Panic disorders

Introduction

Panic disorder is a disorder characterized by episodic attacks of extreme fear, mostly unrelated to specific objects or situations.
It is associated with multiple somatic and
cognitive symptoms.
Each attack lasts for about 5-30 minutes
and often begins abruptly.
It affects about 0.5-1.0% of the population

Clinical features

  • A feeling of choking
  • Pounding heart
  • Chest pressure or pain
  • Dizziness
  • Shortness of breadth
  • Trembling
  • Sweating
  • Tingling or numbness in the hands or feet Hot flushes

Differential diagnoses

  • Other causes of intense fear (phobias, obsessive-compulsive disorders, etc.)
  • Medical causes (e.g. hyperthyroid states, episodic hypoglycemia, etc)
  • Seizure disorders.

Complications

  • Phobia
  • Depression
  • Suicide

Investigations

As indicated to exclude medical aetiologies

Treatment objectives

  • To reduce intensity and frequency of attacks
  • To reduce anticipatory anxiety

Non-drug treatment

  • Cognitive-behavioural treatment

Drug treatment

A. Initial management for patients unresponsive to non pharmacological treatment

1st Line Treatment
Evidence Rating: [B]
Fluoxetine, oral,
Adults: 10 mg daily (as a single morning dose) then increase up to 60 mg daily if necessary
Children

  • 6-18 years; 10 mg daily then increase up to 20 mg after 1-2 weeks if necessary

Or

Sertraline, oral,
Adults: 25 mg daily (as a single evening dose) Then increase to 50 mg after 1 week if necessary, then 50 mg weekly to a max. of 200 mg daily if necessary
Children: Not recommended

Or

Imipramine, oral,
Adults: 25-50 mg daily (as a single evening dose) max. 150 mg daily
Children: Not recommended for this indication

B. For very frequent panic attacks

Lorazepam, oral,
Adults: 1-4 mg daily for 2 weeks
Children:

  • 2-18 years; 0.05 mg/kg daily for 2 weeks

C. For anticipated anxiety attacks

Lorazepam, oral,
Adults: 1-4 mg stat.
Children: 0.25-0.5 mg stat.

D. For Acute Symptomatic Control

Lorazepam, oral,
Adults: 1-4 mg 8-12 hourly as required (max. 10 mg daily)
Children: Not recommended for this indication.

Or

Alprazolam, oral,
Adults: 0.25-0.5 mg 6-8 hourly. Increase if necessary every 3-4 days, max. 4 mg daily.
Children < 18 years; Not recommended

Or

Diazepam, oral,
Adults: 2-5 mg 12 hourly for 2 weeks and gradually taper off over the next 2 weeks (Do not give for more than one month continuously)
Children:

  • 1-12 years; 1.25-5 mg 6 hourly as needed

Note

Duration of treatment for recurrent cases should be at least 6 weeks and should be continued for up to 6 months or more after attacks have remitted to prevent early relapse. Wean off slowly over a month or more.

Supportive measures

  • Psychotherapy
  • Relaxation techniques

Notable adverse drug reactions

  • Tricyclic antidepressants are cardiotoxic in overdose
  • Increased risk of suicidal attempts by patients with panic disorder

Prevention

  • No specific primary prevention measures.

Referral Criteria

  • Refer children with symptoms suggestive of a panic disorder to a paediatrician.
  • Also refer patients to a psychologist for Cognitive Behaviour Therapy and to a psychiatrist for additional drug therapy where indicated