Panic disorder

Panic disorder is an anxiety disorder characterized by recurring panic attacks, causing a series of intense episodes of extreme anxiety during panic attacks. It may also include significant behavioral changes, and ongoing worries about having other attacks. The latter are called anticipatory attacks (DSM-IVR). According to the American Academy of Child & Adolescent Psychiatry, panic disorder usually begins during adolescence and can be hereditary. Over 3 million Americans experience panic disorder during their lifetime.

Panic disorder is not the same as agoraphobia (fear of public places), although many afflicted with panic disorder also suffer from agoraphobia. Panic attacks cannot be predicted, therefore an individual may become stressed, anxious or worried wondering when the next panic attack will occur. Panic disorder may be differentiated as a medical condition. The DSM-IV-TR describes panic disorder and anxiety differently. Whereas anxiety is preceded by chronic stressors which build to reactions of moderate intensity that can last for days, weeks or months, panic attacks are acute events triggered by a sudden, out-of-the-blue cause: duration is short and symptoms are more intense. Panic attacks can occur in children, as well as adults. Panic in young people may be particularly distressing because children tend to have less insight about what is happening, and parents are also likely to experience distress when attacks occur.

Screening tools like Patient Health Questionnaire can be used to detect possible cases of the disorder, and suggest the need for a formal diagnostic assessment.

Panic disorder is a disabling disorder, but can be controlled and successfully treated. Because of the symptoms that accompany panic disorder, it is often mistaken for a physical illness, such as a heart attack. People frequently go to hospital emergency rooms during a panic attack, and extensive medical tests may be performed to rule out other conditions, thus creating further anxiety. Panic attacks are currently classified into three types: unexpected, situationally bounded, and situationally predisposed. Panic disorder affects about 2.3% of people at some point in their life.

Signs and symptoms
Panic disorder sufferers usually have a series of intense episodes of extreme anxiety during panic attacks. These attacks typically last about ten minutes, and can be as short-lived as 1–5 minutes, but can last twenty minutes to more than an hour, or until helpful intervention is made. Panic attacks can wax and wane for a period of hours (panic attacks rolling into one another), and the intensity and specific symptoms of panic may vary over the duration.

In some cases the attack may continue at unabated high intensity, or seem to be increasing in severity. Common symptoms of an attack include rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear such as: the fear of losing control and going crazy, the fear of dying and hyperventilation. Other symptoms are sweating, a sensation of choking, paralysis, chest pain, nausea, numbness or tingling, chills or hot flashes, faintness, crying and some sense of altered reality. In addition, the person usually has thoughts of impending doom. Individuals suffering from an episode have often a strong wish of escaping from the situation that provoked the attack. The anxiety of Panic Disorder is particularly severe and noticeably episodic compared to that from Generalized Anxiety Disorder. Panic attacks may be provoked by exposure to certain stimuli (e.g., seeing a mouse) or settings (e.g., the dentist’s office). Other attacks may appear unprovoked. Some individuals deal with these events on a regular basis, sometimes daily or weekly.

Causes

While there is not just one explanation for the cause of panic disorder, there are certain perspectives researchers use to explain the disorder. The first one is the biological perspective. Past research concluded that there is irregular norepinephrine activity in people who have panic attacks. Current research also supports this perspective as it has been found that those with panic disorder also have a brain circuit that performs improperly. This circuit consists of the amygdala, central gray matter, ventromedial nucleus of the hypothalamus, and the locus ceruleus.

There is also the cognitive perspective. Theorists believe that people with panic disorder may experience panic reactions because they mistake their bodily sensations for life-threatening situations These bodily sensations cause some people to feel as though are out of control which may lead to feelings of panic. This misconception of bodily sensations is referred to as anxiety sensitivity and studies suggest that the people who score higher on anxiety sensitivity surveys than other people, are fives times more likely to be diagnosed with panic disorder.

Panic disorder has been found to run in families, and suggests that inheritance plays a strong role in determining who will get it. It has also been found to exist as a co-morbid condition with many hereditary disorders, such as bipolar disorder, and a genetic predisposition to alcoholism.

Psychological factors, stressful life events, life transitions, and environment as well as often thinking in a way that exaggerates relatively normal bodily reactions are also believed to play a role in the onset of panic disorder. Often the first attacks are triggered by physical illnesses, major stress, or certain medications. People who tend to take on excessive responsibilities may develop a tendency to suffer panic attacks. Post-traumatic stress disorder (PTSD) patients also show a much higher rate of panic disorder than the general population.

Diagnosis
The DSM-IV-TR diagnostic criteria for panic disorder require unexpected, recurrent panic attacks, followed in at least one instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack’s consequences. There are two types, one with and one without agoraphobia. Diagnosis is excluded by attacks due to a drug or medical condition, or by panic attacks that are better accounted for by other mental disorders.
The ICD-10 diagnostic criteria:
The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable.
The dominant symptoms include:

sudden onset of palpitations
chest pain
choking sensations
dizziness
feelings of unreality (depersonalization or derealization)
secondary fear of dying, losing control, or going mad
Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression.

Treatment
Panic disorder is a serious health problem that in many cases can be successfully treated, although there is no known cure. Identification of treatments that engender as full a response as possible, and can minimize relapse, is imperative. Cognitive behavioural therapy and positive self-talk specific for panic are the treatment of choice for panic disorder. Several studies show that 85 to 90 percent of panic disorder patients treated with CBT recover completely from their panic attacks within 12 weeks. When cognitive behavioral therapy is not an option, pharmacotherapy can be used. SSRIs are considered a first-line pharmacotherapeutic option.

Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a psychosocial intervention that is the most widely used evidence-based practice for treating mental disorders. Guided by empirical research, CBT focuses on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions(e.g., thoughts, beliefs, and attitudes), behaviors, and emotional regulation. It was originally designed to treat depression, and is now used for a number of mental health conditions.

The CBT model is based on a combination of the basic principles from behavioral and cognitive psychology. It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind behaviors and then formulates a diagnosis. Instead, CBT is “problem-focused” and “action-oriented”, meaning it is used to treat specific problems related to a diagnosed mental disorder and the therapist’s role is to assist the client in finding and practising effective strategies to address the identified goals and decrease symptoms of the disorder.[7] CBT is based on the belief that thought distortionsand maladaptive behaviors play a role in the development and maintenance of psychological disorders, and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.

When compared to psychotropic medications, review studies have found CBT-alone to be as effective for treating less severe forms of depression and anxiety,posttraumatic stress disorder (PTSD), tics, substance abuse (with the exception of opioid use disorder), eating disorders, and borderline personality disorder, and it is often recommended in combination with medications for treating other conditions, such as severe obsessive compulsive disorder (OCD) and major depression, opioid addiction, bipolar, and psychotic disorders. In addition, CBT is recommended as the first line of treatment for the majority of psychological disorders in children and adolescents, including aggression and conduct disorder. Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults, but CBT was found to be superior in treating most disorders. Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice, and CBT and IPT are the only psychosocial interventions that psychiatry residents are mandated to be trained in.

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