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1. Panic Disorder

2. Definition
▪ It is a recurrent and unexpected anxiety attack of panic,
which is more often called a panic attack.
In a month or more one with features such as the following:
▪ a) Persisting fear of having another attack
▪ b) Worry about the implications and consequences of the attack.
▪ c) Significant changes in behavior after the attacks

3. Some features of Panic Disorder
▪ Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10
minutes, but some symptoms may last much longer. Panic disorder is twice as common in
women as in men. Panic attacks often begin in late adolescence or early adulthood.
▪ Not everyone who experiences panic attacks will develop panic disorder. Many people have
just one attack and never have another. The tendency to develop panic attacks appears to be
inherited. Panic disorder is often accompanied by other serious problems, such as depression,
drug abuse, or alcoholism.

4. Risk Factors
Adolescence or early adulthood.
Major life transitions are perceived as stressful.
Graduating from college, getting married, having a first child.
Genetics.
If a family member has panic disorder, you have an increased risk.
Especially during a time in your life that is particularly stressful.

5. Differences between Panic attack and Panic Disorder
▪ Anyone can suffer from a Panic attack which is an extreme anxiety reaction that results
when a real threat suddenly emerges (E.g.: when they are afraid of somebody in their house
stealing).
▪ The experience of “Panic Disorder,” however, is different.
▪ Panic attacks are periodic, short bouts of panic that occur suddenly, reach a peak, and pass.
▪ Sufferers often fear they will die, go crazy, or lose control.
▪ Attacks happen unexpectedly in the absence of a real threat.
▪ Sufferers also experience dysfunctional changes in thinking and behavior as a result of the
attacks.
▪ Example: sufferer worries persistently about having an attack; plans behavior around
possibility of future attack.

6. Pathophysiology
▪ While the various symptoms of a panic attack may cause the person to feel that their body is
failing, it is in fact protecting itself from harm.
▪ The various symptoms of a panic attack can be understood as follows.
▪ First, there is frequently (but not always) the sudden onset of fear with little provoking
stimulus.
▪ This leads to a release of nonadrenaline which brings about the so-called fight-or-flight
response, wherein the person's body prepares for strenuous physical activity.
▪ This leads to tachycardia, and hyperventilation which may be perceived with dyspnea and
sweating (which increases grip and aids heat loss).

7. Pathophysiology
▪ Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon
dioxide levels in the lungs and then in the blood.
▪ This leads to shifts in blood pH (respiratory alkalosis or hypocapnia), which in turn can lead
to many other symptoms, such as tingling or numbness, dizziness, burning and
lightheadedness.
▪ Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting
in slightly less blood flow to the head which causes dizziness and lightheadedness.
▪ A panic attack can cause blood sugar to be drawn away from the brain and towards the
major muscles.
▪ It is also possible for the person experiencing such an attack to feel as though they are
unable to catch their breath, and they begin to take deeper breaths, which also acts to
decrease carbon dioxide levels in the blood.

8. Pathophysiology
▪ It is also unclear why some people have such abnormalities in norepinephrine activity.
▪ Inherited biological predisposition is one possibility.
▪ Prevalence should be (and is) greater among close relatives.
▪ Among monozygotic (MZ, or identical) twins = 24%.
▪ Among dizygotic (DZ, or fraternal) twins = 11%.

9. Classification
Two diagnoses:
▪ panic disorder with agoraphobia.
▪ panic disorder without agoraphobia (twice more
common).
▪ ~3% of the U.S. population affected in a given
year.
▪ ~5% of the U.S. population affected at some point
in their lives.is

10. What does cause Panic Disorders
▪ There are 3 perspective which can lead to the
pathological abnormality of Noradrenalin activity:
▪ 1) Biological perspective.
2) Pharmacological.
3) Chronic illness (Comorbid disorders in PD
accounts more than 90%).
4) cognitive.

