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.If the patient has panic disorder, she shouldbe treated with a combination of a selective serotonin reuptake inhibitor(SSRI) and a course of cognitive-behavioral therapy; a short-acting benzodi-azepine (alprazolam) can be added for immediate control of her symptoms.Theuse of benzodiazepine should be discontinued after the first several weeks.Ifthe patient has an anxiety disorder because of a substance (thyroid medication),the dose should be decreased, and the panic symptoms should remit.APPROACH TOPanic DisorderDEFINITIONSAGORAPHOBIA: Anxiety about being in places or situations from whichescape might be difficult (or embarrassing) or in which help cannot be avail-able in the event of experiencing a panic attack.These situations includebeing outside the home alone, being in a crowd, being on a bridge, or travel-ing on a bus, train, or automobile.PANIC ATTACK: A period of intense fear lasting for a discrete period of time,associated with at least four of the symptoms listed in Table 3 1.The criteriafor panic disorder are denoted in Table 3 2.Table 3 1 DEFINITION OF PANIC ATTACKPanic attack consists of discrete episodes of at least four of the following:" Palpitations" Sweating" Trembling" Shortness of breath" Feeling of choking" Chest pain" Nausea" Dizziness" Derealization or depersonalization" Fear of losing control or going crazy" Fear of dying" Numbness or tingling" Chills or hot flashes 66 CASE FILES: PsychiatryTable 3 2 CRITERIA FOR PANIC DISORDERRecurrent, unexpected panic attacks.Attacks followed by 1 mo of one of the following: concerns about having additionalattacks, worry about the consequences of attacks, or a change in behavior as a result ofattacks.Attacks are not caused by substance abuse, medication, or a general medical condition.Attacks are not better accounted for by another mental illness.Can occur with or without agoraphobia.CLINICAL APPROACHThe Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)requires that at least one panic attack be followed by concern about anotherattack, fear of the implications of the attack, or a change in behaviorrelated to the attack.The DSM-IV has established two diagnostic criteria forthis disorder: panic disorder with agoraphobia (anxiety about being in placesor situations from which escape would be difficult) and without agoraphobia.It is theorized that agoraphobia stems from the fear of having a panic attackin a place from which escape would prove difficult.Typically, the first panic attack an individual experiences is spontaneous;however, it can also follow excitement, exertion, or an emotional event.Theattack begins within a 10-minute period of rapidly intensifying symptoms(extreme fear or a sense of impending doom) and can last up to 20 to 30 minutes.Patients with agoraphobia avoid being in situations where obtaining helpfrom friends or loved ones would be difficult.These individuals typically needto be accompanied when traveling or when in enclosed areas (tunnels, eleva-tors).Severely affected individuals do not even leave their own homes.In the general population, the lifetime prevalence rate of panic disorderranges from 1.5% to 5%.The mean age of presentation is 25 years of age, withwomen being two or three times more likely to be affected than men.Approximately one-third of patients with panic disorder also have agoraphobia.DIFFERENTIAL DIAGNOSISAt the top of the differential diagnosis list for panic disorder are the numerousmedical conditions that can cause panic attacks.Table 3 3 lists some of them.Intoxication caused by amphetamines, cocaine, or hallucinogens and by with-drawal from alcohol or other sedative-hypnotic agents can mimic panic disor-der.Medications such as steroids, anticholinergics, and theophylline are alsowell known to produce anxiety.Underlying endocrine disorders should alsobe considered.In cases of difficult-to-manage hypertension accompanied by CLINICAL CASES 67Table 3 3 MEDICAL CONDITIONS CAUSING PANIC ATTACKSCardiac" Angina" Arrhythmias" Congestive heart failure" Infarction" Mitral valve prolapseEndocrinologic" Cushing disease" Addison disease" Hyperthyroidism" Hypoglycemia" Hypoparathyroidism" Premenstrual dysphoric disorderNeoplastic" Carcinoid" Insulinoma" PheochromocytomaNeurologic" Seizure disorder" Vertigo" Huntington disease" Migraine" Multiple sclerosis" Transient ischemic attacks" Wilson diseasePulmonary diseases" Asthma" Obstructive pulmonary disease" Hyperventilation" Pulmonary embolusOther diseases" Anaphylaxis" Porphyriaphysical symptoms such as racing