Panic disorder

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Overview

What is panic disorder?

Most people experience moments of panic or periods of anxiety, particularly in response to distressing events or situations. Sudden feelings of overwhelming panic and fear are often referred to as a panic attack and whilst these feelings are a common reaction to stressful situations, frequent and unexpected panic attacks could be a sign of panic disorder.1

Panic disorder refers to the experience of recurrent and disabling panic attacks which last up to a few minutes and are accompanied by physical symptoms such as heart palpitations, shaking, shortness of breath, and dizziness.1, 2 Fear of losing control, of going ‘crazy’, or of dying are also common during a panic attack. People with panic disorder often worry about experiencing further panic attacks and, as a result, may start avoiding activities or certain situations to minimise or avoid the possibility of a future attack.1

In Australia, it is estimated that 5 per cent of the population will experience panic disorder in their lifetime, with women being more likely to be diagnosed with the disorder than men.3, 4 Symptoms of panic disorder can occur at any age, with the typical age of onset ranging from late adolescence to early adulthood.3

Signs and symptoms

Panic attacks are the main symptom of panic disorder. A panic attack is a sudden surge of intense fear or discomfort which reaches a peak within several minutes and is accompanied by at least four of the following:1

  • heart palpitations, or racing/pounding heart
  • shaking or trembling
  • shortness of breath or a feeling of choking
  • chest pain or discomfort
  • nausea or abdominal upset
  • chills or heat sensations/sweats
  • dizziness, light-headedness, or feeling faint or unsteady
  • numbness or tingling sensations
  • derealisation (feelings of unreality) or depersonalisation (feelings of being detached from oneself)
  • fear of losing control or of ‘going crazy’
  • fear of dying.

Two types of panic attack have been identified: expected and unexpected. Expected panic attacks occur following a particular cue or trigger, for example, for some people being in a large crowd or in a lift might frequently trigger a panic attack. Unexpected panic attacks, on the other hand, do not have an identifiable cue or trigger and can occur at any time, even if the person is in a calm state or asleep.1

For a diagnosis of panic disorder, a person must experience at least one unexpected panic attack followed by one month or more of:

  • ongoing concern or worry regarding the experience of further panic attacks or their consequences; and/or
  • changes in behaviour in order to prevent further attacks from happening, for example, the person may avoid situations where they fear a panic attack could occur, such as public transport.1

What causes panic disorder?

Whilst no single cause has been found, a number of factors are thought to contribute to the development of panic disorder and its associated symptoms. These factors include:

  • Genetic factors: People who have a first-degree relative with panic disorder have an increased chance of developing the disorder.5
  • Neurobiological factors: Studies suggest that in individuals with panic disorder, fear circuitry in the brain may be oversensitive and be triggered by events that pose no threat to the person.6-10
  • Cognitive factors: People with panic disorder are thought to have a higher sensitivity to internal bodily sensations (e.g., heart rate, breathing patterns) and misinterpret any changes in these sensations as being life threatening. This increased sensitivity and the negative thoughts that follow are thought to trigger and contribute to panic symptoms.11
  • Stressors in childhood: Childhood maltreatment has been associated with the development of panic disorder.12, 13 Both direct and indirect experiences of physical illness in childhood, particularly respiratory conditions (e.g., asthma), may also play a role.14
  • Stressors in adulthood: Stressors such as the death of a loved one, physical illness and injury, excessive alcohol/substance use, and social conflicts might trigger panic disorder.13
  • Temperament: Personality factors, such as being highly anxious, tense, moody, and self-conscious, may also play a role in the development of panic disorder.13, 15
  • Smoking: Cigarette smoking can serve as a risk factor in the development of panic disorder and may contribute to the experience of panic attacks.16
  • Substance use: The use of stimulants both illicit (e.g. cocaine17) and licit (e.g. caffeine18) is associated with an increased risk of panic attacks.

Evidence-based psychological approaches and strategies

Cognitive behaviour therapy (CBT) is considered the most effective treatment for panic disorder. CBT is a type of psychotherapy that helps a person identify and modify unhelpful thoughts and behaviours that may lead to feelings of panic. CBT for panic disorder involves a range of strategies and techniques, including psychoeducation, self-monitoring, cognitive restructuring, exposure therapy, and relaxation.19-21

Psychoeducation

Psychoeducation involves providing important information about how panic disorder develops in order to improve symptom awareness and empower the person to cope effectively with the disorder. Psychoeducation might also include information on the lifestyle factors that are thought to contribute to feelings of panic (e.g., smoking and the use of stimulants) and those that could decrease the experience of panic symptoms (e.g., regular exercise).21-24

Self-monitoring

Monitoring a person’s thoughts, behaviours, and symptoms is a core feature of CBT. By asking a person to monitor their panic symptoms, the situations in which they occurred and any associated thoughts and behaviours, the psychologist can help develop therapeutic interventions to reduce the number of panic attacks experienced and the way in which the person responds to panic symptoms.19    

