Panic disorder

Overview

Panic disorder affects a sizable proportion of the general population. It has the largest number of doctor visits of any anxiety illness and is an extremely expensive mental health disease. Recurrent, unexpected panic attacks define panic disorder. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) defines panic attacks as "an sudden rush of severe dread or discomfort" that peaks within minutes.

A panic episode is accompanied by four or more of a certain set of physical symptoms. Panic attacks can occur as frequently as several times per day or as seldom as a few times per year. The fact that panic episodes occur without warning is a distinguishing characteristic of panic disorder. Often, there is no one cause of a panic attack. Patients who suffer from these assaults believe they are out of control. Panic attacks, on the other hand, are not restricted to panic disorder.

They can coexist with anxiety, mood, psychosis, drug use, and even medical diseases. In individuals with anxiety and mental illnesses, panic episodes can be related with increased symptom severity of different disorders, suicidal ideation and conduct, and a decreased therapeutic response. Making an accurate diagnosis of panic disorder is impossible without a clear understanding of what panic attacks are.

It is critical to distinguish between symptoms experienced during or associated with a genuine alarm scenario, such as a physical threat, and a true panic attack. According to DSM 5 (Fifth Edition) criteria, at least one panic episode must be followed by one month or more of persistent fear about having future attacks, or maladaptive conduct such as avoidance of work or school activities.

Although panic attacks can be caused by the direct consequences of substance abuse, pharmaceuticals, or a general medical condition such as hyperthyroidism or vestibular dysfunction, they should not be the only cause. The dread and anxiety sensations that people with panic disorder experience emerge predominantly in a somatic rather than a cognitive manner. This is a unique discovery.

What is Panic disorder?

Panic disorder and panic episodes are two of the most frequent psychiatric conditions. Panic disorder is distinct from a panic attack, despite the fact that it is characterized by recurring, sudden panic attacks. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) defines panic attacks as "a sudden rush of severe dread or discomfort" that peaks within minutes. A panic episode is accompanied by four or more of a certain set of physical symptoms.

Epidemiology

Only social anxiety disorder, posttraumatic stress disorder, and generalized anxiety disorder have a higher lifetime prevalence than panic disorder. Notably, as compared to the general population, persons suffering from panic disorder have considerably higher lifetime rates of cardiovascular, pulmonary, gastrointestinal, and other medical disorders.

Panic disorder is more common in European Americans than in African Americans, Asian Americans, or Latinos. Females are more vulnerable than males. Panic disorder is most common in adolescence and early adulthood, with individuals under the age of 14 having a low frequency.

Many additional comorbidities are shared by patients with panic disorders, including OCD, social phobia, asthma, COPD, irritable bowel syndrome, hypertension, and mitral valve prolapse. Pregnant women suffering from panic disorder are also more likely to have babies with low birth weight.

Cardiovascular illnesses (e.g., mitral valve prolapse, hypertension, cardiomyopathy, stroke) are also comorbid factors; panic sufferers are approximately twice as likely as the general population to develop coronary artery disease. Patients with panic disorder and coronary disease can have myocardial ischemia during their panic episodes; consequently, panic disorder is linked to an increased risk of sudden death.

Furthermore, panic disorder is found in 30% of patients with chest discomfort and normal angiography findings, and persons with panic disorder have poorer oxygen consumption and exercise tolerance than the general population.

Asthma is associated with a 4.5-fold increase in the likelihood of getting panic disorder, and those with panic disorder are six times more likely to acquire asthma than those without anxiety disorders. Patients suffering from panic disorder may also experience migraine headaches (12.7 %), tension headaches (5.5 %), or a combination of migraine and tension headaches (14.2 % ). People with epilepsy had a 6.6 percent lifetime incidence of panic disorder.

Around 10-20% of anxiety disorder patients abuse alcohol and other substances, while approximately 10-40% of drinkers have a panic-related anxiety condition. Pregnant moms who have a panic disorder throughout their pregnancy are more likely to have premature labor and babies who are underweight for their gestational age.

Etiology

There are several ideas and models that address the likely origin of panic disorder. Most suggest that chemical imbalances, such as gamma-aminobutyric acid, cortisol, and serotonin abnormalities, are a crucial cause. A genetic and environmental component is thought to have a role in the etiology of panic disorder. Several studies have found that stressful childhood experiences can contribute to panic disorder in adulthood.

Newer study suggests that neural circuitry may play a larger part in panic disorder, where some sections of the brain are hyperexcitable in individuals, predisposing them to the illness.

