Panic disorder in adults

Panic disorder – background Panic disorder is very common and deleterious to mental wellbeing
Lifetime prevalence 1 to14 %
 First described in 1960 – it was seen that patients with panic attacks would respond to imipramine while other patients with anxiety would not
 Often co-exists with agoraphobia- which is avoidance of exposed situations for fear of panic or inability to escape ( Greek- fear of marketplace )

DSM 5 criteria for panic disorder 

A -Individual experiences recurrent unexpected panic attacks- abrupt feelings of intense fear or discomfort that reach heights within minutes , during a time in which atleast 4 of the following symptoms occur

1 palpitations , pounding heart or accelerated heart rate
2 sweating
3 trembling or shaking
4 instances of SOB or feeling smothered
5 feelings of choking
6 chest pain or discomfort
7 nausea or abdominal distress
8 feeling dizzy , unsteady , light headed , or faint
9 chills or heat sensations
10 paraesthesias (numbness or tingling )
11 derealization or derpersonalization
12 fear of loosing control or going crazy
13 fear of dying

B -One or more of the attacks were followed by a month ( or longer ) of one or both of the following

1 persistent concern or worry about additional panic attacks or their consequences ( eg loosing control , having a heart attack or going crazy )
2 significant abnormal change in behaviour in response to the attacks , such as ones intended to avoid unfamiliar situations

C Not caused by a substance ( eg drug abuse , medication ) or another medical condition

D Not better explained by another mental disorder

Aetiology – not fully understood
probably heterogenous Aberrant immunological mechanisms may have a role Role of brain neurotransmitters as GABA , serotonin and noradrenline -provide the basis of drug management

Recognition and diagnosis –Follow a structured approach to make the diagnosis and management plan Ask about
○ personal history
○ self medication
○ cultural or other individual characteristic Check comorbidities 
○ common
○ try to identify the main problem
○ guidance suggests to draw a timeline to determine the priorities of the comorbidities

The emphasis here it appears is to address any underlying cause which may have precipitated the current presentation
 Guidance addresses management of panic attacks in A&E setup.

From GP perspective , points to note

○ patients should not be admitted
○ they should be referred to primary care for subsequent care

Psychological treatment –CBT By trained people and adhering to empirically grounded treatment protocols Usually weekly sessions of 1-2 hrs
Completed within 4 months Optimal is 7-14 hrs If CBT briefer eg 7 hrs
○ integrate with structured self help material
○ supplement with focused information and tasks More intense CBT over a shorter period of time may be appropriate in some situations

Assess progress Short self complete questionnaire could be used to monitor outcomes

Discuss and based on persons preference , offer psychological treatment , drug treatment or self help
 ( in descending order ) for the longest duration of effect

Drug treatment –First line is an SSRI licensed for panic disorder If SSRI cannot be used or no improvement after 12 week course and further medication is appropriate consider imipramine or clomipramine Discuss
○ potential SEs
○ discontinuation / withdrawal symptoms
○ delay in onset of effect
○ time course of treatment
○ compliance Provide written material Starting at a lower dose may minimise side effects Long term treatment and doses at upper end of the indicated range may be necessary

When prescribing –age previous treatment response risk of DSH or accidental OD
tricyclics more dangerous in OD than SSRIs tolerability interactions personal preferences the guidance states very clearly that ” benzodiazepines , sedating antihistamines or antipsyhcotics should not be prescribed for treatment of panic disorder “

Review within 2 weeks of starting treatment and at 4 ,6 and 12 weeks Review at 8-12 week intervals if drug used for > 12 weeks Short self complete questionnaire could be used to monitor outcomes

Self-help-Bibliotherapy based on CBT principle Support groups Exercise

Cochrane review 
concludes that the
 superiority of either 
therapy ( ie psychological versus pharmacological ) over the other is uncertain due to the low and very low quality
 of evidence and little data
 about adverse 
effects

Another Cochrane 
review urges the need of
 further high quality studies -
 to help clinicians choose between antidepressants
 and/or benzodiazepines 
for panic disorder in
 adults

Antidepressant discontinuation / withdrawal symptoms

Inform that anti-depressants are not associated with tolerance or craving but
○ stopping , missing doses , occasionally reducing dose can lead to discontinuation/ withdrawal symptoms
- usually mild and self limiting
- occasionally can be severe if drug stopped abruptly
○ commonly seen discontinuation / withdrawal symptoms are
 ◘ dizziness ◘ numbness and tingling ◘ GI – eg nausea and vomiting 
 ◘ headache ◘ sweating ◘ anxiety ◘ sleep disturbance
 Reduce the dose gradually over an extended period to minimise the risk of development of discontinuation / withdrawal symptoms Mild symptoms – reassured and monitor symptoms Severe discontinuation / withdrawal symptoms
○ consider reintroducing the antidepressant or 
○ prescribing another from the same class with longer 1/2 life and gradually reducing the dose while monitoring symptoms

References
 Psychological therapies versus pharmacological interventions for panic disorder with or without agoraphobia The Cochrane database of systematic reviews Imai H, Tajika A, Chen P, Pompoli A, Furukawa TA – Cochrane Database Syst Rev – October 12, 2016; 10 (); CD011170 (Abstract ) Antidepressants and benzodiazepines for panic disorder in adults. Bighelli I, Trespidi C, Castellazzi M, Cipriani A, Furukawa TA, Girlanda F, Guaiana G, Koesters M, Barbui C – Cochrane Database Syst Rev – September 12, 2016; 9 (); CD011567 (Abstract ) Patient UK- Authored by Dr Colin Tidy, Reviewed by Dr John Cox | Last edited 28 Dec 2016 Management of panic disorder in primary care Simon Davies et al Prescriber Jan 2017 Quick reference guide Generalised anxiety disorder and panic disorder ( with or without agoraphobia ) in adults NCG 113 January 2011


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