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anxiety:panic [on January 20, 2020]
anxiety:panic [on May 16, 2021] (current)
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 **Panic disorder** is a condition where there are recurrent //​unexpected//​ panic attacks, in the absence of triggers. It is marked by persistent concern about additional panic attacks and/or maladaptive change in behaviour related to the attacks. **Panic disorder** is a condition where there are recurrent //​unexpected//​ panic attacks, in the absence of triggers. It is marked by persistent concern about additional panic attacks and/or maladaptive change in behaviour related to the attacks.
  
-==== Epidemiology ​==== +== Epidemiology == 
-The lifetime prevalence of panic disorder is 2.5%, and it affects 3 females for every 1 male. Panic disorder ​is more prevalent ​in patients with medical conditionsincluding thyroid diseasecancerchronic pain, cardiac disease, irritable bowel syndrome, migraine, as well as allergic ​and respiratory diseases compared with the general population. +  ​* ​The lifetime prevalence of panic disorder is between ​2-3in the United States 
-==== Panic Attacks ==== +    * Rates are much lower in Asian, African, and Latin American countries; ​it is similarly lower in LatinosAfrican AmericansCaribbean blacks, and Asian Americans.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual ​of Mental Disorders (5th ed.). ArlingtonVA.)] 
-A panic attack is a single, discrete episode of intense fear and discomfortA panic attack must peak abruptly ​(rapid onset of under 10 minutes), and must be accompanied by a cluster ​of physical symptomsA typical panic attack is relatively short and lasts no more than 15 minutes. The prevalence ​of panic attacks (not disorder) ​is 11.2% in adults, ​and can occur in the context ​of anxiety disorders, other mental disordersand medical conditions.+  * It affects 2 females for every 1 male.[(American Psychiatric Association. (2013). Diagnostic ​and Statistical Manual ​of Mental Disorders (5th ed.)Arlington, VA.)] 
 +  * The rates of panic disorder ​gradually increase in adolescence and peak during adulthood.[(American Psychiatric Association. (2013). Diagnostic ​and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +    * The median age of onset is between 20 to 24 years in the United States.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual ​of Mental Disorders (5th ed.). ArlingtonVA.)]
  
 +== Prognosis ==
 +  * Youth with panic attacks may go on to develop mood disorders such as bipolar disorder and major depressive disorder, other anxiety disorders, eating disorder, psychotic disorders, and personality disorders.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +  * Panic disorder can have a negative impact on physical and psychological function, in addition to stress on the individual'​s interpersonal functioning (especially with their family members).[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +  * Typically, panic disorder has a chronic waxing and waning course over the individual'​s lifetime.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Individuals with panic disorder are at a higher risk for suicide.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +
 +<​callout>​
 +**Note**: The prevalence of panic attacks (//not// disorder) is 11.2% in adults, and can occur in the context of anxiety disorders, other mental disorders, and medical conditions. Panic attacks in and of themselves are //not// pathological,​ and do not require treatment.
 +</​callout>​
 +
 +== Comorbidity ==
 +  * Individuals with panic disorder have a significantly higher risk of being diagnosed with another anxiety disorder, mood disorder, impulse control disorder, or substance use disorder.
 +    * Major depressive disorder is the most common, and occurs in an estimated 30 to 40% of individuals.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +    * Panic disorder also commonly cooccurs with agoraphobia.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 +
 +== Risk Factors ==
 +  * Adverse childhood experiences can increase the risk for panic disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Smoking is a risk factor for panic attacks and panic disorder.
 +  * Most individuals with panic attacks are also able to identify a stressor in the months prior to their panic attack.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Panic disorder is more prevalent in patients with medical conditions, including thyroid disease, cancer, chronic pain, cardiac disease, irritable bowel syndrome, migraine, as well as allergic and respiratory diseases compared with the general population.
