Panic Disorder

Panic disorder is characterized by unexpected, spontaneous (with no known precipitating reason) panic attacks. Their frequency is variable, ranging from several attacks per day to only a few per year.

Panic attacks are periods of intense fear reaching a peak within 10 minutes of starting

Panic attacks can occur due to certain somatic disorders (abnormal thyroid functioning), other mental illnesses like anxiety disorders, substance use (“Bad trip” after Cannabis use, intoxication, withdrawal), bipolar disorder, etc.

Panic disorder is a common psychiatric illness that affects 3-5% of the population

Many etiologic theories exist, which include neurotransmitter dysfunction (serotonin, dopamine, norepinephrine), a state of chronic hyperventilation (with decreased blood level of CO2) or the activation of a “fear network” in the brain.

Many factors may increase the risk of developing Panic Disorder. These factors include a family history of panic disorder and/or other mental illnesses, like mood disorders and depression (often diagnosed after the onset of panic attacks), schizophrenia, OCD, some phobias, and some medical conditions (COPD, IBS, migraine and tension headache, fatigue, CV disorders (mitral valve prolapse, hypertension, asthma…etc.).

Also, panic disorder is more common among women (x 2-3 times) than in men, in particular among women who have never been pregnant and in pregnant women after delivery. Age is a risk factor as well with the highest incidence between the ages of 18 and 45, but can still affect anyone of any age.

10-20% of people with anxiety disorder abuse alcohol/other drugs

10-40% of people with alcohol use disorder have a panic disorder

Possible triggers of a panic attack might be injury, illness, interpersonal conflict, use of cannabis, stimulants (caffeine, cocaine, amphetamine (ecstasy)), or discontinuation of some medications.

Panic attacks are abrupt feelings of intense fear or discomfort that reach great heights within minutes.

Not everyone experiencing panic attacks has panic disorder

For a diagnosis of panic disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists the following criteria that must be met.

DSM-5 Criteria for Panic Disorder:

• Experiencing recurrent unexpected panic attacks, in which at least four of the following symptoms occur: palpitations or quickened heart rate, abnormal sweating, trembling or shaking, shortness of breath or feeling smothered, nausea or abdominal pain, dizziness or faintness, chills or hot flashes, numbness or tingling sensations, derealization (feelings of unreality) or depersonalization (feeling detached from his or her self), fear of losing control or “going crazy”, and fear of death
• One or more of the attacks were followed by a month (or longer) of one or both of the following:

– More than one month of persistent worry about having another panic attack or their consequences

– Behavioral changes to avoid situations that may trigger a panic attack

• Attacks are not directly or physiologically associated with substance use (intoxication or withdrawal), medical conditions (heart, thyroid, respiratory diseases), or another psychiatric disorder

The consequences might be dramatic as panic disorder may significantly impact on daily activities, may cause problems with employment, lead to depression and/or to alcohol abuse (and addiction) and even increase the risk of committing suicide.

Treatment is available and can reduce the severity and frequency of panic attacks and improves functionality and quality of life

The main options are psychotherapy and medications. Each type of treatment may be recommended depending on the individual’s history, the severity of the panic disorder and whether access to therapists who have special training in treating panic disorders is available.

Psychotherapy, also called talk therapy, is the most effective first choice treatment for panic attacks and panic disorder. Psychotherapy helps in understanding panic attacks and panic disorder and in learning how to cope with them.
Cognitive behavioral therapy implements the idea that panic attacks are not that dangerous and they could be dealt with. This all happens through the repetition method whereby the therapist recreates the symptoms in a safe manner and safe environment. Through practice, the symptoms become less and less dangerous and the individual understands them and starts coping with them. Such practices not only affect the panic attacks themselves, but they also improve self-confidence to get through undesirable situations that used to trigger those attacks.
Effort, time, and self-exploration are needed to gradually decrease the symptoms with every passing week and passing month. Maintenance sessions are usually regularly scheduled to ensure that the attacks are still under control.

Medications are very effective in decreasing the symptoms. They include:

• Selective serotonin reuptake inhibitors (SSRIs): Generally safe and used as antidepressants. Nonetheless, they are the primary mode of pharmaceutical treatment in panic disorders. SSRIs that are approved by the Food and Drug Administration (FDA) for the treatment of panic disorder include fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft)
• Serotonin and norepinephrine reuptake inhibitors (SNRIs): Also an antidepressant, SNRI venlafaxine (Effexor XR) is FDA approved for the treatment of panic disorder
• Benzodiazepines: These sedatives are central nervous system depressants. Benzodiazepines approved by the FDA for the treatment of panic disorder include alprazolam (Xanax) and clonazepam (Klonopin). They are usually used for short term treatment since studies have shown that patients could develop different forms of mental and physical dependence to these drugs

Note that when prescribing benzodiazepines, other drugs taken by the patient should be taken into consideration

Symptom improvement after starting medication therapy is not tangible before several weeks of initiation of treatment

NOTE: Please consult with your healthcare provider before using any of the mentioned drug therapies.