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Panic Disorder
Curt Cackovic; Saad Nazir; Raman Marwaha.

Author Information and Affiliations


Last Update: August 6, 2023.

Continuing Education Activity


Panic disorder is fairly common in the general population. Among all anxiety disorders, it has the
highest number of medical visits and serves as a very costly mental health condition. Panic
disorder is characterized by recurrent, unexpected panic attacks. Panic attacks are defined by the
Diagnostic and Statistical Manual of Mental Health Disorders (DSM) as “an abrupt surge of
intense fear or discomfort” reaching a peak within minutes. Four or more of a specific set of
physical symptoms accompany a panic attack. Panic attacks occur as often as several times per
day or as infrequently as only a few attacks per year. A hallmark feature of panic disorder is that
attacks occur without warning. There is often no specific trigger for the panic attack. Patients
suffering from these attacks self-perceive a lack of control. Panic attacks, however, are not
limited to panic disorder. They can occur alongside other anxiety, mood, psychotic, substance
use, and even medical disorders. Panic attacks can be associated with increased symptom
severity of various disorders, suicidal ideation and behavior, and diminished treatment response
in patients with concomitant anxiety and mental disorders. Making an accurate diagnosis of
panic disorder is not possible without a thorough awareness of what constitutes panic attacks. It
is important to differentiate symptoms experienced during or in association with an actual alarm
situation, such as a physical threat, from a true panic attack. According to DSM 5 (Fifth Edition)
criteria, at least one panic attack must be followed by one month or more of persistent concern
over having more attacks, worry about the consequences of the attacks or maladaptive behavior
such as avoidance of work or school activities. Although panic attacks may originate from the
direct effects of substance use, medications, or a general medical condition like hyperthyroidism
or vestibular dysfunction, they must not derive solely from these. For patients with panic
disorder, the fear and anxiety symptoms that they experience primarily manifest themselves in a
physical manner as opposed to a cognitive one. This is a distinctive finding. This activity reviews
panic disorder and the role of the interprofessional team in the recognition and management of
this condition.

Objectives:

Discuss the frequency of panic disorder.

Describe the common features of panic disorder.

Outline the treatment options available for panic disorder.

Reviews panic disorder and the role of the interprofessional team in the recognition and
management of this condition.

Access free multiple choice questions on this topic.

Introduction
Panic disorder and panic attacks are two of the most common problems seen in the world of
psychiatry. Panic disorder is a separate entity from panic attacks, although it is characterized by
recurrent, unexpected panic attacks. Panic attacks are defined by the Diagnostic and Statistical
Manual of Mental Health Disorders (DSM) as “an abrupt surge of intense fear or discomfort”
reaching a peak within minutes. Four or more of a specific set of physical symptoms accompany
a panic attack. These symptoms include; palpitations, pounding heart or accelerated heart rate,
sweating, trembling or shaking, sensations of shortness of breath or smothering, feelings of
choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, light-
headedness, or faint, chills or heat sensations, paresthesias (numbness or tingling sensations),
derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of
losing control or "going crazy," and fear of dying.[1] Panic attacks occur as often as several times
per day or as infrequently as only a few attacks per year. A hallmark feature of panic disorder is
that attacks occur without warning. There is often no specific trigger for a panic attack. Patients
suffering from these attacks self-perceive a lack of control. Panic attacks, however, are not
limited to panic disorder. They can occur alongside other anxiety, mood, psychotic, and
substance use disorder.

In order to make an accurate diagnosis of panic disorder, it is important to differentiate the two
entities from each other. According to DSM 5, panic disorder can be diagnosed if recurrent
unexpected panic attacks are happening, followed by one month or more of persistent concern
over having more attacks, along with a change in the behavior of the individual to avoid a
situation in which they attribute the attack. Although panic attacks may originate from the direct
effects of substance use, medications, or a general medical condition like hyperthyroidism or
vestibular dysfunction, they must not derive solely from these. Panic disorder is not diagnosed
when the symptoms are attributable to another disorder. For example, when panic attacks occur
in the presence of a social anxiety disorder in which the attacks are triggered by social situations
like public speaking, it cannot be considered a part of panic disorder. A distinctive finding in
patients with panic disorder is related to the fear and anxiety that they experience in a physical
manner as opposed to a cognitive one.[2][3][4]

Panic disorder is not a benign disease, it can significantly affect the quality of life and lead to
depression and disability. In addition, these patients are also at a higher risk for alcoholism and
substance abuse compared to the general population.

