Panic Disorder

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

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.

Description

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

Causes

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 patien’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.

Symptoms

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
• sweating
• shaking
• 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.

Demographics

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.

Diagnosis

Differential diagnosis

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 post-traumatic 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.

Dual diagnosis

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).

Treatments

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.

Medical treatments

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 anti-panic 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:

• benzodiazepines
• 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 neuro-transmitters in the brain, including dopamine and serotonin. Atypical antidepressants, including bupropion (Well-butrin), mirtazapine (Remeron), Trazodome (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 (Klo-nopin) 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.

Alternative therapies

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 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.

Prognosis

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

KEY TERMS

Agoraphobia —People with this condition worry that they will not be able to get help or flee a place if they have a panic attack; or refusal to go to places that might trigger a panic attack.

Amygdala —An almond-shaped brain structure in the limbic system that is activated in acute stress situations to trigger the emotion of fear.

Cognitive-behavioral therapy (CBT) —An approach to psychotherapy that emphasizes the correction of distorted thinking patterns and changing one’s behaviors accordingly.

GABA —Gamma-aminobutyric acid, an inhibitory neurotransmitter in the brain.

Hypersensitive internal suffocation alarm —A sensitive alarm goes off and the affected person’s brain sends the body false signals that not enough oxygen is being received, causing an increase in their breathing rate.

Locus ceruleus —A part of the brain where the neurotransmitter causes excitation.

Panic attack —Specific periods of time when a person has a feeling that s/he is dying or having a heart attack with chest pain, a feeling as though s/he could pass out, and fear that s/he is going insane.

Panic disorder with agoraphobia —Repeated panic attacks in which the patient is worried about the attacks enough that the worry restricts their activity.

Panic disorder without agoraphobia —Repeated panic attacks without symptoms of agoraphobia.

50–80% efficacy. If patients are committed to staying in treatment, their prognosis is very favorable.

Prevention

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.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised. Washington DC: American Psychiatric Association, 2000.

Cox, Brian J. and Stephen Taylor. “Anxiety Disorders Panic and Phobias.” In Oxford Textbook of Psycho-pathology, edited by Theodore Millon, Paul H. Blaney, and Roger D. Davis. New York: Oxford University Press, 1999.

Sadock, Benjamin J., M.D., and Virginia A. Sadock, M.D., eds. “Anxiety Disorders.” In Comprehensive Textbook of Psychiatry. Volume I, 7th edition. Written by Jack Gorman M.D., Laszlo A. Papp, M.D., Glen O. Gabbard, M.D., and others. Philadelphia, PA: Lippincott Williams and Wilkins, 2000.

Swede, Shirley and Seymour Sheppard Jaffe, M.D. The Panic Attack Recovery Book: Revised and Updated. 2nd edition, revised. New York: Penquin Putnam Inc, 2000.

PERIODICALS

Frank, Ellen, Ph.D. and others. “Influence of Panic Agoraphobic Spectrum Symptoms on Treatment Response in Patients With Recurrent Major Depression.” American Journal of Psychiatry July 2000: 1101–1107.

Kessler, Ronald C. Ph.D. and others. “The Use of Complementary and Alternatives Therapies to Treat Anxiety and Depression in the United States.” American Journal of Psychiatry February 2001: 289–294.

Milrod, Barbara, M.D., and others. “Open Trial of Psy-chodynamic Psychotherapy for Panic Disorder: A Pilot Study.” The American Journal of Psychiatry November 2000: 1878–1880.

Sheikh, Javaid I.,M.D., M.B.A., Gregory A. Leskin, Ph.D. and Donald F. Klein, M.D. “Gender Differences in Panic Disorder: Findings From the National Comor-bidity Survey.” American Journal of Psychiatry January 2002: 55–58.

Warsaw, Meredith G., M.S.S. and others. “Suicidal Behavior in Patients With Current or Past Panic Disorder: Five Years of Prospective Data From the Harvard /Brown Anxiety Research Program.” American Journal of Psychiatry November 2000, 1876–1878.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington D.C. 20005. http://www.psych.org/public_info/panic.html

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852.(301) 231-9350. www.adaa.org

National Center for Complementary and Alternative Medicine. P.O. Box 7923, Gaithersburg, MD 20898. (888) 644-6226. http://nccam.nih.gov

National Institute of Mental Health. 6001 Executive Boul-vevard, Rm.8184, MSC9663,Bethesda,MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov/anxiety/panicmenu.cfm

Open Mind, http://open-mind.org/SP

Susan Hobbs, M.D.

Panic disorder

Definition

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.

Description

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

Causes

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.

Symptoms

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
• sweating
• shaking
• 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.

Demographics

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.

Diagnosis

Differential diagnosis

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.

Dual diagnosis

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).

Treatments

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.

Medical treatments

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:

• benzodiazepines
• 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.

Alternative therapies

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.

Prognosis

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.

Prevention

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.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington DC: American Psychiatric Association, 2000.

Cox, Brian J. and Stephen Taylor. "Anxiety Disorders Panic and Phobias." In Oxford Textbook of Psychopathology, edited by Theodore Millon, Paul H. Blaney, and Roger D. Davis. New York: Oxford University Press, 1999.

