History

Fact Explanation
Recurrent unexpected panic attacks A panic attack is a period of intense fear and discomfort accompanied by somatic and cognitive symptoms. (any four of the following). a)palpitations b) sweating c) tremors d) sensation of shortness of breath e) feeling of chocking f) chest pain g) nausea h) feeling dizzy i ) derealization and depersonalization j) fear of loosing control k) fear of dying l) paresthesias m)chills or hot flushes [1]
At least one attack is followed by a month of concern Persistent concern about having additional attacks, worry about the consequences of the attacks, a significant change in behavior due to the attacks ( help-seeking, fearful avoidance). [1]
Presence of agoraphobia Avoidance situations in which an attack may occur , which can confer significant limitations in social, work, and family functioning. [1]
Attacks are not due to the direct physiological effects of the substance or due to any medical condition Alcohol and other substance can cause panic attacks. Hyperthyroidism, arrhythmias, attacks of asthma can cause panic attacks. [2]
Panic attacks are not due to another mental disorder Social phobia, specific phobia, obsessive- compulsive disorder, post-traumatic stress disorder, separation anxiety disorder. [2]
References
  1. HOLT RL, LYDIARD RB. Management of Treatment-Resistant Panic Disorder Psychiatry (Edgmont) [online] , 4(10):48-59 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860526
  2. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173

Examination

Fact Explanation
Cardiovascular examination: irregularly irregular pulse , tachycardia, tachypnoea, irregular cardiac rhythm on auscultation Panic attacks can be due to cardiac ischemia or arrhythmia. [1]
Respiratory system examination: increased respiratory rate, shallow breathing, rhonchi Acute exacerbation of asthma also can mimic panic attacks in panic disorder. [2]
Signs of hyperthyroidism: thyroid goiter, exopthalmos, lid lag, fine hair, hair loss, myxoedema or leg swelling are present in thyroid disease but not in panic disorder. Tremors, sweaty palms , tachycardia, tachypnoea, can be seen in panic attacks as well as hyperthyroidism. [3]
Mental state examination: Appearance and behaviour Horizontal furrows on the brow and dilated pupils indicate anxiety. Worried expression with down turned corners of the mouth if associated depression is present. Patient maybe with tremors. [3]
Mental State examination: Speech Depressed patients will have a reduced speech. [3]
Mental State Examination: Mood Associated symptoms of dry mouth, tremors, sweating can be seen. If depression present mood will be low and blunted. [3]
Mental State Examination: Thinking Preoccupation with anxious thoughts. [3]
Mental State Examination: Perception No illusions or hallucinations found in panic disorder. [3]
Mental State Examination: Cognitive functions Cognitive functions are preserved. [3]
Mental State Examination Insight Preserved. [3]
References
  1. KATERNDAHL DA. Chest Pain and Its Importance in Patients With Panic Disorder: An Updated Literature Review Prim Care Companion J Clin Psychiatry [online] 2008, 10(5):376-383 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629063
  2. MEURET AE, RITZ T. Hyperventilation in Panic Disorder and Asthma: Empirical Evidence and Clinical Strategies Int J Psychophysiol [online] 2010 Oct, 78(1):68-79 [viewed 26 May 2014] Available from: doi:10.1016/j.ijpsycho.2010.05.006
  3. MARCHESI C. Pharmacological management of panic disorder Neuropsychiatr Dis Treat [online] 2008 Feb, 4(1):93-106 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515914

Differential Diagnoses

Fact Explanation
General medical conditions Hyperthyroidism, hyperparathyroidism, pheochromocytoma, cardiac conditions (arrhythmia, supra ventricular tachycardia) [1]
Substance induced panic disorder Central nervous system stimulants ( cocaine, amphetamines, caffeine), cannabis(cannabis use and dependence is prospectively associated with increased odds for the development of panic attacks and panic disorder) and withdrawal from central nervous system depressants (alcohol, barbiturates) can precipitate panic attacks. [2]
Other anxiety disorders Social phobia, specific phobia, obsessive - compulsive disorder, post- traumatic stress disorder can have panic attacks which can mimic panic disorder. [3]
References
  1. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173
  2. ZVOLENSKY MJ, LEWINSOHN P, BERNSTEIN A, SCHMIDT NB, BUCKNER JD, SEELEY J, BONN-MILLER MO. Prospective Associations between Cannabis Use, Abuse, and Dependence and Panic Attacks and Disorder J Psychiatr Res [online] 2008 Oct, 42(12):1017-1023 [viewed 27 May 2014] Available from: doi:10.1016/j.jpsychires.2007.10.012
  3. HOLT RL, LYDIARD RB. Management of Treatment-Resistant Panic Disorder Psychiatry (Edgmont) [online] , 4(10):48-59 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860526

