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Panic Disorder Symptoms and Therapy
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Panic Disorder Definition, Symptoms and Treatment. An educational website of:2121 NW 40th Terr. Suite B, Gainesville, FL 32605Gainesville - Ocala Florida
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Definition: Panic Disorder is a DSM-IV diagnosis which requires a pattern of having recurrent attacks and development of either a persistent fear of having future panic attacks, persistent worry about the implications of the attack or consequences (such as worrying about losing control, having a heart attack, or having irrational fears of some undiagnosed disease), or persistent changes in behavior (such as avoidance, rituals, or maladaptive tension-reduction behavior) related to the attacks. The changes or persistent fears must occur for a month or more. The disorder must cause some impairment in health, social, recreational and/or occupational functioning. Panic Disorder is classified as occurring with or without agoraphobia.
Panic Disorder is not diagnosed when the symptoms can be better accounted for by another psychiatric disorder. Careful psychological assessment in late teens or early adults for the possibility of schizophrenia, psychotic disorder or bipolar disorder is important since the age of onset is similar.
In some cases the number of symptoms, course, or frequency of attacks may not meet strict diagnostic criteria for panic disorder. In these cases a diagnosis of Anxiety Disorder, NOS may be made, or sometimes these are subsumed under or better accounted for by another anxiety disorder such as Generalized Anxiety Disorder, Social Phobia, or possibly Post-Traumatic Stress Disorder (PTSD).
Due to the physiological symptoms which are associated with Panic Attacks and Panic Disorder, many individuals may see several physicians before obtaining a formal diagnosis of Panic Disorder.
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FAQ: What is a Panic Attack?
Many anxiety attack symptoms are typical of increased physiological arousal associated with the brain’s “Fight or Fight” response and some symptoms can occur in other Anxiety Disorders. In a Panic attack multiple symptoms occur at once, and individual may fear they are having a heart attack or going to die. Many may present to the emergency room, where usually a cardiac workup and bloodwork will be performed. Sometimes Mitral Valve Prolapse or hyperthyroidism will provoke or simulate a panic attack. In some cases neurological conditions may also be a cause.
Panic attacks often come on suddenly, peak rapidly, and then improve. Panic attacks can occur at night, but are more common during the day. An individual may cycle through a number of these in an episode. Some people may develop full blown attacks by becoming anxious at early signs of anxiety or a pending attack. Such attacks can produce a sense of not being in control of one’s emotions or thoughts and can produce fears of future attacks.
Anxiety attacks are far more common than Panic Disorder. Some people may have a few isolated anxiety attacks and have little other interference in functioning or other mental health problems. Others may have repeated attacks and go on to develop Panic Disorder. Some people may come to feat stimuli they associate with the attacks, and those who develop panic disorder with agoraphobia may become afraid of leaving familiar surroundings of home.
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Panic Attack Symptoms:
• Increased Heart Rate
• Shortness of Breath
• Sense of Intense Fear, Terror or Panic
• Dizziness
• Lightheadedness
• GI Complaints such as nausea
• Trembling or shaking
• Increased Perspiration, hot flashes, or chills
• Clammy Hands
• Flushing
• Chest Pain
• Tingling in hands or feet
• Feeling of Unreality
• Intense Feeling of Needing to Escape
• Fear of Dying or Losing Control
• Feeling or Fearing one is Being Smothered, Choking or Having a Heart Attack
FAQ: What Treatments are Available?
Medication and psychological therapies which incorporate cognitive and behavioral components are the most common treatment approaches, alone or in combination. Many people treated with medication can come to control their attacks through psychological techniques with some studies estimating 70% or more being able to reduce or discontinue medication through such learned techniques. A smaller percentage may continue to require psychoactive medication for some time.
Much of the therapy for Panic Attacks share components to approaches for Phobias, Social Anxiety Disorder, and even management for chronic pain. Psychologists help provide psychoeducation about the physiology of anxiety, common triggers, and features and course of the disorder. The role of sleep, exercise, nicotine, caffeine and other habits should be discussed. Reassurance is provided for fears that individuals may experience. Negative beliefs or self-defeating thoughts are often addressed and replaced with a more appropriate perspective in a cognitive-restructuring approach.
Individual cognitive-behavioral therapy by a psychologist will often involve exploring an individual’s personal triggers for the attacks. Some individuals who have difficulty identifying triggers, or feeling attacks “come out of the blue” may be asked to complete behavioral diaries. Triggers may be thoughts, bodily reactions or sensations, a situation or person, or even more subtle phenomenon. Sometimes learning and identifying the trigger provides a better sense of control and relief, and at other times, the psychologist may teach and utilize relaxation techniques such as deep breathing or muscle relaxation and bring these skills to bear in avoiding the anxiety attack or reaction.