 +  * Agents such as sodium lactate, yohimbine, [[addictions:​caffeine:​home|caffeine]],​ isoproterenol,​ carbon dioxide, and cholecystokinin,​ can provide panic attacks in individuals with panic disorder more so than in healthy controls (but this is not a diagnostic marker).[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +
 +== Cultural ==
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​
 +See also article: **[[anxiety:​z-other-specified-anxiety|]]**
 +</​alert>​
 +  * Panic attacks can have various cultural interpretations and is linked to various cultural syndromes.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] Having an understanding of the cultural concepts of disease and mental disorders is important when assessing panic attack symptoms in a cultural context.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +    * In Hispanic individuals,​ //ataque de nervios// ("​attack of nerves"​) is a cultural syndrome used frequently to describe symptoms of intense emotional upset including acute anxiety, anger, or grief, screaming and shouting uncontrollably,​ attacks of crying, trembling, feeling of heat in the chest rising into the head, and verbal and physical aggression.[([[https://​pubmed.ncbi.nlm.nih.gov/​8184996/​|Liebowitz,​ M. R., Salmán, E., Jusino, C. M., Garfinkel, R., Street, L., Cárdenas, D. L., ... & Davies, S. (1994). Ataque de nervios and panic disorder. The American journal of psychiatry.]])] Some individuals may even report dissociative episodes.
 +    * In Cambodians, "//​Khyâl//​ attacks"​ (//khyâl cap//) or "wind attacks"​ include palpitations,​ shortness of breath, dizziness, and cold extremities. Individuals also have other symptoms of anxiety and autonomic arousal such as neck soreness and tinnitus.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 ===== Diagnostic Criteria ==== ===== Diagnostic Criteria ====
 +== Criterion A ==
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
-== Criterion A == 
 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 at least ''​4''​ of the following symptoms occur (**Note:** The abrupt surge can occur from a calm state or an anxious state): 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 at least ''​4''​ of the following symptoms occur (**Note:** The abrupt surge can occur from a calm state or an anxious state):
- 
   - Sweating   - Sweating
   - Trembling or shaking   - Trembling or shaking
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 **Note:** Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. **Note:** Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
 </​callout>​ </​callout>​
- 
-== Criterion B == 
-At least ''​1''​ of the attacks has been followed by at least ''​ 1''​ month of at least ''​1''​ of the following: 
-  - Persistent concern or worry about additional panic attacks or their consequences (e.g. - losing control, having a heart attack, “going crazy”). 
-  - A significant maladaptive change in behavior-related to the attacks (e.g. - behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). 
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-== Criterion C =+<callout type="​tip"​ title="Panic Attack Definition"​ icon="​true">​ 
-The disturbance ​is not attributable to the physiological effects of [[anxiety:​substance-anxiety|substance (e.g. - a drug of abuse, a medication)]] or another medical condition (e.g. - hyperthyroidism,​ cardiopulmonary disorders). +  * A panic attack ​is a single, discrete episode ​of intense fear and discomfort
- +  * panic attack can be expected or unexpected, but in order to diagnose panic disorder, there must be at least **one** unexpected panic attack! 
-== Criterion D == +  * A panic attack must peak abruptly ​(rapid onset of under ''​10''​ minutes), and must be accompanied by a cluster of physical symptoms. 
-The disturbance is not better explained by another mental disorder: +  * A typical panic attack is relatively short and lasts no more than 15 minutes. 
