PANIC DISORDER

Mrs. AMRITA ROYM.SC PSYCHIATRIC NURSINGNIMHANS,BANGALORE

ONSET AND COURSE

The age of onset of panic disorder is usually in the early 20s.

Onset in children and in people in middle age is unusual but does occur.

The frequency of panic attacks varies

PREVALENCE(Neerakal I & Srinivasan K, 2002).

Males (47.9%) and females (52.1 %) were equally distributed among the study sample.

The average age of the sample at the time of the interview was about 35 years (Mean=34.7±10.58).

The mean age at onset of panic attacks was 28.9 years (Mean=28.9±10.37) and the average duration of panic symptoms was 5.7 years (Mean=5.7±7.3).

PHENOMENOLOGY OF PANIC ATTACKS

( I. Neerakal K. Srinivasan, 2003)

Table 1. Patients reporting panic symptoms (n = 94)Symptoms n %Anxiety 92 97.9Tachycardia 79 84Panicky 78 83Fear of dying 73 77.7Weakness 73 77.7Heart pounding 72 76.6Feeling depressed 72 76.6Trembling 67 71.3Sweating 65 69.1Short of breath 59 62.8Hot flushes 50 53.2Dizziness 45 47.9

.( I. Neerakal K. Srinivasan, 2003)4

Irritability 41 43.6Chest pain 39 41.5Fidgety 38 40.4Abdominal distress 37 39.4Paraesthesia 36 38.3Hyperventilation 35 37.2Going crazy 33 35.1Thought block 27 28.7Fainting 21 22.3Choking 16 17Derealization 16 17Difficulty in swallowing 14 14.9Globus hystericus 11 11.7

CLINICAL SUBTYPES

Factor analysis of 94 panic subjects with a view to identify clinical subtypes of panic disorder was done using the principal component method, which yielded clinically meaningful sub-types of panic attacks. (Neerakal I & Srinivasan K, 2002).

CLINICAL SUBTYPES Factor I was hot flushes, trembling and

sweating.

Factor II had cognitive symptoms such as going crazy and derealization.

Factorlll had chest pain, fear of dying, nausea and paraesthesia.

Factor IV had respiratory symptoms in the form of choking sensation and being short of breath.

CAUSES OF PANIC DISORDER

a) The Biological Theory of Panic Disorder Serotonin, norepinephrine and

dopamine Gamma Aminobutyric Acid (GABA)

b) Metabolic Theoriesc)  Learning theoryd) Cognitive theories

Catastrophic cognition theory - Clark’s model

e) Psychodynamic theory

DIAGNOSISICD 10: F41.0 Panic disorder

[episodic paroxysmal anxiety]For adefinitive diagnosis, several severe attacks of autonomic anxiety should have occurred within a period of about 1 month:

A] in circumstances where there is no objective danger

B] without being confined to known or predictable situations

C] with comparative freedom from anxiety symptoms between the attacks( although anticipatory anxiety is common.

COMORBIDITY In a study conducted by (Srinivasa K, Neerakal I, 2002), 43 patients (45.7%)

with panic attacks had comorbid depression

In the present study, majority of panic subjects with comcrbid depression had primary depression (69.8%), while secondary depression was diagnosed in only 30.2%.

Generalized anxiety disorder was significantly more frequent as a comorbid condition in both primary 12 (40%) and secondary depression 6 (46.2%) as compared to panic disorder without depression 5 (9.8%).

Phobia ( inclusive of simple, social and agoraphobia was more frequent as a co-morbid in panic disorder without depression 24 (47.1%) as compared to primary depression with panic attacks 13 (43.3%) and panic disorder with secondary depression 6(46.2%).

DIFFERENTIAL DIAGNOSIS

Psychiatric disorders in which panic attacks occur:

Agoraphobia (often co-exists). Social anxiety disorder (often co-

exists). Generalized anxiety disorder Phobias Posttraumatic stress disorder Substance-induced anxiety disorder

(caffeine, amphetamine, cocaine intoxication)

DIFFERENTIAL DIAGNOSIS

Organic disorders that cause symptoms associated with panic attacks

Heart disease; Heart attack (chest pain) Mitral valve prolapse (rapid heart rate) Paroxysmal atrial tachycardia (recurrent,

sudden attacks of rapid heartbeat) Pulmonary embolism (sudden shortness of

breath and chest pain) Hypothyroidism (tremor) Hypoglycemia (sweating, tremor, palpitation) Pheochromacytoma (sudden attacks of

palpitations, anxiety, sweating) Postconcussion syndrome (dizziness)

TREATMENT

Psychotherapy for Panic DisorderA] Cognitive behavioural therapy (CBT)

A Studt by M Manjula et al. in 2009 titled Cognitive behavior therapy in the treatment of panic disorder shows that comprehensive treatment is efficacious as an independent treatment modality and it is an effective alternative for patients who are not willing to take pharmacological treatment and who do not benefit completely from pharmacotherapy. CBI is found to be efficacious in handling panic symptoms, cognitions, and behaviors related to panic in a short duration of six weeks. It is also evident that CBI brings about reliable, functional change of a greater magnitude.

TREATMENT

B] Group therapy can often be used just as effectively to teach relaxation and related skills. Psychoeducational groups in this area are often beneficial.

C] Biofeedback, a specific technique which allows the client to receive either audio or visual feedback about their body’s physiological responses while learning relaxation skills, is also an appropriate psychotherapeutic intervention.

Pharmacotherapy for Panic Disorder

Selective serotonin reuptake inhibitors (SSRIs)

Tricyclic antidepressants - Imipramine and clomipramine

MIXED ANXIETY AND DEPRESSIVE DISORDERS

ICD-10 describes Mixed anxiety and depressive disorder :

"...when symptoms of anxiety and depression are both present, but neither is clearly predominant, and neither type of symptom is present to the extent that justifies a diagnosis if considered separately. When both anxiety and depressive symptoms are present and severe enough to justify individual diagnoses, both diagnoses should be recorded and this category should not be used."

MIXED ANXIETY AND DEPRESSIVE DISORDERS

The Diagnostic and Statistical Manual of Mental Health Disorders IV has defined certain requirements for diagnosing mixed anxiety-depressive disorder:

A dysphoric mood is chronic or recurring for a minimum of four weeks and has at least four of the following symptoms: troubles concentrating or with memory, disturbed sleep, tiredness or lack of energy, feeling irritable, worrying, crying easily, enhanced sensory state, expecting the worst, feeling hopeless or pessimistic, or having low self-esteem/feeling worthless.

MIXED ANXIETY AND DEPRESSIVE DISORDERS

The symptoms presented are not caused by medications, drugs, or a health condition.

The symptoms cause significant impairments or distresses in aspects of daily life.

The symptoms do not meet the criteria for different and separate mental health disorders

MIXED ANXIETY AND DEPRESSIVE DISORDERS

TREATMENTThe priority is to treat the most

disabling of either the anxiety or depression first and then consider treatments such as SSRI antidepressants and/or CBT which are effective for both anxiety and depression.