Continuing Education Activity

Panic disorder is fairly common in the general population. Among all anxiety disorders, it has the highest number of medical visits and serves as a very costly mental health condition. Panic disorder is characterized by recurrent, unexpected panic attacks. Panic attacks are defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) as “an abrupt surge of intense fear or discomfort” reaching a peak within minutes. Four or more of a specific set of physical symptoms accompany a panic attack. Panic attacks occur as often as several times per day or as infrequently as only a few attacks per year. A hallmark feature of panic disorder is that attacks occur without warning. There is often no specific trigger for the panic attack. Patients suffering from these attacks self-perceive a lack of control. Panic attacks, however, are not limited to panic disorder. They can occur alongside other anxiety, mood, psychotic, substance use, and even medical disorders. Panic attacks can be associated with increased symptom severity of various disorders, suicidal ideation and behavior, and diminished treatment response in patients with concomitant anxiety and mental disorders. Making an accurate diagnosis of panic disorder is not possible without a thorough awareness of what constitutes panic attacks. It is important to differentiate symptoms experienced during or in association with an actual alarm situation, such as a physical threat, from a true panic attack. According to DSM 5 (Fifth Edition) criteria, at least one panic attack must be followed by one month or more of persistent concern over having more attacks, worry about the consequences of the attacks or maladaptive behavior such as avoidance of work or school activities. Although panic attacks may originate from the direct effects of substance use, medications, or a general medical condition like hyperthyroidism or vestibular dysfunction, they must not derive solely from these. For patients with panic disorder, the fear and anxiety symptoms that they experience primarily manifest themselves in a physical manner as opposed to a cognitive one. This is a distinctive finding. This activity reviews panic disorder and the role of the interprofessional team in the recognition and management of this condition.

Objectives:

• Discuss the frequency of panic disorder.
• Describe the common features of panic disorder.
• Outline the treatment options available for panic disorder.
• Reviews panic disorder and the role of the interprofessional team in the recognition and management of this condition.

Introduction

Panic disorder and panic attacks are two of the most common problems seen in the world of psychiatry. Panic disorder is a separate entity from panic attacks, although it is characterized by recurrent, unexpected panic attacks. Panic attacks are defined by the Diagnostic and Statistical Manual of Mental Health Disorders (DSM) as “an abrupt surge of intense fear or discomfort” reaching a peak within minutes. Four or more of a specific set of physical symptoms accompany a panic attack. These symptoms include; palpitations, pounding heart or accelerated heart rate, sweating, trembling or shaking, sensations of shortness of breath or smothering, feelings of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, light-headedness, or faint, chills or heat sensations, paresthesias (numbness or tingling sensations), derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or "going crazy," and fear of dying.[1] Panic attacks occur as often as several times per day or as infrequently as only a few attacks per year. A hallmark feature of panic disorder is that attacks occur without warning. There is often no specific trigger for a panic attack. Patients suffering from these attacks self-perceive a lack of control. Panic attacks, however, are not limited to panic disorder. They can occur alongside other anxiety, mood, psychotic, and substance use disorder. 

In order to make an accurate diagnosis of panic disorder, it is important to differentiate the two entities from each other. According to DSM 5, panic disorder can be diagnosed if recurrent unexpected panic attacks are happening, followed by one month or more of persistent concern over having more attacks, along with a change in the behavior of the individual to avoid a situation in which they attribute the attack. Although panic attacks may originate from the direct effects of substance use, medications, or a general medical condition like hyperthyroidism or vestibular dysfunction, they must not derive solely from these. Panic disorder is not diagnosed when the symptoms are attributable to another disorder.  For example, when panic attacks occur in the presence of a social anxiety disorder in which the attacks are triggered by social situations like public speaking, it cannot be considered a part of panic disorder. A distinctive finding in patients with panic disorder is related to the fear and anxiety that they experience in a physical manner as opposed to a cognitive one.[2][3][4]

Panic disorder is not a benign disease, it can significantly affect the quality of life and lead to depression and disability. In addition, these patients are also at a higher risk for alcoholism and substance abuse compared to the general population.