-  * The panic attacks do not occur only in response ​to feared social situations ([[anxiety:​social-anxiety|social anxiety ​disorder]]) +</​callout>​
-  ​In response to circumscribed phobic objects or situations ([[anxiety:​phobia|specific phobia]]) +
-  * In response to obsessions ​([[ocd:​1-ocd|obsessive-compulsive disorder]]+
-  * In response to reminders of traumatic events ([[trauma-and-stressors:​ptsd|post-traumatic stress disorder]]) +
-  * In response to separation from attachment figures ([[anxiety:​separation|separation anxiety disorder]]) +
 <callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​ <callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​
- 
 The mnemonic ''​**STUDENTS FEAR the 3 C'​s**''​ can be used to remember the panic disorder criteria: The mnemonic ''​**STUDENTS FEAR the 3 C'​s**''​ can be used to remember the panic disorder criteria:
-<​HTML><​br><​br></​HTML>​+\\ \\
   * ''​**S**''​ - **Sweating**   * ''​**S**''​ - **Sweating**
   * ''​**T**''​ - **Trembling**   * ''​**T**''​ - **Trembling**
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   * ''​**C**''​ - **Choking**   * ''​**C**''​ - **Choking**
 </​callout>​ </​callout>​
-<callout type="​tip"​ title="​Asking 'Do you experience panic attacks?'​ Is Too Vague!"​ icon="​true">​A 'panic attack'​ means different things to different people. It is more important to explore what cluster of physical symptoms the patient experiences. It is also helpful to identify if there are specific triggers that lead to panic attacks.</​callout>​ 
-<callout type="​warning"​ title="​Chronic Anxiety vs. Panic Attacks"​ icon="​true">​Chronic anxiety fluctuates over hours and days. A true panic attack occurs only during a discrete period of time, must peak abruptly, and is accompanied by physical symptoms.</​callout>​ 
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
 +== Criterion B ==
 +At least ''​1''​ of the attacks has been followed by at least ''​ 1''​ month of at least ''​1''​ of the following:
 +  - Persistent concern or worry about additional panic attacks or their consequences (e.g. - losing control, having a heart attack, “going crazy”).
 +  - A significant maladaptive change in behavior-related to the attacks (e.g. - behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
  
-===== Pathophysiology =====+== Criterion C == 
 +The disturbance is not attributable to the physiological effects of [[anxiety:​substance-medication|a substance (e.g. - a drug of abuse, a medication)]] or another medical condition (e.g. - hyperthyroidism,​ cardiopulmonary disorders).
  
 +== Criterion D ==
 +The disturbance is not better explained by another mental disorder:
 +  * The panic attacks do not occur only in response to feared social situations ([[anxiety:​social-anxiety|social anxiety disorder]])
 +  * In response to circumscribed phobic objects or situations ([[anxiety:​phobia|specific phobia]])
 +  * In response to obsessions ([[ocd:​1-ocd|obsessive-compulsive disorder]])
 +  * In response to reminders of traumatic events ([[trauma-and-stressors:​ptsd|post-traumatic stress disorder]])
 +  * In response to separation from attachment figures ([[anxiety:​separation|separation anxiety disorder]])
 +==== Signs and Symptoms ====
 +  * 50% of individuals with panic disorder have //​expected//​ panic attacks in addition to unexpected panic attacks.
 +    * Thus, having //​expected//​ panic attacks does not rule out the diagnosis of panic disorder. However, at least one unexpected full symptom panic attack is required for the diagnosis of panic disorder (as per ''​Criterion A''​).[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * The frequency and severity of panic attacks can differ greatly between people
 +    * Moderate frequency can be one per week for several months, or
 +    * Individuals may have "​bursts"​ of frequent daily panic attacks and then weeks or months without any attacks.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Individuals also may have maladaptive behaviours to minimize or avoid panic attacks or the  consequences of the panic attacks (e.g. - avoiding physical exertion, restricting usual activities, avoiding agoraphobia-type situations, reorganizing routines to ensure that help is available in the event of a panic attack, severe restrictions on food intake or medications for fear it may trigger attacks).
 +  * Between 1/3 to 1/4 of individuals may also have nocturnal panic attacks that wake them from sleep.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
  
 +<callout type="​tip"​ title="​Asking 'Do you experience panic attacks?'​ is too vague!"​ icon="​true">​
 +A 'panic attack'​ means different things to different people, and they may not actually be experiencing panic attacks. It is more important to explore whether a cluster of physical symptoms occurs and the chronology of the symptoms. It is also helpful to identify if there are specific triggers that lead to symptoms.
 +\\ \\
 +A true panic attack occurs only during a discrete period of time, must peak abruptly, and is accompanied by physical symptoms. Chronic anxiety on the other hand fluctuates over a period of hours to days.
