7B anxiety-panic disorder مقالي 🛑

• Panic disorder is an anxiety disorder characterized by:

  • Extreme and frequent unexpected panic attacks

• Attacks may be:

  • with no apparent cause

  • Or triggered by a specific event or situation

What is Panic Disorder?

At least one of the following for ≥ (more or equal) 1 month:

1. Persistent fear of having another attack

2. Worry about the consequences of the attack

3. Behavioral changes related to the attacks

What conditions must be present for diagnosing Panic Disorder over one month?

• Repeated intense episodes of extreme anxiety

• Duration:

  • Usually 10 minutes

  • May be 1–5 minutes

  • May exceed 10 minutes

• Attacks may:

  • Wax and wane for hours

  • Occur as rolling attacks

• Severity and symptoms vary between patients

What are the general signs and course of Panic Disorder? + duration + it’s rhythm?

1. Rapid heart rate

2. Sweating

3. Nausea

4. Dizziness

5. Trembling

6. Shortness of breath

7. Chest pain

8. Chills

9. Numbness

What are the Physical Symptoms of Panic Attacks?

• Fear of losing control or going crazy

• Fear of dying or having a heart attack

• Feeling detached from reality

What are the Psychological Symptoms of Panic Attacks?

• They often feel as if:

  • They are having a heart attack

  • They are about to die

How do patients describe a panic attack?

• Avoidance of certain places or situations

• Use of safety behaviors for reassurance

What are the Behavioral Symptoms of Panic Disorder?

• Continuous avoidance of feared situations and objects

  ↳This avoidance may gradually develop into phobias

How can Panic Disorder lead to Phobias?

• Persistent worry about future panic attacks

• Impairment in daily functioning

What psychological distress occurs in Panic Disorder?

• Recurring and unexpected panic attacks

• For at least one month

What is meant by Duration and Frequency?

What is the Difference between Panic Attack & Panic Disorder?

• Recurrent unexpected panic attacks

• Peak within minutes

• With 4 or more of the following:

1. Palpitations

2. Sweating

3. Trembling

4. Shortness of breath

5. Choking

6. Chest pain

7. Nausea

8. Dizziness

9. Chills or heat sensations

10. Paresthesia

11. Derealization or depersonalization

12. Fear of losing control

13. Fear of dying

What is DSM Criterion A of panic disorder?

At least one attack followed by one of:

1. Persistent worry about new attacks or their consequences

2. Maladaptive behavioral changes (avoidance)

• for month or more

What is DSM Criterion B?

• not attributed to the physiological effects of a substance

  • Substance use

  • Medication

  • Medical condition (e.g., hyperthyroidism, cardiopulmonary disorders)

What is DSM Criterion C?

• Not better explained by another disorder:

  • SAD

  • Specific phobia

  • OCD

  • PTSD

  • SepAD

What is DSM Criterion D?

1. Hyperthyroidism

2. Hypothyroidism

3. Temporal-lobe epilepsy

4. Asthma

5. Cardiac arrhythmias

6. Excess caffeine and stimulants

What diseases mimic Panic Disorder?

• Usually begins before age 25

• May occur in the mid-30s

• Saudi females: 1.9%

• Saudi males: 1.3%

• KSA overall prevalence: 1.6%

What is the age onset of panic disorder and its prevalence of ?

1. Family history

2. Smoking

3. Psychological stress

4. History of child abuse

What are the risk factors of Panic Disorder?

1. Biological

2. Pharmacological

3. Chronic illness (comorbidity > 90%)

4. Cognitive

What are the main perspectives explaining(causes) of Panic Disorder?

• Runs in families

• Twin studies: higher concordance in identical twins

• First-degree relatives: 40% risk

▶ Neurochemical imbalance:

• GABA (gamma-aminobutyric acid)

• Cortisol

• Serotonin

• Hyperexcitable neural circuitry in the brain

What explains Panic Disorder biologically?

1. Stimulants

2. Caffeine

3. Amphetamine

4. Alcohol

5. Some medications

6. Psychosomatic drug phobias

What substances can trigger Panic Disorder?

• Alcohol withdrawal

• Benzodiazepine withdrawal

• Both may cause rebound panic attacks

What is the effect of substance withdrawal?

1. Major life transitions

2. Stimulus generalization

3. Learned helplessness

4. Maintained by negative reinforcement

5. Excessive threat focus

What are the cognitive causes of Panic Disorder?

1. Test/preformance anxiety

2. Poor academic performance

3. School avoidance

4. Public speaking stress

Why does Panic Disorder appear in school?

• Schizophrenia

• OCD

• Specific phobias

• Social phobia

• Agoraphobia

What psychiatric disorders are comorbid with Panic Disorder?

1. Heart disease

2. Hyperthyroidism

3. Drug use

What is the differential diagnosis of Panic Disorder?

1. Life restriction

2. Job and housing limitation

3. Avoidance of driving and shopping

4. One-third become housebound

5. Development of agoraphobia

What are the outcomes of untreated Panic Disorder?

1. Decrease frequency of attacks

2. Decrease intensity of attacks

3. Decrease anticipatory anxiety

4. Decrease phobic avoidance

What are the goals of treatment?

1. A psychiatrist

2. psychologist, or a mental health care provider.

Who should monitor all patients with PD?

Psychiatric care.

What type of care is shown to be the most effective and low cost for patients with PD?

1. Higher efficacy

2. Lower cost

3. Lower dropout rate

4. Lower relapse rate

5. 12–16 weekly sessions

6. Focus on symptom recreation and response modification

Why is CBT the treatment of choice?

• A thought

• A situation

• A heartbeat change

What can act as triggers?

• Separate panic from the trigger

• Increase trigger awareness

What are the CBT therapy goals?

1. Gradual exposure

2. Desensitization

3. Relaxation techniques

4. Respiratory training:

   • to control hyperventilation during panic attacks

5. Controlled breathing

• Triggers can be created such as:
  

  • Light-headedness

  • Blurred vision

  • Dizziness

What does behavioral therapy include in anxiety and panic disorder?

• Benzodiazepines (short-term)

• SSRIs (long-term)

• Used with psychotherapy

What medications are used?

1. First follow-up in 2 weeks

2. Start SSRIs at lowest dose

3. Assess suicide risk

4. Treat substance use

5. Refer to cardiologist if needed

What is the follow-up plan?

1. Dangerous behavior

2. Suicidal or homicidal ideation

3. Intoxication or withdrawal

4. Inability to follow outpatient care

5. Medical instability

When is hospitalization (inpatient) required?

1. Major life stress

2. Loss of loved ones

3. Requires restarting:

   • CBT

   • SSRIs

   • Tricyclics if SSRIs fail

Why does relapse occur?

• 65% achieve remission within 6 months

• CAD risk nearly doubled

• Panic can induce myocardial ischemia

• Combined CBT + medication effective in >85% of cases

What is the prognosis of Panic Disorder?