Etiology

Multiple theories and models exist which speak to the possible etiology of the panic disorder itself. Most indicate the potential role of chemical imbalance as a major factor, including abnormalities in gamma-aminobutyric acid, cortisol, and serotonin. It is believed that genetic and environmental factor plays a role in the pathogenesis of panic disorder. Several studies show that adverse childhood conditions may lead to panic disorder in adulthood. Newer research indicates that neural circuitry may have a greater role in panic disorder whereby certain areas of the brain are hyperexcitable in individuals, and that would make them prone to developing the disorder. [5][6]

Some studies show that genetic factors may play a role in the etiology of panic disorder. First-degree relatives have a 40% risk of developing the syndrome if someone in the family already has been diagnosed with the disorder. In addition, patients with panic disorder also have a high risk of developing other mental health disorders.

Epidemiology

Panic disorder has a relatively high lifetime prevalence, ranking behind only social anxiety disorder, posttraumatic stress disorder, and generalized anxiety disorder. Notably, patients suffering from panic disorder have much higher lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems compared to the general population. European Americans are more likely to suffer from panic disorder than African Americans, Asian Americans, or Latinos. Females are more affected than men. Panic disorder peaks in adolescence and early adulthood, with low prevalence in children below the age of 14.[5][7][8]

Patients with panic disorders also share many other comorbidities, including OCD, social phobia, asthma, COPD, irritable bowel syndrome, hypertension, and mitral valve prolapse. Pregnant females with panic disorder are also more likely to have small birth weight infants.

Pathophysiology

Many neurotransmitters and peptides within the central nervous system appear to play a major role in the physical manifestations. Results of brain imaging studies have shown characteristic changes, including increased flow and receptor activity, in specific geographic regions, including the limbic and frontal regions. The amygdala is proposed as the main area of dysfunction. From a pathophysiological and psychological standpoint, medical illness and panic disorder are highly correlated. There are two main theories that attempt to explain why patients are more likely to experience panic attacks. The first hypothesizes that susceptible patients lack the appropriate neurochemical mechanisms, which would normally inhibit serotonin, and this increased serotonin causes alterations in the fear network model of the autonomic nervous system. The second theorizes that a deficiency in endogenous opioids results in separation anxiety and increased awareness of suffocation.[9][10]

History and Physical

The vast majority of patients with panic disorder complain of chest pain, palpitations, or dyspnea on multiple occasions. Other common symptoms may include diaphoresis, tremor, a choking sensation, nausea, chills, paresthesias, or feelings of depersonalization.  Because most patients complain of physical symptoms, they often inquire about alternative explanations of their symptoms not related to mental health. They frequently shy away from care by mental health professionals and, instead, seek reassurance from specialty medical consultants. It is important to remember that conditions such as irritable bowel syndrome, asthma, and vocal cord dysfunction also have many symptoms similar to panic disorder.

Evaluation

There are no specific laboratory, radiographic, or other tests required to diagnose panic disorder. The DSM 5 criteria can be used to diagnose panic disorder which has been mentioned earlier. Certain rating scales designed by clinicians are used in practice to assess the severity of panic attacks.  It is, however, important that healthcare providers perform a thorough examination of the patient to rule out an alternative diagnosis. Panic disorder occurs in the absence of other medical or psychiatric conditions that can better explain the symptoms.[11]

Treatment / Management

The main approaches to the treatment of panic disorder include both psychological and pharmacological interventions. Psychological interventions consist of cognitive-behavioral therapy. As an added benefit in patients with a panic disorder that also has concomitant comorbid medical conditions, there are components of their therapeutic regimens that may also secondarily improve their respective medical illnesses. Breathing training is a method of reducing panic symptomatology by utilizing capnometry biofeedback to decrease the number of episodes of hyperventilation. Several of these slow breathing techniques have been shown to benefit patients with asthma and hypertension. Hyperventilation reduction can help patients with cardiovascular disease. Anxiety and stress-reduction techniques can lower adverse outcomes in cardiovascular illness by decreasing sympathetic activity.   

Antidepressants and benzodiazepines are the mainstays of pharmacologic treatment. Among the different classes of antidepressants, selective serotonin reuptake inhibitors (SSRIs) are recommended over monoamine oxidase inhibitors and tricyclic antidepressants. SSRIs are considered the first-line treatment option for patients with panic disorder. In patients with co-existing conditions or where the patients are having severe symptoms, it is preferred that a benzodiazepine such as alprazolam is used until the anti-depressants take effect. In patients with substance use disorder and panic disorder, it is recommended that gabapentin and mirtazapine be used.[12][13][14]

Because of the risk of suicide, some patients may need inpatient monitoring until the symptoms have subsided.

