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Panic Disorder: clinical

CLINICAL FEATURES - Panic disorder

The first panic attack is often quite spontaneous, but occasionally may be the result of excitement, exercise, sexual activity or emotional trauma mo awake.

The DSM-IV stresses that, to meet the diagnostic criteria for panic disorder, at least the first attacks of Vono be unexpected (no trigger).

The physician should try to establish any habit or situation that it typically precedes the panic attack in a given patient. These activities may include the use of caf fein, alcohol, nicotine or other drugs, atypical patterns of are no specific environmental or food and situations, like a bright light in the workplace.

Panic attacks often begin with a 10-minute period of rapid increase in the severity of symptoms.

The main mental symptoms are extreme fear and a sense of impending death or doom. Patients usually are unable to report the source of their fear, they feel confused and have difficulty concentrating. Physical signs often include tachycardia, palpitations, shortness of breath and sweating.

Patients often try to leave any situation in which they are to seek help. The attack usually lasts from 20 to 30 minutes and rarely more than an hour. A formal examination of mental condition during a panic attack may reveal rumination, difficulty speaking, such as stuttering, and alteration of memory.

Those affected may experience depression or depersonalization during an attack.

Symptoms may gradually withdraw or rapid heating. Among

an attack and another patient may have anticipatory anxiety concerning the possibility of having another attack.

The differentiation between anticipatory anxiety and generalized anxiety disorder can be difficult, even if the subjects with panic disorder with anxious anticipation, are able to show stimulation of their anxiety.

fears of physical death due to cardiac or respiratory problems may be the main object of the patient during panic attacks. Subjects may believe that palpitations and chest pain indicating the imminence of death. Up to 20% of them did indeed syncopal episodes during a panic attack.

Typically, patients presenting to the emergency room are young (early twenties), in good physical health and yet claim to be persistently on the verge of dying from a heart attack. Instead of immediately diagnose

un'ipocondria, the emergency doctor vrebbe do consider the diagnosis of panic attack.

The hyper ventilation causes respiratory alkalosis and other symptoms. Sometimes it may be helpful to the old practice of breathing the rare patient in a bag.

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Agoraphobia: diagnostic criteria for panic disorder with agoraphobia

DSM-IV diagnostic criteria for ' agoraphobia

Note: agoraphobia is not a codable disorder . Specify the disorder in which occurs the agoraphobia (eg, panic disorder with agoraphobia or agoraphobia without history of panic disorder).

A.
Anxiety on being in places or situations from which it can be difficult (or embarrassing) or in which help may not be available in case of a panic attack or panic-like symptoms or related to the unexpected situation. The Agoraphobic fears typically involve groups characteristic of situations that include being outside the home alone in a crowd or standing in queue, on a bridge and travel by bus, train or automobile.

Note: Consider the diagnosis of specific phobia if the avoidance is limited to one or a few specific situations, or social phobia if the avoidance is limited to social situations.

B. The
situations are avoided (eg, travel is restricted) or are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.

C.
The anxiety or phobic avoidance are not better accounted for by another mental disorder , such as social phobia (eg, avoidance limited to social situations because of fear of embarrassment), specific phobia (eg, the 'avoidance is limited to a single situation, as elevators), obsessive-compulsive disorder (eg, avoidance of dirt in a subject with the obsession of contamination), posttraumatic stress disorder from the stress (eg, avoidance of stimuli associated with a severe stressor), or the disturbance d 'separation anxiety (eg, avoidance of removal from the home or family).

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DSM-IV diagnostic criteria for panic disorder with agoraphobia

A. Either (1) or (2);

(1) recurrent unexpected panic attacks

(2) at least one of the attacks was followed by a month (or more) of one (or more) of the following symptoms:

(a) persistent concern about having other attacks
(b) concern about the implications of the attack or its consequences (eg, losing control, have a heart attack, "going crazy")
(c) significant behavioral changes related to the attacks

B. Presence of agoraphobia.

C. Panic attacks are not due to the direct physiological effects of a substance (for example, a subject of substance abuse, a medication) or a general medical condition (eg, hyperthyroidism).

D. Panic attacks are not better accounted for by another mental disorder , such as social phobia



(for example, occur after exposure to feared social situations), specific phobia

the ;

(for example, following exposure to a specific phobic situation), the

obsessive-compulsive

(for example, upon exposure to dirt a person with an obsession about contamination) ,

the post-traumatic stress disorder

(for example, in response to stimuli associated with a severe stressor)

disorder or separation anxiety

(for example, in response to being away from home or away from close relatives).

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panic disorder: diagnostic criteria

Panic disorder: diagnostic criteria

The DSM-IV contains two diagnostic criteria for panic disorder, agoraphobia, one without and one with agoraphobia, but both require the presence of panic attacks, as shown in Table visible in the post: Diagnosis of Panic Attacks .

