History

Fact Explanation
Recurrent attacks of severe anxiety. An attack is a period of intense fear or discomfort which is of sudden inset, builds up to a peak rapidly. They are unexpected in occurrence. They have to be accompanied by 4 out of 13 somatic or cognitive symptoms. (DSM-4). Patient is free of anxiety in between attacks. [1]
Fear is accompanied by somatic symptoms in panic attacks. According to the DSM-4 criteria for the diagnosis of Panic disorder, 4 out of the following 14 symptom should be present. 1) Palpitations 2) Sweating 3) Trembling or shaking 4) Sensation of shortness of breath or smothering 5) Feeling of choking 6) Chest pain or discomfort 7) Nausea 8) Feeling dizzy 9) Derealization 10) Fear of loosing control 11) Fear of dying 12) Paraesthsia 13) Chills or hot flushes [1]
One month or more of concern about recurrence. Persistent concern about recurrence, worry about the implications of the attacks or its consequences, significant change in behavior because of the attacks. [2]
Absence of agoraphobia Agoraphobia is avoidance of situations in which panic attacks are presumed likely by the person. [3]
Exclusion of panic attacks due to the direct effect of substance abuse or due to medical conditions. People who use cannabis or have dependence were associated with increased odds for the development of panic attacks and panic disorder. Hyperthyroidism can give cause panic attacks. [1]
The panic attacks are not due to another mental disorder. Mental disorders such as Social phobias, specific phobias, Obsessive- Compulsive disorders, Post traumatic stress disorder and separation anxiety disorder can give rise to panic attacks. [4]
References
  1. 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 19 May 2014] Available from: doi:10.1016/j.jpsychires.2007.10.012
  2. KESSLER RC, CHIU WT, JIN R, RUSCIO AM, SHEAR K, WALTERS EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication Arch Gen Psychiatry [online] 2006 Apr, 63(4):415-424 [viewed 19 May 2014] Available from: doi:10.1001/archpsyc.63.4.415
  3. MCTEAGUE LM, LANG PJ, LAPLANTE MC, BRADLEY MM. Aversive imagery in panic disorder: Agoraphobia severity, comorbidity and defensive physiology Biol Psychiatry [online] 2011 Sep 1, 70(5):415-424 [viewed 20 May 2014] Available from: doi:10.1016/j.biopsych.2011.03.005
  4. ZLOMUZICA A, DERE D, MACHULSKA A, ADOLPH D, DERE E, MARGRAF J. Episodic Memories in Anxiety Disorders: Clinical Implications Front Behav Neurosci [online] :131 [viewed 20 May 2014] Available from: doi:10.3389/fnbeh.2014.00131

Examination

Fact Explanation
Cardiovascular examination Symptoms of anxiety similar to panic disorder is seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea. [1]
Respiratory system examination Hyperventilation is a sign that can be seen in patients with bronchial asthma and panic attacks. Respiratory system examination findings should be normal in panic disorder. [2]
Signs of hyperthyroidism Tachycardia, irregularly irregular pulse, tachypnoea, lid retraction, sweaty palms, hand tremors , restlessness can be seen in both hyperthyroidism and panic disorder. Thyroid goiter, exophthalmos, opthalmoplegia, fine hair due to hair loss, are specific to thyroid disease.
Mental State Examination: Appearance Facial expression may show signs of anxiety- horizontal furrows on the brow, wide palpebral fissures, dilated pupils. Posture- sits upright, head erect. Movement - restless, may have tremors. Also exclude co-morbid conditions like depression [3] where vertical furrows in the brow can be seen.
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. [3]
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor. [3]
Mental State Examination: Thoughts Preoccupations of reasons for anxiety and fear of a catastrophic event may prolong the disorder. [3]
Mental State Examination: Perception. They do not have any illusions or hallucinations. [3]
Mental State Examination: Depersonalization/ Derealization Depersonalization can occur during a panic attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves.
Mental State Examination: Cognitive function. Normal. [3]
Mental State Examination: Insight Insight is preserved in patients with panic disorder. [3]
References
  1. KATERNDAHL DA. The Association Between Panic Disorder and Coronary Artery Disease Among Primary Care Patients Presenting With Chest Pain: An Updated Literature Review Prim Care Companion J Clin Psychiatry [online] 2008, 10(4):276-285 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528236
  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 20 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 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515914

