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Case

J. is a 30-yo female who shares an apartment with a roommate. It was the end of a long workday, and after a long ride on the subway, J. had just arrived home to her apartment. All of a sudden, out of the blue, she felt her heart racing and became out of breath. It felt as if she were having a heart attack. Luckily, her roommate was there, and was able to drive her to the local emergency department. Since that first episode, she has had a panic attack every 1 to 2 weeks. She has become increasingly anxious about triggering attacks. Due to her fears of having another attack, she taken a short-term leave of absence from work and spends her days at home. 

Epidemiology

• Prevalence of 2-13% in primary care settings (Stein et al., 1999)
• Gender: Females > Males
• Onset: Late adolescence or early adulthood

Screening

Consider screening patients with the following risk factors:

• Anxiety sensitivity (outlook to believe that symptoms of anxiety are harmful)
• History of “fearfull spells” (not full criteria of panic attack)
• Personal or family history of anxiety and/or panic attacks
• Smoking

Screening Questions

Consider using questions from the Autonomic Nervous System Questionnaire (ANSQ) (Stein et al., 1999) (high sensitivity 94%, however note low specificity 25%)

• Clinician:
  
  1) In the past 6 months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy? Yes/No
  
  2) In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath? Yes/No

If patient answers yes to 1) or 2), proceed to rest of ANSQ questions

3. Did any of these spells or attacks ever happen in a situation when you were the center of attention? If yes, then consider social anxiety / social phobia

4. How many times have you had a spell/attack in the past month? (0, once, 2-3 times, 4-10 times, more than 10 times)

5. In the past month, how worried have you been that spells or attacks might happen again? (Not at all worried, Somewhat worried, very worried)

Diagnosis

• Essential features:
  • Recurrent unexpected panic attacks
  • Anticipatory anxiety
  • Distress/dysfunction
    Diagnosis may be difficult to diagnose due to the potential seriousness of symptoms such as chest pain and shortness of breath (Ham et al., 2005)

DSM-5 Criteria

• Recurrent unexpected panic attacks: A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following symptoms occur:

  • Palpitations, pounding heart, or accelerated heart rate

  • Sweating

  • Trembling or shaking

  • Sensations of shortness of breath or smothering

  • Feelings of choking

  • Chest pain or discomfort

  • Nausea or abdominal distress

  • Feeling dizzy, unsteady, light-headed, or faint

  • Chills or heat sensations

  • Paresthesias (numbness or tingling sensations)

  • Derealisation (feeling of unreality) or depersonalization (being detached from oneself)

  • Fear of losing control or going crazy

  • Fear of dying
     

• At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

  • Persistent concern or worry about additional panic attacks or their consequences (losing control, having a heart attack, “going crazy”)

  • A significant maladaptive change in behaviour related to the attacks (behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
     

• The disturbance is not attributable to the physiological effects of a substance (drug of abuse, a medication) or another medical condition (hyperthyroidism, cardiopulmonary disorders)
   

• The disturbance is not better explained by another mental disorder (the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder)

Differential Diagnosis

Anxiety disorder due to another medical condition

• Hyperthyroidism
• Hyperparathyroidism
• Hypoglycemia
• Pheochromocytoma
• Vestibular dysfunctions
• Seizure disorders
• Cardiopulmonary conditions (arrhythmias, asthma, etc)
• Substance/medication-induced anxiety disorder
• CNS stimulants (cocaine, amphetamines, caffeine)
• Cannabis
• Withdrawal from CNS depressants (alcohol, barbiturates)

Other mental disorders with panic attacks as an associated feature

• Triggered by social situations (social anxiety disorder)
• Triggered by phobic objects or situations (specific phobia)
• Triggered by worry (generalized anxiety disorder)
• Triggered by separation from attachment figure (separation anxiety disorder)

Comorbidity

Comorbid psychiatric conditions in those with panic disorder:

• Depression (in 30-50% of patients with panic disorder)
• Suicide attempts (in 20% of patients with panic disorder)
• Agoraphobia (in 30-50% of patients with panic disorder) 

Reference: CPA Guidelines, 2006; Vanin J et al., 1998

The following medical conditions are more common in those with panic disorder (Katzman et al., 2014):

