Panic Disorder

WHAT IS PANIC DISORDER?

Panic disorder is a problem characterized by extremely powerful feelings of fear and anxiety that quickly overwhelm a person.¹ These very frightening experiences are called panic attacks. Most often, a panic attack will intensify over a ten- to fifteen-minute period and will usually end within thirty minutes.² Many people will experience a panic attack in their lifetime, and most initial attacks will be caused by hyperventilation, a fast and excessively deep type of breathing that often accompanies fear and stress.

People who struggle with other anxiety problems such as generalized anxiety disorder and social phobia will also experience panic attacks when they’re forced to do something that they’re afraid of, like speaking in public, driving in traffic, or shopping in a crowded store. However, people who have panic disorder experience multiple, unexpected panic attacks that seem to come out of nowhere. They also worry about the possibility of the attacks reoccurring and often change their behavior to try to prevent the attacks.¹ In severe cases of panic disorder, people might not leave their home due to a fear of being stranded and helpless somewhere while having a panic attack. This additional problem is called agoraphobia.

Severe physical symptoms accompany panic attacks, such as an intense pounding of the heart, an inability to move, dizziness, a feeling of being separated from reality, stomach sickness, numbing of the senses, tightening in the throat, an inability to breathe comfortably, hot or cold sensations, excessive perspiration, and shaking.¹ Many people who experience panic attacks think that they’re having a heart attack, going insane, or dying.¹ In fact, a large number of people who experience panic attacks first seek treatment at hospital emergency rooms³ or from their general medical provider.⁴

Although many people who have panic attacks mistake their problems for a medical condition,^{5, 6} it’s always necessary to have a medical examination to identify or rule out any real physiological problems. Some medical conditions can cause symptoms that are very similar to panic attacks. These conditions include thyroid disease and mitral valve prolapse, a common heart condition that can cause chest pains and palpitations similar to those experienced during panic attacks.^{7, 8}

When people are suffering with panic disorder, they may experience panic attacks as frequently as every week or the attacks may occur irregularly, with a space of months between attacks. Either way, they are probably very frightened of having another one, and this fear limits their ability to function in everyday life. For example, they might no longer travel for vacations or shop at stores due to the fear of having a panic attack in front of other people. This fear can also interfere with important relationships or cause people to miss time at work. And in cases where panic disorder is severe, people sometimes confine themselves to their homes. Most people with agoraphobia are afraid of having a panic attack in a social situation that they can’t escape or in an unfamiliar place where they can’t find help.⁹

ARE THERE OTHER PROBLEMS RELATED TO PANIC DISORDER?

The 2005 U.S. National Comorbidity Survey Replication¹⁰ observed that people with panic disorder also struggle with other mental health problems such as specific and social phobias, generalized anxiety disorder, post-traumatic stress disorder, depression, dysthymia, bipolar disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disorder. Other studies have observed that many people with panic disorder also suffer with drug and alcohol problems.¹¹

Panic disorder is also common among people struggling with some kind of personality disorder, such as a paranoid personality, dependent personality, obsessive-compulsive personality, antisocial personality, and schizoid personality.¹²

WHO IS AFFECTED BY PANIC DISORDER?

A 1996 report published by the World Health Organization and the Harvard School of Public Health¹³ stated that panic disorder was the fifth most disabling mental health problem in the developed world. It’s estimated that almost 1 to 2 percent of the general population will suffer with panic disorder in any given year,^{11, 14} and approximately 5 percent of the population will experience panic disorder at some point in their lives.^{14, 15}

By some estimates, approximately two million adults in the United States suffer with panic disorder each year.¹⁶ Most often, panic disorder develops in the teenage or early adult years.¹ One-third to one-half of the people with panic disorder will also develop agoraphobia, usually within the first year of experiencing recurrent, untreated panic attacks.¹ However, not everyone who has panic attacks will develop panic disorder. It’s estimated that 3 to 5 percent of the general population has panic attacks every year without worrying about the recurrence of the attacks and without changing their behaviors.¹⁷

WHAT CAUSES PANIC DISORDER?

The exact causes of panic attacks are unknown. However, they’re believed to have both biological and social risk factors. The human body’s reaction during a panic attack is the same reaction it’s designed to have during an encounter with any sign of danger. This reaction is called the fight-or-flight response, or the sympathetic nervous system response. In the face of immediate threat, the human body is designed to automatically prepare itself to fight the danger or to run away from it (or, in some cases, to freeze). During the fight-or-flight response, the body becomes physically prepared to react to danger. The adrenal glands release increased amounts of adrenaline, increasing the heart rate, blood pressure, and energy level. This is the same thing that happens to the body during a panic attack. Normally, this adrenaline surge only lasts two to three minutes.¹⁸ However, during a panic attack, further worry and anxiety can cause the adrenal glands to initiate another surge of adrenaline, which prolongs the panic attack.