Use of relaxation techniques have a long and successful history in the treatment of fears or phobias. This often involves programmatic learning of how to apply learned relaxation responses to objects, thoughts or images that are associated with increasing fear response. Since physiological responses such as increased heart rate, tightening of the vocal cords, flushing, perspiration, etc. can become triggers of fear of having a panic attack, precipitating the attack itself, psychologists may teach individuals to use relaxation techniques to these physiological triggers or physical sensations. This has been referred to as 'interoceptive exposure.'
This is similar to the systematic desensitization used to cure phobias, but what it focuses on is exposure to the actual physical sensations that someone experiences during a panic attack. People with panic disorder are more afraid of the actual attack than they are of specific objects or events; for instance, their 'fear of flying' is not that the planes will crash but that they will have a panic attack in a place, like a plane, where they can't get to help. Others won't drink coffee or go to an overheated room because they're afraid that these might trigger the physical symptoms of a panic attack.
Group therapy or support groups can also be helpful. The National Institute of Mental Health (NIMH) notes that while internet support groups may sometimes be useful, “any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common”. While NIMH notes that talking with a trusted friend or member of the clergy can also provide support, due to the seriousness of serious complications or consequences, such support is not a substitute for care from a mental health professional.
Medications used to treat other anxiety disorders are also commonly used to treat panic disorder. These include antidepressants, anti-anxiety medication, and a class of heart medication known as beta-blockers. Often prompt treatment with medication as a panic disorder is first developing can prevent some of the subsequent sensitization and fear of developing further attacks. As noted previously, many people can be treated without medication, and many people on medication can use psychological techniques to eventually be able to reduce or continue medication. Of course, this should all be done under the direction of a physician and licensed psychologist. Many individuals can complete cognitive behavioral treatment for panic disorder in 10-20 weekly sessions, but others may need longer term treatment for complicating depression or other co-existing disorders.
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PANIC DISORDER
FREQUENTLY ASKED QUESTIONS
FAQ: When Does Panic Disorder Usually Develop?
Panic Disorder is a serious condition that has an estimated prevalence rate of 1-2% in the population. As with Social Anxiety Disorder (Social Phobia), the most common onset is during the teens or early adulthood.
Usually, it is diagnosed by age 25, although some studies find a high rate of first onset up to the age of 30. Most studies find females are about twice as likely to get the disorder as men.
There are some studies demonstrating that children can experience panic disorder with many of the same features and co-existing conditions as adults. However, DSM-IV does not officially recognize Panic Disorder as a condition typically diagnosed in childhood. Consulting with a child psychologist would certainly be advised.
FAQ: Is Panic Disorder Biological, Genetic, or Learned?
In all probability all of the above factors play a part. Some individuals with no family history of psychiatric illness or panic disorder can develop the disorder, but half of individuals developing panic disorders had some form of psychiatric difficulties as children or adolescents. Individuals with family history of panic disorder or other anxiety disorders are at greater risk. Twin studies indicate a high concordance rate, supporting a genetic component.
Recent losses such as deaths of a spouse, child, family member, or close friend or psychological losses may precipitate anxiety attacks or panic disorder. Life changes and major life events such as starting a new school, starting college, starting a job, getting married, having a child, getting a promotion, being laid off, buying a home, and moving are amongst the stressors that may precipitate and individual’s first or subsequent episodes of panic disorder.
While most of the above involve discreet stressors, chronic stress is also a risk factor for panic disorder and other anxiety disorders. Childhood physical or sexual abuse and other traumas can also precipitate panic attacks or other anxiety disorders such as Post-traumatic Stress Disorder (PTSD).
FAQ. Can Alcohol, Coffee, Cigarettes, Drugs or Medication Cause Anxiety Attacks?
A variety of legal and illegal drugs, medications, or withdrawal from substances can trigger or precipitate an anxiety attack.
Anxiety attacks or panic disorder can occur in reaction to withdrawal from addictive medications, be precipitated by stimulants such as coffee, nicotine, or illicit medications such as cocaine. Anxiety attacks also can occur with marijuana. Sometimes, prescribed stimulant medication often used to treat weight loss or Attention-Deficit Hyperactivity Disorder may precipitate increased anxiety or anxiety attacs. Activating antidepressant medications may also precipitate an anxiety attack or other psychiatric reactions. This highlights risks of substance abuse as well as the importance of thorough psychiatric or psychological assessment prior to prescription of such medications and close follow up immediately following prescriptions of stimulants or antidepressant medication. When solely due to a physical problem such as hyperthyroidism or solely due to being precipitated by a drug or medication (or withdrawal from alcohol or a drug), panic disorder would not normally be diagnosed.
In summary, like many psychiatric disorders, that there are environmental and biological factors which play a role in the development of panic attacks or panic disorder.
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FAQ: What conditions can co-exist with Panic Disorder?
Other anxiety disorders such as social phobia, other phobias, depression, bipolar disorder, alcoholism and substance abuse or dependence have increased rates of co-occuring with Panic Disorder. Suicidal ideation and increased suicidal risk can be present with Panic Disorder.
