What Is Panic Disorder?
Panic disorder is characterised by recurrent episodes of intense fear, known as panic attacks. These sudden surges of overwhelming fear or discomfort manifest themselves with a range of physical and cognitive symptoms, including rapid heartbeat, shortness of breath, dizziness, trembling and irrational fears of death, insanity or loss of control.
While panic attacks are common to many anxiety disorders, what makes panic disorder different is the unexpected nature of these attacks. They seem to come “out of the blue” with no apparent trigger (American Psychiatric Association, 2013; Craske & Barlow, 2007). For a diagnosis of panic disorder, these unanticipated panic attacks must be accompanied by a significant change in behaviour or followed by at least one month of persistent worry about experiencing another attack or its possible consequences.
Panic disorder affects a significant number of people, with approximately 2-3% of the US population experiencing the condition each year (Kessler, Chiu, Demler, & Walters, 2005; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012).
Humans have developed an instinctive ‘fight or flight’ response to deal with threatening situations. When faced with danger, the body undergoes specific changes, such as redirecting blood flow from the extremities to the large muscles, releasing adrenaline and increasing heart rate, in preparation for self-defence.
These physiological responses are essential for survival. However, there are cases where these responses occur in the absence of real danger, leading to misinterpretation of bodily signals as signs of imminent harm or real threat. For example, people may associate an increased heart rate with previous panic attacks and misinterpret bodily sensations as signs of imminent death or loss of control.
This phenomenon is known as ‘fear of fear’ (Craske & Barlow, 2007). “Fear of fear maintains and perpetuates panic attacks and their associated symptoms, creating a self-perpetuating cycle. Essentially, an elevated heart rate can be misinterpreted as negative, which triggers anxiety, which further elevates the heart rate, reinforcing the cycle. These associations can be automatic, even without conscious thought, and shed light on the underlying processes at work.
Symptoms of panic attacks
The symptoms of panic disorder are clearly outlined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.
- Recurrent, unexpected panic attacks
- A panic attack is characterised by a sudden surge of intense fear or discomfort that peaks within a few minutes. During this episode, a person experiences four or more of the following symptoms
- Fast or pounding heart rate.
- Excessive sweating.
- Shaking or trembling.
- Shortness of breath or breathlessness.
- Feeling of choking.
- Chest pain or discomfort.
- Nausea or stomach pain.
- Dizziness, lightheadedness, or feeling faint.
- Cold or heat sensation.
- Numbness or tingling.
- Feelings of unreality or detachment from yourself.
- Fear of losing control or going mad.
- Fear of dying.
- After at least one panic attack, the person must experience either of the following:
- Persistent worry about future panic attacks or their consequences.
- Significant changes in behaviour related to the attacks, such as avoiding certain situations or activities.
- The symptoms cannot be attributed to substance use, medication or a medical condition.
Treatment options for panic attacks
There are several effective treatments for panic disorder, including both psychological/therapeutic and medical approaches.
Cognitive behavioural therapy (CBT) is widely regarded as the most effective treatment for panic disorder. It involves educating people about their condition, identifying and modifying maladaptive thoughts and fears, learning relaxation techniques and coping strategies, and gradually confronting fears. Research shows that CBT is effective even in the presence of other co-occurring disorders. The exposure component of CBT is particularly important for successful outcomes (Hofmann, 2011).
Other therapeutic approaches, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and online/computerised treatments, have shown promise in the treatment of panic disorder (Arch et al., 2017). However, CBT remains the most extensively researched and established treatment. Further research is needed to assess the comparative effectiveness of MBSR, ACT and other treatments. It is generally recommended to choose empirically supported treatments that are based on scientific research in the psychological and medical fields.
As with other mood and anxiety disorders, medication can be used to treat panic disorder. Selective serotonin reuptake inhibitors (SSRIs) such as Paxil, Prozac and Zoloft, benzodiazepines such as Xanax and Lorazepam, and selective norepinephrine reuptake inhibitors (SNRIs) such as Cymbalta, Effexor and Pristiq are commonly prescribed. D-cycloserine is another drug that is being studied to enhance the effects of CBT.
It is important to consult a doctor before starting or stopping these medications, as they can have side effects and lead to tolerance, withdrawal or dependence. Combining medication with behavioural therapy, such as CBT, has shown significant benefits for people with panic disorder. However, psychotherapy alone is also highly effective (Arch et al, 2017).
Coping Strategies & Support for Assisting Individuals with Panic Attacks
One of the most alarming early encounters in panic disorder is experiencing a panic attack without comprehending its nature. By delving into a deeper understanding of panic attacks and panic disorder, one gains the ability to identify and label these distressing episodes. It is crucial to recognize that panic attacks do not pose a mortal threat or lead to complete loss of control; they do not signify a descent into madness.
Simply knowing the nature of the experience can provide some relief. For instance, during a panic attack, individuals can reassure themselves by acknowledging, “This is anxiety. I have encountered this before, and I managed to overcome it.”
