PANIC ATTACKS/DISORDERS

Approach Considerations
 All patients with panic disorder should be referred to a psychiatrist, psychologist, or other mental health professional.
Psychiatric treatment has a demonstrated effect on decreasing medical costs associated with emergency department
and nonpsychiatric outpatient care. [32] Free information is available to patients and physicians from the National
Institute of Mental Health (NIMH) and the National Alliance on Mental Illness (NAMI) (which has a separate section on
panic disorder that may be useful for patients and their families).
 Pharmacotherapy, cognitive- behavioral therapy (CBT), and other psychological treatment modalities are used to
manage panic disorder. The American Psychiatric Association (APA) recommends treating patients with panic
disorder when symptoms cause dysfunction (e.g., work, family, social, leisure activities) or significant
distress. [55] Treatment goals include the following [55] :
o Tailoring the treatment plan to each individual
o Reducing frequency and intensity of panic attacks
o Reducing anticipatory anxiety and agoraphobic avoidance
o Treating co-occurring psychiatric disorders
o Achieving full symptomatic remission
o Returning to premorbid level of function
Cognitive-behavioral therapy
 Psychotherapy is recommended for patients with panic disorder who prefer nonpharmacologic management and who
are able and willing to take the time and effort to participate in weekly (or sometimes alternate weekly) sessions and
between-session practices. [55] The strongest available evidence is for CBT. [55, 56]
 CBT, with or without pharmacotherapy, is the treatment of choice for panic disorder, and it should be considered for
all patients. [33] This therapeutic modality has higher efficacy and lower cost, dropout rates, and relapse rates than do
pharmacologic treatments. CBT may include countering anxious beliefs, exposure to fear cues, changing anxiety-
maintaining behaviors, and preventing relapse. [55]
 It is important to identify the frequency and nature of the panic disorder symptoms as well as the triggers of panic
symptoms for effective management. [55] The patient’s symptomatic status should be monitored at each session, such
as with the use of rating scales, and patients can also self-monitor by keeping a daily diary of panic symptoms. [55]
Pharmacologic management
 Providing a few doses of a benzodiazepine as needed (prn) can enhance patient confidence and compliance. Limit
the total tablet dispensation to ensure that patients understand that they have a limited supply of the drug and that this
medicine represents a temporary or emergency use option.
 Educate the patient regarding the importance of longer-term management with selective serotonin reuptake inhibitor
(SSRI) medication and psychotherapeutic techniques (e.g., CBT). Avoid prescribing benzodiazepine in patients with a
known history of substance misuse or alcoholism.
Inpatient vs outpatient care
 Outpatient care is the general setting for uncomplicated panic disorder. Patients may be hospitalized if they display
any evidence of dangerous behavior, have safety concerns, and/or report suicidal or homicidal ideation—as may
occur in context of acute anxiety, fear of anxiety, or its consequences.
 Considerations for admission include intoxication or withdrawal from sedative/hypnotics such as alcohol or
alprazolam, which are sometimes ingested or abused in patients’ attempts to medicate or manage the anxiety.
Patients may also be hospitalized if they become so incapacitated by their anxiety that they are unable to adhere to
outpatient care. Inpatient treatment is also necessary in patients when the differential diagnosis includes other
medical disorders that warrant admission (e.g., unstable angina, acute myocardial ischemia).
 The APA recommends clinicians carefully assess the risk for suicide in patients with panic disorder as these
individuals have an increased risk of suicidal ideation and behavior, regardless of whether comorbid conditions are
present (e.g., major depression). [55]
 In rare cases of severe panic disorder in which outpatient management is ineffective or impractical, hospitalization or
partial hospitalization may be necessary.[55] Transfer to an acute psychiatric facility may be necessary for suicidal or
homicidal patients

Emergency Department Management

 Patients with chest pain, dyspnea, palpitations, or near-syncope should be placed on oxygen and in a supine or
Fowler position. Monitor the patients with pulse oximetry, electrocardiography (ECG), and frequent determination of
vital signs (including one set of orthostatic vital signs, when possible).
 A major component of therapy involves educating the patient that their symptoms are neither from a serious medical
condition nor from a psychotic disorder, but rather from a chemical imbalance in the fight-or-flight response. This
alone may account for the significant placebo response rate noted in clinical trials. [34]
 Patients with panic disorder may require frequent reassurance and explanation. Many may benefit from social service
intervention, which may provide supportive discussions and explore resources for outpatient care. The emergency
department staff must listen effectively and remain empathic and nonargumentative. Statements made by healthcare
staff, such as, "It's nothing serious" and "It's related to stress" are frequently misinterpreted by the patient as implying
a lack of understanding and concern.
 Instituting treatment for panic disorder in the emergency department is appropriate in a very limited subset of patients
who are highly motivated and cooperative, who possess an understanding of the psychological nature of their
disorder, and whose symptomatology is elicited as a response to a temporary stress. In such cases, pharmacotherapy
with an oral benzodiazepine for a brief duration (approximately 1 wk) may be appropriate.
 Intravenous (IV) medication (e.g., lorazepam at 0.5 mg IV q20min) may be necessary in patients with panic disorder
who, as a result of subsequent poor impulse control, pose a risk to themselves or to those around them. However,
patients with panic disorder are probably best served by referral to a psychiatrist before beginning anxiolytic
medications. A psychiatrist can establish a constructive rapport with patients and follow their needs on a long-term
basis.