11. (1) Biological perspective
Vulnerability to panic disorder tends to run in families. E.g.: Twin studies: Higher concordance
rates among identical twins.
Among monozygotic (MZ, or identical) twins = 24%
Among dizygotic (DZ, or fraternal) twins = 11%
Possible imbalance of neurotransmitters involved in arousal
Serotonin & Norepinephrine. (Smokers have a fourfold risk of a 1st-time panic attack.

12. (2) Pharmacological Triggers
▪ Certain chemical substances, mainly stimulants but also certain depressants, can either
contribute pharmacologically to a constellation of provocations, and thus trigger a panic
attack or even a panic disorder, or directly induce one.
▪ This includes caffeine, amphetamine, alcohol, and many more.
▪ Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus
have a merely psychosomatic effect, thereby functioning as drug triggers by
nonpharmacological means.
▪ Alcohol, medication, or drug withdrawal — Various substances both prescribed and
unprescribed can cause panic attacks to develop as part of their withdrawal syndrome or
rebound effect.
▪ Alcohol withdrawal and benzodiazepine withdrawal are the most well-known to cause these
effects as rebound withdrawal symptoms of their tranquillizing properties.

13. (3) Chronic illness
Chronic/serious illness — Cardiac conditions that can cause sudden death such as long QT
syndrome; catecholaminergic polymorphic ventricular tachycardia or Wolff-Parkinson-White
syndrome can also result in panic attacks.
This is particularly difficult to manage as the anxiety relates to events that may occur such as
cardiac arrest, or if an implantable cardioverter-defibrillator is in situ, the possibility of having a
shock delivered.
It can be difficult for someone with a cardiac condition to distinguish between symptoms of
cardiac dysfunction and symptoms of anxiety.
In CPVT the anxiety itself can and does trigger arrhythmia.
Current management of panic attacks secondary to cardiac conditions appears to rely heavily on
benzodiazepines, selective serotonin reuptake inhibitors and/orcognitive behavioural therapy.
However, people in this group often experience multiple and unavoidable hospitalisations; in
people with these types of diagnoses, it can be difficult to differentiate between symptoms of a
panic attack versus cardiac symptoms without an electrocardiogram.

14. (4) Cognitive
▪ 1. Major life transitions (post-graduation,
losing a job, after marriage).
▪ 2. Stimulus generalization.
▪ 1st attack occurs in one location.
▪ Fear another attack in similar locations.
▪ 3. Being helpless increases fear.
▪ 4. Maintained by negative reinforcement
▪ 5. Excessive focus on potential threats
(Cognitive).

15. PD in school life
There are many student that appears with PD in the school life time, why does it happen?
I. Test/performance anxiety.
II. Poor academic performance.
III. Avoidance of school entirely. What can we do to help?
Talk with them about possible triggers.
Stand near them in stressful situations (e.g. speeches).

16. Outcomes
People who have full-blown, repeated panic attacks can become very disabled by their condition
and should seek treatment before they start to avoid places or situations where panic attacks have
occurred.
For example, if a panic attack happens in an elevator, someone with panic disorder may develop a
fear of elevators that could affect the choice of a job or an apartment, and restrict where that
person can seek medical attention or enjoy entertainment.
Some people's lives become so restricted that they avoid normal activities, such as grocery
shopping or driving.
About one-third become housebound or are able to confront a feared situation only when
accompanied by a spouse or other trusted person. When the condition progresses this far, it is
called agoraphobia, or fear of open spaces.

17. DSM Criteria for PD diagnosis
▪ DSM (Diagnostic and Statistical Manual of Mental Disorders) expects at least 4 of 13
symptoms in stating the patient has had a “panic attack.” List as many of the 13.

