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Panic Disorder: Causes, Symptoms, Diagnosis & Treatment

Panic Disorder

Panic Disorder

Panic disorders come under the classification of anxiety disorders. So, first, you have to understand what anxiety and anxiety disorder are.

Anxiety is a normal, typical, defensive, psychological response to an undesirable or compromising circumstance. Mild to moderate anxiety can improve execution, and performance and guarantee proper move is made.

However, excessive or long-term anxiety can be disabling or crippling, leading to severe distress, pain, and discomfort and causing much impairment to social functioning.

Anxiety disorders are described as anxiety that is out of proportion to any actual threat and is excessive for the situation or distressing to the point that it interferes with daily functioning. Both medical and medication-related factors can cause or exacerbate anxiety. Study In Detail About The Most Common Types Of Anxiety Disorders

Panic disorder is clinically manifested by panic or extreme fear attacks. It also causes increased heart rate, GI disturbances, and sensations of disassociation with the actual body that are regularly not analyzed or misdiagnosed because they are attributed by the patient to a clinical ailment, increased respiration, and tremors.

You will feel abrupt sensations of fear when there is no genuine threat. You will lose control of yourself. The duration of symptoms of panic disorder ranges from minutes to hours. The onset of symptoms is more common during the age of late teens to mid-30s. You can also develop panic attacks at some particularly stressful times or extremely stressful situations in your life.

Panic disorders are two to three times more common in women than men. Women also develop these panic attacks during the prenatal and postpartum periods. Besides this, women are more prone to the development of agoraphobia after panic attacks.

In agoraphobia, you will feel extreme fear from being in circumstances where departure may be troublesome or that help wouldn't be accessible if things turn out badly. Agoraphobia is anything but a more unpredictable condition. Somebody with agoraphobia might be frightened of going in an open vehicle.

Approximately 28% of the general population experiences a single isolated panic attack at some time in their lives. Some people suffer from recurrent panic attacks but they do not fulfill the diagnostic criteria used for panic disorder. The estimated lifetime prevalence of panic disorder ranges from 4% to 5%.  

People with a family history of panic disorder are at higher risk for developing panic attacks. The risk is also increased in people facing major changes in their life such as sexual assault, sexual abuse, serious accident, child abuse, and divorce. Some people develop panic disorder at the death of their loved ones. Smoking, alcohol, and caffeine also increase the incidence of panic attacks.

The standard treatment plan used for panic disorders incorporates cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or benzodiazepines. These medications can also be used in combination therapy depending on your symptoms.

Your healthcare professional can prescribe a combination of cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines and selective serotonin reuptake inhibitors (SSRIs) in combination therapy.

Causes Of Panic Disorder

The panic disorder's exact cause is still unknown. There is a lot of evidence to support the biological basis of panic disorder. An amygdala-mediated intervention in the fear and anxiety response to negative stimuli has been proposed as a neuroanatomical model for alarm issues. Your amygdala is the part of your brain that deals with the fight-or-flight response, anxiety, and fear. Additionally, it is essential to memory.

Various projections from the amygdala, including the nerve center and the LC, trigger autonomic and neuroendocrine reactions bringing about tension and fits of anxiety. Patients with panic disorder have an uplifted nervousness sensitivity (fear of anxiety or uneasiness-related sensations). 

 A variety of substances and circumstances are equipped for setting off the neural dread organization, enacting the tension and panic response. Acute fits of anxiety are accepted to be brought about by deregulated firing in the LCas and hyperresponsiveness of the NE framework might be a hidden reason for panic disorder.

Administration of certain substances causes panic attacks rather consistently in persons with panic disorder. For example, hypertonic sodium chloride, CCK-B agonists, high concentrations of carbon dioxide, yohimbine, flumazenil, caffeine, norepinephrine, and sodium lactate.

GABA-A benzodiazepine binding sites are reduced in people with panic disorder. Neuroactive steroids are abnormally regulated and hyperactivation of the HPA axis is also reported in panic disorder. Another major finding of panic disorder is CCK-B receptor gene polymorphism.

Panic attacks are precipitated by hypersensitivity to 35% CO2 inhalation and it is considered a biological trait marker for panic disorder.

Family history or genetics also plays an important role in the occurrence of panic disorder. The risk of panic disorder is 8 to 21-fold greater in first-degree relatives. Both genetic and environmental factors contribute to this familial pattern. 

Anxiety sensitivity is increased in people with panic disorder. "Catastrophic cognitions" are thought to be the cause. In this condition, harmless normal physical sensations are misinterpreted as being dangerous and cause extreme fear and panic attacks.

Major life changes such as sexual assault, sexual abuse, serious accident, child abuse, and divorce can also cause the occurrence of panic disorder. After a significant event, such as the death of a loved one, some people may develop panic disorder. Panic attacks are also more common in people who smoke, drink alcohol, and drink caffeine.

Symptoms Of Panic Disorder

People diagnosed with panic disorders develop panic attacks or episodes of extreme fear that are sudden in onset. These panic attacks can occur at any time at any place without any warning. The duration of these panic attacks may range from minutes to hours.

Other common symptoms of panic disorders are chest pain or tightness, tachycardia, palpitations, dizziness, vertigo, shaking or trembling, shortness of breath, lightheadedness, nausea, extreme sweating, and chills.

You can also develop changes in mental state, depersonalization, derealization, and the feeling that you are choking. Feelings of numbness, sensations of tingling in your hands or feet, and fear of death can also develop in people with panic disorder.

