Transcript Panic Disorder

Potential questions on Panic
Disorder
Answers based on DSM-IV-TR, APA Practice
Guideline, and other references that as
identified on the specific screen. As of August
1, 2006.
Criteria of “panic attack”
Q. DSM criteria, very general?
Ans. Outline of Dx of Panic
Disorder
• 1. Recurrent unexpected panic attacks
• 2. Following the attacks, pt has been
concerned for more than a month about
additional attacks, implications of the
attacks or had a change in behavior as a
result to the attacks.
• 3. Panic attacks are not part of another
disorder.
Panic attack symptoms
Q. DSM expects at least 4 of 13 symptoms
in stating the pt has had a “panic attack.”
List as many of the 13 as you can.
Criteria of “Panic Attack”?
Two slides
• 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
Criteria for Panic Attack
second slide
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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
Rule outs
Q. Names some key rule outs to making the
dx of panic disorder.
Key Rule Outs
1. Substances
2. Non-psychiatric medical conditions, e.g.,
hyperthyroidism.
3. Phobias, including agoraphobia
4. OCD
5. PTSD
6. Separation anxiety disorder
Lab findings
Q. What are laboratory findings?
Laboratory Findings?
Ans. None are specific to panic disorder, but
pts with this disorder do tend to have panic
attacks with an infusion of Na+ lactate
than those without the disorder.
More common
Q. Which is more common Panic Disorder
with agoraphobia or panic disorder without
agoraphobia?
More common
Ans. Panic Disorder without agoraphobia is
twice as common.
Gender
Q. Gender breakdown?
Gender Breakdown
Ans. Women to men: two to one says
Practice Guideline, Some say three to
one.
Onset
Q. Age at onset?
Onset:
Ans. Bimodal onset:
– Late teens/early twenties, highest
– Mid thirties, second highest peak
Lifetime prevalence
Q. Lifetime Prevalence?
Lifetime prevalence
Ans. 2%
Annual prevalence
Q. Annual Prevalence?
Annual Prevalence
Ans. 1%
Primary care
Q. Prevalence in Primary Care Practice?
Prevalence in Primary Care
Practice
Ans. 3 – 8 %
• Ref: NEJM 2006; 354:2360-7
Entry
Q. A common place for people with panic disorder to enter the health
care system?
Entry
Ans. Common entry point is the ER
Hospitalize
Q. When to hospitalize a pt with panic
disorder?
When to hospitalize a pt with panic
disorder
Ans. Only hospitalize if there is another
psychiatric disorder present that so
justifies.
Risk factors
Q. What are risk factors for panic disorder?
Risk Factors
Ans. 1. Genetic, higher in monozygotic than
dizygotic twins and 8 times as common
among close relatives.
• 2. May have abnormally sensitive fear
network.
• 3. Hx of sexual or physical abuse as child.
• 4. 80% of pts report major stresses in the
12 months before attacks.
Ref : NEJM 2006; 354:2360-7
Comorbid
Q. What percentage will have comorbid psych disorders during their lifetime?
comorbid
Ans. Lifetime comorbid disorders: 90%
• Ref: NEJM 2006; 354:2360-7
Mimic
Q. What conditions can mimic a panic
attack?
mimic
Ans. Potential mimics:
Hyperthyroidism
Hypothyroidism
Temporal-lobe epilepsy
Asthma
Cardiac arrhythmias
Pheochromocytoma
Too much coffee and other stimulants
• Ref: NEJM 2006; 354:2360-7
Screen for depression
Q. Why screen for depression?
Screen for depression to
Ans. Screen for depression to ascertain if pt
also has depressive disorder. An
associated depression increases risk of
suicide.
Suicide rate
Q. What is suicide rate?
Suicide rate
Ans. Practice Guideline says 1/5, but NEJM
article implies that is so because so many
are also depressed. Still, it would seem
that “1/5” would be correct answer.
Personality disorders
Q. Which three personality disorders have high co-occurrence with
panic disorder?
Common co-occurring personality
disorders are
Ans. Common co-occurring personality
disorders:
Avoidant
Obsessive-compulsive
Dependent
Medications
Q. Which five classes of meds have been
shown to be the most efficacious?
[“Efficacious” implies potency alone, not
related to more general issues as to the
use of the med.]
Five Classes have Been Shown to
Be Effective
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1.
2.
3.
4.
5.
SSRIs
SNRIs
High potency benzodiazepines
Tricyclics
MAOIs
Ref: NEJM 2006; 354:2360-7
Q. Of the five classes of meds,
which is preferred?
Q. Which of the five classes of meds in the
prior screen is preferred for pts with panic
attacks?
Preferred medical class
• SSRIs
•Ref: NEJM 2006; 354:2360-7
Q. What about bupropion?
Q. What about using bupropion in pts with
panic attacks?
