Kembara Xtra - Medicine - Panic Disorder

Kembara Xtra - Medicine - Panic Disorder
A typical panic attack is characterized by a sudden onset of extreme terror and a brief period of sympathetic nervous system hyperarousal.
Multiple panic attacks (including at least two without a discernible trigger) take place as a result of panic disorder. Patients worry about future attacks and/or unhelpful (such as avoidance) behaviors for at least one month.


Incidence
24 years is the median age at onset. After 60 years, the prevalence drastically declines.
 Female is more prevalent than male (2:1)

Prevalence
4.7% of people in their lifetime.
25% of patients who report to the emergency room with chest pain have panic disorder, and chest pain is more likely to be caused by panic if it is unusual, the patient is younger, female, and has a history of anxiety issues.

the pathology and etiology 

Patients fight off the initial adrenaline rush, which worsens their symptoms; in other words, they become nervous about feeling anxious.
Genetics There are a few genes linked to panic disorder, and it is more common in family members, but no one gene pattern is entirely understood to account for the syndrome.

Risk Factors Stressors in daily life of any form might cause attacks.
Addiction to drugs or alcohol, smoking, bipolar disorder, significant depression, obsessive-compulsive disorder (OCD), and a basic phobia are all indicators of past sexual or physical abuse.

Prevention 

A healthy lifestyle that incorporates mindfulness and stress-reduction methods is beneficial.

Accompanying Conditions 
More prevalent in patients with asthma, migraine headaches, hypertension, mitral valve prolapse, reflux esophagitis, interstitial cystitis, irritable bowel syndrome, fibromyalgia, and nicotine dependence. Other psychiatric diagnoses include PTSD, social phobia, simple phobia, major depression, bipolar disorder, substance abuse, OCD, and separation anxiety disorder.


The diagnosis of a panic attack is when four or more of the following symptoms suddenly appear, followed by an abrupt rush of extreme dread that peaks within minutes: (i) palpitations, a fast heartbeat, or palpitations; (ii) sweating; (iii) trembling or shaking; (iv) a feeling of being choked; (v) chest pain or discomfort; (vi); (vii) nausea or discomfort in the abdomen; (viii) feeling faint, woozy, unstable, or light-headed; (ix) depersonalization (feeling distant from oneself) or derealization (feeling detached from reality); (x) the fear of going crazy or losing control; (xi) the fear of passing away; paresthesias (xii); Chills or hot flashes (xiii)
 Panic disorder: Recurrent, unexpected panic attacks that are not better explained by another mental health condition (such as PTSD, OCD, separation anxiety disorder, social anxiety disorder, or specific phobia), are not brought on by drugs of abuse, physical ailments, or medications prescribed by a doctor, and have at least one of the following symptoms for more than a month: (i) anxiety about future attacks or anxiety about the effects of the attack (such as losing control, having a heart attack, or "going crazy"); (ii) a severe maladaptive change in behavior as a result of the attacks.

Get a thorough background by asking thoughtful, nonjudgmental questions. The patient's anxieties and fears, physical and emotional symptoms, current life stressors, separations, recent deaths, and interpersonal issues should all be elicited.
It's crucial to have a complete medical and substance usage history.
Review the DSM-5 diagnostic standards. Inquire about any patterns of avoidance that have emerged since the commencement of panic attacks.

Visual Inspection 
Tactical symptoms of an attack include tachycardia, hyperventilation, and diaphoresis.
Checking the thyroid for nodules or fullness. Look out for lid lag or exophthalmos.
 Cardiac examination for arrhythmias or murmurs
 Lung examination to rule out asthma (wheezing, restricted airflow)

