Hello I’m Dr. Carlo Carandang and I’m a psychiatrist with AnxietyBoss.com. Today, I will talk about panic disorder, which is an anxiety disorder where you have repeating panic attacks and you have extreme fear of the next attack coming. So the audience will benefit from this presentation by learning more about panic disorder and how it can be treated.
Panic Disorder Facts
The lifetime prevalence of panic disorder in the population is 5%. Those at increased risk for developing panic disorder include women, middle-aged, low-income earners, and people who are widowed, separated, or divorced. Panic disorder also runs in families and is moderately heritable.
Panic Disorder Symptoms
Panic disorder is characterized by recurrent panic attacks which are random and have abrupt onset. A panic attack is a period of intense fear and it interferes with your functioning. This is followed by persistent concerned about having another panic attack, which is also known as anticipatory anxiety. So let’s define panic attacks. Panic attacks are characterized by palpitations where you can feel your heart pounding or you might have chest pain. You might also have sweating, chills or hot flushes. You might have trembling or shaking. You may have sensations of shortness of breath or you may feel like you are choking. You might feel that you are dizzy, lightheaded, or you feel like you’re going to faint. You may also have the fear of losing control, fear of dying, or fear of going crazy. So when you have these panic attacks, they generally lasts from between 5 to 15 minutes and then they go away. If you have a panic attack that lasts for hours or all day, then it’s probably not a panic attack- it’s something else like an anxiety attack which is triggered by something else. So panic attacks are spontaneous episodes which occur abruptly and peak-out at between 5 to to 15 minutes. So anything that lasts longer than that or an attack that lasts all day, then it is most likely not a panic attack.
Panic Disorder Diagnosis
So how do you make the diagnosis of panic disorder? Well, panic disorder is characterized by recurrent panic attacks which can occur throughout the day and it can occur several times per week and you also have avoidance of places or situations for fear of having a panic attack there. And it’s these symptoms of panic attacks and avoidance which interfere with your life and disrupt your functioning. So these symptoms have to be present for at least one month for the diagnosis of panic disorder.
Panic Disorder Clinical Course
Panic disorder tends to occur more in women and in early adulthood. In women it tends to start in the mid-20s to the mid-30s, while in men it tends to occur in their 30s to mid-40s. Panic disorder has a high relapse rate and is chronic. So in other words, panic disorder last a long time. And even if you don’t get panic attacks for a while, they most likely come back without treatment. As panic disorder progresses, agoraphobia may develop, which is a fear of places or situations where escape or help may be difficult, in the event of having another panic attack. So when you have panic disorder and it goes on untreated, what happens is that it can progress and worsen to the point where you develop agoraphobia.
So people can develop agoraphobia with their panic disorder and become homebound because they have a fear of going out into places or situations where they may not get help, as they are fearful that they may have a panic attack in those situations. So when you develop agoraphobia, it severely limits your functioning as those folks are generally homebound and therefore cannot go to work, and they don’t interact with family and friends. So when you get agoraphobia, it is a sign that it’s severe and that the panic disorder has progressed in a big way, and you need help.
Why Do Panic Attacks Come Out of Nowhere?
So I often get the question from people who have panic disorder about why panic attacks seem to come out of nowhere when they have panic disorder. Well, the unprovoked panic attacks are caused by a malfunctioning in the fear circuit based in the amygdala in your brain. So this fear circuit malfunctions in an unexpected and catastrophic manner which leads to the panic attacks. So the reason that you’re having unprovoked panic attacks is that your fear circuit is malfunctioning, and it malfunctions in unexpected bursts. So therefore you can get the panic attacks while you’re sitting doing nothing or you may get panic attacks when you’re lying in bed sleeping, so the panic attacks can wake you from sleep. So this is why the panic attack seems to come out of nowhere, as your fear circuit malfunctions in an unexpected and catastrophic manner. So this is the reason…it’s based on a malfunctioning fear circuit in your brain.
The malfunctioning in your fear circuit is exacerbated by ongoing activation of the worry circuit which is located on the corticostriatothalamocortical (CSTC) circuit in your brain. So what happens is that these worry circuits then feed and kindle the ongoing problems with your fear circuits, and this in turn enhances your panic attacks. So the intermittent and catastrophic malfunctioning of the fear circuit leading to unexpected panic attacks is exacerbated and perpetuated by the malfunctioning in the worry circuit where you are having anticipatory anxiety about when the next panic attack will occur. So worrying about the next panic attack only serves to kindle future panic attacks. So this is why you have to address both the unexpected panic attacks with treatment such as medications and you also have to address the worrying about the next panic attack occurring through treatments such as cognitive behavioral therapy (CBT) which I will discuss later in this presentation.
So let’s talk about the worry circuits, about how being worried about the next panic attack occurring and your avoidance of situations which may induce panic attacks actually serve to maintain and worsen your panic disorder. So here we have what’s called a negative cycle of panic disorder. Let’s say your trigger is you having physical sensation of anxiety where you’re having increased heart rate, palpitations, and chest pains. So this situation that’s associated with the chest pains induces thoughts about what’s happening, so you may think I am having a heart attack from the chest pains- these thoughts then induce anxiety.
