Panic Disorder

Curt Cackovic; Saad Nazir; Raman Marwaha.

Author Information and Affiliations

Last Update: August 6, 2023.

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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.

Access free multiple choice questions on this topic.

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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.

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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.

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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.

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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]

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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.

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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]

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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.

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

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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.

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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.

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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.

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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]