Panic disorder is a condition in which the person with the disorder suffers recurrent panic attacks. Panic attacks are sudden attacks that are not caused by a substance (like caffeine), medication, or by a medical condition (like high blood pressure), and during the attack, the sufferer may experience sensations such as accelerated or irregular heartbeats, shortness of breath, dizziness, or a fear of losing control or "going crazy." The sudden attack builds quickly (usually within 10 minutes) and is almost paralyzing in its severity. When a diagnosis of panic disorder is given, the disorder can be considered one of two different types—panic disorder with or without agoraphobia .
The handbook for mental health professionals (called the Diagnostic and Statistical Manual of Mental Disorders , or the DSM-IV-TR) classifies both types of panic disorder as anxiety disorders.
Panic disorder without agoraphobia
Panic disorder without agoraphobia is defined by the DSM-IV-TR as a disorder in which patients are plagued by panic attacks that occur repeatedly and without warning. After these attacks, the affected individual worries for one month or more about having more embarrassing attacks, and may change his or her behavior with regard to these attacks. For example, a patient may fear that he or she has a cardiac condition, and may quit a job or quit exercising because of the fear. Patients may also worry that they are going to lose control or appear insane to other people. Panic disorder without agoraphobia has a less severe set of symptoms than panic disorder with agoraphobia. Patients without agoraphobia do not become housebound—they suffer panic attacks but do not have significant interference in their level of function and are still able to accomplish their daily activities.
Panic disorder with agoraphobia
People who suffer from this kind of panic disorder may experience their agoraphobia in one of two ways. They may experience sudden, unexpected panic attacks that cause them to fear being in a place where help might not be available; or, they may experience sudden panic attacks in specific, known situations, and fear those situations or places that may trigger attacks. In either case, the fear of further panic attacks restricts the affected person's activities. For example, people whose attacks are triggered by being in crowds may avoid shopping malls for fear that they will be in a crowd and have a panic attack . Or, a person may experience sudden, debilitating panic attacks without a particular trigger, and, as a result, he or she is afraid to go to a supermarket (or similar place) for fear that a panic attack could occur while there and no one could help.
Panic disorder can be very difficult to distinguish from other mental illnesses such as major depression, other anxiety disorders, or medical conditions such as heart attacks. Panic attacks differ from general anxiety in that they are episodes that last for discrete periods of time and the symptoms that people suffer are more intense. Panic attacks have three types: unexpected, situationally bound, and situationally predisposed. The unexpected attacks occur without warning and without a trigger. The situationally bound attacks happen repeatedly when the person is performing some activity, about to do that activity, or even when the person thinks about doing that activity. For example, a person whose panic attacks are triggered by being in crowds can have an attack just by thinking about going to a shopping mall. Situationally predisposed attacks are similar to the situationally bound attacks, except that they do not always occur when the trigger stimulus is encountered. For example, someone who experiences panic attacks while in crowds may sometimes be in crowds and not experience attacks, or may experience attacks in other, non-crowded situations, as well.
Patients who suffer from panic disorder without treatment usually have a diminished quality of life and end up spending excessive money on health care because of frequent visits to emergency rooms and to other medical doctors. However, very effective treatments for panic disorder exist.
Agoraphobia is a fear of being in a place or situation from which escape might be difficult or embarrassing, or in which help may not be available in the case of a panic attack. It is not clear why some people develop agoraphobia and other people do not. Many people may develop their agoraphobia symptoms right after their first attack, but others do not develop agoraphobia until sometimes years after their attacks began.
Causes and symptoms
BIOCHEMICAL/PHYSIOLOGICAL CAUSES. It is extremely difficult to study the brain and the underlying causes of psychiatric illness; and understanding the chemistry of the brain is the key to unlocking the mystery of panic disorder. The amygdala is the part of the brain that causes fear and the response to stress . It has been implicated as a vital part of anxiety disorders. Sodium lactate, a chemical that the body produces when muscles are fatigued, and carbon dioxide are known to induce panic attacks. These substances are thought to inhibit the release of neurotransmitters in the brain, which leads to the panic attacks. One hypothesis is that sodium lactate stimulates the amygdala and causes panic attacks. Another hypothesis is that patients with panic disorder have a hypersensitive internal suffocation alarm. This means that the patient's brain sends the body false signals that not enough oxygen is being received, causing the affected person to increase his or her breathing rate. Panic disorder patients have attacks when their overly sensitive alarm goes off unpredictably. Yohimbine, a drug used to treat male sexual dysfunction, stimulates a part of the brain called the locus ceruleus and induces panic symptoms thus pointing to this area of the brain's involvement in panic disorder. Brain neurotransmitters serotonin and GABA are suspected to be involved in causing the disorder, as well.
