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Panic disorder is an anxiety disorder where people recurrent and unexpected panic attacks and employ subsequent avoidance behaviors that have a major impact on daily life. Treatment may consist of psychoeducation, psychological therapy or medication.

One in four people worldwide will be affected by mental ill-health at some point in their lifetime and anxiety disorders are currently the most commonly experienced mental health issue in the USA. It is estimated that more than 40 million adults (or over 18 percent of the population) experience difficulties every year. While anxiety is often highly responsive to widely available interventions (both professional-led and self-help), less than 40 percent of those struggling with anxiety receive treatment.

We will all experience stress and some symptoms of anxiety during our lives and this is perfectly normal; even adaptable. Anxiety is an emotion is therefore experienced in varying degrees of intensity by different people. At one end of the spectrum it is normal and helps us to function; at another it can be extremely maladaptive and result in considerable distress for the sufferer. It is the duration, intensity, and frequency that separate normal, functional anxiety from abnormal, pathological anxiety.

Panic attacks - what are they? 

As part of anxiety, people may experience panic attacks – anxiety may reach a peak and the result is a panic attack. A panic attack is where the normal response to fear is exaggerated. It can be extremely distressing as when it happens for the first time people often don't understand what is happening: often the physiological symptoms means people believe they are having a heart attack or stroke or another catastrophic medical emergency. They are different from other anxiety symptoms in that they tend to come on suddenly, are focused on the present (rather than worrying about the future as in other forms of anxiety) and are characterized by overwhelming fear and a feeling of needing to escape.

Common symptoms and sensations of a panic attack include:

Physical Symptoms

  • Difficulty breathing

  • Pain or tightness in the chest

  • Palpitations

  • Dissociation – a feeling of being unreal or detached

  • Trembling or shaking

  • Dizziness

  • Perspiring

  • Feeling faint or losing your balance

  • Need to urinate or defecate

  • Ringing in the ears

Psychological Symptoms

  • Feeling out of control

  • Feeling unable to cope

  • Feeling trapped

  • A feeling of intense apprehension

These symptoms are part of normal fight and flight response and would be completely adaptive if we were in danger. When you have a panic attack, the same symptoms are experienced but in the context of no danger. As a result, a person can fear of having another one, or fear to experience the fear itself, in case it leads to an attack. People then employ avoidance behavior which becomes extremely restrictive.

A panic attack is deemed to be where people experience four 4 of the following 13 symptoms:

  • Palpitations or heart racing or thumping

  • Sweating

  • Shakiness or other dyskinetic symptoms

  • Feeling unable to breathe or being short of breath

  • Feeling like you might choke

  • Pain or discomfort in the chest

  • Feeling like you might vomit

  • Dizziness or lightheadedness or fear you might faint

  • Feeling flushed or extremely cold

  • Numbness or "pins and needles"

  • Derealization (a sense of unreality) or depersonalization (detachment from yourself)

  • Fear of loss of control or that you are "going mad"

  • Fear you are going to die.

A limited-symptom panic attack is when someone has less than four symptoms; it usually comprises of feeling short of breath, owing to hyperventilation.

Panic disorder

Panic disorder is thought to affect approximately 5% of the population at some point in their lives, although this figure may be even higher given that the survey used to collect this was undertaken in 2002. It is thought to be more common in women than men and tends to develop in late adolescence to early adulthood. Research suggests that children with more fearful personality types may be more likely to go on to develop panic disorder later in life and, as with other anxiety disorders, there seems to be a family link which may or may not be genetic. As might reasonably be expected, traumatic life experiences (especially sexual abuse) are associated with later development of panic disorder.

If you are diagnosed with panic disorder you will be experiencing regular panic attacks with no apparent trigger, otherwise known as recurrent, unexpected attacks. The panic attacks can seem to “come out of nowhere” and be extremely frightening; unsurprisingly you are then likely to worry about having another panic attack. Expected panic attacks take place in the context of an obvious cue or trigger: for example, as part of a specific phobic disorder or such as generalized anxiety.

Diagnostic criteria for panic disorder 

In addition to the aforementioned criteria for panic attacks, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) stipulates that the following criteria should be met for panic disorder to be diagnosed:

  • Recurrent fear about having another panic attack and/or any possible result such as having a heart attack, for example

  • Behavior has changed considerably as a result of the attacks; this might include avoidance behaviors

These must persist for at least one month after any one or more of the attacks.

In addition:

  • The difficulties are not due to the physiological effects of any substance (prescribed or illicit) or medical condition.

  • No other mental health issue, such as social anxiety disorder or specific phobia is present that might better account for the attacks.

What causes panic attacks?

It is not exactly clear what causes panic disorder; however several theories have been proposed:

  • Genetic bases – it has been hypothesized that an inherited neuro-chemical dysfunction may be to blame, including serotonin, cortisol, norepinephrine or dopamine

  • Medical conditions – epilepsy; cardiac issues, hyperthyroidism, blood sugar sensitivities, substance use, hypersensitivity to carbon dioxide (causing hyperventilation)

  • Autonomic (physical) over-reaction to normal events causing inaccurate attributions: raised heart rate in response to a stressful event triggers an excessive release of stress hormones leading to an attack

What maintains this cycle of panic?

Essentially, how you react to the event and think about it perpetuates the anxiety. In panic disorder, people make an inaccurate assessment of risk based upon two factors:

  • Inaccurate appraisal of their own ability to cope (usually underestimation)

  • Inaccurate appraisal of threat (overestimation).

Treatment of panic disorder

Like most anxiety disorders, treatment for panic disorder focuses on the following elements:

  • Psycho-education and self-help strategies such as support groups

  • Psychological therapies such as CBT, mindfulness-based approaches, relaxation training

  • Psychopharmacology, typically involving the prescribing of SSRIs or SNRIs in the first instance.

What can you do at the moment of having a panic attack?

  • Don't fight the sensation or leave the situation until the feeling has passed

  • Focus on breathing slowly and deeply

  • Tell yourself it will pass

  • Try to focus on positive thoughts and relaxing imagery

  • Remind yourself it will not harm you – it is just anxiety

  • Once it has passed, refocus on your surroundings and reconnect with what you were doing before it started.

What can you do to prevent a panic attack?

  • Practice daily relaxation

  • Exercise regularly

  • Ensure you watch your diet and eat regularly to avoid blood sugar drops and spikes

  • Avoid stimulants or depressants such as caffeine, nicotine or alcohol

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