Panic Disorder _ Etiology & Clinical Features
-
Upload
drkadiyala2 -
Category
Documents
-
view
221 -
download
0
Transcript of Panic Disorder _ Etiology & Clinical Features
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
1/49
PAN IC D ISO RD ER –ETIO LO G Y & CLIN ICAL
FEATU RES
C/P: Dr. Aruna
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
2/49
Introduction
Panic disorder is defned as a type oanxiety disorder characterized byrecurrent & unexpected panicattacks (DS !"#$
A%oraphobia ! anxiety about bein% inpaces or situations ro' hich
escape 'i%ht be di)cut (ore'barrassin%$ or in hich hep 'aynot be a*aiabe in the e*ent o
ha*in% an unexpected or
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
3/49
Epidem iology
,ieti'e pre*aence+ Panic disorder : -+
,ieti'e pre*aence+ Panic attacks: +-0
,ieti'e pre*aence+ A%oraphobia: 0+1
0+2 ti'es 'ore in o'en
en + ithout & 3o'en ! itha%oraphobia
0 peaks o onset: -4+0 yrs & 4+4 yrs 5 6isk ith: idoed/di*orced/separated
i*in% in cities7 i'ited education7 earyparenta oss7 physica/sexua abuse
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
4/49
89",;
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
5/49
Genetic predisposition
=+> od 5 rates in -st de%ree reati*es
5 'onozy%otic concordance (2- *s ? $
@i%h rates o anxiety disorders in chidreno aduts ith panic disorder
;enes ! AD60A -?>20/9 CCB C6@%enes or 4@9-A 4@90A C9 S869
9rau'atic eary ie e*ents
Dependent personaity traits o*erprotecti*eness
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
6/49
Neurotransm itters
8:
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
7/49
Neurotransm itters
4@9:
5 in 4@9 trans'ission decreases panicdisorder
4@9 neurons in *entroatera PA; (+$ssy'pathoexcitation & f%ht/Gi%ht response inrats
SS6"s eHecti*e in panic disorder
Iu'azeni causes 'id anxiety inun'edicated panic disorder patients
P89 : F in brain 4@9-A receptors & 4@9transporter bindin%
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
8/49
Neurotransm itters
;AEA:
EJD a%onists ! eHecti*e in panic disorder
Iu'azani ! panico%enic eHect in panicdisorder
euroi'a%in% studies !
+ i'paired ;AEA neurona response to EJDs
+ F ;AEA in cin%uate & basa %an%ia + F EJD bindin% in inerior parieto+te'poro+
occipita areas
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
9/49
Neurotransm itters
CCB+penta%astrin:
Panic disorder patients de*p panic
attacks in a dose+dependent ashionith ad'inistration o penta%astrin
CCB %ene poy'orphis's
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
10/49
Neuroanatom ical hypothesis
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
11/49
Cognitive m odel
;odstein & Cha'bess (-K=>$:
A noxius sti'uus (panic attack$ that
occurs ith a neutra sti'uus (busride$
A*oidance o neutra sti'uus
Panic A*oidance 6e exposure
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
12/49
Cognitive m odel
Cark (-K>1$:
Catastrophicay 'isinterpret
autono'ic arousa sensations thatoccur in the context o non+pathoo%ica anxiety (e%. Physicainess exercise substances$
Autono'ic sy'pts 'isinterpreted panic
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
13/49
Cognitive m odel
6eiss et a (-KK-$:
-. Predispositiona tendency tocatastrophicay 'isinterpret & respond
ith ear0. A earned ear o anxiety that is 'aintained
by the experience o panic attacks
Aut sy'pts 'isinterpret panic earnedear & hence a*oidance re exposure/autsy'pts panic
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
14/49
Cognitive m odel
Eouton (0??-$:
8xposure to panic attack conditions the personto respond ith anticipatory anxiety to
interna arousa & contextua cues
Panic attack ith ear & autono'ic sy'pto's
"nterna arousa / contextua cues anyti'e
Anticipatory anxiety (so'eti'es panic attacks$
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
15/49
Psychodynam ic m odels
Peope at risk or panic disorder ha*e:
-. europhysioo%ica *unerabiity topanic attacks &/or
0. utipe experiences ode*eop'enta trau'a
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
16/49
Psychodynam ic m odels
9rau'a ith/ithout *unerabiity
Chid excessi*ey earu o una'iiarsituations
Eeco'es excessi*ey dependant onpri'ary care%i*er to pro*ide a senseo saety
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
17/49
Psychodynam ic m odels
Care%i*er unabe to pro*ide supportaays
Chid de*eops a earu dependency
De*eop'ent o unconsciousconficts about dependency
( "ndependence *s 6eiance onothers$ & an%er
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
18/49
Psychodynam ic m odels
8*oke a*ersi*e e'otions ike anxiety an%er & %uit
Eeni%n arousa sensations acco'panyin% these
e'otions beco'es the ocus o Lconscious &unconscious co%niti*e catastrophisin%M
ConGicts PA"C A99ACBS
($ unconscious/conscious antasies o catastrophic
dan%er
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
19/49
Psychodynam ic m odels
Patients ith panic disorder ha*e ahi%her incidence o stressu iee*ents in the 'onths beore the onseto panic disorder.
