Professional Documents
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Panic Disorder
Curt Cackovic; Saad Nazir; Raman Marwaha.
Objectives:
Reviews panic disorder and the role of the interprofessional team in the recognition and
management of this condition.
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]
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
Pulmonary embolism
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.
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
References
1. Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications
for Child Serious Emotional Disturbance [Internet]. Substance Abuse and Mental Health
Services Administration (US); Rockville (MD): Jun, 2016. [PubMed: 30199184]
2. Berenz EC, York TP, Bing-Canar H, Amstadter AB, Mezuk B, Gardner CO, Roberson-Nay
R. Time course of panic disorder and posttraumatic stress disorder onsets. Soc Psychiatry
Psychiatr Epidemiol. 2019 May;54(5):639-647. [PMC free article: PMC6509003] [PubMed:
30003310]
3. Indranada AM, Mullen SA, Duncan R, Berlowitz DJ, Kanaan RAA. The association of panic
and hyperventilation with psychogenic non-epileptic seizures: A systematic review and meta-
analysis. Seizure. 2018 Jul;59:108-115. [PubMed: 29787922]
4. Perna G, Caldirola D. Is panic disorder a disorder of physical fitness? A heuristic proposal.
F1000Res. 2018;7:294. [PMC free article: PMC5843823] [PubMed: 29623195]
5. Sivolap YP. [Panic disorder: clinical phenomena and treatment options]. Zh Nevrol Psikhiatr
Im S S Korsakova. 2017;117(4):112-116. [PubMed: 28617392]
6. Santos M, D'Amico D, Spadoni O, Amador-Arjona A, Stork O, Dierssen M. Hippocampal
hyperexcitability underlies enhanced fear memories in TgNTRK3, a panic disorder mouse
model. J Neurosci. 2013 Sep 18;33(38):15259-71. [PMC free article: PMC6618414]
[PubMed: 24048855]
7. Farris SG, Robinson JD, Zvolensky MJ, Hogan J, Rabius V, Cinciripini PM, Karam-Hage M,
Blalock JA. Panic attacks and smoking cessation among cancer patients receiving smoking
cessation treatment. Addict Behav. 2016 Oct;61:32-9. [PMC free article: PMC5912332]
[PubMed: 27235990]
8. Foldes-Busque G, Fleet RP, Denis I, Poitras J, Chauny JM, Diodati JG, Marchand A.
Nonfearful Panic Attacks in Patients With Noncardiac Chest Pain. Psychosomatics. 2015
Sep-Oct;56(5):513-20. [PubMed: 25583556]
9. Lai CH. Fear Network Model in Panic Disorder: The Past and the Future. Psychiatry
Investig. 2019 Jan;16(1):16-26. [PMC free article: PMC6354036] [PubMed: 30176707]
10. Quagliato LA, Freire RC, Nardi AE. Risks and benefits of medications for panic disorder: a
comparison of SSRIs and benzodiazepines. Expert Opin Drug Saf. 2018 Mar;17(3):315-
324. [PubMed: 29357714]
11. Blackwelder R, Bragg S. Anxiety disorders: A blended treatment approach. Int J Psychiatry
Med. 2016;51(2):137-44. [PubMed: 26936807]
12. Ströhle A, Fydrich T. [Anxiety disorders: which psychotherapy for whom?]. Nervenarzt.
2018 Mar;89(3):271-275. [PubMed: 29383412]
13. Tanguay Bernard MM, Luc M, Carrier JD, Fournier L, Duhoux A, Côté E, Lessard O,
Gibeault C, Bocti C, Roberge P. Patterns of benzodiazepines use in primary care adults with
anxiety disorders. Heliyon. 2018 Jul;4(7):e00688. [PMC free article: PMC6039319]
[PubMed: 29998202]
14. Thibaut F. Anxiety disorders: a review of current literature. Dialogues Clin Neurosci. 2017
Jun;19(2):87-88. [PMC free article: PMC5573565] [PubMed: 28867933]
15. Legey S, Aquino F, Lamego MK, Paes F, Nardi AE, Neto GM, Mura G, Sancassiani F,
Rocha N, Murillo-Rodriguez E, Machado S. Relationship Among Physical Activity Level,
Mood and Anxiety States and Quality of Life in Physical Education Students. Clin Pract
Epidemiol Ment Health. 2017;13:82-91. [PMC free article: PMC5633699] [PubMed:
29081825]
16. Spijker J, van Vliet IM, Meeuwissen JA, van Balkom AJ. [Update of the multidisciplinary
guidelines for anxiety and depression]. Tijdschr Psychiatr. 2010;52(10):715-8. [PubMed:
20931485]
17. Apolinário-Hagen J. Internet-Delivered Psychological Treatment Options for Panic
Disorder: A Review on Their Efficacy and Acceptability. Psychiatry Investig. 2019
Jan;16(1):37-49. [PMC free article: PMC6354039] [PubMed: 30122031]
18. Caldirola D, Alciati A, Riva A, Perna G. Are there advances in pharmacotherapy for panic
disorder? A systematic review of the past five years. Expert Opin Pharmacother. 2018
Aug;19(12):1357-1368. [PubMed: 30063164]
19. Schwartz RA, Chambless DL, McCarthy KS, Milrod B, Barber JP. Client resistance predicts
outcomes in cognitive-behavioral therapy for panic disorder. Psychother Res. 2019
Nov;29(8):1020-1032. [PubMed: 30049247]
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.