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panic_disorder

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Information about panic_disorder
Science-Technology

Published on December 17, 2008

Author: aSGuest7002

Source: authorstream.com

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Slide 2: MacKenzie (1920) War neurosis Schnur (1939) Cardiac neurosis Gorlin (1962) Hyperkinetic heart syndrome Frohlich et al (1966) Hyperdynamic ?-adrenegic circulatory state Barlow et al (1968) MVP Slide 3: Maclean (1867) Irritable-heart symptoms Da Costa (1871) Irritable-heart syndrome Beard et al., (1880) Neurasthenia Freud (1894) Anxiety neurosis Lewis (1917) Effort syndrome Oppenheimer (1918) Neurocirculatory asthenia Slide 4: The word “PANIC” is derived from the Greek god Pan, whose shrill and unexpected noises frightened people Diagnosis of Panic Disorder : Diagnosis of Panic Disorder Unexpected, unprovoked, paroxysmal symptoms of anxiety Duration : 1 - 2 minutes to 1 hour Frequency: 3 - 4 attacks / week Usually 4 - 8 symptoms The Nature of Panic : The Nature of Panic A panic is an episode of intense fear of sudden onset. The fear, often bordering on terror, generally is accompanied by unpleasant bodily sensations, difficulty in reasoning, and a feeling of imminent catastrophe. Most of panic attacks are not associated with fear. Criteria For Panic Attack - I : Criteria For Panic Attack - I Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Criteria For Panic Attack - II : Criteria For Panic Attack - II Feeling dizzy, unsteady, lightheaded, or faint De-realization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Parasthesias (numbness or tingling sensations Chills or hot flushes The Feelings of Imminent Catastrophe : The Feelings of Imminent Catastrophe “Something terrible is happening to me” “I feel that I am in great danger” “I feel that I am about to completely lose control” “I am going insane” “I am losing consciousness” “I may fall with giddiness and it would be very embarrassing” Epidemiology of Panic Disorder : Epidemiology of Panic Disorder Life time prevalence: 1.5 to 5% panic disorder 3 to 5.6% panic attacks 2.2% limited symptoms Sex: F : M = 2-3: 1 Precipitating factor - recent divorce or separation Mean age of presentation: < 25 years Can occur at any age Underdiagnosed in children Prevalence of Panic Disorder : Prevalence of Panic Disorder General community 1.6% Experience a panic attack 3% - 10% Among primary care patients 13.3% “Distressed high utilizers” 12% “Lifetime” 30.2% Settings in Which Patients With Panic Disorder Are Treated : Settings in Which Patients With Panic Disorder Are Treated First Later Contact (%) (%) Medical 85 49 Emergency department 43 32 Minor emergency room center 7 11 Office General or family practitioner 35 35 Cardiologist 6 9 Otolaryngologist 6 3 Prevalence of Panic Phenomenology : Prevalence of Panic Phenomenology Fearful spells 16% Without agoraphobia 2% With agoraphobia 1.5% Panic disorders 3.5% Panic attacks 7.3% Panic Disorder In The Medical Setting : Panic Disorder In The Medical Setting 50-60% of psychiatric illnesses are seen and treated exclusively in general practice Anxiety was the commonest disorder seen in GP (N=300) ? Prescription of BDZ 20% of the patients have panic disorder ? Utilization of health care services Panic Disorder frequently misdiagnosed 90% report somatic symptoms They have seen > 10 physicians They have spent > 10 years before diagnosis Life Course : Life Course Panic disorder has a chronic, fluctuating course 50 percent of the victims are disabled to some degree 73 to 92 percent are symptomatic ? mortality from suicide ? mortality from cardiovascular disease Panic Disorder