Transcript Anxiety Disorders - ::: Punjab Institute of Mental Health

Panic Disorder
Dr. Muhammad Waseem
Consultant Psychiatrist(Emergency)
Punjab Institute of Mental Health
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
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)
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 pain
5.
sweating
6.
dizziness ,unsteady feelings or faintness
7.
nausea or abdominal distress
8.
Depersonalization or derealiZation
9.
Numbness/ tingling in the hands or feet
10. chills or hot flashes
11. trembling or shaking
12. Fear of dying
13. 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 believes
 People
with panic attacks believe that
something is physically wrong with
them.
What happens when someone experiences a
Panic Attack?
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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...?
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:
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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?
Usually:

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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
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 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?
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
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
o
o
o
o
o
o
o
o
o
myocardial infarction (heart attack)
congestive heart failure
high blood pressure
pulmonary embolism
cerebrovascular accident (stroke)
epilepsy
Parkinson's Disease
multiple sclerosis
thyroid disease
diabetes
Can medications sometimes cause a
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:
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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 Causes
What Causes Panic Disorder?
Three main hypothesis about origin of
panic disorders
1. Biochemical Abnormality
2.Hyperventilation
3.Cognitive abnormalities

1.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

2.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

Fear about serious physical or
mental illnesses are more frequent
among pts with Panic attack than
among anxious pts without panic
attacks.
Differential 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
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
SSRI (Fluvoxamine ) 100 -200mg P/d
Psychotherapy(Cognitive therapy is as effective as high
doses of imipramine given 225mg pd)Clark etc….1994
Relaxation training
2.
o
o
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 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?