heart, sweating, nervousness, headache, mus-cle tension, chest pain, and abdominal distress, pheochromocytoma should besuspected.Tachycardia, heat intolerance, weight loss, and anxiety are featuresof hyperthyroidism which may be mistaken for an anxiety disorder.Obtaining athorough history (including details of alcohol and substance use), performing a 68 CASE FILES: Psychiatryphysical examination, and ordering appropriate lab studies (ie, TSH, plasmametanephrine) can usually clarify the issue.Except for the elevated blood pres-sure and pulse rate found in anxious states, no abnormalities are seen on exam-ination.Any significant abnormal findings discovered should prompt a furtherworkup for a nonpsychiatric cause.Treating the underlying conditions, adjust-ing medications, and/or initiating a detoxification process are also likely toresolve the anxiety symptoms.Distinguishing panic disorder from other anxiety disorders can often beconfusing.Panic attacks can be seen in many other anxiety states, as well asin depression.In fact, major depressive disorder has a high rate of comorbid-ity with panic disorder.The hallmark of panic disorder is unexpected panicattacks not provoked by any particular stimulus.This condition is distinctfrom other anxiety disorders, where panic attacks are the result of exposure toa certain cue.For example, a car backfiring might provoke a panic attack in apatient with posttraumatic stress disorder, or being near a dog might provokea panic attack in someone with a specific phobia to dogs.The other impor-tant aspect to remember is that in panic disorder, the fear is actually of havingan attack, not of a specific situation (contamination in the case of obsessive-compulsive disorder or performance in the case of social phobia) or of a num-ber of activities (as in generalized anxiety disorder).TREATMENTAntidepressants such as SSRIs, tricyclic antidepressants, and monoamineoxidase inhibitors are highly effective in treating panic disorder.Bestresults are obtained when medication is used in combination with a courseof cognitive behavioral therapy (CBT).As in depression, a significant ther-apeutic effect may not be seen for several weeks.Treatment with a benzodi-azepine may be needed on a short-term basis to provide more immediaterelief [ Pobierz całość w formacie PDF ]
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.If the patient has panic disorder, she shouldbe treated with a combination of a selective serotonin reuptake inhibitor(SSRI) and a course of cognitive-behavioral therapy; a short-acting benzodi-azepine (alprazolam) can be added for immediate control of her symptoms.Theuse of benzodiazepine should be discontinued after the first several weeks.Ifthe patient has an anxiety disorder because of a substance (thyroid medication),the dose should be decreased, and the panic symptoms should remit.APPROACH TOPanic DisorderDEFINITIONSAGORAPHOBIA: Anxiety about being in places or situations from whichescape might be difficult (or embarrassing) or in which help cannot be avail-able in the event of experiencing a panic attack.These situations includebeing outside the home alone, being in a crowd, being on a bridge, or travel-ing on a bus, train, or automobile.PANIC ATTACK: A period of intense fear lasting for a discrete period of time,associated with at least four of the symptoms listed in Table 3 1.The criteriafor panic disorder are denoted in Table 3 2.Table 3 1 DEFINITION OF PANIC ATTACKPanic attack consists of discrete episodes of at least four of the following:" Palpitations" Sweating" Trembling" Shortness of breath" Feeling of choking" Chest pain" Nausea" Dizziness" Derealization or depersonalization" Fear of losing control or going crazy" Fear of dying" Numbness or tingling" Chills or hot flashes 66 CASE FILES: PsychiatryTable 3 2 CRITERIA FOR PANIC DISORDERRecurrent, unexpected panic attacks.Attacks followed by 1 mo of one of the following: concerns about having additionalattacks, worry about the consequences of attacks, or a change in behavior as a result ofattacks.Attacks are not caused by substance abuse, medication, or a general medical condition.Attacks are not better accounted for by another mental illness.Can occur with or without agoraphobia.CLINICAL APPROACHThe Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)requires that at least one panic attack be followed by concern about anotherattack, fear of the implications of the attack, or a change in behaviorrelated to the attack.The DSM-IV has established two diagnostic criteria forthis disorder: panic disorder with agoraphobia (anxiety about being in placesor