The research on panic disorder suggests that most people remember experiencing some type of stress during their first panic attack.¹⁹ After this initial attack, the person might begin to closely monitor his or her body for signs of a second panic attack. This constant monitoring then develops into a heightened awareness and sensitivity to even minor body sensations, especially changes in heartbeat.^{20, 21} When this occurs, a slight fluctuation in heartbeat can be enough to trigger another panic attack.²² In addition, if people have a real problem with their heart, such as mitral valve prolapse, or if they consume even modest amounts of caffeine (which can cause symptoms of anxiety), a second panic attack is even more likely.

Excluding genuine medical problems, like mitral valve prolapse, the usual cause of recurring panic attacks is the fear of having another panic attack, along with the mistaken assumption that the person is going to die during that attack.²² Add to this problem the fact that most panic attacks take place outside of the person’s home, and it’s easy to see why many people with panic disorder eventually develop agoraphobia and cannot leave their homes.²³

WHAT TREATMENTS ARE EFFECTIVE FOR PANIC DISORDER?

According to findings from the National Institute of Mental Health Epidemiologic Catchment Area Program,²⁴ over one million people are treated for panic disorder each year in the United States. Sadly, however, many people wait as long as ten years before seeking treatment for this illness.²⁵ This is unfortunate, considering that cognitive behavioral therapy is a very effective treatment for panic disorder with or without agoraphobia. In a study reported in the professional journal Behavior Therapy, the cognitive behavioral treatment for panic disorder helped 85 percent of the patients become panic free,^{26, 27} and two years later 81 percent of them were still panic free,²⁸ all without using medications.

However, despite the successes of cognitive behavioral therapy, most patients are initially prescribed medications for their panic attacks²² because they first seek treatment from a medical professional.⁴ Antidepressant medications such as fluoxetine (Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are usually the initial medications prescribed.²⁹ However, faster acting antianxiety medications such as diazepam (Valium) and alprazolam (Xanax) are also used. (Click here for information about the use of medications.)

These medications can all be effective for the short-term treatment of panic attacks. However, in long-term treatment studies,^{30, 31} one of which was reported in 2000 in the Journal of the American Medical Association,³¹ the use of cognitive behavioral therapy was superior to the use of medications and provided more benefits, including lower relapse rates.²² In fact, unless it’s immediately necessary, antianxiety and antidepressant medications are not recommended for the treatment of panic attacks. The potential problem is that people on medications might start to rely on medications for relief instead of relying on the skills they’ve developed in cognitive behavioral therapy.

COGNITIVE BEHAVIORAL THERAPY FOR PANIC DISORDER

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for panic disorder is usually composed of seven steps:³²

1. Conduct an assessment and provide education

2. Develop controlled, diaphragmatic breathing skills to resist hyperventilation

3. Challenge and correct anxious thinking using a risk assessment

4. Engage in safe and systematic exposure to panic-inducing symptoms

5. Engage in exposure to feared events to treat agoraphobia

6. Develop skills to cope with chronic worries

7. Prevent relapse
   

1. Conduct an Assessment and Provide Education

The first step in the CBT treatment for panic disorder is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with panic disorder and not some other similar problem. Once people have been diagnosed with panic disorder, it’s important that they understand the basic nature and causes of the problem, especially the fight-or-flight nervous system response (as highlighted above). It’s also important for people with panic disorder to learn the truth about their worst fears, sometimes called the focal fears of panic disorder. For example, many people with panic disorder are afraid that they are going to faint, when, in fact, during most panic attacks people’s blood pressure actually rises, which prevents them from fainting. (Click here for more information about the fight-or-flight response and focal fears.)

It’s also important for the person to understand that CBT is an active form of treatment that requires him or her to do work outside of the therapy session.

2. Develop Controlled, Diaphragmatic Breathing Skills to Resist Hyperventilation

The second step is to learn controlled, diaphragmatic breathing skills. The diaphragm is a muscle at the bottom of the lungs that helps a person breathe in a slow, rhythmic way. This is important to learn because many people who struggle with panic disorder have a habit of hyperventilating, a rapid, deep breathing pattern that often causes them to feel light-headed. This by itself can sometimes trigger a panic attack. Controlled diaphragmatic breathing—inhaling and exhaling to a slow, even count—can correct hyperventilation and slow down or prevent other symptoms of panic attacks. In general, diaphragmatic breathing also helps many people feel calmer, especially when confronted with anxiety-provoking situations. (Click here for instructions on how to use diaphragmatic breathing.)

