Contents

Search

panic disorder

An anxiety disorder characterized by discrete intense periods of fear & associated symptoms. Panic disorder may be accompanied by agoraphobia. Etiology: - absence of underlying medical conditions or substance abuse - risk factors: family history, psychosocial stress Epidemiology: 1) 30-40% of patients with recurrent or atypical chest pain presenting to the emergency room 2) 1.5-3.5% lifetime prevalence 3) more common in women than men 4) less common in the elderly - 1% of community-dwelling elderly - onset is typically before age 25 Clinical manifestations: 1) abrupt onset of recurrent, unpredictable episodes of fear - older patients often report a more gradual onset [3] 2) episodes peak within 10 minutes & last 30-90 minutes, but may last all day [13] 3) somatic symptoms a) symptoms masquerading as cardiac disease 1] chest pain 2] dyspnea 3] palpitations, tachycardia 4] diaphoresis b) symptoms masquerading as neurologic disease 1] dizziness, lightheadedness 2] paresthesias 3] trembling or shaking c) symptoms masquerading as gastrointestinal disease 1] abdominal pain 2] nausea d) chills or hot flashes 4) agoraphobia with chronic panic disorder 5) smothering sensation or choking 6) sense of unreality, losing control or going insane 7) fear of dying 8) feeling of self-detachment (depersonalization, derealization) 9) a change in behavior (avoidance) related to the attacks 10) persistent concern about additional attacks - persistent concern of impending doom - worry about implications of attacks Diagnostic criteria: - a panic attack is characterized by sudden onset of extreme fear or anxiety & >= 4 of the following: - fear of dying - fear of losing control - palpitations, diaphoresis, tremor, dyspnea - chest pain, nausea, dizziness, chills or heat sensation - paresthesia - perception that the world is not real [1]] - panic disorder is characterized by recurrent, unexpected panic attacks & persistent worry about future attacks [1] Differential diagnosis: - pulmonary: - hyperventilation, COPD asthma, pulmonary embolism - cardiac disease - arrhythmia, myocardial infarction, heart failure - endocrine - hyperthyroidism, hypoglycemia, pheochromcytoma - neurologic - movement disorders, temporal lobe epilepsy [6], stroke - substance withdrawal - alcohol, benzodiazepines, sedative, SSRI - psychiatric - depression - generalized anxiety disorder [12] (>= 6 months duration) - illness anxiety disorder (>= 6 months duration, fear of having specific disease) - somatic symptom disorder - characterized by a symptom-specific complaint, such as pain or dysphagia - may be multiple complaints - patient does not ruminate about somatic concern(s) - functional neurologic disorder/conversion disorder - physical symptoms (paralysis, abnormal movement, dysphagia, speech disorder, seizures, sensory impairment) - medications - caffeine, glucocorticoids, nicotine, psychotropics, sympathomimetics, excess thyroxine [4] Management: 1) reassurance for a single panic attack 2) cognitive behavioral therapy 3) antidepressants a) selective serotonin reuptake inhibitors (SSRI)* - escitalopram & sertraline with best benefit/risk ratio [11] b) serotonin & norepinephrine reuptake inhibitors (SNRI) - venlafaxine is effective c) alternative agents - tricyclic antidepressants (TCA) - mirtazapine is sometimes useful as an alternative or adjunctive agent, especially if sedation may be beneficial [3] d) continue for at least 6 months after remission 4) benzodiazepines during initial period a) alprazolam (Xanax)* b) clonazepam (Klonopin) c) reserve long-term use for patients with refractory panic disorder [10] * agents of choice during pregnancy [2] & in the elderly [3]; SSRI as first line medication [1] * only escitalopram with strong evidence supporting use [8]

Interactions

disease interactions

Related

agoraphobia benzodiazepine hyperventilation selective serotonin reuptake inhibitor (SSRI) tricyclic antidepressant (TCA)

General

anxiety disorder

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Work Group on Panic Disorder. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder. Am J Psychiatry. 1998 May;155(5 Suppl):1-34. PMID: 9585731 (Corresponding NGC guideline withdrawn Jan 2015)
  2. Prescriber's Letter 7(11):65 2000
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  4. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  5. Katon WJ. Clinical practice. Panic disorder. N Engl J Med 2006 Jun 2; 354:2360 PMID: 16738272
  6. Hurley RA, Fisher R, Taber KH. Sudden onset panic: epileptic aura or panic disorder? J Neuropsychiatry Clin Neurosci. 2006 Fall;18(4):436-43. PMID: 17135371
  7. Katon WJ. Clinical practice. Panic disorder. N Engl J Med. 2006 Jun 1;354(22):2360-7. Review. PMID: 16738272
  8. Wong J, Motulsky A, Abrahamowicz M et al. Off-label indications for antidepressants in primary care: Descriptive study of prescriptions from an indication based electronic prescribing system. BMJ 2017;356:j603 PMID: 28228380 Free PMC Article http://www.bmj.com/content/356/bmj.j603
  9. NEJM Knowledge+ Question of the Week. Oct 28, 2020 https://knowledgeplus.nejm.org/question-of-week/1827/
  10. Soreff S Fast Five Quiz: Anxiety Medscape. August 9, 2021 https://reference.medscape.com/viewarticle/955963 - Memon MA, Welton RS Panic Disorder Medscape. March 21, 2018 https://emedicine.medscape.com/article/287913-overview
  11. Chawla N et al. Drug treatment for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. BMJ 2022 Jan 19; 376:e066084. PMID: 35045991 Free article https://www.bmj.com/content/376/bmj-2021-066084
  12. NEJM Knowledge+ Question of the Week. Nov 1, 2022 https://knowledgeplus.nejm.org/question-of-week/1287/ - Herr NR et al. Does this patient have generalized anxiety or panic disorder? The rational clinical examination systematic review. JAMA 2014 Jul 2; 312:78. PMID: 25058220 https://jamanetwork.com/journals/jama/fullarticle/1884581
  13. NEJM Knowledge+ Psychiatry