GENETICS. Genetics also plays a pivotal role in the development of panic disorder. Twin studies have demonstrated that there is a higher concordance in identical versus fraternal twins thus supporting the idea that panic disorders are inherited. Family studies have also demonstrated that panic attacks run in families. Relatives of patients with panic disorder are four to 10 times more likely to develop panic disorder. People who develop early onset of panic attacks in their mid-20s are more likely to have relatives who have panic disorder. When relatives of patients with panic disorder are exposed to high levels of carbon dioxide, they have panic attacks. Another hypothesis is that patients with panic disorder who develop agoraphobia have a more severe form of the disease. Current efforts to identify a gene for panic disorder have not been successful.
PERSONAL VARIABLES. There are several themes in the psychology of panic disorder. Research has shown that patients who develop panic disorder have difficulty with anger. They also have difficulty when their job responsibilities are increased (as in the case of a promotion), and are sensitive to loss and separation. People with this disorder often have difficulty getting along with their parents, whom they see as controlling, critical, and demanding, causing the patients to feel inadequate. Early maternal separation is thought to be an underlying cause of panic disorder.
Panic disorder patients also have a pattern of dependency in their interpersonal relationships. As children, people with panic disorder relied on parents to protect them from fear. As a result, they develop an angry dependence on their parents and fear detaching from them. They constantly feel as though they are trapped.
There is also an association between sexual abuse and patients who have panic attacks. Sixty percent of female patients with panic disorder were sexually abused as children. This explains their difficulty with developing trusting relationships.
PANIC ATTACK SYMPTOMS. The DSM-IV-TR lists thirteen symptoms to meet the criteria for a diagnosis of panic attack. The affected person must have four or more of these symptoms within ten minutes of the beginning of an attack in order to meet the panic attack criteria:
- bounding or pounding heartbeat or fast heart rate
- shortness of breath
- feeling of choking
- pains in the chest; many people they feel as though they are having a heart attack
- nausea or stomach ache
- feeling dizzy or lightheaded as if he or she is going to pass out
- feeling of being outside of one's body or being detached from reality
- fear that he or she is out of control or crazy
- fear that he or she is going to die
- feeling of tingling or numbness
- chills or hot flashes
Symptoms of panic disorder without agoraphobia
The DSM-IV-TR criteria for panic disorder without agoraphobia include:
- recurrent panic attacks (see above) that occur without warning for one month
- persistent worry that panic attacks will recur
- possible change in behavior because of that fear
- no agoraphobia
- not due to a medical condition or substance abuse
- not due other mental illness like specific phobia, social phobia , obsessive-compulsive disorder , separation anxiety disorder , or post-traumatic stress disorder
Symptoms of panic disorder with agoraphobia
The DSM-IV-TR criteria for panic disorder with agoraphobia are the same as above, but agoraphobia is present. The symptoms of agoraphobia include fear of being in situations that can trigger panic attacks, and avoiding places where attacks have occurred because of the affected person's fear that he or she will not be able to leave, or will not be able to get help. People with this condition may need to have another person accompany them when going to a place that may trigger anxiety attacks. Sometimes this fear can be so severe that the person becomes housebound. This fact is important to consider because 15% of the general population can have one spontaneous panic attack without the recurrence of symptoms.
