Download The Anxiety Disorders Some Practical Questions & Answers

Panic Disorder
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DFAPA
November 28, 2011
1 My
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goal with these talks is to provide you with the minimum practical information you will need to treat these patients.
Please let me know whether I have succeeded on your evaluation forms.
Why is this important?
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Up to 35-percent of us will experience
panic attacks each year.
Most of us will not develop
agoraphobia (up to 5-percent will) or
panic disorder (less than 1-percent
will).
But those who do are significantly
impaired and distressed, and the
prevalence in clinical populations is
much higher.
Many other disorders are masked by
anxiety making the underlying
disorders more difficult to recognize
and treat.
These patients typically have other
significant comorbid conditions.
They are at clear risk for substance
abuse and suicide.1
They are frequently missed,
misdiagnosed, mistreated and
misunderstood.
1 Paradoxically,
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marijuana often triggers panic in first-time users.
After mastering the information in
this presentation, you will be able
to
– Describe how patients with Panic
Disorder often present,
– Detail the diagnostic criteria,
– Describe some of the associated
features,
– List some differential diagnoses,
– Write a preliminary treatment
plan, and
– Identify some of the frequent
treatment challenges.
What specific diagnoses are included here?
• Panic Disorder Without Agoraphobia
(300.01)1
• Panic Disorder with Agoraphobia
(300.21)
• Agoraphobia Without History of Panic
Disorder (300.22)
1 If
you make this diagnosis early and initiate treatment quickly, you may prevent many complications.
How might patients with panic disorder
present?
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This is a 25-year-old woman.
“My panic attacks started about seven
years ago.”1
“They usually come on without
warning or when I’m upset or feel out
of control.”
“Sometimes they wake me up”2
“I stopped using caffeine because the
doctor told me this might trigger panic”
“Even chocolate makes me jittery—but
I haven’t given that up yet!”
“When they come on, my heart races
and I get scared”
“I’m afraid that something awful is
going to happen.”
“I used to hyperventilate and this
would make things even worse.”
“I’ve learned to control that, mostly.”
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“Both my mother and her brother have
had the same problem.”3
“I used to go to the emergency room all
the time because I thought I was having
a heart attack, but they could never find
anything wrong.”
My doctors prescribed an
antidepressant and a sedative, but I
didn’t like how they made my feel.”
“I still keep a few alprazolam pills with
me for security.”
“If it gets too bad, I know the pills will
stop it.
“I now understand that the panic
attacks will probably come and go the
rest of my life.”
“I think I can manage them without
taking medicine regularly.”
“At least I want to try.”
The peak age of onset of spontaneous panic attacks is between 15 and 25 years. (Goldman, 2000)
Panic attacks may result from noradrenergic dysfunction in the locus ceruleus (Nutt, et al, 1992)
3 Twin studies reveal some genetic basis for the disorder, but the exact inheritance is not clear.
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What are the criteria for panic
attack?1
• Four or more of the
following must begin
suddenly and peak within
ten minutes
– Sensation of a racing
heartbeat
– Sweating
– Feeling shaky
– Smothering or fear of
choking
– Chest pain or discomfort
– Nausea or abdominal
distress
1A
• Core symptoms
– Feeling dizzy, unsteady,
lightheaded or faint
– Feelings of derealization or
depersonalization
– Sensation of going crazy or
losing control
– Fear of dying
– Tingling sensations
(paresthesias)
– Hot flashes or chills
panic attack cannot be coded as a psychiatric disorder (DSM-IV-TR).
What are the criteria for
agoraphobia?1
• Anxiety about being in places where one might have a
panic attack or where help or escape might be difficult
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Being outside alone
Being in a crowd
Standing in line
Being on a bridge
Traveling in a confined space
And so on
• Feared situations are avoided or reassuring
companionship is sought
• This phobic avoidance is not better accounted for by
another mental disorder
1 Agoraphobia
cannot be coded as a psychiatric disorder (DSM-IV-TR).
