C/P: Dr.

Aruna

PA N IC D IS O R D ER
ETIO LO G Y & C LIN IC A L
FEATU R ES

Introduction
Panic disorder is defined as a type of

anxiety disorder characterized by

recurrent & unexpected panic
attacks (DSM IV)
Agoraphobia anxiety about being in
places or situations from which
escape might be difficult (or
embarrassing) or in which help may
not be available in the event of
having an unexpected or

Epidem iology
Lifetime prevalence- Panic disorder : 1-4%
Lifetime prevalence- Panic attacks: 4-12%
Lifetime prevalence- Agoraphobia: 2-6%
2-3 times more in women
Men - without & Women with

agoraphobia
2 peaks of onset: 15-24 yrs & 45-54 yrs
Risk with: widowed/divorced/separated
living in cities; limited education; early
parental loss; physical/sexual abuse

ETIOLOGY

G enetic predisposition
7-8 fold rates in 1st degree relatives
monozygotic concordance (31 vs 0 %)
High rates of anxiety disorders in children

of adults with panic disorder

Genes ADOR2A, 10832/T, CCK, CRH,
genes for 5HT1A, 5HT2A, COMT, SERT
Traumatic early life events
Dependent personality traits, over
protectiveness

N eurotransm itters
NE:
Yohimbine & Isoproterenol (+) panic
attacks in panic disorder patients
Both these drugs firing rate of
locus ceruleus
Drugs for treatment of panic
disorders firing rate of locus
ceruleus

N eurotransm itters
5HT:
in 5HT transmission decreases panic
disorder
5HT neurons in ventrolateral PAG (-)s
sympathoexcitation & fight/flight response in
rats
SSRIs effective in panic disorder
Flumazenil causes mild anxiety in
unmedicated panic disorder patients
PET : in brain 5HT1A receptors & 5HT
transporter binding

N eurotransm itters
GABA:
BZD agonists effective in panic disorder
Flumazanil panicogenic effect in panic
disorder
Neuroimaging studies
- impaired GABA neuronal response to BZDs
- GABA in cingulate & basal ganglia
- BZD binding in inferior parieto-temporooccipital areas

N eurotransm itters
CCK-pentagastrin:
Panic disorder patients devp panic
attacks in a dose-dependent fashion
with administration of pentagastrin
CCK gene polymorphisms

N euroanatom icalhypothesis

Cognitive m odel
Goldstein & Chambless (1978):

A noxius stimulus (panic attack) that

occurs with a neutral stimulus (bus
ride)
Avoidance of neutral stimulus
Panic Avoidance Re exposure

Cognitive m odel
Clark (1986):

Catastrophically misinterpret
autonomic arousal sensations that
occur in the context of nonpathological anxiety (eg. Physical
illness, exercise, substances)
Autonomic sympts misinterpreted
panic

Cognitive m odel
Reiss et al (1991):
1. Predispositional tendency to

catastrophically misinterpret & respond

with fear
2. A learned fear of anxiety that is maintained
by the experience of panic attacks
Aut sympts misinterpret panic learned
fear & hence avoidance re exposure/aut
sympts panic

Cognitive m odel
Bouton (2001):

Exposure to panic attack conditions the person

to respond with anticipatory anxiety to
internal arousal & contextual cues
Panic attack with fear & autonomic symptoms
Internal arousal / contextual cues anytime
Anticipatory anxiety (sometimes panic attacks)

Psychodynam ic m odels
People at risk for panic disorder have:
1. Neurophysiological vulnerability to

panic attacks &/or

2. Multiple experiences of

developmental trauma

Psychodynam ic m odels
Trauma with/without vulnerability
Child excessively fearful of unfamiliar
situations
Becomes excessively dependant on
primary caregiver to provide a sense
of safety

Psychodynam ic m odels
Caregiver unable to provide support
always
Child develops a fearful dependency
Development of unconscious
conflicts about dependency
( Independence vs Reliance on
others) & anger

Psychodynam ic m odels
Evoke aversive emotions like anxiety, anger & guilt
Benign arousal sensations accompanying these
emotions becomes the focus of conscious &
unconscious cognitive catastrophising
Conflicts

PANIC ATTACKS

(+) unconscious/conscious fantasies of catastrophic

danger

Psychodynam ic m odels
Patients with panic disorder have a

higher incidence of stressful life

events in the months before the onset
of panic disorder.
~60% women have h/o childhood
sexual abuse
Cause - unconscious meaning of
stressful events
Pathogenesis - neurophysiological
factors triggered by the psychological

DIAGNOSIS

D SM IV TR
Recurrent & unexpected panic attacks
At least 1 of these attacks must be

followed by 1 month or more of:

1. persistent concern about having more
attacks,
2. worry about the implications or
consequences of the attack, or
3. changes to typical behavioral patterns
(e.g., avoidance of work or school
activities) as a result of the attack.

