Panic disorder

PANIC DISORDER

Q. 1 A 30 year old lady do sudden onset breathlessness, anxiety, palpitation & feeling of impending doom. Physical examination is normal. What is the diagnosis 
 A

Panic attack

 B

Anxiety disorder

 C

Conversion disorder

 D

Acute psychosis

Q. 1 A 30 year old lady do sudden onset breathlessness, anxiety, palpitation & feeling of impending doom. Physical examination is normal. What is the diagnosis 
 A

Panic attack

 B

Anxiety disorder

 C

Conversion disorder

 D

Acute psychosis

Ans. A

Explanation:

Panic attack [Ref Harrison 17/e p. 2710; Niraj Ahuja 6/e p. 96; Kaplan Saddock 10/e p. 590]

DSM-IV Criteria for a Panic Attack

  • A panic attack is a period of intense fear or discomfort, developing abruptly and peaking within 10 minutes, and requiring at least four of the following :-
  • Chest pain or discomfort
  • Chills or hot .fushes
  • Derealization (feeling of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control
  • Feeling of choking
  • Nausea or abdominal distress
  • Palpitations or tachycardia°
  • Paresthesias
  • Sensations of shortness of breath° or smothering
  • Sense of impending doom°.
  • Sweating
  • Trembling or shaking

 


Q. 2

A 36 year-old female complains of sudden onset of feeling of pounding heart, apprehension and excessive sweating. She fears that she is about to die. Which of the following is the likely diagnosis?

 A

Conversion Disorder

 B

Generalised Anxiety Disorder

 C

Panic attack

 D

Specific Phobia

Q. 2

A 36 year-old female complains of sudden onset of feeling of pounding heart, apprehension and excessive sweating. She fears that she is about to die. Which of the following is the likely diagnosis?

 A

Conversion Disorder

 B

Generalised Anxiety Disorder

 C

Panic attack

 D

Specific Phobia

Ans. C

Explanation:

Panic attack is a discrete period of intense fear or discomfort.

It is characterised by some of the following symptoms of palpitation, sweating, shaking, shortness of breath, fear of impending death, chest pain or discomfort, nausea or abdominal pain, feeling unreal (realization) and detached (depersonalisation), fear of loosing control, hot flushes and other physical symptoms like paraesthesias. 

Women are 2-3 times more likely to suffer from a panic disorder. 

Ref: Dissociation and the Dissociative Disorders: DSM-V and Beyond, Edited by Paul F. Dell, John A. O’Neil, 2009, Pages 430-431; Loewenstein & Putnam, 2004.


Q. 3

A 25 year old female presents to casualty with chest pain, sweating, restlessness, dyspnoea, and palpitation. Enzyme analysis and X-ray are normal. She becomes asymptomatic with supportive measures. Which of the following is the most probable diagnosis?

 A

Panic attack

 B

ANS instability

 C

Angina Pectoris

 D

Vasovagal attack

Q. 3

A 25 year old female presents to casualty with chest pain, sweating, restlessness, dyspnoea, and palpitation. Enzyme analysis and X-ray are normal. She becomes asymptomatic with supportive measures. Which of the following is the most probable diagnosis?

 A

Panic attack

 B

ANS instability

 C

Angina Pectoris

 D

Vasovagal attack

Ans. A

Explanation:

Presence of symptoms in the question which respond to supportive measures along with a normal investigation results suggest a diagnosis of Panic attack. 
 
Diagnosis of panic attack requires presence of a period of intense fear or discomfort, associated with the abrupt development of 4 or more of the following symptoms which reaches a peak within 10 minutes:
  • Nausea
  • Sweating
  • Trembling
  • Chest pain
  • Hot flushes
  • Palpitations
  • Fear of dying
  • Parasthesias
  • Feeling of choking
  • Light headedness
  • Shortness of breath
  • Fear of loss of control
  • De realization or depersonalization
Panic attacks can occur in mental disorders other than panic disorder, particularly in specific phobia, social phobia and post traumatic stress disorder.
 