And Normal Coronary Arties : Panic Disorder And Normal Coronary Arties Continued chest pain Worsening of health Greater reduction of exertional capacity Poor social adjustment ? Anxiety symptoms ? Psychological distress NCP With “Non-Fear Panic Disorder” : NCP With “Non-Fear Panic Disorder” Attacks involve discrete periods of intense discomfort without fear Demographically similar to panic disorder except age of onset They respond with pain with sodium lactate infusion They respond to the same treatment as panic disorder Unusual Symptoms of Panic Disorder : Unusual Symptoms of Panic Disorder Noncardiac chest pain (NCP) A disabling and costly syndrome 50% of patient do not have cardiac cause 10-30% of angiograms are normal 70% of “functional” patient-persist with their complaints, have significant disability and consult doctors repeatedly Many patients with adequate treatment for CAD-persist with chest pain Clinical Characteristics of NCP : Clinical Characteristics of NCP Age over 40 years 25-57% of NCP have panic disorder (normal angiograms) NCP with panic disorder have higher incidence of Anxiety disorder (33%) Somatization Fear of bodily sensations Agoraphobic avoidance (21%) Depression (32%) Physical Causes of NCP : Physical Causes of NCP Esophageal motility disorders Gastroesophageal reflux disease Mitral valve prolapse Microvascular angina Abnormal visceral nociception Slide 21: P - Psychological A - Alimentary N - Neurological I - Inspiratory (RS) C - Cardiac Symptoms of Panic Disorder : Symptoms of Panic Disorder Psychologic Fear of losing control Fear of dying Derealization Alimentary Nausea Abdominal distress Neurologic Dizziness Syncope Paresthesia Trembling or shaking Symptoms of Panic Disorder : Symptoms of Panic Disorder Inspiratory (Respiratory) Shortness of breath Feeling of smothering Feeling of choking Cardiac Palpitations, pounding heart, or accelerated heart rate Chest pain or discomfort Sweating Chills or hot flushes Masked Presentation of Panic Attack : Masked Presentation of Panic Attack No obvious anxiety (20%) “Skipping or racing” of heart Dizziness, light headedness Choking sensation Pain in the left side of chest Paraesthesias Physical Symptomatology In Panic Disorder (N=55) : Physical Symptomatology In Panic Disorder (N=55) Average number of symptoms: 12 - 14 Commonest: Cardiac (chest pain) GI. (33%) Neurologic (44%) Alcoholism (15%) Psychological: only 11% (Commonly misdiagnosed for Hypochondriasis) Consequences of Panic Disorder : Consequences of Panic Disorder ? Incidence of hypertension ? Incidence of peptic ulcer disease ? Incidence of death due to CV disease ? work performance ? Relapses and recurrences Laboratory induced stress produces ischaemia of CAD Long-Term Outcome of Panic Disorder : Long-Term Outcome of Panic Disorder Outcome Rate (%) Range (%) Panic-free 54 30 - 83 Phobic avoidance remission 31 18 - 64 Development of depression 29 12 - 60 Absence of functional impairment 50 33 - 61 Common Stages of Panic Disorder : Common Stages of Panic Disorder Stage 1: Limited symptom attacks Stage 2: Panic attacks Stage 3: Health worries Stage 4: Extensive phobias Stage 5: Demoralization, depression Medical Conditions That Mimic Panic Disorder : Medical Conditions That Mimic Panic Disorder Anemia Angina Arrhythmias Chronic obstructive pulmonary disease Cushing’s disease Electrolyte disturbance Epilepsy, particularly temporal lobe epilepsy Medical Conditions That Mimic Panic Disorder : Medical Conditions That Mimic Panic Disorder Hyperthyroidism Hypoglycemia Parathyroid disorders Pheochromocytoma Pulmonary embolus Transient ischemic attacks Relationship Between Alcohol And Panic Disorder : Relationship Between Alcohol And Panic Disorder