Sadock, Benjamin J., M.D., and Virginia A. Sadock,M.D., eds. "Anxiety Disorders." In Comprehensive Textbook of Psychiatry. Volume I, 7th edition. Written by Jack Gorman M.D., Laszlo A. Papp, M.D., Glen O. Gabbard,M.D., and others. Philadelphia, PA: Lippincott Williams and Wilkins, 2000.

Swede, Shirley and Seymour Sheppard Jaffe, M.D. The Panic Attack Recovery Book: Revised and Updated. 2nd edition, revised. New York: Penguin Putnam Inc, 2000.

PERIODICALS

Frank, Ellen, Ph.D. and others. "Influence of Panic Agoraphobic Spectrum Symptoms on Treatment Response in Patients With Recurrent Major Depression." American Journal of Psychiatry July 2000: 1101–1107.

Kessler, Ronald C., Ph.D. and others. "The Use of Complementary and Alternatives Therapies to Treat Anxiety and Depression in the United States." American Journal of Psychiatry February 2001: 289–294.

Milrod, Barbara, M.D., and others. "Open Trial of Psychodynamic Psychotherapy for Panic Disorder: A Pilot Study." The American Journal of Psychiatry November 2000: 1878–1880.

Sheikh, Javaid I.,M.D., M.B.A., Gregory A. Leskin, Ph.D. and Donald F. Klein, M.D. "Gender Differences in Panic Disorder: Findings From the National Comorbidity Survey." American Journal of Psychiatry January 2002: 55–58.

Warsaw, Meredith G., M.S.S. and others. "Suicidal Behavior in Patients With Current or Past Panic Disorder: Five Years of Prospective Data From the Harvard /Brown Anxiety Research Program." American Journal of Psychiatry November 2000,1876–1878.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW,Washington, D.C. 20005. <http://www.psych.org/public_info/panic.html>.

Anxiety Disorders Association of America. 11900 Parklawn Drive, Suite 100, Rockville, MD 20852. (301) 231-9350. <www.adaa.org>.

National Center for Complementary and Alternative Medicine. P.O. Box 7923, Gaithersburg, MD 20898. (888) 644-6226. <http://nccam.nih.gov>.

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>.

Open Mind, <http://open-mind.org/SP>.

Susan Hobbs, M.D.

Panic Disorder

Definition

A panic attack is a sudden, intense experience of fear coupled with an overwhelming feeling of danger, accompanied by physical symptoms of anxiety, such as a pounding heart, sweating, and rapid breathing. A person with panic disorder may have repeated panic attacks (at least several a month) and feel severe anxiety about having another attack.

Description

Each year, panic disorder affects one out of 63 Americans. While many people experience moments of anxiety, panic attacks are sudden and unprovoked, having little to do with real danger.

Panic disorder is a chronic, debilitating condition that can have a devastating impact on a person's family, work, and social life. Typically, the first attack strikes without warning. A person might be walking down the street, driving a car, or riding an escalator when suddenly panic strikes. Pounding heart, sweating palms, and an overwhelming feeling of impending doom are common features. While the attack may last only seconds or minutes, the experience can be profoundly disturbing. A person who has had one panic attack typically worries that another one may occur at any time.

As the fear of future panic attacks deepens, the person begins to avoid situations in which panic occurred in the past. In severe cases of panic disorder, the victim refuses to leave the house for fear of having a panic attack. This fear of being in exposed places is often called agoraphobia.

People with untreated panic disorder may have problems getting to work or staying on the job. As the person's world narrows, untreated panic disorder can lead to depression, substance abuse, and in rare instances, suicide.

Causes and symptoms

Scientists are not sure what causes panic disorder, but they suspect the tendency to develop the condition can be inherited. Some experts think that people with panic disorder may have a hypersensitive nervous system that unnecessarily responds to nonexistent threats. Research suggests that people with panic disorder may not be able to make proper use of their body's normal stress-reducing chemicals.

People with panic disorder usually have their first panic attack in their 20s. Four or more of the following symptoms during panic attacks would indicate panic disorder if no medical, drug-related, neurologic, or other psychiatric disorder is found:

• pounding, skipping or palpitating heartbeat
• shortness of breath or the sensation of smothering
• dizziness or lightheadedness
• nausea or stomach problems
• chest pains or pressure
• choking sensation or a "lump in the throat"
• chills or hot flashes
• sweating
• fear of dying
• feelings of unreality or being detached
• tingling or numbness
• shaking and trembling
• fear of losing control or going crazy

A panic attack is often accompanied by the urge to escape, together with a feeling of certainty that death is imminent. Others are convinced they are about to have a heart attack, suffocate, lose control, or "go crazy." Once people experience a panic attack, they tend to worry so much about having another attack that they avoid the place or situation associated with the original episode.

Diagnosis

Because its physical symptoms are easily confused with other conditions, panic disorder often goes undiagnosed. A thorough physical examination is needed to rule out a medical condition. Because the physical symptoms are so pronounced and frightening, panic attacks can be mistaken for a heart problem. Some people experiencing a panic attack go to an emergency room and endure batteries of tests until a diagnosis is made.

Once a medical condition is ruled out, a mental health professional is the best person to diagnose panic attack and panic disorder, taking into account not just the actual episodes, but how the patient feels about the attacks, and how they affect everyday life.

