1. Name: Gustavo Duarte Viana Group: 17 Professor: Evgeniya Evgenevna Tretjakova 2014 1

2. Contents Definition Some features of PD Risk factors Difference between panic attack or panic disorder Pathological physiology Classification Cause PD in school time Outcomes DSM criteria When to hospitalize a PD patient Disease which mmic PD Sucide rate Ttreatment Store products which interfere with the treatment Relapse Prognosis3 4 5 6 7 9 10 15 16 17 19 20 21 22 35 36 37 2 3. Defination It is a recurrent and unexpected anxiety attack of panic, which are more often called as panic attach. In a month or more of one with feature such as following: a) Persisting fear of having another attach b) Worry about the implications and consequence of the attack. c) Significant changes of behavior after the attacks3 4. Some features of PD Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults. Panic disorder is twice as common in women as men. Panic attacks often begin in late adolescence or early adulthood, Not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited. Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.4 5. Risk factors Adolecence or early adulthood Major life transitions perceived as stressful Graduating from college, getting married, having a first child Genetics If a family member has panic disorder, you have an increased risk Especially during a time in your life that is particularly stressful.5 6. Differences between Panic attack and Panic Disorder Anyone can suffer of a Panic attack that is an extremeanxiety reaction that result when a real threat suddenly emerges (E.g.: when they are afraid of somebody in their house stealing) The experience of Panic Disorder, however, is different Panic attacks are periodic, short bouts of panic that occursuddenly, reach a peak, and pass Sufferers often fear they will die, go crazy, or lose control Attacks happen unexpectedly in the absence of a real threat Sufferers also experience dysfunctional changes in thinking andbehavior as a result of the attacks Example: sufferer worries persistently about having an attack; plans behavior around possibility of future attack 6 7. Pathophysiology While the various symptoms of a panic attack may cause the person to feel that their body is failing, it is in fact protecting itself from harm. The various symptoms of a panic attack can be understood as follows. First, there is frequently (but not always) the sudden onset of fear with little provoking stimulus. This leads to a release of nonadrenaline which brings about the so-called fight-or-flight response, wherein the person's body prepares for strenuous physical activity. This leads to a tachycardia, hyperventilation which may be perceived with dyspnea and sweating (which increases grip and aids heat loss). Because strenuous activity rarely ensues, the hyperventilation leads to a drop in carbon dioxide levels in the lungs and then in the blood. This leads to shifts in blood pH (respiratory alkalosis or hypocapnia), which in turn can lead to many other symptoms, such as tingling or numbness, dizziness, burning and lightheadedness. Moreover, the release of adrenaline during a panic attack causes vasoconstriction resulting in slightly less blood flow to the head which causes dizziness and lightheadedness. A panic attack can cause blood sugar to be drawn away from the brain and towards the major muscles. It is also possible for the person experiencing such an attack to feel as though they are unable to catch their breath, and they begin to take deeper breaths, which also acts to decrease carbon dioxide levels in the blood.7 8. It is also unclear why some people have suchabnormalities in norepinephrine activity Inherited biological predisposition is one possibility Prevalence should be (and is) greater among close relatives Among monozygotic (MZ, or identical) twins = 24% Among dizygotic (DZ, or fraternal) twins = 11%8 9. Classification Two diagnoses: panic disorder with agoraphobia panic disorder without agoraphobia (twice more common) ~3% of U.S. population affected in a given year ~5% of U.S. population affected at some point in theirlives9 10. What does cause Panic Disorders There are 3 perspective which can lead to the pathological abnormality of Noradrenalin activity: 1) Biological perspective 2) Pharmacological 3) Chronic illness (Comorbid disorders in PD accounts more than 90%) 4) cognitive10 11. Biological perspective Vulnerability to panic disorder tends to run in families. E.g.:Twin studies: Higher concordance rates among identical twins. Among monozygotic (MZ, or identical) twins = 24% Among dizygotic (DZ, or fraternal) twins = 11%Possible imbalance of neurotransmitters involved in arousal Serotonin & Norepinephrine. (Smokers have a fourfold risk of a 1st-time panic attack. Why?)11 12. Pharmacological Triggers Certain chemical substances, mainly stimulants but also certain depressants, can either contribute pharmacologically to a constellation of provocations, and thus trigger a panic attack or even a panic disorder, or directly induce one. This includes caffeine, amphetamine, alcohol and many more. Some sufferers of panic attacks also report phobias of specific drugs or chemicals, that thus have a merely psychosomatic effect, thereby functioning as drug triggers by nonpharmacological means. Alcohol, medication or drug withdrawal Various substances both prescribed and unprescribed can cause panic attacks to develop as part of their withdrawal syndrome or rebound effect. Alcohol withdrawal and benzodiazepine withdrawal are the most well known to cause these effects as a rebound withdrawal symptom of their tranquillising properties. 