Cognitive restructuring

Feelings of panic often stem from a person’s unhelpful thoughts and misinterpretations of panic symptoms (e.g., “my heart is beating fast... I must be having a heart attack”). Cognitive restructuring is a CBT technique which helps a person to identify and challenge these negative thoughts and develop a more rational and helpful style of thinking (e.g., “a racing heart does not mean I am having a heart attack”).19, 20

Exposure therapy

Exposure therapy is a CBT technique where the psychologist guides a person through scenarios which are known to trigger feelings of panic. This may involve directly exposing a person to a feared situation (e.g., a crowded train) or by inducing physical sensations which the person finds distressing (e.g., a racing heart). Through a gradual process of exposure, often beginning with the least anxiety-provoking situation, the person builds a tolerance of the uncomfortable feelings and sensations that they experience during times of panic and learns to confront their fears with decreased levels of anxiety.19, 20

Relaxation skills training and breathing retraining

Relaxation techniques, such as progressive muscle relaxation, have been found to improve symptoms of panic disorder by decreasing muscle tension and the body’s physical response to stressors.20, 21 Another technique which can be incorporated into CBT for panic disorder is breathing retraining which teaches people about the role of breathing in panic disorder and outlines strategies to correct unhelpful breathing patterns which commonly occur during panic attacks (e.g., rapid and shallow breathing).25

How a psychologist can help

Through discussion and the possible use of questionnaires and monitoring tools, the psychologist develops an understanding of the potential factors involved in the onset and maintenance of the person’s symptoms of panic disorder. A treatment plan is then developed by the psychologist together with the person involved.

The psychologist may also assist the person to address any lifestyle factors which may increase their capacity to better manage their difficulties, and reduce symptoms of panic disorder. They may also suggest involving a supportive family member or friend to assist in the understanding of the person’s situation and to support treatment.

Other professionals who might be involved

A medical review with a GP may be suggested to determine if another health condition could account for the panic symptoms. A GP or psychiatrist can also offer advice and assistance around whether medication might be of benefit.

When to seek professional help

If some of the signs and symptoms mentioned in this information sheet are affecting a person’s work, school, home life, or relationships, psychological assistance should be considered. The APS Find a Psychologist service can be used to locate a psychologist in your local area: call 1800 333 497 or visit www.findapsychologist.org.au. A GP can also organise a referral to a registered psychologist under the Better Access to Mental Health Care items.

More information

The Australian Psychological Society
Australia’s largest professional association for psychologists
http://www.psychology.org.au

beyondblue
Provides information on anxiety, depression, and related disorders
www.beyondblue.org.au

headspace
Australia’s National Youth Mental Health Foundation, providing young people with assistance and information on mental health issues
www.headspace.org.au

Lifeline
A 24-hour counselling, suicide prevention and mental health support service
Telephone: 13 11 14
www.lifeline.org.au

  • Contributor(s)
    APS Member Resources Team

    Dr Peter McEvoy
    Associate Professor
    School of Psychology and Speech Pathology
    Curtin University
  • Publish date
    16 Mar 2015
  • References
    View

References

1.    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington DC: Author.

2.    World Health Organization. (2008). ICD-10: International statistical classification of diseases and related health problems (10th Rev.). New York, NY: Author.

3.    McEvoy, P. M., Grove, R., & Slade, T. (2011). Epidemiology of anxiety disorders in the Australian general population: Findings of the 2007 Australian National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry, 45(11), 957-967. doi: http://dx.doi.org/http://dx.doi.org/10.3109/00048674.2011.624083

4.    Yates, W. R. (2009). Phenomenology and epidemiology of panic disorder. Annals of Clinical Psychiatry, 21(2), 95-102.

5.    Schumacher, J., Kristensen, A. S., Wendland, J. R., Nöthen, M. M., Mors, O., & McMahon, F. J. (2011). The genetics of panic disorder. Journal of Medical Genetics, 48(6), 361-368. doi: http://dx.doi.org/http://dx.doi.org/10.1136/jmg.2010.086876

6.    Johnson, P. L., Federici, L. M., & Shekhar, A. (in press). Etiology, triggers and neurochemical circuits associated with unexpected, expected, and laboratory-induced panic attacks. Neuroscience & Biobehavioral Reviews. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.neubiorev.2014.07.027

7.    Dresler, T., Guhn, A., Tupak, S. V., Ehlis, A.-C., Herrmann, M. J., Fallgatter, A. J., . . . Domschke, K. (2013). Revise the revised? New dimensions of the neuroanatomical hypothesis of panic disorder. Journal of Neural Transmission, 120(1), 3-29. doi: http://dx.doi.org/http://dx.doi.org/10.1007/s00702-012-0811-1

