Panic Disorder _ Etiology & Clinical Features

8/17/2019 Panic Disorder _ Etiology & Clinical Features

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PAN IC D ISO RD ER –ETIO LO G Y & CLIN ICAL

FEATU RES

C/P: Dr. Aruna


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Introduction

Panic disorder is defned as a type oanxiety disorder characterized byrecurrent & unexpected panicattacks (DS !"#$

A%oraphobia ! anxiety about bein% inpaces or situations ro' hich

escape 'i%ht be di)cut (ore'barrassin%$ or in hich hep 'aynot be a*aiabe in the e*ent o

ha*in% an unexpected or


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Epidem iology

,ieti'e pre*aence+ Panic disorder : -+

,ieti'e pre*aence+ Panic attacks: +-0

,ieti'e pre*aence+ A%oraphobia: 0+1

0+2 ti'es 'ore in o'en

en + ithout & 3o'en ! itha%oraphobia

0 peaks o onset: -4+0 yrs & 4+4 yrs 5 6isk ith: idoed/di*orced/separated

i*in% in cities7 i'ited education7 earyparenta oss7 physica/sexua abuse


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89",;


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Genetic predisposition

=+> od 5 rates in -st de%ree reati*es

5 'onozy%otic concordance (2- *s ? $

@i%h rates o anxiety disorders in chidreno aduts ith panic disorder

;enes ! AD60A -?>20/9 CCB C6@%enes or 4@9-A 4@90A C9 S869

9rau'atic eary ie e*ents

Dependent personaity traits o*erprotecti*eness


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Neurotransm itters

8:


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Neurotransm itters

4@9:

5 in 4@9 trans'ission decreases panicdisorder

4@9 neurons in *entroatera PA; (+$ssy'pathoexcitation & f%ht/Gi%ht response inrats

SS6"s eHecti*e in panic disorder

Iu'azeni causes 'id anxiety inun'edicated panic disorder patients

P89 : F in brain 4@9-A receptors & 4@9transporter bindin%


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Neurotransm itters

;AEA:

EJD a%onists ! eHecti*e in panic disorder

Iu'azani ! panico%enic eHect in panicdisorder

euroi'a%in% studies !

+ i'paired ;AEA neurona response to EJDs

+ F ;AEA in cin%uate & basa %an%ia + F EJD bindin% in inerior parieto+te'poro+

occipita areas


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Neurotransm itters

CCB+penta%astrin:

Panic disorder patients de*p panic

attacks in a dose+dependent ashionith ad'inistration o penta%astrin

CCB %ene poy'orphis's


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Neuroanatom ical hypothesis


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Cognitive m odel

;odstein & Cha'bess (-K=>$:

A noxius sti'uus (panic attack$ that

occurs ith a neutra sti'uus (busride$

A*oidance o neutra sti'uus

Panic A*oidance 6e exposure


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Cognitive m odel

Cark (-K>1$:

Catastrophicay 'isinterpret

autono'ic arousa sensations thatoccur in the context o non+pathoo%ica anxiety (e%. Physicainess exercise substances$

Autono'ic sy'pts 'isinterpreted panic


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Cognitive m odel

6eiss et a (-KK-$:

-. Predispositiona tendency tocatastrophicay 'isinterpret & respond

ith ear0. A earned ear o anxiety that is 'aintained

by the experience o panic attacks

Aut sy'pts 'isinterpret panic earnedear & hence a*oidance re exposure/autsy'pts panic


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Cognitive m odel

Eouton (0??-$:

8xposure to panic attack conditions the personto respond ith anticipatory anxiety to

interna arousa & contextua cues

Panic attack ith ear & autono'ic sy'pto's

"nterna arousa / contextua cues anyti'e

Anticipatory anxiety (so'eti'es panic attacks$


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Psychodynam ic m odels

Peope at risk or panic disorder ha*e:

-. europhysioo%ica *unerabiity topanic attacks &/or

0. utipe experiences ode*eop'enta trau'a


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9rau'a ith/ithout *unerabiity

Chid excessi*ey earu o una'iiarsituations

Eeco'es excessi*ey dependant onpri'ary care%i*er to pro*ide a senseo saety


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Care%i*er unabe to pro*ide supportaays

