Let’s go through the diagnostic criteria
for panic disorder in more detail.
It’s an abrupt surge of intense
fear or intense discomfort
that reaches a peak within minutes.
And during which time, four or more of
the following symptoms are present.
There are a lot of symptoms here.
So a patient has to have four or more.
of breath, sweating,
feeling that they’re being choked,
trembling or shaking, chest pain,
fear of going crazy, nausea,
feeling dizzy or
a feeling of derealization or
paresthesias, numbness or tingling.
These symptoms are
recurrent and unexpected.
So patients having
continuous panic attacks
and at least one attack is
followed by one or more months of
persistent fear or worry about
additional panic attacks,
like a fear of losing
control or going crazy,
or maladaptive changes to behavior and
response to panic, such as avoidance.
Other medical conditions
that need to be ruled out
t include hyperthyroidism and
Remember before diagnosing
any psychiatric condition,
you must first rule out
general medical conditions
and also, you have to rule out
that there is any substance use
that could be causing the panic.
So what is the
when a patient comes in to your office
and says, ”Doctor, I’m having panic.”
Well, what’s going to
go through your mind?
Before diagnosing panic disorder, you
have to consider all of these things.
So you’re going to think of maybe
a somatic symptom disorder
because that patient may not
say, “Doctor, I’m having panic.”
They may say, “I’m having chest pain and
heart palpitations, and I’m sweating a lot.”
You’re also going to consider
all of the anxiety disorders.
You’ll consider a specific
phobia for example.
You’ll consider substance abuse and of
course, general medical conditions.
Because this is so important,
you want to screen
and rule out all of the
epilepsy and embolus,
and also medication side effects, which
can actually mimic panic disorder,
things like hypoglycemia from
taking too much insulin,
So medicines that are often used for
asthma will actually incite panic.
So it’s really important to rule out
all of these general medical conditions
before diagnosing panic disorder.
And the point is with
general medical conditions,
when you rule them out, you
can actually treat them.
So if you do find somebody has
a general medical condition,
you can treat it appropriately.
And if simple nonrecurrent panic
attacks with common causes,
like a stressful exam situation
are not just resolving,
you really do want to go through
that differential list.
Some medications used in the treatment
of panic disorder are as follows.
This is a very broad list, but it gives you
some ideas of different treatment options.
Several examples of SSRIs are
listed here for you to see.
And some facts about the SSRIs,
which are of course selective
serotonin reuptake inhibitors,
are that they’re very efficacious
compared to placebo.
And we can actually dose
them at very low doses
and you want to do that because you don’t
want to overstimulate your patient.
Keep the range low
for about a month
because it can take that amount of
time for medications to start to work.
And then you can consider increasing the
medicine if there’s no clinical response.
Some of the most common side effects of
the SSRI medications include headache,
irritability, stomach discomfort,
insomnia , and sexual dysfunction.
Other medications include SNRIs,
medicines that increase both
serotonin and noradrenaline.
There are a couple of examples listed
here and some facts about the SNRIs
include that they can actually reduce
the core components of panic disorder,
which include attack frequency,
anticipatory anxiety, and phobic avoidance.
The side effects are broad,
but a few are noted here,
nausea, dry mouth, constipation,
somnolence, sexual dysfunction,
And then there are the benzodiazepines.
Now, these work very quickly,
but we also want to be cautious with them
because of the high potential for abuse.
And here’s some examples, alprazolam,
lorazepam, and clonazepam.
And some facts about these medicines
are that they also can reduce
the components of a panic attack,
the three core components of it,
anxiety and phobic avoidance.
Alprazolam and clonazepam are FDA approved
for the treatment of panic disorder
and the side effects are very
notable for potential addiction,
so you want to use these short
term and with caution in patients.
They also can cause withdrawal
if a patient is using them
frequently and then abruptly stops.
There’s sedation, fatigue,
and psychomotor impairment
and reduced concentration
and cognitive difficulties
when taking a benzodiazepine.
Drowsiness is also a core
component and side effect
and people are advised not operate
cars, vehicles or machinery
when taking these medicines.
are sometimes used as well.
A few examples are listed here
and note that these also superior to
placebo in treating panic attacks.
But before initiating treatment with TCAs,
it’s very important to do a baseline
EKG to check for cardiac function.
These medications can
actually cause arrhythmia
and can potentially lead
to death and overdose.
So it’s very important to
screen for suicidality as well
and never give these
medications to somebody
who is at risk for self-harming.
Some side effects include
anticholinergic effects, sweating,
sleep disturbance, hypotension,
fatigue and weakness,
weight gain, changes to blood
pressure and also sexual dysfunction.
The MAOIs are another class
of atypical antidepressants
that can sometimes be useful in
the treatment of panic attack.
They are efficacious, however,
rarely used in practice
because there are so many dietary
restrictions placed on them.
The reason for the dietary
restriction is that
you want to have low tyramine diet
or else the patient can develop
a hypertensive crisis.
So the duration of treatment for an MAOI is
really going to vary for panic disorder,
but usually you’d want to continue
whatever is working for the patient
for about a year until their
symptoms are controlled.
So MAOI side effects are
so again they’re rarely used for this,
but just important to know
about for your exam.
They can cause dizziness, headaches,
sedation, fatigue, tremor,
blurred vision, sweating,
constipation, and sexual dysfunction
and a huge note is that they
can cause that tyramine crisis
or hypertensive crisis in a patient
who’s eating the wrong kinds of foods.
The wrong kinds of foods being things
like cheese, red wine, and cured meats.
So a lot of good stuff
that people want to have.
So again, MAOIs are rarely
used for panic disorder.