Panic Disorder A Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for the Students of

1. Panic DisorderA Patient-Centered, Evidence-Based Diagnostic and Treatment Process A Presentation for the Students of Ohio University College of Osteopathic Medicine Kendall L. Stewart, M.D. November 29, 2010 1 My goal with these talks is to provide you with the minimum practical information you will need to treat these patients. 2 Please let me know whether I have succeeded on your evaluation forms.

2. Why is this important? • After mastering the information in this presentation, you will be able to • Describe how patients with Panic Disorder often present, • Detail the diagnostic criteria, • Describe some of the associated features, • List some differential diagnoses, • Write a preliminary treatment plan, and • Identify some of the frequent treatment challenges. • Up to 35-percent of us will experience panic attacks each year. • Most of us will not develop agoraphobia (up to 5-percent will) or panic disorder (less than 1-percent will). • But those who do are significantly impaired and distressed, and the prevalence in clinical populations is much higher. • Many other disorders are masked by anxiety making the underlying disorders more difficult to recognize and treat. • These patients typically have other significant comorbid conditions. • They are at clear risk for substance abuse and suicide.1 • They are frequently missed, misdiagnosed, mistreated and misunderstood. 1 Paradoxically, marijuana often triggers panic in first-time users.

3. What specific diagnoses are included here? • Panic Disorder Without Agoraphobia (300.01)1 • Panic Disorder with Agoraphobia (300.21) • Agoraphobia Without History of Panic Disorder (300.22) 1 If you make this diagnosis early and initiate treatment quickly, you may prevent many complications.

4. How might patients with panic disorder present? • This is a 25-year-old woman. • “My panic attacks started about seven years ago.”1 • “They usually come on without warning or when I’m upset or feel out of control.” • “Sometimes they wake me up”2 • “I stopped using caffeine because the doctor told me this might trigger panic” • “Even chocolate makes me jittery—but I haven’t given that up yet!” • “When they come on, my heart races and I get scared” • “I’m afraid that something awful is going to happen.” • “I used to hyperventilate and this would make things even worse.” • “I’ve learned to control that, mostly.” • “Both my mother and her brother have had the same problem.”3 • “I used to go to the emergency room all the time because I thought I was having a heart attack, but they could never find anything wrong.” • My doctors prescribed an antidepressant and a sedative, but I didn’t like how they made my feel.” • “I still keep a few alprazolam pills with me for security.” • “If it gets too bad, I know the pills will stop it. • “I now understand that the panic attacks will probably come and go the rest of my life.” • “I think I can manage them without taking medicine regularly.” • “At least I want to try.” 1 The peak age of onset of spontaneous panic attacks is between 15 and 25 years. (Goldman, 2000) 2 Panic attacks may result from noradrenergic dysfunction in the locus ceruleus (Nutt, et al, 1992) 3 Twin studies reveal some genetic basis for the disorder, but the exact inheritance is not clear.

5. What are the criteria for panic attack?1 • Four or more of the following must begin suddenly and peak within ten minutes • Sensation of a racing heartbeat • Sweating • Feeling shaky • Smothering or fear of choking • Chest pain or discomfort • Nausea or abdominal distress • Core symptoms • Feeling dizzy, unsteady, lightheaded or faint • Feelings of derealization or depersonalization • Sensation of going crazy or losing control • Fear of dying • Tingling sensations (paresthesias) • Hot flashes or chills 1 A panic attack cannot be coded as a psychiatric disorder (DSM-IV-TR).

6. What are the criteria for agoraphobia?1 • Anxiety about being in places where one might have a panic attack or where help or escape might be difficult • Being outside alone • Being in a crowd • Standing in line • Being on a bridge • Traveling in a confined space • And so on • Feared situations are avoided or reassuring companionship is sought • This phobic avoidance is not better accounted for by another mental disorder 1 Agoraphobia cannot be coded as a psychiatric disorder (DSM-IV-TR).

7. What are the criteria for panic disorder? • Both • Recurrent unexpected panic attacks • At least one of the attacks has been followed by a month (or more) of one (or more) of the following • Persistent concern about future attacks • Worry about the implications of the attacks • A significant change in behavior because of the attacks • The presence or absence of agoraphobia1 • Attacks are not substance-induced • Attacks are not better accounted for by another mental disorder • Listen to a patient account here. 1 Whether agoraphobia is present or absent clarifies the specific diagnosis. (DSM-IV-TR).

