Panic disorder

Question 1

What is the ICD-10 definition?

Answer 1

The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealisation). There is often also a secondary fear of dying, losing control, or going mad. Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression.

Question 2

How is panic disorder defined?

Answer 2

as recurrent, unexpected attacks

Question 3

How is a panic attack defined?

Answer 3

A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, listed below, arise rapidly and peak within 10 minutes of the onset of the attack:
• Attacks usually last at least 10 minutes but their duration is variable.
• The symptoms must not arise as a result of alcohol or substance misuse, medical conditions or other psychiatric disorders, in order to satisfy the diagnostic criteria.

Question 4

For panic disorder to be diagnosed what must be associated with the panic attacks?

Answer 4

Panic attacks must be associated with >1 month’s duration of subsequent, persisting anxiety, the consequences of attacks or significant behavioural changes associated with them.

Question 5

What are the characteristic Sx?

Answer 5

• Palpitations, pounding heart, accelerated heart rate
• Sweating
• Trembling, shaking
• Dry mouth
• Feeling short of breath, or sensation of smothering
• Feeling of choking
• Chest pain/discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed or faint
• Derealisation or depersonalisation
• Fear of losing control or ‘going crazy’
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flushes

Question 6

What are associated psychiatric diseases?

Answer 6

o Agoraphobia - affects around 26% of sufferers
o Social Phobia - affects 33% sufferers
o Mood disorders - particularly depression, lifetime prevalence 50-60%
o Anxiety disorders
o Alcohol and substance misuse

Question 7

Are there any associated medical conditions?

Answer 7

o May co-exist but wouldn’t use term panic disorder term if symptoms arise directly from physical illness

Question 8

What are the psychiatric DDx?

Answer 8

o	Agoraphobia
o	Social anxiety disorder
o	Anxiety disorders e.g. GAD
o	Adjustment disorders
o	Bipolar disorder
o	Depression
o	Dissociative disorders
o	Factitious illness
o	Somatisation disorder
o	OCD
o	PTSD 
o	Specific phobia disorders

Question 9

What are the medical DDx?

Answer 9

o	Hyperthyroidism
o	Phaeochromocytoma
o	Carcinoid syndrome
o	Hypoglycaemic episodes
o	Paroxysmal cardiac dysrhythmia
o	Mitral valve prolapse

Question 10

What lifestyle changes and self-help may help management of panic disorder?

Answer 10

• Avoid anxiety-producing substances e.g. caffeine, alcohol, drugs
• Exercise
• Breathing exercises  abdominal and diaphragmatic breathing
• Yoga
• Self-help groups
• Mindfulness

Question 11

Psychological Mx?

Answer 11

• CBT – focusses on the recognition of factors that trigger the attacks and behavioural methods to cope with the symptoms

Question 12

Medical Mx of panic disorder?

Answer 12

• SSRIs – first line unless contraindicated (needs reviewing at 2, 4, 6, 8 and 12 weeks and then at 8-12 week intervals)
• Imipramine or clomipramine if no improvement on SSRIs for 12 weeks (although neither of these are licensed for this in the UK)