11850798 Panic Disorder

7/21/2019 11850798 Panic Disorder

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Monday, February 23, 2015 PANIC DISORDER BY DR. ISAM AFANE

ANXIETY DISORDERS

No Need to Panic

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PANIC DISORDER BY DR

. ISAM AFANE

Definition of Anxiety

From the German wordAngst.

It is indistinguishable From fear exceptas to cause.

It is the same Experience of dread andforeboding

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• Unknown internal stimulus

• Inappropriate to the reality of an externalstimulus

• Concerned with a future stimulus

Definition of anxiety:-

Except that it drives :-

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NormalNormal versus Pathological anxietyversus Pathological anxiety

•Normal fear and anxiety serve a usefulfunction, that is, they protect us from danger.

• Such anxiety make sense of identity and meaning of the

life

•Pathological anxiety, the fear and anxietyresult in dysfunction and distress.

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In psychiatry

• Anxiety Disorders:

- Separate clinical

entities

- Not secondary toorganic causes

- Functional (no

demonstrable CAUSE

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Anxiety disorders are

characterized by:• persistent fear and anxiety

that

• occurs too often,is

• too severe,

and is • triggered too easily or lasts too long.

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Cont….

•Behavior:

-IF anxiety impairs coping.

- IF normal function is disrupted.

- IF avoidance or withdrawal behavior occurs.

….. It is’’IF’’ A pathologic nature .

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Definition of subtypes

•Generalized anxiety disorder (GAD)

-symptoms of anxiety are persistent- Varying little from one situation to another

• Phobic anxiety disorder - Symptoms are episodic but associated with defined circumstances

•Panic disorder- Symptoms are episodic

not associated with defined

circumstances

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Monday, February 23, 2015

PANIC DISOD! "# D$ %IS%AM AFAN!%

Panic disorderPanic disorderNamed after Pan, the Greek god of Named after Pan, the Greek god of

naturenature

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Panic disorder

•Criteria of panic attack

•Epidemiology

• Risk Factors•Differential diagnosis

•Treatment

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Panic disorder

•Cardiac neurosis

•Da Costa's Syndrome

•Effort Syndrome

•Nervous syndrome

•NeurocirculatoryAsthenia

•Soldier's heart

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•Periodic short bouts of panic

•Sudden feelings of terror that occur suddenly andwithout warning,&ithout any 'ause or (re'i(itation

• )he Atta'*s o''ur in 50+-5+ o. 'ases durin/ non !M see(

ni/ht (ani' in addition to day o''urren'e

DEFINITION OF PANIC ATTACK :

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• Onset

Most can recall the precise date ,time, nature and circumstances of the first

panic attack

•Course• Frequency of attacks vary considerably between;

Few attacks in a life time.

Daily attacks for months ,then disappear and reappear.

Panic attacks

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• Duration

From seconds to minutes in most

cases, rarely it persists for hoursfollowed by exhaustion orheadaches and sometimes longsleep!

Panic attacks

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Monday, February 23, 2015Monday, February 23, 2015 PANIC DISORDER BY DR. ISAMPANIC DISORDER BY DR. ISAM

AFANEAFANE

Pan!" A##a"$ "r!#er!aPan!" A##a"$ "r!#er!a

%&e abru'# on(e# o) an e'!(ode o) !n#en(e )ear or%&e abru'# on(e# o) an e'!(ode o) !n#en(e )ear or

d!("o*)or#, +&!"& 'ea$( !n a''ro!*a#e-y 10 *!nu#e(, andd!("o*)or#, +&!"& 'ea$( !n a''ro!*a#e-y 10 *!nu#e(, and

!n"-ude( a# -ea(# )our o) #&e )o--o+!n (y*'#o*(/!n"-ude( a# -ea(# )our o) #&e )o--o+!n (y*'#o*(/

A )ee-!n o) !**!nen# daner or doo* %&e need #o e("a'e Pa-'!#a#!on(

S+ea#!n %re*b-!n S&or#ne(( o) brea#& or a (*o#&er!n

)ee-!n A )ee-!n o) "&o$!n C&e(# 'a!n or d!("o*)or#

Nau(ea or abdo*!na- d!("o*)or# D!!ne(( or -!&#&eadedne(( A (en(e o) #&!n( be!n unrea-,

de'er(ona-!a#!on A )ear o) -o(!n "on#ro- or o!n "ray A )ear o) dy!n %!n-!n (en(a#!on( C&!--( or &o# )-u(&e(

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. ISAM AFANE

There are three types of Panic AttacksThere are three types of Panic Attacks

1. Unexpected - the attack "comes out of the blue"without warning and for no discernable reason.

2. Situational - situations in which an individualalways has an attack, for example, upon entering atunnel.

3. Situationally Predisposed - situations in whichan individual is likely to have a Panic Attack, butdoes not always have one. An example of thiswould be an individual who sometimes has attackswhile driving.