Chid de*eops a earu dependency

De*eop'ent o unconsciousconficts about dependency

( "ndependence *s 6eiance onothers$ & an%er


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8*oke a*ersi*e e'otions ike anxiety an%er & %uit

Eeni%n arousa sensations acco'panyin% these

e'otions beco'es the ocus o Lconscious &unconscious co%niti*e catastrophisin%M

ConGicts PA"C A99ACBS

($ unconscious/conscious antasies o catastrophic

dan%er


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Patients ith panic disorder ha*e ahi%her incidence o stressu iee*ents in the 'onths beore the onseto panic disorder.

N1? o'en ha*e h/o chidhoodsexua abuse

Cause + unconscious 'eanin% ostressu e*ents

Patho%enesis + neurophysioo%ica

actors tri%%ered by the psychoo%ica


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D"A;S"S


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DSM IV TR

6ecurrent & unexpected panic attacks

At east - o these attacks 'ust beooed by - 'onth or 'ore o:

1. persistent concern about having moreattacks,

2. worry about the implications or

consequences of the attack, or 3. changes to typical behavioral patterns

(e.g., avoidance of work or schoolactivities) as a result of the attack.


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DSM IV TR

"n addition the panic attacks 'ust notste' soey ro':

the direct eHects o iicit substanceuse medication or a generalmedical condition

are not better expained by another

'enta disorder (e.%. such as sociaphobia or attacks that occur ony insocia situations$


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DSM IV TR Panic attac!

A panic attack is a discrete period o intense fear or

disco'ort in the absence of real danger that

de*eops abruptly reaches a peak within 1 minand is acco'panied by ! (or more) o the ooin%

-2 sy'pto's:

(-$ Papitations poundin% heart or acceerated heart

rate

(0$ Seatin%


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(2$ 9re'bin% or shakin%

($ Sensations o shortness o breath or s'otherin%

(4$ Ieein% o chokin%

(1$ Chest pain or disco'ort

(=$ ausea or abdo'ina distress

(>$ Ieein% dizzy unsteady i%ht+headed or aint

(K$ Dereaization (eein%s o unreaity$ or

depersonaization (bein% detached ro' onese$


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(-?$ Iear o osin% contro or %oin%

crazy

(--$ Iear o dyin%

(-0$ Paresthesias (nu'bness or

tin%in% sensations$

(-2$ Chis or hot Gushes


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DSM IV TR Panic attac! types

"ne#pected + not associated ith anidentifabe interna or externa tri%%erand appear to occur Lout o the bueM

$ituationally bound % a'ost in*ariabyoccur hen exposed to a situationatri%%er or hen anticipatin% it

$ituationally predisposed % usuay butnot necessariy occur hen exposed toa situationa tri%%er or henanticipatin% it


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DSM IV TR

Panic disorder ith a%oraphobia +arranted hen the criteria or panicdisorder are satisf ed andacco'panied by a%oraphobia

limited symptom attacks % panic+ike

episodes co'prisin% eer than sy'pto's.


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DSM IV TR " #gorapho$ia

A%oraphobia + anxiety about bein% in paces orsituations ro' hich escape 'i%ht be di)cut(or e'barrassin%$ or in hich hep 'ay not be

a*aiabe in the e*ent o ha*in% an unexpected orsituationay predisposed panic attack / panic+ikesy'pto's.

A%oraphobic ears typicay in*o*e characteristiccusters o situations such as bein% outside theho'e aone bein% in a crod standin% in a inebein% on a brid%e or tra*ein% in a 'otor *ehice.


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DSM IV TR " #gorapho$ia

9he situations are a*oided or areendured ith 'arked distress ororry about ha*in% a panic attack orpanic+ike sy'pto's. Conrontin%situations is aided by the presence oa co'panion.

9he anxiety or a*oidance is notbetter accounted or by another

'enta disorder.


