ANXI ET Y

DISORDE RS

No Need to Panic
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 Definition of Anxiety

From the German word Angst.

It is indistinguishable From fear except
as to cause.
It is the same Experience of dread and
foreboding

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 -: Definition of anxiety

-: Except that it drives

• Unknown internal stimulus
• Inappropriate to the reality of an external
stimulus
• Concerned with a future stimulus

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Normal versus Pathological anxiety

• Normal fear and anxiety serve a useful

function, that is, they protect us from danger.
• Such anxiety make sense of identity and meaning of the
life

• Pathological anxiety, the fear and anxiety

result in dysfunction and distress.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 In psychiatry
• Anxiety Disorders:
- Separate clinical
entities
- Not secondary to
organic causes
- Functional (no
demonstrable CAUSE)

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Anxiety disorders are
characterized by:
• persistent fear and anxiety
that
• occurs too often,
is
• too severe,
and is
• triggered too easily or lasts too long.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Cont….
• Behavior :
-IF anxiety impairs coping.
- IF normal function is disrupted.
- IF avoidance or withdrawal behavior occurs.
….. It is’’ IF’’ A pathologic nature .

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Definition of subtypes
• Generalized anxiety disorder (GAD)
- symptoms of anxiety are persistent
- Varying little from one situation to another

• Phobic anxiety disorder

- Symptoms are episodic but associated with defined circumstances

• Panic disorder
- Symptoms are episodic not associated with defined
circumstances

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic disorder
Named after Pan, the Greek god of
Named after Pan, the Greek god of
nature

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic disorder

• Criteria of panic attack

• Epidemiology
• Risk Factors
• Differential diagnosis
• Treatment

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic disorder
• Cardiac neurosis
• Da Costa's Syndrome
• Effort Syndrome
• Nervous syndrome
• Neurocirculatory
Asthenia
• Soldier's heart

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 :DEFINITION OF PANIC ATTACK

• Periodic short bouts of panic

• Sudden feelings of terror that occur suddenly and
without warning ,without any cause or precipitation

• The Attacks occur in 50%-75% of cases during non REM sleep

( night panic) in addition to day occurrence

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic attacks
• Onset
Most can recall the precise date ,time, nature and circumstances of the first
panic attack

• Course
• Frequency of attacks vary considerably between;
 Few attacks in a life time.
 Daily attacks for months ,then disappear and reappear.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

Panic attacks

• Duration
From seconds to minutes in most
cases, rarely it persists for hours
followed by exhaustion or
headaches and sometimes long
sleep.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic Attack criteria

The abrupt onset of an episode of intense fear or

discomfort, which peaks in approximately 10 minutes, and
includes at least four of the following symptoms:

• A feeling of imminent danger or doom • Nausea or abdominal discomfort

• The need to escape • Dizziness or lightheadedness
• Palpitations • A sense of things being unreal,
• Sweating depersonalization
• Trembling • A fear of losing control or "going crazy"
• Shortness of breath or a smothering • A fear of dying
feeling • Tingling sensations
• A feeling of choking • Chills or hot flushes
• Chest pain or discomfort
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 There are three types of Panic Attacks

1. Unexpected - the attack "comes out of the blue"

without warning and for no discernable reason.

2. Situational - situations in which an individual

always has an attack, for example, upon entering a
tunnel.

3. Situationally Predisposed - situations in which

an individual is likely to have a Panic Attack, but
does not always have one. An example of this
would be an individual who sometimes has attacks
while driving.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Case video

Panic attack and Occupational Therapy.flv

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Diagnostic Criteria: Panic Disorder
DSM-IV criteria

• Recurrent unexpected panic attacks

• A month or more of at least one of the
following after an attack:
– Persistent concern about having more
attacks.
– Worry about the implications or cause of
attack.
– Significant change in behavior related to
attack.
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 Diagnostic Criteria:
Panic Disorder

• Absence or presence of agoraphobia

• Panic attacks not due to substance or

another mental disorder
• Various symptoms present with attacks

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Agoraphobia

Fear of the marketplace (agora)” = fear of public areas

(stores, theater, public transport), fear of being away
from safe places (home)

• Hypothesis: almost exclusively a complication

of panic
– Patient afraid of being caught somewhere
having a panic attack, where escape would be
difficult/impossible

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Facts Panic Disorder

• 3.5% lifetime prevalence

• More common in females 2:1
• Age typically 20’s to 40’s, risk may decrease with age
• Rates are similar across studies conducted in different
nations (e.g., US, Switzerland, Puerto Rico, far East)
except for lower rates in one Taiwan study

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Primary models for
understanding Panic
Disorder

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Biological model

 Some evidence of a genetic predisposition

ِ

 Abnormal norepinephrine activity

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Biological model for understanding Panic Disorder Con’t

 genetics :-Some evidence for

24% of identical twins (Monozygotic)
11% of fraternal twins (Dizgotics)
Disorder runs in families

10 times more likely in biological relatives of those with

panic disorder (genetic vs. environmental factors?)

