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Panic Disorder

A panic attack is an alarm reaction. When real danger is present (such as when one’s life is being threatened), the alarm is a “true” alarm. In panic disorder, the panic attacks are “false” alarms, because the feeling of the alarm occurs even though there is no real danger.

A panic attack is defined as a sudden rush of intense fear or dread, which usually goes along with several of the following physical symptoms and thoughts: shortness of breath or smothering feelings, dizziness, feeling faint or unsteady, racing or pounding heart, trembling or shaking, sweating, choking sensations, nausea or abdominal distress, feelings of being detached or things seeming unreal, numbness or tingling sensations, hot flashes or cold chills, chest pain or discomfort, fears of going crazy, fears of losing control, and fears of dying. In a panic attack these symptoms are not the result of a real medical condition, such as illness, too much caffeine, or alcohol or drug intoxication.

Features of panic attacks are the suddenness with which fear is experienced— panic attacks usually occur and peak in a very short time (1 to 10 minutes), and the peak lasts on average only 5 to 10 minutes. Panic attacks are very different from other types of anxiety: there is a strong urge to escape and reach safety (also know as the fight-or-flight response); and the attacks come out of the blue, with no obvious outside cause. However, over time, most attacks become connected with specific situations (such as traveling long distances from home).

Panic Attacks Are Common

Six to 12% of the general population reports an unexpected surge of fear or panic at some time during a given year. According to the latest survey, from 2% to 6% of the general population suffers from panic disorder in any given 6- month period. Thus, as many as 14 million Americans have panic disorder.

Panic disorder is distinguished from other anxiety disorders by the unexpected nature of the alarm reactions as well as the continuing anxiety about their return. Worry about the return of panic often leads to the avoidance of situations in which help may not be available or from which escape is difficult, should a panic attack occur. The types of situations avoided may include crowded shopping malls, theaters, highway driving, elevators, walking alone, or traveling far from home. This is known as “agoraphobic avoidance.” In contrast, the occasional panic attack experienced by people with other types of anxiety problems is rarely a major source of concern, and rarely leads to significant avoidance behaviors.

An untreated panic disorder may result in depression, reliance on alcohol and drugs to take some of the edge off the nervous tension, missed work, and social disability.

Characteristics of Panic Disorder

Panic attacks may occur as early as 10 years of age, but panic attacks typically begin in the mid- to late-20s. The average age at which treatment is sought is 34. Many panic sufferers seek medical treatment before seeking psychological help. More women than men are diagnosed with this condition.

What Causes Panic Disorder?

Stressful life events often come just before an individual’s first panic attack. Approximately 80% of people who panic can relate their first panic attack to stressful life circumstances. This might be positive, such as having a child, getting married, or moving to a new city, or negative, such as a bad drug experience, or losing someone close. Conditions that may add to the chances of having an attack under stressful conditions include certain physical and psychological vulnerabilities.

Physical vulnerabilities refer to aspects of body functioning that may make panic symptoms or paying attention to panic symptoms more likely. The biological basis for this susceptibility can be shown by panic attacks occurring in several members of the same family. However, the notion of physical vulnerabilities should not be misunderstood to mean that certain physical aspects “guarantee” the development of panic disorder. Panic disorder seems to develop from a combination of psychological and physical factors.

The psychological vulnerabilities include beliefs that the physical symptoms of anxious arousal (e.g., shortness of breath or dizziness) are harmful or threatening, and a sense that they are difficult to predict or control. These beliefs seem to form the basis of continuing worry about the return of panic attacks.

Chronic worry is characterized by focusing on and searching for any bodily sensations that may mark another panic attack, and by high levels of physical tension in general. Because such tension produces frequent physical symptoms, worrying about panic can lead to the experience of more panic attacks.

The panic attack itself can be viewed as the combination of physical sensations and the frightening thoughts about these sensations: “The chest pain that I am feeling must mean that I am having a heart attack.” In other words, panic attacks are in many ways like phobias, but instead of being afraid of a specific object or situation, panic sufferers are afraid of their own bodily sensations. Therefore, harmless changes in physical state linked with routine activities (such as walking up stairs), drinking coffee, or other mood states (such as anger), might lead the person to become panicky. The sensations are likely to be mistaken as signs of immediate physical or mental danger, such as losing control, dying, fainting, or going crazy.

Because these thoughts are frightening, the nervous system is turned on (as would occur under conditions of real danger). As a result, more physical symptoms are likely to be experienced, which in turn may be thought of as further evidence of danger. That is, panic breeds an increasing cycle of fear and physical symptoms. The urge to escape may increase the cycle even further, particularly if escape is difficult or impossible. The attack cycle is interrupted when the physical activation has run its course, or when safety factors come into play (such as the arrival of a reassuring friend or doctor).

Persistent overbreathing or hyperventilation (taking in more air than is needed) may contribute to panic attacks. It is certainly natural to breathe more quickly and more deeply when afraid. However, overbreathing does not explain all panic attacks; it is important for some but not for others.

Cognitive Behavioral Treatment for Panic Disorder

Researchers from different centers around the world have developed treatment methods, but all tend to include the same four components:

  • reeducation about the physical symptoms of anxiety and fear, to correct misinterpretations of them as being harmful or dangerous;
  • training in methods for reducing physical tension, usually by learning to breath differently and practicing relaxation techniques;
  • repeated exposure to feared and avoided physical situations; and
  • repeated exposure to feared and avoided sensations.

In exposure, specific exercises are used to produce the various symptoms that characterize panic attacks. For example, aerobic exercise might be used to produce shortness of breath and a pounding heart, and overbreathing might be used to produce lightheadedness and dizziness. Systematic exposure to these sensations reduces the person’s fear of them, and teaches the person that the sensations are not dangerous. Activities that were avoided are practiced to establish that they are not dangerous. These activities might include climbing flights of stairs for aerobic effects, eating certain foods, drinking coffee, and so on.

When fear of the body sensations is lessened, so is the fear of the return of a panic attack. These new behavioral treatments eliminate panic attacks in most clients. This favorably compares to the use of prescription medications to reduce panic attacks. Research has shown that 2 years following cognitive behavioral treatment, most patients remain panic-free. In contrast, patients treated with prescription medications often experience a return of panic when the medications are discontinued.

What is Cognitive Behavior Therapy?

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