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Panic disorder

Panic disorder

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Panic disorder is an anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...

 characterized by recurring severe panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...

s. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks (DSM-IVR). Panic disorder is not the same as agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...

 (fear of public places), although many 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. There are other schools of thought that Panic disorder is differentiated as a medical condition, or chemical imbalance
Chemical imbalance
Chemical imbalance is one hypothesis about the cause of mental illness. Other causes that are debated include psychological and social causes....

. The DSM-IV-TR describes Panic disorder and Anxiety differently. Panic attacks have a sudden or out-of-blue cause that lasts shorter with more intense symptoms, as opposed to Anxiety attacks having stressors that build to less severe reactions and can last for weeks or months. Panic attacks can occur in children, as well as adults. Panic in young people may be particularly distressing because the child has less insight about what is happening, and his/her parent is also likely to experience distress when attacks occur.

Screening tools like Panic Disorder Severity Scale
Panic Disorder Severity Scale
The Panic Disorder Severity Scale is a questionnaire developed for measuring severity of panic disorder. The clinician-administered PDSS is intended to assess severity and considered a reliable tool for monitoring of treatment outcome...

 can be used to detect possible cases of disorder, and suggest the need for a formal diagnostic assessment.

Background


Panic disorder is a potentially disabling disorder, but can be controlled and successfully treated. Because of the intense symptoms that accompany panic disorder, it may be mistaken for a life-threatening physical illness such as a heart attack
Myocardial infarction
Myocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...

. This misconception often aggravates or triggers future attacks (some are called Anticipatory 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. Nonetheless, Coryell et al. found death rates in panic disorder patients exceeded those in the general population. In their study, 20% of deaths in 113 former psychiatric inpatients with panic disorder followed 35 years later were suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...

s; however, due to the co-morbidity of anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...

s, it is unclear whether panic disorder was the main cause of suicide. This study also found that men with panic disorder had twice the risk of cardiovascular mortality compared to men in the general population. Effective treatment of panic disorder has been shown to offset costs of medical care by as much as 94%. There are three types of panic attacks: unexpected, situationally bounded and situationally predisposed (American psychiatric association 2000).

Signs and symptoms


Panic disorder sufferers usually have a series of intense episodes of extreme anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

 during panic attacks. These attacks typically last about ten minutes, but can be as short-lived as 1–5 minutes and last as long as twenty minutes or until medical intervention. However, 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. Common symptoms of an attack include rapid heartbeat
Tachycardia
Tachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...

, perspiration
Diaphoresis
Diaphoresis is excessive sweating commonly associated with shock and other medical emergency conditions.Diaphoretic is the state of perspiring profusely, or something that has the power to cause increased perspiration....

, dizziness
Dizziness
Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....

, dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...

, trembling
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...

, uncontrollable fear
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...

 such as; the fear of losing control and going crazy the fear of dying and hyperventilation. Other symptoms are sweating, shortness of breath, sensation of choking, chest pain, nausea, numbness or tingling, chills or hot flashes,faintness 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. There are instances when panic attacks are provoked by exposure to certain stimuli e.g. seeing a mouse. Other attacks may emanate out of nowhere or in specific settings e.g. the dentist's office. 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 (e.g. embarrassment, social stigma, social isolation
Social isolation
Social isolation refers to a lack of contact with society for members of social species. There may be many causes and individuals in numerous generally social species are isolated at times, it need not be a pathological condition. In human society, in those cases where it is viewed as a pathology,...

, etc.).

Limited symptom attack
Limited symptom attack
A Limited Symptom Attack , also referred to as a Limited Symptom Panic Attack , is a milder, less comprehensive panic attack with fewer than 4 panic related symptoms being experienced . For example, a sudden episode of intense dizziness or trembling accompanied by fear that something terrible is...

s are similar to panic attacks, but have fewer symptoms. Most people with PD experience both panic attacks and limited symptom attacks.

Causes


There is no single cause for panic disorder, however, panic disorder has been found to run in families, and suggests that inheritance
Heredity
Heredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause some species to evolve...

