Panic: Diagnosis and Management

by Helen Farrell, MD

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    00:01 Let’s go through the diagnostic criteria for panic disorder in more detail.

    00:07 It’s an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.

    00:14 And during which time, four or more of the following symptoms are present.

    00:20 There are a lot of symptoms here.

    00:21 So a patient has to have four or more.

    00:23 Palpitations, shortness of breath, sweating, feeling that they’re being choked, trembling or shaking, chest pain, fear of going crazy, nausea, feeling dizzy or lightheaded, chills, a feeling of derealization or paresthesias, numbness or tingling.

    00:47 These symptoms are recurrent and unexpected.

    00:52 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.

    01:14 Other medical conditions that need to be ruled out t include hyperthyroidism and cardiopulmonary disease.

    01:21 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.

    01:34 So what is the differential diagnosis 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.

    01:48 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.

    02:02 You’ll consider a specific phobia for example.

    02:05 You’ll consider substance abuse and of course, general medical conditions.

    02:10 Because this is so important, you want to screen and rule out all of the following conditions.

    02:17 Angina, arrhythmias, cardiopulmonary disease, temporal lobe epilepsy and embolus, asthma, hyperthyroidism, pheochromocytoma, and also medication side effects, which can actually mimic panic disorder, things like hypoglycemia from taking too much insulin, using aminophylline or theophylline.

    02:40 So medicines that are often used for asthma will actually incite panic.

    02:45 So it’s really important to rule out all of these general medical conditions before diagnosing panic disorder.

    02:52 And the point is with general medical conditions, when you rule them out, you can actually treat them.

    02:58 So if you do find somebody has a general medical condition, you can treat it appropriately.

    03:04 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.

    03:18 Some medications used in the treatment of panic disorder are as follows.

    03:23 This is a very broad list, but it gives you some ideas of different treatment options.

    03:28 So SSRIs.

    03:29 Several examples of SSRIs are listed here for you to see.

    03:33 And some facts about the SSRIs, which are of course selective serotonin reuptake inhibitors, are that they’re very efficacious compared to placebo.

    03:42 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.

    03:50 Keep the range low for about a month because it can take that amount of time for medications to start to work.

    03:57 And then you can consider increasing the medicine if there’s no clinical response.

    04:02 Some of the most common side effects of the SSRI medications include headache, irritability, stomach discomfort, insomnia , and sexual dysfunction.

    04:15 Other medications include SNRIs, medicines that increase both serotonin and noradrenaline.

    04:21 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.

    04:38 The side effects are broad, but a few are noted here, nausea, dry mouth, constipation, anorexia, sweating, somnolence, sexual dysfunction, and hypertension.

    04:51 And then there are the benzodiazepines.

    04:53 Now, these work very quickly, but we also want to be cautious with them because of the high potential for abuse.

    05:01 And here’s some examples, alprazolam, lorazepam, and clonazepam.

    05:08 And some facts about these medicines are that they also can reduce the components of a panic attack, the three core components of it, frequency, anticipatory anxiety and phobic avoidance.

    05:19 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.

    05:33 They also can cause withdrawal if a patient is using them frequently and then abruptly stops.

    05:39 There’s sedation, fatigue, and psychomotor impairment and reduced concentration and cognitive difficulties when taking a benzodiazepine.

    05:48 Drowsiness is also a core component and side effect and people are advised not operate cars, vehicles or machinery when taking these medicines.

    05:58 Tricyclic antidepressants are sometimes used as well.

    06:01 A few examples are listed here and note that these also superior to placebo in treating panic attacks.

    06:08 But before initiating treatment with TCAs, it’s very important to do a baseline EKG to check for cardiac function.

    06:17 These medications can actually cause arrhythmia and can potentially lead to death and overdose.

    06:23 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.

    06:31 Some side effects include anticholinergic effects, sweating, sleep disturbance, hypotension, fatigue and weakness, weight gain, changes to blood pressure and also sexual dysfunction.

    06:44 The MAOIs are another class of atypical antidepressants that can sometimes be useful in the treatment of panic attack.

    06:52 They are efficacious, however, rarely used in practice because there are so many dietary restrictions placed on them.

    07:01 The reason for the dietary restriction is that you want to have low tyramine diet or else the patient can develop a hypertensive crisis.

    07:11 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.

    07:26 So MAOI side effects are pretty significant, so again they’re rarely used for this, but just important to know about for your exam.

    07:34 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.

    07:51 The wrong kinds of foods being things like cheese, red wine, and cured meats.

    07:56 So a lot of good stuff that people want to have.

    07:58 So again, MAOIs are rarely used for panic disorder.

    About the Lecture

    The lecture Panic: Diagnosis and Management by Helen Farrell, MD is from the course Anxiety and Stress-Related Disorders. It contains the following chapters:

    • How to Diagnose Panic Disorder?
    • SSRIs
    • SNRIs
    • Benzos

    Included Quiz Questions

    1. Projectile vomiting
    2. Paresthesias
    3. Sweating
    4. Chest pain
    5. Lightheadedness
    1. Benzodiazepine abuse
    2. Anxiety disorder
    3. Somatic symptom disorder
    4. Pheochromocytoma
    5. Hyperthyroidism
    1. Paroxetine
    2. Ondansetron
    3. Esomeprazole
    4. Cinnarizine
    5. Terbutaline
    1. Attack frequency, anticipatory anxiety, and phobic avoidance
    2. Sweating, palpitations, and chest pain
    3. Recurrence, irritability, and phobias
    4. Nausea, derealization, and chills
    5. Shortness of breath, paresthesias, and lightheadedness
    1. ECG
    2. Thyroid profile
    3. Liver function tests
    4. Serum creatinine
    5. Urine drug screen
    1. Driving
    2. Smoking
    3. Consuming tyramine rich foods
    4. Deep-sea diving
    5. Ranitidine

    Author of lecture Panic: Diagnosis and Management

     Helen Farrell, MD

    Helen Farrell, MD

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