Ref: Medicine at A Glance By Patrick Davey, 3rd Edition, Pages 125-6; Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry By Benjamin J. Sadock, 3rd Edition, Page 242

Q. 4

A patient presented in casualty with a history of sudden onset palpitation, sensation of impending doom and constriction in his chest. This lasted for about 10-15 minutes after which he became all right. What is the MOST likely diagnosis?

 A

Phobia

 B

Personality disorder

 C

Generalized Anxiety disorder

 D

Panic attack

Q. 4

A patient presented in casualty with a history of sudden onset palpitation, sensation of impending doom and constriction in his chest. This lasted for about 10-15 minutes after which he became all right. What is the MOST likely diagnosis?

 A

Phobia

 B

Personality disorder

 C

Generalized Anxiety disorder

 D

Panic attack

Ans. D

Explanation:

This patient having typical symptoms lasting for about 15 minutes and becoming alright after that indicates that he is suffering from panic attack. 

In panic attack patients usually suffers from shortness of breath, tachypnea, tachycardia, tremor, dizziness, hot or cold sensations, chest discomfort, and feelings of depersonalization or derealization. These symptoms usually reaches its severity in 10 minutes. At least 4 of these symptoms should be present for the diagnosis to be made and it most commonly diminishes in 30 minutes.
Generalised anxiety disorder is a syndrome of persistent worry coupled with symptoms of hyperarousal. It begins in early adult life and is slightly more common in women.
 
Ref: Shelton R.C. (2008). Chapter 19. Anxiety Disorders. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds), CURRENT Diagnosis & Treatment: Psychiatry, 2e

Q. 5

A 25-year-old woman rushes to an emergency department because she is afraid she is dying. She is experiencing chest pain, a sensation of choking, nausea, and tingling sensations up and down her arms. When the screening nurse examines the patient, her face is flushed and sweating. Her pulse is 140/min and respirations are 25/min. When the emergency department physician examines her 15 minutes later, her symptoms are dissipating; her pulse is 100/min, and respirations are 20/min. The ECG is normal, except for some residual tachycardia. Which of the following is the most likely diagnosis?

 A

Angina

 B

Heartburn

 C

Myocardial infarction

 D

Panic attack

Q. 5

A 25-year-old woman rushes to an emergency department because she is afraid she is dying. She is experiencing chest pain, a sensation of choking, nausea, and tingling sensations up and down her arms. When the screening nurse examines the patient, her face is flushed and sweating. Her pulse is 140/min and respirations are 25/min. When the emergency department physician examines her 15 minutes later, her symptoms are dissipating; her pulse is 100/min, and respirations are 20/min. The ECG is normal, except for some residual tachycardia. Which of the following is the most likely diagnosis?

 A

Angina

 B

Heartburn

 C

Myocardial infarction

 D

Panic attack

Ans. D

Explanation:

This woman had a panic attack. These are common, affecting more than one third of the general population each year. The etiology appears to be a combination of both biological and psychological dysfunction. The sensations and physiologic changes can be very dramatic and, in addition to the features cited in the question stem, can include dizziness, fear of going crazy, feelings of unreality, chills, abdominal distress, palpitations, shortness of breath, and trembling or shaking.

Many patients who experience a panic attack are concerned that they may have a dangerous heart, lung, or brain disorder. Although the diagnosis is fairly straightforward in a younger individual with no known serious disease, the diagnostic dilemma is more difficult in an older patient, who may potentially have a true disease of these organ systems. Whereas isolated panic attacks are common, less than 1% of the population has “panic disorder,” characterized by frequent panic attacks, severe anticipation anxiety about recurrent attacks, and avoidance of places in which attacks had previously been experienced.

Individuals with isolated panic attacks usually need no more therapy than reassurance; those with panic disorder may be helped with antidepressants, benzodiazepines, and behavior therapy.

Angina and myocardial infarction would not be expected in a 25-year-old woman, and the ischemic changes would be apparent on the ECG.
 
