Understanding and Treating Panic Disorder

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When a person perceives there is danger, a fight-or-flight response sets into motion many physiological changes that prepare him or her to address the danger. Heart rate and breathing speed up, blood pressure rises; the person is energized and, hopefully, ready to meet the challenge.

Just as it helped the caveman defend against (or run from) the sabre-toothed tiger, the fight-or-flight response helps us address modern day dangers (eg, getting out of the way of a moving vehicle).

For many people who have panic attacks, the intense anxiety may be related to the fight-or-flight response occurring in the absence of real danger. Consider the following scenario: A person notices that his or her heart rate is faster than usual. He or she begins to worry that there is a health crisis occurring. This perceived danger triggers the fight-or-flight response. But there is no clear way to respond, and so the fear increases. The fight-or-flight response intensifies.

Imagine what it is like to suffer from panic disorder. For people who suffer from this disorder, a panic attack can come on suddenly, often without warning. There may be a feeling that catastrophe is about strike. They may experience physical symptoms such as a pounding heart, shortness of breath, or dizziness. They may have a feeling they are about to die of a heart attack or that they are going crazy.

Although their terror is not based in reality, it all feels very real.

As it is currently conceptualized in the DSM-IV-TR, panic disorder can occur with or without agoraphobia. This article will describe what is involved in determining whether an individual has panic disorder and how to treat it.

First, let’s define the terms panic attack and agoraphobia as described in the DSM-IV-TR. The DSM-IV-TR defines a panic attack as “a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom.” More specifically, four or more of the following symptoms develop abruptly, peaking within 10 minutes:

  • 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, or faint
  • derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • fear of losing control or going crazy
  • fear of dying
  • paresthesias (numbness or tingling sensations)
  • chills or hot flushes

The DSM-IV-TR describes the essential feature of agoraphobia as “anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a panic attack or panic-like symptoms (eg, fear of having a sudden attack of dizziness or a sudden attack of diarrhea).”

The Prevalence of Panic Disorder

Let’s look at the epidemiology of panic disorder among adults in the United States.

Different methodologies result in different findings regarding the prevalence of panic disorder. According to statistics from the National Institute of Mental Health (NIMH), 4.7% of adults have had panic disorder in their lifetimes (http://1.usa.gov/UraFxY). The NIMH indicates 2.7% of adults have a current (past 12 months) panic disorder, with almost half (44.8%) of those adults having severe panic disorder. The median age of onset of panic disorder is 24 years of age. Panic disorder is uncommon in early childhood, with peaks of onset occurring in late adolescence and in the mid-thirties. It is unusual for panic disorder to begin in individuals older than 45 years of age.

Agoraphobia is common in panic disorder. Data cited in the DSM-IV-TR indicate that a majority of individuals seen clinically for panic disorder also have agoraphobia. Even though the rate of agoraphobia in non-clinical (ie, community) samples is lower than in clinical samples, it is still substantial with agoraphobia occurring in one-third to one-half of individuals with panic disorder.

Does panic disorder run in families? The answer is ‘yes.’ Having a first-degree biological relative (ie, a parent, sibling, or offspring) with panic disorder increases the likelihood of having the disorder (currently or in the past or future) by at least eightfold. That said, it is also the case that many individuals with panic disorder do not have any close relatives with panic disorder, as reflected by data showing that to be the case in 50% to 75% of panic disorder clients seen by health practitioners.

Establishing a Diagnosis

Any diagnosis of panic disorder entails the assessment that the panic attacks are recurrent and unexpected. In order to diagnosis a client with panic disorder, the individual must have, for at least one month after a panic attack, at least one of the following: a) a persistent concern about having additional panic attacks; b) worry about what might happen if he or she has another panic attack (eg, that he or she might lose control, have a heart attack, or ‘go crazy’); or c) a significant behavioral change related to the panic attacks.

So, if a person has a panic attack, it does not necessarily mean that a panic disorder diagnosis is indicated. For example, if the individual has had only one panic attack, the diagnosis is not made. Similarly, if the panic attacks are recurrent, but predictable, or if they are not a concern to the individual, the diagnosis is not made.

And there are other circumstances in which an individual who has a panic attack does not necessarily have panic disorder. For example, a panic attack is not a diagnostic indicator of panic disorder if it is a direct physiological result of a substance. A panic attack can be brought on by the use of an illicit substance or even a properly used medication. It can be brought on by stimulant intoxication (whether from caffeine, amphetamines, or cocaine) or withdrawal from central nervous system depressants, such as alcohol or barbiturates. Similarly, a panic attack is not a diagnostic indicator of panic disorder if it is a direct physiological result of a medical condition (eg, hyperthyroidism, seizure disorders, a cardiac arrhythmia, or tachycardia). However, after that, if the panic attacks recur in the absence of the use of the substance or in the absence of the medical source event, panic disorder may have developed, and thus could be an appropriate diagnosis.