 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
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...

, and a genetic predisposition to alcoholism
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...

.

Psychological 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 medication
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...

s. 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.

There is some evidence to suggest hypoglycemia
Hypoglycemia
Hypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...

, hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...

, mitral valve prolapse
Mitral valve prolapse
Mitral valve prolapse is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. There are various types of MVP, broadly classified as classic and nonclassic. In its nonclassic form, MVP carries a low risk of...

, labyrinthitis
Labyrinthitis
Labyrinthitis is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house the vestibular system . Labyrinthitis can cause balance disorders....

, pheochromocytoma
Pheochromocytoma
A pheochromocytoma or phaeochromocytoma is a neuroendocrine tumor of the medulla of the adrenal glands , or extra-adrenal chromaffin tissue that failed to involute after birth and secretes excessive amounts of catecholamines, usually noradrenaline , and adrenaline to a lesser extent...

 and respiratory conditions can cause or aggravate panic disorder.

Prepulse inhibition
Prepulse inhibition
Prepulse Inhibition is a neurological phenomenon in which a weaker prestimulus inhibits the reaction of an organism to a subsequent strong startling stimulus . The stimuli are usually acoustic, but tactile stimuli Prepulse Inhibition (PPI) is a neurological phenomenon in which a weaker...

 has been found to be reduced in patients with Panic Disorder.

Stimulants like caffeine
Caffeine
Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...

, in excess, are a rather common cause for panic attacks. Many SSRI
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...

s also have stimulant side-effects during the beginning of treatment which may exacerbate the condition and have actually caused first-time panic attacks in otherwise healthy individuals being treated for depression.

There are other researchers looking at some individuals with panic disorder as having a chemical imbalance within the limbic system
Limbic system
The limbic system is a set of brain structures including the hippocampus, amygdala, anterior thalamic nuclei, septum, limbic cortex and fornix, which seemingly support a variety of functions including emotion, behavior, long term memory, and olfaction. The term "limbic" comes from the Latin...

 and one of its regulatory chemicals GABA
Gabâ
Gabâ or gabaa, for the people in many parts of the Philippines), is the concept of a non-human and non-divine, imminent retribution. A sort of negative karma, it is generally seen as an evil effect on a person because of their wrongdoings or transgressions...

-A. The reduced production of GABA-A sends false information to the amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...

 which regulates the body's "fight or flight response" mechanism and in return, produces the physiological symptoms that lead to the disorder. Clonazepam, an anticonvulsant benzodiazepine with a long half-life, has been successful in keeping the condition in check http://www.psychweekly.com/aspx/article/articledetail.aspx?articleid=547.

Mediators and Moderators of Panic Disorder


Recently, researchers have begun to identify mediators and moderators of aspects of panic disorder. One such mediator is the partial pressure of carbon dioxide, which mediates the relationship between panic disorder patients receiving breathing training and anxiety sensitivity; thus, breathing training affects the partial pressure of carbon dioxide in a patient’s arterial blood, which in turn lowers anxiety sensitivity. Another mediator is hypochondriacal concerns, which mediate the relationship between anxiety sensitivity and panic symptomatology; thus, anxiety sensitivity affects hypochondriacal concerns which, in turn, affect panic symptomatology.

Perceived threat control has been identified as a moderator within panic disorder, moderating the relationship between anxiety sensitivity and agoraphobia; thus, the level of perceived threat control dictates the degree to which anxiety sensitivity results in agoraphobia. Another recently-identified moderator of panic disorder is genetic variations in the gene coding for galanin
Galanin
Galanin is a neuropeptide encoded by the GAL gene, that is widely expressed in the brain, spinal cord, and gut of humans as well as other mammals. Galanin signaling occurs through three G protein-coupled receptors....

; these genetic variations moderate the relationship between females suffering from panic disorder and the level of severity of panic disorder symptomatology.

Substance abuse and panic disorder


A growing body of evidence exists that shows a link between substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...

 and panic disorder.

