Panic Disorder

Panic disorder is characterized by sudden episodes of acute apprehension or intense fear that occur “out of the blue,” without any apparent cause. Intense panic usually lasts no more than a few minutes, but, in rare instances, can return in “waves” for a period of up to two hours. During the panic itself, any of the following symptoms can occur:

• Shortness of breath or a feeling of being smothered
• Heart palpitations—pounding heart or accelerated heart rate
• Dizziness, unsteadiness, or faintness Trembling or shaking
• A feeling of choking Sweating
• Nausea or abdominal distress
• A feeling of unreality—as if you’re “not all there” (depersonalization)
• Numbness or tingling in hands and feet
• Hot and cold flashes
• Chest pain or discomfort
• Fears of going crazy or losing control
• Fears of dying

At least four of these symptoms are present in a full-blown panic attack, while having two or three of them is referred to as a limited-symptom attack.
Your symptoms would be diagnosed as panic disorder if 1) you have had two or more panic attacks and 2) at least one of these attacks has been followed by one month (or more) of persistent concern about having another panic attack or worry about the possible implications of having another panic attack. It’s important to recognize that panic disorder, by itself, does not involve any phobias. The panic doesn’t occur because you are thinking about, approaching, or actually entering a phobic situation. Instead, it occurs spontaneously, unexpectedly, and for no apparent reason. Also, the panic attacks are not due to the physiological effects of a drug (prescription or recreational) or a medical condition.
You may have two or three panic attacks without ever having another one again or without having another one for years. Or you may have several panic attacks followed by a panic-free period, only to have the panic return a month or two later. Sometimes an initial panic attack may be followed by recurring attacks three or more times per week unremittingly until you seek treatment. In all of these cases, there is a tendency to develop anticipatory anxiety or apprehension between panic attacks focusing on fear of having another one. This apprehension about having another panic attack is one of the hallmarks of panic disorder.
If you are suffering from panic disorder, you may be very frightened by your symptoms and consult with doctors to find a medical cause. Heart palpitations and an irregular heartbeat may lead to EKG and other cardiac tests, which, in most cases, turn out normal. (Sometimes mitral valve prolapse, a benign arrhythmia of the heart, may coexist with panic disorder.) Fortunately, an increasing number of physicians have some knowledge of panic disorder and are able to distinguish it from purely physical complaints.
A diagnosis of panic disorder is made only after possible medical causes including hypoglycemia, hyperthyroidism, reaction to excess caffeine, or withdrawal from alcohol, tranquilizers, or sedatives—have been ruled out. The causes of panic disorder involve a combination of heredity, chemical imbalances in the brain, and personal stress. Sudden losses or major life changes may trigger the onset of panic attacks.
People tend to develop panic disorder during late adolescence or in their twenties. About half of the people who have panic disorder develop it before the age of twenty-four. In about a third of cases, panic is complicated by the development of agoraphobia (as described in the following section). Between 1 and 2 percent of the population have “pure” panic disorder, while about 5 percent, or one in every twenty people, suffer from panic attacks complicated by agoraphobia. Women are about twice as likely as men to develop panic disorder.
Cigarette smoking increases the risk of panic disorder (Isensee et al. 2003). About 30 percent of people with panic disorder use alcohol to self- medicate (Mental Health America 2007), which often worsens their symptoms when the effects of alcohol wear off. Cannabis often precipitates panic in some people.
Panic disorder is in part influenced by excessive activity in parts of the brain known as the amygdala and the hypothalamus. See chapter 2 for more detailed information on the neurobiology of panic disorder.

Current Treatment

All of the following strategies are considered state-of-the-art treatments for panic disorder.
Relaxation Training. Practicing abdominal breathing and some form of deep muscle relaxation (such as progressive muscle relaxation) on a daily basis. This helps to reduce the physical symptoms of panic as well as anticipatory anxiety you might experience about having a panic attack. A

physical exercise program may also be recommended to reduce anxiety. (See chapters 4 and 5.)
Panic-Control Therapy. Identifying and eliminating catastrophic thoughts (such as “I’m trapped!” “I’m going to go crazy!” or “I’m going to have a heart attack!”) that tend to trigger panic attacks. (See chapter 6.)
Interoceptive Desensitization. Practicing voluntary habituation to the bodily symptoms of panic, such as rapid heartbeat, sweaty hands, shortness of breath, or dizziness. Such symptoms are created deliberately, usually in the therapist’s office. For example, dizziness might be induced by spinning in a chair or rapid heartbeat by running up and down stairs. Repeated exposure to unpleasant bodily symptoms promotes desensitization, which basically means getting used to them to the point that they no longer frighten you. (See chapter 7.)
Medication. SSRI antidepressant medications such as Zoloft, Lexapro, Celexa, or Cymbalta—or benzodiazepine medications such as Xanax, Ativan, or Klonopin—may be used to reduce severity of panic symptoms. Such medications are best used in conjunction with the first three strategies above. (See chapter 17.)
Lifestyle and Personality Changes. Some of the lifestyle changes that can reduce your tendency to have panic attacks include stress management, regular exercise, eliminating stimulants and sugar from your diet, slowing down and creating “downtime,” and altering your attitudes about perfectionism, the excessive need to please, and the excessive need to control. (Chapters 4, 5, 10, and 15 address these issues.)