Dr. Dunlop: State-of-the-art treatment for panic disorder
Ms. K, a 24-year-old waitress who lives with her boyfriend, was referred by her primary care physician for evaluation of panic attacks that began “out of nowhere” at work approximately 6 months ago. The unpredictable attacks occur multiple times per week, causing her to leave work and cancel shifts.
Ms. K reports that before the panic attacks began, she felt happy in her relationship, enjoyed hobbies, and was hopeful about the future. However, she has become concerned that a potentially catastrophic illness is causing her panic attacks. She researches her symptoms on the Internet, and is preoccupied with the possibility of sudden death due to an undiagnosed heart condition. Multiple visits to the emergency room have not identified any physical abnormalities. Her primary care doctor prescribed alprazolam, 0.5 mg as needed for panic attacks, which she reports is helpful, “but only in the moment of the attacks.” Ms. K avoids alcohol and illicit substances and limits her caffeine intake. She is not willing to accept that her life “feels so limited.” Her dream of earning a nursing degree and eventually starting a family now seems unattainable.
Panic disorder (PD) occurs in 3% to 5% of adults, with women affected at roughly twice the rate of men.1 Causing a broad range of distress and varying degrees of impairment, PD commonly occurs with other psychiatric disorders. For most patients, treatment is effective, but those who do not respond to initial approaches require a thoughtful, stepped approach to care. Key considerations include establishing an accurate diagnosis, clarifying comorbid illnesses, ascertaining patient beliefs and expectations, and providing appropriately dosed and maintained treatments.
Panic attacks vs PD
Panic attacks consist of rapid onset of intense anxiety, with prominent somatic symptoms, that peaks within 10 minutes (Figure).2 Attacks in which <4 of the listed symptoms occur are considered limited-symptom panic attacks.
Figure: Body locations of panic attack symptoms
Diagnosis of a panic attack requires the sudden development of intense fear or discomfort characterized by ≥4 of the 13 symptoms listed above that peaks in intensity within 10 minutes of onset
Source: Reference 2
Panic attacks can occur with various disorders, including other anxiety disorders, mood disorders, and substance intoxication or withdrawal. Because serious medical conditions can present with panic-like symptoms, the initial occurrence of such symptoms warrants consideration of physiological causes. For a Box2 that describes the differential diagnosis of panic attacks, see this article at CurrentPsychiatry.com.
Differential diagnosis of panic attacks
To meet diagnostic criteria for panic disorder, panic attacks must initially occur “out of the blue,” meaning no specific object or situation induced the attack. The differential diagnosis of panic attacks includes assessing for other psychiatric disorders that may involve panic attacks. Evaluation requires considering the context in which the panic attacks occur, including their start date, pattern of attacks, instigating situations, and associated thoughts.
Social phobia. Attacks occur only during or immediately before a social interaction in which the patient fears embarrassing himself or herself.
Obsessive-compulsive disorder (OCD). Attacks occur when the patient cannot avoid exposure to an obsessional fear or is prevented from performing a ritual that diffuses obsessional anxiety.
Posttraumatic stress disorder (PTSD). Attacks occur when confronted by a trauma-related memory or trigger.
Specific phobia. Attacks occur only when the patient encounters a specifically feared object, place, or situation, unrelated to social phobia, OCD, or PTSD.
Medical conditions. Conditions to consider include—but are not limited to—hyperthyroidism, pulmonary embolism, myocardial infarction, cardiac dysrhythmias, hypoglycemia, asthma, partial complex seizures, and pheochromocytoma.
Source: Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000
A PD diagnosis requires that repeated panic attacks initially must occur from “out of the blue,” meaning no specific object or situation induced the attack. In addition, the diagnosis requires 1 of 3 types of psychological or behavioral changes as a result of the attacks (Table 1).2 Agoraphobia is diagnosed if 1 of the behavioral changes is avoidance of places or situations from which escape might be embarrassing or difficult should an attack occur. A patient can be diagnosed as having PD with agoraphobia, PD without agoraphobia, or agoraphobia without PD (ie, experiences only limited symptom panic attacks, but avoids situations or stimuli associated with them).
Table 1
Definitions of panic disorder and agoraphobia
| Panic disorder |
|---|
|
| Agoraphobia |
| Anxiety about, or avoidance of, being in places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone, being in a crowd, standing in a line, being on a bridge, or traveling in a bus, train, or automobile |
| Source: Reference 2 |