Psychiatry - Neurosis/Panic Disorder

Question 1

Panic Disorder?

Answer 1

Panic Attack:

• Period of intense fear characterised by a constellation of symptoms
• Symptoms develop rapidly, peak of intensity ~ 10min
• Can last ~ 20–30min (rarely over 1 hour)
• Spontaneous Vs situational attacks

Question 2

Panic Disorder?

Answer 2

Panic Disorder:

• Recurrent panic attacks, not 2° to substance misuse, medical conditions, or another psychiatric disorder
• Frequency of occurrence may vary – many a day Vs few a year
• Persistent worry about having another attack or consequences of the attack – may lead to phobic avoidance

Question 3

Panic Disorder?

Symptoms?

Answer 3

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sense of shortness of breath or smothering
• Feeling of choking or difficulties swallowing (globus hystericus)
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Derealisation or depersonalisation
• Fear of losing control or going crazy
• Fear of dying (angor animus)
• Numbness or tingling sensations (paraesthesia)
• Chills or hot flashes

Question 4

Panic Disorder?

Epidemiology?

Answer 4

Women are 2–3 times more likely to be affected than men

Age of onset: Bimodal distribution - highest peak incidence at 15–24yrs plus second peak at 45–54yrs, rare after age 65 (0.1%)

Other risk factors:

• Widowed
• Divorced
• Separated
• Living in a city
• Limited education
• Early parental loss
• Physical or sexual abuse

Question 5

Panic Disorder?

Co-morbidity?

Answer 5

• Agoraphobia (community surveys: 30–50%; psychiatric clinics: 75%)
• Depressive disorder (up to 68%)
• Other anxiety and related disorders (up to 50% e.g. social phobia, OCD)
• Alcohol (up to 30%) and substance misuse
• BPAD (20%)
• Medical conditions (e.g. mitral valve prolapse, hypertension, cardiomyopathy, COPD, HVS, IBS, migraine)

Question 6

Panic Disorder?

Differentials?

Answer 6

• Other anxiety or related disorder
• Substance or alcohol misuse/withdrawal e.g. amphetamines, caffeine, cannabis, cocaine, theophylline, sedative-hypnotics, steroids
• Mood disorders
• Psychiatric disorders secondary to medical conditions
• Medical conditions presenting with similar symptoms

Question 7

Panic Disorder?

Investigations?

Answer 7

• No specific tests
• Exclude other causes if supported by history/physical examination e.g. FBC, U&Es, glucose, TFTs, ECG, Ca2+, urinary vanillyl mandelic acid [VMA]/plasma homovanillic acid [pHVA], echo, and EEG

Question 8

Panic Disorder?

Management?

Answer 8

• NICE and local guidelines
• Pharmacological and psychological Tx combined
• Patient preference, past history of previous benefit, costs, and availability
• Emergency management of panic attack

Question 9

Panic Disorder?

Management?

Answer 9

Pharmacological:

• Antidepressants: SSRIs, SNRIs, TCAs, and MAOIs
• Benzodiazepines: Dependence, misuse, cognitive impairment, 1-2 weeks in combination with ADx

Second line

• Continue treatment for 12–18mths before trial discontinuation (gradually tapering of dose over 2–4mths). ‘Withdrawal’ effects (10–20% of patients) Vs re-emergence of symptoms (50–70% of patients). Pts may want to continue indefinitely
• Tx of comorbidities

Psychological:

• CBT
• Brief psychodynamic psychotherapy

Question 10

Panic Disorder?

Course?

Answer 10

• Patients may have already experienced chronic symptoms for 10–15yrs
• Untreated = runs a chronic course
• With treatment, functional recovery is seen in 25–75% after the first 1–2yrs, falling to 10–30% after 5yrs
• Long-term, around 50% will experience only mild symptoms
• Poor responses associated with: very severe initial symptoms, marked agoraphobia, low socio-economic status, less education, long duration of untreated symptoms, restricted social networks (including loss of a parent, divorce, remaining unmarried), and presence of personality disorder

Question 11

Panic Disorder?

Emergency Tx of An Acute Panic Attack?

Answer 11

Maintain a reassuring and calm attitude (most resolve within 30 minutes):

• If symptoms are severe and distressing consider prompt use of BDZs
• If first presentation, exclude medical causes
• If panic attacks are recurrent, consider differential diagnosis for panic disorder and address underlying disorder (may require psychiatric referral)