Panic Disorder Flashcards
Definition
ICD-10: recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable / AKA: Episodic Paroxysmal Anxiety
- Several within a month
- In between episodes, relatively fine with minimal anxiety
- Panic disorder should not be main diagnosis if a depressive disorder exists at the time attacks start
- Discrete episodes of intense fear or apprehension accompanied by the rapid concurrent onset of several characteristic symptoms
- Persistent concern about the recurrence or significance of panic attacks, or behaviours intended to avoid their recurrence, that results in significant impairment in personal, family, social, educational, occupational or other important areas of functioning
Epidemiology
25-44 y/o
Prevalence decreases with age
F>M
-Symptoms
Sudden onset; occur ‘out of the blue’; last ≤30 minutes
Alarming thoughts (i.e. I’m going to die) provoke further panic until reassurance or engagement in ‘safety behaviour’ occurs (i.e. call ambulance, take aspirin, etc.)
- Palpitations
- Sweating
- Trembling
- SOB
- Choking
- Chest pain
- Dizziness
- Light-headedness
- Chills
- Hot flushes
- Fear of imminent death
- Tachycardia
- Tingling of hands, feet or around mouth
- Nausea
Signs & symptoms – classically described as ‘100%’ anxiety with accompanying physical symptoms
Investigations
Cardiorespiratory exam
Rule out organic causes: ECG, TFTs, LFTs, blood glucose, urine drug screen, urine VMAs, drug withdrawals
Other differentials
- Other anxiety disorders e.g., GAD or agoraphobia
- Depression - this takes precedence
- Alcohol or drug withdrawal - can cause severe anxiety which may be mistakes for panic attacks
- CV or resp diseases
- Pheochromocytoma
GAD-7
HADS (Hospital Anxiety and Depression Scale)
Social and occupational assessments for effect on QoL
Management
STEP 1: Recognition and Diagnosis of Panic Disorder
- Identify any comorbidities, in particular panic disorder with depression or with substance misuse
- Education, reassurance and self help
- Relaxation techniques and breathing exercises
- Get them to write a symptom and trigger diary
STEP 2: Offer Treatment in Primary Care (Mild-Moderate Panic Disorder)
- Low Intensity Psychological Therapy - 6 wks
- Individual non-facilitated self-help
- Individual facilitated self-help
- Psychoeducational groups
Social Interventions
- Exercise benefits
- Encourage relying on natural supports- friends, family, faith groups
- Support groups: Anxiety UK, Mind, No Panic
Befriending or rehabilitation programme
STEP 3: Review and Offer Alternative Treatment if Needed in Primary Care (Moderate-Severe Panic Disorder)
- Consider referral for CBT OR antidepressant if psychological intervention declined or ineffective
Psychological Therapy:
- CBT referral
- Biological Treatment
- Antidepressants
1st LINE: SSRI(citalopram or sertraline)
2nd Line: TCAs (e.g. clomipramine, imipramine)
Offered if SSRI C/I or no response after 12 weeks
- NOTE: Benzodiazepines should NOT be prescribed for treatment
- Sedating antihistamines or antipsychotics should NOT be prescribed for treatment
STEP 4: Review and Offer Referral to Specialist Mental Health Services
If there have been TWO interventions provided and the person still has significant symptoms, then offer referral to specialist mental health services
STEP 5: Specialist Mental Health Services
- Treatment of comorbidities
- Psychological Therapy
- CBT
- Home-based CBT can be offered if difficult to attend clinic
Biological Treatment
- Full exploration of pharmacotherapy
Social Interventions
- As above + day support to relive carers and family members
- Referral for advice, assessment or management to tertiary centres
summary
Education, reassurance and self-help
Step 1: low-intensity psychological intervention
- Self-help (individual, non-guided) 6 weeks
- Self-help (individual, guided) 6 weeks, weekly therapist appointment
Step 2: high-intensity psychological intervention ± medications
- 1st line: CBT ± SSRI (Citalopram)
- 2nd line (after 12w): change class to TCA (imipramine) or add BDZ (not exceeding 2-4 weeks)
Psychodynamic psychotherapy
- Step 3: refer to psychiatry
Complications
Complications
Serotonin withdrawal syndrome
Substance use
Prognosis
Good, 65% achieve complete remission
10-20% continue to have significant symptoms
Relapse rates are higher amongst women than men
PACES
We think you are experiencing a type of anxiety disorder called panic disorder. Panic disorder is an anxiety disorder where you regularly have sudden attacks of panic or fear.
Everyone experiences feelings of anxiety and panic at certain times. It’s a natural response to stressful or dangerous situations. But someone with panic disorder has feelings of anxiety, stress, and panic regularly and at any time, often for no apparent reason.
During a panic attack you get a rush of intense mental and physical symptoms. It can come on very quickly and for no apparent reason which can make is very frightening and distressing.
Most panic attacks last between 5 and 20 minutes. Some have been reported to last up to an hour. The number of attacks you have will depend on how severe your condition is. Some people have attacks once or twice a month, while others have them several times a week.
Although panic attacks are frightening, they’re not dangerous. An attack will not cause you any physical harm, and it’s unlikely you’ll be admitted to hospital if you have one. Be aware that most of these symptoms can also be symptoms of other conditions or problems, so you may not always be experiencing a panic attack. For example, you may have a racing heartbeat if you have very low blood pressure.
Treatment aims to reduce the number of panic attacks you have and ease your symptoms.
The main treatments for panic disorder is talking therapies and medicine Talking therapies involve talking with a therapist about how you react when you have a panic attack and what you think about it. The therapist can teach you ways of changing your behaviour to help you keep calm during an attack. This type of talking therapy is called cognitive behavioural therapy (CBT).
It might be helpful to take some medications too, which include antidepressants and anti-epilepsy medicines which reduce the frequency of panic attacks.
When a pt is having a panic attack in front of you
Remain calm and speak firmly
Explain how it is a panic attack and that is will be over within a few mins
Remove any triggers
Get them to sit still and ask them to breath slowly (in for 3 and out for 5 or paper bag method)
