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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. . Criteria of “panic attack”. Q. DSM criteria, very general?. Ans. Outline of Dx of Panic Disorder.

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potential questions on panic disorder

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.

criteria of panic attack
Criteria of “panic attack”

Q. DSM criteria, very general?

ans outline of dx of panic disorder
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.
panic attack symptoms
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.

criteria of panic attack two slides
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
criteria for panic attack second slide
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
rule outs
Rule outs

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

key rule outs
Key Rule Outs
  • Substances
  • Non-psychiatric medical conditions, e.g., hyperthyroidism.
  • Phobias, including agoraphobia
  • OCD
  • PTSD
  • Separation anxiety disorder
lab findings
Lab findings

Q. What are laboratory findings?

laboratory findings
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.

more common
More common

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

more common1
More common

Ans. Panic Disorder without agoraphobia is twice as common.


Q. Gender breakdown?

gender breakdown
Gender Breakdown

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


Q. Age at onset?


Ans. Bimodal onset:

  • Late teens/early twenties, highest
  • Mid thirties, second highest peak
lifetime prevalence
Lifetime prevalence

Q. Lifetime Prevalence?

annual prevalence
Annual prevalence

Q. Annual Prevalence?

primary care
Primary care

Q. Prevalence in Primary Care Practice?

prevalence in primary care practice
Prevalence in Primary Care Practice

Ans. 3 – 8 %

  • Ref: NEJM 2006; 354:2360-7

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


Ans. Common entry point is the ER


Q. When to hospitalize a pt with panic disorder?

when to hospitalize a pt with panic disorder
When to hospitalize a pt with panic disorder

Ans. Only hospitalize if there is another psychiatric disorder present that so justifies.

risk factors
Risk factors

Q. What are risk factors for panic disorder?

risk factors1
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


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


Ans. Lifetime comorbid disorders: 90%

  • Ref: NEJM 2006; 354:2360-7

Q. What conditions can mimic a panic attack?


Ans. Potential mimics:



Temporal-lobe epilepsy


Cardiac arrhythmias


Too much coffee and other stimulants

  • Ref: NEJM 2006; 354:2360-7
screen for depression
Screen for depression

Q. Why screen for depression?

screen for depression to
Screen for depression to

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

suicide rate
Suicide rate

Q. What is suicide rate?

suicide rate1
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.

personality disorders
Personality disorders

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

common co occurring personality disorders are
Common co-occurring personality disorders are

Ans. Common co-occurring personality disorders:





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.]

five classes have been shown to be effective
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

q of the five classes of meds which is preferred
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?

preferred medical class
Preferred medical class
  • SSRIs
  • Ref: NEJM 2006; 354:2360-7
q what about bupropion
Q. What about bupropion?

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

ans as to bupropion
Ans. As to bupropion
  • Bupropion has not been shown to be effective.
  • PG, 645
  • Q. What about antipsychotics?
ans as to antipsychotics
Ans. As to antipsychotics
  • Have not been shown to be effective
  • PG, 646
q what about propranolol
Q. What about propranolol?

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

ans as to propranolol
Ans. As to propranolol
  • Inferior to benzodiazepines for as needed situations. Thus, OK for PRN.
  • PG, 646
q what is medication strategy
Q. What is medication strategy?

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

dosing strategy of ssris in panic disorder
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
q goal of medication treatment
Q. Goal of medication treatment?

Q. Goal of medication treatment in pts with panic disorders?

ans treatment goal with meds
Ans. Treatment Goal with meds:
  • 1. Decrease frequency of attacks
  • 2. Decrease intensity of attacks
  • 3. Decrease anticipatory anxiety
  • 4. Decrease phobic avoidance
  • Ref: PG, p 640
first choice
First Choice?