Differential Diagnoses

Fact Explanation
Anxiety disorders due to a medical conditions Metabolic or autonomic abnormalities caused by the illness produce the symptoms of anxiety. Hyperthyroidism and hypothyroidism, pheochromocytoma, temporal-lobe epilepsy, asthma, cardiac arrhythmias, congestive heart failure, give rise to anxiety disorders. [1]
Substance induced anxiety disorder Use or abuse of substance like caffeine, amphetamines, marijuana, cocaine as well as the withdrawal from alcohol or sedative-hypnotics causes anxiety symptoms. [1]
Other anxiety disorders. Social phobias, specific phobias, Obsessive -compulsive disorder (OCD), Post - traumatic stress disorder (PTSD) In Panic disorder the anxiety attacks are unexpected unlike in other anxiety disorders, in which the attacks are situation bound or situationally predisposed.[1]
Use of anxiogenic medications Such as β-adrenergic agonists, theophylline, corticosteroids, thyroid hormone, sympathomimetics, psycho-stimulants. [1]
References
  1. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743

Investigations - for Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. [1]
Thyroid function tests TSH and T4 levels. To exclude thyroid disease giving rise to panic attacks. [2]
References
  1. SOARES-FILHO GL, MESQUITA CT, MESQUITA ET, ARIAS-CARRIóN O, MACHADO S, GONZáLEZ MM, VALENçA AM, NARDI AE. Panic attack triggering myocardial ischemia documented by myocardial perfusion imaging study. A case report Int Arch Med [online] :24 [viewed 20 May 2014] Available from: doi:10.1186/1755-7682-5-24
  2. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743

Management - General Measures

Fact Explanation
Patient education about his/ her symptoms Educate the patient about the symptoms of anxiety and how these symptoms give rise to more anxiety, in essence creating a vicious cycle. Education about 'panic disorder' as the cause of symptoms. [1]
Patient education about the treatment process and treatment options Panic disorder requires long-term treatment to achieve remission and to to prevent relapses. Patients should be educated about pharmacological therapy and Cognitive Behavioral Therapy (CBT) and advantages of each modality. [1]
Educate the patient that symptom improvement will take place gradually rather than a rapid response to drugs To improve compliance of the patient to the treatment. [2]
References
  1. MARCHESI C. Pharmacological management of panic disorder Neuropsychiatr Dis Treat [online] 2008 Feb, 4(1):93-106 [viewed 20 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 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860526

Management - Specific Treatments

Fact Explanation
Psychological treatment - cognitive behavioral therapy (CBT). Psycho-education about the nature of anxiety, Diaphragmatic breathing and progressive muscle relaxation training, flash cards given to reassure patients during attacks, distraction methods, cognitive restructuring to identify and challenge panic-relevant, negative automatic thoughts. Exposure exercises.[1]
Pharmacological Treatment: Antidepressants Selective serotonin re-uptake inhibitors (SSRIs)-the first line treatment option. Examples- fluoxetine , sertraline , citalopram , escitalopram, fluvoxamine ,paroxetine, vilazodone. Selective nor epinephrine-serotonin re-uptake inhibitor (SNRIs)- venlafaxine, desvenlafaxine, duloxetine. Alternatively Tricyclic antidepressants can be used (TCAs) - Imipramine. Combining Imipramine and CBT shows limited advantage in the acute setting but there is a more significant advantage during maintenance.
Pharmacological Treatment: Benzodiazepines No longer used as first line therapy because of the risk of dependence associated with their chronic use. Used as a treatment for acute anxiety in the short term. Can be prescribed if the patient needs to attend a potentially panic inducing event during the initial period of therapy, such as family gathering, wedding or a business event. [2]
References
  1. TEACHMAN BA, MARKER CD, SMITH-JANIK SB. Automatic associations and panic disorder: Trajectories of change over the course of treatment J Consult Clin Psychol [online] 2008 Dec, 76(6):988-1002 [viewed 20 May 2014] Available from: doi:10.1037/a0013113
  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 20 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173