Panic Attacks and Panic Disorder

A panic attack is an episode of intense fear or impending doom that happens suddenly and without warning. A panic attack is like a false alarm, a sudden surge of fear without a real threat. Panic attacks can happen anywhere, and they usually last less than an hour.

A panic disorder is recurrent panic attacks, or a persistent fear of having another panic attack. It affects up to 5 percent of adults at some point in their life.[1] Because a panic attack feels so overwhelming, it’s normal to worry that you might have another one. If your worry is severe enough, you may develop a panic disorder. If the disorder progresses, some people begin to avoid normal, everyday activities out of fear that they might have another panic attack.

Panic disorder can be treated, and you can enjoy a better quality of life. A good place to begin is with an overview of anxiety including the symptoms, causes, and treatment.

Six Symptoms of a Panic Attack

• Heart: Racing heart, skipped beats
• Chest: Chest tightness, difficulty breathing
• Autonomic: Sweating, nausea
• Muscles: Tremors, shakes
• Dizziness: Unsteady, lightheaded, faint
• Fear: Fear of impending doom or dying

Definition of Panic Disorder

A panic attack is an episode of intense fear or impending doom where the symptoms reach a peak within minutes. You must have at least four of the following symptoms for a panic attack.

• Pounding heart, rapid heartbeat, chest pain or discomfort
• Difficulty breathing, feeling smothered or choked
• Sweating, hot flashes, chills
• Trembling, shaking, numbness, tingling
• Nausea, abdominal pain
• Feeling dizzy, unsteady, lightheaded, faint
• Fear of losing control or losing your mind
• Fear of impending doom or dying

Panic Disorder definition and diagnosis based on the DSM-5.[2]

• • Have you experienced recurrent panic attacks for at least one month?

OR

• After a panic attack, have you had at least one of the following symptoms for at least one month?
• Do you worry intensely that you will have another panic attack?
• Have you significantly changed your behavior to avoid another attack? For example, do you avoid certain places or situations?
• Your symptoms are not due to medication, substance abuse, or any other medical condition (e.g., hyperthyroidism).
• Your symptoms are not due to another mental health condition such as social anxiety disorder, specific phobia, or post-traumatic stress disorder.
• You are not suffering from depression, which can cause panic attacks.

If you answered yes to all of the above criteria, you may meet the DSM definition of panic disorder.

Tests

Medical Tests

Your health care provider can determine if your panic disorder is caused by an underlying medical condition, such as heart disease or thyroid problems. This may require blood tests and an electrocardiogram (ECG). A complete assessment should also include questions about your caffeine and alcohol consumption, and any substance use, which can contribute to an anxiety disorder.

Standardized Screening Tests for Panic Disorder

There is no screening test for panic disorder, probably because panic attacks are so clear cut that no test is needed. But for monitoring panic symptoms as part of treatment, the Panic Disorder Severity Scale has been proven effective.[3] There are also a number of screening tests for anxiety in general.[4]

Here is an online version of the Generalized Anxiety Disorder Test – GAD7 (pdf).

Causes and Risk Factors of Panic Attacks

Before looking at the treatment of panic attacks and panic disorder, it helps to understand the causes because they can help guide the treatment. The two main causes of panic attacks are chronic stress and catastrophizing.

Chronic Stress

A panic attack is like when a volcano suddenly releases pressure. It usually takes at least a year of chronic stress to build up enough pressure to have a panic attack. If you've had a panic attack, think back to the months before your first attack. Were you under high stress during that time?

Once you are under enough stress, almost anything can set off a panic attack. Suppose you are under a lot of stress, but still managing. If you add even more stress, your brain will begin to feel under siege. Your body will respond by releasing adrenaline as part of the fight or flight response. That will cause more anxiety, which will create a vicious feedback that will turn into a panic disorder.

Once you've had one panic attack, you're more likely to have another. Panic attacks are so uncomfortable that the fear of having another one can become another source of stress. Panic attacks then trigger more panic attacks.

The buildup phase of a panic attack is the most important phase, because it is when you can prevent it. If you are under chronic stress, you become worn down and have no reserve left. Anything can push you over the edge. But if you regularly reduce your stress through a combination of cognitive behavioral therapy and mindfulness, you will have enough reserve left to handle life’s surprises.

Catastrophizing

Catastrophizing is the idea that, “If something is going to happen, it will probably be the worst-case scenario.” Common catastrophizing thoughts that lead to panic attacks are usually about your health:

• “I worry about having a heart attack or stroke.”
• “I worry about choking or suffocating.”
• “I worry that I might be losing my mind.”
• “I worry that I may be institutionalized.”

Fear of a Heart Attack

Fear of having a heart attack is one of the common fears that can lead to a panic attack. Chest pain and difficulty breathing can be signs of a heart attack. Therefore, it’s understandable that you might be worried if you have these symptoms. But these symptoms are also due to anxiety and hyperventilation.

Catastrophizing is taking symptoms that are commonly caused by anxiety and assuming that they are due to a heart attack.

The problem with catastrophizing is that it is rigid thinking. Suppose you worry that you’re having a heart attack every time you experience some chest pain. It’s usually easy for a health professional to distinguish between anxiety and a heart attack. But catastrophizing resists new information. Even though, your doctor has done tests in the past and has reassured you many times, you worry that this time will be different. Your exaggerated fear is preventing you from changing your thinking, and is keeping you stuck.