Etiology
Multiple theories and models exist which speak to the possible etiology of the panic disorder
itself. Most indicate the potential role of chemical imbalance as a major factor, including
abnormalities in gamma-aminobutyric acid, cortisol, and serotonin. It is believed that genetic and
environmental factor plays a role in the pathogenesis of panic disorder. Several studies show that
adverse childhood conditions may lead to panic disorder in adulthood. Newer research indicates
that neural circuitry may have a greater role in panic disorder whereby certain areas of the brain
are hyperexcitable in individuals, and that would make them prone to developing the
disorder. [5][6]

Some studies show that genetic factors may play a role in the etiology of panic disorder. First-
degree relatives have a 40% risk of developing the syndrome if someone in the family already
has been diagnosed with the disorder. In addition, patients with panic disorder also have a high
risk of developing other mental health disorders.
Epidemiology
Panic disorder has a relatively high lifetime prevalence, ranking behind only social anxiety
disorder, posttraumatic stress disorder, and generalized anxiety disorder. Notably, patients
suffering from panic disorder have much higher lifetime rates of cardiovascular, respiratory,
gastrointestinal, and other medical problems compared to the general population. European
Americans are more likely to suffer from panic disorder than African Americans, Asian
Americans, or Latinos. Females are more affected than men. Panic disorder peaks in adolescence
and early adulthood, with low prevalence in children below the age of 14.[5][7][8]

Patients with panic disorders also share many other comorbidities, including OCD, social phobia,
asthma, COPD, irritable bowel syndrome, hypertension, and mitral valve prolapse. Pregnant
females with panic disorder are also more likely to have small birth weight infants.

Pathophysiology
Many neurotransmitters and peptides within the central nervous system appear to play a major
role in the physical manifestations. Results of brain imaging studies have shown characteristic
changes, including increased flow and receptor activity, in specific geographic regions, including
the limbic and frontal regions. The amygdala is proposed as the main area of dysfunction. From a
pathophysiological and psychological standpoint, medical illness and panic disorder are highly
correlated. There are two main theories that attempt to explain why patients are more likely to
experience panic attacks. The first hypothesizes that susceptible patients lack the
appropriate neurochemical mechanisms, which would normally inhibit serotonin, and this
increased serotonin causes alterations in the fear network model of the autonomic nervous
system. The second theorizes that a deficiency in endogenous opioids results in separation
anxiety and increased awareness of suffocation.[9][10]

History and Physical


The vast majority of patients with panic disorder complain of chest pain, palpitations, or dyspnea
on multiple occasions. Other common symptoms may include diaphoresis, tremor, a choking
sensation, nausea, chills, paresthesias, or feelings of depersonalization. Because most patients
complain of physical symptoms, they often inquire about alternative explanations of their
symptoms not related to mental health. They frequently shy away from care by mental health
professionals and, instead, seek reassurance from specialty medical consultants. It is important to
remember that conditions such as irritable bowel syndrome, asthma, and vocal cord dysfunction
also have many symptoms similar to panic disorder.

Evaluation
There are no specific laboratory, radiographic, or other tests required to diagnose panic disorder.
The DSM 5 criteria can be used to diagnose panic disorder which has been mentioned earlier.
Certain rating scales designed by clinicians are used in practice to assess the severity of panic
attacks. It is, however, important that healthcare providers perform a thorough examination of
the patient to rule out an alternative diagnosis. Panic disorder occurs in the absence of other
medical or psychiatric conditions that can better explain the symptoms.[11]

Treatment / Management
The main approaches to the treatment of panic disorder include both psychological and
pharmacological interventions. Psychological interventions consist of cognitive-behavioral
therapy. As an added benefit in patients with a panic disorder that also has concomitant comorbid
medical conditions, there are components of their therapeutic regimens that may also secondarily
improve their respective medical illnesses. Breathing training is a method of reducing panic
symptomatology by utilizing capnometry biofeedback to decrease the number of episodes of
hyperventilation. Several of these slow breathing techniques have been shown to benefit patients
with asthma and hypertension. Hyperventilation reduction can help patients with
cardiovascular disease. Anxiety and stress-reduction techniques can lower adverse outcomes in
cardiovascular illness by decreasing sympathetic activity.

