PANIC DISORDER-

DIAGNOSIS &
MANAGEMENT

Presented by – Prachi Patel

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Contents
• Definition

• Diagnosis

• Management
- Pharmacological Therapy
- Psychological Therapy
• Summary

• References

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Definition
• An acute intense attack of anxiety accompanied by feelings of
impending doom is known as panic disorder.

• The anxiety is characterised by discrete periods of intense fear,

that can vary from several attacks during one day to a few
attacks during a year.

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Diagnosis
• Panic disorder is assigned the code F41.0 in ICD-10

• According to it , panic disorder can be diagnosed by presence

of following features

• Recurrent attacks of severe anxiety(panic),which is not

restricted to any particular situation or set of circumstances,
and are therefore unpredictable(i.e. also called- episodic
paroxysmal anxiety)

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• Sudden onset

-Palpitations
-Chest pain
-Choking sensations
-Dizziness
-Feeling of unreality (Depersonalization or Derealization)

• Secondary fear of – dying, losing control, or going mad

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• Most patients with panic disorder(91%) have at least one other
psychiatric disorder

• Most commonly associated disorder – Agarophobia

• About 1/3rd persons with panic disorder have major depressive

disorder before onset

• 2/3rd – experience panic disorder during or after the onset of

major depression

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DSM-5
 A) Recurrent unexpected panic attacks. A panic attack is an abrupt
surge of intense fear or intense discomfort that reaches a peak
within minutes and during which time several symptoms occur.
- Palpitations, -sweating,- chest pain,-trembling,-nausea,-
dizziness,- paresthesia,-derealization,- fear of dying
 B) At least one of the attacks has been followed by 1 month(1 or
more) of the following
1. Persistent concern or worry about additional panic attacks or
their consequences
2. A significant maladaptive change in behaviour related to the
attacks
 C) The disturbance is not attributable to the physiological effects
of the substance or another medical condition.
 D) The disturbance is not better explained by another mental
disorder 7
 Management
• Panic disorder can be managed by 2 ways –

- Psychotherapy

- Pharmacotherapy

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Psychotherapy
Cognitive Behavioural Therapy(CBT)
• Effective in producing long lasting remission of symptoms.

• 2 major foci of cognitive therapy for panic disorder are –

- instruction about patient’s false beliefs-
which centers on patient’s tendency to misinterpret mild
bodily sensations as impending panic attacks, doom or death.
-information about panic attacks –
it includes explanations that, when panic attacks
occur, they are time limited and not life threatening

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Relaxation Techniques
• Breathing Exercises
• JPMR(Jacobson’s Progressive Muscle Relaxation)
• Mindfulness

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Pharmacotherapy
• Benzodiazepines
Starting dose(mg) Maintenance
dose(mg)
Alprazolam 0.25 - 0.5 tid 0.5 – 2 tid
Clonazepam 0.25 – 0.5 bid 0.5 – 2 bid
Diazepam 2 -5 bid 5 -30 bid
Lorazepam 0.25 – 0.5 bid 0.5 -2 bid

• Alprazolam is most widely used for panic disorder.

• It is the most rapid acting drug used against panic disorder,so
can be used in panic crisis.
• Some patients use BZDs as needed when faced with a phobic
stimulus.
• S/E – dependance, cognitive impairment, abuse- after long term
use 11
• SSRI
Starting dose(mg) Maintenance
dose(mg)
Paroxetine 5 - 10 20 - 60
Fluoxetine 2-5 20 - 60
Setraline 12.5 - 25 50 - 200
Fluvoxamine 12.5 100 - 150

• 1st line of treatment for panic disorder

• Sedative effect – calm the patient ,so greater compliance and
less discontinuation
• S/E – weight gain

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TCA
Starting dose(mg) Maintenance
dose(mg)
Clomipramine 5 – 12.5 50 - 125
Imipramine 10 -25 150 - 500
Desipramine 10 - 25 150 - 200

MOA Inhibitor
Starting dose(mg) Maintenance
dose(mg)
Phenelzine 15 bid 15 -45 bid
Tranylcypromine 10 bid 10 – 30 bid
RIMA
Starting dose(mg) Maintenance
dose(mg)
Moclobemide 50 50 - 150
Brofaromine 50 150 - 200
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• ATYPICAL ANTIDEPRESSANT
Starting dose(mg) Maintenance
dose(mg)

Venlafaxine 6.25 - 25 50 - 150

Venlafaxine XR 37.5 150 - 225

• Other Agents
Starting dose(mg) Maintenance
dose(mg)

Valproic Acid 125 bid 500 -750 bid

Inositol 6000 bid 6000 bid

• Duration of pharmacotherapy –
8-12 months
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Summary
• Panic attack is defined as an acute intense attack of anxiety
accompanied by feelings of impending doom .

• It characterised by Sudden onset palpitations, chest pain,

choking sensations ,dizziness etc.

• It can be managed by combined treatment consisting –

pharmacotherapy and behavioural therapy

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References
• Synopsis of Psychiatry -12 th Edition
• ICD - 10

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THANK
YOU

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