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DSM IV TR

Panic disorder ithout a%oraphobia

Panic disorder ith a%oraphobia

A%oraphobia ithout history o panic

disorder


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ICD"%&

I?.? A%oraphobia

.?? ithout panic disorder

.?- ith panic disorder

I-.? Panic disorder (episodic

paroxys'a anxiety$


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ICD"%& " #gorapho$ia

(a$ the psychoo%ica or autono'ic sy'pto's'ust be pri'ariy 'aniestations o anxietyand not secondary to other sy'pto's such as

deusions or obsessiona thou%hts7

(b$ the anxiety 'ust be restricted to (or occur'ainy in$ at east 0 o the ooin% situations:

crods pubic paces tra*ein% aay ro'ho'e and tra*ein% aone7

(c$ a*oidance o the phobic situation 'ust be or


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ICD"%& Panic Disorder

Se*era se*ere attacks o autono'ic anxiety shoudha*e occurred ithin a period o about - 'onth:

(a$ in circu'stances here there is no obOecti*e dan%er7

(b$ ithout bein% confned to knon or predictabesituations7 and

(c$ ith co'parati*e reedo' ro' anxiety sy'pto'sbeteen attacks (athou%h anticipatory anxiety isco''on $


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Co"m or$idities

,ieti'e co 'orbidity in panic disorder >?

"n panic disorder ith a%oraphobia ! -??

&a'or epressive isorder ! 14

od 5 in suicide atte'pt ith DD & Panic dis $omatoform *ain related disorders ! reQ

R @ypochondriasis + 4?

R A/c & Chronic uscuoskeeta pain ! >4 ?

R "rritabe Eoe Syndro'e ! -=+-


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Co"m or$idities

+ther n#iety isorders +

Socia phobia & ;AD: -4+2?

Specifc phobia: 0+0?

CD: -?

P9SD: 0+-?

a/c stress disorder: no studies yet


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Co"m or$idities

lcohol use disorders

? in 'aes7 -2 in e'aes

Precipitatin% aintainin% &

A%%ra*atin% roe

Can precede or de*eop secondary to

panic disorder (as 'eans o se+

'edication$


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Co"m or$idities

*ersonality disorders:

?+4?

A*oidant

Dependent

@istrionic


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Di''erential Diagnosis


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General M edical Conditions

8ndocrine

@yperthyroidis'

@ypo/hyperparathyroidis' @ypo%yce'ia D

Pheochro'ocyto'a

Carcinoid syndro'e Cushin%s disease Addisons disease

PS enopausa disorders


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Cardio*ascuar

#P

Supra*entricuar arryth'ias An%ina " C@I

@ypertension

Ane'ia


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Pu'onary diseases

CPD

Eronchia Asth'a

@yper*entiation

Pu'onary e'bous


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euroo%ica diseases

C#D 9"A

Seizures i%raine

#estibuar diseases

utipe Scerosis

@untin%tons disease

3isons disease


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thers

Anaphyaxis

Syste'ic inections

8ectroyte disturbances

Tre'ia

@ea*y 'eta poisonin%

E-0 defciency

S,8 9e'pora arteritis


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Su$stance induced

"ntoxication ith CS sti'uants

Cocaine

A'pheta'ine

CaHeine 9heophyine icotine

"ntoxication ith other dru%s

@aucino%ens Cannabis A'ynitrite

Antichoiner%ics


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Su$stance induced

3ithdraa ro' CS depressants

Acoho

piates & opioids

Sedati*e+hypnotics

Antihypertensi*es


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Psychiatric disorders

+ther an#iety disorders

;AD

Specifc phobias Socia phobia

CD

P9SD

Separation anxiety disorder

&ood disorders, *sychotic disorders


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Psychiatric disorders

Iactors hepu in 'akin% Oud%'ent or Usis:

Iocus o anxiety

9ype & no. o panic attacks

o. o situations a*oided

,e*e o intercurrent anxiety


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Conclusion

Panic disorder is a co''ony 'isseddia%nosis in 'edica settin%s

Eoth bioo%ica & psychoo%ica

actors pay a roe

Co 'orbidities ! co''on & oHerschaen%e in dia%nosis & treat'ent

3ary o other diseases si'uatin%panic disorder

9hank you


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9hank you

-rigger for panic attack

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Panic Disorder _ Etiology & Clinical Features