What is Panic Disorder?
Panic disorder is a type of anxiety disorder, in which you experience repeated unexpected panic attacks, and are constantly concerned or worried about having more such attacks or change your routine because of the panic attacks (e.g., avoidance of unfamiliar locations). Panic attacks are sudden marked increases of intense fear or intense discomfort that reach a peak within minutes, accompanied by physical and/or cognitive symptoms (American Psychiatric Association, 2013). Many people have just one or two panic attacks in their lifetimes, and the problem goes away, such as when a stressful situation ends.
Panic attacks may be expected, such as in response to a typically feared object or situation, or unexpected, occurring for no apparent reason. A clinician decides whether panic attacks are expected or unexpected, based on a combination of careful questioning as to the sequence of events leading up to the attack and the individual’s own judgment of whether or not the attack seemed to occur for no apparent reason. You can experience terrified and overwhelmed feelings, even though there is no impending danger.
When panic attacks occur, you might think you are losing control, having a heart attack or even dying. Although panic attacks are not life-threatening, they can be frightening and diminish the quality of your life. However, treatment is usually very effective.
Around 10% of adults in the US have panic attacks each year. About a third of people have one such attack in their lifetime. But, not everyone who has panic attacks goes on to have panic disorder. Only about 3% of adults have panic disorder. Symptoms of panic disorder often start in the late teens or early adulthood. The median age at onset for panic disorder in the United States is 20-24 years. It is twice as common in women compared to men.
Symptoms of Panic Disorder
Panic attacks typically begin suddenly, without warning. They can strike at any time—when you are shopping, driving, sleeping or in a business meeting. Panic attacks can occur occasionally or frequently. In terms of frequency, they may be moderately frequent attacks (e.g., one per week) for months at a time, or more frequent attacks (e.g., daily) separated by weeks or months without any attacks or less frequent attacks (e.g., two per month) over many years.
Symptoms usually reach a peak within minutes. You may feel extremely tired and worn out after a panic attack ends.
Some of the signs and symptoms are:
- Palpitations, pounding heart, or a fast heartbeat.
- Trembling or shaking.
- Shortness of breath or sensation of being smothered.
- Choking feeling.
- Chest discomfort or pain.
- Nausea or abdominal distress.
- Dizziness, unsteadiness, light-headedness, or faint-feeling.
- Chills or heat sensations.
- Numbness or tingling sensations (paresthesias).
- Feelings of unreality (derealization) or being detached from oneself (depersonalization).
- Fear of losing control or “going crazy.”
- Fear of dying.
The maladaptive behaviors to minimize or avoid panic attacks include avoiding physical exertion, reorganizing daily life to ensure that help is available in the event of a panic attack, restricting usual daily activities, and avoiding agoraphobia-type situations, such as leaving home, using public transportation, or shopping.
Panic disorder is associated with high levels of social, occupational, and physical disability, and the highest number of medical visits among the anxiety disorders. They may be frequently absent from work or school for doctor and emergency room visits, which can lead to unemployment or dropping out of school. In older adults, there may be neglect in caregiving duties or volunteer activities.
Panic disorder diagnosed in the past 12 months is related to a higher rate of suicide attempts and suicidal ideation in the past 12 months even when co-existing disorders and a history of childhood abuse and other suicide risk factors are taken into account.
The usual course of the untreated disorder is chronic but waxing and waning. Some may have episodic outbreaks with years of remission in between. Others may have continuous severe symptoms. Very few individuals have full remission without subsequent relapse within a few years.
Causes and Risk Factors for Panic Disorder
The exact cause of panic disorder is not known. There is irregular norepinephrine activity in people who have panic attacks. It runs in families, so it may be genetically linked. People with panic disorder may be temperamentally oversensitive to fear or prone to negative emotions. It can be triggered by certain situations. Major stress can bring it on.
Drugs or alcohol can worsen the symptoms. It could be accompanied by major depression though there seems to be no causal link between the two. Post-traumatic stress disorder (PTSD) patients also have a much higher rate of panic disorder than the general population. It significantly co-occurs with many general medical symptoms and conditions, including dizziness, irregular heartbeats, hyperthyroidism, asthma, chronic bronchitis, and irritable bowel syndrome.
The following are risk factors for an increase in the risk of developing panic attacks or panic disorder:
- Physical or sexual abuse in childhood
- Family history of panic attacks or panic disorder
- Negative affectivity (neuroticism) (i.e., proneness to experiencing negative emotions) and anxiety sensitivity (i.e., the disposition to believe that symptoms of anxiety are harmful) are risk factors – people who score higher on anxiety sensitivity surveys are five times more likely to be diagnosed with panic disorder.