Most health insurance policies include some limited amount of mental health coverage, although few completely cover outpatient mental health care.

Treatment

Most patients with panic disorder respond best to a combination of cognitive-behavioral therapy and medication. Cognitive-behavioral therapy usually runs from 12-15 sessions. It teaches patients:

• how to identify and alter thought patterns so as not to misconstrue bodily sensations, events, or situations as catastrophic
• how to prepare for the situations and physical symptoms that trigger a panic attack
• how to identify and change unrealistic self-talk (such as "I'm going to die!") that can worsen a panic attack
• how to calm down and learn breathing exercises to counteract the physical symptoms of panic
• how to gradually confront the frightening situation step by step until it becomes less terrifying
• how to "desensitize" themselves to their own physical sensations, such as rapid heart rate

At the same time, many people find that medications can help reduce or prevent panic attacks by changing the way certain chemicals interact in the brain. People with panic disorder usually notice whether or not the drug is effective within two months, but most people take medication for at least six months to a year.

Several kinds of drugs can reduce or prevent panic attacks, including:

• selective serotonin reuptake inhibitor (SSRI ) antidepressants like paroxetine (Paxil) or fluoxetine (Prozac), are approved specifically for the treatment of panic
• tricyclic antidepressants such as clomipramine (Anafranil)
• benzodiazepines such as alprazolam (Xanax) and clonazepam (Klonopin)

Finally, patients can make certain lifestyle changes to help keep panic at bay, such as eliminating caffeine and alcohol, cocaine, amphetamines, and marijuana.

Alternative treatment

One approach used in several medical centers focuses on teaching patients how to accept their fear instead of dreading it. In this method, the therapist repeatedly stimulates a person's body sensations (such as a pounding heartbeat) that can trigger fear. Eventually, the patient gets used to these sensations and learns not to be afraid of them. Patients who respond report almost complete absence of panic attacks.

A variety of other atlernative therapies may be helpful in treating panic attacks. Neurolinguistic programming and hypnotherapy can be beneificial, since these techniques can help bring an awareness of the root cause of the attacks to the conscious mind. Herbal remedies, including lemon balm (Melissa officinalis ), oat straw (Avena sativa ), passionflower (Passiflora incarnata ), and skullcap (Scutellaria lateriflora ), may help significantly by strengthening the nervous system. Homeopathic medicine, nutritional supplementation (especially with B vitamins, magnesium, and antioxidant vitamins ), creative visualization, guided imagery, and relaxation techniques may help some people experiencing panic attacks. Hydrotherapies, especially hot epsom salt baths or baths with essential oil of lavender (Lavandula officinalis ), can help patients relax.

Prognosis

While there may be occasional periods of improvement, the episodes of panic rarely disappear on their own. Fortunately, panic disorder responds very well to treatment; panic attacks decrease in up to 90% of people after 6-8 weeks of a combination of cognitive-behavioral therapy and medication.

Unfortunately, many people with panic disorder never get the help they need. If untreated, panic disorder can last for years and may become so severe that a normal life is impossible. Many people who struggle with untreated panic disorder and try to hide their symptoms end up losing their friends, family, and jobs.

Prevention

There is no way to prevent the initial onset of panic attacks. Antidepressant drugs or benzodiazepines can prevent future panic attacks, especially when combined with cognitive-behavioral therapy. There is some suggestion that avoiding stimulants (including caffeine, alcohol, or over-the-counter cold medicines) may help prevent attacks as well.

Resources

ORGANIZATIONS

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

Anxiety Disorders Association of America. 11900 Park Lawn Drive, Ste. 100, Rockville, MD 20852. (800) 545-7367. 〈http://www.adaa.org〉.

Freedom From Fear. 308 Seaview Ave., Staten Island, NY 10305. (718) 351-1717.

National Alliance for the Mentally Ill (NAMI). Colonial Place Three, 2107 Wilson Blvd., Ste. 300, Arlington, VA 22201-3042. (800) 950-6264. 〈http://www.nami.org〉.

National Anxiety Foundation. 3135 Custer Dr., Lexington, KY 40517. (606) 272-7166. 〈http://www.lexington-online.com/naf.html〉.

National Institute of Mental Health, Panic Campaign. Rm 15C-05, 5600 Fishers Lane, Rockville, MD 20857. (800) 647-2642. 〈http://www.nimh.nih.gov〉.

National Mental Health Association. 1021 Prince St., Alexandria, VA 22314. (703) 684-7722. 〈http://www.nmha.org〉.

OTHER

The Anxiety and Panic Internet Resource. 〈http://www.algy.com/anxiety〉.

Anxiety Network Page. 〈http://www.anxietynetwork.com〉.

National Institute of Mental Health Page. 〈http://www.nimh.nih.gov〉.

"Panic Disorder." Internet Mental Health Page. 〈http://www.mentalhealth.com〉.

KEY TERMS

Agoraphobia— Fear of open spaces.

Benzodiazepines— A class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety or panic.

Cognitive-behavioral therapy— A type of psychotherapy used to treat anxiety disorders (including panic disorder) that emphasizes behavioral change together with alteration of negative thought patterns.

