Panic disorder is characterized by extreme

and frequent panic attacks

May experience the attacks unexpectedly

and for no apparent reason, but they can
also be preceded by some sort of
triggering event or situation.

Include symptoms such as severe feelings

of terror, rapid breathing and rapid heart
rate.
Mindy Markowitz is an attractive … 25-year-old art director … who comes to
an anxiety clinic … seeking treatment for “panic attacks” that have occurred
with increasing frequency over the past year, often two or three times a day.
These attacks begin with a sudden, intense wave of “horrible fear” that
seems to come out of nowhere, sometimes during the day, sometimes
waking her from sleep. She begins to tremble, is nauseated, sweats profusely,
feels as though she is choking, and fears that she will lose control and do
something crazy, like run screaming into the street. . . .

Mindy has had panic attacks intermittently over the 8 years since her first
attack, sometimes not for many months, but sometimes, as now, several
times a day. There have been extreme variations in the intensity of the
attacks, some being so severe and debilitating that she has had to take a day
off from work. Mindy has always functioned extremely well in school, at
work, and in her social life, apart from her panic attacks. . . . She is a lively,
friendly person … who has never limited her activities . . . She says . . . she is
as likely to have an attack at home in her own bed as on the subway, so there
is no point in avoiding the subway. . . . [Wherever] she has an attack . . . she
says, “I just tough it out.”
 DIAGNOSTIC CRITERIA DSM-5
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.
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., behaviors 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

 The age of onset of panic disorder is usually in the
early 20s.

 Onset in children and in people in middle age

is unusual but does occur.

 The frequency of panic attacks varies

83 percent of people with panic disorder have at least one
comorbid disorder

Most commonly these include generalized anxiety disorder,

social phobia, specific phobia, PTSD, depression, and
substance-use disorders

It is estimated that 50 to 70 percent of people with panic

disorder will experience serious depression at some point in
their lives
Biological Causal Factors
Genetic Factors: According to family and twin studies, panic disorder
has a moderate heritable component

Panic and the Brain: it is recognized that it is increased activity in the

amygdala that plays a more central role in panic attacks. The
amygdala is a collection of nuclei in front of the hippocampus in the
limbic system of the brain that is critically involved in the emotion of
fear.

Stimulation of the central nucleus of the amygdala is known to

stimulate the locus coeruleus as well as the other autonomic,
neuroendocrine, and behavioral responses that occur during panic
attacks
Amygdala
Hippocampus

Prefrontal
cortex

Locus
coeruleus

A Biological Theory of Panic, Anxiety, and Agoraphobia: According to one theory,

panic attacks may arise from abnormal activity in the amygdala, a collection of nuclei
in front of the hippocampus in the limbic system. The anticipatory anxiety that people
develop about having another panic attack is thought to arise from activity in the
hippocampus of the limbic system, which is known to be involved in the learning of
emotional responses. Agoraphobic avoidance, also a learned response, may also
involve activity of the hippocampus and higher cortical centers (Gorman et al., 2000).
Biochemical Abnormalities :
Serotonin
GABA (GABA has been shown to be abnormally low in certain parts
of the cortex in people with panic disorder)

Psychological Causal Factors

Cognitive Theory of Panic

individuals with panic disorder are hypersensitive to their bodily
sensations and are very prone to giving them the direst possible
interpretation.
For example, a person who develops panic disorder might notice that
his heart is racing and conclude that he is having a heart attack.
These very frightening thoughts may cause many more physical
symptoms of anxiety, which further fuel the catastrophic thoughts,
leading to a vicious circle culminating in a panic attack
Comprehensive learning theory of panic: Learning
theory argues that the person goes through two types
of conditioning – interoceptive and exteroceptive.
The initial attacks become related to the internal and
external cues which actually condition them to anxiety.
The more intense the anxiety, more robust the
conditioning will occur. The exteroceptive and
interoceptive conditioning can range from heart
palpitations, dizziness to social places like shopping
malls. Most of the time a panic attack is “out of the
blue” but it is the internal cues that the person was
unconsciously conditioned to generate anxiety.
(Acheson, 2012)
Anxiety sensitivity and perceived control: Anxiety
sensitivity means that some people have a tendency to
notice certain bodily sensations with harmful
consequences. These people are more prone to develop
panic disorder. They say statements like “When I feel dizzy,
I worry that I might faint”. In addition to this sensitivity,
there is a term called perceived control which means that if
there is an element of safety around a person who is
suffering from panic disorder, the susceptibility of a panic
attack becomes low. (Dixon, 2013) (Carleton, 2014)
A. Cognitive behavioural therapy (CBT)

B. Group therapy can often be used just as effectively to teach relaxation

and related skills. Psycho educational groups in this area are often
beneficial.

C. Biofeedback, a specific technique which allows the client to receive

either audio or visual feedback about their body’s physiological
responses while learning relaxation skills, is also an appropriate
psychotherapeutic intervention
Pharmacotherapy for Panic Disorder

 Selective serotonin reuptake inhibitors

(SSRIs)

 Tricyclic
antidepressants -
Imipramine and clomipramine