Smoking

Several studies have found that cigarette smoking increases the risk of panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...

s and panic disorder in young people.
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
Respiratory system
The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...

 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. Respiratory abnormalities have been found in children with high levels of anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...

, which suggests that a person with these difficulties may be susceptible to panic attacks, and thus more likely to subsequently develop panic disorder. Nicotine
Nicotine
Nicotine is an alkaloid found in the nightshade family of plants that constitutes approximately 0.6–3.0% of the dry weight of tobacco, with biosynthesis taking place in the roots and accumulation occurring in the leaves...

, a stimulant
Stimulant
Stimulants are psychoactive drugs which induce temporary improvements in either mental or physical function or both. Examples of these kinds of effects may include enhanced alertness, wakefulness, and locomotion, among others...

, could contribute to panic attacks. However, nicotine withdrawal
Nicotine withdrawal
Nicotine withdrawal is a term used to describe the effects felt by a person who is nicotine dependent and suddenly stops or significantly reduces his/her nicotine intake. Since smoking cigarettes is the most popular form of nicotine use, the effects of nicotine withdrawal have been most commonly...

 may also cause significant anxiety which could contribute to panic attacks.

Alcohol and sedatives

About 30% of people with panic disorder use alcohol
Alcoholic beverage
An alcoholic beverage is a drink containing ethanol, commonly known as alcohol. Alcoholic beverages are divided into three general classes: beers, wines, and spirits. They are legally consumed in most countries, and over 100 countries have laws regulating their production, sale, and consumption...

 and 17% use other 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. Utilization of recreational drugs or alcohol generally make symptoms worse. 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.

Deacon and Valentiner (2000) 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
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....

 and sedative
Sedative
A sedative or tranquilizer is a substance that induces sedation by reducing irritability or excitement....

 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) that panic disorder patients self-medicate
Self-medication
Self-medication is a term used to describe the use of drugs or other self-soothing forms of behavior to treat untreated and often undiagnosed mental distress, stress and anxiety, including mental illnesses and/or psychological trauma...

 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.

While alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...

 initially helps ease panic disorder symptoms, medium- or long-term alcohol abuse can cause panic disorder to develop or worsen during alcohol intoxication, especially during alcohol withdrawal syndrome
Alcohol withdrawal syndrome
-Protracted withdrawal:A protracted alcohol withdrawal syndrome occurs in many alcoholics where withdrawal symptoms continue beyond the acute withdrawal stage but usually at a subacute level of intensity and gradually decreasing with severity over time. This syndrome is also sometimes referred to...

. This effect is not unique to alcohol but can also occur with long term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquilizers to people with alcohol problems. The reason chronic alcohol misuse worsens panic disorder is due to distortion of the brain chemistry and function.

Approximately 10% of patients will experience notable protracted withdrawal symptoms, which can include panic disorder, after discontinuation of benzodiazepines. Protracted withdrawal symptoms tend to resemble those seen during the first couple of months of withdrawal but usually are of a subacute level of severity compared to the symptoms seen during the first 2 or 3 months of withdrawal. It is not known definitively whether such symptoms persisting long after withdrawal are related to true pharmacological withdrawal or whether they are due to structural neuronal damage as result of chronic use of benzodiazepines or withdrawal. Nevertheless such symptoms do typically lessen as the months and years go by eventually disappearing altogether.

A significant proportion of patients attending mental health services for conditions including anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...

s such as panic disorder or social phobia
Social anxiety
Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...

 have developed these conditions as a result of alcohol or sedative
Sedative
A sedative or tranquilizer is a substance that induces sedation by reducing irritability or excitement....

 abuse. Anxiety may pre-exist alcohol or sedative independence, which then acts to perpetuate or worsen the underlying anxiety disorder. Someone suffering the toxic effects of alcohol abuse or chronic sedative use or abuse will not benefit from other therapies or medications for underlying psychiatric conditions. as they do not address the root cause of the symptoms. Recovery from sedative Symptoms may temporarily worsen during alcohol withdrawal or benzodiazepine withdrawal. The World Council of Anxiety does not recommend benzodiazepines for the long term treatment of anxiety disorders due to a range of problems associated with long term use of benzodiazepines including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence
Physical dependence
Physical dependence refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction...

