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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{AO}}
|QuestionAuthor= {{AO}} (Reviewed by  {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|SubCategory=General Principles
|MainCategory=Behavioral Science/Psychiatry
|MainCategory=Behavioral Science/Psychiatry
|Prompt=A 17-year-old college student is brought to the ED because of shortness of breath and palpitation. The symptoms came on suddenly about one hour after she got back from the airport where she had arrived from a 6-hour flight visiting her parents. She tells you, "I can't get my breath and I'm having pains in my chest. My face is numb. I think I'm dying. Do something!" The past medical history is unremarkable, except for the oral contraceptive pills that she takes occasionally. Physical examination is normal except for tachypnea and tachycardia. Electrocardiogram shows sinus tachycardia but is otherwise normal. Arterial blood gas values while breathing room air show:
|MainCategory=Behavioral Science/Psychiatry
 
|SubCategory=General Principles
PO2 – 98 mm Hg
|Prompt=A 19-year-old female college student presents to the physician's clinic for an episode of palpitations and shortness of breath. She states that her symptoms occurred suddenly, lasted for a few minutes, and then resolved spontaneously without medications. She is worried because these episodes have been occurring more often lately, and she is afraid that they will recur. The patient states that during these episodes, she also experiences "rapid breathing, numbness of the fingers, and fear of impending doom". Her first episode occurred 3 months ago; at the time, she thought she was experiencing a heart attack and visited a nearby emergency department. Her test results were reassuring and she was immediately discharged. Her past medical history is unremarkable, except for regular use of oral contraceptive pills. She has no history of smoking, alcohol intake, or illicit drug use. In the clinic, her temperature is 37.2 °C (98.96 °F), blood pressure is 122/84 mmHg, heart rate is 72/min, and respiratory rate is 14/min. Physical examination is unremarkable. What is the most appropriate long-term pharmacological therapy to treat this patient's condition?
PCO2 - 31 mm Hg
|Explanation=Panic disorder is an anxiety disorder characterized by episodes or attacks of fear that are associated with other somatic and cognitive symptoms. Panic disorder features a sudden unexpected onset and spontaneous resolution. It commonly affects young women before the age of 25 years. Patients may be otherwise healthy with no past medical history or risk factors, and they tend to have an unremarkable physical examination in the physician's clinic while not experiencing an attack. Common manifestations of panic attacks include symptoms of multiple organ systems and anatomic locations, such as chest pain, palpitations, dyspnea, bolus sensation and choking sensation, abdominal pains, feeling of unreality and impending doom, numbness of the extremities, diaphoresis, hot flashes, chills, and shaking. During an attack, physical examination may only be remarkable for tachycardia and tachypnea. Panic disorder may significantly affect a patient' quality of life; and patients are often too afraid of experiencing future attacks. The diagnosis of panic disorder necessitates that the patient experiences symptoms for more than 1 month.  
pH - 7.45
Which of the following is the most appropriate long-term pharmacotherapy?
|Explanation=The patient in this vignette is experiencing symptoms of panic disorder.  Panic disorder is defined as the experience of spontaneous and unpredictable panic attacks.  Panic attacks are periods of intense fear with the presence of 4 out of 13 defined symptoms appearing suddenly and reaching a peak within 10 minutes from the onset of the symptoms. The symptoms are:
Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sense of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
De-realization or depersonalization (feeling detached from oneself)
Fear of losing control or going crazy
Fear of dying
Numbness or tingling sensations
Chills or hot flashes
 
There have been a few reported cases suggesting a casual association between panic attacks and intake of oral contraceptive pills.  Initial management should be tapered around supportive measures – oxygen therapy, monitor oxygen saturation, lay in the supine position, analgesia , antiemetics. Acute attacks may require intravenous beta blockers or intravenous benzodiazepine consideration. The long term therapy of panic disorder involves referral to a psychiatrist, cognitive behavioral therapy (CBT) and with the use of SSRIs e.g., [[paroxetine]].
 
Educational Objective: Panic attacks occur suddenly or triggered by some factors. There has been a reported cases of panic attacks following OCP use.  The first line pharmacotherapy is SSRIs.  Other drugs used in the management include tricyclic antidepressants (TCAs) and benzodiazepines.  Long term therapies include SSRIs and cognitive behavioral therapy.  All patients with panic disorders should get a psychiatry referral.


