Panic disorder

Question 1

Panic attack

Answer 1

discrete period of intense fear or discomfort in which 4 four or more of the following symptoms developed abruptly, and reached a peak within 10 minutes:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensation of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light-headed, or faint
9. Derealisation or depersonalisation
10. Fear of losing control or going crazy
11. Fear of dying
12. Paraesthesia (numbing or tingling)
13. Chills or hot flushes.

Question 2

Panic disorder

Answer 2

According to DSM 5, to diagnose panic disorder, one needs:
 One or more of the attacks followed by a month (or longer) of one or both of the following:
 Persistent worry about having more panic attacks and / or their consequences (e.g., having a heart attack).
 A significant abnormal change in behaviour in response to the attacks, such as avoiding unfamiliar situations.
 The disturbance cannot be attributed to the physiological effects of a substance, such as a drug or medication, or another medical condition.
 The disturbance cannot be better explained by another mental disorder, such as social anxiety disorder or specific phobia, which may involve panic attacks

Question 3

Management of a panic attack

Answer 3

The management should include:

1. Clear reassurance about the nature of attack, and the fact that these attacks are not lethal and will resolve spontaneously.
2. Directing the patient to loosen the tight clothes.
3. Allow room and space for breathing, allow fresh air to come in.
4. Encourage to do controlled breathing: try to relax by taking slow, deep and complete breaths.
5. Encourage to use positive statements to oneself like: ‘I know this is just an anxiety attack’, ‘I am not going to die’, ‘This is going to finish soon’.
6. If the attack continues, a fast-acting benzodiazepine like clonazepam may be offered but is best avoided.
7. The therapist / clinician must remain calm and in control throughout the process.

Question 4

Risks of Benzodiazepine misuse and using medication from an unlicensed source

Answer 4

BZD misuse can be divided into two patterns:

1) deliberate or recreational abuse with the intention of getting high and
2) unintentional misuse that begins as legitimate use but later develops into inappropriate use.

1. Specific to unlicensed source:
   Risk of misuse and diversion, forensic implications,
2. General to benzo misuse
   dependence, social/interpersonal/occupational complications, driving, falls/cognition in elderly, floppy sedated baby if pregnant

Question 5

How to prescribe BZD for those at higher risk of substance use

Answer 5

provide thorough education on the risk of combining these drugs with alcohol or other substances, discuss diversion, prescribe a BZD with lower abuse potential, monitor for adverse effects, and monitor for inappropriate use.

Reductions in inappropriate prescribing rather than all prescribing should be emphasised and encouraged.

Question 6

Overview mx (specific treatments) panic disorder RANZCP guidelines

Answer 6

1. A collaborative, pragmatic approach is recommended, beginning with psychoeducation and advice on life-style factors followed by specific treatment.
2. take into account severity, patient preference, accessibility, cost, tolerability and safety.
3. level I evidence ->CBT, antidepressant pharmacotherapy with SSRIs, SNRIs or TCAs and benzodiazepines for the treatment of panic disorder.
4. (limited or lower quality evidence for other psychological therapies, other antidepressant classes and other medication classes.)
5. Initial treatment options are CBT, medication with an SSRI (or an SNRI if SSRIs are ineffective or are not tolerated) in combination with graded exposure to anxiety triggers, or a combination of CBT plus medication.

Question 7

CBT for panic disorder

Answer 7

1. address the physical, cognitive and behavioural symptoms of panic disorder, + prevent relapse in three stages.
2. The first stage includes psychoeducation (explaining about anxiety and the symptoms of panic disorder), formulation, treatment rationale, symptom monitoring and addressing factors that facilitate or hinder therapy.
3. Motivational interviewing and education of the person’s family or members of their social support network should also be considered, and written information or links to reliable online information should be provided.
4. The second stage->identifying and reducing cognitive symptoms->challenging unhelpful thinking, particularly about catastrophic cognitions, using behavioural experiments and in vivo exposure to test hypotheses, with the aim of reducing safety behaviours and avoidance, and interoceptive exposure to feared physical sensations.
5. The final stage is relapse prevention->identifying potential precipitants for setbacks, identifying the patient’s early warning signs and developing a plan to manage setbacks and prevent relapse.

The optimal duration of CBT for panic disorder is 7–14 hours, usually delivered in weekly sessions.

Question 8

Response rates for medication

Answer 8

50-70%

Question 9

Medications with less supportive evidence

Answer 9

Mirtazapine, Duloxetine, Milnacipran, Moclobemide, Bupropion, Divalproex, levetiracetam and Gabapentin.

No clear benefit for SGA in panic disorder

Question 10

Other psychological therapies and interventions

Answer 10

1. Exercise as a form of treatment has been reported to be less effective than medication and no more effective than relaxation-> National Institute for Health and Care Excellence (NICE) as part of general health care
2. Panic-focussed psychodynamic psychotherapy delivered twice a week in a 12-week manualised treatment program has been shown to be effective in one RCT
3. Emotion-Focussed Therapy (EFT) developed by Shear and Colleagues, specifically targets emotional regulation as it related to interpersonal control and to fears of being abandoned or trapped
4. Eye Movement Desensitisation and Reprocessing (EMDR) have reported equivocal or unsustained benefits, and do not support the use of EMDR for panic disorder
5. Relaxation Therapies such as progressive muscle relaxation have been regarded as weak treatments for panic disorder.