Paradoxically, embracing one’s emotional experience can prove highly beneficial during panic attacks. Acknowledging that anxiety is akin to a wave, rising and subsiding, allows individuals to avoid the “fear of fear” cycle that exacerbates their distress. When panic symptoms emerge, labeling the experience and reminding oneself, “I will be fine. This shall pass in due time,” promotes acceptance. Embracing the experience rather than resisting it enables a swifter reduction in panic symptoms and facilitates a smoother journey.
Mindfulness entails dedicating time to focus on the present moment, adopting a nonjudgmental stance toward one’s thoughts and feelings. Although seemingly straightforward, it can be challenging as our minds tend to wander. Allocating at least ten minutes each day to concentrate on a single activity, such as mindful breathing, cultivates awareness of physical sensations, the sound and rhythm of breath, and the cyclical movements of the chest and lungs.
Maintaining focus on these sensations and gently redirecting the mind when it strays fosters emotional centeredness. Online resources, applications, and books offer comprehensive information on mindfulness practices and guided exercises.
Approach, Don’t Avoid
Resisting the temptation to evade or suppress panic-related emotions proves paramount. Instead, embracing the experience and practicing acceptance (as discussed earlier) is crucial. Although avoidance may provide temporary relief by reducing anxiety, it proves detrimental in the long run, as it reinforces the belief that these physical sensations constitute genuine threats. By gradually approaching anxiety-inducing situations and bodily sensations, individuals can rewire their brains to recognize their benign nature.
Engaging in this approach repeatedly fosters the realization that these physical sensations are less intimidating, thereby reducing panic symptoms in the future or at least rendering them more manageable in the present moment. Remember the adage, “avoidance is anxiety’s best friend,” for the more we avoid, the more anxiety tends to prevail. Therefore, adopt an attitude of “I can overcome this!” and venture forth to confront anxiety-inducing stimuli.
Prevalence of panic disorder
The prevalence of panic disorder varies considerably and is influenced by a number of factors, including race, ethnicity and gender. In the United States and Europe, panic disorder affects approximately 2-3% of the population each year. Notably, Native American Indian populations have higher rates of the disorder compared to non-Latino white Americans.
Conversely, African Americans, Latinos, Caribbean Blacks and Asian Americans have lower rates of panic disorder. There are also gender differences, with women twice as likely as men to be diagnosed with panic disorder. Although several factors such as biology, temperament, exposure to stressors and trauma, cognitive elements and environmental influences have been identified as potential contributors to these gender differences, a definitive explanation remains elusive.
The typical course of panic disorder begins in adolescence and peaks in the early to mid-twenties. Symptoms are rarely seen in children under 14 or in adults over 64. Carers should be alert to signs of panic attacks in adolescents, along with noticeable behavioural changes such as avoidance of intense physical sensations, which may indicate the onset of panic disorder. This disorder primarily develops between the ages of 20 and 24, and although women are more susceptible to panic disorder, there are no significant differences in its presentation.
Understanding panic disorder through a cultural lens
Adopting a cultural perspective is essential to understanding the manifestation of panic disorder. Research highlights cultural differences in the perception of panic attacks and the reception and interpretation of panic disorder diagnoses among different racial and ethnic groups.
Phenomena similar to panic disorder have been identified across cultures, such as “ataque de nervios” in Latin American communities. Studies show that African Americans experience greater functional impairment, which affects their ability to carry out daily activities, than non-Latino white Americans. It is important to recognise that the above cultural factors represent only a fraction of the influences on panic disorder. Nevertheless, they highlight the importance of cultural differences in the presentation of panic disorder and individual interpretations of panic symptoms.
Aetiology, risk factors and comorbidities of panic disorder
Panic disorder is widely understood from a psychobiological perspective, suggesting the presence of certain biological factors that may be inherited or genetically transmitted, making some individuals more susceptible to experiencing panic disorder symptoms. As a result, the disorder often runs in families, with other members of an individual’s family at higher risk of developing panic symptoms or panic disorder. It is important to note, however, that inheriting these predispositions does not guarantee the onset of panic attacks, as one’s thoughts and behaviour can play an important role in preventing them.
Psychological factors also play an important role in the psychobiological conceptualisation of panic disorder. These factors revolve around fear of bodily sensations or specific beliefs that increase an individual’s anxiety about physical symptoms, such as interpreting a racing heart as a sign of heart disease. Anxiety sensitivity, or the belief that anxiety is harmful, is often discussed in this context.
Although the belief that physical symptoms are harmful may increase the likelihood of panic attacks, it does not make panic attacks inevitable. In certain situations, panic attacks may seem abnormal, occurring when there is no real reason to be afraid. However, it is important to recognise that anxiety can also be adaptive or beneficial in the face of genuine threats.
When looking at comorbidities, agoraphobia is one of the most common disorders to co-occur with panic disorder. Agoraphobia involves distressing anxiety in situations such as leaving home, using public transport, being in open or confined spaces, or encountering crowds. This fear often leads to extreme avoidance for fear of not being able to escape. Depression is another common comorbidity, with estimates ranging from 10% to 65% over a lifetime.