3. Challenge and Correct Anxious Thinking Using a Risk Assessment

The third step of the CBT treatment for panic disorder is to challenge and correct anxious thoughts by using a risk assessment thought log. Negative thoughts are often the cause of anxious feelings. At the most observable level are automatic thoughts. People with panic disorder often think and say automatic fearful thoughts to themselves prior to panic attacks. Two examples of automatic thoughts might be “I’m going to lose control” and “I’m choking and I’m going to die.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious or afraid. (Click here for information on identifying automatic thoughts.)

The initial stages of the CBT treatment for panic disorder will be spent identifying and reevaluating these errors in thinking using a risk assessment thought log. First, the risk assessment will help the person with panic disorder identify cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. (Click here for information on identifying cognitive distortions.)

Next, the risk assessment thought log will help the person identify the situations that trigger the panic attacks and the automatic thoughts that accompany those situations. For example, a person might notice that every time he goes shopping he starts to feel light-headed and then he thinks, “I’m going to faint and look foolish.” In this example, the risk assessment would help that person identify evidence that both supports and refutes his prediction, and help him create a more well-balanced thought that eases his anxiety. Using the previous example, in support of the automatic thought, the man might say, “I’d look stupid if I passed out in the store,” but refute the thought by noting, “I’ve never actually passed out in a store before, no matter how bad I’ve felt.” Then, using these two thoughts, the man might come up with a healthier alternative thought: “Just because I sometimes feel light-headed, it doesn’t mean that I’ll faint and look foolish.”

The goal of this exercise is to lessen the strength of the initial automatic thought and therefore also lessen the person’s level of anxiety. The exercise can also help the person figure out the actual risk of a feared event taking place and help the person decide what he or she would do if the worst did happen.

As the work on challenging automatic thoughts continues, a person using a thought log will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to panic attacks. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought log and other techniques. (Click here for instructions on challenging core beliefs.)

4. Engage in Safe and Systematic Exposure to Panic-Inducing Symptoms

As was stated in this introduction to panic disorder, most people who struggle with this problem have developed a fear of bodily sensations, such as a change in heartbeat or sweaty palms. As a result, they frequently monitor their bodies for these “symptoms,” and when they detect one, it’s often enough to trigger a panic attack. However, the truth is that all of us feel sensations like these; they are part of the normal experience of being alive. Thus, part of the CBT treatment for panic disorder is to renormalize these physical sensations and to help people master their fear by exposing them to those sensations in a safe and systematic way. This is often called interoceptive exposure. It’s very important to the success of the treatment that the person refrain from using safety behaviors while engaging in these exposures; examples include carrying medication in a pocket “just in case,” or having a safety person present during the exposure. These safety behaviors limit the effectiveness of the exposure. (Click here for instructions on interoceptive exposure.)

5. Engage in Exposure to Feared Events to Treat Agoraphobia

Just as people with panic disorder need to be exposed to feared bodily sensations, they also need help overcoming feared events, places, and situations if they also struggle with agoraphobia. This includes getting out of their homes, going out to public places, and engaging in other feared (but rationally safe) activities in a safe and systematic way. People who have both panic disorder and agoraphobia should be encouraged to confront these fears as early as possible in treatment. And again, it’s important to the success of the treatment that they refrain from safety behaviors during the exposure. (Click here for instructions on exposure to feared events for the treatment of agoraphobia.)

6. Develop Skills to Cope with Chronic Worries

People with panic disorder often need to learn other specific skills to cope with chronic worries that may or may not be linked to their panic attacks. These skills often include stress reduction skills, relaxation techniques, and assertive communication skills. (Click here for stress reduction and relaxation techniques, and for assertive communication skills.)

7. Prevent Relapse

Finally, the last step of the CBT treatment for panic disorder is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning panic disorder in order to take steps to prevent relapse. (Click here for instructions on preventing relapse of panic disorder.)

REFERENCES FOR PANIC DISORDER

1. American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association.

2. U.S. Department of Health and Human Services. 1999. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

3. Katerndahl, D. A., and J. P. Realini. 1995. Where do panic attack sufferers seek care? Journal of Family Practice 40: 237-243.

4. Wang, P. S., M. Lane, M. Olfson, H. A. Pincus, K. B. Wells, and R. C. Kessler. 2005. Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 629-640.

5. Ballenger, J. C. 1997. Panic disorder in the medical setting. Journal of Clinical Psychiatry 38: 13-17.

6. Stahl, S. M., and S. Soefje. 1995. Panic attacks and panic disorder: The great neurologic imposters. Seminars in Neurology 15: 126-132.

7. Carter, C. S., D. Servan-Schreiber, and W. M. Perlstein. 1997. Anxiety disorders and the syndrome of chest pain with normal coronary arteries: Prevalence and pathophysiology. Journal of Clinical Psychiatry 58: 70-73.

