Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 8: Neuropsychiatric Disorders

Panic Disorder

Background

Panic disorder is persistent fear that interferes with the ability to conduct activities of daily living. A patient is diagnosed as having panic disorder when he or she has experienced 4 panic attacks within a 4-week period, or at least 1 panic attack followed by a month of persistent fear. Panic attacks are discrete, sudden-onset episodes of intense fear or apprehension accompanied by specific somatic or psychiatric symptoms (eg, palpitations, shortness of breath, or fear of losing control).

Patients may associate panic attacks with various activities, such as leaving home, driving, and even visiting health care providers for medical appointments. The symptoms of panic disorder usually begin in late adolescence to the mid-30s and may coincide with the presentation of major depressive disorder, social phobia, or generalized anxiety disorder. Symptoms may mimic physical illness. Patients with panic disorder have an increased incidence of suicide.

S: Subjective

The patient complains of panic attacks, or describes episodes of:

• Chest pain or discomfort
• Depersonalization or derealization
• Dizziness, lightheadedness, faintness, or feeling of unsteadiness
• Fear of dying
• Fear of going crazy or losing control
• Hot flashes or chills
• Nausea or abdominal distress
• Numbness or tingling sensations
• Palpitations or accelerated heart rate
• Sensation of choking
• Shortness of breath or smothering sensation
• Sweating
• Trembling or shaking

In the absence of physical causes, 4 or more of the above symptoms accompanying multiple panic attacks are diagnostic of panic disorder. Panic attacks are, by definition, self-limited and they peak quickly, usually within 10 minutes. Symptoms that persist continuously for longer periods suggest other causes.

History

Inquire about the following:

• Any associated or concurrent symptoms, such as rash, cough, or fever
• Current medications, herbal products, and supplements
• Family history of mood and psychiatric illnesses, particularly anxiety and panic
• Frequency, duration, and onset of panic episodes
• Any relationship to food or hunger
• Settings in which attacks occur to determine whether there are triggers, such as being outdoors (agoraphobia)
• Intake of caffeine, recreational drugs, and alcohol (current and recent)
• New onset versus previous incidents
• Sleep disturbances
• Concomitant illnesses

O: Objective

Perform a complete physical examination, including vital signs and thyroid, cardiac, pulmonary, and neurologic evaluation.

During actual panic attacks, patients may have an increased heart rate or respiratory rate.

A: Assessment

A partial differential diagnosis includes the following conditions:

• Allergic reactions
• Cardiac insufficiency, congestive heart failure, myocardial ischemia
• Hyperthyroidism
• Hypoglycemia
• Major depression with superimposed panic attack
• Medication effect
• Pheochromocytoma medication effect
• Phobia (phobia is a specific response to a specific stimulus, whereas a patient with panic attacks is unsure when they will recur and what will trigger them )
• Respiratory infection
• Pheochromocytoma
• Withdrawal from or intoxication with psychoactive substances (eg, caffeine, amphetamines, cocaine, hallucinogens, or medications)

P: Plan

Diagnostic Evaluation

Perform the following tests:

• Blood glucose; gamma-glutamyl transpeptidase (GGT) if symptoms are related to hunger or are consistent with rebound hypoglycemia
• Thyroid studies
• Arterial blood gases if the patient has persistent shortness of breath
• Electrocardiogram if chest pain is present

Treatment

Once other diagnoses have been ruled out, consider the following treatments:

Cognitive-behavioral therapy

Options include individual cognitive-behavioral therapy (CBT) interventions (refer to community-based support), a stress management group, relaxation therapy, visualization, and guided imagery. Emergency referrals may be needed.

Psychotherapy

Psychotherapy may be indicated if the patient is capable of forming an ongoing relationship with a therapist. If possible, refer to an HIV-experienced professional.

Pharmacotherapy

Patients with advanced HIV disease, like geriatric patients, may become more vulnerable to the central nervous system (CNS) effects of certain medications. Medications that affect the CNS should be started at low doses and should be titrated slowly. Similar precautions should apply to patients with liver dysfunction.

Some interactions occur between selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and HIV medications. Consult with an HIV expert or pharmacist before prescribing.

Treatment should be continued for at least 6 months beyond the resolution of symptoms.

Options

• SSRI-type antidepressants, including fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) may be effective. Venlafaxine timed-release formulation (Effexor XR), at a dosage of 75-225 mg/d, has been approved for the treatment of generalized anxiety disorder. There is a risk of hypertension at the higher dosages of venlafaxine; monitor blood pressure.
• Tricyclic antidepressants may be used at low doses, including nortriptyline (Pamelor), 10-75 mg at bedtime; desipramine (Norpramin), 10-50 mg daily; amitriptyline (Elavil), 25-75 mg at bedtime; and imipramine (Tofranil), 25-75 mg at bedtime. Doses should be titrated slowly. Tricyclic antidepressants may reach higher blood concentrations when coadministered with certain protease inhibitors, including ritonavir (contained in Kaletra); consult with an HIV expert or pharmacist.
• Many patients will require initial short-term treatment with benzodiazepines, which are titrated downward as the antidepressant is titrated upward. Benzodiazepines should be used only for acute, short-term management, because of the risks of tolerance and physiologic dependence. These risks are more problematic in patients with a history of addiction. Note that protease inhibitors and nonnucleoside reverse transcriptase inhibitors may raise blood concentrations of many benzodiazepines. If benzodiazepines are used, they should be started at low doses, and other CNS depressants should be avoided. Consult with a clinical pharmacist before prescribing.
• Note that midazolam (Versed) and triazolam (Halcion) are contraindicated with all protease inhibitors and with delavirdine and efavirenz.

Patient Education

• Behavioral interventions can help to reduce the frequency and severity of panic attacks. Patients should seek help from a therapist, an experienced source, or a friend.
• Some patients develop problems with sexual function because of the medications. Patients should report any problems to their prescribers.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Association; 1994.
• New York State Department of Health AIDS Institute. Mental Health Care for People with HIV Infection: Clinical Guidelines for the Primary Care Practitioner. 2001. Available online at www.hivguidelines.org/. Accessed February 7, 2006.
• U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. May 4, 2006. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=7. Accessed May 19, 2006.