Panic Disorder with and without Agoraphobia

What is a Panic Attack?
To receive a diagnosis of panic disorder, it must first be established that a person is experiencing panic attacks. A panic attack is defined as a discrete period of intense fear or discomfort, in which at least four from a list of 13 standard symptoms develop abruptly and reach a peak within 10 minutes. Although the symptoms must peak within 10 minutes, the attacks often peak within a few seconds and the symptoms gradually subside over a period lasting from a few minutes to about a half hour. In addition to these “official” symptoms, panic attacks may be accompanied by other symptoms as well (e.g., blurred vision).

The official list of 13 panic attack symptoms include:
racing or pounding heart
sweating
trembling or shaking
shortness of breath
feeling of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, or faint
feeling unreal or detached
paresthesias (i.e., numbness or tingling sensations)
chills or hot flushes
fear of dying
fear of going crazy or losing control

Panic attacks occur across all the anxiety disorders, usually triggered by a feared situation or object, or by an anxious thought or worry. In fact, even people without an anxiety disorder may experience panic attacks from time to time (e.g., when giving a formal presentation or taking an exam, or upon encountering some other stressful situation). Panic attacks occur frequently in the general population, with some studies showing that up to a third of individuals experience a panic attack during a given year.

Unlike most panic attacks, which are typically triggered by stress, worries, or feared situations, the panic attacks that occur in panic disorder often occur out of the blue, without any obvious trigger or cause.

Official Criteria for Panic Disorder:
Based on criteria from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000)

• the individual must experience recurrent, unexpected or uncued panic attacks (i.e., panic attacks occurring out of the blue, without any obvious triggers).

• the individual must experience a period lasting at least a month, in which the individual:

1. is concerned or worried about having more panic attacks.

2. is concerned about the consequences of his or her attacks (e.g., worries about dying, having a heart attack or stroke, fainting, having diarrhea, vomiting, losing control, going “crazy,” being embarrassed, etc.)

3. changes his or her behavior because of the attacks (e.g., avoiding feared situations, avoiding activities that produce arousal, such as sex and exercise, carrying certain objects to feel more comfortable, etc.)

• it must be established that the panic symptoms are not being caused by a medical condition (e.g., thyroid condition, diabetes, heart condition) or by a drug or substance (e.g., cocaine use, caffeine, withdrawal from alcohol).

• it must be established that the panic attacks are not exclusively due to another psychological problem. For example, if the individual has an eating disorder and tends to have panic attacks only when she or he is worrying about food or weight, a diagnosis of panic disorder would not be given.

What is Agoraphobia?
There is a misconception that the term agoraphobia refers to a fear of open spaces. This is not true. In fact, most people with agoraphobia are much more fearful of enclosed spaces, such as tunnels, small rooms, and elevators. The term agoraphobia literally means a “fear of the market place.” Interestingly, supermarkets, shopping malls, and other crowded places are among those often avoided by people with agoraphobia.

Agoraphobia is defined in DSM-IV (American Psychiatric Association, 1994) as anxiety about being in places or situations in which escape might be difficult or help might not be available in the event of having a panic attack or panic-like symptoms. Most, but not all, people with panic disorder develop at least some degree of agoraphobia. In extreme cases, an individual with panic disorder and agoraphobia may be completely unable to leave the house. More typically, people with agoraphobia experience some restrictions in what they are able to do, but they are able to leave the house, especially if they are accompanied by someone they know.

Some of the situations that are often avoided by individuals with panic disorder and agoraphobia include:

• Being more than a short distance from home
• Leaving home alone
• Shopping in a crowded supermarket
• Walking through a crowded shopping mall, away from the exits
• Riding a bus, train, or subway
• Flying on an airplane
• Sitting in a theater, away from the exit, or in the middle of a row
• Going to a concert
• Attending a sports event
• Walking alone in the neighborhood
• Standing in a long bank line
• Going to a party
• Sitting in a meeting
• Enclosed places (e.g., riding elevators, being in tunnels, small rooms)
• Visiting a museum
• Walking on a crowded street
• Driving on highways, city streets, or other roads
• Exercising
• Sexual activity

Causes of Panic Disorder and Agoraphobia

Biological Factors
• Brain Activity – brain imaging studies using a technique called positron emission tomography (PET) have shown that people with panic disorder have different amounts of activity in particular areas of the brain (especially an area known as the hippocampus), compared to people without panic disorder. The precise nature of these differences is not completely understood, and studies tend to have inconsistent results.

• Neurotransmitters – A number of neurotransmitters (i.e., chemical messengers that pass information from one nerve cell in the brain to the next) are thought to play a role in the development and maintenance of panic attacks and panic disorder. The neurotransmitter for which the evidence is strongest is norepinephrine. For example, substances that increase norepinephrine in the brain (e.g., inhaling carbon dioxide enriched air) have been shown to trigger panic attacks in people with panic disorder. Also, medications that act on the norepinephrine system have been found to block panic attacks. In addition to norepinephrine, other neurotransmitters that may contribute to panic disorder include serotonin and cholecystokinin.