Selective serotonin reuptake inhibitors (SSRIs)— A class of antidepressants used to treat panic that affects mood by boosting the levels of the brain chemical serotonin.

Tricyclic antidepressants— A class of antidepressants named for their three-ring structure that increase the levels of serotonin and other brain chemicals. They are used to treat depression and anxiety disorders, but have more side effects than the newer class of antidepressants called SSRIs.

Panic Disorder

Definition

Panic disorder is an anxiety disorder characterized by recurrent and unexpected panic attacks. A panic attack is an acute response that has intense symptoms, which typically include shortness of breath, rapid heartbeat, sweating, nausea, hyperventilation, and a sense of being smothered. These symptoms not caused by substance intake or certain medical conditions (such as hyperthyroidism, asthma , or other breathing disorders). Panic disorder can be a disabling condition, causing people to quit jobs or withdraw from social activities, avoid going outside their home or avoid exercising. It also commonly leads to frequent and visits to hospital emergency rooms. About 8 percent of all patients who go to emergency departments fearing they are having a heart attack are diagnosed with panic disorder or a related psychiatric condition.

Description

Panic attacks

The most noticeable symptom of panic disorder is a panic attack, which is defined as a period of intense fear with a sudden onset that builds to a peak within a few minutes (usually about 10 minutes). The attack is often accompanied by a general feeling of doom and an urge to leave or escape from the setting in which the attack occurs. There may or may not be a pattern to a person's panic attacks; some individuals may have one or two attacks a week over a period of time, while others may have several attacks close together and then go for months or years before another attack.

It is important to distinguish between panic attacks themselves and panic disorder. Panic disorder is characterized by recurrent panic attacks, but it is possible for a person to have panic attacks without having panic disorder. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), which is commonly used in the United States and Canada to guide doctors' evaluations of patients with emotional problems, defines three different types of panic attacks:

• Unexpected or uncued. These panic attacks come “out of the blue”; that is, the patient does not associate the beginning of the attack with any kind of situational trigger.
• Situationally bound. This type of panic attack almost always occurs when the patient is exposed to or anticipates a particular situational trigger. For example, a person might almost always have a panic attack while driving on a specific stretch of highway where the person once had an accident.
• Situationally predisposed. These are similar to situationally bound panic attacks; the chief difference is that the patient sometimes has a panic attack during the feared situation and sometimes does not. For example, a person may sometimes have a panic attack before boarding an airplane but does not have one on every occasion of boarding.

Recurrence of unexpected or uncued panic attacks is the condition that warrants a diagnosis of panic disorder. Situationally bound or situationally predisposed panic attacks may affect patients diagnosed with panic disorder, but they also occur in patients with such other mental disorders as generalized anxiety disorder (GAD) or posttraumatic stress disorder (PTSD).

DSM-IV specifies 13 symptoms that characterize panic attacks. A person must experience at least four of the 13 to be diagnosed as having a panic attack. The first ten symptoms are physical; the remaining three are cognitive (related to thinking or memory):

• heart palpitations or rapid heartbeat
• sweating
• trembling or shaking
• shortness of breath
• choking sensations
• chest pain
• nausea or pain in the abdomen
• dizziness or lightheadedness
• tingling sensations
• chills or hot flushes
• depersonalization (a feeling that the self is unreal) or derealization (a feeling that the external environment is unreal)
• fear of losing control (“going crazy”)
• fear of dying Panic attacks that have fewer than four symptoms are called limited-symptom attacks.

Panic disorder

DSM-IV defines panic disorder as “the presence of recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the possible implications or consequences of the panic attacks, or a significant behavioral change related to the attacks.” There are two other major criteria of the diagnosis: first, the patient is not having the attacks because of substance use or a medical condition; and second, the panic attacks cannot be accounted for by another mental disorder (e.g., specific phobia, PTSD).

There are two subtypes of panic disorder: panic disorder with agoraphobia and panic disorder without agoraphobia. Agoraphobia is an unrealistic fear of going outside the safety of the home, particularly to use public transportation or visit large public places (shopping malls, sports arenas, or even parks or recreational facilities). It comes from two Greek words that mean “fear of the marketplace.” According to the National Institute of Mental Health (NIMH), about one third of Americans diagnosed with panic disorder have panic disorder with agoraphobia. Panic disorder with agoraphobia develops when the person's fear of recurrent panic attacks takes the form of avoiding places from which a quick exit or escape might be difficult or embarrassing (e.g., airplanes, trains, or buses; crowded stores; attendance at worship services or other group activities,) This form of panic disorder can interfere significantly with a senior's ability to shop for groceries, meet friends outside the home, or take care of other household responsibilities.

Demographics

Panic disorder is less common in seniors than in younger age groups. Although between 1 and 4 percent of the general American population are thought to have panic disorder, most of these are people in late adolescence or the early adult years. According to the NIMH, the median age at onset is 24. A small number of cases begin in childhood, but onset after age 45 is unusual. According to the Merck Manual of Geriatrics, panic attacks in the elderly are uncommon, and when they do occur, they are less severe than in adolescents and younger adults. The most important feature of new-onset panic attacks in seniors is that they are more likely to take the form of chest pain and thus be mistaken for a heart attack. In all age groups, however, women are between two and three times as likely as men to develop panic disorder.