• Thyroid disease
• Cancer
• Chronic pain
• Cardiac disease
• Irritable bowel syndrome
• Migraine
• Allergic and respiratory diseases

Investigations

• Panic disorder is a clinical diagnosis; there are no pathognomonic diagnostic tests
• Investigations are useful to eliminate other conditions based on patient symptoms:
  • CBC (haemoglobin to rule out syncope)
  • Electrolytes (rule out hypokalemia and acidosis)
  • Glucose (rule out hypoglycaemia)
  • TSH (rule out hyperthyroidism)
  • Calcium (rule out hyperparathyroidism)
  • Cardiac enzymes (rule out acute coronary events)
  • D-dimers (rule out pulmonary embolism)
  • Urine toxicology (amphetamine, cocaine, cannabis)
  • ECG (ischemia, infarction, pericarditis, ventricular preexcitation)
  • Holter monitor (suspected arrhythmias)

Physical Exam

• There are no physical signs specific for panic disorder
• The physical exam is to help rule out contributory medical conditions
• During an acute panic attack, physical signs may include:
  • Cardiac
    • Hypertension
    • Tachycardia
    • Examine for rhythm disturbances such as arrhythmia, supraventricular tachycardia
  • Respiratory
  • Increased respiratory rate
  • Examine for asthma (e.g. wheezes) and chronic obstructive pulmonary disease
  • Mild tremors
  • Dermatologic
  • Abdominal exam
  • out abdominal causes for possible complaints of epigastric pain
  • Rule out neurologic causes for possible complaints of headaches, vertigo/dizziness, and syncope symptoms
  • Neurologic
  • Clammy skin
  • Neurological exam

Management: Overview

• Goals of treatment:
  • Decrease frequency and severity of panic attacks
  • Reduce anticipatory anxiety and avoidance
  • Improve functioning
  • CBT alone or CBT with pharmacotherapy should be considered first-line management (Katzman et al., 2014)
• CBT alone may not be sufficient for patients with severe, frequent panic attacks, moderate-to-severe major depression, suicidal ideation, or worsening agoraphobia

Prognosis

• Panic disorder is generally chronic
• Although relapses can occur, they can nonetheless be treated

Management: Education about Panic Disorder including Self-Help Strategies

Educate the patient about Panic Disorder to include elements such as :

• The bad news:
  • Validate that the patient’s experience is real, and that panic attacks are a very scary experience
  • Panic attacks happen when the body’s alarm system (i.e. autonomic system) is activated, however, it is a false alarm.  
• The good news:
• Let the patient know that panic attacks are not life-threatening, are almost never acutely dangerous, are not uncommon, and will get better over time
• Reassurance that there is no actual danger can be very reassuring
• Getting enough sleep
• Reducing use of caffeine, nicotine, alcohol and any other stimulants or recreational drugs
• Reading about panic disorder
• Treatment options such as
  • Counseling/therapy
  • Medications
• Self-help strategies such as

Educate family members about how to support their loved one with Panic Disorder :

• Ask the patient about how s/he would like to be supported
• During a panic attack, common support strategies include :
  • Helping me to get to a quiet place
  • Be with me
  • Staying calm
  • Breathing slowly with me
  • Don’t say things like « Its all in your head », « Just get a grip on yourself », etc.

Management: Psychological

• Cognitive behaviour therapy (CBT)
  • CBT can be delivered in various formats, such as individual CBT, group CBT, minimal intervention format (self-help books), telephone, online CBT website, or online CBT therapist
• Elements of CBT include:
  • Education about Panic Disorder
    • Explain panic attacks and the panic cycle including body reactions and behaviours
    • Explain the plan for treatment including goals, and reading materials
  • Cognitive strategies
    • Describe the worry thoughts (e.g. catastrophic thinking) that often accompanies panic attacks
    • Work with the patient to come up with more helping coping thoughts
    • Challenges the unrealistic thoughts using behavioural experiments
       
  • Exposure
    • Help the patient to gradually expose him/herself to feared sensations and situations such as
    • Somatic symptoms experienced during a panic attack
    • Show the patient how symptoms (e.g. dizziness, breathlessness, heart racing) can be reproduced through hyperventilation
  • Real-life avoided situations in a graded format (typically between sessions)
     