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FAQ: Can Panic Disorder be successful treated or managed?
Most cases of Panic disorder respond well treatment with a variety or combination of therapies. If other anxiety problems, avoidance, or social anxiety persist after cessation of panic attacks, further psychotherapy is often helpful. See elsewhere on this page for treatment strategies.
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FAQ: Are There Serious Risks Associated with Panic Disorder ?
Left untreated, Panic Disorder can have serious consequences and be quite disabling.
Panic Disorder can come to be associated with phobias or multiple phobias, leading some individuals to be afraid to leave their residence or avoid places which make daily independent living quite difficult. Recreational activities, social activities and travel can become restricted.
Individuals with panic disorder may develop alcohol abuse or dependence, illicit drug abuse or dependence, and may even begin to abuse or become dependent on prescription medications (some medications used to treat anxiety can be very addictive). This can lead to serious occupational, social, legal and health consequences.
Individuals with Panic Disorder may tend to undergo multiple emergency department admission, and may undergo multiple medical tests or procedures, incurring costs and risks associated with medical interventions (iatrogenic disease). Necessary medical workup may vary in individuals and may need to rule out cardiac disease, substance abuse, respiratory, metabolic or neurological disease.
Panic Disorder, left untreated can cause job loss, underemployment, or disability.
There is a higher than average risk of suicide associated with panic disorder. In a large study of approximately 18,000 individuals, Weissman and colleagues (1989) found that that individuals with panic disorder are slightly more than 2.5 times more likely than individuals with other psychiatric conditions to attempt suicide and a nearly 18% greater rate of attempting suicide than individuals with no psychiatric diagnosis. In the study, approximately 1 in 5 individuals with Panic Disorder had made at least one suicide attempt.
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References: Links and Resources:
American Psychiatric Association, Diagnostic and Statistical Manual DSM-IV
What is Social Anxiety Disorder or Social Phobia?
CPANCF Articles on Stress and Coping
Common Childhood Fears
MM Weissman, GL Klerman, JS Markowitz, and R Ouellette. Suicidal ideation and suicide attempts in panic disorder and attacks. (1989) New England Journal of Medicine 321(18) 1209-1214
National Institute of Mental Health Information on Panic Disorder
Panic Disorder in Children and Adolescents (American Academy of Child and Adolescent Psychiatry) Also available in Spanish
Anxiety Disorders Association of America
National Institute of Mental Health: When Fear Overwhelms: Panic Disorder. Easy to Read (.pdf).
Spanish version: Siente ataques súbitos de terror sin motivo? (.pdf )
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Medication Often Used to Treat Panic Disorder and other Anxiety Disorders:
A variety of antidepressants and other medications have been found to be helpful for some individuals with social anxiety disorder.
MAO – Inhibitors require dietary restrictions and had been the main antidepressant used for Social Anxiety Disorder until antidepressants with far fewer side effects came to be prominently favored.
Selective-Serotonin Reuptake Inhibitor antidepressant medications (SSRI’s) have been used with some success in treating social anxiety disorder and have the advantage of not being addictive. While psychiatrists or physicians may sometimes use a variety of SSRI’s for treatment of social phobia, Paxil, Effexor, and Zoloft have been FDA approved for such use.
Serotonin and Norepinepherine Reuptake Inhibitors (SNRIs) include duloxetine (Cymbalta) and venlafaxine (Effexor, Effexor XR). Neuroscientists believe that norepinepherine as well as serotonin play a role in anxiety disorder.
Beta-Blockers - Beta-blockers are most commonly used for heart conditions, but have been used to reduce some of the outward physiological manifestations associated with anxiety such as racing heart, sweating or tremulousness, but may not offer as much relief of the individual’s experience of being anxious.
Anti-Seizure Medications: Gabapentin, an anti-epileptic drug has also been studied for use with Social Anxiety Disorder, though, as with the benzodiazepines, there are some concerns about neuropsychological or cognitive interference.
Anxiolytic Medication: Anti-anxiety medication such as benzodiazepine medications and Buspar (the latter is non-addictive) are sometimes used to treat anxiety disorders including anxiety attacks and panic disorder. However, benzodiazepines tend to have cognitive side effects and have abuse and addiction potential.
Cautions:
Children or adolescents and anyone who may be predisposed to bipolar disorder should be followed closely when placed on antidepressant medication. FDA recommendations suggest this should be at least weekly for the first months. Often children and adolescents will respond best to psychotherapy provided by a child psychotherapist or a therapist who has experience working with adolescents. Some antidepressants can cause weight gain, which can be an issue for people who are anxious or concerned about their health, have concerns about body image, and appearance.
As noted above, anxiolytic medication does have abuse and addiction potential. Anxiolytic and anti-seizure medication can interfere with attention, memory or other cognitive skills.
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