12 13. Chronic illness Chronic/serious illness Cardiac conditions that can cause suddendeath such as long QT syndrome; catecholaminergic polymorphic ventricular tachycardia or Wolff-Parkinson-White syndrome can also result in panic attacks. This is particularly difficult to manage as the anxiety relates to events that may occur such as cardiac arrest, or if an implantable cardioverter-defibrillator is in situ, the possibility of having a shock delivered. It can be difficult for someone with a cardiac condition to distinguish between symptoms of cardiac dysfunction and symptoms of anxiety. In CPVT the anxiety itself can and does trigger arrythmia. Current management of panic attacks secondary to cardiac conditions appears to rely heavily on benzodiazepines, selective serotonin reuptake inhibitors and/orcognitive behavioural therapy. However, people in this group often experience multiple and unavoidable hospitalisations; in people with these types of diagnoses, it can be difficult to differentiate between symptoms of a panic attack versus cardiac symptoms without an electrocardiogram.13 14. Cognitive 1. 2.3. 4. 5.Major life transitions (post graduation, losing job, after marriage) Stimulus generalization 1st attack occurs in one location Fear another attack in similar locations Being helplessness increases fear Maintained by negative reinforcement Excessive focus on potential threats (Cognitive)14 15. PD in school life There are many student that appears with PD in the schoollife time, why does it happen? I. Test/performance anxiety II. Poor academic performance III. Avoidance of school entirely What can we do to help? Talk with them about possible triggers. Stand near them in stressful situations (e.g. speeches)15 16. outcomes People who have full-blown, repeated panic attacks can becomevery disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment. Some people's lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. When the condition progresses this far, it is called agoraphobia, or fear of open spaces. 16 17. DSM Criteria for PD diagnosis DSM (Diagnostic and Statistical Manual of Mental Disorders) expects at least 4 of 13 symptoms in stating the patient has had a panic attack. List as many of the 13.17 18. At least 4 of following develop suddenly and peak in 10 minutes: 1.palpitations or increased pulse 2. sweating 3. trembling or shaking 4. sensation of shortness of breadth 5. feeling of choking 6. chest discomfort 7. nausea or stomach distress 8. dizzy, unsteady, lightheaded, or faint 9. derealization/depersonalization 10. fear of losing control or going crazy 11. fear of dying 12. paresthesias 13. chills or hot flashes 18 19. When to hospitalize a patient with PD? Only hospitalize if there is another psychiatric disorder present that so justifies.19 20. Disease which mimic PD i. ii. iii. iv. v. vi. vii.Hyperthyroidism Hypothyroidism Temporal-lobe epilepsy Asthma Cardiac arrhythmias Pheochromocytoma Too much coffee and other stimulants20 21. Suicide rate Guideline says 1/5, but article implies that is so because many have comorbid with depression. Still, it would seem that 1/5 would be correct answer.21 22. Treatment goals 1. Decrease frequency of attacks 2. Decrease intensity of attacks 3. Decrease anticipatory anxiety 4. Decrease phobic avoidance22 23. All patients with PD should be monitored by apsychiatrist, psychologist or a mental healthy care, it is shown that a psychiatric care is the most effective and low costs because of addition of pharmacological therapy, decreasing emergency department intake and costs and nonpsychiatric outpatient care23 24. Cognitive behavioral therapy(CBT) CBT with or without pharmacotherapy, is the treatment of choice for panic disorder, and it should be considered for all patients.CBT has higher efficacy and lower cost, dropout rates, and relapse rates than do pharmacologic treatments. In 12 to 16 sessions, usually weekly, the focus is on recreating the feared symptoms and then modifying the patients response. The trigger in an individual case could be something like A thought A situation Something subtle like a slight change in heartbeat. Therapy Goals Understanding that the panic attack is separate and independent of the trigger Awareness of the trigger(s) so it begins to lose some of its power to induce an attack.24 25. Behavioral therapy Behavioral therapy involves sequentially greater exposure of the patient to anxietyprovoking stimuli; over time, the patient becomes desensitized to the experience. Relaxation techniques also help to control patients' levels of anxiety. Respiratory training can help patients to control hyperventilation during panic attacks and to control anxiety with controlled breathing. Capnometry feedback-assisted breathing training can be used to prevent hypocapnia and stabilize the respiratory rate. The trigger could be: Intentional hyperventilation creates lightheadedness, derealization, blurred vision, dizziness Spinning in a chair creates dizziness, disorientation Straw breathing creates dyspnea, airway constriction Breath holding creates sensation of being out of breath Running in place creates increased heart