18. At least 4 of the following develop suddenly and peak in 10 minutes:
▪ 1. palpitations or increased pulse.
2. sweating.
3. trembling or shaking.
4. sensation of shortness of breadth.
5. feeling of choking.
6. chest discomfort.
7. nausea or stomach distress.
8. dizzy, unsteady, lightheaded, or faint.
9. derealization/depersonalization.
10. fear of losing control or going “crazy”.
11. fear of dying.
12. paresthesias.
13. chills or hot flashes.

19. When to hospitalize a patient with PD?
▪ Only hospitalized if there is another psychiatric disorder present that so justifies.

20. Disease which mimic PD
Hyperthyroidism
Hypothyroidism
Temporal-lobe epilepsy
Asthma
Cardiac arrhythmias
Pheochromocytoma
Too much coffee and other stimulants

21. The suicide rate
▪ Guideline says 1/5, but the article implies that is so because many have
comorbid with depression. Still, it would seem that “1/5” would be the
correct answer.

22. Treatment goals
▪ 1. Decrease frequency of attacks
2. Decrease intensity of attacks
3. Decrease anticipatory anxiety
4. Decrease phobic avoidance.
▪ All patients with PD should be monitored by a psychiatrist, psychologist, or mental health
care, it is shown that psychiatric care is the most effective and low costs because of the
addition of pharmacological therapy, decreasing emergency department intake and costs, and
nonpsychiatric outpatient care.

23. Cognitive behavioral therapy(CBT)
▪ CBT with or without pharmacotherapy, is the treatment of choice for panic disorder, and it
should be considered for all patients. CBT has higher efficacy and lower cost, dropout rates,
and relapse rates than pharmacologic treatments.
▪ In 12 to 16 sessions, usually weekly, the focus is on recreating the feared symptoms and then
modifying the patient’s response.
▪ The trigger in an individual case could be something like:
A thought,
A situation,
Something subtle like a slight change in a heartbeat.
▪ Therapy Goals.
Understanding that the panic attack is separate and independent of the trigger.
Awareness of the trigger(s) so it begins to lose some of its power to induce an attack.

24. Behavioral therapy
Behavioral therapy involves sequentially greater exposure of the patient to anxiety-provoking
stimuli; over time, the patient becomes desensitized to the experience.
Relaxation techniques also help to control patients' levels of anxiety.
Respiratory training can help patients to control hyperventilation during panic attacks and to
control anxiety with controlled breathing.
Capnometry feedback-assisted breathing training can be used to prevent hypocapnia and
stabilize the respiratory rate.
The trigger could be: Intentional hyperventilation – creates lightheadedness, derealization,
blurred vision, dizziness.
Spinning in a chair – creates dizziness, disorientation.
Straw breathing – creates dyspnea, airway constriction.
Breath holding – creates sensation of being out of breath.
Running in place – creates increased heart rate, respiration, perspiration.
Body tensing – creates feelings of being tense and vigilant Therapy goals: it help the patient to
come through an attack by controlling the symptoms.

25. Pharmacological therapy
▪ Providing a few doses of a benzodiazepine as needed (prn) can enhance patient confidence
and compliance.
▪ Total tablet dispensing should remain limited to ensure that patients understand that they
have a limited supply of the drug and that this medicine represents a temporary or
emergency use option.
▪ The patient should be made to understand the importance of longer-term management with
SSRI medication and psychotherapeutic techniques (eg, CBT).
▪ Avoid the prescription of benzodiazepine in patients with a known history of substance
misuse or alcoholism.

26. Follow-up care and referrals
▪ Initial follow-up care should occur within 2 weeks because SSRIs can cause an initial
exacerbation of panic symptoms.
▪ For this reason, begin with the lowest dose with the understanding that the dose must be
increased at the initial follow-up visit.
▪ Assess potential suicide risk at all appointments. Ensure continuing treatment of any
concurrent substance use disorders.
▪ Follow-up care by a chemical dependence treatment specialist is recommended when
indicated.
▪ Patients with ventricular dysrhythmias, abnormal findings on ECG, abnormal findings on
cardiac examination, or significant risk factors for heart disease should be referred to a
cardiologist.