Differential Diagnosis: The usage of medications can mimic panic attacks and exacerbate anxiety: Antidepressants, short-acting benzodiazepines (alprazolam), -blockers, and short-acting opioids can all cause interdose rebound anxiety. Benzodiazepine treatment causes panic when patients take too much and run out of these medications too soon. Bupropion, levodopa, amphetamines, steroids, albuterol, sympathomimetics, fluoroquinolones, and sympathomimetic drugs can also cause panic
 Alcohol withdrawal, benzodiazepine withdrawal, opioid withdrawal, caffeine withdrawal, amphetamine abuse, MDMA abuse, hallucinogen abuse (PCP, LSD), dextromethorphan abuse, and misuse of synthetic cathinones (bath salts), among others.
The following medical conditions are listed in alphabetical order: cardiovascular (tachyarrhythmias, myocardial infarction, mitral valve prolapse), pulmonary (asthma, COPD, hypoxia, pulmonary embolism), endocrine (hypo-/hyperthyroidism, premenstrual dysphoric disorder, menopause, pregnancy, hypoglycemia [in diabetes], carcinoid syndrome, pheochromocytoma, Note that it is uncommon for someone to experience their first panic attack after turning 40, making it even more crucial to rule out other medical issues in those patients.
● Mood, anxiety, and personality disorders include major depression, bipolar disorder, PTSD, borderline personality disorder, social phobia, OCD, and generalized anxiety disorder are among the psychiatric illnesses with overlapping symptomatology. In PTSD, the panic episode is always preceded by a memory or visual image. In social phobia, the panic attack is preceded by a dread of being observed. When a patient has bipolar disorder, significant depression, borderline personality disorder, or substance abuse in particular, they frequently complain initially of anxiety and panic attacks and downplay other potentially important symptoms and behaviors.

Laboratory Results 
Other than to rule out illnesses in the differential diagnosis, no specific lab testing are recommended.
If chest discomfort exists, get the necessary testing.
Consider Holter monitoring, stress testing, and/or chest CT in some individuals; electrocardiogram and pulse oximetry.
A diabetic patient's fingerstick blood sugar in an emergency situation
 Complete metabolic panel, CBC, and thyroid-stimulating hormone (TSH)
If you have nighttime panic episodes, you should think about doing a sleep study to check for sleep apnea.

Other/Diagnostic Procedures
Do the required workup if a medical problem is strongly suspected to be causing the anxiety.
The Panic Disorder Severity Scale (PDSS) is a medical or self-administered tool for tracking changes in symptom severity and therapy response.


Management 

When treating panic disorder in its first stages, combined antidepressant therapy and psychotherapy is preferable to either one used alone. Cognitive behavioral therapy (CBT), mindfulness-based therapy (MBT), and exposure therapy are the most successful forms of therapy. Long-lasting treatment is provided via psychotherapy, frequently without the need for additional medication.

General Actions 
Patient education is an essential component of care. A helpful abbreviation is HR BET (you would have bet on Babe Ruth to hit a home run, or your "HR BET").
Explain to patients the cause of their symptoms to prevent harm. For instance, hyperventilation may alter the blood's acid/base balance, resulting in lightheadedness, tingling in the extremities, and strange out-of-body sensations.
Explain how resistance might prolong the panic and exacerbate it. When one is anxious, one becomes anxious.
Teach deliberate diaphragmatic breathing.
Discuss how adrenaline can cause feelings of excitement or worry. Consider it an energy burst instead of a panic attack, and ask them whether they can feel the energy pulsing through their veins.
Develop the ability to observe thoughts without necessarily believing them all. It is possible to teach people how to refute irrational thoughts and beliefs (for instance, how to refute the statement "I'm dying now" with the statement "I've had many of these attacks before; they have been thoroughly evaluated by my doctor and are not harmful; if I don't resist them and just do my diaphragmatic breathing, they resolve more quickly").

In the event that psychotherapy is unsuccessful, medication management may be suggested. Psychotherapy may also be combined with medication management.
Tricyclic antidepressants (TCA), monoamine oxidase inhibitors (MAOI), benzodiazepines, and selective serotonin reuptake inhibitors (SSRI) have all demonstrated effectiveness in treating panic disorder.
To lower the chance of relapse, it is advised that drugs be used for at least a year after symptom control.