Life Events

Childhood traumatic events increase the risk of developing a panic disorder in adulthood.[5, 6]

• separation from parents
• death or illness of parents
• parental marital problems or divorce
• family violence
• physical or sexual abuse

Substance Use

Tobacco, caffeine, drugs, and alcohol can all increase anxiety and the risk of developing panic attacks. If you suffer from an anxiety disorder, the quickest thing you can do to reduce your anxiety is reduce your caffeine use and quit smoking tobacco.

Long-term substance abuse of drugs or alcohol leads to increased anxiety. Even drugs such as tranquilizers, alcohol, and marijuana will eventually increase your anxiety.

Medical Causes

A number of medical conditions can cause anxiety symptoms. These include an overactive thyroid, hypoglycemia, mitral valve prolapse, anemia, asthma, COPD, inflammatory bowel disease, Parkinson's disease, and dementia among others. Your physician may perform certain tests to rule out these conditions. But it is important to remember that anxiety is more often due to poor coping skills or substance abuse than any medical condition.

Treatment of Panic Attacks

The three main treatments for panic attacks are cognitive behavior therapy, mindfulness-meditation, and anti-anxiety medications.

Five Things You Can Do About Your Panic Attacks

• Quit smoking, reduce your alcohol and caffeine use. These can all cause or worsen anxiety symptoms.
• Review your over-the-counter medications such as diet pills and cold medications that can contain stimulants, which may trigger anxiety.
• Learn relaxation and stress-management techniques and make them part of your life. Develop healthy coping skills.
• Rule out any medical causes for your symptoms.
• Ask for help. Talk with a health professional about your anxiety. Review your thought patterns, and identify any negative thinking that can contribute to your anxiety.

Cognitive Behavioral Therapy for Panic Attacks

Cognitive behavioral therapy (CBT) changes your inner dialogue. It is a step-by-step process for identifying the negative thinking that contributes to your anxiety and replacing it with healthier thinking. You will see situations clearer, feel calmer, and react more effectively.

Cognitive therapy is an effective treatment of panic disorder.[7] It helps you change your thinking from “I’m having a heart attack” or “I’m going crazy” to “This is just anxiety. It will pass.” You gain control over your anxiety.

MRI studies have shown that cognitive behavioral therapy changes brain pathways and results in a more permanent change in thinking and behavior.[8, 9]

Cognitive behavioral therapy also has a behavioral component. The idea is to safely recreate some of the situations that trigger your anxiety and begin to believe that you can handle them. With each safe exposure to your anxiety and the fight-or-flight symptoms you will begin to see that, “This is just anxiety. It will pass.” (Learn more about cognitive behavioral therapy)

Stress Management for Panic Attacks

Prevention is more effective than treatment for panic attacks. Prevention involves stress management methods such as meditation and mindfulness to reduce your stress so that it doesn’t accumulate and eventually erupt into a panic attack. Prevention is not about stopping a panic attack just before it happens. The best you can do just before a panic attack is manage it.

Reducing stress may require some difficult choices. Most people’s lives are overbooked with responsibilities. Rushing from one responsibility to the next with little time to relax is a definite stressor in life. Some of those responsibilities are essential, but some are not. They only seem essential at the time.

Ask yourself, “If I have to make a change in my life, what am I willing to give up in order to reduce my stress? What am I not willing to give up, even if it means having another panic attack?” (Learn more about stress management and mindfulness)

Panic attacks are treatable. The most important step you can take is reaching out and asking for help. You can change your life.

References

1. National Comorbidity Survey, Lifetime Prevalence of DSM-IV Disorders.  https://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_Estimates.pdf.
2. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
3. Shear, M. K., Brown, T. A., Barlow, D. H., Money, R., et al., Multicenter collaborative panic disorder severity scale. Am J Psychiatry, 1997. 154(11): p. 1571-5.
4. Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., et al., Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract, 2015. 22(1): p. 5-19. PMC4310476.
5. Grenier, J., Greenman, P.S., Farmanova, E., Atchessi, N., et al., Scoping Review of Risk Factors of Anxiety Disorders and Post-Traumatic Stress Disorder: A Public Health Perspective. Annals of Depression and Anxiety, 2015. 2(7): p. 1068.
6. Safren, S. A., Gershuny, B. S., Marzol, P., Otto, M. W., et al., History of childhood abuse in panic disorder, social phobia, and generalized anxiety disorder. J Nerv Ment Dis, 2002. 190(7): p. 453-6.
7. Pompoli, A., Furukawa, T. A., Imai, H., Tajika, A., et al., Psychological therapies for panic disorder with or without agoraphobia in adults: a network meta-analysis. Cochrane Database Syst Rev, 2016. 4: p. CD011004.
8. Beutel, M. E., Stark, R., Pan, H., Silbersweig, D., et al., Changes of brain activation pre- post short-term psychodynamic inpatient psychotherapy: an fMRI study of panic disorder patients. Psychiatry Res, 2010. 184(2): p. 96-104.
9. Linden, D. E., How psychotherapy changes the brain--the contribution of functional neuroimaging. Mol Psychiatry, 2006. 11(6): p. 528-38.