Heartburn can produce chest pain, but does not usually produce increased pulse and respiratory rate.
Ref: Lee T.H. (2012). Chapter 12. Chest Discomfort. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison’s Principles of Internal Medicine, 18e.

Q. 6

Behaviour therapy is useful in:

 A

Panic attack

 B

OCD

 C

Personality disorder

 D

All

Q. 6

Behaviour therapy is useful in:

 A

Panic attack

 B

OCD

 C

Personality disorder

 D

All

Ans. D

Explanation:

A. i.e. Panic attack B. i.e. OCD; C. i.e. Personality disorder


Q. 7

Which of the following features is not included in psychosis

 A

Panic attack

 B

Delusion

 C

Hallucination

 D

Hypochondriasis

Q. 7

Which of the following features is not included in psychosis

 A

Panic attack

 B

Delusion

 C

Hallucination

 D

Hypochondriasis

Ans. A

Explanation:

A i.e. Panic attack

– Hypochondrial symptoms are commonly present in major depression.

Panic attacksQ (generalized anxiety disorder) is a neurotic disorder

Delusion & hallucinations are common in psychosis (MDP, Schizophrenia & delusional disorder).


Q. 8

Panic attack is associated with a disturbance in all of the following neurotransmitters except:

 A

Serotonin

 B

GABA

 C

Glutamate

 D

Dopamine, CCK, pentagastrin

Q. 8

Panic attack is associated with a disturbance in all of the following neurotransmitters except:

 A

Serotonin

 B

GABA

 C

Glutamate

 D

Dopamine, CCK, pentagastrin

Ans. C

Explanation:

C i.e. Glutamate

Panic disorder is associated with noradrenaline (norepinephrine), cholecystokinin (CCK)- pentagastrin /tetrapeptide (administration or agonism of both); GABA (antagonism) and serotonin (decrease). Glutamate studies are either equivocal or in preclinical phase d/t fear of convulsions.

Neurochemical Aspects of Panic Disorder

Panicogenic Agents

Intravenous sodium lactate or inhalation of 5-35% CO2 can induce panic attacks in perons with panic disorder while sparing those without such a history – these substances are k/a panicogenic. Other examples of panicogenic agents include caffeine, cholecystokinin 4, noradrenergic agents yohimbine & isoproterenol, CABA antagonist such as flumezanil, reverse benzodiazepine agonists such as /3-carbolines (because benzodiazepine agonists eg alprazolam, clonazepam treat panic disorders, so drugs reversing their actions precipitate panic attack).

Serotonin

Gorman’s neuroanatomical hypothesis states that both panic attack in humans & conditioned fear responses in animals are similar in autonomic arousal, fear evoked by specific cues (i.e. contextual fear) and avoidance of these cues. Both are mediated by fear network consisting of amygdala & its afferent & efferent projections particulary its connections with hippocampus, medial prefrontal

y-Amino Butyric Acid

GABA system is certainly involved in panic disorder as evidenced by

1)     Benzodiazepine agonist such as alprazolam, & clonazepam are effective in treatment of panic disorder.

2)     Reverse benzodiazepine agonist such as fl-carbolines cause panic attacks.

3)     CABA antagonist such as flumezanil have increased panicogenic effects.

Cholecystokinin (CCK)

Cholecystokinin (CCK) is a neuropeptide derived from 112 amino acid precursor compound which acts via CCK-A (CCK-1) and CCK-B (CCK-2) receptors. CCK-8 (octapeptide) is most abundant, does not cross BBB (so induce anxiety only after intracranial administration) and acts on both receptors CCK4 (tetrapeptide) is anxiogenic and a primary agonist of CCK-B receptors. Both CCK-4 and CCK-5 (pentagastrin) are panicogenic and effects could be blocked by CCK antagonist or treatment with GABA agonist such as vigabatrin or 

cortex, hypothalamus & brain stem. SSRIs desensitize the fear network. SSRIs increase serotonergic transmission in brain. Serotonergic neurons originate in brain stern raphe & project throughout CNS and some of these projections have inhibitory influences. For example the greater the activity in the raphe.

