Panic Disorder

by Mike Nichols on June 23, 2008 · 39 comments

Panic Disorder is at the same time the most treatable of the Anxiety Disorders, and the most devastating. It can progress very quickly from the first panic attack to major Anxiety to Agoraphobia if untreated. Panic attacks mimic dire physical problems such as heart attack, and disabling fear is characteristic of Panic Disorder. From personal experience, I can tell you that it is one of the most miserable feelings one can have.

Panic disorder and panic attacks are hard to separate from one another: One must have panic attacks to have Panic Disorder, but one can have a panic attack without having Panic Disorder. This article describes Panic Disorder. For information on panic attacks, please see Panic Attacks.

What are the diagnostic criteria for Panic Disorder?

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) lists the criteria for Panic Disorder as follows: (1)

A) Both (1) and (2)

(1) recurrent unexpected Panic Attacks

(2) at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

(a) persistent concern about having additional attacks

(b) worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, “going crazy”)

B) The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

C) The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

What is the Prevalence and Occurrence of Panic Disorder?

The National Institute of Mental Health (NIMH) estimates that about two percent of American adults — six million people — have Panic Disorder. It is twice as common in women as among men. (2) Panic attacks often begin in late adolescence or early adulthood. About half of all people with Panic Disorder develop the condition before age 24. As many as thirty-six percent of people with Panic Disorder also have Agoraphobia. (See the article “Agoraphobia” for more information.)

Panic Disorder may assault a person daily, for weeks, for months or even for years, depending on how and when treatment is sought. If left untreated, it can worsen rapidly, to the point where the person’s life is seriously affected by panic attacks and by attempts to avoid or conceal the condition. With some, symptoms may abate for a period of time, then recur. There is some research that indicates that some people over 50 may experience diminishing symptoms.

It is not uncommon for the lives of sufferers of Panic Disorder to become severely restricted. They avoid normal activities such as driving, going to the store, or talking on the phone. About one-third become house-bound. When the restriction progresses to this point, it is called Agoraphobia. Panic Disorder is often accompanied by other serious problems such as Depression, drug abuse, or alcoholism.

What are the causes of Panic Disorder?

It is not known exactly what causes Panic Disorder. Researchers are actively seeking the root causes in the body, brain and genes, but nothing conclusive has been discovered yet. Some feel that the amygdala, the part of the brain that triggers the “fight or flight” response, may cause a person having a panic attack to feel that their life is truly in danger. It is also thought that the overproduction of the hormonal/adrenal glands may be a source of physical symptoms.

However, studies have revealed several factors that contribute to the panic attacks that lead to Panic Disorder. Panic Disorder tends to run in families, which may mean that it is a hereditary disorder. It has also been found that it is comorbid with hereditary disorders such as Bipolar Disorder and alcoholism. However, many with no family history of any of these disorders develop Panic Disorder. People with Post Traumatic Stress Disorder show a much higher incidence of Panic Disorder than the general populace.

Several studies have found that there is a link between substance abuse and Panic Disorder. Cigarette smoking seems to increase the risk of panic attacks and Panic Disorder, since nicotine, a stimulant, has been shown to contribute to panic attacks.

It is believed that other factors may exaggerate normal bodily reactions and play a role in the onset of Panic Disorder. These include stressful life events; life transitions such as birth, death and moving; excessive responsibilities; and environmental factors like poor living conditions, unemployment and health status. There is some evidence to suggest that hypoglycemia, hyperthyroidism and other physical conditions can cause or aggravate Panic Disorder.

What are the Symptoms of Panic Disorder?

As stated in the DSM-IV criteria for diagnosing Panic Disorder (see above), sufferers usually have a series of panic attacks within a relatively short period, are worried that they will have another, and significantly change their behavior due these factors.

Panic Attacks are intense episodes of extreme anxiety, typically lasting ten minutes, though they may be as short as one to five minutes. They can come and go for a number of hours, one panic attack following another. Symptoms of a panic attack include a pounding heart, perspiring, trembling, shortness of breath, a feeling of choking, chest pain, feelings of unreality and fear of dying.

The outward signs of a panic attack often cause negative social experiences, such as embarrassment, social stigma, and social isolation. However, experienced sufferers can often have intense attacks with very little outward signs of the attack occurring.

