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Emergency Psychiatry For General Practicioners: (Discussion continued) Case 4: Panic attack or acute anxiety state 1. Panic attacks are paroxysms of severe anxiety accompanied with palpitation, choking, sweating and fear of impending death. 2. It is an emergency because of intense distress not only to the patient but even more to the attendant. (*physicians and emergency medicine doctors encounter them often*) 3. It is at times very difficult for the emergency doctor to explain to the patient and attendant about the psychological causation. 4. Its important for emergency psychiatrist to know that apart from panic disorder, several other organic conditions can give rise to above said symptoms:  Myocardial infarction or angina  Hyperthyroidism  Pheochromocytomas  Temporal lobe seizures  Hypoglycemia  Cocaine intoxication state  Mitral valve prolapse  Pulmonary embolism 5. Management: The first and foremost in all cases of panic attacks presenting in emergency with acute symptoms of anxiety is a thorough medical examination conducted by a specialist as far as possible. 6. Routine investigations that can be done in emergency setting are mostly required especially electrocardiograph and chest x ray in order to look for life threatening cardiac conditions if at all present. 7. Amongst pharmacological interventions benzodiazepines especially high potency like alprazolam and clonazepam are found very beneficial in emergency setting. Injectable lorazepam can be used as and when required. 8. Apart from panic disorder there are some other psychiatric conditions which simulate panic attacks like:  Generalised anxiety disorder  Depressive disorders  Somatoform disorders  Depersonalisation disorder  Phobic anxiety disorders 9. After initial management proper history and assessment is done to find out an appropriate psychiatric diagnosis and long term treatment is started with anti anxiety agents where SSRI(selective serotonin reuptake inhibitor)s are the preferred agents. Tricyclic antidepressants have been also shown to be beneficial in long run.
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