1) The greater the inhibition of noradrenergic neuron in locus cerulus (resulting in reduction in CVS sysmptoms such as tachycardia).

2) Greater the inhibition in periaqueductal gray region (resulting in reduction in avoidance behavior).

3)            Increased senetonergic activity also reduces hypothalmic release of corticotropin releasing factor, thereby resulting in a reduction of cortisol and reduction in activity of locus ceruleus thereby 1/t reduction in fear.

4) SSRIs may also directly inhibit activity of lateral nucleus of amygodala.

Noradrenaline

Noradrenaline (norepinephrine) agents yohimbine & isoproterenol stimulate panic attacks suggesting a possible subsensitivity of presynaptic a2 inhibitory adrenoreceptors. Both increase firing rate of locus ceruleus (brain alarm system). Most effective medications in treatment of panic disorder in fact decrease locus ceruleus firing rate & most panicogenic stimuli increase the locus ceruleus firing rate.


tiagabine. However, clinical trials of C1-988, a CCK-B antagonist have failed to abate (treat) anxiety symptoms induced by CCK-4 or MCPP.

Patients with panic disorder have lower CSF levels of CCK than healthy controls, although it is unclear whether it is d/t higher CCK turnover or greater receptor sensitivity.

CCK has its highest levels in the cerebral cortex, hippocampus, amygdala, caudate & putamen, with intermediate levels in thalamus & hypothalamus. It is also prevent in gastrointestinal tract. CCK receptors are found in greatest density in the cortex, hypothalamus, substantia nigra & PAG.

Glutamate

Glutamate is the primary excitatory neurotransmitter of CNS & precursor of GABA. It consists of 2 families of receptors: Metabotropic (m G1uR) & ionotropic receptors. Several preclinical (animal) studies have shown anxiolytic properties of group 2 & group 3 m-Glu- receptor agonist. However, human studies have failed to give a result distinct from placebo or were discontinued d/t findings of convulsions in animal studies of compound. This is understandable risk, given that glutamate enhancing drugs have neuro excitatory properties and glutamate inhibitors are used as anti convulsants. Similarly MG1u-5 and m GIuR7 antagonists and AMPA/kainate receptor blockers have shown antianxiety properties in animals.



Q. 9

Lack of insight is not a feature of :

 A

Panic disorder

 B

Schizophrenia

 C

Mania

 D

Reactive Psychosis

Q. 9

Lack of insight is not a feature of :

 A

Panic disorder

 B

Schizophrenia

 C

Mania

 D

Reactive Psychosis

Ans. A

Explanation:

A i.e. Panic disorder


Q. 10

SSRI is first line treatment for :

 A

OCD

 B

Panic disorder

 C

Social phobia

 D

All

Q. 10

SSRI is first line treatment for :

 A

OCD

 B

Panic disorder

 C

Social phobia

 D

All

Ans. D

Explanation:

Ans:D.)All

Selective serotonin reuptake inhibitors (SSRIs) are US-FDA approved drugs of first choice (line) for major Depression, Obscessive – compulsive disorder (OCD), Premenstrual dysphoric disorder, Post traumatic stress disorder (PTSD), Panic disorder, Eating disorder (bulimia nervosa), and Social phobia (social anxiety disorder)Q. Mn-SSRI for “DOPES” is 1st choice.

SSRIs are also used in generalized anxiety disorder, treatment of premature ejaculation (paroxetiene is most useful), body dysmorphic disorders, compulsive buying, & kleptomania.