• Coping strategies for anxiety such as
  • Deep breathing
    • Paced breathing can trigger panic type symptoms, which is the idea behind the classic breathing into a paper bag
  • Mindfulness practice to reduce anxiety
    • Teach patients how to focus on the present as opposed to the future
    • Teach patients to be in full awareness of their senses such as seeing, hearing, feeling, touch
  • Problem solving and relapse prevention
    • Panic disorder often occurs during or following periods of stressful life events, thus learning to problem-solve stresses is important
    • Help the patient identify what stresses they are facing in their life
      • E.g. “What stresses are you under these days? E.g. work, school, relationships, conflicts, etc.?”
    • Help the patient come up with strategies to deal with these stresses
    • E.g. “What do you wish different with this stress? What do you think you could do?”
• Help the patient come up with a plan on how to cope with future episodes or anxiety or panic
  • E.g. “Let’s problem-solve how you are going to cope if the panic attacks come back.”  

Management: Medications

• Consider medications if non-medication strategies have not been successful
• Onset of action: With SSRIs, improvement may be seen as early as 1-week, though significant improvement usually takes several weeks (up to 6-8 weeks)
• If medication successful
  • Continue medication until patient is no longer avoiding feared situations
  • Continue therapy for 8 to 12 months
    • When discontinuing medication
  • Taper dosage gradually over 8 weeks, for example reducing the dosage by 25% each 1-2 weeks
  • Continue CBT strategies such as exposure / relaxation during this period

Medications for Panic Disorder

First line

• Citalopram: Start 20 mg daily; max daily 40-60 mg
• Escitalopram: Start 5-10 mg daily; max daily 20 mg
• Fluoxetine: Start 20 mg daily; max daily 80 mg
• Fluvoxamine: Start 50 mg daily; max daily 300 mg
• Paroxetine: Start 20 mg daily; max daily 60 mg
• Sertraline: Start 50 mg daily; max daily 200 mg
• Venflaxine XR: Start 37.5-75 mg daily; max daily 225 mg

Second-line

• Clomipramine: Start 25 mg daily; max daily 200 mg
• Imipramine: Start 25 mg daily; max daily 150 mg
• Mirtazapine: Start 15 mg daily; max daily 45 mg
• Reboxetine: Start 4 mg twice daily, max 12 mg daily

Benzodiazepines

• Alprazolam: Start 0.5 mg three times daily; average effective dose 5-6 mg daily
• Lorazepam: Start 0.5 mg daily; max daily 3-4 mg
• Diazepam: Start 2.5 mg daily; max daily 10 mg
• Clonazepam: Start 0.25 mg twice daily; target dose 1 mg daily; max daily 4 mg

Table. Medications Commonly Used for Panic Disorder. Dosages from CPA Practice Guidelines, 2006; CPS Monographs, 2014.

The following medications are NOT recommended for panic disorder:

• Buspirone
• Trazadone
• Propranolol
• Tigabine
• Carbamazepine

When to Refer

Consider referring to mental health professionals if

• Unclear diagnosis
• Risk of self-harm or harm to others
• Multiple psychiatric or medical co-morbidities
• Initial attempts at treatment have been unsuccessful.
• There is a need for counselling/therapy such as CBT.

Clinical Practice Guidelines

• Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorder. BMC Psychiatry. 2014; 14(Suppl1): S1.
• Clinical Practice Guidelines: Management of Anxiety Disorders. The Canadian Journal of Psychiatry.  2006; 51(2).

References

• Ham P, Waters DB, Oliver MN. Treatment of Panic Disorder. Am Fam Physician. 2005; 71(4): 733-739.
• Stein MB et al. Psychosomatic Medicine. Jan 1999 61: 359–364.
• Vanin JR, Vanin SK. Editorials: Panic disorder: Diagnosis and Treatment in Primary care. Am Fam Physician. 1998; 57(10): 2328-2334.

About this Document

Written by Talia Abecassis (uOttawa Medical Student, Class of 2017). Reviewed by Dr. Dhiraj Aggarwal, along with members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), M. Cheng (psychiatrist).

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance.

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