14.

PANIC ATTACKS A N D PANIC DISORDER

RoGert D. Davies, M.D
1. List the common symptoms that constitute a panic attack. A panic attack is defined as a discrete episode of intense discomfort or fear during which there
is a sudden onset of at least four of the following symptoms: palpitations dizziness or lightheadedness sweating paresthesias tremulousness chills or flushing a sense of smothering or shortness feelings of unreality (derealization) or being of breath detached from oneself (depersonalization) a sensation of choking a fear of losing control or of going crazy chest pain a fear of dying nausea or abdominal distress The development of these symptoms must reach a peak within 10 minutes.

2. What differentiates a panic attack from panic disorder?

A panic attack is not considered to be a psychiatric disorder in and of itself. Panic attacks may occur infrequently in some people without being part of any clinical syndrome-as much as 15% of the population report having had at least one panic attack in their lifetime. Panic attacks also occur in many psychiatric disorders other than panic disorder. Panic disorder is a distinct clinical disorder consisting of recurrent, unexpected panic attacks. People with panic disorder experience at least a month of worrying about having another panic attack or about the possible implications of such an attack (such as dying, crashing their car, being unable to function). Often it is the anxiety and worry between panic attacks (called anticipatory anxiety)that becomes the most disabling feature of the disorder. People with panic disorder often begin associating their attacks with certain situations (such as being a traffic or being in crowds) and may fuel future panic attacks by anticipating exposure to those situations. They may begin avoiding those situations that they believe are eliciting their attacks. In many cases of panic disorder, the attacks occur randomly, without any precipitant; in some, attacks occur during sleep (nocturnal panic attacks).

3. List other psychiatric disorders in which panic attacks might occur. Specific phobias Obsessive-compulsive disorder Social phobia Stimulant intoxication Major depression Substance withdrawal syndromes Post-traumatic stress disorder
4. Are there any medical conditions that might cause panic-like symptoms? Absolutely. Take that cup of coffee in your hand, for instance. Caffeine use, as well as the use of other psychostimulants (e.g., amphetamines, cocaine) can cause panic symptoms. Asthma (and other pulmonary diseases), angina, cardiac arrhythmias, hyperthyroidism, hyperparathyroidism, vestibular dysfunction, transient ischemic attacks, and seizure disorders all can cause panic-like symptoms. This may explain why only about 35% of patients seeking treatment for panic initially go to a mental health setting. In fact, many people with panic disorder seek out numerous medical evaluations (including repeated trips to the emergency department) before seeking psychiatric care. For this reason it is clear that a detailed medical history and focused medical work-up are important when evaluating panic attacks.
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5. How common is panic disorder?

Estimates from epidemiologic surveys show a 3.5% prevalence in the general population, with women being twice as likely as men to experience panic disorder (5% and 2%, respectively). Onset is typically before the age of 30 (often starting in adolescence), although the disorder may develop in some people later in life. In these late-onset cases, it is particularly important to look for medical causes. The course of panic disorder varies: approximately one-third of patients go into a stable remission; 45% have a more unremitting, chronic course of their symptoms; and the remaining 24% have an intermittent course, with remissions and relapses throughout their lifetime.

6. Do people with panic disorder ever have other psychiatric disorders as well?
Comorbidity in psychiatric illness is exceedingly common-it is estimated that 48% of people with a psychiatric disorder actually have more than one. Panic disorder is certainly no exception. Estimates of comorbidity in panic disorder range from 24% to as high as 91%. Clearly the most common comorbid diagnosis is depression, with as many as 50% of people with panic disorder experiencing depression at some point. The longer the history of panic disorder in an individual, the more likely depression is to develop. Proper diagnosis and treatment of panic disorder often are delayed, as people tend to seek out medical explanations of their symptoms. By the time they are appropriately diagnosed and treated, depression may already be present. The presence of anxiety or panic in depressed individuals inf panic creases the risk of suicide. For this reason, among others, early recognition and treatment o disorder is imperative. Substance abuse also is common, as people with panic attacks (as well as other anxiety disorders) try to self-medicate. Tolerance to the brief anxiolytic effect of alcohol leads them to gradually increase the amount of alcohol they consume as they attempt to regain the initial effect. As many as 15% of people who seek treatment for alcoholism also have an anxiety disorder. Other anxiety disorders, such as simple phobias, social phobia, or generalized anxiety disorder, can co-occur with panic disorder as well.