8. What are the criteria for agoraphobia without a history of panic disorder? • The presence of Agoraphobia • Criteria have never been met for Panic Disorder1 • The fear is not the direct result of a substance or a general medical condition • If a general medical condition is also present, the fear is clearly greater than would usually be associated with that condition 1 In clinical settings, over 95% of people presenting with agoraphobia also have panic disorder. (DSM-IV-TR).

9. What associated features might you see? • “Free-floating” anxiety is common. • They are often worrywarts. • They may be convinced that they have some deadly condition that their doctors have missed.1,2 • Shame, embarrassment and discouragement are common. • There quest for curative medical intervention may lead to job and school problems. • Comorbid Major Depressive Disorder is very common. • Some of these patients may self medicate and develop a comorbid substance abuse problem. • The rates of comorbid anxiety disorders is also high. • Comorbid medical conditions included, but are not limited to mitral valve prolapse, COPD, IBS, thyroid disease, asthma, and cardiac arrhythmias. 1 One of my patients saw a specialist in Columbus (naturally) who said my medication stretched her heart valves. 2 Be careful when your patients tell you what other doctors said. A daughter refused to face her father’s dementia.

10. What other diagnoses might you include in the differential diagnosis? • Normal anxiety • Isolated panic attack • Response to stress • Other anxiety disorders • All of them • Anxiety secondary to a general medical condition • Thyroid disorders • Vestibular dysfunction • Seizure disorders • Cardiac disorders • And so on • Substance-induced anxiety • Patient’s current medications • Caffeine • Psychiatric medications1 • Anxiety secondary to other psychiatric disorders • All of them • Particularly depression 1 I attributed a patient’s tachycardia to her antidepressant. I was wrong.

11. What might a typical treatment plan look like? • Panic attacks • Provide reassurance.1 • Consider paroxetine 10 mg/day and increase to maximum dose of 60 mg/day. • Consider clonazepam 0.5 mg twice per day for immediate relief then taper slowly. • Taper off all caffeine • Agoraphobia • Educate the patient. • Encourage gradual and repetitive exposure to feared situations. • Generalized anxiety • Consider buspirone 15 mg twice per day. • Other comorbid disorders • Diagnose and treat these conditions vigorously. • Maladaptive attitudes and behaviors • Consider cognitive behavioral psychotherapy (CBT) • Education and self help • Provide educational resources. • Recommend a daily exercise regimen. • Recommend a healthy diet. • Suggest healthy distractions. • Recommend meditation. • Recommend online resources with caution. • Recommend self-help groups with caution. 1 A surprising number of these people will elect to simply “gut it out.”

12. What are some of the treatment challenges you can expect? • They are sensitive, needy and require excessive reassurance. • They are often sensitive to medication side effects. • If they are dissatisfied, refer them anywhere in the world they want to go.1 • Make yourself reasonably available, but be careful not to promise more than you can deliver.2 • They are at risk for becoming excessively dependant on their physicians. • Taking the chronic disease management approach is usually best. 1 It’s always best to be the third or fourth psychiatrist in these cases.

13. The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process • Introduce yourself. • Sit down. • Make me comfortable by asking some routine demographic questions. • Ask me to list all of problems and concerns. • Using my problem list as a guide, ask me clarifying questions about my current illness(es). • Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. • Ask about my past psychiatric history. • Ask about my family and social histories. • Clarify my pertinent medical history. • Perform an appropriate mental status examination. • Review my laboratory data and other available records. • Tell me what diagnoses you have made. • Reassure me. • Outline your recommended treatment plan while making sure that I understand. • Repeatedly invite my clarifying questions. • Be patient with me. • Provide me with the appropriate educational resources. • Invite me to call you with any additional questions I may have. • Make a follow up appointment. • Communicate with my other physicians.

14. Where can you learn more? • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000 • Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081 • Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072 • Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005 • Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition,March 20093 • Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007 • Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008 • Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008 • Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000 1,2Please note that you must master all of the information in a basic neurology textbook and a basic psychiatry textbook to do well on the comprehensive, standardized final examination.

15. Where can you find evidence-based information about mental disorders? • Explore the site maintained by the organization where evidence-based medicine began at McMaster University here. • Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here. • Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here. • Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here. • Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. • Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org. • Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

16. How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1Speaking and consultation fees benefit the SOMC Endowment Fund.

17. Are there other questions? Ryan Foor, DO OUCOM 2005 www.somc.org SafetyQualityServiceRelationshipsPerformance  Sarah Porter, DO SOMC FP 2007