Factors such as race, gender and socioeconomic status are important factors in the development of panic disorder. An individual has a chance of between one and two percent of developing panic disorder with or without agoraphobia. The symptoms usually begin when the person is in his or her early to mid-twenties. Women are twice as likely as men to develop panic attacks regardless of age. The National Institute of Mental Health Epidemiologic Catchment Area Study (ECA) shows no real significant differences between the races or ethnic groups, although it appears that African American and Hispanic men between the ages of 40 and 50 have lower rates of panic disorder than white men. Panic disorder patients are at increased risk for major depression and the development of agoraphobia. According to ECA studies, an individual with panic disorder has a 33% chance of developing agoraphobia. People without panic disorder only have a 5.5% chance of developing agoraphobia. Again, women were more likely to develop agoraphobia than men. Over the course of their lifetime, African Americans were more likely to develop agoraphobia than whites or Hispanics. Agoraphobia is more prevalent among people with less education and lower economic class.
Differential diagnosis is the process of distinguishing one diagnosis from other, similar diagnoses. Panic disorder can be difficult to distinguish from other anxiety disorders such as specific phobia and social phobia. However, in general, specific phobia is cued by a specific trigger or stimulus and social phobia by specific social situations, while the panic attacks of panic disorder are completely uncued and unexpected. In certain cases, it may be difficult to distinguish between certain, situational phobias and panic disorder with agoraphobia, and the mental health professional must use the DSM and professional judgment in these cases. Panic attacks that occur during sleep and wake the person up are more characteristic of panic disorder, than are the other disorders that include panic attacks. It can be distinguished from posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD) again by what cues the attacks. In PTSD, thinking about the traumatic event can trigger attacks. In obsessive-compulsive disorder, worries about getting dirty can fuel an attack of anxiety. In generalized anxiety disorder, general worries or concerns can lead to the symptoms of panic. However, in panic disorder, a main component is that the affected individual fears recurrent panic attacks.
Panic attacks can often be difficult to distinguish from other physical problems such as hyperthyroidism, hyperparathyroidism, seizure disorder, and cardiac disease. If patients are middle aged or older and have other complaints, including dizziness and headaches, their attacks are more likely to be another medical problem and not panic attacks. Panic attacks can also be difficult to distinguish from drug abuse since any drug that stimulates the brain can cause the symptoms. For example, cocaine, caffeine, and amphetamines can all cause panic attacks. Therefore, a person must be free of all drugs before a diagnosis of panic disorder can be made. Many patients may attempt to self-medicate with alcohol to try to calm down. Withdrawal from alcohol can lead to worse panic symptoms. The patient may believe that he or she is reducing symptoms while actually exacerbatng their panic attacks.
Individuals with panic disorders have a high rate of coexisting depression. Patients who have panic disorder have about a 40–80% chance of developing major depression. In most situations, the panic disorder happens first and the depression comes later. Patients are also at risk for substance abuse difficulties as a result of attempts to stop attacks. These attempts may involve the use of alcohol, illicit or unprescribed sedatives, or benzodiazepines (medications that slow down the central nervous system, having a calming effect). Patients with panic disorder are not at high risk for suicide attempts. A recent Harvard-Brown study showed that people with panic disorder with or without agoraphobia are not at risk for suicide unless they have other conditions such as depression or substance abuse.
Psychological measures and diagnostic testing
Currently there is no diagnostic test for panic disorder. Any patient who has panic attacks should receive a thorough medical examination to rule out any medical condition. Patients should have baseline blood counts and glucose should be measured. Patients with cardiac symptoms need a cardiac workup and should see their primary medical doctor. Patients who have complaints of dizziness should receive a thorough neurological evaluation. There are several psychological inventories that can help the clinician diagnose panic disorder including the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Specific Fear Inventory, Clinical Anxiety Scale (CAS), and the Clinical Global Inventory (CGI).
Psychological and social interventions
A psychotherapeutic technique that is critical to the treatment of panic disorder is cognitive-behavioral therapy (CBT). Patients are panic-free within six months in about 80–90% of cases. Some people even experience long-term effects after the treatments have been stopped. About half of the patients say that they have rare attacks even two years after treatment has ended.
New studies reveal that the approach to treating panic disorder should have three aspects: the cognitive, the physiological, and the behavioral. The cognitive techniques try to focus on changing the patient's negative thoughts—for example, "I will die if I don't get help." Patient education about symptoms is also critical to the treatment of panic attacks. In one physiological approach, patients are taught breathing techniques in an effort to try to help them lower their heart rate and decrease their anxiety. Repeated exposure to physical symptoms associated with the panic disorder is also a part of treatment. The patients cause themselves to hyperventilate in effort to reproduce the panic symptoms. In behavioral approaches, the individual who experiences panic attacks also needs to be exposed to situations that he or she may have previously feared. A patient can also be taken to places associated with agoraphobia with the therapist.
