Panic Disorder

(Date of publication 6 December 2004)

"It came upon me by surprise. I began to feel wave after wave of fear and my stomach gave out on me. I could hear my heart pounding so loudly I thought it would come out of my chest. Pains were shooting down my legs. I became so afraid I couldn’t catch my breath. What was happening to me? Was I having a heart attack? Was I dying?" This account of a panic attack shows just how frightening one can be. They are also surprisingly common; according to the Merck Manual they affect more than a third of the population in a single year.

Symptoms of an attack include a feeling of doom, palpitations, shortness of breath, chest pain, nausea, dizziness and a fear of losing control. There are three different categories:

Most people recover from occasional panic attacks without treatment, but a small proportion, usually in late adolescence or early adulthood, go on to develop panic disorder. More than twice as many women as men are affected and there appears to be a connection with major lifetime events, especially those involving loss or separation. Sufferers not only have repeated panic attacks, but are persistently in fear of them, sometimes to the extent that it totally dominates their lives. If these symptoms sound familiar and you are concerned that you may have the disorder, the online self-test facility here may prove useful.

There are both physical and psychological causes, according to the American Psychological Association, and there seems to be a genetic predisposition. Research in Barcelona has revealed that many individuals with anxiety problems (including panic disorder, agoraphobia and social phobia) share the same genetic abnormality, which has been termed DUP25. The region in which this mutation occurs contains more than 60 genes, some involved in communication within the nervous system, and it may be that an imbalance in the proteins they produce makes the brain over-sensitive to stressful events.

There is a detailed account of the psychological evolution of panic disorder on this self-help group site. It maintains that panic attack sufferers are actually frightened of the physical sensations of the fight/flight response. When these sensations are produced by general stress, increased adrenalin production or hyperventilation, and these is no apparent danger causing them, the brain invents a reason such as 'I am dying' or 'I am losing control'. This, in turn, reinforces the panic symptoms and creates a vicious spiral.

Many sufferers worry about experiencing a panic attack where help is not readily available and consequently avoid such places as bridges, tunnels, lifts or crowded streets, i.e. they develop agoraphobia. Any movement outside their 'safety zone' results in mounting anxiety and in extreme cases individuals may become unable to leave their homes. This article from Psychology Today has an extensive list of agoraphobia symptoms and treatment, plus some results of research into panic disorder itself. For example, evidence suggests that panic disorder may be associated with increased activity in the hippocampus and locus coeruleus, areas of the brain which control responses to internal and external stimuli, and also with abnormalities of the benzodiazepine receptors, which react with anxiety-reducing substances within the brain.

We have already seen that psychotropic drugs can be valuable in the treatment of panic disorder, the main groups of agents used being tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors (MAOIs) and selective serotonin re‑uptake inhibitors (SSRIs).

Tricyclic antidepressants are often effective in reducing attacks, do not lead to the development of tolerance and are non-addictive. However, they take from 4-12 weeks before beneficial effects kick in, may cause postural hypotension and often lead to considerable weight increase – 25% of patients gain 20 pounds or more. Benzodiazepines can relieve severe anxiety but may have strong sedative effects and prolonged use can lead to tolerance and dependency. Nevertheless, these are among the most widely prescribed CNS drugs – 100 million prescriptions per year in the USA.

MAOIs essentially block the breakdown of neurotransmitters such as noradrenaline and serotonin. They work more quickly than tricyclics and stimulate rather than sedate. Side effects are more severe though; in particular, the reaction with certain foods (e.g. cheese, processed meats, fish and soy products) and alcoholic beverages can lead to hypertension, stroke and coma. SSRIs similarly boost the level of serotonin, but in this case by reducing its re-absorption by nerve cells after release. The mechanism by which this produces a beneficial effect on mood is not completely understood.

Cognitive behavioural therapy is at least as important as pharmacotherapy in treating panic disorder. Here the subject is covered by a patient, and here by a clinician. There are six components – education, breathing training, relaxation exercises, cognitive re-structuring, situational exposure and interoceptive exposure –of which the first three are self-explanatory. Cognitive re-structuring, a major part of the therapy, aims to change patients' reaction to their symptoms so they can deal effectively with anxiety-provoking situations. Later on, situational exposure involves confronting precisely the circumstances which provoke panic and using coping strategies to deal with them. Interoceptive exposure intentionally generates panic-like physical sensations, such as dizziness or rapid heart rate, to accustom the patient to harmless body sensations.

Now for the $64,000 question; just how effective is treatment? Most of the sites on this tour are of one accord – the great majority of patients benefit from treatment and experience a great improvement in their condition.

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A Tour around Panic Disorder

A Tour around Panic Disorder