PANIC DISORDER
Panic disorder is like an anxiety tornado. It strikes suddenly, wreaks havoc, and disappears. In contrast to generalized anxiety disorder, which involves chronic tension and anxiety, panic disorders occur suddenly and unpredictably, and they are much more intense in nature.
Panic Disorder is characterized by discrete episodes of acute anxiety accompanied by feelings of impending doom. For every one person in 75 with this disorder, anxiety suddenly escalates into a terrifying panic attack: - a minutes-long episode of intense fear that something horrible is about to happen. The intense fear may vary from several attacks during a day to a few attacks during a year. During which the patient reports: heart palpitation, shortness of breath, choking sensations, trembling, or dizziness, which may be misperceived as a heart attack or other serious physical ailment. Smokers have at least a doubled risk of panic disorder (Zvolensky & Bernstein, 2005). Because nicotine is a stimulant, lighting up doesn’t lighten up.
Panic attacks usually occur out of the blue and in the absence of any identifiable stimulus. It is this unpredictable quality that makes panic attacks so mysterious and terrifying to their victims. About 60 percent of people with daytime panic disorders also experience attacks during their sleep. Their symptoms awaken them, and they fear that they are dying (Craske & Rowe, 1997).
Many people who suffer recurrent panic attacks develop agoraphobia, an aversion to public places; because they fear that they will have an attack in public. In extreme cases, they may fear leaving the familiar setting of the home, and some have been known to remain housebound for years at a time because of their “fear of fear” (Milrod et al., 1997).
Example of Panic Disorder is when one woman recalled suddenly she felt, hot and as though she couldn’t breathe. Her heart was racing and she started sweating and trembling and was sure she felt she was going to faint. Felt numbness and tingly in her fingers and things seemed unreal. It was so bad that she wondered if she was dying and asked her husband to take her to the emergency room. By the time they got there (about 10 minutes) the worst of the attack was over and she just felt washed out, (Greist et al., 1986).
EPIDEMIOLOGY
The lifetime prevalence of panic disorder is in the 1 to 4 percent range, with 6-month prevalence approximately 0.5 to 1.0 percent and 3 to 5.6 percent for panic attacks. Women are two to three times more likely to be affected than men. The onset is usually in early third decade with often a chronic course. The panic attacks occur recurrently every few days. There may or may not be an underlying generalized anxiety disorder.
COMORBIDITY
Of patients with panic disorder, 91 percent have at least one other psychiatric disorder. About one-third of persons with panic disorders have major depressive disorder before onset; about two-thirds first experience panic disorder during or after the onset of major depression.
Other disorders also commonly occur in persons with panic disorder. Of persons with panic disorder, 15 to 30 percent also have social anxiety disorder or social phobia, 2 to 20 percent have specific phobia, 15 to 30 percent have generalized anxiety disorder, 2 to 10 percent have PTSD, and up to 30 percent have OCD. Other common comorbid conditions are hypochondriasis or illness anxiety disorder, personality disorders, and substance-related disorders.
ETIOLOGY
BIOLOGICAL FACTORS
Research on the biological basis of panic disorder has produced a range of findings; one interpretation is that the symptoms of panic disorder are related to a range of biological abnormalities in brain structure and function. Considerable evidence indicates that abnormal regulation of brain noradrenergic systems is also involved in the pathophysiology of panic disorder. The autonomic nervous systems of some patients with panic disorder have been reported to exhibit increased sympathetic tone, to adapt slowly to repeated stimuli, and to respond excessively to moderate stimuli. The major neurotransmitter systems that have been implicated are those for norepinephrine, serotonin, and GABA. Serotonergic dysfunction is quite evident in panic disorder, and various studies with mixed serotonin agonist-antagonist drugs have demonstrated increased rates of anxiety. Structural brain imaging studies, for example, MRI, in patients with panic disorder have implicated pathological involvement in the temporal lobes, particularly the hippocampus and the amygdala.
GENETIC FACTORS
Various studies have found that the first-degree relatives of patients with panic disorder have a four- to eightfold higher risk for panic disorder than first-degree relatives of other psychiatric patients. The twin studies conducted to date have generally reported that monozygotic twins are more likely to be concordant for panic disorder than are dizygotic twins.
PSYCHOSOCIAL FACTORS
Psychoanalytic theories conceptualize panic attacks as arising from an unsuccessful defense against anxiety-provoking impulses. What was previously a mild signal anxiety becomes an overwhelming feeling of apprehension, complete with somatic symptoms. Many patients describe panic attacks as coming out of the blue, as though no psychological factors were involved, but psychodynamic exploration frequently reveals a clear psychological trigger for the panic attack. Although panic attacks are correlated neurophysiologically with the locus ceruleus, the onset of panic is generally related to environmental or psychological factors. Patients with panic disorder have a higher incidence of stressful life events (particularly loss). Moreover, the patients typically experience greater distress about life events than others in the population.
DIAGNOSIS
According to he fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for panic disorder are:
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur;
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).
TREATMENT
The two most effective treatments are pharmacotherapy and cognitive-behavioural therapy. Family and group therapy may help affected patients and their families adjust to the patient’s disorder and to the psychosocial difficulties that the disorder may have precipitated.
1. Pharmacotherapy: It is useful to begin the treatment of panic disorders with small doses of anti depressants, usually SSRIs (e.g. fluoxetine). Benzodiazepines (such as alprazolam and clonazepam) are useful in short-term treatment of both generalized anxiety and panic disorders. However, tolerance and dependence potential limit the use of these drugs.
2. Cognitive and Behaviour Therapies: The two major foci of cognitive therapy for panic disorder are instruction about a patient’s false beliefs and information about panic attacks. The instruction about false beliefs centers on the patient’s tendency to misinterpret mild bodily sensations as indicating impending panic attacks, doom, or death. The information about panic attacks includes explanations that when panic attacks occur, they are time limited and not life threatening.
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REFERENCES:
· Craske, M. G., & Rowe, M. K. (1997). Nocturnal panic. Clinical Psychology: Science and Practice,
· 4, 153–174.David G. Myers Psychology 9th eds. 2010 by Worth Publishers
· Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
· Greist, J. H., Jefferson, J. W., & Marks, I. M. (1986). Anxiety and its treatment: Help is available. Washington, DC: American Psychiatric Press. (p. 602)
· KAPLAN & SADOCK S Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry eleventh edition ISBN 978-1-60913-971-1
· Milrod, B., Busch, F., Cooper, A., & Shapiro, T. (1997). Manual of panic-focused psychodynamic psychotherapy. Washington, DC: American Psychiatric Press.
· Niraj Ahuja 2011, A Short Textbook of PSYCHIATRY Seventh Edition Published by Jaypee Brothers Medical Publishers (P) Ltd
· Passer, Michael W. and Ronald E. Smith: Psychology: the science of mind and behavior (4th ed.), Published by McGraw-Hill 2009
· Zvolensky, M. J., & Bernstein, A. (2005). Cigarette smoking and panic psychopathology. Current Directions in Psychological Science, 14, 301–305. (p. 602)
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