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Case video

Panic attack and Occupational Therapy.fv

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Diagnostic Criteria: Panic DisorderDiagnostic Criteria: Panic Disorder

DSM-IV criteriaDSM-IV criteria

• e'urrent une(e'ted (ani' atta'*s

• A 4onth or 4ore o. at east one o. the

.oo&in/ a.ter an atta'* 6 Persistent 'on'ern about ha7in/ 4ore

atta'*s$

6 8orry about the i4(i'ations or 'ause o.

atta'*$ 6 Si/ni.i'ant 'han/e in beha7ior reated to

atta'*$

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Diagnostic Criteria:

Panic Disorder

•Absence or presence of agoraphobia

•Panic attacks not due to substance oranother mental disorder

• 9arious sy4(to4s (resent &ith atta'*s

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Fear of the marketplaceFear of the marketplace (agora)”(agora)” = fear of public areas= fear of public areas

(stores, theater, public transport, fear of bein! a"ay(stores, theater, public transport, fear of bein! a"ay

from safe places (homefrom safe places (home

## $ypothesis:$ypothesis: almost exclusivelyalmost exclusively a complicationa complication

of panicof panic

% % Patient afraid of bein! cau!ht some"herePatient afraid of bein! cau!ht some"here

havin! a panic attack, "here escape "ould behavin! a panic attack, "here escape "ould bedifficult&impossibledifficult&impossible

A/ora(hobia

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Facts Panic Disorder

• .!" lifetime prevalence

• #ore common in females $%&

• '(e typically $)*s to +)*s, risk may decrease with a(e

• -ates are similar across studies conducted in dierentnations /e.(., U0, 0wit1erland, Puerto -ico, far 2ast3

except for lower rates in one Taiwan study

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2015

PANIC DISORDER BY DR. HISHAM

AFANEH

Primary models forunderstanding PanicDisorder

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Biological modelmodel

Some evidence of a genetic predisposition

Abnormal norepinephrine activity

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10 #!*e( *ore -!$e-y !n b!o-o!"a- re-a#!4e( o) #&o(e +!#&

'an!" d!(order ene#!" 4(. en4!ron*en#a- )a"#or(67

ene#!"( /8So*e e4!den"e )or

29: o) !den#!"a- #+!n( Monoyo#!"7

11: o) )ra#erna- #+!n( D!o#!"(7D!(order run( !n )a*!-!e(

B!o-o!"a- *ode- )or under(#and!n Pan!" D!(order Con;#

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"ioo/i'a 4ode .or understandin/ Pani' Disorder Con:t

•Redmund: that he could stimulate anorepinephrine rich area of the brain and

cause panic attacks in monkeys.

• Bourin: Induced panic attacks in humans by

injecting them with drugs which affectnorepinephrine levels.

• Evidence that other neurotransmitters may

also play a role.

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Cognitive – Behavioral Model

for understanding Panic DisorderCognitive anxiety sensitivity ;A 4isunderstandin/ o. bodiy .un'tions sy4(atheti' arousa

6 Intense .o'us on body sensations bioo/i'a (redis(osition<

6 Assess those sensations io/i'ay out o. 'ontro=dan/erous

6 Inter(ret the4 as har4.u

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The panic vicious

circle:spiralling out ofcontrol0hort of 4reath

Chest pain, etc

<I;* o!n #o 'a(( ou#=Fr!&#ened and 'e#r!)!ed

Thinkin( a4out(oin( whereyou previouslyhad a panic

attack

<I;* dy!n=

How panic works…….How panic works…….

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Panic Disorder: Risk Factors

• 0tatistically associated with heart condition knownas mitral valve prolapse /#5P3, which does not

rule out 'xis I dia(nosis of panic disorder

• Caeine and stimulant medications fre6uentlyincrease panic attack fre6uency

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Panic Disorder: Risk Factors,cont’d

• 7epression a risk factor forisolated panic attacks

8 &!9!" of all depressed

patients9 -isk for committin( suicide

&!"