There is conflicting evidence regarding whether panic disorder is more common in some racial or ethnic groups than in others. Some studies suggest that African Americans have a slightly higher rate of panic disorder than either Caucasian or Asian Americans, whereas other researchers think that these findings point to flaws in the screening interviews used to detect panic disorder rather than the actual rates of occurrence.

Causes and symptoms

The causes of panic disorder were not completely understood as of the late 2000s. Possible causes that were being researched include:

• Genetic predisposition. Research indicates that a first-degree relative (child or sibling) of a person with panic disorder is eight times as likely to develop the disorder as a person in the general population.
• Biochemical imbalances in the central nervous system that cause overreactions to stimuli in the person's external environment.
• A tendency to confuse anxious thoughts with physical symptoms Which is sometimes called the cognitive theory of panic attacks.
• A tendency to escalate otherwise insignificant physical sensations into the physical symptoms of a full-blown panic attack. For example, a man whose heartbeat speeds up when he is angry may worry when he notices the change in heart rate, and the resulting anxiety is then experienced as the chest pain of a panic attack. This pattern is sometimes called the behavioral theory of panic attacks.

QUESTIONS TO ASK YOUR DOCTOR

• What treatment would you recommend for panic disorder?
• How many patients have you treated for this condition?
• Is there any way to distinguish between a panic attack and a genuine medical emergency?

Diagnosis

The diagnosis of panic disorder, with or without agoraphobia, is primarily a diagnosis of exclusion, which means there are no laboratory or imaging tests for panic disorder as of 2008 and the doctor must proceed by ruling out other conditions that may be related to the panic attacks. These include examining the patient for such medical conditions as disorders of the thyroid gland; asthma or other breathing disorders; or substance abuse. Men in particular are likely to self-medicate with alcohol in order to cope with panic attacks, and the doctor will want to make sure that the senior is not abusing alcohol or prescription drugs.

Doctors in hospital emergency departments commonly ask two simple questions to screen for panic disorder in patients complaining of chest pain. First, has the patient had a spell or attack in the past six months when all of a sudden he felt anxious, frightened, or very uneasy? Second, in the past six months, has he ever had a spell in which he felt his heart race, could not catch his breath, or felt faint? An affirmative answer to either question is considered a positive screen for panic disorder.

KEY TERMS

Agoraphobia —An irrational fear of venturing outside the home or into open spaces, so pervasive that a large number of activities outside the home are limited or avoided altogether. Agoraphobia is often associated with panic attacks.

Cognitive —Pertaining to thinking, learning, or memory.

Cue —A stimulus, either internal body sensations or an external event or object that causes a learned response in an individual. Cues are sometimes called triggers.

Inositol —A form of vitamin B8 that is thought to be beneficial for some patients with panic disorder.

Panic attack —An episode of intense fear, abrupt in onset, lasting for several minutes, and accompanied by physical symptoms and/or temporary cognitive disturbances. Panic attacks may be unexpected, or they may be cued.

Phobia —An unfounded or morbid dread of a specific object or situation that arouses feelings of panic.

Treatment

Treatment of panic disorder in seniors usually consists of a combination of psychotherapy and medications.

Nutrition/Dietetic concerns

A senior who is having panic attacks or has been diagnosed with panic disorder should cut down on coffee, tea, cola, and other beverages containing caffeine . If alcohol abuse is a factor, it should be treated first in order for psychotherapy to be effective. In some cases, the senior may benefit from having prescription drugs currently taken adjusted or changed.

Inositol, a form of vitamin B8, has been recommended by some practitioners of alternative medicine for treatment of panic disorder and may be helpful to some seniors as a dietary supplement. It does not appear to have problematic side effects and can be used alongside other medications for anxiety.

Therapy

The two forms of psychotherapy that have been shown to be most helpful in treating seniors with panic disorder are exposure therapy (for those with agoraphobia) and cognitive behavioral therapy. In exposure therapy, individuals are introduced to the feared situation in gradual stages until they feel comfortable with it. For example, individuals who are afraid to go shopping for groceries might start by just opening the front door of their homes; then walking down the front path to the sidewalk; then walking a few blocks; then going to the store itself and purchasing only one item; and so on. Some persons recovering from agoraphobia refer to exposure therapy as the “5 Rs,” which stand for react, retreat, relax, recover, and repeat.

In cognitive behavioral therapy (CBT), individuals are given some education about anxiety and are taught to recognize and control their reactions to panic attacks. They also learn to modify their behavior so that it is more adaptive. They may also be taught biofeedback or other relaxation techniques as part of either exposure therapy or CBT.

The doctor involved may prescribe medications in addition to psychotherapy, particularly if the panic attacks keep affected individuals virtually housebound. The medications prescribed for older adults are usually antidepressants, either one of the selective serotonin reuptake inhibitors (SSRIs) or one of the tricyclic antidepressants (TCAs). The first group includes such drugs as fluoxetine (Prozac) and paroxetine (Paxil); the second group includes clomipramine (Anafranil) and imipramine (Tofranil). Seniors who do not benefit from an antidepressant medication may be given a benzodiazepine tranquilizer, most commonly alprazolam (Xanax).