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

Biological model for understanding Panic Disorder Con’t

• Redmund: that he could stimulate a

norepinephrine rich area of the brain and
cause panic attacks in monkeys.
• Bourin: Induced panic attacks in humans by
injecting them with drugs which affect
norepinephrine levels.
• Evidence that other neurotransmitters may
also play a role.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Cognitive – Behavioral Model
for understanding Panic Disorder
Cognitive: anxiety sensitivity =
A misunderstanding of bodily functions (sympathetic arousal)
– Intense focus on body sensations (biological predisposition?)
– Assess those sensations illogically (out of control/dangerous)
– Interpret them as harmful

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 How panic works…….
The panic vicious
circle:
Thinking about spiralling out of
going where control
Short of breath
you previously Chest pain, etc
had a panic
attack

Frightened and petrified “I’m going to pass out”

“I’m dying”
 Panic Disorder: Risk Factors

• Statistically associated with heart condition known

as mitral valve prolapse (MVP), which does not
rule out Axis I diagnosis of panic disorder

• Caffeine and stimulant medications frequently

increase panic attack frequency

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

Panic Disorder: Risk Factors,cont’d
• Depression a risk factor for
isolated panic attacks
– 15-35% of all depressed
patients
- Risk for committing suicide
15%
• Alcoholism
- 20-40% of all panic patients

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 DIFERENTIAL
DIAGNOSIS

• MEDICAL CONDITIONS
 Acute myocardial infarction
- in pure panic attacks patient doesn't
experience crushing chest pain

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 DIFERENTIAL DIAGNOSIS
2. Catecholamine secreting tumors
( pheochromcytoma)
 Severe Abdominal or Back pain
 Hypertensive response to smoking
 Malignant hypertensive episodes
 Sweating in the chest and back
while in panic in soles , palms and
forehead
 Splitting headache
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 DIFERENTIAL
DIAGNOSIS
3. Substance Abuse :
 Cocaine.
 Marijuana
 Alcohol
 Opiates

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 DIFERENTIAL
DIAGNOSIS
4.Hypoglycemia:-
Extremely rarely cause panic
attacks
5. Caffeine:-
More than 700mg may cause
panic attacks , also patient with
panic disorder may aggravate
with one cup of coffee.
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 What You Can Do

• Assessment
• Intervention

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Assessment

•Physical exam and baseline lab investigations should be

performed before initiation of pharmacological treatment
• Regularly monitor weight changes and adverse effects of
medication, including sexual dysfunction

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Assessment

Explore the possibility of physical causes for

emotional symptoms
A physical exam should be part of the
assessment when new symptoms are
present
Look for a history that does not fit
Review personal and family history
carefully
Be suspicious if the onset of the disorder
Saturday, February is late in
7, 2009 life
PANIC DISORDER BY DR. HISHAM AFANEH
 Assessment
 Be suspicious if there is a history of
recent onset of headaches, loss of
function, unusual perceptions (tingling,
dissociation, visual disturbances, or
hallucinations- especially visual, olfactory,
or tactile)
Drugs, drugs, drugs.

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Baseline Lab Investigations
 Complete blood count (CBC)
 Fasting glucose
 Electrolytes
 Liver enzymes
 Serum bilirubin
 Serum creatinine
Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH
 Urinanalysis
 Urine toxicology for
substance use
 24-hour creatinine clearance
(if history of renal disease)
 Thyroid stimulating hormone
 Electrocardiogram (>40 years or if
indicated)
 Pregnancy test (if relevant)
 Prolactin
 TREATMENT

IN Emergency Department
Most cases the attack exhausts itself within minutes
but if it persists An injectable form of
benzodiazepines can be used

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Panic Disorder: Initial Therapy
Citalopram, escitalopram, fluoxetine,
First line fluvoxamine, paroxetine, sertraline,
venlafaxine XR

Clomipramine,imipramine, mirtazapine, benzodiazepines (e.g.,

Second line alprazolam,clonazepam, lorazepam, diazepam)
adjunctive clonazepam

Bupropion, divalproex, gabapentin, moclobemide, olanzapine, adjunctive

pindolol, phenelzine, risperidone, quetiapine
Third line

Not Buspirone, trazodone, propranolol,

recommended carbamazepine

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 How to Alleviate Panic Attacks How to Help Someone Having a Panic Attack2.flv

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Treatment of
hyperventilation …..

– Rebreathing
- An immediate treatment is to
rebreathe expired air from bag in
order to increase the concentration of
CO2 in alveolar air
– As an effective way of demonstrating
the connection between symptoms
and hyperventilation

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Cognitive therapy

• The two major foci of cognitive therapy for panic

disorder are :-
 Instruction regarding the patient's false beliefs

( patient's tendency to misinterpret mild bodily sensations

as indicative of impending panic attack, doom or death)

 Information regarding panic attacks

( when they occur , are time – limited and not life-
threatening)

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Behavioral and Cognitive Therapy

• Teaches patient to react differently to situations and

bodily sensations that trigger anxiety
• Teaches patient to understand how thinking
patterns that contribute to symptoms
• Patients learn that by changing how they perceive
feelings of anxiety, the less likely they are to have
them
• Examples: Hyperventilating, writing down list of
top fears and doing one of them once a week,
spinning in a chair until dizzy; after awhile patients
learned to cope with the negative feelings associated
with them and replace them with positive ones

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Strategies to reduce anxiety

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Breathing exercises
 Produce slow deep breathing
 Prevent hyperventilation
 Prevent excessive blowing off of CO2

How to Alleviate Panic Attacks How to Do Breathing Exercises3.flv

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Meditation
• Cultivates calmness to create a sense
of control over life
• Practice: Sit quietly in a position
comfortable to you and take a few
deep breaths to relax your muscles,
next choose a calming phrase (such
as “om” or that with great
significance to you), silently repeat
the word or phrase for 20 minutes

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 How to Do Breathing Exercises Breathing Exercises with Enchanting.flv

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Self Love
 The most important holistic treatment of all
 Laugh: be able to laugh at yourself and with others;
increases endorphin levels and decreases stress
hormones
 Let go of frustrations
 Do not judge self harshly: don’t expect more from
yourself than you do others
 Accept your faults

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH

 Questions?

Saturday, February 7, 2009 PANIC DISORDER BY DR. HISHAM AFANEH