 +</​callout>​
 +===== Screening and Rating Scales =====
 +<panel title="​Panic Disorder Scales"​ no-body="​true">​
 +<​mobiletable 1>
 +^ Name                                  ^ Rater      ^ Description ​                                                      ^ Download ​                                              ^
 +^ Panic Disorder Severity Scale (PDSS) ​ | Clinician ​ | The PDSS is a 7 question scale to grade panic disorder severity. ​ | [[https://​pubmed.ncbi.nlm.nih.gov/​9356566/​|Download]] ​ |
 +</​mobiletable>​
 +</​panel>​
 +
 +
 +===== Pathophysiology =====
 +  * Multiple genes are thought to confer a risk for the development of panic disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Current neuroscience models of panic disorder suggest that the amygdala has a role in the development of panic disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +  * Panic attacks are also thought to be related to hypersensitive medullary carbon dioxide detectors, resulting in hypocapnia and respiratory changes.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)]
 +
 +==== Learning Theory ====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​
 +See main article: **[[teaching:​behavioural-modification|]]**
 +</​alert>​
 +  * The learning theory of panic disorder posits that classical conditioning plays a role in the development of panic disorder.
 +  * During a panic attack, if an individual immediately left a situation where the panic attack occurred (e.g. - at a party), the panic symptoms subside, and the behaviour of escape is "​rewarded"​ by the reduction in panic symptoms (this is called negative reinforcement). The removal ("​negative"​) of unpleasant panic symptoms leads to an increase in that behaviour ("​reinforcement"​),​ hence the term negative reinforcement.[([[https://​pubmed.ncbi.nlm.nih.gov/​11212632/​|Bouton,​ M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological review, 108(1), 4.]])]
 ===== Differential Diagnosis ===== ===== Differential Diagnosis =====
-<callout>See also: [[http://​www.psychiatrictimes.com/​special-reports/​managing-anxiety-medically-ill|Dong,​ Yu, et al. Managing anxiety in the medically ill. Psychiatric Times 32.1 (2015): 33-33.]]</​callout+<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw"> 
-  * Thyroid disease ​(hyperthyroidism,​ hypothyroidism,​ thyroiditis+See also: **[[http://​www.psychiatrictimes.com/​special-reports/​managing-anxiety-medically-ill|Dong,​ Yu, et al. Managing anxiety in the medically ill. Psychiatric Times 32.1 (2015): 33-33.]]** 
-    * A TSH level should be always ​be ordered +</alert> 
-  Cardiovascular + 
-    * Cardiac arrythmias ​(e.g. - atrial fibrillation,​ flutter, palpitations,​ dyspnea, syncope) +<WRAP group> 
-    Pulmonary embolism (order D-dimer assay to exclude) +<WRAP half column
-    ​* Acute Coronary Syndrome ​or Myocardial Infection[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​8873507|Fleet,​ R. P., Dupuis, G., Marchand, A., Burelle, D., Arsenault, A., & Beitman, B. D. (1996). Panic disorder in emergency department chest pain patients: prevalence, comorbidity,​ suicidal ideation, and physician recognition. The American journal of medicine, 101(4), 371-380.]])] +  * **Other specified anxiety disorder or unspecified anxiety disorder** 
-      * This is especially important for women, who commonly present with atypical features compared with men +    * Panic disorder should not be diagnosed if full-symptom ​(i.e. - unexpectedpanic attacks have never been experienced. In the case of only limited-symptom unexpected panic attacks, the diagnosis of "other specified anxiety disorder or unspecified anxiety disorder diagnosis"​ should be considered. 
-    * Electrocardiography (ECG) to assess for signs of ventricular preexcitation (short PR and delta wave), for short or long QT interval in patients with palpitations, and for ischemia, infarction, or pericarditis patterns in patients with chest pain.  +  * **Anxiety disorder due to another medical condition** 
-  * Endocrine +    * Panic disorder ​should ​not be diagnosed if the panic attacks are thought to be a direct physiological result of another medical condition. 
