Panic disorder is a type of anxiety disorder.
Anxiety - Is defined as "Subjective sense of unease, dread or foreboding, can indicate a primary psychiatric disorder or can be a component of, or a reaction to a primary medical disease.
Panic disorder - Defined as recurrent and unpredictable panic attacks which are distinct episodes of intense fear and discomfort associated with a variety of physical symptoms including palpitations, sweating, trembling shortness of breath, chest pain, dizziness and a fear of impeding doom or death,Paresthesias, gastrointestinal distress, air hunger and feelings of unreality are common.
First attack is usually outside the home.Onset is usually in late adolescence to early adulthood.Anticipatory anxiety occurs in some people leading to generalized fear and avoidance of places or situations where panic attack may recur.
Panic attack occurs suddenly over a period of 10 mins and resolving over a period of one hour.The attacks usually occur in an unexpected fashion.
Agoraphobia is commonly seen in panic disorder patients.It is an 'acquired irrational' fear of being in places where one might feel trapped or unable to escape.It leads to progressive restriction in lifestyle or in a geography.Frequently patients are embarrassed that they are housebound and dependent on others to go out into the world and do not volunteer this information.
Differential diagnosis :
A variety of cardiovascular, pulmonary, endocrine and neurological conditions can present with anxiety as chief complaint.So the diagnosis of panic attack is made after a medical etiology of panic attack is ruled out.Patients with true panic attack often focus on one specific feature and tend to exclude others.
When the history is nonspecific, physical examination and thorough laboratory testing must be done to rule our anxiety states resulting from medical disorders like Pheochromocytoma, thyrotoxicosis, Hypoglycemia.
ECG may show paroxysmal atrial tachycardia, mitral valve prolapse (these are the cardiovascular disorders usually associated with panic).
Panic disorder is also diagnosed in patients referred for pulmonary function testing or with irritable bowel syndrome.
Diagnostic criteria also requires at least one month of concern or worry about the attacks or the change of behavior related to the attack.
Etiology :
The cause is unknown but genetic predisposition, altered autonomic responsivity and social learning are usually associated with these attacks.
Genome wide screens have identified suggestive risk loculi over 1q, 10q, 13q, 7p15, 11p.Acute panic disorders are associated with increased noradrenergic discharges in locus coeruleus.
Few Precipitating factors observed in some patients - Intravenous infusion of sodium lactate, Alpha2 adrenergic antagonist-Yohimbine, Cholecystokinin tetrapeptide (CCK 4), Carbon dioxide inhalation.
Each of these stimulants activates a pathway involving noradrenergic neurons in coeruleus and serotonergic neurons in dorsal raphe.
Treatment :
1. Tricyclic Antidepressants (TCAs) - imipramine and clomipramine (10-25 mg/day).Low doses are given initially to avoid increase in monoamine levels associated with these drugs.
2. Selective Serotonin Reuptake Inhibitors (SSRIs) - Are equally effective but do not have the adverse effects of TCAs.Usually started at 1/3 to 1/2 of their usual antidepressant dosage.
3. Monoamine Oxidase Inhibitors (MAOIs) - Specifically beneficial in patients with atypical depression with symptoms like hyperosmia, weight gain.They have adverse effects like Orthostatic hypertension, Insomnia and the need to maintain a low tyramine diet (avoidance of cheese and wine)
4. To avoid anticipatory anxiety and for immediate relieving of symptoms - Benzodiazepines (Alprazolam - 0.5 mg to 4 mg/day; Clonazepam - 2 mg to 4 mg/day) are used.But patients should be monitored closely as they may cause dependence.
5. Education of symptoms and their control, assurance, encouraging patients to voluntarily expose themselves to precipitating factors, breathing techniques are very important part of the treatment.
Once satisfactory response if obtained, the treatment is continued for 1 to 2 years.The efficiency of the treatment is 75-80%.
Anxiety - Is defined as "Subjective sense of unease, dread or foreboding, can indicate a primary psychiatric disorder or can be a component of, or a reaction to a primary medical disease.
Panic disorder - Defined as recurrent and unpredictable panic attacks which are distinct episodes of intense fear and discomfort associated with a variety of physical symptoms including palpitations, sweating, trembling shortness of breath, chest pain, dizziness and a fear of impeding doom or death,Paresthesias, gastrointestinal distress, air hunger and feelings of unreality are common.
First attack is usually outside the home.Onset is usually in late adolescence to early adulthood.Anticipatory anxiety occurs in some people leading to generalized fear and avoidance of places or situations where panic attack may recur.
Panic attack occurs suddenly over a period of 10 mins and resolving over a period of one hour.The attacks usually occur in an unexpected fashion.
Agoraphobia is commonly seen in panic disorder patients.It is an 'acquired irrational' fear of being in places where one might feel trapped or unable to escape.It leads to progressive restriction in lifestyle or in a geography.Frequently patients are embarrassed that they are housebound and dependent on others to go out into the world and do not volunteer this information.
Differential diagnosis :
A variety of cardiovascular, pulmonary, endocrine and neurological conditions can present with anxiety as chief complaint.So the diagnosis of panic attack is made after a medical etiology of panic attack is ruled out.Patients with true panic attack often focus on one specific feature and tend to exclude others.
When the history is nonspecific, physical examination and thorough laboratory testing must be done to rule our anxiety states resulting from medical disorders like Pheochromocytoma, thyrotoxicosis, Hypoglycemia.
ECG may show paroxysmal atrial tachycardia, mitral valve prolapse (these are the cardiovascular disorders usually associated with panic).
Panic disorder is also diagnosed in patients referred for pulmonary function testing or with irritable bowel syndrome.
Diagnostic criteria also requires at least one month of concern or worry about the attacks or the change of behavior related to the attack.
Etiology :
The cause is unknown but genetic predisposition, altered autonomic responsivity and social learning are usually associated with these attacks.
Genome wide screens have identified suggestive risk loculi over 1q, 10q, 13q, 7p15, 11p.Acute panic disorders are associated with increased noradrenergic discharges in locus coeruleus.
Few Precipitating factors observed in some patients - Intravenous infusion of sodium lactate, Alpha2 adrenergic antagonist-Yohimbine, Cholecystokinin tetrapeptide (CCK 4), Carbon dioxide inhalation.
Each of these stimulants activates a pathway involving noradrenergic neurons in coeruleus and serotonergic neurons in dorsal raphe.
Treatment :
1. Tricyclic Antidepressants (TCAs) - imipramine and clomipramine (10-25 mg/day).Low doses are given initially to avoid increase in monoamine levels associated with these drugs.
2. Selective Serotonin Reuptake Inhibitors (SSRIs) - Are equally effective but do not have the adverse effects of TCAs.Usually started at 1/3 to 1/2 of their usual antidepressant dosage.
3. Monoamine Oxidase Inhibitors (MAOIs) - Specifically beneficial in patients with atypical depression with symptoms like hyperosmia, weight gain.They have adverse effects like Orthostatic hypertension, Insomnia and the need to maintain a low tyramine diet (avoidance of cheese and wine)
4. To avoid anticipatory anxiety and for immediate relieving of symptoms - Benzodiazepines (Alprazolam - 0.5 mg to 4 mg/day; Clonazepam - 2 mg to 4 mg/day) are used.But patients should be monitored closely as they may cause dependence.
5. Education of symptoms and their control, assurance, encouraging patients to voluntarily expose themselves to precipitating factors, breathing techniques are very important part of the treatment.
Once satisfactory response if obtained, the treatment is continued for 1 to 2 years.The efficiency of the treatment is 75-80%.
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