According to certain research, genetic factors may play a role in the genesis of panic disorder. If someone in the family has previously been diagnosed with the syndrome, first-degree relatives have a 40% chance of acquiring it. Furthermore, persons with panic disorder are at a significant risk of acquiring additional mental health problems.

The catecholamine hypothesis proposes enhanced sensitivity to or inappropriate processing of adrenergic CNS discharges, as well as presynaptic alpha-2 receptor hypersensitivity.

Fear is felt as a result of reciprocal regulatory activity that begins in the amygdala and is projected to the anterior cingulate cortex and/or orbitofrontal cortex. Endocrinologic reactions to fear are then mediated by projections from the amygdala to the hypothalamus.

Pathophysiology

Many neurotransmitters and peptides found in the central nervous system appear to be important in the physical symptoms. Brain imaging studies have revealed distinctive alterations, such as enhanced flow and receptor activation, in specific geographic locations such as the limbic and frontal regions. The amygdala is thought to be the primary source of malfunction.

Medical sickness and panic disorder are closely connected from a pathophysiological and psychological perspective. There are two major ideas that try to explain why patients are more susceptible to have panic attacks.

The first hypothesizes that vulnerable patients lack the proper neurochemical processes that would usually regulate serotonin, and that this elevated serotonin produces changes in the autonomic nervous system's fear network model. The second theory proposes that a lack of endogenous opioids causes separation anxiety and greater sense of suffocation. 

Panic disorder Symptoms

The great majority of panic disorder patients have chest discomfort, palpitations, or dyspnea on repeated occasions. Diaphoresis, tremor, a choking sensation, nausea, chills, paresthesias, or feelings of depersonalization are all common symptoms.

Because the majority of patients report physical symptoms, they frequently enquire for other reasons for their symptoms that are not connected to mental health. They typically avoid care from mental health specialists in favor of comfort from speciality medical doctors. It's crucial to realize that several illnesses, including irritable bowel syndrome, asthma, and vocal cord dysfunction, exhibit symptoms that are similar to panic disorder.

DSM-5 criteria for panic disorder include four or more panic episodes within four weeks, or one or more panic attacks followed by at least one month of fear of another panic attack.

The following are potential symptom manifestations of a panic attack:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sense of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Derealization or depersonalization (feeling detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flashes

Types of panic attacks

There is no recognized trigger for unexpected panic episodes. Panic attacks that are situationally bound (cued) reoccur consistently in temporal connection to the trigger; these panic attacks frequently imply the diagnosis of a specific phobia. Panic attacks are more likely to occur in response to a specific trigger, although they may not always occur.

A nonfearful panic disorder variation is associated with high rates of medical resource utilization (32-41 percent of individuals with panic disorder seek treatment for chest discomfort) and a poor prognosis.

Panic triggers

Triggers of panic can include the following:

• Injury (e.g., accidents, surgery)
• Illness
• Interpersonal conflict or loss
• Use of cannabis 
• Use of stimulants, such as caffeine, decongestants, cocaine, and sympathomimetics 

Evaluate triggering events (for example, important life events), phobias, agoraphobia, obsessive-compulsive behavior, and suicide ideation and/or planning. In one study, people with simple panic disorder had a greater lifetime risk of suicide attempts (7%) than those without a mental disease (1 percent ). Determine whether there is a family history of panic disorder or other psychiatric disorders. 

Exclude alcohol, nicotine, illegal substances (e.g., cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide, cannabis), and pharmaceuticals (e.g., caffeine, theophylline, sympathomimetics, anticholinergics), including over-the-counter (OTC) agents.

In experimental settings, hyperventilation, carbon dioxide inhalation, caffeine ingestion, or intravenous infusions of hypertonic sodium lactate or hypertonic saline, cholecystokinin, isoproterenol, flumazenil, or naltrexone can provoke symptoms in persons with panic disorder. The carbon dioxide inhalation challenge elicits panic sensations in smokers in particular.

Physical Examination

There are no unique physical symptoms of panic disorder. If the patient is in a condition of acute panic, he or she might physically exhibit any expected symptom of an elevated sympathetic state. Hypertension, tachycardia, moderate tachypnea, minor tremors, and chilly, clammy skin are examples of nonspecific symptoms.

Blood pressure and temperature may be within normal limits. A panic episode usually lasts 20-30 minutes after it begins, but in exceptional circumstances, it can last up to an hour. During an attack, patients may be preoccupied with somatic concerns such as mortality from cardiac or pulmonary difficulties. Patients may wind up at the emergency room.

