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SOURCE

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Source: Melton ST, Kirkwood CK. Anxiety disorders: generalized anxiety, panic, and social anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146065193.

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DEFINITION

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  • Anxiety disorder characterized by unexpected and repeated episodes of panic attacks, which involve a surge of intense fear or intense discomfort.

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ETIOLOGY

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  • Genetic component.

  • Several biochemical theories have been postulated.

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PATHOPHYSIOLOGY

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  • Associated with activation of brainstem and basal ganglia regions.

  • May be abnormal activation of parahippocampal region and prefrontal cortex.

  • 5-HT may have role in development of anticipatory anxiety.

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EPIDEMIOLOGY

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  • Affects 6 million Americans over age of 18

  • One-year prevalence rate: 3.1%

  • Twice as common in women as in men.

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RISK FACTORS

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  • Family history of panic disorder.

  • Stressful life events.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Psychological symptoms:

    • Excessive anxiety.

    • Worries that are difficult to control.

    • Feeling keyed up or on edge.

    • Trouble concentrating or mind going blank.

    • Depersonalization.

    • Derealization.

    • Fear of losing control, going crazy, or dying.

  • Physical symptoms:

    • Restlessness.

    • Fatigue.

    • Muscle tension.

    • Sleep disturbance.

    • Irritable.

    • Abdominal distress.

    • Chest pain or discomfort.

    • Chills.

    • Dizziness or lightheadedness.

    • Choking feeling.

    • Hot flushes.

    • Palpitations.

    • Nausea.

    • Paresthesias.

    • Shortness of breath.

    • Sweating.

    • Tachycardia.

    • Trembling.

  • Symptoms of panic attack peak within 10 min and usually last 20–30 min.

  • Many patients eventually develop agoraphobia, which is avoidance of specific situations (eg, being in crowded places) where they fear attack might occur.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • History of recurrent, unexpected panic attacks followed by:

    • At least 1 month of concern about having another attack.

    • Worry about consequences of attacks.

    • Behavioral changes because of attacks.

  • During attack, there must be at least four physical symptoms in addition to psychological symptoms.

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DESIRED OUTCOMES

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  • Goal is remission.

    • Free of panic attacks.

    • Minimal or no anticipatory anxiety and agoraphobic avoidance.

    • No functional impairment.

  • Acute phase.

    • Usually 1–3 months.

    • Goal is reduction of symptoms.

  • Maintenance phase and discontinuation.

    • Usually treat for 12–24 months, the discontinue treatment over 4–6 months to avoid relapse.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Cognitive behavioral therapy (CBT) may be used alone for patients who cannot or will not take medications.

  • Aerobic exercise may be beneficial.

  • Educate patients to avoid:

    • Caffeine.

    • Stimulants.

    • Drugs of abuse.

    • Smoking.

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TREATMENT: PHARMACOLOGIC THERAPY

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  • Selective serotonin reuptake inhibitor (SSRIs) are first-line agents due to tolerability and efficacy.

  • Imipramine is second line due to cardiovascular and anticholinergic effects.

  • Benzodiazepines are second line due to risk of dependency.

  • Figure 1: Algorithm for pharmacotherapy of panic disorder.

  • Drug ...

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