Prognosis

Panic disorder is highly treatable even in the elderly. Psychotherapy for panic disorder is reported to have a success rate of about 75 percent, and even seniors who do not benefit from psychotherapy can usually manage their anxiety with medications.

Prevention

There was no known way to prevent panic disorder as of the late 2000s because its causes were not yet fully understood.

Caregiver concerns

Caregivers of seniors should be concerned about the following potential problems associated with panic disorder:

• The additional housekeeping burden on other family members if affected seniors have panic disorder with agoraphobia.
• Unnecessary trips to hospital emergency rooms, particularly if the affected seniors experience chest pain.
• The possibility of alcohol or drug abuse, particularly if the seniors are male.
• An increased risk of suicide if the disorder is not treated.

Resources

BOOKS

Beers, Mark H., and Thomas V. Jones. Merck Manual of Geriatrics, 3rd ed. Chapter 34, “Anxiety Disorders.” Whitehouse Station, NJ: Merck, 2005.

PERIODICALS

Cayley, William A. “Diagnosing the Cause of Chest Pain.” American Family Physician 72 (November 15, 2005):2012–2021.

Corna, L. M., J. Cairney, N. Herrmann, et al. “Panic Disorder in Later Life: Results from a National Survey of Canadians.” International Psychogeriatrics 19 (December 2007): 1084–1096.

Ford, B. C., K. M. Bullard, R. J. Taylor, et al. “Lifetime and 12-month Prevalence of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Disorders among Older African Americans: Findings from the National Survey of American Life.” American Journal of Geriatric Psychiatry 15 (August 2007):652–659.

Ham, Peter, David B. Waters, and M. Norman Oliver. “Treatment of Panic Disorder.” American Family Physician 71 (February 15, 2005):733–740.

Johnson, M. R., A. G. Hartzema, T. L. Mills, et al. “Ethnic Differences in the Reliability and Validity of a Panic Disorder Screen.” Ethnicity and Health 12 (June 2007):283–296.

Saeed, Sy A., Richard M. Bloch, and Diana J. Antonacci. “Herbal and Dietary Supplements for Treatment of Anxiety Disorders.” American Family Physician 76 (August 15, 2007): 549–556.

Smoller, J. W., M. H. Pollack, S. Wassertheil-Smoller, et al. “Panic Attacks and Risk of Incident Cardiovascular Events among Postmenopausal Women in the Women's Health Initiative Observational Study.” Archives of General Psychiatry 64 (October 2007):153–1160.

OTHER

“Anxiety Disorders.” National Institute of Mental Health (NIMH). NIH Publication No. 06-3879. Bethesda, MD: NIMH, 2006.

Yates, William R. “Anxiety Disorders.” eMedicine. August 23, 2007 [cited March 31, 2008]. http://www.emedicine.com/med/topic152.htm">.

ORGANIZATIONS

American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA, 22209, (703) 907-7300, apa@psych.org, http://www.psych.org/.

Anxiety Disorders Association of America (ADAA)., 8730 Georgia Ave., Suite 600, Silver Spring, MD, 20910, (240) 485-1001, (240) 485-1035, http://www.adaa.org/.

National Alliance on Mental Illness (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201, (703) 524-7600, (800) 950-6264, (703) 524 9094, http://www.nami.org/Hometemplate.cfm.

National Institute of Mental Health (NIMH), 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD, 20892, (301) 443-4513, (866) 615-6464, (301) 443-4279, nimhinfo@nih.gov, http://www.nimh.nih.gov/index.shtml.

Rebecca J. Frey Ph.D.

Panic disorder

Definition

A panic disorder is a psychological state characterized by acute (rapid onset) feelings, which engulf a person with a deep sense of destruction, death and imminent doom. The main feature of panic disorder (PD) is a history of previous panic attacks (PA). The PA symptoms are pronounced and the affected person will gasp for air, have increased breathing (hyperventilate), feel dizzy (light headed), and develop a loss of sensation (parasthesia). Most patients will run outside and symptoms like increased breathing will slow and the PA symptoms will subside. Most PA last three to ten minutes. It is rare for PA to extend in duration over 30 minutes.

Description

The essential characteristics of panic disorder, consist of specific and common criteria. The affected person usually has recurrent and unexpected panic attacks (the active presentation of panic disorder). The PA is characterized by a discrete, rapid onset feeling of intense fear or discomfort. Affected persons have several somatic (referring to physical signs) or cognitive (thinking) symptoms. Affected persons usually react in a manner that indicates impending doom. They commonly exhibit signs of a sweating, racing heart beat, chest pain, shortness of breath, and the perception of feeling smothered. The panic attack (PA) is usually followed by one month (or more) of one or more of the following thought processes:

• Persistent concern or preoccupation about having future attacks
• Worry about the possible consequences, complications, or behavioral changes associated with attacks (e.g. losing control, going crazy, or having a serious medical condition like a heart attack).

