Anxiety: Panic Disorder I

Assessment:  

Whilst the history of anxiety attacks is fairly clear in this scenario, the patient is older with co-morbidities, and care should be taken to exclude cardiovascular or respiratory disease.  Equally important is a risk assessment, as anxiety can be associated with depression, alcoholism, and risk of harm to self or others (please see the ‘depression’ case for a more detailed guide to risk assessment).  

Remember to enquire about symptoms of psychosis, illicit drug use and past history of mental health problems. Always attempt to place symptoms in a social context, assessing the degree of distress and functional impairment  

The GAD7 can be a useful screening tool to assess the severity of anxiety. Scores of 5, 10 and 15 are associated with mild, moderate or severe anxiety respectively. Using 10 as a threshold yields a sensitivity of 89% and specificity of 82% for generalized anxiety disorder and a 74% sensitivity and 81% specificity for panic disorder. 

Management:  

If the generalized anxiety disorder is associated with harmful alcohol or substance abuse, then the substance abuse should be dealt with first, either in house if the expertise exists or by referral to a suitable service.  

NICE published some guidelines back in 2011 (UPDATED in 2020) that cover the management of generalised anxiety and panic disorder in adults

Exercise has shown some benefits above and beyond the placebo effect. Low-intensity psychological interventions can be offered initially if symptoms are mild: including guided self-help based on CBT principles, group sessions, or individual non-facilitated self-help.  

If symptoms are worse or there is significant functional impairment, then high-intensity psychological interventions: such as individual CBT can be offered.  

It can be tricky to remember who may need what, so thankfully if the patient is referred through IAPT, they can assess and they can discuss with the patient, and they can recommend the most suitable options. Remember that in a lot of areas, patients can now self-refer to IAPT. There are also other services that can offer help, such as well women's clinics, and some church-based support groups.  

In this case, addressing her particular concern of being unwell at home by providing a personal alarm for this lady, may help her anxieties. The security of knowing she can get hold of someone may be enough to reassure her.   

There is also the option of medication, such as either cardio-selective beta blockers for symptom relief from panic attacks, or long-term SSRI for the management of generalized anxiety. Sertraline is the SSRI of choice in anxiety management.  

Try to avoid giving benzodiazepines for the management of panic disorder, due to their highly addictive nature.