27. Inpatient care
▪ Inpatient care is rarely considered for uncomplicated panic disorder. Patients may get
admitted if they display any evidence of dangerous behavior, or safety concerns,
report suicidal or homicidal ideation as may occur in the context of acute anxiety, fear
of anxiety or its consequences, or with another psychiatric disorder.
▪ Patients may require hospitalization for intoxication or withdrawal from
sedatives/hypnotics such as alcohol or Xanax, which sometimes get ingested or
abused in attempts to medicate or manage the anxiety. Patients may also get
hospitalized if they become so incapacitated by their anxiety that they are unable to
adhere to outpatient care.
▪ Inpatient treatment is necessary for patients with suicidal ideation and plan or with
serious alcohol or sedative withdrawal symptoms, or when the differential includes
other medical disorders that warrant admission (eg, unstable angina, acute myocardial
ischemia).

28. 5 groups of drugs used in the PD
▪ 1. SSRIs
▪ 2. SNRIs
▪ 3. High potency benzodiazepines
▪ 4. Tricyclics
▪ 5. MAOIs

29. SSRIs
SSRIs are the first choice for the treatment of PD.
Fluoxetine, Paroxetine, Sertraline, or fluvoxamine:
MOA: It is an antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT.
It also has a negligible affinity for cholinergic and histaminergic receptors.

30. SNRIs
▪ Trazodone: it is used in PD with or without agoraphobia.
▪ MOA: It is an antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT.
It also has a negligible affinity for cholinergic and histaminergic receptors.

31. Intermediate to strong Benzodiazepam
▪ Lorazepam, clonazapam, alprazolam or diazepam.
▪ It is not a primary choice because of the dependence and side effects caused.
▪ Useful in situations such as apprehensiveness about taking an airplane flight MOA: it
potentiates GABA by binding to specific GABA receptors.

32. Tricyclic antidepressants
▪ Imipramine, desipramineor clomipramine.
It has a low risk of dependence and no diatary restrictions, but they are in 35% cases
discontinued because of its side effects such as blurred vision, dry mouth, dizziness, weight
gain, GIT distubences, agitation, headache, insonia and decreased libido, to avoid side effects
abruptly, it must be first administered in low dose.
MOA: they are Serotonin and Nonadrenaline reuptake inhibitors.

33. Monoamine oxidase inhibitors
Phenelzine or tranylcypromine, is effective in patients with PD or other associated phobia.
MOA: Nonselective monoamine oxidase inhibitor; may inhibit the enzyme monoamine oxidase,
which is responsible for the breakdown of dopamine, serotonin, epinephrine, and
norepinephrine, in turn causing an increase in endogenous concentrations of these
neurotransmitters.

34. Stores products
Patients can buy some products especially in the depression or anxiety period that can interfere
with the treatment such as:
1. Cigarettes
2. Coffee
3. sympathomimetics [nasal decongestants]
They should be advised that they can not use this product while they are in the
pharmacological therapy.

35. Relapses
▪ After a successful treatment many patients may fall into a relapse,
specially after a makeable event in patients life as the loss of a beloved
one, discovered of a severe illness and etc.
▪ We should adopted the prior treatment of CBT and drugs (SSRIs or
SNRIs) and if it does not work, should be maintained the CBT and change
the group of drug (tricyclic).

36. Prognosis
Long-term prognosis is usually good, with almost 65% of patients with panic disorder
achieving remission, typically within 6 months.
The risk of coronary artery disease in patients with panic disorder is nearly doubled. In
patients with coronary disease, panic can induce myocardial ischemia.
The risk of sudden death may also theoretically be increased due to reduced heart rate
variability and increased QT interval variability.
Appropriate pharmacologic therapy and cognitive- behavioral therapy, individually or in
combination, are effective in more than 85% of cases.

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