Cases of comorbid depression are more likely to coincide with the recognition and diagnosis of panic disorder, although approximately 30% of people experience major depression before meeting the criteria for panic disorder. Panic disorder can also co-occur with other anxiety disorders, including generalised anxiety disorder (GAD) and social anxiety disorder (SAD).
In addition, people with panic disorder may have comorbid bipolar disorder, alcohol or substance use disorders, or medical conditions that accompany their panic symptoms. Common medical problems associated with panic disorder include thyroid problems, respiratory problems, heart problems and dizziness.
In general, it has been reported that about 93.7% of people with panic disorder meet criteria for at least one other medical or mental disorder. However, it is important to note that comorbidity is not an inevitable consequence of panic disorder and it is crucial to discuss symptoms thoroughly with a health professional. Also, the causality of the relationship between panic disorder and medical conditions remains unclear.
Managing panic attacks
When faced with a panic attack, consider the following tips for yourself or a loved one:
- Acknowledge the limits of anxiety: Recognise that anxiety has a threshold beyond which it cannot escalate indefinitely. Physiologically, there is a point at which anxiety reaches its peak and cannot be sustained indefinitely. While reaching this peak can be uncomfortable, it is important to remember that anxiety will eventually subside over time.
- Accept the ebb and flow of emotions: Understand that emotions, including anxiety, come in waves. They will rise and fall naturally. Remind yourself or your loved one that this intense anxiety is temporary and will eventually pass.
- Draw on past experiences: Think about previous encounters with panic attacks. Remind yourself or your loved one that you have been through similar experiences before and have emerged capable and resilient. Have confidence in your ability to deal with the situation again.
- Avoidance is anxiety’s ally: Resist the urge to avoid or evade situations that trigger anxiety. Remember that avoidance only increases anxiety in the long run. Instead, gradually expose yourself to anxiety-provoking situations, allowing yourself to rewire your response and learn that these experiences are not as threatening as they may seem.
In addition, the following resources provide valuable information and support for people helping loved ones with panic disorder:
- American Psychiatric Association (2013). Diagnostic and statistical manual for mental disorders (5th ed.). Washington, DC.
- Arch, J. J., Kirk, A., & Craske, M. G. (2017). Panic Disorder. In W. Craighead, D. J. Miklowitz, & L. W. Craighead (Eds.), Psychopathology: History, Diagnosis, and Empirical Foundations (pp. 85-149). John Wiley & Sons.
- Asnaani, A., Gutner, C., Hinton, D., & Hofmann, S. G. (2009). Panic disorder, panic attacks, and panic attack symptoms across race-ethnic groups: Results of the Collaborative Psychiatric Epidemiology Survey. CNS Neuroscience & Therapeutics, 15, 249-254.
- Craske, M. G. & Barlow, D. H. (2007). Mastery of Your Anxiety and Panic: Therapist Guide. New York: Oxford University Press, Inc.
- Craske, M. G. & Barlow, D. H. (2007). Mastery of Your Anxiety and Panic: Workbook for Primary Care Settings. New York: Oxford University Press, Inc.
- Craske, M. G., Kircanski, K., Epstein, A., Wittchen, H. U., Pine, D. S., Lewis‐Fernández, R., & Hinton, D. (2010). Panic disorder: a review of DSM‐IV panic disorder and proposals for DSM‐V. Depression and Anxiety, 27(2), 93-112.
- Hofmann, S. G. (2011). An introduction to modern CBT: Psychological solutions to mental health problems. Chichester, UK: Wiley-Blackwell.
- Hofmann, S. G., & Hinton, D. E. (2014). Cross-cultural aspects of anxiety disorders. Current Psychiatry Reports, 16:450.
- Hofmann, S. G., Smits, J. A., Rosenfield, D., Simon, N., Otto, M. W., Meuret, A. E., … & Pollack, M. H. (2013). D-Cycloserine as an augmentation strategy with cognitive-behavioral therapy for social anxiety disorder. American Journal of Psychiatry, 170(7), 751-758.
- Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627.
- Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169-184.
- Lewis-Fernández R., Hinton D.E., Laria A. J., Patterson, E. H., Hofmann, S. G., Craske, M. G.,…Liao, B, (2010). Culture and the anxiety disorders: recommendations for DSM-V. Depression and Anxiety 27(2), 212–229.
- McLean, C. P., & Anderson, E. R. (2009). Brave men and timid women? A review of the gender differences in fear and anxiety. Clinical Psychology Review, 29(6), 496-505.
- McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity, and burden of illness. Journal of Psychiatric Research, 45, 1027-1035.
- Meuret, A. E., White, K. S., Ritz, T., Roth, W. T., Hofmann, S. G. & Brown, T. A. (2006). Panic attack symptom dimensions and their relationship to illness characteristics in panic disorder. Journal of Psychiatric Research, 40, 520-527.