Panic Disorder

Panic disorder is an anxiety disorder characterised by reoccurring unexpected panic attacks, which are sudden periods of intense fear. These attacks may include symptoms such as palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen.

The intensity of symptoms peaks within minutes. Individuals often worry about having further attacks and may avoid places where previous attacks have occurred.

Signs and Symptoms

Panic attacks typically last about ten minutes but can be as short as 1–5 minutes or extend to over an hour. The attacks can be severe and episodic, differentiating them from generalised anxiety disorder. Symptoms include a rapid heartbeat, perspiration, dizziness, dyspnea, trembling, uncontrollable fear, hyperventilation, sensations of choking, chest pain, nausea, numbness or tingling, chills or hot flashes, vision problems, faintness, crying, and altered reality. A person may have an overwhelming desire to escape the triggering situation. Nocturnal panic attacks, occurring during sleep, are also common.

Causes

The exact cause of panic disorder is unknown. However, it runs in families, suggesting a genetic component. Psychological models indicate irregular norepinephrine activity and improper functioning of brain circuits including the amygdala and hypothalamus. Cognitive theories suggest that misinterpretation of bodily sensations as life-threatening leads to panic. Psychological stress, life transitions, PTSD, and substance use are additional contributing factors. Smoking, especially starting in adolescence, increases the risk.

Diagnosis

Diagnosis is primarily based on symptoms, after ruling out other potential causes such as heart disease, hyperthyroidism, and drug use. The DSM-IV-TR criteria require unexpected, recurrent panic attacks followed by significant behavioural changes or persistent concern about further attacks. The ICD-10 criteria also describe recurrent attacks of severe anxiety that are unpredictable. The Panic Disorder Severity Scale (PDSS) can measure the severity of the disorder.

Treatment

Panic disorder is often treated with counselling and medications. Cognitive behavioural therapy (CBT) is effective in more than half of the patients, helping them confront anxiety triggers and reduce irrational fears. In cases where CBT is not accessible, pharmacotherapy is used. Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacotherapeutic option, while benzodiazepines are used with caution due to the risk of dependence.

Psychotherapy

Cognitive behavioural therapy involves techniques such as intentional hyperventilation, spinning in a chair, and straw breathing to induce and then confront anxiety symptoms. Panic-focused psychodynamic psychotherapy addresses underlying emotional conflicts. Support structures including family and friends, and support groups can also aid in recovery.

Medication

Medications include SSRIs, MAOIs, tricyclic antidepressants, and norepinephrine reuptake inhibitors. Benzodiazepines can be effective but are not recommended as a first-line treatment due to dependence risks. Discontinuation of caffeine and other stimulants can also reduce anxiety symptoms.

Epidemiology

Panic disorder affects about 2.5% of people at some point in their life, typically beginning in adolescence or early adulthood. Women are more likely than men to develop panic disorder. The prevalence and incidence rates are similar across the globe, with higher rates in North America, Oceania, and Europe for women. Panic disorder can continue for months or years if left untreated and may significantly impact personal relationships, education, and employment.

Children

About 40% of adult patients report that their disorder began before the age of 20. Symptoms in children mirror those in adults but may be harder for them to articulate. Parents play a very important role in treatment, which involves cognitive behaviour therapy adapted for children. Despite evidence of early-onset panic disorder, it is not currently recognised in the DSM-IV-TR list of anxiety disorders for children.

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Self-assessment MCQs (single best answer)

What is a common symptom of a panic attack?

Which therapy is most effective for treating panic disorder?

What is the first-line pharmacotherapeutic option for panic disorder?

What is a potential risk of using benzodiazepines for treating panic disorder?

What is the typical duration of a panic attack?

Which part of the brain is implicated in the causes of panic disorder?

What is the primary method of diagnosing panic disorder?

Which demographic is more likely to develop panic disorder?

What percentage of people are affected by panic disorder at some point in their life?

What is an effective non-medication treatment for panic disorder?