Panic disorder

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| ICD9 = , | OMIM = | MedlinePlus = | eMedicineSubj = | eMedicineTopic = | MeshID = D016584 Panic Disorder is the medical term for a psychiatric illness characterized by recurring panic attacks in combination with significant behavioral change or at least a month of ongoing worry about the implications or concern about having other attacks.(DSM-IV)

Symptoms

Panic disorder sufferers usually have a series of intense episodes of extreme anxiety, known as panic attacks. These attacks typically last 10 minutes, but can be as short-lived as 1–5 minutes. However, attacks can wax and wane for a period of hours—one panic attack rolling into another. They may vary in intensity and specific symptoms of panic over the duration (i.e. rapid heartbeat, perspiration, dizziness, dyspnea, trembling, psychological experience of uncontrollable fear, etc.). Some individuals deal with these events on a regular basis—sometimes daily or weekly. The outward symptoms of a panic attack often cause negative social experiences (i.e. embarrassment, social stigma, social isolation, etc.). However, experienced sufferers can often have intense panic attacks with very little outward manifestation of the attack occurring. As a result, as many as 36% of all individuals with panic disorder also have agoraphobia.

Occurrence

Panic disorder is a serious health problem but can be successfully treated in most cases. It is estimated that up to 1.7 percent of the adult American population has panic disorder at some point in their lives. It typically strikes in early adulthood; roughly half of all people who have panic disorder develop the condition before age 24, especially if the person has been subjected to a traumatic experience. However, some sources say that the majority of young people affected for the first time are between the ages of 25 and 30. Women are twice as likely as men to develop panic disorder.Panic disorder can continue for months or even years, depending on how and when treatment is sought. If left untreated, it may worsen to the point where the person's life is seriously affected by panic attacks and by attempts to avoid or conceal the condition. In fact, many people have had problems with friends and family or employment while struggling to cope with Panic Disorder. Some people with Panic Disorder may begin to lie to conceal their condition. In some, individuals symptoms may occur frequently for a period of months or years, then many years may pass symptom-free. In others, the symptoms persist at the same level indefinitely. There is also some evidence that many individuals (especially those who develop symptoms at an early age) may experience a cessation of symptoms naturally later in life (i.e. past age 50). It is advised, however, not to alter any current treatment or medications without the advice of a physician.

Substance Abuse and Panic Disorder

A growing body of evidence exists that shows a link between substance abuse and panic disorder. Several studies have found that cigarette smoking increases the risk of panic attacks and Panic Disorder in young people.Johnson, J. G., Cohen, P., Pine, D. S., Klein, D. F., Kasen, S., & Brook, J. S. (2000). Association between cigarette smoking and Anxiety Disorders during adolescence and early adulthood. JAMA: Journal of the American Medical Association, 284(risk of panic: Findings from a prospective community study. Archives of General Psychiatry, 60(7), 692-700. Goodwin, R. D., Lewinsohn, P. M., & Seeley, J. R. (2005). Cigarette smoking and panic attacks among young adults in the community: The role of parental smoking and anxiety disorders. Biological psychiatry, 58(9), 686-693. While the mechanism of how smoking increases panic attacks is not fully understood, a few hypotheses have been derived. Smoking cigarettes may lead to panic attacks by causing changes in respiratory function (e.g. feeling short of breath). These respiratory changes in turn can lead to the formation of panic attacks, as respiratory symptoms are a prominent feature of panic.Breslau, N., & Klein, D. F. (1999). Smoking and panic attacks: An epidemiologic investigation. Archives of General Psychiatry, 56(12), 1141-1147.Johnson, J. G., Cohen, P., Pine, D. S., Klein, D. F., Kasen, S., & Brook, J. S. (2000). Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. JAMA: Journal of the American Medical Association, 284(18), 2348-2351. Respiratory abnormalities have been found in children with high levels of anxiety, which suggests that a person with these difficulties may be susceptible to panic attacks, and thus more likely to subsequently develop Panic Disorder.Pine, D. S., Klein, R. G., Coplan, J. D., Papp, L. A., Hoven, C. W., Martinez, J., et al. (2000). Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group. Archives of General Psychiatry, 57(10), 960-967. Gorman, J. M., Kent, J., Martinez, J., Browne, S., Coplan, J., & Papp, L. A. (2001). Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: Evidence for a central fear mechanism. Archives of General Psychiatry, 58(2), 125-131. Smoking marijuana has also been found to increase the risk of panic attacks. A study conducted by Dannon, Lowengrub, Amiaz, Grunhaus, & Kotler (2004)Dannon, P. N., Lowengrub, K., Amaze, R., Grahams, L., & Kilter, M. (2004). Comorbid cannabis use and panic disorder: Short term and long term follow-up study. Human Psychopharmacology: Clinical and Experimental, 19(2), 97-101. on 66 adults examined the rates of comorbid cannabis use and Panic Disorder. Of the 24 participants who suffered from Panic Disorder and had comorbid chronic cannabis use, all reported that their first panic attack occurred within 48 hours of smoking marijuana. Interestingly, smoking marijuana did not increase the frequency of attacks in the comorbid cannabis use group compared to the non-users. Neither severity of symptoms nor age of first use was reported. It remains to be seen whether a link exists between the age of first use and risk of developing panic disorder. Furthermore, while the frequencies of attacks did not differ between the groups, it is not clear as to whether or not marijuana use increases the severity of panic disorder symptoms. Deacon and Valentiner (2000)Deacon, B. J., & Valentiner, D. P. (2000). Substance use and non-clinical panic attacks in a young adult sample. Journal of substance abuse, 11(1), 7-15. conducted a study that examined co-morbid panic attacks and substance use in a non-clinical sample of young-adults who experienced regular panic attacks. The authors found that compared to healthy controls, therapeutic alcohol and sedative use was greater for non-clinical participants who experienced panic attacks. These findings are consistent with the suggestion made by Cox, Norton, Dorward, and Fergusson (1989)Cox, B. J., Norton, G. R., Forward, J., & Fergusson, P. A. (1989). The relationship between panic attacks and chemical dependencies. Addictive Behaviors, 14(1), 53-60. that Panic Disorder patients self-medicate if they believe that certain substances will be successful in alleviating their symptoms. If Panic Disorder patients are indeed self-medicating, there may be a portion of the population with undiagnosed Panic Disorder who will not seek professional help as a result of their own self-medication. In fact for some patients, Panic Disorder is only diagnosed after they seek treatment for their self-medication habit. Cox, B. J., Norton, G. R., Swenson, R. P., & Ender, N. S. (1990). Substance abuse and panic-related anxiety: A critical review. Behaviour research and therapy, 28(5), 385-393.