Genetic profile

Panic disorder definitely runs in families and twin studies suggest that about 20% of patients who have the criteria for diagnosis have first-degree relatives with the disorder. In families with no history of affected first-degree relatives the prevalence decreases to 4%. The ratio between monozygotic twins (identical) to dizygotic (non-identical) twins is 5:1 for PD. Recent evidence suggests that there is a genetic mutation in the SLC6A4 gene . This gene is related to a brain chemical called serotonin, a chemical in the brain, which is known to effect mood. If the transport of serotonin is imbalanced then certain parts of the brain may not receive the correct stimulus causing alterations in mood. Some studies have demonstrated that there is no positive family history in about 50% of patients diagnosed with PD. Other possible causes of PD include social learning and autonomic responsivity (the attack will affect the body and hypersensitizes nerve cells in the brain).

Demographics

PD usually begins during the affected persons late teens or in the twenties, and is uncommon after age 35 and unusual after age 45 years. Global studies suggest that the lifetime prevalence of PD is between 1.5% and 3.5%. In the United States approximately 3–5% of the population is affected with the disorder. In any given year approximately 1.7% of the U.S. population has PD. This represents about 2.4 million Americans. PD is twice as common in females compared to males (female:male ratio is 2:1).

Agoraphobia (anxiety state about being in situations or places that might make escape embarrassing or difficult) is seen in approximately one-third to one-half of persons who meet the criteria for PD diagnosis. Other reports indicate that about 95% of persons affected with agoraphobia also have a previous history or current diagnosis of PD. In some cultures PA is believed to be associated with magic or witchcraft. Additional causes of PA may include intentional suppression of one's freedoms or public life.

Signs and symptoms

Criteria for panic attack:

• Cardiac palpitations (pounding, racing or accelerated heart rate).
• Sweating.
• Shaking (trembling).
• Breathing difficulties, including shortness of breath or perceptions of being smothered.
• Feeling of choking.
• Chest discomfort or pain.
• Feeling light-headed (faint, dizzy or unsteady).
• Stomach discomfort or nausea.
• Affected individuals may lose contact with reality during the attack.
• A feeling of being detached and out of contact with oneself.
• Fear of losing control of oneself (going "crazy").
• Fear of dying.
• Tingling or numbness sensations.

Criteria for panic disorder:

• Recurrent and unexpected PA.
• Worry about the consequences, implications, or behavioral changes associated with PA (perceptions of going "crazy," losing control of actions, or suffering from a life threatening condition, such as a heart attack).
• PA is not caused by or associated with a medical condition.
• PA is not associated with another mental disorder, such as phobia (an exaggerated fear to something like spiders or heights). Exposure to a specific phobia situation or object can promote a PA.

Criteria for agoraphobia:

• The essential feature of agoraphobia is anxiety about being in situations or places that make escape embarrassing or difficult. These fears usually involve characteristic clusters of situations that include being on a bridge, being in a crowd, standing in line in a department store, or traveling in a train, bus, or automobile. Elevators are another common cause promoting the occurrence of PA. These situations, which lead to the PA, are often difficult or embarrassing to abruptly flee from.
• Avoidance of the affected person's fear, which usually limits travel away from home, causing impaired functioning.

Criteria for PD without agoraphobia:

Recurrent unexpected PA; at least one attack followed by one month or more of one or more of the following symptoms:

• Persistent concern about having future attacks
• Worry about consequences associated with attacks
• A change in behavioral patterns related to the attacks (e.g. the affected person avoids travel).
• Absence of agoraphobia
• PA are not due to a medical condition
• PA not associated with another mental disorder (e.g. phobias).

Criteria for panic disorder with agoraphobia:

• Criteria 1, 2, and 5 for PD without agoraphobia must be present.
• The presence of agoraphobia.

Diagnosis

There are no specific laboratory findings associated with diagnosing PD. However, evidence suggests that some affected persons may have low levels of carbon dioxide and an important ion in the human body called bicarbonate (helps in regulating blood from becoming to acidic or alkaline). These chemical changes may hypersensitize (making cells excessively sensitive) nerve cells, which can increase the activity of other structures throughout the body, such as sweat glands (sweating) and the heart (racing, accelerated or pounding rate). Additionally, lactic acid (a chemical made in the body from sugar) plays a role in nerve cell hypersensivity. The diagnosis of PD can be made accurately if the specific symptoms and criteria are established.

Neuroimaging studies indicate that the arteries (vessels that deliver oxygen rich blood to cells and tissues) are constricted (smaller diameter) as a result of increased breathing rates during a PA.

The consulting clinician must exclude other possible causes of panic attacks such as intoxication with stimulant drugs (cocaine, caffeine, amphetamines [speed]). Withdrawal from alcohol and barbiturates can also induce panic-like behaviors. Additionally, the consulting therapist should obtain a comprehensive medical history and examination to determine if the PA is caused by a medical condition frequently observed in hormonal diseases (overactive thyroid), tumors that secrete chemicals causing a person to have pronounced "hyper" changes (racing heartbeat, sweating, shaking). Other causes include a possible cardiac (heart) disease such as an irregularly beating heart.

Treatment and management

Moderate to severe PD is characterized by frequent PA ranging from five to seven times a week or with significant disability associated with anxiety between episodes. In addition to cognitive-behavioral therapy an affected person will usually require medications. There are three classes of medications commonly prescribed for PD patients.