8.    Pannekoek, J. N., van der Werff, S. J. A., Stein, D. J., & van der Wee, N. J. A. (2013). Advances in the neuroimaging of panic disorder. Human Psychopharmacology: Clinical and Experimental, 28(6), 608-611. doi: http://dx.doi.org/10.1002/hup.2349

9.    Nardi, A. E., Freire, R. C., & Zin, W. A. (2009). Panic disorder and control of breathing. Respiratory Physiology & Neurobiology, 167(1), 133-143. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.resp.2008.07.011

10.    Meuret, A. E., & Ritz, T. (2010). Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies. International Journal of Psychophysiology, 78(1), 68-79. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.ijpsycho.2010.05.006

11.    Pilecki, B., Arentoft, A., & McKay, D. (2011). An evidence-based causal model of panic disorder. Journal of Anxiety Disorders, 25(3), 381-388. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.janxdis.2010.10.013

12.    Cougle, J. R., Timpano, K. R., Sachs-Ericsson, N., Keough, M. E., & Riccardi, C. J. (2010). Examining the unique relationships between anxiety disorders and childhood physical and sexual abuse in the National Comorbidity Survey-Replication. Psychiatry Research, 177(1-2), 150-155. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.psychres.2009.03.008

13.    Klauke, B., Deckert, J., Reif, A., Pauli, P., & Domschke, K. (2010). Life events in panic disorder: An update on “candidate stressors”. Depression and Anxiety, 27(8), 716-730. doi: http://dx.doi.org/http://dx.doi.org/10.1002/da.20667

14.    Peters, T. E., & Fritz, G. K. (2010). Psychological considerations of the child with asthma. Child and adolescent psychiatric clinics of North America, 19(2), 319-333. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.chc.2010.01.006

15.    Benítez, C. I. P., Shea, M. T., Raffa, S., Rende, R., Dyck, I. R., Ramsawh, H. J., . . . Keller, M. B. (2009). Anxiety sensitivity as a predictor of the clinical course of panic disorder: A 1-year follow-up study. Depression and Anxiety, 26(4), 335-342. doi: http://dx.doi.org/http://dx.doi.org/10.1002/da.20423

16.    Cosci, F., Knuts, I. J. E., Abrams, K., Griez, E. J. L., & Schruers, K. R. J. (2010). Cigarette smoking and panic: A critical review of the literature. Journal of Clinical Psychiatry, 71(5), 606. doi: http://dx.doi.org/http://dx.doi.org/10.4088/JCP.08r04523blu

17.    Alvarado, G. F., Storr, C. L., & Anthony, J. C. (2010). Suspected causal association between cocaine use and occurrence of panic. Substance Use & Misuse, 45(7-8), 1019-1032. doi: http://dx.doi.org/http://dx.doi.org/10.3109/10826080903534509

18.    Lara, D. R. (2010). Caffeine, mental health, and psychiatric disorders. Journal of Alzheimer's Disease, 20, 239-248. doi: http://dx.doi.org/http://dx.doi.org/10.3233/JAD-2010-1378

19.    McHugh, R. K., Smits, J. A. J., & Otto, M. W. (2009). Empirically supported treatments for panic disorder. Psychiatric Clinics of North America, 32(3), 593-610. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.psc.2009.05.005

20.    Craske, M. G., & Barlow, D. H. (2008). Panic disorder and agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders (4 ed., pp. 1-64). New York, NY: Guilford Press.

21.    Sánchez-Meca, J., Rosa-Alcázar, A. I., Marín-Martínez, F., & Gómez-Conesa, A. (2010). Psychological treatment of panic disorder with or without agoraphobia: A meta-analysis. Clinical Psychology Review, 30(1), 37-50. doi: http://dx.doi.org/http://dx.doi.org/10.1016/j.cpr.2009.08.011

22.    Vilarim, M. M., Rocha Araujo, D. M., & Nardi, A. E. (2011). Caffeine challenge test and panic disorder: A systematic literature review. Expert Review of Neurotherapeutics, 11(8), 1185-1195. doi: http://dx.doi.org/http://dx.doi.org/10.1586/ern.11.83


23.    Freire, R. C., Perna, G., & Nardi, A. E. (2010). Panic disorder respiratory subtype: Psychopathology, laboratory challenge tests, and response to treatment. Harvard Review of Psychiatry, 18(4), 220-229. doi: http://dx.doi.org/http://dx.doi.org/10.3109/10673229.2010.493744

24.    Morgan, A. J., & Jorm, A. F. (2009). Outcomes of self-help efforts in anxiety disorders. Expert Review of Pharmacoeconomics & Outcomes Research, 9(5), 445-459. doi: http://dx.doi.org/http://dx.doi.org/10.1586/erp.09.47

25.    Meuret, A. E., Rosenfield, D., Seidel, A., Bhaskara, L., & Hofmann, S. G. (2010). Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity. Journal of Consulting and Clinical Psychology, 78(5), 691-704. doi: http://dx.doi.org/http://dx.doi.org/10.1037/a0019552

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