Q. If the First Choice SSRI is not effective, what to do?

ans if ssri fails then
Ans. If SSRI fails, then


1. CBT or

2. Another SSRI

  • Ref: NEJM 2006; 354:2360-7
in the face of 2 ssri failures
In the face of 2 SSRI failures

Q. If two SSRIs have failed?

ans in the face of failure of two ssris
Ans. In the face of failure of two SSRIs:
  • CBT or
  • Another class of meds:
    • Tricyclic
    • MAHO
    • Or
    • SNRI
  • Ref: NEJM 2006; 354:2360-7
  • Q. What about use of benzodiazepines?
ans as to use of benzodiazepines
Ans. As to use of benzodiazepines:
  • Not recommended as primary med because of addiction potential and the tendency of withdrawal to have discontinuation syndrome.
  • Useful for as needed situations, such as apprehensiveness about taking a airplane flight.
  • Ref: NEJM 2006; 354:2360-7
  • Q. Which benzodiazepines are recommended for as needed use, i.e., for PRNs?
a recommended benzodiazepines
A. Recommended benzodiazepines
  • Long lasting:
    • ER alprazolam
    • Clonazepam
  • Ref: NEJM 2006; 354:2360-7
  • Q. FDA approved for panic disorder are?
only fda approved meds for panic disorders of all classes
Only FDA approved meds for panic disorders of all classes:
  • Alprazolam
  • Clonazepam
  • Fluoxetine
  • Paroxetine
  • Sertraline
discontinuation syndrome
Discontinuation syndrome
  • Q. Signs of discontinuation syndrome?
ans signs of discontinuation syndrome
Ans. Signs of Discontinuation Syndrome:
  • Fearfulness
  • Irritability
  • Headache
  • Muscle tension
  • Perceptual abnormalities
  • Insomnia
  • Decreased concentration
  • Cardiovascular symptoms

[Ref: NEJM 2006; 354:2360-7]

Q. To avoid discontinuation syndrome in pts on benzodiazepines for a lengthy period of time ?
ans to avoid discontinuation syndrome
Ans. To avoid discontinuation syndrome
  • Taper with a slow acting benzodiazepine for over a month or two.
  • Ref: NEJM 2006; 354:2360-7
cbt consist of
CBT consist of?

Q. For panic disorder, of what does CBT consist?

ans cbt consists of
Ans. CBT consists of:
  • In 12 to 16 sessions, usually weekly, the focus is on recreating the feared symptoms and then modifying the pt’s response. For example, if attack is precipitated by increase pulse, have pt jog and that helps correct the cognitive distortions.
  • Ref: NEJM 2006; 354:2360-7
cbt v meds
CBT v. Meds
  • Q. CBT compared to meds as to efficaciousness?
cbt and meds
CBT and Meds
  • They are equally effective.
  • Meds obtain results more rapidly.
  • PG, 650
drug store
Drug Store
  • Q. What can the pt buy at the drug store that may interfere with treatment of panic disorder?
at the drug store could obtain
At the drug store, could obtain
  • 1. Cigarettes
  • 2. Coffee
  • 3. sympathomimetics [nasal decongestants]
other psychotherapies
Other psychotherapies

Q. What about other psychotherapies? Are there any controlled studies?

as to other psychotherapies
As to other psychotherapies
  • No controlled studies
  • Q. What if pt relapses, months after apparently successful treatment?
after a relapse
After a relapse
  • Repeat prior treatment
  • Ref: NEJM 2006; 354:2360-7
two relapses
Two relapses
  • Q. What to do after two relapses?
after two relapses
After two relapses,
  • Consider long term use of meds
  • Ref: NEJM 2006; 354:2360-7
q pt has panic disorder irritable bowel syndrome respiratory signs and migraine
Q. Pt has panic disorder, irritable bowel syndrome, respiratory signs, and migraine.
  • Can one class of meds service all of these?
pt has become dependent on you
Pt has become dependenton you
  • Q. What to do if the pt becomes dependent on the psychiatrist?
when pt becomes dependent on psychiatrist
When pt becomes dependent on psychiatrist
  • Maintain available and address directly. DO NOT address through unavailability.
  • PG, 649