• Genetics – Evidence is quite strong that panic disorder runs in families. In fact, if an individual has panic disorder, his or her immediate relatives are about three times as likely to develop panic disorder than relatives of an individual who doesn’t have panic disorder. In addition, studies on identical and fraternal twins suggest that part of the reason that panic disorder is transmitted from generation to generation has to do with our genetic make up. Environmental factors, such as learning, may also contribute to the tendency for panic disorder to occur across multiple family members.

Psychological Factors
• Misinterpretating Panic Symptoms – People with panic disorder tend to misinterpret their physical symptoms as a sign of danger. For example, a racing heart may be misinterpreted as a signal that one is having a heart attack; dizziness may be misinterpreted as a sign that one is about to faint; feelings of unreality may be misinterpreted as a sign that one is going to lose control or go “crazy.” Anxiety-provoking beliefs about one’s panic-related symptoms can trigger a full blown panic attack in response to symptoms that might otherwise be ignored.

• Attention and Memory – People with panic disorder tend to pay special attention to the physical symptoms that frighten them. For example, they may scan their bodies for unusual symptoms (e.g., dizziness, racing heart), and in so doing, they are more likely to notice these feelings than other people. Individuals with panic disorder are also more likely to remember information that is consistent with their panic-related beliefs than are people without panic disorder. For example, they may recall stories about young athletes who experienced a heart attack while exercising and use this information as evidence that exercise is dangerous.

• Life Experiences – Life stress puts people at risk for developing panic attacks and panic disorder. During stressful periods (e.g., work stress, marital problems, health problems, exams at school), people with panic disorder often report more frequent and intense panic attacks. In addition, many people with panic disorder report that their panic attacks began following a period of life stress (e.g., divorce, unemployment, graduation, etc.).

Effective Treatments for Panic Disorder and Agoraphobia

Biological Treatments
A number of medications have been shown to be useful for treating panic disorder. These include antidepressant drugs as well as drugs that are traditionally used for treating anxiety. Examples of medications that are often helpful for panic disorder include:

Type of Medication	Generic Name	Brand Name
SSRI Antidepressants	Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Celexa Prozac Luvox Paxil Zoloft
Tricyclic Antidepressant	Clomipramine Imipramine	Anafranil Tofranil
Other Antidepressants	Nefazodone Venlafaxine	Serzone Effexor
Antianxiety Medications	Alprazolam Clonazepam Lorazepam	Xanax Klonapin or Rivotril Ativan

The decision of whether to take medication for panic disorder, and which medication to take should be based on the individual’s past treatment history, the individual’s medical history, possible interactions between the medication and other drugs that person may be taking, potential side effects, and other factors.

Psychological Treatments
The type of psychological treatment that has been shown to be most useful for treating panic disorder is called cognitive behavior therapy (CBT). CBT includes a number of useful strategies, including:

• Cognitive Therapy – Involves learning to identify one’s anxious thoughts and to replace them with more realistic thoughts. For example, if an individual is convinced that he or she is having a heart attack each time a racing heart is experienced, the individual might be taught to examine the evidence for the belief (e.g., my heart has raced hundreds of times in the past, and it has never been a heart attack…chances are it’s not a heart attack this time either.

• Exposure to Feared Situations – this technique, also called in vivo exposure , involves confronting a feared situation repeatedly, until the situation no longer triggers fear. For example, an individual who fears having panic attacks while driving would be encouraged to practice driving for an hour or two each day, until driving is no longer a problem. Exposure works best when it occurs frequently (e.g., several times per week), and lasts long enough for the fear to decrease (up to two hours).

• Exposure to Feared Sensations – this technique, also called interoceptive exposure, involves teaching people to confront feared symptoms repeatedly until the symptoms no longer provoke fear. For example, someone who fears the feeling of lightheadedness might be encouraged to hyperventilate (i.e., breathe quickly) for short periods (e.g., a minute) to induce lightheadedness. Someone who fears a racing heart might be encouraged to run up and down the stairs to increase his or her pulse rate.

• Breathing Retraining – this technique involves teaching individuals to slow down their breathing. It is particularly useful for individuals who tend to overbreathe when they are feeling anxious, which can lead to an increase in panic-like symptoms.

Combined Treatments

Generally medications and CBT work about equally well in the short term, although some people may respond better to one approach or the other. For many people, the combination of medication and CBT does not work any better than either approach alone, although some individuals respond best to combination treatment. In the long term, CBT is probably more effective than medication for many individuals with panic disorder. Once treatment has stopped, individuals who have been treated with CBT are less likely to experience a return of their symptoms than are individuals who have been treated with medication.

Did you know ...?

• Panic disorder often begins during teenage and early adulthood.
• Panic disorder is more frequently diagnosed in women than in men.
• A typical panic attack lasts for several minutes but it can even last up to an hour.
• The after effects of a panic attack - anxiety - can linger for hours or days.