N1? o'en ha*e h/o chidhoodsexua abuse
Cause + unconscious 'eanin% ostressu e*ents
Patho%enesis + neurophysioo%ica
actors tri%%ered by the psychoo%ica
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
20/49
D"A;S"S
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
21/49
DSM IV TR
6ecurrent & unexpected panic attacks
At east - o these attacks 'ust beooed by - 'onth or 'ore o:
1. persistent concern about having moreattacks,
2. worry about the implications or
consequences of the attack, or 3. changes to typical behavioral patterns
(e.g., avoidance of work or schoolactivities) as a result of the attack.
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
22/49
DSM IV TR
"n addition the panic attacks 'ust notste' soey ro':
the direct eHects o iicit substanceuse medication or a generalmedical condition
are not better expained by another
'enta disorder (e.%. such as sociaphobia or attacks that occur ony insocia situations$
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
23/49
DSM IV TR Panic attac!
A panic attack is a discrete period o intense fear or
disco'ort in the absence of real danger that
de*eops abruptly reaches a peak within 1 minand is acco'panied by ! (or more) o the ooin%
-2 sy'pto's:
(-$ Papitations poundin% heart or acceerated heart
rate
(0$ Seatin%
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
24/49
DSM IV TR Panic attac!
(2$ 9re'bin% or shakin%
($ Sensations o shortness o breath or s'otherin%
(4$ Ieein% o chokin%
(1$ Chest pain or disco'ort
(=$ ausea or abdo'ina distress
(>$ Ieein% dizzy unsteady i%ht+headed or aint
(K$ Dereaization (eein%s o unreaity$ or
depersonaization (bein% detached ro' onese$
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
25/49
DSM IV TR Panic attac!
(-?$ Iear o osin% contro or %oin%
crazy
(--$ Iear o dyin%
(-0$ Paresthesias (nu'bness or
tin%in% sensations$
(-2$ Chis or hot Gushes
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
26/49
DSM IV TR Panic attac! types
"ne#pected + not associated ith anidentifabe interna or externa tri%%erand appear to occur Lout o the bueM
$ituationally bound % a'ost in*ariabyoccur hen exposed to a situationatri%%er or hen anticipatin% it
$ituationally predisposed % usuay butnot necessariy occur hen exposed toa situationa tri%%er or henanticipatin% it
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
27/49
DSM IV TR
Panic disorder ith a%oraphobia +arranted hen the criteria or panicdisorder are satisf ed andacco'panied by a%oraphobia
limited symptom attacks % panic+ike
episodes co'prisin% eer than sy'pto's.
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
28/49
DSM IV TR " #gorapho$ia
A%oraphobia + anxiety about bein% in paces orsituations ro' hich escape 'i%ht be di)cut(or e'barrassin%$ or in hich hep 'ay not be
a*aiabe in the e*ent o ha*in% an unexpected orsituationay predisposed panic attack / panic+ikesy'pto's.
A%oraphobic ears typicay in*o*e characteristiccusters o situations such as bein% outside theho'e aone bein% in a crod standin% in a inebein% on a brid%e or tra*ein% in a 'otor *ehice.
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
29/49
DSM IV TR " #gorapho$ia
9he situations are a*oided or areendured ith 'arked distress ororry about ha*in% a panic attack orpanic+ike sy'pto's. Conrontin%situations is aided by the presence oa co'panion.
9he anxiety or a*oidance is notbetter accounted or by another
'enta disorder.