Initial Line

Due to their effectiveness, low risk of misuse, and benign side effect profile, SSRIs and SNRIs are used as first-line treatments.
● Start taking a low-dose SSRI once a day in the morning, such as fluoxetine 5 mg, paroxetine 10 mg, sertraline 25 mg, citalopram 10 mg, or escitalopram 5 mg. (This can be altered to a nighttime dose if sedation develops.) Over the course of six weeks, titrate up gradually every one to two weeks to therapeutic dosages. If necessary, additional dose increases typically occur no more frequently than once per month. Anger, diarrhea, and sexual dysfunction are among the side effects, with hyponatremia, GI bleeding, manic episodes (if the patient has bipolar disorder), increased LFTs, QT prolongation (more frequently with citalopram), and serotonin syndrome occurring less frequently. Inform those beginning escitalopram that nausea occurs frequently but typically goes away after one week of therapy. Young patients may exhibit suicidal tendencies. Due to the possibility of withdrawal syndrome, SSRIs should be tapered off gradually over a few months. Comparatively speaking, this is more significant for drugs like paroxetine that have a shorter half-life than drugs like fluoxetine.
Venlafaxine extended release (ER) is a potent SNRI. After seven days, titrate up to 75 mg/day (a maximum dose of 225 mg/day), starting at 37.5 mg/day.
At greater doses, there is a danger of hypertension, therefore taper gradually over many weeks to stop. Other side effects are comparable to those of SSRIs. You can also try SNRIs like desvenlafaxine or duloxetine.

Next Line
The recommended starting dose of mirtazapine is 15 mg QHS, with a maximum recommended dose of 30 mg QHS. Use may be restricted by sedative side effects and weight gain, however this medicine may be beneficial for those who are experiencing weight loss and insomnia.
TCAs, notably imipramine, offer an alternative but are rarely used (due to dosing challenges, more side effects, and a higher risk of overdose compared to SSRIs). ECGs should be used to check for cardiac conduction system in patients older than 40.
In comparison to a placebo, MAOIs like phenelzine and tranylcypromine are also effective. Given the possibility of serotonin syndrome, avoid using serotonergic drugs. The usage of these drugs is additionally constrained by dietary restrictions and numerous other drug interactions.
● Benzodiazepines should only be used in times of emergency and for quick relief of uncomfortable symptoms. FDA-approved medications for panic disorder include clonazepam (starting at 0.5 mg BID PRN) and alprazolam (starting at 0.25 mg TID PRN). Alprazolam has a lesser risk for abuse and a shorter half-life than clonazepam. Sedation, dependence, an increase in falls, an increase in car accidents, and an increase in death are all linked to benzos.
Overdose risk is increased when benzodiazepines are prescribed to individuals who are using opioids.


Consider referring a patient to a psychiatrist if they have concomitant bipolar illness, borderline personality disorder, schizophrenia, suicidality, alcoholism, drug misuse, or if they have not responded to treatment after trying CBT, mindfulness-based therapy, or exposure therapy.

Further Therapies 
Yoga, tai chi, and aerobic exercise can all help symptoms.
With applications like Ten Percent Happier, Headspace, and UCLA Mindful, as well as stress-reduction workshops like Mindfulness-Based Stress Reduction (MBSR), you can practice mindfulness meditation. Free meditations are available at stressremedy.com/audio as well.

Alternative Therapies 
There is little evidence to back up the use of supplements to treat anxiety problems. Due to the possibility of liver failure, kava kava should be avoided. According to a 2018 metaanalysis, taking 2 grams of EPA-rich omega-3 fatty acids daily (which would start at 1 grams) may reduce anxiety.


Admission 
Hospitalize the patient to finish the evaluation if certain life-threatening mimics of panic disorder, such as a myocardial infarction or pulmonary embolus, have not been ruled out.
An admission to a mental health facility is necessary if a patient with panic disorder has actual suicidal thoughts.

Follow-Up
​ The full therapeutic benefit of antidepressants frequently takes 4 to 6 weeks to take effect. When initiating antidepressants in patients 24 years of age or younger, keep an eye out for suicidal thoughts (often within 1 to 2 weeks).
A diet high in natural foods and plants and low in caffeine may be beneficial.

Prognosis 
The mean time to remission is approximately 5.7 months, and remission occurs in 64.5% of patients. In patients who experienced remission, recurrence happens in 21.4% of cases. Women, the absence of persistent stressors, and a low initial attack frequency are all predictors of remission.

In bipolar patients who were given unopposed antidepressants for panic disorder, complications included iatrogenic benzodiazepine dependence and iatrogenic mania.