By watching breathing, hyperventilation may be difficult to identify since respiratory rate and tidal volume may look normal. Patients may sigh often or have trouble holding their breath. Symptom reproduction with overbreathing is uncertain. There may be a Chvostek sign, a Trousseau sign, or an overt carpopedal spasm.

The remainder of the physical examination results are usual in panic disorder. However, keep in mind that panic disorder is mostly an exclusion diagnosis, and focus should be placed on the exclusion of other diseases.

Diagnosis

To diagnose panic disorder, no special laboratory, radiographic, or other testing are necessary. The previously listed DSM 5 criteria can be utilized to diagnose panic disorder. In practice, clinician-created rating systems are used to measure the severity of panic episodes. However, it is critical that health care practitioners do a comprehensive evaluation of the patient to rule out alternative diagnoses. Panic disorder develops when there are no other medical or psychological diseases that can explain the symptoms.

Panic disorder Treatment

Both psychological and pharmaceutical therapies are commonly used to treat panic disorder. Cognitive-behavioral therapy is one type of psychological intervention. There are components of their therapy regimens that may indirectly improve their respective medical diseases in individuals with panic disorder who also have concomitant comorbid medical ailments.

Breathing training is a way of lowering panic symptoms by using capnometry biofeedback to reduce the amount of hyperventilation episodes. Several of these slow breathing strategies have been demonstrated to aid asthma and hypertension sufferers. Patients suffering from cardiovascular disease may benefit from reducing their hyperventilation. By lowering sympathetic activity, anxiety and stress-reduction approaches can improve results in cardiovascular disease.

The cornerstones of pharmacologic therapy are antidepressants and benzodiazepines. Selective serotonin reuptake inhibitors (SSRIs) are preferred above monoamine oxidase inhibitors and tricyclic antidepressants among the many antidepressant groups. For people with panic disorder, SSRIs are considered the first-line therapeutic choice.

In individuals with co-existing diseases or severe symptoms, it is preferable to use a benzodiazepine such as alprazolam until the antidepressants take action. Gabapentin and mirtazapine are indicated for people with drug use disorder and panic disorder.

Cognitive-behavioral therapy

Psychotherapy is indicated for individuals with panic disorder who desire nonpharmacologic care and are able and willing to commit to weekly or alternate weekly sessions and between-session activities. Cognitive behavioral treatment has the most compelling evidence (CBT)

The treatment of choice for panic disorder is cognitive behavioral therapy (CBT), with or without pharmacology, and it should be considered for all patients. This therapy approach outperforms pharmaceutical therapies in terms of effectiveness, cost, dropout rate, and recurrence rate. CBT may entail challenging anxious beliefs, exposing oneself to fear triggers, altering anxiety-maintaining behaviors, and preventing relapse.

For optimal care, it is critical to establish the frequency and type of panic disorder symptoms, as well as the triggers of panic symptoms. The patient's symptomatic condition should be assessed at each session, for example, with rating scales, and patients can also self-monitor by maintaining a daily journal of panic symptoms.

Differential Diagnosis

• Angina
• Asthma
• Congestive heart failure
• Mitral valve prolapse
• Pulmonary embolism
• Substance use diosrder
• Other mental health disorders associated with panic attacks

Prognosis

Panic disorder is a chronic condition that has a varied course. In more than 85 percent of instances, appropriate pharmacologic treatment and cognitive-behavioral therapy (CBT), either alone or in combination, are beneficial. Patients who have strong premorbid functionality and a short duration of symptoms have a better prognosis. Approximately 10-20% of individuals continue to experience substantial symptoms.

Overall, the long-term prognosis is usually favorable, with about 65 percent of panic disorder patients reaching remission within 6 months. However, as discussed in History, trigger factors can cause panic attacks; several of these triggers are associated with poor outcome, including severe illness at the time of the initial assessment, high interpersonal sensitivity, low social class, separation from a parent due to death during childhood, divorce, and unmarried status.

Patients suffering from panic disorder have a significantly increased risk of coronary artery disease. Panic can cause myocardial ischemia in people with coronary disease. The risk of sudden death may also be elevated hypothetically owing to decreased heart rate variability and increased QT interval variability. Individuals suffering from panic disorder have a far greater suicide rate than the normal population.