Treatment

Panic Disorder is real and potentially disabling, but it can be controlled and successfully treated in most cases. Because of the disturbing symptoms that accompany panic disorder, it may be mistaken for a life-threatening physical illness. This misconception often aggravates or triggers future attacks. People frequently go to hospital emergency rooms when they are having panic attacks, and extensive medical tests may be performed to rule out these other conditions, thus creating further anxiety. Medical tests which do not identify an underlying physical cause are not uncommon. In the case of severe reactive hypoglycemia, a sudden drop in blood sugar is often overlooked in a healthy person, while tests are designed to reveal the blood-sugar profile of a diabetic rather than an individual with this specific disorder. Pursuing healthy nutritional therapy in the case of any psychiatric illness is essential.The current treatment suggested by the American Psychiatric Association and the American Medical Association is a comibination of medications and a type of psychotherapy known as cognitive-behavioral therapy. The mental health professionals that typically can assist an individual in treatment of panic disorder are psychiatrists, psychologists, mental health counselors, and social workers. To pursue a medical treatment for panic disorder, one should visit a medical doctor, typically a psychiatrist. Psychotherapy is typically provided by a clinical or counseling psychologist, a Licensed Professional Counselor (LPC), or a Licensed Clinical Social Worker (LCSW). In remote areas, or when a psychiatrist is unavailable, a general practice physician ("family doctor") may be competent to manage the pharmacological ("medications") treatment in coordination with a psychologist or LCSW. A psychiatrist is, by training, better prepared than a general practice physician in the pharmacological treatment and should be sought out if available. A psychologist is not a medical doctor and cannot prescribe medication, although some have advanced training in panic control.Medications can be used to break the psychological connection between a specific phobia and panic attacks.. Medications can also be used to treat Panic Disorder. Medications can include:
  • Antidepressants (SSRIs, SNRI's, Nassa MAOIs, etc.): these are taken regularly every day, and build a resistance to the occurrence of the symptoms. Although these medications are described as "antidepressants", nearly all of them have anti-panic properties as well—many panic sufferers do not have classical symptoms of depression, and may be misled by the name "antidepressant" into believing these drugs are not targeted to their symptoms, when they are often the most effective treatment in combination with psychotherapy.
  • Anti-anxiety drugs (benzodiazepines): these drugs are taken during or at the onset of panic attacks or before challenging/anxiety provoking situations. Some sufferers also take them daily to prevent panic attacks from occurring. These drugs may be habit-forming if not used according to a physician's directions. They are often most effective at the beginning of treatment when the resistance properties of the antidepressants have not yet built up, and are generally utilized less and less as other parts of the treatment (antidepressants, psychotherapy) become more effective.
    • Exposure to the phobia trigger multiple times without a resulting panic attack (due to medication) can often break the phobia–panic pattern, allowing people to function around their phobia without the help of medications. However, minor phobias that develop as a result of the panic attack can often be eliminated without medication through monitored cognitive-behavioral therapy or simply by exposure.Usually, a combination of psychotherapy and medications produces good results. Some improvement may be noticed in a fairly short period of time—about 6 to 8 weeks. Often, it may take longer to find the right pair of medications and mental health professional. Thus appropriate treatment by an experienced professional can prevent panic attacks or at least substantially reduce their severity and frequency—bringing significant relief to 70 to 90 percent of people with Panic Disorder. Relapses may occur, but they can often be effectively treated just like the initial episode.In addition, people with Panic Disorder may need treatment for other emotional problems. Clinical depression has often been associated with Panic Disorder, as have alcoholism and drug addiction. Research has also suggested that suicide attempts are more frequent in people with panic disorder, although this research remains controversial. There is evidence of comormidity with tremor and epilepsy. More extensive treatment is required for people with treatment-resistant Panic Disorder, which may not respond to many drug and behavior therapies.Experimental treatment for Panic Disorder has included nutritional consultation and the use of substances such as inositol, amino acid gamma-aminobutyric acid (GABA), glycine, glutamine, and the calming amino acid L-theanine. Treatment with GABA is both questionable and controversial, as orally ingested GABA cannot cross the blood-brain barrier. Orthomolecular therapy useful in the treatment