Finally, as is generally the case when making diagnoses, it is important to determine whether something else may account for the symptoms. In the case of panic attacks, it is particularly important to ascertain that they are not better accounted for by other disorders, such as posttraumatic stress disorder, obsessive-compulsive disorder, or another anxiety disorder (eg, social anxiety disorder or any of a number of specific phobias).

How to Treat Panic Disorder

Currently, the treatments with the most data to support their use for panic disorder are cognitive-behavior therapy (CBT), pharmacotherapy, and CBT plus pharmacotherapy. Another psychotherapy option is psychodynamic psychotherapy, for which there are good preliminary data (eg, Busch FN et al, J Am Psychoanalytic Assoc 2009;57(1):131–148).

There are several components that comprise CBT for panic disorder. Just which components get applied may vary on a case-by-case basis. Among the components that are used are cognitive restructuring, interoceptive exposure, in vivo exposure, breathing exercises, relaxation exercises, and self-monitoring. The first three of these are described here, as used in a study of panic disorder treatment (Van Apeldoorn F et al, J Clin Psychiatry 2010;71(5):574–586, derived from the work of Clarke DM, Beh Res and Therapy 1986;24(4):461–470; Craske MG and Barlow DH, Panic disorder and agorapobia. In Barlow DH, ed. Clinical handbook of psychological disorders. New York, NY: Guilford Press; 1993:1–47.

Cognitive restructuring. First, there’s the cognitive therapy part, which includes what is often referred to as cognitive restructuring. Cognitive therapy entails identifying the client’s beliefs, appraisals, and assumptions. Clients are taught to assess their cognitions by considering all the available evidence and actively collecting the new evidence. What kinds of automatic appraisals do they make (eg, “If I panic, I will lose control”)? In a sense, this is a person-as-scientist model in which the client is taught to make the appraisals more accurate by generating and testing alternative hypotheses. In this way, for example, the client’s conclusion of “If I panic, I will lose control,” becomes one of several hypotheses to be tested, enabling the client to see that, based on evidence, other hypotheses may be more accurate, such as, “Even if I panic, I will not lose control.”

Interoceptive exposure. A second aspect of CBT may entail interoceptive exposure, which is designed to help the client become less fearful of, or even comfortable with, bodily sensations that have become associated with panic. Interoceptive exposure involves provoking bodily sensations that have been associated with panic. Examples are a) provoking dizziness/loss of balance by turning to look behind oneself quickly while walking, and b) engaging in aerobic activities that increase heart rate (appropriate to the individual’s physical health status). Applying these techniques teaches clients that “bodily sensations can indeed be provoked, that these sensations spontaneously subside, and that these sensations are not dangerous, and are not followed by any harmful consequences.”

In vivo exposure. A third aspect of CBT is in vivo exposure, which entails constructing an individualized fear hierarchy. This approach includes between-session assignments in which clients try to stay in the feared situation (starting with less feared situations) until their anxiety levels have substantially decreased. During the in vivo exposure experiences, the clients are not permitted to use ‘safety-seeking behaviors.’ Examples of safety seeking behaviors are walking close to structures to provide a sense of physical support or tightly gripping the steering wheel while driving due to fear of losing control. (Examples of safety-seeking behaviors are from Barlow DH and Craske MG, Mastery of Your Anxiety and Panic. New York, NY: Oxford University Press; 2007.)

Course of Treatment

Although treatment for panic disorder tends to be somewhat structured and time-limited, determining the specific length of time and the degree of structure will depend on many factors. In some cases, simply educating a client about panic disorder is all that is required. Once the client re-attributes the panicky feelings to anxiety, rather than to a heart attack or to ‘going crazy,’ the panic attacks may stop occurring. At the other extreme, panic disorder can be resistant to treatment, with treatment requiring longer than the hoped-for, brief one to twelve session course of treatment.

TCRBH’s Verdict: Treatment that takes longer than expected may occur for any of a number of reasons. Perhaps there is an undiagnosed comorbid condition. Perhaps there is not a good therapist-client match. Maybe, despite CBT being the standard nonmedication treatment of choice, this specific client would benefit from a different type of treatment (eg, the addition of pharmacotherapy, or a change to another type of psychotherapy). If a client with panic disorder does not show improvement relatively quickly, this suggests that a change (perhaps a tweak or perhaps a major shift in the treatment ) is needed.

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