Alcohol is an anxiolytic and reduces anxiety Alcohol when used for prolonged period can heighten anxiety Withdrawal from alcohol produces symptoms of anxiety Phobic fears and probably panic may not alleviated by alcohol but it may worsen Functional Neuroanatomy of Fear And Anxiety : Functional Neuroanatomy of Fear And Anxiety Amygdala Locus cerulus Thalamus Hippocampus Orbitofrontal cortex Periaqueductal gray Panic Inducing Substances : Panic Inducing Substances Yohimbine CO2 Sodium lactate Bicarbonate Fenfluramine MCPP Flumazenil Cholecystokinin (CCK) Caffeine Isoproterenol A Model of The Etiology of PD : A Model of The Etiology of PD Neurochemistry of Panic Disorder : Neurochemistry of Panic Disorder Norepinephrine - yohimbine, clonidine Serotonin - fenfluramine Lactate and carbon dioxide BDZ and GABA-mCPP, flumazenil Peptides - CCK Comorbidity of Panic Disorder : Comorbidity of Panic Disorder Major depression Other anxiety disorder Obsessive compulsive disorder Post-traumatic stress disorder Personality disorder Substance abuse disorder Alcohol And Panic Disorder : Alcohol And Panic Disorder 2 - 17% (mean 6%) persons abusing alcohol have anxiety problems 2 - 41% (mean 9%) persons abusing alcohol have agoraphobia 28% of panic disorder patients abuse alcohol Relationship Between Alcohol And Panic Disorder : Relationship Between Alcohol And Panic Disorder Both alcohol and panic may be genetically linked Alcohol may ? NE in CNS which will ? activation LC Alcohol abuse may lead to kindling process Treatment of Panic Disorder : Treatment of Panic Disorder Reassure the patient Start the medications immediately to control panic symptoms Start BDZ immediately Alprozolam .5 tid or more Clonazepam .5 tid or more (Do not stop BDZ suddenly) Treatment of Panic Disorder : Treatment of Panic Disorder Simultaneously start very small dose of SSRI Sertraline 12.5 mg/day Fluoxetine 5 mg / day Very gradually increase to full dose Sertraline 150 mg / day Fluoxetine 30 mg / day in small increments (Panic disorder patients are extra sensitive to anxiogenic side effects of drugs) Reduce BDZ very gradually over period of 3-6 months Pharmacotherapy of Panic Disorder : Pharmacotherapy of Panic Disorder SSRIs Fluoxetine Sertraline Benzodiazepine Alprazolam Clonazepam TCAs Imipramine Clomipramine Pharmacotherapy of Panic Disorder : Pharmacotherapy of Panic Disorder SSRIs > BDZ > TCAs Relative Merits, Concerns, And Dosing of Antipanic Drugs : Relative Merits, Concerns, And Dosing of Antipanic Drugs Initial Dose Starting Range, Dose mg Advantage Benzodiazepines Alprazolam 0.5 mg t.i.d. 2-10 Rapid Clonazepam action, well Lorazepam tolerated Concern - Sedation, dependence withdrawal syndrome and ? antidepressant effect Relative Merits, Concerns, And Dosing of Antipanic Drugs : Relative Merits, Concerns, And Dosing of Antipanic Drugs Initial Dose Starting Range, Dose mg Advantage Cyclic agents Imipramine 12.5 mg b.i.d. 50-300 Effective Clomipramine 12.5 mg b.i.d. 75-200 Concern - Anticholinergic effects; cardiotoxicity, hypotension, weight gain, poor long-term compliance, and lethality in overdose, 6-8 weeks for therapeutic benefit Relative Merits, Concerns, And Dosing of Antipanic Drugs : Relative Merits, Concerns, And Dosing of Antipanic Drugs Initial Dose Starting Range, Advan- Dose mg tage Concern SSRIs Fluoxetine 10 mg q.d. 20-80 Well Sexual Sertraline 25 mg q.d. 50-200 tolerated, dysfunction; good compliance long-term, and low lethality in overdose Cognitive Behavioral Therapy For Panic Disorder : Cognitive Behavioral Therapy For Panic Disorder Cognitive restructuring Breathing retraining Interoceptive exposure Situational exposure

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