Panic Disorder Criteria
Recurrent unexpected panic attacks + ≥ 1 month of persistent worry about subsequent attacks or maladaptive behavior changes; first-line long-term: SSRI/SNRI + CBT.
Alcohol Withdrawal Stages
6–24h: Tremors, insomnia; 12–48h: Hallucinations (clear sensorium); 24–48h: Withdrawal seizures; 48–96h: Delirium Tremens (autonomic instability, confusion, fever).
Cluster B Personalities
Antisocial (conduct disorder < 15, lack of remorse), Borderline (splitting, self-harm, DBT), Histrionic (attention-seeking, provocative), Narcissistic (grandiosity, lack empathy).
PTSD vs. Acute Stress
PTSD: Intrusive trauma symptoms, avoidance, negative mood, hyperarousal lasting > 1 month (first-line: SSRI + Trauma-focused CBT). Acute Stress Disorder: 3 days to 1 month.
Anxiety & Trauma-Related Disorders Master Comparison
| Disorder | Core Diagnostic Features | Duration Requirement | First-Line Evidence-Based Treatment |
|---|---|---|---|
| Generalized Anxiety Disorder (GAD) | Excessive, uncontrollable worry about everyday issues ± ≥ 3 somatic symptoms: fatigue, restlessness, poor concentration, irritability, muscle tension, sleep disturbance | ≥ 6 Months | SSRIs or SNRIs (Sertraline, Escitalopram, Duloxetine) + Cognitive Behavioral Therapy (CBT); Buspirone as non-benzodiazepine adjuvant |
| Panic Disorder | Recurrent unexpected panic attacks (intense fear peaking in minutes: palpitations, diaphoresis, dyspnea, chest pain, fear of dying) followed by ≥ 1 month of persistent worry about further attacks or agoraphobia | ≥ 1 Month of anticipatory dread or behavioral change | SSRIs / SNRIs + CBT; Benzodiazepines (Alprazolam, Clonazepam) reserved only for acute abortive management, avoiding long-term dependence |
| Post-Traumatic Stress Disorder (PTSD) | Exposure to actual or threatened death, serious injury, or sexual violence; 4 symptom clusters: 1. Intrusion (nightmares, flashbacks), 2. Avoidance of trauma cues, 3. Negative mood/cognition, 4. Hyperarousal (hypervigilance, exaggerated startle) | > 1 Month | SSRIs (Sertraline, Paroxetine) or Venlafaxine + Trauma-focused CBT / Prolonged Exposure; Prazosin (alpha-1 blocker) for trauma-related nightmares |
| Obsessive-Compulsive Disorder (OCD) | Recurrent intrusive thoughts/urges causing distress (obsessions) relieved by repetitive mental or behavioral acts (compulsions); ego-dystonic | Time-consuming (> 1 hr/day) or causing significant impairment | High-dose SSRIs (Fluoxetine, Fluvoxamine, Sertraline) + Exposure and Response Prevention (ERP); Clomipramine (TCA) for refractory cases |
Alcohol & Substance Withdrawal Syndromes
| Substance | Withdrawal Timeline & Symptoms | Life-Threatening Risks | Medical Management Protocol |
|---|---|---|---|
| Alcohol Withdrawal | 6–12h: Tremulousness, anxiety, GI upset; 12–24h: Alcoholic hallucinosis (auditory/visual, sensorium intact); 24–48h: Generalized tonic-clonic seizures; 48–96h: Delirium Tremens (DTs) | Delirium Tremens: Severe confusion, gross agitation, hyperthermia, hypertension, diaphoresis; 5% mortality from cardiovascular collapse | Symptom-triggered long-acting Benzodiazepines (Diazepam, Chlordiazepoxide); use LOT (Lorazepam, Oxazepam, Temazepam) in hepatic impairment; IV fluids + Thiamine (BEFORE glucose to prevent Wernicke) |
| Opioid Withdrawal | 6–12 hours (heroin) or 24–48 hours (methadone): Dysphoria, rhinorrhea, lacrimation, piloerection ('cold turkey'), yawning, severe abdominal cramping, diarrhea, mydriasis | Severely distressing but NOT inherently fatal (unless severe dehydration/electrolyte collapse from vomiting/diarrhea) | Buprenorphine-Naloxone or Methadone; symptomatic relief with Clonidine (alpha-2 agonist relieves autonomic hyperactivity), Loperamide, and Ondansetron |
| Benzodiazepine Withdrawal | Onset depends on half-life (short: Alprazolam within 24h; long: Diazepam after several days); Anxiety, tremors, insomnia, perceptual distortions, delirium, seizures | Status epilepticus, autonomic hyperarousal, psychosis; high mortality if untreated | Gradual taper with long-acting benzodiazepine (Diazepam or Clonazepam) over weeks/months |
OMM Board Correlate: Autonomic Regulation & Diaphragmatic Mechanics in Anxiety
- Sympathetic Down-Regulation: Chronic anxiety and panic activate central fight-or-flight mechanisms, causing paraspinal hypertonicity throughout T1–L2. Bilateral gentle thoracic rib raising, suboccipital inhibition, and sacral rocking shift autonomic tone toward parasympathetic dominance.
- Hyperventilation Mechanics: Panic-induced hyperventilation recruits secondary respiratory muscles (scalenes, pectoralis minor, sternocleidomastoid), creating superior thoracic inlet restriction and first rib exhalation somatic dysfunctions. Muscle energy to the 1st rib and scalenes relieves chest tightness.
Board Traps & Common Distractors
- In patients presenting with suspected alcohol withdrawal, ALWAYS administer IV Thiamine (Vitamin B1) BEFORE or concurrently with dextrose-containing IV fluids; giving glucose first triggers acute exacerbation of Wernicke encephalopathy (triad: encephalopathy, oculomotor dysfunction, ataxia) and irreversible Korsakoff psychosis.
- Delirium Tremens is a medical emergency that carries a 5% mortality rate if untreated; continuous ICU monitoring and aggressive escalating doses of IV benzodiazepines (Lorazepam or Diazepam) are required until calm and lightly somnolent.
- Opioid withdrawal produces severe mydriasis, rhinorrhea, lacrimation, and piloerection, but is non-fatal; conversely, alcohol and benzodiazepine withdrawals cause life-threatening seizures and autonomic collapse.