Differential Diagnosis

• Angina
• Asthma
• Congestive heart failure
• Mitral valve prolapse
• Pulmonary embolism
• Substance use diosrder
• Other mental health disorders associated with panic attacks

Prognosis

Prognosis can be guarded. The presence of panic disorder without other psychopathology is rare. Most people will have a recurrence of symptoms even after a symptom-free period. Compliance with treatment is a major issue, and thus relapse of symptoms is common. Only about 60% of patients achieve remission within 6 months. Triggers for poor outcomes include a chronic illness, high interpersonal sensitivity, unmarried, low social class, and living alone. Besides premature adverse cardiac events, these patients are also at risk for suicide.

Complications

Panic disorder is associated with a higher risk of suicidal ideation. It is also associated with a decrease in the quality of life as the patient is not able to function normally in his social and family life. The disorder is associated with an increased risk of comorbid medical conditions and smoking.

Deterrence and Patient Education

It is important for a provider to inform the patient about the symptoms that he may suffer from if he is diagnosed with the disorder. If a patient is not aware of these symptoms, it is probable that he would fear his condition more and would tend to get frequent attacks. Pharmacotherapy and cognitive-behavioral therapy should be discussed with the patients so that they can understand the treatment options for the condition that they have.

Enhancing Healthcare Team Outcomes

There is no cure for panic disorder, and it can present in a number of ways, thus making the diagnosis difficult. The majority of patients with panic disorder present to the emergency department, and hence the role of the nurse and emergency clinician cannot be overemphasized. The patient needs a thorough education on the disorder and understands that the symptoms are not life-threatening. The patient needs to be told about the different treatments available and the need for compliance. Plus, the pharmacist should caution the patient against the use of alcohol or recreational drugs. The patient should be taught to recognize the triggers and avoid them. Before starting any drug therapy, the patient should be informed about the side effects and benefits. In addition, the family should be educated by the nurse and clinician in helping the patient overcome unrealistic fears and other behaviors. Finally, the patient should be educated on a healthy lifestyle by adopting good sleep hygiene, exercise, and a healthy diet. The patient should be advised against any herbal supplements without first speaking to the primary care provider.[15][16] [Level 5] A team approach to the care of these patients will lead to the best outcomes. [Level 5]

Outcomes 

Panic disorder has no cure, and its course is unpredictable. The currently available pharmacological therapy and cognitive behavior therapy does work in about 80% of patients, but relapses are common. About 20% of patients continue to have symptoms that lead to poor quality of life. About two-thirds of treated patients have a good prognosis, achieving remissions for about six months at a time. If the trigger factors like stress, alcohol, financial problems, and divorce are not controlled, the symptoms can create havoc. More important, there is a high risk of coronary artery disease in patients with panic disorder, and the risk of sudden death is increased compared to the general population. Finally, the suicide rate is much higher in patients with panic disorder. There is a high association of social, occupational, and physical disability caused by panic disorder.[17][18][19] [Level 5]

Review Questions

• Access free multiple choice questions on this topic.
• Click here for a simplified version.
• Comment on this article.

References

1.

Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Substance Abuse and Mental Health Services Administration (US); Rockville (MD): Jun, 2016. [PubMed: 30199184]

2.

Berenz EC, York TP, Bing-Canar H, Amstadter AB, Mezuk B, Gardner CO, Roberson-Nay R. Time course of panic disorder and posttraumatic stress disorder onsets. Soc Psychiatry Psychiatr Epidemiol. 2019 May;54(5):639-647. [PMC free article: PMC6509003] [PubMed: 30003310]

3.

Indranada AM, Mullen SA, Duncan R, Berlowitz DJ, Kanaan RAA. The association of panic and hyperventilation with psychogenic non-epileptic seizures: A systematic review and meta-analysis. Seizure. 2018 Jul;59:108-115. [PubMed: 29787922]

4.

Perna G, Caldirola D. Is panic disorder a disorder of physical fitness? A heuristic proposal. F1000Res. 2018;7:294. [PMC free article: PMC5843823] [PubMed: 29623195]

5.