Diagnosis Of Panic Disorder

The DSM-IV-TR criteria are used for the diagnosis of panic disorder which is discussed below,

Presence of at any rate two surprising fits of anxiety, portrayed by at any rate four of the accompanying symptoms, which grow suddenly and arrive at a top within 10 minutes:

1. Palpitations
2. High pulse rate
3. Perspiring
4. Shuddering or shaking
5. Impressions of windedness or covering
6. Sensation of gagging
7. Chest torment or distress
8. Sickness or stomach trouble
9. Feeling mixed up, shaky, unsteady, or weak
10. Derealization or depersonalization
11. Dread of letting completely go or going off the deep end
12. Dread of passing on
13. Deadness or shivering sensations
14. Chills or hot flushes

In any event, one of the assaults has been trailed by at any rate one of the following symptoms for a length of any rate multi-month:

1. Steady worry about having another assault
2. Stress over the ramifications or results of the assault
3. The critical change in conduct due to the assault

Manifestations are not inferable from the immediate impacts of a prescription, substance, or general ailment

Fits of anxiety are worse represented by another mental or nervousness issue (e.g., fears, fanatical impulsive issues)

It May happen with or without agoraphobia

Treatment Of Panic Disorder

Approximately 70% to 90% of patients with panic disorder may experience substantial relief with currently available treatments, which include both pharmacologic therapies and cognitive behavioral therapy (CBT). 

Medications and cognitive behavioral therapy (CBT), both are effective for reducing panic attacks initially and their effects on phobic avoidance generally occur later.

First-line medication used for the treatment of panic disorder incorporates selective serotonin reuptake inhibitors (SSRIs) and venlafaxine. Benzodiazepines also are effective but no longer recommended as first-line treatment because they do not treat concomitant depression and possess abuse liability.

Several tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOIs) antidepressants are also effective in treating panic disorder but are reserved as second or third-line options because of their clinical disadvantages compared with selective serotonin reuptake inhibitors (SSRIs).

Panic Disorder Medications

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

Paroxetine, sertraline, fluoxetine, and venlafaxine are FDA-approved selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder. Other SSRIs such as fluvoxamine, citalopram, and escitalopram are also effective in treating panic disorder. 

Although low starting dosages of selective serotonin reuptake inhibitors (SSRIs) are recommended to reduce the incidence of side effects. The doses used are 25 mg/day for sertraline, 10 mg/day for paroxetine, and citalopram, and 5–10 mg/day for fluoxetine and escitalopram. 

The recommended target dosage range of paroxetine, citalopram, and fluoxetine for panic disorder is 20 to 40 mg/day. Recommended therapeutic ranges for sertraline and fluvoxamine are 100 to 200 mg/day. These medicines should be used for at least 6 weeks to assess response. After that continued improvements may be seen during a treatment period of 6 months or longer.

BENZODIAZEPINES

The benzodiazepines alprazolam and clonazepam are approved by the Food And Drug Administration for the treatment of panic disorder.  Other benzodiazepines such as diazepam and lorazepam are also proven to be as effective as alprazolam and clonazepam when they are used in equivalent doses.

The dose of alprazolam effective for treating panic disorder is 4 to 6 mg/day. The optimal response is achieved using 10 mg/day of alprazolam. The minimum effective dose of clonazepam appears to be 1 mg/day.

One major problem reported with the use of alprazolam in panic disorder is breakthrough anxiety or panic attacks before the next scheduled dose because of its relatively short duration of action.

TRICYCLIC ANTIDEPRESSANTS, MONOAMINE OXIDASE INHIBITORS & OTHER ANTIDEPRESSANTS

TCAs were the first medications widely used in the treatment of panic disorder. Imipramine and clomipramine are as effective as alprazolam but are less well tolerated. TCAs should be started in low doses to reduce the initial anxiety-like side effects. The recommended low dose should be 10mg/day or less.

Most patients with panic disorder discontinue TCA therapy because of poor tolerability. Clomipramine appears to be more effective than other TCAs for panic disorder, perhaps because of its greater serotonergic effects. Clomipramine is proven to be most effective when used within doses of 50 to 150 mg/day.

Among the MAOIs, phenelzine is remarkably effective in the treatment of panic disorder. But it is generally considered as an option of last resort for treatment of panic disorder. Some studies also suggest that mirtazapine may also be beneficial in treating panic disorder in patients who do not respond to SSRI therapy. Bupropion, buspirone, and trazodone are generally ineffective for the treatment of panic disorder.

MISCELLANEOUS AGENTS

Trials of propranolol, calcium-channel blockers, and clonidine have yielded mixed, but largely negative, results. These agents are considered an appropriate treatment option for panic disorder.

Other medications such as gabapentin, vigabatrin, tiagabine, valproic acid, olanzapine, and risperidone when used in combination with SSRI are also effective treatment options used for panic disorder.

NONPHARMACOLOGIC TREATMENT Of PANIC DISORDER

Non-pharmacologic therapy merges strong supportive psychotherapy, dynamic psychotherapy, psychological treatment, intellectual treatment, cognitive therapy, and relaxation training. Psychotherapy like cognitive behavioral therapy (CBT) can correspondingly be utilized alone or in the mix with the medication treatment.

Cognitive-behavioral therapy (CBT) is based on the level of anxiety sensitivity in these patients and asserts that physical anxiety sensations are misinterpreted as being serious or life-threatening. The purpose behind the psychological treatment is to perceive the negative idea designs inciting, instigating, or decaying or deteriorating apprehension/nervousness. Then, at that point, psychological treatment changes these negative thoughts into positive musings.

Combining medication with cognitive-behavioral therapy (CBT) can be useful, especially in patients with severe agoraphobia. Psychotherapy can also be termed talk therapy or psychological counseling.