AlCu ni population studies have indicated that the attacks pa nico are frequent and a bit of the main aspects in the development of diagnostic criteria for panic disorder has been the determination of a threshold value or frequency of panic attacks to meet the diagnosis. A threshold too low

knows favors a diagnosis of panic disorder in patients without functional alteration following an occasional panic attack, too high a threshold results in a situation where patients who are disturbed by their attacks Panic not meet the diagnostic criteria.

The uncertainty in the determination of threshold is marked by the range of thresholds included in the diagnostic criteria for us. The Research Diagnostic Criteria (RDC) requires six panic attacks in a period of six weeks .

The tenth revision of International Classification of Diseases (ICD-10) requires three attacks in three weeks (moderate disease) or four attacks in four weeks (for severe disease).

The DSM-IV does not specify a number to me synonymous with panic attacks or a period, but requires that at least one attack is followed by a period of at least one month during which the patient is afraid of having another panic attack or is concerned about the implications of AT heel, or a significant change of behavior.

The DSM-IV also requires that panic attacks are generally unexpected, but it also attacks expected or prepared by the situation.


Table: diagnostic criteria for panic disorder without agoraphobia

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DIAGNOSIS
Panic attacks

Unlike the DSM-III-R criteria diagnostic at the heels of panic in the DSM-IV are listed separately (see table).

Panic attacks may occur in mental disorders outside of panic disorder, particularly in specific phobia, social phobia in and posttraumatic stress disorder Stress .

unexpected panic attacks appear from nowhere and are not associated with any identifiable situational stimulus.

However, panic attacks do not necessarily unexpected, because in patients with social phobia and specific are usually expected or otherwise linked to a specific stimulus recognizable.

Cuni Al panic attacks do not fit easily into the distinction between expected and unexpected attacks, in this case are as dicati panic attacks with predisposition situa tion, which may appear or not when a patient is exposed to a specific stimulus, or may occur immediately after exposure, or even with considerable delay.

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Diagnosis of Panic Attacks Panic Attacks: Genetic Components in the psychodynamic hypothesis



Psychosocial factors have been developed theories and cognitive-behavioral and psychoanalytic theories to explain the pathogenesis of panic disorder and dell'agorafobia .

psychoanalytic theories

Psychoanalytic theories consider the panic attacks as a result of the failure of a defense against impulses that cause anxiety.

What was initially a modest signal anxiety becomes an overwhelming feeling of apprehension, combined with somatic symptoms.

Nell ' agoraphobia psychoanalytic theories emphasize the loss of a parent in childhood and a history of separation anxiety. The finding himself alone in public places revives anxiety sen thyrsi abandoned infant.

defense mechanisms used to take with repression, displacement, symbolization and avoidance.

traumatic separations during childhood may influence the development of the baby's nervous system, which consequently becomes susceptible to anxiety as adults.

Many patients describe panic attacks as if they appear out of nowhere, as if psychological factors were not involved, but the exploration of the psychodynamics banks often an obvious psychological motive.

Although panic attacks are related in terms of neurophysiological locus coeruleus, the onset of panic is usually related to environmental factors or psychological.

Subjects with panic disorder have a higher incidence of stressful life events, especially losses, compared to controls, in the months before the onset of panic disorder. In addition, patients typically experience a greater torment against life events than controls.

The hypothesis that psychological stressful events produce mak neurophysiological in panic disorder is so Stegne in a study of female twins. This research has revealed that panic disorder is strongly associated with both the separation of parents and their deaths before the age of 17 years. In a cohort of 1018 pairs of ge melle it was found that early separation from the mother more likely to cause a panic disorder compared to the separation from her father. Another

support for a psychological mechanism in the genesis of panic disorder can be deduced from a study of patients with panic disorder who were treated successfully with psychotherapy. Before therapy, subjects responded to induction by lactate with a panic attack. After successful treatment, the infusion of lactate was no longer able to determine a panic disorder.

Research indicates that the cause of panic attacks probably involves the unconscious meaning of the stressful and even you that their pathogenesis may be related to neuropsychological factors triggered reactions from psychologists.

Psychiatrists psychodynamic should always carried a sanctuary full search of possible triggers every time you perform a diagnostic evaluation on a patient with panic disorder.

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Genetic factors

Although the number of well-controlled studies on the basic policy of the gene and panic disorder dell'agorafobia is reduced, the current data support the conclusion that the disturbances may ave a re different genetic component.

In addition, some data suggest that panic disorder with agoraphobia is but for a severe panic disorder without agoraphobia, and that is much easier to inherit. Several studies have

found an increase of 4-8 times the risk of panic disorder in the pa-rent of first degree relatives of patients with panic disorder re compared with those of subjects with other psychiatric illnesses.

The twin studies conducted to date have shown that identical twins are more likely to concordance for panic disorder than dizygotic twins.

