Panic disorders

What is it?

Panic disorder is a type of anxiety disorder. A person with panic disorder has panic attacks. These are repeated, unexpected episodes of intense fear and anxiety accompanied by physical symptoms that are similar to the body's normal response to danger.

If you are truly in danger (for example, if you are confronted by a criminal with a gun), your body readies itself for "fight or flight." Heart rate increases. Blood rushes to arm and leg muscles, causing a trembling or tingling sensation. You may sweat and become flushed. You become intensely fearful, aroused and very alert. For people having a panic attack, these changes occur even though there is no physical threat. At the height of a panic attack, there may be a frightening feeling that the environment has somehow become unreal or detached. The person may worry about dying, having a heart attack, losing control or "going crazy."

Some people with panic disorder have several panic attacks every day, while others go weeks or months between attacks. Since panic attacks occur without warning even during sleep people who suffer from panic disorder are usually anxious that an attack may begin at any moment. They worry not only about the psychological pain and physical discomfort of the panic attack, but also that their extreme behavior during a panic episode might embarrass them or frighten others. This unshakable fear and anticipation eventually may lead to avoiding public places where it would be difficult or embarrassing to make a sudden exit.

This fear is called agoraphobia. People who have agoraphobia may, for example, avoid attending a performance in a crowded stadium or movie theater; waiting in line at a store; traveling on a bus, train or plane; or driving on roads that have bridges or tunnels. If this symptom is pronounced enough, a doctor may assign "agoraphobia" as an additional diagnosis.

Although researchers do not completely understand why some people develop panic disorder, they believe that the illness involves a disturbance in brain pathways that regulate emotion. Also, it is possible that people with panic disorder may have inherited a "fight or flight" response that is either more sensitive than normal or responds more intensely than usual.

Studies of close relatives of people with panic disorder show that this disease has a genetic (inherited) basis. These relatives are four to eight times more likely to develop the illness than people with no family history of the problem. Women are two times more likely than men to have panic disorder, and about three times more likely to develop agoraphobia. On average, symptoms start at around age 25, but panic disorder and agoraphobia can affect people of all ages.

Some people with panic disorder first develop symptoms after a stressful life event, such as divorce, job loss or a death in the family. Scientists still do not understand exactly how panic attacks are triggered, but there is growing evidence that stress early in life makes a person more likely to develop panic symptoms.

People who have panic disorder have a relatively high risk for developing other types of psychiatric problems. In fact, at the time of diagnosis, more than 90% of people with panic disorder also have major depression, another anxiety disorder, a personality disorder or some form of substance abuse.

Symptoms

A panic attack is defined by having at least four of the following symptoms:

• palpitations, heart pounding or a rapid pulse
• sweating
• trembling or shaking
• breathing problems, such as shortness of breath or feeling smothered
• feeling of choking
• chest pain or chest discomfort
• abdominal discomfort, upset stomach or nausea
• feeling faint, dizzy, light-headed or unsteady on your feet
• feeling unreal or detached from yourself
• fear of losing control
• fear of dying
• numbness or tingling in arms, legs or other parts of the body
• chills or hot flushes.

Between panic attacks, someone with panic disorder usually has persistent worries that a new attack will occur. These worries may cause the person to dramatically change his or her behavior or lifestyle to avoid the embarrassment of "losing control" while with other people.

Diagnosis

If you develop panic disorder, you may consult a primary care doctor first because the physical symptoms often make the person feel like they're having a heart attack, a stroke or a breathing problem. Many medical illnesses can cause symptoms that mimic panic attacks, including heart disease, asthma, cerebrovascular disease, epilepsy, hormone abnormalities, infections and disturbances in levels of certain blood chemicals.

Symptoms of a panic attack can also be triggered by the use of amphetamines, cocaine, marijuana, hallucinogens, alcohol and other drugs, as well as by certain prescription medications.

