Figure 1. Panic disorder is a debilitating condition that leaves sufferers with acute anxiety that persists long after a specific panic attack has subsided. When this anxiety leads to deliberate avoidance of particular places and situations a person may be given a diagnosis of agoraphobia. [Image: Nate Steiner, https://goo.gl/dUYWDf, Public Domain]

Have you ever gotten into a near-accident or been taken by surprise in some way? You may have felt a flood of physical sensations, such as a racing heart, shortness of breath, or tingling sensations. This type of physiological reaction is called the fight-or-flight response (Cannon, 1929) and is your body’s natural reaction to fear, preparing you to either fight or escape in response to threat or danger. It is likely you are not too concerned with these sensations because you knew what was causing them. But imagine if this alarm reaction came out of the blue, for no apparent reason, or in a situation in which you did not expect to be anxious or fearful. This sudden onset is considered an unexpected panic attack or a false alarm. Because there is no apparent reason or cue for the alarm reaction, you might react to the sensations with intense fear, maybe thinking you are having a heart attack, going crazy, or even dying. You might begin to associate the physical sensations you felt during this attack with this fear and may start to go out of your way to avoid having those sensations again.

Panic Disorder

Unexpected panic attacks such as these are at the heart of panic disorder (PD). However, to receive a diagnosis of PD, a person must not only have unexpected panic attacks but also must experience continued intense anxiety and avoidance related to the attack for at least one month, causing significant distress or interference in their lives. People with panic disorder tend to interpret even normal physical sensations in a catastrophic way, which triggers more anxiety and, ironically, more physical sensations, creating a vicious cycle of panic (Clark, 1986, 1996). The person may begin to avoid a number of situations or activities that produce the same physiological arousal that was present during the beginnings of a panic attack. For example, someone who experienced a racing heart during a panic attack might avoid exercise or caffeine. Someone who experienced choking sensations might avoid wearing high-necked sweaters or necklaces. Avoidance of these internal bodily or somatic cues for panic has been termed interoceptive avoidance (Barlow & Craske, 2007; Brown, White, & Barlow, 2005; Craske & Barlow, 2008; Shear et al., 1997).

Panic Attacks

People with panic disorder experience recurrent (more than one) and unexpected panic attacks, along with at least one month of persistent concern about additional panic attacks, worry over the consequences of the attacks, or self-defeating changes in behavior related to the attacks (e.g., avoidance of exercise or unfamiliar situations) (APA, 2013). As is the case with other anxiety disorders, the panic attacks cannot result from the physiological effects of drugs and other substances, a medical condition, or another mental disorder. A panic attack is defined as a period of extreme fear or discomfort that develops abruptly and reaches a peak within 10 minutes. Its symptoms include accelerated heart rate, sweating, trembling, choking sensations, hot flashes or chills, dizziness or lightheadedness, fears of losing control or going crazy, and fears of dying (APA, 2013). Sometimes panic attacks are expected, occurring in response to specific environmental triggers (such as being in a tunnel); other times, these episodes are unexpected and emerge randomly (such as when relaxing). According to the DSM-5, the person must experience unexpected panic attacks to qualify for a diagnosis of panic disorder.

Experiencing a panic attack is terrifying. Rather than recognizing the symptoms of a panic attack merely as signs of intense anxiety, individuals with panic disorder often misinterpret them as a sign that something is intensely wrong internally (thinking, for example, that the pounding heart represents an impending heart attack). Panic attacks can occasionally precipitate trips to the emergency room because several symptoms of panic attacks are, in fact, similar to those associated with heart problems (e.g., palpitations, racing pulse, and a pounding sensation in the chest) (Root, 2000). Unsurprisingly, those with panic disorder fear future attacks and may become preoccupied with modifying their behavior in an effort to avoid future panic attacks. For this reason, panic disorder is often characterized as a fear of fear (Goldstein & Chambless, 1978).

Panic attacks themselves are not mental disorders and are fairly common in the United States. Approximately 23% of Americans experience isolated panic attacks in their lives without meeting the diagnostic criteria for panic disorder (Kessler et al., 2006). Panic disorder is, of course, much less common, afflicting 4.7% of Americans during their lifetime (Kessler et al., 2005). Many people with panic disorder develop agoraphobia, where they experience fear and avoidance of situations where it is difficult to or to access help during a panic attack. In addition, people with panic disorder often have another mental health disorder, a comorbid disorder, such as other anxiety disorders or a major depressive disorder (APA, 2013).

Causes of Panic Disorder

Figure 3. Some of the physical manifestations of a panic attack are shown. People may also experience sweating, trembling, feelings of faintness, or a fear of losing control, among other symptoms.

