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Journal Presentation PANIC DISORDER

Background
Panic disorder is characterized by the spontaneous and unexpected occurrence of panic attacks, the frequency of which can vary from several attacks per day to only a few attacks per year. Panic attacks can occur in other anxiety disorders but occur without discernible predictable precipitant in panic disorder.

During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation).

Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
Panic disorder is usually qualified with the presence or absence of agoraphobia. Agoraphobia is defined as anxiety toward places or situations in which escape may be difficult or embarrassing. Following exclusion of somatic disease and other psychiatric disorders, confirmation of the diagnosis of panic disorder with a brief mental status screening examination and initiation of appropriate treatment and referral is time- and cost-effective in patients with this condition, who have high rates of medical resource use.

Epidemiology
Incidence of panic disorder in the United States
Lifetime prevalence estimates range from 1.55% for panic disorder and 3-5.6% for panic attacks.

Mortality and morbidity associated with panic disorder

Panic disorder often coexists with mood disorders, with mood symptoms potentially following the onset of panic attacks. Lifetime prevalence rates of major depression may be as much as 50-60%. Panic disorder is also associated with a higher risk of sudden death 30% with chest pain and normal findings on angiography. 5-40% with asthma, 15% with headache, 20% with epilepsy, and 10% of patients in primary care settings. The rate of substance abuse (especially stimulants, cocaine, and hallucinogens) in persons with panic disorder is 7-28%, a risk 4-14 times greater than that of the population. In addition, panic disorder is found in 815% of individuals in alcohol treatment programs. Pregnant mothers with panic disorder during pregnancy are more likely to have preterm labor and infants of smaller birth-weight for gestational age.

Contd
Race predilection in panic disorder
Data on prevalence in different racial groups are inconsistent. Symptom manifestations may differ, with African Americans more often presenting with somatic symptoms and more likely seeking help in medical rather than psychiatric settings.

Sex predilection in panic disorder

One-month prevalence estimates for women are 0.7%, versus 0.3% for men (women are more likely to be affected than men by a 2- to 3-fold factor). Panic is more common in women who have never been pregnant and during the postpartum period, but it is less common during pregnancy.

Age predilection in panic disorder

Although panic can occur in people at any age, it usually develops between the ages of 18 and 45 years. The average age of onset, as with most anxiety disorders, is in the third decade of life. Patients with late-onset panic disorder have a tendency toward less mental health use, lower comorbidity and hypochondriasis, and better coping behavior

HISTORY
Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (eg, avoiding situations or locations) and worry about the implications of the attack or its consequences (eg, losing control, going crazy, dying).

Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn.

DSM-IV criteria include 4 or more attacks in a 4week period or 1 or more attacks followed by at least 1 month of fear of another.

Etiology
neurochemical dysfunction genetic hypothesis cognitive theory

Types of panic attacks


Unexpected panic attacks have no known precipitating cue; these attacks often support the diagnosis of panic disorder without agoraphobia.

Situationally predisposed panic attacks are more likely to occur in relation to a given trigger, but they do not always occur. This pattern more likely describes panic disorder with agoraphobia.

A variant of panic disorder unrelated to fear (nonfearful panic disorder [NFPD]) is associated with high rates medical resource use (32-41% of patients with panic disorder seeking treatment for chest pain) and poor prognosis

Panic triggers
Triggers of panic can include the following:

Injury (eg, accidents, surgery) Illness Interpersonal conflict or loss Use of cannabis (can be associated with panic attacks, perhaps because of breath-holding)[5] Use of stimulants, such as caffeine, decongestants, cocaine, and sympathomimetics (eg, amphetamine, MDMA)[6] Certain settings, such as stores and public transportation (especially in patients with agoraphobia) Sertraline, which can induce panic in previously asymptomatic patients[7] The selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, which can induce symptoms similar to those experienced by panic patients

Physical Examination
No signs on physical examination are specific for panic disorder. Acute state of panic, can physically manifest any anticipated sign of an increased sympathetic state. These nonspecific signs may include hypertension, tachycardia, mild tachypnea, and mild tremors. The attack normally lasts 20-30 minutes from onset, although in rare cases it can go on for more than an hour. Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in an emergency department. The patient may have an anxious appearance. Tachycardia and tachypnea are common; blood pressure and temperature may be within the reference range. Cool, clammy skin may be observed. Hyperventilation may be difficult to detect by observing breathing, because respiratory rate and tidal volume may appear normal.

Mental Status Examination


While the patient may or may not appear anxious at the time of interview, the results on his or her Mini-Mental Status Examination, including: Cognitive performance

Memory

Proverb interpretation

Baseline intellectual functioning

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
Criteria for panic disorder, panic attacks must be associated with More than 1 month of subsequent persistent worry about:
1. Having another attack 2. Consequences of the attack, or 3.Significant behavioral changes related to the attack

Panic attacks are a period of intense fear in which 4 of 13 defined symptoms develop abruptly and peak rapidly less than 10 minutes from symptom onset

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR)
The DSM-IV-TR delineates the following potential symptom manifestations of a panic attack: Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sense of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, unsteady, lightheaded, or faint Derealization or depersonalization (feeling detached from oneself) Fear of losing control or going crazy Fear of dying Numbness or tingling sensations Chills or hot flashes

DIAGNOSTIC
History

Clinical manifestasions

Laboratorium

Imaging examinations
Positron emission tomography (PET) Magnetic resonance imaging (MRI)

DIFFERENTIAL DIAGNOSIS

THERAPY

THERAPY

Selective Serotonin Reuptake Inhibitors


SSRIs are first-line agents for long-term management of anxiety disorder Sertraline, paroxetine, fluvoxetine, citalopram

Benzodiazepine
By binding to specific receptor sites, intermediate-acting benzodiazepines appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. Lorazepam, clonazepam, alprazolam, diazepam

Serotonin Norepinephrine Reuptake Inhibitors


Its indicated for panic disorders Venlavaxine

Psycological Theraphy
Inform patients that the causes of panic disorder are likely biological and psychosocial Advise patients to avoid anxiogenic substances, such as caffeine, energy drinks, and other OTC stimulants educate patients about recognizing trigger stimuli so that they can contribute this to their psychological treatment approach Family education

Psychoeducation

Cognitivebehavioral theraphy (CBT)

cognitive restructuring relaxation techniques breathing exercises hypnotic suggestion interoceptive exposure may prevent recurrence

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.

Appropriate pharmacologic therapy and cognitivebehavioral therapy, individually or in combination, are effective in more than 85% of cases

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