panic disorder

age at onset of panic disorder

20s

DSM 5 criteria

recurrent unexpected panic attacks

atleast 1 of the attacks followed by 1mo or more of

• persistent concern or worry about additional attacks or their consequences and/or

• significant maladaptive changes in behavior related to the attacks (ex: behaviors are to avoid having attacks)

not attributable to a substance or medical condition or better explain by another psychiatric disorder

list some sx of panic attacks (must have 4+ to be PD)

palpitations, increased HR

sweating

trembling

SOB or smothering sensation

feelings of choking

chest pain/discomfort

nausea/GI distress

dizzy, lightheaded/faint

chills or heat sensations

derealization/depersonalization

losing control or going crazy

fear of dying

when is treatment indicated for PD

when patient shows marked distress OR experiences complications resulting from PD (ex: SI, alcohol abuse)

treatment for PD may include..

psychoeducation + reassurance

lifestyle changes as appropriate (avoid alcohol, caffeine, nicotine, other stimulants, stress reduction, healthy eating, regular exercise/yoga, sleep hygiene)

mobilization of family/social supports

supportive counseling psychotherapy (CBT most effective)

pharmacotherapy

first line pharmacotherapy for PD

citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine XR

second line pharmacotherapy for PD

alprazolam, clomipramine, clonzepma, diazepam, imipramine, lorazepam, mirtazapine, reboxetine

third line pharmacotherapy for PD

bupropion SR, divalproex, duloxetine, gabapentin, levetiracetam, milnacipran, moclobemide, olanzapine, phenelzine, quetiapine, risperidone, tranylcypromine

second line Tx adjunct for PD

alprazolam ODT, clonzapem

third line adjunct Tx for PD

aripiprazole, divalproex, olanzapine, pindolol, risperidone

which meds are not recommended in PD

buspirone, propranolol, tiagabine, trazodone

antidepressant onset of action

2-6wks, may take up to 12 wks or more to see max response

when would you use quick onset meds like benzos in PD

rapid control of Sx required (acute panic attacks)

patient about to quit school, job etc

benzos time to effect

some effect w/ 1st dose

may see reduction in panic attacks after 1 wks

several weeks for full response

in what order do you see Sx of PD resolve

PA resolve, then anticipatory anxiety, then the maladaptive behaviors