Panic attack disorder

The elderly client diagnosed with a panic attack disorder is in the busy day room of a long-term care facility and appears anxious, is starting to hyperventilate, is trembling, and is sweating. Which action should the nurse implement first ... 

In two studies in which benzodia2epines were gradually tapered, concurrent cognitive-behavioral therapy (CBT) did not increase the proportion of patients who were able to successfully discontinue their use of these agents (Oude Voshaar et al. 2003 Vorma et al. 2003). On the other hand, other studies of patients with panic disorder found that CBT facilitated the discontinuation of benzodiazepine use (Otto et al. 1993). Similarly, CBT may be superior to supportive medical management in preventing the reoccurrence of panic attacks in panic disorder patients in whom alprazolam has been tapered (Bruce etal. 1999). 

Nutt DJ, Glue P, Lawson C, et al Flumazenil provocation of panic attacks evidence for altered benzodiazepine receptor sensitivity in panic disorder. Arch Gen Psychiatry 47 917-923, 1990... 

The acute phase of panic disorder treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and social anxiety avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 

The main objectives of treatment are to reduce the severity and frequency of panic attacks, reduce anticipatory anxiety and agoraphobic behavior, and minimize symptoms of depression or other comorbid disorders.48 The long-term goal is to achieve and sustain remission. 

The essential feature of SAD is an intense, irrational, and persistent fear of being negatively evaluated in a social or performance situation. Exposure to the feared situation usually provokes a panic attack. Symptoms of SAD are shown in Table 68-3. The fear and avoidance of the situation must interfere with daily routine or social/occupational functioning. It is a chronic disorder with a mean age of onset in the teens. 

The goals of therapy of panic disorder include a complete resolution of panic attacks, marked reduction in anticipatory anxiety and phobic fears,... 

It is not unusual for nosologic systems to adopt a mixed approach that contains both monothetic and polythetic elements. This type of system, which is used in the DSM, may require that certain diagnostic criteria are present. Other criteria for the disorder may be definitive but not necessary so that any combination of these latter criteria may be sufficient for the diagnosis. For example, panic attacks and some form of panic-related worry are both definitive and necessary criteria for panic disorder. However, any combination of 4 of the 13 symptoms constituting a panic attack is sufficient for this particular element in the diagnosis. 

Essentially this is a four-component definition. First, the person has to have panic attacks. Second, these attacks should not be caused by a substance or general medical condition, or be accounted for by another mental disorder. Third, at least two of these panic attacks have to be unexpected. Fourth, they should lead to a clinical syndrome that includes concern about additional attacks, worry about the consequences of panic, or significant behavioral change as a result of fear of panicking. This syndrome is the heart of panic disorder, and taxometric analyses would focus on it. However, an investigator should deal with the other components first. 

In the case of panic disorder, the exclusion criteria specify that only certain types of panic attacks are relevant to this diagnosis (i.e., panic attacks resulting from drugs, other anxiety disorders do not count). One could sim-... 

It is less clear how one should handle the requirement of unexpected and recurrent panic attacks. This is an inclusion criterion in form, while it is an exclusion criterion in function. This requirement can be operationalized either as a selection filter or as a component of the syndrome. We think it useful to break up unexpected and recurrent into two components and consider them separately. The unexpectedness of the panic attack is such a fundamental requirement in the DSM definition that it makes sense to operationalize it as a selection criterion. According to the DSM, individuals who have only experienced situationally bound panic attacks cannot have a panic disorder diagnosis, which can happen if this criterion is used as an indicator in CCK analyses. An individual can become a taxon member by being elevated on some, but not necessarily all, indicators. Moreover, unexpectedness of a panic attack cannot be easily coded as a continuous variable, which can present computational difficulties, especially for MAXCOV. 

We hope these examples make another important idea apparent. The DSM should be evaluated from the bottom up, starting with basic syndromes such as panic attacks or manic episodes and working up toward complicated disorders. Syndromes are building blocks of the DSM diagnoses, and there are considerably fewer syndromes than there are disorders. Evaluation of syndromes seems to be a logical place to start. 

Amering, M., Katschnig, H. (1990). Panic attacks and panic disorder in cross-cultural perspective. Psychiatric Annals, 20, 511-516. 

Panic disorder is characterized by the occurrence of panic attacks that occur spontaneously and lead to persistent worry about subsequent attacks and/or behavioral changes intended to minimize the likelihood of further attacks. Sporadic panic attacks are not limited, however, to those with syndromal panic disorder as they do occur occasionally in normal individuals and in those with other syndromal psychiatric disorders. The hallmark of panic disorder is that the panic attacks occur without warning in an unpredictable variety of settings, whereas panic attacks associated with other disorders typically occur in response to a predictable stimulus. For example, a person with acrophobia might experience a panic attack when on a glass elevator. A patient with obsessive-compulsive disorder (OCD) with contamination fears may have a panic attack when confronted with the sight of refuse, and a combat veteran with post-traumatic stress disorder (PTSD) may experience a panic attack when a helicopter flies overhead or an automobile backfires. 