-    * Cushing disease, diabetes mellitus (check for hypoglycemia),​ parathyroid disease (hyperparathyroidism,​ pseudo-hyperparathyroidism),​ pancreatic tumours, and pituitary disease +    Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack (e.g. - vertigo, loss of consciousness,​ loss of bladder or bowel control, slurred speech, amnesia) suggest the possibility that an other medical condition or a substance may be causing the panic attack symptoms. 
-  Pheochromocytoma,​ rarely, this should be considered on the differential. Especially ​if the patient is not responding to conventional treatments[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5890079/​|Alguire,​ C., Chbat, J., Forest, I., Godbout, A., & Bourdeau, I. (2018). Unusual presentation of pheochromocytoma:​ thirteen years of anxiety requiring psychiatric treatment. Endocrinology,​ diabetes & metabolism case reports, 2018.]])][([[https://​www.endocrine-abstracts.org/​ea/​0032/​ea0032p569|Muroya,​ Y., Kumagai, N., Shimodaira, M., Tsuzawa, K., Sorimachi, E., Arioka, H., & Honda, K. (2013, April). A case of pheochromocytoma that recognized as panic disorder before its exact diagnosis. In 15th European Congress of Endocrinology (Vol. 32). BioScientifica.]])] +    * Examples of medical conditions that can cause panic attacks include hyperthyroidism,​ hyperparathyroidism,​ pheochromocytoma,​ vestibular dysfunctions,​ seizure disorders, and cardiopulmonary conditions ​(e.g. - arrhythmias, ​atrial fibrillation,​ flutter, palpitations,​ dyspnea, syncope, supraventricular tachycardia,​ asthma, and chronic obstructive pulmonary disease [COPD]
-     The classic triad of pheochromocytoma symptoms includes headache, excessive sweating, and palpitations. Around 15%-20% of patients with a pheochromocytoma patients may be normotensive. +  ​* ​**Acute ​coronary syndrome ​or myocardial infarction (MI)**[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​8873507|Fleet,​ R. P., Dupuis, G., Marchand, A., Burelle, D., Arsenault, A., & Beitman, B. D. (1996). Panic disorder in emergency department chest pain patients: prevalence, comorbidity,​ suicidal ideation, and physician recognition. The American journal of medicine, 101(4), 371-380.]])] 
-    * Plasma metanephrines ​(95% sensitivity),​ 24-hour urinary metanephrines ​(99% sensitivity), MRI (100% sensitivitypheochromocytomas demonstrate ​distinctive appearance), scintigraphyand abdominal CT.[([[https://www.clinicaladvisor.com/home/features/​an-incidental-finding-twice-removed-in-an-anxious-patient/​|Clinical AdvisorAn incidental findingtwice removed ​in an anxious patient]])]+    * This is especially important for women, who commonly present with atypical features ​of MI compared with men, and their symptoms may be dismissed as a "panic attack." 
 +  * **Endocrinopathies** 
 +    * Cushing disease, diabetes mellitus (check for hypoglycemia), [[cl:​thyroid-disorders|thyroid disease]], parathyroid disease ([[cl:​hypercalcemia-hyperparathyroidism|hyperparathyroidism]], pseudo-hyperparathyroidism),​ pancreatic tumours, and pituitary disease ​may cause symptoms similar to panic attacks. 
 +    Pheochromocytomas ​should be considered on the differential ​in rare cases, especially ​if the patient is not responding to conventional treatments.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC5890079/​|Alguire,​ C., Chbat, J., Forest, I., Godbout, A., & Bourdeau, I. (2018). Unusual presentation of pheochromocytoma:​ thirteen years of anxiety requiring psychiatric treatment. Endocrinology,​ diabetes & metabolism case reports, 2018.]])][([[https://​www.endocrine-abstracts.org/​ea/​0032/​ea0032p569|Muroya,​ Y., Kumagai, N., Shimodaira, M., Tsuzawa, K., Sorimachi, E., Arioka, H., & Honda, K. (2013, April). A case of pheochromocytoma that recognized as panic disorder before its exact diagnosis. In 15th European Congress of Endocrinology (Vol. 32). BioScientifica.]])] 