of depression or which enhances the healthy functioning of the brain may have a role in the treatment of this condition. About 30% of people with panic disorder use alcohol and 17% use psychoactive drugs. This is in comparison with 61% (alcohol)[http://www.cdc.gov/nchs/fastats/alcohol.htm] and 7.9% (other psychoactive drugs) [http://www.cdc.gov/nchs/fastats/druguse.htm] of the general population who use alcohol and psychoactive drugs, respectively. It often varies between individual cases whether any observed drug use worsens the condition, or is initiated by the sufferer to alleviate the condition ("self medication"). Most stimulant drugs (caffeine, nicotine, cocaine) would be expected to worsen the condition, since they directly increase the symptoms of panic, such as heart rate. The medically established psychoactive properties of marijuana present a special case—at low doses there may be some anti-anxiety psychological effects comparable to those of benzodiazepines, whereas at some undefined threshold (as dose is increased), marijuana has been shown to produce extreme anxiety on its own, with an intensity potentially comparable to that of the Panic Disorder symptoms themselves.[http://www.yale.edu/opa/newsr/04-06-14-01.all.html] However, generally only new marijuana users experience anxiety because they are not used to their heart rate temporarily being increased.[http://homepages.poptel.org.uk/DrDrew/health.html#mind]As with many disorders, having a support structure of family and friends who understand the condition can help increase the rate of recovery. During an attack, it is not uncommon for the sufferer to develop irrational, immediate fear, which can often be dispelled by a supporter who is familiar with the condition. For more serious or active treatment, there are support groups for anxiety sufferers which can help people understand and deal with the disorder.Other forms of treatment include journalling, in which a patient records their day-to-day activities and emotions in a log to find and deal with their personal stresses. Breathing exercises, such as diaphragmatic breathing, can also be found helpful. In some cases, a therapist may use a procedure called interoceptive exposure, in which the symptoms of a panic attack are induced in order to promote coping skills and show the patient that no harm can come from a panic attack. Stress-relieving activities such as tai-chi, yoga, and physical exercise can also help ameliorate the causes of Panic Disorder. Many physicians will recommend stress management, time management, and emotion-balancing classes and seminars to help patients avoid anxiety in the future. Research has also shown that the herbal supplement 5-HTP can be used to treat panic disorders by its ability to boost serotonin levels. This works by providing the body with the raw material to make serotonin, as opposed to SSRIs which work by recycling serotonin.

    Interoceptive Desensitization/Symptom Inductions

    One particularly helpful and effective form of cognitive behavioral therapy (CBT) is Interoceptive Desensitization. Techniques used may include those based upon the concept that intentional exposure to the symptoms will help decrease the sufferer's fear of panic attacks. In a study by Barlow & Craske (1989), 87% of the individuals that participated in the two of four treatments that involved Interoceptive Desensitization were free of panic at the end of treatment and these results were maintained at a 2-year follow up. In controlled studies of Interoceptive Desensitization treatments compared to other treatments, those treatments that included Interoceptive Desensitization were found to be significantly superior to other treatments such as muscle relaxation alone, or education or insight-oriented treatments. Indeed, Interoceptive Desensitization often leads to a dramatic reduction in the frequency and intensity of panic attacks and as such should be implemented immediately under the guidance of a mental health professional. It is important the patient is given medical clearance and permission from a medical doctor before attempting these exercises.Symptom inductions generally occur for one minute and may include:
  • Intentional hyperventilation – creates lightheadedness, derealization, blurred vision, dizziness
  • Spinning in a chair – creates dizziness, disorientation
  • Straw breathing – creates dyspnea, airway constriction
  • Breath holding – creates sensation of being out of breath
  • Running in place – creates increased heart rate, respiration perspiration
  • Body tensing – creates feelings of being tense and vigilant
    • The key to the induction is that the exercises should mimic the most frightening symptoms of a panic attack. Symptom Inductions should be repeated 3-5 times per day until the patient has little to no anxiety in relation to the symptoms that were induced. Often it will take a period of weeks for the afflicted to feel no anxiety in relation to the induced symptoms. With repeated trials, a person learns through experience that these internal sensations do not need to be feared—the individual becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (Hippocampus & Amygdala) to not fear the sensations, and the sympathetic nervous system activation fades.

