Panic DisorderPanic Disorder

Dr. Muhammad WaseemConsultant Psychiatrist(Emergency)

Punjab Institute of Mental Health

What is Panic Disorder?What is Panic Disorder?

Panic Disorder is a serious anxiety disorder.Sudden attacks of anxiety in which physical symptoms predominate

and are accompanied by fear of a serious consequence such as heart attack.

Diagnosis is made when panic attack occur unexpectedly (not response to known phobic stimulus).& when more than 4 attacks have occurred in 4 weeks or one attack is followed by 4 weeks of persistent fear of another attack

When does someone experience a When does someone experience a Panic Attack?Panic Attack?Panic attacks happen unexpectedly.

It is common that people who have panic attacks report significant stresses in their lives but the attack itself is generally perceived as unexpected. It may occur in sleep.

Symptoms of panic attack(DSM –IV)Symptoms of panic attack(DSM –IV)

A panic attack is a sudden episode of intense fear with symptoms that may include the following:

1.shortness of breath or smothering sensation 2.choking 3.Palpitation & accelerated heart rate.4.Chest discomfort or pain5.sweating 6.dizziness ,unsteady feelings or faintness7.nausea or abdominal distress8.Depersonalization or derealiZation9.Numbness/ tingling in the hands or feet 10.chills or hot flashes 11. trembling or shaking12.Fear of dying13.Fear of going crazy or doing some thing uncontrolled.

A person needs to have 4 or more of these symptoms, one of these symptoms does not mean that he/she is having a panic attack. Some of the above symptoms can also be indications of serious medical conditions that would require a physician's medical evaluation.

What the patient believesWhat the patient believes

People with panic attacks believe that something is physically wrong with them.

What happens when someone experiences a What happens when someone experiences a Panic Attack?Panic Attack?

Panic attacks last 20-30 minutes No lasting effects In healthy individuals, the medical evaluation is

usually normal, except for a mildly elevated heart rate and a mildly elevated breathing rate during the attack

What happens next?

What happens next...?What happens next...? Individuals who suffer from panic attacks can frequently begin to:

Worry about having another attack (Panic attacks + fears about having more attacks = Panic Disorder)

Or may progress to:

Avoid situations where they experienced an attack in the past (out of fear of having another attack)

Avoid going anywhere alone Avoid leaving home (Panic Disorder + avoiding situations that

may cause panic = Panic Disorder with Agoraphobia)

Who experiences Panic Disorder?Who experiences Panic Disorder?

Usually:

Healthy people in their 20's or 30's (but any age may be affected)

Females more than males(Twice) Lifetime prevalence of panic attacks in the general

population is 3 to 4%

How does Panic Disorder affect How does Panic Disorder affect the family?the family?

Family members more likely to have Panic Disorder?

Statistics show that there is a 6 to 8 times greater risk of Panic Disorder in family members of individuals with Panic Disorder.

Untreated Panic AttacksUntreated Panic Attacks

distress breathlessness

GP visits

ambulance calling

hospitalisation

medications and medical interventions

distress in middle of night

•Therefore costs to the person and to the health services

What is the medical evaluation?What is the medical evaluation?

For first time panic attacks need medical evaluation

The usual medical evaluation includes: physical examination blood tests ECG (electrocardiogram of the heart) sensors are placed

on the chest to record the electrical current in the heart

What medical problems can What medical problems can sometimes cause a panic attack?sometimes cause a panic attack?

There are many medical problems that may sometimes cause symptoms of a panic attack or have symptoms that are similar to a panic attack, including:

o myocardial infarction (heart attack) o congestive heart failure o high blood pressure o pulmonary embolismo cerebrovascular accident (stroke) o epilepsy o Parkinson's Disease o multiple sclerosis o thyroid disease o diabetes

Can medications sometimes cause a Can medications sometimes cause a panic attack?panic attack?

Yes. There are some medications that may cause symptoms of a panic attack or have symptoms that are similar to a panic attack in some people, including:

cold and allergy medications, cough medicine appetite suppressants "herbal remedies" containing ephedrine motion sickness and nausea medications asthma inhalers Nicotine, coffee, tea Alcohol – withdrawal, Opium-withdrawal, sedative-withdrawal

Panic Disorder CausesPanic Disorder CausesWhat Causes Panic Disorder?

Three main hypothesis about origin of panic disorders

1. Biochemical Abnormality

2.Hyperventilation

3.Cognitive abnormalities

1.Biochemical Abnormality1.Biochemical Abnormality

Chemical agents i.e. Sodium lactate and yohimbine can induce panic attacks

Drugs reduce the panic attacks like Imipramine,fluvoxamine etc.

Genetics-Family members have 6 to 8 times more panic

attacks than general population.Effect of drugs suggests that 5-HT mechanism is

important in panic disoders.i.e Impipramine,fluvoxamine

2.Hyperventilation2.Hyperventilation

Some pts with panic disorders hyperventilate with the effect that

Hypothesis is that spontaneous panic attack result from involuntary hyperventilation and further symptoms are added. weakness, faintness, numbness etc..)

3.Cognitive abnormalities 3.Cognitive abnormalities

Fear about serious physical or mental illnesses are more frequent among pts with Panic attack than among anxious pts without panic attacks.

Differential DiagnosisDifferential Diagnosis

Panic attacks occur in

1. In GAD

2. Phobic anxiety disorders (most often agoraphobia)

3. Depressive disorders

4. Acute organic Disorder.

Note: in DSM IV PD can be diagnosed when these disorders are present but in UK it is custom not to diagnose in the presence of these disorders.

What is the treatment for Panic What is the treatment for Panic Disorder?Disorder?

There are several common treatments for Panic Disorder including:

o Anti-anxiety medication given in high doses (Alprazolam)

o Anti-depressant medication.1. Tricyclic (Imipramine) 175-225mg P/d

2. SSRI (Fluvoxamine ) 100 -200mg P/do Psychotherapy(Cognitive therapy is as effective as high

doses of imipramine given 225mg pd)Clark etc….1994 o Relaxation training

Course & Prognosis Course & Prognosis

Course was characterised by fluctuation anxiety and depression.

One study of pts of PD found 90% still have symptoms 20 years later

Mortality rate from unnatural causes and among men from cardiovascular have been found to higher than average

Case HistoryCase History

Mr.Ibrar is a 19 –year old unmarried resident of district Layya, educated up to 8th class, farmer by occupation presented to PIMH Emergency 3 months ago with the following complaints:-

Palpitation one month

Shortness of breath 15 days

chest discomfort 15 days

Fear of death 15 days

First episode occurred after hearing the death story of one of his relative. He woke up in the mid of night and started crying with accelerated heart rate. He was taken to district hospital and doctor on duty after attending him gave tablet propranalol and bromazepam.He remained in the hospital for 2 to 3 hours and then discharged.

Next morning his family consulted cardiologist at Bhakhar.After taking history, doing physical and systemic examination,ECG and some blood tests. He declared that he is not having any cardiac problem. However he prescribed tablet inderal and Lexotanil to the patient

consulted some peer Then he started having shortness of

breath, chest discomfort, and fear of death.

Next day he presented to PIC.

Thank you for your attention and staying

awake

Any Questions?Any Questions?