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:

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. There is no obvious cue or trigger for the attack. Also, the panic attacks are not due to the physiological effects of a drug (prescription or recreational) or a medical condition.

People vary in how frequently panic attacks occur. 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 recent 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 two and three percent of the population have “pure” panic disorder, while about five percent, or one in every twenty people, suffer from panic attacks complicated by agoraphobia. Very few individuals develop panic disorder in childhood or after age 65. Women are about twice as likely as men to develop panic disorder. White Americans are more likely to be diagnosed with panic disorder than other ethnic groups.

Cigarette smoking increases the risk of panic disorder. About 30 percent of people with panic disorder use alcohol to self-medicate, which often worsens their symptoms when the effects of alcohol wear off. Cannabis often precipitates panic in some people.

About one fourth of individuals who have panic attacks will have an occasional nocturnal panic attack (panic upon awakening from sleep).

Panic disorder is in part influenced by excessive activity in parts of the brain known as the amygdala and the hypothalamus.

Panic Attacks During Adolescence

About 20 percent of adolescents in the United States experience a diagnosable anxiety disorder, the most common one being panic disorder. Up until recently, the explanation for this situation was in terms of the social and emotional challenges faced by adolescents, such as separating from their parents, gaining acceptance into a peer group, and/or figuring out their own personal identity. While these social issues certainly do play a role, more recent research has discovered an additional neurological basis for teenagers being more prone to anxiety.

Different parts of the brain develop at different rates. For adolescents, it turns out that the amygdala, the brain center that instigates fear, matures several years before the prefrontal cortex, the brain center that can limit the amygdala's reaction by evaluating the environment to see if there is any legitimate threat. So adolescents during their teens have an enhanced capacity for fear and panic, conjoined with an underdeveloped capacity for calm reasoning (the prefrontal cortex doesn't fully develop until a person's early twenties).

To compound this problem, there has been a significant increase in the use of stimulant drugs such as Ritalin and Adderall by teenagers in recent years. Such stimulants only serve to further aggravate panic and anxiety.

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.

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.

Interoceptive Exposure
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 a process of desensitization, which basically means “getting less sensitive” or getting more used to the symptoms to the point that they no longer frighten you.

SSRI antidepressant medications such as Zoloft, Lexapro, Celexa, or Paxil—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. A downside of medication treatment for panic disorder is that more than 50% of people can relapse if the medication is discontinued a year or more after beginning it.

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.