• 'lcoholism

9 $)9+)" of all panic patients

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DIFERENTIAL

DIAGNOSIS

• MEDICAL CONDITIONS

1.Acute myocardial infarction - in pure panic attacks patient doesn'texperience crushing chest pain

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DIFERENTIAL DIAGNOSIS

2.Catecholamine secreting tumors

( pheochromcytoma)

Severe Abdominal or Back pain

Hypertensive response to smoking

Malignant hypertensive episodes

Sweating in the chest and backwhile in panic in soles , palms andforehead

Splitting headache

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DIFERENTIAL

DIAGNOSIS3.Substance Abuse :

Cocaine.

Marijuana

Alcohol

Opiates

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DIFERENTIAL

DIAGNOSIS4.Hypoglycemia:-

Extremely rarely cause panic

attacks5.Caffeine:-

Morethan 700mg may causepanic attacks , also patient with

panic disorder may aggravatewith one cup of coffee.

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What You Can Do

•Assessment

•Intervention

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Monday, February 23, 2015Monday, February 23, 2015 PANIC DISORDER BY DR. ISPANIC DISORDER BY DR. IS

AM AFANEAM AFANE

A((e((*en# A((e((*en#

P&y(!"a- ea* and ba(e-!ne -ab !n4e(#!a#!on( (&ou-d beP&y(!"a- ea* and ba(e-!ne -ab !n4e(#!a#!on( (&ou-d be

'er)or*ed be)ore !n!#!a#!on o) '&ar*a"o-o!"a- #rea#*en#'er)or*ed be)ore !n!#!a#!on o) '&ar*a"o-o!"a- #rea#*en#

Reu-ar-y *on!#or +e!&# "&ane( and ad4er(e e))e"#( o) Reu-ar-y *on!#or +e!&# "&ane( and ad4er(e e))e"#( o)

*ed!"a#!on, !n"-ud!n (eua- dy()un"#!on*ed!"a#!on, !n"-ud!n (eua- dy()un"#!on

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AM AFANEAM AFANE

A((e((*en# A((e((*en#

E'-ore #&e 'o((!b!-!#y o) '&y(!"a- "au(e( )or E'-ore #&e 'o((!b!-!#y o) '&y(!"a- "au(e( )or

e*o#!ona- (y*'#o*(e*o#!ona- (y*'#o*(

>>

A '&y(!"a- ea* (&ou-d be 'ar# o) #&e A '&y(!"a- ea* (&ou-d be 'ar# o) #&e

a((e((*en# +&en ne+ (y*'#o*( are 're(en#a((e((*en# +&en ne+ (y*'#o*( are 're(en#

>> ?oo$ )or a &!(#ory #&a# doe( no# )!#?oo$ )or a &!(#ory #&a# doe( no# )!#

>> Re4!e+ 'er(ona- and )a*!-y &!(#ory "are)u--yRe4!e+ 'er(ona- and )a*!-y &!(#ory "are)u--y

>> Be (u('!"!ou( !) #&e on(e# o) #&e d!(order !(Be (u('!"!ou( !) #&e on(e# o) #&e d!(order !(

-a#e !n -!)e-a#e !n -!)e

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AM AFANEAM AFANE

A((e((*en# A((e((*en#

Be (u('!"!ou( !) #&ere !( a &!(#ory o)Be (u('!"!ou( !) #&ere !( a &!(#ory o)

re"en# on(e# o) &eada"&e(, -o(( o)re"en# on(e# o) &eada"&e(, -o(( o)

)un"#!on, unu(ua- 'er"e'#!on( #!n-!n,)un"#!on, unu(ua- 'er"e'#!on( #!n-!n,

d!((o"!a#!on, 4!(ua- d!(#urban"e(, or d!((o"!a#!on, 4!(ua- d!(#urban"e(, or

&a--u"!na#!on(8 e('e"!a--y 4!(ua-, o-)a"#ory,&a--u"!na#!on(8 e('e"!a--y 4!(ua-, o-)a"#ory,

or #a"#!-e7or #a"#!-e7

>> Dru(, dru(, dru(.Dru(, dru(, dru(.

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AM AFANEAM AFANE

Ba(e-!ne ?ab In4e(#!a#!on(Ba(e-!ne ?ab In4e(#!a#!on(

Co*'-e#e b-ood "oun# CBCCo*'-e#e b-ood "oun# CBC77

Fa(#!n -u"o(eFa(#!n -u"o(e

E-e"#ro-y#e(E-e"#ro-y#e(

?!4er eny*e(?!4er eny*e(

Seru* b!-!rub!nSeru* b!-!rub!n

Seru* "rea#!n!neSeru* "rea#!n!ne

'rinanalysis'rinanalysis

'rine toxicolo!y for'rine toxicolo!y for

substance usesubstance use )-hour creatinine clearance)-hour creatinine clearance

