Panic attacks first attack

Evaluate patients for symptom improvement frequently (e.g., weekly) during the first 4 weeks of therapy. The goal is to alleviate panic attacks and reduce anticipatory anxiety and phobic avoidance with resumption of normal activities. Alter the therapy of patients who do not achieve a significant reduction in panic symptoms after 6 to 8 weeks of an adequate dose of antidepressant or 3 weeks of a benzodiazepine. Regularly evaluate patients for adverse effects, and educate them about appropriate expectations of drug therapy. 

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. 

The first task is to select some operationalization of a panic attack. The investigator can rely on the DSM definition or she or he can perform a CCK analysis of the phenomenon. Specifically, panic attack symptoms can be ana-... 

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. 

Benzodiazepines. The introduction of the benzodiazepines represented a significant advance in the treatment of panic disorder. In contrast to MAOIs and TCAs, the benzodiazepines begin to provide relief the very first day of treatment, and many patients experience a complete response by the end of the second week of therapy. All benzodiazepines should theoretically alleviate the symptoms of a panic attack at comparable doses, but the benzodiazepines of choice are alprazolam (Xanax, Xanax XR) and clonazepam (Klonopin). It likely is not coincidental that these two are among the highest potency benzodiazepines. However, they differ considerably from a pharmacokinetic standpoint. If clonazepam is the tortoise of benzodiazepines, then alprazolam is the hare. 

Panic disorder. Sixty-six panic disorder patients were included in a study. All of whom met the DSM-IV diagnosis of panic disorder (n = 45) or panic disorder with agoraphobia ([PDA] n = 21). Twenty-four patients experienced their first panic attack within 48 hours of cannabis use and then went on to develop panic disorder. All the patients were treated with paroxetine (gradually increased up to 40 mg/day). The two groups responded equally well to paroxetine treatment as measured at the 8 weeks and 12 months follow-up visits. There were no significant effects of age, sex, and duration of illness as covariates with response rates between the two groups. In addition, panic disorder or panic disorder... 

Ventilatory abnormalities have been identified in first-degree relatives of patients with panic disorder (Perna et ah, 1995 Coryell, 1997), as well as in patients with possible precursors for panic disorders, such as separation anxiety disorder (Pine et ah, 2000) or isolated panic attacks (Perna et ah, 1995). Additionally, studies have found family loading for panic disorder in the relatives of panic patients with respiratory abnormalities (Perna et al., 1996), suggesting that hypersensitivity to CO2 inhalation may be a trait marker for panic disorder rather than a state marker. These data suggest that parents with panic disorder may transmit a diathesis for certain forms of anxiety (e.g., separation anxiety disorder) that is observable in the respiratory... 

Bradwejn and colleagues first administered CCK-4 to patients with panic disorder by using a double-blind, placebo-control methodology. Bolus injections of CCK-4 (50 pg] precipitated a panic attack, as defined by DSM-111 criteria (American Psychiatric Association 1980] and patient self-report. 

Before 1980, the term anxiety neurosis was used to describe a syndrome that included both chronic generalized anxiety and panic attacks. GAD and panic were first listed as discrete diagnoses in the DSM-III, in part because of observed differences in their response to available drug treatments (i.e., the former to benzodiazepines, the latter to antidepressants for a more detailed discussion of panic disorder, see Chapter 13). 

Paroxetine was the first SSRI approved for the treatment of PD with or without agoraphobia. Oral doses of 10 to 60 mg per day significantly reduce the frequency of panic attacks, and long-term therapy has been shown to be efficacious for the symptoms of PD ( IIQ). Long-term paroxetine therapy has also been shown not only to maintain efficacy but also to produce continued improvement. This is an important asset for antipanic pharmacotherapy in a chronic illness subject to relapse ( 111). 