 and a benzodiazepine withdrawal syndrome
Benzodiazepine withdrawal syndrome
Benzodiazepine withdrawal syndrome—often abbreviated to benzo withdrawal—is the cluster of symptoms which appear when a person who has taken benzodiazepines long term and has developed benzodiazepine dependence stops taking benzodiazepine drug or during dosage reductions...

 upon discontinuation of benzodiazepines.

Panic Attack DSM Disorder Criteria Summary include: Palpitations, pounding heart, or accelerated heart rate, sweating, trembling or shaking, Sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, Nausea or abdominal distress, Feeling dizzy, unsteady, lightheaded, faint, derealization, fear of losing control or going crazy, fear of dying, paresthesias, chills or hot flushes. This is DSM Disorder Criteria Summary for panic attacks.

Diagnosis


The DSM-IV-TR diagnostic criteria for panic disorder require unexpected, recurrent panic attacks, followed in at least once 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.

Treatment


Identification of treatments that engender as full a response as possible, and can minimize relapse, is imperative. Cognitive behavioural therapy is the treatment of choice for panic disorder. When cognitive behavioural therapy is not an option pharmacotherapy can be used. SSRIs are considered a first line pharmacotherapeutic option.

In addition, people with panic disorder may need treatment for other emotional problems. Comorbid clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...

, personality disorders and alcohol abuse
Alcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...

 are known risk factors for treatment failure.

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.

Current treatment guidelines American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...

 and the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

 primarily recommend either cognitive-behavioral therapy or one of a variety of psychopharmacological interventions. Some evidence exists supporting the superiority of combined treatment approaches.

Psychotherapy


Panic Disorder is not the same as phobic symptoms, although phobias commonly result from panic disorder. CBT and one tested form of psychodynamic psychotherapy
Psychodynamic psychotherapy
Psychodynamic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. In this way, it is similar to psychoanalysis. It also relies on the interpersonal relationship between client...

 have been shown efficacious in treating panic disorder with and without agoraphobia. A number of randomized clinical trials have shown that CBT achieves reported panic-free status in 70-90% of patients.

For children with panic disorder, CBT is the only scientifically-proven psychotherapeutic treatment. The methods used are similar to those used with adults, but may be modified to be developmentally-appropriate

Cognitive behavioral therapy is seen as the most effective form of treatment for people who experience panic attacks. This type of therapy focuses on the thinking patterns and behaviors that people continue to engage in without noticing that they may be the cause of their panic attacks. The acceptability and low cost of CBT makes it a very valued option in treating panic disorder. Below are several strategies that have been proven to be effective in decreasing anxiety for many people with panic disorder :

Thought stoppage and Calmative Breathing:
When a negative thought comes into the mind, it is important for the person to recognize and the label the thought as negative. The person should say “STOP” and should inhale deeply for four seconds, hold their breath for four more seconds, and exhale through pursed lips, always at the appearance of a negative thought.

Cortical Shifting:
In cortical shifiting, the person can shift their thoughts to something else in order to reduce their anxiety. There are twelve things the person can think about in order to reduce anxiety if they feel an anxiety attack coming on: three things you can do (e.g. count to 100, talk to someone), three things you can see, three things you can hear, or three things you can touch. :

“Best Case Scenario”:
Anxiety causes many people to think of exaggerated catastrophes. One way to dispute and reframe is to create the “best case scenario” which gives the mind other possible and positive alternatives rather than destructive exaggerated ones .

Eye Movement Desensitization and Reprogramming (EMDR):
This is a technique of imaginary desensitization with accompanying eye movements. The participant follows a moving finger at the same time as they are focused on past emotional events. A therapist then coaches progressive relaxation while focusing on past traumatic experiences .

