Potential questions on Panic Disorder

1. Potential questions on Panic Disorder Answers based on DSM-IV-TR, APA Practice Guideline, and other references that as identified on the specific screen. As of August 1, 2006.

2. Criteria of “panic attack” Q. DSM criteria, very general?

3. Ans. Outline of Dx of Panic Disorder • 1. Recurrent unexpected panic attacks • 2. Following the attacks, pt has been concerned for more than a month about additional attacks, implications of the attacks or had a change in behavior as a result to the attacks. • 3. Panic attacks are not part of another disorder.

4. Panic attack symptoms Q. DSM expects at least 4 of 13 symptoms in stating the pt has had a “panic attack.” List as many of the 13 as you can.

5. Criteria of “Panic Attack”?Two slides • At least 4 of following develop suddenly and peak in 10 minutes: • 1.palpitations or increased pulse • 2. sweating • 3. trembling or shaking • 4. sensation of shortness of breadth • 5. feeling of choking • 6. chest discomfort

6. Criteria for Panic Attacksecond slide • 7. nausea or stomach distress • 8. dizzy, unsteady, lightheaded, or faint • 9. derealization/depersonalization • 10. fear of losing control or going “crazy” • 11. fear of dying • 12. paresthesias • 13. chills or hot flashes

7. Rule outs Q. Names some key rule outs to making the dx of panic disorder.

8. Key Rule Outs • Substances • Non-psychiatric medical conditions, e.g., hyperthyroidism. • Phobias, including agoraphobia • OCD • PTSD • Separation anxiety disorder

9. Lab findings Q. What are laboratory findings?

10. Laboratory Findings? Ans. None are specific to panic disorder, but pts with this disorder do tend to have panic attacks with an infusion of Na+ lactate than those without the disorder.

11. More common Q. Which is more common Panic Disorder with agoraphobia or panic disorder without agoraphobia?

12. More common Ans. Panic Disorder without agoraphobia is twice as common.

13. Gender Q. Gender breakdown?

14. Gender Breakdown Ans. Women to men: two to one says Practice Guideline, Some say three to one.

15. Onset Q. Age at onset?

16. Onset: Ans. Bimodal onset: • Late teens/early twenties, highest • Mid thirties, second highest peak

17. Lifetime prevalence Q. Lifetime Prevalence?

18. Lifetime prevalence Ans. 2%

19. Annual prevalence Q. Annual Prevalence?

20. Annual Prevalence Ans. 1%

21. Primary care Q. Prevalence in Primary Care Practice?

22. Prevalence in Primary Care Practice Ans. 3 – 8 % • Ref: NEJM 2006; 354:2360-7

23. Entry Q. A common place for people with panic disorder to enter the health care system?

24. Entry Ans. Common entry point is the ER

25. Hospitalize Q. When to hospitalize a pt with panic disorder?

26. When to hospitalize a pt with panic disorder Ans. Only hospitalize if there is another psychiatric disorder present that so justifies.

27. Risk factors Q. What are risk factors for panic disorder?

28. Risk Factors Ans. 1. Genetic, higher in monozygotic than dizygotic twins and 8 times as common among close relatives. • 2. May have abnormally sensitive fear network. • 3. Hx of sexual or physical abuse as child. • 4. 80% of pts report major stresses in the 12 months before attacks. Ref : NEJM 2006; 354:2360-7

29. Comorbid Q. What percentage will have comorbid psych disorders during their lifetime?

30. comorbid Ans. Lifetime comorbid disorders: 90% • Ref: NEJM 2006; 354:2360-7

31. Mimic Q. What conditions can mimic a panic attack?

32. mimic Ans. Potential mimics: Hyperthyroidism Hypothyroidism Temporal-lobe epilepsy Asthma Cardiac arrhythmias Pheochromocytoma Too much coffee and other stimulants • Ref: NEJM 2006; 354:2360-7

33. Screen for depression Q. Why screen for depression?

34. Screen for depression to Ans. Screen for depression to ascertain if pt also has depressive disorder. An associated depression increases risk of suicide.

35. Suicide rate Q. What is suicide rate?

36. Suicide rate Ans. Practice Guideline says 1/5, but NEJM article implies that is so because so many are also depressed. Still, it would seem that “1/5” would be correct answer.

37. Personality disorders Q. Which three personality disorders have high co-occurrence with panic disorder?

38. Common co-occurring personality disorders are Ans. Common co-occurring personality disorders: Avoidant Obsessive-compulsive Dependent

39. Medications Q. Which five classes of meds have been shown to be the most efficacious? [“Efficacious” implies potency alone, not related to more general issues as to the use of the med.]

40. Five Classes have Been Shown to Be Effective • 1. SSRIs • 2. SNRIs • 3. High potency benzodiazepines • 4. Tricyclics • 5. MAOIs Ref: NEJM 2006; 354:2360-7

41. Q. Of the five classes of meds, which is preferred? Q. Which of the five classes of meds in the prior screen is preferred for pts with panic attacks?

42. Preferred medical class • SSRIs • Ref: NEJM 2006; 354:2360-7

43. Q. What about bupropion? Q. What about using bupropion in pts with panic attacks?

44. Ans. As to bupropion • Bupropion has not been shown to be effective. • PG, 645

45. Antipsychotics • Q. What about antipsychotics?

46. Ans. As to antipsychotics • Have not been shown to be effective • PG, 646

47. Q. What about propranolol? Q. What about propranolol use in pts with panic disorders?

48. Ans. As to propranolol • Inferior to benzodiazepines for as needed situations. Thus, OK for PRN. • PG, 646

49. Q. What is medication strategy? Q. After selecting the medication, what is medication strategy for panic disorders?

50. Dosing strategy of SSRIs in panic disorder? • Begin with low doses and titrated every weekly as tolerated. Example, 10 mg of fluoxetine with range of 5 – 80. • Ref: NEJM 2006; 354:2360-7