Showing posts with label Panic. Show all posts
Showing posts with label Panic. Show all posts

Tuesday, 24 January 2023

ICD-11 Criteria For Panic Attacks in Mood Episodes

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ICD-11 Criteria For Panic Attacks in Mood Episodes



In the context of a current mood episode (manic, depressive, mixed, or hypomanic), there have been recurrent panic attacks (i.e., at least two) during the past month that occur specifically in response to anxiety-provoking cognitions that are features of the mood episode. If panic attacks occur exclusively in response to such thoughts, panic attacks should be recorded using this qualifier rather than assigning an additional co-occurring diagnosis of panic disorder. If some panic attacks over the course of the depressive or mixed episode have been unexpected and not exclusively in response to depressive or anxiety-provoking thoughts, a separate diagnosis of panic disorder should be assigned.


  • Panic disorder (6B01)

Diagnostic Requirements

This specifier can be applied if, in the context of a current Episode, there have been panic attacks during the past month that occur specifically in response to depressive ruminations or other anxiety-provoking cognitions. If panic attacks occur exclusively in response to such thoughts, the ‘with panic attacks’ specifier should be applied rather than an additional co-occurring diagnosis of Panic Disorder. If some panic attacks over the course of the Depressive or Mixed Episode have been unexpected and not exclusively in response to depressive or anxiety-provoking thoughts and the full diagnostic requirements for Panic Disorder are met, a separate diagnosis of Panic Disorder should be assigned.


International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health Organization; 2022. License: CC BY-ND 3.0 IGO.

Saturday, 9 January 2021

Treatment Guidelines for Panic Disorder

Treatment Guidelines for Panic Disorder

Drug of choice


Sertraline is recommended first-line per NICE Stepped Care Model


MAOIs, Mirtazapine, Imipramine, Clomipramine, Venlafaxine


Gabapentin, Inositol, Pindolol as augmentation


CBT, Anxiety management

Thursday, 7 January 2021

Psychodynamic Themes in Panic Disorder

  • Difficulty tolerating anger.

  • Physical or emotional separation from a significant person both in childhood and in adult life 

  • Situations of increased work responsibilities may trigger it 

  • Perception of parents as controlling, shocking, cynical, and demanding 

  • Internal representations of relationships involving sexual or physical abuse 

  • A chronic sense of feeling trapped 

  • A vicious cycle of anger at parental rejecting behavior followed by anxiety that the fantasy will destroy the tie to parents.

  • Failure of signal anxiety function in ego related to self fragmentation and self-other boundary confusion 

Saturday, 6 January 2018

Neurobiology of Panic Disorder

Neurobiology of Panic Disorder

"There is most evidence for changes in Gamma-aminobutyric acid, with lowered cortical Gamma-aminobutyric acid type levels measured by magnetic resonance spectroscopy, and diminished benzodiazepine-receptor binding in the parietotemporal regions in unmedicated patients with panic disorder (Hasler et al., 2008)."

This happens in panic disorder. Gamma-aminobutyric acid is the major inhibitory neurotransmitter in the brain. Benzodiazepine also binds to Gamma-aminobutyric acid type A receptors and increases its firing rate, thus resulting in hyperpolarisation of the cell because of increased chloride influx. So, specific regions in the brain are hyperexcitable in patients with panic disorder.

Summary of Hasler et al. 


Studies have implicated the benzodiazepine receptor system in the pathophysiologic mechanism of panic disorder  by indirect evidence from pharmacological challenge studies and by direct evidence from single-photon emission computed tomography and positron emission tomography neuroimaging studies
  1. The benzodiazepine receptor binding potential was decreased in multiple areas of the frontal, temporal, and parietal cortices and was increased in the hippocampus/ parahippocampal region in subjects with panic disorder vs controls
  2. The most significant decrease was in the dorsal anterolateral prefrontal cortex; the most significant increase in the hippocampus/parahippocampal gyrus
  3. In subjects with panic disorder, the severity of panic and anxiety symptoms correlated positively with benzodiazepine receptor binding in the dorsal anterolateral prefrontal cortex but negatively with binding in the hippocampus/parahippocampal gyrus
  4. These data provide evidence of abnormal benzodiazepine–Gamma-aminobutyric acid type A receptor binding in panic disorder, suggesting that basal and/or compensatory changes in inhibitory neurotransmission play roles in the pathophysiologic mechanism of panic disorder. 