Antidepressants and benzodiazepines are the mainstays of pharmacologic treatment. Among the
different classes of antidepressants, selective serotonin reuptake inhibitors (SSRIs) are
recommended over monoamine oxidase inhibitors and tricyclic antidepressants. SSRIs are
considered the first-line treatment option for patients with panic disorder. In patients with co-
existing conditions or where the patients are having severe symptoms, it is preferred that a
benzodiazepine such as alprazolam is used until the anti-depressants take effect. In patients with
substance use disorder and panic disorder, it is recommended that gabapentin and mirtazapine be
used.[12][13][14]

Because of the risk of suicide, some patients may need inpatient monitoring until the symptoms
have subsided.

Differential Diagnosis

Angina

Asthma

Congestive heart failure

Mitral valve prolapse

Pulmonary embolism

Substance use diosrder

Other mental health disorders associated with panic attacks

Prognosis
Prognosis can be guarded. The presence of panic disorder without other psychopathology is rare.
Most people will have a recurrence of symptoms even after a symptom-free period. Compliance
with treatment is a major issue, and thus relapse of symptoms is common. Only about 60% of
patients achieve remission within 6 months. Triggers for poor outcomes include a chronic illness,
high interpersonal sensitivity, unmarried, low social class, and living alone. Besides premature
adverse cardiac events, these patients are also at risk for suicide.

Complications
Panic disorder is associated with a higher risk of suicidal ideation. It is also associated with a
decrease in the quality of life as the patient is not able to function normally in his social and
family life. The disorder is associated with an increased risk of comorbid medical conditions and
smoking.

Deterrence and Patient Education


It is important for a provider to inform the patient about the symptoms that he may suffer from if
he is diagnosed with the disorder. If a patient is not aware of these symptoms, it is probable that
he would fear his condition more and would tend to get frequent attacks. Pharmacotherapy and
cognitive-behavioral therapy should be discussed with the patients so that they can understand
the treatment options for the condition that they have.

Enhancing Healthcare Team Outcomes


There is no cure for panic disorder, and it can present in a number of ways, thus making the
diagnosis difficult. The majority of patients with panic disorder present to the emergency
department, and hence the role of the nurse and emergency clinician cannot be overemphasized.
The patient needs a thorough education on the disorder and understands that the symptoms are
not life-threatening. The patient needs to be told about the different treatments available and the
need for compliance. Plus, the pharmacist should caution the patient against the use of alcohol or
recreational drugs. The patient should be taught to recognize the triggers and avoid them. Before
starting any drug therapy, the patient should be informed about the side effects and benefits. In
addition, the family should be educated by the nurse and clinician in helping the patient
overcome unrealistic fears and other behaviors. Finally, the patient should be educated on a
healthy lifestyle by adopting good sleep hygiene, exercise, and a healthy diet. The patient should
be advised against any herbal supplements without first speaking to the primary care provider.
[15][16] [Level 5] A team approach to the care of these patients will lead to the best outcomes.
[Level 5]

Outcomes

Panic disorder has no cure, and its course is unpredictable. The currently available
pharmacological therapy and cognitive behavior therapy does work in about 80% of patients, but
relapses are common. About 20% of patients continue to have symptoms that lead to poor quality
of life. About two-thirds of treated patients have a good prognosis, achieving remissions for
about six months at a time. If the trigger factors like stress, alcohol, financial problems, and
divorce are not controlled, the symptoms can create havoc. More important, there is a high risk
of coronary artery disease in patients with panic disorder, and the risk of sudden death is
increased compared to the general population. Finally, the suicide rate is much higher in patients
with panic disorder. There is a high association of social, occupational, and physical disability
caused by panic disorder.[17][18][19] [Level 5]

Review Questions

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Disclosure: Curt Cackovic declares no relevant financial relationships with ineligible companies.

Disclosure: Saad Nazir declares no relevant financial relationships with ineligible companies.

Disclosure: Raman Marwaha declares no relevant financial relationships with ineligible companies.

Copyright © 2023, StatPearls Publishing LLC.


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