Many of us experience occasional panic attacks, especially during times of stress. For most of us, the attacks are annoying, but these events do not change how we live our lives. Nevertheless, when panic attacks become a common occurrence, when they are not usually provoked by any situation, and when a person begins to worry about having them and changes behaviours as a result of this worry, a diagnosis of Panic disorder may be made.
The Diagnostic and Statistical Manual of Mental Disorders, Text Revision-IV (DSM-IV-TR) provides the framework of the criteria of Panic disorder.
A) Recurrent unexpected panic attacks, defined as a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:
- Palpitations, pounding heart, sweating
- Trembling or shaking
- Shortness of breath or choking
- Chest pain or discomfort, feeling of getting choked
- Nausea or abdominal distress
- Feeling dizzy, light-headed
- Derealization or depersonalization
- Fear of losing control or going crazy
- Fear of dying, chills or hot flushes
- Paresthesia (tingling, pricking, or burning sensation on the skin)
B) At least one of the attacks is followed by one month (or more) of one or more of the following:
1. Persistent concern about having additional attacks
2. Worry about the implications of the attack or its consequences
3. A clinically significant change in behavior related to the attacks
Some individuals with panic disorder have many episodes in a short period of time, such as every day for a week, and then go weeks or months without any episodes, followed by another period of frequent attacks. Other individuals have attacks less frequently but more regularly, such as once every week for months. Between full-blown attacks, they may possibly experience minor bouts of panic.
People with panic disorder often fear that they have a life-threatening illness. Even after such an illness is ruled out, they may continue to believe they are about to die of a heart attack, seizure, or other physical crisis. Another common but erroneous belief is that they are “going crazy” or “losing control.”
About 3 to 5 percent of people develop panic disorder at some time (Craske & Waters, 2005; Kessler et al., 2005), usually between late adolescence and the mid-thirties. It is more common in women and tends to be chronic (Craske & Waters, 2005).
Those with panic disorder who are depressed or who abuse alcohol may be at increased risk for suicide attempts (Goodwin & Roy-Byrne, 2006).
Let us look at the potential causes for Panic disorder.
- The Integrated Model
Many people who develop panic disorder seem to have a biological vulnerability to a hypersensitive fight-or-flight response. With only a mild stimulus, their heart begins to race, their breathing becomes rapid, and their palms begin to sweat. They typically will not develop frequent panic attacks or a panic disorder, however, unless they engage in catastrophizing thinking about their physiological symptoms. This thinking increases physiological activation, and a full panic attack ensues. For example: A person prone to panic disorder who feels a bit dizzy after standing up too quickly might think, “I’m really dizzy. I think I’m going to faint. Maybe I’m having a seizure. What’s happening?”
This kind of thinking increases the subjective sense of anxiety as well as physiological changes such as increased heart rate. The person interprets these feelings catastrophically and is on the way to a full panic attack. These cognitions also make the individuals hypervigilant for signs of another panic attack, putting them at a constant mild to moderate level of anxiety. This anxiety increases the probability that they will become panicked again, and the cycle continues.
Some individuals then begin to associate certain situations with symptoms of panic and may begin to feel them again if they return to the situations.
By avoiding these situations, they reduce their symptoms, thereby reinforcing their avoidance behavior. This process is known as a conditioned avoidance response. Thus, a man who has a panic attack while sitting in a theater may later associate the theatre with his symptoms and begin to feel anxious whenever he is near it. By avoiding it, he can reduce his anxiety. He may associate other places, such as his home or a specific room, with lowered anxiety levels, so being in these places is reinforcing. Eventually, he confines himself only to his safe places and avoids a wide range of places he thinks are unsafe. As a result, agoraphobia develops.
Treatment for Panic disorder involves Cognitive-behavioral therapy: that teaches clients to use relaxation exercises and to identify and challenge their catastrophic styles of thinking. Often panic attacks are induced in therapy sessions in order to challenge catastrophic thinking.
Cognitive-behavioural therapy facilitates clients to confront the thoughts and situations that arouse anxiety. Confrontation helps in two ways: It allows irrational thoughts about these situations to be challenged and changed, and it extinguishes anxious behaviour.
- First, clients are taught relaxation and breathing exercises, which impart some control over symptoms.
- Second, the therapist guides clients in identifying the catastrophizing cognitions. Clients may keep diaries of their thoughts on days between sessions, particularly at times when they begin to feel they are going to panic.
- Third, clients practice relaxation and breathing exercises while experiencing panic symptoms in the session. If attacks occur during sessions, the therapist talks to the client, coaching them in the use of relaxation and breathing skills and suggesting ways of improving their skills. The therapist notes the clients’ success in using the skills to control the attacks.
- Fourth, the therapist challenges clients’ catastrophizing thoughts and teaches them to challenge these thoughts themselves.
- Fifth, the therapist uses systematic desensitization therapy to expose clients gradually to a hierarchy of fears while helping them maintain control over their symptoms.