D SM IV TR
In addition, the panic attacks must not
stem solely from:
the direct effects of illicit substance
use, medication, or a general
medical condition
are not better explained by another
mental disorder (e.g., such as social
phobia for attacks that occur only in
social situations)

D SM IV TR Panic attack
A panic attack is a discrete period of intense fear or

discomfort in the absence of real danger that

develops abruptly, reaches a peak within 10 min,
and is accompanied by 4 (or more) of the following
13 symptoms:
(1) Palpitations, pounding heart, or accelerated heart
rate
(2) Sweating

D SM IV TR Panic attack
(3) Trembling or shaking
(4) Sensations of shortness of breath or smothering
(5) Feeling of choking
(6) Chest pain or discomfort
(7) Nausea or abdominal distress
(8) Feeling dizzy, unsteady, light-headed, or faint
(9) Derealization (feelings of unreality) or
depersonalization (being detached from oneself)

D SM IV TR Panic attack
(10) Fear of losing control or going
crazy
(11) Fear of dying
(12) Paresthesias (numbness or
tingling sensations)
(13) Chills or hot flushes

D SM IV TR Panic attack types

Unexpected - not associated with an

identifiable internal or external trigger

and appear to occur out of the blue
Situationally bound - almost invariably
occur when exposed to a situational
trigger or when anticipating it
Situationally predisposed - usually, but
not necessarily, occur when exposed to
a situational trigger or when
anticipating it

D SM IV TR
Panic disorder with agoraphobia -

warranted when the criteria for panic

disorder are satisfi ed and
accompanied by agoraphobia
limited symptom attacks - panic-like

episodes comprising fewer than 4

symptoms.

D SM IV TR -Agoraphobia
Agoraphobia - anxiety about being in places or

situations from which escape might be difficult

(or embarrassing) or in which help may not be
available in the event of having an unexpected or
situationally predisposed panic attack / panic-like
symptoms.
Agoraphobic fears typically involve characteristic

clusters of situations, such as being outside the

home alone, being in a crowd, standing in a line,
being on a bridge, or traveling in a motor vehicle.

D SM IV TR -Agoraphobia
The situations are avoided or are

endured with marked distress or

worry about having a panic attack or
panic-like symptoms. Confronting
situations is aided by the presence of
a companion.
The anxiety or avoidance is not

better accounted for by another

mental disorder.

D SM IV TR
Panic disorder without agoraphobia
Panic disorder with agoraphobia
Agoraphobia without history of panic

disorder

ICD -10
F40.0 Agoraphobia

.00 without panic disorder

.01 with panic disorder
F41.0 Panic disorder (episodic

paroxysmal anxiety)

ICD -10 -Agoraphobia

(a) the psychological or autonomic symptoms
must be primarily manifestations of anxiety
and not secondary to other symptoms, such as
delusions or obsessional thoughts;
(b) the anxiety must be restricted to (or occur
mainly in) at least 2 of the following situations:
crowds, public places, travelling away from
home, and travelling alone;
(c) avoidance of the phobic situation must be, or

ICD -10 Panic D isorder

Several severe attacks of autonomic anxiety should

have occurred within a period of about 1 month:

(a) in circumstances where there is no objective danger;
(b) without being confined to known or predictable
situations; and
(c) with comparative freedom from anxiety symptoms
between attacks (although anticipatory anxiety is
common )

Co-m orbidities
Lifetime co morbidity in panic disorder >80%
In panic disorder with agoraphobia 100%
Major Depressive Disorder 65%
4 fold in suicide attempt with MDD & Panic dis
Somatoform & Pain related disorders freq

* Hypochondriasis - 50%
* A/c & Chronic Musculoskeletal pain 85%, 40%
* Irritable Bowel Syndrome 17-41%

Co-m orbidities
Other Anxiety Disorders Social phobia & GAD: 15-30%
Specific phobia: 2-20%
OCD: 10%
PTSD: 2-10%
a/c stress disorder: no studies yet

Co-m orbidities
Alcohol use disorders
40% in males; 13% in females
Precipitating, Maintaining &

Aggravating role
Can precede or develop secondary to

panic disorder (as means of selfmedication)

Co-m orbidities
Personality disorders:
40-50%
Avoidant
Dependent
Histrionic

D iff
erentialD iagnosis

G eneralM edicalConditions
Endocrine
Hyperthyroidism,

Hypo/hyperparathyroidism
Hypoglycemia, DM
Pheochromocytoma
Carcinoid syndrome
Cushings disease, Addisons disease
PMS, Menopausal disorders

G eneralM edicalConditions
Cardiovascular
MVP
Supraventricular arrythmias
Angina, MI, CHF
Hypertension
Anemia

G eneralM edicalConditions
Pulmonary diseases
COPD
Bronchial Asthma
Hyperventilation
Pulmonary embolus

G eneralM edicalConditions
Neurological diseases
CVD, TIA
Seizures, Migraine
Vestibular diseases
Multiple Sclerosis
Huntingtons disease
Wilsons disease

G eneralM edicalConditions
Others
Anaphylaxis
Systemic infections
Electrolyte disturbances
Uremia
Heavy metal poisoning
B12 deficiency
SLE, Temporal arteritis

Substance induced
Intoxication with CNS stimulants
Cocaine
Amphetamine
Caffeine, Theophylline, Nicotine
Intoxication with other drugs
Hallucinogens , Cannabis, Amyl

nitrite
Anticholinergics

Substance induced
Withdrawal from CNS depressants
Alcohol
Opiates & opioids
Sedative-hypnotics
Antihypertensives

Psychiatric disorders
Other anxiety disorders
GAD
Specific phobias
Social phobia
OCD
PTSD
Separation anxiety disorder
Mood disorders, Psychotic disorders

Psychiatric disorders
Factors helpful in making judgment for
sis:
Focus of anxiety
Type & no. of panic attacks
No. of situations avoided
Level of intercurrent anxiety

Conclusion
Panic disorder is a commonly missed

diagnosis in medical settings

Both biological & psychological
factors play a role
Co morbidities common & offers
challenge in diagnosis & treatment
Wary of other diseases simulating
panic disorder

Thank you

Trigger for panic attack???