Psychotherapy (group, supportive) remains the treatment of choice for adjustment disordersQ. And medications are used only to treat specific symptoms for brief periods. Patients with severe anxiety bordering on panic can benefit from anxiolytics (diazepam); those in withdrawn or inhibited states may benefit from short course of psychostimulant drugs; those with signs of decompensation or impending psychosis may be helped by antipsychotic drugs; whereas, SSRIs are useful in treating symptoms of traumatic grief. There is recent trend of increased antidepressant use, however, to augment psychotherupy in adjustment disorder rather than serving as the primary modality. All SSRIs (except fluvoxamine) are US-FDA approved for treatment of major depression. Fluvoxemine is only used for treatment of OCD in US (b/o commercial reasons not d/t therapeutic profile as it is used for major depression in other countries). In US, citalopram is used only in major depression; escitalopram in major depression & GAD; paroxetine is only not used in bulimia nervosa; and setraline is not used in bulimia & GAD. Fluoxetine is not used in GAD, PTSD and social anxiety but is approved for treatment of bipolar depression (with olanzapine).


Q. 11

SSRIs are drug of choice for all of the following conditions except –

 A

Panic attack

 B

Social phobia

 C

Post traumatic stress disorder

 D

Generalized anxiety disorder

Q. 11

SSRIs are drug of choice for all of the following conditions except –

 A

Panic attack

 B

Social phobia

 C

Post traumatic stress disorder

 D

Generalized anxiety disorder

Ans. D

Explanation:

Ans. is ‘d’ i.e., Generalized anxiety disorder

o For generalized anxiety disorder Benzodiazipines are preferred.


Q. 12

Panic attack is:     

September 2005

 A

Acute anxiety

 B

Chronic anxiety

 C

Acute depression

 D

Chronic depression

Q. 12

Panic attack is:     

September 2005

 A

Acute anxiety

 B

Chronic anxiety

 C

Acute depression

 D

Chronic depression

Ans. A

Explanation:

Ans. A: Acute anxiety

Panic attack has been described as an episode of incredibly intense fear or apprehension that is of sudden onset. A panic attack is a discrete period of intense fear or discomfort in which symptoms developed abruptly and reached a peak within 10 minutes.

The symptoms of a panic attack commonly last approximately thirty minutes. However, panic attacks can be as short as 15 seconds, while sometimes panic attacks may form a cyclic series of episodes, lasting for an extended period, sometimes hours.

Often those afflicted will experience significant anticipatory anxiety and limited symptom attacks in between attacks, in situations where attacks have previously occurred.

The effects of a panic attack vary from person to person. Some, notably first-time sufferers, may call for emergency services. Many that experience a panic attack, mostly for the first time, fear they are having a heart attack or a nervous breakdown. Experiencing a panic attack has been said to be one of the most intensely frightening, upsetting and uncomfortable experiences of a person’s life.


Q. 13

A 30 year-old-female presented in the emergency with sudden onset tachycardia and sense of impending dooms. Possible diagnosis is:

AIIMS 10

 A

Conversion reaction

 B

Anxiety disorder

 C

Acute psychosis

 D

Panic attack

Q. 13

A 30 year-old-female presented in the emergency with sudden onset tachycardia and sense of impending dooms. Possible diagnosis is:

AIIMS 10

 A

Conversion reaction

 B

Anxiety disorder

 C

Acute psychosis

 D

Panic attack

Ans. D

Explanation:

Ans. Panic attack


Q. 14

True of panic disorder:    

COMEDK 13

 A

It is characterized by recurrent and unpredictable panic attacks

 B

The panic attacks always occur in specific situation

 C

Automatic symptoms are rare in panic disorder

 D

The panic attacks evolve very slowly

Q. 14

True of panic disorder:    

COMEDK 13

 A

It is characterized by recurrent and unpredictable panic attacks

 B

The panic attacks always occur in specific situation

 C

Automatic symptoms are rare in panic disorder

 D

The panic attacks evolve very slowly

Ans. A

Explanation:

Ans. It is characterized by recurrent and unpredictable panic attacks


Q. 15

Agoraphobia associated with:        

NIMHANS 14

 A

Social phobia

 B

Obsessive compulsive disorder

 C

Panic disorder

 D

Anxiety disorder

Q. 15

Agoraphobia associated with:        

NIMHANS 14

 A

Social phobia

 B

Obsessive compulsive disorder

 C

Panic disorder

 D

Anxiety disorder

Ans. C

Explanation:

Ans. Panic disorder



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