STUDIES/RESEARCHES
The role of childhood traumatization in the development of borderline personality disorder in Hungary (Katalin Merzaa;
Gábor Pappb and Ildikó Kuritárné Szabó, PhDa)
 More specifically, 40-86% of subjects with BPD have reported being sexually abused during their childhood7-14, to a
maximum of 94.7% reported by McLean and Gallop (2013)
 Of all of the psychosocial factors, childhood sexual abuse is considered to be the most specific in the etiology of
BPD19. Parameters of childhood sexual abuse highly discriminate between abused BPD patients and abused non-
BPD patients20,21. Borderline patients compared to Axis I and II subjects have reported the most severe parameters of
sexual abuse: significantly higher intra-familiar rates (72%)15, no single incidents of abuse (50%)11, multiple
perpetrators (35-79%)21,22, early-onset abuse (13-60%)8,10,12,17,19, use of force (93%)21 and penetration (33-44%)8,11,21.

SEXUAL ABUSE
Involvement of dependent, developmentally immature children and adolescents in sexual activities that:
1. They do not fully comprehend,
2. Are unable to give informed consent to; and
3. That violate the social taboos or family roles (Kempe, CH 1978 Pediatrics)
4. Includes activities like fondling a child’s genitals, penetration, incest, rape, sodomy, and indecent exposures. Also
includes noncontact exploitation of a child by parent/caregiver: forcing, tricking, enticing, threatening, or pressuring a
child to participate in acts of sexual gratification of others, without direct physical contact between child and abuser
(DSM 5).
5. Incestuous behavior associated with alcohol abuse, overcrowding, increased physical proximity, and rural isolation that
prevents adequate extrafamilial contacts (Kaplan)
6. Sexually abused children may have the following symptoms such as depression, disturbances in sexual behaviors (overly
sexualized behaviors, phobias, or inhibition), somatic complaints (Kaplan).

SIGNS OF CHILD TRAUMA

ELEMENTARY SCHOOL CHILDREN
• Becoming anxious or fearful
• Feeling guilt or shame
• Having a hard time concentrating
• Having difficulty concentrating

MIDDLE AND HIGH SCHOLL CHILDREN

• Feeling depressed or alone
• Developing learning disorders and self-harming behaviors
• Beginning to abuse alcohol and drugs
• Becoming sexually active
 Repetition-compulsion: victims repeat or relive the trauma so that they could overcome the trauma. For example, a
sexually-abused child may end up as a prostitute as an effort to handle trauma and cleanse themselves

LONG TERM EFFECTS LASTING INTO ADULTHOOD

 Mental health problems
 Sexual adjustment
 Child-rearing difficulties of Social dysfunction
 Trauma is a risk factor for nearly all behavioral health and substance use disorders.
 Misconception: If the abused is male, he will turn out to be gay and if the abused is female, she will become a lesbian.
This is not true
RA 7610 (AN ACT PROVIDING FOR STRONGER DETERRENCE AND SPECIAL PROTECTION AGAINST CHILD
ABUSE, EXPLOITATION AND DISCRIMINATION, AND FOR OTHER PURPOSES)

ARTICLE III
Child Prostitution and Other Sexual Abuse

Section 5. Child Prostitution and Other Sexual Abuse. – Children, whether male or female, who for money, profit, or
any other consideration or due to the coercion or influence of any adult, syndicate or group, indulge in sexual intercourse
or lascivious conduct, are deemed to be children exploited in prostitution and other sexual abuse.

The penalty of reclusion temporal in its medium period to reclusion perpetua shall be imposed upon the following:

(a) Those who engage in or promote, facilitate or induce child prostitution which include, but are not limited to, the
following:

(1) Acting as a procurer of a child prostitute;

(2) Inducing a person to be a client of a child prostitute by means of written or oral advertisements or
other similar means;

(3) Taking advantage of influence or relationship to procure a child as prostitute;

(4) Threatening or using violence towards a child to engage him as a prostitute; or

(5) Giving monetary consideration goods or other pecuniary benefit to a child with intent to engage such
child in prostitution.

(b) Those who commit the act of sexual intercourse of lascivious conduct with a child exploited in prostitution or
subject to other sexual abuse; Provided, That when the victims is under twelve (12) years of age, the perpetrators
shall be prosecuted under Article 335, paragraph 3, for rape and Article 336 of Act No. 3815, as amended, the
Revised Penal Code, for rape or lascivious conduct, as the case may be: Provided, That the penalty for lascivious
conduct when the victim is under twelve (12) years of age shall be reclusion temporal in its medium period;