rate, respiration, perspiration Body tensing creates feelings of being tense and vigilant Therapy goals: it help the patient to come through an attack by controlling the symptoms.25 26. Pharmacological therapy Providing a few doses of a benzodiazepine as needed (prn)can enhance patient confidence and compliance. Total tablet dispensing should remain limited to ensure that patients understand that they have a limited supply of the drug and that this medicine represents a temporary or emergency use option. The patient should be made to understand the importance of longer-term management with SSRI medication and psychotherapeutic techniques (eg, CBT). Avoid the prescription of benzodiazepine in patients with a known history of substance misuse or alcoholism.26 27. Follow-up care and referrals Initial follow-up care should occur within 2 weeks, because SSRIscan cause an initial exacerbation of panic symptoms. For this reason, begin with the lowest dose with the understanding that the dose must be increased at the initial follow-up visit. Assess potential suicide risk at all appointments. Ensure continuing treatment of any concurrent substance use disorders. Follow-up care by a chemical dependence treatment specialist is recommended when indicated. Patients with ventricular dysrhythmias, abnormal findings on ECG, abnormal findings on cardiac examination, or significant risk factors for heart disease should be referred to a cardiologist.27 28. Inpatient care Inpatient care is rarely considered for uncomplicated panic disorder.Patients may get admitted if they display any evidence of dangerous behavior, safety concerns, report suicidal or homicidal ideation as may occur in context of acute anxiety, fear of anxiety or its consequences or with another psychiatric disorder. Patients may require hospitalization for intoxication or withdrawal from sedative/hypnotics such as alcohol or Xanax, which sometimes get ingested or abused in attempts to medicate or manage the anxiety. Patients may also get hospitalized if they become so incapacitated by their anxiety that they are unable to adhere to outpatient care. Inpatient treatment is necessary in patients with suicidal ideation and plan or with serious alcohol or sedative withdrawal symptoms, or when the differential includes other medical disorders that warrant admission (eg, unstable angina, acute myocardial ischemia).28 29. 5 groups of drugs used in the PD 1. SSRIs 2. SNRIs 3. High potency benzodiazepines 4. Tricyclics 5. MAOIs29 30. SSRIs SSRIs is the fist choice for the treatment of PD.Flouxetine, Paroxitine, Sertraline or fluvoxamine: MOA: It is an antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. It also has a negligible affinity for cholinergic and histaminergic receptors.30 31. SNRIs Trazodone: it is used in PD with or withoutagoraphobia. MOA: It is an antagonist at the 5-HT2 receptor and inhibits the reuptake of 5-HT. It also has a negligible affinity for cholinergic and histaminergic receptors.31 32. Intermediate to strong Benzodiazepam Lorazepam, clonazapam, alprazolam or diazepam. It isnot a primary choice because of the dependence and side effects caused. Useful in situation as apprehensiveness about taking a airplane flight MOA: it potentiate GABA by binding to specific GABA receptor.32 33. Tricyclic antidepressants Imipramine, desipramineor clomipramine.It has a low risk of dependence and no diatary restrictions, but they are in 35% cases discontinued because of its side effects such as blurred vision, dry mouth, dizziness, weight gain, GIT distubences, agitation, headache, insonia and decreased libido, to avoid side effects abruptly, it must be first administered in low dose. MOA: they are Serotonin and Nonadrenaline reuptake inhibitors. 33 34. Monoamine oxidase inhibitors Phenelzine or tranylcypromine, they are effective in patient with PD orother associated phobia MOA: Nonselective monoamine oxidase inhibitor; may inhibit the enzyme monoamine oxidase, which is responsible for the breakdown of dopamine, serotonin, epinephrine, and norepinephrine, in turn causing an increase in endogenous concentrations of these neurotransmitters.34 35. Stores products Patient can buy some products specially in the depressionor anxiety period that can interfere with the treatment such as: 1. Cigarettes 2. Coffee 3. sympathomimetics [nasal decongestants] They should be advised that they can not used this products while they are in the pharmacological therapy.35 36. Relapses After a successful treatment many patients may fallinto a relapse, specially after a makeable event in patients life as the loss of a beloved one, discovered of a severe illness and etc. We should adopted the prior treatment of CBT and drugs (SSRIs or SNRIs) and if it does not work, should be maintained the CBT and change the group of drug (tricyclic)36 37. Prognosis Long-term prognosis is usually good, with almost 65% ofpatients with panic disorder achieving remission, typically within 6 months. The risk of coronary artery disease in patients with panic disorder is nearly doubled. In patients with coronary disease, panic can induce myocardial ischemia. The risk of sudden death may also theoretically be increased due to reduced heart rate variability and increased QT interval variability. Appropriate pharmacologic therapy and cognitivebehavioral therapy, individually or in combination, are effective in more than 85% of cases. 37