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PANIC DISORDER

Panic 1

PANIC DISORDER

• PANIC ATTACK– Pan Greek god (satyr), scared people

• PANIC DISORDER WITHOUT AGORAPHOBIA– agora- meeting or market place

• PANIC DISORDER WITH AGORAPHOBIA• AGORAPHOBIA WITHOUT HISTORY OF PANIC

Panic 2

• AGORAPHOBIA WITHOUT HISTORY OF PANIC ATTACK

• AGORAPOBIA WITH HISTORY OF PANIC ATTACK

DIAGNOSTIC CRITERIA FOR PANIC ATTACK• A discrete period of fear or discomfort, in which at least four of the

following symptoms developed abruptly and reached a peak within 10 minutes1) PALPITATIONS, POUNDING HEART, OR ACCELERATED HEART

RATE2) SWEATING, 3) TREMBLING OR SHAKING4) SENSATIONS OF SHORTNESS OF BREATH OR SMOTHERING5) FEELING OF CHOKING, 6) CHEST PAIN OR DISCOMFORT7) NAUSEA OR ABDOMINAL DISTRESS

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7) NAUSEA OR ABDOMINAL DISTRESS8) FEELING DIZZY, UNSTEADY, LIGHTHEADED, OR FAINT9) DEREALIZATION (FEELINGS OF UNREALITY) OR

DEPERSONALIZATION (BEING DETACHED FROM ONESELF)10) FEAR OF LOSING CONTROL OR GOING CRAZY11) FEAR OF DYING12) PARESTHESIAS (NUMBNESS OR TINGLING SENSATIONS)13) CHILLS OR HOT FLASHES

FOUR DIMENSIONS OF PANIC

1) EMOTIONAL: feel nervous, feel tense feeling dizzy, unsteady, lightheaded, or faint

2) PHYSIOLOGICAL: palpitations, sweating, trembling or shaking, shortness of breath, chest pain, nausea or abdominal distress

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3) COGNITIVE: derealization, depersonalization, fear of losing control or going crazy, fear of dying

4) BEHAVIOURAL: stuttering, pausing, lying down, avoidance behaviour

2

PANIC DISORDER

Both 1) and 2)1) Recurrent unexpected Panic Attacks2) At least one attack has been followed by:

a) persistent concern about additional attacks

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b) worry about the implications of the attack (e.g. losing control, going crazy, heart attack)

c) significant change in behaviour related to the attacks

1. UNEXPECTED (UNCUED) PANIC ATTACKS– no situational trigger

2. SITUATIONALLY PREDISPOSED– more likely in certain situations but not

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yalways (e.g. driving)

3. SITUATIONALLY BOUND– invariably cued (e.g. snake etc.)

One-Year Prevalence(%)/Life

Female: Male Ratio

Typical Age at Onset

Prevalence Among Close Relatives

% Receiving Treatment

Generalized anxiety disorder

3.1/5 2:1 0-20 yrs Elevated 27%

Simplephobias

9.0/11 3:1 Variable Elevated 12%

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Social phobias

8.0/13 3:2 10-20 yrs Elevated 21%

Panic disorder

2.3/3.5 3:1 15-35 yrs Elevated 54.4%

Obsessive-compulsive disorder

1.0/2.3 1.5:1 4-25 yrs Elevated 41.3%

Any Anxiety Disorder

17.2/24.9 2:1 Elevated

Figure 1. Panic Disorder: Comorbidity (Lifetime Prevalence)

60%

80%% Patients Panic

(Uncomplicated)Agoraphobia

Other Anxiety

Panic 8

0%

20%

40%Other AnxietyDisordersDepression

Drug and AlcoholAbuse

3

30%

Figure 2. Percent Who Attempted Suicide

PD ONLY

Panic 9

0%

10%

20% PD COM

MDD ONLY

MDD COM

Panic 10

Panic 11 Panic 12

4

CHALLENGE EXPERIMENTS• EARLY RESEARCH SHOWED LACTATE

INFUSION (SODIUM LACTATE INFUSION) OR CARBON DIOXIDE PRECIPITATED PANIC IN PANIC PATIENTS

• NON-PATIENTS DID NOT HAVE AS HIGH A PROBABILITY OF ATTACK

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• BOTH GROUPS HAD DISCOMFORT

• PERHAPS PANIC Ss MISINTERPRET SYMPTOMS

HYPERVENTILATION EXPERIMENT

INSTRUCTIONS PANICPATIENTS

NORMALCONTROLS

PACEDBREATHINGTEST

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PANIC ATTACKTEST

60 BREATHS/MIN FOR 3 MIN

Anxiety Rating

0123456

Baseline HV

Anx

iety

Lev

el

Pacedbreathing(controls)

Panic attacktest (controls)

Pacedbreathing(panic patients)

Panic attacktest (panicpatients)

Panic Symptoms

02468

Baseline HVNum

ber o

f Sym

ptom

s

Pacedbreathing(controls)

Panic attacktest (controls)

Pacedbreathing(panic patients)

Panic attacktest (panic

Panic 15

p ) test (panic

Heart Rate

0

20

40

60

80

100

Baseline HV

bpm

Pacedbreathing(controls)

Panicattack test(controls)

Pacedbreathing(panicpatients)

Panicattack test(panic

Systolic BP

Baseline HV

mm

Hg

Pacedbreathing(controls)

Panic attacktest (controls)

Pacedbreathing(panic patients)

Panic attacktest (panicpatients)

Heart pumping

Diastolic BP

Hg

Paced breathing(controls)Panic attack test(controls)

Heart is relaxed

Panic 16

Baseline HV

mm

(controls)Paced breathing(panic patients)Panic attack test(panic patients)

5

CHALLENGE PHYSIOLO-GICAL

NORMALSNO PANIC

INTERPRETATION OF CHALLENGE EXPERIMENTS

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AROUSAL

PANIC

DISORDER

PATIENTS

PANIC ATTACKMisinterpretation

is key

Cognitive/Biological Model of Panic Disorder

PHYSIOLOGICAL AROUSAL

Panic 18

Misinterpretation is key