(if history of renal disease(if history of renal disease

*hyroid stimulatin! hormone*hyroid stimulatin! hormone Electrocardio!ram (+) years or ifElectrocardio!ram (+) years or if

indicatedindicated

Pre!nancy test (if relevantPre!nancy test (if relevant

ProlactinProlactin

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TREATMENT

IN Emergency Department

Most cases the attack exhausts itself within minutes but if it persists An injectable form of benzodiazepines can be used

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Panic Disorder: Initial Therapy

First lineC!#a-o'ra*, e("!#a-o'ra*, )-uoe#!ne,

)-u4oa*!ne, 'aroe#!ne, (er#ra-!ne,

4en-a)a!ne @R

Se"ond -!neC-o*!'ra*!ne, !*!'ra*!ne, *!r#aa'!ne, benod!ae'!ne( e..,

a-'rao-a*,"-onae'a*, -orae'a*, d!ae'a*7

adun"#!4e "-onae'a*

%&!rd -!ne

Bu'ro'!on, d!4a-'roe, aba'en#!n, *o"-obe*!de, o-ana'!ne, adun"#!4e

'!ndo-o-, '&ene-!ne, r!('er!done, ue#!a'!ne

No#

re"o**ended

Bu('!rone, #raodone, 'ro'rano-o-,

"arba*ae'!ne

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:ow to 'lleviate Panic 'ttacks :ow to :elp 0omeone :avin( a Panic 'ttack$.fv

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Treatment of

hyperventilation …..

–Rebreathing

-An immediate treatment is torebreathe expired air from bag inorder to increase the concentration ofCO2 in alveolar air

–As an effective way of demonstrating

the connection between symptomsand hyperventilation

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Cognitive therapy

• The two major foci of cognitive therapy for panicdisorder are :-

Instruction regarding the patient's false beliefs

(patient's tendency to misinterpret mild bodily sensationsas indicative of impending panic attack, doom or death)

Information regarding panic attacks

(when they occur , are time – limited and not life-threatening)

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Behavioral and Cognitive Therapy

• Teaches patient to react differently to situations and bodily sensations that trigger anxiety• Teaches patient to understand how thinking patternsthat contribute to symptoms

• Patients learn that by changing how they perceivefeelings of anxiety, the less likely they are to havethem

• Examples: Hyperventilating, writing down list oftop fears and doing one of them once a week,spinning in a chair until dizzy; after awhile patientslearned to cope with the negative feelings associatedwith them and replace them with positive ones

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AM AFANEAM AFANE

S#ra#e!e( #o redu"e an!e#yS#ra#e!e( #o redu"e an!e#y

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AM AFANEAM AFANE

Brea#&!n eer"!(e(Brea#&!n eer"!(e(

Produ"e (-o+ dee' brea#&!nProdu"e (-o+ dee' brea#&!n

Pre4en# &y'er4en#!-a#!onPre4en# &y'er4en#!-a#!on

Pre4en# e"e((!4e b-o+!n o)) o) CO2Pre4en# e"e((!4e b-o+!n o)) o) CO2

:ow to 'lleviate Panic 'ttacks :ow to 7o ;reathin( 2xercises .fv

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Meditation

•Cultivates calmness to create a senseof control over life

•Practice: Sit quietly in a position

comfortable to you and take a fewdeep breaths to relax your muscles,next choose a calming phrase (suchas “om” or that with great

significance to you), silently repeatthe word or phrase for 20 minutes

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:ow to 7o ;reathin( 2xercises ;reathin( 2xercises with 2nchantin(.fv

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AM AFANEAM AFANE

Se-) ?o4eSe-) ?o4e

%&e *o(# !*'or#an# &o-!(#!" #rea#*en# o) a--%&e *o(# !*'or#an# &o-!(#!" #rea#*en# o) a--

?au&/ be ab-e #o -au& a# your(e-) and +!#& o#&er(?au&/ be ab-e #o -au& a# your(e-) and +!#& o#&er(

!n"rea(e( endor'&!n -e4e-( and de"rea(e( (#re((!n"rea(e( endor'&!n -e4e-( and de"rea(e( (#re((

&or*one(&or*one( ?e# o o) )ru(#ra#!on(?e# o o) )ru(#ra#!on(

Do no# ude (e-) &ar(&-y/ don;# e'e"# *ore )ro*Do no# ude (e-) &ar(&-y/ don;# e'e"# *ore )ro*

your(e-) #&an you do o#&er(your(e-) #&an you do o#&er(

A""e'# your )au-#( A""e'# your )au-#(

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ue(#!on(6ue(#!on(6

11850798 Panic Disorder

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