Researchers are not entirely sure what causes panic disorder. Children are at a higher risk of developing panic disorder if their parents have the disorder (Biederman et al., 2001), and family and twins studies indicate that the heritability of panic disorder is around 43% (Hettema, Neale, & Kendler, 2001). The exact genes and gene functions involved in this disorder, however, are not well understood (APA, 2013). Neurobiological theories of panic disorder suggest that a region of the brain called the locus coeruleus may play a role in this disorder. Located in the brainstem, the locus coeruleus is the brain’s major source of norepinephrine, a neurotransmitter that triggers the body’s fight-or-flight response. Activation of the locus coeruleus is associated with anxiety and fear, and research with nonhuman primates has shown that stimulating the locus coeruleus either electrically or through drugs produces panic-like symptoms (Charney et al., 1990). Previous findings have led to the theory that panic disorder may be caused by abnormal norepinephrine activity in the locus coeruleus (Bremner, Krystal, Southwick, & Charney, 1996).

Conditioning theories of panic disorder propose that panic attacks are classically conditioned responses to subtle bodily sensations resembling those normally occurring when one is anxious or frightened (Bouton, Mineka, & Barlow, 2001). For example, consider a child who has asthma. An acute asthma attack produces sensations, such as shortness of breath, coughing, and chest tightness, that typically elicit fear and anxiety. Later, when the child experiences subtle symptoms that resemble the frightening symptoms of earlier asthma attacks (such as shortness of breath after climbing stairs), he may become anxious, fearful, and then experience a panic attack. In this situation, the subtle symptoms would represent a conditioned stimulus, and the panic attack would be a conditioned response. The finding that panic disorder is nearly three times as frequent among people with asthma as it is among people without asthma (Weiser, 2007) supports the possibility that panic disorder has the potential to develop through classical conditioning.

Cognitive factors may play an integral part in panic disorder. Generally, cognitive theories (Clark, 1996) argue that those with panic disorder are prone to interpret ordinary bodily sensations catastrophically, and these fearful interpretations set the stage for panic attacks. For example, a person might detect bodily changes that are routinely triggered by innocuous events such as getting up from a seated position (dizziness), exercising (increased heart rate, shortness of breath), or drinking a large cup of coffee (increased heart rate, trembling). The individual interprets these subtle bodily changes catastrophically (“Maybe I’m having a heart attack!”). Such interpretations create fear and anxiety, which trigger additional physical symptoms; subsequently, the person experiences a panic attack. Support of this contention rests with findings that people with more severe catastrophic thoughts about sensations have more frequent and severe panic attacks, and among those with panic disorder, reducing catastrophic cognitions about their sensations is as effective as medication in reducing panic attacks (Good & Hinton, 2009).

Agoraphobia

Figure 2. An ancient Roman agora in Tyre, Lebanon. This is one of the public spaces after which the condition agoraphobia is named.

An individual may also have experienced an overwhelming urge to escape during the unexpected panic attack. This can lead to a sense that certain places or situations—particularly situations where escape might not be possible—are not safe. These situations become external cues for panic. If the person begins to avoid several places or situations, or still endure these situations but does so with a significant amount of apprehension and anxiety, then the person also has agoraphobia (Barlow, 2002; Craske & Barlow, 1988; Craske & Barlow, 2008). Agoraphobia can cause significant disruption to a person’s life, causing them to go out of their way to avoid situations, such as adding hours to a commute to avoid taking the train or only ordering take-out to avoid having to enter a grocery store. In one tragic case seen by our clinic, a woman suffering from agoraphobia had not left her apartment for 20 years and had spent the past 10 years confined to one small area of her apartment, away from the view of the outside. In some cases, agoraphobia develops in the absence of panic attacks, and therefore is a separate disorder in DSM-5. However, agoraphobia often accompanies panic disorder.

Agoraphobia, which literally means “fear of the marketplace,” is characterized by intense fear, anxiety, and avoidance of situations in which it might be difficult to escape or receive help if one experiences symptoms of a panic attack. These situations include public transportation, open spaces (parking lots), enclosed spaces (stores), crowds, or being outside the home alone (APA, 2013). About 1.4% of Americans experience agoraphobia during their lifetime (Kessler et al., 2005).

Treatment for Panic Disorder

Panic disorder is generally treated with psychotherapy, medication, or both. A type of psychotherapy called cognitive-behavioral therapy (CBT) is especially useful as a first-line treatment for panic disorder. CBT teaches different ways of thinking, behaving, and reacting to the feelings that come on with a panic attack, which can begin to disappear once a patient learns to react differently to the physical sensations of anxiety and fear that occur during panic attacks.

Some types of medications to help treat panic disorder include

• selective serotonin reuptake inhibitors (SSRIs),
• serotonin-norepinephrine reuptake inhibitors (SNRIs),
• beta-blockers, and
• benzodiazepines.

SSRIs and SNRIs are commonly used to treat depression, but they are also helpful for the symptoms of panic disorder. They may take several weeks to start working or may also cause side effects, such as headaches, nausea, or difficulty sleeping. Beta-blockers can help control some of the physical symptoms of panic disorder, such as rapid heart rate. Although doctors do not commonly prescribe beta-blockers for panic disorder, they may be helpful in certain situations that precede a panic attack. Benzodiazepines, which are sedative medications, are powerfully effective in rapidly decreasing panic attack symptoms, but they can cause tolerance and dependence if used continuously.