Question 11

Benzo’s not recommended as first line treatment, why?

Answer 11

Despite their efficacy, benzodiazepines are not recommended as first-line treatment options, largely because of the risk of side effects (particularly sedation and cognitive impairment), tolerance and dependence (especially with alprazolam). Their use in combination with CBT also has potentially detrimental effects. Because of these concerns, recommendations are for benzodiazepines to be used short term, and to be dosed regularly rather than ‘as required’

Question 12

Benzos for treatment of panic disorder in those with SUD

Answer 12

Occasionally, benzodiazepines may be useful in an emergency setting for short-term management of severe agitation or anxiety, and for the management of an acute panic attack.

They should not be used as a treatment for panic disorder in people with a history of substance use disorder.

Question 13

Example formulation for panic disorder-> using benzo’s, history of invalidating parents/violent father, history of substance use

Answer 13

1. Reason for referral:
   Anthony is a 36-year-old male who was referred by his GP for psychiatric assessment due to the presence of panic symptoms.
2. Precipitating:
   These panic symptoms were closely correlated to Anthony commencing his own accounting business.
3. One might hypothesise that Anthony’s fear of failure, and somewhat dependent nature made it difficult for him to work in a more autonomous role.
4. Perpetuating:
   From a cognitive persepective, Anthony is experiencing a vicious cycle of anxiety and avoidance. His physical symptoms of anxiety lead to the cognition that he is suffering from a medical illness (e.g. heart attack), which fuels his physical symptoms further resulting in avoidance of areas he deems unsafe.
5. Perpetuating:
   His anticipatory anxiety regarding the fear of further attacks reinforces his avoidance which ultimately leads to greater dysfunction.
6. Anthony is currently managing his anxiety symptoms with benzodiazepines which, in the short term, alleviates his anxiety. He is at risk of benzodiazpine dependence with tolerance to the effects of his clonazepam, as well as the risk associated with acquiring an ongoing supply of medications in an illicit manner which may lead to forensic related issues. This is of particular concern, given his past history of alcohol misuse, and a similar history in his father which may indicate a biological predisposition towards substance abuse or dependence.
7. Perpetuating:
   It would seem that Anthony has adpoted a physical explanatory model for his symptoms. He believes that he has a ‘medical illness’ which shifts the focus away from psychological strategies, and other ways of dealing with his anxiety. The possibility of a medical explanation for his symptoms (e.g. arrythmia) merits consideration, and this is, potentially, a driving factor for his anxiety.
8. Predisposing:
   Anthony’s developmental history may shed some light on his current difficulties. He has a childhood history of anxiety with fears of separation. As a small child he utilised periods of distress to obtain care from his mother which may have led to more entrenched dependence. His current panic symptoms may, from a psychodynamic perspective, be an unconscious expression of distress which has the aim of eliciting care from those around him.
9. Anthony seems to have had an ingrained sense of poor self worth, perhaps dating back to the invalidation and violence he witnessed from his father, as well as the feeling of disappointing his mother. His feelings of being unable to manage his anxiety may be compounding his low sense of self-worth, and a feeling of helplessness.
10. Prognostic:
    Looking to the future, Anthony has a number of challenges. His ongoing stress at work may continue to fuel his anxiety, and his misuse of benzodiazepines may lead to dependence, as well as rejection of psychological therapies for his panic disorder.
11. Protective:
    Despite these, Anthony seems to have a number of protective factors. He has engaged well with his psychiatrist, and his family seems to be a source of support for him.

Question 14

Have we over-estimated risk of benzo use?

Answer 14

Some clinicians have argued the medical community has over estimated the risk.
May deprive patients of effective treatment
Do risk/benefit analysis
- risk of poorly controlled mental illness-> +anxiety may lead to worsening substance use/alcohol

Advocate for appropriate prescribing as opposed to inappropriate or no prescribing
Monitor for inappropriate use

Salzman C, Shader RI. Not again: benzodiazepines once more under attack, J Clinical Psychopharmacol. 2015.

Question 15

Aspects of the medical expert for management

Answer 15

1. demonstrating awareness of the efficacy of treatment (CBT, antidepressant pharmacotherapy with SSRIs, SNRIs or TCAs and benzodiazepines for the treatment of panic disorder)
2. demonstrating the understanding of these treatments;
3. identifying specific treatment outcomes and prognosis; appropriate selection, benefits / risks, application, adherence, monitoring of specific interventions;
4. medication(s) choice, dosing and monitoring; application of psychoeducation;
5. sensitive consideration of barriers to implementation;
6. identifying the role of other health professionals.