Fast Fact and Concept #145: Panic Disorder at the End of Life

Author: VJ Periyakoil, MD

Anxiety and fear occur commonly in the dying patient. However, disabling anxiety and/or panic is not a normal aspect of the dying process. Separating “normal” death-related anxiety from pathological panic is an important palliative care skill.

DEFINITIONS

A panic attack is defined in the DSM-IV as “a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: palpitations, pounding heart or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded or faint, derealization or depersonalization, fear of losing control or going crazy, fear of dying."

Derealization – a sensation of f eeling estranged or detached from one’s environment.

Depersonalization - an altered and unreal perception of self, feelings and/or situation. Described by one patient as “feeling like you are on the outside looking in”.

DIAGNOSIS

• A combination of physical symptoms (feeling dizzy, weak, nauseous, unsteady, lightheaded, breathless) and affective symptoms (fear of loss of control) are used to diagnose a panic disorder.
• Terminally ill patients may often have many of the physical symptoms listed above as a part of their illness process. Thus the presence of derealization, depersonalization and fear of loss of control are more useful in making the diagnosis of panic disorder in the terminally ill.
• A contributing feature to the diagnosis of panic disorder is if a patient develops recurrent symptoms, worries about future ‘attacks’ and alters her/his behavior in anticipation of such attacks.
• Terminally ill patients with chronic dyspnea may often worry about “suffocating to death”

MANAGEMENT

• Educate patients about the diagnosis and reassure them that their symptoms can be greatly palliated with appropriate treatment.
• Optimize medical management of symptoms like pain, non-pain symptoms (especially dyspnea) and depression.
• Ideal therapy is a combination of medical therapy with psychological counseling.
• Add complementary/alternative treatments: music therapy, massage therapy, guided imagery, biofeedback.
• Medical management is influenced by anticipated lifespan and severity of panic symptoms.
• SSRI monotherapy or SSRI therapy augmented with low dose benzodiazepines for a period of 3 to 4 weeks followed by SSRI monotherapy (taper off benzodiazepines after 3 weeks) is indicated in patients with an anticipated lifespan of at least several weeks.
• SSRIs can exacerbate anxiety in some patients during the first few days of therapy. Consider adding benzodiazepines as needed for the first few weeks in such cases.
• Benzodiazepine monotherapy should be considered in patients with anticipated lifespan of days to weeks. Consider low dose long acting benzodiazepine therapy on schedule (e.g. diazepam 1 mg every 12 hours) with short acting benzodiazepines (e.g. lorazepam 0.5 mg every 4 to 6 hours as needed) for acute breakthrough symptoms.
• Many terminally ill patients need maintenance therapy for the rest of their life span, as relapse rates are high on treatment discontinuation. In cases where treatment termination is attempted, it is recommended that the medications be tapered gradually over a several week period to allow early detection of a relapse.
• Abrupt termination of benzodiazepine therapy often may result in intense rebound anxiety. This may happen when the patient is actively dying and unable to take oral medications. In such cases, use alternate routes of drug administration (diazepam gel, diazepam rectal suppository or diazepam or midazolam infusions).

References:

1. Periyakoil VS, Skultety K, Sheikh J; Panic, Anxiety, and Chronic Dyspnea J. of Palliative Medicine. Apr 2005; 8: 453-459
2. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington, DC: American Psychiatric Association; 1994.
3. http://anxiety-panic.com/dictionary/en-dictd.htm accessed 080405

Copyright/Referencing Information: Users are free to d ownload and distribute Fast Facts for educational purposes only. Citation for referencing: Periyakoil VJ. Fast Facts and Concepts #145; Panic Disorders at the End of Life. November, 2005. End-of-Life/Palliative Education Resource Center www.eperc.mcw.edu.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

 Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge and Patient Care

Keyword(s): Non pain symptoms & syndromes; psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders