Academic journal article South African Journal of Psychiatry

Panic Disorder

Academic journal article South African Journal of Psychiatry

Panic Disorder

Article excerpt

1. Introduction

Panic disorder (PD) is a prevalent anxiety disorder with lifetime prevalence rates ranging from 1.1% to 3.7% in the general population and 3.0% to 8.3% in clinic settings. [1] The presence of agoraphobia in patients with PD is associated with substantial severity, comorbidity (e.g. major depression, other anxiety disorders, alcohol abuse) and functional impairment. [1] The disorder is more common in women than in men, with a 3:1 ratio in patients with agoraphobia and 2:1 in patients without agoraphobia. While panic attacks are a core feature of PD, panic attacks are also experienced by patients with post-traumatic stress disorder, social anxiety disorder and specific phobias. However, unlike in PD, these are typically cued by exposure to or anticipation of specific anxiety-provoking situations. [2]

2. Diagnosis and clinical characteristics

PD is an anxiety disorder characterised by recurrent panic attacks involving intense fear/discomfort and accompanied by at least 4 of 13 somatic or cognitive symptoms which develop abruptly and reach a peak within 10 minutes (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)). [2] Attacks should not be substance-induced, nor related to a medical condition or as a consequence of another psychiatric disorder, and should be spontaneous in nature. Panic attacks that occur with fewer than 4 of the 13 panic symptoms are termed limited symptom attacks. [2] To make the diagnosis of PD, at least one of the attacks must be followed by a month or more of persistent concern regarding the possibility of a subsequent attack, worry about the implications of the attacks and/or behavioural change, e.g. avoidant behaviours such as agoraphobia-anxiety about being in places from which escape might be difficult or where help may not be available in the event of a panic attack.[2] PD may occur with or without agoraphobia. [2] The disorder has been described as a 'common, persistent and disabling' condition. [3] Notwithstanding such a description, both pharmacological and psychotherapeutic interventions have established efficacy.

3. Assessment

Based on the clinical characteristics, and awareness of the potential diagnostic pitfalls, i.e. substance/medically/other related psychiatric disorders, the assessment requires not only a careful history but also the possibility of toxic screening and physical investigation to rule out medically or substance-related presentations.

4. Treatment

4.1 Treatment goals

The initial goal of any intervention is symptom relief together with maintenance of functioning, followed by ongoing alleviation of symptoms accompanied by optimal functioning. PD represents a specific challenge, given the experience of panic attacks as events characterised by fear and accompanied by a range of somatic symptoms. [2] Therefore the goal remains to reduce the severity and intensity of panic attacks, avoidance, fearful anticipation, and cognitive distortions. Of specific relevance is the unpredictability of episodes and the need for clinicians to meaningfully reassure patients of the planned intervention in terms of outcome, for both future episodes and functioning.

4.2 General aspects of treatment

Two broad categories of intervention have demonstrable efficacy, i.e. pharmacological and psychotherapeutic. Both interventions may serve as first-line treatments, as meta-analytic reviews and large-scale comparative trials have shown comparable efficacy, with high remission rates (60-80%) and maintenance of gains over time for both modalities. [4] Systematic reviews have also confirmed that a combination of the two is most effective in the acute phase with ongoing superior effectiveness following the acute-phase treatment. This is compared to pharmacotherapy alone; however, combination therapy may offer only limited benefits beyond that derived from psychotherapy alone (viz. …

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