Panic disorder is a disorder characterised by extreme anxiety, or panic attacks, that occur unexpectedly and for no particular reason.
A panic attack is an extreme, life-threatening episode of anxiety that is accompanied by physical symptoms such as a rapidly beating heart, tightness in the chest, shortness of breath, and sweating.
In addition to psychosocial factors such as psychoanalytic and cognitive behavioural theories, recent research has identified biological factors as a major cause of panic disorder.
Problems with brain function and structure have been reported, including abnormalities in neurotransmitter systems such as norepinephrine, serotonin, and GABA (γ-aminobutyric acid), and abnormalities in brain structures such as the temporal and prefrontal lobes.
It is known that many people with panic disorder experience stressful situations prior to the onset of symptoms.
The first panic attack may follow excitement, physical activity, sexual activity, or emotional hurt, but it often occurs spontaneously and without cause. Once they occur, they usually peak in intensity within 10 minutes.
If there is a recurring event that precedes a panic attack (e.g., coffee, alcohol, cigarettes, or after a change in sleep, diet, or excessive light), it is important to investigate these conditions further.
The main psychiatric symptoms are extreme fear and a sense of imminent death.
Patients are usually unaware of the cause of this fear, confused and unable to concentrate. Physical symptoms (autonomic nervous system symptoms) such as tachycardia (rapid pulse), palpitations, shortness of breath, and sweating are present. The attacks usually last 20 to 30 minutes and rarely exceed an hour.
Anticipatory anxiety is another major symptom, which is the fear of having another seizure once you have experienced one.
Physical symptoms related to heart and breathing problems are the most common concerns of panic attack sufferers, who often visit the emergency room because they think they are about to die. About one in five people faint during a panic attack.
Worries about panic attacks and their consequences may be related to the presence of a life-threatening illness (e.g., heart disease, seizure disorder), worries about being judged negatively or embarrassed by others when having a panic attack, social worries about being judged negatively or embarrassed by others when having a panic attack, and worries about mental functioning, such as the fear of going “crazy” or losing control.
Negative behavioural changes may be made to avoid or minimize the panic attack or its consequences. Examples include avoiding physical exercise, reorganising your daily routine to help you when you have a panic attack, limiting your usual daily activities, or avoiding situations that are likely to trigger agoraphobia, such as leaving the house, using public transport, or going shopping. If agoraphobia is present, a separate diagnosis of agoraphobia should be made.
This behaviour can create marital problems and lead to a misdiagnosis of marital problems as the main problem. Before an accurate diagnosis is made, the patient may fear that they are becoming strange.
Diagnostic criteria according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
A. Recurrent, unexpected panic attacks. The panic attack must be a sudden onset of extreme fear and distress that peaks within a few minutes, during which time four or more of the following symptoms are present.
Note: The sudden onset of symptoms can occur in both calm and anxious states.
Palpitations. Palpitations or an increase in the number of heartbeats.
Trembling or shaking in the body
Shortness of breath or feeling stuffy
Feeling like you’re choking
Chest pain or chest discomfort
Nausea or abdominal discomfort
Feeling dizzy, unsteady, lightheaded, or like you’re going to fall down
Feeling cold or burning
Paresthesia (feeling numb or tingling)
Unreality (feeling like it’s not real) or derealisation (feeling separated from you)
Fear of losing control or going crazy
Fear of dying
Note: Culture-specific symptoms (e.g., tinnitus, scratchy throat, headaches, uncontrollable shouting or crying) may also be present. These symptoms are not included in the four symptoms required for diagnosis above.
B. One or more of the following conditions must be present for at least one month after at least one attack
Persistent worry about having another panic attack or its consequences (e.g., losing control, having a heart attack, going insane).
Significant maladaptive changes in behaviour related to the attacks (e.g., avoiding exercise or unfamiliar environments as a way to avoid panic attacks).
C. The impairment is not due to the physiological effects of a substance (e.g., a drug of abuse or therapeutic medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disease).
D. The impairment is not better explained by another mental illness (e.g., social anxiety disorder).
The attacks do not occur exclusively in feared social situations, as in social anxiety disorder, or exclusively in feared objects or situations, as in specific phobias. They must not be triggered by obsessive thoughts, as in obsessive-compulsive disorder.
They must not be associated only with memories of traumatic events, as in post-traumatic stress disorder. It must not be caused by separation from an attachment object, as in separation anxiety disorder).
Medication and cognitive behavioural therapy are the mainstays of treatment, with most patients experiencing dramatic symptomatic improvement. Family therapy and group therapy can also be helpful for patients and their families.
Medications include antidepressant medications such as selective serotonic reuptake inhibitors (SSRIs) and anti-anxiety medications from the benzodiazepine class, with other classes used as needed. Medication usually needs to be maintained for 8 to 12 months to show symptomatic improvement.
2) Cognitive behavioural therapy
Combining medication with cognitive behavioural therapy has been shown to be more effective than either treatment alone.
A key component of cognitive therapy is to correct the patient’s misperception of minor bodily sensations as catastrophic, such as doom or death, and to make them aware that panic attacks are not actually life-threatening if they pass in time.
Treatments include relaxation therapy, breathing exercises, and in vivo exposure.
Panic disorder usually begins in late adolescence or early adulthood. Although the course of the disease is variable, it tends to be chronic.
In general, 30 to 40 percent of people become symptom-free, about half have symptoms that are mild and don’t affect their lives, and 10 to 20 percent continue to have severe symptoms.
The severity and frequency of panic attacks can vary, from several times a day to less than once a month.
Comorbidity with other mental illnesses, such as depressive disorders, is common and can affect the overall course of the disorder.