Panic disorder

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Panic disorder
ICD-10	F41.0
ICD-9	300.01, 300.21
DiseasesDB	30913
MedlinePlus	000924

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Yashasvi Aryaputra[3]

Overview

Panic disorder is a psychiatric condition 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. Panic disorder sufferers usually have a series of intense episodes of extreme anxiety, known as panic attacks. These attacks typically last 10 minutes, however, they can be short-lived at around 1-5 minutes as well. 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, clinical depression, 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.). As a result, as many as 36% of all individuals with panic disorder also have agoraphobia. If not treated,insomnia and/or anorexia can occur.

Historical Perspective

• Panic Disorder has a long history, dating back to folklores.
• Greek Mythology has one of the examples. The term 'Panic' originated from the Greek god, Pan who was responsible for anxiety.
• In Greek myths, 'Pan' was a man with horns and legs of a goat. His mere appearance was so frightening that it developed irrational fear in people, without any apparent reason. This came to be known as panic attacks or terrors.
• Fear of meeting Pan once more made travelers stop going to the market. In Greek, agora stands for market and this led to the development of the term 'agoraphobia'. It stands for the fear of public places or large open spaces.
• In 1621, Burton elaborated different varieties of pathological anxiety. He related the anxiety to delirium, depersonalization, hypochondria, hyperventilation, and a variety of phobias.
• In 1812, Benjamin Rush (father of American psychiatry), described the relation between somatic causes and phobias in his book. He established an association between depression and hypochondriasis.
• In 1879, Henry Maudsley elaborated a melancholic panic, and also used the term panic for the first time in psychiatry.
• Sigmund Freud, in the year 1925, described the condition of anxiety neurosis. He separated anxiety neurosis from neurasthenia and further explained it with a particular clinical presentation.
• In 1964, Klein elaborated the three types of panic attacks: situational (related to agoraphobia), spontaneous, and in response to a stimulus (like height, animals, etc.).

Classification

• In 1980, due to Klein's description of panic attacks,for the first time panic disorder was described in DSM-III.
• After consistent work on DSM forthe next seven years, in 1987, DSM-III-R described agoraphobia as a consequence of panic disorder. So, agoraphobia was divided into 'panic disorder with and without agoraphobia'.
• In 1992, DSM-IV also defined panic attacks to occur in relation to other conditions. It was not required to fulfill all the criteria for panic disorder.
• A revised version of DSM-IV was published in 2000, entitled DSM-IV-TR, in which the criteria for panic disorder remained the same.
• DSM-5 has unlinked panic disorder and agoraphobia.
• The tenth edition of International Classification of Diseases (ICD-10) describes agoraphobia as a distinct condition that may not occur with panic attacks.

Pathophysiology

• Multiple factors are associated with the pathophysiology of panic disorder.
• Imbalance of neurobiological, neuroanatomic, and neurochemical factors produce this condition.
• Pathogenesis of Panic Disorder is associated with the amygdala, which is the hub of emotions like fear processing. MRI studies have further substantiated this finding by revealing lesser left and right-sided amygdalar volumes in panic disorder patients as compared to controls.
• There is also dysregulation of the prefrontal cortex and the subcortical components.
• The patients with panic disorder are also hypothesized to have higher noradrenergic neuronal activity than controls.
• Another neurochemical theory suggests that these patients have deficient serotonergic inhibition of neurons in the dorsal periaqueductal gray matter of the midbrain and the rostral ventrolateral medulla.
• The endogenous opioids buffer the panic attacks in normal subjects, and their deficit results in the development of panic disorder.
• Panic disorder patients have also been found to have lower total occipital cortex GABA levels. Evidence by other studies suggest a dysfunction of GABA(A) receptors in the pathophysiology of panic disorder. This is further illustrated by improvement in symptoms by treatment focussing on GABA binding site of the GABA(A) and benzodiazepine receptor complex.

Differential Diagnosis

There are some medical and psychiatric conditions with symptomatology mimicking panic disorder-

• Anxiety disorder due to other medical condition

• Hyperthyroidism
• Hyperparathyroidism
• Pheochromocytoma
• Vestibular dysfunctions
• Seizure disorders
• Sleep apnea
• Cardiopulmonary conditions

• Arrhythmias
• Supraventricular tachycardia
• Asthma
• Chronic obstructive pulmonary disease

• Other mental disorders with panic attacks as an associated feature

• Other anxiety disorders
• Psychotic disorders

• Other specified anxiety disorder or unspecified anxiety disorder
• Substance/medication-induced anxiety disorder

• Cocaine
• Amphetamines
• Caffeine
• Cannabis
• Withdrawal from central nervous system depressants (e.g., alcohol, barbiturates)

Epidemiology and Demographics

Prevalence

• The 12-month prevalence of the panic disorder is 2,000-3,000 per 100,000 (2%-3%) of the overall population.
• 2.7-7.1% of the general population suffers from a lifetime prevalence of panic disorder, means having repeated panic attacks.

Gender

• Women are twice as likely as men to develop the panic disorder.
• Similar age at onset of Panic Disorder is observed for men and women. Preceding premorbidity was found to be different for men and women.
• Men had higher rates of body dysmorphic disorder, cyclothymia, and depersonalization preceding panic disorder. Whereas, women had higher rates of bulimia nervosa. Life stressors played a significant role in precipitating Panic Disorder in women.

Age

• Anticipation is characterized by the decrease in age at onset and/or the increase in severity of a disorder in successive generations. It helps in exploring the genetic basis of some familial illness.
• Anticipation is observed in panic disorder and the is responsible for the familial aggregation of this condition.
• There is an increased risk of panic disorder in relatives of individuals with panic disorder onset at or before the age of 20 years. The age of onset is useful in determining the familial subtypes of panic disorder.

Race

• Various studies presented with mixed results.
• A study comparing the White, African American, Asian, and Latino groups found that the White group had higher rates of panic disorder, as compared to the African American, Latino, and Asian groups.

Risk Factors

Several factors can increase the chances of development of Panic Disorder-

• Asthma
• Childhood sexual and physical abuse
• Genetic predisposition
• History of "fearful spells"
• Identifiable stressors

• Interpersonal stressors
• Stressors related to physical well-being

• Negative experiences with illicit or prescription drugs
• Disease
• Death in the family

• Negative affectivity (neuroticism)
• Offspring of parents with anxiety, depressive, and bipolar disorders
• Separation anxiety in childhood
• Smoking

Natural History, Complications, and Prognosis

• Anxiousness and overadaptation in people with panic disorder begins in childhood. This can be the result of traumatic life events or distressing family conditions.

Diagnostic Criteria

DSM-V Diagnostic Criteria for Panic Disorder

“

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur; Note:The abrupt surge can occur from a calm state or an anxious state. 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chills or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. AND B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”). 2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). AND C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). AND D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder:in response to circumscribed phobic objects or situations, as in specific phobia:in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in post traumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).

”

Treatment

Panic Disorder is real and potentially disabling, but it can be controlled and successfully treated. 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.

Some individuals with panic disorder have turned to 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.

Medications can be used to break the psychological connection between a specific phobia and panic attacks. Medications can include:

• antidepressants (SSRIs, 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.

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% abuse psychoactive drugs. This is in comparison with 61% (alcohol)[4] and 7.9% (other psychoactive drugs) [5] 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.[6] However, generally only new marijuana users experience anxiety because they are not used to their heart rate temporarily being increased.[7]

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.

• 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 vigilante

• 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.

• Transcranial electrical stimulation can be used to treat the anxiety aspects of panic disorder. Otherwise, there is no other strong evidence for brain stimulation therapy being used to treat panic disorders.

References

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