Panic DO and Agoraphobia

Panic Disorder DSM 5

•Panic attack is an abrupt surge of intense fear or discomfort that include at least FOUR of the following sx:

•Palpitations

•Sweating

•Trembling

•SOB

•Choking feeling

•Chest pain

•Nauseas or GI distress

•Dizzy/light-headedness

•Chills or heat sensation

•Paresthesia's

•Derealization or depersonalization

•Fear of losing control or “going crazy”

•Fear of dying

•At least one of the attacks is followed by one or both of the following:

•Concern or worry about another one

•Significant maladaptive change in behavior (avoidance)

Panic Disorder: Stats

Prevalence: 2-3%; Female to males: 2:1; Prevalence declines in older age; Age of onset 20-24 years; Onset after 45 years is rare

Agoraphobia

Fearful about two or more of the following five situations: public transportation; open spaces; enclosed places, being in a crowd/standing in ine; being outside the home alone; Fear that they will not be able to escape, have panic symptoms that are incapactiating/embarassing. Lasting 6 months or more

Symptoms/Differentials

Sleep problems, low motivation or initiation of new activities; Restructed eating, behavioral outbursts

Treatment options: Agoraphobia

Benzos (yikes), SSRI, TCA, Psychotherapy

Treatment options: specific phobia

Behavior therapy, insight-oriented therapy, virtual therapy, exposure therapy, sometimes need pharmacotherapy, beta blockers

Meds slide SSRIs

Agent	Initial daily dose	Suggested dose titration based upon response	Maintenance daily dose range	Selected characteristics*
Selective serotonin reuptake inhibitors (SSRIs)*
Fluoxetine	Children: 5 to 10 mg Adolescents: 10 mg	After 7 days increase daily dose to 20 mg; then after 4 and 8 weeks increase daily dose by 20 mg, if needed	10 to 80 mg	•Prolonged half-life. •Metabolized by and inhibits CYP2D6.
Fluvoxamine	25 to 50 mg at bedtime	Increase daily dose by 25 mg (child) or 25 to 50 mg (adolescent) after a minimum of 7 days, if needed	50 to 300 mg	•Girls generally require lower maintenance doses than boys. •Give with meals and bedtime in divided doses to minimize side effects. •Metabolized by CYP1A2 and 2D6. •Inhibits CYP1A2 and 2C19.
Sertraline	12.5 to 25 mg	Increase daily dose by 12.5 mg (child) or 25 to 50 mg (adolescent) after a minimum of 7 days, if needed	50 to 200 mg	•Diarrhea more frequent than other SSRIs. •Metabolized by CYP2D6. •Inhibits CYP2D6 with larger doses.
Paroxetine	5 to 10 mg	Increase daily dose by 5 mg (child) or 10 mg (adolescent) after a minimum of 7 days, if needed	10 to 60 mg	•Short half-life. •Mild anticholinergic side effects. •Metabolized by and inhibits CYP2D6. •Weight gain.

Meds slide: SNRIs

Serotonin norepinephrine reuptake inhibitor (SNRI)*
Venlafaxine extended-release (ER)	37.5 mg	Increase daily dose by 37.5 mg (child) or 75 mg (adolescent) after a minimum of 7 days, if needed	75 to 225 mg	•Dose-related increase in diastolic blood pressure and/or heart rate may be seen. •Some children may experience weight loss. •Metabolized by CYPs 2D6 and 3A4. •Prolongation of Qt interval.
Duloxetine	30 mg	Increase daily dose by 30 mg after a minimum of 14 days, if needed	30 to 60 mg Some patients may benefit from a higher daily dose, increased by 30 mg increments every 2 to 4 weeks, to maximum of 120 mg per day	•Some children may experience dose-related gastrointestinal-related adverse effects (egg, nausea and abdominal pain), and weight loss. Palpitations and increased pulse were observed more frequently than with placebo in a pediatric GAD trial. •Use with strong inhibitors (egg, fluvoxamine) or inducers (egg, carbamazepine, rifampin) of CYP1A2 should in general be avoided. •Strong CYP2D6 inhibitors (egg, fluoxetine, paroxetine, tipranavir) can increase duloxetine concentrations by up to 60%.

Med slide: TCA

Tricyclic antidepressants (TCA)
Clomipramine	Children ≥10 years old and adolescents: 25 mg	Increase daily dose by 25 mg after a minimum of 7 days, if needed; give in divided doses with meals and bedtime	25 to 250 mg (2 to 6¶ mg/kg per day); doses >2.5 mg/kg per day should be used cautiously¶	•Applies to clomipramine and imipramine: Cardiovascular screening including ECG recommended prior to initiating treatment.¶ •Anticholinergic side effects may limit usefulness in children. •Drowsiness, irritability and vomiting may be seen. •Give in divided doses with meals and at bedtime to minimize side effects. •Metabolized by CYPs 1A2, 2C19 and 3A4.
Imipramine	10 to 25 mg	Increase daily dose by 25 mg after a minimum of 7 days, if needed; give in divided doses with meals and bedtime	10 to 300 mg (2 to 6¶ mg/kg per day); doses >2.5 mg/kg per day should be used cautiously¶

Med slide: benzos

Benzodiazepines
Clonazepam	0.25 to 0.5 mg		1 to 6 mg	•Applies to clonazepam and lorazepam:Drowsiness, irritability and oppositional behavior may be seen •Subject to abuse, addiction and diversion
Lorazepam	0.25 to 0.5 mg		0.25 to 8 mg