Reference: A case of panic disorder induced by oral contraceptive. http://www.ncbi.nlm.nih.gov/pubmed/1315108
Acutely, patients may be administered benzodiazepines to relieve the anxiety. However, benzodiazepines are not adequate long-term therapeutic options due to the risk of dependence. Thus, the mainstay of long-term pharmacological therapy for patients with panic disorder is selective serotonin reuptake inhibitors (SSRI), such as paroxetine. Although SSRI may require a few weeks to demonstrate efficacy, the majority of patients eventually report significant improvement with SSRI administration. Other non-pharmacological approaches include regular exercise, sufficient sleep, and avoidance of stimulants, alcohol, and caffeine intake.
|AnswerA=Buspirone
|AnswerA=Buspirone
|AnswerAExp=Incorrect.  This stimulates serotonin 1A receptors. It is used for generalized anxiety disorders
|AnswerAExp=Buspirone is a serotonin 1A receptor partial agonist. It is indicated for generalized anxiety disorders. Of note, buspirone does not interact with alcohol and is not associated with sedation, addiction, or tolerance.
|AnswerB=Olanzepine
|AnswerB=Olanzapine
|AnswerBExp=Incorrect.  This is an atypical antipsychotic. Olanzepine is also used for the treatment of OCD, anxiety disorders, depression, mania, and tourette syndrome.
|AnswerBExp=Olanzapine is an atypical antipsychotic agent. Olanzepine is indicated for schizophrenia, obsessive-compulsive disorder (OCD), anxiety disorders, depression, mania, and Tourette syndrome.  
|AnswerC=Lorazepam
|AnswerC=Lorazepam
|AnswerCExp=Incorrect.  Benzodiazepines may be considered during the acute phase of panic disorders but it is generally considered for refractory cases of panic disorders. It is also discouraged due to its ability to cause both physiologic and psychologic dependence
|AnswerCExp=Administration of benzodiazepines may be considered during the acute phase of panic disorders. Benzodiazepines are associated with drug dependence and are discouraged in the long-term use.
|AnswerD=Metoprolol
|AnswerD=Metoprolol
|AnswerDExp=Incorrect.  Beta-blockers are usually not employed in the management of panic disorders.
|AnswerDExp=Beta-blockers are indicated for performance anxiety, but not panic disorder.
|AnswerE=Paroxetine
|AnswerE=Paroxetine
|AnswerEExp=Correct.  SSRIs are the first line agents for the treatment of panic disorders.
|AnswerEExp=SSRIs are the first-line agents for the treatment of panic disorders.
|EducationalObjectives=Panic disorder is an anxiety disorder characterized by episodes or attacks of fear that are associated with other somatic and cognitive symptoms. For the diagnosis to be made, the symptoms should persist for at least 1 month. The mainstay of long-term pharmacological therapy for patients with panic disorder is selective serotonin reuptake inhibitors (SSRI)
|References=Kircanski K, Craske MG, Epstein AM, et al. Subtypes of panic attacks: a critical review of the empirical literature. Depress Anxiety. 2009;26(10):878-87.<br>
First Aid 2014 page 508
|RightAnswer=E
|RightAnswer=E
|WBRKeyword=Panic disorder, panic attack, selective serotonin reuptake inhibitors
|WBRKeyword=Panic disorder, Panic attack, Anxiety disorder, SSRI, Selective serotonin reuptake inhibitor, Paroxetine
|Approved=No
|Approved=No
}}
}}