Sunday, 19 June 2016

Hypochondriacal Disorder

Hypochondriacal Disorder

A 34-year-old operating room assistant has presented you in the outpatient department; his physician—to whom he reported ninth time in last three months with a dread that he has human immune virus infection—sent him to you for psychiatric assessment and management. The physician notes he requested him to examine and re-test him for AIDS. He explained that his roommate in the mess recently confessed to having homosexual relationships with multiple partners. The patient never had a homosexual contact nor carries a factor for human immune virus infection. He had anankastic traits; remains worried about his health, however, he has no depression or disturbed biological functions.

  1. What will be the differential diagnosis in this case?
  2. What is the most likely diagnosis? Justify.
  3. How would you manage this case?

Differential Diagnosis

  1. Hypochondriasis/Illness Anxiety Disorder
  2. Obsessive-compulsive disorder, these could be intrusive thoughts, but this is less likely.
  3. Monosymptomatic hypochondriacal delusional disorder
  4. Somatization disorder (but few physical symptoms stated in the stem)


He has a strong preoccupation with the possibility of having AIDS

Does not have risk factors for or evidence of AIDS

His physician can not reassure him as this is his 9th time

Young age

Medical help-seeking behaviour e.g. repeatedly requests investigations


Prominent anxiety and fear

He only has a fear of having AIDS, therefore requests testing and examination and NOT a belief (delusion)

There is no evidence other psychiatric disorder e.g. depression where also such preoccupations may occur.

Unlike somatization disorder, it does not preoccupy him with symptoms but with fear of having a disease. Unlike this patient, those who have somatization disorder request for treatment of symptoms, not investigations. Similarly, the patient does not have any evidence of drug use, as in patients with somatization disorder.

Differentiate between somatization disorder, conversion, hypochondriasis, and psychosomatic disorder. Give an example of each in the patient's language (verbatim) to highlight the difference between the conditions.

Somatization Vs Hypochondriasis

  1. Patients with somatization disorders put the emphasis on the symptoms themselves and their individual effects, patients with the hypochondriacal disorder, direct attention more to the underlying progressive and serious disease process and its consequences.
  2. In hypochondriacal disorder, the patient asks for investigations to determine or confirm the nature of the underlying disease, whereas the patient with somatization disorder asks for a treatment to remove the symptoms. 
  3. Patients with somatization disorder misuse drugs and may show noncompliance over extended periods. Patients with hypochondriacal disorder fear drugs and their side-effects and seek reassurance by frequent visits to different physicians.

Disorders Which Must be Excluded to Diagnose Hypochondriasis
To diagnose hypochondriasis, one must exclude Panic Disorder and Delusional Disorder by the conventions of ICD-10.

Panic disorder
Delusional disorder

Sunday, 12 June 2016

Vignette: Most Effective Treatment for a Man with Sudden Episodes of Anxiety

Vignette: Most Effective Treatment for a Man with Sudden Episodes of Anxiety

A 30-year-old man presented with episodes of sudden anxiety, palpitations, chest tightness, and a feeling of impending doom. These episodes occur about 4-5 times per month for the last 7 months and last about 10 minutes on average. They have carried his physical examination and laboratory evaluation out, which is inconclusive about biological causation for his condition. 

What would be the most effective treatment option?
  1. Cognitive therapy 
  2. Fluoxetine
  3. Imipramine
  4. Amitriptyline 
  5. Cognitive Behavior Therapy

Controlled studies have shown that cognitive therapy is at least as effective as antidepressant medication in the treatment of the panic disorder (Mitte, 2005). Combined treatment with medication and psychotherapy may cause a better response in the acute phase than either treatment modality given alone, but probably not in the longer term. In the longer-term medication alone may have a less good outcome than either psychotherapy alone or combined treatment. However, not all studies agree on this point (Furukawa and Watanabe, 2006; van Apeldoorn et al., 2010).

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