When you are terrified, this is also associated with further physical sensations of the adrenaline response, where you have increased heart rate, you have tremors, you have lump in the throat, you have butterflies in the stomach, your muscles are tense, and you might be breathing faster. So this anxiety makes you avoid so you may then try to escape the situation and you try to avoid the triggers. However ,this avoidance maintains the belief that you are having a heart attack and what this does is that it maintains this negative cycle and this further develops your panic disorder.
So one of the parts of treatment for panic disorder is to address this worry circuit that contributes to this negative cycle of panic disorder. The way to address this anticipatory anxiety is through psychotherapy, such as cognitive behavioral therapy (CBT), as a first-line treatment for panic disorder. However, it is difficult to treat panic disorder with psychotherapy alone, at least initially, because CBT only addresses the avoidance and the anticipatory anxiety, but it does not really address the unexpected panic attacks. CBT only addresses the avoidance and anticipatory anxiety, while medications helps to address the malfunctioning and hyperactive fear circuits. So you need a combination treatment where the CBT addresses the malfunctioning worry circuits and the avoidance, while the medications addresses the malfunctioning fear circuits. So prescription drug treatment for panic disorder is oftentimes necessary as panic attacks are occurring spontaneously.
Panic Disorder Medications
Medications that are effective for panic disorder include selective serotonin reuptake inhibitors, also known as SSRIs. However, SSRIs take a few weeks in order to kick in and sometimes SSRIs can be activating in that it might actually increase anxiety and agitation at first. So while the SSRIs are coming on board, sometimes your doctor will prescribe you a benzodiazepine, as it can work immediately to decrease your panic attacks, until your SSRI becomes effective weeks later. I want to emphasize that taking benzodiazepines is not a long-term solution- it’s only a short-term solution until your SSRI becomes effective weeks later. So let’s say your SSRI starts to become effective two to three weeks after you start taking it. Then at that time, your doctor may start to taper and discontinue the benzodiazepine. So at most, you’ll be on your benzodiazepine for a few weeks, then it’s discontinued. The problem with benzodiazepines is that it’s highly addictive, so it’s not a good idea to continue it for more than a few weeks. And of course, if you have a substance abuse problem, then benzodiazepines are contraindicated. In that case there are alternative panic disorder treatment such as exercise, progressive muscle relaxation, diaphragmatic breathing, meditation, yoga, tai chi, massage, and martial arts, to help calm you. However, I want to emphasize that these alternative treatments are meant to augment your primary treatments for panic disorder.
Panic Disorder Alternative and Natural Treatments
If you have bonafide panic disorder and you’re having severe panic attacks which are severely impacting your functioning, then the best treatment choice would be to go to your doctor to start treatments with cognitive behavioral therapy and prescription medication treatment. So these alternative panic disorder treatments are meant to augment those primary treatments. So you know exercise, progressive muscle relaxation, meditation, and yoga- these are good to get your overall stress levels down. They help to calm you down enough to the point where it’s actually helping your primary treatments. Other alternative panic disorder treatments include natural supplements, which are for people who absolutely do not want to take prescription medication drugs, as they’re expensive, and they also have a lot of side effects.
There are multiple studies showing several different natural supplements are effective and safe for anxiety disorders such as panic disorder, and as I said before, natural supplements generally have fewer side effects and are generally less expensive than prescription medications for anxiety. So for people who don’t want to take prescription medications for panic disorder, then you may consider natural anxiety supplements, as these have preliminary evidence that they are safe and effective.
However, if you have severe panic disorder, then I would recommend that you go to your doctor and consider taking prescription medication treatments with CBT, as these are proven to work. So these alternative treatments such as natural supplements are only for milder cases of panic disorder, and also if you absolutely do not want to take prescription drugs for anxiety.
Another alternative panic disorder treatment includes self-help. Preliminary research has shown that self-help interventions are effective for panic disorder and other anxiety disorders. Self-help interventions have several advantages, as they are convenient, can be done on your own time, do not require doctor visits, do not require therapist visits, and are relatively inexpensive. However, if you have severe panic disorder which is really affecting your functioning, then I still would recommend that you go to your doctor to consider CBT and prescription drug treatment. So self-help treatments are mainly for people who have milder symptoms of panic disorder or who have gone through a successful course of treatment and their panic disorder is under control, and then you could use the self-help to maintain the gains that you learned in treatment. Self-help is useful in that it helps you to prevent future relapses of your panic disorder.
Panic Disorder Summary
To summarize, panic disorder is characterized by recurrent panic attacks and anticipatory anxiety. Panic disorder is best treated with combination treatment with CBT and prescription medications. Alternative treatments such as exercise, progressive muscle relaxation, diaphragmatic breathing, natural supplements, and self-help have preliminary evidence that they are both effective and safe for anxiety disorders such as panic disorder. However, as I mentioned previously, these alternative treatments are meant to augment the primary treatments for panic disorder, which include CBT and prescription medications. If you have severe panic disorder, then you especially want to consider CBT and prescription medications. Now you could go to alternative treatments if your panic disorder symptoms are milder, or if you have successfully completed a course of treatment for panic disorder and you have recovered from panic disorder- then you can use the alternative treatments to help you continue to recover from your panic disorder so that you don’t get a relapse of symptoms.
So this concludes my presentation on panic disorder. Please visit the rest of AnxietyBoss.com to learn more about panic disorder and other anxiety problems. I’m Dr. Carlo Carandang, thank you for visiting.