specific phobia, OCD, PTSD, separation anxiety disorder)

Question 4

Panic disorder - mx

Answer 4

Psychological interventions (first-line)

1. Education about the disorder (especially the way in which the panic attack produces physical symptoms). Breathing control strategies for panic attacks, relaxation strategies
2. CBT = treatment of choice. Most commonly used tx = panic control treatment, which involves exposure to deliberately induced symptoms + techniques for controlling symptoms

Pharmacotherapy (if CBT not available or effective; may need tx for 6-12mo - reduce dose slowly and stop drug if possible after this period)

3. First-line = SSRIs, or venlafaxine. Note - on initiation of tx there may be a transient increase in anxiety (can lessen dose or co-administration of BZD but use BZD with caution)
4. If at least one first-line drug unsuccessful, consider TCAs (e.g. clompramine, imipramine)
5. Specialist psychiatric practice = MAOIs, BZD
   - Note: BZD have risk of dependence