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
30/49
DSM IV TR
Panic disorder ithout a%oraphobia
Panic disorder ith a%oraphobia
A%oraphobia ithout history o panic
disorder
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
31/49
ICD"%&
I?.? A%oraphobia
.?? ithout panic disorder
.?- ith panic disorder
I-.? Panic disorder (episodic
paroxys'a anxiety$
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
32/49
ICD"%& " #gorapho$ia
(a$ the psychoo%ica or autono'ic sy'pto's'ust be pri'ariy 'aniestations o anxietyand not secondary to other sy'pto's such as
deusions or obsessiona thou%hts7
(b$ the anxiety 'ust be restricted to (or occur'ainy in$ at east 0 o the ooin% situations:
crods pubic paces tra*ein% aay ro'ho'e and tra*ein% aone7
(c$ a*oidance o the phobic situation 'ust be or
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
33/49
ICD"%& Panic Disorder
Se*era se*ere attacks o autono'ic anxiety shoudha*e occurred ithin a period o about - 'onth:
(a$ in circu'stances here there is no obOecti*e dan%er7
(b$ ithout bein% confned to knon or predictabesituations7 and
(c$ ith co'parati*e reedo' ro' anxiety sy'pto'sbeteen attacks (athou%h anticipatory anxiety isco''on $
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
34/49
Co"m or$idities
,ieti'e co 'orbidity in panic disorder >?
"n panic disorder ith a%oraphobia ! -??
&a'or epressive isorder ! 14
od 5 in suicide atte'pt ith DD & Panic dis $omatoform *ain related disorders ! reQ
R @ypochondriasis + 4?
R A/c & Chronic uscuoskeeta pain ! >4 ?
R "rritabe Eoe Syndro'e ! -=+-
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
35/49
Co"m or$idities
+ther n#iety isorders +
Socia phobia & ;AD: -4+2?
Specifc phobia: 0+0?
CD: -?
P9SD: 0+-?
a/c stress disorder: no studies yet
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
36/49
Co"m or$idities
lcohol use disorders
? in 'aes7 -2 in e'aes
Precipitatin% aintainin% &
A%%ra*atin% roe
Can precede or de*eop secondary to
panic disorder (as 'eans o se+
'edication$
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
37/49
Co"m or$idities
*ersonality disorders:
?+4?
A*oidant
Dependent
@istrionic
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
38/49
Di''erential Diagnosis
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
39/49
General M edical Conditions
8ndocrine
@yperthyroidis'
@ypo/hyperparathyroidis' @ypo%yce'ia D
Pheochro'ocyto'a
Carcinoid syndro'e Cushin%s disease Addisons disease
PS enopausa disorders
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
40/49
General M edical Conditions
Cardio*ascuar
#P
Supra*entricuar arryth'ias An%ina " C@I
@ypertension
Ane'ia
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
41/49
General M edical Conditions
Pu'onary diseases
CPD
Eronchia Asth'a
@yper*entiation
Pu'onary e'bous
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
42/49
General M edical Conditions
euroo%ica diseases
C#D 9"A
Seizures i%raine
#estibuar diseases
utipe Scerosis
@untin%tons disease
3isons disease
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
43/49
General M edical Conditions
thers
Anaphyaxis
Syste'ic inections
8ectroyte disturbances
Tre'ia
@ea*y 'eta poisonin%
E-0 defciency
S,8 9e'pora arteritis
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
44/49
Su$stance induced
"ntoxication ith CS sti'uants
Cocaine
A'pheta'ine
CaHeine 9heophyine icotine
"ntoxication ith other dru%s
@aucino%ens Cannabis A'ynitrite
Antichoiner%ics
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
45/49
Su$stance induced
3ithdraa ro' CS depressants
Acoho
piates & opioids
Sedati*e+hypnotics
Antihypertensi*es
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
46/49
Psychiatric disorders
+ther an#iety disorders
;AD
Specifc phobias Socia phobia
CD
P9SD
Separation anxiety disorder
&ood disorders, *sychotic disorders
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
47/49
Psychiatric disorders
Iactors hepu in 'akin% Oud%'ent or Usis:
Iocus o anxiety
9ype & no. o panic attacks
o. o situations a*oided
,e*e o intercurrent anxiety
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
48/49
Conclusion
Panic disorder is a co''ony 'isseddia%nosis in 'edica settin%s
Eoth bioo%ica & psychoo%ica
actors pay a roe
Co 'orbidities ! co''on & oHerschaen%e in dia%nosis & treat'ent
3ary o other diseases si'uatin%panic disorder
9hank you
-
8/17/2019 Panic Disorder _ Etiology & Clinical Features
49/49
9hank you
-rigger for panic attack