* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Panic Disorder
Bipolar II disorder wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
Personality disorder wikipedia , lookup
Major depressive disorder wikipedia , lookup
Antipsychotic wikipedia , lookup
Bipolar disorder wikipedia , lookup
Factitious disorder imposed on another wikipedia , lookup
Autism spectrum wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Rumination syndrome wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Anxiety disorder wikipedia , lookup
Excoriation disorder wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Mental disorder wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Abnormal psychology wikipedia , lookup
History of psychiatry wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Spectrum disorder wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
Conversion disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Asperger syndrome wikipedia , lookup
Conduct disorder wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Potential questions on Panic Disorder Answers based on DSM-IV-TR, APA Practice Guideline, and other references that as identified on the specific screen. As of August 1, 2006. Criteria of “panic attack” Q. DSM criteria, very general? Ans. Outline of Dx of Panic Disorder • 1. Recurrent unexpected panic attacks • 2. Following the attacks, pt has been concerned for more than a month about additional attacks, implications of the attacks or had a change in behavior as a result to the attacks. • 3. Panic attacks are not part of another disorder. Panic attack symptoms Q. DSM expects at least 4 of 13 symptoms in stating the pt has had a “panic attack.” List as many of the 13 as you can. Criteria of “Panic Attack”? Two slides • At least 4 of following develop suddenly and peak in 10 minutes: • 1.palpitations or increased pulse • 2. sweating • 3. trembling or shaking • 4. sensation of shortness of breadth • 5. feeling of choking • 6. chest discomfort Criteria for Panic Attack second slide • • • • • • • 7. nausea or stomach distress 8. dizzy, unsteady, lightheaded, or faint 9. derealization/depersonalization 10. fear of losing control or going “crazy” 11. fear of dying 12. paresthesias 13. chills or hot flashes Rule outs Q. Names some key rule outs to making the dx of panic disorder. Key Rule Outs 1. Substances 2. Non-psychiatric medical conditions, e.g., hyperthyroidism. 3. Phobias, including agoraphobia 4. OCD 5. PTSD 6. Separation anxiety disorder Lab findings Q. What are laboratory findings? Laboratory Findings? Ans. None are specific to panic disorder, but pts with this disorder do tend to have panic attacks with an infusion of Na+ lactate than those without the disorder. More common Q. Which is more common Panic Disorder with agoraphobia or panic disorder without agoraphobia? More common Ans. Panic Disorder without agoraphobia is twice as common. Gender Q. Gender breakdown? Gender Breakdown Ans. Women to men: two to one says Practice Guideline, Some say three to one. Onset Q. Age at onset? Onset: Ans. Bimodal onset: – Late teens/early twenties, highest – Mid thirties, second highest peak Lifetime prevalence Q. Lifetime Prevalence? Lifetime prevalence Ans. 2% Annual prevalence Q. Annual Prevalence? Annual Prevalence Ans. 1% Primary care Q. Prevalence in Primary Care Practice? Prevalence in Primary Care Practice Ans. 3 – 8 % • Ref: NEJM 2006; 354:2360-7 Entry Q. A common place for people with panic disorder to enter the health care system? Entry Ans. Common entry point is the ER Hospitalize Q. When to hospitalize a pt with panic disorder? When to hospitalize a pt with panic disorder Ans. Only hospitalize if there is another psychiatric disorder present that so justifies. Risk factors Q. What are risk factors for panic disorder? Risk Factors Ans. 1. Genetic, higher in monozygotic than dizygotic twins and 8 times as common among close relatives. • 2. May have abnormally sensitive fear network. • 3. Hx of sexual or physical abuse as child. • 4. 80% of pts report major stresses in the 12 months before attacks. Ref : NEJM 2006; 354:2360-7 Comorbid Q. What percentage will have comorbid psych disorders during their lifetime? comorbid Ans. Lifetime comorbid disorders: 90% • Ref: NEJM 2006; 354:2360-7 Mimic Q. What conditions can mimic a panic attack? mimic Ans. Potential mimics: Hyperthyroidism Hypothyroidism Temporal-lobe epilepsy Asthma Cardiac arrhythmias Pheochromocytoma Too much coffee and other stimulants • Ref: NEJM 2006; 354:2360-7 Screen for depression Q. Why screen for depression? Screen for depression to Ans. Screen for depression to ascertain if pt also has depressive disorder. An associated depression increases risk of suicide. Suicide rate Q. What is suicide rate? Suicide rate Ans. Practice Guideline says 1/5, but NEJM article implies that is so because so many are also depressed. Still, it would seem that “1/5” would be correct answer. Personality disorders Q. Which three personality disorders have high co-occurrence with panic disorder? Common co-occurring personality disorders are Ans. Common co-occurring personality disorders: Avoidant Obsessive-compulsive Dependent Medications Q. Which five classes of meds have been shown to be the most efficacious? [“Efficacious” implies potency alone, not related to more general issues as to the use of the med.] Five Classes have Been Shown to Be Effective • • • • • 1. 