 +      * The classic triad of pheochromocytoma symptoms includes headache, excessive sweating, and palpitations. Around 15%-20% of patients with a pheochromocytoma patients may be normotensive. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +  * **[[anxiety:​substance-medication|Substance/​medication-induced anxiety disorder]]** 
 +    * Panic disorder should not be diagnosed if the panic attacks are judged to be a direct physiological consequence of a substance. Intoxication with central nervous system stimulants ​(e.g. cocaine, amphetamines,​ caffeine) or cannabis and withdrawal from central nervous system depressants ​(e.g. - alcohol, barbituratescan precipitate a panic attack. Howeverif panic attacks continue to occur out side of the context of substance use (e.g. - long after the effects of intoxication or withdrawal have ended), a diagnosis of panic disorder should be considered. Since panic disorder may precede substance use in some individuals and may be associated with increased substance use (i.e. - self medication), a detailed history should be taken to see if the individual had panic attacks prior to excessive substance use. If this is the casea diagnosis of panic disorder should be considered in addition to a diagnosis of substance use disorder. 
 +  * **Other mental disorders with panic attacks as an associated feature ​(e.g. - [[anxiety:home|other anxiety disorders]] and [[psychosis:​home|psychotic disorders]])** 
 +    * Panic attacks that occur as a //symptom// of other anxiety disorders are expected. For example, panic attacks can be triggered by: 
 +      * Social situations ​in [[anxiety:​social-anxiety|social anxiety disorder]] 
 +      * Phobic objects or situations in specific phobia or [[anxiety:agoraphobia|agoraphobia]]. 
 +      * In [[anxiety:​phobia|specific phobia]]the fear is of the situation itself (e.g. - falling) rather than the possibility of having a panic attack. 
 +      * Worry in [[anxiety:​gad|generalized anxiety disorder]] 
 +      * Separation from home or attachment figures in [[anxiety:​separation|separation anxiety disorder]
 +    * In each of these above cases, the individual would not meet criteria for panic disorder. Remember always that panic disorder is characterized by recurrent //​unexpected//​ panic attacks, and the unexpected nature of the panic attacks is a defining feature of the disorder. If the panic attacks typically only occur in response to specific triggers, then only the relevant anxiety disorder is assigned. However, if the individual experiences unexpected panic attacks as well and then begins to show persistent concern and worry or begins making behavioural change because of the attacks, then an additional diagnosis of panic disorder may be considered. 
 +</​WRAP>​ 
 +</​WRAP>​ 
 ===== Investigations ===== ===== Investigations =====
-  * TSH, glucose ​as baseline if not already done+  * Depending on the initial presenting symptoms (e.g. - dizzinesstachycardia),​ potential investigations can include: CBC, fasting ​glucose, fasting lipid profiles, electrolytes,​ liver enzymes, serum bilirubin, serum creatinine, urinalysis, [[meds:​urine-drug-screen|urine toxicology]] for substance use, thyroid stimulating hormone (TSH).[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +    * Generally speaking, a TSH level should be always be ordered 
 +  * Consider an electrocardiogram (ECG) to assess for signs of ventricular preexcitation (short PR and delta wave), for short or long QT interval in patients with palpitations,​ and for ischemia, infarction, or pericarditis patterns in patients with chest pain. 
 +  * If considering a work up for pheochromocytoma,​ the following investigations are recommended:​ plasma metanephrines (95% sensitivity),​ 24-hour urinary metanephrines (99% sensitivity),​ abdominal MRI (100% sensitivity,​ pheochromocytomas demonstrate a distinctive appearance),​ scintigraphy,​ and/or abdominal CT.[([[https://​www.clinicaladvisor.com/​home/​features/​an-incidental-finding-twice-removed-in-an-anxious-patient/​|Clinical Advisor: An incidental finding, twice removed in an anxious patient]])] 
 +  * If panic attacks are acute and associated with cardiac symptoms and persistent vital sign changes, consider a pulmonary embolism work up and order D-dimer. 