Latest revision as of 00:56, 28 October 2020

 
Author [[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1] (Reviewed by Yazan Daaboul, M.D.)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Behavioral Science/Psychiatry
Sub Category SubCategory::General Principles
Prompt [[Prompt::A 19-year-old female college student presents to the physician's clinic for an episode of palpitations and shortness of breath. She states that her symptoms occurred suddenly, lasted for a few minutes, and then resolved spontaneously without medications. She is worried because these episodes have been occurring more often lately, and she is afraid that they will recur. The patient states that during these episodes, she also experiences "rapid breathing, numbness of the fingers, and fear of impending doom". Her first episode occurred 3 months ago; at the time, she thought she was experiencing a heart attack and visited a nearby emergency department. Her test results were reassuring and she was immediately discharged. Her past medical history is unremarkable, except for regular use of oral contraceptive pills. She has no history of smoking, alcohol intake, or illicit drug use. In the clinic, her temperature is 37.2 °C (98.96 °F), blood pressure is 122/84 mmHg, heart rate is 72/min, and respiratory rate is 14/min. Physical examination is unremarkable. What is the most appropriate long-term pharmacological therapy to treat this patient's condition?]]
Answer A AnswerA::Buspirone
Answer A Explanation AnswerAExp::Buspirone is a serotonin 1A receptor partial agonist. It is indicated for generalized anxiety disorders. Of note, buspirone does not interact with alcohol and is not associated with sedation, addiction, or tolerance.
Answer B AnswerB::Olanzapine
Answer B Explanation AnswerBExp::Olanzapine is an atypical antipsychotic agent. Olanzepine is indicated for schizophrenia, obsessive-compulsive disorder (OCD), anxiety disorders, depression, mania, and Tourette syndrome.
Answer C AnswerC::Lorazepam
Answer C Explanation AnswerCExp::Administration of benzodiazepines may be considered during the acute phase of panic disorders. Benzodiazepines are associated with drug dependence and are discouraged in the long-term use.
Answer D AnswerD::Metoprolol
Answer D Explanation AnswerDExp::Beta-blockers are indicated for performance anxiety, but not panic disorder.
Answer E AnswerE::Paroxetine
Answer E Explanation AnswerEExp::SSRIs are the first-line agents for the treatment of panic disorders.
Right Answer RightAnswer::E
Explanation [[Explanation::Panic disorder is an anxiety disorder characterized by episodes or attacks of fear that are associated with other somatic and cognitive symptoms. Panic disorder features a sudden unexpected onset and spontaneous resolution. It commonly affects young women before the age of 25 years. Patients may be otherwise healthy with no past medical history or risk factors, and they tend to have an unremarkable physical examination in the physician's clinic while not experiencing an attack. Common manifestations of panic attacks include symptoms of multiple organ systems and anatomic locations, such as chest pain, palpitations, dyspnea, bolus sensation and choking sensation, abdominal pains, feeling of unreality and impending doom, numbness of the extremities, diaphoresis, hot flashes, chills, and shaking. During an attack, physical examination may only be remarkable for tachycardia and tachypnea. Panic disorder may significantly affect a patient' quality of life; and patients are often too afraid of experiencing future attacks. The diagnosis of panic disorder necessitates that the patient experiences symptoms for more than 1 month.

Acutely, patients may be administered benzodiazepines to relieve the anxiety. However, benzodiazepines are not adequate long-term therapeutic options due to the risk of dependence. Thus, the mainstay of long-term pharmacological therapy for patients with panic disorder is selective serotonin reuptake inhibitors (SSRI), such as paroxetine. Although SSRI may require a few weeks to demonstrate efficacy, the majority of patients eventually report significant improvement with SSRI administration. Other non-pharmacological approaches include regular exercise, sufficient sleep, and avoidance of stimulants, alcohol, and caffeine intake.
Educational Objective: Panic disorder is an anxiety disorder characterized by episodes or attacks of fear that are associated with other somatic and cognitive symptoms. For the diagnosis to be made, the symptoms should persist for at least 1 month. The mainstay of long-term pharmacological therapy for patients with panic disorder is selective serotonin reuptake inhibitors (SSRI)
References: Kircanski K, Craske MG, Epstein AM, et al. Subtypes of panic attacks: a critical review of the empirical literature. Depress Anxiety. 2009;26(10):878-87.
First Aid 2014 page 508]]

Approved Approved::No
Keyword WBRKeyword::Panic disorder, WBRKeyword::Panic attack, WBRKeyword::Anxiety disorder, WBRKeyword::SSRI, WBRKeyword::Selective serotonin reuptake inhibitor, WBRKeyword::Paroxetine
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