7. What is agoraphobia? Agoraphobia is the fear of being in a place or situation from which escape would be difficult or embarrassing, or where it might be difficult to get help should panic symptoms arise. The anxiety caused by this fear is so great that such situations are avoided or tolerated only with extreme distress. Agoraphobia may occur in panic disorder or it may occur in the absence of panic. People with agoraphobia tend to limit their activities (e.g., not go to stores or, in extreme cases, not leave their homes) or they may pursue such activities only when accompanied by someone with whom they feel safe (such as a spouse).

8. What causes panic disorder? Panic disorder rates are 3 to 6 times higher in the families of people with panic disorder than in
the general population. Studies have shown that children raised by mothers with panic disorder end up having higher rates of anxiety disorders than do children whose mothers do not have panic disorder. It is not clear whether this represents a genetic factor at play, a learned anxiety response, or a combination of the two. The biological basis of panic disorder is not fully understood. Serotonin is widely considered to be involved in the pathogenesis of panic. However, theories suggesting both serotonin excess as well as serotonin deficits have been proposed. It is known that several brain regions are involved in the production of panic symptoms. The serotonergic inputs to the periaqueductal gray matter may be involved in the mediation of an unconditioned fear response. It is hypothesized that a deficit of serotonin blunts this mediation, resulting in panic symptoms. The amygdala is believed to be involved in the development of a conditioned fear response that could equate to anticipatory anxiety and phobic avoidance. Increased levels of serotonin in this area may actually induce anxiety. The effectiveness of selective serotonin reuptake inhibitors (SSRIs) does not help clarify the precise role of serotonin in panic, as they may increase serotonin levels initially, through reuptake inhibition, as well as decrease serotonin later on, through down-regulation of postsynaptic receptors.

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9. What medications are beneficial in the treatment of panic disorder? Several classes of medications have been shown to be beneficial in the treatment of panic disorder. Benzodiazepineshave long been a mainstay of treatment, although womes about tolerance and abuse have made some clinicians leery about using them. Benzodiazepines with short onsets of action (such as alprazolam) are useful in quickly reducing the intensity of panic symptoms. Those with longer onsets of action and longer half-lives (such as clonazepam) may be beneficial in preventing future attacks-particularly when taken on a regular, scheduled dose. Monoamine oxidase inhibitors (MAOIs) (particularly phenelzine) and tricyclic antidepressants (TCAs; imipramine, clomipramine) decrease the frequency and the intensity of panic attacks. SSRIs (fluoxetine, sertraline, paroxetine) are efficacious as well. SSRIs have become the first-line treatment option for many clinicians because of the preferential side-effect profile when compared to either MAOIs or TCAs. Care must be taken, however, to start at very low doses to aid patients in tolerating these medications, as they may experience some initial agitation or anxiety which may trigger panic symptoms. This initial agitation and the delayed onset of the beneficial effect from the antidepressants point to short-term use of a benzodiazepine to offer some immediate relief of symptoms. Rapid symptoms relief can help decrease the formation of avoidance patterns.

10. Are there other treatments available for panic disorder? Medications alone are sometimes used to treat panic disorder. Relapse rates following discontinuation of medications may exceed 50%. Although medications are clearly beneficial in decreasing the frequency of attacks and the severity of symptoms, they are not particularly beneficial in decreasing anticipatory anxiety or the phobic avoidance that often develops. Cognitive behavioral therapy (CBT), used alone or in combination with medications, is particularly useful in treating these aspects of panic disorder-which often are the most disabling symptoms. CBT is usually a short-term (12-20 sessions) therapy that incorporates relaxation skills, such as diaphragmatic breathing and progressive muscle relaxation, with the examination of catastrophic and distorted thought processes. Patients are taught to challenge these thought processes, which helps to decrease their anticipatory anxiety. Then they gradually are exposed to the anxiety-producing situations that are linked to their panic attacks in an effort to extinguish their anxious response and decrease their phobic avoidance. CBT helps people successfully taper off medications like benzodiazepines without an immediate re-emergence of symptoms, thereby improving the overall outcome of treatment. When patients do have an eventual recurrence of symptoms, a brief refresher of the techniques of CBT often is useful in limiting the severity and length of the recurrence.
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