    Causes

    Panic Disorder has been found to run in families, and this may mean 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 alcoholism. However, many people who have no family history of the disorder develop it. Malfunctioning of brain structures, such as the amygdala and hormonal/adrenaline glands, may cause an overproduction of certain chemicals and could be source of the physical symptoms.Other biological factors, stressful life events, life transitions, environment, and 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. The exact causes of Panic Disorder are unknown at this point.There is some evidence to suggest hypoglycemia, hyperthyroidism, mitral valve prolapse, labyrinthitis and pheochromocytoma can cause or aggravate Panic Disorder.Studies in animals and humans have focused on pinpointing the specific brain areas involved in Anxiety Disorders such as Panic Disorder. Fear, an emotion that evolved to deal with danger, causes an automatic, rapid protective response that occurs without the need for conscious thought. This is termed the fight or flight response. It has been found that the body's fear response is coordinated by a small but complicated structure deep inside the brain called the amygdala. Eating disorders have also been linked to have caused panic attacks in several people. Some mood disorders can cause Panic Disorder. In addition to clinical depression, bipolar disorder can cause Panic Disorder in some people. Due to the nature of the fight or flight response many cases of Panic Disorder may be linked with the limbic system and be initiated by those biological factors that could be biological, reinterpreted emotionally as a threat to survival, such as hypoxia (lack of oxygen). If Panic Disorder is experienced more severely during sleep, it would be recommended to have the sufferer evaluated for conditions such as sleep apnea or hypopnea. A sleep-related panic disorder could be most easily distinguished from a night terror by the ability (usually instantaneous) of the Panic Disorder sufferer to regain full consciousness, unlike the night terror sufferer.Prepulse inhibition has been found to be reduced in patients with Panic Disorder [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=543839]. Disorders with PPI deficits are characterized by a loss of the normal ability to suppress or gate irrelevant sensory, motor or cognitive information. This loss of ‘gating’ may be experienced as intrusive thoughts or sensory information. Reduced PPI and gating functions may be a cause of the heightened state of sensory overload that patients suffering from panic attack often experience. Stimulants are a rather common cause for panic attacks. An excess of common stimulants such as caffeine and nicotine often can induce panic attacks in less experienced users. Chemicals, including carbon monoxide, in tobacco smoke can also trigger panic attacks in certain people. Some people's response to small amounts of carbon monoxide is to panic. Not surprisingly, the attacks stop or get much less severe after they quit the cause, such as smoking.Psychological explanations of Panic Disorder have also been put forward. Clark (1986) suggests that Panic Disorder is often caused by "catastrophic misinterpretations", whereby normal bodily sensations, often normal responses to anxiety such as palpitations and sweating, are interpreted as indicating something seriously wrong such as a heart-attack, and this interpretation can be done either consciously or subconsciously. Quite a bit of evidence exists for this theory. For example, activating catastrophic misinterpretations increases anxiety and panic; panic attacks can be reduced as a result of cognitively challenging these misinterpretations; with ambiguous events questionnaires, panic-disorder patients interpret ambiguous sensations more catastrophically than controls. Further, a study by Ehler which provided false heart-rate feedback to participants found that those with panic disorder react with far greater anxiety.

    DSM-IV criteria

    DSM-IV diagnostic criteria for panic disorder with (or without) agoraphobia: :A. Both (1) and (2): ::# recurrent unexpected panic attacks ::# at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: :::
  • persistent concern about having additional attacks
    • :::
  • worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack, "going crazy")
    • :::
  • significant change in behavior related to the attacks
    • :B. The presence (or absence) of agoraphobia :C. The panic attacks are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). :D. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g., occurring on exposure to feared social situations), specific phobia (e.g., on exposure to a specific phobic situation), obsessive-compulsive disorder (e.g., on exposure to dirt in someone with an obsession about contamination), post-traumatic stress disorder (e.g., in response to stimuli associated with a severe stressor), or separation anxiety disorder (e.g., in response to being away from home or close relatives).

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