Complications

Suicidal thoughts is more common in people who suffer from panic disorder. It is also linked to a reduction in quality of life since the patient is unable to operate regularly in his social and family life. The disease is linked to an increased risk of concomitant medical disorders as well as smoking.

Furthermore, those suffering from panic disorder have a substantially higher chance of alcohol misuse or dependency, as well as suicidality, than the general population. However, some research show that in the absence of additional risk factors, such as affective disorders, drug use disorders, eating disorders, and personality disorders, panic disorder is not a risk factor for suicide.

Patient Education

Inform patients that the reasons of panic disorder are most likely biological and psychological, and that panic symptoms are neither life-threatening nor unusual.

Educate patients on their diagnosis and treatment choices, as well as the potential side effects of their treatment drugs and any concomitant substance use, such as alcohol intake and recreational drug use. These psychotropic drugs have the potential to alter the course of panic disorder. Although certain medications appear to alleviate the agony of an acute attack, they frequently jeopardize the long-term treatment strategy.

Consider teaching panic disorder patients about cognitive biases that can aggravate anxiety. Teach patients to detect trigger cues so that they may include them into their psychological therapy plan.

For psychotropic drugs, get verbal informed permission and document the discussion of the risks and benefits of treatment medications. Encourage healthful practices such as exercise and proper sleep hygiene. Caffeine, energy drinks, and other over-the-counter stimulants should be avoided by patients.

Discuss with the patient's family the necessity of decreasing the patient's avoidance behaviors and maintaining pharmaceutical compliance and adherence to treatment visits. Assist the family in comprehending the nature of the anxiety symptoms and making suitable accommodations.

 In the context of continuous cognitive-behavioral treatment (CBT) in which the patient learns coping strategies to control anxiety, family members can be very helpful in assisting the patient to overcome exaggerated worries and entrenched avoidance patterns.

Although dietary changes (e.g., 5-hydroxytryptophan or inositol supplementation) may be useful in reducing recurrence, CBT and medicines have far greater evidence of efficacy. Herbal supplements should be avoided until the patient has spoken with his or her psychiatrist or primary care physician about it.

Panic disorder with Agoraphobia

Agoraphobia with panic disorder is a phobic-anxious condition where patients avoid circumstances or locations in which they fear being embarrassed, or being unable to flee or receive treatment if a panic attack happens.

Conclusion 

Panic attacks can occur as frequently as several times per day or as seldom as a few times per year. The fact that panic episodes occur without warning is a distinguishing characteristic of panic disorder. A panic attack is not always caused by a specific event. Patients who suffer from these assaults believe they are out of control. Panic attacks, on the other hand, are not restricted to panic disorder. They can coexist with anxiety, mood, psychosis, and drug use disorders.

It is critical to distinguish between the two entities in order to obtain an appropriate diagnosis of panic disorder. According to the DSM 5, panic disorder can be diagnosed when recurring sudden panic attacks occur, followed by one month or more of persistent fear about having future attacks, as well as a change in the individual's behavior to avoid a circumstance to which they ascribe the attack.

Although panic attacks can be caused by the direct consequences of substance abuse, pharmaceuticals, or a general medical condition such as hyperthyroidism or vestibular dysfunction, they should not be the only cause. When the symptoms are caused by another disorder, panic disorder is not identified.

 For example, panic episodes cannot be regarded a component of panic disorder when they occur in the midst of a social anxiety disorder and are triggered by social events such as public speaking. A distinguishing feature of people with panic disorder is the dread and worry that they experience physically rather than cognitively.

Panic disorder is not a harmless condition; it may have a substantial impact on one's quality of life and lead to sadness and incapacity. Furthermore, as compared to the general community, these patients are at a higher risk for alcoholism and substance misuse.

There is no treatment for panic disorder, and it can manifest itself in a variety of ways, making diagnosis challenging. Because the majority of panic disorder patients arrive to the emergency department, the responsibility of the nurse and emergency clinician cannot be overstated. The patient need a clear understanding of the illness and that the symptoms are not life-threatening.

The patient must be informed about the many therapies available as well as the importance of compliance. Furthermore, the pharmacist should advise the patient against using alcohol or recreational drugs. The patient should be trained to detect and avoid triggers. Before beginning any pharmacological therapy, the patient should be advised of the potential risks and advantages.

Furthermore, the nurse and clinician should educate the family on how to assist the patient in overcoming false worries and other habits. Finally, the patient should be instructed on how to live a healthy lifestyle by practicing proper sleep hygiene, exercising, and eating a nutritious food.