Nocturnal Panic Attacks

[Chrismander]

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Have any of you seen nocturnal panic attacks, where a patient is woken from a deep sleep into the midst of a panic attack? I have a patient with panic disorder complaining of this. This has become her major complaint, since it disturbs her sleep and happens every night. I was trying to do some CBT with her but it's hard when there's no pre-panic attack thought or whatever to work on. She doesn't even recall having dreams prior to that might have triggered them.
Also, should I be concerned for a medical cause here, like some sort of sleep disorder? She does get them during the day too, so a sleep study or something has been lower on my differential (about 2-3 attacks during the day, 1-2 during sleep).
I haven't seen a lot of honest to goodness pure Panic Disorder, so thanks for your input.

 

[whopper]

A sleep disorder would be on my radar in addition to panic disorder.

With only the very little information you presented...

If you're convinced the person has panic disorder, definitely treat that. If you don't want to do the sleep study till later, see if the nocturnal issues improve with the panic disorder treatment.

 

[nitemagi]

I'd also think about PTSD and nightmares, and screen thoroughly for that. Also inquire about onset and duration. If lifelong check for childhood abuse, if new onset inquire about recent traumas. Does the patient have a partner that can give collateral about what happens just before, kicking in sleep, etc?

 

[masterofmonkeys]

don't forget SVT...

 

[TheWowEffect]

REM Sleep Behavior Disorder is a possibility and a sleep study with limb leads can help rule it out.

 

[Doc Samson]

While everything already listed here is far more likely, I'd include pheochromocytoma in the DDx for panic attacks that wake a patient from sleep.

 

[Manicsleep]

What medications, if any, is the patient taking? Include OTC, etoh/drugs/caffeine.

 

[whopper]

Doc Samson's post reminded me of the one panic disorder patient I had where I suspected pheochromocytoma. This patient was tried on 3 SSRIs with buspirone augmentation, then an SNRI (venlafaxine), then pindolol, then propranolol augmentation, then gabapentin and none of them improved his situation at all. The only thing that helped was benzodiazapines, and I did not want to give this to him long term. I don't think he was malingering for benzos because when I told him of the long term problems with the meds, he didn't want them either.

I experienced a lot of red tape trying to get the testing done. My insurance carrier didn't want me testing for it because it was outside the scope of psychiatry. The PCP didn't know what I was talking about, so I had to tell him what labs to order.

All the labs came up negative. Turned out the 2nd SNRI I tried-duloxetine with buspirone augmentation got him stable. This is after the course of 4 months of no success with other medications.

 

[Ollie123]

I don't want to take away from the differential dx others have recommended, which all seem reasonable though I'm lacking the medical background to say with certainty. However, every treatment manual I have read on PD makes it a point to state that nocturnal panic is very common in people with PD and emphasizes the need to pass this along to clients. If memory serves, it is actually on the order of 50% (though that is people who experience them sometimes...not necessarily nightly). Anecdotally, the 3 PD clients I have seen in my short-time in psychology have all had them. I wouldn't spend too much time chasing a ghost unless you have reason to believe it isn't related to the panic disorder.

 

[masterofmonkeys]

I don't want to take away from the differential dx others have recommended, which all seem reasonable though I'm lacking the medical background to say with certainty. However, every treatment manual I have read on PD makes it a point to state that nocturnal panic is very common in people with PD and emphasizes the need to pass this along to clients. If memory serves, it is actually on the order of 50% (though that is people who experience them sometimes...not necessarily nightly). Anecdotally, the 3 PD clients I have seen in my short-time in psychology have all had them. I wouldn't spend too much time chasing a ghost unless you have reason to believe it isn't related to the panic disorder.

http://archinte.ama-assn.org/cgi/content/abstract/157/5/537

http://ajp.psychiatryonline.org/cgi/content/abstract/143/4/478

http://ajp.psychiatryonline.org/cgi/content/abstract/143/4/478

Just a few sources (of many) from which I tend to infer that we may be looking at two distinct populations both of whom are diagnosed with panic d/o. A sizable proportion may have an intervenable PSVT with secondary panic, either through pharmacologic or interventional means. While another subset of patients may suffer from panic attacks not directly associated with abnormal rhythm.

Also, the idea that a psychiatrist shouldn't be involved in medical r/o just seems stupid. I hate insurance companies.

 

[nitemagi]

http://archinte.ama-assn.org/cgi/content/abstract/157/5/537

http://ajp.psychiatryonline.org/cgi/content/abstract/143/4/478

http://ajp.psychiatryonline.org/cgi/content/abstract/143/4/478

Just a few sources (of many) from which I tend to infer that we may be looking at two distinct populations both of whom are diagnosed with panic d/o. A sizable proportion may have an intervenable PSVT with secondary panic, either through pharmacologic or interventional means. While another subset of patients may suffer from panic attacks not directly associated with abnormal rhythm.

Also, the idea that a psychiatrist shouldn't be involved in medical r/o just seems stupid. I hate insurance companies.

Agreed. The problem with epidemiological data on an issue like medical cause is that real workups are rarely done. So the real prevalence of medical causes in a population of panic disorder patients may be grossly underestimated. Unless someone has a study to refute this.