2. 3. 4. 5. SSRIs SNRIs High potency benzodiazepines Tricyclics MAOIs Ref: NEJM 2006; 354:2360-7 Q. Of the five classes of meds, which is preferred? Q. Which of the five classes of meds in the prior screen is preferred for pts with panic attacks? Preferred medical class • SSRIs •Ref: NEJM 2006; 354:2360-7 Q. What about bupropion? Q. What about using bupropion in pts with panic attacks? Ans. As to bupropion • Bupropion has not been shown to be effective. • PG, 645 Antipsychotics • Q. What about antipsychotics? Ans. As to antipsychotics • Have not been shown to be effective • PG, 646 Q. What about propranolol? Q. What about propranolol use in pts with panic disorders? Ans. As to propranolol • Inferior to benzodiazepines for as needed situations. Thus, OK for PRN. • PG, 646 Q. What is medication strategy? Q. After selecting the medication, what is medication strategy for panic disorders? Dosing strategy of SSRIs in panic disorder? • Begin with low doses and titrated every weekly as tolerated. Example, 10 mg of fluoxetine with range of 5 – 80. •Ref: NEJM 2006; 354:2360-7 Q. Goal of medication treatment? Q. Goal of medication treatment in pts with panic disorders? Ans. Treatment Goal with meds: • • • • 1. Decrease frequency of attacks 2. Decrease intensity of attacks 3. Decrease anticipatory anxiety 4. Decrease phobic avoidance • Ref: PG, p 640 First Choice? Q. If the First Choice SSRI is not effective, what to do? Ans. If SSRI fails, then Ans. 1. CBT or 2. Another SSRI • Ref: NEJM 2006; 354:2360-7 In the face of 2 SSRI failures Q. If two SSRIs have failed? Ans. In the face of failure of two SSRIs: • CBT or • Another class of meds: – Tricyclic – MAHO – Or – SNRI • Ref: NEJM 2006; 354:2360-7 Benzodiazepines • Q. What about use of benzodiazepines? Ans. As to use of benzodiazepines: • Not recommended as primary med because of addiction potential and the tendency of withdrawal to have discontinuation syndrome. • Useful for as needed situations, such as apprehensiveness about taking a airplane flight. • Ref: NEJM 2006; 354:2360-7 benzodiazepines • Q. Which benzodiazepines are recommended for as needed use, i.e., for PRNs? A. Recommended benzodiazepines • Long lasting: – ER alprazolam – Clonazepam • Ref: NEJM 2006; 354:2360-7 FDA • Q. FDA approved for panic disorder are? Only FDA approved meds for panic disorders of all classes: • • • • • Alprazolam Clonazepam Fluoxetine Paroxetine Sertraline Discontinuation syndrome • Q. Signs of discontinuation syndrome? Ans. Signs of Discontinuation Syndrome: • Fearfulness • Irritability • Headache • Muscle tension • Perceptual abnormalities • Insomnia • Decreased concentration • Cardiovascular symptoms [Ref: NEJM 2006; 354:2360-7] Q. To avoid discontinuation syndrome in pts on benzodiazepines for a lengthy period of time ? Ans. To avoid discontinuation syndrome • Taper with a slow acting benzodiazepine for over a month or two. • Ref: NEJM 2006; 354:2360-7 CBT consist of? Q. For panic disorder, of what does CBT consist? Ans. CBT consists of: • In 12 to 16 sessions, usually weekly, the focus is on recreating the feared symptoms and then modifying the pt’s response. For example, if attack is precipitated by increase pulse, have pt jog and that helps correct the cognitive distortions. • Ref: NEJM 2006; 354:2360-7 CBT v. Meds • Q. CBT compared to meds as to efficaciousness? CBT and Meds • They are equally effective. • Meds obtain results more rapidly. • PG, 650 Drug Store • Q. What can the pt buy at the drug store that may interfere with treatment of panic disorder? At the drug store, could obtain • 1. Cigarettes • 2. Coffee • 3. sympathomimetics [nasal decongestants] Other psychotherapies Q. What about other psychotherapies? Are there any controlled studies? As to other psychotherapies • No controlled studies Relapses • Q. What if pt relapses, months after apparently successful treatment? After a relapse • Repeat prior treatment •Ref: NEJM 2006; 354:2360-7 Two relapses • Q. What to do after two relapses? After two relapses, • Consider long term use of meds • Ref: NEJM 2006; 354:2360-7 Q. Pt has panic disorder, irritable bowel syndrome, respiratory signs, and migraine. • Can one class of meds service all of these? One class has hopes of reaching all: • SSRIs • PG, 657 Pt has become dependent on you • Q. What to do if the pt becomes dependent on the psychiatrist? When pt becomes dependent on psychiatrist • Maintain available and address directly. DO NOT address through unavailability. • PG, 649