situations from which escape would be difficult) and without agoraphobia.It is theorized that agoraphobia stems from the fear of having a panic attackin a place from which escape would prove difficult.Typically, the first panic attack an individual experiences is spontaneous;however, it can also follow excitement, exertion, or an emotional event.Theattack begins within a 10-minute period of rapidly intensifying symptoms(extreme fear or a sense of impending doom) and can last up to 20 to 30 minutes.Patients with agoraphobia avoid being in situations where obtaining helpfrom friends or loved ones would be difficult.These individuals typically needto be accompanied when traveling or when in enclosed areas (tunnels, eleva-tors).Severely affected individuals do not even leave their own homes.In the general population, the lifetime prevalence rate of panic disorderranges from 1.5% to 5%.The mean age of presentation is 25 years of age, withwomen being two or three times more likely to be affected than men.Approximately one-third of patients with panic disorder also have agoraphobia.DIFFERENTIAL DIAGNOSISAt the top of the differential diagnosis list for panic disorder are the numerousmedical conditions that can cause panic attacks.Table 3 3 lists some of them.Intoxication caused by amphetamines, cocaine, or hallucinogens and by with-drawal from alcohol or other sedative-hypnotic agents can mimic panic disor-der.Medications such as steroids, anticholinergics, and theophylline are alsowell known to produce anxiety.Underlying endocrine disorders should alsobe considered.In cases of difficult-to-manage hypertension accompanied by CLINICAL CASES 67Table 3 3 MEDICAL CONDITIONS CAUSING PANIC ATTACKSCardiac" Angina" Arrhythmias" Congestive heart failure" Infarction" Mitral valve prolapseEndocrinologic" Cushing disease" Addison disease" Hyperthyroidism" Hypoglycemia" Hypoparathyroidism" Premenstrual dysphoric disorderNeoplastic" Carcinoid" Insulinoma" PheochromocytomaNeurologic" Seizure disorder" Vertigo" Huntington disease" Migraine" Multiple sclerosis" Transient ischemic attacks" Wilson diseasePulmonary diseases" Asthma" Obstructive pulmonary disease" Hyperventilation" Pulmonary embolusOther diseases" Anaphylaxis" Porphyriaphysical symptoms such as racing heart, sweating, nervousness, headache, mus-cle tension, chest pain, and abdominal distress, pheochromocytoma should besuspected.Tachycardia, heat intolerance, weight loss, and anxiety are featuresof hyperthyroidism which may be mistaken for an anxiety disorder.Obtaining athorough history (including details of alcohol and substance use), performing a 68 CASE FILES: Psychiatryphysical examination, and ordering appropriate lab studies (ie, TSH, plasmametanephrine) can usually clarify the issue.Except for the elevated blood pres-sure and pulse rate found in anxious states, no abnormalities are seen on exam-ination.Any significant abnormal findings discovered should prompt a furtherworkup for a nonpsychiatric cause.Treating the underlying conditions, adjust-ing medications, and/or initiating a detoxification process are also likely toresolve the anxiety symptoms.Distinguishing panic disorder from other anxiety disorders can often beconfusing.Panic attacks can be seen in many other anxiety states, as well asin depression.In fact, major depressive disorder has a high rate of comorbid-ity with panic disorder.The hallmark of panic disorder is unexpected panicattacks not provoked by any particular stimulus.This condition is distinctfrom other anxiety disorders, where panic attacks are the result of exposure toa certain cue.For example, a car backfiring might provoke a panic attack in apatient with posttraumatic stress disorder, or being near a dog might provokea panic attack in someone with a specific phobia to dogs.The other impor-tant aspect to remember is that in panic disorder, the fear is actually of havingan attack, not of a specific situation (contamination in the case of obsessive-compulsive disorder or performance in the case of social phobia) or of a num-ber of activities (as in generalized anxiety disorder).TREATMENTAntidepressants such as SSRIs, tricyclic antidepressants, and monoamineoxidase inhibitors are highly effective in treating panic disorder.Bestresults are obtained when medication is used in combination with a courseof cognitive behavioral therapy (CBT).As in depression, a significant ther-apeutic effect may not be seen for several weeks.Treatment with a benzodi-azepine may be needed on a short-term basis to provide more immediaterelief [ Pobierz całość w formacie PDF ]