Investigations - for Diagnosis

Fact Explanation
ECG and echocardiogram Panic attacks can mimic cardiac conditions like arrhythmia and supra ventricular tachycardia.To exclude such conditions investigations needed. [1]
Thyroid function tests (T4 and TSH) To exclude panic attacks due to hyperthyroidism. [2]
References
  1. KATERNDAHL DA. Chest Pain and Its Importance in Patients With Panic Disorder: An Updated Literature Review Prim Care Companion J Clin Psychiatry [online] 2008, 10(5):376-383 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629063
  2. MARCHESI C. Pharmacological management of panic disorder Neuropsychiatr Dis Treat [online] 2008 Feb, 4(1):93-106 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515914

Management - General Measures

Fact Explanation
Education of the patient and his family members about the disorder and reassuring them. Morbidity of the disorder includes distress, reduced quality of life and functional impairment and places a significant economical burden on the patient and family. [1]
Advice against alcohol use smoking and use of substance (cannabis, cocaine, amphetamines) These can precipitate panic attacks and panic disorder. [2]
Look for co morbid disorders. Panic disorder patients commonly have co morbid depressive disorder. [3]
Educate about the agoraphobia and the effect that can have on patient's life. Agoraphobia is avoidance situations in which an attack may occur, and this restrict the patient's social life, day to day work and may disturb his/her occupation. [4]
Educate the patients and their family about the treatment options , treatment duration, in order to enhance the adherence. Explain that the panic disorder can be treated by both psychological and pharmacological treatment and combination of both gives a better long term results. pharmacological treatment has to go up to at least 8 months.And the improvement is gradual rather than immediate. [4]
Discuss the expected adverse effects of medication. Patients should be informed about the frequency, the time of onset of side-effects of the medications. SSRI-anxiety, agitation, insomnia, tremors, nausea, anorexia, headache and sexual dysfunction Benzodiazepines - sedation, somnolence, drowsiness, cognitive impairment, impairment of motor coordination. This increases the compliance of the patient. [4]
References
  1. WALTERS K, RAIT G, GRIFFIN M, BUSZEWICZ M, NAZARETH I. Recent Trends in the Incidence of Anxiety Diagnoses and Symptoms in Primary Care PLoS One [online] , 7(8):e41670 [viewed 27 May 2014] Available from: doi:10.1371/journal.pone.0041670
  2. ZVOLENSKY MJ, LEWINSOHN P, BERNSTEIN A, SCHMIDT NB, BUCKNER JD, SEELEY J, BONN-MILLER MO. Prospective Associations between Cannabis Use, Abuse, and Dependence and Panic Attacks and Disorder J Psychiatr Res [online] 2008 Oct, 42(12):1017-1023 [viewed 27 May 2014] Available from: doi:10.1016/j.jpsychires.2007.10.012
  3. TILLI V, SUOMINEN K, KARLSSON H. Panic disorder in primary care: Comorbid psychiatric disorders and their persistence Scand J Prim Health Care [online] 2012 Dec, 30(4):247-253 [viewed 27 May 2014] Available from: doi:10.3109/02813432.2012.732471
  4. HOLT RL, LYDIARD RB. Management of Treatment-Resistant Panic Disorder Psychiatry (Edgmont) [online] , 4(10):48-59 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860526

Management - Specific Treatments

Fact Explanation
Pharmacological treatment.- Antidepressants 1)Selective serotonin re-uptake inhibitors (SSRIs)- recommended as the 1st line treatment for the beneficial side-effect profile of this class of drugs. - Paroxetine, fluoxetine, fluvoxamine, and sertraline. [1] 2)Selective norepinephrine-serotonin re-uptake inhibitor (SNRIs) - venlafaxine 3)Tricyclic antidepressants (TCAs) - given a lower dose than in depression because they can increase the frequency of panic attacks initially. [2]
Anxiolytics- Benzodiazepines Alprazolam - Short term use in the early part of the treatment. It is combined with antidepressants because antidepressants take 4-6 weeks to act. [2]
Psychological treatment - Cognitive behavioral therapy (CBT) CBT includes 1)psycho education- explaining the cognitive model to the patient-That the panic patients are prone to misinterpret body sensations and that it is the misinterpretation which is responsible for the induced attack. 2)anxiety control- patients are taught of methods of controlling anxiety like breathing exercises and relaxation training 3)self- monitoring 4)cognitive reconstructure - patients are guided to interpret bodily sensations in a more benign way. 5)exposure- patients are gradually exposed to the situations they have been avoiding due to the panic attacks. [3]
References
  1. MARCHESI C. Pharmacological management of panic disorder Neuropsychiatr Dis Treat [online] 2008 Feb, 4(1):93-106 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515914
  2. HOLT RL, LYDIARD RB. Management of Treatment-Resistant Panic Disorder Psychiatry (Edgmont) [online] , 4(10):48-59 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860526
  3. TEACHMAN BA, MARKER CD, CLERKIN EM. Catastrophic misinterpretations as a predictor of symptom change during treatment for panic disorder J Consult Clin Psychol [online] 2010 Dec, 78(6):964-973 [viewed 27 May 2014] Available from: doi:10.1037/a0021067