Download Panic Disorder

The Philippine College of
Psychopharmacology
2008
Anxiety Disorders
(Focus on Panic Disorder)
TEACHING MODULE FOR THE
PRIMARY CARE PHYSICIANS
Objectives
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At the end of this module, the primary care
physician is expected to:
1. understand the nature of anxiety disorders
2. diagnose the main anxiety disorder (Panic D)
3. treat panic disorder with the appropriate drugs
quickly, effectively, and safely
Basic Facts on Anxiety Disorders
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Prevalence rates of 5-15% in adults
Can be quite debilitating ; affects quality of life
Frequently overlap with depression (60%)
When diagnosed properly, easy to treat
Most often seen first by non-psychiatrists
Who see anxious patients first?
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1. Internists
2. Family Physicians
3. OB-Gyne/EENT
4. Psychiatrists
5. Others
– 40%
– 25%
– 20%
– 10%
– 5%
Anxious Patient: Usual Profile
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Young (20s – 30s)
More women affected
Natural worrier (from childhood)
Strict, with high standards
Inadequate outlets
The Many ‘Faces’ of Anxiety
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MSK –
CVS –
RESP _
GIT –
back/headache, spasms, fatigue
palpitations, chest pain
dyspnea, hyperventilation
lump in the throat,
nausea/vomiting, “butterflies”
GUT – frequent micturition, premature
ejaculation, impotence
CNS – dizziness, tremors, numbness, ‘pins
and needles’
Try to rule out…
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Hyperthyroidism – T3, T4, TSH
Hypoglycaemia – RBS, FBS
Complex partial seizure (TLE) – EEG
Mitral valve prolapse – 2D-ECHO; may co-exist
Illegal drugs, e.g. methamphetamines – urine test
Avoid too much work-up; may reinforce anxiety
If patients insist on more tests, convince otherwise
Role of Genetics
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Family studies:
20% morbidity risk in relatives compared to 2%
in controls
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Twin studies:
45% morbidity in identical versus 15% in nonidentical twins
Biological Abnormalities
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Functional imbalance in the following:
1. Autonomic nervous system – increased sensitivity
of the sympathetic system due to cumulative effects
of life stresses
Other areas in the brain also affected , e.g. locus
ceruleus (site of greatest number of noradrenergic
neurons)
Biological Abnormalities
2. Locus ceruleus – abnormal increased sensitivity
of noradrenergic neurons
3. BZ/ GABA complex – decreased sensitivity of
BZ receptors and decreased inhibition of
GABA
Panic Attack: Working Hypothesis
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Genetic vulnerabilities →
cumulative effects of life stresses →
increased activity of the SNS →
activation of locus ceruleus →
decreased sensitivity of Bz receptors →
decreased inhibition of GABA →
panic attacks
Main Features of Anxiety Disorders
1. GAD pervasive worries
2. Panic Disorder - feeling of doom
3. Phobias morbid fear
4. OCD –
repetitive rituals
5. PTSD –
recurrent flashbacks
6. Others (drugs/
medical cases) feeling restless
Panic Disorder
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Lifetime prevalence- 1-3%
More in women – 2-4x
Co-morbid with depression – 60%
With or without agoraphobia
Tendency to become chronic (15%)
Main feature – panic attack
PANIC ATTACK
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Main Characteristics:
1. Sudden, unexpected (“out of the blue”)
2. Feeling of “impending doom”
3. Increasing and decreasing intensity
from start to finish ( 30-60 minutes)
4. Several attacks in one month
5. Multi-system involvement
Top Five Symptoms of PD (Noyes)
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Fearfulness or worry
Nervousness
Palpitations
Muscle aches
Trembling
-
96%
95%
93%
89%
89%
Psychopharmacology of Panic Disorder
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Antidepressants
1. Tricyclics (TCAs)
2. Selective serotonin reuptake inhibitors (SSRIs)
3. Dual antidepressants (SNRIs, NaSSA)
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Anxiolytics
1. Benzodiazepines (alprazolam, clonazepam)
ANTIDEPRESSANTS 1
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Tricyclics: hardly a choice now
1. Effective (delayed by 1-2 weeks)
2. Plenty of side-effects (almost immediate)
3. Unsafe in overdose (arrhythmia)
4. Inexpensive
5. No abuse potential
6. Dose: 3x/day (e.g. Trimipramine 25 mg)
ANTIDEPRESSANTS 2
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SSRIs: drugs of choice
1. Effective (delayed by 1-2 weeks)
2. Side-effects mainly GIT (serotonin-based)
3. Safe in overdose
4. Expensive (but generics now available)
5. No abuse potential
6. Single dose (e.g. Sertraline 50 mg/day)
ANTIDEPRESSANTS 3
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SNRI/NaSSA: first choice for GAD