Humor:
As a person gets better with dealing with phobais and obsessions, humor can become a powerful tool. Humor can stop or decrease the amount of adrenaline released into the body that causes subsequent anxiety. Even death, a topic many people with anxiety disorder think about, can be dealt with through humor. Humor is a good way to get rid of anxiety and is a good strategy to implement for overcoming anxiety .

Clinically, a combination of psychotherapy and medication can often produce good results, although research evidence of this approach has been less robust. Some improvement may be noticed in a fairly short period of time — about 6 to 8 weeks. Psychotherapy can improve the effectiveness of medication, reduce the likelihood of relapse for someone who has discontinued medication, and offer help for people with panic disorder who do not respond at all to medication.

The goal of cognitive behavior therapy is to help a patient reorganize thinking processes and anxious thoughts regarding an experience that provokes panic. An approach that proved successful for 87% of patients in a controlled trial is interoceptive therapy, which simulates the symptoms of panic to allow patients to experience them in a controlled environment.

Symptom inductions generally occur for one minute and may include:
  • Intentional hyperventilation – creates lightheadedness
    Lightheadedness
    Light-headedness is a common and often unpleasant sensation of dizziness and/or feeling that one may be about to faint, which may be transient, recurrent, or occasionally chronic. In some cases, the individual may feel as though his or her head is weightless. The individual may also feel as...

    , derealization
    Derealization
    Derealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...

    , blurred vision, dizziness
    Dizziness
    Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....

  • Spinning in a chair – creates dizziness
    Dizziness
    Dizziness refers to an impairment in spatial perception and stability. The term is somewhat imprecise. It can be used to mean vertigo, presyncope, disequilibrium, or a non-specific feeling such as giddiness or foolishness....

    , disorientation
  • Straw breathing – creates dyspnea
    Dyspnea
    Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...

    , airway constriction
  • Breath holding – creates sensation of being out of breath
  • Running in place – creates increased heart rate
    Heart rate
    Heart rate is the number of heartbeats per unit of time, typically expressed as beats per minute . Heart rate can vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep....

    , respiration
    Respiratory system
    The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...

    , 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 three to five 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 and becomes less sensitized or desensitized to the internal sensation. After repeated trials, when nothing catastrophic happens, the brain learns (hippocampus
Hippocampus
The hippocampus is a major component of the brains of humans and other vertebrates. It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation. Humans and other mammals have two hippocampi, one in...

 & amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...

) to not fear the sensations, and the sympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...

 activation fades.

For patients whose panic disorder involves agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...

, the traditional cognitive therapy approach has been in vivo exposure, in which the affected individual, accompanied by a therapist, is gradually exposed to the actual situation that provokes panic.

Another form of psychotherapy which has shown effectiveness in controlled clinical trials is panic-focused psychodynamic psychotherapy, which focuses on the role of dependency, separation anxiety, and anger in causing panic disorder. The underlying theory posits that due to biochemical vulnerability, traumatic early experiences, or both, people with panic disorder have a fearful dependence on others for their sense of security, which leads to separation anxiety and defensive anger. Therapy involves first exploring the stressors that lead to panic episodes, then probing the psychodynamics of the conflicts underlying panic disorder and the defense mechanisms that contribute to the attacks, with attention to transference and separation anxiety issues implicated in the therapist-patient relationship.

Comparative clinical studies suggest that muscle relaxation techniques and breathing exercises are not efficacious in reducing panic attacks. In fact, breathing exercises may actually increase the risk of relapse.