Limited Symptom Panic Attacks are similar to panic attacks, but have less than four symptoms listed in the DSM-IV diagnosis criteria.(3) Most people with Panic Disorder experience both full-blown panic attacks and Limited Symptom Panic Attacks.

Please see the complete article on panic attacks, found under “Reference & Info.”

What is the Treatment for Panic Disorder?

Panic Disorder is one of the most treatable of the Anxiety Disorders. Since it tends to progress rapidly, early treatment is essential to prevent the sufferer from developing Agoraphobia or other mental disorders as well. Unfortunately, many people with Panic Disorder go from doctor to doctor for years and visit the emergency room frequently before someone correctly diagnoses their condition. It is relatively common for people to self-medicate with legal and illegal substances in an attempt to alleviate their symptoms. Therefore, a portion of the population may go undiagnosed until they seek treatment for their self-medication habit.

Successful treatment involves a three-pronged approach to help people with Panic Disorder: education, psychotherapy, and medication. (4)

Psychotherapy is usually the first step in the treatment of Panic Disorder. Individual psychotherapy is preferred, since it emphasizes education, support and the teaching of more effective coping strategies. The sufferer is instructed about the body’s “fight or flight” mechanism and the physiological symptoms that accompany it. Learning to recognize these symptoms is a necessary initial phase in the treatment of Panic Disorder.

Later, therapy teaches relaxation and imagery techniques. These can be used during a panic attack to reduce the body’s distressing symptoms and the fears that go along with the attack, such as fear of dying, fainting, or being embarrassed. Cognitive Behavioral Therapy or Rational Emotive Behavioral Therapy usually work best in this area, since they emphasize confronting and dissipating irrational and fear-laden thoughts. Group therapy is as effective as individual therapy in teaching relaxation techniques such as deep breathing, meditation and muscle relaxation.

The patient is required to practice relaxation skills and lessons learned in psychotherapy on a daily basis for them to be effective. There are often homework assignments, as well. If the patient is unable or unwilling to practice their homework assignments on a daily basis, treatment will be unsuccessful or at best less successful.

Many people can be treated successfully for Panic Disorder without Medication. When medication is necessary, the benzodiazepines such as Clonazepam and Alprazolam are appropriate, as are SSRI antidepressants. Treatment with medication alone is rare, since education and psychotherapy are so important to a successful outcome. Philip W. Long, M.D. says that: (5)

Clonazepam (Klonopin, Rivotril) and alprazolam (Xanax), are the treatment of choice in the treatment of Panic Disorder. Clonazepam and alprazolam are preferred to antidepressant drugs because of their less severe side effects.

He also states that trying the benzodiazepines first is preferred, since the SSRI’s have more side effects. Xanax can be addictive, so it is only used with care.

It has been stated several times in this article, but it bears repeating: Panic Disorder is a rapidly progressing mental disorder that can lead to severe effects and even complete disability in a relatively short time if left untreated, or even if it has been treated. This has been my experience. It has taken five years for me to overcome some of the effects of Panic Disorder and Agoraphobia, even with the best of treatment. I urge you to seek treatment as soon as possible if you suspect that you might have this disorder!

FOOTNOTES

(1) DSM-IV is the abbreviation for the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, which is a publication of the American Psychiatric Association. It is a primary American source for mental health professionals that lists categories of mental disorders and the criteria for diagnosing them. It is used by clinicians and researchers, insurance companies, pharmaceutical companies and policy makers. The American Psychiatric Association has more information on the DSM-IV. http://www.psych.org/MainMenu/Research/DSMIV.aspx

(2) National Institute of Mental Health. (2008). Anxiety Disorders: Panic Disorder. Retrieved June 30, 2008 from National Institute of Mental Health Web site: http://www.nimh.nih.gov/health/publications/anxiety-disorders/panic-disorder.shtml

(3) Centre for Anxiety Disorders and Trauma. (2005). Panic Disorder. Retrieved June 30, 2008 from Centre for Anxiety Disorders and Trauma Web site: http://psychology.iop.kcl.ac.uk/cadat/GPs/panic-disorder.aspx

(4, 5) Psych Central. (2006). Panic Disorder Treatment. Retrieved June 27, 2008 from Psych Central Web site: http://psychcentral.com/disorders/sx28t.htm