- Major stress, such as the death or serious illness of a loved one
- Trauma, such as sexual assault or a serious accident
- Significant transitions in life, such as going to college, birth of the first child, or a divorce
- Smoking or excessive caffeine intake
Diagnosis of Panic Disorder
The diagnostic criteria listed by DSM-5 are (American Psychiatric Association, 2013):
- Recurrent unexpected panic attacks. However, the presence of expected panic attacks does not rule out the diagnosis of panic disorder. During the panic attack, four (or more) of the 13 symptoms enumerated above occur. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
- At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
- The disturbance is not attributable to substance abuse, a medication or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
- The disturbance is not better explained by another mental disorder (e.g., social anxiety disorder; specific phobia; obsessive-compulsive disorder; posttraumatic stress disorder; or separation anxiety disorder).
Associated features that can be present supporting the diagnosis are the following (American Psychiatric Association, 2013):
- A nocturnal panic attack (i.e., waking from sleep in a state of panic, which differs from panicking after fully waking from sleep).
- Constant or intermittent feelings of anxiety that are more broadly related to health and mental health concerns. For example, individuals with panic disorder often anticipate a catastrophic outcome from a mild physical symptom or medication side effect (e.g., thinking that they may have heart disease or that a headache means the presence of a brain tumor).
- Pervasive concerns about abilities to complete daily tasks or withstand daily stressors.
- Excessive use of drugs (e.g., alcohol, prescribed medications or illicit drugs) to control panic attacks.
- Extreme behaviors aimed at controlling panic attacks (e.g., severe restrictions on food intake or avoidance of specific foods or medications because of concerns about physical symptoms that provoke panic attacks).
Treatment of Panic Disorder (Mayo Clinic Staff, 2018)
Treatment can reduce the intensity and frequency of panic attacks and improve functioning in daily life. Treatment is mainly with psychotherapy or medications, or a combination of the two.
Psychotherapy is an effective first-line treatment. It can help you understand and cope with the panic disorder. Cognitive behavioral therapy (CBT) teaches you different ways of thinking, behaving, and reacting to the feelings that come on with a panic attack. CBT can help you learn from your own experience that panic symptoms are not dangerous, by gradually re-creating the symptoms of a panic attack in a safe, repetitive manner and also confronting you with the triggers that arouse your anxiety. Once that is seen, the panic attacks begin to resolve. You also overcome fears of situations that you were avoiding because of panic attacks.
Another form of psychotherapy that can help is panic-focused psychodynamic psychotherapy. This focuses on the role of dependency, separation anxiety, and anger in causing panic disorder. The underlying theory is that people with panic disorder have a fearful dependence on others for their sense of security, which leads to separation anxiety and defensive anger. Here, the stressors that lead to panic episodes are explored, and then the psychodynamics of the conflicts and the defense mechanisms are probed, paying attention to transference and separation anxiety issues involved in the therapist-patient relationship.
The reduction of symptoms can take weeks or several months. Even after resolution of the symptoms, you may need to make several maintenance visits to the psychotherapist.
Medications can help reduce not only the symptoms of panic attacks but also those of depression if present. It can take several weeks after first starting a medication for symptoms to improve. The medications used in panic disorder are as follows:
- Selective serotonin reuptake inhibitors (SSRIs).SSRI antidepressants are the first choice of medications to treat panic disorder. SSRIs approved by the FDA for treating panic disorder include fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).
- Serotonin and norepinephrine reuptake inhibitors (SNRIs).The SNRI antidepressant venlafaxine (Effexor XR) is FDA approved for treating panic disorder.
- Benzodiazepines. These are sedatives and anti-anxiety medications. Benzodiazepines approved by the FDA for treating panic disorder include alprazolam (Xanax) and clonazepam (Klonopin). Because they can be habit-forming, causing mental or physical dependence, they are used only on a short-term basis.
Lifestyle and Home Remedies
- Join a support group.It can connect you with others facing the same problems and share your experiences.
- Avoid caffeine, alcohol, smoking and recreational drugs.They can trigger or worsen panic attacks.
- Practice stress management and relaxation techniques.For example, yoga, deep breathing, progressive muscle relaxation, and meditation.
- Aerobic activity can calm your mood.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing.
Mayo Clinic Staff, 2018. Panic attacks and panic disorder. [Online]
Available at: https://www.mayoclinic.org/diseases-conditions/panic-attacks/diagnosis-treatment/drc-20376027
[Accessed 26 Nov 2019].