What are the criteria for panic
disorder?
• Both
– Recurrent unexpected panic attacks
– At least one of the attacks has been followed by a month
(or more) of one (or more) of the following
• Persistent concern about future attacks
• Worry about the implications of the attacks
• A significant change in behavior because of the attacks
• The presence or absence of agoraphobia1
• Attacks are not substance-induced
• Attacks are not better accounted for by another mental
disorder
• Listen to a patient account here.
1 Whether
agoraphobia is present or absent clarifies the specific diagnosis. (DSM-IV-TR).
What are the criteria for agoraphobia
without a history of panic disorder?
• The presence of Agoraphobia
• Criteria have never been met for Panic
Disorder1
• The fear is not the direct result of a substance
or a general medical condition
• If a general medical condition is also present,
the fear is clearly greater than would usually
be associated with that condition
1 In
clinical settings, over 95% of people presenting with agoraphobia also have panic disorder.
(DSM-IV-TR).
What associated features might you
see?
• “Free-floating” anxiety is common.
• They are often worrywarts.
• They may be convinced that they have some deadly condition that
their doctors have missed.1,2
• Shame, embarrassment and discouragement are common.
• There quest for curative medical intervention may lead to job and
school problems.
• Comorbid Major Depressive Disorder is very common.
• Some of these patients may self medicate and develop a comorbid
substance abuse problem.
• The rates of comorbid anxiety disorders is also high.
• Comorbid medical conditions included, but are not limited to mitral
valve prolapse, COPD, IBS, thyroid disease, asthma, and cardiac
arrhythmias.
1 One
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of my patients saw a specialist in Columbus (naturally) who said my medication stretched her heart valves.
Be careful when your patients tell you what other doctors said. A daughter refused to face her father’s dementia.
What other diagnoses might you include in
the differential diagnosis?
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Normal anxiety
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Other anxiety disorders
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Patient’s current medications
Caffeine
Psychiatric medications1
Anxiety secondary to other psychiatric disorders
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Thyroid disorders
Vestibular dysfunction
Seizure disorders
Cardiac disorders
And so on
Substance-induced anxiety
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All of them
Anxiety secondary to a general medical condition
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Isolated panic attack
Response to stress
All of them
Particularly depression
attributed a patient’s tachycardia to her antidepressant. I was wrong.
What might a typical treatment plan
look like?
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Panic attacks
– Provide reassurance.1
– Consider paroxetine 10 mg/day
and increase to maximum dose of
60 mg/day.
– Consider clonazepam 0.5 mg twice
per day for immediate relief then
taper slowly.
– Taper off all caffeine
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Other comorbid disorders
– Diagnose and treat these
conditions vigorously.
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Maladaptive attitudes and
behaviors
– Consider cognitive behavioral
psychotherapy (CBT)
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Education and self help
Agoraphobia
– Educate the patient.
– Encourage gradual and repetitive
exposure to feared situations.
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Generalized anxiety
– Consider buspirone 15 mg twice
per day.
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A surprising number of these people will elect to simply “gut it out.”
– Provide educational resources.
– Recommend a daily exercise
regimen.
– Recommend a healthy diet.
– Suggest healthy distractions.
– Recommend meditation.
– Recommend online resources with
caution.
– Recommend self-help groups with
caution.
What are some of the treatment
challenges you can expect?
• They are sensitive, needy and require excessive
reassurance.
• They are often sensitive to medication side effects.
• If they are dissatisfied, refer them anywhere in the
world they want to go.1
• Make yourself reasonably available, but be careful not
to promise more than you can deliver.2
• They are at risk for becoming excessively dependant on
their physicians.
• Taking the chronic disease management approach is
usually best.
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It’s always best to be the third or fourth psychiatrist in these cases.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment
plan while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Ryan Foor, DO
OUCOM 2005
Sarah Porter, DO
SOMC FP 2007
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