 +===== Physical Exam ===== 
 +  * Cardiac, respiratory,​ and abdominal exam should be performed according to the clinical presentation.
 ===== Treatment ===== ===== Treatment =====
-The following treatment recommendations are based on the 2014 Canadian ​Clinical Practice Guidelines ​for anxiety, posttraumatic stress and obsessive-compulsive disorders.[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman ​MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.]])] Generallya combination of psychotherapy and pharmacotherapy with antidepressants is superior to CBT or pharmacotherapy ​alone during the acute treatment ​phase for panic disorder.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/19392811|Bohni, M. K., SpindlerH., ArendtM., HougaardE., & RosenbergN. K. (2009). A randomized study of massed three‐week cognitive behavioural therapy schedule ​for panic disorderActa Psychiatrica Scandinavica120(3), 187-195.]])]+  * During ​the acute phase (i.e. - first 4 to 12 weeks), combination cognitive behavioural therapy with exposure and medication should be offered (as medication may be especially helpful in cases where symptoms are too distressing for patients to be able to do exposure therapy).[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​19392811|Bohni,​ M. K., Spindler, H., Arendt, M., Hougaard, E., & Rosenberg, N. K. (2009). A randomized study of massed three‐week cognitive behavioural therapy schedule for panic disorder. Acta Psychiatrica Scandinavica,​ 120(3), 187-195.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian ​clinical practice guidelines ​for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +  * During the follow up and recovery phase, combination therapy is superior to medications alone.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman, M. A., BleauP., BlierP.Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, ​14(1), 1-83.]])] 
 +    * Similarly, CBT alone is as effective as doing combination therapy ​during ​this phase. 
 +    * At the three year follow up point in some studies, the benefits of CBT are still maintained, whereas they are not maintained in medication-only ​treatment
 +  * Additionally,​ there is also evidence to suggest that adding benzodiazepines to psychotherapy may be worse than doing therapy alone.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/|Katzman, M. A., BleauP., BlierP., ChokkaP., Kjernisted, K., & Van AmeringenM. (2014). Canadian clinical practice guidelines ​for the management of anxiety, posttraumatic stress and obsessive-compulsive disordersBMC psychiatry14(1), 1-83.]])]
  
 ==== Psychotherapy ==== ==== Psychotherapy ====
-<​callout>​It is often helpful to explain to patients that having panic disorder is like having a car with an oversensitive alarm system: every car has an alarm system that activates when a window is smashed, but sometimes the alarm system can be hypersensitive,​ and even a small bump or breeze can activate it.</​callout>​ +<​callout ​type="​tip"​ icon="​true"​ title="​Psychotherapy Tip"> 
-[[psychotherapy:​cbt|]] has been extensively studied and is very efficacious in the treatment for panic disorder. In fact, CBT has been shown to be significantly more effective than pharmacological treatment in several meta-analyses.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​19392811|Roshanaei‐Moghaddam,​ B., Pauly, M. C., Atkins, D. C., Baldwin, S. A., Stein, M. B., & Roy‐Byrne,​ P. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety?. Depression and anxiety, 28(7), 560-567.]])]+It is often helpful to explain to patients that having panic disorder is like having a car with an oversensitive alarm system: every car has an alarm system that activates when a window is smashed, but sometimes the alarm system can be hypersensitive,​ and even a small bump or breeze can activate it. 