Some patients may benefit from psychodynamic psychotherapy and group therapy . Psychodynamic psychotherapy explores thoughts and ideas of the person's subconscious. It takes a longer time to achieve efficacy than cognitive-behavioral therapy, but it can be just as effective for patients with panic disorder. Group therapy is also just as helpful to some patients as CBT. Support groups can also be helpful to some patients. It can be very therapeutic and healing to the individual to discuss their problems with someone who has actually experienced the same symptoms. Patients can learn from each other's coping styles.
Panic disorder patients have a 50–80% chance of responding to treatment, which attempts to block the symptoms of panic attacks. Treating the agoraphobia symptoms is more challenging. Developing some antipanic regimens that address all symptoms is important.
The Food and Drug Administration (FDA) to treat panic disorder approves only five classes of drugs. They are:
- Selective serotonin reuptake inhibitors (SSRIs), which cause a buildup of serotonin. This buildup is thought to cause the antidepressant effect.
- Tricylic antidepressants (TCAs).
- Monoamine oxidase inhibitors (MAOIs) and reversible MAOIs, which inhibit the breakdown of neurotransmitters in the brain, including dopamine and serotonin.
- Atypical antidepressants, including bupropion (Wellbutrin), mirtazapine (Remeron), trazodone (Desyrel), and others.
Patients should first be started on a low-dose SSRI and then the dose should be increased slowly. Patients with panic disorder are extremely sensitive to the side effects that many patients experience in the first weeks of antidepressant therapy. Patients should also have a benzodiazepine, such as clonazepam (Klonopin) or alprazolam (Xanax), in the first weeks of treatment until the antidepressant becomes therapeutic. Most people need the same dose of antidepressant as patients with major depression. About 60% of patients will have improvement in their symptoms while taking an antidepressant and a benzodiazepine. Patients with mitral valve prolapse may benefit from a beta blocker. Patients who have tried an SSRI, and after six weeks, show no improvement can be switched to another SSRI, benzodiazepine, TCA, MAOI, or venlafaxine (Effexor). An SSRI should be stopped if the patient has intolerable side effects such as loss of sexual libido, weight gain, or mild form of manic depression. When SSRIs are stopped, it is important that the dosage is gradually tapered because patients can suffer symptoms when it is abruptly withdrawn. These symptoms may include confusion, anxiety and poor sleep.
Some alternative therapies for panic disorder are hypnosis, meditation , yoga , proper nutrition, exercise, and abdominal breathing techniques that foster relaxation and visualization. Visualization is imagining oneself in the stressful situation while relaxed so that coping strategies can be discovered. The herb kava kava has been studied in trials to treat anxiety attacks and has been found to be effective in some clinical trials; but has not been studied intensely enough to determine its benefits and side effects, and has been associated liver toxicity. The National Center for Complementary and Alternative Medicine was going to conduct two research studies of kava kava but as of 2002 it has suspended the trials until the FDA has determined whether or not the herbal supplement is safe.
Patients with panic disorder have a poor prognosis particularly if untreated. Patients often relapse when they attempt to discontinue treatment. However, if patients are compliant and willing to stay in treatment, then the long-term prognosis is good. According to one study, eight years after treatment has been done, 30–40% of patient are doing better. Only 10–20% of patients do poorly. The patient with panic attacks has a relapsing and remitting course that can be worsened by significant stressors such as the death of the spouse or divorce. Cognitive-behavioral therapy has an 80–90% chance that the patient will benefit six months after treatment. Medications have a 50–80% efficacy. If patients are committed to staying in treatment, their prognosis is very favorable.
Although panic disorder is not totally preventable, individuals with a strong family history of them who are susceptible to panic atacks are encouraged to be aware of the symptoms and get treatment early. Compliance with treatment is important to the recovery from panic disorder.
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Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. <www.adaa.org> .
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National Institute of Mental Health. 6001 Executive Boulvevard, Rm.8184, MSC9663,Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov/anxiety/panicmenu.cfm> .
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Susan Hobbs, M.D.