Appropriate treatment by an experienced professional can prevent panic attacks or at least substantially reduce their severity and frequency — bringing significant relief to percent of people with panic disorder. Relapses may occur, but they can often be effectively treated just like the initial episode.

vanApeldoorn, F.J. et al. (2011) demonstrated the additive value of a combined treatment incorporating an SSRI treatment intervention with cognitive behavior therapy (CBT). Gloster et al. (2011) went on to examine the role of the therapist in (CBT). They randomized patients into two groups: one being treated with CBT in a therapist guided environment, and the second receiving CBT through instruction only, with no therapist guided sessions. The findings indicated that the first group had a somewhat better response rate, but that both groups demonstrated a significant improvement in reduction of panic symptomatology. These findings lend credibility to the application of CBT programs to patients who are unable to access therapeutic services due to financial, or geographic inaccessibility. Koszycky et al. (2011) discuss the efficacy of self-administered cognitive behavioural therapy (SCBT) in situations where patients are unable to retain the services of a therapist. Their study demonstrates that it is possible for SCBT in combination with and SSRI to be as effective as therapist-guided CBT with SSRI. Each of these studies contribute to a new avenue of research that allows effective treatment interventions to be made more easily accessible to the population.

Medication


Appropriate medication is highly effective for panic disorder. Although there is little evidence that pharmacological interventions can directly alter phobias, few studies have been performed, and medication treatment of panic makes phobia treatment far easier. Medications can include:
  • Antidepressant
    Antidepressant
    An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...

    s (SSRI
    Selective serotonin reuptake inhibitor
    Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...

    s, MAOIs, tricyclic antidepressant
    Tricyclic antidepressant
    Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...

    s): these are taken regularly every day, and alter neurotransmitter configurations which in turn can help to block symptoms. Although these medications are described as "antidepressants", nearly all of them — especially the tricyclic antidepressants — have anti-anxiety properties, in part, due to their sedative effects. SSRIs have been known to exacerbate symptoms in panic disorder patients, especially in the beginning of treatment and have even provoked panic attacks in otherwise healthy individuals. SSRIs are also known to produce withdrawal symptoms
    Withdrawal syndrome
    A withdrawal syndrome, also called a discontinuation syndrome, occurs when a person suddenly stops taking or reduces the dosage of some types of medications...

     which include rebound anxiety and panic attacks. Comorbid depression has been cited as imparting the worst course, leading to chronic, disabling illness.


Pollack, et al. (2006) compared the efficacy of venlafaxine extended-release, an SNRI against the standard SSRI treatment and a placebo in the treatment of panic disorder. The SNRI demonstrated results comparable in efficacy and tolerability to paroxetine thereby adding another pharmacological treatment option for panic disorder.
  • Anti-anxiety drugs (benzodiazepine
    Benzodiazepine
    A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...

    s): Use of benzodiazepines for panic disorder is controversial with opinion differing in the medical literature. The American Psychiatric Association
    American Psychiatric Association
    The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...

     states that benzodiazepines can be effective for the treatment of panic disorder and recommends that the choice of whether to use benzodiazepines, antidepressants with antipanic properties or psychotherapy should be based on the individual patient's history and characteristics. They reported that in their view there is insufficient evidence to recommend one treatment over another for panic disorder. The APA noted that while benzodiazepines have the advantage of a rapid onset of action, that this is offset by the risk of developing a benzodiazepine dependence
    Benzodiazepine dependence
    Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...

    . The National Institute of Clinical Excellence came to a different conclusion, they pointed out the problems of using uncontrolled clinical trials to assess the effectiveness of pharmacotherapy and based on placebo controlled research they concluded that benzodiazepines were not effective in the long-term for panic disorder and recommended that benzodiazepines not be used for longer than 4 weeks for panic disorder. Instead NICE clinical guidelines recommend alternative pharmacotherapeutic or psychotherapeutic interventions. Other experts believe that benzodiazepines are best avoided due to the risks of the development of tolerance and physical dependence
    Physical dependence
    Physical dependence refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction...

    . The World Federation of Societies of Biological Psychiatry, say that benzodiazepines should not be used as a first line treatment option but are an option for treatment resistant cases of panic disorder. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety as recommended best practice, benzodiazepines have remained a commonly used medication for panic disorder.

Epidemiology



Panic disorder is a serious health problem that in many cases can be successfully treated, although there is no known cure. 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, because of the stigma of mental illness. 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).