Tricyclic antidepressants

Tricyclic antidepressants are a class of medications used to treat depression and other closely related mental disorders. Individuals affected with PD are usually given imipramine, which has been shown in some studies to be effective in approximately 70% of cases. Medications in this category usually have a prolonged lag time until a positive response is observed. This is primarily due to adverse side effects, which prevent rapid increases of dosage and also because they act on specific chemical imbalances in the brain, which take time to stabilize.

The first choice of medication treatment for PD is tricyclics (imipramine, desipramine and nortriptyline). These medications require careful dosing and monitoring. The actual blood level (therapeutic level necessary to make improvements) may vary in special populations who have the disorder. Elderly patients may require a smaller dose, due to decrease in metabolism (in this context metabolism refers to the breakdown of large chemicals to smaller ones for usage) and kidney function, which are part of aging. Some patients may develop gastrointestinal (stomach) side effects, which may interfere with absorption from the gut, thereby decreasing beneficial blood levels. Furthermore, patients who receive tricyclics may develop dry mouth and low blood pressure. The heart may be adversely affected (altered rate and rhythm) especially in patients with preexisting diseases, causing direct damage or strain in the heart. Affected persons receiving tricyclics also commonly experience changes in sexual functioning, including loss of desire and ejaculation. Adverse (negative) side effects usually decrease patient compliance (the person stops taking medications to avoid side effects). Recently, a new group of tricyclics was made available. These tricyclics (fluoxetine, sertraline, paroxetine and fluvoxamine) act on specific areas in the brain to correct potential chemical imbalances.

Monoamine oxidase inhibitors (MAOIs)

A second line category of medications used to treat PD are the monoamine oxidase (a chemical that assists in storing certain chemicals in nerve cells) inhibitors (MAOI). MAOI will stop the action of MAO, thereby decreasing the amount of certain chemicals in the brain that may influence PAs. This group of medications is effective in approximately 75–80% of cases, especially for refractory (not active) depression. Affected individuals using MAOI must avoid specific foods to prevent a hypertensive crisis (when the blood pressure rapidly increases). These foods include cheeses (except cream cheese, cottage cheese, and fresh yogurt); liver of all types; meat and yeast extracts; fermented or aged meats (such as salami and bologna); broad and Chinese bean pods; all types of alcohol-containing products; soy sauce; shrimp and shrimp paste; and sauerkraut. Although MAOI are effective medications for treatment of PD, they are underutilized due to strict dietary limitations.

Benzodiazepines

Benzodiazepines are another class of medications used to treat PD. They include medications such as diazepam (Valium), lorazepam, and clonazepam. They have been reported to be effective in 70–90% of patients with PD. However, the effective dose is approximately two to three times higher for PD than milder forms of simple anxiety (these medications are usually indicated for mild anxiety). This increased dosing in patients with PD is undesirable since there is risk of physical dependence and withdrawal (commonly exhibited when the medication is rapidly tapered down or stopped). However, they are indicated when PD affected patients respond poorly to tricyclics or have a fear of taking MAOIs due to dietary restrictions and problems associated with eating the wrong foods accidentally.

Long term management

Reassuring the PD patient that anticipated panic attacks are unlikely while taking medication is essential for long-term maintenance. Cognitive-behavioral therapy is also important for long-term treatment. Weaning off medications must be done slowly since patients develop a sense of security that they will not have an attack while actively dosing.

Prognosis

The course of PD and agoraphobia varies considerably over time. Some cases may experience spontaneous remissions (the disorder is present but it is not active). The course can be so variable that an affected person may go on for years without a PA, then have several attacks, and then enter a second phase of remission, which may last for years. In some cases a decrease in PA may be closely related to a decrease and avoidance of anxiety-associated situations, which promote agoraphobia. Agoraphobia itself may become chronic (long term or permanent) with or without PA. In general, approximately 50–60% will recover substantially five to 20 years after the initial attack. Approximately 20% will still have long term impairment, which will stay the same or slightly worsen. Generally, the earlier treatment is sought, the better the outcome. The course in children and adolescents is chronic (long term), usually lasting about three years. Generally, PD shows the highest risk of developing new psychological disorders during follow up visits. If PA is treated early, anticipatory anxiety and phobia may be more manageable and responsive to treatment.

Resources

BOOKS

American Psychiatric Association Staff. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Maxmen, J. S., and M. G. Ward. Essential Psychopathology and Its Treatment. New York: W. W. Norton & Company, 1995.

Muench, K. H. Genetic Medicine. New York: Elsevier Science Publishing Co., Inc., 1988.

PERIODICALS

Bakker, A., R. van Dyck, P. Spinhoven, and A. J. L. M van Ballrom. "Paroxetine, clomipramine, and cognitive therapy in the treatment of panic disorder." Journal of Clinical Psychiatry 60 (1999): 831–38.

Coplan, J. D., and R. B. Lydiard. "Brain circuits in panic disorder." Biological Psychiatry 44 (1998): 1264–76.

Masi, G., L. Favilla, and R. Romano. "Panic disorder in children and adolescents." Panminerva medica 41 (1999): 153–56.

ORGANIZATIONS

Anxiety Disorders Association of America. 11900 Parklawn Dr., Suite 100, Rockville, MD 20852. (301) 231-9350. Fax: (301) 231-7392. anxdis@adaa.org.

Laith Farid Gulli, MD

Bilal Nasser, MS