There has been a report of two patients with treatment-resistant PD who responded to treatment with olanzapine added to ongoing treatment with clonazepam (2 mg per day), ketazolam (30 mg per day), and venlafaxine (150 mg per day). The first patient was started on 7.5 mg at bedtime, and 2 weeks later he was much calmer and sleeping well. Olanzapine was increased to 12.5 mg per day, and venlafaxine was replaced with nefazodone up to 60 mg per day. Over the next few weeks, he improved progressively and clonazepam and ketazolam were discontinued. After 4 months, he was free from panic attacks and left his home alone. The second patient had 10 mg olanzapine daily added to ongoing treatment with 75 mg per day amitriptyline and 10 mg per day diazepam. After 2.5 months, she was being given olanzapine and had started going out on her own (126). 

In another case, one of the core members lost his job as a result of being taken to a psychiatric hospital in an LSD panic attack. Becker has pointed out that such a crisis can often be the first step in a frankly deviant career (Becker, 1963). However, this young man simply got himself another job, in which such an item on his record would not cause him trouble. It is also of considerable interest that this panic attack occurred away from the group, when he took LSD with some friends he was introducing to the drug. 

Imipramine was first shown in 1962 to have a beneficial effect in the acute episodes of anxiety that have come to be known as panic attacks. Recent studies have shown it to be as effective as MAO inhibitors and benzodiazepines. It has also been demonstrated that SSRIs are effective in panic disorder. In some instances, benzodiazepines are preferred, as they are well tolerated and their clinical effects become evident promptly. Alternatively, if one wishes to avoid the physiologic dependence associated with chronic benzodiazepine use, SSRIs are acceptable for many patients though they require several weeks to produce full therapeutic effects. 

A 29-year-old woman with bulimia nervosa and a family history of anxiety was enrolled in a trial of naltrexone (100 mg/day). She had no history of opioid use. Within hours of her first dose she experienced alarm, anxiety, chest discomfort, shortness of breath, a fear of dying, sweating, nausea, and derealization. She was unable to remain at home or to go out alone. For 3 days she continued to take naltrexone, with an increasing frequency of panic attacks. On day 4 she was treated with alprazolam (0.5 mg) but relapsed after further naltrexone. Withdrawal of naltrexone led to complete remission of symptoms. 

The female client taking lorazepam (Ativan), a benzodiazepine, for panic attacks tells the clinic nurse that she is trying to get pregnant. Which action should the nurse take first ... 

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 ... 

A panic attack is defined in the DSM-IV-TR (APA 2000 393) as a discrete period in which there is a sudden onset of intense apprehension, fearfulness or terror, often associated with feelings of impending doom . Three sub-types of panic attack are described. These are situationally bound, situationally pre-disposed and unexpected or uncued panic attacks. Situationally bound panic attacks occur immediately on exposure to, or in anticipation of, a specific situation. Situationally pre-disposed panic attacks are slightly different, in that while they are associated with a particular situation, they do not necessarily occur immediately on exposure to, or anticipation of, that situation. However, they are more likely to happen in that situation than others. Unexpected or uncued panic attacks occur in the absence of any obvious situational triggers. In the context of the work situation, the first two types are more commonly encountered and they are linked to specific triggering situations or tasks in the workplace. However, the formulation and treatment for each sub-type is similar and is described below. 

Andrea was initially not convinced that her problem was panic attacks. She was convinced that she had some serious physical illness she was unable to believe that psychological factors could make her feel so bad. However, after a visit to her doctor and a number of physical tests had indicated that there was nothing physically wrong with her, she began to accept that her symptoms were due to anxiety. At our first session, Andrea described herself as a fighter and stated that she was determined that her anxiety was not going to beat her. 

Andrea, the medical consultant in the case study presented above, was determined to confront and overcome her anxiety and consequently, with a little encouragement, was able to put herself back into the situations which triggered her panic attacks in the first place. However, it is not always the case that an individual can confront their fears in this way. Frequently, once an individual has experienced a panic attack or a sequence of panic attacks in a given situation, they want to avoid that situation in case it happens to them again. Where the fear and avoidance of a specific situation becomes persistent and excessive, it is described as phobic anxiety (APA 2000). 

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