Ans. As to bupropion
• Bupropion has not been shown to be
effective.
• PG, 645
Antipsychotics
• Q. What about antipsychotics?
Ans. As to antipsychotics
• Have not been shown to be effective
• PG, 646
Q. What about propranolol?
Q. What about propranolol use in pts with
panic disorders?
Ans. As to propranolol
• Inferior to benzodiazepines for as needed
situations. Thus, OK for PRN.
• PG, 646
Q. What is medication strategy?
Q. After selecting the medication, what is
medication strategy for panic disorders?
Dosing strategy of SSRIs in panic
disorder?
• Begin with low doses and titrated every
weekly as tolerated. Example, 10 mg of
fluoxetine with range of 5 – 80.
•Ref: NEJM 2006; 354:2360-7
Q. Goal of medication treatment?
Q. Goal of medication treatment in pts with
panic disorders?
Ans. Treatment Goal with meds:
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•
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1. Decrease frequency of attacks
2. Decrease intensity of attacks
3. Decrease anticipatory anxiety
4. Decrease phobic avoidance
• Ref: PG, p 640
First Choice?
Q. If the First Choice SSRI is not effective,
what to do?
Ans. If SSRI fails, then
Ans.
1. CBT or
2. Another SSRI
• Ref: NEJM 2006; 354:2360-7
In the face of 2 SSRI failures
Q. If two SSRIs have failed?
Ans. In the face of failure of two
SSRIs:
• CBT or
• Another class of meds:
– Tricyclic
– MAHO
– Or
– SNRI
• Ref: NEJM 2006; 354:2360-7
Benzodiazepines
• Q. What about use of benzodiazepines?
Ans. As to use of benzodiazepines:
• Not recommended as primary med
because of addiction potential and the
tendency of withdrawal to have
discontinuation syndrome.
• Useful for as needed situations, such as
apprehensiveness about taking a airplane
flight.
• Ref: NEJM 2006; 354:2360-7
benzodiazepines
• Q. Which benzodiazepines are
recommended for as needed use, i.e., for
PRNs?
A. Recommended benzodiazepines
• Long lasting:
– ER alprazolam
– Clonazepam
• Ref: NEJM 2006; 354:2360-7
FDA
• Q. FDA approved for panic disorder are?
Only FDA approved meds for panic
disorders of all classes:
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Alprazolam
Clonazepam
Fluoxetine
Paroxetine
Sertraline
Discontinuation syndrome
• Q. Signs of discontinuation syndrome?
Ans. Signs of Discontinuation
Syndrome:
• Fearfulness
• Irritability
• Headache
• Muscle tension
• Perceptual abnormalities
• Insomnia
• Decreased concentration
• Cardiovascular symptoms
[Ref: NEJM 2006; 354:2360-7]
Q. To avoid discontinuation syndrome in pts on benzodiazepines for
a lengthy period of time ?
Ans. To avoid discontinuation
syndrome
• Taper with a slow acting benzodiazepine
for over a month or two.
• Ref: NEJM 2006; 354:2360-7
CBT consist of?
Q. For panic disorder, of what does CBT
consist?
Ans. CBT consists of:
• In 12 to 16 sessions, usually weekly, the
focus is on recreating the feared
symptoms and then modifying the pt’s
response. For example, if attack is
precipitated by increase pulse, have pt jog
and that helps correct the cognitive
distortions.
• Ref: NEJM 2006; 354:2360-7
CBT v. Meds
• Q. CBT compared to meds as to
efficaciousness?
CBT and Meds
• They are equally effective.
• Meds obtain results more rapidly.
• PG, 650
Drug Store
• Q. What can the pt buy at the drug store that may interfere with
treatment of panic disorder?
At the drug store, could obtain
• 1. Cigarettes
• 2. Coffee
• 3. sympathomimetics [nasal
decongestants]
Other psychotherapies
Q. What about other psychotherapies? Are
there any controlled studies?
As to other psychotherapies
• No controlled studies
Relapses
• Q. What if pt relapses, months after
apparently successful treatment?
After a relapse
• Repeat prior treatment
•Ref: NEJM 2006; 354:2360-7
Two relapses
• Q. What to do after two relapses?
After two relapses,
• Consider long term use of meds
• Ref: NEJM 2006; 354:2360-7
Q. Pt has panic disorder, irritable bowel
syndrome, respiratory signs, and migraine.
• Can one class of meds service all of
these?
One class has hopes of reaching
all:
• SSRIs
• PG, 657
Pt has become dependent
on you
• Q. What to do if the pt becomes
dependent on the psychiatrist?
When pt becomes dependent on
psychiatrist
• Maintain available and address directly.
DO NOT address through unavailability.
• PG, 649