Panic disorder in children


A retrospective study has shown that 40% of adult panic disorder patients reported that their disorder began before the age of 20. In an article examining the phenomenon of panic disorder in youth, Diler et al. (2004) found that only a few past studies have examined the occurrence of juvenile panic disorder. They report that these studies have found that the symptoms of juvenile panic disorder almost replicate those found in adults (e.g. heart palpitations, sweating, trembling
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...

, hot flashes, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...

, abdominal distress, and chills). The anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...

s co-exist with staggeringly high numbers of other mental disorders in adults. The same comorbid disorders that are seen in adults are also reported in children with juvenile panic disorder. Last and Strauss (1989) examined a sample of 17 adolescents with panic disorder and found high rates of comorbid anxiety disorders, major depressive disorder, and conduct disorder
Conduct disorder
Conduct disorder is psychological disorder diagnosed in childhood that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated...

s. Eassau et al. (1999) also found a high number of comorbid disorders in a community-based sample of adolescents with panic attacks or juvenile panic disorder. Within the sample, adolescents were found to have the following comorbid disorders: major depressive disorder (80%), dysthymic disorder (40%), generalized anxiety disorder (40%), somatoform disorder
Somatoform disorder
In psychology, a somatoform disorder is a mental disorder characterized by physical symptoms that suggest physical illness or injury - symptoms that cannot be explained fully by a general medical condition, direct effect of a substance, or attributable to another mental disorder . The symptoms that...

s (40%), substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...

 (40%), and specific phobia
Specific phobia
A specific phobia is a generic term for any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations...

 (20%). Consistent with this previous work, Diler et al. (2004) found similar results in their study in which 42 youths with juvenile panic disorder were examined. Compared to non-panic anxiety disordered youths, children with panic disorder had higher rates of comorbid major depressive disorder and bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...

.

Children differ from adolescents and adults in their interpretation and ability to express their experience. Like adults, children experience physical symptoms including accelerated heart rate, sweating, trembling or shaking, shortness of breath, nausea or stomach pain, dizziness or light-headedness. In addition children also experience cognitive symptoms like fear of dying, feelings of being detached from oneself, feelings of losing control or going crazy, but they are unable to vocalize these higher order manifestations of fear. They simply know that something is going wrong and that they are very afraid. Children can only describe the physical symptoms. They have not yet developed the constructs to put these symptoms together and label them as fear. Parents often feel helpless when they watch a child suffer. They can help children give a name to their experience, and empower them to overcome the fear they are experiencing

The role of the parent in treatment and intervention for children diagnosed with panic disorder is discussed by McKay & Starch (2011). They point out that there are several levels at which parental involvement should be considered. The first involves the initial assessment. Parents as well as the child should be screened for attitudes and treatment goals, as well as for levels of anxiety or conflict in the home. The second involves the treatment process in which the therapist should meet with the family as a unit as frequently as possible. Ideally all family members should be aware and trained in the process of cognitive behaviour therapy (CBT) in order to encourage the child to rationalize and face fears rather than employ avoidant safety behaviours. McKay & Starch (2011) suggest training/modeling of therapeutic techniques and in session involvement of the parents in the treatment of children to enhance treatment efficacy.
Despite the evidence pointing to the existence of early-onset panic disorder, the DSM-IV-TR currently only recognizes six anxiety disorders in children: separation anxiety disorder
Separation anxiety disorder
Separation anxiety disorder is a psychological condition in which an individual experiences excessive anxiety regarding separation from home or from people to whom the individual has a strong emotional attachment...

, generalized anxiety disorder, specific phobia
Specific phobia
A specific phobia is a generic term for any kind of anxiety disorder that amounts to an unreasonable or irrational fear related to exposure to specific objects or situations...

, obsessive-compulsive disorder
Obsessive-compulsive disorder
Obsessive–compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors aimed at reducing the associated anxiety, or by a combination of such obsessions and compulsions...

, social anxiety disorder
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...

 (a.k.a. social phobia), and post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...

. Panic disorder is notably excluded from this list.

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