Sivolap YP. [Panic disorder: clinical phenomena and treatment options]. Zh Nevrol Psikhiatr Im S S Korsakova. 2017;117(4):112-116. [PubMed: 28617392]

6.

Santos M, D'Amico D, Spadoni O, Amador-Arjona A, Stork O, Dierssen M. Hippocampal hyperexcitability underlies enhanced fear memories in TgNTRK3, a panic disorder mouse model. J Neurosci. 2013 Sep 18;33(38):15259-71. [PMC free article: PMC6618414] [PubMed: 24048855]

7.

Farris SG, Robinson JD, Zvolensky MJ, Hogan J, Rabius V, Cinciripini PM, Karam-Hage M, Blalock JA. Panic attacks and smoking cessation among cancer patients receiving smoking cessation treatment. Addict Behav. 2016 Oct;61:32-9. [PMC free article: PMC5912332] [PubMed: 27235990]

8.

Foldes-Busque G, Fleet RP, Denis I, Poitras J, Chauny JM, Diodati JG, Marchand A. Nonfearful Panic Attacks in Patients With Noncardiac Chest Pain. Psychosomatics. 2015 Sep-Oct;56(5):513-20. [PubMed: 25583556]

9.

Lai CH. Fear Network Model in Panic Disorder: The Past and the Future. Psychiatry Investig. 2019 Jan;16(1):16-26. [PMC free article: PMC6354036] [PubMed: 30176707]

10.

Quagliato LA, Freire RC, Nardi AE. Risks and benefits of medications for panic disorder: a comparison of SSRIs and benzodiazepines. Expert Opin Drug Saf. 2018 Mar;17(3):315-324. [PubMed: 29357714]

11.

Blackwelder R, Bragg S. Anxiety disorders: A blended treatment approach. Int J Psychiatry Med. 2016;51(2):137-44. [PubMed: 26936807]

12.

Ströhle A, Fydrich T. [Anxiety disorders: which psychotherapy for whom?]. Nervenarzt. 2018 Mar;89(3):271-275. [PubMed: 29383412]

13.

Tanguay Bernard MM, Luc M, Carrier JD, Fournier L, Duhoux A, Côté E, Lessard O, Gibeault C, Bocti C, Roberge P. Patterns of benzodiazepines use in primary care adults with anxiety disorders. Heliyon. 2018 Jul;4(7):e00688. [PMC free article: PMC6039319] [PubMed: 29998202]

14.

Thibaut F. Anxiety disorders: a review of current literature. Dialogues Clin Neurosci. 2017 Jun;19(2):87-88. [PMC free article: PMC5573565] [PubMed: 28867933]

15.

Legey S, Aquino F, Lamego MK, Paes F, Nardi AE, Neto GM, Mura G, Sancassiani F, Rocha N, Murillo-Rodriguez E, Machado S. Relationship Among Physical Activity Level, Mood and Anxiety States and Quality of Life in Physical Education Students. Clin Pract Epidemiol Ment Health. 2017;13:82-91. [PMC free article: PMC5633699] [PubMed: 29081825]

16.

Spijker J, van Vliet IM, Meeuwissen JA, van Balkom AJ. [Update of the multidisciplinary guidelines for anxiety and depression]. Tijdschr Psychiatr. 2010;52(10):715-8. [PubMed: 20931485]

17.

Apolinário-Hagen J. Internet-Delivered Psychological Treatment Options for Panic Disorder: A Review on Their Efficacy and Acceptability. Psychiatry Investig. 2019 Jan;16(1):37-49. [PMC free article: PMC6354039] [PubMed: 30122031]

18.

Caldirola D, Alciati A, Riva A, Perna G. Are there advances in pharmacotherapy for panic disorder? A systematic review of the past five years. Expert Opin Pharmacother. 2018 Aug;19(12):1357-1368. [PubMed: 30063164]

19.

Schwartz RA, Chambless DL, McCarthy KS, Milrod B, Barber JP. Client resistance predicts outcomes in cognitive-behavioral therapy for panic disorder. Psychother Res. 2019 Nov;29(8):1020-1032. [PubMed: 30049247]

Disclosure: Curt Cackovic declares no relevant financial relationships with ineligible companies.

Disclosure: Saad Nazir declares no relevant financial relationships with ineligible companies.

Disclosure: Raman Marwaha declares no relevant financial relationships with ineligible companies.