8. Pollock, M. H., R. Kradin, M. W. Otto, J. Worthington, R. Gould, S. A. Sabatino, et al. 1996. Prevalence of panic in patients referred for pulmonary function testing at a major medical center. American Journal of Psychiatry 153: 110-113.

9. Cox, B. J., N. S. Endler, and R. P. Swinson. 1995. An examination of levels of agoraphobic severity in panic disorder. Behaviour Research and Therapy 33: 57-62.

10. Kessler, R. C., W. T. Chiu, O. Demler, and E. E. Walters. 2005. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 617-627.

11. Grant, B. F., F. S. Stinson, D. A. Dawson, P. Chou, M. C. Dufour, W. Compton, et al. 2004. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 61: 807-816.

12. Grant, B. F., D. S. Hasin, F. S. Stinson, D. A. Dawson, S. P. Chou, W. J. Ruan, et al. 2005. Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the U.S.: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Psychiatric Research 39: 1-9.

13. Murray, C. J. L., and A. D. Lopez, eds. 1996. Summary: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press.

14. Kessler, R. C., K. A. McGonagle, S. Zhao, C. B. Nelson, M. Hughes, S. Eshleman, et al. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51: 8-19.

15. Kessler, R. C., P. A. Berglund, O. Demler, R. Jin, and E. E. Walters. 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 593-602.

16. National Institute of Mental Health. 2004. The numbers count: Mental disorders in America. www.nimh.nih.gov/publicat/numbers.cfm. Accessed June 19, 2004.

17. Norton, G. R., B. J. Cox, and J. Malan. 1992. Nonclinical panickers: A critical review. Clinical Psychology Review 12: 121-139.

18. McKay, M., M. Davis, and P. Fanning. 1997. Thoughts and Feelings: Taking Control of Your Moods and Your Life. Oakland, CA: New Harbinger Publications.

19. Craske, M. G., P. P. Miller, R. Rotunda, and D. H. Barlow. 1990. A descriptive report of features of initial unexpected panic attacks in minimal and extensive avoiders. Behaviour Research and Therapy 28: 395-400.

20. Ehlers, A., and P. Breuer. 1996. How good are patients with panic disorder at perceiving their heartbeats? Biological Psychology 42: 165-182.

21. Ehlers, A., P. Breuer, D. Dohn, and W. Geigenbaum. 1995. Heartbeat perception and panic disorder: Possible explanations for discrepant findings. Behaviour Research and Therapy 33: 69-76.

22. Craske, M. G., and D. H. Barlow. 2001. Panic disorder and agoraphobia. In Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual, edited by D. H. Barlow. New York: Guilford Press.

23. Williams, S. L., P. J. Kinney, S. T. Harap, and M. Liebmann. 1997. Thoughts of agoraphobic people during scary tasks. Journal of Abnormal Psychology 106: 511-520.

24. Narrow, W. E., D. A. Regier, D. S. Rae, R. W. Manderscheid, and B. Z. Locke. 1993. Use of services by persons with mental and addictive disorders: Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry 50: 95-107.

25. Wang, P. S., P. A. Berglund, M. Olfson, H. A. Pincus, K. B. Wells, and R. C. Kessler. 2005. Failure and delay in initial treatment contact after first onset of mental disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 603-613.

26. Barlow, D. H. 1990. Long-term outcome for patients with panic disorder treated with cognitive-behavioral therapy. Journal of Clinical Psychiatry 51: 17-23.

27. Barlow, D. H., M. G. Craske, J. A. Cerny, and J. S. Klosko. 1989. Behavioral treatment of panic disorder. Behavior Therapy 20: 261-282.

28. Craske, M. G., T. A. Brown, and D. H. Barlow. 1991. Behavioral treatment of panic disorder: A two-year follow-up. Behavior Therapy 22: 289-304.

29. American Psychiatric Association. 1998. Practice guideline for the treatment of patients with panic disorder. American Journal of Psychiatry 155: 1-34.

30. Marks, I. M., R. P. Swinson, M. Basoglu, K. Kuch, H. Noshirvani, G. O’Sullivan, et al. 1993. Alprazolam and exposure alone and combined in panic disorder with agoraphobia: A controlled study in London and Toronto. British Journal of Psychiatry 162: 776-787.

31. Barlow, D. H., J. M. Gorman, M. K. Shear, and S. W. Woods. 2000. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. Journal of the American Medical Association 283: 2529-2536.

32. Zuercher-White, E. 1999. Overcoming Panic Disorder and Agoraphobia: A Cognitive Restructuring and Exposure-Based Protocol for the Treatment of Panic and Agoraphobia. Oakland, CA: New Harbinger Publications.