 +</​callout>​
  
-==== Medications ​==== +  * [[psychotherapy:​cbt|Cognitive behavioural therapy]] has been extensively studied in panic disorder and is very efficacious in the treatment for panic disorder agoraphobia,​ and is preferred by patients.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​19392811|Roshanaei‐Moghaddam,​ B., Pauly, M. C., Atkins, D. C., Baldwin, S. A., Stein, M. B., & Roy‐Byrne,​ P. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety?. Depression and anxiety, 28(7), 560-567.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
-<panel type="​info"​ title="​Pharmacotherapy for panic disorder" no-body="​true"​ footer="​CR = controlled release; ODT = orally disintegrating tablets; SR = sustained release; XR = extended release">​+    * The addition of exposure makes the therapy even more effective.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 +  * [[psychotherapy:​brief-short-psychodynamic|Psychodynamic therapy]] has also been used in the treatment of panic disorder.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC3330557/​|Busch,​ F. N., Milrod, B. L., & Singer, M. B. (1999). Theory and technique in psychodynamic treatment of panic disorder. The Journal of psychotherapy practice and research, 8(3), 234.]])][([[https://​pubmed.ncbi.nlm.nih.gov/​23768260/​|Beutel,​ M. E., Scheurich, V., Knebel, A., Michal, M., Wiltink, J., Graf-Morgenstern,​ M., ... & Subic-Wrana,​ C. (2013). Implementing panic-focused psychodynamic psychotherapy into clinical practice. The Canadian Journal of Psychiatry, 58(6), 326-334.]])] 
 +  * Since the evidence is so strong for psychotherapy,​ it should be offered as a first line treatment alone, or in combination with medications.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])] 
 + 
 +==== Pharmacotherapy ​==== 
 +<panel type="​info"​ title="​Pharmacotherapy for Panic Disorder (and Agoraphobia)" no-body="​true" subtitle="​Katzman,​ M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83." footer="​CR = controlled release; ODT = orally disintegrating tablets; SR = sustained release; XR = extended release">​
 ^ 1st line            | Citalopram, escitalopram,​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2656325/​|Townsend,​ M. H., & Conrad, E. J. (2007). The therapeutic potential of escitalopram in the treatment of panic disorder. Neuropsychiatric disease and treatment, 3(6), 835.]])] fluoxetine, fluvoxamine,​ paroxetine, paroxetine CR, sertraline, venlafaxine XR                                                     | ^ 1st line            | Citalopram, escitalopram,​[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2656325/​|Townsend,​ M. H., & Conrad, E. J. (2007). The therapeutic potential of escitalopram in the treatment of panic disorder. Neuropsychiatric disease and treatment, 3(6), 835.]])] fluoxetine, fluvoxamine,​ paroxetine, paroxetine CR, sertraline, venlafaxine XR                                                     |
 ^ 2nd line            | Alprazolam, clomipramine,​ clonazepam, diazepam, imipramine,​[([[https://​www.ncbi.nlm.nih.gov/​m/​pubmed/​10815116/​|Barlow,​ D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Jama, 283(19), 2529-2536.]])] lorazepam, mirtazapine,​ reboxetine ​                                                              | ^ 2nd line            | Alprazolam, clomipramine,​ clonazepam, diazepam, imipramine,​[([[https://​www.ncbi.nlm.nih.gov/​m/​pubmed/​10815116/​|Barlow,​ D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Jama, 283(19), 2529-2536.]])] lorazepam, mirtazapine,​ reboxetine ​                                                              |
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 </​panel>​ </​panel>​
  
 +===== Guidelines =====
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[teaching:​clinical-practice-guidelines-cpg|]]**</​alert>​
 +
 +{{page>​teaching:​clinical-practice-guidelines-cpg#​panic-disorder&​nouser&​noheader&​nodate&​nofooter}}
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
 <WRAP quarter column> <WRAP quarter column>
-==== For Patients ​====+== For Patients ==
   * [[https://​www.anxietycanada.com/​|AnxietyCanada:​ Patient Resources]]   * [[https://​www.anxietycanada.com/​|AnxietyCanada:​ Patient Resources]]
  
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 <WRAP quarter column> <WRAP quarter column>
-==== For Providers ==== +== For Providers ==
-  * [[http://​psychiatryonline.org/​pb/​assets/​raw/​sitewide/​practice_guidelines/​guidelines/​panicdisorder-guide.pdf|Panic Disorder Practice Guideline (APA)]]+
   * [[https://​www.youtube.com/​watch?​v=nXrKKwHmPz4|YouTube:​ Mark Zuckerberg Panic Attack]]   * [[https://​www.youtube.com/​watch?​v=nXrKKwHmPz4|YouTube:​ Mark Zuckerberg Panic Attack]]