1. Effective – (delayed also; NaSSA a tad early?)
2. Side-effects – mainly noradrenergic-based
3. Safe in overdose
4. Most expensive; one generic available
5. No abuse potential
6. Single dose (Duloxetine 60mg; Mirtazapine 30mg)
ANXIOLYTICS
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Benzodiazepines: second choice
1. Rapid onset ; excellent for acute attacks
2. Side-effects mainly drowsiness, weakness
3. Tricky in overdose ; deadly with alcohol
4. Inexpensive ; generics available
5. With abuse potential
6. Dose: 1-2x/day (e.g. Alprazolam 500 mcg -1 mg)
Practical Psychiatry 101
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Panic attacks are acute, intense, prolonged
Quick symptom control crucial
Drugs of choice are antidepressants ( NOT
benzodiazepines); slow in onset but no potential
for abuse
Second choice is a benzodiazepine like
alprazolam, quick in onset but with potential for
abuse
Practical Psychiatry 101
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What is needed is an approach that would
quickly control panic attacks without exposing
patients to dependence/abuse
Dependence usually takes weeks or months of
continuous drug use, at higher than
recommended doses
So, what to do?
Practical Psychiatry 101
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Recommendations:
1. Give an SSRI (e.g. Sertraline 50 mg hs) AND a
benzodiazepine (e.g. Alprazolam 500 mcg – 1.0 mg
2x a day) for 10 to 14 days
Rationale: Sertraline takes a while to take effect whilst
alprazolam acts very quickly to control the attacks.
Patient is relieved of his panic symptoms in a day or
two.
Practical Psychiatry 101
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Recommendations:
2. After 10-14 days, gradually reduce Altrox by 0.5
mg/week and totally stop it within two - three weeks.
Keep Serenata at same dose as maintenance
Rationale: At two weeks, the level of Sertraline is
already peaking and can now stand on its own;
stopping alprazolam at this time would avoid
dependence or abuse
Practical Psychiatry 101
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Recommendations:
3. Don’t give a benzodiazepine as the sole drug,
either in acute phase or maintenance period
(easier said than done)
Rationale: It would be hard to discontinue and
the danger of dependence would be real
(‘iatrogenic dependence’)
ALPRAZOLAM
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Very effective, especially in acute attacks
Not too sedating (unlike clonazepam)
Generic bioequivalent available (Altrox)
Dose range: 1-2 mg/day for acute attacks
Potential for abuse negligible when used well
SUMMARY
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Anxiety disorders are very common and can be
debilitating in their effects
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Vague, multiple, repetitive, nonphysiologic
physical complaints suggest an anxiety disorder
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Panic attacks need to be controlled quickly,
effectively, and safely
SUMMARY
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An initial combination of an antidepressant and
an anxiolytic is recommended
After 10-14 days, (maximum of 30 days)
antidepressant is continued whilst anxiolytic is
discontinued
Giving anxiolytic as sole drug is not
recommended because of dependence problems
No more worries, I hope
THANK YOU VERY MUCH INDEED