As you might expect, the diagnostic criteria for panic disorder requires the presence of recurrent panic attacks, but panic attacks alone are not sufficient for the diagnosis of panic disorder. Those with other anxiety disorders, for example, can experience panic attacks when confronted by the situation or object that they fear. 

Furthermore, DSM-IV does not specify a minimum number of panic attacks or a minimum frequency of panic attacks. The hallmark of panic disorder is that the panic attacks are unpredictable. They must occur without warning in a variety of settings, and they inexorably lead to a persistent anticipatory worry about the meaning of the attacks or the possibility of having more attacks. See Table 5.5 for the diagnostic criteria for panic disorder. 

Although the delineation of panic disorder as a unique diagnostic entity is a relatively recent development, references to what would today be known as panic attacks commonly appeared in the annals of medical and psychiatric literature. For example, cardiologists, who frequently encounter patients with panic disorder due to the dramatic presentation of cardiac symptoms in association with panic, have numerous terms for panic including cardiac neurosis, DaCosta s syndrome, soldier s heart, and neurocirculatory asthenia. 

The functional impairment associated with panic disorder is often underestimated. This may in part be due to the fact that the panic attacks themselves are brief and occupy only a small fraction of the patient s waking hours. However, the... 

Panic disorder is a common clinical problem. Over the course of their lives, about 1 of every 5 people experience at least one panic attack. Less than half of these have a spontaneous or unexpected panic attack in a situation in which they would not have expected to be anxious, but even those do not necessarily fulfill the diagnostic criteria for panic disorder, which requires a persistent worry about the consequences of attacks or the possibility of having future attacks. The lifetime incidence of panic disorder is 2-4%. It is evenly distributed among all races and ethnic groups, but women are twice as likely to be affected as men. Early childhood trauma, such as sexual abuse, markedly increases the risk for the development of panic disorder in adulthood. 

Panic disorder usually begins during adolescence or early adulthood with the mean age of onset in the early twenties. New onset panic disorder in the elderly is relatively uncommon, though panic attacks may be seen in those with medical illnesses such as emphysema or heart disease. 

As noted above, panic disorder is commonly accompanied by agoraphobia as avoidant behaviors develop in what are usually partially successful attempts to reduce the frequency and intensity of panic attacks. Estimates for the co-occurrence of agoraphobia in patients with panic disorder range from 30% to 50%. 

The symptoms of a panic attack are so frightening that an unusually large number of those with panic disorder (in comparison to other psychiatric illnesses) seek treatment on their own accord. However, easily half of those who seek treatment do so in general medical settings such as hospital emergency rooms and the offices of primary care physicians. Easily mistaken for severe and even life-threatening medical conditions such as asthma attacks and heart attacks, panic disorder results in disproportionately higher health care utilization than other anxiety disorders. 

Panic disorder is typically a chronic condition, but its severity often waxes and wanes over time. Some experience continuous symptoms whereas others have long periods of remission interspersed with periodic outbreaks of panic attacks. When agoraphobia accompanies panic disorder, it usually begins within the first year or so of panic attacks. The course of agoraphobia varies. The severity of the agoraphobic avoidance can either fluctuate with the frequency of panic attacks or remain constant despite changing severity in the panic attacks themselves. 

The differential diagnosis of panic disorder includes other psychiatric illnesses, medical illnesses, and substances that can cause panic attacks. Also included are medical illnesses that cause symptoms resembling panic attacks. It should be mentioned that these other conditions, which are described below, and panic disorder are not necessarily mutually exclusive. In fact, there is a high rate of comorbidity between panic disorder, other anxiety disorders, and mood disorders. Because panic disorder is frequently accompanied by agoraphobia, the differential diagnosis also includes illnesses that are associated with symptoms resembling the avoidance of the agoraphobic patient. 

Generalized Anxiety Disorder (GAD). Theoretically, panic disorder and GAD should be fairly easy to distinguish. The symptoms of a panic attack are known for their intensity and their brevity, whereas the symptoms of GAD tend to be somewhat milder and considerably more persistent. Nevertheless, patients commonly confuse the two when describing their symptoms. It is not at all unusual for a patient to describe an anxiety attack or panic attack that comes on gradually and lasts several hours (or even days). This does not represent a true panic attack but a periodic fluctuation in the severity of their anxiety. 

Obsessive-Compulsive Disorder (OCD). Like those with social phobia, patients with OCD can also experience a panic attack when confronted by the object of their fear. Again, the distinction from panic disorder lies in discriminating such stimulus-induced panic attacks from spontaneous panic attacks. 

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