A doctor may do tests to rule out medical problems, but the results of these tests will usually be normal. The doctor may then ask you questions about your family history; psychiatric history; current anxieties; recent stresses; and daily use of prescription and nonprescription drugs, including caffeine and alcohol. If your doctor suspects that the problem is panic disorder, he or she will refer you to a mental health professional for care.

A mental health professional will do a full evaluation that includes:

• questions about thoughts, feelings and physical symptoms during a panic attack
• asking about thoughts, feelings and behaviors between attacks
• checking for symptoms of other forms of psychiatric illness.

Expected duration

Panic disorder can be long-lasting, especially if it is not treated. Fortunately, it is a very treatable illness. With proper care, many people find long-term relief from their symptoms.

Prevention

There is no way to prevent panic disorder. However, if you have been diagnosed with panic disorder, you may be able to prevent panic attacks by cutting down on caffeine, alcohol or other substances that might be triggering your symptoms. Once a diagnosis is made, treatment often eliminates panic attacks or makes them less intense.

Treatment

If you have panic attacks, there are several treatment options both medications and psychotherapy.

Antidepressants – Despite their name, many of these drugs are very effective for anxiety. They are used very commonly to treat generalized anxiety disorder. The popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft) and escitalopram (Lexapro) are often the first choice. Antidepressants that have a different mechanism of action work too. Examples are mirtazapine (Remeron), venlafaxine (Effexor) and duloxetine (Cymbalta). Older antidepressants are also effective, but may have more troublesome side effects. They include tricyclic antidepressants (for example, nortriptyline, imipramine) and monoamine oxidase inhibitors (MAOIs, for example, phenelzine).

Since antidepressants often take several weeks to work, your doctor may also prescribe a fast-acting benzodiazepine for relief.

Benzodiazepines – These drugs affect a chemical messenger that works in the brain's fear response system. The first two benzodiazepines — chlordiazepoxide (Librium) and diazepam (Valium) — were discovered in the early 1960s. Common, newer benzodiazepines are clonazepam (Klonopin) and lorazepam (Ativan). They are reasonably safe when taken as directed and often bring quick relief from symptoms of anxiety. Since they act immediately, they may be prescribed during the first weeks of treatment while waiting for an antidepressant medication to take hold.

Another reason these drugs are prescribed for a relatively short time is that the body sometimes becomes accustomed to the effect. That is, benzodiazepines may provide less relief as time goes on. If you need to stop taking these drugs, do so gradually under a doctor's direction, because withdrawal reactions can occur.

The FDA requires all benzodiazepines to carry the strongest warning regarding the risks of dependency, addiction, or withdrawal symptoms. The FDA also emphasized the importance of not combining a benzodiazepine drug with an opioid because it can stop a person's breathing.

Cognitive therapy – This nondrug therapy is designed to help a person with panic attacks recognize the unreasonableness of the fears that cause panic. The therapist will often teach specialized techniques to help manage the attacks.

Behavior therapies – These treatments include in vivo exposure, a form of behavior therapy that gradually exposes the person to fear-provoking situations; respiratory training, a technique that focuses on breath control as a way of fighting panic; and applied relaxation, a method that teaches the patient to control his or her anxiety level by using muscle control and imagination. For many patients, the most effective approach is a combination of one or more medications, plus some form of cognitive or behavior therapy.

When To Call a Professional

If you have symptoms of a panic attack, and you have never been diagnosed with panic disorder, seek medical help immediately. Remember, symptoms of a panic attack can mimic those of many life-threatening medical illnesses. For this reason, a doctor should evaluate your problem comprehensively.

Prognosis

With appropriate treatment, the prognosis is good. Between 30% and 40% of patients become symptom-free for extended periods, while another 50% continue to experience only mild symptoms that do not significantly affect daily life.

Additional info

American Psychiatric Association
https://www.psychiatry.org/

National Institute of Mental Health
https://www.nimh.nih.gov/

Anxiety and Depression Association of America
https://www.adaa.org/