Panic Disorder

PANIC DISORDER

INTRODUCTION

  • Panic Disorder Definition:

    • Panic disorder is characterized by recurrent, unexpected panic attacks.

    • Panic Attack Definition: Defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) as "an abrupt surge of intense fear or discomfort" reaching a peak within minutes.

    • Frequency: Panic attacks can occur several times per day or infrequently, such as only a few attacks per year.

    • Feature: A hallmark feature of panic disorder is that attacks occur without warning.

PANIC REVIEW

  • Extreme Anxiety: Panic is the most extreme level of anxiety and results in markedly dysregulated behavior.

  • Behavioral Characteristics:

    • Individuals may be unable to process what is going on in the environment and may lose touch with reality.

    • Possible behaviors include pacing, running, or screaming, to complete withdrawal.

  • Psychological Symptoms:

    • Report a sense of impending doom or danger.

    • Feelings of unreality or detachment.

  • Physical Symptoms include:

    • Racing heart, sweating, chills, hot flashes, trembling, shortness of breath, weakness or dizziness, tingly or numb hands.

    • Other somatic symptoms: headache, nausea, abdominal cramping, chest pain.

DSM-5 CRITERIA

  • An abrupt surge of intense fear or discomfort reaching a peak within minutes, during which time four or more symptoms occur:

    • Palpitations, pounding heart, or accelerated heart rate.

    • Sweating.

    • Trembling or shaking.

    • Sensations of shortness of breath or smothering.

    • Feeling of choking.

    • Chest pain or discomfort.

    • Nausea or abdominal distress.

    • Feeling dizzy, unsteady, lightheaded, or faint.

    • Derealization (feelings of unreality) or depersonalization (being detached from oneself).

    • Fear of losing control or “going crazy.”

    • Fear of dying.

    • Paresthesias (numbness or tingling sensation).

    • Chills or heat sensations.

RISK FACTORS

  • Demographics:

    • Panic disorder is nearly 2 times more common in women than in men.

    • More likely to occur with agoraphobia in women.

    • Most likely to appear in individuals aged 20 to 29 years, but onset may occur in teenage years or as late as 30 to 40 years.

  • Genetic Factors: Having a close family member such as a parent, brother, or sister diagnosed with panic disorder.

  • Coping Skills: Lack of coping skills.

  • Stressful Life Events:

    • Loss of a job.

    • Marriage or the birth of a first child.

    • Prior victimization through crime or abuse.

  • Baseline Anxiousness: Elevated levels of baseline anxiousness—taking something normal and worrying excessively.

  • Mental Health Issues: Especially prevalent with other anxiety disorders or depression.

  • Substance Use Disorders: Problems with alcohol use disorder or substance use disorder.

TREATMENT OVERVIEW

  • Treatment Response: Between 70% and 90% of patients with panic disorder respond well to treatment.

  • Treatment Modalities: Two main modalities employed:

    • Drug Therapy:

    • Suppresses panic attacks.

    • Cognitive Behavioral Therapy (CBT):

    • Helps patients become more comfortable with anxiety-provoking situations and places.

    • Combined Treatment: Combining drug therapy with CBT is more effective than either modality alone.

  • Lifestyle Modifications and Maintenance:

    • Avoiding caffeine and sympathomimetics (which can trigger panic attacks).

    • Avoiding sleep deprivation (can predispose to panic attacks).

    • Engaging in regular aerobic exercise (can reduce anxiety).

  • Duration of Drug Therapy: Drug therapy should continue for at least 6 to 9 months; stopping sooner is associated with a high rate of relapse.

NON-PHARMACOLOGIC INTERVENTIONS

  • Calm Environment: Promote a calm environment by reducing environmental stimuli, as stimulating environments increase anxiety.

  • Support & Reassurance: Providing reassurance to the patient that help is available to reduce anxiety.

  • Anxiety Reduction Techniques:

    • Assist the patient in reducing anxiety from severe or panic levels to mild or moderate through slow, deep breathing techniques or prescribed medication.

    • It is crucial to lower anxiety levels to allow subsequent learning.

  • Problem Reframing: Reframe problems in a way that is solvable, providing a new perspective and addressing distorted perceptions to facilitate finding workable solutions.

IDENTIFYING TRIGGERS AND TEACHING TECHNIQUES

  • Trigger Identification: Identifying thoughts or feelings before the onset of anxiety helps recognize triggers for escalating anxiety and understanding why these are frightening to the patient.

  • Relaxation Techniques: Teaching relaxation techniques such as deep breathing exercises, meditation, or progressive muscle relaxation enhances patients' ability to assess situations and improves problem-solving skills.

  • Cognitive Skills: Identifying negative self-talk (e.g., “I’ll never be able to do this right” or “This means I’ll never succeed in anything”) can be addressed through cognitive skills to assist in reframing thinking effectively.

MEDICATIONS

  • First-Line Choices:

    • Selective Serotonin Reuptake Inhibitors (SSRIs):

    • Examples include fluoxetine, paroxetine, and sertraline.

  • Second-Line Choices:

    • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

    • Example includes venlafaxine.

    • Tricyclic Antidepressants (TCAs):

    • Examples include imipramine and clomipramine; typically not as well-tolerated as SSRIs.

    • Benzodiazepines:

    • Examples include alprazolam, clonazepam, and lorazepam; also a second-line choice due to risks for abuse and dependence.

  • SSRIs Preference: SSRIs are preferred due to better tolerability, and TCAs should generally be administered only after a trial with at least one SSRI has failed.