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Neuroimaging of Panic Panic Panic

struc tural neuroimaging studies (eg, magnetic resonance imaging [MRI]) in patients with panic disorder showed a disease of the temporal lobe, particularly the hippocampus.

For example, one study reported MRI abnormalities, especially cortical atrophy in the right temporal lobe of subjects with panic disorder .

neuroinimagine functional studies (eg, the positropi emission tomography [PET]) have shown a dysregulation of cerebral blood flow.

Specified mind, anxiety disorders and panic attacks are associated with cerebral vasoconstriction, which can result in symptoms in the central nervous system, such as dizziness, and peripheral nervous system is, that can be induced by hyperventilation and dall'ipocapnia.

Most neuroimaging studies functional used a substance that induces panic (eg, lactate, yohimbine, caffeine) in combination with PET or computed tomography single photon emission tomography (SPECT) to determine the effects on cerebral blood flow of the substance inducing panic and resulting panic attack.

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induced Factors in organic substances

The substances that trigger panic (sometimes called panicogene) are substances that induce panic attacks in most patients with panic disorder and a lower proportion of subjects sen za or without panic disorder history of panic attacks .

The use of substances that induce panic is closely mitato them to research, there are clinical reasons to stimulate panic attacks in patients.

The so-called panic-inducing substances cause a respiratory respiratory stimulation and a shift in ' acid-base balance, they include carbon dioxide (mixture 5 to 35%), lactate and sodium bicarbonate. The

neurochemicals that induce panic, which act through specific neurotransmitter systems, including yohimbine, an adrenergic receptor antagonist, fenfluramine, a releasing agent serotonin, chlorophenylpiperazine (mCPP), a substance with multiple effects serotonergic drugs μ-carbolines, inverse agonists of GABAB receptors, flumazenil, an antagonist of GABAB receptors, cholecystokinin and caffeine. Although isoproterenol is a substance that causes the panic, although the mechanism of action is unknown.

substances that cause respiratory panic may initially act on the peripheral cardiovascular baroreceptors and release their signal from vagal afferents to the nucleus of the solitary tract nucleus paragigantocellulare and then to the bulb.

The panic-inducing neurochemicals exert presumably their primary effects directly on the central noradrenergic receptors, serotonergic and GABAergic.

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Panic

Research on the biological basis of panic disorder has produced a series of data, according to one interpretation, the symptoms of panic disorder can cause various biological abnormalities in brain structure and function (see also post on biological theories of anxiety ).

Most of the work was done through the use of biological stimulants to induce a panic attack in patients with panic disorder.

These and other studies have suggested that involve pro duct a dysregulation of the peripheral and central nervous system in the pathophysiology of panic distur bo.

The autonomic nervous system of some individuals have an increased sympathetic tone, a slow adaptation to repeated stimuli and an excessive response to stimuli moderates. Research on neuroendocrine function in patients with panic disorder have identified various abnormalities, although the results of the studies were not unique.

The major neurotransmitter systems involved are noradrenergic, serotonergic and GABA-ergic (gamma-ami no-butyrate) .

The totality of biological data has led to a focus on the trunk brain (particularly neurons of the locus coeruleus noradrenergic and serotonergic neurons of the median raphe nucleus), the limbic system (perhaps the origin of ' anticipatory anxiety) and the prefrontal cortex (perhaps the origin of' phobic avoidance ).

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Epidemiological studies have reported a lifetime prevalence of 1 0.5 to 5% for panic disorder and 3 to 5.6% for ' panic attack.

For example, a recent study of more than 1600 randomly selected adults in Texas has found a lifetime prevalence of 3.8% for your trouble panic, 5.6% for panic attacks and 2.2% for panic attacks with limited symptoms that do not fully meet the diagnostic criteria.

Women are 2 to 3 times more affected than men, even if a tendency to under-diagnosed disorder co loaves in men may contribute to this distribution so skewed. The differences among Hispanic, white non-Hispanics and blacks are minimal.

The only social factor identified that could contribute to the development of panic disorder is a recent history of divorce or separation. The distur

bo panic occurs more often among young adults (age average onset is 25 years), but both panic disorder and agoraphobia can develop at any age. For exam ple, the first has also been reported in children and adolescents and is probably underdiagnosed in these groups.

The lifetime prevalence of 'agoraphobia has ranged from a low of 0.6% to a maximum of 6%. The major factor behind this heterogeneity of the estimates is attributable to the use of diagnostic criteria and different assessment methods.

Although studies of 'agoraphobia am in psychiatric environment have reported that at least three-quarters of affected patients also have a panic disorder , sull'agorafobia in community studies have found that up to half of the subjects manifested agoraphobia without panic disorder.

The reasons for such divergent findings are unknown, but probably involve differences in assessment techniques. In many cases the onset dell'agorafobia is following a traumatic event.